rms orthodontic residents

1. Orthodontic case
presentation
Done by:
Moeen Salih Al-Bahloli
3rd year orthodontic resident

2. Personal Data
• Patient’s Name: M.A
• Gender: Female
• Age : 15 Years, 5 Months
• occupation: Student
• Nationality: Jordanian

3. Chief Complaint
“ I have unerupted tooth in my lower jaw
And rotated upper anterior teeth”

4. Medical & Dental History
• Medical History:
Denied Any Medical History.
• Dental History:
• Routine dental
treatment
(filling in UR6&LR6).
• Extraction of LL 1st primary molar, 1 month ago.

5. History
• Trauma: No history of trauma.
• Habits: No Habits.
• Motivation: Internally Motivated.
• Growth status: Non- grower .

6. Jaw & Occlusal Functions
• Mastication: Normal masticatory function.
• Speech: No difficulty.
• TMJ:
No clicking.
No Crepitus or tenderness.
No displacement.
Normal opening.

7. Extra-Oral Photos:
(Frontal View)

8. (Profile View)
Extra-Oral Photos:

9. :Extra-Oral Photos
(Oblique View)

10. :Intra-Oral Photo

11. Extra-Oral Examination
skeletal assessment
A. Anterio-posterior Assessment:
• Class I skeletal pattern

12. :B. Vertical Assessment
• Average LAFH.
C. Transverse Assessment:
• Symmetrical face.

13. Soft Tissue Examination
• Equal thirds of the face.
• Upper lip in the upper
1/3 of the lower.
• Lower lip in the lower
2/3 of the lower.
1/3
2/3

14. Asymmetrical face.
Larger middle 1/5th .
Interpupillary distance larger
than the width of the mouth.

15. • competent lips
• Straight facial profile.
• Frontonasal angle: 128 ˚
“ normal 115˚ -135˚’’
• Nasolabial angle: 106˚
“ normal 90˚ -110˚”
• Labiomental angle: 132˚
“ normal 114˚ -140˚”

16. Intra-Oral Examination
• Oral Hygiene : Good.
• Normal frenum attachment
& oral mucosa.

17. • Teeth present:
76E4321 1234567
7654321 1234567
• Caries in UL6.
• Lower left 1st premolar & Lower
left 2nd molar partially erupted.
• Primary Upper right 2nd molar still
present with no mobility.

18. Lower arch
• U-shaped arch.
• Anterior segment:
 Upright incisors.
 Distally tilted LL2&LL3.
• Posterior segment:
 Partially erupted LL4
directed lingually.
 Partially erupted LL7.
 Rotated LL5&LR5.

19. Upper arch
• U-shaped arch.
• Anterior segment:
 Upright anterior teeth.
 Rotated Rt&Lt central incisors .
• Posterior segment:
 Primary right 2nd molar still
present with no mobility.
 Rotated left 2nd premolar.
 Caries in UL6.

20. Anterior segment in occlusion
• Incisor relationship: class 1
• Midline: Lower shifted to
the left 2mm.
• Overjet : 2mm.
• Overbite: incomplete 50%.

21. Buccal segment in occlusion
• Molar relationship:
Cl III ¼ unit in the right side.
Cl I in the left side.
• Canine relationship:
Cl I in the right side.
Cl II ½ unit in the left side.

22. Study model analysis in occlusion
Anterioposterior:
• Molar : Cl III1/4 unit.
• Canine : Cl I .
O.J : 2mm
• Molar : Cl I .
• Canine : Cl II ½ unit .
Right Left

23. Transverse:
Midline discrepancy 2mm.

24. Vertical:
Incomplete overbite 50%

25. :Curve of spee
2mm 3mm
Right Left

26. :Upper arch
• U-shaped arch.
• Asymmetrical arch.
• Intercanine width:
37mm ( increased ).
• Intermolar width:
47mm ( increased ).

28. Lower Arch:
• U-shaped arch.
• Asymmetrical arch.
• Intercanine width:
27mm (increased ).
• Intermolar width:
48mm( increased ).

29. Radiographical examination
Orthopantomogram “OPT” Analysis :
• No pathology.
• All teeth are present except UR 2nd premolar & all wisdom teeth.
• Primary Upper right 2nd molar still present with good bone level.
• Lower left 1st premolar & Lower left 2nd molar partially erupted.
• Roots of lower left&right 2nd molar not completely formed.
• Fillings in UR6&LR6.
• Other features look normal.

30. Cephalometric
Analysis Measurements Average
SNA 83.6˚ (81)+-3
SNB 81.8˚ (78)+-3
ANB 1.8˚ (3)+-1
SN-MAX 2˚ (8)+-3
Wits
Appraisal
-2mm (0) +-
1.77mm
“f”
MMPA 24˚ (27)+-4
LAFH Ratio 56% 55%+-
2%
UI - MAX 107˚ (109)+-6
LI - MAN 90˚ (93)+-6
IIA 138˚ (135)+-
10Skeletal relationship: cl III

31. Space analysis
Lower Arch:
Space available 62mm
Space required 62mm
0mm ( no crowding)
Upper arch:
Space available 73mm
Space required 70mm
+ 3mm
10.5 6.5 7 7 6.5 8 8 6.5 7 7 6.5 10.5 91 43
6 5 4 3 2 1 1 2 3 4 5 6 over
all
ante
rior
10 7 7 6.5 5.5 5 5 5.5 6.5 7 7 10 82 34
90%=Over all ratio: 82/91
Normal: 91.3% +/- 1.9
Anterior ratio: 34/43 = 79%
Normal: 77.2% +/- 1.7
Normal Bolton Ratio
Note: mesiodistal width of UR primary 2nd molar 9mm.

32. Royal London space planning
LowerUpper
0+3 mmCrowding and spacing
- 2 mm0Leveling of occlusal curve
00Incisors AP position
00Inclination change
-2 mm+3mmTotal

33. Pre-treatment (IOTN)
Aesthetic Component :
Figure 1
Mild treatment need

34. Dental Health Component :
• Grade 5
“Extreme /Need Treatment”
5i Impeded eruption of teeth
due to retained deciduous
teeth

35. Diagnostic summary
• M.A 15,5months years old female, denied any medical problem, presented
with concern unerupted tooth in her lower jaw & rotated upper anterior
teeth, good oral hygiene and caries in UL1st molar.
• She has a class I incisors relationship based on class III skeletal pattern,
average lower anterior facial height , straight profile, and asymmetrical soft
tissue face.
• She has missing UR 2nd premolar, over jet 2mm, incomplete overbite 50%,
no crowding in upper and lower arches, rotated lower Rt & Lt 2nd premolars,
distally tilted LL lateral incisor &LL canine, partially erupted LL 1st premolar
&LL 2nd permanent molar, retained upper primary right 2nd molar with no
mobility and good bone level, rotated upper left 2nd premolar& Rt and Lt
central incisors, lower midline shifted to the left side 2mm.
• She has cl III ¼ unit molar relationship in Rt side, cl I in Lt side & cl I canine
relationship in Rt side, cl II1/2 unit in Lt side and increased curve of spee.

36. Problems list
Pathological problems:
Caries in UL 1st molar.
Patient’s concern:
I have unerupted tooth in my
lower jaw and rotated upper
anterior teeth.
Skeletal problems:
Class III skeletal pattern.
Soft tissue problems:
• Asymmetrical face.
Dental problems:
• Missing upper right 2nd premolar and
retained upper primary right 2nd molar.
• Partially erupted LL 1st premolar.
• Rotated lower Rt & Lt 2nd premolars.
• Distally tilted LL lateral incisor &LL
canine.
• Rotated upper left 2nd premolar& Rt and
Lt central incisors.
• Lower midline shifted to the right side
2mm.
• Molars are cl III ¼ unit in Rt side and cl I
in Lt side.
• Canines are cl I in right side and cl II ½
unit in left side.
• Increased curve of spee.

37. Treatment Aims
 Restoration of carious tooth.
 Correct the patient complaint.
 Accept skeletal cl III pattern.
 Accept soft tissue problems.
 Accept retained upper primary right 2nd molar and consider
future artificial replacement for the missing UR 2nd premolar.
 Achieve class I molar and cl I canine relationship in Rt&Lt side.
 Correction of rotated and tilted teeth.
 Correction of dental midline shift in lower arch.
 Correction of curve of spee.

38.  Treatment plan: “ Non- Extraction Case”
“ camouflage case ”
1. Refer patient to cons. clinic to treat carious tooth.
2. Oral hygiene instruction.
3. Lower holding arch.
4. Upper & Lower Fixed Appliance: using SWA technique.
“ Pre-adjusted edgewise, Roth prescription, slot 0.022”
5. Interproximal reduction of UR 2nd primary molar.
6. Retention:
( Long term) lower bonded retainer 3-3.
Upper bonded retainer 1-1.
( Short term) Upper and lower Hawley retainer appliance.

39. Justification
1. Camouflage :
 Patient passed the peak of growth spurt.
 Mild cl III skeletal.
 Good vertical facial proportion.
 No dental compensation.
 Normal overbite and overjet.
2. Non- extraction :
 Upper and lower arches with no crowding.
 Space can be gained by correction of rotated, tilted teeth and arch
wire expansion .

40. 3. Refer patient to cons. clinic to treat carious tooth.
4. Oral hygiene instruction to maintain stability of the
periodontal tissue.
5. Lower holding arch:
to prevent distal tipping of LL6 during opening space for
LL4 which may interfere with LL7 eruption, and maintain
cl I molar relationship.
As anchorage – to maintain molar relationship – to aid in
traction if the case necessitates .
6. Fixed appliance using Roth prescription:
 For 3D tooth movement.
 Average torque is needed.

41. 7. Interproximal reduction of UR 2nd primary molar:
Interproximal reduction 2.5mm(M&D sides) of UR 2nd
primary molar to achieve cl I molar relationship in the Rt side and
create accurate space for future artificial replacement of UR 2nd
premolar.
8. Retention:
(Long term )
Lower fixed retainer (3-3) to stabilize the position of anterior teeth and
prevent lower late labial segment crowding .
To maintain aligment of rotated LL3
Upper fixed retainer (1-1) to stabilize the position of central incisors.
(Short term)
Upper and lower Hawley retainer appliance for more settling and
stability.

42. Mechanics
• At direct bonding of U&L fixed appliance:
- Raising bite at lower Rt&Lt 6 –to disarticulate the occlusion in the early
phase of aligment
- lace back in all quadrents except lower left one ( 6 – 3) .
• At working arch wire (19 X 25 S.S):
- Open spring between LL3&LL5 to create space for LL4, achieve cl I
canine in Lt side and correct lower midline.
- Bonding of LL4 and piggyback for traction of partially erupted LL 4.
• At finishing stage:
- Remove lower holding arch.
- TMA wire ( 21 X 25 ) for root parallism.
- CSF .

43. Thank you