This document presents the case of a 12-year-old male patient named Punith who is seeking orthodontic treatment. He has forwardly placed upper and lower front teeth, a family history of malocclusion, and a tongue thrust habit. Clinical examination found spacing in his upper and lower anterior teeth, a class I molar relationship, and 7mm of lip incompetence. Radiographs and cephalometric analysis indicate he has a developing vertical skeletal dysplasia. The treatment plan is to use myofunctional exercises and appliances to correct his tongue thrust, achieve lip competence, improve facial profile, and align his teeth through extraction and the use of sectional wires and a high pull headgear.

1. INDIAN DENTAL ACADEMY
Leader in continuing dental education
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2. CASE PRESENTATION
A male patient named Punith, aged 12 years came to the department with
chief complaint of forwardly placed upper and lower front teeth .
No significant information was reveled on prenatal and postnatal history.
No history of oral habits,
Childhood diseases – He has history of epileptic attack at the age of 1
½ & 3 yr age. He was under medication , but now stopped after physicians
advice.
Familial malocclusion History:-Yonger brother & mother has bimaxillary
protrusion
He is internally motivated with positive attitude towards orthodontic
treatment and is citing esthetics as the main reasons for taking orthodontic
treatment.
Pubertal Status:- Pre-pubertal
Physical Examination :- He is moderately built with 4’5” height, weighs 26
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kgs with mesomorphic body type.

3. Extra oral Examination :-
Mesocephalic, Leptoprosopic,
Interlabial gap of 7mm
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Convex profile, Nasolabial angle of 87 0

4. Complex type of smile, incisor exposure
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of 7 mm during speech & 9mm on smile,

5. Face follows the rule of fifths & lower 1/3rd
of face is more
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6. Functional Examination :- He is found to have Nasal respiration
No abnormality is detected in respiration & speech. TM Joint is normal
both in open & closed mouth positions.
He has tongue thrust during swallowing.
He has 2mm of freeway space and 7mm of incisor crown length exposure
during speech and 9 mm of exposure during smile.
Intra oral Examination
•Oral hygiene status is fair; frenal attachments are normal; oral mucosa,
gingiva and tongue are normal.
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7. Teeth Present
6EDC21 12CDE6
76ED321 123DE67
Spacing in the U/L anteriors with lower
midline shifted to right side by 0.5 mm.
Class 1 molar relation
Class 1 molar relation
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8. Proclined upper anteriors with spacing
& ovoid arch form , Normal depth of
palatal vault.
Spacing in anterior segment, mild
proclination of mandibular incisors , ovoid
arch form.
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9. RADIOGRAPHIC RECORD
O.P.G.
Hand wrist radiograph
7’s in stage F stage &
3, 4, 5 in stage F stage
Dental age 11.5 years
Cervical vertebrae:
1st stage
85 to 100 % growth
remaining
PP2, 1st stage 3yrs from pubertal
growth spurt, approx.skeletal age
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10.6 Yrs.

10. CEPHALOMETRIC ANALYSIS
Relationship of Mandible
Soft Tissue Analysis
N Perp. Pog :(0 to -4 mm)
-7mm
N Pog – TH ( 87.5+/-2.5)
1040
Facial Angle :(900)
880
Nose tip to H-Line : (12mm)
3.5mm SNB : 80
850
Upper Sulcus depth : (5mm)
17.5mmEff.Mand.Lng: (114.4+/- 4.3)
106 mm
Skeletal convexity at point A (-2) +7mm SND : (76)
74
Upper lip strain : (2mm)
Ext. of Mand.:(76mm)
69mm
Saddle Angle :(123+/-5)
122
Y Axis :(66)
700
2.5
Upper lip curvature :(2-5)
7mm
Soft Tissue chin
Thickness : (10-12)
0 ,
0
13mm Relationship of Maxilla, and Mandible
Relation to TVL
Go Me – FH : (26+/-4)
300
Upper lip anterior : (3.3+/-1.7)
3mm
Go Gn – Sn : (32)
360
Lower lip Anterior : (1+/- 2.2)
-2mm
Gonial angle :(128+/-7)
1310
A Point ‘ : ( -.3+/-1)
0.5mm Basal Plane angle:(25)
B Point’ : (-7.1+/- 1.6)
-15.5mm Anterior to Posterior
Pogonion’ : (-3.5+/- 1.8)
-15mm face height ratio : (62-65%)
33.50
62.5%
Skeletal Relationship of maxilla
Maxillary Incisors
SNA : (820)
850
1 – NA : (4)
9mm
Ext.of Max.Base : (50.3)
47mm
1 – NA : (22)
340
N Perp. To Pt. A :(0+/-2)
+4mm,
1 – Pt A : (4)
10mm
Eff.Max Lng:(92.1+/-4.1)
86mm
1 – SN : (102+/-2)
1180
NA – TH : (90+/-3)
920
1 – PP : (70+/-5)
57.50
Angle of Inclination : (850)
890
TVL Mx1 :(-12.1+/- 1.8)
-6mm
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Mandibular Incisors
1 – NB : (4)
11.5mm
1 – NB : (25)
340
1 – APo Line :(1 to 2)
6mm
IMPA : (90+/- 3)
1000
TVL Md1:(-15.4+/-1.9)
-13mm
Max.1 to Mand.1: (131)
870

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12. MODEL ANALYSIS
Tanaka & Johnston and Moyers Analysis
Maxilla has approximately 2-3 mm spacing in each quadrant, but mandible do not
have.
DIAGNOSIS
A 12 yr old male patient named Punith is diagnosed as a developing vertical
skeletal dysplasia with Dental class I molar relation; upper & lower ant. spacing with
bimaxillary dentoaloveolar protrusion; with lip incompetence of 7 mm, and tongue
thrust habit..
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13. TREATMENT OBJECTIVES
To restrict the clockwise rotation of mandible.
To correct tongue thrust habit
To achieve lip competence.
To improve facial profile
To close spacing in maxillary and mandibular arch
To correct midline
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14. TREATMENT PLAN :
Myofunctional exercises for
correction of tongue thrust
Vertical holding appliance in
maxilla
Extraction of
canines in maxilla
deciduous
Sectional align followed by
utility arch in Maxilla &
Mandible till buccal teeth
erupts
Retraction of upper anteriors
in utility arch
High pull head gear during
circumpubertal growth period
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