A 14-year-old female patient presented with irregularly placed and crowded upper and lower front teeth with poor smile display. Her examination revealed Class I malocclusion with crowding in the maxillary and mandibular anterior segments, retroclined lower incisors, and maxillary midline shift. Treatment objectives were to relieve crowding, procline the retroclined teeth, extrude maxillary incisors to improve smile display, and correct the midline shift through non-extraction therapy over 11 months.

1. CASE PRESENTATION
A patient by name Monika, aged 14 years residing in Davangere District,
came to the department with chief complaint of Irregularly placed upper and
lower front teeth along with poor display of teeth during smile
No significant information was elicited on recording prenatal and postnatal
history and childhood diseases.
No history of oral habits and injuries.
Familial malocclusion History:- Has two Younger brothers with similar
type of teeth arrangement as reported by her.
She is internally motivated with positive attitude towards orthodontic
treatment and is citing esthetics is the main reasons for taking orthodontic
treatment.
Pubertal Status:- Post pubertal by 8 months
Physical Examination :- She is moderately built with 5’3” in height, weighs
74 kgs with endomorphic body type.www.indiandentalacademy.com

2. Extraoral Examination :-
Mesocephalic, Brachyfacial, Interlabial
gap of 0mm, Decreased Length of nose,
Decreased lower anterior face height
Cuspid type of smile, Maxillary midline
shifted to right by 1mm, Poor display of
teeth during smile characterized by 4mm
of crown length exposure with no
exposure of gingiva
Concave profile, anterior divergence,
Nasolabial angle of 1030
, Deep
mentolabial sulcus , Hyperactive Mentalis
, obliterated throat neck angle
due to sub mental fat deposition,
Decreased length of nose
Dished - in appearance of lower anterior face due to prominent
chin and excessive deposition of fat in cheeks
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3. Lower anterior face height is decreased by 4mm
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4. Functional Examination :- She is found to have Nasal respiration
 Food Lodgment in maxillary and mandibular anterior segments
No abnormality is detected in deglutition. TM Joint appears normal
She has 3mm of freeway space and 1mm of incisor crown length exposure during
speech and 4mm of crown length exposure during smile.
Intraoral Examination
Oral Hygiene status is fair , Brushes once
daily, Maxillary midline shifted to right by
1mm, Crowding seen in anterior segment
with overlapping right maxillary central
incisor.
Class –I molar relation & canine relation,
Retroclined mandibular incisors with crowding
7654321 1234567
7654321 1234567
# Maxillary left central incisor (Ellis class -II )
Teeth Present
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5. Class I molar and canine relation, #
Maxillary central incisor, retrocline
mandibular incisors.
Maxillary Dental Midline shift to right by
1mm, Crowding in anterior segment with
overlapping central incisors, tapered arch
form , Normal depth of palatal vault.
crowding in anterior segment, retroclined
incisors , square arch form.
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6. RADIOGRAPHIC RECORD
Examination of O.P.G. Hand wrist radiograph
Closed apex of canines approximate
dental age 14 to 15 years
PP3u completed, start of MP3u , 8th
stage of pubertal growth spurt,
approx. age 13.9
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7. CEPHALOMETRIC ANALYSIS
Soft Tissue Analysis
Facial Angle : 990
Nose tip to H-Line : 7 mm
Upper Sulcus depth : 4mm
Skeletal convexity at point – A : -2mm
Upper lip strain : 2mm
Upper lip curvature : 4mm
Soft Tissue chick Thickness : 15mm
Relation to TVL
Upper lip anterior : + 3mm
Lower lip Anterior : 0mm
A Point ‘ : 0mm
B Point’ : - -5.5mm
Pogonion’ : +1.5mm
S Line
Upper lip : 0.5mm retrusive
Lower LIP : -3mm retrusive
Skeletal Relationship of maxilla
SNA : 80.50,
, Ext.of Max.Base : 46mm
N Perp. To Pt. A : +1mm, Eff.Max Lng:87
NA – TH : 900
, N-A (11 HP) –3mm
PNS-ANS : 48mm
Mandibular Incisors
1 – NB : 1mm
1 – NB : 140
1 – APO Line : 0mm
IMPA : 89 0
TVL Md1 : -15mm
Max.1 to Mand. 1 - 1360
Relationship of Mandible
N Perp. Pog : +5 mm N Pog – TH : 920,
SNB : 80.5, Eff.Mand.Lng: 114mm
SND : 770 ,
N-B (11 HP) –3mm,Go-Pg : 72
N-Pg(11HP) 0mm, Ext. of Mand.: 73mm
Articular angle : 1370,
Saddle Angle 1250
B-Pg : 8.2mm
Relationship of Maxilla, and Mandible
Go Me – FH : 150
Go Gn – Sn : 250
Gonial angle : 1180
Basal Plane angle : 150
Anterior to Posterior face height ratio : 76%
Pn to Occlusal Plane : 800
Dental - Maxillary Incisors
1 – NA : 5mm
1 – NA : 290
1 – Pt A : 5mm
1 – SN : 1050
1 – PP : 660
TVL Mx1 : -11mm
Upper 1 – NF : 22mm
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8. MODEL ANALYSIS
Bolton Tooth Ratio
Anterior ratio (81%) indicates mandibular excess of 2mm
Overall Tooth ratio (93.1%) indicates Mandibular excess of 1.4mm
Careys / Arch Perimeter Analysis
Crowding in Maxillary arch of 5mm and mandibular arch of 7.2mm
Ashley Howe’s Analysis
P.M.B.A.W % = 40% , (Border line case )
DIAGNOSIS
14 year old post pubertal female patient by name Monika is diagnosed as a case of
skeletal class-I, hypodivergent jaw pattern characterized by anticlockwise rotating
mandible,decreased lower anterior face height, prominent soft tissue chin button,
crowding in mandibular and maxillary anterior segment with intruded maxillary
incisors, Maxillary midline shift to the right by 1mm.
DIFFERENTIAL DIAGNOSIS
Class – III skeletal base
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9. Treatment objectives
 To relieve crowding
To procline retroclined mandibular and also maxillary incisors
 To extrude the intruded maxillary incisors and incisor display
To correct maxillary dental midline shifts.
To reduce the prominence of chin
Muscle exercises to relieve hyperactive mentallis activity
Treatment plan :
Non-extraction line of treatment.
Banding of Ist
and IInd
molars
Continuous arch Mechanics to be employed to proclined and extrude the
maxillary incisors, Brackets on anterior teeth to be placed gingivally
In mandibular arch proximal stripping to be done in premolars followed by tight
lace back and segmental approach followed by continious arch mechanic to
procline retroclined lower anteriors.
Opening arch wires – 0.014” HANT arch wires, without lace back and bend
backs in maxillary arch
Reshaping pogonion with myotomy to reduce the prominence of chin button.
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10. Max1 -PP 61o
Mand1 - MP 99o
Max1-Mand1 - 124o
Nasolabial angle - 96o
Treatment duration :
> Leveling aligning --> 4+2 months.
> Extruding Anteriors --> 2 months
> Midline correction --> 1 month.
> Finishing and detailing --> 2 months.
Total duration -> 11 months.
Retention :
Removable wraparound retainer in maxillary & mandibular
arches along with fixed retainer in mandibular arch
6 months full time wear, 4 months night only, 2 months
alternate night, 2 months once a week.
Maxillary Mandibular
R L R L
-2.5 -2.5 -3.5 -3.5
+2.0 +2.0 +3.5 +3.5
+1.5 +1.5 0 0
+1.0 -1.0 0 0
0 0
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11. ANTICIPATED TREATMENT CHANGE
0
1 1 0
0 1 0 1
0
1
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