This case presentation summarizes the orthodontic treatment plan for a 15-year-old female patient. The patient presented with spaced upper teeth and a crossbite on the right side. The examination revealed Class II malocclusion, missing upper lateral incisors, and crowding. Treatment aims to widen the maxilla with rapid palatal expansion, align the arches with fixed appliances, and achieve a Class I occlusion. The plan includes expansion, molar derotation, fixed appliances, space maintenance for future prosthetics, and retainers.

1. Case presentation
Done by : Dr.Raed Al-Abbadi
3rd year orthodontic resident
Supervised by :
Dr.Ahmad Al-Tarawneh
Dr.Raed Al-Rbata
Dr.Nancy Sarayrah

2. Patient details
• name :Z.A
• Age: 15 years
• Occupation : Student
• Nationality :Jordanian

3. Chief complaint
• My teeth in upper jaw are spaced
• Something wrong with bite on right side of my mouth

4. • Medical history : denied any medical history
• Dental history : routine dental visits
• Trauma or habits : denied any .
• TMJ findings : nothing abnormal
• Displacement : yes

5. Extra oral examination
skeletal and soft tissue assessment
Frontal view
• Symmetrical face
• square face
• Competent lips

6. Extra oral examination
skeletal and soft tissue assessment
Frontal smile
• Thin lips
• Normal level occlusal plane (no canting).
• upper midline to facial mildline : diastema ??
Middle of it >>Coincident.
• lower midline to upper midline:
Lower midline shifted to right
• Increased buccal corridor
• Increased incisal show

7. Extra oral examination
skeletal and soft tissue assessment
Profile view
• Slightly convex profile
• normal nasolabial angle
• Average frontonasal angle
• Obtuse labiomental angle
• Average throat length
• Average throat angle
• Average lower facial height
• Average FMPA

8. Intra oral examination
Frontal
• Fair oral hygiene
• Class I incisal classification
• Reduced overjet
• Missing upper right and left lateral incisors
• Midline diastema
• Fluorosis on lower right lateral and canine
• Cross bite on right side ( seems on both but
lower tilited lingually )
• Reduced overbite
• Lower midline shift to right by 1-2 mm
• Normal oral mucosa.

9. Right side
• Class II ½ unit molar relationship
• Canine relationship full unit class II
• Caries on upper right central
• Cross bite on right side ( 3,4,5,6)
• Amalgam filling on lower right 1st
molar

10. Left side
• Class I molar relationship
• Canine relationship class II ¼ unit
• Caries on upper left central
• Retained lower left primary 2nd
molar
• Calculus on upper left 1st molar

11. Upper arch
• U shaped arch
• Spacing
• Missing laterals on both sides
• Rotated 1st molars
• Teeth present 1,3,4,5,6,7

12. Lower arch
• U shaped arch
• Normal tongue size
• Carious lower right 2nd molar
• Rotated lower right 2nd premolar
• Retained lower right primary 2nd molar
• Lower right 1st molars filled with
amalgam
• Teeth present 1-7

13. Study model analysis
Anteroposterior
• Class II canine on right
• Class II ½ unit molar
• Class II 1/2 unit canine
• Class I molar

14. OJ = 1mm on upper right central , 2mm on
upper left

15. Vertical
• Reduced overbite

16. Transverse
• Cross bite on right side.
• Lower midline shifted to right by
2mm .

17. Curve of spee
Left sideRight side
flat
4 mm depth

18. study model analysis
Maxillary arch
• Asymmetrical
• Inter canine width=28
• Intermolar width =43
• Rotated upper right and left 1st molar

19. study model analysis
mandibular arch
• Asymmetrical
• Inter canine width=30
• Intermolar width =43
• Rotated lower right 2nd premolar
• Retained lower left primary 2nd molar

20. Teeth widths
5 4 3 2 1 1 2 3 4 5
6.5 7 7.5 **6.9 9.5 9.5 **6.9 7.5 6.5 6.5
7 7 6.5 6 6 6 6 6.5 6.5 8
5 4 3 2 1 1 2 3 4 E
If open space applied to replace missing laterals
Mesio distal needed according to anterior Bolton ratio >>>
37/0.772 = 2x+34 >>>2x =47.9-34=13.9
X=13.9/2=6.95mm

21. Space analysis
• Upper: Available space =70 ,,, Required =74.5 ( need 4.5 mm )
• Lower : Available space =67.5,,, Required = 65.5 ( there is extra 2mm )

22. Royal college of London analysis
Lower arch Upper arch
Crowding / spacing +1( estimated after extraction of
lower left E )
+1 de-rototaion of lower right 5
-4.5
Leveling curve of spee -1.5(4mm) on left side 0
Arch width change 0 +5mm ( .5mm for every 1mm
increase in width )
10 mm expansion>>+5
Insicior A/p change 0 0
Angulation change 0 0
Inclination change 0 0
Result +0.5 +0.5

23. IOTN-dental component =great 4.h

24. IOTN aesthetic component =5

25. Opt
• amalgam filled lower right 1st molar
• Endo treated lower left 1st molar , flled with amalgam
• Wisdom teeth present in lower arch
• Missing upper laterals + lower left 2nd premolar
• Retained lower left primary 2nd molar , resorbed roots
• Mesial tilted lower left 1st molar

26. Lateral cephalogram
Normal Value
SNA 84 81 +- 3
SNB 81 78 +- 3
ANB 3 2-4
S-N/ANS-PNS 3.8 8 +- 3
Corrected ANB 3
MMPA 26.9 27 +- 3
UAFH 51.7
LAFH 68.2
LAFH % 56.8% 55 +- 2
U1/Mx 111 108 +- 6
L1/Mn 92 93 +- 6
IAA 128 133 +- 10
Wits Appraisal 2 0 + 1.77 mm

27. Case summary
• ZA is 15 years old medically fit female .She has attended the orthodontic
clinic with esthetic concern related to her upper teeth , her chief complaint
is spaced upper teeth and smoothing wronge on right side when biting , she
has fair oral hygiene and localized calculus related to upper left 6, she has
class I malocclusion on skeletal base class I with class II ½ unit molar on
right , class II full unit canine on right , class II 1/2 unit on left side , reduced
OJ , reduced OB , cross bite on right side ,deep curve of spee on right side ,
lower midline shifted to right by 2mm , midline diastema , spacing in upper
arch , complicated by missing upper right and left laterals and missing lower
left 2nd premolar, rotated lower right 2nd premolar , retained lower left
primary 2nd premolar .

28. Problem list• Oral health :
• Calculus on upper left molar
• Skeletal
• Constricted maxilla
• Soft tissue
• Slightly convex profile
• Obtuse labiomental angle
• Dental
• Increased buccal corridor
• Increased incisal show
• Reduced overjet
• Missing upper right and left lateral incisors
• Missing lower left 2nd premolar
• Carious upper right and left centrals
• Midline diastema
• Fluorosis on lower right lateral and canine
• Cross bite on right side ( seems on both but lower tilited lingually )
• Reduced overbite
• Lower midline shift to right by 1-2 mm
Class II ½ unit molar relationship & Canine relationship full unit class II on right side
Canine relationship class II ¼ unit on left side
Rotated upper 1st molars
Retained lower right primary 2nd molar
4 mm depth of COS on left side
Spacing in upper arch

29. Treatment aims
• Stabilization of periodontal condition.
• Treatment of carious teeth .
• Attain a normal width of maxilla
• Level and align arches.
• Correct centerlines.
• Correct crossbite on right side
• Normalize OJ and OB.
• Achieve Class I canine and molar relationship
• Open space for upper lateral incisors and maintain space of lower left 2nd premolar.
• Coordinate dental arches with good buccal interdigitation.
• Retain the corrected results.

30. Treatment plan
1. OHI
2. Treatment of carious teeth .
3. Rapid maxillary expansion.
4. Modified TPA.
5. upper and lower fixed appliance ( Roth 0.022’’)
Open space for upper laterals for future prosthesis
Consider disking lower left E
6. Retention : upper permanent retention and Hawley retainer with acrylic teeth in place of
laterals , lower Hawley retainer .

31. justification
• Rapid maxillary expansion with hyrax is good for her case because we want a skeletal effect more
than dental effect .
• Expand until we overcorrect the width ( palatal cusps of upper on lingual inclines of buccal
cusps of lower ) in anticipation of some relapse.( lee 1999)
• Modified TPA to derotate upper 1st molars .
• Fixed Appliance is needed because of
• Bodily teeth movement is required.
• Alignment of teeth.
• Close the extraction spaces.
• Preserve / correct teeth torque.
• Roth prescription slot 0.022 because teeth are in normal inclination and average torque is needed.
• Leave lower left primary 2nd molar as natural space maintainer for lower left 2nd premolar until
restore it with a prosthesis .
• Fixed retainers are indicated for long-term retention of the labial segments, particularly for generalized
spacing and for retention of a midline diastema (Proffit WR, Fields HW, Sarver DM. Contemporary
Orthodontics. (4th ed.), Chapter 17, St Louis, Mosby Elsevier, 2007)

32. The End