The patient presented with Class II malocclusion, crowding, midline discrepancies, and rotated teeth. The proposed treatment plan is to use a modified twin block appliance for growth modification followed by fixed appliances to align and level the teeth, close extraction spaces, and achieve Class I canine and molar relationships. Upon completion of active treatment, fixed retainers will be placed in the upper and lower arches for long-term retention.

1. D O N E B Y : D R . J A M A L B I N H A F I Z
S U P E R V I S E D B Y : D R . A H M A D A L T A R A W N E H
D R . J U M A N A T B A I S H A T
D R . B A S H A R A L M O M A N I
D R . A N W A R A L R A H A M N E H
Orthodontic Case Presentation

2. Patient Information
Name: R.K
Age: 14yrs
Occupation: Student
Marital status: Single
Residence: Amman
Nationality: Jordanian

3. Medical and Dental History
Medical History: Denied any medical problems
Dental History: Trauma 4 years ago on Upper Central and lateral
incisors with incisal filling on the Left central and
lateral incisors.
Habits: No Habits

4. Chief Complaint
“ ‫العلوية‬ ‫أسناني‬‫و‬ ‫بعض‬ ‫فوق‬‫طالعة‬
‫لبرا‬. ”
“ My upper teeth are
overlapped and
protruded.”

5. Extra Oral Photos

6. Skeletal Assessment
Anteroposterior:
Class II Skeletal Pattern

7. Skeletal Assessment
Vertical Assessment:
Average lower facial height

8. Skeletal Assessment
Transverse: P-A X-ray Symmetrical face

9. TMJ
 Signs of TMD (No clicking, crepitus, but find
tenderness and pain to palpation).
 Normal mouth opening.
 Displacement. *
 No Limitation in lateral movement.

10. Soft Tissue Assessment
Convex facial profile

11. Soft Tissue Assessment
Transverse: composite photographs
Facial Asymmetry

12. Soft Tissue Assessment
Lip tonicity and competence:
•Thick upper and lower lips
•Incompetent lips

13.  Frontonasal angle: 135⁰
(Normal 115⁰-135⁰)
 Nasolabial angle: 85⁰
(Normal 90⁰-110⁰)
 Labiomental angle: 95⁰
(Normal 114⁰-140)

14. Smile Aesthetics Assessment
Mini- estathetic
• 80% crown show when smiling
• No gingival show of the upper
gingiva.
• Smile extends to mesial surface
of first premolar on the right side,
and to distal surface of canine on
left side.

15. Smile Analysis
• Buccal corridors: narrow
• The smile arc: Incisal edges
of upper anterior teeth are
not parallel to the upper
border of the lower lip
• Flat smile arc.
• Less attractive smile.

16. Tooth Proportions
Micro – esthetic:
Golden proportion for maxillary
anterior teeth is 55%
Height:width
1:9 90%

17. Gingival Height, Connectors
 Gingival level: Low gingival
level of canines.
 Normal connectors

18. Intra Oral Examination

20. Intra Oral Examination
• Fair oral hygiene with mild gingivitis and dental plaque.
•Composite filling on upper left 1,2 and upper Rt. 4
•White spot lesion on upper Rt. 5.
• Thin attached gingiva in lower ant. segment.
• Teeth Present in oral cavity (permanent dentition)
7 6 5 4 3 2 1 1 2 3 4 5 6 7
7 6 5 4 3 2 1 1 2 3 4 5 6 7

21. Lower Arch
 U-shaped lower arch
 Anterior segment:
 Will alignment anterior segment
 Labially inclined
 Buccal segment:
 Lingually inclined lower left 4,5
 Rotated lower right 5

22. Upper Arch
 U-shaped arch.
 Anterior segment:
 Rotated upper incisors with
mild crowding .
 Upper left canine palatally
tilted.
Normal Buccal segment

23. Anterior Segment Relationship
 Class II div. I incisor relationship
 Midlines discrepancy; lower shifted 3mm to Rt. And
upper shifted 1mm to Lt.
• Overjet = 6.5 mm
 Overbite = 40% Complete on teeth

24. Buccal Segment Relationship
 Molar relationship: R: Class II L: Class I
 Canine relationship: R: Class II L: Class I
 Scissor bite in Lt.4&5

25. Functional Asymmetry (dental displacement)
C.R
C.O

26. Study Model Analysis

27. Study Model Analysis
 Anteroposterior:
Canine: Class II
Molar: Class II
Canine : Class I
Molar: Class I

28. Study Model Analysis
 Transverse
Midlines discrepancy.

29. Study Model Analysis
 Vertical
O.B= 40% deep bite complete on the teeth.

30. Study Model Analysis
Right side: 1 mm Left side: 3mm
Curve of Spee:

31. Study Model Analysis

32. Study Model Analysis
Lower arch
 U shaped arch form
 Slight Dental Asymmetry
 Intermolar width: 42mm
(Noraml 41.1 mm)
 Intercanine width: 25 mm
(Normal 24.4mm )

33. Study Model Analysis
upper arch
 U shaped arch form
 Slight Dental Asymmetry
 Intermolar width 44mm
(normal 44.3)
 Intercanine width 32 mm
(Normal 31.3)

34. Space Analysis
1177889.59.57877.511U
654321123456
1077.5765.55.5677.5710L
Upper Arch:
Space available 75 mm
Space required 78.5 mm
-3.5 mm (mild crowding)
Lower Arch:
Space available 67 mm
Space required 66 mm
1 mm (spacing)

35. Bolton Analysis
1177889.59.57877.511U
654321123456
1077.5765.55.5677.5710L
Anterior Bolton ratio= 37/50= 74%
(normal value: 77.2± 1.65%)
Overall Bolton ratio= 86/100.5= 85.5%
(normal value: 91.3± 1.91%)

36. Royal London Analysis
Upper ArchLower Arch
-3.5 mm+1 mmCrowding/Spacing
00Angulation change
0-1Leveling curve of Spee
0-2Inclination change
-80Incisors A/P change
00Arch Width
-11.52-Total

37. Visualized Treatment Objectives
 Midline-Molar relationship
R LMolar
Cl II
Molar
Cl I
Midline

38. Visualized Treatment Objectives
 Lower arch discrepancy
0
0
0
0
-1 -1
0 -1
-3 +3
-4
-4
+1
+1
Crowding 3*3
6*6
Protrusion
Curve of
Spee
Midline
Total 3*3
6*6
R L

39. Visualized Treatment Objectives
 Anticipated treatment change
Midline MolarMolar CuspidCuspid

40. Pre-Treatment IOTN
Dental Health Component
 Grade 4 a
Increased Over jet greater
than 6 mm and less than 9 mm

41. Pre-Treatment IOTN
Aesthetic Component
 Grade 2

42. Radiography Analysis

43. Variable Pre-
Treatment
Normal value
SNA 85º 81 ± 3
SNB 79º 78 ± 3
ANB 6º 3 ± 2
S-N/MX 4º 8 ± 3
ANB* - -
MMPA 24º 27 ± 3
FMA 21˚ 28 ± 3
LFH 56% 55 ± 2
Jarabak ratio 64% 61± 2
U1/Mx 116 109 ± 6
L1/Mn 106º 93 ± 6
IIA 110º 133 ± 10
Wits
Appraisal
+4 mm 1 ±1.9 F

44. Panoramic Radiograph
All teeth are present including all 8’s
Right side ramus length = 69.1
Left side ramus length =69.3

45. Diagnostic Summary
 R.K is a 14 year old female, denied any relevant medical problem and multiple
dental fillings with fair oral hygiene, complains of “My upper teeth are
protruding and overlapping”.
 She has a class II/I incisor relationship based on class II skeletal pattern,
average lower facial height, incompetent lips, and a mildly convex facial
profile, acute labiomental and nasolabial angles with slight facial asymmetry.
 Cant of maxilla ,O.J of 6.5 mm, O.B average complete to the teeth, mild
crowded upper arch. Upper midline shift to the left 1 mm and lower midline
shift to the right 3 mm. Scissor bite on the lower left 4,5. Molar relationship is
class I on the left side and class II on the right side, canine relationships is
class I on the left side and class II on the right side.
 Complicated by lower dental displacement to the right, Proclined lower labial
segment, Rotated upper left 1,2 and right 2, lower right 5. Lingualy tilted lower
left 4,5, Deep curve of spee in the lower Lt. side, and anterior Bolton
discrepancy .

46. Problem List…
 Pathological:
Gingivitis and plaque deposition, white spot lesion on upper Rt. 5
 C/C “Protruding and overlapping my upper teeth”
 Skeletal:
Class II skeletal pattern
 Soft tissue:
Slight facial asymmetry
Incompetent lips
Convex facial profile
Acute labiomental and nasolabial angles

47. Problem List
 Dental:
Cant of maxilla
Class II div. I incisor relationship
Overjet 6.5 mm.
Scissor bite on the lower left side 4,5,.
Displacement of lower arch.
Upper midline shift to the left 1 mm and lower midline shift to the right
3mm
Lower incisor proclined
Lingually tilted lower left 4,5
Rotated upper left 1,2, right 2 and lower right 5
Class II full unit molar and canine on the Rt.side.
Mild upper arch crowding
Deep curve of spee on the lower left side of arch.
Anterior bolton discrepancy

48. Treatment Aims
 Improve oral hygiene.
 Address c/c of the patient’s
 Skeletal:
 Accept mild class II SK pattern
 Correct maxilla cant.
 Soft tissue:
 Accept Slight facial soft tissue
asymmetry
 Achieve competent lips
 Accept convex profile
 Correct labiomental and nasolabial
angles
Dental:
 correct dentoalveoular Cant of maxilla
Achieve class I incisor relation.
Correct Over jet.
Correct scissor bite and displacement .
Correct rotated teeth.
Correct mild crowding in upper.
Correct upper and lower midline shift.
Correct inclination of lower anterior segment.
Achieve class I canine in the Rt. Side and
maintain class I in the Lt. side.
Achieve class II molar in left side and
minatine class II in the Rt. Side.
Level curve of spee.
Correct Bolton discrepancy.
Maintain the correct result.

49. Treatment Plan
(GROWTH MODIFICATION)
(Hybrid Appliance)
1. OHI.
2. Modified Twin block appliance(Hybrid Appliance).
3. Upper and lower fixed app.
4. Re-evaluation for Extraction pattern.
5. Retention:
 Long term: Upper and lower fixed retainer from 3-3 &(SCF )
 Short term: Upper and Lower H.R

50. Justification (Extraction)
DENTAL:
CRITERIA VALUE NORMAL V. PRO/CON
Tooth size- arch length Upper : -3.5 mm
Lower: +1
8-11 mm crowding CON. Ext
Curve of Spee L:3mm,R:1mm More than 6 severe CON. Ext
Bolton discrepancy 85% If 4* more then extract CON. Ext
Peck & Peck L1:80%
L2: 75%
L1:88-92 (if less extract)
L2: 90-95 (if less
extract)
PRO. Ext
PRO. Ext
Irregularity index 0 mm X>6.5 mm extract CON. Ext
Incisor-Man. Plane angle 105˚ 85˚-95˚ PRO. Ext
Frankfurt-Man. Incisal angle 55 60˚-75˚ PRO. Ext
Upper incisor to NA 6mm, 27.5˚ 4mm anterior, (22-25) PRO. Ext
Lower incisor to NB 7 mm, 37˚ 4 mm anterior ( 22-25) PRO. Ext
Lower incisor to A-pog 4 1-3 mm anterior to it PRO. Ext

51. Justification (Extraction)
SKELETAL
CRITERIA VALUE NORMAL VALUE PRO/CON NON-
EXTRACTION
FMA 21˚ 20˚-30˚ CON. Ext
SN-MP 31˚ 31˚-34˚ CON. Ext

52. Justification (Extraction)
SOFT TISSUE
CRITERIA VALUE NORMAL VALUE PRO/CON
NON-EXTRACTION
POSITION OF
UPPER LIP –E LINE
3.5mm 2mm ±3 CON. Ext
POSITION OF
LOWER LIP- E LINE
2 mm 2mm ±3 CON. Ext
NASOLABIAL
ANGLE
85 90˚-115˚ PRO. Ext
UPPER LIP
MORPHOLOGY
12mm≠
15mm
(strained)
3 mm belowe sk A
point =
Vermilion to labial
surface of teeth ±1
PRO. Ext.

53. Justification
OTHER FACTORS
CRITERIA VALUE PRO/CON NON-EXTRACTION
GROWTH Non growing patient PRO. Ext
MIDLINE In-coincident PRO. Ext
PATIENT PEREFERENCE Extraction PRO. Ext

54. Justification
 Growth Modification: (Modified twine block)
 Mild Skeletal class II.
 Cant maxilla
 Dentoalveoular effect
 Fixed Appliance
 Alignment and leveling of teeth
 3-D tooth movement( bodily movement)
 Closing of spaces and retraction of anterior
teeth
 Upper and lower arch coordination
MBT prescription slot 0.022:
High torque is needed to retract the
anterior teeth
Less anchorage demand.

55. Justification
 Retention:
 Upper fixed retainer: crowding ,rotation and midline
shift.
 Upper CSF: rotated incisors
 Upper H.R: to prevent re opening Ext. space and
improve settling.
 Lower H.R.: stabilize dental arch and improve
settling.
 Lower fixed retainer: prevent late anterior mandibular
crowding and midline shift.

56. Treatment Details and Mechanics
1. Full records
2. Impression for modified twin block
3. Delivery of modified twin block(wear full time)
After we get true molar and canine relationship
by dentoalveoular effect:
11. Separators on upper and lower 6’s
12. Band selection and cementation on upper and lowe
6’s
13. Upper and lower direct bonding of fixed appliance
MBT slot 22.

57. Treatment Details and Mechanics
15. Aligning and leveling upper and lower arch using wires
0.014, 0.018 and 0.017*0.025 NiTi
16. Working upper wire 0.019*0.025 SS (expanded)
17. Re-evaluat for extraction pattern
18. Retraction of upper anterior teeth into class 1 by close
coil spring.
20. Steel ligation from 3-3 in the upper arch.
21. Close remaining space from post- anterior.
22. Interproximal reduction of lower ant. teeth and
reshaping of upper incisors.
23. Finishing and detailing using 0.021*0.025 TMA wire

58. Treatment Details and Mechanics
25. settling .
26. Retention:
 Upper and lower fixed retention from 3-3 using
multistranded 17.5 mil SS.
 Debonding of upper and lower fixed app.
 Upper impression for upper and lowerH.R.
26. Insertion of upper and lower H.R.

60. The End
Thank You...