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1. Orthodontics Case Presentation
Supervised by:
Dr. Ahmad Al-Tarawneh
Dr. Raghda Al-Shmmout
Dr. Anwar Al-Rahamneh
Dr. Hanan Al-Habarneh
Done By : Dr. Yasmin Hzayyen - 2nd Year Resident

2. Personal Data
• Patient’s initials: Ghadeer Yahya
• Gender: Female
• Age: 14 Yrs-7 months
• Career: Student
• Nationality: Jordanian

3. Chief Complaint
• “ I feel that my upper teeth are too forward” she pointed at her
upper laterals
• “ Lower teeth too inside”

4. Medical & Dental History
• Medical History:
Denies any medical problems
• Dental History:
Previous visits to dental clinic for check-ups
When she was 8 years old she had fissure sealants

5. History
• Trauma: No history of dental trauma
• Habits: No previous or on going habits mentioned or noticed
• Motivation: Patient is motivated (self- motivation)

6. Extra-oral Photos

7. Intra-oral Photos
OJ= 0.5mm
0B= edge-
edge
decreased
Complete
to tooth
structure

8. Intraoral Photos

9. Study Models

10. Panoramic View

11. CEPHALOMETRIC
ANALYSIS
SNA 83 81⁰ ± 3⁰
SNB 79 78⁰ ± 3⁰
ANB 4 3⁰ ± 2⁰
Sn-Mx 5.3 8⁰ ± 3⁰
Corrected ANB 3
Wits appraisal +3 0 (+-1.9) mm
(F)
MMPA 35 27⁰ ± 4⁰
FMPA 36.5 28⁰ ± 4⁰
UAFH 53mm
LAFH 79mm
AFH Ratio 60% 55% ± 2%
UI-MX 108 109⁰ ± 6⁰
LI-Mn 103 93⁰ ± 6⁰
IIA 108 135⁰ ± 10⁰
Jarabak ratio 64% 59-63%

12. Facial and Dental Appearance
• 1. The face (macro-esthetics)
• 2. Smile Frame (mini-esthetics)
• 3. Teeth (micro-esthetics)

13. Extraoral Examination (Macro-esthetics)
• Anteroposterior assessment:
Maxilla to mandible relationship
• Vertical assessment:
Facial thirds
Angle of lower border of mandible to the maxilla
• Transverse assessment:
Facial asymmetry
• Soft tissue assessment

14. Anteroposterior Assessment
• Slightly convex

15. Anteroposterior Assessment
• Zero meridian line
• >(0+/-2) to soft tissue Pogonion
2mm
A vertical line dropped from soft tissue nasion,
perpendicular to the Frankfort horizontal plane. Ideally
passes through the soft tissue pogonion ( 0 +/- 2 ) to
zero meridian and 8mm posterior to Sn. • Variation
indicates Retrusion / Protrusion in mandible and maxilla
separately.

16. Vertical Assessment
Clinical increase in LFH
Upper lip in the upper 1/3 , lower lip in the lower 2/3 of lower
third FMPA

17. Transverse Assessment
• The pt has mild asymmetry
• Facial midline showing
alignment of the middle part
of the upper lip at the vermillion border and
chin point

18. Transverse Assessment
• Equal medial and lateral
Fifths
• -Inter-pupillary distance = the width of the
mouth.
• -The width of the nose = the central fifth

19. Soft Tissue Examination
• Normal tongue size and function
• Frontonasal Angle:(115-135)
135 normal
• Nasolabial Angle: (90-110)
96 normal
• Labio-mental Angle: (110-130)
93 Acute

20. Facial and Dental Appearance
1. The face (macro-esthetics)
2. Smile Frame (mini-esthetics)
3. Teeth (micro-esthetics)

21. Smile Analysis
The smile index =
inter-commisure width/ inter-labial gap on smiling
=7.0/1.4 = 5mm
(Ackerman et al )1998
** The lower the smile index, the less youthful the smile appear
The buccal corridor ratio=
Inter commissure width-visible maxillary dentition)/inter
commissure width x 100%
(7-6)/7%=14%
Medium- smile
(Frush and Fisher) 1958

22. Facial and Dental Appearance
1. The face (macro-esthetics)
2. Smile Frame (mini-esthetics)
3. Teeth (micro-esthetics)

23. Teeth (micro-esthetics)
• Slightly reduced
incisal show

24. Tooth Proportions
• Gingival lines:
• Central incisors show almost
same gingival level
• UL2 high gingival line
• UR2 gingival margin lower
than centrals

25. Intraoral Examination

26. Intraoral Examination
• Dentition status: Permanent dentition
• Teeth present 765421 124567
7654321 1234567
• Caries: Clinically, LR 6; buccal pit caries

27. Intraoral Examination
• Fair Oral Hygiene.
• Plaque accumulations on the
buccal surfaces of lower cuspids
and all posterior teeth.

28. Intraoral Examination
• Central Lines:
Co-incident
• Incisors classification:
Class III
• OJ:
0.5 mm
• OB:
Edge – edge; complete to tooth structure
• Crossbites:
U2s –L3s (edge to edge)
• No Displacement

29. Intraoral Examination
Class I Molar Relationships Class I Molar Relationship

30. Upper Arch
• U-shaped, spacing UR1-UR2, UR2-UR4,
UL1-UL2, UL2-UL4
• No canines shown
• Normal incisors inclination
• Rotated UR4,UR5,UL4

31. Lower arch
• Symmetric , mild crowding
in the anterior region
• Proclined LLS

32. Study Models Examination

33. Front View
• Midlines coincident

34. A-P view
• Class III Incisal relation
• Decreased complete overbite.

35. Upper Cast Occlusal
• Interpremolar width =
35mm (average)
• Intermolar width =
47mm (Increased)

36. Lower Cast Occlusal
• Interpremolar width =
31mm (average)
• Intermolar width =
40mm (almost average)

38. Curve Of Spee
Rt : 2mm Lt: 2mm

39. Estimation of Canines Size
• Tanaka and Johnston :
• ½ the MD width of incisors +11mm= width 3,4,5
(23/2) +11= mm
22.5= U3 + 14 ------ U3= 8.5mm

40. Space Analysis
• Upper arch:
• Symmetric
• Space available= 66 mm
• Space needed= 73 mm
• Moderate crowding 7 mm

41. Space Analysis
• Lower arch:
• Symmetric
• Space available= 65 mm
• Space needed= 66 mm
• Mild crowding of 1mm

42. Tooth Size Analysis (Bolton)
• Bolton Analysis:
• Σ Lower anterior teeth widths = 37mm
• Σ Upper anterior teeth widths = 47mm
• Σ Lower all teeth widths = 89
• Σ Upper all teeth widths = 96.5
• Overall ratio= 89/96.5 * 100%= 92.2%
n= 91.3 +/- 1.91
• Anterior ratio= 37/47 *100% = 78.7%
n= 77.2 +/- 1.65
6 5 4 3 2 1 1 2 3 4 5 6
12 7 7 8.5 6 8 8 6 8.5 7 7 11.5
6 5 4 3 2 1 1 2 3 4 5 6
12 7 7 7 6 5.5 5.5 6 7 7 7 12

43. Royal London
Lower arch Upper arch
Crowding/Spacing -1 -6
Angulation /inclination
change
-3mm 0
Leveling curve of Spee 0 0
Arch width change 0 0
Incisors A/P change 0 0
Total -4mm -6mm

44. Panoramic Interpretation
-All wisdom teeth buds are present
-Upper canines show good prognosis
-No other apparent pathologies

45. Localization of Impacted upper canines
1. Inspection
2. Palpation
3. Radiography

46. Inspection
• Delayed eruption
• Flared laterals
• No mobility or tenderness in
lateral incisors

47. Palpation
• Absence of buccal bulge for both canines
• Left ruggae area is larger than right (minimal
difference)

48. Radiography : Vertical parallex
• Right upper canine: palatal Left upper canine: within the arch

49. Prognosis
1. Canine angulation to the midline
2. A-P position of the canine apex
3. Vertical height of the canine crown
4. Canine crown overlap to the adjacent incisor
“Power and Short”

50. Canine angulation to the midline
• Grade 1=0-15 degree UR3
• Grade2=16-30 degree UL3
• Grade 3= more than 30
• Average UL3 - Good UR3

51. A-P position of the canine apex
• Grade 1: Above the region of the
canine position UR3
• Grade 2: Above the upper first
premolar region UL3
• Grade 3: Above the upper second
premolar region
• Average UL3 – Good UR3

52. Vertical height of the canine crown
• Grade 1: Below the level of the
CEJ
• Grade 2: Above the CEJ, but less
than half way up the root UL3
• Grade 3: More than half way up
the root, but less than full root
length UR3
• Grade 4: Above the full length
of the root
Average UR3 – Good UL3

53. Canine crown overlap to the adjacent incisor
• Grade 1: No horizontal
overlap UL3
• Grade 2: Less than half the
root width UR3 (minimal)
• Grade 3: More than half, but
less than the whole root
width
• Grade 4: Complete overlap
of root width or more
• Average UL3 –Good UR3

54. IOTN-dental health component
5i Impeded
eruption of
teeth ( with the
exception of
third molars)
owing to
crowding,
displacement,
the presence of
supernumerary
teeth, retained
primary teeth
and any
pathological
cause.

55. IOTN- Esthetic component
• N/A

56. Diagnostic Summary
• G.Y 14yrs- 7 months old female pt , MF, complaining of poor
position of her anterior teeth. Patient has fair OH, a class III
malocclusion on a class I skeletal base with increased vertical
dimension. She has a mild asymmetrical face with minimally
compromised smile esthetics; Complicated by impacted upper
canines. She has a class I M.R on both sides.
OJ is 0.5mm , OB is decreased (edge-edge). Upper & Lower
midline is co-incident. Upper arch has moderate crowding, and
mild crowding in the lower.

57. Problem List
Pathological problems:
– Pathological problems:
• Poor OH
• Plaque accumulations on the labial surface of the lower 3s and
posterior teeth
• Buccal pit caries in the LR6
•
Developmental problems:
Patient’s concern: the position of teeth
• Smile esthetics: compromised smile complicated by
impacted canines
• Soft tissue: Clinically slightly convex profile
• Acute labiomental angle
Alignment and symmerty:
o Slightly proclined lower arch with mild crowding
o upper arch with moderate crowding
o Rotated UR 4+ UL 4 + UL5
o Impacted upper canines
Skeletal and dental problems in A-P plane:
• Mild facial asymmetry
• OJ= 0.5 mm
o Incisor class III
Skeletal and dental problems in transverse plane:
Lower canines in crossbite
Skeletal and dental problems in vertical plane:
o Increased LFH
o Decreased OB= edge to edge

58. Treatment Aims
• Improve Oral hygiene
• Treat carious buccal pit in LR6
• Correct position of anterior teeth (C/C) (( Achieve class I Incisor Relationship))
• Accept mild facial asymmetry
• Accept high vertical dimension
• Increase labiomental angle
• Improve her smile by creating more normal gingival relationships and more incisal show
• Relief crowding in upper and lower arches , and align the teeth
• Correct rotated teeth
• Traction and Open space for the impacted upper canines.
• Achieve 2mm OJ
• Achieve class I canine relationship
• Maintain class I molar relationship
• Achieve normal OB
• Finishing and detailing of occlusion.
• Retain corrected results

59. Treatment Plan
Camouflage; Extraction all 4s
1. OHI
2. Treat Carious buccal pit LR6
2. Anchorage: T.P.A
3. Upper & Lower fixed appliance
4. After surgical exposure for UR3 & UL3, make sure no ankylosis
of the upper canines and good eruption
5. Extraction of all 4s
6. Retention

60. Retention Protocol
• Short term:
• Upper modified and lower Hawley retainers (full time wear for
6 months, night time wear for another 6 months)
• Long term :
• Upper and lower permenant retainers from 3-3 (braided steel
wire of 17.5 mil

61. Justification
• Anchorage reinforcement is needed because of:
Vertical anchorage for the traction of the upper canines (TPA)
Transverse anchorage during canine traction (TPA)
We want to maintain class I Molar Relationship

62. Justification
• Extraction :
• Normal NLA
• Slightly reduced incisal show
• No wide buccal corridor
• Increased vertical dimention
• LLS proclined
• Mild crowding in lower arch, moderate in upper arch
• Upper 4’s to allow space for the impacted canines
• Upper canines have good prognosis
• Fixed Appliance
• Bodily teeth movement is required.
• Alignment of teeth.
• Upper MBT : to avoid retroclination of the incisors while retraction
• Lower roth: minimal torque needed
• Preserve / correct teeth torque.

63. Justification
• RETENTION:
Long term (permenant retainer U 3-3 L 3-3)
Late mandibular crowding
To prevent relapse after closing spaces between
upper laterals & centrals
A-P change of the anterior teeth

64. Treatment details and mechanics
1. Full records
2. separators around 6’s
3. Band selection: impression for T.P.A
4. Cementation of T.P.A
5. Direct bonding of the brackets( 0.022 roth)
6. Lower Laceback , cinch back
7. Refer to surgery for exposure of canines + place attachments

65. Treatment details and mechanics
8. Leveling and aligment :
.014 niti superelastic
.016 niti superelastic
.018 niti superelastic
.017 *.025 niti superelastic only on upper

66. Treatment details and mechanics
0.019*0.025 SS wire
9. Traction for UR3 + UL3 with gold chain
10. final alignment with NiTi wire when the canines reach the arch
11. Finishing and detailing
TMA wire .021* .025
Settling
11. Debonding
Impression for retainers
Short term: U&L modified Hawley
Long term: U&L permanent .0175 inch SS wire

67. Thank You