This case presentation summarizes the orthodontic treatment of a 15-year-old female patient. The patient's chief complaint was the alignment of her teeth, particularly her palatally positioned upper right canine. Clinical examination revealed class II malocclusion, gummy smile, rotated and tipped teeth. Treatment goals were to correct the malocclusion through non-extraction therapy using fixed appliances along with headgear and bite turbos. The proposed treatment plan was to address the patient's oral hygiene, align and level the teeth to achieve class I occlusion, and provide retainers.

1. Case Presentation
Done By: Dr. Hadeel Almasri
Supervised By:
Dr. Ahmad Al-Tarawneh
Dr. Raed Al-Rbata
Dr. Anwar Al-Rahamneh

2. Personal Data
 Patient’s Name : T.M
 Gender: Female
 Age: 15 years, 7 months
 Occupation: Student
 Nationality: Jordanian

3. History
 Trauma: No History of Trauma
 Habits: No Habits
 Growth status: Non-grower

4. Medical and Dental History
 Medical History: Medically fit
 Dental History: Routine dental treatment

5. Chief Complaint
“ I don’t like the alignment of my teeth, especially
this pushed back tooth ( pointing at her upper
right canine) “ .

6. Extra – Oral photos
(Frontal View)

7. Extra – Oral photos
(Oblique View)

8. Extra – Oral photos
(Profile View)

9. Intra – Oral photos

10. Intra – Oral photos

11. Extra – Oral Examination
Skeletal Assessment
Antero-posterior assessment:
Straight profile

12. Extra – Oral Examination
Skeletal Assessment
Vertical Assessment:
Normal vertical proportions

13. Extra – Oral Examination
Skeletal Assessment
 Transverse Assessment:
The chin is slightly deviated
to the right side

14. Soft tissue Examination
Equal thirds of the face
The upper lip is in the upper
third of the lower part
The lower lip is in the lower
two thirds of the lower part

15. Soft tissue Examination
Equal facial fifths
Interpupillary
distance is larger than
the width of the mouth
The width of the nose is
larger than the middle fifth
Competent lips

16. Soft tissue Examination
Frontonasial angle : 149
“ normal 115 – 135 “
Naso labial angle : 108
“ normal 90 – 110 “
Labiomental angle: 102
“ normal 114 – 140 “

17. Soft tissue Examination
 Excessive gingival
show on smiling
(Gummy Smile)

18. Intra oral Examination
Oral hygiene is fair
Gingivitis
Calculus accumulation on
the lingual surfaces of the LLS
and on the upper first molars
Class II caries mesially on
the upper left first molar
Hypominealization in the
upper left central incisor

19. Teeth Present
7654321 1234567
7654321 1234567

20. Lower arch
U-shaped symmetrical arch
Well-aligned
 The right and left buccal
segments are lingually
tipped

21. Upper arch
 U-Shaped Asymmetrical arch
Palatally instanding upper right
canine
Buccaly erupting upper left canines
Distopalatally rotated upper left first
premolar
Mesiopalatally rotated upper right
first molar
Mesiolabially rotated upper right
lateral incisor
Retroclined upper central incisors

22. Teeth in occlusion
Incisor relationship: Class II div 2
Overjet: 2 mm
Overbite: 70% complete to teeth
The upper dental midline is coincident
with the facial midline
The lower dental midline is shifted by
3 mm to the right side
The upper right canine is in crossbite
Displacement to the right side

23. Buccal segment in occlusion
(Molar relationship)
Right side: ICP: Class II full unit Left side: ICP: Class I
RCP: Class II ½ unit RCP: Class II ½ unit

24. Buccal segment in occlusion
(Canine relationship)
Right side: ICP: Class II full unit Left side: ICP: Class I
RCP: Class II ½ unit RCP: Class II ½ unit

25. Study model analysis in occlusion
Right Left
-Molar: Cl II full unit
-Canine: Cl II full unit
-Molar: Cl I
-Canine: Cl I
OJ: 2 mm

26. Transverse
Lower midline shifted 3 mm to
the right side relative to the
facial midline

27. Vertical
Overbite 70% complete to teeth

28. Curve of Spee
Right Left
3 mm 3 mm

29. Upper arch
- U- shaped arch.
- symmetrical arch.
- Intercanine width:
29 mm ( Reduced)
- Intermolar width :
48 mm (Increased)

30. Lower Arch
- U shaped arch.
- Symmetrical.
- Intercanine width:
32 mm (increased)
- Intermolar width:
42 mm (normal)

32. Radiographical examination
Orthopantomogram “OPT” Analysis:
No pathology
All teeth are present including the tooth buds of all 8 ‘s
Class II caries mesially in the upper left first molar
Dilaceration in the lower left first premolar root

33. Cephalometric Analysis
Cephalometric Analysis
83 ( 81 ) + - 3SNA
78 ( 78 ) + - 3SNB
5 ( 3 ) + - 1ANB
4.5 ( 3 ) + - 1ANB*
101 ( 109 ) + -6UI- MAX
97 ( 93 ) + - 6LI- MAN
139 ( 135 ) + - 10IIA
7.5 ( 8 ) + - 3SN- MAX
0.56 (0.55) + - 2LFH
25 ( 27 ) + -4MMPA
2.5 ( 0 ) + - 1.77WITS
Appraisal
Skeletal relationship: CL II

34. Space Analysis
Lower arch:
Space needed: 67 mm
Space available: 67 mm
(No crowding)
Upper arch:
Space needed:77 mm
Space available:73 mm
(4 mm crowding-mild)

35. Space Analysis ( continued )
4897107.5787997877.510
AnterOverall654321123456
38891087.57666677.5810
Overall ratio = 91.7%
Normal: 91.3% + - 1.9
Anterior ratio: 79%
Normal: 77.2% + - 1.7
Normal bolton ratio

36. Pre – treatment (IOTN)
Aesthetic Component
Figure 2
Mild treatment need

37. Dental Health Component
4.C (Great need) : Anterior or
posterior crossbite with more
than 2 mm discrepancy between
the RCP and ICP

38. Diagnostic Summary
T.M 15 years and 7 months old female, denied any medical problem, presented concern
that “ I don’t like the alignment of my teeth, especially this pushed back tooth ( pointing
at her upper right canine) “ . She has fair oral hygiene, gingivitis, calculus deposits,
hypomeniralization (UL1), dilacerations (LL4) and caries in the UL6.
She has class II div 2 incisor relationship based on mild class II skeletal pattern, average
LAFH, straight profile, mild chin deviation to the right side, and gummy smile.
She has 2 mm overjet, overbite is 70% complete to teeth, no crowding in the lower arch
and 4 mm crowding in the upper, the upper right canine is in crossbite with
mandibular displacement to the right side, the upper left canine is buccaly erupted, UR
2 an UR6 and UL 4 are rotated, the lower right and left buccal segments are lingually
tipped, and the lower dental midline is shifted 3 mm to the right side relative to the
facial midline.
She has Cl II full unit molar and canine relationship on the right side in ICP and Cl II ½
unit in RCP, and Cl I molar and canine relationship on the left side in ICP and Cl II ½
unit in RCP, and deep curve of spee.

39. Problem List
Pathological Problems:
1. Fair oral hygiene
2.Gingivitis and calculus deposits
3.Caries in the UL6
4.Hypomeniralized enamel of the UL1
5.Dilacerated root of the LL4
Patient’s concern:
“ I don’t like the alignment of my teeth, especially
this pushed back tooth ( pointing at her upper
right canine) “
Skeletal Problems:
1. Mild Class II skeletal base
2. Mandibular deviation to the right side.
Soft tissue problems:
1. Obtuse Frontonasial angle and acute
Labiomental angle
2. Gummy smile
3. Interpupillary distance is larger than the width
of the mouth
4. The width of the nose is larger than the middle
fifth
 Dental problems:
1. class II div 2 incisor relationship with
retroclined upper incisors
2. Deep overbite
3. Deep curve of spee
4. lower dental midline shifted 3 mm to the right
5. Cl II full unit molar and canine relationship on
the right side in ICP and Cl II ½ unit in RCP
6. Cl I molar and canine relationship on the left
side in ICP and Cl II ½ unit in RCP
7. Upper right canine is in crossbite with
mandibular displacement to the right side
8. Upper left canine is buccaly erupted
9. UR 2 an UR6 and UL 4 are rotated
10. The lower right and left buccal segments are
lingually tipped
11. Mild crowding in the upper arch

40. Treatment Aims
- Improve patient’s oral hygiene
- Referral to periodontics department for stabilization of periodontal health
- Referral to conservative department for treatment of the carious UL6
-Accept dilacerated LL4 and hypomineralization
- correction of patient’s complaint
- Accept skeletal class II base
- Accept soft tissue problems
- Improve smile aesthetics
- Alignment and leveling of teeth
- Correct crossbite on the UR canine and mandibular displacement
- Correct lower midline shift
- Correction of deep overbite and flatten curve of spee
- Relieve crowding
- Achieve class I incisor relationship
- Achieve class I canine and molar relationship
- Finishing and detailing of occlusion
- Retain the corrected results

41. Treatment Plan
( Camouflage, Non-Extraction case)
- OHI
- Referral to periodontics department for stabilization of periodontal health
- Referral to conservative department for treatment of the carious UL6
- Straight pull Headgear for bilateral molar distalization and for anchorage
- Bite turbos on the upper central incisors
- Upper and lower fixed appliance ( SWA , MBT(for the upper arch and lower buccal
segments),Roth(for the lower labial segment), slot 0.022 )
-Retention.

42. Retention protocol
 Short term:
Upper and lower Hawley retainers (full time wear for 6 months, and night time wear
for another 6 months)
 Long term:
Upper and lower permanent retainer 3-3 (Multistrand SS wire 17.5 mil)

43. Justification
1. Camouflage:
- Patient chief complaint
-Mild skeletal discrepancy
-Average vertical facial proportions
-Patient passed the peak of growth spurt
2. Non – extraction:
- No crowding in the lower arch, average inclination of the lower incisors, and space
needed for leveling curve of spee is 1 mm each side, and this can be provided by
uprighting of the lingually tipped lower buccal segment.
-Mild crowding in upper arch and space can be gained by molar distalization, arch
wire expansion, proclination of upper incisors, and correction of rotated teeth.
-Presence of displacement that complicates the relation

44. Justification
3.Straight pull headgear for bilateral distalization:
-Average LAFH
-Deep overbite
-Class II ½ unit molar relationship
-Mild crowding in the upper arch
-For anchorage: to preserve cl I molar relationship
4.Bite turbos on the upper central incisors:
-For correction of crossbite on the UR canine
-To free the occlusion posteriorly to allow lower posterior segment uprighting and
some extrusion for correction of deep overbite and COS
-Some incisor intrusion ( aid in correction of deep overbite)
-Allow bonding of brackets on the lower incisors

45. Justification
5. Fixed appliance:
- 3-D tooth movement
- Bodily teeth movement needed
- Semi customized appliance:
 MBT for the upper labial segment : for more palatal root torque, and to counteract
the effect of retraction of the ULS ( to prevent retroclination)
 MBT for the lower buccal segment: to reduce lingual crown torque
 Roth for the lower labial segment: average root torque needed
 For the palatally displaced UR canine use inverted lower contra-lateral canine
bracket Roth prescription (-11 torque)

46. Justification
6. Retention:
 Hawley retainers: for more settling and stability of incisor relationship and other
posterior teeth.
 Lower permanent retainer: to stabilize the position of lower anterior teeth and
prevent late mandibular crowding.
 Upper permanent retainer: to stabilize the position of the upper incisors and for
the rotated UR lateral incisor

47. Treatment details and mechanics
1. Full records
2. Separators around upper and lower 6’s
3. Bands selection and cementation
4. Straight pull headgear fitting+ give instructions to the patient about it (use it for
distalization first and then for anchorage)
5. Composite bite turbos on the upper central incisors
6. Direct bonding of brackets ( place the upper incisors brackets more incisally for
some intrusion that helps in reducing the deep overbite and improving gummy
smile, and also increase the mesial tip of the upper canines to help in reducing
overbite)
7. Levelling and alignment:
0.014 niti superelastic
0.016 niti superelastic
0.018 niti superelastic
0.017*0.025 niti superelastic

48. Treatment details and mechanics
0.019*0.025 SS wire , start retraction of the upper labial segment and space closure.
Here I will consider adding torque by 3rd order bend to avoid retroclination of the
upper labial segment with retraction ( since the more incisal position of the bracket I
used can reduce torque expression)
8. Finishing and detailing
TMA 0.021*0.025 wire
Settling
9. Debonding
impression for retainers
short term: U&L Hawley
Long term : U&L permanent .0175 inch multistrand wire