rms

1. ORTHODONTIC CASE
PRESENTATION
D O N E B Y : D R . N O O R ALTAM I M I
S U P E RV I S E D B Y: D R . AH M A D AL TAR AW N E H
D R . R AG H D A S H AM M O U T
D R . AN WAR AL R AH A M N E H
D R . H AN A N AL H AB A R N E H

2. PATIENT INFORMATION
Name: A.M
Age: 13yrs 10mons
Occupation: Student
Marital status: Single
Residence: Amman
Nationality: Jordanian

3. MEDICAL AND DENTAL HISTORY
Medical History: Denied any medical problems
Dental History: Heavily restored UR6, Amalgam on LL6 & UL6
Habits: No habits

4. CHIEF COMPLAINT
“‫في‬ ‫العلوي‬ ‫السن‬ ‫بروز‬
‫الحلق‬ ‫سقف‬”
Palatally positioned
UR2

5. FACIAL AND DENTAL APPEARANCE
• The face (Macroesthetics)
• Smile frame (Microesthetics)
• Teeth (Minieshtetics)

6. EXTRA ORAL PHOTOS

7. EXTRA ORAL EXAMINATION
(MACROESTHETICS)
Skeletal Assessment
Anteroposterior:
Class I Skeletal Pattern

8. SKELETAL ASSESSMENT
Vertical Assessment:
Reduced lower facial
height

9. SKELETAL ASSESSMENT
Transverse:
Mild Asymmetry
Chin deviated to the
right

10. SKELETAL ASSESSMENT
Transverse:
Mild Asymmetry
Interpupillary distance >
width of the mouth

11. TMJ
• No signs of TMD (No clicking, crepitus, and
tenderness to palpation)
• Normal range of opening, lateral movement, and NO
DISPLACEMENT.

12. SOFT TISSUE ASSESSMENT
Lip tonicity and competence:
• Thin upper lip
• Thicker normal lower lip
• Competent lips

13. SOFT TISSUE ASSESSMENT
• Straight profile
• Zero Meridian line to soft
tissue Pog +1

14.  Frontonasal angle:140
(Normal 115⁰-135⁰)
 Nasolabial angle:97
(Normal 90⁰-110⁰)
 Labiomental angle:122 (Normal
114⁰-140)
SOFT TISSUE ASSESSMENT

15. SMILE AESTHETICS ASSESSMENT
(MICROESTHETICS)
•Showing most of upper centrals
when smiling
• Minimal gingival show
• Smile extends from UR4-UL4

16. SOFT TISSUE ASSESSMENT
Commissure height > philtrum
height
Tooth show at rest more than 9
mm

17. SOFT TISSUE ASSESSMENT
• Upper lip length 17 mm
• Lower lip length 30 mm
• Upper lip thickness 12 mm
• Lower lip thickness 14 mm

18. 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

19. TOOTH PROPORTIONS
(MINIESTHETICS)
• Golden proportion for
maxillary anterior teeth
is 55%
• Width:Height
85%

20. GINGIVAL HEIGHT, CONNECTORS
 Gingival level of lateral 0.5 mm lower to
central incisors
 Gingival connectors between centrals almost equal
connectors between central and lateral

21. INTRA ORAL PHOTOS

22. INTRA ORAL EXAMINATION
• Poor oral hygiene
•Teeth Present in oral cavity (Permanent dentition)
6 5 4 3 2 1 1 2 3 4 5 6 7
7 6 X 4 3 2 1 1 2 3 4 5 6 7
•UR7 Partially erupted

23. INTRA ORAL PHOTOS

24. LOWER ARCH
• U-shaped lower arch
• Asymmetric arch
• Anterior segment:
Mild crowding in anterior
segment
• Buccal segment:
Lingually tipped
Impacted LR5
• Erupted LR7&LL7

25. UPPER ARCH
• U-shaped upper arch,
Asymmetric arch
• Anterior segment:
 palatally erupted UR2
UR7 is partially erupted

26. PERIODONTAL HEALTH AND
TEETH HEALTH
• Periodontal health:
poor oral hygiene, calculus formation on upper 6’s
• Multiple restorations
6 1 1 6
6

27. ANTERIOR SEGMENT
RELATIONSHIP
 Class I incisor relationship
 Upper midline shifted to R 2mm
 Lower midline shifted to R 3mm
 Overjet = 3 mm
 Overbite = Deep 50% complete to tooth
 UR2 in cross bite

28. BUCCAL SEGMENT RELATIONSHIP
• Molar relationship: L: Class I R: Class I
• Canine relationship: L: Class I R: Class II 1/2

29. STUDY MODEL ANALYSIS

30. STUDY MODEL ANALYSIS
• Anteroposterior
Canine: Class II 1/2
Molar: Class I
Canine : Class I
Molar: Class I

31. STUDY MODEL ANALYSIS
• Transverse
Upper midline shifted to R 2mm
Lower midline shifted to L 3mm

32. STUDY MODEL ANALYSIS
• Vertical
O.B= deep bite complete to the tooth 50%.

33. Right side:2 mm Curve of
Spee
STUDY MODEL ANALYSIS
Left side:3 mm Curve of
Spee

34. STUDY MODEL ANALYSIS
Upper arch
• U shaped arch form
• Dental Asymmetry
• Intermolar width: 43mm
• Intercanine width: 32 mm

35. STUDY MODEL ANALYSIS
Lower arch
• U shaped arch form
• Dental Asymmetry
• Intermolar width 40 mm
• Intercanine width 25 mm

37. SPACE ANALYSIS
• Upper Arch:
Space available (Arch circumference):76 mm
Space needed (MD teeth width) :70 mm
• Lower Arch:
Space available 66mm
Space needed 61mm

38. BOLTON ANALYSIS
11668698786611U
654321123456
12676.55555.577
(5*)
11L
6.5
Anterior Bolton ratio= 34/46*100%= 73.9%
(normal value: 77.2± 1.65%)
Overall Bolton ratio= 83.5/92*100%= 90.7%
(normal value: 91.3± 1.91%)

39. ROYAL LONDON ANALYSIS
Upper ArchLower Arch
-3 mm-3.5mmCrowding/Spacing
+3+2Angulation change
--1Leveling curve of
Spee
-+0.5Inclination change
-+1.2Arch width change
--Incisors A/P change

40. VISUALIZED TREATMENT OBJECTIVES
• Midline-Molar relationship
R LMolar
Cl I
Molar
Cl I
Midline
3mm

41. • Lower arch discrepancy
0
-2.5
-0.5
0
- -
1 1
0 3
0
-3.5
-0.5
-5
Crowding 3*3
6*6
Protrusion
Curve of Spee
Midline
Total 3*3
6*6
R L
VISUALIZED TREATMENT OBJECTIVES

42. • Anticipated treatment change
Midline MolarMolar CuspidCuspid
VISUALIZED TREATMENT OBJECTIVES
3mm

43. PRE-TREATMENT IOTN
DENTAL HEALTH COMPONENT
• Grade 5 i
Impeded eruption of teeth due
to crowding

44. PRE-TREATMENT IOTN
AESTHETIC COMPONENT
• Grade 8

45. CEPHALOMETRIC
ANALYSIS

46. Variable Pre-
Treatment
Normal value
SNA 78º 81 ± 3
SNB 76º 78 ± 3
ANB 2º 3 ± 2
S-N/MX 7º 8 ± 3
ANB* 3.5º -
MMPA 20º 27 ± 3
FMA 18˚ 28 ± 3
LFH 55% 55 ± 2
Jarabak ratio 50% 61± 2
U1/Mx 110º 109 ± 6
L1/Mn 95º 93 ± 6
IIA 127º 133 ± 10
Wits
Appraisal
1 mm 1 ±1.9 F

47. PANORAMIC
RADIOGRAPH

48. PANORAMIC RADIOGRAPH
All teeth are present including all 8’s except UR8
UR6 is heavily restored
Right side ramus length = 65
Left side ramus length = 63

49. PROBLEM LIST
 Gingivitis with Calculus
 C/C “Palatally positioned UR2”
 Skeletal:
Mild Asymmetry, chin deviated to
right side.
Decreased lower facial height
 Soft tissue:
Increased Frontonasal angle
Thin upper lip
Dental:
Mod-Severe crowding in upper and
lower
Shifted upper and lower midlines
Increased(deep complete) over bite
Class 2 ½ unit UR3
UR2 in cross bite
Buccally erupted UR3
Rotated upper molars
Impacted LR5
Mesially tipped LR6
Distally tipped LR5

50. DIAGNOSTIC SUMMARY
• A.M is a 13 year old male, Medically fit, with gingivitis and
calculus on upper 6s,complains of palatally positioned
UR2. He has a class I incisor relationship based on class I
skeletal pattern, reduced lower facial height, competent
lips, and a straight facial profile. O.J of 3 mm, deep
complete to the tooth O.B. Deep COS in lower arch
Mod- Severe crowding in upper arc anteriorly and lower
arch psteriorly. Midlines are not coincident, UR2 in
crossbite, LR5 is impacted. Molar relationship is class I on
both sides, canine relationship is class 1 on left side,1/2 unit
class 2 on right side.

51. TREATMENT AIMS
 Improve oral hygiene and treatment of calculus
 Address C/C: correct position of UR2
 Skeletal:
Accept Mild Asymmetry
Improve Lower facial height
 Soft tissue:
Improve smile esthetics
 Dental:
Correct crowding in upper and lower arches
Correct Overbite
Correct buccal segment relationship on right side to class I
Bring LR5 into position
Correct angulation of upper and lower post teeth
Correct midline discrepancies
Correct Bolton discrepancy

52. TREATMENT PLAN
(Camouflage, Non-extraction case, space provided by
arch wires)
1. OHI.
2. Modified TPA (Zachrisson)
3. Upper and lower fixed appliance (MBT) slot 22” with bite
turbos on upper centals, open space for impacted LR5
4. Miniscrew on lower right retromolar area
5. Retention:
Upper: anterior bite plane (wear time at night until end of vertical
growth) and fixed retainer from 3-3
Lower: fixed retainer from 3-3

53. JUSTIFICATION (NON-EXTRACTION)
DENTAL:
CRITERIA VALUE NORMAL VALUE PRO/CON
NON-EXTRACTOION
Tooth size- arch length Upper :6 mm
excess
Lower: 5
8-11 mm crowding PRO
Curve of Spee L:3mm,R:2mm More than 6 severe PRO
Bolton discrepancy 90.7% If 4* more then extract PRO
Peck & Peck L1:75%
L2: 91%
L1:88-92 (if less extract)
L2: 90-95 (if less extract)
CON
PRO
Irregularity index .05 mm X>6.5 mm extract PRO
Incisor-Man. Plane angle 95˚ 85˚-95˚ PRO
Frankfurt-Man. Incisal
angle
69˚ 60˚-75˚ PRO
Upper incisor to NA 7mm, 34˚ 4mm anterior, (22-25) CON
Lower incisor to NB 3 mm, 23˚ 4 mm anterior ( 22-25) PRO
Lower incisor to A-pog 1 1-3 mm anterior to it PRO

54. JUSTIFICATION (NON-EXTRACTION)
SKELETAL
CRITERIA VALUE NORMAL VALUE PRO/CON NON-EXTRACTION
FMA 18˚ 20˚-30˚ PRO
SN-MP 25˚ 31˚-34˚ PRO

55. JUSTIFICATION (NON-EXTRACTION)
SOFT TISSUE
CRITERIA VALUE NORMAL VALUE PRO/CON
NON-EXTRACTION
POSITION OF
UPPER LIP –E LINE
2 mm 2mm ±3 PRO
POSITION OF
LOWER LIP- E LINE
0 mm 2mm ±3 PRO
NASOLABIAL ANGLE 97˚ 90˚-115˚ PRO
UPPER LIP
MORPHOLOGY
13mm≠
8 mm
3 mm below sk A point
=
Vermilion to labial
surface of teeth ±1
CON

56. JUSTIFICATION (NON-EXTRACTION)
OTHER FACTORS
CRITERIA VALUE PRO/CON NON-EXTRACTION
GROWTH Growing patient PRO
MIDLINE Not coincident CON
PATIENT PEREFERENCE Non-extraction PRO

57. JUSTIFICATION
 Camouflage:
 Skeletal is class 1, wits 1, molars are class 1, problem is mainly concentrated in upper anterior
region , spaces can be gained by arch expansion in upper and lower arches, and molar
uprighting provides space in lower arch
• Expansion by arch wires:
 Arch development
 Correct angulation of lower teeth
 Fixed Appliance
 Alignment of teeth
 Bodily movement
 Correct cross bite , traction of impacted tooth and molar uprighting
 Upper and lower arch coordination
• Bite turbos:
 Reduction of deep overbite, dis-occlusion of upper and lower teeth
• Modified TPA (Zachrisson) :
 Correct rotated upper molars

58. JUSTIFICATION
• Miniscrew on lower right retromolar area
 help in uprighting lower molars and distalization
• MBT prescription slot 0.022:
 Increased maxillary incisors labial crown torque
 Increased lingual crown torque of LLS (to counteract the effect of RCOS during deep
OB correction)
 Less anchprage demand
 Provides better intercsupation
• Retention ( Upper and Lower fixed retainer ), Upper Anterior bite plane
 Upper fixed retainer: maintain position of UR2
 Upper Anterior bite plane as retainer : to maintian corrected deep bite until end of
vertical growth
 Lower fixed retainer: prevent late anterior mandibular crowding

59. TREATMENT DETAILS AND
MECHANICS
1. Full records
2. Separators on all 6’s
3. Bands selection on all 6’s
4. Impression for Zachrisson type TPA
5. Cementation of lower bands
6. Cementation of TPA

60. TREATMENT DETAILS AND
MECHANICS
7.Direct bonding of upper and lower fixed appliance with
anterior bite turbos on upper centrals, Check OPG to
achieve the right teeth angulations.
Regarding bracket positioning
-Place brackets more incisally on upper anteriors
-Increase mesial angulation of upper canines
-Invert brackets on upper laterals
8.Alignment arch wire 0.014 Niti, 0.016*0.022 NiTi for
leveling

61. 10. On working arch wire 0.019*0.025 SS:
Open coil spring between UR1-UR3, LR4-LR6
Use piggyback 0.012 NiTi technique to bring UR2 into the
arch
Ligate btw UR3-UR6, UR1-UL2 to maintain space of UR2
Refer for exposure of LR5 (if didn’t erupt by itself after space provision-
note that the root is not fully formed yet)
TREATMENT DETAILS AND
MECHANICS

62. TREATMENT DETAILS AND
MECHANICS
11. Band all 7s to aid in correction of deep bite after they are fully erupted
12. Consider use of reverse curve of spee in lower arch
13. Midline correction can be achieved with correction of teeth
angulations and differential elastics
14. Finishing and detailing 0.017*0.025 TMA, consider reshaping of upper
anterior teeth
15. Upper impression for anterior bite plane (to be used until the end of
vertical growth)
16. Upper and lower fixed retention from 3-3 using multistranded SS

63. THE END