This orthodontic case involves a 16-year-old male patient presenting with a class 3 malocclusion and an impacted upper left canine. The proposed treatment plan is camouflage non-extraction therapy using removable appliances for anterior expansion and fixed appliances to align the teeth, correct rotations, relieve crowding, and traction the impacted canine into occlusion. Retention will involve removable and permanent retainers to maintain the corrected results.

1. Orthodontics Case
Presentation

2. Personal Data
• Patient’s Name• H.A
• Nationality • Jordanian
• Gender • Male
• Age • 16 years old
• Career • Student

3. Presenting
Complaint
• “ sometimes people don't understand what
I'm saying” & “i don't like the appearance of
my teeth” .

4. Medical & Dental History
• Medical history:
Patient denies any medical problems.
• Dental history:
Patient has no dental history, this is his first visit to a
dentist.

5. Extraoral Photos

6. Intraoral Photos

7. Intraoral Photos

8. Study Models
Right side : Angle Class 3 molar Full unit Left side : Angle Class 3 molar 1/4 unit
Molar Relationship
Left side :N/A
Canine Relationship
Right side :Full unit Class 3 canine

9. Orthopantomogram X-Ray

10. Localization of Impacted upper canine

11. SNA 88⁰ 81⁰ ± 3⁰
SNB 87⁰ 78⁰ ± 3⁰
ANB 1⁰ 3⁰ ± 2⁰
Sn-Mx 3 8⁰ ± 3⁰
Corrected ANB N/A
Wits appraisal -6 1(+-1.9) mm
(M)
MMPA 27⁰ 27⁰ ± 4⁰
FMPA 28⁰ ± 4⁰
AFH Ratio 55% 55% ± 2%
UI-MX 118⁰ 109⁰ ± 6⁰
LI-Mn 95⁰ 93⁰ ± 6⁰
IIA 135⁰ 135⁰ ± 10⁰
Cephalometric Analysis

12. Extraoral Examination
• Anteroposterior assessment:
Profile : slight convex
Anterior divergent

13. Extraoral Examination
• Vertical assessment
facial thirds
slight increase in LFH
FMPA
• slightly increased

14. • Transverse assessment
Facial symmetry
• Pt has a symmetrical face
• Facial midline showing
alignment of the middle part
of the upper lip at the
vermillion border and chin point

15. Lips -> Upper is normal
Lower slightly everted
Competent at rest
Soft Tissue Examination

16. Soft Tissue Examination
• Frontonasal Angle: (115-135)
145 increased
• Nasolabial Angle: (90-110) 88
decreased
• Labiomental Angle: (110-130)
138 increased

17. Intraoral Examination

18. Intraoral Examination
• Dentition status: Permanent dentition
• Teeth present: 7654321 12c4567
7654321 1234567
• Teeth unerupted: all 8’s and UL3
• Caries: Clinically, Caries free

19. Intraoral Examination
• Fair Oral Hygiene

20. • Central lines:
lower shifted to the left 3mm
• Incisors classification:
Right: Class 1 Left: Class 3
• OJ:
Right: positive left : negative
• OB:
3mm
• Crossbites:
Anterior cross bite UL1 & UL2
Unilateral posterior crossbite
Displacement : to the left
Intraoral Examination

21. Right side : Angle Class 3 molar Full unit Left side : Angle Class 3 molar 1/4 unit
Intraoral Examination
Molar Relationship

22. Right side :Full unit Class 3 canine Left side : palataly impacted
Intraoral Examination
Canine Relationship

23. •Upper Arch
• U-shaped
• Asymmetric
• Mild Spacing
• No left canine shown
(remaining c)
• asymmetrical incisors inclination
• Rotated UR3, UL4

24. •Lower arch
• Symmetrical
• Mild crowding
• Rotated LL3

25. Study Models Examination

26. Study Models Examination
Front View:
• Midlines not coincident
• Lower shifted left 3 mm

27. Upper Cast Occlusal
• Interpremolar width = 37mm
(normal)
• Intermolar width = 47mm
(normal)
Study Models Examination

28. Lower cast occlusal
• Intercanine width = 23mm
(decreased) N= 24.7
• Interpremolar width = 31mm
(normal)
• Intermolar width = 43mm
(normal)
Study Models Examination

29. Curve Of Spee
Right : 1mm Left : 1mm
Study Models Examination

30. Estimation of canines size
• Tanaka and Johnston :
• ½ the MD width of incisors +11mm = width of ( 3,4,5 )
(24/2) +11= 23 mm
23 = X + 14.5  X = 8.5 mm
Study Models Examination

31. Space analysis
• Upper arch:
• Asymmetric
• Space available= 93mm
• Space needed= 91mm
Study Models Examination

32. Space analysis
• Lower arch:
• Space available= 96mm
• Space needed= 98mm

33. Tooth Size Analysis (Bolton)
• Lower anterior teeth widths —> 40mm
• Upper anterior teeth widths —> 49mm
• = 81.6 % N = 77.2 (+/- 1.65)
• Lower all teeth widths —> 91mm
• Upper all teeth widths —> 98mm
• = 92.8 % N= 91.3 (+/- 1.91)
6 5 4 3 2 1 1 2 3 4 5 6
10 7 7.5 8.5 7 9 9 7 X (8.5) 7.5 7 10
6 5 4 3 2 1 1 2 3 4 5 6
11 7.5 7 8 6 6 6 6 8 7 7.5 11

34. Panoramic interpretation
-Upper left canine
show good prognosis
-No other apparent
pathologies

35. Localization of Impacted upper canine
1. Inspection
2. Palpation
3. Radiography

36. Localization of Impacted upper canine
1. Inspection
• Remaining
deciduous
• No mobility or
tenderness in
lateral incisor

37. Localization of Impacted upper canine
1. Inspection
2. Palpation
• Absence of
buccal bulge
• bulging in the left
rugae area

38. Localization of Impacted upper canine
1. Inspection
2. Palpation
3. Radiography
Horizontal parallex
• palataly impacted

39. Impacted canine 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

40. Impacted canine Prognosis
1. Canine angulation to the midline
• Grade 1=0-15 degree
• Grade2=16-30
• Grade 3= more than 30

41. Impacted canine Prognosis
2. A-P position of the canine apex
• Grade 1: Above the region of the
canine position
• Grade 2: Above the upper first
premolar region
• Grade 3: Above the upper second
premolar region

42. Impacted canine Prognosis
3. 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
• Grade 3: More than half way up the root, but less than full
root length
• Grade 4: Above the full length of the root

43. Impacted canine Prognosis
4. Canine crown overlap to the
adjacent incisor
• Grade 1: No horizontal overlap
• Grade 2: Less than half the root width
• Grade 3: More than half, but less than the whole root
width
• Grade 4: Complete overlap of root width or more

44. IOTN-dental health component
IOTN- Esthetic
component
N/A

45. Diagnostic Summary
16 years old male, MF, complaining of speech difficulty and
teeth appearance. Patient has fair OH. Class 3 malocclusion
based on skeletal class 3 with average vertical dimension.
He has a symmetrical face complicated by an impacted
upper left canine. He also has mandibular displacement to
the left, upon closing. A class 3 molar & canine relationship,
lower midline shifted to the left 3 mm, asymmetrical Upper
dental arch with mild spacing and mild crowding in the lower
arch.

46. Dental:
1) Mild crowding in the lower arch
2) Rotated LL3
3) Lower midline shifted 3mm to the left
4) Slightly proclined lower labial segment
5) Mild spacing in the upper arch
6) Asymmetrical upper arch
7) Rotated UR3, UL4
8) Class 3 incisor, canine & molar relationship
9) Retained upper left C
10) Impacted upper left canine
11) Cross bite on the left side
12) Mandibular displacement to the left
Pathological problems:
• Pathological problems:
• Fair OH
Patient concern:
• “ sometimes people don't understand what
I'm saying & i don't like the appearance of my
teeth”
• Skeletal:
1)Class 3 skeletal base
2) slightly convex profile
3) Anteriorly divergent
Problem List

47. •Improve Oral hygiene
•Relieve crowding in the lower arches , and align the teeth
•Correct rotated teeth
•Open space and Traction for the impacted UL3
•Correct the mandibular displacement
•Correct lower midline shift
•Accept class 3 skeletal base( achieve better facial profile)
•Achieve positive OJ
•Achieve class 1 incisor relationship
•Flatten Curve of Spee
•Finishing and detailing of the occlusion.
•Retain corrected results
•
Treatment Aims

48. Camouflage, Non extraction
space provided by expansion in the upper and lower stripping
1. OHI + Refer for speech specialist for consultation
2. Start with upper removable appliance with posterior bite block & ant
expansion to correct the left anterior crossbite and correct the mandibular
displacement
3. Anchorage: TPA
4. Upper & lower fixed appliance (MBT 0.22)
5. Surgical exposure of impacted canine
6. Retention
Treatment Plan

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

50. 1. Camouflage:
- patient chief complaint
- Mild skeletal problem
- Acceptable facial proportions
2. Non extraction:
- Facial profile
- Space can be provided by other means
( Upper —> expansion Lower —> Stripping )
- Presence of displacement which complicate the relation
- Normal inclination of upper & lower incisors
Justification

51. 3. Anterior expansion:
- correct the displacement
4. Lower stripping:
-Provide space for mild crowding
- Retrocline LLS
5. Removable appliance:
- pt internally motivated
- good compliance is expected
Justification

52. 6. Anchorage:
• Traction of the displaced canines to the occlusion.
• Transverse & vertical anchorage during canine traction.
7. Fixed Appliance:
• Bodily teeth movement is required.
• Alignment of teeth & leveling
• Preserve / correct teeth torque.
Justification

53. 8. MBT prescription :
- (-6) torque in the lower incisors to prevent further proclination
- increase torque in upper incisors
- lower contralateral inverted canine will be placed on the palataly impacted
canine
Justification

54. 9. retention protocol:
- Hawley retainer —-> to retain expanded upper arch
- Better interdigitation than VFR
- permanent retainer :
Upper —-> palataly erupted canine
Lower ——> rotation of the LL3
LLS more prone to relapse
Justification

55. 1. Impression for Upper removable anterior expansion screw with posterior bite blocks
2. One turn every day .25 mm for 7-10 days
3. Construction of TPA
4. Bonding Upper & Lower
- swaping lower canines brackets
5. Laceback on lowers
6. On reaching Rigid arch wire Extraction of Retained c
7. Apply open coil spring to provide space
8. Open exposure for impacted canine with direct
bonding of the gold chain
9. Start traction ( ballista spring or piggy back)
10. when canine is in the line of the arch complete alignment normally using conventional NiTi wires
11. leveling of both arches using continuous mechanics
12. Finishing and detailing
13. Retention of achieved results
Treatment (Special) Mechanics

56. Thank You