This document presents a case report for a 17-year-old male patient complaining that his upper front teeth are sticking out. The patient has poor oral hygiene, multiple cavities, mouth breathing issues, and a Class II malocclusion with crowding. Treatment will involve initial orthodontics with extractions to align the teeth, followed by double jaw surgery for mandibular advancement and maxillary impaction. Post-surgical orthodontics and retainers will complete treatment and stabilization. The goal is to correct the patient's skeletal and dental issues, improve function and aesthetics, and achieve a stable occlusion.

1. Case Presentation
Done By: Dr. Hanan Abu Mnaizel
Supervised By:
Dr. Ahmad Al-Tarawneh
Dr. Jumana Tbeishat
Dr. Raed H. Alrbata
Dr. Bashar Momani
Dr. Anwar Rahamneh

2. Personal Data
Patient’s Name : A.A
Gender: M.
Age: 17 yrs.
Occupation: Student.
Residency: Al-Salt.
Nationality: Jordanian.

3. Medical and Dental History
 Medical History:
Pt denied any relevant medical history.
 Dental History:
-Previous Dental fillings:
UR5,UR6,LR7,UL2,UL6,UL4,LL6,LL7.
-History of failed previous orthodontic treatment using
URA ( 5 years ago ).

4. Medical and Dental History
 Habits: Not mentioned but:
Signs of mouth breathing noticed:
- Dry Gingiva.
- Extended Backward head posture.
- Multiple carious teeth.
 Motivation : Highly Motivated.
 Expectation: Realistic Expectations.

5. Chief Complaint
“My teeth ( pointing to upper canines ) are sticking out”

6. Oral Health
 Poor oral hygiene.
 Carious UR7,UR4, UR2, LR7,LR6, UL4, UL5,UL7.

7. Extra – Oral photos
( Frontal View )

8. Extra – Oral photos
( Profile View )

9. Extra – Oral photos
( Oblique View )

10. Intra – Oral photos

11. Extra – Oral Examination
Skeletal Assessment:
A. Antero- posterior assessment:
Convex profile

12. B. Vertical Assessment:
Increased lower anterior
facial height.

13. C.Transverse Assessment:
No gross facial asymmetry .

14. Smile Aesthetics:-
 On full smile the whole length of the maxillary incisors shows plus
4mm gingiva.
 At rest 4mm of the maxillary incisors shows.
 Upper incisors edges do not run parallel to the lower lip ( Non
Consonant smile arc ).
 Upper midline is coincident with the facial midline.
 Lower midline is shifted to the lift side by 1mm.
 On smile upper incisors don’t touch lower lip.

15. E - Line
-E- Ricket's line : a line dropped from tip
of the nose
to the chin.
-Both upper and lower lips lie behind
this line. Upper lip: (2-3mm).
Lower lip: (1-2 mm).
-Lower lip behind E- Line

16. Soft tissue Examination
- Increased LAFH.
-Upper lip in the upper third of the lower part .
-Lower lip in the lower two thirds of the lower part.

17. Soft tissue Examination
- Interpupillary
distance larger than
mouth width.
-Potentially Competent lips.
-Intercanthal distance is
Smaller than alar base
Width.

18. Soft tissue Examination
- Frontonasial angle : 143.
“ normal 115 – 135 “
--Nasolabial angle : 110 . “
normal 90 – 110. “
-- Labiomental angle 135
-normal 114 – 140

19. Teeth Present
87654321 12345678
87654321 12345678
Note: Partially erupted.8 8

20. Lower arch
-U-shaped arch and symmetric.
-Mildly crowded lower arch with lower right central incisor
displaced labially.
- Proclined lower incisors.
- lingually tipped RT & LT
buccal segment.
-Deep curve of spee.
-Carious LR6,LR7.
-Composite filling LL6,LL7.
-Lower midline shifted to the left side by 1 mm

21. Upper arch
-U-shaped and symmetric.
-Retroclined upper incisors.
-Mildly crowded upper arch.
-Mesiobuccally rotated upper canines.
-Lingually displaced.
-Carious UR2,UR4, UR7,UL4,UL5,UL7.
-Fillings UR5,UR6,UR7,UL2,UL4,UL6.

22. Teeth in occlusion
- Incisor relationship: class II intermediate.
- Overjet: 5mm.
- Overbite: 80%. increased complete to tooth, atraumatic.
- Midline:
1- upper midline coincident with the facial midline.
2- lower midline shifted to the left side by 1 mm.
slight midline discrepancy between the upper and lower
midlines.

23. Buccal segment in occlusion
-Molars:
Rt: class II 3/4 unit.
Lt: full unit II
-Canines:
Rt: 3/4 unit class II.
Lt: 3/4 unit class II
-Displacements:
None detected.

24. Study model analysis
Anterioposterior:
Right Left
Molar: ¾ Unit II
Canine: ¾ Unit II
Molar: full unit class II
Canine: ¾ unit class II

25. Transverse
Midline discrepancy 1mm
lower to the left side

26. Vertical
Increased overbite 80%

27. Curve of Spee
Right Left
3mm 3mm

28. Upper arch
- U shaped arch.
- symmetrical .
- Inter canine width:
32 mm decreased.
- Inter molar width :
46 mm decreased.

29. Lower Arch
- U shaped arch.
- Symmetrical.
- Intercanine width:
25mm increased.
- Intermolar width:
40mm decreased.

31. Radiographical Examination
Orthopantomogram “OPT” Analysis
- no pathology.
-All teeth are present including all 8 ‘s.
-All root apices are closed except 8 ‘s .
-UR3 root distally angulated.
- UR2 root mesially angulated.

32. Cephalometric Analysis
Cephalometric Analysis
81 ( 81 ) + - 3SNA
73 ( 78 ) + - 3SNB
8 ( 3 ) + - 1ANB
35.5 ( 27 ) + - 4MMPA
98 ( 109 ) + -6UI- MAX
101 ( 93 ) + - 6LI- MAN
129 ( 135 ) + -
10
IIA
( 8 ) + - 3SN- MAX
%58 (.55) + - 2LFH
--- ---ANB*
6.5 ( 0 ) + - 1.77WITS
Appraisal
Skeletal relationship: CL II

33. Nasion Perpendicular
• Normal range in adult male
= +/-2
• Finding: -14.5
• Interpretation: retrognathic
mandible

34. Cephalometric Interpretation
• Antero posterior:-
I. Normal maxilla.
II. Retrognathic mandible.
III. Skeletal class II.
• Vertical:
- Increased LAFH :
A. Downward rotation of the maxilla.
B. Backward mandibular growth rotation.
• Dental:
1) Retroclined upper incisors.
2) Proclined lower incisors.
i .e Compensated teeth .

35. CVM
CVMS 5

36. Space Analysis
Lower arch:
Space needed: 65 mm.
Space available:62 mm.
Upper arch:
Space needed: 73 mm
Space available: 69 mm

37. Space Analysis
4793106786.5996.587610
AnterOverall654321123456
3885106.5776666776.510
Over all ratio = 91.3 %
Normal: 91.3% + - 1.9
Anterior ratio: 80 %
Normal: 77.2% + - 1.7

38. Royal London space planning
UpperLower
-4-3Crowding and spacing
0-1Leveling of occlusal curve
00Incisors AP position
+2-2Inclination change
+2+2Arch width change
0-4Total

39. Pre – treatment (IOTN)
Aesthetic Component
3: mild need

40. Dental Health Component:
Grade 3a

41. Diagnostic Summary :-
A.A is a17 years old, male patient denied any relevant
medical history, complaining that his upper teeth
“pointing to upper canines” being sticking out. Upon
examination he has poor oral hygiene, multiple
fillings, multiple carious teeth, mouth breathing.
He has classII intermediate incisal relationship,
increased OJ. Increased OB, retroclined upper
incisors, rotated upper canines complicated by
increased LAFH, potentially competent lips, gummy
smile, inconsonant smile arc.

42. ……..Continued
mildly crowded upper and lower archs, rotated
upper canines, distally angulated upper left
lateral incisor.
He has classII molar relationship:- full unit LT
side, ¾ unit on RT side, canines ¾ RT & LT side.
OJ 5mm, OB 80% increased complete to tooth
atraumatic, lower dental midline shifted by 1mm
to LT side.

43. Problem List
 Pathological Problem:-
1- Poor oral hygiene.
2- Multiple carious teeth.
3-Mouth breathing.
 Patient’s concern:-
A.A. is complaining that “my upper teeth are sticking out
“pointing to upper canines.”
 Skeletal Problems:-
1- Class II skeletal base (retrognathic mandible and downward
growth of the maxilla)
2- increase LAFH.
3- increase MMPA.
7 4
2
4 5 7
7 6

44. ……..Continued
 Soft Tissue problems :-
1- Gummy smile.
2- Potentially competent lips.
3- Convex facial profile.
4-Inconsonant smile arc.
5- Short upper incisor length (W/L % = 1.125)

45. ……..Continued
 Dental problems :
1- Mildly crowded upper and lower archs.
2-Proclined lower incisors..
3- labially displaced LR central incisor.
4- MB- rotated upper canines.
5- Buccaly displaced upper canines.
6- Increased OJ.
7- Increased OB.
8- Lower midline shifted to RT side by I mm.

46. Treatment Aims:-
- Improve oral hygiene.
- Treat carious teeth.
- Improve breathing capacity.
- Correct PT Chief Complaint
- Correct PT skeletal base” A – P “.
- Reduce skeletal vertical proportions.
- Correct gummy smile.
- Achieve lip competency.
- Correct smile arc.
- Relieve crowding, correct rotation.
- Level and allign arches.
- Correct OJ.
- Correct OB.

47. ……Continued
- Correction of inclination.
- Correction of Angulation.
- Correct mid line shift.
-Achieve class I canine.
Achieve class III molar.
Finishing and detailing of occlusion.
-Retain corrected results.

48. Treatment Plan
Orthognathic Surgerey
Extraction case
- OHI
- Referral for ENT specialist to address the cause of mouth breathing.
- Referral for restorative dentist to treat carious teeth.
A- Initial orthodontic treatment:-
- Expansion of upper arch by arch wire to achieve arch coordination
- Extraction of
- Upper and lower fixed appliance (Upper MBT, Lower Roth)
- Extract and assess the need for extraction of with the surgeon.
4 4
8 8
8 8

49. ……Continued
B- Orthogenetic Surgery:
- mandibular advancement.
- maxillary impaction.
C- Post- surgical Orthodontics:
D- Finishing.
E- Assess the need for gingivectomy for the ULS
F- Retention:- Fixed retainers.
- Hawely retainers.

50. Retention protocol
Upper arch:
Long term retention: fixed retainer (3 to 3)
Short term retention: Hawley retainer.
Lower arch:
long term retention: fixed retainer (3 to 3 ) short term:
Hawley retainer.
Upper and lower Hawley Retainers 6 months full time
wearing followed by 6 months night time wearing.

51. Justification
A- Extraction of to :-
1. Relieve mild crowding.
2. Correct lower teeth inclination.
3. Decompensation to increase surgical movement.
B- Upper and lower fixed appliance:-
1. Achieve 3-D tooth control.
2. Alignment of rotated teeth.
3. Closing of spaces.
4. Correct midline shift.
5. ( placing the upper incisors brackets more gingivally; the upper incisors
are intruded compensating for the downwardly grown maxilla, so we
want to extrude them as a decompensation)
C- Expansion of upper arch by arch wire for arch coordination.
4 4

52. Justification
D. Extract for surgical cuts
-Assess if in surgical cuts to be removed ortherwise
maintain them.
E. Orthognathic surgery:
1.Severe skeletal discrepancy A-P and vertical
2.Unacceptable facial aesthetics ( convex profile)
3.Obtuse NLA ( doesn’t favor extraction in the upper arch)
4.Compensated teeth
5.non-grower
- maxillary impaction to:-
1- Reduce lower anterior facial height.
2- Correct gummy smile.
3- Allow mandibular autorotation without increasing LAFH.
4- Avoid relapse “ avoid stretching of pterygomandibular sling.
8 8
8 8

53. Justification
Mandibular advancement:-
1- Correct class II skeletal relationship.
2- Sagittal skeletal discrepancy is severe but dentally
compensated.
3- Help to increase tongue space & enhance breathing capacity .
F- Post surgical orthodontics:-
1. Replace the stabilizing arch wire with working arch wire to
bring the teeth to their final position.
2. To allow settling of occlusion.

54. Justification
G- Retention:-
1- H.R:- - to allow occlusal settling.
-hold expansion.
2- Fixed retainer :-
- prevent lower labial segment crowding.
- prevent relapse of rotated canines.

55. Mechanics
- Metal brackts is the best.
- 0.022 Slot to allow rigid wire for stability.
- Second molar should be banded.
- Stabilizing arch wire 21*25 TMA or s.s.
- Hooks added as attachments to the jaws together.
- Stabilizing arch wire placed at least 4 wks before
surgery so they are passive when impressions taken for
surgical splint.

56. Mechanics
- Splint should be thin 2mm thickness with adequate
strength.
- Post surgerey:-
- Light vertical elastics are needed in the initial post
surgical phase with working arch wire.
- Settling can be achieved by using light round wire (
16 mil steel ) and posterior box elastics with anterior
vector
.

57. Treatment Details
1. Full records.
2. Separators.
3. Band selection and cementation.
4. Direct bonding ( placing the upper incisors
brackets more gingivally) .
5. Alignment by super elastic 0.014 niti , then 0.016 *
0.022.
6. Working arch wire 0.019 * 0.025niti.
7. Referral to extract & 8s.
8. Space closure: can use class III elastics.
9. Stabilizing A.W 21 * 25 TMA.
44

58. Treatment Details
10- Construction of surgical wafer.
11-Final treatment plan after joint clinic discussion.
12-Referral for surgery.
13-Once a range of motion is achieved and the
surgeon is satisfied with initial healing the finishing
stage started.
14- (2 – 4) wks post surgery stabilizing arch wires
are removed and replaced by 0.016 S.S wire.

59. Treatment Details
15- Light vertical elastics.
16-Elastics regime:-
- 4wks full time.
- 4wks full time except for eating.
- 4wks night time only.
17- Finishing: 21 *25 TMA wire.
18- Impressions for retainer.