rms

1. Done by : Dr. Luma Najada – 2nd year resident.
Supervised by: Dr. Ahmad Tarawneh
Dr. Jumana Tbaishat
Dr. Bashar momani
Dr. Anwar Rahamneh

2. Name: Samah issam
Age: 29 yrs
Occupation: dental technician
Marital status: Single
Residence: Amman
Nationality: Jordanian

3. Medical History: M.F
Dental History: Previous orthodontic treatment 12 years ago
Routine dental procedures ( fillings)
Habits: None

4. “ I don’t like the
apperance of my
teeth upon smiling.”

11. Variable Pre-
Treatment
Normal value
SNA 80.7º 81 ± 3
SNB 76.5º 78 ± 3
ANB 4.2 3 ± 2
S-N/MX 8.3º 8 ± 3
ANB* 4.5 -
MMPA 29.7º 27 ± 3
FMA 30 28 ± 3
LFH 56% 55 ± 2
Jarabak ratio 53% 61± 2
U1/Mx 102º 109 ± 6
L1/Mn 88.4º 93 ± 6
IIA 135º 133 ± 10
Wits
Appraisal
0 mm 1 ±1.9 F

12. Anteroposterior:
Class II Skeletal Pattern

13. Vertical Assessment:
Slightly increased lower
facial height

14. Transverse:
Asymmetrical face

15. Lip tonicity and competence:
• Thin strained upper lip
• normal lower lip
• High lower lip line
• competent lips

16.  Convex facial profile

17.  Frontonasal angle: 143⁰
(Normal 115⁰-135⁰)
 Nasolabial angle: 119⁰
(Normal 90⁰-110⁰)
 Labiomental angle: 87⁰
(Normal 114⁰-140 ⁰)

18. • 100% crown show when smiling
• gingival show on upper centrals
approx. 3 mm
• Smile extends from 5 to 6

19. • Buccal corridors: narrow
• The smile arc: straight
related to lower lip

22. • Poor oral hygiene
•Teeth Present in oral cavity (permenant dentition)
7 6 5 4 3 2 1 1 2 3 X 5 6 7
7 6 5 4 3 2 1 1 2 3 4 5 6 7

23.  U-shaped lower arch
 Anterior segment:
 moderate crowding in anterior
segment
 Buccal segment:
 Lingually inclined

24.  u-shaped arch.
 Anterior segment:
 retroclined upper
incisors
Mild cowding

25.  Periodontal health:
poor oral hygiene.
 Carious :
 fillings :
6 1 1 6 7
7 6 6 7
7 2
4

26.  Previous abscess related to UR2
 Impacted upper 8’s.

27.  Class II div. 2 incisor relationship
 Midlines : upper deviated to the left by 4 mm
lower deviated to the right by 2 mm
 Overjet = 3.5 - 4 mm
 Overbite = Deep 70 % Incomplete .

28.  Molar relationship: L: Class II R: Class II 3/4
 Canine relationship: L: Class III 1/4 R: Class II 3/4

30.  Anteroposterior
Canine: Class II 3/4
Molar: Class II 3/4
Canine : Class III 1/4
Molar: Class II

31.  Transverse
Midlines deviated

32.  Vertical
O.B= deep bite incomplete

33. Right side: flat Curve of Spee Left side: flat Curve of Spee

34. Upper arch
 u shaped arch form
 Dental Asymmetry
 Intermolar width: 40 mm
(normal : 43.9 mm)
 Intercanine width: 31 mm
(normal: 31.2)

35. Lower arch
 U shaped arch form
 Dental Symmetry
 Intermolar width : 37 mm
(normal: 41.7 mm )
 Intercanine width : 22 mm
(normal: 23.1 mm)

36. 117X878.5877.576.511U
654321123456
11
7.
5
776.55566.577.511L
Anterior Bolton ratio= 36/46*100%= 78.2%
(normal value: 77.2± 1.65%)
Overall Bolton ratio= 87/88.5*100%= 98%
(normal value: 91.3± 1.91%)

37. Upper ArchLower Arch
-2.5 mm-6.5Crowding/Spacing
--Angulation change
00Leveling curve of
Spee
+1.5+1Inclination change
+2+2.5Arch width change
--Incisors A/P change
+1mm-3.5total

38.  Grade 3 d
contact point
Displacement greater than 2 less
than 4

39.  Grade 3

41. Variable Pre-
Treatment
Normal value
SNA 80.7º 81 ± 3
SNB 76.5º 78 ± 3
ANB 4.2 3 ± 2
S-N/MX 8.3º 8 ± 3
ANB* 4.5 -
MMPA 29.7º 27 ± 3
FMA 30 28 ± 3
LFH 56% 55 ± 2
Jarabak ratio 64% 61± 2
U1/Mx 102º 109 ± 6
L1/Mn 88.4º 93 ± 6
IIA 135º 133 ± 10
Wits
Appraisal
0 mm 1 ±1.9 F

43. All teeth are present except UL5, lower 8’s

44.  S.O is a 29 years old female, medicaly fit, with history of
failed orthodontic treatment with fixed appliance, with multiple
fillings and carious teeth, extracted UL4. Presented
complaining of “ I don’t like my smile “ . she has class II/II
incisor relationship based on class II skeletal pattern,slightly
increased LFH, she has asymmetrical face with chin deviated
to the right side with compromised smile esthetics.
 O.J of 4 mm, deep Incomplete O.B. complicated by extracted
UL4, upper midline deviated to the left by 4 mm and the lower
to the right by 2mm, moderate crowded lower arch (localized
anteriorly), mild crowding in the upper arch. upper 7’s are in
scissor bite, molar on left side is class II , on right side class II
3/4. Canine on left side is class III ¼, and on right side class
II ¾.

45.  Pathological problems :
1. poor oral hygiene
2. carious UR7, UR2, LR4.
3. unesthetic composite fillings on upper centrals.
 Developmental problems :
Patients’s concern : the unesthetic smile
Alignment and symmerty:
Asymmetric lower arch with with 6.5 mm crowding.
lingually inclined lower molars.
rotated LR4, LR2,LL2.
Asymmetric upper arch with 2.5 mm crowding
extracted UL4
retroclined upper incisors
upper 7’s scissor bite
rotated UL2, UR2
Skeletal and dental problems in transverse plane:
Asymmetric skeletal
upper midline deviated to the left by 4mm
lower midline deviated to the right by 1-2 mm

46. Skeletal and dental problems in A-P plane:
Mild class 2 skeletal base (retrognatheic mandible)
insicor class 2 div 2
right Canine: Class II 3/4
right Molar: Class II ¾
left Canine : Class III ¼
Skeletal and dental problems in vertical plane:
slightly increased LFH
increased incomplete OB
Soft tissue problems :
high lower lip line
obtuse nasolabial angle
acute labiomental fold.

47.  Improve OH
 Treat carious teeth
 Redo composite fillings on upper centrals.
 Root canal treatment for UR2
 Improve her smile by creating more normal gingival relationships , and smile
symmetry
 Relief crowding in upper and lower arches , and align the teeth
 Correct rotated teeth
 Corret retroclination of upper teeth
 Correct bolton discrepancy
 Correct upper and lower midline shift
 Correct scissor bite on upper 7’s.
 Accept class 2 skeletal base
 Accept Asyymetrical face.
 Achieve 2mm OJ
 Achieve class II molar and class I canine relationship
 Achieve class 1 incisor relationship
 Achieve normal OB
 Finishing and detailing of occlusion.
 Retain corrected results

48. (Camouflage, extraction case)
1. OHI.
2. Treatment of carious teeth, redo composite
fillings.
3. Anchorage : TPA with midpalatal miniscrew.
4. Extraction UR4
5. Lower and Upper fixed appliance
6. Bite raising on post. Teeth.
7. Consider stripping in lower ant. Teeth to
provide space
8. Retention.

49.  Short term:
 Upper modified Hawley retainers and
lower hawley (full time wear for 6 months,
night time wear for another 6 months).
 Long term :
 Upper and lower permenant retainers from
3-3

50. DENTAL:
CRITERIA VALUE NORMAL VALUE PRO/CON
EXTRACTOION
Tooth size- arch length Upper : 2mm
Lower: 6.5 mm
8-11 crowding CON
Curve of Spee L:0mm,R:0mm More than 6 severe CON
Bolton discrepancy 78.2% If 4* more then extract CON
Irregularity index 5 mm X>6.5 mm extract CON
Incisor-Man. Plane angle 88.4 85˚-95˚ CON
Frankfurt-Man. Incisal
angle
61˚ 60˚-75˚ CON
Upper incisor to NA 0 MM 4mm anterior, (22-25) CON
Lower incisor to NB 4 mm, 4 mm anterior ( 22-25) CON
Lower incisor to A-pog -1.2 1-3 mm anterior to it CON

51. SKELETAL
CRITERIA VALUE NORMAL VALUE PRO/CON NON-EXTRACTION
FMA 30 20˚-30˚ CON

52. SOFT TISSUE
CRITERIA VALUE NORMAL VALUE PRO/CON
EXTRACTION
NASOLABIAL ANGLE 118 90˚-115˚ CON

53. OTHER FACTORS
CRITERIA VALUE PRO/CON EXTRACTION
GROWTH Non-growing patient PRO
MIDLINE deviated PRO
PATIENT PEREFERENCE Non-extraction PRO

54.  Camouflage:
 Skeletal is class mild 2 , wits 0.
 Chief complain is mainly related to malaligned teeth,
 Fixed Appliance
 Alignment of teeth
 Bodily movement
 Upper and lower arch coordination
 Upper MBT :to avoid retroclination of the incisors while retraction
 Lower roth: average torque needed
 TPA with Midpalatal miniscrew :
 Maximum anchorage is needed on right side, and aboslute anchorage
on left side.
 To preserve space to retract the canine and correct midline
 Molar relationship ¾ and class II fill unit.

55.  Bite raising :
 Disocclusion allow freedom of movement of upper 7’s
 Lower stripping :
 To gain space in lower arch
 MBT prescription slot 0.022:
 High torque is needed to proclined the retracted anterior teeth
 Extraction :
 To correct the midline
 To achieve full unit molar and canine
 Retention ( Upper and Lower fixed retainer ),
 Upper fixed retainer: presence of rotated teeth
 Lower fixed retainer: prevent late anterior mandibular
crowding
 rotation

56. 1. Full records.
2. Separators around 6’s , upper 7’s.
3. Bands selection on 6’s , upper 7’s.
4. Impression for TPA.
5. Cementation of TPA.
6. direct bonding of fixed appliance ( upper MBT, lower ROTH)
with bite raising on post teeth.
7. Aligning by 0.016 NiTi, .0 017*0.025 NiTi
8. Insertion of midpalatal miniscrew
9. Refer to surgery for extraction of UR4
10. Start space closure and correction of midline
11. Interdental stripping on lower anterior teeth with Working arch
wire 0.019*0.025 SS .

57. 12. Finishing and detailing
 TMA wire .021* .025
 Settling by posterior elastics using light wires
13 . Debonding :
 Impression for retainers
 Short term: modified Hawley
 Long term upper , lower permanent