orthodontics

1. Orthodontic Case
Presentation
Done By :- Dr Wesam Alsaadi
Supervised by :- DR Ahmad Altarawneh
Dr Ragdah Shamout
Dr Anwar Rahamneh

2. Patient's Initials:- F.B
Age:- 16 years, and 3
months
Ocupation :- Student
Residency :-Al-Fhais
Nationality:-Jordainian

3. “ I don't Like the
apperance of my teeth
upon Smiling
Specially my Upper
Right canine”

4.  Medical History:
Food Hypersensitivity,
 Dental History
- Extracction of upper left second Molar
- Amalgam Filling in the Upper Right 6
- History of Failed previous orthodontic
Treatment Using URA ( 4years ago)
 Habits: No habits noticed or mentioned
 Motivation: Highly motivated, Internal
(self-motivation)
 Expectations: realistic expectations

5.  Carious Upper left Second
Premolar
 Poor Oral Hygine with inflamed
Swolen REd Gingival MARGIN

6.  Speech
Normal flow of speech. No difficulties
detected
 habbit
mouth breathig
 TMJ
- Clicking on Right Side upon Closure
-Deviation of the mandible to the right
upon closure
-Displacement present:- there is a
discrepancy between CR and CO

7. Extra oral Examinations
Frontal View

8. Extra oral Examinations
Profile View

9. Extra oral Examinations
Oplique View

10. Facial Propotions “Macro Esthetic”
 Frontal View
 1) Symetry
 No gross
asymetry
“within
normal”

11. Facial Propotions “Macro Esthetic”
 2) Frontal facila
proprtion
 Fifths :
 Sepration of the eye
and width of the nose
are equal
 the nose and the chin
are centered within
central fifth
 inter pupillary distance
equal the width of the
nose

12. Facial Propotions “Macro Esthetic”
 Frontal
view
 3) Lower
Facial Hight:-
 slightly
increased
 The mouth one
third of the way
between the
base of the
nose and the
chin
1/
3
2/3

13. Facial Propotions “Macro Esthetic”
 profile
analysis
 soft tissue profile:-
Slightly Convex
Profile, “ mild Class II”

14. Facial Propotions “Macro Esthetic”
 Profile
Analysis
 Naso-Labial Angle
“normal 90-110”
- 93 degree “within
normal”
 Labio-Mental Fold “
normal 110-130”
- 162 degree “obtuse”
 Fronto-Nasal Angle“
normal 114-140”
- 140 “within normal

15. Smile Framework “ Mini Esthetic”
 Profile
Analysis
 mandibular
plane angle
 is within normal
nither too steep
nor too flat

16. Tooth - Lip relationship “Mini-Esthetic'
 Mini-Esthetic are affected by
size of the view and they are
best viewed in full face
1. Dental midlines
 minimal shift in the upper
dental center line to the right
2. Buccal Corridors
 buccal corridor (as % black
space of intercommisure
width) “normal 13% and Max
17%
- pt has 25% “wide buccal
corridor, narrow smile”

17. Tooth - Lip relationship “Mini-Esthetic'
3. Teeth and Gingival Display
 full incisal show upon smiling
and within normal gingival
display “ up to 4mm gingival
display”
4. Smile Arc
 smile arc of upper teeth is
not parallel to lower lip arc
since the pt has hight bucally
erupted right canine

18. Dental Apperance: Micro-Esthetic
 micro esthetic are not affected
by size of the view
 the deviation from normal is
seen on the right side in the
gingival hight
 the canine gingival hight
should be at same level of
Central incisor, but for the pt it
is higher

19. Intra Oral Examination

20. Intra Oral Examination

21. Lower Arch
 Large tongue size
 All teeth present From LL7 to
LR7
 u shaped broad arch
 slightly proclined lower labial
sigment
 upright canines
 minimal rotation in the LR
2nd Pm and LL 1st PM

22. Upper Arch
 all teeth present except UL7
 carious UL5
 constrected comparec to the
lower arch
 mild crowding” mainly
anteriorly”
 upright upper Central Incisors
 severly rotated UL 5
 Bucally erpted UR3
 rotated UL and UR 6s

23. In Occlusion
 Very poor O.H
 class III incisal relation
 Upper center line shifted to
the right 0,5 mm
 Lower centerline shifted to
the left 1mm
 Oj =1 mm
 OB = 10% “reduced”
 anterior cross bite UL2

24. Left Buccal Segment in Occlusion
 cross bite from the canine to
UL6
 1/4 unit class II canine
relation
 1/2 unit class II molar
relation

25. Right Buccal Segment in Occlusion
 Cross Bite From UR 4 to
UR6
 Class I canine relation
 1/4 unit Class II Molar
relaTION

26. Upper center line shifted to the
right 0,5 mm
Lower centerline shifted to the left
1mm
Oj =1 mm
anterior cross bite UL2
Study Models
• Lower incisors occlude anterior
to Upper Incisor Cingulum
“class III”
• Over bite Only 10% complete
with the Teeth

27. Study Models

28. Curve of Spee
Right Side Curve of spee:-
1mm
Left Curve of Spee:-
zero mm

29. Lower Study Model
 Wide Lower Arch
 Inter Canine Width :-
- 40 mm “ normal 27.58 for M”
Inter Molar Width :-
-53 mm “ 44.7 mm fot Males”

30. Upper Cast
 Constricted Upper Arch
 Inter-Canine Width:-
- 36 mm “normal 34 for Males”
 Inter-Molar Widt1h :-
- 47 mm “ 50.45 mm for Males”

31. Space Analysis
Lower Arch
 Space Available = 74 mm
 Space Required = 73.5 mm
 Extra Space OP 0.5 mm
 well aligned lower arch with
minimal
25
12 12
2
5

32. Upper Arch
Space Analysis
 Space Available = 74 mm
 Space Required = 76 mm
 Defeient Space = 2mm
 mild upper crowding
22
1616
20

33. Tooth Size Analysis “Bolton”
5 4 3 2 1 1 2 3 4 5
8 8 8 6 6 6 6 8 8 8
LR
5 4 3 2 1 1 2 3 4 5
7 7 8 7 9 9 7 8 7 7
LR

34. Tooth Size Analysis “Bolton”
 Bolton Analysis:
 Σ Lower anterior teeth widths
Σ Upper anterior teeth widths
83% increased “n= 77.2 +/- 1.65”
 Σ Lower all teeth widths
Σ Upper all teeth widths
94% increased “ n= 91.3 +/- 1.91”
 This indicates excess of tooth
material in the lower arch

35. Royal London Analysis
Lower Arch Upper arch
Crowding/Spacing + 0.5 mm - 2 mm
Angulation
/inclination change
0 0
Leveling curve of
Spee
0 0
Arch width change 0 4mm
Incisors A/P change - 1 mm 0
Total - 0.5 mm + 2mm

36. Panoramic X-Ray
 No Bone Pathology
 Left Side Opening of the condyle not the same as on the right side
 Unerupted Conical Supernumeary tooth between roots of UR2 and 3
 all teeth are present except UL 7
 tooth Buds of all third molars are present

37. Cephalpmetric Analysis
SNA 84
81⁰ ±
3⁰
Orthognathic
SNB 78
78⁰ ±
3⁰
Orthognsthic
Mandible
ANB 6 3±2
SN-
MAX
6 5±3
need Eastman
Correction
ANB* 4.5 mild Class II Sk
MMP
A
28
27⁰ ±
4⁰
Within Normal
UI-
MX
106
109⁰
± 6⁰
Normal
Inclination
LI-
MD
98
93⁰ ±
6⁰
Normal
Inclination
LFH
%
56%
55-
60%
within Normal
LFH
wits zero

38. IOTN - Dental Component
 4c “Srevere / Need of
Treatment
 Anterior or Posterior
crossbite with greater
than 2mm discripancy
Between Retruded
Contact
&iNTERCUSPAL
POSITION

39. IOTN - Esthetic component
Pic 7:-
Moderat Need for
Orthodontic
Teatment

40. Diagnostic Summary
 F.B 16 years old ,male patient, with history of Food Poisining,mouth breathing,
and History of Failed Orthodontic Treatment with Removable Appliance 4 Years
ago, and Very Poor O.H with Gingivitis Plus Carious UL5, also he has newly
extracted his UL7, Complaining of unesthetic smile Especially because of the
position of UR3.
 F.B has Class III incisal relation Based on mild Class II Skeletel Relationship with
Competent Lips and Large Tounge, wide buccal corridors complicated by
unerupted conical Supernumerary tooth between the roots of UR 2 and 3, Plus
Bilateral Posterior Cross bite with displacement, and anterior Cross Bite On UR2,
which could be the reason for the clicking on the right side of his jaw upon
opening his mowth
 F.B Molar Relation is 1/2 unit class II on the left side for both molar and canine,
while his Molar relation on the right side is 1/4 II and the canine is class I.
Oj=2mm and reduced OB to 10% with lower center line shifted 1mm to the left,
mild crowding in the upper arch, mild rotations in L & U R5, both U 6s while his
UL5 is severly rotated.

41. Problem List

42. Problem List
 Pathological problems:
1- Mouth breathing
2- Very Poor Oral Hygine
3- Carious UL5
4-Unerupted SN bet Roots of Ur 2,3
Developmental problems:
A) Patients concern:- “i don't like my
smile sepically me upper right 3”
B) Smile esthetics: bucally erupted UR3,
wide bucal corridors
C) Alignment and symmerty:-
1- Asymetric arch,mild rotation LR5
2- Asymetric Upper arch with Costricted Max,
rotations in both U6s and UL5
D) Skeletal and dental problems in
transverse plane:
1-No skeletal asymmetry
2- Upper midline shifted 0.5mm to the
Right
3- Lower Midline shifted 1mm to the left
4-Bilateral posterior Cross bite with
displacement
E)Skeletal and dental problems
in A-P plane:
1- Convex Profile
2- Mild Class II Skeletal relationship
3- 1/2 Unit class II Molar, Canine on left
side
4- 1/4 II moal on RT, with class I canie
5- class III incisal relation with 2mm OJ
F)Skeletal and dental problems in
vertical plane:
1- Reduced Over Bite 10%

43. Treatment Aims
 Improve patients' breathing through the
nose
 Improve pts O.H
 treat carious UL5
 Surgical Removal of the SN
 Improve pts' Smile Esthetic and alighn
upper Right 3
 Correct Posterior and Anterior cross
Bite and removing the displacement
 Achieve class I Molar and Canine
relationship on both sides
 correct rotated Teeth
 Achieve class I Incisal relation, and
correct centerline shift on both arches

44. Tratment PLan
 Camoflage
Treatment
 Non Extraction
 EXPANSION
1- Referr pt to ENT clinic to detect and mansge
his mouth breathing problem, and to perio Clinic
for consultation and mangment of Pts Periodental
Health
2- Treat Carious UL5
3-Surgical Removal of Unerupted SN bet Roots
Of UR 2 , 3
4- Banded RME with Extended Armes
5- Modefied TPA with extended Arms “zakirson
type” to Derotate U6s
6- Upper and Lower Fixed Appliance “SWA “, MBT
prescription slot 0.022
7- Consider Stripping In Lower Anterior Teeth to
Correct Bulton Discripancy
8- Retention
Short Term : Upper Hawely retaine.
Long Term: Upper and Lower Fixed Retainers with
CSF to rotated teeth mainly UL5”

45. Justification
 refreeal to ENT to improve pt'
breathing inorder to have stable results
with maxillary expansion.
 Patient is non-grower whose
Consirned only about Dental problems,
with class I Skeletal, good vertical
facial proportions,and normal soft
tissue features
 Surgical Removal of the Unerupted SN
to avoir its interferance with tooth
movement
 No Need for Extraction Niether to
Relief Crowding, nor to Correct Molar
relation , nor Incisal inclination, space
will be gained From expansion and
IPR
 We need Expansion to Correct
Cross bite and improving smile
esthetics, getting benefit from
the extra space to align the
Upper Teeth, although
intercanine width and intermolar
width are within normal we are
expansion to camoflage the
extra wide mandible, which its
constriction will be more difficult

46. Justification
 Zakirson TPA with extended
arms is important to maintan
the Expansion and To
Derotate U6, To help in
Acvieve Class I Molar
Relation
 Fixed Applincs is essencial
to correct reotated teeth and
to have precise 3D posiotion
of Teeth
 MBT prescription is used ,
since it has Less Tipping to
menimize Class III incisal
relation and Prevent Further
Inclination Of lower incisors.
 Stripping to reduce lower
incisor Proclination and
achieve positive OJ and
OB.
 short Term Retention Uper
Hawely Retainer “ to
maintain Expansion”, and
Lower VFR
 Long Term Retention which
is Fixed Retainer to Avoid
Late Lower iNcisor
Crowding, and Upper Fixed
To avoid relapse of the
UR3