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1. Orthodontics Case
Presentation
Done By : Dr. Noor Haddadin - 3nd Year Resident

2. Personal Data
• Patient’s initials: Yehya Khalid
• Gender: Male
• Age: 12Yrs-5 months
• Career: Student
• Nationality: Jordanian

3. Chief Complaint
• “ My teeth are not straight” ,pointing to LLs.

4. Medical & Dental History
• Medical history:
denies any medical problems
• Dental history:
Previous visits to dental clinic for check ups
Fillings UR6,UL6,LR6

5. History
• Trauma :No history of dental trauma
• Habits :No previous or on going habits mentioned or noticed
• Motivation :Patient is motivated( self- motivation)

6. Extraoral Photos

7. Intraoral Photos

8. Intraoral Photos

9. Study Models

10. Panoramic View

11. CEPHALOMETRIC
ANALYSIS
SNA 80 81⁰ ± 3⁰
SNB 75 78⁰ ± 3⁰
ANB 5 3⁰ ± 2⁰
Sn-Mx 8.5 8⁰ ± 3⁰
Corrected ANB 5.5
Wits appraisal 1.3mm 1(+-1.9) mm
(M)
MMPA 33 27⁰ ± 4⁰
FMPA 34.5 28⁰ ± 4⁰
UAFH 52mm
LAFH 63mm
AFH Ratio 57% 55% ± 2%
UI-MX 110 109⁰ ± 6⁰
LI-Mn 89 93⁰ ± 6⁰
IIA 135 135⁰ ± 10⁰
Jarabak ratio 61% 59-63%

12. Cervical Vertebral Maturation

13. Facial And Dental Appearance
• 1. The face (macroesthetics)
• 2. Smile Frame (miniesthetics)
• 3. Teeth (microesthetics)

14. Extraoral Examination(Macroesthetics)
• Anteroposterior assessment
maxilla to mandible relationship
• Vertical assessment
facial thirds
Angle of lower border of mandible to the maxilla
• Transverse assessment
Facial asymmetry
• Soft tissue assessment

15. Anteroposterior Assessment
• Convex profile

16. Anteroposterior Assessment
• Zero meridian line
• >(0+/-2) to soft tissue Pogonion
3 mm

17. Vertical Assessment
Clinical slight increase in LFH
Upper lip in the upper 1/3 , lower lip in the lower 2/3
of lower third
FMPA

18. Transverse Assessment
• The pt has symmetrical face
• Facial midline showing
alignment of the middle part
of the upper lip at the vermillion
border and chin point
• Nose deviated to the right

19. Transverse Assessment
• Equal medial and lateral
• Fifths
• -Interpupillary distance > the
width of the mouth.
• -The width of the nose > the
central fifth

20. Soft Tissue Examination
• Normal tongue size and function
• Frontonasal Angle:(115-135)
• 137 normal
• Nasolabial Angle: (90-110)
105 normal
• Labiomental Angle: (110-130)
• 118 Acute

21. Facial and Dental Appearance
1. The face (macroesthetics)
2. Smile Frame (miniesthetics)
3. Teeth (microesthetics)

22. Smile analysis
The smile index = intercomisure width/ interlabial gap on
smiling
=7.3/1.5=4.8 (Ackerman et al )1998
** The lower the smile index, the less youthful the smile appear
Asymmetric smile
The buccal corridor ratio=(inner commissure width-visible
maxillary dentition)/inner commissure x 100%
(5-3.9)/5=15%
Medium- smile
(Frush and Fisher) 1958

23. Facial And Dental Appearance
1. The face (macroesthetics)
2. Smile Frame (miniesthetics)
3. Teeth (microesthetics)

24. 3.Teeth (microesthetics)
• Normal incisal show

25. Tooth proportions
• gingival lines:
• Central incisors show almost
same gingival level
• UL2 high gingival line
• UR2 gingival margin lower than
centrals

26. Intraoral Examination

27. Intraoral Examination
• Dentition status: Permanent dentition
• Teeth present 765421 124567
765421 1234567
• Restored :LR6,UR6,UL6
• Caries: Clinically, Caries free

28. Intraoral Examination
• Fair-poor Oral Hygiene
• Yellow discoloration(initial
decalcification spots) Around the
buccal side of the teeth

29. Intraoral Examination
• Central lines:
Lower shifted 1mm to the right
• Incisors classification:
Class II div 1
• OJ:
4 mm
OB:
60%
• Crossbites:
UL2 –LL3 edge to edge
• No Displacement

30. Intraoral Examination
Class 1 molar ½ unit class 2 molar

31. Upper Arch
• U-shaped, Asymmetric, spacing
UR2,UR4
• No canines shown
• Normal incisors inclination
• Rotated UR6,UR5,UL4
• Restored UR6,UL6

32. Lower arch
• Asymmetric , crowded
• Uprighted LLS
• Lingually impacted LR3
• Mesially tipped LR4
• Distally tipped LL3
• Rotated LL4,LL5
• Lingually tipped LL6

33. Study Models Examination

34. Front View
• Midlines not coincident
• Lower shifted 1mm to the Rt

35. A-P view
• Class II div 1 incisal relation
• Increased incomplete overbite

36. Upper Cast Occlusal
• Interpremolar width = 32mm
(decreased)
• Intermolar width = 45mm
(normal)

37. Lower cast occlusal
• Interpremolar width = 30mm
(decreased)
• Intermolar width = 40mm
(decreased)

39. Curve Of Spee
Rt : 3mm Lf: 3mm

40. Estimation of canines size
• Tanaka and Johnston :
• ½ the MD width of incisors +10.5mm= width 3,4,5
(26/2) + 10.5 =23.5mm
23= LR3 + 15------- LR3 =8.5mm
• ½ the MD width of incisors +11mm= width 3,4,5
(26/2) +11= 24 mm
24 = U3 + 15 ------ U3= 9mm

41. Space analysis
• Upper arch:
• Asymmetric
• Space available= 19+36+16=71 mm
• Space needed=78.5 mm
• Moderate crowding of -7.5mm

42. Space analysis
• Lower arch:
• Asymmetric
• Space available= 22+24+18=64 mm
• Space needed= 73 mm
• severe crowding of - 9 mm

43. Tooth Size Analysis (Bolton)
• Bolton Analysis:
• Σ Lower anterior teeth widths = 43mm =86.86%
• Σ Upper anterior teeth widths 49.5mm
• n= 77.2 +/- 1.65
• Σ Lower all teeth widths = 96mm = 94.58%
• Σ Upper all teeth widths 49.5mm
• n= 91.3 +/- 1.91
6 5 4 3 2 1 1 2 3 4 5 6
11.5 7 7.5 9 6.5 9 9 7 9 7.5 7 11.5
6 5 4 3 2 1 1 2 3 4 5 6
11.5 7.5 7.5 8.5 6.5 6.5 6.5 6.5 8.5 7.5 7.5 11.5

44. Royal London
Lower arch Upper arch
Crowding/Spacing -9 7.5
Angulation /inclination
change
+0.5 0
Leveling curve of Spee -1 0
Arch width change +2 +2
Incisors A/P change 0 0
Total -7.5 -5.5

45. Panoramic interpretation
-All wisdom teeth buds are present
-Upper canines show good prognosis ,LR3
-Amalgum restorations on LR6,UR6
-No other apparent pathologies

46. 1. Inspection
2. Palpation
3. Radiography
Localization of Impacted upper canines

47. 1. Inspection
• Delayed eruption
• Flared laterals
• No mobility or tenderness in
lateral incisors

48. 2.Palpation
• Absence of buccal bulge for both
canines
• Right reggae area is larger than
left

49. 3. Radiography : Vertical parallex
• Rt : palatal / Lt: within the arch

50. 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
• power and short

51. 1. Canine angulation to the midline
• Grade 1=0-15 degree
• Grade2=16-30
• Grade 3= more than 30
• Average

52. 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
• Average

53. 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
Good

54. 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
• Good

55. IOTN-dental health component

56. IOTN- Esthetic component
• N/A

57. Diagnostic Summary
• Y.K 12yrs- 5 months old male pt , MF, complaining of not having
straight teeth. Patient has fair-poor OH, a class II div 1 Malocclusion
on a class II skeletal base with increased vertical dimension. He has a
symmetrical Face with compromised smile esthetics. Complicated by
impacted upper canines and lower Rt canine. He has a ½ unit II molar
on left side, class I on right side. OJ is 4mm , OB is increased. Lower
midline is shifted 1 mm to the Rt. Upper arch has moderate crowding,
and severe crowding in the lower.

58. Problem List
• Skeletal and dental problems in transverse plane:
o
o Lower midline shifted 1mm to the right
o
• Skeletal and dental problems in A-P plane:
• Clinically convex profile
• Class 2 Skeletal base ( retrognathic mandible)
• Oj 4mm
o Lt Molar : ½ unit II
o Incisor class II div 1
• Skeletal and dental problems in vertical plane:
o Slightly increased LFH
o Increased OB
o 3 mm depth curve of spee
Pathological problems:
• Pathological problems:
• Poor OH
• Yellow discoloration around the teeth in buccal
segment
• Developmental problems
DevePatient’s concern the malaligned teeth
• Smile esthetics: compromised smile complicated
by impacted canines
• Alignment and symmerty:
o Asymmetric lower arch with with 9 mm
crowding
o Asymmetric upper arch with 7.5mm crowding
o Rotated teeth
o Impacted Ul3,UR3,LR3

59. Treatment Aims
• Improve Oral hygiene
• Improve his smile by creating more normal gingival relationships , and smile symmetry
• Relief crowding in upper and lower arches , and align the teeth (C/C)
• Correct rotated teeth
• Traction and Open space for the impacted UL3,UR3,LR3
• Correct lower midline shift
• Correct class 2 skeletal base( achieve better facial profile)
• Achieve 2mm OJ
• Achieve class I molar and canine relationship
• Achieve class 1 incisor relationship
• Restrain vertical growth
• Achieve normal OB
• Flaten curve of spee
• Finishing and detailing of occlusion.
• Retain corrected results

60. Treatment plan
1. OHI
2.Anchorage: high pull headgear, T.P.A and lingual bar
3. Upper, Lower fixed appliance(SWA MBT, roth)
4.Surgical exposure for UL3,UR3, remove soft tissue around LR3 +
traction
5.Extraction
6. Retention

61. Retention Protocol
• 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

62. Justification
• Anchorage reinforcement is needed because of
Traction of the displaced canines to the occlusion.
Transverse anchorage during canine traction
Preserve the extraction space.

63. Justification
• Extraction :
• Normal NLA
• Normal incisal show
• Thin gingival biotype around LLS
• severe crowding in lower arch, moderate in upper arch
• Upper 4’s to allow space for the impacted canines
• Upper canines has good prognosis
• Fixed Appliance
• Bodily teeth movement is required.
• Alignment of teeth.
• Upper MBT :to avoid retroclination of the incisors while retraction
• Lower roth: average torque needed
• Close the extraction spaces.
• Preserve / correct teeth torque.

64. Treatment details and mechanics
1. Full records
2. separators around 6’s
3. Band selection: impression for T.P.A + lingual bar
4. Cementation of T.P.A +lingual bar +delivery of headgear (wear time 8-10
hrs/day) , give instruction about how to wear it
5. Direct bonding of the brackets( upper MBT, Lower roth) positioning the
brackets incisaly to control the bite
6. Refer to surgery for exposure of canines +place attachemts
7. After assurance that canines are moving(not ankylosed) refer to extract

65. Treatment details and mechanics
8. Laceback , cinch back
9. Leveling and aligment :
.014 niti superelastic
.016 niti superelastic
.018 niti superelastic
.017 *.025 niti superelastic
10. Space closure and molar relation correction
.019* .025 s.s wire

66. Treatment details and mechanics
10. Sliding mechanins
piggy back for UL3,UR3,LR3 with .014 niti
Continue space closure
11. Finishing and detailing
TMA wire .021* .025
Settling by posterior elastics using light wires
12. Debonding
Impression for retainers
Short term: modified Hawley
Long term upper , lower permanent .0175 inch s.s wire

67. Thank You