This document presents the orthodontic case of a 12-year-old female patient. She is dissatisfied with the appearance of her teeth and has a Class III malocclusion with crowding. Treatment aims to relieve crowding, correct rotations, and improve her smile appearance through nonextraction orthodontics while monitoring mandibular growth. Extractions are proposed to relieve moderate upper arch crowding and achieve a Class II molar relationship on the right side and 1/2 unit on the left. Fixed appliances and retention with removable and fixed retainers are recommended.

1. Orthodontics Case
Presentation
Presented by : Dr. Lubna Abu Alrub – 3rd Year Resident

2. Personal Data
• Patient’s initials: M.S
• Gender: female
• Age: 12Yrs-5 months
• Career: Student
• Nationality: Jordanian

3. Chief Complaint
• I don’t like the appearance of my teeth , I have a displaced tooth “

4. Medical & Dental History
• Medical history:
denied any medical problems
• Dental history:
Previous visits to dental clinic for check ups
Fillings LL6,LR6

5. History
• Trauma :No history of dental trauma
• Habits :Grinding on maxillary central incisors

6. Extraoral Photos

7. CEPHALOMETRIC
ANALYSIS
SNA 77 81⁰ ± 3⁰
SNB 78 78⁰ ± 3⁰
ANB -1 3⁰ ± 2⁰
Sn-Mx 9.5 8⁰ ± 3⁰
Corrected ANB +1
Wits appraisal -1 1(+-1.9) mm
(M)
MMPA 22 27⁰ ± 4⁰
FMPA 23 28⁰ ± 4⁰
UAFH 53mm
LAFH 62mm
AFH Ratio 55% 55% ± 2%
UI-MX 105 109⁰ ± 6⁰
LI-Mn 101 93⁰ ± 6⁰
IIA 132 135⁰ ± 10⁰
Jarabak ratio 71% 59-63%

8. Cervical Vertebral Maturation

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

10. 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

11. Anteroposterior Assessment
• straight profile

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

13. Vertical Assessment
Average LAFH
Upper lip in the upper 1/3 , lower lip in the lower 2/3
of lower third
Reduced MMPA

14. Transverse Assessment
• Slight facial assymtry
• upper and lower midlines shifted
to the right by 1 mm.

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

16. Soft Tissue Examination
• Normal tongue size and function
• Frontonasal Angle:(115-135)
• 133 normal
• Nasolabial Angle: (90-110)
110 normal
• Labiomental Angle: (110-130)
• 120 normal

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

18. Smile analysis
The smile index = intercomisure width/ interlabial gap on
smiling
=9.00/.8=11.25 (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%
(9-7.1)/9=22%
Medium- narrow
(Frush and Fisher) 1958

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

20. 3.Teeth (microesthetics)
• reduced incisal show at smile .
• Increased buccal corridor.
• Upper lip is thin with no
vermillion display , lower lip is
fuller .

21. Tooth proportions
• gingival lines:
• Central incisors show almost
same gingival level
• UL2 gingival line lower than the
centrals
• UR2 gingival margin lower due
to cross bite

22. Intraoral Examination

23. Intraoral Examination
• Fair Oral Hygiene
• Mild deposits of plaque around
gingival margins – initial
gingivitis

24. Intraoral Examination
• Central lines:
Upper and lower shifted to the right by 1
mm.
• Incisors classification:
Class III
• OJ:
1mm
OB:
zero
• Crossbites:
UR2
• No Displacement

25. Intraoral Examination
Right canine full II
molar 3/4 unit Class 2
Left Canine ½ II
Molar ½ unit class 2

26. Upper Arch
• U-shaped, Asymmetric,
• Upper incisors appear to be
upright
• UR3 crowded buccally , Ur2 in
crossbite .
• Rotated UR6, UR5 , UL4 ,UL5
UL6
• Upper arch has moderate
crowding

27. Lower arch
• Asymmetric U shaped arch.
• Mildly crowding in lower
anterior labial segment.
• LR5 ectopic eruption
• Mesially tipped LR6
• Lower arch is mildly crowded

28. Study Models

29. Front View
• Midlines are coincident
And shifted to the right by 1 mm

30. A-P view
• Class III incisal relation
• Reduced overbite – edge to edge

31. Upper Cast Occlusal
• Interpremolar width = 35mm
(normal)
• Intermolar width = 49mm
(increased)

32. Lower cast occlusal
• Interpremolar width = 31mm
(normal)
• Intermolar width = 45mm
(increased)

33. Curve Of Spee
Right : 1mm Left : almost flat
Perpendicular distance of deepest cusp tip and flat plane –
Masoami 2003

34. Space analysis
• Upper arch:
• Asymmetric
• Space available= 24+23+23=70 mm
• Space needed=77.5 mm
• Moderate crowding of -7.5mm

35. Space analysis
• Lower arch:
• Asymmetric
• Space available= 22+22+21=65 mm
• Space needed= 67 mm
• mild crowding of - 2 mm

36. Tooth Size Analysis (Bolton)
• Bolton Analysis:
• Σ Lower anterior teeth widths = 38mm =78.3%
• Σ Upper anterior teeth widths 48.5mm
• n= 77.2 +/- 1.65
• Σ Lower all teeth widths = 89mm = 89.9%
• Σ Upper all teeth widths 99mm
• n= 91.3 +/- 1.91
6 5 4 3 2 1 1 2 3 4 5 6
11 7 7 9 6.5 9 9 6 9 7 7 10.5
6 5 4 3 2 1 1 2 3 4 5 6
11 7 7.5 8 6 5 5 6 8 7.5 7 11
Normal
Normal

37. Royal London
Lower arch Upper arch
Crowding/Spacing -2 -7.5
Angulation /inclination
change
0 +2
Leveling curve of Spee 0 0
Arch width change 0 0
Incisors A/P change -1 0
Total -3 -5.5

38. Visualized treatment objectives
6
1
3.5
Chart no.1
RT LT
C 3*3 0 0
C 6*6 -3 0
P 0 0
COS 0 0
M +1 -1
T 3*3 +1 -1
T 6*6 -2 -1
IPR =2.5mm

39. Visualized treatment objectives
• Chart no.3
1
1 3.5
1
6 2.5
2
(7)(7)

40. Panoramic interpretation
-All wisdom teeth buds are present
-impeded eruption of LR5
-Amalgum restorations on LR6,LL6
-No other apparent pathologies

41. Possible etiology
A.Skeletal : (A-P) Class III skeletal pattern : Genetic (Litton et al 1970). 1/3
of patients with severe class III have a parent with class III problems but
there is no detected autosomal dominant or recessive method of
transmission.
B.Dental : (A-P)Class 2 molars and canine s : early loss of deciduous teeth ,
drift of posterior teeth , loss of leeway space
Reduced OJ , OB : features of class III skeletal pattern – no dental
compensation
Secondary crowding ; early loss of deciduous teeth , tooth size arch size
discrepancy.
C.Soft tissues : not envolved in etilogy but encourage dento lveolar
compensation .

42. IOTN-dental health component

43. IOTN- Esthetic component
• N/A

44. Diagnostic Summary
• M.S 12yrs- 5 months old female pt , MF, dissatisfied with the
appearance and crowding of her teeth. Patient has fair-poor OH, a
class III incisal classification on a class III skeletal base with average
vertical dimension. she has a asymmetrical Face with compromised
smile esthetics. Complicated by crowded upper right canine and
upper right permenant lateral in crossbite . she has a ½ unit II molar
on left side, class II on right side. OJ is 1mm , OB is zero . Upper and
lower midlines are shifted 1 mm to the Rt. Upper arch has moderate
crowding and mild crowding in the lower.

45. Problem List
• Skeletal and dental problems in transverse plane:
o
o Facial assymetry
o Upper and Lower midlines are shifted 1mm to the right
o
• Skeletal and dental problems in A-P plane:
• Skeletal class III base relationship
• Oj 1mm
o Canines : Rt full unit II left ½ II
o Rt molar ¾ II lt ½ unit II
o Incisor class III
• Skeletal and dental problems in vertical plane:
o Reduced OB
o Slight increase in LAFH
Pathological problems:
• Pathological problems:
• Poor OH
• Initial gingivitis with cervical plaque deposites .
• Developmental problems
DevePatient’s concern the malaligned teeth
soft tissues : thin upper lip, obtuse NL angle.
• Smile esthetics: compromised smile complicated by
buccally displaced UR3 and UR2 in anterior crossbite
• Reduced incisal show .
• Alignment and symmerty:
o Fairly symmetric lower arch with minimum crowding
o Asymmetric upper arch with moderate crowding
o Rotated teeth
o Buccaly erupted UR3
o UR2 in crossbite

46. Treatment Aims
• Improve Oral hygiene
• Relief crowding in upper and lower arches , and align the teeth (C/C)
• Accept class 3 skeletal pattern , moniter growth .
• Improve patients smile by creating more normal gingival relationships , and smile symmetry , increase incisal show .
• Correct rotated teeth
• Correct upper and lower lower midline shift
• achieve better facial profile through improving upper teeth inclination
• Achieve normal 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

47. Treatment plan
“Orthodontic camouflage – extraction case”
1. OHI
2. Upper, Lower fixed appliance(Straight arch wire technique , MBT
perscription)
3.Extraction
4. Absolute anchorage “ indirect anchorage “
5. Retention : upper and lower permanent retainers
upper and lower HR.
4 4
*monitor growth of the mandible

48. • Monitoring the growth of mandible
Serial Clinical measurements like OJ
Serial Study models
Serial Photograph or 3D stereo photogrammetry
Serial Ceph (not justified)
Growth Treatment Response Vector (GTRV) analysis

49. Retention Protocol
• Short term:
Upper modified HR , lower regular HR , worn full time for 6 months ,
part time for 6 months .
• Long term :
Upper and lower permeant retainers from 3-3 (braided steel wire of
17.5 mil

50. Justification
1. OHI
 to stabilize patients periodontal health before
comprehensive orthodontic treatment .
Visible plaque deposits on gingival margins.

51. 2.Camouflage
• Patient has passed the optimal age for protraction Facemask –not
applicable .
• Mild skeletal class 3.
• Acceptable profile.
• Good vertical proportions
• Normal SNB
• Concerned with dental problems only
• No dental compensation

52. 3. Extraction :
• Moderate crowding in the upper arch ( -7.5 mm)
• Extraction spaces will be used to relief crowding and correct molar
relationship – ¾ II left ½ II right .
• Mild crowding in the lower arch , space can be gained from IPR .
• No extraction in lower arch to keep the cop of decompensation if
orthodontic-orthognathic approach is decided later on.

53. • Regarding extraction and smile width : studies have looked at
whether or not extraction causes a “ dark buccal crridor “ and found
that this is not the case – Johnson & smith ,1995 ; Gianelly , 2003.
• Extraction and patients profile : latest cochrane review published in
American Journal of orthodontics states that no significant
difference between 2 groups of patients designed to an extraction
group and non in terms of facial esthetics – lared W, koga da silva et
al – American journal of orthodontics 2017 .
• Extraction treatment did not result in a narrow maxillary dental
arches – Akyalcin et at 2011

54. 4.Fixed appliance
• To enable 3D control of tooth movement .
• Bodily tooth movement required
• To close extraction spaces and midline shift
• Orthodontic problems such as :Crowding , rotations , anterior
crossbite , ectopic LR5 are best addressed by fixed appliances .

55. MBT system
• Upper palatal root torque
• Lower labial root torque
Camouflag class 3

56. •Why not pendulum (distalization )?
Reduced OB
Right molar is in ¾ class 2 relationship
7s are fully erupted
Oral hygiene still to be improved , pendulum
carries the potential of food impaction and
loss of compliance. .

58. Why to extract maxillary first premolars (4s) not 5s ?
Space is conveniently sighted to relief crowding (closer to labial
segment).
3 to 5 contact is generally considered acceptable .
More anchorage loss when 5s are extracted in prefereance to 4s.
5s are extracted to avoid retro inclination of upper incisors in class 3
malocclusion , this can be avoided by correct and proper mechanics .

59. Absolute Anchorage
• Absolute anchorage is needed to move upper buccal segments into
full unit class II without altering incisal A-P position .
• Patient reached the age of bone maturity suitable for TADS ( 11 years
old ) , according to proffit .
• Indirect vs direct : indirect anchorage is used to stabilize anterior
segment to preserve position and inclination while closing coil spring
is run from a stabilized anterior segment to a hook soldered mesial to
the upper buccal segment .

60. Retention
• Upper and lower Hawley retainer
VFR ineffective to retain extrusion of teeth ( which is needed for this
patient ).
• Permenant retainer
Prolonged retention is needed because of reduced OB , labial canine
, to prevent late mandibular crowding in the lower arch .

61. Treatment details and mechanics
1. Full records
2. separators around 6’s
3. Band selection , Banding 7`s to increase posterior anchorage to retract lower
dentition
4. To aid derotation of upper molars :
• Position the band in an offset position so that rigid SS
wires can easily pass through the molar tubes , then
reposition the band to correct the axial inclination of
the molars gradually .
• Use molar band with convertible tubes allow sliding of
the non fully seated arch wire through the molar tubes
, this aid molar derotation

62. 4. Direct bonding of the brackets( upper Lower MBT) positioning the
bracket in middle facial third with good angulations and vertical
placement to help transmit true torque values .
5. invert UR2 bracket to reverse torque values
6. Swap lower canines brackets to reverse tip values .
7. Consider early lace backs and cinch backs in the lower arch to avoid
lower incisors proclination .
8. Normal wire sequence through aligment and leveling stage :
14 or 16 superelastic Niti , 16 steel with COS ,

63. Treatment details and mechanics
6. Sliding mechanics
• 19*25 SS wire left passive for a visit , check for it to swivel , start sliding mechanics in upper arch .
• Open space for UR2 via open coil spring , align UR2 via piggy back over main arch wire ,
• posterior bite raising while aligment of UR2
• Close residual space in upper arch via forward movement of posterior segments utilizing indirect anchorage .
• Stabilize anterior segment (3-3) to miniscrews inserted distally to upper canines .and run closing coil spring ( active
tieback ) to soldered hook mesial to (UR5-UR6) ,( UL5 –UL6) – to avoid upper rotroinclination.
• If UR2 needs more torque , apply 3rd order bend .
in lower arch , keep LR5 space via passive open coil spring throughout aligment and
levelling . open space for LR5 on passive S.S wire , then carry lower IPR , place round SS
wire in the lower arch with a power chain to preserve lower retro inclination .
7.Check for root parallelism on OPG
21*25 M NITI

64. 8.Finishing and detailing
TMA wire .021* .025
short class III elastics can be used to retrocline LLS and move UBS
mesially .
Settling by anterior elastics using upper light wires – to increase
incisal show .
12. Debonding
Impression for retainers
Short term: HR
Long term upper , lower permanent .0175 inch s.s wire

65. Thank You