Orthodontic Clinical Case PresentationBy: Murad F.Maraqa 3 rd Year Orthodontic Resident
Supervisors:Dr. Ahmad M. Al TarawnehDr. Raghda ShamoutDr. Raed Al Rbatta
Personal DataPatients Name:R.SGender:FemaleAge:15 Years, 8 MonthsCareer: StudentNationality: Jordanian
Chief Complain I dont like how my upper teeth dont show when I smile
Medical & Dental HistoryMedical History:Denied Any Medical History.
Dental History: RCT UR 6 + Amalgam fillingRestorations on the UL6 , LL6 and LR6
HistoryTrauma: No history of trauma.Habits: No HabitsMotivation: Internal Motivated.Growth status: Passed the growth spurt .
Jaw & Occlusal FunctionsMastication:Normal masticatory function.Speech:No difficulty.TMJ:No clicking No Crepitus or tenderness. No displacementNormal opening.
Extra-Oral PhotosFrontal View
Profile ViewExtra-Oral Photos
Extra-Oral PhotosOblique View
Right sideLeft side
Cephalometric AnalysisAngleMeasurementAverageSNA82(81)+-3SNB82(78)+-3ANB0(2)+-2SN-MAX9.8(8)+-3Corrected ANB-0.5Wits Apprasial-3(0) + 1.77mm fMMPA26(27)+-4AFH Ratio57%55%+-2%UI - MAX110(109)+-6LI - MAN99(93)+-6IIA121(135)+-10
A. Anteroposterior AssessmentProfile:Convex facial profile.
B. Vertical AssessmentAverage LAFHUpper lip in the upper 1/3Lower lip in the lower 2/3
C. Transverse AssessmentFacial Symmetry:The patient has asymmetrical face.Tip of nose deviated to the right side.Chin deviated to the right.Larger Right medial 1/5s than Left medial1/5s .Interpupillary distance larger than the width of the mouth.
E. Soft Tissue ExaminationThin, competent lips.Normal tongue size and function.Frontonasal angle: 115-135130 Nasolabial angle: 90-110115.Labiomental angle: 110-130140.
Asymmetric smile.Reduced incisors show 30%Increased Buccal Corridor
Ackerman et al 1998The lower the smile index, the youthful the smile appear Buccal Corridor:(Inner commissure visible maxillary dentition) / inner commissure * 100% Frush and fisher 195818
Right sideLeft side
Intra-Oral ExaminationTeeth present:
Intra-Oral ExaminationOral Hygiene :Poor
RCT UR 6 + Amalgam fillingRestorations on the UL6 , LL6 and LR6
Intra-Oral ExaminationCenterlines:Upper: shifted to the left 1mmLower: shifted to the right 1mmOJ: -1.2mmOB: 20% decreasedCrossbite on:Right: 2,1Left: 1
Intra-Oral ExaminationRight buccal segment relationships:Canine: Class III 1/4Molar: Class I
Left buccal segment relationships:Canine: Class IMolar: Class III 1/4
Lower ArchU- shaped arch form.Symmetrical.No crowding.LL6 needs refilling or crowning
Upper ArchU- shaped arch form.Constricted Anteriorly.Palatally displaced central incisors and right lateral incisor.Palatally inclined lateral incisors.
Frontal ViewClass III Incisor relationshipOJ: -1.2mmOB: 20%
Right SideMolar: Class ICanine: Class ICrossbite: 1,2
Left SideMolar: Class ICanine: Class ICrossbite: 1
Lower Cast OcclusalIntercanine width: 26 cusp tip cusp tip
Intermolar width: 46 MB-MB
Omar Gabriel article30
Upper Cast OcclusalIntercanine width: 33 mm cusp tip cusp tipIntermolar width:46 mm from the MB-MBNormal
Curve of SpeeLeft side: 1 mm
Right side: 1 mm
Tooth Size Analysis (Bolton Ratio)Over all ratio = 87.5/9890% Normal: 91.3%Anterior ratio = 36.5/45.580% increasedNormal: 77.2%11788.5698688711.59845.5654321123456overallanterior11.577.5766666.576.511.587.536.5
All third molar buds are present.No apparent pathology. RCT UR 6 + Amalgam filling Restorations on the UL6 , LL6 and LR6
IOTN Dental Health ComponentGrade:
IOTN Esthetic ComponentNot Applicable
Diagnostic SummaryR.S is a 16 years old, female, denied any medical history. She came complaining that her upper teeth dont show while smiling.She has poor oral hygiene.Class III Incisors relationship based on mild skeletal Class III with Average anterior facial height.She has asymmetrical face with chin deviated to the Right side. Compromised smile esthetics.She has Class I molar with Class I canine relationships on right side and a Class I molar with ClassI canine relationships on left side. OJ is -1.2mm with decreased OB to 20% incompleteUpper midline shifted to the left by 1 mm and lower shifted to the right by 1 mm.Mild crowding in the upper and well-aligned lower arch.Crossbite on UR 1,2and UL 1.
Problem list Pathological problems:Poor O.H. Visible Plaque AccumulationLL6 needs refilling or crowning Patients concern I dont like how my upper teeth dont show when I smile Skeletal and dental problems in transverse plane:Chin deviated to the right side.Upper midline shifted to the left by 1mm.Lower midline shifted to the right by 1mm.Skeletal and dental problems in A-P :Skeletal Class III prognathic mandible
OJ -1.2 mmSkeletal and dental problems vertically Decreased OB. 20%
Treatment AimsImprove O.H.Restorative treatment LL6.Accept skeletal discrepancy.Accept facial asymmetry Correct Anterior crossbite.Correct centerlines shift.Achieve and maintain Class I molar and canine relationships.Achieve Positive OJ Increase OB.Finishing and detailing of occlusion.Retain corrected results
Treatment PlanNon-ExtractionO.H. improvement.Upper and Lower Fixed MBT 0.22 slot.Bite raising on the lower Incisors .Stripping in the lower arch6. Conventional Retention Upper/Lower Hawley Retainer.
High pull head gear Midpalatal closure: Females 12-13Males 13-1440
JustificationOHI : Visible Plaque Camouflage :Patients chief complaintAge of the patient Good vertical facial proportions Mild Class III skeletal within orthodontics treatment limitsNormal soft tissue features Non Extraction :Space will be provided by proclination of the upper incisors and stripping in the lower incisors Fixed appliance using MBT prescription: For 3D tooth movement .Maxillary incisors palatal torque.Retroclination of the lower incisors .
Justification Bite Raising : Disoclussion allow freedom in movement of upper incisors Lower stripping to gain space to retrocline lower incisors .Conventional Retention :Upper and Lower Hawley 6month full time wear and 6 month night time . After Achieving overbite the results are generally stable
To get further proclination of ULS, use MBT in the ULSLingual crown torque on LLS Contra-lateral canine brackets (to avoid LLS proclination)Lacebacks in LA (to avoid LLS proclination)Cinch back in LA (to avoid LLS proclination)Closing space created by stripping on a round wire in the lower arch will facilitate retroclination of the lower incisors.