Orthodontic Case presentation

Prof Dr .
KHALED AL- DHOREA

Dr .
SALAH AL- HAIDARY

Afaf Al-Mekhlafi
 Clinical Examination
Chief complaint
I Can not speech very well

I want to have good Smile and want

my teeth upper and lower to be
contact
 Medical History: No Medical History
Dental History: simple restoration 16 , 46

Family History: relevant history

Habits: There are no Any sings of associated habits

Physical Growth: complete

Growth States Beginning of adulthood

Patient’s Motivation toward orthodontic treatment: Internally motivated patient .

 Extra oral Examination

TMJ (Extra-oral): Occlusal Function

- No sign or symptoms of • -Slightly defect of mastication
TMD
-Difficulty in speech
-No Clicking
-No Tenderness Breathing
-Normal opening path and nasal
closure
Habite:
Tongue size and behavior: Normal None
Double lip with slightly height •
smile line lip competence •
Extra Oral Photogrphs.
 Extra oral Examination

1- Anterioposterior assessment
Maxilla to mandible relationship

2- Vertical assessment
Facial third
Angle of lower border of mandible to
maxilla

3- Transverse assessment
Facial asymmetry

Soft tissue assessment

 (Skeletal Assessment) •

A -anterio-posterior

A and B POINT soft tissue

- skeletal Class III : < 2 mm

The soft tissue A-Point is slightly behind
(2mms) of the soft tissue B-Point
Profile angle (of Arnett)

Or (Angle of Facial Convexity)

angel = 6 •
Normal ( 12 +/- 4 ) •
Concave profile •
Skeletal class III •
 Zeromerdian line
retroted upper soft tissue A point •

Zero merdian line < 2mm to soft tissue

pogonion

Chin protruded •
retroted profile •

Position of Maxilla: In relation to •

upper face Slightly •
retrognathism

Position of Mandible: In relation

to upper face Prognathism
Role of thirds

Lower facial height

proportion ( LAFH )

increased slitly 56 %

Normal lip length

anterior to the occipital region =
45 degree
Normal range =
25 degree (+ or –3)

So, the patient has vertical

growth pattern
 Skeletal Assessment

B-Transverse

• facial asymmetry :
• No significant facial asymmetry
 Midline :
• Upper center line is
not coincident with
FCL

• Shift of midline to
right side
upper midline :
Not Coincident

Lower Midline:

Not Coincident
 The head (Dolichocephalic )

Facial form : Leptoprosopic

-Face symmetry /no chin

deviation
-Five section equal
-Nose and chin centered in the
central fifth
-Interpupillary distance equals
the width of the mouth
C- Vertical assessment

Lower facial height

proportion
Increased LFH
Upper lip in the upper
third ,
and lower lip in the lower
2\3 of lower third of the
face
Soft tissue assessment

Ricket’s E-line
E Line u = - 5mm
retrudede upper lip

E Line Lower = 0mm

 NASOLABIAL ANGLE MENTOLABIAL ANGLE
• NLA in degrees :100 • MLA in degrees :120
• normal • Shallow

• N = 90 - 110 • N = 110- 130

Frontonasal angle =143 •

Normal angle = 115-135 •

Facial and Dental Appearance

1- The Face (Macroesthetic)

2- Smile Frame (Miniesthetic)

3-Teeth (microesthetic)
 Smile Frame (Miniesthetic)

1-Smile Analysis

2-Amount of incisors and gingival show

3-The Smile Arc

 1-Smile Analysis
Smile Index =
Intercommissure width =10.5 \3.5 = 3
The lower the smile index ,the
Interlabial gap in smiling less youthful the smile appear

Upper midline shifted 5mm to

right
Asymmetrical smile
(more showing on the left side)
 The buccal corroidor ratio =
Inner commissure width - visible maxillary dentition *100 % =
Inner commissure

9 - 7.5 \ 9 * 100%
= 16 %

Patient has medium smile category

 2-Amount of incisors and gingival show
--The whole length of incisors are visible
,with lip line slightly high ( high smile line )

-Gingival margins are seen for all anterior

-Gingival margins for centrals are in higher
level than laterals and canines
-Laterals gingival margin are low

-Canines are more promenent show

-Small and narrow buccal corridor-

 3-The Smile Arc
-Upper incisors not parallel to the lower lip
,and not touching lower lip
Non consonant in the canines area
 Teeth (microesthetic)
1-Width releation (golden Ratio)
1.0 : 0.62 : 0.38
UL1 : UL2 : UL3
1.0 : 0.55 : 0.77

2-tooth proportion
Square central incisors
Central height 11 mm increased
Central width 9 mm normal
Ratio = 81%
(normal)
3- Connector and Embrasures

-Connector height is greatest between the

central incisors
-No black triangles
-Gingival embrasures are filled by the
interdental papilla
-Incisal embrasures are largest between the
canines ande laterals
(Larger when moving posteriorly)
Smile aesthetic assessment

Commissure height >philtrum height

Buccle corridors : small and narrow

Intra Oral Assesement

Intra Oral
PHOTOGRAPHS
Intra-Oral Assessment
Frontal view
• Incisor relationship::class III
• Canting of occlusal plane
• Over jet =: -3 mm in central
• -4mm in lateral
• upper centerline : shift of
midline to right side 5mm
• Over bite : 3 mm in central
• Over jet :
• -4mm in lateral

Open bite: 4mm

Lateral Views
Occulssion feature -buccal segments
Left molar relationship Right molar relationship
classIII classIII
Left canine relationship Right canine relationship
class III class III
Upper and Lower Occlusal Views Intra-arch (Intra-oral):
Maxillary arch:
-V shaped Slightly narrow
-All permanent teeth are present
Anterior segment
-Left central overlapped
-Laterals in both sides inclined palately
-Slightly crowded with both canines inclined
buccally
Posterior segment
-R6 restored
-Right third molar partially erupted
-Left third molar erupted
Mandibular arch:
U Shaped
All permanent teeth are present
Anterior segment
Slightly crowding with lower right and
left canines are rotated
Posterior segment
Right third molar partially erupted ,
Left third molar impacted
R,L6 are deep decayed

Lingual Frenum : Normal

Periodontal health : fit
Oral hygiene: not Good
Erupted teeth present:
7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
General dental condition: filling in upper right 6
Fractred filling in lower right 6 and deep decayed in left 6
panoramic Radiograph
Periodontal :- normal
Missed : No
Pre extracted ; No
RCT : NO
Pathology :- lesion in 36
Restoration :- 3 molars
All third molars are present
Lateral Cephalometric Radiograph
Cephalo Analysis
 AP
SNA =78.5
SNB =81.6
ANB = -3.1

AP
Wits = BO ahead AO 4cm
Skeletal assesement

FMA=41
Skeletal

SN _MP = 50
 Dental

U1 - NA = 0
retroclination of upper
teeth

L1 – NB = 5
Normal
Dental
Incisors inclination
U1 SN = 110
Normal = 104

L1- MP =75
Normal = 90
- Skeletal class III (Retrognathic Maxilla )
- SNA = 78.5
- ANB = -3.1
Wits Appraisal BO ahead AO 4 mm
High angle FMA
Model cast analysis
 Frontal view
Transverse:
Anterior and posterior segment
in cross bite
Shift of midline to right side 5
mm

Vertical :
Open bite ( in table ) •
Over jet 9 in table ) •

3 2 1 1 2 3 Molar classIII
Open 1 4 3 3 3 3
bite Canines clas III
Over jet 0 -4 -3 -3 -5 -2.5
 Left side

Molar classIII

Canine clas III

Anterior and posterior segment in cross bite

Right side

Molar classIII

Canine clas III

Anterior cross bite

4-5 cross bite
Upper arch

Inter Canine width = 33mm

Inter molar width = 47 mm

Lower arch

Inter Canine width = 22 mm

Inter molar width = 35 mm
 Curve of spee

left₌1mm Right₌ 1 mm
Normal
Maxillary and mandibular arch asymmetry
 Space Analysis ( Arch perimeter analysis )
Upper
Space available =94
Space Required=97

Lower
Space available =89
Space Required=92

11 6 7.5 8 7 9 9 6 8.5 8 7 10 94 97 slight

6 5 4 3 2 1 1 2 3 4 5 6 Space space
available required
12 7 8 7.5 6 5.5 6 6 7.5 8 7 11.5 89 92 slight
 Tooth Size Analysis (Bolton)
Lower anterior teeth width = 81.1 %
Upper anterior teeth width

Increased
Normal 77.2%
Lower all teeth width = 94.8%

Upper all teeth width

Increased
Normal 91.3 %
11 6 7.5 8 7 9 9 6 8.5 8 7 10 97 47.5

6 5 4 3 2 1 1 2 3 4 5 6 Over all [Link] increas

ratio o ed
12 7 8 7.5 6 5.5 6 6 7.5 8 7 11.5 92 38.5
If the over all ratio is more than 91.3% it indicates mandibular anterior
excess. The amount of mandibular anterior excess is determined by

Mandibular 12 = Sum of the maxillary 12 x 91.3

100

97 X 91.3 = 88 .6
100

Mandibular excess = Actual Mandibular 12 – Computed

mandibular 12
= 92 – 88.6 = 3.7 mm
 Ashley Howes Analysis

T.T.M = 97 mm.
P.M.D= 41 mm.
P.M.B.A.W.= 39 mm.
P.M.B.A.W. = P.M.B.A.W.X 100 = 39 X100 = 40
T.T.M 97

The case is borderline

6 5 4 3 2 1 1 2 3 4 5 6
11 6 7.5 8 7 9 9 6 8.5 8 7 11
Index of Orthodontic Treatment Need
(IOTN)
63

1
6

16
8
 5

1 1

12
24

25
 2

4
Disrepancy Index
= 63

Very difficult
 diagnostic summery
• 19 y old male Arabian presented medically fit patient

• He came complaining from his smaile ,speech and teeth appearance

• class III incisor relationship on skeletal class III base with high vertical proportion and concave
profile

• It was complicated with mid line shifte ,gummy smile,, He has compromised smile esthetic

• class III canines and molars relation in both sides, reversed over jet ,slightly increased open bite,
Posterior crossbite

• retroclined and inclined upper teeth , and normal lower anterior teeth and companant lip

• narrow maxilla with slightly crowded in both jaws , Canting of occlusal plane
•
 ACKERMANN-PROFIT CLASSIFICATION

Dentofacial
appearance Teeth \arch form
symmetry Asymmetry
Not aligned teeth

Transverse
Sagittal deviation
deviation Skeletal class lII
Molar relation; : class
lII on right and left side
Narrow maxilla Canine: class IlI on right
midline -upper and left
shifted Revers Overjet

to right 5 mm normal
curve of spee

Vertical Asymetrical
deviation crowding
concave profile
Open bite 5 mm
Upper lip •
retruted • Incisor display :
Exceesive
Poor oral hygiene Problem list
Large restoration in UR6 , badly decayed in LR6 ,LL6

Skeletal and dental problems in Transverse plane

-Upper midline shifted 5mm to right side
-LR 4,5,6 and LL45 in cross bite( Narrow maxilla) , Canting of occlusal plane
-Both upper canines inclined buccally and crowded
-Upper Laterals in both sides inclined palately
-In lower Slightly crowding with lower right and left canines are rotated
-anterior Bolton discripancy
Skeletal and dental problems in A_ P plane
-Maxilla is retrognathic , mandible is slightly prognathic
-Concave profile
Proclination of upper anteriors
-Canines and molars full class III
-Reverse over jet
Skeletal and dental problems in vertical plane
-Increase FMA angle with increased lower vertical height (LFH)
-Open bite
 Treatment Aims
-improve oral hygiene
-Treat the carious teeth
-relief crowding in upper and lower arches and aligne the teeth
-DE rotated rotated teeth
Skeleta (TVA)
Correct narrowing of maxilla and upper midline and midline asymmetry
-Correct ant ,post cross bite -
-correct lower facial hight -
-Achieve class I molar and canine relation or at less canine relation , and OB -
dental -
-Achieve normal OJ ,OB -
Soft tissue -
-Achieve straight prfile -
-Improve smile -
 Treatment Plane
-According to all documents and analysis

Orthognathic surgery
But patient refuse surgery

So we give him other option (Camoflage)

-
 Correct three dimension in order of
TVA

Expantion of maxilla with hyrax or quidhiex appliance

-Fixed upper and lower appliance (lower MBT upper Roth)

-Extraction of lower sixes in both sides with maximum

anchorage prefer to use mini implant
-correct overjet and crosse bite

-Correct of open bite in finishing stage by Box elastic

 used hyrax or quidhiex to expaned upper arch to corret slightly narrowing in
it and to correct arch width and correct anterior and posterior crossbite and
to correct Bolton discrepancy
and it use for anchorage (expantion with mini implant is prefer)

Extraction of LL,LR6 to correct proclination to correct of OJ

(Camoflage retraction of lower arch)
Why extract lower 6s
Because increased lower facial hight they are badly decayed and I prefer to
extract them rather sound 4s

-Fixed upper and lower appliance (MBT(0.022)

Lower need more torque because extraction
 NOTE
According of smile analysis of patient the brackets
placement prefer to place in SAP (Smile Arc Protection)
Because patient has long crowns of teeth and good
tooth propertion
To obtain adequate occlusion and an esthetic smile
 Retention
Long term retention
Bonded wire retainer:
as permanent retainer

Vacumm night guard :

full time wearing on the 1st 48 hrs then 12 hrs daily for 3
month ,and gradually decrease during the next month
Prepared by :

Dr \ AFAF ALMEKHLAFI

‫د \ عفاف المخالفي‬