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CASE PRESENTATION
RHEA THOMASPG STUDENT
SAVEETHA UNIVERSITY.
CHIEF COMPLAINT A 23 year old male patient by name
KUMAR reported to the department with a chief complaint of crowding in the lower anteriors
History• PRENATAL HISTORY: NRH
• POSTNATAL HISTORY: NRH
• CHILDHOOD DISEASES: NRH
• HABITS: NIL
• ANY INJURIES SUFFERED: NIL
• FAMILIAL MALOCCLUSION : NIL
General History• Reasons for orthodontic treatment : Esthetics .
• Attitude : positive.
Clinical ExaminationPHYSICAL STATUS:
Build : ModerateBody type : Mesomorphic
EXTRA ORAL EXAMINATION:
• Shape of head : mesocephalic • Facial form : mesoprosopic • Interlabial gap : nil
EXTRA ORAL EXAMINATION:
• Mild Convex profile• Mild posterior
divergence• Normal Nasolabial angle• average FMA • Chin: not prominent• competent lips
Functional examination
• Incisor Exposure – at rest : not vissible
– during smile : 4mm
Functional examination• Respiration : Nasal • path of closure : NAD• TMJ : NAD• Mastication and speech : NAD• Deglutition :NAD• Perioral muscle activity: Normal
Intra oral examination
• Oral Hygiene : Fair• Gingiva : normal• Frenal Attachment : Normal• Tongue ( size , shape and movements ) :
Normal• Oral Mucosa : Normal• Palatal Contour : high vault
Hard tissue examination
87654321 12345678 87654321 12345678 present .
Maximum mouth opening ; 45mmFreeway space ; 4mmCurve of spee ; 3mmMidline : lower midline shift
Inter Arch Relationship
Maxillary arch
• V shaped • asymmetrical • Crowding in relation to
upper anteriors
Mandibular arch
• u shaped• Asymmetrical• Crowding in relation
to lower anteriors
Vertical relation ship• Overbite; 5mm
• Overjet; 8 mm
horizontal relation ship
Antero posterior relationship
• Molar relation:
right side - Class 1
left side – Class 1
• Canine relation:
right side – Class 2
left side – Class 2
Model photographs
Model analysis
Carey’s Analysis Tooth material excess by 5mm in lower arch,
indicates need for extraction of 1st premolars.
Arch perimeter analysis Tooth material excess by 9 mm in upper arch,
indicates need for extraction of 1st premolars .
Model analysis
Ashley howe’s analysis PMBAW % - 50% indicates non extraction
Pont’s analysis measured pre molar and molar values less than calculated pre
molar and molar values, indicate need for extraction
Bolton’s analysis 0verall ratio of 91.66% and anterior ratio of 83.33%
• Indicating over all mandibular tooth material excess by 9.6mm and anterior mandibular excess by 3.9mm
LATERALCEPH
OPG
CEPHALOMETRIC EVALUATION
Measurements Mean Actual
SKELETAL
SNASNBGo-Gn to SNANBSNDSLSE
820 800 320 20 760 51 mm22 mm
84822720 800 58 mm18 mm
Orthognathic Maxilla orthognathic mandibleHorizontal growth patternClass I skeletal pattern
Steiner’s Analysis
FH – SN =
DENTAL
1 to NA (mm)
1 to NA __ 1 to NB (mm)__ 1 to NB __1 to 1
Occl to SN
PP to SN
4 mm
220
4 mm
250
1310
140
80
14 mm
480
6mm
300
1050
160
100
Severely proclined upper incisors
Severely proclined lower incisors
Reduced interincisal angle
Wits Analysis :
AO is coincident with BO indicating a SK CL.I
Mc Namara’s AnalysisMeasurements Mean ActualN perpendicular to Point AN perpendicular to PogonionFacial AxisMandibular Plane angle Eff. Max lengthEff. Mand lengthMaxillomandibular differentialLower Anterior Face Height
0 + 2 mm0 to – 4 mm
900
26 + 482 - 83 mm
58 - 59 mm
+2mm+1mm
960
250
89mm110 mm21mm65 mm
Orthognathic maxilla
Orthognathic mandible
average growth pattern
Mildly Increased lower ant height
Measurements Mean Actual1 to point AL1 to A Po line Nasolabial Angle
4 mm1 – 2 mm90 - 1100
7 mm5mm1040
Proclined upper and lower incisors
Acute nasolabial angle
Measurements Mean ActualSaddle angle Articular Angle Gonial AngleU/ Gonial AngleL/ Gonial Angle Sum of Posterior Angle
123 + 50
143 + 60
128 + 70
52 – 550
72 -750
396+ 60
1020
1400
1210
520
690
3630 Horizontal growth pattern
Rakosi Jarabak’s Analysis
Schwartz Analysis
Measurements Mean Actual
Extent of Anterior Cranial Base
Extent of Ascending Ramus
Extent of Maxillary length Extent of Mandibular base
52 mm 48.5mm
67mm
66mm
47 mm
53 mm
72mm
Mildly reduced ascending ramus height
C Axis
S – Mpt : 440 [ 42-440 ]
67mm [age + 48.51]
G Axis
S – G pt : 690 (66-670+_ 4)
BETA angle : 25 degrees [27 -35]
indicating
Holdaway’s Soft Tissue Analysis
Measurements Mean Actual
Upper Lip CurvatureH line angle Nose tip to H line Upper Sulcus DepthUpper lip thicknessUpper lip strainLower lip to H lineSoft tissue chin thicknessLower sulcus depth
907 – 15 0 mm5 mm15 mm2 mm0 mm10 – 12 mm5mm
85mm 23mm -7mm10mm15 mm5 mm5 mm10 mm4mm
\
Imbalance in between lips.
A case of skeletal class I with orthognathic maxilla,orthognathic mandible with horizontal growth pattern and mildly increased lower anterior facial height with proclined upper and lower incisors, acute nasolabial angle .
SYNTHESIS OF CEPHALOMETRIC EVALUATION
Antero posteriorSKELETAL
Skeletal CL.I
ANB: 2(2) SteinersConvexity of pt A; +3 mm rickettsAO coincident BO WIT”S Appraisal
SNA :84(82) N- Pt A: 2mmEff max length : 89 mm(82-83mm)
Convexity at Pt A : +3 mm
Antero posterior
ORTHOGNATHIC MAXILLA
Steiner’s
Mc Namara
Ricketts
SKELETAL
ORTHOOGNATHIC MANDIBLE
SNB : 82 ( 80 )N Pog; 1mm (0-4mm)Effective mandibular length-110mm(115-118mm)
Steiner’sMc Namara
Horizontal Relation Horizontal growth pattern
FMA : 21(25 )Lower Gonial angle: 69( 72 – 75)Jaraba2k ratio :%Basal plane angle :(25)
Dental AXIAL Inclination
upper incisor proclined
1 to NA (mm) : 14 mm (4 mm) 1 to NA : 48 ( 22) 1 to SN : 115( 102 + 2) 1 to Palatal plane : 60 (70 + 5)
Dental AXIAL Inclination
lower incisor proclined L 1 to NB - 6mm L 1 to NB - 80 L 1 to APog - mm L 1 to APog -
Space analysisSpace required; maxilla mandible
Correction of crowding 0mm 0mm
Levelling curve of spee 0mm 0mm
Correction of proclination 22mm 15mm
Correction of molar relation 0mm 0mm
correction of rotation Ant 0mm 2mm
Total space required 22mm 17mm
Space available;Space present between teeth 7mm 2mm
Space obtained from proclination 0mm 0mm
Space obtained by derotation 1mm 0mm
Total space available 8mm 2mm
Discrepancy 14mm 15mm
A case of skeletal class I attributable to anteinclined orthognathic maxilla and orthognathic mandible with mildly increased lower anterior facial height with vertical growth pattern with Angles class I malocclusion with increased overjet, with proclined anteriors with spacing in anteriors and convex profile, acute nasolabial angle and incompetent lips .
Diagnosis
Problem ListSkeletal; horizontal growth pattern. mildly increased lower ant face height.
dental; mildly proclined upper and severly proclined lower anteriors spacing in upper and lower anteriors
Soft tissue; convex profile imbalance in between lips acute nasolabial angle
TREATMENT OBJECTIVES
• maintain class I molar and canine relation on both sides
• Correction of proclination in upper and lower anteriors
• Space closure in upper an lower anteriors
• Improving facial balance and lip competency.
FACTORS TAKEN IN TO CONSIDERATION
• Skeletal class I• orthognathic maxilla• orthognathic mandible• Vertical growth pattern• Mildly Increased lower anterior facial height• Class I Molar and canine relation• Increased overjet • Normal upper and lower dental heights• Acute nasolabial angle• Incompetent lips• Convex profile
TREATMENT PLAN
camouflage method;- Extraction of 14,24,34 and 44.- Strap up with PEA .022 M.B.T. prescription.- To use transpalatal arch and second molar banding to aid in
anchorage- To give nance palatal button before starting with retraction for
aiding in retraction- To start levelling and aligning with 016 NiTi and to step up till
019x025 s.s.- To use friction mechanics for retraction- Anchorage; maxilla-maximum. mandible-maximum-Retention plan- upper- hawleys retainer. lower- lower lingual bonded retainer.