Done by : Dr. Luma Najada – 2nd year resident.

Supervised by: Dr. Ahmad Tarawneh

Dr. Jumana Tbaishat

Dr. Bashar momani

Dr. Anwar Rahamneh

Name: Samah issamAge: 29 yrsOccupation: dental technicianMarital status: Single Residence: AmmanNationality: Jordanian

Medical History: M.F

Dental History: Previous orthodontic treatment 12 years ago

Routine dental procedures ( fillings)

Habits: None

“ I don’t like the

apperance of my

teeth upon smiling.”

Variable Pre-

Treatment

Normal value

SNA 80.7º 81 ± 3

SNB 76.5º 78 ± 3

ANB 4.2 3 ± 2

S-N/MX 8.3º 8 ± 3

ANB* 4.5 -

MMPA 29.7º 27 ± 3

FMA 30 28 ± 3

LFH 56% 55 ± 2

Jarabak ratio 53% 61± 2

U1/Mx 102º 109 ± 6

L1/Mn 88.4º 93 ± 6

IIA 135º 133 ± 10

Wits

Appraisal

0 mm 1 ±1.9 F

Anteroposterior:

Class II Skeletal Pattern

Vertical Assessment:

Slightly increased lower

facial height

Transverse:

Asymmetrical face

Lip tonicity and competence:

• Thin strained upper lip

• normal lower lip

• High lower lip line

• competent lips

Convex facial profile

Frontonasal angle: 143⁰(Normal 115⁰-135⁰)

Nasolabial angle: 119⁰

(Normal 90⁰-110⁰)

Labiomental angle: 87⁰

(Normal 114⁰-140 ⁰)

• 100% crown show when smiling

• gingival show on upper centrals

approx. 3 mm

• Smile extends from 5 to 6

• Buccal corridors: narrow

• The smile arc: straight

related to lower lip

• Poor oral hygiene

•Teeth Present in oral cavity (permenant dentition)

7 6 5 4 3 2 1 1 2 3 X 5 6 7

7 6 5 4 3 2 1 1 2 3 4 5 6 7

U-shaped lower arch

Anterior segment:

moderate crowding in anterior

segment

Buccal segment:

Lingually inclined

u-shaped arch.

Anterior segment:

retroclined upper

incisors

Mild cowding

Periodontal health:

poor oral hygiene.

Carious :

fillings :

6 1 1 6 7

7 6 6 7

7 2

4

Previous abscess related to UR2

Impacted upper 8’s.

Class II div. 2 incisor relationship

Midlines : upper deviated to the left by 4 mm

lower deviated to the right by 2 mm

Overjet = 3.5 - 4 mm

Overbite = Deep 70 % Incomplete .

Molar relationship: L: Class II R: Class II 3/4

Canine relationship: L: Class III 1/4 R: Class II 3/4

Anteroposterior

Canine: Class II 3/4

Molar: Class II 3/4

Canine : Class III 1/4

Molar: Class II

Transverse Midlines deviated

Vertical O.B= deep bite incomplete

Right side: flat Curve of Spee Left side: flat Curve of Spee

Upper arch

u shaped arch form

Dental Asymmetry

Intermolar width: 40 mm

(normal : 43.9 mm)

Intercanine width: 31 mm

(normal: 31.2)

Lower arch

U shaped arch form

Dental Symmetry

Intermolar width : 37 mm

(normal: 41.7 mm )

Intercanine width : 22 mm

(normal: 23.1 mm)

117X878.5877.576.511U

654321123456

117.

5776.55566.577.511L

Anterior Bolton ratio= 36/46*100%= 78.2%

(normal value: 77.2± 1.65%)

Overall Bolton ratio= 87/88.5*100%= 98%

(normal value: 91.3± 1.91%)

Upper ArchLower Arch

-2.5 mm-6.5Crowding/Spacing

--Angulation change

00Leveling curve of

Spee

+1.5+1Inclination change

+2+2.5Arch width change

--Incisors A/P change

+1mm-3.5total

Grade 3 d

contact point

Displacement greater than 2 less

than 4

Grade 3

Variable Pre-

Treatment

Normal value

SNA 80.7º 81 ± 3

SNB 76.5º 78 ± 3

ANB 4.2 3 ± 2

S-N/MX 8.3º 8 ± 3

ANB* 4.5 -

MMPA 29.7º 27 ± 3

FMA 30 28 ± 3

LFH 56% 55 ± 2

Jarabak ratio 64% 61± 2

U1/Mx 102º 109 ± 6

L1/Mn 88.4º 93 ± 6

IIA 135º 133 ± 10

Wits

Appraisal

0 mm 1 ±1.9 F

All teeth are present except UL5, lower 8’s

S.O is a 29 years old female, medicaly fit, with history of failed orthodontic treatment with fixed appliance, with multiple fillings and carious teeth, extracted UL4. Presented complaining of “ I don’t like my smile “ . she has class II/II incisor relationship based on class II skeletal pattern,slightlyincreased LFH, she has asymmetrical face with chin deviated to the right side with compromised smile esthetics.

O.J of 4 mm, deep Incomplete O.B. complicated by extracted UL4, upper midline deviated to the left by 4 mm and the lower to the right by 2mm, moderate crowded lower arch (localized anteriorly), mild crowding in the upper arch. upper 7’s are in scissor bite, molar on left side is class II , on right side class II 3/4. Canine on left side is class III ¼, and on right side class II ¾.

Pathological problems :1. poor oral hygiene2. carious UR7, UR2, LR4. 3. unesthetic composite fillings on upper centrals.

Developmental problems :Patients’s concern : the unesthetic smileAlignment and symmerty: Asymmetric lower arch with with 6.5 mm crowding.lingually inclined lower molars.rotated LR4, LR2,LL2.Asymmetric upper arch with 2.5 mm crowdingextracted UL4retroclined upper incisorsupper 7’s scissor biterotated UL2, UR2Skeletal and dental problems in transverse plane:Asymmetric skeletal upper midline deviated to the left by 4mmlower midline deviated to the right by 1-2 mm

Skeletal and dental problems in A-P plane: Mild class 2 skeletal base (retrognatheic mandible)insicor class 2 div 2right Canine: Class II 3/4right Molar: Class II ¾left Canine : Class III ¼Skeletal and dental problems in vertical plane:slightly increased LFH increased incomplete OBSoft tissue problems : high lower lip lineobtuse nasolabial angleacute labiomental fold.

Improve OH Treat carious teeth Redo composite fillings on upper centrals. Root canal treatment for UR2 Improve her smile by creating more normal gingival relationships , and smile

symmetry Relief crowding in upper and lower arches , and align the teeth Correct rotated teeth Corret retroclination of upper teeth Correct bolton discrepancy Correct upper and lower midline shift Correct scissor bite on upper 7’s. Accept class 2 skeletal base Accept Asyymetrical face. Achieve 2mm 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

(Camouflage, extraction case)

1. OHI.2. Treatment of carious teeth, redo composite

fillings.3. Anchorage : TPA with midpalatal miniscrew. 4. Extraction UR45. Lower and Upper fixed appliance6. Bite raising on post. Teeth.7. Consider stripping in lower ant. Teeth to

provide space 8. Retention.

Short term:

Upper modified Hawley retainers and

lower hawley (full time wear for 6 months,

night time wear for another 6 months).

Long term :

Upper and lower permenant retainers from

3-3

DENTAL:

CRITERIA VALUE NORMAL VALUE PRO/CON

EXTRACTOION

Tooth size- arch length Upper : 2mm

Lower: 6.5 mm

8-11 crowding CON

Curve of Spee L:0mm,R:0mm More than 6 severe CON

Bolton discrepancy 78.2% If 4* more then extract CON

Irregularity index 5 mm X>6.5 mm extract CON

Incisor-Man. Plane angle 88.4 85˚-95˚ CON

Frankfurt-Man. Incisal

angle

61˚ 60˚-75˚ CON

Upper incisor to NA 0 MM 4mm anterior, (22-25) CON

Lower incisor to NB 4 mm, 4 mm anterior ( 22-25) CON

Lower incisor to A-pog -1.2 1-3 mm anterior to it CON

SKELETAL

CRITERIA VALUE NORMAL VALUE PRO/CON NON-EXTRACTION

FMA 30 20˚-30˚ CON

SOFT TISSUE

CRITERIA VALUE NORMAL VALUE PRO/CON

EXTRACTION

NASOLABIAL ANGLE 118 90˚-115˚ CON

OTHER FACTORS

CRITERIA VALUE PRO/CON EXTRACTION

GROWTH Non-growing patient PRO

MIDLINE deviated PRO

PATIENT PEREFERENCE Non-extraction PRO

Camouflage:

Skeletal is class mild 2 , wits 0.

Chief complain is mainly related to malaligned teeth,

Fixed Appliance

Alignment of teeth

Bodily movement

Upper and lower arch coordination

Upper MBT :to avoid retroclination of the incisors while retraction

Lower roth: average torque needed

TPA with Midpalatal miniscrew :

Maximum anchorage is needed on right side, and aboslute anchorage

on left side.

To preserve space to retract the canine and correct midline

Molar relationship ¾ and class II fill unit.

Bite raising : Disocclusion allow freedom of movement of upper 7’s Lower stripping : To gain space in lower arch MBT prescription slot 0.022: High torque is needed to proclined the retracted anterior teeth Extraction : To correct the midline To achieve full unit molar and canine Retention ( Upper and Lower fixed retainer ), Upper fixed retainer: presence of rotated teeth Lower fixed retainer: prevent late anterior mandibular

crowding rotation

1. Full records.

2. Separators around 6’s , upper 7’s.

3. Bands selection on 6’s , upper 7’s.

4. Impression for TPA.

5. Cementation of TPA.

6. direct bonding of fixed appliance ( upper MBT, lower ROTH)

with bite raising on post teeth.

7. Aligning by 0.016 NiTi, .0 017*0.025 NiTi

8. Insertion of midpalatal miniscrew

9. Refer to surgery for extraction of UR4

10. Start space closure and correction of midline

11. Interdental stripping on lower anterior teeth with Working arch

wire 0.019*0.025 SS .

12. Finishing and detailing

TMA wire .021* .025

Settling by posterior elastics using light wires

13 . Debonding :

Impression for retainers

Short term: modified Hawley

Long term upper , lower permanent