Case presentation

*Name: Faris Shnbor

*Age: 11 years old

*Gender: Male

*Occupation: Student

*Date of examination: 9 – Oct -2014

**Chief Complaint:

-Patient complained of his forwardly placed and misaligned upper incisors.

**Medical history:

-His dad claimed that Faris is medically fit and he doesn't take any medications.

**Dental history:

- multiple previous restorations, and primary teeth extractions, with no complications

**Social history & habits : -Patient denied any habit. **patient motivation:

The patient was very motivated to start and follow up the treatment.

Extra-Oral Examination

Extra-Oral photos

Extra oral Examination

Frontal View

*Acceptable facial balance and symmetry.

* Deviated chin

*Normal Lower anterior Facial Height (50-55%)

Extra oral examination Frontal view

Facial symmetry Upper & lower facial heights

Extra oral Examination

Profile View

Convex profile angle.Class II skeletal Relationship.

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Extra oral examination profile view

Profile view

Average FMPA.(about 30°)

Extra oral Examination

Soft tissue analysis

Soft tissue Analysis1. Incompetent lips

2. Reduced Nasolabial angle

Soft tissue Analysis, Cont.

Prominent upper and lower lips to the E-Line

Upper lip by(2mm) lower lip by (4mm)

Soft tissue Analysis, Cont.

Paranasal area

Soft tissue Analysis, Cont.

Intra-Oral Examination

Intra-oral photos

Intra-Oral Examination

Upper Arch

Poor Oral Hygiene

Upper Arch:

Teeth Number: 12 teeth. 6 teeth/ sideCs, Ds, Es were still presentU shaped archMultiple restorationsAverage upper incisors inclinationmild crowding (4 mm) ‘clinically” ????????????

Intra Oral Examination

Intra-Oral Examination

Lower Arch

Lower Arch:

Teeth Number: 12 teeth, 6 teeth per side Cs, Ds, Es were still present

Average Incisor inclination.

Mild crowding in the lower anterior segment.(2mm) “clinically”

Intra-Oral ExaminationInter-arch relation ships

Increased Over Jet (8 mm)Class II div I incisor relationship

????????Right Side: Canine (class II quarter unit)Molar (class II full unit)

Left Side:Canine (class II quarter unit)Molar (class II full unit)

Anterior Posterior Relation

Vertical Relation:Increased OverbiteHyper active upper lip muscle Gummy smile

Transverse RelationNormal Upper midline is coincident with the midfacial axisUpper and lower midline is not concident ( lower midline is shifted to the right by 2mm)

Study casts

Space Analysis Jonhston and Tanaka Upper Jaw

Space available: Rt 24 Lf 25 Space Predicted: Rt 22 Lf 22 Spacing +2 mm +3mm

Space Analysis Johnston and Tanaka Lower Jaw

Space available: Rt 27 Lf 27 Space Predicted: Rt 21.5 Lf 21.5 Spacing +5.5 mm +5.5 mm

Panoramic Radiograph Late mixed dentition All teeth are present

No pathology Rotated lower

premolars

Lateral cephalogram

Cephalometric Land marks

Cephalometric Tracing

Normal value interpretation

Pre- Treatment Variable

82± 3 82 SNA

79 ± 3 retrognathic mandible

75 SNB

1±3 skeletal class II 7 ANB

108 ± 5 105 UI - Mx

92 ± 5 proclined 101 LI - Mn

5±126 127 Gonial angle

27 ± 5 30 MM angle

27 ± 5 31 FM angle

1- skeletal class II 2 AO ahead of BO

Wit’s measurements

50%-55% 52% Anterior face height

0-2 1.5 Lower incisor to A-Po

90±5

133±10

93

123

A-B/FOP

Interincisal angle

87±3 retrognathic mandible

76 SN-Po

Diagnosis Class II div I incisor relaionship based on class II skeletal

relationship complicated by

Increased overjet and over bite Bilateral Class II full unit molar relationship Mild upper and lower crowding of the current dentition Incompetent lips Shifted lower midline to the right by 1mm Prominent upper and lower lips Gummy smile

Over all Aims of Treatment To correct incisor relationship, align the upper incisors

and relief the anterior crowding in the upper arch To correct molar relation ships To reduce the overjet and overbite To correct the shifted midline To achieve esthetically pleasing soft tissue “correct the

gummy smile”

Treatment plan suggestion

Phase 1 Functional appliance to stimulate the

mandibular growth and to decrease upper and lower skeletal discrepancy

Phase 2 Reassessment of the dentition, and referal for

fixed treatment

Functional applianceAndreasen with maxillary torquing spurs

Retention

possibly Continue wearing the functional appliance

during phase 1

Thank you