Orthodontic Clinical

Case Presentation
By: Shareef M.T. Al Shanableh “2’nd Year Orthodontic Resident”

Supervisors: Dr. Ahmad M. Al Tarawneh

Dr. Raghda Shamout
Dr. Ra’ed Al Rbatta
Dr. Nancy Al Sarayrah
Personal Data

▪ Patient’s Name: Haneen Nabil

▪ Gender: Female
▪ Age: 13Yrs, 4 Months
▪ Career: Student
▪ Nationality: Jordanian
 Chief Complaint
“ My teeth are overlapped, especially on palatal area”

»‫«سناني طالعين فوق بعض خصوصا عند سقف حلقي‬

Medical & Dental History

▪ Medical History:
Impaired breathing, undergone Adenoidectomy 1
year ago.

▪ Dental History:
Never been to dental clinic.
History

▪ Trauma:
No history of trauma.
▪ Habits:
Mouth breather.
▪ Motivation:
Motivated.
▪ Growth status:
Still growing patient.
 Jaw & Occlusal Functions

▪ Mastication:
Normal masticatory function.
▪ Speech:
No difficulty.
▪ TMJ:
No clicking
No Crepitus, or tenderness.
Normal opening, and side to side movement.
Extra-Oral Photos
Intra-Oral Photos
Study Model Examination
Orthopantomograph “OPT”
Cephalometric Analysis Angle Measurement Average
SNA 82.5 (81)+-3
SNB 75.5 (78)+-3
ANB 7.5 (2)+-2
SN-MAX 6.1 (8)+-3
Corrected 6.5
ANB
Wits Apprasial Zero (0) +
1.77mm “f”
MMPA 40.5 (27)+-4
FMPA 32 (28)+-4
UAFH
LAFH 58 mm
AFH Ratio 60% 55%+-2%
UI - MAX 110 (109)+-6
LI - MAN 83.1 (93)+-6
IIA 125 (135)+-10
Cervical Vertebral Maturation “CVM”

▪ CVM: Stage “3”

– Less than 1 year prior to peak growth.
 Facial and Dental appearance

1. The Face “Macro-esthetics”.

2. Smile Frame “Mini-esthetics”.

3. Teeth “Micro-esthetics”.
 1.The Face “Macro-esthetics”

A. Anteroposterior assessment:
Maxilla to mandible relationship.

B. Vertical Assessment:
a. Facial thirds.
b. Angle of lower border to mandible.

C. Transverse assessment:
D. Facial symmetry.
E. Soft tissue Assessment.
A. Anteroposterior Assessment

▪ Profile:
Convex facial profile.
Skeletal Class 2
Increased Lower anterior facial
height.
A. Anteroposterior Assessment

▪ Zero Meredian Line:

> 2mm to soft tissue

pogonion.
B. Vertical Assessment

▪ Increased LAFH
▪ Upper lip in the upper 1/3
▪ Lower lip in the lower 2/3

▪ Increased FMPA angle.

 C. Transverse Assessment

▪ Facial Symmetry:
 The patient has asymmetrical face.
 Tip of nose deviated to the left side.
 Chin deviated to the right.
 Equal medial & lateral 1/5s.
 Width of the nose equals the
central 1/5.
 Interpupillary distance larger than
the width of the mouth.
E. Soft Tissue Examination

▪ Thin, competent lips.

▪ Normal tongue size and
function.
▪ Frontonasal angle: “115-13
– 110 “obtuse”

▪ Nasolabial angle: “90-110”

– 96.

▪ Labiomental angle: “110-130”

– 121.
 2. Smile Frame “Mini-esthetics”

▪ Smile index:
– “intercomissure width/interlabial gap
on smiling”.

– 32.07/10.76= 2.9

▪ Asymmetric smile.
▪ Buccal corridor ratio:
– 12.07% (between medium &
medium-broad)
Incisor and Gingival display & smile arc

▪ Upper incisors are not parallel with lower lip.

▪ Upper incisors are not touching lower lip
▪ Whole length of upper incisors are visible.
▪ More than 0.5 mm gingival margin display. “increased”
▪ Non constant smile.
3. Teeth “Micro-esthetics”

I. Tooth proportions.
II. Width relationship and golden
ratio.
III. Connectors and embrasures.
I. Tooth Proportions

▪ Square centrals.
▪ Central height: 9.5mm
▪ Central width: 8 mm

▪ Ratio: 84%
 II. Width relationship and the Golden
Ratio

▪ Golden Ratio:
1.0 : 0.62 : 0.38 : 0.24
UL1 : UL2 : UL3 : UL4
1.0 : 57% : 137% : 73%
III. Connectors and Embrasures

▪ Connectors height is greatest

between central incisors.
▪ No black triangles, as gingival
embrasures are filled with
interdental papillae.
▪ Incisal embrasures is getting
larger as moving posteriorly.
Intra-Oral
Examination
 Intra-Oral Examination

▪ Teeth present:

6 6
6 7

▪ Upper and lower 7s are still

erupting.
 Intra-Oral Examination

▪ Oral Hygiene: Fair

▪ Caries:
 Class I on UR 6
 Class II on LR 6
 Intra-Oral Examination

▪ Centerlines:
– Upper:
▪ shifted to the left by 1
mm.
– Lower:
▪ shifted to the right by 1
mm.
▪ OJ: 5mm
▪ OB: 10% “decreased”
▪ Crossbite on:
▪ Right: 4,5,6
▪ Left: 5
 Intra-Oral Examination

▪ Right buccal segment

relationships:
 Canine: Class I
 Molar: Class II ‘3/4’

▪ Left buccal segment

relationships:
 Canine: Class III ‘1/2’
 Molar: Class I
 Lower Arch

▪ U- shaped arch form.

▪ Asymmetric / constricted.
▪ Moderate crowding.
▪ Mesially inclined canines.
▪ Lingually displaced:
– LR 2 & LL 2

▪ Lingually inclined:
– LR & LL 4,5s

▪ Class II on LR 6
 Upper Arch

▪ V- shaped arch form.

▪ Constricted.
▪ Overlapping central incisors.
▪ Palatally inclined lateral
incisors.
▪ Palatally erupting 2’nd
premolars on both sides.
▪ Rotated:
▪ UR 4, 6
▪ UL 4, 6

▪ Class I caries on UR 6.
Study Model Examination
Frontal View

▪ Class II div 1 incisor

relationship.
▪ OJ: 5mm
▪ OB: 10%
Posteroanterior View
Right Side

▪ Molar: Class II ‘3/4’

▪ Canine: Class I
▪ Crossbite: 4,5,6
Left Side

▪ Molar: Class I
▪ Canine: Class III ‘1/2’
▪ Crossbite: 5
 Lower Cast Occlusal

▪ Intercanine width:
– 23 mm “more decreased”
 (A decrease in intercanine
width “esp females from 13 –
20”.)
– Sinclair and Little 1983

▪ Intermolar width:
– 42 mm “normal”
Upper Cast Occlusal

▪ Intercanine width:
– 27.5 mm “decreased”

▪ Intermolar width:
– 41 mm “decreased”
 Curve of Spee

▪ Right side: 1 mm

▪ Left side: 1.5 mm

Space Analysis:

▪ Upper arch:
– Symmetric.

▪ Space available=
– 17+19.5+19.5+16.5= 72.5mm

▪ Space needed = 75.5

▪ Crowding:
▪ 72.5-75.5 = -3 mm “Mild
crowding”
Space Analysis:

▪ Lower Arch:
▪ Asymmetric.

▪ Space available=
– 21+8+10+20= 59 mm

▪ Space needed= 64.5

▪ Crowding:
▪ 59-64.5 = -5.5 “Moderate
crowding”
 Tooth Size Analysis (Bolton Ratio)

▪ Over all ratio = 87.5/98

▪ 89.2% “Decreased”
– Normal: 91.3%

▪ Anterior ratio = 36.5/45.5

▪ 80.2% “increased”
– Normal: 77.2%
11 7 8 8.5 6 9 8 6 8 8 7 11.5 98 45.5
over ante
6 5 4 3 2 1 1 2 3 4 5 6 all rior
11.5 7 7.5 7 5.5 5.5 6 6 6.5 7 6.5 11.5 87.5 36.5
Royal London Space Analysis

Lower Arch Upper Arch

Crowding \ Spacing -5.5 -3

Angulation \ Inclination 0 -2
Change
Levelling curve of Spee -1

Arch Width change 0 +2

Incisor A\P change 0 -3

Total -6.5 -6
VTO “Visualized Treatment Objectives”

▪ Chart 1:
Midline – Molar position
Right Left
5 mm Zero
1 mm

1 mm
 VTO “Visualized Treatment Objectives”

▪ Chart 2: Right Left

– Lower Arch Discrepancy Crowding 3*3 -4 -1.5

6*6 -0.5 -0.5

Protrusion +2 +2

Curve of Spee -1 -1

Midline +1 -1

Total 3*3 -1 -0.5

6*6 -1.5 -0.5
VTO “Visualized Treatment Objectives”

▪ Chart 3:
– Anticipated treatment change

Right Left
6.5 mm 1mm 1 mm 0.5 mm 4.5 mm

6.5 mm 1 mm 1 mm 2 mm 7.5 mm
• Normal condyles.
• Approximately equal length
of rami.
▪ All third molar buds are present.
▪ No apparent pathology.
▪ Caries on:
▪ UR 6 Class I
▪ LR 6 Class II
IOTN Dental Health Component

▪ Grade: 4.d (Severe need)

 IOTN Esthetic Component

▪ 7 : Moderate/ Borderline
 Diagnostic Summary
▪ H.N is a 13 years, 4 months old, female, undergone adenoidectomy with no serious medical
condition.
With mouth breathing habit claiming that it was stopped one year ago.
She came complaining of teeth overlap, especially on posterior area.
She has fair oral hygiene.
Class II div 1 incisor relationship based on skeletal Class II with increased anterior facial height.
She has asymmetrical face with chin deviated to the left side. Compromised smile esthetics.
She has Class II “3/4” molar with Class I canine relationships on right side and a Class I molar with
Class 3 “1/2” canine relationships on left side.
OJ is 5mm with decreased OB to 10% “incomplete”
Upper midline shifted to the left by 1 mm and lower shifted to the right by 1 mm.
Severe crowding on upper arch and moderate crowding on lower.
Crossbite on UR 4,5,6 and UL 5. Palatally erupting UR&UL 5s with lingually displaced lower
laterals. Rotated UR & UL 4,6. Palatally inclined upper laterals.
Carious lesions on UR and LR 6s.
 Problem list ▪ Skeletal and dental problems in
transverse plane:
– Constricted maxilla.
▪ Pathological problems: – Chin deviated to the left side.
– Upper midline shifted to the left by 1mm.
– Fair O.H.
– Lower midline shifted to the right by 1mm.
– Carious lesions on UR 6 & LR 6
– UR 4,5,6 UL 5 on crossbite.
▪ Developmental problems:
– Mouth breathing.
▪ Skeletal and dental problems in A-P :
– Convex profile “class II skeletal”
– Patient’s concern about the overlapped teeth.
– Molars: RT: Class II “3/4”. LT: Class I
– Smile esthetics: overlapped central incisors.
– Canines: RT: Class I. LT: Class III ‘1/2’
– Alignment and symmetry:
▪ Asymmetric lower arch with crowding of -6 mm
– OJ 5 mm
with lingually displaced laterals .
▪ Symmetric upper arch with crowding -7mm with
▪ Skeletal and dental problems
palatally erupting upper 5s and rotated UR 4&6 – Increased LAFH
UL 4&6. – Decreased OB. 10%
 Treatment Aims

▪ Improve O.H. ▪ De-rotate rotated teeth.

▪ Treat the carious teeth.
▪ Assess mouth breathing.
▪ Relief crowding on upper and lower
arches. And align the teeth.
▪ Correct centerlines shift.
▪ Correct crossbites on UR: 4,5,6 and
UL 5.
▪ Correct skeletal discrepancy.
▪ Achieve Class I molar and canine
relationships.
▪ Achieve normal OJ &OB.
▪ Obtain flat curve of spee.
▪ Finishing and detailing of occlusion.
▪ Retain corrected results
 Treatment Plan: “Growth modification”
“Non-Extraction”
1. O.H. improvement.
2. Assess breathing pattern. “If still mouth breathing, treat with oral screen
from 3-6 months. Or by referral to ENT specialist.
3. Upper and lower Fixed appliance with T.P.A.
4. High pull head gear.
5. Rapid maxillary expansion.
6. Permanent retention on upper from 5 – 5 & lower from 3 – 3. using
sandblasted S.S 0.030 – 0.032 inch.
With upper Hawley retainer and lower vacuum formed.
 Justification

Why growth modification?

The patient is still growing and on stage 3 CVM so we can benefit from
mandibular growth on peak of growth modification.

Why non extraction?

Due to moderate crowding on upper and lower arches, no need for
camouflage as growth can be modified.
Space can be gained from different aspects such as Bolton discrepancy
and de-rotation of rotated teeth.
 Justification

▪ Oral screen: in case the patient is still mouth breather.

▪ Fixed appliance :
– For 3D tooth control “Derotation, intrusion, extrusion & torque”.
– Maxillary incisors palatal torque.
– Buccal crown torque of lower posterior teeth as they are lingually inclined.
– 0.022 better sliding mechanics.
– For alignment of upper second premolars.

▪ Headgear to strain maxillary forward growth and allow mandibular auto rotation.
▪ Rapid palatal expansion, due to presence of maxillary constriction and V shaped
arch form.
Justification

▪ Transpalatal arch: derotation of 1’st molars.

▪ Permanent retention: due to severely displaced upper 2’nd premolars
and lower lateral incisor.
▪ Hawley retainer: to get maximum interdigitation, preserve MMPA
angle. Full time wearing on 1’st 3-4 months then part time at least 12
months or until growth cease.
▪ Vacuum formed: full time wearing on the 1’st 48 hrs then 12 hrs daily
for 3 months, and gradually decrease the wearing days during the
next 9 months.
Thank You