MEM BERSHIP IN O R T H O D O N T I C S: C A S E HI ST O RY M. K.

THE ROYAL COLLEGE OF SURGEONS OF EDINBURGH

MEMBERSHIP IN ORTHODONTICS

CASE HISTORY
DATE OF EXAMINATION: November 2016
CANDIDATE NUMBER: 101

CASE NUMBER: B

PATIENT‟S INITIALS: M.K.

COLOUR CODE:

CASE SUMMARY

Case Summary Max 150 words

An 11 year 6 month old Fijian Indian male presented with a Class II division I incisor relationship
on a Class II skeletal base (retrognathic mandible) with a lower lip trap and a neutral tending
horizontal growth pattern. He has a 12mm overjet, and a 95% overbite with an increased Curve
of Spee. He has mild upper and lower arch crowding, and has a constricted upper arch with a
3mm maxillary transverse deficiency in the molar region and 5.5mm maxillary transverse
deficiency in the premolar region. His upper midline is 2mm to the right and lower midline is
coincident with the mid-sagittal plane. The patient has a CS2 cervical maturation stage, which
indicates that he has 65-85% adolescent growth remaining.
Treatment involved orthopaedic growth modification, utilising a removable twin block with a mid-
palatal expansion screw for 11 months. This was followed by full upper and lower pre-adjusted
edgewise appliances (0.022”x0.028” slot) with MBT prescription and class II elastics.

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SECTION 1. PRE-TREATMENT ASSESSMENT

PATIENT DETAILS

Initials M.K.

Sex Male

Age at start of treatment 11yrs and 6months

Date of start of treatment August 2014

25 months
Duration of treatment
Top teeth ‘stick out’
Patient Complaint
Medical History Nil relevant

Thumb sucker/ trauma to UR1

Other relevant information

EXTRA-ORAL ASSESSMENT

II, mandibular retrognathic

Skeletal Antero-posterior
Reduced
Skeletal Vertical
No sig. assym.
Skeletal Transverse

Nasolabial increased
Soft tissue Assessment
Labiomental fold. Decreased chin-throat length

INTRA-ORAL AESSESSMENT

Mandibular Arch crowding/Spacing 2mm

Maxillary Arch crowding/Spacing 4mm

Incisor relationship II div 1

Overjet (mm) 12mm

Overbite 95% and traumatic

Centrelines coinicident

Left Buccal Segment relationship (molars) ¾ unit Class II

Left Buccal segment relationship (canines) ¾ unit Class II

Right Buccal Segment Relationship (molars) ¾ unit Class II

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Right Buccal Segment Relationship (Canines) ¾ unit Class II

Crossbite (Displacement) None

Other occlusal features Curve of Spee 3mm

Bolton Analysis (3-3) 77%

Bolton Analysis (6-6) 91%

General Dental Condition Oral hygiene good, no teeth of poor prognosis

GENERAL RADIOGRAPHIC EXAMINATION

Absent teeth None

Teeth of poor prognosis LR6 caries

Other relevant radiographic findings Root resorption UR1, UL1

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PRE-TREATMENT PHOTOGRAPHS: EXTRA-ORAL

PRE-TREATMENT
PHOTOGRAPHS: INTRA-
ORAL

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PRE-TREATMENT STUDY MODELS

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PRE -TREATMENT RADIOGRAPHS

Radiographs Other

Radiographs Other

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PRE-TREATMENT CEPHALOMETRIC TRACING

PRE-TREATMENT CEPHALOMETRIC ANALYSIS (T0)

Variable Norms T0
SNA 81 ± 3° 79.1°

SNB 77 ± 3° 72.0°

ANB 4.3 ± 1.9° 7.1°

MMPA 285° 23.1°

Face height ratio 55% + 2 52.9%

SN to maxillary plane 73° 7.0°

Upper incisor to maxillary plane 1116° 122.0°

Lower incisor to mandibular plane 965° 105.4°

Interincisal angle 1259° 109.6°

Wits appraisal 02 10.4

Lower incisor to APo line 0-2 mm +2mm

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DIAGNOSTIC SUMMARY

Diagnostic Summary (100 words max)

M.K is an 11 year 6 month old Fijian Indian male who presented with a Class II division 1 malocclusion
on a Skeletal II base with a retrognathic mandible and a lower lip trap. He has a 12 mm overjet, 95%
overbite, mild crowding in the upper and lower arches and a maxillary transverse deficiency. He has a
neutral, tending horizontal growth pattern and is CS2, indicating 65-85% adolescent growth remaining.

PROBLEM LIST (max 10 bullet points)

1. Increased overjet (12mm) and proclined upper incisors (chief complaint)

2. Severe Class II skeletal pattern (retrognathic mandible).

3. Class II Division I malocclusion

4. Decreased vertical skeletal proportions

5. 95% traumatic overbite

6. Constricted upper arch

7. Mild crowding upper and lower arches

8. Upper midline 2mm to RHS of MSP

9. Incompetent lips with lower lip trap

TREATMENT PLAN

Appliances Removable twin block with midline expansion.

Followed by upper and Lower pre-adjusted
edgewise fixed appliances (MBT prescription)
Extractions None

Special Anchorage Twin Block for class II correction and maintained

with class II elastics in fixed appliance phase.
Additional dental treatment None

Retention. Bonded retainer Upper 2-2, lower 3-3

Upper and lower VFR’s

TREATMENT PROGRESS

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Age at start of active treatment 11yrs 6 months

Total active treatment 25 months

End of retention Ongoing

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SECTION 2. TREATMENT
IMAGES OF KEY STAGES/MECHANICS IN TREATMENT. (20 Images Max) (Comment Box max
30 words)

Comment Box:
Inserted removable twin block. Patient instructed to turn mid-palatal expansion screw 1x/5 ays

Comment Box:
Twin block removed. Full bond-up MBT twins 0.022”x0.028” slot. 014 NiTi upper and lower
arches

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Comment Box:
Upper: Bonded 17 and 27. 018 NiTi Lower: Bonded 37 and 47. 018 NiTi to control overbite

Comment Box:
Upper: 17x25 SS. Open power chain 6-6
Lower: 19x25 SS with small bite opening sweeps. IPR lower incisors
Other: Class II ¼ inch 3.5 oz elastics U3sL6s

Comment Box:
Upper: 17x25 SS retained; mesial inset 21; mesial inset 22; step in 14; open power chain 6-6
Lower: 19x25 SS retained; distal root tip 33; slight distal offset 41
Other: Class II ¼ inch 3.5 oz elastics U3sL6s full time RHS and LHS

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MID-TREATMENT CEPH ANALYSIS (Max two cephalometric. analyses)

End of Functional (T1)

Variable T0 T1

SNA 79.1° 79.1

SNB 72.0° 75.0

ANB 7.1° 4.1

MMPA 23.1° 20.6

Face height ratio 52.9% 52.1%

SN to maxillary plane 7.0° 8.5°

Upper incisor to maxillary plane 122.0° 118.6°

Lower incisor to mandibular plane 105.4° 112.8°

Interincisal angle 109.6° 108.0°

Wits appraisal 10.4 4.0

Lower incisor to APo line +2mm +2mm

Near End of Treatment (T2)

Variable T0 T1 T2

SNA 79.1° 79.1 78.1°

SNB 72.0° 75.0 73.6°

ANB 7.1° 4.1 4.5°

MMPA 23.1° 20.6 23.0°

Face height ratio 52.9% 52.1% 53.5%

SN to maxillary plane 7.0° 8.5° 9.2°

Upper incisor to maxillary plane 122.0° 118.6° 112.7°

Lower incisor to mandibular plane 105.4° 112.8° 109.6°

Interincisal angle 109.6° 108.0° 114.7°

Wits appraisal 10.4 4.0 1.1

Lower incisor to APo line +2mm +2mm 0mm

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CEPHALOMETRIC SUPERIMPOSITION
Pre-treatment: Black
Post-functional (T1): Blue
End of Treatment (T2): Red

A) Overall superimposition, registered on Bjork’s stable structures

B) Maxillary superimposition, registered on C) Mandibular superimposition, registered on

Bjork’s stable mandibular structures Bjork’s stable mandibular structures

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SECTION 3. POST-TREATMENT ASSESSMENT

END OF TREATMENT STUDY MODELS

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POST- TREATMENT PHOTOGRAPHS (Max 8 images)

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POST- TREATMENT PHOTOGRAPHS (Retainers) (Max 3 images)

SECTION 4.
CRITICAL APPRAISAL (max 250 words)

Facial Aesthetics
The facial aesthetics improved throughout treatment. Lip competency was obtained and the profile became
less convex with more chin projection. Neutral tending horizontal growth pattern continued, and a slight
increase in lower face height was achieved through molar extrusion and ramal growth.

Smile Aesthetics
The smile arc followed the curvature of the lower lip well. The slow maxillary expansion enabled broadening
of the smile and a reduction in buccal corridor widths . The case finished with good upper incisal display at
rest and smiling.

Skeletal
Although significant mandibular growth occurred throughout treatment, the patient still was mandibular
retrognathic post-treatment. Overbite and overjet were corrected by a combination of dentoalveolar and
skeletal changes. Removal of the lower lip trap aided profile improvement and good buccal interdigitation will
aid retention of the treatment result.

Dental
A class I occlusion was achieved with normal overbite and overjet and good interdigitation. Upper midline
finished 0.5mm to right of mid-sagittal plane, which was acceptable.
Mx: good alignment of the maxillary teeth was achieved, however 11 and 21 required slightly more mesial
root tip; 23 required more mesial root tip and 25 required more distal root tip.
Md: good alignment of the lower teeth was achieved however the 46 needed more mesial offset and toe-in.

Retention
Upper and lower fixed linguals and removable VFRs were issued.
The 3-month retention appointment was uneventful and the treatment appears stable at this point in time.

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