Orthodontic casepresentation

Done by: Moeen Salih Al-Bahloli

3rd year orthodontic resident

Personal Data

• Patient’s Name: M.A• Gender: Female• Age : 15 Years, 5 Months• occupation: Student• Nationality: Jordanian

Chief Complaint

“I have unerupted tooth in my lower jawAnd rotated upper anterior teeth”

Medical & Dental History

• Medical History: Denied Any Medical History.

• Dental History: • Routine dental treatment (filling in UR6&LR6).• Extraction of LL 1st primary molar, 1 month ago.

History

• Trauma: No history of trauma.• Habits: No Habits.• Motivation: Internally Motivated.• Growth status: Non- grower .

Jaw & Occlusal Functions

• Mastication: Normal masticatory function.

• Speech: No difficulty.

• TMJ:No clicking. No Crepitus or tenderness.

No displacement. Normal opening.

Extra-Oral Photos:(Frontal View)

(Profile View)Extra-Oral Photos:

:Extra-Oral Photos

(Oblique View)

:Intra-Oral Photo

Extra-Oral Examination skeletal assessment

A. Anterio-posterior Assessment:

• Class I skeletal pattern

:B. Vertical Assessment

• Average LAFH.

C. Transverse Assessment:• Symmetrical face.

Soft Tissue Examination

• Equal thirds of the face.• Upper lip in the upper

1/3 of the lower.• Lower lip in the lower

2/3 of the lower.1/3 2/3

Asymmetrical face.Larger middle 1/5th .Interpupillary distance larger

than the width of the mouth.

• competent lips

• Straight facial profile.

• Frontonasal angle: 128 ˚ “ normal 115˚ -135˚’’

• Nasolabial angle: 106˚ “ normal 90˚ -110˚”

• Labiomental angle: 132˚ “ normal 114˚ -140˚”

Intra-Oral Examination

• Oral Hygiene : Good.• Normal frenum attachment

& oral mucosa.

• Teeth present:

76E4321 1234567 7654321 1234567• Caries in UL6.• Lower left 1st premolar & Lower

left 2nd molar partially erupted.• Primary Upper right 2nd molar still

present with no mobility.

Lower arch• U-shaped arch.• Anterior segment: Upright incisors. Distally tilted LL2&LL3.• Posterior segment: Partially erupted LL4

directed lingually. Partially erupted LL7. Rotated LL5&LR5.

Upper arch• U-shaped arch.• Anterior segment: Upright anterior teeth. Rotated Rt&Lt central incisors .• Posterior segment: Primary right 2nd molar still

present with no mobility. Rotated left 2nd premolar. Caries in UL6.

Anterior segment in occlusion

• Incisor relationship: class 1

• Midline: Lower shifted to the left 2mm.

• Overjet : 2mm.• Overbite: incomplete 50%.

Buccal segment in occlusion

• Molar relationship: Cl III ¼ unit in the right side. Cl I in the left side.• Canine relationship: Cl I in the right side. Cl II ½ unit in the left side.

Study model analysis in occlusionAnterioposterior:

• Molar : Cl III1/4 unit.• Canine : Cl I .

O.J : 2mm

• Molar : Cl I .• Canine : Cl II ½ unit .

Right Left

Transverse :

Midline discrepancy 2mm.

Vertical :

Incomplete overbite 50%

:Curve of spee

2mm 3mm

Right Left

:Upper arch

• U-shaped arch.• Asymmetrical arch.• Intercanine width: 37mm ( increased ). • Intermolar width: 47mm ( increased ).

Lower Arch:

• U-shaped arch.• Asymmetrical arch.• Intercanine width: 27mm (increased ).• Intermolar width: 48mm( increased ).

Radiographical examination

Orthopantomogram “OPT” Analysis:

• No pathology.• All teeth are present except UR 2nd premolar & all wisdom teeth. • Primary Upper right 2nd molar still present with good bone level.• Lower left 1st premolar & Lower left 2nd molar partially erupted.• Roots of lower left&right 2nd molar not completely formed.• Fillings in UR6&LR6.• Other features look normal.

Cephalometric Analysis Measuremen

tsAverage

SNA 83.6˚ (81-+)3SNB 81.8˚ (78-+)3ANB 1.8˚ (3-+)1

SN-MAX 2˚ (8-+)3Wits

Appraisal-2mm (0 -+ )

1.77mm “f”

MMPA 24˚ (27-+)4LAFH Ratio 56% 55%-+2%UI - MAX 107˚ (109-+)6LI - MAN 90˚ (93-+)6

IIA 138˚ (135-+)10Skeletal relationship: cl III

Space analysisLower Arch:Space available 62mm

Space required 62mm 0mm ( no crowding)

Upper arch: Space available 73mm

Space required 70mm + 3mm

10.5 6.5 7 7 6.5 8 8 6.5 7 7 6.5 10.5 91 43

6 5 4 3 2 1 1 2 3 4 5 6 overall

anterior

10 7 7 6.5 5.5 5 5 5.5 6.5 7 7 10 82 34

90%=Over all ratio: 82/91 Normal: 91.3% +/- 1.9

Anterior ratio: 34/43 = 79% Normal: 77.2% +/- 1.7

Normal Bolton Ratio

Note: mesiodistal width of UR primary 2nd molar 9mm.

Royal London space planning

Lower Upper

0 + 3 mm Crowding and spacing

- 2 mm 0 Leveling of occlusal curve

0 0 Incisors AP position

0 0 Inclination change

-2 mm +3mm Total

Pre-treatment (IOTN) Aesthetic Component:

Figure 1 Mild treatment need

Dental Health Component:

• Grade 5“Extreme /Need Treatment” 5i Impeded eruption of teeth due to retained deciduous teeth

Diagnostic summary • M.A 15,5months years old female, denied any medical problem, presented with

concern unerupted tooth in her lower jaw & rotated upper anterior teeth, good oral hygiene and caries in UL1st molar.

• She has a class I incisors relationship based on class III skeletal pattern, average lower anterior facial height , straight profile, and asymmetrical soft tissue face.

• She has missing UR 2nd premolar, over jet 2mm, incomplete overbite 50%, no crowding in upper and lower arches, rotated lower Rt & Lt 2nd premolars, distally tilted LL lateral incisor &LL canine, partially erupted LL 1st premolar &LL 2nd permanent molar, retained upper primary right 2nd molar with no mobility and good bone level, rotated upper left 2nd premolar& Rt and Lt central incisors, lower midline shifted to the left side 2mm.

• She has cl III ¼ unit molar relationship in Rt side, cl I in Lt side & cl I canine relationship in Rt side, cl II1/2 unit in Lt side and increased curve of spee.

Problems list Pathological problems:Caries in UL 1st molar.Patient’s concern:

I have unerupted tooth in my lower jaw and rotated upper anterior teeth.

Skeletal problems: Class III skeletal pattern.

Soft tissue problems:• Asymmetrical face.

Dental problems:• Missing upper right 2nd premolar and

retained upper primary right 2nd molar.• Partially erupted LL 1st premolar.• Rotated lower Rt & Lt 2nd premolars.• Distally tilted LL lateral incisor &LL

canine.• Rotated upper left 2nd premolar& Rt and

Lt central incisors.• Lower midline shifted to the right side

2mm.• Molars are cl III ¼ unit in Rt side and cl I

in Lt side.• Canines are cl I in right side and cl II ½

unit in left side.• Increased curve of spee.

Treatment Aims Restoration of carious tooth. Correct the patient complaint. Accept skeletal cl III pattern. Accept soft tissue problems. Accept retained upper primary right 2nd molar and consider

future artificial replacement for the missing UR 2nd premolar. Achieve class I molar and cl I canine relationship in Rt&Lt side. Correction of rotated and tilted teeth. Correction of dental midline shift in lower arch. Correction of curve of spee.

Treatment plan: “ Non- Extraction Case” “ camouflage case ”

1. Refer patient to cons. clinic to treat carious tooth.2. Oral hygiene instruction.3. Lower holding arch.4. Upper & Lower Fixed Appliance: using SWA technique. “ Pre-adjusted edgewise, Roth prescription, slot 0.022”

5. Interproximal reduction of UR 2nd primary molar.6. Retention: ( Long term) lower bonded retainer 3-3. Upper bonded retainer 1-1. ( Short term) Upper and lower Hawley retainer appliance.

Justification1. Camouflage : Patient passed the peak of growth spurt. Mild cl III skeletal. Good vertical facial proportion. No dental compensation. Normal overbite and overjet. 2. Non- extraction : Upper and lower arches with no crowding. Space can be gained by correction of rotated, tilted teeth and arch wire expansion .

3. Refer patient to cons. clinic to treat carious tooth.4. Oral hygiene instruction to maintain stability of the

periodontal tissue.

5. Lower holding arch: to prevent distal tipping of LL6 during opening space for LL4 which may interfere with LL7 eruption, and maintain cl I molar relationship.As anchorage – to maintain molar relationship – to aid in traction if the case necessitates .

6. Fixed appliance using Roth prescription: For 3D tooth movement. Average torque is needed.

7. Interproximal reduction of UR 2nd primary molar: Interproximal reduction 2.5mm(M&D sides) of UR 2nd primary molar to achieve cl I molar relationship in the Rt side and create accurate space for future artificial replacement of UR 2nd premolar.

8. Retention: (Long term ) Lower fixed retainer (3-3) to stabilize the position of anterior teeth and

prevent lower late labial segment crowding . To maintain aligment of rotated LL3

Upper fixed retainer (1-1) to stabilize the position of central incisors. (Short term) Upper and lower Hawley retainer appliance for more settling and

stability.

Mechanics• At direct bonding of U&L fixed appliance: - Raising bite at lower Rt&Lt 6 –to disarticulate the occlusion in the early phase of aligment - lace back in all quadrents except lower left one ( 6 – 3) .

• At working arch wire (19 X 25 S.S): - Open spring between LL3&LL5 to create space for LL4, achieve cl I canine in Lt side and correct lower midline. - Bonding of LL4 and piggyback for traction of partially erupted LL 4.

• At finishing stage: - Remove lower holding arch. - TMA wire ( 21 X 25 ) for root parallism. - CSF .

Thank you