By: dr alaa Al-Ibrahimi

Supervision:

Dr. Ahmad AltarawnehDr Anwar Al rahamneh

Name : R . M

Gender : female

Age : 11 years , 10 months

Occupation : Student

Nationality Jordanian

Medical History: Denied any relevant medical conditions .

Trauma : denied any history of trauma.

Habits : denied any habits , no habits have been noticed.

Growth status : growing patient .

Dental History :

- lower left first molar was extracted 6 months ago because it was non-restorable .

- Big amalgam filling on lower right first molar .

- Routine dental care: ( composite fillings on UR6 , UL 4,5,6.

-

”سناني هدول طالعين(pointing to the upper centrals) “و كلهم راكبات فوق بعض

Transverse:

Mild asymmetry ;

Left side of the face is

slightly larger than the

right side .

..transverse :

The central fifth is

almost equal to each

medial fifth.

Inter pupillary distance

Equals the width of the

mouth .

The width of the nose is

slightly wider than the central fifth.

Antero-posterior

- Convex profile

Vertical ;

Clinically average facial

Proportions ; the lower

facial third is slightly

longer than the middle

third.

The mouth is one third

of the way between

the base of the nose and the chin.

Competent lips.

Normal tongue size and function..

Fronto-nasal angle:

155 (normal: 115-135)

Naso-labial angle:

97 (normal 90-110)

Labio-mental angle:

108 (114-140)

Smile arc: the contour of

the incisal edges of the

maxillary anterior teeth

match the curvature of

the lower lip (consonant).

Incisor and gingival

display: display of all

maxillary incisors and some gingiva.

Buccal corridor : wide buccal corridor ; buccal corridor ratio = 21% (ideal 13%).

Smile extends to upper second premolars.

Different gingival levels on right and left central incisors ( lower on the right)

On left side the gingival level of lateral is lower than central (1mm), the canine is the same as central.

On right side the gingival levels are the same.

No apparent pathology.

Normal condyles

All 7s have started root formation.

Third molars not evident yet. (normal).

Poor oral hygiene.

Plaque visible on teeth , gingivitis.

Normal oral mucosa

No caries .

Teeth present : 6 5 4 3 2 1 1 2 3 4 5 6

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

Class II intermediate incisor relation. ( incisors are of

normal inclination but the overjet is 5-7 mm ,, williams and stephens 1992,,)

Over jet : 7 mm .

Over bite : deep (90%) incomplete .

Lower midline shifted 2 mm to the right .

Cross bite on left first premolar.

No displacement.

Canine relation : Right: class II ¾ unit

left: class II ½ unit.

Molar relation : Right : class II full unit

Left : N.A

U shaped arch.

Mild crowding

in anterior segment.

extracted LL6

LL7 close to erupt

(blanching).

Rotated LR4.

U shaped arch.

Mild crowding.

Lingually tilted UL4.

Rotated UL1 , UL3

UL5,UL6 ,UR4.

Dental health component is 4.a ; increased over jet greater than 6 but less than or equal 9 mm.

( severe/ need treatment.)

OJ= 7mm.

7 ; moderate need.

Midline : lower shifted to the right 2mm.

Canine : II ¾ unit . Canine : II ½ unit.

Molar : II full unit. Molar: N.A

OJ: 7mm

Deep bite incomplete.

Asymmetrical

U- shaped arch.

Intercanine width

= 28 mm.(norm:31.5).

Intermolar width

=41mm(norm:44.6).

Asymmetrical .

U- shaped arch.

Intercanine width =

23 mm (norm =24.8).

Intermolar width =

43 mm (norm: 41.8)

Right : 1 mm.

Left : 3 mm.

Anterior Bolton ratio =37/49 * 100% =75.5%

(n= 77.2 +/- 1.65).

Overall Bolton ratio = 85.5/94 *100% = 90.9%

(n= 91.3 +/- 1.91).

Upper Arch:-Space available:92 mm.- space required : 94 mm.Mild crowding 2mm

Lower Arch:-space available :83 mm.-space required : 85.5( 2.5 mm mild crowding.)

-

R 5mm L 5mm

2 mm

Chart 1 molar-midline position.

R L crowding 3*3

6*6

protrusion

C.O.S

Midline

Total 3*3

6*6

Chart 2. lower arch discrepancy .

1 1

4 4

5 2 3

Chart 3 ; anticipated treatment change

2+4+12+4+4 =26

R.M is a 11.10 y.o female patient, denied any medical history. complaining of protruding and mal-aligned teeth .She has class II intermediate incisor relation based on class II skeletal relation with poor O.H .complicated by increased overjet (7mm) , deep overbite , upper mild crowding , lower mild crowding , extracted LL6 , she has class II canine and molar relationship on both sides . Crossbite on left 1st premolars . Lower midline shift.

Pathological problems : Dental :- Poor oral hygiene.

- Gingivitis , plaque deposition. -extracted lower left 6.

Patient’s chief complaint: -lower midline shift 2mm to Rt.

-protruded and mal-aligned teeth. - cross bite on left 1st premolar.

Developmental problems: - increased overjet ( 7mm).

Skeletal : - class II intermediate incisor relation.

-mild asymmetry. - class II canines & molars relation.

-class II skeletal base (retrognathic mandible). - deep incomplete overbite.

-increased LAFH. -mild crowding in U and L arches.

Soft tissue : -rotated ul1,3,5,6 ,ur 6,lr4.

- Convex profile. - lingually tilted UL4.

- Increased frontonasal angle (obtuse)

- Reduced labiomental angle. (acute)

Improve oral hygiene. Stabilization of periodontal health. Correct pr’s chief complaint ( protrusion and mal-alignment). Accept the mild facial asymmetry. Correct skeletal class II relationship. Accept slightly increased LFH. Improve facial profile and labiomental angle. And accept obtuse

frontonasal angle. Correct lower dental midline shift. Correct the crossbite on left 1st premolars. Achieve normal Overjet.(2-3 mm) Achieve normal Overbite. Achieve class 1 incisor relationship. Achieve class 1 canine and molar relationship on both sides. Relief crowding in upper and lower arches. correct rotated teeth(ul1,3,5,6 ,ur 6,lr4) and lingually tilted UL4. Finishing and detailing of the occlusion. maintain the corrected results.

Phase 1: growth modification (functional).- Oral hygiene instructions

- Referral to periodontics clinic for maintenance of periodontal condition.

- Twin block appliance.

Phase 2: Re-evaluate the case after phase 1 .- Upper and lower Fixed applinace MBT slot 0.022.

- Retention.

URA:• Adam’s clasps on the 4s and 6s.• torquing spurs on upper incisors without labial

bow.• Midline Jack screw. • Blocks on 4, 5,6. (7-8 mm thickness and 70-75

degrees angle with occlusal plane.)

LRA: • Adam’s clasps on 4s.• Lower incisor capping. • blocks on 4s and 5s at an angle of 70 -75 degrees to

the occlusal plane and 7-8 mm thickness.

After phase 1 : : inclined anterior bite plane (8 mm depth , 70 degrees inclination.)

After phase 2 : -short term : upper Hawley retainer, lower VFR.( full

time wear for 6 months, night time wear for another 6 months)

- A fixed A-splint retainer (heavy intracoronal wire) to keep the space of LL6. directly at debondingvisit.

- long term : Upper and lower bonded retainers from 3-3 (braided steel wire of 17.5 mil.

Growth modification > functional appliance::

- growing patient.

-class II skeletal base with retrognathic mandible

- moderate to severe class II intermediate with no incisors compensation .

-normal MMPA with increased overbite.

- minimal crowded arches.

- Class II canine and molar relationships.

- Increased overjet.

OHI : patient has poor oral hygiene . Referral to periodontics clinic: patient has

gingivitis with visible plaque deposits .

Twin block appliance: • Robust • Easy to repair• Easy to activate.• Relatively well tolerated by the patient because it is

two pieces that is not interfering with function. • Expansion is easy by a midline screw• Incorporation of auxiliary and headgear is easy.

Torquing spurs:

- To impede further eruption of upper incisors (deep bite) .

- To minimize retroclination of upper incisors which are already crowded and with normal inclination.

Lower incisor capping:

- To impede further eruption of the lower incisors (deep bite).

No clasp on lower molars:

To permit eruption of the molars ( deep bite).

Inclined anterior bite plane:

- to retain functional appliance results during transition to fixed appliance .

- allow settling of the occlusion.

- Maintain transverse correction.

Upper and lower Fixed applinace .

We need 3D teeth movement.

MBT prescription is preferred::

- It correct LLS and ULS inclination.

- Less rebound effect because of zero tipping of U6 and U3.

- Compensation for tipped molar due to expansion by increased palatal root torque of buccal segment.

Open space for LL6:

- the third molar still not evident ( normal) and we can not guarantee that it will be present and in good position and angulation to replace the second molar .

Long term bonded retainer (3-3)::

- In upper arch to retain the derotaion of upper left incisor.

- Lower arch to minimize late incisor crowding.

A- Splint (heavy intracoronal wire)::

- The best choice to maintain space for posterior restoration.

- Reduce the mobility of teeth and makes it easier to place a fixed bridge (if it is the choice).

- It will be definitely required as a fixed retainer if implant is to be placed because of the long period before an implant can be placed.

Full records

Take impresion for Twin Block appliance and functional bite with 2mm seperation at incisors (deep bite) with the patient biting edge to edge.

Delivery of the appliance and instructions

After finishing the functional phase deliver the inclined anterior bite plane to retain functional appliance results during transition to fixed appliance

Then bonding of the fixed appliance MBT prescription on lower arch first.

Alignment with superelastic 0.016”niti wire. The normal sequence of wires until reaching rigid S.S 19*25 wires. Then we bond the upper arch and follow the same sequence.

Opening the space of LL6 with niti coil springs.

TMA wire for finishing and settling of the occlusion .

Debonding and impression taking for upper hawley and lower VFR . And bonding of A-splint retainer ( heavy intracoronal wire) between LL5 and LL7.

The bonding of upper and lower fixed retainer from 3-3.

Referral to prosthodontics clinic to arrange for prosthetic replacement of LL6 at the appropriate age.

Thank you