orthodontics case discussion / fixed orthodontics courses for general dentists in india

CASE DISCUSSION

CHIEF COMPLAINTName: Nalla Shilpa

Age: 21 years

Sex: Female

Patient complains of irregularly placed upper and lower front teeth.

EXTRA ORAL EXAMINATION

FRONTAL AT REST FRONTAL AT SMILE

EXTRA ORAL EXAMINATION PROFILE AT REST


OBLIQUE AT REST OBLIQUE AT SMILE

INTRA ORAL EXAMINATION

FRONTAL


MAXILLARY ARCH MANDIBULAR ARCH


OVERJET OVERBITE

RELATION

RIGHT OCCLUSION LEFT OCCLUSION

PAST DENTAL HISTORY

No relevant history

GENERAL HISTORY

• Improvement of esthetics is prime reason for the patient to seek treatment and is positively motivated for treatment.

• Patients brushes once daily and does not use any other oral hygiene aid.

CLINICAL EXAMINATION

GENERAL HEALTH STATUS

• Height :5 feet, 3 inches• Weight : 52 kgs• Posture : Upright• Body type : Mesomorphic • Gait : normal

EXTRA ORAL EXAMINATION - FRONTAL

• Mesocephalic head.• Leptoprosopic face.• Apparently symmetrical• Vertical proportionalityUpper – 61 mmMiddle – 57 mmLower – 65 mm• Stomium line to nose– 20 mm Stomium line to chin – 41mmIncompetent lipsInterlabial gap-4 mm

EXTRA ORAL EXAMINATION - FRONTAL

•Consonant smile arc.

•7 mm of upper incisor display (70%)

• Upper dental midline shifted to right by 2 mm

•Lower dental midline shifted to leftby 2 mm

EXTRA ORAL EXAMINATION-PROFILE

• Straight facial profile.• Average nasolabial

angle.• Average clinical FMA.• Incompetent lips

FUNCTIONAL EXAMINATION

• Respiration is oronasal.• No TMJ or jaw function complaint.• Interocclusal clearance : 3mm • Maximum mouth opening : 45 mm • Protrusion 11mm• Right excursion 8 mm.• Left excursion 8 mm.• Normal swallow.• Normal speech.


SOFT TISSUE EXAMINATION:• Fair oral hygiene status.• Tongue- normal shape & movements.• Gingival recession-31


HARD TISSUE EXAMINATIONTeeth present- full compliment

of teeth except 18,28,38,48Generalised Enamel hypoplasiaGingival recession and grade 1

mobility -31


HARD TISSUE EXAMINATION (MAXILLARY ARCH)

• U-shaped arch.• Asymmetrical arch.• Upper anterior crowding • Labially and highly placed 13• RotationsDistobuccal-16,26,25Mesiolabial- 11,12,14

Spacing between 12/ 14


HARD TISSUE EXAMINATION (Mandibular arch)• U-shaped arch.• Asymmetrical arch.• Lower anterior crowding.• Amalgam restoration – Buccal pits- 36,46• Rotations-• Mesiolabial-34,42 • Distobuccal- 35,36,44,45Gingival recession and grade 1 mobility -31Curve of speeRight-3.5 mmLeft-4mm


ANTERIOR OVERJET OVERBITE RELATIONSHIP

Overjet – 2mm(21/31), 2.5mm(11/42)

Overbite – 1 mm(21/31), 2mm(21/41)

Incisor relation – Class I


RIGHT

Molar Relation – Class I

Canine relation- Class III( Highly placed 13/43)

LEFT

Molar relation– Class I

Canine relation– Class I

DIAGNOSTIC RECORDS

ORTHOPANTOMOGRAM

LATERAL CEPHALOGRAM

MODEL ANALYSIS

BOLTONS ANALYSIS

Anterior mandibular tooth material excess of 0.8 mm

Overall maxillary tooth material excess of 0.73 mm

CAREY’S ANALYSIS

9.5 mm tooth material excess- 1st premolar extraction

ARCH PERIMETER ANALYSIS

5 mm tooth material excess – extraction of 1st premolars

PONT’S ANALYSIS

Calculated values are greater than measured values in premolar area

NEED FOR EXPANSION

ASHLEY HOWE’S ANALYSIS

PMD-36.5mm & PMBAW- 40mm. Expansion is possible

PMBAW%=39.4% Borderline case

ANGLE MEAN ACTUAL

INFERENCE

FMPA 250 340 Hyperdivergent

IMPA 900 990 Proclined lower incisors

FMIA 650 480 Poor esthetic balance

TWEED’S ANALYSIS

MEASUREMENTS MEAN ACTUAL INFERENCE

Facial Plane 87.5±3.60 860 Average positioned chin

Convexity 0 ±5.10 +90 Convex profile

A-B Plane -4.6to3.7 -100 Skeletal class II

MP angle(FH-Go-Me)

22 ± 30 310 Hyperdivergent

Y-axis 60±40 600 Normodivergent

Occ Plane (OP) 9±40 100 Average

U1-L1 (angle) 135±6 0 1090 Proclined incisors

L1-OP (angle) 75±40 580 Proclined Lower anteriors

L1-MP 92±40 1010 Proclined Lower anteriors

U1- A-Po 2±3mm 12mm Proclined upper anteriors

DOWN’S ANALYSIS

STEINERS ANALYSISMEASUREMENTS MEAN ACTUAL INFERENCE

SNA 820 820 Orthognathic maxilla

SNB 800 760 Retrognathic mandible

SND 76 740 Backward positioned chin

ANB 2±20 60 Skeletal Class II

Go-Gn to SN 320 350 Hyperdivergent

UPPER 1 to N-A 4mm 4 mm Average

UPPER 1 to N-A 220 300 Proclined upper incisors

LOWER 1 to N-B 4mm 8 mm Anteriorly positioned lower incisors

LOWER 1 TO N-B 250 360 Proclined lower incisors

UPPER 1 to LOWER 1 1310 1090 Proclined upper and lower incisors

OCCLUSAL TO S-N 140 190 Clockwise rotation of occlusal plane

STEINERS ANALYSIS

SOFT TISSUE

Upper lip 1 mm posterior to S-line

lower lip 1.5 mm anterior to S-line.

indicating retrusive upper and protrusive lower lips

WITS APPRAISAL• AO IS AHEAD OF BO BY 3 mm.

Indicating SKELETAL CLASS II tendency

McNAMARA ANALYSISMEASUREMENTS MEAN ACTUAL INFERENCE

Na ┴ -Point A (mm) 0-1 -1 mm Orthognathic maxilla

Na ┴ -Pg (mm) 0 to-4 -9 mm Retrognathic mandible

Facial axis angle 00 -30 Hyperdivergent

MP angle (FH-Go-Me) 22 ± 40 310 Hyperdivergent

Mx length(Co-PointA) 93.6±3.2 90mm Average

Md length(Co-Gn) 121.6±4.5 112mm Decreased

Mx-Md differential 28.0±3.2 22mm Decreased

LAFH (ANS-Me) 67.2±4.7 67mm Average

U1- Point A 4mm 4mm Average

L1- A-Po 1-2mm 3.5mmAnteriorly positioned

lower incisors

Naso labial angle 90-110 0 1040 Average

PARAMETERS MEAN PRE RX INFERENCE

Se-N (Length of Ant Cranial Base) 70.1mm 73 mm Increased

Go-Pg (Length of Mandibular Base)

Se-N+3mm(76mm) 74mm Decreased

ANS-PNS (Length of Maxil lary Base) 48.1-56.1mm 57mm Increased

Co-Go (Length of ramus) 53.2mm 48mm Decreased

ANS-PNS/ Go-Pg 2:3 2.1:2.9Decreased mandibular base length relative to

maxilla

Co-Go/ Go-Pg 5:7 4.7:7.3Increased mandibular base length relative to

ramus height

SCHWARZ ANALYSIS

RAKOSI JARABAK’S ANALYSIS

MEASUREMENT MEAN ACTUAL INFERENCE

SADDLE ANGLE 1230 ± 5 1250 Average

ARTICULAR ANGLE 143 ± 60 1380 Average

GONIAL ANGLE 128 ± 70 1360 Average

U/ GONIAL ANGLE 52-550 590 Increased

L/ GONIAL ANGLE 72-750 770 Increased

SUM OF POSTERIOR ANGLES

396 ± 60 3990 Normodivergent

MANDIBULAR PLANE ANGLE

320 350 Hyperdivergent

ANGLE OF INCLINATION 850 850 Average

N-PERP TO OCCLUSAL PLANE

750 800 Forward rotation of occlusal plane

MEASUREMENTS MEAN ACTUAL INFERENCE

N-PERP TO MANDIBULAR PLANE

650 590 Clockwise rotation of mandibular plane

BASAL PLANE ANGLE 250 250 Normodivergent

PALATAL PLANE TO OCCLUSAL PLANE

110 50 Anticlockwise rotation of occlusal plane

OCCL. PLANE TO MP 140 200 Clockwise rotation of mandibular plane

Y AXIS 660 680 Hyperdivergent

INTERINCISAL ANGLE 1350 1090 Proclined incisors

UPPER 1 TO S-N 102±2º 1110 Proclined upper incisors

LOWER1 TO MAND. PLANE (IMPA)

90±30 1010 Proclined lower incisors

UPPER1 TO PALATAL 70±50 570 Proclined upper incisors

ANTERIOR TO POSTERIOR FACE HT. RATIO

62-65%

70/118=%

Increased anterior facial height –hyperdivergent

growth pattern

COMPOSITE ANALYSIS

• On sagittal analysis, patient shows skeletal class II pattern due to retrognathic mandible

• On vertical analysis patient shows hyperdivergent growth pattern.

• Clockwise rotation of lower jaw base.• Dentoalveolar analysis

Retraction of upper incisors by 3.1mm

Retraction of lower incisors by 3.8mm

Total space analysis

• Upper arch discrepancy = 8.1 mm• Lower arch discrepancy = 17.5mm


FRONTAL AT REST FRONTAL AT SMILE

EXTRA ORAL EXAMINATION PROFILE AT REST


OBLIQUE AT REST OBLIQUE AT SMILE


FRONTAL


MAXILLARY ARCH MANDIBULAR ARCH


OVERJET OVERBITE

RELATION

RIGHT OCCLUSION LEFT OCCLUSION

CEPHALOMETRIC DIAGNOSIS

A case of skeletal class II pattern due to orthognathic maxilla and retrognathic

mandible with hyperdivergent growth pattern and mild proclination of upper and lower

incisors.

DIAGNOSIS

A 21 year old female presents with Angle’s

Class I malocclusion on a mild Class II skeletal base due to orthognathic maxilla and

retrognathic mandible with a hyperdivergent growth pattern, straight profile, incompetent

lips, enamel hypoplasia , mild upper and lower anterior proclination, upper and lower

anterior crowding, gingival recession and grade 1 mobility -31,deviated upper dental

midline towards right side by 2 mm deviated lower dental midline towards left by 2 mm

PROBLEM LISTFACIAL PROPORTIONS AND ESTHETICS

Incompetent lips

DENTAL ALIGNMENT AND SYMMETRYSevere Crowding and mild proclination in upper and

lower anteriors, deviated upper dental midline towards right side by 2 mm, lower dental midline deviated to left by 2 mm, Rotations in upper and lower anteriors, buccally placed 13, gingival recession and grade 1 mobility -31

PROBLEM LISTTRANSVERSE RELATIONSHIP

ANTEROPOSTERIOR RELATIONSHIP

VERTICAL RELATIONSHIP

SOFT TISSUE TREATMENT OBJECTIVES

• Correction of incompetent lips

SKELETAL TREATMENT OBJECTIVES

• Correction of class II skeletal base

DENTAL TREATMENT OBJECTIVES

• Relieving the crowding in upper and lower anteriors.

• Correction of inclination of upper and lower incisors.

• Derotation of rotated teeth • Attaining stable canine relation on right side.• Shifting of deviated upper and lower dental

midline.• Levelling of curve of spee.

TREATMENT PLAN – Extraction of 14 in upper arch for alignment of 13– Extraction of 31(poor prognosis) and 44 in lower arch for

relieving the crowding and levelling the curve of spee and to attain Class I canine relation on right side.

– Fixed mechanotherapy.– Leveling and alignment.– Space closure using sliding mechanics– Finishing and detailing

PROGNOSIS AND RETENTION PLAN

Probable orthodontic treatment duration – 1 ⅟2 to 2years.

Prognosis – Fair

Retention

Upper & Lower – Bonded fixed retainer.

orthodontics case discussion / fixed orthodontics courses for general dentists in india

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