Orthodontics case presentation Dr-noor haddadin

Orthodontics Case Presentation

Done By : Dr. Noor Haddadin - 2nd Year Resident

Supervisors : Dr. Ahmad Al-tarawneh Dr. Raed Alrabta Dr. Nancy Al Sarayrah

Personal Data Patient’s initials: Saba’ Omar Gender: Female Age: 12 Yrs-9 months Career: Student Nationality: Jordanian

Chief Complaint “wants my upper and lower teeth straight”

Medical & Dental History Medical history:

>denies any medical problems Dental history:

>Previous visits to dental clinic for check ups > Large restorations on lower right and left 1st molars

History Trauma :No history of dental trauma

Habits :No previous or on going habits

Motivation :Patient is motivated( self- motivation) with realistic expectations Growth status :Patient is still growing

Clinical Evaluation Oral health Jaw and Occlusal function Facial and dental appearance

Jaw And Occlusal Function Mastication: normal masticatory pattern Speech: no difficulties detected TMJ:

> No clicking , crepitus or tenderness on palpation > Normal opening range of the jaw and side to side movement

Facial And Dental Appearance

1. The face (macroesthetics)

2. Smile Frame (miniesthetics)

3. Teeth (microesthetics)

Extraoral Photos

Intraoral Photos

Study Models Examination

Panoramic View

CEPHALOMETRIC ANALYSISSNA 82◦ 81⁰ ± 3⁰

SNB 76° 78⁰ ± 3⁰

ANB 6° 3⁰ ± 2⁰

Sn-Mx 6.2° 8⁰ ± 3⁰

Corrected ANB

5.5°

Wits appraisal

0.4 mm 0 + 1.77 mm (F)

MMPA 32.8° 27⁰ ± 4⁰

FMPA 33° 28⁰ ± 4⁰

UAFH 56mmLAFH 66mmAFH Ratio 56% 55% ± 2%

UI-MX 106° 109⁰ ± 6⁰

LI-Mn 89.5° 93⁰ ± 6⁰

IIA 141° 135⁰ ± 10⁰

Extraoral Examination The Face (Macroesthetics)

Anteroposterior assessment maxilla to mandible relationship

Vertical assessment facial thirds Angle of lower border of mandible to the maxilla

Transverse assessment Facial asymmetry

● Soft tissue assessment

Anteroposterior Assessment

Profile: slightly convex Mild class 2 Slight increase LFH

Anteroposterior Assessment

Zero meridian line >(0+/-2) to soft

Tissue Pogonion

Vertical Assessment

SLIGHTLY INCREASED LFHUPPER LIP IN THE UPPER 1/3 , LOWER LIP IN THE LOWER 2/3 OF LOWER THIRD

INCREASE FMPA

Transverse Assessment

The pt has symetrical face

Facial midline showing alignment of the middle part of the upper lip at the vermillion border and chin point

Transverse Assessment

-Equal medial and lateralFifths-Nose and chin centered in the central fifth -Interpupillary distance equals the width of the mouth.-The width of the nose equals the central fifth

Soft Tissue Examination Potentially competent lips

(strain on mentalis muscles)

Normal tongue size and function

Frontonasal Angle:(115-135)

134 normal Nasolabial Angle: (90-110) 86 slightly acute Labiomental Angle: (110-

130) 117

Facial and Dental Appearance




Smile Frame (Miniesthetics)

1.Smile analysis2.Amount of incisor and Gingival show3.The smile Arch

1.Smile analysis

-The smile index = intercomisure width/ interlabial gap on smiling =10/2.2=4.5 (Ackerman et al )1998** The lower the smile index, the less youthful the smile appear

-Upper dental midline shifted 1mm to the left -Asymmetric smile (more showing on the left side)

1.Smile analysis

The buccal corridor ratio=(inner commissure width-visible maxillary dentition)/inner commissure x 100% = (7.5-6.4)/7.5x 100% =14% (Frush and Fisher) 1958

The Buccal Corridor RatioSmile category Percentage BCRnarrow 28%Medium- narrow 22%medium 15%Medium-broad --most attractive (Ahmad 2005)

10%

Broad---------- preferred 2%

Patient has medium smile

category

-Parallelism of upper incisor curve to lower lip on smiling: centrals are parallel

-Upper incisors not touching lower lip on smiling

-The whole length of upper incisors are visible on full smile , with the lip line slightly high displaying more than the cervico-incisal length of max. incisor and interproximal gingiva(could be acceptable in females)

-The gingival margins are seen for centrals and laterals

2. Amount Of Incisor And Gingival Show

-The gingival margins for centrals and laterals are same level-Canines gingival margins are high

2. Amount Of Incisor And Gingival Show

3. The Smile Arch

Non consonant in the canines area

3 Teeth(microesthetics)

1.Tooth proportions2.Width relationships and the “Golden ratio”3. Connectors and embrasures

1.Tooth Proportions

Square central incisors Central height 8.5mm ->reduced Central width 8.5mm->normal

2.Width Relationships And The “Golden Ratio”

1.0:0.62:0.38UL1:UL2:UL31.0 :0.75:0.88

3. Connectors And Embrasures

Connector height is greatest between the central incisors No Black triangles; gingival embrasures are filled by the interdental papillae Incisal embrasures are lager when moving posteriorly

Intraoral Examination

Intraoral Examination▪Teeth present:

7 7 6 6

▪ 7’s still erupting

▪Heavily restored LR6,LL6

Intraoral Examination ● Oral Hygiene: - poor-Gingivitis especially around UL3,UR3,UR4 -calculus deposits on buccal surface of upper 6’s -white spot on UL1●Caries: Clinically, Caries free

Intraoral Examination Central lines:

upper shifted 1mm to the left Incisors classification:

Class 1 OJ:

2mm OB:

50% normal Crossbites:

X Scissors bite:

LL5

Intraoral ExaminationRIGHT BUCCAL SEGMENT RELATIONSHIP:CANINE: ½ CLASS IIMOLAR: ¾ CLASS II

LEFT BUCCAL SEGMENT RELATIONSHIP:CANINE: ½ CLASS IIMOLAR: CLASS I

Upper Arch U-shaped arch form Asymmetric

/constricted Retroclined incisors UR3,UL3 out of the

arch Inward UR4,UR5 UR6 slightly rotated

ML Moderately crowded

Lower Arch U-shaped arch form Asymmetric /

constricted Moderate crowding slight Fan shaped

incisors Upright and mesially

tipped canines LL5 lingualy erupting Rotated premolars Heavily restored

lower 6’s

Study Models Examination

Front View

Class 1 incisors classificationOJ: 2mmUpper midline shifted to the left 1mm

Posterio-anterior View

OB : 70% complete with teeth

Right Side

-Molar: ¾ class II-Canine: ½ class II-No crossbites (UR5 edge to edge LR5)

Left Side

-Molar: class I-Canine: ½ II-LL5 in scissors bite

Upper Cast Occlusal

Intercanine width: 36.5mmIntermolar width : 48 mm

Lower Cast Occlusal

Intercanine width: 26mmIntermolar width:42mm

Curve Of Spee

left side =3 mm right side =2.5 mm

Space Analysis

Upper arch:Asymmetric Space available= 19+15+15+21= 71mmSpace needed= 77mmModerate crowding of -6mm

Space Analysis

Lower arch:Asymmetric Space available= 19+11.5+11.5+20.5= 62.5 mmSpace needed= 67mmModerate crowding of - 4.5 mm

Tooth Size Analysis (Bolton)

Bolton Analysis: Σ Lower anterior teeth widths = 78% normalΣ Upper anterior teeth widths n= 77.2 +/- 1.65

Σ Lower all teeth widths = 92.8% normalΣ Upper all teeth widths n= 91.3 +/- 1.91

6 5 4 3 2 1 1 2 3 4 5 610.5 7.

57.5

8.5

6.5

8.5

8.5

6.5

8.5

7.5

7.5

10.5

6 5 4 3 2 1 1 2 3 4 5 612 7.

57.5

7 6 5.5

5.5

6 7 7.5

7.5

12

Royal London

LL6 move distaly

Upper Arch Lower Arch

-6 -4.5 Crowding/Spacing

0 0 Angulation /inclination change

0 -2 Leveling curve of Spee

+ 1

+ 1 Arch width change

0 + 4 Incisors A/P change

- 5 - 1.5 Total

VTO - Visualized Treatment Objectives

Chart 1 MIDLINE-MOLAR POSITION

right left 5mm 1mm 0mm midline

VTO Chart 2 LOWER ARCH DISCREPENCY

RT LT

Crowding 3x3 6x6

-1 -2

+1 -1.5

Protrusion +2 +2Curve of spee -1 -1Midline 0 0 Total 3x3 6x6

-1 -1

+1 - 0.5

LIn-Apo= -1)

VTO Chart 3 –ANTICIPATED TREATMENT CHANGE

Rt Lt <--4mm <-- 2 <--1 2mm 1.5mm

1mm 2 0 <-- 2mm 1.5mm

Panoramic Radiograph

-All wisdom teeth buds are present -Amalgum restorations on lower 6’s

-Class II caries on UL6 + UR6-No other apparent pathologies

IOTN-dental health componant Grade 4.I (great

need) Posterior lingual

crossbite with no functional occlusal contact in one or both buccal segments.

IOTN- Esthetic component

3: slight need

Diagnostic Summary S.O is a 12 Yrs-9 months old female medically fit

patient. She came complaining from the alignment of her upper and lower anterior teeth. She has poor OH , a class 1 Malocclusion on a class II skeletal base with slightly increased vertical dimension. She has a symmetrical Face with compromised smile esthetics. She has a class I molar on left side, class ¾ II on right side. Canines are ½ unit II on both sides . OJ is 2mm , OB is increased. Upper midline is shifted 1 mm to the left. Upper and lower arches are moderately crowded with LL5 in scissors bite.

Problem ListPathological problems:• Oral hygiene is poor• Gingivitis (especially: UL3,UR3,UR4)• Calculus (UR6,UL6) • First permanent lower molars have large restorations• First permanent upper molars are carious• White spot on UL1

Developmental problems:• Patients concern about the malaligned teeth• Smile esthetics: buccaly erupted canines, retroclined upper incisors • Alignment and symmerty:

o Asymmetric lower arch with with 4.5 mm crowdingo Asymmetric upper arch with 6mm crowding o Rotated teeth

• Skeletal and dental problems in transverse plane:o No skeletal asymmetryo Upper midline shifted 1mm to the left o LL5 in scissors bite

• Skeletal and dental problems in A-P plane:o Mandible is slightly retrognathic , clinically acceptable o Convex profile mild class II skeletally o Molars : Rt: ¾ class II o Canines: Rt: ½ class II Lt: ½ class II

• Skeletal and dental problems in vertical plane:o Slightly increased LFHo Increased OBo 2.5 mm depth curve of spee

Treatment Aims Improve oral hygiene Treat the carious teeth Improve her smile by creating more normal gingival relationships , and

smile symmetry Relief crowding in upper and lower arches , and align the teeth Correct upper midline correct scissors bite of LL5 Accept the skeletal class II or maybe differential mandibular growth will

take place ? Procline upper incisors Derotate rotated teeth Achieve class I molar and canine relationship Achieve normal OB Maintain OJ Obtain a Flat Curve of spee Finishing and detailing of occlusion. Retain the corrected results.

Treatment plan1st option:1. OHI 2.High pull Headgear

Justification To restrain the max and allow forward

autorotation of the mandible (growth modification ) High pull: patient has increased LFH

Treatment plan2nd option:1. IOH2. Extract upper 8’s3. Upper & lower pre-adjusted edgewise

fixed appliance (upper MBT, lower Roth) + Forsus appliance

4. Retention

Justification Upper lower FA: 3-Dimensional tooth

control (Derotation, intrusion , extrusion , torque)

MBT 0.22: Increased maxillary incisors palatal torque . 0.22 ->sliding mechanics

Treatment mechanics1. Proclination of lower labial segments2. Open Ni-Ti coil spring on rigid archwire to open space LL5

Justification Forsus appliance No patient compliance needed Consistant force 200gm with the mouth closed

and this decreases very little over time(the system’s susceptibility to mechanical fatigue is negligible compared with that of elastics, whose period of action is only a few hours)

It works by creating a mesial force on the mandibular arch + procline LLS and a distal force on the maxillary arch.

The deep bite :The intrusive force of forsus can intrude mandibular incisors.

Retention ProtocolShort term retention: Upper and lower Vacuum formed retainers

(VFR) -> part time wear 10hrs/day , for 6 months post debond .

VFR: simple, cheap, requires no adjustments Permanent retention:( Bonded wire retainer) (.175 inch multistrand SS) deep bite, proclination of LLS, rotated premolars and to prevent late lower labial crowding

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Orthodontics case presentation Dr-noor haddadin

Health & Medicine

Transcript of Orthodontics case presentation Dr-noor haddadin