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Orthodontic Clinical Case Presentation
Orthodontic Clinical Case Presentation
Orthodontic Clinical Case Presentation
Case Presentation
By: Shareef M.T. Al Shanableh “2’nd Year Orthodontic Resident”
▪ Medical History:
Impaired breathing, undergone Adenoidectomy 1
year ago.
▪ Dental History:
Never been to dental clinic.
History
▪ Trauma:
No history of trauma.
▪ Habits:
Mouth breather.
▪ Motivation:
Motivated.
▪ Growth status:
Still growing patient.
Jaw & Occlusal Functions
▪ Mastication:
Normal masticatory function.
▪ Speech:
No difficulty.
▪ TMJ:
No clicking
No Crepitus, or tenderness.
Normal opening, and side to side movement.
Extra-Oral Photos
Intra-Oral Photos
Study Model Examination
Orthopantomograph “OPT”
Cephalometric Analysis Angle Measurement Average
SNA 82.5 (81)+-3
SNB 75.5 (78)+-3
ANB 7.5 (2)+-2
SN-MAX 6.1 (8)+-3
Corrected 6.5
ANB
Wits Apprasial Zero (0) +
1.77mm “f”
MMPA 40.5 (27)+-4
FMPA 32 (28)+-4
UAFH
LAFH 58 mm
AFH Ratio 60% 55%+-2%
UI - MAX 110 (109)+-6
LI - MAN 83.1 (93)+-6
IIA 125 (135)+-10
Cervical Vertebral Maturation “CVM”
3. Teeth “Micro-esthetics”.
1.The Face “Macro-esthetics”
A. Anteroposterior assessment:
Maxilla to mandible relationship.
B. Vertical Assessment:
a. Facial thirds.
b. Angle of lower border to mandible.
C. Transverse assessment:
D. Facial symmetry.
E. Soft tissue Assessment.
A. Anteroposterior Assessment
▪ Profile:
Convex facial profile.
Skeletal Class 2
Increased Lower anterior facial
height.
A. Anteroposterior Assessment
▪ Increased LAFH
▪ Upper lip in the upper 1/3
▪ Lower lip in the lower 2/3
▪ Facial Symmetry:
The patient has asymmetrical face.
Tip of nose deviated to the left side.
Chin deviated to the right.
Equal medial & lateral 1/5s.
Width of the nose equals the
central 1/5.
Interpupillary distance larger than
the width of the mouth.
E. Soft Tissue Examination
▪ Smile index:
– “intercomissure width/interlabial gap
on smiling”.
– 32.07/10.76= 2.9
▪ Asymmetric smile.
▪ Buccal corridor ratio:
– 12.07% (between medium &
medium-broad)
Incisor and Gingival display & smile arc
I. Tooth proportions.
II. Width relationship and golden
ratio.
III. Connectors and embrasures.
I. Tooth Proportions
▪ Square centrals.
▪ Central height: 9.5mm
▪ Central width: 8 mm
▪ Ratio: 84%
II. Width relationship and the Golden
Ratio
▪ Golden Ratio:
1.0 : 0.62 : 0.38 : 0.24
UL1 : UL2 : UL3 : UL4
1.0 : 57% : 137% : 73%
III. Connectors and Embrasures
▪ Teeth present:
6 6
6 7
▪ Centerlines:
– Upper:
▪ shifted to the left by 1
mm.
– Lower:
▪ shifted to the right by 1
mm.
▪ OJ: 5mm
▪ OB: 10% “decreased”
▪ Crossbite on:
▪ Right: 4,5,6
▪ Left: 5
Intra-Oral Examination
▪ Lingually inclined:
– LR & LL 4,5s
▪ Class II on LR 6
Upper Arch
▪ Class I caries on UR 6.
Study Model Examination
Frontal View
▪ Molar: Class I
▪ Canine: Class III ‘1/2’
▪ Crossbite: 5
Lower Cast Occlusal
▪ Intercanine width:
– 23 mm “more decreased”
(A decrease in intercanine
width “esp females from 13 –
20”.)
– Sinclair and Little 1983
▪ Intermolar width:
– 42 mm “normal”
Upper Cast Occlusal
▪ Intercanine width:
– 27.5 mm “decreased”
▪ Intermolar width:
– 41 mm “decreased”
Curve of Spee
▪ Right side: 1 mm
▪ Upper arch:
– Symmetric.
▪ Space available=
– 17+19.5+19.5+16.5= 72.5mm
▪ Lower Arch:
▪ Asymmetric.
▪ Space available=
– 21+8+10+20= 59 mm
Angulation \ Inclination 0 -2
Change
Levelling curve of Spee -1
Total -6.5 -6
VTO “Visualized Treatment Objectives”
▪ Chart 1:
Midline – Molar position
Right Left
5 mm Zero
1 mm
1 mm
VTO “Visualized Treatment Objectives”
Protrusion +2 +2
Curve of Spee -1 -1
Midline +1 -1
▪ Chart 3:
– Anticipated treatment change
Right Left
6.5 mm 1mm 1 mm 0.5 mm 4.5 mm
6.5 mm 1 mm 1 mm 2 mm 7.5 mm
• Normal condyles. ▪ All third molar buds are present.
• Approximately equal length ▪ No apparent pathology.
of rami.
▪ Caries on:
▪ UR 6 Class I
▪ LR 6 Class II
IOTN Dental Health Component
▪ 7 : Moderate/ Borderline
Diagnostic Summary
▪ H.N is a 13 years, 4 months old, female, undergone adenoidectomy with no serious medical
condition.
With mouth breathing habit claiming that it was stopped one year ago.
She came complaining of teeth overlap, especially on posterior area.
She has fair oral hygiene.
Class II div 1 incisor relationship based on skeletal Class II with increased anterior facial height.
She has asymmetrical face with chin deviated to the left side. Compromised smile esthetics.
She has Class II “3/4” molar with Class I canine relationships on right side and a Class I molar with
Class 3 “1/2” canine relationships on left side.
OJ is 5mm with decreased OB to 10% “incomplete”
Upper midline shifted to the left by 1 mm and lower shifted to the right by 1 mm.
Severe crowding on upper arch and moderate crowding on lower.
Crossbite on UR 4,5,6 and UL 5. Palatally erupting UR&UL 5s with lingually displaced lower
laterals. Rotated UR & UL 4,6. Palatally inclined upper laterals.
Carious lesions on UR and LR 6s.
Problem list ▪ Skeletal and dental problems in
transverse plane:
– Constricted maxilla.
▪ Pathological problems: – Chin deviated to the left side.
– Upper midline shifted to the left by 1mm.
– Fair O.H.
– Lower midline shifted to the right by 1mm.
– Carious lesions on UR 6 & LR 6
– UR 4,5,6 UL 5 on crossbite.
▪ Developmental problems:
– Mouth breathing.
▪ Skeletal and dental problems in A-P :
– Convex profile “class II skeletal”
– Patient’s concern about the overlapped teeth.
– Molars: RT: Class II “3/4”. LT: Class I
– Smile esthetics: overlapped central incisors.
– Canines: RT: Class I. LT: Class III ‘1/2’
– Alignment and symmetry:
▪ Asymmetric lower arch with crowding of -6 mm
– OJ 5 mm
with lingually displaced laterals .
▪ Symmetric upper arch with crowding -7mm with
▪ Skeletal and dental problems
palatally erupting upper 5s and rotated UR 4&6 – Increased LAFH
UL 4&6. – Decreased OB. 10%
Treatment Aims
▪ Headgear to strain maxillary forward growth and allow mandibular auto rotation.
▪ Rapid palatal expansion, due to presence of maxillary constriction and V shaped
arch form.
Justification