1

CASE
PRESENTATION
 2
CASE RECORD

 Patient’s Name: Neetu Kunwar

 Sex : Female

 Age: 13

 OPD NO: 0609230181

 3
CHIEF COMPLAINT

 Chief complaint: patient complains of irregularly

placed teeth in upper and lower front tooth region.
 HISTORY 4

 SIGNIFICANT MEDICAL HISTORY – No relevant history

 PRENATAL HISTORY- No relevant history

 HABITS- No relevant habits

 PAST DENTAL HISTORY- No relevant history

 GENERAL HISTORY –No relevant history

 BRUSHING HABITS –Twice a day

 DIET – Non-Vegetarian
 5
Clinical examination- GENERAL

• Stature - Normal
• Physique – Mesomorph
• Growth status – Growing
• Assessment of attitude – Positive
 Extra-oral examination
Frontal view 6

 Shape of the head – Brachycephalic

(120/135)X100=88.9%
 Facial form – Hyperleptoprosopic
(110/100)X100=110%
 Facial symmetry – symmetrical
 Lips - Incompetent
 Vertical proportions-
Upper face: 32.4%
Middle face: 32.4%
Lower face: 35.2%
Extra-oral examination
( Profile view) 7

 Facial profile – straight

 Nose size - Average
 Nasolabial angle- Acute
 Chin Position – Normal
 VTO- Negative
Extraoral examination –
Frontal Smile 8

 Interlabial gap (at rest) – 11 mm

 Midline – dental midline shifted towards
right side by 2 mm
 Smile Arc – consonant smile arc
 Incisor exposure - 100% incisor exposure
with 3 mm of gingival exposure
 Intra-oral examination –
Soft tissue 9

• Gingival condition : Firm and resilient

• Labial Frenum :

Maxillary- mucosal attachment

Mandibular- mucosal attachment

• Tongue Posture- normal

• Palate- normal
 EXAMINATION OF ARCHES 10

• Arch form : Upper - ovoid

Lower- ovoid

• Arch Symmetry: Upper - symmetrical

Lower- symmetrical

EXAMINATION OF TEETH :

Teeth present : 7654321 12C4567

7654321 1234567
 INTRA ORAL EXAMINATION
OCCLUSION- 11
AXIAL INCLINATION
• Maxillary incisor inclination: Proclined

• Mandibular incisor inclination: Upright

ALIGNMENT
• Rotations: Absent

• Spacing: Absent

• Crowding: Present in maxillary and

mandibular anteriors
A-P PLANE
1. Molar relationship: Class II B/L
2. Canine relationship: Endon B/L
3. Overjet: 10 mm

TRANSVERSE PLANE :
1. Midline : shifted towards right
side by 2 mm
2. Crossbite : Absent

VERTICAL PLANE
1. Overbite – 9 mm & 90%
2. Curve of Spee- Flat
Functional examination 13

 CR-CO: 2 mm
 Freeway Space: 4 mm
 TMJ examination: Normal
 Max mouth opening: 45 mm
 Mandibular protrusion: 2 mm
 Swallowing: Normal
 Respiration: Normal
 Speech: Normal
Lateral Cephalogram
14

CVMI – stage III

(TRANSITION STAGE)
 OPG
15

• Erupting 23
• Retained 63
• Developing bud irt 38,48
• Missing irt 18,28
• Good bone support
• Condyles are normal
 16

MODEL ANALYSIS
 17
MAXILLARY ARCH

TOOTH NO RIGHT (in mm) LEFT (in mm)

1 8 9

2 7.5 7
3 8 8
4 8 7.5
5 7 6.5
6 11 10.5
TOTAL 98
 MANDIBULAR ARCH 18

TOOTH NO RIGHT (in mm) LEFT (in mm)

1 6 6.5

2 6 6

3 7 7

4 7.5 7

5 7.5 7.5

6 10.5 10.5

TOTAL 89
 19
ARCH PERIMETER ANALYSIS/NANCE
AND CAREY’S INDEX
TTM ARCH Difference Inference
PERIMETER

UPPER 76.5mm 73mm 3.5mm Extraction of 2nd

premolar

LOWER 68mm 62mm 6mm Extraction of 1st

premolar
 ESTIMATION OF ARCH WIDTH
20

PONT’S INDEX
Measured Calculated Inference
Premolar 34mm 39.4mm
SI*100/80
Molar 38mm 49.2mm
SI*100/64
Maxilla is narrow
LINDER HARTH’S INDEX in premolar and
molar region
Measured Calculated

Premolar SI*100/85 34mm 37.1mm

Molar 38mm 49.2mm
SI*100/65
 ASHLEY HOWE’S INDEX 21

Patient’s Value Inference

Canine fossa width 40/37.5

PMBAW/PMD
Expansion is possible
Borderline case
Percentage 40.8%
 BOLTON ANALYSIS 22

Overall ratio > 91.3 – mand. Excess Maxillary overall teeth

90.8% < 91.3 – max. excess excess= 0.5 mm

Anterior ratio 81% >77.2 – mand. excess Mandibular anterior teeth

< 77.2 – max Excess excess= 1.8 mm
 SKELETAL ANALYSIS

Antero-posterior plane
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CEPHALOMETRIC NORMAL PATIENT’S VALUES
PARAMETER VALUE PRE INF

SN orientation angle 7 7-11= -4

SNA ( Steiner ) 820 ± 2 79+4=83° Average maxilla

SNB ( Steiner ) 800 ± 2 740 +4= 78° Average mandible

ANB ( Steiner ) 20 ± 2 5°
Wits appraisal M: -1, F: 0 mm 7mm Class I skeletal
pattern
Beta angle 270-340 27°
NA-Pog (deg) 0 to 5 deg 7° Increased skeletal
convexity
Facial angle ( Down’s ) 870 ± 5 86° Average facial angle
Angle of convexity ( Down’s ) -8.5 to 100 7° Average

AB plane angle ( Down’s ) 0 to -90 -9° Normal position of

mandible irt maxilla
 SKELETAL ANALYSIS

Vertical plane
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NORMAL PATIENT’S VALUE
CEPHALOMETRIC PARAMETER VALUE PRE INF

SN-MP ( Steiner ) 320 ± 3 37 - 4=33°

FH-MP ( Down’s ) 17 to 280 28°
FMPA ( Tweed ) 22 to 280 30° normodivergent
Y-axis ( Down’s ) 53 to 660 59°

SN-OP ( Steiner ) 140 ± 5 24°

FH-OP (Down’s) 1.5 to 14º 13° Average
Base plane angle 250 30°
average growth
pattern
PP-OP 110 15°
OP-MP 140 15°

Facial Axis (Ricketts) 86.5 to 93.5º 86° Average chin

Jarabak Ratio 62-65% 61.7% normal growth pattern
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LOCATION OF MAXILLARY PLANE
in
CEPHALOMETRIC PARAMETER NORMAL PATIENT’S VALUES
VALUE PRE INFERENCE
Inclination angle ( Schwarz ) 850 ± 5 89° normal rotation of
maxilla

LOCATION OF MANDIBLE IN SPACE ( Rakosi’s Analysis )

Saddle angle 1230 ± 5 129° Posteriorly positioned
glenoid fossa
Articular angle 1430 ± 6 127° Anteriorly positioned
mandible
Gonial angle 1280 ± 7 139°
Upper 520 -550 61° increased
vertical height
Lower 700-750 78°
Bjork Sum 396±6º 395º
 PROPORTION OF JAW BASES:
CEPHALOMETRIC NORMAL PATIENT’S INFERENCE
PARAMETER VALUE VALUES

Se-N 60 59mm Average anterior

(Anterior Cranial Base) cranial base

Mand Base 21:20 Calculated=62mm Decreased

Se-N*21/20 mandibular base size

Measured=52mm

Ramus 5:7 Calculated =44.3mm Decreased ramus

height
Mand. Base*5/7 Measured=39mm

Max Base 2:3 Calculated= 41mm Average maxillary

base size
Mand. Base*2/3 Measured=41.3mm

TAFH 112mm

UAFH 45% 42.5% decreased UAFH

LAFH 55% 57.5% increased LAFH

 DENTAL ANALYSIS

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CEPHALOMETRIC NORMAL PATIENT’S
PARAMETER VALUE VALUES Inference

Upper incisor inclination:-

1-NA ( Steiner ) 220 32°
1-NA : Linear ( Steiner ) 4 mm 9mm
1-SN ( Rakosi ) 1020 ± 2 110°+4=114° Proclined upper
anteriors
1-Apog ( Down’s ) -1 to 5 mm 11mm

Lower incisor inclination:-

1-NB ( Steiner ) 250 25°
1-NB : Linear ( Steiner ) 4 mm 6mm Normal
lower anteriors
1-APog 02mm 3mm
IMPA ( Tweed ) 870 86°

Inter-incisal angle ( Steiner ) F = 120.8 to 132.6º 118° Proclined upper and

M = 122.9 to 138.1º normal lower anteriors
 SOFT TISSUE ANALYSIS
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CEPHALOMETRIC NORMAL PATIENT’S VALUES INFERENCE
PARAMETER VALUE

980-1060 92°
Nasolabial angle
U-25 35° Protrusive upper lip
L-77 57°
S-line U / Lip ( Steiner ) -2 to 2 mm 4mm

L / Lip ( Steiner ) -2 to 2 mm 2mm

Protrusive upper and lower
E-line U / Lip ( Rickett ) -1 to 1 mm 2mm lip

L / Lip ( Rickett ) -4 to 0 mm 1.5mm

Lip Strain 0 1mm

Lip Length Upper 23mm 7mm Short upper lip

 TOTAL SPACE ANALYSIS
UPPER 29
S.NO PARAMETERS VALUE

1. Space available 1 mm

2. Space obtained by derotation 0 mm

3. Space required for correcting:

Levelling 0 mm
Proclination 9.6 mm

Crowding 3.5 mm

4. Total space required 13 mm

5. Total discrepancy 12 mm (reqd.)

 TOTAL SPACE ANALYSIS
LOWER 30

S.NO PARAMETERS VALUE

1. Space available 0 mm

2. Space obtained by derotation 0 mm

3. Space required for correcting:

Levelling 3mm
Proclination 0.8 mm

Crowding 7 mm

4. Total space required 10.8 mm

5. Total discrepancy 10.8 mm (reqd.)

 CEPHALOMETRIC SUMMARY
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SKELETAL
A) Sagittal :
• Maxilla: Normal maxilla
• Mandible: Normal mandible
• Jaw bases relationship: Normodivergent growth pattern

B) Vertical :
• Rotation of maxilla: Normal rotation of maxilla
• Rotation of mandible : backward rotation of mandible
• Rotation of jaw bases : Divergent

C) Transverse – Normal Arches

• DENTAL : Proclined upper and normal lower anteriors
• SOFT TISSUE: protrusive upper and lower lip
• INFERENCE : Skeletal class I malocclusion with normal maxilla and mandible
Proclined upper and normal lower anteriors with protrusive upper and lower lip
 32
DIAGNOSIS

1. Skeletal-
Sagittal - Class I with normal maxilla and mandible
Vertical - Normodivergent growth pattern
Transverse - Normal arches.
2. Dental - Angle’s Class II div 1 M/O
3. Soft tissue - Convex profile
incompetent lips
 PRIORITISED PROBLEM LIST
Patient’s chief problem Forwardly placed upper front teeth.
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Pathology/ others -
Space discrepancy Crowding in lower anteriors
Dimension Skeletal Dental Soft tissue
Antero-posterior Class I skeletal bases 1. Proclined upper 1. Convex profile.
with normal maxilla anteriors 2. Protrusive upper
and mandible 2. Increased and lower lips
Overjet 3. Incompetent lips
3. Class II molar
relation B/L
4. Endon canine
relation B/L
5. Erupting 23
Transverse - 1. Crossbite- absent
2. Midline – shifted
to right side by
2mm

Vertical - Increased Overbite increased LAFH

 TREATMENT OBJECTIVES
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Parameter Inference
s
Pathology/ Absent
others
Alignment Correction of crowding in lower anteriors

Dimension Skeletal Dental Soft tissue

Antero-posterior - 1. Correction of proclined Achieving aesthetic
upper anteriors with normal soft tissue profile.
overjet.
2. Achieving Class I molar
and canine relationship B/L
Transverse - - -

Vertical - Establish normal overbite. -

Treatment options 35
Treatment Plan 36