CASE PRESENTATION

CASE RECORD

Patient’s Name: RAJAN JOSHI

Sex : MALE

Age: 21/M

OPD NO: 1509230121

 CHIEF COMPLAINT

Patient complains of forwardly placed teeth in the upper

and lower front tooth region.
 HISTORY

SIGNIFICANT MEDICAL HISTORY – NO RELEVANT HISTORY

PRENATAL HISTORY – NO RELEVANT HISTORY
HABITS- NO RELEVANT HISTORY
PAST DENTAL HISTORY- NO RELEVANT HISTORY.
GENERAL HISTORY
Brushing habits – TWICE A DAY, DAILY
Diet – VEGETARIAN
 CLINICAL EXAMINATION
(GENERAL)

Stature - NORMAL
Physique – ECTOMORPHIC
Growth status – COMPLETED
Assessment of attitude – POSITIVE
 EXTRA-ORAL EXAMINATION
(FRONTAL VIEW)

Shape of the head – 130/158 = 82.3%,

Brachycephalic
Facial form – 125/137 = 91.2%, Leptoprosopic
Facial symmetry – Bilaterally symmetrical
Lips – Incompetent
Vertical proportions –
UPPER – 28%
MIDDLE – 31.4%
LOWER – 39.6%
EXTRA-ORAL EXAMINATION (PROFILE
VIEW)

Facial profile – Convex

Nose size - Large
Nasolabial angle –
Average
Chin Position - Retruded
VTO – -
EXTRAORAL EXAMINATION –
FRONTAL SMILE

 Interlabial gap (at rest): 8 mm

 Midline: upper dental midline shifted
to right side by 2 mm.
 Smile Arc: Flat smile arc
 Asymmetrical smile
 Incisor exposure: 98% incisor
exposure on smile.
INTRA-ORAL EXAMINATION
–SOFT TISSUE

• Gingival condition : Firm and resilient

• Labial Frenum :
Maxillary – mucosal attachment
Mandibular – mucosal attachment
• Tongue Posture - Normal
• Palate – Deep and narrow
 EXAMINATION OF ARCHES

• Arch form : Upper - Tapered

• Lower - Tapered
• Arch Symmetry: Upper – symmetrical
Lower - symmetrical

• EXAMINATION OF TEETH :

Teeth present : 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
7654321 1234567
 INTRA ORAL EXAMINATION (OCCLUSION)-

AXIAL INCLINATION

• Maxillary incisor inclination: Proclined

• Mandibular incisor inclination: Upright

ALIGNMENT

• Rotations: Present irt 34,45.

• Spacing: Present wrt maxillary and

mandibular anteriors.

• Crowding: Absent.
A-P PLANE:
1. Molar relationship: Class II bilaterally
2. Canine relationship: End-on bilaterally
3. Overjet: 10 mm

TRANSVERSE PLANE:
1. Midline : upper dental midline deviated to
right side by 2 mm.
2. Crossbite: Absent
3. Arches: Tapered

VERTICAL PLANE:
1. Overbite – 8 mm & 100%
2. Curve of Spee: Present, flat.
 FUNCTIONAL EXAMINATION
PARAMETERS VALUES

FREEWAY SPACE 2 MM

TMJ EXAMINATION NO CLICKING OR DEVIATION

MAXIMUM MOUTH OPENING 46 MM

MAXIMUM PROTRUSION 2 MM

SWALLOWING NORMAL

RESPIRATION NASAL

SPEECH NORMAL
 LATERAL
CEPHALOGRAM

CVMI Stage – Stage VI

(Completion Stage)
 OPG

• Missing irt 38, 48.

• Good bone support
MODEL ANALYSIS
 MAXILLARY ARCH
TOOTH NO RIGHT LEFT

1 10 10

2 8 8

3 9 9

4 8 8

5 7.5 7.5

6 11.5 11.5
 NANCE AND CAREY’S INDEX
(ARCH PERIMETER)

TTM ARCH DIFFERENCE INFERENCE

PERIMETER

85 87 2 mm (avail) -
 ESTIMATION OF ARCH WIDTH

PONT’S INDEX
Actual Calculated Inference

Premolar SI*100/80 35 mm 45 mm

Molar SI*100/64
45 mm 56.2 mm

Linder Harth’s index

Arch is narrow in
Actual Calculated premolar & molar region.

Premolar SI*100/85 35 mm 42.3 mm

Molar SI*100/65 45 mm 55 mm
 ASHLEY HOWE’S INDEX

Patient’s Value Inference

Canine fossa width PMBAW: 48 MM Expansion is possible

PMBAW/PMD PMD: 41 MM

Percentage 44% Borderline case

 MANDIBULAR ARCH
TOOTH NO RIGHT LEFT

1 6.5 6.5

2 7 7

3 7.5 7.5

4 8 8

5 8 8

6 13 13
 NANCE AND CAREY’S INDEX

ARCH
TTM PERIMETER DIFFERENCE INFERENCE

74 MM 72 MM 2 MM (req) Proximal stripping

 BOLTON ANALYSIS

Overall ratio 92.5% > 91.3 – mand. Excess Mandibular overall

< 91.3 – max. excess tooth material
excess by 0.1 mm

>77.2 – mand. excess Mandibular

Anterior ratio 77.7% < 77.2 – max Excess anterior anterior
tooth excess by 0.4
mm
 SKELETAL ANALYSIS
Antero-posterior plane
CEPHALOMETRIC NORMAL PATIENT’S VALUES
PARAMETER VALUE PRE INF
7 7-6= 1º
SN orientation angle
SNA ( Steiner ) 820 87-1 = 86º Prognathic maxilla

SNB ( Steiner ) 800 81-1 = 80º Orthognathic mandible

ANB ( Steiner ) 2° 6º
Wits appraisal M: -1, F: 0 mm 4 MM
Class II skeletal pattern
Beta angle 270-350 21º

NA-Pog (deg) 0-5 deg 6º Average skeletal

convexity
Facial angle (Down’s) 82-950 89º Normal

Angle of convexity 0 (8.5-100) 6º Average skeletal

(Down’s) convexity
AB plane angle (Down’s) -4.6(-9-0)0 -10º Retrusive mandible wrt
maxilla
 SKELETAL ANALYSIS
Vertical plane
CEPHALOMETRIC NORMAL PATIENT’S VALUE
PARAMETER VALUE PRE INF
SN-MP ( Steiner ) 320 28+1 = 29º Average growth pattern

FH-MP ( Down’s ) 21.90 23º

FMPA ( Tweed ) 250 26º
Average growth pattern
Y-axis ( Down’s ) 59.4 0
57º
SN-OP ( Steiner ) 140 11º
FH-OP 9.30 6º
Base plane angle 250 26° Normal jaw bases

PP-OP 110 9º Normal

OP-MP 140 17º Normal
Facial Axis (Ricketts) 90 87º Normal position of chin

Jarabak Ratio 62-65% 63% Average growth pattern

 LOCATION OF MAXILLARY PLANE

CEPHALOMETRIC NORMAL PATIENT’S VALUES

PARAMETER VALUE PRE INFERENCE
Inclination angle ( Schwarz ) 850 91º Normal rotation of
maxilla

LOCATION OF MANDIBLE IN SPACE ( Rakosi’s Analysis )

Saddle angle 123±5º 117º Average position of
glenoid fossa
Articular angle 143±6º 149º Normal
Gonial angle 128±7º 122º Normal rotation of
mandible

Upper 520 -550 50º -

Lower 700-750 72º Average growth
pattern
Bjork Sum 396±6º 388º Average growth
pattern
 PROPORTION OF JAW BASES:

CEPHALOMETRIC NORMAL PATIENT’S INFERENCE

PARAMETER VALUE VALUES
74 MM
Se-N 60
Measured: 80 MM
Mand Base 21:20 Average mandibular
Se-N*21/20 base size
Calculated: 77.7 MM

Measured: 51 MM Average ramus height

Ramus 5:7
Mand. Base*5/7 Calculated: 55.5 MM

Measured: 58 MM Increased maxillary

Max Base 2:3
base size
Mand. Base*2/3 Calculated: 51.8 MM

123
TAFH
39% Decreased UAFH
UAFH 45%
61%
LAFH 55% Increased LAFH
 DENTAL ANALYSIS
CEPHALOMETRIC NORMAL PATIENT’S
Inference
PARAMETER VALUE VALUES
Upper incisor inclination:-
1-NA ( Steiner ) 220 26º
Proclined upper
1-NA : Linear ( Steiner ) 4 mm 11 mm anteriors
1-SN ( Rakosi ) 1020 113-1 = 112º

1-Apog ( Down’s ) 2.7 mm 13 mm

Lower incisor inclination:-

1-NB ( Steiner ) 250 21º
1-NB : Linear ( Steiner ) 4 mm 7 mm

Upright lower
1-APog 2mm 2 mm
anteriors
IMPA ( Tweed ) 900 92º
Inter-incisal angle ( Steiner ) 1310 123º
 SOFT TISSUE ANALYSIS

CEPHALOMETRIC NORMAL PATIENT’S VALUES INFERENCE

PARAMETER VALUE

900-1100 103º Average nasolabial angle

Nasolabial angle U-25 29º
L-75 74º
S-line U / Lip (Steiner) 0 mm 1 mm
Normal upper and lower
lip
L / Lip (Steiner) 0 mm 0 mm

E-line U / Lip (Rickett) -4 mm -2 mm

L / Lip (Rickett) -2 mm -2 mm

Lip Strain 0 5 mm Increased

Lip Length Upper 23mm 20 mm Average upper lip length

 ARNETT’S ANALYSIS

CEPHALOMETRIC NORMAL PATIENT’S VALUES INFERENCE

PARAMETER VALUE

Max occlusal plane 95° 90°

U1-Max occlusal plane 54-60° 55°
L1-Mand. Occlusal 60-68° 53°
plane
Overjet 3.2 mm 10 mm Increased

Overbite 3.2 mm 5 mm Increased

Upper lip thickness 14.8 mm 11 mm Normal

Lower lip thickness 15 mm 15 mm Normal

Pog – Pog’ 14 mm 11 mm Normal

Me – Me’ 9 mm 5 mm Normal
 ARNETT’S ANALYSIS

CEPHALOMETRIC NORMAL PATIENT’S VALUES INFERENCE

PARAMETER VALUE

Upper lip angle 3-13° 19° Protrusive upper lip

Na – Me’ 131-143 mm 129 mm
Upper lip length 22-26 mm 20 mm Decreased

Interlabial gap 2.4 mm 8 mm Increased

Lower lip length 52-56 mm 47 mm Decreased

Lower 1/3rd of face 76 - 86 mm 75 mm Average

U1 exposure 4 mm 6 mm Increased upper incisor

exposure
Maxillary height 25 - 31 mm 26 mm
 ARNETT’S ANALYSIS

CEPHALOMETRIC NORMAL PATIENT’S VALUES INFERENCE

PARAMETER VALUE

Mandibular height 53-59 mm 53 mm Normal

Glabella -8 mm -13 mm Normal

Orbital rims -22 mm -31 mm

Nasal projection 16-20 mm 14 mm

Subnasale 0 mm 0 mm Normal

A’ -3 mm 0 mm Increased
 ARNETT’S ANALYSIS

CEPHALOMETRIC NORMAL PATIENT’S VALUES INFERENCE

PARAMETER VALUE

UL anterior 3 mm 4 mm Protrusive upper lip

U1 -12 mm -5 mm Proclined upper incisor

L1 -15 mm -15 mm Normal

Lower lip anterior 1 mm -2 mm Retrusive lower lip

B point’ -7 mm -8 mm Average depth of

mentolabial sulcus

Pog’ -3 mm -6 mm Average chin position

 COGS ANALYSIS (HARD TISSUE)

CEPHALOMETRIC NORMAL PATIENT’S

PARAMETER VALUE VALUES INFERENCE

Ar - PTm 37 mm 30 mm posterior position of mandible irt

cranial base
PTm – N 52 mm 55 mm Normal position of maxilla irt
cranial base
N – A - Pog 4° 6°

N-A 4 mm 4 mm Normal position of the apical base of

maxilla
N-B -5 mm -2 mm Normal position of the apical base of
mandible

N-Pog -4 - 8 mm 2 mm Normal position of chin

N-ANS 55 mm 48 mm Decreased middle 3rd face height

ANS-Gn 69 mm 72 mm Average lower 3rd face height

PNS-N 54 mm 54 mm Average posterior maxillary height

 COGS ANALYSIS (HARD TISSUE)

CEPHALOMETRIC NORMAL PATIENT’S

PARAMETER VALUE VALUES INFERENCE

MP-HP 23° 20° Normal rotation of the mandible

U1 – NF 30 mm 32 mm Average upper anterior dental height

L1 – MP 45 mm 46 mm Average lower anterior dental height

U6 – NF 26 ± 2 mm 17 mm Decreased upper posterior dental

height
L6 – MP 36 ± 3 mm 30 mm Decreased lower posterior dental
height
PNS – ANS 58 mm 63 mm Average maxillary length

Ar – Go 52 mm 55 mm Average ramal length

Go – Pog 84 mm 80 mm Average mandibular body length

B – Pog 9 mm 12 mm Average prominence of chin irt

 COGS ANALYSIS (HARD TISSUE)

CEPHALOMETRIC NORMAL PATIENT’S VALUES INFERENCE

PARAMETER VALUE

Ar – Go – Gn 119° 122° Indicates an average skeletal

growth pattern
OP – upper HP 6° 3° Normal
AB – OP 2 mm 4 mm Average relationship between
maxillary and mandibular
apical bases irt OP
U1 – NF (angle) 111° 116° Protrusive maxillary incisors
irt NF
L1 – MP (angle) 96° 97° Upright mandibular incisors irt
MP
 COGS ANALYSIS (SOFT TISSUE)

CEPHALOMETRIC NORMAL PATIENT’S

PARAMETER VALUE VALUES INFERENCE

Facial convexity angle 12° 17° Straight profile

Maxillary prognathism 6 mm 10 mm Prognathic maxilla

Mandibular 0 mm 0 mm Normal position of mandible

prognathism
Vertical height ratio 1 0.9 Increased lower 3rd face height

Lower face throat 100° 114 Increased height of lower face throat
angle
Lower vertical height – 1.2 1.2
depth ratio
Upper lip protrusion 2-4 mm 6 mm Protrusive upper lip

Lower lip protrusion 1-3 mm 2 mm Normal

Mentolabial sulcus 2-6 mm 5 mm Average mentolabial sulcus

 COGS ANALYSIS (SOFT TISSUE)

CEPHALOMETRIC NORMAL PATIENT’S VALUES INFERENCE

PARAMETER VALUE

Vertical lip chin ratio 0.5 0.4 Average length of upper lip irt
chin length
Maxillary incisor 0-4 mm 6 mm Increased incisor exposure
exposure
 CEPHALOMETRIC SUMMARY
SKELETAL
A) Sagittal :
• Maxilla: Protrusive
• Mandible: Orthognathic
• Jaw bases relationship: Class II skeletal relation

B) Vertical :
• Rotation of maxilla: Normal rotation of maxilla
• Rotation of mandible: Normal rotation of mandible.
• Rotation of jaw bases: Normodivergent.

C) Transverse – Tapered Arches

• DENTAL : Proclined maxillary anteriors and upright mandibular anteriors.
• SOFT TISSUE: Average length of upper lip with a normal upper lip and lower lip
• INFERENCE : Skeletal class II malocclusion with a Protrusive maxilla and
orthognathic mandible, and Proclined maxillary anteriors.
 TOTAL SPACE ANALYSIS
UPPER
S.NO PARAMETERS VALUE

1. Space available 4.5 MM

2. Space obtained by derotation 0 MM

3. Space required for correcting:

Proclination 0.8x10 = 8 mm

Crowding 0 MM

4. Total space required 8 MM

5. Total discrepancy 3.5 MM (req)

 TOTAL SPACE ANALYSIS
LOWER
S.NO PARAMETERS VALUE

1. Space available 4 MM

2. Space obtained by derotation 1 MM

3. Space required for correcting:

Proclination 0 MM

Crowding 0 MM

4. Levelling 2.5 MM

5. Total space required 2.5 MM

5. Total discrepancy 2.5 MM (available)

 DIAGNOSIS

1. Skeletal -
Sagittal - Class II skeletal relation with a Protrusive maxilla.

Vertical - Average growth pattern.

Transverse – Tapered arches

2. Dental - Angle’s Class II div 1 malocclusion with maxillary anterior

proclination.

3. Soft tissue - Convex profile with incompetent lips.

 PRIORITISED PROBLEM LIST
Patient’s chief Forwardly placed teeth in the upper and lower front tooth region.
problem
Pathology/ others -
Space discrepancy Spacing irt maxillary and mandibular anteriors.

Dimension Skeletal Dental Soft tissue

Antero-posterior Class II skeletal relation 1. Proclination of 1. Convex profile
due to protrusive maxilla maxillary anteriors 2. Incompetent lips
2. Spacing irt maxillary
and mandibular
anteriors
3. Class II molar and
canine relation
bilaterally
4. Increased overjet

Transverse Tapered arches Upper dental midline shift -

to right side by 2 mm.

Vertical - Increased overbite -

 TREATMENT OBJECTIVES
Parameters Inference
Pathology/ others -
Alignment Closure of existing spaces in the maxillary and mandibular arches

Dimension Skeletal Dental Soft tissue

Antero-posterior Anterior 1. Alignment of maxillary Achieving a balanced

segmental and mandibular arch soft tissue profile.
maxillary 2. Closure of existing spaces
osteotomy to 3. Achieving class I molar
and canine relation
correct bilaterally
protrusive 4. Achieving normal overjet
maxilla

Transverse - Correction of upper dental

midline shift

Vertical - Achieving normal overbite -

 TREATMENT PLAN
 alignment and levelling of maxillary and mandibular arches
 Extraction of 14 and 24
 Anterior Segmental Maxillary Osteotomy
 TREATMENT OPTIONS
.