rms

2. Name: I.M
DOB: 10/October/2003
Age: 14 yrs 1 mth
Occupation: Student
Marital status: Single
Residence: Amman
Nationality: Jordanian

3. ”‫اسناني‬ ‫كيف‬ ‫بكره‬ ‫انا‬
‫بعض‬ ‫على‬ ‫الفة‬ ‫العلوية‬.“
“I hate how my upper
teeth are rotated”

4. Medical and Dental History
Medical History: Fit and healthy
Dental History: Regular dental visits, multiple fillings
Habits: Mouth breather

5.  No signs of TMD (No clicking, crepitus, and
tenderness to palpation)
 Normal range of opening, lateral movement,
and no displacement.

7. Anteroposterior:
Class III Skeletal Pattern

8. Vertical Assessment:
Slightly increased lower facial
height

9. Transverse
R-L

10.  Straight facial profile.

11.  frontal facial proportions :
Equal medial and lateral fifths
 Interpupillary distance not equal
width of the mouth
 The nose & Chin not centered
within the central fifth
Transverse Assessment

12.  Frontal view
Upeer lip length : 21 mm
Lower lip length : 45 mm
Mouth is one-third of the way
between the base of the
nose and the chin

13. Lip tonicity and competence:
• thin upper lip.
• Normal lower lip.
• Potentially competent
unstrained lips.

14. 1 mm
Norm. (0 +/- 2)

15.  Frontonasal angle: 137
(Normal 115⁰-135⁰)
 Nasolabial angle: 84
(Normal 90⁰-110⁰)
 Labiomental angle: 126
(Normal 114⁰-140)

16. Soft tissue pogonion to tip of
the nose
Norm. ( L lip 2mm behined the
line )

17. • 100% crown show when smiling.
• Slight gingival show upper right
lateral incisor.
• Smile extends to mesial of the
right first premolar to distal upper
left canine.
.

18.  dental midline : upper
shifted to lt 3 mm

19. • Buccal corridors: wide
• The smile arc: Incisal edges of upper anterior teeth are not
parallel to the upper border of the lower lip

20.  Golden proportion :
Visual width of lat. Inc 37 % and canine 75 %
Golden proprotion : 1 : 0.62 : 0.38 : 0.24

21. Hight width relationship :
Rt central width 93 %
Lt central width 94 %
Of its hight
Norm. ( width of the tooth 80% of it’s height )

22.  Gingival line :
Central incisor and canine
show
same gingival level
UR 2 gingival
line below central by
1mm
Dental apperance “ micro esthetic “

25. • Poor oral hygiene, external staining is evident on the
cervical regions of the teeth.
• Normal oral mucosa with racial pigmentation.
• Teeth Present in oral cavity;
7 6 5 4 3 2 1 1 2 3 4 5 6 7
7 6 5 4 X 2 1 1 2 3 4 5 6 7

26.  U-shaped lower arch
 Anterior segment:
› crowding in anterior
segment with impacted
lower right 3 and rotated
lower left 3.
› Lower midline shift to the
right 3mm.
 Buccal segment:
Rotated lower 4 and 5
bilaterally.

27.  U-shaped arch.
 Anterior segment:
 Instanding upper
left 2.
 Rotated upper
right 1,2, and 3.
And left 1 and 3.
 Midline is shifted
to the left 3 mm.

28.  Class II div 1 incisor relationship.
 Upper midline shifted to the left 3 mm.
 Lower midline shifted to right 3 mm
 Overjet = 5 mm
 Overbite = 20% incomplete.

29.  Molar relationship: L: Class I R: Class I
 Canine relationship: L: ¼ unit Class III

30.  Periodontal health:
poor oral hygiene, plaque and calculus
deposition on the canine to the molars, and
inflamed gingivae.
 Carious lower first molars.

32.  Anteroposterior
Canine:?
Molar: Class I
Canine : ¼ unit Class III
Molar: Class I

33.  Transverse

34.  Vertical
Reduced O.B

35. Upper arch
 U shaped arch form
 Dental Asymmetry
 Intermolar width: 48mm
 Intercanine width: 33 mm

36. Lower arch
 U shaped arch form
 Dental Asymmetry
 Intermolar width= 45 mm
 Intercanine width= ?? mm

38.  tanaka and jhonson
Estimated width of mandibular canine and
premolars = One half of the mesiodestal
width of the four lower inc + 10.5
C+ 8+7.5 = 25.7/2 +10.5
Width of canine = 7.85

39. 1177.498.39.49.3897.5711U
654321123456
118.38.37.46.66.666.57.8587.511L
Anterior Bolton ratio= 77 %
(normal value: 77.2± 1.65%)
Overall Bolton ratio= 91.4 %
(normal value: 91.3± 1.91%)

42. Upper ArchLower Arch
-9.8 mm-14 mmCrowding
--Angulation change
-0Leveling curve of
Spee
--Inclination change
--Arch width change
--Incisors A/P change

43.  Grade 5.i
› Impeded eruption of teeth
due to crowding.

46. Variable Pre-
Treatment
Normal value
SNA 83º 81 ± 3
SNB 82º 78 ± 3
ANB 1º 3 ± 2
S-N/MX 3.5º 8 ± 3
ANB* - -
MMPA 28.8º 27 ± 3
FMPA 20˚ 28 ± 3
LFH 59% 55 ± 2
Jarabak ratio 66% 61± 2
U1/Mx 116º 109 ± 6
L1/Mn 89º 93 ± 6
IIA 132.5º 133 ± 10
Wits
Appraisal
0 mm 1 ±1.9

48. All teeth are present including all third molar buds.
Impacted lower right 3.

49. Clinically :
Palpation  no labial or lingual bulge
X ray : parallex techinique
SLOB  within the line of the arch

50.  I.M is a 14 yrs 1mo old Female, medically fit and healthy
patient, complains of “I hate how my upper teeth are rotated”
. she has a class II div 1 incisor relationship based on class
III skeletal pattern, slightly increased lower facial height,
potentially competent lips, and a straight facial profile.has
compromised smile esthetic ,complicated by impacted LR3 ,
O.J of 5 mm, reduced O.B, Molar relationship is class I on
both sides, canine relationships is ¼ unit class III on LEFT
side, upper midline shifted to LT 3mm and lower midline
shifted to RT 3mm , rotated UR 1,2 UL 1 3, palatally
instanding UL2 , Rotated LL3 LR 4 5 , severely crowded
upper and lower arch

51. PATHOLOGICAL PROBLEM
 Carious LL6 .
 Poor oral hygiene
 Gingivitis with plaque accumulation.
 Yellow discoloration on upper anterior teeth
SOFT TISSUE : Potentially competent lip
DEVELOPMENTAL PROBLEM :
 Patient’s chief complaint; “I hate how my upper teeth are rotated”
 smile esthetic : compromised smile
 Aligment and symmetry :
¼ class III canine relation on lt side
Severe Lower arch crowding.
Severe upper arch crowding.
Rotated lower right 4 5 and left 3 .
Rotated upper right 1 2 and left 1 3
Palatally instanding ul 2
Impacted LR3

52.  Skeletal and dental problems in transverse plane :
Lower midline shifted to rt 3mm and upper midline shifted to left by 3 mm
 Skeletal and dental problem in A-P plane
Straight profile
o.J 5 mm
Skeletal and dental problem in vertical plane
Slightly increased LFH
Reduced O.B

53.  Treat carious LL6.
 achieve optimal oral health through appropriate calculus removal and plaque control
as well as motivation.
 Accept Mild Asymmetry
 Improve smile esthetics
 Correct crowded lower and upper arches
 Correct rotated teeth
 Preserve CL I molar relationships
 Achieve CL I incisor relationship
 Correct canine relationships
 Correct midline shift
 open space of impacted LR3
 Achieve 2 mm O.J
 Achieve normal O.B
 Finishing and detailing the occlusion
 Retain correct result

54. ( Extraction case)
1. OHI.
2. Treatment of carious teeth.
3. Refer to conservative department for LL6 .
4. Refer to ENT clinic to manage mouth breathing
5. Upper & lower fixed appliance (Roth.0 22)
6. Anchorage : upper  nance + lower  LLA
7. Extraction of upper and lower first premolars
8. CSF
9. Retention.

55.  short term :
Modified Upper and lower hawley retainer
 long term :
Upper and lower permenant retainer from 3-3 (
braided steel wire )

56. • OHI & referal to perio & cons clinic:
Obvious plaque deposition and carious tooth
 Fixed Appliance
 Alignment of teeth
 Bodily movement
 Upper and lower arch coordination
 Anchorage
 anchorage required for the retraction of upper and lower canines and
achieving cl 1 canine relationships and preserving class 1 relationship
 Retention (Lower fixed retainer )
 Lower fixed retainer: prevent late anterior mandibular crowding
 Upper fixed and CSF to reduce postretention relapse of derotated teeth.

57. DENTAL:
CRITERIA VALUE NORMAL VALUE PRO/CON
EXTRACTOION
Tooth size- arch length Upper :9.8 mm
Lower: 14
8-11 mm crowding PRO
Curve of Spee L:0 mm, R:0 mm More than 6 severe CON
Bolton discrepancy 90.4% Normal 91.3 % CON
Peck & Peck L1:100%
L2: 83%
L1:88-92 (if less
extract)
L2: 90-95 (if less
extract)
CON
PRO
Irregularity index 2 mm X>6.5 mm extract CON
Incisor-Man. Plane angle 89˚ 85˚-95˚ CON
Frankfurt-Man. Incisal
angle
73 60˚-75˚ CON
Upper incisor to NA 30˚ 4mm anterior, (22-25) PRO
Lower incisor to NB 28˚ 4 mm anterior ( 22-25) PRO
Lower incisor to A-pog 1.5 1-3 mm anterior to it CON

58. OTHER FACTORS
CRITERIA VALUE PRO/CON EXTRACTION
GROWTH Non-Growing patient PRO
MIDLINE Uncoincident PRO
PATIENT PEREFERENCE Indifferent -

59.  Full records
 Separators on upper and lower 6’s
 Band selection on upper and lower 6’s
 Impression of nance And LLA
 Cementation of the nance and lower lingual
arch
 direct bonding of the brackets
 Invert upper left 2 bracket

60.  Referral for extraction upper and lower first
premolars. (first extract upper RT 1st
premolar to correct upper midline and LL4
to correct lower midline then extract UL 4
AND LR4 )
 start alignment and leveling of the whole
arch using 0.012 NiTi through 0.017*0.025
NiTi archwires.
 Space closure at working AW 19*25 ss

61.  Upper and lower TMA archwires for finishing
and settling.
 Debonding
 Impression for retainer
 Upper and lower bonded retainers from 3-3