case presentation

2.  Patient’s initials: M.S
 Gender: female
 Age: 16 yrs
 Career: Student
 Nationality: Jordanian

3.  OPG
Medical history: denied any medical problems
Dental history: previous filling on UL6 & extraction of LR6

4. “ My anterior teeth are irregular”

6. Anteroposterior:
Class II Skeletal Pattern

7.  Decreased lower
facial height

8. Transverse:
Mild Asymmetry
Facial midline showing
alignment of the
middle part
of the upper lip at the
vermillion
border and chin point

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

10.  Slightly convex profile

11. Lip tonicity and
competence:
• Competent lips
• Upper lip L: 17
• Lower lip L:40

12.  Frontonasal angle: 136⁰
(Normal 115⁰-135⁰)
 Nasolabial angle: 93⁰
(Normal 90⁰-110⁰)
 Labiomental angle: 111
(Normal 114⁰-140)

13. •Showing 60% of upper and lower incisors
•No gingival show

14. The golden proportion for maxillary ant.
Teeth is 66%,Height: width 0.9:0.8

15. -Unequal Gingival
levels of centrals
(0.5mm difference)
-Palatally displaced
laterals
On R -2mm
On L -1mm

16.  Gingival connectors between
centrals> than central & lateral

19. • Good oral hygiene
•Teeth Present in oral cavity
7 6 5 4 3 2 1 1 2 3 4 5 6 7
7 X 5 4 3 2 1 1 2 3 4 5 6 7


20.  U-shaped lower arch
 Anterior segment:
 Mild crowding anteriorly
 Buccal segment:
 Extracted LR6
 Distally tipped lower right anteriors
 Distally inclined LL3

21.  V-shaped arch.
Severe crowding
 Anterior segment:
 Overlapping upper
central incisors
Palatally displaced
U2s
 UR3 Buccally
erupted (out of the
arch)

22.  Periodontal health:
 Good oral hygiene,
 Restored 6

23.  Class II div 1 incisor relationship
 Upper shifted 2mm to the Right, lower 1 mm to the right
 Overjet 5mm UR1, 6mm UL1
 Overbite = 70% deep incomplete

24.  Molar relationship:
R: X (extracted LR6) L: Class II Full unit
 Canine relationship:
R: X (buccally erupted UR3) L: Class II full unit

26.  Molar relationship:
R: X (extracted LR6) L: Class II Full unit
 Canine relationship:
R: X (buccally erupted UR3) L: Class II Full unit

27.  Midlines not
coincident
 Upper shifted 2mm
to the right
 Lower shifted 1 mm
to the right

28.  Vertical
OB:
70% deep
incomplete

29. Right side: 2 mm Curve of
Spee
Left side: 1 mm Curve of
Spee

30. Upper arch
 V shaped arch form
 Dental Asymmetry
 Intermolar width: 39mm
 Intercanine width: ??mm

31. Lower arch
 U shaped arch form
 Dental Symmetry
 Intermolar width ?? mm
 Intercanine width 26 mm

33.  Bolton Analysis:
 Σ Lower anterior teeth widths = 39/51=76.5 %
 Σ Upper anterior teeth widths
 n= 77.2 +/- 1.65
 Σ Lower all teeth widths = 91/96=94.8%
 Σ Upper all teeth widths
 n= 91.3 +/- 1.91
6 5 4 3 2 1 1 2 3 4 5 6
10 5 7 9 8 9 9 8 8 7 6 10
6 5 4 3 2 1 1 2 3 4 5 6
X(12) 7 7 7 7 6 6 6 7 7 7 12

34.  Upper arch
Space available 67 mm
Space needed 76 mm

35.  Lower arch
Space available 66mm
Space needed 67mm

36. Upper ArchLower Arch
-9 mm1 mmCrowding/Spacing
--Angulation change
-1Leveling curve of
Spee
--Inclination change
+2-Arch width change
- 6 mm-Incisors A/P change

37.  Grade 4 d
Severe displacement > 4mm

38.  8

40. SNA 76 81⁰ ± 3⁰
SNB 72 78⁰ ± 3⁰
ANB 4 3⁰ ± 2⁰
Sn-Mx 8 8⁰ ± 3⁰
Corrected
ANB
5.5
Wits
appraisal
3mm 1(+-1.9) mm
(M)
MMPA 23 27⁰ ± 4⁰
FMPA 24 28⁰ ± 4⁰
AFH Ratio 52 % 55% ± 2%
UI-MX 114 109⁰ ± 6⁰
LI-Mn 90 93⁰ ± 6⁰
IIA 122 135⁰ ± 10⁰
Jarabak
ratio
61 59-63%

42. Condyles are symmetrical
All 8s are missing, except LR8
Previous extraction of LR6
Mesially tipped LR7

43. M.S. is a 16 years old female, Medically fit, complains of
the appearance of her upper anterior teeth. She has a
class II div. I incisor relationship based on class II
skeletal pattern, decreased lower facial height,
competent lips, convex facial profile. Average NL & LM
angles. O.J of 5mm , 70%O.B. Class II full unit on the
left buccal segment , severe crowding in upper arch &
mild crowding in the lower. Complicated by V-shaped
upper arch, extracted LR6, palatally displaced U2s
upper mildline shift 2mm to right side, lower midline
shift of 1 mm to the right.

44.  C/C “Aligment of upper anteriors”
 Skeletal:
Mild Asymmetry.
Mild Class II skeletal base
Decreased Lower facial height
 Soft tissue:
Slightly decreased LM
Decreased Length upper & lower lips
 Dental:
 V shaped upper arch
Severe crowding in upper arch, mild on lower
Class II div I incisors relationship
OJ 5mm , 70% OB
Upper Midline shift to left 2mm,lower 1 mm
Dental:
Class 2 full unit on L. buccal
segment
Buccally erupted U3s
Palatally displaced U2s
Over lapped U1s
Distally angulated LR123
Lingually displaced L67
Distally inclined LL3
Extracted LR6

45.  Improve oral hygiene
 Address patients chief complaint (Anetriors alignment)
 Skeletal:
Accept Mild skeletal class II
 Soft tissue:
Improve smile esthetics
 Dental:
Alignment and leveling
Correct severe crowding in upper, and mild in lower arch
Correct Overjet
Correct Overbite
Correct Midline shift
Maintain Full unit class 2 Molars on L side
Achieve class one canines
Open space of extracted LR6

46. (Camouflage, Extraction case
1. OHI.
2. Nance assisted by TADs for anchorage.
3. Extraction of upper 4s
4. Upper and lower fixed appliance (Roth) slot 22”
5. Open extraction space of LR6
6. Retention:
 Upper anterior bite plane (wear time at night until
end of vertical growth) and fixed retainer from 3-3
 Lower fixed retainer from 3-3

47. DENTAL:
CRITERIA VALUE NORMAL VALUE PRO/CON
EXTRACTOION
Tooth size- arch length Upper :7
Lower: 1
8-11 mm crowding PRO
Curve of Spee L:2mm,R:1mm More than 6 severe Con
Bolton discrepancy 94.8% If 4* more then extract PRO
Peck & Peck L1:90%
L2: 100%
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 93 85˚-95˚ Con
Frankfurt-Man. Incisal
angle
80 60˚-75˚ PRO
Upper incisor to NA 8mm, 33˚ 4mm anterior, (22-25) PRO
Lower incisor to NB 2 mm, 23˚ 4 mm anterior ( 22-25) Con

48. SKELETAL
CRITERIA VALUE NORMAL VALUE PRO/CON EXTRACTION
FMA 20˚ 20˚-30˚ Con
SN-MP 35˚ 31˚-34˚ PRO

49. SOFT TISSUE
CRITERIA VALUE NORMAL VALUE PRO/CON
EXTRACTION
POSITION OF
UPPER LIP –E LINE
8 mm 2mm ±3 PRO
POSITION OF
LOWER LIP- E LINE
6 mm 2mm ±3 PRO
NASOLABIAL ANGLE 93˚ 90˚-115˚ CON
UPPER LIP
MORPHOLOGY
12mm≠
6mm
(strained)
3 mm belowe sk A
point =
Vermilion to labial
surface of teeth ±1
PRO

50. OTHER FACTORS
CRITERIA VALUE PRO/CON EXTRACTION
GROWTH Not Growing patient PRO
MIDLINE Not Coincident PRO
PATIENT PEREFERENCE Non-extraction con

51.  Camouflage:
 Mild skeletal class 2, Minimal ANB, vertical proportions can still be camouflaged at this age
(since vertical growth continues into adulthold)
 patient is non grower (CVM 5), good proportionate facial profile
 Addressing patient chief complaint
 Nance Assissted by TADs :
 Case needs absolute anchorage to retract Canines and correct OJ.
 Fixed Appliance
 Alignment & leveling of teeth
 Retraction of canines, closure of extraction spaces
 Correct midline discrepancy
 Open space LR6
 Archwire expansion to correct V shaped upper arch
 Roth prescription slot 0.022:
 0.022 slot to control Buccolingual inclination of teeth
 Wide twin brackets help control rotaions and tipping
 Retention ( Upper and Lower fixed retainer ), Upper Anterior bite plane
 Upper fixed retainer: palatally displaced U2s, buccally erupted 3s
 Upper Anterior bite plane as retainer : to maintian corrected deep bite until end of vertical
growth
 Lower fixed retainer: prevent late anterior mandibular crowding

52. 1. Full records
2. Bands selection & Impression for Nance appliance
3. Separators on U6’s
4. Cementation of Nance
5. Insertion of R&L buccal miniscrew between U5*6
(diameter 1.6 mm, Length 6mm)
6. Extraction of U4s
7. Bonding of upper canines And direct traction with
power chain into class one
8. Seps and bands on LR7,LL6
9. (consider banding of U7s to aid in OB correction)

53. 10. Direct Bonding of upper and lower arches taking
in to consideration bracket positioning on:
11. U1s (unequal gingival margins)
12. Invert brackets on U2s
13. Gingival positioning of U5s to correct marginal
ridge discrepancy with U6s (check Upper cast)
14. With initial bite raising on U2s palatally (only
teeth touching anteriorly)
15. Alignment and leveling with 0.014 NiTi,0.018 Niti
17*25 NiTi

54. 16. Working upper wire 0.019*0.025 SS (expanded) and
lower 0.019*0.025 SS
17. Start traction and space closure on upper left side to
correct midline, then en-mass retraction to correct OJ
18. Open space of LR6 with coil spring between LR5 &
LR7
19. Finishing and detailing using 0.019*0.025 TMA wire
settling
20. Upper impression for anterior bite plane (to be used
until the end of vertical growth)
21. Upper and lower fixed retention from 3-3 using
multistranded SS with A splint between LR5&7 to
maintain space until final restoration or implant is
placed.

55.  Not moving the lower incisors too far forward, if happen should be
permanently retained.
 Ensuring that the upper incisors are retracted sufficiently to be in
control of the lower lip.
 Proper interdigitation of the posterior occlusion after bracket removal
Regarding the treated deep overbite:
 Good interincisal angle. The interincisal angle must be corrected
(average 135°) Correct mandibular incisor edge-centroid
relationship.
 The crowns of the incisor teeth should also be maintained within the
zone of soft tissue equilibrium between the musculature of the
tongue and the lips.
 Vertical facial growth: place a bite-plane on the maxillary removable
retainer after the completion of orthodontic treatment.