case presentation

1. Done By:
Dr. Jamal Hafiz Al-Qadhi
2rd Year Orthodontic Resident
Supervised by:
Dr. Ahmad Al-Tarawneh.
Dr. Raed Al-Rbata.

2. Data of assessment
Personal data:-
 Patient’s Initials: T. M.
 Address: Amman
 Gender: Female.
 Date of birth: 27/7/2000
(16 years old).
 Occupation: Student.
 Nationality: Jordanian.

3. Chief Complaint
“ Spaces behind my upper anterior teeth
and upper jaw is protruded”

4. Medical History:
Patient denied any medical problem.
Dental History:
Pervious orthodontic treatment
(4 years ago).

5. Orthodontic History :-
Patient Started orthodontic treatment before 4 years .
Upper and lower fixed appliance with treatment plan
based on extraction upper 1st premolars; and she didn't
wear the retainer ( Hawley retainer) because the
patient wasn’t motivated

6. Extra Oral Assessment
Frontal View

7. Extra Oral Assessment
Profile View

8. Extra Oral Assessment
Oblique View

9. Extra Oral Assessment
Skeletal Assessment
Anteroposterior:
Skeletal Class II Pattern

10. Skeletal Assessment
Vertical:
Average lower
facial height

11. Skeletal Assessment
Transverse:
Symmetrical face

12. T.M.J.
 No signs of TMD(No clicking , crepitus and
tenderness to palpation).
 Normal range of opening, lateral movement and
no displacement.

13. Extra Oral Assessment
Soft tissue Assessment
:Asymmetrical face
The patient has slight facial
Asymmetry
•Nose deviated to
left side.

14. Soft tissue Assessment
 Incompetent lips.
 Average of upper & lower
lip length.
 Convex facial profile.
 No habits.

15. Soft tissue Assessment
 Normal frontonasal angle
133⁰ (Normal 115⁰-135⁰)
 Normal nasolabial angle
97⁰ (Normal 90⁰-110⁰)
 Normal labiomental angle
115⁰ (Normal 114⁰-140)

16. Smile Aesthetics Assessment
•Full crown of incisor show with
slightly increased gingival show.
•Smile extend to 1st molar.
•smile is acceptable

17. Intra Oral Examination
•Good Oral Hygiene.
•Normal frenal attachment.
•High gingival margin on UL2.
•Normal oral mucosa.
•Teeth Present (Permanent dentition).
87 6 5 3 2 1 1 2 3 5 6 7 8
87 6 5 4 3 2 1 1 2 3 4 5 6 7

18. Lower arch
 U-shaped of lower arch
 Anterior segment:
 Upright incisors and canines.
 Buccal segment:
 Rotated LR4&5
 Space between LL3&4
 Unerupted LL8
• Midline shift to right 2mm

19. Upper arch
 U-shaped arch.
 Anterior segment:
 Upright upper incisors &
Canines.
 Palatally tilted UL2.
 Buccal segment:
 Previously extracted
U 1STPremolars.
 Rotated U 1ST Molars &
UL2nd premolar.

20. Teeth In Occlusion
Anterior segment
 Class II div. I incisor relationship .
 Lower midline shift to the right 2mm .
 Overjet 5 mm.
 Deep Complete overbite 70%.
2mm

21. Buccal Segment
 Molar relationship: More than CL II full
unit Rt. & Lt sides.
 Canine relationship: CL II ½ unit Rt side
and CL II ¼ unit Lt side.

22. Study model analysis
 Anteroposterior
 O. J = 5mm.
Class II 1/2unit canine
More than class II full unit
molar relationships.
Class II ¼ unit canine and
More than class II full unit
molar relationships.

23. Study model analysis
 Transverse
 Lower midline shift to the right side 2mm.

24. Study model analysis
 Vertical
 O. B = deep complete 70%.

25. Study model analysis
Right side:
curve of spee 2mm
Left side:
curve of spee 2mm

26. Study model analysis
Upper arch
 U shape arch form.
 Dental asymmetry.
 Intermolar width 43mm.
 Intercanine width 31mm.
43mm
31mm

27. Study model analysis
Lower arch
 U shape arch form.
 Dental asymmetry.
 Intermolar width 42mm.
 Intercanine width 25mm
42mm
25mm

28. Space Analysis
 Lower Arch:
Space Available: 81mm
Space Required: 79mm
+2mm (Spacing )
 Upper Arch:
Space Available: 87mm
Space Required: 93mm
Space demand: -6 mm (Moderate Crowding)
1076.58788786.5710
654321123456
654321123456
9.576.565.5555.566.579.5

29. Bolton Ratio
 Anterior Ratio: (3 - 3): 33/45 = 73.3% (Normal:
77.2%).
 Overall Ratio: (6 - 6): 79/93= 84.9% (Normal:
91.3%).
• There’s a decrease in anterior bolton
ratio.

30. Royal London Space Analysis
Upper ArchLower Arch
-6+2Crowding/Spacing
00Angulation change
0-2Leveling curve of Spee
00Inclination change
00Arch width change
00Incisors A/P change
According to Royal London space analysis:
- Lower Arch : 0mm.
- Upper Arch : needs -6 mm.

31. Pre-Treatment IOTN
Aesthetic Component
• Figure2
•No treatment
need.

32. Pre-Treatment IOTN
Dental Health Component
Grade 4
Grade 4h:
Less extensive
hypodontia (one
tooth per Quadrant
) requiring pre-
restorative
orthodontics or
orthodontic space
closure.

33. Radiographic Examination OPT
 All permanent teeth are present except UR&L 1st
premolars.
 LL 3rd molar unerupted.
 No pathology or abnormalities could be identified.
L

34. Lateral Cephalogram
Variable Pre-
Treatment
Normal
Value
SNA 81º 81 +- 3
SNB 74º 78 +- 3
ANB 7º 3 +- 2
S-N/MX 6.5º 8 +- 3
ANB*
MMPA 30º 27 +- 3
FMPA 29º 28-+3
UFH 53
LFH 74
LAFH % 58% 55 +- 2
U1/Mx 101º 109 +- 6
L1/Mn 91º 93 +- 6
IIA 135º 133 +- 10
Wits +6.5mm 0-+1.7 F

35. Diagnostic Summary
T.M 16 year old female, denied any medical problem, with good oral
health, complaining of spacing behind the upper anterior teeth
and her upper jaw is protruded . She has class II/I incisor
relationship based on class II skeletal pattern, average lower facial
height, incompetent lips, gingival recession on UL2, convex facial
profile, asymmetrical soft tissue with nose deviated to the left side.
She has missing UR&UL 1st premolars, O.J of 5mm, deep complete
overbite 70%, lower midline shift to right 2mm, moderate crowding
upper arch and spaced lower arch. She has more than class II full
unit molar s on both sides, and class II ½ unit canine relationship on
right sides, class II ¼ unit canine relationship on the left side, and
palataly tilted UL2 , rotated U 1st molars UL5 and LR4&5.

36. Problems List
 Gingival recession on UL2.
 Spacing behind upper anterior teeth and upper jaw is protruded.
 Skeletal :-
 Class II skeletal pattern.
 Soft tissue:-
• Convex profile.
• Asymmetrical face.
• Incompetent lips.
 Dental :-
• Previously extracted upper R& L 1st premolar.
• Increased Overjet 5mm.
• Deep complete over bite 70%.
• Lower mid line shift 2 mm to the right.
• Rotated lower right 1st and 2nd premolar.
• Rotated upper right & left st molars and upper left 2nd premolar.
• Palataly tilted upper left lateral incisor.
• Moderated crowding in upper arch .
• More than class II full unit molar in right & left sides.
• Class II ½ unit canine in right side and class II ¼ unit in left side.
• Anterior bolton discrepancy.

37. Treatment Aims
 Correction of gingival recession (orthodontically)
 Correction of patient chief complaint.
 Accept skeletal class II pattern.
 Accept soft tissue problems.
 Correct over jet.
 Correct over bite(centroid relationship).
 Correct lower midline shift.
 Correct Rotated lower right 1st and 2nd premolar.
 Correct Rotated upper right & left st molars and upper left 2nd
premolar.
 Correct Palataly tilted upper left lateral incisor.
 Correction of moderated crowding in upper arch.
 Achieve Class II full unit molar in right & left sides.
 Achieve Class I canines relationship.
 Accept anterior bolton discrepancy.

38. Treatment Plan
“ Non-Extraction case ”
 O.H.I .
 Quadhelix to derotate upper first molars and after correction replace
quadhelix with TPA
 Use Tads or straight pull headgear to maximize anchorage.
 Upper and lower fixed Appliance.
( Straight arch wire technique; MBT prescription slot 0.022)
 Retention.
Upper and lower permanent retainer and VFR

39. Justification :
 Quadhelix
 derotation of upper 1st molars to achieve class II full unit molars relationship .
 Create space to achieve class one canines relationship.
 Straight pull headgear or Tads to maximize anchorage .
• Fixed Appliance MBT prescription slot 0.022:
 torque is needed not to tip anterior teeth while being retracted ( they are already
inclined , patient suffers from gummy smile )
 Bodily teeth movement is required .
 Correct lower midline shift.
 Alignment of rotated teeth.
 Closing of spaces.
 Leveling curve of spee.
• Retention:
 long term : Upper: permanent retainer from 5-5.
Lower : permanent retainer from 3-3.
due to patient previous lack of co-operation regarding the removable retainer
 Short term: Lower and upper FVR to preserve teeth in their position.

40. Thank You