Case presentationDone by : Dr.Raed Al-Abbadi3rd year orthodontic resident

Supervised by :Dr.Ahmad Al-Tarawneh

Dr.Raed Al-RbataDr.Nancy Sarayrah

Patient details

• name :Z.A• Age: 15 years• Occupation : Student • Nationality :Jordanian

Chief complaint

• My teeth in upper jaw are spaced• Something wrong with bite on right side of my mouth

• Medical history : denied any medical history • Dental history : routine dental visits• Trauma or habits : denied any .• TMJ findings : nothing abnormal • Displacement : yes

Extra oral examinationskeletal and soft tissue assessment

Frontal view• Symmetrical face• square face• Competent lips

Extra oral examinationskeletal and soft tissue assessment

Frontal smile• Thin lips • Normal level occlusal plane (no canting).• upper midline to facial mildline : diastema ??Middle of it >>Coincident.• lower midline to upper midline:Lower midline shifted to right• Increased buccal corridor • Increased incisal show

Extra oral examinationskeletal and soft tissue assessment

Profile view• Slightly convex profile • normal nasolabial angle• Average frontonasal angle • Obtuse labiomental angle• Average throat length • Average throat angle• Average lower facial height• Average FMPA

Intra oral examinationFrontal

• Fair oral hygiene• Class I incisal classification • Reduced overjet• Missing upper right and left lateral incisors • Midline diastema• Fluorosis on lower right lateral and canine• Cross bite on right side ( seems on both

but lower tilited lingually )• Reduced overbite • Lower midline shift to right by 1-2 mm• Normal oral mucosa.

Right side

• Class II ½ unit molar relationship

• Canine relationship full unit class II

• Caries on upper right central • Cross bite on right side ( 3,4,5,6)• Amalgam filling on lower right

1st molar

Left side

• Class I molar relationship• Canine relationship class II

¼ unit• Caries on upper left

central• Retained lower left

primary 2nd molar • Calculus on upper left 1st

molar

Upper arch

• U shaped arch• Spacing • Missing laterals on both

sides• Rotated 1st molars• Teeth present 1,3,4,5,6,7

Lower arch

• U shaped arch• Normal tongue size• Carious lower right 2nd molar• Rotated lower right 2nd premolar• Retained lower right primary 2nd

molar• Lower right 1st molars filled with

amalgam• Teeth present 1-7

Study model analysisAnteroposterior

• Class II canine on right • Class II ½ unit molar

• Class II 1/2 unit canine • Class I molar

OJ = 1mm on upper right central , 2mm on upper left

Vertical

• Reduced overbite

Transverse

• Cross bite on right side.• Lower midline shifted to

right by 2mm .

Curve of spee

Left side Right side

flat4 mm depth

study model analysis Maxillary arch

• Asymmetrical • Inter canine width=28• Intermolar width =43• Rotated upper right and left 1st molar

study model analysis mandibular arch

• Asymmetrical • Inter canine width=30• Intermolar width =43• Rotated lower right 2nd premolar• Retained lower left primary 2nd molar

Teeth widths 5 4 3 2 1 1 2 3 4 56.5 7 7.5 **6.9 9.5 9.5 **6.9 7.5 6.5 6.57 7 6.5 6 6 6 6 6.5 6.5 85 4 3 2 1 1 2 3 4 E

If open space applied to replace missing laterals Mesio distal needed according to anterior Bolton ratio >>>37/0.772 = 2x+34 >>>2x =47.9-34=13.9X=13.9/2=6.95mm

Space analysis

• Upper: Available space =70 ,,, Required =74.5 ( need 4.5 mm )

• Lower : Available space =67.5,,, Required = 65.5 ( there is extra 2mm )

Royal college of London analysis Lower arch Upper arch

Crowding / spacing +1( estimated after extraction of lower left E ) +1 de-rototaion of lower right 5

-4.5

Leveling curve of spee -1.5(4mm) on left side 0Arch width change 0 +5mm ( .5mm for every

1mm increase in width )10 mm expansion>>+5

Insicior A/p change 0 0Angulation change 0 0Inclination change 0 0Result +0.5 +0.5

IOTN-dental component =great 4.h

IOTN aesthetic component =5

Opt

• amalgam filled lower right 1st molar• Endo treated lower left 1st molar , flled with amalgam • Wisdom teeth present in lower arch • Missing upper laterals + lower left 2nd premolar • Retained lower left primary 2nd molar , resorbed roots• Mesial tilted lower left 1st molar

Lateral cephalogramNormal Value

SNA 84 81 +- 3

SNB 81 78 +- 3

ANB 3 2-4S-N/ANS-PNS 3.8 8 +- 3

Corrected ANB 3MMPA 26.9 27 +- 3

UAFH 51.7LAFH 68.2

LAFH % 56.8%

55 +- 2

U1/Mx 111 108 +- 6

L1/Mn 92 93 +- 6

IAA 128 133 +- 10

Wits Appraisal 2 0 + 1.77 mm

Case summary • ZA is 15 years old medically fit female .She has attended the orthodontic

clinic with esthetic concern related to her upper teeth , her chief complaint is spaced upper teeth and smoothing wronge on right side when biting , she has fair oral hygiene and localized calculus related to upper left 6, she has class I malocclusion on skeletal base class I with class II ½ unit molar on right , class II full unit canine on right , class II 1/2 unit on left side , reduced OJ , reduced OB , cross bite on right side ,deep curve of spee on right side , lower midline shifted to right by 2mm , midline diastema , spacing in upper arch , complicated by missing upper right and left laterals and missing lower left 2nd premolar, rotated lower right 2nd premolar , retained lower left primary 2nd premolar .

Problem list • Oral health :

• Calculus on upper left molar

• Skeletal • Constricted maxilla

• Soft tissue • Slightly convex profile• Obtuse labiomental angle

• Dental • Increased buccal corridor

• Increased incisal show• Reduced overjet

• Missing upper right and left lateral incisors

• Missing lower left 2nd premolar

• Carious upper right and left centrals

• Midline diastema

• Fluorosis on lower right lateral and canine

• Cross bite on right side ( seems on both but lower tilited lingually )

• Reduced overbite

• Lower midline shift to right by 1-2 mm

Class II ½ unit molar relationship & Canine relationship full unit class II on right sideCanine relationship class II ¼ unit on left sideRotated upper 1st molarsRetained lower right primary 2nd molar4 mm depth of COS on left sideSpacing in upper arch

Treatment aims• Stabilization of periodontal condition.

• Treatment of carious teeth .

• Attain a normal width of maxilla

• Level and align arches.

• Correct centerlines.

• Correct crossbite on right side

• Normalize OJ and OB.

• Achieve Class I canine and molar relationship

• Open space for upper lateral incisors and maintain space of lower left 2nd premolar.

• Coordinate dental arches with good buccal interdigitation.

• Retain the corrected results.

Treatment plan1. OHI2. Treatment of carious teeth .3. Rapid maxillary expansion.4. Modified TPA.5. upper and lower fixed appliance ( Roth 0.022’’)

Open space for upper laterals for future prosthesis Consider disking lower left E

6. Retention : upper permanent retention and Hawley retainer with acrylic teeth in place of laterals , lower Hawley retainer .

justification• Rapid maxillary expansion with hyrax is good for her case because we want a skeletal effect more

than dental effect .

• Expand until we overcorrect the width ( palatal cusps of upper on lingual inclines of buccal cusps of lower ) in anticipation of some relapse.( lee 1999)

• Modified TPA to derotate upper 1st molars .

• Fixed Appliance is needed because of • Bodily teeth movement is required.

• Alignment of teeth.

• Close the extraction spaces.

• Preserve / correct teeth torque.

• Roth prescription slot 0.022 because teeth are in normal inclination and average torque is needed.

• Leave lower left primary 2nd molar as natural space maintainer for lower left 2nd premolar until restore it with a prosthesis .

• Fixed retainers are indicated for long-term retention of the labial segments, particularly for generalized spacing and for retention of a midline diastema (Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontics. (4th ed.), Chapter 17, St Louis, Mosby Elsevier, 2007)

• Hawley retainers to retain the expanded maxillary arch because of its rigidity .

The End