orthodontic case presentation dr lubna abu alrub
TRANSCRIPT
Done by : Dr. Lubna Mohammad Abu Alrub
Name: M.A Age: 19 yearsOccupation: StudentMarital status: Single Residence: AmmanNationality: Jordanian
Medical History: Medically fit
Dental History: Routine dental work
Habits: Non reported
أسناني العلوية طالعة لبرا“
.لثوية-و شكل ابتسامتي مزعج ”
“ My upper teeth are
protruded and I have
a gummy smile “
Anteroposterior:
Class II Skeletal Pattern
Vertical Assessment:
Dolichocephalic head pattern.
increased lower facial height
Transverse:
Mild Asymmetry
No signs of TMD (No clicking, crepitus,
and tenderness to palpation)
Normal range of opening, lateral
movement, and no displacement.
Lip tonicity and competence:
• incompetent lips
• Short upper lip , longer lower
lip .
Profile is markedly
convex with short upper
lip .
Distance from lower lip
to chin is excessive .
Frontonasal angle: 144⁰(Normal 115⁰-135⁰)
Nasolabial angle: 85⁰
(Normal 90⁰-110⁰)
Labiomental angle: 138⁰
(Normal 114⁰-140)
• full crown and upper gingival
show while smiling 5 mm .
•At rest : almost full incisor show
• Smile extends to mesial of
second premolars .
•Narrow buccal corrisors
Commissure height
> philtrum height .
Lip strain on closure
• Buccal corridors: narrow
• The smile arc: Incisal edges
of upper anterior teeth are
not parallel to the upper
border of the lower lip.
• Golden proportion for
maxillary anterior teeth
is 55%
• Height:width of central
incicors
1:1
Gingival level of upper right
lateral 2 mm apical to central ,
and of the left lateral 1 mm
apical , ginigival relationships
and connectors does not folllow
ideal .
• good oral hygiene
• Normal oral mucosa
• Teeth Present in oral cavity (late mixed dentition)
7 6 5 4 3 2 1 1 2 3 4 5 67 8
8 7 6 5 4 3 2 1 1 2 3 4 5 67 8
U-shaped lower arch
Anterior segment:
moderate crowding in anterior
segment
Proclined lower incisors .
Buccal segment:
slight lingual inclination.
U-shaped arch.
Anterior segment:
Upright upper
central incisors
Upper laterals and
incisors are labially
displaced .
deep palatal vault .
Periodontal health:
good oral hygiene.
Carious : none.
Class II div. II incisor relationship
Lower midline shift to right 1 mm .
Overjet = 4mm
Overbite = Deep Complete to the palate atraumatic
Molar relationship: R: Class II L: Class II
Canine relationship: R: Class II 3/4 L: Class II 1/2
Anteroposterior
Canine: Class II 3/4
Molar: Class II full unit
Canine : Class II 1/2
Molar: Class II full unit
Lower midline shifted 1 mm to the right
Vertical O.B= deep bite complete to the palate atraumatic.
Right side: 2 mm Curve of
Spee
Left side: 2 mm Curve of
Spee
Lower incisors are over erupted , occluding palatally to upper
incisors
Upper arch
U shaped arch form
Dental Symmetry
Intermolar width: 41mm
( reduced )
Intercanine width: 32 mm(
normal )
Deep palatal vault
Lower arch
U shaped arch form
Dental asymmetry
Intermolar width 37 mm
( reduced)
Intercanine width 25 mm
(increased)
10789599597710U
654321123456
11877555577811L
Anterior Bolton ratio= 34/46*100%= 73.9%
(normal value: 77.2± 1.65%)
Overall Bolton ratio= 86/95*100%= 90.52%
(normal value: 91.3± 1.91%)
Upper ArchLower Arch
-6 mm-5 mmCrowding/Spacing
--Angulation change
--Leveling curve of
Spee
+.5 mm -Inclination change
--Arch width change
--4 mmIncisors A/P change
Grade 4D
contact point displacement
More than 4 mm .
Grade 7
Variable Pre-
Treatment
Normal value
SNA 80 81 ± 3
SNB 73º 78 ± 3
ANB 7º 3 ± 2
S-N/MX 8º 8 ± 3
ANB* 7.5 -
MMPA 39º 27 ± 3
FMA 38˚ 28 ± 3
LFH 58% 55 ± 2
Jarabak ratio 56% 61± 2
U1/Mx 105º 109 ± 6
L1/Mn 101º 93 ± 6
IIA 102º 133 ± 10
Wits
Appraisal
8 mm 1 ±1.9 F
Cephalometric interpretation :
SNA : Normal
SNB : Reduced : retrognathic mandible
ANB increased : class II skeletal pattern .
MMPA LAFH increased : high angle case
: backward rotation of mandible
Jaraback Ratio : posterior facial height /
anterior facial height reduced : Increase
LAFH , reduced PFH .
Upright maxillary central incisors ,
proclined lower incisors .
All teeth are present including all 8’s
No apparent pathology .
M.A is a 19 year old female , medically fit with routine
past dental history , complains of protruding upper teeth
with gummy smile and compromised smile esthetics.
she has a class II/II incisor relationship based on class II
skeletal pattern, increased lower facial height,
incompetent lips, and a convex facial profile. O.J of 4
mm, deep complete to the palate O.B, moderately
crowded upper and lower arch (localized anteriorly).
Molar relationship is class II on both sides, canine
relationships is class 2 3/4 unit on right side , ½ unit II on
left side, Bolton discrepancy in anterior region , lower
midline shifted to right by 1 mm .
C/C “Protruding upper teeth and gummy smile ”
Skeletal:
A-P :Class II.
Vertical :Vertical maxillary excess and increased LAFH
Soft tissue:
Incompetent lips , short upper lip and long lower lip .
Acute nasolabial angle
Obtuse labiomental, nasofrontal angle
Dental:
moderate crowding in upper and lower arches .
Over erupted lower incisors with deep complete overbite
Overjet 4 mm
Class II molars and ¾ canine right side , ½ unit II left side
Lower midline shifted to right by 1 mm.
Anterior bolton discrepancy
1. Correct skeletal discrepancies ( class II skeletal and maxillary vertical excess)
2. Achieve competent lips
3. Improve facial esthetics
4. Improve smile esthetics by creating smile symmetry and normal gingival
relationships .
5. Relief crowding in upper and lower arches
6. Correct Overjet
7. Correct Overbite
8. Correct canines and molar relationship
9. Correct Bolton discrepancy
10. Correct lower midline shift
11. Finishing and detailing f occlusion
12. Retention
Orthognathic –Orthodontic caseNon -Extraction case
1. Presurgical orthodontic phase Extraction of upper and lower 8s .Upper and lower fixed orthodontic appliance refer to conservative department to build up upper lateral incisors .
3. Surgical phase : maxillary impaction with BSSO of mandible .
4. Post surgical phase : finishing and detailing of occlusion
5. Retention : upper and lower permanent retainers , upper and lower HR
Slot .22 MBT
prescription
Orthognathic :
Profile is class II .
problems are mainly skeletal ; vertical maxillary excess complicated by
Retrognathic position of the mandible .
patients chief complaint ( gummy smile – excess of 4 mm indication
of surgery )
Fixed Appliance
Surgical decompensation to maximize surgical movements.
Alignment of teeth and levelling of teeth.
Bodily movement
Closing extraction spaces , and controlling spaces around upper
permanent lateral incisors before buildup .
Upper and lower arch coordination
Non -extraction
non extraction is our choice in this case
Overjet will be created in the upper arch
after alignment and this will be of benifet to
surgeons to achieve maximum mandibular
advancement
1. Full records2. Seperators3. Band selection and cementation .4. Direct bonding , lowers are over erupted – bond
more incisally and bond uppers more gingival to maximize decompensation.
5. Refer to extract upper and lower 8s at least 6 months before surgery
6. Aligment by superelastic Niti .014 , .018.- lacebackin lower arches .
7. Regtangular Niti 17 *25 8. Working arch wire 19*25 SS .
9. Position laterals more mesial towrd centrals for best esthetics , drop
arch wire for a visit and refer to conservative departments .
10. Stabilizing arch wire 21*25 TMA
11. New records before surgery consisting of new lateral ceh , OPG ,
facial and intraoral photographs and study models ( because
maxillary surgery is planned a face bow transfer to semi adjustable
articulater is preferable)
9. Joint Orthodontic – surgical clinic to discuss final plan.
10. Construction of surgical wafer according to final plan .
11. Refer to surgery
12. Once a range of motion is achieved and the surgeon is satisfied with
initial healing finishing can be started .
9. 2-4 weeks post surgery wires are
replaced with more resilient ones , light
vertical elastics .
10.Elastic regime :
4 weeks full time
4 weeks full time except for eating
4 weeks night time only
16. Finishing 17*25 TMA arch wire
17 . Debond , impression for retainers ,
Metal brackets and .022 slot are best options for surgery
Bracket modification options : +7 on upper canines , +6 on lower canine to avoid deheisenceand retract canines distally into center of alveolus ( MBT philosophy ) .
Second molars should also be banded to limit any interference that would hinder surgical movement
Arch coordination done using study models to ensure no gross transverse discrepancy exists , if expansion is needed it is done by over expanded arch wires .
Mandibular arch should be fully levelled before surgery because the aim is to decrease LAFH , intrusion of over erupted lower incisors should be done in the decompensation phase by auxillary intrusion arch wire , Tads , segmental mechanics ..etc.
The amount of vertical repositioning of the maxilla is critical , take great care during surgery to position the maxilla in the planned position , for optimum esthetics , the maxilla should also be positioned slightly farward.