Neethu Jose / orthodontic courses by Indian dental academy

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• Name : Neethu jose

• Age : 19yrs

• Sex : Female

• Address : Narayana college , Nellore.• Occupation : student



HISTORY


Chief complaint :

Patient complaints of forwardly placed front teeth in upper and lower arches.


Pre-natal history

• Informer :Patient

• Condition of the mother : Normal

• Delivery : Full term

• Type : Normal


Post-natal history

• Type of feeding : Breast feeding

• Milestones of development : Normal


Childhood diseases

• Not reported

Habits

• Tongue thrusting


Familial Malocclusion History Siblings : NRH Parents : NRH

General history Reasons for taking orthodontic treatment :Esthetics Attitude of the patient towards treatment: Positive


Clinical examination record


Physical status

• Build : Mesomorphic• Height : 150 cms (5’ )• Weight : 51 kgs• Gait : Normal• Posture : Normal• Body type : Atheletic


EXTRA ORAL EXAMINATION


• Shape of the head : Dolicocephalic

• Facial form : leptoprosopic

• Facial profile : Convex

• Facial Divergence : Posterior

• Clinical FMA : high angle


RULE OF FIFTH:-Symmetrical face


Vertical facial evaluation:- symmetrical face


Convex Profile average nasiolabial angle

shallow mentolabial sulcus


• Inter labial gap : 1 mm• Smile Arc : non Consonent• Lip posture and : partially competent tonicity : everted lower lip• Lip length : At philtrum : 17 mm At corner of mouth : 23 mm


Functional examination


• Respiration : nasal• Speech : Normal• Amount of incisor exposure• At rest : 1 mm• During speech : 7 mm • During smile : 10 mm• Free way space: 2 mm Curve of Spee = Rt 1 mm & Lt 1 mm• Range of Motion 1) Maximum Opening 45 mm (normal= 35-50 mm) 2) Protrusion 5 mm 3) Rt Excursion 8 mm 4) Lt Excursion 8 mm (normal= 8 to 10 mm)


TMJ

• Jaw function/TMJ complaint now : (No)• History of Pain : (No)• History of Sounds : (No)• Joint tenderness to palpation : (No)• Muscle tenderness to palpation : (No)• Deflection of Mandible : NAD


INTRA ORAL EXAMINATION


Soft tissue examination • Soft tissue Oral hygiene status : Satisfactory Gingiva : Normal Brushing habits : Satisfactory Position of mucogingival junction : Normal Frenal attachment : Normalfrenal attachment Tongue : Normal Oral mucosa : Normal Palatal contour : Normal


Hard tissue examination • Number of teeth present : 87654321 12345678 87654321 12345678

• Impacted teeth :


Right side Class - I Molar relationship.

Class - I Canine relationship.

Class - I Incisor relationship

Left side

Class - I Molar relationship

Class - I Canine relationship

Class - I Incisor relationships


• U shaped arch

• Symmetrical

• mild crowding of anteriors

• square shaped arch

• ASymmetrical

• crowding and proclination of anteriors.


Over jet - 4 mm

Overbite - 2 mm

Mid line coinciding


TMJRt & Lt condyle appears normalRt & Lt articular eminence appears normal

NO. of teeth present

87654321 12345678

87654321

12345678


CEPHALOMETRIC ANALYSIS


CVMI

completion STAGE: growth completed.


8 Measurement Mean/SD ACTUAL Inference

SNA 82º±2 82º Normal Maxilla

SNB 80º±2 75º Retrognathic Mandible

SND 76º 72 º Retruded chin

ANB 2º±2 7 Class – II Skeletal

Go-Gn to SN 32º±4 44 º Increased MPA

UI to NA (mm) 4mm 9 mm Protruded UI

UI to NA (angle) 22º 34 Proclined UI

LI to NB (mm) 4mm 15 mm Protruded LI

LI to NB (angle) 25º 40 Proclined LI

Interincisal Angle 131º 98º Proclined U/L Incisors

Occl. to SN angle 14º 16º Hyperdivergent

STEINERS ANALYSIS


7º

30º

1 mm17º

5.25 mm

STEINERS ACCEPTABLE COMPRAMISE


McNAMARA ANALYSISMEASUREMENT MEAN ACTUAL INFERENCE

N Perpendicular to Pt. A 0±2mm + 2 mm

normal Maxilla

N Perpendicular to Pogonion 0to -4mm - 11 mm retrognathic chin

Facial Axis angle 0º -6º vertical growth

Mandibular Plane angle 26±4º 37º High MPA

Eff. Max. Length 100.9+3.9 91 mm decreased maxilla size

Eff. Mand. Length 118.9± 5.0 mm 116 mm Normal mandible

Maxillofacial Differential 30.1+3.9 25 mm Class – II Skeletal

Lower Ant. Face Height (LAFH)

71.6+4.9 73 mm normal

U1 to Point A distance 4mm 10 mm Forwardly placed upper incisor

L1 to APog line distance 1-2mm 11 mm Forwardly placed lower incisor

Naso Labial angle 90-110º 96º Normal Nasolabial angle


RAKOSI – JARABAK ANALYSIS Measurement Mean Actual

Saddle angle 123±5º 133º posterirly positioned glenoid fossa irt condyle

Articular angle 143±6º 128º prognathic mandible

Gonial angle 128±7º 146º vertical growth

Upp.Gonial angle 52-55º 59 º Increased(caudal growth)

Low.Gonial angle 72-75º 87º Increased (caudal growth)

Sum of posterior angles 396±6º 407º Vertical growth

Mandibular Plane angle 32º 44º increased

Angle of Inclination 85º 85º no inclination of maxilla

Pn to Occlusal plane 75º º Hyperdivergent

Pn to Mandibular plane 65º º Hypodivergent

Basal Plane angle 25º 30º increased

Palatal plane to Occl. Plane 11º 0º HypodivergentOccl. Plane to MP 14º 30º Hyperdivergent


Jarabak ratio:(ant. to post. Face ht. ratio)

62-65% 58.7% Vertical growth

Y-Axis 66º 73º Vertical growth

Interincisal angle 135º 98º Proclined U/L incisors

U1 to SN plane 102 ± 2º 116º Proclined upper incisors

U1 to Palatal plane 70º ± 5º 49º Proclined upper incisors to palatal plane

L1 to Mandibular plane 90 ± 3º 99º Proclined lower incisor


RICKETTS ANALYSISMEASUREMENT MEAN ACTUAL INFERENCE

Facial Axis angle(Ba.Na-Ptm.Gn’)

90 ± 3.5º 95º vertical Growth

Facial Depth (N.Pog-FH) 87 ± 3º 84º Slight retrognathic profile

M.P.angle (Go’.Gn’-FH) 26 ± 4.5º 34º Increased MPA

Convexity of Pt.A. 2 ± 2mm +2 mm Class – I Sk pattern

L1 to A.Pog (angle) 22 ± 4º 32º Proclined lower incisors

L1 to A.Pog (mm) 1 ± 2mm 11 mm Protruded lower incisors

U6 to PtV Age +3mm19+3=22

22mm Normal upper Molar

L.Lip to E- plane -2+2 -8 mm retruded lower lip


WITS APPRAISAL

AO ahead of BO by 7 mm ( Class – II Skeletal pattern)

BO

AO

OP


MEASUREMENT NORMAL ACTUAL INFERENCE

FMA

25º 37º

vertical growth

FMIA 65º 44º Proclined lower incisor

IMPA 90º 99º Proclined lower incisor

FMA 16 to 28 degrees prognosis poor

TWEEDS ANALYSIS

www.indiandentalacademy.com 33º– Class – I sk pattern ( 27º-- 35º norm)

β - ANGLE

β


Composite analysis


HARD TISSUE PRE-TREATMENT

Normal Measured ClassANB 2˚ 7° IIA ⊥ to B ⊥ on FH 4mm 12 mm IIAO to BO 0 –

1mm 7 mm II

Beta angle 27˚to 35˚

33° I

NA – Pog -8.5 to 10˚

-15° II

AB – N.pog 0 to -9˚ -9° IMax : Mand (ANS-PNS, GoGn)

2 : 3 2.37 : 3 II

Harvold’s unit length difference

Chart 25 I

Skeletal Class IISoft tissue Profile Angle 161˚ 153° II

Total tissue Profile angle 133˚(males) 137˚(femal

es)

123° II

Soft tissue facial angle 90 + 3 84° IISubnasale ⊥ to chin -2.5±2.6 -15 mm II

SAGITTAL RELATION


Effects of soft tissues if any&

Basic Upper lip Normal, Thick, Thin (14+1)

15 mm

Soft Tissue chin Normal, Thick, Thin (10-12)

10mm

INFERENCE

SKELETALClass – IClass – II

*

Class – III

SEVERITY

Mild (2_4)

Moderate (4_6)

Severe (>6) *

SOFT TISSUEMatching Compensating

Aggravating *


Discrepancy analysis: (sagittal)

MAXILLAMax apical base Norms Pre Rx INFERENCE

SNA 82±2˚ 82˚ NORMAL maxillaA – N ⊥ (Mc namara) 0 ± 2mm 2 mm normal maxilla

CAUSEMax size- ANS – PNS 52 mm 55 mm Increased maxilla by 3mm

Max effective length 100 ± 4 91 mm Decreased by 5 mmMax placement S ⊥ NF – PTM ⊥ NF

18mm 20 mm Anteriorly placed by 2mm


MANDIBULAR APICAL BASESNB 80±2˚ 75˚ retrognathic mandibleB - N ⊥ -2 ± 2mm - 10 mm retruded mandibleChin

N –Pog –FH (facial angle) 87˚ 84˚ decreased

CAUSESIZE Mand corpus size 78 mm 69 mm decreased by 9mm.Mand ramus Ht 58 mm 49 mm decreased by 9mm


Norms Pre Rx inference

Mand eff. Length 131+4.6 116 mm retrognathic mandible

MANDIBULAR PLACEMENT

Saddle angle 123±5˚ 133˚ Increased by 5

Post cranial base 32 – 35 33 mm normal

Effect of gonial angle 128±7˚ 146 ˚ increased by 11˚

Effect of ramus orientation S – Ar – Go

143±6˚ 128 ˚ Decreased by 9

INFERANCE

Fault with

Maxilla Size (I) Placement (A)

Mandible Size (D) Placement (P)


VERTICAL RELATION Pre Rx Post growth modulation

Normal

calculated

Mid/Lower face ht 45:55 43:57 Increased LAFHSN – Go – Gn 32° 44°

VERTICAL growth

F – M – A (Tweed) 25° 37°

vertical growth

Jarabak ratio 62-65%

58.7% vertical growth

BJORK sum 396° 407°

vertical growth

Saddle angle 123±5°

133° Posterior positioned glenoid fossa

Articular angle 143±6

°

128° Sagital growth mandible

U- Gonial angle 52-55° 59° caudal growth of mandibleL- Gonial angle 72-75° 87° caudal growth of mandibleY- axis N –S – Gn 60° 73° vertical growth Y- axis FH – S – Gn 66° 64° horizontall growthFacial axis (Ricketts)

90°+3.5

95° vertical growth


Basal plane angle 25° 30° hyperdivergent

occlusal NF to MP

11°

14°

0°

30°

Vertical maxillary placement

Nasion to ANS 54.7+ 3.2 56 mm no rotation of maxillary jaw base

Maxillary rotation 85° 85° No inclination of maxilla


Divergence of jaw bases Per Rx Post growth

modulation

Anterior Divergent

Anterior convergent

Upward anterior rotation of both max and mand

Downward anterior rotation of mand

*


UPPER INCISOR EXPOSURE

U1 exposure at rest 0mm

U1exposure in smile 10 mm normal

ANS to Incisor (33±3/30±3) 28 mm normal

U lip length (22-24/20) 23 mm normal

INFERANCE No excessive exposure


Dento Alveolar Analysis Correlated With SOFT TISSUES

UPPER

normal Pre Rx P. Gr. Mod

U1 – SN 102˚+ 2 116° U1 proclined in relation to anterior cranial base

U1 – NA 22˚, 4mm 34°, 9 mm U1 proclined

U1 - N⊥ 2 – 4mm 12 mm Proclined U1

U1 – A Pog 25˚ , 4mm 50°, 14 mm Proclined and protruded U1

U1 – N Pog 10mm 19 mm U1 protrusion in relation to facial plane


normal Pre Rx

Nasolabial angle 90 - 110° 96°

Labial angle 12° °

U lip thickness 14 mm 15 mm

Basic U lip thickness 13 - 15mm 12 mm

Lip Strain 3 mm lip strain


INFERENCEIncisor retraction needed

In relation to cranium and maxilla 5 mm

For camouflage treatment 10 mm

SUPPORTED BY

Nasolabial angle

Lip strain *

Lip thickness

Lip in relation to esthetic line *


LOWER normal Pre Rx inference

L1 – FH 65° 44 ° Proclined lower incisorL1 – MP 90°+3 99° Proclined lower incisorL1 – NB 25°,4mm 40°, 15 mm Proclined and protruded

lower incisorsL1 – A Pog 25°,4mm 33°, 11 mm Proclined and protruded

lower incisorsL1 – N Pog 4 mm 15 mm Forward placement of

lower incisors in relation to facial plane

L1 – NB – NB – Pog(holdaway ratio)

1:1 8:1 increased

Mentolabial angle 120±10° 123° average mento labial sulcus

L – lip thickness 12±3 15 mm normalL – lip length 40±5 55 mm increased


INFERENCE Lower incisor retraction needed

In relation to mandibular 11 mm

For camouflage Rx 7 mm

Supported by

Mentolabial sulcus

Lower lip thickness

Holdaway ratio *

Lip in relation to esthetic line *


COGS


BURSTONE ANALYSIS (HARD TISSUE)MALE FEMALE Pt’s Value INFERENCE(Problem List)

Cranial Base

Ar-Ptm (// Hp) 37.1±2.8 32.8±1.9 36 mmPtm-N (//Hp) 52.8±4.1 50.9±3 53 mm Horizontal

N-A-Pg (angle) 3.9º±6.4º 2.6º±5.1º +15º RetrognathicN-A (//Hp) 0.0±3.7 -2±3.7 -1 mm Average maxillaN-B (//Hp) -5.3±6.7 -6.9±4.3 -16 mm Decreased mandibleN-Pg (//Hp) -4.3±8.5 -6.5±5.1 -18 mm decreased chin

Vertical

N-ANS (Hp) 54.7±3.2 50±2.4 56 mm Increased MAFH

ANS-Gn (Hp) 68.6±3.8 61.3±3.3 66 mm Increased LAFH

PNS-N (Hp) 53.9±1.7 50.6±2.2 48 mm Average middle posterior facial height

Mp-Hp (Angle) 23.0º±5.9º 24.2º±5º 36º INCREASED

U1-NF (NF) 30.5±2.1 27.5±1.7 28 mm average anterior maxillary dento-alveolar height

L1-MP (MP) 45.0±2.1 40.8±1.8 45 mm Increased anter mandibular dento-alveolar height

U6-NF (NF) 26.2±2.0 23±1.3 25 mm Increased post. Maxillary dento-alveolar height

L6-MP (MP) 35.8±2.6 32.1±1.9 35 mm Increased post. Mandibular dento-alveolar height


Maxilla-Mandible

PNS-ANS (// Hp) 57.7±2.5 52.6±3.5 54.5 mm

Average maxillary length

Ar-Go (Linear) 52.0±4.2 46.8±2.5 49 mm Average Ramal height

Go-Pg (Linear) 83.7±4.6 74.3±5.8 68 mm Decreased corpus length

B-Pg (//MP) 8.9±1.7 7.2±1.9 4 mm Decreased chin thickness

Ar-Go-Gn (Angle) 119.1º±6.5 122º±6.9 142º Increased Go Angle

Dental

OP – HP (Angle) 6.2º±5.1 7.1º±2.5 10º average divergent

A-B (// OP) -1.1±2.0 -0.4±2.5 7mm Class II skeletal pattern

U1-NF (Angle) 111.0º±4.7º 112.5º±5.3º 132º Proclined Upper incisor

L1-MP (Angle) 95.9º±5.2º 95.9º±5.7º 102º Proclined Lower incisor


Holdaway Soft tissue analysis

LAND MARKS MEAN PATIENT VALUES

INFERENCE

Facial angle 90º 84º retrognathic mandible

Upper lip curvature 2.5 mm 3mm high

Skeletal convexity at A -2 ± 2 8 mm class skeletal

H – line angle 7º to 15º 20º Protruded upper lip

Nose tip to H – line 12 mm (max) -1 mm Posterior placed

Upper sulcus depth 5 mm 7 mm Increased

Upper lip thickness 15 mm 15 mm normal

Upper lip strain 14 – 16 12mm 3 mm lip strain

Lower lip to H – line -1 to +2 mm +7mm increased

Lower sulcus depth 5 mm -2 mm decreased

Soft tissue chin thickness 10 – 12 mm 10 mm normal chin thickness


CEPHALOMETRIC SUMMARY Skeletal:

Class II skeletal patternHIGH MPAhigh- LAFHvertical growth patternretrognathic MANDIBLE

Dental Proclined and protruded upper incisors Proclined and protruded lower incisors Soft tissue: normal nasolabial angle average mentolabial sulcus


MODEL ANALYSIS

11.5

Right Left

9 mm 9 mm

7 mm 7 mm

8 mm 8 mm

7.5 mm 7.5 mm

6.5 mm 6.5 mm

9.5 mm 9.5 mm

Right Left

5.5 mm 5.5 mm

6 mm 6 mm

6.5 mm 6.5 mm

7 mm 7 mm

7.5 mm 7.5 mm

10 mm 10 mm

UPPER LOWER

12 TM 95 mm 85 mmANT 6 TM 48 mm 36 mm


BOLTON TOOTH RATIO OVERALL RATIO: Mand 12 TM x 100 =91.3% (normal) Max 12 TM 85 x 100 = 89.47% 2 mm MAXILLARY tooth 95 material excess

Ant. RATIO: mand 6 TM x 100 = 77.2% (normal) max 6 TM

36 x 100 = 75% 1.4 mm maxillary tooth 48 material excess


CAREYS ARCH PERIMETER ANALYSIS Upper Lower Tooth Material : 76 mm 65 mm

Arch length : 76 mm 60 mm Difference : 0 mm (available) 5 mm(required)


ASHLEY-HOWE ANALYSIS

• UPPER• PMD = 42 mm

• PMBAW = 41 mm PMD > PMBAW NEED FOR EXTRACTION• • PMBAW 100; 41100 = 43.1% BORDERLINE CASE• TM 95

• LOWER• PMD = 36.5mm

• PMBAW = 33 mm PMD > PMBAW NEED FOR EXTRACTION • • PMBAW 100; 33100 = 38.8 % Borderline case• TM 85


• LINDER-HEARTH ANALYSIS

• UPPER• MPV = 36mm CPV = 37.6mm CPV > MPV EXPANSION IS INDICATED.

• MMV = 42 mm CMV = 50mm CMV >MMV EXPANSION IS INDICATED.

• LOWER

• MPV = 31.5mm CPV = 27mm CPV ˂ MPV EXPANSION IS NOT INDICATED.

• MMV = 35.5mm CMV = 35.9mm CMV >MMV EXPANSION IS INDICATED.


TOTAL SPACE ANALYSIS Upper arch • Space discrepancy ( Arch perimeter) = 0 mm (available)• Space obtainable by Derotation of Molars = 0 mm• Space required for correcting Canine rotations = 0mm Incisor Retroclination UI to NA = 34º

For ANB of 7º = 17º

To retrocline = 17x 0.8 = 13.6mm Leveling Curve of Spee = 2 mm►Total space available = 0 mm►Discrepancy = 13.6+2 = 15.6 mm►Space required for molar correction on RT =0 mm LT =0 mm►Hence space required on RT 7.8 mm LT 7.8 mm


Lower arch • Space discrepancy ( Arch perimeter) = 5 mm(required)• Space required for Derotation of molars = 0 mm• Retroclination L I to NB = 40 º For ANB of 7º = 30º To Retrocline = 10X 0.8 =8 mm

Leveling Curve of Spee = 2 mm ► Space required to establish class I molar relation =0 mm ► Discrepancy = 8+5+2 = 15 mm► Hence space required on RT 7.5 mm LT 7.5 mm


DIAGNOSIS AND TREATMENT PLAN DIAGNOSIS:

ACKERMAN-PROFFIT CLASSIFICATION: Evaluation of Facial Proportions and Esthetics:

Convex profile, potentially competent lips normal maxilla, retrognathic mandible retruded chin Proclined upper and Proclined lower incisors increased LAFH average nasiolabial angle Average Mentolabial sulcus Intra-Arch alignment and symmetry


Diagnosis

• Angle’s Class-I Dentoalveolar malocclusion on class II skeletal base with Class – II soft tissue profile with proclination of upper and lower anteriors.

• Lingually inclined upper left first premolar.• Severe crowding in relation to lower anteriors.


Treatment objectives

• To align& level upper and lower arches• To correct tongue thrusting habit• To correct the proclination• Establishing soft tissue harmony• To stabilize the corrections achieved


Treatment plan

Extraction all 4s• PAE with MBT mechanotherapy • Leveling and Alignment.• Retraction using type A anchorage • Finishing & Detailing.• Stability and Retention.


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Neethu Jose / orthodontic courses by Indian dental academy