Neethu Jose / orthodontic courses by Indian dental academy

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INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

www.indiandentalacademy.com

Name : Neethu jose

Age : 19yrs

Sex : Female

Address : Narayana college , Nellore.Occupation : student


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HISTORYwww.indiandentalacademy.com

Chief complaint :

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

Pre-natal historyInformer :Patient

Condition of the mother : Normal

Delivery : Full term

Type : Normalwww.indiandentalacademy.com

Post-natal history

Type of feeding : Breast feeding

Milestones of development : Normal


Childhood diseasesNot reported HabitsTongue thrusting www.indiandentalacademy.com

Familial Malocclusion History Siblings : NRH Parents : NRH

General history Reasons for taking orthodontic treatment :Esthetics Attitude of the patient towards treatment: Positive www.indiandentalacademy.com

Clinical examination recordwww.indiandentalacademy.com

Physical statusBuild : MesomorphicHeight : 150 cms (5 )Weight : 51 kgsGait : NormalPosture : NormalBody 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 facewww.indiandentalacademy.com

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Vertical facial evaluation:- symmetrical facewww.indiandentalacademy.com

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Convex Profile average nasiolabial angle shallow mentolabial sulcus


Inter labial gap : 1 mmSmile Arc : non ConsonentLip posture and : partially competent tonicity : everted lower lipLip length : At philtrum : 17 mm At corner of mouth : 23 mm


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Functional examinationwww.indiandentalacademy.com

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 mmRange 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)


TMJJaw 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 EXAMINATIONwww.indiandentalacademy.com

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.


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Measurement Mean/SDACTUALInference SNA822 82 Normal Maxilla SNB 802 75 Retrognathic Mandible SND76 72 Retruded chin ANB22 7 Class II Skeletal Go-Gn to SN324 44 Increased MPA UI to NA (mm)4mm 9 mm Protruded UIUI to NA (angle)22 34 Proclined UI LI to NB (mm) 4mm 15 mm Protruded LI LI to NB (angle)25 40Proclined LIInterincisal Angle131 98Proclined U/L IncisorsOccl. to SN angle14 16Hyperdivergent

STEINERS ANALYSIS


7301 mm175.25 mmSTEINERS ACCEPTABLE COMPRAMISE


McNAMARA ANALYSIS

MEASUREMENTMEANACTUALINFERENCEN Perpendicular to Pt. A02mm + 2 mm normal MaxillaN Perpendicular to Pogonion0to -4mm - 11 mmretrognathic chin Facial Axis angle0 -6 vertical growth Mandibular Plane angle 264 37High MPA Eff. Max. Length 100.9+3.9 91 mm decreased maxilla sizeEff. Mand. Length 118.9 5.0 mm 116 mmNormal mandibleMaxillofacial Differential 30.1+3.9 25 mmClass II SkeletalLower Ant. Face Height (LAFH) 71.6+4.9 73 mmnormalU1 to Point A distance4mm 10 mmForwardly placed upper incisorL1 to APog line distance1-2mm11 mmForwardly placed lower incisorNaso Labial angle90-110 96Normal Nasolabial angle


MEASUREMENT

MEAN

ACTUAL

INFERENCEN Perpendicular to Pt. A02mm +1 mm Normal MaxillaN Perpendicular to Pogonion0to -4mm -2 mmNormal MandibleFacial Axis angle0-2 Vertical growth patternMandibular Plane angle 26424Normal MPA Eff. Max. Length 92.32.0mm 91mmNormal Eff. Mand. Length 1194.5 mm 121 mmNormal Maxillofacial Differential 27.03.2mm 34 mmNormal ( Lower end )Lower Ant. Face Height (LAFH) 664.7mm 67 mmNormal U1 to Point A distance4mm 8 mmForwardly placed upper incisorL1 to APog line distance1-2mm 5 mmForwardly placed lower incisorNaso Labial angle90-11086Acute

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RAKOSI JARABAK ANALYSIS

MeasurementMeanActual Saddle angle1235 133posterirly positioned glenoid fossa irt condyleArticular angle1436 128prognathic mandibleGonial angle1287 146vertical growth

Upp.Gonial angle52-55 59 Increased(caudal growth)Low.Gonial angle72-75 87Increased (caudal growth)Sum of posterior angles3966 407Vertical growth

Mandibular Plane angle32 44 increasedAngle of Inclination85 85no inclination of maxillaPn to Occlusal plane75 HyperdivergentPn to Mandibular plane65 HypodivergentBasal Plane angle25 30increased Palatal plane to Occl. Plane11 0HypodivergentOccl. Plane to MP14 30Hyperdivergent


Jarabak ratio:(ant. to post. Face ht. ratio) 62-65% 58.7%Vertical growth Y-Axis66 73Vertical growthInterincisal angle135 98Proclined U/L incisors

U1 to SN plane102 2 116Proclined upper incisors U1 to Palatal plane70 5 49Proclined upper incisors to palatal plane

L1 to Mandibular plane90 3 99Proclined lower incisor


RICKETTS ANALYSIS

MEASUREMENTMEANACTUALINFERENCEFacial Axis angle(Ba.Na-Ptm.Gn)90 3.5 95vertical GrowthFacial Depth (N.Pog-FH)87 3 84Slight retrognathic profileM.P.angle (Go.Gn-FH)26 4.5 34Increased MPAConvexity of Pt.A.2 2mm +2 mmClass I Sk pattern L1 to A.Pog (angle)22 4 32Proclined lower incisorsL1 to A.Pog (mm)1 2mm 11 mmProtruded lower incisorsU6 to PtVAge +3mm19+3=22 22mmNormal upper MolarL.Lip to E- plane-2+2 -8 mmretruded lower lip


WITS APPRAISAL

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

BOAOOPwww.indiandentalacademy.com

MEASUREMENTNORMALACTUALINFERENCEFMA 25 37 vertical growthFMIA65 44Proclined lower incisorIMPA90 99 Proclined lower incisor

FMA 16 to 28 degrees prognosis poor TWEEDS ANALYSIS


33 Class I sk pattern ( 27-- 35 norm)

- ANGLE


Composite analysis


HARD TISSUE PRE-TREATMENT NormalMeasured ClassANB 27IIA to B on FH 4mm 12 mmIIAO to BO 0 1mm 7 mmIIBeta angle 27to 3533INA Pog -8.5 to 10-15IIAB N.pog 0 to -9-9IMax : Mand (ANS-PNS, GoGn) 2 : 32.37 : 3IIHarvolds unit length difference Chart 25ISkeletal Class IISoft tissue Profile Angle161153II

Total tissue Profile angle133(males) 137(females) 123IISoft tissue facial angle90 + 384IISubnasale to chin-2.52.6-15 mmII

SAGITTAL RELATIONwww.indiandentalacademy.com

Effects of soft tissues if any&Basic Upper lipNormal, Thick, Thin (14+1)15 mmSoft Tissue chinNormal, Thick, Thin (10-12)10mm

INFERENCESKELETALClass IClass II*Class III SEVERITYMild (2_4)Moderate (4_6)Severe (>6)*SOFT TISSUEMatching CompensatingAggravating *


Discrepancy analysis: (sagittal)MAXILLAMax apical base Norms Pre RxINFERENCESNA 822 82 NORMAL maxillaA N (Mc namara) 0 2mm 2 mm normal maxilla

CAUSEMax size- ANS PNS 52 mm 55 mmIncreased maxilla by 3mmMax effective length 100 4 91 mmDecreased by 5 mmMax placement S NF PTM NF 18mm 20 mmAnteriorly placed by 2mm


MANDIBULAR APICAL BASESNB 802 75retrognathic mandibleB - N -2 2mm - 10 mmretruded mandibleChinN Pog FH (facial angle)87 84decreasedCAUSESIZE Mand corpus size78 mm 69 mm decreased by 9mm.Mand ramus Ht58 mm 49 mm decreased by 9mm


Norms Pre RxinferenceMand eff. Length 131+4.6 116 mm retrognathic mandibleMANDIBULAR PLACEMENTSaddle angle 1235 133 Increased by 5 Post cranial base 32 35 33 mm normalEffect of gonial angle 1287 146 increased by 11 Effect of ramus orientation S Ar Go 1436 128 Decreased by 9

INFERANCEFault withMaxillaSize (I) Placement (A)Mandible Size (D)Placement (P)


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VERTICAL RELATION Pre RxPost growth modulationNormal calculated Mid/Lower face ht45:5543:57Increased LAFHSN Go Gn3244 VERTICAL growth F M A (Tweed)2537 vertical growth Jarabak ratio62-65%58.7%vertical growthBJORK sum396407 vertical growthSaddle angle1235133Posterior positioned glenoid fossaArticular angle 1436128Sagital growth mandibleU- Gonial angle 52-55 59caudal growth of mandibleL- Gonial angle72-7587caudal growth of mandibleY- axis N S Gn 6073vertical growth Y- axis FH S Gn 6664horizontall growthFacial axis (Ricketts) 90+3.595vertical growth


Basal plane angle25 30hyperdivergentocclusal NF to MP 11

14 0

30Vertical maxillary placement Nasion to ANS 54.7+ 3.256 mmno rotation of maxillary jaw base Maxillary rotation85 85No inclination of maxilla


Divergence of jaw bases Per RxPost growth modulationAnterior DivergentAnterior convergent Upward anterior rotation of both max and mand Downward anterior rotation of mand *


UPPER INCISOR EXPOSUREU1 exposure at rest 0mmU1exposure in smile 10 mmnormalANS to Incisor (333/303) 28 mmnormalU lip length (22-24/20) 23 mmnormal

INFERANCE No excessive exposure


Dento Alveolar Analysis Correlated With SOFT TISSUESUPPER normal Pre Rx P. Gr. ModU1 SN 102+ 2 116 U1 proclined in relation to anterior cranial baseU1 NA 22, 4mm 34, 9 mmU1 proclined U1 - N 2 4mm 12 mmProclined U1U1 A Pog 25 , 4mm 50, 14 mmProclined and protruded U1 U1 N Pog 10mm 19 mmU1 protrusion in relation to facial plane


normal Pre RxNasolabial angle 90 - 110 96Labial angle 12 U lip thickness 14 mm15 mmBasic U lip thickness 13 - 15mm 12 mmLip Strain 3 mm lip strain


INFERENCEIncisor retraction neededIn relation to cranium and maxilla5 mmFor camouflage treatment10 mm

SUPPORTED BYNasolabial angle Lip strain *Lip thicknessLip in relation to esthetic line *


LOWER normal Pre Rx inferenceL1 FH 65 44 Proclined lower incisorL1 MP 90+3 99Proclined lower incisorL1 NB 25,4mm 40, 15 mmProclined and protruded lower incisorsL1 A Pog 25,4mm 33, 11 mmProclined and protruded lower incisorsL1 N Pog4 mm 15 mmForward placement of lower incisors in relation to facial planeL1 NB NB Pog(holdaway ratio) 1:18:1 increasedMentolabial angle 12010 123 average mento labial sulcusL lip thickness 123 15 mmnormalL lip length 40555 mm increased


INFERENCELower incisor retraction neededIn relation to mandibular11 mmFor camouflage Rx7 mm

Supported byMentolabial sulcus Lower lip thicknessHoldaway ratio*Lip in relation to esthetic line*


COGSwww.indiandentalacademy.com

BURSTONE ANALYSIS (HARD TISSUE)

MALEFEMALEPts ValueINFERENCE(Problem List) Cranial Base Ar-Ptm (// Hp)37.12.832.81.936 mmPtm-N (//Hp)52.84.150.9353 mm HorizontalN-A-Pg (angle)3.96.42.65.1+15 RetrognathicN-A (//Hp)0.03.7-23.7-1 mmAverage maxillaN-B (//Hp)-5.36.7-6.94.3-16 mmDecreased mandibleN-Pg (//Hp)-4.38.5-6.55.1-18 mmdecreased chinVerticalN-ANS (Hp)54.73.2502.456 mmIncreased MAFHANS-Gn (Hp)68.63.861.33.366 mmIncreased LAFHPNS-N (Hp)53.91.750.62.248 mmAverage middle posterior facial heightMp-Hp (Angle)23.05.924.2536INCREASEDU1-NF (NF)30.52.127.51.728 mmaverage anterior maxillary dento-alveolar heightL1-MP (MP)45.02.140.81.845 mmIncreased anter mandibular dento-alveolar heightU6-NF (NF)26.22.0231.325 mmIncreased post. Maxillary dento-alveolar heightL6-MP (MP)35.82.632.11.935 mmIncreased post. Mandibular dento-alveolar height


Maxilla-MandiblePNS-ANS (// Hp)57.72.552.63.554.5 mmAverage maxillary lengthAr-Go (Linear)52.04.246.82.549 mmAverage Ramal heightGo-Pg (Linear)83.74.674.35.868 mmDecreased corpus lengthB-Pg (//MP)8.91.77.21.94 mmDecreased chin thickness Ar-Go-Gn (Angle)119.16.51226.9142Increased Go Angle DentalOP HP (Angle)6.25.17.12.510 average divergent A-B (// OP)-1.12.0-0.42.5 7mmClass II skeletal patternU1-NF (Angle)111.04.7112.55.3132Proclined Upper incisorL1-MP (Angle)95.95.295.95.7102Proclined Lower incisor


Holdaway Soft tissue analysisLAND MARKS MEAN PATIENT VALUES INFERENCE Facial angle 90 84 retrognathic mandible Upper lip curvature 2.5 mm 3mm highSkeletal convexity at A -2 2 8 mm class skeletal H line angle 7 to 15 20 Protruded upper lip Nose tip to H line 12 mm (max) -1 mm Posterior placed Upper sulcus depth 5 mm 7 mm IncreasedUpper 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 increasedLower sulcus depth 5 mm -2 mm decreasedSoft 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 ANALYSIS11.5Right Left 9 mm9 mm7 mm7 mm8 mm8 mm7.5 mm7.5 mm6.5 mm6.5 mm9.5 mm9.5 mm

Right Left 5.5 mm5.5 mm6 mm6 mm6.5 mm6.5 mm7 mm7 mm7.5 mm7.5 mm10 mm10 mm

UPPERLOWER

12 TM95 mm85 mmANT 6 TM48 mm36 mm


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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 mmDifference : 0 mm (available) 5 mm(required) www.indiandentalacademy.com

ASHLEY-HOWE ANALYSIS

UPPERPMD = 42 mm

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

LOWERPMD = 36.5mm

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


LINDER-HEARTH ANALYSIS

UPPERMPV = 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. www.indiandentalacademy.com

TOTAL SPACE ANALYSIS Upper arch Space discrepancy ( Arch perimeter) = 0 mm (available)Space obtainable by Derotation of Molars = 0 mmSpace required for correcting Canine rotations = 0mm Incisor Retroclination UI to NA = 34 For ANB of 7 = 17 To retrocline = 17x 0.8 = 13.6mm Leveling Curve of Spee = 2 mmTotal space available = 0 mmDiscrepancy = 13.6+2 = 15.6 mmSpace required for molar correction on RT =0 mm LT =0 mmHence 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 For ANB of 7 = 30 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 mmHence 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 www.indiandentalacademy.com

Diagnosis

Angles 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.


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Treatment objectives

To align& level upper and lower archesTo correct tongue thrusting habitTo correct the proclinationEstablishing soft tissue harmonyTo stabilize the corrections achieved


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Treatment plan

Extraction all 4sPAE 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