Case PresentationSupervised by: Dr. Ahmad Al Tarawneh

Dr. Raed Al Rbata

Prepared by: Dr. Hiba Al Zghoul

Personal Data Initials: A. Z.

Gender: Male

Age: 25 year old

Education: Bachelor’s degree

Occupation: Sergeant in JAF

Place of residence: Amman, Jordan

History

Medical history: Denied any medical history

Dental history: Irregular dental attendant Previous upper and lower right

premolar extractions

Habits: Smoker, 15 cigarettes/day

Chief Complaint: My teeth are not straight

Extraoral Examination

Macro Esthetics

Frontal: Mild facial asymmetry:

Nose deviated to the left

Philtrum of the lip deviated to the left

Chin slightly deviated to the right

Macro Esthetics Frontal:

Width of the nose slightly larger than the intercanthal distance

Width of the mouth slightly less than the interpupillary distance

Macro Esthetics Frontal:

Canting of the occlusal plane downwards to the left

Upper midline in shifted 2 mm to the right, and the lower shifted 3 mm to the right

Macro EstheticsAnteroposterior:

Slightly convex profile

Slightly decreased LFH

Lips competent

Obtuse Nasiolabial angle

Average Labiomental angle

Short throat length

Macro Esthetics

Vertical :

Slightly increased lower facial height

Short upper lipUpper lip to lower lip = 1:4

Mini Esthetics

Smile esthetics:

Asymmetric smile

Increased show on the left

Acceptable incisal show

Smile arc does not follow the lower lip

Upper midline shifted 2mm to the right

Narrow smile

Micro Esthetics Tooth proportions:

Canine to central incisor ratio= 40%

Width of upper right central incisor to its height = 75%

Width of upper left central incisor to its height = 90%

Micro Esthetics

Connector lengthLess between central incisor and lateral incisor than between lateral incisor and canine

Roll:Incisal line canted downwards on the left

Intraoral Examination

Teeth present:

8 7 6 3 C 1 1 C 3 4 6 7 88 7 6 4 3 2 1 1 2 3 4 6 7 8

Intraoral Examination

Poor oral hygiene. Calculus deposits on lower anterior teeth and right posterior teeth

Caries:Class III caries on the upper left primary canine

No abnormal mobility on retained upper primary canines

Intraoral Examination

Central line: Shifted in the upper arch to the left by 2 mm

Gingival line: Higher in the upper right

central incisor Lower gingival line on

retained primary canines and upper right permanent canine

Intraoral Examination

Incisor classification: Class I

Overjet = 2 mm

Overbite = 50 %, Complete

Crossbite: Right side: upper primary

canine, permanent canine, first molar

Left side: upper first premolar

Intraoral Examination

Molar relationships: Right > class II Left: class III

Canine relationships: Right: class I Left: class III ¼ unit

Study Cast Examination

Study Cast Examination

Bolton Analysis: Σ Lower anterior tooth widths = 78 %Σ Upper anterior tooth widths n= 77.2 +/- 1.65

Σ Lower all tooth widths = 90%Σ Upper all tooth widths n= 91.3 +/- 1.91

Study Cast Examination

Upper Arch

V- shaped upper arch

Asymmetrical arch with the right side narrower and shorter than the left side

The dental central line does not follow the skeletal midline

Intercanine width= 32 mm

Intermolar width = 41 mm

Study Cast Examination Tooth alignment Mesiopalatally rotated upper right first molar

Mesiolabially rotated upper right permanent canine

Mesiolabially rotated upper right primary canine

Mesiolabially rotated upper left primary canine

Mesiolabially rotated upper left permanent canine

Mesiobuccally rotated upper left first premolar

Study Cast Examination

Lower Arch

U-shaped lower arch

Asymmetrical

Study Cast Examination Tooth alignment

Distolingually rotated lower right second molar

Distobuccally rotated lower right first molar

distolabially rotated lower right lateral incisor

Mesiolabially rotated lower right central incisor

Mesiolabially rotated lower left central incisor

Mesiolingally rotated lower left canine

Mesiolingually rotated lower left first premolar

Study Cast Examination

Lower Arch

Curve of Spee: 3mm depth

Severely mesially tipped lower first molars

IOTN- Esthetic Component

6: moderate need

IOTN

4.h (Great)Less extensive hypodontia requiring prerestorative orhodontics or orthodontic space closure to obviate the need for prosthesis

OPT

Slightly asymmetric condyles Carious upper and lower right first molar Pericoronal lesions on lower right third molars Generalized decrease in bone height Crown/Root ratio of upper primary canines = 1/1 Severely mesially tipped upper and lower right first molars

Lateral CephalogramSNA 77.5

°

SNB 74.5 °

ANB 3 °

Corrected ANB

---

UI-MX 106 °

LI-MN 86°

MMA 27 °

UI-LI 142 °

SN-MX 13 °

Wits Appraisal

2 mm

LFH 53%

Diagnostic Summary

A. Z. is a 25 year old male, medically fit, complaining “my teeth are not straight”. He presented with a class I incisor relationship on a class I skeletal base with slightly reduced lower facial height. He has a normal overjet of 2 mm, 50% complete overbite, with missing upper lateral incisors, retained primary canines, missing all second premolars and upper right first premolar. He has narrow upper arch and moderate crowding in the lower arch, and a shifted upper and lower midlines of 2, and 3 mm to the right correspondingly. He has class II molar and class I canine relationships on the right side, class III molar and class III ¼ unit canine relationship on the left side.

Problem List1. Poor oral hygiene and gingival inflammation2. Carious upper left primary canine, right upper and lower first molars 3. Generalized decrease in bone height 4. Pericoronitis on lower third molars 5. Chief complaint: poor smile esthetics with malaligned teeth6. Asymmetric face with nose and philtrum deviated to the left7. Short upper lip8. Obtuse nasiolabial angle9. Slightly convex profile10. Short throat length11. Canted occlusal line and narrow smile 12. Missing upper lateral incisors, with retained primary canines13. Missing second premolars and upper right first premolar14. Crossbite on the right from primary canine to first molar and upper left first premolar15. V-shaped narrow upper arch16. Upper central line shift of 2 mm to the right17. Lower central line shift of 3 mm to the right18. Moderate crowding in lower arch19. Severely mesially tipped upper and lower right first molars20. Class II molar relationships on the right and class III on the left21. Canine relationships of class III ¼ unit on the left

Treatment Aims

Improve and maintain good oral hygiene throughout treatment Accept facial asymmetry and skeletal relationship Correction of crossbite Achieve Class I canine relationships, and molar relationship on

the left side Achieve full class II relationship on right side Correct tooth alignment and proper angulation and inclination Maintain overjet and overbite

Treatment Plan1. Improvement of oral hygiene 2. Upper and lower fixed appliance3. Space closure for missing premolars4. Extraction of upper primary canine and prosthetic replacement

with implants to restore lateral incisors5. Finishing6. Retention

Treatment Mechanics1. Roth prescription, .022” slot2. Include upper and lower second molars3. Start with alignment and leveling using NiTi wire sequence4. Upper arch expansion with expanded SS wires5. Distalize lower left molars and maintain upper left molars in position

utilizing micro implants and closing coil spring6. Closure of lower space towards the left side to correct lower midline

shift7. Upright lower right second molar first then first molar utilizing micro

implants

Retention Protocol Upper and lower Hawley retainers

Maintain primary canine extraction space with acrylic teeth until prosthetic replacement is carried out

24 hours wear for 3 months, then 12 hours/day for 1 year

Justification Fixed appliance: due to the necessity of precise control of tooth

movement in the three dimensions Roth prescription slot .022”: due to use of sliding mechanics Upper arch expansion: to correct crossbite and provide space for

space opening Space closure of the left upper and lower buccal segments:

acceptable angulation of upper and lower first molars, and midline shift

Space closure for the right upper and lower buccal segments: due to acceptable contact between teeth

Extraction of upper primary canines: because of increased crown/root ratio and poor prognosis and unacceptable esthetics. Extraction delayed to maintain bone height.