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CHIEF COMPLAINTName: Nalla Shilpa
Age: 21 years
Sex: Female
Patient complains of irregularly placed upper and lower front teeth.
GENERAL HISTORY
• Improvement of esthetics is prime reason for the patient to seek treatment and is positively motivated for treatment.
• Patients brushes once daily and does not use any other oral hygiene aid.
GENERAL HEALTH STATUS
• Height :5 feet, 3 inches• Weight : 52 kgs• Posture : Upright• Body type : Mesomorphic • Gait : normal
EXTRA ORAL EXAMINATION - FRONTAL
• Mesocephalic head.• Leptoprosopic face.• Apparently symmetrical• Vertical proportionalityUpper – 61 mmMiddle – 57 mmLower – 65 mm• Stomium line to nose– 20 mm Stomium line to chin – 41mmIncompetent lipsInterlabial gap-4 mm
EXTRA ORAL EXAMINATION - FRONTAL
•Consonant smile arc.
•7 mm of upper incisor display (70%)
• Upper dental midline shifted to right by 2 mm
•Lower dental midline shifted to leftby 2 mm
EXTRA ORAL EXAMINATION-PROFILE
• Straight facial profile.• Average nasolabial
angle.• Average clinical FMA.• Incompetent lips
FUNCTIONAL EXAMINATION
• Respiration is oronasal.• No TMJ or jaw function complaint.• Interocclusal clearance : 3mm • Maximum mouth opening : 45 mm • Protrusion 11mm• Right excursion 8 mm.• Left excursion 8 mm.• Normal swallow.• Normal speech.
INTRA ORAL EXAMINATION
SOFT TISSUE EXAMINATION:• Fair oral hygiene status.• Tongue- normal shape & movements.• Gingival recession-31
INTRA ORAL EXAMINATION
HARD TISSUE EXAMINATIONTeeth present- full compliment
of teeth except 18,28,38,48Generalised Enamel hypoplasiaGingival recession and grade 1
mobility -31
INTRA ORAL EXAMINATION
HARD TISSUE EXAMINATION (MAXILLARY ARCH)
• U-shaped arch.• Asymmetrical arch.• Upper anterior crowding • Labially and highly placed 13• RotationsDistobuccal-16,26,25Mesiolabial- 11,12,14
Spacing between 12/ 14
INTRA ORAL EXAMINATION
HARD TISSUE EXAMINATION (Mandibular arch)• U-shaped arch.• Asymmetrical arch.• Lower anterior crowding.• Amalgam restoration – Buccal pits- 36,46• Rotations-• Mesiolabial-34,42 • Distobuccal- 35,36,44,45Gingival recession and grade 1 mobility -31Curve of speeRight-3.5 mmLeft-4mm
INTRA ORAL EXAMINATION
ANTERIOR OVERJET OVERBITE RELATIONSHIP
Overjet – 2mm(21/31), 2.5mm(11/42)
Overbite – 1 mm(21/31), 2mm(21/41)
Incisor relation – Class I
INTRA ORAL EXAMINATION
RIGHT
Molar Relation – Class I
Canine relation- Class III( Highly placed 13/43)
LEFT
Molar relation– Class I
Canine relation– Class I
MODEL ANALYSIS
BOLTONS ANALYSIS
Anterior mandibular tooth material excess of 0.8 mm
Overall maxillary tooth material excess of 0.73 mm
CAREY’S ANALYSIS
9.5 mm tooth material excess- 1st premolar extraction
ARCH PERIMETER ANALYSIS
5 mm tooth material excess – extraction of 1st premolars
PONT’S ANALYSIS
Calculated values are greater than measured values in premolar area
NEED FOR EXPANSION
ASHLEY HOWE’S ANALYSIS
PMD-36.5mm & PMBAW- 40mm. Expansion is possible
PMBAW%=39.4% Borderline case
ANGLE MEAN ACTUAL
INFERENCE
FMPA 250 340 Hyperdivergent
IMPA 900 990 Proclined lower incisors
FMIA 650 480 Poor esthetic balance
TWEED’S ANALYSIS
MEASUREMENTS MEAN ACTUAL INFERENCE
Facial Plane 87.5±3.60 860 Average positioned chin
Convexity 0 ±5.10 +90 Convex profile
A-B Plane -4.6to3.7 -100 Skeletal class II
MP angle(FH-Go-Me)
22 ± 30 310 Hyperdivergent
Y-axis 60±40 600 Normodivergent
Occ Plane (OP) 9±40 100 Average
U1-L1 (angle) 135±6 0 1090 Proclined incisors
L1-OP (angle) 75±40 580 Proclined Lower anteriors
L1-MP 92±40 1010 Proclined Lower anteriors
U1- A-Po 2±3mm 12mm Proclined upper anteriors
DOWN’S ANALYSIS
STEINERS ANALYSISMEASUREMENTS MEAN ACTUAL INFERENCE
SNA 820 820 Orthognathic maxilla
SNB 800 760 Retrognathic mandible
SND 76 740 Backward positioned chin
ANB 2±20 60 Skeletal Class II
Go-Gn to SN 320 350 Hyperdivergent
UPPER 1 to N-A 4mm 4 mm Average
UPPER 1 to N-A 220 300 Proclined upper incisors
LOWER 1 to N-B 4mm 8 mm Anteriorly positioned lower incisors
LOWER 1 TO N-B 250 360 Proclined lower incisors
UPPER 1 to LOWER 1 1310 1090 Proclined upper and lower incisors
OCCLUSAL TO S-N 140 190 Clockwise rotation of occlusal plane
STEINERS ANALYSIS
SOFT TISSUE
Upper lip 1 mm posterior to S-line
lower lip 1.5 mm anterior to S-line.
indicating retrusive upper and protrusive lower lips
McNAMARA ANALYSISMEASUREMENTS MEAN ACTUAL INFERENCE
Na ┴ -Point A (mm) 0-1 -1 mm Orthognathic maxilla
Na ┴ -Pg (mm) 0 to-4 -9 mm Retrognathic mandible
Facial axis angle 00 -30 Hyperdivergent
MP angle (FH-Go-Me) 22 ± 40 310 Hyperdivergent
Mx length(Co-PointA) 93.6±3.2 90mm Average
Md length(Co-Gn) 121.6±4.5 112mm Decreased
Mx-Md differential 28.0±3.2 22mm Decreased
LAFH (ANS-Me) 67.2±4.7 67mm Average
U1- Point A 4mm 4mm Average
L1- A-Po 1-2mm 3.5mmAnteriorly positioned
lower incisors
Naso labial angle 90-110 0 1040 Average
PARAMETERS MEAN PRE RX INFERENCE
Se-N (Length of Ant Cranial Base) 70.1mm 73 mm Increased
Go-Pg (Length of Mandibular Base)
Se-N+3mm(76mm) 74mm Decreased
ANS-PNS (Length of Maxil lary Base) 48.1-56.1mm 57mm Increased
Co-Go (Length of ramus) 53.2mm 48mm Decreased
ANS-PNS/ Go-Pg 2:3 2.1:2.9Decreased mandibular base length relative to
maxilla
Co-Go/ Go-Pg 5:7 4.7:7.3Increased mandibular base length relative to
ramus height
SCHWARZ ANALYSIS
RAKOSI JARABAK’S ANALYSIS
MEASUREMENT MEAN ACTUAL INFERENCE
SADDLE ANGLE 1230 ± 5 1250 Average
ARTICULAR ANGLE 143 ± 60 1380 Average
GONIAL ANGLE 128 ± 70 1360 Average
U/ GONIAL ANGLE 52-550 590 Increased
L/ GONIAL ANGLE 72-750 770 Increased
SUM OF POSTERIOR ANGLES
396 ± 60 3990 Normodivergent
MANDIBULAR PLANE ANGLE
320 350 Hyperdivergent
ANGLE OF INCLINATION 850 850 Average
N-PERP TO OCCLUSAL PLANE
750 800 Forward rotation of occlusal plane
MEASUREMENTS MEAN ACTUAL INFERENCE
N-PERP TO MANDIBULAR PLANE
650 590 Clockwise rotation of mandibular plane
BASAL PLANE ANGLE 250 250 Normodivergent
PALATAL PLANE TO OCCLUSAL PLANE
110 50 Anticlockwise rotation of occlusal plane
OCCL. PLANE TO MP 140 200 Clockwise rotation of mandibular plane
Y AXIS 660 680 Hyperdivergent
INTERINCISAL ANGLE 1350 1090 Proclined incisors
UPPER 1 TO S-N 102±2º 1110 Proclined upper incisors
LOWER1 TO MAND. PLANE (IMPA)
90±30 1010 Proclined lower incisors
UPPER1 TO PALATAL 70±50 570 Proclined upper incisors
ANTERIOR TO POSTERIOR FACE HT. RATIO
62-65%
70/118=%
Increased anterior facial height –hyperdivergent
growth pattern
COMPOSITE ANALYSIS
• On sagittal analysis, patient shows skeletal class II pattern due to retrognathic mandible
• On vertical analysis patient shows hyperdivergent growth pattern.
• Clockwise rotation of lower jaw base.• Dentoalveolar analysis
Retraction of upper incisors by 3.1mm
Retraction of lower incisors by 3.8mm
CEPHALOMETRIC DIAGNOSIS
A case of skeletal class II pattern due to orthognathic maxilla and retrognathic
mandible with hyperdivergent growth pattern and mild proclination of upper and lower
incisors.
DIAGNOSIS
A 21 year old female presents with Angle’s
Class I malocclusion on a mild Class II skeletal base due to orthognathic maxilla and
retrognathic mandible with a hyperdivergent growth pattern, straight profile, incompetent
lips, enamel hypoplasia , mild upper and lower anterior proclination, upper and lower
anterior crowding, gingival recession and grade 1 mobility -31,deviated upper dental
midline towards right side by 2 mm deviated lower dental midline towards left by 2 mm
PROBLEM LISTFACIAL PROPORTIONS AND ESTHETICS
Incompetent lips
DENTAL ALIGNMENT AND SYMMETRYSevere Crowding and mild proclination in upper and
lower anteriors, deviated upper dental midline towards right side by 2 mm, lower dental midline deviated to left by 2 mm, Rotations in upper and lower anteriors, buccally placed 13, gingival recession and grade 1 mobility -31
DENTAL TREATMENT OBJECTIVES
• Relieving the crowding in upper and lower anteriors.
• Correction of inclination of upper and lower incisors.
• Derotation of rotated teeth • Attaining stable canine relation on right side.• Shifting of deviated upper and lower dental
midline.• Levelling of curve of spee.
TREATMENT PLAN – Extraction of 14 in upper arch for alignment of 13– Extraction of 31(poor prognosis) and 44 in lower arch for
relieving the crowding and levelling the curve of spee and to attain Class I canine relation on right side.
– Fixed mechanotherapy.– Leveling and alignment.– Space closure using sliding mechanics– Finishing and detailing