classII malocclusion, non vital central incisor

1. Personal information
• Patient name : SA
• Age : 14yrs
• Sex : Female
• History:
1. Medical history: There was no relevant medical
history
2. Dental history:
Patient had been to a general dentist concerning about
her Irregular upper and lower front teeth. The dentist
has operated root canal treatment for front upper two
teeth and has referred to consult an orthodontist for
further needful appropriate treatment.

2. Chief Complaint
Patient’s father complains of irregular front upper
and lower teeth of his daughter.

3. Case summary
A 14 years female presented with a class II incisal relationship on a skletal class II
base complicated by an increase overjet of 6mm, narrow upper arch, diminitive upper
lateral incisors, moderate crowding in upper and lower anteriors.

4. Extra oral examination
• Facial Type : Mesocephalic
• Anteroposterior : Skeletal Class II
• Vertical : Average
• Transverse : Symmetrical face
• Incisal Display
At smile : Average (7-8mm)
At Rest : 4mm
Soft Tissue
• NLA : Average
• Lips : Potentially
Competent
• Mentolabial sulcus : Shallow
• Funtional examintion : NAD

5. …. …
…

6. Intra Oral Examination
• Oral Hygiene : Good
• Dental Health : Root canal Treated teeth UR1, UL1,
(Restorations/Caries) Restoration s in LL4, LL5,LL6,LL7,LR5,LR6
• Occlusion:
Incisor relationship : Class II division 1
Overjet : 6mm
Overbite : 50%
Molar Relation : Class II molar relationship bilaterally.
Canine Realtionship : Class II ½ unit bilaterally
• Lower Arch : Moderate crowding, both mandibular canines
are disto – angular. LR2 Lingually displaced
• Upper Arch : Severe Crowding with proclined maxillary central incisors
High labially placed right canine.
7654321 1234567
7654321 1234567
• Teeth Present

7. 1. UR1,UL1 Root canal treated and diminutive UL2 and UR2.
2. Evidence of normal developing crowns of LR8,LL8,UL8 but no evidence of UR8
Panorama

8. Lateral cephalometry
 Pre treatment

9. Cephalometric analysis
1- Skeletal: Anteroposterior :
SNA : 82 ± 3 88
SNB : 79 ± 3 83
ANB (E) : 3 ± 1 5
Wits appraisal : 0mm 3
Vertical :
MMPA : 27 ± 5 30
SN to Max. : 8 ± 3 9
Upper ant FH : 56.8 ± 3.7mm 54
Lower ant FH : 82.8 ± 5.6mm 65
Face height ratio : 55% ± 5 54.5%
2- Dental
U.I. to Mx. Plane angle : 108 ± 5 126
L.I.to Md. plane angle : 92 ± 5 105
Interincisal angle : 133 ± 10 100
3-Soft tissue
Nasolabial angle : 102 ± 8 90
Lower lip to E line : -2 mm -2

10. Cephalometric interpretation
Skeletal :
Anteroposterior
ANB measured at 5 degrees which indicates that the case is class Il skeletal
pattern
Vertically
The skeletal measurement in vertical shows average value.
Dental:
 UI. To maxillary plane angle measured at 126 degree indicates
that the upper incisors are proclined.
 LI. To mandibular plane is 105 degree which indicates proclined teeth.
 Interincisal angle is measured at 100 degrees which indicates
bimaxillary proclination.
Soft tissue :
 Nasolabial angle measured at 90 degree indicated protrusive lip.

11. Cast analysis
 The patient has 4.33mm crowding in the upper and 4.33mm in the lower arch
 Average curve of spee.
 Over jet 6mm.
 Over bite is 50 %
 Bolton ratio of the anterior teeth is :
𝑶𝒗𝒆𝒓𝒂𝒍𝒍 𝒓𝒂𝒕𝒊𝒐 =
𝟗𝟎. 𝟕𝟐
𝟗𝟓. 𝟖𝟓
𝒙 𝟏𝟎𝟎 = 𝟗𝟒. 𝟔𝟒
𝑨𝒏𝒕𝒆𝒓𝒊𝒐𝒓 𝒓𝒂𝒕𝒊𝒐 =
𝟑𝟕. 𝟖
𝟒𝟓
𝒙 𝟏𝟎𝟎 = 𝟖𝟒
So there is 3.06 mm excess tooth material in the lower arch
Rt6 Rt5 Rt4 Rt3 Rt2 Rt1 Lt1 Lt2 Lt3 Lt4 Lt5 Lt6
Up 10.8 7.14 7.5 8 5.6 8.8 8.8 5.8 8 7.5 7.11 10.8
Lo 11.86 7.5 7.10 7.30 6 5.6 5.6 6 7.30 7.10 7.5 11.86

12. Space analysis
lower upper
Crowding /
spacing
-4.33mm -4.33mm
Leveling
occlusal
curve
mm mm
Arch width
change
+0.5mm +2mm
Incisor A/P
change
-9mm -8mm
Angulation /
inclination
-2mm -3mm
total -14.83 mm -13.33 mm
Space requirement
Lower Upper
Slicing mm mm
extraction 14.20mm 15mm
Mesialization
of posterior
mm mm
Residue 0.63mm 1.67 mm
Space creation

13. Problems list
• Occlusion:
Incisor relationship : Class II division 1
Overjet : 6mm
Overbite : 50%
Molar Relation : Class II molar relationship bilaterally.
Canine Realtionship : Class II ½ unit bilaterally
• Lower Arch : Moderate crowding, both mandibular canines
are disto – angular. LR2 Lingually displaced
• Upper Arch : Severe Crowding with proclined maxillary central incisors
High labially placed right canine.

14. Treatment objectives
• Correction of proclined upper and lower anteriors.
• Space creation for correction of upper and lower arch crowding through all 4’s extraction.
• Space distribution in upper anteriors for ideal tooth width (Golden proportion).
• Correction of transverse width in upper arch through expansion.
• Correction of overbite

15. Treatment plan
 Anchorage :
1. Maximum anchorage in upper arch through IZM TAD OR Cervical Headgear.
2. Bonding of upper and lower second molars
3. Maximum anchorage in lower arch through TAD in Buccal shelf
 Extraction
1.Extraction of all 4’s
 Appliance Design:
1. Weldable RME
2. 0.022 SLOT MBT Brackets.
3. Buccal tubes triple convertible on upper first molar and double convertible on lower first molar and
non covertibale single buccal tubes on all second molars.
4. Arch wire : 0.014, 0.016, 17*25 , 19*25 (HANT ARCH WIRE) for level and alignment ,19*25(SS)
key loop arch wire (SS), 16*16(SS) finishing,