neethu jose / orthodontic courses by indian dental academy
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INDIAN DENTAL ACADEMY
Leader in continuing dental education www.indiandentalacademy.com
• Name : Neethu jose
• Age : 19yrs
• Sex : Female
• Address : Narayana college , Nellore.• Occupation : student
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HISTORY
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Chief complaint :
Patient complaints of forwardly placed front teeth in upper and lower arches.
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Pre-natal history
• Informer :Patient
• Condition of the mother : Normal
• Delivery : Full term
• Type : Normal
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Post-natal history
• Type of feeding : Breast feeding
• Milestones of development : Normal
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Childhood diseases
• Not reported
Habits
• Tongue thrusting
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Familial Malocclusion History Siblings : NRH Parents : NRH
General history Reasons for taking orthodontic treatment :Esthetics Attitude of the patient towards treatment: Positive
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Clinical examination record
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Physical status
• Build : Mesomorphic• Height : 150 cms (5’ )• Weight : 51 kgs• Gait : Normal• Posture : Normal• Body type : Atheletic
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EXTRA ORAL EXAMINATION
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• Shape of the head : Dolicocephalic
• Facial form : leptoprosopic
• Facial profile : Convex
• Facial Divergence : Posterior
• Clinical FMA : high angle
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RULE OF FIFTH:-Symmetrical face
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Vertical facial evaluation:- symmetrical face
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Convex Profile average nasiolabial angle
shallow mentolabial sulcus
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• 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
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Functional examination
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• 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)
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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
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INTRA ORAL EXAMINATION
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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
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Hard tissue examination • Number of teeth present : 87654321 12345678 87654321 12345678
• Impacted teeth :
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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
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• U shaped arch
• Symmetrical
• mild crowding of anteriors
• square shaped arch
• ASymmetrical
• crowding and proclination of anteriors.
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Over jet - 4 mm
Overbite - 2 mm
Mid line coinciding
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TMJRt & Lt condyle appears normalRt & Lt articular eminence appears normal
NO. of teeth present
87654321 12345678
87654321
12345678
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CEPHALOMETRIC ANALYSIS
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CVMI
completion STAGE: growth completed.
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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
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7º
30º
1 mm17º
5.25 mm
STEINERS ACCEPTABLE COMPRAMISE
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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
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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
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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
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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
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WITS APPRAISAL
AO ahead of BO by 7 mm ( Class – II Skeletal pattern)
BO
AO
OP
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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
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Composite analysis
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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
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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 *
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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
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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
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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)
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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
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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
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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
*
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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
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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
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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
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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 *
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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
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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 *
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COGS
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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
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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
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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
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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
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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
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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
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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)
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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
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• 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.
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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
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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
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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
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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.
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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
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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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