Done by : Dr. Lubna Mohammad Abu Alrub

Name: M.A Age: 19 yearsOccupation: StudentMarital status: Single Residence: AmmanNationality: Jordanian

Medical History: Medically fit

Dental History: Routine dental work

Habits: Non reported

أسناني العلوية طالعة لبرا“

.لثوية-و شكل ابتسامتي مزعج ”

“ My upper teeth are

protruded and I have

a gummy smile “

Anteroposterior:

Class II Skeletal Pattern

Vertical Assessment:

Dolichocephalic head pattern.

increased lower facial height

Transverse:

Mild Asymmetry

No signs of TMD (No clicking, crepitus,

and tenderness to palpation)

Normal range of opening, lateral

movement, and no displacement.

Lip tonicity and competence:

• incompetent lips

• Short upper lip , longer lower

lip .

Profile is markedly

convex with short upper

lip .

Distance from lower lip

to chin is excessive .

Frontonasal angle: 144⁰(Normal 115⁰-135⁰)

Nasolabial angle: 85⁰

(Normal 90⁰-110⁰)

Labiomental angle: 138⁰

(Normal 114⁰-140)

• full crown and upper gingival

show while smiling 5 mm .

•At rest : almost full incisor show

• Smile extends to mesial of

second premolars .

•Narrow buccal corrisors

Commissure height

> philtrum height .

Lip strain on closure

• Buccal corridors: narrow

• The smile arc: Incisal edges

of upper anterior teeth are

not parallel to the upper

border of the lower lip.

• Golden proportion for

maxillary anterior teeth

is 55%

• Height:width of central

incicors

1:1

Gingival level of upper right

lateral 2 mm apical to central ,

and of the left lateral 1 mm

apical , ginigival relationships

and connectors does not folllow

ideal .

• good oral hygiene

• Normal oral mucosa

• Teeth Present in oral cavity (late mixed dentition)

7 6 5 4 3 2 1 1 2 3 4 5 67 8

8 7 6 5 4 3 2 1 1 2 3 4 5 67 8

U-shaped lower arch

Anterior segment:

moderate crowding in anterior

segment

Proclined lower incisors .

Buccal segment:

slight lingual inclination.

U-shaped arch.

Anterior segment:

Upright upper

central incisors

Upper laterals and

incisors are labially

displaced .

deep palatal vault .

Periodontal health:

good oral hygiene.

Carious : none.

Class II div. II incisor relationship

Lower midline shift to right 1 mm .

Overjet = 4mm

Overbite = Deep Complete to the palate atraumatic

Molar relationship: R: Class II L: Class II

Canine relationship: R: Class II 3/4 L: Class II 1/2

Anteroposterior

Canine: Class II 3/4

Molar: Class II full unit

Canine : Class II 1/2

Molar: Class II full unit

Lower midline shifted 1 mm to the right

Vertical O.B= deep bite complete to the palate atraumatic.

Right side: 2 mm Curve of

Spee

Left side: 2 mm Curve of

Spee

Lower incisors are over erupted , occluding palatally to upper

incisors

Upper arch

U shaped arch form

Dental Symmetry

Intermolar width: 41mm

( reduced )

Intercanine width: 32 mm(

normal )

Deep palatal vault

Lower arch

U shaped arch form

Dental asymmetry

Intermolar width 37 mm

( reduced)

Intercanine width 25 mm

(increased)

10789599597710U

654321123456

11877555577811L

Anterior Bolton ratio= 34/46*100%= 73.9%

(normal value: 77.2± 1.65%)

Overall Bolton ratio= 86/95*100%= 90.52%

(normal value: 91.3± 1.91%)

Upper ArchLower Arch

-6 mm-5 mmCrowding/Spacing

--Angulation change

--Leveling curve of

Spee

+.5 mm -Inclination change

--Arch width change

--4 mmIncisors A/P change

Grade 4D

contact point displacement

More than 4 mm .

Grade 7

Variable Pre-

Treatment

Normal value

SNA 80 81 ± 3

SNB 73º 78 ± 3

ANB 7º 3 ± 2

S-N/MX 8º 8 ± 3

ANB* 7.5 -

MMPA 39º 27 ± 3

FMA 38˚ 28 ± 3

LFH 58% 55 ± 2

Jarabak ratio 56% 61± 2

U1/Mx 105º 109 ± 6

L1/Mn 101º 93 ± 6

IIA 102º 133 ± 10

Wits

Appraisal

8 mm 1 ±1.9 F

Cephalometric interpretation :

SNA : Normal

SNB : Reduced : retrognathic mandible

ANB increased : class II skeletal pattern .

MMPA LAFH increased : high angle case

: backward rotation of mandible

Jaraback Ratio : posterior facial height /

anterior facial height reduced : Increase

LAFH , reduced PFH .

Upright maxillary central incisors ,

proclined lower incisors .

All teeth are present including all 8’s

No apparent pathology .

M.A is a 19 year old female , medically fit with routine

past dental history , complains of protruding upper teeth

with gummy smile and compromised smile esthetics.

she has a class II/II incisor relationship based on class II

skeletal pattern, increased lower facial height,

incompetent lips, and a convex facial profile. O.J of 4

mm, deep complete to the palate O.B, moderately

crowded upper and lower arch (localized anteriorly).

Molar relationship is class II on both sides, canine

relationships is class 2 3/4 unit on right side , ½ unit II on

left side, Bolton discrepancy in anterior region , lower

midline shifted to right by 1 mm .

C/C “Protruding upper teeth and gummy smile ”

Skeletal:

A-P :Class II.

Vertical :Vertical maxillary excess and increased LAFH

Soft tissue:

Incompetent lips , short upper lip and long lower lip .

Acute nasolabial angle

Obtuse labiomental, nasofrontal angle

Dental:

moderate crowding in upper and lower arches .

Over erupted lower incisors with deep complete overbite

Overjet 4 mm

Class II molars and ¾ canine right side , ½ unit II left side

Lower midline shifted to right by 1 mm.

Anterior bolton discrepancy

1. Correct skeletal discrepancies ( class II skeletal and maxillary vertical excess)

2. Achieve competent lips

3. Improve facial esthetics

4. Improve smile esthetics by creating smile symmetry and normal gingival

relationships .

5. Relief crowding in upper and lower arches

6. Correct Overjet

7. Correct Overbite

8. Correct canines and molar relationship

9. Correct Bolton discrepancy

10. Correct lower midline shift

11. Finishing and detailing f occlusion

12. Retention

Orthognathic –Orthodontic caseNon -Extraction case

1. Presurgical orthodontic phase Extraction of upper and lower 8s .Upper and lower fixed orthodontic appliance refer to conservative department to build up upper lateral incisors .

3. Surgical phase : maxillary impaction with BSSO of mandible .

4. Post surgical phase : finishing and detailing of occlusion

5. Retention : upper and lower permanent retainers , upper and lower HR

Slot .22 MBT

prescription

Orthognathic :

Profile is class II .

problems are mainly skeletal ; vertical maxillary excess complicated by

Retrognathic position of the mandible .

patients chief complaint ( gummy smile – excess of 4 mm indication

of surgery )

Fixed Appliance

Surgical decompensation to maximize surgical movements.

Alignment of teeth and levelling of teeth.

Bodily movement

Closing extraction spaces , and controlling spaces around upper

permanent lateral incisors before buildup .

Upper and lower arch coordination

Non -extraction

non extraction is our choice in this case

Overjet will be created in the upper arch

after alignment and this will be of benifet to

surgeons to achieve maximum mandibular

advancement

1. Full records2. Seperators3. Band selection and cementation .4. Direct bonding , lowers are over erupted – bond

more incisally and bond uppers more gingival to maximize decompensation.

5. Refer to extract upper and lower 8s at least 6 months before surgery

6. Aligment by superelastic Niti .014 , .018.- lacebackin lower arches .

7. Regtangular Niti 17 *25 8. Working arch wire 19*25 SS .

9. Position laterals more mesial towrd centrals for best esthetics , drop

arch wire for a visit and refer to conservative departments .

10. Stabilizing arch wire 21*25 TMA

11. New records before surgery consisting of new lateral ceh , OPG ,

facial and intraoral photographs and study models ( because

maxillary surgery is planned a face bow transfer to semi adjustable

articulater is preferable)

9. Joint Orthodontic – surgical clinic to discuss final plan.

10. Construction of surgical wafer according to final plan .

11. Refer to surgery

12. Once a range of motion is achieved and the surgeon is satisfied with

initial healing finishing can be started .

9. 2-4 weeks post surgery wires are

replaced with more resilient ones , light

vertical elastics .

10.Elastic regime :

4 weeks full time

4 weeks full time except for eating

4 weeks night time only

16. Finishing 17*25 TMA arch wire

17 . Debond , impression for retainers ,

Metal brackets and .022 slot are best options for surgery

Bracket modification options : +7 on upper canines , +6 on lower canine to avoid deheisenceand retract canines distally into center of alveolus ( MBT philosophy ) .

Second molars should also be banded to limit any interference that would hinder surgical movement

Arch coordination done using study models to ensure no gross transverse discrepancy exists , if expansion is needed it is done by over expanded arch wires .

Mandibular arch should be fully levelled before surgery because the aim is to decrease LAFH , intrusion of over erupted lower incisors should be done in the decompensation phase by auxillary intrusion arch wire , Tads , segmental mechanics ..etc.

The amount of vertical repositioning of the maxilla is critical , take great care during surgery to position the maxilla in the planned position , for optimum esthetics , the maxilla should also be positioned slightly farward.