L k. invisalign 2 yh

ORTHODONTIC CASEPRESENTATION

L KDMD IV

Date: April 8th, 2012

Treatment Completed

PRE-TREATMENT

Initial Patient Presentation

Age: 16 years old

Sex: female

C.C. “ I want my lower 4 teeth fixed”

Pre-treatment

Patient History

Past medical history: NSF

Medications: None

Allergies: NKDA

Past dental history: Last seen dentist 9m ago for exam and cleaning (referred by family dentist)

Brushes 2x/day and flosses 2x/week

Oral hygiene: Fair (moderate plaque and calculus accumulation

Extra Oral Examination

Facial Type:Normocephalic

Facial Proprtions: UFH = LFH

Facial Symmetry:Symmetrical

Extra Oral Examination

Facial Profile:Slightly convex

Nasolabial angle:Slightly obtuse

Lips:Upper lip length is normalLips normal at restNo upper incisors showing

at rest

Neuromuscular and TMJ Examination

Tongue at rest:WNL

Swallowing pattern:WNL

Muscles of mastication:WNL

TMJ:Normal articulationNormal range of motionNormal muscles of mastication

Extra Oral Intra Oral Examination

Facial Symmetry Upper midline:No deviation Upper dental midline:No deviation Lower midline:No deviation Lower dental midline:Deviated 3 mm to the right

Pre-treatment

Occlusion

Right Side Dental Midline Left SideMolar class I Upper: no deviation Molar

class ICanine class I Lower: 3mm to right Canine

class I

Pre-treatment

Intra Oral Examination

40-50 % Overbite

Pre-treatment

Intra Oral Examination

Right: 4 mm Left:2 mm

Overjet

Pre-treatment

Intra Oral Examination Teeth present: 17 to 27 and 37 to 47

Arch ShapeUpper: Lower:

Normal Normal

Pre-treatment

Intra Oral Examination

Soft Tissue Assessment Fair oral hygiene

Periodontal Status PSR II; moderate gingivitis Adequate attached gingiva

Anterior crossbite: 1.2&4.2

Rotations 1.3 & 4.3

Pre-treatment

Intra Oral ExaminationIntra Oral Examination Amount of Crowding

Upper: Lower:

Amount of Crowding

Upper: Lower:

Moderate Mild-Moderate

Pre-treatment

Panoramic Radiographic Analysis

Clinical Findings:- All permanent dentition except for third molars are erupted- Rotations 2.3, 3.3, 4.3 - Normal condylar and ramus architecture

Pre-treatment

Cephalometric AnalysisMeasurement Value Normal SD

SKELETAL

SNA 86 81º 3

SNB 80.5 78 3

ANB 5.5 3 2

Facial Angle 91.2 88 4

Witts -0.8 2 2

Mand. Plane Angle 30 33 3

Y axis 62 60 4DENTO-ALVEOLAR

Upper inc. to NA 18 23 6

Lower inc. to NB 27 27.5 5

Upper inc./Lower inc

129.4 130 7

Lower Inc. to Mand. Plane

98 91.4 4

Pre-treatment

Dental Cast Analysis

Normal Curve of Spee For Maxilla Moderate Curve of Spee for

MandiblePre-treatment

Dental Cast Analysis

Molar rotation: 16, 26, 36, 46 - normal

Angle Classification:

Right: Class I molar, Class I canine

Left: Class I molar, Class I canine

Overbite 40-50 %

Overjet 4 mm (right), 2 mm (left)

Pre-treatment

Tooth Positioning

Abnormal tip: 11 & 12(mesial), 21&22 (mesial) Abnormal torque:

Labial: 22, 42Lingual: 12, 11, 21, 32 ,31 ,41, 43

Rotation: 11 mesial, 12 mesial, 21 mesial, 22 mesial, 32 distal, 33 distal, 35 mesial, 36 mesial, 43 distal, 45 mesial

Pre-treatment

Bolton Analysis

∑UA = 49.5 mm∑LA = 37.1 mm ∑LA / ∑UA = 37.1/49.5 = 74.9%

(norm=77%)

Tooth Upper right

Upper left Ideal

Central I 9.1 9.3 8.85

Lateral I 7.4 7.4 6.9

Canine 8.2 8.1 7.88Tooth Lower

rightLower left Ideal

Central I 5.4 5.3 5.5

Lateral I 6.3 6.3 6

Canine 6.9 6.9 6.95

Pre-treatment

Summary of Findings DENTAL:

Position of the upper incisor in the relation to the maxilla (18, N = 23 ± 6): upper incisors slightly retroclined

Position of the lower incisor in relation to the mandible (27, N = 27.5 ± 5): normal

Lower incisor to the mandibular plane (98, N = 91.4 ± 4) : slightly proclined in relation to mandibular plane

Interincisal angle (129.4, N =130 ± 7): normal

SKELETAL: Position of the maxilla in relation to the cranial base (SNA = 86, N = 81± 3): slightly

prognathic maxilla

Position of the mandible on relation to the cranial base (SNB = 80.5, N = 78 ± 3): normal

Relationship of the mandible and maxilla (ANB = 5.5, N = 3± 2): normal (CI skeletal pattern)

(Witts -0.8, 2± 2): normal (CI / slight C3 skeletal pattern)

Facial angle = 91.2, N = 88 ± 4: normal, slight vertical growth pattern

Mandibular plane angle (30, N = 33 ± 3): normal

Y axis (62, N = 60 ±4): normal growth pattern

Pre-treatment

Relevant Diagnostic Findings

Class I, type I malocclusion Very slight convex profile Crossbite (1.2 / 4.2) 40-50 % overbite 4mm (R) and 2mm (L) overjet Crowding in the anterior permanent

teeth in both dental arches Dento-alveolar / tooth mass discrepancy Several rotated teeth

Lower dental midline shifted 3 mm to the right

Pre-treatment

Ideal Treatment Objectives

Maintain Class I occlusion Alleviate crowding Align anterior teeth Correct deviated dental midline Maintain overbite and overjet Preserve facial profile Address patient’s chief complaint and

satisfy patient expectations (realistically)

TREATMENT OPTIONS

Invisalign on both arches- align/coordinate upper and lower arches- relieve anterior crossbite (Q1 / 4)- de-rotate teeth with the use of attachment buttons

Interproximal stripping - aid in creating space and relieving the crowding present - shift the lower anteriors towards the left correcting

dental midline shift

Compromised Treatment Option #1

Compromised Treatment Option #2

NiTi archwire upper arch 2x4 only - align/coordinate upper and lower arches

and midlines - de-rotate and align teeth

Interproximal stripping - correct the moderate crowding present - shift the lower anteriors towards the left correcting dental midline shift

Extraction of upper and lower first premolars

Complete bracketing of the upper arch and lower arch- relieve crowding- de-rotate and align teeth- coordinate upper and lower

arches/midlines

Ideal Treatment Option

Treatment Done

Patient did not want upper and lower bracketing

Complete bracketing is not done at the McGill Undergraduate Dental Clinic

Selected:“Compromised Treatment Option #1”Invisalign with interproximal reduction

- align teeth and both arches / midlines - relieve anterior crossbite

MID-TREATMENT No mid-treatment phase: patient completed

treatment plan by orthodontist and Invisalign

POST-TREATMENT

Total treatment time: 1 year, 5 months

Patient Presentation

Age: 18 years old

Sex: female

Post-Tx perspective:Patient is very happy withtreatment results. - However, there are a few things that she would like to modify (later).

Post-treatment

Extra Oral Examination

Facial Profile:Slightly convex

Lips:Upper lip normalLips normal at restNo upper incisors show

at rest

Nasolabial angle: Slightly

obtuse

No change from pre-treatment

Occlusion

Right Side Dental Midline Left SideMolar class I Upper: no deviation Molar

class ICanine class I Lower: no deviation Canine

class I

Post-treatment

Intra Oral Examination

15 % Overbite

Post-treatment

40-50 % Overbite

Pre-treatment

Post-treatment

Intra Oral Examination

Right: 1 mm Left: 1 mm

Overjet

Post-treatment

Right: 4 mm Left: 2 mm

Pre-treatment

Intra Oral Examination Arch Shape

NormalPost-treatment

NormalNormal

NormalPre-treatment

Intra Oral Examination Crowding

NormalPost-treatment

NormalModerate

Mild-ModeratePre-treatment

Modified Findings

Crossbite fixed (1.2 / 4.2) Crowding alleviated in both arches (due

to rotated and misaligned teeth) Dental midline corrected (only 0.5mm

deviation to the right) Overbite slightly reduced (only 15%) Overjet evened out to 1mm right and left

Post-treatment

Panoramic Radiographic Analysis

Permanent Dentition: Symmetric mandible; 8’s unerupted

Normal condylar and skeletal architecturePost-treatment

Cephalometric AnalysisMeasurement Value Normal SD

SKELETAL

SNA 87 81º 3

SNB 83 78 3

ANB 4 3 2

Facial Angle 87 88 4

Witts 1 2 2

Mand. Plane Angle 30 33 3

Y axis 64 60 4DENTO-ALVEOLAR

Upper inc. to NA 22 23 6

Lower inc. to NB 26 27.5 5

Upper inc./Lower inc

127 130 7

Lower Inc. to Mand. Plane

94 91.4 4

Post-treatment

Cephalometric changes

Measurement Value Normal SD

SKELETAL

SNA 87 81º 3

SNB 83 78 3

ANB 4 3 2

Facial Angle 87 88 4

Witts 1 2 2

Mand. Plane Angle 32 33 3

Y axis 64 60 4

DENTO-ALVEOLAR

Upper inc. to NA 22 23 6

Lower inc. to NB 26 27.5 5

Upper inc./Lower inc 127 130 7

Lower Inc. to Mand. Plane 94 91.4 4

Measurement Value Normal SD

SKELETAL

SNA 86 81º 3

SNB 80.5 78 3

ANB 5.5 3 2

Facial Angle 91.2 88 4

Witts -0.8 2 2

Mand. Plane Angle 30 33 3

Y axis 62 60 4

DENTO-ALVEOLAR

Upper inc. to NA 18 23 6

Lower inc. to NB 27 27.5 5

Upper inc./Lower inc 129.4 130 7

Lower Inc. to Mand. Plane 98 91.4 4

Pre-treatment Post-treatment

Dental Cast Analysis

Normal Curve of Spee

Post-treatment

Dental Cast Analysis

Molar rotation: 16 (normal), 26 (normal)

36 (normal), 46 (distally - mild)

Angle Classification:

Right: Class I molar, class I canine

Left: Class I molar, class I canine

Overbite 15 %

Overjet 1 mm (right), 1 mm (left)

Post-treatment

Tooth Positioning

Abnormal tip: 12, 13, 14, 22

Abnormal torque: 12, 13

Rotation (molar): 46 (distally – mild)

Post-treatment

Bolton Analysis

∑UA = 47 mm∑LA = 36.1 mm ∑LA / ∑UA = 36.1/47 = 76.8%

(norm=77%)

Tooth Upper right

Upper left Ideal

Central I 8.7 8.8 8.85

Lateral I 7.0 7.1 6.9

Canine 7.6 7.8 7.88Tooth Lower

rightLower left Ideal

Central I 5.3 5.3 5.5

Lateral I 5.9 6.0 6

Canine 6.8 6.8 6.95

Post-treatment

Summary of Findings DENTAL:

Position of the upper incisor in the relation to the maxilla (22, N = 23 ± 6): normal

Position of the lower incisor in relation to the mandible (26, N = 27.5 ± 5): normal

Lower incisor to the mandibular plane (94, N = 91.4 ± 4) : normal

Interincisal angle (127, N =130 ± 7): normal

SKELETAL: Position of the maxilla in relation to the cranial base (SNA = 87, N = 81± 3): slightly

prognathic maxilla

Position of the mandible on relation to the cranial base (SNB = 83, N = 78 ± 3): slightly prognathic mandible

Relationship of the mandible and maxilla (ANB = 4, N = 3± 2): normal (CI skeletal pattern)

(Witts 1, 2± 2): normal (CI skeletal pattern)

Facial angle = 87, N = 88 ± 4: normal

Mandibular plane angle (32, N = 33 ± 3): normal

Y axis (64, N = 60 ±4): normal / slight vertical growth pattern tendency Post-treatment

Maintained Findings

Slight convex profile Class I molars and canines (right & left) Vertical growth pattern tendency Increased lower face height

Post-treatment

Post-Treatment Concerns

Patient is not satisfied with appearance of teeth 1.2 and 1.3 (slightly rotated and lingually inclined)

She also feels that her 2 upper central incisors look “big”.

Post-treatment

Post-Treatment Concerns

Invisalign Refinement Trays New Invisalgn impressions, Jetbite registration, photos,

Panorex and Cephalometric radiographs were taken

Special instructions sent for tray fabrication: 1.2: labial root torque, rotation of mesial contact point into

proper contact, extrusion of 1mm; possibly IPR 1.3: labial root torque, extrusion 2.2: rotation of contact point mesially Refine 1st and 2nd premolars into occlusion Possible re-alignment of dental midlines (at present, 0.5mm

to the right)

Post-treatment

Thank you!