Diagnosis and Treatment Plan

Diagnosis and Treatment Plan

For

Sharon Blake

By

Yosemite Dental Group

333 top of the mountain Dr.

Yosemite, CA

640-333-4534

January 8, 2005

Initial Appearance

Characteristics of the Malocclusion

Upon the initial clinical evaluation the following characteristics were noted.

Dental Evaluation

Female age 33 with a permanent dentition and a Class II Division 1 malocclusion. The right side has a Class II molar of 4 mm., and a Class II cuspid of 5 mm. The left side has a Class I molar of 0 mm., and a Class I cuspid of 0 mm. Dental Crowding was estimated at 4 mm. in the lower arch and 2 mm. of Crowding in the upper arch.

The vertical dimension is dental Average. The transverse dimension of the dental arches showed the presence of unilateral anterior crossbite and posterior crossbite. The supporting structures of the teeth had no obvious problems. The missing teeth noticed at the clinical examination are the 18,28,38,48.

Additional features included a Flat curve of spee, Ovoid archform, and well formed upper incisors. The mandible seated in the fossa with a functional shift to the right.

Facial Survey

The patient has a mesofacial facial pattern, with a Straight profile. The upper midline is centered relative to the facial midline. The lips are Thin, the sublabial fold average, and the naso-labial angle is 90° - 110°. The upper incisor shows 1 mm. of tooth below the resting upper lip, with -2 mm. of gingival display upon the highest smile given at the evaluation.

Myofunctional Evaluation

The lip competency was Adequate, with lip tonicity being Normal. Breathing was observed to be Nasal. The dental bite was open with a negative anterior overjet.

Temporo-mandibular Joint Evaluation

On the right side Early clicking was noted. The patient reported, fullness in the right ear, ringing in the right ear, pain in the right ear. Upon opening the jaw deviated to the Right with a maximum opening of 24 mm. The patient reported having 7 headaches per week.

Conclusions Following the Initial Evaluation

A verbal discussion was held, at which time several treatments were considered possible, including Non-Extraction, and bicuspid Extraction. The estimated time of treatment was 18-24 months, with an estimated fee of $4500-5500.

The findings at the clinical examination were consistent with the patients’ chief complaint of TMJ Symptoms. When asked about the perception of protrusion, the patient’s opinion was: Acceptable Now, Can Move the Teeth Forward

It is estimated that the front teeth will Advance 3.25 mm. if a non-extraction treatment is chosen.

Other Notes

The patient is a Television reporter and is concerned about the appearance of orthodontic appliances on camera

Cephalometric Numbers and Conclusions

Skeletal Summary

The Skeletal vertical dimension is Average with a dental Average bite. At the time of initial evaluation, growth was completed for this adult patient. The maxilla is positioned in Retruded position, and the mandible is Average. The relationship of the upper and lower jaws is Class III based on evaluation of the ANB and Wits measurements.

Dental Summary

The lower incisors are Average with the antero-posterior position being Average. The upper incisors are Proclined with the antero-posterior position being Average. Based on the cephalometric evaluation, the initial clinical impressions, and the patients’ feelings about the position of their teeth, a treatment objective has been decided to leave the incisors near the starting position.

Description - Relationship / Measurement / Range / Mean / Patient Measurement
Palatal Plane to Mandibular Plane:
Skeletal Open/Closed / ANS - PNS to Mand. Plane / 24 (Closed) to 33 (Open) / 28 / 28.7
Mand Plane Angle
Skeletal Open/Closed / 9 yr FMA / Adult FMA / 20(Closed) to 30(Open)
18(Closed) to 28(Open) / 26° / 27.7
Y-Axis - Vert/Hor Growth / SGN - FH / 57 (Horizontal) to 62 (Vertical) / 59 / 57.8
Maxilla to Cranium: N Perpendicular Reference to A / N Perpendicular A Point / -1 (Retruded) to +3 (Protruded) / +1mm / -1.6
Maxilla to Cranium / SNA / 76 (Retruded) to 83 (Protruded) / 81° / 74.8
Mandible to Cranium:
N Perpendicular Reference to Pogonion / N Perpendicular Po / -10 (Retruded) to -4 (Protruded)
-4 (Retruded) to 1 (Protruded) / 9yr - 7mm
Adult - 1mm / -3.5
Mandible to Cranium / SNB / 75 (Retruded) to 83 (Protruded) / 80° / 73.1
Maxilla to Mandible / ANB / CI +2 to +4.5
CIII tendency 0.5 to 1.5 / 2° / 1.7
Wits / A, B Perpendicular Occlusal Plane / Class I -1 to +2 / 0 / 0.5
Interincisal Angle / Upper 1 to Lower 1 / Best Finish 125 to 130 / 130° / 121
Lower Incisor Inclination / Lower 1 to MP / 89 (Retroclined) to 98 (Proclined) / 92° / 89.9
Lower Incisor Protrusion / Lower 1 to NB / +1 (Retruded) to +6 (Protruded) / +4mm / 4.7
Lower Incisor Protrusion / Lower 1 to APo / 0 (Retruded) to +4 (Protruded) / +2mm / 2.6
Upper Incisor Inclination / Upper 1 to SN / 99 (Retroclined) to 106 (Proclined) / 103° / 107.6
Upper Incisor Protrusion / Upper 1 to APo / +2 (Retruded) to +7 (Protruded) / 5mm / 6.6
Upper Incisor Protrusion / Upper 1 to A Vertical
(to FH) / +2 (Retruded) to +6 (Protruded) / 4mm / 5.9
Naso Labial Angle / 90 to 110 / 100° / 117
Soft Tissue Line (E Plane) Upper / +1 to -4 / -2mm / -6.9
Soft Tissue Line (E Plane) Lower / +1 to -4 / -2mm / -4.4

Individual Appliance Ò Design

A personalized appliance has been designed by Dr. McGann for the treatment of Sharon Blake after considering the characteristics of the malocclusion, the final desired aesthetics, the long-term retention, and the unwanted tooth movements from force application. This appliance includes selection of brackets, bands, and archwires with a custom prescription to obtain the most optimal treatment results.

Tooth # / Description / Bracket/Band / Height,mm / Instructions / Band Size / Qty. / Notes
18 / Missing / 0
17 / 17R2 / 4 / 1
16 / 16R2sh / 12 / 1
15 / Mesial / 15MCer / 4.0 / 1
14 / Distal / 14DCer / 4.0 / 1
13 / Distal / 13DCer / 4.5 / 1
12 / Distal / 12DCer / 3.5 / 1
11 / Distal / 11DCer / 4.0 / 1
21 / Distal / 21DCer / 4.0 / 1
22 / Distal / 22DCer / 3.5 / 1
23 / Distal / 23DCer / 4.5 / 1
24 / Mesial / 24MCer / 4.0 / 1
25 / Mesial / 25MCer / 4.0 / 1
26 / 26R2sh / 12 / 1
27 / 27R2 / 5 / 1
28 / Missing / 0
38 / Missing / 0
37 / 37R2 / 5 / 1
36 / 36R2 / 11 / 1
35 / Mesial / 35M / 4.0 / 1
34 / Mesial / 34M / 4.0 / 1
33 / Distal / 33D / 4.5 / 1
32 / Distal / 32DLa / 4.0 / 1
31 / Mesial / 31MLa / 4.0 / 1
41 / 41La / 4.0 / 1
42 / Distal / 42DLa / 4.0 / 1
43 / Distal / 43D / 4.5 / 1
44 / 44R / 4.0 / 1
45 / Distal / 45D / 4.0 / 1
46 / 46R2 / 11 / 1
47 / 47R2 / 5 / 1
48 / Missing / 0

Archwire selection

The lower archform was selected to maintain the ovoid-medium dental archform. The upper archform was selected to expand the dental arche, and was chosen to be ovoid, non-extract #2.

Treatment Design

Goals

- Improve TM Joint Symptoms

- Posterior Crossbite Corrections

- Straighten Teeth

- Class II Correction And Associated Overjet

Limitations

- Right lateral functional shift of Mandible

- Crossbite: Posterior

- Crossbite: Anterior

- Crossbite: Unilateral

- Missing Teeth - Upper Right 8

- Missing Teeth - Upper Left 8

- Missing Teeth - Lower Left 8

- Missing Teeth - Lower Right 8

- Temporomandibular Dysfunction-Clicking-Right: Early

- Temporomandibular Dysfunction-Fullness in the Right Ear

- Temporomandibular Dysfunction-Ringing in the Right Ear

- Temporomandibular Dysfunction-Pain in the Right Ear

- Temporomandibular Dysfunction- Headache Frequency per week 7

May not be able to correct

- Class II Without Patient Cooperation

- TMD symptoms may not be reversible

- Adult crossbite without surgery

Treatment Alternatives Considered

- 031. Limit lower incisor advancement, one wire technique

- 067. Skeletal open bite, leave the incisor near the starting position. Class II 4mm or less

Treatment Decision

- 141. TMD Case

- 032. Limit lower incisor advancement, standard wire progression

Additional Notes

Surgical correction of the posterior crossbite may be needed due to the age of the patient. This will be determined after an attempt at non surgical maxillary expansion is made.

Treatment Plan

32. Non-extraction, limit lower incisor advancement, standard wire progression

Incisor torque: R/La. Labial lower torque to prevent incisor advancement

cuspid torque: R/R

Molar buccal tubes: 16/26R2sh. Lingual sheaths for TPA crossbite correction. 36/46CIIE2 to compensate for expected class II elastics. Band 7s to control open bite and transverse

archwires: expand upper, maintain lower.

rotations: see IP tab

positioning: Average 0%

Summary:

1. align on 012nitie for 2 months, then 18x25N heat activated to establish incisor torque, archform, and finish alignment.

2. Reposition brackets

3. Change to 19x25ss upper and lower. Stripping at a wire change. Check for arch coordination

4. class II elastics as needed

5. Finishing

In this plan, we are usually working on a growing patient. The class II will be corrected without the use of class II elastics that would be detrimental to lower incisor advancement. Headgear or functional appliances may be used for this purpose, with headgear the most common appliance used in the POS system. The headgear is delivered early in the treatment to allow for class II correction by growth restraint and some dental distalization while the alignment and wire progression stages are taking place. In skeletal class II cases, 24 oz headgear will be used. In skeletal class I cases, 12 oz headgear force will be used. Cervical headgear is the most effective in correcting class II, so we will use this appliance most commonly in these types of cases, even in the presence of skeletal open bite.

IP Appliance TM Design:

1. Choose brackets for the lower incisors with added labial root torque (lingual crown torque) to prevent the crowns from moving forward. 32La, 31La, 41La, 42 La (or combinations if rotations).

2. Select IP rotation brackets consistent with the archwire selected, standard Roth on all teeth that are aligned from the start.

3. Add headgear tubes to the upper molars, so this appliance can be used during the alignment and wire progression stage. (16Rhg, 26Rhg)

4. Expanded archwire: when selecting an archwire size, consider one with expansion for the purpose of limiting lower incisor advancement. Be watching for under-expansion of the lower arch, causing premature contact of the incisors. Class II elastics, headgear, and other appliances will be ineffective with the premature incisor contact. The upper arch will appear to be over-expanded, where the lower arch is under-expanded due to buccal cortical bone resistance. Constrict the upper arch to recover.

Mechanics for standard wire progression:

1. align on 012N or 014N. Use 18x25N heat activated as the second archwire if brackets with added Lingual (Li) or Labial (La) torque are present. If starting with 016N, be certain to use the proper IP archwire shape and size. Cervical headgear is added at the second month of treatment, or after the patient has adjusted to the fixed appliances. Use 12 oz in skeletal class I cases and 24 oz in skeletal class II cases. The headgear wear time should be at least 10-14 hours per day.

2. Bracket position evaluation: Evaluate bracket position with a progress study model, and panoramic x-ray. Reposition brackets as needed, and reinsert the nickel titanium alignment archwire to gain full alignment.

3. Wire progression to 19x25 ss upper and lower. Stripping of enamel may be done at wire change appointments (stripping is only allowed when the teeth are straight) to limit the incisor advancement. Watch for the under-expansion of the lower arch relative to the upper arch due to the use of expanded archwires. Class II elastics and headgear will be ineffective in the presence of incisor protrusive interference. Constrict the upper archwire with a hollow chop plier to recover needed overjet when arch coordination is the problem.

4. Reevaluate for inter-arch elastics. If headgear cooperation has been poor or resistance to correction of the class II has been encountered, then class II elastics will be necessary to complete the correction to class I (at the expense of lower incisor advancement). The class II elastics are used from the lower molars to upper cuspids to reduce upper anchorage. If significant correction must be made, then spaces may develop between upper 3-2. In this situation, T loops with cinchback activation should be used to close these spaces following class I cuspid being attained. Common mistake is to use power chain to close these spaces, which will result in upper molar advancement to class II due to the excess force needed to overcome friction and detorquing of the upper incisor against the lower incisors (especially true when chain is used on round wire). Bite opening increases the amount of class II dental, so class II elastics should be used with caution in skeletal open bite cases. Extraction treatment should have been considered in most skeletal open bite cases with class II and crowding for the purpose to keep the bite closed.

5. Finish in 018ss. Round wire finishing allows for the muscles to help seat the occlusion. Ligature wire lace all finishing wires to avoid spaces from opening. Vertical elastics (rabbits) may also be used to help seat the occlusion, especially in skeletal open bite cases that have weaker muscle patterns. The vertical elastics may have a short class II component. Consider fiberotomy and stripping for those teeth with moderate to severe rotations to start.