l k. invisalign 2 yh
DESCRIPTION
Treatment of a young female patient wit a combination of Invisalign and distalizing appliance. Well treated by one of our students under my supervision. Please commentTRANSCRIPT
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!