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
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ORTHODONTIC CASEPRESENTATION
L KDMD IV
Date: April 8th, 2012
Treatment Completed
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PRE-TREATMENT
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Initial Patient Presentation
Age: 16 years old
Sex: female
C.C. “ I want my lower 4 teeth fixed”
Pre-treatment
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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
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Extra Oral Examination
Facial Type:Normocephalic
Facial Proprtions: UFH = LFH
Facial Symmetry:Symmetrical
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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
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Neuromuscular and TMJ Examination
Tongue at rest:WNL
Swallowing pattern:WNL
Muscles of mastication:WNL
TMJ:Normal articulationNormal range of motionNormal muscles of mastication
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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
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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
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Intra Oral Examination
40-50 % Overbite
Pre-treatment
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Intra Oral Examination
Right: 4 mm Left:2 mm
Overjet
Pre-treatment
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Intra Oral Examination Teeth present: 17 to 27 and 37 to 47
Arch ShapeUpper: Lower:
Normal Normal
Pre-treatment
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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
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Intra Oral ExaminationIntra Oral Examination Amount of Crowding
Upper: Lower:
Amount of Crowding
Upper: Lower:
Moderate Mild-Moderate
Pre-treatment
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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
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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
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Dental Cast Analysis
Normal Curve of Spee For Maxilla Moderate Curve of Spee for
MandiblePre-treatment
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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
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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
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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
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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
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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
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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)
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TREATMENT OPTIONS
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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
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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
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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
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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
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MID-TREATMENT No mid-treatment phase: patient completed
treatment plan by orthodontist and Invisalign
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POST-TREATMENT
Total treatment time: 1 year, 5 months
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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
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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
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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
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Intra Oral Examination
15 % Overbite
Post-treatment
40-50 % Overbite
Pre-treatment
Post-treatment
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Intra Oral Examination
Right: 1 mm Left: 1 mm
Overjet
Post-treatment
Right: 4 mm Left: 2 mm
Pre-treatment
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Intra Oral Examination Arch Shape
NormalPost-treatment
NormalNormal
NormalPre-treatment
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Intra Oral Examination Crowding
NormalPost-treatment
NormalModerate
Mild-ModeratePre-treatment
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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
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Panoramic Radiographic Analysis
Permanent Dentition: Symmetric mandible; 8’s unerupted
Normal condylar and skeletal architecturePost-treatment
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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
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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
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Dental Cast Analysis
Normal Curve of Spee
Post-treatment
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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
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Tooth Positioning
Abnormal tip: 12, 13, 14, 22
Abnormal torque: 12, 13
Rotation (molar): 46 (distally – mild)
Post-treatment
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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
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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
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Maintained Findings
Slight convex profile Class I molars and canines (right & left) Vertical growth pattern tendency Increased lower face height
Post-treatment
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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
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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
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Thank you!