爱丁堡病例-拔牙参考

THE ROYAL COLLEGE OF SURGEONS OF EDINBURGH

MEMBERSHIP IN ORTHODONTICS

FULL Y DOCUMENTED CASE HISTORY

DATE OF EXAMINATION: Nov 2010

CANDIDATE NUMBER: 109

CASE NUMBER : 2

PATIENT’S INITIALS : C.L.Q.

COLOUR CODE :

CASE SUMMARY

CLQ, a 19-year-old Chinese schoolboy, presented with a Class III malocclusion on a skeletal Class III base. He had increased lower facial height, prominent lower lip, acute naso-labial angle, shallow labiomental fold and incompetent lips. He was in the permanent dentition stage with moderate crowding, crossbite in labial and left buccal segments, both upper and lower midlines shifted left, proclined upper incisors. Patient didn’t consent to surgical approach, so a camouflage treatment approach of extraction was commenced.

SECTION 1. PRE-TREA TMENT ASSESSMENT

PATIENT DETAILS

Initials: C.L.Q.

Sex: Male

Date of birth: 1st Dec 1989

Age at start of treatment: 19 years old

PATIENTS COMPLAINTS

Patient disliked his irregular teeth.

RELEVANT MEDICAL HISTORY

Tonsillitis.

CLINICAL EXAMINATION: EXTRA-ORAL FEATURES

Patient had prominent lower lip, acute naso-labial angle, shallow labiomental fold, incompetent lips. There was no apparent facial asymmetry. The temporomandibular joints were normal.

CLINICAL EXAMINATION: INTRA-ORAL FEATURES

Soft tissues: Gingivitis

Oral hygiene: Inadequate

General dental condition: #15 was restored.

CROWDING / SPACING

Maxillary arch 8 mm crowding

Mandibular arch 2 mm crowding

OCCLUSAL FEATURES

Incisor relationship: Class III

Overjet (mm): 1 mm (on #11)

Overbite: 1 mm (crossbite on #12，#21 and #22)

Centrelines: Upper midline was 1.5 mm to left of facial midline

Lower midline was 2 mm to left of facial midline

1/4 unit Class III

Left buccal segment

relationship:

1/2 unit Class III

Right buccal segment

relationship:

Crossbites: #12，#21，#22，#24，#25，#26 Displacements: #23 blocked out

Other occlusal features: None

PRE-TREATMENT PHOTOGRAPHS: EXTRA-ORAL

PRE-TREATMENT PHOTOGRAPHS: INTRA-ORAL

GENERAL RADIOGRAPHIC EXAMINATION

Pre-treatment radiographs taken:

Lateral Cephalogram 14th Oct 2008

Dental panaromic tomogram 14th Oct 2008

Bitewing

Unerupted teeth:

Teeth absent:

Other relevant radiographic findings:

Dental panaromic tomogram Full permanent dentition was present. Roots’morphology

was normal. No other obvious pathology was noted. Bitewing

PRE-TREATMENT RADIOGRAPHS

CEPHALOMETRIC TRACING: PRE-TREATMENT

1

CEPHALOMETRIC ANALYSIS

VARIABLE PRETREATMENT NORMAL SNA 81.5°82° ± 3.5 SNB 83°79° ± 3.0 ANB -1.5° 3.0° ± 2.0 Wits appraisal-4.5 mm-4.5 mm ± 3.0 Upper incisor to maxillary plane angle 128°118° ± 6 Lower incisor to mandibular plane angle 96°97° ± 7 Interincisal angle 113.5115° ± 8 Maxillary mandibular planes angle 15.5°26° ± 5 Upper anterior face height 58 mm 54.0 mm Lower anterior face height 78 mm64.0 mm Face height ratio57.4%55%± 1% Lower incisor to APo line 6.5 mm 5.5 mm ± 2.5 Lower lip to Ricketts E Plane 1 mm 4.0 mm ± 2.5

Source of normal values for Chinese: Cooke MS and Wei SHY (1988)

Normal

One standard deviation

Two standard deviations

INTERPRETATION

The SNB value was increased and ANB value was negative which suggested a skeletal Class III pattern. Although lower facial height was increased, maxillary mandibular angle were decreased, indicating smaller ratio of posterior to anterior facial height.

The upper incisors were proclined.

DIAGNOSTIC SUMMARY

19-year-old patient presenting with Class III malocclusion on a skeletal Class III base. He had increased facial height with increased lower facial height ratio, prominent lower lip, reduced upper facial height ratio, protrusive upper lip, acute naso-labial angle, shallow labiomental fold and incompetent lips. He was in the permanent dentition stage with moderate crowding, crossbite in labial and left buccal segments. both upper and lower midlines shifted left,proclined upper incisors.

PROBLEM LIST

1. Acute naso-labial angle, protrusive upper lip, shallow labiomental fold and

incompetent lips.

2. Class III malocclusion with crossbite in labial and left buccal segments.

3. Crowding of both arches.

4. Both midlines shifted left.

RATIONALE FOR TREATMENT

1. There was moderate crowding in the upper arch and mild in the lower, significant midline

shifts, proclined upper incisors and crossbite in labial segment. Extraction of upper second premolars and lower first premolars followed by fixed appliance treatment with maximum anchorage provides space for alignment, increasing overbite and overjet, correction of midlines.

2. Retraction of lower frontal teeth can eliminate crossbite and improve lip competency.

3. Placement of removable Hawley retainers.

AIMS AND OBJECTIVES OF TREATMENT

1. Relieve crowding, level and align teeth and harmonize arches

2. Correct crossbite

3. Correct both midlines

4. Improve lip competency

5. Retention and review third molar eruption

TREATMENT PLAN

Extractions: #15，#25，#34，#44

Appliances: Fixed appliance

Special anchorage requirements: None

Minor adjunctive surgery: None

Major adjunctive surgery: None

Additional dental treatment:

Proposed retention strategy: Hawley retainers.

Additional notes on treatment plan: Refer to hygienist to improve the oral hygiene. Prognosis for stability: The prognosis for stability is good.

SECTION 2. TREA TMENT

TREATMENT PROGRESS

Start of active treatment: Dec 2008 Age at start of active treatment: 19 years old End of active treatment: Oct 2010 Age at end of active treatment: 21 years old End of retention: Ongoing

KEY STAGES IN TREATMENT PROGRESS

DATE STAGE

1. Dec 2008 Referral to hygienist. Placement of fixed appliances with 0.022 X

0.028” slot and initial levelling and alignment archwires on upper

and lower teeth.

TIME INTO

STAGE

TREATMENT

1. 2 months Leveling in 0.012” NiTi archwire

Lower arch changed from0.018”NiTi to 0.016” x 0.022”NiTi

archwire

2. 4 months Placement of broaden 0.016” x 0.022” NiTi archwire on upper

arch and 0.017” x 0.025” NiTi archwire on lower arch.Class III

elastics at night with light force to correct molar relationship

3. 5 months Placement of 0.018” x 0.025” NiTi archwire on both upper and

lower arch

4. 6 months Placement of 0.019” x 0.025” NiTi archwire on both upper and

lower arch

5. 8 months #17 buccal tube repositioned, placement of 0.016” x 0.022” NiTi

archwire on upper arch and 0.016” x 0.022” NiTi reversed curve

of spee archwire on the lower arch for further levelling

6. 10 months Placement of 0.017” x 0.025” SS archwire on both upper and

lower arch，oblique elastics in labial segment to correct shifted

midlines

7. 15 months Placement of 0.018” x 0.025” SS archwire on both upper and

lower arch，asymmetric elastics to correct shifted midlines

8. 17 months #35，#36，#45，#46 brackets repositioned, placement of 0.016”

x 0.022” NiTi archwire on lower arch. -20° torque in upper

archwire at the place of #22

10. 22 months Debonding and placement of Hawley retainers.

MID-TREATMENT PHOTOGRAPHS:

5m

Placement of 0.018” x 0.025” NiTi archwire on both upper and lower arch

10m

Placement of 0.017” x 0.025” SS archwire on both upper and lower arch，oblique elastics in labial segment to correct shifted midlines

MID-TREATMENT PHOTOGRAPHS:

12m

Power chain to distalize #43 for coordination of midlines, #22 bracket occlusally positioned to slightly intrude #22, upper archwire back to 0.018” NiTi

15m

Placement of 0.018” x 0.025” SS archwire on both upper and lower arch，asymmetric elastics to correct shifted midlines

17m

#35，#36，#45，#46 brackets repositioned, placement of 0.016” x 0.022” NiTi archwire on lower arch. -20° torque in upper archwire at the place of #22.