爱丁堡病例-拔牙参考

THE ROYAL COLLEGE OF SURGEONS OF EDINBURGHMEMBERSHIP IN ORTHODONTICSFULL Y DOCUMENTED CASE HISTORYDATE OF EXAMINATION: Nov 2010CANDIDATE NUMBER: 109CASE NUMBER : 2PATIENT’S INITIALS : C.L.Q.COLOUR CODE :CASE SUMMARYCLQ, 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 ASSESSMENTPATIENT DETAILSInitials: C.L.Q.Sex: MaleDate of birth: 1st Dec 1989Age at start of treatment: 19 years oldPATIENTS COMPLAINTSPatient disliked his irregular teeth.RELEVANT MEDICAL HISTORYTonsillitis.CLINICAL EXAMINATION: EXTRA-ORAL FEATURESPatient 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 FEATURESSoft tissues: GingivitisOral hygiene: InadequateGeneral dental condition: #15 was restored.CROWDING / SPACINGMaxillary arch 8 mm crowdingMandibular arch 2 mm crowdingOCCLUSAL FEATURESIncisor relationship: Class IIIOverjet (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 midlineLower midline was 2 mm to left of facial midline1/4 unit Class IIILeft buccal segmentrelationship:1/2 unit Class IIIRight buccal segmentrelationship:Crossbites: #12，#21，#22，#24，#25，#26 Displacements: #23 blocked outOther occlusal features: NonePRE-TREATMENT PHOTOGRAPHS: EXTRA-ORALPRE-TREATMENT PHOTOGRAPHS: INTRA-ORALGENERAL RADIOGRAPHIC EXAMINATIONPre-treatment radiographs taken:Lateral Cephalogram 14th Oct 2008Dental panaromic tomogram 14th Oct 2008BitewingUnerupted teeth:Teeth absent:Other relevant radiographic findings:Dental panaromic tomogram Full permanent dentition was present. Roots’morphologywas normal. No other obvious pathology was noted. BitewingPRE-TREATMENT RADIOGRAPHSCEPHALOMETRIC TRACING: PRE-TREATMENT1CEPHALOMETRIC ANALYSISVARIABLE 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 ± 2.5Source of normal values for Chinese: Cooke MS and Wei SHY (1988)NormalOne standard deviationTwo standard deviationsINTERPRETATIONThe 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 SUMMARY19-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 LIST1. Acute naso-labial angle, protrusive upper lip, shallow labiomental fold andincompetent 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 TREATMENT1. There was moderate crowding in the upper arch and mild in the lower, significant midlineshifts, 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 TREATMENT1. Relieve crowding, level and align teeth and harmonize arches2. Correct crossbite3. Correct both midlines4. Improve lip competency5. Retention and review third molar eruptionTREATMENT PLANExtractions: #15，#25，#34，#44Appliances: Fixed applianceSpecial anchorage requirements: NoneMinor adjunctive surgery: NoneMajor adjunctive surgery: NoneAdditional 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 TMENTTREATMENT PROGRESSStart 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: OngoingKEY STAGES IN TREATMENT PROGRESSDATE STAGE1. Dec 2008 Referral to hygienist. Placement of fixed appliances with 0.022 X0.028” slot and initial levelling and alignment archwires on upperand lower teeth.TIME INTOSTAGETREATMENT1. 2 months Leveling in 0.012” NiTi archwireLower arch changed from0.018”NiTi to 0.016” x 0.022”NiTiarchwire2. 4 months Placement of broaden 0.016” x 0.022” NiTi archwire on upperarch and 0.017” x 0.025” NiTi archwire on lower arch.Class IIIelastics at night with light force to correct molar relationship3. 5 months Placement of 0.018” x 0.025” NiTi archwire on both upper andlower arch4. 6 months Placement of 0.019” x 0.025” NiTi archwire on both upper andlower arch5. 8 months #17 buccal tube repositioned, placement of 0.016” x 0.022” NiTiarchwire on upper arch and 0.016” x 0.022” NiTi reversed curveof spee archwire on the lower arch for further levelling6. 10 months Placement of 0.017” x 0.025” SS archwire on both upper andlower arch，oblique elastics in labial segment to correct shiftedmidlines7. 15 months Placement of 0.018” x 0.025” SS archwire on both upper andlower arch，asymmetric elastics to correct shifted midlines8. 17 months #35，#36，#45，#46 brackets repositioned, placement of 0.016”x 0.022” NiTi archwire on lower arch. -20° torque in upperarchwire at the place of #2210. 22 months Debonding and placement of Hawley retainers.MID-TREATMENT PHOTOGRAPHS:5mPlacement of 0.018” x 0.025” NiTi archwire on both upper and lower arch10mPlacement of 0.017” x 0.025” SS archwire on both upper and lower arch，oblique elastics in labial segment to correct shifted midlinesMID-TREATMENT PHOTOGRAPHS:12mPower chain to distalize #43 for coordination of midlines, #22 bracket occlusally positioned to slightly intrude #22, upper archwire back to 0.018” NiTi15mPlacement of 0.018” x 0.025” SS archwire on both upper and lower arch，asymmetric elastics to correct shifted midlines17m#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.SECTION 3. POST-TREA TMENT ASSESSMENTOCCLUSAL FEATURESIncisor relationship: Class IOverjet (mm): 2 mmOverbite: 2 mmCentrelines: Coincident with facial midlineLeft buccal segmentClass Irelationship:Class IRight buccal segmentrelationship:Crossbites: NoneDisplacements: NoneFunctional occlusal features Canine guidance was present on the left and rightduring lateral excursions and incisal guidance waspresent on protrusion. There were no non-workingside interferences during function.Other occlusal features: Good buccal interdigitation was achieved.COMPLICATIONS ENCOUNTERED DURING TREATMENTOverall, the patient was motivated, compliant with oral hygiene and tolerant with all aspects of treatment.OCCLUSAL INDICESINDEX PARAMETER VALUEIndex of Treatment NeedDental Health Component Start 5iFinish 1 Aesthetic Component Start 8Finish 1Start 56Peer Assessment Rating(PAR)Finish 1Change 55% Change 98RADIOGRAPHS TAKEN TOWARDS / AT END OF TREATMENTRadiographs taken:Lateral Cephalogram 21st Oct 2010Dental panaromic tomogram 21st Oct 2010Relevant findings:Dental panaromic tomogramRoot parallelism could have been better but clinical aesthetics did not support prolonging of treatment time. No other pathology was noted.POST-TREATMENT RADIOGRAPHSCEPHALOMETRIC TRACING: POST-TREATMENTCEPHALOMETRIC ASSESSMENTVARIABLE POSTTREATMENT CHANGE SNA 81 -0.5°SNB 81.5°-1.5°ANB -0.5°1°Wits appraisal -3 mm 1.5 mm Upper incisor to maxillary plane angle 122.5°-5.5°Lower incisor to mandibular plane angle 81.5°-14.5°Interincisal angle 135°22.5°MM angle 20°-2.5°Upper anterior face height 58 mm 0 mm Lower anterior face height 80 mm 2 mmFace height ratio 58%+0.6% Lower incisor to APo line 2 mm -4.5 mm Lower lip to Ricketts E Plane -0.5 mm -1.5 mmSource of normal values for Chinese: Cooke MS and Wei SHY (1988)NormalOne standard deviationTwo standard deviationsINTERPRETATIONMaxillary superimposition on maxillary stable structures indicates that there has been retroclination, some buccal root torque and extrution of vertical position of upper incisors. The upper molars have been mesialized.Mandibular superimposition indicates that there has been lower incisor retroclination over normal limits with reference to A-Po line and maintenance of vertical position. There was a small extrusion and mesialization of lower molars.C E P H A L O M E T R I C S U P E R I M P O S I T I O NOverall superimposition of pre- and post-treatment cephalometric radiographs registered on anterior cranial base.Pre-treatmentPost-treatmentCEPHALOMETRIC SUPERIMPOSITION (where appropriate)Maxillary superimposition and pre- and post-treatment cephalometric radiographs registered on the anterior border of zygomatic processPre-treatmentPost-treatmentMandibular superimposition and pre- and post-treatment cephalometric radiographs registered on Björk’s stable mandibular structuresPre-treatmentPost-treatmentPOST-TREATMENT PHOTOGRAPHS: EXTRA-ORALPOST-TREATMENT PHOTOGRAPHS: INTRA-ORALSECTION 4. CRITICAL APPRAISALThe patient was treated in 22 months.Dental Cast AnalysisClass I molar relationship was achieved. Upper and lower dental midlines are coincident. Arches are coordinated. Overjet and overbite are within normal limits. Buccal interdigitation has been achieved.Soft TissueDental midlines are also coincident with facial midline. Nasolabial angle is no longer acute after treatment. Lower lip is less protrusive and is in good relationship with upper lip and nose. Lip competency was possible without obvious mentalis muscle strain. Labiomental angle is more aesthetic but chin is still anteriorly positioned. The gingival condition is satisfactory.Radiographic AnalysisThe growth pattern of this patient is stable. After active treatment, the maxilla is almost in initial position, but the mandible presents a little growth vertically. Rretroclination of lower incisors and Class III elastics contribute to reduce the prominence of the lower lip. Facial height has almost been kept in initial proportion. Upper incisors have been retroclined to normal values while the lower incisors have been retroclined excessively so as to correct crossbite.Long term PrognosisThe patient has little growth potential at his age. The position of the developing #18 and #28 needs to be reviewed. As interincisal angle is increased, long-term retention of overbite and overjet involving removable retainers is suggested.。