Sample 2 : CASE DESCRIPTION (Example of Complex case description)

This will include : C/O (complaint), HX C/O (history of complaint), Medical HX, Dental HX, E/O & I/O examination, Investigations, Special investigations (e.g ; cbct, vitality test etc), Examination findings, Radiographic images & findings, Differential diagnosis, Treatment planning, Immediate management and the definitive treatment done. Any additional findings, records of materials used and notes to further highlight the case is encouraged.

Short Case Description

The patient, a 17-year-old girl, referred to our dental office with the main complaint of her protruded lower jaw and asymmetrical lower third of the face. We started with a full orthodontic analysis which included analysis of extra- and intraoral photographs, preparation of diagnostic study models, X-rays, CBCT and analysis of lateral and front cephalometric radiographs. Afterwards, the case-specific diagnosis and orthodontic treatment plan were prepared.

Diagnostic result:

• Skeletal Class 3;
• Dental Class 3;
• Protruded lower jaw (SNB: 87);
• Horizontal Overjet -1 mm, Overbite -3 mm;
• Constricted maxillary arch;
• Open bite in the front;
• Crossbite on the left;
• Lower midline shifted 2 mm to the left;
• Proclined upper incisors;
• Wisdom teeth – 18, 28, 38, and 48;
• Assymetrical lower third of the face;
• Maxillary and mandibular arch showed slight anterior crowding;
• Concave facial profile;
• Low mandibular plane angle (according to the Tetragon Plus Analysis -MP – sella-nasion-mandibular plane).

Pre-treatment cephalometric analysis showed:

ANB: -2 °, SNA: 85°, SNB: 87 °, UI-SN: 118°, Li-MP: 86 °, SN-MP: 30 °, UI-Li: 126°, Wits: -6 mm

Recommended treatment plan:

• Maxillary expansion with rapid palatal expander;
• Extraction of the wisdom teeth;
• Alignment and leveling of the teeth in the upper and lower teeth with Alexander 0.018 slot braces;
• Due to the inclination of the upper front teeth after 1 year and a half reconsidering the need of extraction of the upper premolars;
• Planning the orthognathic surgery;
• Orthognathic surgery for achieving Class 1 relationship, correction of the overjet, overbite and a balanced face;
• Necessity of subsequent restorative dental treatment in the front upper teeth.

Treatment steps:

The orthodontic treatment began with placing a rapid palatal expander in the upper jaw and composite bite raisers – on the upper first molars. 

1th month:
After the RPE activation was completed, brackets were fixed on the lower teeth with a round 0.016 Nickel Titanium (NiTi) achwire and Class 3 elastics were given to be worn.

2th month:
On the next appointment the wisdom teeth were extracted and bands were cemented on the lower molars. 

5th month:
Brackets on the lower canine were rebonded and a rectangular 0.016 x 0.022 NiTi was placed. Class 3 elastics were stopped.

7th month:
The rapid palatal expander was removed and the braces on the upper jaw were placed with a round 0.016 NiTi achwire.
On the lower teeth a rectangular 0.016 x 0.022 Stainless Steel (SS) with omega loops and tie-back was placed. 

12th month:
After correction of rotation a rectangular 0.016 x 0.022 SS archwire with omega loops and tie-back was placed on the upper teeth.

15th month:
Control X-rays were taken and cephalometric analysis was performed again. 
The treatment continued without the need of extraction of the two bicuspids in the upper arch.

17th month:
An analog orthognathic surgery planning was done and a splint for the surgery was made.

24th month:
The surgical procedure consisted of bilateral sagittal split osteotomy of the mandible with mandibular setback and slight anticlockwise rotation, as well as rotation to the right for correction of the facial lower third asymmetry. After orthognathic surgery, orthodontic finishing was performed in order to obtain better teeth interdigitation. During postsurgical period the patient was instructed to wear vertical intermaxillary elastics.

27th month:
Addition torque plus was applied on the maxillary archwire in the area of tooth 23, and the mandibular archwire was cut. 

30th month:
The maxillary archwire was cut. Redirect bonding of the upper left incisor was performed. A round 0.016 SS archwire and a power chain were placed on the upper teeth to maintain space closure.

31st month:
The braces were removed and a removable clear retainer was provided for the upper teeth to be worn during sleep. A fixed retainer was placed on the lower teeth from canine to canine.

Maxillary Archwire Sequence:
• 0.016 NiTi
• 0.016 SS
• 0.016 x 0.025 SS
• 0.016 SS

Mandibular Archwire Sequence:
• 0.016 NiTi
• 0.016 x 0.022 NiTi
• 0.016 x 0.022 SS

Individualized Forces:

• RPE
• Elastics 

After-treatment cephalometric analysis showed:

ANB: 0 ° ,SNA: 84 °, SNB: 84 °, UI-SN: 115°, Li-MP: 88°, SN-MP: 31 °, UI-Li: 126°, Wits: -4 mm

The results of treatment:
–  Expansion of the upper arch;
–  Crossbite correction;
–  Leveling and alignment of the –  upper and lower teeth;
–  Dental Class 1
–  Overjet 2 mm; Overbite 2 mm;
–  Symmetry of the lower third part of the face;

Other dental procedures:
–  Teeth whitening was done.
–  Restorations on the upper front teeth.

Closing the gaps between the upper incisors in a conservative manner. 
The decision to complete the aesthetic treatment of the patient was to restore the incisors with photo composite (bonding). The goal was to create proportionality in the sizes of the lateral and central incisors and also to close small tremas and diastema. After initial clarification with the patient, we isolated the teeth with a rubber dam. We cleaned them with airflow to remove biofilm and treated the bonding areas with 50-micron Al2O3 sand. Then we treated the enamel with orthophosphoric acid for 30 seconds, rinsed thoroughly with water, and applied bonding agent (G-Premio Bond). After bonding the two centrals using a matrix (clear matrix diastema mesial), we applied composite. First, on one central medially, then on the other. This slightly widened the centrals and closed the diastema. We repeated the procedure individually on the two laterals, isolating adjacent teeth with Teflon during etching and bonding. After completing the restorations, we finished and polished the teeth. Then removed the rubber dam and checked the static and dynamic occlusion. The upper jaw was scanned, and a vacuum retainer was remade to prevent tooth movement after orthodontic treatment.