Diagnosis and Treatment Plan
For
Sharon Blake
By
Yosemite Dental Group
333 top of the mountain Dr.
Yosemite, CA
640-333-4534
February 16, 2016
Initial Appearance
Characteristics of the Malocclusion
Upon the initial clinical evaluation the following characteristics were noted.
Dental Evaluation
Female age 33 with a permanent dentition and a Class II Division 1 malocclusion. The right side
has a Class II molar of 4 mm., and a Class II cuspid of 5 mm. The left side has a Class I molar of 0
mm., and a Class I cuspid of 0 mm. Dental Crowding was estimated at 4 mm. in the lower arch and
2 mm. of Crowding in the upper arch.
The vertical dimension is dental Average. The transverse dimension of the dental arches showed
the presence of unilateral anterior crossbite and posterior crossbite. The supporting structures of the
teeth had no obvious problems. The missing teeth noticed at the clinical examination are the
18,28,38,48.
Additional features included a Flat curve of spee, Ovoid archform, and well formed upper incisors.
The mandible seated in the fossa with a functional shift to the right.
Facial Survey
The patient has a mesofacial facial pattern, with a Straight profile. The upper midline is centered
relative to the facial midline. The lips are Thin, the sublabial fold average, and the naso-labial angle
is 90° - 110°. The upper incisor shows 1 mm. of tooth below the resting upper lip, with -2 mm. of
gingival display upon the highest smile given at the evaluation.
Myofunctional Evaluation
The lip competency was Adequate, with lip tonicity being Normal. Breathing was observed to be
Nasal. The dental bite was open with a negative anterior overjet.
Temporo-mandibular Joint Evaluation
On the right side Early clicking was noted. The patient reported, fullness in the right ear, ringing
in the right ear, pain in the right ear. Upon opening the jaw deviated to the Right with a maximum
opening of 24 mm. The patient reported having 7 headaches per week.
Conclusions Following the Initial Evaluation
A verbal discussion was held, at which time several treatments were considered possible,
including
Non-Extraction, and bicuspid Extraction. The estimated time of treatment was 18-24
months, with an estimated fee of $4500-5500.
The findings at the clinical examination were consistent with the patients’ chief complaint of
TMJ Symptoms. When asked about the perception of protrusion, the patient’s opinion was:
Acceptable Now, Can Move the Teeth Forward
It is estimated that the front teeth will Advance 3.25 mm. if a non-extraction treatment is
chosen.
Other Notes
The patient is a Television reporter and is concerned about the appearance of orthodontic appliances
on camera
Cephalometric Numbers and Conclusions
Skeletal Summary
The Skeletal vertical dimension is Average with a dental Average bite. At the time of initial
evaluation, growth was completed for this adult patient. The maxilla is positioned in Retruded
position, and the mandible is Average. The relationship of the upper and lower jaws is Class III
based on evaluation of the ANB and Wits measurements.
Dental Summary
The lower incisors are Average with the antero-posterior position being Average. The upper
incisors are Proclined with the antero-posterior position being Average. Based on the cephalometric
evaluation, the initial clinical impressions, and the patients’ feelings about the position of their teeth,
a treatment objective has been decided to leave the incisors near the starting position.
Description Relationship
Measurement
Range
Mean
Palatal Plane to Mandibular
Plane:
Skeletal Open/Closed
Mand Plane Angle
Skeletal Open/Closed
Y-Axis - Vert/Hor Growth
Maxilla to Cranium: N
Perpendicular Reference to
A
Maxilla to Cranium
Mandible to Cranium:
N Perpendicular Reference
to Pogonion
Mandible to Cranium
Maxilla to Mandible
ANS - PNS to Mand. Plane
24 (Closed) to 33 (Open)
28
Patient
Measure
ment
28.7
9 yr FMA / Adult FMA
20(Closed) to 30(Open)
18(Closed) to 28(Open)
57 (Horizontal) to 62 (Vertical)
-1 (Retruded) to +3 (Protruded)
26°
27.7
59
+1mm
57.8
-1.6
SNA
N Perpendicular Po
76 (Retruded) to 83 (Protruded)
-10 (Retruded) to -4 (Protruded)
-4 (Retruded) to 1 (Protruded)
81°
9yr - 7mm
Adult - 1mm
74.8
-3.5
SNB
ANB
80°
2°
73.1
1.7
Wits
A, B Perpendicular Occlusal
Plane
Upper 1 to Lower 1
Lower 1 to MP
Lower 1 to NB
Lower 1 to APo
Upper 1 to SN
75 (Retruded) to 83 (Protruded)
CI +2 to +4.5
CIII tendency 0.5 to 1.5
Class I -1 to +2
0
0.5
Best Finish 125 to 130
89 (Retroclined) to 98 (Proclined)
+1 (Retruded) to +6 (Protruded)
0 (Retruded) to +4 (Protruded)
99 (Retroclined) to 106
(Proclined)
+2 (Retruded) to +7 (Protruded)
+2 (Retruded) to +6 (Protruded)
130°
92°
+4mm
+2mm
103°
121
89.9
4.7
2.6
107.6
5mm
4mm
6.6
5.9
90 to 110
+1 to -4
100°
-2mm
117
-6.9
+1 to -4
-2mm
-4.4
Interincisal Angle
Lower Incisor Inclination
Lower Incisor Protrusion
Lower Incisor Protrusion
Upper Incisor Inclination
Upper Incisor Protrusion
Upper Incisor Protrusion
Naso Labial Angle
Soft Tissue Line (E Plane)
Upper
Soft Tissue Line (E Plane)
Lower
SGN - FH
N Perpendicular A Point
Upper 1 to APo
Upper 1 to A Vertical
(to FH)
Individual Appliance  Design
A personalized appliance has been designed by Dr. McGann for the treatment of Sharon
Blake after considering the characteristics of the malocclusion, the final desired aesthetics, the longterm retention, and the unwanted tooth movements from force application. This appliance includes
selection of brackets, bands, and archwires with a custom prescription to obtain the most optimal
treatment results.
Tooth #
Description
18
17
16
15
14
13
12
11
21
22
23
24
25
26
27
28
38
37
36
35
34
33
32
31
41
42
43
44
45
46
47
48
Missing
Mesial
Distal
Distal
Distal
Distal
Distal
Distal
Distal
Mesial
Mesial
Bracket/Band
17R2
16R2sh
15MCer
14DCer
13DCer
12DCer
11DCer
21DCer
22DCer
23DCer
24MCer
25MCer
26R2sh
27R2
Height,
mm
Instructions
Band
Size
4
12
4.0
4.0
4.5
3.5
4.0
4.0
3.5
4.5
4.0
4.0
12
5
Missing
Missing
Mesial
Mesial
Distal
Distal
Mesial
Distal
Distal
Distal
Missing
37R2
36R2
35M
34M
33D
32DLa
31MLa
41La
42DLa
43D
44R
45D
46R2
47R2
5
11
4.0
4.0
4.5
4.0
4.0
4.0
4.0
4.5
4.0
4.0
11
5
Qty.
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
0
Notes
Archwire selection
The lower archform was selected to maintain the ovoid-medium dental archform. The upper
archform was selected to expand the dental arche, and was chosen to be ovoid, non-extract #2.
Treatment Design
Goals
-
Improve TM Joint Symptoms
Posterior Crossbite Corrections
Straighten Teeth
Class II Correction And Associated Overjet
Limitations
-
Right lateral functional shift of Mandible
Crossbite: Posterior
Crossbite: Anterior
Crossbite: Unilateral
Missing Teeth - Upper Right 8
Missing Teeth - Upper Left 8
Missing Teeth - Lower Left 8
Missing Teeth - Lower Right 8
Temporomandibular Dysfunction-Clicking-Right: Early
Temporomandibular Dysfunction-Fullness in the Right Ear
Temporomandibular Dysfunction-Ringing in the Right Ear
Temporomandibular Dysfunction-Pain in the Right Ear
Temporomandibular Dysfunction- Headache Frequency per week 7
May not be able to correct
- Class II Without Patient Cooperation
- TMD symptoms may not be reversible
- Adult crossbite without surgery
Treatment Alternatives Considered
- 031. Limit lower incisor advancement, one wire technique
- 067. Skeletal open bite, leave the incisor near the starting position. Class II 4mm or less
Treatment Decision
- 141. TMD Case
- 032. Limit lower incisor advancement, standard wire progression
Additional Notes
Surgical correction of the posterior crossbite may be needed due to the age of
the patient. This will be determined after an attempt at non surgical maxillary
expansion is made.
Treatment Plan
32. Non-extraction, limit lower incisor advancement, standard wire progression
Incisor torque: R/La. Labial lower torque to prevent incisor advancement
cuspid torque: R/R
Molar buccal tubes: 16/26R2sh. Lingual sheaths for TPA crossbite correction. 36/46CIIE2 to
compensate for expected class II elastics. Band 7s to control open bite and transverse
archwires: expand upper, maintain lower.
rotations: see IP tab
positioning: Average 0%
Summary:
1. align on 012nitie for 2 months, then 18x25N heat activated to establish incisor torque,
archform, and finish alignment.
2. Reposition brackets
3. Change to 19x25ss upper and lower. Stripping at a wire change. Check for arch coordination
4. class II elastics as needed
5. Finishing
In this plan, we are usually working on a growing patient. The class II will be corrected without the use of class II
elastics that would be detrimental to lower incisor advancement. Headgear or functional appliances may be used for
this purpose, with headgear the most common appliance used in the POS system. The headgear is delivered early in
the treatment to allow for class II correction by growth restraint and some dental distalization while the alignment and
wire progression stages are taking place. In skeletal class II cases, 24 oz headgear will be used. In skeletal class I
cases, 12 oz headgear force will be used. Cervical headgear is the most effective in correcting class II, so we will use
this appliance most commonly in these types of cases, even in the presence of skeletal open bite.
IP Appliance TM Design:
1. Choose brackets for the lower incisors with added labial root torque (lingual crown torque) to prevent the
crowns from moving forward. 32La, 31La, 41La, 42 La (or combinations if rotations).
2. Select IP rotation brackets consistent with the archwire selected, standard Roth on all teeth that are aligned
from the start.
3. Add headgear tubes to the upper molars, so this appliance can be used during the alignment and wire
progression stage. (16Rhg, 26Rhg)
4. Expanded archwire: when selecting an archwire size, consider one with expansion for the purpose of limiting
lower incisor advancement. Be watching for under-expansion of the lower arch, causing premature contact of
the incisors. Class II elastics, headgear, and other appliances will be ineffective with the premature incisor
contact. The upper arch will appear to be over-expanded, where the lower arch is under-expanded due to
buccal cortical bone resistance. Constrict the upper arch to recover.
Mechanics for standard wire progression:
1. align on 012N or 014N. Use 18x25N heat activated as the second archwire if brackets with added Lingual (Li) or
Labial (La) torque are present. If starting with 016N, be certain to use the proper IP archwire shape and size.
Cervical headgear is added at the second month of treatment, or after the patient has adjusted to the fixed
appliances. Use 12 oz in skeletal class I cases and 24 oz in skeletal class II cases. The headgear wear time
should be at least 10-14 hours per day.
2. Bracket position evaluation: Evaluate bracket position with a progress study model, and panoramic x-ray.
Reposition brackets as needed, and reinsert the nickel titanium alignment archwire to gain full alignment.
3. Wire progression to 19x25 ss upper and lower. Stripping of enamel may be done at wire change appointments
(stripping is only allowed when the teeth are straight) to limit the incisor advancement. Watch for the underexpansion of the lower arch relative to the upper arch due to the use of expanded archwires. Class II elastics
and headgear will be ineffective in the presence of incisor protrusive interference. Constrict the upper
archwire with a hollow chop plier to recover needed overjet when arch coordination is the problem.
4. Reevaluate for inter-arch elastics. If headgear cooperation has been poor or resistance to correction of the class
II has been encountered, then class II elastics will be necessary to complete the correction to class I (at the
expense of lower incisor advancement). The class II elastics are used from the lower molars to upper cuspids
to reduce upper anchorage. If significant correction must be made, then spaces may develop between upper
3-2. In this situation, T loops with cinchback activation should be used to close these spaces following class I
cuspid being attained. Common mistake is to use power chain to close these spaces, which will result in upper
molar advancement to class II due to the excess force needed to overcome friction and detorquing of the
upper incisor against the lower incisors (especially true when chain is used on round wire). Bite opening
increases the amount of class II dental, so class II elastics should be used with caution in skeletal open bite
cases. Extraction treatment should have been considered in most skeletal open bite cases with class II and
crowding for the purpose to keep the bite closed.
5. Finish in 018ss. Round wire finishing allows for the muscles to help seat the occlusion. Ligature wire lace all
finishing wires to avoid spaces from opening. Vertical elastics (rabbits) may also be used to help seat the
occlusion, especially in skeletal open bite cases that have weaker muscle patterns. The vertical elastics may
have a short class II component. Consider fiberotomy and stripping for those teeth with moderate to severe
rotations to start.
141. TMD case. To be added to the orthodontic treatment plan.
The following principles should be added to the treatment plan chosen when significant TMD symptoms are
reported at the start of the case.
a. Bite opening mechanics is considered more favorable in TMD cases. Avoid protrusive interference due to deep
bite and incisor detorquing. These problems are most often seen when retracting upper incisors in skeletal
class II cases. The protrusive interference prevents movement of the mandible.
b. Splint success ONLY establishes which reported symptoms are related to the dental complex. The vertical
dimension of the splint is of no importance.
c. The splint is left in place while the opposing arch is aligned and the wire progression is completed. The patient
can remove the splint as soon as the symptoms are tolerable, usually when 020ss is engaged in the opposing
arch.
d. Orthodontic treatment is only one part of an overall treatment for TMD symptoms. There is a step-by-step
approach taken in all TMD treatment, re-evaluating the impact of each change on the reported symptoms.
Orthodontic treatment should not be considered a cure.
e. Symptoms will change every day as the bite changes.
f. Surgery of the TM joint should be delayed until the best possible occlusion can be established. Otherwise,
healing following surgery may be compromised and if the occlusion was a factor in the symptoms, then the
chances for recurrence is significant. It is a better approach to first establish the best occlusion with
orthodontic treatment, then re-evaluate for TM joint surgery after a period of retention.
g. Clear overlay retainers aggravate TMD symptoms by placing an extra thickness of material on the lingual of the
upper teeth and the labial of the lower teeth. It is more standard to use an upper Hawley retainer with an
anterior bite plane following orthodontic treatment on TMD patients.
h. If symptoms become significantly worse during orthodontic treatment, then stop tooth movement, and reevaluate the occlusion with a splint constructed over the top of the brackets, monitoring the changes in the
symptoms every two weeks to see what changes. Tomograms or Magnetic Resonance Imaging (MRI) is
needed to establish if condylar resorption or anterior displaced discs are present.
Copyright 2003 Progressive Orthodontic Seminars
Consent
As with all dental treatment, treatment has possible risk to the dental structures. A
discussion of the following potential risks specific to the type of malocclusion and
treatment planned was held at the second consultation visit on (date from treatment
history). The possible risks are not limited to this list, but these were felt to be the most
common at the start of treatment. All efforts will be made to detect and limit any such
damage.
_X__root resorption: Shortening of the tooth during orthodontic treatment. Since there is no
method of predicting which cases will have noticeable root resorption, progress x-rays may be
requested during treatment to evaluate the condition of the tooth roots. Failure of the patient to
allow such screening x-rays will not allow the detection of the problem early in treatment, and
eliminating the chance to change the treatment objectives and treatment plan to reduce the
potential damage to the teeth.
_X__bone or tooth loss: Orthodontic appliances compromise the ability of the patient to clean their
teeth and gums properly. Additional effort is required of the patient to maintain their teeth, gums,
and supporting bone during the treatment time. Failure to do this can result in gingivitis and
periodontitis with a loss of supporting structures. In extreme cases, tooth loss is possible.
_X_gingival recession: Movement of teeth and lack of good dental care by the patient can lead to
gingival recession. In severe cases, gingival grafting during or after orthodontic treatment may be
necessary.
_X__tooth decalcification: The lack of diligent dental hygiene during orthodontic treatment can
lead to decalcification of the dental enamel, leaving white streaks or spots. These marks are
permanent and can only be corrected by placing white dental fillings or porcelain crowns. In
extreme cases of prolonged neglect, or in patients susceptible to dental decay, the decalcification
can break through the enamel covering of the tooth, resulting in the need for restorative (fillings or
crowns) work.
_X__Incomplete bite correction: Patient compliance with the treatment instructions is of utmost
importance to the success of the treatment. A lack of patient compliance and/or the inherent
skeletal resistance of the malocclusion can result in an incomplete bite correction.
_X__TM joint symptoms: There may already be irreversible damage to the jaw joints before
treatment has started. Changing the bite can aggravate these damaged joints, resulting in pains to
the head, jaws, and face.
_X__Open contacts after orthodontics: Spaces between the teeth must be made to fit the
orthodontic bands. After treatment, almost all of these spaces close either spontaneously or by the
orthodontic retainer. In some cases, spaces open and in other cases the spaces fail to close. The
usual treatment is to place a filling or crown to keep food from packing between the teeth.
_X__Surgery: Surgery may be a part of your treatment, including, but not limited to tooth
extraction, gingival grafting, corticotomy, and orthognathic (jaw) surgery. The usual risks associated
with dental surgery include excessive bleeding, loss of flaps with exposed bone and delayed healing,
damage to the teeth, nerve damage, and loss of tooth vitality.
_X__Change in treatment plan: Although the best effort has been made to make the most
complete diagnosis and the most accurate treatment decision, it is possible that changes in the
treatment plan may be required during treatment to reach the listed treatment goals. If consent is
not given for the recommended treatment, even if not included in this initial treatment plan, the
dentist cannot be held responsible to reach the listed treatment goals.
_X__Non-specialist: The doctor is not a specialist in orthodontics, although he/she has a special
interest in this part of the profession. The complexity of the case has been carefully considered
before accepting the case for treatment. The patient/parent has been offered the referral to a
specialist, and requests the treatment from this dentist instead, understanding the training to be
less than the specialist.
The goals, limitations, and treatment alternatives, and risks have been presented to
me, and I request treatment as suggested. Photographs and x-rays may be used for
professional journal publication, seminars, websites, and other professional uses.
__________________________________
patient/parent
date:_____________________
__________________________________
Staff member or Doctor
date:_____________________
Contract
The dental practice of Dr. Donald McGann agrees to provide orthodontic care to Sharon Blake
for the total fee of $5500. Treatment is expected to be 18-24 months. The initial banding fee is
$1500, with the remaining treatment fee to be due in 10 equal payments of $400.
It is understood that the full amount (total fee) is due before removal of the orthodontic
appliances, no matter what the reason to discontinue treatment. No interest will be charged unless
any payment becomes overdue by 30 days, at which time a penalty of 1% will be added to the
amount of the missed payment.
The above orthodontic fee does NOT include fees for the following:
____Extractions (if needed)
__X__Retention
__X__Tooth cleaning
__X__x-rays taken during orthodontic treatment
____bridges
__X__crowns
__X__dental fillings
____possible bonding or veneers after orthodontics
__X__initial orthodontic records
__X__final orthodontic records
__X__fiberotomy
____corticotomy
____gingival grafts
____cosmetic gingivectomy
__X__ceramic brackets
It is expected that the patient will maintain their orthodontic appliances during the treatment
time. In the event of breakage or loss of an appliance, an extra fee will be charged for its repair or
replacement. These may include:
___functional appliance
___headgear and/or facebow
_X__orthodontic brackets
_X__archwires
_X__retainers
___other
If the patient moves out of the area before the orthodontic treatment is completed, a
determination of the fee for services rendered to date will be made. This amount will be the sum of
the initial banding fee plus the number of treatment visits made to the practice at the rate
determined in the above calculation. The financing arrangement does not in any way determine the
fee for services at any one time during the treatment period.
The fee determined by this agreement will be due upon transfer. If the fee is not paid, then the
initial records and the transfer letter will not be sent to the subsequent treating doctor without the
payment in advance for the duplication of the records plus $150 for the transfer letter. It is
understood that changing treating dentists almost always results in longer treatment time and
higher overall fees for the treatment.
`
The person(s) responsible for the payment of this account agree to the above terms and
conditions.
_________________________
responsible person(s)
date_________________
_________________________
presenting staff member
date__________________