The American Orthodontic Society
Credentialing

Sample Case - Case Report Format

Patient: Sheri McCarty - Age:11.1 - Race: Caucasian - Sex: Female

Medical and Dental History

Sheri came to my office for orthodontic care. Her chief complaint is "the space between my front teeth and I have buckteeth". She is receiving restorative dental care from another office. The dental exam revealed no caries with healthy periodontia. She presented a negative medical history with no allergies or recent hospitalizations.

Clinical Analysis:

Sheri is an eleven-year-old Caucasian female who presents in the late mixed dentition. Clinical oral exam reveals a Class II Division I malocclusion. There is 8 mm overjet, 8mm overbite and a 2mm-midline discrepancy. There are no obvious tooth size discrepancies. There is moderate crowding on the mandibular arch and moderate to severe crowding on the maxillary arch.

TMJ Examination:

The TMJ evaluation for Sheri is good. She relates no history of headaches, joint dysfunction or pain, and no history of clenching or grinding. The TMJ screening is within normal limits with a vertical opening of 57mm, left deviation to 14mm, and right deviation to 15mm.

Radiographic Analysis:

A panoramic radiograph shows all teeth to be present including third molars. There are no impacted teeth and the eruption pattern is normal for her age. All surrounding processes and tissues appear normal.

A cephalometric radiograph taken and traced, using a modified Stiener analysis, demonstrates a Class II skeletal pattern. The mandibular plane angle indicates a normal or neutral growth pattern. The lower incisor in relationship to the chin button indicates that the incisors could be moved forward some to improve this ratio. The soft tissue profile is straight to concave thus also benefiting from the forward movement of the lower incisors.

Transcranial radiographs show that the condyles appear normal in shape with no unusual blunting or distortion. The position of the condyles is centered in the fossa.

Treatment Objectives:

To obtain Class I dental occlusion and improve her profile and smile esthetics.

Treatment Plan:

• Extraction of mandibular third molars.
• Straight Wire Appliances with arch wire sequence on the maxillary arch.
• 3-D Multi-Action Transpalatal Appliance on the maxillary arch
• Lip Bumper with class III elastics on the mandibular arch.
• Straight Wire Appliances with arch wire sequence on the lower arch.
• Multi-Distalizing Arch on the maxillary arch.
• Maxillary hawley with a bonded lower lingual arch for retention.

30 - 36 months