Orthodontic Malocclusion Assessment

Patient Information

• Chloe Vance, 14 yo female, DOB: 12/08/2010, MRN: 492-810-33, Mob: 0412 345 678, Address: 14 Banksia St, Subiaco WA 6008

Chief Complaint

• Referred by orthodontist for concurrent TMJ/myofascial assessment and management; c/o "sticking Out front teeth" and bilateral jaw ache/clicking for 6 months, worse on waking and chewing tough foods.

Medical History

• Mild asthma, nil prior surgeries or hospital admissions, NKDA. Current meds: salbutamol (Ventolin®) 100 mcg INH PRN.

Dental History

• Regular 6-monthly dental checks; fissure sealants placed 15/03/2022; nil history of periodontal disease.
• Uncomplicated enamel fracture to tooth 11 following fall from bike in 2019, restored with composite resin, remains vital and asymptomatic.

Social History

• Year 9 student, non-smoker, nil ETOH. Brushes BD with fluoridated toothpaste, flosses 2x/week. High stress recently due to school exams.

Family History

• Father had Class II malocclusion treated with premolar extractions and fixed appliances; mother has history of nocturnal bruxism and TMD.

Clinical Examination

Extra Oral Examination

• Facial Symmetry: Mild mandibular deviation to the right at rest (approx. 1.5 mm); symmetrical vertical facial thirds.
• Profile Analysis: Convex profile with retrognathic mandible.
• Lip Posture and Competency: Incompetent lips at rest (4 mm interlabial gap); marked mentalis strain on closure; lower lip trapped behind upper incisors.
• TMJ Assessment: Reciprocal click R TMJ at 22 mm opening and 12 mm closing; mild tenderness to palpation R lateral pole and bilateral masseter/temporalis muscles; active ROM: MIO 42 mm (pain-free to 35 mm), L lateral excursion 9 mm, R lateral excursion 7 mm, protrusion 6 mm with C-type deviation to the right on opening.

Intra Oral Examination

Soft Tissue Assessment

• Mucosa: Bilateral buccal mucosa linea alba and scalloped lateral borders of tongue (indicative of parafunctional clenching); palate, floor of mouth and vestibule NAD.
• Gingiva: Pink and firm generally; mild marginalerythema and localized gingivitis around lower anterior labial gingiva; nil pocketing or recession.

Occlusal Analysis

• Molar Relationship: Right: Angle Class II full unit; Left: Angle Class II half unit.
• Canine Relationship: Right: Angle Class II; Left: Angle Class II.
• Midline Assessment: Upper dental midline coincident with facial midline; lower dental midline deviated 2 mm to the right.
• Overbite: 5 mm (70%), increased and complete to palatal mucosa.
• Overjet: 8 mm, increased.
• Crossbite: Unilateral posterior lingual crossbite of tooth 15 to 45.
• Crowding: Moderate crowding in the upper arch (5 mm); mild crowding in the lower arch (3 mm).
• Spacing: Nil spacing in either arch.
• Functional Shift: Mandibular shift of 1.5 mm to the right from initial contact on tooth 15/45 into maximum intercuspation.

Functional Examination

• Mastication: Unilateral chewing preference on the left side; reports fatigue and dull ache in R masseter after chewing firm foods.
• Swallowing: Adaptive anterior tongue thrust to achieve anterior oral seal.
• Speech: NAD, sibilants clear.
• Habits: Lower lip biting/sucking habit and nocturnal clenching, contributing to proclination of upper incisors, retroclination of lower incisors, and myofascial pain.

Radiographic Examination

• Panoramic Radiograph: All permanent teeth present, third molars (18, 28, 38, 48) in crypts; normal alveolar bone levels; mild flattening of R mandibular condylar head; nil periapical pathology.
• Cephalometric Analysis: SNA 81°, SNB 75°, ANB 6°, Skeletal Class II base, normodivergent vertical growth pattern (FMA 26°), proclined upper incisors (U1-SN 112°).

Diagnostic Casts and Impressions

• Intraoral 3D digital scan (iTero) obtained; demonstrates V-shaped constricted maxillary arch, ovoid mandibular arch, and deep Curve of Spee (3.5 mm).

Photographic Records

• Extraoral Photographs: Frontal at rest, frontal smiling, right profile, and 45-degree oblique views obtained; confirm lip incompetence, mentalis strain, and convex profile.
• Intraoral Photographs: Anterior, right/left buccal, and upper/lower occlusal views obtained; confirm Class II buccal segments, deep overbite, and moderate anterior crowding.

Diagnosis

• Skeletal Class II malocclusion with Angle Class II division 1 incisor relationship, complicated by right TMJ disc displacement with reduction, masticatory myofascial pain, and parafunctional clenching/lip habit.

Treatment Plan

• Treatment Options: Option 1: Growth modification (Twin Block functional appliance) followed by comprehensive fixed appliances, alongside concurrent physiotherapy for TMD/habit reversal. Option 2: Camouflage orthodontic treatment with upper first premolar extractions and fixed appliances. Option 1 recommended to address skeletal retrognathia and optimise facial profile while growth potential remains, following initial stabilization of TMJ symptoms.
• Orthodontic Plan: Phase 1: 4 weeks pre-orthodontic physiotherapy (Rocabado 6x6 exercises, masseter/temporalis myofascial release, habit awareness, and thermal therapy) to settle myofascial pain. Phase 2: Twin Block appliance for 9–12 months to advance mandible and eliminate lip trap. Phase 3: Upper and lower fixed pre-adjusted edgewise appliances (0.022" slot) for 15–18 months to level, align, and coordinate arches.
• Post-Treatment Plan: Bonded lingual retainers (upper 12–22, lower 33–43) and nocturnal vacuum-formed retainers (Essix) with anterior bite plane design; ongoing monitoring of TMJ function at 3, 6, and 12 months post-deband.

Prognosis

• Good for achieving Class I occlusion, improving facial profile, and reducing overjet; guarded-to-good for long-term stability, heavily dependent on patient compliance with Twin Block wear, cessation of lower lip habit, and management of nocturnal clenching.

Review and Follow-up

• Physiotherapy review in 2 weeks (26/03/2025 at 14:00 AWST) to reassess TMJ ROM and myofascial tenderness; joint orthodontic review in 4 weeks for Twin Block impression/scan once acute muscular symptoms have resolved; 6–8 weekly reviews during active orthodontic phase.