Clinical Orthodontic Report: Shifra Putash (Case #336747092)

Patient Demographics & Clinical History

Patient Name:	Shifra Putash	Record Date:	January 12, 2025
Patient ID:	336747092	Age:	13.3 years
Insurance Provider:	Kupat Holim Meuchedet (ID: 589958495)	Referred by:	Dr. Gil Dina Rom
Chief Complaint:	Malocclusion with concerns regarding spacing and alignment. Parent reports missing tooth and concerns about small tooth on lower arch.
Medical History:	No significant medical conditions reported. No allergies to medications or dental materials.
Dental History:	Regular dental check-ups. No previous orthodontic treatment. History of congenital absence of tooth #14.

Clinical Examination Findings

Extraoral Assessment:

Facial symmetry: Symmetrical facial features with appropriate vertical proportions
Profile: Slightly convex profile with mild retrognathic maxilla and mandible
Nasolabial angle: Within normal limits (~100-110°)
TMJ function: No clicking, popping, or restriction of movement noted
Lip competence: Competent lip seal at rest
Smile line: Appropriate gingival display on full smile

Intraoral Assessment:

Dentition: Mixed dentition transitioning to permanent dentition
Hygiene status: Good
Periodontal status: Healthy with no signs of inflammation
Caries status: No active carious lesions detected
Missing teeth: Tooth #14 (upper left first premolar) congenitally missing
Anomalies: Microdontia of tooth #22 (lower left lateral incisor)
Overjet: 3.5mm (slightly increased)
Overbite: 30% (within normal limits)
Midlines: Upper midline coincident with facial midline; lower midline deviated 1mm to the left

Radiographic Analysis

Panoramic Radiograph Assessment

Fig 1. Enhanced panoramic radiograph (4800×6000px, 600 DPI) - Exposure settings: 68.0kV 5.0mA

Dental Development:

Dental age consistent with chronological age
Eruption sequence: Appropriate for age, transitioning to permanent dentition
Third molars: Developing, all four present in early crown formation stage
Root morphology: Normal with complete root formation for erupted permanent teeth
Congenitally missing tooth #14 (upper left first premolar)
No supernumerary teeth or odontomas noted
No evidence of pathology in tooth structure or alveolar bone

Morphological Assessment:

Condyles: Symmetrical with normal morphology; no evidence of remodeling or pathology
Sinuses: Clear with normal pneumatization
Microdontia: Tooth #22 (lower left lateral incisor) exhibits pronounced reduction in mesiodistal and buccolingual dimensions
Space from missing #14: Approximately 7mm space present, minimal drift of adjacent teeth observed
Bone height: Normal with no evidence of periodontal bone loss
Airway: Patent with normal dimensions

Cephalometric Analysis

Fig 2. Enhanced lateral cephalometric radiograph with digital tracing overlay

Measurement	Patient Value	Norm (±SD)	Deviation	Clinical Significance
SNA (°)	80.0	82.0 ± 2.0	-2.0	Slight maxillary retrognathism
SNB (°)	77.0	80.0 ± 2.0	-3.0	Moderate mandibular retrognathism
ANB (°)	3.0	2.0 ± 2.0	+1.0	Class I skeletal relationship
Wits (mm)	0.5	0.0 ± 2.0	+0.5	Consistent with Class I skeletal pattern
FMA (°)	26.5	25.0 ± 3.0	+1.5	Normal mandibular plane angle
IMPA (°)	93.0	90.0 ± 5.0	+3.0	Slight lower incisor proclination
U1 to SN (°)	103.0	102.0 ± 5.0	+1.0	Normal upper incisor inclination
Interincisal Angle (°)	128.0	130.0 ± 5.0	-2.0	Slightly decreased due to lower incisor proclination
Lower Facial Height (%)	56.0	55.0 ± 2.0	+1.0	Normal vertical proportions
Nasolabial Angle (°)	105.0	102.0 ± 8.0	+3.0	Normal soft tissue relationship

Advanced Cephalometric Assessment:

Ricketts Analysis:
• Facial Axis: 89°
• Facial Depth: 86°
• Mandibular Plane: 26.5°
• Lower Face Height: 45°
• Mandibular Arc: 28°
• Growth Prediction: Mesofacial pattern with average growth vector

Steiner-Tweed Analysis:
• SND: 75°
• GoGn-SN: 31°
• U1-NA: 4mm/22°
• L1-NB: 5mm/25°
• Pog-NB: 1mm

Jarabak Analysis:
• Saddle Angle: 123°
• Articular Angle: 143°
• Gonial Angle: 128°
• Anterior Cranial Base: 71mm
• Posterior Cranial Base: 32mm
• Anterior Face Height: 112mm
• Posterior Face Height: 71mm
• S-Ar/Ar-Go Ratio: 0.78

Sassouni Analysis:
• Maxillary position relative to cranial base: Normal
• Mandibular position relative to cranial base: Slightly retrusive
• Vertical proportions balanced

Cephalometric Assessment Summary:

The cephalometric analysis reveals a Class I skeletal pattern with mild bimaxillary retrusion. The vertical dimensions are well-controlled with normal facial height proportions. The mandibular plane angle is within normal limits, suggesting a neutral growth pattern. Dental inclinations show slight lower incisor proclination, while upper incisors present with normal inclination to the cranial base. The soft tissue profile displays normal nasolabial angle and good lip competence.

Specific Dental Anomaly Analysis

Missing Tooth #14 (Upper Left First Premolar)

Edge detection highlighting missing tooth area

Fig 3. Edge detection processing highlighting the absent #14 region with spatial analysis

Detailed Assessment of Missing Tooth #14:

Etiology: Likely congenital agenesis based on symmetry of adjacent structures and absence of evidence of extraction
Space dimensions: 7.2mm mesiodistally measured at alveolar crest level
Alveolar ridge: Mild vertical deficiency (2.3mm) with adequate buccolingual width (8.1mm)
Adjacent teeth:
- Tooth #13 (canine) shows mild mesial tipping (11° from vertical)
- Tooth #15 (second premolar) shows distal drifting of 2.4mm from ideal position
- Root parallelism of adjacent teeth maintained
Occlusal implications:
- Lower left first premolar lacks proper antagonist contact
- Functional shift observed during lateral excursions
- Class I molar relationship bilaterally, though asymmetric canine relationship (Class II tendency on left side)

Microdontia of Tooth #22 (Lower Left Lateral Incisor)

Fig 4. Enhanced anterior view highlighting the microdontia of tooth #22 with comparative measurements

Detailed Assessment of Microdontia:

Dimensional analysis:
- Mesiodistal width: 4.2mm (compared to 5.8mm for contralateral tooth #27)
- Crown height: 7.1mm (compared to 8.3mm for contralateral tooth #27)
- Estimated reduction in volume: ~38% compared to antimere
Morphological characteristics:
- Crown shape: Conical with reduced mesiodistal dimension
- Root structure: Fully formed with appropriate length but reduced diameter
- Enamel thickness: Appears normal radiographically
Clinical implications:
- Adjacent diastema formation (1.5mm mesially, 0.8mm distally)
- Altered incisal guidance during protrusive movements
- Potential aesthetic concerns in smile display
- Interdigitation challenges with opposing dentition

Digital Smile Analysis

Smile Aesthetics Assessment:

Midline alignment: Upper midline coincident with facial midline; lower midline deviated 1mm left
Smile arc: Consonant with lower lip contour
Buccal corridors: Moderate display (12% of total smile width)
Gingival display: 1mm on maxillary anterior teeth (within aesthetic range)
Incisal display at rest: 3mm of maxillary incisors visible
Golden proportion analysis: Disrupted by missing #14 and microdont #22
Tooth shade: A2 (Vita scale) with good uniformity across the dentition

Treatment Planning & Clinical Considerations

Diagnosis

Skeletal: Class I skeletal relationship with slight maxillary and moderate mandibular retrognathism
Dental:
- Class I molar relationship bilaterally with asymmetric canine relationship (Class II tendency on left)
- Congenital absence of tooth #14 (upper left first premolar)
- Microdontia of tooth #22 (lower left lateral incisor)
- Moderate crowding in both arches (4mm upper, 3mm lower)
- Mild lower incisor proclination (IMPA 93°)
Functional: Functional shift during lateral excursions due to missing premolar antagonist
Aesthetic: Disrupted smile line due to dental anomalies with potential for significant improvement

Treatment Options Analysis

Clinical Consideration	Option A: Space Closure	Option B: Space Maintenance for Prosthesis
Missing #14 Management	Complete space closure with mesial movement of posterior segment	Space maintenance for future implant or bridge restoration
Extraction Pattern	Contralateral premolar extraction (#4) to maintain symmetry	Non-extraction approach
Microdont #22 Management	Space redistribution with future restoration	Maintain current size with minor alignment, future restoration
Treatment Duration	Approximately 24-30 months	Approximately 18-24 months
Biomechanical Complexity	Moderate-High (Asymmetrical space closure)	Moderate (Space maintenance protocols)
Post-Treatment Stability	Good (no prosthetic component)	Dependent on prosthetic quality and long-term maintenance
Future Restorative Needs	Limited to #22 restoration only	Implant/bridge for #14 plus #22 restoration

Recommended Treatment Approach

Treatment Plan Recommendation: Option B - Space Maintenance with Non-Extraction Approach

Rationale:

Patient's mild to moderate crowding can be addressed without extractions
Maintaining space for future implant at #14 site provides optimal functional and aesthetic outcome
Preservation of #4 avoids unnecessary removal of healthy tooth structure
Asymmetric extractions would create additional biomechanical challenges
Patient's age (13.3 years) is conducive to non-extraction orthodontic management
Good alveolar ridge dimensions at #14 site favor future implant placement

Proposed Treatment Sequence

Records: Complete 3D digital models, CBCT, and full photographic series
Appliance Selection: Fixed appliance therapy with MBT prescription .022" slot
Initial Phase (1-6 months):
- Alignment and leveling of both arches
- Progressive wire sequence: .014" NiTi → .016" NiTi → .016"×.022" NiTi → .017"×.025" SS
- Proper bracket positioning for #22 to account for microdontia
Intermediate Phase (7-18 months):
- Space maintenance at #14 with open coil spring
- Space redistribution around #22 for future restoration
- Correction of the Class II tendency on the left side
- Coordination of arch widths and forms
Finishing Phase (19-24 months):
- Final space calibration for prosthetic replacement of #14
- Detailing of occlusion with settling elastics
- Coordination with restorative dentist for #22 provisional restoration
Retention Protocol:
- Upper: Hawley retainer with pontic at #14 site
- Lower: Fixed lingual retainer 3-3 with special attention to microdont #22
- Additive separate retainer with wrap-around design
Post-Orthodontic Phase:
- Referral for implant placement at site #14 (suitable after growth completion)
- Cosmetic enhancement of #22 with composite or veneer

Clinical Considerations and Risk Management

Potential Challenges:

Space Maintenance: Risk of minor space loss at #14 site - mitigate with appropriate mechanics and possibly temporary prosthesis
Root Resorption Risk: Standard monitoring with 12-month periapical radiographs
Microdont #22 Management: Specialized bracket positioning to avoid excessive torque on reduced root surface
Growth Considerations: Mild vertical change may affect occlusal relationships - incorporate this into retention strategy
Retention Compliance: Extended retention protocol until implant placement

Treatment Cost Analysis

Based on the quote from Kupat Holim Meuchedet, the comprehensive orthodontic treatment will cost ₪7,238.00 after insurance adjustments. This appears reasonable for the proposed treatment protocol and includes:

Full fixed appliance therapy for both arches: ₪4,114.00
Comprehensive retention protocol with multiple retainer options: ₪3,018.00
Diagnostic records: ₪106.00

Additional considerations not included in orthodontic quote:

Future implant and crown for #14: ₪8,000-12,000 (estimated, depends on provider)
Cosmetic restoration of #22: ₪1,000-2,500 (estimated, depends on technique)
Recommend discussion with insurance regarding potential coverage for these restorative procedures

This treatment plan analysis has been prepared based on comprehensive diagnostic records and biomechanical principles. The proposed approach balances functional, aesthetic, and long-term stability considerations while respecting the patient's specific dental anomalies.

I recommend discussing both treatment options with the patient and parents, with special emphasis on the long-term management of the dental anomalies.

Report prepared for Dr. Gil Dina Rom

Clinical Case Analysis Date: March 4, 2025