Adolescent orthodontic treatment /certified fixed orthodontic courses by Indian dental academy


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Adolescent orthodontic treatment /certified fixed orthodontic courses by Indian dental academy

  1. 1. ADOLESCENT ORTHODONTIC TREATMENT INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Introduction  Adolescence is the transitional period between childhood & adult years.  It is a time of awakening, aspirations, rebellion, learning to drive.  Often characterized using terms such as ‘tumultuous & turbulent’.
  3. 3.  This complex intersection of accelerated physical growth & dynamic hormonal change is accompanied by intensified self awareness & conflicting forces of acculturation to demands of society.  Orthodontic treatment of the adolescent patient presents many unique opportunities that may not be possible for adults.
  4. 4.  It is important , as far as understanding the possible stresses faced by the orthodontist, to recognize that the adolescent age is frequently the optimum time for treatment.  Even though orthodontic correction is indicated & time is opportune, the patient may not be enthusiastic.
  5. 5.  Reason is obvious. Orthodontic appliances imply a deformity, and at the very least are no asset to a young adolescent who is unsure of his/her attractiveness.  The prospective patient cannot always accept what seems as further mutilation, despite the fact that the treatment is of importance for future attractiveness.
  6. 6.  Most likely motivation for any patient to seek care stems from the patient’s desire to improve smile; however there may be factors influencing the adolescent patient's decision to undergo orthodontic treatment.  Trulsson et al ( J.O.2002 ) interviewed adolescent patients in an effort to analyze the factors affecting their decision to undergo orthodontics.
  7. 7.  The teenagers in study believed that they would make the final decision to initiate orthodontic treatment, but this decision was heavily influenced by “ the norm in their actual or desired reference group & by the surrounding world including the media's ideal body image”.  Teenagers wanted orthodontic care so that they could ‘be like everyone else’ & ‘to obey social norms’.
  8. 8.  In addition teenagers thought that a “nice appearance would lead to a high self esteem”.  Investigators noted that teenagers in study were not aware of the factors influencing their decision to undergo orthodontics.
  9. 9.  Another concern is compliance of patient due to length of time required to treat the patient.  Lack of compliance can impact the final treatment result. Can result in the patient being worse after treatment than before treatment.
  10. 10.  Adolescence is also the stage in psychosocial development in which a unique personal identity is acquired.  Includes both a feeling of belonging to larger group & a realization that one can exist outside the family.  According to Erikson adolescence age (12 to17) is where there is development of personal identity.
  11. 11.  Requires a partial withdrawal from the family, peer group increases still further in importance.  Members of peer group become role model, and the values & tastes of parents & other authority figure is being rejected.  So a poor psychological situation is created by orthodontic treatment if it is being carried out primarily because parents want , not child.
  12. 12.  Motivation for treatment can be divided into external and internal.  External motivation – Pressure from others.  Internal motivation – Individual’s own desire for treatment to correct a defect that he perceives in himself.  Approval of the peer group is extremely important.
  13. 13.  It is extremely important for an adolescent to actively desire the treatment as something being done ‘for’, not ‘to’ him/her.  According to Jean Piaget cognitive development theory, when an adolescence consider what others are thinking about, he assumes that others are thinking about the same thing he is thinking about, namely himself.  They feel as though they are constantly “on stage”, being observed & criticized by those around them. This phenomenon has been called the “imaginary audience” by Elkind.
  14. 14.  As a result of ‘imaginary audience’ a second phenomenon emerges , Elkind called it “ personal fable”. It makes adolescents thing that nothing could happen to them as they are unique.  Imaginary audience depending on what adolescent believes , may influence to accept or reject treatment, and to wear or not wear appliance.
  15. 15.  The personal fable may make a patient ignore threats to health, such as decalcification of teeth from poor oral hygiene during orthodontic therapy.  Orthodontist should not force upon the patient to wear a particular appliance if he is concerned about what others will think.  A more useful approach that does not deny the point of view of the patient is to agree with him, that he may be right, but ask him to try for a specified time.
  16. 16.  Encouraging a reluctant teenager to try it & judge his peers response is much likely to get him to wear the elastics than telling him every body else does it so he should do.  Cooper & Shapiro(1996) suggested taking time to identify an adolescent's concern & then to treat them as individuals, recognizing their values & issues. This approach reduces compliance barriers.   Orthodontists should understand that adolescents are not influenced strongly by health specific goals
  17. 17.       Grewal K, Sunny JP, Valiathan A (2003) A questionnaire study done at Manipal between April 2003 & June 2003 regarding patients expectations and perceptions towards orthodontic treatment . Mean age – 19.54yrs. 67%- Believed that their self confidence may be positively enhanced 42%- Felt that improved facial appearance would not be an advantage as far as their career opportunities are concerned. More than half of the total respondents felt that, to attain straight teeth was the first motivating factor to undergo treatment. Only 31.8% - felt that improvement in dental appearance may lead to enhanced facial appearance
  18. 18.  Orthodontic treatment of teenagers can be very rewarding, but some deeper issues of health care might be missed by the unprepared professional. This patient group is often viewed as inherently healthy, and important signs and symptoms of disease can be missed simply because of a biased outlook.  A particularly vital portion of the care of teenagers is monitoring for depression and other psychosocial disorders, including substance abuse. This period of life is a time of great psychological, social, and physical changes.
  19. 19.  Tobacco: cigarettes and smokeless tobacco : May have poor brushing habits ,Association with risky behaviors and antisocial personality types.  Alcohol : Antisocial behavior, Missed appointments ,Risky behaviors, Increased risk of hard drug use.  Opiates including heroin : Antisocial behavior Risky sexual behavior, Multi drug use, particularly with cocaine, Missed appointments Very poor oral hygiene.
  20. 20.  Steroids : Missed appointments, Aggressive behavior, Poor self esteem, Premature cessation of growth at epiphyseal plates.  The orthodontist is in a unique position to monitor adolescents for substance abuse.  Typical orthodontic treatment involves frequent appointments over several years.  By carefully noting intraoral and extraoral physical changes, the practitioner can monitor patients for signs of drug and alcohol abuse
  21. 21.  Treatment for most disorders centers on a combination of counseling and pharmacotherapy. Although it is not within an orthodontist’s practice to treat substance-abuse disorders, it is important to appropriately make a referral if a problem is detected.  It is of the utmost importance to respect the patient’s privacy in these instances and discuss substance abuse in a private consultation. Careful questioning of both the child and the parent can lead to a better understanding of the situation and an easy decision on referral .
  22. 22.  Teens often undergo significant peer pressure to try drugs and alcohol. It has been shown that orthodontic patients who use tobacco are at risk for other high-risk behaviors.  Suicidal behavior and substance abuse have been clearly linked, as have substance use and depression.  Because many orthodontic practices have been touched by suicide, it is important to be aware of some significant risk factors for this undesirable outcome
  23. 23. General Characteristics of Adolescent Malocclusion  a) Dentition and occlusal relationships are established!  b) Skeletal growth may be mostly over and decelerating.  c) Muscle function is matured. .  d) Functional malocclusions are less frequent since they have largely been accommodated by dentoalveolar, skeletal, and/or mandibular joint adaptations.
  24. 24.  e) Temporomandibular dysfunction is more frequent since dental, skeletal, and joint adaptability have diminished.  i) Psychological aspects are more significant than at younger ages.
  25. 25.  Irfan Dawoodbhoy & Ashima Valiathan (JICD 1993) have listed following treatment objectives for adolescent patients 1) Dentofacial esthetics 2) Stomatognathic system 3) Stability 4) Static & dynamic class I occlusion.
  26. 26. Advantages of Adolescent Treatment  a) Control of all permanent teeth, except third molars, is now possible.  b) It is beneficial to treat when bone turnover rates are still high though adult dimensions are nearly achieved. Repair and remodeling occur readily in response to orthodontic forces though the basic craniofacial morphology is largely established.  c) Motivation for treatment is high, especially when facial esthetics are affected.  d) Treatment goals can be more surely defined, does not have to counter, as much as earlier, the dynamics of growth.
  27. 27. Difficulties in Adolescent Treatment  a) The best opportunities for control and manipulation severe skeletal dysplasia are past.  b) Sports and social activities, so important to adolescents, often compete with plans for orthodontic treatment.  c) The time necessary for treatment may be longer for certain malocclusions.  d) Tooth positioning is often more difficult when occlusion is fully established and root formation is complete than tooth guidance was during eruption.
  28. 28.  Since precise tooth positioning is the principal strategy in adolescent treatment, cephalometric analysis for treatment planning is essential and many analyses have been designed solely to , determine the placement of teeth within particular skeletal morphologic patterns.
  29. 29.  Moyers group treatment goals for discussion, quantification, and planning as follows: (I) skeletal; (2) dental; (3) occlusal and functional; (4) soft-tissue and facial esthetics; and (5) compromises.
  30. 30.    I. Skeletal Improvement in the craniofacial skeleton by orthodontic treatment is still possible in adolescence, although the greatest opportunities for so doing may be over by this age. A primary aim of some clinicians is to predict the time of the adolescent of maturity When maxillo-mandibular relationships are altered , it is important to ascertain whether maxilla or mandible, or both are to be changed and to quantify the change sought in each jaw
  31. 31.  Although mandibular impedence or enhancement is more difficult after pubescence, midface changes are possible with intensive orthodontic forces.  Vertical change is most apt to occur within dentoalveolar process or by rotation of the mandible following dentoalveolar changes Planned horizontal and vertical skeletal changes ,should be quantified and monitored regularly by cephalometric analysis.
  32. 32.  2. Dental  a) Axial Inclinations : The roots of posterior teeth should be approximately parallel to one another, especially those roots adjacent to extraction sites. Artistic positioning of the crowns of anterior teeth usually results in a slight divergence of the roots.  The root angulation of the anterior teeth is lingual and an interincisal angle of 130 degrees may serve as a rough guide.  However, the percentage of the 130 degrees contributed by upper incisors and lower incisors varies greatly with the maxillo-mandibular relationship and the steepness of the mandibular and occlusal lines .
  33. 33.  b) Incisal Relations Ideally the overbite should be approximately one-third of the lower incisal crown. The overjet which is determined by a) the axial inclination of incisors, b) the skeletal relationship, c) the relation of the widths of upper to lower teeth (Bolton Index) , and d) the labiolingual thickness of the crowns should provide incisal centric stops in the intercuspal (usual occlusal) position.  c) Midlines The dental midlines should coincide with each other and with the mid-sagittal plane of the craniofacial skeleton.
  34. 34.     d) Arch Form The arch forms should be symmetric and coordinated with each other and should, as much as possible, be concordant with the forms of their skeletal bases. The mandibular intercanine diameter should rarely increase during adolescent treatment, since such an increase has been shown repeatedly to be unstable irrespective of the appliance use e) Spacing Ideally, all teeth in both arches should have firm interproximal contacts and there should be neither crowding nor rotations of the teeth. However, the Bolton Index may reveal that such perfect results are impossible and that some spacing or crowding is inevitable
  35. 35.  3. Occlusal and Functional.  The desired occlusal pattern (group function or cuspid rise) should be determined at the start and brackets placed accordingly.  The treated occlusion should display no deflective interferences during mandibular occlusal movements or in the retruded contact position (centric relation).  There should be no balancing interferences and the posterior teeth should disclude during protrusive movements.
  36. 36.   4. Soft Tissue Profile and Esthetics It is harder to quantify esthetic goals of treatment and personal tastes vary , yet there are some commonly accepted standards. The incisor positions should not strain the lip musculature and the incisal overlap should be harmonious with the lip line.  Little display of the gingivae during smiling is desirable. The lips should be without strain at rest and in function.  The incisors should not be retracted excessively lest the lip drape at rest will give an aged or edentulous appearance to the soft-tissue profile. Excessive retraction of the incisors also robs the lips of proper participation in facial expressions. 
  37. 37.   5. Compromises When defining goals for adolescent treatment, one begins with the ideals, listed above, accepting compromises only when the conditions of the case force one to do so. In adult treatment, one often is forced to begin with compromise .  In adolescent treatment every necessary compromise in the treatment plan should be quantified in terms of the skeletal profile and tooth positions, and all of the "tradeoffs" and consequences of compromise should be noted and understood at the start.  Often a hastily, casually, or unwittingly accepted compromise at the beginning has serious consequences later. Adolescent treatment should aim for idealism.
  38. 38.  When adolescent treatment is progressing in an unsatisfactory manner or an unsatisfactory result is observed at the "end" of treatment there are no easy alternatives.  Poor treatment does not stabilize or improve with time. Retreatment to the standards to be described is really the only satisfactory solution.  For this reason adolescent treatment must be accompanied not only by meticulously designed original goals but also by persistent monitoring throughout treatment.
  39. 39. Treatment planning   a) Congenitally Missing Teeth I. Maxillary Lateral Incisors.If a bridge or bridges are to be placed, the goals of treatment must include attentive detail to the positioning of the central incisors and cuspids which may be abutment teeth. When the cuspid and all other maxillary posterior teeth are to be moved mesially, obviating the need for a bridge, then the principal new goal is the meticulous placement of the cuspid root to parallel the central incisor. The first bicuspid and all posterior teeth are moved forward into a Class II relationship.
  40. 40.
  41. 41.
  42. 42.    Moving the first bicuspid forward into the cuspid region usually creates balancing interferences; therefore, its lingual cusp must be reduced gradually during its mesial movement. If a cuspid rise occlusion is desired, the bracket height on bicuspid must be placed atypically to guarantee its extrusion. Particular attention must be paid to the positioning of the molars and they must be equilibrated by occlusal grinding to secure the occlusal result.
  43. 43.  Mandibular Second Premolars.- The goals of treatment obviate the need for a bridge, secure a more correct intercuspation, and guarantee the height and health of the alveolar bone on mesial aspect of the mesial root of the first molar.  If a primary second molar is retained unduly, this usually results in an undesirable relationship of the alveolar septum between the second primar y molar's root and the first permanent molar
  44. 44.  Treatment of congenitally missing mandibular second bicuspids by mesial movement of all posterior teeth is not a difficult technical problem for anyone skilled in precision bracketed appliance therapy.  While the problem is best treated earlier it can still be treated well in adolescence with bracketed appliances. Its treatment with removable appliances is not recommended since ultimate parallelism of the roots is essential for a stable result.
  45. 45.  Eruption Problems.  Failure of a permanent tooth to erupt creates a severe orthodontic problem. A localized problem is typically created either by displacement of a permanent tooth from its normal eruption path so that the tooth becomes impacted (usually a maxillary canine) or by trauma that leads to ankylosis (usually a maxillary incisor) .   A generalized problem implies an abnormality in the eruption mechanism.
  46. 46.  Impacted Teeth. An impacted canine or other tooth in a teenage patient can usually be brought into the arch by orthodontic traction after being surgically exposed. In older patients, there is an increasing risk that the impacted tooth has become ankylosed. Even adolescents have a risk that surgical exposure of a tooth will lead to ankylosis. (Becker A, 1998) .  In planning treatment for an impacted permanent tooth, three principles should be followed: (1) The prognosis should be based on the extent of displacement and the surgical trauma required for exposure. As a rule, the greater the displacement and the greater the trauma, the poorer the prognosis.
  47. 47.    Extraction of a severely impacted tooth and orthodontic space closure or prosthetic replacement may be better judgment than heroic efforts to bring the tooth into the arch. (2) During surgical exposure, flaps should be reflected so that the tooth is ultimately pulled into the arch through keratinized tissue, not through alveolar mucosa. (3) Adequate space should be provided in the arch before attempting to pull the impacted tooth into position.
  48. 48.  Diagnostic factors of interest include the position of both crown and apex, the space available to accommodate the cuspid in the arch, and the position and health of adjacent teeth especially the roots of the lateral incisor,  the intactness of the labial cortical plate of bone, the willingness of the patient to undergo prolonged orthodontic treatment, and the relationship of the condition to other orthodontic treatment needed.  All require a meticulous radiographic perspective. The size of an impacted cuspid may be determined by measuring the antimere. 
  49. 49.  If both cuspids are impacted, measure the crown width of the maxillary first and second premolars and estimate the size of the cuspid crown by referring to appropriate tooth size charts .  Do not forget that sexual dimorphism in crown size is more obvious in the maxillary cuspid than any other tooth.  Measurement of crown size of impacted cuspids in the radiograph is flawed by distortion due to the angulation and the curvature of the film. Study carefully, in the radiograph, the health and morphology of the cuspid's root as well as its position
  50. 50.  If a tooth is severely impacted, surgical transplantation is a possible treatment approach. This involves removing the tooth, creating a socket at the appropriate site in the arch, and replanting the tooth in its correct position.  External root resorption often ensues after transplantation and is the major cause of failure. Approximately two thirds of transplanted teeth are functional for 5 rears, but only about one third are retained for 10 years.( Moss, 1972).  Orthodontic movement is preferable if it is possible.
  51. 51.    Generalized Eruption Failure. An eruption delay that affects several teeth in an adolescent patient is an ominous sign. If the problem is a mechanical interference with eruption the obvious treatment plan is to remove the interference and proceed with orthodontic therapy. The condition called "primary failure of eruption”, results from a failure of the eruption mechanism itself. Unfortunately, not only do the involved teeth not erupt spontaneously, they do not respond to orthodontic force and cannot be pulled into the arch. Since prosthetic replacement is the only practical solution, it is fortunate that the condition is rare.
  52. 52.  Hemisection: one large step toward management of congenitally missing lower second premolars. ( Angle 2004) Northway W. When the primary molar cannot be retained in cases of agenesis of the lower second premolar (CML5), there is the possibility of alveolar atrophy, and space closure might have a negative impact on facial fullness.  Bearing these in mind, the removal of the distal half of the second primary molar might allow closure in stages. Subsequent removal of the mesial half can be followed by space closure. Using this hemisection approach, space closure can be continued with ease improving treatment results.
  53. 53.  In order to test the amount of anchorage loss resulting from this approach, the pitchfork analysis was used to compare a group of 23 consecutively treated patients, each treated by hemisection, with two groups of 30 patients, each of whom was treated with the extraction of four premolars.  One group had four first premolars removed and the second group had second premolars removed.
  54. 54.    The CML5 group was divided into those which had upper teeth extracted in order to facilitate the correction and those who were treated without extraction in the upper. The hemisection groups showed statistically significant diminished distal movement of the upper incisor as well as the upper and lower lip. Lower molar protraction and molar relation was significantly increased. The process facilitates the keeping of upper premolars, which further enhances facial fullness.
  55. 55.     Ankylosis – First molars, maxillary cuspids, maxillary incisors are the permanent teeth most likely to be ankylosed. Etiology – unclear. History of trauma associated with incisor ankylosis. The goal of treatment in adolescence is to establish, if possible, proper occlusion: three methods are used: surgical, orthodontic, and restorative. The tooth should first be surgically exposed, carefully luxated, and splinted into an improved position. Subsequent orthodontic movements to an ideal position should then be attempted, though ankylosis usually reappears.
  56. 56.  If ankylosis recurs and the tooth is to be retained consider building it up to occlusion with composite until growth is apparently over and a permanent restoration can be placed.  There is a danger in retaining ankylosed teeth, namely localized cessation of alveolar growth which may bare the roots of adjacent teeth and predisposes to periodontal difficulties  If an ankylosed molar must be extracted, do not overlook the possibility of orthodontic closure of the edentulous space
  57. 57.
  58. 58. Variations in shape & size of teeth    a) "Large Teeth" This problem is really that of simple crowding b) Small Teeth . Esthetics are more critical at this age than during childhood and "permanent" treatment combining orthodontics and restorative dentistry can be quite successful. The introduction of composites, laminates, and porcelain veneered crowns offers esthetic and functional success previously not possible.
  59. 59.  c) Anomalies of Tooth Shape A more permanent treatment of crown anomalies is possible when started in adolescence. Moreover, problems handled earlier often may be treated again, advantageously, to an esthetic result which was not possible earlier. Anomalies in root length and morphology are more obvious in adolescence and often play an important role in treatment planning (e.g. , deciding whether to remove first or second bicuspids in extraction cases) .
  60. 60. Alignment Problems  When there is crowding in the early permanent dentition, an accurate space analysis can be carried out directly, without the necessity for predicting the size of unerupted teeth.  In this age group, however, it remains true that it is necessary to evaluate the amount of protrusion as well as the amount of crowding to totally evaluate the space situation.
  61. 61.  The diagnostic setup, a cephalometric analysis, and judgment of facial esthetics and the lip musculature are critical in defining a simple crowding case and planning its treatment.  One may advance and reposition the incisors in the cephalometric tracing to visualize twodimensionally and statically how such repositioning encroaches on the lip muscles.
  62. 62.  A significant difference between mixed dentition and early permanent dentition patients is that the simple appliances that can be used to solve space problems in the mixed dentition are no longer effective after the permanent teeth have erupted.  Whether a patient in the early permanent dentition is to be treated by arch expansion or by extraction, a bonded or banded fixed appliance is needed to position the teeth correctly.  Removable appliances of all types, along with lingual arches and other round wire or partially fixed appliances, are effective only for tipping teeth to new positions..
  63. 63.  Extraction of first premolars provides the greatest flexibility in terms of closing space which of course is a major reason for this being the most frequent extraction.  In contrast, little useful space for either purpose is provided by second molar extraction.
  64. 64.     Tooth Size Discrepancies – A tooth size discrepancy of less than 1.5 mm is usually insignificant, but larger discrepancies create a problem that must be solved in the development of a treatment plan. There are five possible approaches: (1) compensate for a small size differential by changing the inclination of the incisors;  (2) reduce the width of some teeth by interproximal stripping of enamel;  (3) build up the width of an anomalously small tooth or teeth by adding composite resin or a crown;
  65. 65.  (4) alter the normal extraction plan to compensate for size discrepancies (for instance, by extracting anomalously large lower second premolars rather than first premolars in what would otherwise be a first premolar extraction case);  (5) accept a small space in one of the arches, usually distal to the lateral incisors.
  66. 66.  Before one of the possible plans is accepted, it is important to determine whether the discrepancy is caused by a variation in one of the teeth or a generalized size difference between upper and lower teeth. This determination can be accomplished by Bolton analysis .  The usual culprits in tooth size problems are the upper lateral incisors, but second premolars in both arches also vary in size. Reducing or building up lateral incisors, if these are the source of the discrepancy, is the best approach. It is less easy to alter the width of premolars, and one of the other solutions may be required.  A diagnostic setup is usually needed to verify that a proposed treatment plan for tooth size discrepancy can succeed.
  67. 67.  If the permanent teeth have been allowed to erupt completely while still malaligned, it is rare that a satisfactory result can be obtained without using an orthodontic appliance that can change root positions. Just tipping the crowns to a new location is not enough.  If extraction is required to provide enough space, root movement is required to satisfactorily close the space
  68. 68.  Transverse Problems  Transverse problems in the adolescent age group, as in younger patients, are most likely the result of a narrow maxillary arch.  The necessary maxillary expansion may be approached either skeletally or dentally, depending on the anatomic basis of the problem.
  69. 69.  Single tooth crossbites or true unilateral asymmetries of the dental arch are usually best corrected by cross elastics in the affected area , provided that there is not a skeletal vertical problem that the elastics could aggravate. Reciprocal tooth movement will result if one tooth is pitted against another.  Differential unilateral maxillary expansion can be achieved by placing a lower fixed appliance and using cross elastics from the stabilized lower arch to the maxillary teeth on the affected side
  70. 70.
  71. 71.  Skeletal asymmetries - Posteroanterior cephalograms in the postural and occlusal positions are necessary for one to identify and differentiate both mediolateral and vertical skeletal asymmetry.  Mandibular landmarks which change between the two vertical positions are evidence of residual neuromuscular occlusal dysfunction.
  72. 72.  TMJ region should be searched for evidence of condylar or fossa asymmetry of either shape or position.  PA, lateral & oblique cephalograms, panoramic or special radiographic projections of TMJ may be necessary.
  73. 73.  True skeletal asymmetries in the adolescent age group pose an extremely difficult problem.  Treatment include RME, gradual expansion with a Quad Helix appliance.  Functional jaw orthopedic appliances can be used, but best time for their use is past.  If orthognathic surgery is necessary it usually is done later.
  74. 74. Sagittal Problems  The preferred treatment for skeletal problems, whatever the plane of space, is always growth modification. For greatest success, growth modification treatment should begin before the adolescent growth spurt, and the amount of remaining growth must be evaluated carefully before treatment is planned for an adolescent.  Girls mature earlier than boys, and it is possible that by the time a girl's permanent teeth have erupted, it is too late for effective growth modification.
  75. 75.  A second plan for correcting anteroposterior discrepancies is to camouflage them by differential movement of upper and lower incisors.  If the problem is severe, a third option is surgical repositioning of the jaws.
  76. 76. Class II malocclusion  Even in more favorable circumstances it is unlikely that more than half of the changes needed to correct class II malocclusion in adolescent would be gained by differential jaw growth.( max. 3 – 4mm ).  If a functional appliance is desired for adolescent treatment, often a fixed functional appliance is preferred.
  77. 77.  Distal driving of maxillary first molars becomes difficult .  Extraction of maxillary second molars & distal movement of remaining upper teeth can successfully correct moderate class II malocclusion. Here also one should not expect more than 4mm distal movement.
  78. 78.    Premolar extraction can produce excellent occlusion. Can also use class II elastics without extractions. However moving the lower incisors anteriorly more than 2mm lead to instability & relapse. Prolonged use of class II elastics can result in convex profile with protrusive lower incisors & a prominent lower lip. This is best described as relapse waiting to occur.
  79. 79.  Vertical growth is needed when inter arch elastics are used, to prevent rotating the mandible down & back as lower molars are elongated, and even then the elastics may produce an unesthetic elongation of the upper incisors.
  80. 80.  Skeletal, dental and soft-tissue changes induced by the Jasper Jumper appliance in late adolescence. ( Angle 2005) Nalbantgil D, Arun T, Sayinsu K, Fulya I. The purpose of this study was to evaluate the skeletal, dental, and soft-tissue changes in lateadolescent patients treated with Jasper Jumper applied with sectional arches. The study sample consisted of 30 subjects (15 treated, 15 untreated) with skeletal and dental Class II malocclusion.
  81. 81.  The results revealed that, in late- adolescent patients, the Jasper Jumper corrected Class II discrepancies mostly through dentoalveolar changes. It is suggested that this treatment method could be an alternative to orthognathic surgery in borderline Class II cases.
  82. 82. Class III malocclusion  Primary reason of treating class III malocclusion in adolescents is that, if postponed, the probabilities of needing orthognathic surgery combined with orthodontic therapy are greatly increased.  One can rationalize the treatment of class III in girls during adolescence is easier than that of boys, because treatment in girls is less apt to be thwarted by pubescent growth spurting & they are nearer adult dimensions than boys at each chronologic age.
  83. 83.  Strategies for treatment in adolescence include – 1) Ventral displacement of the midface. 2) Inhibition of mandibular growth. 3) Redirection of mandibular growth. 4) Dental & alveolar process repositioning. Facemask is used in cases of midface deficiency.
  84. 84.
  85. 85.
  86. 86.
  87. 87.
  88. 88.
  89. 89.  Mandibular prognathism is a more severe problem in adolescence than midface deficiency, particularly when the mandible is already hyperplastic prior to the adolescent growth spurt.  Chin cup treatment can be used in milder cases of mandibular prognathism.  Combining functional appliance with fully bracketed appliances in both arches is also useful in treatment.
  90. 90.  One must be prepared to accept defeat in some cases of mandibular prognathism, particularly in boys, whose dramatic growth during treatment may be a problem.  In such instances, secure cephalometric & cast records, remove the appliances, place retainers to maintain the arch. Monitor the case cephalometrically until such time as orthognathic surgery is indicated.
  91. 91.  Postpubertal assessment of treatment timing for maxillary expansion and protraction therapy followed by fixed appliances. ( AJO 2004) Franchi L, Baccetti T, McNamara JA. In this cephalometric investigation, authors evaluated the correction of Class III malocclusion in subjects who had attained postpubertal skeletal maturity and considered whether treatment timing influenced favorable craniofacial modifications. All subjects (n = 50) were treated with an initial phase of rapid maxillary expansion and protraction facemask therapy, followed by a second phase of preadjusted edgewise therapy.
  92. 92.  The treated sample was divided into an early treated group (early mixed or late deciduous dentition, 33 subjects) and a late treated group (late mixed dentition, 17 subjects). Mean treatment duration times were 7 years 2 months for the early treatment group and 4 years 5 months for the late treatment group.  The findings showed that orthopedic treatment of Class III malocclusion was more effective when it was initiated at an early developmental phase of the dentition (early mixed or late deciduous) rather than during later stages with respect to untreated Class III control groups.
  93. 93.  Patients treated with rapid maxillary expansion and facemask therapy in the late mixed dentition, however, still benefited from the treatment, but to a lesser degree.  Early treatment produced significant favorable postpubertal modifications in both maxillary and mandibular structures, whereas late treatment induced only a significant restriction of mandibular growth.
  94. 94. Vertical problems    The major vertical problems of adolescents are anterior open bite and anterior deep bite, both of which are likely to be seen in combination with some anteroposterior problem. As a child becomes older, it is more and more likely that malocclusion in the vertical plane of space, as in the anteroposterior plane of space, is related to skeletal jaw proportions and not just to displacement of the teeth. Eruption problems are also likely to be more serious in this age group.
  95. 95.  Anterior Open Bite. The skeletal indications of anterior open bite are increased anterior face height and a steep mandibular plane, both of which reflect excessive vertical growth of the maxilla and rotation of the mandible; and excessive eruption of posterior teeth.  Because of the downward and backward rotation of the mandible, the patient is likely to have a Class II jaw relationship in addition to the vertical problem.  Growth modification treatment, focuses on controlling both the vertical maxillary growth and eruption in both arches.
  96. 96.  The treatment of simple open bite in adolescence consists of identifying and controlling localized etiologic factors first, then bracketing teeth and coordinating arch forms. In a few cases, these steps alone may be sufficient  Vertical elastic traction is necessary to acquire full centric stops on all teeth. Check the occlusion carefully with articulation paper to determine that each tooth has been seated fully into occlusion.
  97. 97.  Allow the patient to wear the banded appliances for the initial period of retention, but do not remove them until normal swallowing and lip function obtain at all times.  Persistent hyperactive mentalis muscle activity may be treated with a modified vestibular shield.  For posterior simple open bite, a Hawley retainer with extended lingual flanges vertically is useful to control the tongue during retention.
  98. 98.     Complex open bite typically is difficult to treat orthodontically. In moderate cases, one attempts to achieve some esthetic cover-up of the skeletal dysplasia by alveolar process compensation. Extractions may be necessary , even when simple crowding is absent, to provide space for tooth positioning and alveolar remodeling. If initial orthodontic treatment does not succeed in more severe cases, surgery at a later age may be indicated. Growth tends to aggravate, not obscure, all cases of complex open bite.
  99. 99.  By the time adolescence is reached, environmental causes of anterior open bite have become less important than skeletal factors . It is rare for anterior open bite in an adolescent to be due solely to some habit, or for the open bite to correct spontaneously at this age after a habit has been corrected.  In the past, tongue thrust swallowing was blamed for many anterior open bites in this age group, and efforts at training the patient to swallow correctly were used in an attempt to control anterior open bite problems.
  100. 100.  Contemporary research, however, makes it clear that tongue thrust swallow is more an adaptation to the open bite than the cause of it .  Myofunctional therapy for tongue thrusting, for that reason, is ineffectual and not recommended.
  101. 101.  Deep Overbite. Anterior deep bite problems may result from an upward and forward rotation of the mandible, or from excessive eruption of mandibular incisor teeth.  Supra-eruption of lower incisors often accompanies a Class II malocclusion, because when there is excessive overjet, the lower incisors tend to erupt until they contact the palatal mucosa.  In comprehensive orthodontic treatment, usually it is necessary to correct this elongation of the lower incisors, by leveling out an excessive curve of Spee in the lower arch.
  102. 102.  In an adolescent whose face height is still increasing, it is only necessary to prevent further eruption of the lower incisors as vertical growth continues to achieve a relative intrusion.  Continuous arch mechanics are appropriate. In the absence of growth, however, absolute intrusion is required, and segmented arch mechanics must be used to achieve this
  103. 103.  Correction of skeletal deep bite problems requires rotating the mandible downward, thereby increasing the mandibular plane angle and anterior face height.  Keep in mind that in a patient with short anterior facial dimensions and a skeletal deep bite, rotating the mandible downward to correct the deep bite will reveal a skeletal mandibular deficiency.  Thus the growth modification techniques necessary to deal with this problem are typically those for correction of mandibular deficiency.
  104. 104.  Severe cases of deep bite combined with severe AP skeletal dysplasia. may require orthognathic surgery later.
  105. 105. Temporomandibular Joint Dysfunction  Temporomandibular dysfunction and associated signs and symptoms are more frequently seen in adolescence than in childhood. The origins are important to an understanding of the clinical problem in adolescence.  A history of facial trauma or temporomandibular joint trauma is often found.  Temporomandibular joint dysfunction may be seen with a variety of malocclusions in adolescence, although it is most frequently associated with Class II, deep bite, open bite, and skeletal asymmetry .
  106. 106.  Of particular importance are those cases with occlusal dysfunction such as an abnormal distance between the retruded contact and intercuspal positions and markedly deviant or erratic paths of mandibular closure.  A meticulous examination of the joints and associated musculature is essential for every adolescent malocclusion .  Many adolescents are unaware of myalgia or pain in tendons and the joint region because the condition has appeared so gradually that they have accommodated through time. Precise palpation may elicit points of tenderness of diagnostic significance.
  107. 107.  Treatment consists of correcting the malocclusion to the finest and most precise functional occlusal results, giving particular attention to the joints.  Detailed attention to tooth positioning, occlusal equilibration, and precise occlusal coordination are essential. Intermaxillary elastic traction during treatment is contraindicated in patients with TMJ symptoms.  Retention should not be started until perfect occlusal coordination is seen, but occlusal equilibration may be begun while the bracketed appliances are still in place.
  108. 108.  References have been made in the literature implicating adolescent orthodontic treatment as a causative factor in adult temporomandibular dysfunction,  but sound long-term clinical studies by Sadowsky & Begole ( AJO 1980 ) clearly show orthodontic treatment is not a significant etiologic factor on a population basis.  Any poor occlusal treatment at any age can contribute to temporomandibular pain or joint derangement.
  109. 109.  Orthodontic treatment significantly reduces the prevalence of temporomandibular joint disrders in adolescents, for the condition is more prevalent in malocclusions before their treatment
  110. 110. Current Trends    A recent trend is the use of invisible removable aligners for minor tooth movement. For adolescent orthodontic patients in whom growth/ orthopedic effects are deemed unnecessary, possibility exists for use of implant assisted orthodontics. Carano ( JCO 2005) however, caution against the use of orthodontic implants for girls younger than 16yrs & boys younger than 18yrs.
  111. 111. ASSESSMENT OF RESULTS OF ADOLESCENT TREATMENT  Evaluation of orthodontic treatments must be done precisely and with caution for there are many variables which determine the quality of a treated result.  Unless one knows exactly the conditions under which a case was treated, it is wise and professionally prudent to be cautious in conclusion and discreet in comment .
  112. 112.    Poor treatment does not stabilize or improve with time. Retreatment to the standards to be described is really the only satisfactory solution. For this reason adolescent treatment must be accompanied not only by meticulously designed original goals but also by persistent monitoring throughout treatment.
  113. 113.     Occlusion a) Occlusal Plan. If a cuspid rise occlusion was chosen, then the entire occlusion should be consonant with that theory .If group function was the plan, then the occlusion should be judged by the principles of that approach. b) Molar Relationships Much orthodontic treatment focuses only on first molar occlusion, but the occlusal relations of all molars and bicuspids should be studied carefully and the lingual molar occlusion is particularly revealing.
  114. 114.  c) Cuspid Occlusion While the cuspid occlusion is as important as the molars, it is not always possible to have equally good molar and cuspid reIationships if there are tooth size disharmonies.  More compromises in cuspid occlusion and overbite and overjet are necessary in men and boys because of the sexual dimorphism in maxillary cuspid size.
  115. 115.  d) Incisor Position Incisors must be placed well over the basal bone in each arch and well related to one another. Careful root positioning determines incisal stability and esthetics.  e) Functional Occlusal Relations :The occlusion must be studied in the retruded contact position (Centric relation) and in the intercuspal position (centric occlusion).
  116. 116.  There should be no occlusal interferences in retruded contact position nor any between the retruded contact and intercuspal positions.  It is especially important that there be balancing interferences . In protrusive occlusion the incisors should contact symmetrically and there must be complete posterior disclusion.
  117. 117.  f) Root Positions : In extraction cases, it is important that the roots be parallel directly beneath the crowns to avoid loss of interproximal contact. In treated crossbite cases, root positions must agree with correction.  g) Alignment : Crown size disharmonies may still be present at the end of treatment when there is a Bolton discrepancy. Disharmonies of tooth size and the adaptation of occlusal function to continuing growth may deny perfect alignment in some cases.
  118. 118.     Soft Tissues Facial and tongue musculature play an important role in stabilizing orthodontically treated cases, and the facial soft tissues determine, to a great extent, esthetic results. The time of treatment and the time of the evaluation are important since there are significant soft tissue growth changes during childhood and adolescence. One must also decide whether or not any adaptive functions which accompanied the malocclusion are still present after treatment.
  119. 119.  Gingiva: Gingival health after orthodontic treatment reflects not only oral hygiene but also the positions of the teeth achieved at the end of orthodontic therapy.  Especially vulnerable is the gingival height of mandibular incisors and the gingival relationship to maxillary molar and bicuspid roots after palatal expansion.
  120. 120.    Facial Esthetics Because each face is unique, it is impossible to produce identical results for all patients; rather, orthodontic treatment should enhance the patient's individual esthetic features. Special care must be taken in evaluating the child patient for there is a tendency to apply adult standards of facial esthetics
  121. 121.  The most common problems in facial esthetics involve extraction. In some cases choosing not to extract strains the limits of the alveolar process to achieve alignment, yet time, growth, occlusal function, etc. , may improve the eventual facial esthetics.  In other instances, unfortunately, the same factors produce crowding and malalignment.  Extractions which produce adult faces in young adolescents are to be deplored. for those same faces a few years later may look almost edentulous.
  122. 122.  No formulas are infallible when planning treatment and it is always easier to secondguess treatments after the fact.  Criticism comes easier than craftsmanship.  Facial esthetics is a matter of personal judgment, so one's own opinions about esthetics should be imposed with caution on colleagues who saw the patient at another time.
  123. 123. CONCLUSION  Some malocclusion are best treated in adolescence and a few are singular to this stage of development.  More malocclusions are probably treated in adolescence than any other period, not because it is always best time for therapy, but rather because this is the time at which patient & parent often become aware of this problem
  124. 124.  There are really very few proper clinical research reports on the effects of adolescent orthodontic treatment. Most other clinical writing at this time , reveal more personal clinical experiences & perceptions.  Therefore proper treatment planning for an adolescent case as well as highly developed clinical judgement & skill in use of fixed appliances are required.
  125. 125. References  Amanpreet Kaur Grewal, James Sunny P, Valiathan A. Expectations and perceptions of patients towards orthodontic treatment in Manipal . J Pierre Fauchard Academy 2003;19:83-88.  Sachdeva Sunil & Valiathan Ashima: "Whose mouth is it anyway?". Journal of Indian Orthodontic Society, 1994; 22(3): 105-108.  Sunil Sachdeva & Valiathan Ashima: Co-operation in orthodontics. Nepal Dental Journal 1999 :2(1)21-26.  Irfan Dawoodbhoy, Valiathan Ashima: Age & Orthodontics. Journal of International College of Dentist. 1993; 34: 20-25
  126. 126.  Nalbantgil D, Arun T, Sayinsu K, Fulya I : Skeletal, dental and soft-tissue changes induced by the Jasper Jumper appliance in late adolescence . Angle Orthod. 2005 May;75(3):426-36.  Franchi L, Baccetti T, McNamara JA. :Postpubertal assessment of treatment timing for maxillary expansion and protraction therapy followed by fixed appliances . AJODO. 2004 Nov;126(5):555-68  Northway W. : Hemisection: one large step toward management of congenitally missing lower second premolars. Angle Orthod. 2004 Dec;74(6):792-9.
  127. 127.  Carano A, Velo S, Leone P : Clinical application of the mini screw anchorage system. JCO 2005; 39 (1) 9-24.  Sadowsky C, Begole EA : Long term effects of TMJ function & functional occlusion after orthodontic treatment. AJO 1981; 78;201-212.  Trulsson U, StrandmarkM, Mohlin B : A qualitative study of teenager’s decision to undergo orthodontic treatment with fixed appliances. J Orthod 2002; 29 (3) : 197-204.
  128. 128.  Daniel J Rinchuse, Donald J Rinchuse : Developmental Occlusion, Orthodontic Interventions, and Orthognathic surgery for adolescents. DCNA 2006,(50); 69- 86.  Cooper ML, Shapiro ML: Motivations for health behaviors among adolescents. In Mcnamara JA, Trotman CF (eds) : Creating the compliant patient, Ann Arbor, Mich, 1996.  Robert E Moyers : Handbook of orthodontics. 4th edtn, Year book medical publishers, INC, Chicago, 1988. Pg432-471.
  129. 129.  Samir E Bishara : Textbook of orthodontics.2nd Reprint 2003, Elsevier , New Delhi. Pg – 454460.  William R Proffit : Contemporary Orthodontics . 3rd edtn, St.Louis, Mosby. Pg - 56-61, 229233,272-275.  Wendell W. Neeley, G. Thomas Kluemper ,Lon R. Hays : Psychiatry in orthodontics. Part 2: Substance abuse among adolescents and its relevance to orthodontic practice. AJODO 2006, 129 ( 2 ) ; 168-174.
  130. 130. Thank you Leader in continuing dental education