Adult orthodontics 1


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Adult orthodontics 1

  1. 1. ADULT ORTHODONTICS INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Index • Adult ? • History of adult orthodontics • Adult orthodontics • Reasons for increased interest of adults in orthodontic treatment • Indications • Contraindications • Difference between adult and adolescent patients • Limitations
  3. 3. Index • Treatment objectives • Diagnosis • Treatment planning : Psychological considerations Biomechanical considerations Periodontal considerations TMJ • Treatment : Adjunctive treatment Comprehensive treatment Surgical treatment • Conclusion
  4. 4. ADULT ? • Adult is defined as one who is fully grown, most males 18 and above and most females of 16 and above can be considered to be adults, although residual growth is left. • It is however quite impractical to determine the exact time when adulthood begins, since there is no definite age when a person reaches physical maturity.
  5. 5. HISTORY • Kingsley, in 1880, indicated an early awareness regarding orthodontic potential in adult patient. • He stated, “It may be regarded as settled fact that there are hardly any limits to the age when movement of teeth might not succeed.”
  6. 6. HISTORY • MacDowell(1901) was of the opinion that after the age of 16 years, a complete and permanent change in transition of the occlusion & hence orthodontic treatment, is almost impossible owing to the development of, - adult glenoid fossa, - density of the bones , - muscles of mastication.
  7. 7. HISTORY • Lischer (1912) believed that the period from 6th to 14th year was a golden age of treatment
  8. 8. HISTORY • In 1921 Calvin Case demonstrated the value of orthodontic therapy in the lower anterior area for the aged, periodontally affected patient.
  9. 9. ADULT ORTHODONTICS • Ackerman : “Adult orthodontics is concerned with striking a balance between achieving optimal proximal and occlusal contact of the teeth, acceptable dentofacial aesthetics, normal function and reasonable stability.”
  10. 10. Recent AAO survey : Increased % of patients >21 yrs, from 4% ten yrs ago, to almost 7% today; in another decade’s time adult pts would constitute 11% of avg orthodontic practice. • [JCO:1997:Gottleib,Nelson]
  11. 11. INCREASED INTEREST IN THE ADULT PATIENT Reasons [Melsen in „Curent controversies in Orthodontics‟] 1] Innovations in appliance placement techniques – Direct bonding, lingual/invisible appliances
  12. 12. 2] Innovations in material research – ceramic brackets & tooth coloured wires 3] Role of family dentist - Increased desire of restorative dentists and patients for treatment of dental mutilation problems using tooth movement rather than
  13. 13. 4] Role of media, visual as well as print - Articles in magazines ,news paper as well as community programs have increased patient awareness towards health & esthetics. 5] Better management of TMJ dysfunction.
  14. 14. 6] More effective management of skeletal jaw dysplasias with advanced orthognathic surgical techniques. 7] Reduced vulnerability to periodontal breakdown as a result of improved tooth relationships and occlusal functions. 8] A broader understanding of the biology of the tooth movement especially with regard to age changes.
  15. 15. 9] Ingenious approaches to anchorage management such as implants. 10] Role of Insurance companies – in the US 11] Affluence – Improving socioeconomic standards makes orthodontics more affordable today .
  16. 16. INDICATIONS (RAVINS) 1) Improvement of tooth-periodontal tissue relationship. 2) Establishing an improved plane of occlusion to distribute the forces of occlusion better. 3) Balancing the existing space for better prosthetic replacement. 4) Improve occlusion and coordination between the muscle and TMJ. 5) Improve patient
  17. 17. CONTRAINDICATIONS (BARRER) 1) Severe skeletal discrepancies. 2) Advanced local or systemic disease. 3) Excessive alveolar bone loss. 4) Poor stability prognosis – tooth movt into unfavourable positions. 5) Lack of patient motivation & co- operation, resistance to wear the
  18. 18. 6) Inability to prevent excessive hard/soft tissue destruction 7)Inadequate space for tooth movt 8)Movt of teeth against occlusal opposition or into occlusal trauma 9)No improvement in PDL health, function/esthetics. 10)Negative anchorage potential – movt of teeth against inadequate anchorage.
  19. 19. CONTRAINDICATIONS (Marks and Corn) • Advanced systemic disease • Lack of patient motivation.
  20. 20. 1] Younger adults (under 35, often in their 20’s) 2] Older patients (in their 40’s and 50’s) [Proffit-Fields] 2 GROUPS OF ADULT ORTHODONTIC PATIENTS
  21. 21. YOUNGER GROUP Goal – Comprehensive treatment & maximum possible improvement; improved quality of life.
  22. 22. Reasons for not receiving orthodontic treatment early 1) Did not desire treatment. 2) Were not aware of orthodontic treatment. 3) Parents could not afford. 4) Were not given proper advise by family dentist. 5) No orthodontist located in the vicinity.
  23. 23. 6) Incomplete orthodontic treatment when younger or were uncooperative. 7) Had orthodontic treatment as children but relapse occurred. 8) More conscious of appearance with age. 9) Anterior teeth started to crowd or minor crowding becomes worse. 10) Dissatisfaction with the outcome of previous treatment
  24. 24. OLDER GROUP Goal - - Maintain proper dental health. - For easy & effective control of disease & restoration of missing teeth. - As an adjunctive procedure to the larger periodontal & restorative goals ; not necessarily interested in the ideal result.
  25. 25. Reasons for seeking orthodontic treatment 1) Malposed teeth contributing to PDL disease. 2) Increased difficulties with mastication. 3) Anterior spaces enlarging or new ones developing. 4) For better tooth positioning prior to prosthetic preparation. 5) Tooth interferences & mandibular slide causing TMJ problems.
  26. 26. ADOLESCENT vs ADULT ORTHODONTIC PATIENT Levitt : “In adult patient there is no growth and only tooth movement”. Barrer : “Adult, unlike the child is a relentless patient, who will not cover our deficiencies in skills or our errors in the use of mechanical procedures by helpful settling in post-treatment.”
  27. 27. • Ackerman : “In a child ,one occasionally calls on another specialist. On the other hand it is a rare adult whom one treats orthodontically without finding it necessary to collaborate with another specialist.”
  28. 28. • Adults – orthodontic treatment is based on symptoms detected by the patient • Children - treatment is based more often on signs detected by practitioners/parents.
  29. 29. • Adult – seeks treatment more often for esthetics & hence is likely to have unreasonable expectations about the outcome, is less adaptable to the appliance & is uncompromising in appraisal of the Rx results. • Brighter side – cleaner, more careful, punctual, prompt paying, much less sensitive to pain & Rx time is either same/less than that for younger patients.
  30. 30. FIVE MAJOR CATEGORIES IN WHICH ADULT PATIENTS SIGNIFICANTLY DIFFER FROM THEIR ADOLESCENT COUNTERPARTS 1) Clarification & individualization of treatment objectives 2) The diagnostic process 3) Treatment plan selection 4) Acceptance of recommended therapy 5) Achievement of treatment objectives
  31. 31. 1) Clarification & individualization of treatment objectives- This requires specific study of the problem & the indicated therapeutic refinements.
  32. 32. 2) The diagnostic process- Problem oriented dental record aides in making the appropriate diagnosis, for it requires that the patient’s problems be listed and a plan be developed to manage each problem.
  33. 33. Diagnostic steps: 1) Collect data accurately. 2) Analyze data base. 3) Develop problem list. 4) Prepare tentative treatment plan. 5) Interact with those who are involved; discuss plans and options; clarify sequence, acquire patient acceptance. 6) Create final treatment plan.
  34. 34.
  35. 35. Before starting the treatment, the orthodontist needs to be prepared to do the following: 1) Diagnose different stages of PDL disease and their associated risk factors. 2) Diagnose TMJ dysfunction before, during or after tooth movement.
  36. 36. 3) Determine which cases require surgical management and which ones require incisor reangulation to camouflage the skeletal base discrepancy. 4) Work cooperatively with team of other specialists to give the patient the best outcome.
  37. 37. 3) Treatment plan selection- More systemic & detailed analysis is required for adults than for adolescents. Factor affecting treatment plan selection: i) Existing oral pathology: - dental caries - periodontal disease - faulty restoration - TMJ adaptability - occlusal
  38. 38. ii) Skeletal relationship. iii) Biological consideration: - neuromuscular maturity/adaptability . - periodontal susceptibility:bone loss/gingival inflammation . - rate of tooth movement. - growth. iv) Therapeutic approach available: - functional appliances. - orthognathic surgery. - restorative
  39. 39. v) Extraction therapy: 4 PM / asymmetric, lower incisor. vi) Anchorage requiremen: headgear / completely erupted 1st & 2nd molars vii) Missing teeth: space closure without / with prostheses
  40. 40. 4) Patient‟s acceptance of the treatment plan- Patients thorough understanding of & agreement with the recommended Rx are necessary. Also, an informed consent should be signed i) Sociobehavioral interaction: - Office environment: group / privacy - Team coordination, interaction: multidisciplinary approach ii) Duration of treatment.
  41. 41. iii) Cost of treatment: with/without insurance cover iv) Perceived risk/benefit ratio: more benefits compared to minimal risks v) Appliance selection. vi) Insurance coverage
  42. 42. • Vii) Negative conditioning: in the past . viii) Positive conditioning.
  43. 43. 5) Achievement of treatment objectives- -requires specific study of the problem & the indicated therapeutic refinements - depends on : i) Dental history. ii) Ability of the orthodontist to interface the treatment plan with those of other dental specialist. iii) skills and knowledge of orthodontist and staff.
  44. 44. LIMITATIONS OF TREATMENT 2 types of factors : • Intrinsic – Biological nature • Extrinsic – Biomechanical systems
  45. 45. INTRINSIC FACTORS • Most marked – Adult is no longer growing, so orthodontic Rx is limited to tooth movt & related modelling of the alveolar process only (may vary with the age & health ) • Periodontium – primary tissue to get affected. • Norton : decreasing blood flow & vascularity with increasing age – insufficient source of progenitor(preosteoblasts) cells – delayed response to mechanical stimulus.
  46. 46. • Alveolar bone – cortical bone becomes denser & spongy bone reduces with age & structure of bone changes from honeycomb to a network • Apical displacement of marginal bone level - local factor, age related but is also due to progressive PDL disease
  47. 47. • Teeth - adults are more likely to have missing teeth, teeth reduced in dimension due to attrition or teeth with large restorations.
  48. 48. EXTRINSIC FACTORS • Force system used differs from that used in young, growing individuals. • Forces used should be at a lower level than those used in children, as adults often have PDL problems & reduced bone support. • Initial forces should be further kept low as the immediate pool of cells available for resorption is low.
  49. 49. • M/F ratio for a particular tooth movt should be increased as per the periodontally compromised state of the dentition, to counter the tipping tendency.
  50. 50. • In the presence of marginal bone loss, light continuous intrusive forces should be maintained during tooth displacement.
  51. 51. !!! ADULT PROBLEMS DIFFICULT TO TREAT BY ORTHODONTICS !!! • Deep bite – extrusion of post teeth is not compensated for by condylar growth • Posterior crossbite – arch expansion is not stable • Skeletal discrepancies – since growth is complete.
  53. 53. 1) Dentofacial aesthetics 2) Stomatognathic function 3) Stability 4) Achieving Class I occlusion :ADULT ORTHODONTICS - TREATMENT OBJECTIVES
  54. 54.
  55. 55. ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES 1) Parallelism of abutment teeth : - Restoration will have better prognosis as excess cutting or devitalization during abutment preparation are avoided. - Allows for a better pdl response. - Allows for better
  56. 56.
  57. 57. 2) Most favorable distribution of teeth : - Evenly for replacement of fixed/removable prostheses in the individual arches - Teeth should be positioned in such a way that occlusion of natural teeth can be established bilaterally between the arches.
  58. 58.
  59. 59. 3) Redistribution of occlusal and incisal forces – Helpful in case of significant bone loss, to maintain the occlusal vertical dimension.
  60. 60.
  61. 61. 4) Adequate embrasure space and proper root position – Allows for better pdl health, especially when placement of restorations is necessary.
  62. 62.
  63. 63. 5) Acceptable occlusal plane and potential for incisal guidance at satisfactory vertical dimension – For a mutilated dentition with bite collapse, the Hawley bite plane adjusted to the correct vertical height, is inserted – allows a centric relation at an acceptable vertical dimension, simulatneous bilateral neuromuscular activity; Curve of spee should be mild to flat bilaterally – unilateral orthodontic treatment of an accentuated occlusal plane should be
  64. 64.
  65. 65. 6) Adequate occlusal landmark relationships: - Most difficult dimension to correct & maintain orthodontically – transverse sagittal vertical. - Teeth must be positioned to achieve acceptable B-L landmarks. Post crossbites due to severe transverse skeletal dysplasias – maxillary buccal cusps contact lower central fossae with the crossover for incisal guidance in the PM or canine
  66. 66.
  67. 67. 7) Better lip competency and support - Inadequate support may create change in antero-posterior and vertical position of upper lip and increase wrinkling. Some Class II, division 1 patients (surgery rejected) – lower incisors can be placed procumbent with bilateral posterior restorations – establish incisal guidance; avoids palatal tissue irritation. Some class III’s – maxillary incisors kept more flared than normal
  68. 68. 8) Improved crown/root ratio – In case of individual teeth bone loss, the crown to root ratio can be improved by decreasing the length of clinical crown with a high speed handpiece as the tooth is erupted orthodontically.
  69. 69.
  70. 70.
  71. 71. 9) Improvement/ correction of mucogingival and osseous defects:- Proper repositioning of prominent teeth in arch will improve gingival topography. Adolescents – brackets placed to level marginal ridges & cusp tips Adults – level crestal bone between adjacent CEJ’s; favorable osseous & soft tissue changes with tooth movt , diminished need for osseous/mucogingival surgery; continuous adjustment to prevent premature post teeth contact causing occlusal
  72. 72.
  73. 73. 10) Better self maintenance of pdl health: Location of gingival margin - determined by axial inclination & alignment of the tooth. For better periodontal health, teeth should be positioned properly over their basal bone support. 11) Esthetics and functional improvement: Rx= acceptable esthetics + improved muscle function + normal speech + mastication Therapeutic occlusion = ant teeth as disarticulators; post teeth support the vertical dimension.
  74. 74. Treatment planning Usual sequence of procedure is as follows – • Eliminate all pathology (caries, PDL disease, retained roots, etc) • Orthodontic Rx • Periodontal re-evaluation (& therapy if necessary) • Prosthetic restoration (when necessary) • Orthodontic retention • Periodontal maintenance • Occlusal adjustment (grinding) whenever necessary
  75. 75. BIOMECHANICAL CONSIDERATIONS: - Control of anchorage requires that anchor teeth should not be allowed to tip. - Fixed appliance is necessary.
  76. 76. • Adult patients demand for removable appliance but they are not useful in adjunctive treatment. - But in case of multiple missing teeth removable appliance is useful.
  77. 77. Placement of brackets • A=ideal position – uprighting of ant teeth (movt of anchor teeth is undesirable) • B=brackets placed in position of max convenience- maintains existing tooth
  78. 78. • - In case of reduce periodontal support and bone loss , lighter forces and relatively larger movements are needed.
  79. 79. TIMING AND SEQUENCE OF TREATMENT:- - Before any type of tooth movement any caries or pulpal pathology should be eliminated. - Larger restoration require detail occlusal anatomy should be carried out after orthodontic treatment is over.
  80. 80. - Periodontal disease should be controlled before any tooth movement. - Scaling, curettage and gingival graft should be carried out before treatment. - Surgical pocket elimination and osseous surgery should be carried out after orthodontic treatment.
  81. 81.
  82. 82. Psychological considerations • Children & adolescents – motivation for ortho Rx = parent’s desire; not emotionally involved in their own Rx • Adults – seek ortho Rx because they themselves want something, that is not always clearly expressed=hidden set of motivations/unrealistic expectations • Imp – explore why pt wants Rx & why now “Ortho Rx cannot repair personal relationships, save jobs, or overcome a series of financial disasters” -
  83. 83. • Most adults – have realistic expectations, more positive self image than average, a good deal of ego strength. • Internally motivated responds well to Rx than externally motivated. • Demand for invisible orthodontic appliances- unrealistic for a patient to expect that ortho Rx can be carried out without other people knowing about it
  84. 84. • Sometimes - Rx in a pvt area if the patient demands so; Most adults – learning from interacting with other patients = beneficial • Patient handling – Adolescents = passive acceptance of what is being done Adults = considerble degree of explanation of what is happening & why; Interest in Rx does not automatically translate into compliance with instructions
  85. 85. • Adults – less tolerant of discomfort & more likely to complain about pain after adjustments & about difficulties in speech, eating & tissue adaptations. Additional chair time to meet these demands should be anticipated
  88. 88. ADJUNCTIVE TREATMENT- “ Tooth movement carried out to facilitate other dental procedures necessary to control disease and restore function.”
  89. 89. GOALS - 1) Facilitates restorative treatment by positioning the teeth. 2) Improve periodontal health by removing plaque harboring areas . 3) Establishing favourable crown to root ratio and position of the teeth.
  90. 90. PROCEDURES CARRIED OUT IN ADJUNCTIVE TREATMENT : - 1) Up righting posterior teeth. 2) forced eruption. 3) alignment of anterior teeth. 4) cross bite correction.
  92. 92. 1) DENTAL ORIGIN:- a) Faulty eruption from the normal functional position. b) Insufficient arch length. c) Excessive arch length. d) Prolonged retention of primary teeth. e) Ectopic eruption.
  93. 93. g) Prolonged finger and thumb sucking habits. h) Clenching and grinding. i) Improper swallow pattern with tongue thrusting. j) Effects of tongue pressure on the anterior teeth.
  94. 94. k) Macroglossia. l) Premature loss of deciduous teeth. m) Loss of permanent teeth.
  95. 95. 2) SKELETAL ORIGIN:- a) Cleft palate. b) Gross mediolateral disharmony of the craniofacial skeleton.
  97. 97. • Loss of 1st perm molars – frequent problem in adults = adjacent teeth drift, tip/ rotate, gingival tissue becomes folded forming a pseudopocket.
  98. 98.
  99. 99. 1) If third molar is present , whether both second and third molar should be uprighted. 2) Whether to upright tipped teeth by distal crown tipping(increased space for a pontic) or by mesial root movement (reduce/close the edentulous space) – depending on the position of the teeth, occlusion desired, anchorage available, contour of the bone in the edentulous area
  100. 100.
  101. 101. 3) Whether slight extrusion is permissible or maintain the existing occlusal height during uprighting – tipping the tooth distally extrudes it, reduces the depth of the pseudopocket found on the mesial surface. Also, the crown-root ratio will be improved if the ht of the clinical crown is systematically reduced as the uprighting proceeds 4) Whether premolar should be repositioned or not – depending on the existing contacts, opposing intercuspation, restorative plan; mostly yes – close spaces between premolars=improves PDL prognosis & long term stability.
  102. 102.
  103. 103. APPLIANCE FOR MOLAR UPRIGHTING:- - Partial fixed appliance. - Anchorage –heavy stabilizing lingual arch (canine-to-canine). - Placement of brackets on canine and premolars(anchorage unit) – bonding preferred to banding – decreased gingival irritataion.
  104. 104.
  105. 105. • Molar to be uprighted – should have a combination attachment consisting of a wide twin bracketwith a convertible cap & a auxillary tube. • Lingual buttons/cleats should be welded to bands – if rotations/crossbites are also to be corrected
  106. 106.
  107. 107. UPRIGHTING A SINGLE MOLAR:-  Moderately tipped molar:- Flexible rect wire - 17x25 braided s.s, if the anchor teeth are relatively well aligned - 17x25 Ni-Ti, if the anchor teeth require alignment. Relieve occlusal contacts against the molar, otherwise mobility, increased Rx time  Severely tipped molar:- -stiff 19x25 s.s in the anchor segment - Uprighting spring ( 17x25 beta- Ti without helical loop/ 17x25 ss with loop)- mesial arm should hook over the stabilizing wire, Hook –should be free to slide distally as the molar uprights
  108. 108. • Slight lingual bend in the spring – to counter the forces that tend to tip the anchor teeth buccally & molar lingually • Frequent occlusal adjustments reqd to reduce developing interferences
  109. 109. Uprighting with minimal extrusion • After initial alignment with a light flexible wire, sectional “ T- loop” - 17x25 s.s - 19x25 beta-Ti Uprighting force on the molar- root mesial crown distal • Activation of T-loop by 1 to 2 mm – done when the pontic space is to be
  110. 110. modified T-loop. • In severely rotated teeth • End of archwire inserted through the distal of the tube.
  111. 111. Final positioning of molars and premolars. • After molar uprighting – increase the available pontic space & close open contacts in the anterior segment • Use of compressed coil spring - steel - A Ni-Ti; Stiff base arch = 17x25 ss/ 18 ss in 22 slot • Occlusion should be checked carefully for the desired movt .
  112. 112. Unilateral/bilateral uprighting
  113. 113. Uprighting 2 molars in the same quadrant • Since resistance is high, only small amounts of space closure should be attempted (unilaterally) • Combination of mesial root & distal crown tipping • 3rd Molar should carry a single rect tube & cap should be removed from the convertible bracket on the 2nd molar. • 2nd molar –usually more tipped than the 3rd –increased flexibility of wire mesial & distal to it is required. • Best approach = use of a highly flexible wire initially = 17x25 NiTi
  114. 114. Duration • Distal crown tipping faster than mesial root movt • Usually 8-10 weeks • Occlusal interferences –prolong Rx time • up righting 2 molars with mesial root movt may take 20-24 wks
  115. 115. RETENTION • Prosthesis –provides long term retention – should be placed within 6 wks • For shorter period – 19x25 ss /21x25 TMA designed to fit the brkts passively • For a longer period= - Intracoronal wire splint-19x25 or heavier ss wire bonded into shallow preparations on the abutment tooth
  116. 116. Segmental approach to mandibular molar uprighting - Roberts, Chacker, and Burstone • Stages of fabrication of the uprighting spring. [AJODO:1982 Mar (177 - 184)] 18X25 ss in 22 slot
  117. 117. Buccal and occlusal views (photographed at different stages of treatment) of the molar- uprighting appliance. The spring is offset lingually in the edentulous area for added patient comfort.
  118. 118. Anterior stabilizing segment • A lingual arch wire (approximately 0.032 inch) bonded, or soldered to bands, from canine to canine. Bonding the mandibular incisors to the lingual arch wire adds stability to these periodontally involved teeth. • Buccal edgewise brackets (0.018 or 0.022 inch slots) banded or bonded to the canine and premolars in the involved quadrant(s). The canine bracket contains two horizontal slots. • A full-size rectangular stabilizing wire passing from canine to premolar(s), stopped at both ends in order to prevent spacing and inserted into the occlusal slot of the canine
  119. 119. Jan Lindhe • Definite osseous defect due to periodontitis on the mesial surface of the inclined molar, uprighting, tipping distally = widen the defect • Furcation defects & orthodontic Rx: remain the same or worsen especially in the presence of inflammation (Burch et al, 1992) • Hence, initial PDL therapy & excellent oral hygiene & control of forces avoiding extrusion as much as possible are required.
  120. 120. • 1st described in 1973 by Heithersay • Elevates the root, expands PDL fibers results in coronal shift of marginal gingiva & bone. [Jan Lindhe] FORCED ERUPTION
  121. 121. • Indications:- - Defects in cervical third . - teeth with 1 or 2 walled vertical periodontal defects Due to - horizontal/oblique fracture -internal/external resorption -decay -pathologic perforation -PDL disease
  122. 122. Advantages • Improved endodontic access • Allow isolation under rubber dam, when not possible otherwise • Crown margins can be placed on sound tooth structure • Uniform gingival contour maintained-improved esthetics • Alv bone ht & bony support of adjacent teeth is not compromised • Apparent crown length is maintained • Maintains biologic width
  123. 123.
  124. 124. TREATMENT PLANNING:- - Periapical radiograph = for vertical extent of the defect, PDL support, root morphology & position; check for hypercementosis/dilaceration - Single tapering root morphology – ideal; flared and divergent root morphology – increasing root proximity with extrusion. - Endodontic therapy = before/after orthodontic Rx
  125. 125.
  126. 126. How much tooth should be extruded can be determine by 3 factors:- 1) Location of the defect.(fracture line, root perforation) 2) Space to place margin of the restoration, so that it is not at thebase of the gingival sulcus(1 mm) 3) An allowance for the biological width of the gingival attachment.(2 mm) crown-root ratio at the end of treatment should be 1:1 or better
  127. 127.  Duration:- depends on age of the pt, dist the tooth has to be moved, PDL viability - 1mm/week without damaging pdl. - 3 to 6 week.
  128. 128. TECHNIQUE • Appl – quite rigid over the anchor teeth, flexible where it attaches to the extruding tooth • Continuous flexible wire is contraindicated-produce the desired extrusion but would also tip the adjacent teeth towards the teeth being extruded, reducing the space for the pontic & disturbing the interproximal contacts
  129. 129. 2 METHODS Without orthodontic bracket. Heavy 19x25/21x25 ss bonded directly to the facial surfaces of teeth; Post & core with temporary crown, pin on the Rx tooth & an E module/ auxiliary NiTi spring is used to extrude the
  130. 130. With orthodontic brackets - better control. • Brackets are placed- more occlusally on anchor teeth than its ideal position; more gingivally on the Rx tooth • T-loop arch wire - - 17x25 s.s - 19x25 beta-Ti Part of the T loop engaging the tooth to be extruded should lie more occlusal than the anchor segment
  131. 131.
  132. 132.
  133. 133. RECALL & STABILIZATION : - Pt is seen every 1-2 wks for occlusal reduction of the extruding tooth, control inflammation & monitor progress - Stabilization - By passively fitting rectangular arch wire.(3 to 6 weeks) – allows proper reorganization of PDL, remodelling of bone - PDL surgey – if reqd, can be done after 1 month of completion of extrusion
  134. 134. Alternative method Jrnl of Prosthetic Dentistry: 1998: 79: 246-48: Ziskind, Schmidt, Hirschfeld • Horizontal channel on the adjacent tooth surface • A hook adapted to the canal walls cemented with a temporary cement. • Titanium post in the space of the missing coronal surfaces fixed over the hook by composite • Elastic thread tied between the hook & post = extrusive force • Replaced weekly, for approx 3 wks- required movt • Dist between hook & wire=dist the tooth can be extruded
  135. 135.
  136. 136.
  137. 137. Advantages • No orthodontic bands/brackets /wires used • Adjacent teeth exclusively as anchors • More comfortable, minimal irritation to soft tissues • Decreased risk of dental caries
  138. 138.
  139. 139. Biologic width • Maintained in a tooth with periodontal pocket (osseous defect ) • The connective tissue gets inflamed/ulcerated • The junctional epithelium migrates down the cementum=pocket formation
  140. 140. Molar Uprighting & Osseous defect • Angular bone loss along the mesial surface of tipped molars. • Uprighting such a tooth appears to cause a shallowing-out of the angular defect with new bone forming at the mesial alv crest, attachment level remains unchanged. • Uprighting, by tipping distally = widens the defect
  141. 141.
  142. 142. Movt into compromised bone areas • In patients with previous extraction of 1st molar & a more or less compromised alv process (reduced bone height- avg=1.3mm/constricted area) – second molars can be moved mesially • Complications- vertical bone loss, space reopening, buccal or lingual bone dehiscences • Light forces – a thin bone plate recreated ahead of the moving tooth • Excellent oral
  143. 143. • For markedly atrophied alv ridges, new bone tissue growth should be considered using osseous reconstructive surgery
  144. 144. Tooth movement into intrabony defects • Provided elimination of the subgingival infection is performed before the orthodontic tooth movt – no detrimental effect on the level of attachment • Angular bony defect – eliminated but no coronal gain of attachment; a thin epithelial lining covers the root surface corresponding to its pre Rx
  145. 145. • Periodontal therapy with elimination of plaque induced lesion should be performed before Orthodontic Rx is begun + maintainence of excellent oral hygiene throughout the course of Rx • If orthodontic tooth movt into & through a site of inflammation & angular bone loss - enhanced rate of PDL destruction
  146. 146. Use of orthodontic movt to reduce infrabony pockets in adult periodontal patients – Intnl jrnl of periodontics, restorative dentistry 2002:22:365-371-Stefania Re et al • Coronal tooth movt – able to fill osseous defects – alv bone follows the tooth in its displacement. • Intrusive displacement – can establish a healthy & well functioning dentition, does not cause decrease in marginal bone level if gingival inflammation is
  147. 147. • 44yr old woman with severe PDL disease that led to spacing, extrusion of maxillary left central incisor & serious functional, esthetic problems. • Radiologically – a deep angular bony defect on the mesial surface of the left central
  148. 148. • Initial probing depth= 9mm(mesial surface) • Gingival recession=3.5mm • Supra, sub gingival scaling with oral hygiene instructions + surgical periodontal Rx (Flap)on the incisor – to eliminate the infection • Fixed appls in place 1 week after the surgery = early stimulation of connective tissue progenitor cells necessary to foster regeneration • Light, continuous forces=10gm; 15 months • Periodic follow up=every 2 weeks; Prophylaxis=every 3 months
  149. 149. • Anterior fixed bonded splint – to avoid relapse + masticatory comfort • Final IOPA – elimination & almost complete fill of the defect • Clinically – only a physiologic sulcus, no gingival recession, no bleeding on probing
  150. 150.
  151. 151. ALIGNMENT OF ANTERIOR TEETH Indications:- 1) To improve access and permit placement of well contoured restorations (composite build up/splinting periodontally compromised incisors). 2) To permit placement of crowns and pontics .
  152. 152. 3) To reposition closely approximated roots and to improve the amount of interradicular bone. 4) To position teeth so that implants can be placed to support restorations.
  153. 153. Rx planning • Ant teeth that need alignment shld be brought into their proper position before definitive restorative procedures. • Progressive interproximal stripping – to create space • Diagnostic setup – very helpful in planning Rx = alternative tooth positions may be tried to determine the optimum for each pt. & feasibility of ortho Rx evaluated
  154. 154.
  155. 155. Alignment of crowded, rotated and displaced incisors Using a fixed appl – initial arch wire = light, flexible : 016NiTi/0175 braided ss – cinched 3-4 week recall progress to rectangular flexible wire to achieve root positioning Retention –removable retainer –immediately after debonding - rotations=supracrestal fiberotomy; -crown construction – after 6-8
  156. 156.
  157. 157.
  158. 158. Interdental gingivae • In the anterior regions – pyramidal; since contact points present • In the premolar, molar regions – tent shaped, concave(flattened) in the B-L direction • Histologically – thin, non keratinized epithelium
  159. 159.
  160. 160. • Shape is determined by the contact relationship between teeth, width of adjacent tooth surfaces & the course of CEJ
  161. 161. Interdental recession - “Dark triangles”/empty spaces between teeth = unesthetic - Dist between crestal bone & contact point=5mm or less=normal papilla; if this distance >5mm =dark triangles form [Tarnow, Fletcher, Ma gner:Jrnl of Periodontology 1992:63:995-996]
  162. 162. Reasons : • Advanced PDL disease - by tissue destruction/pocket elimination due to surgery • Roots excessively divergent due to improper brkt placement • Triangular tooth shape due to interproxmimal wear in crowded positions before ortho Rx Rx : • Mucogingival surgery-coronally repositioned flaps, GTR • M-D enamel reduction • Paralleling the roots of adjacent teeth • Gingival
  163. 163. Gingival Zenith • Most apical position of the gingiva over the facial aspect • On maxillary central incisor & canine – it is slightly distal to the long axis of the tooth while in the maxillary lateral incisor, it is at the long axis. • At the same levels approx for the central incisors & canines • Slightly at a lower level for the laterals(1mm) [Esthetics of ant fixed prosthodontics – Gerarad Cliché, Alain Pinault; Esthetic dentistry – Dr Ratnadeep Patil]
  164. 164. • Esthetic consideration – gingival margins of maxillary central incisors & canines are positioned at vermillion border of upper lip & gingival margins of lateral incisors are located 1-2mm more incisally or at the same height of the central incisors & canines.
  165. 165. • Whenever a patient displays the gingival margins easily on smiling/speaking , a definite pattern of the gingival display can be recorded which can be either esthetic/unesthe tic; • Unesthetic=whe never the lateral incisors are placed more apical to the central incisors
  166. 166. Separation of approximated teeth. • Close root proximity - prevents satisfactory restorative procedures, increased susceptibility to rapid progression if PDL disease develops • Root movt –using fixed appls • Duration = 8-10 wks • Confirm using an IOPA
  167. 167.
  168. 168. Managing Treatment for the Orthodontic Patient With Periodontal Problems David P. Mathews and Vincent G. Kokich (Semin Orthod 1997;3:21-38.) • Generally, 2 to 3 mm of root separation will provide adequate bone and embrasure space to improve periodontal health. • During this time the patient should be maintained by their restorative dentist or periodontist to ensure that a favorable bone response will occur as the roots are moved apart. • In addition, these patients will need occasional occlusal adjustment to recontour the crown as the roots are moving apart. As this happens, the crowns may develop an unusual occlusal contact with the opposing arch. This should be equilibrated to improve the
  169. 169. Position teeth for single tooth implant 3 factors that determine the space available for implant 1-space needed for implant itself - Minimum 6mm of space is required =1mm between the implant & adjacent teeth for proper healing & adequate space for the papilla + 4 mm width of the implant at the shoulder 2- esthetics= contra lateral & adjacent teeth for the prosthetic replacement - size, bilateral symmetry 3- occlusion =less than ideal space for implant due to crowding
  170. 170.
  171. 171. • Technique –for space regaining/root positioning – careful brkt placement & control of anchorage • Duration – ideal root placement – 6 months; confirm by IOPA
  172. 172. Interdisciplinary Management of Single-Tooth Implants Frank M. Spear, David M. Mathews, and Vincent G. Kokich (Semin Orthod 1997;3:45-72.) • If the implant is placed and restored too early, relative to the patient's tooth eruption, the reaction of the implant will be similar to that of an ankylosed tooth. The adjacent teeth may erupt, and a discrepancy will be created between the gingival margins of the implant and the natural teeth. • In a patient with a high lip line, this could be esthetically unacceptable. For these reasons patients should have completed the majority of their tooth eruption before the placement of an implant.
  173. 173. • It is advisable to wait until an adolescent male has completed growth in height (as late as their early 20s). In girls, the growth of the face is often completed by 15 years of age. Therefore, it may be possible to place implants for congenitally missing teeth as early as 15-17 yrs years in girls without the risk of eruption of adjacent teeth. • In adults, who lose a tooth, implant can be placed soon afterward-minimizes the loss of alveolar bone in the newly edentulous space • Maintaining primary teeth-even though their roots are partially resorbed, also helps in maintaining alveolar ridge height & width for implant
  174. 174.
  175. 175. Buccal & coronal bone augmentataion using orthodontic tooth movt – T Nozawa, T Sugiyama et al: Intnl jrnl of periodontics, restorative dentistry 2003:23:585-591 • Combination of forced eruption & buccal root torque to achieve buccal & coronal bone augmentation & soft tissue enlargement for immediate implant placement • 45 yr old woman
  176. 176. • Mandibular left 2nd premolar – facial probing depth = 6mm at mesial, middle & distal; 3mm at midlingual • Recession at midfacial gingiva=5mm; width of keratiinized gingiva=1mm, tooth mobility=grade1; poor prognosis • Initial periodontal surgery – with enamel matrix derivative placement • Post surgery 5months – angular defects had exaggerated
  177. 177. • Post surgery 7 months –RCF done & forced eruption using hook was started; buccal root torque added 4 wks later; brkt position was displaced gradually in an apical direction at 8wks • 12 wks later-tooth was extruded by 15mm; dist between root apex & bone =3.5mm • At 20 wks-dist between root apex & bone =1 mm
  178. 178. • Reentry surgery – tooth extracted, bone defect completely disappeared • Implant placed, 20 months later - provisional restoration; 41 months later – definitive restoration
  179. 179. • Root moved beyond the buccal alv process – gingival recession with bone dehiscence occurred • Coronal & buccal bone formation induced till the original buccal bone plate • Tension force breaks down the adhesion between root surface & junctional epithelium, shifts apically -recession
  180. 180. CROSSBITE CORRECTION:- - Crossbites can cause functional problem – occlusal interferences, occlusal trauma & improper occlusal loading. - Single tooth crossbite – due to displacement of crowded teeth/ectopic eruption - Group of teeth in crossbite - part of skeletal
  181. 181. Correction with removable appliances – Especially in an anterior segment – when the etiology is displaced teeth requiring only tipping movements -Disadvantage : as a tooth rotates labially/buccally, there is a vertical change in occlusal level=apparent intrusion, reduction in overbite -Problem with retention- as a positive overbite is the key to retain the crossbite correction.
  182. 182.
  183. 183. Fixed appliance –necessary for vertical control & bodily movement • Progressive stiffer round wires are placed to align , final correction of root position achieved only by placing a rectangular wire that will almost fill the slot • Reciprocal force – tends to move the anchor teeth into crossbite - use of a TPA • In case of deepbite with crossbite – correction will be much easier if a temporary bite plane to free the occlusion is
  184. 184. • Posterior segments -Correction with the “through the bite” elastics from a conveniently placed tooth in the opposing arch. • Tips the teeth into correct occlusion + extrudes them, hence must be used with caution as they change occlusal relationships
  185. 185.
  186. 186.
  187. 187. Intrusion of teeth • Indications : for teeth with horizontal bone loss or infrabony pockets; for increasing the clinical crown length of single teeth (to level the gingival margins to desired heights then to be provided with veneers/crowns) • Oral hygiene is inadequate – intrusion may shift supragingival plaque into a subgingival location =PDL destruction • Clinically, ortho tooth movt intrudes a long epithelial attachment beneath the margin of alveolar bone [Melsen et al:AJODO 1989:96:232-41]
  188. 188. Orthodontic movt into bone defects augmented with bovine bone mineral, fibrin sealer – Intnl jrnl of periodontics, restorative dentistry 2002:22:365-371-Stefania Re et al • Periodontal disease-migration of ant teeth with the presence of intrabony defects • Combination of orthodontic therapy & bone grafting – to treat an adult periodontal patient with extrusion, proclination of maxillary central incisor & intrabony defect on their
  189. 189. • 57 yr old woman with adult periodontitis – pathologic extrusion, lengthening of clinical crown with gingival recession, bleeding on probing • Initial probing depth on the lingual surface: >/=
  190. 190. • Initial - Supra, sub gingival scaling with oral hygiene instructions + passive ortho appls inserted to avoid tooth mobility
  191. 191. • After anesthesia, surgery to augment the osseous defect done • 10 days post op: sutures removed, a ctive orthodontic movt
  192. 192. • Light, continuous forces = about 10gm • Left central incisor-1st realigned with an intrusive base arch (.017x.025 TMA) , simultaneously intruded & moved the tooth lingually into the defect • Ortho Rx- 6 months • Periodic follow up=every 2 weeks; Prophylaxis=every 3 months
  193. 193. • Anterior fixed bonded splint – to avoid relapse + masticatory comfort • Final IOPA – elimination & almost complete fill of the defect • Clinically – only a physiologic sulcus, no gingival recession, no bleeding on probing
  194. 194. Anterior diastema closure and space redistribution:- Causes for drifting/spacing of incisors- - Loss of posterior teeth. - Small teeth. - Loss of bone support.
  195. 195. • Partial closure of incisor spacing &redistribution of diastema space, followed by composite build ups &/or replacement of missing teeth = best esthetics
  196. 196. TREATMENT:- -Diastema is small/is due to adjacent teeth tipped in opposite directions = With Removable appliance -using finger springs to close the space by simple tipping. -Teeth are bodily displaced/widely separated = With fixed appliance – control both crown & root positions
  197. 197. Fixed appliance: • Continuous arch from molar to molar if several teeth are to be moved or involve just the anterior segment if only 2 or 3 teeth are to be moved • Initial alignment – with a light wire 016 NiTi or 0175 braided steel • After 3-4 weeks , replaced with 016 or 018 ss along which the teeth are repositioned using E modules or coil springs • If tooth size discrepancy exists(abnormally small teeth in one arch) – impossible to close all the space- teeth moved into an ideally separated position & crowns built up either with composite/
  198. 198.
  199. 199. • Permanent retention – lingual bonded retainer, fused crowns, FPD • Restorations of the teeth – (using composite build ups) when excess spaces are present = should be placed on the same day the orthodontic appliance is removed
  200. 200. Tooth movement through cortical bone • When a tooth is moved bodily in a labial direction towards & through the cortical plate, no bone formation takes place in front of the tooth - Experimental studies in animals • After initial thinning of the bone plate, a labial bone dehiscence is hence created • Such perforation of the cortical plate can occur during orthodontic Rx either accidentally or because it was considered
  201. 201. • Cortical plate perforation & root resorption may happen: - In the mandibular ant region due to frontal expansion of incisors (facial root tipping) [Wehrbein et al; AJODO 1994:106:455-462] - In the maxillary post region during lat expansion of cross-bites [Greenbaum, Zachrisson; AJODO 1982:81:12-21] - Lingually in the maxilla associated with retraction & lingual root torque of maxillary incisors in patients with large overjets [Ten Hoeve, Mulie; JCO 1976:6:804-822] - By pronounced traumatic jiggling of teeth [Nyman et al ]
  202. 202. • Repair : may take place when the malpositioned teeth are moved back toward their original positions & bone apposition may take place • Bone dehiscences that have occurred may be repaired when the teeth are brought back, or relapse towards a proper position within the alveolar process, even if this occurs several months later.
  203. 203.
  204. 204. Chester S. Handelman : The anterior alveolus: its importance in limiting orthodontic treatment and its influence on the occurrence of iatrogenic sequelae [Angle Orthodontist:1996;No.2;95 – 110] • To delineate the limits of orthodontic tooth movement in adult patients prior to the start of treatment. • To enhance treatment planning, especially in situations where the skeletal discrepancy is severe or where one or both arches can accommodate only limited tooth repositioning, especially in borderline orthodontic-surgical cases.
  205. 205. • Cephalometric films of 107 adults were measured to determine the width of alveolar bone anterior and posterior to the incisor apex in each arch. • Thin alveolar widths were found both labial and lingual to the mandibular incisors in groups of Class I, II, and III individuals with high SN-MP angle and in a group of Class III average SN-MP individuals. • Thin alveolar widths were also found lingual to the maxillary incisors in a Class II high angle group.
  206. 206. • The labial and lingual cortical plates at the level of the incisor apex may represent the anatomic limits of tooth movement. • Clinical cases showed that orthodontic tooth movement may be limited in patients with narrow alveolar bone widths and that these patients are likely to experience increased iatrogenic sequelae (root resorption, bone loss, gingival recession).
  207. 207. Edwards J G [AJODO 1976] : • Studied a large group of individuals with Class II malocclusion and bidental protrusion. • He noted that despite prolonged palatal retraction and root torquing of incisors, the width of the anterior palate at the level of the apex remained unchanged. The alveolus can, however, remodel at the mid-root level and at the alveolar margin when the lingual cortex is approached and passed. • He postulated an anatomic barrier against further tooth movement in the higher areas at the anterior palatal curvature as it approaches the horizontal
  208. 208. Edwards J G: • A: The assumption is that the total alveolus can remodel to accommodate unlimited tooth movement. This is not seen in clinical practice. • B: The assumption is that only the midroot and marginal alveolus can remodel, while the bone at the level of the apex does not remodel and is thus a limit to orthodontic tooth movement.
  209. 209. Ten Hoeve and Mulie [JCO 1976] : • Studied tooth movement at each stage of the Begg technique in a group of adolescent patients using cephalometric x-rays, and laminagraphs • They concluded that while there is no anatomical limit to tooth movement in the marginal area of the alveolus, there is a definite limit to tooth movement as the apex abuts the palatal cortex. • In the mandible, following contact of the root with the lingual cortical plate of the symphysis, tooth movement comes to a standstill. Eventually, if greater forces are applied, a perforation or dehiscence
  210. 210. The measurements used in this study are illustrated below : • UP -Bone posterior (lingual) to upper incisor apex. Apex of the maxillary central incisors to the limit of the palatal cortex, along a plane parallel to the palatal plane, drawn through the apex. • UA -Bone anterior (labial) to upper incisor apex. Apex of the maxillary central incisors to the limit of the labial cortex, along a plane parallel to ANS-PNS, drawn through the apex. • LP -Bone posterior (lingual) to mandibular incisor apex. Apex of the mandibular central incisor to the limit of the lingual cortex, along a plane parallel to the occlusal plane, drawn through the apex.
  211. 211. • LA -Bone anterior (labial) to mandibular incisor apex. Apex of the mandibular central incisors to the limit of the labial cortex, along a plane parallel to the occlusal plane, drawn through the apex. • UH -Bone superior to upper incisor apex. The shortest distance from the maxillary incisor apex to the ANS-PNS plane. • LH -Bone inferior to mandibular incisor apex. The shortest distance from the apex of mandibular incisor apex to the lowest point on the mandibular synthesis that is transected by a line parallel to occlusal plane.
  212. 212. • Cephalometric measurements that define the width and height of the incisor alveolus.
  213. 213. • Class I average skeletal pattern. The mean for each alveolar measurement is illustrated.
  214. 214. Repositioning teeth beyond the alveolar housing: Mulhe and Ten Hoeve - • If the apex was moved beyond the alveolus, the cortex in that region would not significantly remodel and the lingual cortical plate of the symphysis could be perforated. • The combination of age and the extremely thin alveolus can contribute to the perforation by the apex. • Long-term stabilization not only prevents mobility, but will possibly allow for remodeling repair of the bone loss on the lingual of the
  215. 215. Conclusions 1. Cephalometric measurements were established for the various combinations of horizontal and vertical facial types for the width of bone labial and lingual to the incisor apices. 2. A narrow alveolus was frequently noted around the mandibular incisors in high SN-MP groups and in the Class III average group. A thin alveolus was often noted lingual to the maxillary incisor apex in the Class II high SN-MP group. 3. While individuals of any facial type could have a thin alveolus, this was rarely seen in low SN-MP groups or in the Class I average SN-MP
  216. 216. 4. Clinical cases demonstrate that the palatal wall of the maxilla and the posterior cortex of the symphysis represent “orthodontic walls” or barriers to tooth movement. 5. While the iatrogenic response to challenging the anatomic limits is variable, the severity of this response can compromise the periodontal support of the incisors involved. 6. Norms for alveolar width in the Class I average group are presented. A simplified prediction can be achieved using overlay acetate tracings of the projected
  217. 217. 7. Patients with either narrow alveolar width or severe skeletal discrepancies are most likely to demonstrate limitation in orthodontic correction and may require surgery. 8. These same patients are also likely to exhibit severe iatrogenic loss of periodontal support when tooth movement challenges the “orthodontic walls” represented by the dense cortical plates at the level of the incisor apices. 9. The width of the anterior alveolus combined with a visualized treatment projection can be used in determining if the borderline patient is best treated via conventional orthodontics or a combined orthodontic-surgical program.
  218. 218. Root resorption in adults • Orthodontic treatment and apical root resorption have been associated for many years • The exact nature of the initiation and control of apical root resorption remains essentially unknown. • Although apical root resorption may occur in individuals who have never experienced orthodontic tooth movement (normal physiological process, perhaps akin to continuous bone remodeling), the incidence among treated individuals is quite high [Etiology and Sequelae of Root Resorption : Vicki Vlaskalic, Robert L. Boyd, and Sheldon Baumrind: Semin Orthod 1998;4:124-131]
  219. 219. • It must be concluded from the body of evidence existing in the literature that the sequelae of orthodontically related resorption does not pose a long-term threat to the patient. • Long-term treatment outcome studies reported on the frequent detection of resorption but of only minor nature and with no discernible clinical significance.
  220. 220. Lupi, Handelman, Sadowsky : AJODO 1996 : 109:28-37 : they used periapical radiographs of maxillary and mandibular incisors to measure apical root resorption. • Sample : 88 ethnically and racially diverse adults • Result : 15% of teeth had resorption before treatment and that this increased to 73% after at least 12 months of fixed appliance treatment. • Although only 2% of the teeth showed moderate (beyond blunting and up to one third of root length) to severe (beyond one third of root length) resorption before treatment, 24.5% displayed this severity after treatment. Two percent of patients experienced resorption beyond one third of the original root length.
  221. 221. Risk factors of root resorption : Mirabella, Artun : AJODO 1995:108:48-55 • Sample : 343 patients, aged 20.0 to 70.1 years at T-1 (mean 34.5, SD 9.0) and treated for 0.6 to 5.2 years (mean 2.0, SD 0.7) • Type of initial malocclusion may not be of importance for amount of apical root resorption during treatment. Some believe that overjet is a powerful predictor for resorption • Treatment time was not detected as a predictor for resorption. • Mean apical root resorption of the most severely resorbed central and lateral incisor and canine per patient was 1.47 mm (SD 1.40), 1.63 mm (SD 1.24), and 1.25 mm (SD 1.52),
  222. 222. • Use of elastic forces may increase the risk of apical root resorption only on the tooth that support the elastics, probably because of jiggling movements of the anchor teeth. Therefore it seems that biomechanically complex orthodontic treatment may lead to an increased risk for apical root resorption. • In conclusion, amount of root movement and presence of long, narrow, and deviated roots increase the risk for apical root resorption. In addition, use of elastics may be a risk factor for the teeth that support the elastics.
  223. 223. Baumrind, Korn, and Boyd : AJODO 1996:110:311-320 • Studied the relationship between the magnitude and direction of movement of the upper central incisor apex with apical root resorption in orthodontically treated adults • Magnitude of displacement was measured on lateral cephalograms with resorption measured on standardized anterior periapical radiographs (points were digitized in random order). • Sample : 81 nongrowing patients, who were treated in the offices of 3 experienced orthodontic specialists. • The mean apical resorption was 1.36 mm (SD ± 1.46; range = -1.03 to 5.58).
  224. 224. • An average of 0.99 mm(standard error ± 0.34) of root resorption was implied in the absence of root displacement and an average of 0.49 mm (standard error = ±0.14) of resorption was implied per millimeter of retraction. • With the exception of incisor retraction, the assumption that certain tooth movements are associated with differences in resorption response was not corroborated in this study. • The other statistically significant positive finding was that resorption is likely to occur even when the apex of the tooth does not appear to move. The latter may be consistent with either apical root resorption occurring in untreated populations or with jiggling movements produced in
  225. 225.
  226. 226. Orthognathic surgery combines orthodontic treatment with surgery of the jaw to correct or establish a stable functional balance between the teeth, jaws and facial structures. Orthognathic basically involves planned fracturing of the facial skeletal parts and reposition them as desired. Combined Surgical & Orthodontic Treatment
  227. 227. Indications for Orthognathic Surgery • Severity of skeletal and dental malocclusion • When growth modification can not be achieved • Esthetic and psychosocial considerations
  228. 228. Camouflage vs Surgical Rx
  229. 229.
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  233. 233. Function: Normal chewing, speech, respiratory function . Esthetics: Establish facial harmony and balance Stability: Avoid short and long term relapse Minimize treatment time: Provide efficient and effective treatment. Goals Of Orthognathic Surgery
  234. 234. Timing of Surgery • Usually done when all growth is complete • Assessed by superimposition of serial lat cephs • Can be performed when growth is not yet complete in cases of psychosocial problems or great severity when function is compromised (i.e. breathing, chewing)
  235. 235. Orthognathic Surgery Correction of A-P relationships: • maxillary advancement • retraction of anterior maxillary segment • mandibular advancement • mandibular setback • double jaw surgery
  236. 236. Orthognathic Surgery Correction of Vertical Relationships: • maxillary impaction/intrusion • maxillary extrusion • mandibular ramus surgery
  237. 237. Orthognathic Surgery Correction of Transverse Relationships: • surgically assisted maxillary expansion • surgically assisted mandibular expansion
  238. 238. Orthognathic Surgery Correction of Asymmetries: • maxilla • mandible • maxilla and mandible
  239. 239. Surgical Techniques • Le Fort I • Le Fort II • Le Fort III Le Fort I Le Fort II Le Fort III
  240. 240.
  241. 241. Surgical Techniques • BSSO • Genioplasty
  242. 242. Pre Surgical Orthodontic Objectives • to level and align the arches and make them compatible • to resolve crowding and/or spacing • to establish anteroposterior and vertical position of incisors (decompensate) • to place teeth relative to their own supporting
  243. 243.
  244. 244. Diagnostic Records • Analysis of pictures-photographs • Cephalometric analysis • Surgical prediction - STO • Model/occlusion analysis
  245. 245.
  246. 246.
  247. 247. Preparation for Surgery • Check for any TMJ problems • Manipulate models mounted in an articulator to check for interferences and occlusion • Splint fabrication (1 or 2 splints)
  248. 248. Post Surgical Orthodontic Treatment • Post 1 week: check occlusion, splint and appliances • 4-6 weeks: reinitiate orthodontic tx (after range of motion and stability are achieved) • Remove splint; change to light wires and light vertical elastics • Treatment usually completed in 4 to 12 months (average 6 months)
  249. 249. Relapse and Stability • Rigid fixation has improved stability • Stability is mostly influenced by the pattern of rotation of the mandible as it is advanced • Advancement of maxilla and/or mandible will stretch soft tissues promoting relapse • The more advancement needed, the greater the probability for relapse
  250. 250. Relapse and Stability
  251. 251. SUMMARY:- There is wide variety of etiology that can cause an adult malocclusion. Also each patient’s need for treatment are different so treatment should be carried out taking his/her needs in consideration. Adult orthodontic treatment helps by facilitating other dental procedures, controlling disease and restoring
  252. 252. THANK YOU
  253. 253.
  254. 254. SURGICAL TREATMENT: - - orthognathic basically involves planned fracturing of the facial skeletal parts and reposition them as desired. - Moderate to severe skeletal discrepancy. - Patient education.
  255. 255. SURGICAL PROCEDURES: - 1) Correction of anteroposterior relationship: - both maxilla and mandible can be moved forward or backward for correction of jaw discrepancy.
  256. 256. A) MAXILLARY SURGERY: - The LeFort 1 downfracture procedure is used to reposition the maxilla.
  257. 257.
  258. 258. B) MANDIBULAR ADVANCEMENT:- - Bilateral saggital split osteotomy(BSSO) of the mandibular ramus. - stretching and retraction of the inferior alveolar nerve.
  259. 259.
  260. 260. C) MANDIBULAR SETBACK: - - BSSO. - The transoral vertical oblique ramus osteotomy(TOVRO).
  261. 261. 2) CORRECTION IN VERTICAL PLANE: - a) Maxillary surgery: - - LeFort 1 downfracture of the maxilla, with superior reposition of the maxilla. - In downward movement of the maxilla rigid fixation are used.(synthetic hydroxyapatite)
  262. 262.
  263. 263. b) Mandibular surgery: - mandibular ramus surgery in open bite cases avoided. Short face(skeletal deep bite) best treated by saggital split mandibular ramus surgery.
  264. 264. 3) CORRECTION OF TRANSVERSE RELATIONSHIP: - easy to move maxilla in transverse direction then mandible.
  265. 265. A) MAXILLARY EXPANTION: - Constriction or expantion done during course of Lefort 1 downfracture procedure.
  266. 266. GENIOPLASTY
  267. 267. RETENTION: - - More difficult in adult then in adolescent patient , - slower tissue turn over rate. - Normal functional adaptation occurs more when growth has been completed. - Reduce height of periodontium.
  268. 268. -Hawley retainer. - Hawley retained with tongue cribs. - fixed bonded retainer(max. and mand. Anterior segments)
  269. 269. Restorative retainers: - - composite restoration. - amalgam, inlay or onlay. - pontics (fixed/removable).
  270. 270. Periodontal surgical retention procedure: - Fibrotomy. - gingivectomy.
  271. 271.
  273. 273.
  274. 274. Check List for Treatment Planning • A-P relationships maxillary deficiency/protrusion mand prognathism/deficiency amount of deficiency • Vertical relationships open bite deep bite • Transverse relationships crossbites before surgery expansion surgically assisted expansion during surgery {
  275. 275. Check List for Treatment Planning • Asymmetries cant of occlusal plane mandible/chin deviation • Occlusal relationships • Missing teeth/ malformed teeth • Genioplasty • Nose/lip relationship - rhinoplasty
  276. 276.
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  280. 280.
  281. 281. PERIODONTAL ASPECT OF ADULT TREATMENT:- 1) Minimal periodontal involvement. 2) Moderate periodontal involvement. 3) Severe periodontal involvement.
  283. 283. 2) MODERATE PERIODONTAL INVOVEMENT: - All periodontal disease should be controlled before tooth movement. Fully bonded orthodontic appliance is preferred in periodontally involve adult patient.
  284. 284. Steel ligatures or self legating brackets are preferred. Periodontal maintenance therapy at 2-4 month interval.
  285. 285. 3) SEVERE PERIODONTAL INVOVEMENT: - Periodontal maintenance should be scheduled at more frequent intervals. Orthodontic goals and mechnics should be modified to keep force value minimum.
  286. 286. SPACE CLOSURE VS. PROSTHETIC REPLACEMENT: - Old extraction site: - Space closure is difficult in adult. The involvement of cortical bone tend to produce reciprocal space closure. Implant in the ramus can be use to provide necessary anchorage.
  287. 287. TOOTH LOST DUE TO PERIODONTAL DISEASE: - Unwise to move a teeth in area where bone is destroyed because of periodontal disease.
  288. 288. Thank you For more details please visit