Adult orthodontics


Published on

Published in: Health & Medicine
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Adult orthodontics

  1. 1.
  2. 2. Adult Orthodontics Adult orthodontics INDIAN DENTAL ACADEMY Leader in continuing dental education
  3. 3. Adult orthodontics • Contents – Introduction – History – Classifications – Goals and Objectives – Adjunctive orthodontics – Comprehensive orthodontics – Surgical orthodontics – Recent advances – Retention – Conclusion – References
  4. 4. INTRODUCTION • The frequency of malocclusion in adults is equal (or) greater than that observed in children and adolescents. Until recent years adults seeking orthodontic treatment was unusual. Since 1990’s 15% of the ortho patients were adults. They fall into 2 different groups • (1) younger adults (under35, often in their 20’) who desired, but not received ortho treatment during adolescents. • (2) An older group, typically in their 40’s or 50’s who have other dental problems and need orthodontics as part of larger treatment plan.
  5. 5. • HISTORY • Conflicting opinions have always existed regarding the feasibility of orthodontic treatment in the adult • Kingsley (1880) suggested that there were hardly any limits to the age of when tooth movement might not succeed (he treated a 40 year old patient with anterior cross bite). • In contrast Mac Dowell (1901) was of the opinion that after 16 years of age, orthodontic treatment was also impossible owing to the development of the glenoid fossa, the density of the bones and muscles of masticator.
  6. 6. • Lischer (1912) believed that the period between 6–14. years was a golden age of treatment • Case (1921) demonstrated treatment possibilities in aged and periodontally affected patients • Lindegaard et al (1971)-3 factors. 1.A disease or abnormality must be present 2.The need for treatment must be understood, the priority for orthodontic care based on personal and professional judgment 3.The patient must have a strong desire for treatment
  7. 7. • Reidel & Dougherty (1976) predicted the status of adult ortho treatment today and stresses the need for adjunctive orthodontic services provided by periodontist and restorative dentist. • “orthodontics is total discipline and it makes no difference whether the patient is young or old”
  8. 8. Adult practice today
  9. 9. Scope of procedures Musich’s (1986)study of 1370 consecutively examined adults
  10. 10. Why do adults seek orthodontic Rx ??? • Did not want orthodontic treatment as children • Did not know about orthodontics as children • Parents couldn't afford orthodontic treatment as children. • No orthodontist located in their vicinity when younger • Incomplete orthodontic treatment as children, non cooperative • Had orthodontic treatment as children but relapsed. • More conscious of appearance with age • Malpositioned teeth contributing to PDL disease • Spaces b/w anterior teeth enlarging ,new spaces opening up.
  11. 11. Classification- Graber,Vanarsdall • Physiologic occlusion • Psychological disorientation • Adjunctive orthodontics • Corrective orthodontics • Orthognathic surgery • Periodontally susceptible • TMJ-dysfunction • Enamel wear beyond that expected for chronologic age • Dental mutilation • Combination • Borderline surgical case
  12. 12. Acc to Gurkeerat singh ( jco 1996) For all practice purposes the adult patients are classified in 3 groups 1.Group I : 18 to 25 years of age 2. Group II: 26 to 35 years of age 3. GroupIII: 36 years and alder
  13. 13. DIAGNOSIS AND ADULT ORTHODONTICS • Careful diagnosis and treatment planning on a multidisciplinary basis is required to treat adult patients. In truth, the adult, unlike the child, is a relentless patient who will not cover up deficiencies in the skill of diagnosis or errors in the use of mechanical procedures by helpful settling – in post treatment. He presents with no growth, little rebound and meager accommodation to mechanics.
  14. 14. In addition, the adult may exhibit a potential for such pathological changes as knife-edge ridges,increased cortical thickness, buried roots, impactions, periodontal breakdown, atropic changes TMJ problems osteoporosis, osteomalacia, diabetes mellitus. These conditions, which obtain as a result of hormonal, vitamin or systemic disorders common to the adult, necessitate more careful and extensive diagnosis evaluations.
  15. 15. • Orthodontic diagnosis involves development of a comprehensive database of pertinent information. The standard diagnostic aids such as case history, clinical examination and study casts, radiographs and photographs are mandatory. • I.O.P.A, occlusal and TMJ films should be obtained routinely in addition to the panoramic radiograph and the cephalogram. The problem oriented diagnostic approach as described by Proffit and Ackerman is strongly recommended to ensure that no aspect of the patient need is neglected.
  16. 16. • Additional diagnostic procedures that we should consider in an adult patient are • A full series of TMJ x – rays • Muscle examination • Splint therapy • Diet evaluation
  17. 17. Psychological status of patients seeking orthodontic treatment. • Psychological outcomes of orthodontics on the patients self image is positive. • Psychology to the clinical practice of orthodontics can be divided into:- -Social psychology -Motivational psychology
  18. 18. • (i) Social Psychology of Orthodontics:- Why patients seek orthodontic treatment? -Dentofacial anomalies such as crooked teeth & skeletal disharmonies have been reported as the cause of teasing & harassment among children. -Bennet & Philip. • Adults seek for treatment to improve their facial & dental appearance which in turn will lessen social embarrassment & improve the self confidence. -Hunt & Johnston.
  19. 19. Psychologic outcomes of orthodontic treatment:- Dentofacial esthetics play an important role in a individual’s self image. Children with malocclusion did not have poor self image & orthodontic treatment did not improve it-Dann. Dentofacial disharmonies have significant social & psychological effect on the patient-Albino.
  20. 20. • Kiyak et al reported psychological influences on the timing of orthodontic treatment. -Developing children well being may be an indication for early orthodontic treatment. -Racial differences may be present in the psychological influences of orthodontics.
  21. 21. • (ii) Motivational psychology:- The success of orthodontic therapy depends on patient compliance.  Egolf described a compliant patient as one who practices good oral hygiene, wears appliance, follows an appropriate diet and keeps appointment.  Southard et al pointed out that improved co-operation by the patient helps to achieve the treatment objectives within a minimum time.
  22. 22. • Improved oral hygiene can decrease damage to the periodontal tissues and limit the effects of enamel decalcification and caries -Nanda & Sinha
  23. 23. • PERIODONTAL DIAGNOSIS • Assess the patients potential for bone loss and gingival recession during orthodontic tooth movement. • Patient should be screened for the risk factors of periodontal disease. • Pre treatment consultation with the periodontist should be routine and orthodontic objectives be altered according to his advice. Movement of teeth in the presence of periodontal inflammation will result in an increased loss of attachement and irreversible crestal loss.
  24. 24. TMD Diagnosis • Signs of symptoms of TMD often increase in frequency and severity during adult treatment. So it is imperative for the orthodontist to be familiar with their diagnostic and treatment parameters. • Adult patients especially females with TMJ sign and symptoms should be evaluated regarding exposure to stress and her handling of stress. • SCHIFMANN et al divided TMD problems into • Muscle disorders - 23% • Joint disorders – 19% • Muscle / Joint disorder combination – 27% • Normal – 31%
  25. 25. • TMJ DISORDERS • Deviation in form - Irregularities in intracapsular soft and hard articular tissue. • Disc displacement with reduction – Altered Disc- condyle structural relationship is not maintained during translation, reciprocal clicking is present. • Disc displacement without reduction – Altered Disc-condyle relationship is maintained during translation. • TMJ Hypermobility – Excessive disc / condylar translation well beyond the eminence. • Dislocation – Condyle positioned anterior to the articular eminence and unable to return to a closed positioned.
  26. 26. • Synovitis – Inflammation of the synovial lining of the TMJ • Capsulitis–Inflammation of the joint capsule • Osteoarthosis–Degenerative non-inflammatory condition of the joint characterized by structural change of the joint surface. • Osteoarthritis–Degenerative condition accompanied by secondary inflammation. • Polyarthirides–Arthitis caused by generalized systemic polyarthritis. • Ankylosis–Restricted mandibular movement with deviation to the affected side on opening. • Fibrous ankylosis – Ankylosis produced by adhesions within the TMJ. • Bony ankylosis – Union of bones of the TMJ caused by proliferation of bone cells resulting in complete immobility of the joint.
  27. 27. • Treatment of joint disorders – • Patient’s education • Pain free diet • Therapeutic exercises to rehabilitate the joint • Anti-inflammatory drugs &muscle relaxants • Physical therapy – • Heat / ice massage • Gentle range of motion exercises with in the pain tolerance.( 6 times a day for 30-60 secs ) • Joint shouldn’t hurt more than 10mins after exercise • Night time splint -reduces forces on the joint.
  28. 28. • Night guard, controls parafunctional habit, temporary stabilizes an uneven occlusion – allows the joint to rest. • Should have a flat plane . • Soft night guard is given for children with developing occlusion / mixed dentition. •
  29. 29. • Diagnosis for Osteoporosis • Adults patients particularly females between 45 – 50yrs (post – menopausal women) have a high incidence of osteopenia (asymptomatic low bone mass) or osteoporosis (symptomatic low bone mass). • WHO defines. • Osteopenia as bone mass 1 to 2.5 standard deviations (SD) below young adult mean (YAM)
  30. 30. • Bone mineral density (BMD) measurements of adult women over age of 50 indicated that 13% to 18% had osteoporosis, 37 to 50% had osteopenia. • So when evaluating adults for surgical procedures or orthodontics, a BONE METABOLIC ASSESSMENT is an essential part of diagnosis. • Treatment of osteoporosis is problematic during orthodontic therapy because drugs that inhibit bone resorption (Bisphosphonates, Calcitonin) Estrogen Replacement Therapy (ERT) may disturb bone remodeling
  31. 31. • Oral Manifestations of Osteoporosis • Osteoporosis is a systemic deterioration of the skeletal system with following dental manifestations. • Decreased edentulous ridge height • Decreased posterior maxillary arch width • Progressive alveolar bone loss • Loss of attachment and gingival recession • Loss of teeth
  32. 32. • Effects of Estrogen Replacement Therapy: • ERT has variety of oral health benefits, including a decreased in loss of periodontal attachments and greater retention of teeth during post – menopausal period. • Once the negative calcium balance in stabilized, patients with osetoporosis are excellent candidate for orthodontics and other bone manipulative therapy. • After osseous structures of jaw are enhanced, treatment planning is directed towards optimal function loading to avoid disuse atropy of alveolar process through implants, by fixed prosthosis after orthodontic repositioning
  33. 33. GOAL OF ORTHODONTIC TREATMENT • Since the adult differs in many respects from the adolescent and exhibits limitations, the goal for adult orthodontics would be different from that of the adolescent. • According to ACKERMAN, adult orthodontics is concerned with a striking balance between “achieving optimal proximal and occlusal contacts of the teeth, acceptable dentofacial esthetics, normal function and reasonable stability”. • Jackson’s Triad of traditional objectives (ie) esthetics, function and structural balance are neither realistic nor always necessary for all adult patients. Class I occlusal goals can be considered over treatment for patients under multiple provider group.
  34. 34. Adult orthodontic treatment objectives • Dentofacial esthetics • Stomatognathic function • Stability • Normal occlusion
  35. 35. Additional AOT objectives • Parallelism of abutment teeth • Most favorable distribution of teeth • Redistribution of occlusal & incisal forces • Adequate embrasure space & proper tooth position • Adequate occlusal landmark relationships • Better lip competency & support • Improved crown/root ratio • Improved self-maintenance of periodontal health.
  36. 36. Parallelism of abutment teeth • Abutment teeth-parallel • Permit-easy insertion of replacements • Allow –restorations • Better prognosis • Better PDL response.
  37. 37. Most favorable distribution of teeth • Distributed evenly-replacements • To establish normal occlusion.
  38. 38. Redistribution of occlusal & incisal forces. • Cases with significant bone loss(60-70%) • To maintain occlusal vertical dimension
  39. 39. Adequate embrasure space &proper root position. • Better PDL health • Helps in interproximal cleaning • Placement of restorative material.
  40. 40. Adequate occlusal landmark relationships • Transverse dimension – difficult to correct
  41. 41. Better lip competency & support • In case of anterior restoration-retractions • Inadequate support-change in anteroposterior &vertical position of upper lip & increase in wrinkling.
  42. 42. Improved crown/root ration • In case of bone loss • Reduced crown/root ratio • Can be corrected by reducing the clinical crown.
  43. 43. Better self maintenance of PDL health Teeth should be positioned properly over basal bone Improved self maintainace of PDL health occurs with proper tooth position
  44. 44. Esthetic & functional improvement. Should provide acceptable dentofacial esthetics Improved muscle function Normal speech & masticatory function
  45. 45. • LIMITATIONS OF TREATMENT IN ADULTS • There are two categories of factors:- • (a) INTRINSIC - BIOLOGICAL • (B) EXTRINSIC - BIOMECHANICAL SYSTEMS • The marked intrinsic limitation is the lack of growth in adults; skeletal discrepancies can therefore be corrected by Orthognathic surgery. The orthodontic treatment is limited to tooth movement and related modeling of the alveolar process only. Since orthodontic tooth movement is a result of cellular reaction to a mechanical stimulus, the cellular response may vary with the health and age of the individual
  46. 46. • Other Intrinsic Factors Periodontium • The primary tissue to be influenced by the mechanical forces applied to the teeth in the PDL. According to Norton, insufficient source of progenitors cells may be due to vascularity with increasing age. Insufficient source of preosteoblast account for the delayed response to mechanical stimulus. Alveolar bone • Structure: Orthodontic tooth movement as a result of bone modeling and remodeling also depends greatly on age related changes of the skeleton. Cortical bone becomes denser while the spongy bone reduces with age and the structure of bone changes from that of a honeycomb to a network. Pathology : Apical displacement of the marginal bone level is a local factor that influences the biological backgrounds for tooth movement in adults. The marginal bone loss is age related but is also the result of progressive periodontal disease. Teeth : Adults are also more likely to have missing teeth, teeth reduced in dimension due to attrition as well as teeth with large restorations
  47. 47. • Lace like Bone pattern Honeycomb Bone pattern
  48. 48. • Without Marginal Bone Loss • With Marginal Bone Loss
  49. 49. • BIOMECHANICAL CONSIDERATIONS IN ADULT ORTHODONTICS • (Lindauer JS. Rebellato J), (Dent Clin North Am 1996 : 40 : 811 – 836.) • Orthodontic treatment in the adult must be planned without the expectation that growth or any changes in jaw relationships will compensate for interarch discrepancies. A precise biomechanical control of tooth movement is necessary to achieve correction of malocclusion in all 3 dimensions. • The forces used in the adults should be at a lower level than those used in children. The initial forces should further be kept low because the immediate pool of progenitor cells available for resorption are low. • In adults with periodontal involvement where bone has been lost, PDL are decreases with the results that the same force against the crown would produce greater pressure in the PDL. The absolute magnitude of force must therefore be reduced.
  50. 50. • Marginal bone loss results in CRES (b) being displaced apically. Magnituide of the tipping moment is the product of force and distance (point of force application to the CRES). • Since the CRES has moved apically greater will be the tipping moment for same force, so a counter vailing COUPLE is necessary to affect BODILY movement. • Force levels should be decreased but the magnitude of the couple applied to counteract the tendency to tip should not be decreased proportionally.
  51. 51. • Selection of Mechanics • The appliance should produce a controlled and constant force system in all three planes to reader a low lead deflection rate possible • Vertical control and facial profile • Maintaining vertical control and facial profile is very important in treating adult patients. A child tolerates extrusive tooth movement better since condylar growth and vertical development of the alveolar process during child hood permit such tooth movement. In contrast, any extrusive movement, of the posterior teeth in the adult will lead to an opening of the bite through backward rotation of the mandible resulting in an increased facial height and overjet. • Extrusion of incisors can be undersirable since the majority of patients suffering from advanced periodontal disease have extruded and spaced maxillary teeth. Such patients need intrusion and retraction.
  52. 52. Loss of vertical control • Unintentional extrusion is possible with both fixed and removable appliance. According to Burstone, such loss of vertical control is possible in a number of instances of fixed appliances therapy such as. • Tip back bend • Incorrect bracket positioning • Excessive force • Straight wire leveling • Anterior root correction •
  53. 53. • AJO 1989 • Ronas, Kleinent & Melson B & Burstone • Force system developed by `V` Bends in an elastic Orthodontic wire • Burstone indicated a number of examples related to fixed appliances that lead to loss of vertical control (or) untoward extrusive effects • TIPBACK BEND: • Any major `V` Bend will result in the development of vertical forces if the bends are not localized exactly at the center between two tooth units • It produces Extrusion the vertical forces are closely related to the degree of bending & degree of eccentricity of bend. • INCORRECT BRACKET POSTIONING. • A difference in Orientation (or) cant can act as `` shape producing a change in the level of the occlusal plane. • ESTHETIC BEND • Combination `V` bend & step bend high vertical forces produced. Teeth will cut be intruded at this force level. Only extrusion takes place
  54. 54. • Factor in selection of treatment plan. • Existing oral pathology • Skeletal relationship • Biological considerations • Therapeutical approaches available • Extraction (vs) Non extraction therapy • Anchorage requirements • Missing teeth (Dental mutilation)
  55. 55. • Existing oral pathology : include recurrent decay, restorative failures, root decay with pulpal involvement periodontal bone loss, TMJ symptoms and retained roots. These conditions should be treated first before proceedings to orthodontics with a multi-disciplinary approach. • Skeletal Relationships : No growth with minimal skeletal adaptability. Therefore surgical procedures are frequently required to correct moderate to severe skeletal disharmonies. • Biological Considerations : Neuromuscular maturity – mechanical options for an adult are limited because of lack of neuromuscular adaptability. There is a tendency towards iatrogenic transitional occlusal trauma, coinciding with orthodontic occlusal changes. Periodontal susceptibility – higher degree of bone loss as result of periodontal disease can be evidenced during orthodontic therapy.
  56. 56. • Therapeutic approaches available – • Tooth Movement : most of them require tooth moving forces • Orthopedics : not effective • Orthognathic surgery : needed in 10 to 20% of the adult patients. • Restorative dentistry : frequently required. • Extraction (vs) Non Extraction Therapy : Classical 4 premolars extraction to resolve crowding rarely done .upper premolars extraction alone is a common alternative..
  57. 57. • Anchorage requirements : Adults have greater anchorage potential because of completely erupted 1st, and 2nd molars as well as accentuated mesial drift particularly in the mandibular arch. On the other hand 40% of the adults patient are partially edentulous. • Implants for orthodontic anchorage plays an important role in their treatment. (BJO 2002, VOL 29, 239-245) (Ismail and Johal-UK) Osseo integrated implants may be used for direct as well as indirect anchorage.
  58. 58. • Direct anchorage utilizes forces from actual implant which takes the place of a missing tooth and eventually supports a dental restorations. • Indirect anchorage uses the implants to stabilize specific dental units to which clinical forces are then applied. Such MID PALATAL FIXTURES are the ONPLANTS and ORTHOPLANTS which are placed solely for orthodontic purposes in adults. (JCO-2000- july,Celenza and Hochman)
  59. 59. • Onplants were introduced by • BLOCK & HOFEMAN in 1995, made of titanium and consist of base of 10mm and 2mm height with one side smooth and other side textured and coated with hydroxy apatite. Base has internal thread for screwing transgingival abutment to which force is applied. • Site is surgically exposed and coated surface is placed close to the bone. • After 6 – 8 weeks the base is exposed and transgingival abutment is placed and loaded.
  60. 60. • Adult patients requiring intrusion of molars to control Skeletal – Open bite are the apt candidates for Skeletal Anchorage System MIKAKO, SUGAWARA,MITRA ( AJO 1999; 115: 166-74) • Titanium miniplates were fixed at the buccal cortical bone around the apical regions of 6,7 on both side. Elastic threads were used as a source of orthodontic force to reduce excessive (3 to 5mm) molar height. The system was very effective. • BIOS (Glaatzmier) EJO 18 : 1996 465 – 469) is designed to provide anchoring functions in adults and adolescent and then be resorbed with out foreign body reactions. Secondary operations for removal at the conclusion of orthodontic treatment is not needed. It resorbs in 9 to 12
  61. 61. • (7) Missing teeth (Dental mutilations) • In adults, most of these spaces cannot be closed without a prostheses either a temporary tooth replacement during FA therapy or fixed prostheses later. Implants have become a reliable alternative. • Therefore a multidiscipilinary team approach is required for their comprehensive rehabilitations.
  62. 62. Treatment for adults • proffit - – Younger adults(20-35yrs) – Older group(40-50yrs) • Adjunctive orthodontic treatment • Comprehensive orthodontic treatment
  63. 63. COMPREHENSIVE TREATMENT FOR ADULTS • Comprehensive orthodontic treatment aims at making the patient’s occlusion as ideal as possible, repositioning all or nearly all the teeth in the process. • The ideal time for comprehensive orthodontic treatment is during adolescence, when the succedaneous teeth have just erupted, some vertical and antero posterior growth of the jaws remains and the social adjustment to orthodontic treatment is not a great problem.
  64. 64. • Comprehensive treatment is also possible for adults, but it poses some special problems that do not exist for younger patients. • The following considerations should be kept in mind while treating adults • Lack of growth • Heightened possibility of periodontal disease • Different motivations for seeking orthodontic treatment.
  65. 65. • While treating adults • Appliance should be simple in order to elicit maximum patient cooperation • Appliance should exert light forces for best physiological response. • Appliance should be long acting to decrease the number of appointments. • Appliance should be invisible as possible(plastic, ceramic brackets, fixed lingual appliances) • Appliance should be better retained (fixed) • Adult treatment mechanics need not differ from the standard technique; they are modified only to meet specific treatment requirements. Simplicity with maximum control is the by word. • Comprehensive orthodontic treatment implies an effort to make the patient’s occlsion as ideal as possible by repositioning nearly all the teeth in the process.
  66. 66. • Motivations for adult treatment: The major motivations for adults to undergo comprehensive treatment is due to psychological reasons. Though a small percentage of them may seek complete treatment for periodontal and restorative needs. • Internal motivations : if the individual wants to improve his appearance or function of teeth and so seeks treatment – he is said to be internally motivated and is expected to respond well psychologically • External motivation : an individual whose motivations is the urging of • others he said is to be externally motivated and has a complex set of unrecognized expectation for orthodontic treatment.
  68. 68. • Possible tooth movement in adjunctive treatment • (a) Mesial or distal movements of specific crowns and roots. • (b) Correction of axial inclination of drifted teeth. • (c) Correction of buccolingual position of certain teeth • (d) Corrections of rotations. • Intrusion of teeth is avoided as an adjunctive procedure because of the technical difficulties involved and possibility of periodontal complications. • Excessively extruded teeth are treated by reduction of crown height which improves the crown / root ratio.
  69. 69. • Biomechanical considerations: • Control of anchorage requires that anchor teeth not be allowed to tip. This is major reason that adjunctive treatment usually requires a fixed appliance. • EDGEWISE APPLIANCE recommended, twin brackets of 0.022 slot dimension are used preferably • Rectangular slot controls bucco – lingual axial inclination • Twin bracket prevents undesirable rotations and tipping • Larger slot allows the use of stabilizing wires which are stiffer. • Bracket are placed in an ideal position only on teeth to be moved, remaining teeth incorporated in the anchor system and are bracketed so the archwire slot are closely aligned. Passive engagement of the wires to anchor teeth produce minimal disturbance of teeth.
  70. 70. • PERIODONTAL ASPECTS OF ADULT TREATMENT • There is no contra indications to treating adults with periodontal disease long as the disease is under control • Three risk groups are identified in the population – Those with rapid progression (10%) – Those with moderate progression (80%) – Those with no progression despite the presence of gingival inflammation (10%).
  71. 71. • MINIMAL PERIODONTAL INVOLVEMENT: • Bacterial plaque being the main etiological factor in periodontal breakdown, patient undergoing orthodontic especially adults must take extra care • For adults orthodontic patient’s GINGIVAL RECESSION is to be prevented rather than to try correcting it later. Creation of “BLACK TRIANGLES” between maxillary central incisors by gingival recession after periodontal loss is practically distressing. • According to the present concept, gingival recession occurs secondary to alveolar bone dehiscence; if overlying tissues are stressed. Stress can be due to
  72. 72. • Tooth brush trauma • Plaque induced inflammation • Stretching and thinning of gingiva created by labial tooth movement • FREE GINGIVAL GRAFT is helpful in adult patients to control inflammation before orthodontic treatment begins. and in whom arch expansion is indicated for aligning incisors.
  73. 73. • MODERATE PERIODONTAL INVOLVEMENT: • Disease control: Preliminary periodontal therapy is preformed which includes meticulous root surface preparative and curettage and patient kept under observation to watch whether the disease is controlled. • Treatment procedures like osseous contouring (or) repositioned flaps to compensate areas of gingival recession are best deferred until final occlusal relationships have been established.
  74. 74. • PERIODONTAL MAINTENANCE • Fully boned orthodontic appliance is recommended. Steel ligatures (or) self ligating bracket are preferred for periodontally involved patients rather than elastomeric rings to retain arch wires because such patient have higher level of micro organisms in gingival plaque. • During comprehensive treatment, patient with moderalte periodontal problems should be on a maintanence schedule (2 – 4 months interval) • HYGIENE AIDS: Electric tooth brushes, rubber interdental stimulators, proximal brushes and adjunctive chemicals (eg. Chlorhexidine) should be considered.
  75. 75. • SEVERE PERIODONTAL INVOLVEMENT: • The general approach in the same as outlined earlier but • 1. Periodontal maintenance schedule is at more frequent intervals (every 4 to 6 weeks) • 2. Orthodontic goals modified and forces kept to absolute minimum of because of the reduced area of PDL • Muco-gingival Corrections • Attention if paid to 3 factors prior to orthodontic therapy can make the treatment easier and more predictable. • Reduction of thick tissue either distal to the terminal tooth or in edentulous areas • Inadequate bands of keratinized
  76. 76. • Frenal attachments • Thick tissue gets bunched up and can slow down tooth movement considerably. While uprighting a second or a third molar, the tissue moves coronally on the tooth and a pseudopocket develops. This can become a nidus for bacteria and a potential locus for the apical migration of the attachment. • If there is a minimal band of keratinized tissue and the roots move out of the alveolus, there is bound to be recession. • Frenal attachements that prevent or slow down tooth movements may be removed during or before tooth movement. However, if retention is the chief concern, then the removal may be effected at the conclusion of tooth movement.
  77. 77. • ORTHODONTIC TREATMENT OF PERIODONTAL DEFECTS –(Seminars in orthodontics) vincent kokich -1997 • Advanced Horizontal Bone Loss: • After the treatment has been planned, one of the most important factors that determines the outcome of orthodontic therapy, is the location of the bands and brackets on the teeth. • In a periodontaly healthy individual, the position of the bracket is usually determined by the anatomy of the crown of the tooth. Anterior brackets should be positioned relative to the incisal edges. Posterior bands or brackets are positioned relative to the marginal ridges. If the incisal edges and marginal ridges are at the correct level, the CEJs will also be at the same level. This relationship will create a flat bony contour between the teeth. • However, if a patient has underlying periodontal problems and significant alveolar bone loss around certain teeth, using the anatomy of the crown to determine bracket placement is inappropriate.
  78. 78. • The bone level may have receded several millimeters from the CEJ. As this occurs, the crown to root ratio will become less favourable. By aligning the crowns of the teeth, the clinician may perpetuate tooth mobility by maintaining an unfavourable crown to root ratio. • The orthodontist can correct many of these problems by using the bone level as a guide to positioning the brackets on the teeth. In these situations, the crowns of the teeth may require considerable equilibration . If the tooth is vital, the equilibration should be performed gradually to allow the pulp to form secondary dentin to insulate the tooth during the requilibration process. The goal of equilibration and creative bracket placement is to provide a more favourable bony architecture as well as a more favourable crown to root ratio.
  79. 79. • HEMISEPTAL DEFECT: • Adult patients may have marginal ridge discrepancies caused by uneven tooth eruption before orthodontic treatment. When the orthodontist encounters marginal ridge discrepancies, the decision as to where to place the bracket or band is not determined by the anatomy of the tooth. • If the bone level is oriented in the same direction as the marginal ridge discrepancy, then leveling the marginal ridges will level the bone. However, if the bone level is flat between adjacent teeth and the marginal ridges are at significantly different levels, correction of the marginal ridge discrepancy orthodontically will produce a hemiseptal defect in the bone. This could cause a periodontal pocket between the two teeth.
  80. 80. • During orthodontic treatment, when teeth are being extruded to level hemiseptal defects, the patients should be regularly monitored by the periodontist. Initially, the hemiseptal defect will have a greater sulcular depth and be more difficult for the patient to clean. As the defect is compensated through tooth extrusion, interproximal cleaning becomes easier.
  81. 81. • Tissue response to various tooth movements. • EXTRUSION: • Extrusion or Eruption of a teeth (or) Several teeth along with reduction of the clinical crown height reduces infrabony defects & decreases product depth. • AJO 1986 TISSUE REACTION OF EXTRUSIVE AND INTRUSIVE FORCES TO TEETH IN ADULT MONKEYS ( BIRTE MELSEN) • On histologic section, clear signs of bone deposited during forced Eruption is seen • INTRUSION:- • INTRUSION OF INCISORS IN ADULT PATIENTS WITH MARGINAL BONE LOSS • (AJO 1989 MELSON B ET AL • In this study 3 different methods for intrusion were applied. The marginal bone level approached CEJ in almost all cases. All cases demonstrated root resorption. • The intrusion was best performed when • Forces were low (5 to 15 gm per tooth ) with line of action of force passing through (or) close to the center of resistance. • Gingival status was healthy. • No interference with perioral function present.
  82. 82. Adjunctive orthodontic treatment • Definition :tooth movement carried out to facilitate other dental procedures necessary to control disease & restore function. • Uprighting of posterior teeth • Forced eruption • Alignment of anterior teeth • Crossbite correction
  83. 83. Goals of AOT • Facilitate restorative treatment • Improve PDL health • Favorable crown : root • “Goal of AOT is to provide a physiologic occlusion & facilitate other dental treatment & has little to do with Angle’s concept of an ideal tooth relationships.”
  84. 84. Principles of AOT • Diagnostic & treatment planning. – Collecting an adequate data base. – Developing a problem list.
  85. 85. • Diagnostic records – OPG. – Full mouth IOPAs. – Lateral ceph – photographs. – Dental casts.
  86. 86. Biomechanical considerations • Characteristics of the orthodontic appliance. – Anchorage control – 22-slot edgewise appliance with twin brackets – Removable/Fixed appliance. – Bracket placement-ideal-tooth to be moved.
  87. 87. Removable appliances
  88. 88. Bracket placement
  89. 89. Effects of reduced periodontal support • Bone support • Bone loss-PDL area decreases • CR-shifts more appically
  90. 90. Timing & sequence of treatment Active disease Disease control Establish occlusion Definitive restorative Rx maintenance Re-evaluate stabilize
  91. 91. Uprighting posterior teeth • Treatment planning consideration – Loss of posterior teeth – If the 3rd molar is present? – Uprighting by distal crown/ mesial root movement? – Slight extrusion of tipped molar is permissible?
  92. 92. Loss of posterior teeth
  93. 93. Distal crown/ mesial root movement
  94. 94. Crown: root length
  95. 95. Appliances for molar uprighting • Partial fixed appliance • Active & reactive unit • bonding>banding
  96. 96. Uprighting a single molar • Distal crown tipping with occlusal antagonist – Flexible rectangular wire- 17x25 NiTi – Anchorage unit-19x25 steel – 17x25 beta-Ti
  97. 97. Uprighting with minimal extrusion • Uprighting with no occlusal antagonist • “T-Loop”-17x25 steel/ 19x25 beta Ti
  98. 98. Uprighting of lower molars Birte melsen,JCO 1996 case1 56yrs/M Missing lower 1st molar
  99. 99. case1
  100. 100. Case 2 42/F Missing 46
  101. 101. Case 2
  102. 102. Distal jet
  103. 103. A simple technique for molar uprighting –E Capelluto,JCO 1996 “MUST”
  104. 104.
  105. 105. Final positioning of molar & PMs Compressed coil springs 018 steel
  106. 106. Uprighting two molars in the same quadrant. • Combination of distal crown & mesial root • No bilateral uprighting - same time • 17x25 Niti
  107. 107. Retention • Fixed bridge-within 6 weeks • Short time-19x25 steel /21x25 beta Ti • >few weeks-intermediate splinting
  108. 108. Forced eruption • Indications – Defects in cervical 3rd of the root – Horizontal / vertical # – Internal/external resorption – Decay – PDL – disease – To obtain good access for endodontic and restorative process
  109. 109. Forced eruption • Treatment planning – Good periapical radiographs • Periodontal support • Root morphology and position – Endodontic therapy should be completed
  110. 110. Orthodontic technique • Anchor teeth –rigid • Flexible –tooth to be extruded • With / without the use of orthodontic bracket
  111. 111.
  112. 112. Alignment of anterior teeth • Indications – To improve access & permit placement of restoration – To permit placement of crowns & pontics – To reposition the closely approximated roots – To place implants.
  113. 113. Treatment planning • Interproximal stripping • Diagnostic setup-very helpful
  114. 114. Orthodontic technique • Alignment of crowded, rotated & displaced incisors – Edgewise brackets-canine –canine – Initial wire-light & flexible – 016 Niti – Crown reduction
  115. 115. Positionining tooth for single tooth implants • Missing teeth-implants – Space needed for implant, esthetics& the occlusion • Space needed for implants – Narrowest – 4mm – 1mm –in b/w implants • Contralareral & adjacent teeth –size of the implant
  116. 116. Timing of implant placement • Implants to support restorations should not be placed until all vertical growth has been completed. • Boys-20yrs • Girls-15-17yrs. • For adults-soon after –minimizes bone loss.
  117. 117. Case reports • 48yrs/F • Class II div 1 • Deep bite • Missing12,47,46,45,35,36,37 Treatment plan: surgical correction 6 implants on 37,26,25,47,46,45 Healing period -4 months Implant-supported FPD Uprighting of 3rd molar + alignment Same implants-abutments. Kenji W Higuchi
  118. 118. Case 1
  119. 119. case1
  120. 120. Case 2 • 53yrs/M • Class III • Ant &post crossbites • spacing Treatment plan: 2 implants,35&36 Healing period -4 months Implant-supported FPD
  121. 121. Case 3 • 64yrs/F • Class I • Impacted canine • Missing teeth Treatment plan: Extrusion of impacted canine 1 implant -16 Healing period-6 months Implant supported FPD-anchorage Same implant-abutment
  122. 122. Case 3
  123. 123. Anterior diastema closure • Loss of posterior teeth, abnormally small teeth, loss of bone support-drifting/spacing. • Partial closure-composite build ups-permanent retention • Smaller diastema-removable appliance • 016 niti,018 steel with coil springs.
  124. 124. Diastema closure
  125. 125. Crossbite correction Crossbite-functional problem Ant crossbite -esthetic Tipped teeth-removable apl Elastics Establishing a good overbite relationship is the key to maintaining crossbite correction.
  126. 126. SPLINTING WHEN TO SPLINT? • The splinting of mobile teeth is often, of value as a means of stabilization before, during, and after periodontal therapy. • For most patients, splinting should be considered only after the preliminary phase of periodontal therapy has been completed. • Cohen and Chacker have noted, "When large areas of attachment apparatus have been destroyed, the artificial support offered by temporary stabilization may allow a new, healthy tooth-bone relationship to be established. • Therefore it would seem advisable that when the treatment plan is being formulated the need for stabilization be determined on the basis of the, nature and extent of the destructive process present.
  127. 127. PRINCIPLES OF SPLINTING: • The main objective of splinting is to decrease movement three-dimensionally. • This objective often can be met with the proper placement of a cross-arch splint. • Conversely, unilateral splints that do not cross the midline tend to permit the affected teeth to rotate in a faciolingual direction about a mesio-distal linear axis.
  128. 128. INDICATIONS FOR SPLINTING: • Splinting is indicated when moderate to advanced mobilities (2 degrees or more) are present and cannot be treated by any other means. • There is no reason for splinting non mobile teeth or teeth with a slight, non progressive mobility as a preventive measure. • Splinting should only be used with other necessary measures such as oral hygiene instructions, root planing, pocket elimination, and occlusal adjustment. • When pre-prosthetic surgery or orthodontic measures are called for they should be completed before splinting whenever possible.
  129. 129. • One obvious indication for splinting is when a patient presents with multiple teeth that have become mobile as a direct result of gradual alveolar bone loss, a reduced periodontium. • A second indication for splinting is when the patient presents with increased tooth mobility accompanied by pain or discomfort in the affected teeth. • Splinting may be a way to gain stability, reduce or eliminate the mobility, and relieve the pain and discomfort. • Following loosening of teeth by accidental (or) surgical trauma. • To immobilize excessively mobile teeth so that the patient can chew more comfortably. • To avoid dislodging teeth prior to and during re-constructive procedures (Occlusal reconstruction).
  130. 130. • To stabilize teeth in their new positions after orthodontic repositioning. • As supportive measure to facilitate periodontal therapeutic procedures for hypermobile teeth. CONTRAINDICATIONS FOR SPLINTING: • Splinting teeth is not recommended if occlusal stability and optimal periodontal conditions cannot be obtained. • Any tooth mobility present before treatment must be reduced by means of occlusal equilibration combined with periodontal therapy. • Otherwise if the tooth involved does not respond, it must be extracted prior to proceeding from provisional restorations to definitive treatment. • Insufficient number of firm / sufficiently firm teeth to stabilize mobile teeth.
  131. 131. The following qualifications identify an ideal splint : It should • be simple, • economic, • stable and efficient, • hygienic, • nonirritating, • not interfere with treatment, • esthetically acceptable, and • not provoke iatrogenic disease.
  132. 132. OBJECTIVES OF SPLINTING: • Rest is created for the supporting tissues giving them a favorable climate for repair of trauma. • Reduction of mobility immediately and hopefully permanently. In particular jiggling movements are reduced or eliminated. • Redirection of forces - redirected in a more axial direction over all the teeth included in the splint. • Redistribution of forces - ensures that forces do not exceed the adaptive capacity. Forces/received by one tooth are distributed to a number of teeth. • Restoration of functional stability - functional occlusion stabilizes mobile abutment teeth.
  133. 133. • To preserve arch integrity - restores proximal contacts, reducing food impaction & consequent break down. • To stabilize mobile teeth during surgical, especially during regenerative periodontal therapy. • To prevent migration and over eruption. • Psychologic well being - gives the patient comfort from mobile teeth a sense of well being. • Masticatory function is improved. • Discomfort and pain are eliminated.
  135. 135. Meanings of the Face • “The face is the area of one’s body that produces the greatest concern regarding physical attractiveness; it is the individual’s focal point and the source of vocal and emotional communications with others” • Berscheid et al in a survey of over 1000 adults found that people who were satisfied with their facial features expressed greater self-confidence.
  136. 136. Meanings of the Face • Berscheid et al – the area of greatest dissatisfaction for subjects in their large sample was the appearance of their teeth • Attractive adults & children are evaluated as more successful and more intelligent than are unattractive persons and are viewed as more socially skilled – GR Adams
  137. 137. Psychosocial characteristics of patients with facial deformities • Children with craniofacial anomalies are more introverted, neurotic and demonstrate poor self-concept – Perschuk et al • Children with Down’s syndrome were rated as being less intelligent, less attractive, and less socially acceptable. Postoperative ratings of these same children were significantly more positive in all three domains – Strauss et al
  138. 138. Psychosocial characteristics of patients with facial deformities • A seriously handicapping orthodontic condition is the one that “severely compromises a person’s physical or emotional health” – AL Morris et al • Physical compromise – serious problems with breathing, speaking, or eating, especially if accompanied by tissue destruction • Emotional health – includes other’s reactions to the individual in a way that influences self-esteem
  139. 139. Summary • Research in the areas of self-esteem and attractiveness indicates that the face is a major source of one’s psychologic identity • Orthognathic surgery differs from surgery for congenital anomalies (in that the changes in appearance are less dramatic and improvements in occlusion, mastication, speech, and TM joint function are likely to be major reasons for treatment) – but patients undergoing this surgeries also expect esthetic changes. They must adapt not only to changes in their oral function, but also to changes in their perceived appearance and interactions with others
  140. 140. Psychosocial studies of patients with dentofacial deformities - Kiyak et al • The First Study – To study patient’s motives for seeking orthognathic surgery, the effect of this procedure on people with diverse needs, and patient’s satisfaction with treatment outcomes – 6 questionnaires were asked over a 26 month period • The Second Study – Attempted to examine in greater detail the variables that emerged as significant predictors of long-term outcomes – The effect of orthognathic surgery was measured by comparing patients who underwent surgery and orthodontics with those who were recommended to have both but elected orthodontics alone – 6 questionnaires were asked before and up to 24 months after surgery
  141. 141. Patients before surgery • Motives for treatment • A scale to assess patient’s motives • Self-perceptions of facial profile • Sex differences • Orthognathic-surgery patients
  142. 142. Motives for surgery Parameter Male Female Professional advice Orthodontist 24(83%) 34(76%) Family dentist 12(41%) 17(38%) Other 5(17%) 1(2%) Desire esthetic changes 12(41%) 13(53%) Functional problems Mastication 12(41%) 13(29%) Speech 4(14%) 1(2%) TM joint 1(3%) 7(16%) Social: family, friends 12(41%) 24(53%)
  143. 143. A scale to assess patient’s motives • Subjective Expected Utility (SEU) Model – Items are based on interviews with orthognathic surgery patients, orthodontists, and oral-maxillofacial surgeons – Using a 10 point scale, patients are asked to indicate the importance of each item in the list above and whether they consider it positive , negative or neutral. – In this study, SEU suggest that the decision to seek surgical correction is influenced by functional reasons. Conversely, the decision to reject surgery and undergo conventional orthodontics seems to be based more on a desire for improved esthetics
  144. 144. A scale to assess patient’s motives Questions Score Less difficulty with chewing 3 Stop jaw from clicking 0 Eat foods unable to eat now 0 Better fit of upper/lower teeth 1.5 General health improvement 1.5 Possible pain after surgery 0 Better smile 0 Improved profile, jaw and chin 0 Straight teeth 0 Cost of surgery 0 Lost time from work/school 0.8 Chance of unsuccessful surgery 1.9 Be able to speak clearer 0 Less self-conscious 0 Perform better in job/school 0 Advice of family/friends 0 Advice of dentist/orthodontist 0.9 Know of someone else’s surgery 0
  145. 145. Self-perceptions of facial profile • For all dimensions of facial deformity, patients who accept surgical treatment view themselves as less normal than do those who opt for no treatment or orthodontics • At the 24-month follow-up assessment, nearly all the surgery patients rated themselves as normal. Orthodontics-only patients also rated themselves improved on all scales, but the improvement was not as great.
  146. 146. Sex differences • Broverman and colleagues have found experimental evidence that women place relatively greater importance on physical attractiveness • Kurtz et al found that women can more easily distinguish what they like and dislike about their bodies than can men of the same age, who give only global self-descriptions.
  147. 147. Orthognathic surgery patients • In present study both men and women scored within the normal range, notably better than the cosmetic-surgery population. • Sex differences were not significant in post surgical satisfaction or in self-reports of pain.
  148. 148. Response to treatment • Overall satisfaction with the outcomes is generally high at all post surgical assessments • Overall body image was found to be in the moderate range throughout the course of treatment • Surgery patients initially expressed a lower body image than did non surgical and no-treatment patients • Surgical patients had high levels of tension and anxiety just before surgery, with a steady decline later • Orthodontics-only patients had negative mood states at 6 months which later improved • In surgical-orthodontic patients, expectations matched the actual experience for most patients.
  149. 149. Application of research findings to patient management • Summary of research findings – The patients undergoing orthognathic surgery are always within the psychologically normal range – They are more stable than people who seek plastic surgery – Their greatest concern before treatment appears to be self- consciousness regarding their facial body image, but functional problems also are important
  150. 150. Application of research findings to patient management • Summary of research findings – Orthodontics-only patients report negative emotions during the later stages of their treatment – Contrary to literature on cosmetic surgery, most patients undergoing orthognathic surgery readily accept changes in appearance and are satisfied with the esthetic effects – 85% to 90% of the patients undergoing surgical-orthodontic treatment eventually indicate that they are satisfied with the treatment
  151. 151. Recommendations for interaction with patients • There is a need for systematic selection of patients, preparation for surgical treatment, and careful psychologic management throughout the course of surgical and orthodontic treatment • Provide greater psychosocial support and encouragement for the patient with a neurotic personality style, especially in the early stages of treatment • Patient education materials provide information in a standard way so that no important points are omitted, and the patient can review it repeatedly to gain a better understanding of the process.
  152. 152. Pre- and post surgical psycho-emotional aspects of the orthognathic surgery patient - Bertolini et al • Levels of pre surgical anxiety, post surgical depression, body concept, and all the important changes in physiologic functions were measured by 4 questionnaires. • The results of this study suggest that surgery does in fact, produce improvements in self-esteem and body image and in mastication and speech, and therefore in their lifestyles • All patients experienced a medium to high level of pre surgical anxiety, but no major problems after surgery.
  153. 153. • OGS can be performed in both jaws and is all 3 planes of space. • In Anterioposterior plane. • - MAXILLARY SURGERY • The Lefort I downfracture procedure almost always is used now to reposition the maxilla. If the maxilla is advanced, a graft in the retromolar area or at a step created in the lateral wall usually is required. • MANDIBULAR ADVANCEMENT • Currently the bilateral sagittal split osteontomy (BSSO) of the mandibular ramus, performed from an intro oral approach, is the preferred procedure for most patients who need mandibular advancement.
  154. 154. • MANDIBULAR SETBACK • Reduction of mandibular prognathism can be accomplished by one of two techniques performed in the ramus, each having advantages and dis-advantages. The BSSO (discussed previously) can be used to move the mandible posteriorly as well as anteriorly,. It is widely used for setbacks because of excellent control of the condylar segments and because osteosynthesis screws can be employed for fixation. • The transoral vertical oblique ramus osteotomy (TOVRO) is limited to mandibular setback and required full-thickness overlapping of the segments. This procedure requires less time than the sagittal split osteotomy and is less likely to produce neurosensory changes, but jaw immobilization after surgery is necessary and control of the condylar fragment can be difficult. Especially when both the maxilla and mandible are repositioned in treatment of Class III problems, the advantage of rigid fixatio BSSO outweighs the advantages of TOVRO.
  155. 155. • CORRECTION OF VERTICAL RELATIONSHIPS • Problems of excessive and deficient face height, which usually are accompanied by severe anterior open bite and deep bite respectively. The long face problems are treated best by superior repositioning of the maxilla. This allows the mandible to rotate around the condyle, thereby reducing the mandibular plane angle and shortening the face. Short face problems, in contrast, are treated most predictably and successfully by mandibular ramus surgery that allows the mandible to move donwnward only at the chin, increasing the mandibular plane angle by shortening the ramus and opeing the gonial angle by shortening the ramus and opening the gonial angle rather than by rotating at the condyle.
  156. 156. • MAXILLARY SURGERY • The contemporary surgical approach to the skeletal open bite (long face) deformity involves a LeFort I downfracture of the maxilla, with superior, repositioning of the maxilla after removal of bone from the lateral walls of the nose, sinus, and nasal septum. • It is important to shorten the nasal septum or free its base so that the septum is not bent when the maxilla is elevated. The overall facial height is shortened as the mandible responds by rotating upward and forward. Excellent stability of the vertical position of the maxilla is observed post-surgically, but ling-term, some continued vertical growth of the maxilla may occur. • In contrast, when the maxilla is moved downward to increase face height, it tends to relapse back up post surgically, so that 20% or more of the vertical change often is last even when rigid fixation is used. Both the use of more rigid graft materials (like synthetic dydroxylapattite) and simultaneous osteotomy of the mandibular ramus have been reported to improve the stability of downward movement of the maxilla.
  157. 157. • MANDIBULAR SURGERY: • Patients with a ling face, skeletal open bite and anteroposterior mandibular deficiency often have a short mandibular ramus. Surgery to reduce to mandibular plane angle and close the open bite by rotating the mandible down posteriorly and up anteriorly has been found to be highly unstable. Because the fulcrum for rotation is the posterior teeth, this rotation lengthens the ramus and stretches the muscles of the pterygomandibular sling. The instability is attributed primarily to lack of neuromuscular adaptation in these powerful muscles, which can produce relapse to pre-surgical or even worse mandibular positions. • Patients with a short face (skeletal deep bite) problem are characterized by a long mandibular ramus, square gonial angle and short nose-chin distance. Often the maxillary incisors are tipped lingually in Angle’s Class II, division 2 pattern. Despite the deep overbite, excessive eruption of the lower incisors often has not occurred, as demonstrated by a normal distance from the chin to the incisal edge. They are teated best by sagittal split mandibular ramus surgery to rotate the mandible slightly forwad and down and the gonial angle area.
  158. 158. • CORRECTION OF TRANSVERSE RELATIONSHIPS: • Transverse problems fall into two categories: those due to symmetrical narrowing or (less frequently) widening of one dental arch and those due to jaw asymmetry. • Maxillary Expansion for Lingual Crossbite: • Constriction of the maxilla rarely occurs without some coexisting vertical or sagittal problem. Maxillary constriction or expansion can be accomplished easily by segmenting the maxilla in the course of LeFort I downfracture surgery to correct other problems, and this is the usual approach. Expansion is done with parasagittal osteotomies in the lateral floor of the nose or medial floor of the sinus that are connected by a transverse cut anteriorly. • Surgically assisted palatal expansion, using bone cuts to reduce the resistance without totally freeing the maxillary segments, followed by rapid expansion of the jackscrew, is another possible treatment approach for adult patients with skeletal maxillary constriction.
  159. 159. • GENIOPLASTY IN ORTHOGNATHIC TREATMENT: • Lack of surrounding anatomic structures gives the surgeon considerable latitude in alteration of chin morphology, and movement of the chin in all three planes of space is possible. • Genioplasty Techniques: • For most patients, the preferred approach to genioplasty is a lower border osteotomy to free a wedge shaped portion of the symphysis and inferior border that remains pedicled on the genioglossus and geniohyoid muscles. This segment can be advanced to augment chin contour, shifted sideways to correct asymmetry, or downgrafted to increase lower face height. • Genioplasty can be used as an Adjunct to Non-extraction Orthodontic Treatment • SEQUENCING TREATMENT: • Surgical and Orthodontic Phases of Treatment: • Successful management of combined surgical and orthodontic treatment requires the integration of presurgical orthodontic, surgical and post surgical orthodontic phases of treatment.
  160. 160. principles that influence post-surgical stability can be proposed: • Stability is greatest when soft tissues are relaxed during the surgery and least when they are stretched. • Moving the maxilla upward relaxes tissues. • Moving the mandible forward stretches tissues, but rotating it upward posteriorly and downward anteriorly decreases the amount of stretch. • It is not surprising that the lease stable mandibular advancements are those that lengthen the ramus and rotate the chin up, while the most stable advancements rotate the mandible in the opposite direction. • .
  161. 161. • The least stable orthognathic surgical procedure is widening of the maxilla that stretches the heavy, inelastic palatal mucosa • Neuromuscular adaptation is an essential requirement for stability, • Repositioning of the tongue to maintain airway dimensions occurs as an adaptation to changes produced by mandibular osteotomy. • Neuromuscular adaptation does not occur when the pterygomandibular sling is stretched during mandibular osteotomy, as when the mandible is reotated to close an open bite.
  162. 162.  Neuromuscular adaptation affects muscular length, not muscular orientation. If the orientation of a muscle group such as the mandibular elevators is changed, adaptation cannot be expected.
  163. 163. • Periodontal – Surgical Retention Procedures • Certain periodontal-surgical procedures may be necessary to achieve overall stability of the treated adult patient. • The following are the procedures that may have to be performed. • Pericision • Gingivectomy and Gingivoplasty.
  164. 164. • Pericision • Significantly rotated teeth should be over corrected to an extent of 5-10° prior to debonding. • A supracrestal gingival fibrotomy will reduce the risk of relapse. • Gingivectomy and Gingivoplasty: • These procedures arc indicated when significant vertical changes, such as deep overbite correction have been made orthodontically. • In general, adults require a greater period of retention.
  165. 165. RECENT ADVANCES • LESS VISIBLE TREATMENT MODALITIES FOR ADULTS : - • Adults patients are conscious and demand less visible appliances. • CLEAR BRACKETS • (plastic / ceramic bracket) along with tooth coloured arch wire are the most esthetic combinations to be used in a conscious adult patients. The esthetic arch wire (FRC Fibre Reinforced Composite AJO 2000) is composed of ceramic fibres embedded in a cross-linked polymer matrix. Its coefficient of friction is reduced by modifying the surface chemistry (eg: ion implantation) inspite of this, adults are often averse to wearing traditional fixed appliance with wires, bands and brackets.
  166. 166. Invisalign • What is invisalign? - Invisible alignment of the teeth - An invisible way to align the teeth Uses a series of clear removable aligners to straighten teeth without metal wires or brackets. Developed by Align Technology,CA
  167. 167. • A The INVISALIGN SYSTEM (BJO-2003 – December vol 30 (L.joffe-UK) • now makes it possible for orthodontists to offer adults patients requiring full mouth orthodontic treatment with an esthetically agreeable solutions. • Introduced about 4 years ago by ALIGN TECHNOLOGIES Santa clara, California • It is an orthodontic technique that uses a series of clear plastic aligners to move teeth. • Worn for a minimum of 20 hours per day. • Changed on a 2 weekly basis. • Each aligner moves a tooth or a small group of teeth about 0.25 – 0.33mm • Align technology using computer – aided scanning, imaging and manufacturing technology has pushed this technique into realms of every orthodontic practice.
  168. 168. • The revolutionary aspect of invisalign is the scanning in and imaging of high precision casts made from very accurate impressions (poly-vinyl silicon impression). This allows the patient’s teeth to be replicated as “on screen” 3D model, which can be manipulated and virtually corrected through a treatment plan developed by orthodontist and translated by invisalign using sophisticated propriety software. (CAD-CAM technology) The clinician has the ability to view the “virtual” models” from malocclusion to correction, movement by movement through an internet connection program called Clincheck. Changes are made through clincheck system until the result achieved is to the clinicians liking. Only then are the actual aligners made and dispatched.
  169. 169. Impressions are made using Polyvinyl Siloxane Impression and bite send along with a detailed treatment plan. advanced imaging technology transforms plaster models into a highly accurate 3-D digital image. A computerized movie - called ClinCheck® - depicting the movement of teeth from the beginning to the final position is created. After wearing all of the aligners in the series, customized set of aligners are made from these models, sent to the doctor, and given to the patient. Pt to wear each aligner for about two weeks. From the approved file, laser scanning to build a set Invisalign® uses of actual models that reflect each stage of the treatment plan. Using the Internet, the doctor reviews the ClinCheck file - if necessary, adjustments to the depicted plan are made. Procedure
  170. 170. Invisalign
  171. 171. Invisalign Patient gets the first aligner 6 weeks after the 1st visit Most treatments require 20 – 60 aligners  Worn for 2 weeks each Should be taken off only for eating and brushing
  172. 172. Invisalign • Limitations  Patients with severe malocclusions cannot be treated  Children,mixed dentition – growing jaws and erupting teeth too complicated for the computer to model  No precise control over root movements
  173. 173. Invisalign system in adult orthodontics: mild crowding & space closure cases Robert L Boyd, R J Miller,JCO 2000 April Case 1 23yrs/F Spacing b/w teeth
  174. 174.
  175. 175. 33yrs/M Spacing b/w teeth Case 2
  176. 176.
  177. 177. case3 35yrs/M Mild crowding
  178. 178.
  179. 179. Lower incisor extraction treatment with invisalign system-Ross J Miller 2001 JCO nov • Case report 24yrs/F Lower incisor crowding Class I molar reln Midline shift-3mm Rt side
  180. 180.
  181. 181.
  182. 182.
  183. 183.
  184. 184. Rapid orthodontic decrowding with alveolar augmentation: case report William . M . Wilcko Thomas . Wilcko World Journal Orthodontics 2003:4:197-205 Demonstrates a New orthodontic method that provides shortened treatment times. Case report 27yrs/F Class I with moderate crowding
  185. 185. • Extrusive, intrusive and rotational abilities of investigations are under trial • Software individualizes each tooth, so they can be individually repositioned and soft ware relates to upper and lower teeth together so that co-ordinate in kept between arches. • Manufacturing process is a computer aided technology. The 3D – models of each setup in the realignment are transformed into hard copy models through a process of laser build up. These models are then used to make the pressure formed aligners • [IPR] Interproximal reductions are done at the time of delivery of the aligners. • A typical invisalign treatment will take around 25 aligners and 50 weeks of treatment. – Handles simple to moderate non-extraction alignments better than mild to moderate extraction corrections – It has only limited ability to keep teeth upright during space closure. • Conditions treated with invisalign • It can be used as RETAINERS, NIGHT GUARD, TMJ SPLINTS BLEACHING TRAYS AND FOR TOOTH MOVEMENT
  186. 186. • Tooth Movements • Mildly crowded and malaligned problems (1 – 5mm) Treatment can be done with slight lateral or anterioposterior expansion, with minor interporximal tooth reduction or by removal of lower incisor. • Spacing of 1 – 5mm • Deep overbite problems (class II Div 2 type where the overbite can be reduced by intrusion and advancement of incisors • Narrow arches. • Certain aspects are more difficult to handle – Crowding and spacing over 5mm – Skeletal anterio posterior discrepancies of more than 2mm – CR and Co discrepancies – More than 20o rotations – Open bites – Extrusions – Severely tipped teeth (more than 45o) – Teeth with short clinical crowns – Arches with multiple missing teeth. • Though certain aspects are difficult to be treated by invisalign. Combinations treatment can be under taken. Conventional appliance may be used along with it whenever neede
  187. 187. • Advantages • Ideal esthetics : aligners are relatively invisible apart from a slight sheen to the teeth is close up. • Easy to use for the patient • Comfortable • Simplicity of care and better oral hygiene • Invisalign allows for refinement aligners which can be added at the end of scheduled treatment procedures. • Disadvantages • Limited control of root movement such as root paralleling, gross rotation correction, tooth uprighting and tooth extrusion. • Limited intermaxillary correction : severe skeletal discrepancy cannot be contemplated with invisalign alone. Surgery or a pre- invisalign functional phase would be necessary. • Lack of operator control : as the aligners are prefabricated there no chance of altering it. • Thus it is an esthetic technique used to treat simple to moderate alignment cases in adults.
  188. 188. • LINGUAL ORTHODONTICS • Most lingual orthodontics patients are adults and have greater demands and expectations than do labial orthodontic patients, Esthetics is a crucial factor. • Advantages : • • Labial enamel surface, is preserved which plays an important esthetic role. Susceptibility of this enamel surface to permanent decalcification following chemical insults from etchant materials and to plaque accumulation are prevented. • Lingual appliance allow easy access for routine oral hygiene procedures. • Evaluation of individuals tooth positions can be easily assessed as the labial surface is free of distracting metal (or) plastic brackets
  189. 189. • Lingual appliances are effective in the following situations • 1. Intrusion of anterior teeth. • Lingual bracket positioning is dictated by the morphology of lingual surface, it places the bracket closer to the CRES of the tooth. It allows the intrusive force rector to be directed through the CRES of the tooth. • Mandibular anterior dentition occludes with the anterior horizontal plane of maxillary anterior brakets, BITE PLANE effect results. Net effect is a LIGHT CONTINUOUS INTRUSIVE FORCE in the anterior and a passive extrusive force in the posterior segments. • 2. Maxillary arch expansion • More remarkable dentoalveolar expansion are achieved through lingual mechanics • Reasons may be due to • The force developed in of a CENTRIFUGAL TYPE (from inside towards the outside of the arch) • Thickness of the brackets which interpose between the tongue and lingual wall of the teeth contribute to the expansive effect/. • Short interbracket distance may play a significant role
  190. 190. • 3. Combining mandibular repositioning therapy with orthodontic movements : • Usually patients with TMD are treated in 2 distinct clinical phases. Initial phase consists of splint therapy followed by changes in occlusion. • Lingual appliances system allows both arches to be treated simultanesously. The anterior occlusally oriented inclined plane functions as a bite plane. Flat acrylic mini supports are added to the 1st and 2nd molars. This combination can stimulate the action of conventional splint thereby allowing treatment to progress simultaneously in both arches. • 4. Distalisation of maxillary molars • Lingual bracket are placed closer to CROT than the labial bracket. The molar distalisation through lingual technique produce more bodily movement of the tooth and less dental tipping.
  191. 191. • Finishing and detailing • Finishing does not differ significantly from adolescence • Patients with moderate to severe periodontal loss are stabilized with immediately placed retainers as soon as the finishing archwires are removed. • Later detailing of occlusal relationship by equilibration takes place. • In TMD patient undergoing comprehensive treatment, use of interocclusal splint prevents clenching and grinding from recurring
  192. 192. • NEWER TECHNIQUES: • CORTICOTOMY ASSISTED ORTHODONTICS – (JCO 2001 MAY- Chung OH and KO) • CORTICOTOMY has been used in difficult adult cases as an alternative to conventional orthodontic treatment or Orthognathic surgery. The original procedure of single tooth osteotomies or corticotomies was introduced by KOLE in 1959. The primary resistance to tooth movement is encountered in the cortical layer – corticotomy makes teeth to move faster. Teeth acts as handles by which the bands of less dense medullary bone are moved block by block. • Thus orthodontic tooth movement after corticotmy is a process of moving block of bone rather than moving only individual teeth. • It can be used in treatment of • 1. Ankylosed teeth • 2. Teeth surrounded by narrow cortical bone • 3. Significant arch length discrepancies • 4. Transversely constricted maxilla • 5. Can be used for posterior intrusion and rapid anterior retraction with maximum anchorage
  193. 193. • 6. Can be combined with orthopeadic therapy • Corticotomy surgery initiates and potentiates normal healing process by way of an accelerated transient burst of hard and soft tissue remodeling by means of a process called REGIONAL ACCELERATORY PHENOMENON (RAP). It was described by an Orthopedist Harold frost. • In the alveolar bone adjacent to corticotomy, there was marked increase in regional bone turn over. Tissue forms 2 – 10 times faster than normal regional regeneration process. • RAP – decreased the treatment duration especially in adults and multilated cases where conventional orthodontics may not be possible. • Examples of clinical applications of RAP in Orthodontics • Simple canine retraction immediately after 1st premolar extraction • Various corticotomy procedures. • Distraction osteogenesis procedure
  194. 194. • ACCELERATED INVISIALING TREATMENT • (Albert H. Owen) (JCO 2002 June Vol. 35 No.6) • Thomas and William Wilcko, using CT discovered that rapid tooth movement following corticotomies was due to reduced mineralization of the alveolar bone housing the involved teeth. • 2 years follow up CT showed alveolar bone was adequately remineralized. Wilckos thought that patient could benefit from alveolar augmentation in conjunction with a decorticating procedure. (Augmentation increases the alveolar. crestal height, increases the thickness of the alveolar bone and prevent dehiscenses. • Technique developed by Wilckos, called WILCKODONTICS System (or) ACCELERATED OSTEOGENIC ORTHODONTICS (AOO) is similar to single tooth corticotomy. Here it is extended to all the teeth to be moved orthodontically.
  195. 195. 1. Procedure: 2. 1. Comprehensive FA. 3. 2. Full thickness flap – decortication of alveolar bone 4. 3. Placement of resorbable bone graft agumentation. 5. 4. Soft tissue flap closed. 6. Following surgical procedure, orthodontic adjustment is made weekly to take advantage which RAP, which lasts only for 3 to 4 months. Rate of tooth movement then returns to normal once the bone has healed. 7. Owen combined the AOO procedure and Invisalign therapy in his adult patients. After 10 days of uneventful healing aligners were given. It was found that 3 to 4 times faster tooth movement occurred.
  196. 196. Retention & Post treatment stability in Adults. • “After malposed teeth have been moved into the desired position, they may be mechanically supported until all of the tissue involved in their support & maintenance in their new positions shall have become thoroughly modified , both in their structure & function to meet new requirements.” -E H Angle
  197. 197. Retention • Hawley’s retainer remains the most commonly used retainer. • Hawley’s with tongue crib • Indicated in managing residual neuro muscular problems, especially postural tongue problems. • Bondable Lingual retainers • They are mostly used the lower segments in patients requiring long-term retention. They are esthetic and usually go unnoticed. • Invisible retainers • They are retainers that fully cover the clinical crowns and a part of the gingival tissue. They are made of ultra thin transparent thermo-plastic sheets using a Biostar machine. They are esthetic and often go unnoticed. These can be used in adult patients who are especially concerned about estheticsComprehensive restorative procedures • Crowns and bridges may be required in mutilated cases at the termination of orthodontic treatment. They are not only prosthetic replacements but also retain the teeth
  198. 198. Removable appliances & retainers Hawley retainer Tooth positioner Spring retainer Fixed retainer Bonded retainer Banded retainer
  199. 199. Hawley retainer
  200. 200. Hawley retainer –modified
  201. 201. Positioner
  202. 202. Positioner
  203. 203. Fixed retainer
  204. 204. Fixed retainer
  205. 205. QCM-Organic polymer retainer
  206. 206. Labial fixed retainer
  207. 207. Labial fixed retainer
  208. 208. • CONCLUSION • Biomechanical modifications made to accommodate orthodontic treatment of adult dentitions are generally minor and adhere to the basic laws of physics as they apply to orthodontic tooth movement. Some adult presentations necessitate changes in treatment strategy from what would otherwise be employed in adolescent patients to achieve similar goals. In other cases, objectives themselves may need to be modified because of lack of growth potential, constraints of treatment mandated by the patient or the presence of multiple missing or compromised teeth. By planning treatment and mechanotherapy taking into account the individual circumstances that may affect the patient’s biological response to treatment, realistic goals of orthodontics can be mutually recognized and agreed on by both the provider and the patient before therapy is initiated, resulting in an immensely rewarding experience.
  209. 209. REFERENCES • Vanserdall RL ,Musich DR. Adult Orthodontics: Diagnosis and Treatment in Graber TM Vanarsdall RL. Orthodontics . Current principles and pratice 2 nd ed .C.V.Mosby . St Louis 1994.pp 750-836 • Contemporary fixed prosthodontics: Second edition Stephen F. Rosenstiel • Tylman theory and practice of fixed prosthodontics: 8th edition: W.F.P. Malone • Fundamentals of fixed prosthodontic: 3rd edition, Herbert T. Shillingberg • Fixed prosthodontics: Keith E. Thayer. • Implants in dentistry: Michael S.Block • William R. Profit 3rd edition Text book of orthodontics
  210. 210. • Shapiro P.A. and Cruz A.D (1995): Long term changes in arch form after orthodontic treatment and retention. Am J Orthod.107:518-31 • Saadia M. and Valencia(1998): Six blind men and the elelphant-The paradox story on relapse. Am J orthod.:687-9 • Sperry T.P. (1993): Limitations of Orthodontic treatment. Angle Orthod;63 :155-8. • Spahl T.K(1995) The tem great laws of orthodntics. Funtional Orthod:14-29
  211. 211. Thank you For more details please visit