Adolescent Orthodontic Treatment: Unique Challenges and Opportunities

ADOLESCENT ORTHODONTIC TREATMENT

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Introduction
 Adolescence is the transitional period

between childhood & adult years.
 It is a time of awakening, aspirations,

rebellion, learning to drive.
 Often characterized using terms such as

‘tumultuous & turbulent’.



This complex intersection of accelerated
physical growth & dynamic hormonal change is
accompanied by intensified self awareness &
conflicting forces of acculturation to demands of
society.



Orthodontic treatment of the adolescent patient
presents many unique opportunities that may
not be possible for adults.


 It is important , as far as understanding

the possible stresses faced by the
orthodontist, to recognize that the
adolescent age is frequently the optimum
time for treatment.

 Even though orthodontic correction is

indicated & time is opportune, the patient
may not be enthusiastic.


 Reason is obvious. Orthodontic

appliances imply a deformity, and at the
very least are no asset to a young
adolescent who is unsure of his/her
attractiveness.

 The prospective patient cannot always

accept what seems as further mutilation,
despite the fact that the treatment is of
importance for future attractiveness.

 Most likely motivation for any patient to

seek care stems from the patient’s desire
to improve smile; however there may be
factors influencing the adolescent patient's
decision to undergo orthodontic treatment.
 Trulsson et al ( J.O.2002 ) interviewed
adolescent patients in an effort to analyze
the factors affecting their decision to
undergo orthodontics.


 The teenagers in study believed that they

would make the final decision to initiate
orthodontic treatment, but this decision
was heavily influenced by “ the norm in
their actual or desired reference group &
by the surrounding world including the
media's ideal body image”.

 Teenagers wanted orthodontic care so

that they could ‘be like everyone else’ & ‘to
obey social norms’.

 In addition teenagers thought that a “nice

appearance would lead to a high self
esteem”.
 Investigators noted that teenagers in study

were not aware of the factors influencing
their decision to undergo orthodontics.


 Another concern is compliance of patient

due to length of time required to treat the
patient.
 Lack of compliance can impact the final

treatment result. Can result in the patient
being worse after treatment than before
treatment.




Adolescence is also the stage in psychosocial
development in which a unique personal identity
is acquired.



Includes both a feeling of belonging to larger
group & a realization that one can exist outside
the family.



According to Erikson adolescence age (12 to17)
is where there is development of personal
identity.


 Requires a partial withdrawal from

the
family, peer group increases still further in
importance.
 Members of peer group become role
model, and the values & tastes of parents
& other authority figure is being rejected.
 So a poor psychological situation is
created by orthodontic treatment if it is
being carried out primarily because
parents want , not child.

 Motivation for treatment can be divided

into external and internal.
 External motivation – Pressure from
others.
 Internal motivation – Individual’s own
desire for treatment to correct a defect that
he perceives in himself.
 Approval of the peer group is extremely
important.



It is extremely important for an adolescent to actively
desire the treatment as something being done ‘for’, not
‘to’ him/her.



According to Jean Piaget cognitive development theory,
when an adolescence consider what others are thinking
about, he assumes that others are thinking about the
same thing he is thinking about, namely himself.



They feel as though they are constantly “on stage”, being
observed & criticized by those around them. This
phenomenon has been called the “imaginary audience”
by Elkind.


 As a result of ‘imaginary audience’ a

second phenomenon emerges , Elkind
called it “ personal fable”. It makes
adolescents thing that nothing could
happen to them as they are unique.
 Imaginary audience depending on what

adolescent believes , may influence to
accept or reject treatment, and to wear or
not wear appliance.



The personal fable may make a patient ignore
threats to health, such as decalcification of teeth
from poor oral hygiene during orthodontic
therapy.



Orthodontist should not force upon the patient to
wear a particular appliance if he is concerned
about what others will think.



A more useful approach that does not deny the
point of view of the patient is to agree with him,
that he may be right, but ask him to try for a
specified time.



Encouraging a reluctant teenager to try it & judge his
peers response is much likely to get him to wear the
elastics than telling him every body else does it so he
should do.



Cooper & Shapiro(1996) suggested taking time to
identify an adolescent's concern & then to treat them as
individuals, recognizing their values & issues.
This approach reduces compliance barriers.




Orthodontists should understand that adolescents are
not influenced strongly by health specific goals












Grewal K, Sunny JP, Valiathan A (2003)
A questionnaire study done at Manipal between April
2003 & June 2003 regarding patients expectations and
perceptions towards orthodontic treatment . Mean age –
19.54yrs.
67%- Believed that their self confidence may be
positively enhanced
42%- Felt that improved facial appearance
would not be an advantage as far as their career
opportunities are concerned.
More than half of the total respondents felt that, to attain
straight teeth was the first motivating factor to undergo
treatment.
Only 31.8% - felt that improvement in dental
appearance may lead to enhanced facial appearance




Orthodontic treatment of teenagers can be very
rewarding, but some deeper issues of health care might
be missed by the unprepared professional. This patient
group is often viewed as inherently healthy, and
important signs and symptoms of disease can be missed
simply because of a biased outlook.



A particularly vital portion of the care of teenagers is
monitoring for depression and other psychosocial
disorders, including substance abuse. This period of life
is a time of great psychological, social, and physical
changes.



Tobacco: cigarettes and smokeless tobacco :
May have poor brushing habits ,Association with
risky behaviors and antisocial personality types.



Alcohol : Antisocial behavior, Missed
appointments ,Risky behaviors, Increased risk of
hard drug use.



Opiates including heroin : Antisocial behavior
Risky sexual behavior, Multi drug use,
particularly with cocaine, Missed appointments
Very poor oral hygiene.




Steroids : Missed appointments, Aggressive behavior,
Poor self esteem, Premature cessation of growth at
epiphyseal plates.



The orthodontist is in a unique position to monitor
adolescents for substance abuse.



Typical orthodontic treatment involves frequent
appointments over several years.



By carefully noting intraoral and extraoral physical
changes, the practitioner can monitor patients for signs
of drug and alcohol abuse



Treatment for most disorders centers on a
combination of counseling and
pharmacotherapy. Although it is not within an
orthodontist’s practice to treat substance-abuse
disorders, it is important to appropriately make a
referral if a problem is detected.



It is of the utmost importance to respect the
patient’s privacy in these instances and discuss
substance abuse in a private consultation.
Careful questioning of both the child and the
parent can lead to a better understanding of the
situation and an easy decision on referral .



Teens often undergo significant peer pressure to
try drugs and alcohol. It has been shown that
orthodontic patients who use tobacco are at risk
for other high-risk behaviors.



Suicidal behavior and substance abuse have
been clearly linked, as have substance use and
depression.



Because many orthodontic practices have been
touched by suicide, it is important to be aware of
some significant risk factors for this undesirable
outcome

General Characteristics of
Adolescent Malocclusion
 a) Dentition and occlusal relationships are

established!
 b) Skeletal growth may be mostly over and
decelerating.
 c) Muscle function is matured. .
 d) Functional malocclusions are less
frequent since they have largely been
accommodated by dentoalveolar, skeletal,
and/or mandibular joint adaptations.

 e) Temporomandibular dysfunction is

more frequent since dental, skeletal, and
joint adaptability have diminished.
 i) Psychological aspects are more

significant than at younger ages.


 Irfan Dawoodbhoy & Ashima Valiathan

(JICD 1993) have listed following
treatment objectives for adolescent
patients 1) Dentofacial esthetics
2) Stomatognathic system
3) Stability
4) Static & dynamic class I occlusion.

Advantages of Adolescent Treatment


a) Control of all permanent teeth, except third molars, is
now possible.



b) It is beneficial to treat when bone turnover rates are
still high though adult dimensions are nearly achieved.
Repair and remodeling occur readily in response to
orthodontic forces though the basic craniofacial
morphology is largely established.



c) Motivation for treatment is high, especially when facial
esthetics are affected.



d) Treatment goals can be more surely defined, does not
have to counter, as much as earlier, the dynamics of
growth.

Difficulties in Adolescent Treatment


a) The best opportunities for control and manipulation
severe skeletal dysplasia are past.



b) Sports and social activities, so important to
adolescents, often compete with plans for orthodontic
treatment.



c) The time necessary for treatment may be longer for
certain malocclusions.



d) Tooth positioning is often more difficult when
occlusion is fully established and root formation is
complete than tooth guidance was during eruption.


 Since precise tooth positioning is the

principal strategy in adolescent treatment,
cephalometric analysis for treatment
planning is essential and many analyses
have been designed solely to , determine
the placement of teeth within particular
skeletal morphologic patterns.


 Moyers

group treatment goals for
discussion, quantification, and planning as
follows: (I) skeletal; (2) dental; (3) occlusal
and functional; (4) soft-tissue and facial
esthetics; and (5) compromises.







I. Skeletal
Improvement in the craniofacial skeleton by
orthodontic treatment is still possible in
adolescence, although the greatest opportunities
for so doing may be over by this age. A primary
aim of some clinicians is to predict the time of
the adolescent of maturity
When maxillo-mandibular relationships are
altered , it is important to ascertain whether
maxilla or mandible, or both are to be changed
and to quantify the change sought in each jaw



Although mandibular impedence or
enhancement is more difficult after pubescence,
midface changes are possible with intensive
orthodontic forces.



Vertical change is most apt to occur within
dentoalveolar process or by rotation of the
mandible following dentoalveolar changes

Planned horizontal and vertical skeletal
changes ,should be quantified and monitored
regularly by cephalometric analysis.



2. Dental



a) Axial Inclinations : The roots of posterior teeth should
be approximately parallel to one another, especially
those roots adjacent to extraction sites. Artistic
positioning of the crowns of anterior teeth usually results
in a slight divergence of the roots.



The root angulation of the anterior teeth is lingual and an
interincisal angle of 130 degrees may serve as a rough
guide.



However, the percentage of the 130 degrees contributed
by upper incisors and lower incisors varies greatly with
the maxillo-mandibular relationship and the steepness of
the mandibular and occlusal lines .




b) Incisal Relations
Ideally the overbite should be approximately one-third of
the lower incisal crown.
The overjet which is determined by a) the axial
inclination of incisors, b) the skeletal relationship, c) the
relation of the widths of upper to lower teeth (Bolton
Index) , and d) the labiolingual thickness of the crowns
should provide incisal centric stops in the intercuspal
(usual occlusal) position.



c) Midlines
The dental midlines should coincide with each other and
with the mid-sagittal plane of the craniofacial skeleton.









d) Arch Form
The arch forms should be symmetric and coordinated
with each other and should, as much as possible, be
concordant with the forms of their skeletal bases.
The mandibular intercanine diameter should rarely
increase during adolescent treatment, since such an
increase has been shown repeatedly to be unstable
irrespective of the appliance use
e) Spacing
Ideally, all teeth in both arches should have firm
interproximal contacts and there should be neither
crowding nor rotations of the teeth. However, the Bolton
Index may reveal that such perfect results are
impossible and that some spacing or crowding is
inevitable




3. Occlusal and Functional.



The desired occlusal pattern (group function or cuspid
rise) should be determined at the start and brackets
placed accordingly.



The treated occlusion should display no deflective
interferences during mandibular occlusal movements or
in the retruded contact position (centric relation).



There should be no balancing interferences and the
posterior teeth should disclude during protrusive
movements.





4. Soft Tissue Profile and Esthetics
It is harder to quantify esthetic goals of treatment and
personal tastes vary , yet there are some commonly
accepted standards. The incisor positions should not
strain the lip musculature and the incisal overlap should
be harmonious with the lip line.



Little display of the gingivae during smiling is desirable.
The lips should be without strain at rest and in function.



The incisors should not be retracted excessively lest the
lip drape at rest will give an aged or edentulous
appearance to the soft-tissue profile.
Excessive retraction of the incisors also robs the lips of
proper participation in facial expressions.







5. Compromises
When defining goals for adolescent treatment, one
begins with the ideals, listed above, accepting
compromises only when the conditions of the case force
one to do so. In adult treatment, one often is forced to
begin with compromise .



In adolescent treatment every necessary compromise in
the treatment plan should be quantified in terms of the
skeletal profile and tooth positions, and all of the "tradeoffs" and consequences of compromise should be noted
and understood at the start.



Often a hastily, casually, or unwittingly accepted
compromise at the beginning has serious consequences
later. Adolescent treatment should aim for idealism.



When adolescent treatment is progressing in an
unsatisfactory manner or an unsatisfactory result
is observed at the "end" of treatment there are
no easy alternatives.



Poor treatment does not stabilize or improve
with time. Retreatment to the standards to be
described is really the only satisfactory solution.



For this reason adolescent treatment must be
accompanied not only by meticulously designed
original goals but also by persistent monitoring
throughout treatment.

Treatment planning



a) Congenitally Missing Teeth
I. Maxillary Lateral Incisors.If a bridge or bridges are to be placed, the goals of
treatment must include attentive detail to the positioning
of the central incisors and cuspids which may be
abutment teeth.
When the cuspid and all other maxillary posterior teeth
are to be moved mesially, obviating the need for a
bridge, then the principal new goal is the meticulous
placement of the cuspid root to parallel the central
incisor. The first bicuspid and all posterior teeth are
moved forward into a Class II relationship.








Moving the first bicuspid forward into the cuspid
region usually creates balancing interferences;
therefore, its lingual cusp must be reduced
gradually during its mesial movement.
If a cuspid rise occlusion is desired, the bracket
height on bicuspid must be placed atypically to
guarantee its extrusion.
Particular attention must be paid to the
positioning of the molars and they must be
equilibrated by occlusal grinding to secure the
occlusal result.



Mandibular Second Premolars.- The goals of
treatment obviate the need for a bridge, secure
a more correct intercuspation, and guarantee
the height and health of the alveolar bone on
mesial aspect of the mesial root of the first
molar.



If a primary second molar is retained unduly, this
usually results in an undesirable relationship of
the alveolar septum between the second primar y
molar's root and the first permanent molar



Treatment of congenitally missing mandibular
second bicuspids by mesial movement of all
posterior teeth is not a difficult technical problem
for anyone skilled in precision bracketed
appliance therapy.



While the problem is best treated earlier it can
still be treated well in adolescence with
bracketed appliances. Its treatment with
removable appliances is not recommended
since ultimate parallelism of the roots is
essential for a stable result.




Eruption Problems.



Failure of a permanent tooth to erupt creates a
severe orthodontic problem.
A localized problem is typically created either by
displacement of a permanent tooth from its
normal eruption path so that the tooth becomes
impacted (usually a maxillary canine) or by
trauma that leads to ankylosis (usually a
maxillary incisor) .





A generalized problem implies an abnormality in
the eruption mechanism.



Impacted Teeth. An impacted canine or other tooth in a
teenage patient can usually be brought into the arch by
orthodontic traction after being surgically exposed. In
older patients, there is an increasing risk that the
impacted tooth has become ankylosed. Even
adolescents have a risk that surgical exposure of a tooth
will lead to ankylosis. (Becker A, 1998) .



In planning treatment for an impacted permanent tooth,
three principles should be followed: (1) The prognosis
should be based on the extent of displacement and the
surgical trauma required for exposure. As a rule, the
greater the displacement and the greater the trauma, the
poorer the prognosis.








Extraction of a severely impacted tooth and
orthodontic space closure or prosthetic
replacement may be better judgment than heroic
efforts to bring the tooth into the arch.
(2) During surgical exposure, flaps should be
reflected so that the tooth is ultimately pulled
into the arch through keratinized tissue, not
through alveolar mucosa.
(3) Adequate space should be provided in the
arch before attempting to pull the impacted tooth
into position.



Diagnostic factors of interest include the position of both
crown and apex, the space available to accommodate
the cuspid in the arch, and the position and health of
adjacent teeth especially the roots of the lateral incisor,



the intactness of the labial cortical plate of bone, the
willingness of the patient to undergo prolonged
orthodontic treatment, and the relationship of the
condition to other orthodontic treatment needed.



All require a meticulous radiographic perspective.
The size of an impacted cuspid may be determined by
measuring the antimere.






If both cuspids are impacted, measure the crown width
of the maxillary first and second premolars and estimate
the size of the cuspid crown by referring to appropriate
tooth size charts .



Do not forget that sexual dimorphism in crown size is
more obvious in the maxillary cuspid than any other
tooth.



Measurement of crown size of impacted cuspids in the
radiograph is flawed by distortion due to the angulation
and the curvature of the film. Study carefully, in the
radiograph, the health and morphology of the cuspid's
root as well as its position




If a tooth is severely impacted, surgical transplantation is
a possible treatment approach. This involves removing
the tooth, creating a socket at the appropriate site in the
arch, and replanting the tooth in its correct position.



External root resorption often ensues after
transplantation and is the major cause of failure.
Approximately two thirds of transplanted teeth are
functional for 5 rears, but only about one third are
retained for 10 years.( Moss, 1972).



Orthodontic movement is preferable if it is possible.







Generalized Eruption Failure. An eruption delay that
affects several teeth in an adolescent patient is an
ominous sign. If the problem is a mechanical
interference with eruption the obvious treatment plan is
to remove the interference and proceed with orthodontic
therapy.
The condition called "primary failure of eruption”, results
from a failure of the eruption mechanism itself.
Unfortunately, not only do the involved teeth not erupt
spontaneously, they do not respond to orthodontic force
and cannot be pulled into the arch. Since prosthetic
replacement is the only practical solution, it is fortunate
that the condition is rare.




Hemisection: one large step toward management of
congenitally missing lower second premolars.
( Angle 2004)
Northway W.
When the primary molar cannot be retained in cases of
agenesis of the lower second premolar (CML5), there is
the possibility of alveolar atrophy, and space closure
might have a negative impact on facial fullness.



Bearing these in mind, the removal of the distal half of
the second primary molar might allow closure in stages.
Subsequent removal of the mesial half can be followed
by space closure. Using this hemisection approach,
space closure can be continued with ease improving
treatment results.



In order to test the amount of anchorage loss
resulting from this approach, the pitchfork
analysis was used to compare a group of 23
consecutively treated patients, each treated by
hemisection, with two groups of 30 patients,
each of whom was treated with the extraction of
four premolars.



One group had four first premolars removed
and the second group had second premolars
removed.







The CML5 group was divided into those which
had upper teeth extracted in order to facilitate
the correction and those who were treated
without extraction in the upper.
The hemisection groups showed statistically
significant diminished distal movement of the
upper incisor as well as the upper and lower lip.
Lower molar protraction and molar relation was
significantly increased. The process facilitates
the keeping of upper premolars, which further
enhances facial fullness.








Ankylosis – First molars, maxillary cuspids, maxillary
incisors are the permanent teeth most likely to be
ankylosed.
Etiology – unclear. History of trauma associated with
incisor ankylosis.
The goal of treatment in adolescence is to establish, if
possible, proper occlusion: three methods are used:
surgical, orthodontic, and restorative.
The tooth should first be surgically exposed, carefully
luxated, and splinted into an improved position. Subsequent orthodontic movements to an ideal position
should then be attempted, though ankylosis usually
reappears.



If ankylosis recurs and the tooth is to be retained
consider building it up to occlusion with
composite until growth is apparently over and a
permanent restoration can be placed.



There is a danger in retaining ankylosed teeth,
namely localized cessation of alveolar growth
which may bare the roots of adjacent teeth and
predisposes to periodontal difficulties



If an ankylosed molar must be extracted, do not
overlook the possibility of orthodontic closure of
the edentulous space

Variations in shape & size of teeth





a) "Large Teeth"
This problem is really that of simple crowding
b) Small Teeth . Esthetics are more critical at
this age than during childhood and "permanent"
treatment combining orthodontics and
restorative dentistry can be quite successful.
The introduction of composites, laminates, and
porcelain veneered crowns offers esthetic and
functional success previously not possible.



c) Anomalies of Tooth Shape
A more permanent treatment of crown
anomalies is possible when started in
adolescence.

Moreover, problems handled earlier often may be
treated again, advantageously, to an esthetic
result which was not possible earlier.
Anomalies in root length and morphology are
more obvious in adolescence and often play an
important role in treatment planning (e.g. ,
deciding whether to remove first or second
bicuspids in extraction cases) .

Alignment Problems


When there is crowding in the early permanent
dentition, an accurate space analysis can be
carried out directly, without the necessity for
predicting the size of unerupted teeth.



In this age group, however, it remains true that it
is necessary to evaluate the amount of
protrusion as well as the amount of crowding to
totally evaluate the space situation.




The diagnostic setup, a cephalometric analysis,
and judgment of facial esthetics and the lip
musculature are critical in defining a simple
crowding case and planning its treatment.



One may advance and reposition the incisors in
the cephalometric tracing to visualize twodimensionally and statically how such
repositioning encroaches on the lip muscles.



A significant difference between mixed dentition and
early permanent dentition patients is that the simple
appliances that can be used to solve space problems in
the mixed dentition are no longer effective after the
permanent teeth have erupted.



Whether a patient in the early permanent dentition is to
be treated by arch expansion or by extraction, a bonded
or banded fixed appliance is needed to position the teeth
correctly.



Removable appliances of all types, along with lingual
arches and other round wire or partially fixed appliances,
are effective only for tipping teeth to new positions..


 Extraction of first premolars provides the

greatest flexibility in terms of closing
space which of course is a major reason
for this being the most frequent extraction.
 In contrast, little useful space for either

purpose is provided by second molar
extraction.








Tooth Size Discrepancies –
A tooth size discrepancy of less than 1.5 mm is usually
insignificant, but larger discrepancies create a problem
that must be solved in the development of a treatment
plan.
There are five possible approaches:
(1) compensate for a small size differential by changing
the inclination of the incisors;



(2) reduce the width of some teeth by interproximal
stripping of enamel;



(3) build up the width of an anomalously small tooth or
teeth by adding composite resin or a crown;

 (4) alter the normal extraction plan to

compensate for size discrepancies (for instance,
by extracting anomalously large lower second
premolars rather than first premolars in what
would otherwise be a first premolar extraction
case);


(5) accept a small space in one of the arches,
usually distal to the lateral incisors.




Before one of the possible plans is accepted, it is
important to determine whether the discrepancy is
caused by a variation in one of the teeth or a generalized
size difference between upper and lower teeth. This
determination can be accomplished by Bolton analysis .



The usual culprits in tooth size problems are the upper
lateral incisors, but second premolars in both arches also
vary in size. Reducing or building up lateral incisors, if
these are the source of the discrepancy, is the best
approach. It is less easy to alter the width of premolars,
and one of the other solutions may be required.



A diagnostic setup is usually needed to verify that a
proposed treatment plan for tooth size discrepancy can
succeed.



If the permanent teeth have been allowed to
erupt completely while still malaligned, it is rare
that a satisfactory result can be obtained without
using an orthodontic appliance that can change
root positions. Just tipping the crowns to a new
location is not enough.



If extraction is required to provide enough space,
root movement is required to satisfactorily close
the space


 Transverse Problems


Transverse problems in the adolescent age
group, as in younger patients, are most likely the
result of a narrow maxillary arch.



The necessary maxillary expansion may be
approached either skeletally or dentally,
depending on the anatomic basis of the
problem.




Single tooth crossbites or true unilateral
asymmetries of the dental arch are usually best
corrected by cross elastics in the affected area ,
provided that there is not a skeletal vertical
problem that the elastics could aggravate.
Reciprocal tooth movement will result if one
tooth is pitted against another.



Differential unilateral maxillary expansion can be
achieved by placing a lower fixed appliance and
using cross elastics from the stabilized lower
arch to the maxillary teeth on the affected side



Skeletal asymmetries - Posteroanterior
cephalograms in the postural and occlusal
positions are necessary for one to identify and
differentiate both mediolateral and vertical
skeletal asymmetry.



Mandibular landmarks which change between
the two vertical positions are evidence of
residual neuromuscular occlusal dysfunction.


 TMJ region should be searched for

evidence of condylar or fossa asymmetry
of either shape or position.
 PA, lateral & oblique cephalograms,

panoramic or special radiographic
projections of TMJ may be necessary.




True skeletal asymmetries in the adolescent age
group pose an extremely difficult problem.



Treatment include RME, gradual expansion with
a Quad Helix appliance.



Functional jaw orthopedic appliances can be
used, but best time for their use is past.



If orthognathic surgery is necessary it usually is
done later.


Sagittal Problems


The preferred treatment for skeletal problems,
whatever the plane of space, is always growth
modification. For greatest success, growth
modification treatment should begin before the
adolescent growth spurt, and the amount of
remaining growth must be evaluated carefully
before treatment is planned for an adolescent.



Girls mature earlier than boys, and it is possible
that by the time a girl's permanent teeth have
erupted, it is too late for effective growth
modification.

 A second plan for correcting

anteroposterior discrepancies is to
camouflage them by differential movement
of upper and lower incisors.


If the problem is severe, a third option is
surgical repositioning of the jaws.


Class II malocclusion
 Even in more favorable circumstances it is

unlikely that more than half of the changes
needed to correct class II malocclusion in
adolescent would be gained by differential
jaw growth.( max. 3 – 4mm ).
 If a functional appliance is desired for

adolescent treatment, often a fixed
functional appliance is preferred.

 Distal driving of maxillary first molars

becomes difficult .
 Extraction of maxillary second molars &
distal movement of remaining upper teeth
can successfully correct moderate class II
malocclusion. Here also one should not
expect more than 4mm distal movement.







Premolar extraction can produce excellent
occlusion.
Can also use class II elastics without
extractions. However moving the lower incisors
anteriorly more than 2mm lead to instability &
relapse.
Prolonged use of class II elastics can result in
convex profile with protrusive lower incisors & a
prominent lower lip. This is best described as
relapse waiting to occur.


 Vertical growth is

needed when inter arch
elastics are used, to prevent rotating the
mandible down & back as lower molars
are elongated, and even then the elastics
may produce an unesthetic elongation of
the upper incisors.




Skeletal, dental and soft-tissue changes
induced by the Jasper Jumper appliance in
late adolescence.
( Angle 2005)
Nalbantgil D, Arun T, Sayinsu K, Fulya I.
The purpose of this study was to evaluate the
skeletal, dental, and soft-tissue changes in lateadolescent patients treated with Jasper Jumper
applied with sectional arches. The study sample
consisted of 30 subjects (15 treated, 15
untreated) with skeletal and dental Class II
malocclusion.

 The results revealed that, in late-

adolescent patients, the Jasper Jumper
corrected Class II discrepancies mostly
through dentoalveolar changes. It is
suggested that this treatment method
could be an alternative to orthognathic
surgery in borderline Class II cases.


Class III malocclusion


Primary reason of treating class III malocclusion
in adolescents is that, if postponed, the
probabilities of needing orthognathic surgery
combined with orthodontic therapy are greatly
increased.



One can rationalize the treatment of class III in
girls during adolescence is easier than that of
boys, because treatment in girls is less apt to be
thwarted by pubescent growth spurting & they
are nearer adult dimensions than boys at each
chronologic age.

 Strategies for treatment in adolescence

include – 1) Ventral displacement of the
midface.
2) Inhibition of mandibular growth.
3) Redirection of mandibular growth.
4) Dental & alveolar process repositioning.
Facemask is used in cases of midface
deficiency.

 Mandibular prognathism

is a more severe
problem in adolescence than midface
deficiency, particularly when the mandible
is already hyperplastic prior to the
adolescent growth spurt.
 Chin cup treatment can be used in milder
cases of mandibular prognathism.
 Combining functional appliance with fully
bracketed appliances in both arches is
also useful in treatment.



One must be prepared to accept defeat in some
cases of mandibular prognathism, particularly in
boys, whose dramatic growth during treatment
may be a problem.



In such instances, secure cephalometric & cast
records, remove the appliances, place retainers
to maintain the arch. Monitor the case
cephalometrically until such time as orthognathic
surgery is indicated.




Postpubertal assessment of treatment timing for
maxillary expansion and protraction therapy
followed by fixed appliances.
( AJO 2004)
Franchi L, Baccetti T, McNamara JA.
In this cephalometric investigation, authors evaluated the
correction of Class III malocclusion in subjects who had
attained postpubertal skeletal maturity and considered
whether treatment timing influenced favorable
craniofacial modifications. All subjects (n = 50) were
treated with an initial phase of rapid maxillary expansion
and protraction facemask therapy, followed by a second
phase of preadjusted edgewise therapy.




The treated sample was divided into an early
treated group (early mixed or late deciduous
dentition, 33 subjects) and a late treated group
(late mixed dentition, 17 subjects). Mean
treatment duration times were 7 years 2 months
for the early treatment group and 4 years 5
months for the late treatment group.



The findings showed that orthopedic treatment
of Class III malocclusion was more effective
when it was initiated at an early developmental
phase of the dentition (early mixed or late
deciduous) rather than during later stages with
respect to untreated Class III control groups.



Patients treated with rapid maxillary expansion
and facemask therapy in the late mixed
dentition, however, still benefited from the
treatment, but to a lesser degree.



Early treatment produced significant favorable
postpubertal modifications in both maxillary and
mandibular structures, whereas late treatment
induced only a significant restriction of
mandibular growth.

Vertical problems






The major vertical problems of adolescents are
anterior open bite and anterior deep bite, both of
which are likely to be seen in combination with
some anteroposterior problem.
As a child becomes older, it is more and more
likely that malocclusion in the vertical plane of
space, as in the anteroposterior plane of space,
is related to skeletal jaw proportions and not just
to displacement of the teeth.
Eruption problems are also likely to be more
serious in this age group.



Anterior Open Bite. The skeletal indications of anterior
open bite are increased anterior face height and a steep
mandibular plane, both of which reflect excessive vertical
growth of the maxilla and rotation of the mandible; and
excessive eruption of posterior teeth.



Because of the downward and backward rotation of the
mandible, the patient is likely to have a Class II jaw
relationship in addition to the vertical problem.



Growth modification treatment, focuses on controlling
both the vertical maxillary growth and eruption in both
arches.




The treatment of simple open bite in adolescence
consists of identifying and controlling localized etiologic
factors first, then bracketing teeth and coordinating arch
forms. In a few cases, these steps alone may be
sufficient



Vertical elastic traction is necessary to acquire full
centric stops on all teeth. Check the occlusion carefully
with articulation paper to determine that each tooth has
been seated fully into occlusion.




Allow the patient to wear the banded appliances
for the initial period of retention, but do not
remove them until normal swallowing and lip
function obtain at all times.



Persistent hyperactive mentalis muscle activity
may be treated with a modified vestibular shield.



For posterior simple open bite, a Hawley
retainer with extended lingual flanges vertically
is useful to control the tongue during retention.










Complex open bite typically is difficult to treat
orthodontically. In moderate cases, one attempts
to achieve some esthetic cover-up of the
skeletal dysplasia by alveolar process
compensation.
Extractions may be necessary , even when
simple crowding is absent, to provide space for
tooth positioning and alveolar remodeling.
If initial orthodontic treatment does not succeed
in more severe cases, surgery at a later age
may be indicated.
Growth tends to aggravate, not obscure, all
cases of complex open bite.



By the time adolescence is reached,
environmental causes of anterior open bite have
become less important than skeletal factors . It
is rare for anterior open bite in an adolescent to
be due solely to some habit, or for the open bite
to correct spontaneously at this age after a habit
has been corrected.



In the past, tongue thrust swallowing was
blamed for many anterior open bites in this age
group, and efforts at training the patient to
swallow correctly were used in an attempt to
control anterior open bite problems.

 Contemporary

research, however, makes
it clear that tongue thrust swallow is more
an adaptation to the open bite than the
cause of it .
 Myofunctional therapy for tongue
thrusting, for that reason, is ineffectual and
not recommended.




Deep Overbite. Anterior deep bite problems may result
from an upward and forward rotation of the mandible, or
from excessive eruption of mandibular incisor teeth.



Supra-eruption of lower incisors often accompanies a
Class II malocclusion, because when there is excessive
overjet, the lower incisors tend to erupt until they contact
the palatal mucosa.



In comprehensive orthodontic treatment, usually it is
necessary to correct this elongation of the lower incisors,
by leveling out an excessive curve of Spee in the lower
arch.




In an adolescent whose face height is still
increasing, it is only necessary to prevent further
eruption of the lower incisors as vertical growth
continues to achieve a relative intrusion.



Continuous arch mechanics are appropriate. In
the absence of growth, however, absolute
intrusion is required, and segmented arch
mechanics must be used to achieve this




Correction of skeletal deep bite problems
requires rotating the mandible downward,
thereby increasing the mandibular plane angle
and anterior face height.



Keep in mind that in a patient with short anterior
facial dimensions and a skeletal deep bite,
rotating the mandible downward to correct the
deep bite will reveal a skeletal mandibular
deficiency.



Thus the growth modification techniques
necessary to deal with this problem are typically
those for correction of mandibular deficiency.

 Severe cases of deep bite combined with

severe AP skeletal dysplasia. may require
orthognathic surgery later.


Temporomandibular Joint Dysfunction


Temporomandibular dysfunction and associated signs
and symptoms are more frequently seen in adolescence
than in childhood. The origins are important to an
understanding of the clinical problem in adolescence.



A history of facial trauma or temporomandibular joint
trauma is often found.



Temporomandibular joint dysfunction may be seen with
a variety of malocclusions in adolescence, although it is
most frequently associated with Class II, deep bite, open
bite, and skeletal asymmetry .




Of particular importance are those cases with occlusal
dysfunction such as an abnormal distance between the
retruded contact and intercuspal positions and markedly
deviant or erratic paths of mandibular closure.



A meticulous examination of the joints and associated
musculature is essential for every adolescent
malocclusion .



Many adolescents are unaware of myalgia or pain in
tendons and the joint region because the condition has
appeared so gradually that they have accommodated
through time. Precise palpation may elicit points of
tenderness of diagnostic significance.



Treatment consists of correcting the malocclusion to the
finest and most precise functional occlusal results, giving
particular attention to the joints.



Detailed attention to tooth positioning, occlusal
equilibration, and precise occlusal coordination are
essential. Intermaxillary elastic traction during treatment
is contraindicated in patients with TMJ symptoms.



Retention should not be started until perfect occlusal
coordination is seen, but occlusal equilibration may be
begun while the bracketed appliances are still in place.




References have been made in the literature implicating
adolescent orthodontic treatment as a causative factor in
adult temporomandibular dysfunction,



but sound long-term clinical studies by Sadowsky &
Begole ( AJO 1980 ) clearly show orthodontic treatment
is not a significant etiologic factor on a population basis.



Any poor occlusal treatment at any age can contribute to
temporomandibular pain or joint derangement.


 Orthodontic treatment significantly

reduces the prevalence of
temporomandibular joint disrders in
adolescents, for the condition is more
prevalent in malocclusions before their
treatment


Current Trends





A recent trend is the use of invisible removable
aligners for minor tooth movement.
For adolescent orthodontic patients in whom
growth/ orthopedic effects are deemed
unnecessary, possibility exists for use of implant
assisted orthodontics.
Carano ( JCO 2005) however, caution against
the use of orthodontic implants for girls younger
than 16yrs & boys younger than 18yrs.

ASSESSMENT OF RESULTS OF
ADOLESCENT TREATMENT


Evaluation of orthodontic treatments must be
done precisely and with caution for there are
many variables which determine the quality of a
treated result.



Unless one knows exactly the conditions under
which a case was treated, it is wise and
professionally prudent to be cautious in
conclusion and discreet in comment .






Poor treatment does not stabilize or improve
with time.
Retreatment to the standards to be described is
really the only satisfactory solution.
For this reason adolescent treatment must be
accompanied not only by meticulously designed
original goals but also by persistent monitoring
throughout treatment.








Occlusion
a) Occlusal Plan. If a cuspid rise occlusion was
chosen, then the entire occlusion should be
consonant with that theory .If group function was
the plan, then the occlusion should be judged by
the principles of that approach.
b) Molar Relationships
Much orthodontic treatment focuses only on first
molar occlusion, but the occlusal relations of all
molars and bicuspids should be studied carefully
and the lingual molar occlusion is particularly
revealing.



c) Cuspid Occlusion While the cuspid occlusion
is as important as the molars, it is not always
possible to have equally good molar and cuspid
reIationships if there are tooth size
disharmonies.



More compromises in cuspid occlusion and
overbite and overjet are necessary in men and
boys because of the sexual dimorphism in
maxillary cuspid size.



d) Incisor Position Incisors must be placed well
over the basal bone in each arch and well
related to one another. Careful root positioning
determines incisal stability and esthetics.



e) Functional Occlusal Relations :The occlusion
must be studied in the retruded contact position
(Centric relation) and in the intercuspal position
(centric occlusion).


 There should be no occlusal interferences

in retruded contact position nor any
between the retruded contact and
intercuspal positions.



It is especially important that there be
balancing interferences . In protrusive
occlusion the incisors should contact
symmetrically and there must be complete
posterior disclusion.



f) Root Positions : In extraction cases, it is
important that the roots be parallel directly
beneath the crowns to avoid loss of
interproximal contact. In treated crossbite cases,
root positions must agree with correction.



g) Alignment : Crown size disharmonies may still
be present at the end of treatment when there is
a Bolton discrepancy. Disharmonies of tooth size
and the adaptation of occlusal function to
continuing growth may deny perfect alignment in
some cases.









Soft Tissues
Facial and tongue musculature play an
important role in stabilizing orthodontically
treated cases, and the facial soft tissues
determine, to a great extent, esthetic results.
The time of treatment and the time of the
evaluation are important since there are
significant soft tissue growth changes during
childhood and adolescence.
One must also decide whether or not any
adaptive functions which accompanied the
malocclusion are still present after treatment.

 Gingiva: Gingival health after orthodontic

treatment reflects not only oral hygiene but also
the positions of the teeth achieved at the end of
orthodontic therapy.


Especially vulnerable is the gingival height of
mandibular incisors and the gingival relationship
to maxillary molar and bicuspid roots after
palatal expansion.






Facial Esthetics
Because each face is unique, it is impossible to
produce identical results for all patients; rather,
orthodontic treatment should enhance the
patient's individual esthetic features.
Special care must be taken in evaluating the
child patient for there is a tendency to apply
adult standards of facial esthetics




The most common problems in facial esthetics involve
extraction. In some cases choosing not to extract strains
the limits of the alveolar process to achieve alignment,
yet time, growth, occlusal function, etc. , may improve
the eventual facial esthetics.



In other instances, unfortunately, the same factors
produce crowding and malalignment.



Extractions which produce adult faces in young
adolescents are to be deplored. for those same faces a
few years later may look almost edentulous.




No formulas are infallible when planning
treatment and it is always easier to secondguess treatments after the fact.



Criticism comes easier than craftsmanship.



Facial esthetics is a matter of personal
judgment, so one's own opinions about esthetics
should be imposed with caution on colleagues
who saw the patient at another time.


CONCLUSION


Some malocclusion are best treated in
adolescence and a few are singular to this stage
of development.



More malocclusions are probably treated in
adolescence than any other period, not because
it is always best time for therapy, but rather
because this is the time at which patient &
parent often become aware of this problem




There are really very few proper clinical research
reports on the effects of adolescent orthodontic
treatment. Most other clinical writing at this
time , reveal more personal clinical experiences
& perceptions.



Therefore proper treatment planning for an
adolescent case as well as highly developed
clinical judgement & skill in use of fixed
appliances are required.

References


Amanpreet Kaur Grewal, James Sunny P, Valiathan A.
Expectations and perceptions of patients towards
orthodontic treatment in Manipal . J Pierre Fauchard
Academy 2003;19:83-88.



Sachdeva Sunil & Valiathan Ashima: "Whose mouth is
it anyway?". Journal of Indian Orthodontic Society,
1994; 22(3): 105-108.



Sunil Sachdeva & Valiathan Ashima: Co-operation in
orthodontics. Nepal Dental Journal 1999 :2(1)21-26.



Irfan Dawoodbhoy, Valiathan Ashima: Age &
Orthodontics. Journal of International College of
Dentist. 1993; 34: 20-25



Nalbantgil D, Arun T, Sayinsu K, Fulya I : Skeletal,
dental and soft-tissue changes induced by the Jasper
Jumper appliance in late adolescence . Angle Orthod.
2005 May;75(3):426-36.



Franchi L, Baccetti T, McNamara JA. :Postpubertal
assessment of treatment timing for maxillary expansion
and protraction therapy followed by fixed appliances .
AJODO. 2004 Nov;126(5):555-68



Northway W. : Hemisection: one large step toward
management of congenitally missing lower second
premolars. Angle Orthod. 2004 Dec;74(6):792-9.




Carano A, Velo S, Leone P : Clinical application
of the mini screw anchorage system. JCO 2005;
39 (1) 9-24.



Sadowsky C, Begole EA : Long term effects of
TMJ function & functional occlusion after
orthodontic treatment. AJO 1981; 78;201-212.



Trulsson U, StrandmarkM, Mohlin B : A
qualitative study of teenager’s decision to
undergo orthodontic treatment with fixed
appliances. J Orthod 2002; 29 (3) : 197-204.



Daniel J Rinchuse, Donald J Rinchuse : Developmental
Occlusion, Orthodontic Interventions, and Orthognathic
surgery for adolescents. DCNA 2006,(50); 69- 86.



Cooper ML, Shapiro ML: Motivations for health
behaviors among adolescents. In Mcnamara JA,
Trotman CF (eds) : Creating the compliant patient, Ann
Arbor, Mich, 1996.



Robert E Moyers : Handbook of orthodontics. 4th edtn,
Year book medical publishers, INC, Chicago, 1988. Pg432-471.




Samir E Bishara : Textbook of orthodontics.2nd
Reprint 2003, Elsevier , New Delhi. Pg – 454460.



William R Proffit : Contemporary Orthodontics .
3rd edtn, St.Louis, Mosby. Pg - 56-61, 229233,272-275.



Wendell W. Neeley, G. Thomas Kluemper ,Lon
R. Hays : Psychiatry in orthodontics. Part 2:
Substance abuse among adolescents and its
relevance to orthodontic practice. AJODO 2006,
129 ( 2 ) ; 168-174.

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Adolescent Orthodontic Treatment: Unique Challenges and Opportunities

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