INDIAN DENTAL ACADEMY
Leader in continuing dental education
• Adult ?
• History of adult orthodontics
• Adult orthodontics
• Reasons for increased interest of adults in
• Difference between adult and adolescent
• Adult is defined as one who is fully grown, most
males 18 and above and most females of 16
and above can be considered to be adults,
although residual growth is left.
• It is however quite impractical to determine the
exact time when adulthood begins, since there is
no definite age when a person reaches physical
• Kingsley, in 1880, indicated an early awareness
regarding orthodontic potential in adult patient.
• He stated, “It may be regarded as settled fact
that there are hardly any limits to the age when
movement of teeth might not succeed.”
• MacDowell(1901) was of the opinion that
after the age of 16 years, a complete and
permanent change in transition of the occlusion
& hence orthodontic treatment, is almost
impossible owing to the development of,
- adult glenoid fossa,
- density of the bones ,
- muscles of mastication.
• Lischer (1912) believed that the period
year was a golden age of
• In 1921 Calvin Case demonstrated the value of
orthodontic therapy in the lower anterior area for
the aged, periodontally affected patient.
• Ackerman : “Adult orthodontics is concerned
with striking a balance between achieving
optimal proximal and occlusal contact of the
teeth, acceptable dentofacial aesthetics, normal
function and reasonable stability.”
Recent AAO survey : Increased % of patients >21
yrs, from 4% ten yrs ago, to almost 7% today; in
another decade’s time adult pts would constitute
11% of avg orthodontic practice.
INCREASED INTEREST IN
THE ADULT PATIENT
[Melsen in ‘Curent controversies in
1] Innovations in appliance placement techniques
– Direct bonding, lingual/invisible appliances
2] Innovations in
material research –
ceramic brackets &
3] Role of family
dentist - Increased
desire of restorative
treatment of dental
4] Role of media, visual as well as print -
Articles in magazines ,news paper as well
as community programs have increased
patient awareness towards health &
5] Better management of TMJ dysfunction.
6] More effective management of skeletal jaw
dysplasias with advanced orthognathic surgical
7] Reduced vulnerability to periodontal breakdown
as a result of improved tooth relationships and
8] A broader understanding of the biology of the
tooth movement especially with regard to age
9] Ingenious approaches to anchorage management
such as implants.
10] Role of Insurance companies – in the US
11] Affluence – Improving socioeconomic standards
makes orthodontics more affordable today .
1) Improvement of tooth-periodontal tissue
2) Establishing an improved plane of occlusion to
distribute the forces of occlusion better.
3) Balancing the existing space for better prosthetic
4) Improve occlusion and coordination between the
muscle and TMJ.
5) Improve patient esthetic.www.indiandentalacademy.com
1) Severe skeletal discrepancies.
2) Advanced local or systemic disease.
3) Excessive alveolar bone loss.
4) Poor stability prognosis – tooth movt into
5) Lack of patient motivation & co-operation,
resistance to wear the appliance.www.indiandentalacademy.com
6) Inability to prevent excessive hard/soft tissue
7)Inadequate space for tooth movt
8)Movt of teeth against occlusal opposition or into
9)No improvement in PDL health, function/esthetics.
10)Negative anchorage potential – movt of teeth
against inadequate anchorage.
(Marks and Corn)
• Advanced systemic disease
• Lack of patient motivation.
1] Younger adults (under 35, often in their 20’s)
2] Older patients (in their 40’s and 50’s)
2 GROUPS OF ADULT
Comprehensive treatment & maximum possible
improvement; improved quality of life.
Reasons for not receiving orthodontic
1) Did not desire treatment.
2) Were not aware of orthodontic treatment.
3) Parents could not afford.
4) Were not given proper advise by family
5) No orthodontist located in the vicinity.
6) Incomplete orthodontic treatment when
younger or were uncooperative.
7) Had orthodontic treatment as children but
8) More conscious of appearance with age.
9) Anterior teeth started to crowd or minor
crowding becomes worse.
10) Dissatisfaction with the outcome of previous
- Maintain proper dental health.
- For easy & effective control of disease &
restoration of missing teeth.
- As an adjunctive procedure to the larger
periodontal & restorative goals ; not necessarily
interested in the ideal result.
Reasons for seeking orthodontic
1) Malposed teeth contributing to PDL disease.
2) Increased difficulties with mastication.
3) Anterior spaces enlarging or new ones developing.
4) For better tooth positioning prior to prosthetic
5) Tooth interferences & mandibular slide causing
ADOLESCENT vs ADULT
Levitt : “In adult patient there is no growth
and only tooth movement”.
Barrer : “Adult, unlike the child is a
relentless patient, who will not cover our
deficiencies in skills or our errors in the
use of mechanical procedures by helpful
settling in post-treatment.”
• Ackerman : “In a child ,one occasionally
calls on another specialist. On the other
hand it is a rare adult whom one treats
orthodontically without finding it necessary
to collaborate with another specialist.”
• Adults – orthodontic treatment is based on
symptoms detected by the patient
• Children - treatment is based more often
on signs detected by practitioners/parents.
• Adult – seeks treatment more often for
esthetics & hence is likely to have
unreasonable expectations about the
outcome, is less adaptable to the
appliance & is uncompromising in
appraisal of the Rx results.
• Brighter side – cleaner, more careful,
punctual, prompt paying, much less
sensitive to pain & Rx time is either
same/less than that for younger patients.
FIVE MAJOR CATEGORIES IN WHICH
ADULT PATIENTS SIGNIFICANTLY
DIFFER FROM THEIR ADOLESCENT
1) Clarification & individualization of
2) The diagnostic process
3) Treatment plan selection
4) Acceptance of recommended therapy
5) Achievement of treatment objectives
1) Clarification & individualization of
This requires specific study of the problem &
the indicated therapeutic refinements.
2) The diagnostic process-
Problem oriented dental record aides
in making the appropriate diagnosis,
for it requires that the patient’s
problems be listed and a plan be
developed to manage each problem.
1) Collect data accurately.
2) Analyze data base.
3) Develop problem list.
4) Prepare tentative treatment plan.
5) Interact with those who are involved;
discuss plans and options; clarify
sequence, acquire patient acceptance.
6) Create final treatment plan.
Before starting the treatment, the
orthodontist needs to be prepared to
do the following:
1) Diagnose different stages of PDL
disease and their associated risk factors.
2) Diagnose TMJ dysfunction before,
during or after tooth movement.
3) Determine which cases require surgical
management and which ones require
incisor reangulation to camouflage the
skeletal base discrepancy.
4) Work cooperatively with team of other
specialists to give the patient the best
3) Treatment plan selection-
More systemic & detailed analysis is
required for adults than for adolescents.
Factor affecting treatment plan
i) Existing oral pathology:
- dental caries
- periodontal disease
- faulty restoration
- TMJ adaptability
- occlusal awarenesswww.indiandentalacademy.com
4) Patient’s acceptance of the
Patients thorough understanding of &
agreement with the recommended Rx are
necessary. Also, an informed consent
should be signed
i) Sociobehavioral interaction:
- Office environment: group / privacy
- Team coordination, interaction:
ii) Duration of treatment.
iii) Cost of treatment: with/without
iv) Perceived risk/benefit ratio: more
benefits compared to minimal risks
v) Appliance selection.
vi) Insurance coverage
• Vii) Negative conditioning: in the past .
viii) Positive conditioning.
5) Achievement of treatment
-requires specific study of the problem &
the indicated therapeutic refinements
- depends on :
i) Dental history.
ii) Ability of the orthodontist to interface
the treatment plan with those of other
iii) skills and knowledge of orthodontist
and staff. www.indiandentalacademy.com
LIMITATIONS OF TREATMENT
2 types of factors :
• Intrinsic – Biological nature
• Extrinsic – Biomechanical systems
• Most marked – Adult is no longer growing, so
orthodontic Rx is limited to tooth movt & related
modelling of the alveolar process only (may vary
with the age & health )
• Periodontium – primary tissue to get affected.
• Norton : decreasing blood flow & vascularity with
increasing age – insufficient source of
progenitor(preosteoblasts) cells – delayed
response to mechanical stimulus.
• Alveolar bone – cortical bone becomes
denser & spongy bone reduces with age &
structure of bone changes from
honeycomb to a network
• Apical displacement of marginal bone
level - local factor, age related but is also
due to progressive PDL disease
• Teeth - adults are more likely to have
missing teeth, teeth reduced in dimension
due to attrition or teeth with large
• Force system used differs from that used in
young, growing individuals.
• Forces used should be at a lower level than
those used in children, as adults often have PDL
problems & reduced bone support.
• Initial forces should be further kept low as the
immediate pool of cells available for resorption is
• M/F ratio for a
movt should be
increased as per
state of the
• In the presence of marginal bone loss,
light continuous intrusive forces should be
maintained during tooth displacement.
!!! ADULT PROBLEMS DIFFICULT
TO TREAT BY ORTHODONTICS !!!
• Deep bite – extrusion of post teeth is not
compensated for by condylar growth
• Posterior crossbite – arch expansion is
• Skeletal discrepancies – since growth is
1) Dentofacial aesthetics
2) Stomatognathic function
4) Achieving Class I occlusion
:ADULT ORTHODONTICS -
1) Parallelism of abutment teeth :
- Restoration will have better prognosis as
excess cutting or devitalization during
abutment preparation are avoided.
- Allows for a better pdl response.
- Allows for better retention.www.indiandentalacademy.com
2) Most favorable distribution of teeth :
- Evenly for replacement of fixed/removable
prostheses in the individual arches
- Teeth should be positioned in such a way
that occlusion of natural teeth can be
established bilaterally between the arches.
3) Redistribution of occlusal and incisal
Helpful in case of significant bone loss, to
maintain the occlusal vertical dimension.
4) Adequate embrasure space and proper
root position –
Allows for better pdl health, especially
when placement of restorations is
5) Acceptable occlusal plane and potential
for incisal guidance at satisfactory vertical
For a mutilated dentition with bite collapse,
the Hawley bite plane adjusted to the
correct vertical height, is inserted – allows
a centric relation at an acceptable vertical
dimension, simulatneous bilateral
Curve of spee should be mild to flat
bilaterally – unilateral orthodontic
treatment of an accentuated occlusal
plane should be avoided.www.indiandentalacademy.com
6) Adequate occlusal landmark
- Most difficult dimension to correct &
maintain orthodontically – transverse
- Teeth must be positioned yo achieve
acceptable B-L landmarks.
Post crossbites due to severe transverse
skeletal dysplasias – maxillary buccal
cusps contact lower central fossae with
the crossover for incisal guidance in the
PM or canine positions.www.indiandentalacademy.com
7) Better lip competency and support -
Inadequate support may create change in
antero-posterior and vertical position of upper lip
and increase wrinkling.
Some Class II, division 1 patients (surgery
rejected) – lower incisors can be placed
procumbent with bilateral posterior restorations
– establish incisal guidance; avoids palatal
Some class III’s – maxillary incisors kept more
flared than normal
8) Improved crown/root ratio –
In case of individual teeth bone loss, the
crown to root ratio can be improved by
decreasing the length of clinical crown
with a high speed handpiece as the tooth
is erupted orthodontically.
9) Improvement/ correction of mucogingival and
Proper repositioning of prominent teeth in arch will
improve gingival topography.
Adolescents – brackets placed to level marginal
ridges & cusp tips
Adults – level crestal bone between adjacent
CEJ’s; favorable osseous & soft tissue changes
with tooth movt , diminished need for
osseous/mucogingival surgery; continuous
adjustment to prevent premature post teeth
contact causing occlusal trauma.www.indiandentalacademy.com
10) Better self maintenance of pdl health:
Location of gingival margin - determined by axial
inclination & alignment of the tooth.
For better periodontal health, teeth should be
positioned properly over their basal bone
11) Esthetics and functional improvement:
Rx= acceptable esthetics + improved muscle
function + normal speech + mastication
Therapeutic occlusion = ant teeth as
disarticulators; post teeth support the vertical
Usual sequence of procedure is as follows –
• Eliminate all pathology (caries, PDL disease,
retained roots, etc)
• Orthodontic Rx
• Periodontal re-evaluation (& therapy if
• Prosthetic restoration (when necessary)
• Orthodontic retention
• Periodontal maintenance
• Occlusal adjustment (grinding) whenever
- Control of anchorage requires that
anchor teeth should not be allowed to tip.
- Fixed appliance is necessary.
• Adult patients
appliance but they
are not useful in
- But in case of
appliance is useful.
Placement of brackets
• A=ideal position
– uprighting of
ant teeth (movt
of anchor teeth
position of max
• - In case of
bone loss ,
TIMING AND SEQUENCE OF
- Before any type of tooth movement
any caries or pulpal pathology should
- Larger restoration require detail
occlusal anatomy should be carried
out after orthodontic treatment is
- Periodontal disease should be
controlled before any tooth
- Scaling, curettage and gingival graft
should be carried out before
- Surgical pocket elimination and
osseous surgery should be carried
out after orthodontic treatment.
• Children & adolescents – motivation for ortho Rx
= parent’s desire; not emotionally involved in
their own Rx
• Adults – seek ortho Rx because they themselves
want something, that is not always clearly
expressed=hidde set of motivations/unrealisti
• Imp – explore why pt wants Rx & why now
“Ortho Rx cannot repair personal relationships,
save jobs, or overcome a series of financial
disasters” - Proffitwww.indiandentalacademy.com
• Most adults – have realistic expectations, more
positive self image than average, a good deal of
• Internally motivated responds well to Rx than
• Demand for invisible orthodontic appliances-
unrealistic for a patient to expect that ortho Rx
can be carried out without other people knowing
• Sometimes - Rx in a pvt area if the patient
Most adults – learning from interacting with other
patients = beneficial
• Patient handling –
Adolescents = passive acceptance of what is
Adults = considerble degree of explanation of what
is happening & why;
Interest in Rx does not automatically translate into
compliance with instructions
• Adults – less tolerant of discomfort & more
likely to complain about pain after
adjustments & about difficulties in speech,
eating & tissue adaptations.
Additional chair time to meet these
demands should be anticipated
ACCORDING TO PROFFIT ADULT
ORTHODONTIC TREATMENT IS
DIVIDED IN TO 3 PARTS:
1) ADJUNCTIVE TREATMENT.
2) COMPREHENSIVE TREATMENT
3) SURGICAL TREATMENT.
ADJUNCTIVE TREATMENT AND
IS INDISTINCT,AS ANY TREAMENT
WHICH REQUIRE MORE THAN 6
MONTHS IS CALLED AS
“ Tooth movement carried out to
facilitate other dental procedures
necessary to control disease and
1) Facilitates restorative treatment by
positioning the teeth.
2) Improve periodontal health by
removing plaque harboring areas .
3) Establishing favourable crown to
ratio and position of the teeth.
PROCEDURES CARRIED OUT IN
ADJUNCTIVE TREATMENT : -
1) Uprighting posterior teeth.
2) forced eruption.
3) alignment of anterior teeth.
4) crossbite correction.
1) DENTAL ORIGIN:-
a) Faulty eruption from the
normal functional position.
b) Insufficient arch length.
c) Excessive arch length.
d) Prolonged retention of primary
e) Ectopic eruption.
g) Prolonged finger and thumb
h) Clenching and grinding.
i) Improper swallow pattern with
j) Effects of tongue pressure on the
l) Premature loss of deciduous teeth.
m) Loss of permanent teeth.
2) SKELETAL ORIGIN:-
a) Cleft palate.
b) Gross mediolateral disharmony of
the craniofacial skeleton.
1) If third molar is present ,
whether both second and third
molar should be uprighted.
2) Whether to upright tipped
teeth by distal crown tipping or
by mesial root movement.
- Defects in cervical third .
- Periapical radiograph.
- Single tapering and flared and
divergent root morphology.
- Endodontic therapy.
How much tooth should be extruded
can be determine by 3 factors:-
1) Location of the defect.(fracture
2) Space to place margin of the
3) An allowance for the biological
width of the gingival attachment.(2www.indiandentalacademy.com
- 1mm/week without damaging pdl.
- 3 to 6 week.
• Continuous flexible
– With orthodontic
– Without orthodontic
• Brackets are placed
more occlusally on
anchor teeth than its
- 17x25 s.s
- 19x25 beta-Ti
- By passively fitting rectangular arch
wire.(3 to 6 week).
ALIGNMENT OF ANTERIOR TEETH
1) To improve access and permit
placement of well contoured
2) To permit placement of crowns
and pontics .
3) To reposition closely
approximated roots and to improve
the amount of interradicular bone.
4) To position teeth so that implants
can be placed to support
* Alignment of crowed, rotated and
* Separation of approximated teeth.
• Position teeth for single tooth
- Minimum 6mm of space is require.
- Apices of adjacent teeth.
Anterior diastema closure and
- Loss of posterior teeth.
- Small teeth.
.- Loss of bone support.
- With Removable appliance.
- With fixed appliance.
- It can cause functional problem and
- Single tooth crossbite.
- Group of teeth in crossbite.(part of
- Correction with removable
- Correction with the “through the
bite” elastics.(posterior segment).
There is wide variety
of etiology that can cause an adult
malocclusion. Also each patient’s
need for treatment are different so
treatment should be carried out
taking his/her needs in consideration.
Adjunctive treatment helps by
facilitating other dental procedures to
control disease and restore function.
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