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4. Periodontal ligament
Fibroblast
• Blood borne origin
• Pleuropotential cell
• Collagen & proteoglycans
• Collagen turnover in PDL- 2.5-6.5 day
• Aging-imbalance.
• Proteoglycans-withstand the forces.
• Retains water-changes with age.
• PGs-prostaglandins & leukokines-resorption of bone.
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5. Capillary bed.
Number of branches found in the vascular bed –
decreases
Amount of blood flow to tissues-decreases
Nerve tissue
Changes in number of neuro receptor
Age related decrease in sensory responsiveness.
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6. Bone
Mechanical properties change
Macroscopically- trabecular bone volume decreases.
Osteoblastic activity-reduces
Imbalance b/w resorption & replacement
Sinus size-increases
Bone density decreases &porosity increases with
age.
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7. Teeth
More root exposure
Short crown root ratio
CR shift –apically
Diameter of pupal canal reduces
Decreased vascularity&innervation -pulp recovery.
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10. History
Kingsley(1880)-early awareness of the orthodontic
potential for the adult pts.
Published statements-Negative.
MacDowell(1901)- Impossible age.
Lischer(1912)-optimal age for treatment.
• Golden age of treatment
Case (1921)-value of adult 0rthodontic therapy
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12. History
Lindegaard et al (1971)-3 factors.
Reidel & Dougherty (1976)
“orthodontics is total discipline and it
makes no difference whether the patient
is young or old”
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15. 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.
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16. factors adolescents adults
Dental caries More susceptible Recurrent decay
restorative failures, root
decay& pulpal pathosis
PDL disease Resistance to bone loss
Susceptible to gingival
inflammation
Susceptible to bone loss
TMJ
adaptability
high Symptoms with
dysfunction
Occlusal
awareness
Infrequent Increased enamel wear
with adverse change in
supporting tissue.
comparison
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17. Factors Adolescents adults
Growth factors Growth-orthopedic
Stable correction .
No growth
Minimal skeletal adaptability.
Surgical option
Dentofacial
esthetics
Reasonable concern Concern occasionally
disproportionate to degree of
existing problem
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18. factors adolescents adults
Rate of tooth movement rapid slower
orthopedics 50% Small percentage
Orthognathic surgery 1-5% 10-20%
Restorative dentistry Smaller percentage frequently
Combination treatment uncommon 80%
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24. Most favorable distribution of
teeth
Distributed evenly-replacements
To establish normal occlusion.
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25. Redistribution of occlusal &
incisal forces.
Cases with significant bone loss(60-70%)
To maintain occlusal vertical dimension
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26. Adequate embrasure space
&proper root position.
Better PDL health
Helps in interproximal cleaning
Placement of restorative material.
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27. Adequate occlusal landmark
relationships
Transverse dimension – difficult to correct
Skeletal crossbite cases-only anterior crossbite can
be corrected.
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28. Better lip competency & support
In case of anterior restoration-retractions
Inadequate support-change in anteroposterior
&vertical position of upper lip & increase in wrinkling.
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29. Improved crown/root ration
In case of bone loss
Reduced crown/root ratio
Can be corrected by reducing the clinical
crown.
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30. 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
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31. Esthetic & functional
improvement.
Should provide acceptable dentofacial esthetics
Improved muscle function
Normal speech & masticatory function
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32. 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
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34. 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
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35. 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.”
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36. Principles of AOT
Diagnostic & treatment planning.
• Collecting an adequate data base.
• Developing a problem list.
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37. Diagnostic records
• OPG.
• Full mouth IOPAs.
• Lateral ceph
• photographs.
• Dental casts.
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38. 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.
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41. Effects of reduced periodontal
support
Bone support
Bone loss-PDL
area decreases
CR-shifts more
appically
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42. Timing & sequence of treatment
Active disease
Disease control
Establish occlusion
Definitive restorative Rx
maintenance
Re-evaluate
stabilize
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43. Adjunctive orthodontic Rx
procedure.
Uprighting of posterior teeth
• Uprighting a single molar
• Uprighting with minimal extrusion
• Final positioning of molar & PM
• Uprighting two molars in the same quadrant
• Retention
Forced eruption
Alignment of anterior teeth
Crossbite correction
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44. 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?
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58. Final positioning of molar & PMs
Compressed coil springs
018 steel
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59. Uprighting two molars in the
same quadrant.
Combination of distal crown & mesial
root
No bilateral uprighting - same time
17x25 Niti
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60. Retention
Fixed bridge-within 6 weeks
Short time-19x25 steel /21x25 beta Ti
>few weeks-intermediate splinting
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61. 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
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62. Forced eruption
Treatment planning
• Good periapical radiographs
• Periodontal support
• Root morphology and position
• Endodontic therapy should be completed
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63. Orthodontic technique
Anchor teeth –rigid
Flexible –tooth to be extruded
With / without the use of orthodontic
bracket
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65. 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.
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68. 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
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69. 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.
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70. 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
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73. Case 2
53yrs/M
Class III
Ant &post crossbites
spacing
Treatment plan: 2 implants,35&36
Healing period -4 months
Implant-supported FPD
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74. 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
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77. Rigid implant anchorage to close a
mandibular first molar extraction site-
W.Eugene Roberts, Charles nelson,jco1997
Rigid endoesseous implants are
a reliable source of orthopedic
anchorage
For managing malocclusions
that are the usual scope
of orthodontic practice
45yrs/M
Missing lower molar
Case report
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81. 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.
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83. 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.
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85. Comprehensive treatment
Motivation for adult treatment
• Psychological considerations
• PDL & restorative needs as motivating factor
• TMJ dysfunction as motivating factor
Periodontal aspects of adult treatment
Special aspects of orthodontic appliance
therapy.
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86. Psychological considerations
High motivation-self referred for esthetic
reasons
Low motivation-dentist referred for adjunctive
correction
Turned off-unaesthetic appliances, fear of
pain, extended treatment time, personal
inconvenience & cost
Adults are less tolerant of discomfort & more
likely to complain about difficulties in speech
,eating,& tissue adaptation.
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87. Periodontal aspects of adult
treatment
Periodontal considerations are
increasingly important as patient
become older ,regardless of whether
periodontal problems were a motivating
factor.
Minimal PDL involvement
Moderate PDL involvement
Severe PDL involvement
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88. Minimal periodontal involvement
Hygiene status
• Special care-adults
• Inter dental aids, proximal brushes
Level & condition of attached gingiva
Gingival recession
Gingival grafts
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90. Special aspects of orthodontic
appliance therapy
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91. intrusion
light & continuous force
• With continuous arch wires
• Segmental arch wires
In case of PDL compromised-anchorage
Intrusion should never be attempted
without excellent control of inflammation.
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92. Intrusion of incisors in adult patients
with marginal bone loss
Birte Melsen, AmJ Orthod 1989
Common problems-adults-PDL disease
• Migration spacing, elongation of incisors
Progressive bone loss-CR shifts
appically
Aim :to intrude elongated teeth with
varying degrees of PDL damage & thus
evaluating the influence of treatment on
pdl status.
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93. Material & method
• 30 sample
• 5M/25F
• AGE:22-60yrs
• PDL preparation
Orthodontic appliance-4 types
• J hook for intrusion
• Ricketts utility arch-016x016 steel
• Intrusion bend into loops of full arch-017x025 steel
• Burstone’s continuous intrusion arch
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94. Analysis applied
• Study casts
• Latral ceph
• Opg
• IOPA-special film holder
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95. Results
• True intrusion=0-3.5mm
• Clinical crown length reduction =0.5-2mm
• Root resorption =1-3mm
• Total amount of alveolar
support=unaltered/increased
Utility & Burstone’s base arch-largest
intrusion &largest gain in bony support.
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105. Adult diagnostic considerations
Diagnostic steps
• Collect data
• Analyze database
• Develop problem list
• Prepare tentative treatment plan
• Interact with other provider
• Final treatment plan
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106. Periodontal diagnosis
Awareness of risk factors
General factors
• Family history
• General health status
• Nutritional status
• Current stress factors
Local factors
Plaque indices
Crown root ratio
Habits
Restorative status
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