Adjunctive orthodontics

Adjunctive Orthodontics
Presented by Kritika Suroliya

Contents
• Introduction
• Goals of adjunctive treatment
• Principles of Adjunctive treatment
• Diagnostic and Treatment Planning Considerations
• Biomechanical Considerations
• Timing and sequence of Treatment
• Adjunctive treatment procedures
• Conclusion
• Bibliography

Introduction
Seek to improve
quality of life
Seek to
maintain
what they
have
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.

Psychological Consideration?
Exceptional personality (tries harder, overcompensates)
Inadequate personality (uses deformity as a shield)
Pathologic personality (small deformity, big problem)

Definition
• Adjunctive Orthodontic treatment for adults is, by definition,
tooth movement carried out to facilitate other dental
procedures necessary to control disease, restore function,
and/or enhance appearance.

• This concept is broadly defined as a multidisciplinary treatment
approach for achieving optimal esthetics and function consistent
with a physiologically stable occlusion.
Bishara. Textbook of Orthodontics. Chapter 28.

Goals of adjunctive treatment
• Whatever the occlusal status originally, the goals of adjunctive
treatment should be:
1. Improve periodontal health by eliminating plaque-harbouring
areas and improving the alveolar ridge contour adjacent to the
teeth.

2. Establish favourable crown-to-root ratios and position the teeth
so that occlusal forces are transmitted along the long axes of the
teeth.

3. Facilitate restorative treatment by positioning the teeth so that:
• More ideal and conservative techniques (including implants) can
be used.
• Optimal aesthetics can be obtained with bonding, laminates, or
full-coverage porcelain restorations.

Principles of Adjunctive
treatment

Diagnostic and Treatment Planning
Considerations
• Planning for adjunctive treatment requires two steps:
(1) Collecting an adequate diagnostic data base
(2) Developing a comprehensive but clearly stated list of the
patient’s problems, taking care not to focus unduly on any one
aspect of a complex situation.

Biomechanical Considerations
• Characteristics of the orthodontic appliance:
• 22-slot edgewise appliance with twin brackets recommended.
• The rectangular (edgewise) bracket slot permits control of
buccolingual axial inclinations, the relatively wide bracket helps
control undesirable rotations and tipping, and the larger slot size
allows the use of stabilizing wires that are stiffer.

• Recently, further developments in clear aligner therapy have provided
an effective type of removable appliance that can be well suited to
alignment of anterior teeth.
• With aligners, both discomfort and interference with speech and
mastication are minimized, and patient co-operation improves.
• Despite this aesthetic advantage, there are biomechanical limitations.
• Control of root positions is extremely difficult, and it is also difficult to
correct rotations and to extrude teeth.

• Since, adjunctive treatment is concerned with only limited tooth movements,
usually it is neither necessary nor desirable to alter the position of every
tooth in the arch.
• For this reason, in a partial fixed appliance for adjunctive treatment, the
brackets are placed in an ideal position only on teeth to be moved, and the
remaining teeth that are to be incorporated in the anchor system are
bracketed so that the archwire slots are closely aligned.

• Effects of reduced periodontal support:
• Since patients who need adjunctive treatment have often lost
alveolar bone to periodontal disease before it was brought
under control, the amount of bone support of each tooth is an
important special consideration.

• When bone is lost, the PDL area decreases, and the same force
against the crown produces greater pressure in the PDL of a
periodontally compromised tooth than a normally supported
one.
• The absolute magnitude of force used to move teeth must be
reduced when periodontal support has been lost.

• In addition, the greater the loss of attachment, the smaller the
area of supported root, and further apical will be the center of
resistance.
• This affects the moments created by forces applied to the crown
and the moments needed to control root movement.

Timing and Sequence of Treatment
• Before any tooth movement, active caries and pulpal pathology
must be eliminated, using extractions, restorative procedures,
and pulpal or apical treatment as necessary.
• Endodontically treated teeth respond normally to orthodontic
force, if all residual chronic inflammation has been eliminated.
• Restorations requiring detailed occlusal anatomy should not be
placed until any adjunctive orthodontic treatment has been
completed because occlusion will inevitably be changed.

• Periodontal disease must also be controlled before any
orthodontics begins because orthodontic tooth movement
superimposed on poorly controlled periodontal health can lead
to rapid and irreversible breakdown of the periodontal support
apparatus.
• Surgical pocket elimination and osseous surgery should be
delayed until completion of the orthodontic phase of treatment
because significant soft tissue and bony recontouring occurs
during orthodontic tooth movement.

Comprehensive treatment plan
Stage 1: Disease Control
Stage 2: Establish Occlusion
Stage 3: Definitive perio/restorative tx
Stage 4: Maintenance
Re-evaluate
Stabilize

Adjunctive treatment
Procedures

Missing Teeth: Space Closure Vs.
Prosthetic Replacement
• Old Extraction Sites : In adults,
closing an old extraction site is
likely to be difficult. After
several years, resorption results
in a decrease in the vertical
height of the bone, but more
importantly, remodeling
produces a buccolingual
narrowing of the alveolar
process as well. When this has
happened, closing the
extraction space requires a
reshaping of the cortical bone.
• Tooth Loss Due to Periodontal
Disease: A space closure
problem is also posed by the
loss of a tooth due to
periodontal disease. It is unwise
to move a tooth into an area
where bone has been destroyed
by periodontal disease, because
of the risk that normal bone
formation will not occur as the
tooth moves into the defect.

Uprighting posterior teeth
• Treatment planning considerations:
• When molar uprighting is planned, a
number of interrelated questions
must be answered:
• If the third molar is present, should
both the second and third molars be
uprighted?

• How should the teeth be uprighted? By distal crown movement
(tipping), which would increase the space available for a bridge
pontic or implant, or by mesial root movement, which would
even reduce or close the edentulous space?

• Is extrusion of a tipped molar
permissible?
• Unless slight extrusion or crown-
height reduction is acceptable,
which usually is the case, the
patient should be considered to
have problems that require
comprehensive treatment and
treated accordingly.

• Should the premolars be repositioned as part of the treatment?
• It is particularly desirable to close spaces between premolars
when uprighting molars because this will improve both the
periodontal prognosis and long-term stability.

Appliances for Molar Uprighting
• A partial fixed appliance to upright tipped molars consists of
bonded brackets on the premolars and canine in that quadrant
and bonded/banded rectangular tube on the molar.
• Where premolar and canine brackets should be placed depends
on the intended tooth movement and occlusion.

Uprighting a single molar
• Distal crown tipping:
• If the molar is only moderately tipped, treatment often can be
accomplished with a flexible rectangular wire such as 0.017x0.025 NiTi.

• If the molar is severely tipped, a continuous wire that uprights the molar will
have side effects on the position and inclination of the second premolar.
• Hence, sectional uprighting springs are preferred.

• Mesial root movement:
• Skeletal anchorage is required if the goal is to close the old
extraction space.

• If a small amount of mesial movement to prevent opening too
much space is the goal, a single “T-loop” sectional archwire of
17x25 SS or 19x25 beta-Ti can be effective.

• Final positioning of the molars and premolars:

• Uprighting two molars in the same quadrant:
• Unless comprehensive orthodontics with a complete fixed appliance
is planned, the goal should be a modest amount of distal crown
tipping of both teeth, which typically would leave space for a
premolar-sized implant or pontic.

• Trying to upright the second and third molars bilaterally at the
same time is not a good idea, as significant movement of anchor
teeth is inevitable unless skeletal anchorage is used.

• Retention:
• After molar uprighting, the teeth are in an unstable position until
the prosthesis that provides the long term retention is placed.
• As a general guideline, a fixed bridge can and should be placed
within 6 weeks after uprighting is completed.

Case Report
TIMOTHY G. SHAUGHNESSY. IMPLEMENTING ADJUNCTIVE ORTHODONTIC TREATMENT. JADA, Vol. 126, May 1995

Replacement of Missing Laterals
• Clinically, the absence of maxillary lateral incisors is reflected by
the presence of anterior spacing, including a diastema between
the central incisors and a mesial drifting of the cuspids.
Nayak A., Malviya N., Crasta D. Adjunctive Orthodontics. Heal Talk / March-April 2010 / Vol. III / Issue 04

• Treatment options include :
• 1. The opening of the space to replace the missing lateral
incisors with bridges or implants when indicated. This treatment
strategy is favoured when the posterior occlusion is Class I.
• 2. The space corresponding to the missing lateral incisors may be
closed by protraction of the cuspids and the buccal segments of
the teeth in a posterior Class II occlusion. The cuspids can be
reshaped into lateral incisors.

Crossbite Correction
• Posterior crossbites are corrected using “through the bite”
elastics from a conveniently placed tooth in the opposing arch,
which moves both the upper and lower tooth.

• One way to obtain more movement of a maxillary tooth than its
antagonist in the lower arch is to have several teeth in the lower
arch stabilized by a heavy archwire segment.

• If anterior crossbite is due to a displaced tooth and correcting it
requires only tipping, and a removable appliance or clear aligner
may be used to tip the tooth into normal position.

Gingival Esthetic Problems
Gingival Esthetic problems fall into two categories:
• Those created by excessive or uneven display of gingiva
• Those created by gingival recession after periodontal bone loss

• A particularly distressing problem is created by gingival recession
after periodontal bone loss, which creates “black triangles” or
“black holes” between the maxillary incisor teeth.
• One approach to treating this problem is by removing some
interproximal enamel, so that the incisors can be brought close
together.
• This moves the contact points more gingivally, minimizing the
open space between the teeth.

Extrusion
• Treatment Planning:
• For teeth with defects in or adjacent to the cervical third of the
root, controlled extrusion (sometimes called forced eruption)
can be an excellent alternative to extensive crown lengthening
surgery.

• Extrusion of tooth allows:
• Isolation of a tooth under rubber dam for endodontic therapy
• Crown margins to be placed on sound tooth structure while
maintaining a uniform gingival contour
• In addition, alveolar bone height is not compromised.

• The distance the tooth should be extruded is determined by 3 things:
1. The location of the defect (e.g fracture line, root perforation, or
resorption site)
2. Space to place the margin of the restoration so that it is not at the
base of the gingival sulcus (typically 1mm is needed)
3. An allowance for the biological width of the gingival attachment
(about 2 mm)

• The crown to root ratio at the end of treatment should be 1:1 or
better.
• Isolated one or two walled vertical defects pose a particular
esthetic problem if they occur in the anterior region of the
mouth.
• Forced eruption of such teeth, with concomitant crown
reduction, can improve the periodontal condition while
maintaining excellent esthetics.

• Orthodontic Technique:

Conservative Dentistry &
Endodontics

Anterior Restorations
• There are three particularly important considerations in deciding
where the orthodontist should position the teeth that are to be
restored:
1. The total amount of space that should be created
2. The mesio-distal positioning of the tooth within the space
3. The bucco-lingual positioning.

Alignment of Anterior Teeth
• Diastema Closure and Space Redistribution:
• The major indication for adjunctive
orthodontic treatment to correct malaligned
anterior teeth is preparation for buildups,
veneers, or implants to improve the
appearance of maxillary central incisors.
• The most frequent problem is a maxillary
central diastema, which is often further
complicated by irregular spacing related to
small or missing lateral incisors.

TIMOTHY G. SHAUGHNESSY. IMPLEMENTING ADJUNCTIVE ORTHODONTIC TREATMENT. JADA, Vol. 126, May 1995

• Crowded, rotated and displaced incisors:
• Crowding usually is the problem when
alignment of incisors is considered to provide
access for restorations, achieve better
occlusion, or enable the patient to maintain
the teeth.
• The key question is whether crowding should
be relieved by expanding the arch, removing
interproximal enamel or by extraction of a
single tooth.

Conclusion
• With proper team work, better and more esthetic and
conservative treatment results can be achieved.
• Orthodontic movement can serve to establish an environment
which provides for physiologic function as well as the re-
establishment of what is considered as a proper occlusion.

Bibliography
• Contemporary Orthodontics, 5e. Proffit, Fields and Sarver.
• Bishara. Textbook of Orthodontics. Chapter 28.
• Nayak A., Malviya N., Crasta D. Adjunctive Orthodontics. Heal
Talk / March-April 2010 / Vol. III / Issue 04

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