Adult orthodontics (2)

Adult orthodontics
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Adult orthodontics
 Contents
• Introduction
• History
• Comparison b/w adolescents & adults
• Objectives
• Classifications
• Adjunctive orthodontics
• Comprehensive orthodontics
• Retention

Basic biological concepts
associated with adult orthodontics.
 Periodontal ligament.
 Bone
 Teeth .

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.

 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.

 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.

 Teeth
 More root exposure
 Short crown root ratio
 CR shift –apically
 Diameter of pupal canal reduces
 Decreased vascularity&innervation -pulp recovery.

CEJ–alveolar crest distance
Significant reduction in crest
height with age
0.017mm/year

Prevalence of PDL pockets

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

History

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”

Adult practice today

Scope of procedures
Musich’s (1986)study of 1370 consecutively examined adults

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.

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

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

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%

Anchorage
potential
Head gear implants
Missing
teeth
Space closure
without prosthesis
Restorative

Extraction
controversy
4 PMs Less
frequently
Strategic
extraction
uncommon common

Adult orthodontic treatment
objectives
 Dentofacial esthetics
 Stomatognathic function
 Stability
 Normal occlusion

Additional AOT objectives
 Parallelism of abutment teeth
 Most favorable distribution of teeth
 Redistribution of occlusal & incisal forces
 Adequate embrasure space & proper tooth
position
 Adequate occlusal landmark relationships
 Better lip competency & support
 Improved crown/root ratio
 Improved self-maintenance of periodontal
health.

Parallelism of abutment teeth
 Abutment teeth-parallel
 Permit-easy insertion of
replacements
 Allow –restorations
 Better prognosis
 Better PDL response.

Most favorable distribution of
teeth
 Distributed evenly-replacements
 To establish normal occlusion.

Redistribution of occlusal &
incisal forces.
 Cases with significant bone loss(60-70%)
 To maintain occlusal vertical dimension

Adequate embrasure space
&proper root position.
 Better PDL health
 Helps in interproximal cleaning
 Placement of restorative material.

Adequate occlusal landmark
relationships
 Transverse dimension – difficult to correct
 Skeletal crossbite cases-only anterior crossbite can
be corrected.

Better lip competency & support
 In case of anterior restoration-retractions
 Inadequate support-change in anteroposterior
&vertical position of upper lip & increase in wrinkling.

Improved crown/root ration
 In case of bone loss
 Reduced crown/root ratio
 Can be corrected by reducing the clinical
crown.

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

Esthetic & functional
improvement.
Should provide acceptable dentofacial esthetics
Improved muscle function
Normal speech & masticatory function

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

Treatment for adults
 proffit -
• Younger adults(20-35yrs)
• Older group(40-50yrs)
 Adjunctive orthodontic treatment
 Comprehensive orthodontic treatment

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

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.”

Principles of AOT
 Diagnostic & treatment planning.
• Collecting an adequate data base.
• Developing a problem list.

 Diagnostic records
• OPG.
• Full mouth IOPAs.
• Lateral ceph
• photographs.
• Dental casts.

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.

Removable appliances

Bracket placement

Effects of reduced periodontal
support
 Bone support
 Bone loss-PDL
area decreases
 CR-shifts more
appically

Timing & sequence of treatment
Active disease
Disease control
Establish occlusion
Definitive restorative Rx
maintenance
Re-evaluate
stabilize

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

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?

Loss of posterior teeth

Distal crown/ mesial root
movement

Crown: root length

Appliances for molar uprighting
 Partial fixed appliance
 Active & reactive unit
 bonding>banding

Uprighting a single molar
 Distal crown tipping with
occlusal antagonist
• Flexible rectangular wire-
17x25 NiTi
• Anchorage unit-19x25 steel
• 17x25 beta-Ti

Uprighting with minimal
extrusion
 Uprighting with no occlusal
antagonist
 “T-Loop”-17x25 steel/
19x25 beta Ti

Uprighting of lower molars
Birte melsen,JCO 1996
case1
56yrs/M
Missing lower 1st
molar

case1

Case 2
42/F
Missing 46

Case 2

Distal jet

A simple technique for molar
uprighting –E Capelluto,JCO 1996
“MUST”

Final positioning of molar & PMs
Compressed coil springs
018 steel

Uprighting two molars in the
same quadrant.
 Combination of distal crown & mesial
root
 No bilateral uprighting - same time
 17x25 Niti

Retention
 Fixed bridge-within 6 weeks
 Short time-19x25 steel /21x25 beta Ti
 >few weeks-intermediate splinting

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

Forced eruption
 Treatment planning
• Good periapical radiographs
• Periodontal support
• Root morphology and position
• Endodontic therapy should be completed

Orthodontic technique
 Anchor teeth –rigid
 Flexible –tooth to be extruded
 With / without the use of orthodontic
bracket

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.

Treatment planning
 Interproximal stripping
 Diagnostic setup-very helpful

Orthodontic technique
 Alignment of crowded, rotated &
displaced incisors
• Edgewise brackets-canine –canine
• Initial wire-light & flexible
• 016 Niti
• Crown reduction

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

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.

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

Case 1

Case 2
 53yrs/M
 Class III
 Ant &post crossbites
 spacing
Treatment plan: 2 implants,35&36
Healing period -4 months
Implant-supported FPD

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

Case 3

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

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.

Diastema closure

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.

Comprehensive
orthodontic treatment.
Adult orthodontics.

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.

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.

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

Minimal periodontal involvement
 Hygiene status
• Special care-adults
• Inter dental aids, proximal brushes
 Level & condition of attached gingiva
 Gingival recession
 Gingival grafts

Special aspects of orthodontic
appliance therapy

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.

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.

 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

 Analysis applied
• Study casts
• Latral ceph
• Opg
• IOPA-special film holder

 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.

Space closure

 35yrs/M
 Class III
 Upper midline shift
 Asymmetric smile
 Missing teeth
Treatment plan:

Finishing & retention procedure

Special considerations in pts
with TMJ dysfunction.

Applications of segmented arch
technique

Adult diagnostic considerations
 Diagnostic steps
• Collect data
• Analyze database
• Develop problem list
• Prepare tentative treatment plan
• Interact with other provider
• Final treatment plan

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

Diagnosis of TMJ dysfunctions
 Schiffman et al(1998)
• Muscle disorders- 23%
• Joint disorders- 19%
• Muscle joint combinations -27%
• Normal – 31%

Adult orthodontics (2)

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