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Adult Orthodontics, From Past to Present: A Review

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Review Article
___________________________________________________
J Res Adv Dent 2019;9:2s:69-73.
JRAD ____________________

Adult Orthodontics, From Past to Present: A Review

Amit Bhardwaj1 Tanu Joshi2* Kratika Mishra3

1Professorand Head, Department of Orthodontics, Modern Dental College & Research Centre, Indore, Madhya Pradesh, India.
2PG Student, Department of Orthodontics, Modern Dental College & Research Centre, Indore, Madhya Pradesh, India.
3Senior Lecturer, Department of Orthodontics, Modern Dental College & Research Centre, Indore, Madhya Pradesh, India.

ABSTRACT

Background: In the recent era, more adults are seeking orthodontic treatment when compared with the past
with varying degree of malocclusion. They are more conscious about their esthetics, so need for invisible
orthodontics is increased. In this review we discuss important considerations and treatment modalities for
treating adult patients.

Keywords: Dentistry, history, orthodontics.

INTRODUCTION LIMITATIONS OF TREATMENT IN ADULTS

The frequency of malocclusion in adults is equal There are two categories:

(or) more than that observed in children and
adolescents. Since 1990’s 15% of the orthodontic INTRINSIC-BIOLOGICAL
patients were adults. They fall into 2 different
The intrinsic limitations are lack of growth in
groups (1) younger adults (under35, often in their
adults; skeletal discrepancies can therefore be
20’s) who desired, but not received orthodontic
corrected by Orthognathic surgery.
treatment during adolescents. (2) A mature group,
in their 40’s or 50’s who have other dental Other Intrinsic Factors
problems and require orthodontics as part of
immense treatment plan. Periodontium- According to Norton, inadequate
source of progenitor’s cells may be due to
DIFFERENCE BETWEEN THE ADOLESCENT AND vascularity with increasing age. Insufficient pre
THE ADULT Osteoblast accounts for the delayed response to
mechanical stimulus.
In the adolescent, tooth movement is pretentious by
growth and symptoms are detected by practitioners Alveolar bone- Orthodontic tooth movement
or parents. While in adult there is tooth movement depends greatly on age related changes of the
alone since the growth is completed and symptoms skeleton. Cortical bone becomes denser while the
are noticed by the patient. Adult seeks orthodontic spongy bone reduces with age.
treatment more often for esthetic reasons.
Adolescents are likely to show significantly more Teeth - Adults are likely to have missing teeth, teeth
plaque accumulation and gingival inflammation reduced in dimension due to attrition as well as
during fixed orthodontic treatment than adults.1On teeth with large restorations.
a brighter note, adult patients are tidy, more careful
more sincere, financially sound, less sensitive to Extrinsic Limitations- BIOMECHANICAL SYSTEMS
pain and treatment time is either the same or less
than that of younger patients.

_______________________________________________________________________________________
Received: Nov. 11, 2018: Accepted: Jan. 21, 2019
*Correspondence Dr. Tanu Joshi.
Department of Orthodontics, Modern Dental College & Research Centre, Indore, Madhya Pradesh, India.
Email: dr.tanujoshi27@gmail.com

Copyright ©2019 pISSN 2278-0076

www.jrad.co.in eISSN 2321-9270
The force system used for treating adults differs in correct moderate to severe skeletal
several respects from that used in young growing disharmonies.
individual.
3. Biological Considerations: Neuromuscular
Deep bite: Extrusion of posterior teeth is not maturity – mechanical options for an adult are
compensated by condylar growth. limited because of lack of neuromuscular
adaptability.
Posterior cross bite: Arch expansion is not stable.
4. Therapeutic approaches available
Barrer and Chasens et al suggested that it was
advisable to stop orthodontic treatment when there Tooth Movement: Most of them need tooth moving
is Uncontrolled/advanced local or systemic disease, forces
excessive alveolar bone loss, severe skeletal
discrepancy, inability to prevent excessive Orthopedics: not effective
hard/soft tissue destruction, movement of teeth
Orthognathic surgery: required in 10 to 20% of
against occlusal opposition or into occlusal trauma,
adult patients.
and no improvement in periodontal health, function
or esthetics are possible. Restorative dentistry: frequently required.

DIAGNOSIS 5. Extraction (vs.) Non Extraction Therapy:

Atypical extractions are usually undertaken in
Careful diagnosis and treatment planning on a
adults. 4 premolars extraction are done to resolve
multidisciplinary basis is essential to treat adult
crowding. Upper premolars extraction is done
patients. The standard diagnostic aids such as case
which is a common alternative.
history, clinical examination and study casts,
radiographs and photographs are mandatory. 6. Anchorage requirements: Anchorage control is
important criteria in orthodontics. Adults have
I.O.P.A, occlusal and TMJ films should be obtained
more anchorage potential because of completely
routinely in addition to the panoramic radiograph
erupted 1st and 2nd molars as well as accentuated
and cephalograms. The problem oriented
mesial drift particularly in the mandibular arch. On
diagnostic approach as described by Proffit and
the other hand 40% of the adult’s patient is partially
Ackerman is strongly recommended to ensure that
edentulous.
no aspect of the patient need is neglected.
7. Missing teeth (Dental mutilations)
Additional diagnostic procedures in an adult
patient includes - full series of TMJ x – rays, Muscle Adult requires a temporary tooth replacement
examination, Splint therapy, Diet evaluation, during fixed appliance therapy or fixed prostheses
Conference with allied practitioner. later. Implants have become a reliable alternative.
Therefore a multidisciplinary team approach is
Factor in selection of treatment plan
required for their comprehensive rehabilitations.
1. Existing oral pathology: Include recurrent
GOAL OF ORTHODONTIC TREATMENT
decay, restorative failures, root decay involving
pulp, periodontal bone loss, TMJ symptoms and Since the adult vary in many respects from the
retained roots. These conditions should be adolescent and has limitations, the goal for adult
corrected first before proceedings to orthodontics would be different from that of the
orthodontics with a multi-disciplinary adolescent.
approach.
Jackson’s Triad based on objectives of esthetics,
2. Skeletal Relationships: No growth with function and structural balance are neither realistic
minimal skeletal adaptability. Therefore nor always necessary for all adult patients.
surgical procedures are frequently required to

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Orthodontist works on achieving the following  Comprehensive treatment
objectives in adult patients:  Surgical-orthodontic treatment

1. Parallelism of abutment teeth Adjunctive treatment

2. Most favorable distribution of teeth
3. Redistribution of occlusal and incisal forces Adjunctive orthodontic treatment is tooth
4. Adequate embrasure space and proper root movement carried out to facilitate other dental
position. procedures mandatory to control disease and
5. Adequate occlusal plane and potential for restore function. Some of them are Repositioning of
incisal guidance at satisfactory vertical teeth, Forced eruption of badly broken down teeth,
dimension. Alignment of anterior teeth, and Correction of cross
6. Adequate Occlusal Landmark Relationships bites, etc.
7. Better lip competency and support
Comprehensive treatment
8. Improved crown / root ratio
9. Improvement (or) correction of mucogingival Comprehensive orthodontic treatment aims at
and osseous defects. making the patient’s occlusion as ideal as possible,
10. Better self – maintenance of periodontal by repositioning either all or nearly all the teeth in
health. the process.
11. Esthetic and Functional improvement
The ideal time for comprehensive orthodontic
BIOMECHANICAL CONSIDERATIONS IN ADULT treatment is during adolescence, but
ORTHODONTICS Comprehensive treatment is also possible for
adults. Adult’s appliance should be simple, exert
Sometimes it becomes necessary to change
light forces, long acting, invisible, and better
treatment strategy for adults from what would
retained (fixed).
otherwise be used in adolescent patients to achieve
similar goals.2 PERIODONTAL ASPECTS OF ADULT
TREATMENT1
Selection of Mechanics
The periodontal condition may be modified by a
Exact biomechanical control of tooth movement is
number of factors, prominent among which is age of
obligatory to rectify malocclusion in all 3
patient, type of forces used, and individual variation
dimensions. The forces applied in adults should be
in tissue morphology and response.3
at a lower level than those used for children. Force
levels should be reduced but the magnitude of the There are no contraindications to treat adults with
couple applied to counteract the tendency to tip periodontal disease long as the disease is under
should not be declined proportionally. control.

Vertical control and facial profile Attention if paid to 3 factors prior to orthodontic
therapy can make the treatment easier and more
Maintaining vertical control and facial profile is very
predictable.
important in treating adult patients. A child
tolerates extrusive tooth movement better due to  Reduction of thick tissue either distal to the
condylar growth and vertical development of the terminal tooth or in edentulous areas
alveolar process but in adult there will be opening  Inadequate bands of keratinized tissues.
of the bite by backward rotation of the mandible  Frenal attachments
resulting in an increased facial height and over jet.
There are many options to treat adults rather than
ACCORDING TO PROFFIT, ADULT metal brackets keeping in view their esthetic
ORTHODONTIC PROCEDURE IS CLASSIFIED INTO concern. These are:-
THREE CATEGORIES.
CLEAR BRACKETS (plastic / ceramic bracket) along
 Adjunctive treatment with tooth colored arch wire

71
LINGUAL ORTHODONTICS CORTICOTOMY ASSISTED ORTHODONTICS-
Alveolar corticotomy is an effective means of
The INVISALIGN SYSTEM accelerating orthodontic treatment. Orthodontic
treatment time is reduced with this technique to
Invisalign® (Align Technology, Santa Clara, CA,
one-third of that in conventional orthodontics.6
USA) is a method for correcting orthodontic
Corticotomy has been used in difficult adult cases as
problems that uses the action of a series of
an alternative to conventional orthodontic
transparent removable aligners.4 They also close
treatment or Orthognathic surgery. It was
spaces in mild crowding.
introduced by KOLE in 1959.
SURGICAL ORTHODONTICS
REGIONAL ACCELERATORY PHENOMENON
Correction of severe skeletal deformity in an adult is (RAP) - It was described by an Orthopedist Harold
achieved by surgical means. 10 – 20% of adults fall frost. It decreases the treatment duration
into this category. Orthognathic surgery involves a especially in adults and mutilated cases where
plan of fracturing the facial skeletal parts and conventional orthodontics may not be possible.
repositioning them as desired. Orthognathic surgery
ACCELERATED INVISALIGN TREATMENT 7 -
can be performed in both jaws and in all 3 planes of
Technique developed by Wilckos, called
space.
WILCKODONTICS System (or) ACCELERATED
Antero posterior plane- OSTEOGENIC ORTHODONTICS (AOO) is similar to
single tooth corticotomy. Here it involves all the
Mandibular deficiency requires BSSO and teeth to be moved orthodontically. Owen
mandibular advancement. amalgamates the AOO procedure and Invisalign
therapy in his adult patients. After 10 days of
Mandibular excess requires BSSO and mandibular uneventful healing, aligners were given. 3 to 4 times
setback. faster tooth movement occurred.
Severe dento alveolar proclination in bimaxillary CONCLUSION
protrusion cases – requires anterior segmental
osteotomy. Biomechanical modifications made to accommodate
orthodontic treatment of adult dentitions.2 some
In vertical plane adult patients necessitate changes in treatment
strategy from what would otherwise be employed
Vertical maxillary excess– Lefort Osteotomy with
in adolescent patients to achieve similar goals. In
superior repositioning.
other cases, objectives themselves may need to be
In Transverse plane modified because of lack of growth potential,
constraints of treatment mandated by the patient or
The skeletal problems–required SURGICALLY the presence of multiple missing or compromised
ASSISTED RAPID PALATAL EXPANSION5 teeth.

Retention CONFLICT OF INTEREST

Retention is a critical and challenging aspect of No potential academic conflict of interest relevant
adult orthodontics. Rotated teeth should be over to the above article was reported.
corrected to an extent of 5-10° before debonding. A
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