Adult orthodontics

Contents
Introduction
History
Difference Between The Adolescent And
The Adult
Limitations Of Treatment In Adults
Diagnosis And Adult Orthodontics
Treatment Planning For Adult Patients
Biomechanical Considerations In Adult
Orthodontics
Adjunctive Treatment Procedures
Comprehensive Treatment For Adults
Surgical Orthodontics
Less Visible Treatment Modalities For
Adults

Introduction
Stenvik (EJO 1997)
Studies in Sweden and Holland by Salonen (EJO
1992)

Adult patients
Younger adults

An older group

History
Kingsley (1880)
Mac Dowell (1901)

 Lischer (1912)
Case (1921)
Reidel& Dougherty (1976)

Difference between the

Adolescent and the Adult

Growth Factors

 Dentofacial esthetics

Neuromuscular Maturity

 Periodontal susceptibility

Rate of tooth movement

10

Extractions

11

 Anchorage Potential

12

 Missing Teeth

13

 Patient compliance

14

Factors

Comparis
on
Adolescents
Adults

Dental caries

More susceptible

PDL disease

Resistance to bone loss Susceptible to bone loss

Susceptible to gingival
inflammation

TMJ
adaptability

high

Symptoms with
dysfunction

Occlusal
awareness

Infrequent

Increased enamel wear

with adverse change in
supporting tissue.

Recurrent decay
restorative failures, root
decay& pulpal pathosis

15

LIMITATIONS OF TREATMENT IN
ADULTS

Limitatio
ns

Intrinsic

Lack of
growth

PDL

Alveolar
bone

Extrinsic

Teeth

Force
system

16

Intrinsic Factors
1. Periodontium
Reitan (1954)
Nortoninsufficient source of progenitors
cells may be due to less vascularitywith
increasing age.
Bond (DCNA 1972)
Graber
17

2. Alveolar bone

Structure
Pathology

3. Teeth

18

Lace like Bone pattern

Honeycomb Bone patte

Without Marginal Bone With Marginal Bone

Loss
Loss
19

Extrinsic Limitations
Barrer and Chasens et al

Local/systemic disease
No
Hard/soft
improvement
Skeletal
Alveolar
Occlusal
tissue
discrepancy
bone
trauma
in
destruction
PDL
losshealth

20

Diagnosis and treatment planning

Collect data accurately
Analyze the data base
Develop problem list
Prepare tentative treatment plan
21

Diagnosis and treatment planning

Interact with those who are involved;
discuss plans and options
clarify sequence;
acquire patient acceptance

Create final treatment plan

22

 IOPA, Occlusal and TMJ films

23

TMJ x
rays

Additio
Muscle
Splint
examinati
nal
therapy
on
diagnos
tic
procedu
Conferen res
ce with
Diet
allied
practition
er

evaluatio
n

24

Diagnosis and treatment planning

Chief Complaint
base of the diagnostic tree

25

Diagnosis and treatment planning

Medical evaluation

Genetic problems
Acquired health problems
Calcium metabolism and bone
mass
Medications
Psychologic factors
26

Diagnosis and treatment planning

Clinical examination
Extraorally
Frontal symmetry
Profile
Lip protrusion and
competence.

27

Diagnosis and treatment planning

Intraoral examination
Soft tissue:
Periodontium
Pathologic condition of the mucosa

Hard Tissues
28

PERIODONTAL
DIAGNOSIS

29

TMD Diagnosis
SCHIFMANN et al divided TMD problems
into

Muscle disorders - 23%

Joint disorders 19%
Muscle / Joint disorder combination 27%
Normal 31%

30

Diagnosis for Osteoporosis

Osteopenia as asymptomatic low
bone mass
Osteoporosis as symptomatic low
bone mass

31

Oral Manifestations of Osteoporosis

Decreas
ed
edentulo
us ridge
height

Decreas
ed
posterior
maxillary
arch
width

Progressi
ve
alveolar
bone
loss

Loss of
attachm
ent and
gingival
recessio
n

Loss of
teeth

32

Estrogen Replacement Therapy

33

TREATMENT PLANNING FOR ADULT

PATIENTS
Scope of Procedures
Musich conducted a study on 1400 adults and
demonstrated the scope of treatment planning
considerations
5% of the adults require no treatment
25.5% came under the SOLO-PROVIDER GROUP
(required only conventional correction
orthodontics)
45.2% came under the DUAL PROVIDER GROUP
(two primary providers were required to
complete the treatment).
Orthodontist / Restorative dentist 30.4%
Orthodontist / periodontist 8.0%
Orthodontist / Oral Surgeon 6.8%
34

Existing
oral
patholog
y
Therapeu
tical
approach
es
available

Extractio
n (vs)
Non
extractio
n therapy

Skeletal
relations
hip

Factors
in
selectio
n of
treatme
nt plan.

Anchorag
e
requirem
ents

Biological
considera
tions

Missing
teeth
(Dental
mutilatio
n)
35

Existing oral pathology

Skeletal Relationships

Biological Considerations

Neuromuscular maturity
Periodontal susceptibility

36

Therapeutic approaches available

Tooth Movement
Orthopedics
Orthognathicsurgery
Restorative dentistry

Extraction (vs) Non Extraction Therapy

37

 Anchorage requirements

Implants for orthodontic anchorage plays an

important role in their treatment. (BJO 2002, VOL 29,
239-245) (Ismail and Johal-UK)
Direct anchorage
Indirect anchorage

Missing teeth - Dental mutilations

38

GOALS OF ORTHODONTIC
TREATMENT
Ackerman
achieving optimal proximal and
occlusal contacts of the teeth,
acceptable dentofacial esthetics, normal
function and reasonable stability
Jacksons triad

39

Treatment objectives
Parallelism of abutment teeth
Most favorable distribution of teeth
Redistribution of occlusal and incisal
forces
Adequate embrasure space and proper
root position

40

 Adequate occlusal plane and potential for

incisal guidance at satisfactory vertical
dimension
Bilateral neuromuscular activity
Adequate Occlusal Landmark Relationships
Better lip competency and support
41

 Improved crown / root ratio

Improvement (or) correction of
mucogingival and osseous defects
Better self maintenance of periodontal
health
Esthetic and Functional improvement
42

BIOMECHANICAL CONSIDERATIONS IN
ADULT ORTHODONTICS
(Lindauer JS. Rebellato J, Dent Clin North Am 1996 : 40 : 811
836.)

43

44

According to Proffit:
Adjunctive treatment
Comprehensive treatment
Surgical-orthodontic treatment

45

Types of adult orthodontic

treatment

Adjunctive

Comprehens
ive

Goal
Performed by
Extent of Appliance
Time Frame
Type of problem
46

Adjunctive Treatment
Procedures
Goals:
Facilitate restorative treatment
Improve Periodontal ligament health
Favorable crown : root

47

Timing & sequence of

treatment
Active disease
Disease control

Re-evaluate

Establish occlusion

stabilize

Definitive restorative Rx
Maintenance
48

Biomechanical considerations
Edgewise appliance
Twin bracket
Larger slot

49

50

Various Adjunctive Treatment

Procedures
Uprighting of the posterior teeth
Loss of a lower molar can lead to:
tipping and drifting of adjacent
teeth
poor interproximal contacts
poor gingival contour, reduced
interradicular bone
supra eruption of unopposed
teeth.
51

 position of the
opposing teeth
the occlusion desired
the anchorage
available
contour of the bone in
the edentulous ridge
area.

52

Uprighting a single molar

Distal crown tipping with
occlusal antagonist
Flexible rectangular
wire-17x25 NiTi
Anchorage unit-19x25
steel
17x25 beta-Ti

53

Uprighting with minimal extrusion

54

Uprighting of lower molars

BirteMelsen, JCO 1996
Case1
56yrs/M
Missing lower 1st molar

55

Case1

56

Case 2
42/F
Missing 46

57

Case 2

58

Distal jet

59

Final positioning of Molar &

Premolars
Compressed coil springs: 018 steel

60

Uprighting two molars in the same

quadrant
Combination of distal crown & mesial root
No bilateral uprighting - same time

61

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

62

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

63

64

65

The distance the tooth to be extruded is

determined by:
Location of the defect
Space to place the margin of the
restoration so that it is not at the base of
the gingival sulcus (at least 1mm above
the base of sulcus)
Allowance for the biological width of the
attached gingiva (2mm)
66

Alignment of anterior teeth

Anterior diastema closure
and space redistribution.
Done in two ways1. 2x4 appliance
2. Sets of clear aligners
- Made by orthodontist on dental casts for modest
amount of tooth movement
or
- 15 to 20 sets fabricated on stereolithographic
models for extensive tooth movements.
67

68

 Alignment of Crowded, Rotated,

and Displaced Incisors (common
in lower incisors)
Three options Expansion of a crowded incisor segment.(fixed
appliance/aligners)
Proximal stripping.
Extraction of incisor in severe crowding cases.

69

Comprehensive orthodontic
treatment in adults

A younger group
(age 20 to early
40s)
Goal is to improve
their quality of life.
Wanted but didnt get
at early age.

An older group (30s

to 60s)
Goal is to keep what
they have
Integration of
extensive orthodontics
into a larger treatment
plan is required
70

Psychological
considerations
Younger patients
o Internally motivated
o More likely to respond well
o Hidden set of motivations
o Unrealistic expectation
71

 Highly motivated adults:-Concerned about visibility of appliance

-Prefer invisible orthodontic appliance
Compromises associated with invisible
approaches should be thoroughly
discussed with patient in advance.
72

Separate treatment area for

adults?
Interaction with other patients is
helpful to
Understand and tolerate the treatment
procedure
Compare their experiences

73

The impact of personality on adult

patients adjustability to
orthodontic appliances
Rena Cooper-Kazaz et al.
Angle Orthod. 2013;83:7682
Anxious individuals tend to prefer lingual and clear
aligner appliances. The selection of lingual and clear
aligner appliances governs the patients response
and recovery process, leaving little room for the
effect of psychological features. On the other hand,
the buccal appliance allows for greater impact of
personality traits on adjustability
74

Influence of Patient Financial Account

Status on
Orthodontic Appointment Attendance
Steven J. Lindaue et al
Angle Orthod. 2009;79:755758.)

-Patients with delinquent financial accounts were

three times as likely to miss an orthodontic
appointment as those whose contracts were
current.
- Increased rates of missed orthodontic appointments
were also found for males, patients scheduled by
mailing a postcard, and patients who had missed
their previous appointment.
75

Prosthodontic Implant Interactions

Problems Related to Loss of Tooth
Structure

76

Proximal tooth material loss

Options:1. Composite buildup - tooth should be in the centre of the dental arch.
2. Facial veneers - place the tooth more lingually.

77

Minute incisal edge

fractures
Smoothen the fractured surface
Extrude or elongate the tooth
May lead to uneven gingival margins
Should be limited to 1-2 mm

78

Gingival Esthetic Problems

Two categories:1. Excessive and/or uneven display of
gingiva.
2. Gingival recession after periodontal
bone Ioss.

79

Excessive and/or uneven display of

gingiva
1. Replacing lateral incisor with canine
(extrude the cannine and reduce its crown height)
2. Extrusion of multiple teeth after loss of

clinical crown height.

(intrude the incisors and then restore the crown
height)

80

Gingival recession after periodontal

bone Ioss
Creates black triangles
Remove some inter-proximal enamel
contact points moves more gingivally
Open space between the teeth reduces on
space closure

81

Missing Teeth: Space Closure

versus
Prosthetic Replacement

Old Extraction Sites

(Decrease B-L dimensions and reduced alveolar

height)
- Reshaping of the cortical bone is done
Drifting of teeth in extraction site

- Prosthodontic consultation should be done.

(implants can be used as anchor sites)
82

83

 Tooth Loss Due to Periodontal

Disease
As a general rule, it is better to move teeth
away from periodontally involved an
area.

Aggressive periodontitis
Mesial movement of 2nd molars is prefered
84

Comprehensive Orthodontics in Patients

Planned for Implants
Following points should be
considered:
1. Need of bone grafting
2. Residual vertical development
3. Ankylosis of damaged tooth
85

Banking of alveolus

86

Periodontal aspects of adult

treatment

87

Is PDL Involvement a Contraindication?

Nelson & Artun 1997, Re et al. 2000) have
confirmed that
pretreatment evidence of periodontal tissue
destruction is no contraindication for orthodontics,
orthodontic therapy improves the possibilities of
saving and restoring a deteriorated dentition, and
the risk of recurrence of an active disease process is
not increased during appliance therapy.
88

Pts can be grouped

into 3 categories
(Proffit)
Minimal periodontal
involvement
Moderate periodontal
involvement
89

Minimal periodontal
involvement
For adults orthodontic patients Gingival
recession is to be prevented rather than to
try correcting it later.
Consider Stress generated due to
Tooth brush trauma
Plaque induced inflammation
Stretching and thinning of gingiva
created by labial tooth movement

90

involvement
Disease control
Treatment procedures like osseous contouring
(or) repositioned flaps to compensate areas of
gingival recession are best deferred until final
occlusal relationships have been established.
Fully bonded orthodontic appliance preferred
Steel ligatures(Forsberg et al. 1991)/ self ligating
bracket are preferred
Maintenance schedule (2 4 months)
HYGIENE AIDS

91

Severe periodontal
involvement
The general approach is the same as
outlined earlier but
1. Periodontal maintenance schedule is at
more frequent intervals (every 4 to 6
weeks)
2. Orthodontic goals modified and forces
kept to absolute minimum of because of
the reduced area of PDL

92

High-Risk factors for development

of PDL disease
Previous history
Gingival bleeding from probing, tooth
mobility, and thin, friable gingival tissue.
Tobacco use, oseteoporosis and diabetes
mellitus
Patients with transverse discrepancy

93

Tissue Response to Certain Types of

Tooth Movement
Extrusion (Eruption)
Melsen-

94

95

Intrusion
Conflicting evidence
Melsen -reported that intrusion of individual teeth
did not result in the development of pockets. She
also reported reduction in alveolar bone height in
animal experiments.
Clinical suggestion (Melsen)- 10-12gms/ tooth
Marks MH, Corn H. have cautioned that intrusion
of anterior teeth during leveling of the occlusal
plane to correct overbite can deepen infrabony
defects on individual teeth

96

97

Tipping
The effect of orthodontic tilting
movements on the periodontal tissues of
infected and noninfected dentitions in
dogs.
Ericsson I, Thilander B, Lindhe J, Okamoto
H.
J ClinPeriodontol. 1977;4:278.

98

Bodily Movement into a

Defect
Experimental reports (Lindskog- Stokland
et al. 1993) and clinical studies (Stepovich
1979, Horn & Turley 1984, Goldberg &
Turley 1989, Thilander 1996) have shown
that a reduction in vertical bone height is
not a contraindication for orthodontic
tooth movement towards, or into, the
constricted area.

99

Bodily Movement into a

Defect
Horn & Turley 1984- limited reduction in
vertical bone height, averaging -1.3 mm.

100

Bodily Movement into a

Defect

101

102

 Bonding every 1mm of bone loss,

0.6mm more apical positioning of the
bracket
After GTR- teeth movement should be
through slight intrusion and sagittal
movement
Use sufficiently low and well controlled
force
Work with segmental appliances- better
control in all 3 dimentions
-Melsen
103

 The occlusion must be controlled during

periods of stress and severe bruxism
throughout orthodontic treatment so that
occlusal trauma and excessive tooth
mobility will be prevented. The Hawley
bite plane is used for disarticulation as
necessary throughout treatment
-Lidhe, Vanasdall

104

 As a rule, orthodontics should logically

precede definitive osseous surgery. The
optimal approach is as follows
complete the orthodontic therapy,
establish a stable occlusion, and
wait a minimum of 6 months before
requesting the periodontistto intervene
for definitive periodontal procedures
-Vanarsdall, Musich
105

Special aspects of orthodontic

therapy

106

Modifications
Minimally
apparent
or
invisible
orthodont
ics

Light
orthodont
ic forces

Intrusion

Skeletal
anchorag
e
107

CAT

Esthetic
applianc
es
Ceram
ic
bracke
ts

Lingu
al
ortho
108

Clear Aligner Therapy

109

Applicability
CAT Performs
well
Mild to moderate

crowding with IPR or

expansion
Posterior dental
expansion
Close mild-moderate
spacing
Absolute intrusion (1/2
teeth)
Lower incisor extraction
for severe crowding
Tip molar distally

CAT does not perform

well

Dental expansion for

blocked out teeth
Extrusion of incisors
High canines
Severe rotations
Leveling by relative
intrusion
Molar uprighting
Translation of molars
Closure of premolar
extraction spaces 110

111

Other considerations

Use of attachments
IPR
Careful monitoring
Bleaching

112

Lingual orthodontics

113

Ceramic Brackets

114

Application of skeletal
anchorage

Positioning individual teeth

Retraction of protruding incisors
Distal/mesial movement of molars
Intrusion of posteriors/ anteriors in open
bite/deep bite cases

115

116

117

Surgical Orthodontics

Mandibular
surgeries

Maxillary
surgeries

Combinatio
n

118

Envelope of Discrepancy

119

Newer techniques
Corticotomy assisted orthodontics
Accelerated Invisalign treatment

120

Finishing

121

Evaluation before
debonding

Root parallelism
Coincidence of CR with habitual occlusion
Incisal guidance
Joint symptoms
Excursive movements
Patient input

122

 Reaffirmation of restorative commitment

Reevaluation of periodontal consideration
Reevaluation of anterior and posterior tooth size
discrepancies
Anticipated retention problems
Reassessment of the characteristics of the
original malocclusion.

123

Coordination of debonding
with other treatment
providers
Posttreatment radiographs

Periodontal reevaluation and treatment

Restorative treatment and retention
consideration
Duration of retention

124

Stability and Retention

Harris et al 1994
Overall relapse in the molar relation was
same

125

Various methods of
retention
Periodontal surgical retention Pericision
Removable retainers Hawleys with
tongue crib
Fixed lingual retainers
Invisible retainers
Comprehensive restorative procedures
Splinting

126

Common pitfalls
Tendency to extract premolars in
borderline cases
Extraction in lower arch which is already
placed distally
Extraction of upper premolars only in
vertical excess cases with lip
incompetency
Attempting to close excess extraction
spaces
127

Indefinite retention
Generalized spacing
In Lip competency, transfer space to
posterior segment
Tooth discrepancy in anterior area

128

Conclusion

129

Thank you.

130

References
1. David P. Mathews and Vincent G. Kokich. Managing Treatment for
the Orthodontic Patient With Periodontal Problems (SeminOrthod
1997;3:21- 38.)
2. Vincent G. Kokich and Frank M. Spear Guidelines for Managing the
Orthodontic-Restorative Patient (SeminOrthod 1997;3:3-20.
3. Frank M. Spear, David M. Mathews, and Vincent G. Kokich
Interdisciplinary Management of Single-Tooth Implants.
(SeminOrthod 1997; 3:45-72.)
4. Ingber J. Forced eruption: Part I. A method of treating isolated one
and two wall infrabony osseous defects - rationale and case report. J
Periodontol 1974;45:199-206.
5. Thilander B. Infrabony pockets and reduced alveolar bone height in
relation to orthodontic therapy. SeminOrthod 1996;2(1):55-61.
6. Burch JG, Bagci B, Sabulski D, Landrum C. Periodontal changes in
furcations resulting from orthodontic uprighting of mandibular
molars. Quintessence Int 1992;23:509-13
7. Melsen B. Dr. BirteMelsen on adult orthodontic treatment. Interview
by VittorioCacciafesta. J ClinOrthod. 2006 Dec;40(12):703-16

7. Liu CC, Baylink DJ, Wergedal JE, Allenbach HM, Sipe J. Pore
size measurements and some age-related changes in
human alveolar bone and rat femur. J Dent Res
1977;56:143-50.
8. Levitt HL. Adult orthodontics. J Clin Orthod 1971;5:130-5.
9. Ackerman JL. The challenge of adult orthodontics. J
ClinOrthod 1985;12:43-8.
10.Graber, Vanarsdall. Orthodontics Current Principles and
Techniques. 3rd edition Mosby, p 839
11.Shaughnessy. Implementing Adjunctive Orthodontic
treatment. JADA, vol 126, may 1995, 679
12.Janson, Crepaldi, Freitas, Janson. Evaluation of anterior
open-bite treatment with occlusal adjustment. Am J
Orthod Dentofacial Orthop 2008;134:10.e1-10.e9
13.Contemporary Orthodontics:5th Editionby William
R.Proffit.

Questions asked
The role of orthodontics in modern day
practice of esthetic dentistry. (5)
Special considerations during adult
orthodontic treatment. (5)
Adult versus child orthodontics (5)
Motivation in adult orthodontics (5)
Limitations in adult orthodontics (20)
Long essay
Adult orthodontics
Esthetics in adult orthodontics
133

Retention and relapse

Dr. Malvika Gandhi

134

Contents Part 1
Introduction
Factors in relapse
- Continuing growth
- Neuromuscular and periodontal
forces
- Biomechanical factors
- Third molars
- Tooth dimensions and axial
inclination

135

Contents - Part 2
Retention
- Theorems of retention
- Retention planning clinical
considerations
- countdown to retention
- retention protocol (duration and
timing)
- Retainers
Recovery after relapse
Conclusion
136

References
Proffit WR, Fields HW, Ackerman JL, Bailey LJ, Tulloch
JF. Contemporary Orthodontics. 3 rd ed. St. Louis:
Mosby; 2000.
Moyers RE. Handbook of Orthodontics. 4 th ed.
Chicago: Year Book Medical Publishers; 1988.
Graber TM, Swain BF. Current Orthodontic Principles
and Techniques. St. Louis: Mosby; 2000.
Graber TM, Vanarsdall RL. Orthodontics Current
Principles and Techniques. 3 rd ed. St. Louis: Mosby;
2000.
Nanda R, Burstone CJ. Retention and Stability in
Orthodontics. Philadelphia: W.B. Saunders Company.
137