CONTENTS

1 Introduction

2 History

3 Difference between Adolescent and Adult

4 Limitations of Treatment in Adults

5 Diagnosis and Adult Orthodontics

6 Treatment Planning for Adults

7 Goals of Adult Orthodontics

8 Biomechanical Considerations In Adult

Orthodontics

9 Adjunctive Treatment

10 Comprehensive Treatment

11 Surgical-Orthodontic Treatment

12 Retention

13 Newer Techniques for adults

14 Conclusion

1:0 INTRODUCTION

The frequency of malocclusion in adults is equal (or) greater than that

observed in children and adolescents. Until recent years adults seeking
orthodontic treatment was unusual. Since 1990’s 15% of the ortho patients
were adults. They fall into 2 different groups (1) younger adults (under35,
 often in their 20’) who desired, but not received ortho treatment during
adolescents. (2) An older group, typically in their 40’s or 50’s who have other
dental problems and need orthodontics as part of larger treatment plan.

REASONS FOR INCREASED NUMBER OF ADULTS PATIENTS ARE:

1) Improved appliance placement techniques

2) Innovations in material research such as ceramic brackets & tooth
coloured wires.
3) More sophisticated and successful management of to the symptoms
associated with joint dysfunction
4) More effective management of skeletal dysplasias using advanced
Orthognathic surgical techniques.
5) Increased desire of patients and restorative dentists for treatment of
dental mutilation problems using tooth movement and fixed prostheses
rather than removable restorations
6) Reduced vulnerability to periodontal breakdown as a result of improved
tooth relationship and occlusal function
7) Role of family dentist
8) Role of media and visual aids.
9) Improved socio –economic status.
10) Greater awareness of health & esthetic concerns.

2:0 HISTORY

Conflicting opinions have always existed regarding the feasibility of

orthodontic treatment in the adult

 ➢ Kingsley (1880) suggested that there were hardly any limits to the age of

when tooth movement might not succeed (he treated a 40 year old patient

with anterior cross bite)

➢ In contrast Mac Dowell (1901) was of the opinion that after 16 years of

age, orthodontic treatment was also impossible owing to the development of

the glenoid fossa, the dentistry of the bones and muscles of masticator.

➢ Lischer (1912) believed that the period between 6–14. years was a golden

age of treatment

➢ Case (1921) demonstrated treatment possibilities in aged and periodontally

affected patients.

➢ Reidel & Dougherty (1976) predicted the status of adult ortho treatment

today and stresses the need for adjunctive orthodontic services provided by

periodontist and restorative dentist.

3:0 DIFFERENCE BETWEEN THE ADOLESCENT AND THE ADULT

In the adolescent, tooth movement is affected by growth while the adult

we deal strictly with tooth movement alone. In addition, orthodontic treatment
in the adults is often based on symptoms detected by the patient while in
children, it is based more often on signs detected by practitioners or parents. Of
equal significance is the fact that the adults seeks treatment more often for
esthetic reasons and hence is likely to have unreasonable expectations about the
outcome of the treatment, is less adaptable to the appliance and is
uncompromising in his appraisal of the treatment results. On a brighter note,
adult patients are cleaner, more careful more punctual, prompt paying, much
less sensitive to pain and treatment time is either the same or less than that of
younger patients.
4:0 LIMITATIONS OF TREATMENT IN ADULTS
There are two categories of factors:-
(a) INTRINSIC - BIOLOGICAL
(B) EXTRINSIC - BIOMECHANICAL SYSTEMS

4:1 The marked intrinsic limitation is the lack of growth in adults; skeletal
discrepancies can therefore be corrected by Orthognathic surgery. The
orthodontic treatment is limited to tooth movement and related modeling of the
alveolar process only. Since orthodontic tooth movement is a result of cellular
reaction to a mechanical stimulus, the cellular response may vary with the
health and age of the individual.

Other Intrinsic Factors

4:1:1 Periodontium

The primary tissue to be influenced by the mechanical forces applied to

the teeth in the PDL. According to Norton, insufficient source of progenitors
cells may be due to vascularity with increasing age. Insufficient source of
preosteoblast account for the delayed response to mechanical stimulus.

4:1:2 Alveolar bone

Structure: Orthodontic tooth movement as a result of bone modeling and

remodeling also depends greatly on age related changes of the skeleton.
Cortical bone becomes denser while the spongy bone reduces with age and the
structure of bone changes from that of a honeycomb to a network.

Pathology : Apical displacement of the marginal bone level is a local factor

that influences the biological backgrounds for tooth movement in adults. The

marginal bone loss is age related but is also the result of progressive

periodontal disease.
4:1:3 Teeth : Adults are also more likely to have missing teeth, teeth reduced in

dimension due to attrition as well as teeth with large restorations.

4:2 Extrinsic Limitations : Invariably caused by our inability to adapt the force
system to produce the desired stimulus. The force system used for treating
adults differs in several respects from that used in young growing individual.

Keeping the above limitation in mind, it is easy to see that the following
Problems are difficult to treat by orthodontics alone:

Deep bite: Extrusion of posterior teeth is not compensated for by condylar

growth.
Posterior cross bite: arch expansion is not stable.
Skeletal discrepancies: since growth is completed.

Since the adult patient posses so many problems to the orthodontist,

Barrer and Chasens et al suggested that it was advisable to defer orthodontic

treatment when faced with the following situation.

1. Uncontrolled/advanced local or systemic disease.

2. Excessive alveolar bone loss.

3. Severe skeletal discrepancy.

4. Inability to prevent excessive hard/soft tissue destruction.

5. Movement of teeth against occlusal opposition or into occlusal trauma.

6. No improvement in periodontal health, function or esthetics possible.

5:1 DIAGNOSIS AND ADULT ORTHODONTICS

Careful diagnosis and treatment planning on a multidisciplinary basis

is required to treat adult patients. In truth, the adult, unlike the child, is a
relentless patient who will not cover up deficiencies in the skill of diagnosis or
errors in the use of mechanical procedures by helpful settling – in post
treatment. He presents with no growth, little rebound and meager
accommodation to mechanics.

In addition, the adult may exhibit a potential for such pathological

changes as knife-edge ridges increased cortical thickness, buried roots,
impactions, periodontal breakdown, atropic changes TMJ problems
osteoporosis, osteomalacia, diabetes mellitus. These conditions, which obtain
as a result of hormonal, vitamin or systemic disorders common to the adult,
necessitate more careful and extensive diagnosis evaluations.

Orthodontic diagnosis involves development of a comprehensive

database of pertinent information. The standard diagnostic aids such as case
history, clinical examination and study casts, radiographs and photographs are
mandatory.

I.O.P.A, occlusal and TMJ films should be obtained routinely in

addition to the panoramic radiograph and the cephalogram. The problem
oriented diagnostic approach as described by Proffit and Ackerman is
strongly recommended to ensure that no aspect of the patient need is neglected.

Additional diagnostic procedures that we should consider in an adult patient

are

• A full series of TMJ x – rays • Diet evaluation

• Muscle examination • Conference with allied
• Splint therapy practitioner

Diagnostic Steps

1. Collect database accurately

2. Analyse database
3. Develop problem list
4. Prepare tentative treatment plan
 5. Interact with those who involved. Acquire patient acceptance

6. Create final treatment plan

5 : 2 PERIODONTAL DIAGNOSIS

• Assess the patients potential for bone loss and gingival recession during
orthodontic tooth movement.
• Patient should be screened for the risk factors of periodontal disease.

General Factors Local factors

1. Family H/o. Premature tooth loss 1. Tooth alignment (eg. Marginal

(indicates deficiency of immune ridge, CEJ relationship)
system to chronic bacterial infection
associated with periodontal disease)
2. Evidence of chronic disease 2. Plaque indices
eg : Diabetes
3. Nutritional status 3. Occlusal loading
4. Current stress factors 4. Crown / Root ratio
5. Life stage of women 5.Grinding, clenching habits.
6. Restorative status

Pre treatment consultation with the periodontist should be routine and

orthodontic objectives be altered according to his advice. Movement of teeth in

the presence of periodontal inflammation will result in an increased loss of

attachement and irreversible crestal loss.

5 : 3 TMD Diagnosis

• Signs of symptoms of TMD often increase in frequency and severity during

adult treatment. So it is imperative for the orthodontist to be familiar with
their diagnostic and treatment parameters.
• Adult patients especially females with TMJ sign and symptoms should be
evaluated regarding exposure to stress and her handling of stress.

SCHIFMANN et al divided TMD problems into

• Muscle disorders - 23%

• Joint disorders – 19%
• Muscle / Joint disorder combination – 27%
• Normal – 31%
TMJ DISORDERS

1. Deviation in form - Irregularities in intracapsular soft and hard articular

tissue.

2. Disc displacement with reduction – Altered Disc-condyle structural

relationship is not maintained during translation, reciprocal clicking is
present.

3. Disc displacement without reduction – Altered Disc-condyle relationship

is maintained during translation.

4. TMJ Hypermobility – Excessive disc / condylar translation well beyond

the eminence.

5. Dislocation – Condyle positioned anterior to the articular eminence and

unable to return to a closed positioned.

6. Synovitis – Inflammation of the synovial lining of the TMJ

7. Capsulitis–Inflammation of the joint capsule

8. Osteoarthosis–Degenerative non-inflammatory condition of the joint

characterized by structural change of the joint surface.

9. Osteoarthritis–Degenerative condition accompanied by secondary

inflammation.

10. Polyarthirides–Arthitis caused by generalized systemic polyarthritis.

 11. Ankylosis–Restricted mandibular movement with deviation to the affected
side on opening.

12. Fibrous ankylosis – Ankylosis produced by adhesions within the TMJ.

13. Bony ankylosis – Union of bones of the TMJ caused by proliferation of

bone cells resulting in complete immobility of the joint.

MUSCLE DISORDERS

1. Myofacial pain–Pain associated with tenderness in firm bands of muscles

and tendons.

2. Myositis–Painful generalised inflammation of the entire muscle.

3. Tendomyositis–Inflamed tendons

4. Tendonitis spasm–sudden, involuntary contraction of muscle.

5. Reflex splinting–reflex rigidity of a muscle to avoid pain

6. Muscle contracture–chronic resistance of a muscle to passive stretch.

5:4:1 Diagnosis for Osteoporosis

Adults patients particularly females between 45 – 50yrs (post – menopausal

women) have a high incidence of osteopenia (asymptomatic low bone mass) or
osteoporosis (symptomatic low bone mass).

WHO defines.
Osteopenia as bone mass 1 to 2.5 standard deviations (SD) below young adult
mean (YAM)
• Osteoporosis – as > 2.5 SD below YAM

• Bone mineral density (BMD) measurements of adult women over age of

50 indicated that 13% to 18% had osteoporosis, 37 to 50% had
osteopenia.
 So when evaluating adults for surgical procedures or orthodontics, a BONE
METABOLIC ASSESSMENT is an essential part of diagnosis.

Treatment of osteoporosis is problematic during orthodontic therapy

because drugs that inhibit bone resorption (Bisphosphonates, Calcitonin)
Estrogen Replacement Therapy (ERT) may disturb bone remodeling.

5:4:2 Oral Manifestations of Osteoporosis

Osteoporosis is a systemic deterioration of the skeletal system with

following dental manifestations.

1. Decreased edentulous ridge height

2. Decreased posterior maxillary arch width
3. Progressive alveolar bone loss
4. Loss of attachment and gingival recession
5. Loss of teeth

Effects of Estrogen Replacement Therapy:

ERT has variety of oral health benefits, including a decreased in loss of

periodontal attachments and greater retention of teeth during post – menopausal
period.

Once the negative calcium balance in stabilized, patients with

osetoporosis are excellent candidate for orthodontics and other bone
manipulative therapy.

After osseous structures of jaw are enhanced, treatment planning is

directed towards optimal function loading to avoid disuse atropy of alveolar
process through implants, fixed prosthosis after orthodontic repositioning.

6:0 TREATMENT PLANNING FOR ADULT PATIENTS

6:1 Scope of Procedures

 Musich’s 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%
• 24.3% - came under the MULTIPLE PROVIDER GROUP

6:2 Factor in selection of treatment plan.

1. Existing oral pathology

2. Skeletal relationship
3. Biological considerations
4. Therapeutical approaches available
5. Extraction (vs) Non extraction therapy
6. Anchorage requirements
7. Missing teeth (Dental mutilation)

1. Existing oral pathology : include recurrent decay, restorative failures, root

decay with pulpal involvement periodontal bone loss, TMJ symptoms and
retained roots. These conditions should be treated first before proceedings
to orthodontics with a multi-disciplinary approach.

2. Skeletal Relationships IPS: No growth with minimal skeletal adaptability.

Therefore surgical procedures are frequently required to correct moderate to
severe skeletal disharmonies.
3. Biological Considerations : Neuromuscular maturity – mechanical options
for an adult are limited because of lack of neuromuscular adaptability.
There is a tendency towards iatrogenic transitional occlusal trauma,
coinciding with orthodontic occlusal changes. Periodontal susceptibility –
higher degree of bone loss as result of periodontal disease can be evidenced
during orthodontic therapy.

4. Therapeutic approaches available –

Tooth Movement : most of them require tooth moving forces

Orthopedics : not effective

Orthognathic surgery : needed in 10 to 20% of the adult patients.

Restorative dentistry : frequently required.

5. Extraction (vs) Non Extraction Therapy : Atypical extractions are

usually undertaken in adults Classical 4 premolars extraction to resolve
crowding rarely done upper premolars extraction alone is a common
alternative. Atypical extraction patterns vary from extraction of one to four
teeth with numerous combinations other than 1st and 2nd premolar.

(AO – 1995, Vol 2 – EXTRACTION FREQUENCIES, Joseph R. Val notes)

Asymmetric extractions and stripping of bulky restorations also done.

Strategic extractions are extraction dictated by other pathologies like
periodontitis or other irreversible damages. Careful analysis will lead to the
strategic extraction to solve alignment problems as well as to eliminate
damaged teeth.

6. Anchorage requirements : Adults have greater anchorage potential because

of completely erupted 1st, and 2nd molars as well as accentuated mesial drift
particularly in the mandibular arch. On the other hand 40% of the adults patient
are partially edentulous.
 Implants for orthodontic anchorage plays an important role in their
treatment. (BJO 2002, VOL 29, 239-245) (Ismail and Johal-UK) Osseo
integrated implants may be used for direct as well as indirect anchorage.

Direct anchorage utilizes forces from actual implant which takes the place
of a missing tooth and eventually supports a dental restorations.

Indirect anchorage uses the implants to stabilize specific dental units to

which clinical forces are then applied. Such MID PALATAL FIXTURES are
the ONPLANTS and ORTHOPLANTS which are placed solely for orthodontic
purposes in adults. (JCO-2000-july,Celenza and Hochman)

Onplants were introduced by BLOCK & HOFEMAN in 1995, made of

titanium and consist of base of 10mm and 2mm height with one side smooth
and other side textured and coated with hydroxy apatite. Base has internal
thread for screwing transgingival abutment to which force is applied. Site is
surgically exposed and coated surface is placed close to the bone. After 6 – 8
weeks the base is exposed and transgingival abutment is placed and loaded.

In partially edentulous conditions osseointergrated implants can be used but

malocclusion can deteriorate further as it requires a healing period.

On the contrary, simple and an inexpensive form of maxillary anchorage

is the ZYGOMA ligatures. (JCO, March 1998 –Melsern, Petersen costa)

The best bone quality in a partially edentulous patient is zygomatic arch and
infra-zygomatic crest. 2 holes are drilled in the superior portion of
infrazygomatic crest and double twisted 012” SS wire is pulled through this
canal. To this coil springs and elastics are attached for intrusion and retraction
of anteriors.
 Adult patients requiring intrusion of molars to control Skeletal – Open bite
are the apt candidates for Skeletal Anchorage System MIKAKO,
SUGAWARA,MITRA ( AJO 1999; 115: 166-74)

Titanium miniplates were fixed at the buccal cortical bone around the apical
regions of 67 on both side. Elastic threads were used as a source of orthodontic
force to reduce excessive (3 to 5mm) molar height. The system was very
effective.

BIOS (Glaatzmier) EJO 18 : 1996 465 – 469) is designed to provide

anchoring functions in adults and adolescent and then be resorbed with out
foreign body reactions. Secondary operations for removal at the conclusion of
orthodontic treatment is not needed. It resorbs in 9 to 12 months.

(7) Missing teeth (Dental mutilations)

In adults, most of these spaces cannot be closed without a prostheses

either a temporary tooth replacement during FA therapy or fixed prostheses
later. Implants have become a reliable alternative.

Therefore a multidiscipilinary team approach is required for their

comprehensive rehabilitations.

7:0 GOAL OF ORTHODONTIC TREATMENT

Since the adult differs in many respects from the adolescent and exhibits
limitations, the goal for adult orthodontics would be different from that of the
adolescent.

According to ACKERMAN, adult orthodontics is concerned with a

striking balance between “achieving optimal proximal and occlusal contacts of
the teeth, acceptable dentofacial esthetics, normal function and reasonable
stability”.
 Jackson’s Triad of traditional objectives (ie) esthetics, function and
structural balance are neither realistic nor always necessary for all adult
patients. Class I occlusal goals can be considered over treatment for patients
under multiple provider group.

7:1 Orthodontist commonly tries to achieve the following objectives when treating
adult patients:

1. Parallelism of abutment teeth : (Permits insertion of multiple unit

replacements and does not require excess cutting or devitalizations
during abutment preparation).

2. Most favourbale distribution of teeth : (teeth should evenly

distributed for replacement of fixed and removable prostheses in the
individual arches.

3. Redistribution of occlusal and incisal forces : cases with bone loss of

60 to 70% required the occlusal forcs to be directed vertically along the
long axis of the root to maintain the occlusal vertical dimension.

4. Adequate embrasure space and proper root position. : it allows for

better periodontal health, especially when the placement of restorations
is necessary Interproximal cleaning becomes easier.

5. Adequate occlusal plane and potential for incisial guidance at

satisfactory vertical dimension. : In a mutilated dentition with bite
collapse, adequate occlusal plane can be established by giving
HAWLEY BITE PLANE with the platform of anterior plane adjusted at
right angles to long axis of lower incisors. This allows centric relations
at an acceptable VD.

 Bite plane also allow simultaneous BILATERAL

NEUROMUSCULAR ACTIVITY.
  Curve of spee should be mild to flat bilaterally. This is difficult
to acheive if there are supraerupted molars.

6. Adequate Occlusal Landmark Relationships: when teeth are to

restored, they should be positioned to acheive acceptable buccolingual
landmarks. Posterior cross bites that cannot undergo surgery are
positioned such that the maxillary buccal cusps contact the lower central
fossa with the cross-over for incisal guidance in premolar or canine area.

7. Better lip competency and support: Adults have long upper lips which
precludes significant maxillary retraction. In cases requiring anterior
restorations, retraction is recommended to achieve lip competency.
Lower incisors extending 1 to 2mm into the palatal mucosa (Class II
Div 1 cases) cause soft tissue irritations. So their IMPA is increased
(105o to 120o) to establish incisal guidance. Adequate lip support is
created to prevent wrinkling which makes the face prematurely aged.

8. Improved crown / root ratio: If bone loss is isolated on a single tooth,

length of clinical crowns is reduced and tooth can be erupted
orthodontically thereby improving the crown / root ratio.

9. Improvement (or) correction of mucogingival and osseous defects. :

Repositioning of prominent teeth will improve the gingival topography.
In adults the goal should be to LEVEL THE CRESTAL BONE between
adjacent CEJ: Favorable osseous and soft tissues changes will diminish
the need for muco-gingival surgery.

10. Better self – maintenance of periodontal health. : Improved self –

maintenance of periodontal health occurs with proper tooth position.
This can be seen after the correction of bite collapse and accelerated
mesial drift.
 11. Esthetic and Functional improvement: A plan should provide
acceptable dentofacial esthetics and allow for improved muscle,
function, normal speech and masticatory improvements.

8:0 BIOMECHANICAL CONSIDERATIONS IN ADULT ORTHODONTICS

(Lindauer JS. Rebellato J), (Dent Clin North Am 1996 : 40 : 811 – 836.)

Orthodontic treatment in the adult must be planned without the

expectation that growth or any changes in jaw relationships will conpensate for
interarch discrepancies. A precise biomechanical control of tooth movement is
necessary to achieve correction of malocclusion in all 3 dimensions.

 The forces used in the adults should be at a lower level than those used in
children. The initial forces should further be kept low because the
immediate pool of progenitor cells available for resorption are low.

 In adults with periodontal involvement where bone has been lost, PDL are
decreases with the results that the same force against the crown would
produce greater pressure in the PDL. The absolute magnitude of force
must therefore be reduced.
 Marginal bone loss results in CRES (b) being displaced apically.
Magnituide of the tipping moment is the product of force and distance (point of
force application to the CRES).

Since the CRES has moved apically greater will be the tipping moment
for same force, so a counter vailing COUPLE is necessary to affect BODILY
movement.

 Force levels should be decreased but the magnitude of the couple applied to
counteract the tendency to tip should not be decreased proportionally.

 In the presence of marginal bone loss, light continuous intrusive forces

should be maintained.

8:1 Selection of Mechanics

The appliance should produce a controlled and constant force system in

all three planes to reader a low lead deflection rate possible

8:2 Vertical control and facial profile

Maintaining vertical control and facial profile is very important in

treating adult patients. A child tolerates extrusive tooth movement better since

condylar growth and vertical development of the alveolar process during child

hood permit such tooth movement. In contrast, any extrusive movement, of the

posterior teeth in the adult will lead to an opening of the bite through backward

rotation of the mandible resulting in an increased facial height and overjet.

Extrusion of incisors can be undersirable since the majority of patients

suffering from advanced periodontal disease have extruded and spaced

maxillary teeth. Such patients need intrusion and retraction.

8:2:1 Loss of vertical control

Unintentional extrusion is possible with both fixed and removable

appliance. According to Burstone, such loss of vertical control is possible in a

number of instances of fixed appliances therapy such as.

 Tip back bends  Straight wire leveling

 Incorrect bracket positioning  Anterior root correction

 Excessive force

Loss of vertical control is also possible with the use of removable appliances

such as

 Bite block  Occipital head gears

 Active springs  Magnetic appliances
 Chin cap  Myofunctional appliance
Considerable care should be exercised in the use of the above in order to avoid

unnecessary extrusion of teeth.

9:0 ACCORDING TO PROFFIT, ADULT ORTHODONTIC PROCEDURE

CAN BE CONVENIENTLY CLASSED INTO THREE CATEGORIES.
1. Adjunctive treatment

2. Comprehensive treatment

3. Surgical-orthodontic treatment

9:1 ADJUNCTIVE TREATMENT:

Adjunctive orthodontic treatment is tooth movement carried out to

facilitate other dental procedures necessary to control disease and restore

function.

Typically, adjunctive treatment will involve any or all of several procedures:

  Repositioning of teeth that have drifted after extractions or bone loss so as
to facilitate the placement of removable or fixed partial dentures or even
implants.

 Forced eruption of badly broken down teeth to expose sound root structure
on which to place crowns.

 Alignment of anterior teeth to allow more esthetic restorations or

successful splinting.

 Correction of cross bites if these compromise jaw function.

9: 2 Goals:
 Facilitates restorative treatment by positioning the teeth so that more ideal
and conservative technique can be used.
 To improve periodontal health by eliminating plaque harboring areas and
improving the alveolar ridge contour adjacent to the teeth.
 To establish favourable crown to root ratios and position the teeth so that
occlusal forces are transmitted along the long axis of the teeth.
9: 3 Characteristics of therapy

Adjunctive orthodontics implies limited orthodontics goals

(a) Appliances are required only a portion of the dental arch. (i.e) partial
fixed appliance.

(b) Treatment should be completed with in 6 months.

(c) Orthodontic treatment for TMD should not be considered adjunctive.

9:4 Diagnosis and treatment planning consideration

Planning for adjunctive treatment required 2 steps.

a. collecting an adequate date base

b. Developing a comprehensive but clearly stated list of patient’s
problem
Records include IOPA and panoramic x-rays

 Pre-Treatment cephalogram not required.

 Dental casts made from fully extended impression covering the contour

of supporting alveolar bone is required.

9:5 Treatment sequence

After the development of comprehensive treatment plan 1st step is to

control the active dental disease. (i.e.) active caries, pulpal pathology,
periodontal disease before any orthodontic tooth movement is initiated.

COMPREHENSIVE TREATMENT

STAGE 1: DISEASE CONTROL

Revaluate

STAGE 2: ESTABLISH OCCLUSION

Stabilize

STAGE 3: DEFINITIVE PERIO / RESTORATIVE TREATMENT

STAGE 4: MAINTANENCE

HERE ORTHODONTICS IS USED TO ESTABLISH OCCLUSION.

9:6 Possible tooth movement in adjunctive treatment

(a) Mesial or distal movements of specific crowns and roots.

(b) Correction of axial inclination of drifted teeth.

(c) Correction of buccolingual position of certain teeth

(d) Corrections of rotations.

 Intrusion of teeth is avoided as an adjunctive procedure because of the
technical difficulties involved and possibility of periodontal complications.

Excessively extruded teeth are treated by reduction of crown height

which improves the crown / root ratio.

9:7 Biomechanical considerations:

Control of anchorage requires that anchor teeth not be allowed to tip.

This is major reason that adjunctive treatment usually requires a fixed
appliance.

 EDGEWISE APPLIANCE recommended, twin brackets of 0.022 slot

dimension are used preferably

 Rectangular slot controls bucco – lingual axial inclination

 Twin bracket prevents undesirable rotations and tipping

 Larger slot allows the use of stabilizing wires which are stiffer.

 Bracket are placed in an ideal position only on teeth to be moved, remaining

teeth incorporated in the anchor system and are bracketed so the archwire

slot are closely aligned. Passive engagement of the wires to anchor teeth

produce minimal disturbance of teeth.

9:8 The procedures commonly carried out as a part of adjunctive

orthodontic treatment are

 Uprighting Posterior Teeth.  Alignment of teeth.

 Forced eruption.  Cross-bite correction.

9: 8: 1 - Uprighting Posterior Teeth

When a posterior tooth is lost, the adjacent teeth usually tip, drift or
rotate. As these teeth move, the adjacent gingival tissue becomes folded and
distorted, forming a plaque harbouring pseudo pocket that may be virtually
impossible for the patient to clean.

When planning molar uprighting, the following factors are considered.

1. If the 3rd molar is present, whether both 2nd and 3rd molar should be
uprighted.

For many patients, distal positioning of the third molar would move this
tooth into a position where good hygiene cannot be maintained or the
uprighted third molar would not be in functional occlusion. In these
circumstances, it is more appropriate to extract the third molar.

2. Whether to upright the tipped teeth by distal crown movement,

which would increase the space available for a later pontic, or by mesial
root movement which would maintain, reduces or even close the
edentulous space.

This decision will depend on :

a) Position of the opposing tooth.

b) Occlusion desired

c) Anchorage available

d) Contour of the bone in the edentulous ridge area.

If conditions are not favourable, then distal crown tipping for uprighting molar
is preferred.

3. Whether slight extrusion of a tipped molar is permissible or whether the

existing occlusal height must be maintained as the uprighting occurs. Tipping a
tooth distally generally extrudes it. This has the merit of reducing the depth of
the pseudo pocket found on the mesial surface. In addition, if the height of the
clinical crown is systemically reduced as uprighting proceeds, the ultimate
crown-root length ratio will be improved.

4. Whether the premolars are to be repositioned.

Depends on the position of these teeth, the existing contacts and the opposing
intercuspation as well as the restorative plan.

In many cases it has to be repositioned because it is desirable to close space

between premolars when uprighting molars because this will improve both the
periodontal prognosis as well as long term stability.

APPLIANCE FOR MOLARS UPRIGHTING

A partial fixed appliance with the required attachments (wide twin

brackets and gingivally placed auxiliary tube preferred) is preferred for
uprighting tipped molars.

Initial bracket alignment: using a light flexible wire such as a 17 x 25 A-NiTi

or a 17x25 braided stainless steel from molar to canine.

Right from the time of placement of the initial wire, it is always advisable to
relieve occlusal contacts against the molar. Failure to do so prevents the molars
from tipping. It greatly slows the desired tooth movement and may cause
excessive tooth mobility.

If the molar is severely tipped distally, a continuous wire that uprights the
molar will also tip the 2nd premolar distally, which is undesirable. It is better
therefore to carry out the bulk of the uprighting using a sectional uprighting
spring.

A stiff rectangular wire (19 x 25 SS) maintains the relationship of the teeth in
the anchor segment and an auxiliary spring is placed in the molar auxiliary
tube.
The uprighting spring is formed either from a 17 x 25 -Ti without a helical

loop or a 17x25 SS with a loop added to reduce the force level. Because the
force is applied to the facial surface of the teeth, a helical uprighting spring
tends, not only to extrude the molar, but also to roll it lingually, while at the
same time intruding the premolars and flaring them buccally. To counteract this
side effect, the uprighting spring should be curved bucco lingually so that when
it is placed in the molar tube, the loop should lie lingual to the arch wire prior
to activation.

A T- Looped spring in 17 x 25 steel wire with an angulation of the distal arm

can also be used to upright a single tipped molar.

In cases where it is desired to upright molars and close spaces simultanouesly,

the distal arm of the T – Loop can be pulled distally and cinched behind the
molar tube, thus opening the loop and creating a mesial force.

A modification of the T – Loop can also be used to upright a severely tipped

or rotated molar. In this case, the terminal part of the spring is inserted from the
distal opening of the molar tube.

Once the molar uprighting has been almost accomplished, it often is desirable
to increase the available pontic space and close any open contacts in the
anterior segments. This is done best using a relatively stiff base wire with either
SS or A-NiTi open coil spring.

After molar uprighting, the teeth are in an unstable position until the fixed or
removable prosthesis that provides the long term retention is placed. Recently
moved teeth are often quite mobile and may change position easily during
prosthesis construction. Therefore, before the placement of prosthesis, an
intermediate form of splinting is necessary to maintain the postion of all
abutment teeth in all patients.
There are two methods of intermediate splinting.

1. Extra coronal splinting.

2. Intra coronal splinting.

EXTRA CORONAL SPLINTING

A 19 x 25 SS or 21 x 25  - Ti wire designed to fit the brackets passively will

prevent any tooth movement. Such a splint must be free of any occlusal
interfaces.

Extra Coronal Splinting

INTRA – CORONAL SPLINTING

The preferred approach to intermediate splinting is an intracoronal wire splint.

Shallow cavities may be prepared in the abutment teeth and a splint of 19 x 25
or heavier steel wire secured intracoronally with either amalgam or composite
resins. This type of splint causes little gingival irritations and can be left in
place for a considerable period of time.

Intra Coronal Splinting

9:9:2 Forced eruption

Teeth with defects in the cervical third of the root pose a complex dental
problem. These problems can arise after horizontal or oblique, fracture, internal
or external resorption, decay or pathological perforations. As a rule endodontic,
treatment should be completed before extrusion of root.

As the tooth is extended, the attached gingiva should follow the cemento
enamel junction, thereby increasing the width of the keratinized tissue.
However, it may be necessary to recontour the gingiva to produce an even
gingival contour in relation to the adjacent teeth in order to improve esthetics.

The occlusion should be examined to make sure that sufficient space

still exists, both within the arch and relative to the opposing teeth to permit the
placement of a satisfactory esthetic restoration. A final consideration is the
crown-to-root ratio at the end of treatment, which should be at least 1:1 or
better.

The length of time required for forced eruption will vary with the age of
the patient, the distance the tooth has to be moved and the viability of the PDL.
In general, extrusion can be as rapid as 1 mm per week without damage to
the PDL. Too much force and too rapid a rate of tooth movement runs the risk
of tissue damage and ankylosis.

APPLIANCE

1) The appliance needs to be quite rigid over the anchor teeth and flexible
where it attaches to the tooth that is being extruded. Use of a continuous
flexible arch wire is not indicated because it would tip the adjacent teeth
towards the tooth being extruded thereby reducing the space for subsequent
restorations and disturbing the inter proximal contacts within the arch.
 2) A T-Looped arch. wire is made from 17x25 SS or 19x25 B-Ti . The part of
the wire engaging the tooth to be extruded should be designed to lie more
occlusal than the anchor segment.

3) An alternative technique of extrusion is to use a heavy stabilizing wire of 19

x 25 SS bonded directly to the facial surface of adjacent teeth and place a post
and core and a temporary crown with a pin on the tooth to be extruded.
Elastomeric modules are used to extrude the teeth. This method is simple but
lack the control of the T-Loop technique.

9: 9: 3 Alignment of teeth

Indications to correct malaligned anterior teeth are

1. To improve access and permit placement of well adapated and

contoured restorations (eg. when composite resin build ups to recontour
 incisours are planned (or) when periodontally compromised incisors
must be splinted.

2. To permit placement of crowns and pontics without overcontoured

crowns that would produce poor embrasure form.

3. To reposition closely approximately roots to improve the embrasure

form and increase the amount of interradicular bone which controls
periodontal disease.

4. To position teeth so implants can be placed to support restorations

Rotations, crowding, spacing, cross bite and tipped teeth all pose problems
for restoratives and periodontal procedures. A ‘diagnostic set up’ can be very
helpful in planning treatment for alignment problems, particularly if crowding
and spacing problems are to corrected.

Points to be remembered

 Moving teeth lingually and correcting rotations of anterior teeth requires

additional space within the arch.

 Dertotating posterior teeth and uprighting tipped teeth usually cause them
to occupy less space within the arch.

 Moving teeth facially increases arch length.

 Space also may be created by proximal stripping. Sheridan recommended

removing no more than 1/2mm of the enamel and applying topical
fluoride to the exposed surface.

TECHNIQUE
Alignment Of Crowed, Rotated And Displaced Incisal

The initial wire should be light and flexible (e.g. NITI). The wire is

cinched gingivally at the distal end of the molar tube to prevent labial flaring
while aligning. After initial alignment, stiffer round or rectangular wires are

placed.

Positioning teeth for single tooth implants

For satisfactory implant placement there must be enough room.

narrowest implants available are 4mm in width at the shoulder,1mm of space is

required between the implant and adjacent tooth to allow proper healing. So

minimum of 6 mm of space should be available

Anterior diastema closure : Is relatively simple but requires permanent

retention with a bonded lingual retainer.

If th diastema is small or results from adjacent teeth begin tipped is opposite

directions, a removable appliance with finger springs may be used. If widely

separated and requires bodily movement, a fixed appliance is preffered.

9: 9: 4 Cross bite correction

Cross bite may occur in any part of the arch and often cause functional

problems such as occlusal interferences, occlusal trauma and improper occlusal

loading. Anterior cross bites are an esthetics problem as well. If the cross bites

are of a dental nature. Orthodontic correction is possible. If it is a skeletal

problem, the patient should be considered for comprehensive orthodontic

treatment that may include Orthognathic surgery.

 If cross bite is due to only DISPLACED TEETH which requires only

tipping movements then a REMOVABLE APPLIANCE may be used.

 When the tooth rotates labially or buccally to a new position there is a

vertical change in the occlusal level.

 In the POSTERIOR SEGMENTS, cross bite are corrected using “through

the bite” elastic from a conveniently placed tooth into correct occlusion.

To be used with caution in adults as it may cause extrusion.

 If VERTICAL CONTROL IS CRITICAL and some degree of bodily

movement is required in cross bite correction. An ideal arch system is used.

Anchorage is obtained from adjacent teeth and contralatertal molar via

TPA. A flexible wire engaged in the bracket generates necessary controlled

forces.

10.1 COMPREHENSIVE TREATMENT FOR ADULTS

Comprehensive orthodontic treatment aims at making the patient’s

occlusion as ideal as possible, repositioning all or nearly all the teeth in the
process.
The ideal time for comprehensive orthodontic treatment is during
adolescence, when the succedaneous teeth have just erupted, some vertical and
antero posterior growth of the jaws remains and the social adjustment to
orthodontic treatment is not a great problem.
Comprehensive treatment is also possible for adults, but it poses some
special problems that do not exist for younger patients.
The following considerations should be kept in mind while treating adults
 Lack of growth
 Heightened possibility of periodontal disease
 Different motivations for seeking orthodontic treatment.
 While treating adults
 Appliance should be simple in order to elicit maximum patient cooperation
 Appliance should exert light forces for best physiological response.
 Appliance should be long acting to decrease the number of appointments.
 Appliance should be invisible as possible(plastic, ceramic brackets, fixed
lingual appliances)
 Appliance should be better retained (fixed)
Adult treatment mechanics need not differ from the standard technique;
they are modified only to meet specific treatment requirements. Simplicity
with maximum control is the by word.
Comprehensive orthodontic treatment implies an effort to make the patient’s
occlsion as ideal as possible by repositioning nearly all the teeth in the process.

10:2 Motivations for adult treatment: The major motivations for adults to
undergo comprehensive treatment is due to psychological reasons. Though a
small percentage of them may seek complete treatment for periodontal and
restorative needs.

10:2:1 Internal motivations : if the individual wants to improve his appearance or

function of teeth and so seeks treatment – he is said to be internally
motivated and is expected to respond well psychologically

10:2:2 External motivation : an individual whose motivations is the urging of

others he said is to be externally motivated and has a complex set of
unrecognized expectation for orthodontic treatment.

Other motivating factors

10:2:3 TMD (Temporamandibular pain and dysfunction is significant motivating

factor for some adults. Ortho treatment can sometimes help these patients but it
cannot be relied on to correct them. TMD symptoms arise due to 2 major
causes.
 1. Muscle Spasm and Fatigue

2. Internal Joint Pathology.

Stress Clenching, grinding MUSCLE SPASM (1) pain

AND
FATIGUE (2) clicking
INTERNAL (3) Limited
JOINT PATHOLOGY Opening

 Symptoms due to muscle spasm and fatigue may be helped by orthodontic

treatment where as it is not helpful in internal joint pathologies.
3 broad approaches to MYOFACIAL PAIN SYMPTOMS
1. Reducing the amount of stress
2. Reducing the patient’s reaction to stress
3. Improving the occlusal relationship through restorative dental procedures
or orthodontical treatment.
10: 3 PERIODONTAL ASPECTS OF ADULT TREATMENT
 There is no contra indications to treating adults with periodontal
disease long as the disease is under control
 Three risk groups are identified in the population
(a) Those with rapid progression (10%)
(b) Those with moderate progression (80%)
(c) Those with no progression despite the presence of gingival
inflammation (10%).
10:3:1 MINIMAL PERIODONTAL INVOLVEMENT:

 Bacterial plaque being the main etiological factor in periodontal breakdown,

patient undergoing orthodontic especially adults must take extra care
  For adults orthodontic patient’s GINGIVAL RECESSION is to be
prevented rather than to try correcting it later. Creation of “BLACK
HOLES” between maxillary central incisors by gingival recession after
periodontal loss is practically distressing.

According to the present concept, gingival recession occurs secondary to

alveolar bone dehiscence; if overlying tissues are stressed. Stress can be due to

1. Tooth brush trauma

2. Plaque induced inflammation

3. Stretching and thining of gingiva created by labial tooth movement

FREE GINGIVAL GRAFT is helpful in adult patients to control inflammation

before orthodontic treatment begins. and in whom arch expansion is indicated
for aligning incisors.

10:3:2 MODERATE PERIODONTAL INVOLVEMENT:

Disease control: Preliminary periodontal therapy is preformed which includes

meticulous root surface preparative and curettage and patient kept under
observation to watch whether the disease is controlled.

Treatment procedures like osseous contouring (or) repositioned flaps

to compensate areas of gingival recession are best deferred until final occlusal
relationships have been established.

Disease control also requires endodontic treatment of any pulpally

involved teeth. Temporary restorations (composite resins) are placed to control
caries and definitive the restorative procedures (cast restoration) are delayed
after orthodontic phase of treatment.
 PERIODONTAL MAINTENANCE

Fully boned orthodontic appliance is recommended. Steel ligatures (or)

self ligating bracket are preferred for periodontally involved patients rather
than elastomeric rings to retain arch wires because such patient have higher
level of micro organisms in gingival plaque.

During comprehensive treatment, patient with moderalte periodontal

problems should be on a maintanence schedule (2 – 4 months interval)

HYGIENE AIDS: Electric tooth brushes, rubber interdental stimulators,

proximal brushes and adjunctive chemicals (eg. Chlorhexidine) should be
considered.

10:3:3 SEVERE PERIODONTAL INVOLVEMENT:

The general approach in 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

Muco-gingival Corrections

Attention if paid to 3 factors prior to orthodontic therapy can make the

treatment easier and more predictable.

1. Reduction of thick tissue either distal to the terminal tooth or in edentulous

areas

2. Inadequate bands of keratinized tissues.

3. Frenal attachments
  Thick tissue gets bunched up and can slow down tooth movement

considerably. While uprighting a second or a third molar, the tissue moves

coronally on the tooth and a pseudopocket develops. This can become a

nidus for bacteria and a potential locus for the apical migration of the

attachment.

 If there is a minimal band of keratinized tissue and the roots move out of

the alveolus, there is bound to be recession.

 Frenal attachements that prevent or slow down tooth movements may be

removed during or before tooth movement. However, if retention is the

chief concern, then the removal may be effected at the conclusion of tooth

movement.

10 : 4 : 1 Orthodontic positioning of tooth

 Should be done with the eventual restorative plans is mind

3 important considerations are

1. Total amount of space that should be created

2. MD postioning of tooth within the space

3. Buccolingual postion

 Orthodontic postioning of tooth should create adequate space for the

restorations.

 MD positioning may be in centre of the space available if symmetric

additions on both sides are planned.

 If composite build up is planned tooth is positioned in the centre of the

arch.
  If a facial veneer is decided, then to tooth should be lingually positioned to

compensate for the veneer thickness on buccal side.

10:4:2 LESS VISIBLE TREATMENT MODALITIES FOR ADULTS : -

Adults patients are conscious and demand less visible appliances.

 CLEAR BRACKETS (plastic / ceramic bracket) along with tooth coloured

arch wire are the most esthetic combinations to be used in a conscious

adult patients. The esthetic arch wire (FRC Fibre Reinforced Composite

AJO 2000) is composed of ceramic fibres embedded in a cross-linked

polymer matrix. Its coefficient of friction is reduced by modifying the

surface chemistry (eg: ion implantation) inspite of this, adults are often

averse to wearing traditional fixed appliance with wires, bands and

brackets.

10:4:2A The INVISALIGN SYSTEM (BJO-2003 – December vol 30 (L.joffe-

UK) now makes it possible for orthodontists to offer adults patients requiring

full mouth orthodontic treatment with an esthetically agreeable solutions.

 Introduced about 4 years ago by ALIGN TECHNOLOGIES Santa clara,

California

 It is an orthodontic technique that uses a series of clear plastic aligners to

move teeth.

 Worn for a minimum of 20 hours per day.

 Changed on a 2 weekly basis.

 Each aligner moves a tooth or a small group of teeth about 0.25 – 0.33mm
 Align technology using computer – aided scanning, imaging and
manufacturing technology has pushed this technique into realms of every
orthodontic practice.

 The revolutionary aspect of invisalign is the scanning in and imaging of

high precision casts made from very accurate impressions (poly-vinyl
silicon impression). This allows the patient’s teeth to be replicated as “on
screen” 3D model, which can be manipulated and virtually corrected
through a treatment plan developed by orthodontist and translated by
invisalign using sophisticated propriety software. (CAD-CAM
technology) The clinician has the ability to view the “virtual” models”
from malocclusion to correction, movement by movement through an
internet connection program called Clincheck. Changes are made through
clincheck system until the result achieved is to the clinicians liking. Only
then are the actual aligners made and dispatched.

 Extrusive, intrusive and rotational abilities of investigations are under trial

 Software individualizes each tooth, so they can be individually

repositioned and soft ware relates to upper and lower teeth together so that
co-ordinate in kept between arches.

 Manufacturing process is a computer aided technology. The 3D – models

of each setup in the realignment are transformed into hard copy models
through a process of laser build up. These models are then used to make
the pressure formed aligners

 [IPR] Interproximal reductions are done at the time of delivery of the

aligners.

 A typical invisalign treatment will take around 25 aligners and 50 weeks

of treatment.
 Handles simple to moderate non-extraction alignments better than mild to
moderate extraction corrections

 It has only limited ability to keep teeth upright during space closure.

Conditions treated with invisalign

It can be used as RETAINERS, NIGHT GUARD, TMJ SPLINTS

BLEACHING TRAYS AND FOR TOOTH MOVEMENT

Tooth Movements

a. Mildly crowded and malaligned problems (1 – 5mm) Treatment can be

done with slight lateral or anterioposterior expansion, with minor
interporximal tooth reduction or by removal of lower incisor.

b. Spacing of 1 – 5mm

c. Deep overbite problems (class II Div 2 type where the overbite can be
reduced by intrusion and advancement of incisors

d. Narrow arches.

Certain aspects are more difficult to handle

 Crowding and spacing over 5mm

 Skeletal anterio posterior discrepancies of more than 2mm
 CR and Co discrepancies
 More than 20o rotations
 Open bites
 Extrusions
 Severely tipped teeth (more than 45o)
 Teeth with short clinical crowns
 Arches with multiple missing teeth.
 Though certain aspects are difficult to be treated by invisalign.
Combinations treatment can be under taken. Conventional appliance may be
used along with it whenever needed.

Advantages

1. Ideal esthetics : aligners are relatively invisible apart from a slight sheen
to the teeth is close up.
2. Easy to use for the patient
3. Comfortable

4. Simplicity of care and better oral hygiene

5. Invisalign allows for refinement aligners which can be added at the end
of scheduled treatment procedures.
Disadvantages

1. Limited control of root movement such as root paralleling, gross rotation

correction, tooth uprighting and tooth extrusion.

2. Limited intermaxillary correction : severe skeletal discrepancy cannot be

contemplated with invisalign alone. Surgery or a pre-invisalign
functional phase would be necessary.

3. Lack of operator control : as the aligners are prefabricated there no

chance of altering it.

Thus it is an esthetic technique used to treat simple to moderate alignment

cases in adults.
10:4:2B LINGUAL ORTHODONTICS

Most lingual orthodontics patients are adults and have greater demands and

expectations than do labial orthodontic patients, Esthetics is a crucial factor.

Advantages :

1. Labial enamel surface, is preserved which plays an important esthetic

role. Susceptibility of this enamel surface to permanent decalcification
following chemical insults from etchant materials and to plaque
accumulation are prevented.

2. Lingual appliance allow easy access for routine oral hygiene procedures.

3. Evaluation of individuals tooth positions can be easily assessed as the

labial surface is free of distracting metal (or) plastic brackets

Lingual appliances are effective in the following situations

1. Intrusion of anterior teeth.

 Lingual bracket positioning is dictated by the morphology of lingual

surface, it places the bracket closer to the CRES of the tooth. It allows the
intrusive force rector to be directed through the CRES of the tooth.

 Mandibular anterior dentition occludes with the anterior horizontal plane

of maxillary anterior brakets, BITE PLANE effect results. Net effect is a
LIGHT CONTINUOUS INTRUSIVE FORCE in the anterior and a
passive extrusive force in the posterior segments.

2. Maxillary arch expansion

 More remarkable dentoalveolar expansion are achieved through

lingual mechanics

Reasons may be due to

i. The force developed in of a CENTRIFUGAL TYPE (from inside

towards the outside of the arch)
 ii. Thickness of the brackets which interpose between the tongue and
lingual wall of the teeth contribute to the expansive effect/.

iii. Short interbracket distance may play a significant role

3. Combining mandibular repositioning therapy with orthodontic

movements :

Usually patients with TMD are treated in 2 distinct clinical phases.

Initial phase consists of splint therapy followed by changes in occlusion.

Lingual appliances system allows both arches to be treated

simultanesously. The anterior occlusally oriented inclined plane functions as a
bite plane. Flat acrylic mini supports are added to the 1st and 2nd molars. This
combination can stimulate the action of conventional splint thereby allowing
treatment to progress simultaneously in both arches.

4. Distalisation of maxillary molars

Lingual bracket are placed closer to CROT than the labial bracket. The
molar distalisation through lingual technique produce more bodily movement
of the tooth and less dental tipping.

SEGMENTAL LINGUAL ORTHODONTICS in highly effective in

multi-disciplinary cases to bring about uprighting of molars, forced eruption,
correction of cross bites and teeth rotations.

The inout values varied dramatically between anterior and posterior

segments. To adjust for this with bracket design alone, would make the anterior
bracket very thick. So afirst order bend was placed at the insertion of canine
and premolars and the premolars and molar. This gives a MUSH-ROOM
SHAPE to the archwire.
 Effects of reverse curve mushroom archwire on adult patient on lower
incisor (AO 2001, Vol 72 No.6)

Results revealed that the archwire is capable of intruding the lower

incisors with minimal side effects on posterior teeth. No change occurred in the
mandibular angle.

10:4:3 Space closure (Vs) Prosthetic replacements in Old Extraction sites

 Closing an old extraction site in an adult is problematic because of

resorption and remodeling of alveolar bone that has occurred.

 Resorption resulted in a decrease in the vertical height of the bone.

 Remodeling produced buccolingual narrowing of alveolar process.

Space closure require reshaping of the buccal and lingual cortical plates.
Even then the response of cortical bone is SLOWER.

If a molar is to be moved forward into an old extraction site,

TEMPORARY implants is placed in the ramus to provide necessary anchorage

Otherwise partially closed extraction site may be opened by simple orthodontic

treatment and replace missing tooth with a bridge or an implant

The decision should be taken after consulting with the prosthodontist.

10:5 MODIFIED MECHANOTHERAPY ADULTS

Segmented arch treatment is widely used in adults. It creates a stable

anchor unit consisting of several teeth rigidly connected together to create a
functional equivalent of a single large multi-rooted anchor tooth. This
anchorage is used to provide precisely controlled force against the teeth to be
moved.
 10:5:1 Intrusion is often required in leveling of both arches. Due to lack of growth,
even small extrusions lead to mandibular rotations.

It is achieved through SECTIONAL MECHANICS in adults. In

periodontally involved adults, anchorage is likely to be compromised, so
soldered lingual arches are used for anchorage.

Burstone – type depressing arches (or) Rickets utility arches both

using a long span from stabilized posterior segments to the anterior area where
intrusion is desired.

Forces should be extremely light for anterior intrusion otherwise

posterior will get extruded. Potential problem with intrusion is periodontally
involved adults in the DEEPENING OF PERIODONTAL POCKETS due to
the formation of epithelial cuff.

The crown root ratio is an important factor in long tern prognosis –

shortening the crown improves it.

10:5:2 Space closure: Continous arch wire can be used for space closure in adults
but segmented approach has its own advantages.

1. Direct HG retraction for sliding teeth along the archiwre is not possible
because it is unrealistic to expect an adult to wear it on a full time basis.

2. Two step space closure with frictionless mechanics will reduce the strain on
anchorage and highly recommended.

3. Attempting space clsorue of old extraction sites are problematic. Plan for a
prosthetic replacement.

10:5:3 Finishing and detailing

 Finishing does not differ significantly from adolescence

  Patients with moderate to severe periodontal loss are stabilized with

immediately placed retainers (suck down plastic wafer) as soon as

the finishing archwires are removed.

 Later detailing of occlusal relationship by equilibration takes place.

 In TMD patient undergoing comprehensive treatment, use of

interocclusal splint prevents clenching and grinding from recurring.

11:1 SURGICAL ORTHODONTICS

 Correction of severe skeletal deformity in an adult is achieved by

surgical means. 10 – 20% of adults fall into this category.

 OGS basically involves planned fracturing of the facial skeletal parts

and repositioning them as desired.

 OGS can be performed in both jaws and is all 3 planes of space.

In Anterioposterior plane.

 Mandibular deficiency requires BSSO and mandibular advancement.

 Mandibular excess requires BSSO and mandibular setback.

 Severe dento alveolar procliniation as in bimaxillary protusion cases –

requires anterior segmental osteotomy.

In vertical plane

 Vertical maxiallary excess– Lefort Osteotomy with superior repositioning.

In Transverse plane

 The skeletal problems–required SURGICALLY ASSISTED RAPID

PALATAL EXPANSION

(SARPE) (JCO -1995 – DEC – VOL29)

 The results achieved in the transverse planes are most unstable SARPE
reduces the resistance of closed mid-palatal suture. Adequate retention is
required even after this. Expansion appliance is cemented in place before
surgery and activated 3 to 4, ¼ turns by surgeon after the bony cuts are
made. (1 midline cut and 2 lateral cuts on the maxillary buttres above the
root apices.) Further expansion expansion is achieved daily increments for
about 2 weeks RPE is left in place without activation for 3 months.

11:2 Orthodontist can help in the achievement of improved

Orthognathic surgical results by

 Facilitating movement of surgical segments by means of pre –

surgical orthodontics.

 Facilitating fixation

 Help in establishing stable occlusion through post surgical

orthodontics.

 Giving proper retention

12:1 Retention

 Retention is a critical and challenging aspect of adult orthodontics.

 The general principles of retention hold good for adult patients.

 Retention mechanics should be a part of the original treatment plan.

 In many cases of adult orthodontics, the need for post orthodontic

stabilization will coincide with the need for both restoration of mutilated
dentitions and cross arch stabilization.

 It may include removable retainers, operative procedures and/or fixed

retention.
  When the patient has abnormal lip, tongue or cheek muscle activities, it
is incumbent on the orthodontist to prepare the patient for long-term use
of fixed retainers.

12:2 Periodontal – Surgical Retention Procedures

Certain periodontal-surgical procedures may be necessary to achieve overall

stability of the treated adult patient.

The following are the procedures that may have to be performed.

 Precision
 Gingivectomy and Gingivoplasty.

12:2:1 Precision

 Significantly rotated teeth should be over corrected to an extent of 5-10°

prior to debonding.

 A supracrestal gingival fibrotomy will reduce the risk of relapse.

12:2:2 Gingivectomy and Gingivoplasty:

These procedures arc indicated when significant vertical changes, such

as deep overbite correction have been made orthodontically.

In general, adults require a greater period of retention.

12:3 Types of retainer used

Hawley’s retainer remains the most commonly used retainer.

 Hawley’s with tongue crib

Indicated in managing residual neuro muscular problems, especially

postural tongue problems.

 Bondable Lingual retainers

They are mostly used the lower segments in patients requiring long-term
retention. They are esthetic and usually go unnoticed.
  Invisible retainers

They are retainers that fully cover the clinical crowns and a part of the
gingival tissue. They are made of ultra thin transparent thermo-plastic sheets
using a Biostar machine. They are esthetic and often go unnoticed. These can
be used in adult patients who are especially concerned about esthetics.

 Comprehensive restorative procedures

Crowns and bridges may be required in mutilated cases at the termination of

orthodontic treatment. They are not only prosthetic replacements but also retain
the teeth.

 Splinting And Adult Orthodontics

Mutilated dentitions having periodontal problems with qualitative and

quantitative loss of the attachment apparatus may require some form of
temporary or permanent, partial or full arch splinting.

13:0 NEWER TECHNIQUES:

13:1 CORTICOTOMY ASSISTED ORTHODONTICS – (JCO 2001 MAY- Chung

OH and KO)

CORTICOTOMY has been used in difficult adult cases as an alternative

to conventional orthodontic treatment or Orthognathic surgery. The original
procedure of single tooth osteotomies or corticotomies was introduced by
KOLE in 1959. The primary resistance to tooth movement is encountered in
the cortical layer – corticotomy makes teeth to move faster. Teeth acts as
handles by which the bands of less dense medullary bone are moved block by
block.

Thus orthodontic tooth movement after corticotmy is a process of

moving block of bone rather than moving only individual teeth.
It can be used in treatment of

1. Ankylosed teeth

2. Teeth surrounded by narrow cortical bone

3. Significant arch length discrepancies

4. Transversely constricted maxilla

5. Can be used for posterior intrusion and rapid anterior retraction with

maximum anchorage

6. Can be combined with orthopeadic therapy

Corticotomy surgery initiates and potentiates normal healing process by way of

an accelerated transient burst of hard and soft tissue remodeling by means of a
process called REGIONAL ACCELERATORY PHENOMENON (RAP). It
was described by an Orthopedist Harold frost.

In the alveolar bone adjacent to corticotomy, there was marked increase in

regional bone turn over. Tissue forms 2 – 10 times faster than normal regional
regeneration process.

RAP – decreased the treatment duration especially in adults and

multilated cases where conventional orthodontics may not be possible.

Examples of clinical applications of RAP in Orthodontics

 Simple canine retraction immediately after 1st premolar extraction

 Various corticotomy procedures.

 Distraction osteogenesis procedure

ACCELERATED INVISIALING TREATMENT

(Albert H. Owen) (JCO 2002 June Vol. 35 No.6)

Thomas and William Wilcko, using CT discovered that rapid tooth

movement following corticotomies was due to reduced mineralization of the
alveolar bone housing the involved teeth.

2 years follow up CT showed alveolar bone was adequately

remineralized. Wilckos thought that patient could benefit from alveolar
augmentation in conjunction with a decorticating procedure. (Augmentation
increases the alveolar. crestal height, increases the thickness of the alveolar
bone and prevent dehiscenses.

Technique developed by Wilckos, called WILCKODONTICS System

(or) ACCELERATED OSTEOGENIC ORTHODONTICS (AOO) is similar
to single tooth corticotomy. Here it is extended to all the teeth to be moved
orthodontically.

Procedure: 1. Comprehensive FA.

2. Full thickness falp – decortication of alveolar bone

3. Placement of resorbable bone graft agumentation.

4. Soft tissue flap closed.

Following surgical procedure, orthodontic adjustment is made weekly to

take advantage which RAP, which lasts only for 3 to 4 months. Rate of tooth
movement then returns to normal once the bone has healed.

Owen combined the AOO procedure and Invisalign therapy in his

adult patients. After 10 days of uneventful healing aligners were given. It was
found that 3 to 4 times faster tooth movement occurred.
14.0 CONCLUSION

Biomechanical modifications made to accommodate orthodontic

treatment of adult dentitions are generally minor and adhere to the basic laws
of physics as they apply to orthodontic tooth movement. Some adult
presentations necessitate changes in treatment strategy from what would
otherwise be employed in adolescent patients to achieve similar goals. In other
cases, objectives themselves may need to be modified because of lack of
growth potential, constraints of treatment mandated by the patient or the
presence of multiple missing or compromised teeth. By planning treatment and
mechanotherapy taking into account the individual circumstances that may
affect the patient’s biological response to treatment, realistic goals of
orthodontics can be mutually recognized and agreed on by both the provider
and the patient before therapy is initiated, resulting in an immensely rewardmg
experience.)