Adult orthodontics

Perceptor : dr. hema sharma

Presented by: Umang Tripathi
M.D.S IInd yr

ADULT ORTHDONTICS PERCPTOR- DR. HEMA SHARMA

PRESENTED BY- UMANG TRIPATHI
M.D.S 2ND YR
 ✓CONTENTS:

• Introduction
• Etiology of malocclusion in adults
• Review of literature
• Age- Relates changes in adults
i. Age-related changes in the skeleton
ii. Age –realated changes in the cranofacial skeleton
iii. Changes in the local environment
iv. Soft- tissue profile changes in adults
• Biomechanical considerations
• Tissue reaction
i. Orthopedic effects
ii. Orthodontic effects
iii. Orthodontically induced apical root resorption
• Bonding related problems in adults
• Material related problems
• TMD’s in adult orthodontic patients
• Invisalign , lingual orthodontic technique
• Progressive slenderzing technique
• Post- treatment stability
• Conclusion
ADULT ORTHODONTICS
▪ DEFINITION

• According to Ackerman, Adult orthodontics is defined as ‘The

branch of orthodontics concerned with striking a balance between
achieving optimal proximal & occlusal contact of the teeth,
acceptable dentofacial esthetics, normal function & reasonable
stability’.
 • CLASSIFICATION OF ADULT PATIENTS

• Could have been treated

Young Adult
earlier
• Needs surgery
Adult patient

Old Adult • always has a malocclusion

• Has developed a secondary

malocclusion
REVIEW OF LITERATURE
• Alfred T. Baum(1975): Conventional fixed orthodontic appliances are
unaesthetic for the patients and maybe socially and professionally
embarassing for the patient
• B Ingervall(1978): Orthodontics is the method of choice in adult
patients with cuspal interferences as seen in anterior crossbite or in
patients with arch-width discrepancy, where grinding therapy is
inappropriate.
• J.A Salzmann( 1983): The problems of an adult as an orthoddontic
patient includes the most important factor as motivation in an adult
for the orthodontic treatment. Failure to ascertain the motivation of
the patient who seeks orthodontic therapy is among the prime causes
of deterioration of patient-orthodontist relations and is the underlying
cause of poor treatment results.
A. Davide(1995
• Concluded the risk factors involved for apical root resorption in adult
orthodontic patients are the amount of root movement, presence of
long,narrow and deviated roots increase the risk for root resorption.
In addition use of elastics may be a risk factor for the teeth that
support the elastics.
• E. A BeGole(1998): Effectiveness and duration of orthodontic
treatment in adults and adolescents : there is no difference between
adults and adolescents with respect to treatment effectiveness or
treatment duration
The number of broken appointments and appliance repair explained
46% of variability in treatment duration.
• Melsen B(2003): Changes in clinical crown height as a result of
transverse expansion of maxilla in adults: the results of present study
did not demonstrate any relationship between gingival recession and
transverse expansion in adults. The mean increase in crown height
was 016mm compared with 0.03 mm in control group.
• Moderate expansion of 1-5mm is an acceptable alternative to
extractions to solve space problems in adults.

• Kenealy P et al(2009): orthodontic treatment neither causes nor

prevents TMD. Female sex and TMD in adolescence were the only
predictors of TMD in young adulthood.
• Hassan AH (2010): Assesed the effect of different orthodontic treatment
needs on the oral health-related quality of life of young adults and
concluded that orthodontic treatment need significantly affected mouth
aching,self-consciousness, tension, embarassment, irritability in both
sexes.however, pronounciation and ability to do jobs were not significantly
affected.

• Johal A & Joury E(2016): evaluated the factors that predict orthodontic
treatment uptake among adults attending a specialist practice and
concluded that the age, marital status and oral health related quality of
life(OHRQOL) are the factors that predict the uptake of orthodontic
treatment among adults
• Hutchinson E.F(2016): Importance of teeth in maintaining the
morphology of adult mandible in humans: The state of dentition may
influence the functional ability of the jaw and this in turn may affect
the remodelling of mandibular bone. The overall dimensions of the
edentulous mandibles were significantly smaller than those of
mandibles where teeth were present.
 • AETIOLOGY OF MALOCCLUSION IN
ADULTS:
• Adult malocclusions originate from two sources:
i. Malocclusions that occur during the period of occlusal development,
which may worsen with age
ii. As a result of the ongoing age-related deterioration of the permanent
dentition.
✓ AGE-RELATED CHANGES IN ADULT PATIENTS:
A. AGE – RELATED CHANGES IN THE SKELETON:
• Changes include reduction of the absolute volume of bone as a result of
remodelling & Change in the outer shape of the bones as a result of
modelling.
• Rate of resorption is higher than rate of apposition
• The relative extension of resorption surface is always lower than that of
apposition .
• The temporal surface of resorption and subsequent apposition –
remodeling cycle
Purpose of remodelling
• To allow the bone to serve as a mineral store for normal calcium
homeostasis
• To repair osteocytes
• To allow changes in bone architecture in response to change in
mechanical demands
• The most well known age-related changes occuring in the skeleton is the
general bone loss. The rate and magnitude varies ,but it occurs all over the
skeleton.

• The loss is about 1% a year between 25 and 75 years of age(Parfitt et

al.1983).
Systemic diseases
• Diabetes mellitus

Hyerglycemia glycation and oxidation of proteins and lipids

formation of advanced glycation end products

Alter the phenotypes of macrophages

induce inflammatory tissue destruction followed by

alveolar bone loss
• Hyperparathyroidism / hyperthyroidism – will reduce the resistance
to spontaneous tooth migration , causes bone loss
• Pregnancy
progesterone influence the biosynthesis of
prostaglandins

leads to inflammation and bone loss

 B. AGE-RELATED CHANGES IN THE
CRANIOFACIAL SKELETON:
• Acc to Reich & Dannhauer(1996) there was an increase in prognathism of
both jaws along with an anterior rotation of the mandible leading to
decrease in lower facial height.

• Driscoll-Gilliland et al.(2001) age –related changes were smaller in cases

with Angle’s Class I relationship than in cases of Class II or Class III dental
relationship.

• Fig 3.22

• Dysfunction can result in excessive wear and abrasion of the dentition

contributes to reduction in anterior face height and deepening of bite.
C. AGE –RELATED CHANGES IN THE LOCAL
ENVIRONMENT

decrease in periodontal support .

apical displacement of marginal bone level due to the severity of periodontal
disease.(Beck 1996)
• widening of periodontal ligament.
• Bruxism & other parafunction habits result in alteration of tooth
 D. SOFT-TISSUE PROFILE CHANGES WITH AGE

• Soft tissue thickness, measured at the nose, upper lip, lower lip and chin, as
well as the length of the upper and lower lip, all increased by varying
amounts over time.

• Females acquired more growth as a percentage of their adult size (at age
18) than males in all variables except the angle of inclination of the
skeletal chin which increased more in males.

(Nanda R.S, Kapila S .Growth changes in the soft tissue facial

profile.Angle Orthod:1990:60(3)13-16)
 ✓ CONSEQUENCES OF DETERIORATION OF THE DENTITION:

• With a reduced periodontium the center of resistance of tooth or group of

teeth is displaced apically for which reason the functional forces acting
on the crowns of the teeth may generate moment leading to migration of
teeth.
• The migration of anterior teeth will lead to flaring, spacing and
deepening of bite.
• Deepening of bite leads to increase in crowding of the lower incisors.
 Musich’s
study 1986

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
✓ Factor in selection of treatment plan.

•Existing oral pathology- recurrent decay, restorative failure, periodontal bone

loss, retained root
•Skeletal relationship
•Therapeutical approaches- tooth movement, orthopedics , orthognathic
surgery, restorative dentistry
• Extraction (vs) Non Extraction : Atypical extractions are usually undertaken in adults Classical
4 premolars extraction to resolve crowding rarely done.
(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.
• 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 -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.
✓ 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.
✓ SELECTION OF MECHANICS
The appliance should produce a controlled and constant force system in all
three planes.
▪ 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.

✓ 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.

Incorrect bracket positioning

Excessive force
Straight wire leveling
Anterior root correction
Loss of vertical control is also possible with the use of removable
appliances such as

Bite block
Active springs
Chin cap
Occipital head gears
Magnetic appliances
Myofunctional appliance

Considerable care should be exercised in the use of the above in order to

avoid unnecessary extrusion of teeth.
✓TISSUE REACTION
Orthopaedic Effects
• Herbst appliance
▪ TISSUE • Forward posturing
• Palatal expansion
REACTION

Orthodontic effects
• Effects upon orthodontic loading
• Orthodontically induced apical
root resorption
 ✓ORTHOPAEDIC EFFECTS
▪ Herbst appliance: Woodside1987
• Condylar changes and modelling of the glenoid fossa following herbst
treatment have been demonstrated in both young and adult patients.
• Minor skeletal discrepancies in young adults can be corrected with herbst
appliance treatment.
• Evidence of modelling of the TMJ ,the condyles as well as articular fossa
in young adults was confirmed by magnetic resonance and 3-D x rays.
▪ Palatal Expansion:
• The dental arches can be expanded by opening the mid-palatal suture
or modelling of the alveolar processes.
• Rapid palatal expansion is performed with a cemented appliance and
the skeletal contribution to the treatment result depends on the degree
of opening of the suture.
• Once tight interdigitation is established rapid palatal expansion is
achieved by fracture within or adjacent to the suture,Melsen 1972
• As, a result SARME was introduced.
• Although the risk of buccal dehiscence is reduced by SARME, the
potential risk of periodontal damage between upper central incisors
should be taken into consideration.Cureton and Cuenin 1999
✓ORTHODONTIC EFFECTS IN ADULT
PATIENTS:
▪ Tissue reaction to orthodontic loading:
• The tissues that are affected by mechanical loading comprise: the root
surface, PDL, and the alveolar bone.
• Each tissue has its own cellular and extracellular elements and
mechanical properties and behaviour is controlled by both local and
systemic factors.(Verna et al.1999).
• When treating a adult patient special attention should be paid to
physiological age-related changes as well as changes related to
metabolic diseases and chronic medications both being more frequent
in adult patients.(Verna et al.2006)
 ✓THE CLASSICAL PRESSURE-TENSION MODEL:
Orthodontic force application

Pressure in certain areas Tension in certain areas

PDL is streched
PDL is compressed

Reduced vascularity Initially vascularity is increased

Decreased vascularity Decreased vascularity due to

overstreching of PDL

Induces chemical changes and inflamatory type of

 ✓ ORTHODONTICALLY INDUCED APICAL
ROOT RESORPTION

• External apical resorption is a known phenomenon associated with

orthodontic treatment(Segal et al,2004).
• Among the patient related factors, possible role of genetics, immune
system, and medical history has been suggested.
• In a meta analysis, Segal et al.(2004) found that mean apical root
resorption was strongly correlated with total apical displacement and
treatment duration, thus indicating that the total distance the apex has
to be moved and the treatment duration should be considered risk
factors.
• The type of appliance used for a treatment also influences the risk of root
resorption. Fixed appliances are more detrimental than removable
appliances.
• The level of forces applied also determine the amount of root resorption.
Continuous forces were found to be more detrimental than intermittent
force and it was found that superelastic wires resulted in more resorption
than stainless steel.(Acar et al,1999)
• In conclusion, once a careful examination of the patient is performed, the
risk of root resorption in the adult patient does not represent a limiting
factor for orthodontic treatment.
Treatment planning consideration- uprighting
molars
If the 3rd molar is present , should both the second and the third molar be
uprighted?
How should the teeth be uprighted ?
Distal crown movement, mesial root movement
• Is extrusion of a tipped molar permissible?
Appliance for molar uprighting
 ✓BONDING PROBLEMS RELATED TO
ADULT REHABILITATED DENTITIONS:
• With the advent of the acid etching technique and different adhesives ,orthodontic
bonding procedures began to change(Buonocore 1955).

i. Metal Brackets:
There advantage include relatively low levels of friction between archwire and the bracket
slot, greater resistance to fracture, easier to debond ,low risk of damage to enamel surface
during debonding.
AESTHETIC BRACKETS:

• In order to improve the aesthetic appearance of the appliance ,three

possibilities have been attempted:
Altering the appearance or reducing the size of the stainless steel
brackets appliance.
• Positioning the appliance on the lingual surface of the teeth.
• Change the material from which brackets are made.

ii. Ceramic Brackets

iii. Self-ligating Brackets
 ✓BASIC BONDING
PROCEDURE

i. Cleaning
ii. Enamel conditioning
iii.Sealing
iv. Bonding
v. Light curing
✓BONDING TO CROWNS AND RESTORATIONS:
• Today’s orthodontic practice includes a larger proportion of adult
patients and it is possible that crowns, bridges( porcelain, gold, non-
precious metals) or restorations may require to be bonded.
• Bonding the bracket to the restoration provides a satisfactory
alternative and orthodontist should use the methods that permit the
attachment of brackets to porcelain or non-precious metals.
• Microetching( for about 3 seconds with 100um aluminium oxide
powder) is essential for bonding to large amalgam, gold or non-
precious restorations.
• The abrasive particles create a retentive surface to which bonding
with highly filled composite is greatly enhanced.
• For bonding to porcelain surfaces, the most commonly used etchant
is 9.6% hydrofluoric acid in gel form for 2-4 minutes. Placement of
rubber dam and a barrier gel on gingiva is recommended as the
material is severe tissue irritant .
• Laser irradiation (2W for 20 sec) might be an alternative
conditioning method for pre-treating ceramic surfaces,it provides a
porous surface texture without cracks and increased bond strength
can be achieved.
✓MATERIAL- RELATED ADVERSE
REACTIONS IN ORTHODONTICS:

• 18% of the adult patients reported to have ulcerations often or

always and 9% classified their intra-oral ulcerations as ’bad
wounds’ .
• Material-related adverse reactions (toxic/allergic) to orthodontic
appliances can thus,unless particularly severe-be misdiagnosed or
go undetected.
✓FIXED APPLIANCE: NICKEL ALLERGY
HYPERSENSITIVITY (NAH)
• Nickel has been found to be the most prevalent chemical contact
allergen among the general population of the industralized world.
• The exposure can be through skin, mucous membrane, diet
,inhalation, or impalnts.(Hostynek1999).
• NICKEL APPLICATIONS IN ORTHODONTICS:
• In orthodontics nickel is one of the most commonly used metals,
being a component of,for example stainless steel and superelastic
and shape-memory wires.
 • RELEASE OF NICKEL FROM DENTAL ALLLOYS:

• Leakage of metal ions from orthodontic appliances in the saliva is

preceded by disintegration of the alloy either by corrosion or
mechanical abrasion.
• Microscopy studies of orthodontic appliances have shown that after
10 months of intraoral wear,corrosion is present on all intraoral metal
appliances.
• Laboratory studies clearly demonstrate that physical factors such as
surface structure, Ph and oxygen state influence the corrosivness of
dental alloy.
✓ CLINICAL ASPECTS OF HYPERSENSITIVITY REACTIONS TO
NICKEL & CHROMIUM IN DENTAL ALLOY:

• INTRAORAL REACTIONS:
• Slight erythema to large erythematous macular lesions or ulcerations
• Subjective symptoms ranging from mild to very painfull burning
sensations compromising normal oral functions.
• In rare cases present as hygiene- resistant severe gingivitis.
• In sum, reports on verified intra-oral adverse reactions to nickel are
very rare.
 • EXTRAORAL REACTIONS:
• Soreness , blisters and ulcerations of the contacting skin area were
often seen.
• Eczematous lesions have been noted in remote locations. Eg: face,
fingers, arms, trunk,and feet.
• Angular chelitis and fissures of the lips or severe perioral and facial
eczema have been described in relation to NAH.
✓NICKEL-FREE ALTERNATIVES:
• It has been reported that even some patients with a strong positive
skin tests reaction to nickel may well tolerate the intraoral placement
of nickel-containing alloys.
• In few cases, it maybe necessary to completely avoid nickel-
containing alloys.
• Nickel free wires of TMA or pure titanium or gold plated wires as
well as plastic/resin coated NiTi archwires with less corrosion
potential may be considered.
• Brackets are available in different ceramic forms as well as
polycarbonate brackets.
• The succesful use of titanium frameworfor rapid palatal expansion
devices and activators nickel –sensitive patients have been described.
✓ PATIENTS WITH PERIODONTAL
PROBLEMS:
• The risk of gingival recession, attachment loss, and probing
depth>4mm increases significantly with age.
• Shei et al(1959) found that with increasing age ,oral hygiene had a
significantly greater impact on the marginal bone level.
 ✓MALOCCLUSION AND PERIODONTAL
DISEASE
• A malocclusion has no direct influence on periodontal
breakdown(Shaw et al,1980).
• However, it has been indicated that untreated occlusal discrepancies
are associated with more rapid progression of periodontal disease
and that occlusal treatment reduces the progression.
• The only malocclusion in which there is a direct co-relation between
malocclusion and attachment loss is deep bite,impinging either
lingually to the upper incisor’s or/and labially to the lower incisors.
FACTORS AFFECTING PERIODONTAL DISEASE

GENERAL FACTORS LOCAL FACTORS

• Gender • Oral Hygiene
• Genetic Factors • Dental Caries
• Social Status • Crowding
• General health • Occlusion
• Smoking
✓ Malocclusions in adult patients that may be considered as indications
for orthodontic treatment are:

• INTRA-ARCH PROBLEMS: gingival topography, poor crown to

root ratio, uneven bone level, distema, crowding and tipping.

• INTER-ARCH PROBLEMS: Sagittally , increased overjet, vertically,

deep bite or open bite.

• SIGNS OF MALFUNCTION: that may aggravate a malocclusion

include flaring of incisor’s, posterior and lateral forced bites.
 ✓ SEQUENCE OF TREATMENT IN PERIODONTALLY
INVOLVED PATIENTS:
• Motivation and instruction followed by scaling and removal of
factors such as overhanging fillings interferring with good oral
hygiene.
• ESSENTIAL PROCEDURES:
i. Oral prophylaxis
ii. Restorative dentistry
iii. Endodontics
iv. Extractions
v. Temporary restorations
 ✓ TIMING OF ORTHO-PERIO TREATMENT

• (Mathews and Kokich,1997)

✓ PROCEDURE PERFORMED PRIOR TO ORTHODONTIC TREATMENT
• Oral hygiene motivation
• Prophylaxis or therapy to control inflamation
• Surgery to eliminate deep pockets
• Elimination of gingival clefts.

✓ PROCEDURES PERFORMED DURING ORTHODONTIC TREATMENT:

• Prophylaxis to control elimination
• Surgical exposure of impacted teeth
• Fibrotomy and curettage

✓ PROCEDURES PERFORMED DURING/OR POST ORTHODONTIC

TREATMENT:
• Prophylaxis
• Clinical crown lengthening
• Gingivoplasy
• Root coverage
✓PATIENTS WITH TEMPOROMANDIBULAR
JOINT(TMJ) PROBLEMS
• The fact that patients are generally registered in maximum
intercuspation,which does not necessarily represent a mandibular position
that is in harmony with the functional occlusion may be a confounding
factor when assesing the correlation between occlusion and TMD.(Tallgren
et al.1979).
• As,the functional deviation may be related to the deterioration of the
dentition, adult patients with TMD should be asked to explain their version
of the development of the problem. This also applies to all aspects of oral
function such as parafunctional habits and bruxism.
• Misarticulation is more frequent in patients with certain types of
malocclusion such as excessive overjet,lateral crossbite and anterior open
bite.
• Analysis of jaw movements and palpation of muscles should precede the
analysis of occlusion. The muscles included in the examination are
temporal,masseter,digastric,and the pterygoid muscles. Jaw movement can
be evaluated using clinically or registered by means of jaw tracking
equipment.
• Clicking during opening may reflect an anterior disc displacement and the
click during closing occurs when the condyle slips off the disc again.
• A limitation in the protrusion may be a sign of permanently forward
displace disc.
ORTHODONTIC TREATMENT,GENETIC
FACTORS,RISK OF TMD
• Temporomandibular disorders(TMD) are a set of painful musculoskeletal
disorder of multifactorial etiology.

• “BIOPSYCHOSOCIAL MODEL”
I. Anatomical variation in the masticatory system
II. Psychosocial characteristics
III. Pain in other body region
IV. Demographics.

• TMD are best classified as complex, multifactorial disorder that are

induced and influenced by both diverse environmental factors(eg:
trauma,lifestyle,stress) and a complex array of multiple genetic
polymorphism.

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• In 2003,Zubietta and co-workers reported that a common variant of the gene
that codes for the enzyme catechol-O-methyltransferase(COMT) was associated
in humans with diminished activity of pain regulatory mechanism in CNS.
• COMT is a multisubstrate enzyme catalyzing methylation of
catecholamines,including neurotransmitters,norepinephrine and dopamine.
• Thus,TMD illustrate an example of gene-environment
interaction,demonstrating that risk of TMD associated with orthodontic
treatment (environmental influence) was dependent on a gene encoding COMT.
• Fixed orthodontic treatment could play a causal role in TMD etiology among
people who are genetically predisposed to pain. Periodic adjustments made to
fixed orthodontic appliances apply forces to teeth that can cause transient
discomfort or pain.

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 ✓MANAGEMENT:

• PHYSICAL • PHARMACOLOGICAL • PSYCOLOGICAL

• Strech therapy • Topical NSAIDS • Information
• Jaw exersices • NSAIDs • Counselling
• Massage • Acetaminophen • Education
• Ultrasound • Muscle relaxants • Stress
• Laser • TCA management
• Heat/ Cold • Opoids • Relaxation
• TENS • Psycotherapy
• Oral Splints
 ✓PHYSICAL MANAGEMENT
• Oral splints have been extensively used for management or even for curing
TMD pain. This was to a large extent based on the assumption related to the
importance of structural deviation in the occlusion and problem with
alignment of the condyle-disk complex in the temporal fossa.
• Recent meta-analysis concluded that oral splints appear to be of some
benefit in the treatment of TMD pain but that more and well –aligned
controlled studies are needed( Al- Ani et al 2004).
 ✓INVISALIGN
• From 1971 onwards, several publications
on clear appliances appeared .
• These appliances were mainly used as
retainers, as active plates they lacked
precision and required too much work to
move teeth into the desired
position(Sheridan et al1993)
• With the advent of CAD/CAM , Invisalign
system introduced in 1997 with the idea of
moving teeth with clear plastic appliances
took a new turn.
✓ PRE-TREATMENT CONSIDERATIONS?

• Photographs(extra-oral/ intra-oral)
• Radiographs( panoramic or periapical, optional: lateral cephalogram)
• Vinyl polysiloxane impressions plus bite registration
• Completed treatment forms

• One of the biggest difference is that the Invisalign treatment has to be

planned from the first to the last movements in all possible details.in contrast
to most other treatment modalities,the sequence, the direction and the
amount of any tooth movement can only be changed by a mid-course
correction which implies additional cost and delay of treatment.
• The visualisation of anticipated outcome is helpful.
 ✓ INDICATIONS:
• The chief complaint of patients seeking Invisalign treatment includes:
• Crowding or spacing
• Supra or infra erupted teeth

• Spacing or flaring can be resolved without problems.

• Intrusion of supra erupted teeth is not a problem as long as aligners are not
dislodged occlusally from the anchor teeth.

✓ MATERIAL?
• Aligners are made of 0.75mm thick foils composed of polyurethane with
methylene diphenyl diisocynate and 1.6hexanediol. This material has
sufficient viscoelasticity to allow some elastic deformation.
✓ CONSEQUENCES OF POOR OR GOOD
ALIGNER FIT?
• The presence of saliva bubbles between the tooth and the inner aligner
surface indicates an inadequate aligner fit.
• Other indications: void spaces occlusally/incisally, aligner concavities.
• In case of poor aligner fit,cause must be detected. Most likely it would be
lack of patient co-operation or lack of tooth movement.
• Egs of such movements are:
• Rotations of the cylindrical tooth
• Extrusions
• Translations over larger distances
• Pure root movements.
✓LINGUAL ORTHODONTICS
 ✓ PROGRESSIVE SLENDERIZING
TECHNIQUE
• Slenderizing refers to the mechanical reduction of the dental interproximal
enamel layer, which is carried out in order to shape the contact area and
decrease the mesio-distal diameter of the teeth to facilitate alignment.
• Ballard (1944) described this technique for the first time .Other authors have
since contributed to its development( Sheridan 1997)
• The ratio between enamel loss and space gain is 1:1,that is for each
milimeter of slenderizing, 1mm of space is gained.
OBJECTIVES:
• Correction of dentoalveolar discrepancy.
• Adjustment of interdental contact point to papilla shape
• Treatment of tooth size discrepancy between upper and lower
teeth.(Bolton’s discrepancy)
INDICATIONS:
• Crowding
• Bolton’s discrepancy
• Triangular and barrel tooth shapes
• Macrodontia
• Over-extended crowns and fillings
• Adult patient(narrow pulp chamber)
HOW MUCH ENAMEL CAN BE STRIPPED?

• According to the enamel thickness studies of Hudson(1956), Gillings and

Buonocore(1961) and shillinburg & Grace(1973):
• There is no relation between tooth size and enamel thickness ,thus
macrodontic teeth should not be stripped more than microdontic teeth.
• There is no relation between tooth shape and thickness of the enamel.
• The the enamel thickness is slightly thicker in the contact points and the
thickness gradually decreases towards CEJ
• It is important to know how much of enamel can be grinded so as to
decide between extraction and non-extraction.
• Berrer(1975) claims that lower incisor can be stripped to gain
4mm,which is 0.5mm of slenderizing per proximal surface of lower
incisor.
• Hudson (1956) suggested 0.20mm for central incisor,0.25 for lateral and
0.30 for lower canines.
• Sheridan suggested 0.8mm slenderizing per surface of posterior teeth
0.25mm in anterior teeth gaining in total 8.9mm.
POST-TREATMENT STABILITY

• According to Zachrisson the key to succesful stability is paying more

attention to finishing.
• Post-treatment changes can be divided into two categories:
i. Tendency of teeth to move back to its original position immediately after
treatment.
ii. Continous development related to growth in young patients and ageing
process in adults.
• In a cochrane systematic review paper, Littlewood et al.(2006) made an
attempt to evaluate the effectiveness of different retention strategies and
concluded that there was insufficient research data on which clinicians
could base their retention strategy.
BIOLOGICAL MAINTENANCE

• The maintenance of the treatment result comprise two aspects:

i. Biological maintenance
ii. Mechanical maintenance

• Mechanical retention usually involves orthodontic retention

• Biological maintenance includes the dental & periodontal health.
✓ FIBROTOMY:
• Mechanical retention is genrallly used following orthodontic treatment
with the purpose of maintaining the positions of theteeth and
occlusion.
• Following derotation of a rotated tooth, in addition to mechanical
retention, a circumferential supracrestal fibrotomy(CSF) has been
recommended to prevent relapse.
• In a systematic review ,Littlewood et al(2006) concluded a significant
stability in mandibular and maxillary anterior segment when CSF was
performedin conjuction with hawley retainer, compared with hawley
retainer alone.
MECHANICAL MAINTENANCE- RETENTION
• Mechanical maintenance comprises fixed and removable retainers.
• Fixed retainers include bonded flexible wires, bonded rigid wires, threaded
composite retainers.
• Removable retainers include thermoplastic clear retainers, fully balanced
acrylic splint, plate and wire retainers.
• Intermaxillary retention – soft & hard.
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 rewarding experience