Adult

orthodontics
DR. TONY PIOUS

Download by Yasser Magrami

Adult orthodontics

 Contents
 Introduction
 History
 Comparison b/w adolescents & adults
 Objectives
 Classifications
 Adjunctive orthodontics
 Comprehensive orthodontics
 Retention
Basic biological concepts associated with
adult orthodontics.

 Periodontal ligament.
 Bone
 Teeth .
Periodontal ligament

 Fibroblast
 Blood borne origin
 Pleuropotential cell
 Collagen & proteoglycans
 Collagen turnover in PDL- 2.5-6.5 day
 Aging-imbalance.
 Proteoglycans-withstand the forces.
 Retains water-changes with age.
 PGs-prostaglandins & leukokines-resorption
of bone.
 Capillary bed.
 Number of branches found in the vascular
bed –decreases
 Amount of blood flow to tissues-decreases
 Nerve tissue
 Changes in number of neuro receptor
 Age related decrease in sensory
responsiveness.
 Bone
 Mechanical properties changes
 Macroscopically- trabecular bone volume
decreases.
 Osteoblastic activity-reduces
 Imbalance b/w resorption & replacement
 Sinus size-increases
 Bone density decreases &porosity increases
with age.
 Teeth
 More root exposure
 Short crown root ratio
 CR shift –apically
 Diameter of pupal canal reduces
 Decreased vascularity&innervation -pulp
recovery.
 CEJ–alveolar crest distance

Significant reduction in crest

height with age
0.017mm/year
Prevalence of PDL pockets
History

 Kingsley(1880)-early awareness of the

orthodontic potential for the adult pts.
 Published statements-Negative.
 MacDowell(1901)- Impossible age.
 Lischer(1912)-optimal age for treatment.
 Golden age of treatment
 Case (1921)-value of adult 0rthodontic
therapy
History
History

 Lindegaard et al (1971)-3 factors.

 Reidel & Dougherty (1976) “orthodontics is total
discipline and it makes no difference whether the
patient is young or old”
Adult practice today
Scope of procedures

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

Why do adults seek
orthodontic Rx
 Did not want orthodontic treatment as children
 Did not know about orthodontics as children
 Parents couldn't afford orthodontic treatment as children.
 No orthodontist located in their vicinity when younger
 Incomplete orthodontic treatment as children, non cooperative
 Had orthodontic treatment as children but relapsed.
 More conscious of appearance with age
 Malpositioned teeth contributing to PDL disease
 Spaces b/w anterior teeth enlarging ,new spaces opening up.
 comparison

factors adolescents adults

Dental caries More susceptible Recurrent decay
restorative failures, root
decay& pulpal pathosis
PDL disease Resistance to bone loss Susceptible to bone loss
Susceptible to gingival
inflammation
TMJ high Symptoms with
adaptability dysfunction

Occlusal Infrequent Increased enamel wear

awareness with adverse change in
supporting tissue.
Factors Adolescents adults
Growth factors Growth-orthopedic No growth
Stable correction . Minimal skeletal adaptability.
Surgical option

Dentofacial Reasonable concern Concern occasionally

esthetics disproportionate to degree of
existing problem
factors adolescents adults
Rate of tooth movement rapid slower

orthopedics 50% Small percentage

Orthognathic surgery 1-5% 10-20%

Restorative dentistry Smaller percentage frequently

Combination treatment uncommon 80%

factors adolescents adults

Anchorage Head gear implants

potential

Missing Space closure Restorative

teeth without prosthesis
factors adolescents adults
Extraction 4 PMs Less
controversy frequently

Strategic uncommon common

extraction
Adult orthodontic treatment
objectives
 Dentofacial esthetics
 Stomatognathic function
 Stability
 Normal occlusion
Additional AOT objectives

 Parallelism of abutment teeth

 Most favorable distribution of teeth
 Redistribution of occlusal & incisal forces
 Adequate embrasure space & proper tooth
position
 Adequate occlusal landmark relationships
 Better lip competency & support
 Improved crown/root ratio
 Improved self-maintenance of periodontal
health.
 Parallelism of abutment
teeth
 Abutment teeth-parallel
 Permit-easy insertion of
replacements
 Allow –restorations
 Better prognosis
 Better PDL response.
Most favorable distribution
of teeth
 Distributed evenly-replacements
 To establish normal occlusion.
Redistribution of occlusal &
incisal forces.
 Cases with significant bone loss(60-70%)
 To maintain occlusal vertical dimension
Adequate embrasure space
&proper root position.
 Better PDL health
 Helps in interproximal cleaning
 Placement of restorative material.
Adequate occlusal landmark
relationships
 Transverse dimension – difficult to correct
 Skeletal crossbite cases-only anterior
crossbite can be corrected.
Better lip competency &
support
 In case of anterior restoration-retractions

 Inadequate support-change in
anteroposterior &vertical position of upper
lip & increase in wrinkling.
Improved crown/root ration

 In case of bone loss

 Reduced crown/root ratio
 Can be corrected by reducing the clinical crown.
 Better self maintenance of
PDL health
Improved self maintainace of PDL
health occurs with proper tooth position

Teeth should be positioned properly

over basal bone
Esthetic & functional
improvement.

Should provide acceptable dentofacial esthetics

Improved muscle function

Normal speech & masticatory function

Classification- Graber,Vanarsdall

 Physiologic occlusion
 Psychological disorientation
 Adjunctive orthodontics
 Corrective orthodontics
 Orthognathic surgery
 Periodontally susceptible
 TMJ-dysfunction
 Enamel wear beyond that expected for
chronologic age
 Dental mutilation
 Combination
 Borderline surgical case
Treatment for adults

 proffit -
 Younger adults(20-35yrs)
 Older group(40-50yrs)
 Adjunctive orthodontic treatment
 Comprehensive orthodontic treatment
Adjunctive orthodontic
treatment
 Definition :tooth movement carried out to facilitate
other dental procedures necessary to control disease
& restore function.
 Uprighting of posterior teeth
 Forced eruption
 Alignment of anterior teeth
 Crossbite correction
Goals of AOT

 Facilitate restorative treatment

 Improve PDL health
 Favorable crown : root
 “Goal of AOT is to provide a physiologic occlusion &
facilitate other dental treatment & has little to do with
Angle’s concept of an ideal tooth relationships.”
Principles of AOT

 Diagnostic & treatment planning.

 Collecting an adequate data base.
 Developing a problem list.
 Diagnostic records
 OPG.
 Full mouth IOPAs.
 Lateral ceph
 photographs.
 Dental casts.
Biomechanical
considerations
 Characteristics of the orthodontic appliance.
 Anchorage control
 22-slot edgewise appliance with twin brackets
 Removable/Fixed appliance.
 Bracket placement-ideal-tooth to be moved.
Removable appliances
Bracket placement
Effects of reduced
periodontal support
 Bone support
 Bone loss-PDL area
decreases
 CR-shifts more appically
Timing & sequence of
treatment
Active disease

Disease control Re-evaluate

Establish occlusion stabilize

Definitive restorative Rx

maintenance
Adjunctive orthodontic Rx
procedure.
 Uprighting of posterior teeth
 Uprighting a single molar
 Uprighting with minimal extrusion
 Final positioning of molar & PM
 Uprighting two molars in the same quadrant
 Retention
 Forced eruption
 Alignment of anterior teeth
 Crossbite correction
Uprighting posterior teeth

 Treatment planning consideration

 Loss of posterior teeth
 If the 3rd molar is present?
 Uprighting by distal crown/ mesial root movement?
 Slight extrusion of tipped molar is permissible?
Loss of posterior teeth
Distal crown/ mesial root
movement
Crown: root length
Appliances for molar
uprighting
 Partial fixed appliance
 Active & reactive unit
 bonding>banding
Uprighting a single molar

 Distal crown tipping with

occlusal antagonist
 Flexible
rectangular wire-
17x25 NiTi
 Anchorage unit-19x25 steel
 17x25 beta-Ti
Uprighting with minimal
extrusion
 Uprighting with no occlusal
antagonist
 “T-Loop”-17x25 steel/
19x25 beta Ti
Uprighting of lower molars
Birte melsen,JCO 1996
case1
56yrs/M
Missing lower 1st molar
case1
 Case 2
42/F
Missing 46
Case 2
Distal jet
A simple technique for molar uprighting –
E Capelluto,JCO 1996

“MUST”
 Final positioning of molar &
PMs

Compressed coil springs

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

 Fixed bridge-within 6 weeks

 Short time-19x25 steel /21x25 beta Ti
 >few weeks-intermediate splinting
Forced eruption

 Indications
 Defects in cervical 3rd of the root
 Horizontal / vertical #
 Internal/external resorption
 Decay
 PDL – disease
 To obtain good access for endodontic and restorative
process
Forced eruption

 Treatment planning
 Good periapical radiographs
 Periodontal support
 Root morphology and position
 Endodontic therapy should be completed
Orthodontic technique

 Anchor teeth –rigid

 Flexible –tooth to be extruded
 With / without the use of orthodontic bracket
Alignment of anterior teeth

 Indications
 To improve access & permit placement of restoration
 To permit placement of crowns & pontics
 To reposition the closely approximated roots
 To place implants.
Treatment planning

 Interproximal stripping
 Diagnostic setup-very helpful
Orthodontic technique

 Alignment of crowded, rotated & displaced incisors

 Edgewise brackets-canine –canine
 Initial wire-light & flexible
 016 Niti
 Crown reduction
Positionining tooth for single
tooth implants
 Missing teeth-implants
 Space needed for implant, esthetics& the
occlusion

 Space needed for implants

 Narrowest – 4mm
 1mm –in b/w implants

 Contralareral & adjacent teeth –size of the

implant
Timing of implant placement

 Implants to support restorations should not

be placed until all vertical growth has been
completed.

 Boys-20yrs

 Girls-15-17yrs.

 For adults-soon after –minimizes bone loss.

 Case reports
Kenji W Higuchi

 48yrs/F
 Class II div 1
 Deep bite
 Missing12,47,46,45,35,36,37
Treatment plan: surgical correction
6 implants on 37,26,25,47,46,45
Healing period -4 months
Implant-supported FPD
Uprighting of 3rd molar + alignment
Same implants-abutments.
Case 1
case1
 Case 2

 53yrs/M
 Class III
 Ant &post crossbites
 spacing

Treatment plan: 2 implants,35&36

Healing period -4 months
Implant-supported FPD
Case 3

 64yrs/F
 Class I
 Impacted canine
 Missing teeth

Treatment plan:
Extrusion of impacted canine
1 implant -16
Healing period-6 months
Implant supported FPD-anchorage
Same implant-abutment
Case 3
Anterior diastema closure

 Loss of posterior teeth, abnormally small

teeth, loss of bone support-drifting/spacing.

 Partial closure-composite build ups-

permanent retention

 Smaller diastema-removable appliance

 016 niti,018 steel with coil springs.

Diastema closure
 Crossbite correction

Crossbite-functional problem
Ant crossbite -esthetic
Tipped teeth-removable apl
Elastics
Establishing a good overbite
relationship is the key to maintaining
crossbite correction.
Comprehensive
orthodontic
treatment.
ADULT ORTHODONTICS.
Comprehensive orthodontic
treatment-Adults
 Special considerations for adults
 Different motivations for seeking orthodontic treatment & different
psychological differences to it.
 Heightened susceptibility to periodontal disease.
 Lack of growth.
Comprehensive treatment

 Motivation for adult treatment

 Psychological
 PDL & restorative needs as motivating factor
 TMJ dysfunction as motivating factor
 Periodontal aspects of adult treatment
 Special aspects of orthodontic appliance therapy.
Psychological considerations

 High motivation -self referred for

esthetic reasons
 Low motivation -dentist referred for
adjunctive correction
 Turned off -unaesthetic appliances, fear
of pain, extended treatment time,
personal inconvenience & cost
 Adults are less tolerant of discomfort &
more likely to complain about difficulties
in speech, eating & tissue adaptation.
Periodontal diagnosis

 Awareness of risk factors

 General factors
 Family history
 General health status
 Nutritional status
 Current stress factors
 Local factors
Plaque indices
Crown root ratio
Habits
Restorative status
Periodontal aspects of adult
treatment
 Periodontal considerations are increasingly
important as patient become older
,regardless of whether periodontal problems
were a motivating factor.

 Minimal PDL involvement

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

 Disease control
 Preliminary PDL-treatment
 Scaling,curettage,flap surgery etc
 Endodontic treatment
 Cast restorations should be delayed

 Period of observations

 PDL-maintenance
 Full arch bonding> banding
 Steel ligature > elastomeric rings
 maintenance = 2-4 months
 Hygiene maintenance- electric tooth brushes,
mouthwashes
Severe PDL- involvement

 Disease control
 Scaling,curettage,flep surgery, osseous
surgery
 Endodontic therapy

 Period of observation

 PDL- maintenance
 More frequent intervals,4-6 weeks
 Very light forces should be used.
Temperomandibular
dysfunction
 Internal joint pathology
 Muscle origin
Temperomandibular
dysfunction
•Prevalence of TMD problems-
Schiffman et al (1998)

Muscle disorder 23%

Joint disorder 19%
Combination 27%  Diagnostic records
Normal 31%  Full TMJ series x-rays
 Opg
 Muscle examination
 Stress evaluation
Intrusion

 light & continuous force

 With continuous arch wires
 Segmental arch wires

 In case of PDL involved-anchorage

compromised.

 Intrusion should never be attempted without

excellent control of inflammation.
Intrusion of incisors in adult patients with
marginal bone loss
Birte Melsen, AmJ Orthod 1989
 Common problems-adults-PDL disease
 Migration, spacing, elongation of incisors
 Progressive bone loss-CR shifts appically
 Aim :to intrude elongated teeth with varying degrees of PDL
damage & thus evaluating the influence of treatment on pdl
status.
 Material & method
 30 sample
 5M/25F
 AGE:22-60yrs
 PDL preparation
 Orthodontic appliance-4 types
 J hook for intrusion
 Ricketts utility arch-016x016 steel
 Intrusion bend into loops of full arch-017x025 steel
 Burstone’s continuous intrusion arch
 Analysis applied
 Study casts
 Latral ceph
 Opg
 IOPA-special film holder

Piece of 021x028 elgiloy

 Results
 True intrusion=0-3.5mm
 Clinical crown length reduction =0.5-2mm
 Root resorption =1-3mm
 Total amount of alveolar support=unaltered/increased
 Utility & Burstone’s base arch -largest intrusion
&largest gain in bony support.
Upper molar intrusion
Birte melsen JCO 1996
 Case 1
 38yrs/F
 Missing teeth
 Chewing difficulty
4.5mm-intrusion
7.5mm- mesial movement
2mm- reduction of clinical crown ht.
Case 2

40yrs/F
Missing 15,16,25,27,28,35,37,38,44,45,47,48
Chewing difficulty.
3mm-intrusion
8mm-mesial movement of molar.
Lower-implants
Interproximal stripping for the treatment
of adult crowding-Julia F Harfin JCO 2001
Nov
 Crowding
 Mild- less than 3mm
 Moderate- 3-5mm
 Severe -more than 5 mm
 Thickest enamel -maxillary arch
 M & D surfaces of cuspids
 Distal surface of central incisors
 Mandibular arch
 M & D surfaces of cuspids
 Distal surface of the lateral incisor
Case reports
Case1
22yrs/F
Moderate crowding
Case 2
24yrs/F
Severe crowding
Case 3
21yrs/M
Anterior crossbite
crowding
Space closure

 Old extractions sites -difficult to close

 Resorption

 Remodeling of the bone.

 Such situation-better to use prosthesis or
Implants.
 Temporary implants in the ramus - to protract
the molars
 Rigid implant anchorage to close a mandibular first
molar extraction site-W.Eugene Roberts, Charles
nelson,jco1997

Rigid endoesseous implants are

a reliable source of orthopedic
anchorage
For managing malocclusions
that are the usual scope
of orthodontic practice

Case report

45yrs/M
Missing lower molar
 Space closure- Removable prosthesis

 35yrs/M
 Class III
 Generalized attrition
 Upper midline shift
 Asymmetric smile
 Missing teeth
Treatment plan:
Comprehensive orthodontic therapy
Definitive implant & PDL therapy
Invisalign

 What is invisalign?
- Invisible alignment of the teeth
- An invisible way to align the teeth

 Uses a series of clear removable aligners

to straighten teeth without metal wires or
brackets.

 Developed by Align Technology,CA

Impressions are Impression and advanced imaging A computerized movie -
made using bite send along called ClinCheck® -
technology transforms depicting the movement of
Polyvinyl with a detailed plaster models into a teeth from the beginning
Siloxane treatment plan. highly accurate 3-D to the final position is
digital image. created.

Procedure

customized set of aligners

are made from these
After wearing all of models, sent to the doctor,
the aligners in the and given to the patient. Pt
series, to wear each aligner for
about two weeks.
From the approved file,
laser scanning to build a
set Invisalign® uses of
actual models that reflect
each stage of the treatment
plan.
Using the Internet, the
doctor reviews the
ClinCheck file - if
necessary, adjustments to
the depicted plan are
made.
Invisalign
Invisalign

 Patient gets the first aligner 6 weeks after the 1st visit
 Most treatments require 20 – 60 aligners
 Worn for 2 weeks each
 Should be taken off only for eating and brushing
Invisalign

 Limitations

 Patients with severe malocclusions cannot be treated

 Children,mixed dentition – growing jaws and erupting
teeth too complicated for the computer to model
 No precise control over root movements
Invisalign system in adult orthodontics: mild
crowding & space closure cases
Robert L Boyd, R J Miller,JCO 2000 April

Case 1
23yrs/F
Spacing b/w teeth
Case 2

33yrs/M
Spacing b/w teeth
 case3

35yrs/M
Mild crowding
Lower incisor extraction treatment with
invisalign system-Ross J Miller
2001 JCO nov

 Case report
24yrs/F
Lower incisor crowding
Class I molar reln
Midline shift-3mm Rt side
Rapid orthodontic decrowding with alveolar augmentation: case report
William . M . Wilcko
Thomas . Wilcko World Journal Orthodontics 2003:4:197-205

Demonstrates a New orthodontic method that provides

shortened treatment times.
Case report
27yrs/F
Class I with moderate crowding
After 1 wk of bracketing & wire activation-selective Decortications.
Decorticotomy
Bone grafting /augmentation
 Post treatment

Total treatment time 6mnths.

Discussion

 Rapid decrowding & minimal root resorption -2

phenomenon
 Increased Regional bone turn over
 osteopenia

Selective
decortications.
Conclusion

 Takes shorter treatment time

 Pre-existing fenestrations/dehiscence can be

corrected-alveolar augmentation.

 Lip support can be achieved-alveolar

augmentation.
Accelerated Invisalign treatment-Albert H
Owen,JCO 2001 June

Esthetics & speed

Decorticotomy( AOO)
Invisalign therapy
Class I Occlusion
Mild crowding in lower arch
Lower midline shift
Only lower canine-canine decorticotomy.
After 10 days of corticotomy
Invisalign therapy started.
Aligners changed –every 3 days.
Rx completion-4 months.
Retention & Post treatment
stability in Adults.

 “After malposed teeth have been moved into the desired

position, they may be mechanically supported until all of
the tissue involved in their support & maintenance in their
new positions shall have become thoroughly modified ,
both in their structure & function to meet new
requirements.”
-E H Angle
Retention

Removable appliances & retainers

Hawley retainer
Tooth positioner
Spring retainer

Fixed retainer
Bonded retainer
Banded retainer
Hawley retainer
Hawley retainer –modified
Positioner
Positioner
Fixed retainer
Fixed retainer
QCM-Organic polymer
retainer
Labial fixed retainer
Labial fixed retainer