adult orthodont ics

ADULT ORTHODONTICS

www.indiandentalacademy.com

INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

Index• Adult ?

• History of adult orthodontics

• Adult orthodontics

• Reasons for increased interest of adults in orthodontic treatment

• Indications

• Contraindications

• Difference between adult and adolescent patients

• Limitationswww.indiandentalacademy.com

Index• Treatment objectives• Diagnosis • Treatment planning :Psychological considerationsBiomechanical considerationsPeriodontal considerationsTMJ• Treatment :Adjunctive treatmentComprehensive treatmentSurgical treatment• Conclusion


ADULT ?

• Adult is defined as one who is fully grown, most males 18 and above and most females of 16 and above can be considered to be adults, although residual growth is left.

• It is however quite impractical to determine the exact time when adulthood begins, since there is no definite age when a person reaches physical maturity.


HISTORY

• Kingsley, in 1880, indicated an early awareness regarding orthodontic potential in adult patient.

• He stated, “It may be regarded as settled fact that there are hardly any limits to the age when movement of teeth might not succeed.”


HISTORY

• MacDowell(1901) was of the opinion thatafter the age of 16 years, a complete and permanent change in transition of the occlusion & hence orthodontic treatment, is almost impossible owing to the development of,- adult glenoid fossa,- density of the bones ,- muscles of mastication.


HISTORY

• Lischer (1912) believed that the period from 6th to 14th year was a golden age of treatment


HISTORY• In 1921 Calvin Case demonstrated the value of

orthodontic therapy in the lower anterior area for the aged, periodontally affected patient.


ADULT ORTHODONTICS

• Ackerman : “Adult orthodontics is concerned with striking a balance between achieving optimal proximal and occlusal contact of the teeth, acceptable dentofacial aesthetics, normal function and reasonable stability.”


Recent AAO survey : Increased % of patients >21 yrs, from 4% ten yrs ago, to almost 7% today; in another decade’s time adult pts would constitute 11% of avg orthodontic practice.

• [JCO:1997:Gottleib,Nelson]


INCREASED INTEREST IN THE ADULT PATIENT

Reasons [Melsen in ‘Curent controversies in

Orthodontics’]

1] Innovations in appliance placement techniques – Direct bonding, lingual/invisible appliances


2] Innovations in material research – ceramic brackets & tooth coloured wires

3] Role of family dentist - Increased desire of restorative dentists and patients for treatment of dental mutilation problems using tooth movement rather than prostheses.


4] Role of media, visual as well as print - Articles in magazines ,news paper as well as community programs have increased patient awareness towards health & esthetics.

5] Better management of TMJ dysfunction.


6] More effective management of skeletal jaw dysplasias with advanced orthognathic surgical techniques.

7] Reduced vulnerability to periodontal breakdown as a result of improved tooth relationships and occlusal functions.

8] A broader understanding of the biology of the tooth movement especially with regard to age changes.


9] Ingenious approaches to anchorage management such as implants.

10] Role of Insurance companies – in the US

11] Affluence – Improving socioeconomic standards makes orthodontics more affordable today .


INDICATIONS (RAVINS)

1) Improvement of tooth-periodontal tissue relationship.

2) Establishing an improved plane of occlusion to distribute the forces of occlusion better.

3) Balancing the existing space for better prosthetic replacement.

4) Improve occlusion and coordination between the muscle and TMJ.

5) Improve patient esthetic.www.indiandentalacademy.com

CONTRAINDICATIONS (BARRER)

1) Severe skeletal discrepancies.

2) Advanced local or systemic disease.

3) Excessive alveolar bone loss.

4) Poor stability prognosis – tooth movt into unfavourable positions.

5) Lack of patient motivation & co-operation, resistance to wear the appliance.www.indiandentalacademy.com

6) Inability to prevent excessive hard/soft tissue destruction

7)Inadequate space for tooth movt

8)Movt of teeth against occlusal opposition or into occlusal trauma

9)No improvement in PDL health, function/esthetics.

10)Negative anchorage potential – movt of teeth against inadequate anchorage.


CONTRAINDICATIONS (Marks and Corn)

• Advanced systemic disease

• Lack of patient motivation.


1] Younger adults (under 35, often in their 20’s)

2] Older patients (in their 40’s and 50’s)

[Proffit-Fields]

2 GROUPS OF ADULT ORTHODONTIC PATIENTS


YOUNGER GROUP

Goal –

Comprehensive treatment & maximum possible improvement; improved quality of life.


Reasons for not receiving orthodontic treatment early

1) Did not desire treatment.

2) Were not aware of orthodontic treatment.

3) Parents could not afford.

4) Were not given proper advise by family dentist.

5) No orthodontist located in the vicinity.www.indiandentalacademy.com

6) Incomplete orthodontic treatment when younger or were uncooperative. 7) Had orthodontic treatment as children but relapse occurred.

8) More conscious of appearance with age.

9) Anterior teeth started to crowd or minor crowding becomes worse.

10) Dissatisfaction with the outcome of previous treatment www.indiandentalacademy.com

OLDER GROUP

Goal -

- Maintain proper dental health.

- For easy & effective control of disease & restoration of missing teeth.

- As an adjunctive procedure to the larger periodontal & restorative goals ; not necessarily interested in the ideal result.


Reasons for seeking orthodontic treatment

1) Malposed teeth contributing to PDL disease.

2) Increased difficulties with mastication.

3) Anterior spaces enlarging or new ones developing.

4) For better tooth positioning prior to prosthetic preparation.

5) Tooth interferences & mandibular slide causing

TMJ problems. www.indiandentalacademy.com

ADOLESCENT vs ADULT ORTHODONTIC PATIENT

Levitt : “In adult patient there is no growth and only tooth movement”.

Barrer : “Adult, unlike the child is a relentless patient, who will not cover our deficiencies in skills or our errors in the use of mechanical procedures by helpful settling in post-treatment.”


• Ackerman : “In a child ,one occasionally calls on another specialist. On the other hand it is a rare adult whom one treats orthodontically without finding it necessary to collaborate with another specialist.”


• Adults – orthodontic treatment is based on symptoms detected by the patient

• Children - treatment is based more often on signs detected by practitioners/parents.


• Adult – seeks treatment more often for esthetics & hence is likely to have unreasonable expectations about the outcome, is less adaptable to the appliance & is uncompromising in appraisal of the Rx results.

• Brighter side – cleaner, more careful, punctual, prompt paying, much less sensitive to pain & Rx time is either same/less than that for younger patients.


FIVE MAJOR CATEGORIES IN WHICH ADULT PATIENTS SIGNIFICANTLY

DIFFER FROM THEIR ADOLESCENT COUNTERPARTS

1) Clarification & individualization of treatment objectives

2) The diagnostic process

3) Treatment plan selection

4) Acceptance of recommended therapy

5) Achievement of treatment objectives


1) Clarification & individualization of treatment objectives-

This requires specific study of the problem & the indicated therapeutic refinements.


2) The diagnostic process-

Problem oriented dental record aides in making the appropriate diagnosis, for it requires that the patient’s problems be listed and a plan be developed to manage each problem.


Diagnostic steps:

1) Collect data accurately.2) Analyze data base.3) Develop problem list.4) Prepare tentative treatment plan.5) Interact with those who are involved; discuss plans and options; clarify sequence, acquire patient acceptance. 6) Create final treatment plan.


Before starting the treatment, the orthodontist needs to be prepared to do the following:

1) Diagnose different stages of PDL disease and their associated risk factors.

2) Diagnose TMJ dysfunction before, during or after tooth movement.


3) Determine which cases require surgical management and which ones require incisor reangulation to camouflage the skeletal base discrepancy.

4) Work cooperatively with team of other specialists to give the patient the best outcome.


3) Treatment plan selection-

More systemic & detailed analysis is required for adults than for adolescents.

Factor affecting treatment plan selection:i) Existing oral pathology: - dental caries - periodontal disease - faulty restoration - TMJ adaptability

- occlusal awarenesswww.indiandentalacademy.com

ii) Skeletal relationship.

iii) Biological consideration:- neuromuscular maturity/adaptability . - periodontal susceptibility:bone loss/gingival inflammation . - rate of tooth movement. - growth.

iv) Therapeutic approach available: - functional appliances. - orthognathic surgery. - restorative dentistry.


v) Extraction therapy: 4 PM / asymmetric, lower incisor.

vi) Anchorage requiremen: headgear / completely erupted 1st & 2nd molars

vii) Missing teeth: space closure without / with prostheses


4) Patient’s acceptance of the treatment plan-

Patients thorough understanding of & agreement with the recommended Rx are necessary. Also, an informed consent should be signed i) Sociobehavioral interaction:

- Office environment: group / privacy- Team coordination, interaction: multidisciplinary approach

ii) Duration of treatment.www.indiandentalacademy.com

iii) Cost of treatment: with/without insurance cover

iv) Perceived risk/benefit ratio: more benefits compared to minimal risks

v) Appliance selection.

vi) Insurance coverage


• Vii) Negative conditioning: in the past .

viii) Positive conditioning.


5) Achievement of treatment objectives-

-requires specific study of the problem & the indicated therapeutic refinements- depends on :i) Dental history.ii) Ability of the orthodontist to interface the treatment plan with those of other dental specialist.iii) skills and knowledge of orthodontist and staff.


LIMITATIONS OF TREATMENT

2 types of factors :

• Intrinsic – Biological nature

• Extrinsic – Biomechanical systems


INTRINSIC FACTORS

• Most marked – Adult is no longer growing, so orthodontic Rx is limited to tooth movt & related modelling of the alveolar process only (may vary with the age & health )

• Periodontium – primary tissue to get affected.

• Norton : decreasing blood flow & vascularity with increasing age – insufficient source of progenitor(preosteoblasts) cells – delayed response to mechanical stimulus.


• Alveolar bone – cortical bone becomes denser & spongy bone reduces with age & structure of bone changes from honeycomb to a network

• Apical displacement of marginal bone level - local factor, age related but is also due to progressive PDL disease


• Teeth - adults are more likely to have missing teeth, teeth reduced in dimension due to attrition or teeth with large restorations.


EXTRINSIC FACTORS

• Force system used differs from that used in young, growing individuals.

• Forces used should be at a lower level than those used in children, as adults often have PDL problems & reduced bone support.

• Initial forces should be further kept low as the immediate pool of cells available for resorption is low.


• M/F ratio for a particular tooth movt should be increased as per the periodontally compromised state of the dentition, to counter the tipping tendency.


• In the presence of marginal bone loss, light continuous intrusive forces should be maintained during tooth displacement.


!!! ADULT PROBLEMS DIFFICULT TO TREAT BY ORTHODONTICS !!!

• Deep bite – extrusion of post teeth is not compensated for by condylar growth

• Posterior crossbite – arch expansion is not stable

• Skeletal discrepancies – since growth is complete.


1) Dentofacial aesthetics

2) Stomatognathic function

3) Stability

4) Achieving Class I occlusion

:ADULT ORTHODONTICS - TREATMENT OBJECTIVES


ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES

1) Parallelism of abutment teeth :

- Restoration will have better prognosis as excess cutting or devitalization during abutment preparation are avoided.

- Allows for a better pdl response.

- Allows for better retention.www.indiandentalacademy.com

2) Most favorable distribution of teeth :

- Evenly for replacement of fixed/removable prostheses in the individual arches

- Teeth should be positioned in such a way that occlusion of natural teeth can be established bilaterally between the arches.


3) Redistribution of occlusal and incisal forces –

Helpful in case of significant bone loss, to maintain the occlusal vertical dimension.

4) Adequate embrasure space and proper root position –

Allows for better pdl health, especially when placement of restorations is necessary.


5) Acceptable occlusal plane and potential for incisal guidance at satisfactory vertical dimension –

For a mutilated dentition with bite collapse, the Hawley bite plane adjusted to the correct vertical height, is inserted – allows a centric relation at an acceptable vertical dimension, simulatneous bilateral neuromuscular activity;

Curve of spee should be mild to flat bilaterally – unilateral orthodontic treatment of an accentuated occlusal plane should be avoided.www.indiandentalacademy.com

6) Adequate occlusal landmark relationships:

- Most difficult dimension to correct & maintain orthodontically – transverse sagittal vertical.

- Teeth must be positioned yo achieve acceptable B-L landmarks.

Post crossbites due to severe transverse skeletal dysplasias – maxillary buccal cusps contact lower central fossae with the crossover for incisal guidance in the PM or canine positions.www.indiandentalacademy.com

7) Better lip competency and support -

Inadequate support may create change in antero-posterior and vertical position of upper lip and increase wrinkling.

Some Class II, division 1 patients (surgery rejected) – lower incisors can be placed procumbent with bilateral posterior restorations – establish incisal guidance; avoids palatal tissue irritation.

Some class III’s – maxillary incisors kept more flared than normal


8) Improved crown/root ratio –

In case of individual teeth bone loss, the crown to root ratio can be improved by decreasing the length of clinical crown with a high speed handpiece as the tooth is erupted orthodontically.


9) Improvement/ correction of mucogingival and osseous defects:-

Proper repositioning of prominent teeth in arch will improve gingival topography.

Adolescents – brackets placed to level marginal ridges & cusp tips

Adults – level crestal bone between adjacent CEJ’s; favorable osseous & soft tissue changes with tooth movt , diminished need for osseous/mucogingival surgery; continuous adjustment to prevent premature post teeth contact causing occlusal trauma.www.indiandentalacademy.com

10) Better self maintenance of pdl health:

Location of gingival margin - determined by axial inclination & alignment of the tooth.

For better periodontal health, teeth should be positioned properly over their basal bone support.

11) Esthetics and functional improvement:

Rx= acceptable esthetics + improved muscle function + normal speech + mastication

Therapeutic occlusion = ant teeth as disarticulators; post teeth support the vertical dimension.


Treatment planningUsual sequence of procedure is as follows – • Eliminate all pathology (caries, PDL disease,

retained roots, etc)• Orthodontic Rx• Periodontal re-evaluation (& therapy if

necessary)• Prosthetic restoration (when necessary)• Orthodontic retention• Periodontal maintenance• Occlusal adjustment (grinding) whenever

necessary


BIOMECHANICAL CONSIDERATIONS:

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

- Fixed appliance is necessary.


• Adult patients demand for removable appliance but they are not useful in adjunctive treatment.

- But in case of multiple missing teeth removable appliance is useful.


Placement of brackets

• A=ideal position – uprighting of ant teeth (movt of anchor teeth is undesirable)

• B=brackets placed in position of max convenience-maintains existing tooth alignmentwww.indiandentalacademy.com

• - In case of reduce periodontal support and bone loss , lighter forces and relatively larger movements are needed.


TIMING AND SEQUENCE OF TREATMENT:-

- Before any type of tooth movement any caries or pulpal pathology should be eliminated.

- Larger restoration require detail occlusal anatomy should be carried out after orthodontic treatment is over.


- Periodontal disease should be controlled before any tooth movement.

- Scaling, curettage and gingival graft should be carried out before treatment.

- Surgical pocket elimination and osseous surgery should be carried out after orthodontic treatment.


Psychological considerations

• Children & adolescents – motivation for ortho Rx = parent’s desire; not emotionally involved in their own Rx

• Adults – seek ortho Rx because they themselves want something, that is not always clearly expressed=hidde set of motivations/unrealisti expectations

• Imp – explore why pt wants Rx & why now

“Ortho Rx cannot repair personal relationships, save jobs, or overcome a series of financial disasters” - Proffit


• Most adults – have realistic expectations, more positive self image than average, a good deal of ego strength.

• Internally motivated responds well to Rx than externally motivated.

• Demand for invisible orthodontic appliances-unrealistic for a patient to expect that ortho Rx can be carried out without other people knowing about it


• Sometimes - Rx in a pvt area if the patient demands so;

Most adults – learning from interacting with other patients = beneficial

• Patient handling – Adolescents = passive acceptance of what is

being doneAdults = considerble degree of explanation of what

is happening & why; Interest in Rx does not automatically translate into

compliance with instructionswww.indiandentalacademy.com

• Adults – less tolerant of discomfort & more likely to complain about pain after adjustments & about difficulties in speech, eating & tissue adaptations.

Additional chair time to meet these demands should be anticipated


ACCORDING TO PROFFIT ADULT ORTHODONTIC TREATMENT IS DIVIDED IN TO 3 PARTS:

1) ADJUNCTIVE TREATMENT.

2) COMPREHENSIVE TREATMENT

FOR ADULTS.

3) SURGICAL TREATMENT.


DIFFERENCE BETWEEN ADJUNCTIVE TREATMENT AND COMPREHENSIVE TREAMTMENT IS INDISTINCT,AS ANY TREAMENT WHICH REQUIRE MORE THAN 6 MONTHS IS CALLED AS COMPREHENSIVE TREATMENT.


ADJUNCTIVE TREATMENT-

“ Tooth movement carried out to facilitate other dental procedures necessary to control disease and restore function.”


GOALS -

1) Facilitates restorative treatment by positioning the teeth.

2) Improve periodontal health by removing plaque harboring areas .

3) Establishing favourable crown to root ratio and position of the teeth.


PROCEDURES CARRIED OUT IN ADJUNCTIVE TREATMENT : -

1) Uprighting posterior teeth.2) forced eruption.3) alignment of anterior teeth.4) crossbite correction.


THANK YOU


* Etiology of adult malocclusion.* Types of adult orthodontic patients.* Types of adult orthodontic treatment.* Adjunctive treatment:- Goals- Biomechanical considerations. - Timing and sequence.- Procedures carried out.


ETIOLOGY OF ADULT TOOTH MALPOSITION:-

1) DENTAL ORIGIN2) SKELETAL ORIGIN


1) DENTAL ORIGIN:-

a) Faulty eruption from the normal functional position.b) Insufficient arch length.c) Excessive arch length.d) Prolonged retention of primary teeth.e) Ectopic eruption.


g) Prolonged finger and thumb sucking habits.h) Clenching and grinding.i) Improper swallow pattern with tongue thrusting.j) Effects of tongue pressure on the anterior teeth.


k) Macroglossia.l) Premature loss of deciduous teeth.m) Loss of permanent teeth.


2) SKELETAL ORIGIN:-

a) Cleft palate.

b) Gross mediolateral disharmony of the craniofacial skeleton.


UPRIGHTING POSTERIOR TEETH:-


1) If third molar is present , whether both second and third molar should be uprighted.

2) Whether to upright tipped teeth by distal crown tipping or by mesial root movement.


3) Whether we need slight extrusion or maintain occlusal height during uprighting.

4) Whether premolar should be repositioned or not.


APPLIANCE FOR MOLAR UPRIGHTING:-

- Partial fixed appliance.

- Anchorage.

- Placement of brackets on canine and premolars.


UPRIGHTING A SINGLE MOLAR:-

Moderately tipped molar:-

- 17x25 braided s.s

- 17x25 Ni-Ti Severely tipped

molar:- -19x25 s.s - Uprighting spring ( 17x25 beta- Ti)


• “ T-loop”

- 17x25 s.s

- 19x25 beta-Ti

• Activation of T-loop.


• Severely tipped teeth:-

- Use of modified T-loop.


• Final position of molars and premolars.

• Use of open coil spring - steel

- A Ni-Ti• Occlusion should be

checked carefully.


RETENTION

• For shorter period

• For a longer period.

- Intracoronal wire splint


FORCED ERUPTION:-

Indications:-

- Defects in cervical third .


TREATMENT PLANING:-

- Periapical radiograph.

- Single tapering and flared and divergent root morphology.

- Endodontic therapy.


How much tooth should be extruded can be determine by 3 factors:-

1) Location of the defect.(fracture line)

2) Space to place margin of the restoration.(1 mm)

3) An allowance for the biological width of the gingival attachment.(2 mm)


Duration:-

- 1mm/week without damaging pdl.

- 3 to 6 week.


TECHANIQUE

• Continuous flexible wire is contraindicated.


2 METHODS

– With orthodontic bracket.

– Without orthodontic bracket.


• Brackets are placed more occlusally on anchor teeth than its ideal position.

• T-loop,

- 17x25 s.s

- 19x25 beta-Ti


RETENTION:-

- By passively fitting rectangular arch wire.(3 to 6 week).


ALIGNMENT OF ANTERIOR TEETH

Indications:-

1) To improve access and permit placement of well contoured restorations.

2) To permit placement of crowns and pontics .


3) To reposition closely approximated roots and to improve the amount of interradicular bone.

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


* Alignment of crowed, rotated and displaced incisors.

* Separation of approximated teeth.


• Position teeth for single tooth implant:-

- Minimum 6mm of space is require. - Apices of adjacent teeth.


Anterior diastema closure and space redistribution:-

Causes:-- Loss of posterior teeth.- Small teeth..- Loss of bone support.


TREATMENT:-

- With Removable appliance.

- With fixed appliance.


CROSSBITE CORRECTION:-

- It can cause functional problem and occlusal trauma.

- Single tooth crossbite.

- Group of teeth in crossbite.(part of skeletal problem).


- Correction with removable appliances.(anterior segment)

- Correction with the “through the bite” elastics.(posterior segment).


SUMMARY:- There is wide variety of etiology that can cause an adult malocclusion. Also each patient’s need for treatment are different so treatment should be carried out taking his/her needs in consideration.Adjunctive treatment helps by facilitating other dental procedures to control disease and restore function.


Thank you

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adult orthodont ics

Health & Medicine

index adult

adult orthodontics ackerman

golden age of treatment

adult patient reasons

adult glenoid fossa

decades time adult pts

orthodontic potential

patient awareness