Adult orthodontics

orthodontics

1. Adult
orthodontics
DR. TONY PIOUS

2. Adult orthodontics
Contents
Introduction
History
Comparison b/w adolescents & adults
Objectives
Classifications
Adjunctive orthodontics
Comprehensive orthodontics
Retention

3. Basic biological concepts associated
with adult orthodontics.
Periodontal ligament.
Bone
Teeth .

4. 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.

5. 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.

6. 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.

7. Teeth
More root exposure
Short crown root ratio
CR shift –apically
Diameter of pupal canal reduces
Decreased vascularity&innervation -pulp
recovery.

8. CEJ–alveolar crest distance
Significant reduction in crest
height with age
0.017mm/year

9. Prevalence of PDL
pockets

10. 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

11. History

12. 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”

13. Adult practice today

14. Scope of procedures
Musich’s (1986)study of 1370 consecutively examined adults

15. 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.

16. factors adolescents adults
Dental cariesMore susceptible Recurrent decay
restorative failures, root
decay& pulpal pathosis
PDL disease Resistance to bone loss
Susceptible to gingival
inflammation
Susceptible to bone loss
TMJ
adaptability
high Symptoms with
dysfunction
Occlusal
awareness
Infrequent Increased enamel wear
with adverse change in
supporting tissue.
comparison

17. Factors Adolescents adults
Growth factorsGrowth-orthopedic
Stable correction .
No growth
Minimal skeletal adaptability.
Surgical option
Dentofacial
esthetics
Reasonable concern Concern occasionally
disproportionate to degree of
existing problem

18. factors adolescents adults
Rate of tooth movementrapid slower
orthopedics 50% Small percentage
Orthognathic surgery1-5% 10-20%
Restorative dentistrySmaller percentagefrequently
Combination treatmentuncommon 80%

19. factors adolescents adults
Anchorage
potential
Head gear implants
Missing
teeth
Space closure
without prosthesis
Restorative

20. factors adolescentsadults
Extraction
controversy
4 PMs Less
frequently
Strategic
extraction
uncommon common

21. Adult orthodontic
treatment objectives
Dentofacial esthetics
Stomatognathic function
Stability
Normal occlusion

22. 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.

23. Parallelism of abutment
teeth
Abutment teeth-parallel
Permit-easy insertion of
replacements
Allow –restorations
Better prognosis
Better PDL response.

24. Most favorable distribution
of teeth
Distributed evenly-replacements
To establish normal occlusion.

25. Redistribution of occlusal
& incisal forces.
Cases with significant bone loss(60-70%)
To maintain occlusal vertical dimension

26. Adequate embrasure
space &proper root
position.Better PDL health
Helps in interproximal cleaning
Placement of restorative material.

27. Adequate occlusal
landmark relationships
Transverse dimension – difficult to correct
Skeletal crossbite cases-only anterior
crossbite can be corrected.

28. Better lip competency &
support
In case of anterior restoration-retractions
Inadequate support-change in
anteroposterior &vertical position of
upper lip & increase in wrinkling.

29. Improved crown/root
ration
In case of bone loss
Reduced crown/root ratio
Can be corrected by reducing the clinical crown.

30. Better self maintenance of
PDL health
Teeth should be positioned properly
over basal bone
Improved self maintainace of PDL
health occurs with proper tooth position

31. Esthetic & functional
improvement.
Should provide acceptable dentofacial esthetics
Improved muscle function
Normal speech & masticatory function

32. 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

33. Treatment for adults
proffit -
Younger adults(20-35yrs)
Older group(40-50yrs)
Adjunctive orthodontic treatment
Comprehensive orthodontic treatment

34. 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

35. 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.”

36. Principles of AOT
Diagnostic & treatment planning.
Collecting an adequate data base.
Developing a problem list.

37. Diagnostic records
OPG.
Full mouth IOPAs.
Lateral ceph
photographs.
Dental casts.

38. 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.

39. Removable appliances

40. Bracket placement

41. Effects of reduced
periodontal support
Bone support
Bone loss-PDL area
decreases
CR-shifts more appically

42. Timing & sequence of
treatment
Active disease
Disease control
Establish occlusion
Definitive restorative Rx
maintenance
Re-evaluate
stabilize

43. 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

44. Uprighting posterior teeth
Treatment planning consideration
Loss of posterior teeth
If the 3
rd
molar is present?
Uprighting by distal crown/ mesial root movement?
Slight extrusion of tipped molar is permissible?

45. Loss of posterior teeth

46. Distal crown/ mesial root
movement

47. Crown: root length

48. Appliances for molar
uprighting
Partial fixed appliance
Active & reactive unit
bonding>banding

49. Uprighting a single molar
Distal crown tipping with
occlusal antagonist
Flexible rectangular wire-
17x25 NiTi
Anchorage unit-19x25
steel
17x25 beta-Ti

50. Uprighting with minimal
extrusion
Uprighting with no
occlusal antagonist
“T-Loop”-17x25 steel/
19x25 beta Ti

51. Uprighting of lower molars
Birte melsen,JCO 1996
case1
56yrs/M
Missing lower 1
st
molar

52. case1

53. Case 2
42/F
Missing 46

54. Case 2

55. Distal jet

56. A simple technique for molar
uprighting –E Capelluto,JCO 1996
“MUST”

58. Final positioning of molar
& PMs
Compressed coil springs
018 steel

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

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

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

62. Forced eruption
Treatment planning
Good periapical radiographs
Periodontal support
Root morphology and position
Endodontic therapy should be completed

63. Orthodontic technique
Anchor teeth –rigid
Flexible –tooth to be extruded
With / without the use of orthodontic bracket

65. 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.

66. Treatment planning
Interproximal stripping
Diagnostic setup-very helpful

67. Orthodontic technique
Alignment of crowded, rotated & displaced
incisors
Edgewise brackets-canine –canine
Initial wire-light & flexible
016 Niti
Crown reduction

68. 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

69. 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.

70. Case reports
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 3
rd
molar + alignment
Same implants-abutments.
Kenji W Higuchi

71. Case 1

72. case1

73. Case 2
53yrs/M
Class III
Ant &post crossbites
spacing
Treatment plan: 2 implants,35&36
Healing period -4 months
Implant-supported FPD

74. 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

75. Case 3

76. 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.

77. Diastema closure

78. 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.

79. Comprehensi
ve
orthodontic
treatment.
ADULT ORTHODONTICS.

80. 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.

81. 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.

82. 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.

83. 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

84. 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

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

86. 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

87. 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.

88. Temperomandibular
dysfunction
Internal joint pathology
Muscle origin

89. Temperomandibular
dysfunction
Diagnostic records
Full TMJ series x-rays
Opg
Muscle examination
Stress evaluation
•Prevalence of TMD problems-
Schiffman et al (1998)
Muscle disorder 23%
Joint disorder 19%
Combination 27%
Normal 31%

91. 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.

92. 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.

93. 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

95. Analysis applied
Study casts
Latral ceph
Opg
IOPA-special film holder
Piece of 021x028 elgiloy

97. 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.

98. Upper molar intrusion
Birte melsen JCO 1996
Case 1
38yrs/F
Missing teeth
Chewing difficulty

101. 4.5mm-intrusion
7.5mm- mesial movement
2mm- reduction of clinical crown ht.

102. Case 2
40yrs/F
Missing 15,16,25,27,28,35,37,38,44,45,47,48
Chewing difficulty.

104. 3mm-intrusion
8mm-mesial movement of molar.
Lower-implants

105. 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

106. Case reports

107. Case1
22yrs/F
Moderate crowding

109. Case 2
24yrs/F
Severe crowding

111. Case 3
21yrs/M
Anterior crossbite
crowding

113. 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

114. 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
45yrs/M
Missing lower molar
Case report

118. 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

120. 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

121. Impressions are
made using
Polyvinyl
Siloxane
Impression and
bite send along
with a detailed
treatment plan.
advanced imaging
technology
transforms plaster
models into a
highly accurate 3-D
digital image.
A computerized movie -
called ClinCheck® -
depicting the movement of
teeth from the beginning
to the final position is
created.
After wearing all of
the aligners in the
series,
customized set of aligners
are made from these
models, sent to the doctor,
and given to the patient. Pt
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.
Procedure

122. Invisalign

123. Invisalign
Patient gets the first aligner 6 weeks after the 1
st

visit
Most treatments require 20 – 60 aligners
 Worn for 2 weeks each
Should be taken off only for eating and brushing

124. 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

125. 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

127. 33yrs/M
Spacing b/w teeth
Case 2

129. case3
35yrs/M
Mild crowding

131. 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

136. Rapid orthodontic decrowding with alveolar augmentation: case report
William . M . Wilcko
Thomas . WilckoWorld 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

137. After 1 wk of bracketing & wire activation-selective Decortications.

138. Decorticotomy

139. Bone grafting
/augmentation

140. Post treatment
Total treatment time 6mnths.

141. Discussion
Rapid decrowding & minimal root resorption -2
phenomenon
Increased Regional bone turn over
osteopenia
Selective
decortications.

142. Conclusion
Takes shorter treatment time
Pre-existing fenestrations/dehiscence can
be corrected-alveolar augmentation.
Lip support can be achieved-alveolar
augmentation.

143. 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.

144. After 10 days of corticotomy
Invisalign therapy started.
Aligners changed –every 3 days.
Rx completion-4 months.

145. 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

146. Retention
Removable appliances & retainers
Hawley retainer
Tooth positioner
Spring retainer
Fixed retainer
Bonded retainer
Banded retainer

147. Hawley retainer

148. Hawley retainer –modified

149. Positioner

150. Positioner

151. Fixed retainer

152. Fixed retainer

153. QCM-Organic polymer
retainer

154. Labial fixed retainer

155. Labial fixed retainer