AGE FACTORS IN ORTHODONTICS An important consideration in orthodontic diagnosis and treatment planning is the age of the patient. In addition age factors influence the treatment mechanics and prognosis. There are certain features which are normal to a child, however if present in an adult would constitute malocclusion. These malocclusions need no treatment at that age as they get corrected automatically as the age advances. The chronological age may sometimes be misleading and may not reflect the exact growth status. Thus skeletal and dental ages of the patient should be ascertained for a more accurate diagnosis.

1. AGE FACTORS IN
ORTHODONTICS

2. INTRODUCTION
An important consideration in orthodontic diagnosis and
treatment planning is the age of the patient. In addition age
factors influence the treatment mechanics and prognosis.
There are certain features which are normal to a child,
however if present in an adult would constitute
malocclusion. These malocclusions need no treatment at
that age as they get corrected automatically as the age
advances.
The chronological age may sometimes be misleading and
may not reflect the exact growth status. Thus skeletal and
dental ages of the patient should be ascertained for a more
accurate diagnosis.

3.  Some of the transient malocclusions are
1. Open bite seen in gum pads
2.Spacing in deciduous dentition
3.First deep bite

4. 4.Flush terminal plane
5.Ugly duckling stage
6.Second deep bite

5.  Chronological age:
Age of a person measured in years, months and days
from the date the person was born. Variations in
human growth patterns arise from complex genetic
and environmental interactions. Variability is
expressed clinically as differences in the timing and
intensity of growth events. There for chronological age
may not be very accurate in reflecting the growth
status.

6.  Biological age
The biological age of an individual is determined by
physiological factors rather than accepting the
chronological age. The biological age is determined by
studyind certain biomarkers which could also include
changes in the physical body, motor skills etc.
 Dental age
The dental age does not always match the chronogical age.
Development status of dentition can be late or early
compared to chronological age. Dental age is determined
according to:
Eruption of permanent tooth
Level of root resorption of primary teeth
State of calcification and root development of the
permanent teeth

7.  Skeletal age or bone age
The skeletal age or bone age is determined by studying
a hand-wrist radiograph. The ossification and union of
skeletal centres follow a definite timetable and pattern.
Thus by ascertaining the status of these ossification
centres and comparing them with standard we can
find out the exact skeletal maturity status of an
individual.

8.  Diastema in early mixed dentition
stage
- Should be left untreated to avoid
impacting the permanent maxillary canine
- At early stages of dental development the
cusp tips of the erupting canines are too
close to the apices of the lateral incisors -
positioning the mesially inclined roots of
the incisors upright with the orthodontic
appliance could place the lateral incisor
roots in the path of eruption of canine

9. - Might cause either the impaction of canines or the
resorption of root of lateral incisor
- Orthodontic treatment that involves such movements
should be postpone until the level of the cusp tip has
atleast passed beyond the apical third of the root of the
lateral incisor

10.  Molar relationship
- Cases with distal step in the
primary dentition stage –
treatment started soon because
condition will not self correct
with time
- Patient’s with flush terminal
plane relationship present a
more challenging question –
half of these cases progress to
normal class I relationship, rest
to either class II or end to end
occlusion

11.  Tooth size arch length discrepancy
- Significantly increased from early adolescence until early
adulthood
- So,without long term retention ,adolescents who were
orthodontically treated to a perfectly aligned dentition
should expect some crowding to occur in the anterior part
of the dental arches
- The patient should be made aware of the probability of
these changes occurring after the retention appliances have
been discontinued

13. 1. Reasons for treatment
- To remove obstacles to normal growth of the face
and dentition
- To maintain or restore normal function

14. 2. Conditions that should be treated
- Anterior and posterior cross bites
- Cases in which primary teeth have
been lost and loss of arch space may
result

15. - Unduly retained primary incisors which
interfere with normal eruption of the permanent
incisors
- Malpositioned teeth which interfere with
normal occlusal function or induce faulty
patterns of mandibular closure
- All habits or malfunctions which may distort
growth

16. 3. Conditions that may be treated
- Distoclusions that are atleast partly positional.Occlusal
equilibration or tooth movements may restore normal
function , the rest of the problem may be treated at this
time or later
- Certain distoclusions of a skeletal nature are best treated
at this age , but the patient must be socially mature and the
cases must be carefully chosen
- Open bite due to tongue thrusting or digital sucking habit

17. 4.Contraindication to treatment in the primary dentition
- when there is no assurance that the results will be
sustained
- when a better result can be achieved with less effort at
another time
- when social immaturity of the child makes treatment
impractical

18. 1. Reasons for treatment
- To remove obstacles to normal growth of the face and
dentition
- When the malocclusion cannot be treated more
efficiently in the permanent dentition
2. Conditions that should be treated
- Loss of primary teeth endangering the available space in
the arch
- Closure of space due to premature loss of primary teeth
- Crossbites of permanent teeth
- Supernumerary teeth that may cause malocclusion
- Class II cases of functional , dental and skeletal type
- Space supervision problems

19. 3. Conditions that may be treated
- Class II malocclusion of skeletal type
- Class III malocclusion where early treatment is
possible
- All malocclusions accompanied by extremely large
teeth . If serial extractions are to be undertaken ,
treatment must be instituted in the mixed dentition
- Gross inadequacies or disharmonies of the apical
base

20.  when properly executed, will result in self-correction or
prevention of the development of irregularities in the
incisal segments of both maxillary and mandibular
dentures.

21.  Such procedures, excluding the existence of abnormal
tongue and swallowing habits, will permit the mandibular
incisors to tip and move lingually to positions of functional
balance, thus giving the orthodontist a valuable clue to the
correct location and inclinations of these teeth.
 If such information is recorded and the positions and
inclinations of the mandibular incisors maintained until
the conclusion of orthodontic treatment, little difficulty
will be experienced during the retention period.
–Charles H. Tweed, 1966
(Angle Orthodontist, 1990: Serial extraction of first
premolars – postretention evaluation of stability and
relapse Robert M. Little, Richard A...)

22.  Expansion of the maxillary arch is the most common
treatment intervention to correct posterior cross bite ,and
the treatment approach is related to the age of the patient
 Before the mid palatine suture fusion orthopedic forces
may be applied to separate the suture and allow the bone to
fill in the expanded midpalatine area

23.  Once the suture closes , at about 16 yrs of age ,a decline in
the ability of rapid palatal expansion occurs as a result of
the progressive interdigitation and fusion of the various
sutures as well as the resistance of the skeletal and soft
tissue structures , which in turn become less responsive to
the expansion forces
 Although , it is relatively easy to widen the maxilla by
opening the mid palatal suture during adolescence , it
becomes gradually more difficult during late adolescence
 As a result , the effectiveness of RME decreases and after 16
yrs of age is usually not recommended

24.  The ability to increase the skeletal transverse
dimension in the adults may be accomplished with
a surgically assisted rapid palatal expansion or
during orthognathic surgery when a two or three
piece maxillary osteotomy widens the maxilla

25. 1. General characteristics of adolescent malocclusion
- Dentition and occlusal relationships are established
- Skeletal growth may be mostly over and decelerating
- Muscle function is matured
- Functional malocclusions are less frequent since they have
largely been accommodated by dentoalveolar , skeletal ,
or mandibular joint adaptations

26. 2. Advantages of adolescent treatment
- Control of all permanent teeth except third molars is now
possible
- It is beneficial to treat when bone turnover rates are still high
though adult dimensions are nearly achieved
- Motivation for treatment is high , especially when facial
esthetics are affected
- Since treatment is less dictated by developmental events ,
treatment options are lessened

27. 3.Some difficulties in adolescent treatment
- The best opportunities for control and manipulation of
severe skeletal dysplasia are past
- Sports and social activities so important to adolescent ,
often compete with plans for orthodontic treatment
- The time necessary for treatment may be longer for certain
malocclusions
- Tooth positioning is often more difficult when the
occlusion is fully established and root formation is
complete than was tooth guidance during eruption

28.  When treating adults orthodontist needs to be prepared to
do the following
- Diagnose different stages of periodontal disease and their
associated risk factors
- Diagnose TMJ dysfunction before , during , after tooth
movement
- Determine which cases require surgical management and
which ones require incisor reangulation to camouflage the
skeletal base discrepancy
- Work cooperatively with a team of other specialists to give
the patient the best outcome

29.  To improve tooth - periodontal relationship
 To establish an improved plane of occlusion in order to
distribute forces through the broadest area possible
 To balance the existing space between teeth for better
prosthetic replacement
 To improve spaces to provide for normal tooth to tooth
contact
 To improve occlusion and coordination with the
masticatory muscles and TMJ
 To satisfy the esthetic desires of the patient

30. Contra indications
 Severe skeletal discrepancies
 Advanced local or systemic disease
 Excessive alveolar bone loss
 Inability to obtain a satisfactory result
 Poor stability prognosis
 Lack of patient motivation

31.  Mandibular skeletal problem in pre adolescent
child –
 AP direction
- Excess – orthopedic posterior force (chin cup )
- Deficiency - orthopedic anterior force (functional
appliances )

32.  Vertical direction
- Excess - orthopedic vertical maxillary force ( vertical pull chin
cup + bite block )
- Deficiency – Appliance to increase the vertical alveolar
development ( bite plane )

33.  Mandibular skeletal problem in non growing
patients
 AP direction
- Excess – mild - camouflage
- severe – surgical mandibular set back
- Deficiency - mild - camouflage
- severe – surgical mandibular advancement

34. Vertical direction
- Excess - mild - camouflage
- severe – surgical height reduction
- Deficiency - mild - camouflage
- severe – surgical height increase

35.  Maxillary skeletal problem in pre
adolescent child –
 AP direction
- Excess – orthopedic posterior force
(head gear )
- Deficiency - orthopedic anterior force
( reverse pull head gear )

36.  Vertical direction
- Excess - orthopedic vertical maxillary force ( high pull
head gear )
- Deficiency – Appliance to increase the vertical alveolar
development (functional appliance )

37.  Maxillary skeletal problem in non growing
patients
 AP direction
- Excess – mild - camouflage
- severe – surgical maxillary set back
- Deficiency - mild - camouflage
- severe – surgical maxillary advancement
 Vertical direction
- Excess - mild - camouflage
- severe – surgical maxillary impaction
- Deficiency - mild - camouflage
- severe – surgical maxillary inferior position

39.  The adult supporting structures react
somewhat differently when compared to the
young tissues because the anatomic
environment in the adults is different
 The periodontal structures , particularly the
labial and lingual bony plates are composed
of a dense lamellated bone tissue with
relatively small marrow spaces,Spongy bone
exists in the interseptal areas
 So,tooth movement in a MD direction
within the “alveolar trough”is more
favorable than in a labiolingual direction

40.  Along the inner bone surface of adults ,a series of darkly
stained resting lines are seen ,indicating that only minor
tissue changes have occurred over a long time
 The root exhibits a thick layer of cementum and strong
apical fibres
 The apical third of the root is more firmly anchored in
adults than in young patients
 Hence , when an adult tooth is tipped over a short distance
there is comparatively little tooth movement of the apical
third of the root
 On the other hand , if the tipping is prolonged , the tooth
will begin to act as a two – armed lever
 There may be apical resorption and destruction of alveolar
bone wall as well

41.  Successful extrusion of teeth is largely dependent on
whether the treatment is performed during favorable
growth period
 Extrusion in a mass movement may result in complete
and permanent closure of the bite provided the
treatment is performed shortly after the eruption of the
teeth
 Such a favorable result is due to the readiness by which
the supporting tissues of young persons are transformed
and rearranged after tooth movement

42.  After the age of 18 – 20 yrs there is less growth
activity
 The pdl fiber bundles will become stretched
after extrusion , but are less readily elongated
and rearranged
 There is also a tendency for more distant fibers
along the alveolar crest to stretch
 Extrusion of adult teeth in a mass movement
may thus result in relapse after displacement
and subsequent contraction of the whole
gingival fiber system
 In such cases , closure of an open bite may be
performed with greater success if front teeth
are extruded individually and not in a mass
movement

43.  Some practitioners state that intrusion of
adult teeth cannot be undertaken without a
corresponding shortening of the apices by
root resorption
 If carefully measured forces are applied ,
there will be less tendency for such
shortening of roots
 Stabilisation of tooth position after intrusion
of adult teeth can be attained only by
establishing a correct MD relationship
between the dental arches

44.  Early jaw surgery has little inhibitory effect on further
growth
 Actively growing patient’s with mandibular prognathism
can be expected to outgrow surgical correction and
require retreatment
 So , the correction of mandibular growth must be
delayed until the late teens

45.  In contrast to mandibular set back , mandibular
advancement at age 14 – 15 is quite feasible
 Maxillary advancement should be delayed until
the early adolescent growth spurt unless there are
preponderant psycological considerations

46.  In an adult patient the amount of bone support of each
tooth is an important consideration
 When bone has been lost ,the Pdl area decreases,and the
same force against the crown produces greater pressure in
the Pdl of a periodontally compromised tooth than a
normally supported one
 The absolute magnitude of force used to move teeth must
be reduced , to prevent damage to the Pdl ,bone ,
cementum and root
 The greater the loss of attachment,the smaller the area of
supported root and the further apical the center of
resistance will become

47.  The magnitude of tipping moment produced by a force is
equal to the force times the distance from the point of force
application to the center of resistance
 Orthodontic force must be applied to the crown of a tooth,
and the further the point of force application is from the
COR,the greater will be the tipping moment produced by any
given force

48.  The number of adult patients in most clinical orthodontic
practices has increased in recent years. Because orthopedic
jaw control through growth is impossible in adult patients
and periodontal disease is more likely,orthodontic tooth
movement is more complex in adults than in adolescents.
 In particular, adults who have periodontal problems risk
permanent damage to the periodontal tissues
 The periodontal ligament (PDL), plays a significant role in
bone remodeling at the PDL-alveolar bone interface during
tooth movement.
 Proliferative activity of fibroblast-like cells in the PDL
decreases with age, and faster or more efficient tooth
movement can be achieved in younger individuals
Age related changes in periodontal ligament

49.  Orthodontic tooth movement as a result of bone modeling
and remodeling also depends greatly on age related
changes of the skeleton
 Cortical bone becomes more dense while the spongeous
bone reduces with age and the structure changes from that
of a honeycomb to a network

50. The biologic background for orthodontic tooth movement in
adults indicates that
1.The forces used in adults should be at a lower level than
those used in children
2.The initial forces should be kept low because the
immediate pool of cells available for bone resorption is low
3.The moment – to – force ratio should be increased
according to the periodontal status of the individual teeth
4.With increasing marginal bone loss , light continuous
intrusive force should be maintained during tooth
displacement

51.  The amount of growth remaining after orthodontic
treatment will obviously depend on the age , sex , and
relative maturity of the patient
 After growth modification treatments ,post treatment
rebound is likely ,with more growth of the upper than the
lower jaw
 Relapse tendency controlled in 2 ways
- To continue head gear on the upper molar on a reduced
basis
- Functional appliance of the activator – bionator type to
hold tooth position and the occlusal relationship

52.  Adult patient’s should be brought to their final orthodontic
relationship with archwires and then stabilized with
immediately placed retainers before eventual detailing of
occlusal relationship by equilibration
 A suckdown plastic wafer is the best choice immediately
upon removing the orthodontic appliance

53. – Scope for growth modification:Skeletal malocclusions
that occurs as a result of altered growth direction and amount
can be interepted by modulating further growth.
– Scope for preventive and interceptive orthodontics:It is the
main advantage of early treatment. Even if the
malocclusion is not totally eliminated, its severity can be
reduced so that complex orthodontic treatment involving
extractions and surgery can be minimized.
Advantages of treating at an early age are:

54. – Helps harnessing natural growth forces: Enables the
dentist to guide erupting teeth into more favorable
positions utilizing the natural guidance of erupting
teeth to move in a mesio-occlusal direction.
– Minimizes psychological distress:Treating at an early
age minimizes psychological distress that can develop
due to a full fledged malocclusion

55. • Role of growth:
– Orthodontic treatment carried out during adolescence or still
later in adults cannot make use of growth potential.Cases
decided for orthognathic surgery should be treated only after
growth completion, to avoid recurrent growth changes with
continuation of abnormal growth pattern.
• Limited treatment option:
– Since the growth is complete, the orthodontist`s treatment
option will be narrowed to moving teeth, and surgery, if needed,
and not on growth modulation, guidance of eruption use of
naturalforcesetc.
• Compromise on treatment objectives:
– Since growth is over, all the objectives for ideal dentition such
as, proper function, aesthetics, and stability may not be
achieved. The treatment may have to be compromised

56. • Vitality of tissues:
– Orthodontic tooth movement is less responsive in adult patients,
owing to decreased vascularity and cellularity, of their periodontal
membrane and bone. Hence tooth movt. requires more time
• Role of growth:
– Orthopedic correction cannot be achieved after growth completion,
however orthodontic correction can be achieved in an adult, by
altering the force magnitude and duration.

57. • Role of apical foramen
-For adults, the apical foramen is narrower, in contrast to
younger individuals, hence force application on the
tooth can pose a greater chance for non-vitality, root
resorption, and ankylosis of teeth to occur.In younger
patients there is lesser chance of pulpal damage.

58. • Density of bone:
Since the bone density if higher for adults,
tooth movement is slower.

59. • An adult patient may have additional problems
such as:
– Periodontitis
– Faulty restorations
– Attrition
– Loss of teeth
– Impaction
– Bone loss
• The diagnosis for an adult should consider
these factors, for the success of the orthodontic
treatment.

60. • Myofunctional and orthopedic appliances
cannot be used for adults, owing to growth
cessation.
• Young patients tolerate most appliances and are
not bothered about the appearance of the
appliance
• Since esthetics is the prime concern of adults,
removable appliances, fixed appliances (for
e.g.Lingual orthodontics),orthognathic surgery
etc, are the treatments options available

61. • More cooperation is usually achieved from
an adult, rather than from a child

62. • Since adult treatment most often needs to be
compromised, the orthodontist has to strike the
best balance between the three objectives of
orthodontic treatment namely; function,
esthetics and stability.

63. • Adult patients appreciate treatment results
better than children.

64. The Indications are:
• Prosthodontic
• Periodontal
• Temperomandibular joint
• Esthetic

65. These are:
* Parallelism of abutment teeth
* Uprighting of tilted teeth
* Regaining lost extraction spaces
* Derotation of rotated teeth
* Intrusion of supraerupted teeth
* Distribution of extraction space more
favorably

66. • Crowding of teeth:
– Crowding Plaque accumulation
Periodontitis
• Spacing between teeth:
– Spacing between teeth Food lodging
Periodontal Pocket formation

67. • Usually caused due to early loss of posterior
teeth, leading to over closure, and loss of
vertical height
• Orthodontist can relieve the symptoms using
splints before embarking on prosthetic
rehabilitation

68. • This is the most motivating factor behind
seeking treatment
• Usual causes of esthetic concern are:
– Crowding
– Rotations
– Migrations, etc
All owing to periodontal problems

69. • Medical: Bone formation is compromised in certain diseases
such as Diabetes. Also treating medically compromised
individuals is difficult
• Periodontitis: Patients with poor oral hygiene, mobile teeth, and
periodontitis are poor orthodontics patients
• Skeletal malocclusions: These require surgical intervention, and
thus may not be taken up, owing to the physical and medical
status of the patient
• Under motivated patients: It is advised not to start the treatment
unless the patient is determined to see the therapy through to
completion
• Poor stability prognosis

70.  In recent times there has been an increase in the
number of adult patients seeking orthodontic
correction of malocclusion
 However orthodontic treatment yields best results in
younger age group, that is, during the growing period
as the orthodontist has the growth potential to work
with and merely relies on tooth movement and
surgery.