Adult orthodontics 1 /certified fixed orthodontic courses by Indian dental academy

Adult orthodontics

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

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 gingival
inflammation

Susceptible to bone loss

TMJ
adaptability

high

Symptoms with
dysfunction

Occlusal
awareness

Infrequent

Increased enamel wear
with adverse change in
supporting tissue.


Factors

Adolescents

adults

Growth factors

Growth-orthopedic
Stable correction .

No growth
Minimal skeletal adaptability.
Surgical option

Dentofacial
esthetics

Reasonable concern

Concern occasionally
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
potential

implants

Missing
teeth

Restorative

Space closure
without prosthesis


factors

adolescents adults

Extraction 4 PMs
controversy

Less
frequently

Strategic
extraction

common

uncommon


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 3 molar is present?
• Uprighting by distal crown/ mesial root
rd

•

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 wire17x25 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 3 of the root
• Horizontal / vertical #
• Internal/external resorption
• Decay
• PDL – disease
• To obtain good access for endodontic and
rd

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


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 problemsSchiffman et al (1998)
Muscle disorder
Joint disorder
Combination
Normal

23%
19%
27%
31%



Diagnostic records

•
•
•
•

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

•
•
•



Thickest enamel -maxillary arch

•
•



Mild- less than 3mm
Moderate- 3-5mm
Severe -more than 5 mm
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 siteW.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
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.

Procedure

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.

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
World Journal Orthodontics 2003:4:197-205
Thomas . Wilcko
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 treatmentAlbert 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


Fixed retainer


QCM-Organic polymer retainer


Labial fixed retainer


CASE NO-3
D.P 21/F


34

D.P.21/F


35

D.P.21/F
SEVERE SKELETAL CLASS II WITH
MATCHING SOFT TISSUES
HYPERDIVERGENT JAW BASES
SEVERE PROCLINATION OF U-ANTERIORS.


36

D.P.21/F
PRESURGICAL PHASE


37

D.P.21/F
PRESURGICAL PHASE


38

D.P.21/F
POST SURGICAL PHASE


39

D.P.21/F
PRE -FINISHING RADIOGRAPHS

SUPERIMPOSITION


40

D.P.23/F


40

D.P.23/F


41

D.P.23/F


42

D.P.23/F
COMPARISON


43

D.P.23/F
COMPARISON


44

Thank you
Leader in continuing dental education


Adult orthodontics 1 /certified fixed orthodontic courses by Indian dental academy

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