adult orthodontics
TRANSCRIPT
Adult orthodonticsDR. TONY PIOUS
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 crestheight with age0.017mm/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.
factors adolescents adultsDental caries More susceptible Recurrent decay
restorative failures, root decay& pulpal pathosis
PDL disease Resistance to bone lossSusceptible to gingivalinflammation
Susceptible to bone loss
TMJ adaptability
high Symptoms with dysfunction
Occlusal awareness
Infrequent Increased enamel wear with adverse change in supporting tissue.
comparison
Factors Adolescents adultsGrowth factors Growth-orthopedic
Stable correction .No growthMinimal skeletal adaptability.Surgical option
Dentofacial esthetics
Reasonable concern Concern occasionally disproportionate to degree of existing problem
factors adolescents adultsRate 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 potential
Head gear implants
Missing teeth
Space closure without prosthesis
Restorative
factors adolescents adultsExtraction controversy
4 PMs Less frequently
Strategic extraction
uncommon common
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
Teeth should be positioned properly over basal bone
Improved self maintainace of PDLhealth occurs with proper tooth position
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 treatmentActive disease
Disease control
Establish occlusion
Definitive restorative Rx
maintenance
Re-evaluate
stabilize
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 molarsBirte melsen,JCO 1996case1
56yrs/MMissing lower 1st molar
case1
Case 242/FMissing 46
Case 2
Distal jet
A simple technique for molar uprighting –E Capelluto,JCO 1996
“MUST”
Final positioning of molar & PMs
Compressed coil springs018 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 48yrs/F Class II div 1 Deep bite Missing12,47,46,45,35,36,37Treatment plan: surgical correction6 implants on 37,26,25,47,46,45Healing period -4 monthsImplant-supported FPDUprighting of 3rd molar + alignmentSame implants-abutments.
Kenji W Higuchi
Case 1
case1
Case 2
53yrs/M Class III Ant &post crossbites spacing
Treatment plan: 2 implants,35&36Healing period -4 monthsImplant-supported FPD
Case 3
64yrs/F Class I Impacted canine Missing teeth
Treatment plan: Extrusion of impacted canine1 implant -16Healing period-6 monthsImplant supported FPD-anchorageSame 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 problemAnt crossbite -estheticTipped teeth-removable aplElasticsEstablishing a good overbite relationship is the key to maintainingcrossbite 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 factorsLocal factorsPlaque indicesCrown root ratioHabitsRestorative 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
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%
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 lossBirte 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 intrusionBirte melsen JCO 1996
Case 1 38yrs/F Missing teeth Chewing difficulty
4.5mm-intrusion7.5mm- mesial movement2mm- reduction of clinical crown ht.
Case 2
40yrs/FMissing 15,16,25,27,28,35,37,38,44,45,47,48Chewing difficulty.
3mm-intrusion8mm-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
Case122yrs/FModerate crowding
Case 224yrs/FSevere crowding
Case 321yrs/MAnterior crossbitecrowding
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 area reliable source of orthopedic anchorageFor managing malocclusions that are the usual scope of orthodontic practice
45yrs/MMissing lower molar
Case report
Space closure- Removable prosthesis
35yrs/M Class III Generalized attrition Upper midline shift Asymmetric smile Missing teethTreatment plan:Comprehensive orthodontic therapyDefinitive 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.
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
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 casesRobert L Boyd, R J Miller,JCO 2000 April
Case 123yrs/FSpacing b/w teeth
33yrs/MSpacing b/w teeth
Case 2
case3
35yrs/MMild crowding
Lower incisor extraction treatment with invisalign system-Ross J Miller2001 JCO nov
Case report24yrs/FLower incisor crowdingClass I molar relnMidline shift-3mm Rt side
Rapid orthodontic decrowding with alveolar augmentation: case report
William . M . WilckoThomas . Wilcko World Journal Orthodontics 2003:4:197-205
Demonstrates a New orthodontic method that provides shortened treatment times.
Case report27yrs/FClass 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 OcclusionMild crowding in lower archLower midline shift
Only lower canine-canine decorticotomy.
After 10 days of corticotomyInvisalign 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 & retainersHawley retainerTooth positionerSpring retainer
Fixed retainerBonded retainerBanded retainer
Hawley retainer
Hawley retainer –modified
Positioner
Positioner
Fixed retainer
Fixed retainer
QCM-Organic polymer retainer
Labial fixed retainer
Labial fixed retainer