adult orthodontics

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