Adult orthodont ics

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

Index
• Adult ?
• History of adult orthodontics
• Adult orthodontics
• Reasons for increased interest of adults in
orthodontic treatment
• Indications
• Contraindications
• Difference between adult and adolescent
patients
• Limitations

Index
• Treatment objectives
• Diagnosis
• Treatment planning :
Psychological considerations
Biomechanical considerations
Periodontal considerations
TMJ
• Treatment :
Adjunctive treatment
Comprehensive treatment
Surgical treatment
• Conclusion www.indiandentalacademy.com

ADULT ?
• Adult is defined as one who is fully grown, most
males 18 and above and most females of 16
and above can be considered to be adults,
although residual growth is left.
• It is however quite impractical to determine the
exact time when adulthood begins, since there is
no definite age when a person reaches physical
maturity.

HISTORY
• Kingsley, in 1880, indicated an early awareness
regarding orthodontic potential in adult patient.
• He stated, “It may be regarded as settled fact
that there are hardly any limits to the age when
movement of teeth might not succeed.”

HISTORY
• MacDowell(1901) was of the opinion that
after the age of 16 years, a complete and
permanent change in transition of the occlusion
& hence orthodontic treatment, is almost
impossible owing to the development of,
- adult glenoid fossa,
- density of the bones ,
- muscles of mastication.

HISTORY
• Lischer (1912) believed that the period
from 6th
to 14th
year was a golden age of
treatment

HISTORY
• In 1921 Calvin Case demonstrated the value of
orthodontic therapy in the lower anterior area for
the aged, periodontally affected patient.

ADULT ORTHODONTICS
• Ackerman : “Adult orthodontics is concerned
with striking a balance between achieving
optimal proximal and occlusal contact of the
teeth, acceptable dentofacial aesthetics, normal
function and reasonable stability.”

Recent AAO survey : Increased % of patients >21
yrs, from 4% ten yrs ago, to almost 7% today; in
another decade’s time adult pts would constitute
11% of avg orthodontic practice.
• [JCO:1997:Gottleib,Nelson]

INCREASED INTEREST IN
THE ADULT PATIENT
Reasons
[Melsen in ‘Curent controversies in
Orthodontics’]
1] Innovations in appliance placement techniques
– Direct bonding, lingual/invisible appliances

2] Innovations in
material research –
ceramic brackets &
tooth coloured
wires
3] Role of family
dentist - Increased
desire of restorative
dentists and
patients for
treatment of dental
mutilation problems
using tooth
movement rather
than prostheses.

4] Role of media, visual as well as print -
Articles in magazines ,news paper as well
as community programs have increased
patient awareness towards health &
esthetics.
5] Better management of TMJ dysfunction.

6] More effective management of skeletal jaw
dysplasias with advanced orthognathic surgical
techniques.
7] Reduced vulnerability to periodontal breakdown
as a result of improved tooth relationships and
occlusal functions.
8] A broader understanding of the biology of the
tooth movement especially with regard to age
changes.

9] Ingenious approaches to anchorage management
such as implants.
10] Role of Insurance companies – in the US
11] Affluence – Improving socioeconomic standards
makes orthodontics more affordable today .

INDICATIONS (RAVINS)
1) Improvement of tooth-periodontal tissue
relationship.
2) Establishing an improved plane of occlusion to
distribute the forces of occlusion better.
3) Balancing the existing space for better prosthetic
replacement.
4) Improve occlusion and coordination between the
muscle and TMJ.
5) Improve patient esthetic.www.indiandentalacademy.com

CONTRAINDICATIONS
(BARRER)
1) Severe skeletal discrepancies.
2) Advanced local or systemic disease.
3) Excessive alveolar bone loss.
4) Poor stability prognosis – tooth movt into
unfavourable positions.
5) Lack of patient motivation & co-operation,
resistance to wear the appliance.www.indiandentalacademy.com

6) Inability to prevent excessive hard/soft tissue
destruction
7)Inadequate space for tooth movt
8)Movt of teeth against occlusal opposition or into
occlusal trauma
9)No improvement in PDL health, function/esthetics.
10)Negative anchorage potential – movt of teeth
against inadequate anchorage.

CONTRAINDICATIONS
(Marks and Corn)
• Advanced systemic disease
• Lack of patient motivation.

1] Younger adults (under 35, often in their 20’s)
2] Older patients (in their 40’s and 50’s)
[Proffit-Fields]
2 GROUPS OF ADULT
ORTHODONTIC PATIENTS

YOUNGER GROUP
Goal –
Comprehensive treatment & maximum possible
improvement; improved quality of life.

Reasons for not receiving orthodontic
treatment early
1) Did not desire treatment.
2) Were not aware of orthodontic treatment.
3) Parents could not afford.
4) Were not given proper advise by family
dentist.
5) No orthodontist located in the vicinity.

6) Incomplete orthodontic treatment when
younger or were uncooperative.
7) Had orthodontic treatment as children but
relapse occurred.
8) More conscious of appearance with age.
9) Anterior teeth started to crowd or minor
crowding becomes worse.
10) Dissatisfaction with the outcome of previous
treatment www.indiandentalacademy.com

OLDER GROUP
Goal -
- Maintain proper dental health.
- For easy & effective control of disease &
restoration of missing teeth.
- As an adjunctive procedure to the larger
periodontal & restorative goals ; not necessarily
interested in the ideal result.

Reasons for seeking orthodontic
treatment
1) Malposed teeth contributing to PDL disease.
2) Increased difficulties with mastication.
3) Anterior spaces enlarging or new ones developing.
4) For better tooth positioning prior to prosthetic
preparation.
5) Tooth interferences & mandibular slide causing
TMJ problems.

ADOLESCENT vs ADULT
ORTHODONTIC PATIENT
Levitt : “In adult patient there is no growth
and only tooth movement”.
Barrer : “Adult, unlike the child is a
relentless patient, who will not cover our
deficiencies in skills or our errors in the
use of mechanical procedures by helpful
settling in post-treatment.”

• Ackerman : “In a child ,one occasionally
calls on another specialist. On the other
hand it is a rare adult whom one treats
orthodontically without finding it necessary
to collaborate with another specialist.”

• Adults – orthodontic treatment is based on
symptoms detected by the patient
• Children - treatment is based more often
on signs detected by practitioners/parents.

• Adult – seeks treatment more often for
esthetics & hence is likely to have
unreasonable expectations about the
outcome, is less adaptable to the
appliance & is uncompromising in
appraisal of the Rx results.
• Brighter side – cleaner, more careful,
punctual, prompt paying, much less
sensitive to pain & Rx time is either
same/less than that for younger patients.

FIVE MAJOR CATEGORIES IN WHICH
ADULT PATIENTS SIGNIFICANTLY
DIFFER FROM THEIR ADOLESCENT
COUNTERPARTS
1) Clarification & individualization of
treatment objectives
2) The diagnostic process
3) Treatment plan selection
4) Acceptance of recommended therapy
5) Achievement of treatment objectives

1) Clarification & individualization of
treatment objectives-
This requires specific study of the problem &
the indicated therapeutic refinements.

2) The diagnostic process-
Problem oriented dental record aides
in making the appropriate diagnosis,
for it requires that the patient’s
problems be listed and a plan be
developed to manage each problem.

Diagnostic steps:
1) Collect data accurately.
2) Analyze data base.
3) Develop problem list.
4) Prepare tentative treatment plan.
5) Interact with those who are involved;
discuss plans and options; clarify
sequence, acquire patient acceptance.
6) Create final treatment plan.

Before starting the treatment, the
orthodontist needs to be prepared to
do the following:
1) Diagnose different stages of PDL
disease and their associated risk factors.
2) Diagnose TMJ dysfunction before,
during or after tooth movement.

3) Determine which cases require surgical
management and which ones require
incisor reangulation to camouflage the
skeletal base discrepancy.
4) Work cooperatively with team of other
specialists to give the patient the best
outcome.

3) Treatment plan selection-
More systemic & detailed analysis is
required for adults than for adolescents.
Factor affecting treatment plan
selection:
i) Existing oral pathology:
- dental caries
- periodontal disease
- faulty restoration
- TMJ adaptability
- occlusal awarenesswww.indiandentalacademy.com

ii) Skeletal relationship.
iii) Biological consideration:
- neuromuscular maturity/adaptability .
- periodontal susceptibility:bone
loss/gingival inflammation .
- rate of tooth movement.
- growth.
iv) Therapeutic approach available:
- functional appliances.
- orthognathic surgery.
- restorative dentistry.www.indiandentalacademy.com

v) Extraction therapy: 4 PM / asymmetric,
lower incisor.
vi) Anchorage requiremen: headgear /
completely erupted 1st
& 2nd
molars
vii) Missing teeth: space closure without /
with prostheses

4) Patient’s acceptance of the
treatment plan-
Patients thorough understanding of &
agreement with the recommended Rx are
necessary. Also, an informed consent
should be signed
i) Sociobehavioral interaction:
- Office environment: group / privacy
- Team coordination, interaction:
multidisciplinary approach
ii) Duration of treatment.

iii) Cost of treatment: with/without
insurance cover
iv) Perceived risk/benefit ratio: more
benefits compared to minimal risks
v) Appliance selection.
vi) Insurance coverage

• Vii) Negative conditioning: in the past .
viii) Positive conditioning.

5) Achievement of treatment
objectives-
-requires specific study of the problem &
the indicated therapeutic refinements
- depends on :
i) Dental history.
ii) Ability of the orthodontist to interface
the treatment plan with those of other
dental specialist.
iii) skills and knowledge of orthodontist
and staff. www.indiandentalacademy.com

LIMITATIONS OF TREATMENT
2 types of factors :
• Intrinsic – Biological nature
• Extrinsic – Biomechanical systems

INTRINSIC FACTORS
• Most marked – Adult is no longer growing, so
orthodontic Rx is limited to tooth movt & related
modelling of the alveolar process only (may vary
with the age & health )
• Periodontium – primary tissue to get affected.
• Norton : decreasing blood flow & vascularity with
increasing age – insufficient source of
progenitor(preosteoblasts) cells – delayed
response to mechanical stimulus.

• Alveolar bone – cortical bone becomes
denser & spongy bone reduces with age &
structure of bone changes from
honeycomb to a network
• Apical displacement of marginal bone
level - local factor, age related but is also
due to progressive PDL disease

• Teeth - adults are more likely to have
missing teeth, teeth reduced in dimension
due to attrition or teeth with large
restorations.

EXTRINSIC FACTORS
• Force system used differs from that used in
young, growing individuals.
• Forces used should be at a lower level than
those used in children, as adults often have PDL
problems & reduced bone support.
• Initial forces should be further kept low as the
immediate pool of cells available for resorption is
low.

• M/F ratio for a
particular tooth
movt should be
increased as per
the periodontally
compromised
state of the
dentition, to
counter the
tipping
tendency.

• In the presence of marginal bone loss,
light continuous intrusive forces should be
maintained during tooth displacement.

!!! ADULT PROBLEMS DIFFICULT
TO TREAT BY ORTHODONTICS !!!
• Deep bite – extrusion of post teeth is not
compensated for by condylar growth
• Posterior crossbite – arch expansion is
not stable
• Skeletal discrepancies – since growth is
complete.

1) Dentofacial aesthetics
2) Stomatognathic function
3) Stability
4) Achieving Class I occlusion
:ADULT ORTHODONTICS -
TREATMENT OBJECTIVES

ADDITIONAL ORTHODONTIC
TREATMENT OBJECTIVES
1) Parallelism of abutment teeth :
- Restoration will have better prognosis as
excess cutting or devitalization during
abutment preparation are avoided.
- Allows for a better pdl response.
- Allows for better retention.www.indiandentalacademy.com

2) Most favorable distribution of teeth :
- Evenly for replacement of fixed/removable
prostheses in the individual arches
- Teeth should be positioned in such a way
that occlusion of natural teeth can be
established bilaterally between the arches.

3) Redistribution of occlusal and incisal
forces –
Helpful in case of significant bone loss, to
maintain the occlusal vertical dimension.
4) Adequate embrasure space and proper
root position –
Allows for better pdl health, especially
when placement of restorations is
necessary.

5) Acceptable occlusal plane and potential
for incisal guidance at satisfactory vertical
dimension –
For a mutilated dentition with bite collapse,
the Hawley bite plane adjusted to the
correct vertical height, is inserted – allows
a centric relation at an acceptable vertical
dimension, simulatneous bilateral
neuromuscular activity;
Curve of spee should be mild to flat
bilaterally – unilateral orthodontic
treatment of an accentuated occlusal
plane should be avoided.www.indiandentalacademy.com

6) Adequate occlusal landmark
relationships:
- Most difficult dimension to correct &
maintain orthodontically – transverse
sagittal vertical.
- Teeth must be positioned yo achieve
acceptable B-L landmarks.
Post crossbites due to severe transverse
skeletal dysplasias – maxillary buccal
cusps contact lower central fossae with
the crossover for incisal guidance in the
PM or canine positions.www.indiandentalacademy.com

7) Better lip competency and support -
Inadequate support may create change in
antero-posterior and vertical position of upper lip
and increase wrinkling.
Some Class II, division 1 patients (surgery
rejected) – lower incisors can be placed
procumbent with bilateral posterior restorations
– establish incisal guidance; avoids palatal
tissue irritation.
Some class III’s – maxillary incisors kept more
flared than normal

8) Improved crown/root ratio –
In case of individual teeth bone loss, the
crown to root ratio can be improved by
decreasing the length of clinical crown
with a high speed handpiece as the tooth
is erupted orthodontically.

9) Improvement/ correction of mucogingival and
osseous defects:-
Proper repositioning of prominent teeth in arch will
improve gingival topography.
Adolescents – brackets placed to level marginal
ridges & cusp tips
Adults – level crestal bone between adjacent
CEJ’s; favorable osseous & soft tissue changes
with tooth movt , diminished need for
osseous/mucogingival surgery; continuous
adjustment to prevent premature post teeth
contact causing occlusal trauma.www.indiandentalacademy.com

10) Better self maintenance of pdl health:
Location of gingival margin - determined by axial
inclination & alignment of the tooth.
For better periodontal health, teeth should be
positioned properly over their basal bone
support.
11) Esthetics and functional improvement:
Rx= acceptable esthetics + improved muscle
function + normal speech + mastication
Therapeutic occlusion = ant teeth as
disarticulators; post teeth support the vertical
dimension.

Treatment planning
Usual sequence of procedure is as follows –
• Eliminate all pathology (caries, PDL disease,
retained roots, etc)
• Orthodontic Rx
• Periodontal re-evaluation (& therapy if
necessary)
• Prosthetic restoration (when necessary)
• Orthodontic retention
• Periodontal maintenance
• Occlusal adjustment (grinding) whenever
necessary

BIOMECHANICAL
CONSIDERATIONS:
- Control of anchorage requires that
anchor teeth should not be allowed to tip.
- Fixed appliance is necessary.

• Adult patients
demand for
removable
appliance but they
are not useful in
adjunctive
treatment.
- But in case of
multiple missing
teeth removable
appliance is useful.

Placement of brackets
• A=ideal position
– uprighting of
ant teeth (movt
of anchor teeth
is undesirable)
• B=brackets
placed in
position of max
convenience-
maintains
existing tooth
alignmentwww.indiandentalacademy.com

• - In case of
reduce
periodontal
support and
bone loss ,
lighter forces
and relatively
larger
movements are
needed.

TIMING AND SEQUENCE OF
TREATMENT:-
- Before any type of tooth movement
any caries or pulpal pathology should
be eliminated.
- Larger restoration require detail
occlusal anatomy should be carried
out after orthodontic treatment is
over.

- Periodontal disease should be
controlled before any tooth
movement.
- Scaling, curettage and gingival graft
should be carried out before
treatment.
- Surgical pocket elimination and
osseous surgery should be carried
out after orthodontic treatment.

Psychological considerations
• Children & adolescents – motivation for ortho Rx
= parent’s desire; not emotionally involved in
their own Rx
• Adults – seek ortho Rx because they themselves
want something, that is not always clearly
expressed=hidde set of motivations/unrealisti
expectations
• Imp – explore why pt wants Rx & why now
“Ortho Rx cannot repair personal relationships,
save jobs, or overcome a series of financial
disasters” - Proffitwww.indiandentalacademy.com

• Most adults – have realistic expectations, more
positive self image than average, a good deal of
ego strength.
• Internally motivated responds well to Rx than
externally motivated.
• Demand for invisible orthodontic appliances-
unrealistic for a patient to expect that ortho Rx
can be carried out without other people knowing
about it

• Sometimes - Rx in a pvt area if the patient
demands so;
Most adults – learning from interacting with other
patients = beneficial
• Patient handling –
Adolescents = passive acceptance of what is
being done
Adults = considerble degree of explanation of what
is happening & why;
Interest in Rx does not automatically translate into
compliance with instructions

• Adults – less tolerant of discomfort & more
likely to complain about pain after
adjustments & about difficulties in speech,
eating & tissue adaptations.
Additional chair time to meet these
demands should be anticipated

ACCORDING TO PROFFIT ADULT
ORTHODONTIC TREATMENT IS
DIVIDED IN TO 3 PARTS:
1) ADJUNCTIVE TREATMENT.
2) COMPREHENSIVE TREATMENT
FOR ADULTS.
3) SURGICAL TREATMENT.

DIFFERENCE BETWEEN
ADJUNCTIVE TREATMENT AND
COMPREHENSIVE TREAMTMENT
IS INDISTINCT,AS ANY TREAMENT
WHICH REQUIRE MORE THAN 6
MONTHS IS CALLED AS
COMPREHENSIVE TREATMENT.

ADJUNCTIVE TREATMENT-
“ Tooth movement carried out to
facilitate other dental procedures
necessary to control disease and
restore function.”

GOALS -
1) Facilitates restorative treatment by
positioning the teeth.
2) Improve periodontal health by
removing plaque harboring areas .
3) Establishing favourable crown to
root
ratio and position of the teeth.

PROCEDURES CARRIED OUT IN
ADJUNCTIVE TREATMENT : -
1) Uprighting posterior teeth.
2) forced eruption.
3) alignment of anterior teeth.
4) crossbite correction.

THANK YOU

* Etiology of adult malocclusion.
* Types of adult orthodontic patients.
* Types of adult orthodontic
treatment.
* Adjunctive treatment:
- Goals
- Biomechanical considerations.
-
Timing and sequence.
- Procedures carried out.

ETIOLOGY OF ADULT TOOTH
MALPOSITION:-
1) DENTAL ORIGIN
2) SKELETAL ORIGIN

1) DENTAL ORIGIN:-
a) Faulty eruption from the
normal functional position.
b) Insufficient arch length.
c) Excessive arch length.
d) Prolonged retention of primary
teeth.
e) Ectopic eruption.

g) Prolonged finger and thumb
sucking habits.
h) Clenching and grinding.
i) Improper swallow pattern with
tongue thrusting.
j) Effects of tongue pressure on the
anterior teeth.

k) Macroglossia.
l) Premature loss of deciduous teeth.
m) Loss of permanent teeth.

2) SKELETAL ORIGIN:-
a) Cleft palate.
b) Gross mediolateral disharmony of
the craniofacial skeleton.

UPRIGHTING POSTERIOR
TEETH:-

1) If third molar is present ,
whether both second and third
molar should be uprighted.
2) Whether to upright tipped
teeth by distal crown tipping or
by mesial root movement.

3) Whether we need slight extrusion
or maintain occlusal height during
uprighting.
4) Whether premolar should be
repositioned or not.

APPLIANCE FOR MOLAR
UPRIGHTING:-
- Partial fixed appliance.
- Anchorage.
- Placement of brackets on canine
and premolars.

UPRIGHTING A SINGLE MOLAR:-
 Moderately tipped
molar:-
- 17x25 braided
s.s
- 17x25 Ni-Ti
 Severely tipped
molar:-
-19x25 s.s
- Uprighting spring
( 17x25 beta- Ti)

• “ T-loop”
- 17x25 s.s
- 19x25 beta-Ti
• Activation of T-loop.

• Severely tipped
teeth:-
- Use of modified T-
loop.

• Final position of
molars and
premolars.
• Use of open coil
spring - steel
- A Ni-Ti
• Occlusion should be
checked carefully.

RETENTION
• For shorter period
• For a longer period.
- Intracoronal wire
splint

FORCED ERUPTION:-
Indications:-
- Defects in cervical third .

TREATMENT PLANING:-
- Periapical radiograph.
- Single tapering and flared and
divergent root morphology.
- Endodontic therapy.

How much tooth should be extruded
can be determine by 3 factors:-
1) Location of the defect.(fracture
line)
2) Space to place margin of the
restoration.(1 mm)
3) An allowance for the biological
width of the gingival attachment.(2www.indiandentalacademy.com

 Duration:-
- 1mm/week without damaging pdl.
- 3 to 6 week.

TECHANIQUE
• Continuous flexible
wire is
contraindicated.

2 METHODS
– With orthodontic
bracket.
– Without orthodontic
bracket.

• Brackets are placed
more occlusally on
anchor teeth than its
ideal position.
• T-loop,
- 17x25 s.s
- 19x25 beta-Ti

RETENTION:-
- By passively fitting rectangular arch
wire.(3 to 6 week).

ALIGNMENT OF ANTERIOR TEETH
Indications:-
1) To improve access and permit
placement of well contoured
restorations.
2) To permit placement of crowns
and pontics .

3) To reposition closely
approximated roots and to improve
the amount of interradicular bone.
4) To position teeth so that implants
can be placed to support
restorations.

* Alignment of crowed, rotated and
displaced incisors.
* Separation of approximated teeth.

• Position teeth for single tooth
implant:-
- Minimum 6mm of space is require.
- Apices of adjacent teeth.

Anterior diastema closure and
space redistribution:-
Causes:-
- Loss of posterior teeth.
- Small teeth.
.- Loss of bone support.

TREATMENT:-
- With Removable appliance.
- With fixed appliance.

CROSSBITE CORRECTION:-
- It can cause functional problem and
occlusal trauma.
- Single tooth crossbite.
- Group of teeth in crossbite.(part of
skeletal problem).

- Correction with removable
appliances.(anterior segment)
- Correction with the “through the
bite” elastics.(posterior segment).

SUMMARY:-
There is wide variety
of etiology that can cause an adult
malocclusion. Also each patient’s
need for treatment are different so
treatment should be carried out
taking his/her needs in consideration.
Adjunctive treatment helps by
facilitating other dental procedures to
control disease and restore function.

Thank you
For more details please visit

Adult orthodont ics

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