Adult orthodontics

Adult Orthodontics
Adult orthodontics
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Adult orthodontics
• Contents
– Introduction
– History
– Classifications
– Goals and Objectives
– Adjunctive orthodontics
– Comprehensive orthodontics
– Surgical orthodontics
– Recent advances
– Retention
– Conclusion
– References

INTRODUCTION
• The frequency of malocclusion in adults is equal (or) greater
than that observed in children and adolescents. Until recent years
adults seeking orthodontic treatment was unusual. Since 1990’s
15% of the ortho patients were adults. They fall into 2 different
groups
• (1) younger adults (under35, often in their 20’) who desired,
but not received ortho treatment during adolescents.
• (2) An older group, typically in their 40’s or 50’s who have
other dental problems and need orthodontics as part of larger
treatment plan.

• HISTORY
• Conflicting opinions have always existed
regarding the feasibility of orthodontic
treatment in the adult
• Kingsley (1880) suggested that there were
hardly any limits to the age of when tooth
movement might not succeed (he treated a 40
year old patient with anterior cross bite).
• In contrast Mac Dowell (1901) was of the
opinion that after 16 years of age, orthodontic
treatment was also impossible owing to the
development of the glenoid fossa, the density of
the bones and muscles of masticator.

• Lischer (1912) believed that the period between 6–14. years was
a golden age of treatment
• Case (1921) demonstrated treatment possibilities in aged and
periodontally affected patients
• Lindegaard et al (1971)-3 factors.
1.A disease or abnormality must be present
2.The need for treatment must be understood, the priority for
orthodontic care based on personal and professional judgment
3.The patient must have a strong desire for treatment

• Reidel & Dougherty (1976) predicted the
status of adult ortho treatment today and
stresses the need for adjunctive orthodontic
services provided by periodontist and restorative
dentist.
• “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.

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

Acc to Gurkeerat singh ( jco 1996)
For all practice purposes the adult patients are
classified in 3 groups
1.Group I : 18 to 25 years of age
2. Group II: 26 to 35 years of age
3. GroupIII: 36 years and alder

DIAGNOSIS AND ADULT
ORTHODONTICS
• Careful diagnosis and treatment planning on
a multidisciplinary basis is required to treat
adult patients. In truth, the adult, unlike the
child, is a relentless patient who will not cover
up deficiencies in the skill of diagnosis or errors
in the use of mechanical procedures by helpful
settling – in post treatment. He presents with no
growth, little rebound and meager
accommodation to mechanics.

In addition, the adult may exhibit a potential for
such pathological changes as knife-edge
ridges,increased cortical thickness, buried roots,
impactions, periodontal breakdown, atropic
changes TMJ problems osteoporosis,
osteomalacia, diabetes mellitus. These
conditions, which obtain as a result of
hormonal, vitamin or systemic disorders
common to the adult, necessitate more careful
and extensive diagnosis evaluations.

• Orthodontic diagnosis involves development of a
comprehensive database of pertinent information. The
standard diagnostic aids such as case history, clinical
examination and study casts, radiographs and
photographs are mandatory.
• I.O.P.A, occlusal and TMJ films should be obtained
routinely in addition to the panoramic radiograph and
the cephalogram. The problem oriented diagnostic
approach as described by Proffit and Ackerman is
strongly recommended to ensure that no aspect of the
patient need is neglected.

• Additional diagnostic procedures that we
should consider in an adult patient are
• A full series of TMJ x – rays
• Muscle examination
• Splint therapy
• Diet evaluation

Psychological status of patients seeking orthodontic
treatment.
• Psychological outcomes of orthodontics on the patients
self image is positive.
• Psychology to the clinical practice of orthodontics can
be divided into:-
-Social psychology
-Motivational psychology

• (i) Social Psychology of Orthodontics:-
Why patients seek orthodontic treatment?
-Dentofacial anomalies such as crooked teeth & skeletal
disharmonies have been reported as the cause of teasing &
harassment among children.
-Bennet & Philip.
• Adults seek for treatment to improve their facial & dental
appearance which in turn will lessen social embarrassment &
improve the self confidence.
-Hunt & Johnston.

Psychologic outcomes of orthodontic treatment:-
Dentofacial esthetics play an important role in a individual’s
self image.
Children with malocclusion did not have poor self image &
orthodontic treatment did not improve it-Dann.
Dentofacial disharmonies have significant social &
psychological effect on the patient-Albino.

• Kiyak et al reported psychological influences on
the timing of orthodontic treatment.
-Developing children well being may be an
indication for early orthodontic treatment.
-Racial differences may be present in the psychological
influences of orthodontics.

• (ii) Motivational psychology:-
The success of orthodontic therapy depends on patient compliance.
 Egolf described a compliant patient as one who practices good
oral hygiene, wears appliance, follows an appropriate diet and keeps
appointment.
 Southard et al pointed out that improved co-operation by the patient
helps to achieve the treatment objectives within a minimum time.

• Improved oral hygiene can decrease damage to the
periodontal tissues and limit the effects of enamel
decalcification and caries
-Nanda & Sinha

• PERIODONTAL DIAGNOSIS
• Assess the patients potential for bone loss and gingival
recession during orthodontic tooth movement.
• Patient should be screened for the risk factors of
periodontal disease.
• Pre treatment consultation with the periodontist should
be routine and orthodontic objectives be altered
according to his advice. Movement of teeth in the
presence of periodontal inflammation will result in an
increased loss of attachement and irreversible crestal
loss.

TMD Diagnosis
• Signs of symptoms of TMD often increase in frequency and
severity during adult treatment. So it is imperative for the
orthodontist to be familiar with their diagnostic and treatment
parameters.
• Adult patients especially females with TMJ sign and symptoms
should be evaluated regarding exposure to stress and her
handling of stress.
• SCHIFMANN et al divided TMD problems into
• Muscle disorders - 23%
• Joint disorders – 19%
• Muscle / Joint disorder combination – 27%
• Normal – 31%

• TMJ DISORDERS
• Deviation in form - Irregularities in intracapsular soft
and hard articular tissue.
• Disc displacement with reduction – Altered Disc-
condyle structural relationship is not maintained during
translation, reciprocal clicking is present.
• Disc displacement without reduction – Altered
Disc-condyle relationship is maintained during
translation.
• TMJ Hypermobility – Excessive disc / condylar
translation well beyond the eminence.
• Dislocation – Condyle positioned anterior to the
articular eminence and unable to return to a closed
positioned.

• Synovitis – Inflammation of the synovial lining of the TMJ
• Capsulitis–Inflammation of the joint capsule
• Osteoarthosis–Degenerative non-inflammatory condition of the joint
characterized by structural change of the joint surface.
• Osteoarthritis–Degenerative condition accompanied by secondary
inflammation.
• Polyarthirides–Arthitis caused by generalized systemic polyarthritis.
• Ankylosis–Restricted mandibular movement with deviation to the affected
side on opening.
• Fibrous ankylosis – Ankylosis produced by adhesions within the TMJ.
• Bony ankylosis – Union of bones of the TMJ caused by proliferation of
bone cells resulting in complete immobility of the joint.

• Treatment of joint disorders –
• Patient’s education
• Pain free diet
• Therapeutic exercises to rehabilitate the joint
• Anti-inflammatory drugs &muscle relaxants
• Physical therapy –
• Heat / ice massage
• Gentle range of motion exercises with in the pain tolerance.( 6
times a day for 30-60 secs )
• Joint shouldn’t hurt more than 10mins after exercise
• Night time splint -reduces forces on the joint.

• Night guard, controls parafunctional habit, temporary stabilizes an uneven
occlusion – allows the joint to rest.
• Should have a flat plane .
• Soft night guard is given for children with developing occlusion / mixed
dentition.
•

• Diagnosis for Osteoporosis
• Adults patients particularly females between 45
– 50yrs (post – menopausal women) have a high
incidence of osteopenia (asymptomatic low
bone mass) or osteoporosis (symptomatic low
bone mass).
• WHO defines.
• Osteopenia as bone mass 1 to 2.5 standard
deviations (SD) below young adult mean (YAM)

• Bone mineral density (BMD) measurements of adult women
over age of 50 indicated that 13% to 18% had osteoporosis, 37
to 50% had osteopenia.
• So when evaluating adults for surgical procedures or
orthodontics, a BONE METABOLIC ASSESSMENT is an
essential part of diagnosis.
• Treatment of osteoporosis is problematic during orthodontic
therapy because drugs that inhibit bone resorption
(Bisphosphonates, Calcitonin) Estrogen Replacement Therapy
(ERT) may disturb bone remodeling

• Oral Manifestations of Osteoporosis
• Osteoporosis is a systemic deterioration of the
skeletal system with following dental
manifestations.
• Decreased edentulous ridge height
• Decreased posterior maxillary arch width
• Progressive alveolar bone loss
• Loss of attachment and gingival recession
• Loss of teeth

• Effects of Estrogen Replacement Therapy:
• ERT has variety of oral health benefits, including a
decreased in loss of periodontal attachments and greater
retention of teeth during post – menopausal period.
• Once the negative calcium balance in stabilized, patients
with osetoporosis are excellent candidate for orthodontics and
other bone manipulative therapy.
• After osseous structures of jaw are enhanced, treatment
planning is directed towards optimal function loading to avoid
disuse atropy of alveolar process through implants, by fixed
prosthosis after orthodontic repositioning

GOAL OF ORTHODONTIC
TREATMENT
• Since the adult differs in many respects from the adolescent and
exhibits limitations, the goal for adult orthodontics would be
different from that of the adolescent.
• According to ACKERMAN, adult orthodontics is
concerned with a striking balance between “achieving optimal
proximal and occlusal contacts of the teeth, acceptable
dentofacial esthetics, normal function and reasonable stability”.
• Jackson’s Triad of traditional objectives (ie) esthetics,
function and structural balance are neither realistic nor always
necessary for all adult patients. Class I occlusal goals can be
considered over treatment for patients under multiple provider
group.

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

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 PDL
health occurs with proper tooth position

Esthetic & functional
improvement.
Should provide acceptable dentofacial esthetics
Improved muscle function
Normal speech & masticatory function

• LIMITATIONS OF TREATMENT IN ADULTS
• There are two categories of factors:-
• (a) INTRINSIC - BIOLOGICAL
• (B) EXTRINSIC - BIOMECHANICAL
SYSTEMS
• The marked intrinsic limitation is the lack of growth in
adults; skeletal discrepancies can therefore be corrected by
Orthognathic surgery. The orthodontic treatment is limited to
tooth movement and related modeling of the alveolar process
only. Since orthodontic tooth movement is a result of cellular
reaction to a mechanical stimulus, the cellular response may vary
with the health and age of the individual

• Other Intrinsic Factors
Periodontium
• The primary tissue to be influenced by the mechanical forces applied to
the teeth in the PDL. According to Norton, insufficient source of
progenitors cells may be due to vascularity with increasing age. Insufficient
source of preosteoblast account for the delayed response to mechanical
stimulus.
Alveolar bone
• Structure: Orthodontic tooth movement as a result of bone modeling and
remodeling also depends greatly on age related changes of the skeleton.
Cortical bone becomes denser while the spongy bone reduces with age and
the structure of bone changes from that of a honeycomb to a network.
Pathology : Apical displacement of the marginal bone level is a local factor
that influences the biological backgrounds for tooth movement in adults. The
marginal bone loss is age related but is also the result of progressive
periodontal disease.
Teeth : Adults are also more likely to have missing teeth, teeth reduced in
dimension due to attrition as well as teeth with large restorations

• Lace like Bone
pattern
Honeycomb Bone pattern

• Without Marginal Bone Loss • With Marginal Bone Loss

• BIOMECHANICAL CONSIDERATIONS IN ADULT
ORTHODONTICS
• (Lindauer JS. Rebellato J), (Dent Clin North Am 1996 : 40 :
811 – 836.)
• Orthodontic treatment in the adult must be planned without the
expectation that growth or any changes in jaw relationships will
compensate for interarch discrepancies. A precise biomechanical
control of tooth movement is necessary to achieve correction of
malocclusion in all 3 dimensions.
• The forces used in the adults should be at a lower level than
those used in children. The initial forces should further be kept
low because the immediate pool of progenitor cells available for
resorption are low.
• In adults with periodontal involvement where bone has been
lost, PDL are decreases with the results that the same force
against the crown would produce greater pressure in the PDL.
The absolute magnitude of force must therefore be
reduced.

• Marginal bone loss results in
CRES (b) being displaced
apically. Magnituide of the
tipping moment is the product
of force and distance (point of
force application to the CRES).
• Since the CRES has
moved apically greater will be
the tipping moment for same
force, so a counter vailing
COUPLE is necessary to affect
BODILY movement.
• Force levels should be
decreased but the magnitude of
the couple applied to
counteract the tendency to tip
should not be decreased
proportionally.

• Selection of Mechanics
• The appliance should produce a controlled and constant force
system in all three planes to reader a low lead deflection rate
possible
• Vertical control and facial profile
• Maintaining vertical control and facial profile is very important in
treating adult patients. A child tolerates extrusive tooth
movement better since condylar growth and vertical
development of the alveolar process during child hood permit
such tooth movement. In contrast, any extrusive movement, of
the posterior teeth in the adult will lead to an opening of the bite
through backward rotation of the mandible resulting in an
increased facial height and overjet.
• Extrusion of incisors can be undersirable since the majority of
patients suffering from advanced periodontal disease have
extruded and spaced maxillary teeth. Such patients need
intrusion and retraction.

Loss of vertical
control
• Unintentional extrusion is
possible with both fixed and
removable appliance. According to
Burstone, such loss of vertical
control is possible in a number of
instances of fixed appliances
therapy such as.
• Tip back bend
• Incorrect bracket positioning
• Excessive force
• Straight wire leveling
• Anterior root correction
•

• AJO 1989
• Ronas, Kleinent & Melson B & Burstone
• Force system developed by `V` Bends in an elastic Orthodontic wire
• Burstone indicated a number of examples related to fixed appliances that lead
to loss of vertical control (or) untoward extrusive effects
• TIPBACK BEND:
• Any major `V` Bend will result in the development of vertical forces if the
bends are not localized exactly at the center between two tooth units
• It produces Extrusion the vertical forces are closely related to the degree of
bending & degree of eccentricity of bend.
• INCORRECT BRACKET POSTIONING.
• A difference in Orientation (or) cant can act as `` shape producing a change
in the level of the occlusal plane.
• ESTHETIC BEND
• Combination `V` bend & step bend high vertical forces produced. Teeth will
cut be intruded at this force level. Only extrusion takes place

• Factor in selection of treatment plan.
• Existing oral pathology
• Skeletal relationship
• Biological considerations
• Therapeutical approaches available
• Extraction (vs) Non extraction therapy
• Anchorage requirements
• Missing teeth (Dental mutilation)

• Existing oral pathology : include recurrent decay, restorative
failures, root decay with pulpal involvement periodontal bone
loss, TMJ symptoms and retained roots. These conditions
should be treated first before proceedings to orthodontics with
a multi-disciplinary approach.
• Skeletal Relationships : No growth with minimal skeletal
adaptability. Therefore surgical procedures are frequently
required to correct moderate to severe skeletal disharmonies.
• Biological Considerations : Neuromuscular maturity –
mechanical options for an adult are limited because of lack of
neuromuscular adaptability. There is a tendency towards
iatrogenic transitional occlusal trauma, coinciding with
orthodontic occlusal changes. Periodontal susceptibility –
higher degree of bone loss as result of periodontal disease can
be evidenced during orthodontic therapy.

• Therapeutic approaches available –
• Tooth Movement : most of them require tooth moving forces
• Orthopedics : not effective
• Orthognathic surgery : needed in 10 to 20% of the adult
patients.
• Restorative dentistry : frequently required.
• Extraction (vs) Non Extraction Therapy : Classical 4
premolars extraction to resolve crowding rarely done .upper
premolars extraction alone is a common alternative..

• Anchorage requirements : Adults have greater
anchorage potential because of completely erupted 1st,
and 2nd molars as well as accentuated mesial drift
particularly in the mandibular arch. On the other hand
40% of the adults patient are partially edentulous.
• Implants for orthodontic anchorage plays an
important role in their treatment. (BJO 2002, VOL 29,
239-245) (Ismail and Johal-UK) Osseo integrated
implants may be used for direct as well as indirect
anchorage.

• Direct anchorage utilizes forces from actual implant
which takes the place of a missing tooth and eventually
supports a dental restorations.
• Indirect anchorage uses the implants to stabilize
specific dental units to which clinical forces are then
applied. Such MID PALATAL FIXTURES are the
ONPLANTS and ORTHOPLANTS which are placed
solely for orthodontic purposes in adults. (JCO-2000-
july,Celenza and Hochman)

• Onplants were introduced by
• BLOCK & HOFEMAN in 1995, made of
titanium and consist of base of 10mm and 2mm
height with one side smooth and other side
textured and coated with hydroxy apatite. Base
has internal thread for screwing transgingival
abutment to which force is applied.
• Site is surgically exposed and coated surface is
placed close to the bone.
• After 6 – 8 weeks the base is exposed and
transgingival abutment is placed and loaded.

• Adult patients requiring intrusion of molars to control
Skeletal – Open bite are the apt candidates for Skeletal
Anchorage System MIKAKO,
SUGAWARA,MITRA ( AJO 1999; 115: 166-74)
• Titanium miniplates were fixed at the buccal cortical
bone around the apical regions of 6,7 on both side.
Elastic threads were used as a source of orthodontic
force to reduce excessive (3 to 5mm) molar height. The
system was very effective.
• BIOS (Glaatzmier) EJO 18 : 1996 465 – 469) is
designed to provide anchoring functions in adults and
adolescent and then be resorbed with out foreign body
reactions. Secondary operations for removal at the
conclusion of orthodontic treatment is not needed. It
resorbs in 9 to 12 months.www.indiandentalacademy.com

• (7) Missing teeth (Dental mutilations)
• In adults, most of these spaces cannot be
closed without a prostheses either a temporary
tooth replacement during FA therapy or fixed
prostheses later. Implants have become a
reliable alternative.
• Therefore a multidiscipilinary team approach is
required for their comprehensive rehabilitations.

Treatment for adults
• proffit -
– Younger adults(20-35yrs)
– Older group(40-50yrs)
• Adjunctive orthodontic treatment
• Comprehensive orthodontic treatment

COMPREHENSIVE TREATMENT FOR
ADULTS
• Comprehensive orthodontic treatment aims at
making the patient’s occlusion as ideal as
possible, repositioning all or nearly all the teeth
in the process.
• The ideal time for comprehensive orthodontic
treatment is during adolescence, when the
succedaneous teeth have just erupted, some
vertical and antero posterior growth of the jaws
remains and the social adjustment to
orthodontic treatment is not a great problem.

• Comprehensive treatment is also possible for
adults, but it poses some special problems that
do not exist for younger patients.
• The following considerations should be kept in
mind while treating adults
• Lack of growth
• Heightened possibility of periodontal disease
• Different motivations for seeking orthodontic
treatment.

• While treating adults
• Appliance should be simple in order to elicit maximum patient
cooperation
• Appliance should exert light forces for best physiological
response.
• Appliance should be long acting to decrease the number of
appointments.
• Appliance should be invisible as possible(plastic, ceramic
brackets, fixed lingual appliances)
• Appliance should be better retained (fixed)
• Adult treatment mechanics need not differ from the
standard technique; they are modified only to meet specific
treatment requirements. Simplicity with maximum control
is the by word.
• Comprehensive orthodontic treatment implies an effort to make
the patient’s occlsion as ideal as possible by repositioning nearly
all the teeth in the process.

• Motivations for adult treatment: The major
motivations for adults to undergo comprehensive
treatment is due to psychological reasons. Though a
small percentage of them may seek complete treatment
for periodontal and restorative needs.
• Internal motivations : if the individual wants to
improve his appearance or function of teeth and so
seeks treatment – he is said to be internally motivated
and is expected to respond well psychologically
• External motivation : an individual whose motivations
is the urging of
• others he said is to be externally motivated and
has a complex set of unrecognized expectation for
orthodontic treatment.

• COMPREHENSIVE TREATMENT
• STAGE 1: DISEASE CONTROL
• Revaluate
• STAGE 2: ESTABLISH OCCLUSION
Stabilize
• STAGE 3: DEFINITIVE PERIO / RESTORATIVE
TREATMENT
• STAGE 4 :MAINTENANCE
• HERE ORTHODONTICS IS USED TO ESTABLISH
OCCLUSION.

• Possible tooth movement in adjunctive treatment
• (a) Mesial or distal movements of specific crowns and roots.
• (b) Correction of axial inclination of drifted teeth.
• (c) Correction of buccolingual position of certain teeth
• (d) Corrections of rotations.
• Intrusion of teeth is avoided as an adjunctive procedure
because of the technical difficulties involved and possibility of
periodontal complications.
• Excessively extruded teeth are treated by reduction of
crown height which improves the crown / root ratio.

• Biomechanical considerations:
• Control of anchorage requires that anchor teeth not be
allowed to tip. This is major reason that adjunctive treatment
usually requires a fixed appliance.
• EDGEWISE APPLIANCE recommended, twin brackets of
0.022 slot dimension are used preferably
• Rectangular slot controls bucco – lingual axial inclination
• Twin bracket prevents undesirable rotations and tipping
• Larger slot allows the use of stabilizing wires which are stiffer.
• Bracket are placed in an ideal position only on teeth to be
moved, remaining teeth incorporated in the anchor system and
are bracketed so the archwire slot are closely aligned. Passive
engagement of the wires to anchor teeth produce minimal
disturbance of teeth.

• PERIODONTAL ASPECTS OF ADULT
TREATMENT
• There is no contra indications to treating adults with
periodontal disease long as the disease is under control
• Three risk groups are identified in the population
– Those with rapid progression (10%)
– Those with moderate progression (80%)
– Those with no progression despite the presence of gingival
inflammation (10%).

• MINIMAL PERIODONTAL INVOLVEMENT:
• Bacterial plaque being the main etiological factor in
periodontal breakdown, patient undergoing orthodontic
especially adults must take extra care
• For adults orthodontic patient’s GINGIVAL
RECESSION is to be prevented rather than to try
correcting it later. Creation of “BLACK TRIANGLES”
between maxillary central incisors by gingival recession
after periodontal loss is practically distressing.
• According to the present concept, gingival recession
occurs secondary to alveolar bone dehiscence; if
overlying tissues are stressed. Stress can be due to

• Tooth brush trauma
• Plaque induced inflammation
• Stretching and thinning of gingiva created by
labial tooth movement
• FREE GINGIVAL GRAFT is helpful in adult
patients to control inflammation before
orthodontic treatment begins. and in whom arch
expansion is indicated for aligning incisors.

• MODERATE PERIODONTAL
INVOLVEMENT:
• Disease control: Preliminary periodontal
therapy is preformed which includes meticulous
root surface preparative and curettage and
patient kept under observation to watch whether
the disease is controlled.
• Treatment procedures like osseous
contouring (or) repositioned flaps to
compensate areas of gingival recession are best
deferred until final occlusal relationships have
been established.

• PERIODONTAL MAINTENANCE
• Fully boned orthodontic appliance is recommended. Steel
ligatures (or) self ligating bracket are preferred for periodontally
involved patients rather than elastomeric rings to retain arch
wires because such patient have higher level of micro organisms
in gingival plaque.
• During comprehensive treatment, patient with moderalte
periodontal problems should be on a maintanence schedule (2 –
4 months interval)
• HYGIENE AIDS: Electric tooth brushes, rubber interdental
stimulators, proximal brushes and adjunctive chemicals (eg.
Chlorhexidine) should be considered.

• SEVERE PERIODONTAL INVOLVEMENT:
• The general approach in the same as outlined earlier but
• 1. Periodontal maintenance schedule is at more
frequent intervals (every 4 to 6 weeks)
• 2. Orthodontic goals modified and forces kept to
absolute minimum of because of the reduced area of
PDL
• Muco-gingival Corrections
• Attention if paid to 3 factors prior to orthodontic
therapy can make the treatment easier and more
predictable.
• Reduction of thick tissue either distal to the terminal
tooth or in edentulous areas
• Inadequate bands of keratinized tissues.www.indiandentalacademy.com

• Frenal attachments
• Thick tissue gets bunched up and can slow down tooth
movement considerably. While uprighting a second or a third
molar, the tissue moves coronally on the tooth and a
pseudopocket develops. This can become a nidus for bacteria
and a potential locus for the apical migration of the attachment.
• If there is a minimal band of keratinized tissue and the roots
move out of the alveolus, there is bound to be recession.
• Frenal attachements that prevent or slow down tooth
movements may be removed during or before tooth movement.
However, if retention is the chief concern, then the removal may
be effected at the conclusion of tooth movement.

• ORTHODONTIC TREATMENT OF PERIODONTAL
DEFECTS –(Seminars in orthodontics) vincent kokich -1997
• Advanced Horizontal Bone Loss:
• After the treatment has been planned, one of the most
important factors that determines the outcome of orthodontic
therapy, is the location of the bands and brackets on the teeth.
• In a periodontaly healthy individual, the position of the bracket
is usually determined by the anatomy of the crown of the tooth.
Anterior brackets should be positioned relative to the incisal
edges. Posterior bands or brackets are positioned relative to the
marginal ridges. If the incisal edges and marginal ridges are at the
correct level, the CEJs will also be at the same level. This
relationship will create a flat bony contour between the teeth.
• However, if a patient has underlying periodontal problems and
significant alveolar bone loss around certain teeth, using the
anatomy of the crown to determine bracket placement is
inappropriate.

• The bone level may have receded several millimeters from the
CEJ. As this occurs, the crown to root ratio will become less
favourable. By aligning the crowns of the teeth, the clinician may
perpetuate tooth mobility by maintaining an unfavourable crown
to root ratio.
• The orthodontist can correct many of these problems by
using the bone level as a guide to positioning the brackets on the
teeth. In these situations, the crowns of the teeth may require
considerable equilibration . If the tooth is vital, the equilibration
should be performed gradually to allow the pulp to form
secondary dentin to insulate the tooth during the requilibration
process. The goal of equilibration and creative bracket
placement is to provide a more favourable bony architecture as
well as a more favourable crown to root ratio.

• HEMISEPTAL DEFECT:
• Adult patients may have marginal ridge
discrepancies caused by uneven tooth eruption before
orthodontic treatment. When the orthodontist
encounters marginal ridge discrepancies, the decision as
to where to place the bracket or band is not determined
by the anatomy of the tooth.
• If the bone level is oriented in the same direction as
the marginal ridge discrepancy, then leveling the
marginal ridges will level the bone. However, if the
bone level is flat between adjacent teeth and the
marginal ridges are at significantly different levels,
correction of the marginal ridge discrepancy
orthodontically will produce a hemiseptal defect in the
bone. This could cause a periodontal pocket between
the two teeth.

• During orthodontic treatment, when teeth are
being extruded to level hemiseptal defects, the
patients should be regularly monitored by the
periodontist. Initially, the hemiseptal defect will
have a greater sulcular depth and be more
difficult for the patient to clean. As the defect is
compensated through tooth extrusion,
interproximal cleaning becomes easier.

• Tissue response to various tooth movements.
• EXTRUSION:
• Extrusion or Eruption of a teeth (or) Several teeth along with reduction of the clinical
crown height reduces infrabony defects & decreases product depth.
• AJO 1986 TISSUE REACTION OF EXTRUSIVE AND INTRUSIVE FORCES
TO TEETH IN ADULT MONKEYS ( BIRTE MELSEN)
• On histologic section, clear signs of bone deposited during forced Eruption is seen
• INTRUSION:-
• INTRUSION OF INCISORS IN ADULT PATIENTS WITH MARGINAL BONE
LOSS
• (AJO 1989 MELSON B ET AL
• In this study 3 different methods for intrusion were applied. The marginal bone level
approached CEJ in almost all cases. All cases demonstrated root resorption.
• The intrusion was best performed when
• Forces were low (5 to 15 gm per tooth ) with line of action of force passing through
(or) close to the center of resistance.
• Gingival status was healthy.
• No interference with perioral function present.

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
Establish occlusion
Definitive restorative Rx
maintenance
Re-evaluate
stabilize

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 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 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
• Missing12,47,46,45,35,36,37
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.
Kenji W Higuchi

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.

SPLINTING
WHEN TO SPLINT?
• The splinting of mobile teeth is often, of value as a means of stabilization before,
during, and after periodontal therapy.
• For most patients, splinting should be considered only after the preliminary phase
of periodontal therapy has been completed.
• Cohen and Chacker have noted, "When large areas of attachment apparatus have
been destroyed, the artificial support offered by temporary stabilization may allow a
new, healthy tooth-bone relationship to be established.
• Therefore it would seem advisable that when the treatment plan is being formulated
the need for stabilization be determined on the basis of the, nature and extent of the
destructive process present.

PRINCIPLES OF SPLINTING:
• The main objective of splinting is to decrease movement three-dimensionally.
• This objective often can be met with the proper placement of a cross-arch splint.
• Conversely, unilateral splints that do not cross the midline tend to permit the
affected teeth to rotate in a faciolingual direction about a mesio-distal linear
axis.

INDICATIONS FOR SPLINTING:
• Splinting is indicated when moderate to advanced mobilities (2 degrees or
more) are present and cannot be treated by any other means.
• There is no reason for splinting non mobile teeth or teeth with a slight, non
progressive mobility as a preventive measure.
• Splinting should only be used with other necessary measures such as oral
hygiene instructions, root planing, pocket elimination, and occlusal adjustment.
• When pre-prosthetic surgery or orthodontic measures are called for they should
be completed before splinting whenever possible.

• One obvious indication for splinting is when a patient presents with multiple
teeth that have become mobile as a direct result of gradual alveolar bone loss, a
reduced periodontium.
• A second indication for splinting is when the patient presents with increased
tooth mobility accompanied by pain or discomfort in the affected teeth.
• Splinting may be a way to gain stability, reduce or eliminate the mobility, and
relieve the pain and discomfort.
• Following loosening of teeth by accidental (or) surgical trauma.
• To immobilize excessively mobile teeth so that the patient can chew more
comfortably.
• To avoid dislodging teeth prior to and during re-constructive procedures
(Occlusal reconstruction).

• To stabilize teeth in their new positions after orthodontic repositioning.
• As supportive measure to facilitate periodontal therapeutic procedures for
hypermobile teeth.
CONTRAINDICATIONS FOR SPLINTING:
• Splinting teeth is not recommended if occlusal stability and optimal periodontal
conditions cannot be obtained.
• Any tooth mobility present before treatment must be reduced by means of
occlusal equilibration combined with periodontal therapy.
• Otherwise if the tooth involved does not respond, it must be extracted prior to
proceeding from provisional restorations to definitive treatment.
• Insufficient number of firm / sufficiently firm teeth to stabilize mobile teeth.

The following qualifications identify an ideal splint : It should
• be simple,
• economic,
• stable and efficient,
• hygienic,
• nonirritating,
• not interfere with treatment,
• esthetically acceptable, and
• not provoke iatrogenic disease.

OBJECTIVES OF SPLINTING:
• Rest is created for the supporting tissues giving them a favorable climate for
repair of trauma.
• Reduction of mobility immediately and hopefully permanently. In particular
jiggling movements are reduced or eliminated.
• Redirection of forces - redirected in a more axial direction over all the teeth
included in the splint.
• Redistribution of forces - ensures that forces do not exceed the adaptive
capacity. Forces/received by one tooth are distributed to a number of teeth.
• Restoration of functional stability - functional occlusion stabilizes mobile
abutment teeth.

• To preserve arch integrity - restores proximal contacts, reducing food impaction
& consequent break down.
• To stabilize mobile teeth during surgical, especially during regenerative
periodontal therapy.
• To prevent migration and over eruption.
• Psychologic well being - gives the patient comfort from mobile teeth a sense of
well being.
• Masticatory function is improved.
• Discomfort and pain are eliminated.

•SURGICAL
ORTHODONTICS

Meanings of the Face
• “The face is the area of one’s body that produces the greatest
concern regarding physical attractiveness; it is the individual’s
focal point and the source of vocal and emotional
communications with others”
• Berscheid et al in a survey of over 1000 adults found that people
who were satisfied with their facial features expressed greater
self-confidence.

Meanings of the Face
• Berscheid et al – the area of greatest dissatisfaction for
subjects in their large sample was the appearance of their
teeth
• Attractive adults & children are evaluated as more
successful and more intelligent than are unattractive
persons and are viewed as more socially skilled – GR
Adams

Psychosocial characteristics of patients with facial
deformities
• Children with craniofacial anomalies are more introverted, neurotic and
demonstrate poor self-concept – Perschuk et al
• Children with Down’s syndrome were rated as being less intelligent,
less attractive, and less socially acceptable. Postoperative ratings of
these same children were significantly more positive in all three
domains – Strauss et al

Psychosocial characteristics of patients with facial
deformities
• A seriously handicapping orthodontic condition is the one that
“severely compromises a person’s physical or emotional health”
– AL Morris et al
• Physical compromise – serious problems with breathing,
speaking, or eating, especially if accompanied by tissue
destruction
• Emotional health – includes other’s reactions to the individual in
a way that influences self-esteem

Summary
• Research in the areas of self-esteem and attractiveness indicates that the face
is a major source of one’s psychologic identity
• Orthognathic surgery differs from surgery for congenital anomalies (in that
the changes in appearance are less dramatic and improvements in occlusion,
mastication, speech, and TM joint function are likely to be major reasons for
treatment) – but patients undergoing this surgeries also expect esthetic
changes. They must adapt not only to changes in their oral function, but also
to changes in their perceived appearance and interactions with others

Psychosocial studies of patients with dentofacial
deformities - Kiyak et al
• The First Study
– To study patient’s motives for seeking orthognathic surgery, the effect of
this procedure on people with diverse needs, and patient’s satisfaction
with treatment outcomes
– 6 questionnaires were asked over a 26 month period
• The Second Study
– Attempted to examine in greater detail the variables that emerged as
significant predictors of long-term outcomes
– The effect of orthognathic surgery was measured by comparing patients
who underwent surgery and orthodontics with those who were
recommended to have both but elected orthodontics alone
– 6 questionnaires were asked before and up to 24 months after surgery

Patients before surgery
• Motives for treatment
• A scale to assess patient’s motives
• Self-perceptions of facial profile
• Sex differences
• Orthognathic-surgery patients

Motives for surgery
Parameter Male Female
Professional advice
Orthodontist 24(83%) 34(76%)
Family dentist 12(41%) 17(38%)
Other 5(17%) 1(2%)
Desire esthetic changes 12(41%) 13(53%)
Functional problems
Mastication 12(41%) 13(29%)
Speech 4(14%) 1(2%)
TM joint 1(3%) 7(16%)
Social: family, friends 12(41%) 24(53%)

A scale to assess patient’s motives
• Subjective Expected Utility (SEU) Model
– Items are based on interviews with orthognathic surgery patients,
orthodontists, and oral-maxillofacial surgeons
– Using a 10 point scale, patients are asked to indicate the importance of
each item in the list above and whether they consider it positive , negative
or neutral.
– In this study, SEU suggest that the decision to seek surgical correction is
influenced by functional reasons. Conversely, the decision to reject
surgery and undergo conventional orthodontics seems to be based more
on a desire for improved esthetics

A scale to assess patient’s motives
Questions Score
Less difficulty with chewing 3
Stop jaw from clicking 0
Eat foods unable to eat now 0
Better fit of upper/lower teeth 1.5
General health improvement 1.5
Possible pain after surgery 0
Better smile 0
Improved profile, jaw and chin 0
Straight teeth 0
Cost of surgery 0
Lost time from work/school 0.8
Chance of unsuccessful surgery 1.9
Be able to speak clearer 0
Less self-conscious 0
Perform better in job/school 0
Advice of family/friends 0
Advice of dentist/orthodontist 0.9
Know of someone else’s surgery 0

Self-perceptions of facial profile
• For all dimensions of facial deformity, patients who accept
surgical treatment view themselves as less normal than do those
who opt for no treatment or orthodontics
• At the 24-month follow-up assessment, nearly all the surgery
patients rated themselves as normal. Orthodontics-only patients
also rated themselves improved on all scales, but the
improvement was not as great.

Sex differences
• Broverman and colleagues have found experimental evidence that
women place relatively greater importance on physical
attractiveness
• Kurtz et al found that women can more easily distinguish what
they like and dislike about their bodies than can men of the same
age, who give only global self-descriptions.

Orthognathic surgery patients
• In present study both men and women scored within the normal
range, notably better than the cosmetic-surgery population.
• Sex differences were not significant in post surgical satisfaction or
in self-reports of pain.

Response to treatment
• Overall satisfaction with the outcomes is generally high at all post surgical
assessments
• Overall body image was found to be in the moderate range throughout the
course of treatment
• Surgery patients initially expressed a lower body image than did non surgical
and no-treatment patients
• Surgical patients had high levels of tension and anxiety just before surgery,
with a steady decline later
• Orthodontics-only patients had negative mood states at 6 months which later
improved
• In surgical-orthodontic patients, expectations matched the actual experience
for most patients.

Application of research findings to patient
management
• Summary of research findings
– The patients undergoing orthognathic surgery are always
within the psychologically normal range
– They are more stable than people who seek plastic surgery
– Their greatest concern before treatment appears to be self-
consciousness regarding their facial body image, but
functional problems also are important

Application of research findings to patient
management
• Summary of research findings
– Orthodontics-only patients report negative emotions during
the later stages of their treatment
– Contrary to literature on cosmetic surgery, most patients
undergoing orthognathic surgery readily accept changes in
appearance and are satisfied with the esthetic effects
– 85% to 90% of the patients undergoing surgical-orthodontic
treatment eventually indicate that they are satisfied with the
treatment

Recommendations for interaction
with patients
• There is a need for systematic selection of patients, preparation
for surgical treatment, and careful psychologic management
throughout the course of surgical and orthodontic treatment
• Provide greater psychosocial support and encouragement for the
patient with a neurotic personality style, especially in the early
stages of treatment
• Patient education materials provide information in a standard
way so that no important points are omitted, and the patient can
review it repeatedly to gain a better understanding of the process.

Pre- and post surgical psycho-emotional aspects of the
orthognathic surgery patient - Bertolini et al
• Levels of pre surgical anxiety, post surgical depression, body
concept, and all the important changes in physiologic functions
were measured by 4 questionnaires.
• The results of this study suggest that surgery does in fact, produce
improvements in self-esteem and body image and in mastication
and speech, and therefore in their lifestyles
• All patients experienced a medium to high level of pre surgical
anxiety, but no major problems after surgery.

• OGS can be performed in both jaws and is all 3 planes
of space.
• In Anterioposterior plane.
• - MAXILLARY SURGERY
• The Lefort I downfracture procedure almost always is
used now to reposition the maxilla. If the maxilla is
advanced, a graft in the retromolar area or at a step created
in the lateral wall usually is required.
• MANDIBULAR ADVANCEMENT
• Currently the bilateral sagittal split osteontomy (BSSO)
of the mandibular ramus, performed from an intro oral
approach, is the preferred procedure for most patients who
need mandibular advancement.

• MANDIBULAR SETBACK
• Reduction of mandibular prognathism can be accomplished
by one of two techniques performed in the ramus, each having
advantages and dis-advantages. The BSSO (discussed previously)
can be used to move the mandible posteriorly as well as
anteriorly,. It is widely used for setbacks because of excellent
control of the condylar segments and because osteosynthesis
screws can be employed for fixation.
• The transoral vertical oblique ramus osteotomy (TOVRO)
is limited to mandibular setback and required full-thickness
overlapping of the segments. This procedure requires less time
than the sagittal split osteotomy and is less likely to produce
neurosensory changes, but jaw immobilization after surgery is
necessary and control of the condylar fragment can be difficult.
Especially when both the maxilla and mandible are repositioned
in treatment of Class III problems, the advantage of rigid fixatio
BSSO outweighs the advantages of TOVRO.

• CORRECTION OF VERTICAL RELATIONSHIPS
• Problems of excessive and deficient face height, which
usually are accompanied by severe anterior open bite and deep
bite respectively. The long face problems are treated best by
superior repositioning of the maxilla. This allows the mandible to
rotate around the condyle, thereby reducing the mandibular
plane angle and shortening the face. Short face problems, in
contrast, are treated most predictably and successfully by
mandibular ramus surgery that allows the mandible to move
donwnward only at the chin, increasing the mandibular plane
angle by shortening the ramus and opeing the gonial angle by
shortening the ramus and opening the gonial angle rather than by
rotating at the condyle.

• MAXILLARY SURGERY
• The contemporary surgical approach to the skeletal open
bite (long face) deformity involves a LeFort I downfracture of
the maxilla, with superior, repositioning of the maxilla after
removal of bone from the lateral walls of the nose, sinus, and
nasal septum.
• It is important to shorten the nasal septum or free its base
so that the septum is not bent when the maxilla is elevated. The
overall facial height is shortened as the mandible responds by
rotating upward and forward. Excellent stability of the vertical
position of the maxilla is observed post-surgically, but ling-term,
some continued vertical growth of the maxilla may occur.
• In contrast, when the maxilla is moved downward to
increase face height, it tends to relapse back up post surgically, so
that 20% or more of the vertical change often is last even when
rigid fixation is used. Both the use of more rigid graft materials
(like synthetic dydroxylapattite) and simultaneous osteotomy of
the mandibular ramus have been reported to improve the
stability of downward movement of the maxilla.

• MANDIBULAR SURGERY:
• Patients with a ling face, skeletal open bite and anteroposterior
mandibular deficiency often have a short mandibular ramus. Surgery to
reduce to mandibular plane angle and close the open bite by rotating the
mandible down posteriorly and up anteriorly has been found to be highly
unstable. Because the fulcrum for rotation is the posterior teeth, this rotation
lengthens the ramus and stretches the muscles of the pterygomandibular sling.
The instability is attributed primarily to lack of neuromuscular adaptation in
these powerful muscles, which can produce relapse to pre-surgical or even
worse mandibular positions.
• Patients with a short face (skeletal deep bite) problem are characterized
by a long mandibular ramus, square gonial angle and short nose-chin distance.
Often the maxillary incisors are tipped lingually in Angle’s Class II, division 2
pattern. Despite the deep overbite, excessive eruption of the lower incisors
often has not occurred, as demonstrated by a normal distance from the chin
to the incisal edge. They are teated best by sagittal split mandibular ramus
surgery to rotate the mandible slightly forwad and down and the gonial angle
area.

• CORRECTION OF TRANSVERSE RELATIONSHIPS:
• Transverse problems fall into two categories: those due to
symmetrical narrowing or (less frequently) widening of one
dental arch and those due to jaw asymmetry.
• Maxillary Expansion for Lingual Crossbite:
• Constriction of the maxilla rarely occurs without some
coexisting vertical or sagittal problem. Maxillary constriction or
expansion can be accomplished easily by segmenting the maxilla
in the course of LeFort I downfracture surgery to correct other
problems, and this is the usual approach. Expansion is done with
parasagittal osteotomies in the lateral floor of the nose or medial
floor of the sinus that are connected by a transverse cut
anteriorly.
• Surgically assisted palatal expansion, using bone cuts to
reduce the resistance without totally freeing the maxillary
segments, followed by rapid expansion of the jackscrew, is
another possible treatment approach for adult patients with
skeletal maxillary constriction.

• GENIOPLASTY IN ORTHOGNATHIC TREATMENT:
• Lack of surrounding anatomic structures gives the surgeon considerable
latitude in alteration of chin morphology, and movement of the chin in all
three planes of space is possible.
• Genioplasty Techniques:
• For most patients, the preferred approach to genioplasty is a lower
border osteotomy to free a wedge shaped portion of the symphysis and
inferior border that remains pedicled on the genioglossus and geniohyoid
muscles. This segment can be advanced to augment chin contour, shifted
sideways to correct asymmetry, or downgrafted to increase lower face height.
• Genioplasty can be used as an Adjunct to Non-extraction Orthodontic
Treatment
• SEQUENCING TREATMENT:
• Surgical and Orthodontic Phases of Treatment:
• Successful management of combined surgical and orthodontic
treatment requires the integration of presurgical orthodontic, surgical and
post surgical orthodontic phases of treatment.

principles that influence post-surgical stability
can be proposed:
• Stability is greatest when soft tissues are relaxed during
the surgery and least when they are stretched.
• Moving the maxilla upward relaxes tissues.
• Moving the mandible forward stretches tissues, but
rotating it upward posteriorly and downward anteriorly
decreases the amount of stretch.
• It is not surprising that the lease stable mandibular
advancements are those that lengthen the ramus and
rotate the chin up, while the most stable advancements
rotate the mandible in the opposite direction.
• .

• The least stable orthognathic surgical procedure is widening of
the maxilla that stretches the heavy, inelastic palatal mucosa
• Neuromuscular adaptation is an essential requirement
for stability,
• Repositioning of the tongue to maintain airway
dimensions occurs as an adaptation to changes
produced by mandibular osteotomy.
• Neuromuscular adaptation does not occur when the
pterygomandibular sling is stretched during mandibular
osteotomy, as when the mandible is reotated to close
an open bite.

 Neuromuscular adaptation affects muscular length, not
muscular orientation. If the orientation of a muscle
group such as the mandibular elevators is changed,
adaptation cannot be expected.

• Periodontal – Surgical Retention Procedures
• Certain periodontal-surgical procedures may be
necessary to achieve overall stability of the treated adult
patient.
• The following are the procedures that may have to be
performed.
• Pericision
• Gingivectomy and Gingivoplasty.

• Pericision
• Significantly rotated teeth should be over corrected to an extent
of 5-10° prior to debonding.
• A supracrestal gingival fibrotomy will reduce the risk of relapse.
• Gingivectomy and Gingivoplasty:
• These procedures arc indicated when significant vertical changes,
such as deep overbite correction have been made
orthodontically.
• In general, adults require a greater period of retention.

RECENT ADVANCES
• LESS VISIBLE TREATMENT MODALITIES FOR ADULTS : -
• Adults patients are conscious and demand less visible appliances.
• CLEAR BRACKETS
• (plastic / ceramic bracket) along with tooth coloured arch wire are the most
esthetic combinations to be used in a conscious adult patients. The esthetic
arch wire (FRC Fibre Reinforced Composite AJO 2000) is composed of
ceramic fibres embedded in a cross-linked polymer matrix. Its coefficient of
friction is reduced by modifying the surface chemistry (eg: ion implantation)
inspite of this, adults are often averse to wearing traditional fixed appliance
with wires, bands and brackets.

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

• A The INVISALIGN SYSTEM (BJO-2003 –
December vol 30 (L.joffe-UK)
• now makes it possible for orthodontists to offer adults
patients requiring full mouth orthodontic treatment
with an esthetically agreeable solutions.
• Introduced about 4 years ago by ALIGN
TECHNOLOGIES Santa clara, California
• It is an orthodontic technique that uses a series of clear
plastic aligners to move teeth.
• Worn for a minimum of 20 hours per day.
• Changed on a 2 weekly basis.
• Each aligner moves a tooth or a small group of teeth
about 0.25 – 0.33mm
• Align technology using computer – aided scanning,
imaging and manufacturing technology has pushed this
technique into realms of every orthodontic practice.

• The revolutionary aspect of invisalign is the scanning in and
imaging of high precision casts made from very accurate
impressions (poly-vinyl silicon impression). This allows the
patient’s teeth to be replicated as “on screen” 3D model, which
can be manipulated and virtually corrected through a treatment
plan developed by orthodontist and translated by invisalign using
sophisticated propriety software. (CAD-CAM technology) The
clinician has the ability to view the “virtual” models” from
malocclusion to correction, movement by movement through an
internet connection program called Clincheck. Changes are
made through clincheck system until the result achieved is to the
clinicians liking. Only then are the actual aligners made and
dispatched.

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 cases
Robert L Boyd, R J Miller,JCO 2000 April
Case 1
23yrs/F
Spacing b/w teeth

33yrs/M
Spacing b/w teeth
Case 2

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
Thomas . Wilcko World Journal Orthodontics 2003:4:197-205
Demonstrates a New orthodontic method that provides
shortened treatment times.
Case report
27yrs/F
Class I with moderate crowding

• Extrusive, intrusive and rotational abilities of investigations are under trial
• Software individualizes each tooth, so they can be individually repositioned
and soft ware relates to upper and lower teeth together so that co-ordinate in
kept between arches.
• Manufacturing process is a computer aided technology. The 3D – models of
each setup in the realignment are transformed into hard copy models through
a process of laser build up. These models are then used to make the pressure
formed aligners
• [IPR] Interproximal reductions are done at the time of delivery of the
aligners.
• A typical invisalign treatment will take around 25 aligners and 50 weeks of
treatment.
– Handles simple to moderate non-extraction alignments better than mild to
moderate extraction corrections
– It has only limited ability to keep teeth upright during space closure.
• Conditions treated with invisalign
• It can be used as RETAINERS, NIGHT GUARD, TMJ SPLINTS
BLEACHING TRAYS AND FOR TOOTH MOVEMENT

• Tooth Movements
• Mildly crowded and malaligned problems (1 – 5mm) Treatment can be done
with slight lateral or anterioposterior expansion, with minor interporximal
tooth reduction or by removal of lower incisor.
• Spacing of 1 – 5mm
• Deep overbite problems (class II Div 2 type where the overbite can be
reduced by intrusion and advancement of incisors
• Narrow arches.
• Certain aspects are more difficult to handle
– Crowding and spacing over 5mm
– Skeletal anterio posterior discrepancies of more than 2mm
– CR and Co discrepancies
– More than 20o rotations
– Open bites
– Extrusions
– Severely tipped teeth (more than 45o)
– Teeth with short clinical crowns
– Arches with multiple missing teeth.
• Though certain aspects are difficult to be treated by invisalign. Combinations
treatment can be under taken. Conventional appliance may be used along
with it whenever neede

• Advantages
• Ideal esthetics : aligners are relatively invisible apart from a slight
sheen to the teeth is close up.
• Easy to use for the patient
• Comfortable
• Simplicity of care and better oral hygiene
• Invisalign allows for refinement aligners which can be added at
the end of scheduled treatment procedures.
• Disadvantages
• Limited control of root movement such as root paralleling, gross
rotation correction, tooth uprighting and tooth extrusion.
• Limited intermaxillary correction : severe skeletal discrepancy
cannot be contemplated with invisalign alone. Surgery or a pre-
invisalign functional phase would be necessary.
• Lack of operator control : as the aligners are prefabricated there
no chance of altering it.
• Thus it is an esthetic technique used to treat simple to
moderate alignment cases in adults.

• LINGUAL ORTHODONTICS
• Most lingual orthodontics patients are adults and have greater
demands and expectations than do labial orthodontic patients,
Esthetics is a crucial factor.
• Advantages :
•
• Labial enamel surface, is preserved which plays an important
esthetic role. Susceptibility of this enamel surface to permanent
decalcification following chemical insults from etchant materials
and to plaque accumulation are prevented.
• Lingual appliance allow easy access for routine oral hygiene
procedures.
• Evaluation of individuals tooth positions can be easily assessed
as the labial surface is free of distracting metal (or) plastic
brackets

• Lingual appliances are effective in the following situations
• 1. Intrusion of anterior teeth.
• Lingual bracket positioning is dictated by the morphology of lingual surface, it
places the bracket closer to the CRES of the tooth. It allows the intrusive
force rector to be directed through the CRES of the tooth.
• Mandibular anterior dentition occludes with the anterior horizontal plane of
maxillary anterior brakets, BITE PLANE effect results. Net effect is a
LIGHT CONTINUOUS INTRUSIVE FORCE in the anterior and a passive
extrusive force in the posterior segments.
• 2. Maxillary arch expansion
• More remarkable dentoalveolar expansion are achieved through lingual
mechanics
• Reasons may be due to
• The force developed in of a CENTRIFUGAL TYPE (from inside towards
the outside of the arch)
• Thickness of the brackets which interpose between the tongue and lingual
wall of the teeth contribute to the expansive effect/.
• Short interbracket distance may play a significant role

• 3. Combining mandibular repositioning therapy with
orthodontic movements :
• Usually patients with TMD are treated in 2 distinct clinical
phases. Initial phase consists of splint therapy followed by
changes in occlusion.
• Lingual appliances system allows both arches to be treated
simultanesously. The anterior occlusally oriented inclined plane
functions as a bite plane. Flat acrylic mini supports are added to
the 1st and 2nd molars. This combination can stimulate the
action of conventional splint thereby allowing treatment to
progress simultaneously in both arches.
• 4. Distalisation of maxillary molars
• Lingual bracket are placed closer to CROT than the labial
bracket. The molar distalisation through lingual technique
produce more bodily movement of the tooth and less dental
tipping.

• Finishing and detailing
• Finishing does not differ significantly from adolescence
• Patients with moderate to severe periodontal loss are
stabilized with immediately placed retainers as soon as
the finishing archwires are removed.
• Later detailing of occlusal relationship by equilibration
takes place.
• In TMD patient undergoing comprehensive treatment,
use of interocclusal splint prevents clenching and
grinding from recurring

• NEWER TECHNIQUES:
•
CORTICOTOMY ASSISTED ORTHODONTICS – (JCO 2001 MAY- Chung
OH and KO)
• CORTICOTOMY has been used in difficult adult cases as an
alternative to conventional orthodontic treatment or Orthognathic surgery.
The original procedure of single tooth osteotomies or corticotomies was
introduced by KOLE in 1959. The primary resistance to tooth movement is
encountered in the cortical layer – corticotomy makes teeth to move faster.
Teeth acts as handles by which the bands of less dense medullary bone are
moved block by block.
• Thus orthodontic tooth movement after corticotmy is a process of moving
block of bone rather than moving only individual teeth.
• It can be used in treatment of
• 1. Ankylosed teeth
• 2. Teeth surrounded by narrow cortical bone
• 3. Significant arch length discrepancies
• 4. Transversely constricted maxilla
• 5. Can be used for posterior intrusion and rapid anterior retraction with
maximum anchorage

• 6. Can be combined with orthopeadic therapy
• Corticotomy surgery initiates and potentiates normal healing
process by way of an accelerated transient burst of hard and soft
tissue remodeling by means of a process called REGIONAL
ACCELERATORY PHENOMENON (RAP). It was
described by an Orthopedist Harold frost.
• In the alveolar bone adjacent to corticotomy, there was marked
increase in regional bone turn over. Tissue forms 2 – 10 times
faster than normal regional regeneration process.
• RAP – decreased the treatment duration especially in adults and
multilated cases where conventional orthodontics may not be
possible.
• Examples of clinical applications of RAP in Orthodontics
• Simple canine retraction immediately after 1st premolar
extraction
• Various corticotomy procedures.
• Distraction osteogenesis procedure

• ACCELERATED INVISIALING TREATMENT
• (Albert H. Owen) (JCO 2002 June Vol. 35 No.6)
• Thomas and William Wilcko, using CT discovered that
rapid tooth movement following corticotomies was due to
reduced mineralization of the alveolar bone housing the involved
teeth.
• 2 years follow up CT showed alveolar bone was adequately
remineralized. Wilckos thought that patient could benefit from
alveolar augmentation in conjunction with a decorticating
procedure. (Augmentation increases the alveolar. crestal height,
increases the thickness of the alveolar bone and prevent
dehiscenses.
• Technique developed by Wilckos, called
WILCKODONTICS System (or) ACCELERATED
OSTEOGENIC ORTHODONTICS (AOO) is similar to
single tooth corticotomy. Here it is extended to all the teeth to
be moved orthodontically.

1. Procedure:
2. 1. Comprehensive FA.
3. 2. Full thickness flap – decortication of alveolar
bone
4. 3. Placement of resorbable bone graft agumentation.
5. 4. Soft tissue flap closed.
6. Following surgical procedure, orthodontic adjustment is made
weekly to take advantage which RAP, which lasts only for 3 to 4
months. Rate of tooth movement then returns to normal once
the bone has healed.
7. Owen combined the AOO procedure and Invisalign therapy
in his adult patients. After 10 days of uneventful healing aligners
were given. It was found that 3 to 4 times faster tooth
movement occurred.

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
• Hawley’s retainer remains the most commonly used retainer.
• Hawley’s with tongue crib
• Indicated in managing residual neuro muscular problems, especially postural
tongue problems.
• Bondable Lingual retainers
• They are mostly used the lower segments in patients requiring long-term
retention. They are esthetic and usually go unnoticed.
• Invisible retainers
• They are retainers that fully cover the clinical crowns and a part of the
gingival tissue. They are made of ultra thin transparent thermo-plastic sheets
using a Biostar machine. They are esthetic and often go unnoticed. These can
be used in adult patients who are especially concerned about
estheticsComprehensive restorative procedures
• Crowns and bridges may be required in mutilated cases at the termination of
orthodontic treatment. They are not only prosthetic replacements but also
retain the teeth

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

• CONCLUSION
• Biomechanical modifications made to accommodate orthodontic
treatment of adult dentitions are generally minor and adhere to
the basic laws of physics as they apply to orthodontic tooth
movement. Some adult presentations necessitate changes in
treatment strategy from what would otherwise be employed in
adolescent patients to achieve similar goals. In other cases,
objectives themselves may need to be modified because of lack
of growth potential, constraints of treatment mandated by the
patient or the presence of multiple missing or compromised
teeth. By planning treatment and mechanotherapy taking into
account the individual circumstances that may affect the patient’s
biological response to treatment, realistic goals of orthodontics
can be mutually recognized and agreed on by both the provider
and the patient before therapy is initiated, resulting in an
immensely rewarding experience.

REFERENCES
• Vanserdall RL ,Musich DR. Adult Orthodontics: Diagnosis and Treatment in
Graber TM Vanarsdall RL. Orthodontics . Current principles and pratice 2
nd ed .C.V.Mosby . St Louis 1994.pp 750-836
• Contemporary fixed prosthodontics: Second edition Stephen F. Rosenstiel
• Tylman theory and practice of fixed prosthodontics: 8th edition: W.F.P.
Malone
• Fundamentals of fixed prosthodontic: 3rd edition, Herbert T. Shillingberg
• Fixed prosthodontics: Keith E. Thayer.
• Implants in dentistry: Michael S.Block
• William R. Profit 3rd edition Text book of orthodontics

• Shapiro P.A. and Cruz A.D (1995): Long term changes
in arch form after orthodontic treatment and retention.
Am J Orthod.107:518-31
• Saadia M. and Valencia(1998): Six blind men and the
elelphant-The paradox story on relapse. Am J
orthod.:687-9
• Sperry T.P. (1993): Limitations of Orthodontic
treatment. Angle Orthod;63 :155-8.
• Spahl T.K(1995) The tem great laws of orthodntics.
Funtional Orthod:14-29

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