Orthodontic treatment done in Adults

1. Dr. Terence Abraham
MDS Orthodontist
Senior Lecturer, Malabar
Dental College, Edappal

2. Contents
 Introduction
 History
 Adjunctive versus comprehensive treatment
 Goals of adjunctive treatment
 Principles of adjunctive treatment
 Diagnostic and treatment planning considerations
 Biomechanical considerations
 Timing and sequence of treatment
 Adjunctive treatment procedures
 Uprighting posterior teeth
 Crossbite correct ion
 Forced eruption
 Alignment of anterior teeth

3.  Comprehensive Treatment in Adults:
 Psychological considerations
 TMD as a Reason for Orthodontic Treatment
 Periodontal considerations
 Special Aspects of Orthodontic Appliance Therapy
 Esthetic Appliances in Treatment of Adults
 Intrusion and Skeletal anchorage
 Finishing and Retention
 Review of literature
 References

4. Frequently asked questions
 Ortho perio inter relationship (2007)
 Uprighting of molars (2007)
 Adult orthodontics (2010)
 Adjunctive orthodontics(2008)

5. 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 .
 Adults who seek orthodontic treatment fall into two different
groups: (1) younger adults (typically under 35, often in their 20s)
who desired but did not receive comprehensive orthodontic
treatment as youths and now seek it as they become financially
independent
and (2) an older group, typically in their 40s or 50s, who have
other dental problems and need orthodontics as part of a larger
treatment plan.

6.  For the first group, the goal is to improve their quality of life.
They usually seek the maximum improvement that is
possible. They may or may not need extensive treatment by
other dental specialists but frequently need
interdisciplinary consultation.
 The second group seek to maintain what they have, not
necessarily to achieve as ideal an orthodontic result as
possible. For them, orthodontic treatment is needed to
meet specific goals that would make control of dental
disease and restoration of missing teeth easier and more
effective, so the orthodontics is an adjunctive procedure to
the larger periodontal and restorative goals.

7.  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 densityof the bones and muscles of mastication.
 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
 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.

8.  DIFFERENCE BETWEEN THE ADOLESCENT AND THE
ADULT
In the adolescent, tooth movement is affected by growth
while the adult we deal strictly with tooth movement alone.
In addition, orthodontic treatment in the adults is often
based on symptoms detected by the patient while in
children, it is based more often on signs detected by
practitioners or parents. Adult patients are more careful
more punctual, prompt paying, much less sensitive to pain
and treatment time is either the same or less than that of
younger patients.

9. Adjunctive Versus Comprehensive
Treatment Adjunctive orthodontics
 Adjunctive orthodontic treatment for adults is, tooth
movement carried out to facilitate other dental procedures
necessary to control disease, restore function, and enhance
appearance. The primary goal usually is to make it easier or
more effective to replace missing or damaged teeth and to
control periodontal problems.
 The treatment duration will be few months, rarely more than
a year, and long-term retention usually is supplied by the
restorations.

10. Comprehensive orthodontics The goal of comprehensive orthodontics is to produce the
best combination of dental and facial appearance, dental
occlusion, and stability of the result to maximize benefit to
the patient. It requires a complete fixed orthodontic
appliance, intrusion of some teeth, orthognathic surgery.
 The duration of treatment exceeds 1 yr.
 Adults receiving comprehensive treatment are the main
candidates for esthetically enhanced appliances; like ceramic
facial brackets, clear aligners, and lingual appliances.

11. Goals of Adjunctive Treatment Improve periodontal health by eliminating plaque-harboring
areas and improving the alveolar ridge contour adjacent to the
teeth.
 Establish favorable crown-to-root ratios and position the teeth
so that occlusal forces are transmitted along the long axes of the
teeth.
 Facilitate restorative treatment by positioning the teeth so that:
 More ideal and conservative techniques (including implants)
can be used.
 Optimal esthetics can be obtained with bonding, laminates, or
full-coverage porcelain restorations.

12.  Adjunctive orthodontic treatment will involve ,
 (1) repositioning teeth that have drifted after
extractions or bone loss so that more ideal fixed or removable partial
dentures can be fabricated or so that implants can be placed.
 (2) alignment of anterior teeth to allow more esthetic restorations or
successful splinting, while maintaining good interproximal bone
contour and embrasure form,
 (3) correction of crossbite and
 (4) forced eruption of badly broken down teeth to expose sound root
structure on which to place crowns or to level/regenerate alveolar
bone.
 As a general guideline in treatment of adults with
periodontal involvement and bone loss, lower incisor
teeth that are excessively extruded are best treated by
reduction of crown height, which has the added
advantage of improving the ultimate crown-to-root
ratio of the teeth.
Procedures

13. Procedures which can’t consider as
adjunctive procedures. Orthodontic treatment for temporomandibular dysfunction
(TMD)
 Intrusion of teeth
 Crowding of more than 3 to 4 mm.

14. Principles of Adjunctive Treatment:
Diagnostic and Treatment Planning
Considerations Planning for adjunctive treatment requires two steps: (1)
collecting an adequate diagnostic data base and
(2) developing a comprehensive but clearly stated list of the
patient's problems
 Diagnostic records includes opg , IOPA, lateral ceph, computer
prediction models,articulated cast

15.  The goal of providing a physiologic occlusion and facilitating
other dental treatment has little to do with Angle's concept
of an ideal occlusion.

16. Biomechanical Considerations:
Characteristics of the Orthodontic
Appliance
 PEA 022 slot Appliance
 Clear aligner therapy
 Lingual appliances
 PEA 022 with invisible appliances
 For adjunctive orthodontic treatment, movement of the anchor
teeth usually is undesirable, but a straight length of wire will move
them if the brackets are positioned in ideal position. Brackets
placed in the position of maximum convenience, lined up so that a
straight length of wire can be placed without moving the anchor
teeth. This makes things easier if no movement of the anchor teeth
is desired.
 For adjunctive orthodontic procedures like molar uprighting, we
recommend the use of fully adjusted “straight-wire” 22-slot brackets
and working archwires that are somewhat smaller than the bracket
slot to reduce unwanted faciolingual movement of anchor teeth.

18.  When bone is lost, the periodontal ligament (PDL) area
decreases, and the same force against the crown produces
greater pressure in the PDL of a periodontally compromised
tooth than a normally supported one.
 The center of resistance of a single-rooted tooth lies
approximately six-tenths of the distance between the apex of
the tooth and the crest of the alveolar bone.
 The absolute magnitude of force used to move teeth must be
reduced when periodontal support has been lost. In addition,
the greater the loss of attachment, the smaller the area of
supported root and the further apical the center of resistance
will be.This affects the moments created by forces applied to
the crown.

19. Timing and Sequence of Treatment
 Orthodontics is used to establish occlusion but only after
disease control has been accomplished, and the occlusion
should be stabilized before definitive restorative treatment is
carried out.

20.  Periodontal disease also must be controlled before any
orthodontics begins because orthodontic tooth movement
can lead to rapid and irreversible breakdown of the
periodontal support apparatus.
 Scaling, curettage (by open flap procedures, if necessary),
and gingival grafts should be undertaken as appropriate.
 Surgical pocket elimination and osseous surgery should be
delayed until completion of the orthodontic phase of
treatment because significant soft tissue and bony
recontouring occurs during orthodontic tooth movement

21. Adjunctive Treatment Procedures:
Uprighting Posterior Teeth

23.  When a first permanent molar is lost during childhood or
adolescence and not replaced, the second molar drifts
mesially and the premolars often tip distally and rotate as
space opens between them and opposing tooth tend to
extrudes.
 As the teeth move, the adjacent gingival tissue becomes
folded and distorted, forming a plaque-harboring
pseudopocket that may be virtually impossible for the patient
to clean. pseudopockets form adjacent to the tipped teeth.
 Repositioning the teeth eliminates this potentially pathologic
condition and has the added advantage of simplifying the
ultimate restorative procedures.

24.  Uprighting is by distal crown movement (tipping), which
would increase the space available for a
bridge pontic or implant or by mesial root movement, which
would reduce or even close the edentulous space. As a
general rule, treatment by distal tipping of the second molar
and a bridge or implant to replace the first molar is
preferred.
 Uprighting single molar may takes about 8 to 10 weeks, but
uprighting two molars in the same quadrant by tipping
them distally could easily take 6 months.
 A partial fixed appliance to upright tipped molars consists
of bonded brackets on the premolars and canine in that
quadrant and either a bonded rectangular tube on the molar
or a molar band.

25.  Fixed appliance technique for uprighting one molar with a
continuous flexible wire. Initial bracket alignment is
achieved by placing a light flexible wire such as 17 × 25 A-
NiTi, from molar to canine. It is important to relieve the
occlusion as the tooth tips upright. Uprighting essentially
completed in 2 months.

26.  If the molar is severely tipped, a continuous wire that
uprights the molar will have side effects so sectional
uprighting spring was used. After preliminary alignment
of the anchor teeth,stiff rectangular wire (19 × 25steel)
maintains the relationship of the teeth in the anchor
segment, and an auxiliary spring is placed in the molar
auxiliary tube
 The uprighting spring is formed from 17 × 25 beta-Ti
wire.

27.  If a mesial root movement is
desired a single “T-loop” sectional
archwire of 17 × 25 stainless steel or
19 × 25 beta-titanium (beta-Ti)
wire can be effective.
 The distal end of the archwire
should be pulled distally through
the molar tube, opening the T-loop
by 1 to 2 mm, and then bent sharply
gingivally. If opening the space is
desired, the end of the wire is not
bent over so the tooth can slide
distally along it.

28.  A compressed coil spring(.009 wire, .030 lumen) is cut so
that it is 1 to 2 mm longer than the space may be used on
018/17*25ss arch wire to complete molar uprighting while
closing remaining spaces in the premolar region. The coil
spring can be reactivated by compressing it against a split
spacer crimped over the archwire just behind the premolar
bracket.
 It should exert a force of approximately 150 gm to move the
premolars mesially while continuing to tip the molar distally.

29.  After molar uprighting, the teeth are in an unstable position until
the prosthesis that provides the long-term retention is placed. As a
general guideline, a fixed bridge can be placed within 6 weeks
after uprighting is completed.
 There are two ways to provide temporary stabilization: A heavy
rectangular (19 × 25) steel wire engaging the brackets passively
and (B) intracoronal splint made with 19 × 25 or 21 × 25 steel wire
that is bonded in shallow preparations in the proximal enamel
with composite resin. This causes minimal tissue disturbance. The
intracoronal splint is preferred, particularly if retention is to be
continued for more than a few weeks.
Retention

30. Crossbite Correction Posterior crossbites frequently are corrected using
elastics which moves both the upper and lower tooth
this tips the teeth into the correct occlusion but also
tends to extrude them.
 Anterior cross bite is corrected by tipping maxillary
incisors labially nearly always produces an apparent
intrusion and a reduction in overbite

31. Extrusion
 For teeth with defects in or adjacent to the cervical third of
the root, controlled extrusion (sometimes called forced
eruption) can be an excellent alternative. Extrusion also
allows crown margins to be placed on sound tooth structure
while maintaining a uniform gingival contour that provides
improved esthetics.
 As the tooth is extruded, the attached gingiva should follow
the cementoenamel junction. This returns the width of the
attached gingiva to its original level.

32.  Forced eruption can move a tooth that is unrestorable
because of subgingival pathology into a position that
allows treatment. Initially, an elastomeric tie was used
from an archwire segment to an attachment on the post
that was cemented in the root canal. Then loops in a
flexible rectangular wire (17 × 25 beta-Ti) were employed
for quicker and more efficient tooth movement and 4
mm elongation has occurred.

33.  If a fracture is at the height of the alveolar crest, the tooth should
be extruded about 3 mm; if it is 2 mm below the crest, 5 mm of
extrusion is ideal.
 The crown-to-root ratio at the end of treatment should be 1:1. A
tooth with a poorer ratio can be maintained only by splinting it to
adjacent teeth.
 In general, extrusion can be as rapid as 1 mm per week without
damage to the PDL, so 3 to 6 weeks is sufficient.
 After active tooth movement has been completed, at least 3 weeks
of stabilization is needed to allow reorganization of the PDL. If
periodontal surgery is needed to recontour the alveolar bone
and/or reposition the gingiva, it can be done a month after
completion of extrusion.

35. 17*25 TMA wire

36. Alignment of Anterior Teeth:
Diastema Closure and Space
Redistribution The major indication for adjunctive orthodontic treatment to
correct malaligned anterior teeth for buildups, veneers, or
implants to improve the appearance of the maxillary incisor teeth.
If spacing of maxillary incisors is related to small teeth and a
tooth-size discrepancy, composite buildups are an excellent
solution.

37. Crowded, Rotated, and Displaced
Incisors
 A segment of NiTi wire usually is the best way to bring the teeth into
alignment.
 Stripping the contact points of the teeth to remove enamel can provide
space for alignment of mildly irregular lower incisors, and either a fixed
appliance or a clear aligner sequence can provide the tooth movement.
 In severe crowding, removing one lower incisor and using the space to
align the other three incisors can produce a satisfactory result and can be
managed with clear aligner therapy if bonded attachments are part of
the treatment plan.
 Stretched gingival fibers have a potent force for relapse after rotations
have been corrected, and that good long-term stability may require a
fiberotomy.
 Retention by a molded thermoplastic retainer, a canine-to-canine clip on
retainer, or a bonded fixed retainer

38. Comprehensive Treatment in Adults
Psychologic Considerations
 Adults in both the younger and older groups, in contrast, seek
comprehensive orthodontic treatment because they themselves
really want it. For the younger group who are trying to improve
their life, exactly what they want is not always clearly expressed,
and some young adults have a remarkably elaborate hidden set of
motivations. It is important to explore why an individual wants
treatment.
 A patient who seeks treatment primarily because he or she wants
it (internal motivation) is more likely to respond well
psychologically than a patient whose motivation is from others
(external motivation).
 External motivation is often accompanied by an increasing impact
of the orthodontic problem on personality.Such a patient is likely
to have a complex set of expectations for treatment.

39.  Even highly motivated adults are likely to have some concern about the
appearance of orthodontic appliances. The demand for an invisible
orthodontic appliance comes almost entirely from adults who are
concerned about the reaction of others.
 Dentofacial deformity can affect an individual's life adjustment.
Fortunately, most adult orthodontic patients fall into the “no problem”
category psychologically.
 A few highly successful individuals can be thought of overcompensating
for their deformity with their exceptional personability, but they tend to
be personable and very pleasant to work with.
 For some individuals, the orthodontic condition can become the focus
for a wide-ranging set of social adjustment problems that orthodontics
alone will not solve. These patients fall into the “inadequate personality”
and “pathologic personality” categories, who are difficult and almost
impossible to adjust.
 In addition, adults, as a rule, are less tolerant of discomfort and more
likely to complain about pain after adjustments and about difficulties in
speech, eating, and tissue adaptation.

40. Temporomandibular Dysfunction as a
Reason for Orthodontic Treatment
 Temporomandibular pain and dysfunction (TMD symptoms)
rarely are encountered in children seeking orthodontic
treatment, but TMD is a significant motivating factor for
some adults seeking orthodontic treatment.

41.  TMJ DISORDERS
 Deviation - 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 position.
 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.

42.  Masticatory muscle disorders,
 TM joint disorders,
 chronic mandibular hypomobility,
 growth disorders
 Arthritic involvement of the TM joints is most likely to be the
cause of TMD symptoms.
 Disc displacement is caused by trauma to the joint, so that
the ligaments that oppose the action of the lateral pterygoid
muscle are stretched or torn. Muscle contraction moves the
disk forward as the mandibular condyles translate forward on
wide opening, but the ligaments do not restore the disk to its
proper position when the jaw is closed. This result in click
upon opening and closing.
 Occlusal splint is used to prevent the patient from closing
beyond the point at which displacement occurs. This results
relief of pain and discomfort.

43.  Myofascial pain develops when muscles are fatigued and
tend to go into spasm. To produce myofascial pain, the
patient must be clenching or grinding the teeth for many
hours per day, as a response to stress.
 Two factors to produce myofascial pain: an
occlusal discrepancy and a patient who clenches or
grinds the teeth
Arthritic degeneration of a left mandibular condyle .Note the flattening of the condylar
Head.

44. Occlusal relationships in a 24-
year-old woman who had
worn a splint covering only
her posterior teeth for the
previous 18 months

45. Treatment
 Three broad approaches to myofascial pain symptoms can be
considered: reducing the amount of stress;reducing the
patients reactions to stress; or improving the occlusion.
 Some instances, this may involve orthognathic surgery to
reposition the jaws.
 The extent to which TMD symptoms in many adults
disappear when comprehensive orthodontic treatment
begins.
 In some situation interocclusal splint therapy is beneficial.

49. Periodontal Considerations
 Periodontal problems are rarely a major concern during
orthodontic treatment of children and adolescents because
periodontal disease usually does not arise at an early age and
tissue resistance is higher in younger patients but periodontal
considerations are increasingly important as patients become
older.
The prevalence of mucogingival problems
peaks in the twenties and periodontal
problems increases with age which could
affect orthodontic treatment, and
mucogingival considerations are important
in treatment of the younger adult group.

50.  Periodontal disease is not a continuous and steadily
progressive degenerative process. Instead, it is
characterized by episodes of acute attack on some but
usually not all areas of the mouth, followed by
quiescent periods.
 At present, persistent bleeding on gentle probing is
the best indicator of active and progressive disease.
 There is no contraindication to treating adults who
have had periodontal disease and bone loss, as long as
the disease has been brought under control.

51.  58 yr old female came with spacing. She had generalized
periodontal disease with localized severe bone loss. After
the periodontal disease was brought under control ,
orthodontic treatment started. The plan was to use skeletal
anchorage (alveolar bone screws) in both arches to retract
the incisors while maintaining normal overbite. Closure of
the old maxillary left second molar extraction space was
planned. A-NiTi coil springs and sliding mechanics were
used for space closure in both arches, with screws placed
between the first and second premolars in both arches.
 After completion of orthodontic treatment of 35 months
dental alignment and occlusion improved and the
maintenance of her periodontal health. Cephalometric
superimposition showing the major retraction of the
incisors.
Case reports

55. Treatment of Patients with Minimal
Periodontal Involvement
 In adults who will have comprehensive orthodontic
treatment, gingival grafting to create adequate quantity and
thickness of attached gingiva is important before beginning
orthodontic tooth movement.
 The width of the attached gingiva (not all keratinized gingiva
is attached) and the thickness of the gingival tissue are
important. The width of the attached gingiva can be
observed most readily by inserting a periodontal probe and
observing the distance between the point at which the
gingival attachment is encountered and the point at which
the alveolar mucosa begins.

56.  Patient with thin attached gingiva in lower anterior
should carried out gingival grafting before starting
orthodontic treatment. Orthodontic treatment started
after 3 months of flap surgery.

57. Moderate Periodontal Involvement
 Before orthodontic treatment is attempted for patients who have
preexisting periodontal problems, dental and periodontal disease must
be brought under control. Preliminary periodontal therapy can include
all aspects of periodontal treatment. It is important to remove all
calculus and other irritants from periodontal pockets before any tooth
movement is attempted, and it is often wise to use surgical flaps to
expose these areas to ensure the best possible scaling.
 Disease control also requires endodontic treatment of any pulpally
involved teeth. There is no contraindication to the orthodontic
movement of an endodontically treated tooth, so root canal therapy
before orthodontics will cause no problems.
 Attempting to move a pulpally involved tooth, however, is likely to cause
a flare-up of pulpitis and pain.
 The general guideline for preliminary restorative treatment is that
temporary restorations should be placed to control caries, with the
definitive restoration can be delayed until after the orthodontic phase of
treatment.

58.  It is better to use a fully bonded orthodontic appliance
for periodontally involved adults because the margins of
bands can make periodontal maintenance more difficult.
Self-ligating brackets or steel ligatures also are preferred
for periodontally involved patients rather than
elastomeric rings to retain orthodontic archwires
because patients with elastomeric rings have higher
levels of microorganisms in gingival plaque.
Bone loss around a tooth affects both
the force and the moment needed.
Orthodontic movement of
periodontally involved teeth can be
done only with careful attention to
forces (smaller than normal).

59. Severe Periodontal Involvement
 In severe cases (1) periodontal maintenance should be
scheduled at more frequent intervals, (i.e., every 4 to 6
weeks), and (2) orthodontic treatment goals and mechanics
must be modified to keep orthodontic forces to an absolute
minimum.

60.  27 yr old woman came with crowding and severe
periodontitis. She had Class II molar relationship .The
panoramic radiograph shows severe bone loss in multiple
areas. The cephalometric radiograph showed a skeletal Class
II jaw relationship, with moderate maxillary incisor
protrusion. The treatment planned for extraction of the 24
and 15 (chosen because of the large periodontal defect
distal to it, although this would make the orthodontic
treatment more difficult).
 After 18 months of treatment, both the occlusion and
appearance of the teeth were greatly improved. On
Cephalometric superimposition slight retraction of the
maxillary incisors and mild proclination of the mandibular
incisors, as was desired in this case.Repositioning of the
maxillary frenum and sectioning of the elastic gingival
fibers were carried out.
Case reports

64.  48yr old female with crowding ,posterior cross bite and
generalised periodontal bone loss.. The maxillary left lateral
incisor and all four first molars were missing. Treatment
planned as opening space for replacement of the missing
lateral incisor and space closure in the maxillary left molar
area would facilitate opening the anterior space. The
mandibular third molars would be extracted so the second
molars could be uprighted and rolled lingually to improve
the crossbite.
 The acrylic pontic tied to the maxillary archwire in the
lateral incisor space to maintaining the space. In the
mandibular arch, uprighting of second molars and
prosthetic replacement of first molars. An implant was
placed in the lateral incisor area. Retention using fixed
bonded retainer.
Case report

67.  If it is desired to move lower molars forward into an old first
molar or second premolar extraction site, a temporary implant in
the ramus can be used to provide the necessary anchorage and
avoid retracting the lower anterior teeth. This technique,
pioneered by Roberts.
 Use of an implant in the ramus for anchorage to move the
mandibular second and third molars mesially when it is desired
to close an old first molar extraction site. Note that a wire
extending forward from the implant stabilizes the premolar and
through it the anterior teeth, so that they are not pulled
posteriorly in reaction to anterior movement of the second and
third molars.
Protraction of molars

68. Special Aspects of Orthodontic
Therapy for Adults
 The patient's desire for a minimally apparent or invisible
orthodontic appliance should be accommodated if
possible.
 This requires consideration of CAT, ceramic or other
nonmetallic brackets, or lingual orthodontics.
 •In patients who have lost some periodontal support,
orthodontic force must be kept light.
 •Skeletal fixation in the form of miniplates, screws, or
implants is likely to be required for some types of tooth
movement, especially intrusion of posterior teeth,
protraction of posterior teeth, or to support maximum
retraction and/or intrusion of anterior teeth

69. Esthetic Appliances in Treatment of
Adults Clear Aligner Therapy
 The basic approach to comprehensive CAT, involving
the production of a series of aligners on
stereolithographic casts produced from virtual models.

70.  24 yr old female came with anterior open bite. Closure of
anterior openbite using invisalign is difficult. So attachments
were placed using ClinCheck software. Proximal stripping
was done to retract the incisors and reduce overbite.19 upper
and 10 lower aligners were fabricated by CAD CAM. A lower
bonded retainer and a maxillary suck-down retainer were
placed.

71.  47-year-old woman with unilateral open Bite. The
panoramic radiograph showed condylar asymmetry, with
resorption of the left condyle that was tentatively attributed
to Osteoarthritis.
 The treatment plan was to use a fixed appliance in the lower
arch with skeletal anchorage for intrusion of mandibular
molars and close the open bite, while aligning the upper
arch with Invisalign and completing treatment with
Invisalign in both arches. Once the bite was closed (which
took 8 months) a series of aligners was used over a period of
another 4 months to complete the treatment.

73. Lingual orthodontics
 A major difficulty in lingual orthodontics is the short
span of archwires between attachments. For any wire,
the shorter the span, the stiffer the material. The
distances between the teeth along the archwire are so
short that it can be hard to align severely crowded
teeth, particularly for lower incisors. Because the
lingual surfaces of the incisors, canines, and posterior
teeth do not line up nearly as well as the facial surfaces

74. Case 45-year-old woman with crowding in upper anteriors. The
treatment plan was to align the teeth, correct the buccal
occlusion, and level the gingival margins Using lingual
fixed appliances. Facial attachments were bonded to the
maxillary canines and mandibular canines and premolars
to make it easier for her to wear vertical elastics to settle
the posterior teeth into occlusion. After 24 months of
active treatment veneering on the maxillary incisors to
improve their length.

76.  31-year-old woman with crowding of lower incisors, posterior
crossbite, and an anterior open bite, missing 14 and the
deviated dental midline to the right. The treatment planned
for extraction of the mandibular second premolars and
maxillary left second premolar to provide space for alignment
and repositioning of the anterior teeth.
 Lingual fixed appliances were bonded and initial levelling
was done by Computer-formed superelastic A-NiTi
archwires.
Space closure was done with elastomeric chains on (16 × 22)
steel rectangular archwire .Closure of the extraction spaces
with good root paralleling was achieved. Cosmetic
restoration of the maxillary left lateral incisor was planned as
a final treatment procedure.

79. Applications of Skeletal Anchorage
 There are now four major applications for skeletal
anchorage in treatment of adults:
 Positioning individual teeth when no other
satisfactory anchorage is available (usually because
other teeth have been lost due to dental or periodontal
disease).
 Retraction of incisors.
 Distal or mesial movement of molars (and the entire
dental arch if needed).
 Intrusion of posterior teeth to close an anterior open
bite or anterior teeth to open a deep bite.

80. Case report 26-year-old woman with proclined upper anteriors.
Treatment planned as first premolars extraction in both
arches and intrusion of her maxillary incisors. Retraction of
upper arch using bone screws placed mesial to the first
molars and NiTi coil springs attached to the screws
delivering 200 gm of force. Retraction carried out in 2 steps.
First canine retraction followed by anterior segmental. The
mandibular first premolar extraction sites were closed
without support from skeletal .

82. Retraction and Intrusion of
Protruding Incisors
 With segmented arch mechanics, maxillary incisors can be
both retracted and intruded if excellent anchorage is
maintained with stabilizing lingual arches and headgear
which requires patient cooperation, and now its possible by
skeletal anchorage.
 The direction of force, both upward and backward, is ideal
for this purpose, and ANiTi springs provide constant force
levels.
 Retraction of maxillary anterior teeth with implants in the
palate was one of the first applications of skeletal
anchorage.

83. Distal Movement of Molars or the
Entire Dental Arch
 Distal movement of the maxillary molars is one way to
provide space in a crowded maxillary arch; distal
movement of the entire maxillary dental arch would
provide a way to correct a Class II malocclusion due to
a forward position of the upper teeth on their skeletal
base. Bone screws which are placed in the palate or in
the infrazygomatic process away from the roots helps
to retract entire arch by 2 to 4 mm.
 Moving the entire mandibular arch distally can be
done by long bone screw in the mandibular buccal
shelf or the ramus.

84.  28-year-old patient with protruded maxillary arch and a partially
corrected Class II malocclusion by previous orthodontic
treatment. Maxillary first premolars were extracted, the treatment
plan was palatal anchorage with bilateral bone screws for
distalization of the entire maxillary arch.
 First molar were distalised and then the palatal screws were used
to stabilize the molars while the other teeth were retracted.
Cephalometric radiographs showed the overjet reduction and
attainment of the desired molar relationship.

85. Case report
 Patient with crowding and protruded lower anterior teeth
and anterior crossbite. One mandibular second molar had
been lost previously to caries, the other had been treated
endodontically, and the third molars had been removed.
 The plan was extraction of the remaining mandibular
second molar, with distalization of the entire arch to gain a
better functional molar relationship, as well as correct the
 crossbite. Bone screws were placed bilaterally in the buccal
shelf of the alveolar process and NiTi springs were used to
move the dental arch posteriorly.
 Result showed correction of the mandibular anterior
crowding and crossbite.

87. Molar Protraction
 Space closure by bringing molars forward can be accomplished
easily with a miniscrew to provide direct or indirect anchorage.
 28-year-old man had a unilateral anterior crossbite and Class III
molar relationship, with mild skeletal maxillary deficiency. The
treatment plan was movement of the entire maxillary arch
forward, using skeletal anchorage to maintain the
anteroposterior position of the mandibular dental arch.
 Bone screws distal to the canines were used to stabilize the
maxillary posterior segments while the maxillary incisors were
advanced to correct the crossbite. Then the space distal to the
canines was closed by bringing the posterior segments forward.
 The power arm provide the point of force application closer to
the center of resistance of the posterior teeth to decrease their
tendency to tip as they are advanced.

89. Intrusion
 Intrusion of teeth is indicated in
 (1) overerupted incisors leading to excessive display and/or anterior deep bite
and
 (2) overerupted molars in anterior open bite with excessive face height.
 Ideally, intruding a tooth would lead to a reattachment of the periodontal
fibers, but there is no basis for expecting this. There is formation of a tight
epithelial cuff, so that the position of the gingiva relative to the crown
improves clinically, while periodontal probing depths do not increase.
 Histologically showed a relative invagination of the epithelium, but with a
tight area of contact that cannot be probed. If there is any inflammation
subgingivally leads to periodontal breakdown, so oral prophylaxis should be
done before advocating intrusion.
 The crown–root ratio is a significant factor in the long-term prognosis for a
tooth that has suffered periodontal bone loss. Shortening the crown has the
virtue of improving the crown–root ratio.

90.  Most patients with anterior open bite have elongation of the
maxillary posterior teeth, so that the mandible is rotated
downward and backward.
 Intrusion of the posterior segments is the ideal approach to
treatment. Skeletal anchorage now makes orthodontic intrusion
a possible alternative to surgery.
 For intrusion of maxillary posterior teeth, miniplates at the base
of the zygomatic arch provide excellent anchorage
 An ideal force system for intrusion is created by A-NiTi springs,
which provide a relatively constant known force over a
considerable range of activation. Flaring of crown can be
prevented by transpalatal lingual arches .
 A bonded plate covering the occlusal surface of the teeth,
fabricated so that it is off the palate enough to allow the
intrusion, is the preferred method at present. As the mandible
rotates upward and forward as the posterior teeth intrude, it
may be advantageous to Class II malocclusion .
 Average 0.5 mm of posterior intrusion produces 1 mm closure of
anterior open bite and that intrusion up to 4 mm can be
obtained

91.  26 old female with anterior open bite and Increased
anterior face height. She had 6 mm anterior open bite
and contact only on the distal of the first molars and
second molars.
 A long bone screw into the base of the zygoma is used
for anchorage. It is the twin transpalatal arches
connecting the splints, which must be off the palate.

93. Retention
 A clear “suck-down” retainer often is the best choice
immediately upon removing the orthodontic
appliance, but in adults with bone loss, undercuts
must be waxed out on the casts before the retainer is
formed and a wraparound retainer is also indicated.

94.  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
 3. Significant arch length discrepancies
 4. Transversely constricted maxilla
 5. posterior intrusion and rapid anterior retraction with maximum
anchorage
 . Can be combined with orthopaedic therapy

95.  Corticotomy surgery initiates and potentiates normal
healing process by way of an accelerated remodelling of
hard and soft tissue by means of a process called
REGIONAL ACCELERATORY PHENOMENON (RAP). It
was described by an Orthopaedist Harold frost.
 In the alveolar bone adjacent to corticotomy site, there was
marked increase in regional bone turn over. Tissue forms 2
– 10 times faster than normal regeneration process.
 RAP – decreased the treatment duration especially in
adults and mutilated 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

97. Archwire ligation techniques, microbial colonization, and
periodontal status in orthodontically treated patients,
turkkahraman angle ortho 2005
 The aim of this study was to determine the changes in microbial flora and
periodontal status after orthodontic bonding and to determine whether
two different archwire ligation techniques affect these changes.
 A total of 21 orthodontic patients were selected for this split-mouth study.
Two commonly used auxiliaries (elastomeric rings and ligature wires) for
tying archwires were tested. Microbial and periodontal records were
obtained before bonding (T0),
one week later (T1), and five weeks after bonding (T2). Paired t-test and
Wilcoxon signed rank test were used to compare the groups statistically.
 Although, teeth ligated with elastomeric rings exhibited slightly greater
numbers of microorganisms than teeth ligated with steel ligature wires,
the differences were not statistically significant .
 The two archwire ligation techniques showed no significant differences in
the gingival index, bonded bracket plaque index, or pocket depths of the
bonded teeth.
 However, teeth ligated with elastomeric rings were more prone to
bleeding. Therefore, elastomeric ring use is not recommended in patients
with poor oral hygiene.

98. Clinical and microbiological parameters in patients with
self-ligating and conventional brackets during early
phase of orthodontic treatment, Pejda et al Angle ortho
2013 To determine the effect of different bracket designs
(conventional brackets and selfligating brackets) on periodontal
clinical parameters and periodontal pathogens in subgingival
plaque.
 Study done in 38 patients who were divided into two groups with
random distribution of brackets. Recording of clinical
parameters was done before the placement of the orthodontic
appliance (T0) and at 6 weeks (T1), 12 weeks (T2),and 18 weeks
(T3) after full bonding of orthodontic appliances.
 Periodontal pathogens of subgingival microflora were detected at
T3 using a commercially available polymerase chain reaction test
(micro-Dent test) that contains probes for
A.actinomycetemcomitans,Porphyromonas gingivalis, Prevotella
intermedia, Tannerella forsythia, and Treponema denticola

99.  Results showed that there was a statistically significant
higher prevalence of A.actinomycetem- comitans in
patients with conventional brackets than in patients with
self-ligating brackets, but there was no statistically
significant difference for other putative periodontal
pathogens. The two different types
of brackets did not show statistically significant
differences in periodontal clinical parameters.

100. Orthodontic treatment in a periodontal patient
with pathologic migration of anterior teeth,Xie et al AJO 2014
 A 22-year-old man with severe periodontitis and pathologic
tooth migration having spacing in anteriors and extruded
lower incisors. A multidisciplinary approach was chosen. A
thorough scaling and root planning was done. An occlusal
splint was used to prevent occlusal trauma to the anterior teeth
during the early stage of alignment. Slightly grinding the
crown of the extruded mandibular right central incisor to
reduce the ratio of crown to root length could also contribute
to reducing the occlusal trauma.
 After 22 months of treatment, a stable occlusion had been
achieved and maintained for a period of time. Overjet and
overbite were proper, except for minor gaps between the
incisors for preparing for the restorations. After removing the
appliance, fixed lingual retainers were bonded.

103. Apical root resorption of vital and endodontically
treated teeth after orthodontic treatment:
A radiographic evaluation,Esteves et al Dental Press
Endod. 2013
 To evaluate whether vital and endodontically treated teeth
present similar severity of apical root resorption in response to
orthodontic treatment. This study done on twenty-eight patients
who had one upper central incisor endodontically treated
(experimental group) and its vital counterpart untreated (control
group )before orthodontic movement.
 Measurements were made by means of periapical radiographs
taken before and after orthodontic treatment.
 Results: There were no statistically significant differences (P >
0.05) in apical root resorption levels between endodontically
treated and vital teeth.
 Conclusion: Endodontic treatment does not interfere in apical
root resorption after orthodontic treatment.

105. Managing Treatment for the Orthodontic Patient With
Periodontal Problems David P. Mathews and Vincent G.
Kokich, Semin Orthod 1997
 This article describes diagnosis of periodontal problems and discusses the
interdisciplinary management of several periodontal problems requiring
orthodontic intervention. Important means of detecting periodontal disease is
to use a standard periodontal probe. The Michigan "O" and the Marquis
probe are thin, and easy to read and record measurements.
 Common areas for periodontal disease in adults are found in the upper molar
interproximal regions, buccal furcations, and in the lower canine/lateral area,
especially in patients with crowding.
 Clenchers and bruxers can cause extensive osseous breakdown during
orthodontic therapy.. These patients may need a biteplate appliance
(nightguard) while they are undergoing active orthodontic treatment.
 Preorthodontic Periodontal Therapy
 Root planing and subgingival debridement are performed to help diminish
inflammation, bleeding, and suppuration. This initial stage of treatment is
usually about 3 months

106.  Preorthodontic Gingival Surgery
 Gingiva Grafting
 Teeth with less than 2 mm of gingiva may require grafting
 Gingival Recession and Root Coverage
 Areas of recession and root exposure can be predictably covered with various grafting
techniques.
 Gingival grafting and pedicle grafting were the traditional methods for root coverage.
 At the present time the connective tissue graft has become the treatment of choice to
cover denuded roots.
 The connective tissue graft gives a greater degree of root coverage, is more esthetic, and
the procedure is less traumatic than conventional gingival grafting.
 Preorthodontic Osseous Surgery
 The extent of the osseous surgery will depend on the type of defect, ie, crater, hemiseptal
defect, three-walled defect, and/or furcation lesion.
 An osseous crater is an interproximal two-wall defect that will not improve with
orthodontic Treatment. This type of osseous lesion can easily be eliminated by reshaping
the defect and reducing the pocket depth

107.  3 wall defect
 Bone grafts using either autogenous bone from the surgery site, or allografts,
along with the use of resorbable or nonresorbable membranes have been very
successful in filling three-wall defects.
 Hemiseptal Defects
 Hemiseptal defects are one to two wall osseous defects. These are often found
around mesially tipped teeth or teeth that have supererupted. Often these
defects can be eliminated with appropriate orthodontic treatment.
 Furcation Defects
 Furcation defects can be classified as incipient (Class I), moderate (Class II) and
advanced (Class III). These lesions require special attention in the patient
undergoing orthodontic treatment.
 Class I defects are amenable to osseous surgical correction with a good
prognosis. Class II furcation defects can be treated with grafting and
regenerative therapy with barrier membranes.
 Class III furcation defects are more difficult to treat and use of grafting and
membranes in these lesions is not as predictable. Most favourable treatment of
class III furcation is hemisectioning. The most favorable root to remove is the
distobuccal root of an upper molar. This treatment has a good prognosis.

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