3. Basic biological concepts associated
with adult orthodontics.
Periodontal ligament.
Bone
Teeth .
4. Periodontal ligament
Fibroblast
Blood borne origin
Pleuropotential cell
Collagen & proteoglycans
Collagen turnover in PDL- 2.5-6.5 day
Aging-imbalance.
Proteoglycans-withstand the forces.
Retains water-changes with age.
PGs-prostaglandins & leukokines-resorption
of bone.
5. Capillary bed.
Number of branches found in the
vascular bed –decreases
Amount of blood flow to tissues-
decreases
Nerve tissue
Changes in number of neuro receptor
Age related decrease in sensory
responsiveness.
6. Bone
Mechanical properties changes
Macroscopically- trabecular bone
volume decreases.
Osteoblastic activity-reduces
Imbalance b/w resorption & replacement
Sinus size-increases
Bone density decreases &porosity
increases with age.
7. Teeth
More root exposure
Short crown root ratio
CR shift –apically
Diameter of pupal canal reduces
Decreased vascularity&innervation -pulp
recovery.
10. History
Kingsley(1880)-early awareness of the
orthodontic potential for the adult pts.
Published statements-Negative.
MacDowell(1901)- Impossible age.
Lischer(1912)-optimal age for treatment.
Golden age of treatment
Case (1921)-value of adult 0rthodontic
therapy
12. History
Lindegaard et al (1971)-3 factors.
Reidel & Dougherty (1976) “orthodontics is total
discipline and it makes no difference whether the
patient is young or old”
15. 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.
16. factors adolescents adults
Dental caries More susceptible Recurrent decay
restorative failures, root
decay& pulpal pathosis
PDL disease Resistance to bone loss
Susceptible to gingival
inflammation
Susceptible to bone loss
TMJ
adaptability
high Symptoms with
dysfunction
Occlusal
awareness
Infrequent Increased enamel wear
with adverse change in
supporting tissue.
comparison
17. Factors Adolescents adults
Growth factors Growth-orthopedic
Stable correction .
No growth
Minimal skeletal adaptability.
Surgical option
Dentofacial
esthetics
Reasonable concern Concern occasionally
disproportionate to degree of
existing problem
18. factors adolescents adults
Rate of tooth movement rapid slower
orthopedics 50% Small percentage
Orthognathic surgery 1-5% 10-20%
Restorative dentistry Smaller percentage frequently
Combination treatment uncommon 80%
28. Better lip competency &
support
In case of anterior restoration-retractions
Inadequate support-change in
anteroposterior &vertical position of
upper lip & increase in wrinkling.
29. Improved crown/root
ration
In case of bone loss
Reduced crown/root ratio
Can be corrected by reducing the clinical crown.
30. 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
34. 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
35. 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.”
36. Principles of AOT
Diagnostic & treatment planning.
Collecting an adequate data base.
Developing a problem list.
37. Diagnostic records
OPG.
Full mouth IOPAs.
Lateral ceph
photographs.
Dental casts.
38. 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.
42. Timing & sequence of
treatment
Active disease
Disease control
Establish occlusion
Definitive restorative Rx
maintenance
Re-evaluate
stabilize
43. Adjunctive orthodontic Rx
procedure.
Uprighting of posterior teeth
Uprighting a single molar
Uprighting with minimal extrusion
Final positioning of molar & PM
Uprighting two molars in the same quadrant
Retention
Forced eruption
Alignment of anterior teeth
Crossbite correction
44. 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?
61. 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
62. Forced eruption
Treatment planning
Good periapical radiographs
Periodontal support
Root morphology and position
Endodontic therapy should be completed
63. Orthodontic technique
Anchor teeth –rigid
Flexible –tooth to be extruded
With / without the use of orthodontic bracket
64.
65. 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.
68. 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
69. 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.
70. 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
76. 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.
80. Comprehensive
orthodontic treatment-
Adults Special considerations for adults
Different motivations for seeking orthodontic treatment & different
psychological differences to it.
Heightened susceptibility to periodontal disease.
Lack of growth.
81. Comprehensive
treatment
Motivation for adult treatment
Psychological
PDL & restorative needs as motivating factor
TMJ dysfunction as motivating factor
Periodontal aspects of adult treatment
Special aspects of orthodontic appliance
therapy.
82. Psychological
considerations
High motivation -self referred for
esthetic reasons
Low motivation -dentist referred for
adjunctive correction
Turned off -unaesthetic appliances,
fear of pain, extended treatment
time, personal inconvenience & cost
Adults are less tolerant of discomfort
& more likely to complain about
difficulties in speech, eating & tissue
adaptation.
83. Periodontal diagnosis
Awareness of risk factors
General factors
Family history
General health status
Nutritional status
Current stress factors
Local factors
Plaque indices
Crown root ratio
Habits
Restorative status
84. Periodontal aspects of
adult treatment
Periodontal considerations are
increasingly important as patient
become older ,regardless of whether
periodontal problems were a motivating
factor.
Minimal PDL involvement
Moderate PDL involvement
Severe PDL involvement
85. Minimal periodontal
involvement
Hygiene status
Special care-adults
Inter dental aids, proximal brushes
Level & condition of attached gingiva
Gingival recession
Gingival grafts
86. Moderate PDL-
involvement
Disease control
Preliminary PDL-treatment
Scaling,curettage,flap surgery etc
Endodontic treatment
Cast restorations should be delayed
Period of observations
PDL-maintenance
Full arch bonding> banding
Steel ligature > elastomeric rings
maintenance = 2-4 months
Hygiene maintenance- electric tooth brushes,
mouthwashes
87. Severe PDL- involvement
Disease control
Scaling,curettage,flep surgery, osseous
surgery
Endodontic therapy
Period of observation
PDL- maintenance
More frequent intervals,4-6 weeks
Very light forces should be used.
89. Temperomandibular
dysfunction
Diagnostic records
Full TMJ series x-rays
Opg
Muscle examination
Stress evaluation
•Prevalence of TMD problems-
Schiffman et al (1998)
Muscle disorder 23%
Joint disorder 19%
Combination 27%
Normal 31%
90.
91. Intrusion
light & continuous force
With continuous arch wires
Segmental arch wires
In case of PDL involved-anchorage
compromised.
Intrusion should never be attempted
without excellent control of inflammation.
92. Intrusion of incisors in adult patients
with marginal bone loss
Birte Melsen, AmJ Orthod 1989
Common problems-adults-PDL disease
Migration, spacing, elongation of incisors
Progressive bone loss-CR shifts appically
Aim :to intrude elongated teeth with varying degrees of
PDL damage & thus evaluating the influence of
treatment on pdl status.
93. Material & method
30 sample
5M/25F
AGE:22-60yrs
PDL preparation
Orthodontic appliance-4 types
J hook for intrusion
Ricketts utility arch-016x016 steel
Intrusion bend into loops of full arch-017x025
steel
Burstone’s continuous intrusion arch
94.
95. Analysis applied
Study casts
Latral ceph
Opg
IOPA-special film holder
Piece of 021x028 elgiloy
96.
97. Results
True intrusion=0-3.5mm
Clinical crown length reduction =0.5-2mm
Root resorption =1-3mm
Total amount of alveolar
support=unaltered/increased
Utility & Burstone’s base arch -largest intrusion
&largest gain in bony support.
105. Interproximal stripping for the
treatment of adult crowding-Julia F
Harfin JCO 2001 Nov
Crowding
Mild- less than 3mm
Moderate- 3-5mm
Severe -more than 5 mm
Thickest enamel -maxillary arch
M & D surfaces of cuspids
Distal surface of central incisors
Mandibular arch
M & D surfaces of cuspids
Distal surface of the lateral incisor
113. Space closure
Old extractions sites -difficult to close
Resorption
Remodeling of the bone.
Such situation-better to use prosthesis or
Implants.
Temporary implants in the ramus - to
protract the molars
114. Rigid implant anchorage to close a mandibular
first molar extraction site-W.Eugene Roberts,
Charles nelson,jco1997
Rigid endoesseous implants are
a reliable source of orthopedic
anchorage
For managing malocclusions
that are the usual scope
of orthodontic practice
45yrs/M
Missing lower molar
Case report
120. 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
121. 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
123. 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
124. 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
125. 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
131. 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
132.
133.
134.
135.
136. 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
137. After 1 wk of bracketing & wire activation-selective Decortications.
142. Conclusion
Takes shorter treatment time
Pre-existing fenestrations/dehiscence can
be corrected-alveolar augmentation.
Lip support can be achieved-alveolar
augmentation.
143. Accelerated Invisalign treatment-
Albert H Owen,JCO 2001 June
Esthetics & speed
Decorticotomy( AOO)
Invisalign therapy
Class I Occlusion
Mild crowding in lower arch
Lower midline shift
Only lower canine-canine decorticotomy.
144. After 10 days of corticotomy
Invisalign therapy started.
Aligners changed –every 3 days.
Rx completion-4 months.
145. 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
