Adult ortho

Definition – ADULT ORTHODONTICS
According to Ackerman, Adult orthodontics
is defined as ‘The branch of orthodontics
concerned with striking a balance between
achieving optimal proximal & occlusal
contact of the teeth, acceptable dentofacial
esthetics, normal function & reasonable
stability’.
www.indiandentalacademy.com

 History – ADULT ORTHODONTICS
 Kingsley (1880) suggested - Hardly any limits to the age when tooth
movement might not succeed.
 Mac Dowell (1901) stated - After 16 years of age, orthodontic
treatment was almost impossible owing to the development of the
glenoid fossa, the density of the bones & the muscles of mastication.
 Lischer (1912) believed - Period between the 6th & 14th years was a
golden age of treatment.
 Case (1921) demonstrated treatment possibilities in aged,
periodontally affected patients.
 Lindegaard et al (1971) stated - 3 main factors determine which
problems should be treated from both a medical & an orthodontic
point of view:
 1)A disease or abnormality must be present.
 2)The need for treatment must be understood; this need for treatment
should be determined by the clinical gravity of the disorder, the
available resources for orthodontic care, the prognosis for successful
treatment, & the priority for orthodontic care based on personal &
professional judgment.
 3)The patient must have a strong desire for treatment.
 At a conference in 1976, Reidel & Dougherty most accurately
predicted the status of adult orthodontic treatment.

Reidel was supportive regarding the future
of adult therapy, adding that the clinician
should not forget adjunctive orthodontics
services provided by periodontists &
restorative dentists.
Dougherty claimed that “Orthodontics is
total discipline & it makes no difference
whether the patient is young or old”.

 WHEN IS A PERSON ‘ADULT’?
 There is no definite age when the male or female reaches physical maturity & it is
therefore impractical to try to determine exactly when adulthood begins.
 Since an adult is defined as one who is fully grown, most males of 18 or 19 & above &
most females of 16 & above can be considered to be an adult.
 Birte Melsen in her ‘Current controversies in orthodontics’ mentioned the factors
responsible for increase in adult cases.
 Innovations in appliance placement techniques – Indirect bonding as well as lingual /
invisible orthodontics.
 Innovations in materials research – Ceramic brackets & tooth colored wires.
 The above two factors have radically altered the way the adult perceives orthodontics.
 Role of the Family Dentist.
 Role of Media (visual as well as print).
 Role of Insurance companies.
 Affluence.
 Greater awareness – of health & esthetic concerns.

 The orthodontist is able to offer orthodontics as a treatment option for
the myriad problems encountered in adults because of:
 Availability of newer & more sophisticated biomechanical options.
 A broader understanding of the biology of tooth movement,
especially with regard to age changes.
 Advances in management of temporomandibular disorders.
 Ingenious approaches to anchorage management such as implants.
 Availability of reliable surgical procedures.
 Greater experience with adult orthodontics.

 When treating adults then, the orthodontist needs to be
prepared to do the following:
 Diagnose different stage of periodontal disease & their
associated risk factors.
 Diagnose Temporomandibular Joint (TMJ) dysfunction
before during or after tooth movement.
 Determine which cases require surgical management &
which ones require incisor reangulation to camouflage the
skeletal base discrepancy.
 Work cooperatively with a team of other specialists to give
the patient the best outcome.

 TWO GROUPS OF ADULT PATIENTS
 Younger adults – typically under 35, often in their 20s.
 Older adults – typically in their 40s & 50s.
 The first group seeks comprehensive treatment & the maximum possible improvement.
Patients in this group are likely to advance the following reasons for not having sought
treatment earlier:
 1. Did not desire treatment.
 2. Were not aware of orthodontics.
 3. Parents could not afford it.
 4. Were not given the proper advice by the family dentist.
 5. No orthodontist located in the vicinity when younger.
 6. Incomplete orthodontic treatment when younger or were uncooperative.
 7. Had orthodontic treatment as children but there was a relapse.
 8. More conscious of appearance with age.
 9. Dissatisfaction with an outcome of previous treatment.
 10. Anterior teeth started to crowd or minor crowding became worse.

 In contrast, the second group seeks orthodontic treatment as an
adjunctive procedure to the large periodontal & restorative goals.
Patients in this group are likely to advance the following reasons for
seeking treatment:
 1. Malpositioned teeth contributing to periodontal disease.
 2. Increased difficulties with mastication.
 3. Tooth interferences & mandibular slide producing soreness in
TMJ.
 4. Anterior spaces enlarging or new ones developing.
 5. For better tooth positioning prior to prosthetic preparation.

CEPHALOMETRIC APPRAISAL
OF
TREATMENT CHANGES
WITH BEGG

DIFFERENCE BETWEEN
ADOLESCENT & ADULT PATIENT

No . Factor Adult adolescent
1. BASIC DIFFERENCE No growth potential Tooth movement possible
along with presence of
growth
2. APPEARANCE OF APPLIANCES Great concern Great concern
3. APPLIANCE TOLERANCE Find appliance much
more uncomfortable.
Appliances must be well
made, carefully adjusted.
Will tolerate most
appliances readily.
4. SPEECH Adjustment is dificult Adjust quickly
5. PERIODONTAL DISEASE Complicating factor must
be eliminated before
starting orthodontic
treatment
Usually none or not too
severe
6. GENERAL HEALTH Considered more
carefully prior to
treatment
Usually of little concern
7. COOPERATION Well motivated, excellent
cooperation
Ranges from poor to
excellent
8. TREATMENT APPRECIATION Usually very appreciative Not very appreciative

 LIMITATIONS - ADULT TREATMENT
 Two categories of factors:
 1) Intrinsic – Biological nature
 2) Extrinsic – Biomechanical systems
 The most marked intrinsic limitation is the fact
that the adult is non growing; skeletal
discrepancies can therefore only be corrected by
orthognathic surgery. Since orthodontic tooth
movement is a result of cellular reaction to a
mechanical stimulus, the cellular response may
vary with the health & age of the individual.www.indiandentalacademy.com

 Other Intrinsic Factors
 PERIODONTIUM
 The primary tissue to be influenced by the mechanical forces
applied to the teeth is the periodontal ligament. According to
Norton, the decreasing blood flow & vascularity that occurs
with increasing age may provide an explanation for the
insufficient source of progenitor cells.
 ALVEOLAR BONE
 Structure: Orthodontics tooth movement as a result of bone
modeling & remodeling also depends greatly on age related
changes of the skeleton. Cortical bone becomes denser while
the spongy bone reduces with age.
 Pathology: Apical displacement of the marginal bone level is a
local factor that influences the biological background for tooth
movement in adults. The marginal bone loss is age related but
is also the result of progressive periodontal disease.
 TEETH
 Adults also more likely to have missing teeth, reduced in
dimension due to attrition, as well as teeth with large
restorations. www.indiandentalacademy.com

 The biologic background for orthodontic tooth
movement in adults indicates –
1. The forces used in adults should be at a lower level
than those used in children.
2. Initial forces should be kept low because the
immediate pool of cells available for bone resorption
is low.
3. The moment to force ratio for a particular tooth
movement should be increased according to the
periodontal status.
4. With increasing marginal bone loss, light continuous
forces should be maintained during tooth
displacement.

 Extrinsic limitations
 The force system used for treating adults differs in several
respects from that used in young growing individuals.

 Keeping the above limitations in mind, it is easy to see
that the following problems are difficult to treat by
orthodontics alone:
 Deep bite: Extrusion of posterior teeth is not compensated
for by condylar growth.
 Posterior Cross bite: Arch expansion is not stable.
 Skeletal Discrepancies: Since growth is completed.

 Since the adult patients poses so many problems to the
orthodontist, Barrer & Chasens et al suggested that it was
advisable to defer orthodontic treatment when faced with the
following situations:
1. Uncontrolled / advanced local or systemic disease.
2. Excessive alveolar bone loss.
3. Severe skeletal discrepancy.
4. Inability to prevent excessive hard/soft tissue destruction.
5. Inadequate space for tooth movement.
6. Movement of teeth against occlusal opposition or into occlusal
trauma.
7. No improvement in periodontal health, function or esthetics
possible.
8. Movement of teeth against inadequate anchorage – negative
anchorage potential.
9. Movement of teeth into unfavorable positions – poor stability
prognosis.
10. Lack of patient motivation & cooperation, resistance to wear
the appliance. www.indiandentalacademy.com

 ETIOLOGY OF ADULT TOOTH MALPOSITION
 The etiological factors responsible for adult malocclusion (classified by
Marks) into –
 1). Malocclusions – Dental origin
 A. Faulty eruption from the normal functional position
 B. Insufficient arch length
 C. Excessive arch length
 D. Prolonged retention of primary teeth
 E. Ectopic eruption
 F. Prolonged digit sucking habits
 G. Clenching & Grinding
 H. Improper swallow pattern with tongue thrusting
 i. Premature loss of deciduous teeth
 J. Loss of permanent teeth
 2).Malocclusions – Skeletal origin
 A. Cleft palate – Resulting in missing teeth, ectopic eruption adjacent to
cleft
 B. Gross skeletal disharmony – Aberrations in bony growth of maxilla or
mandible (considered in all three planes of space)

Treatment Objectives – ADULT
ORTHODONTICS
The traditional objectives of esthetics, function
& structural balance together called
JACKSON’S TRIAD, may not be realistic or
necessary for all adult patients.
Many Class I occlusal goals can be considered
over treatment for patients who also require
restorative dentistry, prosthetics, plastic
surgery, & other multidisciplinary dentofacial
corrections.

 ADDITIONAL ADULT TREATMENT OBJECTIVE # 1
 Parallelism of abutment teeth
 The abutment teeth must be placed parallel with the other teeth
to permit insertion of multiple unit replacements.
 A restoration will have a better prognosis if the abutment teeth
are parallel before tooth preparation, because that position
does not require excess cutting or devitalization during
abutment preparation & allows for a better periodontal
response.
 A – Drifting & flaring of teeth
 B – Orthodontic preparation


 Most favourable distribution of teeth
 The teeth should be distributed evenly for replacement of fixed &
removable prostheses in the individual arches.
 Mandibular left 1st premolar moved distally allowing for 4 unit
restoration.

 Redistribution of occlusal & incisal forces
 Cases with significant bone loss (60% to 70%) require that occlusal forces
be directed vertically along or on the long axis of the roots to maintain the
occlusal vertical dimension.
 When the posterior teeth are missing, the anterior teeth can be positioned
to allow for more axially directed transfer of force & can then be reshaped
to function as posterior teeth (supporting the vertical dimension).
 Initial contact in CR – between mandibular 1 PM & maxillary 2 PM;
Hawley Bite Plane used to locate CR.
 Maxillary segmental osteotomy positioned maxillary canines axially to
contact the lower dentition bilaterally

 Adequate embrasure space & proper root position
 This allows for better periodontal health, especially when the placement of
restorations necessary. The anatomic relation of the roots is important in
the pathogenesis of periodontal disease, interproximal cleaning, &
placement of restorative materials.
 To establish the acceptable occlusal plane for a mutilated dentition
exhibiting bite collapse, the HAWLEY BITE PLANE is inserted with the
platform of the anterior plane adjusted at a right angle to the long axis of
the lower incisors. This allows a centric relation an acceptable vertical
relationship.
 The curve of spee should be mild to flat bilaterally. This is difficult to
achieve if supraerupted molars are present. Adult molars with amalgam
restorations & normal pulpal recession & mixed constrictions often can be
occlusally reduced 2 to 4 mm & still allow for placement of restorations
without the need for devitalization. The UNILATERAL ORTHODONTIC
TREATMENT of an accentuated occlusal plane should be AVOIDED; one
side cannot be left extruded.

 Acceptable occlusal plane & potential for incisal guidance at
satisfactory vertical dimension
 To establish acceptable occlusal plane for mutilated dentition
exhibiting bite collapse – Hawley Bite plane is inserted with
platform of plane adjusted at right angles to the long axis of
lower incisors. This allows CR at acceptable VD.
 No occlusal stops bilaterally – removable appliances placed
–
 lower canines axially positioned – platform added to
 upper appliance – upper incisors aligned

 Adequate occlusal landmark relationship
 The TRANSVERSE DIMENSION is the most DIFFICULT to correct &
maintain orthodontically, the SAGITTAL next, & the VERTICAL least.
However, when teeth are to be restored, they must be positioned to achieve
acceptable buccolingual landmarks.
 Posterior crossbites involving severe transverse skeletal dysplasias that
are not to undergo surgery should be positioned so that the maxillary
buccal cusps contact the lower central fossae with the crossover for incisal
guidance in the premolar area or the canine positions.
 Class III requiring lower posterior reconstruction – anterior segment
positioned to provide incisal guidance – posterior occlusion left in
crossbite

 Better lip competency & support
 Many adults have long upper lips that preclude significant maxillary
retraction.
 In some of Class II, Division I cases (when orthognathic surgery is
rejected) the lower incisors can be advanced into a more procumbent
position than the usual orthodontic norm to establish incisal guidance.
With the aid of bilateral posterior restorations, the incisors will be
stabilized when in relatively flared positions (IMPA 105O to 112O).
 In some Class III patients as well, the maxillary incisors can be kept in
stable relation (even though more flared than normal) with posterior
restorations.
 Inadequate support may create a change of anteroposterior & vertical
position of the upper lip & increase wrinkling. This often makes the
face seem prematurely aged & is a major esthetic concern of adults,
especially women, who are usually anxious about changes of the
upper lip. www.indiandentalacademy.com

ADDITIONAL ADULT TREATMENT
OBJECTIVE # 8
Improved Crown / Root Ratio
In adult patients who have lost bone on
individual teeth, the length of the clinical
crown can be reduced with the high – speed
handpiece; as the tooth is erupted
orthodontically (the same amount of bone
will remain on the clinical root), the ratio of
crown to root will be improved.www.indiandentalacademy.com

 Improvement or correction of mucogingival & osseous defects
 Proper repositioning of prominent teeth in the arch will improve gingival
topography.
 In adolescents the brackets are placed to level marginal ridges & cusp tips. In
adults the goal should be to level the crestal bone between adjacent
cementoenamel junctions the need for osseous & mucogingival surgery may be
diminished by favorable changes of the osseous & soft tissue topography
during tooth movement.
 During leveling stages any teeth that have erupted above the occlusal plane
should be grossly reduced occlusally. Also, continuous adjustment should be
done to prevent the patient from contacting individual posterior teeth
prematurely & causing occlusal trauma.
 A – Crossbite correction in 14 yr old pt – gingival margins confluent
 B – 61 yr old pt – lower incisors retracted – gingiva created – IG
 D – 38 yr old pt – before
 F – After – tooth movement & stabilization

 ADDITIONAL ADULT TREATMENT
OBJECTIVE # 10
 Better self – maintenance of periodontal health
 The location of the gingival margin is determined
by the axial inclination & alignment of the tooth.
Clinically it appears that improved self–
maintenance of periodontal health occurs with
proper tooth position. This can be seen in adult
patients during correction of bite collapse &
accelerated mesial drift. For better periodontal
health on an individual pattern basis, teeth should
be positioned properly over their basal bone
support. www.indiandentalacademy.com

 Esthetic & functional improvement
 A treatment plan should provide acceptable dentofacial esthetics & allow for
improved muscle function, normal speech, & masticatory improvements. This
is possible when a therapeutic occlusion is provided that enables the anterior
teeth to function as disarticulators & the posterior teeth to support the
vertical dimension.

A, C, E – Gingival form after inflammation control & occlusal therapy (bite
plane in 58 yr old pt), G – 2 yr, H – 22 yr post treatment follow upwww.indiandentalacademy.com

 ADULT DIAGNOSTIC CONSIDERATIONS
 Diagnostic Steps
 Collect data accurately
 Analyze database
 Develop problem list
 Prepare tentative treatment plan
 Interact with those who are involved; discuss plans &
options (may include other providers); clarify
sequence; acquire patient acceptance
 Create final treatment plan
 Get pic 4m book

 Periodontal Diagnosis
 The orthodontist must make an accurate assessment of the
patient’s potential for bone loss or gingival recession
during orthodontic tooth movement.
 Appropriate management of several factors is needed to
prevent negative periodontal sequelae during orthodontic
treatment:
1. Awareness & vigilance of the orthodontist & the staff must
be heightened.
2. Awareness & vigilance of the patient must be frequently
reinforced.
3. Awareness of risk factors related to periodontal
breakdown must be reviewed.www.indiandentalacademy.com

 General Factors
 Family history of premature tooth loss (indication of immune system
deficiency in resistance to chronic bacterial infection associated with
periodontal disease).
 General health status & evidence of chronic disease (e.g. diabetes).
 Nutritional status.
 Current stress factors.
 Local Factors
 Tooth alignment (e.g., marginal ridge, cementoenamel junction
relationship)
 Plaque indices
 Occlusal loading
 Crown-to-root ratio
 Grinding, clenching habits (parafunctional activity)
 Restorative status

 Diagnosis of Temporomandibular Joint Dysfunctions
 Because the signs & symptoms of TMD, increase in frequency & severity during
adult treatment, it is imperative that orthodontists be familiar with their diagnostic
& treatment parameters.
 Temporomandibular Joint Disorders
 - Deviation in form - Capsulitis
 - Disc displacement with reduction - Osteoarthrosis
 - Disc displacement without reduction - Osteoarthritis
 - TMJ hypermobility - Polyarthritides
 - Dislocation - Ankylosis
 - Synovitis -Fibrous ankylosis
- Bony ankylosis
 Masticatory Muscle Disorders
 - Myofacial pain - Reflex splinting
 - Myositis - Muscle contracture
 - Tendomyosits - Hypertrophy
 - Tendonitis Spasm - Neoplasm

 TREATMENT PLANNING
 Diagnosis between Adolescent & Adult orthodontic patients
 The five major categories in which adult patients exhibit
significant differences from their adolescent counterparts
follow:
1. Clarification & individualization of treatment objectives –
This requires specific study of the problem & the indicated
therapeutic refinements.
2. The diagnostic process – A problem – oriented approach to
diagnosis is an absolute necessity.
3. Treatment plan selection – A more systemic & detailed
analysis is required for adults than for adolescents.
4. Acceptance of recommended therapy – The patient’s
thorough understanding of & agreement with the
recommended treatment are necessary. Also, an informed
consent form should be signed.
5. Identifying adult case types – Using an adult classification
system is helpful in maintaining the orthodontist’s & the

FACTORSIN SELECTION OFATREATMENTPLAN
(Comparisonbetweenadolescent & adults)
ExistingOralPathosis
Factors Comparisons Conclusions
De ntalCarie s
Ado le sce nts Sim ple lim ite d carie s le sio ns, m o re susce ptibility
Adults
Re curre nt de cay, re sto rative failure s, ro o t de cay &
pulpalpatho sis
Pe rio do ntaldise ase
Ado le sce nts
Re sistant to bo ne lo ss, susce ptible to g ing ival
inflam m atio n
Adults Hig he r susce ptibility to pe rio do ntalbo ne lo ss
Faulty re sto ratio ns Ado le sce nts Fe w sig nificant re sto rative pro ble m s
Adults
Fre q ue nt re sto rative pro ble m s with e co no m ic &
tre atm e nt planning im plicatio ns
TMJadaptability
Ado le sce nts Hig h de g re e o f TMJ adaptability, infre q ue nt sym pto m s
Adults Fre q ue nt appe arance o f sym pto m s with dysfunctio n
O cclusalaware ne ss
Ado le sce nts Infre q ue nt cause o f pro ble m
Adults
He ig hte ne d; m ay le ad to acce le rate d e nam e lwe ar with
adve rse chang e in suppo rting tissue s

SkeletalRelationships
Gro wth facto rs
Ado le sce nts
Be cause o f g ro wth, an O RTHO PEDIC
TREATMENT O PTIO N is available ; stable
co rre ctio n o f ske le tal discre pancie s is po ssible ;
se q ue nce o f difficulty o f o rtho do ntic co rre ctio n
(m o st to le ast) is ve rtical, ante ro po ste rio r,
transve rse .
Adults
No g ro wth with m inim al ske le tal adaptability;
the re fo re surg ical pro ce dure s are fre q ue ntly
ne ce ssary fo r m o de rate to se ve re ske le tal
disharm o nie s.
De nto faciale sthe tics
Ado le sce nts
Re aso nable co nce rn; fre q ue ntly m atche d to
se ve rity o f co nditio n.
Adults
Co nce rn o ccasio nally dispro po rtio nate to de g re e
o f e xisting pro ble m .

Biologic Considerations
Ne uro m uscular m aturity
Ado le sce nts
Po te ntial fo r adaptability o f sto m ato g nathics syste m ,
allo wing a varie ty o f bio m e chanical cho ice s (i. e . Class
IIe lastics).
Adults
Me chanical o ptio ns are lim ite d; lack o f ne uro m uscular
adaptability.
Gro wth
Ado le sce nts
Sig nificant facto r in se le ctio n o f tre atm e nt plan (po sitive
facto r in re so lutio n o f m any ado le sce nt m alo cclusio ns).
Adults
No g ro wth pre se nt; Sig nificant ske le tal alte ratio ns
witho ut o rtho g nathic pro ce dure s is m inim ize d; De ntal
cam o uflag e o ptio n available fo r m ild to m o de rate
ske le taldisharm o nie s.
Pe rio do ntal
susce ptibility
Ado le sce nts
Mo re re sistant to bo ne lo ss; hig hly susce ptible to
g ing ivalinflam m atio n.
Adults
Hig he r de g re e o f susce ptibility to bo ne lo ss as re sult o f
pe rio do ntal dise ase ; ne e d fo r m o dificatio n o f
m e chano the rapy.
Rate o f to o th m o ve m e nt
Ado le sce nts
Pre dictable & rapid, particularly during e ruptive stag e s
whe n pe rm ane nt ro o t de ve lo pm e nt is no t ye t
co m ple te d.
Adults
Initially so m e what slo we r, but m o re rapid & pre dictable
afte r initialm o ve m e nt has be g un

Therapeutic approaches available
To o th m o ve m e nt
Ado le sce nts Mo st re q uire so m e to o th – m o ving fo rce s
Adults Mo st re q uire so m e m o ving fo rce s
O rtho pe dics
Ado le sce nt Abo ut half re q uire o rtho pe dics
Adult Effe ctive o nly in a sm allpe rce ntag e
O rtho g nathic surg e ry
Ado le sce nts Majo r ske le talalte ratio ns ne e de d in 1 % to 5%
Adults Alte ratio ns ne e de d in 1 0 % to 20 %
Re sto rative de ntistry
Ado le sce nts
Sm alle r pe rce ntag e re q uire it; whe n te e th are
co ng e nitally m issing , o rtho do ntic the rapy, space clo sure
o r space re distributio n, thus avo iding the ne e d fo r
re sto rative de ntistry.
Adults
Fre q ue ntly re q uire d fo r space re o pe ning whe re te e th
have be e n lo st & fo r abutm e nt pre paratio n; inte g rate d
re sto rative plan - re duce duratio n o f fixe d appliance
tre atm e nt.
Co m binatio n tre atm e nt
Ado le sce nts Unco m m o n
Adults Re q uire d in 8 0 % o f o rtho do ntic re sto rative tre atm e nt.

Profile & occlusal changes –
A – D – 4 months in treatment
E – H – 18 months in treatment
ExtractionVs NonextractionTherapy
Extractio n
co ntro ve rsy
Ado le sce nts
Fo ur-pre m o lar e xtractio n - to
re so lve cro wding sym m e trically, as
we ll as pro trusio ns, space g aining
te chniq ue s also available .
Adults
Uppe r pre m o lar e xtractio ns –
co m m o n alte rnative ; asym m e tric
e xtractio n & stripping o f o ve rbulke d
re sto ratio ns.
Strate g ic
e xtractio n
Adults
Irre ve rsible dam ag e to pe rio do ntal
tissue o r to adjace nt te e th - unusual
tre atm e nt plans – to so lve
alig nm e nt pro ble m s, as we ll as to
e lim inate e xisting dam ag e d te e th.

AnchorageRequirements
Ancho rag e
po te ntial
Ado le sce nts
Fre q ue nt inco rpo ratio n o f he adg e ar to
m axim ize ancho rag e & the re tractio n o f
ante rio r te e th.
He adg e ar
co o pe ratio n
m o lar
distalizatio n
Adults
Gre ate r ancho rag e po te ntial be cause o f
co m ple te ly e rupte d first & se co nd
m o lars, im plants in co njunctio n with
re sto rative de ntistry; se ve ral m o lar
distalizatio n te chniq ue s - o ptio ns to
avo id he adg e ar we ar.

MissingTeeth(Dental Mutilation)
Missing
te e th
Ado le sce nts
Early tre atm e nt co ntro l e ruptio n stag e s
facilitate s space clo sure witho ut
pro sthe se s (i. e . co ng e nitally m issing
m axillary late rals o r m issing se co nd
pre m o lars).
Adults
Suprae ruptio n – pro ble m in po ste rio r bite
co llapse ; o cclusal plane m anag e m e nt –
crucial; im plants - re sto rative o ptio n.

RestorativeDentistry(Existing, Planned& /orneeded)
Re sto rative
de ntistry
Ado le sce nts Infre q ue nt pro ble m
Adults
Appliance place m e nt & o rtho do ntic
m o ve m e nt o f e xisting bridg e wo rk po ssible
but difficult.

 ADJUNCTIVE TREATMENT FOR ADULTS
 Definition – Tooth movement carried out to facilitate
other dental procedures necessary to control disease &
restore function.
 Goals
 Facilitate restorative treatment – Positioning the teeth so
that ideal & conservative techniques can be used
(including implants).
 Improved periodontal health – Eliminating plaque
harboring areas & improving the alveolar ridge contour.
 Favorable crown to root ratio – Occlusal forces
transmitted along long axis of the teeth.

 Biomechanical Considerations
 Characteristics of the orthodontic appliance
 It usually requires a fixed appliance
 Control of anchorage - Anchor teeth not allowed to tip
 Proffit recommends 22–slot edgewise appliance with twin brackets.
 Removable appliances - Advantage over fixed appliances for some
patients with multiple missing teeth. They permit the reaction forces
from tooth movement to be spread over adjacent supporting tissues. A
- Brackets placed in the ideal position on the anchor teeth.
 For adjunctive treatment movement of anchor teeth is undesirable
 B – Brackets placed in position of maximum convenience


 Effects of reduced periodontal support
 Absolute magnitude of force must be reduced when periodontal support
has been lost.
 Greater the loss of attachment, the smaller the area of supported root &
the further apical the center of resistance will become.
 Lighter forces & relatively larger moments are needed. A - The
centre of resistance of single rooted tooth lies at six - tenths of the
distance between apex of the tooth & crest of alveolar bone
 B – If centre of resistance moves apically the tipping moment produced
by the force increases & a larger counter vailing moment produced by a
couple applied to the tooth would be necessary

Co m pre he nsive tre atm e nt pla n
Stag e I– Dise ase co ntro l
Stag e II– Establish o cclusio n
Stag e III– De finitive
pe rio /re sto rative tx
Stag e IV– Mainte nance
Timing& Sequenceof treatment
Stabilize
Re -e valuate

Slide 47

 Optimal skeletal health of adults:-Important because
optimal treatment often requires extensive bone
manipulative therapy including imlants, orthodontics, and
prosthesis.
 Maintenance of normal bone resorption is important for
healing, bone adaptation, orthodontic tooth movements,
and maintenance of implant osseointegration.
 Estrogen and other analog preserve bone mass without
directly inhibiting bone resorption. Thus conservation of
skeleton, while maintaining a normal capability for bone
resrption, is an advantage in osteopenic and psteoporotic
male and female.

 Medication , diabetes and orthodontic treatment:-
 Adults patients often have problems that requires prescription
drugs.
 Medication with anti-inflammatory or immunosuppressive
drugs have the potential for interfering with the anti-
inflammatory nature of orthodontic tooth movements.
 A particular area of controversy is the use of nonsteroidal
inflammatory drugs such as ibuprofen and aspirin. These
drugs suggest to inhibit the rate of tooth movements.
 Centrally acting analgesics, such as acetomorpin are preferred
for controlling orthodontic pain. NSAIDS can be used for the
1st
or 2days after the start of the treatment but long term use
can cause gastrointestinal problems.

 Drugs which affect/ modify the bone physiology requires
Specific concern.
 The most c’mon medical problem with dentally significant bone
effects are diabetes and osteoporosis.
 Periodontal disease in patient with uncontrolled disbetes can
results in severe bone loss, so ortho t/t in such patients is a high
risk procedure. Treatment should be well coordinated with
periodontist.
 Patient with controlled diabetes and a healthy periodontium,
multidisplinary implant and orthodontic treatment can be
accomplished in a routine manner.
 C’mon complication of diabetes are renal failure and
osteoporosis resulting from compromised vit D metabolism and
failure to reabsorb calcium from the urine. Renal failure is a
contraindication for orthodontic treatment.
 Treatment of ossteoporosis is potentially problematic for dental,
surgical and orthodontic t/t because drugs that inhibit bone
resorption (biphosphonates and calitonin) may disturb bone
remodeling dynamics.

 Demographic consideration:- is important inDemographic consideration:- is important in
evaluating the cause of the adult malocclusion.evaluating the cause of the adult malocclusion.
 adult often has lost some teeth, usually molars andadult often has lost some teeth, usually molars and
premolars, but retains an adequate dentition for fixedpremolars, but retains an adequate dentition for fixed
or removable prosthesis.or removable prosthesis.
 Due to lost antagonist and adjacent teeth there is aDue to lost antagonist and adjacent teeth there is a
cycle of functional compensation that results incycle of functional compensation that results in
extrusion, spacing and axial inclination changes ofextrusion, spacing and axial inclination changes of
remaining teeth, resulting in acquired malocclusionremaining teeth, resulting in acquired malocclusion
that precludes routine restorative care.that precludes routine restorative care.
 Adjunctive orthodontic t/t is essential for achieving anAdjunctive orthodontic t/t is essential for achieving an
optimal restoration of function and esthetics.optimal restoration of function and esthetics.
www.indiandentalacademy.comwww.indiandentalacademy.com

 Diagnosis and treatment planning:-Diagnosis and treatment planning:-

 The progressive focus of a disciplined orthodonticThe progressive focus of a disciplined orthodontic
diagnosis is essential. There should be systemicdiagnosis is essential. There should be systemic
evaluation trlative to the chief complaints: medicalevaluation trlative to the chief complaints: medical
evaluation, history, genetic problems, andevaluation, history, genetic problems, and
psychological factors.psychological factors.
 The 2The 2ndnd
consideration: frontal symmetry, profile & lipconsideration: frontal symmetry, profile & lip
protrusion and competence.protrusion and competence.
 33rdrd
consideration: soft tissue- periodontiumconsideration: soft tissue- periodontium
(inflammation, & loss of attachment caused by(inflammation, & loss of attachment caused by
pocket, recession and bone loss), pathologicalpocket, recession and bone loss), pathological
condition of mucosa, & cancer screening.condition of mucosa, & cancer screening.
 44thth
consideration: statue of dentition- operative,consideration: statue of dentition- operative,
endodontic, & prosthetics problems.endodontic, & prosthetics problems.
 55thth
and last consideration: evaluation of malocclusion.and last consideration: evaluation of malocclusion.

 Etiology:- each malocclusion is aEtiology:- each malocclusion is a
manifestation of a unique set ofmanifestation of a unique set of
environment (diet, habits, functionalenvironment (diet, habits, functional
compromises, soft tissue posture, caries,compromises, soft tissue posture, caries,
periodontal disease, developmentalperiodontal disease, developmental
aberrations, & trauma) and geneticaberrations, & trauma) and genetic
aberration.aberration.
 FEW EXAMPLES 4M BISHARAFEW EXAMPLES 4M BISHARA
PAGE504.PAGE504.

 DIAGNOSTIC RECORDS ANDDIAGNOSTIC RECORDS AND
TREATMENT PLANNING:-TREATMENT PLANNING:-

Adult ortho

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