Adult orthodontics 1

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ADULT
ORTHODONTICS
DR SANKET AGARKAR
PART II MDS
(ORTHODONTICS),
BVDCH, PUNE

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

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

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

3) Redistribution of occlusal and incisal
forces –
Helpful in case of significant bone loss, to
maintain the occlusal vertical dimension.

4) Adequate embrasure space and proper
root position –
Allows for better pdl health, especially
when placement of restorations is
necessary.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PROCEDURES CARRIED OUT IN
ADJUNCTIVE TREATMENT : -
1) Up righting posterior teeth.
2) forced eruption.
3) alignment of anterior teeth.
4) cross bite correction.

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

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

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

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

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

UPRIGHTING POSTERIOR
TEETH:-

• Loss of 1st perm molars – frequent
problem in adults = adjacent teeth drift, tip/
rotate, gingival tissue becomes folded
forming a pseudopocket.

1) If third molar is present , whether both
second and third molar should be
uprighted.
2) Whether to upright tipped teeth by distal
crown tipping(increased space for a
pontic) or by mesial root movement
(reduce/close the edentulous space) –
depending on the position of the
teeth, occlusion desired, anchorage
available, contour of the bone in the
edentulous area

3) Whether slight extrusion is permissible or
maintain the existing occlusal height during
uprighting – tipping the tooth distally extrudes
it, reduces the depth of the pseudopocket found
on the mesial surface. Also, the crown-root ratio
will be improved if the ht of the clinical crown is
systematically reduced as the uprighting
proceeds
4) Whether premolar should be repositioned or
not – depending on the existing
contacts, opposing intercuspation, restorative
plan; mostly yes – close spaces between
premolars=improves PDL prognosis & long
term stability. www.indiandentalacademy.com

APPLIANCE FOR MOLAR
UPRIGHTING:-
- Partial fixed appliance.
- Anchorage –heavy stabilizing
lingual arch (canine-to-canine).
- Placement of brackets on canine
and premolars(anchorage unit) –
bonding preferred to banding –
decreased gingival irritataion.

• Molar to be uprighted – should have a
combination attachment consisting of a
wide twin bracketwith a convertible cap &
a auxillary tube.
• Lingual buttons/cleats should be welded to
bands – if rotations/crossbites are also to
be corrected

UPRIGHTING A SINGLE MOLAR:-
 Moderately tipped molar:-
Flexible rect wire
- 17x25 braided s.s, if the anchor
teeth are relatively well aligned
- 17x25 Ni-Ti, if the anchor teeth
require alignment.
Relieve occlusal contacts against the
molar, otherwise mobility, increased
Rx time
 Severely tipped molar:-
-stiff 19x25 s.s in the anchor
segment
- Uprighting spring
( 17x25 beta- Ti without helical
loop/ 17x25 ss with loop)- mesial arm
should hook over the stabilizing wire,
Hook –should be free to slide distally as
the molar uprights

• Slight lingual bend in
the spring – to
counter the forces
that tend to tip the
anchor teeth buccally
& molar lingually
• Frequent occlusal
adjustments reqd to
reduce developing
interferences

Uprighting with minimal extrusion
• After initial alignment
with a light flexible
wire, sectional “ T-
loop”
- 17x25 s.s
- 19x25 beta-Ti
Uprighting force on the
molar- root mesial
crown distal
• Activation of T-loop
by 1 to 2 mm – done
when the pontic
space is to be closed.www.indiandentalacademy.com

modified T-loop.
• In severely rotated teeth
• End of archwire inserted through the distal of the
tube.

Final positioning of molars and
premolars.
• After molar uprighting
– increase the
available pontic space
& close open contacts
in the anterior
segment
• Use of compressed
coil spring - steel
- A Ni-Ti;
Stiff base arch = 17x25
ss/ 18 ss in 22 slot
• Occlusion should be
checked carefully for
the desired movt .

Unilateral/bilateral uprighting

Uprighting 2 molars in the same
quadrant
• Since resistance is high, only small amounts of space
closure should be attempted (unilaterally)
• Combination of mesial root & distal crown tipping
• 3rd Molar should carry a single rect tube & cap should be
removed from the convertible bracket on the 2nd molar.
• 2nd molar –usually more tipped than the 3rd –increased
flexibility of wire mesial & distal to it is required.
• Best approach = use of a highly flexible wire initially =
17x25 NiTi

Duration
• Distal crown tipping faster than mesial root
movt
• Usually 8-10 weeks
• Occlusal interferences –prolong Rx time
• up righting 2 molars with mesial root movt
may take 20-24 wks

RETENTION
• Prosthesis –provides long term retention – should be
placed within 6 wks
• For shorter period – 19x25 ss /21x25 TMA designed to fit
the brkts passively
• For a longer period=
- Intracoronal wire splint-19x25 or heavier ss wire
bonded into shallow preparations on the abutment tooth

Segmental approach to mandibular molar
uprighting - Roberts, Chacker, and
Burstone
• Stages of fabrication
of the uprighting
spring.
[AJODO:1982 Mar (177
- 184)]
18X25 ss in 22 slot

Buccal and occlusal views (photographed at
different stages of treatment) of the molar-
uprighting appliance. The spring is offset
lingually in the edentulous area for added patient
comfort.

Anterior stabilizing segment
• A lingual arch wire (approximately 0.032 inch)
bonded, or soldered to bands, from canine to
canine. Bonding the mandibular incisors to the
lingual arch wire adds stability to these
periodontally involved teeth.
• Buccal edgewise brackets (0.018 or 0.022 inch
slots) banded or bonded to the canine and
premolars in the involved quadrant(s). The
canine bracket contains two horizontal slots.
• A full-size rectangular stabilizing wire passing
from canine to premolar(s), stopped at both
ends in order to prevent spacing and inserted
into the occlusal slot of the canine bracket.www.indiandentalacademy.com

Jan Lindhe
• Definite osseous defect due to periodontitis on
the mesial surface of the inclined
molar, uprighting, tipping distally = widen the
defect
• Furcation defects & orthodontic Rx: remain the
same or worsen especially in the presence of
inflammation (Burch et al, 1992)
• Hence, initial PDL therapy & excellent oral
hygiene & control of forces avoiding extrusion as
much as possible are required.

• 1st described in 1973 by Heithersay
• Elevates the root, expands PDL fibers
results in coronal shift of marginal gingiva
& bone. [Jan Lindhe]
FORCED ERUPTION

• Indications:-
- Defects in cervical third .
- teeth with 1 or 2 walled vertical periodontal
defects
Due to
- horizontal/oblique fracture
-internal/external resorption
-decay
-pathologic perforation
-PDL disease

Advantages
• Improved endodontic access
• Allow isolation under rubber dam, when not
possible otherwise
• Crown margins can be placed on sound tooth
structure
• Uniform gingival contour maintained-improved
esthetics
• Alv bone ht & bony support of adjacent teeth is
not compromised
• Apparent crown length is maintained
• Maintains biologic width

TREATMENT PLANNING:-
- Periapical radiograph = for vertical extent of
the defect, PDL support, root morphology &
position; check for hypercementosis/dilaceration
- Single tapering root morphology – ideal; flared
and divergent root morphology – increasing
root proximity with extrusion.
- Endodontic therapy = before/after orthodontic
Rx

How much tooth should be extruded can be
determine by 3 factors:-
1) Location of the defect.(fracture line, root
perforation)
2) Space to place margin of the restoration, so
that it is not at thebase of the gingival sulcus(1
mm)
3) An allowance for the biological width of the
gingival attachment.(2 mm)
crown-root ratio at the end of treatment should
be 1:1 or better www.indiandentalacademy.com

 Duration:-
depends on age of the pt, dist the
tooth has to be moved, PDL viability
- 1mm/week without damaging pdl.
- 3 to 6 week.

TECHNIQUE
• Appl – quite rigid over the anchor teeth, flexible where it
attaches to the extruding tooth
• Continuous flexible wire is contraindicated-produce the
desired extrusion but would also tip the adjacent teeth
towards the teeth being extruded, reducing the space for
the pontic & disturbing the interproximal contacts

2 METHODS
Without
orthodontic
bracket.
Heavy 19x25/21x25
ss bonded directly
to the facial
surfaces of teeth;
Post & core with
temporary
crown, pin on the
Rx tooth & an E
module/ auxiliary
NiTi spring is used
to extrude the
toothwww.indiandentalacademy.com

With orthodontic brackets - better control.
• Brackets are placed-
more occlusally on
anchor teeth than its ideal
position; more gingivally
on the Rx tooth
• T-loop arch wire -
- 17x25 s.s
- 19x25 beta-Ti
Part of the T loop engaging
the tooth to be extruded
should lie more occlusal
than the anchor segment

RECALL & STABILIZATION :
- Pt is seen every 1-2 wks for occlusal
reduction of the extruding tooth, control
inflammation & monitor progress
- Stabilization - By passively fitting
rectangular arch wire.(3 to 6 weeks) –
allows proper reorganization of
PDL, remodelling of bone
- PDL surgey – if reqd, can be done after
1 month of completion of extrusion

Alternative method
Jrnl of Prosthetic Dentistry: 1998: 79: 246-48:
Ziskind, Schmidt, Hirschfeld
• Horizontal channel on the adjacent tooth surface
• A hook adapted to the canal walls cemented
with a temporary cement.
• Titanium post in the space of the missing
coronal surfaces fixed over the hook by
composite
• Elastic thread tied between the hook & post =
extrusive force
• Replaced weekly, for approx 3 wks- required
movt
• Dist between hook & wire=dist the tooth can be
extruded www.indiandentalacademy.com

Advantages
• No orthodontic bands/brackets /wires used
• Adjacent teeth exclusively as anchors
• More comfortable, minimal irritation to soft
tissues
• Decreased risk of dental caries

Biologic width
• Maintained in a tooth
with periodontal pocket
(osseous defect )
• The connective tissue
gets inflamed/ulcerated
• The junctional
epithelium migrates
down the
cementum=pocket
formation

Molar Uprighting & Osseous defect
• Angular bone loss along the mesial
surface of tipped molars.
• Uprighting such a tooth appears to cause
a shallowing-out of the angular defect with
new bone forming at the mesial alv
crest, attachment level remains
unchanged.
• Uprighting, by tipping distally = widens the
defect

Movt into compromised bone areas
• In patients with previous extraction of 1st molar &
a more or less compromised alv process
(reduced bone height- avg=1.3mm/constricted
area) – second molars can be moved mesially
• Complications- vertical bone loss, space
reopening, buccal or lingual bone dehiscences
• Light forces – a thin bone plate recreated ahead
of the moving tooth
• Excellent oral hygienewww.indiandentalacademy.com

• For markedly atrophied alv ridges, new
bone tissue growth should be considered
using osseous reconstructive surgery

Tooth movement into intrabony
defects
• Provided elimination of the subgingival infection is performed
before the orthodontic tooth movt – no detrimental effect on the
level of attachment
• Angular bony defect – eliminated but no coronal gain of
attachment; a thin epithelial lining covers the root surface
corresponding to its pre Rx positionwww.indiandentalacademy.com

• Periodontal therapy with elimination of
plaque induced lesion should be
performed before Orthodontic Rx is begun
+ maintainence of excellent oral hygiene
throughout the course of Rx
• If orthodontic tooth movt into & through a
site of inflammation & angular bone loss -
enhanced rate of PDL destruction

Use of orthodontic movt to reduce infrabony
pockets in adult periodontal patients –
Intnl jrnl of periodontics, restorative
dentistry 2002:22:365-371-Stefania Re et al
• Coronal tooth movt – able to fill osseous
defects – alv bone follows the tooth in its
displacement.
• Intrusive displacement – can establish a
healthy & well functioning dentition, does
not cause decrease in marginal bone level
if gingival inflammation is controlledwww.indiandentalacademy.com

• 44yr old woman with
severe PDL disease
that led to
spacing, extrusion of
maxillary left central
incisor & serious
functional, esthetic
problems.
• Radiologically – a
deep angular bony
defect on the mesial
surface of the left
central incisorwww.indiandentalacademy.com

• Initial probing depth=
9mm(mesial surface)
• Gingival recession=3.5mm
• Supra, sub gingival scaling
with oral hygiene
instructions + surgical
periodontal Rx (Flap)on the
incisor – to eliminate the
infection
• Fixed appls in place 1 week
after the surgery = early
stimulation of connective
tissue progenitor cells
necessary to foster
regeneration
• Light, continuous
forces=10gm; 15 months
• Periodic follow up=every 2
weeks; Prophylaxis=every 3
months

• Anterior fixed
bonded splint – to
avoid relapse +
masticatory comfort
• Final IOPA –
elimination & almost
complete fill of the
defect
• Clinically – only a
physiologic
sulcus, no gingival
recession, no
bleeding on probing

ALIGNMENT OF ANTERIOR TEETH
Indications:-
1) To improve access and permit
placement of well contoured restorations
(composite build up/splinting periodontally
compromised incisors).
2) To permit placement of crowns and
pontics .

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

Rx planning
• Ant teeth that need alignment shld be
brought into their proper position before
definitive restorative procedures.
• Progressive interproximal stripping – to
create space
• Diagnostic setup – very helpful in planning
Rx = alternative tooth positions may be
tried to determine the optimum for each pt.
& feasibility of ortho Rx evaluated

Alignment of crowded, rotated and
displaced incisors
Using a fixed appl –
initial arch wire = light, flexible : 016NiTi/0175
braided ss – cinched
3-4 week recall
progress to rectangular flexible wire to achieve
root positioning
Retention
–removable retainer –immediately after
debonding
- rotations=supracrestal fiberotomy;
-crown construction – after 6-8 wkswww.indiandentalacademy.com

Interdental gingivae
• In the anterior regions – pyramidal; since
contact points present
• In the premolar, molar regions – tent
shaped, concave(flattened) in the B-L
direction
• Histologically – thin, non keratinized
epithelium

• Shape is determined
by the contact
relationship between
teeth, width of adjacent
tooth surfaces & the
course of CEJ

Interdental recession
- “Dark triangles”/empty
spaces between
teeth = unesthetic
- Dist between crestal
bone & contact
point=5mm or
less=normal papilla;
if this distance >5mm
=dark triangles form
[Tarnow, Fletcher, Ma
gner:Jrnl of
Periodontology
1992:63:995-996]www.indiandentalacademy.com

Reasons :
• Advanced PDL disease - by tissue
destruction/pocket elimination due to surgery
• Roots excessively divergent due to improper brkt
placement
• Triangular tooth shape due to interproxmimal
wear in crowded positions before ortho Rx
Rx :
• Mucogingival surgery-coronally repositioned
flaps, GTR
• M-D enamel reduction
• Paralleling the roots of adjacent teeth
• Gingival prosthesiswww.indiandentalacademy.com

Gingival Zenith
• Most apical position of the
gingiva over the facial
aspect
• On maxillary central incisor
& canine – it is slightly distal
to the long axis of the tooth
while in the maxillary lateral
incisor, it is at the long axis.
• At the same levels approx
for the central incisors &
canines
• Slightly at a lower level for
the laterals(1mm)
[Esthetics of ant fixed
prosthodontics – Gerarad
Cliché, Alain Pinault;
Esthetic dentistry – Dr
Ratnadeep Patil]

• Esthetic consideration – gingival margins of maxillary
central incisors & canines are positioned at vermillion
border of upper lip & gingival margins of lateral
incisors are located 1-2mm more incisally or at the
same height of the central incisors & canines.

• Whenever a
patient displays
the gingival
margins easily
on
smiling/speaking
, a definite
pattern of the
gingival display
can be recorded
which can be
either
esthetic/unesthe
tic;
• Unesthetic=whe
never the lateral
incisors are
placed more
apical to the
central incisors

Separation of approximated teeth.
• Close root proximity - prevents satisfactory
restorative procedures, increased susceptibility
to rapid progression if PDL disease develops
• Root movt –using fixed appls
• Duration = 8-10 wks
• Confirm using an IOPA

Managing Treatment for the Orthodontic
Patient With Periodontal Problems
David P. Mathews and Vincent G. Kokich
(Semin Orthod 1997;3:21-38.)
• Generally, 2 to 3 mm of root separation will provide
adequate bone and embrasure space to improve
periodontal health.
• During this time the patient should be maintained by their
restorative dentist or periodontist to ensure that a
favorable bone response will occur as the roots are
moved apart.
• In addition, these patients will need occasional occlusal
adjustment to recontour the crown as the roots are
moving apart. As this happens, the crowns may develop
an unusual occlusal contact with the opposing arch. This
should be equilibrated to improve the occlusion.www.indiandentalacademy.com

Position teeth for single tooth implant
3 factors that determine the space available for
implant
1-space needed for implant itself - Minimum
6mm of space is required =1mm between the
implant & adjacent teeth for proper healing &
adequate space for the papilla + 4 mm width of
the implant at the shoulder
2- esthetics= contra lateral & adjacent teeth for
the prosthetic replacement - size, bilateral
symmetry
3- occlusion =less than ideal space for implant
due to crowding

• Technique –for space regaining/root
positioning – careful brkt placement &
control of anchorage
• Duration – ideal root placement – 6
months; confirm by IOPA

Interdisciplinary Management
of Single-Tooth Implants
Frank M. Spear, David M. Mathews, and Vincent
G. Kokich
(Semin Orthod 1997;3:45-72.)
• If the implant is placed and restored too
early, relative to the patient's tooth eruption, the
reaction of the implant will be similar to that of an
ankylosed tooth. The adjacent teeth may
erupt, and a discrepancy will be created
between the gingival margins of the implant and
the natural teeth.
• In a patient with a high lip line, this could be
esthetically unacceptable. For these reasons
patients should have completed the majority of
their tooth eruption before the placement of an
implant. www.indiandentalacademy.com

• It is advisable to wait until an adolescent male
has completed growth in height (as late as their
early 20s). In girls, the growth of the face is often
completed by 15 years of age. Therefore, it may
be possible to place implants for congenitally
missing teeth as early as 15-17 yrs years in girls
without the risk of eruption of adjacent teeth.
• In adults, who lose a tooth, implant can be
placed soon afterward-minimizes the loss of
alveolar bone in the newly edentulous space
• Maintaining primary teeth-even though their
roots are partially resorbed, also helps in
maintaining alveolar ridge height & width for
implant placementwww.indiandentalacademy.com

Buccal & coronal bone augmentataion using
orthodontic tooth movt – T Nozawa, T
Sugiyama et al: Intnl jrnl of
periodontics, restorative dentistry
2003:23:585-591
• Combination of forced eruption & buccal root
torque to achieve buccal & coronal bone
augmentation & soft tissue enlargement for
immediate implant placement
• 45 yr old woman

• Mandibular left 2nd premolar – facial probing depth = 6mm at
mesial, middle & distal; 3mm at midlingual
• Recession at midfacial gingiva=5mm; width of keratiinized
gingiva=1mm, tooth mobility=grade1; poor prognosis
• Initial periodontal surgery – with enamel matrix derivative placement
• Post surgery 5months – angular defects had exaggerated

• Post surgery 7 months –RCF done & forced eruption using
hook was started; buccal root torque added 4 wks later; brkt
position was displaced gradually in an apical direction at 8wks
• 12 wks later-tooth was extruded by 15mm; dist between root
apex & bone =3.5mm
• At 20 wks-dist between root apex & bone =1 mm

• Reentry surgery – tooth extracted, bone defect
completely disappeared
• Implant placed, 20 months later - provisional
restoration; 41 months later – definitive restoration

• Root moved beyond the buccal alv process – gingival recession
with bone dehiscence occurred
• Coronal & buccal bone formation induced till the original buccal
bone plate
• Tension force breaks down the adhesion between root surface
& junctional epithelium, shifts apically -recession

CROSSBITE CORRECTION:-
- Crossbites can cause functional
problem – occlusal
interferences, occlusal trauma &
improper occlusal loading.
- Single tooth crossbite – due to
displacement of crowded teeth/ectopic
eruption
- Group of teeth in crossbite - part of
skeletal problem.www.indiandentalacademy.com

Correction with removable appliances –
Especially in an anterior segment – when the
etiology is displaced teeth requiring only tipping
movements
-Disadvantage : as a tooth rotates
labially/buccally, there is a vertical change in
occlusal level=apparent intrusion, reduction in
overbite
-Problem with retention- as a positive overbite is
the key to retain the crossbite correction.

Fixed appliance –necessary for vertical control &
bodily movement
• Progressive stiffer round wires are placed to
align , final correction of root position achieved
only by placing a rectangular wire that will
almost fill the slot
• Reciprocal force – tends to move the anchor
teeth into crossbite - use of a TPA
• In case of deepbite with crossbite – correction
will be much easier if a temporary bite plane to
free the occlusion is givenwww.indiandentalacademy.com

• Posterior segments -Correction with the “through
the bite” elastics from a conveniently placed
tooth in the opposing arch.
• Tips the teeth into correct occlusion + extrudes
them, hence must be used with caution as they
change occlusal relationships

Intrusion of teeth
• Indications : for teeth with horizontal bone loss
or infrabony pockets; for increasing the clinical
crown length of single teeth (to level the gingival
margins to desired heights then to be provided
with veneers/crowns)
• Oral hygiene is inadequate – intrusion may shift
supragingival plaque into a subgingival location
=PDL destruction
• Clinically, ortho tooth movt intrudes a long
epithelial attachment beneath the margin of
alveolar bone
[Melsen et al:AJODO 1989:96:232-41]www.indiandentalacademy.com

Orthodontic movt into bone defects augmented
with bovine bone mineral, fibrin sealer –
Intnl jrnl of periodontics, restorative
dentistry 2002:22:365-371-Stefania Re et al
• Periodontal disease-migration of ant teeth
with the presence of intrabony defects
• Combination of orthodontic therapy &
bone grafting – to treat an adult
periodontal patient with
extrusion, proclination of maxillary central
incisor & intrabony defect on their lingualwww.indiandentalacademy.com

• 57 yr old woman with adult periodontitis
– pathologic extrusion, lengthening of
clinical crown with gingival
recession, bleeding on probing
• Initial probing depth on the lingual
surface: >/= 6mmwww.indiandentalacademy.com

• Initial - Supra, sub gingival scaling with oral
hygiene instructions + passive ortho appls
inserted to avoid tooth mobility

• After
anesthesia,
surgery to
augment
the
osseous
defect done
• 10 days
post op:
sutures
removed, a
ctive
orthodontic
movt
startedwww.indiandentalacademy.com

• Light, continuous forces = about 10gm
• Left central incisor-1st realigned with an intrusive
base arch (.017x.025 TMA) , simultaneously
intruded & moved the tooth lingually into the
defect
• Ortho Rx- 6 months
• Periodic follow up=every 2 weeks;
Prophylaxis=every 3 months

• Anterior fixed bonded splint – to avoid
relapse + masticatory comfort
• Final IOPA – elimination & almost
complete fill of the defect
• Clinically – only a physiologic sulcus, no
gingival recession, no bleeding on probing

Anterior diastema closure and
space redistribution:-
Causes for drifting/spacing of
incisors-
- Loss of posterior teeth.
- Small teeth.
- Loss of bone support.

• Partial closure of incisor spacing
&redistribution of diastema
space, followed by composite build ups
&/or replacement of missing teeth = best
esthetics

TREATMENT:-
-Diastema is small/is due to adjacent
teeth tipped in opposite directions = With
Removable appliance -using finger
springs to close the space by simple
tipping.
-Teeth are bodily displaced/widely
separated = With fixed appliance –
control both crown & root positions

Fixed appliance:
• Continuous arch from molar to molar if several
teeth are to be moved or involve just the anterior
segment if only 2 or 3 teeth are to be moved
• Initial alignment – with a light wire 016 NiTi or
0175 braided steel
• After 3-4 weeks , replaced with 016 or 018 ss
along which the teeth are repositioned using E
modules or coil springs
• If tooth size discrepancy exists(abnormally small
teeth in one arch) – impossible to close all the
space- teeth moved into an ideally separated
position & crowns built up either with
composite/castingswww.indiandentalacademy.com

• Permanent retention – lingual bonded
retainer, fused crowns, FPD
• Restorations of the teeth – (using
composite build ups) when excess spaces
are present = should be placed on the
same day the orthodontic appliance is
removed

Tooth movement through cortical
bone
• When a tooth is moved bodily in a labial
direction towards & through the cortical plate, no
bone formation takes place in front of the tooth -
Experimental studies in animals
• After initial thinning of the bone plate, a labial
bone dehiscence is hence created
• Such perforation of the cortical plate can occur
during orthodontic Rx either accidentally or
because it was considered unavoidablewww.indiandentalacademy.com

• Cortical plate perforation & root resorption may
happen:
- In the mandibular ant region due to frontal expansion of
incisors (facial root tipping)
[Wehrbein et al; AJODO 1994:106:455-462]
- In the maxillary post region during lat expansion of
cross-bites
[Greenbaum, Zachrisson; AJODO 1982:81:12-21]
- Lingually in the maxilla associated with retraction &
lingual root torque of maxillary incisors in patients with
large overjets
[Ten Hoeve, Mulie; JCO 1976:6:804-822]
- By pronounced traumatic jiggling of teeth [Nyman et al ]www.indiandentalacademy.com

• Repair : may take place when the
malpositioned teeth are moved back
toward their original positions & bone
apposition may take place
• Bone dehiscences that have occurred may
be repaired when the teeth are brought
back, or relapse towards a proper position
within the alveolar process, even if this
occurs several months later.

Chester S. Handelman :
The anterior alveolus: its importance in limiting
orthodontic treatment and its influence on the
occurrence of iatrogenic sequelae
[Angle Orthodontist:1996;No.2;95 – 110]
• To delineate the limits of orthodontic tooth
movement in adult patients prior to the start of
treatment.
• To enhance treatment planning, especially in
situations where the skeletal discrepancy is severe
or where one or both arches can accommodate
only limited tooth repositioning, especially in
borderline orthodontic-surgical cases.

• Cephalometric films of 107 adults were
measured to determine the width of alveolar
bone anterior and posterior to the incisor apex in
each arch.
• Thin alveolar widths were found both labial and
lingual to the mandibular incisors in groups of
Class I, II, and III individuals with high SN-MP
angle and in a group of Class III average SN-MP
individuals.
• Thin alveolar widths were also found lingual to
the maxillary incisors in a Class II high angle
group.

• The labial and lingual cortical plates at the level
of the incisor apex may represent the anatomic
limits of tooth movement.
• Clinical cases showed that orthodontic tooth
movement may be limited in patients with narrow
alveolar bone widths and that these patients are
likely to experience increased iatrogenic
sequelae (root resorption, bone loss, gingival
recession).

Edwards J G [AJODO 1976] :
• Studied a large group of individuals with Class II
malocclusion and bidental protrusion.
• He noted that despite prolonged palatal
retraction and root torquing of incisors, the width
of the anterior palate at the level of the apex
remained unchanged. The alveolus
can, however, remodel at the mid-root level and
at the alveolar margin when the lingual cortex is
approached and passed.
• He postulated an anatomic barrier against
further tooth movement in the higher areas at
the anterior palatal curvature as it approaches
the horizontal vault.www.indiandentalacademy.com

Edwards J G:
• A: The assumption is
that the total alveolus
can remodel to
accommodate
unlimited tooth
movement. This is not
seen in clinical
practice.
• B: The assumption is
that only the midroot
and marginal alveolus
can remodel, while the
bone at the level of the
apex does not remodel
and is thus a limit to
orthodontic tooth
movement.

Ten Hoeve and Mulie [JCO 1976] :
• Studied tooth movement at each stage of the
Begg technique in a group of adolescent
patients using cephalometric x-rays, and
laminagraphs
• They concluded that while there is no
anatomical limit to tooth movement in the
marginal area of the alveolus, there is a definite
limit to tooth movement as the apex abuts the
palatal cortex.
• In the mandible, following contact of the root with
the lingual cortical plate of the symphysis, tooth
movement comes to a standstill. Eventually, if
greater forces are applied, a perforation or
dehiscence results.www.indiandentalacademy.com

The measurements used in this study are illustrated
below :
• UP -Bone posterior (lingual) to upper incisor apex. Apex
of the maxillary central incisors to the limit of the palatal
cortex, along a plane parallel to the palatal plane, drawn
through the apex.
• UA -Bone anterior (labial) to upper incisor apex. Apex of
the maxillary central incisors to the limit of the labial
cortex, along a plane parallel to ANS-PNS, drawn
through the apex.
• LP -Bone posterior (lingual) to mandibular incisor apex.
Apex of the mandibular central incisor to the limit of the
lingual cortex, along a plane parallel to the occlusal
plane, drawn through the apex.

• LA -Bone anterior (labial) to mandibular incisor apex.
Apex of the mandibular central incisors to the limit of the
labial cortex, along a plane parallel to the occlusal
plane, drawn through the apex.
• UH -Bone superior to upper incisor apex. The shortest
distance from the maxillary incisor apex to the ANS-PNS
plane.
• LH -Bone inferior to mandibular incisor apex. The
shortest distance from the apex of mandibular incisor
apex to the lowest point on the mandibular synthesis that
is transected by a line parallel to occlusal plane.

• Cephalometric
measurements
that define the
width and
height of the
incisor
alveolus.

• Class I
average
skeletal
pattern. The
mean for each
alveolar
measurement
is illustrated.

Repositioning teeth beyond the alveolar housing:
Mulhe and Ten Hoeve -
• If the apex was moved beyond the alveolus, the
cortex in that region would not significantly remodel
and the lingual cortical plate of the symphysis could
be perforated.
• The combination of age and the extremely thin
alveolus can contribute to the perforation by the
apex.
• Long-term stabilization not only prevents
mobility, but will possibly allow for remodeling
repair of the bone loss on the lingual of the incisors.www.indiandentalacademy.com

Conclusions
1. Cephalometric measurements were established
for the various combinations of horizontal and
vertical facial types for the width of bone labial
and lingual to the incisor apices.
2. A narrow alveolus was frequently noted around
the mandibular incisors in high SN-MP groups
and in the Class III average group. A thin
alveolus was often noted lingual to the maxillary
incisor apex in the Class II high SN-MP group.
3. While individuals of any facial type could have a
thin alveolus, this was rarely seen in low SN-MP
groups or in the Class I average SN-MP group.www.indiandentalacademy.com

4. Clinical cases demonstrate that the palatal wall
of the maxilla and the posterior cortex of the
symphysis represent “orthodontic walls” or
barriers to tooth movement.
5. While the iatrogenic response to challenging
the anatomic limits is variable, the severity of
this response can compromise the periodontal
support of the incisors involved.
6. Norms for alveolar width in the Class I average
group are presented. A simplified prediction
can be achieved using overlay acetate tracings
of the projected treatment.www.indiandentalacademy.com

7. Patients with either narrow alveolar width or
severe skeletal discrepancies are most likely to
demonstrate limitation in orthodontic correction
and may require surgery.
8. These same patients are also likely to exhibit
severe iatrogenic loss of periodontal support
when tooth movement challenges the
“orthodontic walls” represented by the dense
cortical plates at the level of the incisor apices.
9. The width of the anterior alveolus combined with
a visualized treatment projection can be used in
determining if the borderline patient is best
treated via conventional orthodontics or a
combined orthodontic-surgical program.

Root resorption in adults
• Orthodontic treatment and apical root resorption have
been associated for many years
• The exact nature of the initiation and control of apical
root resorption remains essentially unknown.
• Although apical root resorption may occur in individuals
who have never experienced orthodontic tooth
movement (normal physiological process, perhaps akin
to continuous bone remodeling), the incidence among
treated individuals is quite high
[Etiology and Sequelae of Root Resorption : Vicki
Vlaskalic, Robert L. Boyd, and Sheldon Baumrind:
Semin Orthod 1998;4:124-131]

• It must be concluded from the body of
evidence existing in the literature that the
sequelae of orthodontically related
resorption does not pose a long-term
threat to the patient.
• Long-term treatment outcome studies
reported on the frequent detection of
resorption but of only minor nature and
with no discernible clinical significance.

Lupi, Handelman, Sadowsky : AJODO 1996 : 109:28-37 :
they used periapical radiographs of maxillary and
mandibular incisors to measure apical root resorption.
• Sample : 88 ethnically and racially diverse adults
• Result : 15% of teeth had resorption before treatment and
that this increased to 73% after at least 12 months of fixed
appliance treatment.
• Although only 2% of the teeth showed moderate (beyond
blunting and up to one third of root length) to severe
(beyond one third of root length) resorption before
treatment, 24.5% displayed this severity after treatment.
Two percent of patients experienced resorption beyond
one third of the original root length.

Risk factors of root resorption : Mirabella, Artun : AJODO
1995:108:48-55
• Sample : 343 patients, aged 20.0 to 70.1 years at T-1 (mean
34.5, SD 9.0) and treated for 0.6 to 5.2 years (mean 2.0, SD
0.7)
• Type of initial malocclusion may not be of importance for
amount of apical root resorption during treatment. Some
believe that overjet is a powerful predictor for resorption
• Treatment time was not detected as a predictor for
resorption.
• Mean apical root resorption of the most severely resorbed
central and lateral incisor and canine per patient was 1.47
mm (SD 1.40), 1.63 mm (SD 1.24), and 1.25 mm (SD
1.52), respectively.www.indiandentalacademy.com

• Use of elastic forces may increase the risk of apical root
resorption only on the tooth that support the
elastics, probably because of jiggling movements of the
anchor teeth. Therefore it seems that biomechanically
complex orthodontic treatment may lead to an increased
risk for apical root resorption.
• In conclusion, amount of root movement and presence of
long, narrow, and deviated roots increase the risk for
apical root resorption. In addition, use of elastics may be
a risk factor for the teeth that support the elastics.

Baumrind, Korn, and Boyd : AJODO 1996:110:311-320
• Studied the relationship between the magnitude and
direction of movement of the upper central incisor apex
with apical root resorption in orthodontically treated
adults
• Magnitude of displacement was measured on lateral
cephalograms with resorption measured on standardized
anterior periapical radiographs (points were digitized in
random order).
• Sample : 81 nongrowing patients, who were treated in
the offices of 3 experienced orthodontic specialists.
• The mean apical resorption was 1.36 mm (SD ± 1.46;
range = -1.03 to 5.58).

• An average of 0.99 mm(standard error ± 0.34) of root
resorption was implied in the absence of root
displacement and an average of 0.49 mm (standard
error = ±0.14) of resorption was implied per millimeter of
retraction.
• With the exception of incisor retraction, the assumption
that certain tooth movements are associated with
differences in resorption response was not corroborated
in this study.
• The other statistically significant positive finding was that
resorption is likely to occur even when the apex of the
tooth does not appear to move. The latter may be
consistent with either apical root resorption occurring in
untreated populations or with jiggling movements
produced in treatmentwww.indiandentalacademy.com

Orthognathic surgery combines
orthodontic treatment with surgery
of the jaw to correct or establish a
stable functional balance between
the teeth, jaws and facial
structures.
Orthognathic basically involves planned
fracturing of the facial skeletal parts and
reposition them as desired.
Combined Surgical &
Orthodontic Treatment

Indications for Orthognathic
Surgery
• Severity of skeletal and dental malocclusion
• When growth modification can not be
achieved
• Esthetic and psychosocial considerations

Camouflage vs Surgical Rx

Function:
Normal chewing, speech, respiratory function
.
Esthetics:
Establish facial harmony and balance
Stability:
Avoid short and long term relapse
Minimize treatment time:
Provide efficient and effective treatment.
Goals Of Orthognathic Surgery

Timing of Surgery
• Usually done when all growth is complete
• Assessed by superimposition of serial lat
cephs
• Can be performed when growth is not yet
complete in cases of psychosocial
problems or great severity when function
is compromised (i.e. breathing, chewing)

Orthognathic Surgery
Correction of A-P
relationships:
• maxillary
advancement
• retraction of
anterior maxillary
segment
• mandibular
advancement
• mandibular setback
• double jaw surgery

Correction of Vertical
Relationships:
• maxillary
impaction/intrusion
• maxillary extrusion
• mandibular ramus
surgery

Correction of Transverse
Relationships:
• surgically assisted
maxillary expansion
• surgically assisted
mandibular expansion

Correction of
Asymmetries:
• maxilla
• mandible
• maxilla and mandible

Surgical Techniques
• Le Fort I
• Le Fort II
• Le Fort III
Le Fort I
Le Fort II
Le Fort III

Surgical Techniques
• BSSO
• Genioplasty

Pre Surgical Orthodontic
Objectives
• to level and align the arches and make
them compatible
• to resolve crowding and/or spacing
• to establish anteroposterior and vertical
position of incisors (decompensate)
• to place teeth relative to their own
supporting bonewww.indiandentalacademy.com

Diagnostic Records
• Analysis of pictures-photographs
• Cephalometric analysis
• Surgical prediction - STO
• Model/occlusion analysis

Preparation for Surgery
• Check for any TMJ problems
• Manipulate models mounted in an
articulator to check for interferences and
occlusion
• Splint fabrication (1 or 2 splints)

Post Surgical Orthodontic Treatment
• Post 1 week: check occlusion, splint and
appliances
• 4-6 weeks: reinitiate orthodontic tx (after
range of motion and stability are achieved)
• Remove splint; change to light wires and light
vertical elastics
• Treatment usually completed in 4 to 12
months (average 6 months)

Relapse and Stability
• Rigid fixation has improved stability
• Stability is mostly influenced by the pattern
of rotation of the mandible as it is
advanced
• Advancement of maxilla and/or mandible
will stretch soft tissues promoting relapse
• The more advancement needed, the
greater the probability for relapse

Relapse and Stability

SUMMARY:-
There is wide variety
of etiology that can cause an adult
malocclusion. Also each patient’s
need for treatment are different so
treatment should be carried out
taking his/her needs in consideration.
Adult orthodontic treatment helps by
facilitating other dental
procedures, controlling disease and
restoring function.www.indiandentalacademy.com

THANK YOU

SURGICAL TREATMENT: -
- orthognathic basically involves
planned fracturing of the facial
skeletal parts and reposition them as
desired.
- Moderate to severe skeletal
discrepancy.
- Patient education.

SURGICAL PROCEDURES: -
1) Correction of anteroposterior
relationship: -
both maxilla and mandible can be
moved forward or backward for
correction of jaw discrepancy.

A) MAXILLARY SURGERY: -
The LeFort 1 downfracture
procedure is used to reposition
the maxilla.

B) MANDIBULAR ADVANCEMENT:-
- Bilateral saggital split
osteotomy(BSSO) of the mandibular
ramus.
- stretching and retraction of the
inferior alveolar nerve.

C) MANDIBULAR SETBACK: -
- BSSO.
- The transoral vertical oblique ramus
osteotomy(TOVRO).

2) CORRECTION IN VERTICAL
PLANE: -
a) Maxillary surgery: -
- LeFort 1 downfracture of the
maxilla, with superior reposition of
the maxilla.
- In downward movement of the
maxilla rigid fixation are
used.(synthetic hydroxyapatite)www.indiandentalacademy.com

b) Mandibular surgery: -
mandibular ramus surgery in open
bite cases avoided.
Short face(skeletal deep bite) best
treated by saggital split mandibular
ramus surgery.

3) CORRECTION OF
TRANSVERSE RELATIONSHIP: -
easy to move maxilla in transverse
direction then mandible.

A) MAXILLARY EXPANTION: -
Constriction or expantion done
during course of Lefort 1
downfracture procedure.

GENIOPLASTY

RETENTION: -
- More difficult in adult then in
adolescent patient ,
- slower tissue turn over rate.
- Normal functional adaptation occurs
more when growth has been
completed.
- Reduce height of periodontium.

-Hawley retainer.
- Hawley retained with tongue cribs.
- fixed bonded retainer(max. and
mand. Anterior segments)

Restorative retainers: -
- composite restoration.
- amalgam, inlay or onlay.
- pontics (fixed/removable).

Periodontal surgical retention
procedure:
- Fibrotomy.
- gingivectomy.

TREATMENT
CONSIDERATIONS IN
PATIENTS WITH
TEMPOROMANDIBULAR
DYSFUNTION

Check List for Treatment Planning
• A-P relationships maxillary deficiency/protrusion
mand prognathism/deficiency
amount of deficiency
• Vertical relationships open bite
deep bite
• Transverse relationships crossbites
before surgery expansion
surgically assisted expansion
during surgery
{

Check List for Treatment Planning
• Asymmetries cant of occlusal plane
mandible/chin deviation
• Occlusal relationships
• Missing teeth/ malformed teeth
• Genioplasty
• Nose/lip relationship - rhinoplasty

PERIODONTAL ASPECT OF
ADULT TREATMENT:-
1) Minimal periodontal involvement.
2) Moderate periodontal involvement.
3) Severe periodontal involvement.

1) MINIMAL PERIODONTAL
INVOVEMENT: -
CHILDREN AND ADOLESCENT
ARE LESS SUSEPTIBLE TO
PERIODONTAL DISEASE
THAN ADULTS.

2) MODERATE PERIODONTAL
INVOVEMENT: -
All periodontal disease should be
controlled before tooth movement.
Fully bonded orthodontic appliance is
preferred in periodontally involve
adult patient.

Steel ligatures or self legating
brackets are preferred.
Periodontal maintenance therapy at
2-4 month interval.

3) SEVERE PERIODONTAL
INVOVEMENT: -
Periodontal maintenance should be
scheduled at more frequent intervals.
Orthodontic goals and mechnics
should be modified to keep force
value minimum.

SPACE CLOSURE VS.
PROSTHETIC REPLACEMENT: -
Old extraction site: -
Space closure is difficult in adult.
The involvement of cortical bone
tend to produce reciprocal space
closure.
Implant in the ramus can be use to
provide necessary anchorage.

TOOTH LOST DUE TO
PERIODONTAL DISEASE: -
Unwise to move a teeth in area
where bone is destroyed because of
periodontal disease.

Thank you
For more details please visit

Adult orthodontics 1

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