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4. Periodontal ligament
Fibroblast
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Blood borne origin
Pleuropotential cell
Collagen & proteoglycans
Collagen turnover in PDL- 2.5-6.5 day
Aging-imbalance.
Proteoglycans-withstand the forces.
Retains water-changes with age.
PGs-prostaglandins & leukokines-resorption of bone.
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5. Capillary
bed.
Number of branches found in the vascular bed –
decreases
Amount of blood flow to tissues-decreases
Nerve
tissue
Changes in number of neuro receptor
Age related decrease in sensory responsiveness.
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6.
Bone
Mechanical properties changes
Macroscopically- trabecular bone volume decreases.
Osteoblastic activity-reduces
Imbalance b/w resorption & replacement
Sinus size-increases
Bone density decreases &porosity increases with
age.
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7. Teeth
More root exposure
Short crown root ratio
CR shift –apically
Diameter of pupal canal reduces
Decreased vascularity&innervation -pulp recovery.
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10. History
Kingsley(1880)-early awareness of the orthodontic
potential for the adult pts.
Published statements-Negative.
MacDowell(1901)- Impossible age.
Lischer(1912)-optimal age for treatment.
• Golden age of treatment
Case (1921)-value of adult 0rthodontic therapy
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12. History
Lindegaard
et al (1971)-3 factors.
Reidel & Dougherty (1976)
“orthodontics is total discipline and it
makes no difference whether the patient
is young or old”
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15. Why do adults seek orthodontic
Rx
Did not want orthodontic treatment as children
Did not know about orthodontics as children
Parents couldn't afford orthodontic treatment as children.
No orthodontist located in their vicinity when younger
Incomplete orthodontic treatment as children, non cooperative
Had orthodontic treatment as children but relapsed.
More conscious of appearance with age
Malpositioned teeth contributing to PDL disease
Spaces b/w anterior teeth enlarging ,new spaces opening up.
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16. comparison
factors
adolescents
adults
Dental caries
More susceptible
Recurrent decay
restorative failures, root
decay& pulpal pathosis
PDL disease
Resistance to bone loss
Susceptible to gingival
inflammation
Susceptible to bone loss
TMJ
adaptability
high
Symptoms with
dysfunction
Occlusal
awareness
Infrequent
Increased enamel wear
with adverse change in
supporting tissue.
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24. Most favorable distribution of
teeth
Distributed evenly-replacements
To establish normal occlusion.
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25. Redistribution of occlusal &
incisal forces.
Cases with significant bone loss(60-70%)
To maintain occlusal vertical dimension
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26. Adequate embrasure space
&proper root position.
Better PDL health
Helps in interproximal cleaning
Placement of restorative material.
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28. Better lip competency & support
In case of anterior restoration-retractions
Inadequate support-change in anteroposterior
&vertical position of upper lip & increase in wrinkling.
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29. Improved crown/root ration
In
case of bone loss
Reduced crown/root ratio
Can be corrected by reducing the clinical
crown.
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30. Better self maintenance of PDL
health
Improved self maintainace of PDL
health occurs with proper tooth position
Teeth should be positioned properly
over basal bone
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31. Esthetic & functional
improvement.
Should provide acceptable dentofacial esthetics
Improved muscle function
Normal speech & masticatory function
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34. Adjunctive orthodontic
treatment
Definition
:tooth movement carried out to
facilitate other dental procedures
necessary to control disease & restore
function.
Uprighting of posterior teeth
Forced eruption
Alignment of anterior teeth
Crossbite correction
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35. Goals of AOT
Facilitate
restorative treatment
Improve PDL health
Favorable crown : root
“Goal of AOT is to provide a physiologic
occlusion & facilitate other dental
treatment & has little to do with Angle’s
concept of an ideal tooth relationships.”
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36. Principles of AOT
Diagnostic & treatment planning.
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Collecting an adequate data base.
Developing a problem list.
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37. Diagnostic
records
• OPG.
• Full mouth IOPAs.
• Lateral ceph
• photographs.
• Dental casts.
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38. Biomechanical considerations
Characteristics
of the orthodontic
appliance.
• Anchorage control
• 22-slot edgewise appliance with twin brackets
• Removable/Fixed appliance.
• Bracket placement-ideal-tooth to be moved.
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41. Effects of reduced periodontal
support
Bone
support
Bone loss-PDL
area decreases
CR-shifts more
appically
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42. Timing & sequence of treatment
Active disease
Disease control
Re-evaluate
Establish occlusion
stabilize
Definitive restorative Rx
maintenance
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43. Adjunctive orthodontic Rx
procedure.
Uprighting of posterior teeth
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Uprighting a single molar
Uprighting with minimal extrusion
Final positioning of molar & PM
Uprighting two molars in the same quadrant
Retention
Forced eruption
Alignment of anterior teeth
Crossbite correction
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44. Uprighting posterior teeth
Treatment
planning consideration
• Loss of posterior teeth
• If the 3 molar is present?
• Uprighting by distal crown/ mesial root
rd
•
movement?
Slight extrusion of tipped molar is
permissible?
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58. Final positioning of molar & PMs
Compressed coil springs
018 steel
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59. Uprighting two molars in the
same quadrant.
Combination
of distal crown & mesial
root
No bilateral uprighting - same time
17x25 Niti
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60. Retention
Fixed
bridge-within 6 weeks
Short time-19x25 steel /21x25 beta Ti
>few weeks-intermediate splinting
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61. Forced eruption
Indications
• Defects in cervical 3 of the root
• Horizontal / vertical #
• Internal/external resorption
• Decay
• PDL – disease
• To obtain good access for endodontic and
rd
restorative process
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62. Forced eruption
Treatment
planning
• Good periapical radiographs
• Periodontal support
• Root morphology and position
• Endodontic therapy should be completed
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63. Orthodontic technique
Anchor
teeth –rigid
Flexible –tooth to be extruded
With / without the use of orthodontic
bracket
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65. Alignment of anterior teeth
Indications
• To improve access & permit placement of
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restoration
To permit placement of crowns & pontics
To reposition the closely approximated roots
To place implants.
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68. Positionining tooth for single
tooth implants
Missing teeth-implants
• Space needed for implant, esthetics& the
occlusion
Space needed for implants
• Narrowest – 4mm
• 1mm –in b/w implants
Contralareral & adjacent teeth –size of the implant
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69. Timing of implant placement
Implants to support restorations should not be placed
until all vertical growth has been completed.
Boys-20yrs
Girls-15-17yrs.
For adults-soon after –minimizes bone loss.
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70. Case reports
Kenji W Higuchi
48yrs/F
Class II div 1
Deep bite
Missing12,47,46,45,35,36,37
Treatment plan: surgical correction
6 implants on 37,26,25,47,46,45
Healing period -4 months
Implant-supported FPD
Uprighting of 3rd molar + alignment
Same implants-abutments.
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73. Case 2
53yrs/M
Class
III
Ant &post crossbites
spacing
Treatment plan: 2 implants,35&36
Healing period -4 months
Implant-supported FPD
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74. Case 3
64yrs/F
Class
I
Impacted canine
Missing teeth
Treatment plan:
Extrusion of impacted canine
1 implant -16
Healing period-6 months
Implant supported FPD-anchorage
Same implant-abutment
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76. Anterior diastema closure
Loss of posterior teeth, abnormally small teeth, loss
of bone support-drifting/spacing.
Partial closure-composite build ups-permanent
retention
Smaller diastema-removable appliance
016 niti,018 steel with coil springs.
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78. Crossbite correction
Crossbite-functional problem
Ant crossbite -esthetic
Tipped teeth-removable apl
Elastics
Establishing a good overbite
relationship is the key to maintaining
crossbite correction.
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80. Comprehensive orthodontic
treatment-Adults
Special
considerations for adults
• Different motivations for seeking orthodontic
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•
treatment & different psychological differences to it.
Heightened susceptibility to periodontal disease.
Lack of growth.
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81. Comprehensive treatment
Motivation
for adult treatment
• Psychological
• PDL & restorative needs as motivating factor
• TMJ dysfunction as motivating factor
Periodontal
aspects of adult treatment
Special aspects of orthodontic appliance
therapy.
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82. Psychological considerations
High motivation -self referred for esthetic
reasons
Low motivation -dentist referred for adjunctive
correction
Turned off -unaesthetic appliances, fear of
pain, extended treatment time, personal
inconvenience & cost
Adults are less tolerant of discomfort & more
likely to complain about difficulties in speech,
eating & tissue adaptation.
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83. Periodontal diagnosis
Awareness of risk factors
General factors
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Family history
General health status
Nutritional status
Current stress factors
• Local factors
Plaque indices
Crown root ratio
Habits
Restorative status
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84. Periodontal aspects of adult
treatment
Periodontal considerations are increasingly important
as patient become older ,regardless of whether
periodontal problems were a motivating factor.
Minimal PDL involvement
Moderate PDL involvement
Severe PDL involvement
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85. Minimal periodontal involvement
Hygiene
status
• Special care-adults
• Inter dental aids, proximal brushes
Level
& condition of attached gingiva
Gingival recession
Gingival grafts
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86. Moderate PDL-involvement
Disease control
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Preliminary PDL-treatment
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Scaling,curettage,flap surgery etc
Endodontic treatment
Cast restorations should be delayed
Period of observations
PDL-maintenance
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Full arch bonding> banding
Steel ligature > elastomeric rings
maintenance = 2-4 months
Hygiene maintenance- electric tooth brushes, mouthwashes
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87. Severe PDL- involvement
Disease control
• Scaling,curettage,flep surgery, osseous surgery
• Endodontic therapy
Period of observation
PDL- maintenance
• More frequent intervals,4-6 weeks
Very light forces should be used.
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91. Intrusion
light & continuous force
• With continuous arch wires
• Segmental arch wires
In case of PDL involved-anchorage compromised.
Intrusion should never be attempted without
excellent control of inflammation.
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92. Intrusion of incisors in adult patients
with marginal bone loss
Birte Melsen, AmJ Orthod 1989
Common problems-adults-PDL disease
• Migration, spacing, elongation of incisors
Progressive bone loss-CR shifts appically
Aim :to intrude elongated teeth with varying degrees of PDL
damage & thus evaluating the influence of treatment on pdl
status.
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93.
Material & method
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30 sample
5M/25F
AGE:22-60yrs
PDL preparation
Orthodontic appliance-4 types
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J hook for intrusion
Ricketts utility arch-016x016 steel
Intrusion bend into loops of full arch-017x025 steel
Burstone’s continuous intrusion arch
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105. Interproximal stripping for the
treatment of adult crowding-Julia F
Harfin JCO 2001 Nov
Crowding
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Thickest enamel -maxillary arch
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Mild- less than 3mm
Moderate- 3-5mm
Severe -more than 5 mm
M & D surfaces of cuspids
Distal surface of central incisors
Mandibular arch
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M & D surfaces of cuspids
Distal surface of the lateral incisor
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113. Space closure
Old extractions sites -difficult to close
• Resorption
• Remodeling of the bone.
Such situation-better to use prosthesis or
Implants.
Temporary implants in the ramus - to protract the
molars
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114. Rigid implant anchorage to close a
mandibular first molar extraction siteW.Eugene Roberts, Charles nelson,jco1997
Rigid endoesseous implants are
a reliable source of orthopedic
anchorage
For managing malocclusions
that are the usual scope
of orthodontic practice
Case report
45yrs/M
Missing lower molar
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120. Invisalign
What is invisalign?
- Invisible alignment of the teeth
- An invisible way to align the teeth
• Uses a series of clear removable aligners
to straighten teeth without metal wires or
brackets.
• Developed by Align Technology,CA
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121. Impressions are
made using
Polyvinyl
Siloxane
Impression and
bite send along
with a detailed
treatment plan.
advanced imaging
technology
transforms plaster
models into a
highly accurate 3-D
digital image.
A computerized movie called ClinCheck® depicting the movement of
teeth from the beginning
to the final position is
created.
Procedure
After wearing all of
the aligners in the
series,
customized set of aligners
are made from these
models, sent to the doctor,
and given to the patient. Pt
to wear each aligner for
about two weeks.
From the approved file,
laser scanning to build a
set Invisalign® uses of
actual models that reflect
each stage of the treatment
plan.
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Using the Internet, the
doctor reviews the
ClinCheck file - if
necessary, adjustments to
the depicted plan are
made.
123. Invisalign
Patient gets the first aligner 6 weeks
after the 1st visit
Most treatments require 20 – 60 aligners
Worn for 2 weeks each
Should be taken off only for eating and
brushing
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124. Invisalign
Limitations
Patients with severe malocclusions
cannot be treated
Children,mixed dentition – growing jaws
and erupting teeth too complicated for
the computer to model
No precise control over root movements
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125. Invisalign system in adult orthodontics:
mild crowding & space closure cases
Robert L Boyd, R J Miller,JCO 2000 April
Case 1
23yrs/F
Spacing b/w teeth
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131. Lower incisor extraction treatment
with invisalign system-Ross J Miller
2001 JCO nov
Case report
24yrs/F
Lower incisor crowding
Class I molar reln
Midline shift-3mm Rt side
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136. Rapid orthodontic decrowding with alveolar augmentation: case report
William . M . Wilcko
World Journal Orthodontics 2003:4:197-205
Thomas . Wilcko
Demonstrates a New orthodontic method that provides
shortened treatment times.
Case report
27yrs/F
Class I with moderate crowding
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137. After 1 wk of bracketing & wire activation-selective Decortications.
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142. Conclusion
Takes shorter treatment time
Pre-existing fenestrations/dehiscence can be
corrected-alveolar augmentation.
Lip support can be achieved-alveolar augmentation.
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143. Accelerated Invisalign treatmentAlbert H Owen,JCO 2001 June
Esthetics & speed
Decorticotomy( AOO)
Invisalign therapy
Class I Occlusion
Mild crowding in lower arch
Lower midline shift
Only lower canine-canine decorticotomy.
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144. After 10 days of corticotomy
Invisalign therapy started.
Aligners changed –every 3 days.
Rx completion-4 months.
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145. Retention & Post treatment
stability in Adults.
“After malposed teeth have been moved into the desired
position, they may be mechanically supported until all of
the tissue involved in their support & maintenance in their
new positions shall have become thoroughly modified ,
both in their structure & function to meet new
requirements.”
-E H Angle
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162. D.P.21/F
SEVERE SKELETAL CLASS II WITH
MATCHING SOFT TISSUES
HYPERDIVERGENT JAW BASES
SEVERE PROCLINATION OF U-ANTERIORS.
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