Adult Orthodontics Guide - Everything You Need to Know

AdultAdult
OrthodonticsOrthodontics
www.indiandentalacademy.com

ContentsContents
Introduction
History
Classifications
Goals and Objectives
Adjunctive orthodontics
Comprehensive orthodontics
Surgical orthodontics
Recent advances
Retention
Conclusion
References

The frequency of malocclusion in adults is equal (or)The frequency of malocclusion in adults is equal (or)
greater than that observed in children and adolescents.greater than that observed in children and adolescents.
Until recent years adults seeking orthodontic treatmentUntil recent years adults seeking orthodontic treatment
was unusual. Since 1990’s 15% of the ortho patientswas unusual. Since 1990’s 15% of the ortho patients
were adults. They fall into 2 different groupswere adults. They fall into 2 different groups
• (1)(1) younger adultsyounger adults (under35, often in their 20’) who(under35, often in their 20’) who
desired, but not received ortho treatment duringdesired, but not received ortho treatment during
adolescents.adolescents.
• (2)(2) An older groupAn older group, typically in their 40’s or 50’s who, typically in their 40’s or 50’s who
have other dental problems and need orthodontics ashave other dental problems and need orthodontics as
part of larger treatment plan.part of larger treatment plan.
INTRODUCTIONINTRODUCTION

• HISTORYHISTORY
• Conflicting opinions have always existedConflicting opinions have always existed
regarding the feasibility of orthodontic treatmentregarding the feasibility of orthodontic treatment
in the adultin the adult
• KingsleyKingsley (1880)(1880) suggested that there weresuggested that there were
hardly any limits to the age of when toothhardly any limits to the age of when tooth
movement might not succeed (he treated a 40movement might not succeed (he treated a 40
year old patient with anterior cross bite).year old patient with anterior cross bite).
• In contrastIn contrast Mac DowellMac Dowell (1901)(1901) was of thewas of the
opinion that after 16 years of age, orthodonticopinion that after 16 years of age, orthodontic
treatment was also impossible owing to thetreatment was also impossible owing to the
development of the glenoid fossa, the density ofdevelopment of the glenoid fossa, the density of
the bones and muscles of masticator.the bones and muscles of masticator.

• LischerLischer (1912)(1912) believed that the period between 6–14. years wasbelieved that the period between 6–14. years was
a golden age of treatmenta golden age of treatment
• CaseCase (1921)(1921) demonstrated treatment possibilities in aged anddemonstrated treatment possibilities in aged and
periodontally affected patientsperiodontally affected patients
• Lindegaard et alLindegaard et al (1971)-3 factors.(1971)-3 factors.
1.A disease or abnormality must be present1.A disease or abnormality must be present
2.The need for treatment must be understood, the priority for2.The need for treatment must be understood, the priority for
orthodontic care based on personal and professional judgmentorthodontic care based on personal and professional judgment
3.The patient must have a strong desire for treatment3.The patient must have a strong desire for treatment

• Reidel & DoughertyReidel & Dougherty (1976) predicted the(1976) predicted the
status of adult ortho treatment today andstatus of adult ortho treatment today and
stresses the need for adjunctive orthodonticstresses the need for adjunctive orthodontic
services provided by periodontist and restorativeservices provided by periodontist and restorative
dentist.dentist.
• ““orthodontics is total discipline and it makes noorthodontics is total discipline and it makes no
difference whether the patient is young or old”difference whether the patient is young or old”

Adult practice todayAdult practice today

Scope of procedures
Musich’s (1986)study of 1370 consecutively examined adults

Why do adults seek orthodonticWhy do adults seek orthodontic
Rx ???Rx ???
• Did not want orthodontic treatment as childrenDid not want orthodontic treatment as children
• Did not know about orthodontics as childrenDid not know about orthodontics as children
• Parents couldn't afford orthodontic treatment as children.Parents couldn't afford orthodontic treatment as children.
• No orthodontist located in their vicinity when youngerNo orthodontist located in their vicinity when younger
• Incomplete orthodontic treatment as children, non cooperativeIncomplete orthodontic treatment as children, non cooperative
• Had orthodontic treatment as children but relapsed.Had orthodontic treatment as children but relapsed.
• More conscious of appearance with ageMore conscious of appearance with age
• Malpositioned teeth contributing to PDL diseaseMalpositioned teeth contributing to PDL disease
• Spaces b/w anterior teeth enlarging ,new spaces opening up.Spaces b/w anterior teeth enlarging ,new spaces opening up.

Classification-Classification- Graber,VanarsdallGraber,Vanarsdall
• Physiologic occlusionPhysiologic occlusion
• Psychological disorientationPsychological disorientation
• Adjunctive orthodonticsAdjunctive orthodontics
• Corrective orthodonticsCorrective orthodontics
• Orthognathic surgeryOrthognathic surgery
• Periodontally susceptiblePeriodontally susceptible
• TMJ-dysfunctionTMJ-dysfunction
• Enamel wear beyond that expected for chronologic ageEnamel wear beyond that expected for chronologic age
• Dental mutilationDental mutilation
• CombinationCombination
• Borderline surgical caseBorderline surgical case

Acc toAcc to Gurkeerat singhGurkeerat singh ( jco 1996)( jco 1996)
For all practice purposes the adult patients areFor all practice purposes the adult patients are
classified in 3 groupsclassified in 3 groups
1.Group I : 18 to 25 years of age1.Group I : 18 to 25 years of age
2. Group II: 26 to 35 years of age2. Group II: 26 to 35 years of age
3. GroupIII: 36 years and alder3. GroupIII: 36 years and alder

DIAGNOSIS AND ADULTDIAGNOSIS AND ADULT
ORTHODONTICSORTHODONTICS
• Careful diagnosis and treatment planning onCareful diagnosis and treatment planning on
aa multidisciplinary basismultidisciplinary basis is required to treatis required to treat
adult patients. In truth, the adult, unlike theadult patients. In truth, the adult, unlike the
child, is a relentless patient who will not coverchild, is a relentless patient who will not cover
up deficiencies in the skill of diagnosis or errorsup deficiencies in the skill of diagnosis or errors
in the use of mechanical procedures by helpfulin the use of mechanical procedures by helpful
settling – in post treatment. He presents with nosettling – in post treatment. He presents with no
growth, little rebound and meagergrowth, little rebound and meager
accommodation to mechanics.accommodation to mechanics.

In addition, the adult may exhibit a potential forIn addition, the adult may exhibit a potential for
such pathological changes as knife-edgesuch pathological changes as knife-edge
ridges,increased cortical thickness, buried roots,ridges,increased cortical thickness, buried roots,
impactions, periodontal breakdown, atropicimpactions, periodontal breakdown, atropic
changes TMJ problems osteoporosis,changes TMJ problems osteoporosis,
osteomalacia, diabetes mellitus. Theseosteomalacia, diabetes mellitus. These
conditions, which obtain as a result ofconditions, which obtain as a result of
hormonal, vitamin or systemic disordershormonal, vitamin or systemic disorders
common to the adult, necessitate more carefulcommon to the adult, necessitate more careful
and extensive diagnosis evaluations.and extensive diagnosis evaluations.

• Orthodontic diagnosis involves development of aOrthodontic diagnosis involves development of a
comprehensive database of pertinent information. Thecomprehensive database of pertinent information. The
standard diagnostic aids such as case history, clinicalstandard diagnostic aids such as case history, clinical
examination and study casts, radiographs andexamination and study casts, radiographs and
photographs are mandatory.photographs are mandatory.
• I.O.P.A, occlusal and TMJI.O.P.A, occlusal and TMJ films should be obtainedfilms should be obtained
routinely in addition to theroutinely in addition to the panoramicpanoramic radiographradiograph andand
thethe cephalogram.cephalogram. TheThe problemproblem oriented diagnosticoriented diagnostic
approachapproach as described byas described by ProffitProffit andand AckermanAckerman isis
strongly recommended to ensure that no aspect of thestrongly recommended to ensure that no aspect of the
patient need is neglected.patient need is neglected.

• Additional diagnostic proceduresAdditional diagnostic procedures that wethat we
should consider in an adult patient areshould consider in an adult patient are
• A full series of TMJ x – raysA full series of TMJ x – rays
• Muscle examinationMuscle examination
• Splint therapySplint therapy
• Diet evaluationDiet evaluation

Psychological status of patients seeking orthodonticPsychological status of patients seeking orthodontic
treatment.treatment.
• Psychological outcomes of orthodontics on the patientsPsychological outcomes of orthodontics on the patients
self image is positive.self image is positive.
• Psychology to the clinical practice of orthodontics canPsychology to the clinical practice of orthodontics can
be divided into:-be divided into:-
-Social psychology-Social psychology
-Motivational psychology-Motivational psychology

• (i) Social Psychology of Orthodontics(i) Social Psychology of Orthodontics:-:-
Why patients seek orthodontic treatment?Why patients seek orthodontic treatment?
--Dentofacial anomalies such as crooked teeth & skeletalDentofacial anomalies such as crooked teeth & skeletal
disharmonies have been reported as the cause of teasing &disharmonies have been reported as the cause of teasing &
harassment among children.harassment among children.
--Bennet & Philip.Bennet & Philip.
• Adults seek for treatment to improve their facial & dentalAdults seek for treatment to improve their facial & dental
appearance which in turn will lessen social embarrassment &appearance which in turn will lessen social embarrassment &
improve the self confidence.improve the self confidence.
--Hunt & Johnston.Hunt & Johnston.

Psychologic outcomes of orthodontic treatmentPsychologic outcomes of orthodontic treatment:-:-
Dentofacial esthetics play an important role in a individual’sDentofacial esthetics play an important role in a individual’s
self image.self image.
Children with malocclusion did not have poor self image &Children with malocclusion did not have poor self image &
orthodontic treatment did not improve it-orthodontic treatment did not improve it-DannDann..
Dentofacial disharmonies have significant social &Dentofacial disharmonies have significant social &
psychological effect on the patient-psychological effect on the patient-AlbinoAlbino..

• Kiyak et alKiyak et al reported psychological influences onreported psychological influences on
the timing of orthodontic treatment.the timing of orthodontic treatment.
-Developing children well being may be an-Developing children well being may be an
indication for early orthodontic treatment.indication for early orthodontic treatment.
-Racial differences may be present in the psychological-Racial differences may be present in the psychological
influences of orthodontics.influences of orthodontics.

• (ii) Motivational psychology(ii) Motivational psychology:-:-
The success of orthodontic therapy depends on patient compliance.The success of orthodontic therapy depends on patient compliance.
 EgolfEgolf described a compliant patient as one who practices gooddescribed a compliant patient as one who practices good
oral hygiene, wears appliance, follows an appropriate diet and keepsoral hygiene, wears appliance, follows an appropriate diet and keeps
appointment.appointment.
 Southard et alSouthard et al pointed out that improved co-operation by the patientpointed out that improved co-operation by the patient
helps to achieve the treatment objectives within a minimum time.helps to achieve the treatment objectives within a minimum time.

• Improved oral hygiene can decrease damage to theImproved oral hygiene can decrease damage to the
periodontal tissues and limit the effects of enamelperiodontal tissues and limit the effects of enamel
decalcification and cariesdecalcification and caries
--Nanda & SinhaNanda & Sinha

• PERIODONTAL DIAGNOSISPERIODONTAL DIAGNOSIS
• Assess the patients potential for bone loss and gingivalAssess the patients potential for bone loss and gingival
recession during orthodontic tooth movement.recession during orthodontic tooth movement.
• Patient should be screened for the risk factors ofPatient should be screened for the risk factors of
periodontal disease.periodontal disease.
• Pre treatment consultation with the periodontist shouldPre treatment consultation with the periodontist should
be routine and orthodontic objectives be alteredbe routine and orthodontic objectives be altered
according to his advice. Movement of teeth in theaccording to his advice. Movement of teeth in the
presence of periodontal inflammation will result in anpresence of periodontal inflammation will result in an
increased loss of attachement and irreversible crestalincreased loss of attachement and irreversible crestal
loss.loss.

TMD DiagnosisTMD Diagnosis
• Signs of symptoms of TMD often increase in frequency andSigns of symptoms of TMD often increase in frequency and
severity during adult treatment. So it is imperative for theseverity during adult treatment. So it is imperative for the
orthodontist to be familiar with their diagnostic and treatmentorthodontist to be familiar with their diagnostic and treatment
parameters.parameters.
• Adult patients especially females with TMJ sign and symptomsAdult patients especially females with TMJ sign and symptoms
should be evaluated regarding exposure to stress and hershould be evaluated regarding exposure to stress and her
handling of stresshandling of stress..
• SCHIFMANNSCHIFMANN et al dividedet al divided TMDTMD problems intoproblems into
• Muscle disorders - 23%Muscle disorders - 23%
• Joint disorders – 19%Joint disorders – 19%
• Muscle / Joint disorder combination – 27%Muscle / Joint disorder combination – 27%
• Normal – 31%Normal – 31%

• TMJ DISORDERSTMJ DISORDERS
• Deviation in formDeviation in form - Irregularities in intracapsular soft- Irregularities in intracapsular soft
and hard articular tissue.and hard articular tissue.
• Disc displacement with reductionDisc displacement with reduction – Altered Disc-– Altered Disc-
condyle structural relationship is not maintained duringcondyle structural relationship is not maintained during
translation, reciprocal clicking is present.translation, reciprocal clicking is present.
• Disc displacement without reductionDisc displacement without reduction – Altered– Altered
Disc-condyle relationship is maintained duringDisc-condyle relationship is maintained during
translation.translation.
• TMJ HypermobilityTMJ Hypermobility – Excessive disc / condylar– Excessive disc / condylar
translation well beyond the eminence.translation well beyond the eminence.
• DislocationDislocation – Condyle positioned anterior to the– Condyle positioned anterior to the
articular eminence and unable to return to a closedarticular eminence and unable to return to a closed
positioned.positioned.

• SynovitisSynovitis – Inflammation of the synovial lining of the TMJ– Inflammation of the synovial lining of the TMJ
• CapsulitisCapsulitis–Inflammation of the joint capsule–Inflammation of the joint capsule
• OsteoarthosisOsteoarthosis–Degenerative non-inflammatory condition of the joint–Degenerative non-inflammatory condition of the joint
characterized by structural change of the joint surface.characterized by structural change of the joint surface.
• OsteoarthritisOsteoarthritis–Degenerative condition accompanied by secondary–Degenerative condition accompanied by secondary
inflammation.inflammation.
• PolyarthiridesPolyarthirides–Arthitis caused by generalized systemic polyarthritis.–Arthitis caused by generalized systemic polyarthritis.
• AnkylosisAnkylosis–Restricted mandibular movement with deviation to the affected–Restricted mandibular movement with deviation to the affected
side on opening.side on opening.
• Fibrous ankylosisFibrous ankylosis – Ankylosis produced by adhesions within the TMJ.– Ankylosis produced by adhesions within the TMJ.
• Bony ankylosisBony ankylosis – Union of bones of the TMJ caused by proliferation of– Union of bones of the TMJ caused by proliferation of
bone cells resulting in complete immobility of the joint.bone cells resulting in complete immobility of the joint.

• Treatment of joint disordersTreatment of joint disorders ––
• Patient’s educationPatient’s education
• Pain free dietPain free diet
• Therapeutic exercises to rehabilitate the jointTherapeutic exercises to rehabilitate the joint
• Anti-inflammatory drugs &muscle relaxantsAnti-inflammatory drugs &muscle relaxants
• Physical therapyPhysical therapy ––
• Heat / ice massageHeat / ice massage
• Gentle range of motion exercises with in the pain tolerance.( 6Gentle range of motion exercises with in the pain tolerance.( 6
times a day for 30-60 secs )times a day for 30-60 secs )
• Joint shouldn’t hurt more than 10mins after exerciseJoint shouldn’t hurt more than 10mins after exercise
• Night time splint -reduces forces on the joint.Night time splint -reduces forces on the joint.

• Night guard, controls parafunctional habit, temporary stabilizes an unevenNight guard, controls parafunctional habit, temporary stabilizes an uneven
occlusion – allows the joint to rest.occlusion – allows the joint to rest.
• Should have a flat plane .Should have a flat plane .
• Soft night guard is given for children with developing occlusion / mixedSoft night guard is given for children with developing occlusion / mixed
dentition.dentition.
•

• Diagnosis for OsteoporosisDiagnosis for Osteoporosis
• Adults patients particularly females between 45Adults patients particularly females between 45
– 50yrs (post – menopausal women) have a high– 50yrs (post – menopausal women) have a high
incidence of osteopenia (asymptomatic low boneincidence of osteopenia (asymptomatic low bone
mass) or osteoporosis (symptomatic low bonemass) or osteoporosis (symptomatic low bone
mass).mass).
• WHO defines.WHO defines.
• OsteopeniaOsteopenia as bone mass 1 to 2.5 standardas bone mass 1 to 2.5 standard
deviations (SD) below young adult mean (YAM)deviations (SD) below young adult mean (YAM)

• Bone mineral density (BMD) measurements of adult womenBone mineral density (BMD) measurements of adult women
over age of 50 indicated that 13% to 18% had osteoporosis, 37over age of 50 indicated that 13% to 18% had osteoporosis, 37
to 50% had osteopenia.to 50% had osteopenia.
• So when evaluating adults for surgical procedures orSo when evaluating adults for surgical procedures or
orthodontics, a BONE METABOLIC ASSESSMENT is anorthodontics, a BONE METABOLIC ASSESSMENT is an
essential part of diagnosis.essential part of diagnosis.
• Treatment of osteoporosis is problematic during orthodonticTreatment of osteoporosis is problematic during orthodontic
therapy because drugs that inhibit bone resorptiontherapy because drugs that inhibit bone resorption
(Bisphosphonates, Calcitonin) Estrogen Replacement Therapy(Bisphosphonates, Calcitonin) Estrogen Replacement Therapy
(ERT) may disturb bone remodeling(ERT) may disturb bone remodeling

• Oral Manifestations of OsteoporosisOral Manifestations of Osteoporosis
• Osteoporosis is a systemic deterioration of theOsteoporosis is a systemic deterioration of the
skeletal system with following dentalskeletal system with following dental
manifestations.manifestations.
• Decreased edentulous ridge heightDecreased edentulous ridge height
• Decreased posterior maxillary arch widthDecreased posterior maxillary arch width
• Progressive alveolar bone lossProgressive alveolar bone loss
• Loss of attachment and gingival recessionLoss of attachment and gingival recession
• Loss of teethLoss of teeth

• Effects of Estrogen Replacement Therapy:Effects of Estrogen Replacement Therapy:
• ERTERT has variety of oral health benefits, including ahas variety of oral health benefits, including a
decreased in loss of periodontal attachments and greaterdecreased in loss of periodontal attachments and greater
retention of teeth during post – menopausal period.retention of teeth during post – menopausal period.
• Once the negative calcium balance in stabilized, patientsOnce the negative calcium balance in stabilized, patients
with osetoporosis are excellent candidate for orthodontics andwith osetoporosis are excellent candidate for orthodontics and
other bone manipulative therapy.other bone manipulative therapy.
• After osseous structures of jaw are enhanced, treatmentAfter osseous structures of jaw are enhanced, treatment
planning is directed towards optimal function loading to avoidplanning is directed towards optimal function loading to avoid
disuse atropy of alveolar process through implants, by fixeddisuse atropy of alveolar process through implants, by fixed
prosthosis after orthodontic repositioningprosthosis after orthodontic repositioning

GOAL OF ORTHODONTICGOAL OF ORTHODONTIC
TREATMENTTREATMENT
• Since the adult differs in many respects from the adolescent andSince the adult differs in many respects from the adolescent and
exhibits limitations, the goal for adult orthodontics would beexhibits limitations, the goal for adult orthodontics would be
different from that of the adolescent.different from that of the adolescent.
• According toAccording to ACKERMANACKERMAN, adult orthodontics is, adult orthodontics is
concerned with a striking balance between “achieving optimalconcerned with a striking balance between “achieving optimal
proximal and occlusal contacts of the teeth, acceptableproximal and occlusal contacts of the teeth, acceptable
dentofacial esthetics, normal function and reasonable stability”.dentofacial esthetics, normal function and reasonable stability”.
• Jackson’s TriadJackson’s Triad of traditional objectives (ie) esthetics,of traditional objectives (ie) esthetics,
function and structural balance are neither realistic nor alwaysfunction and structural balance are neither realistic nor always
necessary for all adult patients. Class I occlusal goals can benecessary for all adult patients. Class I occlusal goals can be
considered over treatment for patients under multiple providerconsidered over treatment for patients under multiple provider
group.group.

Adult orthodontic treatmentAdult orthodontic treatment
objectivesobjectives
• Dentofacial estheticsDentofacial esthetics
• Stomatognathic functionStomatognathic function
• StabilityStability
• Normal occlusionNormal occlusion

Additional AOT objectivesAdditional AOT objectives
• Parallelism of abutment teethParallelism of abutment teeth
• Most favorable distribution of teethMost favorable distribution of teeth
• Redistribution of occlusal & incisal forcesRedistribution of occlusal & incisal forces
• Adequate embrasure space & proper tooth positionAdequate embrasure space & proper tooth position
• Adequate occlusal landmark relationshipsAdequate occlusal landmark relationships
• Better lip competency & supportBetter lip competency & support
• Improved crown/root ratioImproved crown/root ratio
• Improved self-maintenance of periodontal health.Improved self-maintenance of periodontal health.

Parallelism of abutment teethParallelism of abutment teeth
• Abutment teeth-parallelAbutment teeth-parallel
• Permit-easy insertion ofPermit-easy insertion of
replacementsreplacements
• Allow –restorationsAllow –restorations
• Better prognosisBetter prognosis
• Better PDL response.Better PDL response.

Most favorable distribution ofMost favorable distribution of
teethteeth
• Distributed evenly-replacementsDistributed evenly-replacements
• To establish normal occlusion.To establish normal occlusion.

Redistribution of occlusal &Redistribution of occlusal &
incisal forces.incisal forces.
• Cases with significant bone loss(60-70%)Cases with significant bone loss(60-70%)
• To maintain occlusal vertical dimensionTo maintain occlusal vertical dimension

Adequate embrasure spaceAdequate embrasure space
&proper root position.&proper root position.
• Better PDL healthBetter PDL health
• Helps in interproximal cleaningHelps in interproximal cleaning
• Placement of restorative material.Placement of restorative material.

Adequate occlusal landmarkAdequate occlusal landmark
relationshipsrelationships
• Transverse dimension – difficult to correctTransverse dimension – difficult to correct

Better lip competency & supportBetter lip competency & support
• In case of anterior restoration-retractionsIn case of anterior restoration-retractions
• Inadequate support-change in anteroposterior &verticalInadequate support-change in anteroposterior &vertical
position of upper lip & increase in wrinkling.position of upper lip & increase in wrinkling.

Improved crown/root rationImproved crown/root ration
• In case of bone lossIn case of bone loss
• Reduced crown/root ratioReduced crown/root ratio
• Can be corrected by reducing the clinical crown.Can be corrected by reducing the clinical crown.

Better self maintenance of PDLBetter self maintenance of PDL
healthhealth
Teeth should be positioned properly
over basal bone
Improved self maintainace of PDL
health occurs with proper tooth position

Esthetic & functionalEsthetic & functional
improvement.improvement.
Should provide acceptable dentofacial esthetics
Improved muscle function
Normal speech & masticatory function

• LIMITATIONS OF TREATMENT IN ADULTSLIMITATIONS OF TREATMENT IN ADULTS
• There are two categories of factors:-There are two categories of factors:-
• (a) INTRINSIC(a) INTRINSIC -- BIOLOGICALBIOLOGICAL
• (B) EXTRINSIC(B) EXTRINSIC -- BIOMECHANICALBIOMECHANICAL
SYSTEMSSYSTEMS
• The marked intrinsic limitation is the lack of growth inThe marked intrinsic limitation is the lack of growth in
adults; skeletal discrepancies can therefore be corrected byadults; skeletal discrepancies can therefore be corrected by
Orthognathic surgery. The orthodontic treatment is limited toOrthognathic surgery. The orthodontic treatment is limited to
tooth movement and related modeling of the alveolar processtooth movement and related modeling of the alveolar process
only. Since orthodontic tooth movement is a result of cellularonly. Since orthodontic tooth movement is a result of cellular
reaction to a mechanical stimulus, the cellular response may varyreaction to a mechanical stimulus, the cellular response may vary
with the health and age of the individualwith the health and age of the individual

• Other Intrinsic FactorsOther Intrinsic Factors
PeriodontiumPeriodontium
• The primary tissue to be influenced by the mechanical forces applied toThe primary tissue to be influenced by the mechanical forces applied to
the teeth in the PDL. According tothe teeth in the PDL. According to NortonNorton, insufficient source of, insufficient source of
progenitors cells may be due to vascularity with increasing age. Insufficientprogenitors cells may be due to vascularity with increasing age. Insufficient
source of preosteoblast account for the delayed response to mechanicalsource of preosteoblast account for the delayed response to mechanical
stimulus.stimulus.
Alveolar boneAlveolar bone
• StructureStructure:: Orthodontic tooth movement as a result of bone modeling andOrthodontic tooth movement as a result of bone modeling and
remodeling also depends greatly on age related changes of the skeleton.remodeling also depends greatly on age related changes of the skeleton.
Cortical bone becomes denser while the spongy bone reduces with age andCortical bone becomes denser while the spongy bone reduces with age and
the structure of bone changes from that of a honeycomb to a network.the structure of bone changes from that of a honeycomb to a network.
PathologyPathology : Apical displacement of the marginal bone level is a local factor: Apical displacement of the marginal bone level is a local factor
that influences the biological backgrounds for tooth movement in adults. Thethat influences the biological backgrounds for tooth movement in adults. The
marginal bone loss is age related but is also the result of progressivemarginal bone loss is age related but is also the result of progressive
periodontal disease.periodontal disease.
TeethTeeth :: Adults are also more likely to have missing teeth, teeth reduced inAdults are also more likely to have missing teeth, teeth reduced in
dimension due to attrition as well as teeth with large restorationsdimension due to attrition as well as teeth with large restorations

• Lace like BoneLace like Bone
patternpattern
Honeycomb Bone patternHoneycomb Bone pattern

• Without Marginal Bone LossWithout Marginal Bone Loss • With Marginal Bone LossWith Marginal Bone Loss

• BIOMECHANICAL CONSIDERATIONS IN ADULTBIOMECHANICAL CONSIDERATIONS IN ADULT
• (Lindauer JS. Rebellato J), (Dent Clin North Am 1996 : 40 :(Lindauer JS. Rebellato J), (Dent Clin North Am 1996 : 40 :
811 – 836.)811 – 836.)
• Orthodontic treatment in the adult must be planned without theOrthodontic treatment in the adult must be planned without the
expectation that growth or any changes in jaw relationships willexpectation that growth or any changes in jaw relationships will
compensate for interarch discrepancies. A precise biomechanicalcompensate for interarch discrepancies. A precise biomechanical
control of tooth movement is necessary to achieve correction ofcontrol of tooth movement is necessary to achieve correction of
malocclusion in all 3 dimensions.malocclusion in all 3 dimensions.
• The forces used in the adults should be at aThe forces used in the adults should be at a lower levellower level thanthan
those used in children. The initial forces should further be keptthose used in children. The initial forces should further be kept
low because the immediate pool of progenitor cells available forlow because the immediate pool of progenitor cells available for
resorption are low.resorption are low.
• In adults with periodontal involvement where bone has beenIn adults with periodontal involvement where bone has been
lost, PDL are decreases with the results that the same forcelost, PDL are decreases with the results that the same force
against the crown would produce greater pressure in the PDL.against the crown would produce greater pressure in the PDL.
The absolute magnitude of force must therefore beThe absolute magnitude of force must therefore be
reducedreduced..

• Marginal bone loss results inMarginal bone loss results in
CRES (b) being displacedCRES (b) being displaced
apically. Magnituide of theapically. Magnituide of the
tipping moment is the producttipping moment is the product
of force and distance (point ofof force and distance (point of
force application to the CRES).force application to the CRES).
• Since the CRES hasSince the CRES has
moved apically greater will bemoved apically greater will be
the tipping moment for samethe tipping moment for same
force, so a counter vailingforce, so a counter vailing
COUPLE is necessary to affectCOUPLE is necessary to affect
BODILY movement.BODILY movement.
• Force levels should beForce levels should be
decreased but the magnitude ofdecreased but the magnitude of
the couple applied to counteractthe couple applied to counteract
the tendency to tip should notthe tendency to tip should not
be decreased proportionally.be decreased proportionally.

• Selection of MechanicsSelection of Mechanics
• The appliance should produce a controlled and constant forceThe appliance should produce a controlled and constant force
system in all three planes to reader a low lead deflection ratesystem in all three planes to reader a low lead deflection rate
possiblepossible
• Vertical control and facial profileVertical control and facial profile
• Maintaining vertical control and facial profile is very important inMaintaining vertical control and facial profile is very important in
treating adult patients. A child tolerates extrusive toothtreating adult patients. A child tolerates extrusive tooth
movement better since condylar growth and verticalmovement better since condylar growth and vertical
development of the alveolar process during child hood permitdevelopment of the alveolar process during child hood permit
such tooth movement. In contrast, any extrusive movement, ofsuch tooth movement. In contrast, any extrusive movement, of
the posterior teeth in the adult will lead to an opening of the bitethe posterior teeth in the adult will lead to an opening of the bite
through backward rotation of the mandible resulting in anthrough backward rotation of the mandible resulting in an
increased facial height and overjet.increased facial height and overjet.
• Extrusion of incisors can be undersirable since the majority ofExtrusion of incisors can be undersirable since the majority of
patients suffering from advanced periodontal disease havepatients suffering from advanced periodontal disease have
extruded and spaced maxillary teeth. Such patients needextruded and spaced maxillary teeth. Such patients need
intrusion and retraction.intrusion and retraction.

Loss of verticalLoss of vertical
controlcontrol
• Unintentional extrusion isUnintentional extrusion is
possible with both fixed andpossible with both fixed and
removable appliance. Accordingremovable appliance. According toto
BurstoneBurstone, such loss of vertical, such loss of vertical
control is possible in a number ofcontrol is possible in a number of
instances ofinstances of fixed appliancesfixed appliances
therapy such as.therapy such as.
• Tip back bendTip back bend
• Incorrect bracket positioningIncorrect bracket positioning
• Excessive forceExcessive force
• Straight wire levelingStraight wire leveling
• Anterior root correctionAnterior root correction
•

• AJO 1989AJO 1989
• Ronas, Kleinent & Melson B & BurstoneRonas, Kleinent & Melson B & Burstone
• Force system developed by `V` Bends in an elastic Orthodontic wireForce system developed by `V` Bends in an elastic Orthodontic wire
• Burstone indicated a number of examples related to fixed appliances that leadBurstone indicated a number of examples related to fixed appliances that lead
to loss of vertical control (or) untoward extrusive effectsto loss of vertical control (or) untoward extrusive effects
• TIPBACK BENDTIPBACK BEND::
• Any major `V` Bend will result in the development of vertical forces if theAny major `V` Bend will result in the development of vertical forces if the
bends are not localized exactly at the center between two tooth unitsbends are not localized exactly at the center between two tooth units
• It produces Extrusion the vertical forces are closely related to the degree ofIt produces Extrusion the vertical forces are closely related to the degree of
bending & degree of eccentricity of bend.bending & degree of eccentricity of bend.
• INCORRECT BRACKET POSTIONINGINCORRECT BRACKET POSTIONING..
• A difference in Orientation (or) cant can act as `` shape producing a changeA difference in Orientation (or) cant can act as `` shape producing a change
in the level of the occlusal plane.in the level of the occlusal plane.
• ESTHETIC BENDESTHETIC BEND
• Combination `V` bend & step bend high vertical forces produced. Teeth willCombination `V` bend & step bend high vertical forces produced. Teeth will
cut be intruded at this force level. Only extrusion takes placecut be intruded at this force level. Only extrusion takes place

• Factor in selection of treatment planFactor in selection of treatment plan..
• Existing oral pathologyExisting oral pathology
• Skeletal relationshipSkeletal relationship
• Biological considerationsBiological considerations
• Therapeutical approaches availableTherapeutical approaches available
• Extraction (vs) Non extraction therapyExtraction (vs) Non extraction therapy
• Anchorage requirementsAnchorage requirements
• Missing teeth (Dental mutilation)Missing teeth (Dental mutilation)

• Existing oral pathologyExisting oral pathology : include recurrent decay, restorative: include recurrent decay, restorative
failures, root decay with pulpal involvement periodontal bonefailures, root decay with pulpal involvement periodontal bone
loss, TMJ symptoms and retained roots. These conditionsloss, TMJ symptoms and retained roots. These conditions
should be treated first before proceedings to orthodontics withshould be treated first before proceedings to orthodontics with
a multi-disciplinary approach.a multi-disciplinary approach.
• Skeletal RelationshipsSkeletal Relationships : No growth with minimal skeletal: No growth with minimal skeletal
adaptability. Therefore surgical procedures are frequentlyadaptability. Therefore surgical procedures are frequently
required to correct moderate to severe skeletal disharmonies.required to correct moderate to severe skeletal disharmonies.
• Biological ConsiderationsBiological Considerations :: Neuromuscular maturityNeuromuscular maturity ––
mechanical options for an adult are limited because of lack ofmechanical options for an adult are limited because of lack of
neuromuscular adaptability. There is a tendency towardsneuromuscular adaptability. There is a tendency towards
iatrogenic transitional occlusal trauma, coinciding withiatrogenic transitional occlusal trauma, coinciding with
orthodontic occlusal changes.orthodontic occlusal changes. Periodontal susceptibilityPeriodontal susceptibility ––
higher degree of bone loss as result of periodontal disease canhigher degree of bone loss as result of periodontal disease can
be evidenced during orthodontic therapy.be evidenced during orthodontic therapy.

• Therapeutic approaches availableTherapeutic approaches available ––
• Tooth MovementTooth Movement : most of them require tooth moving forces: most of them require tooth moving forces
• OrthopedicsOrthopedics : not effective: not effective
• Orthognathic surgeryOrthognathic surgery : needed in 10 to 20% of the adult: needed in 10 to 20% of the adult
patients.patients.
• Restorative dentistryRestorative dentistry : frequently required.: frequently required.
• Extraction (vs) Non Extraction TherapyExtraction (vs) Non Extraction Therapy : Classical 4: Classical 4
premolars extraction to resolve crowding rarely done .upperpremolars extraction to resolve crowding rarely done .upper
premolars extraction alone is a common alternative..premolars extraction alone is a common alternative..

• Anchorage requirementsAnchorage requirements :: Adults have greaterAdults have greater
anchorage potential because of completely erupted 1st,anchorage potential because of completely erupted 1st,
and 2nd molars as well as accentuated mesial driftand 2nd molars as well as accentuated mesial drift
particularly in the mandibular arch. On the other handparticularly in the mandibular arch. On the other hand
40% of the adults patient are partially edentulous.40% of the adults patient are partially edentulous.
• Implants for orthodontic anchorageImplants for orthodontic anchorage plays anplays an
important role in their treatment.important role in their treatment. (BJO 2002, VOL 29,(BJO 2002, VOL 29,
239-245)239-245) (Ismail and Johal-UK(Ismail and Johal-UK) Osseo integrated) Osseo integrated
implants may be used for direct as well as indirectimplants may be used for direct as well as indirect
anchorage.anchorage.

• Direct anchorageDirect anchorage utilizes forces from actual implantutilizes forces from actual implant
which takes the place of a missing tooth and eventuallywhich takes the place of a missing tooth and eventually
supports a dental restorations.supports a dental restorations.
• Indirect anchorageIndirect anchorage uses the implants to stabilizeuses the implants to stabilize
specific dental units to which clinical forces are thenspecific dental units to which clinical forces are then
applied. Suchapplied. Such MID PALATAL FIXTURESMID PALATAL FIXTURES are theare the
ONPLANTS and ORTHOPLANTS which are placedONPLANTS and ORTHOPLANTS which are placed
solely for orthodontic purposes in adults.solely for orthodontic purposes in adults. ((JCO-2000-JCO-2000-
july,Celenza and Hochman)july,Celenza and Hochman)

• Onplants were introduced byOnplants were introduced by
• BLOCKBLOCK && HOFEMANHOFEMAN in 1995, made ofin 1995, made of
titanium and consist of base of 10mm and 2mmtitanium and consist of base of 10mm and 2mm
height with one side smooth and other sideheight with one side smooth and other side
textured and coated with hydroxy apatite. Basetextured and coated with hydroxy apatite. Base
has internal thread for screwing transgingivalhas internal thread for screwing transgingival
abutment to which force is applied.abutment to which force is applied.
• Site is surgically exposed and coated surface isSite is surgically exposed and coated surface is
placed close to the bone.placed close to the bone.
• After 6 – 8 weeks the base is exposed andAfter 6 – 8 weeks the base is exposed and
transgingival abutment is placed and loaded.transgingival abutment is placed and loaded.

• Adult patients requiring intrusion of molars to controlAdult patients requiring intrusion of molars to control
Skeletal – Open bite are the apt candidates forSkeletal – Open bite are the apt candidates for SkeletalSkeletal
Anchorage System MIKAKO,Anchorage System MIKAKO,
SUGAWARA,MITRA ( AJO 1999; 115: 166-74)SUGAWARA,MITRA ( AJO 1999; 115: 166-74)
• Titanium miniplates were fixed at the buccal corticalTitanium miniplates were fixed at the buccal cortical
bone around the apical regions of 6,7 on both side.bone around the apical regions of 6,7 on both side.
Elastic threads were used as a source of orthodonticElastic threads were used as a source of orthodontic
force to reduce excessive (3 to 5mm) molar height. Theforce to reduce excessive (3 to 5mm) molar height. The
system was very effective.system was very effective.
• BIOSBIOS (Glaatzmier)(Glaatzmier) EJO 18 : 1996 465 – 469EJO 18 : 1996 465 – 469) is) is
designed to provide anchoring functions in adults anddesigned to provide anchoring functions in adults and
adolescent and then be resorbed with out foreign bodyadolescent and then be resorbed with out foreign body
reactions. Secondary operations for removal at thereactions. Secondary operations for removal at the
conclusion of orthodontic treatment is not needed. Itconclusion of orthodontic treatment is not needed. It
resorbs in 9 to 12 months.resorbs in 9 to 12 months.www.indiandentalacademy.com

• (7)(7) Missing teeth (Dental mutilationsMissing teeth (Dental mutilations))
• In adults, most of these spaces cannot beIn adults, most of these spaces cannot be
closed without a prostheses either a temporaryclosed without a prostheses either a temporary
tooth replacement during FA therapy or fixedtooth replacement during FA therapy or fixed
prostheses later. Implants have become a reliableprostheses later. Implants have become a reliable
alternative.alternative.
• Therefore a multidiscipilinary team approach isTherefore a multidiscipilinary team approach is
required for their comprehensive rehabilitations.required for their comprehensive rehabilitations.

Treatment for adultsTreatment for adults
• proffit -proffit -
– Younger adults(20-35yrs)Younger adults(20-35yrs)
– Older group(40-50yrs)Older group(40-50yrs)
• Adjunctive orthodontic treatmentAdjunctive orthodontic treatment
• Comprehensive orthodontic treatmentComprehensive orthodontic treatment

COMPREHENSIVE TREATMENT FORCOMPREHENSIVE TREATMENT FOR
ADULTSADULTS
• Comprehensive orthodontic treatment aims atComprehensive orthodontic treatment aims at
making the patient’s occlusion as ideal asmaking the patient’s occlusion as ideal as
possible, repositioning all or nearly all the teethpossible, repositioning all or nearly all the teeth
in the process.in the process.
• TheThe ideal timeideal time for comprehensive orthodonticfor comprehensive orthodontic
treatment is duringtreatment is during adolescenceadolescence, when the, when the
succedaneous teeth have just erupted, somesuccedaneous teeth have just erupted, some
vertical and antero posterior growth of the jawsvertical and antero posterior growth of the jaws
remains and the social adjustment toremains and the social adjustment to
orthodontic treatment is not a great problem.orthodontic treatment is not a great problem.

• Comprehensive treatment is also possible forComprehensive treatment is also possible for
adults, but it poses some special problems thatadults, but it poses some special problems that
do not exist for younger patients.do not exist for younger patients.
• The following considerations should be kept inThe following considerations should be kept in
mind while treating adultsmind while treating adults
• Lack of growthLack of growth
• Heightened possibility of periodontal diseaseHeightened possibility of periodontal disease
• Different motivations for seeking orthodonticDifferent motivations for seeking orthodontic
treatment.treatment.

• While treating adultsWhile treating adults
• Appliance should beAppliance should be simplesimple in order to elicit maximum patientin order to elicit maximum patient
cooperationcooperation
• Appliance should exertAppliance should exert llight forcesight forces for best physiologicalfor best physiological
response.response.
• Appliance should beAppliance should be long actinglong acting to decrease the number ofto decrease the number of
appointments.appointments.
• Appliance should beAppliance should be invisibleinvisible asas possiblepossible(plastic, ceramic(plastic, ceramic
brackets, fixed lingual appliances)brackets, fixed lingual appliances)
• Appliance should beAppliance should be better retainedbetter retained (fixed)(fixed)
• Adult treatment mechanics need not differ from theAdult treatment mechanics need not differ from the
standard technique; they are modified only to meet specificstandard technique; they are modified only to meet specific
treatment requirements. Simplicity with maximum controltreatment requirements. Simplicity with maximum control
is the by word.is the by word.
• Comprehensive orthodontic treatment implies an effort to makeComprehensive orthodontic treatment implies an effort to make
the patient’s occlsion as ideal as possible by repositioningthe patient’s occlsion as ideal as possible by repositioning nearlynearly
all the teethall the teeth in the process.in the process.

• Motivations for adult treatmentMotivations for adult treatment: The major: The major
motivations for adults to undergo comprehensivemotivations for adults to undergo comprehensive
treatment is due to psychological reasons. Though atreatment is due to psychological reasons. Though a
small percentage of them may seek complete treatmentsmall percentage of them may seek complete treatment
for periodontal and restorative needs.for periodontal and restorative needs.
• Internal motivationsInternal motivations : if the individual wants to: if the individual wants to
improve his appearance or function of teeth and soimprove his appearance or function of teeth and so
seeks treatment – he is said to be internally motivatedseeks treatment – he is said to be internally motivated
and is expected to respond well psychologicallyand is expected to respond well psychologically
• External motivationExternal motivation : an individual whose motivations: an individual whose motivations
is the urging ofis the urging of
• others he said is to be externally motivated andothers he said is to be externally motivated and
has a complex set of unrecognized expectation forhas a complex set of unrecognized expectation for
orthodontic treatment.orthodontic treatment.

• COMPREHENSIVE TREATMENTCOMPREHENSIVE TREATMENT
• STAGE 1:STAGE 1: DISEASE CONTROLDISEASE CONTROL
• RevaluateRevaluate
• STAGE 2STAGE 2: ESTABLISH OCCLUSION: ESTABLISH OCCLUSION
StabilizeStabilize
• STAGE 3STAGE 3: DEFINITIVE PERIO / RESTORATIVE: DEFINITIVE PERIO / RESTORATIVE
TREATMENTTREATMENT
• STAGE 4STAGE 4 :MAINTENANCE:MAINTENANCE
• HERE ORTHODONTICS IS USED TO ESTABLISHHERE ORTHODONTICS IS USED TO ESTABLISH
OCCLUSION.OCCLUSION.

• Possible tooth movement in adjunctive treatmentPossible tooth movement in adjunctive treatment
• (a)(a) Mesial or distal movements of specific crowns and roots.Mesial or distal movements of specific crowns and roots.
• (b)(b) Correction of axial inclination of drifted teeth.Correction of axial inclination of drifted teeth.
• (c)(c) Correction of buccolingual position of certain teethCorrection of buccolingual position of certain teeth
• (d)(d) Corrections of rotations.Corrections of rotations.
• Intrusion of teeth is avoided as an adjunctive procedureIntrusion of teeth is avoided as an adjunctive procedure
because of the technical difficulties involved and possibility ofbecause of the technical difficulties involved and possibility of
periodontal complications.periodontal complications.
• Excessively extruded teeth are treated by reduction ofExcessively extruded teeth are treated by reduction of
crown height which improves the crown / root ratiocrown height which improves the crown / root ratio..

• Biomechanical considerationsBiomechanical considerations::
• Control of anchorage requires that anchor teeth not beControl of anchorage requires that anchor teeth not be
allowed to tip. This is major reason that adjunctive treatmentallowed to tip. This is major reason that adjunctive treatment
usually requires a fixed appliance.usually requires a fixed appliance.
• EDGEWISE APPLIANCEEDGEWISE APPLIANCE recommended, twin brackets ofrecommended, twin brackets of
0.022 slot dimension are used preferably0.022 slot dimension are used preferably
• Rectangular slot controls bucco – lingual axial inclinationRectangular slot controls bucco – lingual axial inclination
• Twin bracket prevents undesirable rotations and tippingTwin bracket prevents undesirable rotations and tipping
• Larger slot allows the use of stabilizing wires which are stiffer.Larger slot allows the use of stabilizing wires which are stiffer.
• Bracket are placed in an ideal position only on teeth to beBracket are placed in an ideal position only on teeth to be
moved, remaining teeth incorporated in the anchor system andmoved, remaining teeth incorporated in the anchor system and
are bracketed so the archwire slot are closely aligned. Passiveare bracketed so the archwire slot are closely aligned. Passive
engagement of the wires to anchor teeth produce minimalengagement of the wires to anchor teeth produce minimal
disturbance of teeth.disturbance of teeth.

• PERIODONTAL ASPECTS OF ADULTPERIODONTAL ASPECTS OF ADULT
TREATMENTTREATMENT
• There is no contra indications to treating adults withThere is no contra indications to treating adults with
periodontal disease long as the disease is under controlperiodontal disease long as the disease is under control
• Three risk groups are identified in the populationThree risk groups are identified in the population
– Those with rapid progression (10%)Those with rapid progression (10%)
– Those with moderate progression (80%)Those with moderate progression (80%)
– Those with no progression despite the presence of gingivalThose with no progression despite the presence of gingival
inflammation (10%).inflammation (10%).

• MINIMAL PERIODONTAL INVOLVEMENTMINIMAL PERIODONTAL INVOLVEMENT::
• Bacterial plaque being the main etiological factor inBacterial plaque being the main etiological factor in
periodontal breakdown, patient undergoing orthodonticperiodontal breakdown, patient undergoing orthodontic
especially adults must take extra careespecially adults must take extra care
• For adults orthodontic patient’s GINGIVALFor adults orthodontic patient’s GINGIVAL
RECESSION is to be prevented rather than to tryRECESSION is to be prevented rather than to try
correcting it later. Creation of “BLACK TRIANGLES”correcting it later. Creation of “BLACK TRIANGLES”
between maxillary central incisors by gingival recessionbetween maxillary central incisors by gingival recession
after periodontal loss is practically distressing.after periodontal loss is practically distressing.
• According to the present concept, gingival recessionAccording to the present concept, gingival recession
occurs secondary to alveolar boneoccurs secondary to alveolar bone dehiscence; ifdehiscence; if
overlying tissues are stressed. Stress can be due tooverlying tissues are stressed. Stress can be due to

• Tooth brush traumaTooth brush trauma
• Plaque induced inflammationPlaque induced inflammation
• Stretching and thinning of gingiva created byStretching and thinning of gingiva created by
labial tooth movementlabial tooth movement
• FREE GINGIVAL GRAFT is helpful in adultFREE GINGIVAL GRAFT is helpful in adult
patients to control inflammation beforepatients to control inflammation before
orthodontic treatment begins. and in whom archorthodontic treatment begins. and in whom arch
expansion is indicated for aligning incisors.expansion is indicated for aligning incisors.

• MODERATE PERIODONTALMODERATE PERIODONTAL
INVOLVEMENT:INVOLVEMENT:
• Disease controlDisease control: Preliminary periodontal: Preliminary periodontal
therapy is preformed which includes meticuloustherapy is preformed which includes meticulous
root surface preparative and curettage androot surface preparative and curettage and
patient kept under observation to watch whetherpatient kept under observation to watch whether
the disease is controlled.the disease is controlled.
• Treatment procedures likeTreatment procedures like osseousosseous
contouring (or) repositioned flapscontouring (or) repositioned flaps toto
compensate areas of gingival recession are bestcompensate areas of gingival recession are best
deferred until final occlusal relationships havedeferred until final occlusal relationships have
been established.been established.

• PERIODONTAL MAINTENANCEPERIODONTAL MAINTENANCE
• Fully boned orthodontic appliance is recommended. SteelFully boned orthodontic appliance is recommended. Steel
ligatures (or) self ligating bracket are preferred for periodontallyligatures (or) self ligating bracket are preferred for periodontally
involved patients rather than elastomeric rings to retain archinvolved patients rather than elastomeric rings to retain arch
wires because such patient have higher level of micro organismswires because such patient have higher level of micro organisms
in gingival plaque.in gingival plaque.
• During comprehensive treatment, patient with moderalteDuring comprehensive treatment, patient with moderalte
periodontal problems should be on a maintanence schedule (2 –periodontal problems should be on a maintanence schedule (2 –
4 months interval)4 months interval)
• HYGIENE AIDS: Electric tooth brushes, rubber interdentalHYGIENE AIDS: Electric tooth brushes, rubber interdental
stimulators, proximal brushes and adjunctive chemicals (eg.stimulators, proximal brushes and adjunctive chemicals (eg.
Chlorhexidine) should be considered.Chlorhexidine) should be considered.

• SEVERE PERIODONTAL INVOLVEMENTSEVERE PERIODONTAL INVOLVEMENT::
• The general approach in the same as outlined earlier butThe general approach in the same as outlined earlier but
• 1. Periodontal maintenance schedule is at more1. Periodontal maintenance schedule is at more
frequent intervals (every 4 to 6 weeks)frequent intervals (every 4 to 6 weeks)
• 2. Orthodontic goals modified and forces kept to2. Orthodontic goals modified and forces kept to
absolute minimum of because of the reduced area ofabsolute minimum of because of the reduced area of
PDLPDL
• Muco-gingival CorrectionsMuco-gingival Corrections
• Attention if paid to 3 factors prior to orthodonticAttention if paid to 3 factors prior to orthodontic
therapy can make the treatment easier and moretherapy can make the treatment easier and more
predictable.predictable.
• Reduction of thick tissue either distal to the terminalReduction of thick tissue either distal to the terminal
tooth or in edentulous areastooth or in edentulous areas
• Inadequate bands of keratinized tissues.Inadequate bands of keratinized tissues.www.indiandentalacademy.com

• Frenal attachmentsFrenal attachments
• Thick tissue gets bunched up and can slow down toothThick tissue gets bunched up and can slow down tooth
movement considerably. While uprighting a second or a thirdmovement considerably. While uprighting a second or a third
molar, the tissue moves coronally on the tooth and amolar, the tissue moves coronally on the tooth and a
pseudopocket develops. This can become a nidus for bacteriapseudopocket develops. This can become a nidus for bacteria
and a potential locus for the apical migration of the attachment.and a potential locus for the apical migration of the attachment.
• If there is a minimal band of keratinized tissue and the rootsIf there is a minimal band of keratinized tissue and the roots
move out of the alveolus, there is bound to be recession.move out of the alveolus, there is bound to be recession.
• Frenal attachements that prevent or slow down toothFrenal attachements that prevent or slow down tooth
movements may be removed during or before tooth movement.movements may be removed during or before tooth movement.
However, if retention is the chief concern, then the removal mayHowever, if retention is the chief concern, then the removal may
be effected at the conclusion of tooth movement.be effected at the conclusion of tooth movement.

• ORTHODONTIC TREATMENT OF PERIODONTALORTHODONTIC TREATMENT OF PERIODONTAL
DEFECTS –(Seminars in orthodontics) vincent kokich -1997DEFECTS –(Seminars in orthodontics) vincent kokich -1997
• Advanced Horizontal Bone Loss:Advanced Horizontal Bone Loss:
• After the treatment has been planned, one of the mostAfter the treatment has been planned, one of the most
important factors that determines the outcome of orthodonticimportant factors that determines the outcome of orthodontic
therapy, is the location of the bands and brackets on the teeth.therapy, is the location of the bands and brackets on the teeth.
• In a periodontaly healthy individual, the position of the bracketIn a periodontaly healthy individual, the position of the bracket
is usually determined by the anatomy of the crown of the tooth.is usually determined by the anatomy of the crown of the tooth.
Anterior brackets should be positioned relative to the incisalAnterior brackets should be positioned relative to the incisal
edges. Posterior bands or brackets are positioned relative to theedges. Posterior bands or brackets are positioned relative to the
marginal ridges. If the incisal edges and marginal ridges are at themarginal ridges. If the incisal edges and marginal ridges are at the
correct level, the CEJs will also be at the same level. Thiscorrect level, the CEJs will also be at the same level. This
relationship will create a flat bony contour between the teeth.relationship will create a flat bony contour between the teeth.
• However, if a patient has underlying periodontal problems andHowever, if a patient has underlying periodontal problems and
significant alveolar bone loss around certain teeth, using thesignificant alveolar bone loss around certain teeth, using the
anatomy of the crown to determine bracket placement isanatomy of the crown to determine bracket placement is
inappropriate.inappropriate.

• The bone level may have receded several millimeters from theThe bone level may have receded several millimeters from the
CEJ. As this occurs, the crown to root ratio will become lessCEJ. As this occurs, the crown to root ratio will become less
favourable. By aligning the crowns of the teeth, the clinician mayfavourable. By aligning the crowns of the teeth, the clinician may
perpetuate tooth mobility by maintaining an unfavourable crownperpetuate tooth mobility by maintaining an unfavourable crown
to root ratio.to root ratio.
• The orthodontist can correct many of these problems byThe orthodontist can correct many of these problems by
using the bone level as a guide to positioning the brackets on theusing the bone level as a guide to positioning the brackets on the
teeth. In these situations, the crowns of the teeth may requireteeth. In these situations, the crowns of the teeth may require
considerable equilibration . If the tooth is vital, the equilibrationconsiderable equilibration . If the tooth is vital, the equilibration
should be performed gradually to allow the pulp to formshould be performed gradually to allow the pulp to form
secondary dentin to insulate the tooth during the requilibrationsecondary dentin to insulate the tooth during the requilibration
process. The goal of equilibration and creative bracketprocess. The goal of equilibration and creative bracket
placement is to provide a more favourable bony architecture asplacement is to provide a more favourable bony architecture as
well as a more favourable crown to root ratio.well as a more favourable crown to root ratio.

• HEMISEPTAL DEFECTHEMISEPTAL DEFECT::
• Adult patients may have marginal ridgeAdult patients may have marginal ridge
discrepancies caused by uneven tooth eruption beforediscrepancies caused by uneven tooth eruption before
orthodontic treatment. When the orthodontistorthodontic treatment. When the orthodontist
encounters marginal ridge discrepancies, the decision asencounters marginal ridge discrepancies, the decision as
to where to place the bracket or band is not determinedto where to place the bracket or band is not determined
by the anatomy of the tooth.by the anatomy of the tooth.
• If the bone level is oriented in the same direction asIf the bone level is oriented in the same direction as
the marginal ridge discrepancy, then leveling thethe marginal ridge discrepancy, then leveling the
marginal ridges will level the bone. However, if themarginal ridges will level the bone. However, if the
bone level is flat between adjacent teeth and thebone level is flat between adjacent teeth and the
marginal ridges are at significantly different levels,marginal ridges are at significantly different levels,
correction of the marginal ridge discrepancycorrection of the marginal ridge discrepancy
orthodontically will produce a hemiseptal defect in theorthodontically will produce a hemiseptal defect in the
bone. This could cause a periodontal pocket betweenbone. This could cause a periodontal pocket between
the two teeth.the two teeth.

• During orthodontic treatment, when teeth areDuring orthodontic treatment, when teeth are
being extruded to level hemiseptal defects, thebeing extruded to level hemiseptal defects, the
patients should be regularly monitored by thepatients should be regularly monitored by the
periodontist. Initially, the hemiseptal defect willperiodontist. Initially, the hemiseptal defect will
have a greater sulcular depth and be morehave a greater sulcular depth and be more
difficult for the patient to clean. As the defect isdifficult for the patient to clean. As the defect is
compensated through tooth extrusion,compensated through tooth extrusion,
interproximal cleaning becomes easier.interproximal cleaning becomes easier.

• Tissue response to various tooth movements.Tissue response to various tooth movements.
• EXTRUSIONEXTRUSION::
• Extrusion or Eruption of a teeth (or) Several teeth along with reduction of theExtrusion or Eruption of a teeth (or) Several teeth along with reduction of the
clinical crown height reduces infrabony defects & decreases product depth.clinical crown height reduces infrabony defects & decreases product depth.
• AJO 1986 TISSUE REACTION OF EXTRUSIVE AND INTRUSIVE FORCESAJO 1986 TISSUE REACTION OF EXTRUSIVE AND INTRUSIVE FORCES
TO TEETH IN ADULT MONKEYS ( BIRTE MELSEN)TO TEETH IN ADULT MONKEYS ( BIRTE MELSEN)
• On histologic section, clear signs of bone deposited during forced Eruption is seenOn histologic section, clear signs of bone deposited during forced Eruption is seen
• INTRUSION:-INTRUSION:-
• INTRUSION OF INCISORS IN ADULT PATIENTS WITH MARGINAL BONEINTRUSION OF INCISORS IN ADULT PATIENTS WITH MARGINAL BONE
LOSSLOSS
• (AJO 1989 MELSON B ET AL(AJO 1989 MELSON B ET AL
• In this study 3 different methods for intrusion were applied. The marginal bone levelIn this study 3 different methods for intrusion were applied. The marginal bone level
approached CEJ in almost all cases. All cases demonstrated root resorption.approached CEJ in almost all cases. All cases demonstrated root resorption.
• The intrusion was best performed whenThe intrusion was best performed when
• Forces were low (5 to 15 gm per tooth ) with line of action of force passing throughForces were low (5 to 15 gm per tooth ) with line of action of force passing through
(or) close to the center of resistance.(or) close to the center of resistance.
• Gingival status was healthy.Gingival status was healthy.
• No interference with perioral function present.No interference with perioral function present.

Adjunctive orthodontic treatmentAdjunctive orthodontic treatment
• DefinitionDefinition :tooth movement carried out to facilitate other:tooth movement carried out to facilitate other
dental procedures necessary to control disease & restoredental procedures necessary to control disease & restore
function.function.
• Uprighting of posterior teethUprighting of posterior teeth
• Forced eruptionForced eruption
• Alignment of anterior teethAlignment of anterior teeth
• Crossbite correctionCrossbite correction

Goals of AOTGoals of AOT
• Facilitate restorative treatmentFacilitate restorative treatment
• Improve PDL healthImprove PDL health
• Favorable crown : rootFavorable crown : root
• ““Goal of AOT is to provide a physiologic occlusion &Goal of AOT is to provide a physiologic occlusion &
facilitate other dental treatment & has little to do withfacilitate other dental treatment & has little to do with
AngleAngle’’s concept of an ideal tooth relationships.s concept of an ideal tooth relationships.””

Principles of AOTPrinciples of AOT
• Diagnostic & treatment planning.Diagnostic & treatment planning.
– Collecting an adequate data base.Collecting an adequate data base.
– Developing a problem list.Developing a problem list.

• Diagnostic recordsDiagnostic records
– OPG.OPG.
– Full mouth IOPAs.Full mouth IOPAs.
– Lateral cephLateral ceph
– photographs.photographs.
– Dental casts.Dental casts.

Biomechanical considerationsBiomechanical considerations
• Characteristics of the orthodontic appliance.Characteristics of the orthodontic appliance.
– Anchorage controlAnchorage control
– 22-slot edgewise appliance with twin brackets22-slot edgewise appliance with twin brackets
– Removable/Fixed appliance.Removable/Fixed appliance.
– Bracket placement-ideal-tooth to be moved.Bracket placement-ideal-tooth to be moved.

Removable appliancesRemovable appliances

Bracket placementBracket placement

Effects of reduced periodontalEffects of reduced periodontal
supportsupport
• Bone supportBone support
• Bone loss-PDL areaBone loss-PDL area
decreasesdecreases
• CR-shifts moreCR-shifts more
appicallyappically

Timing & sequence of treatmentTiming & sequence of treatment
Active diseaseActive disease
Disease controlDisease control
Establish occlusionEstablish occlusion
Definitive restorative RxDefinitive restorative Rx
maintenancemaintenance
Re-evaluate
stabilize

Uprighting posterior teethUprighting posterior teeth
• Treatment planning considerationTreatment planning consideration
– Loss of posterior teethLoss of posterior teeth
– If the 3If the 3rdrd
molar is present?molar is present?
– Uprighting by distal crown/ mesial root movement?Uprighting by distal crown/ mesial root movement?
– Slight extrusion of tipped molar is permissible?Slight extrusion of tipped molar is permissible?

Loss of posterior teethLoss of posterior teeth

Distal crown/ mesial rootDistal crown/ mesial root
movementmovement

Crown: root lengthCrown: root length

Appliances for molar uprightingAppliances for molar uprighting
• Partial fixed appliancePartial fixed appliance
• Active & reactive unitActive & reactive unit
• bonding>bandingbonding>banding

Uprighting a single molarUprighting a single molar
• Distal crown tipping with occlusalDistal crown tipping with occlusal
antagonistantagonist
– Flexible rectangular wire-Flexible rectangular wire-
17x25 NiTi17x25 NiTi
– Anchorage unit-19x25 steelAnchorage unit-19x25 steel
– 17x25 beta-Ti17x25 beta-Ti

Uprighting with minimalUprighting with minimal
extrusionextrusion
• Uprighting with no occlusalUprighting with no occlusal
antagonistantagonist
• ““T-Loop”-17x25 steel/ 19x25T-Loop”-17x25 steel/ 19x25
beta Tibeta Ti

Uprighting of lower molarsUprighting of lower molars
Birte melsen,JCO 1996Birte melsen,JCO 1996
case1
56yrs/M
Missing lower 1st
molar

case1case1

Case 2
42/F
Missing 46

Case 2

Distal jetDistal jet

A simple technique for molarA simple technique for molar
uprighting –E Capelluto,JCO 1996uprighting –E Capelluto,JCO 1996
“MUST”

Final positioning of molar & PMsFinal positioning of molar & PMs
Compressed coil springs
018 steel

Uprighting two molars in theUprighting two molars in the
same quadrant.same quadrant.
• Combination of distal crown & mesial rootCombination of distal crown & mesial root
• No bilateral uprighting - same timeNo bilateral uprighting - same time
• 17x25 Niti17x25 Niti

RetentionRetention
• Fixed bridge-within 6 weeksFixed bridge-within 6 weeks
• Short time-19x25 steel /21x25 beta TiShort time-19x25 steel /21x25 beta Ti
• >few weeks-intermediate splinting>few weeks-intermediate splinting

Forced eruptionForced eruption
• IndicationsIndications
– Defects in cervical 3Defects in cervical 3rdrd
of the rootof the root
– Horizontal / vertical #Horizontal / vertical #
– Internal/external resorptionInternal/external resorption
– DecayDecay
– PDL – diseasePDL – disease
– To obtain good access for endodontic andTo obtain good access for endodontic and
restorative processrestorative process

Forced eruptionForced eruption
• Treatment planningTreatment planning
– Good periapical radiographsGood periapical radiographs
• Periodontal supportPeriodontal support
• Root morphology and positionRoot morphology and position
– Endodontic therapy should be completedEndodontic therapy should be completed

Orthodontic techniqueOrthodontic technique
• Anchor teeth –rigidAnchor teeth –rigid
• Flexible –tooth to be extrudedFlexible –tooth to be extruded
• With / without the use of orthodontic bracketWith / without the use of orthodontic bracket

Alignment of anterior teethAlignment of anterior teeth
• IndicationsIndications
– To improve access & permit placement ofTo improve access & permit placement of
restorationrestoration
– To permit placement of crowns & ponticsTo permit placement of crowns & pontics
– To reposition the closely approximated rootsTo reposition the closely approximated roots
– To place implants.To place implants.

Treatment planningTreatment planning
• Interproximal strippingInterproximal stripping
• Diagnostic setup-very helpfulDiagnostic setup-very helpful

Orthodontic techniqueOrthodontic technique
• Alignment of crowded, rotated & displacedAlignment of crowded, rotated & displaced
incisorsincisors
– Edgewise brackets-canine –canineEdgewise brackets-canine –canine
– Initial wire-light & flexibleInitial wire-light & flexible
– 016 Niti016 Niti
– Crown reductionCrown reduction

Positionining tooth for singlePositionining tooth for single
tooth implantstooth implants
• Missing teeth-implantsMissing teeth-implants
– Space needed for implant, esthetics& the occlusionSpace needed for implant, esthetics& the occlusion
• Space needed for implantsSpace needed for implants
– Narrowest – 4mmNarrowest – 4mm
– 1mm –in b/w implants1mm –in b/w implants
• Contralareral & adjacent teeth –size of the implantContralareral & adjacent teeth –size of the implant

Timing of implant placementTiming of implant placement
• Implants to support restorations should not be placed until all verticalImplants to support restorations should not be placed until all vertical
growth has been completed.growth has been completed.
• Boys-20yrsBoys-20yrs
• Girls-15-17yrs.Girls-15-17yrs.
• For adults-soon after –minimizes bone loss.For adults-soon after –minimizes bone loss.

Case reportsCase reports
• 48yrs/F48yrs/F
• Class II div 1Class II div 1
• Deep biteDeep bite
• Missing12,47,46,45,35,36,37Missing12,47,46,45,35,36,37
Treatment plan: surgical correction
6 implants on 37,26,25,47,46,45
Healing period -4 months
Implant-supported FPD
Uprighting of 3rd
molar + alignment
Same implants-abutments.
Kenji W Higuchi

Case 1Case 1

Case 2Case 2
• 53yrs/M53yrs/M
• Class IIIClass III
• Ant &post crossbitesAnt &post crossbites
• spacingspacing
Treatment plan: 2 implants,35&36
Healing period -4 months
Implant-supported FPD

Case 3Case 3
• 64yrs/F64yrs/F
• Class IClass I
• Impacted canineImpacted canine
• Missing teethMissing teeth
Treatment plan:
Extrusion of impacted canine
1 implant -16
Healing period-6 months
Implant supported FPD-anchorage
Same implant-abutment

Case 3Case 3

Anterior diastema closureAnterior diastema closure
• Loss of posterior teeth, abnormally small teeth, loss of boneLoss of posterior teeth, abnormally small teeth, loss of bone
support-drifting/spacing.support-drifting/spacing.
• Partial closure-composite build ups-permanent retentionPartial closure-composite build ups-permanent retention
• Smaller diastema-removable applianceSmaller diastema-removable appliance
• 016 niti,018 steel with coil springs.016 niti,018 steel with coil springs.

Diastema closureDiastema closure

Crossbite correctionCrossbite correction
Crossbite-functional problem
Ant crossbite -esthetic
Tipped teeth-removable apl
Elastics
Establishing a good overbite
relationship is the key to maintaining
crossbite correction.

SPLINTINGSPLINTING
WHEN TO SPLINT?WHEN TO SPLINT?
• The splinting of mobile teeth is often, of value as a means of stabilization before,The splinting of mobile teeth is often, of value as a means of stabilization before,
during, and after periodontal therapyduring, and after periodontal therapy..
• For most patients, splinting should be considered only after the preliminaryFor most patients, splinting should be considered only after the preliminary
phase of periodontal therapy has been completed.phase of periodontal therapy has been completed.
• Cohen and ChackerCohen and Chacker have noted, "When large areas of attachment apparatushave noted, "When large areas of attachment apparatus
have been destroyed, the artificial support offered by temporary stabilizationhave been destroyed, the artificial support offered by temporary stabilization
may allow a new, healthy tooth-bone relationship to be established.may allow a new, healthy tooth-bone relationship to be established.
• Therefore it would seem advisable that when the treatment plan is beingTherefore it would seem advisable that when the treatment plan is being
formulated the need for stabilization be determined on the basis of the, natureformulated the need for stabilization be determined on the basis of the, nature
and extent of the destructive process present.and extent of the destructive process present.

PRINCIPLES OF SPLINTING:PRINCIPLES OF SPLINTING:
• The main objective of splinting is to decrease movement three-The main objective of splinting is to decrease movement three-
dimensionally.dimensionally.
• This objective often can be met with the proper placement of a cross-archThis objective often can be met with the proper placement of a cross-arch
splint.splint.
• Conversely, unilateral splints that do not cross the midline tend to permitConversely, unilateral splints that do not cross the midline tend to permit
the affected teeth to rotate in a faciolingual direction about a mesio-distalthe affected teeth to rotate in a faciolingual direction about a mesio-distal
linear axis.linear axis.

INDICATIONS FOR SPLINTING:INDICATIONS FOR SPLINTING:
• Splinting is indicated when moderate to advanced mobilities (2 degrees orSplinting is indicated when moderate to advanced mobilities (2 degrees or
more) are present and cannot be treated by any other means.more) are present and cannot be treated by any other means.
• There is no reason for splinting non mobile teeth or teeth with a slight, nonThere is no reason for splinting non mobile teeth or teeth with a slight, non
progressive mobility as a preventive measure.progressive mobility as a preventive measure.
• Splinting should only be used with other necessary measures such as oralSplinting should only be used with other necessary measures such as oral
hygiene instructions, root planing, pocket elimination, and occlusalhygiene instructions, root planing, pocket elimination, and occlusal
adjustment.adjustment.
• When pre-prosthetic surgery or orthodontic measures are called for theyWhen pre-prosthetic surgery or orthodontic measures are called for they
should be completed before splinting whenever possible.should be completed before splinting whenever possible.

• One obvious indication for splinting is when a patient presents with multipleOne obvious indication for splinting is when a patient presents with multiple
teeth that have become mobile as a direct result of gradual alveolar boneteeth that have become mobile as a direct result of gradual alveolar bone
loss, a reduced periodontium.loss, a reduced periodontium.
• A second indication for splinting is when the patient presents with increasedA second indication for splinting is when the patient presents with increased
tooth mobility accompanied by pain or discomfort in the affected teeth.tooth mobility accompanied by pain or discomfort in the affected teeth.
• Splinting may be a way to gain stability, reduce or eliminate the mobility,Splinting may be a way to gain stability, reduce or eliminate the mobility,
and relieve the pain and discomfort.and relieve the pain and discomfort.
• Following loosening of teeth by accidental (or) surgical trauma.Following loosening of teeth by accidental (or) surgical trauma.
• To immobilize excessively mobile teeth so that the patient can chew moreTo immobilize excessively mobile teeth so that the patient can chew more
comfortably.comfortably.
• To avoid dislodging teeth prior to and during re-constructive proceduresTo avoid dislodging teeth prior to and during re-constructive procedures
(Occlusal reconstruction).(Occlusal reconstruction).

• To stabilize teeth in their new positions after orthodontic repositioning.To stabilize teeth in their new positions after orthodontic repositioning.
• As supportive measure to facilitate periodontal therapeutic procedures forAs supportive measure to facilitate periodontal therapeutic procedures for
hypermobile teeth.hypermobile teeth.
CONTRAINDICATIONS FOR SPLINTING:CONTRAINDICATIONS FOR SPLINTING:
• Splinting teeth is not recommended if occlusal stability and optimalSplinting teeth is not recommended if occlusal stability and optimal
periodontal conditions cannot be obtained.periodontal conditions cannot be obtained.
• Any tooth mobility present before treatment must be reduced by means ofAny tooth mobility present before treatment must be reduced by means of
occlusal equilibration combined with periodontal therapy.occlusal equilibration combined with periodontal therapy.
• Otherwise if the tooth involved does not respond, it must be extracted priorOtherwise if the tooth involved does not respond, it must be extracted prior
to proceeding from provisional restorations to definitive treatment.to proceeding from provisional restorations to definitive treatment.
• Insufficient number of firm / sufficiently firm teeth to stabilize mobile teeth.Insufficient number of firm / sufficiently firm teeth to stabilize mobile teeth.

The following qualifications identify an ideal splint :The following qualifications identify an ideal splint : It shouldIt should
• be simple,be simple,
• economic,economic,
• stable and efficient,stable and efficient,
• hygienic,hygienic,
• nonirritating,nonirritating,
• not interfere with treatment,not interfere with treatment,
• esthetically acceptable, andesthetically acceptable, and
• not provoke iatrogenic disease.not provoke iatrogenic disease.

OBJECTIVES OF SPLINTING:OBJECTIVES OF SPLINTING:
• Rest is created for the supporting tissues giving them a favorable climate forRest is created for the supporting tissues giving them a favorable climate for
repair of trauma.repair of trauma.
• Reduction of mobility immediately and hopefully permanently. InReduction of mobility immediately and hopefully permanently. In
particular jiggling movements are reduced or eliminated.particular jiggling movements are reduced or eliminated.
• Redirection of forces - redirected in a more axial direction over all the teethRedirection of forces - redirected in a more axial direction over all the teeth
included in the splint.included in the splint.
• Redistribution of forces - ensures that forces do not exceed the adaptiveRedistribution of forces - ensures that forces do not exceed the adaptive
capacity. Forces/received by one tooth are distributed to a number of teeth.capacity. Forces/received by one tooth are distributed to a number of teeth.
• Restoration of functional stability - functional occlusion stabilizes mobileRestoration of functional stability - functional occlusion stabilizes mobile
abutment teeth.abutment teeth.

• To preserve arch integrity - restores proximal contacts, reducing foodTo preserve arch integrity - restores proximal contacts, reducing food
impaction & consequent break down.impaction & consequent break down.
• To stabilize mobile teeth during surgical, especially during regenerativeTo stabilize mobile teeth during surgical, especially during regenerative
periodontal therapy.periodontal therapy.
• To prevent migration and over eruption.To prevent migration and over eruption.
• Psychologic well being - gives the patient comfort from mobile teeth a sensePsychologic well being - gives the patient comfort from mobile teeth a sense
of well being.of well being.
• Masticatory function is improved.Masticatory function is improved.
• Discomfort and pain are eliminatedDiscomfort and pain are eliminated..

•SURGICALSURGICAL

Meanings of the FaceMeanings of the Face
• ““The face is the area of one’s body that produces the greatestThe face is the area of one’s body that produces the greatest
concern regarding physical attractiveness; it is the individual’sconcern regarding physical attractiveness; it is the individual’s
focal point and the source of vocal and emotionalfocal point and the source of vocal and emotional
communications with others”communications with others”
• Berscheid et al in a survey of over 1000 adults found that peopleBerscheid et al in a survey of over 1000 adults found that people
who were satisfied with their facial features expressed greaterwho were satisfied with their facial features expressed greater
self-confidence.self-confidence.

Meanings of the FaceMeanings of the Face
• Berscheid et alBerscheid et al – the area of greatest dissatisfaction for– the area of greatest dissatisfaction for
subjects in their large sample was the appearance of theirsubjects in their large sample was the appearance of their
teethteeth
• Attractive adults & children are evaluated as moreAttractive adults & children are evaluated as more
successful and more intelligent than are unattractivesuccessful and more intelligent than are unattractive
persons and are viewed as more socially skilled –persons and are viewed as more socially skilled – GRGR
AdamsAdams

Psychosocial characteristics of patients with facialPsychosocial characteristics of patients with facial
deformitiesdeformities
• Children with craniofacial anomalies are more introverted, neurotic andChildren with craniofacial anomalies are more introverted, neurotic and
demonstrate poor self-concept –demonstrate poor self-concept – Perschuk et alPerschuk et al
• Children with Down’s syndrome were rated as being less intelligent,Children with Down’s syndrome were rated as being less intelligent,
less attractive, and less socially acceptable. Postoperative ratings ofless attractive, and less socially acceptable. Postoperative ratings of
these same children were significantly more positive in all threethese same children were significantly more positive in all three
domains –domains – Strauss et alStrauss et al

Psychosocial characteristics of patients with facialPsychosocial characteristics of patients with facial
deformitiesdeformities
• A seriously handicapping orthodontic condition is the one thatA seriously handicapping orthodontic condition is the one that
“severely compromises a person’s physical or emotional health”“severely compromises a person’s physical or emotional health”
–– AL Morris et alAL Morris et al
• Physical compromise – serious problems with breathing,Physical compromise – serious problems with breathing,
speaking, or eating, especially if accompanied by tissuespeaking, or eating, especially if accompanied by tissue
destructiondestruction
• Emotional health – includes other’s reactions to the individual inEmotional health – includes other’s reactions to the individual in
a way that influences self-esteema way that influences self-esteem

SummarySummary
• Research in the areas of self-esteem and attractiveness indicates that the faceResearch in the areas of self-esteem and attractiveness indicates that the face
is a major source of one’s psychologic identityis a major source of one’s psychologic identity
• Orthognathic surgery differs from surgery for congenital anomalies (in thatOrthognathic surgery differs from surgery for congenital anomalies (in that
the changes in appearance are less dramatic and improvements in occlusion,the changes in appearance are less dramatic and improvements in occlusion,
mastication, speech, and TM joint function are likely to be major reasons formastication, speech, and TM joint function are likely to be major reasons for
treatment) – but patients undergoing this surgeries also expect esthetictreatment) – but patients undergoing this surgeries also expect esthetic
changes. They must adapt not only to changes in their oral function, but alsochanges. They must adapt not only to changes in their oral function, but also
to changes in their perceived appearance and interactions with othersto changes in their perceived appearance and interactions with others

Psychosocial studies of patients with dentofacialPsychosocial studies of patients with dentofacial
deformities -deformities - Kiyak et alKiyak et al
• The First StudyThe First Study
– To study patient’s motives for seeking orthognathic surgery, the effect ofTo study patient’s motives for seeking orthognathic surgery, the effect of
this procedure on people with diverse needs, and patient’s satisfactionthis procedure on people with diverse needs, and patient’s satisfaction
with treatment outcomeswith treatment outcomes
– 6 questionnaires were asked over a 26 month period6 questionnaires were asked over a 26 month period
• The Second StudyThe Second Study
– Attempted to examine in greater detail the variables that emerged asAttempted to examine in greater detail the variables that emerged as
significant predictors of long-term outcomessignificant predictors of long-term outcomes
– The effect of orthognathic surgery was measured by comparing patientsThe effect of orthognathic surgery was measured by comparing patients
who underwent surgery and orthodontics with those who werewho underwent surgery and orthodontics with those who were
recommended to have both but elected orthodontics alonerecommended to have both but elected orthodontics alone
– 6 questionnaires were asked before and up to 24 months after surgery6 questionnaires were asked before and up to 24 months after surgery

Patients before surgeryPatients before surgery
• Motives for treatmentMotives for treatment
• A scale to assess patient’s motivesA scale to assess patient’s motives
• Self-perceptions of facial profileSelf-perceptions of facial profile
• Sex differencesSex differences
• Orthognathic-surgery patientsOrthognathic-surgery patients

Motives for surgeryMotives for surgery
ParameterParameter MaleMale FemaleFemale
Professional adviceProfessional advice
OrthodontistOrthodontist 24(83%)24(83%) 34(76%)34(76%)
Family dentistFamily dentist 12(41%)12(41%) 17(38%)17(38%)
OtherOther 5(17%)5(17%) 1(2%)1(2%)
Desire esthetic changesDesire esthetic changes 12(41%)12(41%) 13(53%)13(53%)
Functional problemsFunctional problems
MasticationMastication 12(41%)12(41%) 13(29%)13(29%)
SpeechSpeech 4(14%)4(14%) 1(2%)1(2%)
TM jointTM joint 1(3%)1(3%) 7(16%)7(16%)
Social: family, friendsSocial: family, friends 12(41%)12(41%) 24(53%)24(53%)

A scale to assess patient’s motivesA scale to assess patient’s motives
• Subjective Expected Utility (SEU) ModelSubjective Expected Utility (SEU) Model
– Items are based on interviews with orthognathic surgery patients,Items are based on interviews with orthognathic surgery patients,
orthodontists, and oral-maxillofacial surgeonsorthodontists, and oral-maxillofacial surgeons
– Using a 10 point scale, patients are asked to indicate the importance ofUsing a 10 point scale, patients are asked to indicate the importance of
each item in the list above and whether they consider it positive , negativeeach item in the list above and whether they consider it positive , negative
or neutral.or neutral.
– In this study, SEU suggest that the decision to seek surgical correction isIn this study, SEU suggest that the decision to seek surgical correction is
influenced by functional reasons. Conversely, the decision to rejectinfluenced by functional reasons. Conversely, the decision to reject
surgery and undergo conventional orthodontics seems to be based moresurgery and undergo conventional orthodontics seems to be based more
on a desire for improved estheticson a desire for improved esthetics

A scale to assess patient’s motivesA scale to assess patient’s motives
QuestionsQuestions ScoreScore
Less difficulty with chewingLess difficulty with chewing 33
Stop jaw from clickingStop jaw from clicking 00
Eat foods unable to eat nowEat foods unable to eat now 00
Better fit of upper/lower teethBetter fit of upper/lower teeth 1.51.5
General health improvementGeneral health improvement 1.51.5
Possible pain after surgeryPossible pain after surgery 00
Better smileBetter smile 00
Improved profile, jaw and chinImproved profile, jaw and chin 00
Straight teethStraight teeth 00
Cost of surgeryCost of surgery 00
Lost time from work/schoolLost time from work/school 0.80.8
Chance of unsuccessful surgeryChance of unsuccessful surgery 1.91.9
Be able to speak clearerBe able to speak clearer 00
Less self-consciousLess self-conscious 00
Perform better in job/schoolPerform better in job/school 00
Advice of family/friendsAdvice of family/friends 00
Advice of dentist/orthodontistAdvice of dentist/orthodontist 0.90.9
Know of someone else’s surgeryKnow of someone else’s surgery 00

Adult Orthodontics Guide - Everything You Need to Know

Adult Orthodontics Guide - Everything You Need to Know

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