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Adult orthodontics /certified fixed orthodontic courses by Indian dental academy

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Adult orthodontics /certified fixed orthodontic courses by Indian dental academy

  1. 1. ADULT ORTHODONTICS INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Leader in continuing dental education
  4. 4.  INTRODUCTION  The frequency of malocclusion in adults is equal (or) greater than that observed in children and adolescents. Until recent years adults seeking orthodontic treatment was unusual. Since 1990’s 15% of the ortho patients were adults. They fall into 2 different groups (1) younger adults (under35, often in their 20’) who desired, but not received ortho treatment during adolescents. (2) An older group, typically in their 40’s or 50’s who have other dental problems and need orthodontics as part of larger treatment plan.
  5. 5.  HISTORY  Conflicting opinions have always existed regarding      the feasibility of orthodontic treatment in the adult Kingsley (1880) suggested that there were hardly any limits to the age of when tooth movement might not succeed (he treated a 40 year old patient with anterior cross bite) In contrast Mac Dowell (1901) was of the opinion that after 16 years of age, orthodontic treatment was also impossible owing to the development of the glenoid fossa, the dentistry of the bones and muscles of masticator. Lischer (1912) believed that the period between 6–14. years was a golden age of treatment Case (1921) demonstrated treatment possibilities in aged and periodontally affected patients Reidel & Dougherty (1976) predicted the status of adult ortho treatment today and stresses the need for adjunctive orthodontic services provided by periodontist and restorative dentist.
  6. 6.  3:0 DIFFERENCE BETWEEN THE ADOLESCENT AND THE ADULT In the adolescent, tooth movement is affected by growth while the adult we deal strictly with tooth movement alone. In addition, orthodontic treatment in the adults is often based on symptoms detected by the patient while in children, it is based more often on signs detected by practitioners or parents. Of equal significance is the fact that the adults seeks treatment more often for esthetic reasons and hence is likely to have unreasonable expectations about the outcome of the treatment, is less adaptable to the appliance and is uncompromising in his appraisal of the treatment results. On a brighter note, adult patients are cleaner, more careful more punctual, prompt paying, much less sensitive to pain and treatment time is either the same or less than that of younger patients
  7. 7.  LIMITATIONS OF TREATMENT IN ADULTS  There are two categories of factors: (a) INTRINSIC BIOLOGICAL  (B) EXTRINSIC BIOMECHANICAL SYSTEMS  The marked intrinsic limitation is the lack of growth in adults; skeletal discrepancies can therefore be corrected by Orthognathic surgery. The orthodontic treatment is limited to tooth movement and related modeling of the alveolar process only. Since orthodontic tooth movement is a result of cellular reaction to a mechanical stimulus, the cellular response may vary with the health and age of the individual
  8. 8.  Other Intrinsic Factors  4:1:1 Periodontium  The primary tissue to be influenced by the mechanical forces applied to the teeth in the PDL. According to Norton, insufficient source of progenitors cells may be due to vascularity with increasing age. Insufficient source of preosteoblast account for the delayed response to mechanical stimulus.  4:1:2 Alveolar bone  Structure: Orthodontic tooth movement as a result of bone modeling and remodeling also depends greatly on age related changes of the skeleton. Cortical bone becomes denser while the spongy bone reduces with age and the structure of bone changes from that of a honeycomb to a network. Pathology : Apical displacement of the marginal bone level is a local factor that influences the biological backgrounds for tooth movement in adults. The marginal bone loss is age related but is also the result of progressive periodontal disease.  4:1:3 Teeth : Adults are also more likely to have missing teeth, teeth reduced in dimension due to attrition as well as teeth with large restorations
  9. 9.  Lace like Bone pattern Honeycomb Bone pattern
  10. 10.  Without Marginal Bone  With Marginal Bone Loss Loss
  11. 11.  4:2 Extrinsic Limitations : Invariably caused by our inability to adapt the force system to produce the desired stimulus. The force system used for treating adults differs in several respects from that used in young growing individual.  Since the adult patient posses so many problems to the       orthodontist, Barrer and Chasens et al suggested that it was advisable to defer orthodontic treatment when faced with the following situation. 1. Uncontrolled/advanced local or systemic disease. 2. Excessive alveolar bone loss. 3. Severe skeletal discrepancy. 4. Inability to prevent excessive hard/soft tissue destruction. 5. Movement of teeth against occlusal opposition or into occlusal trauma. 6. No improvement in periodontal health, function or esthetics possible.
  12. 12.  5:1 DIAGNOSIS AND ADULT ORTHODONTICS  Careful diagnosis and treatment planning on a multidisciplinary basis is required to treat adult patients. In truth, the adult, unlike the child, is a relentless patient who will not cover up deficiencies in the skill of diagnosis or errors in the use of mechanical procedures by helpful settling – in post treatment. He presents with no growth, little rebound and meager accommodation to mechanics. In addition, the adult may exhibit a potential for such pathological changes as knife-edge ridges increased cortical thickness, buried roots, impactions, periodontal breakdown, atropic changes TMJ problems osteoporosis, osteomalacia, diabetes mellitus. These conditions, which obtain as a result of hormonal, vitamin or systemic disorders common to the adult, necessitate more careful and extensive diagnosis evaluations.  Orthodontic diagnosis involves development of a comprehensive database of pertinent information. The standard diagnostic aids such as case history, clinical examination and study casts, radiographs and photographs are mandatory.
  13. 13.  I.O.P.A, occlusal and TMJ films should be obtained routinely in addition to the panoramic radiograph and the cephalogram. The problem oriented diagnostic approach as described by Proffit and Ackerman is strongly recommended to ensure that no aspect of the patient need is neglected.  Additional diagnostic procedures that we should consider in an adult patient are             A full series of TMJ x – rays Muscle examination Splint therapy Diet evaluation Conference with allied practitioner Diagnostic Steps Collect database accurately Analyse database Develop problem list Prepare tentative treatment plan Interact with those who involved. Acquire patient acceptance Create final treatment plan
  14. 14.  5 : 2 PERIODONTAL DIAGNOSIS  Assess the patients potential for bone loss and gingival recession during orthodontic tooth movement.  Patient should be screened for the risk factors of periodontal disease.  Pre treatment consultation with the periodontist should be routine and orthodontic objectives be altered according to his advice. Movement of teeth in the presence of periodontal inflammation will result in an increased loss of attachement and irreversible crestal loss.
  15. 15.  5 : 3 TMD Diagnosis  Signs of symptoms of TMD often increase in frequency and severity during adult treatment. So it is imperative for the orthodontist to be familiar with their diagnostic and treatment parameters.  Adult patients especially females with TMJ sign and symptoms should be evaluated regarding exposure to stress and her handling of stress.  SCHIFMANN et al divided TMD problems into     Muscle disorders - 23% Joint disorders – 19% Muscle / Joint disorder combination – 27% Normal – 31%
  16. 16.  TMJ DISORDERS  Deviation in form - Irregularities in intracapsular soft and hard articular             tissue. Disc displacement with reduction – Altered Disc-condyle structural relationship is not maintained during translation, reciprocal clicking is present. Disc displacement without reduction – Altered Disc-condyle relationship is maintained during translation. TMJ Hypermobility – Excessive disc / condylar translation well beyond the eminence. Dislocation – Condyle positioned anterior to the articular eminence and unable to return to a closed positioned. Synovitis – Inflammation of the synovial lining of the TMJ Capsulitis–Inflammation of the joint capsule Osteoarthosis–Degenerative non-inflammatory condition of the joint characterized by structural change of the joint surface. Osteoarthritis–Degenerative condition accompanied by secondary inflammation. Polyarthirides–Arthitis caused by generalized systemic polyarthritis. nkylosisA–Restricted mandibular movement with deviation to the affected side on opening. Fibrous ankylosis – Ankylosis produced by adhesions within the TMJ. Bony ankylosis – Union of bones of the TMJ caused by proliferation of bone cells resulting in complete immobility of the joint.
  17. 17.  5:4:1 Diagnosis for Osteoporosis  Adults patients particularly females between 45 – 50yrs       (post – menopausal women) have a high incidence of osteopenia (asymptomatic low bone mass) or osteoporosis (symptomatic low bone mass). WHO defines. Osteopenia as bone mass 1 to 2.5 standard deviations (SD) below young adult mean (YAM) Osteoporosis – as > 2.5 SD below YAM Bone mineral density (BMD) measurements of adult women over age of 50 indicated that 13% to 18% had osteoporosis, 37 to 50% had osteopenia. So when evaluating adults for surgical procedures or orthodontics, a BONE METABOLIC ASSESSMENT is an essential part of diagnosis. Treatment of osteoporosis is problematic during orthodontic therapy because drugs that inhibit bone resorption (Bisphosphonates, Calcitonin) Estrogen Replacement Therapy (ERT) may disturb bone remodeling
  18. 18.  5:4:2 Oral Manifestations of Osteoporosis  Osteoporosis is a systemic deterioration of the skeletal          system with following dental manifestations. Decreased edentulous ridge height Decreased posterior maxillary arch width Progressive alveolar bone loss Loss of attachment and gingival recession Loss of teeth Effects of Estrogen Replacement Therapy: ERT has variety of oral health benefits, including a decreased in loss of periodontal attachments and greater retention of teeth during post – menopausal period. Once the negative calcium balance in stabilized, patients with osetoporosis are excellent candidate for orthodontics and other bone manipulative therapy. After osseous structures of jaw are enhanced, treatment planning is directed towards optimal function loading to avoid disuse atropy of alveolar process through implants, fixed prosthosis after orthodontic repositioning
  19. 19.  6:0 TREATMENT PLANNING FOR ADULT PATIENTS  6:1 Scope of Procedures  Musich’s conducted a study on 1400 adults and        demonstrated the scope of treatment planning considerations 5% of the adults require no treatment 25.5% came under the SOLO-PROVIDER GROUP (required only conventional correction orthodontics) 45.2% came under the DUAL – PROVIDER GROUP (two primary providers were required to complete the treatment). Orthodontist / Restorative dentist – 30.4% Orthodontist / periodontist – 8.0% Orthodontist / Oral Surgeon – 6.8% 24.3% - came under the MULTIPLE PROVIDER GROUP
  20. 20.  6:2 Factor in selection of treatment        plan. Existing oral pathology Skeletal relationship Biological considerations Therapeutical approaches available Extraction (vs) Non extraction therapy Anchorage requirements Missing teeth (Dental mutilation)
  21. 21.    Existing oral pathology : include recurrent decay, restorative failures, root decay with pulpal involvement periodontal bone loss, TMJ symptoms and retained roots. These conditions should be treated first before proceedings to orthodontics with a multi-disciplinary approach. Skeletal Relationships : No growth with minimal skeletal adaptability. Therefore surgical procedures are frequently required to correct moderate to severe skeletal disharmonies. Biological Considerations : Neuromuscular maturity – mechanical options for an adult are limited because of lack of neuromuscular adaptability. There is a tendency towards iatrogenic transitional occlusal trauma, coinciding with orthodontic occlusal changes. Periodontal susceptibility – higher degree of bone loss as result of periodontal disease can be evidenced during orthodontic therapy.
  22. 22.  Therapeutic approaches available –      Tooth Movement : most of them require tooth moving forces Orthopedics : not effective Orthognathic surgery : needed in 10 to 20% of the adult patients. Restorative dentistry : frequently required. Extraction (vs) Non Extraction Therapy : Classical 4 premolars extraction to resolve crowding rarely done .upper premolars extraction alone is a common alternative..
  23. 23.  6. Anchorage requirements : Adults have greater anchorage potential because of completely erupted 1st, and 2nd molars as well as accentuated mesial drift particularly in the mandibular arch. On the other hand 40% of the adults patient are partially edentulous.  Implants for orthodontic anchorage plays an important role in their treatment. (BJO 2002, VOL 29, 239-245) (Ismail and Johal-UK) Osseo integrated implants may be used for direct as well as indirect anchorage.  Direct anchorage utilizes forces from actual implant which takes the place of a missing tooth and eventually supports a dental restorations.  Indirect anchorage uses the implants to stabilize specific dental units to which clinical forces are then applied. Such MID PALATAL FIXTURES are the ONPLANTS and ORTHOPLANTS which are placed solely for orthodontic purposes in adults. (JCO-2000july,Celenza and Hochman)
  24. 24.  Onplants were introduced by BLOCK & HOFEMAN in 1995, made of titanium and consist of base of 10mm and 2mm height with one side smooth and other side textured and coated with hydroxy apatite. Base has internal thread for screwing transgingival abutment to which force is applied. Site is surgically exposed and coated surface is placed close to the bone. After 6 – 8 weeks the base is exposed and transgingival abutment is placed and loaded.  In partially edentulous conditions osseointergrated implants can be used but malocclusion can deteriorate further as it requires a healing period.  On the contrary, simple and an inexpensive form of maxillary anchorage is the ZYGOMA ligatures. (JCO, March 1998 –Melsern, Petersen costa)  The best bone quality in a partially edentulous patient is zygomatic arch and infra-zygomatic crest. 2 holes are drilled in the superior portion of infrazygomatic crest and double twisted 012” SS wire is pulled through this canal. To this coil springs and elastics are attached for intrusion and retraction of anteriors.
  25. 25.  Adult patients requiring intrusion of molars to control      Skeletal – Open bite are the apt candidates for Skeletal Anchorage System MIKAKO, SUGAWARA,MITRA ( AJO 1999; 115: 166-74) Titanium miniplates were fixed at the buccal cortical bone around the apical regions of 67 on both side. Elastic threads were used as a source of orthodontic force to reduce excessive (3 to 5mm) molar height. The system was very effective. BIOS (Glaatzmier) EJO 18 : 1996 465 – 469) is designed to provide anchoring functions in adults and adolescent and then be resorbed with out foreign body reactions. Secondary operations for removal at the conclusion of orthodontic treatment is not needed. It resorbs in 9 to 12 months. (7) Missing teeth (Dental mutilations) In adults, most of these spaces cannot be closed without a prostheses either a temporary tooth replacement during FA therapy or fixed prostheses later. Implants have become a reliable alternative. Therefore a multidiscipilinary team approach is required for their comprehensive rehabilitations.
  26. 26.  7:0 GOAL OF ORTHODONTIC TREATMENT  Since the adult differs in many respects from the adolescent and exhibits limitations, the goal for adult orthodontics would be different from that of the adolescent.  According to ACKERMAN, adult orthodontics is concerned with a striking balance between “achieving optimal proximal and occlusal contacts of the teeth, acceptable dentofacial esthetics, normal function and reasonable stability”.  Jackson’s Triad of traditional objectives (ie) esthetics, function and structural balance are neither realistic nor always necessary for all adult patients. Class I occlusal goals can be considered over treatment for patients under multiple provider group.
  27. 27.  7:1 Orthodontist commonly tries to achieve the following     objectives when treating adult patients: Parallelism of abutment teeth : (Permits insertion of multiple unit replacements and does not require excess cutting or devitalizations during abutment preparation). Most favourbale distribution of teeth : (teeth should evenly distributed for replacement of fixed and removable prostheses in the individual arches. Redistribution of occlusal and incisal forces : cases with bone loss of 60 to 70% required the occlusal forcs to be directed vertically along the long axis of the root to maintain the occlusal vertical dimension. Adequate embrasure space and proper root position. : it allows for better periodontal health, especially when the placement of restorations is necessary Interproximal cleaning becomes easier.
  28. 28.     Adequate occlusal plane and potential for incisial guidance at satisfactory vertical dimension. : In a mutilated dentition with bite collapse, adequate occlusal plane can be established by giving HAWLEY BITE PLANE with the platform of anterior plane adjusted at right angles to long axis of lower incisors. This allows centric relations at an acceptable VD. Bite plane also allow simultaneous BILATERAL NEUROMUSCULAR ACTIVITY. Curve of spee should be mild to flat bilaterally. This is difficult to acheive if there are supraerupted molars. Adequate Occlusal Landmark Relationships: when teeth are to restored, they should be positioned to acheive acceptable buccolingual landmarks. Posterior cross bites that cannot undergo surgery are positioned such that the maxillary buccal cusps contact the lower central fossa with the cross-over for incisal guidance in premolar or area.
  29. 29.    Better lip competency and support: Adults have long upper lips which precludes significant maxillary retraction. In cases requiring anterior restorations, retraction is recommended to achieve lip competency. Lower incisors extending 1 to 2mm into the palatal mucosa (Class II Div 1 cases) cause soft tissue irritations. So their IMPA is increased (105o to 120o) to establish incisal guidance. Adequate lip support is created to prevent wrinkling which makes the face prematurely aged. Improved crown / root ratio: If bone loss is isolated on a single tooth, length of clinical crowns is reduced and tooth can be erupted orthodontically thereby improving the crown / root ratio. Improvement (or) correction of mucogingival and osseous defects. : Repositioning of prominent teeth will improve the gingival topography. In adults the goal should be to LEVEL THE CRESTAL BONE between adjacent CEJ: Favorable osseous and soft tissues changes will diminish the need for muco-gingival surgery.
  30. 30.   Better self – maintenance of periodontal health. : Improved self – maintenance of periodontal health occurs with proper tooth position. This can be seen after the correction of bite collapse and accelerated mesial drift. Esthetic and Functional improvement: A plan should provide acceptable dentofacial esthetics and allow for improved muscle, function, normal speech and masticatory improvements.
  31. 31.  :0 BIOMECHANICAL CONSIDERATIONS IN ADULT     ORTHODONTICS (Lindauer JS. Rebellato J), (Dent Clin North Am 1996 : 40 : 811 – 836.) Orthodontic treatment in the adult must be planned without the expectation that growth or any changes in jaw relationships will conpensate for interarch discrepancies. A precise biomechanical control of tooth movement is necessary to achieve correction of malocclusion in all 3 dimensions. The forces used in the adults should be at a lower level than those used in children. The initial forces should further be kept low because the immediate pool of progenitor cells available for resorption are low. In adults with periodontal involvement where bone has been lost, PDL are decreases with the results that the same force against the crown would produce greater pressure in the PDL. magnitude of force The absolute must therefore be reduced.
  32. 32.  Marginal bone loss results in CRES (b) being displaced apically. Magnituide of the tipping moment is the product of force and distance (point of force application to the CRES).  Since the CRES has moved apically greater will be the tipping moment for same force, so a counter vailing COUPLE is necessary to affect BODILY movement.  Force levels should be decreased but the magnitude of the couple applied to counteract the tendency to tip should not be decreased proportionally.  In the presence of marginal bone loss, light continuous intrusive forces should be maintained.
  33. 33.  1 Selection of Mechanics  The appliance should produce a controlled and constant force system in all three planes to reader a low lead deflection rate possible  8:2 Vertical control and facial profile  Maintaining vertical control and facial profile is very important in treating adult patients. A child tolerates extrusive tooth movement better since condylar growth and vertical development of the alveolar process during child hood permit such tooth movement. In contrast, any extrusive movement, of the posterior teeth in the adult will lead to an opening of the bite through backward rotation of the mandible resulting in an increased facial height and overjet.  Extrusion of incisors can be undersirable since the majority of patients suffering from advanced periodontal disease have extruded and spaced maxillary teeth. Such patients need intrusion and retraction.
  34. 34. Loss of vertical control        Unintentional extrusion is possible with both fixed and removable appliance. According to Burstone, such loss of vertical control is possible in a number of instances of fixed appliances therapy such as. Tip back bend Incorrect bracket positioning Excessive force Straight wire leveling Anterior root correction
  35. 35.            AJO 1989 Ronas, Kleinent & Melson B & Burstone Force system developed by `V` Bends in an elastic Orthodontic wire Burstone indicated a number of examples related to fixed appliances that lead to loss of vertical control (or) untoward extrusive effects TIPBACK BEND: Any major `V` Bend will result in the development of vertical forces if the bends are not localized exactly at the center between two tooth units It produces Extrusion the vertical forces are closely related to the degree of bending & degree of eccentricity of bend. INCORRECT BRACKET POSTIONING. A difference in Orientation (or) cant can act as `` shape producing a change in the level of the occlusal plane. ESTHETIC BEND Combination `V` bend & step bend high vertical forces produced. Teeth will cut be intruded at this force level. Only extrusion takes place
  36. 36.  0 ACCORDING TO PROFFIT, ADULT ORTHODONTIC PROCEDURE CAN BE CONVENIENTLY CLASSED INTO THREE CATEGORIES.  Adjunctive treatment  Comprehensive treatment  Surgical-orthodontic treatment
  37. 37.  ADJUNCTIVE TREATMENT:  Adjunctive orthodontic treatment is tooth movement      carried out to facilitate other dental procedures necessary to control disease and restore function. Typically, adjunctive treatment will involve any or all of several procedures: Repositioning of teeth that have drifted after extractions or bone loss so as to facilitate the placement of removable or fixed partial dentures or even implants. Forced eruption of badly broken down teeth to expose sound root structure on which to place crowns. Alignment of anterior teeth to allow more esthetic restorations or successful splinting. Correction of cross bites if these compromise jaw function.
  38. 38.  2 Goals:  Facilitates restorative treatment by positioning the teeth so that more ideal and conservative technique can be used.  To improve periodontal health by eliminating plaque harboring areas and improving the alveolar ridge contour adjacent to the teeth.  To establish favourable crown to root ratios and position the teeth so that occlusal forces are transmitted along the long axis of the teeth.  9: 3 Characteristics of therapy  Adjunctive orthodontics implies limited orthodontics goals  (a) Appliances are required only a portion of the dental arch. (i.e) partial fixed appliance.  (b) Treatment should be completed with in 6 months.  (c) Orthodontic treatment for TMD should not be considered adjunctive.
  39. 39.  :4 Diagnosis and treatment planning consideration  Planning for adjunctive treatment required 2 steps.  collecting an adequate date base  Developing a comprehensive but clearly stated list of patient’s problem  Records include IOPA and panoramic x-rays  Pre-Treatment cephalogram not required.  Dental casts made from fully extended impression covering the contour of supporting alveolar bone is required.
  41. 41.  9:6 Possible tooth movement in adjunctive treatment  (a) Mesial or distal movements of specific crowns and      roots. (b) Correction of axial inclination of drifted teeth. (c) Correction of buccolingual position of certain teeth (d) Corrections of rotations. Intrusion of teeth is avoided as an adjunctive procedure because of the technical difficulties involved and possibility of periodontal complications. Excessively extruded teeth are treated by reduction of crown height which improves the crown / root ratio .
  42. 42.  9:7 Biomechanical considerations:  Control of anchorage requires that anchor teeth not      be allowed to tip. This is major reason that adjunctive treatment usually requires a fixed appliance. EDGEWISE APPLIANCE recommended, twin brackets of 0.022 slot dimension are used preferably Rectangular slot controls bucco – lingual axial inclination Twin bracket prevents undesirable rotations and tipping Larger slot allows the use of stabilizing wires which are stiffer. Bracket are placed in an ideal position only on teeth to be moved, remaining teeth incorporated in the anchor system and are bracketed so the archwire slot are closely aligned. Passive engagement of the wires to anchor teeth produce minimal disturbance of teeth.
  43. 43.  9:8 The procedures commonly carried out as a part of adjunctive orthodontic treatment are  Uprighting Posterior Teeth.  Forced eruption.  Alignment of teeth.  Cross-bite correction.
  44. 44.  10.1 COMPREHENSIVE TREATMENT FOR ADULTS  Comprehensive orthodontic treatment aims at making       the patient’s occlusion as ideal as possible, repositioning all or nearly all the teeth in the process. The ideal time for comprehensive orthodontic treatment is during adolescence, when the succedaneous teeth have just erupted, some vertical and antero posterior growth of the jaws remains and the social adjustment to orthodontic treatment is not a great problem. Comprehensive treatment is also possible for adults, but it poses some special problems that do not exist for younger patients. The following considerations should be kept in mind while treating adults Lack of growth Heightened possibility of periodontal disease Different motivations for seeking orthodontic treatment.
  45. 45.  While treating adults  Appliance should be simple in order to elicit maximum       patient cooperation Appliance should exert light forces for best physiological response. Appliance should be long acting to decrease the number of appointments. Appliance should be invisible as possible(plastic, ceramic brackets, fixed lingual appliances) Appliance should be better retained (fixed) Adult treatment mechanics need not differ from the standard technique; they are modified only to meet specific treatment requirements. Simplicity with maximum control is the by word. Comprehensive orthodontic treatment implies an effort to make the patient’s occlsion as ideal as possible by repositioning nearly all the teeth in the process.
  46. 46.  10:2 Motivations for adult treatment: The major motivations for adults to undergo comprehensive treatment is due to psychological reasons. Though a small percentage of them may seek complete treatment for periodontal and restorative needs.  10:2:1 Internal motivations : if the individual wants to improve his appearance or function of teeth and so seeks treatment – he is said to be internally motivated and is expected to respond well psychologically  10:2:2 External motivation : an individual whose motivations is the urging of  others he said is to be externally motivated and has a complex set of unrecognized expectation for orthodontic treatment.
  47. 47.  10: 3 PERIODONTAL ASPECTS OF ADULT TREATMENT  There is no contra indications to treating adults with periodontal disease long as the disease is under control  Three risk groups are identified in the population    Those with rapid progression (10%) Those with moderate progression (80%) Those with no progression despite the presence of gingival inflammation (10%).
  48. 48.  10:3:1 MINIMAL PERIODONTAL INVOLVEMENT:  Bacterial plaque being the main etiological factor in       periodontal breakdown, patient undergoing orthodontic especially adults must take extra care For adults orthodontic patient’s GINGIVAL RECESSION is to be prevented rather than to try correcting it later. Creation of “BLACK TRIANGLES” between maxillary central incisors by gingival recession after periodontal loss is practically distressing. According to the present concept, gingival recession occurs secondary to alveolar bone dehiscence; if overlying tissues are stressed. Stress can be due to Tooth brush trauma Plaque induced inflammation Stretching and thining of gingiva created by labial tooth movement FREE GINGIVAL GRAFT is helpful in adult patients to control inflammation before orthodontic treatment begins. and in whom arch expansion is indicated for aligning incisors.
  49. 49.  10:3:2 MODERATE PERIODONTAL INVOLVEMENT:  Disease control: Preliminary periodontal therapy is preformed       which includes meticulous root surface preparative and curettage and patient kept under observation to watch whether the disease is controlled. Treatment procedures like osseous contouring (or) repositioned flaps to compensate areas of gingival recession are best deferred until final occlusal relationships have been established. Disease control also requires endodontic treatment of any pulpally involved teeth. Temporary restorations (composite resins) are placed to control caries and definitive the restorative procedures (cast restoration) are delayed after orthodontic phase of treatment. PERIODONTAL MAINTENANCE Fully boned orthodontic appliance is recommended. Steel ligatures (or) self ligating bracket are preferred for periodontally involved patients rather than elastomeric rings to retain arch wires because such patient have higher level of micro organisms in gingival plaque. During comprehensive treatment, patient with moderalte periodontal problems should be on a maintanence schedule (2 – 4 months interval) HYGIENE AIDS: Electric tooth brushes, rubber interdental stimulators, proximal brushes and adjunctive chemicals (eg. Chlorhexidine) should considered.
  50. 50.             10:3:3 SEVERE PERIODONTAL INVOLVEMENT: The general approach in the same as outlined earlier but 1. Periodontal maintenance schedule is at more frequent intervals (every 4 to 6 weeks) 2. Orthodontic goals modified and forces kept to absolute minimum of because of the reduced area of PDL Muco-gingival Corrections Attention if paid to 3 factors prior to orthodontic therapy can make the treatment easier and more predictable. Reduction of thick tissue either distal to the terminal tooth or in edentulous areas Inadequate bands of keratinized tissues. Frenal attachments Thick tissue gets bunched up and can slow down tooth movement considerably. While uprighting a second or a third molar, the tissue moves coronally on the tooth and a pseudopocket develops. This can become a nidus for bacteria and a potential locus for the apical migration of the attachment. If there is a minimal band of keratinized tissue and the roots move out of the alveolus, there is bound to be recession. Frenal attachements that prevent or slow down tooth movements may be removed during or before tooth movement. However, if retention is the chief concern, then the removal may be effected at the conclusion of tooth movement.
  51. 51.  ORTHODONTIC TREATMENT OF PERIODONTAL DEFECTS –(Seminars in orthodontics) vincent kokich -1997  Advanced Horizontal Bone Loss:  After the treatment has been planned, one of the most important factors that determines the outcome of orthodontic therapy, is the location of the bands and brackets on the teeth. Ina periodontaly healthy individual, the position of the bracket is usually determined by the anatomy of the crown of the tooth. Anterior brackets should be positioned relative to the incisal edges. Posterior bands or brackets are positioned relative to the marginal ridges. If the incisal edges and marginal ridges are at the correct level, the CEJs will also be at the same level. This relationship will create a flat bony contour between the teeth. However, if a patient has underlying periodontal problems and significant alveolar bone loss around certain teeth, using the anatomy of the crown to determine bracket placement is inappropriate.
  52. 52.  The bone level may have receded several millimeters from the CEJ. As this occurs, the crown to root ratio will become less favourable. By aligning the crowns of the teeth, the clinician may perpetuate tooth mobility by maintaining an unfavourable crown to root ratio.  The orthodontist can correct many of these problems by using the bone level as a guide to positioning the brackets on the teeth. In these situations, the crowns of the teeth may require considerable equilibration . If the tooth is vital, the equilibration should be performed gradually to allow the pulp to form secondary dentin to insulate the tooth during the requilibration process. The goal of equilibration and creative bracket placement is to provide a more favourable bony architecture as well as a more favourable crown to root ratio.
  53. 53.  HEMISEPTAL DEFECT:  Adult patients may have marginal ridge discrepancies caused by uneven tooth eruption before orthodontic treatment. When the orthodontist encounters marginal ridge discrepancies, the decision as to where to place the bracket or band is not determined by the anatomy of the tooth. In these situations, it is important for the orthodontist to assess bite wing or periapical radiographs of these teeth in order to determine the bone level interproximally.  If the bone level is oriented in the same direction as the marginal ridge discrepancy, then leveling the marginal ridges will level the bone. However, if the bone level is flat between adjacent teeth and the marginal ridges are at significantly different levels, correction of the marginal ridge discrepancy orthodontically will produce a hemiseptal defect in the bone. This could cause a periodontal pocket between the two teeth.
  54. 54.  If the bone is flat and a marginal ridge discrepany is present, the orthodontist should not level the marginal ridges orthodontically. In these situations, it may be necessary to equilibrate the crown of the tooth. In some patients, the latter may require endodontic therapy and restoration of the tooth resulting from the amount of reduction of the length of the crown that is required.  In some patients, a discrepancy may exist between both the marginal ridges and the bone levels between two teeth. These discrepancies may however not be of equal magnitude. In these patients, orthodontic leveling of the bone may still leave a discrepancy in the marginal ridges. In these situations, the clinician must not use the crowns of the teeth as a guide for completing orthodontic therapy. The clinician should level the bone orthodontically and equilibrate any remaining discrepancies between the marginal ridges. This method will produce the best occlusal result and improve the periodontal health.  During orthodontic treatment, when teeth are being extruded to level hemiseptal defects, the patients should be regularly monitored by the periodontist. Initially, the hemiseptal defect will have a greater sulcular depth and be more difficult for the patient to clean. As the defect is ameliorated through tooth extrusion, interproximal cleaning becomes easier.
  55. 55.  FURCATION DEFECTS:  Regenerative therapy using polytetrafluorethylene membranes and/or bone grafting, has been successful in Class I and II furcation. However, In Class III furcations, the use of membranes has not produced consistently satisfactory results.  A possible method for treating the Class III furcation is to eliminate it by hemisecting the crown and root of the tooth. This procedure will, however, require endodontic, periodontic, and restorative treatment.
  56. 56.  Tissue response to various tooth movements.  EXTRUSION:  Extrusion or Eruption of a teeth (or) Several teeth along with reduction of the clinical crown height reduces infrabony defects & decreases product depth.  AJO 1986 TISSUE REACTION OF EXTRUSIVE AND INTRUSIVE FORCES TO TEETH IN ADULT MONKEYS ( BIRTE MELSEN)  On histologic section, clear signs of bone deposited during forced Eruption is seen  INTRUSION: INTRUSION OF INCISORS IN ADULT PATIENTS WITH MARGINAL       BONE LOSS (AJO 1989 MELSON B ET AL In this study 3 different methods for intrusion were applied. The marginal bone level approached CEJ in almost all cases. All cases demonstrated root resorption. The intrusion was best performed when Forces were low (5 to 15 gm per tooth ) with line of action of force passing through (or) close to the center of resistance. Gingival status was healthy. No interference with perioral function present.
  57. 57.  11:1 SURGICAL ORTHODONTICS  Correction of severe skeletal deformity in an adult is achieved by surgical means. 10 – 20% of adults fall into this category.  OGS basically involves planned fracturing of the facial skeletal parts and repositioning them as desired.  OGS can be performed in both jaws and is all 3 planes of space.
  58. 58.  OGS can be performed in both jaws and is all 3 planes of space.  In Anterioposterior plane.  - MAXILLARY SURGERY  The Lefort I downfracture procedure almost always is used now to reposition the maxilla. If the maxilla is advanced, a graft in the retromolar area or at a step created in the lateral wall usually is required.  MANDIBULAR ADVANCEMENT  Currently the bilateral sagittal split osteontomy (BSSO) of the mandibular ramus, performed from an intro oral approach, is the preferred procedure for most patients who need mandibular advancement.
  59. 59.  MANDIBULAR SETBACK  Reduction of mandibular prognathism can be accomplished by one of two techniques performed in the ramus, each having advantages and dis-advantages. The BSSO (discussed previously) can be used to move the mandible posteriorly as well as anteriorly,. It is widely used for setbacks because of excellent control of the condylar segments and because osteosynthesis screws can be employed for fixation.  The transoral vertical oblique ramus osteotomy (TOVRO) is limited to mandibular setback and required full-thickness overlapping of the segments. This procedure requires less time than the sagittal split osteotomy and is less likely to produce neurosensory changes, but jaw immobilization after surgery is necessary and control of the condylar fragment can be difficult. Especially when both the maxilla and mandible are repositioned in treatment of Class III problems, the advantage of rigid fixatio BSSO outweighs the advantages of TOVRO.
  60. 60.  CORRECTION OF VERTICAL RELATIONSHIPS  Problems of excessive and deficient face height, which usually are accompanied by severe anterior open bite and deep bite respectively. The long face problems are treated best by superior repositioning of the maxilla. This allows the mandible to rotate around the condyle, thereby reducing the mandibular plane angle and shortening the face. Short face problems, in contrast, are treated most predictably and successfully by mandibular ramus surgery that allows the mandible to move donwnward only at the chin, increasing the mandibular plane angle by shortening the ramus and opeing the gonial angle by shortening the ramus and opening the gonial angle rather than by rotating at the condyle.
  61. 61.  MAXILLARY SURGERY  The contemporary surgical approach to the skeletal open bite (long face) deformity involves a LeFort I downfracture of the maxilla, with superior, repositioning of the maxilla after removal of bone from the lateral walls of the nose, sinus, and nasal septum.  It is important to shorten the nasal septum or free its base so that the septum is not bent when the maxilla is elevated. The overall facial height is shortened as the mandible responds by rotating upward and forward. Excellent stability of the vertical position of the maxilla is observed post-surgically, but ling-term, some continued vertical growth of the maxilla may occur.  In contrast, when the maxilla is moved downward to increase face height, it tends to relapse back up post surgically, so that 20% or more of the vertical change often is last even when rigid fixation is used. Both the use of more rigid graft materials (like synthetic dydroxylapattite) and simultaneous osteotomy of the mandibular ramus have been reported to improve the stability of downward movement of the maxilla.
  62. 62.  MANDIBULAR SURGERY:  Patients with a ling face, skeletal open bite and anteroposterior mandibular deficiency often have a short mandibular ramus. Surgery to reduce to mandibular plane angle and close the open bite by rotating the mandible down posteriorly and up anteriorly has been found to be highly unstable. Because the fulcrum for rotation is the posterior teeth, this rotation lengthens the ramus and stretches the muscles of the pterygomandibular sling. The instability is attributed primarily to lack of neuromuscular adaptation in these powerful muscles, which can produce relapse to pre-surgical or even worse mandibular positions.  Patients with a short face (skeletal deep bite) problem are characterized by a long mandibular ramus, square gonial angle and short nose-chin distance. Often the maxillary incisors are tipped lingually in Angle’s Class II, division 2 pattern. Despite the deep overbite, excessive eruption of the lower incisors often has not occurred, as demonstrated by a normal distance from the chin to the incisal edge. They are teated best by sagittal split mandibular ramus surgery to rotate the mandible slightly forwad and down and the gonial angle area.
  63. 63.  CORRECTION OF TRANSVERSE RELATIONSHIPS:  Transverse problems fall into two categories: those due to symmetrical narrowing or (less frequently) widening of one dental arch and those due to jaw asymmetry.  Maxillary Expansion for Lingual Crossbite:  Constriction of the maxilla rarely occurs without some coexisting vertical or sagittal problem. Maxillary constriction or expansion can be accomplished easily by segmenting the maxilla in the course of LeFort I downfracture surgery to correct other problems, and this is the usual approach. Expansion is done with parasagittal osteotomies in the lateral floor of the nose or medial floor of the sinus that are connected by a transverse cut anteriorly.  Surgically assisted palatal expansion, using bone cuts to reduce the resistance without totally freeing the maxillary segments, followed by rapid expansion of the jackscrew, is another possible treatment approach for adult patients with skeletal maxillary constriction.
  64. 64.  GENIOPLASTY IN ORTHOGNATHIC TREATMENT:  Lack of surrounding anatomic structures gives the surgeon considerable latitude in alteration of chin morphology, and movement of the chin in all three planes of space is possible.  Genioplasty Techniques:  For most patients, the preferred approach to genioplasty is a lower border osteotomy to free a wedge shaped portion of the symphysis and inferior border that remains pedicled on the genioglossus and geniohyoid muscles. This segment can be advanced to augment chin contour, shifted sideways to correct asymmetry, or downgrafted to increase lower face height.  Genioplasty can be used as an Adjunct to Non-extraction Orthodontic Treatment    SEQUENCING TREATMENT: Surgical and Orthodontic Phases of Treatment: Successful management of combined surgical and orthodontic treatment requires the integration of presurgical orthodontic, surgical and post surgical orthodontic phases of treatment.
  65. 65.  Three principles that influence post-surgical stability can be proposed:  Stability is greatest when soft tissues are relaxed during the surgery and least when they are stretched. Moving the maxilla upward relaxes tissues. Moving the mandible forward stretches tissues, but rotating it upward posteriorly and downward anteriorly decreases the amount of stretch. It is not surprising that the lease stable mandibular advancements are those that lengthen the ramus and rotate the chin up, while the most stable advancements rotate the mandible in the opposite direction. The least stable orthognathic surgical procedure is widening of the maxilla that stretches the heavy, inelastic palatal mucosa.  Neuromuscular adaptation is an essential requirement for stability, Fortunately, most orthognathic procedures lead to good neuromuscular adaptation. When the maxilla is moved upward, the postural position of the mandible alters in concert with the new maxillary movement, and occlusal forces tend in increase rather than decrease. This controls any tendency for the maxilla to immediately relapse downward, and contributes to the excellent stability of this surgical movement. Repositioning of the tongue to maintain airway dimensions occurs as an adaptation to changes produced by mandibular osteotomy. Neuromuscular adaptation does not occur when the pterygomandibular sling is stretched during mandibular osteotomy, as when the mandible is reotated to close
  66. 66. 1. Neuromuscular adaptation affects muscular length, not muscular orientation. If the orientation of a muscle group such as the mandibular elevators is changed, adaptation cannot be expected. This concept is best illustrated by the effect of changing the inclination of the mandibular ramus when the mandible is set back or advanced. Successful mandibular advancement required keeping the ramus in an upright position rather than letting it incline forward as the mandibular body is brought forward. The same is true, in reverse, when the mandible is set back a major cause of instability appears to be the tendency at surgery to push the ramus posteriorly when the chin is moved back.
  67. 67.  12:1 Retention  Retention is a critical and challenging aspect of adult      orthodontics. The general principles of retention hold good for adult patients. Retention mechanics should be a part of the original treatment plan. In many cases of adult orthodontics, the need for post orthodontic stabilization will coincide with the need for both restoration of mutilated dentitions and cross arch stabilization. It may include removable retainers, operative procedures and/or fixed retention. When the patient has abnormal lip, tongue or cheek muscle activities, it is incumbent on the orthodontist to prepare the patient for long-term use of fixed retainers.
  68. 68.  12:2 Periodontal – Surgical Retention     Procedures Certain periodontal-surgical procedures may be necessary to achieve overall stability of the treated adult patient. The following are the procedures that may have to be performed. Pericision Gingivectomy and Gingivoplasty.
  69. 69.  12:2:1 Pericision  Significantly rotated teeth should be over corrected to an extent of 5-10° prior to debonding.  A supracrestal gingival fibrotomy will reduce the risk of relapse.  12:2:2 Gingivectomy and Gingivoplasty:  These procedures arc indicated when significant vertical changes, such as deep overbite correction have been made orthodontically.  In general, adults require a greater period of retention.
  70. 70.  12:3 Types of retainer used           Hawley’s retainer remains the most commonly used retainer. Hawley’s with tongue crib Indicated in managing residual neuro muscular problems, especially postural tongue problems. Bondable Lingual retainers They are mostly used the lower segments in patients requiring longterm retention. They are esthetic and usually go unnoticed. Invisible retainers They are retainers that fully cover the clinical crowns and a part of the gingival tissue. They are made of ultra thin transparent thermoplastic sheets using a Biostar machine. They are esthetic and often go unnoticed. These can be used in adult patients who are especially concerned about estheticsComprehensive restorative procedures Crowns and bridges may be required in mutilated cases at the termination of orthodontic treatment. They are not only prosthetic replacements but also retain the teeth. Splinting And Adult Orthodontics Mutilated dentitions having periodontal problems with qualitative and quantitative loss of the attachment apparatus may require some form of temporary or permanent, partial or full arch splinting.
  71. 71.  10:4:2 LESS VISIBLE TREATMENT MODALITIES FOR ADULTS : -  Adults patients are conscious and demand less visible appliances.  CLEAR BRACKETS  (plastic / ceramic bracket) along with tooth coloured arch wire are the most esthetic combinations to be used in a conscious adult patients. The esthetic arch wire (FRC Fibre Reinforced Composite AJO 2000) is composed of ceramic fibres embedded in a cross-linked polymer matrix. Its coefficient of friction is reduced by modifying the surface chemistry (eg: ion implantation) inspite of this, adults are often averse to wearing traditional fixed appliance with wires, bands and brackets.
  72. 72.  10:4:2A The INVISALIGN SYSTEM (BJO-2003 – December vol 30         (L.joffe-UK) now makes it possible for orthodontists to offer adults patients requiring full mouth orthodontic treatment with an esthetically agreeable solutions. Introduced about 4 years ago by ALIGN TECHNOLOGIES Santa clara, California It is an orthodontic technique that uses a series of clear plastic aligners to move teeth. Worn for a minimum of 20 hours per day. Changed on a 2 weekly basis. Each aligner moves a tooth or a small group of teeth about 0.25 – 0.33mm Align technology using computer – aided scanning, imaging and manufacturing technology has pushed this technique into realms of every orthodontic practice. The revolutionary aspect of invisalign is the scanning in and imaging of high precision casts made from very accurate impressions (poly-vinyl silicon impression). This allows the patient’s teeth to be replicated as “on screen” 3D model, which can be manipulated and virtually corrected through a treatment plan developed by orthodontist and translated by invisalign using sophisticated propriety software. (CAD-CAM technology) The clinician has the ability to view the “virtual” models” from malocclusion to correction, movement by movement through an internet connection program called Clincheck. Changes are made through clincheck system until the result achieved is to the clinicians liking. Only then are the actual aligners made and dispatched.
  73. 73.  Extrusive, intrusive and rotational abilities of investigations are under trial  Software individualizes each tooth, so they can be individually repositioned and soft ware relates to upper and lower teeth together so that co-ordinate in kept between arches.  Manufacturing process is a computer aided technology. The 3D – models of each setup in the realignment are transformed into hard copy models through a process of laser build up. These models are then used to make the pressure formed aligners  [IPR] Interproximal reductions are done at the time of delivery of the aligners.  A typical invisalign treatment will take around 25 aligners and 50 weeks of treatment.  Handles simple to moderate non-extraction alignments better than mild to moderate extraction corrections  It has only limited ability to keep teeth upright during space closure.  Conditions treated with invisalign  It can be used as RETAINERS, NIGHT GUARD, TMJ SPLINTS BLEACHING TRAYS AND FOR TOOTH MOVEMENT
  74. 74.  Tooth Movements  Mildly crowded and malaligned problems (1 – 5mm) Treatment can     be done with slight lateral or anterioposterior expansion, with minor interporximal tooth reduction or by removal of lower incisor. Spacing of 1 – 5mm Deep overbite problems (class II Div 2 type where the overbite can be reduced by intrusion and advancement of incisors Narrow arches. Certain aspects are more difficult to handle          Crowding and spacing over 5mm Skeletal anterio posterior discrepancies of more than 2mm CR and Co discrepancies More than 20o rotations Open bites Extrusions Severely tipped teeth (more than 45o) Teeth with short clinical crowns Arches with multiple missing teeth.  Though certain aspects are difficult to be treated by invisalign. Combinations treatment can be under taken. Conventional appliance may be used along with it whenever neede
  75. 75.  Advantages  Ideal esthetics : aligners are relatively invisible apart          from a slight sheen to the teeth is close up. Easy to use for the patient Comfortable Simplicity of care and better oral hygiene Invisalign allows for refinement aligners which can be added at the end of scheduled treatment procedures. Disadvantages Limited control of root movement such as root paralleling, gross rotation correction, tooth uprighting and tooth extrusion. Limited intermaxillary correction : severe skeletal discrepancy cannot be contemplated with invisalign alone. Surgery or a pre-invisalign functional phase would be necessary. Lack of operator control : as the aligners are prefabricated there no chance of altering it. Thus it is an esthetic technique used to treat simple to moderate alignment cases in adults.
  76. 76.  10:4:2B LINGUAL ORTHODONTICS  Most lingual orthodontics patients are adults and have greater demands and expectations than do labial orthodontic patients, Esthetics is a crucial factor.  Advantages :   Labial enamel surface, is preserved which plays an important esthetic role. Susceptibility of this enamel surface to permanent decalcification following chemical insults from etchant materials and to plaque accumulation are prevented.  Lingual appliance allow easy access for routine oral hygiene procedures.  Evaluation of individuals tooth positions can be easily assessed as the labial surface is free of distracting metal (or) plastic brackets
  77. 77.  Lingual appliances are effective in the following situations  1. Intrusion of anterior teeth.  Lingual bracket positioning is dictated by the morphology of lingual surface, it places the bracket closer to the CRES of the tooth. It allows the intrusive force rector to be directed through the CRES of the tooth.  Mandibular anterior dentition occludes with the anterior horizontal plane of maxillary anterior brakets, BITE PLANE effect results. Net effect is a LIGHT CONTINUOUS INTRUSIVE FORCE in the anterior and a passive extrusive force in the posterior segments.  2. Maxillary arch expansion  More remarkable dentoalveolar expansion are achieved through     lingual mechanics Reasons may be due to The force developed in of a CENTRIFUGAL TYPE (from inside towards the outside of the arch) Thickness of the brackets which interpose between the tongue and lingual wall of the teeth contribute to the expansive effect/. Short interbracket distance may play a significant role
  78. 78.  3. Combining mandibular repositioning therapy with orthodontic movements :  Usually patients with TMD are treated in 2 distinct clinical phases. Initial phase consists of splint therapy followed by changes in occlusion.  Lingual appliances system allows both arches to be treated simultanesously. The anterior occlusally oriented inclined plane functions as a bite plane. Flat acrylic mini supports are added to the 1st and 2nd molars. This combination can stimulate the action of conventional splint thereby allowing treatment to progress simultaneously in both arches.  4. Distalisation of maxillary molars  Lingual bracket are placed closer to CROT than the labial bracket. The molar distalisation through lingual technique produce more bodily movement of the tooth and less dental tipping.
  79. 79.  10:4:3 Space closure (Vs) Prosthetic replacements in        Old Extraction sites Closing an old extraction site in an adult is problematic because of resorption and remodeling of alveolar bone that has occurred. Resorption resulted in a decrease in the vertical height of the bone. Remodeling produced buccolingual narrowing of alveolar process. Space closure require reshaping of the buccal and lingual cortical plates. Even then the response of cortical bone is SLOWER. If a molar is to be moved forward into an old extraction site, TEMPORARY implants is placed in the ramus to provide necessary anchorage Otherwise partially closed extraction site may be opened by simple orthodontic treatment and replace missing tooth with a bridge or an implant The decision should be taken after consulting
  80. 80.  10:5 MODIFIED MECHANOTHERAPY ADULTS       Segmented arch treatment is widely used in adults. It creates a stable anchor unit consisting of several teeth rigidly connected together to create a functional equivalent of a single large multirooted anchor tooth. This anchorage is used to provide precisely controlled force against the teeth to be moved. 10:5:1 Intrusion is often required in leveling of both arches. Due to lack of growth, even small extrusions lead to mandibular rotations. It is achieved through SECTIONAL MECHANICS in adults. In periodontally involved adults, anchorage is likely to be compromised, so soldered lingual arches are used for anchorage. Burstone – type depressing arches (or) Rickets utility arches both using a long span from stabilized posterior segments to the anterior area where intrusion is desired. Forces should be extremely light for anterior intrusion otherwise posterior will get extruded. Potential problem with intrusion is periodontally involved adults in the DEEPENING OF PERIODONTAL POCKETS due to the formation of epithelial cuff. The crown root ratio is an important factor in long tern prognosis – shortening the crown improves it.
  81. 81.  10:5:3 Finishing and detailing  Finishing does not differ significantly from adolescence  Patients with moderate to severe periodontal loss are stabilized with immediately placed retainers as soon as the finishing archwires are removed.  Later detailing of occlusal relationship by equilibration takes place.  In TMD patient undergoing comprehensive treatment, use of interocclusal splint prevents clenching and grinding from recurring
  82. 82.  13:0 NEWER TECHNIQUES:   13:1 CORTICOTOMY ASSISTED ORTHODONTICS – (JCO 2001 MAY- Chung OH and KO)         CORTICOTOMY has been used in difficult adult cases as an alternative to conventional orthodontic treatment or Orthognathic surgery. The original procedure of single tooth osteotomies or corticotomies was introduced by KOLE in 1959. The primary resistance to tooth movement is encountered in the cortical layer – corticotomy makes teeth to move faster. Teeth acts as handles by which the bands of less dense medullary bone are moved block by block. Thus orthodontic tooth movement after corticotmy is a process of moving block of bone rather than moving only individual teeth. It can be used in treatment of 1. Ankylosed teeth 2. Teeth surrounded by narrow cortical bone 3. Significant arch length discrepancies 4. Transversely constricted maxilla 5. Can be used for posterior intrusion and rapid anterior retraction with maximum anchorage
  83. 83.  6. Can be combined with orthopeadic therapy  Corticotomy surgery initiates and potentiates normal       healing process by way of an accelerated transient burst of hard and soft tissue remodeling by means of a process called REGIONAL ACCELERATORY PHENOMENON (RAP). It was described by an Orthopedist Harold frost. In the alveolar bone adjacent to corticotomy, there was marked increase in regional bone turn over. Tissue forms 2 – 10 times faster than normal regional regeneration process. RAP – decreased the treatment duration especially in adults and multilated cases where conventional orthodontics may not be possible. Examples of clinical applications of RAP in Orthodontics Simple canine retraction immediately after 1st premolar extraction Various corticotomy procedures. Distraction osteogenesis procedure
  84. 84.  ACCELERATED INVISIALING TREATMENT  (Albert H. Owen) (JCO 2002 June Vol. 35 No.6)  Thomas and William Wilcko, using CT discovered that rapid tooth movement following corticotomies was due to reduced mineralization of the alveolar bone housing the involved teeth.  2 years follow up CT showed alveolar bone was adequately remineralized. Wilckos thought that patient could benefit from alveolar augmentation in conjunction with a decorticating procedure. (Augmentation increases the alveolar. crestal height, increases the thickness of the alveolar bone and prevent dehiscenses.  Technique developed by Wilckos, called WILCKODONTICS System (or) ACCELERATED OSTEOGENIC ORTHODONTICS (AOO) is similar to single tooth corticotomy. Here it is extended to all the teeth to be moved orthodontically.
  85. 85. 1. Procedure: 2. 1. Comprehensive FA. 3. 4. 5. 6. 7. 2. Full thickness flap – decortication of alveolar bone 3. Placement of resorbable bone graft agumentation. 4. Soft tissue flap closed. Following surgical procedure, orthodontic adjustment is made weekly to take advantage which RAP, which lasts only for 3 to 4 months. Rate of tooth movement then returns to normal once the bone has healed. Owen combined the AOO procedure and Invisalign therapy in his adult patients. After 10 days of uneventful healing aligners were given. It was found that 3 to 4 times faster tooth movement occurred.
  86. 86.  14.0 CONCLUSION  Biomechanical modifications made to accommodate orthodontic treatment of adult dentitions are generally minor and adhere to the basic laws of physics as they apply to orthodontic tooth movement. Some adult presentations necessitate changes in treatment strategy from what would otherwise be employed in adolescent patients to achieve similar goals. In other cases, objectives themselves may need to be modified because of lack of growth potential, constraints of treatment mandated by the patient or the presence of multiple missing or compromised teeth. By planning treatment and mechanotherapy taking into account the individual circumstances that may affect the patient’s biological response to treatment, realistic goals of orthodontics can be mutually recognized and agreed on by both the provider and the patient before therapy is initiated, resulting in an immensely rewarding experience.)
  87. 87. Thank you Leader in continuing dental education