Adult orthodontics /certified fixed orthodontic courses by Indian dental academy

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


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INTRODUCTION
HISTORY
DIFFERENCE BETWEEN ADOLESCENT AND
ADULT
LIMITATIONS OF TREATMENT IN ADULT
TREATMENT PLANNING FOR ADULT
PATIENTS
GOAL OF ORTHODONTIC TREATMENT IN
ADULTS
BIOMECHANICAL CONSIDERATION IN ADULT
ORTHODONTICS
ADJUNCTIVE TREATMENT
COMPREHENSIVE TREATMENT
SURGICAL ORTHODONTIC TRATMENT
LESS VISIBLE TREATMENT MODALITIES FOR
ADULTS
RETENTION
NEWER TECHNIQUES

 INTRODUCTION
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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.

 HISTORY
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Conflicting opinions have always existed regarding
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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.

 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

 LIMITATIONS OF TREATMENT IN ADULTS
 There are two categories of factors:
(a) INTRINSIC
BIOLOGICAL
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(B) EXTRINSIC
BIOMECHANICAL
SYSTEMS
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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

 Other Intrinsic Factors
 4:1:1 Periodontium
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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

 Lace like Bone pattern


Honeycomb Bone pattern

 Without Marginal Bone

 With Marginal Bone Loss

Loss


 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
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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.

 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.


 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

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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

 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.

 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
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Muscle disorders - 23%
Joint disorders – 19%
Muscle / Joint disorder combination – 27%
Normal – 31%

 TMJ DISORDERS
 Deviation in form - Irregularities in intracapsular soft and hard articular
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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.

 5:4:1 Diagnosis for Osteoporosis
 Adults patients particularly females between 45 – 50yrs
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(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

 5:4:2 Oral Manifestations of Osteoporosis
 Osteoporosis is a systemic deterioration of the skeletal
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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

 6:0 TREATMENT PLANNING FOR ADULT PATIENTS
 6:1 Scope of Procedures
 Musich’s conducted a study on 1400 adults and
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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

 6:2 Factor in selection of treatment
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plan.
Existing oral pathology
Skeletal relationship
Biological considerations
Therapeutical approaches available
Extraction (vs) Non extraction therapy
Anchorage requirements
Missing teeth (Dental mutilation)

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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.

 Therapeutic approaches available –
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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..


 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)

 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.

 Adult patients requiring intrusion of molars to control
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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.

 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.
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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”.
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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.

 7:1 Orthodontist commonly tries to achieve the following
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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.

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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 caninewww.indiandentalacademy.com
area.

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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.

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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.


 :0 BIOMECHANICAL CONSIDERATIONS IN ADULT
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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. www.indiandentalacademy.com magnitude of force
The absolute
must therefore be reduced.

 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).
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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.

 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.

Loss of vertical
control
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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

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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


 0 ACCORDING TO PROFFIT, ADULT
ORTHODONTIC PROCEDURE CAN BE
CONVENIENTLY CLASSED INTO
THREE CATEGORIES.
 Adjunctive treatment
 Comprehensive treatment
 Surgical-orthodontic treatment


 ADJUNCTIVE TREATMENT:
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Adjunctive orthodontic treatment is tooth movement
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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.

 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.

 :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.


 COMPREHENSIVE TREATMENT
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 STAGE 1: DISEASE CONTROL
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 Revaluate
 STAGE 2: ESTABLISH OCCLUSION

Stabilize

 STAGE 3: DEFINITIVE PERIO / RESTORATIVE
TREATMENT

 STAGE 4 :MAINTENANCE
 HERE ORTHODONTICS IS USED TO ESTABLISH
OCCLUSION.


 9:6 Possible tooth movement in adjunctive treatment
 (a) Mesial or distal movements of specific crowns and
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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 .


 9:7 Biomechanical considerations:
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Control of anchorage requires that anchor teeth not
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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.

 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.

 10.1 COMPREHENSIVE TREATMENT FOR ADULTS
 Comprehensive orthodontic treatment aims at making
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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 www.indiandentalacademy.com
for seeking orthodontic treatment.

 While treating adults
 Appliance should be simple in order to elicit maximum
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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.

 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.

 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
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Those with rapid progression (10%)
Those with moderate progression (80%)
Those with no progression despite the presence of
gingival inflammation (10%).

 10:3:1 MINIMAL PERIODONTAL INVOLVEMENT:
 Bacterial plaque being the main etiological factor in
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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.

 10:3:2 MODERATE PERIODONTAL INVOLVEMENT:
 Disease control: Preliminary periodontal therapy is preformed
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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 bewww.indiandentalacademy.com
considered.

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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.

 ORTHODONTIC TREATMENT OF PERIODONTAL

DEFECTS –(Seminars in orthodontics) vincent kokich
-1997
 Advanced Horizontal Bone Loss:
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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.

 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.
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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.

 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.
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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.

 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.

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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.

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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.

 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.

 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
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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.

 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.

 OGS can be performed in both jaws and is all 3
planes of space.
 In Anterioposterior plane.
 - MAXILLARY SURGERY

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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
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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.

 MANDIBULAR SETBACK
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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.
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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.

 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.


 MAXILLARY SURGERY
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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.
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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.
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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.

 MANDIBULAR SURGERY:
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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.

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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.

 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.
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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.

 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

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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.


 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 www.indiandentalacademy.com
pterygomandibular sling is stretched during
mandibular osteotomy, as when the mandible is reotated to close

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.

 12:1 Retention
 Retention is a critical and challenging aspect of adult
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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.

 12:2 Periodontal – Surgical Retention
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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.

 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.

 12:3 Types of retainer used
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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.

 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.

 10:4:2A The INVISALIGN SYSTEM (BJO-2003 – December vol 30
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(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.

 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

 Tooth Movements
 Mildly crowded and malaligned problems (1 – 5mm) Treatment can
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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
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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

 Advantages
 Ideal esthetics : aligners are relatively invisible apart
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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.

 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

 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
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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

 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.

 10:4:3 Space closure (Vs) Prosthetic replacements in

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

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

 10:5 MODIFIED MECHANOTHERAPY ADULTS




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



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.

 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

 13:0 NEWER TECHNIQUES:

 13:1 CORTICOTOMY ASSISTED ORTHODONTICS – (JCO 2001
MAY- Chung OH and KO)





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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

 6. Can be combined with orthopeadic therapy
 Corticotomy surgery initiates and potentiates normal




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

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

 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.

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.

 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.)

Thank you


Adult orthodontics /certified fixed orthodontic courses by Indian dental academy

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