Adult orthodontics 2

ADULT ORTHODONTICS

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INDIAN DENTAL ACADEMY Leader in continuing dental education

-What is adult?- history of adult orthodontics.- Reasons for increase interest of adults in orthodontic treatment.- Indication- Contraindications. - Difference between adult and adolescent patients.

Adult is defined as one who is fully grown,most males 18 and above and most females of 16 and above can be considered to be adult,although residual growth is left. It is however quite impractical to determine the exact time when adulthood begins.

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

Acc. To MacDowell(1901),after the age of 16 years, a complete and permanent change in transition of the occlusion is almost impossible owing to the development of,- adult glenoid fossa,- density of the bones ,- muscles of mastication.

In 1921 Calvin Case demonstrated the value of orthodontic therapy for the patient with pyorrhea in the lower anterior area.

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

Reasons for the increased interest by orthodontists in the adult as a patient and vice versa. 1) Improved appliance placement techniques.

2) Better management of joint dysfunction.3) More effective management of skeletal jaw dysplasias with advanced orthognathic surgical techniques.

4) Increased desire of patients and restorative dentists for treatment of dental mutilation problems using tooth movement and fixed restorations rather than removable prostheses.5) Reduced vulnerability to periodontal breakdown as a result of improved tooth relationships and occlusal functions.

6) Role of media, visual as well as print articles in magazines ,news paper as well as community programs have increased patient awareness. 7) A broader understanding of the biology of the tooth movement,esp. with regard to age changes.8) Ingenious approaches to anchorage management such as implants.

INDICATIONS: (BY RAVINS)

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

CONTRAINDICATIONS: (BY BARRER)

1) Severe skeletal discrepancies.2) Advanced local or systemic disease.3) Excessive alveolar bone loss.4) Poor stability prognosis.5) Lack of patient motivation.

But mark and cosrn disagree with this list except for systemic disease and lack of patient motivation.

DIFFERENCE B/W ADOLESCENT AND ADULT ORTHODONTIC PATIENT.

Acc to levitt, “ in adult patient there is no growth and only tooth movement”.

Acc to Barrer “ adult, unlike the child is a relentless patient, who will not cover our deficiencies in skills or our errors in the use of mechanical procedures by helpful settling in post-treatment.”www.indiandentalacademy.com

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

FOUR MAJOR CATEGORIES IN WHICH ADULT PATIENT SIGNIFICANTLY DIFFER FROM THEIR ADOLESCENT COUNTERPART:

1) The diagnostic process.2) Treatment plan selection.3) Acceptance of recommended therapy.4) Achievement of treatment objectives.

1) THE DIAGNOSTIC PROCESS.

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

DIAGNOSTIC STEPS:-

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

Before starting the treatment, the orthodontist needs to be prepared to do the following:-

1) Diagnose different stages of pdl disease and their associated risk factors.2) Diagnose TMJ dysfunction before, during or after tooth movement.

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

ADULT ORTHODONTIC TREATMENT OBJECTIVES:

1) Dentofacial aesthetics.2) stomatognathic function.3) Stability.4) Achieving class 1 occlusion.

ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES:-

1) Parallelism of abutment teeth:-

- Restoration will have better prognosis. - Allows for a better pdl response. - Allows for better retention.

2) MOST FAVORABLE DISTRIBTION OF TEETH:-

- Teeth should be positioned in such a way that occlusion of natural teeth can be established bilaterally between the arches.

3) REDISTRIBUTION OF OCCLUSAL AND INCISAL FORCES:-

- helpful in case of significant bone loss.

4) ADEQUATE EMBRESURE SPACE AND PROPRE ROOT POSITION:- - Allows for better pdl health.

5) ACCEPTABLE OCCLUSAL PLANE AND POTENTIAL FOR INCISAL GUIDENCE AT SATISFACTORY VERTICAL DIMENSION.

6) ADEQUATE OCCLUSAL LANDMARK RELATIONSHIP.

7) BETTER LIP COMPETECY AND SUPPORT:-

- Inadequate support may create change in anteroposterior and vertical position of upper lip and increse wrinkling.

8) IMPROVED CROWN/ROOT RATIO:- In case of individual teeth bone loss we can improve the crown to root ratio by decreasing length of clinical crowns tooth is erupted orthodontically.

9) IMPROVEMENT OF MUCOGINGIVAL AND OSSEOUS DEFECTS:- - Proper positioning of teeth in arch will improve gingival topography.

10) BETTER SELF MAINTEINANCE OF PDL HEALTH:- - For better periodontal health tooth should be positioned properly over their basal bone support.

11) ESTHETICS AND FNCTIONAL IMPROVEMENT.

2) TREATMENT PLAN SELECTION:

Factor affecting treatment plan selection:-1) Existing oral pathology: - dental caries - periodontal disease - faulty restoration - TMJ.2) Skeletal relationship.

3) Biological consideration: - neuromuscular maturity. - periodontal susceptibility. - rate of tooth movement. - growth.

4) Therapeutic approach available: - functional appliances. - orthognathic surgery. - restorative dentistry. www.indiandentalacademy.com

5) Extraction/nonextraction.

6) Anchorage requirement.

7) Missing teeth.

FACTOR AFFECTING THE PATIENT’S ACCEPTANCE OF THE TREATMENT PLAN:-

1) Sociobehavioral interaction: - Office environment- Staff training and selection- Team coordination

2) Duration of treatment.www.indiandentalacademy.com

3) Cost of treatment.4) Perceived risk/benefit ratio.5) Appliance selection.6) perceived value orthodontic treatment to dental providers consulted.7) Negative condition.8) Positive conditions.

FACTOR AFFECTING THE ACHIVEMENTS OF TREATMENT OBJECTIVES:-

1) Psychosocial behavioral orientation.2) Previous medical history3) Dental history.4) Ability of the orthodontist to interface the treatment plan with those of other dental specialist.5) skills and knowledge of orthodontist and staff. www.indiandentalacademy.com

1) Psychosocial behavioral orientation:- patient cooperation with the prescribed therapy.- patient’s adaptation to orthodontic appliance.- Patient acceptance of the duration of the treatment.(fatigue factor) - Cost of the treatment.

2) Previous medical history:-

- Minimize force at TMJ in arthritis patient.

- Patient with ulcerative colitis and psoriasis may be taking steroids.

- Uncontrolled diabetic patient.- Patient receiving anticoagulant

therapy. - Patient with hyperacidity can develop root caries during treatment.

- Bacterial and hormonal changes during 2nd trimester of pregnancy can cause severe inflammation.

- Patient with hyperacidity can develop root caries during treatment.- Bacterial and hormonal changes during 2nd trimester of pregnancy -Bacterial and hormonal changes during 2nd trimester of pregnancy can cause severe inflammation.

* Etiology of adult malocclusion.* Types of adult orthodontic patients.* Types of adult orthodontic treatment.* Adjunctive treatment:- Goals- Biomechanical considerations. - Timing and sequence.- Procedures carried out.

ETIOLOGY OF ADULT TOOTH MALPOSITION:-

1) DENTAL ORIGIN2) SKELETAL ORIGIN

1) DENTAL ORIGIN:-

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

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

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

2) SKELETAL ORIGIN:-

a) Cleft palate.

b) Gross mediolateral disharmony of the craniofacial skeleton.

ADULT PATIENTS WHO NEED ORTHODONTIC TREATMENT CAN BE DIVIDED IN TO 2 GROUPS:-

1) YOUNGER ADULTS.( UNDER 35 OFTEN IN THEIR 20’S)

2) OLDER PATIENT IN THEIR 40’S AND 50’S.

1) YOUNGER GROUP:-

Goal:- Improve quality of life.

Reasons for not receiving orthodontic treatment early:-

1) Reluctant about treatment.2) Were not aware of orthodontic treatment.3) Parents could not afford.4) Were not given proper advise by family dentist.5) No orthodontist located in the vicinity.

6) Improper ortho treatment when young or were uncooperative. 7) Had ortho treatment but relapse occurred.8) More conscious of appearance with age.9) Anterior teeth started to crowd or minor crowding becomes worse.

2) OLDER PATIENTS:-

Goal:-

- Maintain proper dental health.

- For the restorative purpose.

Older patient mainly need treatment for:-

1) Malposed teeth contributing to pdl disease.2) Increased difficulties in mastication.3) Anterior space enlarging or developing.4) For better tooth positioning prior to prosthetic preparation. 5) Tooth interference that may causes TMJ problems. www.indiandentalacademy.com

ACCORDING TO PROFFIT ADULT ORTHODONTIC TREATMENT IS DIVIDED IN TO 3 PARTS:-

1) ADJUNCTIVE TREATMENT.2) COMPREHENSIVE TREATMENT FOR ADULTS.3) SURGICAL TREATMENT.

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

1) ADJUNCTIVE TREATMENT:-

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

GOALS :-

1) Facilitates restorative treatment by positioning the teeth.

2) Improve periodontal health by removing plaque harboring areas .

3) Establishing favourable crown to root ratio and position of the teeth.

BIOMECHANICAL CONSIDERATIONS:-

- Control of anchorage requires that anchor teeth should not be allowed to tip.

- Fixed appliance is necessary.

-Adult patients demand for removable appliance but they are not useful in adjunctive treatment.

- But in case of multiple missing teeth removable appliance is useful.

Placement of brackets

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

TIMING AND SEQUENCE OF TREATMENT:-

- Before any type of tooth movement any caries or pulpal pathology should be eliminated.

- Larger restoration require detail occlusal anatomy should be carried out after orthodontic treatment is over.

- Periodontal disease should be controlled before any tooth movement.

- Scaling, curettage and gingival graft should be carried out before treatment.

- Surgical pocket elimination and osseous surgery should be carried out after orthodontic treatment.

PROCEDURES CARRIED OUT IN ADJUNCTIVE TREATMENT : -

1) UPRIGHTING POSTERIOR TEETH.2) FORCED ERUPTION.3) ALIGNMENT OF ANTERIOR TEETH.4) CROSSBITE CORRECTION.

UPRIGHTING POSTERIOR TEETH:-

1) If third molar is present , whether both second and third molar should be uprighted.

2) Whether to upright tipped teeth by distal crown tipping or by mesial root movement.

3) Whether we need slight extrusion or maintain occlusal height during uprighting.

4) Whether premolar should be repositioned or not.

APPLIANCE FOR MOLAR UPRIGHTING:-

- Partial fixed appliance.

- Anchorage.

- Placement of brackets on canine and premolars.

UPRIGHTING A SINGLE MOLAR:-

Moderately tipped molar:-

- 17x25 braided s.s - 17x25 Ni-Ti Severely tipped

molar:- -19x25 s.s - Uprighting spring ( 17x25 beta- Ti)

• “ T-loop”

- 17x25 s.s

- 19x25 beta-Ti

• Activation of T-loop.

• Severely tipped teeth:-

- Use of modified T-loop.

• Final position of molars and premolars.

• Use of open coil spring - steel

- A Ni-Ti

• Occlusion should be checked carefully.

RETENTION

• For shorter period

• For a longer period.

- Intracoronal wire splint

FORCED ERUPTION:-

Indications:-

- Defects in cervical third .

TREATMENT PLANING:-

- Periapical radiograph.

- Single tapering and flared and divergent root morphology.

- Endodontic therapy.

How much tooth should be extruded can be determine by 3 factors:-

1) Location of the defect.(fracture line)

2) Space to place margin of the restoration.(1 mm)

3) An allowance for the biological width of the gingival attachment.(2 mm)

Duration:-

- 1mm/week without damaging pdl.

- 3 to 6 week.

TECHANIQUE

• Continuous flexible wire is contraindicated.

2 METHODS

• With orthodontic bracket.

• Without orthodontic bracket.

• Brackets are placed more occlusally on anchor teeth than its ideal position.

• T-loop,

- 17x25 s.s

- 19x25 beta-Ti

RETENTION:-

- By passively fitting rectangular arch wire.(3 to 6 week).

ALIGNMENT OF ANTERIOR TEETH

Indications:-

1) To improve access and permit placement of well contoured restorations.

2) To permit placement of crowns and pontics .

3) To reposition closely approximated roots and to improve the amount of interradicular bone.

4) To position teeth so that implants can be placed to support restorations.

* Alignment of crowed, rotated and displaced incisors.

* Separation of approximated teeth.

• Position teeth for single tooth implant:-

- Minimum 6mm of space is require. - Apices of adjacent teeth.

Anterior diastema closure and space redistribution:-

Causes:-- Loss of posterior teeth.- Small teeth..- Loss of bone support.

TREATMENT:-

- With Removable appliance.

- With fixed appliance.

CROSSBITE CORRECTION:-

- It can cause functional problem and occlusal trauma.

- Single tooth crossbite.

- Group of teeth in crossbite.(part of skeletal problem).

- Correction with removable appliances.(anterior segment)

- Correction with the “through the bite” elastics.(posterior segment).

SUMMARY:- There is wide variety of etiology that can cause an adult malocclusion. Also each patient’s need for treatment are different so treatment should be carried out taking his/her needs in consideration.Adjunctive treatment helps by facilitating other dental procedures to control disease and restore function.

PERIODONTAL ASPECT OF ADULT TREATMENT:-

1) Minimal periodontal involvement.2) Moderate periodontal involvement.3) Severe periodontal involvement.

1) MINIMAL PERIODONTAL INVOVEMENT: -

CHILDREN AND ADOLESCENT ARE LESS SUSEPTIBLE TO PERIODONTAL DISEASE THAN ADULTS.

2) MODERATE PERIODONTAL INVOVEMENT: -

All periodontal disease should be controlled before tooth movement.

Fully bonded orthodontic appliance is preferred in periodontally involve adult patient.

Steel ligatures or self legating brackets are preferred.

Periodontal maintenance therapy at 2-4 month interval.

3) SEVERE PERIODONTAL INVOVEMENT: -

Periodontal maintenance should be scheduled at more frequent intervals.

Orthodontic goals and mechnics should be modified to keep force value minimum.

SPACE CLOSURE VS. PROSTHETIC REPLACEMENT: -

Old extraction site: -

Space closure is difficult in adult.

The involvement of cortical bone tend to produce reciprocal space closure.

Implant in the ramus can be use to provide necessary anchorage.www.indiandentalacademy.com

TOOTH LOST DUE TO PERIODONTAL DISEASE: -

Unwise to move a teeth in area where bone is destroyed because of periodontal disease.

SURGICAL TREATMENT: -

- orthognathic basically involves planned fracturing of the facial skeletal parts and reposition them as desired.

- Moderate to severe skeletal discrepancy.

- Patient education.

SURGICAL PROCEDURES: -

1) Correction of anteroposterior relationship: -

both maxilla and mandible can be moved forward or backward for correction of jaw discrepancy.

A) MAXILLARY SURGERY: -

The LeFort 1 downfracture procedure is used to reposition the maxilla.

B) MANDIBULAR ADVANCEMENT:-

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

C) MANDIBULAR SETBACK: -

- BSSO.

- The transoral vertical oblique ramus osteotomy(TOVRO).

2) CORRECTION IN VERTICAL PLANE: -

a) Maxillary surgery: -

- LeFort 1 downfracture of the maxilla, with superior reposition of the maxilla.

- In downward movement of the maxilla rigid fixation are used.(synthetic hydroxyapatite)

b) Mandibular surgery: -

mandibular ramus surgery in open bite cases avoided.

Short face(skeletal deep bite) best treated by saggital split mandibular ramus surgery.

3) CORRECTION OF TRANSVERSE RELATIONSHIP: -

easy to move maxilla in transverse direction then mandible.

A) MAXILLARY EXPANTION: -

Constriction or expantion done during course of Lefort 1 downfracture procedure.

GENIOPLASTY

RETENTION: -

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

-Hawley retainer.

- Hawley retained with tongue cribs.

- fixed bonded retainer(max. and mand. Anterior segments)

Restorative retainers: -

- composite restoration.

- amalgam, inlay or onlay.

- pontics (fixed/removable).

Periodontal surgical retention procedure:

- Fibrotomy.

- gingivectomy.

TREATMENT CONSIDERATIONS IN PATIENTS WITH TEMPOROMANDIBULAR DYSFUNTION

TMD as motivating factor for adult patient.

Orthodontic treatment helps patient with TMD problems.

TMD symptoms can be divided in 2 groups: -

- Internal joint pathology.(Arthritis)

- Symptoms of muscle origin caused by spasm and fatigue of the muscle.

TEMPOROMANDIBULAR JOINT DISORDERS: -

- Deviation in form.- Disk displacement.- TMJ hypermobility.- Dislocation.- Synovitis.- Capsulitis.

- Osteoarthritis.

- Ankylosis.

ETIOLOGY

Normal function + An event >

Physiologic tolerance

TMD symptoms www.indiandentalacademy.com

EVENTS: -

1) Local events: -

- History of bruxism.- Trauma- Poorly aligned teeth.- Placement of improperly occluding crown.- Loss of posterior teeth.www.indiandentalacademy.com

Systemic events: -

- Emotional stress.- Acc. To Han Selye “ Stress is a non specific response of the body to any demand made upon it.”

Physiologic tolerance.

Clinical presentation: -

- Pain at preauricular area or temple area or at ear when chewing or opening the mouth.

- Pain may radiate to head, face or eye.

Behavioral changes like,

- Avoiding wide opening of the mouth.

- Patient prefers softer food.

OCCLUSAL STABILITY

HISTORY AND EXAMINATION FOR TMD

- Questionnaire.

- Orofacial pain history.

CLINICAL EXAMINATION

• Nonmasticatory examination.

• Masticatory examination.

Nonmasticatory examination

• Cranial nerve examination.

• Eye examination.

• Ear examination.

• Cervical examination.

Examination of optic nerve andoculomotor, trochlear and abducent

nerve.

CERVICAL EXAMINATION

Masticatory examination

• Muscle examination.

• TMJ examination.

• Dental examination.

MUSCLE EXAMINATION

MASSETER MUSCLE EXAMINATION

STERNOCLIEDOMASTOID MUSCLE

PALPATION OF TMJ

• Maximum interincisal distance.

• Lateral and protrusive movement.

• Opening pathway of mandible.

TREATMENT OF TMD

• Control of myofacial pain.

• Treatment of TMJ.

Three approaches to control myofascial pain: -

1) Reducing the amount of stress.

2) Reducing the patient’s reaction to the stress.

3) Improving the occlusal relationship.

Treatment of TMJ disorders: -

1) Definitive treatment.

2) Supportive treatment.

Definitive treatment: -

1) Occlusal therapy: -

- Reversible occlusal therapy. - Irreversible occlusal therapy.

2) Emotional stress therapy.

2) Supportive therapy: -

a) Pharmacological therapy: - - Analgesics - NSAIDs - Corticosteroids - Muscle relaxants - Local anesthetics.

b) Physical therapy: -

- Thermotherapy.- Coolant therapy.- Ultrasound therapy.- Iontophoresis.- Electrogalvenic stimulation therapy.

-Transcuteneous electrical nerve stimulation.

- Acupuncture.

OCCLUSAL APPLIANCE THERAPY

• It is a removable device, usually made up of hard acrylic that fits over the occlusal and incisal surfaces of the teeth in one arch , creating precise occlusal contact with the teeth of the opposing arch.

TYPE OF OCCLUSAL APPLIANCES

• STABILIZATION APPLIANCE

• ANTERIOR POSITIONING APPLIANCE

• ANTERIOR BITE PLANE

• POSTERIOR BITE PLANE

• PIVOTING APPLIANCE

• SOFT OR RESILIENT APPLIANCE

STABILIZATION APPLIANCE

• Muscle relaxation appliance

• Fabricated on maxillary arch

• Indicated in patient with muscle hyperactivity.

e.g. bruxism

- Fabrication of appliance.- Locating the musculoskeletally stable position.- Developing occlusion.

FINAL CRITERIA FOR STABILIZATION APPLIANCE

• Appliance must accurately fit the maxillary teeth.

• In centric relation all posterior mandibular buccal cusp must contact on flat surface with even force.

• In any lateral movement only mandibular canines should exhibit contact on the appliance.

• It should polished.

ANTERIOR REPOSITIONING APPLIANCE

• It is an interocclusal devise that encourages the mandible to assume a position more anterior then the intercuspal position.

• Mainly used to treat disc derangement disorders.

Locating the correct anterior position

• Anterior stop is constructed.

• Joint symptoms are evaluated.

Sometime orthodontic treatment becomes more complicated by previous splint therapy for TMD problems.

The moment of truth for TMD symptoms comes after orthodontic treatment is completed, when clenching and grinding that originally caused the problem tend to recur.

LIMITATION IN ADULT ORTHODONTIC TREATMENT: -

1) INTRINSIC.

2) EXTRNSIC.

1) INRINSIC: -

- Adults are no longer growing.

- PDL status.

ACCORDING TO CHASENS, ORTHODONTIC TREATMENT SHOULD BE AVOIDED IN FOLLOWING CLINICAL SITUATIONS: -

1) Incontrolled inefection and inflammation.

2) Inadequate retention is present.

3) Lack of patient motivation and cooperation.

4) Systemic problems which cannot be treated or difficult to control.

SUMMARY:- There is wide variety of etiology that can cause an adult malocclusion. Also each patient’s need for treatment are different so treatment should be carried out taking his/her needs in consideration.Adjunctive treatment helps by facilitating other dental procedures to control disease and restore function.

TMD serves as one of the motivating factors for adult patient to visit orthodontist. Relief of pain by providing adequate TMJ therapy motivates patient to undergo the remaining restorative or orthodontic treatment.

THANK YOU

For more details please visit www.indiandentalacademy.com

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