Increased awareness of the importance and benefits of a healthy dentition and a pleasant smile are motivating adults to seek orthodontic treatment more so now than in the past. Presently, the amount of orthodontic treatment rendered to adults comprises 30% of the orthodontic practice. The desire for a better smile is not only being patient generated, but general dentists are also becoming more knowledgeable about the possibilities of adult tooth movement to facilitate the establishment of function and health to the different components of the stomatognathic system.
Interdisciplinary treatment is calling for more orthodontic interaction with the other specialties to obtain more optimum results in the restoration of often broken-down adult dentitions. The advent of new technology, such as esthetic brackets, invisible braces, new orthodontic wire alloys, and better brackets designed to reduce friction and speed up tooth movement, are also an incentive to attract more adults to seek orthodontic treatment.
• Adult orthodontic treatment is usually initiated by the general dentist requesting the establishment of occlusal harmony (Fig. 17-1, A and B).
• The lack of craniofacial growth offers no advantage or disadvantage to the orthodontic treatment.
• Periodontal disease is present in about 80% to 90% of the adult patients (Fig. 17-1, C-E)
• There is a high incidence of missing permanent teeth.
• Increased tooth mobility; this is a consequence of a change in occlusal scheme and loading as a result of the uncontrolled dental shifting caused by the mutilated dentitions and/or periodontal disease.
• The lack of long-term stability resulting from periodontal problems requires a different approach to retention.
• The increased prevalence and incidence of temporomandibular joint (TMJ) disorders requires a careful approach to the change in occlusal scheme.
• The use of segmental orthodontic treatment mechanics and differential forces should be considered when the crown-to-root ratio is unfavorable.
• Most adults are concerned with esthetics and the appearance of braces. The use of less conspicuous orthodontic appliances like ceramic brackets, lingual orthodontics, and Invisalign should be considered.
• Motivation for treatment in adults comes from the pursuit of esthetic changes or to restore a broken-down dentition or alleviate functional problems (e.g., TMJ dysfunction). The psychological response to treatment varies with the initial motivation. Those patients seeking treatment to improve function are more likely to have a better psychological response than those who are expecting an impact in others by their perceived change in facial appearance.
• Most adults require a multidisciplinary treatment plan to adequately restore esthetics and function.
FIG 17-1Adult patient seeking orthodontic treatment. Note the complexity of the malocclusion. A and B, Pretreatment facial photos depicting the skeletal imbalance. C-E, Intraoral photos show the dental and periodontal problems in this adult patient.
2 What are the goals of adult orthodontic treatment?1–3,6,7
The objectives of adult orthodontic treatment are:
• To achieve improved function, stability, and esthetics
• To eliminate occlusal interferences and trauma to reduce tooth mobility and promote periodontal healing
• To obtain better bone and gingival architecture
• To establish proper tooth position and improve the plane of occlusion for prosthodontic rehabilitation
• To achieve harmony between teeth and TMJ function
• To address the patient’s chief complaint, which is usually related to dental and facial esthetics
3 What are the contraindications for adult orthodontic treatment?8–12
• The presence of advanced local and/or systemic diseases such as bone, metabolic, or endocrine and renal disorders could adversely affect tooth movement and bone turnover. The use of bisphosphonates, calcitonin, and ibuprofen has a negative effect on the rate of tooth movement.
• The presence of active periodontal disease contraindicates orthodontic tooth movement, since it could accelerate the process of periodontal problems and concomitant tooth loss.
• Patients with significant root resorption and poor crown-to-root ratio may not benefit from orthodontic treatment.
• When patient compliance with long-term retention and follow-up prosthetic rehabilitation is not present, orthodontic treatment should not be initiated.
• Because of the high incidence of osteopenia and osteoporosis in adults over 50 years of age, a bone mass density test could be prescribed to screen for bone disorders that can lead to alveolar bone loss and loss of teeth.
4 What are the effects of orthodontic treatment on the periodontal tissues?13–17
• The elimination and control of inflammation before and throughout orthodontic treatment is imperative to ensure the health of the supporting tissues. Clinical studies have demonstrated that teeth with reduced periodontal support, in the absence of inflammation, can undergo tooth movement without compromising the periodontal status.
• Reduction of pocket depth and probing in orthodontically moved teeth in adults as well as maintenance of a minimal band of attached gingiva can be accomplished with orthodontic treatment.
• A free gingival graft is recommended when minimum amount of attached gingiva is present and when the tooth movement is directed toward the thin gingival tissue. When tooth movement is confined to the alveolar support, no harmful effects on the surrounding tissues are to be expected.
• Adults have an increased prevalence of root resorption during orthodontic treatment. The use of light forces is recommended to avoid the formation of hyalinized areas and to expedite tooth movement.
5 What kind of periodontal therapy should be instituted before, during, and after adult orthodontic tooth movement is initiated?18
• The elimination of inflammation that rapidly deteriorates the periodontium is essential prior to the initiation of tooth movement. Plaque and inflammation control should continue throughout orthodontic therapy and afterwards.
• Scaling, root planing, open flap surgery, and gingival grafting should be done prior to the commencement of orthodontic treatment.
• Recontouring osseous surgery should be postponed until after orthodontic treatment. The architecture of the bone will change with the tooth movement and possibly less bone recontouring may be necessary after orthodontic treatment.
• Bone grafting procedures to increase alveolar width and height in an edentulous area through which tooth movement is to occur, should be done prior to orthodontic treatment. Bone grafting for implant placement could be done 6 months prior to debanding or postponed until treatment completion.
• Equilibration of occlusal interferences that may arise during treatment should be done at each appointment as necessary to avoid periodontal breakdown and excessive tooth mobility from occlusal trauma.
6 Which orthodontic records are necessary for proper diagnosis and treatment planning of the adult orthodontic patient?19–21
Because of the complexity of factors among which the malocclusion is included, a careful evaluation of the patient, including a thorough medical history, chief complaint, and psychological evaluation, is necessary to properly integrate those factors with the ones related to the actual dental treatment. The standard orthodontic record consists of:
• Facial photographs (frontal with lips in repose, frontal smiling, profile with lips in repose). This will provide important information about the soft tissue drape of the face, such as lip length and competency, soft tissue chin prominence, nose prominence and slope, amount of gingival display, midline deviations, and overall facial proportionality.
• Cephalograms (lateral and frontal).
• Panoramic x-rays and full mouth periapical surveys to evaluate for bony, dental, and periodontal pathologies as well as anatomy of the roots.
• Submental x-ray and TMJ tomograms may be necessary to diagnose skeletal asymmetries and TMJ pathology.
• Models mounted in centric relation will help to detect a CO-CR slide, which is imperative before the commencement of orthodontic treatment. Roth has suggested that even in the absence of obvious signs or symptoms of TMJ dysfunction, adult patients, specifically those with mutilated dentitions, should undergo splint therapy to eliminate muscle splinting and to avoid treatment planning from a false mandibular position.
7 What is the sequence of adult orthodontic treatment?22
Once the diagnosis and treatment plan have been established, a treatment sequence should be considered as follows:
1. Emergency relief of pain—this step, in many instances, will precede the gathering of orthodontic records and follow-up diagnosis.
2. Therapy of soft tissue lesions
• Hygiene instructions
• Scaling and root planning
• Correction of inadequate restoration
• Root resection and endodontic treatment
3. Treatment of the lesions of the attachment
• Flap surgery and root planning
• Guided tissue regeneration
• Autogenous keratinized mucosal or connective tissue grafts
• Orthodontic therapy
• Occlusal adjustment
• Myofunctional therapy
4. Provisional stabilization and retention
5. Reevaluation for further therapy (e.g., extraction of non-restorable teeth)
6. Completion of periodontal treatment
7. Final occlusal adjustment
8. Restorative prosthetic dentistry
9. Continued periodontal care
8 What are the treatment options for adult patients?23
Limited tooth movement and comprehensive orthodontic treatment can be considered when treatment planning an adult orthodontic case. The severity of the malocclusion and treatment goals should be considered when selecting the treatment.
Limited tooth movement is carried out either with removable or partial fixed orthodontic appliances and is aimed at specific treatment goals. In most instances, limited tooth movement is considered as an adjunct to the overall oral rehabilitation of the patient.
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