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AdultOrthodontics
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Adult Orthodontics
Adult orthodontic treatment is the one thatis specially targeting post- adolescent
patients.It also includes tooth movement carried
out to facilitate other dental procedures
necessary to control disease andrestore function.
has been the fastest growing area in
orthodontics in recent years.
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Two groups of adult patients:
Young adults
• who desired but did not receive
comprehensive orthodontic treatment asyouths
Older Adults
• who have other dental problems receiveadjunctive orthodontic treatment to makecontrol of dental disease and restoration
of missing teeth easier and more effective.
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HISTORY OF ADULT ORTHODONTICS
Kingsley (1880 ) indicated an earlyawareness of the orthodontic potential foradult patients and stated that there are
hardly any limits to the age when movementof teeth might not succeed.
• Differences between tooth movement in
adolescent and older patients.
• Results become more and more doubtful withadvancing years when a considerablenumber of teeth are to be moved
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HISTORY OF ADULT ORTHODONTICS
MacDowell (1901) considered the age after 16years as Impossible age. Believed complete and
permanent change cannot be accomplishedsuccessfully except in cases of rare exceptionsowing to
• development of the adult glenoid fossa
• the density of the bones
• less adaptability of muscles of mastication.
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HISTORY OF ADULT ORTHODONTICS
Lischer (1912) considered the period fromthe sixth to the fourteenth year i.e. time in
an when a change from the temporary to thepermanent dentition takes place as theGolden age of treatment.
Case (1921) demonstrated the value ofadult orthodontic therapy for patient withpyorrhea in the lower anterior area.
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HISTORY OF ADULT ORTHODONTICS
Recently, a major reorientation oforthodontic thinking has occurred
regarding adult patients. Because of thefollowing reason :
1. Improved appliance placement techniques
2. More sophisticated and successfulmanagement of the symptoms associatedwith joint dysfunction.
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HISTORY OF ADULT ORTHODONTICS
3. More effective management ofskeletal jaw dysplasia’s using advancedorthognathic surgical techniques
4. Increased desire of patients and
restorative dentists for treatment ofdental mutilation problems using toothmovement and fixed restorations ratherthan removeable prosthesis.
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Adult orthodontics
Adult orthodontics can mainly be dividedinto
Comprehensive treatment of adults
Adjunctive Treatment for AdultsCombined surgical and orthodontic
treatment
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Comprehensive treatment
The boundary between adjunctiveand comprehensive treatment is
indistinct.
Treatment that requires
a complete fixed appliance or
that is complex enough to require morethan 6 months for completion is
considered comprehensive.
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Comprehensive Treatment Plan
The treatment plan is a prospectivesequence of medical and dental
procedures designed to alleviate theprioritized list of problems.
For a favorable long-term prognosis, it
is important to direct treatment ateliminating or at least controlling theetiology of the problems.
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Alternate Treatment Plans
Constructed by arranging the teeth in aseries of drawings that reflect thetherapeutic options.
Way of communicating with patient regarding
• biologic considerations,
• treatment alternatives,
• potential compromises,
• probable consequences.
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Adult orthodontic TreatmentObjectives
The typical adolescent orthodontictreatment objectives
• dentofacial esthetics,• stomatognathic function,
• stability ,
• static and dynamic Class I occlusion
often may not be realistic or necessary for all
adult patients.
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Treatment in which adolescent goals arenot achieved is not necessarilycompromised
The mechanotherapy should satisfy the
objective of providing the minimal dentalmanipulation appropriate for the individualcase.
Adult orthodontic TreatmentObjectives…..
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Adolescent treatment objectives includingClass I occlusal goals can be considered
overtreatment for patients who also require• restorative dentistry,
• prosthetics,
• plastic surgery and
• other multidisciplinary dentofacial
corrections
Adult orthodontic TreatmentObjectives….
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ADDITIONAL ORTHODONTICTREATMENT OBJECTIVES
1. Parallelism of abutment teeth.
2. More favorable distribution of teeth.
3. Redistribution of occlusal and incisal forces.
4. Adequate embrasure space and proper
tooth position.
5. Acceptable occlusal plane and potential forincisal guidance at satisfactory vertical
dimension.
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ADDITIONAL ORTHODONTICTREATMENT OBJECTIVES…
6. Adequate occlusal landmark relationships.
7. Better lip competency and support.8. Improved crown/root ratio.
9. Improvement or self-correction ofmucogingival and osseous defects.
10. Improvement and self-maintenance of
periodontal health.
ADDITIONAL ORTHODONTIC TREATMENT
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ADDITIONAL ORTHODONTIC TREATMENT
OBJECTIVES… Parallelism of abutment teeth.
The abutment teeth must be placedparallel with the other teeth to permit
insertion of multiple unit replacement.
For full-arch splints, the posterior teethshould be reasonably parallel to
anterior abutments.
ADDITIONAL ORTHODONTIC TREATMENT
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ADDITIONAL ORTHODONTIC TREATMENT
OBJECTIVES…
Parallelism of abutment teeth…
Parallel abutments allow for betterrestorative retention
A restoration will have a better prognosis ifthe abutment teeth are parallel beforetooth preparation.
• does not require excess cutting ordevitalization during abutment preparation
• allows for a better periodontal response.
ADDITIONAL ORTHODONTIC TREATMENT
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ADDITIONAL ORTHODONTIC TREATMENT
OBJECTIVES…
More favorable distribution of teeth
The teeth should be distributed evenly forplacement of fixed and removableprostheses in the individual arches.
Moving the teeth to act as favourableabutments can reduce the need for distal
extension partial dentures or implants.They should be positioned so that
occlusion of natural teeth can be
established bilaterally between arches.
ADDITIONAL ORTHODONTIC TREATMENT
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ADDITIONAL ORTHODONTIC TREATMENT
OBJECTIVES… Redistribution of occlusal and incisal forces.
Cases with significant bone loss requireocclusal forces to be directed verticallyalong the long axis of the roots.
• Teeth can be moved orthodontically to morefavourable positions.
• If posterior teeth are missing, anterior teeth canbe positioned to allow favourable transfer offorce and can then be reshaped to functionas posterior teeth (supporting the verticaldimension .
ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES
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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Adequate embrasure space and properroot position
Allows for better periodontal health, especiallywhen the placement of restorations is
necessary.Anatomic relation of the roots is important in
the pathogenesis of periodontal disease,
interproximal cleaning,
placement of restorative materials.
Acceptable occlusal plane and
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Acceptable occlusal plane andpotential for incisal guidance atsatisfactory vertical dimension.
To establish the acceptableocclusal plane for a mutilated
dentition exhibiting bite collapse,the Hawley bite plane is insertedwith the platform of the anterior
plane adjusted at a right angle tothe long axis of the lowerincisors.
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Acceptable occlusal plane andpotential for incisal guidance atsatisfactory vertical dimension.
This allows a centric relation at anacceptable vertical relationship to be
maintained, while
tooth alignment and
movement of the teeth to a morefavorable position
to support the vertical dimensions and
occlusal loading takes place.
Acceptable occlusal plane and
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Acceptable occlusal plane andpotential for incisal guidance atsatisfactory vertical dimension…
If the vertical dimension is excessivepatient may complain of muscle
fatigue.
However when properly adjusted at thecorrect vertical height, the bite plane
will allow simultaneous bilateralneuromuscular activity.
A bl l l l d
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Acceptable occlusal plane andpotential for incisal guidance atsatisfactory vertical dimension…
If supraerupted molars are present,
most extruded posterior segmentdetermines the potential for anorthodontic solution at an acceptablevertical dimension.
The unilateral orthodontic treatment of anaccentuated occlusal plane should beavoided; one side cannot be left extruded.
A bl l l l d
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Acceptable occlusal plane andpotential for incisal guidance atsatisfactory vertical dimension…
Adult molars with amalgamrestorations and normal pulpal
recession often can be occlusallyreduced 2 to 4mm to achieve anacceptable occlusal plane level and
still allow for placement ofrestorations without the need fordevitalization.
A t bl l l l d
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Acceptable occlusal plane andpotential for incisal guidance atsatisfactory vertical dimension…
In some of Class II, division I cases (when orthognathic surgery is
rejected) the lower incisors canbe advanced into a moreprocumbent position than the
usual orthodontic norm toestablish incisal guidance.
A t bl l l l d t ti l
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Acceptable occlusal plane and potentialfor incisal guidance at satisfactoryvertical dimension…
With the aid of bilateral posteriorrestorations, the incisors can be
stabilized when in relatively flaredpositions (IMPA 1050 to 1200).
In some Class III patients as well, the
maxillary incisors can be kept instable relation (even though moreflared than normal) with posterior
restorations.
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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Adequate occlusal landmarkrelationships.
For adult patients, transverse dimension ismost difficult to correct and maintainorthodontically, followed by sagittal andvertical.
• Posterior crossbites with severe transverse
skeletal dysplasis, not to undergo surgeryshould be positioned so that maxillarybuccal cusps contact the lower centralfossae with crossover for incisal guidance in
premolar area or canine positions
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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Better lip competency and support.
Many adults have long upper lips thatpreclude significant maxillary
retraction.
In such cases retraction isrecommended to achieve lip
competency while maintaininglip support.
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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Better lip competency and support…
Inadequate support may create achange of anteroposterior and vertical
position of upper lip and increasewrinkling.
This makes the face seem prematurely
aged and is a major esthetic concernof adults.
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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Improved crown/root ratio
In adult patients who have lost bone onindividual teeth, the ratio of crown to
root can be improved by reducing thelength of the clinical crown with the high-speed handpiece; as the tooth is eruptedorthodontically.
As the tooth erupts orthodontically thebone also follows the tooth so that the
bone support is not compromised.
ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES
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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Improvement or correction ofmucogingival and osseous defects…
Proper repositioning of prominent teeth inthe arch improves gingival topography.
In adults the goal should be to level thecrestal bone between adjacentcementoenamel junctions.
This creates more physiologic osseousarchitecture with the potential to correctcertain osseous defects.
ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES
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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Improvement or correction ofmucogingival and osseous defects…
Need for osseous and mucogingivalsurgery may be diminished by favorabletooth movement.
• During leveling stages, any teeth that haveerupted above the occlusal plane should
be grossly reduced occlusally; to preventposterior premature contact and occlusaltrauma, that can lead to bone loss oradverse changes in the supporting bony
architecture.
ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES
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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Better self-maintenance of periodontalhealth.
The location of the gingival margin isdetermined by the axial inclination and
alignment of the tooth.Clinically improved self-maintenance of
periodontal health occurs with proper
tooth position.
Example: adult patients duringcorrection of bite collapse and
accelerated mesial drift
ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES
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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Better self-maintenance of periodontalhealth…
Patients who need weekly periodontalmaintenance during initial leveling
phases of therapy may require lessfrequent scaling and root planning asperiodontal status improves with
tooth leveling and aligning.For better periodontal health, teeth
should be positioned properly over their
basal bone support.
ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES
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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Better self-maintenance of periodontalhealth.
In the nonsurgical management ofskeletal Class III and Class II
malocclusions, a delicate balanceexists between periodontallydesirable tooth positions and
achievement of other nonsurgicaltreatment objectives.
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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Esthetic and functional improvement.
The adult orthodontic treatment planshould provide acceptable dentofacial
esthetics and allow for improvedmuscle function, normal speech, andmasticatory improvements.
This is possible when a therapeuticocclusion is provided that enables theposterior teeth to support the vertical
dimensions.
Diagnosis and treatment
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Diagnosis and treatmentplanning
Collect data accurately
Analyze the data base
Develop problem list
Prepare tentative treatment plan
Di i d t t t
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Diagnosis and treatmentplanning…
Interact with those who are involved;discuss plans and options
clarify sequence;acquire patient acceptance
Create final treatment plan
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Diagnosis and treatmentplanning…
Chief Complaint base of the “diagnostic
tree”
• Gives an indication of the treatmentexpectations of the patient.
• Realistic treatment expectations are veryimportant in cases of adult orthodontictreatment .
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Psychological considerations
EXEPTIONAL PERSONALITYHIGHLY SUCCESSFUL ,OVERCOMPENSATE
FOR THEIR DEFORMITY
NO PROBLEMREASONABLE TREATMENT EXPECTATIONS
INADEQUATE PERSONALITY
USES DEFORMITY AS SHIELD FORWIDE RANGE OF SOCIAL ADJUSTMENT PROBLEMS
PATHOLOGICAL PERSONALITYSMALL DEFORMITY, BIG PROBLEM
ALMOST IMPOSSIBLE TO HELP
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Diagnosis and treatmentplanning…
Medical evaluation
Genetic problems
Acquired health problems
Calcium metabolism and bone mass
Medications
Psychologic factors.
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Diagnosis and treatmentplanning…
Clinical examination
Extraorally
Frontal symmetry,
Profile
Lip protrusion andcompetence.
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Diagnosis and treatmentplanning…
Intraoral examination
Soft tissue:
Periodontium (inflammation andloss of attachment caused bypockets, recession, and bone loss)
Pathologic condition of the mucosa
Cancer screening.
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Diagnosis and treatment planning…
Intraoral examination
Hard Tissues
The dentition should be evaluated for
operative,
endodontic, and
prosthodontic problems.
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Diagnosis and treatmentplanning…
PERIODONTAL DIAGNOSIS
The orthodontist must make an accurate
assessment of the patient’s potential forbone loss or gingival recession duringorthodontic tooth movement.
Tooth movement and clenching orgrinding instigated by movementinterferences, may lead to significant
bone loss.
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Diagnosis and treatment planning…
PERIODONTAL DIAGNOSIS…
Regaining control of periodontal inflammationis harder than controlling it from the
beginning.Every adult case should be closely
monitored with the periodontal specialist.
Appropriate management of several factorsis needed to prevent negative periodontalsequelae during orthodontic treatment
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Diagnosis and treatment planning… PERIODONTAL DIAGNOSIS…
These include:
1. Awareness and vigilance of the
orthodontist and the staff.
2. Awareness and vigilance of the patientmust be frequently reinforced.
3. Awareness of risk factors related toperiodontal breakdown.
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Diagnosis and treatment planning… PERIODONTAL DIAGNOSIS…
Risk factors
General Factors:
Family history of premature tooth loss(indication of immune system deficiencyin resistance to chronic bacterial
infection associated with periodontaldisease).
General health status and evidence of
chronic diseases (e.g. diabetes).
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Diagnosis and treatment planning… PERIODONTAL DIAGNOSIS…
Nutritional status
Current stress factorsLife stage of women
Local factors:
• Tooth alignment (e.g, marginal ridge,
cementoenamel junction relationship).
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Diagnosis and treatment planning… PERIODONTAL DIAGNOSIS…
Plaque indices
Occlusal loadingCrown-to-root ratio
Grinding, clenching habits(parafucntional activity)
Restorative status
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Diagnosis and treatment planning… PERIODONTAL DIAGNOSIS…
CLASSIFICATION OF PERIODONTALHEALTH OF ADULT PATIENTS
Incipient periodontal disease
Moderate periodontal disease
Advanced periodontal disease
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Diagnosis and treatment planning… PERIODONTAL DIAGNOSIS…
Incipient periodontal disease
Therapy prescribed
1. Scaling and curettage
2. Patient education for home care
3. 2 to 6 month maintenance intervals whilein fixed appliances
Provider General dentist
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Diagnosis and treatment planning… PERIODONTAL DIAGNOSIS…
Moderate periodontal disease
Therapy prescribed
1. Scaling
2. Curettage and periodontal surgery 6 to 8
weeks before orthodontics3.Orthodontic tooth movement
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Diagnosis and treatment planning… PERIODONTAL DIAGNOSIS…
4. 4 to 16 week maintenance intervalsduring orthodontic treatment
5. Periodntal reevaluation 12 weeksafter appliances are removed.
Provider
Periodontist and Orthodontist
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Diagnosis and treatment planning… PERIODONTAL DIAGNOSIS…
Advanced periodontal disease
Therapy prescribed
1. Scaling
2. Periodontal curettage(open-flap-clean-out)
3. Orthodontics
4. Periodontal reevaluation
5. Definitive osseous surgery
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Diagnosis and treatment planning… PERIODONTAL DIAGNOSIS…
6. Final restorative dentistry
7. Periodontal consideration reevaluated- Thisis done clinically with radiographs; checkmobility,perform probing and make softtissue assessment.
Provider Periodontist, orthodontist, generaldentist
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Diagnosis and treatment planning…
DIAGNOSIS OF TEMPOROMANDIBULARJOINT DYSFUNCTIONS
The signs and symptoms of TMD oftenincrease in frequency and severity duringadult treatment.
Thus, it is imperative that orthodontistsshould diagnose any TMD present anddetermine its etiology before starting the
orthodontic treatment.
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TMJ considerations
CLENCHING,GRINDING
(STRESS RESPONSE)
MUSCLE SPASMAND FATIGUE
INTERNAL JOINTPATHOLOGY
TMD SYMPTOMSPAIN
JOINT NOISELIMITED OPENING
Di i d t t t l i
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Diagnosis and treatment planning… Diagnostic records
A complete set of diagnostic records shouldbe obtained including
Casts
Radiographs IOPA
Panoramic
Cephalograms (optional)
Photographs
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Diagnosis and treatment planning…
Evaluation of the malocclusion.
Etiology of malocclusion.
In the absence of congenital anomalies orsignificant trauma most people with a fullcomplement of teeth have the genetic
potential to develop and maintain anormal occlusion.
Thus, the main environmental factors
causing malocclusions are:
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Diagnosis and treatment planning…
habits
functional compromises
soft tissue posture
developmental aberrations and trauma
periodontal disease
caries
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Diagnosis and treatment planning…
Cause of the malocclusion should be carefullyconsidered
Treatment should be directed at eliminatingor controlling the aberrant factors.
Thus, th e diagnosis is a prioritized list ofproblems based on a careful evaluation ofentire database.
Treatment Planning comparisons
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between adolescent and adultorthodontic patients
A through understating of the similaritiesand difference between adolescentand adult patient is required todevelop a less stereotyped and morecustomized treatment plan for adultpatients.
Several authors have identified what theyconsider the major differencesbetween adolescent and adult patient
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Treatment Planning Diagnostic between
adolescent and adult orthodontic patients…
Leavitt (1971): in adult patient there isno growth only tooth movement
Barrer (1977): stated that the adult unlikethe child is a relentless patient who willnot cover our deficiencies in skill or
our errors in the use of mechanicalprocedures by helpful setling in posttreatment.
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Treatment Planning Diagnostic between
adolescent and adult orthodontic patients…
Ackerman(1978) stated
For a child patient one occasionally
calls another specialist. On the otherhand it is a rare adult whom onetreats orthodontically without finding
it necessary to collaborate withanother specialist.
FACTORS IN SELECTION OF A
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TREATMENT PLAN :COMPARISONBETWEEN ADOLESCENT AND ADULT
A. Growth factors
B. Existing oral pathosis
1. Dental caries
2. Periodontal disease
3. Faulty restorations
4. TMJ adaptability
5. Occlusal interferences
6. Dental mutilation
FACTORS IN SELECTION OF A
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TREATMENT PLAN :COMPARISONBETWEEN ADOLESCENT AND ADULT
C. Biological considerations
1. Neuromuscular maturity
2. Rate of tooth movement
3. Periodontal susceptibility
D. Dentofacial esthetics
FACTORS IN SELECTION OF A
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TREATMENT PLAN :COMPARISONBETWEEN ADOLESCENT AND ADULT
E. Therapeutic approachesavailable
1. Orthopedics
2. Orthognathic surgery
3. Restorative dentistry
4. Combination treatment
5. Extraction controversy
6.
Anchorage potential
COMPARISON BETWEEN ADOLESCENT
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COMPARISON BETWEEN ADOLESCENTAND ADULT…
Growth factors
Adolescents
Because of growth an orthopedic optionis available; stable correction ofskeletal discrepancy is possible.
Sequence of difficulty of orthodonticcorrection(most to least) is vertical ,anteroposterior, transverse.
COMPARISON BETWEEN ADOLESCENT ANDADULT
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ADULT…
Growth factors…
Adults
No growth with minimal skeletal
adaptability; therefore surgicalprocedures are necessary for moderateto severe skeletal disharmonies;
Stable correction in skeletal transverseproblems requires surgically assistedrapid palatal expansion.
COMPARISON BETWEEN ADOLESCENT ANDADULT
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ADULT…
Growth factors…
Adults…
• Mandibular deficiency : sagittal splitosteotomy and mandibular advancement;
• Mandibular excess : mandibular setback;
• Vertical maxillary excess with or without open
bite : Lefort osteotomy.
• Combination problems may requirecombination surgery depending on severity
COMPARISON BETWEEN ADOLESCENT ANDADULT
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ADULT…
Growth factors…
FACTORS IN SELECTION OF ATREATMENT PLAN COMPARISON
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TREATMENT PLAN :COMPARISONBETWEEN ADOLESCENT AND ADULT
Existing oral pathosis
Dental caries
Adolescents More likely to have simplecarious lesions, but more susceptible tocaries
Adults More likely to have recurrent decay,restorative failures, root decay, and pulpal
pathosis.
COMPARISON BETWEEN ADOLESCENTAND ADULT
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AND ADULT…
Existing oral pathosis…
Periodontal disease
Adolescents
More resistant to bone loss, but highlysusceptible to gingival inflammation
AdultsHigher susceptibility to periodontal bone loss.
COMPARISON BETWEEN ADOLESCENT
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AND ADULT…
Existing oral pathosis…
Faulty restorations
Adolescents
Few significant restorative problems
Adults
Frequent restorative problems witheconomic and treatment planningimplications
COMPARISON BETWEEN ADOLESCENTAND ADULT
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AND ADULT…
Existing oral pathosis…
TMJ adaptability
Adolescents
Small percentage with symptoms because ofhigh degree of TmJ adaptability; infrequentsymptoms
Adults
Frequent appearance of symptoms with
dysfunction
COMPARISON BETWEEN ADOLESCENTAND ADULT
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AND ADULT…
Existing oral pathosis…
Occlusal interferences
AdolescentsInfrequent cause of problem
Adults
Hightened ; may lead to acceleratedenamel wear with adverse change insupporting tissues.
COMPARISON BETWEEN ADOLESCENT AND
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COMPARISON BETWEEN ADOLESCENT ANDADULT…
Dentofacial esthetics
Adolescents
Reasonable concern frequently matched toseverity of condition
Adults
Concern occasionally disproportionate todegree of existing problem
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COMPARISON BETWEEN ADOLESCENT ANDADULT…
Biological considerations
Neuromuscular maturity
Adolescents Significant potential foradaptability of stomatognathic system,allowing a variety of biomechanical choices
( class II elastics)Adults mechanical options are limitedbecause of lack of neuromuscular
adaptability
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COMPARISON BETWEEN ADOLESCENT ANDADULT…
Rate of tooth movement
Adolescents
Predictable and rapid, particularly duringeruptive stages when permanent rootdevelopment is not yet completed
Adults
somewhat slower
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COMPARISON BETWEEN ADOLESCENT ANDADULT…
Periodontal susceptibility
Adolescents more resistant to bone loss as aresult of periodontal disease
• but highly susceptible to gingival inflamation.
Adults Higher degree of susceptibility to bone
loss as a result of periodontal disease,
• particularly evident during orthodontic therapymay need modification of mechanotherapy
Effects of reduced periodontal
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p
support
When bone has been lost same amount offorce produces greater pressure in PDLof a compromised tooth than a normallysupported one.
Greater the loss of attachment, smaller thearea of supported root and furtherapically the center of resistance
Effects of reduced periodontal
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p
support
The center of resistance of a single rootedtooth is approx. one tenth the distance
between apex and crest of bone. Inperiodontally compromised patient there isreduction in bone level and hence the center
of resistance shifts apically.
Effects of reduced periodontal
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p
support…
This affects moments created byforces applied to the crown and
moments needed to control rootmovement.
Lighter force and larger momentsare needed in such cases.
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Gingival esthetic problems
These are created by
1. Uneven display of gingiva
e.g. substituting a canine for missinglateral incisor
Elongating a tooth to compensate for
broken incisal edge .
Better to restore the incisal edge bycomposite.
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Gingival esthetic problems
2. Gingival recession after periodontalloss
Creates black holes between the
maxillary incisorsRemove interproximal enamel so that
the incisors can be brought closer
together.This moves the contacts gingivally
minimizing the open space between
the teeth.
COMPARISON BETWEEN ADOLESCENT ANDADULT
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ADULT…
Therapeutic approaches available…
Dental mutilation
Adolescents early treatment control duringeruptive stages facilitate space closure without
prosthesis
•e.g, congenitally missing maxillary laterals ormissing second premolars.
Adults present with a number of missing teeth.
• More difficult to treat without prosthesis and
restorations.
COMPARISON BETWEEN ADOLESCENT ANDADULT…
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U
Therapeutic approaches available
Orthopedics
Adolescents About half require orthopedics
Adults Effective only in small percentage
Orthognathic surgery
Adolescents Major skeletal alterationsneeded in 1 to 5%
Adults major alterations needed in 10 to20%
COMPARISON BETWEEN ADOLESCENT ANDADULT…
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ADULT…
Therapeutic approaches available…
Restorative dentistry
Adolescents
Smaller percentage requires it,
when teeth are congenitally missing
frequently orthodontic therapy is useful inspace closure or space redistribution,thus avoiding the need for restorative
dentistry.
COMPARISON BETWEEN ADOLESCENT ANDADULT
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ADULT…
Therapeutic approaches available…
Restorative dentistry…
Adults
Integrated restorative plan can greatlyreduce duration of fixed appliance
treatment
Frequently required for space reopeningwhere teeth have been lost and
for abutment preperation and stabilization
of occlusal relationship;
COMPARISON BETWEEN ADOLESCENT ANDADULT…
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ADULT…
Therapeutic approaches available…
Combination treatment
Adolescents Uncommon
Adults Required in 80% of casesExtraction controversy
Adolescents a treatment plan of fourpremolar extraction is used frequently toresolve crowding and protrusions,
space gaining techniques are also available.
COMPARISON BETWEEN ADOLESCENTAND ADULT…
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Therapeutic approaches available…
Extraction vs nonextraction therapy
Adults
Four premolar extractions are used lessfrequently to resolve crowding, upperpremolar extractions are a common
alternative , asymmetric extraction and
stripping of over bulked restorations.
COMPARISON BETWEEN ADOLESCENT ANDADULT…
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ADULT…
Therapeutic approaches available…
Strategic extractions
Adults Irreversible damage to periodontal
tissues or to adjacent teeth may forceorthodontists into unusual treatment plansfor adults,
Careful analysis may lead to strategicextraction to solve alignmentproblems, as well as to eliminate
existing damaged teeth
COMPARISON BETWEEN ADOLESCENT ANDADULT…
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ADULT…
Therapeutic approaches available…
Anchorage potential
Adolescent more frequent incorporation
of headgear to maximize anchorage andretraction of the anterior teeth.
Headgear cooperation Greater
COMPARISON BETWEEN ADOLESCENT ANDADULT…
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U
Therapeutic approaches available…
Adults
fewer adult cases will be categorized as
maximal anchorage problems,
implants in conjunction with restorativedentistry ,
several molar distalization techniques arebeing developed as options to avoidheadgear wear with adults.
COMPARISON BETWEEN ADOLESCENT ANDADULT…
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Therapeutic approaches available…
Adults
Frequent problems involving anterior and
posterior teeth require restorativecommitment for treatment planning
supraeruption is a problem in posterior bite
collapse,
Occlusal plane management is crucial.
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Sequence of treatment
It can be given in the following steps
Comprehensive treatment plan
Stage 1: disease control
Stage 2: reestablish occlusion
Stage 3: definitive periodontic orrestorative procedures.
Stage 4. : maintenance
COMPLICATIONS IN ADULT
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COMPLICATIONS IN ADULTORTHODONTIC TREATMENT
Medical Concerns
The medical history should be updated
regularly.
If significant medical problems occur,confer with the patient’s physician
regarding continuing or interruptingorthodontic treatment.
COMPLICATIONS IN ADULT ORTHODONTICTREATMENT…
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Medical Concerns…
Some problems e.g. recent myocardialinfarction may require interrupting orterminating all elective care.
Thus, careful monitoring of medicalfactors is essential for effective
management of adult patients duringadjunctive orthodontic treatment or aspart of a comprehensivemultidisciplinary treatment plan.
COMPLICATIONS IN ADULT ORTHODONTICTREATMENT
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TREATMENT…
Poor Cooperation
Treatment with fixed mechanics iscontraindicated until the patient hasdemonstrated the ability to maintaingood oral hygiene.
Oral hygiene and the periodontalcondition should be monitored at eachappointment.
COMPLICATIONS IN ADULT ORTHODONTICTREATMENT
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TREATMENT…
Caries
Incipient and undiagnosed caries in course oftreatment can lead to compromises in
orthodontic results.
§ No previous caries Panoramic radiograph only
§ Previous caries Obvious pathologyAdd bitewing radiographs
§ Deep caries Add periapical radiographs
COMPLICATIONS IN ADULT ORTHODONTICTREATMENT
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TREATMENT…
Technical Problems
Panoramic radiographs and intraoralradiographs should be taken at every 6-
months and cephalometricradiographs should be taken every 12months.
Superimpositions of tracings foridentifyuing complications anddetermining if the treatment can progress
as lanned
COMPLICATIONS IN ADULT ORTHODONTICTREATMENT
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TREATMENT…
Temporomandibular disorders
For a minor problem there may be no need forspecific dental treatment.
Treatment includesIdentifying the bad habit and eliminating it.Rest with limited function
ReassuranceIf there is a clear relationship of symptoms toorthodontic changes in occlusion, theorthodontic treatment should be considered.
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Segmented arch technique in adults
Helpful in controlling the forcemagnitude in adults as it involvescreating a stable anchorage unit
consisting of several teethconnected to act as a singlemultirooted teeth so the force is
distributed over a larger area.
This is more important in periodontallycompromised cases.
Fi i hi d i
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Finishing and retention
Positioners are rarely indicated asfinishing devices in adult patients withperiodontal disease.
In patients having significant bone lossand tooth mobility, both short term andlong term splinting is required.
Treatment is finished with archwires andthen stabilized immediately with
retainers
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type
Physiologicocclusion
(exhibits no
signs of
existing
pathosis)
Characteristic
of major
problem areas
• Mild dentalmalalignment
• normalocclusion ormalocclusionthat isestheticallyacceptable
Associated
healthy
systems
•Occlusalstability
•No decayand lack ofocclusalwear
•Psychological balance
Treatment
OrthodontistConsultationand patienteducation (i.e.,
presentconditionrequires noorthodontictreatment).
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case
type
Major
problem
areas
Associated
healthy systems
Treatment
Physiol-ogic
occlusion
(exhibits
no signsof
existing
pathosis)
•TMJasymptomatic
•No speechimpairment
•No occlusalawareness
•No functional
disorders
•Relieve concern ofreferring dentistthat conditionprobably won’t get
worse
•Make patientaware of existinghealth levels
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
problem
areas
Associated
healthy
systems
Treatment
Physiologic
occlusion
(exhibits no
signs of
existing
pathosis)
•Documentpresentcondition
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
problem
areas
Associated
healthy
systems
Treatment
Psychologicaldisorientation
•Concernabout minordentalconditionfar
exceedingrealsignificanceof the
problem
•Dentitionaligned
•Skeletal
balance
•TMJ
asymptomatic
•Periodontium
healthy
•Make patientaware of the
dental health
condition
•Psychological councelling
as needed
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
problem areas
Associated
healthy
systems
Treatment
Correctiveorthodontics
•Mild tomoderatedental-skeletaldisharmony
•Unsatisfactorydentofacialesthetics
•Psychologicbalance
•Skeletal WNL
•TMJ
asymptomatic•No toothreplacement
required
Restorativedentist orhygienist
Caries andinflammatorycontrol
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
problem
areas
Associated
healthy
systems
Treatment
Corrective
orthodontics
Orthodontist
Comprehensiveorthodontictherapy
(extraction/nonextraction)
Dentist orhygienist
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
problem
areas
Associated
healthy
systems
Treatment
Correctiveorthodontics
Scaling and curettageat 3 to 6mm intervals
Orthodontist
•Retention
•Periodic monitoringof oral health needs.
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major problemareas
Associatedhealthy
systems
Treatment
Orthognathic
surgery
•Dental-skeletaland/orneuromusculardisharmoniesof moderate to
severe degree
Restorativedentist
Caries andinflammatorycontrol
Orthodontist
Presurgicalintra-archorthodontic
re aration
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
problem
areas
Associated
healthy
systems
Treatment
Orthognathicsurgery
Reevaluate recordsOral surgeon
Orthognathic surgeryto correct skeletal-
dental disharmony Orthodontist
post surgicalorthodontic therapy
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
problem
areas
Associated
healthy
systems
Treatment
Orthognathic
surgery
Retention records
Oral surgeon orplastic surgeon
Adjunctive surgical
procedures
(genioplasty,rhinoplasty, facelift)
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major problem
areas
Associated
healthy
systems
Treatment
Periodontallysusceptible •Dental-skeletalmalrelationshipwith moderateto advancedbone loss
•Primarysecondaryocclusal traumamay be present
•Emotionalbalance
•TMJasymptomatic
•Othersystems maybe affectedsecondarily
Restorativedentist orhygienist
Caries
andinflammatory
control
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
problem
areas
Associate
d healthy
systems
Treatment
Periodontallysusceptible
Periodontist orhygienist
•Maintenance of rootsurface preparation
•Subgingival removalof microbiota
•Gingival graftingprocedures
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
problem
areas
Associated
systems
Treatment
Periodontallysusceptible
Orthodontist
Comprehensivetherapy
Selective grinding
Retention
Periodontist
reevaluation anddefinitive periodontal
procedures
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Majorproblem areas
Associatedsystems
Treatment
TMJdysfunction •Dental-skeletalmalrelationship
with jointdysfunction
•TMJsymptoms
Othersystemsmay beaffected
OrthodontistDiagnosticappliance toachieve relief ofsymptoms and todetermine degreeof skeletaldisharmony andneed for further
diagnosis
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
problem
areas
Associated
systems
Treatment
TMJdysfuncti
on
Psychotherapist
Counseling asneeded/stress reductionprogram
Orthodontist
•Occlusal therapy
•Comprehensiveorthodontics
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
problem
areas
Associated
systems
Treatment
TMJdysfunction
•Selective grinding
Oral surgeon
Surgical management
Restorative dentistRestorative dentistry ifrequired
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Case type Majorproblem
areas
Associatedsystems
Treatment
Enamel wear
beyond that
expected for
chronologic
age
•Heavy
musculature(mandibulardeficiency)
•Dental-
skeletal deep-bite
Other
systemsmay beaffectedsecondary
Restorative
dentist
•Caries orinflammatorycontrol
•Occlusalcontrol
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Majorproblem
areas
Associatedsystems
Treatment
Enamel
wear
beyond
that
expectedfor
chronolog
ic age
OrthodontistComprehensiveorthodontics
•Periodontal surgery
•Crown lengthening•Restorativedentistry if required
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
problem areas
Associated
systems
Treatment
Dentalmutilations
•Prematureloss of teeth orcongenitallymissing teeth
•May involvebite collapseand loss ofvertical height
Associatedsystems WNLbut may beaffected assecondary
Restorativedentist
•Caries andinflammatory
control•Occlusalcontrol withmodifiedtreatment goals
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
problem
areas
Associated
systems
Treatment
Dentalmutilation
Comprehensiveorthodontic treatmentwith modified goals
Periodontist
Adjunctiveperiodontal treatment
restorative dentistry
Tooth replacement
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Majorproblem
areas
Associatedsystems
Treatment
Borderlinesurgical case •Dentofacial
imbalance ofmoderateseverity
•Basal bone
discrepancyin both jawscontribute todentofacial
imbalance
•Adequate
attachedgingiva fordentalcompensation
in each arch•Patientacceptsdentofacial
imbalance
Restorativedentist
•Caries andinflammatorycontrol
•occlusalguard tocontrol wear
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
problem
areas
Associated
systems
Treatment
Borderlinesurgical
case
Imbalancelooksgreaterthan it is
•Orthodontist •Differentialdiagnosis of skeletalcomponent to the
problem•Deprogram musclesand reevaluate withmounted study
models
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
proble
m areas
Associated
systems
Treatment
Borderlinesurgical
case
•Comprehensiveorthodontic treatment
Oral surgeon
•Evaluate records andprovide surgical opinion
•Advise patient of risksand benefits of surgery
ADULT ORTHODONTIC
PATIENT TYPES
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PATIENT TYPES
Case type Major
problem
areas
Associated
systems
Treatment
Dental
mutilations
Interdisciplin
ary dental
therapy
(IDT).
C l i
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Conclusion
Thus it can be concluded that adultorthodontic treatment though
having the same basic goals andbiomechanics has certain importantdifferences from the conventional
adolescent treatment that shouldbe carefully evaluated .
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ReferencesLuther F : orthodontics and TM joint: where arewe now? Part 2 functional occlusion,malocclusion and TMD, Angle Orthod 68:357-368,1998.
Hom BM, Turly PK: the effects of space closureof the mandibular first molar area in adults, AJO
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