ADULT ORTHODONTICS Introduction History In 1880 Kingsley, after treating a 40 year old patient for anterior cross-bite stated,

It may be regarded as settled that there are hardly any limits to the age when movement of teeth might not succeed. But he maintained, The action is slower, growing more and more difficult and in cases where a considerable number of teeth are to be moved, the results become more and more doubtful with advancing years. In 1901 Mac Dowell wrote, After the age of 16 years, a complete and permanent change in transition of occlusion the author believes to be almost impossible. There may be a case or two of rare exceptions but as a rule the change cannot be accomplished successfully owing to the development of the adult glenoid fossa and the density of the bones and muscles of mastication. In 1912 Lischer summarized, Recent experiences of many practitioners have ------ us to a better appreciation of the golden age of treatment, but that we mean that time in an individuals life when a change form the temporary to permanent dentition

takes place. This covers the period form the sixth to the 14 t h year. In 1921 Case demonstrated an efficient space closure, for a patient with pyorrhea in the lower anterior area. However, in the past 3 decades, a major reorientation of orthodontic thinking has takes place. The following are some of the reasons for the increased interest by the orthodontics in adult patients, as well as several causes for increased interest shown by adults in orthodontic treatment Improved appliance placement techniques More successful management of TMJ joint symptoms Effective management of skeletal jaw dysplasias using advanced orthognathic surgical techniques Reduced vulnerability to periodontal breakdown as a result of improved tooth relationship and occlusal function ADULT ORTHODONTIC TREATMENT OBJECTIVES 1. Parallelism of abutments The abutment teeth must be placed parallel with the other teeth to permit insertion of multiple unit replacements. A restoration will have a better prognosis when the abutments are parallel before tooth preparation, as it facilitates the transfer of masticatory forces along the long axis of the tooth.

2. Most favorable distribution of teeth The teeth should be distributed evenly for replacement of fixed and reasonable prosthetic in the individual arches. 3. Adequate embrasure space and proper root position The anatomic relationship of the roots is important in the pathogenesis of periodontal disease. Creation of adequate embrasure space and proper root position allows for better periodontal health, especially when the placement of restoration is necessary. 4. Better lip competency and support When adequate support is not given to the upper lip by the upper incisors, it may create a change in the anteroposterior and vertical positioning of the upper lip and increases wrinkling. This often makes the face prematurely aged and is a major concern for adults especially women, who are usually anxious about changes in upper lip. In support. 5. Improved crown/root ratio cases requiring anterior restorations, retraction is

recommended to achieve lip competency while maintaining lip

6. Improvement or correction of mucogingival and osseous defects Proper repositioning of the prominent teeth in the arch which improves gingival topography. ADJUNCTIVE maximum) By definition, adjunctive orthodontic treatment refers to the tooth movement carried out to facilitate other dental procedures to control disease and restore function. (E.g.) Congenital absence of II premolar with mesial migration of first molar. An orthodontist distalises the first permanent molar to replace a satisfactory pontic in second premolar area. Physiologic occlusion Physiologic occlusion, although not necessarily an ideal or class I occlusion is one that adapts to the stresses of function and can be maintained indefinitely. Pathologic occlusion It is one which cannot function with contributing to its own destruction. A pathologic occlusion may manifest itself by any combination of ORTHODONTIC THERAPY (6 months

 Excessive wear of the teeth with sufficient compensatory mechanisms. Temporomandibular pain/dysfunction Pulpal changes ranging from hyperemia to necrosis Periodontal damage For example, when a tooth is lost the adjacent teeth tend to drift, tip and rotate. Whether this requires orthodontic correction will depend upon whether the sings of pathologic occlusion are present. If the patient can still maintain adequate plaque control and if the occlusal forces are within the physiologic tolerance of the support mechanism, and if the patient can function with prematurities or functional shifts, then the occlusion may be considered physiologic and the only indication for orthodontic treatment could be the patient desire for improved esthetics. Goals of adjunctive treatment Facilitate restorative treatment by repositioning the teeth in ideal positions. Improve the periodontal health by eliminating plaque harboring areas. Establish favorable crown to root ratios Position the teeth so that occlusal forces are transmitted along the long axis of teeth Principles of adjunctive orthodontic treatment

1. Diagnostic and treatment planning considerations Planning for adjunctive treatment requires two steps Collecting an adequate database
Developing a clearly stated list of the patient problems

taking care not to focus unduly on any one aspect of the complex situation. The patients motivation for and expectations of treatment, general dental awareness, enthusiasm for the proposed treatment and ability to cooperate with the treatment regimen all must be evaluated. Diagnostic records
Records usually include individual intra-oral radiographs to

supplement the panoramic films that usually supplies for younger and healthier patients. Pre-treatment cephalometric radiographs are usually not required Dental casts obtained from fully intended impressions should be acquired. Once all the problems have been identified and categorized, special attention must then be turned to tooth positions that require modification. The key treatment planning question is can the occlusion be restored within the existing tooth positions or must some teeth be moved to achieve a satisfactory, stable,

healthy and esthetic result? The goal of adjunctive treatment is to produce physiologic occlusion and facilitate other dental treatment and has little to do with the angles concept of ideal class I tooth relation. As a general guideline, adjunctive orthodontic treatment that would take more than 6 months should be avoided as it clearly indicates a need for comprehensive orthodontic treatment involving all the teeth. Biomechanical considerations In adults, the absolute magnitude of forces used to move teeth must be reduced when periodontal support has been lost, to prevent damage to periodontal, bone, cementum and root. In addition, the smaller the area of supported root and farther the C R e s of the tooth. C R e s of a single rooted tooth is at approximately 6/10 t h the distance between the root apex and the alveolar crest, from the root apex. Apical relocation of the C R e s increases the magnitude of the tipping moment (M), for a given tone and consequently a large countervailing couple (M) would be necessary to effect bodily movement. The recommended brackets for adjunctive treatment is 22 slot-edgewise brackets because rectangular slot permits control of buccolingual axial inclination, the wider brackets permit control of rotations and tipping.
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Removable appliances can be used in situations where a number of teeth are missing. They permit the reaction forces to be spread over adjacent supporting tissues such as the palatal vault, alveolar mucosa as well as the anchor teeth. If many teeth are missing, this approach may be the only way to generate anchorage. Bracket placement when placing a partial fixed

appliances for adjunctive treatment, the brackets are placed in the ideal positions only on teeth to be moved and the remaining teeth to be incorporated in the anchor system are bracketed in the most convenient way possible, with the arch wire slots closely aligned. Passive engagement of wires to anchor teeth produces minimal disturbance of teeth that are in a physiologically satisfactory position. 3. Timing and sequence of treatment After the development of a treatment plan the first step is the control of nay active dental disease. Periodontal management before any orthodontic

treatment, destructive periodontal disease must be controlled, because orthodontic tooth movement superimposed on poorly controlled periodontal health can lead to rapid and irreversible breakdown of the periodontal support apparatus. And also
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periodontal therapy should be continued even after orthodontic treatment is started. Scaling, curettage and gingival grafts should be undertaken, before any tooth movement is done. Clinical studies have shown that orthodontic treatment of adults with compromised periodontal tissues can be completed without loss of attachment, provided there is good periodontal therapy both initially and during tooth movement. Surgical pocket elimination and osseous surgery should be delayed until completion of orthodontic phase, because a significant amount of soft tissue and bone recontouring occurs during orthodontic tooth movement. Endodontic treatment before any tooth movement, active caries and pulpal pathology must be eliminated. Tooth should be restored with well placed amalgams and composite resins. Crown, bridges and other restorations requiring detailed occlusal anatomy should not be placed until any adjacent, treatment has been completed, because the occlusal relationship will inevitably be changed by orthodontic tooth movement. ADJUNCTIVE TREATMENT PROCEDURES 1. Uprighting posterior teeth When planning molar uprighting, a number of inter-related questions must be answered. The first is that, if the third molar is present, whether both the second and third molar is present, whether both the second and third molars should be uprighted.
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For many patients, distal tipping of the third molars, places them in such situations where plaque control is a problem or the molar is not in functional occlusion. In such situations, it is ideal to extract the third molars and upright the second molars alone. The second question is, whether to upright the tipped teeth by distal crown tipping that would increases the space available for a later pontic or by a mesial root movement, which would maintain reduce or even close the edentulous span. This decision is influenced by Position of the opposing tooth and the desired occlusion The anchorage available for such movements Most importantly the contour of the bone in the edentulous ridge. If extensive ridge resorption has occurred especially in the B-L direction, mesial movement of a wide molar root will occur very slowly and may lead to the development of dehiscence on the buccal and lingual sides. In general, distal crown tipping is preferred than mesial root movement for uprighting molars. The third question is whether slight extrusion of the tooth is permissible or maintenance of the existing occlusal height is required. Tipping the tooth distally generally extrudes it. If the crown height is systemically reduced as uprighting proceeds, the ultimate crown-root ratio is improved. Unless slight extrusion of crown is acceptable, the patient should be considered to have

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problems that require comprehensive treatment and treated accordingly. Appliances for molar uprighting Each appliance can be separated into an active and a reactive (stabilizing or anchor) unit. To provide appropriable anchorage, canine to canine should be included and linked by a heavy statistically lingual arch. This arch decreases the buccal displacement of anchor teeth. This is mandatory in the mandibular arch and advisable in the maxillary arch. Distal crown tipping with occlusal antagonist Initial alignment 17 x 25 braided SS/17x25 A-NiTi provided the wire can be placed in the brackets with permanent distortion and the occlusal contacts are not too heavy, molar uprighting will begin and a single wire may complete the necessary uprighting. From the placement of the wire, it is always necessary to relieve occlusal contacts against the molar. Failure to relieve may prevent it from uprighting and may cause excessive tooth mobility. If molar severely tipped, continuous wire that uprights the molar will also tip the premolar. To avoid this sectional spring is used where the anchor segment is stabilized with 19x25 SS and an auxiliary spring is placed in the auxiliary tube. The uprighting
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spring 17 x 25 TMA with a helical loop 17 x 25 SS with helical loop decrease the force. The mesial arm of the spring should lie passively in the vestibule and upon activation should hook over the a. wire in stabilizing segment. It is important to see that there is sufficient space for the arm to slide distally when the molar uprights. As this method causes extrusion along with distal tipping, it should be used only in situations where there is an occlusal antagonist. Uprighting without extrusion If the molar has no antagonist, if extrusion is undesirable or if the crown is to be maintained in the same position while the roots are being brought forward an alternative uprighting spring should be used. Initial alignment flexible wire Single T-loop sectional arch-wire 17 x 25 ss/19 x 25 TMA is adapted to fit passively in anchor units and gabled at the T to exert an uprighting force. If the edentulous span is intended to be closed, the distal end of the T-loop is pulled distally to open the loop by 1 2mm. This produces a mesial force on the molar that counteracts the

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distal crown tipping while the tooth uprights by mesial root movement.

Final positioning of molar and premolars Once the uprighting of molars has been accomplished, it often is desirable to increase the available space for the pontic. This is done by using a relatively stiff base a wire (in a 0.022 slot, 18 mil round / 17 x 25 SS) and as open coil spring is placed, which when comprised exerts a force of 100 gms, to move the premolars mesially while continuing to tip the molar distally. Potential problems in Molar Uprighting Excessive mobility of teeth being moved may be because increased force / failure to remove occlusal contacts. Care should be taken to avoid excessive crown reduction, it may be helpful to use a bite splint on the opposing arch. In general, failure to upright the teeth usually results from occlusal interferences rather than insufficient force. Retention After molar uprighting, the teeth are in an unstable position until the fixed or removable appliances that provide long term stability is used. Long delays is taking the final prosthesis should be avoided. For nearly all patients, before placement of prosthesis, an intermediate form of splinting is necessary to
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maintain the position of the abutment teeth. Two methods of intermediate splitting 1. Extracoronal splinting 19 x 25 SS or 21 x 25 TMA was designed to fit the brackets passively will prevent any tooth movement. This type of retention should not be used for long periods because orthodontic appliances themselves make effective oral hygiene maintenance difficult. 2. Intracoronal splinting The preferred approach to intermediate splinting is an intracoronal wire splinting shallow cavities may be prepared in the abutment teeth and a splint of 19 x 25 SS - intracoronally with either amalgam or composite resins. As a general rule, a fixed bridge can be placed within 6 weeks after the orthodontic appliance is removed. Forced eruption Indications Teeth with defects in the cervical third of the teeth Teeth with one or two vertical periodontal defects To obtain good accepts for endodontic and restorative procedures or to reduce pocket depth it would be necessary to perform crown lengthening. However, surgery causes sacrifice of surrounding bone. Extruding the tooth orthodontically improves
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endodontic access and also allows placement of crown margins on sound tooth structure. Factors considered in treatment planning Before beginning treatment, it is essential to have a periapical radiograph to know the vertical extent of the defect, the periodontal support, the root morphology and position. The ideal morphology is a single tapering root. Flared or divergent roots will increase the root proximity with extrusion. The occlusion should also be examined to make sure that sufficient space still exists in relation to the opposing arch, to permit the placement of a satisfactory restoration. A final consideration is the crown-root ratio at the end of treatment, which should be 1:1 or better. The length of time required for forced eruption depends on The age of the patient The distance the tooth has to be moved Viability of the periodontal Rate In general extrusion can be as rapid as 1mm/week without damage to the periodontal (so 3 6 weeks is sufficient for almost any patient). Technique

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Since extrusion is the tooth movement that occurs most readily and intrusion the movement that occurs least , sample anchorage is usually available from adjacent teeth. The appliance needs to be quite rigid ones the anchor teeth and flexible where it attaches to the tooth to be extruded. This except contraindicates the use of a continuous a. wire which would produce the desired extrusion but also lips the adjacent teeth toward the tooth being extruded reducing the spaces. Two appliances
T-loop 17 x 25 s.s / 19 x 25 Ti. Brackets should be

positioned as gingivally as possible on the tooth to be extruded and incisally on the anchor teeth. The part of the wire that gets attached to the tooth to be extruded should be --- occlusal that the wire engaging the anchor segment. The left of the T-loop is limited by the depth of the vestibule.
Heavy stabilizing arch wire (19 x 25 SS) bonded directly to

the facial surface of the adjacent teeth A post and core with temporary crown and pin is placed on the tooth to be extruded and an elastomeric module is used to extrude the tooth. This appliance is simple, provides excellent control of anchor teeth, but the control of the tooth being extruded is not as precise it is with bonded brackets. With either of these, the patient must be seen every 1 2weeks for occlusal reduction to control inflammation and to monitor progress. After active tooth movement, the tooth should
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be stabilized with a passive arch wire or by tying the pin to the binded stabilizing wire. Stabilization allows proper remodeling of the periodontal fibres and allows the bone to remodel that discourages relapse. In general 3 6 weeks of stabilization should be sufficient. ALIGNMENT OF TEETH Indications To improve access and permit placement of well adapted and contoured restorations. To permit placement of crowns and pontics To establish good interproximal contacts, to provide better occlusal loadings and minimize the possibility of occlusal interferences. To reposition closely approximated roots and to increase the amount of inter-radicular bone. Treatment planning A diagnostic set-up will be very useful in planning treatment for alignment problems. Study casts are duplicated and the malaligned teeth are carefully cut from the model, crown dimensions are modified if appropriate and the teeth are waxed back onto the cast. This allows one to assess what tooth movements, crown reshaping or pontic replacement would be necessary occlusion. to produce an esthetically pleasing functional

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The length of time required to align teeth will vary Age of the patient The distance the teeth have to be moved Cellular activity within the periodontal As a general guideline, adjunctive tooth movement that would take longer than 6 months should be avoided, since such patients almost certainly have a complicated malocclusion that would be better handled with comprehensive orthodontic treatment. Technique Alignment of crowded, rotated and displaced incisors Interproximal stripping may be used to create space, within limits established by the thickness of the enamel and the M.D diameter of the teeth at gingival margins. Approximately mm of enamel can be removed from either side of each tooth, giving a maximum of 4mm additional space. In the mandibular arch the smaller M-D diameter of mandibular incisors, reduces the amount of interproximal stripping possible with producing unacceptable root proximity. For this reason, crowding > 3 4mm in the mandibular, anterior region nearly always indicates extraction therapy. Treatment of this type should never be undertaken with a diagnostic set-up that is mandatory to be sure that the teeth will fit satisfactorily.

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A flexible arch wire usually 0.016 round NiTi is used to align teeth. Round wires should be followed by rectangular wires for the precise positioning of the roots. If the wire is not turned gingivally at the distal end of the molar tubes, the teeth will flare labially when they align, that is usually undesirable. Anterior diastema closure and space redistribution Closure of anterior spaces is usually simple but often requires permanent retention with a bonded lingual retainer, fused crowns etc. For best esthetics, partial closure of more incisor spacing and redistribution of the space of a central diastema followed by composite build-ups often i.e. the treatment of choice. If the diastema is small or results form adjacent teeth being tipped in opposite direction a removable application with fingersprings may be used to close the space. A wire bend into ideal arch-wire and involving only the anterior segment of the arch is need. Initial alignment 0.016 minimum followed by 0.016/0.018 SS elastomeric modulus or till springs. Initially the teeth tip, but the stiffness of the wire counteracts this effect and results in bodily movement. If the spacing is the result of abnormally small teeth in one arch (i.e. tooth size discrepancy exists) it will be impossible to close all the spaces while maintaining post occlusion.
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Crossbite correction If only one or two teeth are involved the cross-bite usually results form displacement of crowded teeth or ectopic eruption. If a group of teeth are involved, it is more likely that the crossbite is a skeletal problem and will not respond to limited orthodontic treatment. If a cross-bite is due to displaced teeth and if the tooth corrections required only tipping movements, then a removable application may be used. However when using a removable application, is the tooth tip labially or buccally there is a vertical change in occlusal level produces an apparent intrusion and a reduction in overbite. This presents a problem during retention, since a two overbite serves to retain the cross-bite correction. In post segments cross-bites are frequently corrected using through the bite elastics. Separation of approximated teeth Occasionally two teeth may exhibit close proximity. The lack of inter-radicular space presents satisfactory restorative procedures but also predisposes both teeth to rapid progression if periodontal disease develops. If the roots of such teeth must be separated, the necessary tooth movement can be achieved only with fixed appliance because a force system that applied a moment effective in moving roots should be used.
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SPECIAL CONSIDERATIONS IN COMPREHENSIVE TREATMENT OF ADULTS Special considerations for the adults fall into 3 categories Different motivations for seeking orthodontic treatment and different psychological reactions to it Heightened susceptibility to periodontal disease and the possibility that active periodontal disease is one reason for seeking orthodontic treatment in the first place. A lack of growth, even the small amount of vertical growth on which orthodontists can rely for patients in late adolescence. Motivation for adult treatment A major motivation for orthodontic treatment of children and adolescents is the parents desire for treatment. Adults, in contrast, seek comprehensive treatment because they themselves want something. That something, however, is not always clearly expressed and in fact some adults save a remarkably elaborate hidden set of motivations. It is important to explore why the patient wants treatment to avoid setting up a situation in that the patients expectation from treatment cannot be met. Orthodontic treatment obviously cannot be relied upon to repair personal relationship sure jobs and if the patient has such unrealistic
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expectations, it is much better to deal with them sooner than later. A patient who seeks treatment primarily because he or she wants to improve the appearance or function of the teeth (internal motivation) is more likely to respond well psychologically than a patient whose motivation is the urging of the others or the expected impact of treatment on others (external motivation). The typical adolescents passive acceptance of what is being done is rarely found in adult patients, who want and expect a considerable degree of explanation of what is happening and why. In addition, adults as a rule are less tolerant of discomfort and more likely to complain about pain after adjustments and about difficulties in speech eating and tissue adaptation. Periodontal and restorative needs as motivating factors A very few patients may seek orthodontic treatment as an attempt to improve periodontal considerations. cannot Although the comprehensive orthodontic treatment preclude

possibility of periodontal disease ------- later it can be a useful part of the treatment plan for a patient who already has periodontal involvement. TM pain / dysfunction as a reason for orthodontic treatment

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This condition is a significant motivating factor for some adults who consider orthodontic treatment. Orthodontic treatment can sometimes help patients with TMD problems but cannot be relied upon to correct them. Patients with TMD symptoms can be divided into two groups
Internal

joint pathology including displacement or

destruction of the articular disc Symptoms primarily of muscle origin caused by spasm and fatigue of the muscles that position the jaw and head It is unlikely that orthodontic treatment alone will be of significant benefit to those who have myofascial pain / dysfunction on the other hand, may benefit from improved occlusal relationships. Displacement of the disk can arise from a number of causes. One possibility is trauma to the joint, damaging the ligaments that oppose the action of lateral pterygoid. In this instance, muscle contraction moves the disk toward as the mandibular condyle translate forward on wide opening but the ligaments do not restore the disk to its proper position when the jaw is closed. The click and symptoms associated with it can be corrected if occlusal splint is used to prevent the patient from closing beyond the point at which displacement occurs.

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Myofascial pain develops when the muscles are fatigued and tend to go into spasm. To produce myofascial pain, the patient must be clenching or grinding the teeth for many hours/day, presumably as a response to stress. However, it takes two factors to produce TMD symptoms from myofascial pain An occlusal discrepancy A patient who clenches or grinds the teeth excessively Three broad approaches to myofascial pain symptoms should be considered Reducing the amount of stress Reducing the patients reaction to stress Improving the occlusal relationships, thereby making it harden for the patient to hurt himself/herself. Periodontal aspects of adult treatment Periodontal problems are rarely a major concern during orthodontic treatment of children and adolescents, both because periodontal disease usually does not arise at an early age and because tissue resistance to imitation produced by orthodontic appliances is higher in younger patients. There is no contra-indication to treating adult patients who have periodontal disease as long as the disease has been brought under control.

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Periodontal disease progression is episodic not continuous and likely to affect some but not all areas within the same mouth. At present, persistent bleeding on probing is the best indicator of active and presumably prospective disease. Minimum periodontal involvement Any patient undergoing orthodontic treatment must take extra care to clean the teeth but this is even more important for adults. Bacterial plaque is the main etiologic factor in periodontal breakdowns and plaque-induced gingivitis is the first slip in the disease process. In children and adolescents even if ginigivitis develops in response to the presence of orthodontic appliances, it almost --- extends into periodontitis. This cannot be taken for granted in adults, no another low good this initial periodontal condition. This difficult area for orthodontic patients to clean is the area of each tooth between the brackets and ginigival margin. The periodontal evaluation of an adult patient must include not only the response to periodontal probing but also the level and condition of attached gingiva (the bacteriaized tissue between the depth of periodontal probing and the beginning of alveolar mucosa). Labial movement of incisors in some patients can be followed by gingival recession and loss of attachment. The risk is greatest when irregular teeth are aligned by expanding the dental arch.

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The present concept is that gingival recession occurs secondarily to an alveolar bone dehiscence if overlying tissues are stressed by tooth brush trauma, plaque induced inflammation etc. Recent animal studies suggest that the thickness of the gingival attachment rather than its surface qualities (keratinized or mucosal) may be a major factor in whether recession occurs. It has been recognized that the lower incisors in cases of manidbular prognathism are at particular risk of recession and thin gingival tissue probably is the reason. Even the protective effect of a gingival graft may be due more to the greater gingival thickness than a wider zone of attached tissue. Moderate periodontal involvement Disease control Before orthodontic treatment is attempted for patients who have moderate pre-existing periodontal problems dental and periodontal disease must be brought under control. Preliminary periodontal therapy can include all aspects of periodontal treatment except osseous surgery. It is important to remove all calculus and other irritants from periodontal pockets before any tooth movement is attempted. Osseous surgeries are best deferred until find occlusal relationship has been established. Disease control also requires endodontic treatemtn of any pulpally involved teeth. There
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is

no

contraindication

to

orthodontic movement of an endodontically treated tooth, so root canal therapy before orthodontics will cause no problems. Attempting to move a pulpally involved tooth, however, is likely to flare up the periapical condition. The general guideline is that temporary restorations should be placed to control caries, with definite restorative dentistry delayed until after the orthodontic phase of treatment. Periodontal maintenance Because bonded the margins of for the bands make periodontal involved adults. Steel maintenance more difficult it is always better to use a fully appliance periodontally ligatures rather than elastomeric rings to retain orthodontic a. wires also are preferred for periodontally involved patients, because patients with l-rings have higher levels of microorganisms in gingival plaque. Periodontal maintenance therapy at 2 4 intervals is the usual plan. Severe periodontal involvement Treatment is modified in two ways Periodontal maintenance should be scheduled at more frequent intervals with the patient being seen as frequently for periodontal maintenance as for orthodontic application adjustments (i.e. every 3 4 weeks)

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 Orthodontic goals and mechanics must be modified to keep orthodontic forces to an absolute minimum, because the reduced area of the periodontal means higher pressure in the periodontal from any force. Orthodontic appliance therapy The orthodontic mechanotherapy often must be modified to decrease the force levels. It must be kept in mind that the biologic response is determined by pressure in the periodontal not by the force against the tooth. For orthodontic patients with jaw discrepancies, there are always with broad categories of the Correction through growth Correction through orthodontic camouflage Surgical correction of the jaw discrepancy Space closure It is unrealistic to expect an adult to wear a head gear on the nearly continuous basis necessary to produce efficient tooth movement to slide teeth along an arch wire during closure of extraction space. In addition it may be necessary to use two-step space closure with frictionless mechanics to reduce the strain on anchorage and keep forces as light as possible.

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 Old extraction sites in adults pose mechanical and biologic challenge in orthodontic treatment. In a young patient the extraction site is recent and usually can be closed with any particular problems. In an adult, closure of an extraction site many years after the tooth is lost, is neither straight forward and not predictable. After several years, resorption results in a decrease in the vertical height of the bone, but more importantly remodeling produces a buccolingual narrowing of the alveolar process as well. Closure of such an extraction space will sequence the remodeling of the buccal and lingual cortical plates. The cortical plates respond to orthodontic force, but the reaction is much slower. Typically an old extraction site can be closed part way, but it is difficult to close it completely. Finishing and retention procedures Combined surgical and orthodontic treatment For patients whose orthodontic problems are so severe that neither growth modification nor camouflage offers a solution, surgical realignment of the jaws or dentoalveolar segments is the only possible treatment. Surgery is not the substitute for orthodontics in these patients. The indication for surgery obviously is a problem too severe for orthodontics alone.
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Types of surgical treatment I. Correction of anteroposterior relationships Both the maxillary and mandibular can be moved forward or backward to correct a jaw discrepancy. The mandibular can be moved anterior or posterior with relative ease. Extreme advancement can create stability problems associated with the neuromuscular adaptation and stretch of the investing soft tissue. The maxilla can be moved forward if bone grafts are interposed posteriorly to help stabilize the mucoperiosteum. Posterior movement of the entire maxilla is not easily achieved because other skeletal components that normally support the maxilla interfere with moving it back. The greatest disadvantages of BSSO are altered sensation and a decreased inter-incisal opening post-operatively. Altered sensation in lingual nerve distribution is transient. Paresthesia over the distribution of the inferior alveolar nerve is usually present after surgery that persists for 2 6 months, but 20 25% of patients have retained the paraesthesia. Advancement of only the teeth and alveolar process is also possible. This approach is indicated for adults with adequate chin projection but distal placement of the dentoalveolar on the mandibular corpus.

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