2. Contents
• Introduction
• Goals of adjunctive treatment
• Principles of Adjunctive treatment
• Diagnostic and Treatment Planning Considerations
• Biomechanical Considerations
• Timing and sequence of Treatment
• Adjunctive treatment procedures
• Conclusion
• Bibliography
3. Introduction
Seek to improve
quality of life
Seek to
maintain
what they
have
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
4. Psychological Consideration?
Exceptional personality (tries harder, overcompensates)
Inadequate personality (uses deformity as a shield)
Pathologic personality (small deformity, big problem)
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
5. Definition
• Adjunctive Orthodontic treatment for adults is, by definition,
tooth movement carried out to facilitate other dental
procedures necessary to control disease, restore function,
and/or enhance appearance.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
6. • This concept is broadly defined as a multidisciplinary treatment
approach for achieving optimal esthetics and function consistent
with a physiologically stable occlusion.
Bishara. Textbook of Orthodontics. Chapter 28.
7. Goals of adjunctive treatment
• Whatever the occlusal status originally, the goals of adjunctive
treatment should be:
1. Improve periodontal health by eliminating plaque-harbouring
areas and improving the alveolar ridge contour adjacent to the
teeth.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
8. 2. Establish favourable crown-to-root ratios and position the teeth
so that occlusal forces are transmitted along the long axes of the
teeth.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
9. 3. Facilitate restorative treatment by positioning the teeth so that:
• More ideal and conservative techniques (including implants) can
be used.
• Optimal aesthetics can be obtained with bonding, laminates, or
full-coverage porcelain restorations.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
11. Diagnostic and Treatment Planning
Considerations
• Planning for adjunctive treatment requires two steps:
(1) Collecting an adequate diagnostic data base
(2) Developing a comprehensive but clearly stated list of the
patient’s problems, taking care not to focus unduly on any one
aspect of a complex situation.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
12. Biomechanical Considerations
• Characteristics of the orthodontic appliance:
• 22-slot edgewise appliance with twin brackets recommended.
• The rectangular (edgewise) bracket slot permits control of
buccolingual axial inclinations, the relatively wide bracket helps
control undesirable rotations and tipping, and the larger slot size
allows the use of stabilizing wires that are stiffer.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
13. • Recently, further developments in clear aligner therapy have provided
an effective type of removable appliance that can be well suited to
alignment of anterior teeth.
• With aligners, both discomfort and interference with speech and
mastication are minimized, and patient co-operation improves.
• Despite this aesthetic advantage, there are biomechanical limitations.
• Control of root positions is extremely difficult, and it is also difficult to
correct rotations and to extrude teeth.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
14. • Since, adjunctive treatment is concerned with only limited tooth movements,
usually it is neither necessary nor desirable to alter the position of every
tooth in the arch.
• For this reason, in a partial fixed appliance for adjunctive treatment, the
brackets are placed in an ideal position only on teeth to be moved, and the
remaining teeth that are to be incorporated in the anchor system are
bracketed so that the archwire slots are closely aligned.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
15. • Effects of reduced periodontal support:
• Since patients who need adjunctive treatment have often lost
alveolar bone to periodontal disease before it was brought
under control, the amount of bone support of each tooth is an
important special consideration.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
16. • When bone is lost, the PDL area decreases, and the same force
against the crown produces greater pressure in the PDL of a
periodontally compromised tooth than a normally supported
one.
• The absolute magnitude of force used to move teeth must be
reduced when periodontal support has been lost.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
17. • In addition, the greater the loss of attachment, the smaller the
area of supported root, and further apical will be the center of
resistance.
• This affects the moments created by forces applied to the crown
and the moments needed to control root movement.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
18. Timing and Sequence of Treatment
• Before any tooth movement, active caries and pulpal pathology
must be eliminated, using extractions, restorative procedures,
and pulpal or apical treatment as necessary.
• Endodontically treated teeth respond normally to orthodontic
force, if all residual chronic inflammation has been eliminated.
• Restorations requiring detailed occlusal anatomy should not be
placed until any adjunctive orthodontic treatment has been
completed because occlusion will inevitably be changed.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
19. • Periodontal disease must also be controlled before any
orthodontics begins because orthodontic tooth movement
superimposed on poorly controlled periodontal health can lead
to rapid and irreversible breakdown of the periodontal support
apparatus.
• Surgical pocket elimination and osseous surgery should be
delayed until completion of the orthodontic phase of treatment
because significant soft tissue and bony recontouring occurs
during orthodontic tooth movement.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
20. Comprehensive treatment plan
Stage 1: Disease Control
Stage 2: Establish Occlusion
Stage 3: Definitive perio/restorative tx
Stage 4: Maintenance
Re-evaluate
Stabilize
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
23. Missing Teeth: Space Closure Vs.
Prosthetic Replacement
• Old Extraction Sites : In adults,
closing an old extraction site is
likely to be difficult. 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. When this has
happened, closing the
extraction space requires a
reshaping of the cortical bone.
• Tooth Loss Due to Periodontal
Disease: A space closure
problem is also posed by the
loss of a tooth due to
periodontal disease. It is unwise
to move a tooth into an area
where bone has been destroyed
by periodontal disease, because
of the risk that normal bone
formation will not occur as the
tooth moves into the defect.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
24. Uprighting posterior teeth
• Treatment planning considerations:
• When molar uprighting is planned, a
number of interrelated questions
must be answered:
• If the third molar is present, should
both the second and third molars be
uprighted?
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
25. • How should the teeth be uprighted? By distal crown movement
(tipping), which would increase the space available for a bridge
pontic or implant, or by mesial root movement, which would
even reduce or close the edentulous space?
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
26. • Is extrusion of a tipped molar
permissible?
• Unless slight extrusion or crown-
height reduction is acceptable,
which usually is the case, the
patient should be considered to
have problems that require
comprehensive treatment and
treated accordingly.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
27. • Should the premolars be repositioned as part of the treatment?
• It is particularly desirable to close spaces between premolars
when uprighting molars because this will improve both the
periodontal prognosis and long-term stability.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
28. Appliances for Molar Uprighting
• A partial fixed appliance to upright tipped molars consists of
bonded brackets on the premolars and canine in that quadrant
and bonded/banded rectangular tube on the molar.
• Where premolar and canine brackets should be placed depends
on the intended tooth movement and occlusion.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
29. Uprighting a single molar
• Distal crown tipping:
• If the molar is only moderately tipped, treatment often can be
accomplished with a flexible rectangular wire such as 0.017x0.025 NiTi.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
30. • If the molar is severely tipped, a continuous wire that uprights the molar will
have side effects on the position and inclination of the second premolar.
• Hence, sectional uprighting springs are preferred.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
31.
32. • Mesial root movement:
• Skeletal anchorage is required if the goal is to close the old
extraction space.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
33. • If a small amount of mesial movement to prevent opening too
much space is the goal, a single “T-loop” sectional archwire of
17x25 SS or 19x25 beta-Ti can be effective.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
34. • Final positioning of the molars and premolars:
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
35. • Uprighting two molars in the same quadrant:
• Unless comprehensive orthodontics with a complete fixed appliance
is planned, the goal should be a modest amount of distal crown
tipping of both teeth, which typically would leave space for a
premolar-sized implant or pontic.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
36. • Trying to upright the second and third molars bilaterally at the
same time is not a good idea, as significant movement of anchor
teeth is inevitable unless skeletal anchorage is used.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
37. • Retention:
• After molar uprighting, the teeth are in an unstable position until
the prosthesis that provides the long term retention is placed.
• As a general guideline, a fixed bridge can and should be placed
within 6 weeks after uprighting is completed.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
38. Case Report
TIMOTHY G. SHAUGHNESSY. IMPLEMENTING ADJUNCTIVE ORTHODONTIC TREATMENT. JADA, Vol. 126, May 1995
39. Replacement of Missing Laterals
• Clinically, the absence of maxillary lateral incisors is reflected by
the presence of anterior spacing, including a diastema between
the central incisors and a mesial drifting of the cuspids.
Nayak A., Malviya N., Crasta D. Adjunctive Orthodontics. Heal Talk / March-April 2010 / Vol. III / Issue 04
40. • Treatment options include :
• 1. The opening of the space to replace the missing lateral
incisors with bridges or implants when indicated. This treatment
strategy is favoured when the posterior occlusion is Class I.
• 2. The space corresponding to the missing lateral incisors may be
closed by protraction of the cuspids and the buccal segments of
the teeth in a posterior Class II occlusion. The cuspids can be
reshaped into lateral incisors.
Nayak A., Malviya N., Crasta D. Adjunctive Orthodontics. Heal Talk / March-April 2010 / Vol. III / Issue 04
41.
42.
43. Crossbite Correction
• Posterior crossbites are corrected using “through the bite”
elastics from a conveniently placed tooth in the opposing arch,
which moves both the upper and lower tooth.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
44. • One way to obtain more movement of a maxillary tooth than its
antagonist in the lower arch is to have several teeth in the lower
arch stabilized by a heavy archwire segment.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
45. • If anterior crossbite is due to a displaced tooth and correcting it
requires only tipping, and a removable appliance or clear aligner
may be used to tip the tooth into normal position.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
47. Gingival Esthetic Problems
Gingival Esthetic problems fall into two categories:
• Those created by excessive or uneven display of gingiva
• Those created by gingival recession after periodontal bone loss
Nayak A., Malviya N., Crasta D. Adjunctive Orthodontics. Heal Talk / March-April 2010 / Vol. III / Issue 04
48. • A particularly distressing problem is created by gingival recession
after periodontal bone loss, which creates “black triangles” or
“black holes” between the maxillary incisor teeth.
• One approach to treating this problem is by removing some
interproximal enamel, so that the incisors can be brought close
together.
• This moves the contact points more gingivally, minimizing the
open space between the teeth.
Nayak A., Malviya N., Crasta D. Adjunctive Orthodontics. Heal Talk / March-April 2010 / Vol. III / Issue 04
49.
50. Extrusion
• Treatment Planning:
• For teeth with defects in or adjacent to the cervical third of the
root, controlled extrusion (sometimes called forced eruption)
can be an excellent alternative to extensive crown lengthening
surgery.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
51. • Extrusion of tooth allows:
• Isolation of a tooth under rubber dam for endodontic therapy
• Crown margins to be placed on sound tooth structure while
maintaining a uniform gingival contour
• In addition, alveolar bone height is not compromised.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
52. • The distance the tooth should be extruded is determined by 3 things:
1. The location of the defect (e.g fracture line, root perforation, or
resorption site)
2. Space to place the margin of the restoration so that it is not at the
base of the gingival sulcus (typically 1mm is needed)
3. An allowance for the biological width of the gingival attachment
(about 2 mm)
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
53. • The crown to root ratio at the end of treatment should be 1:1 or
better.
• Isolated one or two walled vertical defects pose a particular
esthetic problem if they occur in the anterior region of the
mouth.
• Forced eruption of such teeth, with concomitant crown
reduction, can improve the periodontal condition while
maintaining excellent esthetics.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
58. Anterior Restorations
• There are three particularly important considerations in deciding
where the orthodontist should position the teeth that are to be
restored:
1. The total amount of space that should be created
2. The mesio-distal positioning of the tooth within the space
3. The bucco-lingual positioning.
Nayak A., Malviya N., Crasta D. Adjunctive Orthodontics. Heal Talk / March-April 2010 / Vol. III / Issue 04
59. Alignment of Anterior Teeth
• Diastema Closure and Space Redistribution:
• The major indication for adjunctive
orthodontic treatment to correct malaligned
anterior teeth is preparation for buildups,
veneers, or implants to improve the
appearance of maxillary central incisors.
• The most frequent problem is a maxillary
central diastema, which is often further
complicated by irregular spacing related to
small or missing lateral incisors.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
60.
61. Case Report
TIMOTHY G. SHAUGHNESSY. IMPLEMENTING ADJUNCTIVE ORTHODONTIC TREATMENT. JADA, Vol. 126, May 1995
62. TIMOTHY G. SHAUGHNESSY. IMPLEMENTING ADJUNCTIVE ORTHODONTIC TREATMENT. JADA, Vol. 126, May 1995
63. • Crowded, rotated and displaced incisors:
• Crowding usually is the problem when
alignment of incisors is considered to provide
access for restorations, achieve better
occlusion, or enable the patient to maintain
the teeth.
• The key question is whether crowding should
be relieved by expanding the arch, removing
interproximal enamel or by extraction of a
single tooth.
Contemporary Orthodontics, 5e. Proffit, Fields and Sarver. Chapter 18.
64. Case Report
TIMOTHY G. SHAUGHNESSY. IMPLEMENTING ADJUNCTIVE ORTHODONTIC TREATMENT. JADA, Vol. 126, May 1995
65. Conclusion
• With proper team work, better and more esthetic and
conservative treatment results can be achieved.
• Orthodontic movement can serve to establish an environment
which provides for physiologic function as well as the re-
establishment of what is considered as a proper occlusion.
66. Bibliography
• Contemporary Orthodontics, 5e. Proffit, Fields and Sarver.
• Bishara. Textbook of Orthodontics. Chapter 28.
• Nayak A., Malviya N., Crasta D. Adjunctive Orthodontics. Heal
Talk / March-April 2010 / Vol. III / Issue 04
Editor's Notes
Adults who seek orthodontic treatment fall into two quite different groups:
Younger adults (typically under 35, often in their 20s) who desired but did not receive comprehensive orthodontic treatment as youths and now seek it as they become financially independent and
An older group, typically in their 40s or 50s, who have other dental problems and need orthodontics as a part of a larger treatment plan.
For the first group, their goal is to improve their quality of life. They may or may not need extensive treatment by other dental specialists, but frequently need interdisciplinary consultation.
The second group seeks to maintain what they have, not necessarily achieve as ideal an orthodontic result as possible. For them, orthodontic treatment is needed to meet specific goals that would make control of dental disease and make restoration of missing teeth easier and more effective, so the orthodontics is an adjunctive procedure to the larger periodontal and restorative goals.
A few highly successful individuals who seek treatment can be thought of as almost overcompensating for their deformity with their exceptional personablity, but they tend to be very pleasant to work with. For some individuals, however, the orthodontic condition can become the focus for a wide ranging set of social adjustment problems that orthodontics alone will not solve. These patients come under inadequate and pathologic personality categories. Need to fit patients into these categories.
Usually, it involves only a part of the dentition, and the primary goal usually is to make it easier or more effective to replace missing or damaged teeth. Making it easier for the patient to control periodontal problems is a frequent secondary goal and sometimes is the primary goal. The treatment duration tends to be a few months, rarely more than a year, and long term retention is supplied by the restorations.
Typically, adjunctive orthodontic treatment will involve any or all of several procedures:
Repositioning teeth that have drifted after extractions or bone loss so that more ideal fixed or removable partial dentures can be fabricated or so that implants can be placed
Alignment of anterior teeth to allow more esthetic restorations or successful splinting, while maintaining interproximal bone contour and embrasure form
Correction of crossbite if this compromises jaw function
Forced eruption of badly broken down teeth to expose sound root structure on which to place crowns or to level/regenerate alveolar bone.
In adjunctive treatment, the restorative dentist or the periodontist is the principal architect of the treatment plan and the orthodontics is to facilitate better restorative treatment.
Traditional removable appliances are rarely satisfactory for adjunctive treatment. They often are uncomfortable and are likely to be worn for too few hours per day to be effective.
Most adults prefer a lingual appliance or a visible fixed appliance.
Modern edgewise brackets of the straightwire type are designed for a specific location on an individual tooth.
Placing the bracket in its ideal position on each tooth implies that every tooth will be repositioned if necessary to achieve ideal occlusion.
Diagram: This allows the anchorage segments of the wire to be engaged passively in the brackets with little bending. Passive engagement of wires to the anchor teeth produces minimal disturbance of teeth that are in a physiologically satisfactory position.
In general terms, tooth movement is quite possible desoite bone loss, but lighter forces and relatively larger moments are needed.
In the development of any orthodontic treatment plan, the first step is control of any active disease.
3. This could necessitate making crowns, bridges, or removable partial dentures.
When a 1st permanent molar is lost during childhood or adolescence and not replaced, the second molar drifts mesially and the premolars often tip distally and rotate as space opens between them. As the teeth move, the adjacent gingival tissue becomes folded and distorted, forming a plaque harbouring pseudopocket that may be virtually impossible for the patient to clean. Repositioning the teeth eliminates this potentially pathologic condition and has the added advantage of simplifying the ultimate restorative procedures.
As a general rule, treatment by distal tipping of the second molar and a bridge or implant to replace the first molar is preferred. If extensive ridge resorption has already occurred, particularly in the buccolingual dimension, closing the space by mesial movement of a wide molar root into a narrow alveolar ridge will proceed very slowly.
Uprighting a mesially tipped tooth by tipping it distally, which leaves the root apex in its pretreatment position, also extrudes it. This has the merit of reducing the depth of the pseudopocket found on the mesial surface, and since the attached gingiva follows the cementoenamel junction while the mucogingival junction remains stable, it also increases the width of the keratinized tissue in that area.
This will depend on position of teeth and the restorative treatment plan, but in many cases the answer is yes.
A general guideline is that molar bands are best when the periodontal condition allows, which means for all practical purposes, they would be used in younger and healthier patients. The greater the degree of periodontal breakdown around the molar to be uprighted, the more a bonded attachment should be considered.
It is important to relieve the occlusion as the tooth tips upright. Failure to do this may cause excessive tooth mobility and increases treatment time.
After preliminary alignment of the anchor teeth if necessary, stiff rectangular wire (19x25 SS) maintains the relationship of the teeth in the anchor segment, and an auxiliary spring is placed in the molar auxiliary tube. The uprighting spring is formed from either 17x25 beta-Ti wire without a loop or a 17x25 SS wire with a loop added to provide more springiness. The mesial arm of the helical spring should be adjusted to lie passively in the vestibule and upon activation should hook over the archwie in the stabilizing segment. It is important to position the hook so that it is free to slide distally as the molar uprights. In addition, a slight lingual bend is placed to counteract the forces that tend to tip the anchor teeth buccally and the molar lingually.
After initial alignment of the anchor teeth with a light flexible wire, the T-loop wire is adapted to fit passively into the brackets on the anchor teeth and gabled at the T to exert an uprighting force.
Because the resistance offered when uprighting two molars is considerable, only small amounts of space closure should be attempted.
If retention is needed for more than a few weeks, the preferred approach is an intracoronal wire splint (19x25 SS) bonded into shallow preparations in the abutment teeth.
A 40-year-old patient was referred by her dentist for molar uprighting and distalization in preparation for a fixed bridge. The teeth in the patient's maxillary left quadrant had become severely tipped following extrac-tion of the second premolar in that region (Figure 1). The first and second molars were tipped mesially, and the first premolar was tipped distally. The entire extraction site was closed, with the first premolar and first molar in proximal contact.
I extracted the maxillary left second molar to facilitate movement of the first molar. I placed limited appliances from the maxillary right canine to the maxillary left first molar. It was necessary to use, in addition to the standard arch wire, an auxiliary uprighting spring inserted into the first molar band.
Molar uprighting was accomplished in 11 months
This tips the teeth into the correct occlusion, but also tends to extrude them.
The reverse can be done for a mandibular tooth
As a general rule, control of apical infection should be completed before extrusion of the root begins. For some patients however, the orthodontic movement must be completed before definitive endodontic procedures because onepurpose of extrusion may be to provide better access for endodontic and restorative procedures.
The size of the pulp chamber or canal at the level of the margin of the future restoration also is a consideration.
Extrusion can be as rapid as 1mm per week, without damage to PDL, so 3-6wks is sufficient for any patient.
Since extrusion is a tooth movement that occurs most readily, sufficient anchorage is available
A 28 yr old woman sought orthodontic treatment to correct a maxillary midline diastema and a displaced mandibular incisor (Figure 6). Her posterior occlusion was excellent, makingher a good candidate forlimited orthodontic treatment. Her ideal oveijet precluded orthodontic space closure alone. I redistributed the maxillary anterior space (Figure 7) so that bonding ofthese teeth could produce an ideal relative toothsize relationship (Figure 8). Bondingofthe central incisors
A 24-year-old patient had congenital absence ofthe maxillary rightlateral incisor and a hypoplastic maxillary left lateral incisor (Figure 3). I opened space forthe missinglateral incisor and simultaneously closed the central diastema with limited fixed appliances, using an arch wire with a coil spring. Space also was redistributed around the left lateral incisor usingthe same technique
I aligned the maxillary anteriorteeth ofa 34-year-old male patientbefore porcelain veneer preparation. This adjunctive tooth movement, which required seven months oforthodontic treatment, afforded the patientwell-aligned labial and lingual arch form and conservative tooth preparation
