Orthodontic treatment usually is thought of as an elec-tive therapy for adolescent patients, most frequently ini-tiated to improve appearance. In addition to esthetic considerations, however, there are many other reasons why limited or comprehensive orthodontic treatment may be recommended to adult patients. For example, it may be advantageous to orthodontically move an impacted tooth into the dental arch, or the vertical dimension of occlusion may need to be increased and an orthodontic approach may be the least invasive and most efficient way to accomplish this goal. Restorative or peri-odontal therapies may be enhanced by uprighting tipped teeth before fabrication of a fixed partial denture or place-ment of implants in an edentulous space. No matter what the reason, the patient deserves to be informed when orthodontics is a reasonable treatment option and what the potential benefits of orthodontic treatment may be.
Malocclusion and tooth position problems may be treated with orthodontics alone or with orthodontics in combi-nation with restorative and/or surgical procedures.
Malocclusions and Related Conditions
The common thread with this series of clinical problems is the malalignment of the teeth and/or jaws.
Angle’s Class I Malocclusion This diagnosis typ-ically involves tooth-arch discrepancies in which the cumulative anteroposterior dimension of the teeth is greater than the length of the available alveolar bone (Figure 8-6). Often the opposing first molars and canines are in normal relationship relative to each other. This type of malocclusion most often is characterized by crowded or malposed teeth, but also may be associated with rotated or tipped teeth, impactions, or isolated cross-bites.
Impacted Maxillary Canines The occurrence of this condition presents the dentist with a unique treat-ment planning challenge. Because of their arrival in the eruption sequence after the incisors and premolars, the maxillary canines are more likely to be impacted or blocked out of the normal dental arch configuration.
Maintaining these teeth in a proper alignment has unique and important advantages given their long root length and their pivotal functional and esthetic role.
Anterior Open Bite This occurs when the posterior teeth are in maximum intercuspation, and there is verti-cal space between one or more pairs of maxillary and mandibular anterior teeth. Depending on the size of the
Figure 8-5 Frenal attachment contributing to mucogingival defects and periodontal disease. (Courtesy Dr. J. Moriarty, Chapel Hill, NC.)
Table 8-1 Periodontal Treatment Alternatives
Condition Treatment Options Keys to Decision Making
Periodontitis not responsive Reinstrumentation An option in the presence of calculus or root roughness where access
to initial therapy limitation does not preclude the procedure
Surgical flap procedure In locations where access to calculus or root roughness is compromised and instrumentation would be more effective after elevating a full-thickness flap;
situations in which bone osteoplasty, removal, or augmentation is indicated;
in locations where apical repositioning of the gingival margins will be beneficial
Local and systemic An option when local factors have been removed; local delivery is an option antimicrobial agents for isolated inflamed sites; systemic antibiotics may be considered in
aggressive forms of periodontitis; microbial testing can be of value in selecting an appropriate regimen
Localized infrabony defects No treatment Possible approach if the patient is resigned to losing the tooth, but wishes to retain it in the short run for space maintenance or esthetics
Extraction Possible option if patient has an immunocompromising condition or debilitated health (ASA III or IV) and the likelihood for improvement is guarded or if patient has poor compliance with recommended oral self care, or lacks the time, energy, or financial resources necessary to retain the tooth
Closed reinstrumentation When the patient refuses a surgical approach and the defect can be stabilized in its present condition using nonsurgical therapy
Root resection May be an option if the defect is isolated to one root and the prognosis for the remaining root or roots is favorable (Note: requires root canal therapy) Guided tissue regeneration Patient and disease site must be a good candidate for regenerative therapy;
or augmentation of the material and technique selection is determined on a case-by-case basis site using osseous
grafting materials
Furcal involvement No treatment except for May be appropriate if furca is stable, cleansable, and without inflammation or maintenance procedures disease progress; in the presence of progressive disease the “no treatment”
option would be permissible only if patient is resigned to losing the tooth but wishes to preserve it temporarily for space maintenance or esthetics Extraction An option if patient has no desire to save the tooth or if dentist deems the
tooth unsalvageable and retention would lead to additional bone loss around the tooth and/or adjacent teeth
Bone regeneration Patient must be motivated to save the tooth and have the financial resources and desire for optimal treatment; case and site selection is important Root amputation or If the patient has motivation, financial resources, and desire as noted above
hemisection and augmentation has been tried unsuccessfully, or if augmentation has been ruled out and at least one residual root is thought to have a good prognosis Root proximity No treatment Current periodontal condition is healthy and stable and patient accepts
responsibility for possible disease progress and tooth loss
Periodontal maintenance Preferred option if patient wishes to retain the teeth as long as possible, but is treatment with bone unwilling to undergo orthodontic therapy
augmentation as feasible and appropriate
Orthodontic correction Ideal solution for a motivated, compliant, and consenting patient who wants followed by definitive optimal treatment to save the teeth
periodontal therapy
Congenital or drug-induced No treatment May be an option if the overgrowth is limited in scope, asymptomatic, not (e.g., phenytoin) gingival progressive, does not exhibit inflammation, and is maintainable in a healthy
overgrowth state
Gingivectomy or gingival Usually necessary if hyperplasia is generalized, symptomatic, progressive, flap surgery and inflamed, and if tissue cannot be maintained in a healthy state
Mucogingival defects No treatment except for The condition is stable, no active inflammation or infection, and no definitive (clefts, recession, absence maintenance procedures restoration or orthodontic therapy is planned for that location
of attached gingiva)
Pedicle graft When the above conditions are not met and the defect is isolated to one tooth;
adjacent papillae must contain sufficient bulk to reposition into the affected area without detaching the base of the flap
Continued
Table 8-1 Periodontal Treatment Alternatives—cont’d
Condition Treatment Options Keys to Decision Making
Autogenous graft from An option when defect is progressive or has persistent inflammation, or if a separate donor site definitive restoration is planned for the area, or when the defect involves
multiple adjacent teeth or a pedicle graft would otherwise not be adequate;
a subepithelial connective tissue graft is the most popular procedure for esthetic procedures involving root coverage
High frenal attachment No treatment In the absence of patient esthetic, phonetic, or functional concerns; no inhibition of desired orthodontic movement or limitation to construction of a prosthesis
Frenectomy When the patient is symptomatic or when the frenectomy would improve the prognosis for orthodontic or prosthodontic treatment
Figure 8-6 Angle’s Class I malocclusion. (Courtesy Dr. L. Bailey, Chapel Hill, NC.)
open bite, this occurrence may represent a significant esthetic, phonetic, or functional problem for the patient (Figure 8-7).
Skeletal Abnormalities Several abnormalities of maxillary or mandibular size, form, or relationship need to be recognized and diagnosed by the general dentist. These include Angle’s Class II or III malocclu-sions, micrognathia, macrognathia, and a complex open bite.
Procedures for Treating Malocclusion
Comprehensive Orthodontics Comprehensive orthodontics involves the movement of several teeth, usually in both arches, to improve tooth alignment, func-tion, and esthetics. Usually the practitioner affixes bands and brackets to the teeth, coupled with arch wires and elastic bands. A new form of treatment that has gained considerable popularity with patients and within the pro-fession involves using Visaline functional appliances. The appliances are more esthetic and are tolerated well by patients. Extraction of some teeth may be necessary.
The treatment time varies and can range from 1 to more than 3 years, depending on the individual characteristics of the case.
Orthodontic treatment has fairly predictable success rates and outcomes. Potential negative sequelae include root blunting and resorption, gingival recession, increased caries activity, and discomfort to periodontium and other soft tissue during treatment.
Limited Orthodontic Tooth Movement Limited orthodontic tooth movement involves tipping or rotation or bodily movement of a limited number of teeth (usually no more than six), usually in just one arch. Several tech-niques are available to the dentist and include both fixed and removable appliances. Treatment is usually accom-plished in less than a year, with less potential for side effects compared with long-term treatment. A specific example of limited tooth movement is forced eruption of an anterior tooth in which caries or fracture of the crown (and root) has compromised the biologic width. Another common type of minor tooth movement involves upright-ing tipped posterior teeth in preparation for use as prosthodontic abutments or to facilitate implant place-ment (see In Clinical Practice box).
Figure 8-7 Anterior open bite in an adolescent. This case is interest-ing because the open bite self-corrected and did not require ortho-dontic intervention. (Courtesy Dr. L. Bailey, Chapel Hill, NC.)
In Clinical Practice
Uprighting a Tipped Molar Tooth
When a posterior tooth is removed and not replaced, the potential exists over time for any distally positioned remain-ing posterior teeth to move or tip mesially into the edentulous space (Figure 8-8). If at a later date, the patient wishes to replace the missing tooth or teeth, a significantly tipped molar may not be optimally positioned to serve as an abutment for a fixed or removable partial denture or to provide adequate space for implant placement in the edentulous site. Two options are available: (1) upright the tooth orthodontically before pros-thesis fabrication or (2) attempt placement of a prospros-thesis or implant in the presence of a tipped abutment or abutments.
Decision-Making Parameters
Will the occlusal forces to the teeth be significantly improved by uprighting?
Will the teeth have a better periodontal prognosis if ortho-dontic uprighting precedes the treatment?
Figure 8-8 Schematic diagram of a typical appliance for molar uprighting. (Courtesy Dr. L. Bailey, Chapel Hill, NC.)
Continued
Orthognathic Surgery Orthognathic surgery may be indicated when the patient has significant skeletal abnormalities in addition to a dental malocclusion. These procedures, usually performed by an oral and maxillofa-cial surgeon in a hospital setting, involve surgical realign-ment of the jaws or repositioning of dentoalveolar segments. Surgical treatment may be preceded and/or fol-lowed by comprehensive orthodontic treatment.
Orthognathic surgery may be the only satisfactory way to correct a severe skeletal defect, especially for the adult patient. Significant swelling and pain can be associated with the procedure, and it usually requires 1 to 2 days of hospitalization. The patient’s jaws may be immobilized after surgery for 6 to 12 weeks to stabilize the new occlusal relationship. Nerve damage during surgery may result in areas of numbness involving the teeth, lips, tongue, and other surrounding tissues.
Keys to Decision Making
Professional Modifiers Before a decision can be made to engage in orthodontic treatment, several impor-tant modifiers should be assessed carefully. Individually or collectively, these items may have a bearing on decid-ing whether to treat, how to treat, and when treatment should take place. For each situation previously dis-cussed, a definitive orthodontic case analysis is in order, such as the “Facial Form Analysis,” developed by Proffit and Fields (see Suggested Readings). At a minimum, panoramic radiographs and a complete mouth series of radiographs and study casts is required. In those cases in which a skeletal component to the malocclusion exists, cephalometric radiographs and a cephalometric analysis also are necessary.
Unless the general dentist has had considerable addi-tional training in orthodontic assessment and treatment, it is usually prudent to enlist the services of an ortho-dontist during this treatment planning process. Key
questions include determining the scope of care (limited vs. comprehensive), whether extractions are necessary or desirable, and whether the option of orthognathic surgery should be pursued. For some adult patients, it may be best to displace teeth relative to the supporting bone to compensate for an underlying jaw discrepancy. This repo-sitioning of teeth primarily for improving facial esthet-ics is referred to as camouflaging and is often a viable alternative to orthognathic surgery.
Before considering orthodontic treatment, the dentist must be certain that the patient does not have active caries or periodontal disease and is not at significant risk for future disease. The teeth and restorations must be in a stable state, capable of supporting the retention of orthodontic appliances for the duration of treatment. It is also the dentist’s responsibility to identify any apical pathology or root abnormality, such as resorption, before orthodontic treatment is initiated. In addition, the dentist should assess the scope and magnitude of the problem for which orthodontic treatment is considered.
If the problem goes untreated, will any significant nega-tive sequelae arise? Is the problem causing, or is it likely to cause, a functional or esthetic problem? In some cases, identifying the specific cause of the problem is critical to the outcome of treatment. For example, if the dentist or orthodontist attempts correction of an anterior open bite without recognizing and addressing the underlying cause, such as a tongue thrust habit, then it is likely that relapse will occur and the treatment will ultimately fail.
Other issues to be considered include the generalist’s training, expertise, and level of comfort with orthodon-tic treatment. Every general dentist should be able to rec-ognize the clinical problems described in this section and to converse with the patient about them. Some general dentists prefer to refer all orthodontic treatment to spe-cialists. Others can manage limited tooth movement cases. A few generalists who have had extensive training can handle more complex malocclusions. In any case, it In Clinical Practice
Uprighting a Tipped Molar Tooth—cont’d ment uprighting, and if the patient concurs, this is the ideal and best course of action. Often, however, the advantages of orthodontic uprighting are not overwhelming, and the patient is less than enthusiastic. Such individuals may dislike the appearance of orthodontic appliances, be less tolerant of the discomfort and the tooth mobility, and less accepting if the treatment takes longer than anticipated or does not result in an ideal outcome. Clearly the patient must make this decision, with a complete understanding of the pros and cons of restorative treatment with and without adjunctive orthodontics.
Will the retention and longevity of the prosthesis be improved by uprighting?
Is the patient receptive to the idea of limited orthodontic treatment?
Are there restorative solutions that would be preferable to the patient and have an equally good or better prognosis?
Reaching a Decision
If the dentist determines that significant periodontal, func-tional, or restorative advantages can be gained through
abut-is wabut-ise for the general dentabut-ist to carefully define the limits of his or her knowledge and ability, and treat only those cases that offer a high likelihood of success. It is also advisable for the general dentist to cultivate a close working relationship with an orthodontist and an oral and maxillofacial surgeon so that cases can be discussed and referrals made when appropriate.
Patient Modifiers A fundamental determinant in orthodontic treatment planning is the patient’s own per-ceived need for that treatment. For most patients, the willingness to accept orthodontic treatment is motivated by a desire to improve appearance, and a direct correla-tion can be made between the strength of that desire and the motivation to receive orthodontic treatment. Changes in the patient’s personal life or career can be extremely powerful and effective motivators for initiating ortho-dontic treatment. Some influences, such as the desire to please a spouse or family member, can be short-lived and if the patient lacks a strong internal motivation to con-tinue, the outcome of treatment may be in jeopardy. The wise practitioner carefully investigates these issues before engaging the patient in orthodontic treatment.
It is important to gain a sense of the patient’s expec-tations about the treatment. Are those expecexpec-tations realistic? Is the patient interested in limited treatment or comprehensive care? If limited care is preferred, is it technically possible to achieve the patient’s goals?
If comprehensive orthodontic care is favored, does he or she have any misperceptions that the treatment can be accomplished in a matter of weeks or by putting braces on a few selected teeth? Does the individual have an aversion to either fixed or removable orthodontic appliances or retainers? If so, will this compromise the treatment?
It is also important to ensure that the patient has a full appreciation of the costs of treatment, in terms of both financial resources and the time and inconvenience that may be required. Is the individual aware of the number of visits that may be required and the number of months over which the treatment will extend? Does he or she rec-ognize that there may be some discomfort to the teeth and soft tissue? Most importantly, can the patient main-tain the health of the oral cavity with effective daily oral self care despite the impediments to plaque removal that orthodontic appliances may raise? If orthognathic surgery is recommended or required, is the patient fully aware of the costs, hazards, inconvenience, and discomfort that the procedure may entail?
Typical treatment options for four common problems that can be treated with orthodontics are summarized in Table 8-2 with guidelines for selecting the most appro-priate option.
NONORTHODONTIC