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Orthodontic treatment in elderly patients
progress in orthodontics 1 1 ( 2 0 1 0 ) 62–75
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Clinical contribution
Orthodontic treatment in elderly patients Cinzia Maspero b , Davide Farronato c , Lucia Giannini d , Giampietro Farronato a,∗ a
MD, DDS, Full Professor and Chairman, Director of the Department of Orthodontics, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy b MD, DDS, Department of Orthodontics, University of Milan, Orthodontic Department, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy c DDS, PhD Department of Surgery and Orthodontics, University of Milan, Orthodontic Department, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy d DDS, Department of Orthodontics, University of Milan, Orthodontic Department, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
a r t i c l e
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a b s t r a c t
Article history:
Objective: In recent years there has been a significant increase in the number of elderly
Received 15 September 2008
patients requesting orthodontist consultations.
Accepted 31 August 2009
Masticatory performance is an important factor influencing the quality of life in independent healthy elderly subjects and only the restoration of skeletal and dental relationships in the
Keywords:
three planes of space can assure oral health and functions with the consequential nutritional
Orthodontics in adult patients
balance of the whole organism.
Multidisciplinary approach
The rehabilitation treatment in elderly subjects must comprehend orthodontic and pros-
Geriatrics
thetic needs. This kind of treatment has two main goals: firstly, the restoration of oral
Orthodontic and prosthetic
function and secondly the restoration of facial morphology.
treatment
Materials and methods: In this article three clinical cases treated with multidisciplinary
Oral rehabilitation
approach are described showing an efficient procedure to a successful management of the elderly patients. Results: The results obtained underlined an oral cavity in good condition which facilitates adequate nutritional intake, an essential factor in the health and well-being of elderly patients and it is important for preserving physical and mental health. Conclusions: With appropriate treatment planning and selection of the patients, the orthodontic therapy can be accomplished successfully elderly patients. © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
1.
Introduction
Nowadays orthodontists frequently have to deal with elderly patients requesting the rehabilitation of their oral function and facial form. The diffusion of health care and prevention, growing care for one’s self image and quality of life, as well
as the increasing involvement of elderly people in the social context have increased the number of senior patients who are unwilling to accept limited therapeutic attitudes.1,2 This situation is supported by the increased availability of work income and by subjects involved in professional activity or in a social context who are not inclined to change their habits or lifestyle.
∗ Corresponding author. Department of Orthodontics, Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, University of Milan, via Commenda 10 - 20100 Milano, Italy. E-mail address: [email protected] (G. Farronato). 1723-7785/$ – see front matter © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved. doi:10.1016/j.pio.2010.04.008
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The geriatric population is the most rapidly growing segment of the population. U.S. census data indicated that the oldest segment of the population has grown the fastest since 1970 and will continue to do so as reflected by population projections.3,4 The population aged 65+ years grew by 67% from 1970 to 1995 and the U.S. population projects 140% growth for residents 65 and older from 1995 to 2050. Older individuals are benefiting from advances in dental education and technology which make them more aware of their oral health quality of life with an ensuing wish to maintain efficiency well into old age. Tooth loss is no longer considered an acceptable consequence of aging.5–7 The purpose of this article is to examine different therapeutic orthodontic options for elderly subjects through the description of three clinical cases, and to underline how it is possible to carry out complex rehabilitating therapies if the patient is adequately motivated.
2.
The oral cavity in elderly subjects
The ageing phenomenon can be represented as a declining processes tending to compromise the functionality of living organisms, but not uniform in all organisms and structures. The oral cavity also undergoes declining modifications in reply to physiological adaptive variations influenced by the individual’s genetic background and environment. Loss of the natural dentition, both partial and total, often evolves in processes of re-absorption accomplished by the alveolar crest and by the soft covering tissues. The explanation of this phenomenon is linked with the loss of the functions of the alveolar bone and the soft periodontal tissues, following the principle of the functional matrix.8 Loss of posterior teeth can lead to tipping and drifting of adjacent teeth, poor interproximal contacts, poor gingival contour, reduced interradicular bone, supraeruption of unopposed teeth.9 It has been demonstrated that these processes are quite similar even in inter-individual variability and can thus be classified. The Cawood and Howell classification is an internationally recognized descriptive classification of atrophy of the edentulous jaws (1988). The atrophy of the upper jaw has been divided into five classes, and that of the mandible into six classes.10 The slow and continuous process of remodelling determines a modification in the morphology of the edentulous areas that carries on throughout life and is more frequent in the totally edentulous cases. Facial morphology and soft tissue change consequent to the loss of the dentition. Early stages of jaw atrophy are associated with a decrease in commissure width and in an increase in the nasolabial angle. Later stages are associated with a decrease in lower face height, an increase in chin prominence due to the clockwise rotation of the mandible and loss of vermillion show of the lips. The lips invert their shape10 and appear introflexed, thinned because of the modification of the tonicity of the flexor and supporting muscles with a reduction of the buccal rima. The nose approaches the chin which may seem to be more enlarged and protruding. The peri-oral facial
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muscles decussate at the modiolus, which lies lateral to the commissure. Furthermore, the size of pulp chambers is reduced or obliterated; dehydration and reduction of pulp cells can also occur. The periodontal tissues also presents similar modifications such as a decrease of vascularization and structural cells, and a tendency to hyalinization.
3. Indications and contraindications for orthodontic treatment in elderly patients The reasons inducing elderly patients to seek orthodontic treatment are different from those for young and/or adult patients. Most of them seek treatment primary because they want to improve the appearance, others because they want to solve temporomandibular pain or dysfunction or psychological problems. Those who have myofascial pain/dysfunction may benefit from improved occlusal relationships although the evidence is limited. An important role is represented by the loss of vertical dimension due to the progressive loss of dental support. In elderly patients a reduction of ANB angle and of the anterior lower vertical dimension of the face can be evidenced. This is often associated with an unstable, nonphysiological mandibular position causing a contractionary state of the masticatory muscles. Temporomandibular pain and dysfunction (TMD) develop (pain, joint noise, limited movement) with possible symptomatic projections in the whole brachial-cervical-facial area. By restoring the vertical dimension, it is possible to re-establish good neuromuscular functions and a functional harmony among all the stomatognathic components (masticatory muscles, temporo-mandibular joints – TMJ, dental component).11 The position of the lips and the reduction of the number of teeth can substantially affect oral and general health as well as overall quality of life. Loss of teeth may affect ability to speak, masticate and socialize. Edentulism can also have profound effects on psychological, emotional, oral and general health.3 Dentures can prevent enjoyment of food and affect overall nutrition causing malnutrition with consequential negative effects on behaviour and social relationships. An overflow of saliva may also occur due to an altered perception of nervous reflexes or irritative processes and lesions of the tongue with infective complications. In this context the psychological aspect is also considerable. Many elderly subjects suffer from depression and insomnia and are often treated with anxiety-relieving medications or antidepressants. These medications if used for a long time, may cause emotional instability and mask oral discomfort indicative of oral disease. All the described alterations can cause a reduced personal esteem due to an appearance considered no longer pleasant, and may induce an elderly patient to seek orthodontic consultation and treatment. It is commonly thought that orthodontic treatment in adult and elderly subjects must be limited to minor orthodontic movements such as the axial repositioning of teeth that have
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drifted after extractions or bone loss, the correction of the crossbites of single teeth, the closing of small diastema.12 This kind of approach is not sufficient to resolve the patient’s malocclusion, but – on the contrary – a complete orthodontic therapy is necessary. Though the goals of orthodontic treatment in the adult are not very different from that of the child; the situation in adults is obviously much more difficult regarding the possibility of modifying the skeletal pattern. In adult patients orthopaedic changes are almost non existent if the possibility is excluded of modifying the vertical dimension through dental extrusion and by separating the state of fibrous synarthrosis still present in some maxillary sutures. For patients with significant jaws discrepancies, orthodontic camouflage and surgical correction must be taken into consideration.9 When restorative or periodontal treatment alone cannot correct the damage produced by a pathologic occlusion, orthodontic treatment becomes an important phase in the overall treatment plan.9 In the elderly subject there are no contraindications for orthodontic treatment if the patient’s general health conditions allow it since the tissue response to dental movements is good.13 The response to orthodontic force may be somewhat slower than in children, but tooth movement occurs in a similar way at all ages. The restorative treatment cannot be considered as a substitution for the orthodontic one when dental malocclusion prevents functional rehabilitation. Orthodontic treatment is contraindicated in presence of medical disorders in progress, such as cardiovascular, cerebrovascular, neurologic, pulmonary, dysmetabolic, dyshormonal diseases and osteoporosis: the beginning of the treatment must be subordinated to the achievement of clinical recovery or of a stable pharmacological compensation. Orthodontist need to confer with primary care physicians possibly to alter medication and to educate and encourage patients to make choices that will improve oral function.
4.
remodelling processes occur more slowly and sometimes root resorption processes can be observed. The orthodontic biomechanics, often must be modified. If the patient has lost some periodontal support, it is important to keep forces light. However, in presence of spaces and suitable bone all dental movements (mesial, distal, vestibular, lingual, extrusion, intrusion and rotation) are possible and require the application of the same biomechanical principles followed in the orthodontic treatment of a young patient. Orthodontics must be effected using light and continuous forces to avoid the risk of vast bone losses. Morphological structural modifications – even if similar to those in children – are established more slowly and, in case of application of incongruous forces, recovery will be delayed and more difficult. Therefore the knowledge of these physiologic factors, typical of the adult, even though inducing prudence, does not have to limit the planning of orthodontic therapy but should tend towards the choice of the easiest and briefest technique.14
5.
Case report 1
The patient was a 62-year-old female. The chief complaint was a progressive protruding and irregular upper incisors with an increase of the diastema. She also suffered from masticatory and digestive difficulties and pain during functional movements. The dental and medical history were unremarkable. The face appeared mesomorphic with some difficulties in closing her lips (Fig. 1).
Orthodontic treatment in elderly patients
If the patient’s skeletal relationship can assure all the functions of the oral cavity, orthodontic treatment must aim at correcting the malocclusion recreating the integrity of the dental arches and restoring a functional occlusion. The periodontal aspect and the previous and present situation must be carefully considered. The design of the appliance to be used will depend on the number of teeth to be moved, the availability of anchorage, and the necessary direction and amount of crown or root movement.9 Bone remodelling processes in adult subjects do not occur rapidly as in children. Sometimes osteoporosis or osteomalacia phenomena can be observed as a consequence of hormonal and vitamin anomalies or systemic disorders, therefore a more cautious and wider diagnostic valuation is required. In adult subjects the cortical bone is increased in thickness due to progressive calcification, the cellular components and the vascularization undergo a decrease, the osteoclastic activity can be more developed than the osteoblastic one, thus the morphological and structural modifications and the
Fig. 1 – A 62 years old patient. Pretreatment extraoral photograph.
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Fig. 2 – (a-c) Pretreatment frontal and lateral intraoral views. (d) Overjet.
Fig. 3 – (a) Pretreatment lateral cephalometric radiograph. (b) Pretreatment frontal cephalometric radiograph. (c) Panoramic film.
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Fig. 4 – Intraoral frontal view at the beginning of the orthodontic treatment.
The second left lower molar appeared mesially inclined after a premature avulsion of the left lower first molar. The right and left upper first molars and the lower right second premolar were absent. Conservative and prosthetic therapy were observable in some dental elements. The upper arch was spaced with a midline diastema and incisors with an average inclination (Fig. 2a-c). Canine and molar class III relationship on both sides was noticed, as well as an increase of the overjet due to the protrusion of the incisors that resulted mobile (Fig. 2d). Functional lower jaw movements were uncoordinated due to occlusal instability and hypertonia of the masticatory muscles. The lateral teleradiography and the cephalometric tracing showed a skeletal class I (ANB = 3.5◦ ) and a skeletal open bite (3 mm) (Fig. 3a). The frontal teleradiography and the
cephalometric tracing underlined a slight asymmetry of the lower jaw (Fig. 3b). The panoramic radiograph showed no evidence of teeth pathology (Fig. 3c). The patient underwent an hygiene and prevention program to eliminate periodontal inflammatory factors and to render the oral cavity suitable for the following orthodontic therapy. Meanwhile therapy was provided for the muscular suffering and pain. After stabilization, a straight wire fixed appliance Roth prescription with pre-established biomechanics and light orthodontic forces was planned. The appliance was bonded in both arches to correct occlusal relationship by retracting the upper incisors using the mandibular posterior segments as anchorage (Fig. 4). Sliding mechanics using lacebacks as anchorage was used to obtain class I relationships. The treatment was continued for one year at the end of which adequate occlusal relationships were obtained with right and left dental class I, overjet and overbite were within the norm as well as good alignment and leveling of dental arches. No diastema were present (Fig. 5a-c). After orthodontic therapy the restorative phase was planned with preparation of a temporary resin bridge and, later on, a definitive gold resin one between the second upper left premolar and the second molar to complete the occlusal table. The anterior upper area between the lateral left incisor and the second right lateral incisor was prothesised with a gold resin fixation. Facial examination showed satisfactory facial proportions and harmony (Figs. 6–8). At the end of therapy upper and lower essix retainers were prescribed in order to maintain the results obtained. She had better balance of the lips and during smiling there was a better dental exposure.
Fig. 5 – (a-c) Intraoral frontal and lateral views at the end of the therapy.
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Functional examination at the end of treatment showed a good coordination of lower jaw movements and the return to an optimum functionality of the masticatory muscles. The patient reported the relief of pain and satisfaction for the achieved aesthetic results; she was then scheduled in a maintenance program with recalls and periodical controls of oral hygiene and occlusion.9
6.
Fig. 6 – Face of the patient at the end of the therapy.
Fig. 7 – Panoramic film at the end of the therapy.
Fig. 8 – Intraoral frontal view at the end of the restorative phase.
Case report 2
The patient was a healthy 65-year-old female and her chief compliant was discomfort and difficulties with speech and chewing and pain at the TMJs. She had no relevant medical problems. The evaluation of facial proportions did not reveal asymmetries, her profile appeared concave with a slight mandibular protrusion and maxillary retrusion (Fig. 9a,b). Her lips were moderately thick and competent. She was partially dentate with a moderately restored dentition. The overbite resulted increased, the lower right and left canine vestibular inclined and in cross bite (Fig. 10a-c). The posterior vertical dimension was increased while the anterior decreased. The lower arch had crowding and lingual inclined incisors. In centric occlusion stable contacts on the back areas were missed and the incisal and lateral guides were compromised due to interference caused by the canines in cross bite. The functional examination showed uncoordinated condylar movements with reduced opening and difficulty in the protrusive and lateral movements. She had functional limitation of mastication, linked with a defect of neuromuscular coordination, with exacerbation during mandibular kinematics. The lateral cephalometric radiograph showed a skeletal class I (ANB = 2◦ ) with the tendency toward a reduction of the anterior vertical dimension (deep bite = -2 mm). The mandibular incisors were lingually inclined. The overbite was increased. The posteroanterior one did not point out relevant asymmetries. The panoramic radiograph showed no evidence of teeth pathology (Fig. 11a-d). The patient underwent a prevention program during which she received instructions on oral hygiene, sessions of professional hygiene and domiciliary motivation. Once the periodontal health was achieved a combined orthodontic and prosthetic rehabilitating treatment was proposed to the patient aiming to restore a correct occlusion with the uprighting of the inclined teeth, to create adequate spaces for posterior right and left bridges and to obtain an adequate vertical dimension that could resolve the patient’s dysfunctional problems. A fixed appliance Roth prescription was bonded in both arched using the straight-wire technique. Light forces were applied (Fig. 12a,b). Sliding mechanics using lacebacks as anchorage was used to obtain class I relationships. After 15 months of therapy optimum occlusal relationships with a dental Class I occlusion, physiological overjet and overbite were denoted. Adequate spaces for restorative procedures were created. Posttreatment
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Fig. 9 – (a) A 66 years old patient. Face. (b) A 66 years old patient. Profile.
Fig. 10 – (a-c) Frontal and lateral intraoral views.
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Fig. 11 – (a) Pretreatment lateral cephalometric radiograph. (b) Pretreatment frontal cephalometric radiograph. (c) Pretreatment panoramic film at the beginning of the therapy. (d) Stratigraphy.
Fig. 12 – (a,b) Phases of the orthodontic therapy.
radiographs showed a considerable improvement of the periodontal conditions with evident bone regeneration mesial to the inclined elements. In fact the orthodontic uprighting stimulated new apposition of bone tissue that filled up the pre-existent defects. Examination of the face showed a harmonious profile with an adequate anterior lower vertical dimension (Fig. 13a,b). Intraoral examination showed optimal results (Fig. 14a-c). The patient was satisfied and the articular symptoms disappeared. Functional movements were normal and there were no signs or symptoms of TMJ dysfunction. She was then scheduled in a maintenance program with periodical recalls and controls. Long term control confirmed the stability of the obtained results with no signs of TMJ dysfunction.
7.
Case report 3
The patient was a 66 years old female complaining that she was unhappy with the appearance of her teeth and complaining with pain during opening and closing her mouth (Fig. 15). She had no relevant medical problems but a previous history of antidepressants assumption. The upper midline appeared deviated towards the right and the lower one towards the left. The dental examination underlined the presence of a fixed prosthesis between the lower left second incisor and the lower right second incisor, the protrusion of the upper left central incisor. The lateral upper left incisor was in cross bite (Fig. 16a-c). The functional
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Fig. 13 – (a,b) Posttreatment face and profile.
Fig. 14 – (a-c) Intraoral frontal and lateral views at the end of the therapy.
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Fig. 15 – A 66 years old patient. Face.
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examination clearly showed a reduction of the width of the mouth opening and difficulties in the lateral and protrusive movements. A component of the muscle spasm and pain was present. This situation was justified by the crowding and retrusion of the upper incisors, and by the loss of three molars. The lateral cephalometric tracing indicated a skeletal class I (ANB = 4◦ 9 with slight open bite (4 mm) (Fig. 17a-c). The TMJs stratigraphies underlined condylar suffering and asymmetry, anatomic damage to the head of the left condyle which was flattened (Fig. 17d). The therapeutic treatment involved the following phases: prevention program with initial periodontal preparation and instructions on oral hygiene; orthodontic treatment in both arches aiming at the correction of the cross bite of lateral left incisor, alignment and leveling of dental elements in order to obtain an adequate vertical dimension, to improve the articular symptoms and the functional movements. Fixed appliances were placed in both arches using the straight wire technique (Fig. 18a,b). The orthodontic movements were performed using very light forces 0.12-0.14 NiTi archwires were used to obtain levelling and aligning. At the end of the therapy that took about 15 months both dental arches were levelled and well aligned, the overjet and overbite were corrected and dental class I relationship was achieved. The midlines were coincident. The prosthetic treatment was performed by a temporary prosthesis and occlusal rehabilitation through selective tooth grinding, followed by a definitive prosthetic rehabilitation by complete fixation of the lower arch and two bridges in the upper arch. Functional movements were normal and there were no signs or symptoms of TMJ dysfunction. The patient was completely satisfied with the aesthetic results and the considerable improvement of the symptoms (Figs. 19, 20a-c, 21a-c).
Fig. 16 – (a-c) Frontal intraoral view.
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Fig. 17 – (a) Pretreatment lateral cephalometric radiograph. (b) Pretreatment frontal cephalometric radiograph. (c) Pretreatment panoramic film. (d) Stratigraphy.
Fig. 18 – (a,b) Phases of the orthodontic therapy.
She was then scheduled in a maintenance program with periodical recalls and controls. Long terms controls confirmed the stability of the obtained results. The author(s) declare that the work has been carried out in agreement with the Helsinki Declaration principles and that the Informed Consent has been achieved from all the participants involved in the study.
8.
Discussions and conclusions
Improved medical and dental management of disease have placed increasing demands on dental and orthodontic treatment in elderly patients.
The geriatric population is the most rapidly growing segment of the population and they have specific oral changes in addition with medical disorders that can affect the provision of dental care. Success in dental treatment and long-term care of elders requires and interdisciplinary consideration of aging. Orthodontic appliances can take advantage of favourable growth in adolescents to achieve treatment goals. In the elders where growth potential is absent, tooth movement is still possible and is a useful help for the realization of aesthetic and functional objectives in multidisciplinary treatment.1,3,7,15 Orthodontic treatment of the elders normally involves limited objectives with goals customised to the patients concerns and functional needs and is often limited to slight dental movements.12
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Fig. 19 – Post-treatment face.
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From the analysis of the described cases it is possible to underline that this approach is insufficient to optimally resolve patients’ problems. An oral cavity in good conditions facilitates adequate nourishment that is an essential factor in the health and well-being of elderly patients. Inadequate nourishment can contribute to an accelerated physical and mental deterioration and a compromised oral cavity can be a noxious factor for the state of nutrition and health. Some authors affirm that alterations of the oral cavity are mainly responsible of malnutrition which in spite of its high frequency in the elderly, has not yet been considered to be important in dentistry. Missing diagnosis and therapy of malnutrition lead to increasing morbidity and mortality.16 A correct diet, on the contrary, opposes malnutrition and can strengthen the resistance to infections as well as delay the onset of cardiovascular diseases and osteoporosis.2,17 It is possible to conclude that, in elderly subjects in general good conditions of health, adequately motivated and collaborating, there are no contraindications to orthodontic treatment and this treatment can improve the health of the patient and the prognosis of wearing a denture successfully, which is an important condition for a correct nutrition. These case report demonstrate that orthodontic treatment of the elders is possible and can improve the function and aesthetics of the dentition and thus increase their quality of life and they also confirm that even elderly subjects can undergo complex rehabilitating treatment, including orthodontics. The realization of aesthetic and functional objectives in multidisciplinary cases represents a considerable clinical challenge and prosthetics.18 In fact, in elderly patients as well, there are no contraindications to orthodontic treatment and the tissue answer to dental movements is good, allowing the achievement of excellent results.
Fig. 20 – (a-c) Post-treatment intraoral frontal and lateral views.
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Fig. 21 – (a) Post-treatment lateral radiograph. (b) Post-treatment frontal radiograph. (c) Post-treatment panoramic film.
Conflict of interest The authors have reported no conflicts of interest.
Conclusioni: In presenza di un corretto piano di trattamento specifico per il paziente, la terapia ortodontica può essere intrapresa con successo anche nei pazienti anziani.
Résumé Riassunto Obiettivo: Nel corso degli ultimi anni vi è stato un significativo aumento nel numerio di pazienti anziani che hanno richiesto il consulto dell’ortodontista. La performance masticatoria è un fattore importante che influenza la qualità della vita dei pazienti anziani e solo il ripristino di corretti rapporti scheletrici e dentali nei tre piani dello spazio può assicurare la salute orale e la corretta funzionalità dell’apparato stomatognatico con un coseguente equilibrio nutrizionale a livello di tutto l’organismo. Il trattamento riabilitativo nei pazienti anziani comprende una fase ortodontica e una fase protesica. Questo tipo di terapia ha due obiettivi principali: dapprima il ripristino della funzionalità e in seguito della corretta morfologia dell’apparato stomatognatico. Materiali e metodi: In questo lavoro vengono descritti tre casi clinici trattati tramite un approccio multidisciplinare e proposta una metodica efficiente per la corretta gestione del paziente anziano. Risultati: I risultati ottenuti sottolineano che un cavo orale in buone condizioni di salute facilita una corretta nutrizione, fattore esenziale per la salute e il benessere del paziente anziano e fondamentale ai fini del ripristino della salute fisica e mentale.
Objectif: Dans ces dernières années il y a eu une croissance significative dans le nombre de vieux patients demandants des consultations d’orthodontie. La qualité de masticattion est un facteur important influenc¸ante la qualité de vie dans de vieux sujets en bonne santé et seulement la restauration des rapports squelettiques et dentaires dans les trois plans de l’espace peut assurer la santé et les fonctions orales avec l’équilibre alimentaire consécutif du corps entier. La réhabilitation des vieux sujets doit comprendre les besoins orthodontiques et prosthétiques. Ce genre de traitement a deux objectifs principaux: premièrement, la restauration de la fonction orale et deuxièmement la restauration de la morphologie faciale. Matériaux et méthodes: Dans les cas cliniques de cet article on decrit trios cas traités avec l’approche multidisciplinaire en montrant un protocol efficace à la bonne gestion des vieux patients. Résultats: Les résultats obtenus ont montré une cavité buccale en bon état qui facilite une prise alimentaire proportionnée, un facteur essentiel dans la santé et le bien-être de vieux patients et tout ca est important pour préserver la santé physique et mentale. Conclusions: Avec la planification de traitement et le choix appropriés des patients, la thérapie orthodontique peut être accomplie avec succès vieux patients.
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Resumen ˜ ha habido un aumento significativo Objetivo: En los últimos anos en el número de pacientes de edad avanzada que solicitan consultas ortodonticas. Una correcta función del aparato masticatorio es un factor importante, que influye en la calidad de vida en sujetos sanos, independientemente de la edad avanzada. Sólo el restablecimiento de las relaciones esqueléticas y dentales en los tres planos del espacio puede asegurar una buena salud oral, de igual forma las funciones con el equilibrio nutricional darán como consecuencia un balance de todo el organismo. El tratamiento de rehabilitación en pacientes ancianos debe tener en cuenta las necesidades ortodonticas y protésicas. Este tipo de tratamiento tiene dos objetivos principales: en primer lugar, la restauración de la función oral y en segundo lugar la restauración de la morfología facial. Materiales y métodos: En este artículo se describen tres casos clínicos tratados con un enfoque multidisciplinario, mostrando un procedimiento eficaz con una gestión exitosa en pacientes de edad avanzada. Resultados: Los resultados obtenidos resaltan que en una cavidad bucal en buenas condiciones, que a su vez facilita una ingesta nutricional adecuada; son factores esenciales en la salud y el bienestar de los pacientes de edad avanzada, que de igual forma también son importantes para preservar la salud física y mental. Conclusiones: Con el plan de terapéutico adecuado y una correcta selección de los pacientes, el tratamiento de ortodoncia se puede lograr buenos resultados en pacientes de edad avanzada.
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Clinical contribution
Orthodontic treatment in elderly patients Cinzia Maspero b , Davide Farronato c , Lucia Giannini d , Giampietro Farronato a,∗ a
MD, DDS, Full Professor and Chairman, Director of the Department of Orthodontics, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy b MD, DDS, Department of Orthodontics, University of Milan, Orthodontic Department, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy c DDS, PhD Department of Surgery and Orthodontics, University of Milan, Orthodontic Department, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy d DDS, Department of Orthodontics, University of Milan, Orthodontic Department, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
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a b s t r a c t
Article history:
Objective: In recent years there has been a significant increase in the number of elderly
Received 15 September 2008
patients requesting orthodontist consultations.
Accepted 31 August 2009
Masticatory performance is an important factor influencing the quality of life in independent healthy elderly subjects and only the restoration of skeletal and dental relationships in the
Keywords:
three planes of space can assure oral health and functions with the consequential nutritional
Orthodontics in adult patients
balance of the whole organism.
Multidisciplinary approach
The rehabilitation treatment in elderly subjects must comprehend orthodontic and pros-
Geriatrics
thetic needs. This kind of treatment has two main goals: firstly, the restoration of oral
Orthodontic and prosthetic
function and secondly the restoration of facial morphology.
treatment
Materials and methods: In this article three clinical cases treated with multidisciplinary
Oral rehabilitation
approach are described showing an efficient procedure to a successful management of the elderly patients. Results: The results obtained underlined an oral cavity in good condition which facilitates adequate nutritional intake, an essential factor in the health and well-being of elderly patients and it is important for preserving physical and mental health. Conclusions: With appropriate treatment planning and selection of the patients, the orthodontic therapy can be accomplished successfully elderly patients. © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
1.
Introduction
Nowadays orthodontists frequently have to deal with elderly patients requesting the rehabilitation of their oral function and facial form. The diffusion of health care and prevention, growing care for one’s self image and quality of life, as well
as the increasing involvement of elderly people in the social context have increased the number of senior patients who are unwilling to accept limited therapeutic attitudes.1,2 This situation is supported by the increased availability of work income and by subjects involved in professional activity or in a social context who are not inclined to change their habits or lifestyle.
∗ Corresponding author. Department of Orthodontics, Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, University of Milan, via Commenda 10 - 20100 Milano, Italy. E-mail address: [email protected] (G. Farronato). 1723-7785/$ – see front matter © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved. doi:10.1016/j.pio.2010.04.008
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The geriatric population is the most rapidly growing segment of the population. U.S. census data indicated that the oldest segment of the population has grown the fastest since 1970 and will continue to do so as reflected by population projections.3,4 The population aged 65+ years grew by 67% from 1970 to 1995 and the U.S. population projects 140% growth for residents 65 and older from 1995 to 2050. Older individuals are benefiting from advances in dental education and technology which make them more aware of their oral health quality of life with an ensuing wish to maintain efficiency well into old age. Tooth loss is no longer considered an acceptable consequence of aging.5–7 The purpose of this article is to examine different therapeutic orthodontic options for elderly subjects through the description of three clinical cases, and to underline how it is possible to carry out complex rehabilitating therapies if the patient is adequately motivated.
2.
The oral cavity in elderly subjects
The ageing phenomenon can be represented as a declining processes tending to compromise the functionality of living organisms, but not uniform in all organisms and structures. The oral cavity also undergoes declining modifications in reply to physiological adaptive variations influenced by the individual’s genetic background and environment. Loss of the natural dentition, both partial and total, often evolves in processes of re-absorption accomplished by the alveolar crest and by the soft covering tissues. The explanation of this phenomenon is linked with the loss of the functions of the alveolar bone and the soft periodontal tissues, following the principle of the functional matrix.8 Loss of posterior teeth can lead to tipping and drifting of adjacent teeth, poor interproximal contacts, poor gingival contour, reduced interradicular bone, supraeruption of unopposed teeth.9 It has been demonstrated that these processes are quite similar even in inter-individual variability and can thus be classified. The Cawood and Howell classification is an internationally recognized descriptive classification of atrophy of the edentulous jaws (1988). The atrophy of the upper jaw has been divided into five classes, and that of the mandible into six classes.10 The slow and continuous process of remodelling determines a modification in the morphology of the edentulous areas that carries on throughout life and is more frequent in the totally edentulous cases. Facial morphology and soft tissue change consequent to the loss of the dentition. Early stages of jaw atrophy are associated with a decrease in commissure width and in an increase in the nasolabial angle. Later stages are associated with a decrease in lower face height, an increase in chin prominence due to the clockwise rotation of the mandible and loss of vermillion show of the lips. The lips invert their shape10 and appear introflexed, thinned because of the modification of the tonicity of the flexor and supporting muscles with a reduction of the buccal rima. The nose approaches the chin which may seem to be more enlarged and protruding. The peri-oral facial
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muscles decussate at the modiolus, which lies lateral to the commissure. Furthermore, the size of pulp chambers is reduced or obliterated; dehydration and reduction of pulp cells can also occur. The periodontal tissues also presents similar modifications such as a decrease of vascularization and structural cells, and a tendency to hyalinization.
3. Indications and contraindications for orthodontic treatment in elderly patients The reasons inducing elderly patients to seek orthodontic treatment are different from those for young and/or adult patients. Most of them seek treatment primary because they want to improve the appearance, others because they want to solve temporomandibular pain or dysfunction or psychological problems. Those who have myofascial pain/dysfunction may benefit from improved occlusal relationships although the evidence is limited. An important role is represented by the loss of vertical dimension due to the progressive loss of dental support. In elderly patients a reduction of ANB angle and of the anterior lower vertical dimension of the face can be evidenced. This is often associated with an unstable, nonphysiological mandibular position causing a contractionary state of the masticatory muscles. Temporomandibular pain and dysfunction (TMD) develop (pain, joint noise, limited movement) with possible symptomatic projections in the whole brachial-cervical-facial area. By restoring the vertical dimension, it is possible to re-establish good neuromuscular functions and a functional harmony among all the stomatognathic components (masticatory muscles, temporo-mandibular joints – TMJ, dental component).11 The position of the lips and the reduction of the number of teeth can substantially affect oral and general health as well as overall quality of life. Loss of teeth may affect ability to speak, masticate and socialize. Edentulism can also have profound effects on psychological, emotional, oral and general health.3 Dentures can prevent enjoyment of food and affect overall nutrition causing malnutrition with consequential negative effects on behaviour and social relationships. An overflow of saliva may also occur due to an altered perception of nervous reflexes or irritative processes and lesions of the tongue with infective complications. In this context the psychological aspect is also considerable. Many elderly subjects suffer from depression and insomnia and are often treated with anxiety-relieving medications or antidepressants. These medications if used for a long time, may cause emotional instability and mask oral discomfort indicative of oral disease. All the described alterations can cause a reduced personal esteem due to an appearance considered no longer pleasant, and may induce an elderly patient to seek orthodontic consultation and treatment. It is commonly thought that orthodontic treatment in adult and elderly subjects must be limited to minor orthodontic movements such as the axial repositioning of teeth that have
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drifted after extractions or bone loss, the correction of the crossbites of single teeth, the closing of small diastema.12 This kind of approach is not sufficient to resolve the patient’s malocclusion, but – on the contrary – a complete orthodontic therapy is necessary. Though the goals of orthodontic treatment in the adult are not very different from that of the child; the situation in adults is obviously much more difficult regarding the possibility of modifying the skeletal pattern. In adult patients orthopaedic changes are almost non existent if the possibility is excluded of modifying the vertical dimension through dental extrusion and by separating the state of fibrous synarthrosis still present in some maxillary sutures. For patients with significant jaws discrepancies, orthodontic camouflage and surgical correction must be taken into consideration.9 When restorative or periodontal treatment alone cannot correct the damage produced by a pathologic occlusion, orthodontic treatment becomes an important phase in the overall treatment plan.9 In the elderly subject there are no contraindications for orthodontic treatment if the patient’s general health conditions allow it since the tissue response to dental movements is good.13 The response to orthodontic force may be somewhat slower than in children, but tooth movement occurs in a similar way at all ages. The restorative treatment cannot be considered as a substitution for the orthodontic one when dental malocclusion prevents functional rehabilitation. Orthodontic treatment is contraindicated in presence of medical disorders in progress, such as cardiovascular, cerebrovascular, neurologic, pulmonary, dysmetabolic, dyshormonal diseases and osteoporosis: the beginning of the treatment must be subordinated to the achievement of clinical recovery or of a stable pharmacological compensation. Orthodontist need to confer with primary care physicians possibly to alter medication and to educate and encourage patients to make choices that will improve oral function.
4.
remodelling processes occur more slowly and sometimes root resorption processes can be observed. The orthodontic biomechanics, often must be modified. If the patient has lost some periodontal support, it is important to keep forces light. However, in presence of spaces and suitable bone all dental movements (mesial, distal, vestibular, lingual, extrusion, intrusion and rotation) are possible and require the application of the same biomechanical principles followed in the orthodontic treatment of a young patient. Orthodontics must be effected using light and continuous forces to avoid the risk of vast bone losses. Morphological structural modifications – even if similar to those in children – are established more slowly and, in case of application of incongruous forces, recovery will be delayed and more difficult. Therefore the knowledge of these physiologic factors, typical of the adult, even though inducing prudence, does not have to limit the planning of orthodontic therapy but should tend towards the choice of the easiest and briefest technique.14
5.
Case report 1
The patient was a 62-year-old female. The chief complaint was a progressive protruding and irregular upper incisors with an increase of the diastema. She also suffered from masticatory and digestive difficulties and pain during functional movements. The dental and medical history were unremarkable. The face appeared mesomorphic with some difficulties in closing her lips (Fig. 1).
Orthodontic treatment in elderly patients
If the patient’s skeletal relationship can assure all the functions of the oral cavity, orthodontic treatment must aim at correcting the malocclusion recreating the integrity of the dental arches and restoring a functional occlusion. The periodontal aspect and the previous and present situation must be carefully considered. The design of the appliance to be used will depend on the number of teeth to be moved, the availability of anchorage, and the necessary direction and amount of crown or root movement.9 Bone remodelling processes in adult subjects do not occur rapidly as in children. Sometimes osteoporosis or osteomalacia phenomena can be observed as a consequence of hormonal and vitamin anomalies or systemic disorders, therefore a more cautious and wider diagnostic valuation is required. In adult subjects the cortical bone is increased in thickness due to progressive calcification, the cellular components and the vascularization undergo a decrease, the osteoclastic activity can be more developed than the osteoblastic one, thus the morphological and structural modifications and the
Fig. 1 – A 62 years old patient. Pretreatment extraoral photograph.
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Fig. 2 – (a-c) Pretreatment frontal and lateral intraoral views. (d) Overjet.
Fig. 3 – (a) Pretreatment lateral cephalometric radiograph. (b) Pretreatment frontal cephalometric radiograph. (c) Panoramic film.
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Fig. 4 – Intraoral frontal view at the beginning of the orthodontic treatment.
The second left lower molar appeared mesially inclined after a premature avulsion of the left lower first molar. The right and left upper first molars and the lower right second premolar were absent. Conservative and prosthetic therapy were observable in some dental elements. The upper arch was spaced with a midline diastema and incisors with an average inclination (Fig. 2a-c). Canine and molar class III relationship on both sides was noticed, as well as an increase of the overjet due to the protrusion of the incisors that resulted mobile (Fig. 2d). Functional lower jaw movements were uncoordinated due to occlusal instability and hypertonia of the masticatory muscles. The lateral teleradiography and the cephalometric tracing showed a skeletal class I (ANB = 3.5◦ ) and a skeletal open bite (3 mm) (Fig. 3a). The frontal teleradiography and the
cephalometric tracing underlined a slight asymmetry of the lower jaw (Fig. 3b). The panoramic radiograph showed no evidence of teeth pathology (Fig. 3c). The patient underwent an hygiene and prevention program to eliminate periodontal inflammatory factors and to render the oral cavity suitable for the following orthodontic therapy. Meanwhile therapy was provided for the muscular suffering and pain. After stabilization, a straight wire fixed appliance Roth prescription with pre-established biomechanics and light orthodontic forces was planned. The appliance was bonded in both arches to correct occlusal relationship by retracting the upper incisors using the mandibular posterior segments as anchorage (Fig. 4). Sliding mechanics using lacebacks as anchorage was used to obtain class I relationships. The treatment was continued for one year at the end of which adequate occlusal relationships were obtained with right and left dental class I, overjet and overbite were within the norm as well as good alignment and leveling of dental arches. No diastema were present (Fig. 5a-c). After orthodontic therapy the restorative phase was planned with preparation of a temporary resin bridge and, later on, a definitive gold resin one between the second upper left premolar and the second molar to complete the occlusal table. The anterior upper area between the lateral left incisor and the second right lateral incisor was prothesised with a gold resin fixation. Facial examination showed satisfactory facial proportions and harmony (Figs. 6–8). At the end of therapy upper and lower essix retainers were prescribed in order to maintain the results obtained. She had better balance of the lips and during smiling there was a better dental exposure.
Fig. 5 – (a-c) Intraoral frontal and lateral views at the end of the therapy.
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Functional examination at the end of treatment showed a good coordination of lower jaw movements and the return to an optimum functionality of the masticatory muscles. The patient reported the relief of pain and satisfaction for the achieved aesthetic results; she was then scheduled in a maintenance program with recalls and periodical controls of oral hygiene and occlusion.9
6.
Fig. 6 – Face of the patient at the end of the therapy.
Fig. 7 – Panoramic film at the end of the therapy.
Fig. 8 – Intraoral frontal view at the end of the restorative phase.
Case report 2
The patient was a healthy 65-year-old female and her chief compliant was discomfort and difficulties with speech and chewing and pain at the TMJs. She had no relevant medical problems. The evaluation of facial proportions did not reveal asymmetries, her profile appeared concave with a slight mandibular protrusion and maxillary retrusion (Fig. 9a,b). Her lips were moderately thick and competent. She was partially dentate with a moderately restored dentition. The overbite resulted increased, the lower right and left canine vestibular inclined and in cross bite (Fig. 10a-c). The posterior vertical dimension was increased while the anterior decreased. The lower arch had crowding and lingual inclined incisors. In centric occlusion stable contacts on the back areas were missed and the incisal and lateral guides were compromised due to interference caused by the canines in cross bite. The functional examination showed uncoordinated condylar movements with reduced opening and difficulty in the protrusive and lateral movements. She had functional limitation of mastication, linked with a defect of neuromuscular coordination, with exacerbation during mandibular kinematics. The lateral cephalometric radiograph showed a skeletal class I (ANB = 2◦ ) with the tendency toward a reduction of the anterior vertical dimension (deep bite = -2 mm). The mandibular incisors were lingually inclined. The overbite was increased. The posteroanterior one did not point out relevant asymmetries. The panoramic radiograph showed no evidence of teeth pathology (Fig. 11a-d). The patient underwent a prevention program during which she received instructions on oral hygiene, sessions of professional hygiene and domiciliary motivation. Once the periodontal health was achieved a combined orthodontic and prosthetic rehabilitating treatment was proposed to the patient aiming to restore a correct occlusion with the uprighting of the inclined teeth, to create adequate spaces for posterior right and left bridges and to obtain an adequate vertical dimension that could resolve the patient’s dysfunctional problems. A fixed appliance Roth prescription was bonded in both arched using the straight-wire technique. Light forces were applied (Fig. 12a,b). Sliding mechanics using lacebacks as anchorage was used to obtain class I relationships. After 15 months of therapy optimum occlusal relationships with a dental Class I occlusion, physiological overjet and overbite were denoted. Adequate spaces for restorative procedures were created. Posttreatment
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Fig. 9 – (a) A 66 years old patient. Face. (b) A 66 years old patient. Profile.
Fig. 10 – (a-c) Frontal and lateral intraoral views.
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Fig. 11 – (a) Pretreatment lateral cephalometric radiograph. (b) Pretreatment frontal cephalometric radiograph. (c) Pretreatment panoramic film at the beginning of the therapy. (d) Stratigraphy.
Fig. 12 – (a,b) Phases of the orthodontic therapy.
radiographs showed a considerable improvement of the periodontal conditions with evident bone regeneration mesial to the inclined elements. In fact the orthodontic uprighting stimulated new apposition of bone tissue that filled up the pre-existent defects. Examination of the face showed a harmonious profile with an adequate anterior lower vertical dimension (Fig. 13a,b). Intraoral examination showed optimal results (Fig. 14a-c). The patient was satisfied and the articular symptoms disappeared. Functional movements were normal and there were no signs or symptoms of TMJ dysfunction. She was then scheduled in a maintenance program with periodical recalls and controls. Long term control confirmed the stability of the obtained results with no signs of TMJ dysfunction.
7.
Case report 3
The patient was a 66 years old female complaining that she was unhappy with the appearance of her teeth and complaining with pain during opening and closing her mouth (Fig. 15). She had no relevant medical problems but a previous history of antidepressants assumption. The upper midline appeared deviated towards the right and the lower one towards the left. The dental examination underlined the presence of a fixed prosthesis between the lower left second incisor and the lower right second incisor, the protrusion of the upper left central incisor. The lateral upper left incisor was in cross bite (Fig. 16a-c). The functional
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Fig. 13 – (a,b) Posttreatment face and profile.
Fig. 14 – (a-c) Intraoral frontal and lateral views at the end of the therapy.
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Fig. 15 – A 66 years old patient. Face.
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examination clearly showed a reduction of the width of the mouth opening and difficulties in the lateral and protrusive movements. A component of the muscle spasm and pain was present. This situation was justified by the crowding and retrusion of the upper incisors, and by the loss of three molars. The lateral cephalometric tracing indicated a skeletal class I (ANB = 4◦ 9 with slight open bite (4 mm) (Fig. 17a-c). The TMJs stratigraphies underlined condylar suffering and asymmetry, anatomic damage to the head of the left condyle which was flattened (Fig. 17d). The therapeutic treatment involved the following phases: prevention program with initial periodontal preparation and instructions on oral hygiene; orthodontic treatment in both arches aiming at the correction of the cross bite of lateral left incisor, alignment and leveling of dental elements in order to obtain an adequate vertical dimension, to improve the articular symptoms and the functional movements. Fixed appliances were placed in both arches using the straight wire technique (Fig. 18a,b). The orthodontic movements were performed using very light forces 0.12-0.14 NiTi archwires were used to obtain levelling and aligning. At the end of the therapy that took about 15 months both dental arches were levelled and well aligned, the overjet and overbite were corrected and dental class I relationship was achieved. The midlines were coincident. The prosthetic treatment was performed by a temporary prosthesis and occlusal rehabilitation through selective tooth grinding, followed by a definitive prosthetic rehabilitation by complete fixation of the lower arch and two bridges in the upper arch. Functional movements were normal and there were no signs or symptoms of TMJ dysfunction. The patient was completely satisfied with the aesthetic results and the considerable improvement of the symptoms (Figs. 19, 20a-c, 21a-c).
Fig. 16 – (a-c) Frontal intraoral view.
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Fig. 17 – (a) Pretreatment lateral cephalometric radiograph. (b) Pretreatment frontal cephalometric radiograph. (c) Pretreatment panoramic film. (d) Stratigraphy.
Fig. 18 – (a,b) Phases of the orthodontic therapy.
She was then scheduled in a maintenance program with periodical recalls and controls. Long terms controls confirmed the stability of the obtained results. The author(s) declare that the work has been carried out in agreement with the Helsinki Declaration principles and that the Informed Consent has been achieved from all the participants involved in the study.
8.
Discussions and conclusions
Improved medical and dental management of disease have placed increasing demands on dental and orthodontic treatment in elderly patients.
The geriatric population is the most rapidly growing segment of the population and they have specific oral changes in addition with medical disorders that can affect the provision of dental care. Success in dental treatment and long-term care of elders requires and interdisciplinary consideration of aging. Orthodontic appliances can take advantage of favourable growth in adolescents to achieve treatment goals. In the elders where growth potential is absent, tooth movement is still possible and is a useful help for the realization of aesthetic and functional objectives in multidisciplinary treatment.1,3,7,15 Orthodontic treatment of the elders normally involves limited objectives with goals customised to the patients concerns and functional needs and is often limited to slight dental movements.12
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Fig. 19 – Post-treatment face.
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From the analysis of the described cases it is possible to underline that this approach is insufficient to optimally resolve patients’ problems. An oral cavity in good conditions facilitates adequate nourishment that is an essential factor in the health and well-being of elderly patients. Inadequate nourishment can contribute to an accelerated physical and mental deterioration and a compromised oral cavity can be a noxious factor for the state of nutrition and health. Some authors affirm that alterations of the oral cavity are mainly responsible of malnutrition which in spite of its high frequency in the elderly, has not yet been considered to be important in dentistry. Missing diagnosis and therapy of malnutrition lead to increasing morbidity and mortality.16 A correct diet, on the contrary, opposes malnutrition and can strengthen the resistance to infections as well as delay the onset of cardiovascular diseases and osteoporosis.2,17 It is possible to conclude that, in elderly subjects in general good conditions of health, adequately motivated and collaborating, there are no contraindications to orthodontic treatment and this treatment can improve the health of the patient and the prognosis of wearing a denture successfully, which is an important condition for a correct nutrition. These case report demonstrate that orthodontic treatment of the elders is possible and can improve the function and aesthetics of the dentition and thus increase their quality of life and they also confirm that even elderly subjects can undergo complex rehabilitating treatment, including orthodontics. The realization of aesthetic and functional objectives in multidisciplinary cases represents a considerable clinical challenge and prosthetics.18 In fact, in elderly patients as well, there are no contraindications to orthodontic treatment and the tissue answer to dental movements is good, allowing the achievement of excellent results.
Fig. 20 – (a-c) Post-treatment intraoral frontal and lateral views.
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Fig. 21 – (a) Post-treatment lateral radiograph. (b) Post-treatment frontal radiograph. (c) Post-treatment panoramic film.
Conflict of interest The authors have reported no conflicts of interest.
Conclusioni: In presenza di un corretto piano di trattamento specifico per il paziente, la terapia ortodontica può essere intrapresa con successo anche nei pazienti anziani.
Résumé Riassunto Obiettivo: Nel corso degli ultimi anni vi è stato un significativo aumento nel numerio di pazienti anziani che hanno richiesto il consulto dell’ortodontista. La performance masticatoria è un fattore importante che influenza la qualità della vita dei pazienti anziani e solo il ripristino di corretti rapporti scheletrici e dentali nei tre piani dello spazio può assicurare la salute orale e la corretta funzionalità dell’apparato stomatognatico con un coseguente equilibrio nutrizionale a livello di tutto l’organismo. Il trattamento riabilitativo nei pazienti anziani comprende una fase ortodontica e una fase protesica. Questo tipo di terapia ha due obiettivi principali: dapprima il ripristino della funzionalità e in seguito della corretta morfologia dell’apparato stomatognatico. Materiali e metodi: In questo lavoro vengono descritti tre casi clinici trattati tramite un approccio multidisciplinare e proposta una metodica efficiente per la corretta gestione del paziente anziano. Risultati: I risultati ottenuti sottolineano che un cavo orale in buone condizioni di salute facilita una corretta nutrizione, fattore esenziale per la salute e il benessere del paziente anziano e fondamentale ai fini del ripristino della salute fisica e mentale.
Objectif: Dans ces dernières années il y a eu une croissance significative dans le nombre de vieux patients demandants des consultations d’orthodontie. La qualité de masticattion est un facteur important influenc¸ante la qualité de vie dans de vieux sujets en bonne santé et seulement la restauration des rapports squelettiques et dentaires dans les trois plans de l’espace peut assurer la santé et les fonctions orales avec l’équilibre alimentaire consécutif du corps entier. La réhabilitation des vieux sujets doit comprendre les besoins orthodontiques et prosthétiques. Ce genre de traitement a deux objectifs principaux: premièrement, la restauration de la fonction orale et deuxièmement la restauration de la morphologie faciale. Matériaux et méthodes: Dans les cas cliniques de cet article on decrit trios cas traités avec l’approche multidisciplinaire en montrant un protocol efficace à la bonne gestion des vieux patients. Résultats: Les résultats obtenus ont montré une cavité buccale en bon état qui facilite une prise alimentaire proportionnée, un facteur essentiel dans la santé et le bien-être de vieux patients et tout ca est important pour préserver la santé physique et mentale. Conclusions: Avec la planification de traitement et le choix appropriés des patients, la thérapie orthodontique peut être accomplie avec succès vieux patients.
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Resumen ˜ ha habido un aumento significativo Objetivo: En los últimos anos en el número de pacientes de edad avanzada que solicitan consultas ortodonticas. Una correcta función del aparato masticatorio es un factor importante, que influye en la calidad de vida en sujetos sanos, independientemente de la edad avanzada. Sólo el restablecimiento de las relaciones esqueléticas y dentales en los tres planos del espacio puede asegurar una buena salud oral, de igual forma las funciones con el equilibrio nutricional darán como consecuencia un balance de todo el organismo. El tratamiento de rehabilitación en pacientes ancianos debe tener en cuenta las necesidades ortodonticas y protésicas. Este tipo de tratamiento tiene dos objetivos principales: en primer lugar, la restauración de la función oral y en segundo lugar la restauración de la morfología facial. Materiales y métodos: En este artículo se describen tres casos clínicos tratados con un enfoque multidisciplinario, mostrando un procedimiento eficaz con una gestión exitosa en pacientes de edad avanzada. Resultados: Los resultados obtenidos resaltan que en una cavidad bucal en buenas condiciones, que a su vez facilita una ingesta nutricional adecuada; son factores esenciales en la salud y el bienestar de los pacientes de edad avanzada, que de igual forma también son importantes para preservar la salud física y mental. Conclusiones: Con el plan de terapéutico adecuado y una correcta selección de los pacientes, el tratamiento de ortodoncia se puede lograr buenos resultados en pacientes de edad avanzada.
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