The rationale for esthetic orthodontic treatment in the adult patient

The rationale for esthetic orthodontic treatment in the adult patient Alfred

T. Baum,

D.D.S., M.S.D.

Los Angeles, Calif.

U

nfortunately, a large number of today’s qualified orthodontists consider the adult patient who “doesn’t want to wear braces that show” to be something of a crank and a nuisance. On consideration, this concern of the prospective adult orthodontic patient for his appearance during treatment does not seem unreasonable. Conventional fixed orthodontic appliances are unesthetic, at best, and may seem to imply a lack of maturity that is incompatible with the patient’s occupation or social relationships. Since esthethic considerations are so much a part of our treatment philosophy and rationale, why this apparent insensitivity P The answer is probably to be found in two separate circumstances. The first is an aversion to becoming identified with the often unfortunate results of the combination of an inexperienced operator with the “invisible” or removable appliances. The second is simply that formal orthodontic training programs seldom have time to include exposure to mechanotherapeutic systems other than basic fixed-appliance treatment techniques. The adult seeking or in need of orthodontic care is becoming more common in our examining rooms, for both esthetic and physiologic considerations. The value of orthodontics as an adjunct to periodontic treatment? 2 and reconstructive prosthetics”, * is also becoming appreciated to a greater degree. The application of combined surgical-orthodontic procedures for the treatment of major facial deformities is also becoming more prevalent.5, 6 Many adults who were denied the benefits of orthodontic treatment as children would simply like to have straight teeth. The number of adults seeking orthodontic treatment has increased markedly as dental insurance plans have proliferated and begun more and more to include orthodontic care. More than 22,000,OOO persons arc now covered, and some authorities estimate that that number will double before this decade is over.7 It would seem time to consider the orthodontic needs of this large body of prospective adult patients. Xead before the Joint in St. Louis, MO.

304

Orthodontic-Periodontic

Conference,

March 25 and 26, 1974,

T-olzmte 67 NzLnlbe>~ 3

Esthetic

orthodontic

treatment

in adult

305

The basic principles of adult orthodontic treatment are no different from those which apply to treatment of young patients, with the obvious exception of systems which depend on control or alteration of growth. These include OCcipital or cervical traction in Class II or Class III malocclusion’ and other devices designed to open juvenile sutures, such as jackscrcw-activated palatal expansion plates.s Differences in the rate of tooth movement between children and adults have been speculated, but there seems to be no valid evidence available to substantiate or quantify this thesis. In principle, appliances are designed to exert force on teeth in the direction in which they are to be moved. The force applied is transmitted to the surrounding tissue on one side of a tooth; bone resorption takes place on this side, and this permits movement of the tooth in a desirable direction. Accompanying this movement is a deposition of bone on the opposite side.1° However, this orderly sequence of events will occur only if the proposed new location for the tooth is mechanically practical and physiologically acceptable. The limitations of orthodontic treatment which govern treatment planning for the junvenile patient operate perhaps more restrictively in the adult. First, there must be space in the dental arch to accommodate all of the crowded or blocked-out teeth. Increase in arch length by expansion is probably an unacceptable solution to arch-length problems, since it has been repeatedly and reliably shown that the human dental arch decreases in width, depth, and length throughout life after maturity, I19l* hypothetical indices and theoretical mathmaticil projections notwithstanding. Second, alveolar bone must be anatomically present in the new location to receive roots of teeth to be moved. Any attempt to move the broad mesial root of a lower molar mesially into the location formerly occupied by a lower premolar will often fail, since the alveolus in that area is not broad enough buccolingually to accept it. In areas where alveolar resorption has occurred as a sequel to an earlier extraction, alveolar height and width may not be adequate to accommodate the proposed root movement. If cross-bites are to be corrected by bodily tooth movement, alveolar width must be adequat,e. Malocclusions are probably more stable in the adult, since the functional forces which determine tooth position are no longer effective after maturity is reached. Moving teeth means upsetting the resulting equilibrium, and this may result in instability after treatment is completed. To quote a popular commercial message : “It’s not nice to fool Mother Nature.” In considering the mechanics of adult orthodontics, the advantages of traditional full-banded treatment should not be overlooked. In cases where maximum control is indicated for improvement of facial esthetics conventional cemented appliances remain the method of choice. Fig. 1 shows before- and after-treatment photographs and superimposed head-film tracings of a 25-year-old patient. They illustrate facial improvements that are possible in adults through orthodontic treatment. Fig. 2 shows beforeand after-treatment photographs and superimposed head-film tracings of a 23year-old patient whose orthodontic treatment included oblique osteotomy of the ramus. Fig. 2, D through Z shows starting models and final intraoral photographs.

Fig. 1. Clinical dontic tracings.

treatment.

records

of

A, Before

a

patient

treatment.

showing

8, After

improvement treatment.

in

facial

esthetics

C, Superimposed

by

ortl IO-

cephalome,

Wit

Volume 6 7 Nun% her 3

Esthetic

orthodontic

treatment

in adult

307

in facial esthetics by SUI.gicalFig. 2. Clinical records of a patient showing improvement orthl odontic treatment. A, Before treatment. B, After treatment. C, Superimposed cer )halometr Gc tracings.

Fig. 2. D, E, and F, Pretreatment

models.

G, H, and I, Intraoral

photographs

Neither of these cases could have been managed equally well with removable appliances. There are cases, however, in which alternative mechanotherapeutic systems can be designed to operate within the limits of acceptable orthodontic treatment. Fig. 3 shows clinical records of a patient before treatment. lt is a Class II malocclusion with an anterior open-bite and partly blocked-out upper canines. Fig. 4 shows the appliance system used, and Fig. 5 presents intraoral views of the treated result. The upper first premolars were removed. The upper second premolars and first molars were banded with conventional edgewise bands and brackets to ensure control during space closure. Transparent plastic edgewise brackets were bonded directly to the upper anterior teeth, since the amount of tooth movement required seemed compatible with the st,ructural strength of the bracket and bonding material. No tooth movement was indicated in the lower arch, but anchorage for Class III elastic traction was required. Here the Crozat appliance worked well, not in its traditional and often ill-advised role as an expansion device but as a stable, removable, interarch anchorage source. The Crozat clasp, shown in two variations in Fig. 6, d and B, is a useful and tenacious clasp and will accept elastic traction. A satisfactory result was achieved with a reasonably esthetic appliance. The case shown in Figs. 7 and 8 illustrates a mild Class II malocclusion with a deep overbite and orerjet. The treatment appliance, as shown in Fig. 9, is an upper and lower Crozat crib with an acrylic bite plane incorporated in the upper appliance. Class II elastic hooks were placed to provide reciprocal interarch anchorage. Fig. 8 shows intraoral photographs of the case after treatment. The superimposed cephalometric tracing in Fig. 7 shows reciprocal tooth movement in both arches, with moderate intrusion of the lower anterior teeth. Following treatment, the appliances were worn periodically at night as retainers, with elastics as needed.

Esthetic

Fig. 3. Clinical records of a patient open-bite and blocked-out canines.

showing

orthodontic

a Class

treatment

II malocclusion

in adult

with

309

an anterior

Another effective means of providing periodic Class II or Class III elastic traction when removable appliances are used is shown in Fig. 10, A and B. This appliance consists of an acrylic or east-metal labiolingual splint with elastic hooks. These appliances can also be used as intermittent “retaining” deviccsl” Fig. 11 illustrates a Class II, Division 2 malocclusion with a characteristic high interincisal angle due to a deep overbite and lingually inclined upper anterior teeth. The treatment appliance is shown in Fig. 12, d to C. It consists of an acrylic palatal plate retained securely by Crozat clasps. The anterior segment of the plate is separate; it can be advanced by a spring-loaded jackscrew, and it is built up incisally to function as an inclined bite plane. Fig. 12, D to P shows

310

,I ~1. .I. Orthod. March 1975

Baum

Fig. 4. Appliance system used to treat case shown in Fig. 3. A, B, and C, Upper arch with edgewise appliance, anterior teeth with plastic brackets, and a lower Crozat appliance with hooks for Class II elastic traction. C, Occlusal views of the upper edgewise appliance in place. E and F, Lower Crozat appliance.

Fig. 5. Dentition

of patient

shown

Fig. 6. Two variations

in Fig. 4, after treatment,

of the Crozat clasp.

the finished intraoral photographs. Here again the appliance served as a retainer since prolonged retention supervision was indicated. Tooth-size discrepancies can produce the unsightly lower anterior crowding shown in the plaster casts in Fig. 13. The compatability of upper and lower tooth sizes can be verified either mathematically by the use of a tooth-size analysiP

Volunae 67 Number 3

Fig. 7. Facial photographs malocclusion with moderate

Esthetic orthodontic

treatment

in adult

and cephalometric tracings of patient showing irregularity of anterior teeth and overbite.

Fig. 8. Original casts and final appliance shown in Fig. 9.

intraoral

photographs

of Class II case treated

mild

with

311

Class II

Crozat

.4w1. J. Ovthod.

March

Fig. 9. Upper in treatment

and of the

lower

Fig. 10. A, Labiolingual II elastic

Crozat

patient

crib

shown

splints

cast

with in Fig.

Class

II elastics

and

an

upper

1975

bite

plane

used

in acrylic

with

Class

8.

in metal.

B, Labiolingual

splints

traction.

or by a wax setup as in Fig. 14. The indicated size reductions are then made interprosimally by abrasive and polishing strips and disks. In this case tooth moremcnt was accomplished simply by adding acrylic to the distolingual area of the lower lateral incisors on a lower Hawley retainer. Fig. 15 shows the finished alignment. Again retention is critical, and consideration should be given (1) to surgical severing of the transseptal fibersl” and (2) to retention by an “invisible” direct-bonded lower canine-to-canine lingual retai1ler.l” Discussion

Much of the adult orthodontic treatment attempted with removable appliances contains the seeds of its own failure. Attempts to stretch the limitations of treatment possibilities are common among untrained or naive practitioners,

Esthetic orthodontic treatment in adult

fig. 11. Pretreatment

Fig. 12. Posttreatment The anterior segment iackscrew.

records of a Class II, Division

313

2 malocclusion.

casts and removable appliance in place in case shown in Fig. 11. of the upper acrylic bite plate was activated with a spring-loaded

often enticed by the extravagant claims made for exotic types of treatment devices and by the ease of appliance fabrication, or even appliance design, by commercial laboratories. There is no magic implicit in tooth movement by removable appliances; indeed, perhaps the reverse is true. Tooth movement, in fact, is more difficult to accomplish without the control provided by fixed appliances. Retention is no less troublesome after removable appliance treatment. Again, perhaps the reverse is more likely. Patients are intrigued by the obviously attractive prospect of being able to remove appliances when their pressence becomes a social or professional impedi-

Fig. 13. Lower incisor crowding

due to tooth-size

discrepancy.

Fig. 14. Laboratory model setup of reduced lower anterior teeth in case shown in Fig. 13. Fig. 15. Posttreatment intraoral photographs of case shown in Fig. 13.

ment (real or imagined) or when the devices become uncomfortable or incomvenient to wear. Even in the best-planned cases, the cooperation and, indeed, perseverance of the patient is essential. However, many cases can be adequately or even excellently treated with mechanotherapeutic appliance systems other than conventional fixed full-banded appliances.

Esthetic Summary

orthodontic

trea.tment in adult

315

and conclusions

1. Conventional fixed orthodontic appliances well be socially and professionally embarrasing 2. Alternative mechanotherapeutic systems consideration to operate within the boundaries ment.

are unesthetic at best and may for the adult patient. can be designed with esthetic of acceptable orthodontic treat-

REFERENCES

1. Baum, Alfred T. : Orthodontics for specialty pract,ice, lecture, School of Dentistry, University of Southern California, September, 1971. 2. Stern, Ralph H., and Baum, Alfred T: Facial growth and the rationale of contemporary orthodontic treatment, J. South. Calif. Dent. Assoc. 29: 218, 1961. Management of tipped abutment molars, J. Am. Dent. 3. Burns Michael H.: Orthodontic Assoc. 87: 843, 1973. 4. Seide, L. J.: Adult orthodontics, J. Prosthet. Dent. 24: 83, 1970. 5. McNeil& William R., Proffit, William R., and White, Raymond P.: Cephalometric prediction for orthodontic surgery, Angle Orthod. 42: 154, 1972. 6. Baum, Alfred T., and Robinson, Marsh: Surgical-orthodontic treatment of skeletal Class JII bimaxillary prognathism; report of a case, J. South. Calif. Dent. Assoc. 38: 959, 1970. 7. Goldberg, M. J. : Dental insurance: Crossing the threshold (editorial), Dent. Management 14: 19, June, 1974. 8. Graber, T. Ed.: Orthodontics-Principles and practice, Philadelphia, 1961, W. B. Saunders Company, p. 699. 9. Haas, A. J.: Rapid expansion of the maxillary dental arch and nasal cavity by opening the midpalatal suture, Angle Orthod. 31: 73, 1961. IO. Storey, Elsdon, and Smith, R.: Force in orthodontics and its relation to tooth movement, Aust. Dent. J. 56: 11-18, 1952. 11. Nance, Hayes N.: The limitations of orthodontic treatment. I. Mixed dentition diagnosis and treatment. II. Diagnosis and treatment in the permanent dentition, AM. J. ORTHOD. ORAL. SURG. 33: 177, 253, 1947. 12. DeKock, William H.: Dental arch depth and width studied longitudinally from twelve years of age to adulthood, AM. J. ORTHOD. 62: 56,1972. 13. Lande, Robert : Private communication. 14. Bolton, W.: Clinical application of a tooth size analysis, AM. J. ORTHOD.43: 18, 1973. 15. Edwards, J. G.: A surgical procedure to eliminate rotational relapse, AM, J. Oa~~ou. 57: 35, 1970. 16. Knierim, R. W.: Invisible lower cuspid to cuspid retainer, Angle Orthod. 43: 218, 1973. 10961 Wilshire

Blvd. (9OOZ4)