Limitations in orthodontics /orthodontic courses by IDA

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INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com LIMITATIONS IN ORTHODONTICS .

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SEMINAR BY DR. SIDDHARTHA DHAR Done under the guidance of PROF. ASHIMA VALIATHAN B.D.S ( Pb), D.D.S, M.S (USA) DIRECTOR OF POSTGRADUATE STUDIES PROFESSOR AND HEAD DEPT. OF ORTHODONTICS AND DENTOFACIAL ORTHOPAEDICS MANIPAL COLLEGE OF DENTAL SCIENCES MANIPAL.   www.indiandentalacademy.com

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Introduction Limitations in evidence. Limitations in growth prediction. Limitations of cephalometry Limitations in management of specific malocclusions. Soft tissue limitations. Limitations associated with adult orthodontics. Limitations imposed by patient compliance. Limitations imposed by Medical/Systemic conditions Relapse Iatrogenic effects Conclusion. www.indiandentalacademy.com

Introduction: :

Introduction: Although we have clearly made significant progress in the development of materials and techniques that have allowed us to move teeth more efficiently and more predictably than they ever could, and although the development of surgical techniques has allowed us to manage severe skeletal problems that were beyond their wildest hopes, many of the core problems that frustrated them when the specialty was in its infancy are still with us today, unresolved! If Edward Angle and Calvin Case were alive today and were to look back and see what last century has brought to the science of orthodontics, their reaction might well be one of mixed pleasure and frustration www.indiandentalacademy.com

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If we truly wish to improve the quality and predictability of orthodontic treatment for our patients in the 21st century, then many of the following challenges must be addressed and overcome: Cause of malocclusion : nature or nuture? Genetics or environment? Control mechanisms of craniofacial growth? What is the best treatment regimen or protocol to follow for a particular malocclusion? Right time for treatment? Early versus late? Prepuberty or post-puberty? Before or after the second molars erupt? How do teeth move? Patient cooperation: an impossible goal? The question of how to ensure patient cooperation has vexed and plagued orthodontists since time immemorial. www.indiandentalacademy.com

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Our current level of knowledge, or rather the lack of it, regarding these and other issues places a limitation on the practice of orthodontics, preventing us from delivering the very best care possible to the patient. On the other hand, several physiologic and anatomic constraints limit the extent to which orthodontic treatment alone can achieve the twin goals of functional occlusion as well as ideal esthetics. These various limitations in orthodontics shall be sequentially discussed. www.indiandentalacademy.com

Limitations in evidence for clinical decisions:   :

Limitations in evidence for clinical decisions:   Orthodontics has traditionally been a specialty in which the opinions of leaders were important. However, as a professional group comes of age, evidence–based decisions should take the place of opinion-based decisions. It is still the case in orthodontics, that important clinical decisions must be made without solid data on which to base them. A hierarchy of quality exists in the evidence on which clinical decisions are made. The best evidence is that obtained from randomized clinical trials , in which patients are randomly assigned in advance to alternative treatment procedures. www.indiandentalacademy.com

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On the other hand, selected case reports as well as the unsupported opinion of an expert are relatively weak forms of clinical evidence. Data from randomized clinical trials now determine many clinical approaches in medicine, and this has recently caught on in orthodontics too. Another important limiting factor to be considered is that historical material from the Burlington and Bolton studies is being used as control data for evaluation of orthodontic treatment procedures, especially growth modification . The validity of their use is being questioned on the grounds of the race of the subjects as well as secular changes over the last 50 years. www.indiandentalacademy.com

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The famous randomized clinical trials of the 1990s at the Universities of North Carolina, Florida and Pennsylvania, showed that single phase treatment of Class II malocclusions was as effective and more efficient than two phase treatment. The use of functional appliances in the first phase did not reduce the need for premolar extractions, nor did it reduce the need for surgical treatment. More such studies regarding various aspects of orthodontics are required to offer the clinician an objective, unbiased body of data on which to base his treatment decisions. In the words of William R. Proffit “Orthodontics has no choice but to become a data based specialty. We need to do it sooner rather than later, willingly rather than unwillingly, taking the lead rather than being dragged along. www.indiandentalacademy.com

Limitations in growth prediction:   :

Limitations in growth prediction:   Even when excellent data are available from clinical trials, it is difficult to predict how any one individual will respond to a particular plan of treatment. Variability in orthodontics is mainly the result of differing growth patterns and the effect of treatment on growth expression. Successful growth prediction requires specifying both the amount and the direction of growth, in the context of a baseline or reference point. For this various cephalometric studies have been done, such as the Bolton Study, The Michigan Study and the Burlington Study, which group together the data to provide a picture of average, normal, growth changes. All three data sets are derived from Whites of North European descent. www.indiandentalacademy.com

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The major difficulty with growth prediction is that a patient may have neither the average amount or direction of growth. In the clinical situation, growth prediction is really required for the child who has a skeletal malocclusion i.e. his growth pattern deviated from the norm. Thus, our ability to predict facial growth on the basis of current data is poorest for the very patients in whom it would be most useful. The new clinical trial data , which use untreated children with specific types of malocclusions as controls, may provide some new data on favorable and unfavorable growth patterns. However, at present, accurate growth predictions are simply not possible for the children who need it most . www.indiandentalacademy.com

Limitations in the use of Cephalometry: :

Limitations in the use of Cephalometry: Conventional lateral cephalograms provide only a 2D view of the skull , which is a three dimensional structure. Studies have shown that this results in significant errors in landmark identification, interpretation. Other investigators have questioned the validity of cephalometric landmarks and conventions from a biological point of view. The 2D nature of lateral cephalograms makes it difficult to apply them in patients with significant asymmetries. www.indiandentalacademy.com

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There seems to be little correlation between the achievement of cephalometric goals and stability . Therefore, cephalometrics can serve as a guide but not as a guarantee of stability. Radiation exposure from cephalograms limits their use. The absence of anatomical references whose size and shape remain constant through time , limits the ability of the clinician to make comparisons of images at different time points. Lack of standardization of lateral cephalograms , with respect to head posture, magnification, further limit their use. Poor processing, storage of cephalograms contribute to loss of information over time, which is a major limitation. www.indiandentalacademy.com

Limitations in management of specific malocclusions: :

Limitations in management of specific malocclusions: Management of Class II malocclusions: There are essentially three alternatives for treating a skeletal Class II problem: growth modification, dental camouflage, and orthognathic surgery. Ideally, all Class II patients should be treated with growth modification procedures, but patient compliance in wearing headgear, functional appliances is a major limiting factor. In addition the patient may have too little growth remaining , or the skeletal problem may be too sever e. www.indiandentalacademy.com

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Specific limitations with headgear use:  Tendency for cervical pull headgear to extrude maxillary molars and cause backward rotation of the mandible. Dependence on patient compliance.   Specific limitations with use of functional appliances: Tendency for backward tipping of maxillary incisors. Tendency for labial tipping of lower incisors . There is still controversy over whether functional appliances actually increase the sum total of mandibular growth or merely accelerate it. www.indiandentalacademy.com

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Limitations of interarch traction: Extrusion of mandibular posterior teeth and maxillary anterior teeth is to be expected, resulting in rotation of the occlusal plane up posteriorly, and down anteriorly. Tendency for mandibular molars to tip buccally. Prolonged use of Class II elastics ( more than 3-6 months) results in excessive vertical display of incisors with gummy smile, and increased lower face height with steep mandibular plane. Dental Camouflage: For Class II patients with a mild to moderate skeletal problems, who have inadequate growth potential, and are not agreeable to surgery. www.indiandentalacademy.com

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Patients who have extensive natural compensation are not suitable candiadates for this treatment. Unless space is present, extractions are invariably needed in one or both arches. For dental camouflage without extractions, distal movement of the upper molars, followed by retraction of anteriors (without anchorage loss) is a major challenge which requires assiduous anchorage neasures ( headgear, TPA, Nance palatal arch.) Fortunately, the increasing use of osseo-integrated attachments as absolute anchorage , is emerging as a solution to this problem. www.indiandentalacademy.com

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For dental camouflage with extractions , headgear is the surest way to prevent anchorage loss during anterior retraction. In the absence of patient compliance, other measures such as individual canine retraction, use of Nance palatal arch, and Class II elastics would be of help. For more severe skeletal problems, beyond the envelope of discrepancy, there may be no other option but surgery. The role of the orthodontist in this case would be to remove the natural dental compensations, and level and align the arches prior to surgery, with or without extractions, as the case may be. www.indiandentalacademy.com

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Management of Class III malocclusions:  The major limitation in the treatment of Class III malocclusions with prognathic mandibles lies in our inability to limit this excessive growth. The use of the chin cup has been a standard procedure in attempting to redirect mandibular growth vertically, as well as to reposition it backwards. Chin-cap force can alter the mandibular form and condylar growth is presumably retarded by the chin-cap force. These changes occur mainly during the first 2 years of chin-cap use. www.indiandentalacademy.com

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Can chin-cap therapy permanently correct a prognathic skeletal pattern? Although mandibular chin position will be greatly improved anteroposteriorly during initial stage (approximately 2 years) of chin-cap therapy, the changes do not take place continuously after that, and the initial changes will not be maintained if chincap use is discontinued before facial growth is complete. Treatment must continue until growth has ceased to prevent redevelopment of the prognathic face after chincap therapy, and some over-correction might be warranted. The patient should wear the chin-cap at night because the condyle should be still when the compressive force is applied. Otherwise there is a higher risk of dislocating the disc at the joint. www.indiandentalacademy.com

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In adolescents and non-growing adults with mild mandibular prognathism and moderate overbite, dento-alveolar compensation can be attempted to camouflage the skeletal discrepancy. This may be done with the help of Class III elastics with or without extractions. However, for patients with continued disproportionate sagittal and vertical growth , or with a combination of mandibular prognathism and maxillary deficiency with divergent facial pattern, surgery may be the only option. This should be left till growth is completed. www.indiandentalacademy.com

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Anterior Open Bite: Even though the incidence of open bit is low, it is high on th clinician’s list because of its potential for frustration and failure. The frustration stems from conflicting reports which lead to ambiguous decisions, leading to relapse or questionable compromise. Sunny J, Rodrigues R, Valiathan A, ( JIOS 2001) reviewed the literature pertaining to open bite and mentioned the importance of making the distinction between a skeletal and a dental open bite, in planning treatment. www.indiandentalacademy.com

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Dental open bites can be treated with orthodontics alone,candidates should meet the criteria as follows: Proclined incisors Little or no gingival display on smile. Normal craniofacial pattern No more than 2-3 mm of upper incisor exposure at rest. Kim proposed the use of multiloop edgewise archwire to alter the occlusal plane, distal upright the posteriors (Angle 1987) while a modification of this technique using 016x 022 Ni Ti was used by Enacar et al.(JCO 1996). www.indiandentalacademy.com

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Orthodontic modalities for treatment of skeletal open bites include Funtional appliances: FR IV, Activator, Bionator. Passive posterior bite blocks (prior to growth cessation) Magnets High pull headgear, vertical chin cup. Osseo-integrated implants Where the discrepancy is too severe, surgery might be the only alternative. www.indiandentalacademy.com

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Soft tissue limitations: :

Soft tissue limitations: Limitations on stability: The soft tissue constraints on orthodontic treatment are: (1) the pressures exerted by the lips, cheeks, and tongue on the teeth; (2) the periodontal attachment apparatus; (3) the muscles and connective tissue components of the temporomandibular joint; and (4) the contours of the integument of the face. They establish the limit to which the orthodontist can alter the dimensions of the dental arches and the position of the mandible. www.indiandentalacademy.com

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To remain within acceptable boundaries, extractions may be necessary in some cases. If the malocclusion cannot be corrected within the envelope, even with extractions for compensation, orthognathic surgery may be needed. Despite repeated efforts to write rules for ideal incisor positions based on cephalometric hard tissue relationships, racial, ethnic, and individual differences make this almost impossible. Because the pretreatment position of the teeth already reflects soft tissue influences, it is better to think in terms of the amount of change in tooth position that treatment would produce and its relationship to stability. www.indiandentalacademy.com

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The following figure briefly summarizes the limits of stability for lower arch expansion. www.indiandentalacademy.com

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Stability is increasingly at risk with anteroposterior expansion of the mandibular incisors by more than 2 mm or transverse expansion of the lower arch more than 4 to 5 mm . Somewhat greater changes are possible in the upper arch. Stability after orthodontic treatment is determined by the ability of the soft tissues to adapt to changes in hard tissue morphology. www.indiandentalacademy.com

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Dental Expansion and the Periodontium: Because individual patients have varying susceptibility to loss of the attachment apparatus, it is important for the orthodontist to evaluate this when treatment is planned. A patient with thin, friable tissue and little attached gingiva on the labial of a mandibular incisor is at risk for gingival recession if the tooth is moved facially out of its alveolar bone housing. If this labial tooth movement is accompanied by inflammation due to plaque retention there is even greater risk of recession . www.indiandentalacademy.com

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If the tissue is thin or if there is inadequate attached gingiva, it may be prophylactically augmented with mucogingival surgery and the placement of a split-thickness gingival graft. Such gingiva appears clinically to be more resistant to recession. No one has quantified how far labially mandibular incisors can be moved without significantly increasing the risk of recession. The anatomy of the alveolar bone and soft tissues in the area suggests that 2 to 3 mm would be the limit for most patients. www.indiandentalacademy.com

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Herberger has shown increased gingival recession on the facial surfaces of maxillary premolars and molars in patients treated with rapid palatal expansion. Even with excellent separation of the midpalatal suture, displacement of the teeth occurs within the alveolar process, and the greater the tooth movement the greater the chance of endangering the periodontium. www.indiandentalacademy.com

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Neuromuscular influences on condylar position: Because the mandible is suspended in a muscular sling, condylar position is controlled by these soft tissues. The precise relationship the condyles should have to the fossa remains controversial . Condyles should not be displaced during treatment by more than a very small distance from their relaxed (muscularly determined) retruded position. In addition to the possibility of TMD symptoms, treatment methods that reposition the mandible more than a small amount are likely to fail in the long-run due to the musculature returning the mandible to a seated condylar position. www.indiandentalacademy.com

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Relation between lip support, tooth position and facial esthetics.   The soft tissue structures of the face are dynamic and appear dramatically different in animation. When an individual smiles, nasolabial folds develop, the alar base widens, the eyes narrow, the commisures of the lips widen, the upper lip shortens, the upper teeth show and a smile line develops. Both orthognathic surgery and orthodontic treatment can affect all these relationships. www.indiandentalacademy.com

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The soft tissue contours of the face are determined by three interacting factors: The skeletal foundation , which for the mid and lower face is provided by the jaws The dental support system provided by the teeth; The soft tissue mask , influenced by both the underlying hard tissues and the components of the soft tissue itself (nose and chin, lip thickness, lip tonicity). The amount of incisor protrusion that is compatible with acceptable facial esthetics cannot be established without reference to all three components of the system. www.indiandentalacademy.com

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Because the soft tissue response to changes in incisor position is sometimes difficult to predict, it may be appropriate to evaluate the esthetic effect of dental arch expansion before making a decision to extract premolars. www.indiandentalacademy.com

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Decisions about facial esthetics should be made largely from the clinical examination of the patient, not from cephalometric analyses. In a patient who cephalo-metrically appears to be mandibularly prognathic but whose soft tissue profile clinically appears to be midface deficient, the plan should follow the clinical rather than the cephalometric diagnosis. www.indiandentalacademy.com

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Esthetic guidelines:   Size of the nose and chin has a profound effect on relative lip prominence . For a patient with a large nose and/or a large chin, if the choices are to protract or retract incisors, moving the incisors forward is better, provided doing so does not deepen the labiomental fold excessively. Surgical advancement of maxilla and mandible, rhinoplasty, genioplasty.   www.indiandentalacademy.com

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2. Severe mid-face deficiency or mandibular prognathism creates unattractive lip positions and may affect throat form . This unesthetic condition can rarely be corrected with orthodontics alone, and orthognathic surgery should be considered as an alternative. www.indiandentalacademy.com

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3. Moderate mandibular deficiency is often esthetically acceptable . 4. An upper lip that inclines backward in relationship to a true vertical line is unesthetic . In a patient who already has a retrusive upper lip, it is better to procline the incisors than retract them further, even if that means orthognathic surgery to correct the malocclusion. The combination of guidelines 3 and 4 poses an uncomfortable orthodontic dilemma: Some moderately severe Class II malocclusions may be more esthetic before treatment than after . If this proves to be the case, sharing this information with the patient is an important point of informed consent to treatment. www.indiandentalacademy.com

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For a patient whose concerns are primarily esthetic, this may mean that no treatment is the best choice. 5 . Lack of a well-defined labiomental sulcus is generally unattractive. This is often related to lip strain in gaining lip seal, and can be due either to increased lower face height or protrusion of the teeth. In this instance, if the choice is to either protract or retract the incisors, retraction is better esthetically. 6 . An extremely high smile line, so that a large band of gingiva is displayed when smiling broadly, is an unesthetic trait. It is better to avoid accentuating this characteristic as can occur when the maxillary incisors are over-retracted or when the occlusal plane is tilted down anteriorly . If this trait is associated with other signs of vertical maxillary excess, especially excessive exposure of the maxillary teeth in repose, orthognathic surgery should be considered.   www.indiandentalacademy.com

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7. A curled or everted lower lip is unattractive . Often occurs when the lower lip is trapped under the maxillary incisors in a patient with excessive overjet. If there is an accompanying acute nasolabial angle and proclined upper lip, the maxillary incisors can be retracted to gain a more comfortable lip seal and more favorable lip posture. If the upper lip lies on the true vertical line or if there is an obtuse nasolabial angle, mandibular advancement surgery would produce a more esthetic outcome.   8. A concave profile with thinning of the lips, so that there is little vermilion border, is an unesthetic trait . In a patient with thin lips, proclining the incisors will tend to create fuller lips, and is likely to be perceived as more attractive.   www.indiandentalacademy.com

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9. Bilabial protrusion generally is an unesthetic trait . If the characteristics of a malocclusion include crowding and protrusion, it may be necessary to extract teeth so as not to further procline the incisors and increase the fullness of the lips. 10. Soft tissue surgical procedures (rhinoplasty, genioplasty, cheiloplasty and/or submental lipectomy) generally have a more dramatic effect on facial soft tissue contours than changes in lip position due to orthodontic tooth movement. If facial esthetics are a major concern—as they often are — it is appropriate to raise the possibility of cosmetic facial surgery in addition to orthodontic alignment of the teeth and correction of the occlusion . www.indiandentalacademy.com

Limitations associated with Adult Orthodontics:   :

Limitations associated with Adult Orthodontics:   Orthodontic treatment strategies have traditionally been targeted toward an adolescent and preadolescent age group, in which a developing or newly formed malocclusion is present. However, the proportion of non-growing adult patients seeking orthodontic treatment has increased over the years. This has brought with it an inherent set of limitations that the orthodontist must work within. www.indiandentalacademy.com

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1.      Absence of skeletal growth potential: Except in cases where surgery is anticipated to effect skeletal changes, orthodontic treatment in adults must be planned without the expectation that growth or any change in jaw relationships will compensate for interarch discrepancies. It is reported that, on average, 70% of Class II correction achieved in adolescents is attained by differential growth of the mandible. Hence, precise biomechanical control of tooth movement is necessary , to achieve correction of malocclusion in all three dimensions. In patients requiring substantial anteroposterior interarch correction, alternatives must be found to the use of traditional headgear and functional appliances . www.indiandentalacademy.com

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Intra-oral molar distalization appliances have become popular for correcting Class II malocclusions. However, once the molars have been tipped or moved distally to or beyond a Class I relationship, the formidable task of moving all the anterior teeth back to close the space still exists. This must be accomplished without losing posterior anchorage. Options include the use of palatal coverage, part- time headgear, but both have their disadvantages. www.indiandentalacademy.com

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A distal tip-back activation added in the main archwire at the molar increases the M:F ratio at the molar and makes it more resistant to anterior crown movement during space closure. Side effects include intrusive force at the anterior attachment segment and extrusive effect at the molars. In cases requiring substantial A-P correction, where surgery is not an alternative, single-arch extractions may be done to achieve Class I canine relationships. Janson et al (AJODO 2004) have reported that treatment of Class II malocclusion with 2 premolar extractions can give a better occlusal success rate than treatment with 4 premolar extractions. www.indiandentalacademy.com

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In certain cases, the lack of growth may actually facilitate treatment planning , e.g. adult Class III patients and open bite patients. The complication of having to plan around unpredictable growth potential is eliminated. Transverse discrepancies in adults are more difficult to treat than in adolescents . Due to calcification of maxillary sutures, RME may not be feasible or predictable. For these patients, surgically assisted RME or a two or three piece Le Fort osteotomy may be performed. www.indiandentalacademy.com

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Adult patients may be reluctant to wear traditional fixed appliances . Hence, alternatives such as removable appliances, limited appliance therapy or esthetic appliances may be offered. Any of the above would force changes in the biomechanical strategy used by the orthodontist. Removable appliances are generally unable to apply couples, they apply high loads for short periods, making tooth movement more painful and possibly slower. This may reduce patient co-operation and lead to treatment failure. www.indiandentalacademy.com

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In some cases limited fixed appliance therapy starting with posterior segmental mechanics may be done, and canine retraction performed without bonding the anteriors. Could substantially decrease the period of time required to actively involve the anteriors.I In such cases it is advisable to use maxillary TPA or lower lingual arch for stabilization. Cosmetic appliances such as ceramic brackets are increasingly popular and esthetically acceptable to adult patients. However, for the orthodontist it involves certain limitations such as their higher coefficient of friction, as well as breakage tendency when third order activations are applied. www.indiandentalacademy.com

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Designing appliances for mutilated dentitions: For adult patients with multiple missing teeth, some degree of creativity is necessary in appliance design. A comprehensive treatment plan in concert with other specialties is required. For teeth that lack occlusal vertical contacts, particular attention needs to be paid to avoid the extrusive side effects of orthodontic mechanics. Vertical control is a key element in appliance design for adults. Lack of viable posterior teeth to use as anchorage may limit the types of tooth movements. In such cases the only movements possible may be relative alignment and arch width changes. www.indiandentalacademy.com

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In patients requiring intrusion, extrusion, or retraction of anterior teeth, placement of implants to serve as reliable anchorage should be considered. Otherwise, the limitations of treating a compromise dentition should be confronted directly and goals set accordingly. Periodontal considerations: The classic periodontal patient usually presents with the maxillary labial segment showing proclination, irregular spacing, rotation, and overeruption of the dentition. www.indiandentalacademy.com

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Before any tooth movement is attempted, a co-ordinated effort by the patient and periodontist should be made to restore and maintain the periodontal health of the dentition. Mechanical modifications are needed during treatment to ensure force delivery that results in predictable tooth movement without risking further periodontal damage. With increasing attachment loss there should b a corresponding decrease in force levels. Also, in order to counter the increased tendency for the teeth to tip in response to retraction forces, a higher moment to force ratio should be applied www.indiandentalacademy.com

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. In adults with increased overjet , and crowding in the mandible, lengthening the mandibular arch through proclination of incisors is often the only alternative to extractions in both jaws. This has traditionally been considered a risk factor for gingival recession. However, Melsen and Allais (AJODO May 2005), in a retrospective study of adult patients ( mean age 34 years), showed that gingival recession of mandibular incisors did not increase significantly with labial orthodontic movement. They stressed however, the importance of thin gingival biotype, plaque and inflammation as useful predictors of recession.    www.indiandentalacademy.com

Limitations imposed by patient compliance:   :

Limitations imposed by patient compliance:   Adolescents: The success of orthodontic therapy frequently depends on patient compliance. Headgear effects, functional appliance treatment, oral hygiene, keeping appointments, are all dependent on the patient’s compliance. Adults are generally, but not always, very compliant patients. Adolescents , who represent the majority of orthodontic patients, are another matter. They are generally undergoing treatment because of their parents’ wishes. www.indiandentalacademy.com

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Adolescence is a period of rapid changes in the life of the individual. A number of challenges present themselves such as multi-tasking, development of competence, joining the peer group, struggle against authority. Compliance problems can stem from the above dilemmas. The rejection of adult rules may manifest itself as non-compliance with doctor’s instructions and reluctance in maintaining oral hygiene.  Solution: Adolescents need to feel adult about their care. Orthodontists need to make them informed and involved consumers by actively including them in the process. The treatment plan and its details should be discussed with them. www.indiandentalacademy.com

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Their concern with self image and identity could be used to motivate them. Individualizing the patient and recognizing adolescent values and issues help to achieve better motivation. Sinha, Nanda , Mc Neil (AJO-DO 1996) concluded from a study that overall, if the doctor wants good co-operation from a patient, the most important factor is establishing good rapport with the patient. Use of Educational psychology : The orthodontist-patient relationship needs to be approached from the perspective of a teacher-student relationship rather than a doctor-patient relationship. www.indiandentalacademy.com

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According to Steed-Veilands (1998), if the orthodontist tries to teach the adolescent patient how to co-operate, rather than dictating a set of doctor’s orders, one could expect better compliance. White (1996), observed that compliance was unpredictable in his practice. Certain problems such as broken appliances, gingivitis, were always seen in the same patients. He concluded that compliance seems to be related to the patient’s sensitivity threshold, which is related to pain tolerance. He offered several suggestions to lessen patient discomfort and encourage co-operation, e.g. use of soft bristle toothbrush, chlorhexidine rinses, simple appliances, analgesics etc. www.indiandentalacademy.com

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Rosen (1996) suggested a patient –centered model of compliance, based on information, motivation and support. Sachdeva S, Valiathan A, (Stomatologica India, 1995) reviewed the literature on compliance in orthodontics and discussed the various theories of patient behaviour as well as means to deal with the co-operation problem. They concluded that “…so far the methods of eliciting or predicting co-operation remain ambiguous. ….Whether he demands, cajoles, rewards, threatens, berates, scolds or pre-selects his patients, the choice is for each individual to make on his own.” www.indiandentalacademy.com

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Agar et al (EJO 2005) studied the role of psycho-social factors in headgear compliance in patients aged 9-15 years, but could not identify any specific behavior problems or competence areas in patients that would predict headgear wear. Psychiatric conditions: Various psychiatric disorders may be encountered in patients such as Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorders, Anxiety disorders , as a result of which the patient is unable to or does not wish to co-operate with the orthodontist. In most cases some sort of behavior management is required. In addition, appropriate medication as well as psychiatric care for more severe cases would be required. www.indiandentalacademy.com

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Orthodontic treatment for the special needs child (Becker et al, Seminars in Orthodontics, 2005) Special needs refers to individuals suffering from developmental disabilities such as mental retardation, cerebral palsy, autism, Down’s Syndrome, etc. Improvement of their facial appearance could improve their integration into society , and this could be a reason for their parents seeking out orthodontic treatment for them. Needless to say, orthodontic treatment in this group of patients is challenging for the following reasons: problematic behavior, poor understanding, uncontrolled limb movements, impaired co-operation, exaggerated gag reflex, drooling, poor oral hygiene. www.indiandentalacademy.com

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Orthodontic treatment in such cases is elective, and depends on the ability of the patient and parents to maintain good oral hygiene. Treatment can be limited by the inability to obtain complete diagnostic records . Hence it may have to be provided on the basis of a tentative treatment plan. Use of removable appliances is preferred for as long as possible, before shifting to fixed appliances. The use of pharmacological techniques such as conscious sedation/GA may be required for performing band, bracket placement. In the view of these authors, denial of treatment because of disability is no longer justifiable. www.indiandentalacademy.com

Limitations imposed by Medical/Systemic conditions:   :

Limitations imposed by Medical/Systemic conditions:   Diabetes Mellitus: Patients with well- controlled diabetes are not contra-indicated for orthodontic treatment However, during treatment, special attention is required with regard to periodontal problems . Patients should be informed about the propensity for gingival inflammation with orthodontic appliances , and the importance of maintaining good oral hygiene to prevent periodontal breakdown. Adjuvant fluoride-rich mouthrinses may be beneficial. Candida infections may occur; Diabetes related micro-angiopathy may result in loss of vitality of teeth. It is advisable to apply light forces to teeth. Orthodontic treatment in poorly controlled or uncontrolled diabetes mellitus is contraindicated. www.indiandentalacademy.com

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Cardiac patients at risk of bacterial endocarditis :   Although most orthodontic treatment is minimally invasive, the placement and removal of orthodontic bands has been suggested to produce bacteremias. Patients with previous history of endocarditis, prosthetic valves, congenital cardiac malformations are at risk for developing endocarditis Oral hygiene and use of chlorhexidine mouthrinse in such patients must be emphasized. Prior to band placement or removal, it is advised to protect the patient with antibiotic prophylaxis consisting of a single dose of Amoxycillin or Clindamycin www.indiandentalacademy.com

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Patients with bleeding disorders risk of systemic infection :   These include thrombocytopenia, hemophilia, leukemia etc. Historically, orthodontic treatment for patients with bleeding disorders was not even considered, but with factor replacement and E amino caproic acid, this is possible. The greatest risk to such a patient during orthodontic treatment is from extractions , which must be carried out only with full factor replacement, use of antifibrinolytics. Care should be taken during placement and removal of orthodontic hardware to minimize risks of mucosal injury . Elastomeric modules are preferred over wire ligatures. www.indiandentalacademy.com

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Asthma: Asthmatics are at greater risk of Candidiasis and xerostomia, due to steroid medication , hence fluoride therapy and extra vigilance are in order. Orthodontic-induced root resorption is reported to occur with greater frequency in asthmatics. It is prudent to disclose this increased risk to the patient. www.indiandentalacademy.com

Relapse: :

Relapse:   We have learned from Angle that orthodontic correction will remain stable if teeth are aligned into normal positions and provided with adequate retention. Today, however, we know that the long-term result of treated cases is the real problem in orthodontics . Despite correct diagnosis and treatment planning followed by careful stabilization of the final result, relapse tendencies still exist in a fairly high percentage of cases treated. We must distinguish the rapid-to-slow relapse that occurs during the period for remodeling of the periodontal structures from the late changes that occur during the post retention period. www.indiandentalacademy.com

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The most persistent relapse tendency is caused by the structures related to the marginal third of the root i.e. the supra alveolar fibers , which are not anchored to bone, and have a very slow turnover rate. So the periodontium itself may be linked to post-treatment relapse. Thus, to avoid relapse, it will become necessary to retain a tooth until total rearrangement of the structures involved has occurred. However, our knowledge of the reactions of the supporting structures is still incomplete , and we have only limited information on the behavior of different structures during and after orthodontic tooth movement. www.indiandentalacademy.com

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More research is required to increase our knowledge of the biologic complexity that determines tooth position, physiologic migration, and occlusal stability. The long-term effect of orthodontic treatment has attracted increasing interest during the last 3 to 4 decades. Various studies demonstrate that 40% to 90% of the patients orthodontically treated have unacceptable dental alignment 10 years after retention, with large individual variations. Overall, the maxillary and mandibular arches become shorter and narrower with age, resulting in crowding. www.indiandentalacademy.com

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Many potential causative factors of relapse have been discussed, such as patient age, length of retention, mandibular rotation, arch dimensions, third molars, tooth size, apical base, position of mandibular incisors, oral habits, and the skill of the operator. It is difficult to stress any single factor and is instead regarded a multi-factorial problem. Most of these causative factors may relate to normal developmental processes. The dynamics of facial development with variations in maxillary and mandibular growth, together with the concomitant dento-alveolar development need to be better understood before we can expect to achieve more stable treatment results. www.indiandentalacademy.com

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In the words of Oppenheim, “ Retention is one of the most difficult problems in orthodontia. In fact it is the problem.” www.indiandentalacademy.com

Iatrogenic effects in Orthodontics:   :

Iatrogenic effects in Orthodontics:   Gingivitis and Periodontitis:   The presence of bands and brackets in the mouth constitute a significant barrier to proper oral hygiene measures by the patient, resulting in higher plaque accumulation. Regular oral prophylaxis and patient motivation, along with prescription of chlorhexidine mouthwash may help to improve oral hygiene. Patients with active periodontal disease are not candidates for orthodontic treatment. www.indiandentalacademy.com

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Demineralization, white spots:   White spot demineralization is a significant problem, which may affect upto 50% of orthodontic patients. Several methods of fluoride delivery have been used to prevent it: topical fluorides (gel, mouthrinse, varnish, toothpaste), fluoride releasing materials (bonding materials, elastomerics.) How useful are these? Benson et al ( JO June 2005) did a systematic review of the literature, and found some evidence that a daily sodium fluoride mouthrinse will reduce the severity of demineralization associated with orthodontic treatment, and that GIC used for bonding reduces the incidence and severity of the same , compared with composite resin. www.indiandentalacademy.com

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Orthodontics and TMJ disorders:   Although current evidence suggests that orthodontic treatment has little to do with TMD, orthodontists are occasionally blamed for causing TMD. Epidemiologic studies show that TMD symptoms are most prevalent among patients between 15 and 25 years old; symptoms then level out as patients approach age 35. Because some people in this age group receive orthodontic treatment that can last for several years, orthodontists may encounter patients who complain about TMD during or after treatment. www.indiandentalacademy.com

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As the number of adult orthodontic patients grows, these complaints might increase. Without sound knowledge, some might erroneously conclude that orthodontic treatment causes or contributes to TMD. A comprehensive meta-analysis on the subject, by Kim et al (AJO-DO 2002) did not indicate that traditional orthodontic treatment increased the prevalence of TMD. www.indiandentalacademy.com

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External Apical Root Resorption: Root resorption is a multifactorial phenomenon. Caution should be exercised in patients in whom the clinician plans to displace the maxillary incisors distally, in patients with abnormally shaped roots, in extraction cases, in patients who have been in treatment for a longer than usual period of time, and in adult patients. Finally, interoffice variation is a significant factor. www.indiandentalacademy.com

Conclusion: :

Conclusion:   Almost every activity of orthodontics from diagnosis to post treatment retention, has its limitations. Some of these are related to the lack of completely reliable information pertaining to various issues, while others are imposed on us by Nature herself. With an ever-increasing knowledge base in orthodontics, derived from randomized controlled trials, as well as advances in molecular biology, which would give us a peep into the workings of Nature, it is hoped that in the future these limitations shall be overcome. www.indiandentalacademy.com

References::

References: Sinclair P.M. Tomorrow’s challenges for the science of orthodontics. AJO-DO 2000; 117(5): 551-2. Sperry T.P. the limitations of orthodontic treatment. Angle Orthod 1993;63(2): 155-158. Huang G.J. Making the case for evidence-based orthodontics. AJO-DO 2004;125:405-6. Tulloch JFC, Proffit WR, Phillips C. Outcomes in a 2-phase randomized clinical trial of early Class II treatment. AJO-DO 2004;125:657-67. Mitani H. Early application of chincap therapy to skeletal Class III malocclusions. AJO-DO 2002;121:584-5. www.indiandentalacademy.com

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Sunny J, Rodrigues R, Valiathan A. Open Bite-An open challenge. JIOS 2001;34:130-132. Ackerman J, Proffit W.R. Soft tissue limitations in orthodontics: Treatment planning guidelines. Angle Orthod 1997;67(5): 327-336. Lindauer SJ, Rebellato J. Biomechanical considerations for orthodontic treatment of adults. DCNA 1996;40 (4):811-836. Dawoodbhoy I, Valiathan A, Age and Orthodontics. JICD 1993; 34 :20-25. Melsen M, Allais D. Factors of importance for the development of dehiscences during labial movement of mandibular incisors: A retrospective study of adult orthodontic patients. AJO-DO 2005; 127: 552-61. www.indiandentalacademy.com

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Sachdeva S, Valiathan A. Co-operation in orthodontics. Stomatologica India 1995; 9: 3-6. Becker A, Chaushu S, Shapira J. Orthodontic treatment for the special needs child. Semin Orthod 2005; 10: 281-92. Goldman S.J. Practical approaches to psychiatric issues in the orthodontic patient. Semin Orthod 2005;10: 259-65. Sonis S. Orthodontic management of selected medically compromised patients: Cardiac disease, bleeding disorders and asthma. Semin Orthod 2005; 10: 277-80. Bensch L, Braem M, Willems G. Orthodontic considerations in the diabetic patient. Semin Orthod 2005; 10:252-258. www.indiandentalacademy.com

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Thilander B. Orthodontic relapse versus natural development. AJO DO 2000: 117(5): 562-3. Benson P, Shah A.A, Millett D.T., Dyer F, Parkin N, Vine R. Fluorides, orthodontics and demineralization: a systematic review. Journal of Orthodontics 2005; 32: 102-114. Kim M, Graber TM, Viana M. Orthodontics and temporo-mandibular disorder: A meta-analysis. (AJO-DO 2002; 121: 438–46). Sameshima GT, Sinclair PM. Predicting and preventing root resorption: Part II. Treatment factors. (AJO-DO 2001;119:511-5) Proffit WR, Fields HW. Contemporary Orthodontics, 3 rd Edn 2000 (Mosby Inc.) Athanasiou A. Orthodontic Cephalometry 1995 (Mosby-Wolfe).   www.indiandentalacademy.com

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