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CHAPTER 21 Adult Interdisciplinary Therapy: Diagnosis and Treatment 575 CHAPTER 21 Adult Interdisciplinary Therapy: Diagnosis and Treatment 575 A B C D E F G H I J K L M FIGURE 21-6 Clinical example of adult treatment objective 3: redistribution of occlusal and incisal forces. A, No natural tooth stops in a 45-year-old woman. The initial tooth contact in centric rela- tion was between the mandibular first premolar and the maxillary second premolar.B, Anteriorly, the mandible fits within the maxillary arch. C, No tooth contact on the left side. D, Soft tissue indentations indicate the location of lower incisor contact with the palate. E, Severe maxillary pro- trusion. A Hawley bite plane was used to locate centric relation at the acceptable vertical. F, After maxillary and mandibular alignment, a splint was placed before maxillary segmental osteotomy. The osteotomy positioned the maxillary canines axially to contact the lower dentition bilaterally. G, After surgery, occlusal platforms placed on the maxillary canines support the vertical dimension. H, Three years post treatment. I, Lower anteriors bonded with composite resin as a form of reten- tion. J, Pretreatment. K, Three years post treatment. L, Pretreatment cephalogram. Acceptable vertical dimension. M, One year post treatment. can be reduced with the high-speed handpiece; as the tooth 4. Improvement or correction of mucogingival and osseous is erupted orthodontically (the same amount of bone will defects. Proper repositioning of prominent teeth in the arch remain on the clinical root), the ratio of crown to root will will improve gingival topography (Fig. 21-12). In adoles- be improved (Fig. 21-11).12 cents, the brackets are placed to level marginal ridges and A B C D E F G H I J K L M FIGURE 21-7 Clinical example of adult treatment objective 4: adequate embrasure space and proper root position. A–E, Pretreatment intraoral photographs showing compromised embrasures and altered root position of lower second molars preventing proper restorations. F–J, Posttreatment intra- oral photographs showing corrected crown and root position. Note no. 7 rotation correction and lower anterior spacing correction. K, Pretreatment radiographs. Note rotated no. 7 and no. 10 and tilted nos. 18 and 31. L, Long-term panoramic radiograph. Note the continued stability of nos. 18, 19, 30, and 31 and the previously rotated no. 7 at 7 years after orthodontic treatment. M, Long-term cephalogram. Note the continued stability of the posterior occlusion 7 years after orthodontic treatment. CHAPTER 21 Adult Interdisciplinary Therapy: Diagnosis and Treatment 577 AB D C E F G H FIGURE 21-8 Clinical example of adult treatment objective 5: acceptable occlusal plane and potential for incisal guidance at satisfactory vertical dimension. A, No occlusal stops bilaterally in a 61-year-old patient. The lower right premolar had only soft tissue attachment. B, Lower canines tipped lingually and mobile. C, Preoperative. D, Upper and lower removable appliances were placed to support the vertical height and move each lower canine labially over its basal support. E, After the lower canines were positioned axially, the restorative dentist (Dan Casullo, Philadelphia) placed a provisional restoration. A platform then was added to the upper appliance (to determine the satisfactory vertical), and the maxillary incisors were aligned. F, Seven years postoperative. G, Final restoration. H, Twenty-year follow-up of patient with advanced attachment loss. 578 CHAPTER 21 Adult Interdisciplinary Therapy: Diagnosis and Treatment A B C D E F GH IJ K FIGURE 21-9 A-B, Pre-treatment cephalometric radiograph and profile picture showing Class III with anterior crossbite of a 51:6 male. C-E, Pre-treatment study models of the patient for whom jaw surgery was the only option recommended by several surgeons and other orthodontists. F-H, Pre-treatment intra-oral photographs of same patient, showing evidence of mild functional shift. Arrow at the abundant attached gingival tissue in maxillary anterior, indicating adequate tissue available for incisor re-angulation and camouflage therapy for this patient.I-K, Intra-oral photo- graphs illustrating favorable response to initial stages of therapy. LM N O P QR FIGURE 21-9, cont’d L-N, Intra-oral photographs with posterior restoration complete. Posterior segments left in cross-bite. O, Pre-treatment panoramic radiograph showing loss of several pos- terior teeth and bone loss. P, Post-orthodontic and restorative radiograph showing restoration of posterior occlusion. Q, Pre-treatment cephalometric radiograph showing Class III with anterior crossbite and loss of posterior vertical support due to extensive tooth loss. Class III relationship has a mild skeletal component and a moderate dental component with a functional shift that increases the severity of the Class III appearance. R, Post-treatment cephalometric radiograph with corrected anterior relationship and restored posterior occlusion. ST U FIGURE 21-9, cont’d S, Pre-treatment of 51:6 year old male with long-standing Class III malocclu- sion. Several specialist had recommended jaw surgery to resolve this problem. Jaw surgery would have been “over-treatment” for this patient. T, Pre and Post treatment cephalometric supra-imposi- tions improved facial balance due to camouflage therapy and the elimination of the functional shift. U, Post-treatment of patient with very favorable achievement of Objective #6 (Adequate Occlusal Landmark Relationships) through non-surgical management of his Class III malocclusion. A B C D E FIGURE 21-10 Clinical example of additional adult orthodontic treatment objective 7: better lip competency and support. A, Pretreatment right occlusion illustrating open bite, protrusive upper and lower incisors with crowding and gingival recession (arrow). B, Posttreatment right occlusion illustrating correction of preexisting malocclusion and incisor retraction with extraction of nos. 5,12, 21, and 28 and correction of gingival recession (arrow). C, Pretreatment profile showing lip incompetence caused by dentoalveolar protrusion. D, Posttreatment profile showing improved lip competence and relaxed mentalis. E, Cephalometric superimposition showing corrected incisor protrusion and subsequent lip position improvement (arrows). A B C D E F G H I J K L FIGURE 21-11 Clinical example of adult treatment objective 8: improved crown-to-root ratio. A, Before correction of an incisor crossbite. Note the normal gingival position on the labially displaced lower left lateral incisor in a 14-year-old patient. After lower incisor alignment the gingival margins were confluent. B, Narrow zone of attached gingiva in a 61-year-old patient. As the lower incisors were retracted and allowed to erupt, more gingiva was created incisogingivally. C, Woman with large osse- ous defect on the mesial of the lower left premolar. Note the significant probing depth.D, Preoperative radiograph of intrabony defect. E, Before orthodontic movement, guided tissue regeneration was used to create new attachment, and then eruption was used to eliminate any remaining osseous defect. Note nonresorbable membrane that was placed over the defect, which was allowed to heal, and was removed 8 weeks later. F, The tooth was extruded to resolve the intrabony defect. G, Buccal view of the preoperative intrabony defect. H, Buccal view of the new bone after the tooth was extruded and prepared for a restoration. I, Lingual view of the preoperative intrabony defect. J, Lingual view of the new bone after regeneration and tooth movement. K, Provisional restoration. The osseous defect has been corrected and the crown-to-root ratio has been improved. L, Radiographic appearance of the premolar. (C–J, Courtesy of Eric Saacks, Bondi Junction, Australia.) 582 CHAPTER 21 Adult Interdisciplinary Therapy: Diagnosis and Treatment A B C D E F G H FIGURE 21-12 Clinical example of adult treatment objective 9: improvement or correction of the mucogingival and osseous defects; and adult treatment objective 10: better self-maintenance of periodontal health. A, C, E, Gingival form after control of inflammation and occlusal therapy with a bite plane in a 58-year-old man. In patients with posterior bite collapse, the posterior teeth are disarticulated with a Hawley bite plane appliance during scaling and root planing. B, D, F, Ahexial positioning of the teeth. Note the changes in gingival form. (The topography improved as the bite collapse was corrected and the teeth were properly positioned.) In addition, controlling gingival inflammation is easier after better tooth position has been established.G, Two years post treatment. H, Twenty-two-year follow-up. The patient has maintained his natural teeth. CHAPTER 21 Adult Interdisciplinary Therapy: Diagnosis and Treatment 583 cusp tips. In adults, the goal should be to level the crestal The needs that prompted development of the POMR have bone between adjacent cementoenamel junctions. It has also influenced dentistry, particularly adult orthodontics.Fig - been demonstrated that the need for osseous and mucogin- ure 21-15 is a synthesized description of the steps necessary to gival surgery may be diminished by favorable changes of the include all variables into the adult patient’s treatment plan- osseous and soft tissue topography during tooth movement. ning process. The format and mechanism used for interpret- Therefore, attachments should be placed on individual teeth ing problems into orthodontic dental records are important to allow the leveling of the attachment apparatus. This cre- steps in improving the practitioner’s understanding
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