European Journal of Orthodontics 1 (1979) 227-241

Published by Churchill Livingstone, London. © European Orthodontic Society, 1979

Indications for orthodontic treatment in

adults
Birgit Thilander
University of Goteborg, Sweden

Summary. The demand and reasons for orthodontic treatment in 1186 adult patients are
evaluated. Factors that must be considered in adult orthodontics and the resources for treat-
ment are discussed. Some typical cases are described.

Surprisingly little has been published about Table 1 Adult referrals to the Department of

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adult orthodontics and most of this has been Orthodontics of the Faculty of Odontology
in the form of case reports. It is therefore in Gothenburg (18-77 years)
understandable that indications for ortho-
dontic treatment in adults have taken a sub- 1970 26
1971 107
ordinate place in total treatment planning. 1972 128
This article analyses the demand and the 1973 109
reasons for orthodontic treatment in an adult 1974 113
Swedish clientele and describes some typical 1975 151
cases. Factors which must be taken into ac- 1976 177
1977 201
count in adult orthodontic treatment and the 1978 174
resources required for treatment of this kind
are discussed. Total 1.186(439 <J + 747 ?)

Demand and reasons for orthodontic treatment

Table 2 Referred by
Between 1970 and 1978, 1186 patients (439 /o
men and 747 women) aged between 18 and 77
years (x = 31 years) were referred to the Private dentist 747 63.0
Department of Orthodontics of the Faculty Hospital doctors 23 1.9
of Odontology in Gothenburg for ortho- Department of the Faculty of
Odontology
dontic treatment (Table 1). oral diagnosis 113 9.5
65% of these patients were referred by oral surgery 130 11.0
dental surgeons in private practice and 1.9% clinical dental physiology 57 4.8
from hospital doctors, who were all psychia- peri odontology 56 4.7
cariology 30 2.5
trists. The remainder were referred by other prosthetics 28 2.4
departments of the Faculty (Table 2). endodontics 2 0.2
Patients with cleft lip and palate, scolio-
sis or maxillary or mandibular retrognathia Total z 1.186
228 INDICATIONS FOR ORTHODONTIC TREATMENT IN ADULTS

and prognathism are not included in this Table 4 Frequency of anomalies of the
report. dentition
The 23 patients referred by psychiatrists
School
suffered from mental conflicts as a result of children Adults
their dental anomalies. <16yrs* >18yrs
Dental anomalies
Dental anomalies were more than twice as Congenitally missing teeth
common in the referred patients as in Swedish (excluding third molars) 6.1% 4.1%
Impaction (excluding third
school children (Table 3). The main problem molars) 5.4 28.7
was impaction of upper canines but impacted Tipped or rotated teeth (>60 °) 3.7 5.9
lower canines and premolars also occurred Miscellaneous (e.g. trauma,
(Table 4). Tipped and rotated teeth were more supra-, infra-occlusion) 3.3 0.6
frequent among the adult patients than the Space anomalies
Median diastema (> 2 mm) 5.0% 8.7%
children and congenitally missing maxillary Spacing (excluding median
lateral incisors were fairly common. diastema) 8.6 4.4
Crowding 26.3 24.2
Occlusal anomalies
Space anomalies and malocclusion were less Postnormal bite 14.1% f S4
Horizontal overjet (>6 mm) 8.0 (5.4
frequent in the adult patients than in school Inverted tooth/teeth 11.1 5.1
children (Table 3) except for median dias- Prenormal bite 4.2 2.2
temas, which were more common in the adults Edge-to-edge bite 1.3 0.3

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(Table 4). With three exceptions all the
patients with median diastemas and/or aplasia
of the upper lateral incisors were women.
The reason for wanting orthodontic treatment
expressed by almost all the patients was a
desire for aesthetic improvement of the front
teeth, especially in the upper jaw, which may
explain the female dominance. Several of the
patients, especially the younger ones, had
been offered orthodontic treatment while at
school but had declined or failed to complete
treatment with appliances, which they now
regretted. Most of the middle-aged and elderly
patients had not been informed about the
Table 3 Frequency of anomalies of the
dentition
School children < Adults>
16 years 18 years
n = 5.459* n = 1.186
Crossbite (uni- or bilaterally) 10.7 2.9
Scissors bite (uni- or
bilaterally) 2.0 2.0
Deep bite ( > 5 mm) 8.4 1.6
Open bite 4.0 3.9
1
Thilanderand Myrberg(1973)
possibilities of orthodontic treatment earlier
in life. Some of the patients had children of
their own who had undergone orthodontic
treatment and the parents now desired
similar aesthetic results for themselves.
In addition to aesthetic and psychological
indications orthodontic consultation was
sought for surgical orthodontic treatment of
impacted teeth, alignment of teeth to facili-
tate prosthetic restorations, elimination of
incisor spacing caused by tooth migration
associated with periodontal disease, treatment
of lateral and frontal forced bites associated
with disorders of the temporomandibular
joint and/or muscle dysfunction.

Dental - anomalies 14.9% 39.3%

Space-anomalies 52.3% 37.3% Factors to be considered in adult orthodontics
Occlusal-anomalies 32.6% 23.4%
Malformations 0.22% Basic differences An adult, in this context, is
' Thilanderand Myrberg (1973) taken to be aged 18 years or more. As growth
INDICATIONS FOR ORTHODONTIC TREATMENT IN ADULTS
is complete, or has almost ceased, it is not
possible to influence zones of growth and
treatment is restricted to alignment of teeth.
Pcriodontium—tissue response Alignment of
teeth is dependent on osteoclastic and osteo-
blastic activity in the periodontium which is
a physiological process that permits constant
remodelling of bone throughout life. With
increasing age, however, cellular activity de-
creases and the tissue becomes richer in
collagen. Age per se is not a contraindication
to orthodontic treatment in the adult but the
tissue response is considerably slower both
as regards cell mobilization and conversion
of collagen fibres, so that hyalin zones on the
pressure side of the tooth are formed more
easily.
The applied force must therefore be light and
preferably of interrupted continual type in
order not to reduce the activity of the bony
tissue. Light forces also reduce the risk of
root resorption.
The duration of retention is usually increased
owing to the low rate of ossification. Relapse
may occur as long as reorganization of the
tissues is taking place and permanent fixation
is therefore not uncommon.
Anchorage may present major problems in
adult orthodontics, especially in partially
edentulous dentitions.
Root-filled or traumatized teeth which have a
normal radiological appearance may be
moved orthodontically provided that light
forces are used.
Oral hygiene and periodontal status must be
good. Orthodontic treatment should always
be preceded by a programme of plaque
control with elimination of calculus and over-
hanging restorations.
229
Difficulty in adapting to the appliance is
common during the initial phase of treat-
ment. Phonetic adjustment to a removable
appliance, for example, generally takes time,
and cosmetic acceptability is particularly im-
portant to the adult. The patient must there-
fore be prepared very thoroughly for the con-
sequences and implications of orthodontic
treatment which should not be started unless
the patient is in full physical and mental
health. Under these conditions the patient
will normally co-operate well and soon accepts
appliances. Patients are usually highly ap-
preciative of the treatment.
Resources for adult orthodontics
There is a demand for adult orthodontic
treatment both from the patients themselves
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and from dental surgeons in general and
specialist practice. This demand is likely to
increase still further as a result of the increas-
ingly positive attitude towards adult ortho-
dontics and the development of more aes-
thetically acceptable appliances, such as
bonded plastic brackets.
In considering the resource requirements
it is of interest to analyse how the 1186 adults
referred for orthodontic treatment were
handled in the Faculty of Odontology in
Gothenburg. 37.5 % were treated or placed on
Table 5 Treatment carried out in the adult
orthodontic referrals
n %
No treatment 164 13.8
(little need for treatment, poor oral
hygiene)
Isolated procedures 265 22.3
(surgical exposure or removal,
transplantation, tooth extraction,
grinding etc.)
Orthodontic treatment 444 37.5
(performed, started, planned) 154
of whom require permanent fixation
Patient declined treatment or
doubtful 313 26.4
Total 1.186 100
230 INDICATIONS FOR ORTHODONTIC TREATMENT IN ADULTS

the waiting list for some type of orthodontic

procedure (Table 5). It was possible to
treat so many because of the Department's
function as a specialist teaching unit with a
postgraduate training programme that re-
quires a certain number of adult patients to
be treated.
It should be emphasized that the reten-
tion period was minimal in almost one-third
of the cases because of the need for permanent
fixation which was carried out by the referring
dentist relatively soon after the active treat-
ment phase.
After consultation and discussion of the
proposed treatment 26.4% of the referred
patients declined orthodontic treatment or
expressed doubts about their ability to co-
operate. They did, however, show a very
positive attitude to the dentists" action in
referring them. In 22.3 % of cases the problem
could be solved by oral surgery or by tooth

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grinding. In 13.8 % of the patients orthodontic
treatment was not considered to be indicated
because of insufficient objective or subjective
need. Several of these patients had been poorly
informed about the implications of ortho-
dontic treatment by their referring prac-
titioner.
The following cases indicate the most
common reasons for referral of patients for
orthodontic treatment alone or as part of a
comprehensive treatment programme carried
out by other dentists.
Case reports
Figure 1 A 22-year-old woman referred by
a private dentist for surgical orthodontic
treatment of an impacted left maxillary
canine. There was space in the arch for the
tooth and the patient was very distressed
about the gap (a). The position and inclina-
tion of the tooth as assessed from radio-
graphs appeared good (b). The tooth was
exposed surgically and was then moved into
position using a lingual arch with a buccal
sectional arch. The treatment took thirteen
months and the result after one year of
treatment is shown (c).
Figure 2 A 25-year-old man with very
carious maxillary right first bicuspid and left
first and second bicuspids (a) and marked
crowding of the mandibular right and left
second bicuspids (b). Treatment was planned
in collaboration with an oral surgeon who
extracted the maxillary first premolars and
transplanted the mandibular second pre-
molars to the extraction sockets. This was
followed by fixation with an orthodontic
appliance (c) for three weeks and endodontic
treatment. Control two years later showed
good clinical and radiological results (d, e, f).
Figure 3 A 23-year-old woman was referred
by her dental practitioner because of a
palatally placed right maxillary lateral incisor
(a, b) which caused her great embarrassment.
She refused treatment with a fixed appliance.
Space was created by distal movement of the
INDICATIONS FOR ORTHODONTIC TREATMENT IN ADULTS
Figure 2
right maxillary canine with a removable
appliance after which the instanding lateral
incisor was tipped buccally. The treatment
lasted five months. Because of the minimal
vertical overbite after treatment (c, d) the
tooth was retained by interproximal bonding
and a retention plate was worn at night.
Figure 4 A 27-year-old woman was referred
by her dental practitioner for treatment of a
231
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proclined overlapping right maxillary central
incisor (a, b). According to the patient, her
dental arch had been regular but gradual
crowding had occurred and she was concerned
that it would become worse. Intercuspidation
was perfect on both sides (c) and extraction
was therefore contraindicated. 4 mm space was
created by stripping the maxillary incisors and
canines interproximally and the teeth were
then aligned with a fixed appliance (d). Active
treatment took four months and was followed
232 INDICATIONS FOR ORTHODONTIC TREATMENT IN ADULTS
by retention with the same appliance during
the summer holidays. The retainer was sub-
sequently changed for a bonded lingual
retainer (e, f).
Figure 5 A 28-year-old woman was referred
by her dental practitioner for treatment of
median diastema (a). The patient was very
embarrassed by the diastema and stated that
it had become worse during the last year and
she had developed a lisp. The maxillary
central incisors were tipped mesially and
retracted by means of a removable plate
resulting in elimination of the diastema. Three
months later a lingual retainer was fitted. The
appearance is shown before and after treat-
ment (c, d).
Figure 6 A 24-year-old woman was referred
by a private dental practitioner for treatment
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of a median diastema and aplasia of the right
and left maxillary lateral incisors (a), with a
great subjective need for treatment. A fixed
appliance (b) was used to parallel the maxil-
lary central incisors. After three months a
bridge prosthesis was constructed (c, d).
Figure 7. A 42-year-old man referred by his
private dental practitioner for correction of a
median diastema and aplasia of the right and
left maxillary lateral incisors (a). Preparation
of the right maxillary canine in connection
with a prosthetic restoration had already been
started. Alignment of the teeth and increase of
the vertical dimension was carried out and
after seven months (b) the median diastema
had closed and space had been created for a
bridge replacement of the right maxillary
first bicuspid and both maxillary lateral
incisors. The result after prosthetic recon-
struction is shown (c).
INDICATIONS FOR ORTHODONTIC TREATMENT IN ADULTS 233

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234 INDICATIONS FOR ORTHODONTIC TREATMENT IN ADULTS

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Figure 7
INDICATIONS FOR ORTHODONTIC TREATMENT IN ADULTS
Figure 8 A 49-year-old woman was referred
by a periodontal specialist because of tooth
migration in the upper and lower frontal
segments (a). She had been treated by this
specialist at regular intervals for the preceding
two years and plaque control was excellent.
Orthodontic treatment was considered ap-
propriate. The incisor spaces were compara-
tively small and evenly distributed and were
closed by means of §" light latex ligatures in
the lower jaw (b) and an alastik chain in the
upper jaw (c). After two months' treatment
the teeth were retained by interproximal
bonding and bonded lingual retainers in both
jaws (d). Special care was taken to allow
room, for cleaning the teeth and for plaque
control.
Figure 9 A 44-year-old woman was referred
by her dental practitioner for correction of
tooth migration in the frontal segments (a) in
a partially endentulous arch for which a
235
bridge prosthesis was planned. As a result of
the migration a median diastema in the upper
jaw had been aggravated. After completion
of periodontal treatment the spaces in the
lower labial segment were closed and retained
with alastiks (b). The space in the upper jaw
was then closed with a fixed appliance (d).
After seven months of active treatment a
temporary alastik retainer (c) was worn for
one month and then a lingual retainer was
fitted in the upper jaw (d). A bridge prosthesis
is to be constructed.
Figure 10 A 30-year-old woman was referred
by a periodontal specialist who had been
treating her for several years for periodontitis
caused by juvenile periodontosis (a). Ortho-
dontic alignment of the teeth was undertaken
preparatory to prosthetic reconstruction (b).
Orthodontic treatment last four months (c)
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after which a bridge (d) was constructed by
the referring specialist.
236 INDICATIONS FOR ORTHODONTIC TREATMENT IN ADULTS

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Figure 9

f TV
INDICATIONS FOR ORTHODONTIC TREATMENT IN ADULTS 237

Figure 11

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238 INDICATIONS FOR ORTHODONTIC TREATMENT IN ADULTS
Figure 13
Figure 11. A 52-year-old woman was referred
by a private dentist for excessive overbite
and tooth migration in the maxillary frontal
segment (a). The patient suffered from chronic
fissures at the corner of the mouth and dis-
comfort and periodic tenderness of the
temporo-mandibular joint and of the masseter
and temporal muscles. The patient tolerated a
bite plane well and the muscle and joint
' V
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symptoms resolved. Periodontal treatment
was carried out simultaneously and then the
diastemas in the upper jaw were closed by
means of a fixed appliance. Retention with
interproximal bonding and a lingual retainer
was instituted after four months (b). A bite
plane was worn in the upper jaw until a
bridge prosthesis could be constructed for
stabilization of the vertical dimension.
INDICATIPNS FOR ORTHODONTIC TREATMENT IN ADULTS
Figure 12 A 24-year-old woman was referred
because of protrusion of the maxillary
incisors and excessive overbite (a, b). The
patient was so interested in the treatment that
she requested fixed appliance therapy in both
jaws. The situation \\ years later is shown (c,
d) when the patient was in retention with a
removable appliance.
Figure 13 A 23-year-old woman was referred
for uprighting of the right mandibular
second molar (a) which had followed early
loss of the corresponding first molar and
second bicuspid. It was intended to use the
second molar as an abutment for a fixed
bridge. The tooth was uprighted (b) and
after two months of orthodontic treatment
the bridge was constructed (c).
Figure 14 A 45-year-old woman was referred
by a periodontal specialist for treatment
239
of a mesially tilted left mandibular second
molar with a pronounced bony pocket and
involvement of the root bifurcation (a, b). It
was considered to be very important to pre-
serve the distal root for a bridge prosthesis.
After periodontal surgery, the tooth was up-
righted and this was followed by bone
regeneration (d). After seven months of treat-
ment the distal root was treated endodontic-
ally, the tooth was separated, the mesial root
was extracted and the bridge prosthesis was
constructed (c).
Figure 15 A 32-year-old woman was referred
for treatment of an incisor crossbite (a, b)
and impacted maxillary canines. From radio-
graphic assessment the prognosis for align-
ment of the canines appeared to be poor and
the patient was not interested in this treatment
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but was anxious to have her crossbite cor-
rected since she associated this with chronic
240 INDICATIONS FOR ORTHODONTIC TREATMENT IN ADULTS
headaches. A bite plane was fitted (b) with
simultaneous correction of the incisor cross-
bite. After six months of treatment a retainer
was inserted and this was worn for two
months, after which the surgically extracted
maxillary canines were replaced with a bridge
(d, e, f).
Figure 15
Figure 16 A 51-year-old woman was referred
to the Department of Oral Diagnosis for
total treatment (a). It was agreed that after
endodontic treatment in the frontal segment
of the lower jaw and periodontal treatment in
both jaws the patient should have ortho-
dontic treatment of the incisor crossbite.
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INDICATIONS FOR ORTHODONTIC TREATMENT IN ADULTS 241

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I I ' >
Figure 16

Because of the patient's social commitments Faculty of Odontology,

the treatment had to be carried out with a University of Goteborg,
removable appliance (b). The crossbite was S-40033 Goteborg,
eliminated after 5£ months of treatment (c). Sweden.
After treatment the periodontal status in the
frontal segments was good. The final result
after construction of a crown prosthesis is
shown (d). Reference

Thilander, B. and Myrberg, N. (1973). The

Address for correspondence
prevalence of malocclusion in Swedish
Professor B. Thilander, schoolchildren. Scandinavian Journal of
Department of Orthodontics, Dental Research, 81: 12-20.