20

Adult orthodontics
S. J.Littlewood

Chapter contents
1. Introduction 252

2. Specific problems in adult orthodontic treatment 252

1. Lackof growth 252
2. Periodontal disease 252
3. Missing or heavily restored teeth 252
4. Physiological factors affecting tooth movement 253
5. Adult motivation and attitudetowards treatment 253
3. Orthodontics and periodontal disease 253
1. Malalignment problems caused byperiodontal disease 253
4. Orthodontic treatment as an adjunct to restorative
work 254
1. Orthodontic managementof patients with periodontal
disease 254
5. Aesthetic orthodontic appliances 257
1. Aesthetic orthodontic brackets andwires 257
2. Clear orthodontic aligners: the Invisalign®concept 258
3. Lingual orthodontics 259
6. Obstructive sleep apnoea and mandibular
advancement splints 260
1. Introduction to Obstructive Sleep Apnoea (OSA) 260
2. Diagnosis ofOSA 260
3. Treatment of OSA including the use ofmandibular
advancementsplints 261
4. Conclusion about removable appliances and OSA 261

Principal sources and further reading 262

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252 Adult orthodontics
Learning objectives for this chapter
• Appreciate the problems that are specifically related to adult orthodontic treatment
• Understand the relationship between periodontal disease and malocclusion and how patients with periodontal disease canbe ortho-
dontically treated
• Appreciate the use of orthodontics as an adjunct to restorative treatment
• Be familiar withthe different types of aesthetic orthodontic appliances
• Understand the role of mandibular advancement splints inthe treatment of obstructive sleep apnoea
20.1 Introduction
The demand for adult orthodontics is increasing. There are really two
distinct groups of adults that request orthodontic treatment. The first
group is looking for comprehensive treatment, having, for whatever rea-
son, missed out on orthodontics asachild (Fig. 20.1). With dental aware-
ness growing, anincreasing demandfor improved dental aestheticsand
20.2 Specific problems in adult orthodontictreatment
In many ways the approach to treatment in adult patients follows the
same process as that for children. There are however some problems
that arespecific to adult patients:
• Lack of growth
• Periodontal disease
• Missing or heavily restoredteeth
• Physiological factors affecting tooth movement
• Adult motivation and attitude towards treatment
Fig. 20.1 Adult wearing ceramic brackets.
better social acceptance of orthodontic appliances, more adults are
willing to wear appliances. The second group of adults requires ortho-
dontic treatment to facilitate restorative and/or periodontal care.Tooth
movement undertaken to facilitate other dental procedures is known as
adjunctiveorthodontic treatment. he-9780199594719-figureGroup-315
20.2.1 Lack of growth
Although growth continues at a very slow rate throughout adulthood,
the majority of growth changes have occurred by the end of puberty.
This means that there is no scope for growth modification, so skeletal
discrepancies can only be treated with either orthodontic camouflage,
or combined orthodontics andorthognathic surgery.
It can also be more difficult to reduce overbites without the benefit of
growth. Where possible, overbite reduction should be achieved by intru-
sion of the incisors, rather than the more common method of extruding
the molars (provided this doesnot compromise the smile aesthetics). This
is becauseextrusion of posterior teeth is more prone to relapse in adults.
20.2.2 Periodontal disease
Adult patients are more likely to be suffering, or have suffered, from
periodontal disease. A reduced periodontium is not acontraindication
to orthodontic treatment, but it is vital that any active periodontal dis-
ease is treated and stabilized before orthodontic treatment can begin.
This is discussed in more detail in Section 20.3.
20.2.3 Missing or heavily restoredteeth
Tooth loss maylead to drifting and/or tilting of adjacent teeth and over-
eruption of opposing teeth into the space. In addition, atrophy of the
alveolar bone can occur, leading to a narrowing or ‘necking’ in the site
of the missing tooth or teeth (Fig. 20.2). This canmake tooth movement
into these areas moredifficult.he-9780199594719-figureGroup-316
Heavily restored teeth are more common in adults and may com-
plicate the orthodontic treatment. The choiceof extractions maybe

Fig. 20.2 Atrophy of alveolus after tooth loss.
determined by the prognosis of the restored teeth, and bonding to
certain restorative materials is more difficult than bonding directly to
enamel. Specialist techniques and materials are needed when bonding
fixed appliances to gold, amalgam and porcelain, and the patient needs
to be warned that the restoration may be damaged when removing the
fixed appliance. For this reason, if possible, it is best to leave any defini-
tive restorations until after the orthodontic treatment.
20.2.4 Physiological factors
affecting tooth movement
There is areduced tissue blood supply and decreased cell turnover in
adults, which can mean that initial tooth movement is slower in
adults, and may be more painful. Lighter initial forces are therefore
advisable.
20.3 Orthodontics and periodontal disease
Periodontal disease is morecommonin adults, andis therefore animpor-
tant factor that must beconsidered in all adult orthodontic patients. It is
wise to undertake afull periodontal examination in all adult patients to
exclude the presence of active periodontal disease. Periodontal attach-
ment loss is not acontraindication to orthodontic treatment, but active
periodontal disease must be treated and stabilized before treatment
begins. The presence of plaque is the most important factor in the ini-
tiation, progression and recurrence of periodontal disease. Teeth with
reduced periodontal support can be safely moved provided there is
adequateplaque control.
Orthodontics and periodontal disease 253
Fig. 20.3 Miniscrew used for anchorage (courtesy of Professor
Hyo-Sang Park). The overjet is being reduced by tractionapplied to
aminiscrew on eachside. By avoiding traction to the molar teeththis
limits the unwanted forward movement of the posteriorteeth.
20.2.5 Adult motivation and
attitude towardstreatment
Adults havethe potential to beexcellent, well-motivated patients. Phys-
iological factors might suggest that adult treatment should take longer
than it does in children; however, this is not always the case. It has been
suggested that the increased co-operation may compensate for slower
initial toothmovement.
Adults tend to bemore conscious of the appearanceof the appliance,
so there has been adrive towards more aesthetic orthodontic applianc-
es (see Section 20.5). Although distal movement of the upper molars
with headgear is technically feasible, adults are more reluctant to wear
extra-oral appliances. Alternative sources of anchorage are therefore
more commonly used in adult patients, such as implant-based anchor-
age(Fig. 20.3).he-9780199594719-figureGroup-317
20.3.1 Malalignment problems caused by
periodontal disease
Loss of periodontal support can lead to pathological tooth migration of
asingle tooth or agroup of teeth. The commonest presentation of peri-
odontal attachment loss is labial migration and spacing of the incisors
(Fig. 20.4). The teeth lie in an area of balance between the tongue lin-
gually and the lips and cheeks buccally. The forces from the tongue are
higher than those exerted by the lips and cheeks, but anormal healthy
periodontium resists these proclining forces from the tongue. If however
periodontal attachment is lost as aresult of disease, then the teeth will
be proclined forwards. In addition, if posterior teeth are lost then this
lack of posterior support produces more pressures on the labial seg-
ment, leading to further proclination of the incisors.
he-9780199594719-figureGroup-318
254 Adult orthodontics

Fig. 20.4 Proclination and spacing of incisors secondary to the loss of periodontal attachment. This patient initially presented with aClass II division
1 incisor relationship with an overjet of 6 mm. However, due to periodontal disease and the subsequent loss of periodontal attachment around the
upper labial segment, these upper incisors have flared forward, and becomespaced.

20.4 Orthodontic treatment as an adjunct to restorativework

With an increasing number of patients keeping their teeth for longer,
there is a greater need for interdisciplinary treatment of patients with
complex dental problems. Where collaboration is needed between the
orthodontist and the restorative dentist, it is helpful to see the patients
jointly to formulate a co-ordinated and appropriate treatment plan.
Orthodontic treatment in these cases does not necessarily require com-
prehensive correction aiming for anideal occlusion. The aims of adjunc-
tive orthodontic treatment areto:
tion of the space, so the over-erupted tooth can be intruded using
orthodontics.
• Extrusion of fractured teeth: sometimes it is necessary to extrude a
fractured tooth, to bring the fracture line supragingivally to allow
placement of acrown or restoration. There is alimit to this, as excess
extrusion will reduce the amount of tooth supported by bone, reduc-
ing the crown-to-root ratio.

• Facilitate restorative work byappropriate positioning ofteeth
• Improve the periodontal health byreducing areasthat harbour plaque,
andmaking it simpler for the patient to maintain goodoral hygiene
• Position the teeth so that occlusal forces are transmitted along the
long axis of the tooth, and tooth wear is more evenly distributed
throughout the arch
The following are examples of problems that benefit from a joint
approachbetweenthe orthodontist andthe restorative dentist:
• Uprighting of abutment teeth: following tooth loss adjacent teeth
may drift into the space. Uprighting these abutment teeth can facili-
20.4.1 Orthodontic management of patients
with periodontaldisease
Once the periodontal disease has been fully stabilized, and the patient
is able to maintain agood standard of oral hygiene, treatment canbegin
(Fig. 20.5). Lighter forces are required, due to the reduced periodontal
support, and ideally bonds rather than bands should be used on the
molars to aid oral hygiene. Removal of excess adhesive will also help to
reduce plaque retention. Due to the reduced alveolar bone support
the centre of resistance of the tooth moves apically. This means there is
agreater tendency for teeth to tip excessively, so this must be carefully
controlled with appropriate treatment mechanics. he-9780199594719-figureGroup-319

tate the placementof replacementprosthetic teeth (Fig. 20.5).

• Redistribution or closure of spaces: following tooth loss it may be pos-
sible to close the remaining space, or move a proposed abutment
tooth into the middle of anedentulous span, in order to aid construc-
tion of a more robust prosthesis. If implants are required then the
roots mayneedto berepositioned to permit surgical placement.
• Intrusion of over-erupted teeth: one of the side effects of tooth loss is
over-eruption of the opposing tooth. This caninterfere with restora-
Retention at the end of treatment needs to be carefully considered.
Even when the teeth are aligned and the periodontium is healthy, the
problem of reduced periodontal support remains. With reduced peri-
odontal attachment there will always beatendency for the forces of the
tongue to procline the incisors. These cases require permanent reten-
tion, often in the form of bonded retainers, and the patient must be
taught how to maintain excellent oral hygiene around these retainers
(see Chapter 16).

Fig. 20.5 Adjunctive orthodontic treatment. (a) Patient PM is 50 years old and was referred from her general dental practitioner with combined
restorative and orthodontic problems. She had initially presented with moderate chronic periodontitis, with extensive bone loss (see DPT
radiograph). This hadled to migration of the teeth, particularly the upper right lateral incisor andupper right canine, which hadboth drifted and
extruded.
Following treatment and stabilization of the periodontal disease, restoration of the upper central incisor space was complicated by the position of
these two teeth. The treatment plan was adjunctive fixed appliance treatment to re-position these teeth, align the upper arch and allow provisionof
an upper removable prosthesis. (b) Following 8 months of upper fixed appliance treatment, the upper arch was aligned and appropriate space made
for the prosthesis. No attempt was madeat comprehensive orthodontic correction, with no treatment in the lower arch and no reduction in overjet.
(c) A removable partial denture was made. A well-fitting aesthetic prosthesis was madepossible by the adjunctive orthodontic treatment.
 Orthodontic treatment as an adjunct to restorative work 255

(a)
256 Adult orthodontics

(b)

(c)
Fig. 20.5 (continued)

20.5 Aesthetic orthodonticappliances
Although aesthetic orthodontic appliances are not restricted to adult
patients, the drive for less visible appliances has come from adults. This
demand has led to the development of anumber of orthodontic appli-
anceswith improved aesthetics (see Box 20.1). he-9780199594719-boxedMater-86
20.5.1 Aesthetic orthodontic brackets andwires
Aesthetic orthodontic brackets (Fig. 20.1) are made of clear or tooth-
coloured material. Although not invisible, they can significantly reduce
the appearanceof fixed appliances. They caneither bemadeof ceramic
materials or polycarbonate (plastic) brackets. Original plastic brack- ets
showed problems with staining and a lack of stiffness, which led to
deformation of the bracket when trying to apply torque. Although
improvements to plastic brackets have been made, by the addition of
metal slots or the addition of ceramic particles, they still haveaproblem
with loss of torque and this lack of control means that at the present
time ceramic brackets are preferred.
All ceramic brackets are composed of aluminium oxide in either a
polycrystalline or monocrystalline form, depending on their method of
fabrication. Despite their undoubted aesthetic advantages, ceramic
brackets dohavesome potential disadvantages:
Box 20.1 Different approaches to reduce the negative
aesthetic impact of orthodontic treatment
• Aesthetic orthodontic brackets and wires
• Clear orthodontic aligners
• Lingual orthodontics
Fig. 20.6 Patient wearing upper ceramic brackets and lower metal brackets. Note the aesthetic wire in the upper arch.
Aesthetic orthodontic appliances 257
• Bonding and bond strength. Ceramic bracketscannotbondchemi- cally
with composite resin, because the aluminium oxide is inert. In an
attemptto addressthis, earlyceramic bracketswerecoatedwith asilane-
bonding agent, but this produced bonds that were too strong, resulting
in enamel fractures at debond. Most current ceramic brackets therefore
bondbymechanicalretention using avariety of ingeniousdesigns.
• Frictional resistance. Ceramic brackets offer more friction to sliding of
the archwire, than standard metal brackets, which may increase the
treatment time.
• Bracket breakage. Bracket breakage, particularly of the tie-wings, is
more common with ceramic brackets, but improvements in the
bracket morphology as well as refining of the manufacturing process
havehelped to reducethe number ofbreakages.
• Iatrogenic enamel damage. Ceramic brackets are harder than enam-
el, so if these brackets are in occlusal contact with the opposing
teeth there is a significant risk of enamel wear. Consequently these
brackets should be avoided in the lower arch if there is a possibility
of occlusal contact. Most patients will accept metal brackets on the
lower arch,asthey will bebarely visible in manypatients (Fig.20.6).
• Debonding. Removing metal brackets at the end of treatment is not
usually a problem, as they are relatively pliable and the base can be
easily distorted. Ceramic brackets aremore rigid andthe sudden force
used to debond brackets canshatter the bracket, or on occasion, may
cause enamel fractures. It is recommended that excess adhesive flash
is removed from around the bracket before debonding. It is also vital
to follow the bracket manufacturer’s instructions, as different brands
of brackets aredesigned to beremovedin different ways. he-9780199594719-figureGroup-320
258 Adult orthodontics

Attempts to make orthodontic wires more aesthetic have proved

more challenging. Two broad approaches have been attempted to pro-
duceaesthetic orthodontic wires:

• Coated metallic wires (Fig. 20.7)

• Non-metallic aesthetic wires
Both stainless steel and nickel titanium wires are available coated
with white epoxy or Teflon. Unfortunately in both cases the coating
can become discoloured and wear off during clinical use. An alterna-
tive that has been tried is rhodium coating, which reduces the reflec-
tivity of the wire, giving it a matt white or frosted appearance, which
although not tooth coloured is more aesthetic than the normal metallic
wireappearance. he-9780199594719-figureGroup-321

Attemptsto makenon-metallic aestheticwires haveso farbeenunsuc-

cessful, as the wires have proved to be unreliable, with their mechanical
properties failing to matchtheir improved aestheticappearance.
Fig. 20.7 Coated metallic aesthetic archwire.
One of the commonest complaints from patients wearing aesthetic
brackets with conventional ligation is that the elastomeric modules or ‘o’
ring that holds the wire in the place have agood appearance initially (Fig
20.8), but discolour with time, usually due to food colouring in the diet.
Self-ligating aesthetic brackets have recently been developed to over-
comethis problem, astheyrequirenoelastomericmodules (seeFig 20.9). he-9780199594719-figue
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20.5.2 Clear orthodontic aligners:

the Invisalign® concept
The use of clear plastic appliances was first described using plastic
retainer materials. Mildly irregular cases were treated by producing a
series of patient casts with the teeth cut off and progressively repo-
sitioned until the teeth were in the correct position. A series of clear
Fig. 20.8 Tooth-coloured modules on brackets using conventional
plastic tooth positioners, or aligners, were fabricated over these casts.
ligation. The photograph shows the appearance when they are first
The patient would then wear this series of clear plastic appliances to placed. However, with time the elastomeric modules oftendiscolour,
move the teeth. This technique was demanding and labour inten- compromising the aesthetic appearance of the appliance.
sive, until the process was computerized by Align Technology in the
late 1990s and the Invisalign® concept was created (Fig. 20.10). There
are now several companies offering variations of this clear aligner
treatment. he-9780199594719-figureGroup-324

Accurate impressions (usually using poly-vinyl siloxane) are taken to

allow the construction of precision casts which can be scanned to pro-
duce avirtual 3-D model. This 3-D model can then be manipulated by
the orthodontist and the malocclusion ‘virtually’ corrected using propri-
etary software. It is important that the clinician has agood understand-
ing of orthodontic principles before undertaking this type of treatment,
recognizing the limitations of the technique and communicating this
clearly to the patient aspart of the consentprocess.
A series of clear plastic aligners are produced that gradually correct
the malocclusion towards the clinician’s goals. Each aligner is worn for 2
weeks, and is only removed for eating, drinking, brushing and flossing.
Eachaligner will movethe teeth approximately 0.25 mm.
The potential advantagesof Invisalign® are:

• Excellent aesthetics Fig. 20.9 Self-ligating aesthetic brackets in the upper arch. Both the
bracket and the sliding clip mechanism are madefrom polycrystalline
• Ease of use and comfort for patient
ceramic material. This removes the need for the wire to be held inplace
• Ease of care and oral hygiene by elastomeric modules, which candiscolour.
 Aesthetic orthodontic appliances 259

Potential disadvantagesare:
• Limited control over rootmovement
• Limited intermaxillary correction (limited anteroposterior changes)
without the use of elastics between thealigners
• Cost
The limited control over root position means that movements such
as root paralleling, correction of severe rotations, tooth upright- ing
and tooth extrusion, are more difficult. This makes space closure more
challenging, so in general Invisalign® is better at treating simple to
moderate non-extraction alignments, rather than corrections requiring
extractions.
The technology is constantly developing to try and improve the con-
trol over tooth movements. This includes the addition of customized
composite attachmentsto the teeth, designed to offer more control over
tooth movements,powerridges built into the plastic anteriorly to improve
torque control, andcustomized attachmentsfor intermaxillaryelastics.
At the present time, Invisalign® is most effective at treating milder
malocclusions presenting with malalignment, but it may be used suc-
cessfully in combination with other techniques to treat more complex
cases. The other treatment techniques may include restorative work,
such as veneers, and even a short phase of fixed appliances. In more
complex cases clear aligner treatment may not replace the use of fixed
appliances, but it may reduce the amount of time the patient needs to
wearless aesthetic labial fixed appliances.
20.5.3 Lingual orthodontics
Lingual appliances (Fig. 20.11) in many ways offer the ultimate in aes-
thetic appliances, as the whole system is bonded to the lingual aspect
of the teeth. After much attention in the early 1980s their popularity

Fig. 20.10 Invisalign® (courtesy of Align

Technology, Inc.). (a) Facial view of apatient
wearing an aligner. (b) Close-up of aligner in
place.
(a) (b)

(a) (b)
Fig. 20.11 Lingual orthodontics (photographs courtesy of Dr Rob Slater). (a) Ormco STb lingual brackets. This patient has anon-customized lingual
appliance in place. Note the temporary pontics that have been placed in the first premolar areas immediately following extractions. This is because
not only does the patient want to hide the orthodontic appliance, but also the extraction spaces. These pontics will be gradually trimmed as the
spaces are closed. Note the mushroom-shaped archwire. This is because the canine and first premolars have markedly different buccal–palatal widths.
Inorder
for the labial surfaces to be properly aligned, the archwire has to be offset between the canine and the first premolar. (b) Customized Incognito® lingual
appliance. This patient has alingual appliance with customizedbrackets and wires.
260 Adult orthodontics
fell, partly due to the introduction of ceramic brackets, but also due to a
number of problems with the appliance. Recent technological improve-
ments and an increased demand for ‘invisible’ appliances have led to a
recent increase in interest in lingual orthodontics.
he-9780199594719-figureGroup-325
Lingual orthodontics offers anumber ofadvantages:
• Aesthetics
• No risk to the labial enamelthrough decalcification
• Position of the teeth canbeseen more accuratelyasit is not obscured
bythe appliance
• Some lingual brackets create abite-plane effect on the upper incisors
and canines, making these types of brackets useful for treating deep
overbites
Lingual orthodontics also has some potential disadvantages:
• Speech alteration
• Discomfort to the patient’stongue
• Masticatory difficulties
• More technically demanding for the operator, which increases the
chair-time and therefore the cost of this approach
• Operator proficiency in indirect bonding is required and rebonding
failed brackets canbe difficult
20.6 Obstructive sleep apnoeaand mandibular advancementsplints
20.6.1 Introduction to Obstructive Sleep
Apnoea(OSA)
Removable mandibular advancement splints can be successfully used
in the treatment of adults suffering from obstructive sleep apnoea
(OSA), a sleep-related breathing disorder. These splints are similar to
orthodontic functional appliances that are used for the treatment of
Class II problems in children, because they posture the mandible for-
wards. As a result, orthodontists have undertaken a lot of the research
in this area.
OSA is characterized by repeated collapse of the upper airway
during sleep, with cessation of breathing. The aetiology is complex,
but involves anatomical and pathophysiological factors that produce
obstruction of the airflow in the upper airway, often in the pharyngeal
region. The compromised airflow often leads to snoring noise, or in
more severe cases occlusion of the airway. The collapse of the upper
airway can lead to periodic cessation of breathing (apnoea) or reduced
airflow (hypopneoa). This can lead to cardiovascular and respiratory
complications, as well as affecting the quality of life of both the patient
and their families. The symptoms of OSA are summarized in Box 20.2
below. These symptoms can be worsened by certain aggravating
factors:
• Alcohol consumption before bedtime
• Obesity
• Supine sleeping position
• More difficult to clean
• Initial alignment canbemorechallenging in morecrowdedcasesdue
to reduced interbracket span
•
Increased bracket loss
The majority of tongue discomfort is related to the mandibular arch,
so patients may choose to have a lingual appliance in the upper arch,
where aesthetics is more crucial andalabial appliancein thelower.
Lingual orthodontics canrange from simple alignment of the upper
labial segment (the so-called ‘social six’) using round wires, to compre-
hensive treatment using appliances madeusingstate-of-the-art compu-
ter-assisted design/manufacture (CAD/CAM) technology (Fig. 20.11b).
CAD/CAM has allowed the production of fully customized appliances,
with individualized production of brackets and wires. One of the chal-
lengesofaligning teethfrom thelingualaspectis theuniquemorphology
ofthe lingual aspect ofteeth, andthe rangeofbucco-lingualthickness of
teeth. Customization of appliances overcomes these problems, improv-
ing the fit of the appliances, increasing the finishing control, as well as
reducing speech problems and tongue irritation. Also if the customized
brackets debond during treatment they canbe rebonded directly, asthe
bracket base-to-tooth fit is so good that incorrect positioning is unlikely.
It remains to beseen if these new developments will continue to lead
to more widespread use of lingual orthodontics.
• Co-existing respiratory disease
• Medication that suppresses the central nervous system, which may
lead to further relaxation of the pharyngeal musculature
he-9780199594719-boxedMater-87
20.6.2 Diagnosis ofOSA
Accurate diagnosis of OSA requires acomprehensive history, examina-
tion, use of screening questionnaires and specialist sleeptests.
Box 20.2 Symptoms of O S A
Nocturnalsymptoms
• Anti-social snoring
• Choking/gasping and witnessed apnoeas
• Restlessness
• Nocturia
Daytime symptoms
• Excessive daytime sleepiness
• Depression
• Headaches
 Obstructive sleep apnoeaand mandibular advancement splints
The history must include a dental, medical and sleep history, and if
appropriate a history from the partner can be useful to describe the
sleep disturbances. Screening questionnaires, such as the validated
Epworth Sleepiness Scale which provides asubjective measurement of
the degree of daytime sleepiness, may be used to determine whether
formal sleep tests areindicated.
In addition to a normal extra-oral and intra-oral examination, a spe-
cialist ear, nose and throat examination maybeindicated to identify any
clear physical obstructions that may be compromising the airway. The
patient’s body mass index (providing ameasurement of possible obes-
ity) and the neck circumference are both measured, as both are known
to affectthe patencyof the upper airway.
If the history, examination and screening questionnaires are suggestive
of OSA, then the diagnosis can be confirmed using sleep tests. This can
be done with an overnight sleep study, known as polysomnography, but
more recently multi-channel monitoring systems have been used for the
patient to wear at home while they are asleep, and the data from these
canhelp confirm the diagnosis ofOSA.
20.6.3 Treatment of OSA including the useof
mandibular advancementsplints
Treatment of obstructive sleep apnoea may be surgical or non-surgi-
cal. Unless a clear anatomical problem can be identified the surgical
approaches often only provide atemporary improvement, and the side-
effects of the surgery arepotentially severe.
Non-surgical approachesinclude the following:
(1) Removal of aggravating factors
(2) Continuous positive airway pressure (CPAP)
(3) Mandibular advancementsplints
The first stage of treatment for all patients suffering from OSA is to
identify and if possible remove the aggravating factors discussed earlier.
This canoften reducethe severity ofOSA.
CPAP is acontinuous stream of filtered air delivered via anasal mask
andis considered the gold standard for the treatment of obstructive
(a) (b)
Fig. 20.12 (a, b). A one-piece mandibular advancement splint, protruding the mandible forwards, with limited vertical opening.
261
sleep apnoea. To be effective the CPAP needs to be worn at least 4-6
hours per night, seven days aweek. However, some patients find it dif-
ficult to wearthe mask andlong-term compliancecanbeaproblem.
Mandibular advancementsplints are used for the treatment of simple
snoring, mild to moderate obstructive sleep apnoea, and for patients
with severe OSA who cannot tolerate CPAP.By advancing the mandible
they increase the pharyngeal airway, pulling the tongue anteriorly and
increasing the muscle tone of the palatal muscles and reducing airway
collapsibility.
There are various designs of mandibular advancement appliances,
but customized appliances constructed from accurate impressions
have been shown to be more successful than semi-customized ver-
sions that the patient adapts to their dentition. The appliances can be
one-piece, or two-piece with interconnection of the maxillary and
mandibular portions. Both types of appliances protrude the mandi-
ble. Figure 20.12 shows a one-piece example. The key to success is a
comfortable, retentive appliance, which protrudes the mandible, with
minimal vertical opening. Excessive vertical opening tends to rotate
the mandible backwards and downwards, which may compromise the
airway.he-9780199594719-figureGroup-326
Patients need to be made aware that the splints can reduce the
symptoms of OSA, but they are not acure, so long-term wear is usually
required. They also need to be aware of the possible side-effects (see
Box 20.3). The sleep physician may suggest arepeat sleep test with the
splint in place to ensure that it has addressed the OSA, particularly in
moreseverecases. he-9780199594719-boxedMater-88
20.6.4 Conclusion about removable
appliances andOSA
Mandibular advancementsplints canplay avital role in the treatment of
OSA. Due to the multi-factorial nature of OSA, these patients must be
treated as part of a team, involving not only the dentist, but also sleep
physicians and ENT surgeons. With acareful diagnosis and liaison with
the other team members, mandibular advancement splints clearly have
animportant role in the treatment of some patients with OSA.
he-9780199594719-boxedMater-89
262 Adult orthodontics

Box 20.3 Possible side effects of mandibular advancement splints

Short term • Occlusion is incorrect on wakening, before gradually returning to
• Discomfort of teeth, muscles of mastication,temporomandibu- normal
lar joints
Long-term
• Excess salivation • Possible minor dento-alveolar changes, with long-termchanges
• Dry mouth in the occlusion

Key points about adult orthodontics

• The demand for adult orthodontics is increasing.
• Certain problems are particularly relevant in adult orthodontics: lack of growth, periodontal disease, missing or heavily restored teeth,
different physiological response in tooth movement, different attitudes to treatment.
• Adult patients are more likely to present with periodontal disease. Orthodontic treatment is possible in patients with periodontal dis-
ease, provided this is treated, stabilized and maintained throughout treatment. Treatment mechanics and retention must be adapted to
allow for the reduced periodontal support.
• Adjunctive orthodontic treatment is tooth movement to facilitate other dental procedures and is more common in adults.
• There is an increased demand for aesthetic orthodontic appliances in adults. This caninclude aesthetic labial fixed appliances,clear
aligners and lingual appliances.

Principal sources and further reading

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(1989). Periodontal implications of orthodontic treatment in adultswith advancement splints in the treatment of O SA , emphasizing a multi-
reduced or normal periodontal tissues versus those ofadolescents. disciplinary approach to treatment.
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Journal of Orthodontics, 22, 331–7.
T h e periodontal implications of orthodontic treatments in adults are
This review covers a range of issues involved in adult orthodontics.
discussed.
Ong, M. A., Wang, H-L., andSmith, F. N. (1998). Interrelationship between
Bressler, J. M., Hamamoto, S., King, G. J., andBollen, A. (2011) Invisalign
periodontics andadult orthodontics. Journal of Clinical Periodontology,
Therapy – asystematic review of lower quality evidence, Chapter 11in
25, 271–7.
Evidence-based Orthodontics, Wiley-Blackwell.
As the title suggests, this review describes the interface between peri-
This chapter provides an overview of the current evidence available odontal and orthodontic treatment.
for the use of clear aligner treatment.
Russell, J. R. (2005). Aesthetic orthodontic brackets. Journal of Orthodon-
Cousley, R. R. J. (2011). Orthodontic bone anchorage, Chapter 30 in Ortho- tics, 32, 146–63.
dontics: Principles and Practice,Wiley-Blackwell.
A summary of the advantages and disadvantages of contemporary
This provides a clear overview on the topic of bone anchorage aesthetic brackets.
devices.
Shah, H.V., Boyd, S. A., Sandy, J. R., andIreland, A. J. (2011). Aesthetic
Creekmore, T. (1989). Lingual orthodontics – its renaissance. American labial appliances – anupdate. Orthodontic Update, 4,70–7
Journal of Orthodontics and Dentofacial Orthopedics, 96, 120–37.
Singh, P. andCox, S. (2011) Lingual orthodontics: anoverview. Dental
This article highlights some of the initial problems with lingual appli-
Update, 38, 390–5.
ances and how they were overcome.
Wiechmann, D., Rummel, V., Thalheim, A., Simon, J-S., andWiechmann,
Joffe, L. (2003). Invisalign®: early experiences. Journal of Orthodontics, 30,
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An easy-to-read overview of the Invisalign ® concept. ics, 124, 593–9.
Johal, A. andBattagel, J. M. (2001). Current principles in the management This paper describes how computer-aided design and manufacturing
of obstructive sleep apnoeawith mandibular advancementappliances. technology is used to produce custom-made brackets to overcome
British Dental Journal, 190, 532–6. some of the problems of lingual orthodontics.

References for this chapter canalso befound at www.oxfordtextbooks.co.uk/orc/mitchell4e/. Where possible, these are presented as
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