Spring 2001 Presentation Summary of the First Annual President's Lecture:

After a special introduction by Dr. John Grubb, PCSO President, the first annual president’s lecturer, Dr. Vincent Kokich, began his presentation with the following question:

Q: What is unique about these six patients?

These individuals are exactly ten years apart in age—from 65 to 15—and many of them were sitting next door in the same busy office at the same time.

• 65-year-old patient showed severe periodontal problems,

• 55-year-old patient had two implants placed as anchorage to erupt teeth using elastics,

• 45-year-old patient extracted two lower central incisors, closing them to create bone,

• 35-year-old patient needed to intrude incisors 5mm prior to restoration,

• 25-year-old patient used implant as an anchorage to intrude some posterior teeth.

Should we treat these adult patients the same as we treat 15-year-old adolescents?

Adults should be managed differently. It can be difficult to give an adult case a careful evaluation as we quickly move from one chair to the next during our orthodontic practice day.

How do we look at adult patients and how should we look at them?

Dr. Kokich identified and discussed eight major differences between adults and adolescents and how we can enhance overall results for our elder patients.

Missing Teeth

Typically, adults show lots of missing teeth while children tend to be completely dentulous.

For example, when an adult patient presents missing two lateral incisors and four premolars, a full mouth reconstruction might be needed. It is difficult for the orthodontist to predict final occlusion in such cases. He advises a diagnostic setup so that the comprehensive orthodontist and the reconstructive restorative dentist can visualize the end result ahead of time in order to achieve the best possible treatment outcome.

Periodontal Disease

Many adults show periodontal disease whereas children are mostly healthy. The orthodontist should realize the possible problems that can result from placing brackets based on the incisal edge or marginal ridge in adult patients who present such periodontal defects.

Dr. Kokich summarized four steps to correctly place brackets on periodontally involved patients:

1. Place the ideal bracket using the cusp tip and marginal ridge as reference,

2. Measure the periodontal defect area using a bitewing X-ray,

3. Make the bracket perpendicular to the root of the tooth, and

4. Equilibrate occlusion.

In adult patients with periodontal defect, leveling using the tooth as a guide, is a disservice. Use the bone-tooth attachment as the guide for leveling adult periodontal patients.

If the bone level is flat, consider enamelplasty or reconstruction rather than intruding or extruding the tooth. Dr. Kokich cautioned that intruding a tooth can create a periodontal bony pocket.

Less Anchorage

Since adults often arrive in your office with missing teeth, you can be faced with insufficient anchorage. In such situations, implants are a good option as they provide additional anchorage for uprighting and/or intrusion of posterior tooth. Dr. Kokich reminded us to do the diagnostic set-up in advance.

Ridge Defect

Adults often have a deficient ridge at the site of a missing tooth. In the case of a missing lower first molar, an implant may not be a good option if the ridge is too narrow. A better plan might be to move a second molar into the narrow ridge. This procedure can create bone and leave a wider ridge posterior to the second molar. Then the implant can be placed in this wider ridge.

In the area of anterior ridge defect, you can gradually extrude a condemned incisor, bringing bone with it. The result is an alveolar ridge that favors the implant placement.

Existing Restorations

Adults who visit orthodontists often have had many restorations. The restorative dentist may have placed an atypically shaped crown to compensate for bad root positions. When you plan treatment, look beyond the crown position. Evaluate bone levels and root positions when you set your goals.

Excessive Wear

Adult teeth are typically worn, not always evenly from one part of the arch to the other. When a patient presents with teeth of different length, do not level the anteriors based on incisor edges but on gingival margin and bone levels. Start with the gingival esthetics, review periapical x-rays, do the set up, confer with the restorative dentist, and then make the plan.

Restorative Treatment Needed

Unlike our adolescent patients, adults often need restorative treatment after orthodontic treatment. We need to carefully prepare the case for any restorative possibility, including an implant.

If lateral incisors are missing, we need to provide proper root space as well as crown space must be created during orthodontic.

The Black Triangle

Because of recession of the papilla, the adult will show more black spaces (the black triangle between teeth and papilla) than adolescents. This is an opportunity to make a welcome esthetic improvement for the patient.

Ideal tooth shape should have a width:height ratio of 3:4. Evaluate tooth shape and the papilla-tooth relationship before assessing black spaces.

Simple solutions for correcting black spaces between teeth are to reshape teeth and close the space (to broaden contact area), or to add or build up teeth if papilla shows a correct ratio in the black space area.

Dr. Kokich concluded by encouraging clinicians in the busy orthodontic practice to be aware of these eight differences between adults and adolescents when treating patients.

As we have grown to expect, Dr. Kokich’s lecture was informative, organized, and very well received. Be sure to take a look at his articles on the topic in Seminars in Orthodontics, Volumes 2(1996) and 3(1997).

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