varians

JADA, Vol. 130, January 1999 73
dramatic rise in adult orthodontic treatment include
increased social awareness of the availability
of orthodontic treatment for adults, an increased
appreciation of how orthodontics can
facilitate other dental treatment to maintain the
dentition, and improvements in orthodontic
appliances.
A key factor in an adult’s decision to seek orthodontic
treatment is the amount and quality
of information available.7 Although most orthodontic
treatment is performed by specialists,
the general dentist plays an important role in
During the past 20 years, orthodontic treatment
for adults has become much more commonplace.1,2
The proportion of orthodontic patients in the
United States who are adults rose from approximately
5 percent in 1970 to a peak of 25 percent in
1990.3-6 During the past few years, the proportion
of adult patients has dropped to around 15 percent,
although the absolute number has remained
constant, at about 600,000. In some areas of the
country, particularly areas with large numbers of
retirees, adults may constitute more than half of
all orthodontic patients.2 Major reasons for the
REFERRING ADULT PATIENTS FOR ORTHODONTIC TREATMENT
THOMAS M. BUTTKE, PH.D.; WILLIAM R. PROFFIT, D.D.S., PH.D.
CLINICAL
PRACTICE
Background. An increasing number of adults
are undergoing orthodontic treatment, but they still
make up only a small proportion of all adults who
could benefit from such therapy. The purpose of this
article is to illustrate the appropriateness and value of
orthodontic treatment in adults.
Methods. The authors review and summarize
previous studies regarding adult orthodontic treatment.
Data from these studies are compared to determine
the prevalence of orthodontic treatment in
adults, the reasons why many adults do not seek treatment
and the outcomes of orthodontic treatment in
adults. In addition, the authors describe a case to
demonstrate how a combination of orthodontic therapy
and orthognathic surgery can facilitate and complement
prosthetic rehabilitation.
Results. Numerous studies indicate that twothirds
to three-fourths of adults possess some form of
malocclusion, yet adults make up only 15 percent of
all orthodontic patients. Reasons given by adults for
not seeking treatment include a lack of awareness
that orthodontic treatment can be performed in
adults, apprehension about possible pain or discomfort
and concern about social acceptance. However,
most patients who underwent orthodontic treatment
reported only mild discomfort of one to two days’
duration, and only 20 percent of patients felt that the
appliances had an adverse social effect. Overall, patients
reported high levels of satisfaction with treatment.
Orthognathic surgery in addition to orthodontics
may be required for the most severe problems,
and is compatible with subsequent fixed and removable
prosthetic treatment.
Conclusions. Adjunctive and comprehensive
orthodontic treatment is feasible for adults of all ages.
Correction of malocclusion makes it possible to improve
the quality of periodontal and restorative treatment
outcomes, in addition to providing psychosocial
benefits.
Clinical Implications. General dentists
are often the first dental professionals to suggest orthodontic
treatment and to refer patients to orthodontic
specialists. Moreover, with the growing emphasis
on cosmetic dentistry, more adults are likely to seek
information regarding orthodontic surgery. This article
provides general dentists with the information
needed to communicate with patients about
treatment.
A B S T R A C T
Copyright ©1998-2001 American Dental Association. All rights reserved.
establishing contact between a
prospective patient and an orthodontist.
It is therefore essential
for general dentists to
understand the indications
and contraindications for, as
well as the consequences of, orthodontic
therapy. The purpose
of this article is to review
adult orthodontic treatment so
that general dentists may be
better prepared to recognize
and refer adult patients who
could benefit from orthodontic
therapy.
PREVALENCE OF
MALOCCLUSION IN
ADULTS
Recent studies have shown
that the frequency of malocclusion
in adults is quite similar
to, or greater than, that observed
in children and adolescents.
8 Searcy and Chisick
found that nearly 77 percent of
U.S. Army recruits had a malocclusion
that could benefit from
orthodontic treatment, and 16
percent of recruits were judged
to have a severe or handicapping
malocclusion.9
A more complete picture of
the extent of malocclusion in
U.S. adults was obtained in the
Third National Health and
Nutrition Examination Survey,
or NHANES III, which included
occlusal traits as part of the
oral health component.10,11
According to NHANES III, only
43 percent of U.S. adults have
an ideal incisor overjet of 1 to 2
millimeters, about 50 percent
exhibit excessive overjet, and
about 6 percent exhibit an anterior
crossbite (reverse overjet).
If the ideal overbite is 0 to 2
mm, then one-half of U.S.
adults have either a deep bite
(47.7 percent) or an open bite
(3.3 percent).11 U.S. adults also
frequently exhibit significant
crowding and misalignment of
maxillary and mandibular incisors,
posterior crossbites and
maxillary diastemas.
Similarly, the prevalence of
malocclusion in western
European adults is between 40
and 76 percent.12,13 Crowding is
the predominant intra-arch
problem in adults in the United
States and western Europe, followed
by spacing, crossbites and
rotated teeth (Figure 1).11 It is
interesting to note that crowding
and rotation are more
prevalent in women than in
men. Collectively, data from
NHANES III and western
European studies suggest that
two-thirds to three-fourths of
adults possess some form of
malocclusion. Therefore, many
adult dental patients might
benefit from the same type of
orthodontic treatment commonly
provided to younger
patients.3
TYPES OF ORTHODONTIC
TREATMENT
What types of orthodontic treatment
are available? Adult orthodontic
treatment can be classified
as adjunctive or
comprehensive.14 Adjunctive orthodontic
treatment is the
movement of teeth to facilitate
other dental procedures necessary
to control disease and restore
function (See Box, “Types
of Adult Orthodontic Treatment”).
For example, when
teeth are crowded, rotated or
misaligned, plaque control may
be more difficult, leading to increased
incidence of caries or
periodontal disease. Adjunctive
treatment is also performed to
establish a favorable crown-toroot
ratio and vertical orientation
so that occlusal forces are
transmitted along the long axis
of the tooth.14
Other problems treatable by
adjunctive orthodontic treat-
74 JADA, Vol. 130, January 1999
CLINICAL PRACTICE
Crowding
Spacing
Crossbite
Deep Bite
Tipped Teeth
Rotated Teeth
Open Bite
0 5 10 15 20 25
PERCENTAGE OF POPULATION SAMPLED
CHARACTERISTIC
Men Women
Figure 1. Occlusal characteristics in U.S. adults (based on data from
Proffit and colleagues11).
Collectively, data
from NHANES III and
western European
studies suggest that
two-thirds to threefourths
of adults possess
some form of
malocclusion.
Copyright ©1998-2001 American Dental Association. All rights reserved.
ment include excessive wear,
pulpitis associated with occlusal
trauma, drifting teeth
after extractions or bone loss,
insufficient tooth structure,
crossbite or misalignment of
anterior teeth. Successful
placement of implants to support
restorations is often easier
and more successful if adjacent
teeth are first repositioned.
Because the goals of adjunctive
therapy are usually limited, orthodontic
appliances typically
are required in only a portion
of the dental arch, and treatment
generally requires only a
few months to complete. Adjunctive
treatment is often appropriately
carried out in the
general dental practice. Thus,
the general practitioner should
be able to both identify the
need for adjunctive treatment
and perform it.
The objectives of comprehensive
orthodontic treatment are
to achieve the best balance between
dental and facial esthetics,
ideal occlusal relationships
and long-term dentoalveolar
stability. Consequently, complete
fixed appliances are used
to reposition all, or nearly all, of
the teeth in one or both arches.
Comprehensive treatment typically
takes longer than 18
months to complete and usually
is carried out by an orthodontic
specialist.
INDICATIONS FOR
COMPREHENSIVE
ORTHODONTIC
TREATMENT
Comprehensive orthodontic
treatment is indicated for malocclusions
that lead to unacceptable
esthetics, reduced masticatory
function or increased
trauma that predisposes a patient
to caries or periodontal
disease. Few definitive associations
have been made between
malocclusion and compromised
oral health, but some specific
relationships have been documented
(for example, traumatic
injury to protruded incisors and
periodontal breakdown due to
deep, impinging overbite).
Although the subject is controversial,
there also may be an association
between temporomandibular
dysfunction and
Class III malocclusion, crossbites
or open bite.8 In one study,
approximately one-third of the
adult patients who sought orthodontic
treatment had functional
complaints related to a
malocclusion.7
In today’s society, a person’s
dentition is an important component
of facial attractiveness,
which can markedly affect his
or her self-esteem and selfimage.
Several studies have
found that nearly one-half of
adults sought orthodontic care
of their own volition, and for
most the primary motivation
was to improve their dental and
facial appearance. Other factors,
in decreasing order of importance,
included psychosocial
factors, dental/periodontal
health, occlusion/function, general
health and speech.1,7,15,16
Although some adults may seek
treatment for unrealistic psychosocial
reasons (for example,
trying to sustain a troubled personal
relationship or to obtain a
job), studies have shown that
most adults who seek orthodontic
treatment have a positive
self-image and reasonable expectations
regarding the
outcome.3,12
According to Gottlieb and colleagues6
and Breece and
Niebeg,15 even when adults were
self-motivated to undergo orthodontic
therapy, one-half to
two-thirds relied on their general
dentist to provide the necessary
referral. Thus, general
practitioners can play an integral
role in identifying adult patients
who might benefit from
orthodontic treatment, as well
as in arranging orthodontic consultation
for patients who have
JADA, Vol. 130, January 1999 75
CLINICAL PRACTICE
TYPES OF ADULT ORTHODONTIC TREATMENT.
To facilitate disease control
and restoration of function
To achieve ideal occlusion
General dentist Orthodontic specialist
One or both arches
Eight to 36 months
Less than a full arch
Six months or less
Extrusion
Molar uprighting
Space redistribution
Incisor alignment
Open bite
Deep bite
Class II or Class III
malocclusion
Skeletal excess or deficiency
ADJUNCTIVE TREATMENT COMPREHENSIVE TREATMENT
Goal
Performed by
Extent of Appliance
Time Frame
Type of Problem
Copyright ©1998-2001 American Dental Association. All rights reserved.
decided on their own to seek
treatment.
DIFFERENCES BETWEEN
ADOLESCENT AND ADULT
PATIENTS
Although some cranial and facial
growth with associated
changes in arch form and tooth
position occurs in adults, such
growth is of little value in correcting
skeletal and dental malocclusions,
in contrast to the situation
for children and
adolescents. Consequently, for
adults with a skeletal discrepancy
such as a severe Class II
or Class III malocclusion, orthognathic
surgery may be required
or the patient may have
to settle for a result that is less
than ideal. However, for most
patients with Class I malocclusions
(for example, crowding,
spacing), the lack of physical
growth will have little or no impact
on orthodontic treatment
and outcome.
Another important difference
between adults and children is
the increased prevalence of
periodontal disease in adults.3
As mentioned earlier, adjunctive
orthodontic treatment, such
as molar uprighting, is sometimes
done to improve periodontal
health by facilitating access
for oral hygiene procedures or
for restoring optimal dentition
relationships.14 Localized bone
loss does not preclude successful
orthodontic treatment, but it
is essential that periodontal disease
be under control before
comprehensive therapy is
begun. Orthodontic appliances
render plaque control more difficult,
but adult orthodontic patients
tend to be more compliant
in regard to oral hygiene
than children and adolescents.
Bonded brackets rather than
bands are indicated for adults
because of the higher crown
height of their teeth, and this
often results in less plaque accumulation
than that in
younger orthodontic patients.17
Aging is associated with
myriad biochemical changes
that theoretically could affect
the feasibility and duration of
orthodontic therapy. For example,
decreased alveolar vascularity
and blood flow, altered
bone mineralization and in-
76 JADA, Vol. 130, January 1999
CLINICAL PRACTICE
Figure 2. Pretreatment (A and B) and posttreatment (C and D) intraoral views are seen. Note the pretreatment
Class II molar and canine relationships (A) as well as the deep overbite (B) compared with the Class I
relationships (C) and reduced overbite (D) after treatment. C. and D. The patient also underwent prosthodontic
treatment to replace missing teeth with combined fixed and removable partial dentures.
A
C
B
D
Copyright ©1998-2001 American Dental Association. All rights reserved.
creased collagen rigidity have
been associated with aging.2
However, such age-related
biochemical changes have not
been found to impede orthodontic
treatment. Despite the
common perception that orthodontic
treatment takes
longer in adults,1,2 studies often
show no difference in the duration
of treatment for adults vs.
that for adolescents.16,18 Several
studies comparing adult and
adolescent orthodontic patients
during and after treatment
found no significant age-dependent
changes in root length,
gingival blood flow, periodontal
attachment loss or posttreatment
stability.17-21
Chronic medical problems
are more likely to be present in
older patients. As with periodontal
disease, most conditions
do not preclude orthodontic
treatment as long as they are
under control and the patient is
receiving regular medical care.
Orthodontic tooth movement is
affected by some drugs used primarily
by adults, especially
some potent prostaglandin inhibitors
used for arthritis (for
example, indomethacin).22
Inhibitors of bone resorption
used to treat osteoporosis (for
example, alendronate) may also
impede tooth movement.
TREATMENT CONCERNS
OF ADULT PATIENTS
Embarrassment. In studies of
adult patients, Breece and
Niebeg15 and Lew16 asked subjects
why they did not seek orthodontic
treatment; nearly
one-half listed the embarrassment
associated with wearing
appliances as the primary reason.
However, of the adults who
initiated orthodontic treatment,
only 20 percent reported that
they felt the appliances had an
adverse social effect, and family
and friends were usually very
supportive.15,16,23 Increased social
acceptance of orthodontic therapy
in adults associated with the
increase in adult orthodontic
patients has diminished some of
the fears of embarrassment.
Other concerns. Additional
reasons given by some adults
for their reluctance to seek orthodontic
treatment include an
unawareness that adults can
wear appliances, the high cost,
duration of treatment and fear
of pain.16 While it is true that
the duration of comprehensive
orthodontic treatment can be
lengthy, for most patients the
time passes rapidly.23 Orthodontic
treatment can cause
some discomfort, especially immediately
after the appliance
has been placed as well as after
periodic adjustments. In fact, in
recent studies of orthodontically
treated adults, subjects reported
that appliance discomfort
was the worst aspect of
orthodontic treatment.7,16
Nonetheless, most patients described
the discomfort as mild
and lasting no more than two
days.16,23,24 Over-the-counter
analgesics and a soft diet reduce
the level of discomfort.
Design advances. Recent
advances in orthodontic appliance
design have increased
patent acceptance. Today’s
metal appliances are much
smaller and less esthetically objectionable
than the appliances
of even a decade ago. Moreover,
JADA, Vol. 130, January 1999 77
CLINICAL PRACTICE
Figure 3. A. Pretreatment panoramic radiograph. B. Posttreatment panoramic radiograph.
A B
Today’s metal appliances
are much
smaller and less esthetically
objectionable
than the appliances
of even a
decade ago.
Copyright ©1998-2001 American Dental Association. All rights reserved.
transparent ceramic brackets,
which are much less noticeable,
can be used on the facial surfaces
of maxillary anterior
teeth, and lingual appliances
are a possibility in some cases.3
TREATMENT OUTCOMES
To be considered successful, orthodontic
treatment must
achieve the objective and subjective
goals identified at the
start of treatment. We find it
gratifying that in the study by
Breece and Niebeg,15 nearly 100
percent of treated adults said if
they had it to do over, they
would undergo orthodontic therapy
again. In most cases, the orthodontist
identifies the objective
goals, such as a Class I first
molar relationship or an ideal
incisor overlap, and then decides
whether the desired occlusal
relationship has been
achieved.
In contrast, the patient decides
if the subjective aims (for
example, facial attractiveness)
have been accomplished.
Fortunately, there is usually
good correlation between these
two outcome parameters.11
Since most adult patients seek
treatment for esthetic reasons
and to improve self-confidence,
it seems reasonable that their
high degree of satisfaction after
treatment reflects contentment
with the cosmetic and psychosocial
outcomes. Indeed, various
studies have shown that after
orthodontic treatment, adults
possess a more positive selfimage,
an improved body image,
greater self-confidence and better
career opportunities and social
life.16,25
Most adults who complete orthodontic
treatment place considerable
value on their dentition
and are highly motivated
with regard to maintaining oral
hygiene and seeking regular
professional dental care. Thus,
facilitating orthodontic therapy
for adults who can benefit clearly
aids both the patient and the
general dentist.
REPORT OF A CASE
A 42-year-old man was referred
for orthodontic consultation and
treatment after he sought replacement
of his missing upper
anterior teeth. The clinical examination
by one of us (W.P.)
showed a severe Class II malocclusion
and the absence of multiple
teeth, trauma to palatal
tissues from his impinging overbite,
caries and periodontal disease
(Figures 2, 3 and 4). The
patient’s primary motivation for
seeking treatment was satisfactory
replacement of his upper
incisors and preventing loss of
all his teeth; however, he also
hoped for improved function
and esthetics. The patient was
willing to accept periodontal,
orthodontic, surgical and
prosthodontic treatment.
After orthodontic preparation,
and with heavy arch wires
in place for stabilization, we
performed orthognathic surgery
to move the mandible forward
and rotate it downward anteriorly.
The resulting mandibular
changes improved both the an-
78 JADA, Vol. 130, January 1999
CLINICAL PRACTICE
Initial tracing at age 43 years, seven months
Final tracing at age 45 years, three months
Figure 4. Superimposition of pretreatment and posttreatment cephalometric
tracings.
Copyright ©1998-2001 American Dental Association. All rights reserved.
teroposterior and vertical positions
of the chin, and provided
vertical space for appropriate
prosthetic rehabilitation. After
postsurgical orthodontic treatment
to detail intra-arch and
interarch dental relationships,
we replaced missing teeth with
fixed restorations in the upper
arch and a removable partial
denture in the lower arch.
CONCLUSION
Many adults possess a dental
malocclusion that is correctable
by adjunctive or comprehensive
orthodontic treatment. It is no
longer unusual to encounter an
adult wearing orthodontic appliances,
and the majority of
adults who have undergone
treatment report that they are
very pleased with the outcome.
Therefore, general dentists
should not hesitate to recommend
orthodontic treatment to
an adult patient when it is likely
to improve the patient’s dental
or periodontal health, or provide
psychosocial benefits.
Dr. Buttke is a fourth-year dental student
in the School of Dentistry, The University of
North Carolina at Chapel Hill.
Dr. Proffit is Kenan Professor and chairman,
Department of Orthodontics, School of
Dentistry, The University of North Carolina
at Chapel Hill, CB# 7450, Brauer Hall,
Chapel Hill, N.C. 27599-7450. Address
reprint requests to Dr. Proffit.
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JADA, Vol. 130, January 1999 79
CLINICAL PRACTICE
Copyright ©1998-2001 American Dental Association. All rights reserved.

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