Adult Orthodontics
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Direct answer
Adults arrive with finished growth, worn or missing teeth, treated or active periodontitis, immovable implants, bone-altering medications and firm opinions about appearance — different biology, different goals. With no growth left, skeletal discrepancies resolve by camouflage (dental correction hiding the skeletal problem) or by orthognathic surgery after presurgical orthodontics that deliberately decompensates the incisors. Periodontal inflammation must be controlled before force is applied; a reduced but healthy periodontium still moves teeth under lighter forces, because bone loss shifts the centre of resistance apically. Much adult work is adjunctive — uprighting molars, redistributing space, forced eruption of fractured teeth — planned backwards from the final restoration.
What you must remember
- Periodontal precondition: inflammation treated and stable (Phase I completed, re-evaluated) before tooth movement — moving teeth in an inflamed periodontium accelerates attachment loss.
- Reduced periodontium: the centre of resistance moves apically, so the same crown force produces a larger moment — forces drop, moments are redesigned, and movement remains possible.
- Adjunctive goals dominate: molar uprighting before bridgework or implants, space redistribution, alignment before veneers, and orthodontic (forced) eruption to expose sound tooth structure of a subgingivally fractured tooth.
- Forced eruption relapses unless the supracrestal fibres are addressed — fiberotomy at the new position, then a stabilization period, before restoration.
- Ankylosis appears in adults, especially in previously traumatised or endodontically treated teeth — an ankylosed tooth will not move.
- Implants do not move: they are planned as the last act of the restorative sequence or exploited as rigid anchor points; bisphosphonates impair bone turnover (and risk MRONJ with surgery), long-term NSAIDs and other prostaglandin inhibitors slow movement, and diabetes and smoking influence periodontal risk — so medications and physician coordination shape the plan.
- Aesthetics-driven mechanics: ceramic, lingual and aligner options trade some control for appearance; TADs replace the headgear adults refuse.
- Retention is longer — often indefinite — with bonded retainers for spaced, periodontally involved or surgically corrected cases.
Uprighting a molar before an implant — an adjunctive walkthrough
A 45-year-old lost the lower left first molar years ago; the second molar has tipped 25 degrees mesially into the space, carrying a deep mesial pocket and collapsing the occlusal plane. The final plan is an implant in the original position, so orthodontics works backwards: upright and distalise the second molar, recreate the implant space, resolve the angular defect the tilting created. Adult biology throughout — light continuous force over a possibly reduced periodontium; a buccal-shelf TAD or a cantilever delivers the uprighting moment without dragging the anterior segment backwards; the spring opens the space while mesial bone remodels. Months later, hold the position during implant integration — implants do not move, so surgery follows orthodontics, maintained by a bonded retainer or a provisional until the crown. The adult method in one case: the restoration defines the target, the periodontium limits the force, the implant defines the sequence.
Where adult cases get damaged
The damage is usually skipped sequence: orthodontic forces in an inflamed periodontium produce rapid attachment loss — the clearest iatrogenic story in the literature; Phase I with re-evaluation precedes any wire. Second, adolescent mechanics transplanted — forces scaled for a full periodontium, or headgear prescribed to a 50-year-old; the adult alternatives are lighter forces, TADs and patience with slower initial movement. Third, the decompensation conversation never happens: the presurgical patient whose incisors are deliberately worsened must be warned beforehand, or consent collapses at the first review. Fourth, the medication history — bisphosphonates make molars refuse to budge and extraction sites heal badly, a pharmacology problem in mechanics clothing. Finally, the promise of perfection: adult treatment finishes in a compromised, restored dentition, and the honest plan says so at the start.
Frequently asked questions
Why are lighter forces used in periodontally compromised adults?
Bone loss shifts the centre of resistance apically, so ordinary crown forces generate larger tipping moments; reducing force magnitude and redesigning moments keeps movement controlled on the reduced support.
What is orthodontic forced eruption used for?
Exposing sound tooth structure in subgingival crown-root fractures — the tooth is extruded a few millimetres, then stabilised (with fiberotomy to prevent relapse) before restoration.
What is presurgical decompensation?
Orthodontically correcting the incisor compensations before orthognathic surgery — which usually worsens the appearance temporarily — so that the jaws can be repositioned to their true skeletal relationship.
Why must implants be placed after, not during, tooth movement?
Implants are ankylosed to bone and cannot be moved orthodontically; placed in the final position after alignment, they also serve as rigid anchor points if planned deliberately.
What caution does bisphosphonate therapy impose?
Impaired bone turnover can arrest tooth movement, and surgical procedures risk medication-related osteonecrosis of the jaw — coordinate with the physician before extractions or surgery.