British Journal of Orthodontics
ISSN: 0301-228X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/yjor19
A Restorative—Orthodontic Treatment Approach in the Older Patient A. P. Howat B.D.S., Ph.D., F.D.S., D.Orth. & K. Warren B.D.S., F.D.S., D.R.D., R.C.S. (Edin.) To cite this article: A. P. Howat B.D.S., Ph.D., F.D.S., D.Orth. & K. Warren B.D.S., F.D.S., D.R.D., R.C.S. (Edin.) (1991) A Restorative—Orthodontic Treatment Approach in the Older Patient, British Journal of Orthodontics, 18:3, 195-201, DOI: 10.1179/bjo.18.3.195 To link to this article: http://dx.doi.org/10.1179/bjo.18.3.195
Published online: 21 Jun 2016.
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Date: 07 March 2017, At: 09:11
British Journal of Orthodontics/Vol. 18/1991/195-201
Case Report A Restorative- Orthodontic Treatment Approach in the Older Patient A. P. How AT, B.D.S., Pu.D., F.D.S., D.ORTH. 12 Fendon Road, Cambridge CBI 4RT K. WARREN, B.D.S., F.D.S., D.R.D., R.C.S. (EDIN.) Birmingham Dental Hospital, St Chads Queensway, Birmingham B4 6NN Received for publication December 1989
Abstract. This report presents a case requiring a combination of restorative dentistry and orthodontic treatment in a mature adult patient. Occlusal splint and periodontal therapies were used initially. Orthodontic treatment combined the use of the occlusal splint and fixed appliance in the maxillary arch. Sectional fixed appliances were used in the mandibular arch. The final restorations were fixed-movable bridges in the mandibular arch and a removable tooth and mucosal/y borne prosthesis in the maxilla. Retention of the orthodontic result was provided by the fixed prostheses in the lower arch and the continued wear of a full coverage maxillary occlusal splint at night served to prevent relapse of the upper teeth. Index words: Adult Orthodontics, Restorative Dentistry.
Introduction
A genuine desire exists amongst many adult patients to retain their natural dentition. This can lead to complex treatment since occlusal, periodontal, and restorative problems may all be present. Such occlusal problems may be termed secondary malocclusions by orthodontists as they develop or are aggravated by tooth migration during adulthood (Thilander, 1979). The increased demand for sophisticated treatment places greater responsibility on those clinicians carrying out such work. It is essential that operators satisfy both the functional and aesthetic requirements of such patients. The formulation and execution of a treatment plan appropriate to the patient's needs and desires is a prerequisite for successful treatment (Robinson, 1963). The prognosis for improving and maintaining periodontal health, stabilizing the occlusion, and realigning drifted teeth must be investigated prior to the planning of the restorative phase. This paper discusses the treatment of a patient requiring occlusal treatment, periodontal therapy, orthodontics, and fixed and removable prosthodontics. 030I-228X/91/000000+00S02.00
Fro. I
Patient N.N. Aged 60 years. © 1991 British Society for the Study of Orthodontics
196 A. P. Howat and K. Warren
BJO Vol. /8 No. 3
increased space in the maxillary anterior region (Fig. 2), an inability to chew properly, and some mild discomfort in the temporomandibular joint region. There was no relevant medical history and the patient appeared to be highly motivated towards improving her dental health.
The dentition and periodontium . . . . teeth were 77655 45 678 . The remammg Th e mtssmg posterior teeth had been heavily filled with amalgam and vitality testing revealed all the standing teeth to be vital. Periapical radiographs revealed generalized horizontal bone loss, but no caries or periapical pathological change were present (Fig. 3). The oral hygiene was relatively poor, generalized bleeding occurred on probing and increased pocket depths of up to 7 mm were present around@. and[§. The maxillary anterior teeth all exhibited increased mobility. Wear faceting was noticed on most of the teeth, which the patient confirmed was due to a bruxing habit.
FIG. 2 Labial drifting and increased spacing of the maxillary anterior teeth.
The patient A 60-year-old female patient presented at the Restorative Department at Birmingham Dental Hospital (Fig. 1). Her General Dental Practitioner indicated that she was a regular attender. The patient's main complaints were mobile teeth,
(a)
BJO August /991
Restorative/Orthodontic Treatment 197
(a)
(b) (b)
3 Pre-treatment radiograph views. (a) Anterior periapicals. (b) Bitewings. FIG.
The occlusion There were gross irregularities in the occlusal plane, which had resulted from loss of many posterior teeth (Fig. 4a, b) and subsequent tilting and overeruption (Fig. 7a, c). Occlusal examination revealed a small and mainly vertical discrepancy between the retruded contact (R.C.P.) and the intercuspal (I.C.P.) positions. A number of interferences were present on the supra-erupted and tilted posterior teeth despite the presence of adequate anterior guidance. There was spacing in the upper anterior ~egion with proclination of the upper incisors, an JOcreased overjet of 7 mm and an over bite of 3 mm. This loss of posterior occlusal stability may have contributed to the labial drifting of the maxillary anterior teeth. Initial treatment and further assessment A phase of intensive periodontal therapy was organized to assess suitability for further treatment. Procedures included instruction in oral hygiene, and thorough scaling and root planing. At reassessment, improvements in plaque and gingival scores,
FIG. 4 Posterior tooth loss and drifting. (a) Maxillary arch. (b) Mandibular arch.
and pocket depth permitted formulation of a definitive treatment plan. Although there had been a good response to periodontal therapy, pockets of 6 mm depth remained at @. and ~· Diagnostic mounted casts were assessed at this stage and analysis confirmed the clinical findings of a mainly vertical R.C.P. to I.C.P. discrepancy, an uneven occlusal plane, adequate anterior guidance, and several lateral and protrusive interferences. In addition, the degree of malalignment of the remaining posterior teeth and the difficulties in attempting to restore the unstable posterior occlusion without prior orthodontic treatment was demonstrated clearly. Overall treatment plan 1. Occlusal splint therapy followed by occlusal adjustment. 2. Periodontal surgery raising buccal and palatal flaps around 11 and 1§, to facilitate thorough root planing. Replacement of the palatal flap and apical repositioning of the buccal flap to eliminate the remaining two 6 mm pockets.
198 A. P. Howat and K. Warren
BJO Vol. 18 No. 3
(a)
(a)
(b)
(b)
5 Occlusal splint with added hooks for anterior elastic and incisal capping for retention. Mandibular edgewise fixed appliances. (a) Right view. (b) Left view. FIG.
3. Orthodontic treatment. 4. Restoration of the posterior occlusion. 5. Oral health maintenance and retention of the orthodontic result. A heat-cured acrylic resin splint was fitted to the maxillary teeth. It required adjustment on three occasions at weekly intervals, until the mandibular •p.osition stabilized and occlusion with the splint remained unchanged. Occlusal adjustment was then undertaken to eliminate the R.C.P. to I.C.P. discrepancy. This was undertaken so as to establish a reproducible jaw relationship for the orthodontist. Other interferences were not adjusted in view of the impending course of orthodontic treatment. Three montlis following the periodontal surgery the orthodontic treatment commenced. There had been no further discomfort in the temporomandibular joint region following usage of the occlusal splint though bruxing continued to be reported. Orthodontic treatment in a patient of 60 years of age is still rare, consequently there was ~m element of uncertainty about the response of the tooth ·supporting tissues to active orthodontic treatment.
(c)
FIG. 6 I.C.P. completion of orthodontic treatment in the maxilla. (a) Right view. (b) Anterior teeth. (c) Left view.
The health of the periodontium had improved greatly, but there was decreased periodontal support. Root resorption or further loss of periodontal attachment, both of which can occur with orthodontic treatment may have necessitated alternative solutions. It was, therefore, decided to test the patient's response by first undertaking the simple tipping movement required in the maxillary arch. If little detrimental effect occurred the movements to the multirooted teeth required in the mandibular arch would be carried out. The first phase objectives
Restorative/Orthodontic Treatment
BJO August /99/
199
of the orthodontic treatment involving the maxillary arch were: (1) to improve the aesthetics by closing the maxillary diastemata; (2) to establish anterior tooth contact in the retruded position by retracting the maxillary anterior teeth while maintaining the initial degree of overbite. In the second phase the objectives were to deal with the mandibular arch: (1) to level the occlusal plane by uprighting the mandibular molars and extracting [8.
FIG. 7 Mandibular arch at completion of orthodontic treatment and removable retaining appliance.
(a)
(b) FIG.
8 Completion of orthodontic treatment. (a) OPG. (b) Lateral cephalogram.
200
A. P. Howat and K. Warren
(2) to produce blocks of abutment teeth for bridges by moving [45 mesially and 6] distally and uprighting f7. In the maxillary arch plastic siamese 0·0 18" slot Edgewise brackets were bonded to 3211123. Space closure was achieved by using elastic power chain along an increasing diameter of sectional arch wires. The occlusal splint was retained in the mouth and trimmed behind the incisors to allow the space closure and retraction. The acrylic collets around ~were not removed, thus anchoring their position while the incisors were retracted. Change in the vertical position of the upper incisors was controlled by retaining the horizontal incisal aspect of the occlusal splint, as the incisors were retracted. Towards the end of space closure the acrylic was trimmed around~ and a hook fixed to the acrylic side blocks. This allowed an elastic band to be stretched lightly across the brackets to tuck in the maxillary canines. To retain the upper labial segment, after debonding, cold cure acrylic incisor capping was added to the occlusal splint and protrusive and lateral excursions rechecked (Fig. Sa, b). Active treatment of the maxillary arch was completed in 5 months, the result at the end of the
(a)
(b)
FIG. 9 I.C.P.-restorative treatment completed. (a) Right view. (b) Left view.
BJO Vol. 18 No. 3
first phase of orthodontic treatment is seen in (Fig. 6a-c). No adverse response to treatment was found and treatment, therefore, continued in the lower arch. In the mandibular arch, bands with edgewise 0·018" attachments were cemented to 86l457. Space closure and uprighting were achieved in the lower right quadrant with sectional arch wires and power chain. Uprighting of the f7 and bodily movement of [45, to contact [3, were achieved by the use of sectional arches and coil spring (Fig. 5b). Active treatment in the mandibular arch took 5 months. To retain the mandibular teeth following debonding a lower removable appliance was used with cribs for retention and acrylic blocks in the edentulous areas (Fig. 7). The acrylic blocks were adjusted for normal excursive movements. The position of the teeth at the end of both phases of orthodontic treatment are shown in Figs Sa, b. No detrimental tooth resorption or loss of periodontal attachment occurred during orthodontic treatment. During the second phase of orthodontic treatment some of the restorative treatment to the maxillary arch was undertaken including a reduction in length of~ and its restoration. Orthodontic intrusion for the premolar was considered; the prognosis of this tooth was uncertain, because of furcation involvement and it was decided that its reduction was a better option. Additionally restorations were placed in ~ and l§.. At the completion of orthodontic treatment new diagnostic casts were made on which the final restorations were planned. A diagnostic wax-up was undertaken to plan the restoration of a stable posterior occlusion. The mandibular arch was restored using fixed-movable, porcelain fused to metal bridges (Nagasawa and Tsuru, 1973) retained by full coverage restorations on 64l57 (Fig. 9a-b). It was possible to use porcelain occlusal surfaces since the teeth possessed adequate clinical crown heights and there was immediate disclusion on protrusion and lateral excursion. A conventional tooth and mucosally borne removable prosthesis was used to restore the maxillary arch. Orthodontic levelling of the occlusal plane had helped in improving posterior occlusal stability whilst ensuring disclusion during the excursive movements. . Retention of the orthodontic result was provided by the fixed prostheses in the mandibular arch. In the maxillary arch the patient continued to wear a full coverage maxillary occlusal splint at night which served to prevent relapse of the maxillary anterior teeth, and to protect the dentition and restorations from any continuing bruxing activity. Removable retainers, which had been used in the maxillary and mandibular arches at the end of the
Restorative/Orthodontic Treatment
BJO August /991
active orthodontic treatment and for long-term retention in the upper arch, have certain disadvantages when compared with fixed retainers. Thus, if ever mislaid orthodontic relapse can occur, particularly if there is substantial loss of periodontal support. In adults with the necessary commitment to complete the type of complex treatment described, however, a high degree of care of the retainers would be anticipated. Comfort is an important factor for satisfactory retainer wear and an adjusted occlusal splint is likely to be more comfortable than the more traditional Hawley or Begg type removable orthodontic retainers. Summary The patient was delighted with the treatment results. The multidisciplinary approach allowed substantial improvement in the function and aes-
201
thetics. The age of the patient had not precluded successful orthodontic treatment. The problems of retention so often present in the mutilated adult dentition where there is loss of periodontal support, was solved well by the combination of specialist treatments provided. References Nagasawa, T. and Tsura, H. (1973) A comparative evaluation of masticatory efficiency of fixed and removable restorations replacing mandibular first molars, Journal of Prosthetic Dentistry, 30, 263-267. Robinson, H. B. G. (1963) The nature of the diagnostic process, Dental Clinics of North America, 3-8. Thilander, B. (1979) Indications for orthodontic treatment in adults, European Journal of Orthodontics, I, 227-241.
ISSN: 0301-228X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/yjor19
A Restorative—Orthodontic Treatment Approach in the Older Patient A. P. Howat B.D.S., Ph.D., F.D.S., D.Orth. & K. Warren B.D.S., F.D.S., D.R.D., R.C.S. (Edin.) To cite this article: A. P. Howat B.D.S., Ph.D., F.D.S., D.Orth. & K. Warren B.D.S., F.D.S., D.R.D., R.C.S. (Edin.) (1991) A Restorative—Orthodontic Treatment Approach in the Older Patient, British Journal of Orthodontics, 18:3, 195-201, DOI: 10.1179/bjo.18.3.195 To link to this article: http://dx.doi.org/10.1179/bjo.18.3.195
Published online: 21 Jun 2016.
Submit your article to this journal
Article views: 1
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yjor19 Download by: [Tufts University]
Date: 07 March 2017, At: 09:11
British Journal of Orthodontics/Vol. 18/1991/195-201
Case Report A Restorative- Orthodontic Treatment Approach in the Older Patient A. P. How AT, B.D.S., Pu.D., F.D.S., D.ORTH. 12 Fendon Road, Cambridge CBI 4RT K. WARREN, B.D.S., F.D.S., D.R.D., R.C.S. (EDIN.) Birmingham Dental Hospital, St Chads Queensway, Birmingham B4 6NN Received for publication December 1989
Abstract. This report presents a case requiring a combination of restorative dentistry and orthodontic treatment in a mature adult patient. Occlusal splint and periodontal therapies were used initially. Orthodontic treatment combined the use of the occlusal splint and fixed appliance in the maxillary arch. Sectional fixed appliances were used in the mandibular arch. The final restorations were fixed-movable bridges in the mandibular arch and a removable tooth and mucosal/y borne prosthesis in the maxilla. Retention of the orthodontic result was provided by the fixed prostheses in the lower arch and the continued wear of a full coverage maxillary occlusal splint at night served to prevent relapse of the upper teeth. Index words: Adult Orthodontics, Restorative Dentistry.
Introduction
A genuine desire exists amongst many adult patients to retain their natural dentition. This can lead to complex treatment since occlusal, periodontal, and restorative problems may all be present. Such occlusal problems may be termed secondary malocclusions by orthodontists as they develop or are aggravated by tooth migration during adulthood (Thilander, 1979). The increased demand for sophisticated treatment places greater responsibility on those clinicians carrying out such work. It is essential that operators satisfy both the functional and aesthetic requirements of such patients. The formulation and execution of a treatment plan appropriate to the patient's needs and desires is a prerequisite for successful treatment (Robinson, 1963). The prognosis for improving and maintaining periodontal health, stabilizing the occlusion, and realigning drifted teeth must be investigated prior to the planning of the restorative phase. This paper discusses the treatment of a patient requiring occlusal treatment, periodontal therapy, orthodontics, and fixed and removable prosthodontics. 030I-228X/91/000000+00S02.00
Fro. I
Patient N.N. Aged 60 years. © 1991 British Society for the Study of Orthodontics
196 A. P. Howat and K. Warren
BJO Vol. /8 No. 3
increased space in the maxillary anterior region (Fig. 2), an inability to chew properly, and some mild discomfort in the temporomandibular joint region. There was no relevant medical history and the patient appeared to be highly motivated towards improving her dental health.
The dentition and periodontium . . . . teeth were 77655 45 678 . The remammg Th e mtssmg posterior teeth had been heavily filled with amalgam and vitality testing revealed all the standing teeth to be vital. Periapical radiographs revealed generalized horizontal bone loss, but no caries or periapical pathological change were present (Fig. 3). The oral hygiene was relatively poor, generalized bleeding occurred on probing and increased pocket depths of up to 7 mm were present around@. and[§. The maxillary anterior teeth all exhibited increased mobility. Wear faceting was noticed on most of the teeth, which the patient confirmed was due to a bruxing habit.
FIG. 2 Labial drifting and increased spacing of the maxillary anterior teeth.
The patient A 60-year-old female patient presented at the Restorative Department at Birmingham Dental Hospital (Fig. 1). Her General Dental Practitioner indicated that she was a regular attender. The patient's main complaints were mobile teeth,
(a)
BJO August /991
Restorative/Orthodontic Treatment 197
(a)
(b) (b)
3 Pre-treatment radiograph views. (a) Anterior periapicals. (b) Bitewings. FIG.
The occlusion There were gross irregularities in the occlusal plane, which had resulted from loss of many posterior teeth (Fig. 4a, b) and subsequent tilting and overeruption (Fig. 7a, c). Occlusal examination revealed a small and mainly vertical discrepancy between the retruded contact (R.C.P.) and the intercuspal (I.C.P.) positions. A number of interferences were present on the supra-erupted and tilted posterior teeth despite the presence of adequate anterior guidance. There was spacing in the upper anterior ~egion with proclination of the upper incisors, an JOcreased overjet of 7 mm and an over bite of 3 mm. This loss of posterior occlusal stability may have contributed to the labial drifting of the maxillary anterior teeth. Initial treatment and further assessment A phase of intensive periodontal therapy was organized to assess suitability for further treatment. Procedures included instruction in oral hygiene, and thorough scaling and root planing. At reassessment, improvements in plaque and gingival scores,
FIG. 4 Posterior tooth loss and drifting. (a) Maxillary arch. (b) Mandibular arch.
and pocket depth permitted formulation of a definitive treatment plan. Although there had been a good response to periodontal therapy, pockets of 6 mm depth remained at @. and ~· Diagnostic mounted casts were assessed at this stage and analysis confirmed the clinical findings of a mainly vertical R.C.P. to I.C.P. discrepancy, an uneven occlusal plane, adequate anterior guidance, and several lateral and protrusive interferences. In addition, the degree of malalignment of the remaining posterior teeth and the difficulties in attempting to restore the unstable posterior occlusion without prior orthodontic treatment was demonstrated clearly. Overall treatment plan 1. Occlusal splint therapy followed by occlusal adjustment. 2. Periodontal surgery raising buccal and palatal flaps around 11 and 1§, to facilitate thorough root planing. Replacement of the palatal flap and apical repositioning of the buccal flap to eliminate the remaining two 6 mm pockets.
198 A. P. Howat and K. Warren
BJO Vol. 18 No. 3
(a)
(a)
(b)
(b)
5 Occlusal splint with added hooks for anterior elastic and incisal capping for retention. Mandibular edgewise fixed appliances. (a) Right view. (b) Left view. FIG.
3. Orthodontic treatment. 4. Restoration of the posterior occlusion. 5. Oral health maintenance and retention of the orthodontic result. A heat-cured acrylic resin splint was fitted to the maxillary teeth. It required adjustment on three occasions at weekly intervals, until the mandibular •p.osition stabilized and occlusion with the splint remained unchanged. Occlusal adjustment was then undertaken to eliminate the R.C.P. to I.C.P. discrepancy. This was undertaken so as to establish a reproducible jaw relationship for the orthodontist. Other interferences were not adjusted in view of the impending course of orthodontic treatment. Three montlis following the periodontal surgery the orthodontic treatment commenced. There had been no further discomfort in the temporomandibular joint region following usage of the occlusal splint though bruxing continued to be reported. Orthodontic treatment in a patient of 60 years of age is still rare, consequently there was ~m element of uncertainty about the response of the tooth ·supporting tissues to active orthodontic treatment.
(c)
FIG. 6 I.C.P. completion of orthodontic treatment in the maxilla. (a) Right view. (b) Anterior teeth. (c) Left view.
The health of the periodontium had improved greatly, but there was decreased periodontal support. Root resorption or further loss of periodontal attachment, both of which can occur with orthodontic treatment may have necessitated alternative solutions. It was, therefore, decided to test the patient's response by first undertaking the simple tipping movement required in the maxillary arch. If little detrimental effect occurred the movements to the multirooted teeth required in the mandibular arch would be carried out. The first phase objectives
Restorative/Orthodontic Treatment
BJO August /99/
199
of the orthodontic treatment involving the maxillary arch were: (1) to improve the aesthetics by closing the maxillary diastemata; (2) to establish anterior tooth contact in the retruded position by retracting the maxillary anterior teeth while maintaining the initial degree of overbite. In the second phase the objectives were to deal with the mandibular arch: (1) to level the occlusal plane by uprighting the mandibular molars and extracting [8.
FIG. 7 Mandibular arch at completion of orthodontic treatment and removable retaining appliance.
(a)
(b) FIG.
8 Completion of orthodontic treatment. (a) OPG. (b) Lateral cephalogram.
200
A. P. Howat and K. Warren
(2) to produce blocks of abutment teeth for bridges by moving [45 mesially and 6] distally and uprighting f7. In the maxillary arch plastic siamese 0·0 18" slot Edgewise brackets were bonded to 3211123. Space closure was achieved by using elastic power chain along an increasing diameter of sectional arch wires. The occlusal splint was retained in the mouth and trimmed behind the incisors to allow the space closure and retraction. The acrylic collets around ~were not removed, thus anchoring their position while the incisors were retracted. Change in the vertical position of the upper incisors was controlled by retaining the horizontal incisal aspect of the occlusal splint, as the incisors were retracted. Towards the end of space closure the acrylic was trimmed around~ and a hook fixed to the acrylic side blocks. This allowed an elastic band to be stretched lightly across the brackets to tuck in the maxillary canines. To retain the upper labial segment, after debonding, cold cure acrylic incisor capping was added to the occlusal splint and protrusive and lateral excursions rechecked (Fig. Sa, b). Active treatment of the maxillary arch was completed in 5 months, the result at the end of the
(a)
(b)
FIG. 9 I.C.P.-restorative treatment completed. (a) Right view. (b) Left view.
BJO Vol. 18 No. 3
first phase of orthodontic treatment is seen in (Fig. 6a-c). No adverse response to treatment was found and treatment, therefore, continued in the lower arch. In the mandibular arch, bands with edgewise 0·018" attachments were cemented to 86l457. Space closure and uprighting were achieved in the lower right quadrant with sectional arch wires and power chain. Uprighting of the f7 and bodily movement of [45, to contact [3, were achieved by the use of sectional arches and coil spring (Fig. 5b). Active treatment in the mandibular arch took 5 months. To retain the mandibular teeth following debonding a lower removable appliance was used with cribs for retention and acrylic blocks in the edentulous areas (Fig. 7). The acrylic blocks were adjusted for normal excursive movements. The position of the teeth at the end of both phases of orthodontic treatment are shown in Figs Sa, b. No detrimental tooth resorption or loss of periodontal attachment occurred during orthodontic treatment. During the second phase of orthodontic treatment some of the restorative treatment to the maxillary arch was undertaken including a reduction in length of~ and its restoration. Orthodontic intrusion for the premolar was considered; the prognosis of this tooth was uncertain, because of furcation involvement and it was decided that its reduction was a better option. Additionally restorations were placed in ~ and l§.. At the completion of orthodontic treatment new diagnostic casts were made on which the final restorations were planned. A diagnostic wax-up was undertaken to plan the restoration of a stable posterior occlusion. The mandibular arch was restored using fixed-movable, porcelain fused to metal bridges (Nagasawa and Tsuru, 1973) retained by full coverage restorations on 64l57 (Fig. 9a-b). It was possible to use porcelain occlusal surfaces since the teeth possessed adequate clinical crown heights and there was immediate disclusion on protrusion and lateral excursion. A conventional tooth and mucosally borne removable prosthesis was used to restore the maxillary arch. Orthodontic levelling of the occlusal plane had helped in improving posterior occlusal stability whilst ensuring disclusion during the excursive movements. . Retention of the orthodontic result was provided by the fixed prostheses in the mandibular arch. In the maxillary arch the patient continued to wear a full coverage maxillary occlusal splint at night which served to prevent relapse of the maxillary anterior teeth, and to protect the dentition and restorations from any continuing bruxing activity. Removable retainers, which had been used in the maxillary and mandibular arches at the end of the
Restorative/Orthodontic Treatment
BJO August /991
active orthodontic treatment and for long-term retention in the upper arch, have certain disadvantages when compared with fixed retainers. Thus, if ever mislaid orthodontic relapse can occur, particularly if there is substantial loss of periodontal support. In adults with the necessary commitment to complete the type of complex treatment described, however, a high degree of care of the retainers would be anticipated. Comfort is an important factor for satisfactory retainer wear and an adjusted occlusal splint is likely to be more comfortable than the more traditional Hawley or Begg type removable orthodontic retainers. Summary The patient was delighted with the treatment results. The multidisciplinary approach allowed substantial improvement in the function and aes-
201
thetics. The age of the patient had not precluded successful orthodontic treatment. The problems of retention so often present in the mutilated adult dentition where there is loss of periodontal support, was solved well by the combination of specialist treatments provided. References Nagasawa, T. and Tsura, H. (1973) A comparative evaluation of masticatory efficiency of fixed and removable restorations replacing mandibular first molars, Journal of Prosthetic Dentistry, 30, 263-267. Robinson, H. B. G. (1963) The nature of the diagnostic process, Dental Clinics of North America, 3-8. Thilander, B. (1979) Indications for orthodontic treatment in adults, European Journal of Orthodontics, I, 227-241.
