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ORTHODONTIC PATIENTS OVER 40: THE RELATIONSHIP BETWEEN
PERIODONTAL BONE LOSS, INCISOR IRREGULARITY, AND ELEVATED
ORTHODONTIC TREATMENT NEEDS
Rustamov Saidakbar Saidislomovich
Assistant lecturer at the Alfraganus University
Email address: saidakbar.rustamov@mail.ru
https://doi.org/10.5281/zenodo.14586362
INTRODUCTION
Orthodontic treatment in adults is becoming increasingly common, even though the
concept is not new. As early as 1723, Pierre Fauchard, one of the pioneers of modern dentistry,
observed that aligning teeth in adults was more challenging compared to children. By the mid-
20th century, the importance of adult orthodontic therapy was recognized in a thesis presented
to the American Board of Orthodontics, which emphasized its necessity to expand orthodontic
care. Victor Hugo Jackson also discussed successful orthodontic treatments in adults aged 40 to
50 in his 1904 textbook. Today, patients aged 40 and older are no longer uncommon in
orthodontic practices and are increasingly seeking treatment for malocclusion correction.
Melsen highlighted the need to differentiate between "young adults," who ideally should
have received treatment earlier, and "older adults," those over 40, who often present with signs
of aging or deterioration. These older adults frequently exhibit secondary malocclusions, which
may have worsened or developed during adulthood, often due to progressive deterioration of
the dentition and periodontium. This underscores the growing importance of collaboration
between orthodontics and periodontics to achieve successful treatment outcomes.
A critical diagnostic link between these disciplines is pathologic tooth migration (PTM),
defined as a change in tooth position resulting from disrupted forces that maintain teeth in their
normal alignment. PTM is often characterized by incisor flaring and has a reported prevalence
of 55.8% among periodontal patients. For many adults, particularly those experiencing anterior
tooth migration, PTM is the primary reason for seeking orthodontic care.
Tooth position is influenced by several factors, including the periodontium, occlusal
forces, soft tissue pressures from the cheeks, tongue, and lips, and various oral habits. Proffit's
"equilibrium theory" suggests that tooth position is maintained by a balance of all forces in its
immediate environment. This balance makes the interaction between orthodontic
malocclusion and periodontal bone levels a key area of interest for both orthodontic and
periodontal research. Recent studies emphasize the need to quantify the relationship between
malocclusion and periodontal bone loss in adult patients.
Study Aims:
To assess periodontal and orthodontic parameters in interdisciplinary patients of
advanced age.
To analyze the impact of alveolar bone loss on incisor irregularity.
To quantify the orthodontic treatment needs of adults in relation to periodontal bone loss.
Patients and Methods
This exploratory, observational, cross-sectional study was approved by Tashkent Medical
Academy (ethics number 3/1/17) and conducted in compliance with the Declaration of
Helsinki. Participation was voluntary, and all patients provided informed consent after being
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fully informed about the study's objectives and design. The report adheres to the STROBE
guidelines for observational studies.
Patients
A total of 126 adult patients were initially screened for participation in the study. All
participants were recruited from the Section of Periodontology at the Department of Preventive
Dentistry and referred to the Department of Orthodontics at the Tashkent Medical Academy for
data collection, which took place between February 2022 and March 2023. Data analysis was
completed by summer 2024 by a single investigator (L.K.).
Of the 126 patients, 118 (51 men and 67 women; mean age: 58.03 years) were included
in the final analysis. Patients were excluded due to lack of interest in orthodontic treatment,
missing anterior teeth, or the need for orthognathic surgery due to severe malocclusion. To
prevent potential bias, no additional controls were included after the initial data acquisition.
Inclusion Criteria:
Age ≥40 years.
Presence of six natural anterior teeth in both the upper and lower jaws.
No history of trauma.
Exclusion Criteria:
Anterior open bite.
History of cleft lip or palate.
Congenital syndromes.
Patients were categorized into three groups based on the severity of periodontal disease,
following the criteria established by the CDC Periodontal Disease Surveillance Working Group:
Group I (Control):
No evidence of moderate or severe periodontitis.
Group II (Moderate Periodontitis):
At least two interproximal sites with clinical
attachment loss (CAL) of ≥4 mm or pocket depth (PD) of ≥5 mm.
Group III (Severe Periodontitis):
At least two interproximal sites with CAL ≥6 mm and
at least one interproximal site with PD ≥5 mm.
Periodontal and orthodontic measurements were taken for each tooth from canine to
canine in both the upper and lower jaws. Figure 1 illustrates digitized orthodontic casts for the
three patient groups.
Results
Demographic Data
No statistically significant differences were found in age across the three groups (p =
0.071). The sex distribution was well-balanced among the groups. Orthodontic treatment
during adolescence was documented in 33% of patients. Angle classes were similarly
distributed, with most patients exhibiting Class I malocclusion (Cramer’s V = 0.123; p = 0.46).
Periodontal and Orthodontic Parameters
Statistically significant differences were observed for all periodontal parameters across
the three groups, with values increasing progressively from the control group (Group I) to
Group III (patients with severe periodontitis). The only exception was mandibular gingival
recession, which was slightly higher in Group II (0.55 mm) compared to Group III (0.38 mm).
Similarly, a gradual increase in orthodontic parameter values was observed, with the
lowest values in Group I and the highest in Group III. Significant intergroup differences were
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noted for overjet, and Little's Index for both the mandible and maxilla, while no significant effect
was detected for overbite.
Intergroup Analysis
Intergroup comparisons revealed significant differences for most periodontal
parameters, except for "pocket depth in the mandible" between Group I and Group II and
"recession in the maxilla and mandible" between Group II and Group III, which showed no
statistical significance. The overall trend confirmed progressively worsening periodontal
conditions in patients with severe periodontitis (Group III).
For orthodontic parameters, significant differences in overjet were observed in
comparisons between Group I and Group II, as well as between Group I and Group III. However,
Little's Index for the maxilla and mandible showed no significant differences between Group I
and Group II but demonstrated significantly higher values in Group III compared to the control
group. Comparisons between Group II and Group III showed no significant differences in
orthodontic parameters.
Discussion
With the evolution of modern orthodontics, therapy for adults is rapidly gaining
momentum. Increasingly, not just young adults in their twenties but also individuals over 40
are seeking orthodontic treatment. This shift in patient demographics from children and
adolescents, traditionally the primary patient group, to older adults represents a significant
transformation in orthodontic practice. In light of this trend, two key principles are becoming
increasingly important for orthodontists: (a) the interplay between periodontal health and
orthodontic treatment and (b) the specific orthodontic treatment needs of adult patients.
In this study, 118 orthodontic patients aged 40 and older were categorized into three
groups based on the degree of periodontal bone loss. Periodontal and orthodontic parameters
were analyzed to explore the relationship between periodontal health and orthodontic needs.
Periodontal Parameters
Clinical attachment loss (CAL) was used as the primary periodontal parameter, enabling
a clear distinction between the control group, patients with moderate periodontitis, and those
with severe periodontitis. Significant differences in CAL were observed in both the maxilla and
mandible among the groups. These findings align with the criteria established by the Centers
for Disease Control and Prevention (CDC) and the American Academy of Periodontology (AAP),
which define CAL thresholds of ≥6 mm for severe periodontitis and ≥4 mm for moderate
periodontitis. CAL is recognized as the gold standard for periodontal diagnostics due to its
accuracy in reflecting disease history and progression, making it a more reliable measure than
pocket depth (PD) alone.
The study results further highlight the limitations of using PD as a standalone diagnostic
parameter, particularly in older patients. While significant differences in PD were observed
between patients with severe periodontitis and the other groups, no significant difference was
found between the control group and patients with moderate periodontitis in the mandible,
and only a marginal difference was noted in the maxilla. This disparity can be attributed to the
age of the study population, as gingival recession tends to progress more rapidly than PD in
individuals over 40. Consequently, CAL and PD may not correlate as strongly in this age group
as they do in younger adults.
Conclusions
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Adult patients of advanced age pose unique challenges for interdisciplinary orthodontic
and periodontal treatment. The results of this study, which focused on individuals over 40 years
of age, revealed that:
Greater degrees of periodontal breakdown are associated with more severe overjet and
overbite.
Anterior tooth irregularity in both the maxilla and mandible increases with the severity
of periodontal damage.
Patients with significant periodontal bone loss report a higher need for orthodontic
treatment compared to those without bone loss.
This specific patient group requires increased attention in both clinical orthodontics and
future research to address their complex treatment needs effectively.
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