O R T H O D O N T IO S T H O D O N T I C S                                      C R        Potential Hazards of Orthodonti...
O RT H O D O N T I C S                                                         they deteriorate rapidly in the mouth15    ...
O RT H O D O N T I C S                                             severe root resorption by good               A penetrat...
O RT H O D O N T I C S                                                       perceive a need for a treatment and fully    ...
O RT H O D O N T I C Shigh standard, with the teeth placed in a                  6.    Buyukyilmaz T, Tangugsorn V, Ogaard...
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  1. 1. O R T H O D O N T IO S T H O D O N T I C S C R Potential Hazards of Orthodontic Treatment – WhatYour Patient Should Know PAMELA E. ELLIS AND PHILIP E. BENSON Enamel DamageAbstract: Orthodontic treatment carries with it the risks of tissue damage, treatment Reports of the prevalence of enamelfailure and an increased predisposition to dental disorders. The dentist must be awareof these risks in order to help the patient make a fully informed choice whether to damage after orthodontic treatment haveproceed with orthodontic treatment. This paper outlines the potential hazards and varied (Figure 1). In one cross-sectionalsuggests how they may be avoided or minimized. study, 50% of individuals undergoing orthodontics had a non-developmental Dent Update 2002; 29: 492–496 enamel opacity, compared with 25% of controls.1 Another study found that,Clinical Relevance: A high proportion of adolescent patients are considering orundergoing orthodontic treatment. It is important that they understand the potential even 5 years after treatment, orthodonticrisks of wearing an orthodontic appliance. patients had a significantly higher incidence of enamel opacities than untreated controls.2 The most important means of preventing demineralization is to ensure that the patient’s oral hygiene is of aA lthough orthodontic treatment has recognized benefits, includingimprovements in dental health, function, involved can he or she make a fully informed choice and consent to go ahead. high standard throughout treatment. Fluoride is a well established anti- cariogenic agent and several methods ofappearance and self-esteem, orthodontic Some patients are more at risk than applying fluoride have been used duringappliances can cause harm. The decision others; they need to be identified early orthodontic treatment to minimize thewhether to proceed with orthodontics and managed appropriately to avoid risk of demineralization.requires comparison of the potential adverse sequelae. The GDP’srisks with the potential benefits. contribution is crucial, even if he or she Topical Application It is important that general dental does not fit orthodontic appliances, in Daily use of 0.05% sodium fluoridepractitioners (GDPs), even if they do not helping to ensure that braces are properly mouthrinse has been shown to beundertake orthodontic treatment maintained by reinforcing oral hygiene effective,3 although only about 50% ofthemselves, are aware of these risks. and preventive measures. The GDP may patients complied with daily rinsing. TheThe GDP usually initiates the also help in an emergency if a wire or worst compliers are often those patientsorthodontic referral and a patient will bracket is causing soft-tissue damage. with poor oral hygiene who are most inoften seek their reassurance, after the The potential hazards of orthodonticconsultation with an orthodontist, about treatment are three-fold:whether to go ahead with treatment.Only when the patient is informed about l tissue damage;the reason for treatment and the risks l treatment failure; l greater predisposition to dental disorders. Pamela E. Ellis, BDS, MSc, FDS, MOrth, Specialist Registrar in Orthodontics, and Philip E Benson, PhD, FDS (Orth), Senior Lecturer/Honorary TISSUE DAMAGE Consultant in Orthodontics, Orthodontic Both intra-oral and extra-oral tissues are Department, Charles Clifford Dental Hospital, at risk of damage during orthodontic Sheffield. Figure 1. Generalized enamel demineralization treatment. following orthodontic treatment.492 Dental Update – December 2002
  2. 2. O RT H O D O N T I C S they deteriorate rapidly in the mouth15 (Figure 2). Other devices have been developed that release small amounts of fluoride over a sustained period of time, possibly up to 6 months, before having to be replaced.16 Enamel FracturesFigure 2. Appearance of a fluoride-releasing Occasionally small cracks in the enamel Figure 4. A patient with previous periodontalelastomeric ligature (upper right lateral incisor) surface are seen following removal of disease seeking orthodontic treatment to correctafter 6 weeks in the mouth. orthodontic brackets. Such cracks the drifted incisors. The periodontal disease is now under control and oral hygiene is excellent. provide stagnation areas for theneed of mouthrinse. development of caries, cause partial Other topical applications, including tooth fracture, or may discolour.17stannous fluoride mouthrinse,4 Zachrisson et al.17 found that thestannous fluoride gel5 and fluoride prevalence of pronounced cracks invarnish,6 have been employed but each relation to the total number of cracks wasrequires adequate compliance from the 6% for debonded/banded teeth and 4%patient to work. for untreated teeth. There were appreciably more cracks with chemicallyFluoride-releasing Materials bonded ceramic brackets.18Given the poor compliance with patient-applied measures, attempts have beenmade to use materials that release Periodontiumfluoride over a period of time. Fluoride- Following placement of a fixed appliancecontaining composite resins have not there is gingival inflammation in almost allbeen found to be effective at reducing orthodontic patients (Figure 3).demineralization,7–9 but both compomer10 Fortunately, this inflammation is usually Figure 5. Radiograph of anterior teethand glass-ionomer cements11 have. transient and does not lead to attachment during orthodontic treatment showingHowever, glass-ionomers are weaker than loss.19–21 Gingival hyperplasia can be a blunting of the lateral incisor apex, which iscomposite resin and consequently there problem around orthodontic bands, characteristic of orthodontic-induced root resorption.is a higher number of bracket failures with leading to pseudo-pocketing and givingsuch materials.12 This problem may be the illusion of attachment loss; however,solved with the development of stronger this usually resolves within weeks ofresin-reinforced glass-ionomer materials. debanding.22 contraindicated in this group, provided Evidence suggests that fluoride- Adult patients may be at risk of the disease is controlled and the patientreleasing elastomeric ligatures may periodontal problems, particularly is sufficiently motivated and dextrous toreduce the prevalence of patients who seek orthodontic treatment maintain excellent oral hygiene duringdemineralization,13,14 although the because of pre-existing periodontal treatment.23 Three-monthly periodontaladdition of fluoride to elastics may disease (for example drifting incisors; checks and routine scaling and polishingaffect their physical properties so that Figure 4). Orthodontic treatment is not are advisable. The orthodontist will often modify the mechanics for these patients by keeping the forces light in view of the shortened root support. Other patientsa b who require particular attention are those with systemic diseases such as diabetes or epilepsy, particularly poorly controlled diabetics and the epileptics whose seizures are controlled by phenytoin- based drugs, which can cause gingival hyperplasia. Particular periodontal problems can occur with certain types of treatment – Figure 3. Oral hygiene, which was excellent before treatment (a), has deteriorated (b): plaque accumulation and marginal gingivitis can be seen. for example, in the Class III patient who has appliances prior to orthognathic Dental Update – December 2002 493
  3. 3. O RT H O D O N T I C S severe root resorption by good A penetrating eye injury may not cause pretreatment assessment of root shape immediate pain, but the oral bacteria and length. For at-risk individuals, multiply and the eye can be lost due to precautions can be taken either before overwhelming infection.32 To minimize treatment to modify the plan or during the risk of injury, headgear now has treatment to change the mechanics used. safety features that stop it being accidentally displaced or recoiling back into the face or eyes (Figure 7). Patients Pulp Damage should be given both verbal and writtenFigure 6. Mucosal trauma caused by a Orthodontic patients may suffer from safety instructions after fittingremovable appliance component. transient pulp ischaemia, causing pain headgear.33 and discomfort in the first few days after adjustment of an appliance. This usuallysurgery, the lower incisors are often settles within a week, although pulp Damage from Orthodonticdeliberately proclined, which may lead death following orthodontic treatment is Materialsto gingival recession or even gingival occasionally reported.31 If appropriate Orthodontic materials can induceclefts.24 Previously it was feared that treatment mechanics and forces are allergic reactions.closure of extraction spaces, particularly used, pulp damage is unlikely to be awhen the lower first premolars are lost, significant problem. Nickelmay lead to bunching of the gingival Nickel hypersensitivity affects three intissues and hence long-term periodontal ten of the general population,34 andproblems25 but this is not usually the Soft-tissue damage nickel is found in stainless steel wires,case. Intra-oral and extra-oral soft tissues bands, brackets and headgear. Patients can be damaged in two ways: become nickel sensitive due to previous contact with jewellery, glasses andRoot Damage l direct damage by removable or fixed watches34 and may develop dermatitis inRoot shortening is almost inevitable in components (Figure 6); response to direct contact withpatients with fixed appliances (Figure 5). l indirect damage by allergic headgear. Females are most susceptible,Fortunately this is usually minimal, reactions to nickel and latex. perhaps due to ear piercing.affecting the apical 1–2 mm only. Such For sensitive patients, exposedresorption should not compromise the Patients may suffer from mouth ulcers, metalwork should be covered with tapelong-term health of the teeth.26 More due to rubbing of the lips and cheeks on or plasters or headgear usesevere resorption, where more than a brackets, bands or cleats, as they discontinued. Intra-oral signs andquarter of the root length is lost, occurs become accustomed to fixed appliances. symptoms of nickel hypersensitivity arein only 3% of patients.27 Fortunately, the oral tissues quickly rare because the concentrations of Risk factors associated with an toughen up to a new appliance, but nickel necessary to provoke a reactionincreased incidence and severity of root whilst this is occurring vegetable wax in the mouth are higher than thoseresorption include the pre-treatment root can be used to give temporary relief. needed on the skin.35 Intra-oral signs areform or length, previous dental trauma Occasionally, palatal or lingual arches highly variable and difficult to diagnose,and the type of mechanics used. Teeth may cause trauma to the palate or for example erythematous areas36 orwith blunted, pipette-shaped, or short tongue. severe gingivitis in the absence ofroots are at increased risk of Some individuals continually damage plaque.37 Because such signs andresorption.28,29 Root-filled teeth are not their appliances leading to extra,necessarily at greater risk of root unscheduled appointments andresorption and may safely be moved prolonged treatment times. It helps tousing orthodontic appliances, providing: recognize these patients early, counsel them about diet and habits and takel teeth are clinically symptomless and extra precautions, such as placing bands radiographically satisfactory; rather than bonds.l it is 6 months after a new root filling;l a radiograph is taken 6 months after The Use Of Headgear the start of active treatment.30 Headgear can cause injury if it is Figure 7. NiTom safety headgear bow (Ortho displaced either during sleep or rough Kinetics Corp, Vista, CA, USA). This has an The orthodontist should employ play. The headgear bow is not only additional arm that clips over the headgear bowsensible measures to minimize the risk of sharp but also covered in oral bacteria. distal to the molar tube.494 Dental Update – December 2002
  4. 4. O RT H O D O N T I C S perceive a need for a treatment and fully Treatment may also fail because the appreciate their commitment – treatment diagnosis and treatment plan were times of approximately 2 years, followed incorrectly formulated, for example in a by a lengthy period of retention. They Class III patient where simple treatment must demonstrate good oral hygiene fails due to continued growth. We can and be free from active dental disease at minimize the number of occasions when the start. treatment goals are not met through A patient’s motivation to maintain good record taking and recognition of good oral hygiene throughout treatment our own limitations.Figure 8. Poor oral hygiene and can decline. This may lead to earlydemineralization has forced early discontinuation removal of appliances to avoid damageof treatment. There is residual spacing, cross-bite, to the teeth and supporting structures. Relapseincreased overbite and overjet. When patients request their appliances Teeth placed in an unstable position to be removed early for personal during orthodontic treatment have asymptoms are difficult to spot, nickel reasons treatment goals cannot be met. high potential for relapse. Furthermore,allergy in response to orthodontic Sometimes patients have difficulty in certain occlusal traits, such as rotatedappliances may be under-diagnosed. tolerating the appliance most teeth and midline diastemas, have a high appropriate for correction of their probability of relapse. Several long-termLatex malocclusion. In such cases often a reviews of patients 10 or 20 years afterLatex sensitivity may occur in response compromised plan can be formulated, orthodontic treatment demonstrate that,to contact with latex gloves or but not always. even with orthodontic treatment of aelastomeric ligatures (modules) andintra- and extra-oral elastics. In the latex-sensitive patient, steel ligatures or self- TISSUE DAMAGEligating brackets may be preferred. The Tissue Problem Treatmenttreatment plan might need to bemodified, avoiding Class II or Class III Enamel Demineralization Oral hygiene instruction; daily fluoride mouthrinses; fluoridated elastomeric ligaturestraction. Fractures Mechanical not chemical bonding (ceramic brackets); careful debonding (especially ceramic brackets)Other Materials Periodontium Gingivitis Good oral hygiene throughout treatmentOther orthodontic materials that may Bone loss Regular periodontal checks and 3-monthly scaling andcause allergic reactions are composite polishing in adult patientsand acrylic. Toxicity is due to Root Resorption Identification of ‘at risk’ individuals; careful use of treatmentunpolymerized material and is greatest mechanicsimmediately following polymerization,although cytotoxicity is still evident 2 Pulp Ischaemia Avoidance of excessive forces; pre-warn the patient Death Caution with heavily restored teethyears after polymerization.38 No-mixadhesives are more toxic than two-paste Soft tissues Iatrogenic damage Careful use of instruments; careful fitting and adjusting ofadhesives.39 appliances to avoid sharp edges TREATMENT FAILURETREATMENT FAILURE Problem TreatmentFailure to complete a course of Incorrect diagnosis Carefully collect full records and documentation at the startorthodontic treatment is frustratinglycommon (4–23%).40 Its sequelae include Incorrect management Keep up-to-date with latest treatment techniquesresidual spacing and malalignment, Patient non-compliance Fully inform patient about treatment times and expectationstraumatic overbite, residual overjet,cross-bite and relapse (Figure 8). INCREASING PREDISPOSITION TO OTHER DISORDERS Treatment may fail through: Disorder Managementl patient non-compliance; Temporomandibular Record signs and symptoms before treatment; advise patients seeking joint disorder treatment for such disorder that there may not be an improvementl incorrect diagnosis; with orthodonticsl incorrect management. Periodontal Maintain good levels of oral hygiene; professional prophylaxis where required It is essential to talk to all orthodonticpatients to establish whether they Table 1. Problems that may occur during orthodontic treatment. Dental Update – December 2002 495
  5. 5. O RT H O D O N T I C Shigh standard, with the teeth placed in a 6. Buyukyilmaz T, Tangugsorn V, Ogaard B,Arends J, 96: 191–198. Ruben J, Rolla G. The effect of titanium 24. McComb JL. Orthodontic treatment and isolatedseemingly stable position, teeth will still tetrafluoride (TiF4) application around orthodontic gingival recession: a review. Br J Orthod 1994; 21:move.41 It is important that patients brackets. Am J Orthod Dentofac Orthop 1994; 105: 151–159.understand that teeth move throughout 293–296. 25. Robertson PB, Schultz LD, Levy BM.life; this is physiological and not 7. Mitchell L. An investigation into the effect of a Occurrence and distribution of interdental fluoride releasing adhesive on the prevalence of gingival clefts following orthodontic movementnecessarily due to relapse. For teeth to enamel surface changes associated with directly into bicuspid extraction sites. J Periodontol 1977;remain straight, some form of indefinite bonded orthodontic attachments. Br J Orthod 48: 232–235.retention will be required. 1992; 19: 207–214. 26. Brezniak N, Wasserstein A. Root resorption 8. Turner PJ. The clinical evaluation of a fluoride- after orthodontic treatment: Part 1. Literature containing orthodontic bonding material. Br J review. Am J Orthod Dentofac Orthop 1993; 103: Orthod 1993; 20: 307–313. 62–66.GREATER PREDISPOSITION 9. Banks PA, Burn A, O’Brien K. A clinical evaluation 27. Kaley J, Phillips C. Factors related to rootTO DENTAL DISORDERS of the effectiveness of including fluoride into an resorption in edgewise practice. Angle OrthodIt has been suggested that orthodontics orthodontic bonding adhesive. Eur J Orthod 1997; 1991; 61: 125–132. 19: 391–395. 28. Linge BO, Linge L. Apical root resorption in uppermay increase the predisposition to 10. Millett DT, McCluskey LA, McAuley F, Creanor SL, anterior teeth. Eur J Orthod 1983; 5: 173–183.certain disorders, including Newell J, Love J. A comparative clinical trial of a 29. 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