Scars in orthodontics


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Scars in orthodontics

  1. 1. SCARS IN ORTHODONTICS INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. INTRODUCTIO N The profession has evolved its set of values with the tacit approval of most clinicians, teachers and researchers. Interestingly a considerable variety of opinion concerning what constitutes “GOOD ORTHODONTICS” has characterised our profession since its beginnings.
  3. 3. THE SCARS ~On teeth ~Supporting structures ~Temporomandibular joint ~Effects of extraction ~Relapse ~Miscellaneous
  4. 4. Effect on teeth ~Enamel ~Dentin ~Pulp ~Cementum
  5. 5. Effects on Enamel ~Initial prophylaxis Bristle brush-10 microns Rubber cup-5 microns
  6. 6. Enamel White Spots ~10% after treatment ~50% increase in white spots ~3.6 % in control group ~Access to flow of saliva ~Distance of bracket to free gingival margin - Gorelick ,1982 AJO
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  8. 8.
  9. 9.
  10. 10.
  11. 11. Prevention ~Mouth Rinse ~Fluoride dentrifice ~Fluoride varnish ~Titanium tetrafluoride -Vanarsdall
  12. 12. DEBONDING Metal brackets ~Hand instrumentation-5-8 m ~Unfilled resins-2-40 m ~Filled resin 10-25 m –High speed 10 m TC bur
  13. 13. Different Debonding scores ~Diamond ~Sandpaper disks & Rubber wheel ~Fine sandpaper disks ~Plain & spiral fluted TC burs - Vanarsdall
  14. 14.
  15. 15. Enamel tearouts ~Depends on type of filler particles Macro-filled 10-30 microns(E-A) Micro-filled 0.2-0.3 microns (reinforcement of adhesive tags) Chemical damage > Mechanical dam.
  16. 16. Clinical implications ~Brackets of mechanical retention ~Avoid scrapping with hand instruments
  17. 17. ENAMEL CRACKS ~Occur as split lines ~Finger shadowing/fiberoptic transillumination ~Multi causal-mechanical/thermal ~Sharp sound denotes enamel cracks
  18. 18. Findings-fiberoptic light technique ~Vertical cracks are common ~Horizontal & oblique few ~No significant difference between prevalence & location ~Maxillary incisors & canines
  19. 19. Clinical implication ~Examine teeth other than canines and centrals-maxillary ~Detect cracks in a horizontal direction ~Reason-lack of ductility in brackets
  20. 20. Adhesive Remnant Wear ~It depends on size, type & amount Of reinforcing filler ~Plaque accumulation over it is Possible ~Undetected when wet due to color resemblance
  21. 21. ADHESIVE REMNANT INDEX 0= No Adhesive 1= Less than half adhesive 2= More than half adhesive 3= All adhesive on tooth with bracket impression -Larry 1997, JCO
  22. 22. Debonding Metal brackets ~Hand Instruments-wide beak/narrow beak pliers- smaller better ~Ultrasonic debonding-force reduced (from 9.2 MPa to .28 MPa), more time ~Electrothermal,can cause pulp damage ~Laser debonding-can cause thermal insult
  23. 23.
  24. 24.
  25. 25. ~TC burs are advised - 1171, 1172 ~Frequency should be less than 30,000 rpm ~The bur should be used in painting motion
  26. 26. Debonding of ceramic brackets ~Slow peeling force ~Compression-fracture of bracket (Clarity brackets) ~Torsional debonding plier ~Rotation ~Slow gradual compression -AJO 1988 SWARTZ
  27. 27.
  28. 28.
  29. 29. Laser debonding ~Causes ablation of resin ~Quick procedure ~Only ill-effect-can cause pupal damage ~Expensive
  30. 30. Conventional Debonding ~Tooth should be supported ~Instrument on the bracket Base ~Pliers lose efficiency as it interacts with ceramic -AJO ,1990 BISHARA
  31. 31. Ultrasonic debonding ~Less enamel damage ~Can be used to remove remnant ~More time consuming ~Wearing of tips ~Need for water ~Soft tissue injury
  32. 32. Electrothermal debonding ~Reduced bracket failure(Bracket/ Adhesive interface) ~Limited clinical applicability ~Pulpal damage ~Mucosal irritation
  33. 33. Improper position of ceramic brackets can cause ~Attrition of the opposing tooth ~Notching
  34. 34.
  35. 35. Effects on dentine ~Tooth sensitivity ~Decalcification ~White spots
  36. 36. Effects on pulp ~Light force – PDL reaction ~Mild inflammatory reaction with Mild pulpitis initially ~H/o trauma=>loss of vitality ~Heavy force=>Undermining resorption ~Endodontically treated-more resorption
  37. 37. ~Banding can cause decalcification after removal ~More common in the anteriors ~Airotor proximal stripping can cause proximal caries and sensitivity at a later date
  38. 38. Root Resorption after Treatment ~Biologic factors Indvidual varitation Genetics Metabolic signals Systemic factors Nutrition
  39. 39. Chronologic age Dental age Gender-not significant Habits-Nail biting, tongue thrusting Tooth structure-Conical Previously traumatised tooth Endodontically treated tooth Alveolar bone density More densemore resorption, Ca level
  40. 40. Specific tooth vulnerability Maxillary teeth>mandibular teeth Maxillary incisors are the most affected Maxillary laterals>maxillary centrals> Mand.incisors>distal root I mand.molar >mand.II bicuspid >maxillary II Bicuspid
  41. 41. Mechanical factors ~Appliances Fixed Vs Removable FA > RA Begg Vs Edgewise Begg light continuous force but resorption seen in Stage III & Intrusion
  42. 42. Magnets – less resorption Intermaxillary elastics-resorption on The side where elastics were used Orthodontic Movement type Intrusion>bodily movement
  43. 43.
  44. 44. Orthodontic Force Degree of force-Higher force= more resorption Continuous Vs Intermittent force Inter.prevents root resorption Jiggling & Occlusal Trauma Poorly aligned dental inclined planes
  45. 45. COMBINED BIOLOGIC & MECH.FACTOR Treatment duration Amount of root loss - 0.9 mm/year Relapse-Overall bone support is a factor Root resorption after appliance removal Active resorption for a week after removal
  46. 46. Other considerations Teeth vitality-Colour does not change Loss of crestal bone and tooth stability Loss of marginal attachment-more detrimental Prediction - radiographs
  47. 47. ROOT FORM
  48. 48.
  51. 51.
  53. 53. Clinical Implications ~Patient should be informed ~Periapical radiographs ~Treatment timing ~Light & intermittent force ~Resorption evident-final goals should be re-evaluated
  54. 54. ~Habits-nail biting,tongue thrust ~Intrusion ~Occlusal traumatisation ~Recognise anatomic & physiological limitations ~Early orthopedic phase-(skeletal) less detrimental
  55. 55. ~Traumatised tooth ~Choice of Different Fixed appliances ~Medical examination & Familial tendency ~Supplement with endodontic, periodontal therapy if resorption -AJO 1993 Wasserstein
  56. 56. MOBILITY & PAIN ~Heavy pressure=Pain as PDL is crushed ~Mild pulpitis soon after orthodontic treatment is started ~Greater force => greater pain ~Light force can prevent pain
  57. 57. Mobility –a moderate increase is Seen during ortho. Treatment ~Heavier forces=>More resorption =>mobility ~All forces should be discontinued until mobility decreases
  58. 58. Effects on Supporting structures ~Gingiva Fibrous enlargement Gingival recession Accumulation of plaque Gingival pocket formation Decrease in width attached gingiva
  59. 59.
  60. 60.
  61. 61. ALVEOLAR BONE ~According to a study cortical bone follows tooth movement as B:T 1:2 in Retraction with tipping 1:2.35 in Retraction with torquing -AJO,1998 Alexander
  62. 62. Effects of alveolar bone height ~Can cause loss of alveolar bone height ~Position of teeth determines the position of the alveolar bone ~Alveolar bone develops with tooth ~Extrusion is similar with eruption ~Intrusion bone height is lost
  63. 63. EFFECTS ON TMJ
  64. 64. ~Sadowsky & Begole (1980) Sadowsky & Pelsen(1984) Orthodontic treatment during adolescence did not increase the risk of TMD later in life
  65. 65. ~Larsson & Ronnerman(1981) Extensive Rx can be done without fear of creating TMD and ortho Rx can prevent TMD ~Janson & Hasund(1981) Early ortho.Rx without extraction may be beneficial to functional disorders
  66. 66. ~Pancherz(1985) Herbst Fixed Functional ApplianceTenderness to palpation initially and Symptoms disappeared after appliance removal ~Smith & Freer(1989) Soft clicks after Rx
  67. 67. ~Nielsen et al (1990) Functional status is not related to TMD Either with Removable appliance or fixed Appliance or extraction therapy. Functional risk is present in persons with occlusal discrepancies
  68. 68. ~Egermark-Eriksson(1990) No significant differences between treated & untreated subjects ~Dibbets & Van der Weele(1991) Original growth pattern rather than Extraction strategy was associated with TMD post-treatment
  69. 69. “ These findings indicate that these signs & symptoms do not progress to serious problems. Ortho Rx did not pose an increased risk for the development of TMD irrespective of extraction / non-extraction therapy”
  70. 70. CONDYLAR POSITION & ORTHO. Ortho. Rx involving bicuspid extractions implicated in producing posteriorly positioned condyle . An internal Derangement may result. Gianelly et al reported no differences between extraction & untreated groups. Condylar position tended to be centered around average but wide variation in position was noted.
  71. 71. TMJ SOUNDS & ORTHO. Rx Occurs in 20-30% of the population and clicks are not associated with pain or discomfort always. Joint sounds or other symptoms may change in character and usually does not progress to degeneration -Wabeke et al 1989
  72. 72. PROGRESSION OF SIGNS/ SYMPTOMS OF TMD Clicking is benign and it does not Progress to serious clinical dysfunction. Symptomatic clicking can be treated Without addressing the position of the Disk.
  73. 73. Joint sounds alone are pathognomonic Of disease and may be present for many years without progression. - Widmer 1989 Joint sounds does not indicate a problem but present a risk factor. No Rx Should be considered in the absence of symptoms -Tallents 1991
  74. 74. ~Greene (1988) A high probability existed that the Emergence of symptoms often associated with a TMD has little or nothing to do with orthodontic therapy.
  75. 75. ~Schligman & Pullinger (1991) They concluded that there is limited role for intercuspal occlusal factors in the cause of TMD. ~Tallents (1991) He concluded that there might not be a strong association between incisal relationships, condylar position & TMD
  76. 76. ~Greene (1988) A prudent orthodontist should Identify and document findings related To the TMJ and mandibular function. Therapy should be modified, gross occlusal Interferences relieved and forces tending To distalise the mandible eliminated.
  77. 77. RAPID PALATAL EXPANSION ~Transmits forces to maxilla through dental tissues & elicits forces on anchor teeth in excess of customary orthodontic force ~It can cause(Graber) Buccal tipping Open bite Non Vitality
  78. 78.
  79. 79. ~Other effects Alveolar dehiscence Fenestration Root resorption - AJO,1982 Langford
  80. 80. EFFECTS OF BICUSPID EXTRACTION ~Narrower smile line ~Pre-maxilla brought in implies diminished support for the upper lip and presents a sunken in appearance ~Retruded chin remains after retraction Class II Div.I case ~The loss in vertical presents a older appearance
  81. 81. ~Retraction of upper resulting in a fish like appearance and nose appears longer (Class II case) ~Extraction shrinks the curve and reduces the fullness of line of sight of the remaining teeth ~The dental arch shrinks ,but the oral opening does not and part of the buccal mucosa of the inner cheek fills in the remaining space
  82. 82.
  83. 83. ~Mesialising the molars in low-angle cases will close the bite and it is not desirable ~Maintenance of contact points is difficult in all cases
  84. 84. A survey was done in 400 cases ~33.5%-open contacts ~48.5% tilted roots adjacent to spaces ~55 % Root resorption ~11 % Anterior open bite
  85. 85. Other untoward effects ~Gingival recession ~Tipping of bicuspids,cuspids & Molars ~Periodontal pockets ~End-end occlusion of molars ~Altered occlusion of molars ~Associated open contacts ~Deep overbite
  86. 86.
  87. 87. ~Loss of VD ~Retroclined lower incisors ~Enamel decalcification ~Loss of lower anteriors due to periodontal disease ~Alveolar bone loss ~Root resorption ~Pulp degeneration ~Roots of adjacent teeth in contact
  88. 88. ~Arch length will decrease ~Intercanine width can return to original or less ~The severity of post-Rx relapse is related to pre-Rx crowding ~Effect of extraction-it overrides facial stability -Witzig, Nanda,Burstone
  89. 89. Effects of incisor extraction(lower) ~In minimal instances of crowding spaces May tend to open ~Generally the most protruded lower incisors are removed the mand. Denture becomes more retro-positioned, hence it is difficult to establish previous relation with Pogonion ~Increase in overbite
  91. 91. Normal Growth, Orthopedic Changes & Relapse ~Rebound towards the original skeletal configuration adds to overall instability of the case
  92. 92. STABILITY AND MANDIBULAR ROTATION DURING TREATMENT ~High incidence of relapse in deep overbite ~Extrusive mechanics can produce rotation and hinging open of the mandible ~Increased VD may maintain itself ~Large interlabial gap
  93. 93. ~Lip pressure can cause crowding ~In high angle cases-true intrusion of anteriors is necessary ~In a growing patient (high angle) the molars should be held without further eruption ~In deepbite-extrusion of posteriors is favorable as there is growth left
  94. 94. ARCH WIDTH & STABILITY ~Expansion of intercanine width can return to original due to cheek pressures,swallowing pressure etc. ~Neuromuscular factor must be taken into account ~In a deep-bite case where the lower cuspid is far away from the cheek musculature can be expanded
  95. 95.
  96. 96. INCISOR POSITION & STABILITY ~The best position for lower incisors is the original position ~In Class II-at the end of Rx the lower lip pressures may allow some protrusion of the lower anteriors ~In Class III-a tight lower lip creates retroclination and crowding ~Stable position is farther back than the Pre-Rx position
  97. 97. The most stable position is the original Malocclusion position as the lip and the tongue adapt to it and the pressures of the musculature The correction of malocclusion may place the relatively stable incisor in a Non-stable position
  98. 98.
  99. 99. INTRA-ARCH FACTORS AND STABILITY ~Rotations should be overcorrected and the soft-tissue should be allowed to adapt ~Fiberotomies may be helpful including early Rx and overcorrection rather than retainers ~Good contact areas and reshaping contact areas is important
  100. 100. FUNCTIONAL OCCLUSION AND STABILITY ~Centric Relation ~Some treated Class II cases can end-up with two intercuspal positions(Sunday bite) This loss of centric is relapse ~The use of elastics (Class II /III) corrects the occlusion temporarily and does not finish in centric relation
  101. 101. The success of an orthodontic patient cannot be evaluated only in centric occlusion, but centric relation using a broad definition must be achieved.
  102. 102.
  103. 103. According to Beyron’s study ~Functional occlusion is important in the stability of the dentition ~Multi-directional chewing=>had minimal migration of teeth ~Sagittal chewers=>flaring of upper incisors
  104. 104.
  105. 105. ~Occlusal interferences may result in passive adaptation such as tooth movement or tooth wear ~Occlusal interferences may result in active adaptation-condylar displacementdue to the absence of neuromuscular adaptation
  106. 106. MISCELLANEOUS ~Ankylosis of impacted teeth Reduced bone support Long clinical crowns Poor gingival attachment Chronic inflammation & pocketing PDL is compromised
  107. 107.
  108. 108. FACE-BOW INJURIES Categories ~Accidental disengagement ~Incorrect handling ~Deliberate disengagement by others ~Unintentional disengagement during sleep
  109. 109. It can cause eye injuries resulting in blindness in some cases It can be prevented by ~Should not be worn while playing ~The head-gear is removed first before face-bow ~Locking face-bows should be checked periodically
  110. 110.
  111. 111.
  112. 112. EFFECTS AFTER SURGERY ~Mandibular advancement can cause Retroposition of the condyle Reduced condylar movement Arthrosis etc ~Le-Fort I can cause Increase in alar base width Flattening of the mid-face Improve the nasal airway resistance(some)
  113. 113. ~Non-vitality of teeth at osteotomy cut Sites ~Relapse tendency etc ~Paraesthesia following injury to the nerves
  114. 114. Miscellaneous ~Radiation exposure due to repeated pre, during & after Rx procedures ~Allergic reactions to acrylic resin, Niti and other archwire materials, latex modules, chain etc ~Injuries to the head during headgear, chin-cup etc ~Damage to hypomineralised teeth
  115. 115. ~Indentations on/or ulcers on the lingual mucosa, floor of mouth etc ~Ulceration of the palatal mucosa in faulty insertion of TPA, Nance buttons, MDA, FFA ~Poor oral hygeine ~Psycho-social factor
  116. 116. INFERENCE 1.Significant differences in treatment Philosophies exist among those who provide orthodontic treatment 2.The need for treatment cannot be objectively defined or determined
  117. 117. 3.In the absence of data on treatment outcomes for any of the currently accepted treatments, but with known cost and possible risks, orthodontic is perceived as having an unacceptably high cost-benefit ratio.
  118. 118. A decision is a conscious intellectual process of choice that results in the acceptance and rejection of alternatives. A patient’s welfare is determined by the decision-making ability of the doctor at least as much as it is by doctor’s technique skill . What is the orthodontist’s concept of decision-making
  119. 119. Given that the desire exists, do we have the information, technique skills,training or practice that are necessary for making conscious, deliberate assessments of options to differentiate between good, better and best ? Patients make certain assumptions concerning the ability of the health professional TO
  120. 120. 1.Distinguish between normal & abnormal 2.Accurately characterize abnormalities by a process of differential diagnosis. 3.Assess the severity of the condition and judge the consequences of intervention versus non-intervention. 4.Identify alternative clinical procedures and know the relative odds in favour of the desired outcome for each option.
  121. 121. 5.Evaluate the relative cost/risk/benefit ratios of each alternative 6.Make a decision that is comprehensible to the patient and best meet the patient’s needs
  122. 122.