RMS Orthodontic residents

1. Clinical Relevance and Management
IATROGENIC EFFECTS OF
ORTHODONTICS
Supervised by : Dr.Ahmad Al-Tarawneh
Dr.Raed Alrbata

2. Root
Damage
Root
Resorption
Pulp
Damage

3. The January/February 2005 issue of the American Association of
Orthodontist’s Bulletin reported that medical malpractice is a significant
problem in the USA today and that patients are filing claims and lawsuits
against medical and dental practitioners, including orthodontists, records of
EARR as an iatrogenic consequence of orthodontic treatment have been
found in some of these claims.
LEGAL ISSUE

4. Root resorption in the permanent dentition is an increasingly rare
complication of orthodontic treatment. Its occurrence may be of little
significance when mild but may be devastating to both patient and operator
when severe.
ROOT RESORPTION

5. • a sustained orthodontic force against a tooth, is great enough to totally
occlude blood vessels and cut off the blood supply to an area within the
PDL
• Blood flow impediment results in hyalinization, also known as sterile
necrosis. During the initial repair phase of the necrosed areas, clast cells
resorb not only the underside of the lamina dura but also the cementum
and dentin.
• Removal of hyalinized tissue leads to removal of cementoid and mature
collagen, leaving a raw cemental surface
HOW IT HAPPENS

6. • if the attack on the root surface produce large defects at the apex, they
eventually become separated from the root surface.
• Shortening occurs

7. • Some degree is inevitable during treatment of Fixed Appliance
• Unpredictable and can be severe 1–5 % of orthodontic patients experience a
severe form of EARR
• Mostly affect
INCIDENCE
2/1 1/2
6/2/1 1/2/6

8. It may be helpful to know how long, on average, the roots of various teeth are
together with crown heights

9. CLASSIFICATIONS

10. A commonly used contemporary classification is that of Levander and
Malmgren (1988) which divides apical root resorption into four categories. In
this classification
• grade 1 indicates an irregular root outline
• grade 2, < 2 mm root resorption (minor)
• grade 3, > 2 mm to one third of root length (severe)
• grade 4, resorption > one third of root length (extreme)

12. All patients should be warned of the possibility of microscopic root
resorption and severe root resorption as part of the informed consent
process. Any particular risk factors should be identified.
There is a strong familial relationship Harris et al.
Suggests that if available records of family members that undergone
orthodontic treatment should be obtained to help quantify risk.
INFORMED CONSENT

13. Årtun J et al. in 2005, reported the results of a multicenter clinical study on
EARR in which maxillary incisor periapical radiographs were obtained in 302
consecutively treated orthodontic patients who had fixed appliances. The
radiographs were taken at three time periods: pre- treatment and 6 and 12
months after appliance placement. The result was that orthodontic patients
with detectable EARR during the first 6 months of active treatment are more
likely to experience resorption in the following 6-month period than those
without such exhibited early EARR.
RISK FACTORS

14. It can be concluded from this study
• that it is critical for clinicians to obtain peri- apical radiographs of
maxillary incisors 6 months after fixed appliance placement of every patient
to identify patients at risk of further EARR.
• genetic predisposition as the major etiologic factor
GENETICS

15. Al-Qawasmi et al. described people homozygous for the IL-1B allele 1 have a
5.6-fold increased risk of EARR greater than 2 mm as compared with those
who are not homozygous for the IL-1B allele 1

16. Patient factors:
1. Race
2. Age
3. Sex
FACTORS
1.Hispanic patients tended
to have more OIIRR than
white patients.
2.In the mixed dentition, patients treated before root formation is
completed experience less root resorption; however, after
treatment, the roots are shorter.
most studies have found little relationship between root
resorption and age.
3.it is generally
accepted that the
effect of sex on root
resorption is trivial and
that neither sex is
more prone OIIRR.

17. systemic diseases may affect EARR. Endocrine disorders, such as
hypothyroidism, hyperparathyroidism and hypopituitarism have all been
implicated in root resorption. High doses of corticosteroids may increase root
resorption while low doses may decrease it.
Alcohol consumption in adults during orthodontic treatment increase root
resorption due to vitamin D hydroxylation in the liver.
Clinically, however, systemic factors will rarely be significant mediators of root
resorption.
SYSTEMIC FACTORS

18. The most vulnerable teeth to OIIRR are:
• maxillary lateral incisors
• maxillary central incisors
• mandibular incisors
• distal root of mandibular first molars
• mandibular second premolars
• maxillary second premolars
TOOTH FACTORS

19. Endodontically treated teeth : less susceptible to root resorption than
normal teeth
Traumatised teeth : If no previous resorption due to trauma it will
behave like normal teeth
Teeth with pre-existing root resorption : These teeth are very much more
susceptible to root resorption As a rough guide, the rate of root resorption seems to
double
Transplanted teeth : Transplanted teeth are no more susceptible to OIIRR
than normal teeth provided the transplant is without complication and the
orthodontist waits three months before attempting tooth movement

20. Tooth shape:
Roots with abnormal shape or size such as , short, blunted, bent (dilacerated)
or pipette shaped roots have a higher susceptibility to OIIRR.

21. teeth with defects or abnormalities of crown formation may also have defects
of root formation that renders them more likely to resorption.
Mirabella and Årtun 1995a showed that diminutive and peg-shaped lateral incisors are
not more susceptible to OIIRR. Kook et al (2003) also confirmed that peg- shaped and
small lateral incisors (those with a smaller mesiodistal width than the mandibular lateral
incisor (Becker et al 1981) are not at more risk of OIRR than normally shaped lateral
incisors.

22. • Hypodontia : occlusal load is not distributed evenly across a sufficient
number of teeth may exhibit root resorption.
• Anterior open bites and Digit-sucking habits have been associated with
increased risk for EARR. This is thought to occur through jiggling forces
from the tongue and lips (forces acting in two different directions)
SPECIFIC MALOCCLUSIONS

23. Tooth movements : bodily movement, intrusion (particularly), palatal
expansion and torque have all been implicated as aggravators of OIIRR.
accentuated or reverse curves of Spee as a treatment of increased overbites results in more
root resorption
TREATMENT FACTORS

24. Camouflage treatment of skeletal problems
• Maxillary incisors torqued in class II patients
• Mandibular incisors tipping in class III patients
First molar torquing against buccal plate to increase anchorage
CORTICAL PLATE
CONSIDERATIONS

25. Although some studies have not found extraction pattern to affect root
resorption, other studies found that patients who had four first premolar
extraction treatment had more root resorption than patients who were treated
non-extraction. Other extraction patterns such as four second premolars, and
asymmetric extractions also showed greater root resorption. Surprisingly,
patients with upper first premolar only extraction patterns did not have levels
of root resorption which were significantly different to the non-extraction
group.
EXTRACTION PATTERNS

26. Heavy forces showed increased amount of root resorption as mentioned
before
LEVEL OF FORCE

27. • Superelastic archwires move teeth more rapidly than stainless steel
archwires, they do so with significantly more root resorption (140%)
probably due to the continuous forces exerted by the superelastic wires
which do not allow time for the root surface to recover from damage; the
intermittent forces delivered by a stainless steel wire do.
• Self-ligating appliance systems : no difference in the amount of root resorption
Pandis N et al(2008)
APPLIANCE SYSTEMS

28. • Patients should be informed of the risk of root resorption through the
informed consent process. Particular risk factors such as pre-existing root
resorption or abnormally shaped roots should be highlighted
• A history from other family members who have had orthodontic
treatment may be helpful in determining any genetic component
• take pre-treatment radiographs and when receiving a transfer case
• encourage patients to stop habits such as nail biting or digit sucking
CLINICAL CONSIDERATIONS

29. • forces should be light and intermittent to allow healing. Longer
appointment intervals may aid this
• keep treatment times a short as reasonably possible
• carefully consider the necessity for biomechanics that unduly stress the
periapical tissues
• consider taking a dentopantomograph six months into treatment to check
both bracket position and incipient root resorption

30. WHEN IT OCCURS

31. • When EARR is detected during orthodontic treatment, it will progress for
as long as the treatment continues, as demonstrated by Årtun et al.
• lighter forces should be applied and alternate upper and lower arch wire
activations, for example, activating once every 2–3 months each individual
arch instead of monthly.
DURING TREATMENT

32. levander et al. in 1994, reported a clinical study evaluating the effect of a
treatment pause on teeth in which EARR was discovered after an initial
treatment period of 6 months with fixed appliances. They found that the
amount of EARR was significantly less in patients treated with a pause of 2–3
months than it was in patients treated without interruption.
PAUSE THE TREATMENT

33. • Once the patient is in the retention phase, EARR ceases and root healing
processes occur, such as remodeling of irregular apical areas, apical
rounding, smoothing of edges, and return to a normal PDL width
• If tooth mobility is present, an intracoronal stabilizer should be bonded
(fixed retainer).
• Keeping a stable occlusion and removing interferences
• Maintenance of excellent oral hygiene and frequent dental appointments
for professional prophylaxis are recommended.
POST TREATMENT

34. Tooth loss due to apical root shortening is rarely reported in the literature.
Many teeth with severe root resorption can be retained in the mouth for
significant lengths of time providing a functional occlusion with excellent
aesthetics
ON TOOTH LONGEVITY

35. The use of teeth with extreme root resorption (> 1/3 of the root length) as
abutment teeth for restorations is contra-indicated.
ON THE USE OF TEETH AS
ABUTMENTS

36. The application of light sustained force to the crown of a tooth should
produce a PDL reaction but should have little if any effect on the pulp. In
fact, although pulpal reactions to orthodontic treatment are minimal, there is
probably a modest and transient inflammatory response within the pulp, at
least at the beginning of treatment
PULPAL DAMAGE

37. • Transiant pulpitis 90% of the patients get pain in the first month
• Rarely leads to loss of vitality
PULP DAMAGE

38. • Traumatized teeth
• Impacted canines
• Carious teeth and heavily restored
• Uncontrolled orthodontics force
• Composite polishing burs/stones
• Electrothermal debonders may cause significant hyperaemia
PREDISPOSING FACTORS

39. In study by Woloshyn H et al in 1994 comparing impacted canines to non-
impacted canines . 21% of impacted had obliterated pulp on radiograph 25%
of them did not respond to electric pulp testing and 3% needed root canal
treatment

40. Uncontrolled tooth movement can observed when incisor teeth were tipped
to an extent that the root apex, moving in the opposite direction ,which
actually moved outside the alveolar process

41. • monitor baseline vitality monthly for teeth at risk
• care when treating previously traumatised/RCT teeth
• use light forces and proper mechanics
• care needed not to overheat teeth when removing composite at debond
• care when using electrothermal debonders, do not heat > 5 degrees for
longer than 5-1 0 seconds, cool tooth with water immediately to counteract
microwave effect
PREVENTION

42. ORTHODONTIC TREATMENT
AND PERIODONTAL HEALTH

43. Gingivitis : Nearly all FA patient will get gingivitis, rarely progresses to
attachment loss
PERIODONTAL INFLAMMATION

44. GINGIVAL ENLARGEMENT

45. • poor oral hygiene
• band ledges
• elastomeric modules
• excessive proclination/expansion of teeth
• host response:
- hormones
- individual variation
CAUSES

46. • gingival enlargement transient resolves within weeks of debond
• bracket placement changes subgingival flora
• bands worse than bonds
• adolescents worse than adults
SHORT-TERM EFFECTS

47. • generally no long-term effects
• mean loss of attachment 0.1mm compared with controls
• 10% of orthodontic patients had significant attachment loss (1- 2mm)
compared with controls, but 50% had NO loss
• patients showed bone loss (0.25mm) but mainly at extraction sites
• decreased bone support in patients compared with controls
• no major periodontal problem related to orthodontic treatment
LONG-TERM EFFECTS

48. GINGIVAL RECESSION

49. FACTORS
• Alveolar bone dehiscence
• Ectopic eruption
• Traumatic overbite
• Smoking
• Para functional habits
• Inappropriate mechanics excessive expansion and proclination

50. PERIODONTAL CARE DURING
TREATMENT

51. No difference in the two methods as long as they are done correctly in terms
of duration and technique
• Brushes that has soft bristles that are fashioned in a V-cut to enable the
bristles to reach over the top of the brackets and make contact with the
tooth surface and gingivae apical to the brackets.
• For patients who do not spend enough time on oral hygiene, electric
toothbrushes may be more effective due to their speedier plaque removal.
MANUAL AND ELECTRIC
TOOTHBRUSHES

52. • no difference in plaque reduction or gingivitis between ionic and a
nonionic toothbrush of the otherwise same design.

53. • Interdental cleaning presents more of a challenge for orthodontic patients.
• With clear instructions and education by dental professionals, and
commitment on the part of the patient, effective flossing can be achieved
using a floss threader
• Manual interdental brushes are effective inter- proximally
• Electric interdental cleaning devices have varying results, and one study
found only a subjective improvement on the part of patients, without any
clinically objective improvement in plaque indices or bleeding upon
probing
INTERDENTAL CLEANING

54. • A recent study found oral irrigators to be effective for plaque reduction
proximally, gingivally, and interproximally, and the study also found that
they result in fewer gingival abrasions than using an electric toothbrush.
ORAL IRRIGATORS
(DENTAL WATER JET)

55. • Studies have found that the use of sustained released chlorhexidine varnish
reduces total bacterial counts in orthodontic patients.
• A study by Boyd found 0.4 percent stannous fluoride to be an effective
adjunct during orthodontic therapy to help reduce gingivitis
CHEMICAL PLAQUE CONTROL

56. using 0.12 percent chlorhexidine for 30 seconds morning and evening resulted
in a reduction in plaque and gingival indices of 64.9 percent and 60 percent,
respectively, and in gingival bleeding by 77 percent.
CHLORHEXIDINE MOUTHRINSES

57. • Ulceration from archwires - distal ends
-long spans
• Displacement of HG
• Initial ulceration from brackets
• Acid burn from etch/SEP
• Thermal burn - hot instrument, electrothermal debonder
• Clumsy instrumentation
MUCOSAL TRAUMA

58. • Careful operating
• Trim or turn in long ends
• Turn in hooks
• Bumper sleeving on long spans of archwires
• Safety straps on HG
• Use of wax as necessary
PREVENTION

59. topical applications for ulceration as necessary
• contain 20 percent benzocaine to relieve intra-oral pain
• a recent study, orthodontic wax combined with slow-release benzocaine for
pain relief was found to reduce pain significantly more than wax alone,
while still providing a physical barrier.
TREATMENT

60. • Soft tissue trauma
• Allergy
EXTRA-ORAL IATROGENIC DAMAGE

61. Headgear Induced
Eyes
• face-bow injury
Skin
• injuries associated with displacement of HG
• bruising associated from neck strap
SOFT TISSUE DAMAGE

62. • safety goggles during fitting and adjustments
• careful adjustments of HG to maintain good fit - not too
tight/loose
• safety products
• clear instructions given to patient/parents regarding wear
and care of HG (written and verbal)
• advise not to play in HG
• any problems to discontinue wear and contact
orthodontist
• advice to seek ophthalmic opinion if trauma occurs
involving the eye
PREVENTION

63. • Nickel
• Bonding agents
• Latex
ALLERGIES

64. Nickel
9 - 28% of population
more common in females
more common extra oral ,usually HG strap 1% of patients experiences
contact dermatitis , and of these, 3% claimed to have rashes with ortho
appliances
ALLERGIES

65. • Patch testing to establish cause
• Tape can be placed around exposed metal of HG to reduce allergic
reactions
• Using nickel free appliances and archwires
• removal of appliance/archwire
TREATMENT

66. The increase in allergic reactions to natural rubber latex over the past two
decades has been accredited to the increased use of latex based gloves and
universal precautions. Disposable medical gloves, particularly powdered gloves
are the main reservoir of latex allergens. Orthodontic elastics used to apply
intermaxillary forces are another potential source of the latex protein. Both
type I and type IV hypersensitivity reactions can occur.
• Almost all orthodontics materials have latex free
alternatives
LATEX

67. SYSTEMIC IATROGENIC EFFECT
OF ORTHDONTICS

68. • new guidelines advise that antibiotic prophylaxis should not be given to
children and adults with structural cardiac: defects undergoing dental
intervention procedures
• chorhexidine (CHX) mouthwash should not be given to patients
BACTERIAL ENDOCARDITIS

69. • no consistent association between having dental procedures and Infective
Endocarditis {IE)
• regular toothbrushing presents greater risk of IE than a
single dental procedure
• clinical effectiveness of antibiotic cover (ABC) not proven
• antibiotic cover may cause more deaths through fatal
anaphylaxis than no ABC
• ABC is not cost effective

70. Patients should be given clear and consistent information including:
• benefits and risks of ABC
• why ABC no longer used
• the importance of maintaining good oral health
• information about symptoms of IE and when to seek help
ADVICE TO PATIENTS

71. • patient to patient
• patient to operator
• Operator to patient
• any source to 3rd party
CROSS INFECTION
TYPES OF CROSS INFECTION

72. • medical history - identify 'at risk' patients
• proper sterilisation/disinfection procedures
• ultrasonic cleaning of tried-in bands reduces but does not completely
eliminate salivary proteins. there is a need to investigate a more effective
method of cleaning
• use cross-infection control measures. e.g. safety googles, gloves, face-masks
• Hepatitis B vaccination
CROSS INFECTION
MEASUREMENTS

74. THANK YOU