School of Dental Sciences

Bharatpur, Chitwan, Nepal

Risk and limitations of

orthodontic treatment

Dr Ajay Chhetri
1
Introduction
• All forms of medical and dental treatment have potential risks and
limitations.

• Orthodontic treatment can cause damages to hard and soft tissues.

Department of Orthodontics and Dentofacial Orthopedics-

2
CMC-SODS first batch 2078
 The damages that can happen during orthodontic treatment can be
broadly classified as :-

• Intra-oral risks
• Extra-oral risks
• Systemic risks

Department of Orthodontics and Dentofacial Orthopedics-

3
CMC-SODS first batch 2078
INTRA ORAL RISKS
• Enamel demineralization
• Enamel trauma
• Enamel wear
• Pulpal reaction
• Root resorption
• Periodontal problem
• Allergy
• Trauma

Department of Orthodontics and Dentofacial Orthopedics-

4
CMC-SODS first batch 2078
EXTRA ORAL RISKS
• Allergy
• Trauma
• Burns
• Tempromandibular disorder (TMD)

Department of Orthodontics and Dentofacial Orthopedics-

5
CMC-SODS first batch 2078
SYSTEMIC RISKS
• Cross infection
• Infective endocarditis

Department of Orthodontics and Dentofacial Orthopedics-

6
CMC-SODS first batch 2078
Enamel Demineralization or white spot lesion
• Enamel demineralization, usually on smooth surfaces, is unfortunately a
common complication in orthodontics .

• The teeth most commonly affected are maxillary lateral incisors,

maxillary canines.

Department of Orthodontics and Dentofacial Orthopedics-

7
CMC-SODS first batch 2078
White spot lesion
 The risk of developing WSLs
during orthodontic treatment is
increased for patients with
• Poor oral hygiene
• Poor gingival health
• Extended treatment time
• Inappropriate diet
• Low compliance with
preventive measures.

Department of Orthodontics and Dentofacial Orthopedics-

8
CMC-SODS first batch 2078
Plaque accumulation

Acid production by bacteria

Dimeneralization

Department of Orthodontics and Dentofacial Orthopedics-

9
CMC-SODS first batch 2078
White spot lesion
• Bands and brackets increase the
retention of plaque and food on
smooth tooth surfaces that
would otherwise tend to have a
low prevalence of caries

Department of Orthodontics and Dentofacial Orthopedics-

10
CMC-SODS first batch 2078
Classification
According to Gorelick et al. :
Score 1 = no white spot
formation;
Score 2 = slight white spot
formation (thin rim);
Score 3 = excessive white spot
formation (thicker bands);
Score 4 = white spot formation
with cavitation

Department of Orthodontics and Dentofacial Orthopedics-

11
CMC-SODS first batch 2078
Carious vs Non carious

Department of Orthodontics and Dentofacial Orthopedics-

12
CMC-SODS first batch 2078
Treatment protocol for white spot lesion:-
• First allow natural remineralization
• Low doses of fluoride applications
• If the lesion persists , professional bleaching is indicated.
• If the effect of bleaching is inadequate , microabrasion is an option
• Lastly , direct or indirect veeners can be considered

Department of Orthodontics and Dentofacial Orthopedics-

13
CMC-SODS first batch 2078
• Fluoride-releasing bonding agents have great potential to minimize
decalcification around orthodontic brackets.

Department of Orthodontics and Dentofacial Orthopedics-

14
CMC-SODS first batch 2078
Fluoride Varnish
• Fluoride varnish are protective coating that are painted on teeth to
prevent from cavities.
• Types of fluoride varnish:
Duraphat
Fluorprotector
Carex

Department of Orthodontics and Dentofacial Orthopedics-

15
CMC-SODS first batch 2078
ENAMEL WEAR
• Wear of enamel against both
metal and ceramic brackets
(abrasion) may occur.

• It is common on upper canine

tips during retraction as the cusp
tip hits the lower canine
brackets.

Department of Orthodontics and Dentofacial Orthopedics-

16
CMC-SODS first batch 2078
ENAMEL TRAUMA
• When placing appliances careless use of a band seater can result
enamel fracture.

• Care is required when large restorations are present since these can
result in fracture of unsupported tooth structure.

• Debonding can also result in enamel fracture, both with metal and
ceramic brackets.

Department of Orthodontics and Dentofacial Orthopedics-

17
CMC-SODS first batch 2078
Pulpal Reactions
• Some degree of pulpitis is expected with orthodontic tooth
movement which is usually reversible or transient.

• Rarely it leads to loss of vitality, but there may be an increase in

pulpitis in previously traumatized teeth with fixed appliances

Department of Orthodontics and Dentofacial Orthopedics-

18
CMC-SODS first batch 2078
• Light forces are advocated with traumatized teeth as well as baseline
monitoring of vitality which should be repeated three monthly.

• Transient pulpitis may also be seen with electro- thermal debonding

of ceramic brackets and composite removal at debonding.

Department of Orthodontics and Dentofacial Orthopedics-

19
CMC-SODS first batch 2078
ROOT RESORPTION
• Root resorption is defined as a condition of dental complication
associated with either a physiological or pathological activity of the
tooth resorbing cells, which results in loss of cementum and or dentin

Department of Orthodontics and Dentofacial Orthopedics-

20
CMC-SODS first batch 2078
ROOT RESORPTION
• Some degree of external root resorption is inevitably associated with
fixed appliance treatment, although the extent is unpredictable

• Resorption may occur on the apical and lateral surface of the roots.

Department of Orthodontics and Dentofacial Orthopedics-

21
CMC-SODS first batch 2078
Levander-Malmgren classification for root
resorption
Grade Definition

0 No evidence for resorption

1 Irregular root contour

2 Apical root resorption less than 2 mm

3 Apical root resoption > 2mm and < 1/3 of original root length

4 Root resorption exceeding 1/3 of original root length

• Maxillary incisors are the teeth that are the most susceptible to the
process.

• Following the incisors in susceptibility to resorption in the maxillary arch

are the molars, followed by the canines.
• In the mandibular arch the most resorption-vulnerable tooth is the
canine, followed by the lateral and central incisors.
Root shape
• Among differently shaped root ends, the least resorption was
observed in blunted root ends and the greatest was seen in pointed
or tapered root ends.

• In comparison to the normal root shape, dilacerated roots show the

most resorption followed by pipette- shaped and the incomplete
roots
PERIODONTAL PROBLEM
• Fixed appliances make oral hygiene difficult even for the most
motivated patients, and almost all patients experience some gingival
inflammation.

Department of Orthodontics and Dentofacial Orthopedics-

26
CMC-SODS first batch 2078
• Bands cause more gingival inflammation than bonds, which is not
surprising since the margins of bands are often seated subgingivally.

• Inflammation may covers the headgear tube and hook on the upper
molar band.

Department of Orthodontics and Dentofacial Orthopedics-

27
CMC-SODS first batch 2078
  The use of adjuncts such as
• interproximal brushes
• chlorhexidine mouthwashes
• fluoride mouthwashes and
• regular professional cleaning must be emphasised

Department of Orthodontics and Dentofacial Orthopedics-

28
CMC-SODS first batch 2078
Allergies
• Natural rubber latex and Nickel

• The most common allergic response is a type IV delayed

hypersensitivity reaction triggered by the chemical accelerators used
in the manufacture of latex.

• This causes a localized contact dermatitis, typically associated with a

pruritic eczematous rash.

Department of Orthodontics and Dentofacial Orthopedics-

29
CMC-SODS first batch 2078
Allergies

• Synthetic gloves composed of vinyl or nitrile are available as an

alternative to latex gloves

• The use of orthodontic elastomeric auxiliaries containing natural

rubber latex should be avoided.

Department of Orthodontics and Dentofacial Orthopedics-

30
CMC-SODS first batch 2078
TRAUMA
• Laceration to the gingiva and mucosa.
• Unsupported wire can cause trauma to the cheeks and lips.
• Eye trauma in a patient wearing headgear.
• Design of loops may impinge the tissue in vestibular area

Department of Orthodontics and Dentofacial Orthopedics-

31
CMC-SODS first batch 2078
Department of Orthodontics and Dentofacial Orthopedics-
32
CMC-SODS first batch 2078
TEMPROMANDIBULAR DYSFUNCTION
(TMD)
• Pre-existence of TMD should be recorded, and patient advised that
treatment will not predictably improve their condition.

• Some patients may suffer with increased symptoms during treatment

which must also be discussed at the beginning of treatment.

• Standard treatment regimes may also be indicated e.g. soft diet, jaw
exercises.

Department of Orthodontics and Dentofacial Orthopedics-

33
CMC-SODS first batch 2078
Dark Triangles
• Unesthetic open gingival embrasure as a result of loss of attachment.

• May occur while correcting crowded or rotated anteriors because

contact point moves incisally.

• Also occur due to poor oral hygiene during treatment.

Department of Orthodontics and Dentofacial Orthopedics-

34
CMC-SODS first batch 2078
SYSTEMIC RISKS
• CROSS INFECTION :-Spread of infection between patients, between
operator and patient and by a third party should be prevented.

• Use of gloves, masks, sterilized instruments and 'clean' working areas

are paramount .

Department of Orthodontics and Dentofacial Orthopedics-

35
CMC-SODS first batch 2078
INFECTIVE ENDOCARDITIS
• Patients at risk of endocarditis should be treated in consultation with
their cardiologist and within the appropriate .

• The patient must exhibit good oral hygiene

• Antibiotic cover will be required for invasive procedures such as

extractions, separation, band placement and band removal.

Department of Orthodontics and Dentofacial Orthopedics-

36
CMC-SODS first batch 2078
Emergencies in orthodontics
• Dental pain following appliance placement or adjustment
• Appliance rubbing on lips and cheeks
• Lost elastic or wire module
• Loose Bracket

Department of Orthodontics and Dentofacial Orthopedics-

37
CMC-SODS first batch 2078
• Buccal attachments causing trauma to cheeks
• Loose archwire
• Heaadgear injuries
• Bonded retainers

Department of Orthodontics and Dentofacial Orthopedics-

38
CMC-SODS first batch 2078
Conclusion
•  Clearly there are a number of sources of potential iatrogenic damage
to the patient during orthodontic treatment.

• Individuals should be assessed for risk factors for all aspects of care.

• Good clinical practice, careful patient selection and information on a

patient's responsibility are essential to minimize tissue damage.

Department of Orthodontics and Dentofacial Orthopedics-

39
CMC-SODS first batch 2078
Department of Orthodontics and Dentofacial Orthopedics-
40
CMC-SODS first batch 2078
Department of Orthodontics and Dentofacial Orthopedics-
41
CMC-SODS first batch 2078