Orthodontic Scars

JIAOMR 10.5005/jp-journals-10011-1299 REVIEW ARTICLE Orthodontic Scars Orthodontic Scars Vinay Reddy, Vijeev Vasudevan, Gowri Sankar, AV Arun, S Mahendra, Mohammed K Khalid ABSTRACT Orthodontic therapy apart from its benefits also has potential risks and limitations in terms of tissue damage. Fortunately, in orthodontics, risks are minimal and infrequent. However, all potential risks and limitations should be considered and addressed when making the decision to undergo orthodontic treatment. Orthodontic treatment carries with it the risk of various types of soft and hard tissue damages (e.g. decalcification of enamel, lacerations, ulcerations, temporomandibular joint disorders, etc.), apart from treatment failure in itself. If correcting a malocclusion is to be of benefit, the advantages offered should outweigh any possible damage. All preventive procedures should be considered during and after orthodontic treatment to restore the normal health of soft and hard tissues. Hence, the orthodontist should be vigilant and prudent enough in assessing and monitoring every aspect of these tissues at any given stage and time in order to achieve a healthy and successful final result. Keywords: Orthodontic scars, Enamel decalcification, Enamel fracture. How to cite this article: Reddy V, Vasudevan V, Sankar G, Arun Av, Mahendra S, Khalid MK. Orthodontic Scars. J Indian Aca Oral Med Radiol 2012;24(3):217-222. Source of support: Nil Conflict of interest: None declared INTRODUCTION Malalignment, crowding, spacing and proclination of teeth have been perennial esthetic problems since ages. Orthodontic treatment has thus become an integral part of the esthetic dentistry in the quest for a perfect smile. Apart from esthetics it also helps some patients by significantly improving mastication, speech, appearance, overall dental health, comfort and self-esteem. However, orthodontic appliances at times can cause harm to the related hard and soft tissues during and after treatment if the orthodontist is not vigilant.1 This potential risk need to be identified early and managed appropriately to avoid such adverse problems. Such damage to the soft and hard tissues that are expressed clinically either intra and/or extra orally are called orthodontic scars. Orthodontic scars may be present during and after treatment and are seldom severe to offset the advantages of treatment. Most of them are reversible damages and are transient in nature on soft tissues. However, the hard tissue damage can be irreversible, resulting in further treatment following the completion of orthodontic therapy as seen in the case of enamel decalcification. Hence, it is imperative that the patient should be addressed about such possibilities prior to orthodontic treatment.2 Orthodontic scars can be broadly classified as follows: 1. Lesions of enamel • Enamel decalcification/white spot lesions • Physical damages on enamel (enamel wear/enamel fractures) 2. Periodontal tissues • Gingivitis/gingival enlargement • Gingival recession • Dark triangles 3. Soft tissues • Direct damage caused by components of removable and/or fixed appliance components: – Removable appliances – Fixed appliances and components causing impingements, ulcerations and lacerations resulting from - Archwires, brackets, bands, etc. - Headgear and face bow, etc. - Loops and utility arches, etc. • Indirect damage by allergic reaction to: – Nickel – Latex • Soft tissue complications related to implants – Ulceration of overlying soft tissue – Peri-implantitis – Fracture during removal LESIONS OF ENAMEL Enamel Decalcification/White Spot Lesions White spot lesions around orthodontic attachments (Fig. 1) is one the most common problem during and after fixed orthodontic treatment.3 Plaque accumulation around the appliance components and bonding materials results in subsequent production of acid by the bacterial plaque resulting in demineralization and alteration in the appearance of the enamel surface. Early lesions appear as opaque, white spots 4 that may progress to caries if demineralization continues without intervention with preventive measures, such as fluoride application and other oral hygiene maintenance protocols. Clinically, they may be clinically detected as early as 1 to 2 months into treatment and their prevalence5 among orthodontic patients ranges from 2 to 96%. The labiogingival area of the central and Journal of Indian Academy of Oral Medicine and Radiology, July-September 2012;24(3):217-222 217 Vinay Reddy et al lateral incisors is the most common site for the white spot lesions while the maxillary posterior segments are the least common sites for their formation.10 Their incidence is found to be more among male patients due to poorer oral hygiene maintenance than females.5,6 The most important means of preventing demineralization is to ensure that the patient’s maintain a high standard of oral hygiene throughout treatment. Fluoride is a wellestablished anticariogenic agent. Topical fluoride applications like 0.05% sodium fluoride, 1.2% acidulated phosphate fluoride mouth rinse (weekly), 0.4% stannous fluoride gel and fluoride varnish can be used to maintain such high standards.7-9 For noncompliant patients, fluoridecontaining cements/bonding agents10 and fluoride-releasing elastomeric ligatures11 can be used for the same. Physical Damages on Enamel (Enamel Wear/ Enamel Fractures) Enamel damage most commonly occurs during debonding of orthodontic brackets. It is more common during debonding of ceramic brackets. The frequently affected areas are–incisal edges of the upper anterior teeth,12 buccal cusps of upper posterior teeth and upper canine tips during debonding. Most commonly, careless use of an orthodontic band seater or band remover or debonding pliers results in enamel fracture (Fig. 1). Care is required especially when large restorations (composite build-up) are present, since these can result in fracture of unsupported cusps and incisal edges. Debonding can also result in enamel cracks that provide stagnation areas for the development of caries.13 Zachrisson found that the prevalence of pronounced cracks in relation to the total number of cracks was 6% for debonded/banded teeth and 4% for untreated teeth. However, there were appreciably more cracks with chemically bonded ceramic brackets.14 Peeling off stroke at the bracket-resin interface is the advocated method of removing brackets and residual bonding agents so as to minimize the risk of enamel fracture. Appropriate dietary advice should be given to minimize tooth substance loss. Carbonated beverages and pure citrus fruit juices are the most common causes of erosion and should be avoided in patients with fixed appliances.15 attachment, etc. The interproximal areas are usually more affected than the facial areas and posterior teeth more than anterior teeth. Gingival hyperplasia/enlargement is generally observed around orthodontic bands, leading to pseudopocketing and giving the illusion of attachment loss (Fig. 2); however, even this condition is transient in nature and usually resolves within weeks of debanding.16-19 Adult patients usually are at higher risk of periodontal problems. Light orthodontics forces are recommended for adult orthodontics. Utmost care should be taken particularly in patients with systemic diseases, such as epilepsy as they may be on phenytoin that causes gingival hyperplasia.20 Gingival Recession Alveolar bone loss and gingival recession in adult orthodontic patients is more common than in normal individuals21 (Fig. 3). Banding induces more gingival inflammation than bonding with composite resins, since they are more plaque retentive and their margins are often placed subgingivally. Gingival recession and loss of alveolar bone have been reported as a result of teeth moving in the presence of inflammation.22 Fig. 1: Post-debonding photograph showing areas of enamel decalcification of anterior teeth and enamel fracture of upper left incisal edge PERIODONTAL TISSUES Gingivitis/Gingival Enlargement Gingival inflammation is the first and foremost immediate clinical tissue response that can be appreciated in almost all orthodontic patients (Fig. 2). It is transient and does not lead to any further complications, such as loss of gingival 218 Fig. 2: Gingival inflammation and enlargement seen between upper right canine and premolar area JAYPEE JIAOMR Orthodontic Scars Dark Triangles Dark triangles may be seen as an unesthetic open gingival embrasure usually between incisors (Fig. 4) during the course of orthodontic treatment due to loss of gingival attachment as a result of periodontal disease or while correcting rotated or crowded anterior teeth.23 Thus, care should be taken to avoid any attachment loss. If such unesthetic areas are observed, they can be treated by removing enamel at the contact point so that the teeth can be moved closer to minimize the space between them. However, care should be taken not to distort the proportional relationships of the teeth to each other in terms of their connector heights. Both, actual and potential black triangles should be noted during examination and the patient should be informed about reshaping the teeth later to minimize the esthetic problem. damage and infection of the eye due to headgear have been reproted.25 Samuels and Jones26 classified the types of headgear injuries based of percentage occurrences: 1. Accidental disengagement of head strap while playing (27%) 2. Incorrect handling (27%) 3. Disengagement by another child (19%) 4. Disengagement while asleep (27%) To reduce the risk of injury, headgears now come with a variety of safety features, which prevent them from causing damage to the face or the eyes. The use of safety bows, rigid necks straps and snap release products are mandatory SOFT TISSUE Intraoral and extraoral soft tissue damage may be discussed under the following headings: Direct Damage caused by Removable and/or Fixed Appliance Components Removable Appliances Retainers given after completion of orthodontic treatment form the bulk of removable appliances. Occasionally the Hawley’s retainer may also be used to correct minor anterior corrections, such as mild spacing or single tooth rotations, crossbite, etc. The acrylic component and wires (retentive clasps, springs, canine retractors, etc.) at times may cause tissue impingement due to sharp edges. Though rare, cases of allergy and toxicity due to the unpolymerzed material of acrylic resin have also been reported.24 To avoid such problems patients should be recalled after 2 weeks to round off any sharp edges or impingements. Fixed Appliance and Its Components Fig. 3: Gingival recession on labial aspect of lower left central incisor Fig. 4: Dark triangle between the central incisors Archwire, Brackets, Bands, Transpalatal Arch Lacerations and ulcerations of the gingiva and oral mucosa occurs often during the initial phase of treatment—insertion of bands, brackets, wires and other auxiliaries (Fig. 5). Keratinization of tissues takes about 2 weeks. Use of dental wax over the brackets and rubber tubing of unsupported wires help reduce pain and discomfort due to trauma caused during this phase.2 Headgear Headgear appliance can cause injury if it is displaced either during sleep or rough play. Most commonly facial skin damage is a result of headgear strap. However, risk of Fig. 5: Ulceration of lip mucosa due to rubbing against lower rightcanine bracket Journal of Indian Academy of Oral Medicine and Radiology, July-September 2012;24(3):217-222 219 Vinay Reddy et al to prevent the bow from disengaging from the molar tubes. Patients should be given both verbal and written safety instructions after fitting the headgear and advised not to wear the appliance while playing outdoor sports. implantation makes them comfortable for the patients. However, potential problems and soft tissue complications are common. The following type of complications can occur with miniscrews: Loops, Utility Arches These are archwires that are often used during orthodontic treatment for space closure, space maintenance or intrusion. Utmost care must be taken during their fabrication as they extend into the vestibular area, which may cause tissue impingement, ulcerations and other types of tissue damage (Fig. 6). Even minor amounts of continuous tissue impingement, if disregarded, may lead to more serious problems like ulceration or tissue hyperplasia around the loop. In extreme situations, the loop may become completely embedded in the hyperplastic tissue requiring surgical excision for removal. Thus, careful fabrication and monitoring of such wire components are essential to avoid such problems. Impingements and Trauma to Soft Tissue Overlying the Implant Implant head being sharp may cause soft tissue damage to the buccal mucosa and/or attached gingiva related to the confined area. Care should be taken by during the implant Indirect Damage by Allergic Reactions Nickel Allergy Nickel hypersensitivity affects three in 10 of the general population. Nickel content is found in orthodontic wires, bands, brackets and headgears.27 However, Intraoral signs and symptoms of nickel hypersensitivity are rare because the concentrations of nickel required to provoke a reaction in the mouth are higher than those needed on the skin as in the case of jewellery and ear piercing. Intraoral signs are highly variable and difficult to diagnose. These include loss of taste or metallic taste, numbness, burning sensation, soreness at the side of the tongue, angular cheilitis (Fig. 7) and erythematous areas or severe gingivitis in the absence of plaque.28 Since such signs and symptoms are difficult to identify, nickel allergy in response to orthodontic appliances may be underdiagnosed. Latex Allergy Fig. 6: Impingement of T-loop on the buccal mucosa showing a T-shaped scar Fig. 7: Nickel allergy Latex sensitivity may occur in response to contact with latex gloves, elastomeric ligatures or intra- and extraoral elastics. The commonest sites affected are the gingivae and tongue, (Fig. 8) but the perioral region may also be affected.29 In latex-sensitive patients, steel ligatures or self-ligating brackets may be used instead of the conventional straight wire brackets and elastic modules and chains.2,27 Soft Tissue Complications related to Implants The introduction of microimplants to orthodontics as a skeletal anchorage option has led to their use in critical anchorage situations. Their simple design and ease in 220 Fig. 8: Latex allergy of the tongue JAYPEE JIAOMR Orthodontic Scars Fig. 9: Implant showing impingement of auxillary wire running from the implant to the second molar placement for its own stability as well as use of auxiliaries with its support, to avoid trauma and subsequent ulceration (Fig. 9).30 Peri-implantitis Peri-implantitis (inflammation of the gingiva around the implant) is as a result of improper oral hygiene maintenance. Patients should be counseled to maintain high level of oral hygiene throughout treatment. Screw Fracture during Removal Applying lateral forces during implant removal can cause fracture. It is important not to wiggle the screwdriver when removing it from the screw head. It is rare if taken out straight. If the micro-implant is left for a very long time, this also could lead to fracture on removal as a result of partial or full osseointegration. Implant failure (mobility/fracture) can also occur if the screw is too narrow or the neck area is not strong enough to withstand the stress of removal.31 The solution is to choose a conical screw with a solid neck and a diameter appropriate to the quality of bone. SUMMARY Most orthodontic scars are transient and self-correcting in nature. One exception to this rule strongly, is enamel decalcification and fractures, which require post-treatment rehabilitation. However, during the course of treatment if these scars are unobserved or untreated, they may cause complications in the form of infections resulting in pain and discomfort. Patient’s oral hygiene maintenance and orthodontist keen observation during recall/review visits is the key to minimize the chances of such scars. REFERENCES 1. Mizrahi E. Risk management in clinical practice. Part 7. Dentolegal aspects of orthodontic practice.Br Dent J 2010 Oct 23;209(8):381-90. 2. Ellis PE, Benson PE. Potential hazards of orthodontic treatment– what your patient should know. Dent Update 2002 Dec;29: 493-97. 3. Maxfield BJ, Hamdan AM, Tüfekçi E, Shroff B, Best AM, Lindauer SJ. Development of white spot lesions during orthodontic treatment: Perceptions of patients, parents, orthodontists, and general dentists. Am J Orthod Dentofacial Orthop 2012 Mar;141(3):337-44. 4. Tanner AC, Sonis AL, LifHolgerson P, Starr JR, Nunez Y, Kressirer CA, et al. White-spot lesions and gingivitis microbiotas in orthodontic patients. J Dent Res 2012 Sep;91(9): 853-58. 5. Sagarika N, Suchindran S, Loganathan S, Gopikrishna V. Prevalence of white spot lesion in a section of Indian population undergoing fixed orthodontic treatment: An in vivo assessment using the visual International caries detection and assessment system II criteria. J Conserv Dent 2012 Apr;15(2):104-08. 6. Zachrisson BU, Zachrisson S. Caries incidence and orthodontic treatment with fixed appliances. Scand J Dent Res 1971;79: 183-92. 7. Behnan SM, Arruda AO, González-Cabezas C, Sohn W, Peters MC. In vitro evaluation of various treatments to prevent demineralization next to orthodontic brackets. Am J Orthod Dentofacial Orthop 2010 Dec;138(6):712. 8. Al Mulla AH, Kharsa SA, Birkhed D. Modified fluoride toothpaste technique reduces caries in orthodontic patients: A longitudinal, randomized clinical trial. Am J Orthod Dentofacial Orthop 2010 Sep;138(3):285-91. 9. Øgaard B, Alm AA, Larsson E, Adolfsson U. A prospective, randomized clinical study on the effects of an amine fluoride/ stannous fluoride toothpaste/mouthrinse on plaque, gingivitis and initial caries lesion development in orthodontic patients. Eur J Orthod 2006 Feb;28(1):8-12. 10. Pithon MM, dos Santos RL, de Oliveira Ruellas AC, Nojima LI, Sant’anna EF. In vitro evaluation of fluoride release of orthodontic bonding adhesives. Orthodontics (Chic) 2011 Winter;12(4):290-95. 11. Miura KK, Ito IY, Enoki C, Elias AM, Matsumoto MA. Anticariogenic effect of fluoride-releasing elastomers in orthodontic patients. Braz Oral Res 2007 Jul-Sep;21(3): 228-33. 12. Chen CS, Hsu ML, Chang KD, Kuang SH, Chen PT, Gung YW. Failure analysis: Enamel fracture after debonding orthodontic brackets. Angle Orthod 2008 Nov;78(6):1071-77. 13. Jones M. Enamel loss on bond removal. Br J Orthod 1980;7: 39-44. 14. Zachrisson BU, Skogan O, Hoymyhr S. Enamel cracks in debonded, debanded, and orthodontically untreated teeth. Am J Orthod 1980;77:307-19. 15. Navarro R, Vicente A, Ortiz AJ, Bravo LA. The effects of two soft drinks on bond strength, bracket microleakage, and adhesive remnant on intact and sealed enamel. Eur J Orthod 2011 Feb;33(1):60-65. 16. Alstad S, Zachrisson BU. Longitudinal study of periodontal condition associated with orthodontic treatment in adolescents. Am J Orthod 1979;76:277-86. 17. Sadowsky C, BeGole EA. Long-term effects of orthodontic treatment on periodontal health. Am J Orthod 1981;80: 156-72. 18. Polson AM, Subtelny JD, Meitner SW, et al. Long-term periodontal status after orthodontic treatment. Am J Orthod Dentofac Orthop 1988;93:51-58. Journal of Indian Academy of Oral Medicine and Radiology, July-September 2012;24(3):217-222 221 Vinay Reddy et al 19. Zachrisson BU. Cause and prevention of injuries to teeth and supporting structures during orthodontic treatment. Am J Orthod 1976;69:285-300. 20. Devanna R, Asif K. Interdisciplinary management of a patient with a drug-induced gingival hyperplasia. Contemp Clin Dent 2010 Jul;1(3):171-76. 21. Dersot JM. Gingival recession and adult orthodontics: A clinical evidence-based treatment proposal. Int Orthod 2012 Mar; 10(1):29-42. 22. McComb JL. Orthodontic treatment and isolated gingival recession: A review. Br J Orthod 1994;21:151-59. 23. Kandasamy S, Goonewardene M, Tennant M. Changes in interdental papillae heights following alignment of anterior teeth. Aust Orthod J 2007 May;23(1):16-23. 24. Gonçalves TS, Morganti MA, Campos LC, Rizzatto SM, Menezes LM. Allergy to auto-polymerized acrylic resin in an orthodontic patient. Am J Orthod Dentofacial Orthop 2006 Mar; 129(3):431-35. 25. Blum-Hareuveni T, Rehany U, Rumelt S. Devastating endophthalmitis following penetrating ocular injury during night sleep from orthodontic headgear: Case report and literature review. Graefes Arch Clin Exp Ophthalmol 2006 Feb;244(2):253-58. 26. Samuels RH, Jones ML. Orthodontic facebow injuries and safety equipment. Eur J Orthod 1994;16:385-94. 27. Pazzini CA, Marques LS, Pereira LJ, Corrêa-Faria P, Paiva SM. Allergic reactions and nickel-free braces: A systematic review. Braz Oral Res 2011 Jan-Feb;25(1):85-90. 28. Dunlap CL, Vincent SK, Barker BF. Allergic reaction to orthodontic wire: Report of case. J Am Dent Assoc 1989;118: 449-50. 29. Beaudouin E, Carolus S, Flabbee J, Renaudin JM, Morisset M, Kanny G, et al. Allergies in orthodontics. Eur Ann Allergy Clin Immunol 2003 Nov;35(9):344-51. 30. Nienkemper M, Wilmes B, Renger S, Mazaud-Schmelter M, Drescher D. Improvement of mini-implant stability in orthodontics. Orthod Fr 2012 Sep;83(3):201-07. 222 31. Casaglia A, Dominici F, Pachì F, Turlà R, Cerroni L. Morphological observations and fractological considerations on orthodontics miniscrews. Minerva Stomatol 2010 Sep;59(9): 465-76. ABOUT THE AUTHORS Vinay Reddy (Corresponding Author) Professor, Department of Orthodontics, Krishnadevaraya College of Dental Sciences, Bengaluru, Karnataka, India e-mail: [email protected] Vijeev Vasudevan Professor, Department of Oral Medicine and Radiology Krishnadevaraya College of Dental Sciences, Bengaluru, Karnataka India Gowri Sankar Professor and Head, Department of Orthodontics, Goverment Dental College and Hospital, Kadapa, Andhra Pradesh, India AV Arun Senior Lecturer, Department of Orthodontics, Krishnadevaraya College of Dental Sciences, Bengaluru, Karnataka, India S Mahendra Senior Lecturer, Department of Orthodontics, Krishnadevaraya College of Dental Sciences, Bengaluru, Karnataka, India Mohammed K Khalid Senior Lecturer, Department of Orthodontics, Oxford Dental College Bengaluru, Karnataka, India JAYPEE