Scars in orthodontics /certified fixed orthodontic courses by Indian dental academy

SCARS
IN

ORTHODONTICS

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


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.

THE SCARS
~On teeth
~Supporting structures
~Temporomandibular joint
~Effects of extraction
~Relapse
~Miscellaneous

Effect on teeth
~Enamel
~Dentin
~Pulp
~Cementum


Effects on Enamel
~Initial prophylaxis
Bristle brush-10 microns
Rubber cup-5 microns


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

Prevention
~Mouth Rinse
~Fluoride dentrifice
~Fluoride varnish
~Titanium tetrafluoride
-Vanarsdall

DEBONDING

Metal brackets

~Hand instrumentation-5-8 m
~Unfilled resins-2-40 m
~Filled resin 10-25 m –High speed
10 m TC bur


Different Debonding scores
~Diamond
~Sandpaper disks & Rubber wheel
~Fine sandpaper disks
~Plain & spiral fluted TC burs
- Vanarsdall

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.

Clinical implications
~Brackets of mechanical retention
~Avoid scrapping with
hand instruments


ENAMEL CRACKS
~Occur as split lines
~Finger shadowing/fiberoptic
transillumination
~Multi causal-mechanical/thermal
~Sharp sound denotes enamel cracks

Findings-fiberoptic light technique

~Vertical cracks are common
~Horizontal & oblique few
~No significant difference between
prevalence & location
~Maxillary incisors & canines

Clinical implication
~Examine teeth other than canines
and centrals-maxillary
~Detect cracks in a horizontal direction
~Reason-lack of ductility in brackets


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

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

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

~TC burs are advised - 1171, 1172
~Frequency should be less than
30,000 rpm
~The bur should be used in painting
motion


Debonding of ceramic brackets
~Slow peeling force

~Compression-fracture of bracket
(Clarity brackets)
~Torsional debonding plier
~Rotation
~Slow gradual compression
-AJO 1988 SWARTZ

Laser debonding
~Causes ablation of resin
~Quick procedure
~Only ill-effect-can cause
pupal damage
~Expensive


Conventional Debonding
~Tooth should be supported
~Instrument on the bracket Base
~Pliers lose efficiency as it interacts
with ceramic
-AJO ,1990 BISHARA

Ultrasonic debonding
~Less enamel damage
~Can be used to remove remnant
~More time consuming
~Wearing of tips
~Need for water
~Soft tissue injury

Electrothermal debonding
~Reduced bracket failure(Bracket/
Adhesive interface)
~Limited clinical applicability
~Pulpal damage
~Mucosal irritation

Improper position of ceramic
brackets can cause
~Attrition of the opposing tooth
~Notching


Effects on dentine
~Tooth sensitivity
~Decalcification
~White spots


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

~Banding can cause decalcification
after removal
~More common in the anteriors
~Airotor proximal stripping can cause
proximal caries and sensitivity at a
later date


Root Resorption after Treatment
~Biologic factors
Indvidual varitation
Genetics
Metabolic signals
Systemic factors
Nutrition

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

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

Mechanical factors
~Appliances
Fixed Vs Removable
FA > RA
Begg Vs Edgewise
Begg light continuous force but
resorption seen in Stage III
& Intrusion

Magnets – less resorption
Intermaxillary elastics-resorption on
The side where elastics were used
Orthodontic Movement type
Intrusion>bodily movement

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

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

Other considerations
Teeth vitality-Colour does not change
Loss of crestal bone and tooth stability
Loss of marginal attachment-more
detrimental
Prediction - radiographs


ROOT FORM


ENDODONTICALLY TREATED


EXTERNAL ROOT RESORPTION


IDIOPATHIC ROOT RESORPTION


Clinical Implications
~Patient should be informed
~Periapical radiographs
~Treatment timing
~Light & intermittent force
~Resorption evident-final goals
should be re-evaluated

~Habits-nail biting,tongue thrust
~Intrusion
~Occlusal traumatisation
~Recognise anatomic & physiological
limitations
~Early orthopedic phase-(skeletal)
less detrimental

~Traumatised tooth
~Choice of Different Fixed appliances
~Medical examination &
Familial tendency
~Supplement with endodontic,
periodontal therapy if resorption
-AJO 1993 Wasserstein

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

Mobility –a moderate increase is
Seen during ortho. Treatment
~Heavier forces=>More resorption
=>mobility
~All forces should be discontinued
until mobility decreases


Effects on Supporting structures
~Gingiva
Fibrous enlargement
Gingival recession
Accumulation of plaque
Gingival pocket formation
Decrease in width attached
gingiva

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

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

EFFECTS ON TMJ


~Sadowsky & Begole (1980)
Sadowsky & Pelsen(1984)
Orthodontic treatment during
adolescence did not increase the risk of
TMD later in life


~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

~Pancherz(1985)
Herbst Fixed Functional ApplianceTenderness to palpation initially and
Symptoms disappeared after
appliance removal
~Smith & Freer(1989)
Soft clicks after Rx


~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


~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

“ 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”


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.

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


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.


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

~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.


~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

~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.


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

~Other effects
Alveolar dehiscence
Fenestration
Root resorption
- AJO,1982 Langford


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

~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

~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

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


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

~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

~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

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

RETENTION & RELAPSE
SUCCESS INDEX=
MAGNITUDE OF IMPROVEMENT/
MAGNITUDE OF RELAPSE


Normal Growth, Orthopedic Changes
& Relapse
~Rebound towards the original skeletal
configuration adds to overall instability
of the case


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

~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

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

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

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


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

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

The success of an orthodontic patient
cannot be evaluated only in centric
occlusion, but centric relation using a
broad definition must be achieved.


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


~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


MISCELLANEOUS
~Ankylosis of impacted teeth
Reduced bone support
Long clinical crowns
Poor gingival attachment
Chronic inflammation & pocketing
PDL is compromised


FACE-BOW INJURIES
Categories
~Accidental disengagement
~Incorrect handling
~Deliberate disengagement by others
~Unintentional disengagement during
sleep

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

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)

~Non-vitality of teeth at osteotomy cut
Sites
~Relapse tendency etc
~Paraesthesia following injury to the
nerves


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

~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


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

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.


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

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

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.

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


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