Orthodontics Orthodontic Scars : A topical Review Dr. Sanjeev Kumar Sharma Senior Resident Dr. Anushree Chaurasia Junior Resident Dr. Pradeep Tandon Professor & HOD Department of Orthodontics and Dentofacial Orthopaedics Faculty of Dental Sciences KGMU, Lucknow, U.P., India Introduction Lesions of Enamel postorthodontic lesions best course is to ince long the aim of orthodontics Enamel decalcification/ white spot wait and watch since most lesions tend to has been to achieve functional lesions Fejerskov and Kidd defined WSL as improve in their appearance over the first 1 Sefficiency, structural balance and the “first sign of a caries lesion on enamel to 2 years afterdebonding15,16.Other methods esthetic harmony. Orthodontics as a science that can be detected with the naked to improve the appearance of WSL include has flourished from the times of Angle, eye.” 1 (Figure 1) The characteristic resin infiltration, vital bleaching, Tweed , Strang, Andrews to the present opaque,chalky, white appearance of WSL is microabrasion and indirect restorations. modern era.An important esthetic goal in due to difference in refractive index due to Enamel wear /fracture orthodontic treatment planning is to loss of mineral from enamel surface or At the time of bracket removal, enamel achieve a balanced smile.However the subsurface, this appearance can easily be loss can occur and depends largely on the actual benefit of any treatment modality visualised by drying the tooth surface.2 bracket material and method of debond. whether in the dental or medical speciality Being one of the most common adverse This is less common with metal brackets can only be evaluated by also analysing its effects of orthodontic treatment, they can where a peeling force is applied to bracket harmful affects and various methods to hamper the dental esthetics. Prevalence has base, leading to bond failure at the bracket- overcome it. We orthodontist are lucky been reported to rangefrom 2% to 96%2–5. adhesive interface, without damaging the enough as the benefits of orthodontic Prevalence priorto orthodontic enamel.19 However a number of reports of treatment, far outweigh the risk factors or treatment ranges from 15.5% to enamel fracture and loss at debond of harm caused by orthodontic appliances and 40%2,6,7whereas incidence of newclinically ceramic brackets have been reported17,18. materials. v i s i b l e W S L o c c u r r i n g d u r i n g Four debonding techniques including In the medical speciality the term “scar” orthodontictreatment ranges between 30% mechanical debonding, electrothermal generally refers to a soft tissue to 70% 4,5,6,8-10. Maxillary anterior teeth are debonding, laser debonding and ultrasonic manifestation on the skin or other body mostcommonly affected, with the order of debonding have been developed 20,21. tissue in the region of a wound , burn or sore incidence beinglateral incisors, canines, Mechanical debonding depends on ,seen during the healing process.Similarly premolars, and centralincisors2,6,11; however, either the deformation of the bracket or Orthodontic scars may be defined as a all teeth are potentially at risk. stressing the adhesive to cause adhesive reversible or irreversible, soft or hard tissue failure. Electro- thermal and laser damage ,that are expressed clinically either Risk factors include: poor pre-treatment and intra-treatment oral hygiene, debonding attempt to dissolve the bonding intra/extraorally, during or after the cement through heat generation Ultrasonic orthodontic treatment. The purpose of this age(preadolescent at start of treatment), increased decayed, missing, or filled teeth, debonding uses ultrasonic vibrations to article is to provide an overview of various break the adhesive interlocking22. Surafce types of orthodontic scars and methods to etching time and surface area, and caries/restorative status of first enamel cracks and wear provide stagnation prevent or treat them. 10,11. molars One important feature is the areas for the development of caries, cause It should be the prime duty of the potential for rapid formation, with clinically partial tooth fracture, or may cause operator to carry out a thorough visible lesions developing in as little as 4 unaesthetic discoloration. Higher examination of the oral cavity of the patient 5 weeks. prevalence of cracks is found in debonded at the onset of treatment and also during teeth compared to untreated teeth.19 subsequent visits to assess,identify and It has been documented that patients, manage orthodontic scars to avoid the parents, general dentists, and orthodontists Restorative procedures can be carried perceive that the responsibility for out to manage the tooth fracture. Applying adverse effects and achieve a successful 12 final result.It is also essential to inform the prevention of WSL lies with thepatient. A debonding forces lower than 13 MPa and patient about such possibilities prior to modified fluoride toothpaste technique adhering to proper debonding techniques involving twice daily brushing for 2 minutes can help avoid the incidence of accidental commencement of orthodontic treatment. 19,22 Orthodontic Scars can be broadly classified followed by vigorous swishing of the tooth fracture into: toothpaste slurry for 30 seconds without Periodontal Tissues rinsing with water, and avoidance of eating Gingivitis/Gingival Enlargement or drinking for 2 hours, has also been shown Some amount of gingival inflammation Orthodontic Scars to reduce the incidence of new caries in 13 is associated with fixed orthodontic orthodontic patients. Daily 0.5% sodium mechanotherapy.(Figure 2) But this is Lesions of enamel Periodontal tissues Soft tissue damage 1.Enamel decalcification/white . Gingivitis/gingival enlargement fluoride rinse in conjunction with usually transient and does not lead to spot lesions . Gingival recession 2.Physical damages on 23 enamel (enamel wear/enamel . Dark triangles fluoridated dentifrice is perhaps the most fractures) attachment loss. Hyperplasia of gingiva is common fluoride regimen recommended by 14 commonly found around orthodontic bands orthodontists .Other measures include use leading to formation of pseudo-pockets. Direct damage due to Indirect damage due Soft tissue complications of fluoride-releasing bonding material, removable or fixed appliances to allergic reactions due to implants However, this usually resolves within weeks fluoride varnishand amorphous calcium of debanding. p h o s p h a t e . F o r m a n a g e m e n t o f 58 / Volume 09 / Issue 05 / May-June-2017 Sharma, et al.: Orthodontic Scars - A topical Review Orthodontics The most important factor in the few days after appliance delivery (approx..7 examination, in case an eye injury is initiation, progression and recurrence of days) to check for any tissue impingement suspected. periodontal disease is the presence of or trauma.36 Indirect Damage by Allergic Reactions microbial plaque.24,25Light orthodontics Fixed Appliance and Its Components Nickel Allergy forces are recommended for adult patients. Archwire, Brackets, Bands, Transpalatal Nickel present in orthodontic Utmost care should be taken particularly in Arch appliances like brackets, bands, and patients with systemic diseases, such as Damage to the oral mucosa is common archwires is responsible for causing allergic epilepsy and patient on calcium channel during orthodontic treatment due to rubbing reactions in some patients. 39Nickel blockers.26 of the lips and cheeks on the archwire, hypersensitivity affects three in ten of the Gingival Recession brackets, bands and hooks35(Figure general population, but the symptoms are The risk of attachment loss can be 4).Although the oral mucosa quickly very mild and unnoticed. These include anticipated when iatrogenic irritations are keratinize and get accustomed to the new lossof taste or metallic taste, numbness, present.27(Figure 3) Patients with good oral appliance relatively fast, this damage can be burning sensation,soreness at the side of the hygiene and absence of any periodontal prevented by: tongue, angular cheilitis and erythematous disorders are at minimal periodontal risk 1.Use of dental wax over the bracket areas or severe gingivitis in the absenceof when optimum forces are used.28 However, 2.Rubber tubing on the unsupported plaque.Nickel-induced contact dermatitis is in the presence of poor oral hygiene and archwire may serve to reduce the initial a Type IV delayed hypersensitivity immune preexisting untreated periodontal disorders, trauma and discomfort. response, occurring 24 hours after fixed orthodontic appliances and tooth 3.The distal ends of the archwire should be exposure.39 It has been found that females movement can contribute to significant and cut off flush with the molar tube or cinched are most susceptible to nickel allergy. permanent periodontal damage.29 This is toward the tooth to avoid mucosal trauma. 36 Patients allergic to nickel can be treated by 29,30 Loops, Utility Arches alternatives like: more common in Adult patients. 40 Orthodontic treatment is not Loops and utility arches are required 1. Use of Titanium wires and brackets . contraindicated in this group, provided the for space closure, space maintenance or 2. Use of epoxy coated nickel titanium disease is well-controlled and the patient intrusion. Main consideration during their wires . maintains excellent oral hygiene throughout fabrication is vestibular extension. Over 3.Ceramic brackets or clear aligners can also the treatment.30 extension may cause blanching, tissue be used