Most Frequent Iatrogenic Effects of Orthodontic Treatment

Topic 1 – Prevention of periodontal deterioration/damage
Alterations in the mucogingival complex can occur during orthodontic tooth movement. In terms of changes in the position of the soft tissue margin and in gingival dimensions, the important factors to consider are the direction of the tooth movement and the bucco-lingual thickness of the gingiva. There are two gingival biotypes: 1. Thick-flat and 2. Thin-scalloped.
Lingual tooth movement will result in an increased bucco-lingual thickness of the tissue at the facial aspect of the tooth which results in coronal migration of the soft tissue margin (decreased clinical crown height). Facial tooth movement, on the other hand, will result in a reduced bucco-lingual tissue thickness and thereby a reduced height of the free gingival portion and an increased clinical crown height even a possible dehiscence.
Some concepts were illustrated with clinical cases:  4 examples of negative consequences of  lower incisor proclination and 2 examples were given of how to avoid lower incisor proclination (extractions and headgear).
Poor diagnosis and treatment management of Extraction Cases treated Nonextraction can result in a worsening full profile due to the “drawbridge effect” and worsen the openbite tendency.  A review of Little’s Irregularity Index and the findings how 10 years post treatment resulted in width constriction as a consistent finding, as was crowding of anterior teeth after retention pointing out as n 89% the postretention record demonstrated clinically unsatisfactory alignment.
Use of the cervical pull headgear is an aid in anchorage control and  differential growth and dentofacial orthopedics.  Though there is considerable controversy among orthodontists about the timing of orthodontic treatment. Those who promote early treatment in the mixed dentition claim to have better results, even though a second phase of orthodontic treatment may be required. Other orthodontists, however, prefer to initiate treatment in the late mixed dentition with the belief that they can achieve equally good clinical results in a single phase. Examples of  Class II, Division 1 cases that may truly benefit from early mixed dentition treatment were shown. Emphasis is made on early treatment to achieve lip competence, prevent incisor fractures, diminish the need for extraction of permanent teeth, and minimize the possibility of external apical root resorption.
You will learn why:

  • Incisor proclination may damage the periodontium and jeopardize stability.
  • Arch length increase to alleviate crowding is the least stable orthodontic treatment.
You will learn how to:

  • Avoid lower incisor proclination and still achieve ideal alignment.
  • Maintain ideal alignment long-term.
  • Early/timely Class II treatment helps to minimize incisor trauma and external apical root resorption.
  • It’s important to prevent incisor tooth trauma to avoid its long-term consequences.
  • Combination headgear is superior to functional appliances.
  • It’s advantageous to utilize the three growth accelerations that occur in growing patients rather than just the adolescent growth acceleration.
  • Maxillary sutural growth can be easily modified while mandibular growth cannot.
  • Differential growth is the key to long-term stability.
You will learn the indications for extraction of:

  • Four first bicuspids.
  • Two mandibular second bicuspids and two maxillary first bicuspids.
Jan L. Wennström. Mucogingival considerations in orthodontic treatment. Seminar in Orthodontics. March 1996Volume 2, Issue 1, Pages 46–54.
Robert M. Little Richard A. Riedel Arthur Stein. Mandibular arch length increase during the mixed dentition: Postretention evaluation of stability and relapse. AJODO May 1990Volume 97, Issue 5, Pages 393–404.
Essam A. Al Yami, Anne M. Kuijpers-Jagtman, Martin A. van ‘t Hof. Stability of orthodontic treatment outcome: Follow-up until 10 years postretention. AJODO  March 1999 Volume 115, Issue 3, Pages 300–304.
Brett C. Fidler, Jon Årtun, DDS Donald R. Joondeph Robert M. Little. Long-term stability of Angle Class II, Division 1 malocclusions with successful occlusal results at end of active treatment. AJODO March 1995 Volume 107, Issue 3, Pages 276–285.
C.L. Steyn, R.J. du Preez, A.M.P. Harris. Differential premolar extractions. AJODO November 1997 Volume 112, Issue 5, Pages 480–486.
Suwannee Luppanapornlarp and Lysle E. Johnston Jr. (1993) The effects of premolar-extraction: A long-term comparison of outcomes in “clear-cut” extraction and nonextraction Class II patients. The Angle Orthodontist: December 1993, Vol. 63, No. 4, pp. 257-272.
Bishara SE Justus R Graber TM. Proceedings of the CDABO Worskhop discussions on early treatment. AJODO 1998 113:5-6.
Topic 2 – Deproteinization of Tooth Enamel Surfaces to Prevent White Spot Lesions and Bracket Bond Failure: A Revolution in Orthodontic Bonding
Orthodontic treatment success is jeopardized by the risk of development of white spot lesions (WSLs) around orthodontic brackets. Unfortunately, the formation of WSLs still remains a common complication during treatment in patients with poor oral hygiene. Nearly 75% of orthodontic patients are reported to develop enamel decalcification because of prolonged plaque retention around brackets. It is the orthodontist’s responsibility to minimize the risk of patients having enamel decalcifications as a consequence of orthodontic treatment. This can be achieved by using hybrid, fluoride-releasing, glass ionomer cement to bond brackets, with deproteinization of the enamel surface prior to phosphoric acid etching.
You will learn why:
  • Enamel is protected from white spot lesions when brackets are bonded with hybrid, fluoride-releasing, glass ionomer cement.
  • Enamel de-proteinization with Clorox (5.25% Sodium Hypochlorite), prior to etching, increases bracket shear bond strength
  • Incidence of bracket bond failure is diminished when the enamel surface is de-proteinized before etching and Type 1 Etching is achieved, not just a Tyupe 2 or 3 etching pattern,  and bonding brackets, both with composite resin and also with glass ionomer cement.
You will learn how to:

  • De-proteinize the enamel surface.
  • Bond brackets with hybrid glass ionomer cement.
Roberto Justus, Tatiana Cubero, Ricardo Ondarza, Fernando Morales. A New Technique With Sodium Hypochlorite to Increase Bracket Shear Bond Strength of Fluoride-releasing Resin-modified Glass Ionomer Cements: Comparing Shear Bond Strength of Two Adhesive Systems With Enamel Surface Deproteinization Before Etching.  Seminars in Orthodontics March 2010Volume 16, Issue 1, Pages 66–75.
Roberto Espinosa, Roberto Valencia, Mario Uribe, Israel Ceja, Marc Saadia. Enamel deproteinization and its effect on acid etching: an in vitro study. The Journal of clinical pediatric dentistry January 2008; 33(1):13-19.
Leon M. Silverstone. Dental Caries: Aetiology, Pathology and Prevention.  Macmillan Press.  1981
Samir E. Bishara, Adam W. Ostby. White Spot Lesions: Formation, Prevention, and Treatment. Seminars in Orthodontics September 2008Volume 14, Issue 3, Pages 174–182.
V. Angnes, G. Angnes, M. Batisttella, R. H. M. Grande, A. D. Loguercio, and A. Reis, “Clinical effectiveness of laser fluorescence, visual inspection and radiography in the detection of occlusal caries,” Caries Research, vol. 39, no. 6, pp. 490–495, 2005.
Greg J. Huang, Brie Roloff-Chiang, Brian E. Mills, Salma Shalchi, Charles Spiekerman, Anna M. Korpak, Jeri L. Starrett, Geoffrey M. Greenlee, Ross J. Drangsholt, Jack C. Matunas.  Effectiveness of MI Paste Plus and PreviDent fluoride varnish for treatment of white spot lesions: A randomized controlled trial. AJODO January 2013 Volume 143, Issue 1, Pages 31–41.  2014 David L. Turpin Award for Best Evidence Based Research Article.
Benson PE1, Shah AA, Millett DT, Dyer F, Parkin N, Vine RS. Fluorides, orthodontics and demineralization: a systematic review. J Orthod. 2005 Jun;32(2):102-14.
Matheus M Pithon , Caio S Ferraz, Gabriel D Couto Oliveira and Adrielle M Dos Santos. Effect of different concentrations of papain gel on orthodontic bracket bonding. Progress in Orthodontics  August 2013;14:22.
Topic 3 – Prevention of External Apical Root Resorption (EARR)
The issue of orthodontic-induced root resorption has attracted the interest of clinicians/investigators because of the alarming clinical and legal implications associated with its occurrence. External apical root resorption (EARR) is a common iatrogenic consequence of orthodontics. EARR is a small problem for the average orthodontic patient, with mean resorption per tooth per patient of less than 1.5 mm. This magnitude of resorption has no adverse clinical consequences. However, 3 to 5% of orthodontic patients experience 4mm, or more, of EARR.
You will learn how to apply the strategies to minimize orthodontically induced EARR:

  • Eruption guidance of maxillary canines,
  • Driftodontics,
  • Early correction of anterior open bite with a spur appliance to establish normal tongue rest posture,
  • Early correction of large overjets associated with Class II malocclusions using skeletal correction (growth modification) to minimize both incisor trauma and EARR.
  • Orthognathic surgery (to avoid moving roots against cortical bone).
You will learn why:

  • EARR occurs.
  • Genes are responsible for EARR.
  • Treatment strategies to minimize EARR must be implemented in every orthodontic case.
You will learn how to:

  • Detect EARR early in treatment.  Recommend the taking of a periapical xray of the  maxillary lateral incisor 6 months after start of treatment to assess.
  • Root sparing treatment strategies include: Alleviating lower incisor crowding through timely extractions and subsequent driftodontics or guidance of eruption
  • Driftodontics to prevent canine impactions and incisor root resorption.
  • Close anterior open-bite malocclusions without brackets by allowing incisors to erupt unhindered by an anterior tongue rest posture using Fixed intraoral spurs to establish a normal tongue rest posture and also interrupt digit-sucking habits
  • The anterior open-bite closes with spurs, without using brackets/wires.
  • Long-term stability post-retention is achieved when spurs are used.
  • Early correction of open-bite protects roots from resorbing
  • Correct Class II, Div I malocclusions by growth modification instead of moving teeth with the risk of developing EARR.
You will learn:

  • What the evidence recommends doing in case of timely detection of EARR.
Riyad A. Al-Qawasmi,, James K. Hartsfield Jr, Eric T. Everett, Leah Flury, Lixiang Liu, Tatiana M. Foroud, James V. Macri, W.Eugene Roberts. Genetic predisposition to external apical root resorption.  AJODO March 2003 Volume 123, Issue 3, Pages 242–252.
Jon Årtun, Isolde Smale, Faraj Behbehani, Diane Doppel, Martin Van’t Hof, and Anne M. Kuijpers-Jagtman/ Apical Root Resorption Six and 12 Months After Initiation of Fixed Orthodontic Appliance Therapy. The Angle Orthodontist: November 2005, Vol. 75, No. 6, pp. 919-926.
Eva Levander , Olle Malmgren , Sören Eliasson. Evaluation of root resorption in relation to two orthodontic treatment regimes. A clinical experimental study. European J Orthodontics June 1994 16(3): 223-228.
Sune Ericson , Jüri Kurol. Early treatment of palatally erupting maxillary canines by extraction of the primary canines. Eur J Orthod March 1988 10 (4): 283-295.
Giulio Alessandri Bonetti, Matteo Zanarini, Serena Incerti Parenti, Ida Marini, Maria Rosaria Gatto Preventive treatment of ectopically erupting maxillary permanent canines by extraction of deciduous canines and first molars: A randomized clinical trial. AJODO March 2011Volume 139, Issue 3,  316–323
Huang JG Justus R Kennedy DB Kokich VG. Stability of Anterior Open Bite Treated with Crib Therapy. Angle Ortho. Spring 1990. Vol 60 (1) 17-24.
Roberto Justus. Correction of anterior open bite with spurs: long-term stability. World J. Orthod 2001 Vol 2(3): 219-231.
Roberto Justus. DNA analysis might provide a more accurate risk assessment for root resorption in the future. FDI News, Montreal, August 2005.
Topic 4 – Methods to Achieve Excellence in Orthodontic Treatment
American Board of Orthodontics’ Standards/Criteria/Methods for Approval of Clinical Cases – Clinical application to our practices.
The objective of this topic is to inform orthodontists on both how to increase their standard of orthodontic care by using the American Board of Orthodontics’ updated criteria for case approval, and also how to apply these criteria in daily practice.
You will learn why the ABO uses:

  • A “Discrepancy Index Form” to score the complexity of a case, using the initial orthodontic records.
  • An Objective Grading System to score candidates´ finishing dental casts and panoramic radiographs.
  • A Case Management Form to score candidates´ final skeletal, dental and facial results, including the quality of the orthodontic records.

For more information click on the icons to link and download the ABO Discrepancy Index and Case Management and Objective Grading Systems (bituin, I want them to be able to click to the image to get to the 3 attachments of Discrepancy Index,  Case management form and Instructions.

You will learn why:

  • Lewis brackets are more efficient in rotating teeth, and also in over-correcting rotated teeth, than twin brackets.
  • Fiberotomy is effective in minimizing/diminishing rotational relapse.
  • Removable night-time retainers hold mandibular alignment better than fixed canine-to-canine retainers.
  • Direct bonding of 2nd molar tubes is important to achieve ideal alignment.
  • Glass ionomer cement is more effective for bonding second molar tubes than resin.
  • 1st and 3rd order wire bends are essential to achieve excellence, even though pre-adjusted brackets are used.
  • Ideal root parallelism is important, and how to achieve it.
You will learn how:

  • The ABO determines a cut-off score for approval/rejection of a candidate´s case.
  • The ABO trains and calibrates its examiners.
  • The ideal maxillary and mandibular retainers should be designed.
S. Ed Owens Jr, Vance J. Dykhouse, Allen H. Moffitt, John E. Grubb, Peter M. Greco, Jeryl D. English, Barry S. Briss, Scott A. Jamieson, Michael L. Riolo. The case management form of the American Board of Orthodontics. AJODO March 2006 Volume 129, Issue 3, Pages 325–329
John S. Casko, James L. Vaden, Vincent G. Kokich, Joseph Damone, R.Don James, Thomas J. Cangialosi, Michael L. Riolo, Stephen E. Owens Jr., Eldon D. Bills. Objective grading system for dental casts and panoramic radiographs. AJODO November 1998 Volume 114, Issue 5, Pages 589–599
Thomas J Cangialosi, Michael L Riolo, S.Ed Owens Jr, Vance J Dykhouse, Allen H Moffitt, John E Grubb, Peter M Greco, Jeryl D English, R.Don James. The ABO discrepancy index: a measure of case complexity. AJODO March 2004 Volume 125, Issue 3, Pages 270–278