Periodontal tissues

Fixed appliances make oral hygiene difficult even for the most motivated patients, and almost all patients experience some gingival inflammation (Fig. 6). Resolution of inflammation usually occurs a few weeks after debond, bands cause more gingival inflammation than bonds, which is not surprising since the margins of bands are often seated subgingivally.

• Root resorption is inevitable with fixed appliance treatment

• On average 1-2 mm of apical root is lost during a course of orthodontic treatment

• Previously traumatised teeth have an increased risk of root resorption

Fig. 6 Severe gingival inflammation during fixed appliance treatment. Note the inflammation covers the headgear tube and hook on the upper molar band
Fig. 7 Disclosing solution highlighting the areas of poor oral hygiene in a patient
Fig. 8 Chronic lack of oral hygiene showing accumulation of plaque gingivally and around the brackets
Fig. 9 Trauma to the cheek from an unusally long distal length of archwire resulting in an ulcer

For the most part, the literature suggests that orthodontic treatment does not affect the periodontal status of patients over the long term. Patients with pre-existing periodontal disease require special attention, but bone loss during treatment does not seem to be related to previous bone loss. The need for excellent oral hygiene during treatment must be emphasised in patients with existing peri-odontal disease. The use of bonds rather than bands on molars and premolars may be more appropriate to eliminate unwanted stagnation areas. Plaque retention is increased with fixed appliances and plaque composition may also be altered. There is an increase in anaerobic organisms and a reduction in facultative anaerobes around bands, which are therefore periopathogenic.25

Oral hygiene instruction is essential in all cases of orthodontic treatment, and the use of adjuncts such as electric toothbrushes, inter-proximal brushes, chlorhexidine mouthwash-es, fluoride mouthwashes and regular professional cleaning must be emphasised. However, patient motivation and dexterity are paramount in the success of hygiene, and there will always be cases where oral hygiene is unsatisfactory from the outset. This should be carefully considered when advising a patient to have treatment. Experience shows those patients who are unable to maintain a healthy oral environment in the absence of fixed orthodontics will fail spectacularly with braces in place. Benefit must therefore significantly outweigh the risk of carrying out treatment in such patients (Figs. 7 and 8).

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