Send Orders for Reprints to reprints@benthamscience.

ae
228 The Open Dentistry Journal, 2015, 9, (Suppl 1: M13) 228-234

Open Access
Iatrogenic Damage to the Periodontium Caused by Orthodontic Treatment
Procedures: An Overview

Syed Rafiuddin1,*, Pradeep Kumar YG2, Shriparna Biswas3, Sandeep S. Prabhu3,

Chandrashekar BM3 and Rakesh MP3

1
Department of Orthodontics, Sri Hasanamba Dental College & Hospital, Hassan, Karnataka, India; 2Department of
Oral Medicine & Radiology, Government Dental College & Hospital & Research Institute, Bellary, Karnataka, India;
3
Department of Periodontology, Rajarajeswari Dental College & Hospital, Bangalore-560074, Karnataka, India

Abstract: In orthodontic treatment, teeth are moved in to new positions and relationships and the soft tissue and underly-
ing bone are altered to accommodate changes in esthetics and function. Function is more important than esthetics. The
speciality of orthodontics has in addition to its benefits, complications as well as risks associated with its procedures.
However the benefits outweigh the risks & complications in most of the treatment cases. Few of the unwanted side effects
associated with treatment are tooth discolorations, enamel decalcification, periodontal complications like open gingival
embrasures, root resorption, allergic reactions to nickel & chromium as well as treatment failure in the form of relapse.
Keywords: Iatrogenic, orthodontics, periodontium, tooth movement.

INTRODUCTION responses [1]. The undesirable side effects of orthodontic

treatment are tissue damage, treatment failure & increased
Increased life expectancy, improved socio-economic
predisposition to dental disorders.
conditions along with a desire for improved self esteem has
resulted in an increase of adult population seeking orthodon-
tic treatment. Furthermore, the changing concepts of esthet-
ics with the advent of esthetic brackets & arch wires have
combined functional benefits with esthetics. In orthodontic
treatment, teeth are moved into new positions and relation-
ships and the soft tissue and underlying bone are altered to
accommodate changes in esthetics and function. Function is
more important than esthetics. The speciality of orthodontics
has in addition to its benefits, complications as well as risks
associated with its procedures. However the benefits out-
weigh the risks & complications in most of the treatment
cases. Few of the unwanted side effects associated with Fig. (1). Gingival inflammation caused by orthodontic brackets.
treatment are tooth discolorations, enamel decalcification,
periodontal complications like open gingival embrasures, Studies have shown that the presence of orthodontic ap-
root resorption, allergic reactions to nickel & chromium as pliances in theoral cavity increases the amount of plaque,
well as treatment failure in the form of relapse. resulting in the formation of gingival hyperplasia & pseudo-
Few of the malocclusions which affect the periodontium pockets [2] (Fig. 1). This changes the subgingival ecosystem
such as anterior deep bite can cause stripping of the labial thereby causing an increase in periodontal pathogen levels
gingiva of lower anteriors and lingual gingiva of upper ante- which stimulate the host cells to release various types of in-
riors. Anterior cross bite can cause localized gingival reces- flammatory cytokines such as interleukin 1
(IL-1
), inter-
sion & mobility of the affected tooth. Correcting these mal- leukin 6 (IL -6), interleukin 8, (IL-8) and growth factors such
occlusions with orthodontic treatment will help to improve as tumor growth factor (TGF) [3]. Orthodontic tooth move-
the periodontal status and overall health of an individual. ment causes reorientation & remodeling of supporting perio-
dontal tissues. When optimum orthodontic forces are applied
Dental plaque has been established as a potential risk fac- it causes expected reactions in the supporting periodontal
tor for the development of periodontal diseases and the pro- tissues.
gression of these diseases depends on the balance between
microbial biofilms and immune and inflammatory host POTENTIAL ADVERSE EFFECTS TO THE PERIO-
DONTAL TISSUES
*Address correspondence to this author at the Department of Orthodontics, Plaque is considered as the major etiological factor in the
Hasanamba Dental College and Hospital, Hassan, Karnataka, India; development of gingivitis [4].
Tel: 08050966179; E-mail: [email protected]

1874-2106/15 2015 Bentham Open

Iatrogenic Damage to the Periodontium Caused by Orthodontic Treatment The Open Dentistry Journal, 2015, Volume 9 229

Experimental animal studies have shown that orthodontic BLACK TRIANGLES

forces & tooth movements do not induce gingivitis in the
Gingival Embrasures are Defined as the Embrasure Ex-
absence of plaque [5]. However similar forces can induce
isting Cervical to the Interproximal Contact [22]
angular bone defects in the presence of plaque. Orthodontic
tooth movements like tipping & intrusion can cause attach- Open gingival embrasures occur when the embrasure
ment loss in the presence of plaque [6]. Healthy, reduced space is not completely covered by gingival tissue leading to
periodontal tissue support regions do not cause gingival in- retention of food debris & adversely affecting the periodon-
flammation when orthodontic forces are kept within the op- tium. This condition is more common in adult patients with
timum limits [7]. Plaque is considered as the most important bone loss [23].
factor in the initiation, progression and recurrence of perio-
Black triangle Fig. (2) or open gingival embrasure can
dontal diseases in reduced periodontium [8].
occur as a complication in about 1/3 of all adult patients & it
In most patients a transient gingival inflammation occurs should be discussed with patients before initiating orthodon-
after placement of fixed appliances which usually does not tic treatment [24].
lead to attachment loss [9, 10] Gingival hyperplasia can de-
velop around orthodontic bands leading to pseudo pocket
formation. However this condition resolves after few days of
debanding.
The importance of plaque control and good oral hygiene
must be stressed to the patient before starting the fixed appli-
ance treatment and adequate patient compliance must be
ensured throughout treatment to prevent gingival inflamma-
tion.

ATTACHMENT LOSS
Fig. (2). Black triangle.
In many orthodontic patients, mechanical irritation
caused by the bands or cement is the principal reason for the Preserving the interdental papilla & avoiding formation
associated gingival and periodontal inflammation along with of black triangles in the esthetic zone forms a key considera-
plaque [11]. Attachment loss can be a major risk in the pres- tion in orthodontic & restorative treatment.
ence of iatrogenic irritants [12]. Histological study conducted
In a survey conducted orthodontists perceived a 2 mm
on human periodontal tissues confirmed thatorthodontic
open gingival embrasure as noticeably less attractive when
banding have to be performed with great care along with
compared with a patient with normal gingival embrasures
excellent oral hygiene inorder to avoid permanent periodon-
[25]. Open gingival embrasures greater than 3 mm were per-
tal destruction [13].
ceived as less attractive by both general dentists & general
A review of the evidence-based literature [14] conducted population.
in the field of periodontics & orthodontics showed that with
Few of the aspects which should be taken into considera-
optimum forces, good oral hygiene and the absence of pre
tion when treating a patient with reduced bone support are
existing periodontal disorders no periodontal risk occurs to
the risk of further bone loss which might lead to the loss of
the patients [15]. However poor oral hygiene & preexisting
teeth, & a change in appliance as well as treatment mechan-
untreated periodontal disorders can lead to significant &
ics [26]. Orthodontic forces may lead to the destruction of
permanent periodontal damage with fixed appliances & vari-
periodontal bone support through the induction of pro in-
ous tooth movements [16].
flammatory cytokines & also by decreasing the expression of
Adult patients with some pre-existing periodontal disease matrix proteins and osteogenic protein [27]. Irritation fac-
are at a higher risk of developing periodontal problems [17]. tors, such as ill-fitting band margins, variable form and di-
Orthodontic treatment is not contraindicated in this group of mension of the interdental embrasure during movement and
patients if they are motivated to maintain good oral hygiene tooth movement itself exerts a toll on the periodontium.
& the disease is kept under control throughout the duration
of treatment [18]. Assessment of periodontal status prior to
fixed appliance treatment is of utmost importance and any
pre-existing problems must be treated before initiating the
treatment. Regular periodontal checkups & routine oral pro-
phylaxis are advisable to keep the periodontal disease under
control [19].
Patients with pre-existing periodontal problems and bone
loss must be referred to and treated by the periodontist be-
fore initiating the orthodontic treatment [20]. Moreover, in
such patients, there is a slight modification in the biome-
chanics with the application of minimal and optimum ortho-
dontic forces, keeping in mind the shortened root support Fig. (3). Mucosal trauma caused by a fixed appliance component.
[21].
230 The Open Dentistry Journal, 2015, Volume 9 Rafiuddin et al.

There are 4 significant factors regarding occlusal trauma-

tism that should be re-emphasized.
1. Occlusal traumatism by itself does not cause pocket for-
mation or gingivitis.
2. Occlusal trauma by itself can cause tooth mobility, bone
resorption and widening of the PDL space.
3. Local irritants, microbial plaque and environmental con-
ditions that harbor plaque can cause pocket formation,
apical migration of the junctional epithelium, attachment
and bone loss.
4. A combination of local irritants and occlusal traumatism Fig. (5). Right lateral view showing inflammatory enlargement.
causes more rapid destruction than do local factors them-
selves.
Gingival and Periodontal changes related to orthodontic
treatment are, in general transient with no permanent dam-
age. Loss of attachment and alveolar bone loss are known to
occur during orthodontic treatment, but are reported to be
temporary [28]. But if long term orthodontic treatment con-
tinues in the absence of oral hygiene, then gingival and
periodontal damage takes place. Deleterious effects includes
gingivitis, mucosal trauma (Fig. 3), gingival hyperplasia,
marginal periodontitis, gingival recession mostly at extrac-
tion areas, loss of attachment, inter dental clefts, mostly at
the vestibular aspects of extracted mandibular first premolar
site, reduced width of keratinized gingiva and marginal bone
and apical root resorption. Some of these undermine the sta-
bility of the orthodontic result, particularly where there is a Fig. (6). Gingival recession.
reduction in the bone support or presence of gingival clefts
or recession.

Periodontitis Caused by Orthodontic Treatment

Exaggerated plaque accumulation during orthodontic
treatment may facilitate the formation of localized, deep an-
aerobic pockets in which periodontal pathogens may flourish
and the situation may deteriorate in to a more serious condi-
tion. Gingiva initially becomes inflammed, owing to plaque
accumulation and later patient complains of pain and bleed-
ing. Clinical examination will then reveal a hemorrhagic
gingiva and pocket that extends to the furcation Figs. (4, 5).

GINGIVAL RECESSION AND CLEFTS Fig. (7). Gingival recession.

Gingival recession (receding gums) (Figs. 6, 7), is the
exposure in the roots of the teeth caused by a loss of gum Several classification systems are in use to help diagnose
tissue and/or retraction of the gingival margin from the gingival recession:
crown of the teeth. • Sullivan & Atkins 1968
• Mlinek et al. 1973
• Miller 1985 Smith 1997
• Mahajan 2010
The most commonly used is the Miller’s classification
which:
• Divides gingival recession defects into 4 categories.
• Evaluates both soft and hard tissue loss.
• Determines the level of root coverage achievable with a
free gingival graft.
Fig. (4). Inflammatory gingival enlargement of labial anterior gin-
• It is therefore diagnostic and prognostic.
giva during orthodontic treatment.
Iatrogenic Damage to the Periodontium Caused by Orthodontic Treatment The Open Dentistry Journal, 2015, Volume 9 231

Miller’s Classification Gingival invaginations which present as superficial

changes in the shape of the gingiva occur in about 35% of
Class I cases after orthodontic space closure procedures [37, 38].
• Marginal tissue recession which does not extend to the These vary from mild fissures in keratinized gingiva to deep
mucogingival junction (MGJ). clefts in the alveolar bone crossing interdental papilla either
buccally or lingually through the alveolar bone [39]. His-
• There is no alveolar bone loss or soft tissue loss in the tological and histo-chemical specimens taken from gingival
inter-dental area. invagination sites demonstrate epithelial as well as the con-
• Complete root coverage obtainable. nective tissue hypertrophy and occasionally loss of gingival
collagen [40]. The reason for the occurrence of these gingi-
Class II val invaginations is still unknown&requires further investi-
• Marginal tissue recession which extends to or beyondthe gations. It could be due tothe break-up in the continuity of
MGJ. the fibers within the gingiva, and also due to root movement
[41]. It has also been proposed that gingival peeling could be
• There is no alveolar bone loss or soft tissue loss in the one thereasons for the formation of these invaginations [42].
interdental area.
Since these gingival invaginations could serve as poten-
• Complete root coverage obtainable. tial sites for dental plaque accumulation, it has been consid-
Class III ered as a potential risk factor for initiation of periodontal
disorders during the course of orthodontic treatment [43].
• Marginal tissue recession which extends to or beyond the Gingival recession has been one of the risk factor during the
MGJ. orthodontic treatment or after treatment completion & has
• Bone or soft tissue loss in the inter dental area is present. been seen to occur more frequently with buccal tooth move-
ment [44]. If teeth are being moved lingually, there is a
• Partial root coverage related to level of papilla height. chance that the gingival tissue will move coronally & be-
Class IV come thicker [45]. It is generally advisable to monitor areas
of thin gingival tissuesduring growth as the width of attached
• Marginal tissue recession which extends to or beyond the gingiva increases from mixed dentition to permanent denti-
MGJ. tion [46].
• The bone or soft tissue loss in the inter dental area is pre- Upper and lower anterior teeth are most commonly af-
sent with gross flattening. fected by gingival recession during orthodontic treatment
• No root coverage. [47]. The relationship between orthodontic movements and
gingival recession has been controversial in relation to tip-
One of the most common esthetic concerns associated ping movements. Batenhorst et al. [48] found an association
with the periodontal tissues is gingival recession. Gingival between gingival recession and orthodontic tipping tooth
recession is the exposure of root surfaces due to apical mi- movements of the lower incisors in monkeys. However,
gration of the gingival tissue margins. Gingival margin mi- other studies revealed no association between gingival reces-
grates apical to the cementoenamel junction. Although it sion or mucogingival defects after orthodontic tipping of the
rarely results in tooth loss, marginal tissue recession is asso- anterior teeth [49].
ciated with thermal and tactile sensitivity, esthetic com-
plaints, and a tendency toward root caries. During surgical decompensation in skeletal class III
cases, the lower incisors are intentionally proclined leading
An adequate width of attached gingiva is necessary for to gingival recession or formation of gingival clefts [50].
healthy periodontal tissues to prevent adverse periodontal This possibility must be addressed during treatment planning
complications due to orthodontic forces [29]. With labial and by undertaking sufficient care when executing the ortho-
bodily movement there is a chance that the incisors develop dontic treatment.Sometimes during orthodontic treatment;
apical migration of marginal gingival [30]. Loss of connec- teeth with adequate gingiva develop localized recession. This
tive tissue results in the presence of preexisting untreated is assumed to occur when forces applied exceed the repara-
gingival inflammation [31]. Therefore, there is a chance of tive & remodeling capacity of alveolar bone. However it is
gingival recession if the tooth movement is likely to result in more possible that the extent & direction of tooth movement
reduction of soft tissue thickness [32]. Experimental studi- might move the tooth through the cortical plate while the
eshave shown that as long as the tooth is moved within the gingival attachment is free of inflammation
alveolar process envelope, it is likely to result in minimal Example: when molar with wide divergent roots is
harmful side-effects on marginal soft tissues [33]. moved into the space of narrow premolar alveolar zone.
It has been found that thin, delicate tissues are more EXTERNAL APICAL ROOT RESORPTION
likely to undergo gingival recession than normal or thick
tissues [34]. If the patient exhibits a minimal zone of at- External apical root resorption is the most common &
tached gingiva or a thin tissue a free gingival graft placed frequent iatrogenic consequence of orthodontic treatment,
before initiating any orthodontic treatment will help in en- although it might also occur in the absence of any orthodon-
hancing tissues around the tooth & in controlling the in- tic treatment.
flammation [35]. Tooth extraction isusually indicated in pa- The etiology, severity & degree of root resorptionis mul-
tients with tooth size-arch length discrepancy [36]. tifactorial, involving both host & environmental factors. Or-
232 The Open Dentistry Journal, 2015, Volume 9 Rafiuddin et al.

thodontically induced root resorption Fig. (8) starts adjacent Root Damage: Root resorption is usually seen in patients
to hyalinized zones and occurs during and after elimination with fixed appliances affecting the apical 1-2 mm. Such re-
of hyalinized tissues. Root resorption occurs when the pres- sorption does not compromise on the long term health of the
sure on the cementum exceeds its reparative capacity and periodontium&the teeth [66]. More so ever, resorption
dentin is exposed, allowing multinucleated odontoclasts to where more than 1/3rd of root length is lost is rare & occurs
degrade the tooth substance. It has been shown that root re- in only 3% of the patients.Risk factors for increased inci-
sorption is highly correlated with longer treatment duration, dence & severity of root resorption are the pretreatment root-
fixed appliance treatment, individual susceptibility, ortho- form or root length, previous history of trauma to teeth, &
dontic forces & the type of orthodontic tooth movement [51]. treatment mechanics. Teeth with blunted roots are at in-
creased risk of root resorption [67].
Microscopic changes which are difficult to detect on rou-
tine radiographic images appear on teeth roots. Root resorp-
tion causes root shortening & weakening of teeth arch [52].
Root resorption of greater than 1-2 mm is considered as
clinically significant [53].
It has also been demonstrated that heavy forces are more
likely to produce root resorption than light forces [54]. In a
study conducted on the direction of force and tooth move-
ment in the occurrence of root resorption, showed that com-
pressive forces cause more resorption than tensile forces
[55]. Another study showed that intrusion of teeth causes
about four times more root resorption than extrusion. How-
ever extrusion of teeth might also lead to root resorption in
susceptible individuals. Intrusive force together with lingual Fig. (8). Radiograph showing orthodontic-induced root resorption.
root torque & jiggling movement are correlated with signifi-
cantly more root resorption [56, 57]. Segal etal indicated that IATROGENIC DAMAGE FROM ELASTICS
factors associated with the duration of active treatment might Periodontal destruction due to use of elastic bands was
result in increase in apical root resorption& intrusive forces firstly reported in the dentistry way back in 1980s. During
& total treatment duration are highly correlated with mean different phases of orthodontic treatment, small elastics or
apical root resorption. They suggested that 2-3 months of rubber bands are used for generating a continuous force to
pauses in active force which can be achieved with a passive achieve individual tooth movement. Elastics have long been
archwire minimizes root resorption [58, 59]. Levander et al. used for the correction of orthodontic problems such as di-
showed that the amount of root resorption is significantly astema, crossbites, and malposed teeth [68]. Elastics are also
less in patients who are treated with pauses than in those used for the intentional non-surgical removal of teeth in
treated with continuous forces [60]. cases of hemophilia and also in patients treated with
Acaret et al. indicated that the application of intermittent bisphosphonates, or some other anticoagulant medication
forces results in less root resorption than does the application [69, 70]. As a part of reducing the expenses, many patients
choose the use orthodontic rubber bands as a treatment op-
of continuous forces. This can be explained by the fact that a
tion for closing diastemas [71]. But it is quiet common that
pause in the force allows the resorbed cementum to heal and
the improper use of rubber bands can lead to severe perio-
prevents further resorption [61].
dontal destruction and tooth loss [72]. The periodontal de-
Among all teeth, maxillary incisors are most frequently struction caused by orthodontic elastic bands could be iatro-
involved in apical root resorption followed by mandibular genic [73]. There are only few published reviews of the lit-
incisors & first molars [62]. Remington et al. concluded that erature and case studies in the recent years, reporting the
maxillary incisors are more frequently affected and to a more effect of orthodontic elastic bands that are retained in the
severe extent than the rest of the dentition [63]. gingival tissues [74].
Apical root resorption does not progress after active or- Periodontal lesions induced by elastic bands are complex
thodontic treatment ends. Reparative processes in the form to diagnose but have quite a few features in common that
of smoothening & remodeling of sharp edges starts after may assist in diagnosis and treatment. This could be due to
cessation of treatment. Teeth with severely resorbed roots the absence of local etiologic factors, lack of information
function in a reasonable manner & apical root resorption gathered from the patients and no history of recent trauma or
does not progress after orthodontic intervention [64]. history of orthodontic treatment. Elastic rubber bands be-
cause of their elasticity, have a tendency to creep toward the
Literature states that the apical part of the root has rela-
narrower portion of the tooth and the roots, especially when
tively minor importance for total periodontal support & ap-
there is no specific attachment mechanism [75]. As the band
proximately 3 mm of apical root loss is equivalent to 1 mm
moves apically, it causes periodontal ligament destruction
of crestal bone loss [65].
[76], resulting in extrusive movement of the tooth. The elas-
Tooth support is measured by the length of the root that tic band acts as a foreign body resulting in inflammatory
is invested with in the alveolar bone. Loss of attached and reaction in the soft tissues, thereby weakening the periodon-
crestal alveolar bone will reduce this support, so too will loss tal attachments [77]. A study reported that the inflammatory
of root length by resorption. reactions close to subgingivally extending rubber bands are
Iatrogenic Damage to the Periodontium Caused by Orthodontic Treatment The Open Dentistry Journal, 2015, Volume 9 233

independent of the degree of plaque colonization [78]. Roots [7] Ericsson I, Thilander B. Orthodontic relapse in dentitions with
of the teeth taper towards the apex and a rubber band around reduced periodontal support: an experimental study in dogs. Eur J
Orthod 1980; 2: 51-7.
the cervical area of two adjacent teeth will tend to move [8] Ericsson I, Thilander B, Lindhe J, Okamoto H. The effect of ortho-
along the root surface, eventually causing a bloodless extrac- dontic tilting movements on the periodontal tissues of infected and
tion of the teeth concerned [79]. non-infected dentitions in dogs. J Clin Periodontol 1977; 4: 278-93.
[9] Alfuriji S, Alhazmi N, Alhamlan N, Al-Ehaideb A, Alruwaithi M,
Alkatheeri N, Geevarghese A. The Effect of Orthodontic Therapy
Extraction on Periodontal Health: a review of the literature. Int J Dent. 2014,
Article ID 585048, 1-8 pages.
Orthodontic treatments that include extraction of dental [10] Polson AM, Subtelny JD, Meitner SW, et al. Long-term periodon-
units and movements of adjacent teeth in to the extraction tal status after orthodontic treatment. Am J Orthod 1988; 93: 51-8.
sites can lead to attachment loss, bone loss, gingival clefts, [11] Boyd RL, Baumrind S. Periodontal implications of orthodontic
gingival recession and root resorption. treatment in adults with reduced or normal periodontal tissue ver-
sus those of adolescents. Angle Orthod 1992; 62: 117-26.
[12] Zachrisson S, Zachrisson BU. Gingival condition associated with
Force orthodontic treatment. Angle Orthod 1972; 42: 26-34.
[13] Alexander SA. Effects of orthodontic attachments on the gingival
Teeth with adequate attached gingiva seldom develop health of permanent 2nd molars. Am J Orthod Dentofacial Orthop
gingival recession during orthodontic treatment. This may 1991; 100(4): 337-40.
occur due to application of excessive forces which prevent [14] Geisinger ML, Abou-Arraj RV, Souccar NM, Holmes CM, Geurs
the repair & remodeling of the alveolar bone. NC. Decision making in the treatment of patients with malocclu-
sion and chronic periodontitis: scientific evidence and clinical ex-
Large forces which are produced by rapid palatal expan- perience. Semin Orthod 2014; 20(3): 170-6.
sion have been shown to create a slight degree of attachment [15] Sanders NL. Evidence-based care in orthodontics and periodontics:
a review of the literature. J Am Dent Assoc 1999; 130: 521-7.
loss and some loss of alveolar bone height particularly in [16] Eliasson LA, Hugoson A, Kurol J, Siwe H. The effects of ortho-
older patients. Excessive orthodontic force is also believed to dontic treatment on periodontal tissues in patients with reduced
increase risk of root resorption [80]. periodontal support. Eur J Orthod 1982; 4: 1-9.
[17] Bagga DK. Adult Orthodontics Versus Adolescent Orthodontics:
An Overview. J Oral Health Comm Dent. 2010; 4(2): 42-7.
CONCLUSION [18] Steffensen B, Storey AT. Orthodontic intrusive forces in the treat-
Apart from the benefits of orthodontic treatment like im- ment of periodontally compromised incisors: a case report. Int J Pe-
rio Rest Dent 1993; 13: 433-41.
provement in general & oral health, function, appearance, [19] McComb JL. Orthodontic treatment and isolated gingival reces-
individual comfort & self esteem, the risks associated with sion: a review. Br J Orthod 1994; 21: 151-9.
its treatment are a reality. The complications associated with [20] Mathews DP, Kokich VG. Managing treatment for the orthodontic
orthodontic treatment are a result of multifactorial process, patient with periodontal problems. Semin Orthod 1997; 3: 21-38.
[21] Gartrell JG, Mathews DP. Gingival recession: the condition, proc-
with the patient, orthodontist & orthodontic appliances & ess and treatment. Dent Clin North Am 1976; 1: 199-213.
procedures playing anvital role. A keen periodontal aware- [22] Ko-Kimura N, Kimura-Hayashi M, Yamaguchi M, et al. Some
ness should prevent or limit damage from the orthodontic factors associated with open gingival embrasures following ortho-
treatment. dontic treatment. Aust Orthod J 2003; 19: 19-24.
[23] Tarnow DP, Magner AW, Fletcher P. The effect of the distance
from the contact point to the crest of bone on the presence or ab-
CONFLICT OF INTEREST sence of the interproximal dental papilla. J Periodontol 1992; 63:
995-6.
The authors confirm that this article content has no con- [24] Kurth JR, Kokich VG. Open gingival embrasures after orthodontic
flict of interest. treatment in adults: prevalence and etiology. Am J Orthod Dentofa-
cial Orthop 2001; 120: 116-23.
ACKNOWLEDGEMENTS [25] Kokich VO Jr, Kiyak HA, Shapiro PA.Comparing the perception of
dentists and lay people to altered dental esthetics. J Esthet Dent
Declared none. 1999; 11: 311-24.
[26] Reichert C, Hagner M, Jepsen S, Jäger A. Interfaces between or-
thodontic and periodontal treatment: their current status. J Orofac
REFERENCES Orthop 2011; 72(3): 165-86.
[27] Nokhbehsaim M, Deschner B, Winter J, et al. Contribution of
[1] Socransky SS, Haffajee AD. Evidence of bacterial etiology: a his-
orthodontic load to inflammation-mediated periodontal destruction.
torical perspective. Periodontol 2000 1994; 5: 7-25. J Orofac Orthop 2010; 71(6): 390-402.
[2] Gong Y, Lu J, Ding X. Clinical, microbiologic and immunologic
[28] Zachrisson BU, Alnaes L. Periodontal conditions in orthodontically
factors of orthodontic treatment-induced gingival enlargement. Am treated & untreated individuals. II. Alveolar bone loss. Radio-
J Orthod Dentofacial Orthod 2011; 140(1): 58-64.
graphic findings. Angle Orthod 1974: 44; 48-55.
[3] Teles R, Sakellari D, Teles F, Konstantinidis A, Kent R, Socransky [29] Dannan A. An update on periodontic - orthodontic interrelation-
S. Relationships among gingival crevicular fluid biomarkers, clini-
ships. J Indian Soc Periodontol 2010; 14: 66-71.
cal parameters of periodontal disease, and the subgingivalmicrobi- [30] Dorfman HS. Mucogingival changes resulting from mandibular
ota. J Periodontol 2010; 81(1): 89-98.
incisor tooth movement. Am J Orthod 1978; 74: 286-97.
[4] Loe H, Theilade E, Jensen SB. Experimental gingivitis in man. J [31] Ericsson I, Thilander B, Lindhe J. Periodontal conditions after
Periodontol 1965; 36: 177-87.
orthodontic tooth movements in the dog. Angle Orthod. 1978;
[5] Naini FB, Gill DS. Tooth fracture associated with debonding a 48(3): 210-218.
metal orthodontic bracket: a case report. World J Orthod 2008;
[32] Coatoam GW, Behrents RG, Bissada NF. The width of keratinized
268: e32-6. gingiva during orthodontic treatment: its significance and impact
[6] Ericsson I, Thilander B. Orthodontic forces and recurrence of
on periodontal status. J Periodontol 1981; 52: 307-13.
periodontal disease: an experimental study in the dog. Am J Orthod [33] Foushee DG, Moriarty JD, Simpson DM. Effects of mandibular
1978; 74: 41-50.
orthognathic treatment on mucogingival tissues. J Periodontol
1985; 56: 727-33.
234 The Open Dentistry Journal, 2015, Volume 9 Rafiuddin et al.

[34] Maynard JG. The rationale for mucogingival therapy in the child [58] Segal G, Shiffman P, Tuncay O. Meta analysis of the treatment
and adolescent.Int J Periodont Restorat Dent 1987; 7: 36-51. related factors of external apical root resorption. Orthod Craniofa-
[35] Meeran NA. Iatrogenic possibilities of orthodontic treatment and cial Res 2004; 7: 71-8.
modalities of prevention. J Orthod Sci 2013; 2(3): 73-86. [59] Mahida K, Agrawal C, Baswaraj H, Tandur AP, Patel B, Chokshi
[36] Bolton WA. The clinical application of a tooth size analysis. Am J H. Root resorption: an abnormal consequence of the orthodontic
Orthod 1962; 48: 504-29. treatment. Int J Contemp Dent 2015; 6: 7-9.
[37] Edwards JG. The prevention of relapse in extraction cases. Am J [60] Levander E, Malmgren O, Eliasson S. Evaluation of root resorption
Orthod 1971; 60: 128-44. in relation to two orthodontic treatment regimes. A clinical experi-
[38] Kurol J, Ronnerman A, Heyden G. Long-term gingival conditions mental study. Eur J Orthod 1994; 16: 223-8.
after orthodontic closure of extraction sites: histological and histo- [61] Acar A, Canyurek U, Kocaaga M, Erverdi N. Continuous vs. dis-
chemical studies. Eur J Orthod 1982; 4: 87-92. continuous forceapplication and root resorption. Angle Orthod
[39] Rivera Circuns AL, Tulloch JF. Gingival invagination in extraction 1999; 69: 159-64.
sites of orthodontic patients: their incidence, effects on periodontal [62] Newman WG. Possible etiological factors in external root resorp-
health, and orthodontic treatment. Am J Orthod 1983; 83: 469-76. tion. Am. J. Orthod. 1975; 67: 522-539.
[40] Ronnerman A, Thilander B, Heyden G. Gingival tissue reactions to [63] Remington DN, Joondeph DR, Artun J, Riedel RA, Chapko MK.
orthodontic closure of extraction sites: histologic and histochemical Long-term evaluation of root resorption occurring during orthodon-
studies. Am J Orthod 1980; 77: 620-6. tic treatment. Am J Orthod Dentofacial Orthop 1989; 96: 43-6.
[41] Atherton JD. The gingival response to orthodontic tooth movement. [64] Brezniak. N, Wasserstein. A.Root resorption after orthodontic
Am J Orthod 1970; 58: 179-86. treatment: Part 2. Literature review.1993; 103(2): 138-146.
[42] Robertson PB, Schultz LD, Levy BM. Occurrence and distribution [65] Weltman B, Vig KWL, Fields HW, Shanker S, Kaizer EE. Root
of interdental gingival clefts following orthodontic movement into resorption associated with orthodontic tooth movement: a system-
bicuspid extraction sites. J Periodontol 1977; 48: 232-5. atic review. Am J Orthod Dentofacial Orthop 2010; 137: 462-76.
[43] Helm S, Petersen PE. Causal relation between malocclusion and [66] Brezniak N, Wasserstein A. Root resorption after orthodontic
periodontal health. Acta Odontol Scand 1989; 47: 223-8. treatment: Part 1. Literature review. Am J Orthod Dentofac Or-
[44] Steiner GG, Pearson JK, Ainamo J. Changes of the marginal perio- thop1993; 103: 62-6.
dontium as a result of labial tooth movement in monkeys. J Perio- [67] Linge BO, Linge L. Apical root resorption in upper anterior teeth.
dontol 1981; 52: 314-20. Eur J Orthod 1983; 5: 173-83.
[45] Boyd RL. Mucogingival considerations and their relationship to [68] Waggoner WF, Ray KD. Bone loss in the permanent dentition as a
orthodontics. J Periodontol 1978; 49: 67-76. result of improper orthodontic elastic band use: a case report. Quin-
[46] Sperry TP, Speidel TM, Isaacson RJ, Worms FW. The role of tessence Int 1989; 20: 653-6.
dental compensations in the orthodontic treatment of mandibular [69] Regev E, Lustmann J, Nashef R. Atraumatic teeth extraction in
prognathism. Angle Orthod 1977; 47: 293-9. bisphosphonate-treated patients. J Oral Maxillofac Surg 2008; 66:
[47] Hall WB. The current status of mucogingival problems and their 1157-61.
therapy. J Periodontol 1981; 52: 569-75. [70] Spouge JD. Hemostasis in dentistry, with special reference to
[48] Batenhorst KF, Bowers GM, Williams JE. Tissue changes resulting hemocoagulation. II. Principles underlying clinical hemostatic
from facial tipping and extrusion of incisors in monkeys. J Perio- practices in normal patients. Oral Surg Oral Med Oral Pathol 1964;
dontal 1974; 45: 660-68. 18: 583-92.
[49] Allais D, Melsen B. Does labial movement of lower incisors influ- [71] Adcock JE. Exfoliation of maxillary central incisors due to misap-
ence the level of the gingival margin? A case-control study of adult plication of orthodontic rubber bands. Tex Dent J 1999; 116: 8-13.
orthodontic patients. Eur J Orthod 2003; 25: 343-52. [72] Pan WL, Chan CP, Su C. Localized periodontitis induced by rubber
[50] Dorfman HS. Mucogingival changes resulting from mandibular bands. Report of two cases. Changgeng Yi Xue Za Zhi 1991; 14:
incisor tooth movement. Am J Orthod 1978; 74: 286-97. 54-60.
[51] Roscoe.MG, Meira.JBC, Cattaneo PM. Association of orthodontic [73] Zilberman Y, Shteyer A, Azaz B. Iatrogenic exfoliation of teeth by
force system and root resorption: a systematic review. Am J Orthod the incorrect use of orthodontic elastic bands. J Am Dent Assoc
Dentofac Orthop. 2015; 147(5): 610-626. 1976; 93: 89-93.
[52] Travess H. Orthodontics. Part 6: risks in orthodontic treatment. Br [74] Vandersall DC, Varble DL. The missing orthodontic elastic band, a
Dent J 2004; 196: 71-7. periodontic: orthodontic dilemma. J Am Dent Assoc1978; 97: 661-
[53] Healey D. Rootresorption 2004. Available from: www. orthodon- 3.
tists.org.nz/root_resorption.htm [75] Olsen CB, Pollard AW. Severe bone loss caused by orthodontic
[54] Jones AS, Darendeliler MA. Physical properties of root cementum: rubber bands; management and nine-year follow-up: report of case.
part 8. Volumetric analysis of root resorption craters after applica- ASDC J Dent Child 1998; 65: 25-8.
tion of controlled intrusive light and heavy orthodontic forces: a [76] Haralabakis NB, Tsianou A, Nicolopoulos C. Surgical intervention
microcomputed tomography scan study. Am J Orthod Dentofacial to prevent exfoliation of central incisors from elastic wear. J Clin
Orthop 2006; 130: 639-47. Orthod 2006; 40: 51-4.
[55] Chan E, Darendeliler MA. Physical properties of root cementum: [77] Al-Qutub MN. Orthodontic elastic band-induced periodontitis - a
part 7. Extent of root resorption under areas of compression and case report. Saudi Dent J. 2012; 24(1): 49-53.
tension. Am J Orthod Dentofacial Orthop 2006; 129: 504-10. [78] Regev E, Lustmann J, Nashef R. Atraumatic teeth extraction in
[56] Han G, Huang S, Von den Hoff JW, Zeng X, Kuijpers-Jagtman bisphosphonate-treated patients. J Oral Maxillofac Surg 2008; 66:
AM. Root resorption after orthodontic intrusion and extrusion: an 1157-61.
intraindividual study. Angle Orthod 2005; 75: 912-8. [79] Zilberman Y, Shteyer A, Azaz B. Iatrogenic exfoliation of teeth by
[57] Costopoulos G, Nanda R. An evaluation of root resorption incident the incorrect use of orthodontic elastic bands. J Am Dent Assoc
to orthodontic intrusion. Am J Orthod Dentofacial Orthop 1996; 1976; 93: 89-93.
109: 543-8. [80] Greenbaum KR, Zachrisson BU. The effect of palatal expansion
therapy on the periodontal supporting tissues. Am J Orthod 1982;
81: 12-21.

Received: December 22, 2014 Revised: March 04, 2015 Accepted: March 10, 2015
© Rafiuddin et al.; Licensee Bentham Open.

This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/-
licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.