Limitations and Risks in Orthodontics Flashcards
Anatomic Limitations
- Skeletal discrepancies
- Alveolar ridge
- Space
- Soft tissue
Limitations of Skeletal Discrepancies
- AP, vertical, transverse
Size of discrepancy
Growth modification: only possible in growing patients and limited improvement
Orthognathic surgery needed in severe cases
Limitations of Alveolar Ridge Defect
- Early extraction creates an alveolar bone defect
- Risk of fenestration/dehiscence
Space Constraints Limitations
- Tooth size-arch length discrepancy
- Patients with reduced arch length:
- Proclination/protrusion of incisors
- Expansion
- Distal movement of molars
- Enamel stripping
- Extractions
Soft Tissue Limitations
- Proclination of incisors >2mm risks instability
- Risk fenestration /dehiscence and stripping of gingiva
- Advancement of incisors B-L
- Dental expansion of premolars and molars >3mm
Compromises with Class II Camouflage (Retract upper incisors and procline lower incisors)
- Poor upper lip support
- Increased lower lip protrusion
- Lingual relapse of lower incisors
- Periodontal risks (lower incisors)
Compromises with Class III camouflage (Procline upper incisors, retract lower incisors)
- Poorly defined labiomental sulcus
- More prominent chin
- Periodontal risks (lower incisors)
Compromises with widening of maxillary arch
- Decrease buccal corridors
- May violate transverse dimensions of dentoalveolar base
Compromises with Incisor Proclination
- Fuller lips
- Risk instability: Relapse of crowding
- Risk fenestration, dehiscence, gingival recession
Physiologic Limitations of Orthodontics
- Systemic problems
- Medications
- Growth is age-dependent, genetically programmed, and unpredictability
Systemic Problems
- Juvenile rheumatoid arthritis: Progressive severe skeletal mandibular deficiency
- Acromegaly (>GH): Mandibular prognathism in adult life
Medications
- Bisphosphonates: Inhibit osteoclast-mediated bone resorption
- Prostaglandin inhibitors (NSAIDs, corticosteroids)
Other agents with mixed agonistic and antagonistic effects on various prostaglandins
Limitations of Growth Modification
- Age
- Side effects
- Magnitude of correction
Therapeutic Limitations in Orthodontics
- Unrealistic expectations
- Motivation/compliance
- Relapse
- Smile esthetics
- TMD
- Impaction
- Ankylosis
- Primary failure of eruption
Limitations of Motivation
- Failed appointments
- Poor compliance with wear of removable appliance
- Repeated appliance breakage
- Diet
- Poor OH
Limitations of Relapse
- Time needed for re-organization of periodontal and gingival tissues
- Initial tooth position
- Final tooth position
- Continuation of original growth pattern
- Habits
- Poor retention planning/compliance
- Specific surgical movements
Smile esthetics
Components cannot be influenced by orthodontics alone
- Harmonious gingival margins
- Tooth proportions
- Incisor and gingival display
Risks in Orthodontics
- Periodontal issues
- Decalcification/Caries
- Devitalization
- Root resorption
- TMD
- Soft tissue inflammation
- Injury by orthodontic appliances
- Relapse
Periodontal Risks of Orthodontics
- Gingivitis with or without gingival hyperplasia
- Periodontitis
Preventive Measures for Periodontal Issues
- Good OH
- Regular recalls
- Good periodontal health before orthodontic treatment
- Mindful of anatomic limitations of tooth movement
- KIV pre-orthodontic soft tissue graft in patients at high risk of gingival recession
Prevention of Decalcification and caries
- Caries controlled with good OH before and during orthodontic treatment
- Fluoride measures
- Dietary advice
- Terminate treatment
Management of White-spot lesions
Topical fluoride varnish
Risk of Devitalisation in Orthodontics
- Over-enthusiastic apical movement
- History of trauma
- Deep caries
- Idiopathic
Management of Devitalisation
- Counsel patient of risks
- Stabilization of endo condition before orthodontic treatment
Risks of Root Resorption
Inevitable, usually not clinically significant
Some patients increased susceptibility and severity
Before ortho treatment, take DPT 6 months into treatment to check root status. Pause or terminate treatment if RR is severe. Start with no extractions
Other causes of root resorption
- Forced movements of roots against cortical plates
- Root morphology
- Dilacerations
- History of trauma
Precautions for Root Resorption
- Avoid risk factors
- Regularly monitor with radiographs
Management of Root Resorption
- Pause treatment
- Terminate treatment
Risk of Soft Tissue Inflammation in Orthodontics
- Stomatitis
- Removable appliances
- Nance appliance - Traumatic ulceration
- Allergies: Latex, nickel
Risk of Injury by Orthodontic Appliances
- Aspiration of broken or loose appliances
- Fracture of enamel or large restorations
- Head-gear associated risks
- Mobility as tooth is moved into traumatic occlusion
- Relapse
