CLINICIAN'S CORNER

Tooth separation: A risk-free procedure?

da Costa Monini,a Murilo de Sousa Guimara
~es,b Luiz Gonzaga Gandini Ju

nior,c
Andre
d
e
Lourdes Santos-Pinto, and Josimeri Hebling
S~ao Paulo, Brazil
This article reports the case of a 12-year-old patient with tooth extrusion, pain, gingival bleeding, and localized
periodontitis near the maxillary second premolar. Despite probing and radiographic examination, it was not possible to establish the etiology. Tooth extraction was indicated because of the severe tooth mobility and extrusion.
Curettage of the tooth socket revealed a rubber separator. Preventive approaches are suggested to avoid
iatrogenesis and legal problems. (Am J Orthod Dentofacial Orthop 2012;142:402-5)

he consequences of invasion of the gingival sulcus

and periodontal ligament by orthodontic elastics
have been reported.1-13 Many of these reports
describe problems that occurred during closure of
diastemas with elastics applied directly to the incisor
crowns.1-8,11,13 The elastics can slide on the tooth
crown because of the lack of stabilization and then
penetrate the gingival sulcus, causing tooth mobility,
bone loss, and gingival retraction. These problems are
treated by basic periodontal therapy,4 ap surgery,1,2,9,11
and splinting of the affected teeth,1,6 but in some cases
the tooth is lost because of the severity of the lesion.7,13
Other reports have described cases of periodontitis
secondary to the invasion of elastics in molars.9,12 The
prognosis in molars is better because of the greater
number of roots and also because the roots are
divergent, whereas anterior teeth have more conical
roots, facilitating the penetration of elastics and
periodontal destruction.9,10
An experimental study investigated the histopathology of periodontal lesions induced by elastics placed in
the gingival sulcus of monkeys.14 After 2 to 4 weeks,
a
Postgraduate student, School of Dentistry, Universidade Estadual Paulista, Araraquara, S~ao Paulo, Brazil.
b
Professor, Faculdades Integradas de Santa F
e do Sul, S~ao Paulo, Brazil.
c
Associate professor, School of Dentistry, Universidade Estadual Paulista, Araraquara, S~ao Paulo, Brazil; adjunct clinical professor, Baylor College of Dentistry,
Dallas, Tex, and Saint Louis University, St Louis, Mo.
d
Professor, School of Dentistry, Universidade Estadual Paulista, Araraquara, S~ao
Paulo, Brazil.
e
Associate professor, School of Dentistry, Universidade Estadual Paulista, Araraquara, S~ao Paulo, Brazil.
The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article.
Reprint requests to: Josimeri Hebling, Faculdade de Odontologia de Araraquara,
Rua Humait
a, 1680, Araraquara, S~ao Paulo, Brazil 14801-903; e-mail,
jhebling@foar.unesp.br.
Submitted, February 2011; revised and accepted, June 2011.
0889-5406/$36.00
Copyright 2012 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2011.06.048

402

the inammation extended to the attached gingiva,

and there were bleeding on probing, pockets of 5 to 8
mm, tooth extrusion, and horizontal and vertical bone
loss. After the elastics were removed, the signs of inammation and tooth mobility improved, yet there was no
return to the conditions observed before placement of
the elastics, and the pocket and bone destruction
persisted.
Even though this event is well reported in the
literature, invasion of the periodontal space by rubber
separators is not a common nding.15,16 Because the
placement of rubber separators is routinely performed
in orthodontic practices, its iatrogenic potential should
not be overlooked. We report a case of tooth loss
caused by invasion of the periodontal ligament by
a rubber separator and discuss some of the options
available to prevent this accident.
CASE REPORT

A 12-year-old boy who was receiving orthodontic

treatment in a private practice dental ofce came to
the emergency service of the Pediatric Dentistry Clinic
at Araraquara Dental School in Brazil with a complaint
of pain and difculty in chewing. The clinical examination showed signicant extrusion of the maxillary right
second premolar, preventing occlusion of the teeth,
and localized gingival inammation, as well as cement
on the smooth surfaces of the maxillary right rst molar
(Figs 1 and 2). The radiographic periapical examination
showed enlargement of the periodontal space, and the
root apex had moved from the bottom of the tooth
socket (Fig 3).
The patient reported that a rubber separator had
been placed between the maxillary right second premolar and rst molar, but it could not be found after 2 days;
painful symptoms developed at the same time. When the
orthodontist was unable to nd the rubber separator, he

Monini et al

Fig 1. Extrusion of the maxillary right second premolar,

preventing dental occlusion, and the orthodontic cement
on the crown of the maxillary right rst molar.

Fig 2. Occlusal view of the extrusion of the maxillary right

second premolar.

403

Fig 4. Buccal ap raised to allow inspection of the periodontal ligament region.

Fig 5. The orthodontic rubber separator found during curettage and irrigation of the tooth socket.

days, the symptoms persisted, and the patient went to

the emergency service at Araraquara Dental School.
After inltrative anesthesia, a buccal gingival ap
was raised, and periodontal probing was performed
(Fig 4). Tooth repositioning was then attempted. When
these procedures were unsuccessful, it was decided to
extract the tooth; the rubber separator was found during
curettage of the tooth socket (Fig 5).
DISCUSSION

Fig 3. Periapical radiograph showing the thickening of

the periodontal ligament of the maxillary right second
premolar, especially in the apical region because of the
extrusion.

placed another in the same site. After a week, the second

rubber separator was removed, and bands were cemented on the maxillary rst permanent molars. The patient reported that the pain was still intense after
banding, both at the site and in the temporomandibular
joint region. There was extensive inammation on the
subsequesnt days, and the band was removed. After 9

Tooth separation for banding of teeth is a routine

procedure in orthodontic clinics. Patients also often return for banding without the rubber separators between
their teeth.17 This commonly occurs because the interproximal space is increased, and the rubber separator is
consequently lost during eating or brushing, and the
loss is unnoticed by the patient.18 However, this case
calls attention to the possible invasion of the periodontal
space by rubber separators. When the rubber separator is
missing at the banding appointment, it is advisable to
determine whether the separator was actually removed.
The patient might report that the rubber separator was
missing, but in some cases the patient might not have
noticed it. If there are complaints of pain, localized acute

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Monini et al

404

Fig 6. Radiographic aspects of several brands of rubber separators: A, GAC (Bohemia, NY); B, Orthosource (Los Angeles, Calif); C, TP Orthodontics (La Porte, Ind); D, 3M Unitek (Monrovia, Calif); E, Den~o Paulo, Brazil); G, The Orthodontic Store
taurum (Ispringen, Germany); F, Morelli (Sorocaba, Sa
(Gaithersburg, Md).

periodontitis, and gingival bleeding associated with

tooth mobility or extrusion, the professional should consider the possibility of subgingival displacement of the
rubber separator.1,5,6,13
Rubber separators are commonly left in the mouth for
1 week17,19-21; they can cause enough discomfort to
require the prescription of analgesic drugs.21 However,
enough space for banding is achieved when rubber separators are placed for only 12 hours before the session,
and the patient should be instructed to come to the ofce 3 to 4 hours before the appointment for separator replacement if the separator was lost.18 A shorter time of
rubber separators in the mouth could be a better measure
to prevent accidents, as reported here. Because the peak
pain occurs 24 hours after separator placement, the discomfort to the patient and the risk of accidents like this
might be minimized if rubber separators are used for only
12 hours before banding associated with prescription of
analgesic drugs.20-23 Studies have demonstrated that,
after 5 to 7 days, pain returns to the threshold levels
observed before separator placement.19,22 However,
banding in this period would imply exposing the
patient to pain for nearly a week, and it also increases
the risk of accidents as reported here.
The periapical radiographic examination did not
show a foreign body in the periodontal ligament region.
Observation of the rubber band was not possible because
of its lack of radiopacity. In this report, the cause of
periodontitis was only elucidated after tooth extraction
and curettage of the tooth socket, notwithstanding the
placement of 2 rubber separators at the same site.
Because of several reports of problems related to
periodontal invasion by rubber separators, 1 suggestion
would be to use radiopaciers in the manufacture
of rubber separators to allow for radiographic diagnosis.9,10,12,13 Even though this characteristic is desirable,

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not all commercially available rubber separators have

this property. Figure 6 shows the radiographic images
of some brands with varying degrees of radiopacity.
The use of more radiopaque rubber separators would
be advisable.
CONCLUSIONS

In cases like this, in which a tooth was lost because of

an iatrogenic accident, the patient could decide to sue
the dental professional. Even if this does not occur, the
patient's condence in the treatment might be lost, or
compliance might be reduced because of the fear of
new accidents or insecurity about the approaches to be
followed. The measures discussed here might help to
prevent situations such as that described in this report.
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Monini et al

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