FEATURED ARTICLE Hong Kong Dental Journal 2006;3:15-22

HK
DJ
Risks and complications in
orthodontic treatment
Paul Yun-Wah Lau *, MDS, DOrthRCS, MOrthRCS, FRCDC, FHKAM (Dental Surgery), FCDSHK (Orthodontics)
Ricky Wing-Kit Wong †, BDS, MOrth, PhD, MOrthRCS, FRACDS, FHKAM (Dental Surgery), FCDSHK (Orthodontics)

ABSTRACT This article describes various aspects of risks and complications, commonly encountered in orthodontic
treatment and also describes ways to minimize such risks and complications in the course of orthodontic treatment.

Introduction

Orthodontic treatment can improve mastication, speech

and appearance, as well as overall health, comfort, and
self-esteem. However, like many other interventions,
orthodontic treatment has inherent risks and complications
(Table 1). Thus, if correcting malocclusion is to be of
benefit, the advantages it offers should outweigh any
possible damage 1. It is also important to implement risk
control procedures during and after orthodontic treatment.

The psychological aspects of orthodontic treatment

should be given due consideration and must not be
overlooked. Patient selection always plays a vital role in
minimizing risks. Moreover, clinicians should be vigilant
in assessing and monitoring every aspect of the patient’s
orthodontic treatment during and after treatment to achieve
an uneventful, secure, and successful final result.
Enamel demineralization/caries
Caries usually occurs on smooth surfaces and is a common
complication in orthodontics, affecting 2% to 96% of all
orthodontic patients 2. Increased caries risk during such
treatment is due to several factors:
• lesions are difficult to locate;
• lowering of resting pH;
• increased volume of dental plaque; and
• a rapid shift in bacterial flora 3.
Maxillary lateral incisors, maxillary canines, and
mandibular premolars are the most commonly affected
* Private practice as Specialist in Orthodontics
†
Faculty of Dentistry, The University of Hong Kong, Hong Kong
Correspondence to:
Dr. Paul Yun-Wah Lau
Suite 329, Central Building, 1 Pedder Street, Central, Hong Kong
Tel : (852) 2868 3831
Fax : (852) 2869 8860
e-mail : DrLau@Ortho-Center.com
Figure 1 Demineralization
teeth 4. However, any tooth may be involved and often a
number of anterior teeth show demineralization (Figure 1).
Whilst the demineralized surface remains intact,
remineralization and reversal of the lesion is possible. In
severe cases, however, there may be frank cavitation
requiring restorative intervention.
Preventive measures to minimize damage include:
patient selection, intensive oral hygiene instruction and
monitoring, and dietary education. At each visit, oral
hygiene and dietary education should be reinforced. At
every adjustment appointment, it is crucial to inspect the
teeth to avoid missing early demineralized spots. When
patients use daily 0.05% sodium fluoride rinse, the
occurrence of caries decreases 5. Professional cleaning of
teeth is also recommended if patients cannot achieve
satisfactory oral hygiene. In severe cases and as a last
resort, early removal of the appliance may be required to
confine the damage.
Where demineralization is present, various methods
have been recommended including the use of fluoride

Hong Kong Dent J Vol 3 No 1 June 2006 15

Lau and Wong

Table 1 List of some possible complications related to paste and adjunct fluoride mouthwashes (0.05% sodium
orthodontic treatment fluoride daily rinse or 0.2% sodium fluoride weekly rinse)
Crowns to help remineralization and reduce unsightly marking. For
Decalcification more severe cases, treatment involving an acid/pumice
Enamel wear micro-abrasion technique has been advocated, but should
Enamel fracture be performed at least 3 months after debond to allow initial
Resorption
remineralization.
Pulpitis
Roots
Resorption Physical damages on enamel
Early closure of root apex
Pulp Enamel damage most commonly stems from occlusal
Pulpitis contacts with orthodontic brackets; being worst with
Periodontal ceramic, metal, and composite brackets (in that order).
Gingivitis
When placing appliances, extreme care is needed to avoid
Periodontitis
Burns direct contact between the orthodontic brackets and the
Recession opposing teeth. The incisal edge of the upper anterior
Dark triangle teeth 6 and the buccal cusps of upper posterior teeth are
Bone frequently affected. If direct contact between orthodontic
Crestal bone resorption bracket and the tooth is unavoidable, then the other teeth
Abnormal development
should properly share the occlusion loading. A night guard
Soft tissues
Direct trauma
is sometimes required for patients who grind their teeth at
Mucosal ulceration due to appliances night.
Trauma from headgear whisker
Clumsy instrumentation Careless use of an orthodontic band seater or band
Soft-tissue clefts remover can result in enamel fracture. Care is required
Poor gingival contours
when large restorations are present, since these can result
Temporomandibular joint
Temporomandibular dysfunction in fracture of unsupported cusps 7. Debonding can also
Condylar resorption result in enamel fracture, both with metal and ceramic
Face brackets 8,9. Care must always be taken to remove brackets
Skin trauma from displaced headgear whisker and residual bonding agents so as to minimize the risk of
Eye damage from displaced headgear whisker enamel fracture. Debonding burs have the potential to
Bruising from headgear strap (uncommon) remove enamel, especially in fast air turbine handpieces.
Chemical burn from etchant
Thermal burns from overheating handpiece Care and attention is needed when adhesives are removed.
Nickel-induced sensitivity associated with headgear
Allergy/sensitivity to nickel Wearing down of enamel due to contact with both metal
Cytotoxicity and ceramic brackets (abrasion) may occur. It is common
Heart on upper canine tips during retraction, as the cusp tips hit
Infective endocarditis lower canine brackets. Such wear and tear may also ensue
Cross-infection
on the incisal edges of upper anterior teeth, where ceramic
Operator to patient
Patient to operator brackets are placed on lower incisors 6. Ceramic brackets
Patient to patient are very abrasive. Attention should be paid to the lower
Any source to third parties teeth wherever there is a possibility of the brackets occluding
Gastro-intestinal tract/respiratory tract with the upper teeth, whilst appreciating that overbite
Swallowing or aspiration of small parts sometimes increases in the early stages of treatment.
Systemic diseases
Bone, blood, endocrine disorders
Any enamel erosion must be recorded prior to
Growth
Unfavorable growth
commencing treatment and appropriate dietary advice
Psychological
given to minimize further tooth substance loss. Since
Teasing carbonated drinks and pure juices are the most common
Abnormal patients/parents behavior causes of erosion, they should be avoided in patients with
Treatment results fixed appliances 10.
Unfavorable results
Unable to maintain results Pulpal reactions
Unable to complete treatment
Failed treatment
Studies using radiorespirometric techniques indicate that

16 Hong Kong Dent J Vol 3 No 1 June 2006


orthodontic forces cause a depression of the oxygen
utilization system within pulp cells. Disturbances in the
circulation of the pulp are more severe when a greater
force is used and when the force is applied for a longer
time 11. The application of light continuous force to the
crown of a tooth will produce a mild and transient
inflammatory response within the pulp. Some degree of
pulpitis is therefore to be expected with orthodontic tooth
movement, but is usually reversible or transient and has
no long-term significance 12. Although it rarely leads to
loss of vitality, there may be an increase in pulpitis in teeth
previously traumatized by fixed appliances. Thus,
particularly with traumatized teeth, only light forces
should be applied and vitality should be monitored every
3 months 13. Though there are reports of pulpal necrosis
following orthodontic therapy 14, they are very few in
comparison with the number of patients having daily
orthodontic treatment.
There is a risk that removing bonding material after
debonding increases local temperature and may result in
pulp damage 15. Temperatures of 46-50 C° for 30 seconds
lead to thrombosis and curtail circulation. Water or air must
therefore be used as a coolant.
One or more teeth that may have been traumatized by
an accident or large fillings can cause nerve damage.
Orthodontic tooth movement may, in some cases,
aggravate this condition and necessitate root canal
treatment.
Root resorption
Some degree of external root resorption is inevitably
associated with fixed appliance treatment, although its
extent is unpredictable 16. The tendency to root resorption
is greater in dentitions, involving dental agenesis, in-
vaginations, and taurodontic root shapes. Other predictors
include: anomalous lateral incisors as well as abnormal
root morphology of incisors and premolars 17,18. Resorption
may occur on the apical and lateral surface of the roots,
but radiographs only reveal a degree of apical resorption.
In many instances no clinically significant resorption is
evident or visualized by routine radiography, but
microscopic surface changes are nevertheless likely to
have occurred. Ketcham 19 found that the upper incisors
are more frequently involved than other teeth. Others
claim that mandibular incisors are more liable to resorption
than the upper ones 20. The buccal roots of the first
maxillary molars and premolars also exhibit frequent root
resorption 21. The degree of root resorption is usually less
than 2 mm, but can be more extensive 22. Even idiopathic
root resorption may occur. However, resorption rarely
compromises the longevity of teeth 23. Vertical loss of bone
through periodontal disease creates a far greater loss of
Risks and complications in orthodontic treatment
attachment and support than equivalent losses around the
apex of a tooth.
The mechanism of tooth resorption during orthodontic
treatment remains unclear. According to one theory,
excessive force and hyalinization of the periodontal
ligament results in excessive activity of cementoclasts and
osteoclasts. Be that as it may, the risk factors associated
with severe resorption are well known and can be
summarized as follows 10:
• Shorter than average roots;
• Previously traumatized teeth;
• Teeth lacking vitality after root treatment;
• Application of excessive forces to teeth; and
• Combining orthodontic and orthognathic procedures.
According to most studies 24-26, understanding the
orthodontic forces in terms of their magnitude, type,
direction, and duration can help explain the resorptive
process. Force duration has been regarded as a more critical
factor than its magnitude, especially when prolonged. The
mechanical influence of the appliance also appears to be
of particular importance. Linge and Linge 24,27 claimed that
for apical root resorption the variables that contributed
significantly were: overjet, pre-treatment trauma to
maxillary incisors, periods of treatment with rectangular
wires and Class II elastics. Lip and tongue dysfunction,
finger-sucking, habits persisting beyond age of 7 years,
and impacted maxillary canines are also important.
Treatment of ectopic canines may induce resorption of
adjacent teeth, because of the treatment duration and
distance the canines are moved. Tooth intrusion is also
associated with increased risk, as well as movement of root
apices against cortical bone. Beyond the age of 11 years,
treatment seems to increase the risk of resorption. Adults
have shorter roots at the outset, which also increases the
potential for resorption.
Opinion is divided as to whether increased treatment
duration is associated with increased resorption; no
correlation as well as definite correlations have been
described. In a few patients systemic disorders such as
hypothyroidism may contribute, but for the most part no
underlying cause (other than individual susceptibility) can
be identified. Familial risk is also known.
The degree of resorption can be very variable,
highlighting the importance of individual susceptibility
over and above other risk factors. Research to identify the
mechanisms of resorption, trigger factors, and reparative
mechanisms is still required, with a view to modifying
future treatment modalities and minimizing root damage.
Currently, no patient is immune from the risk of some root
resorption. All prospective recipients of such treatment
Hong Kong Dent J Vol 3 No 1 June 2006 17
Lau and Wong
Figure 2 Gingival swellings
should therefore be warned at the outset. If root resorption
is to be minimized, at the outset of treatment it is important
to recognize specific risk factors, and take and interpret
radiographs accurately.
If and when resorption is recognized during the course
of the intervention, lighter forces must be used, root length
monitored 6-monthly with radiographs, and the treatment
aims should be reconsidered to maximize longevity of the
dentition. In severe cases, treatment may have to cease in
order to prevent further resorption though this entails
accepting a less-than-ideal result.
Periodontal tissues
Fixed appliances make oral hygiene difficult even for the
most motivated patients, and almost all of them experience
some degree of gingival inflammation. Gingival swelling
(Figure 2) and gingival recession are common sequelae of
orthodontic procedures.
Inflammatory changes (particularly bleeding) are
frequently noted even in orthodontic patients with
excellent tooth cleaning habits. The interproximal areas
are usually more affected than the facial areas, and
posterior more than anterior teeth. Signs of inflamma-
tion subside rapidly after removal of the orthodontic
appliance 28.
Orthodontic appliances have the potential to damage
the periodontal support of treated teeth 29. Alveolar
bone loss occurs more often in orthodontic patients than
in reference subjects, the difference being small but
significant 30,31. Bands induce more gingival inflammation
than bonds, which is not surprising since bands are more
plaque retentive and their margins are often placed
subgingivally. Boyd and Baumrind 32 showed that values
for plaque and gingival indices, bleeding tendency, and
18 Hong Kong Dent J Vol 3 No 1 June 2006
Figure 3 Interproximal recessions
pocket depths were all significantly greater in banded teeth
than in bonded ones.
For the most part, orthodontic treatment appears not
to affect the periodontal status of patients over the long
term. Sadowsky and BeGole 33 studied a group who had
received orthodontic treatment 35 years earlier. They
compared the findings with those in a reference group with
untreated malocclusions. There was no significant
difference in the general prevalence of periodontal
disease between the two groups. No significant damage
or benefit to the periodontal structures could be directly
attributed to the orthodontic therapy. However, it is rare
for gingivae to re-grow into the receded areas, particularly
if they are interproximal (Figure 3). Labial movement of
mandibular incisors may result in gingival recession.
Gingival recession and loss of alveolar bone have been
reported as a result of teeth moving in the presence of
inflammation 34.
Patients with pre-existing periodontal disease require
special attention, but bone loss during treatment does not
seem to be related to previous bone loss. Compressed
gingiva in extraction sites (Figure 3) may nevertheless
produce a long-lasting epithelial tissue fold; most
frequently this occurs on the buccal aspect of mandibular
first premolar extraction sites 35.
In patients with existing periodontal disease, the
need for excellent oral hygiene during treatment must
be emphasized. Use of bonds rather than bands on
molars and premolars may be more appropriate, in
order 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 therefor e
periopathogenic 36.

Figure 4 Ulceration of lip
Oral hygiene instruction is essential in all cases of
orthodontic treatment, and the use of adjuncts such as sonic
electric toothbrushes, interproximal brushes, chlorhexi-
dine mouthwashes, fluoride mouthwashes, and regular
professional cleaning must be reinforced. However,
patient motivation and dexterity are paramount in the
success of hygiene. Moreover, there will always be
individuals whose oral hygiene is unsatisfactory.
Experience shows those who are unable to maintain
a healthy oral environment in the absence of fixed
orthodontics, will fail spectacularly with braces in place.
In such patients, benefit may therefore significantly
outweigh the risks of treatment.
Allergy
Leaching of materials from appliances is responsible for
hypersensitivity reactions and may entail the release of
known allergens such as nickel, chromium, and cobalt.
Other allergens are components or chemical catalysts in
bonding materials, cold curing acrylics, or in latex
components 37.
Gjerdet et al 38 found a significant release of nickel and
iron into the saliva of patients just after placement of fixed
appliances. However, there was no significant difference
in nickel or iron concentrations between controls and
subjects in whom the appliances had been in place for a
number of weeks. The clinical significance of nickel release
is as yet unclear, but should be considered in sensitive
patients. A few patients have suffered severe latex allergies
caused by elastics or operators’ gloves.
Allergy to nickel is more common in extraoral settings,
usually as a result of contacts with face-bow or headgear
strap. Over 1% of patients have some form of contact
dermatitis to zips and buttons/studs on clothing. About
3% of the latter claim to have experienced similar rashes
Risks and complications in orthodontic treatment
Figure 5 Mucosal hyperplasia
with orthodontic appliances. Use of sticking plaster over
the areas in contact with the skin is sufficient to relieve
symptoms. Allergy to latex 39 and bonding materials have
been reported although these are rare.
Trauma
Lacerations to the gingivae and oral mucosa may present
as ulceration or hyperplasia (Figures 4 and 5). They often
occur during treatment or between sessions because of
archwire, brackets and bands, and especially where long
unsupported stretches of wire rest against the lips.
Excessive muscular activities of the cheek or tongue may
act as triggers. The use of dental wax over the bracket may
reduce trauma and discomfort, as may rubber tubing on
the unsupported archwire. Careful rounding-off of sharp
edges of the appliance can be helpful.
Extraoral appliances cause both extra- and intra-oral
adverse reactions 40,41. Reports of injuries with extraoral
appliances have shown that out of the nearly 5000
orthodontists (responsible for treating approximately 4.5
million patients), 4% reported that headgear injury had
ensued in one or more of their patients 40; 40% were
extraoral injuries. Samuels and Jones 41 classified the types
of injuries as follows:
• accidental disengagement when playing (3/11);
• incorrect handling (3/11);
• disengagement by another child (2/11); and
• disengagement while asleep (3/11).
There is a risk of damage and infection of the eye.
The surface of the inner arch of the face-bow is rich in
oral microorganisms and the eye forms an excellent
culture medium following inoculation of microorganisms,
even through a small abrasion. An infection of the eye is
very hard to manage despite appropriate antibiotic
therapy. No matter how prompt and suitable the treatment,
Hong Kong Dent J Vol 3 No 1 June 2006 19
Lau and Wong
the eye may have to be enucleated following such an
injury.
Following a well-publicized case of eye trauma in a
patient wearing headgear 42, a number of safer products
have been designed with explicit guidelines on how to
use them. The latter included the use of safety bows, rigid
neck straps, and snap release products to prevent the bow
from disengaging from the molar tubes or acting as a
projectile. Safety headgear products are strongly recom-
mended, and the information itemized below should be
provided routinely:
• not to be worn when playing;
• if grabbed by another person, take hold of the face-
bow and then slowly release the headgear strap; and
• always remove headgear strap before face-bow 3.
Temporomandibular dysfunction
In the literature, much attention has been focused on the
relationship between temporomandibular dysfunction
(TMD) and orthodontic treatment. Whilst TMD is common
in the general population irrespective of orthodontic
treatment, there is no evidence to support the theory that
orthodontic treatment causes TMD or cures it 43. Moreover,
orthodontic patients do not have a higher chance of
developing TMD than the general population 44 .
Accordingly, it is believed that there is no direct relation
between the two. However, pre-existing TMD should be
recorded, and the patient advised that treatment will not
predictably improve their condition and that some may
suffer increased symptoms. Whenever patients experience
symptoms during treatment, the standard approach to
assessing TMD should be taken. Conservative treatment
should be directed at eliminating discomfort, occlusal
disharmony and joint noises and reassuring the patient.
Other forms of standard treatment (e.g. soft diet, jaw
exercises) may also be indicated.
Profile changes
Unsatisfactory profile changes (dishing in of the face or
increase in facial fullness) have been common complaints
after orthodontic treatment. Some have even blamed ex-
traction of premolars without proper torque control of the
anterior segments. Likewise, excessive expansion of the
dental arch in the anterior-posterior direction will result in
increased fullness of the lip and sticking of incisors. Careful
planning and adequate communication with patients helps
to reduce the chance of the complaints.
A review concluded that orthodontics does not affect
facial profile adversely, whilst also highlighting areas where
planning is crucial 45. Soft tissue changes also occur
naturally with age, regardless of orthodontic intervention.
20 Hong Kong Dent J Vol 3 No 1 June 2006
Proper diagnosis should take account of skeletal
form, tooth position, and soft tissue form so as to negate
any detrimental effect on profile due to treatment
mechanics 46. Ultimately, the patient’s expectation of the
finished profile dictates the choice of treatment.
Infection control
Spread of infection between patients, between operator
and patient, and by third parties should be prevented by
adequate infection control procedures throughout the
surgery. Use of gloves, masks, sterilized instruments, and
‘clean’ working areas are paramount. The use of a runner
in helping the assistant is definitely an effective way to
reduce the chance of cross-contamination. The choice of
a higher level of infection control regimen is desirable if
resources allow. A detailed medical history must be taken
from every patient to determine risk factors.
Patients at risk of endocarditis should be treated in
accordance with appropriate guidelines and in consultation
with a cardiologist 47,48. Immaculate oral hygiene is essential,
and must be coupled with antibiotic cover for invasive pro-
cedures such as extractions, separation, band placement,
and band removal. Bonding attachments are used on all
teeth to negate the need for antibiotic cover against
bacteremia caused by both introduction of separators and
band placements and removal. This also reduces liability to
unwanted plaque in stagnant areas. To minimize bacterial
loading, chlorhexidine mouthwash has been advocated
prior to any treatment and in some cases even daily 49.
Stability or relapse
There is extensive research on post-treatment stability or
relapse 50. Orthodontic treatment results are potentially
unstable and retention is necessary for three major reasons:
1. Gingival, periodontal and supporting bone tissues
change during such treatment and require a period of
time for re-organization when the appliances are
removed.
2. Teeth are inherently in an unstable position after the
treatment, so they are easily affected by unbalanced
soft tissue pressure.
3. Continual growth of the jaws and alveolar processes
affects the orthodontic result.
The initial 6-month post-treatment is important, as it
may take 4 to 6 months for the periodontal ligament and
supporting bone to complete re-organization 51,52. That is
why teeth have a stronger tendency to move immediately
after orthodontic treatment and the effect diminishes
gradually after the alveolar bone and the periodontium
return to their normal pattern 53. Proper use of retainers
can help to reduce post-treatment relapse.

Figure 6 Upper arch after treatment
Most relapses (Figures 6 and 7) are due to inadequate
wearing of retainers and inadequate monitoring. It has
been observed that teeth move throughout life. According
to extensive studies in the University of Washington 54,
teeth move irrespective of whether or not they are
orthodontically treated. Long-term retention and
monitoring are widely advocated 53.
Throughout life the bite can change adversely due to
various causes. These include: eruption of wisdom teeth,
genetic influences controlling the size of the tongue, the
teeth and the jaws, growth and/or maturational changes,
mouth breathing, playing of musical instruments, and
other oral habits. All of the latter may be beyond the control
of the orthodontist. Following treatment, tooth and/or jaw
position may change adversely to a degree that warrants
additional treatment. The extent of any further inter-
ventions depends on the nature of the problem and might
involve a variety of modalities including surgery.
Swallowing/inhalation of small parts
Orthodontic appliances are composed of very small parts
connected together. They can be accidentally swallowed,
aspirated, and they can irritate or damage oral tissues.
Systemic diseases
General medical problems, such as cardiac diseases 49,
blood 49, neurological 55, cancer 56, or endocrine disorders 57,
can affect orthodontic treatment. Any changes in the
patient’s health should be checked for on a regular basis.
Conclusions
There are several sources of potential iatrogenic damage
due to orthodontic treatment. When properly performed,
severe damage is very rare. More benefit is likely to accrue
Risks and complications in orthodontic treatment
Figure 7 Relapse of upper arch
Table 2 Recommended practices
Promote trust
Communication
Records according to minimum data set (personal details,
clinical assessment, diagnosis, aims and objectives, treatment
plan, consent, record of treatment, treatment outcome 54)
Study models—pre- and post-treatment
Radiographs
Photographs
Consent—inform the patient, written consent as an adjunct
In-house complaints procedure
Timely referral to specialists care
from treatment of severe malocclusions. Individuals should
be assessed for risk factors. Rarely, attempts to correct
malocclusion can leave the patient worse off than before
treatment. Good clinical practice 58,59 (Table 2), careful
patient selection, and good cooperation and understanding
between all parties are prerequisites to minimizing tissue
damage.
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