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 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 inflammation subside rapidly after removal of the orthodontic appliance Orthodontic appliances have the potential to damage the periodontal support of treated teeth . Alveolarbon e loss occurs more often in orthodontic patients than in reference subjects, the difference being small but significant . 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 showed that values for plaque and gingival indices, bleeding tendency, and 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 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 . 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 .
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 may nevertheless produce a long-lasting epithelial tissue fold; most frequently this occurs on the buccal aspect of mandibular first premolar extraction sites .
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 therefore periopathogenic .
Oral hygiene instruction is essential in all cases of orthodontic treatment, and the use of adjuncts such as sonic electric toothbrushes, interproximal brushes, chlorhexidine 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.