JIAOMR

10.5005/jp-journals-10011-1299
REVIEW ARTICLE

Orthodontic Scars

Orthodontic Scars
Vinay Reddy, Vijeev Vasudevan, Gowri Sankar, AV Arun, S Mahendra, Mohammed K Khalid

ABSTRACT
Orthodontic therapy apart from its benefits also has potential
risks and limitations in terms of tissue damage. Fortunately, in
orthodontics, risks are minimal and infrequent. However, all
potential risks and limitations should be considered and
addressed when making the decision to undergo orthodontic
treatment. Orthodontic treatment carries with it the risk of various
types of soft and hard tissue damages (e.g. decalcification of
enamel, lacerations, ulcerations, temporomandibular joint
disorders, etc.), apart from treatment failure in itself. If correcting
a malocclusion is to be of benefit, the advantages offered should
outweigh any possible damage. All preventive procedures
should be considered during and after orthodontic treatment to
restore the normal health of soft and hard tissues. Hence, the
orthodontist should be vigilant and prudent enough in assessing
and monitoring every aspect of these tissues at any given stage
and time in order to achieve a healthy and successful final result.
Keywords: Orthodontic scars, Enamel decalcification, Enamel
fracture.
How to cite this article: Reddy V, Vasudevan V, Sankar G,
Arun Av, Mahendra S, Khalid MK. Orthodontic Scars. J Indian
Aca Oral Med Radiol 2012;24(3):217-222.
Source of support: Nil
Conflict of interest: None declared

INTRODUCTION
Malalignment, crowding, spacing and proclination of teeth
have been perennial esthetic problems since ages.
Orthodontic treatment has thus become an integral part of
the esthetic dentistry in the quest for a perfect smile. Apart
from esthetics it also helps some patients by significantly
improving mastication, speech, appearance, overall dental
health, comfort and self-esteem. However, orthodontic
appliances at times can cause harm to the related hard and
soft tissues during and after treatment if the orthodontist is
not vigilant.1 This potential risk need to be identified early
and managed appropriately to avoid such adverse problems.
Such damage to the soft and hard tissues that are expressed
clinically either intra and/or extra orally are called
orthodontic scars.
Orthodontic scars may be present during and after
treatment and are seldom severe to offset the advantages of
treatment. Most of them are reversible damages and are
transient in nature on soft tissues. However, the hard tissue
damage can be irreversible, resulting in further treatment
following the completion of orthodontic therapy as seen in
the case of enamel decalcification. Hence, it is imperative

that the patient should be addressed about such possibilities

prior to orthodontic treatment.2
Orthodontic scars can be broadly classified as follows:
1. Lesions of enamel
Enamel decalcification/white spot lesions
Physical damages on enamel (enamel wear/enamel
fractures)
2. Periodontal tissues
Gingivitis/gingival enlargement
Gingival recession
Dark triangles
3. Soft tissues
Direct damage caused by components of removable
and/or fixed appliance components:
Removable appliances
Fixed appliances and components causing
impingements, ulcerations and lacerations
resulting from
- Archwires, brackets, bands, etc.
- Headgear and face bow, etc.
- Loops and utility arches, etc.
Indirect damage by allergic reaction to:
Nickel
Latex
Soft tissue complications related to implants
Ulceration of overlying soft tissue
Peri-implantitis
Fracture during removal
LESIONS OF ENAMEL
Enamel Decalcification/White Spot Lesions
White spot lesions around orthodontic attachments (Fig. 1)
is one the most common problem during and after fixed
orthodontic treatment.3 Plaque accumulation around the
appliance components and bonding materials results in
subsequent production of acid by the bacterial plaque
resulting in demineralization and alteration in the
appearance of the enamel surface. Early lesions appear as
opaque, white spots 4 that may progress to caries if
demineralization continues without intervention with
preventive measures, such as fluoride application and other
oral hygiene maintenance protocols. Clinically, they may
be clinically detected as early as 1 to 2 months into treatment
and their prevalence5 among orthodontic patients ranges
from 2 to 96%. The labiogingival area of the central and

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Vinay Reddy et al

lateral incisors is the most common site for the white spot
lesions while the maxillary posterior segments are the least
common sites for their formation.10 Their incidence is found
to be more among male patients due to poorer oral hygiene
maintenance than females.5,6
The most important means of preventing demineralization is to ensure that the patients maintain a high standard
of oral hygiene throughout treatment. Fluoride is a wellestablished anticariogenic agent. Topical fluoride
applications like 0.05% sodium fluoride, 1.2% acidulated
phosphate fluoride mouth rinse (weekly), 0.4% stannous
fluoride gel and fluoride varnish can be used to maintain
such high standards.7-9 For noncompliant patients, fluoridecontaining cements/bonding agents10 and fluoride-releasing
elastomeric ligatures11 can be used for the same.
Physical Damages on Enamel (Enamel Wear/
Enamel Fractures)
Enamel damage most commonly occurs during debonding
of orthodontic brackets. It is more common during
debonding of ceramic brackets. The frequently affected
areas areincisal edges of the upper anterior teeth,12 buccal
cusps of upper posterior teeth and upper canine tips during
debonding. Most commonly, careless use of an orthodontic
band seater or band remover or debonding pliers results in
enamel fracture (Fig. 1). Care is required especially when
large restorations (composite build-up) are present, since
these can result in fracture of unsupported cusps and incisal
edges. Debonding can also result in enamel cracks that
provide stagnation areas for the development of caries.13
Zachrisson found that the prevalence of pronounced cracks
in relation to the total number of cracks was 6% for
debonded/banded teeth and 4% for untreated teeth.
However, there were appreciably more cracks with
chemically bonded ceramic brackets.14
Peeling off stroke at the bracket-resin interface is the
advocated method of removing brackets and residual
bonding agents so as to minimize the risk of enamel fracture.
Appropriate dietary advice should be given to minimize
tooth substance loss. Carbonated beverages and pure citrus
fruit juices are the most common causes of erosion and
should be avoided in patients with fixed appliances.15

attachment, etc. The interproximal areas are usually more

affected than the facial areas and posterior teeth more than
anterior teeth. Gingival hyperplasia/enlargement is generally
observed around orthodontic bands, leading to pseudopocketing and giving the illusion of attachment loss
(Fig. 2); however, even this condition is transient in nature
and usually resolves within weeks of debanding.16-19 Adult
patients usually are at higher risk of periodontal problems.
Light orthodontics forces are recommended for adult
orthodontics. Utmost care should be taken particularly in
patients with systemic diseases, such as epilepsy as they
may be on phenytoin that causes gingival hyperplasia.20
Gingival Recession
Alveolar bone loss and gingival recession in adult
orthodontic patients is more common than in normal
individuals21 (Fig. 3). Banding induces more gingival
inflammation than bonding with composite resins, since they
are more plaque retentive and their margins are often placed
subgingivally. Gingival recession and loss of alveolar bone
have been reported as a result of teeth moving in the presence
of inflammation.22

Fig. 1: Post-debonding photograph showing areas of enamel

decalcification of anterior teeth and enamel fracture of upper left
incisal edge

PERIODONTAL TISSUES
Gingivitis/Gingival Enlargement
Gingival inflammation is the first and foremost immediate
clinical tissue response that can be appreciated in almost
all orthodontic patients (Fig. 2). It is transient and does not
lead to any further complications, such as loss of gingival

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Fig. 2: Gingival inflammation and enlargement seen between

upper right canine and premolar area

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Orthodontic Scars

Dark Triangles
Dark triangles may be seen as an unesthetic open gingival
embrasure usually between incisors (Fig. 4) during the
course of orthodontic treatment due to loss of gingival
attachment as a result of periodontal disease or while
correcting rotated or crowded anterior teeth.23 Thus, care
should be taken to avoid any attachment loss. If such
unesthetic areas are observed, they can be treated by
removing enamel at the contact point so that the teeth can
be moved closer to minimize the space between them.
However, care should be taken not to distort the proportional
relationships of the teeth to each other in terms of their
connector heights. Both, actual and potential black triangles
should be noted during examination and the patient should
be informed about reshaping the teeth later to minimize the
esthetic problem.

damage is a result of headgear strap. However, risk of

damage and infection of the eye due to headgear have been
reproted.25
Samuels and Jones26 classified the types of headgear
injuries based of percentage occurrences:
1. Accidental disengagement of head strap while playing
(27%)
2. Incorrect handling (27%)
3. Disengagement by another child (19%)
4. Disengagement while asleep (27%)
To reduce the risk of injury, headgears now come with
a variety of safety features, which prevent them from causing
damage to the face or the eyes. The use of safety bows,
rigid necks straps and snap release products are mandatory

SOFT TISSUE
Intraoral and extraoral soft tissue damage may be discussed
under the following headings:
Direct Damage caused by Removable and/or
Fixed Appliance Components
Removable Appliances
Retainers given after completion of orthodontic treatment
form the bulk of removable appliances. Occasionally the
Hawleys retainer may also be used to correct minor anterior
corrections, such as mild spacing or single tooth rotations,
crossbite, etc. The acrylic component and wires (retentive
clasps, springs, canine retractors, etc.) at times may cause
tissue impingement due to sharp edges. Though rare, cases
of allergy and toxicity due to the unpolymerzed material of
acrylic resin have also been reported.24
To avoid such problems patients should be recalled after
2 weeks to round off any sharp edges or impingements.
Fixed Appliance and Its Components

Fig. 3: Gingival recession on labial aspect of lower left central

incisor

Fig. 4: Dark triangle between the central incisors

Archwire, Brackets, Bands, Transpalatal Arch

Lacerations and ulcerations of the gingiva and oral mucosa
occurs often during the initial phase of treatmentinsertion
of bands, brackets, wires and other auxiliaries (Fig. 5).
Keratinization of tissues takes about 2 weeks. Use of dental
wax over the brackets and rubber tubing of unsupported
wires help reduce pain and discomfort due to trauma caused
during this phase.2
Headgear
Headgear appliance can cause injury if it is displaced either
during sleep or rough play. Most commonly facial skin

Fig. 5: Ulceration of lip mucosa due to rubbing against lower

rightcanine bracket

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to prevent the bow from disengaging from the molar tubes.

Patients should be given both verbal and written safety
instructions after fitting the headgear and advised not to
wear the appliance while playing outdoor sports.
Loops, Utility Arches
These are archwires that are often used during orthodontic
treatment for space closure, space maintenance or intrusion.
Utmost care must be taken during their fabrication as they
extend into the vestibular area, which may cause tissue
impingement, ulcerations and other types of tissue damage
(Fig. 6). Even minor amounts of continuous tissue
impingement, if disregarded, may lead to more serious
problems like ulceration or tissue hyperplasia around the
loop. In extreme situations, the loop may become completely
embedded in the hyperplastic tissue requiring surgical
excision for removal. Thus, careful fabrication and
monitoring of such wire components are essential to avoid
such problems.

implantation makes them comfortable for the patients.

However, potential problems and soft tissue complications
are common.
The following type of complications can occur with
miniscrews:
Impingements and Trauma to Soft Tissue
Overlying the Implant
Implant head being sharp may cause soft tissue damage to
the buccal mucosa and/or attached gingiva related to the
confined area. Care should be taken by during the implant

Indirect Damage by Allergic Reactions

Nickel allergy
Nickel hypersensitivity affects three in 10 of the general
population. Nickel content is found in orthodontic wires,
bands, brackets and headgears.27 However, Intraoral signs
and symptoms of nickel hypersensitivity are rare because
the concentrations of nickel required to provoke a reaction
in the mouth are higher than those needed on the skin as in
the case of jewellery and ear piercing. Intraoral signs are
highly variable and difficult to diagnose. These include loss
of taste or metallic taste, numbness, burning sensation,
soreness at the side of the tongue, angular cheilitis (Fig. 7)
and erythematous areas or severe gingivitis in the absence
of plaque.28 Since such signs and symptoms are difficult to
identify, nickel allergy in response to orthodontic appliances
may be underdiagnosed.
Latex Allergy

Fig. 6: Impingement of T-loop on the buccal mucosa showing a

T-shaped scar

Fig. 7: Nickel allergy

Latex sensitivity may occur in response to contact with latex

gloves, elastomeric ligatures or intra- and extraoral elastics.
The commonest sites affected are the gingivae and tongue,
(Fig. 8) but the perioral region may also be affected.29
In latex-sensitive patients, steel ligatures or self-ligating
brackets may be used instead of the conventional straight
wire brackets and elastic modules and chains.2,27
Soft Tissue Complications related to Implants
The introduction of microimplants to orthodontics as a
skeletal anchorage option has led to their use in critical
anchorage situations. Their simple design and ease in

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Fig. 8: Latex allergy of the tongue

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Orthodontic Scars

Fig. 9: Implant showing impingement of auxillary wire running

from the implant to the second molar

placement for its own stability as well as use of auxiliaries

with its support, to avoid trauma and subsequent ulceration
(Fig. 9).30
Peri-implantitis
Peri-implantitis (inflammation of the gingiva around the
implant) is as a result of improper oral hygiene maintenance.
Patients should be counseled to maintain high level of oral
hygiene throughout treatment.
Screw Fracture during Removal
Applying lateral forces during implant removal can cause
fracture. It is important not to wiggle the screwdriver when
removing it from the screw head. It is rare if taken out
straight. If the micro-implant is left for a very long time,
this also could lead to fracture on removal as a result of
partial or full osseointegration.
Implant failure (mobility/fracture) can also occur if the
screw is too narrow or the neck area is not strong enough to
withstand the stress of removal.31 The solution is to choose
a conical screw with a solid neck and a diameter appropriate
to the quality of bone.
SUMMARY
Most orthodontic scars are transient and self-correcting in
nature. One exception to this rule strongly, is enamel
decalcification and fractures, which require post-treatment
rehabilitation. However, during the course of treatment if
these scars are unobserved or untreated, they may cause
complications in the form of infections resulting in pain
and discomfort. Patients oral hygiene maintenance and
orthodontist keen observation during recall/review visits is
the key to minimize the chances of such scars.
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ABOUT THE AUTHORS

Vinay Reddy (Corresponding Author)
Professor, Department of Orthodontics, Krishnadevaraya
College of Dental Sciences, Bengaluru, Karnataka, India
e-mail: reddy10vinay@gmail.com

Vijeev Vasudevan
Professor, Department of Oral Medicine and Radiology
Krishnadevaraya College of Dental Sciences, Bengaluru, Karnataka
India

Gowri Sankar
Professor and Head, Department of Orthodontics, Goverment Dental
College and Hospital, Kadapa, Andhra Pradesh, India

AV Arun
Senior Lecturer, Department of Orthodontics, Krishnadevaraya
College of Dental Sciences, Bengaluru, Karnataka, India

S Mahendra
Senior Lecturer, Department of Orthodontics, Krishnadevaraya
College of Dental Sciences, Bengaluru, Karnataka, India

Mohammed K Khalid
Senior Lecturer, Department of Orthodontics, Oxford Dental College
Bengaluru, Karnataka, India

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