Download Severe Bone Loss induced by Orthodontic Elastic Separator: A Rare

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10.5005/jp-journals-10021-1136
CASE REPORT
Severe Bone Loss induced by Orthodontic Elastic Separator: A Rare Case Report
Severe Bone Loss induced by Orthodontic
Elastic Separator: A Rare Case Report
1
AE Vishwanath, 2BK Sharmada, 3Sandesh S Pai, 4Nandini Nelvigi
ABSTRACT
A displaced orthodontic elastic separator was proposed as being the source of a gingival abscess that progressed to severe bone loss and
exfoliation in a healthy adolescent patient with sound periodontal status prior to commencement of orthodontic treatment. After 1 year of
undergoing orthodontic treatment, the patient presented with dull pain and mobility in the left upper permanent molar for which there was no
apparent etiology. On clinical examination, the patient had gingival inflammation, associated with a deep pocket and severe mobility (grade III)
in relation to the same teeth. Radiographic examination of an orthopantomogram and intraoral periapical radiography (IOPAR) revealed a chronic
periodontal abscess with severe necrosis of the periodontal ligament and severe alveolar bone loss. A radiopaque mass on the distal surface
below the cementoenamel junction (CEJ) was also observed. The patient was referred to the department of periodontics for assessment and
appropriate treatment. On curettage, it was found that there was orthodontic elastic separator which was displaced subgingivally.
Keywords: Orthodontic separator, Alveolar bone loss, Curettage.
How to cite this article: Vishwanath AE, Sharmada BK, Pai SS, Nelvigi N. Severe Bone Loss induced by Orthodontic Elastic Separator:
A Rare Case Report. J Ind Orthod Soc 2013;47(2):97-99.
INTRODUCTION
CASE REPORT
Local anatomic and iatrogenic factors may promote plaque
retention and proliferation of microorganisms in the
periodontal pocket, resulting in progressive inflammatory
changes.1 An inflammatory process restricted to the gingiva
and refractive to conventional therapy should raise the
possibility of a foreign body etiology.2 Several cases of bone
loss and teeth exfoliation were reported in association with
orthodontic elastic bands,3-5 especially when they had been
used to close a midline diastema between maxillary incisors.
However, there are only a few reported cases of periodontal
destruction caused by displaced orthodontic separators.6,7
Commonly, employed therapeutic modalities include a
combination of laser treatment, antibiotics, splinting, curettage
and bone grafting.8 In order to avoid complications, it was
recommended to use brightly colored elastic bands and to
remove them after 2 weeks.9 This report describes a case of a
chronic periodontal abscess, severe necrosis of periodontal
ligament and severe alveolar bone loss, caused by a displaced
orthodontic elastic separator.
A 19 years old patient undergoing fixed orthodontic treatment
reported to OPD, Department of Orthodontics, Vydehi
Institute of Dental Sciences and Research Centre with the chief
complaint of dull pain and mobility in relation to upper left
first permanent molar (Figs 1 to 3).
The patient gave a history of undergoing orthodontic
treatment in a private clinic for 1 year and had experienced
dull pain in relation to the same tooth 2 to 3 times before but
neglected it. The patient had no relevant medical history and
was free of systemic symptoms. On clinical examination, the
patient had good oral hygiene, with fixed orthodontic
appliances on the upper arch, bite blocks on the lower arch.
The left upper molar band was loose and the gingiva was
inflamed with a deep pocket and severe mobility (grade III).
1
Reader, 2Senior Lecturer, 3Professor and Head, 4Professor
Department of Orthodontics, Vydehi Institute of Dental Sciences
Bengaluru, Karnataka, India
1-4
Corresponding Author: AE Vishwanath, Reader, Department of
Orthodontics, Vydehi Institute of Dental Sciences, Bengaluru, Karnataka
India, e-mail: [email protected]
Received on: 21/4/12
Accepted after Revision: 22/5/12
Fig. 1: Intraoral left lateral view showing inflamed gingiva in relation to
the upper left first molar
The Journal of Indian Orthodontic Society, April-June 2013;47(2):97-99
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AE Vishwanath et al
Fig. 2: OPG showing complete necrosis of PDL, severe alveolar bone
loss and a well circumscribed radiopaque mass at the alveolar crest
region on the distal surface of upper left first molar
Fig. 4: On periodontal curettage, it was confirmed that the mass was
an orthodontic separator
Fig. 3: IOPAR showing severe alveolar bone loss and the subgingival
radiopaque mass
Fig. 5: An intact orthodontic separator which was removed from the
subgingival area
The loose band and bite blocks were removed and patient
exposed to an orthopantomogram (OPG) and intraoral
periapical radiography (IOPA) (Figs 2 and 3).
On examination of radiographs, there was complete
necrosis of the periodontal ligament and severe alveolar bone
loss with less than the apical one-third of the root covered by
bone. A well-defined radiopaque mass was observed below
the cementoenamel junction (CEJ) at the distal surface of
upper left first permanent molar. A subgingivally displaced
orthodontic elastic separator from the banding procedure was
suspected. The patient was referred to the Department of
Periodontics for opinion and treatment. The prognosis of the
tooth was poor as there was severe irreversible alveolar bone
loss, but some amount of recovery was expected as the
etiological factor could be removed. On diagnostic curettage
procedure, it was found that the there was an intact orthodontic
separator subgingivally near the alveolar crest region (Figs 4
and 5).
All active orthodontic forces were temporarily removed
and the patient is under periodontal follow-up.
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DISCUSSION
The present report emphasizes the need for appropriate imaging
to diagnose pathological conditions of the periodontium. It
also highlights potential risks to the periodontium caused by
using orthodontic elastic bands. Localized periodontitis and
periodontal abscesses can be associated with a variety of dental
material, such as silicone impression materials,10,11 rubber
dam,12 and even self-inflicted gingival injury due to habitual
fingernail biting.13 Localized reactive overgrowths of the
gingiva can include the differential diagnoses of pyogenic
granuloma, peripheral giant cell granuloma and periodontal
abscess.14-16 They can result from the invasion of pyogenic
bacteria through the pocket epithelium, secondary to
microtrauma or blockage of flow of inflammatory exudates
from within the periodontal pocket. Entrapment of foreign
bodies may serve as a trigger for these events. Several
millimeters of periodontal attachment and alveolar bone can
be lost within as little as a few days. The onset is sudden and
accompanied by an acute inflammatory response (purulence)
during which tissue necrosis takes place. A painful gingival
swelling may occur anywhere around the affected teeth.
JAYPEE
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Severe Bone Loss induced by Orthodontic Elastic Separator: A Rare Case Report
Swelling might involve the vestibule or cheek, since pus
follows the path of least resistance. Depending on the severity
of the infection, the patient may experience regional
lymphadenitis, malaise or fever. Such circumstances can
represent a true emergency situation.17
Foreign material may cause and aggravate gingival lesions.
A foreign body might induce both inflammatory and
noninflammatory gingival changes manifested clinically as
swelling and/or discoloration. Koppang et al2 found that the
mandibular and maxillary posterior segments were most
frequently affected with foreign body gingival lesions (34 and
29% respectively), followed by the maxillary anterior region
(26%).2 They commented that these findings are probably
attributable to the high frequency of dental procedures in these
segments. Elastic bands should not be used on crowns of teeth
without provision for stabilization.3 A rubber band that slips
undetected under the gingiva might move along the roots,
resulting in significant loss of alveolar bone.3
Foreign body induced reaction should be included in the
differential diagnosis of gingival overgrowths. Periodontal
abnormalities occurring when orthodontic elastic separators
are used should raise the possibility of a band impinging into
the biological width. Appropriate imaging is essential for
accurate diagnosis, especially when those devices are
radiopaque.
CONCLUSION
It was concluded that although orthodontic elastic separator
placement is a simple procedure, every possible precaution
should be taken to ensure that gingival displacement of the
separator below the contact point does not occur. Patients
who present with missing separators at the banding appointment
must be asked if they actually viewed the separator and if not,
careful inspection of the interdental region must be performed.
This may necessitate radiographic examination in cases of
uncertainty to prevent iatrogenic trauma.
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