www.mjms.usm.my © Penerbit Universiti Sains Malaysia, 2012For permission, please email:mjms.usm@gmail.com

Introduction

Orthodontic elastic bands are non-metalliccompounds of foreign body type (1), implicatedin the production of localised periodontitiswhen inadvertently allowed to remain aroundteeth (2). Reports citing orthodontic elasticseparatorsasamajoriatrogeniccauseforlossofperiodontalbonesupportdatesbacktomorethan127 years (3). Several cases have demonstratedthe apical slippage of orthodontic elastic bandsalong the roots resulting in deep periodontalpockets,marked toothmobilityandsevereboneloss, placing the teeth in serious jeopardy (2,4).The phenomena of gingival reattachment andpossibleregenerationaremajorissuesincaseofelastic band-induced periodontitis. A review ofliterature revealed a total of only five reports todate, concerning nine molars out of which fivemandibularmolarswere treated, andonly threeof them showed promising results and superiorperiodontalhealthaftertreatment(2,3,5–7).The

Case Report

Submitted: 26Mar2012Accepted: 1Jun2012

Spontaneous Reversibility of an Iatrogenic Orthodontic Elastic Band-induced Localized Periodontitis Following Surgical Intervention – Case Report

Sowmya Nettem1, Sunil Kumar Nettemu1, K. Kiran Kumar2, G. Venkat reddy3, Pendyala Siva Kumar4

1 Faculty of Dentistry, Melaka-Manipal Medical College, Jalan Batu Hampar, Bukit Baru, 75150 Melaka, Malaysia

2 Department of Orthodontics, S.B Patil Dental College And Hospital, Bidar, Karnataka, India

3 Department of Oral Surgery, Panineeya Dental College, Hyderabad

4 Department of Oral And Maxillofacial Surgery, Aimst University, 08100 Kedah, Malaysia

Abstract Orthodontic elastic bands are an important iatrogenic etiologic factor in the causationof periodontal attachment apparatus breakdown. Appropriate diagnosis and a well constructedtreatment plan tailor-made to suit the requirements of the particular patient is imperative formanagement of periodontal lesions induced by subgingival retention of rubber band. There areconflicting reports regarding the reattachment and regeneration of lost periodontal supportingtissuesinsuchcases.Thepresentcasereporthighlightsthespontaneousreversalandcorrectionofperiodontaldestructiondue to iatrogenicorthodonticelasticbanddisplacementdeep into thesubgingivaltissues.

Keywords:corrective orthodontics, periodontitis, remission, spontaneous

durationofperiodontitisrangedfrom10daystooneyearinallthesecases(8). Thiscasereporthighlights thespontaneouscorrection of localised periodontitis involvinga mandibular molar, initiated by inadvertentdisplacementofanorthodonticelasticbanddeepintothesubgingivalarea.

Case Report

A 20-year-old female patient reported tothe Department of Periodontology and OralImplantologywith a chief complaint of swellingofgumsinrelationtothelowerrightbacktoothregionandassociateddull,achingnatureofpaininthesameregionsincetwodays.Adetailedcasehistorywasrecorded.Thedentalhistoryrevealedthat thepatienthadundergoneoralprophylaxisand orthodontic therapy had been initiatedone week back. The patient’s orthodontist was

77Malays J Med Sci. Oct-Dec 2012; 19(4): 77-80

78 www.mjms.usm.my

Malays J Med Sci. Oct-Dec 2012; 19(4): 77-80

contactedandinformationwasobtainedregardingplacementoforthodonticelasticbandseparatorsin relation to all the first molar regions. Themedicalandfamilyhistorywasnon-contributory. On clinical intraoral examination, the oralhygiene status of the patient was satisfactorywithanoralhygienescoreof0.6accordingtotheoralhygieneindexbyGreeneandVermilion(9).A gingival swelling was detected on the gingivaover the lateral aspectof the root surfaceof themandibular right firstmolar with an associateddeep periodontal pocket of 8mm on the disto-buccal aspect as measured using a William’sgraduated periodontal probe (Hu-Friedy, US).Thesixpointprobingdepthrecordingsrevealeda pocket depth of 5 mm on the midbuccal,distolingual aspects and 3 mm on the mesio-buccal,mid lingualandmesio-lingualaspectsofthe mandibular right first molar. The six pointprobing depths on themandibular right secondmolarwere6mmonthemesio-buccalaspectand3 mm on the mid-buccal, disto-buccal, mesio-lingual,mid-lingualanddisto-lingualaspects.Thesix-pointpocketdepthrecordingsofalltheotherteeth revealedanormalgingival sulcusdepthof2–3mm.Purulentexudatesandseverebleedingonprobingwaspresent in the regionassociatedwith the abscess with a Muhlemann and Sonsulcusbleedingindex(10)recordingsofscores2and1formandibularrightfirstandsecondmolarsrespectively. There was an absence of bleedingon probing around the remaining teeth. Vitalitytest provided negative result and confirmed theabsenceofpulpalinvolvement.Thegingivainallthe other areas appeared clinically healthy withno detectable local deposits. Exploration of thedeep pocket with an explorer (#23 Shepherd’sHook explorer, Hu-Friedy, US) failed to revealthe presence of subgingival calculus or foreignbodies. The orthodontic band was also missingin that region. The apical displacement of theorthodonticbanddeep into thesubgingivalareawassuspectedasapossibleetiological factorfortheabscessformationandassociatedpaininthatlocalizedregion.Intraoralperiapicalradiographicevaluation of the mandibular right first andsecondmolarregionrevealedhorizontalbonelossextendinguptothemiddleonethirdoftherootsin the interdental area between the two teeth(Figure 1). Since the orthodontic bands areradiolucent,itwasnotdiscernibleradiographically.Aprovisionaldiagnosisofiatrogenicorthodonticelastic band-induced periodontal abscess andlocalizedperiodontitisinrelationto46wasmade.

Since, the elastic band lacked radiopacity andwas not readily detectablewith an explorer, thepresence,althoughsuspected,couldnotbeprovenwithoutasurgicalexploration.Theprocedurewasexplained in detail to the patient and a writteninformedconsentwasobtainedfromthepatient. Under 2% lignocaine hydrochloride localanaesthesia (LOX, Neon Laboratories LTD,Andheri, Mumbai, India) containing 1:200 000adrenaline, incisionanddrainageofperiodontalabscess was established and the patient wasplacedonanantibioticandanalgesicregimenofAmoxicillin 500mg anddiclofenac respectively,for8days.Whenthepatientreportedforthenextappointmentthefollowingweek,theperiodontalabscess had completely subsided but the painpersisted in that region. In order to establisha definitive diagnosis and effectively treat thelesion, an access flap surgical procedure wasdecidedupon. The surgical site in the mandibular rightquadrant was anesthetized by 2% lignocainehydrochloride (LOX, Neon Laboratories LTD;Mumbai, IN)with 1:200 000 adrenaline.Usingcrevicular and interdental incisions a localizedmucoperiosteal flap, extending from the distalaspect of mandibular right second premolar tothe distal aspect of mandibular second molarregion. A thorough debridement and curettingwas performed and the elastic band was finallyretrievedfromthedepthofthepocket,closetothealveolarbone (Figure2).The areawas irrigatedwith normal saline and carefully inspected toensurecompleteremovaloftheforeignbodyandotherirritants.Flapwassuturedinpositionwithinterrupted sutures, using non-resorbable 3–0silk (CENTENIAL Surgical Suture LTD, Thane,IN). Postoperative instructions were given andthepatientwasinstructedinusingchlorhexidinegluconate mouthrinse 0.12% (Peridex, ZilaPharmaceuticals,Phoenix,US). Oneweek post surgery, the suture removalwas performed and the patient reported to becompletelyfreeofpainanddiscomfort.Aclinicalexamination at this visit revealed a clinicallyhealthy gingiva and an intraoral periapicalradiograph obtained showed complete bone filland restoration of the bone height to normalhealthylevels(Figure3).Thepatientwasreferredback to the Department of Orthodontics andDentofacial Orthopedics for continuation of thenecessaryorthodontictreatment.Thepatienthasbeen put on regular recall regime to review thegingivalandperiodontalhealthstatus.

Case Report |Reversaloforthodonticelasticband-inducedperiodontitis

www.mjms.usm.my 79

Discussion

The findings of previous studies havepainted a mixed picture. According to onestudy, the the elastic band-induced periodontallesion is not spontaneously reversible andcompleteregenerationofperiodontalattachmentapparatusisnotprobable(12).However,anotherstudy demonstrated the possibility of achievingcomplete regeneration of the lost bone uponremovaloftheoffendingforeignbody(11).Also,another case report involving maxillary centralincisorspublished thatacomplete reattachmentwas achieved in one week following treatmentand removal of the apically displaced multipleorthodonticbands(8). A literature search has revealed a totalof 22 case reports to date, of periodontitisassociated with accidental apical displacementof orthodontic elastic band over the past127 years and the duration of periodontitisextended between 10 days to one year, henceconfirmingthepossibilityofspontaneousreversalof periodontal lesions (8,11). Compared to thecase reports of occurrence of iatrogenic elasticband induced periodontal lesion in the anteriorregion, only a negligible number of cases havebeen reported of the similar conditions in themandibularmolararea,makingthisaratherrareoccurrence.Also,inthepast,variousnon-surgicalaswellassurgicaltreatmentmodalitieshavebeenattempted for themanagement of these lesions,however, the best treatment protocol is not yetfoundintheliterature(8). The radiolucency seen in the pre-operativeradiograph can be confirmed to be the result ofalveolar bone destruction in that region due toforeign body reaction andnotmere presence ofthe displaced band as the orthodontic bands inall the cases reported till date were discernibleradiographically (1–8). Only one case reportidentified the presence of orthodontic elasticband in the radiograph as the authors of thatcase reported that the band appeared as aradio-opaque, rectangular-shaped mass in theinterproximal region indistinguishable fromsubgingivalcalculus(13).

Conclusion

The results of the present study indicatethat the lost alveolar bone can be completelyregenerated within a short span of time, uponabsoluteremovaloftheaberrantforeignbodyandby adopting appropriate treatment modalitiesthus making the iatrogenic orthodontic elastic

Figure 1: Pre-operative intraoral periapicalradiograph of the mandibularrightfirst and secondmolar regionshowing horizontal bone lossextendinguptomiddleonethirdsoftherootsoftheteeth.

Figure 3: Post-operative intraoral periapicalradiograph of the mandibularrightfirst and secondmolar regionshowing complete bone fill andrestoration of the bone height tonormalhealthylevel.

Figure2:Surgical exposureof theelasticbandretrievedfromthedepthofthepocket.

80 www.mjms.usm.my

Malays J Med Sci. Oct-Dec 2012; 19(4): 77-80

band–induced localized periodontitis lesiona spontaneously reversible one. Locatingorthodontic elastic bands that have beendisplaced deep into the supporting periodontaltissues can be an arduous task. Attention todetail, careful monitoring, discriminate useandpatient educationare thebestdeterrents todamage caused by orthodontic elastics (4). Thedevelopment and manufacture of orthodonticelastics that are radiopaque would definitelyminimizetheincidenceandseverityofsuchcases.

Authors’ Contribution

Conception and design, drafting of the article,critical revision of the article for importantintellectualcontent,finalapprovalof thearticle,andcollectionandassemblyofdata:NSConceptionanddesign,analysisandinterpretationofthedata,draftingofthearticle,finalapprovalofthearticle,andobtainingoffunding:NSKCritical revision of the article for importantintellectualcontent,provisionofstudymaterialsor patients, and administrative, technical, orlogisticsupport:KKKCritical revision of the article for importantintellectualcontent,administrative,technical,orlogistic support, and collection and assembly ofdata:GVR,SKD

Correspondence

DrNettemuSunilKumarMaster of Dental Surgery in Periodontology & OralImplantologyDepartmentofPeriodontologyFacultyofDentistryMelaka-ManipalMedicalCollegeJalanBatuHampar,BukitBaru75150Melaka,MalaysiaTel:+60105092130Email:nettemsunil@gmail.com

References

1. Cataldo E, Santis H. Response of the oral tissueto exogenous foreign materials. J Periodontol. 45;93:1974.

2. Zager NI, Barnett ML. Severe bone loss in a childinitiatedbymultipleorthodonticrubberbands:Casereport.J Periodonto.1974;45(9):701–704.

3. McQuillinJH.CareintheuseofIndiarubberrings.Dent Cosmos.1870;12:429–430.

4. AvrumRGoldstein,MarkSchpero.Retainedligaturewireandperiodontalhealth:Reportofacase.Am J Orthod.1984;86(4):315–318.

5. DalitschWW.Dentalextractioninhemophilia.JADA.1934;21:1804–1811.

6. DalitschWW. Removal of teeth by exfoliation withelasticligatures. Dent Digest. 1934;45:310–314.

7. Tilk MA. Endodontic treatment of an orthodonticelasticaccident.J Endod.1978;4(3):91–92.

8. RL Finkbeiner, LS Nelson, J Killebrew. Accidentalorthodontic elastic band induced periodontitis:orthodontic and laser treatment. J Am Dent Assoc.1997;128:1565–1569.

9. Greene JC, Vermillion JR. The oral hygiene index:amethodforclassifyingoralhygienestatus. J Amer Dent Ass.1960;61:29–35.

10. MuhlemannHR,SonS.Gingivalsulcusbleeding–Aleading symptom in initial gingivitis.Helv.Odontol Acta.1971;15:107.

11. SugarmanE,WeathersD. An unusual foreign bodyreaction. J Periodontol.1977;48:290–293.

12. Caton JG, Zander HA. Primate model for testingperiodontal treatment procedures: I. Histologicinvestigation of localized periodontal pocketsproduced by orthodontic elastics. J Periodontol. 1975;46(2):71–77.

13. Talia Becker, Alex Neronov. Orthodontic elasticseparator-inducedperiodontalabscess:Acasereport. Case reports in Dentistry.2012;2012:3.