Emergencies in Orthodontics Part 2: Management of Removable Appliances, Functional Appliances and other Adjuncts to Orthodontic Treatment

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1 Pul Dowsing Alison Murry nd Jonthn Sndler Emergencies in Orthodontics Prt 2: Mngement of Removle Applinces, Functionl Applinces nd other Adjuncts to Orthodontic Tretment Astrct: In the second of two ppers, mngement of orthodontic emergencies involving pplinces other thn fixed pplinces will e detiled. Prolems relting to removle pplinces, s well s other orthodontic djuncts, will e discussed. Unfortuntely, orthodontic pplince rekge does occur, despite the clinicins giving cler nd concise instructions to the ptients nd their prents t fitting. If generl dentl prctitioners hve prcticl knowledge of how to dignose prolems nd to provide pproprite dvice or timely emergency tretment, this will significntly reduce the inconvenience for ll prties concerned. It should lso ensure tht tretment progresses in the most efficient nd comfortle mnner for their ptients. In specific situtions the erly, ccurte identifiction of the prolem nd instigtion of its pproprite mngement cn void more serious consequences. Clinicl Relevnce: Approprite hndling of n orthodontic emergency y the dentist cn, on mny occsions, provide immedite relief to the ptient. This will, in turn, llow tretment to continue in the right direction, thus llowing more efficient nd effective use of vlule resources. Dent Updte 2015; 42: In the first pper, generl prolems encountered in orthodontics nd those specific to fixed pplinces were descried Pul Dowsing, BDS, DGDP(UK), FDS RCPS, MOrth, FDS(Orth) RCPS, MPhil Orth, Consultnt Orthodontist, The Princess Royl Hospitl, Telford, Alison Murry, BDS, MSc, FDS RCPS, MOrth RCS, Consultnt Orthodontist, Royl Dery Hospitl nd Jonthn Sndler, BDS(Hons), MSc, PhD, FDS RCPS, MOrth RCS, Professor nd Consultnt Orthodontist, Chesterfield Royl Hospitl, Chesterfield, Deryshire, UK. in detil. In this second pper, prolems ssocited with the wering of removle pplinces, functionl pplinces, retiners nd other orthodontic uxiliries will e discussed. The im is to remind generl prctitioners out the vrious components of these pplinces, s well s to provide useful nd prcticl dvice should the ptient ttend his/her surgery for n unexpected emergency visit. By mnging the prolem ppropritely, the inconvenience to the ptient cn e minimized. There re some orthodontic prolems which re common to ll pplince types, s well s others tht re of more specific nture nd oth types will e descried. Removle pplinces The widespred use of singlerch removle pplinces is now on the decrese, ut there re still significnt numer of prctitioners who prescrie them in specific circumstnces. Generl prolems with removle pplinces include: Initil difficulties with speech; Temporry excessive production of sliv; nd Initil generl discomfort. These symptoms will soon pss once the ptient hs ecome used to the pplince, therefore every ptient should April 2015 DentlUpdte 221

2 Figure 1. Components of removle pplince: () retentive; () seplte; (c) ctive. e encourged to persevere. If ny of these prolems persist for more thn few dys, then it is more thn likely tht the ptient is not wering the pplince for sufficient mount of time to get used to it. Ptients should e encourged to wer pplinces s directed y their orthodontist nd lso informed tht, only if they do so will the initil feelings of discomfort suside. They lso need to e reminded tht filure to follow the instructions will lmost certinly compromise the tretment outcome. The sic design of removle pplince hs not chnged significntly, though ech is customized in its prticulr components (Figure 1). Knowledge nd fmilirity with the most common components will ensure tht the prctitioner is in the est possile position to del with ny complictions tht my rise. Frctured retentive components Loose, non-retentive pplinces re common cuse of emergency visits nd cn e voided y creful design nd djustment of the retention components of the pplince, ensuring tht sufficient clsps re prescried t the outset. Stisfctory retention of removle pplince will dd to the ptient s confidence nd his/her enthusism to wer the pplince, which will therefore mximize the chnce of successful outcome. It is not uncommon for n Adms clsp to frcture (Figure 2). If there re numer of other Adms clsps providing retention, often the only tretment required is the removl of the frctured clsp nd smoothing of ny cut wires. Another option, if there re fewer c Figure 2. () Frctured Adms clsp. () Wire work trimmed to remove frctured section. (c) Single rrowhed of Adms clsp used for retention. retentive components, is to remove the frctured ridge of the Adms clsp (Figure 2) leving the rrowheds engging the undercut for retention (Figure 2c). The mjority of clsp frctures occur due to work hrdened wire suffering ftigue. The Figure 3. Irreversile dmge to n ctive component of removle type of pplince. likelihood of clsp frcture increses gretly when the ptient clicks the pplince in nd out. The ptient nd his/her prents must e informed how hrmful this irritting hit is to the pplince nd how the inevitle clsp frcture will undoutedly dely the progress of tretment. Active components Applinces re susceptile to dmge round res contining ctive components such s springs or expnsion screws (Figure 3). If spring is significntly distorted, then there my e no option ut to replce it, if further tooth movement is required. Unfortuntely, with significnt dmge, there is little tht cn e usefully done y the generl dentl prctitioner prt from removing shrp ends or loose wires nd referring the ptient ck to his/her orthodontist. If the ptient using n expnsion screw hs left the pplince out of the mouth for dy or two, even fter temporry repir, the pplince cn e extremely difficult to set fully, s some relpse of the expnsion will hve occurred. The dentist cn ttempt to turn the screw ck, in qurterturn increments, until the ptient cn comfortly, fully insert the pplince. The ptient should then e referred ck to the orthodontist, with note detiling the exct djustments tht hd to e mde to the screw, to llow re-insertion. This informtion will then llow the orthodontist to issue pproprite instructions. 222 DentlUpdte April 2015

3 Figure 4. (, ) Cndid infection ssocited with seplte of upper removle pplince. Figure 5. Angulr cheilitis t corners of mouth. Figure 6. (, ) Twin lock pplince. Bseplte A common prolem ptients often present with is frcture of smll res of the crylic. If this is firly miniml, nd doesn t ffect the design or the integrity of the pplince, then smoothing of the rough edges is ll tht is required to prevent soft tissue trum. If the dmge is more severe, new impression is usully necessry for the pplince to e repired y technicin. Referrl ck to the orthodontist is therefore recommended. Prolems relted to pplince hygiene, such s Cndid licns infection cusing inflmmtion to the pltl tissues on the fitting surfce of the pplince (Figure 4), re not uncommon. Alterntively, infection my mnifest s ngulr cheilitis with crcks ppering t the corners of the mouth (Figure 5). Mesures instituted y the generl dentl prctitioner initilly involve instruction to chieve meticulous pplince hygiene, which my include recommendtion of proprietry rce clener. If rpid resolution does not occur, ntifungl mediction, such s Miconzole pplied to the ffected re, my e required. Functionl pplinces The most commonly used functionl pplince in the United Kingdom is the twin lock 1 (Figure 6, ). Generl prolems re very similr to those encountered with single-rch removle pplinces, such s initil discomfort, excessive sliv production nd speech interference, nd they should e delt with s descried previously. After initil fit of the twin lock pplince, the muscles of the jw, s well s the teeth themselves, will che for the first couple of dys of wer. The ptient needs to e informed tht this is to e expected nd ressurnce should e given tht these symptoms will pss. Another common initil prolem is difficulty in speking for the first dy or two. As the twin lock pplince is recommended s full-time pplince, ptients should lso e dvised tht speech will rpidly improve nd, with time nd persevernce, they will lern to spek intelligily with their teeth together. Ulcertion in the lingul sulcus cused y the lower lingul flnges is not uncommon, often in the lower cnine/ premolr re. This cn e redily delt with y the GDP y pproprite trimming of the crylic, just in the re of the inflmed mucos or ulcer (Figure 7). If the twin lock is frctured (most commonly the lower lock in the midine re), new working impressions nd new ite registrtion re often required. The ptient will lmost certinly need to return to his/ her orthodontist for this. Fixed functionl pplince Although the use of these types of pplinces is firly uncommon, the generl prctitioner should e wre of their existence. The Clss 2 corrector pplince is usully ttched to the nds plced on the upper molr teeth nd to either nds or rckets in the lower rch, depending on the prticulr pplince. The components of these complicted pplinces re prone to rekge (Figure 8) nd their repir is not t ll strightforwrd. The generl dentl prctitioner my secure or remove ny loose components, which might provide immedite relief from discomfort for the ptient, nd then return oth the pplince components nd the ptient to the orthodontist s soon s possile. Figure 7. Trimming of crylic, usully lingully, in lower cnine premolr re. Figure 8. Exmple of populr fixed/functionl pplince Herst pplince. April 2015 DentlUpdte 223

4 Hedger Hedger usully consists of n externl hedger cp connected to fceow tht trnsfers force from the ck of the hed to the dentition (Figure 9). This method of supplementing nchorge is not without risk. Oculr injuries from hedger hve een reported in the pst, 2 usully cused y the inner rms of the fceow (Figure 10). At lest two independent sfety mechnisms re now recommended in ll hedger ptients, to prevent recoil injuries following ccidentl disenggement. 3 If there is ny evidence whtsoever tht the fceow hs tendency to come out of the hedger tues, the hedger wer should e immeditely stopped. The ptient must e referred ck to see his/ her orthodontist s soon s possile. Should n oculr injury e suspected, then immedite referrl of the ptient to the locl hospitl ccident nd emergency unit for n ophthlmic opinion is indicted. Any undue dely my well compromise the possiility of successful restortion of vision. 4 Retiners Removle retiners The removle type, vcuumformed retiners re now commonplce. 5 Prolems cused y these retiners include, occsionlly, trum on insertion, prticulrly round the gingivl mrgins. It is very simple mtter for the generl dentl prctitioner, or even the ptient, to trim the prominent flnge ck with pir of shrp scissors then smooth the cut ends with n emery ord (Figure 11). Retiners cn lso wer down or frcture, in which cse replcement will e necessry. Most orthodontists dvise the ptients tht, t some time in the future, their own dentist my need to tke impressions to replce lost or roken retiners, leit on privte sis. Hwley retiners suffer from ll the prolems of removle pplinces nd therefore hve exctly the sme solutions. Additionl prolems specific to the Hwley type of retiner my include distortion of the lil ow, which will need to e crefully redpted to the upper lil segment teeth to minimize the chnce of relpse (Figure 12). Anything more thn very minor distortion will need the pplince to e sent ck to the lortory, or to the treting orthodontist for ttention. plce for mny yers. Prolems occurring with these retiners cn include the frcture of the wire in etween the teeth or the retiner ecoming either prtilly or fully detched from the teeth. If just one composite pd hs ecome dislodged from its tooth (Figure 13), it is usully firly simple mtter to remove the remnnts of composite with urr, clen the lingul tooth surfce nd re-ond nother pd of composite using n cid etch technique. 6 This cn provide n esy nd quick solution, s long s there hs een no distortion of the retiner wire or movement of the ssocited tooth. If the retiner wire hs ctully frctured or distorted, the loose or shrp ends should e cut nd smoothed nd the ptient redirected to his/her originl orthodontist for ny necessry further tretment, s there is lwys the possiility tht relpse my occur. Other potentil orthodontic prolems Possile inhltion or ingestion of n orthodontic component Comprehensive guidelines for the mngement of inhled or ingested foreign odies hve een produced y the British Orthodontic Society 7 Figure 9. Hedger nd fceow eing worn. Bonded retiners Bonded retiners re used these dys in significnt numer of cses. A multistrnd wire is ttched to the individul teeth using composite cement nd these retiners re designed to sty in Figure 12. Hwley retiner with lil ow. Figure 10. Fceow inner rms cn e potentil source of eye dmge Figure 11. Trimming of vcuum-formed retiner with shrp scissors or crown shers. Figure 13. Composite off one tooth only, no relpse yet seen. 224 DentlUpdte April 2015

5 Figure 14. Adominl x-ry tken to locte foreign ody. nd these re n invlule guide tht should e ville in every dentl prctice. Common sense should dictte the most immedite nd pproprite ction, especilly in the first few seconds when it is suspected tht prolem my hve occurred. If the loose or detched oject is still visile in the mouth or orophrynx, n ttempt should e mde to remove it if t ll possile. If this is not possile then the ptient should e encourged to cough up the foreign ody. If the irwy ppers compromised then n mulnce should e clled, nd if possile n ttempt mde to try nd remove the ostructive cuse, if this cn e done sfely. If there is suspicion or concern tht the component hs een inhled or swllowed, the ptient should e referred immeditely to the locl hospitl for n pproprite rdiogrphic exmintion (Figure 14), nd further mngement s pproprite. Idelly, similr orthodontic component to the one inhled or swllowed should lso e sent with the ptient; this will help the rdiologist enormously to identify this prticulr foreign ody. Advice should lso e sought from the ttending physicin in the ccident nd emergency deprtment s to the need for further oservtion or cre, nd the incident fully documented in the ptient s notes. Orthodontic seprtor sugingivlly All ptients will experience vrying levels of pin or discomfort following the plcement of seprting elstics, s often this is the most uncomfortle prt of the whole orthodontic tretment, nd they should certinly e forewrned out this. Prophylctic nlgesi is proly dvisle nd the ptients should continue to tke nlgesics, strictly following the prescried instructions, for s long s they feel the need. Cre must lwys e tken to ensure the numer nd the site of seprtor plcement is recorded in the notes, s well s the site from which they re removed t the next visit. Ech seprtor plced should lwys e ccounted for, nd if ny re missing the ptient should e sked whether they rememer losing them. If unsure, it is lwys dvisle to proe the re gently with the id of the ir syringe. Occsionlly, seprtor my e hidden sugingivlly (Figure 15, ). If this hidden seprtor is indvertently ignored, nd n orthodontic nd is just plced, this could led to significnt periodontl prolems, infection nd possile ultimte tooth loss. Figure 15. () Orthodontic seprtor not immeditely visile ut drk shdow mesilly. () Gentle proing sugingivlly revels hidden seprtor. Deonding of gold chin ttched to impcted tooth Following closed surgicl procedure to expose nd ond n unerupted impcted tooth, gold chin is ttched to its crown to llow susequent orthodontic trction. This free end of the chin is usully sutured into the sulcus, however, it cn sometimes ecome loose nd hng down in the ptient s mouth (Figure 16). If this is irritting the ptient, the loose prt of the chin cn esily e re-ttched either to the rce itself or re-onded onto n djcent tooth. Alterntively, the chin cn e crefully shortened tking cre to ensure tht there re still sufficient numer of links protruding to llow susequent orthodontic trction. This high risk solution is proly est left to the treting orthodontist. Occsionlly, the gold chin my ecome loose due to the filure of the ond to the enmel of the unerupted tooth itself (Figure 16). In these circumstnces, ll tht cn e done is to remove the detched prt of the chin, nd the ptient must e informed further surgicl procedure will proly e required in the ner future to re-ond the chin to the crown. Figure 16. () Loose gold chins cn e onded to djcent teeth or shortened. () Bond filure etween unerupted tooth nd pd of gold chin. April 2015 DentlUpdte 227

6 Summry Most ptients undergoing orthodontic tretment will only hve few prolems during their period of pplince therpy. Orthodontics is specilist rnch of dentl tretment, ut it is importnt tht ll generl dentl prctitioners hve n understnding of the prolems with ll common types of pplinces. The min ojective of n emergency visit is primrily to get the ptient out of discomfort or pin, ut lso to ensure continution of progress with tretment. The help of the generl dentl prctitioner throughout tretment is invlule to chieving this end. The prolems listed in these two ppers re y no mens exhustive, ut they hopefully identify the mjority of dy-to-dy prolems tht my e encountered y generl dentl prctitioners. The ppers offer simple nd strightforwrd, prcticl solutions. In the first instnce, n ttempt should lwys e mde y the ptient to get in touch with his/her orthodontic provider, ut if for some reson this is not possile, then the GDP will often still e le to sve the dy! References 1. Chdwick SM, Bnks P, Wright JL. The use of myofunctionl pplinces in the UK: survey of British orthodontists. Dent Updte 1998; 25(7): Smuels RH. A review of orthodontic fce-ow injuries nd sfety equipment. Am J Orthod Dentofcil Orthop 1996; 110(3): Advice Sheet 8: The Use of Hedger nd Fceows. Development nd Stndrds Committee of the British Orthodontic Society, Yng CS, Lu CK, Lee FL, Hsu WM, Lee YF, Lee SM. Tretment nd outcome of trumtic endophthlmitis in open gloe injury with retined introculr foreign ody. Ophthlmologic 2010; 224(2): Singh P, Grmmti S, Kirschen R. Orthodontic retention ptterns in the United Kingdom. J Orthod 2009; 36(2): Shh AA, Sndler PJ, Murry AM. How to plce lower onded retiner. J Orthod 2005; 32(3): Advice Sheet 9: Mngement of Inhled or Ingested Foreign Bodies. Development nd Stndrds Committee of the British Orthodontic Society, Nothing chnged. Just improved. 4 Unwrp 4 Moisten 4 Use BUY 5 GET 1 FREE Offer extended to 30 JUN out of 10 dentists re convinced the Geistlich Bio-Oss Pen hndles well* For more informtion visit: * Geistlich Phrm AG prctice test, June 2012 LEADING REGENERATION 228 DentlUpdte April 2015