Hygiene Approaches for Fixed-Appliance Treatment
Oral hygiene is more difficult after fixed appliances have been fitted. Efforts to maintain a patient’s oral health should therefore start at the bonding appointment. Removing excess composite around the brackets, which may contribute to plaque accumulation, is as important as sealing the tooth surface surrounding the brackets with fluoride varnishes or other protective agents. A new generation of sealants that gradually release fluoride are a promising development. Although they provide only a very thin covering of the tooth surface, these sealants allow complete polymerization, which is not inhibited by oxygenation. Two of the more widely used products are manufactured by Reliance Orthodontics (Maximum Cure and Pro Seal). The products are reinforced with filler particles and consequently offer good abrasion resistance against everyday wear and tear (such as brushing teeth). According to the manufacturer, the sealing of the surrounding surface area should last for at least 2 years and possibly even longer. Even after 2 years, there is still residual resin on the tooth surface in up to 70% of cases. Reports in the literature1 , 5 have shown that this system provides an equivalent bond strength to that of conventional adhesive systems and that remineralization of the dental enamel from the sealant’s reserve has a protective effect against caries.7 , 14
The operator should carefully remove the adhesive material in the vicinity of the bracket ( Fig. 5.4 ) to allow oral hygiene. Particularly in the area near the gingivae, residual composite can rapidly lead to accumulation of food debris and consequent overgrowth of the gingivae.
Bonding agents that incorporate a light-sensitive dye are colored before setting and thus make it easier for the orthodontist to remove excess composite ( Fig. 5.5 ).
Active Tooth Movement
After fixed appliances have been fitted, plaque undergoes qualitative and quantitative changes, and there is a noticeable increase in Streptococcus mutans. Bearing in mind the etiology and pathogenesis of carious and periodontal disease, the orthodontist should coordinate prophylactic measures specifically during orthodontic treatment with fixed appliances. Important measures include the following:
Instruction and motivation for the patient to practice good oral hygiene
Patient education on the etiology of caries and periodontal disease
Regular maintenance by dental hygienists, with professional cleanings and consultations
Topical fluoride applications
Use of fluoride-containing materials
Chemical plaque control
In a review of the extensive literature, Chadwick et al.3 concluded that there is no single approach to oral hygiene that can be recommended. However, it is possible to significantly reduce the amount of decalcification by using fluoride-containing varnishes and/or sealants, fluoride-containing gels, or fluoride-containing mouth rinses ( Fig. 5.6 ).
Maintaining good oral hygiene is complex and time-consuming for patients receiving treatment with fixed appliances. In addition to the routine cleaning of all tooth surfaces incisal and gingival to the archwire, it is particularly important to pay attention to cleaning the interdental spaces. Patients therefore need to be instructed in depth on hygiene requirements with orthodontic fixed appliances on the day the appliances are placed. It is advisable to use aids such as V-shaped bristled toothbrushes, interdental brushes (such as TePe®), and single tufted brushes ( Fig. 5.7 ). A number of studies have confirmed that for most patients, the time spent on brushing teeth is significantly less than the recommended time. It is therefore very important, particularly when considering treatment periods lasting several years, to monitor oral hygiene regularly and ideally support patients in their efforts to keep the teeth clean by encouraging regular visits to the hygienist, for example.
In addition to daily use of fluoride-containing toothpaste, we also recommend either a daily or weekly fluoride mouth rinse. Local fluoride applications can also be used, and fluoride-containing salt can be used as an adjunct to the above measures.
Effective oral hygiene can also be achieved with an electric toothbrush. These can basically be divided into systems that have a rotating or oscillating head and sonic systems ( Fig. 5.8 ). For systems with rotational or oscillating heads, patients can purchase special heads designed for fixed-appliance treatment.
Some studies have reported that sonic-based systems are superior in comparison with the rotational or oscillating systems,9 , 13 but it remains to be seen whether these findings will be validated in subsequent studies. However, it is very important to remember that regular control visits and careful explanations are often the best way of keeping patients motivated and ensuring the best possible oral hygiene, regardless of which type of toothbrush is used. The peculiarities of the mixed and early permanent dentition in particular often require a very intensive oral hygiene regimen ( Fig. 5.9 ). There is an increased incidence of caries during this period, as self-cleaning of the teeth is significantly reduced and good cleaning, particularly of the molars, can be difficult during their emergence. In addition, food retention and plaque accumulation may occur under residual opercular mucosa that partially covers the erupting teeth. Poor positioning of the teeth relative to the adjacent dentition can also give rise to carious lesions.
Bifluorid 12 (Voco): NaF, CaF2; 55,900 ppm
Duraphat (GABA): NaF; 22,600 ppm
Fluor Protector (Ivoclar, Vivadent): Fluorsilan; 1000 ppm
The fissures on the first and second molars are particularly susceptible to the development of carious lesions.