Abnormal healing after tooth extraction leads to the dense sclerotic bone in the alveolar process centre, hindering orthodontic space closure. Idiopathic jawbone sclerosis is a common, inflammation-unrelated radiopacity. ‘Socket sclerosis’ occurs post-extraction as a radiopaque lesion, which is inconspicuous clinically but relevant in orthodontics. Reactive sclerosis can impede tooth movement, affecting treatment time and space closure. Two approaches have been advocated to facilitate orthodontic tooth movement: mini-implants and targeted force for space closure, surgical removal of sclerosed bone, and immediate force application post-surgery. ^, Despite a lack of clear guidelines, surgical removal of sclerosed bone and planned force delivery may enhance outcomes.

Severe bone loss and mobility during orthodontic treatment, which appears to be of periodontal origin without apparent cause, not resolved with conventional therapy, should be further investigated for foreign body lodgement. Bone loss and tooth exfoliation have been linked to lost orthodontic elastic bands, especially in midline diastema closure. While rare, displaced orthodontic separators can cause periodontal destruction. A case report highlighted severe periodontal issues due to an elastic separator, which had migrated into and infected the periodontium, emphasising the importance of vigilance in orthodontic procedures.

Non-radiopaque objects like elastic and rubber separators are challenging to locate using X-rays. Therefore, current requirements on separator quality include prerequisites for radiopaque material uses.

Nickel alloys, commonly found in orthodontic components, have the potential to trigger nickel allergy, which is more frequent than allergies to other metals combined. The onset of contact dermatitis, characterised as a Type IV delayed hypersensitivity response, may occur at least 24 h after exposure to nickel. Orthodontic appliances can increase nickel levels in saliva and serum. Clinicians must be vigilant for signs such as gingivitis, lip desquamation and burning sensation, with chronic cases leading to mucosal changes. Diagnostic confirmation can be achieved through a patch test. Treatment involves replacing nickel-containing components with nickel-free alternatives like stainless steel or titanium molybdenum alloy arch wires.

A meta-analysis showed that orthodontic treatment alone is not associated with an increase in the prevalence of Ni hypersensitivity unless subjects have a history of Ni exposure from cutaneous piercing. The subjects with nickel allergy should be treated with nickel-free brackets for periodontal health. A review by Pazzini et al. suggested using nickel-free braces (Ni content—2% max.) as a viable alternative for orthodontic patients allergic to nickel ( Fig. 103.1 ).

Nickel allergy from orthodontic appliance.

(A) The clinical condition of the allergic patient after 6 months of treatment.

(B) The clinical condition of the patient 1 month after stopping the treatment.

(C) The clinical condition of the patient 3 months after reassembly with Nickel free brackets.

Source: Cited with permission from Marques LS, Pazzini CA, Pantuzo MC. Nickel: Humoral and periodontal changes in orthodontic patients. Dent Press J Orthod. 2012;17(2):15–17. https://doi.org/10.1590/S2176-94512012000200002 .

Chromium and platinum hypersensitivity are rare but documented reactions in orthodontic patients. The chances of an adverse reaction to chromium found in dental materials appear rare. Similarly, documented cases of platinum hypersensitivity are even rarer than chromium allergy.

Natural rubber latex (NRL) allergy from rubber products has increased in clinical practice due to its use in orthodontic materials and gloves. Type I IgE antibody-mediated responses can cause severe systemic reactions within 5–60 min. Type IV reactions involving chemical accelerators in glove manufacturing lead to allergic contact dermatitis.

Contact stomatitis can result from NRL products such as intermaxillary elastics. ^, Diagnosis relies on medical history and skin tests, avoiding latex exposure in sensitive patients. Latex-free alternatives, such as self-ligating brackets and steel ligatures, should be available. The non-latex elastics may have poor properties compared to the latex elastics. Therefore, non-latex elastics should only be considered when force values and medical conditions demand it.

Residual monomer leaching is a common cause, with clinical manifestations including labial oedema and chronic urticaria.

The mucosal irritation from residual monomer in self-cure acrylic appliances should be differentiated from allergic reactions. Stomatitis allergy may occur when the residual monomer in the self-cure acrylic appliance is within internationally accepted limits. The patch test with monomer confirms an allergic reaction.

Clinicians should be aware of local and systemic reactions, and in cases of hypersensitivity, consider alternative materials for orthodontic appliances.

Resin composite materials may contribute to lichenoid reactions, possibly due to formaldehyde in the composition. Clinicians should remain vigilant for adverse reactions to these materials ( Fig. 103.2 ).

Allergic reaction from acrylic orthodontic appliance.

(i) (a) Acrylic retainer in place. (b) Erythema produced due to allergic reaction to acrylic retainer in palate.

(ii) (a) Acrylic appliance in maxillary arch in place. (b) Erythema and hypertrophy produced due to allergic reaction and continued use of appliance in palate.

Source: From Singh R, Nishant G, Varun G, Gurkeerat S, Ankit C. Allergies in orthodontics: from causes to management. Orthod J Nepal. 2019; 9:71–76. doi: http://dx.doi.org/10.3126/ojn.v9i2.28420 .

A case of lichenoid reaction was documented, where the patient had complained of a reddish painful lesion, gradually increasing in size since one year. The patient had completed the orthodontic treatment, and was using the Hawley retainer since then. The histopathological test confirmed the lichenoid reaction from the acrylic of the retainer, and the patient was prescribed medications and adviced to discontinue the use of retainers. The lesion had regressed on 6 month follow up. ( Fig 103.3 ).

Lichenoid reaction from the acrylic retainer.

(A) The acrylic Hawley retainer

(B) Left dorsolateral side of the tongue showing an erosive lesion

(C) Fiery red lesion on the left side and white keratotic lesion on the right side is seen.

(D) Partial healing after six months with depapillation at the original site

Source: Reproduced with permission from Elhadad MA, Gaweesh Y. Hawley retainer and lichenoid reaction: a rare case report. BMC Oral Health 2019 Nov 20;19(1):250. doi: 10.1186/s12903-019-0949-4. PMID: 31747943; PMCID: PMC6869280.

The unintentional inhalation or swallowing of foreign objects poses serious concerns due to associated health risks. The swallowing of objects is more prevalent than inhalation. Certain individuals are at a heightened risk of swallowing or inhaling foreign objects, including those with systemic, psychological or physical disabilities. The risk significantly rises in children over the age of 15 who have accompanying disabilities.

High-risk adult groups include individuals with mental disabilities, dementia, those using opioids, antidepressants or with a history of alcohol addiction or neurological illnesses (e.g. Parkinson’s or dysphagia associated with stroke) and seizures.

Surprisingly, dental objects are the second most common source of ingested foreign bodies, with reported items including toothpicks, files, reamers, burs and dental prostheses. In orthodontics, the list encompasses brackets, bands, removable appliances, arch wire fragments, expansion appliance keys, retainers, quad helices, coil springs, buccal tubes, sectional arch wires, transpalatal arches and even a fractured twin block.

The case reports by Kharbanda and his group on two reported accidents highlight the need for vigilance during orthodontic procedures on the quality of restorative work and oral anatomy. The first case pertains to a dislodged gold crown along with a cemented molar band, which was accidentally dislodged during the separation of teeth with brass wire and was ingested. The incident happened in a tertiary hospital, facilitating immediate access to investigations and expert advice. Immediate chest and abdomen radiographs and endoscopic examination revealed that the object had passed distal to the duodenum. Therefore, vigil watch by daily radiographic examination was maintained; the crown passed in excreta on the fifth day ( Fig. 103.4 ).

Gold cast crown with cemented molar band dislodged, swallowed and retrieved.

(A) AP chest X-ray within 1 h of swallowing: Metal crown not seen.

(B) AP view the abdomen within 1 h of swallowing, showing a radiopaque foreign body in the duodenum.

(C) AP view of the abdomen after 2 days of swallowing shows a radiopaque foreign body distal to the ileocaecal region.

(D) Gold cast crown that was swallowed and later recovered.

(E) AP view abdomen on the fifth day of swallowing: Normal hard and soft tissue shadows are seen.

Source: Reproduced with permission from Kharbanda OP, Varshney P, Dutta U. Accidental swallowing of a gold cast crown during orthodontic tooth separation. J Clin Pediatr Dent. 1995 Summer;19(4):289–92. PMID: 7547488.

The second case pertains to a cleft child where a small soft palate was mentioned as the reason for the possibility of ingestion or aspiration of a foreign body being relatively higher. The right upper molar band that slipped and ingested was successfully located with X-rays and retrieved with an endoscopic procedure from the cervical part of the oesophagus ( Fig. 103.5 ).

Accidental ingestion of a molar band in a cleft child.

Chest X-ray and lateral cervical spine radiograph showing the swallowed object in the cervical part of the oesophagus. Molar band retrieved from the oesophagus.

Source: From Mahto RK, Rana SS, Kharbanda OP. Accidental swallowing of a molar band. Turk J Orthod. 2019;32(2):115–8. doi:10.5152/TurkJOrthod.2019.18001.

Two other reports from literature are related to quad helix appliance and wire. An unusual case of accidental swallowing of a quad helix appliance in a 13-year-old Down’s syndrome boy got stuck, at the level of the oesophageal–gastric junction which needed surgical endoscopic intervention for its removal ( Fig. 103.6 ).

Accidental swallowing of quad-helix appliance.

(A) Chest radiograph showing quad-helix (white arrowhead) in the lower oesophagus.

(B) Quad-helix is viewed through an endoscope at the oesophageal–gastric junction level.

Source: From Allwork JJ, Edwards IR, Welch IM. Ingestion of a quad helix appliance requiring surgical removal: a case report. J Orthod. 2007 Sep;34(3):154–7. doi: 10.1179/146531207225022131. PMID: 17761797.

An unusual case where part of the lower arch wire migrated through the foramen ovale and caused seizures by intraparenchymal haemorrhage has been reported. The history of visits to an orthodontist for wire change was linked to the suspicion of the object in the CT scan ( Fig. 103.7 ).

Piece of orthodontic wire penetrating through the skull.

(A and B) Coronal and sagittal view of the CT angiogram demonstrates the wire penetrating the skull floor.

(C) Axial view of CT demonstrating the wire in the temporal lobe and the associated intraparenchymal haemorrhage.

(D) Axial bone window CT demonstrating the wire entering through foramen ovale.

Source: Cited from Morgan RD, Chintagunta A, Psaromatis KM, Vojtkofsky NA, Baronia B, Belirgen M. Seizure caused by intraparenchymal haemorrhage from the migration of mandibular dental wire through foramen ovale in a child: a case report. Radiol Case Rep. 2023 Jul18(10):3560–4. doi: 10.1016/j.radcr.2023.07.026. PMID: 37547795; PMCID: PMC10403720.

The management of ingested and inhaled objects requires immediate attention and efforts to track the object, maintain an airway and immediate efforts to retrieve it.

A thorough assessment is essential in cases of a lost object in the oral cavity or oropharynx. Adequate lighting should be used to aid in locating and retrieving the object using forceps or high-speed suction. Maintaining the airway is of utmost importance if there is a risk of ingestion or aspiration. Radiographic investigations can help to identify radio-opaque objects in the gastrointestinal tract. Patients should be reassured and advised to consume a diet rich in cellulose. Serial radiographs are used to track the object, with vigilant monitoring until the object is excreted. Ingested objects may necessitate endoscopic retrieval, particularly for sharp objects. If endoscopic retrieval is unsuccessful, or if symptoms suggestive of gastrointestinal perforation arise, surgical intervention may be required.

According to a comprehensive review, most ingested objects traverse the gastrointestinal tract (GIT) without adverse incident and are subsequently excreted. However, a minority, ranging from 0% to 20%, may necessitate removal. Of these, 10%–20% may require endoscopic intervention, while 1% could necessitate surgical intervention. ^, Furthermore, guidelines aimed at preventing mishaps in orthodontic clinics have been synthesised in Table 103.1 . ^,

In a rare critical orthodontic incident, a 15-year-old patient accidentally swallowed a broken part of his upper removable appliance designed for isolated expansion of an upper first right molar with a cold cured acrylic baseplate having Adams clasps on the other first molar and premolars for retention using a T spring with adjustment loop to provide the single tooth expansion.

X-rays revealed the lost appliance in the mediastinum. Retrieval via a rigid oesophagoscope led to complications, including an oesophageal perforation. Due to outdated equipment, the patient faced challenges. A thoracotomy was performed, revealing signs of mediastinitis and pleural effusion. Despite post-operative complications, including incomplete oesophageal healing, the patient slowly recovered through natural tissue healing.

Therefore, clear instructions during appliance fitting are crucial. Appliances should avoid sharp ends, and immediate referral to a thoracic surgeon is vital in cases of swallowed appliances, with thoracotomy if removal via the oesophagus is challenging.

In this rare complication, a 15-year-old undergoing removable appliance treatment developed a submucosal swelling in the left cheek. The removable appliance, worn for 7 months without problems, resulted in a painless swelling in the left buccal mucosa due to the clasps in the maxillary second molar. Biopsy revealed a non-caseating giant cell lesion invading striated muscle, raising concerns of sarcoid or Crohn’s disease. Exclusion of beryllium allergic reaction and a positive Kveim’s test pointed towards sarcoid infection. Removal of the orthodontic appliance resulted in rapid regression of both cheek swellings, indicating the presence of a local cause. While chronic irritation is not typically an initiator of sarcoid, the disease may manifest in scar tissue. The potential development of sarcoidosis in the patient’s later life warrants consideration despite a lack of prior history and a clear chest X-ray.