https://doi.org/10.53453/ms.2025.6.8
Complications due to orthodontic treatment - literature review
Živilė Oleinikaitė
1
1
Independent researcher, Klaipeda, Lithuania
Abstract
Background. Irregular occlusion can be treated with fixed, removable, or functional orthodontic appliances,
depending on the age of patients. Orthodontic treatment like any other discipline of dentistry can have its adverse
effects. It is mandatory for orthodontists to clarify all possible risk factors before orthodontic treatment, to be able
to identify the type of complication and to refer patient to other specialist for treatment, if it is needed.
Aim: To overview general, hard tissue, periodontal and endodontic complications, induced by orthodontic
treatment.
Methods. A literature review was performed on PubMed using the keywords “orthodontic treatment" and
“complications”, focusing on articles published in the last 10 years, excluding non-English publications.
Results. Pain and discomfort are among the most common complications experienced during orthodontic
treatment. To reduce unpleasant feelings, orthodontists should inform patients about possible discomfort, prescribe
nonsteroidal anti-inflammatory drugs, adjust appliances, and provide dental wax in case of irritation of mucosa.
Orthodontic treatment makes daily oral hygiene more difficult. Plaque control should be maintained, and fluoride
preparations should be used to avoid enamel demineralization. In case of gingivitis or periodontitis, it is essential
to carefully observe the condition through regular periodontal assessments. To avoid endodontic complications, it
is crucial to carefully apply forces to teeth.
Conclusions. Orthodontic treatment is effective in treating malocclusion. However, it has its own adverse effects.
Keywords: orthodontic treatment, endodontic complications, periodontal complications, hard tissue lesions
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Medical Sciences 2025 Vol. 13 (4), p. 92-98, https://doi.org/10.53453/ms.2025.6.8
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1. Introduction
Nowadays, orthodontic treatment is popular more
than has ever been. Although it is expensive,
improving quality of life indicator, leasing
opportunity provided by dentistry clinics and
insurance for dental care allow patients to receive
orthodontic treatment [1-3]. Another reason of
increased demand of orthodontic treatment is
launching of clear aligner products [4]. This type of
dental misalignment treatment is particularly
attractive to adult patients, because of its aesthetic
properties and easier dental care.
Orthodontic treatment is needed for malocclusion
treatment or for aesthetic reasons despite the correct
bite [5, 6].
There are three categories of malocclusion according
to Angle classification: class I, class II and class III,
which are defined by the relationship of permanent
first molars [7].
Class I malocclusion presents normal relationship of
molar teeth, but may present various dental
irregularities despite the normal molar relationship.
These may include crowded incisors, proclination of
maxillary incisors, labial positioning of canines,
edge-to-edge occlusion of anterior teeth, anterior
crossbite, unilateral or bilateral posterior crossbite,
and mesioversion of first permanent molars [8, 9].
The frequency of Class I occlusal discrepancy is
approximately 74.7%, with reported ranges between
31% and 97% across different populations [10].
Class II is referred as distal occlusion [8]. It has two
subcategories. Class II, Subcategory 1 is when upper
incisors are proclined in combination with horizontal
overlap of the maxillary incisors over the mandibular
incisors is more than 3 mm and vertical overlap of
maxillary incisors over the mandibular incisors is
more than 4 mm. Class II, Subcategory 2 is when
central maxillary incisors are retroclined typically
with deep overbite [11]. The prevalence of Angle's
Class II occlusal discrepancy is estimated to be
around 23.8% globally [12].
Class III is referred as mesial occlusion [8]. This
class may be characterized by the lingual inclination
of lower jaw teeth or by palatal inclinaction of upper
jaw teeth, or an abnormal shape of dental arches [13].
Class III occlusal discrepancy prevails in
approximately 5.93% cases[10].
Irregular occlusion can be treated with fixed or
removable orthodontic appliances, depending on the
patient's age [14]. Orthodontic treatment, like any
other discipline of dentistry, can have its adverse
effects. It is mandatory for orthodontists to clarify all
possible risk factors before orthodontic treatment, to
be able to identify the type of complication and to
refer patient to other specialist for treatment, if it is
needed. The aim of this review article is to overview
general, hard tissue, periodontal and endodontic
complications, induced by orthodontic treatment.
2. Methods
This literature review was conducted through a
systematic search of the PubMed database, utilizing
the keywords "orthodontic treatment" and
"complications". Inclusion criteria: articles
published in English language, no older than 10 years
(2015-2025) articles. In order to ensure relevance
and novelty, these inclusion criteria were applied.
3. Results
3.1 Pain and discomfort
Pain and discomfort are among the most common
complications experienced during orthodontic
treatment. Discomfort can be caused by placing
separators, bonding of fixed appliances or
application of increased orthodontic force, which is
associated with release of inflammatory cytokines
[15]. Patients describe discomfort, after the latter
procedures, as tension and soreness. In
Kavaliauskiene et al study, even 72 % of patients felt
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pain, which presented highest scores one day after
the insertion of appliance [16]. Another cause of pain
and discomfort is mucosal ulcers which occur due to
mechanical irritation [17]. Wires, brackets, bands,
and other sharp parts of fixed appliances by constant
friction to mucosa can cause ulceration [18]. To
reduce unpleasant feelings, orthodontists should
inform patients about possible discomfort, prescribe
nonsteroidal anti-inflammatory drugs, adjust
appliances, and provide dental wax in case of
irritation of mucosa.
3.2 Hard tissue lesions
Orthodontic treatment poses challenges to routine
oral hygiene procedures. Appliances contain
numerous small elements that can impede thorough
dental hygiene.
Enamel demineralization is the first stage of caries
formation, caused by imbalance of remineralization
and demineralization [19]. White spot lesions result
from the loss of minerals from enamel, leading to a
porous surface with a matte appearance that becomes
prone to caries [20]. Remineralization can stop the
demineralization process, however, if it progresses, it
may end to irreversible dental caries. Prevalence of
demineralization in patients after 12 months of
orthodontic treatment was 46,57 %, according to Jha
et al study [21]. To prevent enamel demineralization,
cooperation between patient, orthodontist and dental
hygienist is inevitable. Plaque control should be
maintained through proper oral hygiene methods,
and enamel resistance to microbial acid should be
enhanced using fluoride preparations [22].
3.3 Periodontal complications
While orthodontic treatment effectively treats
skeletal and dental anomalies, the presence of
orthodontic devices and attachments complicates
oral hygiene maintenance and encourages plaque
accumulation, which contributes to periodontal
diseases [23].
Dental plaque is the primary contributing factor to
the development of periodontal diseases during
orthodontic treatment. Studies have shown that
patients with fixed appliances are prone to show
higher plaque levels and gingival inflammation
compared to those without appliances [24]. If dental
plaque is not effectively removed, it can develop into
a biofilm that contains Gram-negative anaerobic
bacteria, which are associated with the start of
periodontal diseases.
The presence of these microorganisms causes an
inflammatory response in the gingival tissues,
leading to gingivitis [25]. Clinically, this condition is
characterized by signs such as redness, swelling and
bleeding upon probing. At this moment, the
inflammation is still reversible, and with the
implementation of proper oral hygiene practices, the
progression of the disease can be halted [26]. If
gingivitis is left untreated, the inflammation may
extend to the supporting periodontal structures,
leading to the development of periodontitis.
Periodontitis is characterized by the progressive
destruction of the connective tissue and alveolar
bone, which results in the formation of periodontal
pockets and may lead to tooth mobility [27]. When
signs of gingivitis are observed, patients should
receive oral hygiene instructions and undergo more
frequent professional dental cleanings. In cases of
periodontitis, it is essential to closely monitor the
condition through regular periodontal assessments.
Gingival enlargement is characterized by an increase
in the size of the gingival tissue, often presenting as
swollen, puffy, or overgrowth gums. This condition
can be localized or generalized [28]. Gingival
hyperplasia may occur because of higher plaque
levels. In the study of Bugnas et al, the prevalence
rose from 20% in the absence of plaque to 72% in
cases of abundant plaque [29]. Besides plaque
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accumulation, another predisposing factor for
gingival hyperplasia is the use of nickel–titanium
orthodontic wires, which can release low levels of
nickel ions into the oral cavity. These ions may
stimulate epithelial cell proliferation, thereby
contributing to gingival overgrowth [30].
Gingival recession is migration of gingiva to the
apical direction from cementum-enamel junction,
resulting root exposure [31]. Consequently, this may
result in increased dental sensitivity, susceptibility of
root caries and an unfavorable aesthetic appearance.
Individuals with a thin gingival biotype are more
susceptible to gingival recession, particularly during
orthodontic or restorative procedures, due to the
limited thickness of soft and hard periodontal tissues
[32]. In addition to, orthodontic forces labially or
lingually can indeed lead to fenestration and
dehiscence of the alveolar bone and if the gingival
margin is not enough supported by alveolar bone,
gingival recession can occur [33].
Prior to initiating orthodontic treatment, the
orthodontist should not only emphasize the
importance of proper oral hygiene, but also
investigate about patient’s allergies, evaluate
periodontal condition, and gingival biotype. In
addition to, in case of worsened periodontal
condition the treatment should be suspended until the
condition is stabilized.
3.4 Endodontic complications
Orthodontic treatment can have several side effects
on dental pulp. Excessive orthodontic forces can lead
to various histological and physiological changes.
One of the most common endodontic complications
is a reduction in the pulpal blood flow, leading to
reduction of sensibility [34]. Changes caused by
pressure on the blood vessels are temporary in
healthy pulps, but prolonged ischemia from
excessive forces may predispose the pulp to
degenerative changes [34, 35]. Another complication
related to teeth alignment procedures is pulp canal
calcification. Although pulp canal calcification is not
that common, it can make difficulties if endodontic
treatment is required [36].
Before treatment, orthodontists should carefully
evaluate condition of teeth and do not apply
excessive orthodontic forces if possible.
4. Conculsions
Orthodontic treatment is effective in treating
malocclusion. However, it has its own adverse
effects. Pain and discomfort are common
complications, especially after an insertion of
orthodontic appliance. Gingivitis can occur due to
insufficient oral hygiene caused by the small details
of orthodontic appliances. Periodontitis can be a
consequence of gingivitis or pre-existing periodontal
disease prior to orthodontic treatment. Gingival
recession may occur due to positioning of teeth
beyond the bone boundary. Orthodontist should
carefully evaluate condition of periodontium before
orthodontic treatment, evaluate it during treatment,
instruct patients about proper oral hygiene, and
collaborate with periodontologists if needed.
Endodontic complications, such as reduction in the
pulpal blood flow and canal calcification, are not that
common, but orthodontist should be cautious about
applying severe forces.
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