# Managing Orthodontic Risks

# Question: 

Hey guys, so I am freaking out a little bit. I was removing attachments today to place the patient in her temporary retainers to allow her bite to settle. I was removing the attachment on lower left lateral incisor and noticed mobility. Took a probe to measure pockets and distal measured 8mm. Yikes!  I took a PA, told the patient there is mobility and deep pocket and we will reassess at delivery of the retainers and monitor.  Here is the PA. What do I do?!? Send her to perio?  I am seriously worried I caused this with ortho. Help!


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# Answer:

[https://www.loom.com/share/c2714cbde8fd4986a23015ad5f41d5e0?sid=5195b108-d422-4232-b586-3beabdb1a732](https://www.loom.com/share/c2714cbde8fd4986a23015ad5f41d5e0?sid=5195b108-d422-4232-b586-3beabdb1a732)


Orthodontic treatment involves inherent risks, including recession, bone loss, and even tooth loss. While these outcomes are not highly likely, they remain possible. When discussing treatment with patients, it is crucial to be transparent about these risks.

In many cases, the situation may ultimately be fine. A prudent first step would be to obtain a periapical (PA) radiograph from a different angle to better assess the root positioning, particularly between the lateral and central incisors. If the roots have moved too close together, introducing distal root tip adjustments could be beneficial, though this is not always necessary.

Stabilization of the teeth is often recommended, typically using a lingual wire. There have been cases where radiographs indicated significant radiolucency, prompting a periodontal consultation that suggested tooth extraction. However, after a year, bone levels improved significantly, negating the need for extraction or additional treatment. While clinical bone height and attachment loss were present, the teeth remained viable.

Orthodontic treatment, like any medical procedure, carries risks. A worst-case scenario in this context could involve the need for tooth extraction and subsequent restorative procedures, such as implants or bridges. Some clinicians may opt to cover the cost of an implant and crown in cases where tooth loss occurs due to treatment, both as a professional courtesy and to maintain patient trust.

To mitigate risks, obtaining a PA from a different angle is advisable, as this can provide greater clarity regarding root positioning and potential movement adjustments. Additionally, reviewing pre-treatment PA radiographs, panoramic X-rays, and periodontal probings is crucial. If root movement is not pursued, stabilization becomes the priority. This involves placing a lower lingual wire and allowing six months to a year for reevaluation while ensuring optimal oral hygiene.

If images from before and after treatment are available, they can offer valuable insights into the extent of dental expansion. If significant over-expansion of the lower teeth has occurred, interproximal reduction (IPR) and retraction may be considered.

Although orthodontic treatment can contribute to an increased incidence of periodontal issues, it is important to recognize that periodontal disease is multifactorial. A thorough evaluation of radiographic images often reveals that substantial bone support remains. Even with deep probing depths, stabilization and reevaluation typically represent the first course of action before considering further intervention.