Gingival response to removable

orthodontic appliances
Josef Goultschin, D.D.S.,* and Yerucham Zilberman, D.M.D.**
Jerusalem, Israel

The gingival state of twenty-four young patients (Imean age 9.4 years) wearing simple removable orthodontic
appliances was assessed and followed at monthly intervals for 4 months. In nine of the patients intentional relief
of the appliance was made in the upper right area. The plaque index levels were similar in both “relief” and
“no-relief” groups and reached a similar score at 4 months. The gingival index was significantly higher in the
“relief” group, and all five cases that showed gingival hyperplasia of the experimental area belonged to this
group.

Key words: Removable appliances, gingival response,relief-hyperplasia

R emovable orthodontic appliances, whether

passive or active, present a dilemma to the clinician,
Table I. Number and distribution of cases
in the two groups during the study
since gingival reactions are at times a cause of concern. Experimental No. of
The type of relationship between the appliance and the period patients Relief No relief
marginal gingiva is still a controversial issue. Consider-
able information may be extrapolated from the abundant Before
literature on the subject of removable partial denture
design. I, * However, the special needs of the orthodon- One month

tic removable appliance with respect to retention and Two months

provision of anchorage make many of the recommen-
dations about relief and noncoverage of margins diffi-
cult to apply. In a 1977 article, Bissada and associates”
concluded that when gingival margins are covered by
partial dentures severe pathologic changes occur within
a period of 12 months in areas covered without relief. It
is the purpose of this article to present the results of a
follow-up study of the gingival response in children
undergoing orthodontic therapy with removable appli-
antes, with and without relief of the gingival margins.
METHODS AND MATERIALS
The gingival conditions of twenty-four children
aged 7 to 17 years (mean age, 9.4) attending the orth-
odontic clinic of the Hebrew University-Hadassah
Faculty of Dental Medicine in Jerusalem, Israel, were
assessed by a trained periodontist (J.G.). The children
were selected for the study on the basis of their being
treated by means of simple removable appliances.
For this study, the appliances were of the Hawley
From Hebrew University-Hadassah School of Dental Medicine (founded
the Alpha Omega Fraternity).
*Depaltment of Periodontics and Endodontics.
**Department of Orthodontics.
00X!-9416/82/020147+03$00.30/0 0 1982 The C.V. Mosby Co.
7 girls
Four months 13
6 boys
type, in which an acrylic base, covering the palatal area
of the maxillary arch, was retained by means of Adams
clasps on the first molars and a labial bow on the ante-
rior segment.4 The active elements of these appliances
were as follows: (1) A palatal spring5 to correct the
linguoversion of an incisor tooth. (2) An active labial
bow to retract an increased overjet in an anteriorly
spaced Angle Class I malocclusion. In this situation,
the acrylic was cut away behind these teeth to allow the
movement. (3) An expansion screw in a split plate, for
slow expansion of the dental arch657 in cases in which
there was a unilateral dental cross-bite of a functional
nature. These appliances were worn 24 hours per day,
and the forces were of light magnitude, conforming to
the retention and anchorage limitations of such ap-
pliances.
No randomization was made, but all patients attend-
ing the Monday and Thursday afternoon clinics were
by
examined and followed for a period of up to 4 months.
Of the twenty-four patients, nine were selected at ran-
dom and 2 to 3 mm. of acrylic was removed from the
147
148 Goultschin md Zilberman Am. J. Orrhod
Fehrutq 1982

Table II. Mean gingival index (G.I.) scores and (p) levels of significance
Experimental period Relief Hyperplasia No reliej Hyperplasicr

x = 0.333 None x = 0.35 None

Before
SE = 0.093 SE = 0.053
x = 0.75 None i? = 0.673 None
One month SE = 0.170 SE = 0.091
(p = 0.274) (p = 0.025)
x = 0.80 2 2 = 0.792 None
Two months SE = 0.199 SE = 0.076
(p = 0.028) (p = 0.032)
jT = 1.142 5 x = 0.916 None
Four months SE = 0.092 SE = 0.083
(p = 0.002) (p = 0.028)

Table Ill. Mean plaque index (Pl.1.) values
before and along the study
Experimental period Relief
Before x = 1.055
SE = 0.149
One month x = 1.208
SE = 0.332
Two months x = 1.400
SE = 0.269
Four months k = 1.428
SE = 0.186
gingival margin for relief. The area included the
mesiolingual line angle of the upper right canine distal
to the mesiolingual line angle of the last molar in the
right upper quadrant. The width of the relief area was
about 5 mm. Gingival index (G.I.)X and plaque index
(Pl.1.)” scores of the lingual and mesiolingual surfaces
of the teeth from the upper right canine to the last molar
present in the upper right quadrant were recorded, as
well as the presence or absence of hyperplasia of the
gingival tissues of the area. This was performed prior to
appliance insertion and subsequently at monthly inter-
vals. At the initiation of the experiment all children
were instructed in the use of a soft multitufted tooth-
brush following the modified Bass technique.“) No at-
tempt was made to reinforce the instructions during the
experiment. Because of changes in schedules at school
or because of personal requirements, several of the pa-
tients changed their days of attendance at the clinic;
thus, of the twenty-four original patients, only nineteen
were examined at the l-month interval, eleven at 2
months, and thirteen at the 4-month re-examination
(Table I). Two groups were selected and categorized as
“relief” and “no-relief” subjects, rather than using a
split-mouth approach, because of the difference in ef-
fectiveness of tooth brushing on each side of the mouth.
All the computed mean score values for the gingival
index (G.I.) figures were subjected to the Mann-
Whitney U test for assessment of their levels of sig-
nificance.
No relief RESULTS
x = 1.163 Table II shows the G.I. scores during the experi-
SE = 0.130 mental period. From an almost identical beginning
x = 1.385
(0.33 for the “relief” group versus 0.35 of the “no-
SE = 0.213
?t = 1.167 relief” group), the values diversely increased, reaching
SE = 0.238 a significantly different level at the 4-month period
% = 1.416 when the ‘ ‘relief’ ’ group was 25 percent higher than the
SE = 0.247 “no-relief” group (p = 0.002).
The Plaque Index (Pl.1.) values are given in Table
III. It may be noted that both groups started at a higher
than 1 level, a condition common in this age group.
The plaque scores increased slightly, reaching nearly
identical scores for the “relief” group ( 1.43) and the
“no-relief” group ( 1.42), at the 4-month period.
The gingival tissues in both groups appeared in-
flamed upon examination, and many hemorrhaged eas-
ily on probing. The group in which intentional relief
was performed had the highest scores of clinical gingi-
val pathosis at the end of the study. At the 4-month
examination, gingival hyperplasia was noted in five
cases with relief (Table II) out of a total of thirteen
cases checked at this time (Table I). It is worth noting
that these five patients were all females whereas the two
male subjects in the group did not show hyperplasia.
DISCUSSION
Tissue-borne appliances can have deleterious effects
on the gingiva. Furthermore, there seems to be agree-
ment among foremost periodontists” and experts in oral
rehabilitation12 on the matter of the appliance-gingiva
relationship. In 1968 Waerhaug” stated: “. denture
material, clasps, bars and teeth should be kept as far
away from the gingival margin as possible. ” The rea-
sons for these deleterious effects have been summarized
by McCracken” as (1) pressure, (2) uncleanliness, and
(3) amount of time the appliance is worn.
Volume 81 Gingival response to removable uppliances 149
Number 2

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