dentistry journal

Review
The Influence of Orthodontic Treatment on Periodontal Health
between Challenge and Synergy: A Narrative Review
Ionut Luchian 1,† , Zenovia Surlari 2,† , Ancuta Goriuc 3, *, Nicoleta Ioanid 2, *, Irina Zetu 4 , Oana Butnaru 4 ,
Monica-Mihaela Scutariu 5 , Monica Tatarciuc 6 and Dana-Gabriela Budala 2

1 Department of Periodontology, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and
Pharmacy, 16 Universităt, ii Street, 700115 Iasi, Romania; [email protected]
2 Department of Prosthodontics, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and
Pharmacy, 16 Universităt, ii Street, 700115 Iasi, Romania; [email protected] (Z.S.);
[email protected] (D.-G.B.)
3 Department of Biochemistry, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and
Pharmacy, 16 Universităt, ii Street, 700115 Iasi, Romania
4 Department of Orthodontics, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and
Pharmacy, 16 Universităt, ii Street, 700115 Iasi, Romania; [email protected] (I.Z.);
[email protected] (O.B.)
5 Department of Oro-Dental Diagnosis, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine
and Pharmacy, 16 Universităt, ii Street, 700115 Iasi, Romania; [email protected]
6 Department of Dental Technology, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and
Pharmacy, 16 Universităt, ii Street, 700115 Iasi, Romania; [email protected]
* Correspondence: [email protected] (A.G.); [email protected] (N.I.)
† These authors contributed equally to this work.

Abstract: By correctly repositioning teeth, orthodontic therapy improves both the function and
appearance of an occlusion. The relationship between teeth and the tissues that surround and support
them significantly influences these alterations. With ever more adults seeking orthodontic care,
orthodontists are increasingly seeing patients with periodontal issues. Concerns about the patient’s
appearance, such as uneven gingival margins or functional issues caused by inflammatory periodon-
Citation: Luchian, I.; Surlari, Z.; tal diseases, should be accounted for when designing orthodontic treatment plans. Furthermore,
Goriuc, A.; Ioanid, N.; Zetu, I.; orthodontics may increase the chances of saving and recovering a degraded dentition in cases of
Butnaru, O.; Scutariu, M.-M.; severe periodontitis. Today, general dentists, dontists, and orthodontists play integrative roles that en-
Tatarciuc, M.; Budala, D.-G. The
able them to achieve the best possible results for their patients. This review will improve the results of
Influence of Orthodontic Treatment
interdisciplinary treatments and increase cooperation between dental specialists by drawing attention
on Periodontal Health between
to the essential connection between orthodontics and periodontics in regular clinical practice.
Challenge and Synergy: A Narrative
Review. Dent. J. 2024, 12, 112.
Keywords: periodontal health; periodontal disease; periodontitis; fixed appliances; orthodontic
https://doi.org/10.3390/dj12040112
treatment; removable appliances; aligners
Academic Editor: Philipp Sahrmann

Received: 31 December 2023

Revised: 27 February 2024
Accepted: 16 April 2024 1. Introduction
Published: 17 April 2024 Orthodontic treatment ensures the accurate positioning of the teeth and optimizes the
occlusion–jaw relationship. This approach not only improves the quality of life by helping
patients with eating, talking, and their appearance [1] but also improves their overall health.
Therefore, the number of adult patients choosing orthodontic treatment has steadily risen
Copyright: © 2024 by the authors.
in recent years.
Licensee MDPI, Basel, Switzerland.
Effective collaboration, coordination, and communication between various dental spe-
This article is an open access article
cialists are crucial for ensuring more accurate diagnosis and optimized treatment planning.
distributed under the terms and
Interdisciplinary interaction is paramount and, in certain instances, facilitates coordinated
conditions of the Creative Commons
Attribution (CC BY) license (https://
dental therapy [2].
creativecommons.org/licenses/by/
The effect of orthodontic treatment on the prevalence of periodontitis has been debated
4.0/). among scholars. Recently, periodontal health’s importance has increased in line with the

Dent. J. 2024, 12, 112. https://doi.org/10.3390/dj12040112 https://www.mdpi.com/journal/dentistry

Dent. J. 2024, 12, 112 2 of 16

number of adult orthodontic patients. The orthodontic treatment–periodontitis relationship

has been widely studied by scholars, and it often has a synergistic character. Orthodontic
treatments enhance periodontal health by aligning teeth and balancing occlusion, in turn
improving hygiene by making it easier for patients to access their teeth and reducing oc-
clusal trauma. Fixed orthodontic devices can enhance supragingival biofilm formation and
worsen periodontal tissue’s condition [2]. Orthodontic pressures can lead to inflammation
in the periodontium. This reaction is essential for the orthodontic tooth movement process.
One challenge in orthodontics is performing treatment without impacting the root and
periodontium [2].
Orthodontic tooth movement has enhanced periodontal health in numerous cases,
while periodontal therapy frequently aids the promotion of orthodontic tooth movement [3].
This process could cause potential complications in dentitions impacted by chronic
periodontitis. Adult patients are challenging for orthodontists to treat due to their elevated
aesthetic expectations and existing oral problems potentially impeding treatment, such
as tooth wear, inadequate restorations, and periodontal disease [4]. Adults afflicted with
periodontal disease may undergo supplementary orthodontic therapy before prosthetic
rehabilitation, whether to improve the aesthetics of their smile or address functional issues.
This orthodontic treatment typically forms part of a multidisciplinary treatment plan.
Nevertheless, a lack of adequate data exists regarding the advantages and disadvantages
of using comprehensive orthodontic treatment to treat this specific patient population [2].
Also, scholars have disagreed about the best times and methods for periodontal
therapies. Most patients suffering from periodontal disease are best suited to non-surgical
periodontal therapy methods that decrease microbial populations [2]. Osseous or pocket
reduction/elimination surgery, which are types of periodontal therapy, should not be
performed until the end of orthodontic treatment because shifting teeth might alter the
shape of the gums and bone [3,4].
Several factors, including host resistance, systemic diseases/conditions such as dia-
betes mellitus or a smoking habit, the periodontal phenotype (particularly for the width
of the buccal bone plate), the quantity and type of dental plaque, and the patient’s oral
hygiene routine are all important for maintaining periodontal health during orthodontic
treatment [5,6].
Bone levels and shapes in periodontally affected patients can benefit from orthodontic
therapy as it facilitates plaque removal, a reduction in occlusal trauma, and potential
action to stimulate bone growth within bony defects [7,8]. On the other hand, periodontal
therapy might improve the efficiency of orthodontic treatment. Scholars often advise that
practitioners perform orthodontic treatment after periodontal therapy to prevent quick and
irreparable damage inflammation-related gum damage during such treatment.
Orthodontic treatment, like any other form of medicine, has both positive and nega-
tive aspects. Nonetheless, compared to other surgical and non-surgical procedures, this
treatment’s reported risk and complications are quite low. By highlighting the crucial
relationship between orthodontics and periodontics in everyday clinical practice, we aimed
to enhance multidisciplinary treatments’ success and foster more collaboration between
dental experts.
The current narrative review’s objective was to establish new clinical perspectives on
the ortho-periodontal synergistic relationship to improve these conditions’ prognosis.
In this study, we used the following keywords: periodontal health, periodontal disease,
periodontitis, fixed appliances, orthodontic treatment, removable appliances, and aligners;
two specialists investigated these keywords independently using the PubMed and Web
of Science databases. To avoid the risk of bias, the investigators included both positive
and negative papers on this topic. Only the publications selected by both independent
investigators were considered reliable and included in this narrative review. As a result of
this process, 119 publications were selected.
Dent. J. 2024, 12, 112 3 of 16

2. Mechanisms of Action
The orthodontic and periodontal professions have a common objective, namely im-
proving both the face’s appearance and dental aesthetics while maintaining the masticatory
apparatus’ health and lifespan. In recent decades, a consistent rise in the number of adult
patients seeking orthodontic treatment with fixed equipment has been noted. Furthermore,
a recent survey revealed that 50% of 30-year-old individuals in the United States exhibit
periodontitis symptoms. This correlation between periodontal and orthodontic therapies,
particularly in adult patients, has encouraged clinicians and academics to explore numerous
related lines of inquiry [9].
The propagation of orthodontic forces within the strained tissue matrix to the adjacent
cells in the periodontal ligament and alveolar bone leads to these cells releasing pro-
inflammatory, angiogenic, and osteogenic substances, initiating the process of remodeling
the periodontal ligament and alveolar bone [10]. According to the literature, fixed or-
thodontic appliances (FA) are associated with notable clinical attachment loss and alter the
subgingival bacterial microbiota and gingival inflammation, regardless of the individual’s
dental hygiene practices [11].
The presence of orthodontic brackets and elastic modules hinders the efficient elimina-
tion of plaque, elevating the individual’s susceptibility to gingivitis. Self-ligating brackets’
(SLBs) purported advantages compared to conventional brackets (CB) include improved
bacterial retention and reduced plaque buildup. Past research has indicated that orthodon-
tic treatment, if not well managed, potentially impacts the inflammatory process and causes
the periodontium to deteriorate, leading to a significant loss of attachment [12].
Although the prevailing belief is that SLBs lead to enhanced oral hygiene compared
to CB, several studies have challenged this notion. The debate around this topic remains
unresolved. Potential alternatives to fixed orthodontic appliances (FA) include utilizing
transparent aligners. These aligners have several possible benefits, such as reduced plaque
buildup and enhanced gingival and periodontal parameters, which may be more advanta-
geous than the use of FA [13].
One past study clarified the correlation between orthodontic movement and peri-
odontal disease based on their combined impact on tissue degradation by increasing the
concentrations of pro-inflammatory cytokines [14].
The way in which the jaws and gums react to orthodontic treatment is largely deter-
mined based on the duration and severity of the forces applied to the teeth. The bioelectric
and pressure–tension theories can be used to assess the orthodontic biological mechanisms.
Our first hypothesis states that bending the bone produces piezoelectric currents, in
turn determining changes in bone metabolism. Orthodontic stresses usually cause alveolar
bone displacement, and these strains alter the periodontal ligament, formed by electrons
traveling from side to side within the network of a crystalline material.
According to the pressure–tension theory, chemical signals regulate cell development
and, by extension, tooth movement, as shown in Figure 1.
When a constant strain is applied to a ligament, certain parts experience compres-
sion, decreasing oxygen tension and, eventually, blood flow, while other areas experience
traction, increasing oxygen tension and, ultimately, blood flow [15]. Blood vessel damage
leads to an inflammatory response, producing new blood vessels and connective tissue.
When periodontal fibers are compressed, the “hyalinization” process [16] occurs, lead-
ing to the atrophy and/or pyknosis of cell nuclei and collagen fiber convergence in a
gelatinous-like substance.
Hyalinization, as described by Reitan in his study of histological changes resulting
from the orthodontic application of force [17], involves the loss of normal tissue architec-
ture and discoloration characteristics of collagen present in processed histological material,
occurring in cell-free regions inside the periodontal ligament. Reitan observed that hyalin-
ization occurred within the periodontal ligament if even slight pressure was applied. Direct
resorption occurs after removing hyalinized tissue due to the activated osteoclasts origi-
nating from the ligament, followed by indirect resorption with cellular materials from the
Dent. J. 2024, 12, 112 4 of 16

blood flow. When the periodontal ligament (PDL) is compressed, blood flow within the
PDL decreases until the blood vessels collapse completely, causing ischemia. After 1–2 s
of gentle pressure, the PDL is partially compressed, causing fluids to leak out of both the
periodontal space and the alveolus; after 3–5 s, blood vessels passively compress on the
Dent. J. 2024, 12, x FOR PEER REVIEW 4 of 17
pressure side and dilate on the tension side, with the PDL’s fibers and cells appearing to be
mechanically distorted [18–20].

Figure 1.
Figure 1. Compression
Compression and
and tension
tension zones’
zones’ distributions
distributions based
based on
on the
the application
application of
of force.
force.

These
Whenchanges
a constantin blood
strain flow and oxygen
is applied tension,certain
to a ligament, as well parts
as theexperience
release of prostaglandins
compression,
and inflammatory cytokines, are triggered even by a
decreasing oxygen tension and, eventually, blood flow, while other areas brief application of pressure
experience and its
trac-
maintenance for a few minutes. Several chemical modulators are
tion, increasing oxygen tension and, ultimately, blood flow [15]. Blood vessel damage induced, cyclic adenosine
monophosphate (cAMP) increases
leads to an inflammatory response,and cell differentiation
producing new blood occursvesselswithin the periodontal
and connective tissue.
ligament after at least
When periodontal fibers4 hare
[21,22].
compressed, the “hyalinization” process [16] occurs, leading
to the Orthodontic
atrophy and/ortoothpyknosis
movement of initiation
cell nuclei begins after 48 h,
and collagen during
fiber which time
convergence in the alve-
a gelati-
olar bone is remodeled
nous-like substance. due to the coordinated actions of the osteoclasts and osteoblasts.
WhenHyalinization,
the pressure exerted on the dental
as described by Reitanstructure
in hisisstudy
high, ofthehistological
blood vessels in the periodon-
changes resulting
tal ligament (PDL) collapse on the side experiencing compression.
from the orthodontic application of force [17], involves the loss of normal tissue architec- This collapse occurs
within 3 −
ture and discoloration characteristics of collagen present in processed histological in
a 5 s time frame. Subsequently, after a few minutes, blood circulation the
mate-
PDL’s affected area is interrupted, resulting in sterile necrosis and the
rial, occurring in cell-free regions inside the periodontal ligament. Reitan observed that cellular components
disappearing. These changes manifest as areas of hyalinization [22,23].
hyalinization occurred within the periodontal ligament if even slight pressure was ap-
Therefore, the hyalinization and resorption processes indirectly lead to the necessary
plied. Direct resorption occurs after removing hyalinized tissue due to the activated oste-
postponement of tooth displacement. This delay is accompanied by patient discomfort,
oclasts originating from the ligament, followed by indirect resorption with cellular mate-
primarily due to the ischemia and inflamed regions present within the periodontal ligament
rials from the blood flow. When the periodontal ligament (PDL) is compressed, blood flow
(PDL). The orthodontic forces’ optimal intensity occurs when they facilitate tooth movement
within the PDL decreases until the blood vessels collapse completely, causing ischemia.
by inducing cell differentiation, doing so while avoiding the complete occlusion of blood
After 1–2 s of gentle pressure, the PDL is partially compressed, causing fluids to leak out
vessels in the periodontal ligament. Consequently, an orthodontic force’s biological impact
of both the periodontal space and the alveolus; after 3–5 s, blood vessels passively com-
is contingent upon either its intensity and the extent to which the periodontal ligament
press on the pressure side and dilate on the tension side, with the PDL’s fibers and cells
area is affected, or the pressure exerted on the tooth [24].
appearing to be mechanically distorted [18–20].
Thus, the orthodontic tooth movement process has three distinct phases. The ini-
These changes in blood flow and oxygen tension, as well as the release of prostaglan-
tial phase is distinguished by prompt and swift tooth displacement, occurring within a
24 to 48 hinflammatory
dins and cytokines,
time frame following theare triggered
initial even by
application of aforce.
brief The
application
observed ofrate
pressure and
is mostly
its maintenance for a few minutes. Several chemical modulators
influenced by tooth displacement within the periodontal ligament (PDL) space [24–26]. are induced, cyclic aden-
osineThemonophosphate
lag phase, with (cAMP) increases
a duration of 20and
to 30celldays,
differentiation occursby
is characterized within the perio-
minimal tooth
dontal ligament after at least 4 h [21,22].
displacement. The current stage is characterized by the PDL hyalinization process occurring
in theOrthodontic
compression tooth
area. movement
No moreinitiation begins afteris48observed
tooth displacement h, duringuntil
which thetime
cellsthe al-
have
veolar bone is remodeled due to the coordinated actions of the osteoclasts and osteoblasts.
When the pressure exerted on the dental structure is high, the blood vessels in the perio-
dontal ligament (PDL) collapse on the side experiencing compression. This collapse occurs
within a 3−5 s time frame. Subsequently, after a few minutes, blood circulation in the
PDL’s affected area is interrupted, resulting in sterile necrosis and the cellular components
 Thus, the orthodontic tooth movement process has three distinct phases. The initial
phase is distinguished by prompt and swift tooth displacement, occurring within a 24 to
48 h time frame following the initial application of force. The observed rate is mostly in-
fluenced by tooth displacement within the periodontal ligament (PDL) space [24–26].
Dent. J. 2024, 12, 112 The lag phase, with a duration of 20 to 30 days, is characterized by minimal tooth 5 of 16
displacement. The current stage is characterized by the PDL hyalinization process occur-
ring in the compression area. No more tooth displacement is observed until the cells have
fully eliminated
fully eliminated the primary portion
portion of
of the
the necrotic
necrotic tissues.
tissues. Following
Followingthethelag
lagphase,
phase,a a
subsequent period known
subsequent known as as the
the post-lag
post-lag phase
phaseoccurs,
occurs,where
whereananincrease
increaseininthe
thepace
paceofof
movement occurs
movement occurs [27].
The sequence
The sequence of
ofevents
eventsfollowing
followingorthodontic tooth
orthodontic movement
tooth movement using appropriate
using bi-
appropriate
omarkers isisdescribed
biomarkers describedinin
Figure
Figure2. 2.

Figure 2.
Figure 2. Effects
Effects of
of orthodontic
orthodontic force
force application
application on
on periodontal
periodontaltissues.
tissues.

The interconnectedness
The interconnectednessofofthetheperiodontal
periodontaltissues andand
tissues tooth movement
tooth movementprocesses im-
processes
plies that
implies orthodontic
that treatment
orthodontic treatment is significant forfor
is significant addressing related
addressing issues.
related However,
issues. if
However,
iftooth movement
tooth movementexceeds the the
exceeds alveolar process’
alveolar anatomical
process’ limits,limits,
anatomical it can worsen the perio-
it can worsen the
dontium’s destruction
periodontium’s [28]. [28].
destruction

3.
3. Periodontal
Periodontal and Bone Biomarkers
Biomarkers Related
Relatedto
toOrthodontic
OrthodonticForce
ForceApplication
Application
Orthodontic
Orthodontic tooth movement causes causes aa cascade
cascadeof ofcoordinated
coordinatedcellular
cellularand
andmolecular
molecular
activities resultin
activities that result inconnective
connectivetissue
tissue remodeling
remodeling andand osteoclast
osteoclast activation.
activation. During
During or-
orthodontic
thodontic tooth toothmovement’s
movement’s early
early stages,
stages, IL-1isisone
IL-1 oneofofthe
themost
mostabundant
abundantcytokines
cytokinesinin
the
the periodontium
periodontium [29].
IL-1
IL-1 isisprimarily
primarilyreleased
releasedbyby
macrophages,
macrophages, withwith
macrophage
macrophage increases in compressed
increases in com-
periodontal regions identified
pressed periodontal later during
regions identified treatment.
later during Thus, Thus,
treatment. during toothtooth
during movement’s
move-
early
ment’s stages, IL-1 is produced
early stages, by other
IL-1 is produced by periodontal
other periodontal cell types, such such
cell types, as osteoclasts, as an
as osteoclasts,
immediate
as an immediateresponse to mechanical
response stress.stress.
to mechanical
Previous studieshave
Previous studies havedemonstrated
demonstrated thethe upregulation
upregulation of inflammatory
of inflammatory cytokines
cytokines and
and
theirtheir associated
associated receptors
receptors following
following an inflammatory
an inflammatory responseresponse
generated generated via the
via the perfora-
perforation of thecortical
tion of the buccal buccalplate
cortical plate
in rats in rats undergoing
undergoing orthodonticorthodontic
treatment. The treatment.
mRNA con- The
mRNA concentrations of IL-1β in rats’ periodontal ligaments increase
centrations of IL-1β in rats’ periodontal ligaments increase within a 3 h time frame within a 3 h time
frame following the application of an orthodontic force; this trend is primarily observed on
the side experiencing pressure [30,31].
Therefore, applying IL-1RA therapy suppresses orthodontic tooth movement, as
indicated by the decreased tooth displacement rate observed in IL-1RA-treated mice.
Interleukin-1 beta (IL-1β) is widely acknowledged to be a potent inducer of interleukin-6
(IL-6) synthesis. It has functionalities comparable to those of IL-6 and tumor necrosis
factor-alpha (TNF-α) [32].
Tumor necrosis factor-α (TNF-α) is a pro-inflammatory cytokine demonstrated to
induce both acute and chronic inflammation, as well as promote bone resorption [33].
Additional clinical and animal studies have also established the primary involvement
of prostaglandins E (namely PGE1 and PGE2) in promoting bone loss [34,35]. Prostaglandins
are synthesized from arachidonic acid, originating from phospholipids. The initial reaction
to pressure stimulation releases prostaglandins. This release occurs when cells undergo
mechanical deformation, mobilizing membrane phospholipids. As a result, inositol phos-
phate (IP), a significant chemical messenger, is generated. Furthermore, the PGE2 level is
an indicator of the biological processes that occur in the periodontium during orthodontic
Dent. J. 2024, 12, 112 6 of 16

tooth movement. A prior study observed that a large increase in PGE2 levels occurs on
both the tension and compression sides [36].
During the orthodontic movement process, several proliferative markers are ex-
pressed. The presence of KI-67 and the receptor activator of nuclear factor-Kappa β
ligand (RANKL) [37,38] suggests the recruitment of osteoclasts in regions experiencing
compression. Conversely, the expression of Runx2 [39], Col1-GFP, and BSP-GFP in cells
indicates increases in differentiated osteoblasts in regions experiencing tension [40].
In the early stages of orthodontic tooth movement, the macrophage colony-stimulating
factor (M-CSF) is key to osteoclast differentiation, increasing osteoclast recruitment and
differentiation rates [41]. In particular, optimal M-CSF doses are associated with observable
changes in tooth movement and gene expression. This relationship will enable future
clinical studies for accelerating tooth movement methods.
Vascular endothelial growth factor (VEGF) is the principal mediator of angiogenesis,
and it increases vascular permeability during tissue neoformation, usually due to the
presence of blood vessels [42]. Periodontal ligament angiogenesis and vascular endothelial
growth factor activation [43] are both triggered by compressive forces used in orthodontic
tooth movement.
When teeth are moved for orthodontic treatment, neurogenic inflammation manifests
as an increase in certain proteins’ concentrations in the periodontium. Periodontal pe-
ripheral nerve fibers transmit impulses to the central nervous system via somatosensory
neurons. When orthodontic tension is physiologically applied to the gums, the nerve
gums’ fibers release the neurotransmitters calcitonin gene-related peptide (CGRP) and
substance P [44].
Orthodontic tooth movement causes a biological change, primarily in the bone tissue
around the teeth. Osteoblasts and osteoclasts express alkaline phosphatase (ALP) and acid
phosphatase (ACP), respectively, which are both involved in bone metabolism [45].
The periodontal ligament has significantly higher ALP activity than other connective
tissues [46]. These enzymes are created in the periodontium in response to orthodontic
force, and they diffuse in the gingival crevicular fluid at the affected location. Orthodontic
tooth movement-related tissue changes can be observed by monitoring phosphatase activity
in the gingival crevicular fluid. Prior human and animal studies have linked changes in
GCF phosphatase activity to alveolar bone remodeling [47–49].
To identify histological and biochemical changes in bone turnover and, by extension,
the rate/amount of tooth movement, we must analyze the ALP associated with bone
metabolism under healthy gingival settings. Further study of this enzyme’s diagnostic
potential in orthodontics is warranted because it can differentiate between teeth being
clinically relocated and unmoved teeth [50].

4. Orthodontic Fixed Appliance

For correcting various malocclusions, fixed orthodontic treatment remains the gold
standard [29–51]. Though traditional braces have been widely acknowledged as useful,
there are still drawbacks associated with this treatment option. Plaque buildup in the
teeth is encouraged by the use of a fixed orthodontic appliance because it makes cleaning
teeth more difficult [52–54]. Several studies have analyzed the correlation between bracket
materials, designs, and ligations and the prevalence of cariogenic bacteria and periodontal
damage [55–57]. For bracket ligation techniques, it has previously been hypothesized that
self-ligating brackets (SLBs) exhibit superior periodontal outcomes due to the absence of
ligature materials and reduced number of sites promoting retention [58].

4.1. Self-Ligating Brackets (SLBs) and Conventional Brackets (CBs)

The existing literature contains only a limited number of studies with varying out-
comes for comparing self-ligating brackets (SLBs) to conventional brackets (CBs) for elas-
tomeric ligatures [58]. Several studies have documented that using elastomeric ligated
ceramic brackets (CBs) leads to increased plaque accumulation and periodontal inflam-
Dent. J. 2024, 12, 112 7 of 16

mation compared to self-ligating brackets (SLBs) [3,59]. However, conflicting findings

have also been reported, with other studies indicating no statistically significant difference
between the two bracket types for either factor [56]. In contrast, previous studies also
documented increased bacterial colonization and compromised periodontal health result-
ing from the use of subgingival lingual brackets (SGLBs) [60]. Although SGLBs prevent
the utilization of ligatures, they nonetheless have opening and closing mechanisms that
have the potential to create extra plaque retention areas. White demineralization, caries, or
periodontal disease areas can form at numerous plaque retention sites [61–63].
Multiple studies have shown patients undergoing orthodontic treatment [64–66] to
have an increased level of cariogenic bacteria (such as Streptococcus mutans and Lacto-
bacillus sp.) and, possibly, pathogenic Gram-negative bacteria.
Pellegrini et al. [57] and Mummola et al. [55] reported that using self-ligating brackets
(SLBs) reduced bacterial levels compared to those recorded when using elastomeric ligating
brackets. In contrast, van Gastel et al. [58] observed greater bacterial colonization due
to SLB use. In line with this observation, Nalçaçı et al. [64] and Pandis et al. [53] also
found no significant disparity in salivary SM levels when comparing elastomeric ligated
conventional brackets (CBs) and self-ligating brackets (SLBs).
In their study, Carillo et al. [65] observed that there were no statistically significant
variations in SM and LB levels during the one-month treatment period. Nevertheless, they
observed a deterioration in periodontal health. Another study revealed that one week
after bonding, individuals with SLBs had greater levels of anaerobic and aerobic bacteria
colonization, as well as enhanced gingival hypertrophy, compared with those with CB.
However, no significant disparity in bleeding via probing was identified between the two
cohorts [58].

4.2. Changes in Oral Microbiota

Candida is a commensal, benign bacterium found in the oral cavity of 53% of people
worldwide; however, if aberrations in the microbiota’s usual range or host immunological
deficiency exist, this bacterium may grow to aggressive and dangerous levels [64]. The
colonization of candida and the prevalence of specific strains or species exhibit temporal
variability during orthodontic therapy. Contaldo et al.’s [62] review underscored the lack of
clarity regarding the presence of Candida sp., viruses and protozoa in orthodontic patients’
oral microbiota.
Candida spp. was more prevalent 6 months after bonding orthodontic appliances
compared with the pre-bonding period, while C. tropicalis was identified in 20% of patients
in Hernández-Solise et al.’s study [67]. Furthermore, the studies of Perkowski et al. [68]
and Grzegocka et al. [69] both found that orthodontic treatment positively impacts the
colonization of Candida sp. This correlation has specifically been observed in cases in which
fixed appliances were utilized, while the extent of colonization might vary throughout the
duration of treatment.
Guo et al. [70] conducted a comprehensive review and meta-analysis encompassing
13 articles. Their research objective was to examine microbiological alterations in subgin-
gival plaque among individuals undergoing orthodontic treatment. They found that the
presence of subgingival infections increases during orthodontic therapy, although only
briefly in most cases.
Bergamo et al. noted a decline in Candida sp. levels 60 days following bracket bonding.
However, they only noted a specific decrease in the representation of C. albicans after a
90-day period [71].
Notwithstanding the globally employed conventional procedures’ acknowledged
efficacy, we must acknowledge the inherent limitations of these approaches. For example,
traditional dental techniques are inconvenient and can potentially induce pain, frequently
making oral hygiene maintenance more challenging. The main components of fixed
orthodontic appliances, namely brackets, bands, ligatures, and orthodontic wires, may
impede the natural self-cleaning mechanisms of the tongue and cheeks. Additionally, these
Dent. J. 2024, 12, 112 8 of 16

components may increase bacterial plaque accumulation and alter both the qualitative and
quantitative aspects of the bacterial population [72].
Fixed appliances’ impacts on oral microbiota’s composition and characteristics is a
transient phenomenon contingent on controlling oral hygiene. Patients are advised to
use caution when handling the stent and frequently remove the plaque accumulating
around the wire to enhance the oxidation-reduction potential. Hence, using an alternative
removable orthodontic appliance should make this process easier to perform and promote
improved recovery in individuals in need of prompt interventions [72,73].

4.3. Changes in Periodontal Health

Debate about the association between gingival recessions and orthodontic therapy is
ongoing. The prevalence of this relationship ranges from 5% to 12% upon the completion of
treatment, but it may rise to 47% during the course of long-term surveillance [74]. Certain
writers have proposed that orthodontic treatment is linked to the occurrence of alveolar
bone loss, gingival recession, and reduction in the clinical attachment level [74].
Numerous inquiries have been conducted into the identities of individuals receiving
medical treatment using both permanent and removable apparatus in recent times, as
shown in Table 1. The conclusion derived from these papers, meanwhile, is a subject of
ongoing academic discussion.

Table 1. Outcomes of studies of fixed and removable appliances.

Year of
Authors Parameters Outcome Measures
Publication
PLI, GI, and PD increased significantly in the first 3 months
Liu et al. [75]
2011 PLI, GI, PD following appliance insertion but decreased significantly in
(clinical study)
the first 6 months after appliance removal.
According to the linear regression models, appliance type
Madariaga et al. [76]
did not affect periodontal variables. Thus, fixed appliance
(prospective clinical 2020 PLI, GI, GBI, PD
and clear aligner orthodontic patients had similar gingival
study)
health statuses.
Removable appliances had significantly lower PLIs than
Wu Y. et al. [77] fixed equipment. At 6 months, removable appliances
2020 PLI, GI, PD
(meta-analysis) reduced GI, but they did not do so at 3 months. At 3 months,
mobile devices had lower PDs than fixed appliances.
After 3 months, Invisalign therapy lowered GBI and PD
Li W. et al. [78]
2017 PLI, GI, PD, GBI levels compared to fixed treatment (p < 0.05); however, there
(clinical study)
was no significant difference after 6 months (p > 0.05).
The authors found no significant differences in the plaque
Eroglu et al. [27]
2019 PLI, GI, PD, GBI index, gingival index, bleeding on probing, or probing
(clinical study)
depth (p > 0.05).
Sun et al. [79]
Before and three months after treatment, the two patient
(prospective 2018 PLI, GI, PD, GBI
groups had similar periodontal indicators.
clinical study)
GI = gingival index; PLI = plaque index; PD = probing depth; GBI = gingival bleeding index.

Orthodontic treatment is associated with a high prevalence of periodontal problems [6].

Issues commonly observed through the use of orthodontic fixed appliances include gingivi-
tis, periodontitis, gingival recession or hypertrophy, and alveolar bone loss.

5. Orthodontic Removable Appliance and Periodontal Health

Multiple studies have demonstrated that using orthodontic fixed appliances (FA) leads
to a notable increase in dental plaque accumulation. This trend is primarily attributed to
the challenges related to maintaining adequate oral hygiene while wearing such appliances.
Consequently, this heightened plaque accumulation causes gradual enamel demineral-
Dent. J. 2024, 12, 112 9 of 16

ization and gingival inflammation. Ultimately, these factors may deteriorate the tissues
supporting the teeth [80].
Transparent plastic clear aligners (CAs) have been used to address some restrictions
associated with traditional fixed appliances (FAs). The existing literature characterizes this
treatment option as a secure, comfortable, and visually pleasing intervention [81].
In Pango Madariaga et al.’s study [76], the authors observed that multibracket ap-
pliances exhibited considerable GBI increases compared to aligners during the initial
evaluation. However, they also found that the appliance type did not discernibly impact
periodontal variable enhancement. This finding remained consistent for all factors, such as
aging, and all sites assessed, even if these factors were statistically significant. Thus, the
authors emphasized the need to consider alternative criteria to assess an appliance’s effi-
cacy. Similarly, Chhibber et al. [80] presented findings that challenge the prevailing notion
that removable appliances, relative to multibracket ones, have few adverse periodontal
health impacts.
Levrini et al. [81] reported a statistically significant distinction between the removable
aligner and fixed appliance groups in terms of the plaque index (PLI), gingival bleeding
index (GBI), and probing depth (PD), with patients using aligners having the lowest average
values. The researchers found that removable appliances should be the primary therapy
option for individuals susceptible to periodontal disease.
Similarly, Abbate et al. performed a microbiological examination, although no patients
exhibited periodontopathic anaerobes following a 12-month therapy period. During the
first period of up to one year of therapy, the full mouth plaque (FMPS) value experienced a
threefold increase, while the full mouth bleeding (FMBS) value doubled among adolescents
undergoing treatment with multibracket appliances. Conversely, both the FMPS and FMBS
scores decreased in adolescents using aligners [82].
Azaripour et al. [83] reported an increase in dental plaque accumulation for users of
both orthodontic appliances, with a greater increase observed in the multibracket group
than in the aligners group.
Miethke and Vogt conducted a clinical trial in which all the indexes improved between
the initial and the final screening stages, regardless of the orthodontic appliance used [84].
At the outset, there were no statistically significant disparities detected in the GI and
PBI variables. Furthermore, the results indicated a statistically significant decrease in
the periodontal index (PI) among individuals who underwent treatment with aligners.
At the outset, no statistically significant disparities were identified in the GI and PBI
variables. Furthermore, the data indicated a statistically significant decrease in periodontal
inflammation (PI) among individuals who underwent treatment with aligners. The study’s
authors concluded that no discernible disparities existed between the initial and ongoing
treatment outcomes for multibracket appliances and aligners. They attributed enhanced
dental hygiene to many factors, alongside other criteria.
Issa et al. [85] conducted a study revealing a notable disparity in plaque levels between
patients treated with aligners and those undergoing traditional treatment. The aligner-
treated patients had significantly lower levels of plaque compared with their counterparts.
Furthermore, the authors showed that individuals who underwent aligner treatment
exhibited superior scores for all seven recorded measures.
Numerous physicians hold the belief that CAs are better able to preserve periodontal
health than conventional FAs. However, the available literature is insufficient to substanti-
ate this theory [86,87].

6. Discussion and Perspectives

Significant macroscopic and microscopic alterations were observed in the alveolar
bone and periodontal ligaments subjected to varying degrees of amplitude, frequency, and
duration of forces such as pressure. Applying stress on the tooth also causes changes in
the periodontal tissue’s circulation and blood flow, leading to the production and release
Dent. J. 2024, 12, 112 10 of 16

of different molecules, including cytokines, growth factors, colony-stimulating factors,

enzymes, and neurotransmitters, at the local level.
Orthodontic therapy should be used to straighten the teeth while causing minimal gum
and root damage. One negative side effect of orthodontic treatment is root resorption [88].
Root resorption has been studied for 150 years.
The process of using cementoclastic or osteoclastic methods to break down dentin
or cement is called root resorption [89]. This process can shorten or blunt the root. Root
resorption can also be described as small patches of resorption lacunae observed using
histology methods [90]. Apical root resorption is likely impacted by mechanical factors,
genetic propensity, and individual biological variability [91,92].
Identifying various biomarkers that indicate biological changes after applying or-
thodontic forces is highly valuable for selecting an optimal mechanical force to achieve the
desired tooth movement rate and expedite orthodontic treatment. This approach mitigates
potential negative consequences such as root resorption or bone loss. Apical root resorption
is caused by a mixture of mechanical causes, individual biological variability levels, and
orthodontic forces [92]. In Lupi et al.’s study, root resorption was 15% before orthodontic
treatment and 73% after it [93].
As permanent appliances allow for a greater range of tooth movement, they more ef-
fectively induce root resorption than removable appliances [94]. Research into the potential
for root resorption due to various bracket designs has produced conflicting findings [95,96].
A statistical analysis of root resorption results from three trials comparing self-ligating
devices with traditional edgewise methods found no significant differences [97–99].
In general, having a comprehensive understanding of the dynamic processes taking
place in periodontal tissues during orthodontic interventions can facilitate the selection
of appropriate mechanical loading techniques. Human premolar teeth with 50 g, 100 g,
and 200 g of intrusive force were examined by Harry and Sims using a scanning electron
microscope. They concluded that larger forces accelerated root resorption by increasing
root surface stress, in turning accelerating the development of lacunae [100].
Although Owman-Moll et al. discovered a high degree of interindividual variability
in root resorption frequency and severity, they did not identify any statistically significant
differences. They found that the force’s magnitude had no effect on root resorption, but the
impact of individual reactions may have been greater [101].
The question of whether greater root resorption occurs with continuous or intermittent
pressures is still up for debate. As the tooth cannot move with a discontinuous force
applied, the resorbed cementum has time to repair, leading to the assumption that this type
of force causes less root resorption [102,103]. In contrast, Owman-Moll et al. [101] observed
that applying a buccally directed force of 50 g to human premolars, either continuously or
intermittently, did not affect root resorption’s degree or severity.
This approach, in turn, can reduce the treatment duration and mitigate potential
negative outcomes associated with orthodontic treatment.
The researchers Sameshima and Sinclair found that the degree of root resorption
is proportional to the root’s migration distance. One reason that maxillary incisors are
more likely to experience root resorption is that they are moved more frequently during
orthodontic treatment compared with other teeth [104,105].
The correlation between orthodontic interventions and the state of periodontal tissues
is a complex issue, particularly regarding periodontal well-being during and following or-
thodontic therapy. As orthodontic treatment during inflammation causes the periodontium
to rapidly and irreversibly break down, periodontal therapy is typically completed before
orthodontic treatment [106].
In past studies, it is widely accepted that the appropriate application of orthodontic
appliances does not detrimentally affect the periodontium in its proximity. Orthodontic
appliances also provide support for periodontal tightness and splinting in cases where oral
hygiene is maintained.
Dent. J. 2024, 12, 112 11 of 16

Numerous clinical investigations have documented increases in plaque buildup and

gingivitis occurrence in individuals undergoing orthodontic treatment. Furthermore, or-
thodontic treatment has induced changes in oral bacteria’s composition and diversity. Three
months after orthodontic treatment began, a study comparing the oral microbiota of pa-
tients receiving orthodontic treatment to those of subjects not receiving orthodontic therapy
revealed a statistically significant increase in microbial counts for various periodontopathic
bacteria, including P. gingivalis [107].
An intriguing study conducted by Naranjio examined the relationship between
changes in clinical parameters and subgingival plaque in subgingival microbial sample
cultures taken from orthodontic patients before and after bracket placement, as well as
from control subjects who were not receiving orthodontic treatment. The results showed
that the levels of P. gingivalis, P. media/Prevotella nigrescens, T. forsythia, and Fusobacterium
spp. were higher in patients three months after orthodontic therapy than in both the control
and baseline groups [108].
Through their modulation of osteoclast development and matrix metalloproteinase produc-
tion, pro-inflammatory cytokines such as tumor necrosis factor-α (TNF-α), interleukin-1 (IL-1),
IL-6, and IL-8 enable orthodontic tooth movement, according to multiple studies [109,110]. Re-
cent animal-based research revealed that orthodontic tooth movement exacerbates periodontitis
by increasing IL-1 and TNF- levels [111].
Variables influencing the synthesis and/or activity of these cytokines regulate the
orthodontic tooth movement rate. Orthodontic tooth movement is slowed when soluble
receptors to IL-1 or TNF-α or neutralizing antibodies to VEFG are administered locally. On
the other hand, the tooth movement rate increases when the expression of pro-inflammatory
cytokines near the moving teeth is stimulated via osteo-perforation.
In addition, other studies have shown that the antioxidant n acetyl cysteine (NAC)
reduces pro-inflammatory cytokine generation in gingival fibroblasts when exposed to
lipopolysaccharide, while NAC reduces alveolar bone loss in experimental periodonti-
tis [112,113].
Recently, we have witnessed significant progress in the development and production
of dental motion materials through computer-aided design and manufacturing. This
shift has increased interest in using enhanced specifications for orthodontic treatment
technologies [114].
Nevertheless, numerous studies have showcased current appliances’ ability to rec-
tify and manage various illnesses, including both minor and severe malocclusion, while
improving periodontal health [115].
Extensive research has been conducted into the orthodontic therapy–periodontitis
relationship, encouraging ongoing discussions about the impact of orthodontic treatment
on periodontitis’ prevalence [116].
The results should be interpreted with caution because there are some limitations to
this study’s methodology. Firstly, the cause-and-effect relationship between orthodontic
treatment and the reduction in periodontitis’ prevalence is a controversial subject; therefore,
it is hard to generalize these results on a global scale.
To better understand the orthodontic therapy–periodontitis reduction relationship,
better-controlled, long-term studies are necessary.

7. Conclusions
When using orthodontics to treat individuals with periodontal problems, we must
pay attention to the following aspects: the orthodontic appliance utilized, the state of
the patient’s teeth and periodontal tissues, the depth of the gum pockets, the position of
the teeth in the supporting tissue, and the patient’s motivation and ability to sustain oral
hygiene and health. Orthodontic therapy’s success depends on an orthodontist’s ability
to anticipate and address any periodontal issues arising before, during, or after treatment.
However, process conduction may overcome periodontal defects under specific conditions.
Dent. J. 2024, 12, 112 12 of 16

Author Contributions: Conceptualization, I.L., Z.S. and D.-G.B.; methodology, O.B., N.I., M.-M.S.,
M.T. and I.Z.; writing—original draft preparation, I.L. and Z.S.; writing—review and editing, I.L.,
Z.S., A.G., O.B., M.T., I.Z. and M.-M.S.; supervision, D.-G.B. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: All data are available from the corresponding authors upon
reasonable request.
Conflicts of Interest: The authors declare no conflicts of interest.

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