Orthodontic Banding and Gingival Health: A Six-Months Study from Gaza Strip, Palestine

Orthodontic banding, a crucial step in fixed orthodontic appliance treatment, ensures proper retention and resistance of the appliance against orthodontic forces. This is particularly important for molars, which endure significant forces during treatment. Gaza strip, Palestine is a densely populated area contains about 2.17 million people, who are living in 365 square kilometers [1]. As most of Arab world, there is a noticeable shortage of research about orthodontic treatment in Gaza strip. besides, there is a paucity of up-to-date data regarding the prevalence of periodontitis in the Arab adult population [2]. However, the orthodontic treatment is practiced in many dental clinics in Gaza, and people are well known about it’s importance. They follow it’s parameters and advancements through social media and refer to practice doctors asking for the service either for therapeutic or aesthetic purposes. In orthodontics, attachments can be either banded as orthodontic bands or bonded as orthodontic tubes. Orthodontic appliances form a network in the dentition, which might exacerbate food stagnation [3]. The use of bands in fixed orthodontic equipment has grown in popularity due to the necessity for stability when using functional and orthopedic appliances such as headgear or facemasks, as well as lingual attachments like the trans palatal arch. Molar banding is a tried-and-true orthodontic technique that ensures proper retention and resistance to orthodontic forces. While advancements in adhesive solutions have made bonding attachments to molars commonplace, reducing clinical care time and improving oral hygiene [4]. Many orthodontists still prefer molar bands. This preference is driven by the belief that molar bands have lower failure rates and offer greater reliability [5]. With advancements in band design (mechanical retention mechanisms, micro-etching). Gingival health may be negatively impacted by the positioning of orthodontic bands, which are required to cover a significant portion of the tooth’s surface and pierce deeply into the gingival sulcus to increase retention. Plaque buildup might result from using fixed equipment while disregarding appropriate dental hygiene guidelines. Gingivitis develops as a result of the detrimental alterations in microbiota caused by the plaque buildup accelerated by orthodontic appliances. If inadequately managed, it may progress to periodontitis. [6].

Several factors can exacerbate gingival irritation when using orthodontic bands. Mechanical irritation of the gingival tissues, chemical irritation from the cement used, increased food impaction risk, and patients’ tendency to clean anterior teeth more thoroughly than posterior teeth all play a role. Orthodontic treatment is a dual-action procedure affecting periodontal tissues, which can significantly enhance periodontal health or, conversely, lead to various periodontal disorders Kapoor, et al. (2016) [7]. Atack, et al. (1996) describes four reasons for increasing gingival inflammation with orthodontic bands [8]. These reasons come from irritation to gingival tissues, from cement used to band placement as it is cemented near to gingiva, increase risk of food stagnation and ability for participants to clean their anterior teeth better than posteriors.

This clinical study aimed to assess the effect of orthodontic molar banding on gingival health parameters (gingival margin, plaque index and probing depth) in fixed appliance patients, with evaluations spanning from initial band cementation through the six-month post-treatment period.

Selection of Patients came to our clinic from 05.03.2024 to 04.05.2024 which they 30 participants aged between 12 to 35 years who had just commenced orthodontic treatment with fixed appliances. This study was conducted in full compliance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Palestinian Health Research Council and the Ethics Committee approved the protocol of PHRC/ HC/1169/24. And all participants provided written informed consent prior to their inclusion in the study. The Participants chosen according to the eligibility criteria, patients who are currently free of periodontitis, have not previously undergone orthodontic treatment, without underlying systemic diseases, nonpregnant females, and fall within the age range of 12 to 35 years old are included in the sample. Conversely, patients with missing maxillary first molars, those needing arch expansion or molar distalization, and individuals with systemic diseases are excluded from participation. Prior to cementing the molar band to one upper first molar, an assessment was conducted to evaluate gingival health parameters. This evaluation included measurements of the gingival margin, gingival index, plaque index and probing depth. This initial assessment was denoted as “T0.” Subsequently, fixed orthodontic appliances were conventionally bonded using American orthodontic brackets, extending from the second premolar to the opposing second premolar. The upper first molar was fitted with a 3M-style metal band and cemented by Riva selfcure glass ionomer luting cement (SDI trademark). Participants were provided with comprehensive instructions emphasizing proper oral hygiene practices and maintaining a balanced diet with reduced sugar consumption to ensure a consistent environment during the study. After three months from the initial assessment (T0), a follow-up assessment of gingival parameters for the upper first molar was conducted and denoted as “T3.” Similarly, the same assessment was repeated six months from the start of treatment, denoted as “T6.”

Clinical Evaluation

Gingival parameters were assessed through clinical examinations. A calibrated examiner conducted the assessments using a University of Michigan O probe with William’s markings. International indices were utilized for measurement, and a standardized periodontal diagnostic chart was employed to document the data.

Scoring Criteria

The following indexes used to measure the gingival parameters [7].
• Miller’s classification for gingival recession and Millers and Damm classification for gingival enlargement was used to measure the gingival margin, in case of gingival recession used (–) before the number and in case of gingival enlargement used (+) before the number.
• The Loe & Silness (1963) scheme was used to measure gingival index and Silness & Loe (1964) scheme was employed to measure the Plaque index.
• Probing depth was measured using The University of Michigan O probe with Williams markings, recording the distance from the gingival margin to the deepest part of the sulcus. Six readings were taken per tooth at specific locations.

Gingival margin index: Repeated Measure ANOVA

Table 1:Gingival Margin attributed to duration for cemented bands.

^a.The correlation and t cannot be computed because the standard error of the difference is 0.

From the previous table, the significance level value (P = 0.326 > 0.05) indicates that there is no statistically significant differences in the level of Gingival margin according to the duration of cemented bands using T0, T3 and T6 months..

Table 2:Source of differences for Gingival Margin.

From the previous table, there is no statistically significant differences regarding Gingival Margin as (P = 0.326 > 0.05).

Plaque index: Repeated Measure ANOVA

Table 3:Plaque index attributed to duration for cemented bands.

From the previous table, the significances level value (P = 0.000 < 0.05) indicated that there is statistically significant differences in the level of Plaque index according to the duration of cemented bands using T0, T3 and T6 months therefore, In order to identify the source of the differences, the compare means paired-samples T Test was used.

From the previous table, the significances level value (P = 0.000< 0.05) indicated that there is statistically significant differences in the level of Plaque index according to the duration of cemented bands using T0, T3 and T6 months therefore, In order to identify the source of the differences, the compare means paired-samples T Test was used.

Table 4:Source of differences for Plaque index (1).

Probing depths: Repeated Measure ANOVA

All the measured 6 points for probing depths were calculated for an average and a Mean was used for the analysis for T0, T3 and T6.

From previous table. There is statistically significant difference regarding probing depth in the (p= 0.000<0.05) between T0-T3-T6 for the cemented bands. to know the differences compare means paired-samples T Test was used.

Table 5:Average of Probing depths attributed to duration for cemented bands.

Table 6:Source of difference for the average of Probing depths.

From previous table, There is statistically significant change in the average of probing depths between T0-T3 and T6. That mean the probing depth for the cemented bands changed from the beginning of the treatment and increased as the duration increased. The mean change in the noticeable between T0 and T6 around (2.3667-1.4333= 0.9334) which is high difference between the two values for a 6 months period.

This study aimed to evaluate the effects of molar bands on gingival health in patients undergoing fixed orthodontic treatment, with a focus on gingival margin position, plaque index and probing depth.

The results demonstrated statistically significant differences in all assessed gingival health parameters except gingival margin position when cemented molar bands were used.

In 2020, Amjad Alshanti et al., published a cross-sectional study titled Prevalence and Severity of Gingivitis in High School Students in Gaza Strip – Palestine.” Among its key findings, the study identified paternal education level as a significant risk factor for gingivitis, with students whose fathers had lower educational attainment demonstrating a higher prevalence of the condition compared to those with more educated fathers. The findings of this study are expected to support future research efforts aimed at identifying the underlying causes and risk factors involved in the development of periodontal diseases, as well as establishing effective prevention strategies tailored for the Gaza Strip. However, there is still a notable lack of detailed data regarding the specific causes behind the prevalence and severity of gingivitis. From our perspective, the use of fixed orthodontic appliances may be one such contributing factor. This assumption has motivated us to conduct a focused investigation to explore the potential link between orthodontic treatment and gingivitis in high school students [10].

In 2022 comparative study by Kiani et al. examined periodontal probing status between molar bands and bonded tubes in orthodontic patients. Their results demonstrated significantly greater post-treatment periodontal probing depth values for banded molars compared to those with bonded attachments. These findings align with and substantiate our current study’s results, providing additional evidence that molar banding adversely affects gingival health parameters. The consistency between these independent studies strengthens the clinical significance of our observations regarding the negative periodontal impact of orthodontic molar bands [11].

These findings also align with a 2023 study by Amir et al., which investigated the impact of orthodontic banding on the gingival health of first permanent molars. Both studies concluded that orthodontic banding may negatively affect periodontal health during fixed appliance therapy, particularly when oral hygiene practices are inadequate [12]. His study tested the palque index and gingival index only but this study tested 3 gingival parameters and have the same results that using molar bands adversely affect molar gingival health.

A related study by Shrestha (June 2016) compared the oral health status of Nepalese orthodontic patients treated with either molar bands or bonded tubes. The findings revealed that both attachment methods could contribute to gingival inflammation progression. However, when oral hygiene was properly maintained, no statistically significant differences in periodontal health parameters were observed between the two groups [13].

In 2018, Papageorgiou et al. conducted a systematic review and meta-analysis to assess the impact of orthodontic treatment on periodontal clinical attachment levels. Their findings, based on longitudinal clinical studies, indicated that fixed orthodontic appliances had little to no clinically significant effect on periodontal attachment levels, which contrasts with some previous research [14].

Another study in 2015 by Al-Anezi et al. Examined the influence of orthodontic bands and tubes on periodontal health during the initial phase of treatment. The results revealed that molar bands were associated with greater periodontal inflammation compared to molar bonds in the first three months of treatment. These findings align with existing research suggesting that gingival bands can negatively affect molar gingival health, regardless of sample size and participant age [15].

In Al-Anezi et al.’s study, the participants consisted of 24 individuals with a mean age of 12.6 years, meaning most were adolescents. In contrast, this study involved 30 patients, predominantly adults over 18 years old. This difference confirms that gingival changes due to orthodontic bands can occur at any age, even among cooperative patients who adhere to oral hygiene instructions.

Oral health is an important concern in fixed orthodontic patients. The use of cemented bands for molar teeth during fixed orthodontic treatment has significant differences on gingival health parameters as it can influence these parameters at short rang.

• Ethics approval and consent to participate
This study was conducted in full compliance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Palestinian Health Research Council and the Ethics Committee approved the protocol of PHRC/HC/1169/24. And all participants provided written informed consent prior to their inclusion in the study
• Consent for publication: Not applicable.
• Funding: Not applicable.
• Authors’ contributions: Not applicable.

1. SA Salman, R Salah (2016) The Effect of Fixed Orthodontic Appliances on Gingival Health.
2. Palestinian Central Bureau of Statistic.
3. Lu H, Tang H, Zhou T, Kang N (2018) Assessment of the periodontal health status in patients undergoing orthodontic treatment with fixed appliances and Invisalign system: A meta-analysis. Medicine 97(13): e0248.
4. Flores-Mir C (2011) Bonded molar tubes associated with higher failure rate than molar bands. Evid Based Dent 12(3): 84.
5. Clark JR, Ireland AJ, Sherriff M (2003) An in vivo and ex vivo study to evaluate the use of a glasspolyphosphonate cement in orthodontic banding. Eur J Orthod 25: 319-323.
6. Huser MC, Baehni PC, Lang R (1990) Effects of orthodontic bands on microbiologic and clinical parameters. Am J Orthod Dentofac Orthop 97(3): 213-218.
7. Kapoor A, Singhal L, Kapoor S, Kapoor A (2016) Ortho-perio Interrelationships: An Overview. International Journal of Preventive and Clinical Dental Research 3(3): 206-212.
8. E Atack, J R Sandy, M Addy (1996) Periodontal and microbiological changes associated with the placement of orthodontic appliances. A review. J Periodontol 67(2): 78-85.
9. S Reddy (2011) Essentials of Clinical Periodontology and Periodontics, (3^rd).
10. Amjad Elshanti, Ali Aldirawi (2020) The Prevalence and Severity of Gingivitis in High School Students in Gaza Strip – Palestine. Journal of Medical Research and Health Sciences 3(9): 1098-1105.
11. Kiani HG, Naureen S, Amin B, Hameed A, Hameed U, et al. (2022) Comparison of the Periodontal Probing Status between Molar Bands and Bonded molar Tubes in Orthodontic patients. Pak Oral Dent J 42(2): 70-75.
12. Mashal Amir, Ayesha Iqbal, Farooq Maqsood, Ujala Saif, Mahnoor Parvez, et al. (2023) The effect of orthodontic banding on gingival health of first permanent molars. The Professional Medical Journal 30(04): 546-550.
13. S Shrestha, A Sharma, B Lamichhane (2016) Oral Health Status in Patients with Fixed Orthodontic Appliance with Molar Bands and Bonded Tubes. Orthodontic Journal of Nepal 6(27).
14. Papageorgiou SN, Papadelli AA, Eliades T (2018) Effect of orthodontic treatment on periodontal clinical attachment: A systematic review and meta-analysis. Eur J Orthod 40(2): 176-184.
15. Al-Anezi SA (2015) The effect of orthodontic bands or tubes upon periodontal status during the initial phase of orthodontic treatment. Saudi Dent J 27(3): 120-124.