“Wire syndrome”-induced mucogingival defect management using the laterally closed tunnel technique

Abstract

Wire syndrome is an iatrogenic complication, characterized by unexpected tooth movements during orthodontic retention, even without detachment of the retention wire. It can cause esthetic and functional damage through adverse mucogingival changes. This case report describes the management of gingival recession induced by wire syndrome using the laterally closed tunnel technique with a connective tissue graft. A diagnosis of biofilm-induced gingivitis on a reduced periodontium was established after clinical and radiographic evaluation. The graft was laterally stabilized, and suspended sutures ensured satisfactory root coverage with resolution of hypersensitivity. A gain in keratinized tissue height and thickness was obtained, providing a stable periodontal environment for subsequent orthodontic repositioning.

INTRODUCTION

Retention is an important phase in orthodontic treatment, helping to ensure the long-term stability of treatment.[1] Bonded lingual retainers are recommended by most orthodontists because they are invisible and long-lasting.[2]

Unexpected and undesirable tooth movements can occur during the retention phase even without detachment of the retainer wire. The forces generated by lingual retainers have been evaluated in vitro and recorded during simulated intrusion-extrusion and oral-lingual movements.[3] High forces exceeding 1 N can be generated, which are sufficient to produce undesirable tooth movement during retention.[4] This iatrogenic phenomenon, known as “wire syndrome,” can vary in severity depending on tooth movement and torque variations.[5,6] This complication can occur with all types of wires and wire techniques.[7] It is characterised by angulation changes, translational, or rotational movements of the incisors and canines, often accompanied by diastemas. The combinations of these movements are possible and are more frequent in the mandible.[6,7] As a result, gingival recession may occur due to the positioning of the root outside the bone envelope.[8]

Gingival recession is defined as the apical displacement of the gingival margin relative to the cementoenamel junction.[9] It can lead to dental hypersensitivity, caries, and/or non-carious cervical lesions, as well as esthetic damage.[10] Management of “wire syndrome” requires a periodontal approach, especially when mucogingival conditions are affected. Various periodontal surgical techniques can be used to correct the esthetic and functional damage and to create a stable periodontal environment for the continuation of orthodontic treatment. This case report presents the laterally closed modified tunnel technique for the management of a single gingival recession induced by “wire syndrome.”

CASE REPORT

A 54-year-old female patient in good general health was referred by her orthodontist for the management of gingival recession that had occurred during the orthodontic retention phase, while the bonded restraint wire remained in place. The bonded wire had been in place for 6 years following an 18-month course of orthodontic treatment. The patient reported dentinal hypersensitivity and the presence of interdental spacing between the mandibular incisors. She had incomplete dentition, with teeth #47, #36, and #28 missing. Egression of tooth #38 and complete coronal destruction of tooth #25 were observed. Cast crowns were present on teeth #36, #37, and #46, and amalgam restorations were noted on teeth #15, #16, #17, #27, and #38. The periodontal assessment revealed an O’Leary plaque index of up to 56% and bleeding on probing up to 25%. The gingival phenotype was thick and scalloped according to the classification of Zweers et al.[11] Periodontal probing revealed a maximum interdental attachment loss of 5 mm and a probing depth of 3 mm, with Cairo-type RT2 recession on tooth #31[9] [Figure 1a].

Figure 1.

Initial views. (a) Initial clinical view showing recession of the tooth 31 and rotation of the tooth 32; (b) initial view showing the presence of the orthodontic restraint with offset difference between the teeth 41, 31, 32, and 33; (c) panoramic dental radiograph showing moderate alveolysis

Clinical signs consistent with “wire syndrome” were observed, including egression and lingual inclination of tooth #31, rotation of tooth #32, diastema formation between teeth #31 and #41, and lingual inclination of tooth #33. In static occlusion, an anterior open bite and a deviation of the inter-incisal midline were noted [Figure 1a and b]. Radiographic examination revealed moderate horizontal bone loss, predominantly affecting the mandibular incisors and canines [Figure 1c]. A periodontal diagnosis of plaque-induced gingivitis localized to a reduced periodontium was established.

Following the initial treatment, which included patient motivation, oral hygiene instruction, and scaling, the patient demonstrated good compliance when reassessed after 4 weeks. A laterally closed modified tunnel procedure was then planned to correct the esthetic and functional defect of tooth #31 and to establish a stable periodontal environment. The treatment protocol was thoroughly discussed with the patient, and informed consent was obtained. After local anesthesia using 4% articaine hydrochloride with 1:100,000 epinephrine, root planing of tooth 31 was performed using a Gracey 5/6 curette.

Following an intrasulcular incision with a #15C blade from the distal surface of tooth #41 to that of tooth #32, while preserving papillary continuity, a full-thickness dissection was performed up to the mucogingival junction, followed by an apically split dissection to create a tunnel for the connective tissue graft [Figure 2a]. Flap laxity was assessed using a periodontal probe [Figure 2b and c].

Figure 2.

Intraoperative views. (a) Tunnel preparation; (b and c) Checking tunnel passage and flap laxity

An 18 mm × 5 mm × 1.5 mm connective tissue graft was harvested from the palatal mucosa in the region of teeth 12–15 using a single-incision technique[12] at 3 mm from the gingival margin, with a modified double-blade harvesting approach based on Harris’ technique.[13] The two parallel #15 blades were spaced 2 mm apart. The mucosa was slightly elevated to facilitate correct blade positioning [Figure 3a and b]. After harvesting [Figure 3c], the donor site was sutured [Figure 4a]. The graft was prepared and inserted into the tunnel and secured with an absorbable 6/0 suture before lateral closure of the tunnel [Figure 4b]. The flap was then coronally advanced with sling sutures placed between teeth #42 and #41, #41 and #31, and #31 and #32, anchored via the lingual restraint wire [Figure 4c].

Figure 3.

Intra-operative views. (a and b) Palatal harvesting with the double blade; (c) Connective tissue graft harvested and prepared

Figure 4.

Intra-operative views. (a) Palatal harvesting site sutured; (b) Placement of the connective tissue graft in the tunnel; (c) Lateral closure and traction to cover the graft

Postoperative oral hygiene recommendations were given. To minimize postoperative discomfort, paracetamol 1 g three times daily for 5 days, ibuprofen 400 mg three times daily for 3 days, and amoxiclav 1 g twice daily for 7 days were prescribed orally. A 0.12% chlorhexidine mouthwash was recommended twice daily for 8 days to improve plaque control.

Postoperative evaluation on day 10 and at suture removal on day 16 showed good healing of both the surgical and donor sites [Figure 5a and b]. At the 3-month follow-up, complete root coverage of tooth #31 was achieved, with a significant reduction in hypersensitivity reported by the patient. An increase in the height and thickness of keratinized tissue was observed around teeth #31, #41, and #32 [Figure 5c]. A slight reduction in vestibular depth at tooth #31 was noted, without affecting plaque control. The esthetic and functional outcomes were clinically satisfactory and remained stable at 6 months and 1 year.

Figure 5.

Postoperative views. (a) Harvest site after 10 days; (b) Suture removal at 16 days postoperatively showing the healing process; (c) Postoperative view at 3 months showing recovery of the tooth 31 with an increase in height and thickness of keratinized tissue

DISCUSSION

The concept of “wire syndrome” is relatively recent and has been increasingly documented in the literature.[4,6] Most cases appear within the first 5 years following placement of a bonded orthodontic retainer.[8] The syndrome is characterized by unwanted tooth movements, including rotation, angulation changes, and diastema formation, which can lead to localized gingival recessions, hypersensitivity, and esthetic concerns.

Management of wire syndrome requires a multidisciplinary approach, combining periodontal and orthodontic interventions. Timing of intervention is critical. Periodontal surgery performed before the removal of the orthodontic retainer can create a stable periodontal environment and optimize root coverage,[10,14] whereas the removal of the retainer before surgery may facilitate better oral hygiene and, according to Beitlitum et al., can improve the surgical outcomes in terms of esthetics and tissue stability.[10] In this case, the patient’s temporary refusal to resume orthodontic treatment dictated the sequence of care, with periodontal surgery performed before retainer removal. This approach allowed not only complete root coverage of tooth #31 but also the establishment of a favorable gingival biotype, reducing the long-term risk of periodontal disease.

Periodontal plastic surgery combined with connective tissue grafting remains the gold standard for the management of recessions induced by wire syndrome.[15] Among the available surgical approaches, the laterally closed modified tunnel technique offers several advantages. It allows for maximal root coverage, even in cases with challenging tooth positioning or malalignment, while preserving the integrity of the interdental papillae and ensuring minimal trauma to the surrounding tissues. This technique also maintains adequate flap vascularization, which is critical for graft survival and predictable healing. In addition, it provides excellent esthetic outcomes by avoiding visible surgical scars and ensuring harmonious gingival contours.[16,17]

In the present case, the laterally closed and suspended modified tunnel enabled complete root coverage of teeth #31, #32, and #41, independent of their malposition. The technique also contributed to the establishment of a favorable gingival biotype, reducing the long-term risk of periodontal disease. Its minimally invasive nature facilitated patient comfort and postoperative management, making it particularly suitable when combined with the patient’s temporary refusal to adjust or remove the bonded retainer. These features justify the choice of the modified tunnel approach over alternative methods such as coronally advanced flaps (CAF) or lateral pedicle flaps, which may be less predictable in cases with multiple mandibular incisor recessions and preexisting orthodontic appliances. CAF can provide predictable root coverage when sufficient keratinized tissue is present, while lateral pedicle flaps may be suitable for localized defects.[15] The choice of technique should be guided by tooth position, extent of recession, and patient-specific factors, emphasizing individualized treatment planning.

Despite these favorable results, certain limitations should be acknowledged. First, flap traction slightly reduced the vestibular depth, although this did not interfere with individual plaque control. Second, the patient’s refusal to remove or adjust the retainer limited the capacity to correct all iatrogenic forces, potentially affecting long-term stability. Finally, while this case demonstrates favorable short- to medium-term outcomes (up to 12 months), long-term follow-up is necessary to evaluate the stability of root coverage and the risk of recurrence, particularly if orthodontic forces remain active.

CONCLUSION

Management of wire syndrome-induced recessions should be individualized, taking into account patient preferences, the optimal timing of retainer removal, and the severity of gingival and tooth displacement. Multidisciplinary coordination between periodontists and orthodontists, combined with appropriate surgical techniques such as the laterally closed modified tunnel with connective tissue grafting, allows for predictable and satisfactory functional and esthetic outcomes. However, further studies and long-term follow-up are needed to confirm the stability of the results and to establish the standardized protocols for the management of this iatrogenic complication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.