Opinion
Importance of Early Detection of Wire Syndrome: A Case Series
Illustrating the Main Stages of the Clinical Gradient
Carole Charavet 1,2,3, * , Nathan Israël 1,2 , France Vives 4 and Sophie-Myriam Dridi 5,6
Citation: Charavet, C.; Israël, N.;
Vives, F.; Dridi, S.-M. Importance of
Early Detection of Wire Syndrome: A
Case Series Illustrating the Main
Stages of the Clinical Gradient. Clin.
Pract. 2023, 13, 1100–1110. https://
doi.org/10.3390/clinpract13050098
Academic Editors: Federica Di
Spirito and Francesco D’Ambrosio
Received: 25 July 2023
Revised: 28 August 2023
Accepted: 7 September 2023
Published: 11 September 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Clin. Pract. 2023, 13, 1100–1110. https://doi.org/10.3390/clinpract13050098
1 Département d’Orthodontie, Faculté de Chirurgie-Dentaire, Université Côte d’Azur, 06300 Nice, France;
nath_925@hotmail.fr
2 UEC d’Orthodontie, Institut de Médecine Bucco-Dentaire, Centre Hospitalier Universitaire de Nice,
06300 Nice, France
3 Laboratoire de Microbiologie Orale, Immunothérapie et Santé (MICORALIS) UPR7354,
Faculté de Chirurgie-Dentaire, Université Côte d’Azur, 06300 Nice, France
4 Pratique Privée, 75116 Vitrolles, France; f.vives@hotmail.fr
5 Département de Parodontologie, Faculté de Chirurgie-Dentaire, Université Côte d’Azur, 06300 Nice, France;
dr.sm.dridi@free.fr
6 UF de Parodontologie, Institut de Médecine Bucco-Dentaire, Centre Hospitalier Universitaire de Nice,
06300 Nice, France
* Correspondence: c.charavet@gmail.com
Abstract: (1) Context and Objective: Wire syndrome (WS) refers to dental displacements which
can be qualified as aberrant, unexpected, unexplained, or excessive of teeth still contained by an
intact orthodontic retainer wire without detachment or fracture, leading to evolving aesthetic and/or
functional consequences, both dental and periodontal. The clinical diagnosis of WS in severe cases is
often easy. On the other hand, emerging cases must be detected early to stop this evolutionary process
as soon as possible, as well as to effectively manage unwanted dental displacements and associated
dento-periodontal tissue repercussions. The aim of this retrospective study was to understand the
challenges and importance of early diagnosis, highlight the clinical gradient of WS, and clarify the
key elements of diagnosis for many practitioners confronted with this type of problem. (2) Materials
and Methods: Three cases of increasing complexity were described: the history of wire syndrome, a
description of the key elements of its diagnosis, and the final diagnosis itself. (3) Results: Different
types and locations of wire syndrome have been observed, from early form to terminal wire syndrome.
The three main stages of the clinical gradient are described as follows. In the first case, wire syndrome
starting on tooth 41, called the “X-effect” type, was suspected. X-effect wire syndrome on 21, X-effect
wire syndrome on 41, and Twist-effect wire syndrome on 33 were diagnosed in the second case, which
can be classified as an intermediate case. In the extreme clinical situation of the last case, severe and
terminal wire syndrome on tooth 41, the X-effect type, was observed. (4) Conclusions: This case series
presents the main stages of the clinical gradient of WS. Although in the case of early WS it is very
difficult to identify and/or differentiate it from movements related to a classical relapse phenomenon,
the diagnosis of terminal WS is very easy. The challenge for the practitioner is therefore to detect WS
as early as possible to stop the iatrogenic process and propose a personalized treatment depending
on the severity of clinical signs. The earlier WS is detected, the less invasive the treatment.
Keywords: wire syndrome; bonded retainer; fixed retainer; orthodontic retainer; unexpected movement;
unwanted movement
1. Introduction
In 2007, for the first time, Katsaros et al. [1] published a case report of an unreported
complication associated with bonded orthodontic retainers under the title “unexpected
complications of bonded mandibular lingual retainers”. Subsequently, other authors have
also observed the same complication, which has been given several different names. For
https://www.mdpi.com/journal/clinpract
Clin. Pract. 2023, 13 1101

example, Abudiak et al. (2011) [2] and Pazera et al. (2012) [3] described “a complication
with orthodontic fixed retainer” and “a severe complication of a bonded mandibular lingual
retainer”, respectively. In 2015 in France, Roussarie et al. [4,5] were the first to refer to this
phenomenon as “Syndrome du Fil” (SF), translated into English as “wire syndrome (WS)”
(Table 1).

Table 1. Names of wire syndrome (WS) over time.

Authors Date Name

Katsaros et al. [1] 2007 Unexpected complications of bonded mandibular lingual retainers
Abudiak et al. [2] 2011 A complication with orthodontic fixed retainers
Renkema et al. [6] 2011 Unexpected posttreatment complications
Alessandri Bonetti et al. [7] 2012 Isolated-type recession defects with an abnormal buccolingual inclination
Pazera et al. [3] 2012 Severe complication of a bonded mandibular lingual retainer
Farret et al. [8] 2015 Extreme labial movement of the root
Roussarie et al. [4,5] 2015 and 2018 Syndrome du fil
Kučera et al. [9,10] 2016 Unexpected complications/X-effect, Twist-effect and non-specific complications
Laursen et al. [11] 2016 Complications after unintentional tooth displacement by active bonded retainers
Shaughnessy et al. [12] 2016 Inadvertent tooth movement with fixed lingual retainers
Wolf et al. [13] 2016 Undesired tooth movement
Egli et al. [14] 2017 Unexpected posttreatment changes
Jacobs et al. [15] 2017 Single tooth torque problems
Beitlitum et al. [16] 2020 Unwanted effects such as inadvertent tooth movement and torque changes
Kim et al. [17] 2020 Unexpected tooth movements
Klaus et al. [18] 2020 Unwanted tooth movements
Knaup et al. [19] 2021 Side effects of twistflex retainers
Singh et al. [20] 2021 Extreme complication of a fixed mandibular lingual retainer

The first systematic review on wire syndrome (WS) was published by Charavet et al. [21]
in 2022, defining its prevalence and associated characteristics. This review involved an elec-
tronic search strategy on four databases supplemented by a manual search. All prospective
and retrospective clinical studies, including case reports and case series written in English
or French, with a clear description, detection, or management of WS, were included. Out
of 1891 results, 20 articles were selected. They were published between 2007 and 2021,
mostly in the form of series or case reports; the overall risk of bias was considered high.
The prevalence of WS varied from 1.1% (10 out of the 3500 patients studied) to 27% (18
out of the 163 patients studied). The orthodontic retainer was found to be intact, without
fractures or debonding, except in severe cases where it was altered at the end of the process.
WS was found in patients of all ages, did not depend on gender, and most often developed
in the first five years following the placement of fixed retainers. It is most commonly found
in the mandible where the canines are affected more than the incisors. Although most of the
retainer wires involved in WS are round, multi-strand, twisted stainless steel wires, all types
of wires can be involved, including flat, braided chains. The results of the systematic review
led to a proposed clinical definition of WS. This syndrome refers to dental displacements,
which can be qualified as aberrant, unexpected, unexplained, or excessive on teeth, still
contained by an intact orthodontic retainer wire without detachment or fracture, leading to
evolving aesthetic and/or functional consequences, both dental and periodontal.
Once WS occurs, dental and periodontal consequences, which are initially minor,
progressively worsen over time. However, in the case of early WS, it is very difficult to
identify and/or differentiate it from movements related to a classical relapse phenomenon.
Therefore, the practitioner’s challenge is to diagnose WS as early as possible to stop the
process and propose a personalized treatment according to the severity of the clinical signs.
The aim of this article was also to illustrate three clinical cases of increasing severity to
demonstrate the importance of early detection, highlight the clinical gradient of WS, and
clarify the key elements of the diagnosis.
 identify and/or differentiate it from movements related to a classical relapse phenomenon.
Therefore, the practitioner’s challenge is to diagnose WS as early as possible to stop the
process and propose a personalized treatment according to the severity of the clinical
signs. The aim of this article was also to illustrate three clinical cases of increasing severity
to demonstrate the importance of early detection, highlight the clinical gradient of WS,
Clin. Pract. 2023, 13 1102
and clarify the key elements of the diagnosis.

2. Materials and Methods

2. Materials and Methods
Registration: This study has been approved/registered by the Data Protection Officer
Registration: This study
of the Digital Innovation andhasInformation
been approved/registered by the on
Systems Department Data Protection
the Officer
Nice University
of the Digital Innovation and Information Systems Department
Hospital’s data processing register (reference 2023—EI 548). on the Nice University
Hospital’s data
Patient processing
selection: register
Three (reference
clinical cases of 2023—EI 548). of increasing severity in pa-
wire syndrome
Patient selection: Three clinical cases of wire syndrome
tients who were admitted to the orthodontic department of the of increasing
University severity
Hospital in
of
patients who were admitted to the orthodontic department of the University
Nice were retrospectively included. They presented early wire syndrome, intermediate Hospital of
Nice were retrospectively included. They presented early wire syndrome, intermediate
wire syndrome, and severe wire syndrome.
wire syndrome, and severe wire syndrome.
Data collection: A full set of photographs were taken from the following perspectives:
Data collection: A full set of photographs were taken from the following perspectives:
frontal view, different lateral views, and different occlusal views.
frontal view, different lateral views, and different occlusal views.
Data analysis: The description and analysis of the pictures mainly focused on the
Data analysis: The description and analysis of the pictures mainly focused on the
detection of a wire syndrome; other elements were not considered.
detection of a wire syndrome; other elements were not considered.

3.3.Results
Results
3.1.Early
3.1. EarlyWire
WireSyndrome
Syndrome
AA 22-year-old
22-year-old female
female patient
patientiningood
goodhealth had
health a consultation
had because
a consultation she she
because was was
con-
cerned about
concerned thethe
about “root prominence”
“root prominence”ofoftooth
tooth41.
41.She
Shewore
wore a mandibular retainer
retainer wire
wire
whenshe
when shewas
was16
16years
yearsold
oldatatthe
theend
endofofher
herorthodontic
orthodontictreatment.
treatment. She
She has
has good
good oral
oral
hygiene,despite
hygiene, despitethe
thepresence
presenceofoftartar
tartarbetween
between31 31and
and41,
41,and
andaaright
rightand
andleft
leftClass
ClassIIwith
with
aaslight
slightdeviation
deviationof
ofthe
themidlines
midlines(Figure
(Figure1).
1).

Figure1.1.Early
Figure Earlywire
wiresyndrome.
syndrome.Frontal
Frontaland
andlateral
lateralviews.
views.

InIn Figure
Figure2,2,the
thefollowing
followingcan canbe
beobserved:
observed: aa difference
difference in
ingingival
gingival margin
marginheight
height
between41
between 41and
and31,
31,a adifference
difference inin height
height of of
thethe incisal
incisal edges
edges of compared
of 41 41 compared to adjacent
to the the adja-
cent teeth,
teeth, and
and the the onset
onset of gingival
of gingival recession
recession on 41 associated
on 41 associated with
with the the visibility
visibility of a ves-
of a vestibular
tibular
arch arch corresponding
corresponding to its root.
to its root.
In the lateral view (Figure 3), the prominence of the root of 41 was confirmed.
Occlusal views (Figure 4) confirmed the presence of a mandibular retainer which
appears intact, without fracture or debonding, along its entire length. In addition, the
vestibular surface of 41 appeared to have a difference in visibility from the adjacent teeth.
Based on these clinical findings, wire syndrome starting on tooth 41, called the “X-effect”
type, was suspected.
Clin. Pract. 2023, 13, FOR PEER REVIEW 4

Clin.
Clin.Pract. 2023,13
Pract.2023, 13, FOR PEER REVIEW 11034

Figure 2. Early wire syndrome. Frontal views.

Figure
FigureIn2.2.the
Early
Early wiresyndrome.
lateral
wire syndrome.
view Frontal
(Figure views.
3), the
Frontal prominence of the root of 41 was confirmed.
views.

In the lateral view (Figure 3), the prominence of the root of 41 was confirmed.

Clin. Pract. 2023, 13, FOR PEER REVIEW 5

Figure3.3.Early
Figure Earlywire
wiresyndrome.
syndrome.Lateral
Lateralview.
view.

Figure 3. Early views

Occlusal wire syndrome. Lateral
(Figure 4) view. the presence of a mandibular retainer which ap-
confirmed
pears intact, without fracture or debonding, along its entire length. In addition, the ves-
Occlusal
tibular surfaceviews
of 41(Figure 4) confirmed
appeared to have a the presence
difference inof a mandibular
visibility retainer
from the which
adjacent ap-
teeth.
pears intact, without fracture or debonding, along its entire length. In addition, the
Based on these clinical findings, wire syndrome starting on tooth 41, called the “X-effect” ves-
tibular
type, surface
was of 41 appeared to have a difference in visibility from the adjacent teeth.
suspected.
Based on these clinical findings, wire syndrome starting on tooth 41, called the “X-effect”
type, was suspected.

Figure4.4.Early
Figure Earlywire
wiresyndrome.
syndrome.Occlusal
Occlusalview.
view.

3.2. Intermediate Wire Syndrome

A 26-year-old female patient was referred by her general dentist for suspected wire
syndrome. Orthodontic treatment had been performed 10 years previously, and bonded
restorations had been fitted at the end of the treatment. The patient mentioned several
Clin. Pract. 2023, 13 1104

Figure 4. Early wire syndrome. Occlusal view.

3.2.Intermediate
3.2. IntermediateWire
WireSyndrome
Syndrome
AA26-year-old
26-year-oldfemale
femalepatient
patient was
was referred
referredby
byher
hergeneral
generaldentist
dentistfor
forsuspected
suspectedwire
wire
syndrome. Orthodontic
syndrome. Orthodontic treatment
treatment had
had been
been performed
performed 10 10 years
years previously,
previously,and
andbonded
bonded
restorations had
restorations had been
beenfitted
fitted at
atthe
theend
endofofthe
thetreatment.
treatment.TheThepatient
patientmentioned
mentionedseveral
several
episodes
episodesofofbreakage/adhesion,
breakage/adhesion, without further
further details.
details. She
She has
has good
good oral
oral hygiene
hygiene and
andaa
right
rightand
andleft
leftClass
ClassII(Figure
(Figure5).
5).

Figure5.5.Intermediate
Figure Intermediatewire
wiresyndrome.
syndrome.Frontal
Frontaland
andlateral
lateralviews.
views.

InFigure
In Figure6,6,11
11and
and21 21show
showaadifference
differencein inincisal
incisaledge
edge height
height and
and gingival
gingival margin.
margin.
Tooth41
Tooth 41shows
showsgingival
gingivalrecession
recessiontotothe
themuco-gingival
muco-gingivaljunction
junction(Cairo’s
(Cairo’sRT1)
RT1)with
withroot
root
Clin. Pract. 2023, 13, FOR PEER REVIEW 6
visibility.Tooth
visibility. Tooth3333had
hada asignificant
significant lingual
lingual tilttilt (coronal–lingual
(coronal–lingual torque),
torque), notnot symmetrical
symmetrical to
to tooth
tooth 43. 43.

Figure6.
Figure 6. Intermediate
Intermediate wire
wiresyndrome.
syndrome. Frontal
Frontalview.
view.

Theroot
The rootofoftooth
tooth2121isisvisible
visiblethrough
through
thethe gingiva
gingiva (Figure
(Figure 7). 7). Figure
Figure 8 shows
8 shows the the ex-
extent
tent
of of gingival
gingival recession
recession on tooth
on tooth 41. 41.
 Figure 6.
Figure 6. Intermediate
Intermediate wire
wire syndrome.
syndrome. Frontal
Frontal view.
view.
Clin. Pract. 2023, 13 1105
The root
The root of
of tooth
tooth 21
21 is
is visible
visible through
through the
the gingiva
gingiva (Figure
(Figure 7).
7). Figure
Figure 88 shows
shows the
the ex-
ex-
tent of gingival recession on tooth 41.
tent of gingival recession on tooth 41.

Figure7.
Figure
Figure 7. Intermediate
7. Intermediate wire
Intermediate wiresyndrome.
wire syndrome. Lateral
syndrome. Lateralview.
Lateral view.
view.

Clin. Pract. 2023, 13, FOR PEER REVIEW 7

Figure 8.
Figure 8. Intermediate
Intermediate wire
wire syndrome.
syndrome. Lateral
Lateral views.
views.
Figure 8. Intermediate wire syndrome. Lateral views.

The occlusal
The occlusal views
views provide
provide additional
additional relevant
relevant information
information (Figures
(Figures 99and
and10).
10). A
A
maxillary
maxillary retainer was
was present
presentonon11
11and
and2121only
only and
and a difference
a difference in visibility
in visibility of ves-
of the the
vestibular surfaces
tibular surfaces (differential
(differential torque)
torque) onon these
these same
same teeth
teeth waswas noted.
noted.

Figure9.9.Intermediate
Figure Intermediatewire
wiresyndrome.
syndrome.Occlusal
Occlusalview.
view.
Clin. Pract. 2023, 13 1106

Figure 9. Intermediate wire syndrome. Occlusal view.

Figure10.
Figure 10.Intermediate
Intermediatewire
wiresyndrome.
syndrome.Occlusal
Occlusalview.
view.

Inthe
In themandible,
mandible,the
theretainer
retainerwas
was broken
broken distal
distal to
to 42
42 and,
and, despite
despite being
being intact
intact on
on 33,
33,
this
this tooth
tooth had
hadincreased
increasedvisibility
visibilityofofits
itsvestibular
vestibularsurface
surfacecompared
comparedto toits
itscontralateral
contralateral
tooth
tooth(differential
(differentialtorque).
torque).Finally,
Finally,teeth
teeth3131and
and41
41also
alsoshowed
showedaadifference
differencein inthe
thevisibility
visibility
of their vestibular surfaces (differential torque). Ultimately, the patient was diagnosed
of their vestibular surfaces (differential torque). Ultimately, the patient was diagnosed with
an X-effect
with wire syndrome
an X-effect on 21,on
wire syndrome an21,
X-effect wire syndrome
an X-effect wire syndromeon 41,on
and
41,a and
Twist-effect wire
a Twist-effect
syndrome on 33.on 33.
wire syndrome

3.3.
3.3.Severe
SevereWire
WireSyndrome
Syndrome
AA 40-year-oldpatient
40-year-old patientpresented
presentedwith
withdiscomfort
discomfortinintooth
tooth31,
31,citing
citingpast
pastorthodontic
orthodontic
treatment.
treatment. As shown in Figure 11, the patient was in Class I and had poororal
As shown in Figure 11, the patient was in Class I and had poor oralhygiene
hygiene
associated with the presence of calculus in the incisivo-canine region. The root
associated with the presence of calculus in the incisivo-canine region. The root of 31,of 31, visible
visi-
Clin. Pract. 2023, 13, FOR PEER REVIEW
to
bleitstoapex, was out
its apex, wasofout
theofbone and associated
the bone with severe
and associated gingival
with severe recession
gingival RT2).8
(Cairo(Cairo
recession
Teeth 41 and 42 also showed gingival recession (Cairo RT2 and RT1).
RT2). Teeth 41 and 42 also showed gingival recession (Cairo RT2 and RT1).

Figure 11.
Figure 11. Severe
Severe wire
wire syndrome.
syndrome. Frontal
Frontal and
and lateral
lateral views.
views.

Figures 12
Figures 12 and
and 13
13 show
show aa difference
difference inin the
the height
height of
of the
the free
free edges
edges of
of the
the mandibular
mandibular
incisors and the extent of root visibility of 31.
incisors and the extent of root visibility of 31.
 Figure
Figure 11.
11. Severe
Severe wire
wire syndrome.
syndrome. Frontal
Frontal and
and lateral
lateral views.
views.
Clin. Pract. 2023, 13 1107
Figures
Figures 12
12 and
and 13
13 show
show aa difference
difference inin the
the height
height of
of the
the free
free edges
edges of
of the
the mandibular
mandibular
incisors and the extent of root visibility of 31.
incisors and the extent of root visibility of 31.

Figure
Figure 12. Severe
12.Severe
Figure12. wire
Severewire syndrome.
wiresyndrome. Frontal
syndrome.Frontal view.
Frontalview.
view.

Figure 13.
Figure13. Severe
13.Severe wire
Severewire syndrome.
wiresyndrome. Lateral
syndrome.Lateral views.
Lateralviews.
views.
Figure

No retainer
No retainer
No was
retainer was present
was present in
present in the
in the maxilla,
the maxilla, only
only aaa residual
maxilla, only residual mandibular
residual mandibular retainer,
mandibular retainer, still
retainer, still
still
bonded
bonded to
bondedtoto32 32 and
32and
and42,42, was
42,was visible
wasvisible (Figure
visible(Figure
(Figure 14),
14),
14), as
asas well
well
well as
asas incisal
incisal
incisal crowding
crowding
crowding and
andand a difference
a difference
a difference in
in
in the
the the visibility
visibility of of
visibility of the
thethe buccal
buccal
buccal andand
and root
root
root surfaces
surfaces
surfaces ofof
4141
of 41 compared
comparedtoto
compared the
tothe contralaterals.
thecontralaterals. In
contralaterals.In this
Inthis
this
Clin. Pract. 2023, 13, FOR PEER REVIEW
extreme clinical situation, 9
extremeclinical
extreme situation,aaasevere
clinicalsituation, severe
severeandand terminal
andterminal wire
terminal wire syndrome
wire syndrome
syndrome on on tooth
on tooth 41,
tooth 41, the
the “X-effect”
41, the “X-effect”
“X-effect”
type,
type, was
type,was observed.
wasobserved.
observed.

Figure 14.
Figure 14. Severe
Severe wire
wire syndrome.
syndrome. Occlusal
Occlusal view.
view.

4.
4. Discussion
Discussion
The
The movements causedby
movements caused byWSWSdo donot
not correspond
correspond to atorelapse
a relapse
or aor a physiological
physiological pro-
process [21];
cess [21]; thethe effects
effects of of
WS WS
ononteeth
teethare
arenot
notcorrelated
correlatedwith
with the
the position
position of
of teeth
teeth before
before
orthodontic treatment nor with their position at the time of the debonding of an ortho-
dontic appliance. WS can therefore be considered as a new malocclusion observed after
the placement of a fixed, bonded, post-orthodontic retainer [21]. The aim of this article
was to show, via three clinical cases representing three main situations of WS of increasing
 Figure 14. Severe wire syndrome. Occlusal view.

4. Discussion
Clin. Pract. 2023, 13 The movements caused by WS do not correspond to a relapse or a physiological pro- 1108
cess [21]; the effects of WS on teeth are not correlated with the position of teeth before
orthodontic treatment nor with their position at the time of the debonding of an ortho-
dontic appliance.
orthodontic WS can
treatment northerefore
with theirbe considered
position at the as
timea new
of themalocclusion
debonding ofobserved after
an orthodontic
the placement of a fixed, bonded, post-orthodontic retainer [21].
appliance. WS can therefore be considered as a new malocclusion observed after the The aim of this article
was to show,ofvia
placement three clinical
a fixed, bonded, cases representing three
post-orthodontic main
retainer situations
[21]. The aim of of
WSthis
of increasing
article was
complexity, the relevance of the early diagnosis of this syndrome.
to show, via three clinical cases representing three main situations of WS of increasing
A systematic
complexity, review by
the relevance of Charavet
the early and al. [21]ofidentified
diagnosis four main families of typical
this syndrome.
movements: a torque
A systematic differential
review between
by Charavet andtwo adjacent
al. [21] incisors
identified fourcalled
mainthe “X-effect”,
families an
of typical
opposite inclination between two contralateral canines called the “Twist-effect”,
movements: a torque differential between two adjacent incisors called the “X-effect”, an exag-
gerated torqueinclination
an opposite on a tooth,between
or a non-specific complication
two contralateral (opening
canines calledofthe
space). These move-
“Twist-effect”, an
ments can also be associated with each other, and a variety of clinical
exaggerated torque on a tooth, or a non-specific complication (opening of space). These manifestations can
then be observed.
movements Once
can also beWS occurs, with
associated the consequences
each other, and forahard
varietyandofsoft tissues,
clinical which are
manifestations
initially
can then minor, progressively
be observed. Once WS worsen over
occurs, thetime (Figure 15).for
consequences However,
hard andthissoftsystematic re-
tissues, which
view was notminor,
are initially able toprogressively
elucidate theworsen
circumstances
over time of (Figure
WS emergence and itsthis
15). However, progression.
systematic
Therefore,
review was it seemed
not able important
to elucidatetothe
clarify these points,
circumstances based
of WS on our clinical
emergence and itsimpressions
progression.
and expertise.
Therefore, it seemed important to clarify these points, based on our clinical impressions
and expertise.

Figure 15. Summary of evolving dental and periodontal consequences of wire syndrome over time.
Figure 15. Summary of evolving dental and periodontal consequences of wire syndrome over time.
Although it is reasonable to assume that tissue damage occurs from the initiation
Although
of FS, clinical itmanifestations
is reasonable to assume
start to be that tissue
visible whendamage occurs process
the disease from theresults
initiation of
in root
FS, clinical manifestations start to be visible when the disease process
displacement. We can therefore propose a clinical gradient with dental and periodontal results in root dis-
placement.
consequences We varying
can therefore
from propose a clinicalto
a minor problem gradient with dental
the exposure of the and
rootperiodontal
to the apex of con-
the
sequences varying from a minor problem to the exposure of the root to the
affected tooth (Figure 4). The three clinical situations described in this article illustrate the apex of the
affected toothof
main stages (Figure 4). The three clinical situations described in this article illustrate the
this gradient.
main stages of this gradient.
When the displacement due to wire syndrome is minimal, the result is a slight displace-
mentWhen
of thethe displacement
affected duethe
tooth, with tomaintenance
wire syndrome is minimal,
of contact pointsthe
butresult is aofslight
the loss tooth dis-
neck
placement of the affected tooth, with the maintenance of contact
(cervical margin) alignment and the appearance of discrete gingival recession (Figurepoints but the loss of1).
tooth
In theneck (cervical
lateral view, margin) alignmentofand
the displacement thethe appearance
tooth is visible ofanddiscrete
can begingival
objectified recession
via the
(Figure
digital 1). In the lateral
palpation of the view, thethe
root. In displacement
occlusal view,of the
the tooth
incisalisedges
visible
areand
nocan be objectified
longer completely
aligned. Over time, the more the root becomes displaced, the thinner the gingiva becomes
and the more the attachment worsens, first on the entire face of the tooth (vestibular or
lingual) and then in the interdental area. Clinically, this results in increasingly wide and
deep gingival recessions and the loss of tooth alignment (Figure 2). Eventually, interdental
spaces appear and the displacement of the roots from their sockets is major. Therefore, in
the presence of very large tooth displacements (end of the WS process), the orthodontic
retainer becomes detached or breaks (Figure 3).
In the present case of severe WS, generalized moderate periodontitis was diagnosed,
except on the mandibular incisors, which showed a more severe attachment loss. This
can be explained by the presence of the WS, which aggravates the pathological process.
The presence of bacterial and calculus deposits on the incisors was certainly important,
but it alone cannot explain the severity of tissue destruction, particularly on 31. This case
highlights the problem of the multi-factorial etiology of WS.
Concerning the risk factors associated with the development of WS, several authors
point to inconsistent results, except for the presence of onycophagy parafunction. Fur-
thermore, etiological hypotheses have been associated with the practitioner (bonding of a
non-passive retainer wire, deformation of the wire during bonding, etc.) or with the wire
(deformation of the wire, instability of its mechanical properties, etc.), and thus associated
preventive measures have been proposed [21]. Finally, the complexity of the treatments, of-
Clin. Pract. 2023, 13 1109

ten multidisciplinary, is proportional to the severity of the clinical situations [21]. Currently,
the management of wire syndrome is based on the clinical common sense of clinicians
because there is no scientific-supported consensus.
The present case series has some limitations. First, our hypotheses are not supported
by scientific evidence. However, the present case series constitutes a starting point for the
development of cross-sectional observation studies. For ethical reasons, it seems difficult
to perform prospective trials of exposed/unexposed cohorts. It is not possible to avoid
treating patients with WS (in case of a control group) with the unique aim of identifying the
risk factors associated with this syndrome. Furthermore, we focused solely on the clinical
criteria and did not address the therapeutic aspect. In fact, we also think it interesting to
begin by establishing the foundations of a diagnostic approach based on relevant diagnostic
criteria before proposing a potentially multidisciplinary treatment pathway.

5. Conclusions
The identification of wire syndrome is recent and of increasing concern to clinicians,
orthodontists, general practitioners, and periodontists. Indeed, while severe forms of
wire syndrome are very easily detectable, early forms are more difficult to detect and
can be confused with a classic orthodontic relapse. The stakes are high; early detection
allows for immediate treatment and the application of appropriate therapy, thus preventing
this iatrogenic process. However, additional clinical studies are necessary to clarify the
etiopathogenic mechanisms of wire syndrome and its clinical impacts, ultimately allowing
us to suggest effective preventive therapies.

Author Contributions: Conceptualization: C.C. and S.-M.D. Methodology: C.C. and S.-M.D. Data
extraction: C.C., N.I., F.V. and S.-M.D. Data analysis and interpretation: C.C. and S.-M.D. Drafting the
manuscript: C.C. Reviewing and editing the manuscript: C.C., N.I., F.V. and S.-M.D. All authors have
read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: This study was approved/registered by the Data Protection
Officer of the Digital Innovation and Information Systems Department on the Nice University
Hospital’s data processing register (reference 2023—EI 548).
Acknowledgments: L’Information Dentaire (ISSN 0297-8350), where the original photos were pub-
lished by the authors [22].
Conflicts of Interest: The authors declare no conflict of interest.

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