Clinical

Case Report

The Endodontic-Orthodontic
Sungyoon (Julien) Kim
DMD
Fang-Chi (Alice) Li
DDS PhD
Interplay

M
any orthodontic patients present with teeth altered blood flow and change in oxygen tension, and
that are carious or that have been previous- release of prostaglandins and other cytokines. Within
ly traumatized, often requiring endodontic hours, there are metabolic changes and a release of
treatment. In such patients, interdiscipli- enzymes, increased cyclic adenosine monophosphate,
nary management and treatment planning is critical. and start of cellular differentiation. Within days, oste-
Issues confronting orthodontic patients with endo- oclasts and osteoblasts are activated to participate in
dontic needs range from effects of orthodontic tooth tissue remodelling, leading to 0TM as well as removal
movement (OTM) on pulp status to a possible induction of necrotic tissues (1).
or exacerbation of tooth resorption. Some common Although the blood flow to the pulp is initially
questions regarding the endodontic-orthodontic inter- reduced when orthodontic forces are applied, blood
play include: 1. Does OTM impact the viability of the flow returns to normal within 72 hours. Neuropeptides
dental pulp? 2. What is the role of 0TM on apical root are also initially reduced, but they return to nor-
resorption? 3. Does OTM differ in vital versus endodon- mal within 72 hours as well. In vitro experiments
tically treated teeth? 4. What role does previous tooth with pulp explants show a greater number of micro-
trauma play in OTM? 5. Will an ongoing orthodontic vessels at day five and day 10 from teeth that have been
treatment affect the endodontic outcome? These ques- orthodontically moved, as compared with the control
tions will be answered in this review, with an initial group. There is also a release of growth factors, such as
presentation of a case that illustrates some of the main platelet-derived growth factor, epidermal growth factor,
issues confronted with the delivery of care of patients and transforming growth factor beta. Alterations in the
with orthodontic-endodontic needs. pulpal vasculature affects the metabolism of pulpal cells,
which leads to dystrophic mineralization in the coronal
1. Does orthodontic tooth movement impact and radicular portions of the teeth, consisting of repara-
viability of dental pulp? tive dentine. Fortunately, irreversible pulpal changes
Moving teeth is an intricate interplay between physics such as devitalization is rare in OTM, provided that the
and biology. The physical behaviour of tooth move- force applied is within physiologic limits.
ment due to orthodontic force follows Newton's laws of Orthodontic intrusion is thought to have the most
physics. The biological responses of tissues are mediated significant effects on the pulp due to the concentration
through receptor cells and signalling pathways that lead of force that builds at the apex. Even in such a scenar-
to bone remodelling and tooth movement. Within sec- io, change in blood flow to the pulp is transient and
onds of force application, there is movement of fluids normalizes after 72 hours. Other risk factors for devital-
from areas of compression to areas of tension; develop- ization include use of excessively high force, dragging
ment of strain in cells and the extracellular matrix; and movement close to the dense cortical bone, previous
increased intracellular calcium. Within minutes, there is history of trauma, and large caries. Teeth with immature

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 Case Reporl

root status have less risk of irreversible pulpal changes significantly larger in control teeth than pulpecto-
compared with those with mature apices due to a richer mized teeth (4). One of the reasons could be the loss
neurovascular bundle and less constrained apex (2,3). of the release of neuropeptides frorn a pulp that has
been removed, resulting in a decrease of the calciton-
2. What is the role of OTM on apical root in gene-related peptide immuno-reactive fibres and a
resorption? reduction in the amount of resorption seen in endodon-
Orthodontically induced inflammatory root resorption tically treated teeth (10). One recent systematic review
is a relatively common adverse sequelae of orthodon- including eight clinical studies (four prospective and four
tic treatment. The literature reports a wide range of retrospective studies) demonstrated there was signifi-
incidence, from 20 to 100 per cent of orthodontically cantly less orthodontic-induced external root resorption
treated patients. It is classified under surface transient for endodontically treated teeth, compared with their
inflammatory resorption. Radiographically, the root contralateral teeth with vital pulps. Endodontic treat-
apex may show a rounded or blunted appearance. ment does not seem to increase orthodontic-induced
Maxillary incisors are most prone to resorption, followed external root resorption (11).
by mandibular incisors and first permanent molars (1).
The mechanism behind orthodontically induced 4. What role does previous tooth trauma play
inflammatory root resorption is unclear, but we know it in C)TM?
is in part due to the process of elimination of the hyalin- According to the American Association of Endodontics
ization zone, areas of ischemic necrosis that form during and International Association of Dental Traumatology,
OTM. The imbalance between bone resorption and traumatic dental injuries are classified into fracture,
deposition may mediate the resorption by osteoclasts. luxation and avulsion. Fractures include crown, crown-
Tensile forces in the pulp cells enhance the expression root, root and alveolar fracture, while luxation injuries
of various inflammatory cytokines through the stretch- include concussion, subluxation, extrusive luxation,
activated channel, which may promote the inflammatory lateral luxation and intrusive luxation (12,13).
root resorption during OTM (4). Epidemiological studies indicate the annual incidence
Risk factors for orthodontically induced inflammatory of dental trauma globally at about 4.5 per cent. The
root resorption include genetic and systemic factors; incidence on primary teeth (children, toddlers) is higher
root morphology (e.g. thinner or blunted roots); alveolar than on permanent teeth (adolescents, adults), and the
bone morphology; the nature of orthodontic force (e.g. most frequently affected teeth are the maxillary central
magnitude, continuity of force, direction and duration); incisors (14), due mostly to falls in toddlers at home and
the treatment mechanics used; the nature of tooth engagement in contact sports in adolescents. Traumatic
movement (e.g. intrusion, extrusion, tipping or bodily dental injuries may cause pulp necrosis, tooth attach-
movement, and dragging across palatal bone); distance ment loss and root resorption.
of tooth movement; and overall treatment duration (5). The high prevalence of previous dental trauma in
the orthodontic patient population has recently been
3. Does OTM differ in vital versus reported, with 10.8 per cent of patients sustaining den-
endodontically treated teeth? tal injuries before the onset of orthodontic treatment
Endodontically treated teeth can be moved as easily as (15). In the general population, out of all dental trau-
vital, non-treated teeth. This is because OTM is a sequela ma, extrusive and lateral luxation occurred in seven
of the response to force by the periodontal ligament, not to 11 per cent, while intrusive luxation in two per
the pulp. Root-filled teeth and those with vital pulps cent (7,16). Three types of external root resorptions
move similar distances when subjected to the same can occur in traumatized teeth subject to orthodontic
forces (6). In cases of replacement resorption (ankylosis) movement: external surface resorption, external inflam-
or trauma to the apical periodontium, the replaced bone matory resorption and external replacement resorption
and traumatized periodontal ligament may hinder tooth (17) (Table 1).
movement during orthodontic treatment (7). Orthodontic movement of teeth with repaired root
Interestingly, root resorption is more often observed fractures is possible, even if the fractures at the time
in intact teeth when compared with pulpless teeth. A of the accident are extensive with marked fragment
few studies have shown similar conclusions. In a 1995 dislocation (18). In cases where repair occurs with-
study by Mirabella and Artun, there was significantly out separation of the fragments, apical fragment may
less resorption in endodontically treated teeth (8,9). remain attached to the coronal portion throughout
The amount of inflammatory root resorption was and following orthodontic treatment. However, there

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 Case Report

Table 1. Summary of three types of external root resorptions commonly associated with
orthodontic movement and dental traumatic iniuries (17).

External surface External External

resorption inflammatory replacement
resorption resorption
Pulp status (+) Non-infective, transient, (-) Pulp necrosis (+) May delay
pressure-induced
Cause • Orthodontic tooth • Caries, bacteria ingress • Severe luxation and
movement • Common findings in all avulsion injuries
• Impacted teeth teeth with apical
• Tumours and cysts periodontitis (AP)
• Following severe
traumatic dental injuries
Clinical signs and • Unremarkable • Sensibility test (-) • Unremarkable
symptoms • Possible percussion,
palpation tenderness
(similar to AP)
Radiograph • Root apices are blunted • Visible root canal outline • Lack of periodontal
and/or the roots appear • Periradicular radioluceilly ligainent space only in
shorter in orthodontically • CBCT recommended proximal areas as the
treated teeth affected root surface
• Saucer-shaped or
irregularly-shaped in
teeth adjacent to an
expanding tumour, cyst
or in-lpacted tooth
Treatment • CBCT indicated: • RCT indicated • No effective management
resorption associated to • Electively decoronate
tumour, impacted teeth teeth to promote
normal alveolar bone
development (children
and adolescents)

is the possibility that the separation of the segments moved orthodontically with minimal risk of resorption,
may be exacerbated by orthodontic movement as well. provided the pulp has not been severely compromised
It is considered advisable that teeth with these types (infected or necrotic). If there is evidence of pulpal
of fractures be observed at least two years before ini- demise, appropriate endodontic management is nec-
tiating orthodontic movement (18,19). In previously essary prior to orthodontic treatment (19). When a
avulsed or partially avulsed teeth, research shows that previously traumatized tooth exhibits resorption, there
resorption occurs more readily during and after ortho- is a greater chance that 0TM will enhance the resorptive
dontic treatment (19). process (19). Generally speaking, when a tooth has been
In situations where intrusive luxation is found (as in severely traumatized (intrusive luxation/avulsion) there
the case presented below), the apical area of the tooth may be a greater incidence of resorption, with or with-
may become rapidly moth-eaten due to the crushing out root canal treatment.
injury of the intrusive force, damaging the periodontal
ligament attachment and root surface (7,19), prompting 5. Will an ongoing orthodontic treatment
the recommendation that a permanent root filling be affect the endodontic outcome?
placed prior to orthodontic tooth movement where In the cases with/without apical periodontitis, the endo-
practical (20). There is lack of evidence, however, show- dontic prognosis in about five years followup ranges
ing that traumatized teeth have a greater tendency from 80 to 90 per cent (22,23). However, the endodon-
toward root resorption than non-traumatized teeth after tic prognosis of teeth with luxation history shows a
OTM (complicated and uncomplicated crown fractures, lower outcome: 72 to 75 per cent in one of the studies
concussions, subluxations and luxations) (21). However, (23). There appears to be no significant increase in the
traumatized teeth with signs of root resorption prior periapical index and bone destruction scores after ortho-
to orthodontic treatment may be more prone to root dontic treatment for adequately treated teeth according
resorption during OTM. A traumatized tooth can be to the majority of the studies. Risk for periapical lesions

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 Case Report

Figure 1. Extraoral photographs - frontal, frontal smiling, profile.

Figure 2. Intraoral photographs - occlusal upper, occlusal lower, right, frontal, left.

and bone destruction after orthodontic treatment is Case report

significantly increased for teeth receiving inadequate A patient presented to the Faculty of Dentistry graduate
endodontic treatment compared with those receiving orthodontics clinic with the chief complaint of wanting
adequate endodontic treatment (19,24). Nevertheless, to straighten her teeth, especially the "crooked" tooth
in a 2006 study by de Souza et al., on teeth with #11. Past history revealed that she had sustained a facial
apical periodontitis, the healing process of chronic peri- injury one-and-a-half years prior, which had displaced
apical lesions appears to be faster in the experimental the tooth facially. At the time, she stated the dentist
group, which did not experience orthodontic move- recommended no other treatment but to restore the
ment (25). The authors defined dogs' teeth with apical broken part of the tooth. She had skeletal Class II divi-
periodontitis submitted or not to orthodontic movement sion 1 malocclusion, with a retrognathic mandible and
after root canal treatment (25). Furthermore, healing was increased overjet (Figures 1,4). Intraorally, she had some
late in the teeth with root-filled and root-end resection crowding in both arches and tooth #11 that was labio-
(26), suggesting that endodontically treated teeth and verted (Figure 2). On the panoramic X-ray, teeth #17,
apically surgerized teeth may take a longer time to heal #36, and #46 were previously endodontically treated.
when undergoing orthodontic movement. These studies Tooth #46 had asymptomatic apical periodontitis. She
essentially showed that orthodontic movement delayed, had generalized shortened roots from previous ortho-
but did not hinder, the healing process. dontic treatment as well (Figure 3).

September 2021 • OD 31 I
Case Report

Figure 3. Initial panoramic radiograph. Note the generalized shortened, blunted roots.

Figure 4. Lateral cephalogram, demonstrates Class 11 skeletal pattern due to mandibular retrognathism and increased overiet.

Figure 5. Left: Intraoral photo presents sinus tracts, which appear close to the apices of teeth #11 and #12.
Right: Periapical radiolucencies present on teeth #11 and #12.

I 32 OD • September 2021
 Case Repod

Figure 6. Periapical films show two sinus tracts traced to the apex of tooth #11 and #12; the working length measurement confirmed
with radiographs; and the final obturation with gutta-percha and sealer under warm vertical compaction.

The initial orthodontic treatment plan included a Discussion and conclusion

referral for assessment of the maxillary central incisors, The patient had traumatic injury 18 months prior to
as well as previously root canal treated teeth (#17, #36, the orthodontic treatment, with teeth #11 and #21
#46). The upper second premolars were to be extracted, presenting with intrusive luxation. Besides a restorative
and the maxillary anterior segment to be retracted using procedure of the fractured crown, nothing had been
a temporary anchorage device supported trans-palatal done for the reposition of the teeth. According to the
arch for maximum anchorage. Retention was to follow guideline of treating an intrusive luxation in mature
with fixed lingual retainers and Essix retainers in both permanent teeth with anywhere between 3 to 7 mm
upper and lower arches. intrusion, repositioning the teeth surgically or ortho-
Midway during treatment, sinus tracts appeared in the dontically within three weeks should be considered. In
buccal vestibule (Figure 5) and the patient was referred cases where the displacement is more than 7 mm, there
to the faculty's endodontic clinic within one week. should be surgical repositioning followed by the use of
Sinus tracts were traced to the apices of teeth #11 and flexible splint for two weeks. The pulp willlikely become
#21. Periapical films revealed rarefying osteitis at the necrotic and root canal therapy should be initiated two
periapex of both teeth with a periapical index score of 3 weeks after the injury. After cleaning and disinfection,
and 4 respectively (Figures 5,6) (27). The root end of the a temporary dressing with Ca(OH)- is recommended for
anterior teeth appeared blunt. Teeth #11 and #21 were up to four weeks before obturation (13). Therefore, it
sensitive to palpation, percussion and did not respond would have been ideal if the patient had the opportunity
to cold testing. Probing depths were within normal to receive the immediate treatment mentioned above,
limits (< 3 mm). The diagnosis of teeth #11 and #21 was with root canal treatment initiated immediately right
pulp necrosis with chronic apical abscess. The shape of after the injury. While the patient was seen in the ortho-
the root end was consistent with apical root resorption. dontic clinic, viability of the teeth through sensibility
Root canal treatment under standard optic microscopy testing should have been done prior to the orthodontic
and rubber dam isolation was performed and complet- treatment. This is especially so since studies have shown
ed on both teeth. Root canals were instrumented with that in 98 per cent of teeth with intrusive luxation,
rotary files/K files (Dentsply Sirona) to the apical size of the pulp will become necrotic (7,16,28). According to
#50 and irrigated using 2.5 per cent sodium hypochlo- a recommendation by Kindelan et al., in teeth with
rite. The canals were obturated with gutta-percha and moderate to severe damage to the periodontium, ortho-
epoxy resin sealer (ThermaSeal, Dentsply Sirona) under dontic treatment should start one year after the injury,
warm vertical compaction after final irrigation with 17 when the complete healing of the periodontium can be
per cent ethylenediaminetetraacetic acid followed by achieved (15,29).
2.5 per cent sodium hypochlorite for one minute. The In this case report, it is likely that pulp necrosis of
access cavities of both teeth were restored with com- teeth #11 and #21 was not a consequence of OTM. Pulp
posite resin. Sinus tracts were not completely resolved necrosis is highly associated with intrusive luxation
in two weeks, and unfortunately the patient has not and the chronic apical abscess might have been avoid-
been brought back to the clinic due to the COVID-19 ed had the root canal been treated prior to the OTM.
pandemic. The patient may still experience a certain degree of

September 2021 • OD 33 I
Case Report

orthodontically induced inflammatory root resorption, 8. Mirabella AD, Artun J. Risk factors for apical root
which was already evident before treatment. However, resorption of maxillary anterior teeth in adult ortho-
comparing the radiographs prior to the 0TM and the dontic patients . Amerkan Journal of Orthodontics and
ones one year after the treatment, the apical root resorp- Dentofacial Orthopedics. 1995 Jul 1 ; 108 ( 1 ): 48-55 .
tion was not notable. According to the literature review, 9. Mirabella AD, Artun J. Prevalence and severity of
teeth #11 and #21 can still be moved orthodontically apical root resorption of maxillary anterior teeth in
after endodontic treatment . The degree of apical root adult orthodontic patients. The European Journal of
resorption may not be affected due to the endodontic Orthodontics. 1995 Apr 1 ; 17 ( 2 ): 93 -9 .
treatment; however, it would be possible to have a high- 10. Parlange LM, Sims MR. A TEM stereological analysis
er tendency toward root resorption due to the history of of blood vessels and nerves in marmoset periodontal
intrusive luxation, although this has not been proven ligament following endodontics and magnetic inci-
with evidence . The five-year prognosis of endodontically sor extrusion . The European Journal of Orthodontics.
treated teeth is generally 80 to 84 per cent for teeth with 1993 Feb 1;15(1):33-44.
apical periodontitis. However, one study reveals a four- 11. Alhadainy HA, Flores-Mir C, Abdel-Karim AH,
year prognosis of 72 to 75 per cent in teeth with luxation Crossman J, El-Bialy T. Orthodontic-induced exter-
injuries; and 66.7 per cent among teeth presenting with nal root resorption of endodontically treated teeth:
a sinus tract (23 ). Hence , the endodontic prognosis of A meta- analysis . Journal of Endodontics . 2019 May
the teeth #11 and #21 in the present case may be lower 1;45(5):483-9.
than endodontically treated teeth in general. 12. International Association of Dental Traumatology
(IADT). Dental trauma guidelines. IADT; 2012.
Acknowledgment 13. American Association of Endodontics (AAE). The
This report was prepared and presented as part of the treatment of traumatic dental injuries. AAE; 2013.
requirements for the University of Toronto's Faculty of 14. Lam R. Epidemiology and outcomes of traumatic
Dentistry Clinical Conference Seminar Series PDE9094Y, dental injuries : A review of the literature . Australimi
directed by Dr. S-G Gong. The authors would like to Dental Journal. 2016 Mar;61:4-20.
thank Dr. Michael Tiedemann for the clinical care and 15. Kindelan SA, Day PF, Kindelan JD, Spencer JR, Dug-
photos of the root canal treatment. 1 gal MS. Dental trauma: an overview of its infiuence
on the management of orthodontic treatment . Part
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I 34 OD • September 2021
 Case Report

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dontic treatment on the integrity of endodontically |~ candidate at tile Faculty of Dentistry, University
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f*
lyll f
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