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ENDODONTIC –
     ORTHODONTIC
   RELATIONSHIPS




   INDIAN DENTAL ACADEMY

Leader in Continuing Dental Education
    www.indiandentalacademy.com
CONTENTS

    INTRODUCTION
    EFFECT OF ORTHODONTICS ON THE TOOTH
     BEING MOVED
     ENDODONTIC CONSIDERATIONS RELATED
TO   ORTHODONTICS
    COMBINED ENDO - ORTHO THERAPY
    CONCLUSION
    REFERENCES
INTRODUCTION

   Orthodontic treatment

   The expanding role of endodontics

   Two major areas where Endodontics &

    Orthodontics share

           www.indiandentalacademy.com
EFFECT OF ORTHODONTICS ON THE
     TOOTH BEING MOVED

CAUSES    AND    EFFECT             OF
ORTHODONTIC FORCES ON PULP
    Degenerative or inflammatory
responses in the dental pulp

   Impact of the tooth movement on the
    pulp
CAUSES OF PULP NECROSIS

   Heavy continuous force

   Distal tipping of incisor

   Heat generated by grinding during
removal of ceramic brackets

   Labiolingual expansion appliance

            www.indiandentalacademy.com
EFFECT ON PULP
    Degree of dentinogenic activity
depends on the respiratory role of   pulp
    cells
     Pulp changes appear to be more
severe   with greater orthodontic force
    Alternation in pulpal vasculature with
subsequent     alternation in metabolism of
pulpal cells
    Pulp is very resilient, has greater
potential for healing
EVIDENCE OF PULP INVOLVEMENT

   Increased sensitivity

   Decreased pulp space

   Periapical radiolucency

   Internal resorption
RESORPTION DURING ORTHODONTIC
              THERAPY

    Orthodontically induced root resorption
     – surface       resorption, inflammatory
          resorption     or    rarely
replacement resorption
    External apical root
     resorption (EARR)
CAUSES
    Intrusive or tipping forces

              www.indiandentalacademy.com
EXTENT OF TOOTH MOVEMENT
    Directly proportional to the distance
through roots are moved.
TREATMENT DURATION
     Directly related to the treatment
duration
ROLE OF NEUROPEPTIDES
   Sensory A – delta, C-fibres and
sympathetic neurons
ROLE OF PHARMACOLOGICAL AGENTS
   NSAID’s
   Alcohol
   Corticosteroids
ENDODONTIC      TREATMENT                &
ORTHODONTIC ROOT RESORPTION
   Tooth with root canal treatment
   Previously traumatized or avulsed tooth
    Teeth that have been managed by
surgical endodontic procedure
TYPE OF CEMENTUM
     Acellular and cellular

AGE
     Resorption found more in older children
      than in younger children

TYPE OF APPLIANCE
     Fixed appliances are more detrimental
to    the roots
              www.indiandentalacademy.com
MAGNITUDE OF FORCE

     Continuous     heavy      forces cause

resorption


DIRECTION OF FORCE

      Prolonged       tipping        or   intrusion

movement     www.indiandentalacademy.com
ENDODONTIC CONSIDERATIONS
     RELATED TO ORTHODONTICS

WORKING LENGTH DETERMINATION
    Apical constriction destroyed
     Resorption   on   buccal   and   lingual
aspect
RADIOGRAPHIC INTERPRETATION
    Reflect osseous changes
ACCURACY OF PULP TESTING
    Presence of full metallic bands
TOOTH ISOLATION
   Tooth isolation compromised
ACCESS TO ROOT CANAL
   Alternation in access
DENS-IN DENTIN
   Internal resorption during orthodontic
movement




             www.indiandentalacademy.com
RISK OF RESORPTION
    Risk of external apical resorption
during    movement of any teeth
PRECAUTIONS       DURING      ORTHODONTIC
TREATMENT
    Periodical periapical radiographs
    Incases of severe resorption
    Rest periods of 2 – 3 months
    If resorption persists
ENDODONTIC – ORTHODONTIC
       COMBINED THERAPY
          FORCED ERUPTION
   Angle 1900
   Revised by Heithersay and Ingber




           www.indiandentalacademy.com
INDICATIONS
    Teeth with advanced caries
    Traumatic destruction of clinical crown
    Lateral root perforation
    External and internal root resorption
near alveolar crest
    Over zealous tooth preparation
    Isolated infrabony defects
   Eliminates the need for periodontal

surgery

    Extrusion     –    easiest     orthodontic

movement to     achieve

   20 – 30gram force required

     Preferred        only    in    anteriors    and

premolars     www.indiandentalacademy.com
BASIC PERIODONTAL
 PRINCIPLE FOR FORCED
       ERUPTION
      Biological width -
combined dimension of
supra alveolar gingival
connective     tissue   and
junctional epithelium –
2.04mm
       When the margin of
restoration being         placed,
      very      important      to
maintain      the health and
integrity  of          biological
     Distance from alveolar crest to the
     coronal   extent      of  the   tooth
structure should be > 4mm
    Biological width moves with the tooth
as   the tooth moved under control
orthodontic force
     End results of forced eruption
contributes   more    cosmetic  and
physiological restoration compared to
periodontal surgery
            www.indiandentalacademy.com
BASIC  ENDODONTIC         PRINCIPLES      FOR
FORCED ERUPTION
    Teeth that require endodontic therapy
should have treatment prior to initiation  of
    tooth movement
   Teeth with subalveolar fracture may have
    endodontic therapy through the    clinical
    crown.
     No contraindication to     complete
endodontic therapy while tooth     undergoing
orthodontic movement
    Gutta-percha is the filling material of
choice
BASIC     ORTHODONTIC             PRINCIPLES        FOR
TOOTH MOVEMENT

       Estimate   amount        of    attachment
apparatus remaining at the completion of
tooth movement must be made

   No tooth movement should be started –
    unless retention and stabilization

   Adequate anchorage must be available
               www.indiandentalacademy.com
    Uprighting and correction of axial tooth
    position

   This movement occurs in a vertical plane

    Only light force should be used to
extrude   the tooth (20 – 30gm)

    Stabilization of forced erupted tooth
prevents root back into the alveolus

   Minimum of 6 weeks of stabilization
PROCEDURE

If there is excessive destruction of clinical

                   crown




      A snughly fitting customized or

     prefabricated post is cemented
Brackets with horizontal slots are placed on
               multiple teeth


 Elastic ligature code tide from the loop to
              the rigid arch wire


Anchorage at least two teeth on either side
       of the tooth to be erupted
www.indiandentalacademy.com
Endodontic - orthodontic relation  /certified fixed orthodontic courses by Indian dental academy
REGAINING INTERPROXIMAL SPACE
     Described by Reagan
INDICATION
     A long standing carious lesion on the
      proximal surface results in migration
of    adjacent teeth into the void created by
      the caries.
PROCEDURE

   A core or foundation restoration placed
    in the tooth requiring restoration




   Tooth prepared for a full crown
    An acrylic crown fabricated, cemented and
then an orthodontic separator      inserted into
the proximal space.




     At subsequent appointment elastic is
removed and a piece of 0.6mm brass wire
threaded between the teeth apical to contact.
    Wire is twisted together until the patient
    feels pressure


    At approximately 1week intervals, wire is
    tightened until tooth shows no
movement


     Provisional restoration removed and the
     crown buildup back into contact with
adjacent tooth.
    Brass wire reapplied, as the tooth tipped,
     it may move upward into the occlusal
plane, as it does adjust occlusally.




     Then the full crown as the final
restoration fabricated and cemented
THERAPEUTIC ANKYLOSIS OF PRIMARY
                          TEETH

    Kokich first gave the concept

         Sheller   and     Omnell    gave   detailed
indications

INDICATIONS

    In young patients with mild
     to     moderate      retrusion
     of the maxilla
     Anchorage obtained by ankylosing primary
      canines

      Produces skeletal rather than dental
movement

PROCEDURE

    Under LA and mild sedation primary canines
                    extracted



    Endodontic treatment performed extraorally
A hook bonded to the labial surface of canine




 Before reimplantation periodontal ligament
  curetted, apical 2mm cut off, blood clot
         removed from the socket



       Tooth stabilized for 4-5 weeks

             www.indiandentalacademy.com
Protraction starts 8 weeks after surgery



            Check the occlusion



Retention of ankylosed ranged between 4-36
                   months



Time required for protraction about 6 months,
         ranging from 4 – 12 months
CONCLUSION
      A major percentage of orthodontic patients
presents a problem in terms of root resorption during
functional and esthetic benefits of the orthodontic
treatment. It is recommended that periodical
radiographic and careful clinical examination should
be done for any incipient periapical lesions and to
verify any unusual changes in pulp.

     A combined endodontic – orthodontic therapy
permits placement of a restoration that fulfills the
periodontal and occlusal requirements of the tooth.
REFERENCES

      Endodontic therapy, Franklin S.Weine, Mosby,
Pub.

      Future and advancement in conservative dentistry
       and endodontics (FACE 2)

      E.M. Al-wal, Internal root resorption from palatal
invagination, JCO, 1989 Dec. 802 – 803.

      Wein G et al, Forced eruption – an alternative to
extraction or periodontal surgery. JCO, 1992 Mar.
1-4.
                 www.indiandentalacademy.com
     W. Popp et al, Pulpal response to orthodontic

tooth movement, AJO, 1992 Mar. 1-7.

      Naphtali   et   al,   Orthodontically   induced

inflammatory root resorption, Angle Orthodontist, 2002;

72 : 175 – 184.

     Barbara Sheller, Therapeutic ankylosis of primary

      teeth, JCO, 1991 Aug. 499 - 502.
www.indiandentalacademy.com

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Endodontic - orthodontic relation /certified fixed orthodontic courses by Indian dental academy

  • 1. ENDODONTIC – ORTHODONTIC RELATIONSHIPS INDIAN DENTAL ACADEMY Leader in Continuing Dental Education www.indiandentalacademy.com
  • 2. CONTENTS  INTRODUCTION  EFFECT OF ORTHODONTICS ON THE TOOTH BEING MOVED  ENDODONTIC CONSIDERATIONS RELATED TO ORTHODONTICS  COMBINED ENDO - ORTHO THERAPY  CONCLUSION  REFERENCES
  • 3. INTRODUCTION  Orthodontic treatment  The expanding role of endodontics  Two major areas where Endodontics & Orthodontics share www.indiandentalacademy.com
  • 4. EFFECT OF ORTHODONTICS ON THE TOOTH BEING MOVED CAUSES AND EFFECT OF ORTHODONTIC FORCES ON PULP  Degenerative or inflammatory responses in the dental pulp  Impact of the tooth movement on the pulp
  • 5. CAUSES OF PULP NECROSIS  Heavy continuous force  Distal tipping of incisor  Heat generated by grinding during removal of ceramic brackets  Labiolingual expansion appliance www.indiandentalacademy.com
  • 6. EFFECT ON PULP  Degree of dentinogenic activity depends on the respiratory role of pulp cells  Pulp changes appear to be more severe with greater orthodontic force  Alternation in pulpal vasculature with subsequent alternation in metabolism of pulpal cells  Pulp is very resilient, has greater potential for healing
  • 7. EVIDENCE OF PULP INVOLVEMENT  Increased sensitivity  Decreased pulp space  Periapical radiolucency  Internal resorption
  • 8. RESORPTION DURING ORTHODONTIC THERAPY  Orthodontically induced root resorption – surface resorption, inflammatory resorption or rarely replacement resorption  External apical root resorption (EARR) CAUSES  Intrusive or tipping forces www.indiandentalacademy.com
  • 9. EXTENT OF TOOTH MOVEMENT  Directly proportional to the distance through roots are moved. TREATMENT DURATION  Directly related to the treatment duration ROLE OF NEUROPEPTIDES  Sensory A – delta, C-fibres and sympathetic neurons
  • 10. ROLE OF PHARMACOLOGICAL AGENTS  NSAID’s  Alcohol  Corticosteroids ENDODONTIC TREATMENT & ORTHODONTIC ROOT RESORPTION  Tooth with root canal treatment  Previously traumatized or avulsed tooth  Teeth that have been managed by surgical endodontic procedure
  • 11. TYPE OF CEMENTUM  Acellular and cellular AGE  Resorption found more in older children than in younger children TYPE OF APPLIANCE  Fixed appliances are more detrimental to the roots www.indiandentalacademy.com
  • 12. MAGNITUDE OF FORCE  Continuous heavy forces cause resorption DIRECTION OF FORCE  Prolonged tipping or intrusion movement www.indiandentalacademy.com
  • 13. ENDODONTIC CONSIDERATIONS RELATED TO ORTHODONTICS WORKING LENGTH DETERMINATION  Apical constriction destroyed  Resorption on buccal and lingual aspect RADIOGRAPHIC INTERPRETATION  Reflect osseous changes ACCURACY OF PULP TESTING  Presence of full metallic bands
  • 14. TOOTH ISOLATION  Tooth isolation compromised ACCESS TO ROOT CANAL  Alternation in access DENS-IN DENTIN  Internal resorption during orthodontic movement www.indiandentalacademy.com
  • 15. RISK OF RESORPTION  Risk of external apical resorption during movement of any teeth PRECAUTIONS DURING ORTHODONTIC TREATMENT  Periodical periapical radiographs  Incases of severe resorption  Rest periods of 2 – 3 months  If resorption persists
  • 16. ENDODONTIC – ORTHODONTIC COMBINED THERAPY FORCED ERUPTION  Angle 1900  Revised by Heithersay and Ingber www.indiandentalacademy.com
  • 17. INDICATIONS  Teeth with advanced caries  Traumatic destruction of clinical crown  Lateral root perforation  External and internal root resorption near alveolar crest  Over zealous tooth preparation  Isolated infrabony defects
  • 18. Eliminates the need for periodontal surgery  Extrusion – easiest orthodontic movement to achieve  20 – 30gram force required  Preferred only in anteriors and premolars www.indiandentalacademy.com
  • 19. BASIC PERIODONTAL PRINCIPLE FOR FORCED ERUPTION  Biological width - combined dimension of supra alveolar gingival connective tissue and junctional epithelium – 2.04mm  When the margin of restoration being placed, very important to maintain the health and integrity of biological
  • 20. Distance from alveolar crest to the coronal extent of the tooth structure should be > 4mm  Biological width moves with the tooth as the tooth moved under control orthodontic force  End results of forced eruption contributes more cosmetic and physiological restoration compared to periodontal surgery www.indiandentalacademy.com
  • 21. BASIC ENDODONTIC PRINCIPLES FOR FORCED ERUPTION  Teeth that require endodontic therapy should have treatment prior to initiation of tooth movement  Teeth with subalveolar fracture may have endodontic therapy through the clinical crown.  No contraindication to complete endodontic therapy while tooth undergoing orthodontic movement  Gutta-percha is the filling material of choice
  • 22. BASIC ORTHODONTIC PRINCIPLES FOR TOOTH MOVEMENT  Estimate amount of attachment apparatus remaining at the completion of tooth movement must be made  No tooth movement should be started – unless retention and stabilization  Adequate anchorage must be available www.indiandentalacademy.com
  • 23. Uprighting and correction of axial tooth position  This movement occurs in a vertical plane  Only light force should be used to extrude the tooth (20 – 30gm)  Stabilization of forced erupted tooth prevents root back into the alveolus  Minimum of 6 weeks of stabilization
  • 24. PROCEDURE If there is excessive destruction of clinical crown A snughly fitting customized or prefabricated post is cemented
  • 25. Brackets with horizontal slots are placed on multiple teeth Elastic ligature code tide from the loop to the rigid arch wire Anchorage at least two teeth on either side of the tooth to be erupted
  • 28. REGAINING INTERPROXIMAL SPACE  Described by Reagan INDICATION  A long standing carious lesion on the proximal surface results in migration of adjacent teeth into the void created by the caries.
  • 29. PROCEDURE  A core or foundation restoration placed in the tooth requiring restoration  Tooth prepared for a full crown
  • 30. An acrylic crown fabricated, cemented and then an orthodontic separator inserted into the proximal space.  At subsequent appointment elastic is removed and a piece of 0.6mm brass wire threaded between the teeth apical to contact.
  • 31. Wire is twisted together until the patient feels pressure  At approximately 1week intervals, wire is tightened until tooth shows no movement  Provisional restoration removed and the crown buildup back into contact with adjacent tooth.
  • 32. Brass wire reapplied, as the tooth tipped, it may move upward into the occlusal plane, as it does adjust occlusally.  Then the full crown as the final restoration fabricated and cemented
  • 33. THERAPEUTIC ANKYLOSIS OF PRIMARY TEETH  Kokich first gave the concept  Sheller and Omnell gave detailed indications INDICATIONS  In young patients with mild to moderate retrusion of the maxilla
  • 34. Anchorage obtained by ankylosing primary canines  Produces skeletal rather than dental movement PROCEDURE Under LA and mild sedation primary canines extracted Endodontic treatment performed extraorally
  • 35. A hook bonded to the labial surface of canine Before reimplantation periodontal ligament curetted, apical 2mm cut off, blood clot removed from the socket Tooth stabilized for 4-5 weeks www.indiandentalacademy.com
  • 36. Protraction starts 8 weeks after surgery Check the occlusion Retention of ankylosed ranged between 4-36 months Time required for protraction about 6 months, ranging from 4 – 12 months
  • 37. CONCLUSION A major percentage of orthodontic patients presents a problem in terms of root resorption during functional and esthetic benefits of the orthodontic treatment. It is recommended that periodical radiographic and careful clinical examination should be done for any incipient periapical lesions and to verify any unusual changes in pulp. A combined endodontic – orthodontic therapy permits placement of a restoration that fulfills the periodontal and occlusal requirements of the tooth.
  • 38. REFERENCES  Endodontic therapy, Franklin S.Weine, Mosby, Pub.  Future and advancement in conservative dentistry and endodontics (FACE 2)  E.M. Al-wal, Internal root resorption from palatal invagination, JCO, 1989 Dec. 802 – 803.  Wein G et al, Forced eruption – an alternative to extraction or periodontal surgery. JCO, 1992 Mar. 1-4. www.indiandentalacademy.com
  • 39. W. Popp et al, Pulpal response to orthodontic tooth movement, AJO, 1992 Mar. 1-7.  Naphtali et al, Orthodontically induced inflammatory root resorption, Angle Orthodontist, 2002; 72 : 175 – 184.  Barbara Sheller, Therapeutic ankylosis of primary teeth, JCO, 1991 Aug. 499 - 502.