Endodontic-orthodontic relationships: a review of integrated treatment planning challenges

Literature review There is a paucity of information on the concise relationship between endodontics and orthodontics during treatment planning decisions. This relationship ranges from effects on the pulp from orthodontic treatment and the potential for resorption during tooth movement, to the clinical management of teeth requiring integrated endodontic and orthodontic treatment. This paper reviews the literature based on the definition of endodontics and the scope of endodontic practice as they relate to common orthodontic-endodontic treatment planning challenges. Literature data bases were accessed with a focus on orthodontic tooth movement and its impact on the viability of the dental pulp; its impact on root resorption in teeth with vital pulps and teeth with previous root canal treatment; the ability to move orthodontically teeth that were endodontically treated versus nonendodontically treated; the role of previous tooth trauma; the ability to move teeth orthodontically that have been subjected to endodontic surgery; the role of orthodontic treatment in the provision for and prognosis of endodontic treatment; and, the integrated role of orthodontics and endodontics in treatment planning tooth retention. Orthodontic tooth movement can cause degenerative and/or inflammatory responses in the dental pulp of teeth with completed apical formation. The impact of the tooth movement on the pulp is focused primarily on the neurovascular system, in which the release of specific neurotransmitters (neuropeptides) can influence both blood flow and cellular metabolism. The responses induced in these pulps may impact on the initiation and perpetuation of apical root remodelling or resorption during tooth movement. The incidence and severity of these changes may be influenced by previous or ongoing insults to the dental pulp, such as trauma or caries. Pulps in teeth with incomplete apical foramen, whilst not immune to adverse sequelae during tooth movement, have a reduced risk for these responses. Teeth with previous root canal treatment exhibit less propensity for apical root resorption during orthodontic tooth movement. Minimal resorptive/remodelling changes occur apically in teeth that are being moved orthodontically and that are well cleaned, shaped, and three-dimensionally obturated. This outcome would depend on the absence of coronal leakage or other avenues for bacterial ingress. A traumatized tooth can be moved orthodontically with minimal risk of resorption, provided the pulp has not been severely compromised (infected or necrotic). If there is evidence of pulpal demise, appropriate endodontic management is necessary prior to orthodontic treatment. If a previously traumatized tooth exhibits resorption, there is a greater chance that orthodontic tooth movement will enhance the resorptive process. If a tooth has been severely traumatized (intrusive luxation/avulsion) there may be a greater incidence of resorption with tooth movement. This can occur with or without previous endodontic treatment. Very little is known about the ability to move successfully teeth that have undergone periradicular surgical procedures. Likewise, little is known about the potential risks or sequelae involved in moving teeth that have had previous surgical intervention. Especially absent is the long-term prognosis of this type of treatment. During orthodontic tooth movement, the provision of endodontic treatment may be influenced by a number of factors, including but not limited to radiographic interpretation, accuracy of pulp testing, patient signs and symptoms, tooth isolation, access to the root canal, working length determination, and apical position of the canal obturation. Adjunctive orthodontic root extrusion and root separation are essential clinical procedures that will enhance the integrated treatment planning process of tooth retention in endodontic-orthodontic related cases.     

A novel multidisciplinary approach for the treatment of an intruded immature permanent incisor

The optimal treatment for intruded permanent teeth has not yet been determined. The ideal treatment option is the one with the lowest probability of developing complications such as external root resorption and marginal bone loss. Each case should be considered individually, bearing in mind the severity of the intrusion, the stage of root development, and tooth mobility. Management of an intruded permanent tooth may consist of: (1) observation for spontaneous eruption; (2) surgical crown uncovering; (3) orthodontic extrusion (with or without prior luxation of the intruded tooth); (4) and partial surgical extrusion, immediately followed by orthodontic extrusion and surgical repositioning. The purpose of this article was to review the treatment options for intruded immature permanent incisors, and to present a new modality of an elective internal strengthening of the immature root weakened by external root resorption. A case of an intrusive luxation injury in a 7 1/2-year-old child and the resulting complications utilizing this technique is described. This is the first known report in the pediatric dentistry literature of performing an elective (preventive) internal strengthening of an immature root weakened by severe external inflammatory resorption. The child was followed for 5 years with an excellent clinical outcome. This technique should be considered for treatment of immature permanent teeth with thin cervical root dentin and external or internal root resorption due to trauma or caries.     

微创牵引复位外伤挫入年轻恒牙的临床疗效观察

目的研究微创正畸牵引复位无自发萌出能力的外伤挫入年轻恒牙的临床疗效。 方法选择年轻恒牙外伤挫入的患者8例,年龄7~ 11岁,共11颗上颌切牙,其中9颗重度挫入、2颗中度挫入。观察1个月以上,确定无自发萌出能力后,采用如下微创正畸牵引方式复位：（1）"2 × 4"镍钛弓丝技术：单颗牙中度挫入,邻牙萌出3/4以上;（2）活动基托牵引：重度根向挫入、邻牙萌出不足1/2或伴脱位性损伤;（3）活动基托牵引联合"2 × 4"镍钛弓丝技术：重度唇向或腭向挫入,邻牙萌出不足1/2或伴脱位性损伤。观察治疗后患牙萌出状况、牙根吸收、边缘骨缺损和（或）牙髓变化情况。 结果（1）患牙萌出状况：所有挫入牙均复位;（2）牙根吸收情况：4颗牙出现轻微根吸收,2颗牙牵引前出现根尖部和根中段侧方低密度影,治疗完成时低密度影消退,余牙均无牙根吸收;（3）边缘骨缺损情况：除2颗牙外均无边缘骨缺损;（4）牙髓活力状况：3颗牙齿发育Nolla 10期的挫入牙,牵引前即行牙髓摘除术,4颗牵引中行牙髓摘除术,4颗牙髓活力正常,其中1颗根管钙化。 结论无萌出潜力的挫入年轻恒牙可根据其挫入方向及邻牙萌出程度和受伤情况,分别选择"2 × 4"镍钛弓丝技术、活动基托牵引技术或活动基托联合"2 × 4"镍钛弓丝牵引技术,及时进行微创牵引,可有效复位挫入牙,避免牙根吸收,减少边缘骨缺损,并可能保存活髓,值得进一步推广。     

Management of intrusive luxation of maxillary incisors with dens in dente: a case report

Abstract – Intrusive luxation is one of the most severe types of dental traumatic injuries. The risk of occurrence of pulpal necrosis and inflammatory or replacement resorption is high. In an attempt to prevent or delay the appearance of such lesions, endodontic intervention is required soon after the occurrence of trauma. A 17‐year‐old boy reported to the Department of Conservative dentistry and Endodontics, KLE VK Institute of Dental Sciences, Belgaum, 2 days after a fall from a bicycle. Clinical and radiographic examination revealed an intrusive luxation of the left maxillary central incisor and lateral incisor. There were complicated crown fracture with the right maxillary central incisor and uncomplicated crown fracture with the left maxillary central incisor. Also, all the incisors showed the presence of Oelhers type II Dens‐in‐dente. The management was hence challenging. Immediate surgical repositioning was performed and the teeth were stabilized with a composite resin splint. Endodontic therapy was initiated with the right maxillary central incisor, and the canal was sealed with calcium hydroxide dressing. After 3 weeks, pulp sensitivity was repeated with the maxillary left central and lateral incisors. The result was negative. Considering the incidence of pulp necrosis and root resorption in intruded teeth with complete root formation, they also were dealt in a similar manner as the maxillary right central incisor. The splint was removed after 1 month. After 6 months of calcium hydroxide therapy, there was a satisfactory apical and periodontal healing. At this stage, the teeth were obturated and the fractures were restored with composite resin. A 1‐year follow up revealed a satisfactory clinical and radiographic outcome.     

年轻恒牙挫入性损伤的处理策略

年轻恒牙挫入性损伤是预后最差的牙外伤类型之一,常导致牙齿缺失,影响患儿的美观及健康.治疗方案通常包括观察再萌出、正畸牵引复位和外科复位3种;临床上应根据患牙的牙根发育情况及挫入程度,参考患儿及家长意愿,选择单独或结合使用上述3种治疗方案进行治疗.治疗后的主要并发症包括牙髓坏死、牙根吸收、牙槽骨边缘性吸收、根管闭塞等.尽...     

Long-term Complications of Previously Successful Regenerative Endodontic Procedures after Orthodontic Movement: A Report of 3 Different Complications after 4, 8, and 11 Years

There is a paucity of literature on late complications of regenerative endodontic procedures. The aim of this article was to report 3 cases of previously successful regenerative endodontic procedures with long-term follow-up that developed different complications after the application of orthodontic forces. In the first case, an 8-year-old female patient received a regenerative endodontic procedure in her previously intruded tooth (tooth no. 21) that had been rendered necrotic after a successful spontaneous repositioning procedure. The 5-year follow-up revealed uneventful healing, continuous root development, dentinal wall thickening, and regaining of pulp vitality for tooth no. 21. Four years later, the patient received orthodontic treatment with mild forces that lasted 2 years. The 11-year follow-up revealed severe external invasive cervical resorption, and the tooth had to be extracted. In the second case, a 6-year-old female patient suffered a lateral luxation injury in tooth no. 11. Six months after the injury, the tooth developed symptoms and discoloration and tested negative in pulp vitality testing. Single-step regenerative endodontic procedures were applied, and successful continuous root development, dentinal wall thickening, and apical closure were achieved at the 3-year follow-up. Two months after the initiation of orthodontic treatment, the tooth developed symptomatic apical periodontitis. Root canal treatment was performed to treat the disease, and the orthodontic treatment was continued. In the third case, a previously published successful regenerative endodontic procedure developed a perforating internal resorption 6 months after the application of orthodontic forces. The internal resorption was arrested with root canal treatment, the resorptive defect was repaired with bioceramic obturation, and the orthodontic treatment plan was modified. Previously successful regenerative cases might develop external invasive cervical resorption, regenerative tissue necrosis, or internal resorption after the application of orthodontic forces. Best practice/evidence-based guidelines on the appropriate orthodontic management of successful regenerative endodontic therapy teeth are lacking. Whenever possible, careful monitoring and partial or complete exclusion off orthodontic treatment might be necessary. In some cases, preventive root canal treatment before the initiation of orthodontic movement might be considered.     

Orthodontic movement in traumatically intruded teeth: a case report

Abstract  – Intrusive luxation of permanent mature teeth is one of the most serious injuries to the periodontal ligament in dental traumatology. Various treatment approaches are currently practised. The treatment of choice for traumatically intruded teeth was to combine orthodontic repositioning and endodontic treatment. This case report describes the treatment of a 50-year-old male patient, with four completely intruded mature permanent maxillary incisors. Orthodontic extrusion was initiated 1 week after the trauma. After 10 days, the crowns of the teeth were exposed to start endodontic therapy. Nine weeks after the injury and 8 weeks after the beginning of orthodontic extrusion, the intruded incisors were back about to their original position before the displacement occurred. All treatment management as well as a follow-up 8 years after the trauma are described.     

Occurrence of pulp canal obliteration after luxation injuries in the permanent dentition

Abstract A material of 637 concussed, subluxated, extruded, laterally luxated and intruded permanent incisors was analyzed with respect to factors influencing the development of pulp canal obliteration (PCO) after injury. A total of 96 (15%) developed partial PCO; 9 of these (1% of the total material) went on to develop total PCO. Only 2 teeth exhibited yellow discoloration of the clinical crown and 1 showed grey discoloration. Sensibility to electrometric pulp testing of the teeth with PCO was not significantly different from sensibility of contralateral homologues at the final examination (except for after lateral luxation, where the teeth with PCO had a significantly lower perception threshold). PCO was significantly more frequent among teeth with incomplete root formation than in teeth where root formation was completed. Extrusion, lateral luxation and intrusion showed more frequent occurrence of PCO than did concussion and subluxation. Moreover, the use of orthodontic band/resin splints significantly increased the occurrence of PCO, presumably due to the additional trauma of forceful placement and cementation of orthodontic bands in contrast to the relatively passive placement of an acid-etch/resin splint. Based on previous and present clinical and radiographic findings concerning pulp response to luxation injuries, it is suggested that PCO is a sequel to revascularization and/or reinnervation of a damaged pulp after injury.     

Immediate vs late orthodontic extrusion of traumatically intruded teeth

Abstract –  Although the published papers about this matter is limited to clinical case reports, the aim of this review was to quantify the success rate of immediate vs late orthodontic extrusion of traumatically intruded teeth. From 55 reports in a PubMed and Medline computerized search, 13 reported patients involving 22 traumatically intruded anterior upper teeth with orthodontic extrusion were selected. In the sample of 13 patients, six were males and seven females and the average age was 16.4 years old. The selection criteria were patients presenting traumatized anterior upper teeth resulting in intrusive luxation, with at least 1 year follow-up period. Orthodontic extrusive forces were applied in the immediate group within 10 weeks post-trauma, while in the late group the forces were applied only after 3 months post-trauma. Immediate and late orthodontic extrusion was extremely favorable. The success rate (without or with complications) was 95.4% against only 4.5% (1 tooth) because of inflammatory root resorption with rapid progression. All mature teeth (100%) were endodontically treated. Among the 12 immature traumatically intruded teeth, eight were endodontically treated and four were not. A high rate of success was reported in the literature in traumatically intruded teeth orthodontically extruded, either immediate or late.     

Clinical and histological alterations in the surrounding periodontium of dog's teeth submitted for an intrusive luxation

Abstract –  The clinical and histological alterations on periodontium of dog's teeth after an intrusion luxation was analyzed. An impact device was used on 12 teeth of six adult dogs with the purpose of making a dislocation on the long axis of these teeth. Of the teeth that suffer intrusion luxation, two did not receive treatment and ten were replaced by orthodontic extrusion with activated springs of 100 gf. The traction was initiated either immediately after the trauma or 7 days later. Observation time was 40 days. Endodontic therapy with calcium hydroxide was performed on the fourteenth day after the intrusive luxation. The intruded teeth that did not receive appropriate treatment had signs of extensive and progressive inflammatory resorption. The teeth that were moved immediately after the trauma had lesser degree of replacement resorption compared with those that were extruded 7 days after the trauma.     

Longitudinal clinical and radiographic evaluation of severely intruded permanent incisors in a pediatric population

Abstract – Intrusion is defined as the axial dislodgment of the tooth into its socket and is considered one of the most severe types of dental trauma. This longitudinal outcome study was undertaken to evaluate clinically and radiographically severely intruded permanent incisors in a population of children and adolescents. All cases were treated between September 2003 and February 2008 in a dental trauma service. Clinical and radiographic data were collected from 12 patients (eight males and four females) that represented 15 permanent maxillary incisors. Mean age at the time of injury was 8 years and 9 months (range 7–14 years and 8 months). Mean time elapsed to follow‐up was 26.6 months (range 10–51 months). The analysis of data showed that tooth intrusion was twice as frequent in males. The maxillary central incisors were the most commonly intruded teeth (93.3%), and falling at home was the main etiologic factor (60%). More than half of the cases (53.3%) were multiple intrusions, 73.3% of the intruded teeth had incomplete root formation and 66.6% of the teeth suffered other injuries concomitant to intrusion. Immediate surgical repositioning was the treatment of choice in 66.7% of the cases, while watchful waiting for the tooth to return to its pre‐injury position was adopted in 33.3% of the cases. The teeth that suffered additional injuries to the intrusive luxation presented a fivefold increased relative risk of developing pulp necrosis. The immature teeth had six times more chances of presenting pulp canal obliteration that the mature teeth and a lower risk of developing root resorption. The most frequent post‐injury complications were pulp necrosis (73.3%), marginal bone loss (60%), inflammatory root resorption (40%), pulp canal obliteration (26.7%) and replacement root resorption (20%). From the results of this study, it was not possible to determine whether the type immediate treatment had any influence on the appearance of sequelae like pulp necrosis and root resorption after intrusive luxation, but the existence of additional injuries and the stage of root development influenced the clinical case outcome in a negative and positive manner, respectively.     

Effect of luxation injuries on permanent teeth

Abstract Trauma to the supporting tissues of the teeth are among the most common dental injuries, leading to such complications as pulp canal obliteration, necrosis and root resorption. The aim of this investigation was to study the outcome for young permanent teeth subjected to luxation injuries. From 108 dental records 171 teeth with injuries to the supporting tissue were selected. The material comprised 130 subluxated, 15 extruded, 9 intruded, 15 exarticulated and 6 laterally luxated teeth in children aged 6–19 years. Apart from luxation, 59 teeth (35%) had additional crown and root fractures. 65% of the teeth recovered without complications. 78% of the subluxated teeth and 24% of the luxated teeth showed uneventful posttraumatic healing. Concomitant uncomplicated crown fractures or root fractures without displacement of the coronal fragment did not interfere with the healing. Of 60 teeth with healing complications, 52 (87%) were subsequently recorded as healed, the remaining 8 were extracted or had progressive root resorption. Loss of pulp vitality and external root resorptions were the most often recorded complications (28% and 17% of the total material respectively). Pulp canal obliteration was noted in 3% of the cases. Extent of injury and degree of tooth maturity were found to be related to healing compliations.     

Effect of luxation injuries on permanent teeth.

Trauma to the supporting tissues of the teeth are among the most common dental injuries, leading to such complications as pulp canal obliteration, necrosis and root resorption. The aim of this investigation was to study the outcome for young permanent teeth subjected to luxation injuries. From 108 dental records 171 teeth with injuries to the supporting tissue were selected. The material comprised 130 subluxated, 15 extruded, 9 intruded, 15 exarticulated and 6 laterally luxated teeth in children aged 6-19 years. Apart from luxation, 59 teeth (35%) had additional crown and root fractures. 65% of the teeth recovered without complications. 78% of the subluxated teeth and 24% of the luxated teeth showed uneventful posttraumatic healing. Concomitant uncomplicated crown fractures or root fractures without displacement of the coronal fragment did not interfere with the healing. Of 60 teeth with healing complications, 52 (87%) were subsequently recorded as healed, the remaining 8 were extracted or had progressive root resorption. Loss of pulp vitality and external root resorptions were the most often recorded complications (28% and 17% of the total material respectively). Pulp canal obliteration was noted in 3% of the cases. Extent of injury and degree of tooth maturity were found to be related to healing complications.     

Management of Intruded Immature Maxillary Central Incisor with Pulp Necrosis and Severe External Resorption by Regenerative Approach

Introduction

Intrusive luxation is one of the most severe traumatic injuries of permanent teeth that may adversely affect the pulp and the periodontium. Pulp necrosis and root resorption are the main pathologic entities associated with this injury. The present report describes the endodontic management of an intruded immature maxillary central incisor presented with pulp necrosis and severe inflammatory root resorption by using the regenerative approach.

Management of bilateral impacted upper canines by single tooth dento-osseous osteotomy

When it is difficult to treat impacted teeth with orthodontic traction, surgical techniques including intentional luxation, autografts and distraction osteogenesis may be performed. However, these techniques are associated with problems such as root resorption, gingival recession and pulp circulatory disorders after extrusion. Single tooth dento-osseous osteotomy is considered to be a surgical technique with minimal effect on the pulp and periodontium. We used this method to treat a patient with impacted permanent canine teeth. After concomitant single tooth dento-osseous osteotomy and orthodontic treatment, root resorption of the bilateral canines was kept to a minimum and pulp vitality was confirmed. This method may be effective in patients in whom ordinary traction is difficult.     

Intrusive luxation of 60 permanent incisors: a retrospective study of treatment and outcome

Abstract – Background/Aim: Intrusive luxation in the permanent dentition is an uncommon injury but it is considered one of the most severe types of dental trauma because of the risk for damage to the periodontal ligament, pulp and alveolar bone. Management of intrusive luxation in the permanent dentition is controversial. The purpose of this study was to evaluate pulp survival and periodontal healing in intrusive luxated permanent teeth in relation to treatment alternatives, degree of intrusion and root development. Material and Method: The material consisted of 60 intruded permanent teeth in 48 patients (32 boys and 16 girls) aged 6–16 years (mean 9.4, median 9.0). The observation time was 6–130 months (mean 47.8, median 40.0). The analysed treatments were spontaneous re‐eruption (17 teeth), orthodontic extrusion (12 teeth) and surgical reposition (31 teeth). The degree of intrusion was registered as mild (0–3 mm), moderate (4–6 mm) and severe (≥7 mm). Root development was categorized with respect to root formation and development of the apex into four stages; one‐quarter to three‐quarters root formation, full root formation with open apex, full root formation with half‐closed apex and full root formation with apex closed. Ankylosis‐related resorption with pulp necrosis was diagnosed in 20 teeth, ingrowth of bone apically in two teeth, pulp necrosis without ankylosis‐related resorption in 23 teeth and pulp revitalization occurred in 15 teeth. Results: Significant correlations to the treatment outcome were root development (P = 0.03) and degree of intrusion (P = 0.03). Conclusions: No firm conclusion could be drawn for the difference in outcome between orthodontic extrusion and surgical reposition. To conclude, evaluation of the prognosis for intruded teeth should be based on the stage of root development and degree of intrusion. In teeth with immature root development, no active treatment appears to result in fewer healing complications.     

年轻恒牙震荡和移位后牙髓与牙根变化的临床研究

年轻恒牙外伤后,牙髓坏死和牙根吸收在牙齿震荡和牙齿移位中的发生率及发生的时间;牙根的表浅性吸收,置换性吸收,炎症性吸与外伤类型的关系。方法从１９８４－１９９６年在北京医科大学附属口腔医院儿科就诊的２０１例前牙外伤发生牙震荡和牙移位患者的病历资料中选择７９例１５７颗无冠折根折的外伤牙,并且如果有牙松动者使用全牙Ｈｅ     

Sequelae of trauma to primary maxillary incisors. I. Complications in the primary dentition

Abstract— Two hundred and eighty-seven children with a total of 545 traumatized primary upper incisors were followed using standardized procedures until the age of 10. Extraction was the only treatment offered when intervention was necessary. The immediate as well as the long-term consequences of trauma were studied on the basis of this material. Consequences in the primary dentition comprised: color changes (53%), pulp necrosis (25%), pulp canal obliteration (36%), gingival retraction (6%), permanent displacement after luxation (5–22%), pathological root resorption (1–10%) as well as disturbances in physiological root resorption (4%) and, lastly, premature tooth loss (46%). In a multivariate analysis of the development of pulp necrosis in primary teeth after trauma, the following decisive factors were found: age of the patient at the time of injury, degree of displacement of the tooth as well as the degree of loosening and presence of crown fracture. The factors found to influence development of pulp canal obliteration were: displacement of the tooth at time of injury as well as detectable physiologic root resorption at time of trauma. The presence of crown fracture seemed to decrease the risk of obliteration. The need for scientifically based treatment strategies for managing and reducing complications after trauma in the primary dentition is stressed.     

Treatment of aggressive external root resorption with calcium hydroxide medicaments: a case report

Abstract –  Intrusive luxation is an injury involving the axial displacement of a tooth into the alveolar socket. This paper describes apexification using calcium hydroxide medicaments of an immature permanent central incisor in which spontaneous re-eruption as well as severe inflammatory external root resorption was observed following traumatic intrusion. A 10-year-old boy was referred to the Department of Pediatric Dentistry 3 days after having fallen at school. Intraoral examination revealed intrusive luxation and an enamel-dentin crown fracture of the maxillary left central incisor (Tooth 21). The tooth was not sensitive to percussion and responded positively to electric pulp test. Radiographic examination indicated that the tooth had an open apex and had been intruded approximately 3–4 mm relative to the cemento-enamel junction of the adjacent right central incisor. The tooth was left for possible spontaneous re-eruption. The crown fracture was temporarily restored using glass ionomer cement, and the patient was scheduled for recall in 2 weeks, at which time intraoral examination revealed spontaneous re-eruption of the tooth. However, radiographic examination also showed inflammatory external root resorption. The root canal was accessed and filled with a calcium hydroxide paste; however, follow-up examination indicated continuing resorption after 1 month. Calcium hydroxide plus points (CHPP) was chosen as an alternative treatment. At the end of 6 months of CHPP treatment, examination showed no further progression of external resorption and complete apexification of the tooth. After a 24-month follow-up period, no signs of pathosis were observed.     

外伤及根管治疗后牙齿正畸移动研究进展

临床上,对病损患牙的正畸牙移动越来越多见,尤其是外伤及根管治疗术后的患牙,其牙髓坏死、牙根吸收等问题也受到重视。如何减少这些情况的发生,安全、有效地移动患牙,成为学者们研究的热点。文章就近年来国内外学者对外伤及根管治疗术后患牙的正畸牙移动时机、结果等做一综述,以期为患牙正畸移动的进一步研究提供理论依据。