Orthodontic, Periodontal & Endodontic Interactions PDF

ORTHODONTIC, PERIODONTAL & ENDODONTIC INTERACTIONS Dr. Sakshi Narayan, Dr. Iram Nasir, Dr. Shivani Patel Dr. Melcos, Dr. Camacho, Dr. Pinheiro Interdisciplinary Care November 21, 2024  INTRODUCTION...

ORTHODONTIC, PERIODONTAL & ENDODONTIC INTERACTIONS Dr. Sakshi Narayan, Dr. Iram Nasir, Dr. Shivani Patel Dr. Melcos, Dr. Camacho, Dr. Pinheiro Interdisciplinary Care November 21, 2024  INTRODUCTION There are often challenges in the diagnosis, treatment and prognosis of combined Orthodontic, Periodontal and Endodontics cases periodontics Understanding the interaction between different streams of dentistry is essential for the clinicians Orthodontic Advancements in the ortho techniques and more esthetic interaction fixed appliance options have motivated more adult patents to seek ORTHO TX with Many of these adults have periodontal complications Endodontics TH E ORT HODONTICS -PERIODONTICS CH AL LENGES IN INT EGRATED T REATMENT: A COMPREH ENS IVE RE VI EW Alsulaimani L, Alqarni H, Akel M, Khalifa F. The Orthodontics-Periodontics Challenges in Integrated Treatment: A Comprehensive Review. Cureus. 2023;15(5):e38994. Published 2023 May 14. doi:10.7759/cureus.38994 This review aimed to provide a comprehensive understanding of the orthodontic- periodontic relationship for optimizing therapeutic strategies and achieving the best treatment outcomes in patients INTRODUCTION & B ACKGROUND Tooth movement during orthodontic therapy is accomplished through bone remodeling of the alveolus The periodontal ligament facilitates the bone remodeling response, tooth movement depends on the periodontal ligament, which in turn, relies on a healthy periodontium. Consequently, periodontal treatment is essential throughout most phases of orthodontic therapy, beginning with the orthodontic diagnosis and continuing through to mid-treatment periodontal assessment and post-treatment evaluation INTRODUCTION & B ACKGROUND CONTINUED Common orthodontic issues typically seen in patients with compromised periodontal health: ○ maxillary anterior teeth proclination, absence or loss of interdental spacing, rotated teeth, super-eruption, pathologic tooth migration, tooth loss, traumatic occlusion Orthodontic treatment may be warranted during periodontal treatment: ○ teeth may be orthodontically moved to facilitate oral hygiene and reduce bacterial loading and biofilm formation, correcting abnormal gingival and bone patterns, improving appearance, and aiding prosthetic replacement To enhance the overall treatment outcome, the periodontist and the orthodontist must collaboratively evaluate all periodontal situations and select the most appropriate orthodontic interventions DISCUSSION: ORAL HYGIENE MAINTENANCE Gingival inflammation is maintained under control --> orthodontic therapy does not adversely affect periodontal attachments Orthodontics can be considered a risk factor for periodontal disease if effective oral hygiene compromised Mal-aligned dentition --> effective oral hygiene can be challenging due to the difficulty in reaching all the areas during toothbrushing and flossing ○ --> increased inflammation and bleeding Only a few clinical researchers have reported on periodontal disease and significant clinical attachment loss (CAL) in the maxilla and mandible in orthodontic patients ○ poor oral hygiene in the molar regions due to the presence of molar bands --> food impaction A comprehensive dental care regimen is implemented during orthodontic therapy --> adverse change (ie gingival bleeding or dental plaque quantity) is limited. ○ by facilitating plaque removal --> better periodontal condition achieved  FIXED LINGUAL RETAINER Fig.1 Fixed retainer made of rectangular braided wire bonded to all mandibular incisors and canines. Approximately 4 years after retainer placement and hygiene instructions it is clear that inadequate hygiene resulted in accumulation of supra- and subgingival calculus with concomitant gingivitis Prompt action is necessary - consideration of removing the fixed retainer ○ This decision should be accompanied by a thoughtful evaluation of alternative retention strategies, (ie. removable retainers) tailored to the patient’s evolving oral health needs Fudalej PS, Wegrodzka E. Periodontal implications of fixed retainers. Seminars in Orthodontics. 2024; 30(2):225-231. https://doi.org/10.1053/j.sodo.2023.11.007 DISCUSSION: BRACKET POSITIONS AND MOLAR BAND PLACEMENTS Subgingivally placed orthodontic bands may encroach on the alveolar bone Banding (vs. bonding) associated with increased inflammation and more severe attachment loss Gingival hyperplasia due to the presence of orthodontic bands --> “pseudo periodontal pockets” ○ Gingival hyperplasia generally resolves within a few weeks of disbanding ○ To minimize hyperplasia: ensure that the slots on orthodontic bands are positioned perpendicularly to the tooth's long axis rather than being aligned with the aligned parallel to the occlusal plane If brackets are placed relying on incisal edges, the increased root divergence could result in an open gingival embrasure that is unsightly For periodontal causes, orthodontic treatment using The Clear Aligner system appears to be significantly more beneficial in patients with intact periodontium than lingually or labially fixed appliances DIS CUS SI ON: ORTH ODONT IC FORCES AND PERIODONTAL HEALTH Compromised periodontium – light continuous light forces between 5g and 15 g recommended Time it takes for tooth mobility to begin after periodontal surgery ranges from seven days to one year Several studies have revealed that the degree of root resorption increases as force magnitude increases ○ whether the presence of continuous or intermittent pressures is linked to an increased risk of root resorption is determined by the magnitude of the force Many researchers agree that using intermittent forces --> minimal root resorption ○ disrupted cementum is given time to heal in between tooth movements DISCUSSION: ORTHODONTIC TREATMENT IN SUPPLEMENT TO PERIODONTAL THERAPY Orthodontic therapy may be used in conjunction with periodontal treatment Orthodontic procedures (ie. uprighting of teeth, intrusion, and rotation) ○ used to correct pathologically migrated teeth to arrest the progress of periodontal disease and enhance the patient’s quality of life by improving oral function and appearance Orthodontics should only be carried out if active periodontal disease has been successfully managed DISCUSSION: TEETH MOVEMENT ASSOCIATION WITH INFRA-BONY DEF ECTS Orthodontic movement in teeth with infra-bony defects possible ○ --> no inflammation and the presence of appropriate bacterial plaque control Limited evidence from clinical studies: tooth movement through an intra-bony defect is thought to occur by "carrying the bone" with the tooth ○ improving the bone defect and positions of teeth close to an implant or replacement tooth  MUCOGINGIVAL DEF ORMITY Patients may have an increased risk of developing a mucogingival deformity ○ common if any buccal movement of teeth is planned orthodontically Prior to initiating orthodontic treatment --> careful mucogingival evaluation (part of a comprehensive periodontal evaluation) Mucogingival evaluation should include measuring the width of attached gingiva, the amount of gingival recession, any high frenal attachment, etc. A patient presenting with a labially displaced tooth and a corresponding mucogingival deformity --> orthodontic evaluation and therapy may be considered as the first treatment option vs. periodontal mucogingival therapy (a) Intial Kwon TH, Salem DH, Levin L. Periodontal considerations in orthodontic treatment: A review of the literature and (b) Post orthodontic treatment recommended protocols. Seminars in Orthodontics. 2024; 30(2):80−88. https://doi.org/10.1053/j.sodo.2023.11.007  BONE DEFECTS Morphology of the defect, plaque control, and patient compliance o directly affect the predictability of periodontal regeneration Defect selection is critical to achieve a successful outcome Deep and narrow defects show the most predictable positive response to regenerative procedures o shallow defects --> show poor results In such a scenario, orthodontic intrusion can change a horizontal bone defect into a deep and narrow defect that is more favorable for regeneration of the periodontium through grafting procedures (a) Severe bone loss, spacing and extrusion of incisors. Horizontal defect (H) around maxillary left central incisor. (b) Orthodontic intrusion changes the topography of the defect into a vertical (V) defect and narrow defect. (c) Orthodontic intrusion in the presented case changing the topography of the original horizontal defect. (d) One wall defect in relation to right central incisor prior to periodontal regenerative surgery DISCUSSION: ORTHODONTIC EXTRUSION Orthodontic extrusion (“forced eruption”) involves the repositioning of the intact connective tissue attachment of a tooth in a more coronal position, followed by bone deposition ○ increase the clinical crown height and/or change the height of the free gingival margin As clinical attachment is associated with the cementoenamel junction (CEJ), the crestal bone is approximately preserved ○ crestal bone associated with the extruded tooth and the adjacent teeth are increased (or remodeled) --> shallowing out the intraosseous deformities Clinical crown lengthening --> orthodontic extrusion with supra-gingival fibrotomy suggested ○ osteotomy of the crestal bone is not indicated Orthodontic extrusion may be a viable option for treating vertical periodontal defects ○ ie. dental extrusion of an irreversible tooth before implant = effective option for bone augmentation in implant recipient site --> buccolingual thickness of alveolar ridge should also be increased ▪ Recommendation = extrude the tooth progressively using constant low forces (no more than 2 mm of labial root torque occurs every month) ▪ Prior to tooth extraction – retention duration of more than 1 month desirable EXTRUSI ON FOR CROWN L ENGTH ENI NG Orthodontic extrusion utilized for crown lengthening on UR2 Light continuous force (15- 50cN) and extrusion rate no more than 2mm per month Pre-requisite to this procedure being effective = apical 1/3 of the root needs to have an intact fiber apparatus ○ absence of systemic diseases like DM can impair bone healing Antonarakis GS, Zekeridou A, Kiliaridis S, Giannopoulou C. Periodontal considerations during orthodontic intrusion and extrusion in healthy and reduced periodontium. Periodontology 2000. 2024; 00:1-25. doi:10.1111/prd.12578 DISCUSSION: ORTHODONTIC INTRUSION Essential to keep teeth in the intruded position for least 6 months ○ allow the principal periodontal fibers to adjust to the newly intruded position Oral hygiene maintained properly --> the application of intrusive orthodontic forces may encourage favorable periodontal modifications Poor oral care --> intrusive movements may encourage the development of bacterial plaque in the subgingival region and exacerbate the continuing periodontal destruction process Active intrusion of a tooth --> proficient supragingival and subgingival debridement is essential ○ light forces, ranging from 5 g to 15 g per tooth (also decrease the risk of root resorption) Furcation defects require extra and focused care Guided tissue regeneration (GTR) procedures prior to orthodontic intrusion leads to new bone growth and gingival reattachment  INTRUSION Intrusion arch utilized Leveling of gingival margins --> gingival margin in these cases will move apically together with the tooth Antonarakis GS, Zekeridou A, Kiliaridis S, Giannopoulou C. Periodontal considerations during orthodontic intrusion and extrusion in healthy and reduced periodontium. Periodontology 2000. 2024; 00:1-25. doi:10.1111/prd.12578 DISCUSSION: UPRIGHTING PERMANENT MOLARS The upright of mesially inclined molars involves distal tooth movements --> enables the mesial defect to be filled with alveolar bone ○ gingival overgrowth and plaque retentive region on the mesial side are also removed The mesial inclination of the second molar (particularly the lower one) caused by the absence of the first molar = a common clinical finding Risk of developing localized periodontitis is increased by this mesial inclination Orthodontic uprighting = widely regarded as a beneficial treatment for reducing or eliminating existing periodontal problems Orthodontic uprighting of mesially inclined teeth ---> not been associated with subsequent pocket development, improvement, or elimination DISCUSSION: PERIODONTAL THERAPY AS A SUPPLEMENT TO ORTHODONTIC THERAPY Periodontal treatment is recommended prior to orthodontic treatment --> reduce inflammation Mild to moderate periodontal pockets present --> phase 2 (surgical) periodontal treatment is initiated if better plaque control and bleeding on probing could be achieved, regardless of the orthodontic treatment Even though pocket depths and bleeding on probing cannot be eliminated following initial periodontal treatment, open-flap debridement is still recommended as the first step Before proceeding with orthodontic tooth movement, regenerative periodontal therapy may be recommended in cases with shallow osseous crater-type bone defects (ie. pocket depths of 4-5 mm) ○ deep intra-bony defects or deep osseous crater-type bone defects, may not improve with orthodontic treatment ○ unfavorable crown-root ration and CAL after osseous resection, complete cleaning of deep periodontal defects is impossible Periodontal therapy must be completed 3-6 months before the initiation of orthodontic treatment DISCUSSION: PROCLINATION OR LABIAL TOOTH MOVEMENTS Proclination of teeth (labial tooth movements) = most practical way to treat dental crowding ○ frequently believed to be the cause of gingival recession, but not always ○ areas with a low resistance to inflammation or trauma --> dehiscence of thin soft tissues or bones may result Lingual tooth movements can cause increased labiolingual gingival widths and slight incisal gingival migration ○ labial movements cause the opposite 2 mm of keratinized gingiva is needed for good periodontal health Orthodontic forces lead to tension on the gingival margin --> gingival recession results Increased risk of recession and attachment loss by orthodontic proclination of the incisors (ie. areas where gingival and bone support are lacking – lower incisors)  ORTHODONTICS AID TO REPAIR RECESSION Fig 2 A: LR1 has recession & outside alveolar housing B: Applied lingual root torque on LR1 C: Before pt was referred back to the periodontist D: 5 mo after mucogingical surgery with coronally advanced flap combined with enamel matrix proteins Fig 1 LL1 has recession & outside alveolar housing Applied lingual root torque on LL1 Laursen MG, Rylev M, Melsen B. The role of orthodontics in the repair of gingival recessions. Am Root position corrected and recession reduced J Orthod Dentofacial Orthop, 2020; 157(3): 29 – 34. https://doi.org/10.1016/j.ajodo.2019.01.023  DISCUSSION: UNEQUAL GINGIVAL MARGINS Overall esthetic appeal --> the evenness of the gingival margin of the six maxillary anterior teeth is crucial For a balanced and attractive smile, the gingival margins of the maxillary central incisors should be set 1 mm below their CEJ and at the same level as the cuspid margins ○ teeth adjacent to the lateral incisor may have a lower margin of 1-2 mm Variations in the gingival position or ectopic tooth eruption may lead to differences in the gingival margin level ○ no need to make any adjustments if the uneven gingival margin is not visibl Light orthodontic forces should be used to intrude overerupted teeth Lower the risk of relapse, orthodontic intrusion should be completed 6 months before appliance removal DISCUSSION: THE MISSING INTERDENTAL PAPILLA Crucial esthetic aspect of someone’s appearance --> papilla between maxillary central incisors ○ missing gingival papillae or open gingival embrasures can be a challenge to treat with periodontal treatment and where orthodontic treatment may help Open interdental space is generally caused by three aspects: 1) the shape of the tooth, 2) the angle of the root, 3) bone loss Assess: (1) the distance between the contact points as well as the bone crest, (2) the papillary height as in the interdental space, (3) the extent of root divergence (4) the tooth form First, it is important to determine whether the tooth contacts or the papilla are responsible for the issue ○ papilla = issue --> the underlying periodontal problem is likely the cause of the lack of bone support Many open embrasures have been induced by tooth contact issues DISCUSSION: EXCESSIVE GINGIVAL DISPLAY Current esthetic standards --> the maxillary gingival display in an appealing individual smile should be around 1-2 mm ○ extent of gingival display varies the greatest among children and gradually reduces with age Before starting orthodontic treatment, gummy smiles should be evaluated to determine possible etiology ○ ie. gummy smiles may be caused by a dynamic upper lip, an abnormally short lip, excessive lower facial height, a significant increase in the vertical dimension of the maxilla, extrusion of the anterior dental alveolus, or a shortened clinical crown Certain patients occasionally experience significant delays in the gingival margins' physiological apical migration, together with probing depths of 3-4 mm in the gingival sulcus ○ short clinical crown and a significantly increased labiolingual gingival tissue thickness = two key clinical hallmarks of this gummy smile. Gummy smiles produced by a low upper lip philtrum can be treated neuromuscularly (ie. Botox) --> good but transitory results DISCUSSION: ORTHODONTICS WITH CORTICOTOMY Multiple forms of corticotomy-assisted orthodontics (CAO) have been used to speed up orthodontic treatment Henry Köle developed corticotomy, a fast method of tooth movement, in 1959 Widely accepted that the bone's cortical plates pose the greatest challenge to orthodontic tooth movements In CAO, dental and marginal periodontal health are preserved, while a precise cut is made to disrupt the continuity of the cortical bone to accelerate tooth movement 3 key operations comprise Köle's surgical method: 1) a vertical lingual incision, 2) a vertical buccal incision, 3) a subapical horizontal osteotomy ○ not widely used due to high level of trauma and poor patient acceptance DISCUSSION: PERIODONTALLY ACCELERATED OSTEOGENIC ORTHODONTICS Periodontally accelerated osteogenic orthodontics (PAOO) = rapid osteogenic orthodontic approach ○ aka “Wilckodontics” (the technique was reported by Wilcko et al. in 2001) Elevate full-thickness labial and lingual flaps, insert bone grafts, close the flaps surgically, and then apply orthodontic forces to teeth This treatment requires further labial and lingual cortical bone surgery (corticotomy) and may scar Benefits of PAOO: ○ a) PAOO after surgery has greater stability than conventional orthodontic treatment ○ b) Provides the least resistance to tooth movement where the bone has been removed, while the bone that has been preserved is less impacted by tooth movement overall ○ c) Bone grafting increases the quantity of alveolar bone, and strengthens the periodontal tissue --> reduces the need for anchoring devices ○ d) Root resorption is reduced, and anatomical variations are preserved. Several studies have suggested that PAOO decreases both the resistance to tooth movements and the force used during tooth movements DISCUSSION: MODERN SURGICAL METHODS Ultrasonic-assisted approach (piezopuncture) was examined by Kim et al. in 2013 ○ ultrasonic surgical equipment is used to penetrate the bony cortex via the surrounding associated gingiva. A clinical study by Alikhani examined the impact of micro-osteoperforations (MOPs) on the rate of tooth movement ○ results showed that MOPs increased the speed of tooth movement by a rate of 2.3 In contrast, several systematic reviews have concluded that the MOPs approach does not speed up tooth movements Inadequate evidence to support the use of MOPs alone for facilitating rapid tooth movements DISCUSSION: PIEZ OCISION-FACILITATED ORTHODONTICS In 2020, Sivarajan et al. created a cutting-edge minimally invasive surgical method namely piezosurgery ○ facilitates rapid tooth movements, without the need for protracted treatment or risky surgical procedures ○ tunnel technique and bone and soft tissue grafting are preserved in this method Piezosurgery appears to have additional advantages - safer, less traumatic, and less invasive Certain circumstances, piezocision may be combined with Invisalign to reduce treatment time, while also meeting the patient’s expectation for an esthetic appliance The literature shows that, unlike traditional orthodontics, Piezosurgery method does not cause any further root resorption or periodontal trauma CONCLUSION Orthodontics and periodontal health are intimately associated On the one hand, orthodontics may eliminate areas that retain plaque On the other hand, a dynamic periodontium is essential in facilitating orthodontic tooth movements Increasing number of adults are considering orthodontic treatment as a result of changing lifestyles and aspirations In these circumstances, an integrated orthodontics periodontics approach is helpful and can contribute to ideal qualitative, functional, as well as esthetic planning, leading to optimized treatment plans, especially in complex clinical cases New periodontal surgical techniques, such as PAOO and piezocision, may enhance orthodontic tooth movements, leading to decreased treatment timeframes, while simultaneously boosting treatment effectiveness C AS E REPORT Plan: 1. Phase I therapy comprising of scaling and root planing before orthodontic treatment 2. 2. Alignment of the teeth with light forces using copper NITI wires after extraction of 15, 24, 34, and 44. 3. 3. Continuous monitoring of periodontal health with periodic scaling and root planing and administration of Gengigel (0.8% hyaluronic acid) to improve the attachment was coordinated by the periodontist. 2 Ramachandra CS, Shetty PC, Rege S, Shah C. Ortho-perio integrated approach in periodontally compromised patients. J Indian Soc Periodontol. 2011;15(4):414-417. doi:10.4103/0972-124X.92583  C ASE REPORT 3 Ramachandra CS, Shetty PC, Rege S, Shah C. Ortho-perio integrated approach in periodontally 4 compromised patients. J Indian Soc Periodontol. 2011;15(4):414-417. doi:10.4103/0972-124X.92583  C ASE REPORT 5 Ramachandra CS, Shetty PC, Rege S, Shah C. Ortho-perio integrated approach in periodontally 6 compromised patients. J Indian Soc Periodontol. 2011;15(4):414-417. doi:10.4103/0972-124X.92583  C ASE REPORT 7 Ramachandra CS, Shetty PC, Rege S, Shah C. Ortho- perio integrated approach in periodontally compromised patients. J Indian Soc Periodontol. 2011;15(4):414-417. doi:10.4103/0972-124X.92583 8 CASE – ORTHO/PERIO ID:221118286 46 y/o caucasian female Cc: "I want my teeth straight" Invisalign treatment –CRW on LR6 6/26 month Referred for periodontal consult for moderate horizontal bone loss INITIAL: 01/06/23 PROGRESS: 10/11/23 Left side Right side  Left side Right side 10/11/2023: Appointment Mobility Grade I on LR2, LL2 At REFINEMENT, we need to add... ○ Lingual Crown torque REFLECTION ○ Only soft tissue (free gingival graft) was done with periodontist. ○ What would have helped? Hard tissue bone graft! REFERENCES Alsulaimani L, Alqarni H, Akel M, Khalifa F. The Orthodontics-Periodontics Challenges in Integrated Treatment: A Comprehensive Review. Cureus. 2023;15(5):e38994. Published 2023 May 14. doi:10.7759/cureus.38994 Antonarakis GS, Zekeridou A, Kiliaridis S, Giannopoulou C. Periodontal considerations during orthodontic intrusion and extrusion in healthy and reduced periodontium. Periodontology 2000. 2024; 00:1-25. doi:10.1111/prd.12578 Fudalej PS, Wegrodzka E. Periodontal implications of fixed retainers. Seminars in Orthodontics. 2024; 30(2):225-231. https://doi.org/10.1053/j.sodo.2023.11.007 Kwon TH, Salem DH, Levin L. Periodontal considerations in orthodontic treatment: A review of the literature and recommended protocols. Seminars in Orthodontics. 2024; 30(2):80−88. https://doi.org/10.1053/j.sodo.2023.11.007 Laursen MG, Rylev M, Melsen B. The role of orthodontics in the repair of gingival recessions. Am J Orthod Dentofacial Orthop, 2020; 157(3): 29 – 34. https://doi.org/10.1016/j.ajodo.2019.01.023 Ramachandra CS, Shetty PC, Rege S, Shah C. Ortho-perio integrated approach in periodontally compromised patients. J Indian Soc Periodontol. 2011;15(4):414-417. doi:10.4103/0972- 124X.92583  RELATIONSHIP – ORTHO-ENDO Endo – SOS : Indications for using orthodontic extrusion 1. Fractures below 2. Deep caries in the bone crest and teeth requiring 3. Perforating the tooth is still endodontic resorptions. rehabilitable. treatment. 5. Infraosseous 4. Errors during defects. opening.  RELATIONSHIP – ORTHO-ENDO The diagnosis appers to be…… ThePhoto by PhotoAuthor is licensed under CCYYSA. Asyntomatic Apical Periodontitis Cronical AA AIP, PN- SAP, with CO Endo-Perio. Root fracture Hey Houston, We’ve had a problem here What is the principal problem in the relationship Ortho- Endo? Parachos P. Endodontic- Orthodontic interact ions: a Revi ew and t reatment recommendat ions. Australian dental Journal 2023. EARR. 73-100% Levander, E., & Malmgren, O. (1988). "Evaluation of the risk of root resorption during orthodontic treatment: A study of upper incisors." European Journal of Orthodontics, 10(1), 30-38. Brezniak, N., & Wasserstein, A. (2002). "Orthodontically induced inflammatory root resorption. Part I: The basic science aspects." Angle Orthodontist, 72(2), 175-179. Mirabella, A. D., & Årtun, J. (1995). "Prevalence and severity of apical root resorption of maxillary anterior teeth in adult orthodontic patients." European Journal of Orthodontics, 17(2), 93-99. Burnheimer, J., Baxter D.,Deeley K., Vieira A., Berzamat M.l (2024) " Eploring etiologic contributions to the occurrence of external apical root resoption". AJO- DO, 166 (4) 356-362 Severe resoption 5-6%  Physiology Factors that increase apical root cementum Age Hypercementosis Occlusal trauma Chronic low-grade inflammation Systemic diseases ( hypothyroidism, arthritis) Genetic factors Orthodontic movements Loss of antagonist Chronic low-grade periapical lesion ThePhoto by PhotoAuthor is licensed under CCYYSA.  Factors that decrease apical root cementum Active periapical lesion External root resorption Bacterial infections Systemic conditions affecting bone metabolism ( osteoporosis, vitamin D or calcium deficiency) Prolonged use of corticosteroids or bisphosphonates  HOW DOES THE ORTHODONTICS EFFECT THE PULP? Alteration of the blood The consequences of vessels in the periodontium this pulpal alteration \ are proportional to the Impacts the metabolism of the dental amount of force pulp exerted on that tooth. Pulpal blood flow Hamilton. Gutmann. Endodontic-orthodontic relationships: a review of integrated treatment planning challenges. International Endodontic Journal, 32, 343±360, 1999.  Effects on Pulp from Orthodontic Treatment As a defense mechanism against the aggression caused by movement, the pulp is aided by The presence of neuropeptides Angiogenesis Process of new blood vessel formation Substance P Calcitonin Gene-Related Peptide For which it requires growth factors such (CGRP) as Neurokinin A Vasoactive Intestinal Peptide (VIP) Epidermal Growth Factor (EGF) Neuropeptide Y Platelet-Derived Growth Factor (PDGF) Transforming Growth Factor Beta (TGF-β) Hamilton. Gutmann. Endodontic-orthodontic relationships: a review of integrated treatment planning challenges. International Endodontic Journal, 32, 343±360, 1999.  Pulpal Inflammation Caused by Orthodontic Treatment The presence of neuropeptides As forces sufficient to avoid pulp damage: Necrosis or OEIRR Type of Movement Force Substance P Calcitonin Gene-Related Peptide (CGRP) Tipping 35- 60 Neurokinin A Translation 70-120 Vasoactive Intestinal Peptide (VIP) Neuropeptide Y Rotation 35-60 Intrusion 10-20 They regulate the pulpal blood flow and that of the apical periodontium where the force is applied Hamilton. Gutmann. Endodontic-orthodontic relationships: a review of integrated treatment planning challenges. International Endodontic Journal, 32, 343±360, 1999. Burnheimer, J., Baxter D.,Deeley K., Vieira A., Berzamat M.l (2024) " Eploring etiologic contributions to the occurrence of external apical root resoption". AJO-DO, 166 (4) 356-362  Non-vital teeth: effects on teeth with prior endodontic treatment. Vital Teeth Non-vital Teeth They can be moved in the same way. They can be moved the same distance. Non-vital teeth are less prone to resorption Hamilton. Gutmann. Endodontic-orthodontic relationships: a review of integrated treatment planning challenges. International Endodontic Journal, 32, 343±360, 1999.  F AC T O R S R E L AT I N G TO E X T E R N A L A P I C A L RO O T R E S O R P T I O N ( E A R R ) I N O RT H O D O N T I C M O V E M E N T Previous Malocclusion Medical history: Genetic factors: Tooth anatomy: endodontic factors: Occlusal treatment: Ashma, endocrine, Latinos short root trauma. Overjet. allergies. Depend diagnosis Orthodontics: Heavy forces- tooth Long treatment Intrusion extraction. accelerate  Root resoption index Parachos P. Endodontic- Orthodontic interactions: a Review and treatment recommendations. Australian dental Journal 2023. 11/20/2024 DENTAL T RAUMA F R ACT UR E IN JUR IE S L U X AT IO N I NJ U R IE S TREATMENT PLAN AFTER TRAUMA ORTHODONTIC MANAGEMENT AFTER TRAUMA  O RT H OD O NT I CS A S AN AD J UNC T TO P OS T T R AU MA T R EAT M E NT Primary treatment ▪ Immediate interventions focus on stabilization and realignment. Australian Dental Journal, Volume: 61, Issue: S1, Pages: 21-38, First published: 29 Febr uary 2016, DOI: (10.1111/adj.12396)  O RT H OD O NT I CS A S AN AD J UNC T TO P OS T T R AU MA T R EAT M E NT Secondary treatment oBiomechanics play a critical role in the treatment process. oLong-term management includes oongoing care and treatment evaluation.  C AS E – O RTH O /EN D O Maxillary right central incisor discolored during OTM Vital pulp with normal response during sensibility test  C AS E – O RTH O /EN D O Five-month review radiography and picture 4.3 years radiography showing PCC  C AS E – ORTHO/ENDO DISCUSSION Orthodontic forces may cause physiological effects on the pulp o Decreased pulpal blood flow o Reactive hyperemia o Fibrosis and Calcifications o Reversive Pulpitis Temporary and transient responses o If the forces were within the physiological limits OTM did not routinely cause pulpal necrosis o Vital pulp traumatized during OTM may manifest clinically as a gray discoloration o With an appropriate rest period it may subsequently survive  Clinical Case Orthodontic – Endodontic Relationship Tanaka OM, Filho JB, Vitral RF, Bósio JA. Orthodontic treatment in an endodontically treated maxillary incisors. Eur J Gen Dent 2013;2:72-5.  36-year-old woman Case Report Chief Complain No significant medical history Crowding in the maxillary and mandibular arches Crowding in the maxillary and mandibular arches Need of esthetic treatment Extensive dental reconstruction and endodontic treatment  Extraction of the upper left first premolar for midline correction Align and Level: NiTi and stainless steel round wires and rectangular wires for final detailing. Case Management Periodic radiographic evaluation throughout the treatment due to root resorption and fracture possibilities of the endodontically and extensively restored teeth Removal retainer in the maxilla and a 3x3 lower fixed retainer Treatment time: 34 months Teeth involved in endodontic therapy move as much as the vital teeth BUT THERE ARE SOME QUESTIONS ASSOCIATED WITH THIS MOVEMENT 1. Teeth that have undergone root canal therapy are more susceptible to root resorption? YES Wickwire et. al., 1974; Khan RA et al., 2021 NO Bender et. al., 1997; Mattison et al., 1993; Esteves et al., 2007 In this Clinical Case, maxillary and mandibular incisors did not show any degree of root resorption during or after treatment. The use of heavy forces and prolonged treatment are directly related to increases in root resorption associated with orthodontic treatment Brezniak N, Wasserstein A 1993; Segal, 2007; Yassir YA, McIntyre GT, Bearn DR, 2020; Sameshima GT I gresias-Linares A, 2. Teeth with endodontic treatment can be more susceptible to fracture during orthodontic tooth movement? YES, due to... Loss of Structural Integrity Changes in Tooth Composition Decrease in dentin moisture due to loss of blood supply Orthodontic Forces In this Clinical Case, the entire orthodontic treatment was carried out without any negative incident Despite the poor prognosis, risks of root resorption, fractures, and ankylosis, this case report demonstrates that... Orthodontic treatment can be performed with excellent results in patients with extensive endodontically compromised teeth.  K EY POI NTS Orthodontics forces result in pulpal inflammation, but usually it is reversible. External Root Resorption (ERR) is a multifactorial process, so the ethology most of the time is idiopathic. Teeth with a history of trauma seem to be more susceptible to pulpal and periapical changes with Orthodontic tooth movement (OTM) but will vary depending on the severity of the trauma and the type of Orthodontic tooth movement. o Evidence of pre- Orthodontic tooth movement root resorption may predispose to further resorption. Niduses of calcification within the pulp are common with Orthodontic tooth movement, but pulp canal calcification (PCC) seems more related to a history of trauma or excessive orthodontics forces. When a patient sustains dental injury during treatment, the orthodontic rest period depends on the severity of the injury, and current guidelines, should be followed If the patient needs both Orthodontic tooth movement and endodontic treatment, the order of treatment does not really matter but it is case-dependent. Parachos P. Endodontic- Orthodontic interactions: a Review and treatment recommendations. Australian dental Journal 2023. QUESTIONS 1. W HA T I S T HE PR I MA R Y CON CE RN W HE N PE RFOR M I N G O R TH O DO N T I C T RE AT M EN T ON T EE TH WI T H P RE VI OUS E N DOD ON TI C T HE RA PY ? A. Increase risk of tooth discoloration. B. Risk or root resorption C. Difficulty in achieving proper alignment D. Higher likelihood of bracket detachment E. Greater chance of developing gingivitis 11/20/2024 80 1. WHAT IS THE PRIM ARY CONCERN WHEN PERFORM ING ORTHODONTIC TREATMENT ON TEETH WITH PREVIOUS EN DODONTIC THERAPY? A. Increase risk of tooth discoloration. B. Risk or root resorption C. Difficulty in achieving proper alignment D. Higher likelihood of bracket detachment E. Greater chance of developing gingivitis 11/20/2024 81 2. W HI CH O F T HE F O LLO WI N G T YP ES O F D EN T A L TR AU M A H AS T HE HI G HE S T LI K ELI HO O D O F LE AD I N G T O R O O T R ES O R PT I O N , A CCO RD I N G T O PR O G N O SI S ? A. Avulsion B. Concussion C. Extrusion D. Intrusion 11/20/2024 82 2. W HI CH OF T HE F OLLOWI N G T YP ES OF D EN T A L TR AU M A H AS T HE HI G HE S T LI K ELI HOOD OF LE AD I NG T O R OOT R ES OR PT I ON, A CCORD I N G T O PR OG N OSI S A. Avulsion B. Concussion C. Extrusion D. Intrusion 11/20/2024 83 3. WHI CH NEUROPEP TID E IS ASSOCIA TED WITH TH E STIMULA TION OF RANK A ND ROO T RESORPT ION D URI NG ORT HOD ONTIC TREA TMEN T? A. Angiotensin B. Endorphin C. CGRP D. VIP E. Oxytocin 11/20/2024 84 3. W HI CH NEU ROP EPT I D E I S A SS OCI A T ED WI T H T HE S T I MU LA TI ON OF R A N K AN D ROOT R ES ORP TI ON D U RI N G OR TH ODON T I C TR EA T ME N T ? A. Angiotensin B. Endorphin C. CGRP D. VIP E. Oxytocin 11/20/2024 85 4. W HA T O RT HO D O N TI C M O VEM E N T I N A T O O TH WI T H P RE VI O US T RA U MA RE LA TE D W I T H R OOT R ES OR PT I ON : A. Intrusion B. Extrusion C. Torque D. inclination 11/20/2024 86 4. W HA T ORT HOD ON TI C M OVEM E N T I N A T OOTH WI T H P RE VI O US T RA U MA RE LA TE D W I T H R OOT R ES OR PT I ON : A. Intrusion B. Extrusion C. Torque D. inclination 11/20/2024 87  5. WH AT FOL LO WI NG FA CTOR D OES NOT D ECR EAS E TH E AP I CA L ROOT CEMENT UM? A. Hypercementosis B. Active periapical lesion C. External root resorption D. Bacterial infections 11/20/2024 88  5. WH AT FOL LO WI NG FA CTOR D OES NOT D ECR EAS E TH E AP I CA L ROOT CEMENT UM? A. Hypercementosis B. Active periapical lesion C. External root resorption D. Bacterial infections 11/20/2024 89 THANK YOU!!