Orthodontic and endodontic relation during treatment planning decision

1. Orthodontic-Endodontic
relationships

2. Learning outcomes
1. Describe Endodontic considerations in orthodontic
treatment planning
2. Identify orthodontic- Endodontic relationships
3. Realized the effect of ongoing orthodontic treatment on
endodontic
4. Clarify Orthodontics aid to endodontic treatment
5. Describe Cases with recent trauma and in need of
orthodontic treatment

3. Introduction
• If a patient came to you and he need Endo and Orthodontic
treatment. Which one should be treated first?
• Will ongoing orthodontic treatment have an effect on the
outcome of endodontic treatment?
• How orthodontic treatment help us during and
after Endodontic treatment?
• Cases with recent trauma and need Orthodontic
treatment?

4. Causes of pulp necrosis
• The common cause for pulp necrosis following
orthodontic treatment are following :
1. Type of force applied (Continuous vs interrupted
Heavy continuous force : It causes undermining bone
resorption leading to large increments of change and abrupt
tooth movement resulting in severance of blood supply to
the pulp.
2. Type of movement
i. Distal tipping of incisor: Tipping movement to an extent
that the root tip is actually moved outside the alveolar
process can also cut off the blood supply to the pulp.
ii. intrusion movements: are found to be most commonly
associated with the resorption process.

5. 3. Heat generated by grinding during removal of
ceramic brackets can cause pulp damage.
4. Labiolingual expansion appliance : The movement
afforded by this technique resulted in a tipping motion
in the apical third of the root causes lack of collateral
circulation to the pulp which results in pulpal
degenerations.
5. Length of treatment time: increased treatment time
makes tooth roots more prone to iatrogenic response.

6. 6. Tooth specificity: the maxillary incisors are the
teeth that are the most susceptible to the process.
7. Root shape : least susceptible is in blunted root
ends and the greatest was seen in pointed or tapered
root ends.

7. Evidence of pulp involvement are
1. Increased sensitivity after activation of orthodontic appliances
2. Decreased pulp space
3. Periapical radiolucency
4. Root resorption/blunting

8. Endodontic intervention during
orthodontic therapy
• The presence of ongoing orthodontic treatment may impact on the endodontic treatment depending on a number of factors.
1. History of trauma
• Patient expresses symptoms that might be due to the orthodontic tooth movement or to an inflamed or
degenerating pulp, thus making a differential diagnosis very difficult, especially if there has been a history of
trauma.
• Presence of pulp calcifications may be due to both an inflamed degenerating pulp following trauma or to
orthodontic tooth movement
2. Radiographs
Radiographs may reflect osseous changes that may be misinterpreted as being of pulpal origin
3. Metallic bands
Full metallic bands may prevent an accurate response to electrical or thermal pulp testing ,

9. 4 . Caries detection
Obscuring decay both radiographically and clinically due to metallic bands
5. Tooth isolation
• Rubber dam clamps may need to be modified
• Modification to secure adequate isolation
6. Working length determination
• In teeth actively undergoing tooth movement
• In the presence of apical resorption or even just root blunting in which there is no
discrete apical constriction
7. Canal obturation
– Cleaned , shaped and filled temporarily with calcium hydroxide until the completion of orthodontic
treatment.

10. How orthodontic treatment canhelp us
during and after Endodontic treatment?

11. Effect of orthodontic therapy in influencing
the final outcome of endodontic treatment
1. Improving access to teeth requiring
endodontic treatment,
Mainly two types of tooth movements
are involved:
i. Orthodontic extrusion
ii. Orthodontic uprighting
2. Improving accessofthetoothforagood
restoration.

12. Orthodontics to aid during endodontic
treatment
• The prime objective of tooth extrusion or forced eruption is
i. provide both a sound tissue margin for ultimate
restoration(Deep subgingival decay)
ii. Create a periodontal environment (biologic width) that will
be easy for the patient to maintain thus Ensuring optimal
conditions for the final restoration(crown lengthening

14. • Provide a sound margin for final restoration
• Orthodontically extruded teeth need to be stabilized for 8-
12 weeks prior to final restoration

15. 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.

16. Procedure
1. A core or foundation restoration placed
in the tooth requiring restoration.
2. Tooth prepared for a full crown
3. An acrylic crown fabricated, cemented and then an
orthodontic separator inserted into the proximal space.

17. 4. At subsequent appointment elastic is removed and a
piece of 0.6mm brass wire threaded between the teeth
apical to contact.
5. The brass wire reapplied, as the tooth tipped, it may
move upward into the occlusal plane, as it does, adjust
occlusally to permit to continue to move
6. Then the full crown that will serve as the final
restoration fabricated and cemented.

18. Caseswith recent trauma and needorthodontic
treatment?
• Cases with recent trauma should initially be treated with
calcium hydroxide filling and then monitored during the
course of orthodontic movement
• Definitive root filling postponed until orthodontic
treatment has concluded (Andreasen and Andreasen, 1994).
• Most recommend waiting time between 3-6 months for
inflammation to subside (Proff t and Fields, 2000).

19. References
• Combined endodontic-orthodontic and prosthodontic
Treatment of fractured teeth. Case report (Kocadereli et
• al.,1998)
• Endodontic-orthodontic relationships: a review of Integrated treatment
planning challenges (Hamilton and Gutmann,1999)