endodontics & orthodontics

Endodontics & Orthodontics

Dr Mark Johnstone BDSc (Hons) DClinDent

Endo/Ortho patients

  Pre-Orthodontics

  Mid-Orthodontics

  Post-Orthodontics

Pre-Orthodontics

  Who is a pre-orthodontic patient?

Everyone is a pre-orthodontic patient

•  Approx 1% US adult population sought orthodontic treatment over a 4 year period

•  Majority aged between 18-30 years

•  Significant number of patients > 50yo

Whitesides et al 2008

Bayorthodontics.co.nz

Pre-Orthodontic Diagnostics

  OPG   Quick

  Easy

  Best bang for your buck

  CANNOT diagnose apical periodontitis accurately (Rushton & Horner 1996, Estrela et al 2008)

  Anterior superimposition of cervical spine

CBCT

  Identifies significantly more periapical pathology than conventional radiography (Lofthag-Hansen et al 2007, Estrela et al 2008, Jorge et al 2008, de Paula-Silva 2009).

  Systematic review and meta-analysis (Dutra et al 2016)

  Radiographs good, CBCT BEST

However…

  CBCT is not perfect   5% of radiolucencies show up on PA and not CBCT (Chistiansen

et al 2009)

  Pope et al 2014   Significant variation of “healthy” PDL

Diagnostics

  Investigate questionable teeth/pulp status PRIOR to orthodontic treatment

  Because later it’s not conclusive   Especially EPT (Cave et al 2002)

Endodontically treated teeth

  Endodontic treatment or surgery has no influence on orthodontic tooth movement (Wickwire et al 1974, Mah et al 1996)

  Excluding trauma

Tooth Movement

  Ankylosis/Replacement Resorption   Osseous replacement of dentine

  High percussion tone

  Zero mobility

  1 month – 1 year following trauma   Intrusion/Avulsion

Andreasen et al 1995, Campbell et al 2005

Treatment

Malmgren & Malmgren

Malmgren et al 1984

Preserves alveolar height and thickness Mohadeb et al 2016

Trauma

  10% of orthodontic patients have a previous history of trauma

  Factors related to childhood trauma Overjet   12 times more likely to undergo trauma if > 8mm (Shulman & Peterson

2004)

  Physical activity   Accident prone

Bauss et al 2004, Brin et al 2000

Trauma and Orthodontics

Traumatised teeth more likely to undergo pulp necrosis and resorption during/following orthodontic treatment (Brin et al 1991, Chaushu et al 2004, Bauss et al 2008, 2010)

  Baseline pulp testing of traumatised teeth (Atack 1999)

Crown Fractures

  Three months

Kindelan et al 2008

Root Fractures   1-2 years

  Move when healed

Erdemir et al 2005

Mendoza et al 2010

Concussion/Subluxation/Extrusion

  Three months

Lateral Luxation/Avulsion/Intrusion

  One year Ankylosis

Significant loss of structure

  Orthodontic Extrusion

Kotuyurk et al 2005

Pre-Orthodontic Summary

  Diagnosis

  Baseline data

  Good preparation

Mid-Treatment

Courtesy of Dr Mehdi Rahimi

The Pulp

  Orthodontic treatment is a form of trauma

Upregulates pro-inflammatory cytokines (Bletsa et al 2006, Yamaguchi et al 2008)

  Reversible changes in pulpal blood flow (von Böhl et al 2012)

  Can lead to pulp necrosis (Seltzer & Bender 1984)

The Pulp

  The pulp can recover (Venkatesh et al 2014)

Pathways of the Pulp 10th Edn

Expansion

  Metabolic changes in the pulp in response to RPE   Reversible

Wei et al 2013

Mini-Implants

•  Reversible changes in pulpal blood flow

Sabuncuoglu & Erasahan 2014

Mid-Treatment Disease

  Apical periodontitis   Long term medication?

Long Term Medication?

  Disadvantages   Temporary Seal (Beach et al 1996)

  Flare up

CaOH and reduced fracture strength? (Cvek 1992, Andreasen et al 2002, Rosenberg et al 2007)

Apical Periodontitis

  Complete treatment (Dumsha et al 1995)

RCT and Resorption?

  Evidence equivocal   BUT trends show no difference with RCT vs no RCT

  Contralateral teeth à no difference (Llamas-Carreras et al 2010)

  Endo treatment is a preventive factor? (Mirabella & Artun 1995)

  Systematic review à overall LESS for RCT? (Ioannidou-Marathotou et al 2013)

Wickwire et al 1974, Remington et al 1989, Esteves et al 2007

RCT and Resorption?

  Confirmed with CBCT (Castro et al 2015)

Isolation

  Rubber Dam

  Caulking agents OraSeal

OpalDam

  Remove arch wire

Summary

  Manage endodontic pathology as per normal

Post-Orthodontics

Resorption

  All orthodontic teeth undergo resorption to an extent (Reitan 1964)

  Two main types to consider – Orthodontic Resorption and Invasive Cervical Resorption

Orthodontic Resorption

  Can be in the form of inflammatory or surface resorption

  Tends to be mild

  Severe (> 5mm) resorption occurs in approx 5% of cases (Levander et al 1988)

  Stops once orthodontic treatment is complete (Remington et al 1989)

  Tooth survival unaffected (Kalkwarf et al 1986)


  Systematic Reviews   Roscoe et al 2015

  Increased treatment time

  Increased forces

  Treatment pauses reduce resorption

Weltman et al 2010   Heavy forces

  Previous trauma

  Tooth morphology

  Possibly patient dependent

Aligners

  Less reported resorption (Boyd 2007)

Brezniak & Wasserstein 2008

Invasive Cervical Resorption

  Damage to cementum layer

  Resorption of dentine

  Ingrowth of periodontal tissue

  Orthodontics is a predisposing factor (Heithersay 1999)

Heithersay 2007

Invasive Cervical Resorption

Retainers


Summary

  Comprehensive pre-operative assessment

  Investigate suspect teeth

  Timely management of mid-treatment complications

  Be aware of of resorption

  Remove retainers/wires if necessary

Multidisciplinary Case

Courtesy of Dr Matthew Foo

Courtesy of Dr Matthew Foo

Questions?

[email protected] (NSW)

[email protected] (VIC)

endodontics & orthodontics

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