Orthodontic treatment in an endodontically treated maxillary incisors

doi:10.4103/2278-9626.106823

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CASE REPORT

Year : 2013 | Volume : 2 | Issue : 1 | Page : 72-75

Orthodontic treatment in an endodontically treated maxillary incisors

Orlando Motohiro Tanaka¹, Jorge César Borges Leão Filho¹, Robert Willer Farinazzo Vitral², José A Bósio³
¹ Graduate Dentistry Program in Orthodontics, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
² Graduate Program in Orthodontics, Juiz de Fora Federal University, Brazil
³ Orthodontics, Marquette University School of Dentistry, Milwaukee, WI, USA

Date of Web Publication

2-Feb-2013

Correspondence Address:
Orlando Motohiro Tanaka
Graduate Dentistry Program, Orthodontics, Pontificia Universidade Católica do Paraná School of Health and Biociences Bolsista da Capes - Proc. No BEX 1632/11 6 R. Imaculada Conceição, 1155, CEP: 80215 901 - Curitiba, Pr
Brazil

DOI: 10.4103/2278-9626.106823

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Abstract

The purpose of this study was to analyze the effect of orthodontic movement on non-vital teeth, illustrated with a clinical case. A review of the literature shows it is controversial as to whether or not orthodontic forces can be initiated and sustained without the resorptive process occurring. Induced resorption during tooth movement depends on multiple factors, which require the close attention of the dentist to ensure an accurate diagnosis and correct mechanotherapy with respect to the periodontium. The orthodontic treatment described here was performed on a woman 36 years of age with endodontically treated teeth. This case demonstrated that the biomechanics follow biological principles and thus prevent deleterious effects on the components of the periodontium and the bone and maintains the integrity of the root length.

Keywords: Biomechanics, resorption, root canal therapy

How to cite this article:
Tanaka OM, Filho JB, Vitral RF, Bósio JA. Orthodontic treatment in an endodontically treated maxillary incisors. Eur J Gen Dent 2013;2:72-5

How to cite this URL:
Tanaka OM, Filho JB, Vitral RF, Bósio JA. Orthodontic treatment in an endodontically treated maxillary incisors. Eur J Gen Dent [serial online] 2013 [cited 2013 Jun 5];2:72-5. Available from: http://www.ejgd.org/text.asp?2013/2/1/72/106823

Introduction

Apical root resorption is an undesirable, though frequent, effect of orthodontic treatment, which results in loss of mineralized tissues such as dentin, cementum, and alveolar bone. It may be associated with pathological or physiological process. ^[1]

Root resorption resulting from orthodontic treatment is usually associated with inflammatory process in the periodontal ligament, resulting in shortening of the tooth apex. ^[2],[3],[4]

Some factors associated with root resorption include individual predisposition, ^[5] age ^[6] and gender, ^[7] root anatomy, ^[8] root morphology, bone morphology, movement of endodontically treated teeth, ^[9],[10] previously traumatized teeth, ^[11] deleterious habits, root development stage, ^[12],[13] the type of orthodontic appliances used, ^[14],[15] the type of teeth moved, ^[16] and the magnitude and duration of the treatment forces applied. ^[7],[17] Systemic factors including hypothyroidism, hypophosphatemia, nutrition, and heredity can be also associated. ^[18]

Overall, orthodontics coexists peacefully with induced resorption during forced tooth movement. However, the magnitude of resorption is unpredictable and depends on multiple factors, such as careful clinical evaluation, correct diagnosis, appropriate biology of periodontium mechanotherapy, and periapical X-ray control. ^[6]

The risks of endodontically treated teeth movement involve not only root resorption, but also ankylosis and fractures due to extensive restoration and possible intracanal posts. However, orthodontists should be able to include the endodontically treated teeth in their treatment plans and mechanotherapy. ^[19]

The purpose of this article is to describe an orthodontic treatment for a patient with many endodontic treatments and large teeth reconstruction.

Case Report

A 36-year-old woman with no significant medical history reported a chief complaint of overlapping maxillary left central and lateral incisors and extensive dental reconstruction. Clinical examination revealed no evident skeletal disharmony, Angle Class II division 2 relationship with a normal overbite and overjet, crowded anterior teeth in both jaws, maxillary midline deviation toward the right side, and absence of maxillary first premolar [Figure 1]a and c. The maxillary right lateral incisor, maxillary right central incisor, and maxillary left central incisor were discoloured [Figure 1]b.

Figure 1: Pretreatment. (a) Color alteration in maxillary central and lateral incisors and in mandibular central incisors. (d‑f) Both maxillary central incisors, maxillary right lateral incisor, and both mandibular central incisors with root canal therapy

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The panoramic radiograph showed all third molars missing, as was the maxillary right first premolar [Figure 2]a. Extensive restorations were performed to incisors, molars, and premolars. Maxillary right first molar, lateral incisor [Figure 1]d and e, both central incisors, and mandibular central incisors had been endodontically treated. The maxillary right lateral incisor and central incisors were held in place with a large metallic intracanal post. The patient was referred to an endodontist due to the presence of a radiolucent image in the mandibular left central incisor [Figure 1]f.

Figure 2: Panoramic radiographs. (a) Pre‑orthodontic. (b) Teeth movement 11 months into treatment. (c) Final radiograph after 34 months of orthodontic treatment

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Management

The treatment plan involved the extraction of the upper left first premolar [Figure 3]c, alignment, leveling, and intercuspation between the upper and lower teeth properly positioned at the maxilla. Radiographic evaluation was applied throughout the treatment due to root resorption and fracture possibilities of the endodontically and extensively restored treated teeth [Figure 2]b and [Figure 3]d-f. An interdisciplinary approach was used with this patient. A 0.022-in standard, nontorqued, nonangulated, fixed orthodontic appliance, and round archwire were used for alignment and leveling, followed by rectangular archwires for completion and detail [Figure 3]a and b. Individual teeth were moved with an elastic power chain. Retention involved a removable wraparound maxillary Hawley-type retainer and a 0.028-in mandibular lingual retainer bonded only to the canines. The total treatment time was 34 months. Teeth were significantly moved to the left side to correct the maxillary midline deviation and to close the extraction site [Figure 2]c and [Figure 4]a-c.

Figure 3: Progress: Radiographs taken eleven months after the beginning of orthodontic treatment. (a) Minor teeth movement on the right side, but (b) extensive movement in all endodontically treated teeth to align and correct the deviated midline. (c) The space resulting from the extraction of the maxillary left premolar was closed (d‑f)

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Figure 4: Final records. (a, c) Canines in good occlusion. (b) The maxillary right central and lateral incisors were rehabilitated with porcelain veneer. (d‑f) the length of the roots was maintained

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Discussion

The orthodontic movement of teeth without pulp is possible. ^[20],[21] Teeth involved in endodontic therapy move as much as the vital teeth, but there are some questions associated with this movement. ^[22] Some authors believe that teeth that have undergone root canal therapy are more susceptible to root resorption, ^[19] whereas other authors found no significant difference. ^{[23],[24],[25]} Wickwire et al. ^[19] examined the effect of pulpectomy on tooth movement and showed that teeth without pulp are subject to a greater degree of resorption when compared to teeth with vitality. On the other hand, Bender et al. ^[26] observed greater resorption for vital teeth compared with endodontically treated teeth. Similarly, the endodontically treated teeth reabsorbed less frequently and with less severity than homologous teeth with vitality; however, there was no statistically significant difference between the degrees of root resorption. ^{[1],[3],[18],[27]}

Mattison et al. ^[3] and Esteves et al. ^[28] found no statistically significant difference in the amounts of root resorption between endodontically treated teeth and homologous teeth with vitality when teeth were submitted to orthodontic treatment. This evidence substantiates the present clinical case were the maxillary and mandibular incisors did not show any degree of root resorption during or after treatment. In addition, it is worth noting that there are significant associations between longer treatment durations and higher degrees of external root resorption. ^[15] Moreover, the use of heavy forces and prolonged treatment are directly related to increases in bone resorption associated with orthodontic treatment. ^{[2],[18],[29],[30]} Although the treatment duration was 34 months, no major root or bone resorption was observed during the treatment of this adult patient.

When a tooth is subjected to an endodontic treatment, it becomes more fragile than a vital tooth due to structural defects generated during the canal instrumentation. ^[31] A tooth's resistance to fracture decreases significantly after endodontic treatment due to the mutilation of important parts of the dental structure. Another contributing factor to reduced resistance to tooth fracture is the decrease in dentin moisture due to the loss of blood supply, resulting in a change in the resilience of the tooth. According to Garcia, ^[32] metal posts induce stress concentrated at the apex, which can lead to root fracture because a metal has greater modulus than the dentin. The patient was aware about the fracture risks due to the endodontic treatment and the large metallic intracanal post in the maxillary incisors. In addition, endodontic retreatment may be required if fracture occurs, and depending on the location of the fracture extraction could be necessary. However, the entire orthodontic treatment was carried out without any negative incident.

Another relevant detail to endodontically treated teeth is ankylosis. According to Biederman, ^[33] ankylosis is caused by a disturbance in the local metabolism of the periodontal ligament, resulting in the fusion of the alveolar bone with the cement. Ankylosis can be caused by disturbance of the alveolar bone and/or the periodontal ligament, originated in the orthodontic movement. Although the patient was apprised about this risk, there was no occurrence of ankylosis.

Conclusion

Despite poor prognosis, risks of root resorption, fractures, and ankylosis, this case report demonstrated that orthodontic treatment can be performed with excellent results on patients with extensive endodontically compromised teeth.

References

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