endodontics & orthodontics
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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)
Orthodontic Resorption
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
Orthodontic Resorption
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
Courtesy of Dr Mehdi Rahimi
Retainers
Courtesy of Dr Mehdi Rahimi
Summary
Comprehensive pre-operative assessment
Investigate suspect teeth
Timely management of mid-treatment complications
Be aware of of resorption
Remove retainers/wires if necessary
Courtesy of Dr Mehdi Rahimi
Multidisciplinary Case
Courtesy of Dr Matthew Foo
Courtesy of Dr Matthew Foo
Questions?
mark@gentleendodontics.com.au (NSW)
mark@theendodonticcentre.com.au (VIC)
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