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Open Access Library Journal
2025, Volume 12, e13031
ISSN Online: 2333-9721
ISSN Print: 2333-9705
DOI:
10.4236/oalib.1113031 Mar. 5, 2025 1
Open Access Library Journal
Orthodontic Treatment of Endodontically
Treated Teeth: A Review of Literature
Asmaa El Mabrak, Zineb Safi-Eddine, Sanaa Alami
Orthodontics Department, Faculty of Dentistry, University Hassan II, Casablanca, Morocco
Abstract
Orthodontic treatment is often necessary for patients with endodontically
treated
teeth, with the objective of effective tooth movement while minimizing biolog-
ical risks and discomfort. However, the impact of orthodontic forces on these
teeth remains a source of clinical uncertainty, as they can trigger inflammatory
responses a
nd structural changes in both the periodontal ligament and pulp
tissue. Despite well-
established principles of interdisciplinary management of
these cases, there is a lack of consensus on best practices particularly in relation
to sequencing, timing, and managing potential complications. This review
aims
to address key considerations for orthodontic treatment in endodonticall
y treated
teeth, providing evidence-based guidelines to minimize risks and improve treat-
ment outcomes.
Subject Areas
Dentistry, Orthodontics
Keywords
Orthodontic Treatment, Orthodntics, Endodontically Treated Teeth,
Endodontics, Management
1. Introduction
Orthodontic treatment may be needed for patients with teeth that have been en-
dodontically treated or are in the process of receiving endodontic care. The pri-
mary objectives of orthodontic therapy in these cases are to facilitate effective
tooth movement while minimizing any biological harm and discomfort [1] [2].
However, orthodontic movement of endodontically treated teeth has long been
a source of clinical ambiguity, as it can elicit significant biological responses in
both the periodontal ligament and pulp tissue [2]. These responses—ranging from
How to cite this paper:
El Mabrak, A., Safi-
Eddine, Z. and Alami, S.
(2025)
Orthodontic
Treatment of Endodontically Treated Teeth:
A Review of
Literature.
Open Access Library
Journal
,
12
: e13031.
https://doi.org/10.4236/oalib.1113031
Received:
January 31, 2025
Accepted:
March 2, 2025
Published:
March 5, 2025
Copyright © 20
25 by author(s) and Open
Access Library Inc
.
This work is licensed under the Creative
Commons Attribution
International
License (CC BY
4.0).
http://creativecommons.org/licenses/by/4.0/
Open Access
A. El Mabrak et al.
DOI:
10.4236/oalib.1113031 2
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inflammatory reactions to structural alterations—can complicate the treatment
process and potentially affect the long-term health of the tooth [3].
While the interactions between various dental disciplines are well understood,
the specific relationship between endodontics and orthodontics remains underex-
plored: Despite its clinical relevance, research focused on the orthodontic man-
agement of endodontically treated teeth is limited, and a clear consensus on best
practices is yet to be established [1]. This lack of comprehensive data poses chal-
lenges for clinicians, making it difficult to predict and address potential compli-
cations during orthodontic treatment. Furthermore, the absence of clear guidelines
contributes to uncertainty regarding the appropriate sequencing of treatments,
the timing of interventions, and the management of potential adverse effects [4].
Thus, this review aims to explore key factors to consider in planning orthodon-
tic treatment for endodontically treated teeth and to provide guidelines for mini-
mizing risks and optimizing treatment outcomes.
2. The Relationship between Orthodontics and Endodontics
2.1. Anatomical and Physiological Aspects
Anatomically, the pulp tissue enters the root canal through a neurovascular bun-
dle connected to the apical foramen at the tip of the tooth’s root. This bundle,
composed of blood vessels, nerves, and connective tissue, is continuous with the
surrounding periodontal ligament (PDL) and periapical tissues.
The apical foramen, located at the root tip, plays a crucial role in maintaining
pulp vitality by allowing the passage of blood vessels and nerves that provide sig-
nals, oxygen and nutrients while also removing metabolic byproducts [5].
Physiologically, the dental pulp is a highly active tissue that requires a constant
blood supply to support its cellular functions and repair mechanisms. The neuro-
vascular bundle passing through the apical foramen plays a critical role in main-
taining this supply, providing the pulp with essential nutrients and facilitating
waste removal [5]. When orthodontic forces are applied to the tooth, they can
momentarily impair this circulation, leading to reduced blood flow and hypoxia
(lower oxygen levels) within the pulp [6]. This can disrupt normal cellular activity
and alter the pulp’s ability to respond to external stimuli [5] [6].
Typically, these changes are transient, with blood flow gradually restored through
reactive hyperemia, a compensatory mechanism to restore oxygen levels. How-
ever, excessive or prolonged forces may cause more significant damage, such as
inflammation, fibrosis, or necrosis, especially if the pulp is already weakened by
other factors. As such, careful modulation of orthodontic forces is essential to
avoid detrimental effects on pulp health and ensure favorable treatment outcomes
[5]-[7].
2.2. Pulp Modifications and Orthodontic Movements
Insufficient scientific evidence exists to prove the interrelation between orthodontic
forces and the impact on the dental pulp [8].
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Considering this, it has been shown that under typical clinical conditions, or-
thodontic forces do not alter the morphology or aging process of the dental pulp,
nor do they affect the cellular or tissue mechanisms responsible for tooth move-
ment [9] [10].
They have demonstrated that orthodontic tooth movement may induce tempo-
rary changes in the dental pulp, such as alterations in the expression of key pro-
teins like vascular endothelial growth factor (VEGF), fibronectin, and collagen I.
These changes occur within the first 7 days of force application and are followed
by a recovery phase, with expression levels returning to baseline after 30 days [10].
This transient nature of the pulpal response suggests that orthodontic forces do
not cause permanent or irreversible damage to the pulp. In fact, the reversibility
of these changes supports the safety of applying pre-calibrated orthodontic forces,
as long as the forces remain within the physiological tolerance of the tissues [11].
Overall, while there is no conclusive evidence linking orthodontic forces to
long-term pulpal damage, the potential risks associated with pre-existing pulp
vulnerability—such as from trauma—should be carefully considered [9] [11]. This
highlights the importance of comprehensive evaluation and monitoring of endo-
dontically treated teeth or teeth with a history of trauma before and during ortho-
dontic treatment to minimize potential complications [12].
3. Orthodontic Movement of Endodontically Treated Teeth
3.1. General Considerations
Orthodontic tooth movement is primarily facilitated by the periodontal ligament,
which responds to mechanical forces by inducing local bone remodeling: When
orthodontic forces are applied, they compress the periodontal ligament cells, de-
forming their cytoskeleton and causing mechanical stress.
Simultaneously, the compression of blood vessels results in hypoxia, creating a
metabolic stress that triggers the release of various mediators.
These mediators alternate between stimulating bone resorption and reposition-
ing the bone on the ligament surface, thereby facilitating tooth movement [13].
It has been established that teeth that have undergone endodontic treatment
can be moved with similar ease to teeth with vital pulp: Orthodontic movement is
not significantly impacted by endodontic treatment unless ankylosis develops [1]
Some studies recommend that root canals should be thoroughly cleaned,
shaped, and filled with calcium hydroxide (CH), and occlusal restoration should
be performed to prevent bacterial leakage [14].
If endodontic treatment is required during orthodontic movement, several
challenges may arise due to dental isolation, dental bands, and braces. To ensure
optimal treatment, proper adaptation of clamps and retentive devices is essential
[15].
Other specific difficulties may occur [1]:
• Lingual orthodontic braces, in particular, can present difficulties when opening
the access cavity. In such cases, it may be more efficient to temporarily remove
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the braces and reapply them after the endodontic procedure.
• -The presence of orthodontic attachments can affect the accuracy of radio-
graphic evaluations and pulp vitality tests.
• -Symptoms related to endodontic or periodontal conditions may be con-
founded by orthodontic pain.
3.2. Orthodontic Movement in Endodontically Treated Teeth
without Periapical Lesion
For several decades, up until the 1990s, there was a general belief—largely unsub-
stantiated by empirical evidence—that endodontically treated teeth were at a sig-
nificantly higher risk of root resorption during orthodontic movement [3]. This
view prevailed despite the lack of robust methodological studies to support it [3]
[13].
However, following the landmark publication by Spurrier
et al
. in the 1990s [3],
it was highlighted that properly treated endodontically, teeth subjected to ortho-
dontic forces do not inherently exhibit an increased risk of root resorption, nor
does orthodontic movement confer any protective effect against such resorption
[16].
Hence, orthodontic treatment of endodontically treated teeth without periap-
ical lesions does not typically require special consideration, unless external apical
root resorption (EARR) is present and cannot be attributed to other factors [3]
[17].
Once endodontic treatment is completed, orthodontic forces can typically be
applied within a short period, as inflammatory exudates and cellular infiltration
are resolved within 15 to 30 days, restoring the area to a stable condition [3].
If failure occurs in endodontically treated teeth subjected to controlled, light,
and intermittent orthodontic forces months or years after treatment, such com-
plications should not be ascribed to the orthodontic movement itself [3] [17]. The
forces applied during orthodontic treatment do not alter the pathogenicity or vir-
ulence of the microbial biofilm, nor do they affect chronic periapical lesions [18].
Therefore, any observed failure should be attributed to factors other than the or-
thodontic forces applied [1].
3.3. Orthodontic Movement in Endodontically Treated Teeth with
Periapical Lesion
Periapical lesions are typically confined to the apical region of the tooth. [19].
They are primarily inflammatory in nature and are often associated with a mixed
or pathogenic microbiota present within the root canals of necrotic pulp. Alter-
natively, they can also result from aseptic pulp necrosis due to trauma [3] [19].
Non-inflammatory periapical pathologies are less common and include [3] [19]:
1) Cemental Dysplasia (Periapical Cemento-Osseous Dysplasia): A benign os-
teofibrous dysplasia affecting the periapical bone, particularly in the mandibular
incisors.
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2) Benign Cementoblastoma: An odontogenic tumor, predominantly located at
the periapical region of the mandibular first molars.
Among these non-inflammatory conditions, periapical cemento-osseous dys-
plasia requires accurate diagnosis but typically does not require treatment, as it is
asymptomatic and presents no significant clinical consequences. On the other
hand, benign cementoblastoma necessitates surgical intervention, though it gen-
erally has a favorable prognosis [3] [20].
The inflammatory periapical diseases are generally attributed to two main eti-
ologies: necrotic pulp with associated mixed microbial flora or aseptic pulp necro-
sis resulting from dental trauma [20] [21].
Inflammatory periapical lesions progress through distinct stages, beginning
with acute apical pericementitis [3], which may evolve into an acute dentoalveolar
abscess, potentially transitioning to a chronic state characterized by a fistula [21].
Chronic inflammation may lead to the formation of a periapical granuloma,
which can persist for extended periods or evolve into an apical periodontal cyst
[3].
While endodontic therapy can still achieve favorable outcomes, the risk of treat-
ment failure remains present, especially in cases with more severe or persistent
lesions, where complete microbial eradication is more difficult [3] [22].
In the context of periapical disease, orthodontic movement of teeth may affect
preexisting lesions [4]. While orthodontic forces are typically light, gradual, and
non-abrupt, and have minimal impact on the healing of periapical lesions [23],
complications can still arise, especially in endodontically treated teeth. These mild
forces compress the periodontal ligament slightly, promoting tooth movement
without disrupting the tissue and cellular processes involved in apical and periap-
ical repair. However, if forces are excessive, they can lead to complications such
as apical root resorption and periodontal issues [4]. Despite the generally low risk,
it is important to recognize that such complications can occur, although they are
rare and can usually be managed effectively.
The timing for orthodontic tooth movement post-root canal therapy depends
on factors such as the extent of periapical lesion resolution, the presence or not of
external resorptions, the degree of dental trauma... [24].
When the conditions are favorable, orthodontic tooth movement can be initi-
ated soon after endodontic treatment without impairing the healing of apical and
periapical tissues [3] [23].
Even so, a recommended waiting period of 7 to 15 days, or even up to 30 days
and follow-up with periapical radiographs every three months are advised [23].
In cases where orthodontic forces are applied immediately after endodontic treat-
ment and failure occurs, the failure should be attributed to the inherent technical
limitations of both specialties rather than to the orthodontic movement itself [23].
When endodontic and orthodontic treatments are performed concurrently,
priority should be given to endodontic therapy, as it forms the foundation for
subsequent orthodontic procedures [4] [23].
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Thus, a comprehensive clinical assessment is crucial for determining the most
appropriate treatment strategy and optimizing patient outcomes. A collaborative
and integrated approach between the endodontist and orthodontist is fundamental
to the successful management of these cases, ensuring that both specialties work
synergistically to achieve the best possible results.
4. Complications of Orthodontic Movement on Endodontically
Treated Teeth and Treatment Recommendations
4.1. Endodontically Treated Teeth and Orthodontically Induced
Inflammatory Root Resorption (OIIRR)
Most studies have found no significant differences in the incidence or the extent
of Orthodontically induced inflammatory root resorption (OIIRR) between vital
and endodontically treated teeth and well-executed endodontic treatment was per-
formed [5] [13].
The key criteria for determining the quality of the root obturation are radio-
graphic images showing a dense, well-compacted root filling that extends as close
as possible to the apical foramen [5].
Biologically, this suggests minimal microbial presence, reducing the likelihood
of an inflammatory response in the surrounding tissues. While OIIRR could acti-
vate bacteria or toxins in dentinal tubules or apical areas, well-treated teeth typi-
cally have minimal bacteria, reducing the risk of harm.
Even with apical protrusion of the root filling, the risk of apical pathosis remains
low in properly treated teeth [23] [25].
In contrast, poorly treated endodontic cases, where more bacteria are likely pre-
sent, may be more susceptible to exposure during OIIRR [13], potentially leading
to reinfection and exacerbating apical resorption. Therefore, teeth with poor-
quality root fillings, especially those showing signs of apical pathosis on radio-
graphs, should undergo endodontic retreatment prior to orthodontic movement.
The overall recommendation is that root-filled teeth should be “well-cleaned,
shaped, and obturated” to minimize risks [5].
When resorption is linked to infection, immediate root canal treatment should
be initiated. The canal should be medicated with calcium hydroxide for a period
of three weeks, with the medication being replaced every three months until radio-
lucencies associated with the resorptive lesions resolve. Final root canal obtura-
tion can be performed once radiographic evidence of bone repair is observed. Or-
thodontic movement should only begin after the infection is under control and
the clinical results are stable. Continuous radiographic monitoring is essential
throughout the treatment. At the outset of treatment, the objectives of orthodontic
therapy may need to be adjusted or limited. Whenever possible, it is beneficial to
exclude the affected teeth from orthodontic forces, whether partially or entirely [21].
4.2. Periapical Lesion Recurrence and Orthodontic Treatment
Other factors, independent of orthodontic forces, may contribute to the persistence,
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partial regression, or worsening of the periapicallesion. They require a reassess-
ment of the initial endodontic treatment, particularly regarding its ability to com-
pletely eliminate the microbiota and seal the spaces occupied by it [17] [23]. An-
atomical irregularities, such as apical deltas, dilacerations, and developmental
grooves, could also hinder the effectiveness of endodontic treatment in eradicat-
ing bacteria, making the presence of these factors critical to the overall success of
the therapy [23] [26].
It is important to note that attributing failure solely to orthodontic movement
is not appropriate: Orthodontic forces do not affect the pathogenicity or virulence
of the microbiota involved, nor do they interfere with microbial biofilms or the
biology of chronic inflammatory periapical lesions. The soft tissue in the apical
and periapical regions, formed by the old granuloma or new granulation tissue, is
not susceptible to compression by orthodontic forces. The periodontal ligament,
while delicate, does not obstruct the movement of orthodontic forces through the
broader area of soft tissue repair [23] [27].
From a biological standpoint, orthodontic forces do not negatively impact the
repair of chronic periapical lesions following appropriate endodontic treatment.
In fact, a waiting period of 15 to 30 days post-endodontic treatment allows for the
absorption of exudate and the migration of inflammatory infiltrate, leaving only
macrophages and repair cells in the area. After this period, orthodontic tooth
movement can be safely initiated without compromising the healing process [23]
[27].
5. Conclusions
• Orthodontic treatment for endodontically treated teeth requires careful planning
and coordination between the endodontist and orthodontist to ensure optimal
outcomes.
• Properly executed endodontic therapy, including thorough cleaning and sealing
of the root canal, minimizes the risks of complications such as root resorption
and infection.
• Close monitoring and radiographic evaluation are essential to manage and ad-
dress any complications that may arise during treatment.
Ultimately, a collaborative approach between the two disciplines is key to ensuring
the success of orthodontic interventions in endodontically treated teeth.
Conflicts of Interest
The authors declare no conflicts of interest.
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