Report Peer-reviewed paper. Submitted July 2012; accepted November 2012.
Orthodontic tooth movement of traumatised or root-canal-
treated teeth: a clinical review
V J Beck, S Stacknik, NP Chandler and M Farella
Orthodontic treatment planning for previously root-canal-
treated teeth can be challenging. Patients may present with root-
canal-treated teeth secondary to deep carious lesions or trauma.
The need for orthodontic treatment may develop following
dental trauma or when adult patients seek rehabilitation of their
dentition. Clinicians can sometimes be unsure of how, or when,
to proceed with orthodontic tooth movement of traumatised or
root-canal-treated teeth, or about the risks involved. This article
considers the current recommendations for orthodontic tooth
movement of such teeth.
Previously traumatised teeth
The literature is sparse on the influence of previous trauma
during orthodontic treatment, yet it has been reported that
more than one in ten patients have experienced dental trauma
prior to orthodontic treatment (Chadwick and Pendry, 2004).
The prognosis of traumatised teeth plays a role in orthodontic
treatment planning.
The chance of pulpal healing following a luxation injury is
strongly related to the dimension of the apical foramen, with
clinical and radiographic diagnosis of pulpal necrosis sometimes
occurring years after a luxation injury (Andreasen and Pedersen,
1985). An analysis of 637 luxated teeth revealed that only the
type of injury and stage of root development were important
determinants of pulpal survival. The chance of pulpal necrosis
following a lateral luxation injury (which had occurred in 19%
of the sample) was 9% in teeth with open apices, whereas 77%
of the teeth with closed apices had pulp necrosis (Andreasen
and Pedersen, 1985). A 2004 meta-analysis found that, following
a moderate intrusion injury, nearly half (45.5%) of teeth with
open apices remained vital, yet no teeth with closed apices did
so (Chaushu et al., 2004).
If a traumatic injury has led to pulp necrosis and bacterial
infection, toxins within the pulp space can track through the
dentinal tubules and cause external inflammatory resorption
unless the infected pulp is removed and root canal disinfection
carried out (Andreasen et al., 2011). If there is evidence of pulp
necrosis and bacterial infection, endodontic management
is required prior to orthodontic treatment. It must also be
remembered that adjacent or opposing teeth may have also
experienced trauma at the time of the accident (Majorana et
al., 2002).
When avulsion of a permanent tooth has occurred, important
prognostic factors include the time the tooth is outside the
mouth, and the medium in which the tooth is stored prior to
replantation (Steiner and West, 1997). Immediate replantation is
ideal, because it has been shown that, after 60 minutes of extra-
oral time (even when stored in a physiologic medium such as
milk) or 30 minutes of dry time (Andreasen et al., 1995; Gregg
and Boyd, 1998; Kinirons et al., 2007; Flores et al., 2007b), the
6 Orthodontic movement of teeth
periodontal ligament cells may be viable but compromised (Day
et al., 2008), leading to unavoidable ankylosis (Andersson et al.,
2012). If the tooth needs to be cleaned, it can be gently rinsed
under cold water for less than 10 seconds (Flores et al., 2007b),
then replanted, without any contact with the root surface. The
patient can gently bite to keep the tooth in place until emergency
dental treatment can be sought. If the tooth cannot be replanted,
storage in water must be avoided; the tooth can be stored in
milk, saline solution or special storage solution such as Hanks
Balanced Salt Solution or it can be placed in the patients buccal
vestibule until the dentist can replant it.
Replacement root resorption can result from trauma to the
protective cementum layer of the tooth; it is a pathologic process
involving cementum, dentine and periodontal ligament being
replaced with bone. Ankylosis is the clinical diagnosis for the
end result of replacement resorption, whereby the tooth is no
longer capable of normal physiologic movement due to the
fusion of bone to the root surface (American Association of
Endodontists, 2012). There is a higher likelihood of replacement
resorption following severe trauma, such as extrusive luxation or
avulsion injuries. It has been asserted that ankylosis will occur
if 20% or more of the root surface is affected (Andersson et al.,
1984). Ankylosis can generally be detected two to 12 months
after injury, and its signs may include a high, metallic tone upon
percussion, infra-occlusion and the radiographic appearance of
an obliterated periodontal ligament (Andersson et al., 1984). If
this occurs, teeth will not move through bone upon application of
orthodontic force. Such teeth may, however, be used to enhance
anchorage during orthodontic treatment.
At this stage, there is insufficient evidence to conclude
whether or not orthodontic tooth movement of traumatised
teeth increases the risk of pulp necrosis above that of uninjured
teeth undergoing orthodontic tooth movement (Rotstein and
Engel, 1991; Hamilton and Gutmann, 1999; Healey et al., 2006).
However, if endodontic treatment is required following moderate-
to-severe dental trauma, the additional inflammatory stimulus
from orthodontic tooth movement may prolong the destructive
phase acting on the cementum, thereby increasing the risk of
ankylosis. Orthodontic treatment should therefore be postponed
for up to one year in order to enable observation of healing and
monitoring for ankylosis (Drysdale et al., 1996).
Some patients requiring orthodontic treatment may present
with teeth which have previously sustained root fracture, whether
at the level of the apical third, middle third or cervical third.
In cases of a cervical-third root fracture without separation of
fragments and which has a positive response to sensibility testing
from the coronal portion, the tooth may need to be splinted for
up to four months (Flores et al., 2007a), and the fracture must
be observed for at least two years prior to orthodontic tooth
movement (Zachrisson and Jacobsen, 1974). If separation of the
New Zealand Dental Journal March 2013
fragments has occurred, the displaced coronal segment will need
to be repositioned prior to splinting; if this is not possible, the
clinician may consider removing this fragment and extruding
the apical segment for restorative purposes (discussed below). If
the root fracture involves the middle third or apical third, any
luxated fragments may be repositioned, splinted and reviewed
radiographically after three to four weeks. The splint may be
removed at this appointment, providing there is no sign of
infection at the fracture site (Andreasen et al., 2011). Following a
root fracture, if there is any sign of pulp necrosis with subsequent
bacterial infection, root canal treatment must be carried out on
the coronal fragment, with or without surgical removal of the
apical fragment (Andreasen, 2003). A retrospective study of 34
root-fractured teeth showed good healing in 79% of the teeth,
with the only significant factor contributing to healing being
incomplete root development (where the tooth had an open
apex), which accounted for 79.4% of the total sample (Feely et al.,
2003). Interestingly, the site of the fracture did not significantly
affect healing (74% of the fractures involved the apical third and
24% the middle third).
Teeth requiring root canal treatment during
orthodontic treatment
If the trauma occurs during orthodontic treatment, it may be
difficult to determine whether a patients symptoms result from
pulp inflammation due to the trauma or a transient, reversible
pulpitis due to the normal physiologic pulpal response to the
application of orthodontic force (Hamilton and Gutmann, 1999).
If pulpal necrosis is suspected, it is prudent to check tooth vitality
and look for any radiographic periapical changes while halting
tooth movement for three months. If root canal treatment is
required, patients must be made aware of the greater treatment
time involved, due to tooth movement being discontinued
during root canal treatment and the subsequent (and necessary)
healing period.
The timing of orthodontic tooth movement following root
canal treatment is important. The tooth should be followed up after
root canal treatment in order to assess the outcome and quality of
the treatment. The European Society of Endodontology (2006) has
published quality assurance guidelines, advising that endodontic
treatment can be considered successful one year post-treatment
if there is absence of pain, swelling or other symptoms, as well
as no sinus tract, no loss of function, and radiographic evidence
of a normal periodontal ligament space around the root. If the
treatment was required secondary to dental caries, orthodontic
tooth movement may commence immediately (Drysdale et al.,
1996). If root canal treatment resulted from dental trauma which
occurred during the period in which the patient was undergoing
orthodontic treatment, that treatment should be postponed for
one year to allow observation of healing and monitoring for
ankylosis (Drysdale et al., 1996). If a tooth is deemed to have a poor
prognosis, the patient (and his/her parents) should be informed
of all possible options and consequences before continuing
with any orthodontic treatment. Treatment planning must be
reconsidered with respect to the short-, medium- and long-term
goals of treatment (Day et al., 2008).
Teeth requiring root canal treatment during (or prior to)
orthodontic tooth movement may benefit from being initially
prepared and dressed with calcium hydroxide (Steiner and West,
1997). Steiner and West recommended that dressings should
be replaced every three to six months until the completion of
orthodontic treatment, when final obturation with gutta percha
can be completed. It is thought that calcium hydroxide may halt
New Zealand Dental Journal March 2013
root resorption, because it is alkaline and believed to impede
osteoclastic and cementoclastic activity (Bender et al., 1997), as
well as encouraging apexification in incompletely formed roots
(Steiner and West, 1997). More recently, a single-visit mineral
trioxide aggregate technique has become a popular alternative
for managing teeth with open apices (Rafter, 2005), especially
in the light of later studies showing that prolonged calcium
hydroxide dressings (for longer than 30 days) lead to a higher
risk of cervical root fracture (Andreasen et al., 2002; Doyon et
al., 2005; Rosenberg et al., 2007). Thus, if prolonged orthodontic
tooth movement is planned, the definitive obturation and
a well-sealed coronal restoration should be placed as soon as
possible (Rosenberg et al., 2007), unless the calcium hydroxide is
being used for apexification or disinfection. If a tooth is already
well sealed with gutta percha and shows no signs of periapical
radiolucency, no further root canal treatment is required
(Hamilton and Gutmann, 1999).
Tooth movement does not appear to impede the apexification
process if a calcium hydroxide dressing has been placed (Steiner
and West, 1997), and neither does it prevent periapical healing
in animal models. It does delay the overall healing process,
however, as shown in a dog study where 30 periapical lesions
were created, followed six months later by root canal treatment
of 20 of the teeth (the remaining ten were untreated controls).
Ten teeth were then orthodontically moved, with the other ten
used as comparisons. Both groups showed signs of healing, with
the orthodontically moved teeth showing a slight delay, but no
hindrance of the healing process (de Souza et al., 2006).
Tooth isolation with a dental dam may be difficult due to the
presence of bands and wires, and so root canal treatment may
involve coordinated appointments with the orthodontist and
general dentist or possibly the endodontist and/or paediatric
dentist. Individualised adaptations of clamps and other retentive
devices may be necessary to ensure that an adequate seal is achieved.
Lingual orthodontic brackets can pose a problem when an
access cavity is required, with one means to gain access being via
the incisal edge (LaTurno and Zillich, 1985). It may be simpler and
quicker to de-bond the tooth and replace the bracket following
the endodontic appointment.
Orthodontic treatment timing
The severity of trauma affects the timing of orthodontic
treatment. A post-trauma healing period for the periodontal
ligament is highly recommended, so that no inflammatory
stimulus can cause further damage to the protective cementum
layer (Drysdale et al., 1996). A sound periodontal ligament is
essential for orthodontic tooth movement (Wickwire, 1974),
because this supporting tissue responds to the orthodontic forces
placed upon the teeth; this, in turn, influences the osteoclastic
and/or osteoblastic response leading to tooth movement.
For teeth which have suffered mild-to-moderate trauma
and have an intact periodontal membrane, it is suggested that a
radiographic review to check for periapical pathology and root
resorption be undertaken after four to five months, and prior
to orthodontic tooth movement commencing (Malmgren et
al., 1982). The orthodontic outcome for these teeth is generally
expected to be similar to that for non-traumatised teeth
(especially those with open apices), because the damage risk to
the periodontal ligament is minimal (Andreasen et al., 2011).
More severely traumatised teeth (such as those having suffered
avulsion or extrusive luxation) undergoing orthodontic tooth
movement have a poorer prognosis, especially if inflammatory
or replacement root resorption occurs (Andreasen et al., 2011). A
Orthodontic movement of teeth 7
rest period of at least one year is therefore recommended, in order
to ensure that periodontal healing is complete and to avoid extra
inflammatory stimuli, which may further damage the protective
cementum layer and increase the risk of ankylosis (Kindelan et
al., 2008).
Mild damage to periodontal tissues (such as a concussion
injury causing inflammation of the periodontal ligament)
requires approximately three months of follow-up, whereas
moderate damage requires twelve months of follow-up, in order
to discount the possibility of ankylosis. Root fractures require
an observation period of up to two years prior to orthodontic
treatment, because the associated movement may contribute
to the separation of segments (Zachrisson and Jacobsen, 1974;
Kindelan et al., 2008).
A case report on orthodontic movement of two maxillary
central incisors which had sustained apical-third root fractures
two years previously showed that tipping movements did not
affect the vitality of the pulps, which were monitored at three-
monthly intervals. There was also no increase in root fragment
separation, despite the apical fragment angulation not closely
following the angulation change in the coronal fragment. At the
conclusion of treatment, the overjet had been reduced by 9mm
and there was a slight reduction in vitality testing responses, but
tooth mobility and colour were unchanged (Healey et al., 2006).
Effect of orthodontics on root-canal-treated teeth
There is very little literature on the orthodontic movement of
root-canal-treated teeth, and most clinical recommendations
are opinion-based. The consensus appears to be that root-canal-
treated teeth can be moved as readily (and for the same distance)
as vital teeth, providing ankylosis has not occurred (Huettner and
Young, 1955; Spurrier et al., 1990; Mirabella and Artun, 1995).
Normal force levels can be applied to root-canal-treated teeth
during orthodontic tooth movement, providing the periodontal
ligament is healthy. This was demonstrated in a retrospective
study of endodontically-treated incisors using an untreated, vital
contralateral incisor as control (Spurrier et al., 1990). Root-canal-
treated teeth should be checked clinically and radiographically
six months after orthodontic treatment commences, and, if there
are signs of resorption, the patient should be informed and a rest
period of three months observed before reassessment for further
treatment (Andreasen et al., 2007). Traumatic intrusions treated
via spontaneous eruption and/or orthodontic traction may lead
to discrepancies in gingival height and incisal edge levels due to
ankylosis (Flores et al., 2007a).
There are conflicting reports in the literature on the risk of
root resorption in root-canal-treated teeth during orthodontic
treatment (Wickwire et al., 1974; Spurrier et al., 1990). This may
be due to differences in pulp death aetiology, such as necrosis of
the pulp due to periodontal disease, deep caries, or crown/root
trauma that may be simple, complex, horizontal or vertical. These
factors may not always be specified in studies, yet they can affect
the outcome of orthodontic tooth movement.
Orthodontically induced inflammatory root resorption
(OIIRR) is a pathologic process due to localised injury of the
periodontal ligament and resorption of cementum and dentine
that occurs in conjunction with removal of hyalinised bone
during tooth movement (Brudvik and Rygh, 1993). OIIRR
occurs in most patients that undergo comprehensive orthodontic
treatment, yet it is estimated that only 5% of these patients will
experience more than 5mm of root shortening (Killiany, 1999),
with permanent mobility of the coronal fragment expected when
the root is less than 9mm in length (Levander and Malmgren,
8 Orthodontic movement of teeth
2000). Despite this, the literature is yet to report the loss of a
tooth due to OIIRR. Teeth with blunt or pipette-shaped roots
subjected to heavy orthodontic forces (especially intrusive or
tipping forces) are at a significantly greater risk than teeth with
normally-shaped roots (Reitan, 1974; Levander and Malmgren,
1988). Thus, previously traumatised teeth with blunt apices may
be at a higher risk (Levander and Malmgren, 1988).
Conversely, it has been proposed that root-canal-treated teeth
may be more resistant to root resorption (Spurrier et al., 1990;
Bender et al., 1997). The hardness and density of dentine may be
greater (Brezniak and Wasserstein, 1993), and this could render
them more resistant to the resorption process (Graber and Swain,
1985). Bender and co-workers (1997) have suggested that another
explanation may be the lack of neuropeptide release from pulpal
tissue which would cause inflammatory reactions that contribute
to root resorption.
Recently, a small retrospective study compared 16 traumatised
maxillary central incisors with vital controls. All had undergone
orthodontic treatment for at least 20 months and had intact
periodontal ligaments, with the root canal treatment undertaken
at least one year prior to tooth movement commencing. Upon
completion of orthodontic tooth movement, comparison of pre-
and post-treatment periapical radiographs found no difference
between the two groups in apical resorption (Esteves et al., 2007).
If external apical root resorption of previously root-canal-
treated teeth occurs during or after orthodontic tooth movement,
the integrity of the apical seal may be violated. However, it is
believed that the seal should not be compromised if the root canal
has been adequately cleaned, shaped and obturated (Hamilton
and Gutmann, 1999).
In the clinical setting (as stated above), this means that
previously root-canal-treated teeth can be moved as easily and
as far as non-root-canal-treated teeth, providing there has been no
ankylosis from previous trauma. It also means that those teeth are
not more prone than vital teeth to root resorption, as long as the
roots are of normal shape. Clinicians must ensure that a thorough
informed consent process is undertaken when orthodontically
treating traumatised or root-canal-treated teeth to ensure that
patients and their parents are aware of possible sequelae.
Orthodontic movement of apicected teeth
Little is known about the potential problems and long-term
prognosis of moving teeth which have had previous endodontic
surgical intervention (Hamilton and Gutmann, 1999). Early
application of orthodontic force following an apicectomy has
been shown to delay the healing process, through the tooth
mobility impacting on the ossification process (Baranowskyj,
1969). Periapical lesions should show good radiographic healing
one year following apicectomy treatment. If a radiolucency
persists, further endodontic attention is required (Drysdale et
al., 1996).
Orthodontic extrusion
In some clinical situations, orthodontic extrusion is required to
allow functional restoration of a tooth. Such cases include fracture
of the tooth below bone level, subgingival carious margins on
teeth requiring root canal treatment, and resorptive perforations
(Hamilton and Gutmann, 1999). The objective of orthodontic
extrusion in such cases is to expose a sound tissue margin for
future restoration, and to prevent violation of the biologic
width (Hamilton and Gutmann, 1999). An example might
be orthodontic extrusion combined with crown lengthening
surgery prior to restoration of a traumatised incisor.
New Zealand Dental Journal March 2013
 Many procedures have been suggested for extrusion. For
example, following a fracture of a maxillary incisor below
bone level, a pulpectomy is performed and root filling placed,
followed by the cementation of a post. A sectional archwire is
then attached to orthodontic brackets on adjacent anterior teeth,
with twist-flex wire attached to lightly extrude the apical segment
over approximately four weeks. This is followed by retention for
approximately six weeks to stabilise the periodontal fibres. Finally,
after cementation of the final crown, a removable retainer should
be worn for six months to further stabilise the periodontal fibres
and prevent re-intrusion (Heithersay, 1973). Biggerstaff and
colleagues (1986) suggested that 20-30g of extrusive force results
in eruption with new crestal bone which, when combined with
biologic width realignment, may lead to a better aesthetic outcome
than that attainable with crown lengthening procedures alone.
Autotransplantation
Autotransplantation of premolars can be used to treat premolar
agenesis, extraction spaces due to the removal of teeth of poor
prognosis, or the traumatic loss of anterior teeth. This involves
extraction of the premolar and its transplantation into a surgically
prepared socket elsewhere in the mouth. It can be a useful short-
term treatment to provide an aesthetic, functional tooth and
may be used to preserve bone levels in a growing patient until
an implant can be placed if or when the autotransplant fails.
Andreasen and colleagues studied 370 autotransplanted
premolars in 289 patients and observed that only three teeth were
subsequently extracted; two extractions were due to external
root resorption and one resulted from the non-eruption of the
transplanted tooth germ (Andreasen et al., 1990a; Andreasen
et al., 1990b; Andreasen et al., 1990c). Tooth survival rates
(irrespective of whether the tooth required subsequent root canal
treatment) up to 13 years post-transplantation were over 95% in
both teeth with incompletely formed roots and in those with
completely formed roots. A high survival rate (98%) was also
shown in a 17-year follow-up of 40 consecutive patients with
autotransplanted premolars (Jonsson and Sigurdsson, 2004).
Damage to the periodontal ligament during the procedure
(through accidental severance or compression) can lead to
root resorption, which can be diagnosed radiographically and/
or clinically four to eight weeks after autotransplantation.
Subsequent orthodontic treatment of such teeth with complete
root development resulted in a slight increase in the occurrence
of both surface and inflammatory root resorption (Andreasen
et al., 1990c).
Further clinical studies have shown that mature teeth
with closed apices can be autotransplanted with good success,
providing that root canal treatment is commenced within
7-14 days of the surgery in order to prevent inflammatory root
resorption due to pulp necrosis (Day et al., 2008). Teeth with
an apical foramen narrower than 1mm in diameter should be
carefully monitored.
Autotransplanted teeth have been shown to be successfully
moved, because they heal with a functional periodontal ligament
(Trope, 2002) and may provide an often overlooked treatment
option in hypodontia cases requiring orthodontic treatment.
Orthodontic tooth movement following autotransplantation
should start approximately eight weeks after surgery, once the
periodontal ligament has healed, but prior to complete alveolar
healing. Orthodontic treatment must be aimed at minimising
any inflammatory stimuli which could damage the root surface
during healing (Day et al., 2008).
New Zealand Dental Journal March 2013
Conclusions
When considering the endodontic-orthodontic case, the
clinician must consider the prognosis of any compromised
tooth. Treatment considerations include the quality of previous
root canal treatment, the health of the periodontal membrane,
and making provision for careful application of orthodontic
forces. Even if a root-canal-treated tooth has a poor prognosis,
the clinician may choose to continue treatment to ensure a
favourable base for future autotransplant or implant treatment.
From the evidence available, there seems to be no clinically
significant difference in root resorption during orthodontic
tooth movement between root-canal-treated teeth and vital
teeth. However, if root canal treatment is required subsequent to
trauma, an observation period, to monitor pulp and periodontal
healing, of three months (in cases of mild trauma) or up to two
years (where there has been severe trauma) should be allowed
prior to orthodontic tooth movement.
Root-canal-treated teeth can be moved orthodontically to the
same extent as vital teeth, providing force levels are controlled
to avoid the risk of inflammatory root resorption. Good clinical
and radiographic assessment is important prior to planning any
orthodontic treatment. Informed consent is also important.
To ensure the best treatment outcome, it is essential to have
good interdisciplinary communication with the orthodontist,
endodontist, general dentist and/or paediatric dentist.
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Authors
Victoria Beck BDS
Suzan Stacknik DDS, MS
Discipline of Orthodontics, School of Dentistry, University of
Otago; PO Box 647, Dunedin, New Zealand.
Nicholas P. Chandler BDS (Lond), MSc (Manc), PhD (Lond),
LDSRCS (Eng), FDSRCPS (Glas), FDSRCS (Edin), FFDRCSI
Department of Oral Rehabilitation, School of Dentistry,
University of Otago; PO Box 647, Dunedin, New Zealand
Mauro Farella DDS, Dottore di Ricerca, SpecOrthodontics,
SpecMedStat
Discipline of Orthodontics, School of Dentistry, University of
Otago; PO Box 647, Dunedin, New Zealand.
Address correspondence to:
Victoria Beck, Sir John Walsh Research Institute,
School of Dentistry, University of Otago,

PO Box 647, Dunedin, New Zealand.

Email: becvi843@student.otago.ac.nz

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New Zealand Dental Journal March 2013 Orthodontic movement of teeth 11