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Background:
Review

The Impact of Orthodontic Treatment on Teeth Previously Treated with Regenerative Endodontics: A Systematic Review

by
Cristina Bucchi
1,2,*,
Alain Arias-Betancur
1,
Nicolás Badilla-Wenzel
1 and
Carlos Zaror
3,4
1
Departament of Integral Adult Dentistry, Faculty of Dentistry, Universidad de La Frontera, Temuco 4811230, Chile
2
Oral Biology Research Center, Universidad de La Frontera, Temuco 4811230, Chile
3
Center for Research in Epidemiology, Economics and Oral Public Health (CIEESPO), Universidad de La Frontera, Temuco 4811230, Chile
4
Faculty of Dentistry and Rehabilitation Sciences, Universidad San Sebastián, Sede de la Patagonia, Puerto Montt 4081339, Chile
*
Author to whom correspondence should be addressed.
Appl. Sci. 2024, 14(1), 210; https://doi.org/10.3390/app14010210
Submission received: 5 May 2023 / Revised: 22 September 2023 / Accepted: 3 October 2023 / Published: 26 December 2023
(This article belongs to the Section Applied Dentistry and Oral Sciences)
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Versions Notes

Abstract

:
Objective: To assess the tooth survival rates, adverse events, and need for further treatment of teeth previously treated with regenerative endodontics undergoing orthodontic treatment. Material and Methods: A literature search was performed using MEDLINE, EMBASE, Cochrane, Scopus, and Lilacs databases, grey literature, and endodontic journals, and the date of the last search was 20 April 2022. The included studies involved patients undergoing orthodontic treatment and at least one tooth that was previously treated with regenerative endodontics. A narrative synthesis of the findings was made. The risk of bias and evidence quality were assessed using the Effective Public Health Practice Project tool and the GRADE approach. Results: Five case reports included seven patients and eight teeth with a follow-up of 4 to 11 years. The overall risk of bias was high, and the certainty of evidence was very low. The survival rate was 87.5%. Adverse effects included sinus tracts, root resorption, symptomatology, apical periodontitis, and intracanal tissue necrosis. Five out of eight teeth required further intervention after orthodontics. Conclusions: A high prevalence of adverse effects and further intervention is observed in teeth treated with regenerative endodontics undergoing orthodontic treatment. The low quality of evidence highlights the need for comparative studies and evidence-based guidelines for managing these teeth during orthodontic treatment.

1. Introduction

Revitalization or regenerative endodontic therapy (RET) is a promising new treatment for immature necrotic teeth, with success rates from 82% to 95% of treated cases [1,2,3]. Although a recent systematic review concluded that no robust evidence is available to support that regenerative endodontics is effective in treating apical periodontitis in permanent teeth [4], some studies report encouraging clinical outcomes. Most treated teeth show further root development in the form of apical closure, dentin wall thickening and/or root lengthening, the resolution of clinical symptomatology, and healing of the periapical lesion [2,5]. Additionally, some teeth also respond positively to vitality tests [2]. Since the first modern case reports of the revitalization of necrotic teeth [6,7], the use of regenerative endodontics for the management of necrotic teeth has progressively increased in the past 15 years [8], and it relies on standardized protocols from the European Society of Endodontology [9] and the American Association of Endodontists [10] to perform the treatment.
RET is applied mostly to the immature teeth of young patients that often require orthodontic treatment as well. However, several concerns have been raised regarding the orthodontic tooth movement of teeth previously treated with regenerative endodontics. These concerns may be due to the possibility of a higher risk of internal root resorption compared to that with physiologically mature teeth and the possibility of devitalizing newly developed vascularized and innervated tissues within the root canal due to tooth movement.
The histological evidence after RET demonstrates that root maturation is not based on the apposition of dentin, but rather on the apposition of reparative hard tissues, such as osteodentin and bone-like tissue or cementum-like tissue [11], whereas the secretion of dentin after RET has been reported only in occasional studies [12]. Dentin is a highly organized tissue with a tubule-like structure, while reparative tissues (i.e., cementum and bone) show collagen fibers packed in a disorderly manner and a higher organic composition, with cell lacunae [13]. Moreover, cementum and bone have inferior mechanical properties (i.e., elasticity and hardness) compared to dentin [14]. Thus, the maturation of the root based on reparative hard tissues may affect the performance of the tooth when subjected to mechanical stress due to external forces, such as biting, trauma, or orthodontic loads. Computational studies have shown that physiologically developed teeth distribute mechanical stress more advantageously than teeth that complete root maturation with cementum [15].
Root resorption is a well-known risk of orthodontic treatment [16]. In 2016, the Position Statement on revitalization procedures of the European Society of Endodontology stated that after regenerative endodontics, teeth should be excluded from orthodontic treatment or follow-up intervals should be shortened during orthodontic treatment, since they may be more susceptible to inflammation and apical root resorption [9,17]. However, RET has recently been proposed as a possible solution for root resorption, since it may arrest the resorption process and allow for the progressive healing and remodeling of the lamina dura [18,19], possibly due to the immunomodulatory effect of stem cells associated with the treatment.
Regarding the loss of pulp vitality during orthodontic treatment, the forces applied to teeth and surrounding structures cause alterations in the pulp tissue [20], such as circulatory disturbances [20,21], fibrosis and calcification [21], and a decrease in the pulpal respiration rate [22]. Such histological alterations may lead to necrosis of the newly formed vascularized tissue. However, a recent systematic review stated that, clinically, the orthodontic movements do not induce the loss of pulp vitality [23]. Therefore, it remains inconclusive whether orthodontic tooth movement increases the risk of pulp necrosis above that of physiologically developed teeth undergoing tooth movement.
Considering what was previously stated, the question arises as to whether teeth previously treated with regenerative endodontics can undergo orthodontic tooth movement. Systematically analyzed, the evidence of orthodontic loads on RET-treated teeth is clinically relevant and will provide important information for decision-making in orthodontic practice. Therefore, the objectives of this systematic review are to determine the following: (1) the survival rate of teeth previously treated with regenerative endodontics that undergo orthodontic treatment; (2) the adverse events associated with orthodontic treatment in teeth previously treated with regenerative endodontics; (3) the improvement of quality of life of patients with teeth previously treated with regenerative endodontics that undergo orthodontic treatment; (4) the degree of tooth mobility and need for further intervention of teeth previously treated with regenerative endodontics that undergo orthodontic treatment.

1.1. Materials and Methods

This systematic review was reported according to the guidelines of Preferred Report Elements for Systematic Reviews and Meta-analysis (PRISMA) [24] and registered in the PROSPERO Database (Registration number CRD42022323521).

1.1.1. Eligibility Criteria

  • Study types: Any type of clinical study, irrespective of the design, i.e., randomized and non-randomized clinical trials, prospective and retrospective cohort studies, case-control studies, case series, and case reports in English, Spanish, or Portuguese.
  • Population: Patients with teeth previously treated with regenerative endodontics.
  • Exposure: Orthodontic treatment with fixed and/or removable appliances.
  • Comparator (if applicable): teeth previously treated with regenerative endodontics and not exposed to orthodontic treatment.
  • Outcome measures

1.1.2. Primary Outcomes

Tooth survival was defined as a tooth present in the mouth at the last follow-up. This outcome was measured at 6 months after the initiation of the orthodontic treatment, as a minimum.

1.1.3. Secondary Outcomes

  • Adverse events after the orthodontic treatment, such as pain, swelling, the need for medication (analgesics, antibiotics), the presence of a sinus tract, radiographic evidence of the appearance of or increase in the periapical lesion size, radiographic evidence of an altered periodontal ligament space, radiographic evidence of root resorption, and tenderness on percussion. These were reported separately and as a total number of adverse effects.
  • Quality of life of patients measured using a validated scale, such as the Malocclusion Impact Questionnaire (MIQ), Oral Health Impact Profile (OHIP), and Child Perceptions Questionnaire (CPQ), among others.
  • Degree of tooth mobility after the orthodontic treatment, measured using the Miller Mobility Index or other.
  • Need for further intervention after the orthodontic treatment.

1.1.4. Search Strategy

A systematic search was carried out up to 20 April 2022 as follows:
  • Search in electronic databases: Medline, Cochrane Central Register of Controlled Trials, EMBASE, SCOPUS, and LILACS.
  • A grey literature search was performed through searches in the Open Gray database (www.opengrey.eu), trial registers, such as the US National Institutes of Health Ongoing Trials, Register ClinicalTrials.gov (clinicaltrials.gov), and the WHO International Clinical Trials Registry Platform (https://trialsearch.who.int/), and available repositories (Networked Digital Library of Theses and Dissertations, Open Access Theses and Dissertations, DART-Europe E-theses Portal—DEEP, Open access to UK theses—EThOS).
  • Hand search:
    (i)
    Reference lists of included papers and previously published reviews,
    (ii)
    The last 20 years of International Endodontic Journal, Journal of Endodontics, Australian Endodontic Journal, Clinical Oral Investigations, Angle Orthodontist, Journal of Orthodontics, Orthodontics & Craniofacial Research, European Journal Of Orthodontics, American Journal Of Orthodontics, and Dentofacial Orthopedics.
The following search strategy was used: (Revascularization OR revascularization OR Revitalization OR revitalization OR ‘regenerative endodontics’ OR ‘regenerative endodontic therapy’ OR ‘regenerative endodontic procedures’ OR ‘regenerative endodontic treatment’) AND (Orthodontics OR ‘orthodontic treatment’ OR ‘fixed appliances’ OR ‘Removable appliances’ OR ‘orthodontic tooth movement’)
The search process was reported in accordance with the PRISMA-S guidelines [25].

1.2. Data Management

All references identified were extracted to Zotero software (Zotero, Corporation for Digital Scholarship, Vienna, VA, USA) to delete duplicates. The selection process was carried out with Rayyan QCRI (https://www.rayyan.ai/, accessed on 22 April 2022).
Titles and/or abstracts of studies retrieved were screened independently by two review authors (CB, AA) to identify studies that potentially met the inclusion criteria. Disagreements were resolved with a third reviewer. Full copies of all relevant studies and potentially relevant studies were obtained and those for which there are insufficient data in the title and abstract. Any disagreement was resolved with a third reviewer (CZ). The reasons for exclusion were recorded.
The data extraction was performed by two independent reviewers (CB, AA) who performed duplicate and independent data extraction using a pre-established spreadsheet. Extracted information included the study design/setting, year published, study population and participant demographics, tooth characteristics, details of the intervention and control conditions, outcome data of interest, and follow-up periods.

1.3. Quality Assessment of the Studies

The methodological quality was assessed with the Effective Public Health Practice Project (EPHPP) quality assessment tool [26,27] for quantitative studies, which has six components: (a) selection bias, (b) study design, (c) confounders, (d) blinding, (e) data collection methods, and (f) withdrawals/dropouts. Each component was classified as ‘strong’, ‘moderate’, or ‘weak’, and a global rating was obtained according to the number of components rated as weak (0, 1, or >1) [26]. Studies with weak methodological quality were assessed as having a higher risk of bias. Two researchers (CB and AA) performed the risk of bias assessment independently; any disagreements were resolved by a third researcher (CZ).

1.4. Strategy for Data Synthesis

A narrative synthesis of the findings was made. Tables were used to present information on the characteristics of RET, orthodontic treatment, and main outcomes reported. If the included studies were homogeneous, a meta-analysis using the software Review Manager (The Nordic Cochrane Center, The Cochrane Collaboration, Copenhagen, Denmark) was planned [28,29]. For dichotomous outcomes (such as tooth survival, tooth mobility, the need for further intervention, and adverse effects recorded as yes or no), the estimation of the effect of an intervention was the risk ratios (RRs) and standard mean differences for continuous outcomes (such as quality of life).
We planned to pool the risk ratios and mean differences using random-effects models when at least 2 studies could be included in the meta-analysis. Finally, we planned to elaborate a forest plot using a 95% confidence interval when feasible.

1.5. Assessment of Heterogeneity

A sensitivity test was planned to examine the contribution to the heterogeneity of each investigated parameter.
When feasible, the clinical heterogeneity in the included trials was performed by examining the similarity between the types of participants, interventions, and outcomes using the I² statistic, with values over 50% indicating considerable heterogeneity [29].

1.6. Additional Analysis

If feasible, subgroup analyses were planned as follows:
  • Orthodontic treatment performed using removable or fixed appliances.
  • Time lapse between regenerative endodontic treatment and orthodontic treatment (up to one year, more than one year)
  • Cause of pulp necrosis (caries, trauma, developmental defects).
  • Quality of life questionnaires used.

1.7. Assessment of Reporting Biases

We assessed a possible publication bias if more than 10 studies were included in the synthesis using Funnel plots and Egger’s linear regression method for the primary outcome (tooth survival) [29]. If asymmetry was detected, causes other than publication bias were explored, such as true heterogeneity, poor methodological quality in smaller studies, selective outcome reporting, artifacts, and chance.

1.8. Reporting Conclusions

The overall quality of the evidence for each of the main outcomes was rated by using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach [29,30]. A ‘summary of findings’ table for each comparison and for the outcomes was created using GRADEpro GDT software (http://gdt.guidelinedevelopment.org, accessed on 20 July 2022). We assessed the quality of the body of evidence with reference to the overall risk of bias of the included studies, directness of the evidence, inconsistency of the results, precision of the estimates, risk of publication bias, and magnitude of the effect. The quality of the evidence can be downgraded by one or two levels for each of these factors, reducing the confidence in the estimate of the effect. There are three factors that can increase the quality of evidence: large magnitude of an effect, dose–response gradient, and effect of plausible residual confounding. The quality of the body of evidence was categorized as high, moderate, low, or very low.

2. Results

The selection process is depicted in Figure 1. The electronic search retrieved 210 articles, and no studies were found in the grey literature, the reference list of the included studies, or by manual searching. After the exclusion of duplicates, unrelated articles, and one study with reasons (Figure 1), five studies were included [31,32,33,34,35], all of which were case reports. Thus, no comparative studies were found or included in this review.

2.1. Characteristics of Included Studies

The studies’ characteristics are summarized in Table 1. All case reports were published in the last 5 years. In total, seven patients and eight teeth were treated. Two studies were performed within institutional settings and three were performed in private clinics. No study reported receiving ethics committee approval. The duration of follow-up was between 4 years and 11 years after RET (Table 1).
The risk of bias summary of included articles is depicted in Figure 2. All studies were judged as having as a high risk of bias. The main flaws were the study design, case reports that did not allow for a comparison with a control group, and that the outcome assessors were not blinded to the intervention in any study. Additionally, ‘confounders’ were judged as moderate since different RET protocols were used in the studies and the scarce or null details regarding the characteristics of the orthodontic treatment.

2.2. Characteristics of the Participants

Patients’ characteristics are summarized in Table 1. All teeth were permanent non-vital immature maxillary incisors and premolars (Table 1). All but one tooth were associated with periapical radiolucent lesions before the initiation the regenerative endodontic therapy (Table 1).
None of the included studies applied the regenerative endodontic procedure as described by the two published clinical protocols of the European Society of Endodontology and the American Association of Endodontists. The main differences were the use of irritants at a high concentration, such as 4% to 6% sodium hypochlorite [31,34], and that no study applied a collagen sponge over the blood clot.

2.3. Characteristics of the Intervention (Orthodontic Treatment)

The time lapse between RET and the initiation of orthodontic treatment was between 1 and 6 years. All studies used fixed appliances, and two reported using removable appliances as well. Orthodontic treatment lasted between two months and two years, and it had to be interrupted in two patients, after 2 months and 6 months, due to complications (Table 2).

2.4. Outcomes after RET and Previous Orthodontic Treatment

The outcomes of the studies are summarized in Table 1. After RET, all teeth were asymptomatic and presented with partial or total periapical healing. Two teeth responded positively to the vitality pulp test, and two responded negatively. Five teeth presented with continuous root development in the form of apical closure, root thickening, and/or root lengthening, and two did not (Table 1).

2.5. Outcomes after Orthodontic Treatment

Overall, 87.5% (seven out of eight) of the treated teeth were present in the mouth in the last follow-up, and one was extracted (Table 2). Five patients (71.4%) presented with adverse effects during or after the orthodontic treatment, which were the presence of sinus tracts, external root resorption, invasive root resorption, clinical symptomatology, apical periodontitis, and necrosis of the intracanal tissue (Table 2). Five out of eight teeth (62.5%) needed further intervention after orthodontic treatments; two were treated with a second RET, one was extracted, and two needed root canal treatment (Table 2).
Root development continued after or during orthodontic treatment in three teeth (Table 2).
The oral health-related quality of life after orthodontic treatment was not reported in any study, and the tooth mobility outcome was reported in only one study (within normal limits).
Due to the design of the included studies and the clinical heterogeneity between the studies, a meta-analysis was not possible.

2.6. Certainty of Evidence

Since all studies included had an observational design, the quality of evidence started out low according to the GRADE approach (Table 3). In addition, the quality of evidence was downgraded, mainly due to a high risk of bias and imprecision. Therefore, the certainty of evidence for all outcomes was very low.

3. Discussion

Regenerative endodontic therapy is a promising new treatment for immature necrotic teeth, with encouraging clinical outcomes, such as apical closure, dentin wall thickening and/or root lengthening, the resolution of clinical symptomatology, and healing of the periapical lesion [2,5]. This systematic review sought to analyze whether teeth previously treated with regenerative endodontics, which present with intracanal reparative tissues [11], can undergo orthodontic tooth movement, or if they are at an increased risk of developing adverse effects compared to non-RET teeth. To our knowledge, this is the first systematic review investigating the effect of orthodontic treatment in such teeth. After screening the literature, no comparative clinical trials were found, with only case reports, with weak methodologies. The results showed a high prevalence of severe adverse effects and the need for additional interventions after the orthodontic treatment.
The overall risk of bias assessment in all included studies was high. Bias can be defined as a deviation from the truth and may lead to a false estimation of the intervention effect. As stated, all included studies had a high risk of bias in the domain ‘confounders’. A confounder, such as the protocols performed for RET and orthodontic treatment, is a variable that predicts the outcome of interest. Therefore, in the presence of confounding, the association between the intervention and outcome differs from its causal effect [29]. Similarly, none of the outcome assessors were blinded to the intervention. Blinding of the outcome assessors aims to prevent systematic differences in measurements [29], and thus the lack of it may contribute to bias. Finally, potential biases are likely to be greater for non-randomized studies than for randomized trials [29]; therefore, the results of this systematic review, based on case reports, should be taken with caution.
Biases are likely to be greater for studies, such as case reports, because some of the protections against bias, such as randomization, are not possible to perform. Randomization aims to balance prognostic factors across intervention groups, thus preventing confounding [29]. Thus, to evaluate the risk of adverse effects to an exposure (i.e., orthodontic treatment), randomized controlled trials are considered the gold standard. However, it should also be considered that under certain circumstances, when no such studies are available, case reports may contribute relevant knowledge for systematic reviews [36]. The Cochrane Collaboration handbook states that ‘for some rare or delayed adverse outcomes only case series or case-control studies may be available. Non-randomized studies of interventions with some study design features that are more susceptible to bias may be acceptable for evaluation of serious adverse events in the absence of better evidence’ [29]. This may apply to the specific subject studied in this review, where case reports can serve as the first evidence of the potential effects of orthodontic treatment in teeth previously treated with regenerative endodontics.
None of the included studies applied the regenerative endodontic procedure as described by the two published clinical protocols by the leading endodontic societies. The medications used during RET affects the ability of the mesenchymal stem cells to survive, to adhere to the dentin matrix, and to differentiate into odontoblasts-like cells. Thus, 6% sodium hypochlorite is related to a significant reduction in survival and dentin sialophosphoprotein gene expression, while these effects can be prevented with the use of lower NaOCl concentrations [37]. Further studies should follow standardized and evidence-based protocols.
The papilla apical is a soft tissue rich in mesenchymal stem cells (stem cells from apical papilla—SCAPs) that are able to survive even after a prolonged periapical infection [38,39]. The epithelial–mesenchymal interaction between the apical papilla and the Hertwig epithelial root sheath (HERS), the proliferation of epithelial cells located at the cervical loop of the enamel organ, coordinates the radicular development of the immature teeth. Thus, radicular development requires the survival and interaction of such embryological structures.
It has been reported that in all cases treated with RET, trauma is the most frequent etiology for pulp necrosis, followed by developmental dental anomalies [40]. In the included studies in this systematic review, the cause of pulp necrosis was trauma in all except one tooth that had a dens evaginatus, while caries was the cause of pulp necrosis in no teeth. A previous study suggested that trauma was associated with worse outcomes after regenerative endodontics compared to dens evaginatus, possibly due to the damage to the Hertwig epithelial root sheath and apical papilla stem cells [41]. Although this was rejected in a recent systematic review and meta-analysis that found no statistical differences in the success rate related to the cause of pulp necrosis [42], further studies should assess whether this also applies to teeth previously treated with regenerative endodontics that undergo orthodontic treatment.
Despite the high prevalence of adverse effects and need for further intervention in the included studies, one of the case reports with a remarkably compromised tooth was successful [31]. Before treatment, the tooth had a history of triple trauma, root fracture, and a sinus tract that had not completely healed when orthodontic treatment was initiated. The teeth presented with no adverse effects and no need for further intervention after 5.5 years of the orthodontic treatment. Moreover, the sinus tract and root fracture were healed after the orthodontic treatment.
There is a lack of comparative studies to establish whether teeth treated with RET in the past and subjected to orthodontic treatment are at higher risk of adverse effects compared with non-RET treated teeth. Should that association exist, there is a need to establish the factors influencing the outcomes. Possible factors that would need further investigation are related to the characteristics of the tooth, such as the cause of pulp necrosis, type of teeth, presence of preexisting periapical lesions, and others; the regenerative endodontic procedure, such as the medications used and the time lapse between RET and orthodontic treatment; and the characteristics related to the orthodontic treatment, such as the duration of the treatment and the direction and magnitude of the forces applied to the tooth, among others.
Apparently, there is a high prevalence of adverse effects and a need for further intervention in teeth previously treated with regenerative endodontics that undergo orthodontic treatment, although tooth survival is high. However, all the review findings should be taken with caution, since the certainty of the evidence is very low. The evidence is insufficient to advise clinicians whether orthodontic treatment affects the survival and morbidity of these teeth. Until a higher level of evidence is achieved and whenever possible, clinicians may avoid the inclusion of these teeth in the archwire during the orthodontic treatment or submit these teeth to a low magnitude of orthodontic force. If such teeth are included in the orthodontic treatment, follow-up intervals should be shortened in order to detect possible adverse effects early.
Case reports show a high prevalence of adverse effects and the need for further interventions in teeth previously treated with regenerative endodontics that undergo orthodontic treatment. There is a complete lack of comparative studies regarding the subject. Thus, clinicians can only rely on case reports, with weak methodologies. There is a need for high-quality designs to determine the effect of orthodontic treatment and their intensity on teeth that have been treated with RET in the past.

Author Contributions

Conceptualization, C.B. and C.Z.; methodology, C.B. and C.Z.; software, C.B., A.A.-B. and N.B.-W.; validation, C.B., A.A.-B., N.B.-W. and C.Z.; formal analysis, C.B., A.A.-B., N.B.-W. and C.Z.; investigation, C.B.; resources, C.B.; data curation, C.B., A.A.-B. and N.B.-W.; writing—original draft preparation, C.B.; writing—review and editing, C.B., A.A.-B., N.B.-W. and C.Z.; visualization, C.B.; supervision, C.B. and C.Z.; project administration, C.B. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Acknowledgments

All authors confirm that there is no financial affiliation or involvement with any commercial organization with direct financial interest in the subject or materials discussed in this manuscript, nor have any such arrangements existed in the past three years.

Conflicts of Interest

The authors declare no conflict of interest.

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Applsci 14 00210 g001
Figure 1. Flow chart summarizing the article selection process.
Figure 1. Flow chart summarizing the article selection process.
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Figure 2. Risk of bias of the included studies [31,32,33,34,35].
Figure 2. Risk of bias of the included studies [31,32,33,34,35].
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Table 1. Characteristics of the included studies and outcomes of regenerative endodontic therapy.
Table 1. Characteristics of the included studies and outcomes of regenerative endodontic therapy.
N of PatientsAge at Initiation of RETToothPulp Necrosis EtiologyPresence of Periapical LesionOutcomes after RET and Previous Orthodontic TreatmentTooth Survival
Response to Vitality Pulp TestsSymptomatologyPeriapical HealingRoot Maturation
Alharbi 2021 [34]19Maxillary central incisorTraumaYesNRAsymptomaticHealedNoYes
9Maxillary central incisorTraumaYesNRAsymptomaticHealedNoYes
Chaniotis 2018 [31]19Maxillary central incisorTrauma (intrusion)YesNRAsymptomaticHealingYes (dentin wall thickening and lengthening)Yes
Jawad 2018 [32]115Maxillary central incisorTraumaNoPositiveAsymptomaticNAYes (dentin wall thickening)Yes
Natera 2018 [33]114Lower premolarDens evaginatusYesNegativeAsymptomaticHealedNoYes
Chaniotis 2022 [35]39Maxillary central incisorTrauma (intrusion)YesPositiveAsymptomaticHealedYes (dentin wall thickening)No
6Maxillary central incisorTrauma (lateral luxation injury)YesNRNRHealedYes (dentin wall thickening and lengthening and apical closure)Yes
7Maxillary central incisorTraumaYesNegativeAsymptomaticHealedYes (dentin wall thickening and lengthening and apical closure)Yes
NR: Not reported.
Table 2. Characteristics of orthodontic treatment and outcomes after the orthodontic treatment of teeth previously treated with regenerative endodontics. NR: not reported.
Table 2. Characteristics of orthodontic treatment and outcomes after the orthodontic treatment of teeth previously treated with regenerative endodontics. NR: not reported.
StudyToothOrthodontic DiagnosisTime Lapse between RET and Orthodontic TreatmentUse of Removable AppliancesUse of Fixed AppliancesDuration of Orthodontic TreatmentRoot Development during or after Orthodontic TreatmentN of Adverse Effects (Type) after or during OrthodonticsTooth MobilityNeed for Additional Treatment after Orthodontics (Type)Follow-Up (since RET until Last Follow-Up
Alharbi 2021 [34]Maxillary central incisorNR1 yearNRYesNRYes1 (sinus tract)NRYes (second RET)7 years
Maxillary central incisorNR1 yearNRYesNRYes1 (periapical lesion)NRYes (second RET)7 years
Chaniotis 2018 [31]Maxillary central incisorSkeletal Class II division 1 malocclusion with an overjet of 11 mm3.5 yearsNRYes2 yearsNo0Within normal
limits		No5.5 years
Jawad 2018 [32]Maxillary central incisorSkeletal Class II division 1 with an overjet of 7 mm.4 yearsYesYes22 monthsYes1 (apical root resorption)NRNo6 years
Natera 2018 [33]Lower premolarNR1 yearNRYes2 yearsNo0NRNo4 years
Chaniotis 2022 [35]Maxillary central incisorMandibular prognathism and malocclusion with tooth crowding4 yearsYesYes2 yearsNo2 (external cervical resorption and soft tissue bleeding)NRYes (tooth extraction)11 years
Maxillary central incisorSlight tooth crowding3 yearsNRYes2 monthsNo3 (apical periodontitis, tenderness to percussion, necrosis of intracanal tissue)NRYes (root canal treatment)4 years
Maxillary central incisorMidline diastema due to dental class II division 1 malocclusion6 yearsNRYes6 monthsNo3 (symptomatology, sinus tract, and external root resorption)NRYes (Root canal treatment)6.5 years
Table 3. Summary of findings.
Table 3. Summary of findings.
Certainty AssessmentSummary of Findings
Participants (Studies)Risk of BiasInconsistencyIndirectnessImprecisionPublication BiasOverall Certainty of EvidenceAnticipated Absolute Effects
Tooth survival
Five observational studies
 
(Eight teeth)		very serious anot seriousnot seriousserious bnone⨁◯◯◯
Very low		The tooth survival was 87.5% (seven out of eight teeth)
Need of additional treatment
Five observational studies
 
(Eight teeth)		very serious anot seriousnot seriousserious bnone⨁◯◯◯
Very low		Five out of eight teeth (62.5%) needed further intervention after orthodontic treatments
Adverse effects
Five observational studies
 
(Eight teeth)		very serious anot seriousnot seriousserious bnone⨁◯◯◯
Very low		Five patients (71.4%) presented some adverse effects during or after the orthodontic treatment
Explanations: a we downgraded the evidence by two levels because of serious concerns regarding the risk of bias because all studies had a weak methodological quality. b We downgraded the evidence by a level because of imprecision due to the small number of participants.
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Bucchi, C.; Arias-Betancur, A.; Badilla-Wenzel, N.; Zaror, C. The Impact of Orthodontic Treatment on Teeth Previously Treated with Regenerative Endodontics: A Systematic Review. Appl. Sci. 2024, 14, 210. https://doi.org/10.3390/app14010210

AMA Style

Bucchi C, Arias-Betancur A, Badilla-Wenzel N, Zaror C. The Impact of Orthodontic Treatment on Teeth Previously Treated with Regenerative Endodontics: A Systematic Review. Applied Sciences. 2024; 14(1):210. https://doi.org/10.3390/app14010210

Chicago/Turabian Style

Bucchi, Cristina, Alain Arias-Betancur, Nicolás Badilla-Wenzel, and Carlos Zaror. 2024. "The Impact of Orthodontic Treatment on Teeth Previously Treated with Regenerative Endodontics: A Systematic Review" Applied Sciences 14, no. 1: 210. https://doi.org/10.3390/app14010210

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