Regenerative Endodontics
Orthodontic Movement after Regenerative
Endodontic Procedure: Case Report and
Long-term Observations
Antonis Chaniotis, DDS, MD
Abstract
Introduction: Although regenerative treatment ap-
proaches in teeth with incomplete root formation and
pulp necrosis have become part of the suggested therapeu-
tic endodontic spectrum, little is known about the effect of
orthodontic movement in the tissue that has been regener-
ated. Furthermore, as the number of adults undergoing
orthodontic treatment increases, there is an increasing
S urprisingly, detailed in-
need to investigate the changes that these tissues may un-
dergo during orthodontic movement. Here we describe the
alterations observed after the application of orthodontic
forces in a case of an apically root-fractured necrotic
immature root that had been managed with regenerative
endodontic procedures in the past. Methods: A 9-year-
old male patient was referred after suffering the third inci-
dence of trauma in the anterior maxilla. Radiographic
evaluation revealed a periapical rarefaction associated
with an apically root-fractured immature central incisor.
Clinical evaluation revealed a buccal abscess and grade
3 tooth mobility. Periodontal probing was within normal
limits. The tooth was accessed and disinfected by using
apical negative pressure irrigation of 6% NaOCl. Intraca-
nal dentin conditioning was achieved by using 17% EDTA
for 5 minutes. A blood clot was induced from the periapical
area, and calcium silicate–based cement was placed in
direct contact with the blood clot at the same visit. The
composite resin restoration was accomplished in the
same appointment. Results and Conclusions: Recall
radiographic examination after 24 months revealed
healing of the periapical lesion and signs of continuous
root development despite the apical root fracture. Clinical
evaluation revealed normal tooth development, normal
mobility, and a resolving buccal infection. The tooth was
subjected to orthodontic treatment because of Class II
division 1 malocclusion with an overjet of 11 mm. After
completion of the orthodontic treatment, 5.5 years after
the initial intervention, the radiographic image revealed
marked remodeling of the periapical tissues and repair of
the apical fractures, and the buccal infection had resolved
completely. (J Endod 2018;44:432–437)
From the Endodontics, Warwick Dentistry/Athens Dental School, Kalithea, Atiki, Greece.
Address requests for reprints to Dr Antonis Chaniotis, Warwick Dentistry/Athens Dental School, Endodontics, 17676 Kalithea, Atiki, Greece. E-mail address:
antch8@me.com
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2017.11.008
432 Chaniotis
Key Words
Apical fracture, Biodentine, negative pressure irrigation, orthodontic movement, regen-
erative procedures
formation on the overall
relationships between end-
Significance
The effect of orthodontic tooth movement after
regenerative endodontic repair procedures is
odontics and orthodontics
largely unknown. Under certain circumstances, or-
during treatment planning
thodontic tooth movement might improve the peri-
decisions is sparse and
apical repair of necrotic immature teeth that had
insufficient (1). There is a
been subjected to regenerative endodontic pro-
general belief that ortho-
cedures.
dontic tooth movement
can cause degenerative
and/or inflammatory responses in the dental pulp of teeth with completed apical forma-
tion. Although teeth with incomplete apical foramen are not immune to adverse sequelae
during tooth movement, a reduced risk for these responses is expected (1). The impact of
the tooth movement on the pulp is focused primarily on the neurovascular system, in
which the release of specific neurotransmitters (neuropeptides) could influence both
blood flow and cellular metabolism. The responses induced in these pulps are suggested
to impact on the initiation and perpetuation of apical root remodeling or resorption dur-
ing tooth movement (2). The incidence and severity of these changes might be influenced
by the width of the apical opening and the previous or ongoing insults to the dental pulp
such as trauma or caries. Moreover, for teeth with previous root canal treatments, fewer
propensities for apical root resorption during orthodontic tooth movement are expected
(1). Minimal resorptive/remodeling changes can occur apically in well-cleaned, shaped,
and three-dimensionally obturated teeth that are being moved orthodontically, and the
outcome would depend on the absence of coronal leakage or other avenues for bacterial
ingress.
It is believed that traumatized teeth can also be moved orthodontically with min-
imal risk of resorption, provided the pulp has not been severely compromised (infected
or necrotic). If there is evidence of pulpal disease, appropriate endodontic manage-
ment is necessary before orthodontic treatment. If a previously traumatized tooth ex-
hibits resorption, there is a greater chance that orthodontic tooth movement will
enhance the resorptive process. If a tooth has been severely traumatized (intrusive luxa-
tion/avulsion), there may be a greater incidence of resorption with tooth movement.
Recently, regenerative endodontic procedures were introduced for the induction
of continued root development and dentin wall thickening in necrotic immature trau-
matized teeth. Although early case reports suggested regeneration, histologic studies in
JOE — Volume 44, Number 3, March 2018

animals and extracted teeth from patients, which had received regener-
ative endodontic procedures, suggest that what takes place in some
cases may not be regeneration. It might be healing or repair, which
is defined as tissue formation with a (partial) loss of function of the orig-
inal tissue (3). When it comes to such teeth, very little is known about
our ability to move them. Likewise, little is known about the potential
risks or sequelae involved in moving immature teeth that have had
repair tissue ingrowth after previous regenerative intervention. Espe-
cially absent is the long-term prognosis of this type of treatment in
such teeth.
The aim of this article was to describe the long-term alterations
observed after the application of orthodontic forces in a case of an
apically root-fractured necrotic immature root that had been managed
with regenerative endodontic procedures in the past. The regenerative
endodontic procedure followed is also discussed in detail.
Case Report
A 9-year-old male patient was referred for the evaluation and
possible treatment of his right maxillary central incisor after suffering
the third incidence of trauma. His medical history was non-
contributory. In his dental history, he reported 2 previous impact
injuries during soccer training. The first injury was described as a
concussion injury 8 months before attending our office. The second
injury (3 months later) was described as enamel dentin fracture that
had been managed by composite resin restoration. The third injury
was suffered 1 month before the initial visit and was described as an
intrusion injury with minimal displacement.
Clinical evaluation at the time of the initial visit revealed grade 3
mobility of the tooth combined with a buccal abscess (Fig. 1A). The
tooth was percussion painful. Periodontal probing was less than
3 mm all around the tooth. Thermal and electrical vitality tests were
negative only for the right maxillary central incisor. The incisal edge
of the right maxillary central incisor seemed 0.5 mm lower than its
contralateral central incisor, suggesting an intrusion luxation injury
with minimal displacement (Fig. 1A).
Figure 1. (A) Preoperative labial view of maxillary anterior teeth after intrusion injury; (B) 2-year follow-up labial view showing persistence of buccal abscess; (C)
42-month follow-up labial clinical view showing reduced size of persistent buccal abscess; (D) 5.5-year follow-up clinical view showing healthy tissues.
JOE — Volume 44, Number 3, March 2018
Regenerative Endodontics
The radiographic evaluation of the right maxillary central incisor
revealed an immature root with an associated periapical lesion around
the wide-open apex (Fig. 2A). Detailed examination of the periapical
radiograph revealed 2 apically located fracture lines, suggesting that
the weak root had been fractured in the vertical and horizontal planes
during the intrusion injury. A pulpal diagnosis of pulp necrosis was
made. The periapical diagnosis was acute apical abscess associated
with an apically fractured immature tooth. Tooth retention at that
time seemed extremely challenging because spontaneous repositioning
and normal tooth development were halted. A decision was made to try
and save this tooth by applying regenerative endodontic therapy.
Regenerative Endodontic Therapy
After delivering non–vasoconstrictor-containing infiltration anes-
thesia (Mepivastesin; 3M ESPE, Seefeld, Germany), the rubber dam was
placed and secured with wedges and liquid dam material (Dam Cool;
Danville Materials Inc, San Ramon, CA). Initial access to the wide canal
was achieved by using the Endoguide burs (S S White Burs Inc, Lake-
wood, NJ) and by using a 25-mm-long Endo Z bur (Dentsply Maillefer,
Ballaigues, Switzerland). On entering the wide canal, purulent exudate
was noticed. After the purulent drainage ceased, the wide canal was
rinsed with sterile water.
By using an electronic root canal length measurement device
(Root ZX; J Morita Mfg Corp, Kyoto, Japan) and an ISO 100 Hedstrom
file, the level of the apical fractures was assessed and verified with a
radiograph (Fig. 2B). Disinfection was achieved by using negative pres-
sure irrigation. An Endo Vac macro cannula (Endo Vac; Axis/Sybron
Endo, Coppell, TX) was inserted into the wide canal, and 6% NaOCl so-
lution (CanalPro plus; Coltene/Whaledent, Langenau, Germany) was
delivered in the coronal part of the root. Approximately 45 mL freshly
introduced 6% NaOCl was delivered, followed by 10 mL 17% EDTA so-
lution (Canal Pro; Coltene/Whaledent). The macro cannula was with-
drawn from the canal in the presence of sufficient EDTA solution in
the pulp chamber to ensure that the canal remained totally filled with
EDTA, and no air was drawn into the canal space.
Regenerative Endodontics and Orthodontics 433
Regenerative Endodontics

Figure 2. (A) Preoperative periapical radiograph of tooth 8 (apical fracture of the thin dentinal walls); (B) working length radiograph; (C) postoperative radio-
graph; (D) baseline periapical radiograph; (E) 5-month follow-up periapical radiograph showing initial healing of periapical lesion and hard tissue bridging; (F) 8-
month follow-up periapical radiograph showing progressive healing and signs of continuous root development and thicker hard tissue bridging; (G) 2-year follow-
up radiograph showing signs of healing of apical fractures and signs of continuous root development; (H) 30-month follow-up periapical radiograph showing stable
situation; (I) 42-month periapical radiograph after initiation of orthodontic treatment; (J) 5.5-year follow-up radiographic evaluation showing marked remodeling
of apical fractured walls and complete healing.

The wide canal was left flooded with EDTA 17% solution for 5 mi-
nutes. Final irrigation was achieved with apical negative pressure irriga-
tion of sterile water. The wide canal was dried with the Endo Vac macro
cannula adjusted 1 mm short of the predetermined length.
An ISO 35 Hedstrom file mounted on a file holder was used for
bleeding induction. The Hedstrom file was introduced through the wide ca-
nal under microscopic visualization and used for the laceration of the peri-
apical tissues. Bleeding from the periapical area was easily induced and
visualized under the microscope. The excess blood was evacuated from
the pulp chamber with the Endo Vac macro cannula, leaving the rest of
the blood to clot at a level 3 mm below the cementoenamel junction.
Biodentine putty material (Septodont, Saint Maur-des-Fosses,
France) was prepared in an amalgamator for 30 seconds according
to the manufacturer’s instructions. A small amalgam carrier was used
to deliver the Biodentine over the blood clot, and a temporary restora-
tion was placed (Cavit G; 3M ESPE). A postoperative radiograph was
taken (Fig. 2C). One week later, the tooth was asymptomatic, mobility
was within normal limits, and the buccal abscess had subsided. The per-
manent composite resin restoration was placed, and the patient was
scheduled for re-evaluation. No splinting was performed. A periapical
radiograph was taken as baseline for further evaluations (Fig. 2D).
Follow-ups
The 5-month and 8-month recall radiographs revealed almost
complete healing of the periapical lesion and continuous root develop-
ment of the vertically fractured immature root (Fig. 2E and F). However,
the fracture lines were still detectable. A hard tissue bridge was also
evident under the Biodentine material in both the 5-month and 8-
month periapical radiographs (Fig. 2E and F).
The 24-month clinical evaluation revealed normal tooth develop-
ment. The tooth was asymptomatic, periodontal probing was less than
3 mm all around the tooth, and mobility had returned within normal
limits. The buccal abscess was reduced in size but not completely
resolved. The labial clinical view of the maxillary incisors at the 2-
year follow up can be seen in Figure 1B. The radiographic evaluation
at the 2-year follow-up revealed signs of continuous root development
and healing of the apical fractures (Fig. 2G).
A 30-month follow-up radiograph was taken for the evaluation of
the healing process. The radiographic evaluation revealed a stable sit-
uation with detectable calcified tissue bridging under the Biodentine
material and signs of periapical healing (Fig. 2H).
After 42 months the tooth was asymptomatic, and the buccal abscess
seemed smaller but not completely resolved. At that time the patient at-
tended an orthodontist for the correction of his facial profile. After dis-
cussing with the orthodontist all the alternatives, a common decision
was made to use this tooth during the orthodontic treatment despite
the existence of the persistent but decreasing buccal abscess. Informed
consent was obtained, and the orthodontic treatment was initiated. The
clinical and radiographic images immediately after the initiation of the
orthodontic treatment can be seen in Figures 1C and 2I, respectively.

434 Chaniotis JOE — Volume 44, Number 3, March 2018


Orthodontic Treatment
The orthodontic diagnosis was skeletal Class II division 1 maloc-
clusion with an overjet of 11 mm. The patient did not want surgical
approach to treatment, and even though the underlying sagittal jaw
discrepancy was severe, the selective extraction of 2 permanent maxil-
lary first premolar teeth was considered acceptable. The treatment plan
followed aimed at the nonsurgical correction of the malocclusion with
dental camouflage to mask the skeletal discrepancy. With this treatment
plan, marked improvement in patient’s smile, facial profile, and lip
competence is targeted. The orthodontic treatment lasted 2 years.
At the 5.5-year follow-up immediately after the completion of or-
thodontic treatment, the clinical and the radiographic views of the right
maxillary central incisor can be seen in Figures 1D and 2J, respectively.
The tooth was asymptomatic, and the buccal abscess had resolved. The
radiographic image suggested that the orthodontic movement resulted
in remodeling of the apical tissues and repair of the apical fractured tis-
sues.
Discussion
In the present case, the minor intrusion suffered in the last injury
was complicated, with radiographically detectable vertical and horizon-
tal fractures of the thin dentinal walls combined with an acute periapical
abscess. The prognosis of such immature vertically and horizontally
fractured teeth is usually considered very poor, and extraction seems
the only alternative. However, very recently, a case of hard tissue healing
of multiple horizontal root fractures by following a regenerative end-
odontic procedure was reported (4). Likewise, in the present case, a
decision was made to try and induce hard tissue healing of the fractured
developing structures, continuous root development, and dentin wall
thickening by following a similar regenerative endodontic procedure.
Some years ago when Andreasen et al (5) were investigating the
effect of damaging the Hertwig epithelial root sheath (HERS) on root
growth after autotransplantation of teeth in monkeys, they showed
that the HERS could function normally subsequent to trauma elicited
by surgical separation of the follicle and the post-transplantation distur-
bances in nutrition. In their article, they suggested that a highly regen-
erative potential appeared to exist in this structure, even if just a small
fraction of it was left intact. They also noticed that pulp necrosis usually
leads to complete or almost complete arrest of root formation in all
experimental groups.
In the present case, it was hypothesized that the HERS suffered se-
vere post-trauma nutritional and mechanical disturbances. The apical
fractures of the thin dentinal walls confirmed the magnitude of the
impact injury. Pulp necrosis and periapical lesion growing around
the developing fractured structures suggested complete arrest of root
formation. However, if a small fragment of HERS had been left intact,
it could have maintained a highly regenerative potential as suggested
by Andreasen et al (5).
In this case, it was hypothesized that appropriate disinfection of the
apical third might result in maintaining some fragments of the HERS still
vital. Lin et al (6) reported vital tissues present even in pulp chambers of
mature permanent teeth associated with periapical radiolucencies. In
the case of immature teeth, this situation could be more common. An
open apex usually provides good communication from the pulp space
to the periapical tissues; therefore, it might be possible for periapical
disease to occur while the pulp is only partially necrotic and infected.
Along the same line of reasoning, stem cells in pulp tissue and apical
papilla might also have survived the bacterial invasion (7). HERS frag-
ments combined with the regenerative potential of the apical papilla
could result in the continuous root development of compromised
necrotic fractured cases such as the one reported here.
JOE — Volume 44, Number 3, March 2018
Regenerative Endodontics
Although most regenerative endodontic procedures used either
triple antibiotic paste or calcium hydroxide as intracanal medicament
for disinfection (8), in the present case we decided to follow a
single-step disinfection procedure by using negative pressure irrigation.
Antibiotic pastes containing minocycline can cause visible crown
discoloration (9). Recently, antibiotic alternatives to minocycline
have been proposed for use in combination with minocycline and
metronidazole, including amoxicillin, cefaclor, and doxycycline. In a
spectrophotometric analysis of crown discoloration induced by various
antibiotic pastes used in revascularization, Akcay et al (10) concluded
that only calcium hydroxide and double antibiotic paste showed no co-
lor changes exceeding the perceptibility threshold. Furthermore, there
are concerns other than tooth discoloration that are associated with in-
tracanal use of an antibiotic or antibiotic combination. Such concerns
include the fear of promoting antibiotic resistance in some root canal
bacteria and the risk of precipitating an allergic reaction in a sensitive
patient or inducing sensitivity in a patient who has never been sensitive
(11). Moreover, Ruparel et al (12) demonstrated that high concentra-
tions of antibiotics have a detrimental effect on survival of apical papilla
stem cells. Very recently, Yassen et al (13) raised another concern for
the effects of the medicaments used in endodontic regeneration proced-
ures. The superficial collagen degradation or the demineralization ef-
fect of radicular dentin caused by calcium hydroxide or antibiotic
pastes, respectively, may negatively affect the fracture resistance of
the radicular dentin.
Recently, da Silva et al (14) evaluated in vivo the revascularization
potential for apical and periapical repair of 2 disinfection techniques in
immature dogs’ teeth with apical periodontitis. The techniques tested
included 1-step revascularization procedures by using apical negative
pressure irrigation versus multiple-visit positive pressure irrigation
plus triple antibiotic intracanal dressing. Although statistically significant
difference was found only for the inflammatory infiltrate, the single-step
apical negative pressure group presented more exuberant mineralized
formations, more structured apical and periapical connective tissue,
and a more advanced repair process than triple antibiotic group. The
results of this study demonstrated that from histologic observations,
single-step regenerative procedures with the use of apical negative pres-
sure irrigation might represent an important technical advancement for
the treatment of immature teeth with apical periodontitis, suggesting that
the use of intracanal antibiotics might not be necessary.
Keeping in mind these suggestions, in the present case we used the
macro cannula of the Endo Vac device (Axis/Sybron Endo) to perform
apical negative pressure irrigation of 6% NaOCl solution for the disin-
fection of the apical third of the necrotic fractured immature root.
Because the plastic macro cannula of the Endo Vac is not sterile, we dis-
infected it by leaving it for 5 minutes in a sterile dish filled with 6%
NaOCl. Negative pressure irrigation of 6% NaOCl was followed by
EDTA 17% solution irrigation that was left for 5 minutes inside the
wide canal. The importance of dentin conditioning with EDTA 17%
before the evoked bleeding phase in regenerative endodontic proced-
ures has been reported many times in the literature (15, 16).
Biodentine material (Septodont) was directly applied over the
blood clot. The tricalcium silicate–based cement called Biodentine
has been developed recently. The powder is mainly composed of trical-
cium silicate, calcium carbonate, and zirconium oxide (17). The liquid
contains water, calcium chloride (used as a setting accelerator), and a
modified polycarboxylate (a superplasticizing agent). A single dose of
liquid is dropped in a disposable cap containing the powder and
then mixed with an amalgamator for 30 seconds. Its physical properties
and reduced setting time to 12 minutes (17) as compared with Portland
cements might render the new biomaterial acceptable for use as a cor-
onal barrier in regenerative endodontic procedures.
Regenerative Endodontics and Orthodontics 435
Regenerative Endodontics
Moreover, it has been demonstrated that when Biodentine was
applied directly onto pulp tissue, it induced an early form of reparative
dentin synthesis, probably because of a modulation of pulp cell trans-
forming growth factor (TGF)-b1 secretion (17). An increase in TGF-b1
concentration locally during pulp-capping may contribute to
odontoblast-like cell differentiation and mineralization.
In revascularization procedures, Lovelace et al (18) demonstrated
that the evoked bleeding step triggers the significant accumulation of
undifferentiated stem cells into the canal space where these cells might
contribute to the regeneration of pulpal tissues seen in necrotic imma-
ture teeth undergoing apexogenesis.
In the present case, we hypothesized that Biodentine placed in
direct contact with the blood clot may have stimulated the
odontoblast-like differentiation of the apical papilla stem cells that
were introduced in the wide canal space of the immature root.
Biodentine-induced upregulation of TGF-b1 secretion may explain
the dentinal bridge that was radiographically detectable at the follow-
up periapical radiographs.
Although the fracture lines were still detectable in the 24-month
recall radiograph, the periapical lesion healed almost completely,
and continued root development and apex formation were evident.
However, the developing apical third seemed to be partly detached
from the main wide canal.
Jung et al (19) reported 2 cases of infected immature teeth that
resulted in the formation of a separate root tip after apexification and
revascularization procedures, respectively. These cases revealed that
HERS and stem cells from the apical papilla can in rare situations be
detached by an external force or iatrogenic factors and thereafter pro-
duce a separated tip. They speculated that in their first case the apexi-
fication procedure was responsible for the separation, whereas in the
second case increased mobility acted as the separation force.
In the case reported here, it is possible that HERS and the apical
papilla were partly detached after the third intrusive impact injury. How-
ever, the radiographically detectable vertical root fracture that rendered
regeneration procedures even more challenging complicated the pre-
sent case. The 24-month follow-up examination revealed normal tooth
mobility, no periodontal probing, no crown discoloration, continuous
root development, and formation of the apex.
Orthodontic treatment was initiated 42 months after the initial
intervention. According to the orthodontist, the preservation of this
tooth was crucial for the planning of the orthodontic treatment. Prema-
ture extraction of this tooth would have been detrimental for the facial
development of the patient, and it would have greatly complicated the
orthodontic treatment. Although the persistence of the buccal abscess
raised some concerns, a decision was made to use this tooth in the or-
thodontic treatment planning. The decreasing size of the buccal abscess
and the radiographically detectable healing of the periapical lesion
despite the apical fracture were considered as positive predictors for
the application of orthodontic forces in this case. Possible remodeling
of the apical tissues triggered by the orthodontic movement was hoped
to facilitate further healing by taking advantage of the young patient’s
healing potential. Unfortunately, little is known about our ability to
move such teeth. Most of our relevant knowledge concerns teeth with
vital pulp tissues.
For teeth with vital pulp tissues, it is believed that during rapid
tooth movement, pulpal injury may occur because of an alteration
in the blood vessels in the apical periodontium and those entering
the pulp (20). Historically, the specific angiogenic changes in the hu-
man dental pulp associated with orthodontic movement have received
limited study. Angiogenesis is the formation of new capillary struc-
tures that ultimately lead to the organization of larger structures by
a process of neovascularization (21). By using fluorescent micro-
436 Chaniotis
spheres, Kvinnsland et al (22) showed a substantial increase in blood
flow in the dental pulp of mesially tipped rat molars. Increases in
force application resulted in an increase in blood flow. By using
the rat model, Nixon et al (23) also found that there was a significant
vascular change with an increased number of functional pulpal ves-
sels as related to the specific forces applied. Initially a hyperemic
response was visible after the force applications. In a later study,
Derringer et al (24) moved human teeth orthodontically, extracted
the teeth, and harvested the pulps. The pulps were embedded in
collagen and cultured in growth media for up to 4 weeks. New micro-
vessels were observed within 5 days, and their identification was
confirmed with both light microscopy and electron microscopy.
There were significantly larger numbers of microvessels at day 5
and day 10 of culture in pulp explants from orthodontically moved
teeth than in the control teeth. These findings would suggest not
only the presence of significant angiogenesis in the pulp during ortho-
dontic treatment but also the presence of the necessary angiogenic
growth factors needed such as platelet-derived growth factor,
epidermal growth factor, and TGF-b. These growth factors have
been identified also in periodontal ligament wound healing (25),
in pulp after endodontic injury (26), during tooth development
and eruption (27), and during orthodontic tooth movement in cats
(28). Alterations in the pulpal vasculature with subsequent alter-
ations in the metabolism of the pulpal cells will usually result in
increased deposition of reparative dentin in both the coronal and
radicular portions of the pulp, along with a concurrent increase in
dystrophic mineralization (20).
During regenerative endodontic procedures, the formation of a vi-
tal tissue into an empty but infected root canal space is targeted. The
lack of dentin pulp regeneration in animal (29, 30) and human (31)
studies after current regenerative protocols shows that the regeneration
of the pulp-dentin does not occur, but rather connective tissue with
cementum-like mineralization appears to occur. The findings included
ingrowth of periodontal connective tissues (14) into the root canal
space that contained bone-like tissues (30) and the formation of
cementum or cementum-like tissues (30) on the dentinal walls.
Similar to vital pulp tissues, during orthodontic tooth movement of
revascularized teeth, injury and alteration in the blood vessels of the api-
cal periodontium and those entering the regenerated tissues might
occur. Increase in the blood flow to these tissues during tooth move-
ment might impact the availability of stem cells, which are capable under
local stimulatory factors to differentiate into osteoclasts and influence
the resorptive remodeling process of the affected tooth. In the present
case after the orthodontic treatment, the clinical evaluation revealed
healthy soft tissues and unimpaired tooth development. The radio-
graphic evaluation revealed marked remodeling of the periapical tis-
sues, resulting in resorption of the fractured apical third and
reorganization of the apical repair tissues to a new spatial architecture
consistent with complete healing. The apical remodeling noticed in the
two-dimensional radiograph after the orthodontic treatment seems
optimal. Moreover, the hard tissue bridging under the Biodentine
seemed to thicken over time, and the apical opening seems to be
closing.
Conclusions
Under certain circumstances, orthodontic tooth movement might
improve the periapical repair of necrotic immature teeth that had been
subjected to regenerative endodontic procedures.
Acknowledgments
The authors deny any conflicts of interest related to this study.
JOE — Volume 44, Number 3, March 2018

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