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Vitali - 2021 - Asociación Entre Tto Ortodoncia y Cambios Pulpares
Vitali - 2021 - Asociación Entre Tto Ortodoncia y Cambios Pulpares
ABSTRACT
SIGNIFICANCE
Introduction: Orthodontic force triggers a sequence of biological responses that can affect
Orthodontically moved teeth dental pulp. The aim of this study was to systematically evaluate the clinical and radiographic
may present immediate findings of orthodontic force application on dental pulp. Methods: Two reviewers
reduction in pulpal blood flow, comprehensively and systematically searched 6 electronic databases (Latin American and
increased pulpal sensibility Caribbean Health Sciences [LILACS], Embase, Cochrane Library, MEDLINE/PubMed,
response to pulp tests, Scopus, and Web of Science) and the gray literature (Google Scholar, OpenGrey, and
increased incidence of pulp ProQuest) until April 2021. According to the PICOS criteria, randomized clinical trials and
stones, and changes in the observational studies that evaluated clinical or radiographic findings compatible with dental
pulp cavity dimensions. pulp changes due to orthodontic force were included. Studies in open apex or traumatized
teeth, case series or reports, and laboratory-based or animal studies were excluded. The
Newcastle-Ottawa Scale and Cochrane Risk of Bias 2.0 tool were used to determine the risk
of bias assessment. The overall certainty level was evaluated with the Grading of Recom-
mendations, Assessment, Development and Evaluations tool. Results: Twenty-six studies
were included. Among the clinical findings, orthodontic force promoted an increased pulp
sensibility response and decreased pulp blood flow. Changes in pulp cavity volume and
increased incidence of pulp stones were the radiographic findings observed. The studies
presented a moderate risk of bias for most of the domains. The certainty of the evidence was
considered very low. Conclusions: Orthodontic force promoted changes in the dental pulp,
generating clinical and radiographic findings. It is crucial to know these changes so that
orthodontic mechanics can be safely performed. The clinician has effective noninvasive
methods to assess the health and possible pulp changes during orthodontic
treatment. (J Endod 2022;48:298–311.)
KEY WORDS
From the *Department of Dentistry, Dental pulp; dental pulp calcification; dental pulp test; endodontics; orthodontics; systematic
Federal University of Santa Catarina,
Florianopolis, Santa Catarina, Brazil;
review
†
Department of Orthodontics, University
of Alberta, Edmonton, Alberta, Canada;
and ‡Department of Endodontics, Virgínia
Orthodontic force triggers a sequence of biological events in the dental complex, affecting dental support
Commonwealth University School of
Dentistry, Richmond, Virginia and pulp tissues1. The extent of dental pulp changes depends on many factors, such as the type or
direction of movement, distribution, intensity, and duration of the force2,3. Inherent characteristics of the
Address requests for reprints to Dr Filipe
Colombo Vitali, Department of Dentistry, tooth, such as age, previous orthodontic treatment, and trauma history, may also affect the pulp
Federal University of Santa Catarina, conditions2–4.
Delfino Conti, Trindade, Florianopolis, Noninvasive methods can be applied during orthodontic treatment to assess the condition of the
Santa Catarina, Brazil. pulp because they are simple tools for clinical use5. Laser Doppler flowmetry and electric/thermal pulp
E-mail address: fi[email protected]
0099-2399/$ - see front matter
tests can be used to monitor pulp vitality because they allow repeated clinical detection of blood flow and
pulp sensitivity response without tissue damage6. Therefore, clinicians need to know which clinical signs
Copyright © 2021 American Association
of Endodontists.
and symptoms may represent pulp changes due to orthodontic force.
https://doi.org/10.1016/ When the applied orthodontic force affects pulp tissue, it may concentrate inflammatory mediators,
j.joen.2021.11.018 stimulating resorptive or reparative responses to odontoblasts and odontoblastlike cells and leading to
JOE Volume 48, Number 3, March 2022 Orthodontic Force and Dental Pulp Changes 299
the value of the applied force9–11. The return of
blood flow to baseline values varied according
to studies (ie, 3 weeks for maxillary incisors12
and 3 months for maxillary molars32. The
extrusion force was unable to reduce blood
flow9. For canine retraction, the pulpal blood
flow reduction occurred 10 minutes after the
force application and returned to baseline
values after 72 hours11.
For canine retraction and rapid maxillary
expansion, no significant changes were found
in the pulp cavity dimensions of the maxillary
canines and first molars, respectively39,40. For
maxillary incisors, the pulp chamber
dimensions were reduced in the
cementoenamel junction and increased in the
middle of the crown 1 year after rapid maxillary
expansion40. In addition, an increased
frequency of pulp canal narrowing and a
reduction in pulp cavity volume were observed
for fixed orthodontic after 5 years and 17–
18 months of treatment, respectively37,41. The
presence of pulp stones increased from
1.56%–6.5% after fixed orthodontic
treatment34–37.
Test group
(n) patients, teeth Force type
age range value (g)
Authors (year), country (age mean ± SD) Control group Evaluated teeth Duration Assessment method Main results
Outcome: pulpal sensibility response
Alomari et al (2011)24, n 5 47 patients, n 5 23 patients, Maxillary canines, lateral and COT EPT and TPT 1. Negative responses both
Jordan 282 teeth 138 teeth central incisors 16.1 mo Times: (T0/baseline) before TPT and EPT: increased
12.1–17.3 y 13.7–18.1 y bonding, (T1) after 2 h, after T1, returned to
(15.1 y) (16.2 y) (T2) 30 d, (T3) 60 d, (T4) baseline value after T14;
No treatment 120 d, (T5) 180 d, (T6) 240 P , .001
d, (T7) 300 d, (T8) 360 d, 2. EPT response after T1 was
(T9) after debonding, (T10) higher in the orthodontic
after fitting the retainer, (43.05 u) than the control
(T11) after 3 mo, (T12) 6 group (30.62 u); P , .01
mo, (T13) 9 mo, (T14) 12 3. In the orthodontic group
mo (baseline 34.99 u), EPT
response increased at T1
(41.77 u) to T3 (50.12 u),
decreasing after T4 (48.42
u); P , .01
Cave et al (2002)25, n 5 33 patients, n 5 15 patients, Maxillary central and lateral COT EPT and TPT 1. Negative responses both
Australia 132 teeth 60 teeth incisors 28–252 d Times: (T0/baseline) before TPT and EPT: increased
9.8–29 y 14–27.3 y bonding, (T1) immediately after T1, returned to
(14.4 y) (21.7 y) after initial arch, (T2) after baseline value after T6;
No treatment 28 67 d, (T3) after 56 67 P , .05
d, (T4) after 100 6 14 d, 2. EPT response after T1 was
(T5) after 168 6 14 d, (T6) higher in the orthodontic
after 252 6 14 d (46.21 u) than the control
group (26.77 u); P , .01
3. In the orthodontic group
(baseline 37.96 u), EPT
response increased at T1
Orthodontic Force and Dental Pulp Changes
Test group
(n) patients, teeth Force type
age range value (g)
Authors (year), country (age mean ± SD) Control group Evaluated teeth Duration Assessment method Main results
RME (2 wk after T0), (T2)
2–4 w into retention, (T3)
3–9 mo after the force
stopped.
Ferreira et al (2013)23, n 5 24 patients, n 5 16 patients, Maxillary canines Canine traction TPT 1. Negative responses after
Brazil 32 teeth 32 teeth Time: before and after canine treatment was higher in
No treatment traction treatment the orthodontic (43.8%)
(no time information) than the control group
(3.1%); P , .01
Hall & Freer (1998)26, n 5 7 patients, n 5 2 patients, Maxillary canines, lateral and COT EPT and TPT 1. Negative responses for
Australia 41 teeth 12 teeth central incisors 4–8 w Times: (T0/baseline) before EPT (T0 and T1 5 9.76%):
14–18 y No treatment bonding, (T1) immediately all teeth responded
after initial arch, (T2) 4 wk negatively after T2 (100%).
after, (T3) 8 wk after 2. For TPT, all teeth
responded positively at all
times.
Han et al (2013)20, China n 5 24 patients, n 5 3 patients, Maxillary first premolars Intrusion EPT 1. In the 50-g force group,
48 teeth 6 teeth 50 and 300 g Times: before placement of response in relation to
14–24 y 14–24 y 1–12 wk the lingual button (T0/ baseline (3.44 u) was
(17.9 y) (17.9 y) baseline), (T1) after 1 wk, higher at T2 (5.20 u), T4
No treatment (T2) 2 wk, (T3) 3 wk, (T4) 4 (6.43 u), T5 (7.68 u), T6
wk, (T5) 5 wk, (T6) 6 wk, (8.35 u), and T7 (8.67 u);
(T7) 7 wk, (T8) 8 wk, (T9) 9 P , .05
wk, (T10) 10 wk, (T11) 11 2. In the 300-g force group,
wk, (T12) 12 wk no significant differences
were observed between
baseline and T1–T12
values; P . .05
3. Response at T1, T2, and
T3 was higher in the 300-g
force (6.63 u, 7.20 u, and
JOE Volume 48, Number 3, March 2022
Test group
(n) patients, teeth Force type
age range value (g)
Authors (year), country (age mean ± SD) Control group Evaluated teeth Duration Assessment method Main results
P , .05
3. In the orthodontic group
(baseline 28.48 u),
response increased at T1
(40.83 u), decreasing at
T2 (38.08 u); P , .05
Leavitt et al (2002)28, USA n 5 9 patients, n 5 9 patients, Maxillary central incisors COT EPT 1. No significant differences
17 teeth 18 teeth 5 wk Times: (T0/baseline) after in the response were
13.3–33.8 y 14–37.8 y bracket placement, (T1) 1 observed between groups
(20.6 y) (20.5 y) h after initial arch, (T2) 1 and times; P . .05
No treatment d after T1, (T3) 1 wk after
T1, (T4) 1 mo after T1
Monardes Cortes n 5 37 patients, No group Maxillary and mandibular Rotation (5.8–164.1 g) TPT 1. No significant differences
et al29(2018), Chile 136 teeth incisors and canines or sagittal movement Times: (T0/baseline) before in the response were
11.2–13.4 y (5.1–144.3 g) force, (T1) after 7 d observed between forces;
(12.6 y) 7d Force magnitude was P . .05
measured: extreme: 2. Maxillary central incisors
.100 g (n 5 98), high: 76– showed an increase
100 g (n 5 13), optimal: (38.1%) of response at T1
26–75 g (n 5 23), mild: 0– compared to the baseline;
25 g (n 5 2) P , .05
3. Sagittal movement
promoted greater
sensitivity (34% increased
of response) than the
rotation movement (11%
increased of response);
P , .05
Orthodontic Force and Dental Pulp Changes
Veberiene et al (2009)21, n 5 21 patients, Contralateral teeth Maxillary and mandibular Intrusion EPT 1. Response at T1 was
Lithuania 21 teeth No treatment premolars 61 g Time: (T0/baseline) before higher in the orthodontic
11–21 y 7d treatment, (T1) after (29.65 6 17.92 mA) than
(15.5 6 0.5 y) treatment the control group
(7.76 6 6.48 mA); P , .01
Veberiene et al (2010)22, n 5 13 patients, No group Maxillary premolars Intrusion EPT 1. No significant differences
Lithuania 13 teeth 82–97 g Time: (T1) 7 d after, (T2) 14 in the response were
14–22 y 7–14 d d after observed between times;
(16.5 6 2.7 y) P . .05
Outcome: pulpal blood flow
Barwick & n 5 8 patients, No group Maxillary central incisors Intrusion LDF 1. No significant differences
Ramsay(1996)31, 8 teeth 76–4400 g Times: (T0/baseline) 4 min in PBF between times;
Australia (38.4 6 9 y) 4 min before force, (T1) during P . .05
4 min of force, (T2) 12 min
303
after force
(continued on next page )
TABLE 1 - Continued
304
Vitali et al.
Test group
(n) patients, teeth Force type
age range value (g)
Authors (year), country (age mean ± SD) Control group Evaluated teeth Duration Assessment method Main results
9
Brodin et al (1996) , n 5 6 patients, Contralateral teeth Maxillary lateral incisors Intrusion and extrusion LDF 1. No significant differences
Germany 10 teeth No treatment 204 g Times: (T0/baseline) before in PBF between times for
5 min forces, (T1) immediately extrusion force; P . .05
after forces 2. PBF reduction (80%) at T1
compared to the baseline
for intrusion force; P , .05
Ikawa et al (2001)10, n 5 17 patients, No group Maxillary central incisors Intrusion LDF 1. PBF reduction with the
Japan 17 teeth 51–510 g Times: (T0/baseline) before increase of force, baseline:
14–29 y intrusion, and after 11.23 6 5.62 PU, 51 g:
different forces: 51 g, 102 10.13 6 5.11 PU, 102 g:
g, 510 g (1-min intervals 9.92 6 4.83 PU, and 510
between applications) g: 9.71 6 5.17 PU;
P , .05
McDonald & Pitt Ford n 5 10 patients, Contralateral teeth Maxillary canines Canine retraction 50 g LDF 1. PBF reduction (baseline
(1994)11, England 10 teeth No treatment 2–5 wk Times: (T0/baseline) before 13.54 PU) at T1 (11 PU)
11.2–13.4 y retraction, (T1) 10 min and T2 (10.94 PU),
(12.6 y) after, (T2) 30 min, (T3) followed increase at T4
60 min, (T4) 24 h, (T5) 48 (15.43 PU) and T5 (15.75).
h, (T6) 72 h Returned to baseline value
at T6 (13.28); P , .05
Sabuncuoglu & Ersahan n 5 20 patients, Contralateral teeth Maxillary lateral and central Intrusion LDF 1. PBF reduction (baseline
(2014)12, Turkey 40 teeth No treatment incisors 40 g and 120 g Times: (T0/baseline) before 11.36 6 0.92 PU) at T1
18–25y 3 d to 3 wk intrusion, (T1) after 3 d, (7.72 6 0.50 PU), followed
(20.3 y) (T2) after 3 wk increase at T2
(10.37 6 0.58 PU) for 40-
g force group; P , .01
2. PBF reduction (baseline
11.47 6 0.89 PU) at T1
(7.72 6 0.52 PU), followed
increase at T2
(10.31 6 0.45 PU) for
JOE Volume 48, Number 3, March 2022
Test group
(n) patients, teeth Force type
age range value (g)
Authors (year), country (age mean ± SD) Control group Evaluated teeth Duration Assessment method Main results
Sano et al (2002)33, Japan n 5 8 patients n 5 5 patients Maxillary central incisors Intrusion LDF 1. PBF reduction (baseline
27–31y 27–31 y 51 g Times: (T0/baseline) before 95.19 6 9.84 PU) at T1
No treatment 1–6 d intrusion, (T1) 1 d, (T2) 2 d, (74.68 6 19.09 PU), T2
(T3) 3 d, and (T4) 6 (70.98 6 16.23 PU), T3
d during force; (T5) 1 d, (68.08 6 20.58 PU), and
(T6) 3 d, and (T7) 5 d after T4 (67.29 6 23.37 PU).
force Returned to baseline value
at T5 (103.35 6 17.69
PU), T6 (107.11 6 15.10
PU), and T7
(103.56 6 21.31 PU).
P , .05
Outcome: internal dimensions of the pulp cavity
Abdel-Kader & Ammar n 5 5 patients, No group Maxillary canines Canine retraction CBCT 1. No significant differences
(2015)39, Egypt 10 teeth 150 g Times: (T1) before and (T2) in the internal vertical
14–18y 186 6 1.16 mo after retraction length of pulp chamber
(15.82 6 1.74 y) Evaluated changes: pulp between times (vertical
chamber dimensions and coronal); P . .05
Baratieri et al (2013)40, n 5 15 patients, n 5 15 patients, Maxillary central incisors and RME CBCT 1. No significant differences
Brazil 120 teeth 120 teeth first molars Times: (T1) before and (T2) 1 in molars between times;
7.8–11.6 y 7.6–11.4 y y after RME P . .05
(9.6 y) (9.4 y) Evaluated changes: pulp 2. In incisors, it reduced in
No treatment chamber dimensions the axial slices as it neared
the cementoenamel
junction (20.32, 20.36,
and 20.43 mm2), and on
the middle of the crown
Orthodontic Force and Dental Pulp Changes
Test group
(n) patients, teeth Force type
age range value (g)
Authors (year), country (age mean ± SD) Control group Evaluated teeth Duration Assessment method Main results
Venkatesh et al (2014) , 41
n 5 48 patients, n 5 39 patients Maxillary incisors and COT CBCT 1. Reduction of pulp cavity
India 288 teeth (234 teeth) canines 17–18 mo Times: (T0) before treatment volume for all anterior
(18.1 y) (17.5 y) and (T1) and after teeth between times; P ,
No treatment completion of space .05
closure 2. The highest volume
Evaluated changes: pulp reduction recorded was
cavity volume for the left lateral incisor
(3.86 mm3) and the least
for the right central incisor
(3.04 mm3).
Outcome: pulp stone formation
Delivanis & Sauer n 5 46 patients n 5 46 patients All teeth COT Periapical radiographs 1. No significant differences
(1982)38, USA 13–33 y 13–33y 8 mo to 4 y 7 mo Times: (T1) before and (T2) between orthodontic and
No treatment immediately after control group; P 5 .2
treatment 2. In orthodontic group,
Evaluated changes: canal complete and partial
calcification calcification was observed
in 2 (9.1%) maxillary lateral
incisors
Ertas et al (2017)34, n 5 545 patients, No group Maxillary and mandibular COT Panoramic radiographs 1. Pulp stone numbers
Turkey 16,852 teeth premolars and molars 16.48 mo (62.16 mo) Times: (T1) before and (T2) increased (2.2%) between
12–22 y immediately after times; P , .05
treatment
Evaluated changes: pulp
stone formation
Jena et al (2018)35, India n 5 200 patients, No group Maxillary and mandibular COT Panoramic radiographs 1. Pulp stone numbers
3200 teeth molars and premolars 15.23 mo (61.4 mo) Times: (T1) before and (T2) increased (4%) between
14–26 y immediately after times; P , .05
treatment
Korkmaz et al (2019)36, n 5 504 patients No group All teeth COT Panoramic radiographs 1. Pulp stone numbers
Turkey 12–32 y 24.5 mo (63.1 mo) Times: (T1) before and (T2) increased (6.5%) between
JOE Volume 48, Number 3, March 2022
CBCT, cone-beam computed tomography; COT, conventional orthodontic treatment; EPT, electric pulp test; LDF, laser Doppler flowmetry; PBF, pulpal blood flow; PU, perfusion units; RME, rapid maxillary expansion; SD, standard deviation; T, time;
TPT, thermal pulp test; u, EPT units.
FIGURE 2 – Risk of bias (RoB) assessment for case-control and cohort studies by the Newcastle-Ottawa Scale: a maximum of 4 points for selection, 2 points for comparability, and 3
points for exposure or outcome. Risk of bias for randomized clinical trials by Cochrane tool: (Q1) bias arising from the randomization process, (Q2) bias due to deviations from intended
interventions, (Q3) bias due to missing outcome data, (Q4) bias in measurement of the outcome, (Q5) bias in selection of the reported result, and (Q6) overall bias. Authors’ judgment:
low risk of bias or some concerns (SC).
pulp tissue changes due to orthodontic force have influenced the pulpal sensibility response in groups in which the orthodontic force was
using noninvasive methods. in addition to the orthodontic force, such as applied, there was an increase in the pulpal
Monitoring pulpal sensibility is essential sample age, evaluated tooth, conditions under sensibility response concerning baseline
during orthodontic treatment and may be which the study was performed, the number of values immediately after force application;
performed by several methods, such as laser repetitions of the measurement, and factors however, over time, these values tended
Doppler flowmetry and electric/thermal tests44. related to the patients themselves such as the toward baseline24,25,27. Therefore, the
To assess pulpal sensibility’s response, the concept that people have different pain or application of orthodontic force appeared to
electric test has high accuracy when testing prepain limits45. However, significant have a significant effect on pulpal neural
vital teeth, whereas thermal tests have differences among the measurements responsiveness, however, only immediately
moderate accuracy44. Of the included studies, obtained between the control and orthodontic with progressive normalization.
5 used only electric testing20–22,27,28, 4 used groups were observed and clouded the The increased pulpal sensibility
electric followed by thermal testing24–26,30, and certainty of the possible dental pulp changes response may result from the pressure or
2 only thermal testing23,29. Several factors may due to orthodontic force22,24,25,27. In addition, tension of the apical nerve fibers of the teeth
JOE Volume 48, Number 3, March 2022 Orthodontic Force and Dental Pulp Changes 307
TABLE 2 - Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Assessment
Quality assessment
Outcomes Studies (n) Risk of bias Inconsistency Indirectness Imprecision GRADE quality
Pulpal sensibility response 10 observational studies Serious* Very serious† Not serious Serious‡ 4BBB Very low
1 randomized trial Serious§ Not serious Not serious Serious‡ 4BBB Very low
Pulpal blood flow 6 observational studies Very seriousk Very serious† Not serious Serious‡ 4BBB Very low
1 randomized trial Serious§ Not serious Not serious Serious‡ 4BBB Very low
Internal dimensions 4 observational studies Serious¶ Very serious† Not serious Serious‡ 4BBB Very low
of the pulp cavity
Pulp stone formation 5 observational studies Serious# Very serious† Not serious Serious‡ 4BBB Very low
being orthodontically moved24. Another factor application of intrusion force, there was an maxillary expansion and fixed orthodontic
that may be related is the decrease in blood initial pulpal blood flow decrease, which may treatment. In rapid maxillary expansion,
flow to the dental pulp, mainly when the be the result of a significant compression of despite high forces being applied to the
intrusion force was applied10,32,33. Previous blood vessels caused by the apical anchorage teeth during the active phase of
studies suggested that orthodontic force has displacement of the tooth12,32,33. However, midpalatal suture expansion, minimal changes
an immediate effect on the blood supply of this was eventually followed by a gradual were observed in the internal dimensions of the
the pulp tissue, which can trigger recovery pattern over time, which varied incisors without changes in the molars40. The
hypoxia10–12,32,33. Hypoxia raises pulp between studies12,32,33. sample’s age seems to be a factor influencing
A-fibers’ response threshold, located Several factors may have influenced the results (mean age 5 9.6 years). In younger
peripherally in the pulp, whereas C-fibers are pulpal blood flow changes, such as force patients, the pulp cavity is wider and rich in
less affected20,22. Regarding the number of values, the time elapsed from the force applied blood vessels, which allows it to recover more
negative responses to pulp tests, there was an to the evaluation, and the sample’s quickly from injuries50. For fixed orthodontic
increase in the groups in which the orthodontic characteristics because the pulpal blood flow treatment, a reduction in pulp cavity volume for
force was applied. Still, it started to respond tends to decrease with the patient’s age47. anterior teeth was observed37,41. However, the
positively over time. Therefore, all teeth Histologic evaluation showed that not only did decrease in pulp cavity volume observed in
responded positively in most of the included the number of blood vessels decrease with these studies can result from the physiological
studies23–27. The number of negative age, but also the pulp area decreased due to process of deposition of secondary dentin
responses was only higher in a group in which increased calcified tissues14,47. Pulpal blood related to age because the follow-up period
canine traction was performed. However, flow rates also appear to have been affected varied from 17–60 months after treatment37,41.
there was no follow-up in this study; only a by the evaluated dental group. When the Based on the results of the included studies, it
thermal test was performed after the end of the intrusion force was applied to incisors and can be seen that the orthodontic force
traction23. This denotes that, although the premolars, the return to baseline values of promoted changes in the internal dimensions
pulpal sensibility increased, it was normally not blood flow occurred in 72 hours to 3 of the pulp cavity, and this may be indicative of
enough to trigger the loss of pulp vitality. In weeks11,12,33, whereas in molars it occurred some damage to the pulp tissue. However,
which patients this is likely to trigger this cutoff only after 3 months32. Molars have smaller these changes were considered mild, which
value is unknown at this time. Hopefully, in the apical foramen than incisors, canines, and suggests the pulp tissue’s ability to adapt to
future, we will be able to cluster this specific premolars; this smaller apical diameter may be the applied orthodontic force.
subgroup. Also, this is a rather infrequent responsible for a more significant restriction of The etiologic factors for the formation of
occurrence. blood flow in these teeth48,49. pulp calcifications are not fully understood51.
Laser Doppler flowmetry has high When the applied orthodontic force Factors such as sex, age, systemic diseases,
accuracy in detecting vital teeth and performs affects pulp tissue, it may concentrate chronic irritations, and degenerative lesions of
better than electric and thermal tests44,46. inflammatory mediators, stimulating resorptive the pulp are possible factors that can influence
Laser Doppler flowmetry was used to assess or reparative responses to odontoblasts and pulp stone development51. The included
pulpal blood flow in all included studies. The odontoblastlike cells and leading to resorption studies showed an increase in pulp stone
intrusion force was the most evaluated among processes or deposition of tertiary dentin7,8. formation from 1.56%–6.5% after fixed
the studies because, among the force vectors Such events can promote changes in the pulp orthodontic treatment34–37. However, all of
that can be applied to teeth during orthodontic cavity’s internal dimensions, which can be these studies were retrospective (ie, other
treatment, the intrusion is considered the detected by the clinician, who needs to have factors may have influenced the formation of
movement that promotes a more significant imaging tests for the diagnosis and monitoring pulp stones, such as the age of the patients,
impact on the apical region because it can of the patient during orthodontic treatment7,8. the occurrence of trauma, other dental
cause compression of apical blood Among the 4 studies included, changes in interventions, and the presence of bruxism,
vessels10,12,32,33. It was observed that in the internal dimensions were observed after rapid besides being subjected to the difference of
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