This document discusses joint restorative orthodontic treatment and summarizes several situations where combined orthodontic and restorative treatment may be required, including uprighting tilted molars, managing peg laterals or other diminutive teeth, managing traumatized teeth before or during orthodontic treatment, treating periodontal patients, managing cleft lip and palate patients, and treating orthognathic patients. It also discusses the impact of endodontically treated teeth, the role of orthodontics in prosthodontic treatment, tooth surface loss, and modification of tooth color.

1. Joint Restorative Orthodontic
Treatment
The classic situations where combined orthodontic-restorative management may
be required include:
(i) Up-righting severelytilted molar teeth (refer to PD note)
(ii) Management of 'peg laterals'or other diminutive teeth. (refer to
hypodontia note)
(iii) Managementof teeth that been traumatized before or during
orthodontic treatment (refer to The Orthodontic Implications of Traumatized
Upper IncisorTeeth note)
(iv) Periodontalpatients (refer to PD note)
(v) Management of Cleft Lip and Palate patients (refer to CLP note)
(vi) Orthognathic patients May to be older or present with incomplete
dentitions and hence their treatment may require input from a Restorative
Dentist. Scenarios are too diverse to summarize but major or more minor
'finishing touches' should be discussed in the treatment planning stage to
ascertain the potential benefits. (refer to orthognathic surgery note)
(vii) Hypodontia. (refer to hypodontia note)
(viii) Impact of endodontically treated teeth
(ix) Role of orthodontic in prosthodontics treatment
(x) ToothSurface Loss
(xi) Modificationof tooth color

2. Impact of endodontically treatedteeth
RCT:The aim of root canal treatment is shaping the canal system to producea
gradual smoothtaper that would allow easy access of antimicrobial irrigants to
cleanand remove microorganisms and pulpal debris followed by filling and
obturating the canal with an insoluble filling material.
Indications to RCT:
 Pulpal or periapical pathology.
 Overdenture abutments.
 Internal/ external resorption.
 Pulp exposure is expected.
 Perio-endo lesions, hemisection.
 Pulpal sclerosis
Contraindications:
 Inadequate access.
 Contamination.
 Unrestorable tooth.
 Poorperiodontal supportand tooth mobility.
 Rootfracture.
RCT preparation techniques:
1. Stepbacktechnique
2. Stepdown, crown down allowing the coronal aspectof the canal to be
widened and cleaned before the apical part, with the advantage of
 Improving access ofthe irrigating solution to the apical region,

3.  Reducing the risk of pushing pulp tissue debris and microorganisms into
the periradicular area
 Therefore diminishing the incidence of post-operative pain.
3. The double-flare techniques
4. Hand instrumentation
5. Rotary instrumentation
The endodontic-orthodontic relationship
 The effects oforthodontic tooth movement on the pulp
 RCT needs during orthodontic treatment
 Difficulty in performing RCT during orthodontic treatment
 Orthodontic in assisting RCT
 Rootresorption of endodontically treated teeth causedby orthodontic
forces.
In details:
A. The effects oforthodontic tooth movement on the pulp
One of the iatrogenic effect is loss of the pulp vitality
B. RCT needs during orthodontic treatment
 If RCT commenced during orthodontic treatment, it is suggested that the
canals be cleaned and dressed and filled with non-setting calcium hydroxide in
the interim, this is usually changed every 3 months as it is prone to leakage. The
tooth itself should be well sealed between visits to prevent coronal leakage and
the tooth filled conventionally with well-condensed gutta percha at the end of
treatment. Observation period, usually of a minimum of 6 months, is
recommended for signs of bony healing.

4.  Intermediate filling is not recommended anymore except in apexification
cases (Attack 2008)
C. Difficulty in performing RCT during orthodontic treatment
 Difficulty to diagnose from radiographs due to radiolucent changes at the
apex.
 Brackets/bands may obscuredecay radiographically/clinically.
 The tooth movement may mask symptoms.
 Metal brackets/bands affect pulp testing
 Toothisolation may be compromised
 Working length determination may be hampered as resorption may
destroy the apical constriction and radiographically the periodontal spaceis
widened.
 Canal obturation can be hampered by dentinal sclerosis.
D. Orthodontic in assisting RCT:Toothextrusion using light forces (30-
50gm) may be indicated for fractured teeth with margins below the crestal bone
and deep carious margins. The prime objectives of extrusion being to provide a
sound tissue margin for the ultimate restoration also a sound biological width
for the patient to maintain.
E. Rootresorption of endodontically treated teeth causedby
orthodontic forces.
 Rootfilled teeth are less likely to resorb (Drysdale 1996)
 Other said the opposite
 Initial radiographs followed by radiographic monitoring 6 months after
the start of tooth movement. If signs of resorption are noted, a delay of 3
months should be instituted and endodontic advice should be sought.
 Where resorption is severe, treatment goals should be re-evaluated and
patients and parents informed.

5. Role of orthodontic in prosthodontics treatment
 Short-span bridges have a better overall prognosis than longer-span
bridges (orthodontics can help by reducing space)
 Rootfilled abutments are less reliable than vital abutments (This may be
a factor when there is a choice of teeth which could be extracted as part of an
orthodontic treatment plan)
 If the dynamic guidance is carried on the pontic, the bridge needs
abutments at bothends (Orthodontics may be able to help reduce a hostile
overbite, or create a canine protected occlusion, or levelling arches, simplifying
matters). However, if the dynamic guidance is not carried on the pontic, the
bridge may not need abutments at both ends, (but vertical forces in intercuspal
position may mean that supportat both ends is preferable to prevent a 'tilting'
force on a single abutment)
 Since fixed bridges with more than one abutment need the underlying
preparations to be parallel to one another, it is helpful if the teeth are reasonably
parallel to start with, to avoid the need for excessive removal of tooth tissue
(Orthodontics can help with uprighting teeth)
 Enough tooth height needs to be available to retain a bridge once the
tooth is prepared (Orthodontics may be able to help by extruding/ intruding
teeth)
ToothSurface Loss
Relevance
Toothsurface loss is important to the orthodontist in these ways:
 Orthodontists often see TSL and should be able to recognize the condition, give
advice and consider a tertiary referral.

6.  Orthodontists may be involved in treatment planning and treating of patients
with TSL
Complications of the TSL
1. Aesthetics
2. Mucosal irritation from worn or fractured teeth
3. Functional problems such as difficulty in biting into food.
4. Sensitivity
5. Loss of vertical dimension which make restorative treatment complicated
6. Loss of tooth substance which make restorative treatment complicated
Types of TSL
1. Erosion
2. Abrasion
3. Attrition
4. Demastication
5. Abfraction
In details
1. Erosion
Aetiology
 Acids that have a pH below the critical pH 5.5 erode tooth structure as well as
reduced buffering capacity of the mouth. It can be classified into:
A. Exogenous (dietary)
B. Endogenous (regurgitation of stomachcontents).

7. Feature
1. Smooth, polished appearance
2. Absence of staining
3. Absence of developmental ridges
4. Rounded teeth
5. Increased translucency due to thinning of enamel
6. Amalgam and compositerestorations stand proud
7. Palatal erosion often leaves a small line of enamel at the gingival margin
probably a result of the buffering from gingival crevicular fluid
8. Eroded teeth are more susceptible to attrition and abrasion
2. Abrasion
Aetiology
 Overzealous oral hygiene techniques.
 Toothbrushing soon(within one hour) after the teeth have been softened by acid
insult
 Use of an abrasive toothpaste
 in orthodontics esp. when teeth contactceramic brackets
Feature
 Rounded or V-shaped groove
3. Attrition
Aetiology
Associated with parafunctional habits such as clenching and grinding

8. Features
1. Flat cusp tips or incisal edges (dentine and enamel wear at the same rate)
2. Localized facets on occlusal or palatal surfaces
3. Flat facets related to functional movements
4. Restorations show faceting as well as teeth
4. Demastication
 This term has appeared in the literature and represents a combination of attrition
and abrasion where tooth-tooth contactmay occurduring chewing of fibrous
foods.
 It can be defined as "the loss of tooth tissue by wear during the mastication of
food" and is influenced by the abrasiveness of individual food and chewing
patterns.
5. Abfraction
 This can be defined as "the pathological loss of hard tissue caused by
biomechanical eccentric loading forces".
 Non-centric loading leads to deformation and tooth flexure which disruptions
the enamel crystalline structure at the neck of a tooth that then break away.
 Abfraction is a controversial issue but it is important to appreciate that not all
cervical lesions can be explained by acid erosion and toothbrush/dentifrice
abrasion and the mechanics has been substantiated by finite element analysis
modelling

9. Management (RCS Eng. Guidelines)
I. History
A. Establishing the Patient’s Complaints
B. MedicalHistory
1. Gastric disorders such as gastro-oesophageal reflux, sphincter incompetence,
hiatus hernia,oesophagitis and increased gastric pressure and volume.
2. Repeatedvomiting can result from disorders of psychosomatic, gastrointestinal
and metabolic processes ormay be drug
3. Pregnancyas the increased pressure in the abdomen may predisposeto
regurgitation
4. Eating disorders such as anorexia and bulimia,
5. Medications suchas hydrochloric acid for achlorhydria,iron preparations or
chewable vitamin C. Other drugs may have a less direct role to play, for
example, diuretics and antidepressants cause xerostomia
C. Eating and drinking habits
1. Type of food and drinks like fizzy drink and spicy food
2. Frequency of consuming these foods
3. Habit of eating or drinking certain food or drinks. Eg.holding citrus fruits
against the teeth9 or swishing carbonated drinks in the mouth until the gas
escapes
D. Socioeconomic condition
1. Economic and social condition determine the education background as well as
the quality of food consumed
2. Industrial erosion was frequently described in people exposed to acidic fumes
but it is unlikely to be a factor today due to the more industrial legislation.

10. E. Hobbies and sporting activities
1. Erosion is more common in people who swim regularly in gas chlorinated pools
where the water is acidic.
2. Vigorous exercise will result in dehydration and damage will be compounded if
acidic .sports drinks are consumed after exercise,
F. Habits
1. Localized areas of tooth wear may be seen in hairdressers who hold clips
between their teeth
2. Musicians who play instruments with mouth-pieces that contactthe teeth.
3. Pipe smoking pen chewing and nail biting
G. Alcohol and drugs
1. Alcohol intake given that binge drinking followed by vomiting may cause
substantial damage.
2. Use of drugs due to the low pH of the drug or dehydration it induces
H. OH measures
1. The patient tooth brushing technique should be assessed
2. Oral hygiene products used
II. EXAMINATION
1. An extra-oral examination
 TMJ clicking (associated with attrition)
 masseteric hypertrophy (associated with attrition)
 Parotid enlargement (associated with bulimia).
2. Intra-oral examination
 Features characteristic of the different wear processesmentioned above.
 Location of tooth wear

11. a) Palatal erosion suggests an intrinsic aetiology
b) Labial erosion implicates extrinsic factors
c) Incisal edges and cusps are generally associated with attrition Asymmetric
lesions may be due to abrasion
 intermaxillary occlusion and dynamic occlusion
a) lack of posterior supportcan predisposeto anterior tooth wear
b) Interferences in lateral excursions should be identified as they may encourage
bruxism
3. Special investigations
 Periapical radiographs
 Measure salivary parameters
 Initial study casts
 clinical photographs
 silicone index
III. TREATMENT
A. Prevention must remain the corner stone in the management of dental erosion.
B. Elimination of the aetiological factors: the first priority in treatment of all forms
of tooth substance loss should be to control the aetiological factors and prevent
further destruction of the already compromised tooth tissue
C. Patient advice and counselling including:
 Modifying the diet
 Changing eating habits and frequency of eating
 Instruction in non-abrasive oral hygiene habits

12.  Use of alkaline mouth rinses, such as bicarbonate of sodaNeutral sodium
fluoride mouthwashes.
 a mouthguard or splint may be provided for night wear however, if a
mouthguard is provided in the presence of a condition such as reflux becauseit
would hold the acid against the teeth for prolonged periods and so increase the
damage. This may be overcome by applying an alkali suchas sodium
bicarbonate, magnesium hydroxide or milk of magnesia to the fitting surface of
the tray to neutralize any acids approaching the tooth surfaces
D. Restorative treatment:
 Toothsubstance loss generally proceeds slowly, so for most patients there is no
pressure to commence active restorative therapy (the exception to this would be
a young patient with rapid erosive tooth wear and sensitivity due to the loss of
tooth substanceencroaching on the pulp, or decreasing dental aesthetics due to
chipping of incisal edges)
Definitive treatment categorizedinto:
A. Appearance satisfactory:
 Counselling,
 Resorting the tooth loss by CF or GIC
 Restoration of edentulous spaces where appropriate by fixed or removable or
implant
 Treatment for controlling bruxist or clenching habits,
 Adjustment and elimination of any occlusal interferences
B. Appearance not satisfactory: no increase in occlusal face height required.
Patients in category 2 are managed as for category 1 plus the treatment of the
aesthetic problems by conventional restorative measures.

13. C. Appearance not satisfactory: increase in occlusal face height required:
(i) Sufficient spaceavailable; Patients in this category are managed as for category
2 plus prosthetic work
(ii) Insufficient spaceavailable. Spacecan be provided by:
1. Toothpreparation with the consequent removal of more tooth tissue
2. Changing the jaw relationship surgically.
3. Conventional orthodontic treatment using combinations of fixed and/or
removable appliances:
 In cases of localised anterior tooth wear, interocclusal spacecan be created by
careful overbite reduction and in certain cases lower incisor retraction or upper
incisor proclination.
4. Fixed or removable bite platforms
 Originally described by Dahl in 1970.
 The Dahl appliance is a removable or cemented cobalt chrome appliance which
covers the palatal surfaces of the maxillary anterior teeth.
 This allows contact of the mandibular anterior teeth with the appliance, holding
the posteriors out of occlusion.
 This, in turn, promotes intrusion of the anterior teeth and eruption of the
posteriors, thus providing spaceanteriorly.
 It has been shown in an implant-cephalometric study to result in intrusion of
the anterior teeth by an average of 1.05 mm, and extrusion or eruption of the
remaining teeth, averaging 1.47 mm after 6–14 months, without causing undue
incisor proclination or TMD problems.

14.  Current Dahl 'appliances' Over a period of 3 - 9 months the ICP contact
re-establishes.
Briggs 1997
I. removable chrome bite plane
II. fixed bite plane (essentially Maryland/Resin-bonded bridge retainer
wings otherwise called metal palatal veneers)
III. porcelain palatal veneers
IV. direct composite veneers
V. definitive or temporary crowns.
Modificationof tooth colour
Relevance
A. Before treatment, Discolouration of an individual tooth may signify non-vitality,
which may require attention prior to orthodontic movement
B. During treatment, in respectof bonding appliances to abnormal tooth surfaces,
or restorations
 Previously bleached teeth do not seem to posea major barrier to normal
appliance bonding.
 Teeth, which have been orthodontically bonded and debonded, may respond
more slowly to bleaching than previously unbonded teeth
C. After treatment, in optimizing an aesthetic result

15. Value Hue and Chroma
There are a number of ways of classifying colour, but one way is by dividing it
into three basic components, value, hue and chroma.
Value is most easily explained by imagining that one is looking at a colour on a
black and white television set. Pure white will appear white, and will have the
highest value. Black will appear black and have the lowest value. All other
colours will appear as various shades of grey, with a continuous gradation
between white and black. The position of a colour on this greyscale determines
the value.
Hue can be explained by the colours of the rainbow, red, yellow, blue etc
Chroma relates to the amount of a certain pigment present, bestexplained by
imagining taking a potof white paint, then adding a few drops of red paint to
producea pink of certain chroma. If more red paint is added, the chroma will
alter, but the hue will remain red.
Classification
1. Genetically determined
 Normal dentine/enamel shade (intrinsic)
 Dentinogenesis imperfecta (intrinsic)
 Amelogenesis imperfecta (intrinsic)
2. Acquired during tooth formation
 Fluorosis (intrinsic)
 Drug e.g. tetracycline (intrinsic)

16.  Medical condition effects e.g. high levels of circulating bilirubin, porphyria
(intrinsic)
 Trauma e.g. to deciduous predecessor, ordue to birth (intrinsic)
3. Acquired after tooth formation
 Trauma e.g. deposition of blood products, pulpal sclerosis (intrinsic)
 Restorative materials, e.g. amalgam (intrinsic)
 Caries (intrinsic)
 Physiological reparative deposition of dentine and age-related darkening
(intrinsic)
 Stains onto the surface of the tooth e.g. from foods and drinks, or due to the
action of chromogenic bacteria (extrinsic)
 Iatrogenic due to pooraesthetic dentistry
Treatment
RCSEng. Guidelines by Wellbury 2004
1. Prophylaxis
2. Whitening tooth paste
3. Microabrasion
A. Hydrochloric Acid / Pumice Microabrasion :
 Using this technique a maximum of 100 μm. of enamel is removed.
 Mix 18/% hydrochloric acid with pumice.
 Continue rubbing up to a maximum of 10 x 5 second applications per tooth.
 Apply fluoride drops to the teeth for 3 minutes.
B. Phosphoric Acid / Pumice Microabrasion
 Phosphoric acid 35% to enamel surface for 30 secs, wash and dry.
 Remove frosted enamel with tungsten carbide composite finishing bur,

17. 4. Non-vital bleaching
5. Vital bleaching
 Vital bleaching – Chairside
 Vital bleaching - Nightguard
6. Composite restorations
 Localised Composite Restorations
 Composite Veneers
7. Porcelainveneers