ORIGINAL ARTICLE

Pulp vitality and histologic changes in human

dental pulp after the application of moderate and
severe intrusive orthodontic forces
Guanghong Han,a Min Hu,b Ying Zhang,c and Huan Jiangd
Changchun, China

Introduction: Orthodontic forces produce a series of changes in dental pulp. However, no one has attempted to
investigate the incidence of pulp necrosis after orthodontic therapy in the clinic. In this study, we aimed to investigate pulp vitality and histologic changes after the application of moderate and severe intrusive forces.
Methods: Twenty-seven adolescent patients were assigned to 1 of 3 groups: the control group of 3 subjects;
the moderate-force group, with 12 subjects who received a 50-g force to the rst premolars bilaterally; and
the severe-force group, with 12 subjects who received a 300-g force. The forces were applied for 1, 4, 8, or
12 weeks. An electric pulp tester was used to test for vitality, and teeth that did not respond to the electric
pulp tester were subsequently tested thermally with a stick of heated gutta-percha. Results: The teeth with a
negative response to the electric pulp tester still responded to the thermal test. We found odontoblast disruption,
vacuolization, and moderate vascular congestion in both force groups, but no necrosis was observed. Pulp
stones were formed only in the severe-force group. Conclusions: Dental pulp still has vitality after intrusive
treatment with different forces. These data provide new insights into the effects of intrusive orthodontic forces.
(Am J Orthod Dentofacial Orthop 2013;144:518-22)

rthodontic forces are known to produce a series

of changes in dental pulp after tooth movement.
As a consequence of environmental constraints
in a rigid and noncompliant shell, changes in pulpal
blood ow or vascular tissue pressure have serious implications for the health of dental pulp. The main pulp
changes after the application of intrusive forces include
vacuolization of the pulp tissue, circulatory disturbances, congestion, hemorrhage, and brohyalinosis.1,2
It has been suggested that injury from orthodontic
forces might be permanent, and the pulp could

a
Attending physician, Department of Endodontics, School of Stomatology, Jilin
University, Changchun, China.
b
Professor, Department of Orthodontics, School of Stomatology, Jilin University,
Changchun, China.
c
Master student, Department of Orthodontics, School of Stomatology, Jilin
University, Changchun, China.
d
PhD student, Department of Orthodontics, School of Stomatology, Jilin
University, Changchun, China.
All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conicts of Interest, and none were reported.
Supported by fund from the Natural Science Foundation of China (811709999/
H1409).
Reprint requests to: Min Hu, Department of Orthodontics, School of Stomatology, Jilin University, No 1500, Qinghua Rd, Changchun 130021, Jilin, China;
e-mail, ydhhm@sohu.com.
Submitted, January 2013; revised and accepted, May 2013.
0889-5406/$36.00
Copyright 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.05.005

518

eventually lose its vitality.3 However, other studies

showed that orthodontic forces had no signicant
long-lasting effects.4,5 A recent study showed that
heavier forces applied during rapid palatal expansion
were more likely to affect the pulpal vasculature, but
the pulp of the posterior permanent teeth was still
vital.6 Darendeliler et al7 found that 50 g of constant
and continuous force could produce the ideal amount
of tooth movement, but exceeding this force might
cause periodontal ischemia, leading to root resorption.
However, no study has attempted to investigate the incidence of pulp necrosis after orthodontic therapy in the
clinic. Therefore, in this study, we aimed to investigate
the histologic alterations of the dental pulp resulting
from the application of moderate and severe orthodontic
forces and to determine whether dental pulp loses its vitality after the application of a severe orthodontic force.
MATERIAL AND METHODS

This study was conducted on 54 maxillary rst premolars collected from 27 prospective orthodontic patients (15 male, 12 female) with a mean age of 17.9
years (range, 14-24 years) who required rst premolar
extractions. The 27 subjects were randomly divided
into 3 groups: the control group without orthodontic
forces (3 subjects), the moderate-force group (12

Han et al

519

Fig 1. The experimental setting: A, the appliance used to apply buccally directed forces on both rst
premolars; B, the transpalatal arch was disengaged from occlusal contact.

subjects), and the severe-force group (12 subjects). The

moderate-force group had 50 g of buccally directed orthodontic intrusive force on both sides, and the severeforce group had 300 g of force. The experimental rst
premolars were extracted 1, 4, 8, or 12 weeks after the
initial force application (6 teeth from each group were
extracted at each time).
All study participants met the following criteria: (1)
no major systemic disease, (2) no medication use, (3)
healthy periodontium (minimal gingival inammation,
probing depths #3 mm, and no bone loss as determined
by radiographs), (4) no endodontically treated teeth, (5)
no trauma history, (6) complete root development determined radiographically (and conrmed visually after extractions), and (7) no moderate or severe crowding. The
study was approved by the institutional review board of
Jilin University in Changchun, China, and all participants
gave informed consent.
A lingual button was bonded onto the buccal surfaces of the maxillary rst premolars. Intrusive orthodontic forces were applied by a clear closed
elastomeric chain (ORMAER; Dentsply Raintree Essix
Glenroe, Sarasota, Fla) (Fig 1, A). The force magnitude
was measured with a strain gauge (Dentaurum, Ispringen, Germany) at the beginning of the intrusion to
ensure that proper forces were applied. The elastomeric
chain was changed each time the patients revisited,
once a week. A transpalatal arch was used to reinforce
the anchorage (Fig 1, B). For the moderate-force (50 g)
group, a transpalatal arch was used to reinforce the
anchorage 4 weeks before the application of the force,
and a Nance arch was additionally used to reinforce
the anchorage 8 weeks after the application of the force.
For the severe-force (300 g) group, both transpalatal and
Nance arches were used to reinforce the anchorage
immediately after the application of the force.
An electric pulp tester (Analytic Technology, Redmond, Wash) was used in this study. Toothpaste was
the conducting medium. The testing site was conned
to the buccal cusp tips of the molars and the premolars.

Teeth that did not respond to the electric pulp tester

were tested thermally with a stick of heated gutta-percha
(hot testing). All teeth were isolated with cotton rolls and
dried thoroughly before testing. The testing procedure
was explained to the patients. The readings of the electric pulp tester were recorded, and the results of the thermal testing were recorded as a positive or a negative (yes
or no) response.
Electric pulp tests were performed immediately
before placement of the lingual button to provide a
baseline for the study and at 1, 4, 8, and 12 weeks after
the intrusion treatment.
At week 1, 4, 8, or 12 after the treatment, teeth were
extracted by an oral surgeon with minimum trauma. After extraction, the crown of each tooth was cut with a bur
to facilitate the xation, and the tooth was xed in 10%
formalin for 1 week. Then the specimens were decalcied
and embedded in parafn. Serial sections (5 mm thick)
were cut longitudinally from each tooth and stained
with hematoxylin and eosin dye. The sections were evaluated using a computer image analyzing system (HPIAS1000, version 6.0; Media Cybernetics, Silver Spring, Md).
Statistical analysis

The data were processed with SPSS software (version

11.5; SPSS, Chicago, Ill). The electric pulp tester data
were analyzed using the Student t test and 1-way analysis
of variance. P \0.05 indicated a statistical difference.
RESULTS

The total measurement period was from 1 week to 12

weeks after the application of the orthodontic force.
Teeth that did not respond to the electric pulp tester underwent subsequent thermal testing. All teeth still responded positively to the thermal test. As shown in the
Table, the teeth in the severe-force group responded
negatively to the electric pulp tester from 4 to 12 weeks,
whereas the teeth in the moderate-force group had no
response from 8 to 12 weeks. When the teeth responded

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Table. Comparison of electric pulp tester (EPT) readings between the moderate-force and severe-force groups at the
observation (means 6 standard deviations)
Moderate-force group
Week
0
1
2
3
4
5
6
7
8
9
10
11
12

Teeth (n)
24
6
6
6
6
6
6
6
6
6
6
6
6

Severe-force group

EPT reading
3.44 6 2.37
4.50 6 2.56
5.20 6 2.57y
4.29 6 2.36
6.43 6 2.07y
7.68 6 0.35z
8.35 6 0.38z
8.67 6 0.43z
0
0
0
0
0

Teeth (n)
24
6
6
6
6
6
6
6
6
6
6
6
6

EPT reading
5.33 6 2.45
6.63 6 1.77
7.20 6 0.84
7.67 6 0.58
0
0
0
0
0
0
0
0
0

t
1.900
2.10
2.23
3.55

P
0.07
0.047*
0.045*
0.009*

*P\0.05 compared with the corresponding moderate-force group; yP\0.05 compared with the readings at baseline (week 0); zP\0.001 compared
with the readings at baseline (week 0).

to the electric pulp tester, there were signicant differences between the moderate-force and severe-force
groups at weeks 1, 2, and 3 (P \0.05). Readings of the
moderate-force group at weeks 2 and 4 were signicantly increased compared with those at baseline
(P \0.05). In addition, there were signicant differences
between the readings of the moderate-force group at
weeks 5, 6, and 7 and those at baseline (P \0.001). After
4 weeks, pulp vitality measurements became signicantly different from those during the previous weeks
(P 5 0.009). Readings of the electric pulp tester
increased over time in the severe-force group, but
showed no statistical difference (t 5 3.799; P 5 0.06).
In the control group, we observed a columnar odontoblast cell layer with normal morphology. A cell-free
zone was obvious, and no inammatory cell inltration
or vascular congestion was observed (Fig 2, A).
At week 1, the odontoblast nuclei in the odontoblast
zone in both force groups appeared abnormal, and vacuolization in the odontoblast layer and moderate
vascular congestion were observed. The structure of the
cell-free zone was disrupted in the severe-force group.
No signicant change was observed in the root pulp.
At week 4, in the coronal pulp of the experimental
groups, vacuolization and moderate vascular congestion
were observed. The arrangement of the odontoblast cell
layers, the cell-free zones, the vessels, and the amounts
of pulpal cells were similar to those in the control group.
In addition, the extent of vacuole formation was worse
in the severe-force group than in the moderate-force
group. The resorption of craters in the root with some
cementum deposition was obvious in the severe-force
group (Fig 2, B).

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At week 8, in the coronal pulp of both experimental

groups, vacuolization was particularly obvious. Vascular
congestion and dilatation were more obvious than at
week 4. In the severe-force group, several pulp stones
appeared near the bers, and vacuolization, inammatory extravasation, and adipose degeneration were
clearly observed (Fig 2, C). However, no pulp stones
were found, but root resorption appeared in the
moderate-force group (Fig 2, D).
At week 12, odontoblastic degeneration, vacuole
formation, and adipose degeneration were widespread
in the coronal pulp of the severe-force group
(Fig 2, E). Furthermore, vascular dilatation such as
arborization, extravasation of red blood cells into
pulp tissue, vascular congestion in the cell-rich zone,
and inammatory extravasation were observed (Fig
2, F). In the root pulp, no visible necrotic changes
were found. Calcic lines were found around the
dentin (Fig 2, G), indicating reparative action in
pulp tissues. A few pulp stones were observed near
the bers in both the coronal and root pulps. In the
coronal pulp of the moderate-force group, vascular
congestion and inammatory extravasation were
similar to those in the severe-force group. In the
root pulp, no pulp stones were seen. There were
many resorption craters in the dentin, and inammatory cells were observed around the vessels in the
moderate-force group (Fig 2, H).
DISCUSSION

A force of 15 to 25 g per tooth has been recommended

for the intrusion of nontraumatized maxillary incisors.8
The root surface area of the rst premolar is greater

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Fig 2. Histology of the teeth in the different groups, with representative pictures from multiple teeth in
each group. A, Normal morphology in the control group; D, Dentin; O, odontoblast layer; CFZ, cell-free
zone; CRZ, cell-rich zone; V, vessels; hematoxylin and eosin (HE) staining; magnication, 100 times.
B, At week 4, root resorption was obvious with some cementum deposition in the severe-force group;
HE staining; magnication, 100 times. C, At week 8, several pulp stones were found in the root pulp in
the severe-force group; HE staining; magnication, 100 times. D, At week 12, root resorption appeared
in the moderate-force group; HE staining; magnication, 40 times. E, At week 12, vacuolization in the
odontoblastic layer, adipose degeneration of the pulp cells, and inammatory extravasation were
observed in the severe-force group; HE staining; magnication, 200 times. F, At week 12, vascular dilatation such as arborization and extravasation of red blood cells into pulp tissue, and vascular congestion were observed in the coronal pulp of the severe-force group; HE staining; magnication, 100 times.
G, At week 12, calcic lines were observed around the dentin in the roots of teeth in the severe-force
group; HE staining; magnication, 200 times. H, At week 12, inammatory cell inltration and vascular
congestion were observed around the vessels in the moderate-force group; HE staining; magnication,
100 times.

than that of the incisor. Therefore, the magnitude for

intrusion of the rst premolar should be greater than
that of an incisor.
In a previous study, 25 g was chosen as a relatively
moderate force, and a 9-fold greater force of 225 g
was chosen as a relatively severe force.9 In this study,

to consider the force degradation of elastics and to apply

forces in their optimum ranges, we chose a 50-g force
for intrusive movements and a 6-fold greater force of
300 g as a relatively severe force. We found that root
resorption appeared after an intrusive force was applied
for 8 weeks in the moderate-force group. However, no

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pulp stones or adipose degeneration was found in this

group until 12 weeks. These results suggest that moderate intrusive forces do not severely distort blood vessels.
The pulp vitality test is crucial in monitoring the state
of dental pulp. Thermal testing is considered more reliable than the electric pulp tester for assessing pulp
health. For this reason, teeth that did not respond to
the electric pulp tester underwent subsequent thermal
testing. In this study, teeth in the severe-force group responded negatively to the electric pulp tester from week
4 on, whereas teeth in the moderate-force group had no
response from week 8 on, but all teeth still responded
positively to the thermal test. Therefore, the pulpal state
in the severe-force group was better than that in the
moderate-force group, and no loss of pulp vitality was
found in this study.
We found that even 300 g of force continuously
intruded the premolar for 12 weeks, and the pulp still appeared to have no damage, indicating that it has an
extraordinary ability to withstand insults. Further histologic analysis demonstrated a mild inammatory
response in the dental pulp. At week 4, in the root
pulp, the resorption of cementum was clearly observed
in the severe-force group. At week 8, root resorption appeared in the moderate-force group. These results indicate that a severe force might induce root resorption.10
At week 8, adipose degeneration was found in the root
pulp. A possible explanation could be that the apical
zone is the location that the intrusive force most likely
affects. Therefore, the capacity of the apical vessels
might be signicantly reduced. Pulp stones were found
in both the coronal and root pulp in the severe-force
group; this might be because distorted vessels make
pulp cells anoxemic for a long time. The results demonstrate that supplying vessels in the severe-force group
cause a reduced ability of the pulp to react to the impairment of pulpal blood and maintain a sufcient blood
supply compared with the moderate-force group.
Several limitations of this study should be pointed
out. First, we did not examine intrusive tooth movement

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or the extrusive movement of the molars; these are

important to evaluate the effects of intrusive orthodontic forces. Second, our analysis of the histology of the
dental pulp was only descriptive. Further quantitative
analysis on the indexes after the application of different
forces is needed to provide new insights into the effects
of intrusive orthodontic forces.
CONCLUSIONS

After intrusive treatment with different forces, the

dental pulp still has vitality and no necrosis is observed.
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