Scand. J. dent. Res. 1972: 5-93 Short Root anomaly VOLMER LIND Orthodontic Department of The Public Dental Health Organization, Halmstad, Sweden ansrracr — An anomaly is described, the symptoms of which have hitherto received but little attention and have been misinterpreted, viz. abnormally short roots of characteristi- cally plump shape mainly affecting both maxillary central incisors. The author calls it Short Root anomaly or, in short, the SR-anomaly. This paper describes a method for radiographic ally measuring “the relative root length” which permits quantitative comparisons of the roots in clinical series, Clinical, radiographic and metric examinations were performed on 112 children with abnormally short roots of the maxillary central incisors, 66 children with certain types of external root resorption of the maxillary incisors, and 100 children with normally developed roots used as a control group. The findings, together with available data from the scanty literature, suggest the following conclusions: (1) Irrespective of sex, the Jength of the root of the maxillary central incisor (‘relative root length”) is, on the average, 1.6 times that of the length of the crown, and the corresponding ratio in children with SR-anomaly is 1.1. (2) The SR-anomaly is associated with a predisposition to root resorp- tion in the maxillary front teeth. (3) The shortness of the roots is not due to resorption or to any developmental disturbance of exogenous origin. The condition is a constitutional anomaly and its prevalence varies with sex, race and hereditary predisposition. (Received for publication 27 October, accepted 30 November 1971) c ical description and literature review Like other anatomic details, the size and shape of tooth roots normally vary within a certain range, apart from anomalous or pathologic conditions. Extensive routine radiographic examination of clinical pop- ulations, somewhat more than 15 years ago, brought the author to the discovery that the roots of the maxillary central in- cisors were, in a few cases, so short that they must be regarded as anomalous. As a rule, these roots were characteristically plump and often tended toward an onion shape. Fig. 1 shows some typical cases. Apart from the root morphology, the teeth and their surrounding tissues are radio- graphically and clinically normal. Fig. 2 gives a series of radiographs which show that the development of the root is al- ready abnormal at an early stage and that its final shape is not due to resorption. The Short Root anomaly (SR-anomaly) always affects both central incisors almost symmetrically. Other teeth are more rarely involved (Fig. 3), and when they are, it is usually premolars and canines which are affected. The SR-anomaly and certain types of external root resorption of maxillary front teeth are often seen together. For example, nearly all the Department’s cases with root resorption of the maxillary lateral incisor due to pressure from the canine also showed short root of the central in- cisor. Examples of SR-anomaly with root resorption are given in Fig. 4. Literature studies revealed that this86 Fig. 1. Three cases of SR-anomaly showing the short root condition has received only little attention. Hroiéka (1910) Keronam (1927), Pepersen (1949) and TraTman (1950) reported occurrence of this type of root shortness. Pepersen (1949) supposed it to be a result of resorption. Apo, Kryo- xawa, Nakasnima, SHinso, SANKA, OsH- mA & Atzawa (1969) found the same type of short roots of the maxillary central incisors in 10% of 300 Japanese school- children and thought the condition was a developmental disturbance caused by en- larged occlusal load sustained by the cen- trals in the first period after eruption. Only Awvo et al. (1969) suggest a quan- titative definition; they call the root short when it is of the same size or smaller than the crown. But they do not define root and crown length. None of the above authors have noticed any connection be- tween the short root condition and in- creased occurrence of root resorption. The purpose of the present article is to give details of this short root condition and demonstrate it to be a hitherto un- registered dental anomaly. Another aim is typical morphology of roots of the central incisors. to present a method for comparing root length in radiographic series. Material and methods Every year 800-1000 children are referred to the Orthodontic Department in Halmstad, ie. 50-60% of any one-year age group of the pop- ulation served by the Department. In all these children the teeth are examined radiographi- cally. For about 15 years a register has been Kept of all children with abnormally short roots of the maxillary central incisors. This material discovery that an association between short root is called short root group or S-group. After the condition and increased root resorption could be expected, a special register was kept of all children with certain forms of external root resorption of the maxillary front teeth. Usually these resorptions were due to pressure from embedded canines; a smaller part were of chronic traumatic type (orthodontic stress and traumatic occlusion) or idiopathic. Resorptions caused by acute trauma or inflammation were not registered. Patients with both short-rooted central incisors and resorption were referred to this group, hereafter called resorption group or R-group. Later, these materials were critically ana- lyzed. Only children with fully developed roots of the incisors were accepted. Some cases wereSHORT ROOT ANOMALY 87 Fig. 2. Two cases of SR-anomaly illustrating the development of the roots of the central incisors. Above, girl aged 8 years 1 month, 9 years 7 months, and 22 years. Below, boy aged 8 years and 14 years, respectively. Already early in life the development of the root is clearly abnormal, which demonstrates that the condition is not due to resorpt excluded because of incompleteness of their dental cards or technically poor radiographs. A few cases in the R-group were rejected because the roots of the central incisors had been re- sorbed to such an extent that they could no longer be measured. The final material con- sisted of 112 cases in the S-group and 66 in the R-group. 100 children with normal, fully developed roots and satisfactory radiographs were selected at random, taken alphabetically from the files of the Department and used as controls, C- group. Metric studies of the roots on radiographs present certain problems. Owing to the diffi- culty in attaining precise linear reproduction or radiographs with regularly identical projection, it is necessary to work with relative dimensions within each radiograph. It was therefore de- cided to use “the relative root length” (R/C), defined as the ratio between root length and crown length. Since the root and the crown normally lie in almost the same plane, small differences in projection have the same effect on both dimensions on the radiographic image, provided standardized bisecting-angle technique and a long tube are used, as in the present investigation.88 LIND Fig. 3. A 47-year-old man with SR-anomaly showing short roots more generally. Besides the maxil- lary central incisors, the laterals especially, and some of the canines and premolars, are involved. Fig. 4. SR-anomaly associated with root resorption owing to pressure by embedded canines. Left, female 11 years 9 months. Right, male 15 years. A further case is seen in Fig. 9. Fig, 5 illustrates the measuring method. The vestibular or lingual cemento-enamel junction cannot be used as the boundary line between the crown and the root because it does not lie in the same plane as the apex and the incisal edge. Instead, the following method was used. The points of intersection x and y between the outer contours of the root and the crown, which are always seen clearly in good radiographs, were connected by a straight line. The mid- point of this line was called m. The apex was marked r and the midpoint of the incisal edge i, The relative root length was thus calculated with the following expression: r-m/i-m = R/C. The actual tip of the apex is not always situ- ated exactly on the axis, but this is of less im- portance because the deviations encountered are only small. No markedly bent roots were in- cluded in the C-group and they hardly ever occurred in the S- or R-groups. In all 3 groups both central incisors were measured and the mean of the 2 R/C values was taken as the relative root length for the individual.SHORT ROOT ANOMALY 89 Fig.5. Measurement of “the relative root length”, RIC. Points of intersection between the outer contours of the root and the crown, x and y are connected by a straight line. Root length (R) is measured from the midpoint of this line, m, to the apex, and crown height (C) from m to the middle of the incisal edge. Results The distribution of relative root length in the 3 groups is given in the histogram in Fig. 6. Statistical analysis revealed no dif- ference in relative root length between boys and girls in G-group and therefore the sexes were pooled. In all 3 groups the distribution is that of a Gaussian curve, but the values in S-group and R-group differ clearly from that of C-group. The mean R/C in C-group is 1.6 and in both S-group and R-group it is 1.1. Table 1 gives the mean values found for root Iength and crown length. There is no difference in crown length among the groups. The root length, on the other OS o7 08.09 101) 2 13 15 16 17 18 19 20 21% 25 Bj c-erour 20 S| 100=4980vs+s1GiRLS 15 5| 10 S| aI 5 + o ‘S-GROUP nazepoyseacinis [4° BS z R-GROUP EB ho & 86:22B0YS+4GIRLS [os | 20 i TOTALLY 4 HS 3 500+ 1289 ie 5 Tea ar Fig. 6. Distribution of the values of R/G (the relative root length) in the 3 groups examined, Above, Control group. Below, Short Root group plus Resorption group. The sexes are pooled in the histograms, but the number of boys and girls in the groups are given in numerals. The histogram below also shows the proportion of children with root resorption. As many as 41.1 % of the children with an R/C of less than 1.2 had resorption, while the corresponding frequency for the children with R/C above 1.1 was 30 %. hand, is about 5% mm shorter in the S- and R-groups in relation to C-group. Sex distribution in S- and R-groups (Fig. 7) shows that girls are affected more often than boys — 3 times as often in S- group and twice as often in R-group. If R/C = 1.1 is accepted as the upper limit for a root to be regarded as defini- tive short, 107 of the children have clearly short roots. Ratio girls:boys = 2.7:1. In this material the frequency of root resorp- tion is 41.1%, ic. a rather high risk of root resorption in children with marked SR-anomaly. Children with R/C higher than 1.1 have a much lower frequency of resorption.90 LIND Table 1 Mean values found in normal material (C-group) and in the anomaly groups (S-group and R- group pooled). The values jor the left and the right central incisors are pooled because there was no difference between their mean values. Both crown and root length values are, on the average, Ys— Yo mm larger in boys than in girls, but the differences are not significant. The mean R/C was in C-group 1.640.186, in S-group 1.1140.162 and in R-group 1.100.199 C-group S-group plus R-group 49 boys 51 girls 50 boys 128 girls Length of root 16.82+187 16454171 11474166 10.89+1.46 Length of crown 10.38+1.11 10014092 10.214061 9.92 + 0.78 RIG 16 16 1a ot Study of available data concerning tooth eruption, numeric and morphologic dental variations and the development of occlu- sion in this material with severe SR-anom- aly does not reveal any definite diver- gence from findings in normal populations, except for the noted, high frequency of frontal crossbite. Twenty-eight per cent of the children had this malocclusion which was considerably higher than the 4% fre- quency rate in the normal population served by the Department. Fig. 7 shows a case from the material where only one central incisor was locked in a crossbite and treated orthodontically; but both cen- tral incisors have short roots. As for the theory that the root shortness is caused by stress or load of the central Fig. 7. A girl with maxillary right central incisor in cross-bite. a, frontal occlusion at beginning of orthodontic treatment, when the child was 8 years 10 months. b, normal frontal occlusion at time of full eruption at 13 years. c, radiographs taken at that time shows equally short roots of both central incisors.SHORT ROOT ANOMALY 91 Fig. 8. A girl with SR-anomaly in whom the left central incisor was embedded during develop- ment of the root and was thus not exposed to masticatory pressure or other external load. incisors during root development, the case shown in Fig. 8 is instructive. One of the central incisors was retained during the critical period of root development, but both developed short roots. The SR-anomaly always affects the cen- tral incisors, but sometimes other teeth as well, usually the premolars and canines. In the present material this was seen in 15% of the children. Since several of the children with SR- anomaly were siblings, it was thought that the etiology of the anomaly might include a genetic factor, and therefore the parents of some of the children were examined. In nearly all of these cases a familial oc- currence could be established. Examples are given in Fig. 9. Discussion There are probably several reasons why the SR-anomaly has hitherto received only little attention. (1) The condition pro- duces no clinical symptoms except that in severe cases the central incisors may be somewhat loose. Upon clinical examina- ion, however, it is usually possible in narked case to feel that the root is short by taking a firm grip of the crown and trying to move the tooth. These anomalous central incisors, however, function remark- ably well throughout life unless they are exposed to exceptionally severe stress. (2) The anomaly has been misdiagnosed as resorption. (3) Its frequency among Cau- casian populations is probably fairly low. Judging from the literature it is more common in Mongolian populations: Hrp- u1éka (1910), PEDERSEN (1949) and TratMan (1950) found the condition in Mongolian populations. ANpo et al. (1969) reported that the condition was fairly common in Japan and HrpwréKa (1910) says that short rooted central in- cisors are not uncommon among Amer- indians. PEDERSEN (1949) as well as ANDo et al. (1969) believe that the condition is due to an exogenous factor: masticatory stress. PeperseN (1949) regards the shortness of the roots as a result of resorption, and Awpo et al. (1969) consider it a develop- mental disturbance. This assumption is contradicted by the present study: first, by the clinical findings which showed that the maxillary central incisors are always affected simultaneously and very symme-92 LIND Fig. 9. Two examples of familial occurrence of mother (58 years), daughter (19 years), and son (14 years). Bottom row, maternal grand- mother (73 years), mother (43 years) and son (17 years) trically while the mandibular central teeth are very rarely involved; second, because the anomaly is almost 3 times as common in girls as in boys; third, because the prev- alence of the condition differs with race; and fourth, because it is familial. All this suggests that the condition is a constitu- tional anomaly of genetic origin. The tendency towards an association between the anomaly and frontal cross- bite may be interpreted as a premaxillary growth insufficiency in children with the SR-anomaly. The association between the anomaly and increased resorption has hitherto not been observed and is difficult to explain. SR-anomaly. Upper row from left to right, Concerning the resorption produced by pressure from crowded or dislocated teeth or tooth germs, which was the most com- mon cause in this investigation, it is ob- vious that this resorption does not occur in all cases of this very common situation. The liability to resorption varies not only between individuals but also from one part of the dentition to another. It is, for example, very rare that the frequently crowded and embedded second premolars cause root resorption of neighboring teeth. but it is not so unusual that the maxillary canine in the same situation produces re- sorption of lateral incisors; it never hap- pens with first premolars! In cases of SR-SHORT ROOT ANOMALY 93 anomaly the resistance to root resorption must be abnormally low in the maxillary front teeth. From a practical point of view it is, of course, important that the SR-anomaly be diagnosed as early as possible. Prophy- lactically, attempts should be made to pro- tect the central incisors from strong mas- ticatory stresses and, because of the in- creased risk of resorption, the front teeth should, if possible, not be exposed to fac- tors capable of eliciting resorption, e.g. pressure from retained, crowded and dis- located canines, traumatic occlusion or strong orthodontic stress. Address: Tandregleringspolikliniken Seminariegatan 6B 30232 Halmstad Sweden References Avvo, S., Kryoxawa, K., Naxasnima, T., SHIn- Bo, K., Sanka, Y., Osnia, S. & Aizawa, K. Studies on the consecutive survey of succed- aneous and permanent dentition in the Jap- anese children. Part 4. Behaviour of short- rooted teeth in the upper bilateral central in- cisors. J. Nikon, Univ. Sch. Dent. 1967: 9: 67-80, Hepuiéxa, A.: Contribution to the anthropology of Central and Smith Sound Eskimos. Anthro- pol. Pap. Amer. Mus. Nat. Hist. 1910: 5, part 2: 177-285. Kercuam, A. H.: A preliminary report of an investigation of apical root resorption of vital permanent teeth. Int. J. Orth. Oral. Surg. & Radiogr. 1927: 15: 310-317. Pepersen, P. O.: The East Greenland Eskimo dentition. Meddelelser om Gronland 142; Copenhagen 1949. ‘TrarMan, E. K.: A comparison of the teeth of people of Indo-European racial stock with the mongoloid racial stock. Dent. Rec. 1950: 70: 31-53 and 63-88.This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.