CONTINUING EDUCATION ARTICLE

Are dental anomalies risk factors for apical root resorption in

orthodontic patients?

Rosa Y. Lee, DMD, MSD,a Jon Årtun, DDS, Dr Odont,b and Todd A. Alonzo, MSc
Riverside, Calif, Kuwait, and Seattle, Wash

Regression analyses suggest a weak prediction power of identified risk factors for apical root resorption in
orthodontic patients, indicating the presence of etiologic or causative factors that have not yet been
disclosed. To investigate the possible significance of dental anomalies as risk factors, pretreatment and
posttreatment periapical radiographs of 84 patients with presence of at least one dental anomaly and of 84
patients without such anomalies were compared. The patients in the two groups were matched according to
age, gender, Angle Class, extraction therapy, overbite, and treatment time. Apical root resorption was
calculated by subtracting posttreatment tooth length measurements from the corresponding pretreatment
measurements. Two sample t tests revealed no differences in mean root resorption between the patients in
the two groups (P = .88). Stepwise regression analyses did not identify any of the individual anomalies as
risk factors. In addition, patients with more than one anomaly did not appear to be at increased risk. (Am J
Orthod Dentofacial Orthop 1999;116:187-95)

Epidemiologic studies indicate that apical
root resorption may be a minor problem in the average
orthodontic patient. Scoring of apical morphology1-4 as
well as direct measurements of tooth length5-9 on pre-
treatment and posttreatment radiographs suggest that
very few patients are severely affected.5-9 Patients with
long, narrow roots and atypical root form,9 patients
who have experienced traumatic injuries,5,6 and
patients of long-lasting finger and tongue habits 6,10
may be at increased risk. In addition, associations have
been established between treatment variables such as
amount of root movement,7,9 use of elastics,6,9 and
amount of resorption. However, a recent study of 343
consecutive adult orthodontic patients concluded that
the variation in resorption explained by the identified
risk factors was as low as 20%.9 This finding strongly
suggests a weak predictive power of identified risk fac-
tors and indicates the presence of etiologic or causative
factors for apical root resorption that the authors were
unable to disclose.
It is possible that patients with dental anomalies
have increased risk for apical root resorption during
orthodontic treatment. The mechanism may be that
This article is based on research submitted by the senior author in partial ful-
fillment of the requirements for the master of Science in Dentistry Degree,
Department of Orthodontics, School of Dentistry, University of Washington.
The research was supported by the University of Washington Orthodontic
Alumni Association.
aIn private practice, Riverside, Calif.
bProfessor, Division of Orthodontics, Kuwait University.
cGraduate Student, Department of Biostatistics, University of Washington, Seattle.
Reprint requests to: Dr Jon Årtun, Faculty of Dentistry, Kuwait University, PO
Box 24923, Safat 13110 Kuwait; e-mail, artun@hsc.kuniv.edu.kw
Copyright © 1999 by the American Association of Orthodontists.
0889-5406/99/$8.00 + 0 8/1/95063
cementum and dentin are affected during the tooth for-
mation process in such patients,11 thus possibly reduc-
ing the ability of the cementum and dentin to resist
resorption in situations with exertion of pressure.
Familial and twin studies have established the impor-
tance of hereditary factors in the development of den-
tal anomalies12-14 and it is well documented that tooth
agenesis and peg-shaped lateral incisors may have a
linked genetic relationship.13,14 Because of the high
frequencies of association between different anom-
alies,15-25 some authors have suggested that the genetic
influences of dental anomalies may be polygenic with
expression of traits being influenced by other genes or
environmental factors.18,25 Patients with dental anom-
alies may be overrepresented in an orthodontic popula-
tion. Therefore it may be of clinical significance to test
the possible relationship between dental anomalies and
apical root resorption during appliance therapy.
Kjær26 recently examined pretreatment radiographs
of 100 patients selected by orthodontic practitioners for
having experienced severe apical root resorption. She
found that the frequencies of tooth agenesis, peg-
shaped lateral incisors, tooth invaginations, taurodon-
tism, individual teeth with severely deviated root
forms, abnormal eruption pattern of permanent teeth,
and abnormal resorption pattern of deciduous teeth
ranged from 3% to 40% in the sample. The reported
incidence of such anomalies is less than 8% in the nor-
mal population.27-32 Kjær26 therefore suggested that
dental anomalies may be risk factors for orthodonti-
cally induced apical root resorption. However, the
study design did not allow confirmation of the diagno-
sis of severe root resorption or blindness during the
187
188 Lee, Årtun, and Alonzo
Fig 1. Pretreatment periapical radiographs show patients in the experimental group with Class II (A)
and Class III (B) invaginations. Arrows indicate vertical extension of invaginations.
radiographic examination. In addition, bias during case
selection cannot be ruled out. The purpose of this study
was to test the hypothesis that dental anomalies are risk
factors for apical root resorption during orthodontic
treatment.
MATERIAL AND METHODS
Sample
Experimental group. Pretreatment records of orthodon-
tic patients from two orthodontic practices were screened
by one of us (R.Y.L.) for the presence of one or more of the
following anomalies, using the criteria below:
• Tooth agenesis: congenitally absent tooth, evaluated on
panoramic radiographs. Dental history was carefully
reviewed to rule out tooth extraction.
• Peg-shaped or small lateral incisor: conical crown shape
or proportionately small crown, evaluated on study mod-
els and periapical radiographs.
• Dens invaginatus: a definite lingual invagination or cleft
of enamel, with the presence of a foramen cœcum,33 eval-
uated on periapical radiographs.
Class I - No expansion or dilatation of the cleft.
Class II - Slight dilatation of the cleft, with a definite pit
formation (Fig 1A).
American Journal of Orthodontics and Dentofacial Orthopedics
August 1999
Class III - Dilatation of the cleft. Deep extension into the
pulp chamber (Fig 1B).
Class IV - Larger than Class III invagination.
• Taurodontism: Apical extension of the floor of the pulp
chamber resulting in a proportionately shorter root and
enlarged pulp chamber, evaluated on panoramic radi-
ographs. The diagnosis was based on the distance from
the highest point of the floor of the pulp chamber to the
line connecting the mesial and distal points of the
cemento-enamel junction.34 If the root was not com-
pletely developed on the pretreatment radiograph, the
posttreatment radiograph was measured.
Hypotaurodontism: Distance >3.5 mm and <5.0 mm
Mesotaurodontism: Distance >5.5 mm and <7.0 mm
(Fig 2A).
Hypertaurodontism: Distance >7.5 mm (Fig 2B).
Measurements between intervals were rounded to the
lower number.
• Ectopic eruption: Locking of the mesial portion of the
maxillary 1st permanent molar at the cervical area of the
adjacent primary molar with or without resorption of the
primary molar, evaluated on panoramic radiographs or
from chart entries (Fig 3).
• Abnormally short root: Multi-rooted tooth with one abnor-
mally short root (Fig 4A) and single-rooted tooth with root
American Journal of Orthodontics and Dentofacial Orthopedics Lee, Årtun, and Alonzo 189
Volume 116, Number 2

considerably shorter than that of the contralateral tooth

(Fig 4B), evaluated on panoramic radiographs.
Initially, 130 patients were identified. Upon reevalu-
ation, 14 patents with questionable diagnosis of tau-
rodontism (distance < 4 mm) and 11 with questionable
diagnosis of invagination (Class I or incisors with lin-
gual fillings), both without presence of other anomalies,
were discarded. None of the patients had Class IV
invaginations. In addition, 16 patients with missing
posttreatment periapical radiographs and 5 patients with
a history of trauma to the anterior teeth were discarded.
In the final group of 84 patients, the majority had pres-
ence of only one anomaly (Table I). The most common
anomaly was congenitally missing teeth and peg-shaped
or small maxillary lateral incisors, whereas the least
common was short root and ectopic eruption (Table I).
Information on age, gender, Angle Class, extraction
therapy (extraction of maxillary teeth or orthodontic
closure of space for congenitally missing maxillary
teeth), overbite, and treatment time was collected from
the charts (Table II).
Control group. Pretreatment records from the
same practices were also screened to identify 84
patients without presence of anomalies. Aims were Fig 2. Pretreatment panoramic radiographs show
made to match the two patient groups as closely as patients in the experimental group with mesotaurodon-
possible regarding occurrence of nonexperimental tism of maxillary second molars (A) and hypertaurodon-
variables that may affect apical orthodontic root tism of mandibular second molars (B). Arrows indicate
resorption. Identification of individual matches was distance from CEJ to floor of pulp chamber, defining the
degree of taurodontism.
not intended. Univariate chi-square tests indicated no
statistically significant intergroup differences in dis-
tribution of gender, Angle Class, extraction versus
nonextraction therapy, age category, overbite, and
treatment time (P > .32, Table II). The proportion of
experimental and control patients from each practice
was similar.
Sample Size Determination
The sample size of 84 patients for each group was
based on the ability to detect an intergroup difference
of 0.5 mm in apical root resorption at an alpha level of
0.025 with a power of 0.90.

Examination of Radiographs Fig 3. Pretreatment panoramic radiograph shows

Three pretreatment (T1) and posttreatment (T2)
periapical radiographs of the maxillary anterior teeth
were available for each patient: one intended to pro-
ject the central incisors, and one to project each lateral
incisor area. The radiographs of 6 experimental and 4
control patients were made according to the bisecting
of the angle technique. The remaining were made
with a paralleling long cone technique at one radi-
ographic facility.
Initially, the T1 radiographs of each patient were
patient in the experimental group with ectopic eruption
of maxillary and mandibular right first permanent
molars. Note reversible ectopic eruption of maxillary left
first permanent molar.
examined jointly to determine the representative mea-
surement projection for each tooth, whether to refer-
ence the midlabial or midlingual projection of the
cementoenamel junction (CEJ), and which point on the
incisal edge to reference in cases of marked deviations
190 Lee, Årtun, and Alonzo American Journal of Orthodontics and Dentofacial Orthopedics
August 1999

Table I. Frequency of dental anomalies among the 84

patients in the experimental group as well as in the
population
Frequency Frequency
Anomaly sample (%) population (%)27-32

Tooth agenesis 53.3 2–4

Lateral incisor 33.0 (agenesis of lateral incisors
Canine 1.2 and premolars only)
Premolar 17.9
Molar 1.2
Peg-shaped/small lateral incisor 23.8 Occurs frequently with
agenesis of lateral incisors
Dens invaginatus 17.9 1.2–8
Class II 10.8
Class III 7.1
Taurodontism 32.0 0.5–4.3
Hypo 21.4
Meso 3.6
Hyper 7.1
Ectopic eruption 14.3 3–4.3
Short root 14.3 N/A
Number of anomalies
1 65.4
Fig 4. Pretreatment panoramic radiographs show patients 2 29.8
in the experimental group with an abnormally short single- 3 4.8
rooted tooth compared to the contralateral tooth (A) and
one abnormally short root of a multi-rooted tooth (B).
from 0.21 to 0.24 mm (mean, 0.23 mm). The error for
the crown length measurement ranged from 0.25 to
from the long axis of the tooth. If the incisal edge or 0.32 mm (mean, 0.28 mm).
apex were not identifiable in any projection or if an
endodontic filling was present, the tooth was identified Data Analysis
as nonmeasurable. After this procedure, the radiographs Initially two methods for calculation of apical root
were coded and measured in random order. The radi- resorption were compared; 158 patients with availabil-
ographs were projected onto a screen at approximately ity of periapical radiographs made with the paralleling
×7 magnification. Tooth length was measured as the dis- long cone technique were included. In method I, each
tance from the incisal edge to the root apex, and crown tooth length measurement at T2 was subtracted from
length as the distance from the incisal edge to the CEJ the corresponding measurements at T1 (Fig 5). In
(Fig 4). Both measurements were made along the long method II, root resorption was calculated after adjust-
axis of the tooth and recorded to the nearest whole mil- ing each tooth length measurement at T2 by multiply-
limeter on the magnified image. ing with the corresponding crown length at T1 and
dividing by the corresponding crown length at T2 (Fig
Measurement Error 5). The means of the averaged amount of root resorp-
The reproducibility of the measurements was tion of all 4 incisors and the mean of the most severely
assessed by statistically analyzing the difference resorbed incisor per patient were 0.91 mm (SD, 0.71)
between double measurements taken at least 1 week and 1.41 mm (SD, 0.83) according to method I, and
apart on 40 sets of periapical radiographs selected at 0.52 mm (SD, 0.83) and 1.23 (SD, 1.10) according to
random (20 at T1 and 20 at T2). The measurement error method II, respectively. Paired t tests indicated that the
was calculated from the equation: methods gave significantly different results (P < .01).
The SDs were smaller with method I than with method

!§
ΣD2 II, and the proportion of patients calculated to have
Sx = }
2N tooth elongation was lower with method I (Fig 6). In
addition, the error for calculating the averaged amount
where D is the difference between duplicated measure- of root resorption of all 4 incisors was 0.17 with
ments and N is the number of double measurements.35 method I and 0.45 with method II. For these reasons,
The error for the tooth length measurements ranged the reported data for apical root resorption are based on
American Journal of Orthodontics and Dentofacial Orthopedics Lee, Årtun, and Alonzo 191
Volume 116, Number 2

method I for the 158 patients with availability of peri- Table II. Frequency of matching variables among the 84
apical radiographs with the paralleling long cone tech- patients in the experimental group and among the 84
nique, and on method II for the 10 patients with avail- patients in the control group
ability of periapical radiographs made with the Experimental Control Significance
bisecting the angle technique. frequency frequency of difference
Variable (%) (%) (P)
Means of the averaged amount of root resorption of
all 4 incisors and of the most severely resorbed incisor Age group
per patient were calculated as above for the patients in Adolescent (<18 y) 79.0 74.0 0.469
the experimental and control groups. Two sample t Adult (>18 y) 21.0 26.0
Gender
tests were used to test for any statistically significant
Female 60 61 0.875
differences. Stepwise multiple regression analysis Male 40 39
with a backward elimination procedure was used to Angle Class
test for possible effects of individual anomalies and of Class I 66.7 60.7
number of anomalies. For this analysis, small or peg- Class II, Division 1 25.0 29.8 0.883
Class II, Division 2 7.1 8.3
shaped lateral incisors (Table I) were regarded as tooth
Class III 1.2 1.2
agenesis. Extraction therapy
Nonextraction 78.6 84.5 0.320
RESULTS Extraction 21.4 15.5
No intergroup differences in averaged amount of Overbite
Deep (>50% OB) 21.4 20.2
root resorption or in amount of resorption of the most
Open (no OB) 4.8 4.8 0.983
severely affected tooth were found (P > .48, Table III). Normal (<50% OB) 73.4 75.0
The highest amount of averaged resorption was 2.7 mm Treatment time
for the patients in the experimental group and 3.7 mm 12–24 Months 36.0 39.0
for patients in the control group. Only 2.4% of the 25–36 Months 44.0 38.0 0.735
37+ Months 20.0 23.0
experimental patients and 4.8% of the controls (Fig 7)
had averaged resorption of more than 2.5 mm. Simi-
larly, as many as 20.2% of the experimental patients
(Fig 8) and 23.8% of the controls had less than 0.5 mm also appears to have used less rigorous criteria in scor-
of apical root resorption. The maximum resorption of a ing of dental anomalies than we did in our study. She
single tooth was 4.1 mm for the patients in the experi- considered lateral incisors with fillings on the lingual
mental group and 4.2 mm for the patients in the control surfaces to have dens invaginatus. However, such teeth
group. Only 4.76% and 10.7% of the respective may have had only clefts with no expansion or dilata-
patients had at least one incisor that resorbed more than tion (Class I), which may not be considered true dens
2.5 mm. Stepwise regression analysis indicated no sig- invaginatus.32 In addition, her criteria and method for
nificant effects of either the individual anomalies nor registration of taurodontism were not clear.
the number of anomalies. In our study, both samples were selected from the
same practices, without any knowledge of the actual
DISCUSSION amount of root resorption during treatment. To avoid
We could not confirm Kjær’s26 suggestion that den- effect of possible confounding variables, we also
tal anomalies are risk factors for apical root resorption achieved equal proportion of all identifiable surrogate
in orthodontic patients. One reason for the conflicting variables for type and amount of movement of the
findings may be that Kjær’s sample was not represen- maxillary incisor roots as well as of age category and
tative of the population of patients with severe root gender in the two patient groups. We also ensured
resorption. Selection and detection biases are difficult appropriate blinding and standardization during the
to avoid when practitioners are requested to submit measurement procedure.
records of patients that fit certain criteria. In addition, It may be argued that the experimental group
Kjær did not have access to the posttreatment radi- included too few patients with more than one anomaly
ographs and could therefore not confirm the diagnosis (Table I) to allow valid conclusions. Another potential
of severe root resorption. Another potential problem problem is that scoring of ectopic first molar eruption
was that the nature of the study did not allow a blind frequently was based on chart entries, because radi-
procedure to be used during examination of the pre- ographic examination at the time of first molar erup-
treatment radiographs. Kjær may therefore have over- tion was not part of the protocol in the practices from
scored the presence of certain dental anomalies. She which the patients were selected. We could therefore
192 Lee, Årtun, and Alonzo
Fig 5. Calculation of apical root resorption according to
method I and method II.
Fig 6. Frequency of patients with averaged amount of
apical root resorption of all 4 incisors within each mil-
limeter inverval calculated according to method I and
method II.
not rule out presence of patients with undiagnosed
ectopic eruption in the control group. However, the
risk of such bias is likely to be low because the fre-
quency of ectopic eruption of the maxillary perma-
nent molars only is 3% to 4.3% in the normal popu-
lation. 31,32 These figures are considerably smaller
than the frequency of ectopic molar eruption in the
experimental group. The frequencies of other dental
American Journal of Orthodontics and Dentofacial Orthopedics
August 1999
Table III. Sample means of averaged amount of root
resorption of all 4 incisors (averaged) and of the most
severely resorbed tooth per patient (maximum) among
84 patients with dental anomalies (experimental) and
84 patients without anomalies (control)
Experimental Control Significance of
mean (SD) mean (SD) difference (P)
Averaged (mm) 0.96 (0.66) 0.94 (0.80) .875
Maximum (mm) 1.41 (0.83) 1.51 (0.92) .481
anomalies in our study were also considerably higher
than in the population (Table I). Although few stud-
ies have examined the incidence of single teeth with
short roots in the normal population, the condition
may frequently occur with other dental anomalies
such as dens invaginatus and taurodontism.19,23,24
Because of the rigorous scoring criteria used for
identification of dental anomalies and because of the
frequent occurrence of each anomaly, our experimen-
tal sample may therefore be considered representa-
tive for the population of orthodontic patients with
dental anomalies.
The prevalence of apical root resorption among the
patients in the experimental group was comparable to
that found in large population-based studies.6,8 The
sample means of the averaged amount of resorption of
all incisors as well as of the most severely resorbed
incisor were similar. In addition, the frequency of
patients with severe root resorption was not higher in
our sample. These comparisons support our conclusion
that patients with dental anomalies are not at increased
risk of apical root resorption.
The regression analyses could not identify any of
the individual anomalies as risk factors for apical root
resorption, nor did it seem that patients with presence
of more than one anomaly were at increased risk.
When making this statement, however, it should be
stressed that our study was designed to detect inter-
group differences between patients with and without
presence of anomalies. The power to detect effects of
each anomaly may be considered too low because of
the small sizes of each subsample.
Because most of the radiographic records were
obtained from the same radiographic facility and
were made using the same paralleling technique,
errors as a result of variations in radiographic pro-
jection and enlargement are likely to be small and
randomly distributed in the two samples. Despite
this, we made initial attempts to correct for differ-
ences in tooth enlargements on the pretreatment and
posttreatment radiographs by adjusting for any
change in the crown length measurements when cal-
American Journal of Orthodontics and Dentofacial Orthopedics Lee, Årtun, and Alonzo 193
Volume 116, Number 2

Fig 7. Pretreatment panoramic radiograph (A) as well as pretreatment (B) and posttreatment (C)
periapical radiographs of a patient in the control group with greater than 2.5 mm averaged amount
of apical root resorption. The enamel irregularities (arrows) of the maxillary central incisors were not
considered to be invaginations.

culating root resorption. In keeping with a previous
study,8 we found a large error associated with iden-
tification of the midlabial aspect of the cementoe-
namel junction despite attempts to standardize the
identification of this landmark. We therefore based
our analysis on the tooth length measurements,
except for the few radiographs that were made with
unstandardized technique.
CONCLUSION
Our study does not support the hypothesis that
orthodontic patients with dental anomalies are at
194 Lee, Årtun, and Alonzo American Journal of Orthodontics and Dentofacial Orthopedics
August 1999

Fig 8. Pretreatment panoramic radiograph (A) as well as pretreatment (B) and posttreatment (C)
periapical radiographs of a patient in the experimental group with minimal amount of apical root
resorption. Note Class III invaginations of both maxillary lateral incisors and mesotaurodontism of
maxillary second molars.

increased risk of apical root resorption during active Peter A Shapiro, and Lars G Hollender for valuable
appliance therapy. suggestions and advice during the course of the pro-
ject. We are particularly thankful to Drs Kokich and
We would like to thank Drs Vincent G Kokich, Shapiro for providing the sample, and to the Univer-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 116, Number 2
sity of Washington Orthodontic Alumni Association
for providing financial support.
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