RestorativeDentistry
Zaid Al-Momani
Peter J Nixon
Internal and External Root
Resorption: Aetiology, Diagnosis
and Treatment Options
Abstract: Root resorption is a pathological process that may occur after surgical, mechanical, chemical or thermal insult. Generally, it can
be classified as internal and external root resorption. Depending on the diagnosis, an orthograde, surgical or a combined approach is used
in management of these cases.
Clinical Relevance: General dental practitioners can face difficulties in diagnosis and treatment planning for cases with root resorption. An
understanding of the aetiology and pathogenesis of root resorption is critical for diagnosis, effective management and improves outcome.
Dent Update 2013; 40: 102–112
Root resorption is a pathological process
that is not uncommon after injuries
or irritation of periodontal ligament
or pulp.1 Such injuries may result from
surgical, physical, chemical or thermal
insult. Resorption may also occur due
to mechanical stimulation, infection or
neoplastic disease.
Pathogenesis
The result of this process is
loss of hard dental tissues (ie cementum
and dentine) by dentinoclastic cell action.
The function of dentinoclasts is controlled
by various activating and preventing
resorption factors. Activating factors
include:
Zaid Al-Momani, BDS, MFDS RCSEd,
MDentSci(Rest Dent), Specialist Registrar
in Restorative Dentistry and Peter J
Nixon, BChD(Hons), MFDS RCSEd,
MDentSc, FDS(Rest Dent) RCSEd,
Consultant in Restorative Dentistry,
Restorative Department, Level 5, Leeds
Dental Institute, Clarendon Way, Leeds
LS2 9JT, UK.
102 DentalUpdate March 2013
 Osteoclast activating factor;
 Macrophage chemotactic factor;
 Prostaglandins, heparin and bacterial
products.
Preventive factors acting on
dentinoclasts include: anti-invasion factor
and the intermediate cementum layer.2
Injuries and irritations may stimulate
activating factors or reduce preventive
factors, hence dentinoclasts may become
activated and subsequent root resorption
may occur.
Root resorption continues as
long as the simulating factor is present.
The stimulating factor could be mechanical
stimulation, pressure, infection, neoplastic
process or a combination of any of these
factors.3,4 Once the stimulating factors are
removed, root resorption may be arrested.
Cementum and dentine may form again,
depending on the severity of the damaged
surface area.
Classification
Classification of root resorption
has an important role in the process of
diagnosis and treatment planning (Figure
1).
In addition to classifying the
type of resorption, the following issues
need to be addressed to reach a treatment
plan:
 Will the resorptive process be self
limiting or does it require further
intervention?;
 If the resorptive process is progressive
(as observed from assessment over time),
what treatment options can we provide?;
 If treated, what are the short- and long-
term prognoses?;
 When is extraction and prosthetic
therapy indicated?
The following section will
discuss the signs and symptoms, clinical
and radiographic presentations of each
type of root resorption. This will be
followed by clinical examples on the
management of root resorption.
Internal resorption
The process of internal
resorption occurs in chronic pulpal
inflammation and less commonly after
dental trauma or due to dystrophic
idiopathic changes.5 In this process
the pulp tissues coronal to the lesion
become necrotic. In order for the internal
resorption to progress, both dentinoclast-

Figure 1. Classification of root resorption.
activating factors and the cells viable to
keep the resorptive process going must
be present. Hence, teeth that are actively
continuing to resorb internally must be
connected to the blood supply of the
apical vital tissues.
Signs and symptoms
In most cases of internal root
resorption the tooth is asymptomatic,
however, a history of pulpal symptoms
may be a feature as the pulp is involved
first. If the pulp succumbs completely
and periradicular tissues become
inflamed, symptoms of periapical
periodontitis may be evident.5
Clinical presentation
Clinically, if the internal
resorption is in the cervical/coronal part
of the tooth, it may present as a pinkish
hue because of the prolific capillaries in
the pulpal inflammatory tissue resorbing
the coronal dentine and enamel.6 If
internal resorption is in the mid/apical
third of the root, it is for the most part
clinically silent and would normally be
diagnosed radiographically.7
Radiographic features
Radiographs reveal the lesions
as radiolucent, round, oval or elongated
within the root or crown and continuous
with the image of the pulp chamber
or canal. The outline is usually sharply
defined and smooth or slightly scalloped
March 2013 DentalUpdate 103
RestorativeDentistry
as a result of an irregular widening of the
canal of the pulp8 (Figure 2).
Figure 2. Internal resorption on UL1.
External resorption
External inflammatory resorption
External inflammatory
resorption usually occurs when infection
is superimposed on a traumatic injury,
however, it can also be induced in some
cases of endodontic pathosis. Damage
of the cementum layer will initiate this
resorption, exposing the underlying
dentine to the passage of bacteria or
their metabolites to the external root
surface. This activates the dentinoclast
cells which results in resorption of both
tooth and bone.
Signs and symptoms
Teeth could be asymptomatic
or have signs of irreversible pulpitis or
necrotic pulp.9
Clinical features
Clinical findings may include
tooth discoloration, tenderness to
Figure 3. External cervical root resorption:
percussion, tooth mobility or periodontal
irregular area of resorption involving loss of tooth
defects. Careful evaluation of the
structure on UL2.
periodontal condition is recommended
because inflammatory resorption can be
sustained by bacterial infection involving
gingival tissues.10 area of resorption involving loss of
both tooth structure and adjacent
Radiographic features alveolar bone (Figure 3). The irregular
Radiographically, this type area may appear superimposed
of resorption appears as an irregular over the root canal and could be
 RestorativeDentistry
misdiagnosed as internal resorption. The
main radiographic feature to differentiate
between these two entities is that the
outline and the integrity of the canal
space remain uninterrupted in external
resorption.11
External surface resorption
External surface resorption is
a shallow resorption of cementum, often
with involvement of a small amount
of underlying dentine. This type of
resorption is self limiting and transient
and can follow some traumatic injuries
or orthodontic treatment. In the absence
of superimposed infection surface,
resorption heals by forming reparative
cementum.
Signs and symptoms
Teeth are asymptomatic and
the pulp is usually vital. The tooth in
question is frequently firm and immobile
but not ankylosed in the dental arch.12
Radiographic features
The apical and cervical
regions are common sites for this type
of resorption. When the lesion begins
at the apex, it generally causes smooth
resorption of the tooth structure,
resulting in blunting of the root apex.
The bone and the lamina dura follow the
resorbing root and present with a normal
appearance around the shortened root.8
External replacement resorption
External replacement
resorption follows the death of viable
periodontal ligament cells due to factors
Figure 4. External replacement resorption: loss
of tooth structure followed by the progressive
replacement of tooth structure by bone.
104 DentalUpdate March 2013
such as compression or drying of the
ligament cells in the case of delayed
re-implantation of an avulsed tooth.13
This process involves the progressive
replacement of tooth structure by
alveolar bone and may (in severe cases)
lead ultimately to tooth loss. External
replacement resorption is commonly
seen during and after orthodontic
treatment. An incidence of 1.5% of
external replacement resorption has
been reported for the maxillary central
incisors and 2.2% for lateral incisors.14
What has an effect on the
progression of external root resorption
to either external surface resorption or
external replacement resorption is the
severity of injury and the amount of
damaged surface. If the injury is minimal
and the damaged surface does not cover
a large surface area, the tissues will heal
by forming reparative cementum and
external surface resorption will occur.
On the other hand, if the injury is severe
and the damaged area is large, bone cells
will be able to attach to the root surface
before the cementum-producing cells;
external replacement resorption and
ankylosis are the result of this process.12
Signs and symptoms
Initially, teeth may appear
healthy but, as the tooth loses its vitality,
signs and symptoms of necrotic pulp will
be noted.
Clinical features
Clinically, teeth suffering
from replacement resorption have
metallic sound upon percussion and
lack of mobility; these are signs of
ankylosis. In addition, they may have
other clinical problems, such as infra
occlusion, incomplete alveolar process
development (if the patient was young
when the trauma occurred), and
prevention of normal mesial drift.10
Radiographic features
Radiographically, replacement
resorption appears as total loss of
periodontal ligament space followed by
evidence of the progressive replacement
of tooth structure by bone and, in time,
radiographically the outline of the tooth
External resorption
 Replantation of teeth
 Orthodontic forces
 Eruption of adjacent teeth
 Root fracture
 Trauma
 Necrotic pulp
 Root planing
 Pathology
- Cysts
- Ameloblastoma
- Giant cell tumours
- Fibro-osseous lesions
 Heredity
 Bleaching
 Surgery
- Dento-alveolar
- Orthognathic
 Mandibulectomy/Maxillectomy
Internal resorption
 Chronic pulp inflammation
 Trauma
 Pulpotomy
 Restorative procedures
 Cracked tooth
 Invaginated cingulum
 Orthodontic tooth movement
Table 1. Aetiological factors for root resorption.
root is lost (Figure 4).13
Tables 1 and 2 summarize the
aetiological factors and key features of
root resorption, respectively.
Treatment
Once a diagnosis has been
reached there is a need to assess:
 If endodontic intervention
(orthograde/surgical) will stabilize the
root resorption or not; and
 If the remaining tooth structure is
restorable.
The exact treatment plan
required is specific to each case,
depending on patient factors, clinical
and radiographic findings.
If the tooth is deemed to
be unrestorable, the tooth has to be
extracted and the treatment plan should
be focused on replacing the tooth
with an appropriate fixed/removable
 RestorativeDentistry

Resorption Type Clinical Features Clinical Findings Location on Root Pulp Sensitivity Radiographic Root Canal
(Thermal or Electric) Features

Internal resorption Pink spot on crown May have Anywhere May be positive Symmetrical Canals expand into
in cervical 1/3. tenderness over oval-shaped lesions
Mostly has no apex enlargement of
clinical symptoms root canal
in mid/apical 1/3

External Tooth No symptoms, or Anywhere Negative Irregular Intact

inflammatory discoloration, signs of irreversible radiolucent
resorption tenderness to pulpitis or necrotic lesion of root and
percussion, tooth pulp adjacent bone
mobility and
periodontal defects

External surface Healthy None Usually apical as Positive Smooth resorption Intact
resorption a result of trauma resulting in
or orthodontic blunting of root
treatment apex and
shortened root

External Metallic sound on No symptoms, Anywhere May be positive Asymmetrical Intact

replacement percussion, lack of initially signs replacement of
resorption mobility of necrotic pulp as root structure with
tooth loses vitality bone. Loss of
periodontal
ligament space

Table 2. Key features of root resorption.

prosthesis. However, if the tooth is
restorable, endodontic intervention with
either orthograde or surgical endodontics,
or both, may be feasible to preserve the
tooth.
The aim of orthograde root
canal treatment is to stabilize the root
resorption process and to achieve hermetic
seal. Alteration in the anatomy of root
canal systems due to root resorption may
make this more challenging to achieve.
If root resorption has resulted
in an open apex, then it may be necessary
to create an apical barrier prior to the
obturation stage. Mineral Trioxide
Aggregate (MTA) can be placed from an
orthograde approach (Case 1) to create
this apical barrier.
MTA is considered to be an
ideal material for use against bone,
because it is the only material that is
reported to allow apposition of cementum
and the formation of bone consistently,
and it may facilitate the regeneration of
the periodontal ligament. In addition,
MTA has an antimicrobial effect, is highly
biocompatible and possesses good
sealing properties.15 These properties
also mean that MTA is ideal for surgical
repair of external resorption which is
not supragingival. MTA cannot be used
supragingivally as its slow set (4−24
hours) means that it may be washed
away by saliva. For repairs that are
partly supragingival, a material such as
composite or glass-ionomer is required.
The use of gutta-percha (GP)
cones and thermoplastic GP is generally
the method of choice to achieve complete
obturation of the canals. Thermoplastic GP
is particularly useful to treat irregular canal
anatomy such as that seen in internal root
resorption.
If the tooth suffers from
external root resorption, a surgical
approach may be considered in the
management of these cases. In these
cases, a muco-periosteal flap could be
raised to identify the resorbed area. This
may be followed by curettage and repair
of the root surface area with appropriate
sealing material. Prior to attempting any
surgical repair, it is essential to locate the
position of the resorption (buccal/lingual)
and assess whether its size is likely to be
amenable to repair. The location of root
resorption could be located with the use
of parallax technique, when obtaining
radiographs, or with the use of Cone Beam
Computerized Tomography (CBCT).
In cases of complex external
and internal root resorption, both of the
previously mentioned techniques could be
used in an attempt to arrest root resorption
process. However, these cases should be
appropriately selected and should be
carried out by experienced clinicians.
The following section will
explain cases in which orthograde, surgical
and combined (orthograde and surgical)
techniques were used in the management
of root resorption.

March 2013 DentalUpdate 107

 RestorativeDentistry
Figure 5. Initial transplanted LR5.
Figure 7. The MTA plug on the level of external
root resorption.
Cases 1 and 2: orthograde technique
Case 1
A 24-year-old lady had her LR5
transplanted to replace the UR1 when she
was 11 years of age. She was referred to
the restorative department regarding the
108 DentalUpdate March 2013
Figure 6. External root resorption is on the mesial
aspect of apical third of the root.
Figure 8. Radiograph 18 months post-operatively.
unsatisfactory appearance of the crown
on the UR1 due to gingival recession.
This was improved by adding a small
amount of composite filling cervically.
Figure 5 shows the initially transplanted
LR5 in the position of the UR1. The LR5
was extirpated and a radiograph was
obtained with a file in situ showing that
the root resorption originates from the
mesial aspect of the apical third of the root
(Figure 6). After root canal preparation,
an MTA plug was placed at the level
where the external root resorption is
communicating with the root canal to
achieve appropriate apical seal (Figure 7).
The remainder of root canal space was
filled with thermoplastized gutta-percha
(Obtura II, Spartan, US). After 18 months of
carrying out the treatment, the patient was
still symptom-free. Clinically, the tissues
were healthy and no tenderness was
noted. Radiographic examination revealed
full bony infill and apical healing with the
root-treated tooth (Figure 8).
Case 2
A 66-year-old patient was
referred from his GDP regarding persistent
infection related to his UL1. Upon clinical
examination, the UL1 was not tender to
percussion. No mobility or pocketing was
noted. Radiographic examination revealed
a well-defined, round-oval radiolucency
on the cervical and mid apical third (Figure
2). The diagnosis was internal resorption.
The treatment of choice in this case was
an orthograde approach by chemo-
mechanical debridement of the canal
using conventional hand instruments and
filling the apical two-thirds with GP (Figure
9), as opposed to MTA in the previous case,
and to backfill the remainder of the canal
with thermoplastized gutta-percha (Obtura
II, Spartan, US). The patient was reviewed
6 months later, and there were no signs
of infection, clinically or radiographically
(Figure 10).
Case 3: surgical technique
An 18-year-old patient was seen
in the restorative department regarding
the pink appearance of the UL2. The
patient reported a history of extensive
orthodontic treatment. On clinical
examination, the UL2 had external cervical
resorption, along with gingival overgrowth
covering part of the lesion (Figure 11). The
sensibility tests for the UL2 were positive.
The treatment of choice in this case was to
use the surgical approach to gain access to
the cervical root resorption and to repair

Figure 9. Radiograph with master cone to fill
apical two-thirds with GP.
Figure 11. Ginigival margin overgrowth covering
the cervical root resorption on UL2.
Figure 13. Cervical root resorption was restored
with composite.
with composite. A mucoperiosteal flap
with a distal vertical releasing incision
was raised to expose the lesion (Figure
12). The cervical root resorption was
restored with composite (Figure 13), the
March 2013 DentalUpdate 111
Figure 10. Radiograph 6 months post-operatively.
Figure 12. A mucoperiosteal flap raised from
UL1–3.
Figure 14. Flap repositioned and the gingival
margin contoured.
flap was repositioned and the gingival
margin was contoured with inverse bevel
gingivectomy (Figure 14). The patient was
reviewed and the site of surgery healed
well. Composite was used in this case as
RestorativeDentistry
Figure 15. Pre-operative clinical view of external
cervical root resorption on UL2.
Figure 16. A mucoperiosteal flap raised to
identify the extent of resorbed area on UL2.
Figure 17. The enamel and dentine on UL2 was
minimally prepared.
Figure 18. The resorbed area on UL2 was
restored with composite.
the restoration was partly supragingival.
Case 4: surgical and orthograde approach
A 44-year-old patient was
referred regarding persistent infection
 RestorativeDentistry

related to UL2. Clinical examination

revealed a cavity which was probed on
the labial aspect of the tooth (Figure
15). Radiographic examination revealed
an appearance of external cervical root
resorption and a short single point root
filling (Figure 3). In this case, the plan
was to replace the root canal treatment,
this to be followed up by a surgical
procedure to restore the resorption
area. Figure 19. One year post-operative clinical view
of UL2.
After the root canal
retreatment, a mucoperiosteal flap
was raised to identify the extent of the
resorbed area (Figure 16). The enamel
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