Root resorption a,er orthodontic treatment

sf traumatized teeth Dr’Malmgren

Olle Malmgren, D.D.S., Odont. dr.,* Lars Goldson, D.D.S.,*

Carsten Hill, D.D.S.,* Anders Orwin, D.D.S.,* Lars Petrini, D.D.S.,* and
Margareta Lundberg, D.D.S.**
Stockholm, Sweden

This study concerns the frequency and degree of root resorption in traumatized incisors that have been treated
orthodontically. The subjects were twenty-seven patients (fifteen boys and twelve girls) with fifty-five traumatized
incisors; fifty-five consecutive patients without traumatized teeth sewed as controls. All the control patients were
treated with extraction of four first premolars and a fixed appliance (thirty-three with an edgewise and twenty-two
with a Segg appliance). Signs of root resorption were registered with index scores from 0 to 4 (Fig. 1). The
degree of root resorption in traumatized teeth was compared to that in the uninjured control teeth in the same
patient and in the patients without trauma. Neither the intraindividual nor the interindividual comparisons support
the hypothesis that traumatized teeth have a greater tendency toward root resorption than uninjured teeth. Root
resorption (scores 2 to 4) was found in 51 percent of the traumatized incisors, in 43 percent of the incisors
treated with edgewise appliances, and in 48 percent of those treated with Segg appliances. Traumatized teeth
with signs of root resorption prior to orthodontic treatment may be more prone to root resorption during treatment.

Key words: Trauma, root resorption

T
raumatic dental injuries are very frequent
in schoolchildren.’ Children with an increased maxil-
lary overjet run an especially high risk of injuring their
front teeth.* Following orthodontic treatment with
moderate forces, root resorption is usually superficial
and small.3-5 Tooth movement in connection with end-
odontically treated teeth,‘j previously avulsed teeth, and
partially avulsed teeth7 has been reported to give a
greater frequency of root resorption than such move-
ment of uninjured teeth.
Three types of root resorption after trauma have
been described: uncomplicated surface resorption,
progressive inflammatory resorption, and replacement
resorption (ankylosis). (For a review, see Andreasen.*)
The type and frequency of root resorption after trauma
are clearly related to the type of injury.~ll Slight and
moderate injuries, such as crown fractures and sublux-
ations, cause progressive inflammatory or replacement
resorption in less than 1 percent of injured teeth.lt”
After severe periodontal injuries, such as intrusion, ex-
trusion, and lateral luxation, progressive resorptions
are seen in 8 to 11 percent of injured teeth,“, ‘* while
after replantation of exarticulated teeth progressive re-
sorption has been reported in 74 to 96 percent.8
*Department of Orthodontics, Eastman Institute.
**Department of kdodontics, Eastman Instimte.
The aim of the present investigation was to study
the risk of root resorption following movement of
traumatized incisors, mainly those with slight or mod-
erate injuries. The results are based on traumatized
teeth registered according to trauma type and followed
with frequent recall examinations prior to orthodontic
treatment. The study also includes a comparison of the
frequency and degree of root resorption in traumatized
incisors and in uninjured incisors after conventional
orthodontic treatment.
MATERIAL
During a period of 10 years approximately 300 pa-
tients with traumatized teeth were treated orthodon-
tically at the Eastman Institute in Stockholm. From this
material, we selected patients who had complete rec-
ords from the time of the injury and during an observa-
tion period before and after orthodontic treatment.
Root-fractured teeth were excluded; they will be pre-
sented later.
A total of twenty-seven patients (fifteen boys and
twelve girls) with fifty-five traumatized incisors were
studied. Their ages at the time of injury varied from 7
to 15 years (Table I).
The injured teeth had been examined and treated by
pedodontists at the Eastman Institute according to stan-
dardized procedures and registered on special charts for

0002~9416/82/120487+05$00.50/0 0 1982 Tbe C.V. Mosby Co. 487

 Table I. Traumatized patients treated
orthodontically

Table II. Type of injury

Injury No. of reerh

Crown fracture*
A. Uncomplicated 17
B. Complicated I
Periodontal injury?
1 2 3 4 A. Concussion 17
B. Subluxation 19
C. Luxation I
Fig. 1. Root resorption index for quantitative assessment of root
Totai 55
resorption. 7, irregular root contour. 2, Root resorption apically,
amounting to less than 2 mm. of the original root length. 3, Root *Crown fracture with no associated periodontal injury. Uncom-
resorption apically, amounting to from 2 mm. to one third of the plicated (A) with no pulpal communication and complicated (B)
original root length. 4, Root resorption exceeding one third of the with pulpal exposure.
original root length. +Periodontal injury with and without crown fracture subdivided info
(A) concussion (tenderness to percussion and/or pressure), (8) sub-
trauma cases.‘” All clinical data relevant to this study luxation (increased mobility), and (C) luxation (dislocation).
were extracted from these charts. Radiographs taken at
the time of the accident and at follow-up visits
were examined and the type of injury was recorded as All teeth showed a normal radiographic periodontal
follows: space and normal mobility prior to orthodontic treat-
Crown fracture with no associated periodontal in- ment. Eleven teeth exhibited signs of root resorption.
jury: (A) Uncomplicated, with a fracture confined to The orthodontic treatment was performed with
the enamel or involving enamel and dentin, but not fixed appliances in fourteen patients, with both fixed
exposing the pulp. (B) Complicated, with a fracture and removable appliances in ten patients and with re-
involving enamel and dentin, and exposing the pulp. movable appliances only (activator) in three patients.
Periodontal injury with and without crown fracture. Treatment lasted less than 1 year in one patient, be-
(A) Concussion-An injury to the tooth-supporting tween 1 and 2 years in sixteen patients, and more than 2
structures without abnormal loosening or displacement years in ten patients.
of the tooth but with marked reaction to percussion. (B) All four incisors, both injured and uninjured, in the
Subluxation-An injury to the tooth-supporting struc- same jaw as the traumatized tooth/teeth were registered
tures with abnormal loosening but without displace- in the same way. The uninjured teeth served as controls.
ment of the tooth. (C) Luxation-Displacement of the A control group of fifty-five. consecutive patients
tooth. (thirty-four girls and twenty-one boys) without trauma-
The numbers of teeth with different types of injury tized teeth was also studied. All the control patients
are given in Table II. were treated with extraction of four first premulars and
The follow-up period prior to orthodontic treatment a fixed appliance (thirty-three with an edgewise and
was more than 2 years in twenty patients, between 1 twenty-two with a Begg appliance). Treatment lasted
and 2 years in 2 patients, and less than 1 year but more for 14 to 22 months (mean, 17 months) in the edgewise
than 5 months in five patients. The posttraumatic com- group and 13 to 25 months (mean, 21 months) in the
plications comprised reduced pulpal lumen (oblitera- Begg group. All patients were treated to an end result
tion) in seven teeth, two teeth with root fillings, one with good parallelism of teeth on both sides of the
because of complicated crown fractures, and one be- extraction sites and a good axial inclination of the in-
cause of pulpal necrosis. cisors.
Volume 82 Root resorption ajier treatment of traumatized teeth 489
Number 6

METHODS per-
cent
Intraoral radiographs of the incisors before and after 50
orthodontic treatment were examined. Signs of root re- i 40
sorption were registered, with index scores from 0 to 4
(Fig. 1). All assessments of the degree of root resorp-
tion were performed by two of us simultaneously. An
analysis of the method’s error has been presented ear-
lier.6 The degree of root resorption in each traumatized
incisor was compared with that of the uninjured in-
cisors in the same jaw. For nine of the fifty-five 0 I 2 3 4 score
traumatized teeth it was not possible to evaluate control index
incisors in the same jaw, as all neighboring incisors
were either injured or missing. In eleven cases the de-
gree of root resorption differed among the control teeth;
in these cases the mean value of the resorption index
was used.
The degree of root resorption in traumatized teeth
was also compared with that in uninjured incisors in
persons without trauma.
Group differences in terms of registered root re-
sorption scores have been tested with the chi-square
test, using a level of significance corresponding to 0 I 2 3 4 score
P = 0.05. 0 index
per-
RESULTS cent
50
After the orthodontic treatment, 9 percent of the A3

traumatized incisors showed an irregular root contour

(score l), 32 percent showed small root resorptions
(score 2), 15 percent showed moderate resorptions
(score 3), and only two teeth (4 percent) showed severe
root resorptions (score 4).
Root resorption (scores 2 to 4) was found in seven
of the eighteen incisors with crown fractures (39 per-
cent) and in twenty-one of thirty-seven incisors with
periodontal injuries (57 percent). The difference, how-
ever, was not significant.
Nine teeth exhibited an irregular root contour prior
to treatment (score 1). Two of these remained un-
changed after treatment, four developed resorptions re-
corded as score 2, two as score 3, and one as score 4
during treatment. One tooth that exhibited root resorp-
tion (score 2) before treatment showed score 3 after
treatment, and one tooth with score 4 remained un-
changed.
Seven teeth had a reduced pulpal lumen (oblitera-
tion) prior to treatment. Two of these were moved
without any root resorption, one had an irregular con-
tour after treatment, one developed a root resorption
recorded as score 2, and one developed a root resorp-
tion recorded as score 3. Two teeth were root-filled
prior to treatment. Each had an irregular root contour
(score 1) before treatment; one was moved without any
0 1 2 3 4 score
C index
Fig. 2. Degree of root resorption after orthodontic treatment.
Score O-No root resorption; scores 1-4-see Fig. 1. A, Root
resorption in 55 traumatized teeth. 8, Root resorption in 264
incisors treated with edgewise technique. C, Root resorption in
176 incisors treated with Begg technique.
further root resorption, and the other showed resorption
recorded as score 2.
Intra-individual comparisons (twenty-seven
orthodontically treated patients with
traumatized teeth)
Sixty-three percent of the traumatized teeth and
fifty-five percent of the uninjured control teeth in the
same person showed an irregular root contour or root
resorption after the orthodontic treatment.
Comparing the degree of root resorption between
traumatized and control incisors in the same individual
gave the following results:
No difference
More resorption in the traumatized tooth
Less resorption in the traumatized tooth
Total number of comparisons
The difference in the degree of root resorption be-
tween traumatized and control incisors was not sig-
nificant.
Interindividual comparisons (twenty-seven
orthodontically treated patients with traumatized
teeth and thirty-three nontraumatized patients
treated with edgewise and twenty-two with
Begg technique)
In patients treated with edgewise appliances, 72
percent of the incisors showed an irregular root contour
or root resorption after treatment; the same was the case
in 83 percent of the patients treated with Begg appli-
ances. In the edgewise group twenty-nine percent and
in the Begg group thirty-five percent of the evaluations
were registered as possible root resorption (score 1).
Minor root resorptions (score 2) were found in
thirty-three percent of the edgewise and forty-three per-
cent of the Begg cases; moderate root resorptions (score
3) were found in 10 percent and 5 percent. The differ-
ence in the degree of root resorption between the two
treatment methods was not significant.
Fifty-one percent of the traumatized teeth, 43 per-
cent of the edgewise-treated teeth, and 48 percent of the
teeth treated with Begg appliances showed clearly
defined root resorptions (score 2, 3 and 4) (Fig. 2). The
difference in the degree of root resorption between
traumatized and control teeth was not significant.
Neither the intra-individual nor the interindividual
comparisons showed that traumatized teeth with slight
or moderate injuries have a greater tendency toward
root resorption during orthodontic treatment than unin-
jured teeth.
DISCUSSION
It has been reported that traumatized teeth undergo
more root resorption during orthodontic treatment than
uninjured teeth.6, 7 Previous studies evaluated orth-
odontic movement of teeth with several severe injuries,
which are frequently followed by progressive replace-
ment and/or inflammatory resorption. Our study con-
cerns teeth mainly with slight and moderate injuries, in
which no progressive resorptions were seen. The ob-
servation period prior to treatment was at least 5
months and in most cases more than 1 year. Root re-
sorption due to trauma is reportedly discernible in most
cases within 2 to 5 months after subluxation and luxa-
tion injuries.’
The traumatized incisors that exhibited signs of root
resorption prior to treatment underwent more resorption
during treatment than teeth without such signs. There
may have been damage to the periodontal ligament or
the cementum, making the former teeth more liable to
root resorptions.
Efforts by the orthodontists to avoid heavy forces
on the traumatized teeth may have minimized the ten-
dency to root resorption. Different appliances were
used for treatment. Many patients started and a few
completed their treatment with removable appliances;
this also explains the long duration of treatment in
many of the patients.
The incidence and degree of root resorption in non-
traumatized teeth were 33 percent with score 2 and 10
percent with score 3 in the edgewise group. The corre-
sponding values in the Begg group were 43 percent
with score 2 and 5 percent with score 3. The degree of
root resorption in the Begg group was slightly less than
in an earlier report .6
Further studies are required to evaluate the prog-
nosis for orthodontic movement of teeth with severe
trauma. It is now known that progressive resorption is
related to teeth with severe traumatic injuries. Teeth
which develop inflammatory resorption during an ob-
servation period prior to orthodontic treatment should
receive immediate endodontic treatment and be fol-
lowed until the resorption has been arrested.” Re-
placement resorption in traumatized teeth is progres-
sive, and the teeth do not respond to orthodontic
movement.
CONCLUSION
The conclusion drawn from this study is that teeth
with slight or moderate trauma and an intact periodon-
tal ligament after an observation period of at least 4 to 5
months can be moved with a prognosis comparable to
that of uninjured teeth.
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2. Jarvinen, S.: Incisal overjet and traumatic injuries to upper per-
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3. Wickwire. N. A., McNeil, M. H., Norton, L. A., and Duel],
R. C.: The effects of tooth movement upon endodontically
treated teeth, Angle Orthod. 44:235-242, 1974.
4. Phillips, J. R.: Apical root resorption under orthodontic therapy,
Angle Orthod. 25: l-22, 1955.
5. De Shietds, R. W.: A study of root resorption in treated Class II,
Division 1 malocclusions, Angle Orthod. 39:231-245, 1969.
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Number 6

6. Goldson, L., and Henrikson, C. 0.: Root resorption during clinical and radiographic follow-up study of 189 injured teeth,
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