CLINICAL RESEARCH

Austyn C. Grissom, DMD, MSD,*

Root Surface Changes in Benjamin E. Cozad, DDS, MSD,†
Scott R. Makins, DDS, MS,*
Endodontically Treated Teeth Renato M. Silva, DDS, MS,
PhD,‡ Jeryl D. English, DDS,
following Orthodontic MS,† and Timothy C. Kirkpatrick,
DDS*
Movement

ABSTRACT
SIGNIFICANCE
Introduction: Orthodontically induced external root resorption has been labeled an
unavoidable consequence of orthodontic tooth movement (OTM). The objective of this study Teeth with a history of
was to investigate the change in surface area (mm2) and volume (mm3) of endodontically endodontic treatment showed
treated teeth (ETT) compared with contralateral teeth with a vital pulp (VPT) after OTM. significantly less external root
Methods: Seventy-six teeth were included in this retrospective analysis: ETT (n 5 38) and resorption after orthodontic
VPT (n 5 38). All teeth were evaluated using cone-beam computed tomographic imaging at 2 movement compared with
time periods: before OTM (T1) and after OTM (T2). Study teeth were segmented to include all contralateral vital teeth.
areas contained within the lamina dura and then were converted into a mesh model for data
calculation. The surface area (mm2) and volume (mm3) of each tooth were calculated at T1 and
T2 based on the number of cubic voxels present within the mesh model. Statistical analysis
was performed using a linear mixed-effects model. Results: The average change in surface
area after OTM in ETT was 13.01 mm2 and 19.95 mm2 in VPT (P , .05). The average percent
change in surface area after OTM in ETT was 2.09% and 3.38% in VPT (P , .05). The average
change in volume after OTM in ETT was 22.48 mm3 and 32.44 mm3 in VPT (P , .05). The
average percent change in volume after OTM in ETT was 2.62% and 4.10% in VPT (P , .05).
Conclusions: The results from this study suggest that ETT are less susceptible to root
resorption after OTM than their vital counterparts. (J Endod 2022;48:1361–1366.)

KEY WORDS
Cone-beam computed tomography; endodontic treatment; external root resorption;
orthodontic treatment; root resorption

Orthodontically induced external root resorption (OIERR) has been termed an unavoidable,
iatrogenic consequence of orthodontic tooth movement (OTM)1,2. Histologic studies have reported that
OIERR occurs in over 90% of patients receiving comprehensive orthodontic treatment3. Although the
prognosis of teeth exhibiting OIERR is rarely affected, in 1%–5% of teeth, up to one third of the root length
can be lost3,4. Additionally, OTM has been labeled a risk factor for external cervical resorption5,6 and most From the Departments of *Endodontics
recently has been hypothesized as the cause of failure of 3 teeth successfully treated with regenerative and †Orthodontics, The University of
endodontics for 4, 8, and 11 years that all failed shortly after the application of orthodontic forces7. Texas Health Science Center at Houston
School of Dentistry, Houston, Texas; and
When orthodontic forces are applied to teeth, the blood flow in the periodontal ligament is altered, ‡
Department of Endodontics, The
and a local inflammatory process is induced to facilitate tooth movement8. Hypoxia has been shown to University of Pittsburgh School of Dental
significantly enhance the differentiation of clastic cells, thus explaining why root resorption in some Medicine, Pittsburgh, Pennsylvania
capacity is observed as a result of OTM9–11. Address requests for reprints to Dr Austyn
Since Reitan’s work4 using prescribed movements on human premolars that were scheduled for C. Grissom, 7500 Cambridge Street,
extraction, OIERR has been understood to be a 3-dimensional phenomenon. Until recently, cone-beam Suite 6400, Houston, TX 77054.
computed tomographic (CBCT) imaging has not been widely available within dentistry; therefore, most E-mail address:
austyn@grissomendo.com
available evidence on OIERR stems from 2-dimensional imaging analyses12–18. 0099-2399/$ - see front matter
As the goals of OTM are achieved, we can expect that the root position in both mesial-distal and
Copyright © 2022 American Association
buccal-lingual planes will be altered for each tooth. Although panoramic radiographs have been the gold of Endodontists.
standard of screening for the presence or absence of OIERR, it has been shown that a head tilt of only https://doi.org/10.1016/
2.5 from the ideal imaging position can cause significant distortion of a panoramic radiograph19. j.joen.2022.08.002

JOE  Volume 48, Number 11, November 2022 Root Surface Changes in ETT 1361
 Based on the role of the dental pulp in
OIERR, it has been proposed that
endodontically treated teeth (ETT) may be less
susceptible to OIERR than teeth with vital pulp
(VPT)1,12,16–18,20. One retrospective study
found more OIERR in ETT21; however, more
recent evidence suggests that this could be
influenced by polymorphisms in the interleukin-
1b gene of these patients15. Other groups
have found no difference in the amount of
OIERR noted between VPT and ETT14,22–24.
The literature shows that only 1 study
has used CBCT imaging to report on OIERR of
ETT; however, the study used linear
measurements such as those traditionally used
in 2-dimensional studies12,18,22. Aside from
using a 2-dimensional (linear) measurement to
assess a 3-dimensional phenomenon, this
method of investigating OIERR leaves room for
error, which could result in misreporting of this
entity.
To our knowledge, there are no
published studies that assess OIERR of ETT
compared with VPT in a 3-dimensional
manner. The purpose of this study was to
quantify the 3-dimensional change in surface
area (mm2) and volume (mm3) of ETT and the
corresponding contralateral VPT after OTM.
Our hypothesis was that OTM of ETT results in
FIGURE 1 – (A ) Threshold output. (B ) Manual segmentation edit. (C ) The result of segmentation (.DCM). (D ) The conversion of .DCM to .STL (mesh model).
1362 Grissom et al.
less 3-dimensional root surface changes than
those noted in contralateral VPT.
MATERIALS AND METHODS
Study Population
This study (HSC-DB-21-0102) was granted
exempt status by the University of Texas
Health Science Center at Houston
Institutional Review Board. The records
included in this retrospective study were
obtained from a private orthodontic practice
after all patient identifiers were removed.
The criteria for inclusion in this study were
as follows:
1. Adult patients (ages 191 years)
2. Treated with clear aligner therapy or fixed
orthodontic appliances
3. Preoperative and postoperative CBCT
images available
4. One or more teeth with previous
endodontic treatment
5. Orthodontic treatment time 6 months
Subjects who have any of the following
were excluded from this study:
1. Evidence of root resorption in the
pretreatment scan
2. Patients requiring orthognathic surgery
3. Evidence of apical periodontitis in the pre-
or posttreatment scan
4. No contralateral tooth or a contralateral
tooth with a history of endodontic treatment
5. Evidence of orthodontic appliances in the
pre- or posttreatment scan
Methodology
The records of 213 patients 19 years old with
2 CBCT image volumes available were
included for review. This initial patient pool
contained 105 ETT. Within this group, 38 ETT
were found to have a matched contralateral
tooth available without evidence of root filling
material (VPT) while also satisfying the other
inclusion criteria for the study (n 5 76). Three
patients were identified who had received no
OTM but had 2 CBCT images available over an
average 4-year period. From this group with no
OTM, 16 teeth were investigated separately as
a control group.
All study subjects had a complete set of
CBCT images available from before
orthodontic treatment (T1) and at the
completion of the active treatment phase (T2).
The image volumes were each captured by a
trained auxiliary staff member on the i-CAT FLX
JOE  Volume 48, Number 11, November 2022
 set of scans. A linear mixed-effects model was
used to assess if surface area difference,
percentage of surface area difference, volume
difference, and percentage of volume
difference varied with ETT (P , .05). All
statistical analyses were performed using R
statistical software (R Core Team, Vienna,
Austria).

RESULTS
The average change in surface area after OTM
was 13.01 mm2 in ETT and 19.95 mm2 in
VPT. There was statistical significance
detected for the surface area difference
between ETT and VPT (P , .05). The average
percent change in surface area after OTM
was 2.09% in ETT and 3.38% in VPT. There
FIGURE 2 – A heat map of (left ) a vital pulp tooth and (right ) an endodontically treated tooth.
was also statistical significance detected for
the percent change in surface area
CBCT system (i-CAT, Alpharetta, GA) at the the form of an STL file. The fit and accuracy of between ETT and VPT (P , .05).
same practice location. The scan parameters the generated mesh model were verified in 3 The average change in volume after
used for this study are as follows: pixel size of dimensions in conjunction with the CBCT data OTM was 22.48 mm3 in ETT and 32.44 mm3 in
0.3 mm, slice thickness of 0.3 mm, slice to ensure that all areas of the root within the VPT. There was statistical significance
spacing of 0.3 mm, and 440 basis images per lamina dura were contained. This process is detected for the volume difference between
volume. The deidentified scans were imported illustrated in Figure 1C and D. ETT and VPT (P , .05). The average percent
into Geomagic Design X v. 2016.1.1 (3D The volume and surface area of each change in volume after OTM was 2.62% in ETT
Systems, Rock Hill, SC) software for tooth were calculated in millimeters based on and 4.10% in VPT. There was also statistical
segmentation. the number of cubic voxels contained within significance detected for the percent change in
The study teeth were segmented by each mesh using Geomagic Design X v. volume between ETT and VPT (P , .05). A
converting an array of grayscale voxels to 2016.1.1 software. These results were heat map of 2 study teeth can be found in
binary format by using upper and lower limit documented in an Excel (Microsoft, Redmond, Figure 2, which illustrates the amount of OIERR
inputs, a process also known as thresholding. WA) spreadsheet, and the difference of the seen in the VPT (left) is more intense than that
Once the grayscale values were selected and initial (T1) and final (T2) surface area and seen in the ETT (right).
the mask was set, all voxels that fell within the volume was then calculated in mm2 and mm3, From the group of 3 patients serving as
specified upper and lower limits of the respectively. The difference of the surface area a control, 16 VPT teeth without OTM were
grayscale values for each tooth were reviewed and volume for each tooth was then divided by analyzed over an average 4-year period. The
(Fig. 1A). Those voxels that fell outside of the the respective T1 measurements and average change in surface area of the control
anatomy of interest were removed using an multiplied by 100 to calculate the percent teeth was found to be 7.02 mm2 or 1.00%.
erase segmentation tool (manual change. The average percent change in The average change in volume of the
segmentation). An illustration of the manual volume and surface area was then calculated control teeth was found to be 8.93 mm3 or
segmentation process can be seen in for VPT and ETT. 1.05%.
Figure 1B. A repeated measures analysis was used One month after the initial calculations,
The CBCT data were then converted to account for cases in which .2 ETT included 10 of the 76 study teeth were reanalyzed.
into a mesh or polygon-based surface model in in the study were from the same patient and These results were compared with the study
data, and it was found that 9 of 10 data
points were within 1 percentage point of the
study data, suggesting that the workflow
TABLE 1 - The Distribution of the Teeth Used in This Study used for data collection in this study was
reliable.
VPT ETT Total % of total The average age of patients included
Maxillary within this study was 39.39 6 7.22 years.
Anterior 3 3 6 7.89 Within the study group, 63.2% of teeth were
Premolar 10 10 20 26.32 treated using clear aligner therapy, whereas
Molar 10 10 20 26.32 36.8% of teeth were treated using fixed
Mandibular appliances. More details regarding the teeth
Anterior 0 0 0 0.00 investigated in this study along with a summary
Premolar 4 4 8 10.52 of the findings can be found in Tables 1–3. A
Molar 11 11 22 28.95
complete copy of the study data is available in
Total 38 38 76 100.00
Supplemental Figure S1 (available online at
ETT, endodontically treated teeth; VPT, teeth with vital pulp. www.jendodon.com).

JOE  Volume 48, Number 11, November 2022 Root Surface Changes in ETT 1363
TABLE 2 - The Number of Patients Treated With Clear Aligners versus Fixed Appliances images, producing images like those we would
expect to see clinically29. Although the
VPT ETT Total % of total software was only tested on single-root
Fixed appliances 14 14 28 36.84 premolars, the findings show promise for
Clear aligners 24 24 48 63.16 future research in this area until higher-
Total 38 38 76 100.00 resolution CBCT images are widely available29.
An attempt was made to perform a 2-
ETT, endodontically treated teeth; VPT, teeth with vital pulp.
dimensional analysis on study teeth similar to
other studies that have investigated
OIERR12,14,16–18,20,21,23,24. To accomplish
DISCUSSION applied to each tooth throughout treatment. this, it required that a 2-dimensional panoramic
For this reason, we were intentional with our image be reconstructed from the 3-
The data presented here provide new insight
inclusion and exclusion criteria so that no dimensional CBCT image volume.
into the true 3-dimensional nature of OIERR,
teeth with minimal (,6-month treatment Unfortunately, there was no way to standardize
specifically as it involves ETT. The findings
time) or excessive (patients requiring where the 3-dimensional image was
support our tested hypothesis, and the null
orthognathic surgery) movements would be sectioned. Once the study teeth had been
hypothesis for this study was rejected.
included. We feel that the lack of strict measured on the panoramic images by 2
It has been shown that the tensile forces
inclusion criteria in similar studies on OIERR examiners, extreme variability in root length
induced by OTM cause increased expression
could be the reason why meta-analyses was noted in all teeth, with several teeth
of macrophage colony-stimulating factor,
continue to grade the certainty of evidence gaining length up to 4 mm after OTM. After
receptor activator of nuclear factor kappa-B
on OIERR as very low18. review of these data with both 2- and 3-
ligand, interleukin-1b, and tumor necrosis
Thresholding has been shown to be a dimensional images, all authors believed that
factor-alpha in VPT compared with teeth
reliable means of quantifying data from a 3- the 2-dimensional data were not
undergoing OTM that have received
dimensional image28. However, one of the representative of the OIERR that occurred in
pulpectomy20. By severing the blood supply to
challenges with a study of this nature is the this patient population; therefore, this aim was
the tooth, pulpectomy prevents the ingress of
scatter and beam hardening artifacts that are excluded from further investigation.
these proinflammatory factors into the canal
often prevalent in large-volume CBCT scans. Because this study was a retrospective
space20. Additionally, many of the materials
There were 7 ETT with a contralateral VPT that chart review, we were limited by the available
used in modern endodontic treatment are
were not suitable for inclusion in our study data. One of the major limitations was the type
known to create an alkaline environment on the
group because of the extent of scatter and of teeth available for evaluation. It has been
external root surface25,26. An alkaline pH on
beam hardening artifacts. Despite these cited that maxillary anterior teeth are the most
the external root surface has been shown to
limitations, the findings from the control group likely teeth to undergo OIERR2,30–32 However,
arrest collagenase and acid hydrolase activity
allow us to feel certain that the primary aim of maxillary anterior teeth only made up 7.9% of
of the cells involved with root resorption while
the study was satisfied using this workflow. the teeth included within this evaluation.
also stimulating alkaline phosphatases to aid in
When looking at VPT alone, the average Additionally, none of the patients included
hard tissue repair at the involved site27. These
change in surface area without OTM was within this study reported a history of dental
findings provide insight into how our
1.00% and 3.38% with OTM. The average trauma on the dental history taken before
hypothesis for this study was developed and
change in volume of VPT without OTM was OTM. Lastly, the correlations between patient
also support the findings of many 2-
1.05% and 4.10% with OTM. age, specific tooth movement, treatment
dimensional studies that have investigated
Another challenge with this type of study duration, and treatment type were not
OIERR of VPT and ETT.
is that CBCT images are captured in cubic investigated because of the small sample size.
The goals of OTM are met by applying
voxel format. This alone is not a problem; We suggest these topics should be
light, continuous forces to the teeth
however, the size of the voxels created by the considered in future studies with larger sample
throughout treatment regardless of the
imaging machines used in clinical practice can sizes.
modality used. Within our patient population,
make segmentation challenging. A recent
63.16% were treated with clear aligner
study introduced using artificial intelligence to
therapy (Invisalign; Align Technology Inc,
compensate for this when quantifying data
CONCLUSION
Tempe, AZ), whereas 36.84% were treated
from CBCT images29. The proposed software The results from this study suggest that ETT
with fixed appliances (Damon Q self-ligating
uses an algorithm generated from micro– are less susceptible to OIERR than VPT.
brackets; Ormco, Brea, CA). Unfortunately,
computed tomographic data that allows for a Additionally, these findings support what has
there is no way to track the individual forces
refined, less pixelated version of the CBCT been found in 2-dimensional analyses—the
sole presence of ETT does not increase an
individual’s risk for OIERR1,12,16–18.

TABLE 3 - The Mean Change in Surface Area and Volume

CREDIT AUTHORSHIP
VPT ETT P value CONTRIBUTION STATEMENT
D Surface area (mm2) 19.95 13.02 .0003
Austyn C. Grissom: Methodology,
D Surface area (%) 3.38 2.09 .00001
Investigation, Validation, Writing–original draft;
D Volume (mm3) 32.44 22.48 .0003
D Volume (%) 4.10 2.62 .0000008 Funding acquisition. Benjamin E. Cozad:
Conceptualization, Resources. Scott R.
ETT, endodontically treated teeth; VPT, teeth with vital pulp. Makins: Conceptualization, Writing–review

1364 Grissom et al. JOE  Volume 48, Number 11, November 2022
and editing. Renato M. Silva: ACKNOWLEDGMENTS The authors deny any conflicts of
Conceptualization, Formal analysis, Writing– interest related to this study.
The authors thank Leonard King and the team
review and editing. Jeryl D. English:
at 3DSystems for their support in developing
Conceptualization, Methodology, Writing– SUPPLEMENTARY MATERIAL
this workflow.
review and editing. Timothy C. Kirkpatrick:
Supported in part by a research grant Supplementary material associated with this
Conceptualization, Methodology, Validation,
from the American Association of article can be found in the online version at
Data Curation, Writing–review and editing,
Endodontists Foundation. www.jendodon.com (https://doi.org/10.1016/
Visualization, Supervision.
j.joen.2022.08.002).

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