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Root Resorption in Orthodontics: A Recent Update

Article in Indian Journal of Public Health Research and Development · October 2017
DOI: 10.5958/0976-5506.2017.00360.6

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 DOI Number: 10.5958/0976-5506.2017.00218.2
Indian Journal of Public Health Research & Development. October-December 2017, Vol. 8, No. 4 307

Root Resorption in Orthodontics: A Recent Update

Mithun K1, Harshitha V2, AshithM V3, Naveen Kumar1, Anil Kumar2
1
Assistant Professor, 2Reader, Department of Orthodontics, A J Institute of Dental Sciences. Mangalore, 3Reader,
Department of Orthodontics, Manipal College of Dental Sciences Mangalore

ABSTRACT

Recently due to medico-legal factors, once again a lot of interest has been generated about the root
resorption which is followed by orthodontic treatment. Newer information's are being continuously
added and therefore process of root resorption have been better identified and understood.
Keywords: Root resorption, EARR, Orthodontic Treatment, Orthodontic Forces, Prevention of Root Resorption

INTRODUCTION 2. Ethnic groups: Asian patients experience

Root resorption in permanent teeth was regarded
as a result of trauma1. Ottolengui2 was able to relate
root resorption specifically to orthodontic treatment
with radiographic evidence. Brezniak and
Wasserstein 3suggested the term Orthodontically
induced inflammatory root resorption (OIIRR) to
distinguish this type of resorption from others such as
those caused by trauma, periapical lesions of
periodontal disease.
Risk factors
A. General factors
1. Gene: Interleukin IL-1 (IL-1B)allele 1 has 5.6 fold
increased risk of external apical root resorption
(EARR).Interleukin 1ß (IL-1ß) (13954) gene suggest
a role for this cytokine in the pathogenesis of EARR
and for the protective mechanism of the cementum
against root resorption. 4 Estimates from the
qualitative and quantitative measurement external
root resorption were 44.9% and 42 9% for
monozygotic twins and 24.7% and 28.3%
respectively for dizygotic twins. An overall
heritability estimate of 0.34 was obtained.
significantly less root resorption than white or
Hispanic patients.Smale5recruited patients from 3
different centres in 3 countries and found no
differences in resorption among the subsamples.
3. Systemic diseases: The number of alveolar bone
osteoclasts increased in the compressed PDL areas
over control which suggested that cell populations
involved in resorption were influenced by
inflammatory mediators produced by
asthma.Nishioka6determined association between
excessive root resorption and immune system
factors and found root resorption to be 10.3% higher.
4. Age: When a patient is older than 11 years, risk for
root resorption increases. Child patient’s
periodontal membrane becomes narrower and less
vascularized, aplastic, alveolar bone becomes
denser, and cementum becomes wider with age.
Immature teeth with incomplete root formation will
have the benefit of the remaining growth potential,
and the post treatment elongation of the root even
with EARR.

60. Mithun K--307--.pmd 307 10/14/2017, 6:11 PM

 308 Indian Journal of Public Health Research & Development. October-December 2017, Vol. 8, No. 4
5. Root: The average root-shortening due to
orthodontic tooth movement is approximately 10%
and it ranges from 1.2 -1.5 mm. Oyama in his FEM
study concluded that there was an enhanced risk
for root resorption in short roots and significant
higher degree of EARR in blunt roots.Apically bent
and angulated roots had the highest prevalence of
EARR, and the percentage was 92.11%. 7
6. Endodontically treated tooth: Post orthodontic
endodontically treated teeth and contralateral vital
tooth was compared and found that there is no
difference between the two teeth.Ioannidou-
Marathiotou concluded in a meta anlysis that
available literature is scarce and that root filled teeth
do not increase the risk of ARR. 8
7. Malocclusion: A mean of approximately 1mm of
apical root shortening in class I patients while the
class II division 1 patients showed a mean root
shortening of more than 2 mm.Root resorption
depends on the extent of displacement of incisor
roots and the amount of movement required.
8. Type of tooth: Maxillary incisors are most
commonly used to determine the apical root
resorption as EARR occurs most commonly on these
teeth and they are easily visualized on a lateral
cephalogram.Maxillary incisors undergo more
displacement than other teeth during extraction
treatment. The maxillary laterals are the most often
resorbed teeth followed by the centrals, mandibular
centrals and then the maxillary canines mandibular
first molars, and especially the distal root often is
affected.
9. Ectopic tooth: Maxillary lateral incisor root is the
area most commonly affected by ectopic eruption of
the canine since the root is conical, apex is deep in
the palate. All of these factors make possible the
loss of an entire root within 2 months.
10. Successor tooth: The prognosis of retained primary
mandibular molars lacking successors showed
clinically significant infraocclusion ratios of more
than 0.2 in 43.6 per cent of patients. Infraocclusion
was estimated to be a more critical factor for the
prognosis of retained primary molars than root
resorption.
60. Mithun K--307--.pmd 308
Mechanical factors
1. Continuous vs Intermittent force: The intermittent
force application was obtained with a 3-day resting
period followed by a 4-day force application period
and found significantly less total root resorption.
In a buccally tipped premolar, the greatest amount
of root resorption was in the buccal-cervical area of
the root.
2. Light vs Heavy force: The mean volume of the
resorption crater in the light-force group was 3.49
fold greater and heavy group force group was 11.59
fold greater than the control group. The result
showed that the severity of root resorption increased
particularly with heavy forces and intrusive
movements. Thus the use of light orthodontic forces,
especially with incisor intrusion.
3. Removable vs Fixed: Heavy force (225 g) produced
significantly more root resorption (9 times greater
than the control) than light force (25 g) (5 times
greater than the control).The teeth experiencing
orthodontic movement had significantly more root
resorption than did the control teeth.
4. Type of tooth movement
- Tipping vs bodily: The amount of tooth movement
in the bodily tooth movement group was less than
half that in the tipping tooth movement group. The
greatest amount of tooth movement occurred in the
10gm tipping and 50gm bodily tooth movement
subgroups.
- Extrusion vs intrusion: Root resorption from
extrusive forces was limited and not significantly
different from the control group. Intrusive force
significantly increased the percentage of resorbed
root area by 4 fold.
- Rotation: Examination by scanning electron
microscopy revealed many concavities resorption
lacunaeon the root surfaces of all rotated teeth. The
resorption areas were located mainly at the medial
root third, in regions that corresponded to the
prominent zones of the roots.
5. Correction of curve of spee: Patients with severe
deep bite, treated with intrusion mechanics of
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 Indian Journal of Public Health Research & Development. October-December 2017, Vol. 8, No. 4 309
accentuating and reversing the curve of spee
statistically showed greater root resorption than
patients with normal overbite who did not receive
these mechanics.
6. Torque: Increased hydrostatic pressure correlated
well with the locations of root resorption for each
tooth undergoing torque movement and if
hydrostatic pressure exceeds typical human
capillary blood pressure in the PDL, the risk of root
resorption increases.
7. One phase vs two phase: The children treated in 2
phases with a bionator followed by fixed appliances
had the fewest incisors with moderate to severe
OIIRR, whereas children treated in 1 phase with
fixed appliances had the most resorption.
8. Brackets: Patients treated with Damon3 and
conventionally ligated brackets with identical
archwires and sequencing in all patients. The
results showed that mandibular incisor root
resorption was not statistically different.
9. Duration: One month of extra treatment time causes
0.1 and 0.2 mm of additional root resorption of the
most severely resorbed central and lateral incisor,
respectively.Average treatment length for patients
without root resorption was 1.5 years and for the
patients with severe root resorption 2.3 years
10. Wires used: Incisor root resorption after levelling
did not differ significantly between patients treated
with super-elastic and conventional stainless steel
arch wires, except for a mandibular incisor.
11. Expansion: Root resorption after rapid maxillary
expansion (RME) via cone-beam computed
tomography showed statistically significant volume
loss.Expansion with passive self-ligating brackets
showed clinically significant amounts of expansion
(approximately 3.5 mm in 8 weeks) with no apical
root resorption. 9
12. Restorative buildups: Restorative buildups, used
to increase the vertical dimension by 2 mm for 4
weeks, caused root resorption along the sides of the
teeth during the active bite-increase period.
13. Use of implants for retraction: The time needed for
the greater amount of maxillary en-masse anterior
60. Mithun K--307--.pmd 309
retraction with miniscrew anchorage is longer and
might dispose the patient to more apical root
resorption. 10 The incidence of root resorption
increased when the distance between the mini-
implant and the root was less than 0.6 mm.In case
of root perforation, root resorption and ankylosis
occurred on the side opposite the insertion.
14. Archwire sequence: The studies showed that there
was no statistically significant difference between
archwire sequences on the maxillary left central
incisor root resorption.
15. Sliding one phase vs two phase: The average root
shortening of maxillary central and lateral incisors
was 0.43 and 0.58 mm, respectively, and that of
mandibular central and lateral incisors was 0.23
and 0.22 mm, respectively. No difference was found
in the amount of root shortening between space
closure procedures.11
Diagnosis
1. OPG: Normal anatomical structures can appear as
radiolucent or radiopaque shadows superimposed
over the teeth as either real or actual shadows or as
a ghost or artifacts which can degrade the quality
of the final image. Also roots may get magnified or
foreshortened in markedly class II or class III
patients.
2. Periapical radiography: OPG overestimated the
amount of root loss by 20% or more when compared
with periapical radiographs. In cases where the
apices are obscured or other factors are present that
might suggest higher risk for root resorption
periapical films should be taken.
3. Cone beam computed tomography: An average of
55-91% of teeth showed some degree of root
shortening in class I malocclusion. 7% of patients
had one tooth or more with root shortening
exceeding 4 mm, Slanted root resorption was found
in up to 15% of palatal root surfaces and could be
evaluated only on tomographic images. 12
4. Dentine phosphoproteins: Dentine phosphoproteins
(DPP) is measured in the GCF using an enzyme-
linked immunosorbent assay and there is a
difference in the level of DPP between a group of
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 310 Indian Journal of Public Health Research & Development. October-December 2017, Vol. 8, No. 4
patients with mild root resorption and a control
group.13
5. Elisa combined with electrochemistry: The
electrochemical results extended the lower end of
detection from 5 pg per milliliter (by
spectrophotometry) to 0.5 pgper millilitre thus it is
a reliable and sensitive method to detect dentine
sialophosphoprotein in gingival crevicular fluid.14
6. Mass spectroscopy analysis: The main goal was to
identify novel biomarkers associated with root
resorption and the protocol was able to identify
2789 and 2421 proteins in the control and resorption
pooled samples, respectively 15
MANAGEMENT
Drugs
1. Echistatin: Echistatin is a viper venom disintegrin
(cystein rich proteins) Arginine-glycine-aspartic
acid (RGD) containing peptide. It inhibits the
resorptive activity of isolated clast cells. It blocks
the attachment of clast cells to the substrate via
interaction with theávâ3 integrin structure.
Echistatin significantly decreased root resorption
surface areas and reduced the number of root
resorption lacunae. 16
2. Bisphosphonates: Local clodronate inhibits root
resorption incident to tooth movement. The topical
administration of risedronate caused a significant
and dose-dependent inhibition of root resorption
after the orthodontic force was applied.17
3. Prostaglandin: A significant difference in
root resorption was observed between the PGE2
and control. The findings show the importance
of calcium ions working in association with PGE2
in stabilizing root resorption while significantly
increasing OTM.
4. Lithium: Lithium chloride can attenuate
orthodontically induce root resorption during
orthodontic tooth movement and its effect on tooth
movement is insignificant
5. Nambumetone: Nabumetone was found to be
useful in reducing pulpitis, external root resorption,
and pain caused by intrusive orthodontic
60. Mithun K--307--.pmd 310
movement, without altering tooth movement in
response to the application of orthodontic force. 18
6. NSAID: Prednisolone and celecoxib suppress
orthodontically induced tooth movement and root
resorption. High dosage (16 mg/kg) of celecoxib
suppresses root resorption significantly more than
low dosage(3.2 mg/kg). The mechanisms between
tooth movement and root resorption are suggested
to be different, which may lead to different dose
thresholds of celecoxib affecting tooth movement
and root resorption.
7. Tetracycline: Anti-inflammatory properties of
tetracyclines (and their chemically modified
analogues) unrelated to their antimicrobial effect
has shown a significant reduction in the number of
mononucleated cells on the root surface. Such cells
have been related to root resorption
8. Strontium ranelate: The animals treated with
strontium ranelate showed up to 40% less tooth
movement after four weeks of orthodontic treatment
and may be a viable agent for inducing tooth
anchorage and reducing undesired root resorption
in orthodontic treatment.
9. Lithothamnium supplement: Lithothamnium
supplement, a calcium-rich widely used for mineral
reposition, on strain-induced orthodontic tooth
movement [OTM]).Studies suggests that the CaCO3
from LTT decreases the number of osteoclasts and
inflammatory mediators and, consequently, reduces
alveolar bone resoption. This is a demonstration
that dietary intake might play a role in OTM and
resorption.19
10. Growth harmone: The inhibitory effect of GH on
root resorption by heavy force might be mediated
by RANKL/OPG and IGF-I. Short-term GH
administration may be a method with which to
reduce root resorption and shorten treatment time,
especially in patients who are susceptible to root
resorption
Pause during the treatment
Effect of a pause in active treatment on teeth that
had experienced apical RR during the initial 6-month
period with fixed appliances. The results showed that
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 Indian Journal of Public Health Research & Development. October-December 2017, Vol. 8, No. 4 311
the amount of RR was significantly less in patients
treated with a pause (0.4 - 0.7 mm) than in those treated
with continuous forces without a pause (1.5 - 0.8 mm).
LIPUS (low-intensity pulsed ultrasound)
LIPUS at 100 or 150 MW/cm2 groups displayed
decreased RR, decreased osteoclast numbers and
activity levels, increased OPG/RANKL expression
ratios. High-power SEM revealed reparative cementum
in the LIPUS treated samples. LIPUS regulates
osteoclast differentiation via the OPG/RANKL ratio,
evoking a reparative effect on orthodontically induced
root resorption in rats. 20
Other
Alternative options might include prosthetic
solutions to closespaces, releasing teeth from active
archwires if possible, stripping instead of extracting,
and early fixation of resorbed teeth
CONCLUSION
The finding of EARR is a common sequalae to
orthodontic treatment. As such it needs to be part of the
informed consent process which is to be taken before
orthodontic treatment. Mechanical forces and other
environmental factors do not adequately explain the
variation seen among individual expressions of root
resorption.The question if there is any ideal (optimal)
force to move teeth without root resorption and whether
root resorption is predictable remains unanswered. In
the future, before orthodontic treatment, patients might
be analyzed according to the genes IL-1 (and others) by
DNA analysis from buccal swab cells. Likewise, the
presence of high-risk alleles could also be verified.
Conflict of Interest: Nil
Source of Funding: Self
Ethical Clearance: Ethical clearance not required as it
is a review article
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