ROOT

RESORPTION
Presented By – Dr Shivam Sharma
2nd year PG
CONTENTS
 Introduction
 Histopathology o root
 Root Resorption classification
 Biology of root resorption
 Etiological Factors
 Imaging and visualization
 Management
 Conclusion
INTRODUCTION
 Root resorption is an essential phenomenon that plays a crucial role in the
physiological process of tooth eruption.
 Root resorption that occurs in permanent teeth is an unwanted process and is
considered pathologic.
 In 1856, Bates was the first to discuss root resorption.
 In 1914 Ottolengui, related root resorption directly to orthodontic treatment .
 In 1927 Ketcham demonstrated radiographic evidence of root resorption.
 In 1932 Becks and Marshall brought the word “resorption” into orthodontic
literature .
 In 1944 Oppenheim stated that following orthodontic treatment there was
inevitable damage in cementum, periodontal tissues, alveolar bone, and pulp.
HISTOPATHOLOGY
OF ROOT
CEMENTUM & ITS PROPERTIES
 Non uniform mineralized connective tissue. Cementum is the least mineralized and
the mineral content of cementum is approximately 65%.
 Cementum is less readily resorbed compared to alveolar bone, a feature that is
important for permitting orthodontic tooth movement.

Physical characteristics
 Light yellow color with a hardness less than that of dentin

Composition
 45%-50% inorganic substances
 50%-55% organic substances
TYPES

Acellular cementum

Cellular cementum
Function of cementum
 Primary function – furnish a medium for attachment of collagen fibers that bind the
tooth to the alveolar bone.
 There is a continuous deposition of cementum (unlike bone, it does not resorb under
normal conditions)
 Also serves as a major reparative tissue for root surfaces
CLASSIFICATION OF
ROOT
RESORPTION
ACCORDING TO TYPE

A. Physiologic root resorption

B. Pathologic root resorption

 ACCORDING TO LOCATION

1. Internal root resorption

2. External root resorption (ERR)

ERR is divided into 3 types by Andreasen (1985)

1. Surface resorption
2. Inflammatory resorption
3. Replacement resorption.
1. Surface resorption – self-limiting process, usually involving small outlining areas
followed by spontaneous repair from adjacent parts of the PDL.

2. Inflammatory resorption – caused by persistent inflammation of PDL due to mechanical,

infective, and pressure stimulation . Clinically, external inflammatory root resorptions
(EIRR) are commonly seen in patients with traumatic injuries, orthodontic treatment, root
canal infection and impaction.

3. Replacement resorption – bone replaces the resorbed tooth material that leads to
ankyloses Produces ankylosis of a tooth because bone replaces the resorbed substance.
According to Tronstad (1988)
 Transient inflammatory resorption - stimulation to the damage is minimal and for a
short period. This defect is usually undetected radiographically and is repaired by a
cementum-like tissue.

 Progressive inflammatory resorption -When stimulation is for a long period.

 Ankylosis - extensive necrosis of the periodontal ligament with formation of bone

onto a denuded area of the root surface.
According Brezniak and Wasserstein ( classification of Orthodontically induced
root resorption , 1993)

A. Cemental or surface resorption with remodeling

B. Dentinal resorption with repair (deep resorption)

C. Circumferential apical root resorption.

 Cemental or surface resorption with remodeling

 Dentinal resorption with repair (deep resorption):

Circumferential apical root resorption:
Types of root resorption observed in orthodontic patients Andreasen (1981)
 Resorption that takes place at the root apex, is termed external apical root resorption
(EARR)
GRADING ERR (Edward F. Harris, 2000 )
Index for evaluating the degree of root resorption (Satu Apajalaht, 2007)
 Grade 0, no radiographically visible root resorption
 Grade 1, mild resorption with rounding of root apex to about one-quarter of the root
length, and
 Grade 2, moderate to severe resorption with loss of one-quarter or more of the root
length.
ETIOLOGY
Pulpal infection root resorption
 The most common stimulation factor for root resorption
is pulpal infection.

 Radiographically, radiolucency is observed in the

external root surface of the dentin and adjacent bone, or
in the internal root canal dentinal walls
Periodontal infection root resorption -
 Infrequently, external root resorption may occur after injury
to the pre-cementum, apical to the epithelial attachment,
followed by bacterial stimulation originating from the
periodontal sulcus.
Orthodontic pressure root resorption
 Teeth are asymptomatic and the pulp is usually vital unless
the pressure of the operative procedure is high, which
disturbs the apical blood supply.
 Radiographically, orthodontic pressure resorption is located
in the apical third of the root.
 Impacted tooth or tumor pressure root resorption
 Tumors and osteosclerosis impingning on the root of the tooth
could also be an etiological factor for pressure resorption.

 Tumors that produce root resorption are most frequently those in

which growth and expansion are not rapid such as cysts,
ameloblastomas, giant cell tumors, and fiber-osseoseous lesions.

 This type of root resorption is asymptomatic with vital pulp

through –out the process unless the impacted tooth or tumor is
located near the apical foramen, disturbing the blood supply to the
pulp.
 Ankylotic root resorption –

 Clinically, ankylotic teeth lack the physiologic mobility of

normal teeth. This is one diagnostic sign for ankylotic resorption.
 In addition, these teeth usually have special metallic percussion
sound.
 Radiographically, resorption lacunae are filled with bone, and the
periodontal ligament space is missing. No radiolucent areas are
observed and at some stage, the whole root may be replaced by
bone.
BIOLOGY OF
ROOT
RESORPTION
Etiologic factors
 The etiologic causes and origins of root resorption as a result of orthodontic forces are
multifactorial and presently not clearly understood.

 Till now various authors have put forward numerous etiological factors. There is an
ongoing debate on almost all the factors that whether they really causes RR.

 None of the factors have been proved beyond doubt to be one to cause Root
resorption. But circumstantial evidence have shown that all factors has some role in
the Root resorption
Brezniak & Wasserstein AJO 1993 have given 2 major factors.
1. Biological factors.
2. Mechanical factors.
 BIOLOGICAL FACTORS :
GENETIC FACTOR

 In 1975 Newman reported family clustering of

EARR

 In 1997 report of Harris et al, who explored

the hypothesis of genetic influence on EARR.
 Al-Qawasmi et al (2003) reported that IL-1 gene cluster on human chromosome 2q13
includes 3 genes: Two genes (IL-1A and IL-1B) encode proinflammatory cytokine
proteins IL-1A and IL-1B
 Third gene (IL-1RN) encodes a related protein (IL-1ra) that acts as a receptor
antagonist.
PROPOSED MODEL FOR PATHWAY THROUGH WHICH IL- 1B MODULATES
EXTENT OF ROOT RESORPTION {Riyad A. Al-Qawasmi (2003)}

Proposed model for pathway

through which IL-1B genotype
modulates extent of root resorption
experienced during orthodontic
tooth movement.. This is 1 model
for how these various factors might
be implicated in clinical expression
of root resorption.
RACIAL FACTOR
Asian patients were found to experience significantly less root resorption than white or
Hispanic patients. {Glenn T. Sameshima et al (2001)}

AGE
a. Chronological age : Bishara (1999) showed that no change in root length
between 25 to 45 yrs of age without orthodontic treatment .
Frédéric Rafflenbeul et al (2019), Viganó Pastro et al (2018) in their study found
that there is no correlation between age and EARR.
Many authors say there is increase in RR with increase in age.

b. Dental Age : children before root completion there seem to be less RR.
INDIVIDUAL SUSCEPTABILITY
 Metabolic signals that generate changes in the relationship between osteoblastic and
osteoclastic activity include hormones, body type, and metabolic rate.
 These may modify specific cell metabolism and the person's reaction pattern to
disease, trauma, and aging.

GENDER
 Frédéric Rafflenbeul et al (2019), Viganó Pastro et al (2018) found no correlation
between gender and root resorption.
HABITS
 Nail-biting, tongue thrust associated with open bite, and increased tongue pressure
have been statistically related to increased root resorption.

TOOTH FORM
 Deviated root form is more susceptible to postorthodontic root resorption
 The pipette-shaped root was shown to be the most susceptible root form to root
resorption.
Higher risk for EARR
 Teeth with an odd root shape – Dilacerated roots, pointed roots, and pipette-shaped
roots {sameshima GT,Sinclair PM 2001)} {Pires Fernandes (2019) }
 Teeth with a history of trauma
 Teeth with longer roots
TOOTH LENGTH
 Mirabella and Artun (1995) suggest that the tendency for resorption increases with
increasing tooth length.
 Fernandes (2019) in their study found root resorption is greater in the longer roots.
 Possible explanations for this may be that longer teeth need stronger forces to be
moved, and that the actual displacement of the root apex is larger during tipping or
torquing movements of longer teeth
PREVIOUSLY TRAMATIZED TEETH
 Shaul Lin (2017) Traumatized teeth can exhibit external root resorption without
orthodontic treatment.
 Orthodontically moved traumatized teeth with previous root resorption are more
sensitive to further loss of root material.
 The average root loss for trauma patients after orthodontic therapy was 1.07 mm
compared with 0.64 mm for untraumatized teeth

ENDONTICALLY TREATED TEETH

 It has been suggested that endodontically treated teeth are more resistant to root
resorption by Mirabella and Artun (1995).

 Alhadainy H. A (2019) in their systemic riview concluded that endodontic treatment

does not seem to increase OIERR.
SYSTEMIC FACTORS
 According to Becks, endocrine problems including hypothyroidism, hypopituitarism,
hyperpituitarism, and other diseases are related to root resorption. {Darendeliler, M
(2004)}.

Higher risk for EARR

 Turner syndrome,
 Familial dysostosis ,
 Uncontrolled endocrine disturbance (it has been suggested that hormonal imbalance
does not cause but influences the phenomenon).
INFLAMMATORY MEDIATORS :
Scott Mc Nab (1999) conducted his study in asthmatic patients and found out that the
inflammatory mediators produced outside the PDL that influences cellular interactions
involved in RR, by attracting the cementoclast progenitors increase in conditions like Asthma
, Alcoholism , chronic gingivitis etc.
 Masato Nishioka (2006) concluded that allergy, asthma may be high risk factors for the
development of excessive root resorption during orthodontic tooth movement in Japanese
patients.

 Cibelle Cristina Oliveira (2021) in their systemic review found low level of certainty
which states that individuals with asthma or allergies do not have a different predisposition
to orthodontically induced root resorption when compared to individuals with no asthma or
allergies.
ALVEOLAR BONE DENSITY:
 Controversial reports on root resorption and alveolar bone density appear in the
literature. Several investigators found that the more dense the alveolar bone, more
the root resorption during orthodontic treatment.
 Studies by Goldie .RS. King (1984) & By Ashcraft, Southard, and Tolley (1994)
showed decrease in bone density cause increase in tooth movement. But there is
decrease in RR
 Linares A. I. Et al (2016) in their systemic riview found that Both genetic variation
and the onset of a bone-related disease can influence systemic bone density and local
bone density, such as observed in the mandible and maxilla.

 Less density means more chance of bone remodeling & so more bone resorption than
cementum resorption.
TYPE OF MALOCCLUSION:
 Tulin tanner et al (1999) found significant increase in RR of Cl II than in Cl I
malocclusion.
 The amount of apical displacement has been shown to be a primary factor causing
EARR {(Zhou Y (2015)}.
SPECIFIC TEETH :.
 Sameshima GT, Sinclair PM (2001), Glenn T. Sameshima et al (2001), Fernandes (2019)
Pornputthi Puttaravuttiporn (2018) Maxillary incisors have the greatest amount of root
resorption of all teeth.
Lateral incisors >central incisors. > mandibular incisors > Maxillary and mandibular canines,

Molars rarely resorb, but if they do, it is usually the mesial root.

Reasons
 These are the teeth that are moved greater distance than molars
 Incisors have less root surface area & so less chance of force dessipation.
 Also intrusion is mostly performed in these teeth than any other teeth in the arch

.
MECHANICAL FACTORS :
Many of the Biological factors cannot be controlled by orthodontist. But mechanical
factors should be controlled.

TYPE OF APPLIANCE :
 Fang Xu et al (2019), Aldeeri A (2018), Elhaddaoui R. (2017) found that Clear
aligner treatment that applies enough force to move the roots the same amount as
fixed appliances do will cause EARR, the incidence and severity of resorption could
both be lower compared with results reported by treatment with fixed appliances.

 Pandis N. et al (2018), Leite V (2012) Yu Jianru (2016) Aras et al (2018) found No

difference of root resorption between conventional and self-ligating brackets.
Intermittent forces should be preferred over continuous forces to prevent serious root resorption.
Aras et al (2012) Ozkalayci et al (2018) in their studies concluded that intermittent forces
results in lesser root resorption than continuous force.

 Most of the studies comparing intermittent with continuous forces found that the latter is
associated with greater resorption.
EXTRACTION VS NON EXTRACTION:
 Scott McNab et al (2000) from his study states that there is more chance of EARR
in extraction cases than in non- extraction cases.
 Glen.T.Sameshima et al (2001) supports that orthodontic treatment with extraction
especially all first bicuspids causes higher incidence & degree of root resorption than
in non – extraction treatment strategy.
MAGNITUDE OF FORCE USED :
 Vardimon (1991) found that force magnitude is directly proportional to the severity of root
resorption
 Currell S. D. et al (2019) in their systemic review concluded that There is very low evidence
for supporting positive associations between root resorption and increased force levels, force
continuity, intrusive forces, and treatment duration.

 Moreover, by including a pause in treatment for patients experiencing root resorption, it may
be possible for the clinician to reduce the severity of the condition
LIGHT OR HEAVY FORCE :
 HARRY AND SIMS (1982) concluded that higher stress causes more root
resorption.
 According to Schwartz applied force exceeding the optimal level of 20 to 26 gm/cm2
causes periodontal ischemia, which can lead to root resorption.

Chan & Darendeliler (2005) -their volumetric analysis of RR craters found that
The mean resorption craters
 In light force group was 3.49 fold greater than in control group.
 In heavy force group it was 11.59 fold grater than in control group.
TYPE OF MOVEMENT :
INTRUSION:
 Takayoshi et al in (2003) experimental intrusion of molars using skeletal anchorage
system found that there was severe RR & it reached the dentin without reparative
cementum formation.
 Li et al. (2013) evaluated the amount of root resorption after mini-screw-supported
molar intrusion and stated that the most volumetric material loss occurs in the
mesiobuccal root.
 Pornputthi Puttaravuttiporn (2018) intrusive force to the four upper incisors using
T-loop lead to more apical root volume loss on lateral than central incisors. There was
no relationship between extent of tooth movement and upper incisor root volume loss.

 Silvio Augusto Bellini-Pereira (2020) in their systemic riview found intrusion

mechanics caused less than 1 mm of OIRR, which is within the acceptable limits for
clinical implication.
ROTATION :
 Sao Paulo AJO (2004) studied premolars which had undergone rotation found that
RR is severe on rotated than in controls.

RETRACTION:
 Sheldon Baumrind (1996) Evaluated differences in the extent of root resorption
between continuous arch and sectional mechanics and found both group exhibited
same levels of root resorption indicating side effect may be due to individual variation
and not round tripping.

 Feifei Jiang (2017) EARR appears to be related to amount of apiacal displacement.

The orthodontic load and the genotype should be the focuses for future studies.

 Momen Z. Rizk (2018) in systemic review found no significant differences exist in

the amount of root resorption between en masse retraction and two step retraction.
EXPANSION :
 Forest D. (2014) in their systemic review found statistically significant root volume
loss associated with maxillary expansion therapy
 Antonino Lo Giudice ( 2018) in their systemic review concluded that significant
radicular volume loss was observed in posterior teeth in all RME devices
 F Dindaroğlu (2016) comparison of root resorption between tooth-borne and tooth-
tissue borne rapid maxillary expansion appliances and found both the appliances
cause significant root resorption.
DURATION OF FORCE:

Most studies report that the severity of root resorption is directly related to treatment
duration.

 L. Y. Sharab (2015) CPR Maues (2015) SD Curell (2019) long length of treatment were
significantly associated with EARR.
Apical Root Displacement

 Most studies have found the distance the apex is displaced is a significant risk factor.
Until recently, accurately measuring the actual displacement of the tooth has been
difficult.

 Serial cephalometric tracings superimposed on the maxilla were used to measure

horizontal and vertical displacement of the apex quantitatively

 One of the many limitations of this method of measurement is the uncertainty in

knowing which central incisor is traced on each film. Moving the apex of maxillary
central incisors against the cortical bone was shown in one study using cephalometric
films to increase EARR,
 External apical root resorption (EARR) and horizontal root displacement. A, Pre-
treatment. B, Post treatment showing significant EARR in all maxillary incisors (circled).
C, Cephalometric superimposition shows amount of apical displacement (arrow).
A. Extraction case
 treatment risk factors
include an older sibling
with moderate external
apical root resorption
(EARR). 12 years of
age. 4-mm overjet.

B. Non extraction case

 Severe root resorption
of all four maxillary
incisors 12 years of
age. With 5 mm overjet
 Negative health history
for risk factors.
Maxillary left lateral
may have preexisting
root damage from
erupting canine.
Visualization and Diagnosis of Root Resorption

 Root resorption after orthodontic treatment was examined for many years with
conventional radiographs (periapical graphs, digital radiography,
orthopantomography, and lateral cephalometric radiography), light microscopes, and
scanning electron microscopes.
 Recently, computed tomography (CT) and micro-CT were prevalent, and later on,
cone-beam CT (CBCT) has come to the forefront.
Conventional Radiological Evaluations
 Although shortening of the root length might be detected with conventional methods,
the location, depth, and width of resorption in different parts of the root cannot be
detected or measured
 The reliability of the results of several studies might doubtful due to the magnification
problems of two-dimensional radiographs .

 According to evaluations made using OPG by Sameshima and Asgarifar (2001) ,

there was a 20% or more material loss in the root compared to evaluations using
periapical graphics

 The magnification factor is generally less than 5% in periapical graphs.

Serial Sectioning and Light Microscopy
 Differences in teeth morphologies in the first premolar tooth that are constantly used
at root resorption studies and changes in root numbers can be challenging during
cross-sectioning, and it is difficult to make an ideal longitudinal cross-sectioning
without any data loss along the long axis of the teeth.

 Apical resorptions or resorptions in the middle third of the root cannot be noticed .

 Resorption craters can vary in size and depth. Therefore, irregular C-form craters
and/or small craters can be partially or completely overlooked or miscalculated.
Micro-CT
 Root resorption is essentially characterized by volumetric material loss.
 The volumetric three-dimensional methods used during diagnosis and the quantitative
measures of root resorption can provide more accurate results than those obtained
using either quantitative or semi-quantitative two-dimensional methods .
 Micro-CT, when compared with other methods, has a resolution as high as 3 μm.

With this method, root resorption can be measured or detected only in in vitro
conditions, and to obtain high-resolution images in vivo, high radiation levels are
required. This restricts the use of micro-CT images in vivo.
Cone Beam Computed Tomography
 Cone beam computed tomography was developed for viewing the maxillofacial
region, and it also caused a paradigm shift from two-dimensional methods to three-
dimensional methods .
When compared with conventional CT, the advantages in using CBCT
 Images with lower doses,
 shorter scan time,
 improved image sharpness .

 When compared with micro-CT, one of the most significant advantages is that it can
be used in in vivo assessments.
 Repair of root resorption

 It is thought that active orthodontic forces have an important role in the continuity of
root resorption;
 therefore, the repair process begins after the release of the orthodontic force or
decrease in the magnitude of the force at a certain level. The repair is first observed
around the resorption lacunae.
 Resorption lacunae are recovered with the accumulation of new cementum and
formation of a new periodontal ligamentum .
 Owmann-Moll et al. stated that the possible repair level in resorption cavities that can
be histologically observed can be summarized as follows:

 I- Partial Repair: Part of the surface of the resorption cavity is covered with reparative
cementum (cellular or acellular cementum).
 II- Functional Repair: The total surface of the resorption cavity is covered with
reparative cementum without the re-establishment of the original root contour (cellular
cementum).
 III- Anatomic Repair: The total surface of the resorption cavity is covered with
reparative cementum to an extent such that the original root contour is re-established.
MANAGEMENT
1. Produce good pretreatment images.
2. If risk factors present, then document a special entry in the informed consent.
3. If risk factors present, take periapical radiographs at 6 and 12 months or when apical
displacement has started.
4. During treatment:
a. If external apical root resorption (EARR) is greater than 2 mm, then stop treatment
for 4 months.
b. If EARR is greater than 4 mm or more than one-third of the root, then stop active
tooth movement and consider terminating treatment.
5. If severe EARR occurs on more than two adjacent teeth, the treatment must be
terminated.
6. EARR stops when appliances are removed.
7. Patient and referring dentist must be kept informed at all time points.
8. If short roots are present at the beginning of treatment:
a. Delay applying appliances on the affected tooth as long as possible.
b. Avoid torque and apical displacement.
c. Take more frequent periapical radiographs.
What to Do If Root Resorption Is Detected at Progress
 Generally for a normal length, if the amount of resorption is greater than 2 mm, then the
best course of action is to stop active treatment immediately and wait for 4 months.

 After this resting period, treatment can continue. Overtorquing the tooth is unwise, and the
orthodontist may have to compromise the amount of detailing as well.
 In nonperiodontally involved tooth, If the amount of EARR is 4 mm or more in a patient
who has been in treatment for a long time and the apex has already been moved a
significant distance (1 mm or more), then the orthodontist will have to decide whether to
terminate treatment (debond the case) or
 modify the plan to finish without moving the affected teeth.
When Does External Apical Root Resorption Start?

 It has been hypothesized that EARR will start to occur when the root apex is displaced
—in any direction.
 Smale I. (2005) found that teeth with EARR at 6 months after fixed appliance
placement were the most likely to have severe EARR by the end of treatment.
When Does External Apical Root Resorption Stop?
 It has been clinically observed that as soon as active forces are removed from the
tooth, EARR stops. Studies have shown the reparative process is completed within an
few weeks.

 Generally, removable appliances do not cause EARR; however, tooth positioners may
produce enough force to continue EARR
Are There Any Methods to Detect Root Resorption before It is Visible on
Radiographs?

 J Mah et al (2005) compared levels of dentin phosphoproteins(DPP) in the GCF

among three groups. They found significantly higher levels in active orthodontic tooth
movement group compared to control group.

 L Balducci et al (2007) examined GCF levels of dentin phosphoproteins (DPP) and

other markers and found differences between teeth in patients with root resorption and
a control group with no forces.

 Tarallo F. (2019) in their systemic review found Dentine phosphoprotein (DPP),

Dental sialoprotein (DSP) in the GCF significantly higher levels in active
orthodontic tooth movement. Dentinal matrix (DMP‐1), its presence within the GCF
may not be due exclusively to the process of root resorption in progress but also to the
normal process of bone remodeling.
CONCLUSION
EARR is common during orthodontic treatment, it occurs in nearly every tooth during tooth
movement. Severe EARR is rare but can be destructive and affect more than one tooth.

Proper management of EARR should include an assessment of risk factors, taking quality
images, and following established procedures if severe EARR is detected during treatment.
THANK YOU
 REFERENCE
 Root resorptions and tissue changes during orthodontic treatment.(Bisharra)
 Root resorption after orthodontic treatment part 1 and 2 Nappthali Brezniak, Wasserstein.(AJO
jan 1993 )
 Orthodontically induced inflammatory root resorption Brezniak and wasserstein. Angle 2002
 Genetic predisposition to external apical root resorption Riyad A, James K (AJO 2003
MARCH )
 Root resorption during orthodontic therapy Edward F Harris (seminars in orthodontics , sept
2000 )
 Root resorption in orthodontics Furkan Dindaroglu (TurkJOrthod 2016)
 Orthodontics current principles and practice –Lee W. Graber,Robert L. Vanarsdhall
 Contemporary orthodontics –William Proffit
 Tarallo F, Chimenti C, Paiella G, Cordaro M, Tepedino M. Biomarkers in the gingival
crevicular fluid used to detect root resorption in patients undergoing orthodontic treatment: A
systematic review. Orthodontics & craniofacial research. 2019 Nov;22(4):236-47.
 Andreasen JO. External root resorption: its implication in dental traumatology, paedodontics,
periodontics, orthodontics and endodontics. Int Endod J. 1985;18(2):109–18.
 Tronstad L. Root resorption—etiology, terminology and clinical manifestations. Dent
Traumatol. 1988;4(6):241–52.
 Harris EF. Root resorption during orthodontic therapy. InSeminars in Orthodontics 2000 Sep 1
(Vol. 6, No. 3, pp. 183-194). WB Saunders.