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EXTERNAL ROOT
RESORPTION

D r. Va i s h n a v i K a s a r p a t i l
III MDS
D e p t . o f O r t h o d o n t i c s a n d D e n t o f a c i a l O r t h o p a e1d i c s
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Contents
• Introduction
• C l a s s i fi c a t i o n
• Natural protection mechanism
• Biology
• Fa c t o r s a ff e c t i n g r o o t r e s o r p t i o n
• Predisposing factors
• Methods of assessment
• L o n g t e r m e ff e c t s
• Genetics and resorption
• Management of root resorption
• Conclusion
• Re f e r e n c e s 2 2
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INTRODUCTION

Root resorption is a process that results in the loss of the

cementum and dentine.

types

physiological process pathological inflammatory process

-deciduous dentition -permanent dentition

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• Apical root resorption  orthodontic treatment and it can

be present during the treatment or at the end of it.

• This root resorption is called orthodontically- induced

inflammatory root resorption (OIRR) and it is considered
a distinct pathologic process.

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ROOT title style
RESORPTION

External root Ankylotic root

Internal root
resorption resorption
resorption
• Pulpal infection • Severe dental
• Pulpal • Dental trauma trauma
infection • Bleaching
procedures
• Periodontal
procedures
• Impacted
teeth/cysts and
tumors
• Orthodontic
treatment 6
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There are three degrees of severity of OIIRR
(Naphtali Brezniak et al(2002) Angle Orthod

• 1. Cemental or surface resorption

• 2. Dentinal resorption with repair (deep resorption)

• 3. Circumferential apical root resorption

Brezniak N, Wasserstein A.-- Orthodontically induced inflammatory root resorption. Part I: The basic science aspects.
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Angle Orthod 2002;72:175-9
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Protection Master title style
mechanism
Cementum  resistant to bone
Orthodontic Bone and
resorption compared resorption,
force cementum
with the more vulnerable which leads
bone. to tooth
movement.

Root resorption occurs when pressure Uncalcified mineral tissues -

on the cementum exceeds its reparative osteoid, precementum, and
capacity and dentin is exposed, allowing predentin  resistant to resorption
multinucleated odontoclasts to degrade and may initially prevent loss of
the root substance. root tissue.

Andreasen, relates surface resistance to the innermost cellular layer of

the periodontal ligament.
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Andreasen defines three external root resorption types:

• Surface resorption, which is a self-limiting

process, usually involving small outlining areas
followed by spontaneous repair from adjacent intact
parts of the periodontal ligament.

• Inflammatory resorption, where initial root

resorption has reached dentinal tubules of an
infected necrotic pulpal tissue or an infected
leukocyte zone.

• Replacement resorption, where bone replaces

the resorbed tooth material that leads to ankylosis.

Andreasen FM. Transient root resorption after dental trauma:the clinician's dilemma. J Esthet Restor
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Dent. 2003;15(2):80–92
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Orthodontic force title style
initiation

local compression of PDL

include reduction in width Rygh and co-workers have shown
and vascular changes that cementum adjacent to
hyalinized ( necrotic ) areas in
PDL is “marked” by this contact
remodeling of alveolar and that osteoclast cells attack
bone  tooth movement this marked cementum when the
PDL area is repaired.

HYLANIZATION

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Rygh P. Orthodontic root resorption studied by electron microscopy. Angle Orthod. 1977;47:1–16.
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Osteoclas Mononuclear giant cells

t

 along with bone  root surface

root surface associated with areas of
indiscriminately damaged PDL

• Advanced stages are typified by Odontoclast - The

odontoclast is the root-resorbing cell.
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 The residual matrix covering the surface of the resorption defects

consists of exposed collagen fibrils.

 Both the healing process and early stages of root resorption involve a
high percentage of Mononuclear giant cells.

 Mononuclear giant cells  transform into odontoclasts by the exposed

mineralized root surface.

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The organic matrix degradation :

• According to Jones and Boyde, the osteoclast is credited for both

demineralization of the calcified tissue and degradation of the
organic matrix after demineralization.

• Cysteine proteinases of osteoclastic  removal of organic matrix.

Boyde A, Ali NN, Jones SJ. Resorption of dentine by isolated osteoclasts in vitro. Br Dent J. 1984 Mar 24;156(6):216-20.
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doi: 10.1038/[Link].4805313. PMID: 6584143. 14
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 Resorbing activity  response to mechanical or chemical stimuli by the

periodontal ligament cells.

 Regulated by
 hormones (parathyroid and calcitonin),
 neurotransmitters (substance P, vasoactive intestinal peptide, and
calcitonin gene related peptide),
 cytokines or monokines (interleukin-1 alpha, interleukin-1 beta,
interleukin-2, tumor necrosis factor, and interferon-gamma).

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Initiation, Masterand
Cessation title style
Repair

 First histologic detection of root resorption vary from 1 week to a few

weeks.

 Progression of root resorption in terms of depth and number of lacunae has

been found to increase with continuation of force.

 Cessation of process : resorption ceases with termination of force

application , whereas other studies show that process continues even after
force application ceases.

 Cessation is more likely linked to complete removal of necrotic tissue than

force application.
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Breznlak N and Wassersteln A .Root resorption after orthodontic treatment: Part 1. Literature review. Am. J. Orthod. Dentofac. 16
Orthop.
1993;103(1):62-66.
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• Repair of resorption lacunae has been observed as early as 3-5 weeks

after the initiation of light orthodontic tooth movement.

• Examination of the root surfaces of teeth that have been moved reveals
repaired areas of resorption of both cementum and dentin of the root.

• Cementum (and Dentin , if resorption penetrates through the cementum)

removed form the root surface is restored by the formation of
Dentinocemental junction corresponding to that formed at Odontogenesis.

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Breznlak N and Wassersteln A .Root resorption after orthodontic treatment: Part 1. Literature review. Am. J. Orthod. Dentofac. 17
Orthop.
1993;103(1):62-66.
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 Cemental lacunae become fully anatomically reconstructed.

 Periodontal ligament width is usually normal.

 Root contour is frequently followed by bone contour, which increases tooth

anchorage without compromising function.

 Root remodeling is a constant feature of orthodontic tooth movement, but

permanent loss of root structure would occur only if repair did not replace the
initially resorbed cementum.
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Loss Master title style
of Root Apex

T
O
O
T
H
L
E
N
G
T
H

CAVITIES coalesce
at the APEX
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 Predisposing Patient [Biologic] Factors
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• Individual susceptibility • Traumatized teeth

• Genetics • Presence of root resorption

• Systemic factors before orthodontic treatment

• Nutrition • Endodontically treated teeth

• Gender of the patient • Adverse habits as nail-biting,

tongue thrusting
• Chronologic age
• Specific tooth vulnerability to
• Dental age
tooth resorption
• Tooth structure
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• Treatment Related [Mechanical] • Combined Factors

Factors • Treatment duration
• Type of orthodontic appliances
• Root resorption detected
used
radiographically during
• Magnitude of applied forces orthodontic treatment

• Direction of tooth movement • Root resorption after

• Amount of tooth movement appliance removal

• Jiggling and Occlusal trauma • Relapse

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Click to edit MECHANOTHERAPY
Master title styleAND ROOT
RESORPTION:
• Root resorption after orthodontic mechanotherapy  dependence of this
iatrogenic sequela on various mechanotherapeutics performed has been
studied extensively, but the results have been conflicted

• Many parameters such as:

• the type of malocculsion,

• extraction versus nonextraction,

• the type of appliance used (removable, fixed, or functional appliances),

• the type of tooth movement performed,

• the duration of force application

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• The magnitude of force, as well as rigid fixation of the arch-wire with

brackets or the use of full-size rectangular wires in bracket slots, could be
the most important factors predisposing a tooth to the resorptive process

Brin I. External apical root resorption in Class II malocclusion: A retrospective review of 1-versus 2-phase treatment.
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Am J Orthod Dentofac Orthop. 2003; 124:151-6
 Root
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Master among different
title style
malocclusions
 There is a statistically significant difference
between Class I and Class II Division 1
malocclusions, with the latter exhibiting more
resorption.

 Janson et al (2007) reported a higher resorption

potential for Class II Division 2 cases in
comparison with Class I, Class II Division 1, and
Class III patients.

 Rationale  intrusion mechanics necessary to

correct deep overbite in these cases, as well as
the excessive labial torque needed to correct the
palatal inclination of the incisors, were the cause
Janson G, Niederberger A, Garib DG, Caldas W. Root resorption in Class II malocclusion treatment with Class II elastics.
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Am J Orthod Dentofacial Orthop. 2016 Oct;150(4):585-591. doi: 10.1016/[Link].2016.02.031. PMID: 27692415.
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• However it can be inferred from the published literature that all types of
malocclusion are prone to root resorption when exposed to orthodontic
treatment.

• Harris D et al (2006): showed that the volume of the root resorption

craters after intrusion was found to be directly proportional to the
magnitude of the intrusive force applied.

• The mesial and distal surfaces had the greatest resorption volume, with
no statistically significant difference between the 2 surfaces.

Harris D et al .Physical properties of root cementum: Part 8. Volumetric analysis of root resorption craters after
application of controlled intrusive light and heavy orthodontic forces: A microcomputed tomography scan study.Am26
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Orthod dentofacial Orthop 2006;130:639-47
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Extraction versus Non-extraction modalities.

 Most studies revealed that both techniques have the potential to produce
damage, with extraction therapy being potentially more detrimental.

 Some authors observed a definite increase in root resorption following

extraction therapy.

 Others reported a lack of correlation between root resorption and

treatment with extraction or nonextraction.

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Graber L,Vanarsdall R,Vig k and Huang [Link] current principles and techniques.2017.1 st ed.
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TYPE OF APPLIANCE
• It was recently reported that a lower incidence of resorption, as well as
amount of root resorption, in patients treated with the BIOEFFICENT
THERAPY.
 The incidence rate of root resorption was 3.72 times higher when
extractions were performed as part of Begg appliance therapy.

 An increased amount of root resorption with the Begg appliance has also
been extensively reported in the previous literature.

 L'Abee and Saderink observed root resorption in all three stages of Begg
mechanics, with the second stage exhibiting the least severity.

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L'Abee EM, Sanderink GC. Apical root resorption during Begg treatment. J Clin Orthod. 1985 Jan;19(1):60-1. PMID:
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 Mayoral,AJO 1982  low incidence of root resorption following Begg

mechanics and emphasized the importance of using light forces to diminish
damage to the roots.

 A comparison of standard edgewise with straight-wire appliances reveals

statistically insignificant results except for one study, (Mavragani M et al
EJO 2000 ) which reported increased resorption for central incisors in the
edge­wise group.

 When sectional mechanics were compared with continuous arch mechanics

reported the same resorption potential.
Mayoral G. Treatment results with light wires studied by panoramic radiography. Am J Orthod. 1982 Jun;81(6):489-97.
doi: 10.1016/0002-9416(82)90428-6. PMID: 6960734.
Mavragani M, Vergari A, Selliseth NJ, Bøe OE, Wisth PL. A radiographic comparison of apical root resorption after
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orthodontic treatment with a standard edgewise and a straight-wire edgewise technique. Eur J Orthod. 2000
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Master
of title
toothstyle
movements
 Intrusion and torque  commonly associated with the resorption process.

 The intrusion performed in the first stage and torquing in the third stage
make the Begg technique more vulnerable to resorption.

 Displacement of the root apex horizontally or torquing has been proven

beyond doubt to produce root resorption.

 The highest incidence of root resorption is reported to occur when 3 to 4.5

mm of torquing movement were performed.

Brezniak N. Root resorption after orthodontic treatment. Part II. Literature review. Am J Orthod Dentofac Orthop.1993;
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Treatment

 The length of treatment time and root resorption have been positively
correlated by almost all studies, which have shown that increased
treatment time makes tooth roots more prone to the iatrogenic response

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Aryal N & Jing M. Root Resorption in Orthodontic Treatment: Scoping Review 2017;7(2):47-52.
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Magnitude of applied
force
 Acar et al AO 1999 evaluated the effect of the type of force applied—
continuous versus interrupted— on the resorption pattern and observed
less severe apical blunting and smaller resorption-affected areas when
interrupted force was applied.

 Their findings are in agreement with study in this regard Maltha JC et

al, EJO 1996 and emphasize the use of less detrimental discontinuous
forces (in the form of elastic usage, instead of elastomeric chains during
space-closure stages of orthodontic mechanotherapy.

Acar A, Canyürek U, Kocaaga M, Erverdi N. Continuous vs. discontinuous force application and root resorption. Angle
Orthod. 1999 Apr;69(2):159-63; discussion 163-4. doi: 10.1043/0003-
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Maltha JC, van Leeuwen EJ, Dijkman GE, Kuijpers-Jagtman AM. Incidence and severity of root resorption in 32

orthodontically moved premolars in dogs. Orthod Craniofac Res. 2004 May;7(2):115-21. doi: 10.1111/j.1601-
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• Ballard D et al.(2009) studied the Continuous vs intermittent controlled

orthodontic forces on root [Link] concluded that : Intermittent
force produced less root resorption than continuous force

• Buccally directed intermittent forces for 8 weeks (after 14 days of initial

continuous force application, the intermittent force application was obtained
with a 3-day resting period followed by a 4-day force application period)

• produce significantly less total root resorption than a similarly directed

continuous force of the same magnitude and duration.

Ballard D. Allan S. Petocz P and Darendeliler M. Physical properties of root cementum: Part 11. Continuous vs
intermittent controlled orthodontic forces on root resorption. A microcomputed-tomography study. Am J Orthod
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Dentofacial Orthop 2009;136:8.e1-8.e8
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• Gonzales C. Hotokezaka H. Darendeliler M and Yoshida N concluded

that the resorption and repair processes during the early stages of retention
are balanced, and most of the reparative process occurs after 4 weeks of
passive retention after the application of orthodontic force. Frequent
orthodontic reactivations should be avoided to allow recovery and repair of
root surface damage.

Gonzales C .Hotokezaka H..Darendeliler M and Yoshida N .Repair of root resorption 2 to 16 weeks after the application
of continuous forces on maxillary first molars in rats: A 2- and 3-dimensional quantitative evaluation. Am J Orthod
Dentofacial Orthop 2010;137:477-85 3434
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TOOTH SPECIFICITY
 Evaluation of the vulnerability of specific teeth to the resorption process in
the literature has resulted in common agreement among authors that the
maxillary incisors are the teeth that are the most susceptible to the process

 But controversy still exists regarding which incisors resorb the most: the
centrals or the laterals.

 The majority of studies published reported that central incisors were more
susceptible to the process, except for two recent studies, which favored the
lateral incisors are equally prone for resorption.

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Graber L,Vanarsdall R,Vig k and Huang [Link] current principles and techniques.2017.1 ed.
st
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• Following the incisors in susceptibility to resorption in the maxillary arch are

the molars, followed by the canines.

• In the mandibular arch, the most resorption vulnerable tooth is the canine,
followed by the lateral and central incisors.

• Among posterior teeth, the most resorbed are the mandibular molars (with
the distal root exhibiting more resorption), followed by maxillary molars,
mandibular premolars, maxillary first premolars, and maxillary second
premolars

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Graber L,Vanarsdall R,Vig k and Huang [Link] current principles and techniques.2017.1 ed.
st
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 Beck and Harris, described the relationship of
mechanotherapy to root resorption in the
distal roots of molars.

 According to them, anchorage archwire

bends at the mesial of molars, for bite
opening, cause the distal roots to be
compressed in the tooth sockets, thereby
initiating root resorption.

 It would be of interest to quantify the

consequences of buccal tooth root lengths
with the bioprogressive technique in which
the buccal molar roots are moved toward the
Beckcortical
BW, Harrisplates for
EF. Apical anchorage.
root resorption in orthodontically treated subjects: analysis of edgewise and light 37
wire
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mechanics. Am J Orthod Dentofacial Orthop. 1994 Apr;105(4):350-61.
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ROOTto edit
SHAPEMaster title style

• Various authors have evaluated

abnormalities in root shape and its
association to the resorptive process.

• Among differently shaped root ends

(normal, blunted, dilacerated, pipette
shaped, pointed, and incomplete).

• the least resorption was observed in

blunted root ends and the greatest was
seen in pointed or tapered root ends.

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• This phenomenon is explained by the fact that the pressure from

the axial component of orthodontic forces is felt most at the root
apex regions, which are abnormal in shape.

• This results in localized ischemic necrosis, which denudes the

precementum and cementoblasts, permitting colonization of
dentinoclasts.

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• In comparison to the normal root shape,

dilacerated roots show the most
resorption, followed by pipette-shaped
and incomplete roots.

• Levander and Malmgre(1988) noted that

blunt shaped roots are at greater risk of
resorption.

• Therefore any abnormal root shape

observed in pretreatment diagnostic
records should be observed with caution
and should be monitored throughout the
treatment period for any iatrogenic
damage.
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Levander E, Malmgren O. Evaluation of the risk of root resorption during orthodontic treatment: a study of upper
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incisors. Eur J Orthod. 1988 Feb;10(1):30-8. doi: 10.1093/ejo/10.1.30

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Root length and root resorption

• Root length and resorption were found to have a

positive correlation.

• The studies in this regard report that longer

roots are more prone than shorter ones to
resorption,

• because of the greater displacement required to

produce an equal amount of torque, versus
shorter roots.

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ROOT to CANAL
edit Master title style
TREATMENT AND ROOT
RESORPTION

• The increase in dentin density following

endodontic treatment produces
increased resistance toward the
resorption process, in comparison to
untreated teeth.

• However some studies found no

difference b/w the endodontically
treated tooth and normal tooth(Walker
SL et al (2017 EJO).

Walker SL, Tieu LD, Flores-Mir C. Radiographic comparison of the extent of orthodontically induced external apical
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root resorption in vital and root-filled teeth: a systematic review. Eur J Orthod. 2013 Dec;35(6):796-802.
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to edit and
Master
roottitle style
resorption

• Previous history of trauma and the presence

of pretreatment root resorption have been
positively correlated with root resorption
seen after orthodontic treatment.

• There exists a relationship between cortical

plate proximity and increased root
resorption.

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OVER BITE AND OVER JET

 Positive correlation between an increase in

overjet and root resorption.

 The main reasons attributed to this

phenomenon are the greater amount of torque
and greater root displacements required to
correct excess overjet.

 The use of interrupted rather than continuous

force is one way to reduce this problem

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Baumrind S AJO 1996, Horiuchi A et al AJO 1998 ,Sameshima GT, AJO 2001& McNab S et al AJO 2000
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Crestal alveolar bone levels.

 Sharpe et al (1987) conducted extensive research on relapse,

apical root resorption, and crestal alveolar bone levels.

 Relationships between increased root resorption, decreased

crestal bone levels, and orthodontic relapse.

 A reduction in root length as well as in the crestal bone level

will predispose a tooth toward relapse because of the
decreased resistance against the forces causing relapse

Sharpe W, Reed B, Subtelny JD, Polson A. Orthodontic relapse, apical root resorption, and crestal alveolar bone 45
levels.
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Am J Orthod Dentofacial Orthop. 1987 Mar;91(3):252-8. doi: 10.1016/0889-5406(87)90455-0. PMID: 3469910.

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 At some stage in tooth movement during relapse, these teeth might

undergo further root resorption and crestal bone loss.

 A number of authors have researched the importance of periodontal

support and root length in relation to orthodontic tooth movement.

 They all agreed that the periodontal condition of patients should be

monitored throughout treatment and during the posttreatment period to
prevent relapse tendencies and enhance the longevity of the dentition.

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Krishnan V .Root Resorption with Orthodontic Mechanics: Pertinent Areas [Link] Dent J.2017 ;62(1):71-77
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AGE, GENDER, AND ETHNICITY
• Biologic factors, such as age at the start of treatment and gender,
have long been associated with risk factors for the initiation of root
resorption.

• Age at the start of orthodontic treatment and incidence of root

resorption have been poorly correlated in almost all recent studies.

• Sameshima and Sinclair (2001) claim that mandibular anterior

teeth demonstrate significant root resorption when orthodontic
treatment is carried out in adults. Otherwise, their study agrees
with previous findings of a lack of correlation between age and root
resorption
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Graber L,Vanarsdall R,Vig k and Huang [Link] current principles and techniques.2017.1 st ed.
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 Conflicting results have been seen when gender is considered. Two studies
supported the view that female patients are more prone to the process,
while others cite evidence for men.

 Sameshima and Sinclair state that male subjects are more prone to the
process but the results are statistically insignificant. The majority of the
studies support a lack of correlation between gender and resorption.

 The relationship between ethnicity and root resorption was evaluated . The
results showed less severity among Asians in comparison to Caucasians
and Hispanics (Sameshima GT AJO 2001 et al).

Sameshima GT, Sinclair PM. Predicting and preventing root resorption: Part I. Diagnostic factors. Am J Orthod
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Dentofacial Orthop. 2001 May;119(5):505-10. doi: 10.1067/mod.2001.113409. PMID: 11343022. 48
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Micro-osteoperforations & orthodontic root
resorption
• Chan E et al.(2018) conducted a study to investgate the the effects
of micro-osteoperforations on orthodontic root resorption with
microcomputed tomography.

• They concluded that : Premolars treated with micro-osteoperforation

exhibited significantly greater average total amounts of root resorption

• The total average volumetric root loss of premolars treated with micro-
osteoperforation was 42% greater than that of the control teeth.

Chan E et al. Physical properties of root cementum: Part 26. Effects of micro-osteoperforations on orthodontic root
resorption: A microcomputed tomography study. Am J Orthod Dentofacial Orthop 2018;153:204-13 4949
 Click to editTRAUMA
OCCLUSAL Master title style

• 1. 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.

• 2. The level of pain was not correlated to the amount of root

resorption.

• 3. To improve our current understanding of the detrimental effects of

bite raisers, they should be tested in different heights and different
experimental durations.

Cakmak F et al. Physical properties of root cementum: Part 24. Root resorption of the first premolars after 4 weeks of
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occlusal trauma. Am J Orthod Dentofacial Orthop 2014;145:617-25
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OTHER PREDISPOSING FACTORS FOR ROOT
RESORPTION
• A review of the published literature reveals numerous reports with positive
as well as negative associations of various factors predisposing a patient
to the resorption process evaluated the individual variation expressed in
patients.

• They reported that long, narrow, and deviated roots increased the risk of
resorption.

• Some reports describe a positive correlation between various habits, eg,

lip/ tongue dysfunction with a history of thumb sucking and nail biting

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Tekale P &Vakil K. Orthodontics and root resorption: A review. Europ J Ortho:2015;vol 2(2) pp-589-595.
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• The correction of impacted maxillary canines was identified as a risk factor

for root resorption.

• This might be a result of the ectopic eruption path through which the
orthodontist moves the teeth or intrusive forces compressing the
periodontal ligament of incisors while acting as anchorage.

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• Drugs such as corticosteroids and alcohol (through

vitamin D hydroxylation in the liver) have been
identified as predisposing factors.

• An increased risk for root resorption among asthmatic

patients was reported (McNab et al 1999. AJO DO).

• Asthma  imbalance between T helper 1 and T helper 2

lymphocytes, the latter responsible for the pulmonary
synthesis and release of inflammatory mediators, such
as interleukins 4, 5, 6, 10 and 13.

• They did a tooth-specific analysis and found a higher

incidence of resorption for the roots of maxillary molars.
McNab S, Battistutta D, Taverne A, Symons AL. External apical root resorption of posterior teeth in asthmatics5454
after
orthodontic treatment. Am J Orthod Dentofacial Orthop. 1999 Nov;116(5):545-51.
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METHODS title style
OF ASSESSMENT

• Quantitative as well as
qualitative analyses of the
resorption process are
required to prevent the
occurrence of the most
common iatrogenic damage
following orthodontic tooth
movement

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Click to editMETHODS
VARIOUS Master title style

Radiographic Biologic
Clinical al Histological marker
s

Radiographs remain the most important tool for evaluation of

pretreatment, in progress, and post treatment status of tooth
roots.
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• Radiology offers a variety of choices—
periapicals, panoramic, and digital
radiographs, as well as lateral cephalograms
and the type chosen depends on the specific
tooth location.

• Sameshima and Asgarifar (2002) compared

periapical and panoramic films for
pretreatment analysis of root shape and
posttreatment assessment of apical root
resorption.

• They recommended periapical films, for

patients at high risk for root resorption and
bone loss.

• They also found that root abnormalities were 57

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Sameshima, G.T. and Asgarifar, K.O. (2002) Assessmeeent of Root Resorption and Root Shape: Periapical vs
clearer in periapical films.
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• Armstrong D, Kharbanda OP, Petocz P, Darendeliler MA (2003)

did a study to determine if apical root resorption is related to the type of
appliance used and/or the direction and amount of tooth movement.

• The pre and post-treatment tooth lengths of the maxillary and

mandibular first molars and incisors were measured on panoramic
radiographs of 114 subjects with pre- and post-treatment cephalometric
radiographs.

• Within the groups four teeth decreased significantly in length when the
pre-adjusted appliance was used and four teeth when the Speed
appliance was. Only one tooth was shorter when the Tip-Edge appliance
was used.

• Lower incisors were significantly shorter post treatment if the apices

were moved close to the lingual cortex. 58
58
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 They reported that when panoramic radiographs are used to assess

treatment-induced changes in the lengths of the incisors, apical resorption
is only one factor that should be considered.

 The images of lower incisors proclined during treatment may be

foreshortened and/or the apices may lie outside the focal plane: both may
result in 'shorter' teeth post-treatment.

 Because of the confounding factors panoramic radiographs may not be a

reliable method of determining apical root resorption.

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 Click to edit Master title style

• (Crown A X Root B) / (Root A X Crown B) = Root

B/Root A

• in which "crown" is the distance from the incisive

edge to the cementoenamel junction, "root“ is
the distance from the CEJ to the root apex,

• A and B are two examinations, such as

pretreatment and posttreatment.

Dermaut LR, De Munck A. Apical root resorption of upper incisors caused by intrusive tooth movement: a radiographic
61
study. Am J Orthod Dentofacial Orthop. 1986 Oct;90(4):321-6. doi: 10.1016/0889-5406(86)90088-0. PMID: 3464193.
61
 Click
The to edit Master
grading title
criteria of style
Sharpe et al and scoring
criteria of Levander and Malmgren are the most
commonly used.
Root resorption index for quantitative
assessment of root resorption:
1. Irregular root contour.
2. Root resorption apically, amounting to
less than 2 mm. of the original root
length
3. Root resorption apically, amounting to
from 2 mm. to one third of the original
root length.
4. Root resorption exceeding one third of
the original root length.
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Levander E, Malmgren O, Stenback K. Apical root resorption during orthodontic treatment of patients with multiple
62

aplasia: a study of maxillary incisors. Eur J Orthod. 1998 Aug;20(4):427-34. doi: 10.1093/ejo/20.4.427. PMID:
Beck B, Harris [Link] 1994
Click to edit Master title style
• Grade 0 - no root resorption;
• Grade 1 - mild resorption, root with normal length and irregular contour only
• Grade 2 - moderate resorption with small area of root loss and apex
exhibiting almost straight contour;
• Grade 3 - accentuated resorption with loss of almost one third of root length;
• Grade 4 - extreme resorption with loss of more than one third of root length.

63
63
Beck BW, Harris EF. Apical root resorption in orthodontically treated subjects: analysis of edgewise and light wire
Click to edit Master title style

• Because of the high degree of

reproducibility, some authors have used
lateral cephalograms for assessment of
resorption.

• The main problem with this method is that

it can be used only for evaluation of
damage to the incisors, and the problems
of posterior teeth will not be evident.
64
64
Click to edit
Recent Master
imaging title style
system

• Levander et al and Westphalen et al.(2007) through independent

research conducted studies on diagnostic utility of digital images and
reported that the sensitivity of these radiographs was comparable or better
than the conventional film-based radiographs.

65
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• In addition, digital images offer immediate visualization and a reduction in
radiation exposure to patients.
• The use of computerized tomography for evaluation of resorption and its
sensitivity in site-specific (mesial, distal, buccal, or lingual) detection of the
process has been reviewed recently (Brezniak N,AO 2002)
• The main drawbacks for this excellent innovative technology are its cost and
the need for special equipment.

66
66
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• The physical properties of cementum in root-
resorbed teeth, including its mineral composition,
have been evaluated.

• This is possible with the use of ultra-micro

indentation systems to determine the hardness and
elasticity of human cementum.

• The results of these studies were found to be very

encouraging, as they made it possible to quantify
cementum at different sites.

• This method might also help in identifying the exact

amount of damage produced by mechanotherapy.

67
67
Malek S, Darendeliler MA, Swain MV. –Physical properties of root cementum: A new method for 3-dimensional
evaluation. Am J Orthod Dento­facial Orthop 2001 Aug; 120(2): 198-208
 Click to edit markers
Biological Master title style

• Mah and Prasad (E JO 2004) discovered biologic markers for root

resorption in crevicular fluid.

• In this study, the measured dentin sialophosphoproteins; levels of them

were high in gingival crevicular fluid that was in proximity to resorbing
primary and permanent tooth roots.

• In control areas without root resorption, they observed low levels of

these proteins. This research has provided us with a simple and
practical method for predicting initiation of the process.

68
68
Mah J, Prasad N. Dentine phosphoproteins in gingival crevicular fluid during root [Link] J Orthod 2004;26:25-
Click to edit Master title style

• Balducci L, Ramachandran A, Hao J, Narayanan K, Evans C, George A

(Arch Oral Biol. 2007 ) did a study to identify and quantify extracellular matrix
proteins, dentin matrix protein1 (DMP1), dentin phosphophoryn (PP), and
dentin sialoprotein (DSP) in the gingival crevicular fluid (GCF) of subjects
undergoing orthodontic treatment

• Results - significant difference in the concentrations of DMP1, PP and DSP

between control and root resorption groups.

• They reported that DSP and PP could be suitable biological markers for
monitoring root resorption during orthodontic treatment, since a significant
difference in the level of these dentin specific proteins is detected in all
groups
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Balducci L, Ramachandran A, Hao J, Narayanan K, Evans C, George A. Biological markers for evaluation of root
69

resorption. Arch Oral Biol. 2007 Mar;52(3):203-8. doi: 10.1016/[Link].2006.08.018.

 Click to edit Master title style

• 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

Mithun K , Harshitha V , AshithM , Naveen Kumar and , Anil [Link] Resorption in Orthodontics: A Recent Update.
70
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Indian Journal of Public Health Research & Development. October-December 2017;8, ( 4):307-312.
 Click to edit Master
Elisa combined withtitle style
electrochemistry

• The electrochemical results extended the lower end of detection from

5 mg per milliliter (by spectrophotometry) to 0.5 mg per millilitre thus
it is a reliable and sensitive method to detect dentine
sialophosphoprotein in gingival crevicular fluid

Mithun K , Harshitha V , AshithM , Naveen Kumar and , Anil [Link] Resorption in Orthodontics: A Recent Update.
71
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Indian Journal of Public Health Research & Development. October-December 2017;8, ( 4):307-312.
ClickRole
to edit Master
of drugs title style
in decreasing root
resorption

• The role of bisphosphonates, which produced a dose-dependent

reduction in root resorption when tested on rats

• Alatli et al 1996 recently challenged this hypothesis, stating that bis­

phosphonates induced cementum surface alteration, inhibited
formation of acellular cementum, and delayed formation of cellular
cementum, thereby actually increasing the vulnerability of the tooth
root to the resorptive process.

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• Villa et al (2005) has evaluated the effect of a nonsteroidal anti-

inflammatory drug (NSAID), nabumetone, on tooth roots and found it to
reduce root resorption, as well as pain caused by intrusive orthodontic force,
without affecting tooth movement.

• Jerome J et al 2005 did a study to determine if COX-2 inhibitors like Celebrex

are effective in protecting root resorption associated with orthodontic forces

• Administration of COX-2 inhibitors like Celebrex during the application of

orthodontic forces does not interfere with tooth movement and appears to
offer some slight protection against root resorption.
Villa, P. A. et al. (2005) „Pulp-dentine complex changes and root resorption during intrusive orthodontic tooth
movement in patients prescribed nabumetone‟, Journal of Endodontics, 31(1), pp. 61–66. doi:
10.1097/[Link].0000134212.20525.74. 73
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Jerome J, Brunson T, Takeoka G, Foster C, Moon HB, Grageda E, Zeichner-David M. Celebrex offers a small protection
 Click to edit Master title style

• Ali Reza Sekhavat et al (2011)reported that oral administration of

misoprostol, a prostaglandin E1 analog can be used to enhance orthodontic
tooth movement with minimal root resorption.

• Some drugs such as Lithium chloride can attenuate orthodontically induce

root resorption during orthodontic tooth movement and its effect on tooth
movement is insignificant.

• 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.

Mithun K , Harshitha V , AshithM , Naveen Kumar and , Anil [Link] Resorption in Orthodontics: A Recent Update.
74
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Indian Journal of Public Health Research & Development. October-December 2017;8, ( 4):307-312.
 Click to edit
Effect Master title
of systemic style
fluoride

• Matthew Foo, Alan Jones, and M. Ali Darendeliler ( AJO 2007) did a study to
test the effect of systemic fluoride intake on root resorption in rats .

• They concluded that fluoride reduced the size of resorption craters but the
effect is variable and is not statistically significant

Foo M Jones A and Darendeliler M. Physical properties of root cementum: Part 9. Effect of systemic fluoride intake
75 on
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root resorption in rats. Am J Orthod Dentofacial Orthop 2007;131:34-43
Click
Roletoof
edit Master title
hormones style
and cytokines

• The effect of hormones and cytokines in reducing resorption has been

evaluated. The main hormone attributed to this was L-thyroxine

• It is assumed that it increases the resistance of cementum and dentin

elastic activity.

• Shirazi et al 1999 confirmed this recently through administration of

increased doses of L-thyroxine, which produced less root resorption.

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 Click to edit Master title style

• The major cytokine evaluated for correlation with the resorptive process was
prostaglandin E2.

• While two studies confirmed its role in the process,(Williams S. et al Brudvik

P et al )a evaluation demonstrated no effect for this cytokine on either the
depth or the number of resorption lacunae found in resorbed tooth roots.

Williams S. A histomorphometric study of orthodontically induced root resorption. The European Journal of
Orthodontics. 1984 Jan 1;6(1):35-47.
Brudvik P, Rygh P. The initial phase of orthodontic root resorption incident to local compression of the periodontal
77
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ligament. The European Journal of Orthodontics. 1993 Aug 1;15(4):249-63.
 Click to edit Master title style

• A report by Bialy et al (AJO 2004) evaluated the effect of low-intensity

pulsed ultrasound (LIPUS) on the healing process of orthodontically induced
root resorption in humans.

• They found a significant decrease in areas of resorption and number of

resorption lacunae in LIPUS exposed premolars.

• The result of this study is encouraging, as it demonstrates a non-invasive

method to reduce root resorption in humans.

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Repair of orthodontically induced root resorption by ultrasound in humans El-Bialy, Tarek et al. American Journal
78 of

Orthodontics and Dentofacial Orthopedics, Volume 126, Issue 2, 186 - 193

 Click to edit Master title style
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.

Mithun K , Harshitha V , AshithM , Naveen Kumar and , Anil [Link] Resorption in Orthodontics: A Recent Update.
Indian Journal of Public Health Research & Development. October-December 2017;8, ( 4):307-312. 7979
Click to edit
LONG-TERM MasterOFtitle
EVALUATION style TOOTH ROOTS:
RESORBED
IS IT A CONTINUOUS PROCESS?

• The literature supports the view that there is no apparent increase in

resorption after termination of active orthodontic treatment.

• Some amount of repair is found to occur, including smoothing and

remodeling of the cemental surface as well as the return of a normal
periodontal membrane width.

• The original root contours and length are never re-established, but the
function of the tooth apparatus is not severely affected.

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• The main problem cited for these teeth on a long-term basis is their reduced
suitability as abutments for prosthetic replacements, because of their less
favorable crown/root ratio.

• Teeth will be less resistant to trauma and even marginal periodontitis can
make their prognosis critical.

81
81
Click to edit Master
GENETICS title style IS
AND RESORPTION:
THERE A LINK?
 A landmark study by Harris et al in 1997 provided us with statistically
significant data exhibiting a heritable component for root resorption. It
revealed how a person may be innately susceptible to the process.

 The effect of gene mutation on root resorption is expressed when the

masticatory apparatus is stressed by orthodontic treatment.

 However, the researchers were not able to describe the biochemical

events regulated by the genotype to express the resorption potential.

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• Al-Qawasmi et al conducted breakthrough research in this regard with the help of

DNA isolation and analysis from buccal swab cells.

• They found - linkage disequilibrium of interleukin-lB polymorphism in allele 1 and

external apical root resorption.

• Persons homozygous for the IL-1B allele1 have a 5.6 fold increased risk of external
root resorption greater than 2 mm as compared with those who are not
homozygous for the IL-1B allele1

• The observed low production of IL-1B in allele 1 could result in less catabolic bone
modeling at the cortical bone interface.

83
Al-Qawasmi RA, et al. Genetic predisposition to external apical root resorption. Am J Orthod Dentofacial Orthop
83

[Link]-252.
Click to edit Master title style

MANAGEMENT OF ROOT
RESORPTION

PRE TREATMENT DURING TREATMENT AFTER TREATMENT

85
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BEFORE TREATMENT

 General considerations. The patient/parents must be informed about

the risk of OIIRR as a consequence of orthodontic treatment. The rule
of thumb is better to inform early than to later apologize.

 Familial considerations. A recent study has confirmed previous results

concerning the strong familial association of OIIRR. When treating a
new patient whose close sibling was previously treated, orthodontists
should try to obtain the final diagnostic records including the
radiographs of any treated siblings.

Mithun K .Root Resorption in Orthodontics: A Recent Update. Indian Journal of Public Health Research
86
86 &
Development. 2017;8(4):307-312.
Click to edit Master title style

• General health. The systemic condition of the

patient should be carefully considered.

• It was recently reported that patients with chronic

asthma, both medicated or non medicated, have
an increased incidence of OIIRR that is confined to
a slight blunting of the maxillary molars.

• This finding might result from the close proximity

of the roots to the inflamed maxillary sinus and/or
the presence of inflammatory mediators in these
patients.

87
87
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• The dentition Orthodontic treatment does not stop root

development.

• Teeth with incomplete root formation at the onset of orthodontic

treatment continue to develop roots during treatment, but the
roots reach somewhat less than their expected root length
potential.

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88
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• Gender and age: Most studies have not found a consistent

association between gender and OIIRR.

• Parameters that should be evaluated from radiographs include:

root morphology

endodontic treatment

 bone morphology

 ectopic, and transplanted teeth.

89
89
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When a patient has

transplanted teeth, With regard to the risk
orthodontists are of OIIRR, full assimilated
advised to wait at least transplanted teeth react
three months after to orthodontic force in a
transplantation before way comparable to that
exerting force on the of normal teeth.
teeth.

90
90
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• No orthodontic force can imitate the natural harmless physiologic force.

Although no difference in OIIRR has been found at low and high force
levels (50 g to 200 g),

• It is still recommended not to overload the teeth with high force levels.

• High levels of force will tend to increase the damaged areas in the
periodontal ligament, which may lead to more extensive OIIRR.

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During treatment
• The new light-force rectangular wires that are used in
treatment as initial wires have become very popular in
the last decade.

• But use of these wires might increase the jiggling

movements during the first stage of treatment,
exposing the root to more OIIRR.

• Therefore it is suggested proceeding with this initial

step with caution, until more definitive data are
published. 92
92
Click

to edit Master title style
After 6-12 months of treatment, periapical
radiographs of the teeth involved in this
treatment should be obtained in order to
detect the occurrence of OIRR early.

 Since, in most published data, the incisors

are the teeth that tend to be most affected,
the changes in their root shape might project
on the overall phenomenon.

 When OIIRR is detected in the six-month

periapical radiograph, treatment should be
halted for two to three months with passive
archwires.

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• Halting treatment for three months in one arch while working on the other
is a practical solution that can be implemented without changing the
treatment protocol

• When the treatment is durable, periapical radiographs should be obtained,

with the following consideration.

• When minimal OIIRR is present, the aforementioned procedure is sufficient

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However, when severe resorption is identified, the treatment goals should be

reassessed with the patient; for example, alternative options might include
prosthetic solutions to close spaces,

releasing teeth from active arches if

possible,

stripping instead of extracting,

early fixation of resorbed teeth.

Orthognathic surgery can also be

considered in extreme cases, yet it
cannot be relied on to prevent OIIRR.

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95
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Pausetoduring
edit Master title style
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 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)

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After edit Master title style

• Final records including radiographs are recommended and are even

mandatory.

• If OIIRR is present on the final radiographs, the patient/parents should be

informed.
• Final records and radiographs will be useful for the future orthodontic
treatment of siblings.

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• If severe OIRR is present on the final radiographs, follow-up radiographic
examinations are recommended until OIRR is no longer evident.

• Cemental repair or termination of the active processes of OIRR occurs naturally

after the appliance removal. If it does not occur, sequential root canal therapy
with calcium hydroxide may be considered.

• Gutta-percha filling is the definitive therapy only after root resorption ceases

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Conclusion

• OIIRR is an iatrogenic consequence of orthodontic treatment.

• Keeping this in mind, orthodontists should take all known measures to

reduce its occurrence.

• Although several protective procedures have been suggested, none of

them can actually prevent OIIRR with any degree of certainty.

• An individual's genetic background is the single strongest predictor of

resorption, as shown by familial analysis.

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 REFERENCES:
Click to edit Master title style
• Brezniak N, Wasserstein A.-- Orthodontically induced inflammatory root resorption. Part I:
The basic science aspects. Angle Orthod 2002;72:175-9.
• Brezniak N, Wasserstein A.-- Orthodontically induced inflammatory root resorption. Part
II: The clinical aspects. Angle Orthod 2002; 72:180-184.
• Janson GRP, De Luca Canto GDL, et al.-- A radiographic comparison of apical root
resorption after orthodontic treatment with 3 different fixed appliance techniques: Am J
Orthod Dentofacial Orthop [Link]-273.
• Sameshima GT, Sinclair PM . Predicting and preventing root resorption—Part II—
Treatment factors. Am J Orthod Dentofacial Orthop 2001;119: 511-515.
• Maltha JC, Dijkman GEHM. –Discontinuous forces cause less extensive root resorption
than continuous forces. Eur J Orthod 1996;
18:420-425.
• Levander E, Malmgren 0. Evaluation of the risk of root resorption during orthodontic
treatment-A study of upper incisors. Eur J Orthod [Link]-38
• Mirabella A, Artun J.- Risk factors for apical root resorption of maxillary anterior teeth in
adult orthodontic patients. Am J Orthod Dentofacial Orthop [Link]-55 10
101
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• Remington DN, Joondeph D, et al- Long-term evaluation of root resorption occurring
during orthodontic treatment. Am J Orthod Dentofacial Orthop 1989;96:43-46.
• Linge L, Linge BO. -Patient characteristics and treatment variables associated with
apical root resorption during orthodontic treatment. Am J Orthod Dentofacial Orthop
[Link]-43.
• Remington DN, Joondeph D, et al- Long-term evaluation of root resorption occurring
during orthodontic treatment. Am J Orthod Dentofacial Orthop 1989;96:43-46.
• Al-Qawasmi RA, et al.-- Genetic predisposition to external apical root resorption. Am J
Orthod Dentofacial Orthop [Link]-252.
• Lee RY, Artun J, Alonzo TA.-- Are dental anomalies risk factors for apical root resorption
in orthodontic patients? Am J Orthod Dentofacial Orthop [Link]-195
• Sameshima GT, Asgarifar KO. Assessment of root resorption and root shape-Periapicals
vs. panoramic films. Angle Orthod 2001;71:185-189.
• MalekS, Darendeliler MA, Swain MV. –Physical properties of root cementum: A new
method for 3-dimensional evaluation. Am J Orthod Dento­facial Orthop 2001 Aug;
120(2): 198-208 10
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• Mah J, Prasad N. Dentine phosphoproteins in gingival crevicular fluid during root
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Thank You

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