Root Resorption:

What we know and how it Root resorption

affects our clinical practice.  a physiologic or pathologic process
occurring as a result of changes seen
in the tooth or surrounding
periradicular tissues
AAO 2015 Annual Session
May 19th 2015  characterized by loss of tooth
structure over the root surface

Dr. Belinda Weltman HBSc, MS, DMD, BDent, MSc, FRCD(C)

Type Location
 Physiologic root resorption:  Internal
occurring on deciduous
teeth during eruption of
permanent teeth

 Pathologic: occurring on permanent  External

roots

External Root resorption Trauma/pulp space infection

1) Trauma/pulp space infection

2)Ectopic teeth
Pressure from tumors / cysts

3) Orthodontic treatment Pulpal infection:

Radiolucencies in bone
Radiolucencies in bone
And root resorption

1
 Ectopic Canine Pressure from tumors
A) Buccally impacted canine

B) Resolution of canine impaction

C) Deband

D) 5-8yrs post treatment

Source: American Journal of Orthodontics and Dentofacial Orthopedics 2005; 127:650-654 (DOI:10.1016/j.ajodo.2004.03.031 )
Copyright © 2005 American Association of Orthodontists Terms and Conditions

Orthodontically Induced Inflammatory Root

Resorption (OIIRR) OIIRR

Pre-Treatment

Maxillary incisors
are most commonly
affected

Post-Treatment

How do orthodontic treatment

OIIRR factors influence root resorption?

Orthodontically induced
inflammatory root resorption
(OIIRR)
 External Apical Root Resorption (EARR )

 Cervical Root resorption

 Root resorption (RR): microscopic areas of

resorption lacunae visualized with histological techniques
(Hartsfield et al. 2004)

2
 Orthodontic
force
Three types OIIRR

Hylinization and Activation of 1) Surface resorption:

inflammation osteoclasts
Compression of
the PDL
Only the outer cemental layers are resorbed,
and later fully regenerated/ remodeled when
the etiologic factor is removed.
Removal of Removal of
superficial surface hyaline
or cementum material

Root
resorption

Three types OIIRR Three types OIIRR

2) Deep resorption: 3) Circumferential apical root
The cementum and the outer resorption:
layers of the dentin are resorbed and Tridimensional resorption of the hard
usually repaired with cementum tissue components of the root apex occurs,
material. and root shortening is evident.
When the root looses apical material
The final shape of the root may
beneath the cementum, no regeneration is
or may not be identical to the original possible and the resorption is irreversible.
form.

Methods of identifying root

Why investigate OIIRR? resorption
 Root resorption is undesirable because it  Human and animal studies
can affect the long-term viability of the  Histological (SEM, Light microscope)
dentition.
 Radiographic (Pan, Ceph, Periapical)
 Unfavorable crown:root ratio
 3mm apical loss = 1mm crestal bone loss  Volumetric (Micro-CT, Cone Beam)

* *
 It is important to elucidate which * *
orthodontic treatment factors contribute to
root resorption so that the detrimental
effects can be minimized.

3
Histological illustration: varying SEM – varying severity of RR in
degrees of repair in OIIRR intruded teeth
A) Normal root surface

B) Undermined RR – no repair
Minor RR
C) Partial repair with acellular
cementum (AC)

D) Partial repair with cellular

cementum (CC)

E) Total repair with CC – root Severe RR

contour has been altered

F) Total repair with AC – root

contour was re-established (Owman-Moll, P.
(1995b) (Han G, et al. 2005)

Panoramic radiograph - initial Panoramic radiograph - progress

Cone Beam - CT
Root Resorption Severity

No RR mild moderate severe extreme

Source: American Journal of Orthodontics and Dentofacial Orthopedics 2010; 137:384-388 (DOI:10.1016/j.ajodo.2008.04.024 ) Source: American Journal of Orthodontics and Dentofacial Orthopedics 2009; 135:434-437 (DOI:10.1016/j.ajodo.2008.10.014 )
Copyright © 2010 American Association of Orthodontists Terms and Conditions Copyright © 2009 American Association of Orthodontists Terms and Conditions

4
 Periapical X-rays

Panoramic X-ray Deband

Deband

Consolaro A, Furquim LZ. Extreme root resorption associated with induced tooth movement: A protocol for clinical management. Dental Press J
Orthod. 2014 Sept-Oct;19(5):19-26.

5
 Mean absorbed doses (μGy) to
various tissues for each unit
American Academy of Oral and
NewTom 9000 i-CAT
Panoramic/lateral
cephalometric
Multi-slice CT
Maxillofacial Radiology
Bone marrow
Third cervical vertebra 648.9 731.3 62.8 7525.6 Position statement guidelines for CBCT use in
Mandibular ramus 1244.7 1282.9 360.4 9930.4
orthodontic practice (2013):
Brain
Hypophysis 316.1 745.0 30.2 1488.9
1. Image appropriately according to clinical condition
Eye
Lens 472.8 1229.2 45.8 892.8 2. Assess the radiation dose risk
Thyroid gland 3. Minimize patient radiation exposure
Thyroid 232.4 124.3 13.1 1417.7
4. Maintain professional competency in performing
Salivary glands and interpreting CBCT studies
Submandibular 1426.7 1364.1 566.8 11815.0
Parotid 1678.7 1502.2 324.4 14204.4

Skin
Thyroid 663.8 157.5 25.9 1889.0
Neck (back) 1257.1 651.1 270.8 15837.2
ALARA principle
Philtrum 3273.6 1434.9 25.3 12791.8 as low as reasonably achievable (Mountford & Temperton 1992)
Parotid 1489.4 1510.9 608.7 14734.4
Nasion 451.2 1060.9 19.9 1008.2
Silva 2008

Biological Markers to detect Incidence/Prevalence of EARR and

OIIRR? Orthodontic Treatment

 Dentin sialophosphoprotein (DPP) was  Histological studies: 90% prevalence of RR in

orthodontically treated teeth
higher in proximity to resorbing primary (Stenvik A 1970, Harry MR 1982).

and permanent tooth roots (Mah 2004)  Radiographic studies: report an incidence of
EARR before treatment as 15% and after
treatment as 73% (Lupi JE 1996).
 ELISA combined with electrochemistry is  EARR defined as greater than 4mm or 1/3 of
a reliable and sensitive method to detect the root length (severe): Incidence is reduced
DPP in gingival crevicular fluid (Sha 2014) to 0.5-5% in the post orthodontic treatment
group (Linge 1983, Levander 1988, Levander 1998; Lupi 1996;
Taithongchai 1996; Janson 1999; McNab 1999; Kiliany 2002; Sehr 2011).

6
 Systemic Risk Factors for Orthodontically
Induced Inflammatory Root Resorption
Etiology of OIIRR
Likely Risk Factors Unclear Risk Unlikely Risk
Relationship Factors
 The etiological factors are complex History of previous Root
Nabumetone
(Likely Protective)
and multifactorial, resulting from a Resorption
Bisphosphonates
Paracetamol
(acetaminophen)
combination of: Previous trauma resulting in
Root Resorption
Hormone deficiency Tooth/Root morphology
Previous trauma without
Genetics Asthma
Root Resorption
 individual biological variability and TNFRSF11A gene*
Chronic alcoholism
Endodontic treatment

Root proximity to cortical

Age
bone
 the effect of mechanical factors Severity/type of
Gender
malocclusion
IL-1β allele 1
Alveolar bone density

*Other factors to be identified but evidence supports

a link between genetics and OIIRR, estimated to be over 50%.

Reviewing the data on Root

Orthodontic Risk Factors for OIRR resorption
Meta analysis -
 Treatment Duration Systematic Review

 Magnitude of Force – Heavy/Light Randomized

controlled tirals

 Direction of tooth movement Experimental designs

 Amount of Apical displacement
 Method of force application Cohort control studies

 Continuous vs. Intermittent force Case-Control Studies

 Appliance Type
 Treatment technique (Bracket prescription, Case series/ Case reports
self-ligating, archwire sequence etc…)
Personal Communication

Materials and Methods Null Hypothesis

Structured question using PICO format

1) There is no difference in the incidence and
severity of root resorption between patients,
 Population: patients with no history of root with no history of RR, undergoing
resorption comprehensive orthodontic treatment and an
 Intervention: comprehensive orthodontics untreated group.
 Control/comparison: people who have not 2) There is no difference in the incidence and
had orthodontics / teeth that were not moved severity of root resorption between patients,
orthodontically with no history of RR, undergoing
comprehensive orthodontic treatment who
 Outcome: external root resorption
receive tooth movement with different
techniques.

7
 Inclusion and Exclusion Criteria Databases of published trials included in
the systematic review (14)
 Inclusion:  Cochrane Cental Register of Controlled Trials
• Randomized controlled trials (RCTs), (CENTRAL) AND Database of Systematic
published or unpublished, that evaluated Reviews
root length before and after treatment in
Human subjects.  MEDLINE
• Patients of any age, gender or ethnicity  PubMed
who underwent comprehensive  EMBASE
orthodontic treatment with full fixed
appliances.
 Web of Science
 Exclusion:  EBM Reviews (DARE)
• Animal studies, studies including auto-  Computer Retrieval of Information on Scientific
transplanted teeth, and duplicate Project
publications.  LILACS, PAHO, BBO, WHOLis, CEPS, etc…

Databases of Unpublished literature Additional search methods

included in the systematic review (7)

 Databases of Dissertations and Conference  Requests were sent to relevant

proceedings: professional organizations in an attempt
 Conference Materials, CENTRAL, ProQuest to identify unpublished or ongoing
Dissertation Abstracts and Thesis database studies.
 Databases of research registers:  Hand searching of relevant journals
 TrialCentral, National Research Register (UK),  Searching through reference lists of
www.Clinicaltrials.gov
relevant articles
 Grey Literature:
 SIGLE

Search Strategy (October 2008)

Major Quality Criteria of included
studies
The search strategy developed for MEDLINE via OVID is displayed
below. (MeSH terms: in UPPER CASE. Free text terms: in lower case) A. Method of randomization
#1 ORTHODONTIC*: ME B. Allocation concealment
#2 "braces"
#3 (#1 or #2) C. Blinding of outcome assessors
#4 ROOT RESORPTION*: ME
D. Completeness to follow-up
#5 "external apical root resorption"
#6 "root erosion"
#7 "root blunting"
#8 "root shortening"
A,C,D adequate = Low risk of bias
#9 "tooth-root resorption" 2 criteria adequate= Moderate risk of bias
#10 "orthodontically induced inflammatory root resorption"
#11 (#4 or #5 or #6 or #7 or #8 or #9 or #10) <2 adequate = High risk of bias
#12 (#3 and #11)
#13 HUMAN*: ME
#14 (#12 and #13)

8
Minor Quality Criteria of included Results
studies
 Of the 921 studies found in this field only
11 trials were considered appropriate for
A. Baseline similarities of the groups inclusion in this review.
B. Reporting of eligibility criteria
C. Measure of variability of primary
outcome
D. Sample size calculation
 Protocols were too variable to proceed with
meta-analysis (quantitative evaluation).

Screening of titles and abstracts from all

sources (n= 921)

Excluded citations
Not relevant (n=777 )
Quality Assessment
Potentially relevant trials retrieved for
more detailed, full report, evaluation (n=
144)
Excluded Trials (Appendix Table 1)
with reasons (n=128)
Unable to locate (n=2)
Potentially appropriate RCTs to be
included in the meta-analysis, evaluated
for methodological quality (n=14)

RCTs excluded from meta-analysis (n=1)

1 publication with no direct RR evaluation
Chutimanutskul et al. (2006)

RCTs considered potentially appropriate

to be included in the meta-analysis
13 publications of 11 trials

Meta-analysis not possible due to

differences in RCT methodologies and
reporting. The Kappa scores and percentage agreements between the two raters (BW & KV)
The QUOROM statement flow diagram of the citations retrieved by assessing the major methodological quality of the studies were: randomization 1.0,
reviewing titles and abstracts, and trials that were evaluated in full text. 100%; concealment 0.72, 82%; blinding 0.91, 95%; and withdrawals 1.0, 100%.

Comparison of the Split-Mouth Comparison of the Split-Mouth

Studies Studies

 6 of the 11 studies were Split-Mouth 1) Heavy force application produced significantly

 Limited validity more root resorption that light force application
 Small sample sizes or control (Chan 2004; Chan 2006; Harris 2006; Barbagallo
 Premolars 2008).
 Moderate risk of bias
2) Weak evidence: continuous force produced
 Exception: Han 2005 - Low risk of bias
significantly more root resorption than
Acar 1999 – High risk of bias
interrupted force application (Acar 1999).
 None of the studies lasted longer than 9 weeks.
 Orthodontic force applied to teeth over a short
period can produce resorption lacunae in the
absence of EARR (Kvam 1972).

9
Comparison of the Split-Mouth Comparison of the comprehensive
Studies orthodontic treatment RCTs

3) Limited evidence that both light forces and  Four of these studies were judged to be of high quality and
have a low risk of bias (Brin 2003, Mandall 2006, Reukers 1998,
forces from thermoplastic appliances result in Scott 2008).
similar root resorption, both significantly more  One was judged to have a moderate risk of bias (Levander
1994).
than seen in controls (Barbagallo 2008)
5) Straightwire vs. standard edgewise techniques resulted in
no statistically significant differences in the amount of
4) Both studies examining intrusive force tooth loss or prevalence of root resorption (Reukers 1998).
application found significantly increased RR
rates to controls (Harris 2006, Han 2005). 6) Mandibular incisor root resorption did not differ between
 Root resorption from extrusive force was not self-ligating and conventional systems (Scott 2008).
significantly different than control (Han 2005)

Comparison of the comprehensive Comparison of the comprehensive

orthodontic treatment RCTs orthodontic treatment RCTs

7) No statistically significant difference was found 9) Teeth/roots having unusual morphology before
in the amount of RR between archwire treatment had no significant differences in the
sequences for upper left central incisors. amount of RR (Brin 2003).
 Also, no difference between the proportion of patients
with or without root resorption was seen (Mandall 2006). 10) No statistical significance between one-phase
8) Incisors with clinical signs or patient reports of and two-phase treatment groups when looking
trauma, but no signs of EARR, had the same at OIIRR prevalence or severity.
prevalence of moderate to severe OIIRR as  As treatment time increased, the odds of OIIRR
those without trauma (Brin 2003, Mandall 2006, Levander also increased.
1994).  The odds of a tooth experiencing severe root
resorption were greater if a large reduction of
overjet occurred during phase 2 (Brin 2003).

Comparison of the comprehensive

orthodontic treatment RCTs Discussion

11) For patients already in orthodontic treatment  Comprehensive orthodontic treatment causes
and experiencing root resorption, the total an increase in the incidence and severity of
amount of root resorption was significantly less root resorption
in patients given a 2-3 month treatment pause  Heavy forces are particularly harmful.
than those treated without any interruption  There is no evidence that OIIRR is affected by
(Levander 1994). archwire sequencing, bracket prescription, or
Levander - Amount of EARR by treatment group
self-ligation.
 There is little evidence that previous trauma
25
Number of teeth affected

20

15 Pause
(with no history of EARR) and unusual tooth
10
No Pause
morphology play a role in increased OIIRR.
5

0
0-0.5 0.51-1.49 1.50-2.49 >2.5
Amount of EARR (mm)

10
Implications for Clinical Practice
LIPUS?
 best practice is using light forces, especially when
engaging in intrusive movements.

 progress radiographs should be obtained 6-12  Low intensity pulsed ultrasound (Baily 2004)
months into treatment to detect OIIRR early.
 Decreased the number of resorption
 Once identified, a 2-3 month treatment pause with lacunae
passive archwires, will lead to a decrease in total  Decreased the area or resorption
root resorption by the end of treatment.

Non-invasive method to reduce OIIRR in

Humans

Management of EARR during Implications for Research

Orthodontic Treatment
 Continue with lighter forces / rest periods  More evidence is required to determine risk factors and
effective ways to decrease the severity and prevalence
 Revise treatment goals – shorten treatment of OIIRR.
duration  Parallel group studies, with appropriate randomization,
 Follow-up radiographs during and after allocation concealment and masking of outcome
orthodontic treatment assessment are needed.
 Standardized measurement techniques along with proper
 If termination of RR does not occur, sequential assessment blinding, error analysis and consensus
root canal therapy with calcium hydroxide may measures.
be considered  Assessment of patient centered outcomes
 Retaining the teeth with fixed appliances  Quality of life post treatment, and occurrence of further
should be done with caution since occlusal complications such as mobility, and tooth loss.
trauma of the fixed teeth or segments might  Genetic predisposition and systemic factors should also
be assessed.
lead to extreme EARR (Brezniak 2002b).

Long Term Prognosis Long Term Prognosis

 Root resorption associated with orthodontic treatment  extensive root resorption does not usually affect the
ceases with the termination of active treatment functional capacity or greatly compromise the
(Remington et al. 1989). longevity of the teeth.

 When post treatment root resorption does occur, It is  An average sized normally shaped maxillary central
likely associated with other factors, such as traumatic incisor that experienced no alveolar bone loss during
occlusion and active force-delivering retainers (Copeland orthodontic treatment, with a root shortened by 5mm
& Green 1989).
will still have 75% of its periodontal attachment
remaining (Kalkwarf et al. 1986).

11
1) Case Report: 18 months into orthodontic
Initial Radiographs treatment

Source: American Journal of Orthodontics and Dentofacial Orthopedics 2011; 139:S166-S169 (DOI:10.1016/j.ajodo.2009.05.032 ) Source: American Journal of Orthodontics and Dentofacial Orthopedics 2011; 139:S166-S169 (DOI:10.1016/j.ajodo.2009.05.032 )
Copyright © 2011 American Association of Orthodontists Terms and Conditions Copyright © 2011 American Association of Orthodontists Terms and Conditions

Deband 25 year follow-up

Source: American Journal of Orthodontics and Dentofacial Orthopedics 2011; 139:S166-S169 (DOI:10.1016/j.ajodo.2009.05.032 ) Source: American Journal of Orthodontics and Dentofacial Orthopedics 2011; 139:S166-S169 (DOI:10.1016/j.ajodo.2009.05.032 )
Copyright © 2011 American Association of Orthodontists Terms and Conditions Copyright © 2011 American Association of Orthodontists Terms and Conditions

2) 13 year follow-up 3) 15 year follow-up

12
Retrospective data Conclusions
 100 patients with severe resorption were  Increased incidence and severity of OIIRR is
recalled 14 years after orthodontic treatment: found in patients undergoing comprehensive
 no incidences of tooth loss orthodontic therapy.
 hypermobility in only 2 cases  Heavy force application produced significantly
(Remington et al. 1989). more OIIRR than light force application or
 Patients with severe root resorption (root control.
lengths 5.5-18.1mm), recalled 5-15 years after  Other trends from split mouth studies could
treatment: not be substantiated because of small subject
 no teeth had mobility scores greater than 1 on numbers and short treatment times.
Miller’s index (crown deviates within 1mm of normal)  Standard reporting methods of future clinical
 no teeth had been lost trials are recommended so data can be pooled
(Levander & Malmgren 2000). and stronger clinical recommendations made.

Orthodontic Treatment and OIIRR Thank-you!

 How will you discuss the risks of OIIRR with

your patients/parents before orthodontic tx.?
 Can you predict how much root resorption will
occur?
 What is the average amount of OIIRR to
expect with comprehensive orthodontic
treatment?
 Which teeth are most at risk?
 How can OIIRR be managed if it occurs
during orthodontic treatment?
 What is the prognosis of teeth with OIIRR?

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