ROOT RESORPTION

Contents
 Introduction
 History
 Histopathology of root resorption
 Types of root resorption
 Grading of root resorption
 Etiology of root resorption
 Diagnosis of root resorption
 Repair of root resorption
 Marker of root resorption
 Management
 Conclusion
Introduction
History
 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 resorption
CEMENTUM & ITS PROPERTIES
Non uniform mineralized connective tissue. Cementum is the least
mineralized and the mineral content of cementum is
approximately 65%
TYPES :
1. CELLULAR CEMENTUM :
a ) It is less mineralized
b ) It is deposited around the apical third of cementum
c) It is less calcified & so has a lower hardness & elastic
modulus
 2 . ACELLUR CEMENTUM :

a) It does not have any cellular components

b) It covers the coronal two thirds of the root

c) It consists of only mineralized layers & so has higher hardness

& elastic modulus
RESORPTION PROCESS

PHYSIOLOGICAL PROCESS
PATHOLOGICAL PROCESS

Why selective root resorption process occurs in deciduous

dentition & not in permanent teeth.
A possible role of ECM proteins was proposed to be the reason
(Adam Lee et al AJO 2004 )
 There are 2 ECM proteins, namely Sialoprotein (BSP)
& Osteopontin (OPN) present within PDL . They act as a signal
for odontoclasts activation & adhesion.

 In deciduous dentition they appear locally adjacent to root

surface

 But in permanent teeth roots BSP & OPN are expressed in

generalized pattern in PDL.
PATHOLOGICAL PROCESS
 Root resorption occurs when pressure on the cementum exceeds
its reparative capacity and dentin is exposed , allowing
multinucleated odontoclasts to degrade the root substance
 Orthodontically induced root resorption begins adjacent to

hyalinized zones and occurs during and after elimination of

hyaline tissue
Removal of hyalinized tissue leads to removal of cementoid and
mature collagen , leaving a raw cemental surface that is readily
attacked by dentinoclasts

Rygh and co-workers have shown that clast cells attack cementum
adjacent to hyalinized (necrotic) areas of the PDL when the PDL
area is repaired.
 However , forces are concentrated at the root apex because
orthodontic tooth movement is never entirely translatory , which
places the narrow periapical region in harm’s way.

 Rudolph noted that resorption usually attacks the root tip and
travels coronally making what has been termed a “shed roof “
effect to the root .
Apex is affected more than cervical or middle thirds of root
 Because forces given are concentrated on apex

 It is made of cellular cementum which is less mineralized & so

easiliy resorbed
 Also compression & decrease in the width of the PDL affects
the apex more than it affects the cervical or middle third.
 The role of exposed dentin

 Possible involvement of the pulp through the apices

 Multiple foramina and complicated surface anatomy

 Stresses on the neurovascular bundle exiting the pulp

Repair of the damaged root restores its original contours unless
the attack on the root surface produces large defects at the apex
that eventually become separated from the root surface
TYPES OF ROOT RESORPTION:
Two types :
 1. Internal root resorption ( IRR )
 2. External root resorption ( ERR )
INTERNAL ROOT RESOPTION :
It is an unusal form of resorption that begins centrally within the
tooth , apparently initiated by a inflammatory hyperplasia of
pulp. Though orthodontic tooth movement rarely causes IRR,
 Al Wehidi in 1989 reported 2 cases that aquired IRR after
orthodontic treatment.
EXTERNAL ROOT RESORPTION
ERR is divided into 3 types by Andreasen
1. Surface resorption
2. Inflammatory resorption
3. Replacement resorption.
Andreasen defines three external root resorption types:
 Surface resorption- self-limiting process, usually involving small
outlining areas followed by spontaneous repair from adjacent
parts of the PDL
 Inflammatory resorption-initial root resorption reached

dentinal tubules of an infected necrotic pulpal tissue or an

infected leukocyte zone
 Replacement resorption- bone replaces the resorbed tooth

material that leads to ankylosis.

According to Tronstad
 Transient inflammatory resorption

 Progressive inflammatory resorption

 Ankylosis
According to Tronstad, inflammatory resorption
 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.
Brezniak and Wasserstein
 Orthodontically induced inflammatory root resorption (OIIRR)
for external root resorption (ERR) that is caused by orthodontic
force.
Three degrees of severity of OIIRR:
 Cemental or surface resorption with remodeling-In this process,
only the outer cemental layers are resorbed, and they are
later fully regenerated or remodeled.
 Dentinal resorption with repair (deep resorption)- In this
process, the cementum and the outer layers of the dentin are
resorbed and usually repaired with cementum material.

 Circumferential apical root resorption- In this process, full

resorption of the hard tissue components of the root apex
occurs, and root shortening is evident.
 Classification of root resorption

ROOT
RESORPTION

EXTERNAL INTERNAL
RESORPTION RESORPTION

EXTERNAL INTERNAL
SURFACE INFLAMMATORY REPLACEMENT INTERNAL
RESORPTION ROOT ANKYLOSIS INFLAMMATORY REPLACEMENT
RESORPTION RESORPTIION
RESORPTION RESORPTION
SURFACE RESORPTION --Physiologic process of resorption and
repair that the root sustains during normal physiologic activity
(e.g., mastication).

EXTERNAL INFLAMMATORY ROOT RESORPTION includes any

resorption mediated by the inflammatory process and includes
resorption caused by orthodontic tooth movement and trauma,
among others.
Resorption that takes place at the root apex, is
termed external apical root resorption (EARR)
GRADING ERR (Edward F. Harris SeminOrthod 2000 )

 Grade 0 depicts normal, intact root morphology,

in which the apical outline is smooth and continuous.
Also, the distance between the root and the lamina
dura is uniform.

 Grade 1 shows evidence of erosion periapically,

but root length probably is not yet affected.
 Grade 2 shows scalloping and blunting of the apex

 Grade 3 occurs when at least one-fourth of the root

has been resorbed

 Grade 4 involves the loss of at least one-half the

original root length
Index for evaluating the degree of root resorption
 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. (Satu Apajalaht Eur J
orthod 2007)
Etiologic factors
Brezniak & Wasserstein AJO 1993 have given 2 major factors.
1. Biological factors.
2. Mechanical factors.
Individual’s genetic predisposition is generally accepted as the
primary cause of EARR
What genetic predisposition means to the clinician???
 In 1975 Newman reported family clustering of EARR

 In 1997 report of Harris et al, who explored the hypothesis

of genetic influence on EARR using the sib-pair model
reported high heritability
 Al-Qawasmi et al AJODO 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.
 Recently, several polymorphisms have been described in the
genes of the IL-1 cluster, studies show that these polymorphisms
have been associated with advanced adult periodontitis.

 The presence of IL-1 in the periodontal tissue during tooth

movement further implicates a role for these mediators in tissue
resorption.
 Increased levels of IL-1 have been found in both the gingival
crevicular fluids and the gingival tissues of patients undergoing
orthodontic tooth movement. IL-1 has been implicated in bone
resorption (catabolic modeling) accompanying tooth movement.
PROPOSED MODEL FOR PATHWAY THROUGH WHICH IL- 1B
MODULATES EXTENT OF ROOT RESORPTION(Riyad A. Al-
Qawasmi Am J Orthod Dentofacial Orthop 2003)

Model suggests that low IL-1 production

in case of allele 1 results in relatively
less catabolic bone modeling in cortical
bone interface of periodontal ligament
(PDL) because of decreased number of
osteoclasts associated with lower levels
of this cytokine. Inhibition of bone
resorption in direction of tooth
movement results in maintaining
prolonged dynamic loading of tooth
root adjacent to compressed PDL,
resulting in more root resorption because
of fatigue failure of root. In case of high
IL-1 production associated with allele 2,
compressed PDL space is restored by
resorption of bone interface of PDL,
resulting in only mild root resorption that
is controlled by cementum-healing
mechanism.
2 . RACIAL FACTOR
Asian patients were found to experience significantly less root
resorption than white or Hispanic patients. (Glenn T. Sameshima et
al in AJO 2001)
3 . AGE
a. Chronological age :
Though Bishara in AJO 1999 showed that no change in root
length between 25 to 45 yrs of age without orthodontic
treatment many authors say there is increase in RR with increase
in age.
 Loss of alveolar bone
Highest ratio of surface area for attachment occurs near CEJ.
Loss of crestal bone support leads to decrease in the bone area
available for force dissipation & so increase in RR.
 Diminished stability – Tooth mobility.
 Decrease cell turn over rate
 Due to wear & tear of the of the roots.
 Increase jiggling movements – Increase RR.

4 .DENTAL AGE
 In children before root completion there seem to be less RR
5 . 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.

6. GENDER
 No correlation between gender and root resorption.
According to other studies, females are more susceptible to
root resorption.
7.HABITS
 Nail-biting, tongue thrust associated with open bite, and
increased tongue pressure have been statistically related to
increased root resorption.

8. TOOTH FORM
 Deviated root form is more susceptible to postorthodontic root
resorption. The degree of root resorption in teeth with blunt- or
pipette-shaped roots was significantly higher than in teeth with
normal root form.
Higher risk for EARR
 Teeth with an odd root shape

Dilacerated roots, pointed roots, and pipette-shaped roots

(sameshima GT,Sinclair PM AJODO 2001)
 Teeth with a history of trauma

 Teeth with longer roots

9.TOOTH LENGTH
 A common belief is that short roots undergo more root
resorption. However Mirabella and Artun AJO 1995 suggest
that the tendency for resorption increases with increasing tooth
length.

 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
10. PREVIOUSLY TRAMATIZED TEETH
 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
11. ENDONTICALLY TREATED TEETH
 It has been suggested that endodontically treated teeth are
more resistant to root resorption by Mirabella and Artun AJO
1995.
12. SYSTEMIC FACTORS
 According to Becks, endocrine problems including
hypothyroidism, hypopituitarism, hyperpituitarism, and other
diseases are related to root
 Higher risk for EARR

Turner syndrome,
Familial dysostosis ,
Uncontrolled endocrine disturbance
Asthma.(Nishioka Angle Orthod 2006)
13 . INFLAMMATORY MEDIATORS :
Scott Mc Nab in AJO 1999 conducted his study in asthmatic
patients.
 They found out that the inflammatory mediators produced
outside the PDL influences cellular interactions involved in RR,
by attracting the cementoclast progenitors.
 These mediators are produced in conditions like Asthma ,
Alcoholism , chronic gingivitis etc.,
14 . 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, root resorption during orthodontic treatment.

 Studies by Goldie .RS. King in AJO 1984 & By Ashcraft, Southard,
and Tolley in AJO 1994 showed decrease in bone density cause
increase in tooth movement. But there is decrease in RR
 Less density means more chance of bone remodeling & so
more bone resorption than cementum resorption.
 This is probably why there is increased risk of RR when tooth
roots are pushed out of alveolar trough & towards less resilient
cortical plate as in
• RME
• Intrusion
• Large retraction
15. TYPE OF MALOCCLUSION:
 VonderAhe found no correlation between root resorption and
malocclusion type
 But Tulin tanner et al in EJO 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 Eur J Orthod 2015).
16 . SPECIFIC TEETH :.
 Glenn T. Sameshima et al in AJO 2001, showed that resorption
occurs primarily in the maxillary anterior teeth, averaging over
1.4 mm. The worst resorption was seen in maxillary lateral
incisors.
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.
Maxillary incisors have the greatest amount of root resorption of
all teeth (Sameshima GT, Sinclair PM AJODO 2001)

Lateral incisors are more resorbed than central incisors.

 Maxillary incisors
 Maxillary and mandibular canines,
 Mandibular first bicuspids, with significant EARR

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

Many of the Biological factors cannot be controlled by

orthodontist. But mechanical factors should be controlled.
TYPE OF APPLIANCE :
Intermittent forces should be preferred over continuous forces to
prevent serious root resorption. Aras et al concluded that
intermittent forces results in lesser root resorption than continuous
force
 In particular, the claim that moving teeth with self-ligating
brackets cause less EARR has been proven to be false
 Clear aligner treatment that applies enough force to move the
roots the same amount as fixed appliances do will cause
similar EARR

Limited evidence supports the fact that orthodontic patients

treated with periodontally accelerated osteogenic orthodontics
do not have an increased risk for EARR
BEGG VS EDGEWISE APPLIANCE:
 Scott et al in ANGLE 2000 The incidence of EARR was 2.30 times

higher for Begg appliances compared with edgewise .

 In the first stage of Begg there is uncontrolled tipping that

causes the roots of incisors to be pushed against less resilient

cortical bone. Beck & Harris AJO 94
The intruded roots undergo resorption.
 Begg treatment Molars are more affected than premolars,
Because
 premolars are not touched during the early stages of

treatment.
 Molars are subjected to higher mechanical stress & longer
period than premolars.
EXTRACTION VS NON EXTRACTION:

 Scott McNab et al ANGLE 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 AJO 2001 supports that orthodontic

treatment with extraction especially all first bicuspids causes
higher incidence & degree of root resorption than in non –
extraction treatment strategy.
SERIAL EXTRACTION:
 Serial extractions without complementary orthodontic
treatment gave the least root resorption compared with serial
extractions with orthodontic treatment or to four premolar
extractions followed by fixed appliance treatment.
(Kennedy, Joondeph, and Little AJO 1983)
 MAGNITUDE OF FORCE USED :
Force magnitude is directly proportional to the severity of root
resorption (Vardimon Angle Orthod 1991)
LIGHT OR HEAVY FORCE :
 HARRY AND SIMS ANGLE 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 in AJO 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:
 It is one of the most detrimental movement that causes RR
especially Apical Root Resorption. Takayoshi et al in ANGLE
2003 experimental intrusion of molars using skeletal
anchorage system found that there was severe RR & it reached
the dentin without reparative cementum formation.
 In intrusive movements, almost all pressure is gathered in the
root apex; the risk of resorption markedly increases because
of root anatomy. It has been stated that root resorption occurs
four times more during intrusion than during extrusion
 The most detrimental orthodontic movement that may induce
root resorption is the combination of lingual root movement
with intrusion . Li et al. 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.
ROTATION :
 Sao Paulo AJO 2004 with his SEM study , studied
premolars which had undergone rotation found that RR is
severe on rotated than in controls.
RETRACTION:
Sheldon Baumrind in AJO 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 sideeffect
may be due to individual variation and not round tripping.
Sequence of the arch wire
 There is no information on the relationship between root
resorption and the arch wire sequence. A significant
relationship between resorption and the arch wire sequence
has not been proven . This is important because the aim of the
clinician is to reach the square stainless steel working arch
wires efficiently.
DURATION OF FORCE:

Most studies report that the severity of root resorption is directly

related to treatment duration.

 Only few authors like Dermaut and De Munck AJO 1986 who
concluded that no correlation has been found between the
amount of resorption and the amount and duration of
treatment.
 Goldin in AJO 1989 reported that the amount of root loss
during treatment is 0.9 mm/year.
 There are likely limits to the amount of remodeling cycles the
root apex can withstand.

 The longer the active treatment time, the greater the amount of
EARR, which may also be related to root (apical) displacement
This would also partially explain why round-tripping of teeth
produces more EARR, and jiggling in inconsistent wear of
finishing elastics is thought to increase risk.

Recently, the effects of 4 weeks of jiggling movement were

studied; the conclusion was that short-term buccopalatal light
and heavy jiggling movements do not increase the amount of
EARR.
However, vertical jiggling movements, in comparison with
buccopalatal jiggling movements, were shown to increase
the instances of 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.

Imminent studies with three-dimensional superimposition may

provide more accurate

When practitioners used to rotate and torque the maxillary first

molars (mesial buccal root) against the cortical bone for
anchorage, EARR of the mesiobuccal root was often observed.
Tooth can now be moved using skeletal temporary anchorage
devices (TADs). Pure or absolute intrusion of teeth is now possible
using TADs.
Maxillary teeth in LeFort I osteotomies have a higher incidence of
severe root resorption.
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 , 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. Therefore, periapical films are superior to
panoramic graphs as periapical graphs can provide detailed
information with less distortion.
 A magnification factor that may vary between 5% and 12%
should be considered while performing evaluations with lateral
cephalometric X-rays. Because the roots of central incisors are
superimposed, the reliability decreases, and it is difficult to
accurately visualize root resorption .

 Chan and Darendeliler stated that two-dimensional views

during the diagnosis of root resorption is a good technique;
however, a quantitative evaluation for resorption should be
avoided using these techniques.
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 .
Scanning Electron Microscopy
 It has been reported that Scanning Electron Microscopy (SEM)
results in an enhanced visual and perspective assessment of
root surfaces and that when recorded in stereo pairs, they
provide resolution and details that cannot be attained with
histological models reconstructed from serial sections .
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.
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
“To obtain the best image with the minimal dose,” CBCT comes to
the forefront in terms of related indications.
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.

 Cheng et al. found that resorption continued for 4 weeks after

the stop of the orthodontic force. After four-week light force
application which was followed by 4-week retention, there was
continuous and regular repair, while most of the repair
occurred where the heavy force was applied in 4 weeks, which
was followed by the 4-week retention.
Markers of ERR
 PP(Dentin phosphophoryn) and Dentin sialoprotein(DSP) are
two proteins that could be potential markers for root
resorption(Laura Balducci 2006)
Dentin matrix protein 1 (DMP1), Dentin phosphophoryn (PP) and
Dentin sialoprotein (DSP) are extracellular matrix proteins
associated with dentin mineralization found in the gingival
crevicular fluid (GCF) of subjects undergoing orthodontic
treatment.
PP and DSP are non-collagenous dentin specific matrix proteins
postulated to be involved in the mineralization of pre-dentin into
dentin, while DMP1 is present in dentin as well as in bone.
 Dentin undergoes continuous deposition throughout life as
secondary dentin only on the pulpal surface. Therefore, these
proteins are not routinely released into the surrounding space
as dentin does not undergo the process of remodeling as in
bone. It is only in the presence of active external root
resorption that these proteins could be freed into the
periodontal ligament space.
 Therefore, there will be significant qualitative and quantitative
difference of levels of these proteins exists between
orthodontic patients with radiographic signs of root resorption
and non-treated patients and between patients with mild and
severe root resorption.
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.
 Ideally, the tooth should not be in hyperfunction and no force
applied, which usually means placing a passive archwire to
hold the teeth exactly where they are.
 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.
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.
 Artun 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
What Happens to Teeth with Short Roots Long Term?
Case reports have shown that no relationship exists between teeth
with short roots and (loss of the tooth).

Lateral incisors with severe root resorption (not apical) from

erupting canines can still be orthodontically moved
Invasive cervical root resorption (ICRR).
Heathersay and others describe ICRR - inflammatory process that
penetrates the cementum from the PDL (thus it is external in origin)
apical to the epithelial attachment. Resorbs the dentin and
enamel, generally leaving the dentin surrounding the pulp intact
but causing a hollowing of the tooth.
First sign of ICRR is a pink-appearing crown near the cement-
enamel junction (CEJ). This pink hue is due to the granulation tissue
filling in the resorbed dentin and enamel under the resorbed part
of the crown. The tooth remains vital and asymptomatic.
Orthodontic treatment has been identified as one of the most
commonly associated factors with ICRR. Trauma was the second
most frequent sole factor. Other associated factors were
bleaching, restorations, and combinations of factors.
Recent advances
Are There Any Methods to Detect Root Resorption before
It is Visible on Radiographs?
 Gingival crevicular fluid (GCF) is an intriguing possibility.

 Mah and Prasad compared levels of dentin

phosphoproteins in the GCF among three groups. They
found significantly higher levels in resorbing primary teeth
and teeth undergoing active orthodontic tooth movement.
 George and Evans examined GCF levels of dentin
phosphoproteins and other markers and found differences
between teeth in patients with root resorption and a
control group with no forces.
 There are gene that identify patients at greater risk for EARR,
but genetic material can only be obtained from blood or
buccal swabs. However, a new method for detecting markers in
saliva has been developed at the University of California, Los
Angeles (UCLA).

 Study by Ramos showed that levels of a specific

immunoglobulin are elevated during pretreatment in patients
who subsequently had severe root resorption.
Conclusion
EARR is paradoxical; it occurs in nearly every tooth but is a
benign side effect. 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.

Finally, it must be emphasized that the mere fact of a short root is

not cause for the extraction of the tooth and replacement with an
implant.
Reference
 1) Root resorptions and tissue changes during orthodontic treatment.(Bisharra)
 2)Root resorption after orthodontic treatment part 1 and 2
Nappthali Brezniak, Wasserstein.(AJO jan 1993 )
 3)Orthodontically induced inflammatory root resorption
Brezniak and wasserstein. Angle 2002
 4)Genetic predisposition to external apical root resorption
Riyad A, James K (AJO 2003 MARCH )
 5) Root resorption during orthodontic therapy
Edward F Harris (seminars in orthodontics , sept 2000 )
 6)Root resorption in orthodontics Furkan Dindaroglu (TurkJOrthod 2016)
 Orthodontics current principles and practice –Lee W. Graber,Robert L. Vanarsdhall
 Contemporary orthodontics –William Proffit