root resorption: root resorption - aao · pdf fileroot resorption: what we know and how it...

1

Root Resorption What we know and how it

affects our clinical practice

AAO 2015 Annual Session

May 19th 2015

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

Root resorption

a physiologic or pathologic process occurring as a result of changes seen in the tooth or surrounding periradicular tissues

characterized by loss of tooth structure over the root surface

Type

Physiologic root resorption

occurring on deciduous

teeth during eruption of

permanent teeth

Pathologic occurring on permanent roots

Location

Internal

External

External Root resorption

1) Traumapulp space infection

2)Ectopic teethPressure from tumors cysts

3) Orthodontic treatment

Traumapulp space infection

Radiolucencies in boneAnd root resorption

Pulpal infectionRadiolucencies in bone

2

Source American Journal of Orthodontics and Dentofacial Orthopedics 2005 127650-654 (DOI101016jajodo200403031 )

Copyright copy 2005 American Association of Orthodontists Terms and Conditions

Ectopic Canine

A) Buccally impacted canine

B) Resolution of canine impaction

C) Deband

D) 5-8yrs post treatment

Pressure from tumors

Orthodontically Induced Inflammatory Root Resorption (OIIRR)

Pre-Treatment

Post-Treatment

Maxillary incisors are most commonly

affected

OIIRR

OIIRRHow do orthodontic treatment 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)

3

Orthodontic force

Compression of the PDL

Hylinization and inflammation

Activation of osteoclasts

Removal of hyaline material

Removal of superficial surface

or cementum

Root resorption

Three types OIIRR

1) Surface resorption

Only the outer cemental layers are resorbed and later fully regenerated remodeled when the etiologic factor is removed

Three types OIIRR

2) Deep resorption

The cementum and the outer layers of the dentin are resorbed andusually repaired with cementum material

The final shape of the root may or may not be identical to the original form

Three types OIIRR

3) Circumferential apical root resorption

Tridimensional resorption of the hard

tissue components of the root apex occurs and root shortening is evident

When the root looses apical material beneath the cementum no regeneration is possible and the resorption is irreversible

Why investigate OIIRR

Root resorption is undesirable because it can affect the long-term viability of the dentition

Unfavorable crownroot ratio

3mm apical loss = 1mm crestal bone loss

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

Methods of identifying root resorption

Human and animal studies

Histological (SEM Light microscope)

Radiographic (Pan Ceph Periapical)

Volumetric (Micro-CT Cone Beam)

4

Histological illustration varying degrees of repair in OIIRR

A) Normal root surface

B) Undermined RR ndash no repair

C) Partial repair with acellularcementum (AC)

D) Partial repair with cellular cementum (CC)

E) Total repair with CC ndash root contour has been altered

F) Total repair with AC ndash root contour was re-established (Owman-Moll P

(1995b)

SEM ndash varying severity of RR in intruded teeth

Minor RR

Severe RR

(Han G et al 2005)

Panoramic radiograph - initial Panoramic radiograph - progress



Root Resorption Severity

mild moderate severe extremeNo RR



Cone Beam - CT

5

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-Oct19(5)19-26

6

Mean absorbed doses (μGy) to various tissues for each unit

NewTom 9000 i-CATPanoramiclateral

cephalometricMulti-slice CT

Bone marrow

Third cervical vertebra 6489 7313 628 75256

Mandibular ramus 12447 12829 3604 99304

Brain

Hypophysis 3161 7450 302 14889

Eye

Lens 4728 12292 458 8928

Thyroid gland

Thyroid 2324 1243 131 14177

Salivary glands

Submandibular 14267 13641 5668 118150

Parotid 16787 15022 3244 142044

Skin

Thyroid 6638 1575 259 18890

Neck (back) 12571 6511 2708 158372

Philtrum 32736 14349 253 127918

Parotid 14894 15109 6087 147344

Nasion 4512 10609 199 10082

Silva 2008

American Academy of Oral andMaxillofacial Radiology

Position statement guidelines for CBCT use in orthodontic practice (2013)

1 Image appropriately according to clinical condition2 Assess the radiation dose risk3 Minimize patient radiation exposure4 Maintain professional competency in performing and interpreting CBCT studies

ALARA principle as low as reasonably achievable (Mountford amp Temperton 1992)

Biological Markers to detect OIIRR

Dentin sialophosphoprotein (DPP) was higher in proximity to resorbing primary and permanent tooth roots (Mah 2004)

ELISA combined with electrochemistry is a reliable and sensitive method to detect DPP in gingival crevicular fluid (Sha 2014)

IncidencePrevalence of EARR and Orthodontic Treatment

Histological studies 90 prevalence of RR in

orthodontically treated teeth (Stenvik A 1970 Harry MR 1982)

Radiographic studies report an incidence of

EARR before treatment as 15 and after treatment as 73 (Lupi JE 1996)

EARR defined as greater than 4mm or 13 of the root length (severe) Incidence is reduced to 05-5 in the post orthodontic treatment group (Linge 1983 Levander 1988 Levander 1998 Lupi 1996

Taithongchai 1996 Janson 1999 McNab 1999 Kiliany 2002 Sehr 2011)

7

Etiology of OIIRR

The etiological factors are complex and multifactorial resulting from a combination of

individual biological variability and

the effect of mechanical factors

Systemic Risk Factors for Orthodontically Induced Inflammatory Root Resorption

Likely Risk Factors Unclear Risk Relationship

Unlikely Risk Factors

History of previous Root Resorption

Bisphosphonates

Nabumetone (Likely Protective)

Paracetamol(acetaminophen)

Previous trauma resulting in Root Resorption

Hormone deficiency ToothRoot morphology

Genetics AsthmaPrevious trauma without

Root Resorption

TNFRSF11A geneChronic alcoholism

Endodontic treatment

Root proximity to cortical bone

Age

Severitytype of malocclusion

Gender

IL-1β allele 1Alveolar bone density

Other factors to be identified but evidence supports a link between genetics and OIIRR estimated to be over 50

Orthodontic Risk Factors for OIRR

Treatment Duration

Magnitude of Force ndash HeavyLight

Direction of tooth movement

Amount of Apical displacement

Method of force application Continuous vs Intermittent force

Appliance Type

Treatment technique (Bracket prescription self-ligating archwire sequence etchellip)

Reviewing the data on Root resorption

Randomized controlled tirals

Experimental designs

Cohort control studies

Case-Control Studies

Case series Case reports

Personal Communication

Meta analysis -Systematic Review

Materials and Methods

Structured question using PICO format

Population patients with no history of root resorption

Intervention comprehensive orthodontics

Controlcomparison people who have not had orthodontics teeth that were not moved orthodontically

Outcome external root resorption

Null Hypothesis

1) There is no difference in the incidence and severity of root resorption between patients with no history of RR undergoing comprehensive orthodontic treatment and an untreated group

2) There is no difference in the incidence and severity of root resorption between patients with no history of RR undergoing comprehensive orthodontic treatment who receive tooth movement with different techniques

8

Inclusion and Exclusion Criteria

Inclusion

bull Randomized controlled trials (RCTs) published or unpublished that evaluated root length before and after treatment in Human subjects

bull Patients of any age gender or ethnicity who underwent comprehensive orthodontic treatment with full fixed appliances

Exclusion

bull Animal studies studies including auto-transplanted teeth and duplicate publications

Databases of published trials included in the systematic review (14)

Cochrane Cental Register of Controlled Trials (CENTRAL) AND Database of Systematic Reviews

MEDLINE

PubMed

EMBASE

Web of Science

EBM Reviews (DARE)

Computer Retrieval of Information on Scientific Project

LILACS PAHO BBO WHOLis CEPS etchellip

Databases of Unpublished literature included in the systematic review (7)

Databases of Dissertations and Conference proceedings

Conference Materials CENTRAL ProQuest Dissertation Abstracts and Thesis database

Databases of research registers

TrialCentral National Research Register (UK) wwwClinicaltrialsgov

Grey Literature SIGLE

Additional search methods

Requests were sent to relevant professional organizations in an attempt to identify unpublished or ongoing studies

Hand searching of relevant journals

Searching through reference lists of relevant articles

Search Strategy (October 2008)

The search strategy developed for MEDLINE via OVID is displayed below (MeSH terms in UPPER CASE Free text terms in lower case)

1 ORTHODONTIC ME

2 braces

3 (1 or 2)

4 ROOT RESORPTION ME

5 external apical root resorption

6 root erosion

7 root blunting

8 root shortening

9 tooth-root resorption

10 orthodontically induced inflammatory root resorption

11 (4 or 5 or 6 or 7 or 8 or 9 or 10)

12 (3 and 11)

13 HUMAN ME

14 (12 and 13)

Major Quality Criteria of included studies

A Method of randomization

B Allocation concealment

C Blinding of outcome assessors

D Completeness to follow-up

ACD adequate = Low risk of bias

2 criteria adequate= Moderate risk of bias

lt2 adequate = High risk of bias

9

Minor Quality Criteria of included studies

A Baseline similarities of the groups

B Reporting of eligibility criteria

C Measure of variability of primary outcome

D Sample size calculation

Of the 921 studies found in this field only 11 trials were considered appropriate for inclusion in this review

Protocols were too variable to proceed with meta-analysis (quantitative evaluation)

Results

Excluded citations

Not relevant (n=777 )

Potentially relevant trials retrieved for more detailed full report evaluation (n=

144)

Screening of titles and abstracts from all sources (n= 921)

Excluded Trials (Appendix Table 1)

with reasons (n=128)

Unable to locate (n=2)

RCTs excluded from meta-analysis (n=1)

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

Potentially appropriate RCTs to be included in the meta-analysis evaluated

for methodological quality (n=14)

RCTs considered potentially appropriate to be included in the meta-analysis

13 publications of 11 trials

The QUOROM statement flow diagram of the citations retrieved by reviewing titles and abstracts and trials that were evaluated in full text

Meta-analysis not possible due to differences in RCT methodologies and

reporting

Quality Assessment

The Kappa scores and percentage agreements between the two raters (BW amp KV)

assessing the major methodological quality of the studies were randomization 10

100 concealment 072 82 blinding 091 95 and withdrawals 10 100

Comparison of the Split-Mouth Studies

6 of the 11 studies were Split-Mouth

Limited validity Small sample sizes

Premolars

Moderate risk of bias

Exception Han 2005 - Low risk of bias

Acar 1999 ndash High risk of bias

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)


1) Heavy force application produced significantly

more root resorption that light force application

or control (Chan 2004 Chan 2006 Harris 2006 Barbagallo

2008)

2) Weak evidence continuous force produced

significantly more root resorption than interrupted force application (Acar 1999)

10


3) Limited evidence that both light forces and

forces from thermoplastic appliances result in similar root resorption both significantly more

than seen in controls (Barbagallo 2008)

4) Both studies examining intrusive force

application found significantly increased RR

rates to controls (Harris 2006 Han 2005)

Root resorption from extrusive force was not

significantly different than control (Han 2005)

Comparison of the comprehensive orthodontic treatment RCTs

Four of these studies were judged to be of high quality and have a low risk of bias (Brin 2003 Mandall 2006 Reukers 1998

Scott 2008)

One was judged to have a moderate risk of bias (Levander

1994)

5) Straightwire vs standard edgewise techniques resulted in no statistically significant differences in the amount of tooth loss or prevalence of root resorption (Reukers 1998)

6) Mandibular incisor root resorption did not differ between self-ligating and conventional systems (Scott 2008)


7) No statistically significant difference was found in the amount of RR between archwiresequences for upper left central incisors

Also no difference between the proportion of patients with or without root resorption was seen (Mandall 2006)

8) Incisors with clinical signs or patient reports of trauma but no signs of EARR had the same prevalence of moderate to severe OIIRR as those without trauma (Brin 2003 Mandall 2006 Levander

1994)

9) Teethroots having unusual morphology before treatment had no significant differences in the amount of RR (Brin 2003)

10) No statistical significance between one-phase and two-phase treatment groups when looking at OIIRR prevalence or severity

As treatment time increased the odds of OIIRR also increased

The odds of a tooth experiencing severe root resorption were greater if a large reduction of overjet occurred during phase 2 (Brin 2003)



11) For patients already in orthodontic treatment

and experiencing root resorption the total amount of root resorption was significantly less in patients given a 2-3 month treatment pause

than those treated without any interruption(Levander 1994)

0

5

10

15

20

25

0-05 051-149 150-249 gt25

Nu

mb

er

of

tee

th a

ffe

cte

d

Amount of EARR (mm)

Levander - Amount of EARR by treatment group

Pause

No Pause

Discussion

Comprehensive orthodontic treatment causes an increase in the incidence and severity of root resorption

Heavy forces are particularly harmful

There is no evidence that OIIRR is affected by archwire sequencing bracket prescription or self-ligation

There is little evidence that previous trauma (with no history of EARR) and unusual tooth morphology play a role in increased OIIRR

11

Implications for Clinical Practice

best practice is using light forces especially when engaging in intrusive movements

progress radiographs should be obtained 6-12 months into treatment to detect OIIRR early

Once identified a 2-3 month treatment pause with passive archwires will lead to a decrease in total root resorption by the end of treatment

LIPUS

Low intensity pulsed ultrasound (Baily 2004)

Decreased the number of resorption lacunae

Decreased the area or resorption

Non-invasive method to reduce OIIRR in Humans

Management of EARR during Orthodontic Treatment

Continue with lighter forces rest periods

Revise treatment goals ndash shorten treatment duration

Follow-up radiographs during and after orthodontic treatment

If termination of RR does not occur sequential root canal therapy with calcium hydroxide may be considered

Retaining the teeth with fixed appliances should be done with caution since occlusal trauma of the fixed teeth or segments might lead to extreme EARR (Brezniak 2002b)

Implications for Research

More evidence is required to determine risk factors and effective ways to decrease the severity and prevalence of OIIRR

Parallel group studies with appropriate randomization allocation concealment and masking of outcome assessment are needed

Standardized measurement techniques along with proper assessment blinding error analysis and consensus measures

Assessment of patient centered outcomes

Quality of life post treatment and occurrence of further complications such as mobility and tooth loss

Genetic predisposition and systemic factors should also be assessed

Long Term Prognosis

Root resorption associated with orthodontic treatment

ceases with the termination of active treatment (Remington et al 1989)

When post treatment root resorption does occur It is

likely associated with other factors such as traumatic

occlusion and active force-delivering retainers (Copeland

amp Green 1989)

Long Term Prognosis

extensive root resorption does not usually affect the

functional capacity or greatly compromise the

longevity of the teeth

An average sized normally shaped maxillary central

incisor that experienced no alveolar bone loss during

orthodontic treatment with a root shortened by 5mm

will still have 75 of its periodontal attachment

remaining (Kalkwarf et al 1986)

12

Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )


1) Case ReportInitial Radiographs



18 months into orthodontic treatment



Deband



25 year follow-up

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

13

Retrospective data

100 patients with severe resorption were recalled 14 years after orthodontic treatment

no incidences of tooth loss

hypermobility in only 2 cases

(Remington et al 1989)

Patients with severe root resorption (root lengths 55-181mm) recalled 5-15 years after treatment

no teeth had mobility scores greater than 1 on Millerrsquos index (crown deviates within 1mm of normal)

no teeth had been lost

(Levander amp Malmgren 2000)

Conclusions

Increased incidence and severity of OIIRR is found in patients undergoing comprehensive orthodontic therapy

Heavy force application produced significantly more OIIRR than light force application or control

Other trends from split mouth studies could not be substantiated because of small subject numbers and short treatment times

Standard reporting methods of future clinical trials are recommended so data can be pooled and stronger clinical recommendations made

Orthodontic Treatment and OIIRR

How will you discuss the risks of OIIRR with your patientsparents 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

Thank-you

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8

Blake M Woodside DG Pharoah MJ (1995) A radiographic comparison of apical root resorption after

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Orthodontist 78 1119-24

Brin I Tulloch JFC Koroluk L et al (2003) External apical root resorption in Class II malocclusion a retrospective review of 1- versus 2-phase treatment American Journal of Orthodontics and Dentofacial

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Brudvik P Rygh P (1994) Multi-nucleated cells remove the main hyalinized tissue and start resorption of adjacent root surfaces European Journal of Orthodontics 16 265-73

14

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Chan EKM Darendeliler MA (2004b) Exploring the third dimension in root resorption Orthodontics amp Craniofacial Research 7 64-70

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Christiansen RL (1994) Commentary Thyroxine administration and its effects on root resorption

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Darendeliler MA Kharbanda OP Chan EK et al (2004) Root resorption and its association with alterations in physical properties mineral contents and resorption craters in human premolars following

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79-97

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Evidence Based Dentistry 6 21

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30

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427-34

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clinical trial European Journal of Orthodontics 28 561-6

Mavragnani M Boe OE Wisth PJ et al (2002) Changes in root length during orthodontic treatment

advantages for immature teeth European Journal of Orthodontic 24 91-7

McFadden WM Engstrom C Engstrom H et al (1989) A study of the relationship between incisor intrusion and root shortening American Journal of Orthodontics and Dentofacial Orthopedics 96(5)

390-6

Mc Laughlin KD (1964) Quantitative determination of root resorption during orthodontic treatment American Journal of Orthodonics and Dentofacial Orthopedics 50 143

McNab S Battistutta D Taverne A et al (1999) External apical root resorption of posterior teeth in

asthmatics after orthodontic treatment American Journal of Orthodontics and Dentofacial Orthopedics116 545-51

References McNab S Battistutta D Taverne A et al (2000) External apical root resorption following orthodontic

treatment Angle Orthodontist 70(3) 227-32

Midgett RJ Shaye R Fruge JF Jr (1981) The effect of altered bone metabolism on orthodontic tooth

movement American Journal of Orthodontics and Dentofacial Orthopedics 80 256-62

Mirabella AD Artun J (1995) Risk factors for apical root resorption of maxillary anterior teeth in adult orthodontic patients American Journal of Orthodontics and Dentofacial Orthopedics 108(1) 48-55

Newman WG (1975) Possible etiologic factors in external root resorption American Journal of


Ngan DCS Kharbanda OP Byloff FK et al (2004) The genetic contribution to orthodontic root

resorption a retrospective twin study Australian Orthodontic Journal 20 1-9

Otis L Hong J Tuncay O (2004) Bone structure effect on root resorption Orthodontics amp Craniofacial

Research 7(3) 165-77

Owman-Moll P Kurol J Lundgren D (1995a) Continuous versus interrupted continuous orthodontic

force related to early tooth movement and root resorption Angle Orthodontist 65(6) 395-401

discussion 401-2

Owman-Moll P Kurol J Lundgren D (1995b) Repair of orthodontically induced root resorption Angle


Owman-Moll P Kurol J Lundgren D (1996a) Effects of a doubled orthodontic force magnitude on tooth movement and root resorptions An intra-individual study in adolescents European Journal of

Orthodontics 18(3) 141-50

Owman-Moll P Kurol J Lundgren D (1996b) The effects of a four-fold increased orthodontic force magnitude on tooth movement and root resorptions An intra-individual study in adolescents European

Journal of Orthodontics 18(3) 287-94

Owman-Moll P Kurol J (1998) The early reparative process of orthodontically induced root resorption in adolescents ndash location and type of tissue European Journal of Orthodontics 20 727-32

Parker RJ Harris EF (1998) Directions of orthodontic tooth movements associated with external apical

root resorption of the maxillary central incisor American Journal of Orthodontics and Dentofacial Orthopedics 114(6) 672-83

15

References Pandis N Nasika M Polychronopoulou A et al (2008) External apical root resorption in patients

treated with conventional and self-ligating brackets American Journal of Orthodontics and Dentofacial


Pizzo G Licata ME Guiglia R et al (2007) Root resorption and orthodontic treatment Review of the

literature Minerva Stomatology 56(1-2) 31-44

Poumpros E Loberg E Engstrom C (1994) Thyroid function and root resorption Angle Orthodontist

64 389-93

Proffit WR Fields HW SarverDM (2006) Contemporary Orthodontics Fourth Edition CV Mosby Missouri

Reitan K (1974) Initial tissue behaviour during apical root resorption Angle Orthodontist 44 68-82

Remington DN Joondeph DR Artun J et al (1989) Long-term evaluation of root resorption occurring

during orthodontic treatment American Journal of Orthodontics and Dentofacial Orthopedics 96 (1)

43-6

Reukers E Sanderink g Kuijpers-Jagtman AM et al (1998) Assessment of apical root resorption using

digital reconstruction Dento-Maxillo-Facial Radiology 27 25-9

Rivera EM Walton RE (1994) Extensive idiopathic apical root resorption A case report Oral Surgery

Oral Medicine Oral Pathology Oral Radiology Endodontics 78 673-7

Rygh P Reitan K (1972) Ultrastructural changes in the periodontal ligament incident to orthodontic tooth movement Trans European Orthodontic Society 393-405

Sameshima GT Sinclair PM (2001a) Predicting and preventing root resorption Part I Diagnostic

factors American Journal of Orthodontics and Dentofacial Orthopedics 119(5) 505-10

Sameshima GT Sinclair PM (2001b) Predicting and preventing root resorption Part II Treatment


Sameshima GT Sinclair PM (2004) Characteristics of patients with severe root resorption

Orthodontics amp Craniofacial Research 7(2) 108-14

Schwartz AM (1932) Tissue changes incidental to tooth movement International Journal of


References Scott P DiBiase AT Sherriff M et al (2008) Alignment efficiency of Damon3 self-ligating and

conventional orthodontic bracket systems A randomized clinical trial American Journal of Orthodontics

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Segal G Schiffman P Tuncay O (2004) Meta analysis of the treatment-related factors of external

apical root resorption Orthodontics amp Craniofacial Research 7(2) 71-8

Shirazi M Dehpour AR Jefari F (1999) The effect of thyroid hormone on orthodontic tooth movement

in rats Journal of Clinical Pediatric Dentistry 23 259-64

Smale I Artun J Behbehani F et al (2005) Apical root resorption 6 months after initiation of fixed orthodontic appliance therapy American Journal of Orthodontics and Dentofacial Orthopedics 128

57-67

Snelgrove RA (1995) Generalized idiopathic apical root resorption as an incidental finding in an adolescent A case history Dental Update 22 276-8

Spurrier SW Hall SH Joondeph DR (1990) A comparison of apical root resorption during orthodontic

treatment in endodontically treated and vital teeth American Journal of Orthodontics and Dentofacial Orthopedics 97(2) 130-4

Stevnik A Mjor IA (1970) Pulp and dentine reactions to experimental tooth intrusion A histological

study of the initial changes American Journal of Orthodontics and Dentofacial Orthopedics 57 370-85

Taithongchai R Sookkorn K Killiany Dm (1996) Facial and dentoalveolar structure ad the prediction of

apical root shortening American Journal of Orthodontics and Dentofacial Orthopedics 110 311-20

Taner T Ciger S Sencift Y (1999) Evauation of apical root resorption following extraction therapy in

subjects with class I amd class II maloclussions European Journal of Orthdontics 21 491-6

TenHoeve A Mulie Rm (1976) The effects of antero-postero incisor repositioning on the palatal cortex

as studied with laminagraphy Journal of Clinical Orthodontics 10 804-22

Thongudomporn U Freer TJ (1998) Anomalous dental morphology and root resorption during orthodontic treatment a pilot study Australian Orthodontic Journal 15(3) 162-7

Trope M (1998) Root resorption of dental traumatic origin classification based on etiology Practical

Periodonics and Aesthehetict Dentistry 10 515-22

References Villa PA Oberti G Moncada CA et al (2005) Pulp-dentine complex changes and root resorption during

intrusive orthodontic tooth movement in patients prescribed nabumetone Journal of Endodontics

31(1) 61-6

Walker SL Tieu LD Flores-Mir C (2013) Radiographic comparison of the extent of orthodontically

induced external apical root resorption in vital and root-filled teeth a systematic review European

Journal of Orthodontics 35(6)796-802 Review

Weiland F (2003) Constant versus dissipating forces in orthodontics the effect on initial tooth

movement and root resorption European Journal of Orthodontics 25(4) 335-42

Weltman BJ Vig KWL Fields HW et al (2010) American Journal of Orthodontics and Dentofacial

Orthopedics 137 (4) 462-76

Wheeler In Press

Wickwire NA Mc Neil MH Norton LA et al (1974) The effects of tooth movement upon endodontically

treated teeth Angle Orthodontist 44 235-42

Wu FL Wang LY Huang YQ Guo WB Liu CD Li SG (2013) Interleukin-1β +3954 polymorphisms and

risk of external apical root resorption in orthodontic treatment a meta-analysis Genet Mol Res Oct

1812(4)4678-86

Lombardo L Bragazzi R Perissinotto C Mirabella D Siciliani G Cone-beam computed tomography

evaluation of periodontal and bone support loss in extraction cases Prog Orthod 2013 Sep 111429

Krieger E Drechsler T Schmidtmann I Jacobs C Haag S Wehrbein H Apical root resorption during

orthodontic treatment with aligners A retrospective radiometric study Head Face Med 2013 Aug

14921

Krasny M Zadurska M Cessak G Fiedor P Analysis of effect of non-steroidal anti-inflammatory drugs

on teeth and oral tissues during orthodontic treatment Report based on literature review Acta Pol

Pharm 2013 May-Jun70(3)573-7 Review

Hodges RJ Atchison KA White SC Impact of cone-beam computed tomography on orthodontic

diagnosis and treatment planning Am J Orthod Dentofacial Orthop 2013 May143(5)665-74

References Castro IO Alencar AH Valladares-Neto J Estrela C Apical root resorption due to orthodontic treatment

detected by cone beam computed tomography Angle Orthod 2013 Mar83(2)196-203

Ponder SN Benavides E Kapila S Hatch NE Quantification of external root resorption by low- vs high-

resolution cone-beam computed tomography and periapical radiography A volumetric and linear

analysis Am J Orthod Dentofacial Orthop 2013 Jan143(1)77-91

Picanccedilo GV de Freitas KM Canccedilado RH Valarelli FP Picanccedilo PR Feijatildeo CP Predisposing factors to

severe external root resorption associated to orthodontic treatment Dental Press J Orthod 2013 Jan-

Feb18(1)110-20

Makedonas D1 Lund H Hansen K (2013) Root resorption diagnosed with cone beam computed

tomography after 6 months and at the end of orthodontic treatment with fixed appliances Angle

Orthod May83(3)389-93

Wang Q1 Chen W Smales RJ Peng H Hu X Yin L Apical root resorption in maxillary incisors

when employing micro-implant and J-hook headgear anchorage a 4-month radiographic

study J Huazhong Univ Sci Technolog Med Sci 2012 Oct32(5)767-73

Lund H Groumlndahl K Hansen K Groumlndahl HG Apical root resorption during orthodontic treatment A

prospective study using cone beam CT Angle Orthod 2012 May82(3)480-7

ELlamas-Carreras JM1 Amarilla A Espinar-Escalona E Castellanos-Cosano L Martiacuten-Gonzaacutelez J Saacutenchez-Domiacutenguez B Loacutepez-Friacuteas FJExternal apical root resorption in maxillary root-filled

incisors after orthodontic treatment a split-mouth design study Med Oral Patol Oral Cir Bucal

2012 May 117(3)e523-7

Leite V1 Conti AC Navarro R Almeida M Oltramari-Navarro P Almeida R (2012) Comparison of

root resorption between self-ligating and conventional preadjusted brackets using cone

beam computed tomography Angle Orthod 2012 Nov82(6)1078-82

Dula K Bornstein MM Buser D et al (2014)SADMFR guidelines for the use of Cone-Beam Computed

Tomography Digital Volume Tomography Swiss Dent J 2014124(11)1169-83

American Academy of Oral and Maxillofacial Radiology (2013) Clinical recommendations regarding use of cone beam computed tomography in orthodontics [corrected] Position statement by

the American Academy of Oral and Maxillofacial Radiology Oral Surg Oral Med Oral Pathol Oral

Radiol 2013 Aug116(2)238-57

References El-Bialy T1 El-Shamy I Graber TM (2004) Repair of orthodontically induced root resorption by

ultrasound in humans Am J Orthod Dentofacial Orthop Aug126(2)186-93

Mah J1 Prasad N Dentine phosphoproteins in gingival crevicular fluid during root resorption

Eur J Orthod 2004 Feb26(1)25-30

Sha H1 Bai Y2 Li S3 Wang X4 Yin Y5 (2014) Comparison between electrochemical ELISA and spectrophotometric ELISA for the detection of dentine sialophosphoprotein for root

resorption Am J Orthod Dentofacial Orthop 2014 Jan145(1)36-40

Sehr K Bock NC Serbesis C Houmlnemann M Ruf S Severe external apical root resorption--local cause or genetic predisposition J Orofac Orthop 2011 Aug72(4)321-31

Silva MA Wolf U Heinicke F Bumann A Visser H Hirsch E Cone-beam computed tomography for

routine orthodontic treatment planning a radiation dose evaluation Am J Orthod Dentofacial Orthop 2008 May133(5)640e1-5

2



Ectopic Canine

A) Buccally impacted canine

B) Resolution of canine impaction

C) Deband

D) 5-8yrs post treatment

Pressure from tumors

Orthodontically Induced Inflammatory Root Resorption (OIIRR)

Pre-Treatment

Post-Treatment

Maxillary incisors are most commonly

affected

OIIRR

OIIRRHow do orthodontic treatment 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)

3

Orthodontic force






or cementum

Root resorption

Three types OIIRR



Three types OIIRR

2) Deep resorption



Three types OIIRR















4








(1995b)


Minor RR

Severe RR

(Han G et al 2005)








Cone Beam - CT

5

Periapical X-rays


Deband



6




Bone marrow



Brain

Hypophysis 3161 7450 302 14889

Eye

Lens 4728 12292 458 8928

Thyroid gland

Thyroid 2324 1243 131 14177

Salivary glands

Submandibular 14267 13641 5668 118150

Parotid 16787 15022 3244 142044

Skin

Thyroid 6638 1575 259 18890

Neck (back) 12571 6511 2708 158372

Philtrum 32736 14349 253 127918

Parotid 14894 15109 6087 147344

Nasion 4512 10609 199 10082

Silva 2008















7

Etiology of OIIRR








Bisphosphonates






Root Resorption




Age


Gender




Treatment Duration





Appliance Type
















Null Hypothesis



8


Inclusion



Exclusion




MEDLINE

PubMed

EMBASE

Web of Science

EBM Reviews (DARE)















1 ORTHODONTIC ME

2 braces

3 (1 or 2)



6 root erosion

7 root blunting

8 root shortening



11 (4 or 5 or 6 or 7 or 8 or 9 or 10)

12 (3 and 11)

13 HUMAN ME

14 (12 and 13)









9








Results

Excluded citations



144)













reporting

Quality Assessment







Premolars










2008)



10












Scott 2008)


1994)







1994)










0

5

10

15

20

25

0-05 051-149 150-249 gt25

Nu

mb

er

of

tee

th a

ffe

cte

d

Amount of EARR (mm)


Pause

No Pause

Discussion





11





LIPUS


















Long Term Prognosis






amp Green 1989)

Long Term Prognosis









12









Deband



25 year follow-up


13

Retrospective data









Conclusions












Thank-you










82(5) 356-60















105(4) 350-61



8


















14




















79-97






90(4) 321-6














30












111(3) 301-9

















61(2) 125-32


























427-34









64 395-9











390-6

















discussion 401-2










15







64 389-93





43-6






















57-67

















31(1) 61-6








Wheeler In Press





1812(4)4678-86





14921













Feb18(1)110-20











2012 May 117(3)e523-7








Radiol 2013 Aug116(2)238-57










3

Orthodontic force






or cementum

Root resorption

Three types OIIRR



Three types OIIRR

2) Deep resorption



Three types OIIRR















4








(1995b)


Minor RR

Severe RR

(Han G et al 2005)








Cone Beam - CT

5

Periapical X-rays


Deband



6




Bone marrow



Brain

Hypophysis 3161 7450 302 14889

Eye

Lens 4728 12292 458 8928

Thyroid gland

Thyroid 2324 1243 131 14177

Salivary glands

Submandibular 14267 13641 5668 118150

Parotid 16787 15022 3244 142044

Skin

Thyroid 6638 1575 259 18890

Neck (back) 12571 6511 2708 158372

Philtrum 32736 14349 253 127918

Parotid 14894 15109 6087 147344

Nasion 4512 10609 199 10082

Silva 2008















7

Etiology of OIIRR








Bisphosphonates






Root Resorption




Age


Gender




Treatment Duration





Appliance Type
















Null Hypothesis



8


Inclusion



Exclusion




MEDLINE

PubMed

EMBASE

Web of Science

EBM Reviews (DARE)















1 ORTHODONTIC ME

2 braces

3 (1 or 2)



6 root erosion

7 root blunting

8 root shortening



11 (4 or 5 or 6 or 7 or 8 or 9 or 10)

12 (3 and 11)

13 HUMAN ME

14 (12 and 13)









9








Results

Excluded citations



144)













reporting

Quality Assessment







Premolars










2008)



10












Scott 2008)


1994)







1994)










0

5

10

15

20

25

0-05 051-149 150-249 gt25

Nu

mb

er

of

tee

th a

ffe

cte

d

Amount of EARR (mm)


Pause

No Pause

Discussion





11





LIPUS


















Long Term Prognosis






amp Green 1989)

Long Term Prognosis









12









Deband



25 year follow-up


13

Retrospective data









Conclusions












Thank-you










82(5) 356-60















105(4) 350-61



8


















14




















79-97






90(4) 321-6














30












111(3) 301-9

















61(2) 125-32


























427-34









64 395-9











390-6

















discussion 401-2










15







64 389-93





43-6






















57-67

















31(1) 61-6








Wheeler In Press





1812(4)4678-86





14921













Feb18(1)110-20











2012 May 117(3)e523-7








Radiol 2013 Aug116(2)238-57










4








(1995b)


Minor RR

Severe RR

(Han G et al 2005)








Cone Beam - CT

5

Periapical X-rays


Deband



6




Bone marrow



Brain

Hypophysis 3161 7450 302 14889

Eye

Lens 4728 12292 458 8928

Thyroid gland

Thyroid 2324 1243 131 14177

Salivary glands

Submandibular 14267 13641 5668 118150

Parotid 16787 15022 3244 142044

Skin

Thyroid 6638 1575 259 18890

Neck (back) 12571 6511 2708 158372

Philtrum 32736 14349 253 127918

Parotid 14894 15109 6087 147344

Nasion 4512 10609 199 10082

Silva 2008















7

Etiology of OIIRR








Bisphosphonates






Root Resorption




Age


Gender




Treatment Duration





Appliance Type
















Null Hypothesis



8


Inclusion



Exclusion




MEDLINE

PubMed

EMBASE

Web of Science

EBM Reviews (DARE)















1 ORTHODONTIC ME

2 braces

3 (1 or 2)



6 root erosion

7 root blunting

8 root shortening



11 (4 or 5 or 6 or 7 or 8 or 9 or 10)

12 (3 and 11)

13 HUMAN ME

14 (12 and 13)









9








Results

Excluded citations



144)













reporting

Quality Assessment







Premolars










2008)



10












Scott 2008)


1994)







1994)










0

5

10

15

20

25

0-05 051-149 150-249 gt25

Nu

mb

er

of

tee

th a

ffe

cte

d

Amount of EARR (mm)


Pause

No Pause

Discussion





11





LIPUS


















Long Term Prognosis






amp Green 1989)

Long Term Prognosis









12









Deband



25 year follow-up


13

Retrospective data









Conclusions












Thank-you










82(5) 356-60















105(4) 350-61



8


















14




















79-97






90(4) 321-6














30












111(3) 301-9

















61(2) 125-32


























427-34









64 395-9











390-6

















discussion 401-2










15







64 389-93





43-6






















57-67

















31(1) 61-6








Wheeler In Press





1812(4)4678-86





14921













Feb18(1)110-20











2012 May 117(3)e523-7








Radiol 2013 Aug116(2)238-57










5

Periapical X-rays


Deband



6




Bone marrow



Brain

Hypophysis 3161 7450 302 14889

Eye

Lens 4728 12292 458 8928

Thyroid gland

Thyroid 2324 1243 131 14177

Salivary glands

Submandibular 14267 13641 5668 118150

Parotid 16787 15022 3244 142044

Skin

Thyroid 6638 1575 259 18890

Neck (back) 12571 6511 2708 158372

Philtrum 32736 14349 253 127918

Parotid 14894 15109 6087 147344

Nasion 4512 10609 199 10082

Silva 2008















7

Etiology of OIIRR








Bisphosphonates






Root Resorption




Age


Gender




Treatment Duration





Appliance Type
















Null Hypothesis



8


Inclusion



Exclusion




MEDLINE

PubMed

EMBASE

Web of Science

EBM Reviews (DARE)















1 ORTHODONTIC ME

2 braces

3 (1 or 2)



6 root erosion

7 root blunting

8 root shortening



11 (4 or 5 or 6 or 7 or 8 or 9 or 10)

12 (3 and 11)

13 HUMAN ME

14 (12 and 13)









9








Results

Excluded citations



144)













reporting

Quality Assessment







Premolars










2008)



10












Scott 2008)


1994)







1994)










0

5

10

15

20

25

0-05 051-149 150-249 gt25

Nu

mb

er

of

tee

th a

ffe

cte

d

Amount of EARR (mm)


Pause

No Pause

Discussion





11





LIPUS


















Long Term Prognosis






amp Green 1989)

Long Term Prognosis









12









Deband



25 year follow-up


13

Retrospective data









Conclusions












Thank-you










82(5) 356-60















105(4) 350-61



8


















14




















79-97






90(4) 321-6














30












111(3) 301-9

















61(2) 125-32


























427-34









64 395-9











390-6

















discussion 401-2










15







64 389-93





43-6






















57-67

















31(1) 61-6








Wheeler In Press





1812(4)4678-86





14921













Feb18(1)110-20











2012 May 117(3)e523-7








Radiol 2013 Aug116(2)238-57










6




Bone marrow



Brain

Hypophysis 3161 7450 302 14889

Eye

Lens 4728 12292 458 8928

Thyroid gland

Thyroid 2324 1243 131 14177

Salivary glands

Submandibular 14267 13641 5668 118150

Parotid 16787 15022 3244 142044

Skin

Thyroid 6638 1575 259 18890

Neck (back) 12571 6511 2708 158372

Philtrum 32736 14349 253 127918

Parotid 14894 15109 6087 147344

Nasion 4512 10609 199 10082

Silva 2008















7

Etiology of OIIRR








Bisphosphonates






Root Resorption




Age


Gender




Treatment Duration





Appliance Type
















Null Hypothesis



8


Inclusion



Exclusion




MEDLINE

PubMed

EMBASE

Web of Science

EBM Reviews (DARE)















1 ORTHODONTIC ME

2 braces

3 (1 or 2)



6 root erosion

7 root blunting

8 root shortening



11 (4 or 5 or 6 or 7 or 8 or 9 or 10)

12 (3 and 11)

13 HUMAN ME

14 (12 and 13)









9








Results

Excluded citations



144)













reporting

Quality Assessment







Premolars










2008)



10












Scott 2008)


1994)







1994)










0

5

10

15

20

25

0-05 051-149 150-249 gt25

Nu

mb

er

of

tee

th a

ffe

cte

d

Amount of EARR (mm)


Pause

No Pause

Discussion





11





LIPUS


















Long Term Prognosis






amp Green 1989)

Long Term Prognosis









12









Deband



25 year follow-up


13

Retrospective data









Conclusions












Thank-you










82(5) 356-60















105(4) 350-61



8


















14




















79-97






90(4) 321-6














30












111(3) 301-9

















61(2) 125-32


























427-34









64 395-9











390-6

















discussion 401-2










15







64 389-93





43-6






















57-67

















31(1) 61-6








Wheeler In Press





1812(4)4678-86





14921













Feb18(1)110-20











2012 May 117(3)e523-7








Radiol 2013 Aug116(2)238-57










7

Etiology of OIIRR








Bisphosphonates






Root Resorption




Age


Gender




Treatment Duration





Appliance Type
















Null Hypothesis



8


Inclusion



Exclusion




MEDLINE

PubMed

EMBASE

Web of Science

EBM Reviews (DARE)















1 ORTHODONTIC ME

2 braces

3 (1 or 2)



6 root erosion

7 root blunting

8 root shortening



11 (4 or 5 or 6 or 7 or 8 or 9 or 10)

12 (3 and 11)

13 HUMAN ME

14 (12 and 13)









9








Results

Excluded citations



144)













reporting

Quality Assessment







Premolars










2008)



10












Scott 2008)


1994)







1994)










0

5

10

15

20

25

0-05 051-149 150-249 gt25

Nu

mb

er

of

tee

th a

ffe

cte

d

Amount of EARR (mm)


Pause

No Pause

Discussion





11





LIPUS


















Long Term Prognosis






amp Green 1989)

Long Term Prognosis









12









Deband



25 year follow-up


13

Retrospective data









Conclusions












Thank-you










82(5) 356-60















105(4) 350-61



8


















14




















79-97






90(4) 321-6














30












111(3) 301-9

















61(2) 125-32


























427-34









64 395-9











390-6

















discussion 401-2










15







64 389-93





43-6






















57-67

















31(1) 61-6








Wheeler In Press





1812(4)4678-86





14921













Feb18(1)110-20











2012 May 117(3)e523-7








Radiol 2013 Aug116(2)238-57










8


Inclusion



Exclusion




MEDLINE

PubMed

EMBASE

Web of Science

EBM Reviews (DARE)















1 ORTHODONTIC ME

2 braces

3 (1 or 2)



6 root erosion

7 root blunting

8 root shortening



11 (4 or 5 or 6 or 7 or 8 or 9 or 10)

12 (3 and 11)

13 HUMAN ME

14 (12 and 13)









9








Results

Excluded citations



144)













reporting

Quality Assessment







Premolars










2008)



10












Scott 2008)


1994)







1994)










0

5

10

15

20

25

0-05 051-149 150-249 gt25

Nu

mb

er

of

tee

th a

ffe

cte

d

Amount of EARR (mm)


Pause

No Pause

Discussion





11





LIPUS


















Long Term Prognosis






amp Green 1989)

Long Term Prognosis









12









Deband



25 year follow-up


13

Retrospective data









Conclusions












Thank-you










82(5) 356-60















105(4) 350-61



8


















14




















79-97






90(4) 321-6














30












111(3) 301-9

















61(2) 125-32


























427-34









64 395-9











390-6

















discussion 401-2










15







64 389-93





43-6






















57-67

















31(1) 61-6








Wheeler In Press





1812(4)4678-86





14921













Feb18(1)110-20











2012 May 117(3)e523-7








Radiol 2013 Aug116(2)238-57










9








Results

Excluded citations



144)













reporting

Quality Assessment







Premolars










2008)



10












Scott 2008)


1994)







1994)










0

5

10

15

20

25

0-05 051-149 150-249 gt25

Nu

mb

er

of

tee

th a

ffe

cte

d

Amount of EARR (mm)


Pause

No Pause

Discussion





11





LIPUS


















Long Term Prognosis






amp Green 1989)

Long Term Prognosis









12









Deband



25 year follow-up


13

Retrospective data









Conclusions












Thank-you










82(5) 356-60















105(4) 350-61



8


















14




















79-97






90(4) 321-6














30












111(3) 301-9

















61(2) 125-32


























427-34









64 395-9











390-6

















discussion 401-2










15







64 389-93





43-6






















57-67

















31(1) 61-6








Wheeler In Press





1812(4)4678-86





14921













Feb18(1)110-20











2012 May 117(3)e523-7








Radiol 2013 Aug116(2)238-57










10












Scott 2008)


1994)







1994)










0

5

10

15

20

25

0-05 051-149 150-249 gt25

Nu

mb

er

of

tee

th a

ffe

cte

d

Amount of EARR (mm)


Pause

No Pause

Discussion





11





LIPUS


















Long Term Prognosis






amp Green 1989)

Long Term Prognosis









12









Deband



25 year follow-up


13

Retrospective data









Conclusions












Thank-you










82(5) 356-60















105(4) 350-61



8


















14




















79-97






90(4) 321-6














30












111(3) 301-9

















61(2) 125-32


























427-34









64 395-9











390-6

















discussion 401-2










15







64 389-93





43-6






















57-67

















31(1) 61-6








Wheeler In Press





1812(4)4678-86





14921













Feb18(1)110-20











2012 May 117(3)e523-7








Radiol 2013 Aug116(2)238-57










11





LIPUS


















Long Term Prognosis






amp Green 1989)

Long Term Prognosis









12









Deband



25 year follow-up


13

Retrospective data









Conclusions












Thank-you










82(5) 356-60















105(4) 350-61



8


















14




















79-97






90(4) 321-6














30












111(3) 301-9

















61(2) 125-32


























427-34









64 395-9











390-6

















discussion 401-2










15







64 389-93





43-6






















57-67

















31(1) 61-6








Wheeler In Press





1812(4)4678-86





14921













Feb18(1)110-20











2012 May 117(3)e523-7








Radiol 2013 Aug116(2)238-57










12









Deband



25 year follow-up


13

Retrospective data









Conclusions












Thank-you










82(5) 356-60















105(4) 350-61



8


















14




















79-97






90(4) 321-6














30












111(3) 301-9

















61(2) 125-32


























427-34









64 395-9











390-6

















discussion 401-2










15







64 389-93





43-6






















57-67

















31(1) 61-6








Wheeler In Press





1812(4)4678-86





14921













Feb18(1)110-20











2012 May 117(3)e523-7








Radiol 2013 Aug116(2)238-57










13

Retrospective data









Conclusions












Thank-you










82(5) 356-60















105(4) 350-61



8


















14




















79-97






90(4) 321-6














30












111(3) 301-9

















61(2) 125-32


























427-34









64 395-9











390-6

















discussion 401-2










15







64 389-93





43-6






















57-67

















31(1) 61-6








Wheeler In Press





1812(4)4678-86





14921













Feb18(1)110-20











2012 May 117(3)e523-7








Radiol 2013 Aug116(2)238-57










14




















79-97






90(4) 321-6














30












111(3) 301-9

















61(2) 125-32


























427-34









64 395-9











390-6

















discussion 401-2










15







64 389-93





43-6






















57-67

















31(1) 61-6








Wheeler In Press





1812(4)4678-86





14921













Feb18(1)110-20











2012 May 117(3)e523-7








Radiol 2013 Aug116(2)238-57










15







64 389-93





43-6






















57-67

















31(1) 61-6








Wheeler In Press





1812(4)4678-86





14921













Feb18(1)110-20











2012 May 117(3)e523-7








Radiol 2013 Aug116(2)238-57










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