Republic of Iraq

Ministry of Higher Education

and Scientific Research
University of Baghdad
College of Dentistry

Orthodontic Root Resorption

)Review)
A project submitted to
The Collage of Dentistry, University of Baghdad, Department of
Orthodontic in Partial Fulfillment for the Bachelor of Dental Surgery

Presented by:
Hind Qasim Kareem

Supervised by:
Dr.Hiba M. Hussein
B.D.S, M.SC.
Lecturer of Orthodontics, College of
Dentistry/University of Baghdad

April, 2022
 Certification of the supervisor

I certify that the project entitled " Orthodontic root resorption" was
prepared by the fifth - year student Hind Qasim kareem under my supervision at
the Collage of Dentistry / University of Baghdad in partial fulfilment of the
graduation requirement for the Bachelor Degree in Dentistry.

Supervisors' name : Dr. Hiba M. Hussein

Date:

i
 Dedication

To my great mother

To my great father

God bless them

To my brothers

To everyone who helped me one day

With love

ii
 Acknowledgment

I would like to express my gratitude to Prof. Dr. Raghad abdulrazaq Al-

Hashimi, Dean of College of Dentistry for providing me this opportunity to
study.

My deepest gratitude to Prof. Dr.Yassir Abdual-Khadem Yassir, Head of

the Department of orthodontic dentistry.

My deepest gratitude and appreciation go to the lecturer Dr. Hiba M.

Hussein for her scientific support and for help in facilitating the performance of
this project.

iii
 Lists of contents
Subject Page no.
Cover page
Certification of the supervisor I
Dedication Ii
Acknowledgment Iii
List of content Iv
List of abbreviation Vi
List of figures Vii
Introduction 1
Aims of study 2
Chapter one: review of literature 3
1.1Definitions 3
1.2 History and Classification 3
1.3 Incidence and Prevalence 5
1.4. Internal root resorption 6
1.5 External Root Resorption 8
1.5.1 External Inflammatory Root Resorption 9
1.5.1.1 External Inflammatory Root Resorption after 9
Traumatic Injury
1.5.1.2 External Inflammatory Root Resorption in 10
Orthodontic Treatment (Pressure)
1.5.1.3 External Inflammatory Root Resorption
13
Induced by Root Canal Infection
1.5.1.4 Orthodontic Induced External Root resorption
13
of Endodontically Treated Teeth
1.5.2 Invasive Cervical Root Resorption 14

1.5.3 External Surface Resorption 15

1.6 Risk Factors for Root Resorption 15

1.6.1 Patient-related Factors 15

iv
1.6.1.1 Genetics and Hereditary Factors 16

1.6.1.2 Gender and Age 17

1.6.1.3 Type of Malocclusion 17

1.6.1.4 Pre-existing Root Resorption with or without 18

Trauma
1.6.1.5 Tooth/Root Morphology 18

1.6.1.6 Occlusal trauma and Habits 18

1.6.2 Treatment-Related Factors 18

1.6.2.1 Active Treatment Duration and Associated

19
Loading Regimen
1.6.2.2 Force Properties 19

1.6.2.3 Appliance Design 20

1.7 Treatment options 20

1.7.1 NO Treatment 21

1.7.2 NO Appliance on At-Risk Teeth 21

1.7.3 Avoid Root Movement 21

1.7.4 Short Treatment Time 21

1.7.5 Extractions And Implants 22

1.7.6 Endodontic Therapy 22

1.8 Prevention of root resorption 22

2.Chapter Two : Discussion 24

3.Chapter Three: Conclusion 25

References 26

v
 List of Abbreviations

Abbreviation Description
DPSCS Dental Pulp Stem Cells
ECRR External Cervical Root Resorption
EIRR External Inflammatory Root Resorption
HF Heavy Force
ICRR Invasive Cervical Root Resorption
IL-IP Interleukin-I Peta
IOPAR Intra-oral periapical radiographs
OCPS Osteoclast Precursors
OERR Orthodontic External Root Resorption
OF Orthodontic Force
OIIRR Orthodontically Induced Inflammatory Root
Resorption
PDL Periodontal Ligament

vi
 List of figures
Figure no. Description Page no.
Figure 1 Orthodontic apical root resorption after 2 years of 5
fixed orthodontic treatment. A: Before treatment; B:
after treatment.

Figure 2 Internal cervical root resorption, pink discoloration 7

in inflammation of PDL in maxillary central incisor.
Figure 3 Radiographic appearance showed extensive internal 8
resorption on maxillary central incisor.

Figure 4 (a) A Radiographs of maxillary central incisor have 10

luxation radiolucency around right incisor with
shortened root.
(b) Medicated with calcium hydroxide, extrusion of
intracanal dressing was noticed in the periapical
region.

(c) Extruded calcium hydroxide paste was resorbed

by surrounding tissue.
Figure 5 progressive external resorption of maxillary anterior 12
teeth in mid- and post – orthodontic.

Figure 6 A clinical classification of invasive cervical root 14

Resorption (a) class I (b) class II (c) class III (d)
class IV.

Figure 7 The majority of rapid advances in genetics in the last 17

4 decades, supposed the most diagnostic risk factor
of OIIRR is genetics: (a) in 1980 no data available
on genetic relation. (b): in 2020 genetic
compromised 65% of risk factor to OIIRR.
Figure 8 Orthodontic force direction effects on root 20
resorption. (A): Tipping, (B) Translation (C):
intrusion.

vii
 Introduction
Root resorption is a common pathological procedure that is believed to be
the result of various factors such as pulpal necrosis, trauma, periodontal
treatment, orthodontic treatment (Bansode et al., 2019).

It may be categorized by location (either internal or external), distribution

(localized or generalized) and affected teeth (primary, secondary, or both)
(Krishnan, 2005).

Most studies on root resorption and its relationship with orthodontic

treatment have found that there are multiple factors associated with root
resorption; Age, gender, nutrition, genetics, the type of appliance, the amount of
force used during treatment, extraction or non-extraction, duration of treatment,
influence on root resorption. Generally, the causes and mechanism of resorption
are still unclear (Baumrind et al., 1996; Jiang et al., 2001).

The process of root resorption is attributed to the activity of osteoclast

together with other cell like microphage and monocyte, Osteoclasts are large
multinucleated giant cells associated with the removal and resorption of
mineralized bone (Xing et al., 2005).

Most resorption is clinically insignificant, but if severe, root resorption

threatens the longevity of the teeth. With the improvements in orthodontic
techniques and the increase in patient expectations, orthodontists need to be
aware of this issue (Lindskog, 1985).

1
 AIM OF STUDY

The aim of this review is to explain and clarify the process of root
resorption as well as its causes, complication , in addition to prevention and
management.

2
 Review of Literatures
1.1 Definitions:
Root resorption is defined as destructive process of the tooth structures;
cementum and/or dentine layers of the root caused by activity of the clastic
cell that result in a subsequent resorption and lossin root structure, Root
resorption may be physiological or pathological process. During transition to
the permanent dentition, the Physiological root resorption described as naturally
occurring process in deciduous teeth when permanent teeth start eruption
process. It also may occur to a limited amount in the permanent teeth associated
with physiological tooth movement (Vlaskalic et al., 1998).

Orthodontically induced inflammatory root resorption (OIIRR) is term to

describe the type of root resorption that occurs during orthodontic treatment
process. (Brezniak and Wasserstein, 2002).

Pathological root resorption may occur in association with orthodontic

tooth movement, many pathological condition trauma, and when adjacent teeth
undergo ectopic eruption (Shah, 2017).

1.2 History and classification:

Root resorption was first known in 1856, when Bates first discussed the
Absorption' phenomena of permanent teeth. Using radiographic method in 1927,
Ketcham first demonstrated the distinctions between root shape pre and Post
OT. Soon after, an assortment of histologic, clinical, physiologic and biological
research on root resorption during OT, were published, all of which were well-
received by the orthodontic field (Ketcham, 1927).

3
 Andreasen, put forward a widely-acknowledged classification system in
1970, in which the condition is classified by location, type and etiological
features.

A multitude of classification systems and terminologies have been

Proposed since then, with various researchers trying to discover clinically-
related ones to ameliorate communication among clinicians and researchers in
addition to assisting diagnosis and treatment plans of this pathological state
(Andreasen, 1985; Tronstad, 1988; Patel and Ford, 2007).

Later, OIIRR is classified as Progressive External Inflammatory Root

Resorption by (Brezniak and Wasserstein, 1993b), who then sorted it into
three groups according to severity:

1) Cemental surface resorption with remodelling: resorption of outer cemental

layers only, which later on completely regenerated or remodelled, that similar to
remodelling of trabecular bone.

2) Dentinal deep resorption with repair: where the outer layers of the dentin as
well as the cementum itself are resorbed and repaired with cement material.
The final shape of the root could or could not look like the original form after
this resorption and formation process.

3) Circumferential apical root resorption: where the hard tissue constitutes of the
root apex are completely resorbed, and reduced root length is thus clear. It is
certainly possible there are different degrees of apical root shortening.

The OIIRR can also be called 'Periapical Replacement resorption which

develops when there is persisting pressure. This causes more marked a blunting
of the apex or even extreme root length loss in the more difficult cases as
showed in (Figure 1), which could be caused by the combination of external
inflammatory resorption around apical cementum and internal inflammatory

4
resorption of apical pre-dentine, ensuing in periapical replacement resorption
(Bender, 1997).

Figure 1: Orthodontic apical root resorption after 2years of fixed orthodontic treatment.
A: Before treatment; B: after treatment (Cho and Kim, 2013).

1.3 Incidence and prevalence:

Due to heterogeneity in most published studies, it is strenuous to estimate

a reliable rating of OIIRR incidence in the subjects' teeth (Killiany,1999).
Mostly detected OIIRR is ranged to be minor to moderate in orthodontic
patients according to graded scales assessment of severity (using either
periapical or panoramic radiographs) (Peltola, 2007).

Previous studies have also shown that a reverse relation between

incidence values and OIIRR severity. Recent systematic reviews and meta-
analysis were conducted to qualify and identify the incidence and severity of
OIIRR pre- and post -comprehensive OT in the studies using CBCT, and the
results showed that the anterior maxilla was showing the greatest amount of
OIIRR followed by the anterior, posterior, mandible, and finally the posterior
maxilla (Deng et al., 2018).

5
 The applied OF in previous studies have been of different types,
magnitudes and durations with small samples. Using different orthodontic
treatement techniques, both single and multi-rooted teeth at different root
development stages have been compared. With respect to certain selection
criteria and evaluations of the root resorption, various methodologies for
resorption detection have been applied in the studies. As the majority of studies
have been non-randomized, retrospective, and was inconclusive of all systemic
or local risk factors (Roscoe et al., 2015; Currell et al., 2019).

1.4 Internal root resorption:

In transient internal inflammatory root resorption, pulpal inflammation

compromised the integrity of the odontoblasts attached to the root canal wall. As
a result, no more predentin is formed in the damaged area. With the elimination
of pulpal inflammation, this transient resorptive process can be self-limiting and
requires no clinical treatment. In most cases, the loss of intraradicular dentine is
permanent and progressive because the inflammatory processes in the root canal
are difficult to be contained. Pulpal infection is often associated with internal
inflammatory root resorption; however microbial stimuli alone do not initiate
this resorptive activity. For the progressive resorption to occur, the clastic cells
must be recruited and activated. The clastic cellsadhere to the mineralized dentin
in the resorptive site, where the anti-invasive non- mineralized structures
(odontoblasts layer and predentin) are disrupted and the mineralized tissues are
resorbed. (Tronstad, 1988).

The origin of the metaplastic tissue may be dental pulp stem (DPSCs)
which are able to generate reparative dentine-like tissue on the surface of cells
human dentine (Batouli et al., 2003).

6
 Internal resorption is initiated by damage or loss of odontoblast layers and
protective pre-dentin and is associated with long lasting pulpal
inflammation/infection dental trauma, restorative procedures, cracked tooth,
pulpitis, orthodontic treatment and developmental anomaly are the predisposing
factors contributing to internal root resorption.This type of resorptive defect is
associated with low-grade inflammation of the pulp. Histologically, lamellar
bone-like structures substituted the resorbed dentine with entrapped osteocyte-
like cells (Patel et al., 2010).

Clinically, internal inflammatory root resorption may be asymptomatic in

early stages. When the infection occupies the entire root canal and progresses to
the extraradicular region, periapical symptoms such as pain on biting may be
reported.A classic sign of internal inflammatory resorption taking place in the
pulp chamber is called the Pink tooth of Mummery. (Figure 2) showed A pink-
hued area on the crown of affected tooth. The origins of the resorption of
internal inflammatory root resorption (from the pulp tissue) and invasive
cervical root resorption (from periodontal tissue) are different. Clinically, Pink
tooth of Mummery shows pink discoloration within the clinical crown under the
intact enamel (Tronstad,1988).

Figure 2: Internal cervical root resorption, pink discoloration in inflammation of PDL in

maxillary central incisor (Tronstad, 1988).

7
 Radiographically, the appearance of the lesion is described as well a
circumscribed, symmetrical , oval, or circular-shaped radiolucency , and the
outline of the radiolucency is continuous with the shape of the root canal
showed in Figure (3), When the resorptive lacunae can be detected by routine
radiographs, immediate endodontic treatment is often required to eliminate the
source of infection (Gulabivala, 2014).

Figure 3:radiographic appearance showed extensive internal resorption on maxillary central

incisor (Gulabivala, 2014 ).

The mechanism of the subsequent deposition of metaplastic tissue is

similar to the formation of reparative tertiary dentine by odontoblast- like cells
after the elimination of odontoblasts in pulpal infection. Radiographically,
internal replacement root resorption displays an irregular enlargement of the root
canal space with distortion of the normal root canal outline (Patel et al., 2010).
1.5 External Root Resorption:

External root resorption is commonly associated with dental trauma

orthodontic treatment, and periapical periodontitis. Andreasen has classified
external root resorption into surface, inflammatory and replacement resorptions.
The location of the external resorption usually involves the apical, lateral and
cervical regions (Andreasen ,1985).

1.5.1 External Inflammatory Root Resorption:

8
 This type of root resorption is caused by persistent inflammation of
PDL sustained by mechanical, infective, and pressure stimulation. Clinically
external inflammatory root resorptions (EIRR) are commonly seen in
patients with traumatic injury, orthodontic treatment, root canal infection, and
tooth impaction (Tronstad ,1988).

1.5.1.1 External Inflammatory Root Resorption after Traumatic Injury:

EIRR is a severe complication after dental trauma, especially after tooth

avulsion. A meta-analysis demonstrated that the occurrence of EIRR in a pooled
1656 avulsed teeth was 23.2% (Andreasen and Kristerson, 1981).

An animal study conducted by Andreasen indicated that EIRR can initiate

in 1 week after replantation of avulsed tooth in green vervet monkeys. Four
prerequisites were proposed by Andreasen for this type of resorption to occur
(Andreasen, 1985).

1) Injury to PDL, either from mechanical injury from avulsion, luxation,

intrusion and root fracture or from physical (i.e., extending drying time after
avulsion) or chemical (improper storage solution, for avulsed tooth) damage of
the PDL.

2) Exposure of dentinal tubules of the injured area by damaging the protective

cementum/cementoid, in order to ensure osteo-/odontoclastic activity directly on
dentine surface.

3) Communication between the exposed dentinal tubules and the necrotic pulp
tissue or leucocyte zone harboring bacteria, in order to have bacteria an bacterial
-endotoxins pass through dentinal tubules to root surface to amplify osteo-/odon-
toclastic activity.

4) Avulsed tooth is immature or young matured.

9
 Clinically, patient with EIRR may report no symptoms unless the infection
becomes acute to show signs and symptoms as acute apical abscess (Figure 4),
The radiographical characteristics are a distinctive hollow or blunt surface on
the shorten root and a radiolucency in the root surrounding bone (Heithersay,
2007).

Figure 4: (Heithersay, 2007 )

(A) A Radiographs of maxillary central incisor have luxation radiolucency around right
central incisor with shortened root. (B) Medicated with calcium hydroxide, extrusion of
intracanal dressing was noticed in the periapical region. (C) Extruded calcium hydroxide
paste was resorbed by surrounding tissue

1.5.1.2 External Inflammatory Root Resorption in Orthodontic Treatement

(Pressure):

During orthodontic treatment, the blood flow in the compressed PDL is

disturbed, leading to hyalinization of periodontal tissues. The anti-resorptive
barrier on the root surface is eliminated by macrophages, and the exposed
cementum can be easily accessed and attacked by clastic cells in the favored
resorption-promoting environment around a hyalinized area. The resorptive
process can be arrested when the orthodontic forces are discontinued (Rygh,
1977).

10
 Although most OERR involved teeth remain asymptomatic, the occurrence
of moderate and severe resorption would certainly require clinical attention. An
estimated 1/3 of the patients who have undergone orthodontic treatment showed
more than 3 mm OERR, and 5% of the patients had a resorption more than 5mm
(Killiany, 1999).

EIRR sustained by orthodontic treatment, or orthodontic external root

resorption (OERR), is an undesirable iatrogenic consequence in orthodontics.
maxillary anterior teeth are the most venerable and commonly affected teeth The
by OERR.Understanding the predisposing factors of OERR will facilitate
clinicians to precaution potential root resorption during orthodontic treatment.
Some of the commonly known predisposing factors include dilacerated and
pointed teeth (Sameshima and Sinclair 2001a).

Sameshima and Sinclair concluded that first premolar extraction therapy,

horizontal displacement more than 1.5 mm and longer treatment time are
significantly associated with OERR (Sameshima and Sinclair, 2001b).
Clinically, the involved teeth can maintain vital pulp and remain
asymptomatic.Figure (5) showed a radiographic appearance shows normal PDL
space and surrounding alveolar bone despite shortened root (levander and
malmgren, 2000).

11
Figure 5: (a–c) Progressive external resorption of maxillary anterior teeth in mid- and
post- orthodontic treatment ( levander and malmgren, 2000 ).

12
1.5.1.3 External Inflammatory Root Resorption Induced by Root Canal
Infection (Tronstad, 1988):

Apical persistent external inflammatory resorption is a complication of

root canal. Microorganisms and their by-products in the infected and necrotic
pulp cause inflammatory reactions in PDL adjacent to the exposed dentine in the
apical region. Hard tissue resorption stimulators such as macrophage-
chemotactic factor, osteoclast-activating factor and prostaglandins are released
to initiate the resorptive process.

Clinically, the involved tooth is usually non-responsive to pulpal vitality

test. The affected tooth may present signs as symptomatic apical periodontitis or
chronic apical abscess. Mobility of tooth may be noticed in case of extensive
resorption. A typical sign on radiograph is periapical radiolucency around
shortened root of involved tooth. “Extrusion” of root canal filling material can
be noticed in unsuccessful endodontic treatment cases due to the resorption of
dental tissue in apical portion of the root.

1.5.1.4 Orthodontic Induced External Root resorption of Endodontically

Treated Teeth:

Compare to vital pulp teeth, whether endodontically treated teeth are more
susceptible to orthodontic induced external root resorption remains
controversial. Bender et al. reported one case that orthodontically treated
maxillary incisors exhibited severe apical resorption, while little apical
resorption was observed in the endodontically treated maxillary central tooth.
The reasons might be the loss of the pulpal immunoreactive neuropeptides due
to the removal of pulp tissue during root canal treatment and the application of
long-term used calcium hydroxide that can create an alkaline environment in the
periapical region (Bender et al., 1997).

13
 Orthodontically treated teeth can be subjected to external root resorption,
the especially maxillary anterior teeth (Sameshima and Sinclair, 2001a).
Recently, A meta-analysis including seven prospective and retrospective
controlled clinical trials was conducted, and the result indicated that
orthodontic-induced external root resorption was less in endodontically treated
teeth compared to their contralateral vital pulp teeth. Clinical trial might not be
applicable at this moment when determining whether endodontic treatment
increases the risk of orthodontic induced external root resorption (Alhadainy et
al.,2019).

1.5.2 Invasive Cervical Root Resorption:

Invasive cervical root resorption (ICRR) or external cervical root resorption

(ECRR) is characterized by an aggressively destructive invasion of the cervical
region of the root (Heithersay,1999a). It is commonly considered as a
subcategory under external inflammatory root resorption. The pathologic
process involves a progressive resorption of cementum, enamel, and dentine by
fibro-vascular tissues subsequent to the damage to the cervical attachment
apparatus below the epithelial attachment. (Figure 6) showed A clinical
classification of ICRR has been described by Heithersay based on the
extensiveness of the resorption (Heithersay, 2004).

C D

A B

Figure 6: A clinical classification of invasive cervical root resorption (a) Class I. (b) Class II.
(c) Class III. (d) Class IV (Heithersay,2004).

14
1) Class I: a small invasive resorptive lesion with shallow penetration into the
dentine near the cervical area.

2) Class II: a well-defined resorptive lesion that has penetrated near the coronal
pulp chamber but not extended into the radicular dentine.

3) Class III: a deeper penetration of resorptive lesion into dentine and extended
to the coronal one third of the root canal.

4) Class IV: a larger and deeper penetration of invasive resorptive process

extended beyond the coronal third of the root canal.

1.5.3 External Surface Resorption:

Surface resorption is a self-limiting and transient osteoclastic process

followed by cementum healing and reattachment of PDL. It is a consequence of
limited injury to the root surface or supporting periodontium, often seen in
traumatic injuries and orthodontic treatment (Andreasen, 1985).

1.6 Risk Factors for Root Resorption:

Despite huge number of researches aimed to find out the causal basis of
OIIRR, but they still failed to elucidate the aetiology. As these conditions
multi- factorial; therefore orthodontic treatement effect is still elusive. Many
studies were concluded that it is a result of the inter-relationship between
patient and treatment-related factors. Unfortunately, till now no reliable
measures to predict patients who are more susceptible to experience OIIRR and
severity are currently available (Brezniak and Wasserstein, 2018).

1.6.1 Patient-related Factors:

Major factor to OIIRR aetiology and severity is patient susceptibility, and

these are either systemic or local factors which are as follow (Brezniak and
Wasserstein, 2018).

15
1) Genetics and Hereditary Factors.

2) Gender and Age.

3) Type of Malocclusion.

4) Pre-existing Root Resorption with or without Trauma.

5) Tooth/Root Morphology.

6) Occlusal trauma and Habits.

1.6.1.1 Genetics and Hereditary Factors:

In spite of genetic studies are ultimately heterogeneous, they found

genetic variation in orthodontic patients of the OIIRR, thus suggested that
genetic and hereditary play a crucial role for this susceptibility difference
between patients to patients (Al-gawasm et al., 2003).

Studies in this field attempted to investigate genes that have mostly direct
correlation with bone remodelling pathways (mostly interleukin-I Peta, IL-1p),
and they found a close relation of genetic variation and OIIRR (Abass and
Hartsfield, 2007).

A systematic review and meta-analysis was carried out by (Nowrin et al.,

2018) to investigate the association between various gene Polymorphisms and
their interaction with OIIRR. The consequence of this systematic analysis
indicates that different gene polymorphisms may suggest the occurrence of
OIIRR in some patients undergoing orthodontic treatement . In conclusion, rapid
advance in genomic, proteomics and recently metabolomics application in this
field improved the knowledge of genetic and their products on the process of
resorption to be the major risk factor related to induce orthodontic root
resorption as showed in Figure(7).

16
 Figure 7: The majority of rapid advances in genetics in the last four decades, supposed the
most diagnostic risk factor of OlIRR is genetics. (A): in 1980 no data available on genetic
relation. (B): in 2020 genetic compromised 65% of risk factor to OIIRR (Sameshima, 2021) .

1.6.1.2 Gender and Age:

There is agreement that OIIRR is not consistently gender- related

However, some studies found that the OIIRR was prevalent among either male
or female. There were also controversial findings between studies (Weltman et
al., 2010).

In the literature, the incidence of OIIRR was found to be increased in adult

patient than adolescents. This is justified by age-related changes in periodontium
and vascularity that got worse with increased age (Picanço et al., 2013).

1.6.1.3 Type of Malocclusion:

It was evident previously that the severity of root resorption increased

with increased tooth movement distant; therefore, studies showed teeth
experienced sever OIIRR in specific types of malocclusion than others.
Increased overjet in Class II division 1 malocclusion patients who needed teeth
extraction in the upper arch (mostly upper first premolars) and patients with
anterior open bite (Kuperstein, 2005; Preoteasa and Ionescu, 2011).

17
1.6.1.4 Pre-existing Root Resorption with or without Trauma:

There was a close positive relation between resorption before orthodontic

treatement (due to trauma or idiopathic) and after treatment completion
(Brezniak and Wasserstein, 2002b).

1.6.1.5 Tooth/Root Morphology:

Pipette, pointed or dilacerated roots reported as abnormal roots shape

diagnosed at a high risk level for resorption susceptibility (Sameshima and
Sinclair, 2001).

1.6.1.6 Occlusal trauma and Habits:

Alveolar bone resorption could be associated with root resorption

Occlusal trauma (either due to habits like bruxism or premature contact) showed
to be resulting in alveolar bone loss, thus could encourage root resorption in the
presence of OF application (Sameshima, 2004).

1.6.2 Treatment-Related Factors:

(Aras et al., 2012) stated that in addition to the existing body of scientific
literature on OIIRR-related patients' factors, it fails to recognize a
straightforward method that can be utilized by orthodontists to avoid OIIRR.
Therefore, the investigators aimed to examine clinical data on therapeutic
factors which can reduce irreversible destruction of the tooth structure. There
are many treatment factors could be related to OIIRR, but the mostly related and
the researchers main targeted are as follow:

1.6.2.1 Active Treatment Duration and Associated Loading Regimen

The effect of active versus passive treatment duration showed a strong and
inverse relations with OIIRR, respectively. Previous studies showed resorption

18
initiation occur at the 3rd week of force application and if the force persist, it
would get worsen (Casa et al., 2006).

Clinical studies showed a strong positive correlation between time and

sever OIIRR. Studies evaluated continuous versus intermittent force regimen
showed direct influence with increased OIIRR this could be related to the pause
period that allowed the resorbed cementum repair (Aras et al., 2012).

1.6.2.2 Force Properties

Force magnitude and direction also evaluated on the basis of risk

resorption factors. It was evident that HF application(in most of experimental
clinical studies a 225 vs 25g of force magnitude was compared) results in
increased resorption incidence (Weltman et al., 2010; Roscoe et al., 2015;
Currell et al., 2019).

Particularly, force direction correlations could affect root resorption

severity, as shown in Figure (8). The intrusive forces showed fourfold increase
in OIIRR compared with extrusion force followed by root torqueing (Casa et
al., 2006 Bartley et al., 2011) buccal tipping (Ahuja et al., 2017) and finally,
rotation (Wu et al., 2011).

Figure 8: Orthodontic force direction effects on root resorption. (A): Tipping, (B)
Translation.(C): intrusion (Profit et al., 2019).

19
1.6.2.3 Appliance Design

Orthodontic bracket types, prescription, systems and ligation method with

different wire types and sequencing, were investigated for their correlation with
OIIRR. Surprisingly, no statistical significant correlation with an increase or
decrease in OIIRR (Weltman et al., 2010; Roscoe et al.,2015 and Currell et
al., 2019).

1.7 Treatment options:

Justus in 2015 stated that the key to understanding treatment options lies
in understanding risk factors, educating the patient and dentist, and determining
the best plan for the patient. This may involve compromises or alternative plans.
stated that there were five ways to prevent or circumvent EIRR.

1.Growth modification to correct severe skeletal Class II malocclusions.

2.Early interception of maxillary canines that have mesial eruption paths.

3.Serial extraction to modify eruption paths (guidance of eruption).

4.Correction of anterior open bite with a palatal tongue spur appliance.

5.Orthognathic surgery to avoid moving teeth large distances and against

cortical plates.
There are many treatment options such as no treatment no appliances on
at-risk teeth, avoid root movement and short treatment time.

1.7.1 No Treatment:

Sometimes the best treatment is no treatment or no orthodontics. Veneers

or other restorative solutions may be preferred. Extraction of short-rooted teeth
in itself is not a justification for implants; however, in certain situations it may
be the best course (Sameshima, 2001).

20
1.7.2 No Appliances on At-Risk Teeth:

Do not band or bond any brackets or attachments on teeth at high risk, if

for the possible treatment entirety, if not then for as long as necessary for
alignment and space closure. Brackets must be placed precisely, so no tweaking
with wire bends or repositioning becomes necessary (Sameshima, 2001).

1.7.3 Avoid Root Movement:

The orthodontist must limit apical displacement including torque and

bodily movement. Rotation and tipping on a limited basis with no round tripping
is acceptable. Patient must be forewarned for the need of more frequent
radiographs (Sameshima, 2001).

1.7.4 Short Treatment Time:

Treatment time must not exceed the normal treatment duration for the
type of case. Treatment goals may have to be compromised. Patients’
cooperation in not missing appointments or breaking appliances is important.
Oral hygiene must be monitored and appropriate steps taken (Sameshima,
2001).

1.7.5 Extractions and Implants:

Extraction cases generally take longer, but with proper mechanics and
minimizing movement of at-risk teeth, extractions is important to resolve the
moderate and severe crowding. Not achieving ideal or desired out comes even
such as correcting overjet and overbite completely must be an acceptable
compromise, and the patient must be so informed. The first surgery of the lower
jaw was an interesting solution on a 14-years-old patient who had idiopathic root
resorption by (Carlier et al.,2019).

21
1.7.6 Endodontic Therapy:

Clinical experience and the orthodontic (and endodontic) literature tend to

the support finding that endodontically treated teeth. Bender et al., reported this
in 1997 with a case series review (43 patients). In their comprehensive study of
over 1000 patients found no EARR in teeth that had had a root canal
(Sameshima and Sinclair, 2001).

A systematic review was inconclusive due to a lack of randomized clinical

trials. Resorption of the root apex was found in endodontically treated maxillary
incisors after orthodontic tooth movement in a split mouth study, but there was
no significant difference (Walker 2010; Liamas-Carreras et al., 2012).
1.8 Prevention of root resorption:

During orthodontic treatment, progress radiographs should be obtained

after 6- 12 months to detect the early occurrence of OIIRR. If detected, active
treatment should be halted for 2-3months. So that, a treatment pause of 2-3
months with passive arch wires led to a decrease in the prevalence and severity
of root resorption (Levander, 1994).

If severe resorption is identified the treatment plan should be re-assessed

with the patient. Alternative options might include prosthetic solutions to close
spaces, releasing teeth from active arch wires if possible, stripping instead of
extractions, and early fixation of resorbed teeth (Brezniak, 2002b).

If severe external apical root resorption is observed the treatment on the

final radiographs, follow-up radiographic examinations are recommended until
the resorption has stopped. After appliance removal, stabilization of active
external apical root resorption usually occurs. If resorption does not stop,
sequential root canal therapy with calcium hydroxide may be considered (Pizzo ,
2007).

22
 Chapter Two : Discussion
Orthodontically induced inflammatory root resorption (OIIRR) is
considered to be a particularly important sequelae associated with orthodontic
treatment. Root resorption associated with orthodontic treatment is undesirable
pathologic consequence of orthodontic tooth movement that can jeopardize the
prognosis and the success of orthodontic treatment (Bader, 2001).

The etiology of root resorption accompanied with orthodontic treatment is

complex. Several factors, alone or in combination, could contribute to root
resorption.

Monitoring for resorption in every case should be done, but even more for
of high risk cases during both the active phase of treatment and after the end
treatment. When there is history of trauma or after root canal treatment Also,
there are other factors that can contribute to root resorption such as blunted root,
long treatment time and using heavy force for teeth movement (Bader, 2001).

The screening should involve both the apical and the cervical zones of the
teeth subject to orthodontic forces. A mid-treatment radiographic evaluation
with IOPAR can reveal teeth at risk, if there is suspicion of resorption, the cone
beam is a very precise diagnostic tool. It makes it to possible determine the
anatomical context, as well as the extent and severity of the resorption
(Levander, 1994).

23
 Chapter Three: Conclusion and suggestion
1) Increased incidence and severity of OIIRR is found in patients undergoing
comprehensive orthodontic therapy.

2) Heavy force application produced significantly more OIIRR than light force
application or control.

3) Patient’s age would appear to be an influencing factor in root resorption.

Older patients tend to have significant root resorption after orthodontic treatment
and an element of upper root resorption before treatment.

4) Treatment duration has a statistically significant correlation with post-

treatment root resorption the longer the duration, the more severe the root
resorption.

suggestion
For further studies, we suggest making survey among finished orthodontic
cases, estimating the degree of root resorption, as well as the most affected teeth
with different types and techniques of orthodontic appliance.

24
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