REVISTA

ARTÍCULO DE

REVISIÓN

ROOT RESORPTION FOLLOWED BY ORTHODONTIC

TREATMENT IN INDIVIDUALS WITH ANTERIOR OPEN
BITE. A COMPLETE VISION FOCUSED ON DIFFERENT
TREATMENT ALTERNATIVES: A REVIEW
REABSORCIÓN RADICULAR SEGUIDA DE TRATAMIENTO DE
ORTODONCIA EN INDIVIDUOS CON MORDIDA ABIERTA ANTERIOR. UNA
VISIÓN COMPLETA CENTRADA EN DIFERENTES ALTERNATIVAS DE
TRATAMIENTO: UNA REVISIÓN
Ruth Elizabeth Ramirez-Diaz1 * ABSTRACT
[email protected]
The aim of this review was to determine the incidence of different types of treatment and the
Karen Moscoso-Sivirichi2 prevalence of root resorption in incisors induced by orthodontic treatment in patients with open
[email protected] bite. Libraries and electronic databases were searched, with 322 articles being selected and 55
articles considered regarding PRISMA checklist. It has been shown that apical root resorption of
Michella Consoli-Senno3
[email protected]
the incisors is more frequent in patients with premolar extractions than in those treated without
extractions, due to greater apical displacement during retraction of the anterior teeth in the space
closure phase. On the other hand, it has been described that intrusion of posterior teeth is four
times more likely to cause root resorption than extrusion movement, thereby increasing the risk of
root resorption in posterior teeth compared to conventional orthodontic treatment not requiring
molar intrusions. Finally, aligners, such as orthodontic treatments with fixed appliances, have not
been shown to induce clinically significant root resorption in open bite individuals. Literature on
root resorption in open bite treatments is scarce making difficult conclusions difficult. However,
the amount of root loss in cases of open bite seems to be similar to that of individuals without
open bite.
Keywords: open bite treatment, incisor root resorption, molar root resorption, root resorption,
aligners

Artículo recibido: 25/06/2022 RESUMEN

Arbitrado por pares
Artículo aceptado: 04/09/2022 El objetivo de esta revisión fue determinar la incidencia de los diferentes tipos de tratamiento y la
Artículo publicado: 29/09/2022 prevalencia de la reabsorción radicular en los incisivos inducida por el tratamiento de ortodoncia en
pacientes con mordida abierta. Se realizaron búsquedas en bibliotecas y bases de datos electrónicas,
* Corresponding author:
se seleccionaron 322 artículos y se consideraron 55 artículos de acuerdo con las guías PRISMA. Se
Ruth Elizabeth Ramirez-Diaz
[email protected] ha demostrado que la reabsorción radicular apical de los incisivos es más frecuente en pacientes con
extracciones de premolares que en los tratados sin extracciones, debido al mayor desplazamiento
apical durante la retracción de los dientes anteriores en la fase de cierre de espacios. Por otro lado,
se ha descrito que la intrusión de los dientes posteriores tiene cuatro veces más probabilidades de
©Los autores, 2022. Publicado por la causar reabsorción radicular que el movimiento de extrusión, lo que aumenta el riesgo de reabsorción
Universidad Científica del Sur (Lima, Perú)
radicular en los dientes posteriores en comparación con el tratamiento de ortodoncia convencional
que no requiere intrusiones molares. Finalmente, no se ha demostrado que los alineadores, como
los tratamientos de ortodoncia con aparatos fijos, induzcan una reabsorción radicular clínicamente
Cite as: Ramirez-Diaz RE, Moscoso- significativa en individuos con mordida abierta. La literatura sobre reabsorción radicular en
Sivirichi K, Consoli-Senno M. Root
tratamientos de mordida abierta es escasa, lo que dificulta conclusiones definitivas. Sin embargo, la
resorption followed by orthodontic
treatment in individuals with anterior open cantidad de pérdida de raíz en los casos de mordida abierta parece ser similar a la de las personas
bite. A complete vision focused on different sin mordida abierta.
treatment alternatives: A review. Rev Cient
Odontol (Lima). 2022; 10(3): e118. Palabras clave: tratamiento de mordida abierta, reabsorción de la raíz del incisivo, reabsorción
DOI: 10.21142/2523-2754-1003-2022-118 radicular molar, reabsorción radicular, alineadores
1
School of Dentistry, San Martin de Porres University, Lima, Peru.
2
School of Dentistry, Alas Peruanas University, Lima, Peru.
3
School of Dentistry, Cayetano Heredia University, Lima, Peru.

Rev Cient Odontol (Lima). 2022; 10 (3): e118 ARTÍCULO DE REVISIÓN 1

 Ramirez-Diaz RE, Moscoso-Sivirichi K, Consoli-Senno M.

INTRODUCTION METHODOLOGY

External apical resorption (EAR) is one of the main Information sources and search strategy
undesired effects that may occur in orthodontic
treatment. Several factors can favor EAR, including the This review included a bibliographic search in the main
magnitude, direction, time of use and type of orthodontic sources of scientific information, including Medline
force. The risk of EAR has been calculated as being 3.72- via PubMed, Scopus and the Cochrane library. The
fold higher in patients with premolar extractions than search was carried out until May 5, 2022, and the search
in those without extraction. However, in general, the strategies are presented in Table 1.
origin of EAR is multifactorial and is not only related
to orthodontic treatment (1–15). Other factors identified
include genetic and systemic factors, sex, and the type of Study selection
malocclusion (16–18).
Finally, 24 papers meeting the following inclusion criteria
Treatment of anterior open bite is considered a challenge were included: observational studies, and randomized
for many orthodontists, with a prevalence ranging clinical trials in humans of both sexes. In vitro studies,
between 1.5% and 11% in different age groups and letters to the editor, personal opinions and case reports
populations (19–21). In addition, it is associated with mouth were excluded. (Fig. 1).
breathing, sucking habits, and altered development of the
mandible and maxilla, and thus, orthodontic treatment
must be interdisciplinary, considering several treatment
alternatives including interceptive orthodontics,
orthodontic camouflage, mini-implants, mini-plates and
orthodontic-surgical treatment (22–24).

It is important to recognize the magnitude of root

resorption in patients with anterior open bite treated
orthodontically, since its development is frequent after
performing biomechanics to treat this condition with
posterior intrusion and inevitable anterior extrusion
(25–27). However, although it has not been clearly
demonstrated that anterior extrusive orthodontic
movement induces greater root resorption (26,28–30),
several studies have related root loss after extrusive
movement to a history of trauma and inflammatory Fig 1. Flow chart for the selection of studies.
processes (31,32). Root resorption is an undesired risk
that must be detected as soon as possible, with adequate
periodic radiological monitoring and the corresponding RESULTS AND DISCUSSION
therapeutic precautions (33,34). Additionally, it is
necessary to clarify the magnitude of root resorption Orthodontic treatment of open bite with and without
in the different open bite treatment alternatives and premolar extractions
whether it represents an oral health risk that should be
considered. Therefore, the aim of this literature review Six articles met the inclusion criteria. All were studies
was to compare root resorption of maxillary incisors published in journals indexed in reliable sources of
according to the different alternatives of orthodontic information and described that patient with premolar
treatment for correcting anterior open bite. extractions present more apical root resorption of the

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Root resorption followed by orthodontic treatment in individuals with anterior open bite. A complete vision focused
on different treatment alternatives: a review

TABLE 1. Strategies in the search for scientific articles in condition of open bite that generates a greater risk of root
the main sources of information
resorption but rather root resorption is due to retraction
Source Search Items of the incisors as a result of the retraction movement in
(((root resorption) OR (dental resorption)) OR cases treated with dental extractions (36).
PubMed (89) (orthodontic dental resorption)) AND ((open bite) OR
(open bite treatment))
Regarding the use of anterior vertical elastics used for
(TITLE-ABS-KEY (root AND resorption OR dental AND
resorption OR incisor AND root AND resorption OR
open bite closure and treatment time, neither showed
Scopus (228)
molar AND root AND resorption)) AND (open AND bite a significant association or correlation with the degree
AND treatment OR open AND bite) of root resorption. This is important since it allows
(root resorption OR dental resorption OR incisor root clinicians to more adequately manage these cases (16,37).
SciELO (2) resorption OR molar root resorption) AND (open bite OR
open bite treatment) It is concluded that there is a significant difference in
root resorption in orthodontic treatments in patients
with open bite with and without extractions, with cases
incisor than patients treated without extractions, due treated with extractions presenting a greater amount
to greater apical displacement during the retraction of of root resorption following retraction of the anterior
the anterior teeth in the spaces closing phase. McNab et segment for closure of spaces.
al.35 found that the amount of root resorption was 3.72-
fold greater in patients with extractions than in those
without (95% confidence interval: 1.96–7.04). It should Orthodontic treatment of open bite with intrusion of
be noted that the studies evaluated significantly differed molars and premolars
in terms of the study design used, the methodology, the
comparison with a control group, the characteristics In relation to this topic, 13 articles met the selection
of the treatment, the radiographic technique used, the criteria. Several therapeutic alternatives are able to
standardization of the capture and, therefore, generally achieve intrusion of the posterior teeth, including
had a small sample size (16,35-39). In addition, several traditional biomechanical techniques, such as headgear,
studies did not distinguish the biological variables related chin rest, and active vertical corrector with magnets,
to the patient and the characteristics of each treatment. among others. However, these require a high level of
All these variables can directly influence the degree of cooperation on the part of the patient to effectively
root resorption of the teeth evaluated and are common control molar intrusion (1,37,38). Likewise, the Begg
problems that do not allow generalization of the results, technique, which includes tip-back bends mesial to
thereby limiting their external validity (16,37-39). the tube of first molars, seeks to achieve intrusive
effects similar to the Bioprogressive technique (38-
On the other hand, other studies showed that the 41
). In recent years, skeletal anchorage devices, such as
treatment of open bite carried out with premolar miniplates and miniscrews, have gained popularity
extractions did not show statistically significant due to their great ability to provide stable anchorage
differences in reference to the degree of root resorption throughout orthodontic treatment and the low need for
when compared with groups treated with extractions, patient collaboration. However, the secondary effects
but with normal overbite. Likewise, they found no of intrusion with the use of any of these methods have
differences when comparing groups with open bite been little studied. Nonetheless, the few studies available
treated without extractions versus groups with normal allow some conclusions to be drawn.
overbite treated without extractions. Overall, there
was a statistically significant correlation between root Anterior open bite is characterized by maxillary
resorption and change in horizontal overjet in premolar and/or mandibular vertical dentoalveolar excess and
extraction groups, suggesting that incisor retraction hyperdivergent maxillomandibular growth, making its
could be considered a predictive factor of greater root treatment a clinical challenge for orthodontists (42-45).
resorption (16). This demonstrates that it is not the initial

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 Ramirez-Diaz RE, Moscoso-Sivirichi K, Consoli-Senno M.

Indeed, to solve this vertical alteration, orthodontists complexity, without skeletal discrepancies, mainly with
plan a true molar intrusion that corrects the skeletal mild crowding, favoring the low incidence and severity
open bite. In this sense, it has been reported that the of root resorption by the creation of intermittent forces
intrusion of posterior teeth is four times more likely to due to the occasional extraction of the aligner during
cause root resorption than extrusion movement, thereby the consumption of food and maintenance of hygiene.
increasing the risk of root resorption in posterior teeth However, the use of aligners has evolved rapidly, and
compared to conventional orthodontic treatment that new built-in features facilitate the treatment of more
does not require molar intrusions (46). complex malocclusions (49-51).

Some studies described that apical root resorption in There is at least one report of root resorption in the
posterior teeth subjected to intrusive mechanics ranges general treatment of malocclusions with aligners. This
from 0.02 mm to 2.49 mm while in other studies indicates that as with other orthodontic treatments with
resorption ranged from 0.84 mm to 1.00 mm, with forces fixed appliances, the incidence of root resorption is not
between 200 g and 400 g. However, it is important to reduced. In other studies, post-treatment cases with fixed
note that this amount of resorption, although present appliances and aligners presented 85.3% and 41.81% of
and clinically undesirable, is not very relevant and does root resorption, respectively, mainly affecting the upper
not place the dental health of patients at risk (25,47). lateral incisors and the lower lateral and central incisors
(51-53).
Some researchers recommend the use of cone beam
computed tomography to detect the presence of root Although aligners have often been considered of limited
resorption, since conventional radiographs such as efficacy, some studies have demonstrated their success
lateral cephalogram, panoramic and periapical films are in the treatment of mild anterior open bites, producing
not sufficiently precise. Neither are they the indicated a bite block effect and maintaining vertical control, and
methods to evaluate the amount of resorption, due to thereby making aligners a possible alternative treatment
errors of measurement, magnification and overlaps, for open bite cases (49,54).
which can lead to underestimation or overestimation of
the amount of root resorption (10,16,25,47,48). Few studies have described the use of aligners for
the treatment of open bite and the effect on incisors,
Taking into account the few studies available and the concluding that incisor root resorption was less than 1
unpredictable methods used, such as conventional mm, which is considered a clinically insignificant value.
radiographs, it cannot be concluded that there is Moreover, the results cannot be extrapolated because of
significant apical resorption after performing molar and the few studies available and, thus, further studies are
premolar intrusion mechanics. Nonetheless, it should necessary to clarify the possible benefits of aligners in
be kept in mind that the smaller the force, that is, light the treatment of open bite (55).
and continuous forces, the fewer side effects intrusion
mechanics will have (25,47,48).
LIMITATIONS

TREATMENT OF OPEN BITE WITH Although this study provides valuable information for
ALIGNERS dentistry, the results must be considered with caution
because of the moderate risk of bias of the studies
Regarding this topic, 5 articles meeting the selection included. Likewise, the external validity does not allow
criteria were found, indicating that aligners are an generalization of the results.
orthodontic therapeutic alternative and are promoted
as an aesthetic alternative compared to fixed appliances.
Aligners were initially indicated in cases of low

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Root resorption followed by orthodontic treatment in individuals with anterior open bite. A complete vision focused
on different treatment alternatives: a review

CONCLUSIONS Root resorption of the upper incisors after orthodontic

movement by intrusion or extrusion occurs in patients
Root resorption of incisors after orthodontic treatment with a history of short roots and/or root abnormalities
of patients with open bite seems to be similar to that of and in those in whom the force applied during
patients with normal overbite and should be taken into orthodontic treatment exceeds the repair capacity of the
account in the clinical practice of orthodontists. cement in intensity and duration.

While open bite does not seem to increase root

resorption, cases treated with extractions present a Conflict of interest: None to declare.
greater amount of root resorption in the anterior teeth
after incisor retraction for space closure compared to Financing Sources: Self-financed
cases without extractions.
Contribution of authors: All the authors writing and
Skeletal anchorage devices provide greater stability, participated in research concept and design; collection
control and efficacy in the mechanics of treatment of and/or assembly of data; data analysis and interpretation;
molar intrusion in addition to not requiring patient writing the article; critical revision of the article; and
collaboration. However, intrusion of molars does not final approval of the article.
significantly affect the dental roots, recommending the
use of light and continuous forces.

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 Ramirez-Diaz RE, Moscoso-Sivirichi K, Consoli-Senno M.

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