Root resorption after orthodontic treatment: Part 1.

Literature review
Naphtali Breznlak, MD, DMD, MSD, ~ and Atalta Wassersteln, DMD b
Tel Aviv, Israel

Apical root r e s o r p t i o n is a c o m m o n idio- o r t h o d o n t i c o u t c o m e . I Iowever, m o s t root loss r e s u l t i n g

p a t h i c p r o b l e m a s s o c i a t e d with o r t h o d o n t i c t r e a t m e n t f r o m o r t h o d o n t i c t r e a t m e n t d o e s not d e c r e a s e the
and h a s r e c e n t l y r e c e i v e d c o n s i d e r a b l e a t t e n t i o n b e - l o n g e v i t y or the f u n c t i o n a l c a p a c i t y o f the i n v o l v e d
c a u s e o f m e d i c o l e g a l e x p o s u r e . L o s s o f apical root m a - teeth.
terial is u n p r e d i c t a b l e a n d , w h e n e x t e n d i n g into the A l t h o u g h m o s t root r e s o r p t i o n studies a t t e m p t to
d e n t i n , irreversible. Histologic studies r e p o r t a h i g h in- i n v e s t i g a t e the etiologic factors a n d p r e d i c t a b i l i t y o f this
c i d e n c e , w h e r e a s clinical studies reveal a m o r e v a r i e d p h e n o m e n o n , its o r i g i n s r e m a i n o b s c u r e . I n d i v i d u a l
i n c i d e n c e . E x t e n s i v e p o s t o r t h o d o n t i c root r e s o r p t i o n s u s c e p t i b i l i t y , h e r e d i t a r y p r e d i s p o s i t i o n , s y s t e m i c , lo-
c o m p r o l n i s e s the b e n e f i t s o f a n o t h e r w i s e siaccessful cal, a n d a n a t o m i c factors a s s o c i a t e d w i t h o r t h o d o n t i c
m e c h a n o t h e r a p y are c o m m o n l y c i t e d c o m p o n e n t s .
In m o s t root r e s o r p t i o n s t u d i e s , it is not p o s s i b l e to
'Lieutenant Colonel, Chairper.oon. Orthodt'~nticDepartment. Israel Defence c o m p a r e the results a n d c o n c l u s i o n s b e c a u s e o f t h e i r
Forces; Instructor.OrthodonticDepaament, Maurice and Gabriela Goldschle- d i f f e r e n t m e t h o d s . C o m p a r i s o n o f r a d i o g r a p h i c studies
ger School of Dental Medicine,Tel Aviv University.
"Major, OrthodonticDepartment. Israel Defence Forces. are l i m i t e d b e c a u s e o f the v a r i a b l e s o f t e c h n i q u e stan-
0889-5406/931SI.00 + 0.10 811129808 d a r d i z a t i o n , t i m e d i f f e r e n t i a l s , a n d tooth m o v e m e n t .

T a b l e I. R o o t r e s o r p t i o n data f r o m p u b l i s h e d articles
Average EMraclions
Patients age No. of Teeth Tr#(ltmelzt and
Study (reference) Year Number range teeth e.ramined type none3:traclions Source

Ketcham ~ 1927 385 -- -- All Fixed PA

Ketcham4 1929 500 -- -- All Fixed PA
Ketcham4 1929 2012 - - - - All NT PA
Becks6-' 1936 100 -- -- All Unknown PA
Beckr ~ 1939 72 - - - - All NT PA
Beckr ~ 1939 72 -- -- All Unknown m
PA
Rudolphn 1936 439 10 -- All LL PA
Rudolph~ 1936 4560 7-70 -- All NT PA
Rudolph~'~ 1940 5 !3 - - - - All LL m
PA
ttemley~ 1941 195 -- 4959 All Fixed PA
ltenry and 1951 15 16-58 261 All NT HIST
Weinman~a
Massler and 1954 708 12-49 13263 All NT PA
Malone6~
Massler and 1954 81 12-19 2085 All Unknown PA
Malones5
Massler and 1954 301 17 5844 All NT PA
Perreault 7~ p

Phillipst~ 1955 69 -- 1745 All EW 48/21 PA

PhillipsI~ 1955 62 13:7 62 I EW 44/18 CEPlt
McLaughlinm 1964 28 - - - - I E W - - PA
Deshields~ 1969 52 12:3 208 21 / 12 EW -- CEPH

RTS, Roots. ALL, All teeth. _/, Maxillary central incisors. 21112. Maxillary incisors. PM, Premolars. 3,5, Canines and second premolars.
515 Maxillary and mandibular incisors, canines, and premolars. F&ed, Fixed appliances. NT, No treatment. LL, Labiolingual. EW, Edgewise.
Begg, Begg. ACT, Activator. INTR, Intrusion. Varies, Fixed and removable. SER, Serial extractions. BLEW, Begg/edgewise. PA, Pcriapical.
CEPll, Lateral headfi|m. IlIST, Histology. PANO, Panoramic film.

6 2
Volume103 Root resorption. Part 1 6:3
Number I

The present article reviews the literature related to Root resorption process.* Root resorption of the
root resorption and summarizes the clinical consider- deciduous dentition is a normal, essential, and physi-
ations. ologic process. Usually it is a necessary precursor to
Bates,' in 1856, was the first to discuss root re- the eruption of the permanent teeth. 7'3 Some deciduous
sorption of permanent teeth. Ottolengui,-" in 1914, re- teeth, even with agenesis of the succedaneous teeth,
lated root resorption directly to orthodontic treatment, undergo root resorption. Root resorption of the per-
and mentioned that Schwarzkopf in 1887 demonstrated manent teeth is a complex biologic process of which
resorbed roots in extracted permanent teeth. In 1927 many aspects still remain unclear.
root resorption was a subject of major concern to the Phillips, ~ Reitan, '4 and Shafer et al. ~ enumerated
orthodontic field. Ketcham, 3"4 demonstrated, with ra- the various major factors causing root resorption of
diographic evidence, the differences between root shape permanent teeth: physiologic tooth movement, adjacent
before and after orthodontic treatment. This was fol- impacted tooth pressure, periapical or periodontal in-
lowed by a wide range of histologic, clinical, and phys- flammation, tooth implantation or replantation, contin-
iologic research on root resorption and orthodontic uous occlusal trauma, tumors or cysts, metabolic or
treatment. systemic disturbances, local functional or behavioral
The terms resorption and absorption were used in- problems, orthodontic treatment, and idiopathic
terchangeably in the literature relating to apical root factors.
material loss? In 1932 Becks and MarshalP made an Andreasen ~6 defines three external root resorption
extensive review of the literature and concluded that types: surface resorption, which is a self-limiting pro-
"in all cases in which formed tissues are destroyed and cess, usually involving small outlining areas followed
taken up by the blood or lymph stream,:gne should, in by spontaneous repair from adjacent intact parts of the
medical or dental literature, speak only o f resorption." periodontal ligament; in[lanmtatory resorption, where
The appropriate term to describe any form of apical initial root resorption has reached dentinal tubules of
root loss is therefore resorption. an infected necrotic pulpal tissue or an infected leu-
kocyte zone; and replacetnent resorption, where bone
replaces the resorbed tooth material that leads to an-
kylosis.
Patients with Teeth with Trer According to Tronstad, '7 inflammatory resorption is
resorption resorption Resorption time related to the presence of multinucleated cells that col-
(%) (%) amolllll O'r:mo) onize the mineralized or denuded cemental surface. He
21 m m characterizes two kinds of inflammatory resorption.
19 m m Transient hzflammator3" resorption occurs when the
0.5 m m
stimulation to the damage is minimal and for a short
20 m
period. This defect is usually undetected radiographi-
32 m

73.6 m m
cally and is repaired by a cementum-like tissue. When
57-100 m stimulation is for a long period, Tronstad suggests the
12.6 m m term progressive inflammatory resorption. Ankylosis is
40-100 m m
the result of an extensive necrosis of the periodontal
21.5 3.5 m m
ligament with fornmtion of bone onto a denuded area
-- 90.5 m
of the root surface. Since the tooth becomes a part of
I00 86.4 the bone, normal remodeling process will gradually lead
to a complete destruction of the tooth by the bone,
100 93.3 replacement resorption.
Root resorption after orthodontic treatment is sur-
100 86.4 m m
face resorption, '6 or transient inflammatory resorp-
-- 38.9 m m

92 92 ! .4 m m m tion. ~7Replacement resorption is rarely if ever seen after

-- 92.6 8.27 m orthodontic treatment.
99.08 82.7 1:9 Orthodontic forces applied to the biologic system
act similarly on bone and cementum, which are sepa-

*The Bio!ogical Mechani.~m of Tooth Eruption and Root Resorption. An In.

ternational Conference, e d i t e d b y Z e e v D a v i d o v i t c h . 1988. is the basis for this

part of the review.

64 Brezniak and Wasserstein am. J. Orthod. Dentofac. Orthop.
Januao" 1993

T a b l e I. R o o t r e s o r p t i o n d a t a f r o m p u b l i s h e d a r t i c l e s

[ Average Extractions

Study (reference)

Stenvik and
Mjor~-'
I Year

1970
Patients
Number

--
age
range

10-13
No. of
teeth

35
Teeth
examined

PM
Treatment
type

INTR
and
nonextractions

--
Source

ttIST

Stenvik and 1970 -- 10-13 35 PM NT -- HIST

Mjod:
Rosenbergt~ 1972 -- -- -- 3,5 Begg EXT PANO
Stolien and 1973 59 12:0 1180 5-5 EW EXT PA
Zachfisson~~
Plets et al. s7 1974 50 16:8 100 I NT -- PA
Plets et el.*' 1974 45 12 : 8 45 I Fixed -- CEPtl
Goldson and 1975 42 11-19 924 5-5 Begg EXT PA
llenrikson~
Goldson and 1975 42 11-19 924 5-5 NT -- PA
Henrikson88
Hollender 1980 12 13:3 120 All EW EXT PA
et a l . ~~
Ronnerman and ! 981 23 11-14: 8 -- 21/12 ACTIEW -- PA
Larsson~:
llarry and 1982 10 ! !-18 18 PM 1NTR -- PA / ItlST
Sims~z
tlarry and 1982 .:10 11-18 18 PM NT -- PA/HIST
Sims~ ..
Linge and 1983 719 12:8 2451 21 / 12 Varies -- PA
Linge~
Kennedy 1983 32 -- -- All EW EXT PA
et el. 67
Kennedy 1983 32 -- -- All SER + EW EXT PA
et al. 67
Kennedy 1983 32 -- -- All SER EXT PA
et al. ~7
Copland and 1986 45 13 : 1 45 I Fixed -- CEPH
Green m
Dermaut and 1986 20 15 66 21/12 INTR -- PA
Munek s~
Dermaut and 1986 15 22 58 21112 NT -- PA
Munck ~
Sharpe et al. ~ 1987 18 I 1:4 323RTS All EW -- PA
Sharpe et al. ~ 1987 18 12:7 323RTS All EW -- PA
Levander and 1988 98 15 390 21 / 12 BlEW 72126 PA
Malmgren~:
Levander and 1988 98 15 390 21 / 12 BlEW 72/26 PA
Malmgrcn~-"
Levander and 1988 55 14 22 21/12 BlEW EXT PA
Malmgren9"
Levander and 1988 153 14:4 610 21/12 BlEW 127/26 PA
Malmgren~-"
Goldin ~: 1989 17 8-15:5 17 I EW -- CEPtl
McFadden ., 1989 38 13 : I 152 21 / 12 INTR 14/24 PA / CEPH
et al. 6~

RTS, Roots. ALL, All teeth. _/, Maxillary central incisors. 21112, Maxillary incisors. PM, Premolars. 3,5, Canines and second premolars.
515 Maxillary and mandibular incisors, canines, and premolars. FLred, Fixed appliances. NT, No treatment. LL, Labiolingual. EW, Edgewise.
Begg, Begg. ACT, Activator. INTR, Intrusion. Varies, Fixed and removable. SER, Serial extractions. BLEW, Begg/edgewise. PA, Periapical.
CEPH, Lateral headfilm. IlIST, ttistol~y. PANO, Panoramic film.

rated by the periodontal m e m b r a n e . I f t h e r e are n o w h i c h l e a d s to t o o t h m o v e m e n t . However, resorption

d i f f e r e n c e s in the b i o l o g i c b e h a v i o r o f t h e s e t w o o r g a n s , o f the c e m e n t u m a n d d e n t i n m a y a l s o o c c u r .
both would resorb equally. Since cementum is m o r e T h e r o o t r e s o r b i n g cell, t h e o d o n t o c l a s t , h a s s i m i l a r
r e s i s t a n t to r e s o r p t i o n c o m p a r e d w i t h t h e m o r e v u l n e r - c y t o l o g i c a n d f u n c t i o n a l c h a r a c t e r i s t i c s o f the o s t e o -
able bone, applied forces usually cause bone resorption, c l a s t , t~ T h e o s t e o c l a s t is a l a r g e p l e o m o r p h i c , u s u -
 Volume 103
Number I Root resorption. Part 1 65

ination of their precursors is through the vascular sys-

Patients with Teeth with
tem. -'~However, a local tissue contribution has not been
Trealmellt
resorption resorption Resorption time ruled out. 24.29.30Therefore alveolar bone osteoclasts may
(%) (%) amount O'r : m o) have precursors from both vascular and local sources.
,~ definitive identification of the osteoclast precursor is
-- 93 -- 35 days
still lacking. -'8
- - 0 - - - - Resorption of the calcified dental tissues occurg if
- - 37 - - - - osteoclasts obtain access to the mineralized tissue by a
breach in the formative cell layer covering the tis-
-- -- 0.5-1.8 mm 2:2
sue, 17"21"31 if the mineral and matrix surfaces coincide,-"
27.5 27.5 -- --
46 46 1.78 mm 2:3
or when the precementum is mechanically damaged or
scraped off. '7 The mineralized or denuded root areas
100 77 -- I :8 attract hard tissue resorbing cells to colonize the dam-
aged areas of the root. '7
- - 4 - - - -
The organic matrix degradation is not fully under-
-- 50 <2 mm 1N88% 1:6
stood. According to Jones and Boyde, 2' the osteoclast
is credited for both demineralization of the calcified
39 -- 1-3 mm 2:4-3:2 tissue and degradation of the organic matrix after de-
mineralization. Proton production and acidification of
100 100 -- 70 days
the ruffled border play a role in demineralization. Cys-
0 0 --
9 ".~..

.. --
teine proteinases of osteoclastic origin were found to
be important in the removal of organic matrices, ttow-
-- -- 0.7/ram 0: I I ever, others relate part of this activity to the osteoblast)'-
Recently, published articles demonstrated that re-
26.5 -- -- 1:9
sorbing activity, as a response to mechanical or chem-
20.5 -- -- I :1
ical stimuli by the periodontal ligament cells, is char-
acterized by synthesizing prostaglandin E with concom-
6 -- -- -- itant increase in c A M P ) 3 This process is regulated by
hormones (parathyroid 27"33 and calcitonin27'34), neuro-
9 -- -- 2.93 mm 2:10
transmitters (substance p,35 vasoactive intestinal pep-
- - 86 2.5 mm 0:7
tide, 36 and calcitonin gene related peptide37), and cy-
tokines or monokines (interleukin-I alpha, 27'3s interleu-
0 0 -- -- kin-I beta, 1"-39' interleukin-2, 4~ tumor necrosis
factor, -'7:~ and interferon-gamma4'). It was also sug-
89 20.1 -- 3:7
gested that the osteoclasts are controlled by osteoblasts
83 13.3 -- 2:7
- - 34 - - 0:6-0:9
in many ways.-'""-"
Several theories explaining the resistance of the den-
- - 5 6 - - 1 : 7 5 tal tissues, especially cemental resistance to resorption,
exist. After extensive research in this field, mainly with
1:8
- - - - - -
tooth replantation models, Andreasen, '6 relates surface
"--:- 56 -- 1:8
resistance to the innermostcellular layer of the peri-
odontal ligament. This layer supplies the protective
-- 9 -- 1.36 mm/yr 1:7 mechanism to the root, as well as the potential for a
-- -- f.84 mm upper 2:4 repair. The cementoblasts, fibroblasts, osteoblasts, en-
0.61 lower
dothelial, and perivascular cells are included in this
"layer. Small areas of cell damage in which surface re-
sorption occurs are fully repaired with new cementum
and periodontal ligament fibers from the adjacent vital
parts of the periodontal ligament. Alveolar bone and
bone marrow derived cells are related to the healing of
ally multinucleated, cell formed by fusion of mono- larger zones of damage that leads to ankylosis.
nuclear precursors. It is characterized by a ruffled bor- Andreasen '6 disqualified the role of the peripheral part
der pointed against the hard tissue surface.~~176 There of the periodontal ligament, Sharpey's fibers, cemen-
is a consensus that the osteoclasts are of hematopoietic tum, cementoid, and Mallassez epithelial cells in regard
origin from the bone m a r r o w , 2 4 2 7 and that the dissem- to resorption preventive mechanism in the periodontal
66 Brezniak and Wasserstein Am. J. Orthod. Dentofac. Orthop.
Janua~" 1993

ligament. Jones and Boyde 21did not rule out the cellular ceases. Reitan 44 and Rygh ~ are in agreement that ce-
layer covering the root surface, the Sharpey's fibers at mentoid fills those resorbed lacunae. This process de-
the root side, the superficial layer of unmineralized lays the occurrence of new root resorption and initiates
matrix (precementum and predentin), and elements of the healing process. (Schwartz's range of optimal and
the organic matrix as taking part in the resistance to" detrimental forces was challenged later by Miura 57 to
resorption of the roots. be higher.)
It is documented that the uncalcified mineral tissues, Repair of resorbed lacunae is seen after.35 to 70
osteoid, precementum, and predentin are resistant to days after force application. 51'S'-Cemental resorbed la-
resorption and may initially prevent loss of root tissue.l' cunae become fully anatomically reconstructed. Deep
However, continuous pressure will eventually lead to dentinal lacunae are repaired by a thin cemental layer
resorption of these areas, t4'~7Lately it was demonstrated resulting in an irregular root shape. 16 After both types
that root resorption occurs even in teeth where depo- of repair, the periodontal ligament width is usually nor-
sition of mineralized material was prevented. 31 mal. Root contour is frequently followed by bone c o n -
Resorbed lacunae appear mainly on the pressure tour, which increases tooth anchorage without compro-
side, z~'4s~6and rarely on the tension side. 47 It has been mising function? Repair is described by migration of
claimed that root resorption during orthodontic treat- eementoblasts over the resorbed surface, competing for
ment occurs in the same areas where physiol~ic root available surface and excluding osteo/cementoblasts.'-'
resorption originates. *t These areas may be more sen- A high percentage (90.5%) of nonorthodontically
sitive to local changes. The cementum may be resorbed treated permanent teeth displayed microscopic lesions
directly or indirectly. Indirect resorption is seen as un- of external root resorption (average length of 0.73 mm
dermining resorption--from Hgwship lacunae of the and depth of 0.10 mm were observed)? s All the lesions
dentin. ~4.~ . were either repaired or undergoing repair. According
Human and animal research demonstrates that peri- to this study, idiopathic root resorption is most fre-
odontal hyalinization precedes the root resorption pro- quently found at the apex followed by mcsial, buccal,
cess during orthodontic treatment. 6'4J~64s5~Loss of root distal, and lingual surfaces. Small differences were
material occurs adjacent and subjacent to this area. noted between right and left sides, or between man-
Three stages are described in the hyalinized zone: de- dibular and maxillary teeth. More resorption areas were
generation, elimination of destroyed products, and re- seen on molars since their total surface area is greater
establishment. Hyalinized tissue elimination is related than that of other teeth? 8
to the root resorption process. ~ This section will not be complete without mention-
After application of force, it can take between 10 ing the immunologic theory of root resorption, however,
and 35 days for resorbed lacunae to appear. ~~6"sLs-" adequate data are lacking? 9
Clinically, this degree of resorption cannot be detected
with radiographs, especially when occurring on the buc-
Reprint requests to:
cal and lingual surfaces. 5sss Dr. Naphtali Brezniak
According to Schwartz ~6 when pressure decreases 3 Ray Ashi St. (#31)
below the optimal force (20 to 26 g / cm-') root resorption TeI-Aviv, Israel