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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
Source American Journal of Orthodontics and Dentofacial Orthopedics 2010 137384-388 (DOI101016jajodo200804024 )
Copyright copy 2010 American Association of Orthodontists Terms and Conditions
Root Resorption Severity
mild moderate severe extremeNo RR
Source American Journal of Orthodontics and Dentofacial Orthopedics 2009 135434-437 (DOI101016jajodo200810014 )
Copyright copy 2009 American Association of Orthodontists Terms and Conditions
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)
Comparison of the Split-Mouth Studies
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
Comparison of the Split-Mouth Studies
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)
Comparison of the comprehensive orthodontic treatment RCTs
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)
Comparison of the comprehensive orthodontic treatment RCTs
Comparison of the comprehensive orthodontic treatment RCTs
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 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
1) Case ReportInitial Radiographs
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
18 months into orthodontic treatment
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
Deband
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
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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Adachi H Igarashi K Mitani H et al (1994) Effects of topical administration of a bisphosphonate
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Alexander SA (1996) Levels of root resorption associated with continuous arch and sectional arch mechanics American Journal of Orthodontics and Dentofacial Orthopedics 110 321-4
Al-Qawasmi RA Hartsfield JK Jr Everett ET et al (2003a) Genetic predisposition to external apical root
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Al-Nazhan S (1991) External root resorption after bleaching A case report Oral Surgery Oral
Meddicine Oral Pathology 72 607-9
Andreasen JO (1985) External root resorption its implication in dental traumatology paedodontics
periodontics orthodontics and endodontics International Endodontic Journal 18 109-18
Attati I Hammarstrom L (1996a) Root surface defects in rat molar induced by 1-hydroxyethylidene-1
1-bisphosphonate Acta Odontologica Scandinavica 54 59-65
Attati I Hellsing E Hammarstrom L (1996b) Orthodontically induced root resorption in rat molars after 1-hydroxyethylidene-1 1-bisphosphonate injection Acta Odontologica Scandinavica 54 102-8
Barbagallo LJ Jones AS Petocz P et al (2008) Physical properties of root cementum Part 10
Comparison of the effects of invisible removable thermoplastic appliances with light and heavy orthodontic forces on premolar cementum A microcomputed-tomography study American Journal of
Orthodontics and Dentofacial Orthopedics 133 218-27
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American Journal of Orthodontics and Dentofacial Orthopedics 110(3) 311-20
Beck BW Harris EF (1994) Apical root resorption in orthodontically treated subjects analysis of
edgewise and light wire mechanics American Journal of Orthodontics and Dentofacial Orthopedics
105(4) 350-61
Bishara SE Vonwald L Jakobsen JR (1999) Changes in root length from early to mid-adulthood
resorption or apposition American Journal of Orthodontics and Dentofacial Orthopedics 115(5) 563-
8
Blake M Woodside DG Pharoah MJ (1995) A radiographic comparison of apical root resorption after
orthodontic treatment with the edgewise and Speed appliances American Journal of Orthodontics and
Dentofacial Orthopedics 108 76-84
Bollen A-M (2002) Large overjet and longer teeth are associated with more root resorption when
treated orthodontically Journal of Evidence Based Dental Practice 2 44-5
Boyd RL (2007) Complex orthodontic treatment using a new protocol for the Invisalign appliance Journal of Clinical Orthodontics 4 525-47
Brezniak N Wasserstein A (1993) Root resorption after orthodontic treatment Part 1 Literature
review American Journal of Orthodontics and Dentofacial Orthopedics 103 62-6
Brezniak N Wasserstein A (2002a) Orthodontically induced inflammatory root resorption Part 1 The
basic science aspects Angle Orthodontist 72 175-9
Brezniak N Wasserstein A (2002b) Orthodontically induced inflammatory root resorption Part II The
clinical aspects Angle Orthodontist 72 180-4
Brezniak N Wasserstein A (2008) Root resorption following treatment with aligners Angle
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
Orthopedics 124(2) 151-6
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
References Casa MA Faltin RM Faltin K et al (2001) Root resorptions in upper first premolars after application of
continuous torque moment Intra-individual study Journal of Orofacial Orthopedics 62(4) 285-95
Chan EKM Darendeliler MA Petocz P et al (2004a) A new method for volumetric measurement of
orthodontically induced root resorption craters European Journal of Oral Science 112(2) 134-9
Chan EKM Darendeliler MA (2004b) Exploring the third dimension in root resorption Orthodontics amp Craniofacial Research 7 64-70
Chan E Darendeliler MA (2005) Physical properties of root cementum Part 5 Volumetric analysis of
root resorption craters after application of light and heavy orthodontic forces American Journal of Orthodontics and Dentofacial Orthopedics 127(2) 186-95
Chan E Darendeliler MA (2006) Physical properties of root cementum part 7 Extent of root resorption
under areas of compression and tension American Journal of Orthodontics and Dentofacial Orthopedics 129(4) 504-10
Christiansen RL (1994) Commentary Thyroxine administration and its effects on root resorption
Angle Orthodontist 64 399-400
Copeland S Green LJ (1986) Root resorption in maxillary central incisors following active orthodontic
treatment American Journal of Orthodontics and Dentofacial Orthopedics 89(1) 51-5
Costopoulos G Nanda R (1996) An evaluation of root resorption incident to orthodontic intrusion
American Journal of Orthodontics and Dentofacial Orthopedics 109(5) 543-8
Counts Al Widlak RA (1993) Generalized idiopathic external root resorption Journal of clinical
orthodontics 27 511-3
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
application of light and heavy controlled orthodontic forces Orthodics amp Craniofacial Research 7(2)
79-97
Davidovitch Z Godwin SL Park YG et al (1996) The etiology of root resorption In Orthodontic
Treatment The management of unfavorable sequelae McNamara JA Trotman CA editors University
of Michigan Press Ann Arbor MI 93-117
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DeShields RW (1969) A study of root resorption in treated Class II Division I malocclusions Angle
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Drysdale C Gibbs SL Ford TR (1996) Orthodontic management of root-filled teeth British Journal of
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English H (2001) External apical root resorption as a consequence of orthodontic treatment Journal of New Zealand Society of Periodontology 86 17-23
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after continuous intrusion in humans a transmission electron microscopy study European Journal of Orthodontics 23(1) 35-49
Fox N (2005) Longer orthodontic treatment may result in greater external apical root resorption
Evidence Based Dentistry 6 21
Fuss Z Tsesis I Lin S (2003) Root resorption ndash diagnosis classification and treatment choices based
on stimulation factors Dental Traumatology 19 175-82
Goldie RS King GJ (1984) Root resorption and tooth movement in orthodontically treated calcium-
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30
Goldson L Henrikson CO (1975) Root resorption during Begg treatment a longitudinal roentgenologic
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Han G Huang S Von den Hoff et al (2005) Root resorption after orthodontic intrusion and extrusion
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Hamilton RS Gutmann JL (1999) Endodontic-orthodontic relationships a review of integrated treatment planning challenges International Endodontic Journal 32 343-60
Harris EF Baker WC (1990) Loss of root length and crestal bone height before and during treatment in
adolescent and adult orthodontic patients American Journal of Orthodontics and Dentofacial Orthopedics 98(5) 463-9
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Harris EF Kineret SE Tolley EA (1997) A heritable component for external apical root resorption in
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Harris DA Jones AS Darendeliler MA (2006) Physical properties of root cementum part 8 Volumetric
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Horiuchi A Hotokezaka H Kobayashi K (1998) Correlation between cortical plate proximity and apical root resorption American Journal of Orthodontics and Dentofacial Orthopedics 114(3) 311-8
Igarashi K Adachi H Mitani H et al (1996) Inhibitory effect of topical administration of a
bisphosphonate (risedronate) on root resorption incident to orthodontic tooth movement in rats Journal of Dental Research 75 1644-9
Janson GR De Luca Canto G Martins DR et al (1999) A radiographic comparison of apical root
resorption after orthodontic treatment with 3 different fixed appliance techniques American Journal of Orthodontics and Dentofacial Orthopedics 118(3) 262-73
Jimenez-Pellegrin C Arana-Chavez VE (2004) Root resorption in human mandibular first premolars
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Kaley J Phillips C (1991) Factors related to root resorption in edgewise practice Angle Orthodontist
61(2) 125-32
Kalkwarf KL Krejci RF Pao YC (1986) Effect of apical root resorption on periodontal support Journal of
Prosthetic Dentistry 56 317-9
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Kennedy D Joondeph D Osterberg S et al (1983) The effect of extraction and orthodontic treatment
on dentoalveolar support American Journal of Orthodontics and Dentofacial Orthopedics 84 183-90
Ketcham AH (1927) A preliminary report of an investigation of apical root resorption of vital permanent teeth International Journal of Orthodontics 13 97-127
Killiany DM (1999) Root resorption caused by orthodontic treatment an evidence-based review of
literature Seminars in Orthodontics 5 128-33
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2001 for evidence Progress in Orthodontics 3 2-5
Kjaer I (1995) Morphological characteristics of dentitions developing excessive root resorption during
orthodontic treatment European Journal of Orthodontics 17 25-34
Konoo T Kim YJ Gu GM et al (2001) Intermittent force in orthodontic tooth movement Journal of
Dental Research 80 457-60
Kook Y-A Park S Sameshima GT (2003) Peg-shaped and small lateral incisors not at higher risk for root resorption American Journal of Orthodontics and Dentofacial Orthopedics 123 253-8
Kurol J Owman-Moll P (1998) Hyalinization and root resorption during early orthodontic tooth
movement in adolescents Angle Orthodontist 68 161-5
Lee RY Artun J Alonzo TA (1999) Are dental anomalies risk factors for apical root resorption in
orthodontic patients American Journal of Orthodontics and Dentofacial Orthopedics 116(2) 187-95
Levander E Malmgren O (1988) Evaluation of the risk of root resorption during orthodontic treatment
a study of upper incisors European Journal of Orthodontics 10 30-8
Levander E Malmgren O Eliasson S (1994) Evaluation of root resorption in relation to two orthodontic
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Levander E Malmgren O Stenback K (1998) Apical root resorption during orthodontic treatment of patients with multiple aplasia a study of maxillary incisors European Journal of Orthodontics 20
427-34
References Levander E Malmgren O (2000) Long-term follow-up of maxillary incisors with severe root resorption
European Journal of Orthodontics 22 85-92
Lew K (1990) Intrusion and apical resorption of mandibular incisors in Begg treatment anchorage
bend or curve Australian Orthodontic Journal 11(3) 164-8
Linge BO Linge L (1983) Apical root resorption in upper anterior teeth European Journal of Orthodontics 5(3) 173-83
Linge L Linge BO (1991) Patient characteristics and treatment variables associated with apical root
resorption during orthodontic treatment American Journal of Orthodontics and Dentofacial Orthopedics99 35-43
Loberg EL Engstrom C (1994) Thyroid administration to reduce root resorption Angle Orthodontist
64 395-9
Lupi JE Handelman CS Sadowsky C (1996) Prevalence and severity of apical root resorption and
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Mandall N Lowe C Worthington H et al (2006) Which orthodontic archwire sequence A randomized
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Mavragnani M Boe OE Wisth PJ et al (2002) Changes in root length during orthodontic treatment
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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
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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
Orthodontics and Dentofacial Orthopedics 67 522-39
Ngan DCS Kharbanda OP Byloff FK et al (2004) The genetic contribution to orthodontic root
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Otis L Hong J Tuncay O (2004) Bone structure effect on root resorption Orthodontics amp Craniofacial
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Owman-Moll P Kurol J Lundgren D (1995a) Continuous versus interrupted continuous orthodontic
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discussion 401-2
Owman-Moll P Kurol J Lundgren D (1995b) Repair of orthodontically induced root resorption Angle
Orthodontist 65(6) 403-8
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15
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Orthodontics amp Craniofacial Research 7(2) 108-14
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Weltman BJ Vig KWL Fields HW et al (2010) American Journal of Orthodontics and Dentofacial
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Wheeler In Press
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Lombardo L Bragazzi R Perissinotto C Mirabella D Siciliani G Cone-beam computed tomography
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Krasny M Zadurska M Cessak G Fiedor P Analysis of effect of non-steroidal anti-inflammatory drugs
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Feb18(1)110-20
Makedonas D1 Lund H Hansen K (2013) Root resorption diagnosed with cone beam computed
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Orthod May83(3)389-93
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Lund H Groumlndahl K Hansen K Groumlndahl HG Apical root resorption during orthodontic treatment A
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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
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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
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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
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
Source American Journal of Orthodontics and Dentofacial Orthopedics 2010 137384-388 (DOI101016jajodo200804024 )
Copyright copy 2010 American Association of Orthodontists Terms and Conditions
Root Resorption Severity
mild moderate severe extremeNo RR
Source American Journal of Orthodontics and Dentofacial Orthopedics 2009 135434-437 (DOI101016jajodo200810014 )
Copyright copy 2009 American Association of Orthodontists Terms and Conditions
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)
Comparison of the Split-Mouth Studies
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
Comparison of the Split-Mouth Studies
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)
Comparison of the comprehensive orthodontic treatment RCTs
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)
Comparison of the comprehensive orthodontic treatment RCTs
Comparison of the comprehensive orthodontic treatment RCTs
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 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
1) Case ReportInitial Radiographs
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
18 months into orthodontic treatment
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
Deband
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
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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14
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427-34
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15
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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
Source American Journal of Orthodontics and Dentofacial Orthopedics 2010 137384-388 (DOI101016jajodo200804024 )
Copyright copy 2010 American Association of Orthodontists Terms and Conditions
Root Resorption Severity
mild moderate severe extremeNo RR
Source American Journal of Orthodontics and Dentofacial Orthopedics 2009 135434-437 (DOI101016jajodo200810014 )
Copyright copy 2009 American Association of Orthodontists Terms and Conditions
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)
Comparison of the Split-Mouth Studies
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
Comparison of the Split-Mouth Studies
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)
Comparison of the comprehensive orthodontic treatment RCTs
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)
Comparison of the comprehensive orthodontic treatment RCTs
Comparison of the comprehensive orthodontic treatment RCTs
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 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
1) Case ReportInitial Radiographs
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
18 months into orthodontic treatment
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
Deband
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
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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14
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Davidovitch Z Godwin SL Park YG et al (1996) The etiology of root resorption In Orthodontic
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15
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Orthodontics amp Craniofacial Research 7(2) 108-14
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Wheeler In Press
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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
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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
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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
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
Source American Journal of Orthodontics and Dentofacial Orthopedics 2010 137384-388 (DOI101016jajodo200804024 )
Copyright copy 2010 American Association of Orthodontists Terms and Conditions
Root Resorption Severity
mild moderate severe extremeNo RR
Source American Journal of Orthodontics and Dentofacial Orthopedics 2009 135434-437 (DOI101016jajodo200810014 )
Copyright copy 2009 American Association of Orthodontists Terms and Conditions
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)
Comparison of the Split-Mouth Studies
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
Comparison of the Split-Mouth Studies
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)
Comparison of the comprehensive orthodontic treatment RCTs
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)
Comparison of the comprehensive orthodontic treatment RCTs
Comparison of the comprehensive orthodontic treatment RCTs
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 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
1) Case ReportInitial Radiographs
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
18 months into orthodontic treatment
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
Deband
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
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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Barbagallo LJ Jones AS Petocz P et al (2008) Physical properties of root cementum Part 10
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Orthodontics and Dentofacial Orthopedics 133 218-27
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Beck BW Harris EF (1994) Apical root resorption in orthodontically treated subjects analysis of
edgewise and light wire mechanics American Journal of Orthodontics and Dentofacial Orthopedics
105(4) 350-61
Bishara SE Vonwald L Jakobsen JR (1999) Changes in root length from early to mid-adulthood
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8
Blake M Woodside DG Pharoah MJ (1995) A radiographic comparison of apical root resorption after
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review American Journal of Orthodontics and Dentofacial Orthopedics 103 62-6
Brezniak N Wasserstein A (2002a) Orthodontically induced inflammatory root resorption Part 1 The
basic science aspects Angle Orthodontist 72 175-9
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clinical aspects Angle Orthodontist 72 180-4
Brezniak N Wasserstein A (2008) Root resorption following treatment with aligners Angle
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
References Casa MA Faltin RM Faltin K et al (2001) Root resorptions in upper first premolars after application of
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Chan EKM Darendeliler MA Petocz P et al (2004a) A new method for volumetric measurement of
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Chan EKM Darendeliler MA (2004b) Exploring the third dimension in root resorption Orthodontics amp Craniofacial Research 7 64-70
Chan E Darendeliler MA (2005) Physical properties of root cementum Part 5 Volumetric analysis of
root resorption craters after application of light and heavy orthodontic forces American Journal of Orthodontics and Dentofacial Orthopedics 127(2) 186-95
Chan E Darendeliler MA (2006) Physical properties of root cementum part 7 Extent of root resorption
under areas of compression and tension American Journal of Orthodontics and Dentofacial Orthopedics 129(4) 504-10
Christiansen RL (1994) Commentary Thyroxine administration and its effects on root resorption
Angle Orthodontist 64 399-400
Copeland S Green LJ (1986) Root resorption in maxillary central incisors following active orthodontic
treatment American Journal of Orthodontics and Dentofacial Orthopedics 89(1) 51-5
Costopoulos G Nanda R (1996) An evaluation of root resorption incident to orthodontic intrusion
American Journal of Orthodontics and Dentofacial Orthopedics 109(5) 543-8
Counts Al Widlak RA (1993) Generalized idiopathic external root resorption Journal of clinical
orthodontics 27 511-3
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
application of light and heavy controlled orthodontic forces Orthodics amp Craniofacial Research 7(2)
79-97
Davidovitch Z Godwin SL Park YG et al (1996) The etiology of root resorption In Orthodontic
Treatment The management of unfavorable sequelae McNamara JA Trotman CA editors University
of Michigan Press Ann Arbor MI 93-117
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90(4) 321-6
DeShields RW (1969) A study of root resorption in treated Class II Division I malocclusions Angle
Orthodontist 39(4) 231-45
Drysdale C Gibbs SL Ford TR (1996) Orthodontic management of root-filled teeth British Journal of
Orthodontics 23 255-60
English H (2001) External apical root resorption as a consequence of orthodontic treatment Journal of New Zealand Society of Periodontology 86 17-23
Faltin RM Faltin K Sander FG et al (2001) Ultrastructure of cementum and periodontal ligament
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Fox N (2005) Longer orthodontic treatment may result in greater external apical root resorption
Evidence Based Dentistry 6 21
Fuss Z Tsesis I Lin S (2003) Root resorption ndash diagnosis classification and treatment choices based
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Goldie RS King GJ (1984) Root resorption and tooth movement in orthodontically treated calcium-
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30
Goldson L Henrikson CO (1975) Root resorption during Begg treatment a longitudinal roentgenologic
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Hamilton RS Gutmann JL (1999) Endodontic-orthodontic relationships a review of integrated treatment planning challenges International Endodontic Journal 32 343-60
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Harris EF Kineret SE Tolley EA (1997) A heritable component for external apical root resorption in
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427-34
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15
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Walker SL Tieu LD Flores-Mir C (2013) Radiographic comparison of the extent of orthodontically
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Wu FL Wang LY Huang YQ Guo WB Liu CD Li SG (2013) Interleukin-1β +3954 polymorphisms and
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Lombardo L Bragazzi R Perissinotto C Mirabella D Siciliani G Cone-beam computed tomography
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Krieger E Drechsler T Schmidtmann I Jacobs C Haag S Wehrbein H Apical root resorption during
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Makedonas D1 Lund H Hansen K (2013) Root resorption diagnosed with cone beam computed
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Lund H Groumlndahl K Hansen K Groumlndahl HG Apical root resorption during orthodontic treatment A
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incisors after orthodontic treatment a split-mouth design study Med Oral Patol Oral Cir Bucal
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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
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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
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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
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routine orthodontic treatment planning a radiation dose evaluation Am J Orthod Dentofacial Orthop 2008 May133(5)640e1-5
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)
Comparison of the Split-Mouth Studies
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
Comparison of the Split-Mouth Studies
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)
Comparison of the comprehensive orthodontic treatment RCTs
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)
Comparison of the comprehensive orthodontic treatment RCTs
Comparison of the comprehensive orthodontic treatment RCTs
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 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
1) Case ReportInitial Radiographs
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
18 months into orthodontic treatment
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
Deband
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
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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14
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15
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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)
Comparison of the Split-Mouth Studies
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
Comparison of the Split-Mouth Studies
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)
Comparison of the comprehensive orthodontic treatment RCTs
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)
Comparison of the comprehensive orthodontic treatment RCTs
Comparison of the comprehensive orthodontic treatment RCTs
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 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
1) Case ReportInitial Radiographs
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
18 months into orthodontic treatment
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
Deband
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
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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14
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Davidovitch Z Godwin SL Park YG et al (1996) The etiology of root resorption In Orthodontic
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15
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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)
Comparison of the Split-Mouth Studies
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
Comparison of the Split-Mouth Studies
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)
Comparison of the comprehensive orthodontic treatment RCTs
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)
Comparison of the comprehensive orthodontic treatment RCTs
Comparison of the comprehensive orthodontic treatment RCTs
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 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
1) Case ReportInitial Radiographs
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
18 months into orthodontic treatment
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
Deband
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
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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14
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15
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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)
Comparison of the Split-Mouth Studies
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
Comparison of the Split-Mouth Studies
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)
Comparison of the comprehensive orthodontic treatment RCTs
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)
Comparison of the comprehensive orthodontic treatment RCTs
Comparison of the comprehensive orthodontic treatment RCTs
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 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
1) Case ReportInitial Radiographs
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
18 months into orthodontic treatment
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
Deband
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
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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14
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orthodontically induced root resorption craters European Journal of Oral Science 112(2) 134-9
Chan EKM Darendeliler MA (2004b) Exploring the third dimension in root resorption Orthodontics amp Craniofacial Research 7 64-70
Chan E Darendeliler MA (2005) Physical properties of root cementum Part 5 Volumetric analysis of
root resorption craters after application of light and heavy orthodontic forces American Journal of Orthodontics and Dentofacial Orthopedics 127(2) 186-95
Chan E Darendeliler MA (2006) Physical properties of root cementum part 7 Extent of root resorption
under areas of compression and tension American Journal of Orthodontics and Dentofacial Orthopedics 129(4) 504-10
Christiansen RL (1994) Commentary Thyroxine administration and its effects on root resorption
Angle Orthodontist 64 399-400
Copeland S Green LJ (1986) Root resorption in maxillary central incisors following active orthodontic
treatment American Journal of Orthodontics and Dentofacial Orthopedics 89(1) 51-5
Costopoulos G Nanda R (1996) An evaluation of root resorption incident to orthodontic intrusion
American Journal of Orthodontics and Dentofacial Orthopedics 109(5) 543-8
Counts Al Widlak RA (1993) Generalized idiopathic external root resorption Journal of clinical
orthodontics 27 511-3
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
application of light and heavy controlled orthodontic forces Orthodics amp Craniofacial Research 7(2)
79-97
Davidovitch Z Godwin SL Park YG et al (1996) The etiology of root resorption In Orthodontic
Treatment The management of unfavorable sequelae McNamara JA Trotman CA editors University
of Michigan Press Ann Arbor MI 93-117
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DeShields RW (1969) A study of root resorption in treated Class II Division I malocclusions Angle
Orthodontist 39(4) 231-45
Drysdale C Gibbs SL Ford TR (1996) Orthodontic management of root-filled teeth British Journal of
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English H (2001) External apical root resorption as a consequence of orthodontic treatment Journal of New Zealand Society of Periodontology 86 17-23
Faltin RM Faltin K Sander FG et al (2001) Ultrastructure of cementum and periodontal ligament
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Evidence Based Dentistry 6 21
Fuss Z Tsesis I Lin S (2003) Root resorption ndash diagnosis classification and treatment choices based
on stimulation factors Dental Traumatology 19 175-82
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Goldson L Henrikson CO (1975) Root resorption during Begg treatment a longitudinal roentgenologic
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427-34
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15
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Schwartz AM (1932) Tissue changes incidental to tooth movement International Journal of
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Snelgrove RA (1995) Generalized idiopathic apical root resorption as an incidental finding in an adolescent A case history Dental Update 22 276-8
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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
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Walker SL Tieu LD Flores-Mir C (2013) Radiographic comparison of the extent of orthodontically
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Wheeler In Press
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Wu FL Wang LY Huang YQ Guo WB Liu CD Li SG (2013) Interleukin-1β +3954 polymorphisms and
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Krasny M Zadurska M Cessak G Fiedor P Analysis of effect of non-steroidal anti-inflammatory drugs
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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)
Comparison of the Split-Mouth Studies
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
Comparison of the Split-Mouth Studies
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)
Comparison of the comprehensive orthodontic treatment RCTs
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)
Comparison of the comprehensive orthodontic treatment RCTs
Comparison of the comprehensive orthodontic treatment RCTs
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 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
1) Case ReportInitial Radiographs
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
18 months into orthodontic treatment
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
Deband
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
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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Alexander SA (1996) Levels of root resorption associated with continuous arch and sectional arch mechanics American Journal of Orthodontics and Dentofacial Orthopedics 110 321-4
Al-Qawasmi RA Hartsfield JK Jr Everett ET et al (2003a) Genetic predisposition to external apical root
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Al-Qawasmi RA Hartsfield JKJr Everett ET et al (2003b) Genetic predisposition to external apical
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Al-Nazhan S (1991) External root resorption after bleaching A case report Oral Surgery Oral
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Andreasen JO (1985) External root resorption its implication in dental traumatology paedodontics
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Attati I Hammarstrom L (1996a) Root surface defects in rat molar induced by 1-hydroxyethylidene-1
1-bisphosphonate Acta Odontologica Scandinavica 54 59-65
Attati I Hellsing E Hammarstrom L (1996b) Orthodontically induced root resorption in rat molars after 1-hydroxyethylidene-1 1-bisphosphonate injection Acta Odontologica Scandinavica 54 102-8
Barbagallo LJ Jones AS Petocz P et al (2008) Physical properties of root cementum Part 10
Comparison of the effects of invisible removable thermoplastic appliances with light and heavy orthodontic forces on premolar cementum A microcomputed-tomography study American Journal of
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8
Blake M Woodside DG Pharoah MJ (1995) A radiographic comparison of apical root resorption after
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Boyd RL (2007) Complex orthodontic treatment using a new protocol for the Invisalign appliance Journal of Clinical Orthodontics 4 525-47
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Brezniak N Wasserstein A (2002b) Orthodontically induced inflammatory root resorption Part II The
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Orthodontist 78 1119-24
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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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427-34
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15
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Schwartz AM (1932) Tissue changes incidental to tooth movement International Journal of
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Walker SL Tieu LD Flores-Mir C (2013) Radiographic comparison of the extent of orthodontically
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Weltman BJ Vig KWL Fields HW et al (2010) American Journal of Orthodontics and Dentofacial
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Wu FL Wang LY Huang YQ Guo WB Liu CD Li SG (2013) Interleukin-1β +3954 polymorphisms and
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Lombardo L Bragazzi R Perissinotto C Mirabella D Siciliani G Cone-beam computed tomography
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Makedonas D1 Lund H Hansen K (2013) Root resorption diagnosed with cone beam computed
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Lund H Groumlndahl K Hansen K Groumlndahl HG Apical root resorption during orthodontic treatment A
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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
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10
Comparison of the Split-Mouth Studies
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)
Comparison of the comprehensive orthodontic treatment RCTs
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)
Comparison of the comprehensive orthodontic treatment RCTs
Comparison of the comprehensive orthodontic treatment RCTs
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 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
1) Case ReportInitial Radiographs
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
18 months into orthodontic treatment
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
Deband
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
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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Barbagallo LJ Jones AS Petocz P et al (2008) Physical properties of root cementum Part 10
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8
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Boyd RL (2007) Complex orthodontic treatment using a new protocol for the Invisalign appliance Journal of Clinical Orthodontics 4 525-47
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review American Journal of Orthodontics and Dentofacial Orthopedics 103 62-6
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basic science aspects Angle Orthodontist 72 175-9
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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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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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Chan E Darendeliler MA (2006) Physical properties of root cementum part 7 Extent of root resorption
under areas of compression and tension American Journal of Orthodontics and Dentofacial Orthopedics 129(4) 504-10
Christiansen RL (1994) Commentary Thyroxine administration and its effects on root resorption
Angle Orthodontist 64 399-400
Copeland S Green LJ (1986) Root resorption in maxillary central incisors following active orthodontic
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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
Davidovitch Z Godwin SL Park YG et al (1996) The etiology of root resorption In Orthodontic
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of Michigan Press Ann Arbor MI 93-117
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DeShields RW (1969) A study of root resorption in treated Class II Division I malocclusions Angle
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Drysdale C Gibbs SL Ford TR (1996) Orthodontic management of root-filled teeth British Journal of
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Faltin RM Faltin K Sander FG et al (2001) Ultrastructure of cementum and periodontal ligament
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Fox N (2005) Longer orthodontic treatment may result in greater external apical root resorption
Evidence Based Dentistry 6 21
Fuss Z Tsesis I Lin S (2003) Root resorption ndash diagnosis classification and treatment choices based
on stimulation factors Dental Traumatology 19 175-82
Goldie RS King GJ (1984) Root resorption and tooth movement in orthodontically treated calcium-
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30
Goldson L Henrikson CO (1975) Root resorption during Begg treatment a longitudinal roentgenologic
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Igarashi K Adachi H Mitani H et al (1996) Inhibitory effect of topical administration of a
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Kalkwarf KL Krejci RF Pao YC (1986) Effect of apical root resorption on periodontal support Journal of
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Kennedy D Joondeph D Osterberg S et al (1983) The effect of extraction and orthodontic treatment
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Ketcham AH (1927) A preliminary report of an investigation of apical root resorption of vital permanent teeth International Journal of Orthodontics 13 97-127
Killiany DM (1999) Root resorption caused by orthodontic treatment an evidence-based review of
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Killiany DM (2002) Root resorption caused by orthodontic treatment review of literature from 1998 to
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Kjaer I (1995) Morphological characteristics of dentitions developing excessive root resorption during
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Konoo T Kim YJ Gu GM et al (2001) Intermittent force in orthodontic tooth movement Journal of
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Kook Y-A Park S Sameshima GT (2003) Peg-shaped and small lateral incisors not at higher risk for root resorption American Journal of Orthodontics and Dentofacial Orthopedics 123 253-8
Kurol J Owman-Moll P (1998) Hyalinization and root resorption during early orthodontic tooth
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Lee RY Artun J Alonzo TA (1999) Are dental anomalies risk factors for apical root resorption in
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Levander E Malmgren O (1988) Evaluation of the risk of root resorption during orthodontic treatment
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Levander E Malmgren O Eliasson S (1994) Evaluation of root resorption in relation to two orthodontic
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Levander E Malmgren O Stenback K (1998) Apical root resorption during orthodontic treatment of patients with multiple aplasia a study of maxillary incisors European Journal of Orthodontics 20
427-34
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Lew K (1990) Intrusion and apical resorption of mandibular incisors in Begg treatment anchorage
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15
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Sameshima GT Sinclair PM (2004) Characteristics of patients with severe root resorption
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Schwartz AM (1932) Tissue changes incidental to tooth movement International Journal of
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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
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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
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Stevnik A Mjor IA (1970) Pulp and dentine reactions to experimental tooth intrusion A histological
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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
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31(1) 61-6
Walker SL Tieu LD Flores-Mir C (2013) Radiographic comparison of the extent of orthodontically
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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
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Wheeler In Press
Wickwire NA Mc Neil MH Norton LA et al (1974) The effects of tooth movement upon endodontically
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Wu FL Wang LY Huang YQ Guo WB Liu CD Li SG (2013) Interleukin-1β +3954 polymorphisms and
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1812(4)4678-86
Lombardo L Bragazzi R Perissinotto C Mirabella D Siciliani G Cone-beam computed tomography
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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
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Hodges RJ Atchison KA White SC Impact of cone-beam computed tomography on orthodontic
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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
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Lund H Groumlndahl K Hansen K Groumlndahl HG Apical root resorption during orthodontic treatment A
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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
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Dula K Bornstein MM Buser D et al (2014)SADMFR guidelines for the use of Cone-Beam Computed
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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
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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
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routine orthodontic treatment planning a radiation dose evaluation Am J Orthod Dentofacial Orthop 2008 May133(5)640e1-5
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 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
1) Case ReportInitial Radiographs
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
18 months into orthodontic treatment
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
Deband
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
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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Adachi H Igarashi K Mitani H et al (1994) Effects of topical administration of a bisphosphonate
(risedronate) on orthodontic tooth movement in rats Journal of Dental Research 73 1478-1486
Alexander SA (1996) Levels of root resorption associated with continuous arch and sectional arch mechanics American Journal of Orthodontics and Dentofacial Orthopedics 110 321-4
Al-Qawasmi RA Hartsfield JK Jr Everett ET et al (2003a) Genetic predisposition to external apical root
resorption American Journal of Orthodontics and Dentofacial Orthopedics 123 242-52
Al-Qawasmi RA Hartsfield JKJr Everett ET et al (2003b) Genetic predisposition to external apical
root resorption in orthodontic patients linkage of chromosome-18 marker Journal of Dental Research
82(5) 356-60
Al-Nazhan S (1991) External root resorption after bleaching A case report Oral Surgery Oral
Meddicine Oral Pathology 72 607-9
Andreasen JO (1985) External root resorption its implication in dental traumatology paedodontics
periodontics orthodontics and endodontics International Endodontic Journal 18 109-18
Attati I Hammarstrom L (1996a) Root surface defects in rat molar induced by 1-hydroxyethylidene-1
1-bisphosphonate Acta Odontologica Scandinavica 54 59-65
Attati I Hellsing E Hammarstrom L (1996b) Orthodontically induced root resorption in rat molars after 1-hydroxyethylidene-1 1-bisphosphonate injection Acta Odontologica Scandinavica 54 102-8
Barbagallo LJ Jones AS Petocz P et al (2008) Physical properties of root cementum Part 10
Comparison of the effects of invisible removable thermoplastic appliances with light and heavy orthodontic forces on premolar cementum A microcomputed-tomography study American Journal of
Orthodontics and Dentofacial Orthopedics 133 218-27
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edgewise and light wire mechanics American Journal of Orthodontics and Dentofacial Orthopedics
105(4) 350-61
Bishara SE Vonwald L Jakobsen JR (1999) Changes in root length from early to mid-adulthood
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8
Blake M Woodside DG Pharoah MJ (1995) A radiographic comparison of apical root resorption after
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Dentofacial Orthopedics 108 76-84
Bollen A-M (2002) Large overjet and longer teeth are associated with more root resorption when
treated orthodontically Journal of Evidence Based Dental Practice 2 44-5
Boyd RL (2007) Complex orthodontic treatment using a new protocol for the Invisalign appliance Journal of Clinical Orthodontics 4 525-47
Brezniak N Wasserstein A (1993) Root resorption after orthodontic treatment Part 1 Literature
review American Journal of Orthodontics and Dentofacial Orthopedics 103 62-6
Brezniak N Wasserstein A (2002a) Orthodontically induced inflammatory root resorption Part 1 The
basic science aspects Angle Orthodontist 72 175-9
Brezniak N Wasserstein A (2002b) Orthodontically induced inflammatory root resorption Part II The
clinical aspects Angle Orthodontist 72 180-4
Brezniak N Wasserstein A (2008) Root resorption following treatment with aligners Angle
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
Orthopedics 124(2) 151-6
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
References Casa MA Faltin RM Faltin K et al (2001) Root resorptions in upper first premolars after application of
continuous torque moment Intra-individual study Journal of Orofacial Orthopedics 62(4) 285-95
Chan EKM Darendeliler MA Petocz P et al (2004a) A new method for volumetric measurement of
orthodontically induced root resorption craters European Journal of Oral Science 112(2) 134-9
Chan EKM Darendeliler MA (2004b) Exploring the third dimension in root resorption Orthodontics amp Craniofacial Research 7 64-70
Chan E Darendeliler MA (2005) Physical properties of root cementum Part 5 Volumetric analysis of
root resorption craters after application of light and heavy orthodontic forces American Journal of Orthodontics and Dentofacial Orthopedics 127(2) 186-95
Chan E Darendeliler MA (2006) Physical properties of root cementum part 7 Extent of root resorption
under areas of compression and tension American Journal of Orthodontics and Dentofacial Orthopedics 129(4) 504-10
Christiansen RL (1994) Commentary Thyroxine administration and its effects on root resorption
Angle Orthodontist 64 399-400
Copeland S Green LJ (1986) Root resorption in maxillary central incisors following active orthodontic
treatment American Journal of Orthodontics and Dentofacial Orthopedics 89(1) 51-5
Costopoulos G Nanda R (1996) An evaluation of root resorption incident to orthodontic intrusion
American Journal of Orthodontics and Dentofacial Orthopedics 109(5) 543-8
Counts Al Widlak RA (1993) Generalized idiopathic external root resorption Journal of clinical
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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
application of light and heavy controlled orthodontic forces Orthodics amp Craniofacial Research 7(2)
79-97
Davidovitch Z Godwin SL Park YG et al (1996) The etiology of root resorption In Orthodontic
Treatment The management of unfavorable sequelae McNamara JA Trotman CA editors University
of Michigan Press Ann Arbor MI 93-117
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DeShields RW (1969) A study of root resorption in treated Class II Division I malocclusions Angle
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Drysdale C Gibbs SL Ford TR (1996) Orthodontic management of root-filled teeth British Journal of
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English H (2001) External apical root resorption as a consequence of orthodontic treatment Journal of New Zealand Society of Periodontology 86 17-23
Faltin RM Faltin K Sander FG et al (2001) Ultrastructure of cementum and periodontal ligament
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Fox N (2005) Longer orthodontic treatment may result in greater external apical root resorption
Evidence Based Dentistry 6 21
Fuss Z Tsesis I Lin S (2003) Root resorption ndash diagnosis classification and treatment choices based
on stimulation factors Dental Traumatology 19 175-82
Goldie RS King GJ (1984) Root resorption and tooth movement in orthodontically treated calcium-
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30
Goldson L Henrikson CO (1975) Root resorption during Begg treatment a longitudinal roentgenologic
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Kalkwarf KL Krejci RF Pao YC (1986) Effect of apical root resorption on periodontal support Journal of
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Kennedy D Joondeph D Osterberg S et al (1983) The effect of extraction and orthodontic treatment
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Kjaer I (1995) Morphological characteristics of dentitions developing excessive root resorption during
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Konoo T Kim YJ Gu GM et al (2001) Intermittent force in orthodontic tooth movement Journal of
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Kook Y-A Park S Sameshima GT (2003) Peg-shaped and small lateral incisors not at higher risk for root resorption American Journal of Orthodontics and Dentofacial Orthopedics 123 253-8
Kurol J Owman-Moll P (1998) Hyalinization and root resorption during early orthodontic tooth
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Lee RY Artun J Alonzo TA (1999) Are dental anomalies risk factors for apical root resorption in
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Levander E Malmgren O (1988) Evaluation of the risk of root resorption during orthodontic treatment
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Levander E Malmgren O Eliasson S (1994) Evaluation of root resorption in relation to two orthodontic
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Levander E Malmgren O Stenback K (1998) Apical root resorption during orthodontic treatment of patients with multiple aplasia a study of maxillary incisors European Journal of Orthodontics 20
427-34
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15
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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
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Thongudomporn U Freer TJ (1998) Anomalous dental morphology and root resorption during orthodontic treatment a pilot study Australian Orthodontic Journal 15(3) 162-7
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Walker SL Tieu LD Flores-Mir C (2013) Radiographic comparison of the extent of orthodontically
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Weltman BJ Vig KWL Fields HW et al (2010) American Journal of Orthodontics and Dentofacial
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Wheeler In Press
Wickwire NA Mc Neil MH Norton LA et al (1974) The effects of tooth movement upon endodontically
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Wu FL Wang LY Huang YQ Guo WB Liu CD Li SG (2013) Interleukin-1β +3954 polymorphisms and
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Lombardo L Bragazzi R Perissinotto C Mirabella D Siciliani G Cone-beam computed tomography
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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
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Hodges RJ Atchison KA White SC Impact of cone-beam computed tomography on orthodontic
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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
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Orthod May83(3)389-93
Wang Q1 Chen W Smales RJ Peng H Hu X Yin L Apical root resorption in maxillary incisors
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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
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Dula K Bornstein MM Buser D et al (2014)SADMFR guidelines for the use of Cone-Beam Computed
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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
12
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
1) Case ReportInitial Radiographs
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
18 months into orthodontic treatment
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
Deband
Source American Journal of Orthodontics and Dentofacial Orthopedics 2011 139S166-S169 (DOI101016jajodo200905032 )
Copyright copy 2011 American Association of Orthodontists Terms and Conditions
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
References Acar A Canyurek U Kocaaga M et al (1999) Continuous vs discontinuous force application and root
resorption Angle Orthodontist 69(2) 159-63 discussion 163-4
Adachi H Igarashi K Mitani H et al (1994) Effects of topical administration of a bisphosphonate
(risedronate) on orthodontic tooth movement in rats Journal of Dental Research 73 1478-1486
Alexander SA (1996) Levels of root resorption associated with continuous arch and sectional arch mechanics American Journal of Orthodontics and Dentofacial Orthopedics 110 321-4
Al-Qawasmi RA Hartsfield JK Jr Everett ET et al (2003a) Genetic predisposition to external apical root
resorption American Journal of Orthodontics and Dentofacial Orthopedics 123 242-52
Al-Qawasmi RA Hartsfield JKJr Everett ET et al (2003b) Genetic predisposition to external apical
root resorption in orthodontic patients linkage of chromosome-18 marker Journal of Dental Research
82(5) 356-60
Al-Nazhan S (1991) External root resorption after bleaching A case report Oral Surgery Oral
Meddicine Oral Pathology 72 607-9
Andreasen JO (1985) External root resorption its implication in dental traumatology paedodontics
periodontics orthodontics and endodontics International Endodontic Journal 18 109-18
Attati I Hammarstrom L (1996a) Root surface defects in rat molar induced by 1-hydroxyethylidene-1
1-bisphosphonate Acta Odontologica Scandinavica 54 59-65
Attati I Hellsing E Hammarstrom L (1996b) Orthodontically induced root resorption in rat molars after 1-hydroxyethylidene-1 1-bisphosphonate injection Acta Odontologica Scandinavica 54 102-8
Barbagallo LJ Jones AS Petocz P et al (2008) Physical properties of root cementum Part 10
Comparison of the effects of invisible removable thermoplastic appliances with light and heavy orthodontic forces on premolar cementum A microcomputed-tomography study American Journal of
Orthodontics and Dentofacial Orthopedics 133 218-27
References Baumrind S Korn EL Boyd RL (1996) Apical root resorption in orthodontically treated adults
American Journal of Orthodontics and Dentofacial Orthopedics 110(3) 311-20
Beck BW Harris EF (1994) Apical root resorption in orthodontically treated subjects analysis of
edgewise and light wire mechanics American Journal of Orthodontics and Dentofacial Orthopedics
105(4) 350-61
Bishara SE Vonwald L Jakobsen JR (1999) Changes in root length from early to mid-adulthood
resorption or apposition American Journal of Orthodontics and Dentofacial Orthopedics 115(5) 563-
8
Blake M Woodside DG Pharoah MJ (1995) A radiographic comparison of apical root resorption after
orthodontic treatment with the edgewise and Speed appliances American Journal of Orthodontics and
Dentofacial Orthopedics 108 76-84
Bollen A-M (2002) Large overjet and longer teeth are associated with more root resorption when
treated orthodontically Journal of Evidence Based Dental Practice 2 44-5
Boyd RL (2007) Complex orthodontic treatment using a new protocol for the Invisalign appliance Journal of Clinical Orthodontics 4 525-47
Brezniak N Wasserstein A (1993) Root resorption after orthodontic treatment Part 1 Literature
review American Journal of Orthodontics and Dentofacial Orthopedics 103 62-6
Brezniak N Wasserstein A (2002a) Orthodontically induced inflammatory root resorption Part 1 The
basic science aspects Angle Orthodontist 72 175-9
Brezniak N Wasserstein A (2002b) Orthodontically induced inflammatory root resorption Part II The
clinical aspects Angle Orthodontist 72 180-4
Brezniak N Wasserstein A (2008) Root resorption following treatment with aligners Angle
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
Orthopedics 124(2) 151-6
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
References Casa MA Faltin RM Faltin K et al (2001) Root resorptions in upper first premolars after application of
continuous torque moment Intra-individual study Journal of Orofacial Orthopedics 62(4) 285-95
Chan EKM Darendeliler MA Petocz P et al (2004a) A new method for volumetric measurement of
orthodontically induced root resorption craters European Journal of Oral Science 112(2) 134-9
Chan EKM Darendeliler MA (2004b) Exploring the third dimension in root resorption Orthodontics amp Craniofacial Research 7 64-70
Chan E Darendeliler MA (2005) Physical properties of root cementum Part 5 Volumetric analysis of
root resorption craters after application of light and heavy orthodontic forces American Journal of Orthodontics and Dentofacial Orthopedics 127(2) 186-95
Chan E Darendeliler MA (2006) Physical properties of root cementum part 7 Extent of root resorption
under areas of compression and tension American Journal of Orthodontics and Dentofacial Orthopedics 129(4) 504-10
Christiansen RL (1994) Commentary Thyroxine administration and its effects on root resorption
Angle Orthodontist 64 399-400
Copeland S Green LJ (1986) Root resorption in maxillary central incisors following active orthodontic
treatment American Journal of Orthodontics and Dentofacial Orthopedics 89(1) 51-5
Costopoulos G Nanda R (1996) An evaluation of root resorption incident to orthodontic intrusion
American Journal of Orthodontics and Dentofacial Orthopedics 109(5) 543-8
Counts Al Widlak RA (1993) Generalized idiopathic external root resorption Journal of clinical
orthodontics 27 511-3
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
application of light and heavy controlled orthodontic forces Orthodics amp Craniofacial Research 7(2)
79-97
Davidovitch Z Godwin SL Park YG et al (1996) The etiology of root resorption In Orthodontic
Treatment The management of unfavorable sequelae McNamara JA Trotman CA editors University
of Michigan Press Ann Arbor MI 93-117
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DeShields RW (1969) A study of root resorption in treated Class II Division I malocclusions Angle
Orthodontist 39(4) 231-45
Drysdale C Gibbs SL Ford TR (1996) Orthodontic management of root-filled teeth British Journal of
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English H (2001) External apical root resorption as a consequence of orthodontic treatment Journal of New Zealand Society of Periodontology 86 17-23
Faltin RM Faltin K Sander FG et al (2001) Ultrastructure of cementum and periodontal ligament
after continuous intrusion in humans a transmission electron microscopy study European Journal of Orthodontics 23(1) 35-49
Fox N (2005) Longer orthodontic treatment may result in greater external apical root resorption
Evidence Based Dentistry 6 21
Fuss Z Tsesis I Lin S (2003) Root resorption ndash diagnosis classification and treatment choices based
on stimulation factors Dental Traumatology 19 175-82
Goldie RS King GJ (1984) Root resorption and tooth movement in orthodontically treated calcium-
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Igarashi K Adachi H Mitani H et al (1996) Inhibitory effect of topical administration of a
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Jimenez-Pellegrin C Arana-Chavez VE (2004) Root resorption in human mandibular first premolars
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15
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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
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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Attati I Hammarstrom L (1996a) Root surface defects in rat molar induced by 1-hydroxyethylidene-1
1-bisphosphonate Acta Odontologica Scandinavica 54 59-65
Attati I Hellsing E Hammarstrom L (1996b) Orthodontically induced root resorption in rat molars after 1-hydroxyethylidene-1 1-bisphosphonate injection Acta Odontologica Scandinavica 54 102-8
Barbagallo LJ Jones AS Petocz P et al (2008) Physical properties of root cementum Part 10
Comparison of the effects of invisible removable thermoplastic appliances with light and heavy orthodontic forces on premolar cementum A microcomputed-tomography study American Journal of
Orthodontics and Dentofacial Orthopedics 133 218-27
References Baumrind S Korn EL Boyd RL (1996) Apical root resorption in orthodontically treated adults
American Journal of Orthodontics and Dentofacial Orthopedics 110(3) 311-20
Beck BW Harris EF (1994) Apical root resorption in orthodontically treated subjects analysis of
edgewise and light wire mechanics American Journal of Orthodontics and Dentofacial Orthopedics
105(4) 350-61
Bishara SE Vonwald L Jakobsen JR (1999) Changes in root length from early to mid-adulthood
resorption or apposition American Journal of Orthodontics and Dentofacial Orthopedics 115(5) 563-
8
Blake M Woodside DG Pharoah MJ (1995) A radiographic comparison of apical root resorption after
orthodontic treatment with the edgewise and Speed appliances American Journal of Orthodontics and
Dentofacial Orthopedics 108 76-84
Bollen A-M (2002) Large overjet and longer teeth are associated with more root resorption when
treated orthodontically Journal of Evidence Based Dental Practice 2 44-5
Boyd RL (2007) Complex orthodontic treatment using a new protocol for the Invisalign appliance Journal of Clinical Orthodontics 4 525-47
Brezniak N Wasserstein A (1993) Root resorption after orthodontic treatment Part 1 Literature
review American Journal of Orthodontics and Dentofacial Orthopedics 103 62-6
Brezniak N Wasserstein A (2002a) Orthodontically induced inflammatory root resorption Part 1 The
basic science aspects Angle Orthodontist 72 175-9
Brezniak N Wasserstein A (2002b) Orthodontically induced inflammatory root resorption Part II The
clinical aspects Angle Orthodontist 72 180-4
Brezniak N Wasserstein A (2008) Root resorption following treatment with aligners Angle
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
Orthopedics 124(2) 151-6
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
References Casa MA Faltin RM Faltin K et al (2001) Root resorptions in upper first premolars after application of
continuous torque moment Intra-individual study Journal of Orofacial Orthopedics 62(4) 285-95
Chan EKM Darendeliler MA Petocz P et al (2004a) A new method for volumetric measurement of
orthodontically induced root resorption craters European Journal of Oral Science 112(2) 134-9
Chan EKM Darendeliler MA (2004b) Exploring the third dimension in root resorption Orthodontics amp Craniofacial Research 7 64-70
Chan E Darendeliler MA (2005) Physical properties of root cementum Part 5 Volumetric analysis of
root resorption craters after application of light and heavy orthodontic forces American Journal of Orthodontics and Dentofacial Orthopedics 127(2) 186-95
Chan E Darendeliler MA (2006) Physical properties of root cementum part 7 Extent of root resorption
under areas of compression and tension American Journal of Orthodontics and Dentofacial Orthopedics 129(4) 504-10
Christiansen RL (1994) Commentary Thyroxine administration and its effects on root resorption
Angle Orthodontist 64 399-400
Copeland S Green LJ (1986) Root resorption in maxillary central incisors following active orthodontic
treatment American Journal of Orthodontics and Dentofacial Orthopedics 89(1) 51-5
Costopoulos G Nanda R (1996) An evaluation of root resorption incident to orthodontic intrusion
American Journal of Orthodontics and Dentofacial Orthopedics 109(5) 543-8
Counts Al Widlak RA (1993) Generalized idiopathic external root resorption Journal of clinical
orthodontics 27 511-3
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
application of light and heavy controlled orthodontic forces Orthodics amp Craniofacial Research 7(2)
79-97
Davidovitch Z Godwin SL Park YG et al (1996) The etiology of root resorption In Orthodontic
Treatment The management of unfavorable sequelae McNamara JA Trotman CA editors University
of Michigan Press Ann Arbor MI 93-117
References Dermaut LR De Munck A (1986) Apical root resorption of upper incisors caused by intrusive tooth
movement a radiographic study American Journal of Orthodontics and Dentofacial Orthopedics
90(4) 321-6
DeShields RW (1969) A study of root resorption in treated Class II Division I malocclusions Angle
Orthodontist 39(4) 231-45
Drysdale C Gibbs SL Ford TR (1996) Orthodontic management of root-filled teeth British Journal of
Orthodontics 23 255-60
English H (2001) External apical root resorption as a consequence of orthodontic treatment Journal of New Zealand Society of Periodontology 86 17-23
Faltin RM Faltin K Sander FG et al (2001) Ultrastructure of cementum and periodontal ligament
after continuous intrusion in humans a transmission electron microscopy study European Journal of Orthodontics 23(1) 35-49
Fox N (2005) Longer orthodontic treatment may result in greater external apical root resorption
Evidence Based Dentistry 6 21
Fuss Z Tsesis I Lin S (2003) Root resorption ndash diagnosis classification and treatment choices based
on stimulation factors Dental Traumatology 19 175-82
Goldie RS King GJ (1984) Root resorption and tooth movement in orthodontically treated calcium-
deficient and lactating rats American Journal of Orthodontics and Dentofacial Orthopedics 85 424-
30
Goldson L Henrikson CO (1975) Root resorption during Begg treatment a longitudinal roentgenologic
study American Journal of Orthodontics and Dentofacial Orthopedics 68(1) 55-66
Han G Huang S Von den Hoff et al (2005) Root resorption after orthodontic intrusion and extrusion
an intraindividual study Angle Orthodontist 75 912-8
Hamilton RS Gutmann JL (1999) Endodontic-orthodontic relationships a review of integrated treatment planning challenges International Endodontic Journal 32 343-60
Harris EF Baker WC (1990) Loss of root length and crestal bone height before and during treatment in
adolescent and adult orthodontic patients American Journal of Orthodontics and Dentofacial Orthopedics 98(5) 463-9
References Harris EF Robinson QC Woods MA (1993) An analysis of causes of apical root resorption in patients
not treated orthodontically Quintessence international 24(6) 417-28
Harris EF Kineret SE Tolley EA (1997) A heritable component for external apical root resorption in
patients treated orthodontically American Journal of Orthodontics and Dentofacial Orthopedics
111(3) 301-9
Harris DA Jones AS Darendeliler MA (2006) Physical properties of root cementum part 8 Volumetric
analysis of root resorption craters after application of controlled intrusive light and heavy orthodontic
forces a microcomputed tomography scan study American Journal of Orthodontics and Dentofacial
Orthopedics 130 639-47
Harry MR Sims MR (1982) Root resorption in bicuspid intrusion A Scanning electron microscope
study Angle Orthodontist 52 235-58
Hartsfield JK Jr Everett ET Al-Qawasmi RA (2004) Genetic factors in external apical root resorption
and orthodontic treatment Critical Reviews in Oral Biology Medicine 15 115-22
Horiuchi A Hotokezaka H Kobayashi K (1998) Correlation between cortical plate proximity and apical root resorption American Journal of Orthodontics and Dentofacial Orthopedics 114(3) 311-8
Igarashi K Adachi H Mitani H et al (1996) Inhibitory effect of topical administration of a
bisphosphonate (risedronate) on root resorption incident to orthodontic tooth movement in rats Journal of Dental Research 75 1644-9
Janson GR De Luca Canto G Martins DR et al (1999) A radiographic comparison of apical root
resorption after orthodontic treatment with 3 different fixed appliance techniques American Journal of Orthodontics and Dentofacial Orthopedics 118(3) 262-73
Jimenez-Pellegrin C Arana-Chavez VE (2004) Root resorption in human mandibular first premolars
after rotation as detected by scanning electron microscopy American Journal of Orthodontics and Dentofacial Orthopedics 126(2) 178-84 discussion 184-5
Kaley J Phillips C (1991) Factors related to root resorption in edgewise practice Angle Orthodontist
61(2) 125-32
Kalkwarf KL Krejci RF Pao YC (1986) Effect of apical root resorption on periodontal support Journal of
Prosthetic Dentistry 56 317-9
References Katona TR (2006) Flaws in root resorption assessment algorithms Role of tooth shape American
Journal of Orthodontics and Dentofacial Orthopedics 130 698e19-e27
Kennedy D Joondeph D Osterberg S et al (1983) The effect of extraction and orthodontic treatment
on dentoalveolar support American Journal of Orthodontics and Dentofacial Orthopedics 84 183-90
Ketcham AH (1927) A preliminary report of an investigation of apical root resorption of vital permanent teeth International Journal of Orthodontics 13 97-127
Killiany DM (1999) Root resorption caused by orthodontic treatment an evidence-based review of
literature Seminars in Orthodontics 5 128-33
Killiany DM (2002) Root resorption caused by orthodontic treatment review of literature from 1998 to
2001 for evidence Progress in Orthodontics 3 2-5
Kjaer I (1995) Morphological characteristics of dentitions developing excessive root resorption during
orthodontic treatment European Journal of Orthodontics 17 25-34
Konoo T Kim YJ Gu GM et al (2001) Intermittent force in orthodontic tooth movement Journal of
Dental Research 80 457-60
Kook Y-A Park S Sameshima GT (2003) Peg-shaped and small lateral incisors not at higher risk for root resorption American Journal of Orthodontics and Dentofacial Orthopedics 123 253-8
Kurol J Owman-Moll P (1998) Hyalinization and root resorption during early orthodontic tooth
movement in adolescents Angle Orthodontist 68 161-5
Lee RY Artun J Alonzo TA (1999) Are dental anomalies risk factors for apical root resorption in
orthodontic patients American Journal of Orthodontics and Dentofacial Orthopedics 116(2) 187-95
Levander E Malmgren O (1988) Evaluation of the risk of root resorption during orthodontic treatment
a study of upper incisors European Journal of Orthodontics 10 30-8
Levander E Malmgren O Eliasson S (1994) Evaluation of root resorption in relation to two orthodontic
treatment regimes A clinical experimental study European Journal of Orthodontics 16 223-8
Levander E Malmgren O Stenback K (1998) Apical root resorption during orthodontic treatment of patients with multiple aplasia a study of maxillary incisors European Journal of Orthodontics 20
427-34
References Levander E Malmgren O (2000) Long-term follow-up of maxillary incisors with severe root resorption
European Journal of Orthodontics 22 85-92
Lew K (1990) Intrusion and apical resorption of mandibular incisors in Begg treatment anchorage
bend or curve Australian Orthodontic Journal 11(3) 164-8
Linge BO Linge L (1983) Apical root resorption in upper anterior teeth European Journal of Orthodontics 5(3) 173-83
Linge L Linge BO (1991) Patient characteristics and treatment variables associated with apical root
resorption during orthodontic treatment American Journal of Orthodontics and Dentofacial Orthopedics99 35-43
Loberg EL Engstrom C (1994) Thyroid administration to reduce root resorption Angle Orthodontist
64 395-9
Lupi JE Handelman CS Sadowsky C (1996) Prevalence and severity of apical root resorption and
alveolar bone loss in orthodontically treated adults American Journal of Orthodontics and Dentofacial
Orthopedics 109(1) 28-37
Malmgren O Goldson L Hill C et al (1982) Root resorption after orthodontic treatment of traumatized
teeth American Journal of Orthodontics and Dentofacial Orthopedics 82 487-91
Mandall N Lowe C Worthington H et al (2006) Which orthodontic archwire sequence A randomized
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
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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
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Orthodontics and Dentofacial Orthopedics 67 522-39
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
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Owman-Moll P Kurol J Lundgren D (1995a) Continuous versus interrupted continuous orthodontic
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discussion 401-2
Owman-Moll P Kurol J Lundgren D (1995b) Repair of orthodontically induced root resorption Angle
Orthodontist 65(6) 403-8
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
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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
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Proffit WR Fields HW SarverDM (2006) Contemporary Orthodontics Fourth Edition CV Mosby Missouri
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factors American Journal of Orthodontics and Dentofacial Orthopedics 119(5) 505-10
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57-67
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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
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Walker SL Tieu LD Flores-Mir C (2013) Radiographic comparison of the extent of orthodontically
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movement and root resorption European Journal of Orthodontics 25(4) 335-42
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Wheeler In Press
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Lombardo L Bragazzi R Perissinotto C Mirabella D Siciliani G Cone-beam computed tomography
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14921
Krasny M Zadurska M Cessak G Fiedor P Analysis of effect of non-steroidal anti-inflammatory drugs
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References Castro IO Alencar AH Valladares-Neto J Estrela C Apical root resorption due to orthodontic treatment
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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
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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
14
References Casa MA Faltin RM Faltin K et al (2001) Root resorptions in upper first premolars after application of
continuous torque moment Intra-individual study Journal of Orofacial Orthopedics 62(4) 285-95
Chan EKM Darendeliler MA Petocz P et al (2004a) A new method for volumetric measurement of
orthodontically induced root resorption craters European Journal of Oral Science 112(2) 134-9
Chan EKM Darendeliler MA (2004b) Exploring the third dimension in root resorption Orthodontics amp Craniofacial Research 7 64-70
Chan E Darendeliler MA (2005) Physical properties of root cementum Part 5 Volumetric analysis of
root resorption craters after application of light and heavy orthodontic forces American Journal of Orthodontics and Dentofacial Orthopedics 127(2) 186-95
Chan E Darendeliler MA (2006) Physical properties of root cementum part 7 Extent of root resorption
under areas of compression and tension American Journal of Orthodontics and Dentofacial Orthopedics 129(4) 504-10
Christiansen RL (1994) Commentary Thyroxine administration and its effects on root resorption
Angle Orthodontist 64 399-400
Copeland S Green LJ (1986) Root resorption in maxillary central incisors following active orthodontic
treatment American Journal of Orthodontics and Dentofacial Orthopedics 89(1) 51-5
Costopoulos G Nanda R (1996) An evaluation of root resorption incident to orthodontic intrusion
American Journal of Orthodontics and Dentofacial Orthopedics 109(5) 543-8
Counts Al Widlak RA (1993) Generalized idiopathic external root resorption Journal of clinical
orthodontics 27 511-3
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
application of light and heavy controlled orthodontic forces Orthodics amp Craniofacial Research 7(2)
79-97
Davidovitch Z Godwin SL Park YG et al (1996) The etiology of root resorption In Orthodontic
Treatment The management of unfavorable sequelae McNamara JA Trotman CA editors University
of Michigan Press Ann Arbor MI 93-117
References Dermaut LR De Munck A (1986) Apical root resorption of upper incisors caused by intrusive tooth
movement a radiographic study American Journal of Orthodontics and Dentofacial Orthopedics
90(4) 321-6
DeShields RW (1969) A study of root resorption in treated Class II Division I malocclusions Angle
Orthodontist 39(4) 231-45
Drysdale C Gibbs SL Ford TR (1996) Orthodontic management of root-filled teeth British Journal of
Orthodontics 23 255-60
English H (2001) External apical root resorption as a consequence of orthodontic treatment Journal of New Zealand Society of Periodontology 86 17-23
Faltin RM Faltin K Sander FG et al (2001) Ultrastructure of cementum and periodontal ligament
after continuous intrusion in humans a transmission electron microscopy study European Journal of Orthodontics 23(1) 35-49
Fox N (2005) Longer orthodontic treatment may result in greater external apical root resorption
Evidence Based Dentistry 6 21
Fuss Z Tsesis I Lin S (2003) Root resorption ndash diagnosis classification and treatment choices based
on stimulation factors Dental Traumatology 19 175-82
Goldie RS King GJ (1984) Root resorption and tooth movement in orthodontically treated calcium-
deficient and lactating rats American Journal of Orthodontics and Dentofacial Orthopedics 85 424-
30
Goldson L Henrikson CO (1975) Root resorption during Begg treatment a longitudinal roentgenologic
study American Journal of Orthodontics and Dentofacial Orthopedics 68(1) 55-66
Han G Huang S Von den Hoff et al (2005) Root resorption after orthodontic intrusion and extrusion
an intraindividual study Angle Orthodontist 75 912-8
Hamilton RS Gutmann JL (1999) Endodontic-orthodontic relationships a review of integrated treatment planning challenges International Endodontic Journal 32 343-60
Harris EF Baker WC (1990) Loss of root length and crestal bone height before and during treatment in
adolescent and adult orthodontic patients American Journal of Orthodontics and Dentofacial Orthopedics 98(5) 463-9
References Harris EF Robinson QC Woods MA (1993) An analysis of causes of apical root resorption in patients
not treated orthodontically Quintessence international 24(6) 417-28
Harris EF Kineret SE Tolley EA (1997) A heritable component for external apical root resorption in
patients treated orthodontically American Journal of Orthodontics and Dentofacial Orthopedics
111(3) 301-9
Harris DA Jones AS Darendeliler MA (2006) Physical properties of root cementum part 8 Volumetric
analysis of root resorption craters after application of controlled intrusive light and heavy orthodontic
forces a microcomputed tomography scan study American Journal of Orthodontics and Dentofacial
Orthopedics 130 639-47
Harry MR Sims MR (1982) Root resorption in bicuspid intrusion A Scanning electron microscope
study Angle Orthodontist 52 235-58
Hartsfield JK Jr Everett ET Al-Qawasmi RA (2004) Genetic factors in external apical root resorption
and orthodontic treatment Critical Reviews in Oral Biology Medicine 15 115-22
Horiuchi A Hotokezaka H Kobayashi K (1998) Correlation between cortical plate proximity and apical root resorption American Journal of Orthodontics and Dentofacial Orthopedics 114(3) 311-8
Igarashi K Adachi H Mitani H et al (1996) Inhibitory effect of topical administration of a
bisphosphonate (risedronate) on root resorption incident to orthodontic tooth movement in rats Journal of Dental Research 75 1644-9
Janson GR De Luca Canto G Martins DR et al (1999) A radiographic comparison of apical root
resorption after orthodontic treatment with 3 different fixed appliance techniques American Journal of Orthodontics and Dentofacial Orthopedics 118(3) 262-73
Jimenez-Pellegrin C Arana-Chavez VE (2004) Root resorption in human mandibular first premolars
after rotation as detected by scanning electron microscopy American Journal of Orthodontics and Dentofacial Orthopedics 126(2) 178-84 discussion 184-5
Kaley J Phillips C (1991) Factors related to root resorption in edgewise practice Angle Orthodontist
61(2) 125-32
Kalkwarf KL Krejci RF Pao YC (1986) Effect of apical root resorption on periodontal support Journal of
Prosthetic Dentistry 56 317-9
References Katona TR (2006) Flaws in root resorption assessment algorithms Role of tooth shape American
Journal of Orthodontics and Dentofacial Orthopedics 130 698e19-e27
Kennedy D Joondeph D Osterberg S et al (1983) The effect of extraction and orthodontic treatment
on dentoalveolar support American Journal of Orthodontics and Dentofacial Orthopedics 84 183-90
Ketcham AH (1927) A preliminary report of an investigation of apical root resorption of vital permanent teeth International Journal of Orthodontics 13 97-127
Killiany DM (1999) Root resorption caused by orthodontic treatment an evidence-based review of
literature Seminars in Orthodontics 5 128-33
Killiany DM (2002) Root resorption caused by orthodontic treatment review of literature from 1998 to
2001 for evidence Progress in Orthodontics 3 2-5
Kjaer I (1995) Morphological characteristics of dentitions developing excessive root resorption during
orthodontic treatment European Journal of Orthodontics 17 25-34
Konoo T Kim YJ Gu GM et al (2001) Intermittent force in orthodontic tooth movement Journal of
Dental Research 80 457-60
Kook Y-A Park S Sameshima GT (2003) Peg-shaped and small lateral incisors not at higher risk for root resorption American Journal of Orthodontics and Dentofacial Orthopedics 123 253-8
Kurol J Owman-Moll P (1998) Hyalinization and root resorption during early orthodontic tooth
movement in adolescents Angle Orthodontist 68 161-5
Lee RY Artun J Alonzo TA (1999) Are dental anomalies risk factors for apical root resorption in
orthodontic patients American Journal of Orthodontics and Dentofacial Orthopedics 116(2) 187-95
Levander E Malmgren O (1988) Evaluation of the risk of root resorption during orthodontic treatment
a study of upper incisors European Journal of Orthodontics 10 30-8
Levander E Malmgren O Eliasson S (1994) Evaluation of root resorption in relation to two orthodontic
treatment regimes A clinical experimental study European Journal of Orthodontics 16 223-8
Levander E Malmgren O Stenback K (1998) Apical root resorption during orthodontic treatment of patients with multiple aplasia a study of maxillary incisors European Journal of Orthodontics 20
427-34
References Levander E Malmgren O (2000) Long-term follow-up of maxillary incisors with severe root resorption
European Journal of Orthodontics 22 85-92
Lew K (1990) Intrusion and apical resorption of mandibular incisors in Begg treatment anchorage
bend or curve Australian Orthodontic Journal 11(3) 164-8
Linge BO Linge L (1983) Apical root resorption in upper anterior teeth European Journal of Orthodontics 5(3) 173-83
Linge L Linge BO (1991) Patient characteristics and treatment variables associated with apical root
resorption during orthodontic treatment American Journal of Orthodontics and Dentofacial Orthopedics99 35-43
Loberg EL Engstrom C (1994) Thyroid administration to reduce root resorption Angle Orthodontist
64 395-9
Lupi JE Handelman CS Sadowsky C (1996) Prevalence and severity of apical root resorption and
alveolar bone loss in orthodontically treated adults American Journal of Orthodontics and Dentofacial
Orthopedics 109(1) 28-37
Malmgren O Goldson L Hill C et al (1982) Root resorption after orthodontic treatment of traumatized
teeth American Journal of Orthodontics and Dentofacial Orthopedics 82 487-91
Mandall N Lowe C Worthington H et al (2006) Which orthodontic archwire sequence A randomized
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
Orthodontics and Dentofacial Orthopedics 67 522-39
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
Orthodontist 65(6) 403-8
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
Orthopedics 134(5) 646-51
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
factors American Journal of Orthodontics and Dentofacial Orthopedics 119(5) 511-5
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
Orthodontics 96 331-52
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
and Dentofacial Orthopedics 134 470e1-e8
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
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
Orthopedics 134(5) 646-51
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
factors American Journal of Orthodontics and Dentofacial Orthopedics 119(5) 511-5
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
Orthodontics 96 331-52
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
and Dentofacial Orthopedics 134 470e1-e8
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