Journal of Dental Specialities 2020;8(1):3–8

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Original Research Article

Evaluation of root resorption after orthodontic treatment: A clinical study of
contributory factors
Jasleen Kaur1, *, Divya Shetty1 , Payal Sharma1 , Piush Kumar1 , Achint Juneja1 ,
Monis Raza1
1 Dept of Orthodontics and Dentofacial Orthopaedics, I.T.S Centre for Dental Studies and Research, Muradnagar, Ghaziabad,
Uttar Pradesh, India

ARTICLE INFO ABSTRACT

Article history: Introduction: The aim of this study was to evaluate the contributory factors of external apical root
Received 15-10-2020 resorption.
Accepted 11-02-2020 Materials and Methods: Sixty subjects who had undergone complete orthodontic treatment were selected.
Available online 23-11-2020 The difference of the root length between pre and post-treatment was measured. The degree of root
resorption was scored according to the index proposed by Levander and Malmgren. 1 The mean root
resorption score (MRRS) was calculated. Mann Whitney test was done to compare the groups. Pearson
Keywords: correlation was applied.
Root resorption Results: There was no statistically significant difference in root resorption among males and females.
Fixed orthodontic treatment
Tooth extraction was correlated with MRRS. Except for upper posterior teeth, the duration of treatment
forces
was positively correlated with MRRS. For overjet, there was a positive correlation between upper and
lower anterior teeth and MRRS.
Conclusion: Orthodontic treatment should be carefully performed in patients who need extraction, great
retraction of maxillary incisors and prolonged therapy.

© This is an open access article distributed under the terms of the Creative Commons Attribution
License ([Link] which permits unrestricted use, distribution, and
reproduction in any medium, provided the original author and source are credited.

1. Introduction tissues. And, its pathogenesis is associated with the removal

of the necrotic tissue from the periodontium that gets
During orthodontic treatment, the movement of the teeth compressed by orthodontic forces. 9,10
occurs inside the bony socket. Application of force to the
teeth and their periodontium leads to remodelling of bone The normal function of a tooth is unaffected in mild
and cementum which helps in correcting the position and cases of external apical root resorption, but in severe cases
the malocclusion. 2,3 of external apical root resorption, orthodontic treatment
should be stopped immediately as it allows the cementum
External apical root resorption is defined as surface
to heal. 3,8
resorption with loss of cementum that is irreversible when
involving dentin. 4,5 It is one the most common and Several studies have been done to find the contributory
undesirable iatrogenic effect of orthodontic treatment. 2,6,7 factors associated with external apical root resorption but
It occurs when the pressure on the cementum surpasses the still, it is difficult to predict whether the patient will
reparative capacity of its cellular structures, exposing the develop it or not 11,12 The factors associated with apical
dentine to activated odontoclasts causing irreversible loss root resorption, due to orthodontic treatment, can be either
of root structure. 8,9 Root resorption begins near hyalinised patient-specific or treatment specific. 7,10 Severe resorption
is considered to be a loss of more than 4 mm or more
* Corresponding author. than one-third overall root length and affects 15% of
E-mail address: jasleenkaur_mds18_21@[Link] (J. Kaur). orthodontically treated patients. 9,13

[Link]
2320-7302/© 2020 Innovative Publication, All rights reserved. 3
4 Kaur et al. / Journal of Dental Specialities 2020;8(1):3–8

Knowing the etiology of external apical root resorption and Malmgren 1 (Figure 3), using a 0 – 4 scale of severity,
would allow the clinicians to predict the incidence, location as follows:
and severity of root resorption before the commencement of Score 0: Absence of changes in the root apex
orthodontic treatment. 14 Score 1: Irregular root contour
Orthodontists are still continuously concerned about Score 2: EARR of less than 2 mm
this situation, so the present study was aimed to evaluate Score 3: EARR from 2 mm to one-third of the original
the patient-related and treatment-related factors of external root length
apical root resorption. Thus, the following study was Score 4: EARR exceeding one-third of original root
conducted to evaluate the patient-related and treatment- length
related factors of external apical root resorption, to score The mean root resorption score (MRRS) for every patient
the root resorption level in the subjects and to assess the risk was calculated for four segments in each patient: upper
factors of external apical root resorption. anterior, upper posterior, lower anterior and lower posterior
teeth, using the formula. 6
2. Materials and Methods Mean root resorption score = Sum o f the scores
Number o f teeth
The study was conducted in the Department of our institute
in India. 2.5. Statistical analysis
Statistical analysis was performed using the Statistical
2.1. Sample selection Package for the Social Sciences computer software (SPSS
Sixty patients (30 males and 30 females) who had version 16.0) to analyse the data. Significance level was
undergone fixed appliance orthodontic therapy were fixed as 5% (α = 0.05). Shapiro-Wilks test was carried out
selected according to the following criteria: complete to assess the normality of variables in the study. Descriptive
records of the patients including pre and post-treatment statistics were performed for root resorption values recorded
panoramic radiographs and no relevant medical history in in groups. Mann Whitney U test was used to compare root
the past. Patients excluded were those who had undergone resorption levels between male and female, and extraction
orthognathic surgery, cleft lip/palate patients, low-quality and non-extraction cases. Bivariate correlation and analysis
radiographs, history of systemic illness, history of tooth were undertaken between the type of therapy, duration,
injury, history of impacted teeth or history of parafunctional overjet, and MRRS after treatment. Using the MRRS as the
habits. dependent variable, and age, gender, type of therapy, overjet
and duration of treatment as independent variables, multiple
2.2. Examination of records regression analysis was done.

Pre-treatment data were recorded including gender, age at 2.6. Method error
the start of treatment, overjet, type of treatment (extraction
or non-extraction) and treatment duration. The same observer performed all assessments of root
resorption. Twenty patients were randomly selected
2.3. Examination of panoramic radiographs and panoramic radiographs before and after orthodontic
treatments were measured by the same examiner after
Standardized Pre and Post-treatment panoramic radiographs a 10-day interval to determine reliability. The intra-class
of 60 patients were analysed. Root lengths of all maxillary correlation coefficient between the 2 examinations was 0.93.
and mandibular teeth from central incisors to first permanent The difference between the first and second measurements
molars were measured on the pre and post-treatment was not significant (Table 1).
radiographs of all patients.
3. Results
2.4. Root resorption measurement
3.1. Demographic data
A Digital Vernier calliper with an accuracy of 0.01 was
used for measuring root length. Tooth length was measured 39 patients were treated with extraction and 21 without
as the distance from the root apex to the midpoint of the extraction. The average age of males was 16.05 ± 2.6 years
incisal edge or cusp tip. (Figures 1 and 2) Root resorption and of females was 15.2 ± 3.5 years at the initiation of the
was calculated by the difference of the tooth length between treatment.
the pre and post-treatment measurements. The tooth length MRRS score was more in extraction cases as compared
was measured for the left and right central incisors, lateral to non-extraction cases. Upper anterior teeth had more
incisors, premolars and first molars on both jaws. MRRS scores as compared to other teeth in both extraction
The degree of external apical root resorption (EARR) and non-extraction cases(Table 2). Root resorption was
was scored according to the index proposed by Levander compared on the basis of gender using the Mann Whitney
 Kaur et al. / Journal of Dental Specialities 2020;8(1):3–8 5

U test. Since the P-value was more than 0.05, there was no sucking, genetics, the shape of the root, bone morphology,
statistically significant difference in root resorption among etc. Treatment-specific factors include extractions, the
males and female cases.(Table 3 )Root resorption was also orthodontic technique used, treatment duration, amount
compared between extraction and non-extraction groups and direction of force applied, type of tooth movement
using the Mann Whitney U test. There was a statistically etc. 4,7,10,11,13
significant difference present between the two groups. The clinical diagnosis of root resorption is based mainly
(P < 0.05)(Table 4). Tooth extraction had a statistically on routine radiographic procedures, such as periapical
significant correlation with the mean root resorption score. radiography, panoramic radiography, CBCT and CT scans.
Except for upper posterior teeth, the duration of orthodontic Periapical radiographs are widely used in dentistry,
treatment was positively correlated with MRRS. For overjet, but however limited in their coverage of the maxilla-
there was a statistically significant correlation with upper mandibular structures and multiple films are needed for a
anterior and lower anterior teeth MRRS (Table 5). MRRS comprehensive examination. 6 Periapical films are accurate
was used as the dependent variable and age, gender, overjet, and localised but the amount of radiation exposure, a patient
type of treatment (extraction or non-extraction) and duration is subjected to, increases. 1
of the treatment were taken as independent variables. Conventional extra-oral radiographs such as the lateral
All factors, except age and gender, had a statistically cephalogram can achieve better coverage, but anatomical
significant correlation with root resorption. Treatment type structures of the facial skeleton that are not in the midline
had a positive correlation with root resorption upper anterior cannot be measured accurately because of distortion.
and lower posterior teeth. Treatment duration was correlated Bilateral structures produce two images and it is difficult
with upper and lower anterior teeth root resorption. Over jet to differentiate between right and left sides. 6,7
had a correlation with the resorption of upper anterior teeth A panoramic radiograph is another commonly used
only (Table 6). radiograph that has overcome many limitations of extraoral
radiography including controlled magnification in the
4. Discussion vertical dimension, decreased overlapping of tooth contact
areas and single point contact of the rotating beam onto the
External apical root resorption is a common side effect object to allow for a sharper, well-defined image. Panoramic
of orthodontic treatment. It is a sterile, local inflammatory radiographs are advantageous as the information of all teeth,
process that induces shortening of the roots and weakening dento-alveolar bone and jaws can be taken from a panoramic
of teeth. 4,15 It has a multifactorial etiology. It might film.
be occurring due to individual biology and the effects CT scans and CBCT provide more accurate three-
of mechanical factors. Root resorption is considered as dimensional images of teeth. 7 However it has got
clinically important when 1-2 mm of length is lost. Severe limitations compared to conventional radiographs, which
root resorption during orthodontic treatment (>5 mm) includes increased cost and amount of radiation. The
occurs very rarely just in 5% of patients. 1 effective dose of CBCT is 1.5 to 3.3 times higher than that
The mechanism of root resorption is not completely associated with panoramic radiographs.
explored. According to Brudvik and Rygh, inflammatory Therefore, in the present study, panoramic radiography
root resorption induced by orthodontic treatment is a was used for measuring root resorption because of three
part of the process of elimination of hyaline zone. 16 main reasons. They are:
It is considered that the occurrence of root resorption
can be induced by the strong force through orthodontic 1. A panoramic film is routinely ordered as the primary
treatment and hyalinization of periodontal ligament induced pre-treatment and post-treatment radiograph.
by increased activity of cementoclasts, osteoclasts. During 2. Less radiation exposure, less chairside time, less
tooth movement, areas of compression, where osteoclasts operator time and better patient co –operation.
are inducing bone resorption and areas of tension where 3. Panoramic radiographs have the added advantage of
osteoblasts are inducing bone deposition are formed. Thus, displaying the entire maxilla-mandibular region on a
a tooth moves towards the side of bone resorption. Any single film. It provides increased coverage of the dental
imbalance between bone resorption and deposition results arches and associated structures, relatively undistorted
in loss of protective characteristic of cementum which anatomic images, reduced radiation dosage for the
may contribute to the osteoclastic activity, resorbing areas patient and simplicity of operation.
of the root. Tooth root surface under the hyaline zone
resorbs. 10,16,17 There are two methods to assess root resorption: one that
Several studies have been done to find the measures the length of the root directly to determine the
contributory factors associated with external apical amount of root resorption, the other marks the degree of
root resorption. 4,9,11,15 Patient-specific factors can be root resorption. 6 In this study, the difference between the
age, gender, type of malocclusion, oral habits like thumb total tooth length was measured for evaluating the amount
6 Kaur et al. / Journal of Dental Specialities 2020;8(1):3–8

of root resorption. The same method was used by Jung et In this study, the average treatment duration in the
al., 17 extraction group was 24 ± 4.2 months, longer than in the
In this study, apical root resorption was classified non-extraction group (14.4 ± 4.2 years). Also, the extraction
according to widely accepted index proposed by Levander group showed more external apical root resorption in
and Malmgren. 1 This method has been used in many comparison with the non-extraction group. According to
root resorption studies performed after orthodontically Sharpe et al., the incidence of external root resorption
induced tooth movement. This method does not depend on was 3.72 times higher in the extraction group than the
standardization of initial radiographs. 1,13 non-extraction group. 17 This can be due to the longer
In the present study, the factors associated with external treatment time needed for finishing orthodontic treatment.
apical root resorption were treatment involving extractions, It is assumed that the extraction of teeth could increase
longer treatment duration and greater overjet at the initiation the amount of movement and treatment duration. 13,17
of treatment. It was difficult to compare the prevalence and After doing multiple regression correlation analysis, the
extent of external apical root resorption in our study with resorption of the upper anterior and lower posterior had a
that of other studies because of the variations of methods positive correlation with extraction cases (P < 0.01).
and techniques employed. In this study, there was no Overjet had a positive correlation with external apical
statistically significant difference in root resorption among root resorption in maxillary and mandibular anterior
males and females. This is in contradiction to the results teeth in the present study. This can be because of the
of studies done by Spurrier and Hall 6 who found females correction of large overjet. This finding can also be seen
had more resorption than males. But it is in agreement with in some studies. 13–15 To correct large overjet, anterior teeth
studies done by Linge and Linge, Jiang et al., and Jung et were moved long distances to reduce maxillary anterior
al. 6,17 protrusion and active torque with rectangular wires was also
given, which resulted in external apical root resorption. but,
According to Linge and Linge, external apical root
according to Jung et al., there was no correlation between
resorption was dependent on age. They found out that
the overjet and root resorption. 17
patients starting treatment after 11 years of age experienced
significantly more root resorption than those starting earlier.
The concept was that the root resorption increases with age
because of reduced ability to repair root resorption in older
patients. 6,14 But it is disapproved by Jung et al., and Han et
al. 17,18 This study also showed no relationship between root
resorption and the age of the patient.
In our study, anterior maxillary teeth proved more likely
to present higher mean root resorption scores in both the Fig. 1: Pre-treatment tooth length
extraction (0.44±0.21) and the non-extraction (0.40±0.19)
groups than the teeth located in the mandibular arch.
A similar finding was found in other studies. 13,17 Few
studies 17,19,20 found that the maxillary central incisors
were the most resorbed, with 27% undergoing greater
than 1 mm of root resorption and premolars and canines
were relatively unaffected. Proximity between the roots
of maxillary central incisors and the cortical bone of the
socket, the incisive canal and the alveolar bone on the buccal
surface, combined with the type of movement may explain Fig. 2: Post-treatment tooth length
the higher incidence of severe root resorption these teeth. 13
Whereas in mandibular arch, the extraction space is usually
used to relieve the crowding, so, the incisors might not be
submitted to major retraction. 14
According to the present study, the treatment duration
(mean: 20.36 ± 6.2 months) was significantly correlated
with external apical root resorption. This was in agreement
with other studies, 3,6,13,14,17 although Linge and Linge 15
did not agree with this finding. Difficult treatment plans, Fig. 3: Root resorption score Index - Levander and Malmgren
appointment intervals and poor patient compliance act as
confounding factors and increase the treatment duration This study suggests that the orthodontic treatment should
which is related to external apical root resorption. 17 13 be carefully performed in patients who need an extraction,
 Kaur et al. / Journal of Dental Specialities 2020;8(1):3–8 7

Table 1: Intra class correlation coefficient

95% Confidence Interval F Test with true value 0
Intra class correlation
Lower bound Upper bound Value df1 df2 Sig
Single .939 .906 .960 31.623 79 79 .000
Measures
Average .968 .951 .980 31.623 79 79 .000
Measures

Table 2: Average MRRS for different segments among extraction and non-extraction cases
Upper anterior Upper posterior Lower anterior Lower posterior
Non-extraction cases 0.40±0.19 0.11±0.15 0.23±0.25 0.04 0.04±0.07
Extraction cases 0.44±0.21 0.18±0.17 0.24±0.20 0.18±0.16

Table 3: Mann Whitney U test comparing MRRS among males and females.
MRRS Upper anterior Upper posterior Lower anterior Lower posterior
Mann-Whitney U 409.500 417.500 395.000 339.000
Z -.622 -.514 -.845 -1.760
P value .534 .607 .398 .078
a. Grouping variable: Gender

Table 4: Mann Whitney U test comparing Root resorption on the basis of the type of treatment.
MRRS Upper anterior Upper posterior Lower anterior Lower posterior
Mann-Whitney U 31.000 293.000 118.500 174.000
Z -6.092 -1.931 -4.687 -3.914
P value .000 .054 .000 .000
b. Grouping variable: Type

Table 5: Correlation coefficients of the bivariate correlation analysis between treatment type, duration, overjet and mean root resorption
score after treatment for the upper and lower anterior and posterior teeth
Correlation MRRS MRRS MRRS MRRS
coefficient Upper anterior Upper posterior Lower anterior Lower posterior
Type 0.802** 0.262* 0.585** 0.467**
Duration 0.819** 0.201 0.722** 0.296*
Overjet 0.502** 0.018 0.341** 0.159
**P<0.01 *P<0.05

Table 6: Correlationcoefficients of the multiple regression analysis of MRRS

Upper anterior Upper posterior Lower anterior Lower posterior
Gender -0.08 0.04 -0.09 0.09
Age -0.04 0.12 0.07 -0.13
Type 0.39** 0.25 0.05 0.578**
Duration 0.43** 0.07 0.64** -0.15
Overjet 0.23** -0.09 0.14 -0.39

greater retraction of maxillary incisors and prolonged post-treatment root resorption. There was a statistically
therapy. significant difference between extraction and non-extraction
groups for root resorption. There was a statistically
5. Conclusion significant correlation between treatment duration and the
amount of root resorption: the longer the duration, the more
External apical root resorption is a relatively common severe the root resorption. Overjet greater than or equal to
iatrogenic outcome of orthodontic treatment, which can be 5 mm had a statistically significant correlation with external
seen in routine panoramic radiographs. Age and gender apical root resorption.
were not an influencing factor in root resorption. Overjet
and overbite had a statistically significant correlation with
8 Kaur et al. / Journal of Dental Specialities 2020;8(1):3–8

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DG, et al. External root resorption with the self- ligating Damon
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None.
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external apical root resorption. Am J Orthod Dentofac Orthop.
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