Root Resorption During Orthodontic Therapy

Edward F. Harris

External apical root resorption (EARR) is the most common iatrogenic con-
sequence of orthodontics, and orthodontics is the most common cause of
EARR. Localized root resorption is a normal and constant remodeling pro-
cess, a response to oral microtraumas throughout life. Roots do not shorten
naturally with age unless forces (eg, bruxism, tongue thrusting) overcom-
press the periodontal ligament. Appositional repair normally corrects re-
sorptive defects. Irreversible root shortening occurs with excessive forces or
decreased resistance to normal forces. Orthodontically induced root resorp-
tion starts adjacent to hyalinized zones and occurs during and after elimi-
nation of hyalinized tissue. Incisors are most susceptible to EARR, probably
because of their roots" spindly apex and because incisors typically are
moved farther than other teeth during correction. Intrusion is probably the
most detrimental direction of tooth movement, although simply the dis-
tance the apex is moved is often correlated with the degree of root short-
ening. The strongest single association with EARR seems to be a person's
genotype. Familial studies show that a person's genotype accounts for
about two-thirds of the variation in the extent of periapical resorption. In
most instances, this absolves the orthodontist from blame that treatment
markedly influenced the extent of resorption, and it also means that a test
can be developed that will flag individuals at particular risk of developing
EARR. In any event, all patients" root status should be monitored periodi-
cally. Rapid resorption can be diminished with slow, intermittent forces with
pauses of 2 to 3 months to allow repair of the eroded cementum. (Semin
Orthod 2000;6:183-194.) Copyright 2000 by W.B. Saunders Company

o o t r e s o r p t i o n occurs w h e n pressure o n linized n e c r o t i c tissue a n d r o o t resorption. 5-7 Be-

R the c e m e n t u m exceeds its reparative capac-
ity a n d d e n t i n is exposed, allowing multinucle-
ated odontoclasts to degrade the r o o t substance. 1,2
O r t h o n d o n t i c a l l y i n d u c e d r o o t r e s o r p t i o n be-
gins adjacent to hyalinized zones a n d occurs
d u r i n g a n d after elimination o f hyaline tissues?
Removal o f hyalinized tissue (ie, a z o n e o f sterile
necrosis) leads to removal o f c e m e n t o i d a n d
m a t u r e collagen, leaving a raw c e m e n t a l surface
that is readily attacked by dentinoclasts. 4 T h e r e
is a positive association between removal o f hya-
From the Department of Orthodontics, Collegeof Dentistu, Uni-
versity of Tennessee, Memphis, TN.
Address correspondence to Edward F. Harris, PhD, Department
oJ Orthodontics, Collegeof Dentistry, University of Tennessee, 875
Union Ave, Memphis, TN 38163.
Copyright 0 2000 by W.B. Saunders Company
1073-8746/00/0603-0006510.00/0
doi: 10.1053/sodo.2000. 8084
cause c e m e n t u m n o r m a l l y is m o r e resistant t h a n
b o n e , forces applied to a t o o t h usually cause
b o n e r e s o r p t i o n r a t h e r t h a n loss o f c e m e n t u m .
However, forces are c o n c e n t r a t e d at the r o o t
a p e x because o r t h o d o n t i c t o o t h m o v e m e n t is
never entirely translatory, which places the nar-
row periapical r e g i o n in h a r m ' s way. R u d o l p h 8
n o t e d that r e s o r p t i o n typically attacks the r o o t
tip a n d travels coronally, m a k i n g what has b e e n
t e r m e d a "shed r o o f ' effect to the root. T h e
p o r t i o n o f the r o o t nearest the p u l p a p p e a r s to
be the last to give way. This process is exactly
opposite to that o f t o o t h f o r m a t i o n .
Albert K e t c h a m '-~,~0was the first to b r i n g the
message that apical r e s o r p t i o n is a c o m m o n a n d
occasionally severe iatrogenic c o n s e q u e n c e o f
o r t h o d o n t i c treatment. A d v e n t o f the c o m m o n -
place use o f dental x-ray e q u i p m e n t m a d e it
possible for K e t c h a m to evaluate a large series o f
treated cases. K e t c h a m also m a d e a less well-

Seminars in Orthodontics, Vol 6, No 3 (September), 2000: pp 183-194 183

184 Edward K Harris
known discovery, namely that the appliance used
to move teeth influences the risk of root resorp-
tion. Only in recent years has this difference in
risks between appliances been reevaluated. 11-14
Root Resorption
Root resorption can be classified into at least 3
categories: 15-~9 surface resorption, inflammatory
resorption, and replacement resorption. Surface
resorption occurs constantly as microdefects on
all roots; 2,7,2-22 these normally repair themselves
without notice. It is only consequential when
lacunae in the c e m e n t u m b r o a d e n and permit
dentinoclasia. Surface resorption can occur any-
where on a root but is most c o m m o n periapi-
cally. 2 Surface resorption stops when the insti-
gating agent (usually pressure) is removed and
there is repair of the cementum. 2-~95 Inflamma-
tory resorption occurs when root resorption
progresses into the dentinal tubules to pulpal
tissue that is infected or necrotic or into an
infected leukocyte zone. Thirdly, replacement
resorption produces ankylosis of a tooth because
b o n e replaces the resorbed tooth substance.
The odontoclast is the root-resorbing cellY 6 It
is a large pleomorphic, usually multinucleated,
cell formed by monocyte precursors. 27 Most re-
searchers agree that odontoclasts are of hemato-
poietic origin from the bone marrow and dis-
semination of their precursors is through the
vascular system, 2s so but a local tissue contribu-
tion has not been ruled O U t . 18,~-31
Andreasen et al conducted a series of illuminat-
ing experiments to determine which tissue pro-
tects a root against resorption during normal oral
functions. 32-:~9 If root resorption is a normal and
constant process associated with microtraumatic
injuries and forces of occlusion, what protects the
root surface in permanent teeth against irrevers-
ible external apical root resorption (EARR)?
Andreasen reasoned that the following cell
types and structures could provide a protective
mechanism from irreversible EARR: cemento-
blasts, fibroblasts, osteoblasts, vascular endothe-
lial cells, perivascular cells, Malassez epithelial
cells, cementum, cementoid, osteoid, alveolar
b o n e or Sharpey's fibers, or a combination of
these tissues, is To narrow the possibilities, An-
dreasen 35,36 first removed the c e m e n t u m side
and then the alveolar bone side of the periodon-
tal membrane. In both instances, little resorp-
tion occurred, and he inferred that the protec-
tive structure was in a central region of the
periodontal membrane. Sharpey's fibers (lo-
cated in the innermost and outermost regions of
the periodontal ligament [PDL], which are acel-
lular) also were eliminated as a protective agent
because no resorption occurred when they were
absent. 32 Experiments also serially eliminated
cementum, cementoid, the Malassez epithelial
cell, the cementoblast, the fibroblast, the endo-
thelial cell, and the perivascular cell as protec-
tive agents against resorption.
Andreasen concluded that the innermost cel-
lular structures-cementoblasts, fibroblasts, en-
dothelial cells, and perivascular cells (ie, those
nearest the root surface within the cellular re-
gion of the PDL) are the likely candidates for a
root resorption protective mechanism. To con-
firm this, he destroyed the thin innermost cellu-
lar zone within the PDL. The result was signifi-
cant root resorption, implying that the protective
mechanism was lost with removal of the constitu-
ents of this cellular zone. is
Prevalence
The intentional m o v e m e n t of teeth that is the
backbone of orthodontic treatment typically
produces some blunting of the root apices, and,
in general, tooth types that are moved the far-
thest tend to show the most frequent and most
severe EARR. x4,4-42 However, it is pointless to
compare the frequencies of root resorption
a m o n g studies because of the diverse and gen-
erally undefined criteria used to define resorp-
tion. For example, Hemley 4~ f o u n d that 3% of
the teeth examined of 195 orthodontic patients
showed apical root resorption. Rudolph, s on the
other hand, f o u n d EARR in nearly 100% of the
439 patients he treated. This extreme range is
primarily due to vastly different, but generally
unpublished, criteria for identification. 44
It is clear that incisors are most likely to show
root EARR as well as the most advanced modal
degree of resorption. 4-w47 It has not been estab-
lished whether this is because these are the teeth
moved the farthest or because of the single-root,
spindly cone-shape of the root. Additionally, it may
be that incisors possess biochemical pathways dif-
ferent from other teeth that place them at risk, but
there is no evidence of such a difference.
A n o t h e r consideration is that resorption most
often occurs at the apex. The coronal third of
a root is covered with acellular cementum,
whereas the apical third is cellular and the mid-
dle third is intermediate. Cellular c e m e n t u m
 Root Resorption During O*vthodontic Therapy
forms m o r e rapidly a n d is m o r e active than acel-
lular c e m e n t u m , but this cellular periapical ce-
m e n t u m d e p e n d s o n a p a t e n t vasculature; ac-
cordingly, periapical c e m e n t u m is m o r e friable
a n d easily i n j u r e d in the face o f heavy forces a n d
c o n c o m i t a n t vascular stasis. 48 no
Reitan 5~ r e p o r t e d that thickness o f c e m e n t u m
s o m e h o w m o d u l a t e s the resorptive process. Re-
sorption l a c u n a e o c c u r r e d all a l o n g the r o o t
surface o f teeth with h y p e r c e m e n t o s i s ; a few la-
c u n a e were r e p a i r e d with s e c o n d a r y c e m e n t u m
a n d bone, b u t there was n o loss o f r o o t length.
I n contrast, teeth with thin layers o f c e m e n t o i d
a n d p r e d e n t i n s h o w e d m a r k e d EARR.
Teeth Affected
Single-rooted teeth are at g r e a t e r risk o f experi-
e n c i n g EARR t h a n m u l t i r o o t e d teeth, p r o b a b l y
because o f the g r e a t e r r o o t surface area o f m o -
lars for the dissipation o f forces. 4~52 O n the
o t h e r h a n d , teeth in the a n t e r i o r s e g m e n t are
m o v e d g r e a t e r distances o n average d u r i n g treat-
m e n t t h a n o t h e r teeth in the dental arches, so
the g r e a t e r f r e q u e n c y a n d g r e a t e r m o d a l loss o f
r o o t l e n g t h in the incisor may be a c o m b i n a t i o n
o f b o t h factors. T h e consensus f r o m several stud-
ies is that the average patient receiving c o m p r e -
hensive t r e a t m e n t will loose a b o u t 2 m m f r o m
the apex of the m a x i l l a u central incisor, with loss
o n the lateral incisor being a bit more, perhaps
because o f the m o r e spindly apical region.
Kalkwarf et aD s m o d e l e d the shape o f a max-
illary lateral incisor to quantify the relationship
b e t w e e n loss o f r o o t l e n g t h a n d loss o f surface
area for a t t a c h m e n t (Fig 1). A l t h o u g h the rela-
tionship is essentially linear, it can also be seen
A B
Figure 1. The association
between loss of root length
by EARR and the percent of 100 T
remaining area for attach- ~ |
ment. The specific tooth is a i~ 80
maxillary lateral incisor, one
of the teeth most likely to ~ |
show apical resorption (A). E 60-
The graph is for millimeter
increments. Although the
graph is essentially linear, it ~ 40-
is evident that about 3 mm at "~
the apical end, because of its
spindly shape, has the largest
length to area ratio and a
flatter slope (B). (Data from
Kalkwarf KL, Krejci RF, Pao
~ 20-
0
0
I 6
YC.5~) Millimeters of Root Resorption
185
that the d r o p in surface area is n o t as steep over
the first few millimeters as w h e n m o r e r o o t is
resorbed. T h e r e is an inflection p o i n t at a b o u t 3
m m w h e r e loss o f a t t a c h m e n t slows a n d b e c o m e s
linear. O f note, a b o u t the first 3 m m o f an
incisor r o o t are m o r e spindly and, perhaps,
m o r e p r o n e to r e s o r p t i o n because o f its h i g h e r
ratio o f l e n g t h to area than the rest o f the root.
Almost all reports o f EARR have f o u n d average
r e s o r p t i o n d u e to o r t h o d o n t i c t r e a t m e n t to be
less t h a n 3 m m . Kalkwarffs data also address loss
o f crestal b o n e support. T h e highest ratio o f
surface area for a t t a c h m e n t occurs n e a r the ce-
m e n t o e n a m a l j u n c t i o n , so loss o f b o n e h e i g h t is
m o s t influential in this region. Loss o f b o n y
s u p p o r t o p e n s the d o o r to d i m i n i s h e d stability
a n d to t o o t h mobility. 54-~6 R e d u c e d b o n y sup-
p o r t can increase '~iggling" t o o t h m o v e m e n t s
leading to periapical r o o t resorption. ~6,5r,58 Re-
searchers w h o have m e a s u r e d b o n e s u p p o r t in
relation to o r t h o d o n t i c t o o t h m o v e m e n t r e p o r t
a decrease relative to the adjacent c e m e n t o e -
n a m e l j u n c t i o n (CEJ); this is true o f incisors 56,5'-~
as well as p o s t e r i o r teeth. 41,54,58,6-62 T e e t h used
as a b u t m e n t teeth a n d those with considerable
loss o f crestal b o n e h e i g h t (measured, for in-
stance, by p e r i o d o n t a l p r o b i n g d e p t h ) charac-
teristically show g r e a t e r periapical resorption,
p r e s u m a b l y because o f jiggling forces. 41,6S-65
Considerably m o r e relationships between b o n e
a n d d e n t i n o c c u r t h a n can be covered in this
b r i e f review.
O n e m i g h t suppose that the typical f r e q u e n c y
o f EARR c o u l d be abstracted f r o m a review o f
the literature. This is n o t the case because o f a
n u m b e r o f i m p o r t a n t differences, notably the
teeth observed, the m e c h a n i c s used, the kinds o f
100 ..
8O
60
40
8 1'0 12 14
20
0
0 2 4 6 8 10 12 14
Millimeters of Root Resorption
1 86 Edward F. Harris
radiographic data (particularly periapical v pan-
oramic v cephalometric x-rays), and the sophis-
tication of the m e a s u r e m e n t technique. For ex-
ample, older studies used ordinal scales and only
scored EARR when it was overt, 9,1 whereas
Massler and Perreault 66 apparently used any sug-
gestion o f apical blunting as evidence of resorp-
tion. There also is an important set of studies of
extracted teeth in which light microscopy91,67 or,
even, scanning electron microscopy was used to
evaluate the n u m b e r and severity of resorption
lacunae in the cementum. 2,68,6
Measurement Methods
EARR can be defined operationally as the de-
gree a root has shortened from its original (or
expected) length by elastic activity. Broadly, two
methods have been used to quantify resorption:
visually-assessed grades of resorption (ordinal
scale data) or measurements with calipers or
some computer-aided device (ratio scale data),
almost always on radiographs. A n o t h e r ap-
proach using light or electron microscopy sel-
d o m has yielded quantitative results 2,48,7,71
although histomorphometric methods are be-
ginning to be used. 72-74
Morphological scales, such as in Figure 2, are
easy to use because they d e p e n d on shape crite-
ria rather than size, so measurements are unnec-
essary and there is less c o n c e r n about standard-
ization of orientation o f the tooth r o o t s . 56,75,76
The negative aspect is that the data are ordi-
f'\
ml
0 1 2 3 4 instrument for extension cone paralleling tech-
Figure 2. The ordinal scale used to score the extent
of external apical root resorption. Grade 0 depicts
normal, intact root morphology, in which the apical
outline is smooth and continuous. Also, the distance
between the root and the lamina dura is uniform.
Grade 1 shows evidence of erosion periapically, but
root length probably is not yet affected. Grade 2 shows
scalloping and blunting of the apex. Grade 3 occurs
when at least one-fourth of the root has been
resorbed. Grade 4 involves the loss of at least one-half
the original root length. (Reprinted with permission
from Levander E, Malmgren O.S).
nal scale, which can limit some statistical ap-
proaches and there is the opportunity for differ-
ences within and a m o n g examiners because of
inaccuracies in defining, and discriminating be-
tween grades of resorption.
Various approaches have been used to mea-
sure root length. Dental radiographs can be
measured directly with calipers, although enlarg-
ing the image will decrease error in landmark
identification. It now is generally practical to
capture the radiographic image with a scanner
or import the image from a digital x-ray machine
and make the measurements on a c o m p u t e r
screen with any of several software packages.
Radiography
The key to measuring tooth dimensions and,
thus, loss of root length is standardization o f the
radiographs to, hopefully, eliminate foreshort-
ening and differences in the aspect of the x-ray
source to the tooth. Panoramic radiographs are
not well-suited for this because the focal trough
is not identical to the shape of the individual's
dental arch, so there is variable enlargement of
each tooth and variable orientation to each
tooth. 77 Different sizes and shapes of arches will
also be variably magnified and again there are
variable s o u r c e - o b j e c t differences for each
tooth a m o n g individuals.
Periapical x-rays, particularly with a long-cone
technique, offer greater flexibility in standardizing
orientation to each tooth. However, there com-
monly are problems with ectopic and rotated teeth
in patients before orthodontic treatment. Some
researchers have gone to the effort of fabricating a
jig for each tooth 62,78,79 but Melsen 62 concluded
that, "the benefit of this method was considered
limited in relation to the resources used." A com-
mercially available guide that substantially im-
proves repeatability in conjunction with the long-
cone paralleling technique is the Rinn xcp
nique (Rinn Corporation, Elgin, IL). SjMien and
Zachrisson 6,61 described a method of correcting
for tooth and crestal bone height due to diver-
gence of the x-rays emanating from the source.
Dermaut and De Munck 82 published formulae
that correct for angulation of a tooth relative to the
x-ray film, at least as compared to a prior film:
(Crown A Root B ) / ( R o o t A CrownB)
= Root B / R o o t A
 Root Resorption During Orthodontic Therapy
in which "crown" is the distance from the inci-
sive edge to the c e m e n t o e n a m e l j u n c f i o n , "root"
is the distance from the CEJ to the root apex,
and A and B are two examinations, such as pre-
treatment and posttreatment. The adjustment is
a decimal equivalent of how m u c h root length at
time B differs from that at time A having cor-
rected for differences in parasagittal angulafion.
With EAR.R, the ratio (right side of equation)
will be less than 1. Similar ratios have been
published by Linge and Linge H as well as Costo-
poulos and Nanda. 77
Occlusal Forces
Heavy mastication, occlusal trauma, and chronic
bruxism each increases the risk of root resorp-
tion. 57,67,s3-86Heavy mastication can p r o d u c e loss
of periapical root substance. Baden 8v inferred
that stunting of the developing root occurs when
excessive intrusive forces are introduced to the
tooth during development. Gottlieb and Or-
ban 88 and Dellinger s9 previously had p r o d u c e d
this effect in laboratory animals. I m p r o p e r oc-
clusion or inadequate dental restorations and
prosthetic appliances can also cause occlusal
trauma and 'jiggling" forces that p r o m o t e root
resorption. 9,1 Glickman 9z f o u n d a high fre-
quency of EARR in roots of long-term abutment
teeth. He speculated that this occurs because rel-
atively normal teeth are carrying abnormally
greater occlusal loads when used as bridge abut-
ments.
Adolescents with anterior open bites present to
the orthodontist with significantly shorter roots, a
greater frequency of EARR, and significantly less
facial bony support compared with comparable
patients with a positive overbite. 59 Linge and
Linge 11 found a positive association between
EARR and lip and tongue dysfunction as well as an
association between resorption and a history of
finger-sucking habits persisting beyond age 7. In
the same vein, children who are chronic nail biters
exhibit more EARR than controls. 9a,94 Teeth used
as abutments tend to experience resorption. 58 The
c o m m o n cause seems to be the orthopedic forces
produced by repetitive clenching, thumb or digit
sucking, and tongue thrusting associated with
chronic mouth breathing.
Normal Events of Aging
With increases in the median age of the US
population and more adults seeking orthodon-
187
tic care, it is of interest whether loss of root
length is a natural function of aging. The answer
is "No." Woods et a195 tested for an effect using
cross-sectional data on adults. They f o u n d no
age-dependent trend between root length and
age in people not treated orthodontically, but it
was also obvious that interindividual variation in
root length was so great that only a substantial
a m o u n t of shortening would be detectable. The
only longitudinal study seems to be that of
Bishara et a196 who c o m p a r e d measurements
taken from periapical radiographs o f orthodon-
tically untreated adults at 25 and again at 45
years of age. From comparisons of all tooth types
except third molars, they concluded that root
length remained constant t h r o u g h o u t the age
range studied. The authors n o t e d that this is a
pertinent clinical finding because the orthodon-
tist can be assured that no systematic loss of root
length will occur posttreatment.
The caveat, however, is that the apparent lack
of root shortening seen in the United States and
other westernized countries is probably a fairly
recent p h e n o m e n o n b r o u g h t on by the supplan-
tation of a highly refined diet, requiring very
small axial forces on the teeth and p r o d u c i n g
trivial apical resorption. In prior eras and in
unacculturated societies when most food pro-
cessing was d o n e in the m o u t h by the dentition
(rather than by machines before ingestion),
tooth roots were shorter and blunter. 83,97-99
Predictors of EARR
There is considerable variation in the amount of
root resorption among patients treated orthodon-
tically, even when age, sex, nature of the malocclu-
sion, and type of treatment are held constant. The
differences in patient response would seem to be
due to differences intrinsic to the individual. The
search for key biological factors governing suscep-
tibility has been ongoing for over half a century,
but without a great deal of success.
Sex of the patient is a variable easily obtained
and tested, but the consensus is that neither sex
is more p r o n e to resorption. 12,47,56,1-1z O f the
few studies that have reported a sex difference,
most f o u n d that females were more susceptible
to root resorption. 66,1~-15 Even if there is a sex
difference, it is trivial because in the best of
cases, sex accounts for little of the total variation,
and no study design to date has accounted for
the powerful difference in compliance between
adolescent boys and girls. In addition, it does
188 Edward F. Ha,~is
not appear that any study has accounted for
severity of the malocclusion, which tends to be
greater in male orthodontic patients, although
not in the population at large.
It is well d o c u m e n t e d that males have signif-
icantly longer roots on all tooth types, 95A6 so in
theory, females should lose a greater p r o p o r t i o n
of root length than males. This is not the case,
however, because the association between root
length and the a m o u n t of resorption during
treatment is essentially zero.
The risk of EARR also seems to be indepen-
dent of age once the teeth have completed root
formation. There are several reasons to antici-
pate that adults would be more susceptible.
Rates of alveolar turnover are slower in older
adolescents and adults than in children and
y o u n g adolescents. 17-~ Young persons possess
more loose fibrous tissue in their alveolar bone. 2
Young teeth have more cellular c e m e n t u m in
the apical region, which depends more on a
patent vascular supply than mature acellular ce-
mentum, which is thicker in adults. Initiation of
tooth m o v e m e n t is slower in adults, 17,m per-
haps because of their dense lamellar bone in
their alveolar structures. T o o t h m o v e m e n t gen-
erally is greater in adults because they are not
growing, n2 Taken together, adults are specu-
lated to be at greater risk for root resorption.
One study that explicitly c o m p a r e d the extent
of resorption in adolescents and adults treated
by a single orthodontist f o u n d that the 2 age
groups lost equivalent amounts of root length. 56
On the other hand, adults bad substantially
more resorption at the onset of treatment, pre-
sumably from wear and tear on the roots be-
tween when the adults were adolescents and
when they began treatment. Mirabella and ~r-
tun n4 p e r f o r m e d an extensive study of EARR in
adult orthodontic patients, but without an ado-
lescent comparison.
The effect of age is quite different when dealing
with children in the mixed dentition. Children
treated before their roots are completely formed
encounter less r o o t r e s o r p t i o n . 27,7,114,115 After
treatment, although the roots are not as apt to
show blunting, they are shorter. The suggestion is
that orthodontic treatment slowed root grouch of
the forming teeth, but subsequent root growth
obliterated effects of dentinoclasia, leaving the
roots with reduced final lengths. 55,1u~ Some re-
searchers have used this difference to promote
treatment of patients at earlier ages. 8,45,~16 Case
control studies have disclosed 2 other risk factors,
namely evidence of prior root resorption and ab-
errant root forms. EARR that is evident before
treatment is indicative of an increased susceptibil-
ity to moderate-to-severe root resorption during
full-banded treatment, n,76
Levander and Malmgren 76 conducted one of
the more t h o r o u g h assessments of root form and
its susceptibility to EARR. They scored incisor
roots as normal, short, blunt, apically bent (of-
ten mistakenly termed dilaceration), and pipette
shape (Fig 3). Similar depictions are published
by Mirabella and flkrtun. 113 Reassessment of
Levander and Malmgren's published data using
contingency tables (a = 0.05) shows quite
clearly that irregular root form is a risk factor
and obviously, it is identifiable before treatment.
All 4 varieties of root form increase the risk and
severity of EARR over roots with normal mor-
phology: short roots (X2 = 18.0; P < 0.001);
blunt roots (X2 = 34.3; P < 0.001), apically bent
roots (X2 = 18.0; P < 0.001), and pipette shape
roots (1`2 = 45.0; P < 0.001).
Cortical Plate
Certain directions of tooth movement, notably
intrusion, have been f o u n d to increase the risk
and severity of EARR. The first orthodontists to
describe the association between treatment and
resorption, Ottolengui, 117 O p p e n h e i m , 118 and
Ketcham 9 noted that of the several possible
modes of movement, intrusion and heavy tip-
ping forces are the most likely to cause notice-
able apical resorption. Intrusion damages the
root apex because root shape concentrates pres-
sure at the conical root tip. 7 Several studies
have measured the vertical, horizontal, and an-
gular changes in the maxillary incisor viewed in
Short Blunt Apical Pipette
Bend Shape
Figure 3, Variant root shapes, such as the four shown
here, are significantly more likely to show EARR dur-
ing the course of orthodontic treatment than nor-
mal-shape roots. (Reprinted with permission from
Levander E, Malmgren 0. 8)
 Root Resorption During Orthodontic Therapy
n o r m a lateralis. 4,m,n3,n9 There is a positive cor-
relation between the a m o u n t of resorption and
the a m o u n t of intrusion. Parker and Harris 14
also f o u n d consistent correlations between
EARR and incisor proclination. Mirabella and
fi~rtun stated, "Movement of the roots in either
an anterior or posterior direction is associated
with root resorption." Although they found no
significant association between vertical movement
of the incisor apex and root resorption, they cau-
tioned that few of their patients experienced as
much as 1 m m of extrusion or intrusion.
EARR also is a function of the amount of apical
movement. Sharpe et a141 reported that incisors
experienced more EARR in premolar extraction
cases in which retraction is greater than in nonex-
traction cases. Similarly, cases with anterior open-
bites (apertognathia) lose more root length than
cases requiring less incisor movement, u,5-~,94Linge
and Linge u as well as Beck and Harris 12 found
highly significant, positive associations between
periapical resorption and both overjet and the
AOBO discrepancy. The c o m m o n theme here is
that the amount of movement is itseff predictive of
the degree of resorption to occur.
An important related issue is that tooth roots
are p r o n e to resorption when they are pushed
out of the alveolar through and toward the less
resilient cortical bone. 42A2,191 Attention has fo-
cused on the incisor root being pushed against
the lingual cortical plate, but the risk probably is
as great for the labial plate and, in instances of
marked intrusion, for the nasal floor, s2 Likewise,
Vardimon et a1122q23 have shown that roots of
buccal teeth are resorbed with rapid maxillary
expansion. It would be of interest to quantify the
consequences of buccal tooth root lengths with
the bioprogressive technique 124 in which the
buccal molar roots are moved toward the corti-
cal plates for anchorage.
A 13
Intrusion
and ~ IExtrusion
Figure 4. Different conse- Resor
quences to the mesial and
distal roots of the maxillary
first molar depending on the
mechanics used (A and B).
Comparison shows the re-
sorption-promoting effects
of intrusion and the pro-
tective effects of extrusion.
(Drawn from Beck BW, Har-
ris EF.12).
189
Effects of intrusion also are evident on teeth
besides the incisors. The extent of EARR on the
roots of the maxillary molars used as anchorage
has been studied, and the location and degree
of resorption depends on the malocclusion? 2
More resorption occurs on the distal molar root
when the bite is o p e n e d (as in cases with deep-
bites). Anchorage bends mesial o f the maxillary
first molar intrude the anterior teeth, but they
also compress the distal root of the molar into
the socket (Fig 4A). The deeper the bite, the
greater the tip back placed in the wire, and the
greater the compression of the distal root before
correction of the deep bite is achieved. Con-
versely, in o p e n bite cases and in cases with
overjet that needs to be reduced (Fig 4B), the
mesial molar root is intruded and experiences
more EARR than the distal root. Consequently,
the first molar provides an informative model of
the effects of intrusion (producing resorption)
c o m p a r e d with extrusion, which appears to be
protective of the root. Reitan a,a25 came to the
same conclusion from histologic analysis of hu-
man premolars. Dougherty 13 and Sj~lien and
Zachrisson 6,61 also remarked on this association,
showing that where maximum anchorage was pre-
pared, the greatest resorption occurred on the
distal (intruded) root of mandibular molars.
Familial Factors
A scattering of studies over the past several de-
cades has suggested a familial predisposition for
root resorption. 9,66,15,n6,12(~ It is clear that sus-
ceptibility does not d e p e n d on segregation of a
simple Mendelian gene, either d o m i n a n t or re-
cessive. Instead, inheritance is multifactorial
(polygenic), although no one has yet tested for a
major gene effect.
~ Intrusion
Extrusion and
Resorption
\
eR ! I
Incisor
Intrusion R~action
\J
190 Edward F. Harris
I n a study o f 320 treated o r t h o d o n t i c patients,
only 2 cases s h o w e d e x t r e m e incisor r o o t resorp-
tion (Fig 5). O n inspection, the 2 cases were
brothers, which initiated a formal search for a
heritable c o m p o n e n t f o r EARR a m o n g sib-
lings, lu7 M e a s u r e m e n t s o n 3 roots in a large
series o f siblings, all o f w h o m h a d received com-
prehensive o r t h o d o n t i c treatment, p r o d u c e d
heritability estimates on the o r d e r o f 70% (Fig
6). This m e a n s that a b o u t two-thirds o f the total
variance in r o o t r e s o r p t i o n was a c c o u n t e d for by
the siblings in each family sharing half o f their
genes in c o m m o n by descent. It is, then, primar-
ily biochemically based risk factors that m o d u -
late a given patient's r e s o r p t i o n potential d u r i n g
treatment. This finding also absolves the orth-
o d o n t i s t o f the bulk o f responsibility for the
e x t e n t o f resorption. O n the o t h e r h a n d , the
clinician still bears responsibility for m o n i t o r i n g
the teeth d u r i n g the course o f treatment. 12s
T h e clinical relevance is that the association
b e t w e e n siblings is h i g h e n o u g h that the best
1.0
/
Figure 6. Heritability esti- ~>'0"81
mates plus 95% confidence ~ 0-61
limits for EARR on three 1
roots. In each case, the esti- ~ 0.4J
mate is significantly different /
from zero; the mean h 2 of all 0.2J
3 roots is 70%. (Data from
Harris EF, Kineret SE, Tolley 00
|
EA.127) MX Central Incisor
M;~
Figure 5. Posttreatment close-
ups of cephalograms of 2 broth-
ers showing the similarity in the
extreme degree of root resorp-
tion, which is suggestive of an
inherited susceptibility to loss
of root length in the face of
orthodontic stressors.
available p r e d i c t o r o f o n e p e r s o n ' s susceptibility
to EARR is a p r i o r sibling e x p e r i e n c e in treat-
m e n t . O f m o r e l o n g - t e r m i m p o r t a n c e is recog-
nition that a search for b i o c h e m i c a l markers
(eg, in crevicular fluid) would be fruitful. T h e
goal would be to have a s c r e e n i n g m e t h o d to
identify those few patients w h o are at particular
risk o f EARR d u r i n g treatment. Preliminary re-
sults addressing this issue have already be pub-
lished. 129q33
Periodic E v a l u a t i o n
It is n o t the average o r t h o d o n t i c patient who
presents a p r o b l e m in terms o f r o o t resorption,
as 1 to 2 m m o f apical r o o t loss seems inconse-
quential, particularly in light o f the functional
a n d esthetic benefits o f o r t h o d o n t i c treatment;
instead, it is the u n c o m m o n individual w h o loses
considerable r o o t l e n g t h a l t h o u g h the n a t u r e o f
the malocclusion a n d the t r e a t m e n t seem unre-
markable. T M T h e s e individuals c a n n o t be iden-
MD Molar, Mesial MD Molar, Distal
 Root Resotption During Orthodontic Therapy
tiffed given the present state of knowledge, but
there are some precautions that can be taken.
Periodic periapical radiographs of the maxillary
incisors (the most susceptible teeth) at approx-
imately 6-month intervals will flag those uncom-
m o n cases, 76,a35 and the operator has at least 4
options. The least satisfactory choice is to ignore
the evidence and proceed as usual. 12s In fact,
this is identical to treatment without interim
radiographs. Second, the rate of tooth move-
m e n t can be slowed along using lighter forces,
so that the reparative process of the c e m e n t u m
can keep abreast of the erosive processes of over-
compressing the PDL and forcing the root
against the alveolus. 136,137 Third, "rest periods"
can be built into treatment, 8 that is, the tooth is
moved, then forces are minimized with passive
arch wires for 2 to 3 months to allow root repair,
then m o v e m e n t is resumed. It has been shown in
animal models 123,a3s and h u m a n s t,7,s that a
force-free "rest period" allows the c e m e n t u m to
recover the exposed dentin, thus improving root
length at the end of treatment. A pause also
permits repair of the necrotic hyalinization
zone, including central tissue zones in the PDL
that appear to be protective of the root. 7,18 A
fourth option in the face of severe resorption, is
to compromise treatment, to stop short of the
treatment goals for the sake of the supporting
root structure.
Overview
External apical root resorption is the most com-
mon iatrogenic consequence of orthodontic treat-
ment, but it is seldom severe enough to compro-
mise treatment or a tooth's longevity. The most
c o m m o n kind of root resorption occurs on the
external periapical surfaces of single-rooted teeth,
especially if the tooth has a variant root form, such
as being narrow or apically bent. The tissue that
normally protects cementum from being eroded
seems to reside in the root side of the cellular
region of the PDL, but the tissue and its apocrine
signals have not been isolated. Description and
analysis of EARR extends throughout this century,
but few variables are clinically valuable as predic-
tors of EARR because of the large interindividual
variation in response to treatment. An individual's
genetic background is the single strongest predic-
tor of resorption, as shown by familial analysis.
This suggests that research will lead to a biochem-
ical assay, perhaps of crevicular fluid, that would
191
flag patients at particular risk of EARR. Such re-
search is ongoing.
Acknowledgment
The author thanks former students who conducted research
on root resorption: Dr Barry Beck, Dr Stephen Kineret, Dr
Dale Wheeler, Dr Brandon Boggan, and Dr Robert Parker.
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