Minimizing Or thodontically Induced

Root Resorption: Guidelines Based on

a Re vie w of Clinical S tudies
Olle Malmgren, Odont Dr1/Eva Levander, Odont Dr2

The outcome of orthodontic treatment may be jeopardized by severe apical root resorption,
induced by orthodontic forces. All potential predisposing factors, systemic as well as local,
must be considered before treatment begins. To evaluate the hypothetical influence of sys-
temic factors, a detailed medical history should be recorded. Clinical intraoral examination
should include standardized periapical radiographs taken with a film holder. The following
factors should be evaluated: existing root resorption, including that due to disturbances of
eruption, apical root form, invagination, agenesis, and short root anomalies. In patients
with several predisposing factors, the treatment plan should be modified to take into
account the risk of resorption. Modifications may include a shorter treatment time, less
force, and a limited treatment goal. During treatment, a follow-up visit at 6 months should
include periapical radiographs of all maxillary and mandibular incisors. The absence of
radiographic signs of root resorption at 6 months indicates minimal risk of severe resorp-
tion at the end of treatment, whereas resorption at this stage of treatment indicates a risk of
progressive resorption as treatment proceeds. The risk may be reduced by temporary sus-
pension of active treatment for 2 to 3 months. After completion of treatment, radiographic
examination is mandatory. If there is minor or moderate resorption, no further action is nec-
essary. In severe resorption, where the foreshortened root remaining is no longer than the
crown, there is a risk of increased tooth mobility. World J Orthod 2003;4:19–30.

igh frequencies of orthodontically induced apical 4% of investigated maxillary incisors. Individual vari-
H root resorption have been reported in histologic
studies, and the tissue reactions are well docu-
ations have also been reported, between patients
and between different teeth in the same person.3
mented. In clinical radiographic studies, the Because extensive root resorption may have unto-
reported frequency varies. Phillips 1 found apical ward sequelae, such as tooth mobility and loss of
resorption exceeding one-quarter of the original root supporting bone,4 a strategy to minimize resorption
length in 1.5% of maxillary central incisors and 2.2% must be considered. A plan for follow-up care should
of maxillary lateral incisors. Linge and Linge 2 be established before orthodontic treatment begins.
reported apical root resorption of 3 mm or more in The strategy to minimize resorption includes evalua-
tion of the risk of root resorption before treatment
and at a predetermined stage early in treatment.5
Resorption detected early should be followed up and
1Assistant documented at the end of treatment.
Professor, Department of Orthodontics, Eastmaninsti-
tutet, Stockholm, Sweden.
2Senior Consultant, Department of Orthodontics, Eastmaninsti-

tutet, Stockholm, Sweden. PRETREATMENT

REPRINT REQUESTS/CORRESPONDENCE
Dr Olle Malmgren, Eastmaninstitutet, Department of Orthodon-
Because the individual response is unknown, all fac-
tics, Dalagatan 11, SE 113 24 Stockholm, Sweden. E-mail: tors, systemic as well as local, must be considered
[email protected] before the start of treatment. Assessment of the risk

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Fig 1 Radiographs of two sisters with

short root anomaly. (a) An orthopantomo-
gram shows a 13-year-old girl with a short
root anomaly of the maxillary anterior
teeth and premolars. the maxillary left
incisors are severely resorbed during
eruption of the left canine. (b to d) Radi-
ographs of the girl 1 year later. The premo-
lars have a plump form, and the left cen-
tral incisor is severely resorbed. The left
canine had been moved in a distal direc-
tion with a removable appliance. The lat-
eral incisors were extracted. (e to g) Radi-
a
ographs of the sister at 18 years of age,
also showing short root anomalies.

b c d

e f g

of root resorption starts with the patient’s medical 3. Local factors8,9: Nail biting, parafunctional activ-
history, which will allow the clinician to evaluate the ity, and other oral habits.
hypothetical influence of systemic factors. The his- 4. Trauma10: Earlier trauma, trauma type, and fol-
tory should include: low-up, and, if possible, dental records from the
trauma event (Fig 3).
1. Hereditary factors6: Outcome of any orthodontic
treatment undergone by parents, siblings, or rela- A clinical examination, including standardized peri-
tives (Fig 1). apical radiographs taken with a film holder, should be
2. Systemic factors7: Diabetes, allergic reactions, or performed to assess the potential contribution of local
other systemic diseases (Fig 2). factors. Periodontal conditions should be registered.

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Fig 2 Radiographs of a girl suffering from aller-

gic asthma. She was 15 years of age at start of
orthodontic treatment. Extreme resorption
developed during treatment. (a) Before treat-
ment. (b) After treatment.

a b

a b c

d e

Fig 3 This female patient, 9.7 years of age, suffered a fall during gymnastics. the maxillary right central incisor was
avulsed and the left central incisor laterally luxated. (a) After the trauma, the right central was kept first in mouth
saliva and then in saline. (b) After 85 minutes, the right central was replanted and the left central repositioned. Both
teeth were endodontically treated with an interim dressing of calasept and filled with gutta-percha. (c) At 13.8 years
of age, the orthodontic diagnosis was normal interdigitation, with severe crowding of the maxillary and mandibular
anteriors and a deep overbite. Moderate apical root resorption on the central incisors (index score, 2) can be seen.
Orthodontic treatment comprised extraction of the four first premolars and fixed appliance therapy for 1.7 years. No
further root resorption developed. (d) Radiographs at the end of orthodontic treatment. (e) Follow-up 2 years later.

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a b c

Fig 4 Radiographs of a patient with severe api-

cal root resorption due to eruption disturbances.
Follow-up period: 7 years. (a) Before treatment.
(b,c) After treatment. Severe apical root resorp-
tion of all maxillary incisors. (d,e) At the follow-
up visit. Total root lengths: the right lateral and
left central and lateral incisors were greater than
9 mm; the right central was less than 9 mm and
showed increased mobility. (Reprinted with per-
mission of Oxford University Press. Levander E,
Malmgren O.4)

d e

Based on the radiographic findings, the following fac- TREATMENT

tors should be evaluated: existing root resorption,
including that due to disturbances of eruption11,12 (Fig Once treatment has begun, an initial follow-up visit
4), apical root form13,14 (Fig 5a), invagination15 (Fig is recommended at 6 months5 and should include
5b), agenesis16 (Fig 6), and short root anomalies17–19 periapical radiographs of all maxillary and mandibu-
(see Fig 1). lar incisors, as these are the teeth most susceptible
Treatment planning involves evaluation of the type to root resorption. 20 It is important that the root
and extent of tooth movement needed to correct the apices can be viewed on at least two radiographs,
deviations, the duration of treatment, and whether taken from different directions. To standardize the
extraction is necessary. In patients with several pre- assessment of root resorption, a four-point index can
disposing factors, the individual treatment plan be applied (Fig 7).5
might be modified to make allowance for the risk of If there are no radiographic signs of root resorption
root resorption, eg, shorter treatment time, less at 6 months into treatment, the risk of severe resorp-
force, and a limited goal. tion at the end of treatment is minimal (Fig 8a).
Resorption at 6 months of treatment indicates a risk
of progressive resorption as treatment proceeds (Fig
8b). 5 This risk may be reduced by suspension of

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Fig 5 Typical effect of root resorption. (a) A

pipette-shaped root (left) before and (right) after
treatment. (b) Tooth crown with invagination
(left) before and (right) after treatment.
(Reprinted with permission of Oxford University
Press. Levander E, Malmgren O.5)

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Fig 6 Radiographs of a girl with agenesis of

four premolars. (a) Orthopantomogram before
treatment. (b) Periapical radiographs of maxillary
incisors before and (c,d) after treatment. Severe
resorption after treatment. (Reprinted with per-
mission of Oxford University Press. Levander E
et al.16)

b c d

a b c d

Fig 7 An index for evaluation of root resorption. 1, irregular root contour; 2, apical root resorption less than 2 mm
(minor resorption); 3, apical root resorption from 2 mm to one-third of the original root length (severe resorption); 4,
root resorption greater than one-third of the original root length (extreme resorption). (Reprinted with permission of
Oxford University Press. Levander E, Malmgren O.5)

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a b c

d e f

Fig 8 Root resorption: Posttreatment outcome in relation to degree of resorption 6 to 9

months after start of treatment. (a) Before treatment (left); no resorption after 6 to 9
months (center); minor resorption after treatment (right). (b) Before treatment (left);
minor resorption after 6 to 9 months (center); moderate to severe resorption after treat-
ment (right). (Reprinted with permission of Oxford University Press. Levander E, Malm-
gren O.5)

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a b c

d e f

Fig 9 The risk of severe resorption may be reduced by suspension of active treatment
for 2 to 3 months. (a) Uninterrupted treatment: (left) before treatment, (center) at regis-
tration of initial apical root resorption, and (right) severe resorption after treatment. (b)
Interrupted treatment: (left) before treatment, (center) at registration of initial resorption,
and (right) minimal further resorption after treatment. (Reprinted with permission of
Oxford University Press. Levander E, et al.21)

active treatment for 2 to 3 months (Figs 9a and 9b).21 should be informed if root resorption has occurred.
In teeth showing progressive resorption, further radio- If root resorption is mild or moderate, no further
graphic follow-up every 3 months is recommended. action is indicated. If root resorption is severe, and
the foreshortened root remaining is no longer than
the tooth crown, there is a risk of tooth mobility (Fig
POSTTREATMENT 10).4 In such a case, further follow-up visits and
instructions to the patient are necessary.
After treatment, a radiographic examination is
mandatory, and the patient and referring dentist

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Fig 10 Radiographs of a patient, 31 years of

age, with severe apical root resorption. Follow-
up period 15 years. (a) Before treatment. (b)
After treatment. Severe apical root resorption of
maxillary incisors. (c,d) At follow-up visit after
15 years out of treatment. Total root lengths of
12 to 22 were less than 9 mm. There was
increased mobility in all four incisors. (Reprinted
with permission of Oxford University Press.
Levander E, Malmgren O.4)

a b

c d

DISCUSSION demonstrated a relationship between some dental

anomalies, particularly ectopia and agenesis of
There is no definitive evidence in the literature of the teeth, and a tendency to root resorption during
importance of the interaction between biologic and orthodontic treatment. This observation was verified
mechanical factors during treatment.22,23 However, by an investigation designed to analyze the risk of
these factors must be considered when assessing root resorption associated with agenesis. 16 In
the risk of root resorption, and should be included in patients with multiple agenesis, the risk of root
the treatment plan. resorption must be considered carefully, because
Familial susceptibility to root resorption during the teeth are often intended to serve as prosthetic
orthodontic treatment has been found in a study of abutments. Two variables—treatment with rectangu-
a large number of full siblings, indicating a heritable lar archwires and intermaxillary elastics and dura-
component.6 A correlation between gender and api- tion of treatment—were significantly related to the
cal root resorption also has been reported;18,24–26 severity of root resorption. This may reflect the diffi-
Linge and Linge2 reported that females are more culty of controlling the force applied when fewer
susceptible than males, but other studies27–29 have teeth are available for anchorage.16
failed to verify this finding. Some morphologic characteristics of root anatomy
Davidovitch et al7 have proposed that individuals can be diagnosed in pretreatment intraoral radio-
with pre-existing inflammatory conditions, such as graphs. Oppenheim30 alleged that incisors with deviant
periodontitis, diabetes, and allergy, are at high risk root forms are especially at risk. Lind17 and Newman18
for orthodontic root resorption. Furthermore, Kjær15 claimed that “short root anomaly” predisposes to root

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resorption during orthodontic treatment; the roots are between resorption and the duration of active treat-
abnormal from an early stage of development and the ment has been shown in some studies,35,36 but not
final root shape is not due to resorption. The anomaly in others.37,38
always affects both central incisors almost symmetri- A recent study of root resorption associated with
cally. As a rule, these roots are characteristically standard and straightwire edgewise techniques dis-
plump. Other teeth, less frequently involved, are usu- closed significantly more resorption of central
ally premolars and canines. No clear evidence of the incisors in patients treated with the standard edge-
risk for root resorption in these teeth has been shown. wise technique.39 In another recent study, a tech-
However, even minor resorption might jeopardize their nique using heat-activated and superelastic wires
long-term prognosis. resulted in less resorption than either standard or
In a study by Malmgren et al,31 root resorption straightwire edgewise techniques, where stainless
was analyzed after orthodontic treatment of trauma- steel archwires had been used.20
tized teeth. The material comprised 55 luxated Movement into labial and cortical bone can initi-
incisors and their uninjured contralaterals. At the ate root resorption. Thus, it is important to establish
time of injury, all teeth had been carefully examined the borders of the cortical bone, based on profile
by experienced pedodontists, following standardized radiographs, prior to treatment. 10 If the alveolar
procedures. The extent of resorption was the same crest is narrow, resorption can easily occur during
in the traumatized and the contralateral, uninjured retraction of maxillary incisors. The maxillary incisors
control teeth. However, a few teeth exhibiting resorp- are often protrusive and require palatal root torque
tion before orthodontic treatment became severely during retraction; this root movement should be
resorbed during treatment. made in the roomier cancellous bone area, prefer-
In an ongoing study by Morin, Levander, and ably using an approach that intrudes the anterior
Malmgren, seventeen patients with 27 severely teeth at the onset of treatment.
injured teeth, with complete records from the trauma Owman-Moll 3 found great variability in tissue
episode and follow-up after the trauma, were treated response, regardless of the magnitude of the
with fixed appliances and followed. In cases of applied force. In some patients, substantial resorp-
severe trauma, teeth with severe periodontal dam- tion was detected after a short period of treatment
age, particularly avulsed and replanted teeth, and with light forces. It may be concluded that treatment
teeth with intrusive luxations, the results showed duration, mechanical factors, and individual varia-
that extraction should be done if the teeth had a tions are all of importance.
poor prognosis during the follow-up period after the A major consideration is the management of api-
trauma or they should be looked upon as space cal root resorption detected early during active
maintainers during the orthodontic treatment. Suc- orthodontic treatment. Reitan40 recommended tem-
cessfully treated injured teeth, which show normal porary suspension of treatment in cases showing a
periodontal ligaments after an adequate post- strong tendency to root resorption. Rygh41 has gone
trauma observation period, may be subjected to even further, proposing the scheduling of periods of
orthodontic movement without increased risk of root treatment suspension throughout the course of
resorption. Furthermore, a tooth with a root fracture, orthodontic therapy.
healed with bone or connective tissue, should be There is consensus that root resorption usually
considered a tooth with a short root; if the fracture ceases after orthodontic treatment, when applied
line is located in the middle third of the root, there is forces are discontinued.37,42,43 Histologic studies
risk of further shortening of the short coronal frag- have shown that repair of resorption cavities will
ment during orthodontic movement.10 take place after force removal. Brudvik and Rygh44
The importance of forces has been discussed for studied the reparative process in experiments in rats
years. Most authors consider only heavy forces to be and observed new mineralized cementum on the
responsible for root resorption, but intensity and resorbed root surface at 21 days after the forces
duration are also of great importance. The conclu- were discontinued. In human experiments, Owman-
sions in the literature are, however, conflicting. Moll3 found various degrees of repair after 8 weeks
Kvam, 32 Harry and Sims,33 and Vardimon et al34 and Odenrick et al45 reported deposits of hard tissue
found an association between severity of resorption in resorption lacunae after 53 to 90 days after the
and the magnitude of force, but Owman-Moll3 con- end of active treatment. In a study of patients where
cluded that root resorption did not seem to be force active treatment of initially resorbed teeth had been
sensitive. It is often stated that forces causing jig- suspended for 2 to 3 months, there was significantly
gling of teeth, intrusion, and/or torquing of roots less posttreatment resorption than in cases where
increase the risk of root resorption.2,28 A correlation treatment proceeded without interruption.21

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Little is known of the long-term prognosis of teeth CONCLUSION

with severely or extremely resorbed roots. In agree-
ment with an earlier study by VonderAhe,37 Reming- Radiographic follow-up is indicated after 6 to 9 months
ton et al 43 reported that even teeth with severe of orthodontic treatment with fixed appliances.
orthodontically induced resorption seemed to func- There is a significant correlation between initial
tion reasonably well clinically, several years post- and posttreatment apical root resorption. If no radio-
treatment. In a case repor t of a patient with graphic sign of resorption is found at the 6- to 9-
extremely foreshortened maxillary central incisor month visit, there is little risk of severe resorption by
roots, examined 33 years after treatment, radio- the end of treatment. Minor resorption early in treat-
graphic, visual, and tactile examination revealed that ment indicates a risk of progressive resorption as
the resorbed teeth functioned well.46 It has been treatment continues. The risk of severe resorption
claimed that resorption of up to one-third of the origi- may be reduced by temporary suspension of active
nal root length does not result in decreased treatment for 2 to 3 months, with an inactive archwire.
stability,47 because the highest percentage of perio- There is an increased risk of apical root resorption
dontal attachment is in the crestal two-thirds of the in maxillary incisors with a deviating root form, partic-
root.48 If there is considerable foreshortening of the ularly pipette-shaped roots. Treatment planning for
original root, the longevity of the tooth might be com- patients with multiple agenesis of teeth should
promised; such a tooth might not resist normal func- include consideration of the risk for excessive apical
tional load.49 A further risk is that in the event of cre- root resorption during orthodontic therapy.
stal alveolar bone loss, a critical stage for the If orthodontic treatment leads to severe root
residual periodontal attachment may be reached resorption, with a crown-root ratio less than or equal
prematurely in teeth with pronounced apical root to 1:1, there is a risk of tooth mobility.
resorption.47
The clinical sequelae for severe root resorption
are of major concern. Wainwright50 concluded that REFERENCES
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