RestorativeDentistry

Karun Dewan
Kevin Fairbrother

Multiple Idiopathic External Apical

Root Resorption: A Literature Review
Abstract: Multiple idiopathic external root resorption is an unusual condition that may present in a cervical or an apical form. In this paper,
we review the published literature relating to root resorption and multiple idiopathic external apical root resorption (MIEARR). The article
considers the types, classification and aetiology of root resorption and discusses the restorative options and management. An example of a
patient suffering with multiple idiopathic apical external apical root resorption affecting UR2, UR1, UL1, UL2 and hypodontia affecting the
maxillary canines is described.
Clinical Relevance: This paper offers clinical advice to practitioners to understand the classification of root resorption and appropriate and timely
referral to be made to secondary care for optimum restorative treatment when multiple teeth are involved with no known cause established.
Dent Update 2014; 41: 586595

History, types and classification

Root resorption in deciduous teeth
is a normal physiological response, resulting
in exfoliation of the deciduous teeth with
replacement by the permanent dentition. In
contrast, the process of root resorption in the
permanent dentition has a pathological basis.
The resorption of permanent teeth was first
described by Bates in 1856, who considered
the cause to be trauma to the periodontal
membrane.1 Root resorption is classified as
external and internal, the former being reported
more often.2 Root resorption of permanent
teeth has been attributed to a wide variety of
causes, such as trauma, inflammation, tooth
re-implantation, tumours, cysts, occlusal stress,

Karun Dewan, BDS, LDS RCS, MFDS RCS,

MSc, Specialist Registrar and Honorary
Clinical Lecturer in Restorative Dentistry
and Kevin Fairbrother, BChD, MDS,
DipConSed, MRD RCS, FDS(Rest Dent)
RCS, Consultant in Restorative Dentistry,
School of Dentistry, Birmingham
Dental Hospital, St Chads Queensway,
Birmingham B4 6NN, UK.

586 DentalUpdate

impacted teeth,3 orthodontic movement,4

periodontitis and dietary habits.5,6 Resorption
of the roots can also be related to endocrine
disturbances and systemic conditions, such
as hyperparathyroidism, hypoparathyroidism,
hypophosphataemia, hyperphosphataemia,
Gauchers disease, Pagets disease of bone,
Goltz syndrome, Papillon-Lefvre syndrome
and Turner syndrome.7 However, Henry and
Weinmann highlighted that minimal apical
resorption may be present in all permanent
teeth.8 It is not uncommon that resorption of
unknown aetiology is encountered.9
Idiopathic external root resorption
is the term used when the condition exists
without a known aetiology.10 Mueller and Rony
first reported the condition in 1930.11 It is a rare
condition that has been reported in single and
multiple teeth. Two types have been observed:
apical and cervical.12,13 The majority of reports
involve the apical part of several teeth in young
individuals. In apical idiopathic root resorption,
the resorption starts apically and progresses
coronally causing a gradual shortening and
rounding of the roots, whereas the cervical type
starts in the cervical region and approaches the
pulp.14,15 Various classification systems of root
resorption have been proposed.3,16-20 These
systems have used different terms and categories

to describe dental root resorption. There is

considerable confusion and disagreement in the
literature regarding the manner of considering
and thus classifying root resorption. Bakland
described a simple classification system (Table 1)
based on site, type and aetiology.16

Aetiology and pathogenesis

Aetiology of different types of root
resorption requires two phases: mechanical or
chemical injury to the protective tissues and
stimulation by infection or pressure.21,22 Injury
can be similar in various types of root resorption.
The selection of proper treatment is related to
the stimulation factors. Intrapulpal inflammation
due to pulp disease as a consequence of
the injury is the stimulation factor in internal
root resorption and external periradicular
inflammatory root resorption.23 Adequate
root canal treatment controls intrapulpal
bacteria and arrests the resorption process.23
In cervical root resorption, infection originates
from the periodontal sulcus and stimulates the
pathological process.17,24 As adequate infection
control in the sulcus is unlikely, removal of
granulation tissue from the resorption lacuna
and sealing are necessary for repair.17 Removal
of the stimulation factor, ie pressure, is the
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RestorativeDentistry

Site

Type

Aetiology

Internal
Trauma
Infection
External Surface Trauma

Inflammatory Trauma
Infection

Replacement (Ankylosis)
Avulsion and re-implantation
Luxation
Transplantation

Pressure
Orthodontic tooth movement

Excessive occlusal forces

Impacted teeth

Supernumerary teeth
Tumours
Cysts

Related to systemic conditions
Hyperparathyroidism

Pagets disease

Papillon-Lefvre syndrome

Bone dysplasia

Renal disease

Hepatic disease

Invasive (Cervical)
Trauma

Orthodontic tooth movement

Periodontal treatment

Intracoronal tooth bleaching
Unknown

Idiopathic Unknown
Table 1. Classification and aetiological factors in pathological root resorption.16

treatment of choice in root resorption related

to pressure during orthodontic treatment, or
an impacted tooth or tumour.17 In ankylotic
root resorption, there is no known stimulation
factor; thus, no predictable treatment can be
suggested.17 Therefore, various types of root
resorptions can be classified according to the
stimulation factors:
Pulpal infection resorption;
Periodontal infection resorption;
Orthodontic, impacted tooth or tumour
pressure resorption; and
Ankylotic resorption.17
The process of root resorption
involves a complex interaction of inflammatory
cells, resorbing cells, hard tissue, cytokines
and enzymes such as collagenase, matrix
metalloproteinase and cysteine proteinase.20
The periodontal ligament is a specialized
connective tissue that acts as a barrier between
the alveolar bone and cementum.25 Localized
damage or loss of periodontal ligament renders
September 2014

the denuded cementum surface chemotactic to

osteoclasts.20,21 This can result in root resorption.
In cases where multiple teeth are involved, Le
and Waerhaug have suggested that the dental
tissues become part of the osseous system and
thus subject to remodelling.26
Multiple idiopathic apical root
resorption is a specific entity that must be
differentiated from all other resorptive processes.
Kerr described the phenomenon of multiple
teeth affected with resorption with no known
aetiological pathogenesis, such as trauma,
previous history of orthodontic treatment or
any systemic condition identified.27 Only 14
clearly identified cases of multiple idiopathic
apical root resorption have been reported in the
literature (Table 2), all of which were in relatively
young individuals aged from 14 to 39 years,
and the majority of the affected individuals in
these studies were males. This paper describes
an adult female with multiple idiopathic apical
root resorption of maxillary incisor teeth, as well

as congenitally missing maxillary canines, and

discusses restorative options and subsequent
management.

Case report
A 35-yearold female suffering
with root resorption of maxillary anterior teeth
was referred to the Department of Restorative
Dentistry at Birmingham Dental Hospital by
her general dental practitioner. The patient had
no family history of such anomaly. There was
no previous history of orthodontic treatment,
dental extraction, trauma to teeth or any specific
infection in relation to her maxillary anterior
teeth. The patient also reported discoloration of
her upper left central incisor tooth and general
drifting of her maxillary incisor teeth.
The physical appearance of the
patient was normal, with a skeletal Class I dental
base relationship, and no notable asymmetry of
face was noted. Clinical examination revealed
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RestorativeDentistry

Case report

Gender

Age (years)

No. of teeth affected

Teeth affected

Soni and La Velle (1970)

M
34
9

UR4 UL4, UL5 LL5, LL6,

LL7 LR5, LR6, LR8

Cowie and Wright (1981)29

M
27
9

UR4, UR5, UR6, UR7 UL4,

UL5, UL6, UL7, LL7

Belanger and Coke (1985)10

14

26

All permanent teeth

Brooks (1986)30

17

UR6, LL5, LL36, LR6

28

M
30
13
Pankhurst et al (1988)31

UR5, UR6, UR7, UL2, UL3

UL5, UL6, UL8 LL7, LL8
LR6, LR7, LR8

F X 2 (Twins) 14
16
Saravia and Meyer (1989)32

UR4, UR5, UR6, UR7, UL4, UL5, UL6, UL7,

LL4, LL5, LL6, LL7 LR4, LR5, LR6, LR7

Postlethwaite and Hamilton (1989)14 M

14
20

UR1, UR2, UR3, UR4, UR5, UL1, UL2,

UL3, UL4, UL5, LL1, LL2, LL3, LL4, LL5,
LR1, LR2, LR3, LR4, LR5

Yusof and Ghazali (1989)13

M
35
11

UR4, UR5, UL1, UL4, UL5, UL6 LL4, LL5,

LR1, LR4, LR5

M
23
18
Counts and Widlak (1993)33

UR1, UR2, UR3, UR4, UR5, UR6, UR7,

UL1, UL2, UL3, UL5, UL6, LL4, LL5, LL6,
LL7, LR4, LR5

Rivera and Walton (1994)15

All permanent teeth

24

24

F
26
15
Di Domizio et al (2000)34

UR1, UR2, UR3, UL1, UL2, UL3, UL5,

LR1, LR4, LR7, LL1, LL2, LL4, LL5, LL7

Schtzle et al (2005)35

All permanent teeth

17

28

Cholia et al (2005)
MX3
27
17





37
20








38
11





39
14

UR4, UR5, UR6,

UR7, UL4, UL5,
UL6, UL7, LL4,
LL5, LL6, LL7 LL8,
LR4, LR5, LR7, LR8
UR4, UR5, UR6,
UR7, UR8, UL4,
UL5, UL6, UL7,
UL8, LL4, LL5 LL6,
LL7, LL8, LR4 LR5,
LR6, LR7, LR8
UR4, UR5, UR6,
UR7, UL4, UL5,
UL6, UL7, LR4,
LR5, LR8
UR4, UR5, UR6,
UR7 UR8, UL4,
UL6
UL7, UL8, LL5,
LL6, LL7 LR6, LR7

Moazami and Karami (2007)37

M
27
18

UR1, UR2, UR3, UR4, UR5, UR6, UR7,

UL1, UL2, UL4, UL5, UL6, UL7, UL8, LL5,
LL6, LR5, LR6

Dewan and Fairbrother

(Present study)

UR1, UR2, UL1, UL2

36

35

Table 2. Reported cases of multiple idiopathic external apical root resorption.

588 DentalUpdate

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RestorativeDentistry

missing maxillary canines and a discoloured

maxillary left central incisor (UR1). The maxillary
lateral incisor teeth were atypical in shape
and were diminutive. Generalized spacing
and drifting of anterior incisors was noted.
The maxillary incisor teeth were not tender to
percussion. These teeth were not mobile, with
normal probing depths. The teeth also showed
positive but delayed response to sensitivity
testing with ethyl chloride (Dr Georg Friedrich
Henning Chemische Fabrik Walldorf GmbH,
Walldorf, Germany) and Electronic Pulp Tester
(Analytic Endodontics, Redmond, WA, USA).
Radiographic examination revealed
substantial apical root resorption on UR2, UR1, UL1
and UL2. These teeth had short and malformed
root morphologies. The UL2 and the adjacent UL4
were significantly rotated (Figure 1a, b).
Following an initial assessment, it
was clear that the patients aesthetic concerns
mainly involved the maxillary arch and, as the
mandibular dentition was largely unaffected, the
treatment options considered were:
Orthodontic alignment of maxillary incisors
+/- aesthetic restoration of teeth;
Elective root canal treatment of maxillary
incisors +/- aesthetic restoration of teeth;
Combination of above;
Construction of maxillary partial overdenture
using strategic use of the patients electively
root-treated natural incisors as abutments;
Extraction of maxillary incisor teeth and
provision of a partial denture or implantretained fixed or removable restorations.
Following discussions with the
patient, and in light of the patients age and
expectations, it was decided that any treatment
that involved a removable option would not
be acceptable. Elective root canal treatment of
already compromised teeth, and using them as
abutments for prosthesis retention or restoring
September 2014

them with conventional crowns, would be an

aggressive option with unpredictable life span.
Orthodontic alignment of the affected teeth
was also ruled out because of the compromised
nature of the teeth, the unpredictable outcome
and its unacceptability to the patient. The initial
definitive treatment plan was:
The construction of a maxillary immediate
partial denture following the loss of maxillary
incisor teeth with extractions;
Replacement of the maxillary incisors
and canines with dental implants with
early placement protocol with partial bone
(1216 weeks) healing and subsequent fixed
restorations.
The anterior maxillary teeth were
extracted under local anaesthetic and an
immediate partial prosthesis inserted (Figure
2a, b). The teeth on the denture had ovateshaped pontics to retain ridge shape. The
patient was then reviewed regularly and the
denture relined to compensate for the alveolar
bone changes within the initial phase of socket
healing (modelling). The hygienic design of the
immediate partial denture and pontic shape
maintained a scalloped profile of the alveolar
tissue at the missing space (Figure 3).
Approximately 12 weeks after the
maxillary anterior teeth were extracted, four
dental implants (Astra tech 3.5 mm diameter,
15 mm length at lateral incisors and 4.0 mm
diameter, 15 mm length at central incisors) were
inserted under local anaesthetic and intravenous
midazolam sedation (Figure 4). Twelve weeks
following implant placement, the dental implants
were uncovered, fixture level impressions were
obtained using an open tray technique, the
cast verified and four individual composite
provisional crowns fitted (Figure 5a, b). Three
weeks following insertion of provisionals, when
good tissue conditioning was observed clinically,

Figure 1. (a) OPG demonstrating missing

maxillary canines and apical root resorption
affecting UR2, UR1, UL1 and UL2. (b) Periapical
radiographs pretreatment showing extensive root
resorption of maxillary incisors.

the restorations were replaced with all-ceramic

crowns on zirconia abutment cores (Figure 6a, b).
The patient was subsequently followed for three
years and good bone levels were noted around
the dental implants (Figure 6c).

Discussion
External root resorption that
develops in the absence of a plausible cause
is termed idiopathic. By definition, idiopathic
external root resorption is a diagnosis of
exclusion.38 From the number of reported cases
in the dental literature, multiple idiopathic
external cervical root resorption (MIECRR)
appears to be more common than multiple
idiopathic external apical root resorption
(MIEARR).38 MIEARR affects a wide age range
of patients, from 14 years to 39 years old and, in
contrast to MIECRR, males appear to be more
frequently affected by MIEARR than females,
with a male:female ratio of 11:4.36 In addition,
MIEARR appears to have a predilection for
premolar and molar regions.38
Other common features of the
MIEARR cases appear to be:36
Normal clinical appearance of teeth and
periodontal tissues;
Root resorption associated with vital teeth
and endodontically treated teeth;
Lack of periodontal and periradicular
inflammation;
Alveolar bone levels within normal limits;
Absence of local aetiological factors;
Patients asymptomatic until very late in the
pathological process where increased tooth
mobility reported;
Commonly found as an incidental finding on
DentalUpdate 591

RestorativeDentistry

literature.

was found but missing isolated permanent

canines were noted at clinical examination,
which was confirmed radiographically. The
patient was not aware of missing canines and
did not give a history of previous extractions.
Congenital absence of missing teeth excluding
third molars is called hypodontia. The reported
prevalence of hypodontia in the literature
affecting the permanent dentition often varies,
even within similar populations, with ranges
as wide as 0.336.5%.41 The data from the
literature confirms that hypodontia is more
prevalent in females than in males in a ratio of
3:2. The reported sites and frequency of missing
teeth is also varied among studies.41 The most
common missing teeth in descending order are
mandibular second premolar (3.0%), maxillary
lateral incisor (1.7%), maxillary second premolar
(1.5%) and mandibular central incisor (0.3%).41
Hypodontia affecting exclusively the maxillary
permanent canines is extremely rare and there
are only a few cases of absence reported in the
literature.42,43 Several theories concerning the
aetiology of hypodontia have been proposed,
including suggestions that both genetic and
environmental factors may play a role. Mutations
in the genes Msx1 and Pax9 are associated with
an isolated form of hypodontia.44 MIEARR in a
hypodontia patient has not been reported in the

radiographs;
Intramaxillary and intermaxillary symmetrical
pattern of root resorption.
In this case, the patient was a
35-year-old female who was not aware of the
resorptive process affecting her maxillary incisor
teeth and no signs or symptoms of endodontic
pathology were present. The radiograph also
showed bone levels within normal limits and
sensitivity tests showed a positive response to
the teeth affected. The teeth were not mobile
and pathology was found as an incidental
finding on radiographs by the patients general
dental practitioner.
In an attempt to explain the cause
of idiopathic external root resorption, Pinska and
Jarzynka first suggested genetic susceptibility
in their report of a family with generalized
root resorption.39 Newman then followed
this with a study of 37 families and a tentative
genetic association was found.40 In the case
presented, no family history of root resorption

With no absolute aetiological

factors identified, treatment of MIEARR depends
largely on the presenting symptoms and the
extent and the severity of root resorption. The
usual treatment is the extraction of teeth of poor
prognosis and long-term monitoring of the
remaining dentition using serial radiographs,
periodontal assessment, sensitivity tests or
patient symptoms.36 This was the option chosen
in this case. Edentulous saddles may be restored
using adhesive or conventional fixed bridges,
removable partial dentures or osseointegrated
implants. Abutment teeth must be carefully
assessed for root resorption. The success of
long-term osseointegration in sites where root
resorption has been active is unknown.45 In
severe cases where all permanent teeth are
affected, the only option available may be
extraction of all teeth and construction of a
complete denture or an implant-retained fixed
or removable restoration.
An option of endodontic treatment
of the affected teeth has been well documented
for inflammatory root resorption, where
calcium hydroxide is the current intraradicular
medicament of choice.46 However, a common
finding in MIEARR is that teeth remain vital
even after extensive root resorption, and Rivera

Figure 2. (a, b) Maxillary immediate partial

denture in situ following extractions of incisor
teeth.

Figure 4. OPG demonstrating four 15 mm dental implants .

Figure 3. Clinical view of scalloped alveolar ridge

profile to maintain interdental papilla height.

592 DentalUpdate

Figure 5. (a) Clinical view of tissue healing following implant placement. (b) Provisional composite
crowns in situ.

September 2014

RestorativeDentistry

Figure 6. (a) Clinical view of excellent soft tissue conditioning with temporaries. (b) Definitive crowns in situ. (c) Intra-oral radiographs showing definitive
crowns fit and bone levels after three-year follow-up.

and Walton stated that MIEARR does not seem

to be mediated by or have its source from the
dental pulp. Therefore, root canal treatment is
not indicated.15 In this case too, the affected
teeth showed a positive response to sensitivity
testing and, in light of evidence of extreme
root resorption radiographically on the affected
teeth, root canal treatment of the affected teeth
was not considered.
The use of implants to restore a
patient suffering with MIEARR has not been
described in the literature previously. Although
an implant option was considered in the
treatment, the authors were concerned that
implant placement might result in lack of
osseointegration and complications. However,
in the present case, based upon radiological
examination, the maxillary incisors were likely to
have a guarded long-term prognosis.

Conclusion
Multiple idiopathic external apical
root resorption is a rare dental pathology
affecting the roots of teeth. The aetiology and
pathogenesis of this condition is not known.
Isolated bilateral agenesis of maxillary canines is
also extremely rare. A combination of the above
dental manifestations could affect successful
dental rehabilitation and restorative treatment
of such patients. This paper highlights that
patients with MIEARR can be treated with dental
implants if treatment is timed correctly. The
use of 3-dimensional planning may facilitate

594 DentalUpdate

optimum and precise implant placement, which

in turn allows the implants to be placed in areas
with appropriate bone quality and volume.
The technique may also allow early loading
protocols to be utilized.

11.

12.

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