Root Resorption:

What we know and how it Root resorption

affects our clinical practice.
AAO 2015 Annual Session
May 19th 2015
 a physiologic or pathologic process
occurring as a result of changes seen
in the tooth or surrounding
periradicular tissues
 characterized by loss of tooth
structure over the root surface

Dr. Belinda Weltman HBSc, MS, DMD, BDent, MSc, FRCD(C)

Type Location
 Physiologic root resorption:  Internal
occurring on deciduous
teeth during eruption of
permanent teeth

 Pathologic: occurring on permanent  External

roots

External Root resorption Trauma/pulp space infection

1) Trauma/pulp space infection

2)Ectopic teeth
Pressure from tumors / cysts

3) Orthodontic treatment Pulpal infection:

Radiolucencies in bone
Radiolucencies in bone
And root resorption

1
 Ectopic Canine Pressure from tumors
A) Buccally impacted canine

B) Resolution of canine impaction

C) Deband

D) 5-8yrs post treatment

Source: American Journal of Orthodontics and Dentofacial Orthopedics 2005; 127:650-654 (DOI:10.1016/j.ajodo.2004.03.031 )
Copyright © 2005 American Association of Orthodontists Terms and Conditions

Orthodontically Induced Inflammatory Root

Resorption (OIIRR) OIIRR

Pre-Treatment

Maxillary incisors
are most commonly
affected

Post-Treatment

How do orthodontic treatment

OIIRR factors influence root resorption?

Orthodontically induced
inflammatory root resorption
(OIIRR)
 External Apical Root Resorption (EARR )

 Cervical Root resorption

 Root resorption (RR): microscopic areas of

resorption lacunae visualized with histological techniques
(Hartsfield et al. 2004)

2
 Orthodontic
force
Three types OIIRR

Hylinization and Activation of 1) Surface resorption:

inflammation osteoclasts
Compression of
the PDL
Only the outer cemental layers are resorbed,
and later fully regenerated/ remodeled when
the etiologic factor is removed.
Removal of Removal of
superficial surface hyaline
or cementum material

Root
resorption

Three types OIIRR Three types OIIRR

2) Deep resorption: 3) Circumferential apical root
The cementum and the outer resorption:
layers of the dentin are resorbed and Tridimensional resorption of the hard
usually repaired with cementum tissue components of the root apex occurs,
material. and root shortening is evident.
When the root looses apical material
The final shape of the root may
beneath the cementum, no regeneration is
or may not be identical to the original possible and the resorption is irreversible.
form.

Methods of identifying root

Why investigate OIIRR?
 Root resorption is undesirable because it
can affect the long-term viability of the
dentition.
 Unfavorable crown:root ratio
 3mm apical loss = 1mm crestal bone loss
resorption
 Human and animal studies
 Histological (SEM, Light microscope)
 Radiographic (Pan, Ceph, Periapical)
 Volumetric (Micro-CT, Cone Beam)

* *
 It is important to elucidate which * *
orthodontic treatment factors contribute to
root resorption so that the detrimental
effects can be minimized.

3
Histological illustration: varying SEM – varying severity of RR in
degrees of repair in OIIRR intruded teeth
A) Normal root surface

B) Undermined RR – no repair
Minor RR
C) Partial repair with acellular
cementum (AC)

D) Partial repair with cellular

cementum (CC)

E) Total repair with CC – root Severe RR

contour has been altered

F) Total repair with AC – root

contour was re-established (Owman-Moll, P.
(1995b) (Han G, et al. 2005)

Panoramic radiograph - initial Panoramic radiograph - progress

Cone Beam - CT
Root Resorption Severity

No RR mild moderate severe extreme

Source: American Journal of Orthodontics and Dentofacial Orthopedics 2010; 137:384-388 (DOI:10.1016/j.ajodo.2008.04.024 ) Source: American Journal of Orthodontics and Dentofacial Orthopedics 2009; 135:434-437 (DOI:10.1016/j.ajodo.2008.10.014 )
Copyright © 2010 American Association of Orthodontists Terms and Conditions Copyright © 2009 American Association of Orthodontists Terms and Conditions

4
 Periapical X-rays

Panoramic X-ray Deband

Deband

Consolaro A, Furquim LZ. Extreme root resorption associated with induced tooth movement: A protocol for clinical management. Dental Press J
Orthod. 2014 Sept-Oct;19(5):19-26.

5
 Mean absorbed doses (μGy) to
various tissues for each unit
American Academy of Oral and
NewTom 9000 i-CAT
Panoramic/lateral
cephalometric
Multi-slice CT
Maxillofacial Radiology
Bone marrow
Third cervical vertebra 648.9 731.3 62.8 7525.6 Position statement guidelines for CBCT use in
Mandibular ramus 1244.7 1282.9 360.4 9930.4
orthodontic practice (2013):
Brain
Hypophysis 316.1 745.0 30.2 1488.9
1. Image appropriately according to clinical condition
Eye
Lens 472.8 1229.2 45.8 892.8 2. Assess the radiation dose risk
Thyroid gland 3. Minimize patient radiation exposure
Thyroid 232.4 124.3 13.1 1417.7
4. Maintain professional competency in performing
Salivary glands and interpreting CBCT studies
Submandibular 1426.7 1364.1 566.8 11815.0
Parotid 1678.7 1502.2 324.4 14204.4

Skin
Thyroid 663.8 157.5 25.9 1889.0
Neck (back) 1257.1 651.1 270.8 15837.2
ALARA principle
Philtrum 3273.6 1434.9 25.3 12791.8 as low as reasonably achievable (Mountford & Temperton 1992)
Parotid 1489.4 1510.9 608.7 14734.4
Nasion 451.2 1060.9 19.9 1008.2
Silva 2008

Biological Markers to detect Incidence/Prevalence of EARR and

OIIRR? Orthodontic Treatment

 Dentin sialophosphoprotein (DPP) was  Histological studies: 90% prevalence of RR in

orthodontically treated teeth
higher in proximity to resorbing primary (Stenvik A 1970, Harry MR 1982).

and permanent tooth roots (Mah 2004)  Radiographic studies: report an incidence of
EARR before treatment as 15% and after
treatment as 73% (Lupi JE 1996).
 ELISA combined with electrochemistry is  EARR defined as greater than 4mm or 1/3 of
a reliable and sensitive method to detect the root length (severe): Incidence is reduced
DPP in gingival crevicular fluid (Sha 2014) to 0.5-5% in the post orthodontic treatment
group (Linge 1983, Levander 1988, Levander 1998; Lupi 1996;
Taithongchai 1996; Janson 1999; McNab 1999; Kiliany 2002; Sehr 2011).

6
 Systemic Risk Factors for Orthodontically
Induced Inflammatory Root Resorption
Etiology of OIIRR
Likely Risk Factors Unclear Risk Unlikely Risk
Relationship Factors
 The etiological factors are complex History of previous Root
Nabumetone
(Likely Protective)
and multifactorial, resulting from a Resorption
Bisphosphonates
Paracetamol
(acetaminophen)
combination of: Previous trauma resulting in
Root Resorption
Hormone deficiency Tooth/Root morphology
Previous trauma without
Genetics Asthma
Root Resorption
 individual biological variability and TNFRSF11A gene*
Chronic alcoholism
Endodontic treatment

Root proximity to cortical

Age
bone
 the effect of mechanical factors Severity/type of
Gender
malocclusion
IL-1β allele 1
Alveolar bone density

*Other factors to be identified but evidence supports

a link between genetics and OIIRR, estimated to be over 50%.

Reviewing the data on Root

Orthodontic Risk Factors for OIRR resorption
Meta analysis -
 Treatment Duration Systematic Review

 Magnitude of Force – Heavy/Light Randomized

controlled tirals

 Direction of tooth movement Experimental designs

 Amount of Apical displacement
 Method of force application Cohort control studies

 Continuous vs. Intermittent force Case-Control Studies

 Appliance Type
 Treatment technique (Bracket prescription, Case series/ Case reports
self-ligating, archwire sequence etc…)
Personal Communication

Materials and Methods Null Hypothesis

Structured question using PICO format

 Population: patients with no history of root
resorption
 Intervention: comprehensive orthodontics
 Control/comparison: people who have not
had orthodontics / teeth that were not moved
orthodontically
 Outcome: external root resorption
1) There is no difference in the incidence and
severity of root resorption between patients,
with no history of RR, undergoing
comprehensive orthodontic treatment and an
untreated group.
2) There is no difference in the incidence and
severity of root resorption between patients,
with no history of RR, undergoing
comprehensive orthodontic treatment who
receive tooth movement with different
techniques.

7
 Inclusion and Exclusion Criteria Databases of published trials included in
the systematic review (14)
 Inclusion:  Cochrane Cental Register of Controlled Trials
• Randomized controlled trials (RCTs), (CENTRAL) AND Database of Systematic
published or unpublished, that evaluated Reviews
root length before and after treatment in
Human subjects.  MEDLINE
• Patients of any age, gender or ethnicity  PubMed
who underwent comprehensive  EMBASE
orthodontic treatment with full fixed
appliances.
 Web of Science
 Exclusion:  EBM Reviews (DARE)
• Animal studies, studies including auto-  Computer Retrieval of Information on Scientific
transplanted teeth, and duplicate Project
publications.  LILACS, PAHO, BBO, WHOLis, CEPS, etc…

Databases of Unpublished literature Additional search methods

included in the systematic review (7)

 Databases of Dissertations and Conference  Requests were sent to relevant

proceedings: professional organizations in an attempt
 Conference Materials, CENTRAL, ProQuest to identify unpublished or ongoing
Dissertation Abstracts and Thesis database studies.
 Databases of research registers:  Hand searching of relevant journals
 TrialCentral, National Research Register (UK),  Searching through reference lists of
www.Clinicaltrials.gov
relevant articles
 Grey Literature:
 SIGLE

Search Strategy (October 2008)

Major Quality Criteria of included
studies
The search strategy developed for MEDLINE via OVID is displayed
below. (MeSH terms: in UPPER CASE. Free text terms: in lower case) A. Method of randomization
#1 ORTHODONTIC*: ME B. Allocation concealment
#2 "braces"
#3 (#1 or #2) C. Blinding of outcome assessors
#4 ROOT RESORPTION*: ME
D. Completeness to follow-up
#5 "external apical root resorption"
#6 "root erosion"
#7 "root blunting"
#8 "root shortening"
A,C,D adequate = Low risk of bias
#9 "tooth-root resorption" 2 criteria adequate= Moderate risk of bias
#10 "orthodontically induced inflammatory root resorption"
#11 (#4 or #5 or #6 or #7 or #8 or #9 or #10) <2 adequate = High risk of bias
#12 (#3 and #11)
#13 HUMAN*: ME
#14 (#12 and #13)

8
Minor Quality Criteria of included Results
studies
 Of the 921 studies found in this field only
11 trials were considered appropriate for
A. Baseline similarities of the groups inclusion in this review.
B. Reporting of eligibility criteria
C. Measure of variability of primary
outcome
D. Sample size calculation
 Protocols were too variable to proceed with
meta-analysis (quantitative evaluation).

Screening of titles and abstracts from all

sources (n= 921)

Excluded citations
Not relevant (n=777 )
Quality Assessment
Potentially relevant trials retrieved for
more detailed, full report, evaluation (n=
144)
Excluded Trials (Appendix Table 1)
with reasons (n=128)
Unable to locate (n=2)
Potentially appropriate RCTs to be
included in the meta-analysis, evaluated
for methodological quality (n=14)

RCTs excluded from meta-analysis (n=1)

1 publication with no direct RR evaluation
Chutimanutskul et al. (2006)

RCTs considered potentially appropriate

to be included in the meta-analysis
13 publications of 11 trials

Meta-analysis not possible due to

differences in RCT methodologies and
reporting. The Kappa scores and percentage agreements between the two raters (BW & KV)
The QUOROM statement flow diagram of the citations retrieved by assessing the major methodological quality of the studies were: randomization 1.0,
reviewing titles and abstracts, and trials that were evaluated in full text. 100%; concealment 0.72, 82%; blinding 0.91, 95%; and withdrawals 1.0, 100%.

Comparison of the Split-Mouth Comparison of the Split-Mouth

Studies Studies

 6 of the 11 studies were Split-Mouth 1) Heavy force application produced significantly

 Limited validity more root resorption that light force application
 Small sample sizes or control (Chan 2004; Chan 2006; Harris 2006; Barbagallo
 Premolars 2008).
 Moderate risk of bias
2) Weak evidence: continuous force produced
 Exception: Han 2005 - Low risk of bias
significantly more root resorption than
Acar 1999 – High risk of bias
interrupted force application (Acar 1999).
 None of the studies lasted longer than 9 weeks.
 Orthodontic force applied to teeth over a short
period can produce resorption lacunae in the
absence of EARR (Kvam 1972).

9
Comparison of the Split-Mouth Comparison of the comprehensive
Studies orthodontic treatment RCTs

3) Limited evidence that both light forces and  Four of these studies were judged to be of high quality and
have a low risk of bias (Brin 2003, Mandall 2006, Reukers 1998,
forces from thermoplastic appliances result in Scott 2008).
similar root resorption, both significantly more  One was judged to have a moderate risk of bias (Levander
1994).
than seen in controls (Barbagallo 2008)
5) Straightwire vs. standard edgewise techniques resulted in
no statistically significant differences in the amount of
4) Both studies examining intrusive force tooth loss or prevalence of root resorption (Reukers 1998).
application found significantly increased RR
rates to controls (Harris 2006, Han 2005). 6) Mandibular incisor root resorption did not differ between
 Root resorption from extrusive force was not self-ligating and conventional systems (Scott 2008).
significantly different than control (Han 2005)

Comparison of the comprehensive Comparison of the comprehensive

orthodontic treatment RCTs orthodontic treatment RCTs

7) No statistically significant difference was found 9) Teeth/roots having unusual morphology before
in the amount of RR between archwire treatment had no significant differences in the
sequences for upper left central incisors. amount of RR (Brin 2003).
 Also, no difference between the proportion of patients
with or without root resorption was seen (Mandall 2006). 10) No statistical significance between one-phase
8) Incisors with clinical signs or patient reports of and two-phase treatment groups when looking
trauma, but no signs of EARR, had the same at OIIRR prevalence or severity.
prevalence of moderate to severe OIIRR as  As treatment time increased, the odds of OIIRR
those without trauma (Brin 2003, Mandall 2006, Levander also increased.
1994).  The odds of a tooth experiencing severe root
resorption were greater if a large reduction of
overjet occurred during phase 2 (Brin 2003).

Comparison of the comprehensive

orthodontic treatment RCTs Discussion

11) For patients already in orthodontic treatment  Comprehensive orthodontic treatment causes
and experiencing root resorption, the total an increase in the incidence and severity of
amount of root resorption was significantly less root resorption
in patients given a 2-3 month treatment pause  Heavy forces are particularly harmful.
than those treated without any interruption  There is no evidence that OIIRR is affected by
(Levander 1994). archwire sequencing, bracket prescription, or
Levander - Amount of EARR by treatment group
self-ligation.
 There is little evidence that previous trauma
25
Number of teeth affected

20

15 Pause
(with no history of EARR) and unusual tooth
10
No Pause
morphology play a role in increased OIIRR.
5

0
0-0.5 0.51-1.49 1.50-2.49 >2.5
Amount of EARR (mm)

10
Implications for Clinical Practice
 best practice is using light forces, especially when
engaging in intrusive movements.
 progress radiographs should be obtained 6-12
months into treatment to detect OIIRR early.
 Once identified, a 2-3 month treatment pause with
passive archwires, will lead to a decrease in total
root resorption by the end of treatment.
Management of EARR during
Orthodontic Treatment
 Continue with lighter forces / rest periods
 Revise treatment goals – shorten treatment
duration
 Follow-up radiographs during and after
orthodontic treatment
 If termination of RR does not occur, sequential
root canal therapy with calcium hydroxide may
be considered
 Retaining the teeth with fixed appliances
should be done with caution since occlusal
trauma of the fixed teeth or segments might
lead to extreme EARR (Brezniak 2002b).
Long Term Prognosis
 Root resorption associated with orthodontic treatment
ceases with the termination of active treatment
(Remington et al. 1989).
 When post treatment root resorption does occur, It is
likely associated with other factors, such as traumatic
occlusion and active force-delivering retainers (Copeland
& Green 1989).
LIPUS?
 Low intensity pulsed ultrasound (Baily 2004)
 Decreased the number of resorption
lacunae
 Decreased the area or resorption
Non-invasive method to reduce OIIRR in
Humans
Implications for Research
 More evidence is required to determine risk factors and
effective ways to decrease the severity and prevalence
of OIIRR.
 Parallel group studies, with appropriate randomization,
allocation concealment and masking of outcome
assessment are needed.
 Standardized measurement techniques along with proper
assessment blinding, error analysis and consensus
measures.
 Assessment of patient centered outcomes
 Quality of life post treatment, and occurrence of further
complications such as mobility, and tooth loss.
 Genetic predisposition and systemic factors should also
be assessed.
Long Term Prognosis
 extensive root resorption does not usually affect the
functional capacity or greatly compromise the
longevity of the teeth.
 An average sized normally shaped maxillary central
incisor that experienced no alveolar bone loss during
orthodontic treatment, with a root shortened by 5mm
will still have 75% of its periodontal attachment
remaining (Kalkwarf et al. 1986).
11
1) Case Report: 18 months into orthodontic
Initial Radiographs treatment

Source: American Journal of Orthodontics and Dentofacial Orthopedics 2011; 139:S166-S169 (DOI:10.1016/j.ajodo.2009.05.032 ) Source: American Journal of Orthodontics and Dentofacial Orthopedics 2011; 139:S166-S169 (DOI:10.1016/j.ajodo.2009.05.032 )
Copyright © 2011 American Association of Orthodontists Terms and Conditions Copyright © 2011 American Association of Orthodontists Terms and Conditions

Deband 25 year follow-up

Source: American Journal of Orthodontics and Dentofacial Orthopedics 2011; 139:S166-S169 (DOI:10.1016/j.ajodo.2009.05.032 ) Source: American Journal of Orthodontics and Dentofacial Orthopedics 2011; 139:S166-S169 (DOI:10.1016/j.ajodo.2009.05.032 )
Copyright © 2011 American Association of Orthodontists Terms and Conditions Copyright © 2011 American Association of Orthodontists Terms and Conditions

2) 13 year follow-up 3) 15 year follow-up

12
Retrospective data Conclusions
 100 patients with severe resorption were  Increased incidence and severity of OIIRR is
recalled 14 years after orthodontic treatment: found in patients undergoing comprehensive
 no incidences of tooth loss orthodontic therapy.
 hypermobility in only 2 cases  Heavy force application produced significantly
(Remington et al. 1989). more OIIRR than light force application or
 Patients with severe root resorption (root control.
lengths 5.5-18.1mm), recalled 5-15 years after  Other trends from split mouth studies could
treatment: not be substantiated because of small subject
 no teeth had mobility scores greater than 1 on numbers and short treatment times.
Miller’s index (crown deviates within 1mm of normal)  Standard reporting methods of future clinical
 no teeth had been lost trials are recommended so data can be pooled
(Levander & Malmgren 2000). and stronger clinical recommendations made.

Orthodontic Treatment and OIIRR Thank-you!

 How will you discuss the risks of OIIRR with

your patients/parents before orthodontic tx.?
 Can you predict how much root resorption will
occur?
 What is the average amount of OIIRR to
expect with comprehensive orthodontic
treatment?
 Which teeth are most at risk?
 How can OIIRR be managed if it occurs
during orthodontic treatment?
 What is the prognosis of teeth with OIIRR?

References
 Acar A, Canyurek U, Kocaaga M, et al. (1999) Continuous vs. discontinuous force application and root
resorption. Angle Orthodontist, 69(2), 159-63; discussion 163-4.
 Adachi H, Igarashi K, Mitani H, et al. (1994) Effects of topical administration of a bisphosphonate
(risedronate) on orthodontic tooth movement in rats. Journal of Dental Research, 73, 1478-1486.
 Alexander SA. (1996) Levels of root resorption associated with continuous arch and sectional arch
mechanics. American Journal of Orthodontics and Dentofacial Orthopedics, 110, 321-4.
 Al-Qawasmi RA, Hartsfield JK Jr, Everett ET, et al. (2003a) Genetic predisposition to external apical root
resorption. American Journal of Orthodontics and Dentofacial Orthopedics, 123, 242-52.
 Al-Qawasmi RA, Hartsfield JK,Jr, Everett ET, et al. (2003b) Genetic predisposition to external apical
root resorption in orthodontic patients: linkage of chromosome-18 marker. Journal of Dental Research,
82(5), 356-60.
 Al-Nazhan S. (1991) External root resorption after bleaching: A case report. Oral Surgery Oral
Meddicine Oral Pathology, 72, 607-9.
 Andreasen JO. (1985) External root resorption: its implication in dental traumatology, paedodontics,
periodontics, orthodontics and endodontics. International Endodontic Journal, 18, 109-18.
 Attati I, Hammarstrom L. (1996a) Root surface defects in rat molar induced by 1-hydroxyethylidene-1,
1-bisphosphonate. Acta Odontologica Scandinavica, 54, 59-65.
 Attati I, Hellsing E, Hammarstrom L. (1996b) Orthodontically induced root resorption in rat molars after
1-hydroxyethylidene-1, 1-bisphosphonate injection. Acta Odontologica Scandinavica, 54, 102-8.
 Barbagallo LJ, Jones AS, Petocz P, et al. (2008) Physical properties of root cementum: Part 10.
Comparison of the effects of invisible removable thermoplastic appliances with light and heavy
orthodontic forces on premolar cementum. A microcomputed-tomography study. American Journal of
Orthodontics and Dentofacial Orthopedics, 133, 218-27.
References
 Baumrind S, Korn EL, Boyd RL. (1996) Apical root resorption in orthodontically treated adults.
American Journal of Orthodontics and Dentofacial Orthopedics, 110(3), 311-20.
 Beck BW, Harris EF. (1994) Apical root resorption in orthodontically treated subjects: analysis of
edgewise and light wire mechanics. American Journal of Orthodontics and Dentofacial Orthopedics,
105(4), 350-61.
 Bishara SE, Vonwald L, Jakobsen JR. (1999) Changes in root length from early to mid-adulthood:
resorption or apposition? American Journal of Orthodontics and Dentofacial Orthopedics, 115(5), 563-
8.
 Blake M, Woodside DG, Pharoah MJ. (1995) A radiographic comparison of apical root resorption after
orthodontic treatment with the edgewise and Speed appliances. American Journal of Orthodontics and
Dentofacial Orthopedics, 108, 76-84.
 Bollen A-M. (2002) Large overjet and longer teeth are associated with more root resorption when
treated orthodontically. Journal of Evidence Based Dental Practice, 2, 44-5.
 Boyd RL. (2007) Complex orthodontic treatment using a new protocol for the Invisalign appliance.
Journal of Clinical Orthodontics, 4, 525-47.
 Brezniak N, Wasserstein A. (1993) Root resorption after orthodontic treatment: Part 1. Literature
review. American Journal of Orthodontics and Dentofacial Orthopedics, 103, 62-6.
 Brezniak N, Wasserstein A. (2002a) Orthodontically induced inflammatory root resorption. Part 1: The
basic science aspects. Angle Orthodontist, 72, 175-9.
 Brezniak N, Wasserstein A. (2002b) Orthodontically induced inflammatory root resorption. Part II: The
clinical aspects. Angle Orthodontist, 72, 180-4.
 Brezniak N, Wasserstein A. (2008) Root resorption following treatment with aligners. Angle
Orthodontist, 78, 1119-24.
 Brin I, Tulloch JFC, Koroluk L, et al. (2003) External apical root resorption in Class II malocclusion: a
retrospective review of 1- versus 2-phase treatment. American Journal of Orthodontics and Dentofacial
Orthopedics, 124(2), 151-6.
 Brudvik P, Rygh P. (1994) Multi-nucleated cells remove the main hyalinized tissue and start resorption
of adjacent root surfaces. European Journal of Orthodontics, 16, 265-73.

13
References
 Casa MA, Faltin RM, Faltin K, et al. (2001) Root resorptions in upper first premolars after application of
continuous torque moment. Intra-individual study. Journal of Orofacial Orthopedics. 62(4), 285-95.
 Chan EKM, Darendeliler MA, Petocz P, et al. (2004a) A new method for volumetric measurement of
orthodontically induced root resorption craters. European Journal of Oral Science. 112(2), 134-9.
 Chan EKM, Darendeliler MA. (2004b) Exploring the third dimension in root resorption. Orthodontics &
Craniofacial Research, 7, 64-70.
 Chan E, Darendeliler MA. (2005) Physical properties of root cementum: Part 5. Volumetric analysis of
root resorption craters after application of light and heavy orthodontic forces. American Journal of
Orthodontics and Dentofacial Orthopedics, 127(2), 186-95.
 Chan E, Darendeliler MA. (2006) Physical properties of root cementum: part 7. Extent of root resorption
under areas of compression and tension. American Journal of Orthodontics and Dentofacial
Orthopedics, 129(4), 504-10.
 Christiansen RL. (1994) Commentary: Thyroxine administration and its effects on root resorption.
Angle Orthodontist, 64, 399-400.
 Copeland S, Green LJ. (1986) Root resorption in maxillary central incisors following active orthodontic
treatment. American Journal of Orthodontics and Dentofacial Orthopedics, 89(1), 51-5.
 Costopoulos G, Nanda R. (1996) An evaluation of root resorption incident to orthodontic intrusion.
American Journal of Orthodontics and Dentofacial Orthopedics, 109(5), 543-8.
 Counts Al, Widlak RA. (1993) Generalized idiopathic external root resorption. Journal of clinical
orthodontics, 27, 511-3.
 Darendeliler MA, Kharbanda OP, Chan EK, et al. (2004) Root resorption and its association with
alterations in physical properties, mineral contents and resorption craters in human premolars following
application of light and heavy controlled orthodontic forces. Orthodics & Craniofacial Research. 7(2),
79-97.
 Davidovitch Z, Godwin SL, Park YG, et al. (1996) The etiology of root resorption. In: Orthodontic
Treatment: The management of unfavorable sequelae. McNamara JA, Trotman CA, editors. University
of Michigan Press; Ann Arbor, MI, 93-117.
References
 Harris EF, Robinson QC, Woods MA. (1993) An analysis of causes of apical root resorption in patients
not treated orthodontically. Quintessence international, 24(6), 417-28.
 Harris EF, Kineret SE, Tolley EA. (1997) A heritable component for external apical root resorption in
patients treated orthodontically. American Journal of Orthodontics and Dentofacial Orthopedics,
111(3), 301-9.
 Harris DA, Jones AS, Darendeliler MA. (2006) Physical properties of root cementum: part 8. Volumetric
analysis of root resorption craters after application of controlled intrusive light and heavy orthodontic
forces: a microcomputed tomography scan study. American Journal of Orthodontics and Dentofacial
Orthopedics, 130, 639-47.
 Harry MR, Sims MR. (1982) Root resorption in bicuspid intrusion. A Scanning electron microscope
study. Angle Orthodontist, 52, 235-58.
 Hartsfield JK Jr, Everett ET, Al-Qawasmi RA. (2004) Genetic factors in external apical root resorption
and orthodontic treatment. Critical Reviews in Oral Biology Medicine, 15, 115-22.
 Horiuchi A, Hotokezaka H, Kobayashi K. (1998) Correlation between cortical plate proximity and apical
root resorption. American Journal of Orthodontics and Dentofacial Orthopedics, 114(3), 311-8.
 Igarashi K, Adachi H, Mitani H, et al. (1996) Inhibitory effect of topical administration of a
bisphosphonate (risedronate) on root resorption incident to orthodontic tooth movement in rats.
Journal of Dental Research 75, 1644-9.
 Janson GR, De Luca Canto G, Martins DR, et al. (1999) A radiographic comparison of apical root
resorption after orthodontic treatment with 3 different fixed appliance techniques. American Journal of
Orthodontics and Dentofacial Orthopedics, 118(3), 262-73.
 Jimenez-Pellegrin C, Arana-Chavez VE. (2004) Root resorption in human mandibular first premolars
after rotation as detected by scanning electron microscopy. American Journal of Orthodontics and
Dentofacial Orthopedics, 126(2), 178-84; discussion 184-5.
 Kaley J, Phillips C. (1991) Factors related to root resorption in edgewise practice. Angle Orthodontist,
61(2), 125-32.
 Kalkwarf KL, Krejci RF, Pao YC. (1986) Effect of apical root resorption on periodontal support. Journal of
Prosthetic Dentistry 56, 317-9.
References
 Levander E, Malmgren O. (2000) Long-term follow-up of maxillary incisors with severe root resorption.
European Journal of Orthodontics, 22, 85-92.
 Lew K. (1990) Intrusion and apical resorption of mandibular incisors in Begg treatment: anchorage
bend or curve? Australian Orthodontic Journal. 11(3), 164-8.
 Linge BO, Linge L. (1983) Apical root resorption in upper anterior teeth. European Journal of
Orthodontics. 5(3), 173-83.
 Linge L, Linge BO. (1991) Patient characteristics and treatment variables associated with apical root
resorption during orthodontic treatment. American Journal of Orthodontics and Dentofacial Orthopedics,
99, 35-43.
 Loberg EL, Engstrom C. (1994) Thyroid administration to reduce root resorption. Angle Orthodontist,
64, 395-9.
 Lupi JE, Handelman CS, Sadowsky C. (1996) Prevalence and severity of apical root resorption and
alveolar bone loss in orthodontically treated adults. American Journal of Orthodontics and Dentofacial
Orthopedics, 109(1), 28-37.
 Malmgren O, Goldson L, Hill C, et al. (1982) Root resorption after orthodontic treatment of traumatized
teeth. American Journal of Orthodontics and Dentofacial Orthopedics, 82, 487-91.
 Mandall N, Lowe C, Worthington H, et al. (2006) Which orthodontic archwire sequence? A randomized
clinical trial. European Journal of Orthodontics, 28, 561-6.
 Mavragnani M, Boe OE, Wisth PJ, et al. (2002) Changes in root length during orthodontic treatment:
advantages for immature teeth. European Journal of Orthodontic, 24, 91-7.
 McFadden WM, Engstrom C, Engstrom H, et al. (1989) A study of the relationship between incisor
intrusion and root shortening. American Journal of Orthodontics and Dentofacial Orthopedics, 96(5),
390-6.
 Mc Laughlin KD. (1964) Quantitative determination of root resorption during orthodontic treatment.
American Journal of Orthodonics and Dentofacial Orthopedics, 50, 143.
 McNab S, Battistutta D, Taverne A, et al. (1999) External apical root resorption of posterior teeth in
asthmatics after orthodontic treatment. American Journal of Orthodontics and Dentofacial Orthopedics,
116, 545-51.
References
 Dermaut LR, De Munck A. (1986) Apical root resorption of upper incisors caused by intrusive tooth
movement: a radiographic study. American Journal of Orthodontics and Dentofacial Orthopedics,
90(4), 321-6.
 DeShields RW. (1969) A study of root resorption in treated Class II, Division I malocclusions. Angle
Orthodontist, 39(4), 231-45.
 Drysdale C, Gibbs SL, Ford TR. (1996) Orthodontic management of root-filled teeth. British Journal of
Orthodontics, 23, 255-60.
 English H. (2001) External apical root resorption as a consequence of orthodontic treatment. Journal of
New Zealand Society of Periodontology. 86, 17-23.
 Faltin RM, Faltin K, Sander FG, et al. (2001) Ultrastructure of cementum and periodontal ligament
after continuous intrusion in humans: a transmission electron microscopy study. European Journal of
Orthodontics , 23(1), 35-49.
 Fox N. (2005) Longer orthodontic treatment may result in greater external apical root resorption.
Evidence Based Dentistry 6, 21.
 Fuss Z, Tsesis I, Lin S. (2003) Root resorption – diagnosis, classification and treatment choices based
on stimulation factors. Dental Traumatology, 19, 175-82.
 Goldie RS, King GJ. (1984) Root resorption and tooth movement in orthodontically treated, calcium-
deficient, and lactating rats. American Journal of Orthodontics and Dentofacial Orthopedics, 85, 424-
30.
 Goldson L, Henrikson CO. (1975) Root resorption during Begg treatment; a longitudinal roentgenologic
study. American Journal of Orthodontics and Dentofacial Orthopedics, 68(1), 55-66.
 Han G, Huang S, Von den Hoff, et al. (2005) Root resorption after orthodontic intrusion and extrusion:
an intraindividual study. Angle Orthodontist, 75, 912-8.
 Hamilton RS, Gutmann JL. (1999) Endodontic-orthodontic relationships: a review of integrated
treatment planning challenges. International Endodontic Journal, 32, 343-60.
 Harris EF, Baker WC. (1990) Loss of root length and crestal bone height before and during treatment in
adolescent and adult orthodontic patients. American Journal of Orthodontics and Dentofacial
Orthopedics, 98(5), 463-9.
References
 Katona TR. (2006) Flaws in root resorption assessment algorithms: Role of tooth shape. American
Journal of Orthodontics and Dentofacial Orthopedics, 130, 698.e19-e27.
 Kennedy D, Joondeph D, Osterberg S, et al. (1983) The effect of extraction and orthodontic treatment
on dentoalveolar support. American Journal of Orthodontics and Dentofacial Orthopedics, 84, 183-90.
 Ketcham AH. (1927) A preliminary report of an investigation of apical root resorption of vital
permanent teeth. International Journal of Orthodontics, 13, 97-127.
 Killiany DM. (1999) Root resorption caused by orthodontic treatment: an evidence-based review of
literature. Seminars in Orthodontics 5, 128-33.
 Killiany DM. (2002) Root resorption caused by orthodontic treatment: review of literature from 1998 to
2001 for evidence. Progress in Orthodontics, 3, 2-5.
 Kjaer I. (1995) Morphological characteristics of dentitions developing excessive root resorption during
orthodontic treatment. European Journal of Orthodontics 17, 25-34.
 Konoo T, Kim YJ, Gu GM, et al. (2001) Intermittent force in orthodontic tooth movement. Journal of
Dental Research, 80, 457-60.
 Kook Y-A, Park S, Sameshima GT. (2003) Peg-shaped and small lateral incisors not at higher risk for
root resorption. American Journal of Orthodontics and Dentofacial Orthopedics, 123, 253-8.
 Kurol J, Owman-Moll P. (1998) Hyalinization and root resorption during early orthodontic tooth
movement in adolescents. Angle Orthodontist, 68, 161-5.
 Lee RY, Artun J, Alonzo TA. (1999) Are dental anomalies risk factors for apical root resorption in
orthodontic patients? American Journal of Orthodontics and Dentofacial Orthopedics, 116(2), 187-95.
 Levander E, Malmgren O. (1988) Evaluation of the risk of root resorption during orthodontic treatment:
a study of upper incisors. European Journal of Orthodontics, 10, 30-8.
 Levander E, Malmgren O, Eliasson S. (1994) Evaluation of root resorption in relation to two orthodontic
treatment regimes. A clinical experimental study. European Journal of Orthodontics, 16, 223-8.
 Levander E, Malmgren O, Stenback K. (1998) Apical root resorption during orthodontic treatment of
patients with multiple aplasia: a study of maxillary incisors. European Journal of Orthodontics, 20,
427-34.
References
 McNab S, Battistutta D, Taverne A, et al. (2000) External apical root resorption following orthodontic
treatment. Angle Orthodontist, 70(3), 227-32.
 Midgett RJ, Shaye R, Fruge JF Jr. (1981) The effect of altered bone metabolism on orthodontic tooth
movement. American Journal of Orthodontics and Dentofacial Orthopedics, 80, 256-62.
 Mirabella AD, Artun J. (1995) Risk factors for apical root resorption of maxillary anterior teeth in adult
orthodontic patients. American Journal of Orthodontics and Dentofacial Orthopedics, 108(1), 48-55.
 Newman WG. (1975) Possible etiologic factors in external root resorption. American Journal of
Orthodontics and Dentofacial Orthopedics, 67, 522-39.
 Ngan DCS, Kharbanda OP, Byloff FK, et al. (2004) The genetic contribution to orthodontic root
resorption: a retrospective twin study. Australian Orthodontic Journal 20, 1-9.
 Otis L, Hong J, Tuncay O. (2004) Bone structure effect on root resorption. Orthodontics & Craniofacial
Research. 7(3), 165-77.
 Owman-Moll P, Kurol J, Lundgren D. (1995a) Continuous versus interrupted continuous orthodontic
force related to early tooth movement and root resorption. Angle Orthodontist, 65(6), 395-401;
discussion 401-2.
 Owman-Moll P, Kurol J, Lundgren D. (1995b) Repair of orthodontically induced root resorption. Angle
Orthodontist, 65(6), 403-8.
 Owman-Moll P, Kurol J, Lundgren D. (1996a) Effects of a doubled orthodontic force magnitude on tooth
movement and root resorptions. An intra-individual study in adolescents. European Journal of
Orthodontics. 18(3), 141-50.
 Owman-Moll P, Kurol J, Lundgren D. (1996b) The effects of a four-fold increased orthodontic force
magnitude on tooth movement and root resorptions. An intra-individual study in adolescents. European
Journal of Orthodontics. 18(3), 287-94.
 Owman-Moll P, Kurol J. (1998) The early reparative process of orthodontically induced root resorption
in adolescents – location and type of tissue. European Journal of Orthodontics, 20, 727-32.
 Parker RJ, Harris EF. (1998) Directions of orthodontic tooth movements associated with external apical
root resorption of the maxillary central incisor. American Journal of Orthodontics and Dentofacial
Orthopedics, 114(6), 672-83.
14
References
 Pandis N, Nasika M, Polychronopoulou A, et al. (2008) External apical root resorption in patients
treated with conventional and self-ligating brackets. American Journal of Orthodontics and Dentofacial
Orthopedics, 134(5), 646-51
 Pizzo G, Licata ME, Guiglia R, et al. (2007) Root resorption and orthodontic treatment. Review of the
literature. Minerva Stomatology. 56(1-2), 31-44.
 Poumpros E, Loberg E, Engstrom C. (1994) Thyroid function and root resorption. Angle Orthodontist,
64, 389-93.
 Proffit WR, Fields HW, Sarver,DM (2006) Contemporary Orthodontics: Fourth Edition. CV Mosby,
Missouri.
 Reitan K. (1974) Initial tissue behaviour during apical root resorption. Angle Orthodontist, 44, 68-82.
 Remington DN, Joondeph DR, Artun J, et al. (1989) Long-term evaluation of root resorption occurring
during orthodontic treatment. American Journal of Orthodontics and Dentofacial Orthopedics, 96 (1),
43-6.
 Reukers E, Sanderink g, Kuijpers-Jagtman AM, et al. (1998) Assessment of apical root resorption using
digital reconstruction. Dento-Maxillo-Facial Radiology, 27, 25-9.
 Rivera EM, Walton RE. (1994) Extensive idiopathic apical root resorption. A case report. Oral Surgery
Oral Medicine Oral Pathology Oral Radiology Endodontics 78, 673-7.
 Rygh P, Reitan K. (1972) Ultrastructural changes in the periodontal ligament incident to orthodontic
tooth movement. Trans European Orthodontic Society, 393-405.
 Sameshima GT, Sinclair PM. (2001a) Predicting and preventing root resorption: Part I. Diagnostic
factors. American Journal of Orthodontics and Dentofacial Orthopedics, 119(5), 505-10.
 Sameshima GT, Sinclair PM. (2001b) Predicting and preventing root resorption: Part II. Treatment
factors. American Journal of Orthodontics and Dentofacial Orthopedics, 119(5), 511-5.
 Sameshima GT, Sinclair PM. (2004) Characteristics of patients with severe root resorption.
Orthodontics & Craniofacial Research. 7(2), 108-14.
 Schwartz AM. (1932) Tissue changes incidental to tooth movement. International Journal of
Orthodontics 96, 331-52.
References
 Villa PA, Oberti G, Moncada CA, et al. (2005) Pulp-dentine complex changes and root resorption during
intrusive orthodontic tooth movement in patients prescribed nabumetone. Journal of Endodontics.
31(1), 61-6.
 Walker SL, Tieu LD, Flores-Mir C. (2013) Radiographic comparison of the extent of orthodontically
induced external apical root resorption in vital and root-filled teeth: a systematic review. European
Journal of Orthodontics. 35(6):796-802. Review.
 Weiland F. (2003) Constant versus dissipating forces in orthodontics: the effect on initial tooth
movement and root resorption. European Journal of Orthodontics. 25(4), 335-42.
 Weltman BJ, Vig KWL, Fields HW, et al. (2010) American Journal of Orthodontics and Dentofacial
Orthopedics. 137 (4) 462-76.
 Wheeler: In Press
 Wickwire NA, Mc Neil MH, Norton LA, et al. (1974) The effects of tooth movement upon endodontically
treated teeth. Angle Orthodontist, 44, 235-42.
 Wu FL, Wang LY, Huang YQ, Guo WB, Liu CD, Li SG. (2013) Interleukin-1β +3954 polymorphisms and
risk of external apical root resorption in orthodontic treatment: a meta-analysis. Genet Mol Res. Oct
18;12(4):4678-86
 Lombardo L, Bragazzi R, Perissinotto C, Mirabella D, Siciliani G. Cone-beam computed tomography
evaluation of periodontal and bone support loss in extraction cases. Prog Orthod. 2013 Sep 11;14:29.
 Krieger E, Drechsler T, Schmidtmann I, Jacobs C, Haag S, Wehrbein H. Apical root resorption during
orthodontic treatment with aligners? A retrospective radiometric study. Head Face Med. 2013 Aug
14;9:21.
 Krasny M, Zadurska M, Cessak G, Fiedor P. Analysis of effect of non-steroidal anti-inflammatory drugs
on teeth and oral tissues during orthodontic treatment. Report based on literature review. Acta Pol
Pharm. 2013 May-Jun;70(3):573-7. Review
 Hodges RJ, Atchison KA, White SC. Impact of cone-beam computed tomography on orthodontic
diagnosis and treatment planning. Am J Orthod Dentofacial Orthop. 2013 May;143(5):665-74
References
 El-Bialy T1, El-Shamy I, Graber TM. (2004) Repair of orthodontically induced root resorption by
ultrasound in humans. Am J Orthod Dentofacial Orthop. Aug;126(2):186-93.
 Mah J1, Prasad N. Dentine phosphoproteins in gingival crevicular fluid during root resorption.
Eur J Orthod. 2004 Feb;26(1):25-30.
 Sha H1, Bai Y2, Li S3, Wang X4, Yin Y5 (2014) Comparison between electrochemical ELISA and
spectrophotometric ELISA for the detection of dentine sialophosphoprotein for root
resorption. Am J Orthod Dentofacial Orthop. 2014 Jan;145(1):36-40.
 Sehr K, Bock NC, Serbesis C, Hönemann M, Ruf S. Severe external apical root resorption--local cause
or genetic predisposition? J Orofac Orthop. 2011 Aug;72(4):321-31
 Silva MA, Wolf U, Heinicke F, Bumann A, Visser H, Hirsch E. Cone-beam computed tomography for
routine orthodontic treatment planning: a radiation dose evaluation. Am J Orthod Dentofacial Orthop.
2008 May;133(5):640.e1-5.
References
 Scott P, DiBiase AT, Sherriff M, et al. (2008) Alignment efficiency of Damon3 self-ligating and
conventional orthodontic bracket systems: A randomized clinical trial. American Journal of Orthodontics
and Dentofacial Orthopedics, 134, 470.e1-e8.
 Segal G, Schiffman P, Tuncay O. (2004) Meta analysis of the treatment-related factors of external
apical root resorption. Orthodontics & Craniofacial Research. 7(2), 71-8.
 Shirazi M, Dehpour AR, Jefari F. (1999) The effect of thyroid hormone on orthodontic tooth movement
in rats. Journal of Clinical Pediatric Dentistry 23, 259-64.
 Smale I, Artun J, Behbehani F, et al. (2005) Apical root resorption 6 months after initiation of fixed
orthodontic appliance therapy. American Journal of Orthodontics and Dentofacial Orthopedics, 128,
57-67.
 Snelgrove RA. (1995) Generalized idiopathic apical root resorption as an incidental finding in an
adolescent: A case history. Dental Update, 22, 276-8.
 Spurrier SW, Hall SH, Joondeph DR, (1990). A comparison of apical root resorption during orthodontic
treatment in endodontically treated and vital teeth. American Journal of Orthodontics and Dentofacial
Orthopedics, 97(2), 130-4.
 Stevnik A, Mjor IA. (1970) Pulp and dentine reactions to experimental tooth intrusion. A histological
study of the initial changes. American Journal of Orthodontics and Dentofacial Orthopedics, 57, 370-85.
 Taithongchai R, Sookkorn K, Killiany Dm. (1996) Facial and dentoalveolar structure ad the prediction of
apical root shortening. American Journal of Orthodontics and Dentofacial Orthopedics, 110, 311-20.
 Taner T, Ciger S, Sencift Y. (1999) Evauation of apical root resorption following extraction therapy in
subjects with class I amd class II maloclussions. European Journal of Orthdontics, 21, 491-6.
 TenHoeve A, Mulie Rm. (1976) The effects of antero-postero incisor repositioning on the palatal cortex
as studied with laminagraphy. Journal of Clinical Orthodontics, 10, 804-22.
 Thongudomporn U, Freer TJ. (1998) Anomalous dental morphology and root resorption during
orthodontic treatment: a pilot study. Australian Orthodontic Journal. 15(3), 162-7.
 Trope M. (1998) Root resorption of dental traumatic origin: classification based on etiology. Practical
Periodonics and Aesthehetict Dentistry, 10, 515-22.
References
 Castro IO, Alencar AH, Valladares-Neto J, Estrela C. Apical root resorption due to orthodontic treatment
detected by cone beam computed tomography. Angle Orthod. 2013 Mar;83(2):196-203
 Ponder SN, Benavides E, Kapila S, Hatch NE. Quantification of external root resorption by low- vs high-
resolution cone-beam computed tomography and periapical radiography: A volumetric and linear
analysis. Am J Orthod Dentofacial Orthop. 2013 Jan;143(1):77-91
 Picanço GV, de Freitas KM, Cançado RH, Valarelli FP, Picanço PR, Feijão CP. Predisposing factors to
severe external root resorption associated to orthodontic treatment. Dental Press J Orthod. 2013 Jan-
Feb;18(1):110-20
 Makedonas D1, Lund H, Hansen K (2013) Root resorption diagnosed with cone beam computed
tomography after 6 months and at the end of orthodontic treatment with fixed appliances. Angle
Orthod. May;83(3):389-93.
 Wang Q1, Chen W, Smales RJ, Peng H, Hu X, Yin L. Apical root resorption in maxillary incisors
when employing micro-implant and J-hook headgear anchorage: a 4-month radiographic
study. J Huazhong Univ Sci Technolog Med Sci. 2012 Oct;32(5):767-73.
 Lund H, Gröndahl K, Hansen K, Gröndahl HG. Apical root resorption during orthodontic treatment. A
prospective study using cone beam CT. Angle Orthod. 2012 May;82(3):480-7.
 ELlamas-Carreras JM1, Amarilla A, Espinar-Escalona E, Castellanos-Cosano L, Martín-González J,
Sánchez-Domínguez B, López-Frías FJ.External apical root resorption in maxillary root-filled
incisors after orthodontic treatment: a split-mouth design study. Med Oral Patol Oral Cir Bucal.
2012 May 1;17(3):e523-7.
 Leite V1, Conti AC, Navarro R, Almeida M, Oltramari-Navarro P, Almeida R. (2012) Comparison of
root resorption between self-ligating and conventional preadjusted brackets using cone
beam computed tomography. Angle Orthod. 2012 Nov;82(6):1078-82.
 Dula K, Bornstein MM, Buser D, et. al. (2014)SADMFR guidelines for the use of Cone-Beam Computed
Tomography/ Digital Volume Tomography. Swiss Dent J. 2014;124(11):1169-83
 American Academy of Oral and Maxillofacial Radiology. (2013) Clinical recommendations regarding
use of cone beam computed tomography in orthodontics. [corrected]. Position statement by
the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral
Radiol. 2013 Aug;116(2):238-57.
15