Root resorption associated with orthodontic tooth movement: A systematic review

Belinda Weltman, Katherine W. L. Vig, Henry W. Fields, Shiva Shanker, and Eloise E. Kaizar
AJODO 2010

Introduction
- Root resorption (RR) is undesirable and can affect the long-term viability of teeth
- Although RR is multifactorial, many dentists blame the orthodontist when it occurs during
orthodontic treatment
- Histologic studies report >90% occurrence of root resorption in orthodontically treated
teeth. Radiographic studies report 73%.
- Most cases of resorption are minimal and clinically insignificant. Significant but <2.5 mm
external apical root resorption (EARR) was reported at 6-13%. Severe (> 4 mm) occurs in
1-5% of teeth.
- Maxillary incisors consistently report more RR followed by mandibular incisors and first
molars
- Orthodontic treatment-related factors include: Treatment duration, force magnitude &
application, direction of movement, apical displacement, type of appliance, and treatment
technique.
- Patient-related factors include: Previous history of RR, tooth-root morphology & length,
genetic influences, systemic factors/diseases, drugs (nabumetone), trauma, endodontic
treatment, patient age and sex
- This article aimed to report the relation of EARR with fixed orthodontic appliances

Materials and Methods

- Population: Patients with no history of RR
- Intervention: Comprehensive orthodontics
- Comparison: Untreated people
- Outcome: EARR
- Null hypothesis: There is no difference in incidence and severity of RR between treated
patients with no history of RR and untreated patients. Also, there is no difference in patients
with no history of RR between different treatment techniques.
- 2 reviewers searched a ton of databases
- Quality assessed by: Method of randomization, allocation concealment, blinding, and
completeness of follow-up

Results
- 921 citations  144 full articles  13 articles (11 trials) fulfilled inclusion
- Different methodologies and reporting prevented quantitative synthesis

Methodologic Quality
- Method of randomization: 10/11 adequate
- Allocation Concealment: 4/11 adequate
- Blinding: only 5 trials reported
- Reporting and analysis of withdrawals/dropouts: 11/11 adequate
- Bias: 5 low, 5 moderate, 1 high
Discontinuous vs continuous force
- Continuous force produced significantly more RR
- Reliability: Low, Bias: High

Removable thermoplastic vs fixed light and heavy force

- Heavy force: 9x more RR than control and significantly more than light or thermoplastic
forces
- Light force: 5x more, Thermoplastic: 6x more than control
- Bias: Moderate

Light vs Heavy continuous force

- 4 studies: 3 buccal tipping, 1 intrusive
- Light force: Greater resorption than control (sometimes significant, sometimes not)
- Heavy forces: Significantly more resorption than light force (11.6x more than control)
- Resorption after intrusion was directly proportional to the magnitude of force
- Bias: Moderate

Intrusive vs Extrusive
- Extrusive: Insignificant
- Intrusive: Significantly increased resorption
- Bias: Low

AW Sequence
- No difference between archwire sequences
- Bias: Low

Effect of treatment pause in patients experiencing OIIRR

- RR significantly less in patients treated with a pause than those continuing without pause
- No significant correlations between RR and Angle classification, trauma, extraction
treatment, time with rectangular Aws, time with Class II elastics, or total treatment time
- Bias: Moderate

Straight wire vs Standard Edgewise

- No difference
- Bias: Low

Trauma
- 3 studies on OIRR
- No differences: Patients with trauma had similar prevalence of RR compared to control
- Bias: 2 Low, 1 Moderate

Teeth with Unusual Morphology

- Not significantly more likely to have moderate-severe OIIRR
- Bias: Low

2 Phase vs 1 Phase Class II Treatment

 - 2 phase: Bionator followed by fixed appliances had fewer incisors with moderate-severe
OIIRR but was insignificant
- Odds of tooth experiencing severe RR were greater with large reduction in overjet during
phase 2
- Bias: Low

Self-ligating vs Conventional
- No difference
- Bias: Low

Discussion
- No systematic protocol in measurement or reporting data
- No RCTs representing 24 months of comprehensive orthodontic care
o Split-mouth RCTs included were no longer than 9 weeks and focused on premolars
- Quantitative 3D volumetric evaluation of RR craters is probably the best measurement

- Useful conclusions:
- Orthodontically moved teeth have significantly more RR than control teeth
- Heavy forces produced more RR than light forces (** most reliable conclusion)
o More rapid lacuna development
o Tissue repair compromised
- Limited evidence that continuous force produces significantly more RR
o Perhaps because a pause in force allows cementum to heal
- Limited evidence: Both light forces and forces from thermoplastic appliances result in
similar RR
- Intrusive forces result in significantly increased RR
o Concentrated pressure at tooth apex
o Similar to lingual root torque
- Signs or reports of incisor trauma had similar prevalence of moderate-severe RR as those
without trauma
- Advise your patients about the risk
o Less Crown:Root  less suitable for abutments/anchorage
o 3 mm apical root loss = 1 mm of crestal bone loss; periodontitis will progress more
rapidly if it involves teeth with RR
o RR ceases after active treatment
- Extensive RR does not usually compromise the longevity of teeth
o Average size/shape maxillary central with no bone loss can have its root shortened
by 5 mm and still have 75% of its periodontal attachment remaining
o Tooth loss by apical shortening has not been reported in the literature
o Tooth loss and hypermobility 14 years after orthodontic treatment was rare

Implications for Clinical Practice

- Best practice: Light forces (particularly for intrusion)
- Progress radiographs 6-12 months might detect RR
- Patients in whom RR has been identified, treat with a 2-3 month pause to decrease RR
- With severe resorption: Reassess with treatment plan with the patient
- If resorption continues after treatment, consider RCT with calcium hydroxide
- Caution when retaining teeth via fixed appliances because occlusal trauma might lead to
RR