A comparison of apical root resorption during

orthodontic treatment in endodontically treated and

vital teeth
Steven W. Spurrier, DDS, MSD, Stanton H. Hall, DDS, MS, PhD,*
Donald R. Joondeph, DDS, MS,** Peter A. Shapiro, DDS, MSD, and
Richard A. Riedel, DDS, MSD***
Seattle, Wash.

The purpose of this study was to determine whether vital and endodontically treated incisors exhibit
a similar severity of apical root resorption in response to orthodontic treatment. Forty-three patients
who had one or more endodontically treated incisors before orthodontic treatment and who exhibited
signs of apical root resorption after treatment were studied. In each patient the vital contralateral
incisor served as a control. Vital incisors resorbed to a significantly greater degree than
endodontically treated incisors (p -< 0.05). When patients were separated by gender, control teeth in
males exhibited a statistically significant increase in resorption over control teeth in females. No
significant differences were apparent between males and females when endodontically treated
incisors were compared. (AM J ORTHOD DENTOFACORTHOP 1990;97:130-4.)

O n e of the most common complications as-
sociated with orthodontic treatment is the phenomenon
known as apical root resorption. Numerous investiga-
tors have studied the relationship between apical root
resorption and orthodontic movement in vital teeth. ,.29
Notwithstanding this concentrated effort, neither the
cause nor the prognosis of apically resorbing teeth is
fully understood. The general consensus is that apical
root resorption of vital teeth occurs to some degree in
nearly all orthodontic patients.
There is inconclusive evidence regarding the fre-
quency or extent of apical root resorption in endo-
dontically treated teeth that are subject to orthodontic
forces. Even though endodontically treated teeth re-
spond to orthodontic forces in a manner similar to that
of normal teeth, many orthodontists consider them to
be more susceptible to apical root resorption. Wickwire
et al. 3° reported that although endodontically treated
teeth moved as readily as vital teeth, the endodontically
treated teeth exhibited a greater frequency of root re-
sorption than their vital controls. Conversely, other
From the School of Dentistry, University of Washington.
This article is based on research submitted by the senior author in partial
fulfillment of the requirements for the degree of Master of Science in Dentistry.
This research was supported in part by the Orthodontic Memorial Fund.
*Associate Professor, Department of Orthodontics.
**Professor and Chairman, Department of Orthodontics.
***Professor Emeritus, Department of Orthodontics.
811110459
130
authors 3j'32 have reported no significant differences in
the amount of root resorption. Although Mattison
et al. 33 and Chivian 25 have proposed root canal therapy
for the arrest of resorption occurring either internally
or externally, neither of these studies looked specifically
at the question of root resorption during orthodontic
therapy.
In view of the conflicting reports in the literature,
the susceptibility of endodontically treated teeth to ap-
ical root resorption remains a controversial subject. The
purpose of this study was to determine whether vital
and endodontically treated incisors exhibit a similar
severity of apical root resorption in response to orth-
odontic treatment.
MATERIALS AND METHODS
Sample
The subjects for this study were 43 patients (21
males and 22 females), who had one or more anterior
teeth treated endodontically before orthodontic therapy.
The sample was selected after a review of more than
12,000 patient records from five separate private orth-
odontic practices. The patients included in this study
had completed multiband/bracket orthodontic therapy,
with duration of active treatment exceeding 1 year. In
order that a comparison of the amount and severity of
root resorption could be made, each patient selected
had some degree of resorption evident by the end of
active treatment. All endodontic therapy had been com-
Voh,me97
Number 2 Apical resorption during treatment in endodontically treated and vital teeth
Fig. 1. Example of typical resorptive pattern.
pleted before band placement. The contralateral incisors
had never had invasive pulp therapy, although the extent
to which either tooth may have been traumatized was
not known. Teeth with fractured or otherwise mutilated
roots were not included in the study. In all cases ra-
diographs were of good quality, showing the entire
inciso-apical length of measured teeth with the apex
clearly defined. Of the 43 patients selected, 72% (31)
had Class II (22 Division 1, 9 Division 2) and 28%
(12) had Class I occlusions.
Materials
For each of the 43 patients, periapical radiographs
of the endodontically treated and contralateral vital
teeth, taken both before and after orthodontic treatment,
were used (Fig. 1). The integrity of the incisal edges
of the measured incisors was ensured by examination
of pretreatment and posttreatment study casts. All mea-
surements were made with the use of a Kodak slide
projector and a transparent metric ruler.
Methods
Radiographs were measured at a magnification of
10X as described by Kokich and Artun. 34 Radiographs
were projected through a Kodak slide projector and
adjusted to produce a magnification of 10X. This was
accomplished by projection of an image of known di-
mension and adjustment of the projector until the proper
magnification was achieved. A transparent metric ruler
was used to measure the projected radiographic images
131
Table I. Age of patients and duration of
orthodontic treatment
I Mean(yr-mo) I Range(yr-mo)
Age
Pretreatment 13-11 8-11 to 26-0
Posttreatment 16-0 l 1-3 to 28-5
Duration 2-1 l-0 to 3-6
to the nearest 1.0 mm (equivalent to 0.1 mm on the
radiograph).
Radiographs were standardized by measurement of
the greatest distance from incisal edge to cemento-
enamel junction on each patient's pretreatment and
posttreatment radiographs. These two values were com-
pared in each patient. Differences were calculated as a
foreshortening/elongation factor when incisoapical
tooth length was measured. This method allowed for
intrapatient standardization. Pretreatment and posttreat-
ment orthodontic study casts were examined to ensure
incisal integrity throughout the active treatment period.
Patients with obvious incisal-edge changes were ex-
cluded from the study.
Measurements were made of the greatest inciso-
apical dimension on each endodontically treated incisor
and its contralateral control. Measurements were made
and recorded from radiographs taken both before and
after orthodontic treatment. From these values, tables
132 Spurrier et al. Am. J. Orthod.Dentofac.Orthop.
February1990

Table !1. Comparative results

Mean SD SE I pvalue I Significance
Endo T~T2 vs Control T~T2* (mm) -0.77 ! .75 0.27 0.006 S
Endo T~T2 vs Control TtT2* (%) -2.74 6.31 0.96 0.007 S
Endo TI to T2 (mm) 1.28 1.09 0.17 0.003 S
Control T t to T2 (mm) 2.05 1.49 0.23 0.0008 S
Endo T~ to "1"2(%) 5.14 3.88 0.59 0.008 S
Control T~ to Tz (%) 7.88 5.71 0.87 0.0009 S
Separated by gender
Endo T~ to T: (nun) 0.16 0.54 0.11 0.624 NS
Control T~ to "1"2(mm) I. 13 0.72 0.16 0.011 St
Endo T t to "1"2(%) 0.43 1.29 0.26 0.720 NS
Control T t to T2 (%) 4.08 2.85 0.64 0.017 St

Pretreatment-Tt.
Posttreatment-T,.
*Indicates greater change.
iMales exhibited greater change.

were constructed for both millimetric amounts of re-
sorption and percentage of root loss.
Analysis of data
For all data collected, the mean value, standard
deviation, and range were calculated. To determine sta-
tistical significance across time, the Student t test for
paired data was used. Statistical significance was de-
fined as p --< 0.05.
Error analysis
Ten randomly selected patient radiographs were
measured on three separate occasions at 1-week inter-
vals to determine intrarater reliability. Variance from
original measurements ranged from 0.00 mm to 0.35
mm. The mean error was 0.32 mm for the measurement
of the endodontically treated teeth and 0.18 mm for the
control measurement.
RESULTS
Age and treatment time
The mean pretreatment age for patients in this study
was 13 years 11 months. The mean posttreatment age
was 16 years 0 months. Average treatment time was 2
years I month (Table I).
Comparison of total sample
The mean, standard deviation, and statistical sig-
nificance of the total sample are listed in Table II. A
statistically significant difference was observed in the
millimetric apical resorption of the endodontically
treated teeth as compared to the vital controls. A greater
degree of root shortening occurred in the control teeth
(mean difference, - 0 . 7 7 mm). Statistically significant
differences also were noted in the percentages of apical
root resorption when endodontically treated teeth and
vital controls were compared. The patients' control
teeth again were found to exhibit the greatest mean
amount of resorption (mean difference, 2.74%) (Ta-
ble II).
Twenty-nine (67%) of the forty-three patients ex-
hibited greater resorption of their control teeth than their
endodontically treated antimeres. In fourteen patients
(33%) the endodontically treated teeth resorbed to a
greater extent (Table III).
Both the endodontically treated teeth and the vital
control teeth showed statistically significant levels of
apical root resorption. This was true for both millimetric
and percentage changes. The actual amounts of resorp-
tion and the levels of significance did vary, however
(Table II).
Comparison of sample by gender
When the sample was subdivided by gender, no
significant difference in the amount of resorption of the
endodontically treated teeth was evident. Male patients
exhibited a greater degree of change in the control teeth
(p -< 0.02).
DISCUSSION
This study found a statistically greater degree and
frequency of mean apical root resorption in the vital
control incisors when these teeth were compared with
the contralateral endodontically treated incisors. This
was true of both millimetric and percentage changes.
Studies by Weiss 3z and Mattison 3~ reported no signifi-
cant difference in the amount of root resorption between
vital and nonvital teeth when both were subjected to
Volume97 Apical resorption during treatment in endodontically treated and vital teeth 133
Number2

T a b l e III. Millimeters o f root resorption was determined in the present study, it is the clinical
I Endodontically Control significance that is the most critical. Root resorption is
Patient treated (vital) a clinical problem, and it is the clinical ramification o f
this problem that is the most important to the everyday
1 0.5* 0.3 practice o f orthodontics. A mean difference o f 0.77
2 1.4 3.3*
3 1.1 1.5' m m is virtually undetectable at the clinical level. Be-
4 0.5* 0.0 cause o f this, a major finding of this study was the
5 0.7* 0.4 absence o f major differences between vital and endo-
6 2.3 6.2* dontically treated incisors. With this knowledge, both
7 1.0 2.8* vital and nonvital incisors can be treated with the same
8 0.4 0.9*
9 0.0 3.3* level o f confidence. However, in those patients who
I0 0.1 2.4" experience extreme levels of apical root resorption, the
11 1.7" 1.0 endodontically treated incisor Can be expected to main-
12 0.4 1.7" tain a greater degree of original root length.
13 0.8 5.1" When separated by gender, control teeth exhibited
14 1.9" 1.0
15 3.4* 1.4 a statistically significant difference. Male patients were
16 0.6 0.7* found to have experienced the greatest mean amount
17 0.4 1.4* o f resorption. Phillips 2~ found no difference in severity
18 1.5 2.7* o f resorption between male and female patients. New-
19 1.5* 0.4 man, 2' however, found female patients to be more sus-
20 0.2 0.4*
21 0.5 2.5* ceptible. It is o f interest that when endodontically
22 0.3* 0.1 treated incisors are compared, no statistical differences
23 0.7 3.5* are apparent between male and female patients. The
24 1.6 2.2* role of the dental pulp cannot be ignored when these
25 2.5* 1.7 results are considered.
26 3.6* 2.0
27 1.6 1.7" The results o f this study indicate that there is very
28 1.2 1.8" little clinical difference in the amount or severity o f
29 1.0 5.4* apical root resorption between vital and nonvital teeth.
30 0.6 4.2* These findings in conjunction with earlier studies, sug-
31 0.2 1.1" gest that endodontically treated incisors are of no
32 0.5 1.8"
33 0.8 5.9* greater liability to the orthodontist than are vital teeth.
34 1.2 3.0* On a statistical level, however, endodontically treated
35 2.9* 2.7 incisors proved to be at decreased risk for apical root
36 2.0 3.2* resorption.
37 0.1 0.3*
38 1.4" 0.3 CONCLUSIONS
39 5.4* 2.0
40 1.2 1.3" 1. Endodontically treated incisors resorb with less
41 2.8* 2.2 frequency and severity than vital control teeth.
42 1.5 2.1" 2. No significant difference in root resorption be-
43 1.2 1.4* tween male and female patients was detected in en-
*Indicates greatest change. dodontically treated incisors.
3. Control teeth exhibited significantly more re-
sorption in male patients than in female patents.
4. Even though statistical significance was noted,
othodontic forces. However, Mattison's was an animal clinical differences are minimal when endodontically
study carried out over a 4-month treatment period. This treated and vital incisors are compared.
may have been too brief a time for significant differ-
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Reprint requests to:
Dr. Stanton H. Hall
Department of Orthodontics-SM46
University of Washington School of Dentistry-
Seattle, WA 98195