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External apical root resorption among the Saudi population: a prospective

radiographic study of maxillary and mandibular incisors during orthodontic
treatment.

Article · February 2020

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JOURNAL OF BIOLOGICAL REGULATORS & HOMEOSTATIC AGENTS Vol. 34, no. 1, xx-xx (2020)

EXTERNAL APICAL ROOT RESORPTION AMONG THE SAUDI POPULATION:

A PROSPECTIVE RADIOGRAPHIC STUDY OF MAXILLARY AND MANDIBULAR
INCISORS DURING ORTHODONTIC TREATMENT

I. AL SHAHRANI1, M. AJMAL2, T. ALAM2, M. LUQMAN2, M. A. KAMRAN1

and H. AL MOHIY3

Department of Paediatric Dentistry and Orthodontic Sciences, King Khalid University College

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1

of Dentistry, Abha, Saudi Arabia; 2Department of Diagnostic Sciences, King Khalid University

College of Dentistry, Abha, Saudi Arabia; 3Department of Radiologic Sciences, King Khalid
University College of Dentistry, Abha, Saudi Arabia

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Received December 28, 2019 – Accepted February 6, 2020
To the Editor, paralleling technique is the most preferred because it
Resorption of roots is an inevitable and relatively has the most favorable benefit to risk ratio in detecting

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common side effect of orthodontic tooth movement. the degree of apical root material loss. It provides the
The term ‘orthodontically-induced inflammatory root most appropriate information with the least irradiation
resorption’ (OIIRR) is mainly used in orthodontics to when used for teeth that are most likely to exhibit

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differentiate from other causes of root resorption in blunting of roots: maxillary and mandibular incisors.
permanent teeth (1). External apical root resorption Also, distortion and superimposition errors are less
(EARR) is an undesirable sequel that can significantly as compared to the OPG or the lateral head film.

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compromise the success of orthodontic treatment. Therefore, the purpose of this study was to measure
It is usually common in the apical region because the amount of EARR of maxillary and mandibular
of the concentration of orthodontic forces and an incisor teeth and to evaluate its clinical significance
increased accumulation of stress at the root apex during 9 months of active orthodontic treatment.
(2). It is believed to occur as a response to altered
alignment of periodontal fibers at the apical end due MATERIALS AND METHODS
to the presence of cellular cementum at the apex
(with patent vasculature), rendering the periapical The study was conducted in the Department of
cementum more friable and susceptible to trauma and Orthodontics and Dentofacial Orthopaedics, King
concomitant vascular stasis (3, 4). Although clinically Khalid University, Abha, Saudi Arabia (SRC/
inconsequential, a relatively small percentage of ETH/2018-19/024). The study sample consisted of
patients express EARR severe enough to cause a total of 320 teeth from 40 patients, recruited by
undesirable and irreversible damage to the roots (5). convenience sampling, and divided into two groups
Orthopantomogram (OPG) and periapical views are with mean age 15.6 (range: 14-18) years. The
the most widely used diagnostic technique. A two- patients undergoing treatment in the Department of
dimensional image underrates the actual amount Orthodontics were randomly selected and only those
of root resorption as compared to computerized cases of Angle Class I malocclusion with upper
tomography (6). Despite limitations, the periapical and lower anterior crowding were divided into two

Corresponding Author: 0393-974X (2020)

Dr Ibrahim Al Shahrani, Copyright © by BIOLIFE, s.a.s.
Department of Paediatric Dentistry and Orthodontic Sciences,  This publication and/or article is for individual use only and may not be further
reproduced without written permission from the copyright holder.
King Khalid University College of Dentistry, Unauthorized reproduction may result in financial and other penalties
Abha, Saudi Arabia
e-mail: resperioprof@gmail.com
265 DISCLOSURE: ALL AUTHORS REPORT NO CONFLICTS OF
INTEREST RELEVANT TO THIS ARTICLE.
266 I. AL SHAHRANI ET AL.

groups: Group 1 (n=20) extraction cases, and Group was 0.013” Nickel-Titanium followed by 0.014 Ni-
2 (n=20) non-extraction cases. All patients’ parents Ti, 0.018 Ni-Ti, and 0.016x 0.022 Ni-Ti wires. All
or guardians were required to sign informed consent. the cases were treated by the same clinician to avoid
Cases with a previous history of orthodontic or inter-personnel errors.
endodontic treatment involving incisors, cases with Periapical radiographs of both maxillary and
bimaxillary protrusion, impacted maxillary canines, mandibular incisors (right and left central and lateral
traumatic injuries, crown or root fractures, genetic incisors) were obtained at the following time-points:
or developmental anomalies of teeth, severely at the beginning of treatment (T0), 3 months (T1), 6

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dilacerated roots, congenitally missing laterals, months (T2), and 9 months (T3) after the treatment,
incomplete root formation at the start of treatment, by using Dentsply Rinn XCP paralleling devices.
maxillary incisors with caries and/or periodontal Single rooted teeth were selected to avoid errors
disease and patients with systemic disorders, with multiple roots and differential resorption.

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hormonal imbalance were duly excluded from the Radiographic examination was conducted carefully
study. to ensure good quality images for interpretation
All the patients were treated with pre-coated and determination of root length. Radiographs were
bracket pre-adjusted appliances (Roth brackets) with analyzed by two observers using CS Imaging software

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0.022″ bracket slots and edgewise mechanics were 7.0.3 under 100% magnifications on an LCD monitor.
used during the treatment. The archwire used initially EARR was measured and calculated in the following
manner. Mesial and distal edge points (a, b, c, d, e, and
f) were identified and marked at the region of incisal

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edge, cementoenamel junction and apical foramen
respectively on both the pre-treatment and post-
treatment periapical radiographs. Horizontal lines (a-

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b, c-d, and e-f) were drawn to connect the edge points
and the central point on these lines were connected
vertically. The distance between the horizontal lines
(a-b and c-d) was measured as “crown height” (A)
and the distance between the horizontal lines (c-d and
e-f) was measured as the “root length” (B) (Fig. 1).
In the present study, the “root length” of each
tooth was used to measure apical root resorption in
millimeters (mm) using CS imaging software to a
precision of 0.1 mm. The crown length (unaffected
by EARR) was used as a reference to correct potential
differences in geometric projection in subsequent
radiographs. The averages of the pre-treatment and
post-treatment crown lengths were computed by the
following formula:
Cx = (C1+C2)/2, where Cx= average crown
length, C1= pre-treatment crown length and C2=
post-treatment crown length.
Fig. 1. Mesial and distal edge points a) Mesial incisal Following the calculation of the average crown
edge point; b) distal incisal edge point; c) mesial
length, the following formula was used to adjust the
cementoenamel junction point; d) distal cementoenamel
junction point; e) mesial edge point of the apical foramen; pre-treatment and post-treatment root lengths:
f) distal edge point of the apical foramen; A) crown R1 (adjusted) = R1 x (Cx/C1) where R1= Average
height; B) root length; C) (A+B) total tooth length. root length.
Fig. 1. Mesial and distal edge points a) Mesial incisal edge point; b) distal
mesial cementoenamel junction point; d) distal cementoenamel junction p
 Journal of Biological Regulators & Homeostatic Agents
267

The resultant difference between the second 20) and mixed-method ANOVA was used to analyze the
(post-treatment) and first (pre-treatment) root length data, and an interclass correlation coefficient analysis
measurements were quantified as EARR. Root was carried out to assess the inter-examiner reliability.
length assessment was carried out for a total of 320 The independent variable in this analysis was time and
radiographs by 2 examiners. dependent variable was the treatment (non-extraction
and extraction) and its influence on root resorption.
Statistical analysis Mauchly’s sphericity test was performed to validate the
Data were analyzed using SPSS software (VERSION repeated measures analysis of variance.

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Table I. Mean rootTable
length of maxillary
I. Mean and
root length mandibular
of maxillary incisors atincisors
and mandibular different time intervals.
at different time intervals.
(A) Maxillary incisors

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Group-1 T0 T1 T2 (mean±SD) T3 (mean±SD) P-value
(Extraction) (mean±SD) (mean±SD)
Tooth #11 16.56±0.27 16.09±0.56 15.77±0.69 15.73±0.66 0.00
Tooth #12 16.56±0.27 16.06±0.56 15.71±0.71 15.68±0.68 0.00

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Tooth #21 16.46±0.24 16.16±0.44 15.60±0.60 15.45±0.45 0.00
Tooth #22 17.11±0.34 16.35±0.37 16.00±0.43 15.90±0.41 0.00
Group-2
(Non-extraction)
Tooth #11 16.66±0.42 15.76±0.43 15.36±0.69 15.32±0.49 0.00*

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Tooth #12 16.77±0.63 15.89±0.59 15.57±0.61 15.42±0.59 0.00*
Tooth #21 16.77±0.54 15.80±0.52 15.36±0.66 15.30±0.59 0.00*
Tooth #22 17.25±0.59 16.43±0.68 15.95±0.75 15.88±0.76 0.00*
(B) Mandibular incisors

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Group-1
(Extraction)
Tooth #31 14.56±0.20 14.09±0.56 13.77±0.69 13.73±0.66 0.00*
Tooth #32 15.11±0.34 14.38±0.39 14.04±0.47 13.94±0.46 0.00*
Tooth #41 14.64±0.26 14.10±0.57 13.79±0.69 13.75±0.67 0.00*
Tooth #42 15.11±0.34 14.35±0.37 14.00±0.43 13.90±0.41 0.00*
Group-2
(Non-extraction)
Tooth #31 14.76±0.60 13.85±0.70 13.47±0.77 13.43±0.77 0.00*
Tooth #32 15.28±0.70 14.48±0.88 13.91±0.70 13.85±0.67 0.00*
Tooth #41 14.80±0.76 14.04±0.98 13.49±0.77 13.44±0.75 0.00*
Tooth #42 15.29±0.74 14.53±0.93 13.92±0.67 13.83±0.59 0.00*
NS: Non-significant;
NS: Non-significant; * Statistically significant
* Statistically at p<0.05
significant at p<0.05

T0 T1 T2 T3
Fig. 2. Periapical radiographs of a patient showing the progressive resorption in maxillary lateral incisor.
Fig. 2. Periapical radiographs of a patient showing the progressive resorption in maxillary
lateral incisor.
268 I. AL SHAHRANI ET AL.

RESULTS amount of resorption was statistically significant

for all maxillary and mandibular incisors except
A total of 320 teeth from 40 patients were divided treatment interval T2-T3 for right maxillary lateral
into two groups of 20 cases each. The mean age of incisors (12) and mandibular central incisors (31 and
the subjects was 14-18 years and consisted of 20 41), which was non-significant..
females and 20 male patients. In the present study, A comparison of mean root resorption among
there was progressive resorption of roots with the the groups based on extraction or non-extraction of
time that was significant for all the eight incisors. cases revealed overall root resorption in both the

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In the maxillary central incisor teeth (11 and 21) groups. However, the extent of root resorption was
there was significant resorption of roots observed in relatively lesser in Group 1 but was statistically
both the treatment groups with time (Mauchy’s test insignificant. The inter-examiner reliability and
of Spehericity<0.005, within-subjects effect <0.005, correlation between the two examiners was 97.5%.

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F- Value 268.625 for 11 and F- Value 155.457 for
21). In the maxillary lateral incisor teeth (12 and 22) DISCUSSION
there was significant resorption of roots observed
in both the treatment groups with time (Fig. 2) The average apical root resorption in maxillary

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(Mauchy’s test of Spehericity<0.005, within-subjects incisors, especially the maxillary lateral incisors,
effect <0.005, F- Value 268.625 for 12 and F- Value is found to be consistently more than any other
168.503 for 22) (Table I). analyzed tooth, followed by mandibular incisors and
In the mandibular central incisor teeth (31 and 41) mandibular first molars (7, 8). In this study, there was

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with time there was significant resorption of roots a progressive resorption of roots over time that was
observed in both the treatment groups (Mauchy’s significant for all the eight incisors and the extent of
test of Spehericity<0.005, within-subjects’ effect resorption was relatively more for lateral incisors,

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<0.005, F- Value 178.707 for 31 and F- Value particularly the mandibular lateral incisors. It is
182.708 for 41). In the Mandibular lateral incisor reasoned that maxillary incisors are most subjected
teeth (32 and 42) with time there was significant to orthodontic treatment either due to esthetic or
resorption of roots observed in both the treatment functional reasons and the conical shape of these roots
groups (Mauchy’s test of Spehericity<0.005, makes them susceptible to the resorption (9). Studies
within-subjects effect <0.005, F- Value 282.105 for have also reported a consistent association between
32 and F- Value 150.907 for 42) (Table II). anatomical factors commonly seen in maxillary lateral
Comparison of root resorption between treatment incisors such as greater tooth length, narrow, pointed
intervals (T0, T1, T2, and T3), showed that the and deviated roots to exhibit more root resorption

Table II. Maxillary and mandibular

Table II. Maxillary and mandibular root resorption
root resorption time time trend analysis.
trend analysis.
T0-T1 T0-T2 T0-T3 T1-T2 T1-T3 T2-T3

Maxillary Mean±SD P-value Mean±SD P-value Mean±SD P-value Mean±SD P-value Mean±SD P-value Mean±SD P-value
teeth
Tooth #11 0.77±0.52 0.00* 1.23±0.69 0.00* 1,30±0.71 0.00* 0.77±0.52 0.00* 0.46±0.39 0.00* 0.70±0.14 0.00*
Tooth #12 0.68±0.67 0.00* 0.68±0.67 0.00* 1.07±0.78 0.00* 0.38±0.43 0.00* 0.43±0.42 0.00* 0.45±0.18 NS
Tooth #21 0.72±0.74 0.00* 0.60±0.67 0.00* 1.02±0.77 0.00* 0.48±0.42 0.00* 0.46±0.42 0.00* 0.67±0.14 0.00*
Tooth #22 0.79±0.81 0.00* 1.20±0.90 0.00* 1.29±0.88 0.00* 0.41±0.30 0.00* 0.30±0.32 0.00* 0.82±0.20 0.01*
Mandibular Mean±SD P-value Mean±SD P-value Mean±SD P-value Mean±SD P-value Mean±SD P-value Mean±SD P-value
teeth
Tooth #31 0.69±0.05 0.00* 1.04±0.76 0.00* 1.08±0.74 0.00* 0.35±0.37 0.00* 0.39±0.03 0.00* 0.04±0.01 NS
Tooth #32 0.76±0.05 0.00* 1.22±0.06 0.00* 1.29±0.06 0.00* 0.45±0.03 0.00* 0.53±0.04 0.00* 0.07±0.16 0.00*
Tooth #41 0.64±0.63 0.00* 1.08±0.07 0.00* 1.12±0.06 0.00* 0.43±0.04 0.00* 0.47±0.04 0.00* 0.04±0.01 NS
Tooth #42 0.77±0.08 0.00* 1.24±0.09 0.00* 1.33±0.09 0.00* 0.46±0.04 0.00* 0.56±0.05 0.00* 0.09±0.02 0.00*
NS: Non-significant; * Statistically significant at p<0.05
NS: Non-significant; * Statistically significant at p<0.05
 Journal of Biological Regulators & Homeostatic Agents
269

during orthodontic treatment (10). REFERENCES

Tooth extraction is a known risk factor for
EARR during orthodontic tooth movement because 1. Sondeijker CF, Lamberts AA, Beckmann SH, et
extraction cases require longer treatment time and al. Development of a clinical practice guideline for
are associated with increased and/or extensive orthodontically induced external apical root resorption.
movements and retraction of the apex. In the present Eur J Orthodont 2019. doi:10.1093/ejo/cjz034.
study, overall root resorption was appreciated in both 2. Hartsfield JK Jr, Everett ET, Al-Qawasmi RA.
extraction and non-extraction cases in respect to both Genetic factors in external apical root resorption and

F
time and time intervals. However, the extent of root orthodontic treatment. Crit Rev Oral Biol Med 2004;
resorption was relatively lesser in Group 1 but was 15:115-22.
statistically insignificant. This is in sharp contrast to 3. Kalra S. External apical root resorption in orthodontic
various studies that have noted more severe EARR patients-local cause or genetic predisposition. Acta

O
among extraction cases (11, 12). This contrasting Sci Dent Sci 2019; 3:90-99.
finding could be due to mechanisms that are likely to 4. Feller L, Khammissa RA, Thomadakis G, Fourie J,
be independent of known factors causing EARR or Lemmer J. Apical external root resorption and repair
due to genetic causes. in orthodontic tooth movement: biological events.

O
Our study demonstrated EARR in almost all the Biomed Res Int 2016; 2016:4864195.
teeth expressed as root shortening. This does not 5. Casa MA, Faltin RM, Faltin K, Sander FG, Arana-
mean 100% root resorption in our study because Chavez VE. Root resorptions in upper first premolars

R
none of them demonstrated EARR more than 2 mm, after application of continuous torque moment. Intra-
as we sought to identify change in root length as individual study. J Orofac Orthop 2001; 62:285-95.
expressed only as a slight change in apical contour 6. Harris EF. Root resorption during orthodontic

P
with/without actual root shortening as a result of therapy. Seminars Orthod 2000; 6:183-94.
resorption, whereas few authors consider EARR 7. Kook YA, Park S, Sameshima GT. Peg-shaped and
only when root resorption of more than 4mm or 1/3 small lateral incisors not at higher risk for root
of the original root length occurs, which essentially resorption. Am J Orthod Dentofac Orthop 2003;
means that any EARR of less than 4 mm could be 123:253-58.
a transient change involving remodeling of roots 8. Brin I, Tulloch JF, Koroluk L, Philips C. External
during active tooth movement. apical root resorption in Class II malocclusion: a
It should be noted that root resorption associated retrospective review of 1- versus 2- phase treatment.
with orthodontic treatment ceases with the Am J Orthod Dentofac Orthop 2003; 124:151-56.
termination of active treatment and usually does 9. Sameshima GT, Sinclair PM. Predicting and
not affect the functional capacity or periodontal preventing root resorption: part II. Treatment factors.
integrity of the teeth. Considering the consistent Am J Orthod Dentofac Orthop 2001; 119:511-15.
occurrence of EARR, progress radiographs obtained 10. Maués CPR, Nascimento RR, Vilella OV. Severe
every 3-months during treatment is of great clinical root resorption resulting from orthodontic treatment:
significance in identifying EARR early in the process Prevalence and risk factors. Dent Press J Orthod
so that the orthodontist takes necessary precaution to 2015; 20:52-58.
reduce the extent of resorption. 11. Motokawa M, Sasamoto T, Kaku M, Kawata T,
Matsuda Y, Terao A, Tanne K. Association between
ACKNOWLEDGEMENTS root resorption incident to orthodontic treatment and
treatment factors. Eur J Orthod 2012; 34:350-56.
The authors extend their appreciation to the 12. Weltman B, Vig KW, Fields HW, Shanker S, Kaizar
Maxillofacial Centre at the College of Dentistry, EE. Root resorption associated with orthodontic
King Khalid University for supporting this work tooth movement: a systematic review. Am J Orthod
under grant number MRMC 01-017-005. Dentofacial Orthop 2010; 137:462-76.

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