Journal of the World Federation of Orthodontists xxx (2016) 1e9

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Journal of the World Federation of Orthodontists

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Case Report

Root repair and regeneration after miniscrew root damage

Ju Young Lee a, Pyung Sik Kim a, Catherine Choi b, Ki Beom Kim b, *
a
Private Practice, Suwon, Korea
b
Department of Orthodontics, Saint Louis University, St. Louis, Missouri

a r t i c l e i n f o a b s t r a c t

Article history: Background: Root damage due to miniscrews can be a potentially serious complication. This case report
Received 7 December 2015 describes a 21-year-old woman with bimaxillary protrusion and a congenitally missing mandibular left
Accepted 10 February 2016 lateral tooth. Miniscrews were placed mesial to the maxillary second premolars.
Available online xxx
Methods: After placement of the miniscrews, it was discovered on a periapical radiograph that a min-
iscrew perforated the root of the left maxillary second premolar. On discovery of the perforation, the
Keywords:
miniscrew was immediately removed and a new miniscrew was placed mesial to the first maxillary
Miniscrew
molar. The patient did not complain of pain or discomfort, and there was no evidence of inflammation or
Root damage
Root repair
a periapical lesion. Because the pulp vitality test initially showed the tooth to be nonvital, root canal
Root fracture treatment was originally considered. However, because the source of trauma was removed immediately
and only part of the root was affected, the root was simply monitored and root canal treatment was not
performed.
Results: At 10 months after perforation of the root, the tooth started showing vitality; there were positive
readings during the third and fourth steps of electric pulp testing. At 2 years 6 months after the root
damage, the tooth was completely vital, showing positive pulp tests during all four steps of the electric
pulp testing. Additionally, the fractured part of the root embedded within the bone, reinstating a sound
root form. Three years later, the root continued to demonstrate complete pulp vitality.
Conclusion: Despite root perforation extending into the pulp and causing root fracture, after immediate
removal of the miniscrew, the damaged root repaired itself and regenerated without invasive treatment.
Ó 2016 World Federation of Orthodontists.

1. Introduction (Fig. 4). The patient was promptly referred to an endodontist, and
nonvitality of the pulp was detected through use of an electric pulp
A 21.6-year-old female patient presented with a chief complaint test.
of lip protrusion. The treatment plan involved retraction of the
anterior teeth after extraction of all first premolars except for the 1.1. Treatment progress
left mandibular first premolar (Fig. 1). Miniscrews were placed
mesial to each maxillary second molar to preserve anchorage. Even after the faulty miniscrew placement, the patient did not
Additional miniscrews were planned to be placed mesial and apical complain of pain or discomfort, and there was no evidence of
to the left maxillary second premolars for simultaneous retraction inflammation or a periapical lesion. Because the pulp vitality test
and intrusion of the maxillary anterior teeth (Fig. 2). initially showed the tooth to be nonvital, root canal treatment was
After placement of the miniscrews, it was discovered on a per- originally considered. However, because the source of trauma was
iapical radiograph that a miniscrew perforated the root of the left removed immediately and only part of the root was affected, the
maxillary second premolar (Fig. 3). This occurred due to failure to root was simply monitored without root canal treatment. The root
observe the root’s mesial inclination relative to the crown. On dis- was monitored every 4 weeks (Fig. 5). At the 10-month check, the
covery of the perforation, the miniscrew was immediately removed pulp showed positive results. Thereafter, the tooth was monitored
and a new miniscrew was placed mesial to the first maxillary molar every 2 to 3 months (Fig. 6).

1.2. Treatment results

* Corresponding author: Department of Orthodontics, Saint Louis University, St.
Louis, MO, 63105. Orthodontic treatment was completed within 23 months. Fair
E-mail address: kkim8@slu.edu (K.B. Kim). occlusion was achieved. Molar and canine relationships were Class I

2212-4438/$ e see front matter Ó 2016 World Federation of Orthodontists.

http://dx.doi.org/10.1016/j.ejwf.2016.02.005

Please cite this article in press as: Lee JY, et al., Root repair and regeneration after miniscrew root damage, Journal of the World Federation of
Orthodontists (2016), http://dx.doi.org/10.1016/j.ejwf.2016.02.005
2 J.Y. Lee et al. / Journal of the World Federation of Orthodontists xxx (2016) 1e9

Fig. 1. Despite the Class I molar relationship, there was anterior crowding in the mandibular and maxillary arch. The midline was shifted to the left due to a congenitally missing
mandibular left premolar.

(Fig. 7). All roots showed good parallelism, and the left maxillary damage limited to cementum and dentin can recover completely [3]
second premolar showed a fair shape (Fig. 8). After completion of and be regenerated without complications [4]. It is rare for root
orthodontic treatment, the left second premolar root continued to surface damage to cause irreversible pulp damage [5]. On the other
be observed (Figs. 9 and 10). At 2 years 6 months after the root hand, root damage involving the pulp usually results in loss of vi-
damage, the pulp tissue of the tooth reacted positively to all four tality and damage to the periodontal tissue [6]. Leaving the minis-
steps of the electric pulp test, confirming the pulp’s complete re- crew in the site of damage delays or eliminates the likelihood of root
covery (Fig. 10). Three years after the root fracture, the root repair [7]. Therefore, immediate miniscrew removal is recom-
continued to maintain its form. The pulp tissue still responded mended. Additionally, when miniscrews are removed immediately
positively to all steps of the electric pulp test (Fig. 11). after root damage, symptoms of pain, discoloration, devitalization,
or ankylosis can be avoided [8]. This case report shows an example of
2. Discussion immediate miniscrew removal and the absence of inflammation,
pain, or ankylosis. Despite damage extending into the pulp, complete
A miniscrew’s sharp drilling tip can cause root damage. Despite root repair and regeneration occurred.
such damage, it has been shown that where a root is cut, the Precautionary measures must be taken with regard to miniscrew
cementum has self-repairing properties, and the periodontal liga- placement. Root damage can be prevented by examination of a
ment reorganizes itself [1]. Roots damaged with miniscrews can periapical radiograph and cone beam computed tomography. It is
generate reparative cementum [2]. Studies have shown that root important to accurately assess interradicular distance, as well as

Please cite this article in press as: Lee JY, et al., Root repair and regeneration after miniscrew root damage, Journal of the World Federation of
Orthodontists (2016), http://dx.doi.org/10.1016/j.ejwf.2016.02.005
 J.Y. Lee et al. / Journal of the World Federation of Orthodontists xxx (2016) 1e9 3

Fig. 2. Miniscrews (1.5  8.0 mm, Biomaterials Korea, Seoul, South Korea) were placed mesial to the maxillary second molars to achieve maximum retraction of the anterior teeth.
Additional miniscrews were planned to be placed mesial and apical to the left maxillary second premolars for simultaneous retraction and intrusion of the maxillary anterior teeth.

other anatomical aspects of the teeth adjacent to the miniscrew. In References

this particular case, no periapical radiograph was taken before
miniscrew placement. It is critical to discern between the feel of [1] Robert WE, Helm FR, Marshall KJ, Gongloff RK. Rigid endosseous implants for
orthodontic and orthopedic anchorage. Angle Orthod 1989;59:247e56.
bone compared with the feel of a root while placing a miniscrew [2] Ahmed VKS, Rooban T, Krishnaswamy NR, Mani K, Kalladka G. Root damage and
into the alveolar periodontium. As soon as suspicious signs or repair in patients with temporary skeletal anchorage devices. Am J Orthod
symptoms of root contact are detected, miniscrew placement Dentofacial Orthop 2012;141:547e55.
[3] Brisceno CE, Rossouw PE, Carrillo R, Spears R, Buschang PH. Healing of the roots
should be discontinued immediately, and periapical radiography and surrounding structures after intentional damage with miniscrew implants.
and cone beam computed tomography should be taken to confirm Am J Orthod Dentofacial Orthop 2009;135:292e301.
and evaluate the root condition. [4] Alves Jr M, Baratieri C, Mattos CT, Araújo MT, Maia LC. Root repair after contact
with mini-implants: systematic review of the literature. Eur J Orthod
2013;35:491e9.
[5] Renjen R, Maganzini AL, Rohrer MD, Prasad HS, Kraut RA. Root and pulp
3. Conclusion response after intentional injury from miniscrew placement. Am J Orthod
Dentofacial Orthop 2009;136:708e14.
[6] Bargholz C. Perforation repair with mineral trioxide aggregate: a modified
This case report shows an example of the self-repairing and matrix concept. Int Endod J 2005;38:59e69.
regenerating ability of a perforated and fractured root after im- [7] Kim H, Kim TW. Histologic evaluation of root-surface healing after root contact
or approximation during placement of mini-implants. Am J Orthod Dentofacial
mediate removal of the offending miniscrew. Instead of automati- Orthop 2011;139:752e60.
cally resorting to root canal therapy, the damaged root can be [8] Baik U. Root contact with miniscrews during mesiodistal movement of the
monitored for possible pulp revitalization and regeneration. molar. J World Fed Orthod 2014;3:e95e100.

Please cite this article in press as: Lee JY, et al., Root repair and regeneration after miniscrew root damage, Journal of the World Federation of
Orthodontists (2016), http://dx.doi.org/10.1016/j.ejwf.2016.02.005
4 J.Y. Lee et al. / Journal of the World Federation of Orthodontists xxx (2016) 1e9

Fig. 3. Miniscrew root perforation. Part of the root was fractured and separated from its body due to pressure applied by the miniscrew during its placement. The miniscrew
penetrated through the pulpal tissue, and the pulp became completely nonvital.

Fig. 4. The problematic miniscrew was removed and a new miniscrew was placed between the second premolar and first molar soon after the root perforation was detected.

Please cite this article in press as: Lee JY, et al., Root repair and regeneration after miniscrew root damage, Journal of the World Federation of
Orthodontists (2016), http://dx.doi.org/10.1016/j.ejwf.2016.02.005
 J.Y. Lee et al. / Journal of the World Federation of Orthodontists xxx (2016) 1e9 5

Fig. 5. A periapical radiograph was taken at 2 weeks (A), 6 weeks (B), and 10 weeks (C) after the root damage. The fractured piece was completely separated from the tooth. (C) At
10 weeks, granulation tissue filled up the resorbed bone space. Pulp vitality test results were negative at all three stages.

Fig. 6. A periapical radiograph was taken at 5 months (A), 7 months (B), and 10 months (C). The separated root piece became embedded within the bone. Pulp vitality was negative
when tested at 5 months and 7 months. However, 10 months after the damage, the tooth began to show vitality at the third and fourth step of electric pulp test.

Please cite this article in press as: Lee JY, et al., Root repair and regeneration after miniscrew root damage, Journal of the World Federation of
Orthodontists (2016), http://dx.doi.org/10.1016/j.ejwf.2016.02.005
6 J.Y. Lee et al. / Journal of the World Federation of Orthodontists xxx (2016) 1e9

Fig. 7. Intraoral photographs at the end of orthodontic treatment. Contacts between all teeth were achieved with fair occlusion, and canine guidance and group function were
restored. The molar and canine relationships were Class I. Because the left mandibular canine replaced the left mandibular lateral tooth, the mandibular midline was shifted toward
the right.

Please cite this article in press as: Lee JY, et al., Root repair and regeneration after miniscrew root damage, Journal of the World Federation of
Orthodontists (2016), http://dx.doi.org/10.1016/j.ejwf.2016.02.005
 J.Y. Lee et al. / Journal of the World Federation of Orthodontists xxx (2016) 1e9 7

Fig. 8. Radiographic comparisons of before and after orthodontic treatment, showing retraction of the anterior teeth and improvement of lip posture. The axis of each tooth was
positioned within normal limits, including the left maxillary second premolar.

Please cite this article in press as: Lee JY, et al., Root repair and regeneration after miniscrew root damage, Journal of the World Federation of
Orthodontists (2016), http://dx.doi.org/10.1016/j.ejwf.2016.02.005
8 J.Y. Lee et al. / Journal of the World Federation of Orthodontists xxx (2016) 1e9

Fig. 9. Periapical radiographs at 1 year (A), 1 year, 5 months (B), and 1 year 8 months (C) after the root damage.

Fig. 10. Periapical radiographs at 2 years (A) and 2 years 6 months (B and C) after the root damage. Despite the fracture, the previously separated fragment showed good recovery. At
2 years 6 months after the damage, the pulp showed a positive reaction to all 4 steps of the electric pulp test.

Please cite this article in press as: Lee JY, et al., Root repair and regeneration after miniscrew root damage, Journal of the World Federation of
Orthodontists (2016), http://dx.doi.org/10.1016/j.ejwf.2016.02.005
 J.Y. Lee et al. / Journal of the World Federation of Orthodontists xxx (2016) 1e9 9

Fig. 11. Periapical radiographs at 3 years after root fracture. The pulp continued to respond positively to all four steps of the electric pulp test. The root form maintained its good
form.

Please cite this article in press as: Lee JY, et al., Root repair and regeneration after miniscrew root damage, Journal of the World Federation of
Orthodontists (2016), http://dx.doi.org/10.1016/j.ejwf.2016.02.005