Root resorption in maxillary central incisors

following active orthodontic treatment

Scott Copeland, D.D.S., M.S.,* and Larry J. Green, D.D.S., Ph.D.**
Derry, N. H. and Buffalo, N. g.

The purpose of this study was to determine if apical root resorption associated with orthodontic
treatment continues after the termination of active treatment (that is, the removal of fixed appliances).
A sample of 45 subjects who had experienced root resorption during treatment was selected from
the orthodontic clinic at the State University of New York at Buffalo. The length of the maxillary
central incisors was measured from lateral cephalometric radiograms taken before treatment, after
active treatment, and after retention. From these data, the resorption occurring during and after active
treatment was calculated. The mean amount of root resorption during active treatment was 2.93
ram. The mean amount of root resorption during the posttreatment period was 0.1 mm. There was a
statistical difference between these two means using the Student's t test at the 0.05 level of
significance. The reliability coefficient comparing the first tracings and measurements in the 19 cases
that were retraced and remeasured was r = 0.993. The data from this radiographic study support
the hypothesis that root resorption associated with orthodontic treatment ceases with the termination
of active treatment. There was also evidence to suggest that when posttreatment root resorption
does occur, it is not necessarily associated with large amounts of root resorption during the active
treatment period. It is more likely associated with other factors, such as traumatic occlusion and
active force-delivering retainers. (AM J ORTHOD 89: 51-55, 1986.)

Key words: Root resorption, apical, incisor, cephalometric, orthodontic

A p i c a l root resorption is one of the most
common iatrogenic problems associated with orthodon-
tic treatment. It is becoming an increasingly more se-
rious problem from a medicolegal standpoint. It appears
that no practitioner is able to avoid this problem com-
pletely. Consequently, a great deal of research has been
published on this topic, particularly research undertaken
from a clinical point of view. However, much contro-
versy exists concerning its cause and predisposing fac-
tors. One important question of interest to orthodontists
is, once root resorption has begun will it continue after
active treatment is terminated? Several clinical studies
have been conducted relative to this question. ~.2 These
studies used intraoral radiograms or panoramic-type
films to determine root resorption and were comparative
rather than quantitative in nature. Root resorption has
been quantitatively measured by lateral cephalometric
radiograms, but not during postretention periods? -6 In
this study root length was measured before treatment,
at the debanding, and at some point during the retention
period (usually 2 years). Quantitative measurements
were made from lateral cephalometric radiograms to
determine if root resorption continued after active ortho-
dontic treatment had been completed. The positive hy-
pothesis was that root resorption does not continue once
fixed appliances have been removed.
Much controversy exists in the literature as to the
exact definition of root resorption. In this study external
apical root resorption was defined as any reduction in
length of a maxillary central incisor measured from the
tip of the incisal edge to the apex of the root. Loss of
clinical root length caused by periodontal disease was
not considered nor was lateral external root resorption.
Only the maxillary central incisors were measured as
they are considered by many authors 7-1° to be among
the most frequently affected teeth.

METHODS AND MATERIALS

This article is based on a thesis submitted in partial fulfillment of the require-
merits for the degree of Master of Science, Department of Orthodontics, State
University of New York at Buffalo.
*Present address: 132 E. Broadway, Derry, N. H. In private practice.
**Professor, Department of Orthodontics, State University of New York at
Buffalo.
The sample was drawn from the patient files at the
State University of New York at Buffalo, Department
of Orthodontics. The criteria for case selection were
(1) the availability of a pretreatment, posttreatment, and

51
52 Copeland and Green
\ was large enough to anNyze statistically and was con-
\ Thirteen of the subjects were male; 32 were female.
\\
\ a random number. The apex and incisal edge of the
Fig. 1. Root and crown landmarks for incisor tooth length.
postretention lateral cephalometric radiogram for each
patient and (2) evidence of apical root resorption on the
posttreatment films.
More than 1,000 patient files were screened to iden-
tify cases exhibiting root resorption greater than 1 mm
during active treatment. The length of the shorter max-
illary central incisor on the pretreatment lateral ceph-
alometric radiogram was assessed with a divider and
compared to the posttreatment length to determine if 1
m m or more of resorption had occurred. If the incisors
were crowded in such a way that the central incisor
apices could not be differentiated from those of the
lateral incisors or canines, the case was not included
in the sample. If any film was of such poor quality that
a measurement could not be made, such a film was also
eliminated. Other reasons for case rejection were (1)
obvious root resorption before treatment and (2) im-
mature roots before treatment.
Fifty-six cases were found to meet the initial re-
quirements, but 11 were eliminated for one or more of
the foregoing reasons. A final sample of 45 subjects
Am. J. Orthod.
January 1986
sidered to be a representative sample of all the ortho-
dontic patients at the clinic who had experienced apical
root resorption. All the patients were treated with edge-
wise appliances.
The range of age at the beginning of treatment was
from 10 years 3 months to 23 years 5 months with a
mean of 13 years 1 month. The mean duration of active
treatment was 2 years 10 months. The range of active
treatment time was from ! year 4 months to 4 years 11
months. The mean for the period of time between the
termination of active treatment and the final cephalo-
metric radiogram was 2 years 4 months with a range
from 9 months to 6 years 2 months.
All of the cephalometric radiograms in the present
study were taken on the same Broadbent-Bolton* ceph-
alometer by the same technician. The central incisors
were measured from films taken at three different times
(pretreatment, posttreatment, and some point during the
retention period--usually 2 years after debanding).
These measurements were then compared to determine
the extent of root resorption occurring during active
treatment and during the retention or posttreatment
period.
The pretreatment, posttreatment, and final radio-
grams were gathered for each patient and identified with
shorter of the two maxillary central incisors were
marked on acetate paper with a pinprick. The pinpricks
were circled in pencil for easier location and the acetate
paper was marked with the same number as the ceph-
alometric film (Fig. 1). Dental casts were occasionally
used to more accurately determine the incisal edge. The
three radiograms for each patient were compared during
the landmark identification procedure to maintain con-
sistency, that is, to establish that the same incisal edge
and apex were identified in all three films.
After this landmark identification procedure had
been performed on all of the radiograms, the acetate
tracings were shuffled. The distance between the two
pinpricks was then measured for each tracing by means
of Helios dial caliperst calibrated to 1/2oof a millimeter.
The acetate tracings were then reshuffled and remea-
sured following the same procedure. The two replicated
measurements for each tracing were averaged and the
mean was used as the length of the tooth for that par-
ticular cephalometric film.
The pretreatment, posttreatment, and final means
were recorded for each patient. The amount of apical
*Bolton Fund, Western Reserve University, Cleveland, Ohio.
tMager Scientific Inc., Ann Arbor, Mich.
Volume 89
Number 1
Table I. Summary of resorption data
Active treatment Posttreatment
resorption resorption
(mm) (mm)
Range 1.1 to 7.35 - 0 . 4 to +0.95
Mean 2.93 0.1
Variance 2.1 0.09
Standard 1.45 0.3
deviation
root resorption during active treatment was determined
for each patient by subtracting the posttreatment length
from the pretreatment length. The posttreatment root
resorption was similarly calculated by subtracting the
final length from the posttreatment length. The mean
and standard deviation were calculated for the active
treatment resorption and the posttreatment resorption.
These statistics were compared using the Student's t
test for the difference between two means with a level
of significance of 0.05.
Nineteen of the cases were randomly selected and
retraced by the same procedure. These tracings were
shuffled and measured twice, as before. The mean of
the two measurements was calculated and compared to
the data from the initial tracings. A reliability coeffi-
cient was calculated to determine the reliability of the
tracing and measurement procedure as follows:
n~xy - (Nx)(Zy)
Pearson r =
~SnZx~- (Zx)~ /nZY 2 - (Ey)~
RESULTS
The resorption data are summarized in Table I and
Fig. 2.
The mean amount of apical root resorption during
active treatment was 2.93 mm with a range from 1.1
mm to 7.35 mm. The standard deviation was 1.45 mm.
The mean amount of root resorption after active treat-
ment was 0.1 mm with a range from - 0.4 mm to 0.95
ram. The standard deviation was 0.3 ram.
The null hypothesis stated that there was no differ-
ence between the mean root resorption during the active
treatment period (from the beginning of treatment to
the removal of fixed appliances) and the postactive.
treatment period (from the removal of fixed appliances
to the final cephalometric radiogram). The level of sig-
nificance was set at 0.05; using the Student's t test for
the difference between two means where population
variances were not equal, the critical value was found
to be 1.68. The t-test statistic was calculated to be 12.8.
Therefore, the null hypothesis was rejected (P <
Root resorption in maxillary central incisors 53
3.0 ~ -12-
2.5
E
2.0
0
,¢,,.
'1.5
O
D~
c-
a ~.0
0.5
I I
Active Orthodontic Post-Active
Treatment Period TreatmentPeriod
Fig. 2. Mean root resorption during active orthodontic treatment
and postactive treatment periods.
0.005). It was concluded that there is a difference be-
tween the average amount of apical root resorption that
occurs during the active treatment period and the av-
erage amount of resorption that occurs during the post-
active treatment period--the former being considerably
greater than the latter.
The reliability coefficient obtained from compari-
sons of the first and second tracings and measurements
of 19 cases was 0.993.
DISCUSSION
Most researchers believe that root resorption does
not continue once active orthodontic treatment is ter-
minated.~-3'l~'n The findings of this study support pre-
vious clinical studies by Vonder Ahe 2 and Ronnerman
and Larsson.I Vonder Ahe, in a study of 57 patients
from 12 different practices, found that root resorption
did not continue after active treatment. The average
case was out of retention 6.5 years and some were 17
years posttreatment. Ronnerman and Larsson evaluated
root resorption cases at 3 and 10 years postactive treat-
ment and found no evidence that root resorption had
continued. These studies based their conclusions on
comparisons of periapical, occlusal, and panoramic ra-
54 Copeland a n d Green
diograms. The data used in the present study were quan-
titative and obtained from linear cephalometric mea-
surements of maxillary central incisors. Because these
teeth are located near the midsagittal plane, sequential
measurements could be more accurately compared since
magnification was more consistent and radiographic
distortion minimized.
In this study the average amount of posttreatment
resorption was only 0.1 mm, an amount that could be
accounted for by several different explanations. First,
it may be assumed that the resorption process continued
for a short period of time after active treatment.
Wainwright ~3 described evidence from his study sug-
gesting that root resorption induced by orthodontic
forces may continue for several days after the forces
are removed. After this time repair cementum is de-
posited on the affected root surfaces. Reitan ~4,~5 be-
lieved resorption could continue for as much as a week
after tooth movement was stopped and that cementum
repair required 5 to 6 weeks of orthodontic inactivity.
This could account for the resorption that occurred dur-
ing the posttreatment period. Although the retention
period was considered to be one of nonactive treatment
in this study, all the patients wore maxillary Hawley
retainers and either mandibular Hawley retainers or
fixed retainers from canine to canine. Activated retain-
ers may also explain some of the posttreatment resorp-
tion because an active labial bow could have exerted
significant orthodontic forces during the retention pe-
riod. Gholston and Mattison ~6recently reported a single
case where resorption continued for 3 years postreten-
tion. Such cases are presumably rare and causative fac-
tors such as occlusal trauma must be taken into con-
sideration.
The range for the posttreatment root resorption was
from - 0 . 4 mm to + 0 . 9 5 mm. The most plausible
explanation for the negative values was measurement
error since the possibility of teeth increasing in length
was removed by eliminating from the sample subjects
with maxillary incisors with immature roots. Rygh j2
and others H'13,~7-~9described the process of cementum
repair as primarily a repair of small resorption lacunae;
thus it is unlikely that there would be a net increase in
measureable root length as a result of this process.
It is likely that resorption did not continue in most
subjects. This is supported by the fact that the mean
posttreatment resorption was nearly zero (0.1 ram).
Posttreatment resorption values in 92% of the subjects
were between - 0 . 4 m m and + 0.4 mm. Measurement
error probably accounted for a major portion of the
standard deviation of 0.3 ram.
Only four subjects (8% of the sample) showed post-
treatment resorption values greater than 0.4 mm. In
Am. J. Orthod.
January 1986
these cases, particularly active retainers may expiain
the continuation of the resorption process. Occlusal
trauma may also have been a causative factor in post-
treatment root resorption. It is interesting to note that
these four cases were not always associated with large
amounts of resorption observed during the active treat-
ment period. The subject showing the greatest amount
of posttreatment root resorption (0.95 mm) demon-
strated only 2.3 mm of root resorption during the active
treatment period, which is less than the mean for that
period. Conversely, the subject with the greatest
amount of active treatment resorption (7.35 mm)
showed - 0.2 m m of oosttreatment resorption. Since
92% of the sample did not show significant amounts of
resorption during the posttreatment period and only four
cases demonstrated any significant amount of resorption
during this period, a coefficient of correlation between
resorption during and after active treatment could not
be calculated with statistical significance. However, it
appears that the amount of active-treatment root re-
sorption and posttreatment resorption are not correlated
and that other factors such as occlusal trauma and active
retainers may be responsible for posttreatment root re-
sorption.
The clinical sequelae of root resorption is also a
topic of interest. Vonder Abe 2 reported only one case
of mobility out of 57 resorption cases. Phillips 2° stated
that the degree of root loss in most situations was "clin-
ically insignificant" and "not endangering the life or
function of the dentition." Others are less optimistic.
Oppenheim is believed that shortened roots could never
resist the stress of function as well as or as long as
unresorbed roots. One study 13 found that resorption of-
ten led to mobility and at times exfoliation of the tooth.
Root resorption then should be quantified to make more
valid judgments on its clinical sequelae.
The technique used in this study to measure root
resorption of the maxillary central incisors appeared to
be very reliable. This was supported by the fact that
the reliability coefficient (r) comparing the 19 cases
that were retraced and remeasured to the original trac-
ings and measurements was 0.993.
Two subjects in this study had maxillary central
incisors that had been treated endodontically before
orthodontic treatment. In these subjects it was possible
to visualize root resorption relative to their root canal
fillings. In the pretreatment radiogram of one subject,
the apex and the end of the endodontic filling material
were coincidental. In the posttreatment and final radio-
grams, the filling material extended beyond the apex
for a distance equal to the amount of root resorption.
These cases supported the validity of the measurement
procedure used in this study.
Volume 89
Number 1
Wainwright 13 points out that root resorption occur-
ring on root surfaces other than the apex is often not
seen radiographically. It was noted in this study that
apical resorption is easily detected by most radiographic
techniques when the root apices are obviously blunted
or distorted. However, in many subjects the resorption
pattern was so symmetric that it could be overlooked
if the roots were not actually measured from radiograms
and compared to films taken at an earlier time. Previous
studies to determine the incidence of root resorption
and its relationship to various treatment procedures have
different definitions of root resorption. Many of these
studies could be repeated using a quantitative definition
of apical root resorption and a measurement procedure
similar to the one described in this study.
Many practitioners rely on periapical radiograms of
the maxillary anterior teeth to assess root resorption
during treatment; others use the panoramic radiograms.
But root resorption can b e more accurately assessed
with less radiation by measuring the length of a central
incisor from a progress cephalometric film and com-
paring it to the initial film. If there is no apical root
resorption seen in the maxillary or mandibular central
incisors, then significant apical resorption occurring in
other teeth is less likely because the anterior teeth are
the most frequently affected. 7-~°
Root resorption is one of the most serious iatrogenic
problems associated with orthodontic treatment and its
diagnosis can only be made by maintaining adequate
records. If resorption is discovered, treatment goals
must be reassessed and a decision should be made to
terminate treatment or arrive at a treatment compromise
and, when necessary, stop applying forces. The results
of this study indicate that the termination of active treat-
ment will essentially stop further apical root resorption.
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R o o t resorption in maxillary central incisors 55
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Reprint requests to:
Dr. Scott Copeland
132 E. Broadway
Derry, NH 03038