Severe External Root Resorption Research Articles

Is the presence of severe external apical root resorption a contraindication to orthodontic retraction of maxillary incisors?

Is the presence of severe external apical root resorption a contraindication to orthodontic retraction of maxillary incisors?

Evaluation of Risk Factors for Severe Apical Root Resorption in the Maxillary Incisors Following Fixed Orthodontic Treatment.

The aim of this study was to retrospectively determine the prevalence of severe external root resorption in maxillary inci- sors during fixed orthodontic treatment and to evaluate the possible predisposing factors. The treatment records of 7000 patients who had been treated between 1990 and 2019 at the Department of Orthodontics Faculty of Dentistry Marmara University were examined, and a total of 120 patients with severe root resorption in at least one of their upper incisors were identified. The following data were retrieved from the patients' records and radiographs: gender, root morpholo- gy, overjet, overbite, treatment modality (extraction, non-extraction), treatment duration, buccal and palatal alveolar bone thickness for the maxillary incisors, and amount of movement of the incisal root apices and incisal edges. These data from a group of 90 patients with severe root resorption were compared with the data from a control group of 90 patients with minimal root resorption. The Chi- square test, the Mann-Whitney U-test, and the independent t-test were used for statistical analysis. The prevalence of severe external root resorption was 3.23%, and the results demonstrated significant difference between the groups for the variables of treatment modality (extractions), treatment duration, thickness of the alveolar bone, and amount of incisor movement at the end of the treatment. It can be concluded that extractions, increased treatment duration, thin alveolar bone, and excessive incisor movement represent risk factors for severe root resorption in maxillary incisors following orthodontic treatment.

Influence of clinical factors, IL4 and IL6 genes polymorphisms in functional healing in late replantation.

To investigate the genetic association in a sample of replanted teeth, it is necessary to observe the extreme phenotypes, such as, teeth that underwent functional healing and those extracted due to severe external root resorption. Thus, this study aimed to investigate the association of age of the patients, root development, storage media, and polymorphisms in the interleukin 4 (IL4) and interleukin 6 (IL6) genes with teeth that presented extreme outcomes, as functional healing or extraction, in a group whose replantation techniques did not follow the International Association of Dental Traumatology (IADT) 2012 guidelines. Forty-three avulsed and replanted teeth that did not follow IADT 2012 guidelines and underwent functional healing or were extracted were included. Periapical radiographs employed for this study were taken soon after tooth replantation and after 1 year. For genotypic IL4 and IL6 genes analysis, DNA of oral mucosa cells was extracted. Real-time- PCR performed for genotyping polymorphisms in IL4 and IL6 genes. Clinical and genetic variables were analyzed by the Chi-square test and the "Z" test. P values < .05 were considered significant. The results showed that functional healing and extraction were associated with storage media and with the rs2243268 of IL- 4 gene polymorphisms. As conclusion, the C rs2243268 allele of IL4 gene may have a positive relationship with functional healing teeth that were replanted not following the 2012 IADT guidelines. Keeping the tooth dry is associated to a fast loss of avulsed and replanted teeth after 1-year follow-up.

English

Resorption of the tooth represents a multifactorial and a perplexing problem for all clinicians resulting in complete or partial loss of tooth structure. The present clinical demonstration describes management of the permanent maxillary left central incisor (tooth number #21) affected by external root resorption involving the mesial and distal surface of middle one-third of the root. Conventional nonsurgical endodontic treatment followed by MTA (Mineral trioxide aggregate) obturation (PRoRoot MTA, Dentsply, Tulsa Dental Specialties) was planned. The root canal of the affected teeth was debrided with Dual Rinse HEDP (Medcem Weinfelden, Switzerland) containing etidronate powder and chemomechanical preparation of the root canal was performed with XP endo shaper file system (FKG Dentaire, SA, Switzerland). Thirtysix months’ post-operative follow-up revealed complete healing of the external root resorption defect with no clinical and radiological signs and symptoms. In the present case simple non-surgical endodontic management of severe external root resorption was done in a permanent maxillary tooth by using a continuous chelation irrigation technique, intracanal medicament followed by obturation with bio-ceramic material produced satisfactory results in contrast to the recommended surgical management. Resorption of the tooth being a multifactorial and a perplexing problem for all clinicians results in complete or partial loss of tooth structure. According to the Glossary of Endodontic terms, Resorption is defined as a condition associated with either a physiologic or a pathologic process resulting in the loss of dentine, cementum, and/or bone.1 Traditionally resorption can present either as internal or as external resorption.2 External root resorption occurs on the outer surface of the root and are of dissimilar nature such as external surface resorption, external inflammatory root resorption, ankylosis, and external replacement resorption, the most common being external inflammatory root resorption.3 According to the Glossary of Endodontics, “Inflammatory resorption is defined as an internal or external pathologic loss of tooth structure and possibly bone, resulting in a defect; occurs as the result of microbial infection; characterized radiographically by radiolucent areas along the root”.1 It may result due to dental trauma, forceful orthodontic tooth movement, long standing infection of the pulp or periodontal tissues. External resorption presents as a major resorptive condition of the root without any clinical signs and symptoms.2 The non-surgical management of external inflammatory root resorption is based on its aetiology, which needs to be eliminated

Pulp healing in immature replanted permanent teeth: A competing risk analysis.

Tooth displacement during avulsion causes total rupture of the pulp's neurovascular supply. Revascularization and pulp healing may occur in immature teeth, which gives rise to the recommendation that root canal treatment may not be required. The aim of this study was to evaluate the prognostic factors for the pulp's response after replantation of young permanent teeth. Records from 117 patients with 133 replanted permanent immature teeth were reviewed, and pulp outcomes were classified as healing (hard tissue deposition on the dentinal walls followed by narrowing of the pulp lumen or ingrowth of bone-like tissue inside the pulp canal) or non-healing (pulp necrosis with infection). The effect of clinical and demographic co-variates on the hazards of both outcomes was assessed performing a competing risk model. Pulp necrosis with infection was diagnosed in 78.2% of the teeth, and healing was observed in 12.8% of the teeth. A total of 12 teeth (9.0%) were censored due to prophylactic removal of the pulp or severe external root resorption caused by eruption of adjacent canines. The cs-Cox model demonstrated that the hazards of pulp healing increased in teeth with extra-alveolar periods <15min (csHR: 7.83, 95% CI 1.76-34.80, p=.01), while the hazards of pulp necrosis with infection decreased (csHR: 0.31, 95% CI: 0.10-0.92, p=.04). Teeth replanted with Moorrees' stages 4 and 5 of root development had higher hazards of pulp necrosis with infection than teeth with stage 2 of root development (csHR: 2.23, 95% CI 1.11-4.50, p=.03; csHR: 2.89, 95% CI: 1.40-5.95; p=.01). Pulp healing rarely occurred after replantation of young permanent teeth being associated with short extra-alveolar periods <15min. Early stages of root development decreased the hazards of pulp necrosis with infection.

A tool for assessment of risk of bias in studies of adverse effects of orthodontic treatment applied in a systematic review on external root resorption.

Systematic reviews (SRs) are considered to provide reliable estimates, but flaws in designs, methods of monitoring effects, and outcomes have the potential to bias results. There are several tools for assessing risk of bias (RoB), most of them designed for SRs of beneficial effects. To our knowledge, there is no tool that is adapted specifically to assess RoB in studies of adverse effects associated with orthodontic treatment. To address this, the aim of this study was first to introduce a tool for assessment of RoB in studies of adverse effects associated with orthodontic treatment and, second, to apply it in an SR of external root resorption (ERR) associated with orthodontic treatment with fixed appliance. The approach with domains supported by signalling questions was used for the tool. Domains and signalling questions were tailored to the review questions of the SR of studies of ERR after orthodontic treatment using periapical radiography or cone beam computed tomography. Duplicate study selection, data extraction, and RoB assessment using the tool, followed by meta-analyses, were performed. Using the tool for the assessment of RoB identified shortcomings and report deficiencies of primary studies concerning the presentation of orthodontic treatment, identification of ERR, and analysis of outcomes. RoB assessment resulted in 12 of 32 studies read in full text being included. Reported severe ERR varied across studies between 2 and 14 per cent for all incisors and 10 and 29 per cent for maxillary incisors. Results of ERR related to patients' age and sex, orthodontic diagnosis, and treatment were contradictory. Quality of evidence evaluated by GRADE was low due to study limitations, imprecision, and inconsistency of study results. As the tool and its application highlight important issues to consider when planning, conducting, and reporting research, the tool may have a valuable role for quality enhancement of future studies of outcomes of orthodontic treatment. The tool may also serve for authors when planning SRs. Our SR identified a need for studies that use rigorous methodology and transparent reporting. PROSPERO (ID = CRD42018084725).

Regenerative Endodontic Procedures for Traumatized Immature Permanent Teeth with Severe External Root Resorption and Root Perforation

External root resorption (ERR) is often a complication of traumatic injury to the teeth. Traditionally, external inflammatory root resorption is treated with calcium hydroxide. The outcome of ERR, especially replacement resorption, is unpredictable. The purpose of the present case report was to describe regenerative endodontic procedures (REPs) for 1 replanted avulsed tooth with severe external root resorption and root perforation (tooth #9) and 1 extruded tooth (tooth #8). A 9-year-old girl was referred for the treatment of teeth #8 and #9 4 months after the initial trauma. Clinical examination showed that tooth #9 had a sinus tract present near the periapical area, was tender to percussion and palpation, and did not respond to pulp sensibility tests. Tooth #8 responded to pulp sensibility tests. Periapical radiographic and cone-beam computed tomographic examination showed that tooth #9 had a periapical radiolucent lesion and severe ERRs with a root perforation. Tooth #9 was diagnosed with a necrotic pulp and symptomatic apical periodontitis. Regenerative endodontic procedures (REPs) were initiated. Tooth #8 became nonresponsive to pulp sensibility tests and developed a periapical lesion 12 months after REPs of tooth #9 and was also treated with REPs. The clinical symptoms and apical lesions resolved for both teeth after REPs. The severe ERRs were arrested, and root perforation was repaired for tooth #9. Teeth #8 and #9 underwent canal obliteration by hard tissue formation after REPs and were in function at 18 months and 30 months, respectively. REPs may be used to manage traumatized immature permanent teeth with a necrotic pulp and apical periodontitis associated with severe ERR and root perforation.

Endodontic Management of a Tooth with Severe External Root Resorption using Injected Non-setting Calcium Hydroxide Paste: A Case Report

External Root Resorption (ERR) is a pathological condition that can lead to tooth loss if not diagnosed and treated correctly. Calcium Hydroxide Ca(OH)2 is an intracanal medicament, which is used in cases of teeth with pulp necrosis, peri-radicular lesions and ERR. This paper describes the endodontic management of a tooth with severe ERR using injected non-setting Ca(OH)2 paste. A 28-year-old patient was referred for endodontic evaluation of tooth 47, which presented an extensive composite resin restoration and was negative to cold test. Panoramic and periapical radiographs revealed the presence of a filled pulp chamber, calcified root canals, ERR on the mesial and distal roots, and apical periodontitis in the mesial and distal roots. The diagnosis of asymptomatic apical periodontitis and severe ERR was established, and conventional root canal treatment combined with non-setting Ca(OH)2dressing was chosen. After five months, no more discharge from the root canal was observed, and a decrease in the size of the periapical lesion and arrest of ERR was detected. The root canal was filled, and the patient was referred for restoration. At the 6-months follow-up, radiographic examination evidenced periapical repair and containment of the ERR process. Chemomechanical root preparation in association with a non-setting Ca(OH)2 dressing protocol allows positive outcomes during the management of severe ERR associated with pulp necrosis and periapical inflammation.

Comprehensive orthodontic treatment in an adolescent patient with Class II Division 1 malocclusion and ankylosed maxillary central incisors

While uncommon in orthodontics, the extraction of central incisors may be indicated when such teeth are of poor prognosis. This report details orthodontic treatment of a 13-year and 5-month-old Chinese female, who presented with Class II/1 malocclusion on a Class II skeletal jaw base relationship. Her maxillary central incisors were ankylosed and had undergone severe external root resorption following a previous traumatic episode. Orthodontic treatment involved removal of the maxillary central incisors and the mandibular first premolars. Pre-adjusted edgewise appliances with MBT prescription were used. To enhance anterior esthetics, prosthetic buildup of the four maxillary anterior teeth was performed before appliance removal. Tight intercuspation of teeth and optimal facial esthetics were achieved at appliance debond and maintained at 2-year follow-up.

Impact of CBCT on treatment decision related to surgical removal of impacted maxillary third molars: does CBCT change the surgical approach?

To assess factors influencing treatment decision for maxillary third molars referred for cone beam CT (CBCT). Parameters influencing the decision to treat and to remove either the maxillary second molar or third molar were pursued. 111 impacted maxillary third molars, clinically examined including a panoramic image, in 86 patients (mean age 26 years, range 15-55) were referred for CBCT on suspicion of pathology/root resorption in the second molar, based on information in the panoramic image. The following parameters were assessed from the patient's file, including the radiographic images: (1) third molar angulation; (2) initial treatment plan based on clinical examination and the panoramic image; (3) diagnoses based on information from CBCT; (4) treatment decision after additional CBCT information was available; (5) pre-/post-operative complications; (6) treatment of the maxillary second molar. 70 cases (63.1%) underwent treatment, while 41 (36.9%) received no treatment. Change in treatment plan was registered in 65 cases (58.6%) after CBCT. In 12 cases (10.8%), treatment changed from removal of the third to removal of the second molar, while 25 (22.5%) were scheduled for removal in the initial treatment plan; but after CBCT, the decision was not to treat. If external root resorption involved the pulp of the second molar, there was an almost 17 times higher risk that this tooth was removed instead of the third molar (logistic regression analysis: odds ratio 16.8; p < 0.001). Findings in CBCT often changed the treatment plan. Severe external root resorption observed in CBCT was the main decisive factor for removing the second instead of the third molar.

External apical root resorption in orthodontically treated Class II malocclusions with 2-phase protocol (A 10-year Experience)

Background and objectives: External apical root resorption is one of the proposed sequels of fixed orthodontic appliances used for the treatment of different types of malocclusions specially class II. Many factors may be involved in the etiology and severity of such resorption. This study is conducted to explore the prevalence of root resorption and specify the most possible causative factors during orthodontic treatment. Method: Records of 103 patients (case sheet, panoramic and cephalometric radiograph) with class II malocclusion were retrieved from private clinics and dentistry college clinics. Patients with planned premolar extractions and 2-phase protocol for space closure were involved in the study. The pre- and post-treatment panoramic radiographs were evaluated for external apical root resorption using a scoring method proposed by Levander and Malmgren The effect of variables like age, gender and duration of the treatment on external root resorption were studied. Results: Statistical analysis showed that age and gender has insignificant relation with root resorption. A highly significant relation found between the severe external apical root resorption and the duration of treatment. Conclusion: External apical root resorption is highly associated with long-term duration treatment protocols.

Accuracy of digitally enhanced images compared with unprocessed digital images in the detection of external root resorption

This study was for comparing the accuracy of processed digital images (reverse-contrast and colorization) with that of unprocessed digital images in detection of external root resorption (ERR). Eighty single-rooted human teeth were selected for this study. Mild, moderate, and severe ERR were simulated on 20 teeth each, and 20 were left untreated. Digital images using the paralleling technique were made, and three types of images were finally produced: unprocessed, reverse-contrast, and colorized. Three experienced dentists examined the images. The Wilson confidence intervals were calculated to analyze the diagnostic data. The kappa statistic was used to determine interobserver agreement. For unprocessed images, the rate of correct classification of mild and moderate to severe ERR was 88.3 and 80.0 %, respectively. The corresponding rate for reverse-contrast images was 81.7 and 80.0 %, and that for colorized images was 93.3 and 80.0 %, respectively. The sensitivity of unprocessed images in the detection of mild and moderate to severe ERR was 0.93 and 0.84, respectively. The corresponding sensitivity for reverse-contrast images was 0.83 and 0.84, and that for colorized images was 0.93 and 0.84, respectively. The specificity of unprocessed, reverse-contrast, and colorized images was 0.90, 0.92, and 1.00, respectively. The kappa coefficient for interobserver agreement was 0.86 for unprocessed images, 0.88 for reverse-contrast images, and 0.89 for colorized images. The difference between the sensitivity and specificity of unprocessed, reverse-contrast, and colorized images was not statistically significant (p > 0.05). The three techniques were of similar and desirable accuracy in detection of ERR.

Scanning electron microscopy reveals severe external root resorption in the large periapical lesion.

The present study was designed to investigate the relationships between clinicopathological findings and the resorptive conditions of root apices of teeth with periodontitis. The samples included 21 root apices with large periapical radiolucent lesions. The preoperative computed tomography (CT) and intraoperative findings were correlated with the presence, extension, and the progression pattern of periapical resorption using a scanning electron microscope. The subjects' age, gender, chief complaint, type of tooth, percussion test results, size of periapical lesion using CT, and intraoperative findings were recorded. All apicoectomies were performed under an operative microscope for endodontic microsurgery. A significant large size was observed in cystic lesions compared with granulomatous lesions. The cementum surface at the periphery of the lesion was covered with globular structures (2-3 μm in diameter). Cementum resorption started as small defect formations at the surface. As the defect formation progressed, a lamellar structure appeared at the resorption area, and the size of globular structures became smaller than that of globules at the surface. Further resorption produced typical lacuna formation, which was particularly observed in fracture cases. The most morphologically severe destructive pattern of dentin resorption was observed in large cystic lesions. This study is the first report to elucidate the relationships between three clinical types of undesirable periapical lesions: (1) undertreatment, (2) periapical fracture, (3) macro-level resorption, and the microstructure of external root resorption including from small defects at the cementum surface to a significant destructive pattern inside the dentin. Microsc. Res. Tech. 79:495-500, 2016. © 2016 Wiley Periodicals, Inc.

Severe root resorption resulting from orthodontic treatment: prevalence and risk factors.

OBJECTIVE: To assess the prevalence of severe external root resorption and its potential risk factors resulting from orthodontic treatment. METHODS: A randomly selected sample was used. It comprised conventional periapical radiographs taken in the same radiology center for maxillary and mandibular incisors before and after active orthodontic treatment of 129 patients, males and females, treated by means of the Standard Edgewise technique. Two examiners measured and defined root resorption according to the index proposed by Levander et al. The degree of external apical root resorption was registered defining resorption in four degrees of severity. To assess intra and inter-rater reproducibility, kappa coefficient was used. Chi-square test was used to assess the relationship between the amount of root resorption and patient's sex, dental arch (maxillary or mandibular), treatment with or without extractions, treatment duration, root apex stage (open or closed), root shape, as well as overjet and overbite at treatment onset. RESULTS: Maxillary central incisors had the highest percentage of severe root resorption, followed by maxillary lateral incisors and mandibular lateral incisors. Out of 959 teeth, 28 (2.9%) presented severe root resorption. The following risk factors were observed: anterior maxillary teeth, overjet greater than or equal to 5 mm at treatment onset, treatment with extractions, prolonged therapy, and degree of apex formation at treatment onset. CONCLUSION: This study showed that care must be taken in orthodontic treatment involving extractions, great retraction of maxillary incisors, prolonged therapy, and/or completely formed apex at orthodontic treatment onset.

Generalized severe idiopathic external root resorption and the importance of pre-treatment radiographs: a case report

This report discusses a case of rare idiopathic root resorption in a 13-year-old female and highlights how an upper standard occlusal radiograph proved to be pivotal in the diagnosis and demonstration of its incidence. Management of the case is described, with discussion of treatment alternatives. Clinical Relevance: Generalized idiopathic external root resorption is progressive. Before commencing orthodontic treatment, adequate clinical and radiographic examination is essential to facilitate appropriate management. Currently, UK orthodontists do not routinely take an upper standard occlusal radiograph pre-treatment. However, this case highlights the benefit of such diagnostic imaging, in specific circumstances.

Predisposing factors to severe external root resorption associated to orthodontic treatment

The aim of this study was to evaluate predisposing factors among patients who developed moderate or severe external root resorption (Malmgren's grades 3 and 4), on the maxillary incisors, during fixed orthodontic treatment in the permanent dentition. Ninety-nine patients who underwent orthodontic treatment with fixed edgewise appliances were selected. Patients were divided into two groups: G1 - 50 patients with no root resorption or presenting only apical irregularities (Malmgren's grades 0 and 1) at the end of the treatment, with mean initial age of 16.79 years and mean treatment time of 3.21 years; G2 - 49 patients presenting moderate or severe root resorption (Malmgren's grades 3 and 4) at the end of treatment on the maxillary incisors, with mean initial age of 19.92 years and mean treatment time of 3.98 years. Periapical radiographs and lateral cephalograms were evaluated. Factors that could influence the occurrence of severe root resorption were also recorded. Statistical analysis included chi-square tests, Fisher's exact test and independent t tests. The results demonstrated significant difference between the groups for the variables: Extractions, initial degree of root resorption, root length and crown/root ratio at the beginning, and cortical thickness of the alveolar bone. It can be concluded that: Presence of root resorption before the beginning of treatment, extractions, reduced root length, decreased crown/root ratio and thin alveolar bone represent risk factors for severe root resorption in maxillary incisors during orthodontic treatment.

Clinical management of severe external root resorption and immature open apex with MTA and calcium hydroxide - A case report

External apical root resorption in permanent dentition is usually pathological. Local factors are the most frequent causes of resorption, especially excessive pressure and inflammation. Depending upon the type of resorption and etiology, different treatment regimens have been proposed. This case demonstrates external root resorption arrest and formation of an apical barrier by conventional endodontic therapy combined with calcium hydroxide dressing and a mineral trioxide aggregate (MTA) apical plug. The upper left central incisor exhibited severe external root resorption along with open apex in both right and left central incisors which received pulp space therapy combined with calcium hydroxide dressing. MTA apical plug backfilled with gutta-percha was performed and the access cavity was restored with composite resin. The patient has been regularly recalled every 6 months, and no symptoms or signs have been noted. Radiography the apical lesion healed and the external root resorption has been arrested after 1 year.

Management of inflammatory root resorption using MTA obturation – a four year follow up

A case report of severe external inflammatory root resorption is presented. The patient reported with a complaint of increased tooth mobility after avulsion and replantation. The case was treated with full root canal obturation with mineral trioxide aggregate. A 48 month follow up review showed arrest of root resorption with satisfactory clinical results. This article discusses the aetiology of inflammatory root resorption and the use of the latest root canal obturation materials in improving healing outcomes.

RANKL Increase in Compressed Periodontal Ligament Cells from Root Resorption

The ligand receptor activator of NFkappaB (RANKL) plays an important role in osteoclast formation. However, very little is known about the relationship between external apical root resorption during orthodontic treatment and RANKL. We hypothesized that compressive force is responsible for RANKL formation and up-regulation of osteoclastogenesis in periodontal ligament (PDL) cells from patients with severe orthodontically induced external apical root resorption. RANKL and osteoprotegerin (OPG) production, TRAP-positive cells, and resorptive pits were determined. The increase of RANKL and the decrease of OPG were greater in the severe root resorption group than in the non-resorption group. The numbers of TRAP-positive cells and resorptive pits were also increased in the severe root resorption group than in the non-resorption group. These results support the hypothesis that the compressed PDL cells obtained from tissues with severe external apical root resorption may produce a large amount of RANKL and up-regulate osteoclastogenesis.

Severe External Root Resorption Arrested by Conventional Endodontic Treatment

A case is presented of inflammatory external root resorption detected on radiographic examination. Conventional endodontic treatment, including calcium hydroxide dressing for two weeks and obturation of the root canal system using the vertical compaction of warm gutta-percha technique was a simple and effective treatment modality for arresting the resorptive process and maintaining the integrity of the patient dentition.