Case Report/Clinical Techniques
Transient Apical Breakdown and Its Relationship
with Orthodontic Forces: A Case Report
Oscar Lozano Gonz
alez, DDS,* Jorge Vera, DDS,†‡ Marco Salas Orozco, DDS,*
Jaime Trigueros Mancera, DDS,* Karla Vidal Gonz
alez, DDS,* and Genaro Vega Malag

Abstract
Introduction: Transient apical breakdown (TAB)
caused by orthodontic treatment is a reversible resorp-
tive process in which the apex of a tooth shows some
radiographic evidence of resorption and the crown
may display some discoloration. It usually requires no
treatment other than monitoring and elimination of
the orthodontic forces applied to the tooth. Methods:
This report describes the case of a 48-year-old man
patient who was referred to the department of
endodontics for evaluation of some discoloration of
his upper right central incisor, which was undergoing
orthodontic treatment. The tooth was nonresponsive
to sensitivity tests, it was sensitive to percussion, and,
radiographically, there was some evidence of root
resorption and apical radiolucency. Results: Because
TAB was the suspected cause of the signs and symp-
toms, no treatment was performed on the tooth except
for periodic recalls, and lightening and eventual
removal of the orthodontic appliances was indicated.
Conclusions: Ten weeks after the initial appointment
and removal of the applied orthodontic forces, color
improvement was observed, accompanied by a return
of tooth sensitivity to cold tests. (J Endod
2014;40:1265–1267)
Key Words
Orthodontic forces, spontaneous periapical lesion,
transient apical breakdown
From the *Endodontic Postgraduate Program, Universidad
Aut
onoma of Queretaro, Quer
etaro de Arteaga, Mexico;
†
University of Tlaxcala, Tlaxcala, Mexico; and ‡Private Practice,
Puebla, Mexico.
Address requests for reprints to Dr Genaro Vega Malag
on,
Portal Constituci
on 127-3 Cortazar, Guanajuato, M
exico
CP 38300. E-mail address: oscarlozanogonzalez@gmail.com
0099-2399/$ - see front matter
Copyright ª 2014 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2014.01.006
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on, PhD*
O rthodontic tooth movement is accomplished by the application of force to a
tooth over a period of time, which may take months or up to several years.
This procedure will lead to some degree of a biological reaction in the periodontal
ligament (PDL) and the dental pulp. External root resorption, which is associated
with orthodontic treatment, is both unpredictable and frequent, occurring mostly in
the maxillary anterior teeth and depending on various treatment factors such as the
removal of upper premolars (1–4).
Two morphologic types of external root resorption have been identified: transient
apical breakdown (TAB) and periapical replacement resorption (PARR) without
ankylosis (5). TAB is considered a temporary process in which the apex of a tooth
radiographically shows some evidence of resorption because of trauma or the
application of orthodontic forces (5, 6) and the affected tooth may display color
changes and variable responses to sensitivity tests (6–8). However, the root apex
and surrounding bone returns to normal after repair takes place. The time required
for this to occur is variable and may take as long as 1 year after the removal of the
cause. Because of the regression of signs and symptoms, TAB should be
distinguished by color changes, pulp sensitivity tests, and the history of the case from
physiologic resorption (5). The aim of this case report was to describe the clinical
management of a case of TAB caused by orthodontic forces and its resolution without
the necessity for root canal therapy.
Case Report
A 48-year-old man was referred to the Department of Endodontics, Universidad
Aut
onoma de Quer
eretaro, Guanajuato, Mexico, for discoloration of his upper right
incisor. Initially, the patient had been referred to the department of orthodontics
because of malpositioning of his teeth. Five weeks after the placement of orthodontic
appliances, the upper right central incisor crown showed signs of discoloration,
and, therefore, he was referred to the department of endodontics for evaluation.
Clinically, the tooth presented with gray discoloration and a negative response to
sensitivity tests with cold (Endo-Ice; Hygenic, Cuyahoga, OH); however, it responded
sensitively to vertical and horizontal percussion tests. There were no caries or
restorations present on the tooth, and the probing depth was 2 mm all around.
Radiographically, a small area of apical radiolucency was present as well as
widening of the PDL (Fig. 1A and B). After the initial appointment, the treating dentists
at the department of orthodontics were asked to lighten the applied orthodontic force,
and the patient was given a follow-up appointment 4 weeks later.
At the second appointment, some recovery of the gray discoloration of the
crown was apparent, but the tooth was still nonresponsive to cold sensitivity
tests; there were no radiographic changes in apical radiolucency from the previous
radiograph (Fig. 2A and B). Because of the regression of tooth discoloration, TAB
was suspected as the cause of the signs and symptoms, so the department of
orthodontics was asked to remove the orthodontic wire and all orthodontic forces.
The patient was given all the information concerning possible diagnosis and agreed
to be rescheduled for another appointment 6 weeks later (10 weeks after the initial
appointment).
After a further 6 weeks, the gray discoloration had almost disappeared, the tooth
responded positively to sensitivity tests with cold, there were no responses to percussion
or palpation, and, radiographically, the apical radiolucency had disappeared and the
Transient Apical Breakdown 1265
Case Report/Clinical Techniques
Figure 1. Five weeks after the placement of orthodontic appliances. (A) Gray discoloration of the upper right central incisor. (B) A small area of apical
radiolucency can be seen.
PDL space was within normal limits. In addition, there was no
radiographic shortening of the root (Fig. 3A and B).
Discussion
There are only a few cases of TAB reported in the literature,
including descriptions of its physiology and clinical management.
Proper diagnosis is extremely important so that no treatment other
than periodic recalls is recommended (5). External root resorption
occurring during orthodontic treatment is not rare and is also
unpredictable. Some studies have shown that root resorption will occur
in 19%–31% of teeth being treated (9), with no difference between
teeth with vital pulps and those treated endodontically (10). Genetic
predisposition has also been mentioned as a cause of external apical
root resorption, with many genes such as IL-1B and TNFRSF11 A (which
encodes the receptor activator of nuclear factor-kappa B) contributing
to the problem (11–13).
TAB is related not only to the type of trauma that the tooth suffers
but also to the stage of root development, usually resulting from
moderate injuries from lateral luxation or extrusion of teeth with closed
apexes. Initially, there will be some radiographic widening of the PDL
space followed by surface resorption and then blunting of the apex.
However, these signs of TAB usually return to normal with little evidence
of root resorption or changes in the PDL space (6, 7).
It is important to differentiate TAB from physiologic apical
resorption and PARR (with or without ankylosis). Physiologic apical
resorption will not normally be detected clinically or radiographically;
it is a self-limiting response of the root surface to physiologic stimuli
such as mastication and forms part of the repair process of the
attachment apparatus including the cementum and PDL (14, 15).
PARR with ankylosis commonly occurs after severe trauma such as
avulsion or intrusive luxation, especially in teeth with incomplete root
formation, leading to gradual resorption of the root, which is replaced
Figure 2. Four weeks after the placement of a stainless steel 6-strand coaxial archwire. (A) Some regression of the gray discoloration is noted. (B) A small area of
apical radiolucency is still present.
1266 Gonz
alez et al.
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by bone. As a result, the root canal is obliterated, and the PDL space is
usually lost (9, 16). In contrast, PARR without ankylosis is usually
observed in maxillary or mandibular anterior teeth that are being
treated orthodontically (5), and in this case, the PDL space can be
observed radiographically all around the root except for the apical
portion where it may appear ill defined (9).
Orthodontically induced TAB appears similar to trauma-related
TAB, but changes are transitory and usually tend to regress after
the cause is eliminated. In addition, when compared with trauma-
induced TAB, in TAB caused by the application of orthodontic forces,
pulp obliteration is usually not present. Therefore, an evaluation of
the history involved in the case is essential, and once identified, no
treatment and only periodic recalls are indicated; in general, some
mild residual apical root resorption will be observed in affected
teeth (5).
Even though the development of TAB is incompletely understood,
neurogenic inflammation in the pulp and the periapical region caused
by the applied orthodontic forces has been implicated (17, 18).
Neuropeptides such as substance P, calcitonin gene-related peptide,
neurokinin A, vasoactive intestinal polypeptide, and neuropeptide Y
are present in normal pulpal nerve fibres. An increase in nerve
sprouting in the pulp and periapical region with concomitant release
of neuropeptides would cause increased fluid pressure and cell
infiltration in the area but have also been suggested as a cause of
resorption in PARR (9, 19); therefore, a similar but reversible
mechanism may occur in TAB.
Accurate assessment of pulp vitality would ideally be conducted
when suspecting an ongoing process such as TAB. The use of dual
wavelength spectrophotometry, pulse oximetry, and laser Doppler
flowmetry would be useful to determine the vitality of the pulp
(8, 20); however, in the absence of such technologies and when
relying on sensitivity tests like cold stimulation, an understanding of
the etiology of TAB in teeth that are being orthodontically treated is
JOE — Volume 40, Number 8, August 2014

Figure 3. Ten weeks after the initial appointment and the removal of orthodontic forces. (A) Color regression is almost complete. (B) No periapical radiolucency
is present. At this time, the tooth responded positively to cold sensitivity tests.
essential. In these cases, a no-treatment and wait approach is indicated,
and the reversal of signs and symptoms after the removal of orthodontic
forces should confirm TAB.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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Case Report/Clinical Techniques
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