ORIGINAL ARTICLE

Association between root resorption and

tooth development: A quantitative
clinical study
Xinyi Li, Jingchen Xu, Yuanyuan Yin, Ting Liu, Le Chang, Zhaomeng Tang, and Song Chen
Chengdu, Sichuan, China

Introduction: The aim of this study was to verify less resorption of incompletely developed roots compared with
those that were fully developed during the same orthodontic treatment and to test the value of the amount of
external apical root resorption for predicting tooth development. Methods: A sample of 524 patients aged
10-15 years was selected following the inclusion criteria. For each subject, pretreatment and posttreatment dig-
ital panoramic and lateral radiographs were collected, and tooth development was determined from each radio-
graph. Through calculations, the amount of root resorption was assessed by a created and scientific approach
for large-scale application using radiographs with only 8 measurement indexes for each patient. Other basic
information and treatment parameters regarded as possible risk factors were also collected from
standardized recordings or radiographs. The root length between the groups or in the single group were
compared with t tests and correlation analyses. Linear univariate and multivariate regression analyses were
used to test identify predictors for root resorption and to develop a prediction model. Results: There was a sta-
tistically significant difference in the amount of root resorption with tooth development before correction
(P \0.001) as well as after correction (P 5 0.002). There was a statistically significant correlation (P \0.001)
but no difference between pretreatment and posttreatment root length in the immature tooth group because
of less root resorption. In the multivariate analyses, tooth development (P\0.001), treatment duration, apex hor-
izontal movements, apex vertical movements, and previous orthodontic treatment were included in the final
model as risk factors, and tooth development had the highest beta value. Conclusions: There is an association
between root resorption and tooth development, and tooth development is an important predictor of
root resorption. Patients with immature teeth are at a much lower risk of apical root resorption. (Am J Orthod
Dentofacial Orthop 2020;157:602-10)

E
xternal apical root resorption (EARR) is an inevi-
table side effect of orthodontic treatment.1,2
Whereas external root resorption occurs from all
directions, EARR of teeth shows only apical resorption,
which is characterized by root shortening.3 EARR is esti-
mated to occur in 80%-90% of orthodontic patients.4,5
Although tooth survival and normal function are not
From the State Key Laboratory of Oral Diseases, National Clinical Research Center
for Oral Diseases, Department of Orthodontics, West China Hospital of Stomatol-
ogy, Sichuan University, Chengdu, Sichuan, China.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
This study was supported by funds from the National Natural Science Founda-
tion of China (number 81671021).
Address correspondence to: Song Chen, Department of Orthodontics, West China
Hospital of Stomatology, Sichuan University, Section 3, No. 14, Renmin South
Road, Chengdu, Sichuan, 610041 China; e-mail, songchen882002@hotmail.
com.
Submitted, August 2019; revised and accepted, November 2019.
0889-5406/$36.00
Ó 2019 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2019.11.011
602
affected in most cases of mild EARR, orthodontic treat-
ment should be suspended in some cases of severe EARR,
and it is important for the practitioner to identify the
dominant factors for the development of EARR to be
able to adjust treatment to manage this adverse effect.
According to our previous study,6 EARR was a multifac-
torial problem, and several potential genetic and clinical
risk factors were reported. The common consensus is
that the type and the amount of orthodontic force7-14
were considered as the main causes of EARR in
treatment factors.15,16 As for patient characteristics, ge-
notype,17-19 sex, nutrition, amount of apical
displacement,20-22 and malocclusion type21,23 can also
initiate and induce root resorption.
Previous studies also found that increased ages coin-
cided with more root resorption20,23-25 indicating older
people are more vulnerable.26 However, physiological
age, which many studies used, was unable to accurately
reflect root development, which was more likely to asso-
ciate with root resorption. Thus, considering whether the
Li et al
tooth was fully developed as inclusion and exclusion
criteria can be simple for observers to increase repeat-
ability and reproducibility. The stages of dental maturity
can be assessed by methods such as Demirjian's and
Haavikko's.27,28 In addition, open or closed apical
foramina may play a vital role in root resorption. It has
been suggested that there is a contact between the
root and the alveolar bone causing EARR and a relation-
ship between EARR and pulp,23,29 and the apical
foramina connect the pulp and alveolar bone. Because
the pulp vessels are the branches of alveolar bone vessels,
orthodontic forces can stretch or damage apical vessels,
decrease blood flow, and cause pulpal disturbances.30-32
An unclosed apical foramina, indicating more free space
and adequate blood supply, may help relieve pressure
and maintain balance.
To reliably assess the amount of EARR in a patient is
the major obstacle in such clinical studies. It had been
widely reported that root length change could be consid-
ered as evidence of EARR, and 2-dimensional images
were mainly used for measuring root shortening, but un-
desirable errors may occur when aligning the images
taken at different times.33,34 Thus, both digital pano-
ramic radiographs and lateral radiographs were involved
in this assessment, and the quantitative measurements
that have small changes in the images taken at different
times were selected. Through calculations, the reduced
root length can be obtained and compared before and
after orthodontic treatment.
Therefore, the purpose of this investigation was to
verify the following hypothesis during clinical experi-
ence: There is an association between root resorption
and tooth development, and patients with immature
teeth will undergo less root resorption.
MATERIAL AND METHODS
This longitudinal retrospective study was approved by
the ethical board of West China Hospital of
Stomatology involving all subjects who accepted ortho-
dontic treatment from 2015 to 2018. Patients were
selected according to the following inclusion criteria:
aged 10-15 years during the entire treatment, both digital
panoramic and lateral radiographs before and after treat-
ment, the Frankfort plane of the radiographs parallel to
the floor, good occlusal finishing, and periapical radio-
graphs. All patients were treated the standard fixed–
straight wire appliances with 0.022 3 0.028-in slots and
general archwire sequences of 0.016-in nickel-titanium
to 0.019 3 0.025-in stainless steel. All radiographs were
taken and scanned on the same machine at West China
Hospital of Stomatology with the same setting used.
American Journal of Orthodontics and Dentofacial Orthopedics
603
Radiographs of insufficient quality, films not displaying
the entire root, impacted teeth, and incomplete orthodon-
tic records were excluded.
The tooth development of each radiograph was
determined by 2 observers independently according to
Moorrees and Kent,35 and Moorrees et al.36 The ob-
servers were blinded to sample information, and they
repeated the procedures twice in a 3-week interval.
The within-observer repeatability and reproducibility
of the 2 observers were evaluated using intraclass corre-
lation coefficients (ICCs).37 Then the included cases were
further divided into an immature tooth (IT) group and a
mature tooth (MT) group. Because the maxillary incisors
usually showed more EARR than any other teeth in
several studies,2,38 all maxillary central incisors of which
the apexes had not completely formed both before and
after treatment were viewed as IT cases, and those of
which the apexes had completely formed both before
and after treatment were viewed as MT cases (Fig 1).
The basic information and treatment parameters of
each included patient were collected, including initial
age, sex, history of trauma, history of earlier orthodontic
treatment or endodontic treatment, extraction decision,
and treatment period, which were possible factors for
root resorption.
Then several lengths and angulations were measured
using the same program on the pretreatment and post-
treatment radiographs for each patient. The reference
points and lines for measurements are shown in
Figure 2. Before treatment, the lengths of the crowns
and roots on the lateral radiographs were C1L0 and
R1L0 , and the lengths of the crowns and roots on the
panoramic radiographs were C1P0 and R1P0 . The magnifi-
cations of the lateral and panoramic radiographs were VL
and Vp. Respectively, the real lengths of the crowns and
roots on the lateral radiographs were C1L and R1L, and
the real lengths of the crowns and roots on the pano-
ramic radiographs were C1P and R1P. The minimum scale
of the rules on the lateral radiographs were d1, and the
real minimum scale was d (d 5 10 mm). The angulations
of the maxillary central incisors on the lateral radio-
graphs were q1. Similarly, the lengths and angulations
on the posttreatment radiographs were C2L0 , R2L0 , C2P0 ,
R2P0 , VL, Vp, C2L, R2L, C2P, R2P, d2, d, and q2. Attention
should be paid to the crown and root lengths that
were measured differently compared with those that
were calculated by measuring the distance from the
maxillary central incisal edge to the midpoint of the
line. In the panoramic radiographs, the highest point
of cementoenamel junction (CEJ) was determined, and
the crown lengths were the distance from the incisal
edge to the highest point, whereas the root lengths
May 2020  Vol 157  Issue 5
604 Li et al

Fig 1. Grouping methods of included cases: A, immature tooth group, all maxillary central incisors
apexes had not completely formed both before and after treatment; B, mature tooth group, all maxillary
central incisors apexes had completely formed both before and after treatment.

Fig 2. The reference points and lines for measurements: A, on pretreatment lateral radiographs, the
lengths of crowns and roots were C1L0 and R1L0 , the real lengths of crowns and roots were C1L and
R1L, the minimum scale of the rules were d1 and the real minimum scale was d, the angulations of
the maxillary central incisors were q1, and the magnifications were VL; Similarly, the lengths and angu-
lations on the posttreatment lateral radiographs were C2L0 , R2L0 , VL, C2L, R2L, d2, d, and q2; B, on pre-
treatment panoramic radiographs, the lengths of crowns and roots were C1P0 and R1P0 , the real lengths
of crowns and roots on the panoramic radiographs were C1P and R1P, and the magnifications were Vp;
Similarly, the lengths and angulations on the posttreatment lateral radiographs were C2P0 , R2P0 , Vp, C2P,
R2P; C, the anterior and posterior CEJ points in the lateral radiographs are the highest point of CEJ in
the panoramic radiographs.

were the distance from the highest point to the root where Vp can be presented as
apices.
C1P 0 C1P 0 C1P 0 C1P 0
Through the following calculations, the quantitative VP 5 5 5 0 5 0
C1P C1L 3sin q1 C1L C1L
measurements that had small changes in the images 3sin q1 3sin q1
taken at different times were selected. R1L can be pre- VL d1 =d
sented as
Therefore,
R1P R1P 0 =VP
R1L 5 5 R1P 0 3C1L 0 3d
sin q1 sin q1 R1L 5
C1P 0 3d1

May 2020  Vol 157  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Li et al
Similarly, R2L can be presented as
0 0
R2P 3C2L 3d
R2L 5
C2P 0 3d2
Therefore, the root resorption R is
R1P 0 3C1L 0 3d R2P 0 3C2L 0 3d
R5 
C1P 0 3d1 C2P 0 3d2
Eventually, the quantitative measurements selected
to assess the amount of EARR were only C1P0 , R1P0 ,
C1L0 , d1, C2P0 , R2P0 , C2L0 , and d2 for each patient (Fig 3).
In addition, apical displacement is also a main risk
factor for root resorption. According to the study by Mir-
abella and Artun,39 in lateral radiographs, pretreatment
overjet and the horizontal movement of the incisal
edge during treatment (Dx) and pretreatment overbite
and the vertical movement of the incisal edge during
treatment (Dy) were measured; therefore, the horizontal
(Dx0 ) and vertical (Dy0 ) movements of the apex could be
calculated. The proximity of the central incisor roots to
the palatal cortical bone were scored both before and af-
ter treatment.
Without any other similar study, Xu and Baumrind40
found that the root growth of patients aged 7-10 years
was rapid, whereas that of patients aged 10-13 years was
slow with a total growth of 0.54 mm in 3 years, and the
root length after age 13 years was stable. Therefore, we
Fig 3. The quantitative measurements selected to assess the amount of EARR: A, C1P0 , R1P0 , C1L0 , and
d1 were measured in the pretreatment lateral and panoramic radiographs of a patient; B, C2P0 , R2P0 ,
C2L0 , and d2 were measured in the posttreatment lateral and panoramic radiographs of the same pa-
tient.
American Journal of Orthodontics and Dentofacial Orthopedics
605
added 0.18 mm per year during ages 10-13 years to the
amount of root resorption as the correction.
Two observers were required to measure all subjects
of 50 patients selected randomly again in a 3-week in-
terval, and the average errors were determined by intra-
observer and interobserver comparison using ICCs.
Statistical analysis
The basic data were summarized using means, stan-
dard deviations, and frequencies. Normal distribution of
the variables was verified with Kolmogorov-Smirnov
tests, and all variables showed a normal distribution.
Initial intergroup data were compared using t test and
chi-square test. Associations of tooth development and
EARR between IT and MT groups were analyzed using
independent-samples t tests, and a comparison of pre-
treatment and posttreatment in each single group was
evaluated using paired-samples t tests and correlation
analyses. The statistical significance was P \0.05.
Linear regression analyses were used to test identify
predictors for root resorption. After univariate regres-
sion, stepwise multiple regressions with forward selec-
tion were used to develop a prediction model.
Variables with the lowest P value were successively
entered into the model if their effects were significant
at P \0.05.
May 2020  Vol 157  Issue 5
606 Li et al

RESULTS
Table II. Measurements of EARR in OA group and CA
The intraobserver repeatability of tooth development group (t test)
was high for both observers (ICC 5 0.998 and 0.999),
Open apex Closed apex
and the reproducibility of the 2 observers was also group, n 5 259 group, n 5 265
high (ICC 5 0.855). The intraobserver and interobserver Variable mean (SD) mean (SD) P value
reproducibility of measurements were all high (all C1P0 (mm) 10.57 (2.01) 10.61 (1.83) 0.802
ICC .0.8). R1P0 (mm) 14.73 (2.90) 14.61 (2.53) 0.619
This study included 259 patients in the IT group and C1L0 (mm) 12.19 (1.08) 12.07 (1.08) 0.185
d1 (mm) 10.80 (0.55) 10.75 (0.52) 0.282
265 patients in the MT group. The average ages, sex, his-
C2P0 (mm) 10.09 (1.74) 10.25 (1.62) 0.274
tory of trauma, history of earlier orthodontic treatment R2P0 (mm) 14.34 (2.72) 13.45 (2.48) \0.001*
or endodontic treatment, extraction decision, the ortho- C2L0 (mm) 11.84 (0.97) 11.69 (1.02) 0.069
dontic treatment duration, and the horizontal and verti- d2 (mm) 10.61 (0.57) 10.53 (0.57) 0.113
cal apex movements of the 2 groups were presented Pretreatment root 16.00 (3.24) 15.62 (2.56) 0.146
length (mm)
below, respectively. Initial intergroup data comparisons
Posttreatment root 16.07 (3.10) 14.71 (2.77) \0.001*
(t and chi-square tests) are shown in Table I. length (mm)
The digital panoramic and lateral radiographs of all Root resorption (mm) 0.07 (3.25) 0.91 (2.73) \0.001*
subjects were used for assessing EARRs. Table II and Root resorption after 0.20 (3.26) 1.01 (2.72) 0.002*
Figure 4 show the amount of EARR in the 2 groups, indi- correction (mm)
cating that the IT group has less root resorption than the OA, open apex; CA, closed apex; SD, standard deviation; C1P0 ,
MT group before correction (P \0.001) as well as after the crown lengths on pretreatment panoramic radiographs; R1P0 ,
the root lengths on pretreatment panoramic radiographs; C1L0 , the
correction (P 5 0.002), which are both statistically sig-
crown lengths on pretreatment lateral radiographs; d1, the rule
nificant. The pretreatment and posttreatment root minimum scale on pretreatment lateral radiographs; C2P0 , the crown
lengths in the single group were also compared in lengths on posttreatment panoramic radiographs; R2P0 , the
Table III. root lengths on posttreatment panoramic radiographs; C2L0 , the
Univariate linear regression showed that extraction crown lengths on posttreatment lateral radiographs; d2, the rule
minimum scale on posttreatment lateral radiographs.
decision (P \0.05), treatment duration (P \0.01), the
*Statistically significant at P \0.05.
horizontal movements of the apex (P \0.05), and tooth
development (P \0.01) were associated with the
Root resorption after correction 5 1.599 1 1.09
amount of root resorption after correction. The multi-
(tooth development) 1 0.06 (duration) 1 0.46 (horizon-
variate analyses detected an association between root
tal movement) 1 0.75 (vertical movement)  5.21 (pre-
resorption and possible factors. Tooth development
vious orthodontic treatment)
(P \0.001), treatment duration (P \0.001), apex hori-
zontal movements (P \0.001), apex vertical movements
DISCUSSION
(P \0.05), and previous orthodontic treatment
(P\0.05) were included in the final model as risk factors In this study, we investigated EARR associated with
(Table IV) with r2 5 0.83. The amount of root resorption tooth development, rather than physiological age. It is
after correction could therefore be predicted with this easier for observers to determine the achievement of
formula: tooth development to increase repeatability and

Table I. Initial intergroup data comparison (t test and chi-square test)

Open apex group, n 5 259 Closed apex group, n 5 265
Variable mean (SD) mean (SD) P value
Initial age (y) 11.47 (0.89) 12.67 (0.99) \0.001*y
Duration (mo) 26.92 (9.03) 25.40 (8.84) 0.052y
Overjet reduction (mm) 1.80 (2.35) 1.25 (1.63) 0.002*y
U1-SN reduction ( ) 4.14 (9.46) 3.10 (7.61) 0.166y
Sex \0.001*z
Male 141 79
Female 118 186

SD, standard deviation.

*Statistically significant at P \0.05; yt test; zchi-square test.

May 2020  Vol 157  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Li et al 607

Fig 4. Comparison of EARR in the IT group and MT group.

reproducibility in large-scale application. The EARR was
evaluated using both digital panoramic radiographs and
lateral radiographs for low costs and high follow-up rate,
which is more accurate based on quantitative measure-
ments selected through scientific calculations. For
example, because the apical point on the lateral radio-
graphs was not clear, the root length on the lateral radio-
graphs (R1L0 and R2L0 ) was replaced by other
measurements. The angulations of the maxillary central
incisors on the lateral radiographs (q1 and q2) were
greatly impacted by the subjective position of the SN
plane and had considerable changes measured at
different times, therefore they were removed during cal-
culations. Eventually, after the calculations, only C1P0 ,
R1P0 , C1L0 , d1, C2P0 , R2P0 , C2L0 , and d2 need to be measured
for each patient. The 8 measurements are clear and sim-
ple to determine on radiographs to increase repeatability
and reproducibility in large-scale application. Moreover,
the CEJ is not a straight line, as the labial or lingual curve
protrudes to root, and the mesial or distal curve pro-
trudes to crown. To match C1L and C1P, C2L, and C2P,
R1L and R1P, R2L, and R2P, a common division straight
line of crown and root should be determined on the
labial and proximal surfaces. Because the anterior and
posterior CEJ points in the lateral radiographs are the
highest point of CEJ in the panoramic radiographs, the
division line can be obtained by connecting the anterior
and posterior points or crossing the highest points, and
the crown or root length can be measured from the line
to the incisal edges or root apices. Therefore, the crown
and root lengths were measured more accurately, which
was different from other studies. Thus, the results are
more accurate and reliable as the high intraobserver
and interobserver ICCs showed.
Special attention was dedicated to having an IT
group and MT group with similar characteristics, such
as initial age, sex distribution, history of trauma, history
of earlier orthodontic treatment or endodontic

Table III. Intragroup data comparison of root length (correlation analysis and t test)
Correlation analysis
t test
Variable Pretreatment, mean (SD) Posttreatment, mean (SD) r P value P value
Root length of OA group 16.00 (3.24) 16.07 (3.10) 0.474 \0.001* 0.715
Root length after correction of OA group 16.00 (3.24) 15.79 (3.12) 0.475 \0.001* 0.319
Root length of CA group 15.62 (2.56) 14.71 (2.77) 0.476 \0.001* \0.001*

SD, standard deviation; OA, open apex; CA, closed apex.

*Statistically significant at P \0.05.

American Journal of Orthodontics and Dentofacial Orthopedics May 2020  Vol 157  Issue 5
608 Li et al

Table IV. Results of univariate and multivariate regression analyses with forward selection using root resorption after
correction (mm) as the dependent variables
Univariate Multivariate

Variable (unit) B P value B (SE) Beta P value

Initial age (y) 0.20 0.10
Sex (male/female) 0.26 0.33
Trauma (yes/no) 1.49 0.23
Previous orthodontic treatment (yes/no) 3.36 0.12 5.21 (2.10) 0.11 \0.05*
Endodontic treatment (yes/no) 0.09 0.98
Extraction (yes/no) 0.54 \0.05*
Duration (mo) 0.05 \0.01* 0.06 (0.01) 0.16 \0.001*
Pretreatment overjet (mm) 0.05 0.44
Pretreatment overbite (mm) 0.02 0.69
Horizontal movement (Dx') (mm) 0.44 \0.05* 0.46 (0.13) 0.15 \0.001*
Vertical movement (Dy') (mm) 0.67 0.09 0.75 (0.38) 0.08 \0.05*
Pretreatment proximity to palate (yes/no) 0.53 0.76
Posttreatment proximity to palate (yes/no) 1.77 0.19
Apex closure (yes/no) 0.811 \0.01* 1.09 (0.26) 0.18 \0.001*
SE, standard error.
*Statistically significant at P \0.05.

treatment, extraction decision, treatment duration, and
the horizontal and vertical apex movements, because
these factors may contribute to root resorption (Table
I). Although the treatment time does not seem to be
associated with root resorption as most studies have
indicated, there was a significant difference between
initial age and sex distribution in the groups because
tooth development is closely related to age and happens
earlier in female patients. There was also significant dif-
ference between the horizontal and vertical apex move-
ments, showing that the IT group had more incisor
torque changes or bodily movement, but in the later
investigation, the IT group had less root resorption,
which is different from previous discoveries and indi-
cates the immature teeth can resist the root resorption.
Root resorption was carefully compared between the
IT group and MT group and between each quantitative
measurement (Table II). All single measurements
including C1P0 , R1P0 , C1L0 , d1, C2P0 , R2P0 , C2L0 , and d2
had no statistical significance showing similar character-
istics of the 2 groups. Pretreatment root length had no
statistical significance, but posttreatment root length
had statistical significance and root resorption, which
indicates that there is an association between root
resorption and tooth development. However, most pre-
vious studies ignored the problem of root growth, and
few have determined the amount of root growth.
Although the result in this study will be similar regardless
of the root growth amount, we added 0.18 mm per year
during ages 10-13 years to posttreatment root length as
the correction. After correction, there was also signifi-
cant difference between root resorption, proving again
that the incisor roots in the IT group will undergo less
resorption.
There are 3 possible outcomes in moving an IT—
achieve normal length, be stunted (no further growth),
or real root shortening. To discuss these possibilities, in-
tragroup data of root length were compared in Table III.
The pretreatment root length was statistically signifi-
cantly correlated with the posttreatment root length in
the IT group, but there was no statistical significance be-
tween them, which can be explained by the compensa-
tion of root growth or the small amount of root
resorption. To find the reason, another paired-samples
t test was conducted to compare the pretreatment root
length and posttreatment root length after correction
of the IT group, and the result was the same, indicating
that it was because the root resorption was little in the
cases with immature teeth. Therefore, a tooth with an
IT will suffer little real root shortening but not be
stunted. In addition, there was statistically significantly
correlation and difference between pretreatment and
posttreatment root length, showing more root resorp-
tion in the MT group.
Because EARR is a multifactorial problem, linear
regression analyses were used to test identify predictors
for root resorption (Table IV). According to the multivar-
iate analyses, we also confirmed our hypothesis that pre-
dictability of apical orthodontic root resorption increases
when tooth development is considered. Although the
apical movement (horizontal or vertical), treatment
duration, and previous orthodontic treatment were
also the risk factors for EARR, aligning with previous
studies,41-43 the beta value of tooth development was

May 2020  Vol 157  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Li et al
the highest among risk factors in the final model,
indicating that tooth development contributes
substantially to root resorption.
How tooth development affects EARR has yet to be
determined. One hypothetical explanation is that roots
with unfinished apical development may be more easily
moved than those with completed apical development
because the alveolar bone may be immature around
the underdeveloped root, which may allow the teeth to
move faster.40 Low calcification of underdeveloped
root is also considered less susceptible when it comes
to root resorption. The process of root resorption is
similar to that of bone resorption, and the proliferation
of bone tissue will be activated after external force2;
the orthodontic force of moving teeth may promote
further root growth in teeth with IT. In addition, as stated
previously, the apical foramina connect the pulp and
alveolar bone, and the unclosed apical foramina indi-
cating more free space and adequate blood supply may
help relieve pressure, reduce pulpal disturbances, and
maintain physiological balance during tooth movement.
Because it is generally accepted that the dental follicle
cells are directed to differentiation by epithelial–
mesenchymal interaction in initiating root formation,
both cementogenesis and dentinogenesis,44,45 we spec-
ulated that the lower root resorption in the IT group
may have resulted from the effects of dental follicle cells
in repairing resorption by differentiation toward cemen-
toblast and odontoblast phenotype and regulating mole-
cule signaling; further studies are needed to confirm this
speculation.
CONCLUSIONS
1. An accurate and reliable approach for assessing the
amount of EARR using digital panoramic and lateral
radiographs was created.
2. There is an association between root resorption and
tooth development, and tooth development is an
important predictor for root resorption. Patients
with immature teeth are at a much lower risk of api-
cal root resorption.
SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at https://doi.org/10.
1016/j.ajodo.2019.11.011.
REFERENCES
1. Li W, Chen F, Zhang F, Ding W, Ye Q, Shi J, et al. Volumetric mea-
surement of root resorption following molar mini-screw implant
American Journal of Orthodontics and Dentofacial Orthopedics
609
intrusion using cone beam computed tomography. PLoS One
2013;8:e60962.
2. Castro IO, Alencar AH, Valladares-Neto J, Estrela C. Apical root
resorption due to orthodontic treatment detected by cone beam
computed tomography. Angle Orthod 2013;83:196-203.
3. Sameshima GT, Sinclair PM. Predicting and preventing root
resorption: part II. Treatment factors. Am J Orthod Dentofacial Or-
thop 2001;119:511-5.
4. Massler M, Malone AJ. Root resorption in human permanent teeth:
a roentgenographic study. Am J Orthod 1954;40:619-33.
5. Th€onen A, Peltom€aki T, Patcas R, Zehnder M. Occurrence of cervi-
cal invasive root resorption in first and second molar teeth of or-
thodontic patients eight years after bracket removal. J Endod
2013;39:27-30.
6. Guo Y, He S, Gu T, Liu Y, Chen S. Genetic and clinical risk factors of
root resorption associated with orthodontic treatment. Am J Or-
thod Dentofacial Orthop 2016;150:283-9.
7. Janson GR, De Luca Canto G, Martins DR, Henriques JF, De
Freitas MR. A radiographic comparison of apical root resorption
after orthodontic treatment with 3 different fixed
appliance techniques. Am J Orthod Dentofacial Orthop 2000;
118:262-73.
8. Parker RJ, Harris EF. Directions of orthodontic tooth movements
associated with external apical root resorption of the maxillary
central incisor. Am J Orthod Dentofacial Orthop 1998;114:
677-83.
9. Pandis N, Nasika M, Polychronopoulou A, Eliades T. External api-
cal root resorption in patients treated with conventional and self-
ligating brackets. Am J Orthod Dentofacial Orthop 2008;134:
646-51.
10. McNab S, Battistutta D, Taverne A, Symons AL. External apical root
resorption following orthodontic treatment. Angle Orthod 2000;
70:227-32.
11. Levander E, Malmgren O. Evaluation of the risk of root resorption
during orthodontic treatment: a study of upper incisors. Eur J Or-
thod 1988;10:30-8.
12. Taithongchai R, Sookkorn K, Killiany DM. Facial and dentoalveolar
structure and the prediction of apical root shortening. Amj Orthod
Dentofacial Orthop 1996;110:296-302.
13. Baumrind S, Korn EL, Boyd RL. Apical root resorption in orthodon-
tically treated adults. Am J Orthod Dentofacial Orthop 1996;110:
311-20.
14. Jimenez-Pellegrin C, Arana-Chavez VE. Root resorption in human
mandibular first premolars after rotation as detected by scanning
electron microscopy. Am J Orthod Dentofacial Orthop 2004;126:
178-84: discussion, 184-185.
15. DeShields RW. A study of root resorption in treated Class II, Divi-
sion I malocclusions. Angle Orthod 1969;39:231-45.
16. Viecilli RF, Katona TR, Chen J, Hartsfield JK Jr, Roberts WE. Ortho-
dontic mechanotransduction and the role of the P2X7 receptor.
Am J Orthod Dentofacial Orthop 2009;135:694.e1-16: discussion,
694-695.
17. Al-Qawasmi RA, Hartsfield JK Jr, Everett ET, Flury L, Liu L,
Foroud TM, et al. Genetic predisposition to external apical root
resorption. Am J Orthod Dentofacial Orthop 2003;123:242-52.
18. Ngan DC, Kharbanda OP, Byloff FK, Darendeliler MA. The genetic
contribution to orthodontic root resorption: a retrospective twin
study. Aust Orthod J 2004;20:1-9.
19. Al-Qawasmi RA, Hartsfield JK Jr, Everett ET, Flury L, Liu L,
Foroud TM, et al. Genetic predisposition to external apical root
resorption in orthodontic patients: linkage of chromosome-18
marker. J Dent Res 2003;82:356-60.
May 2020  Vol 157  Issue 5
610
20. Linge BO, Linge L. Apical root resorption in upper anterior teeth.
Eur J Orthod 1983;5:173-83.
21. Mirabella AD, Artun J. Prevalence and severity of apical root
resorption of maxillary anterior teeth in adult orthodontic patients.
Eur J Orthod 1995;17:93-9.
22. de Freitas MR, Beltr~ao RT, Janson G, Henriques JF, Chiqueto K.
Evaluation of root resorption after open bite treatment with and
without extractions. Am J Orthod Dentofacial Orthop 2007;132:
143.e15-22.
23. Linge L, Linge BO. Patient characteristics and treatment variables
associated with apical root resorption during orthodontic treat-
ment. Am J Orthod Dentofacial Orthop 1991;99:35-43.
24. Mavragani M, Bøe OE, Wisth PJ, Selvig KA. Changes in root length
during orthodontic treatment: advantages for immature teeth. Eur
J Orthod 2002;24:91-7.
25. Bishara SE, Vonwald L, Jakobsen JR. Changes in root length from
early to mid-adulthood: resorption or apposition? Am J Orthod
Dentofacial Orthop 1999;115:563-8.
26. Jiang RP, McDonald JP, Fu MK. Root resorption before and after
orthodontic treatment: a clinical study of contributory factors.
Eur J Orthod 2010;32:693-7.
27. An JK, Matsumoto Y, Ono T. The relationships between the
arrangement of teeth, root resorption, and dental maturity in
bovine mandibular incisors. Korean J Orthod 2017;47:365-74.
28. Lauesen SR, Andreasen JO, Gerds TA, Christensen SS, Borum M,
Hillerup S. Association between third mandibular molar impaction
and degree of root development in adolescents. Angle Orthod
2013;83:3-9.
29. Kaley J, Phillips C. Factors related to root resorption in edgewise
practice. Angle Orthod 1991;61:125-32.
30. Graber TM. Orthodontics principles and practice. Bol Odontol (Bo-
gota) 1968;34:62-70.
31. Salzmann JA. Practice of orthodontics. Philadelphia: Lippincott;
1966.
32. McDonald F, Pitt Ford TR. Blood flow changes in permanent
maxillary canines during retraction. Eur J Orthod 1994;16:1-9.
33. Katona TR. Flaws in root resorption assessment algorithms: role of
tooth shape. Am J Orthod Dentofacial Orthop 2006;130:
698.e19-27.
May 2020  Vol 157  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Li et al
34. Katona TR. The flaws in tooth root resorption assessment algo-
rithms: the role of source position. Dentomaxillofac Radiol 2007;
36:311-6.
35. Moorrees CF, Kent RL. Interrelations in the timing of root formation
and tooth emergence. Proc Finn Dent Soc 1981;77:113-7.
36. Moorrees CF, Gron AM, Lebret LM, Yen PK, Fr€ ohlich FJ.
Growth studies of the dentition: a review. Am J Orthod
1969;55:600-16.
37. Schulze D, Heiland M, Thurmann H, Adam G. Radiation exposure
during midfacial imaging using 4- and 16-slice computed tomog-
raphy, cone beam computed tomography systems and conven-
tional radiography. Dentomaxillofac Radiol 2004;33:83-6.
38. Weltman B, Vig KW, Fields HW, Shanker S, Kaizar EE. Root resorption
associated with orthodontic tooth movement: a systematic review.
Am J Orthod Dentofacial Orthop 2010;137:462-76: discussion 12A.
39. Mirabella AD, Artun J. Risk factors for apical root resorption of
maxillary anterior teeth in adult orthodontic patients. Am J Orthod
Dentofacial Orthop 1995;108:48-55.
40. Xu T, Baumrind S. The relationship between apical root resorption
and orthodontic tooth movement in growing subjects. Zhonghua
Kou Qiang Yi Xue Za Zhi 2002;37:265-8.
41. Artun J, Smale I, Behbehani F, Doppel D, Van't Hof M, Kuijpers-
Jagtman AM. Apical root resorption six and 12 months after initi-
ation of fixed orthodontic appliance therapy. Angle Orthod 2005;
75:919-26.
42. Artun J, Van 't Hullenaar R, Doppel D, Kuijpers-Jagtman AM. Iden-
tification of orthodontic patients at risk of severe apical
root resorption. Am J Orthod Dentofacial Orthop 2009;135:448-55.
43. Smale I, Artun J, Behbehani F, Doppel D, van't Hof M, Kuijpers-
Jagtman AM. Apical root resorption 6 months after initiation of
fixed orthodontic appliance therapy. Am J Orthod Dentofacial Or-
thop 2005;128:57-67.
44. Foster BL, Popowics TE, Fong HK, Somerman MJ. Advances in
defining regulators of cementum development and periodontal
regeneration. Curr Top Dev Biol 2007;78:47-126.
45. Jung HS, Lee DS, Lee JH, Park SJ, Lee G, Seo BM, et al. Directing
the differentiation of human dental follicle cells into cemento-
blasts and/or osteoblasts by a combination of HERS and pulp cells.
J Mol Histol 2011;42:227-35.