British Journal of Orthodontics

ISSN: 0301-228X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/yjor19

Iatrogenic Root Resorption of Upper First

Permanent Molars Associated with Orthodontic
Treatment

F. J. Hill

To cite this article: F. J. Hill (1987) Iatrogenic Root Resorption of Upper First Permanent Molars
Associated with Orthodontic Treatment, British Journal of Orthodontics, 14:2, 109-113, DOI:
10.1179/bjo.14.2.109

To link to this article: https://doi.org/10.1179/bjo.14.2.109

Published online: 21 Jun 2016.

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Iatrogenic Root Resorption of Upper First
Permanent Molars Associated with
Orthodontic Treatment
Report of a Case
F. J. J:IILL, M.D.S., F.D.S., D.ORTH. R.C.S.
Department of Children's Dentistry, Institute of Dental Surgery, Eastman Dental Hospital, Gray's Inn Road,
London WCIX 8LD
Received for publication May 1986
Abstract. A case of severe resorption of the roots of upper first molars, associated with second molar
impaction, is reported. The possible causes of this condition, which occurred as a complication of rapid
maxillary expansion and distal movement of the first molars, are discussed.
Introduction
It is many years since the first useful classifications
of root resorption were published (Ottolengui,
l914a, b). Goultschin et al. (1982) describe separ-
ately six different types of root resorption, which
include those caused by excessive orthodontic force
and by impacted teeth, as well as 'idiopathic' forms.
Although this simple etiological classification is
useful, many cases are probably of multifactorial
origin, arising from an obvious local factor acting
in an individual who is, for ill-defined reasons,
susceptible to root resorption.
The case described here is of interest because the
severe resorption which occurred was at least
partly caused by tooth impactions produced by
orthodontic treatment. However, other less obvious
factors may have contributed to this rarely reported
complication.
Case Report
A healthy 16-year-old female was referred by
her dentist concerning her upper first permanent
molars. Although these teeth were symptomless,
bitewing radiographs had demonstrated advanced
resorption of their roots.
The patient had completed orthodontic treat-
ment two years previously, but no records of her
previous treatment were available. On examination
she was found to have a healthy mouth with a
0301·228X/87f004109+5 S02.00
British Journal of Orthodontics/Vol. U I1987//09-113
good functional occlusion. The following teeth were
erupted:
654321,123456
7654321 1234567
1§. was abnormally mobile, but not tender to
pressure.
Figure 1 is an orthopantomograph, taken at this
stage. It showed W to be present and unerupted,
and marked resorption of the roots of §1Q against
which 1Jl were impacted. It was also noted that
the distal root of ffi appeared to be shortened.
§1Q were extracted in view of their poor prognosis
and the urgent need to encourage eruption of lll·
The extractions were completed without difficulty
and macroscopic examination then revealed the
extent of root resorption (Fig. 2).[§ showed almost
complete loss of its palatal and distobucca1 roots
and resorption of the distal part of the mesiobuccal
root. A similar pattern was seen in Qj, but the
resorption was not as extensive, so that the mesial
part of the palatal root had not been completely
lost. The location of these areas of resorption
indicated that 1ll had initially been impacted
against the distopalatal aspects of §l.Q.
The extracted teeth were decalcified and embed-
ded in paraffin wax to prepare sections for micro-
scopic examination. Areas of irregular resorption
were seen with thick deposits of cellular cementum
IC 1987 British Society for the Study of Orthodontics
 110 F. I. Hill BJO Vol. 14 No. 2

FIG. 1 Orthopantomograph taken at 16 years of age showing the resorption of~ roots.

FIG. 2 The resorbed upper first permanent molars viewed from their distal aspects. The mesiobuccal cusps are indicated.

having many resting and reversal lines, character-
istic of an intermittent process of resorption and
repair.
Six months after extraction of ~. when the
patient was last reviewed, 111 had erupted into
occlusion, but were still distally spaced from
(Fig. 3).
Later, records of the patient's orthodontic treat-
ment were obtained. A summary of these is relevant
to the presenting pattern of root resorption. Her
treatment had been planned at 11 years of age
when she was noted to have a Class 11 Division 1
m relationship with a high Frankfort-Mandibular
Plane Angle and crowding, especially of the un-
 BJO April 1987 Iatrogenic Root Resorption of Upper First Permanent Molars Ill

F 10. 3 Orthopantomograph taken six months after extraction of~·

FIG. 4 A pre-treatment orthopantomograph taken at 11 years of age.

3 late~, after which the corrected buccopalatal oc-

erupted ~~ , and a bilateral posterior crossbite.
An orthopantomograph showed second molars to
be present, but there were no signs of third
molars (Fig. 4). This radiograph also shows that
before treatment the distal root offfi was of normal
length.
Appliance therapy had taken 28 months and
involved three overlapping phases:
(1} Rapid maxillary expansion using a double
jointed Hyrax screw attached to bands on 64146
had corrected the posterior crossbite in four weeks.
The Hyrax screw had been removed eight months
clusion was retained with crossed intermaxillary
elastics.
(2) Cervical extra-oral traction had been used
for 17 months to provide space to align the upper
arch by moving~ distally.
(3) Multiband appliances had been used to cor-
rect crowding and to align the arches, over a period
of 27 months. Treatment had included distal
movement of 16 to regain space for 15.
The delayed eruption of 111 had been noted at
the completion of fixed appliance therapy when a
radiograph had shown resorption of§!§. roots. No
 112 F. J. Hill
further active treatment had been undertaken,
because the patient had failed subsequent review
appointments.
Discussion
Severe root resorption of the upper first permanent
molars must be considered a rare complication of
their distal movement, considering the frequency
with which such treatment is undertaken in modern
orthodontic practice.
Only one similar case has been found in the
recent literature: that ofLangford and Sims (1981),
who reported resorption of the distal roots of~
associated with the impaction of 111 after 5!
months of cervical traction in a ten year old girl.
The resorption was less severe than in the present
case and on the worse side had led to the loss of
only the distobuccal root.
The most obvious causal factor was the impac-
tion of 111 against the roots of QJ§_. Various
impacted teeth may produce resorption of adjacent
roots and recent reviews include: third molars
(Nitzan et al., 1981); canines (Howard, 1970); first
permanent molars (Harrison and Michal, 1984);
second premolars (Tracey and Lee, 1985); and
supernumerary teeth (Jokela, 1976).
It has been assumed that pressure exerted by the
impacted teeth leads directly to root resorption
(Rushton et al., 1970). However, few impactions
in fact produce radiographically visible resorption.
For example, in a study of the periapical films of
199 impactions, Nitzan et al. (1981) found evidence
of adjacent root resorption in only 7·5 per cent.
These and other authors have suggested that other
unidentified factors may predispose some individ-
uals to root resorption. Similar observations have
been made in relation to the apical resorption which
may complicate orthodontic tooth movement in
patients who have been considered to have excessive
'resorption potential' (Newman, 1975). Compari-
son of Fig. 1 and Fig. 4 shows that, in addition to
the gross resorption of~ there had been apical
resorption of the distal root of 16. The roots of the
lower incisors may have been abnormally short
before active treatment, although no intra-oral
films are available to confirm this. In view of these
findings the patient might be considered to have
been particularly prone to resorption.
Several microscopic studies of extracted anchor
teeth have shown extensive resorption whenever
RME is used (Timms and Moss, 1971; Barber and References
Sims, 1981; Langford and Sims, 1982; Langford,
1982; Odenrick et al., 1982). It is possible that Barber,
Rapid maxillary expansion and external root resorption in man:
RME may have contributed to the severe resorption a scanning electron microscope study,
seen in the case reported. However, the surface American Journal of Orthodontics, 19, 639-652.
BJO Vol. 14 No. 2
resorption produced by RME is largely confined
to the buccal root surfaces, whereas the resorption
seen in Fig. 2 had clearly begun on the distopalatal
aspects of the roots.
The relationship between orthodontic move-
ment and root resorption may have been a geo-
metrical one. Crowded upper second or third molars
frequently erupt without resorption of adjacent
roots and in so doing they take a distobuccal path
to a typical 'functionless' buccal position. In the
present case the combination of arch expansion and
distal movement placed the distal parts of §1§.
roots buccally to the crowns of m. an unusual
position which may be particularly unfavourable
for second molar eruption. This situation may be
similar to that of the rare 'aggressive' second pre-
molars which are impacted in the line of the arch
and resorb first permanent molar roots (Tracey
and Lee, 1985).
It is difficult to imagine how the reported compli-
cation might have been prevented or satisfactorily
treated. Had active movement of~ been delayed
until m were further erupted, root resorption may
not have occurred, but the pretreatment radiograph
(Fig. 4) gives no indication of impeding second
molar impaction. Earlier discovery of the resorp-
tion might have prompted a change in the timing of
treatment, but the complication occurred without
symptoms, in contrast to the premolar cases re-
ported by Tracey and Lee (1985) in which intermit-
tent pain was a constant feature.
In the case reported by Langford and Sims
(1981), third molars were present and a satisfactory
result was achieved by changing the treatment plan
to extract first molars instead of first premolars.
In the present case treatment options were very
limited because ~ did not develop. An an early
stage surgical disimpaction of 111 might have been
tried, but this would have been difficult because of
their palatal position. For the same reason, root
filling and hemisection, which might be undertaken
for lower molars with resorption of one root, would
have posed insuperable technical problems. At the
late stage when the patient again presented there
was no alternative to first molar extraction to allow
eruption of the second molars. Later treatment
might, with the patient's agreement, involve align-
ment of m and fixed bridge-work to maintain a
functional occlusion with m.
A. F. and Slms, M. R. (1981)
BJO April 1987
Goultschin, J., Nltzan, D. and Azaz, B. (1982)
Root resorption: Review and discussion,
Oral Surgery, Oral Medicine and Oral Pathology, 54, 586-590.
Harrlson, L. M. and Micbal, B. C. (1984)
Treatment of ectopically erupting permanent molars,
Dental Clinics of North America, 28, 57-67.
Howard, R. D. (1971)
The displaced maxillary canine: positional variations associated
with root resorption,
Transactions of the British Society for the Study of Orthodontics,
57, 149-157.
Jokela, M. (1976)
Rapid resorption in central incisor caused by a supernumerary
tooth,
Proceedings of the Finnish Dental Society, 72, 56-59.
Langford, S. R. (1982)
Root resorption extremes resulting from clinical RME,
Americah Journal of Orthodontics, 81, 371-377.
Langford, S. R. and Sims, M. R. (1981)
Upper molar root resorption because of distal movement.
Report of a case,
American Journal of Orthodontics, 79, 669-679.
Langford, S. R. and Sims, M. R. (1982)
Root surface resorption, repair and periodontal attachment
following rapid maxillary expansion in man,
American Journal of Orthodontics, 81, 105-115.
Newman, W. G. (1975)
Possible aetiologic factors in external root resorption,
American Journal of Orthodontics, 67, 522-539.
Iatrogenic Root Resorption of Upper First Permanent Molars 113
Nitzan, D., Keren, T. and Marmary, Y. (1981)
Does an impacted tooth cause root resorption of an adjacent
one?
Oral Surgery, Oral Medicine and Oral Pathology, SI, 221-224.
Odenrick, L., Lilja, E. and Lindback, K-F. (1982)
Root surface resorption in two cases of rapid maxillary expan-
sion,
British Journal of Orthodontics, 9, 37-40.
Ottolengui, R. (1914a)
The physiological and pathological resorption of tooth roots,
Items of Interest, 36, 332-362.
Ottolengui, R. (1914b)
The practical application of our knowledge of the resorption
of the roots of permanent teeth,
Items of Interest, 36, 887,.899.
Rusbton, M. A., Cooke, B. E. D. and Duckwortb, R. (1970)
Histopathology, pp. 88-90, Livingstone: Edinburgh.
Timms, D. J. and Moss, J. P. (1971)
An histological investigation into the effects of RME on teeth
and their supporting tissues,
Transactions of the European Orthodontic Society, 263-271.
Tracey, C. and Lee, R. T. (1985)
Root resorption: the aggressive, unerupted second premolar,
British Journal of Orthodontics, 12,97-101.