Vol. - No.

- Month 2016

A review of cone beam computed tomography for the

diagnosis of root resorption associated with impacted
canines, introducing an innovative root resorption scale
Zynab Jawad, BChD HONS, MFDS RCSEng, MSc Orth, MOrth RCSEd,a
Fiona Carmichael, BDS, FDS, RCPS, DDR RCR,b
Nadine Houghton, BDS, MDentSci, MFDS, MOrth, FDS (Orth) RCS Eng,c and
Claire Bates, BChD, MFDS RCSEd, MClinDent Orth (Dist), DDS Ed, MOrth RCSEd, FDS RCSEd,
PGCETHLE FHEAc

Objective. The aim of the study was to review all cases referred for cone beam computed tomography (CBCT) to the
department of dental radiology at the Leeds Dental Institute to aid diagnosis of root resorption associated with impacted
canines. We aimed to establish if referral for and reporting of these CBCT assessments were in compliance with current
guidelines. In addition, we introduced a new and innovative tool to aid reporting of CBCT images of root resorption associated
with an impacted tooth. All plain film radiographs taken before CBCT were reviewed to determine if root resorption was
evident or suspected from the plain film radiographs.
Study Design. Root resorption was recorded from plain film radiographs taken before CBCT by using a resorption scale
designed by the authors for assessing root resorption associated with impacted canines (Two-Dimensional Leeds Resorption
Scale). CBCT radiography reports of all cases were reviewed to identify cases with confirmed root resorption.
Results. All cases referred for CBCT were compliant with guidelines relating to referrals and reporting.
Conclusions. CBCT provided improved detection rates (63%) of root resorption associated with impacted canines. The
resorption scale developed by the authors (Three-Dimensional Leeds Orthodontic Root Resorption Target Scale) is intended to
address the subjective nature of reporting of CBCT images taken to assess root resorption associated with impacted teeth. (Oral
Surg Oral Med Oral Pathol Oral Radiol 2016;-:1-7)

The introduction of cone beam computed tomography
(CBCT) represents a radical change in dental and
maxillofacial radiology. This innovation in three-
dimensional (3-D) imaging appears to offer the poten-
tial for improved diagnosis in a wide range of clinical
applications, and radiation is usually at lower doses
compared with medical computed tomography (CT).1
However, in CBCT increased radiation doses are
usually given to patients in comparison with
conventional dental radiographic techniques.2
Clarification of the location of impacted teeth (typi-
cally canines and supernumeraries) and elimination of
possible damage to the adjacent teeth is the most
common clinical orthodontic problem that may require
CBCT subsequent to conventional radiography.3 The
maxillary permanent canine is the second most
frequently impacted tooth after the mandibular third
molars.4,5 Several studies have reported the
prevalence of impacted canines to be 1% to 2%.5-7
Studies have shown that ectopic canines occur twice
as often palatally as they do buccally.6 In normal
development, maxillary canines should be palpable in
the buccal sulcus by age 10 to 11 years and should
erupt around age 12 years in girls and 13 years in
boys.4,8
The etiology of ectopic canines is considered poly-
genic and multifactorial.9 They are also linked to absent,
malformed, and microdont lateral incisors.10 A major
risk associated with ectopic canines is resorption of
adjacent teeth. Studies have shown that resorption of
lateral incisors occurs significantly more often in girls
than in boys, with a ratio of 12:1.6 Resorption can be
difficult to diagnose with conventional two-
dimensional (2-D) dental radiographs, especially if the
canine is located in the direct palatal or buccal position
relative to the roots of adjacent teeth.11

a
Specialty Registrar in Orthodontics, Orthodontic Department, Leeds
Dental Institute, Leeds, United Kingdom.
b
Consultant Radiologist, Leeds Dental Institute, Leeds, United Statement of Clinical Relevance
Kingdom.
c
Consultant Orthodontist, Leeds Dental Institute, Leeds, United
The paper highlights a need for a more objective
Kingdom.
Received for publication Jan 23, 2016; returned for revision Apr 19, method for reporting root resorption associated with
2016; accepted for publication Aug 15, 2016. impacted teeth with CBCT imaging. The introduc-
Ó 2016 Published by Elsevier Inc. tion of root resorption scale developed at Leeds aims
2212-4403/$ - see front matter to address this need.
http://dx.doi.org/10.1016/j.oooo.2016.08.015

1
ORAL AND MAXILLOFACIAL RADIOLOGY
2 Jawad et al.
It is essential that the positions of impacted canines
and their surrounding structures are accurately delin-
eated to ensure optimal orthodonticesurgical manage-
ment. The introduction of CBCT has made it possible to
acquire 3-D information that can lead to improved
detection rates (up to 66.7%) of root resorption.7 CT
provides excellent tissue contrast, eliminating any
blurring and overlapping of adjacent teeth.12
Studies on clinical management of ectopic canines
found that orthodontists adapted their approach to treat-
ment when supplementary CBCT information was
available on the extent of root resorption present on the
maxillary lateral incisors.13 Because of the increased
radiation doses associated with CBCT, the Faculty of
General Dental Practitioners and the British Orthodontic
Society recommend that CBCT only be used if
sufficient diagnostic information cannot be obtained
through conventional radiography.14 The SEDENTEX
CT Radiation Protection guidelines for CBCT state that
CBCT is only indicated when there is doubt as to the
viability of a lateral incisor caused by an impacted
canine, as evidenced by conventional radiography.15
According to the European Academy of Dental and
Maxillofacial Radiology’s Basic Principles on the use
of CBCT, a practitioner must justify the use of CBCT
and provide adequate information to a radiologist. In
addition, the radiologist must provide CBCT imaging
with sufficient information to aid in diagnosis and
treatment planning.15
The aims of the study were as follows:
1. To determine what previous imaging was performed
before the referral to CBCT.
2. To find out whether the plain film radiographs taken
before CBCT were of acceptable diagnostic quality
according to the National Radiation Protection
Board guidelines.16
3. To determine if resorption was evident or suspected
from the plain film.
4. To find out if resorption of adjacent tooth/teeth by an
impacted canine was first diagnosed or simply
confirmed by the CBCT.
5. To introduce a new innovative tool to aid reporting
of root resorption associated with impacted teeth for
CBCT imaging.
MATERIALS AND METHODS
The department of dental radiology at the Leeds Dental
Institute (LDI) accepts referrals for CBCT from within
the LDI as well as from regional district hospitals and
primary care centers in the West Yorkshire region. This
study involved the review of all cases in which CBCT
imaging was taken to assess root resorption associated
with impacted canines. The majority of the CBCT im-
ages were taken with an OP300 machine and were
OOOO
Month 2016
considered small volume, (<50 usv). One small volume
CBCT of the anterior maxilla is considered to have an
equivalent dose to one panoramic dental tomogram.
The study was retrospective, looking at all cases from
July 2013 to July 2014 at the LDI. The cases were
identified from the computer software that stores all
images taken at the LDI in a digital format. Data found
on CBCT referrals or request forms and CBCT reports
were also collected from separate electronic software
programs used by the dental radiology department.
Clinical records for the identified cases were
reviewed, along with any previous dental radiographs.
Figure 1 shows a CBCT image taken for the assessment
of root resorption of a lateral incisor associated with an
impacted canine.
A resorption scale (Figure 2) was developed by the
authors of this article for the purposes of this study
and was used to assess the degree of root resorption
associated with the impacted canines for the 2-D plain
film dental radiographs. This scale was based on the
Lavender and Malmgren scale, which was designed to
describe orthodontically induced apical root resorption
associated with orthodontic treatment when reviewing
2-D plain film radiographs.17
In this study, the same operator scored the plain film
radiographs according to the Two-Dimensional Leeds
Resorption Scale (2-D-LRS). For each impacted canine,
the outline of the adjacent teeth were reviewed; if two
or more of the adjacent teeth roots were associated with
the impacted canine, then all roots were reviewed and
the worst score on the 2-D-LRS was recorded. The
diagnosis of root resorption of adjacent teeth was
confirmed from the CBCT reports provided by the
radiology department at the LDI.
RESULTS
A total of 35 cases were identified in a 1-year period,
seven of which had two impacted maxillary canines,
giving a total of 42 impacted canines.
Previous imaging
All of the cases that requested CBCT for the assessment
of resorption of teeth adjacent to an impacted canine
provided a recently taken, conventional radiograph with
the referral. The range of plain film radiographs pro-
vided with the CBCT referral is shown in Table I. All of
the plain film radiographs were reviewed and deemed to
be of acceptable diagnostic quality according to the
National Radiation Protection Board guidelines.
Evidence of root resorption from plain film
radiographs
All 42 canines were reviewed on plain film radiographs
by the same observer (Z.J.), and the 2-D-LRS was
OOOO
Volume -, Number - Jawad et al. 3
Fig. 1. Cone beam computed tomography (CBCT) scan showing resorption on the palatal surface of the upper left lateral incisor.
noted for the tooth or teeth that were adjacent to the
impacted canines and suspected to have root resorption
(Table II).
The dental films were reviewed for a second time by
the same observer to assess the intraoperator reliability
of the 2-D-LRS scores. Intraoperator reliability was
excellent, with a kappa score ¼ 1.00. Nineteen of the 42
cases (45%) had root resorption of adjacent teeth
associated with the impacted canine, as confirmed by
the CBCT. Twelve of the 19 cases (63%) had root
resorption first diagnosed by CBCT (see Table II).
Upon viewing of plain films, only eight cases had a
score of 3 for the 2-D-LRS, indicating definite root
resorption, evident from the plain film radiographs, of
which seven had confirmed root resorption as shown by
CBCT. Of the 14 cases that had a clear root outline on
the plain film (LRS1), five had confirmed root
REVIEW ARTICLE
resorption from the CBCT, indicating superior detec-
tion rates of root resorption with CBCT imaging.
A total of 42 canines were studied, 40 of which were
maxillary canines and two of which were mandibular
canines. The two mandibular canines were buccally
impacted. The position of the maxillary impacted ca-
nines was reviewed, along with rate of diagnosed root
resorption to adjacent teeth (Table III). There appeared
to be no difference in resorption rates between the
buccally and palatally impacted canines (see Table III).
DISCUSSION
In the 1-year period (July 2013 to July 2014), a total of
55 patients underwent CBCT imaging for assessment of
root resorption associated with impacted canines at the
LDI radiology department.
ORAL AND MAXILLOFACIAL RADIOLOGY OOOO
4 Jawad et al. Month 2016

Table II. Root resorption diagnosed by cone beam

computed tomography (CBCT) for the different Two-
Dimensional Leeds Resorption Scale (2-D-LRS) scores
2-D-LRS SCORE LRS1 LRS2 LRS3
Number of cases 14 20 8
Number of cases with 5 7 7
confirmed root resorption
with the CBCT

Table III. Position of maxillary canines and associated

root resorption to adjacent teeth confirmed by cone
beam computed tomography (CBCT)
Position of maxillary impacted canine
Palatal Buccal
Number of canines 27 13
Fig. 2. The Two-Dimensional Leeds Resorption Scale (2-D % of canines 68 32
LRS). LRS1 ¼ No resorption evident, with intact regular root Number of cases diagnosed 13 6
contour and outline. LRS2 ¼ Suspected resorption ¼ with with root resorption
irregular/unclear root outline. LRS3 ¼ Resorption present, following CBCT
obvious resorption affecting root. % of cases diagnosed with 48 48
root resorption following
CBCT

Table I. Range of plain film radiographs provided with

referral for cone beam computed tomography (CBCT)
Type of plain Number Percentage of
film radiograph of cases cases %
Dental panoramic tomograph (OPT) 22 63
Upper anterior occlusal (UAO) 3 9
Periapical (PA) 1 3
OPT þ PA 4 11
OPT þ UAO 5 14
Twenty cases had to be excluded from the study, as
the conventional radiographs taken before the CBCT
were not available for review. The radiology depart-
ment returned them to the referring practitioner in line
with departmental policy. This left a total of 35 cases,
which were included for analysis in this study.
All of the cases referred to the radiology department
for CBCT had provided appropriate referrals, including
recently taken plain film radiographs in accordance with
the SEDENTEXCT radiation protection guidelines.15
Review of plain film radiographs
All plain film radiographs were of acceptable diagnostic
quality. The most commonly provided plain film
radiograph was the dental panoramic tomogram (63%),
which would be expected, as panoramic radiographs are
a common choice for the diagnosis and treatment
planning of impacted canines in patients undergoing
routine orthodontic screening. The resorption was
assessed from the plain film radiographs by using the
2-D-LRS scale (Figure 2), which was developed by the
authors of this paper to allow recording of the presence
and amount of resorption evident from the plain films in
an objective manner (Table II).
Plain film radiographs alone diagnosed root resorp-
tion in 19% of cases. Sixty-three percent of cases
diagnosed with root resorption were first diagnosed by
CBCT, confirming improved detection rates with
CBCT.
Guidelines and recommendations published by the
Faculty of General Dental Practitioners on Selection
Criteria of Dental Radiography state that CBCT would
only be indicated in specific cases. One such case
would be when the results of conventional radiography
show doubtful viability of a lateral incisor because of an
impacted canine. We would therefore anticipate cases
referred for CBCT to have a score of LRS2 or LRS3 on
the initial plain film radiograph.
Our results confirmed that 33% of cases referred for
CBCT had a score of LRS1, indicating a clear root
outline of adjacent teeth with no signs of root resorption
on the plain film radiograph. Of these cases, 36% had
root resorption diagnosed with CBCT, indicating CBCT
to be a superior modality for diagnosis of root resorption.
These results support the findings of previous studies,
which found CBCT to be more accurate than panoramic
radiography in detecting root resorption.15
Reporting of CBCT
According to the European Academy of Dental and
Maxillofacial Radiology, a practitioner must justify the
OOOO
Volume -, Number - Jawad et al. 5
Fig. 3. Three-Dimensional Leeds Orthodontic Root Resorption Target Scale (3-D-LORTS).
Table IV. Reproducibility of the different components
of the Three-Dimensional Leeds Orthodontic Root
Resorption Target Scale (3-D-LORTS)
3-D-LORTS Intraoperator Interoperator
Component reproducibility Kappa agreement Kappa
Vertical position 0.752 0.686
Transverse position 0.641 0.876
Depth 0.766 0.525
need for CBCT and provide adequate information to the
radiologist. In addition, the radiologist must provide
CBCT images with sufficient information to aid diag-
nosis and treatment planning.15 Our findings confirmed
full compliance, with appropriate referrals and reporting
on all the CBCT investigations reviewed in this study.
The CBCT image reports provided by the radiology
department were all in the form of a subjective written
description and stored in patient records. The position,
amount, and severity of the root resorption were
described in a subjective format, with variations in the
level of detail between reports and between different
reporting radiologists.
Patients with severe incisor root resorption present
challenges to both orthodontists and maxillofacial sur-
geons. This may lead to time-consuming and expensive
treatments that may include surgical extraction or expo-
sure of the canine and subsequent orthodontic alignment.
The choice of treatment provided to the patient is influ-
enced by the site and severity of root resorption.
Following this study, the authors developed a scale
called the Three-Dimensional Leeds Orthodontic Root
REVIEW ARTICLE
Resorption Target Scale (3-D-LORTS) (Figure 3). This
scale has been created in an attempt to address the
inconsistencies noted in radiologists’ CBCT reports.
The scale aims to make the reports more detailed and
objective with regard to the description of the location
and severity of root resorption. It is hoped that this
will aid in orthodontic diagnosis and treatment
planning.
The scale has three components: (1) vertical position,
(2) transverse position, and (3) depth. The 3-D-LORTS
allows for a simple and clear description of the vertical
and transverse positions, as well as the depth of root
resorption seen on CBCT images. First, the reporting
radiologist records the vertical position of the resorption
relative to the long axis of the root, as follows: apical
third ¼ V1; mid-third ¼ V2; coronal third ¼ V3. If
more than one-third of the tooth was affected, then the
vertical grade would include both thirds. For example, a
score of V1/2 would be recorded if both the apical third
and the mid-third were affected.
Second, the section pertaining to the transverse
dimension is recorded as follows: buccal ¼ TB;
palatal ¼ TP; mesial ¼ TM; distal ¼ TD. If more than
one transverse aspect is affected by root resorption, then
this would be classified, for example, as TMP, indi-
cating the mesiopalatal area of the root.
The depth of the lesion affected by resorption would
also be indicated at this stage as follows: 1 ¼ cementum
layer contact; 2 ¼ outer dentine <50% depth; 3 ¼ inner
dentine >50% depth; 4 ¼ pulpal involvement. Practi-
cally, the area of resorption affected by resorption could
be shaded on the diagram to aid visual 3-D representation.
ORAL AND MAXILLOFACIAL RADIOLOGY
6 Jawad et al.
An initial pilot study looking at interoperator and
intraoperator reproducibility of the 3-D-LORTS was
carried out for both the vertical and transverse com-
ponents (Figure 3). Two dental radiology consultants
based at the LDI used the 3-D-LORTS to report on
images of 30 individual lateral incisors affected by
impacted canines in 24 patients, included in this review.
They assessed the CBCT images and used the 3-D-
LORTS independently, having had a prior discussion as
to its application. One consultant radiologist repeated
the task 1 week later on the same CBCT images to test
for intraoperator reproducibility.
Kappa statistics were used to assess the agreement
for both intraoperator and interoperator agreement,
looking at the vertical and transverse positions and
the depth components of the tool. The findings are
presented in Table IV. The interoperator agreement
ranged from moderate to excellent for the different
components, with the depth component showing
moderate agreement. It was reported that a number
of CBCT images had an element of movement
artefact, which could have affected the axial
assessment or depth of resorption, making consistency
more difficult. The use of the vertical scale was
reasonably easy to use and showed good agreement.
We expected the target to be the most difficult
element, and certainly the disagreements generally
occurred when the canine was contacting a “corner,”
that is, distobuccal, distopalatal, mesiopalatal, and
mesiobuccal. To overcome this, the authors advise
reporting both surfaces, thus providing maximum
information to the referrers. The intraoperator
agreement was considered substantial to excellent for
the different components.
The 3-D-LORTS aims to aid in the reporting of
CBCT images, making interpretation of the CBCT
images more efficient and offering the benefit of a vi-
sual representation of the root resorption. This is
particularly useful for clinicians who have not received
training in the interpretation of CBCT images and
therefore rely heavily on the CBCT report to aid in their
clinical decision making.
The utility and effect of this reporting aid on clinical
orthodontic decision making is currently being studied
at the LDI.
CONCLUSIONS
All CBCT investigations carried out at the LDI to
assess root resorption associated with impacted canines
had appropriate referrals, with recently taken plain film
radiographs of acceptable diagnostic quality. The radi-
ologist in charge reported on all CBCT images, and a
OOOO
Month 2016
report was available in the patient records for review.
Of all the cases referred for CBCT, 45% had associated
resorption of adjacent teeth. There appeared to be no
difference in resorption rates between buccally and
palatally impacted canines. This study supported
improved root resorption detection rates of 63% with
the use of CBCT. The development of the 3-D-LORTS
is aimed at addressing the subjective nature of reporting
of CBCT images taken to assess root resorption asso-
ciated with impacted teeth.
REFERENCES
1. Ludlow JB, Davies-Ludlow LE, Brooks SL, Howerton WB.
Dosimetry of 3 CBCT devices for oral and maxillofacial radi-
ology: CB Mercuray, NewTom 3 G and i-CAT. Dentomaxillofac
Radiol. 2006;35:219-226.
2. Silva MA, Wolf U, Heinicke F, Bumann A, Visser H, Hirsch E.
Cone-beam computed tomography for routine orthodontic treat-
ment planning: a radiation dose evaluation. Am J Orthod Den-
tofacial Orthop. 2008;133:640.e1-640.e5.
3. Merrett SJ, Drage N, Siphahi SD. The use of cone beam computed
tomography in planning supernumerary cases. J Orthod. 2013;40:
38-46.
4. Ericson S, Kurol J. Longitudinal study and analysis of clinical
supervision of maxillary canine eruption. Commun Dent Oral
Epidemiol. 1986;14:172-176.
5. Hurme VO. Ranges of normalcy in the eruption of permanent
teeth. J Dent Child. 1949;16:11-15.
6. Ericson S, Kurol J. Radiographic examination of ectopically
erupting maxillary canines. Am J Orthod Dentofacial Orthop.
1987;91:483-492.
7. Walker L, Enciso R, Mah J. Three-dimensional localization of
maxillary canines with cone-beam computed tomography. Am J
Orthod Dentofacial Orthop. 2005;128:418-423.
8. Peck S, Peck L, Kataja M. The palatally displaced canine as a
dental anomaly of genetic origin. Angle Orthod. 1994;64:249-
256.
9. Peck S, Peck L, Kataja M. Concomitant occurrence of canine
malposition and tooth agenesis: evidence of orofacial genetic
fields. Am J Orthod Dentofacial Orthop. 2002;122:657-660.
10. Brin I, Becker A, Shalhav M. Position of the maxillary permanent
canine in relation to anomalous or missing lateral incisors: a
population study. Eur J Orthod. 1986;8:12-16.
11. Ericson S, Kurol J. Resorption of maxillary lateral incisors caused
by ectopic eruption of the canines. A clinical and radiographic
analysis of predisposing factors. Am J Orthod Dentofacial
Orthop. 1988;94:503-513.
12. Hurme VO. Developmental opacities of teeth in a New England
community: their relation to fluorine toxicosis. Am J Dis Child.
1949;77:61-75.
13. Alqerban A, Jacobs R, Souza PC, Willems G. In-vitro comparison
of 2 cone-beam computed tomography systems and panoramic
imaging for detecting simulated canine impaction-induced
external root resorption in maxillary lateral incisors. Am J
Orthod Dentofacial Orthop. 2009;136:764.e1-764.e11:discussion
764-765.
14. Faculty of General Dental Practice. Selection Criterior for Dental
Radiography. London, UK: Royal College of Surgeons of En-
gland; 2004.
OOOO REVIEW ARTICLE
Volume -, Number - Jawad et al. 7

15. European Commission. Radiation Protection. Guidelines on Reprint requests:

CBCT for Dental and Maxillofacial Radiology. Brussels,
Zynab Jawad
Belgium: European Union; 2012.
Orthodontic Department
16. National Radiological Protection Board. Guidance Notes for
Leeds Dental Institute
Dental Practitioners on the Safe Use of X-Ray Equipment. Lon-
Clarendon Way
don, UK: Department of Health; 2001.
Leeds LS2 9 LU, UK
17. Malmgren O, Goldson L, Hill C, Orwin A, Petrini L,
zynabjawad@outlook.com
Lundberg M. Root resorption after orthodontic treatment of
traumatized teeth. Am J Orthod. 1982;82:487-491.