ORIGINAL ARTICLE

Physical properties of root cementum: Part 10.

Comparison of the effects of invisible removable
thermoplastic appliances with light and heavy
orthodontic forces on premolar cementum. A
microcomputed-tomography study
Laura J. Barbagallo,a Allan S. Jones,b Peter Petocz,c and M. Ali Darendelilerd
Sydney, Australia

Introduction: Orthodontic treatment with clear sequential removable thermoplastic appliances (TAs) is
gaining popularity as an alternative to treatment with fixed appliances. The amount of orthodontically induced
inflammatory root resorption generated by such appliances has not been investigated. In this prospective
randomized clinical trial, we used x-ray microtomography to quantify resorption generated by treatment with
ClearSmile appliances (ClearSmile, Woollongong, Australia) and compared the effects with those of heavy
and light conventional orthodontic forces and no force. Methods: The sample consisted of 54 maxillary first
premolars in 27 patients who required bilateral extractions as part of their planned orthodontic treatment. The
subjects were randomly assigned to 3 groups, each with 9 subjects. A split-mouth design was used, and
forces were applied to the first premolars. In group 1, TAs were used to move teeth on 1 side in a buccal
direction at a rate of 0.5 mm every 2 weeks (TA movement); the contralateral teeth were not moved and
served at controls. In group 2, TA movement was used on 1 side. A buccal force of 225 g from a beta-titanium
alloy cantilever spring (heavy force) was used on the contralateral side. In group 3, TA movement was used
on 1 side. A buccal force of 25 g from a cantilever spring (light force) was used on the contralateral side. The
treatment duration was 8 weeks (56 days ⫾ 1 day). The TAs were changed every 14 days, and each patient
used 4 appliances. The springs were not reactivated. At the end of the study period, the teeth were extracted
according to a strict protocol to prevent root damage. Resorption was measured with an x-ray microtomo-
graph (1072, SkyScan, Aartselaar, Belgium). Software analysis determined quantity, location, and distribution
of root resorption craters. Results: The control teeth had the least amount of resorption. The light-force teeth
had approximately 5 times more resorption than the control teeth (P ⬍.001). The TA teeth had similar but
slightly greater resorption than the light-force teeth, or approximately 6 times greater than the control teeth
(P ⬍.001). The heavy-force teeth had the most resporption, about 9 times greater than the controls (P ⬍.001).
Conclusions: Clear removable TAs have similar effects on root cementum as light (25 g) orthodontic forces
with fixed appliances. (Am J Orthod Dentofacial Orthop 2008;133:218-27)

E
xternal surface root resorption can be defined
as the active removal of mineralized and
nonmineralized cementum and dentin.1 The
types of factors that cause pathologic external root
resorption are trauma, infection, and tooth move-
ment.2,3 Although the outcome of these root resorp-
tive processes is frequently similar, orthodontic root
resorption is distinct from the other types. Thus, the
term orthodontically induced inflammatory root re-
sorption (OIIRR) has been suggested.4
When OIIRR extends beyond the cementum layer
into the dentin, it is irreversible.5 Extensive postorth-
odontic root resorption compromises the benefits of an
otherwise successful orthodontic outcome. Thus, more
knowledge is needed about the risk factors associated
with new appliances and root resorption.

From the University of Sydney, Sydney, Australia.

a
Postgraduate student, Discipline of Orthodontics, Faculty of Dentistry. Reprint requests to: M. Ali Darendeliler, Discipline of Orthodontics, Faculty of
b
Senior lecturer, Electron Microscope Unit, University of Sydney, Sydney, Dentistry, University of Sydney, Level 2, 2 Chalmers St, Surry Hills NSW
Australia. 2010 Australia. e-mail, adarende@mail.usyd.edu.au.
c
Honorary associate, Discipline of Orthodontics, Faculty of Dentistry; Univer- Submitted, August 2005; revised and accepted, January 2006.
sity of Sydney; statistician, Department of Statistics, Macquarie University, 0889-5406/$34.00
Sydney, Australia. Copyright © 2008 by the American Association of Orthodontists.
d
Professor and chair, Discipline of orthodontics, Faculty of Dentistry. doi:10.1016/j.ajodo.2006.01.043

218
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 2
OIIRR has mainly been detected with radio-
graphs,6,7 light microscopy,8 scanning electron micros-
copy (SEM),9-11 and conventional computed-tomogra-
phy (CT) scanning. The former 2 methods of analysis
rely on 2-dimensional (2D) measurement techniques.
Because OIIRR is 3-dimensional (3D), more accurate
quantitative measurements can be achieved with 3D
techniques including SEM measurements12-14 and x-
ray microtomography (micro-CT).15,16 Two-dimen-
sional radiography is the most conservative diagnostic
tool for the clinical detection of root resorption in
patients. Conventional CT scanning has a significant
advantage over 2D radiography in the clinical detection
and quantification of root resorption, but its high cost
and high radiation exposure to the patient limit its
clinical use. Three-dimensional methods including
SEM and x-ray micro-CT are more accurate and
reliable quantitative measurement tools in studies that
quantify OIIRR in extracted teeth than 2D methods.13
Kesling introduced the use of a flexible removable
orthodontic appliance for minor tooth movements after
fixed appliance therapy in 1945.17 These appliances
were used as orthodontic retainers even earlier.17 Two
commercial systems available in Australia involve a
series of clear thermoplastic appliances (TAs) for
sequential tooth movement as an alternative to treat-
ment with fixed appliances: ClearSmile (ClearSmile,
Woollongong, Australia) and Invisalign (Align Tech-
nology, Santa Clara, Calif).
The ClearSmile laboratory procedure involves
manually resetting teeth in sequential stages on a
plaster model. A series of TAs is then constructed. No
studies have yet been made of the effects of sequential
removable TAs on root cementum.
Few studies have compared OIIRR from removable
appliance treatment with fixed appliance treatment.
Removable appliances do not apply a continuous force
to teeth as do fixed appliances. A radiographic study
established that fixed appliances are more detrimental
to the roots of the maxillary incisors than “activators
and spring plate” removable appliances.18 Another
radiographic study by the same authors involved a
comparison of patients treated with full fixed edgewise
appliances with Class II elastics and rectangular wires
and patients treated with activators, plates with clasps,
and vertical elastics.19 The latter group had no OIIRR.
The authors concluded that open activators, plates with
clasps, and vertical elastics had low correlations with
root resorption. The patients treated with fixed appli-
ances, rectangular archwires, and Class II elastics had
notable OIIRR.19 Because TAs are removable, it is
hypothesized that tooth movement with them would
Barbagallo et al 219
result in less root resorption than movement with fixed
appliances.
Some studies in the literature investigated the rela-
tionship between interrupted or discontinuous forces
compared with continuous forces and OIIRR. A pause
in tooth movement is believed by many authors to
allow the resorbed cementum to heal, and thus many
concluded that discontinuous forces cause less root
resorption.20-27 A number of studies with varying
durations and frequencies of interruption in the applied
forces have led to varied results. One SEM study
involved premolars in a split-mouth setup.26 The au-
thors found that a discontinuous force (100 g, 12 hours
a day) resulted in less OIIRR than a continuous force
(100 g, 24 hours a day).26 A study with young adult
beagle dogs was conducted to compare continuous (24
hours a day) to discontinuous (16 hours a day) forces.25
There were great variations in force levels (10-200 cN)
and treatment durations (4-100 days). Histologic and
histomorphometric evaluations showed that the discon-
tinuous regimen of force application caused signifi-
cantly less resorption than continuous forces.25 Another
histologic study involved human premolars.28 Teeth
with the force reactivated every week over 3 weeks
(which the authors called “constant force”) and teeth
with force not reactivated over 3 weeks with an
additional week of recovery had no histologic evidence
of a significant difference in OIIRR.28 In view of these
findings, it is expected that removable TAs provide the
opportunity, however limited, for resorbed cementum
to heal due to the discontinuous force applied.
The aims of this study were to investigate quanti-
tatively, with x-ray micro-CT, the amount of OIIRR
induced by ClearSmile sequential removal TAs and to
compare the amounts of resorption induced by light and
heavy forces from conventional fixed cantilever orth-
odontic appliances with the amount of OIIRR caused
by the TAs. The force applied by the ClearSmile
appliances to premolars was investigated in another
study.29
MATERIAL AND METHODS
Two commercial orthodontic companies that offer
treatment with clear sequential removal TAs were con-
tacted regarding participation in this study. ClearSmile
agreed to provide the appliances for this study.
The sample consisted of 54 maxillary first premolars
from 27 patients (15 female, 12 male) who required the
bilateral removal of these teeth as part of their planned
orthodontic treatment. Ethics approval was given by the
Central Sydney Area Health Service Ethics Review Com-
mittee (reference number X03-0224). The mean age of the
220 Barbagallo et al
Fig 1. A, Group 1 (n ⫽ 9): TA and control (force, 0 g). B, Group 2 (n ⫽ 9): TA and heavy force
(225 g) with a 0.017 ⫻ 0.025-in beta-titanium alloy cantilever. C, Group 3 (n ⫽ 9): TA and light force
(25 g) with a 0.017 ⫻ 0.025-in beta-titanium alloy cantilever.
patients was 15 years 4 months (range, 12 years 6
months-20 years 0 months). The patient selection criteria
were described previously.30 The subjects were randomly
allocated into 3 groups each consisting of 9 subjects. The
experimental duration was 8 weeks (56 days ⫾ 1 day).
Group 1 (n ⫽ 9) received TA treatment on 1
premolar for buccal movement of 0.5 mm every 2 weeks.
A new appliance was issued every 2 weeks to simulate a
typical clinical situation. The contralateral premolar
served as the control (ie, no movement) (Fig 1, A).
Group 2 (n ⫽ 9) received TA treatment on 1
premolar for buccal movement of 0.5 mm every 2
weeks. A new appliance was issued every 2 weeks to
simulate a typical clinical situation. The contralateral
premolar received an initial buccal force of 225 g (225
cN, heavy force) from a beta-titanium-molybdenum
alloy 0.017 ⫻ 0.025-in cantilever spring. This force
was not reactivated over the 8-week duration to repli-
cate a typical clinical situation (Fig 1, B).
Group 3 (n ⫽ 9) received TA treatment on 1
premolar for buccal movement of 0.5 mm every 2
weeks. A new appliance was issued every 2 weeks. The
contralateral premolar received an initial buccal force
of 25 g (25 cN, light force) from a beta-titanium-
molybdenum alloy 0.017 ⫻ 0.025-in cantilever spring.
This force was not reactivated over the 8-week duration
(Fig 1, C).
The patients were instructed to wear the TA full-
time (excluding meals and oral hygiene procedures) for
2 weeks until the next appliance was issued. It was not
possible to determine how many hours per day the
patients wore the appliances, but each device was
completely passive at the end of its 2-week treatment
period.
The procedure for TA treatment involved the ac-
quisition of a polyvinyl-siloxane impression of the
maxillary arch. After cold sterilization, each impression
was sent to ClearSmile with a prescription for 4 appli-
American Journal of Orthodontics and Dentofacial Orthopedics
February 2008
ances, each with a sequential buccal movement of 0.5 mm
to a maxillary first premolar.
On the side of the dental arch receiving the canti-
lever spring force, 0.022-in slot SPEED brackets (Strite
Industries Ltd, Cambridge, Ontario, Canada) were
bonded to the first molar and the first premolar. The
cantilever spring forces were calibrated to the nearest
gram (or centinewton) with a strain gauge (Dentaurum,
Ispringen, Germany). A tipping tooth movement was
expected to be generated by the cantilever. According
to the protocol of a previous study, the first molars in
the opposing arch of all patients were bonded with a
layer of Multi-cure glass ionomer cement (GIC) (3M
Unitek, Monrovia, Calif).31 The GIC served 2 pur-
poses: to open the occlusion to reduce occlusal
interferences on the study premolars and to minimize
cantilever spring deformation.
One operator (L.J.B.) treated all patients. Origi-
nally, 32 subjects participated in the study. The teeth
from 5 subjects were eliminated for the following
reasons: 1 subject dropped out during treatment, 1
debonded a bracket during treatment, and 3 had loss of
apices during extraction. The loss of the teeth apices
was due to fracture involving loss of one third to one
half of root length; this was related to the difficulty of
the modified extraction technique. Two teeth that had
loss of apices were control teeth, and 1 was a light-
force tooth. The damaged teeth and their undamaged
contralateral opponents were eliminated from the study
because this was a split-mouth setup for the purposes of
univariate analysis of variance (ANOVA). The subject
who dropped out during treatment was from the light-
force group, and the patient who debonded the bracket
was in the heavy-force group.
After the treatment protocol, extractions were per-
formed by 1 of 3 surgeons at the Sydney Dental
Hospital. The procedure involved a modified technique
to prevent damage to the cementum, as outlined in a
American Journal of Orthodontics and Dentofacial Orthopedics Barbagallo et al 221
Volume 133, Number 2

Fig 2. Measurements of tooth movement: top, expected tooth movement measured on photo-
copies of 4 TAs per patient, with 5X magnification; bottom, tooth movement measured on
photocopies (5X magnification) of initial and final study models from the ClearSmile laboratory.
Study models were marked with 0.3-mm pencil.

previous study.12 The teeth were stored in Milli-Q
(deionized water; Millipore Milli-Q, Bedford, Mass),
which has been established as a suitable medium for
storage.32 Tooth disinfection and removal of periodon-
tal ligament remnants were done with a previously
described methodology.16
The accuracy of the amount of movement pro-
grammed by the TAs was determined by measure-
ments of study models and appliances from 13
randomly selected patients. Only initial and final
(after prescribed movement) study models were
available from ClearSmile; thus, the exact amount of
each sequential movement could not be measured
with study models. The ClearSmile laboratory staff
were not informed of the intended measurements to be
made. As previously stated, each appliance was com-
pletely passive after 2 weeks of wear, including the
final appliance in the series of 4.
A permanent ink dot was made on the canine, the
first premolar, and the second premolar buccal cusp tips
of each TA. The appliances were photocopied with
500% magnification (the exact magnification was de-
termined by photocopying a ruler with each model and
appliance). On the printed images, a 0.3-mm pencil line
was drawn from the canine to the second premolar
buccal cusp tips. The relative amount of movement of
the first premolar buccal cusp tip to this line was
measured with electronic digital calipers (with accuracy
of 0.01 mm) and adjusted for magnification (Fig 2, top);
0.3-mm pencil marks were made on the patient’s initial
and final study models in the same locations as the
appliances. Photocopies with 500% magnification were
made of the study models, and the same measurements
were made as for the TAs (Fig 2, bottom).
The cusp tips of the study models were identified
readily because these regions are pointed. The TA cusp
tips were rounded, since the process of appliance
construction does not result in sharp contours. Thus,
measurements were made of both appliance and study
models.
The 54 premolars were scanned with the SkyScan-
1072 x-ray desk-top microtomographer (SkyScan,
Aartselaar, Belgium), and root resorption crater volume
quantification was conducted. This protocol was carried
out with the same methodology, equipment, and soft-
ware as described in a previous study.16 Figures 3
222 Barbagallo et al American Journal of Orthodontics and Dentofacial Orthopedics
February 2008

Fig 3. Three-dimensional and 2D reconstructed images of a premolar subjected to 8 weeks of

buccal movement with TA. From left to right: buccal-mesial view, mesial view, distal-buccal view,
and sagittal slice.

Fig 4. Three-dimensional and 2D reconstructed images of a premolar subjected to 8 weeks of

buccal movement with a light force (25 g). From left to right: lingual view, mesial-buccal view, axial
slice with a lateral canal and a resorption cavity, and sagittal slice.

Fig 5. Three-dimensional reconstructed images of a premolar subjected to 8 weeks of buccal

movement with a heavy force (225 g). From left to right: mesial, buccal-mesial, buccal, and distal
views.

through 6 show examples of images from teeth sub-
jected to forces from the TAs, light and heavy forces,
and control (no force).
RESULTS
From the measurements of the TAs (after adjust-
ments for magnification), the mean amount of move-
ment programmed into the appliances for the maxillary
first premolar was 0.47 mm (range, 0.12-0.92 mm; 1
SD, 0.21 mm; 2 SD, 0.42 mm).
The 2 available sets of patients’ study models from
the ClearSmile laboratory were compared for the
amount of movement of the maxillary first premolar.
Each number was divided by 4 to provide an average
American Journal of Orthodontics and Dentofacial Orthopedics Barbagallo et al 223
Volume 133, Number 2

Fig 6. Three-dimensional reconstructed images of a premolar subjected to no movement (control

tooth) and removed from occlusion with bite-opening GIC bonded to the mandibular first molars for
8 weeks. From left to right: buccodistal, distolingual, mesiobuccal, and lingual views.

Table I. Pair-wise comparisons Table II. Mean total OIIRR for the 4 force groups
(estimated marginal means)
Force Force Mean pair-wise
group group difference† SE Significance‡ 95% CI
0 control 1 light ⫺21.268* 2.767 .000 Force Mean SE Lower bound Upper bound
2 heavy ⫺41.533* 2.767 .000
3 TA ⫺24.121* 1.956 .000 0 control 4.913 1.786 1.228 8.599
1 light 0 control 21.268* 2.767 .000 1 light 26.182 1.786 22.496 29.868
2 heavy ⫺20.265* 2.767 .000 2 heavy 46.447 1.786 42.761 50.133
3 TA ⫺2.852 1.956 .947 3 TA 29.034 .799 27.386 30.682
2 heavy 0 control 41.533* 2.767 .000
1 pixel ⫽ 0.01709 mm.
1 light 20.265* 2.767 .000
Dependent variable, cube root volume tooth (pixels).
3 TA 17.413* 1.956 .000
3 TA 0 control 24.121* 1.956 .000
1 light 2.852 1.956 .947
2 heavy ⫺17.413* 1.956 .000 transformation results in measurements of the amounts
Dependent variable, cube root volume of OIIRR. of root resorption that are closer to normal and hence
Based on estimated marginal means. satisfy more closely the requirements of the optimum
*Mean difference is significant at the .05 level. statistical analysis procedures (ANOVA). Since we
†
Mean pair-wise difference between the force group in column 1 and were interested in the amounts of root resorption, it was
the adjacent force group in column 2.
‡ just as valid to measure this in terms of volume of
Bonferroni adjustment for multiple comparisons.
resorption or radius of an equivalent hemispherical
crater. Thus, the unit of measurement used was 3公 of
programmed movement for the 4 appliances. The mean voxels—ie, pixels—which can easily be converted to
for all patients was again 0.47 mm (range, 0.20-0.66 3
公mm3, or millimeters.
mm; 1 SD, 0.15 mm; 2 SD, 0.3 mm). With a mean of For the 4 force groups (control, light, heavy, and
0.47 mm of movement per appliance, 4 appliances TA), an examination was conducted involving pair-
would produce a mean of 1.88 mm of movement. wise comparisons (with the Bonferroni adjustment for
To estimate the accuracy of the measurements, the multiple comparisons) (Table I). It was found that all
appliances and the models from 10 randomly selected pair-wise differences were significant (P ⬍.001), ex-
patients were remeasured. The coefficients of variation cept the difference between the light-force and the TA
(standard deviation/mean ⫻ 100) were 1.90% for mea- groups, which were not statistically significant.
surements on the appliances and 1.37% for the study Table II and Figure 7 show the mean total resorp-
model measurements. tion for the 4 force groups. The control teeth had the
Univariate ANOVA was performed on the raw root fewest resorption cavities. The light-force teeth had an
resorption data with software (SPSS for Windows, approximately 5 times more root resorption cavities
version 12; SPSS, Chicago Ill). The volumes of the than the control teeth. The TA teeth had a similar but
resorption cavities were transformed into cube-root slightly larger volume of cavities than the light-force
volume readings, a methodology that was used in teeth, approximately 6 times greater than the control
previous 3D volume root resorption studies.12,15,16 This teeth. The heavy-force teeth had the most resorption
224 Barbagallo et al American Journal of Orthodontics and Dentofacial Orthopedics
February 2008

Fig 7. Cube root volume of the resorption cavities Fig 8. Cube root volume of the resorption cavities for
produced by the 4 forces: control (no force), light (25 g the 6 root surfaces for the 4 forces. BC, Buccal-cervical;
cantilever force), heavy (225 g cantilever force), and TA. BM, buccal-middle; BA, buccal-apical, LC, lingual-cer-
vical; LM, lingual-middle; LA, lingual-apical.
cavities, about 9 times greater than the control teeth
(Table II and Fig 5). There was a statistically significant Table III.
Pair-wise comparisons between selected loca-
difference in the volume of root resorption craters be- tions undergoing compression and tension for the light,
tween the control, light-force, and heavy-force groups heavy, and TA root resorption values.
(P ⬍.001). There was also a statistically significant
Force by Force by Mean
difference between the control, TA, and heavy-force position position difference SE Significance†
groups (P ⬍.001). The difference between the TA and
the light-force groups was not statistically significant Light BC Light BA 3.857 3.459 1.000
Light LA Light LC 18.298* 3.459 .000
(P ⫽ .947), even though the mean volume of resorption Heavy BC Heavy BA 19.469* 3.459 .000
craters in the TA group was slightly greater. Heavy LA Heavy LC 26.764* 3.459 .000
The factors used in the second ANOVA analysis TA BC TA BA 12.586* 1.997 .000
were subject (again a random factor) with fixed factors TA LA TA LC 18.744* 1.997 .000
of force (as before) and position. The root surface was Buccal-cervical (BC) with buccal-apical (BA), and lingual-apical
divided into regions according to the location of the (LA) with lingual-cervical (LC).
resorption. There were 3 axial zones, apical, middle, Dependent variable, cube root volume tooth.
and cervical, and 2 surfaces, buccal and lingual. Thus, Based on estimated marginal means.
*Mean difference is significant at the .05 level.
in combination, there were 6 regions. †
Bonferroni adjustment for multiple comparisons.
Figure 8 shows the 6 surface resorption distribu-
tions of the sample divided into the 4 force groups. The
graphic distribution indicates that the teeth in the movements were executed by hand. However, the
heavy-force, TA, and light-force groups had the most average movement of 0.47 mm in 2 weeks was close to
resorption on the buccal-cervical and lingual-apical the prescribed movement of 0.5 mm in 2 weeks. The
surfaces. Table III gives pair-wise comparisons be- average rate of tipping movement that teeth can achieve
tween selected locations that are expected to experience in dense cortical bone in a healthy periodontium is
compression and tension for the light, heavy, and TA 1 mm per month,33 and the maximum biologic potential
root resorption values. Comparisons of buccal-cervical for tooth movement is 3 mm per month.34 Thus, the
(compression) with buccal-apical (tension), and lin- average programmed amount of movement of the TAs
gual-apical (compression) with lingual-cervical (ten- is not unreasonable because an average of 0.47 mm in
sion) were conducted. 2 weeks is programmed per appliance, and 2 appliances
are used each month; this results in a rate of tipping
DISCUSSION movement that approaches the theory of Roberts et al33
The amount of movement of the maxillary first regarding the average rate of movement.
premolar programmed by the TAs was found to be It was not practical to monitor the patients’ com-
highly variable. This is not surprising because the pliance with the instructions to wear the TAs full-time
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 2
(except during meals and oral hygiene procedures).
Upon retrieval of each appliance, it was found to be
completely passive.
The few studies in the literature regarding remov-
able appliances and OIIRR agreed that these appliances
induce less OIIRR than fixed appliances.18,19 Studies
involving a discontinuous force—a pause in active
treatment every day—also found less OIIRR compared
with continuous force.25,26 Our results show that the
OIIRR induced by the TAs is relatively low and is
statistically equivalent to the OIIRR associated with a
light continuous force of 25 g (cN). This can be
explained by the discontinuous and removable nature of
the force. Compliance of the participants, however, was
not determined; thus, poor compliance with wear of
removable appliances is another possible explanation
for the low volume of OIIRR.
It has been proposed that, if the force that induces
orthodontic movement is greater than the partial pres-
sure of the periodontal capillaries (26 g per square
centemeter),35 periodontal ischemia will occur and lead
to root resorption.8,36-38 Many animal39-41 and human
studies16,38,42-45 have determined that the force magni-
tude is directly correlated with the severity of OIIRR.
However, other studies disagree with this principle.46-48
These studies were histologic, involving 2D measure-
ments of a 3D phenomenon. Histologic methods of
quantification of resorption are not as accurate and
reliable as 3D measurement tools such as SEM and
x-ray micro-CT.13 Our 3D volumetric findings of a
statistically significant difference in the volume of root
resorption craters between the control, light-force, and
heavy-force groups agrees with other 3D studies’ find-
ings that the force magnitude is directly correlated with
the severity of OIIRR.16,38,42,43
Schwartz35 in 1932 described his pressure-tension
theory and recommended 7 to 26 g per square centi-
meter as the most favorable force for tooth movement.
He believed that root resorption would occur if the
force went beyond this limit. It has also been suggested
that, when forces are lower than the threshold, the
resorptive process stops.49
As has been described in other root resorption
studies from the University of Sydney, force levels for
the light force of 25 g (25 cN) and the heavy force of
225 g (225 cN) were selected.12,16 This facilitates
comparison of results between the various root resorp-
tion studies from the department. Previous root resorp-
tion studies at the University of Sydney involved 28
days of force application. However, after application of
force, it can take between 10 and 35 days for resorbed
lacunae to appear.8,38,46,50 The duration of this study
was 56 days. This design thus encompassed patients
Barbagallo et al 225
who might require more than 28 days for the resorption
to appear.
Resorbed lacunae after orthodontic tooth movement
appear mainly in the regions of compression3,8,21,50,51
and rarely in the regions of tension.52 The 6 surface
resorption distribution analysis (Fig 8, Table III) of the
teeth in the heavy, light, and TA forces demonstrated
increased buccal-cervical and lingual-apical resorption
distributions. This corresponds with pressure in these 2
regions generated by tipping tooth movements. These
findings agree with another 3D root resorption study.53
However, the patients who participated in the study had
teeth that were in malocclusion and often crowded, and
the adjacent teeth might have influenced the direction
of movement.
The maxillary first premolars of all patients in our
study were examined with panoramic radiography.
All teeth had completed apexification, and no pre-
treatment root shortening was visible before the
study. The patient selection process endeavored to
eliminate those who were predisposed to root resorp-
tion.30 The control teeth had resorption despite the
absence of force application; this was also found in
other studies when no force was applied.12,14,16 The
results support the proposal that other causative
factors are linked to root resorption apart from
orthodontic force.
CONCLUSIONS
A root resorption study involving sequential remov-
able TAs has not been conducted in the past. X-ray
micro-CT is established as an accurate method for
quantifying root resorption compared with 2D meth-
ods.13 Only a few studies in the literature used x-ray
micro-CT to quantify OIIRR.15,16
The following conclusions have been made from
the root resorption analysis of teeth subjected to TA
forces compared with teeth subjected to light and heavy
cantilever forces and no force (control).
1. The teeth in increasing order of root resorption
cementum loss were control, light force, TA force,
and heavy force.
2. The control teeth had the fewest resorption cavities.
The light-force teeth had approximately 5 times
more root resorption cavities than the control teeth
(P ⬍.001). The TA teeth had a similar but slightly
more cavities than the light-force teeth—approxi-
mately 6 times greater than the control teeth
(P ⬍.001). The heavy-force teeth had the most
resorption cavities, about 9 times greater than the
control teeth (P ⬍.001).
226 Barbagallo et al
3. The distribution pattern of the resorption cavities
was greatest in the buccal-cervical and lingual-
apical regions in the teeth in the TA, light-force,
and heavy-force groups. These correspond to re-
gions of compression generated by tipping force;
this agrees with another 3D root resorption study.
It can be concluded from these results that clear
removable TAs have similar effects on root cementum
as light fixed orthodontic forces (25 g). The use of this
relatively new technique as an alternative to fixed
appliances for the treatment of certain minor malocclu-
sions is promising when considering the 3D root
resorption findings.
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