Orthodontically induced inflammatory root resorption: apical and cervical complications

15 Pages·2013·1.87 MB·English

DOI: 10.1051/odfen/2012402 J Dentofacial Anom Orthod 2013;16:102
(cid:2)RODF /EDP Sciences
Orthodontically induced
inflammatory root resorption:
apical and cervical complications*
Dominique LUNARDI, Thibault BE´CAVIN,
Alain GAMBIEZ, E´tienne DEVEAUX
ABSTRACT
External root resorption is a feared complication during orthodontic
procedures. It can affect both the apex, but also the cervical zone of the roots
subjected to orthodontic forces for tooth movement and can compromise the
future of the involved teeth. The patient must be informed about the risks of
resorption as a consequence of orthodontic treatment. The detection of
resorptions can occur during and/or after the active phase of orthodontic
treatment.
Knowledge of the clinical situations predisposing the patient to resorption is
essential. The data are still insufficient to avoid them completely. Early and
precise detection is essential, and the cone beam with its high resolution 3D
images, can compensate for the diagnostic inaccuracy of digital panoramic
and periapical films. There are treatment solutions and their prognosis is
correlated to early detection. Apical resorptions, generally not infected, can
mostly be stopped by discontinuing orthodontic forces. Cervical resorptions,
with a bacterial component, will require surgical intervention with curettage
and restorative build-up of the resorbed area. Current research, particularly in
genetics, is in the developmental stage. In the future, the conclusions of this
research will allow orthodontists to more precisely target at risk patients so
as to avoid these complications.
KEY WORDS
Inflammatory root resorptions,
Apical resorption,
Cervical resorption,
Orthodontic treatment,
Risk factors,
Cone beam.
Conflictsofinterestdeclaredbytheauthor:NONE
Addressforcorrespondence:
Article received:08-2012
D.LUNARDI
Acceptedforpublication: 09-2012
Faculte´ de ChirurgieDentaire
Placede Verdun 1
59000 Lille
[email protected]
*Translatedfrom Frenchby PatrickFinnegan
Article available athttp://www.jdao-journal.orgorhttp://dx.doi.org/10.1051/odfen/2012402
DOMINIQUELUNARDI, THIBAULTBE´CAVIN,ALAINGAMBIEZ,ETIENNEDEVEAUX
INTRODUCTION
Resorption is a clinical condition anatomy of cervical resorptions cre-
associated with a physiological or ates a predisposition to breeding bac-
pathological process leading to a loss teria at theresorption site. Becauseof
of dentin, cementum and/or bone itsinvasivenature13,thissituationpre-
structure7. ventsnewcementumfromforming.
In orthodontics, therapeutic proce- Given the importance of preventing
dures mainly involve restructuring these pathological resorptions, ortho-
bone, periodontal ligaments and ce- dontists must carefully take into ac-
mentum1. All orthodontic treatment count risk factors and conditions
is accompanied by self-limiting and before initiating any treatment. By
reversible micro-resorptions of root taking these precautions, orthodontic
and cementum. Histologically, they treatment can also be adapted to
are radiographically imperceptible sur- more difficult clinical situations.
face resorptions, allowing and ac- If this preventive strategy fails and
companying dental movements19. despite our efforts, invasive inflam-
According to Andreasen et al.2, these matory resorptions appear, they
surface resorptions are followed by should be detected early and accu-
spontaneous repair with the forma- rately. A new diagnostic tool, the
tion of new cementum. This is cone beam, already extensively used
neither a physiological process nor a by endodontists, compensates for
pathological process but instead a the diagnostic inaccuracy of panor-
controlled orthodontic therapeutic exes and periapical radiography40.
process, as long as the dentin is not These two types of images do not
affected. clearly reveal resorption in all its con-
In certain cases, the phenomenon figurations.
is no longer self-limiting: i.e. when the When this is the case, orthodon-
repair of the cementum is disturbed. tists and dentists must act in concert
The action of the odontoclasts to set up a therapeutic strategy.
reaches beyond the cementum to the
The earlier resorption is detected,
underlying dentin. This is a pathologi-
the simpler the treatment solution is
cal process because once the dentin
to safeguard teeth. A thorough follow-
is affected, it continues in an irreversi-
up during and after orthodontic treat-
ble manner. These resorptions can af-
ment is therefore essential and it
fect the tooth at the apex as well as
should be part of a long-term plan. In
the neck. For non-infected apical re-
fact, pathologicalinflammatoryresorp-
sorption, even if the dentin cannot be
tions show up long after the end of
reconstructed, newly formed cemen-
treatment and this is especially true
tum can cover the resorbed area19.
forexternalcervicalresorptions13.
Resorption shortens the root. The
2 Lunardi D, Be´cavin T, Gambiez A, Deveaux E. Orthodontically induced inflammatory root resorption:
apical and cervical complications
ORTHODONTICALLYINDUCEDINFLAMMATORYROOTRESORPTION:APICALANDCERVICALCOMPLICATIONS
HOW DO EXTERNAL PATHOLOGICAL INFLAMMATORY ROOT
RESORPTIONS DEVELOP?
Olivieri et al.29 explains that the de- thatthehighestrateofcervicalresorp-
velopment of external pathological in- tion involved patients who had earlier
flammatory root resorptions results orthodontictreatment. Theanatomical
from the alteration or loss of the pro- shape of the cervical resorption influ-
tective cementum layer due to in- encestheirdevelopment.Thesecervi-
flammation. The cementum protects cal resorptions are in effect subject,
the underlying dentin from resorption by way of the sulci, to a possible
and has the potential for repair30. bacterial infestation promoting inflam-
When a stimulus attacks the cemen- mation and hence the development of
tum and overwhelms its capacity for resorption, even if the movement
repair, dentin is exposed11,13. forcesarediscontinued.
Histologically, the dentin exposure However, orthodontic forces are
to osteoclast precursor cells, originat- not the only etiology likely to cause
ing in the periapical ligament and dif- disturbance in cementum repair and
ferentiating into odontoclasts, marks subsequently pathological root re-
the starting point of the pathological sorption.
process11,13. In fact, only the cemen- It is important for the orthodontist
tum has the potential for repair, and to be aware of the possibility and
as soon as the dentin is attacked and nature of other possible causes of re-
is in turn resorbed, the loss of root sorption. Therefore, they should also
structure becomes irreversible19. be listed as risk factors or additional
Theforcesexerted duringorthodon- etiological factors to orthodontically
tic treatment can, in certain cases, induced external root resorption.
lead to this type of irreversible resorp- When diagnosing an external root re-
tion. The forces represent a potential sorption during or after orthodontic
mechanical stimulus for pressure on treatment, the practitioner can formu-
the cementum. Brezniak and Wasser- late a differential or complementary
stein6, in 2002, suggested the use of diagnosis.
terminology specific to orthodontics
and spoke of orthodontically induced Therefore, if Heithersay13 impli-
inflammatory root resorptions (OIIRR), cates orthodontic treatment in almost
emphasizing the importance of this one fourth of recorded clinical cases
phenomenon.Inorthodonticliterature, of external cervical resorption, he
this is very often associated with the also implicates traumas, internal
notion of apical resorption, but we bleaching, surgical and periodontal
should not forget that resorption can procedures, and other factors such
also involve the cervical area. Heither- as bruxism and delayed eruption of
say shows in one research article13, the dentition.
3
Rev Orthop Dento Faciale 2013;16:102.
DOMINIQUELUNARDI, THIBAULTBE´CAVIN,ALAINGAMBIEZ,ETIENNEDEVEAUX
WHAT ARE THE PREDICTIVE FACTORS FOR THE APPEARANCE OF ROOT
RESORPTIONS IN ORTHODONTICS?
Mizrahi27 reminds us that ortho- more, Hartsfield11 explains that the
dontic treatment, like any other pro- activation of the osteoclasts (resorp-
cedure of dentistry, exposes the tion cells) may be genetically linked.
practitioner to possible litigation. Iglesias-Linares et al. demonstrate
An analysis of the predictive fac- that genetic variations involving the
tors for the appearance of root re- interleukine-1ß gene (implicated in
sorption is indispensable before the inflammatory process associated
beginning orthodontic treatment and with orthodontic movements), may
these factors should be listed in the explain the appearance of certain ex-
informed consent form signed by the ternal apical resorptions. All these ar-
patient6. ticles present a variety of findings
that argue in favor of developing this
In fact, certain patients are more
line of genetic research regarding
predisposed than others to develop-
OIIRR.
ing root resorption during orthodontic
treatment11 and it is crucial to inform
them. From a medico-legal perspec-
Risk factors related to the
tive, Be´ry5 explains that the notion of
general health of the patient
risk is an integral part of patient infor-
mation and that the practitioner
Chronic asthma and certain aller-
should inform them about the known
gies can increase the chances that
risks based on available scientific
OIIRR will develop.
data.
Brezniak and Wasserstein6 report
For OIIRR, these risk factors are
that patients with chronic asthma,
generally related to the genetic pre-
whether treated or not, have a great-
disposition of the patients or to their
er susceptibility to apical OIIRR on
general overall health. They can be
the upper molars. This occurs be-
local, depending on the patient’s prior
cause asthma allows the inflamma-
dental treatment. Finally, there are
tion of the sinuses to come into
risk factors specific to the orthodon-
close contact with the apex of the
tic treatment to the teeth that are in-
maxillary molars and premolars.
volved.
Risk factors related to prior
Genetic factors predisposing to
dental procedures
resorption
For young patients, prior traumatic
In some ethnic groups, we find the
incidents are common and it is not
same susceptibility to orthodontically
unusual for them to have a history of
induced resorption16. According to
fractures, luxations and tooth loss fol-
Sameshima and Sinclair32, Hispanic
lowed by prosthetic replacement. In
patients are more susceptible to re-
addition to any orthodontic treatment,
sorption than Asian patients. Further-
4 Lunardi D, Be´cavin T, Gambiez A, Deveaux E. Orthodontically induced inflammatory root resorption:
apical and cervical complications
ORTHODONTICALLYINDUCEDINFLAMMATORYROOTRESORPTION:APICALANDCERVICALCOMPLICATIONS
the traumatic incidents alone could use the same approach to vital and
account for the appearance of inflam- nonvital teeth in the context of ortho-
matory root absorptions. But, in dontic treatment, except if the endo-
cases of orthodontic treatment, these dontic treatment is associated with
teeth that have already suffered trau- some previous trauma. Nonetheless,
ma or even perhaps have already faced with all these contradictions,
been resorbed will be all the more Iglesias-Linareset al.4 openedupnew
vulnerable to the forces that they will perspectives for research concerning
undergo. Brezniak and Wasserstein6 endodontically treated teeth by focus-
recommend waiting at least 3 ing on the genetic component, espe-
months before exerting force on a ciallyinterleukine-1ß.
transplanted or re-implanted tooth. For teeth that have undergone in-
However, in one study of the factors ternal bleaching, the risk for resorp-
that predispose patients to cervical tion is described separately from any
resorption, Heithersay13 remarks that orthodontic treatment. Similar to trau-
the etiological association of ortho- mas, in the case of orthodontic treat-
dontic-trauma is relatively rare (3% of ment, the risk for resorption of a
the teeth studied). Nonetheless, to- tooth that has undergone an internal
gether, orthodontics and trauma are bleaching will be greater. However,
frequently implicated in the etiology this conclusion needs to be qualified
of resorption. Heithersay’s findings since oxygenated water and the cata-
might therefore be due the effective lyst effect of heat due to friction
caution of orthodontists in applying were essentially implicated in the
force to move teeth that show signs phenomenon of resorption after
of previous trauma. bleaching pulp-free teeth. The pre-
Certain teeth whether traumatized sent use of sodium perborate mixed
or not, must be treated endodonti- with water is a much safer procedure
cally, and in the orthodontic literature, and less likely to induce resorption.
there are many debates about Other currently used therapeutic
whether these filled teeth are more procedures that may have damaged
susceptible or less susceptible to re- the cementum of one or more teeth
sorption. There is no consensusabout may be listed in the medical history
this question and in fact, researchers of the patient and can represent
even arrive at contradictory findings. areas at risk for resorption. Surgical
Mattison et al.26, and more recently procedures can, for example, be-
Esteves et al.8 were unable to offer cause of trauma inflicted on neigh-
anyevidenceofsignificantdifferences boring teeth during manoeuvers for
between live and filled teeth. Mah et extraction (luxating and elevating with
al.22showthatorthodonticallyinduced force), may be the cause for collat-
apical resorptions are slightly greater eral trauma to cementum. Even if
for endodontically treated teeth even young patients are much less in-
if the difference is not statistically sig- volved, periodontal detachment can
nificant, whereas Bender et al.4 arrive also cause damage to the cementum
at the opposite conclusion. Based on and induce secondary external cervi-
our current understanding, we should cal resorption.
5
Rev Orthop Dento Faciale 2013;16:102.
DOMINIQUELUNARDI, THIBAULTBE´CAVIN,ALAINGAMBIEZ,ETIENNEDEVEAUX
The risk factors associated with When inflammatory resorption is
orthodontic treatment and the induced by orthodontic
treated teeth treatment, when does it appear
and what forms does it take?
All categories of teeth do not seem
to have the same susceptibility to re- Resorption resulting from the force
sorption. In his thesis, Makedonas23 of orthodontic traction can occur on
refers to a number of studies and the apex as well as the cervical zone.
concludes that maxillary incisors, and
Apical resorption can appear during
more particularly lateral incisors are
the active phase of orthodontic treat-
more frequently affected by ortho-
ment and this is why the term resorp-
dontically induced apical resorption.
tion in orthodontics is often closely
Apices that are either blunt or drop-
associated with the apex. Orthodon-
per-shaped present a greater degree
tists diagnose them while performing
of resorption compared to normally
routine radiographical examinations
shaped apices. Next, he mentions
occurringperiodicallyduringtheactive
the vulnerability of the lower incisors
phase of treatment. The 6-9 month
and the upper premolars.
period after beginning treatment
Therootanatomymustalsobecon- seems to be important for screening
sidered as a factor. Lavander and Mal- and detecting apical resorption17,19.
mgren17 studied the relationship of The detection of minor resorptions at
the shape of the root to the incidence this time would confirm that there is a
ofapicalresorption.Apiceshavingthin high risk for subsequent aggravation
‘‘pipette-like’’ or blunt shapes had a ofthisphenomenon19.
greater degree of resorption than nor-
As for cervical resorptions, they
mallyshapedapices.
are generally diagnosed much later.
There is a debate as to whether or Heithersay13 diagnosed them in pa-
not orthodontic forces alone cause tients whose orthodontic treatment
root resorption. Should the applied had taken place 18 to 33 months ear-
forces be below a threshold so as to lier. Due to their late detection, these
avoid resorption? Lopatiene and resorptions are not observed by the
Dumbravaite19 attempt to answer orthodontist earlier. In fact, rarely do
this question and agree on forces of patients subject themselves to regu-
7 to 26 g/cm2. Maltha et al.28 confirm lar, long-term post-treatment screen-
that the magnitude of the force ex- ings. External cervical resorption
erted is a decisive factor and that its differs also because of direct expo-
intermittent application causes less sure to the oral environment and
damage than when it is continuous. therefore to bacterial infestation. Due
Esteves et al.8 are in agreement and to this exposure, Heithersay12 is in-
think that the use of intense force in- sistent about the invasive nature of
creases the likelihood of orthodonti- these resorptions and describes their
cally induced resorption. aggressive behavior. However, their
6 Lunardi D, Be´cavin T, Gambiez A, Deveaux E. Orthodontically induced inflammatory root resorption:
apical and cervical complications
ORTHODONTICALLYINDUCEDINFLAMMATORYROOTRESORPTION:APICALANDCERVICALCOMPLICATIONS
progression is slow and their perfora- –level 4: the resorption extends
tion of the pulp only occurs when beyond the first third of the root
there are serious lesions. The dentin length and is now considered ex-
probably contains an inhibitor for re- treme.
sorption39. For external cervical resorption,
A system of classification for the the Heithersay system of classifica-
various types of resorption makes it tion distinguishes four levels of cervi-
possible to make a precise diagnosis cal lesion (Figs. 3 and 4):
regarding their degree of severity. –level 1: the resorption is a small
For apical resorptions, the Levan- invasive cervical lesion that presents
der and Malmgren system17 distin- a shallow dentinal erosion.
guishes four levels of apical lesion –level 2: the resorption lesion is
(Figs. 1 and 2): very limited and penetrates the den-
–level 1: the resorption is minimal tin close to the pulp chamber but
and simply leaves an irregular apical does not extend as far as or only
root contour. slightly onto the root dentin.
–level 2: the resorption lesion is no –level 3: the resorption lesion pre-
greater than 2 mm on the hard tis- sents a deep penetration into the
sues. The authors call it minor re- dentin up to the first third of the root.
sorption. –level 4: the resorption lesion is
–level 3: the resorption destroys widely invasive and spreads apically
up to the first third of the root. There- beyond the first third of the coronal
fore, the resorption is qualified as se- root.
vere.
HOW TO DETECT OIIRR: INPUT FROM THE CONE BEAM
Root resorption presents a clini- course of treatment, but, even with
cally discreet symptomatology, that periapical films, the diagnostic accu-
may be entirely absent, especially in racy40 of this radiographic examina-
the first stages of their development. tion is often limited.
The clinical picture of an external Since the end of the ‘90s, a new
cervical resorption can be limited to a tool has been available, known in the
simple sensation of discomfort with Anglophone world as CBCT20 or
a pinkish cervical discoloration upon ‘‘cone beam computed tomography’’
examination, whereas the clinical pic- scanner.
ture for apical resorption can be to- Scientific research that relies on
tally asymptomatic. CBCT for the study of orthodontically
Because early detection is so es- induced root resorption is increas-
sential, it calls for regular comple- ingly evident in the literature. All
mentary radiographic examinations. these studies confirm the reliability
The orthopantogram is currently used and accuracy of the high resolution
to conduct examinations during the 3D images of the cone beam and
7
Rev Orthop Dento Faciale 2013;16:102.
DOMINIQUELUNARDI, THIBAULTBE´CAVIN,ALAINGAMBIEZ,ETIENNEDEVEAUX
Figure 2
Figure 1
Orthodontically induced inflammatory
The different levels of apical lesions (according to Levander
root resorption on the upper right
and Malmgren17).
lateral incisor: extreme apical lesion,
level 4 Levander and Malgren17.
Figure 4
Orthodontically induced inflamma-
tory root resorption on the upper
Figure 3
left second premolar: deep cervical
The different levels of cervical lesions (according to
lesion, level 3 Heithersay13.
Heithersay13).
8 Lunardi D, Be´cavin T, Gambiez A, Deveaux E. Orthodontically induced inflammatory root resorption:
apical and cervical complications
ORTHODONTICALLYINDUCEDINFLAMMATORYROOTRESORPTION:APICALANDCERVICALCOMPLICATIONS
The HAS report evaluates the ben-
efits of new technology as they per-
tain to each dental discipline.
In orthodontics, the conclusion of
the report indicates that, for now,
CBCT cannot be used in place of
conventional teleradiography for diag-
nostic purposes. However, in endo-
dontics, the report mentions that in
the interest of accuracy the cone
beam should be used when informa-
tion gathered from clinical examina-
tions and radiography do not provide
sufficient data for diagnosis and
Figure 5
therefore a tridimensional image is in-
Cervical resorption detected with cone beam imaging
dispensable. This statement applies
on a maxillary canine (transversal cut).
perfectly to the detection and diagno-
sis of root resorptions (Fig. 6a to 6c).
Recently, Wang et al.38 studied in
show how valuable it is as a tool for
vivo the accuracy of volumetric mea-
detecting resorption3,21,24,28.
surements of the cone beam on a
The HAS10 in France (similar to the sampling of 27 maxillary and mandib-
FDA) states that there is ‘‘a spatial ular premolars. The authors conclude
resolution and reliability comparable that the use of CBCT in the detection
to that of a scanner’’ (Fig. 5). The of orthodontically induced root re-
HAS continues ‘‘the accuracy and re- sorption is an obvious possibility.
liability of the measurements of Lund20 demonstrates the existence
CBCT makes its use in the dento- of resorption on both palatal and lin-
maxillo-facial orthopedic discipline ap- gual surfaces. He also specifies that
propriate since the delivered radiation they would not have been detected
dose is less than that of a scanner’’. with conventional radiography.
WHAT ARE THE THERAPEUTIC SOLUTIONS?
Therapeutic solutions are closely appears. To the extent that routine
related to both the location of the re- radiographic screening is performed,
sorption (apical or cervical), and to the orthodontist is more likely to de-
their stage of development (espe- tect them at the initial point of their
cially for cervical resorption). development. This is why even if se-
Throughout orthodontic treatment, vere cases are detected, they are re-
the practitioner will most often en- latively uncommon19. Sehr et al.33
counter apical resorption. In fact, it is examined a little more than 3000 pa-
especially during the active phase of tients who underwent multi-bracket
orthodontic treatment that resorption treatment between 1991 and 2010:
9
Rev Orthop Dento Faciale 2013;16:102.
DOMINIQUELUNARDI, THIBAULTBE´CAVIN,ALAINGAMBIEZ,ETIENNEDEVEAUX
.Figures 6 a to 6c
a: periapical view with suspicion of orthodontically induced external root resorption on a left upper canine;
b: saggital cut with cone beam imaging: confirmation and precise imaging of cervical resorption;
c: transverse cut with cone beam imaging: confirmation and precise imaging of cervical resorption.
severe apical resorptions were de- absence of infection (in other words
tected in 16 patients. Makedonas23 pulpal necrosis), endodontic treat-
confirms that the literature only ment is absolutely useless and would
comes up with an insignificant per- even be contra-indicated since the
centage of moderate to severe cases elimination of the pulp of a tooth dur-
of resorption. ing the resorptive process does not
When the first radiographic signs restrict the development of resorp-
appear, it is advisable to temporarily tion. Routine clinical examination of
interrupt orthodontic treatment for a the pulpal vitality of the treated teeth
period of 3 months31. In a survey of is however essential, because even
recent literature, Walker37 says that if the pulpal disturbances are minimal
stopping treatment for 2 to 3 months when IOORR occurs34, the practi-
makes it possible to completely re- tioner should never exclude the pos-
duce the progression of root resorp- sibility of necrosis. Other authors
tion. Tirpuwabhrut et al.34 adopt the recommend the use of ultrasound or
solution of stopping treatment and anti-inflammatory medication35. There
confirm that in instances of orthodon- is not a plethora of research in this
tically induced resorption, the practi- area and it is difficult to determine
tioner should, in this case, follow the the best protocol. Once the resorp-
protocol essentially based on elimi- tion process is stabilized, the practi-
nating the causal factor, i.e. ortho- tioner can resume orthodontic
dontic displacements. The Norwegian treatment and cautiously monitor the
authors continue to state that in the results by performing very precise
10 Lunardi D, Be´cavin T, Gambiez A, Deveaux E. Orthodontically induced inflammatory root resorption:
apical and cervical complications