Prevalence of Root Resorption in Patients of RSGM Universitas

Sumatera Utara with Non-extraction Orthodontic Treatment

Siti Bahirrah

, Mimi Marina

, Durgha Gunasegaran

Department Dentistry Faculty, Universitas Sumatera Utara at Jl. Alumni No.2 Universitas Sumatera Utara, Medan 20155

Keywords: Resorption, orthodontic, teeth.

Abstract: Root resorption is a side effect which cannot be prevented in orthodontic treatment. External apical root

resorption (EARR) causes root shortening. The purpose of this study is to assess the prevalence of the degree

of EARR in the incisors between maxillary and mandible before and after orthodontic treatment in patients

with non-extraction cases. This research is an analysis of a cross-sectional study conducted on samples namely

panoramic radiographs of patients before and after orthodontic by using the modification of Lavender and

Malmgren index and Linge and Linge method. Wilcoxson test and Chi-square test was used for statistical

analysis. Samples amounted to a total of 400 incisor teeth which have received orthodontic treatment. Results

shows that of the 400 incisor teeth studied, the results found were 5 incisors (1.25%) with mild EARR (score

1), 368 incisors (92%) had moderate EARR (score 2) and as many as 27 incisors (6.75%) had severe EARR

(score 3). The incisors with extreme EARR (score 4) is 0%. Conclusion, the EARR experienced by incisors

is on score 2 as much as 92% and there are no incisors (0%) experienced extreme EARR (score 4).

1 INTRODUCTION

Orthodontic treatment has a positive effect but can

have undesirable secondary effects. At the roots,

undesirable side effects include severe root resorption

(Preoteasa, 2012). Root resorption is the process of

losing cementum and dentine from the roots (Bishara,

2001).

Apical resorption is an unavoidable complication

and microscopic studies show a prevalence of 100%.

This process can cause the shortening of root

(Preoteasa, 2012]. Based on the research by Kapoor et

al. (2014) when orthodontic force is given then

receptor activator of the nuclear factor kappa-Β

ligand (RANKL) will increase in the gingival

crevicular fluid. This increase stimulates the PGE2

pathway and initiates osteoclast activity leading to

root resorption (Kapoor et al, 2014).

The degree of EARR is determined based on

using the modification of Lavender and Malmgren

index and Linge and Linge method. Linge and Linge

introduced the crown length registration method by

calculating the correction factor. This method can

connect the radiography before and after. The

Lavender and Malmgren index is a subjective method

and EARR can’t be evaluated by this index alone

because distortions in panoramic radiography before

and after treatment may occur which might make it

difficult for researchers to evaluate EAAR.

Therefore, these two methods are used to assess

RAAE incisors before and after treatment (Jacobs et

al, 2014).

Mohandesan et al. (2007) have found root

resorption occurs in maxillary central incisive tooth as

much as 74% and maxillary lateral incisors as much

as 82% (Mohandesan et al, 2007). Agrawal et al.

(2016) has observed root resorption in molar teeth

and the results show extreme EARR especially in

maxillary first molar (53.3-63.3%). This resorption is

caused by the force applied on molars are larger

compared to the premolars. In addition, the incidence

of EARR in the case of extraction occurred 3.72 times

greater than in non-extraction cases (Agarwal et al,

2016).

According to a study by Sunku et al (2011),

the average EARR that occurred in maxillary

central incisors were as much as 27.2% and the

maxillary lateral incisors were 25.2% and the least

root resorption occurred in the mandible lateral

incisors right and left were as much as 19.1% and

17.4% (Sunku et al, 2011). Different results can also

be found in several studies. According to the study of

410

Bahirrah, S., Marinah, M. and Gunasegaran, D.

Prevalence of Root Resorption in Patients of RSGM Universitas Sumatera Utara with Non-extraction Orthodontic Treatment.

DOI: 10.5220/0010068004100414

In Proceedings of the International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches (ICOSTEERR 2018) - Research in Industry 4.0, pages

410-414

ISBN: 978-989-758-449-7

Savoldi et al. (2015), mandible central incisors and

lateral mandible incisors experienced slight

resorption and he concluded that patients with mild-

crowding teeth and orthodontic treatment with low

force might cause mild apical root resorption

especially in the mandible incisors (Savoldi et al,

2015).

Jiang et al. (2010) gained a positive relationship

between root resorption and the duration of treatment

through the Bivariate Correlation analysis and

concluded that the longer the duration of treatment

the more severe the resorption of the roots (Jiang et

al, 2010). A study conducted by Nanekrungsan et al.

(2012) based on 564 periapical radiographs of the

maxillary incisors have obtained results that EARR

occurred as much as 59.6% mild, moderate EARR as

much as 31.9% and severe EARR as much as 8.5%

(Nanekrungsan et al, 2012).

2 METHOD

This research is an analytical research with a cross

sectional approach. Samples were taken based on

inclusion and exclusion criteria. The inclusion criteria

of this study were patients who had completed

orthodontic treatment, patients with non-extraction

cases, medical records before and after treatment

should be complete, patients with 17-40 years of age,

patients with no systematic disease, radiography in

good quality and from the same laboratory and

patients with good oral hygiene. The exclusion criteria

for this study were poor quality radiographs, patients

who had received endodontic treatment in incisors,

had a history of mechanical trauma in incisors and

bad habits (tongue-thrusting, thumb sucking,

bruxism).

2.1 Procedure

The agreement of ethical clearance was obtained

from the Medical Ethics Commission of USU. The

collection of panoramic radiography of patients before

and after treatment. Then, tracing of the anatomic

shape of the maxilla and mandibular incisors.

Evaluation is done based on the modification of

Lavender and Malmgren index and Linge and Linge

method. Operator Test was conducted and the result

of the measurement is then processed by

computerized and the data is analyzed.

2.2 Data Analysis

The data will be computerized and using the

Wilcoxon test because data was not distributed

normally and data analysis followed by Chi-Square

test used to know the difference in EARR between

maxilla and mandibular incisors.

3 RESULTS AND DISCUSSIONS

Root resorption is evaluated in maxillary and

mandible central incisors and lateral incisors. The

number of teeth evaluated was 400 incisors which are

200 maxillary incisors and 200 mandible incisors.

Table 1: EARR distributions occurred in 400 incisors in

non-extraction orthodontic patients.

Score Total

1 2 3 4

n % n % n % n % n %

Inci

sor

1.25

368

6.75

400

100

Table 1 shows that of the 400 incisor teeth studied,

the results found that there were 5 incisors (1.25%)

with mild EARR (score 1), 368 incisors (92%) had

moderate EARR (score 2) and as many as 27 incisors

(6.75%) had severe EARR (score 3). The incisors

with extreme EARR (score 4) is 0%.

Table 2: EARR distribution that occurred in 200 maxillary

incisors.

Score

Tooth

1 2 3 4 Total

N% N % N %n

Maxillary

right

lateral

incisor

- - 50 25 - - - - 50 25

Maxillary

right

central

- - 50 25 - - - - 50 25

Prevalence of Root Resorption in Patients of RSGM Universitas Sumatera Utara with Non-extraction Orthodontic Treatment

411

incisor

Maxillary

left central

incisor

1 0.5 49 24.5 - - - - 50 25

Maxillary

left lateral

incisor

2 1.0 47 23.5 1 0.5 - - 50 25

Total

1.5

196

0.5

200

Table 2 shows the EARR distribution that

occurred in maxillary incisors in non-extraction

orthodontic patients. A total of 196 maxillary incisors

experienced moderate root resorption (score 2) of

98.0%. 0.5% (1 tooth) of maxillary left lateral incisor

experienced severe root resorption (score 3) was and

as much as 3 maxillary incisors which are maxillary

left central incisor and maxillary left lateral incisors

experienced mild root resorption of 0.5% and 1.0%

each. The results show that samples with extreme

EARR (score 4) are zero.

Table 3: EARR distribution that occurred in 200 mandible

incisors.

Score

Tooth

1 2 3 4 Total

N % N % N % n

Mandible

right

lateral

incisor

1 0.5 40 20 9 4.5 - - 50 25

Mandible

right

central

incisor

- - 43 21.5 7 3.5 - - 50 25

Mandible

left central

incisor

1 0.5 43 21.5 6 3 - - 50 25

Mandible

left lateral

incisor

- - 46 23 4 2 - - 50 25

Total 2 1.0 172 86.0 26 13.0 - - 200 100

Table 3 shows the EARR distribution that

occurred in the mandible incisors in non-extraction

orthodontic patients. A total of 172 maxillary incisors

experienced moderate root resorption (score 2) of

86%. A total of 26 mandible incisor teeth experienced

severe root resorption (score 3). Mandible right

lateral incisors had the highest number of EARR

samples (score 3) of 4.5%. A total of 2 mandible

incisors which are mandible right lateral incisor and

mandible left central incisors were subjected to mild

root resorption of 0.5%. The results show that

samples with extreme EARR (score 4) are zero.

Table 4: Chi-square test results

Average

(mm)

-Value

Maxillary

Incisors

2.12 1.71

0.018

Mandible

Incisors

2.77

2.35

Chi-Square test results (table 4) showed that the

average EARR occurred in the maxillary incisors

were 2.12mm ± 1.71 while in the mandible were

2.77mm ± 2.35. The statistical analysis showed that

there were significant EARR differences between

maxillary and mandible incisors (p = 0.018). EARR

occurred in the mandible incisors are higher than the

maxillary incisors.

EARR is one of the most common iatrogenic

problems with orthodontic treatment. This study has

been conducted to observe the prevalence of root

resorption before and after orthodontic treatment in

patients who received non-extraction therapy. The

number of teeth evaluated was 400 incisors which are

200 maxillary incisors and 200 mandible incisors.

The degree of EARR was measured using the

Linge and Linge method modified with Lavender

and Malmgren index. Linge and Linge introduced the

crown length registration method by calculating the

correction factor. This method could connect the

radiography before and after.

ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches

412

The Lavender- Malmgren index is a subjective

method. Assessment of the degree of root resorption

does not depend on radiographic standardization

before treatment. Distortion of panoramic

radiography before and after treatment may occur and

it may be difficult for researchers to evaluate EARR

with the Lavender-Malmgrem index alone.

Therefore, researchers used two methods to assess

EARR of the incisors before and after treatment.

The results (Table 1) shows that of the 400 incisor

teeth studied, the results found shows that 5 incisors

(1.25%) with mild EARR (score 1), 368 incisors

(92%) had moderate EARR (score 2) and as many as

27 incisors (6.75%) had severe EARR (score 3). The

incisors with extreme EARR (score 4) is 0%.

The results of this study are similar to Chavez et al.

(2015) study. He found that the teeth which

experienced severe EARR the most are mandible

central incisor teeth of 1.12mm (Chavez et al, 2015).

Researcher Batool et al. (2010) got the result of

mandible incisors (2.60%) having the greatest EARR

and maxillary central incisors (1.52%) experienced

the least EARR (Batool et al , 2010). Most studies

show different results. Researcher Maues et al.

(2015) found that maxillary central incisor had the

highest percentage of EARR followed by maxilla

lateral incisors and mandible lateral incisors. A total

of 28 teeth (2.9%) out of 959 examined teeth

experienced severe EARR (Maues et al, 2015). The

Sunku et al. (2011) study showed the highest rate of

root resorption occurred in 27.2% maxillary central

incisors and maxillary lateral incisors as much as

25.2% and followed by right and left canines of

23.5% and 21.0% and the least EARR occurred in the

right and left maxillary lateral incisors of 19.1% and

17.4% (Sunku et al, 2011).

Overall, the average EARR score which occurred

in incisors were score 2. This is similar with Sunku et

al. (2011) study that most patients receiving

orthodontic treatment would have root resorption

even if treatment was performed without extraction

(Sunku et al, 2011). Agarwal et al. (2007) study

showed that resorption in patients treated with

extraction (55.9%) experienced higher EARR than

treated patients without extraction (37.9%) (Agarwal

et al, 2016). Researcher Mohandesan et al. (2007)

found that in dental extraction patients, root

resorption occurred in maxillary central incisors and

maxillary lateral incisors are 11.1% and 12.7%. The

root resorption occurred in patients with non-

extraction treatment in maxillary central and lateral

incisors was 8.4% and 9.2 %. This is because,

extraction patients require more teeth movement and

apical displacement than those treated without

extraction to correct the malocclusion. This causes

high EARR in patients treated with extraction

(Mohandesan et al, 2007). There is a research that

yielded the opposite result. Researcher Zahedani et al.

(2013) found that there is no significant difference

between the group of patients treated with dental

extraction and the group treated without dental

extraction (Zahed et al, 2013).

The intraoperator test showed that there were no

significant differences between the first and second

calculations. Chi-Square test results (table 4) showed

that the average EARR that occurred in the maxillary

incisors were 2.12mm ± 1.71 while the mandible

incisors were 2.77mm ± 2.35. Chi-Square test shows

that there is significant EARR difference between

maxillary and mandible incisors (p <0.05).

Based on the data analysis of table 4, the results

showed that the number of mandible incisors that

experienced severe EARR was higher than maxillary

incisors. This is attributed to tooth morphology of

mandible incisors. The morphology of apical

mandible tooth is long, narrow and susceptible to

deviation. Deformed root morphology is susceptible

to increased root resorption as compared to normal

root morphology in the application of orthodontic

force (Pandey et al, 2015, Oyama et al, 2007).

Researcher Pandey et al. (2015) obtained results that

deviated apex teeth received more load than normal

dental apex. This is due to the orthodontic force which

is concentrated on the apex and apical structures such

as the cellular cementum which is less mineralized

and is easily traumatized (Pandey et al, 2015). In

addition, researcher Batool et al. (2010) stated that

mandible incisors experience greater EARR than

maxillary incisors because they may be associated

with denser alveolar bones in the mandible and the

thinner root structures in the mandible incisors

(Batool et al, 2010). The researcher in this study used

panoramic or bidimensional radiographic image (2D)

radiography and there is a disadvantage in the

angulation of incisors and panoramic radiographic as

it has an enlargement of 20% more magnification than

periapical radiographic (Castro et al, 2010).

Panoramic radiography is difficult to be measured

and in determining the diagnosis because the degree

of magnification in a particular area is unknown.

4 CONCLUSIONS

The prevalence of EARR occurred in incisors was

92% in score 2 (moderate RAAE). The average

EARR that occurred in the maxillary incisors are

2.12mm ± 1.71 whereas the in the mandible incisors

Prevalence of Root Resorption in Patients of RSGM Universitas Sumatera Utara with Non-extraction Orthodontic Treatment

413

are 2.77mm ± 2.35. Mandible incisors have a higher

risk of EARR than maxillary incisors. Based on Chi-

Square test results showed significant differences in

EARR between the maxilla and mandibular incisors.

ACKNOWLEDGMENTS

The authors gratefully acknowledged the Research

Department of Universitas Sumatera Utara based on

Talenta Universitas Sumatera Utara Research year

2018 contract with the number of contract of 273

/UN5.2.3.1/PPM/KP-TALENTA USU/2018

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