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Root Resorption Diagnostic: Role of Digital Panoramic Radiography

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DOI: 10.12865/CHSJ.45.02.05

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Iulia Roxana Marinescu et al. - Root Resorption Diagnostic: Role of Digital Panoramic Radiography

Original Paper
Root Resorption Diagnostic:
Role of Digital Panoramic Radiography
IULIA ROXANA MARINESCU1, ALEXANDRA CARINA BĂNICĂ2,
VERONICA MERCUŢ3, ANCA GABRIELA GHEORGHE4,
EMMA CRISTINA DRĂGHICI1, MELANIA OLIMPIA COJOCARU1,
MONICA SCRIECIU3, SANDA MIHAELA POPESCU1
1
Department of Oral Rehabilitation, Faculty of Dental Medicine,
University of Medicine and Pharmacy of Craiova, Romania
2
PhD Student, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, Romania
3
Department of Prosthetic Dentistry, Faculty of Dental Medicine,
University of Medicine and Pharmacy of Craiova, Romania
4
Department of Endodontics, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, Romania

ABSTRACT: Introduction: Root resorption is a pathological process characterized by loss of dental root
substance, caused by bacterial infections, traumatic injuries or chemical irritation. Root resorption might be
accidentally observed on digital panoramic radiography. Objective: The objective of the study was to identify
characteristic radiological aspects for the different types of root resorption that could be observed on digital
panoramic radiography, to make an easier diagnostic of root resorption. Material and Method: The retrospective
study used the X-ray base from the Oral Rehabilitation and Dental Prosthetics Clinic of UMF Craiova to identify the
most representative images for different types of root resorption. Digital panoramic radiographies were analysed by
two investigators, of which the most suggestive images were selected and described. Results: Digital panoramic
radiographies and dental charts of 240 patients were analyzed. 113 cases of root resorption were identified. External
inflammatory root resorption (EIRR) was present in 27.07% of studied cases, external cervical root resorption (ECRR)
was identified in 10.83% of all studied cases, external replacement root resorption (ERRR) was diagnosed in 7.08%
of studied cases and internal root resorption (IRR) was the most rare type of root resorption, with only 2.08% from all
studied cases. 16 cases were selected to describe the radiologic features of different types of root resorption,
featuring the most interesting images of root resorption evident on digital panoramic radiographies. Discussion:
Comparative analyses have been made between our results and the results of other specific studies, with both similar
and different values. The radiological features which lead to the diagnostic of each type of RR were highlighted,
assessing the causes that caused the lesions, as well as the treatment recommendations. Conclusions: Digital
panoramic radiography is a useful tool to identify root resorption, since it has become the most common radiological
investigation for diagnostic in dentistry. Description of radiological aspects of different types of root resorption on
panoramic digital radiography allows faster diagnosis. Still, the CBCT may be recommended in some cases to
confirm the diagnosis.

KEYWORDS: Root resorption, diagnostic, digital panoramic radiography

In 1970, Andreasen [6] divided root
Introduction resorptions into internal (replacement and
Root resorption (RR) is a pathological inflammatory) and external (superficial,
process characterized by the loss of dental root replacement, and inflammatory).
substance as a result of inflammation caused by This classification is largely used until today.
bacterial infections, traumatic injury, physical or In 2002, Benítez et al. [7] classified root
chemical irritation [1,2,3]. resorptions according to their localization and
Root resorption is often randomly diagnosed etiology.
on dental radiographs and it is considered a less In 2003, Fuss et al. [8] also classified it with
understood phenomenon, difficult to treat [4]. regard to treatment options.
Radicular resorption is a pathological and The authors also argued that the most
undesirable process for the permanent teeth, but common stimulating factor of root resorption
for the temporary dentition, it is a physiological was pulp infection.
phenomenon that leads to exfoliation and In 2009, Patel et al. [9] divided root
facilitates the appearance of successors [5]. resorption considering its localization on the
Over time, several classifications have been root surface into internal and external
made. (superficial, inflammatory, replacement, cervical
and apical transitory).

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In 2011, Bruno et al. showed that there could 240 digital panoramic radiographies and
be an idiopathic root resorption, although much dental charts of patients treated between January
less frequent [10,11]. 2017 and January 2019 were analysed by two
The most recent classification of Patel and investigators, in order to detect and diagnose
Saberi, in 2018 has been made considering the root resorption.
location of resorptive lesions and their Digital panoramic radiographic images were
pathogenesis and divided root resorption into taken with Kodak 9000, with exposure
external (external, inflammatory, cervical, parameters of 14.3 seconds, 70kV, 10mA and
surface and transitional apical breakdown) and with Soredex Cranex D (15 seconds, 65kV, and
internal (inflammatory, replacement) [4]. 15mA).
Root resorption diagnosis may be established Age, gender, and the number and type of
using periapical radiography [12], digital teeth with internal or external radicular
panoramic radiography [13], tomosynthetic resorption were collected.
panoramic radiography [14] or cone beam Last classification of root resorption was
computer tomography (CBCT) [15]. used [4].
Digital panoramic radiography was The most representative cases were selected.
considered a useful tool for detecting root Radiological aspects of root resorption were
resorption [14], while CBCT was indicated only described according to morphological features
for cases where a more precise evaluation for a identified on the digital image and correlated
surgical treatment could be necessary [13]. with possible causes.
In our country, the panoramic radiography is Intra-operator (Kappa score=0.879, P<0.001)
a highly recommended complementary exam, and inter-operator (Kappa score=0.871,
therefore, the chances of finding radicular P<0.001) agreements were statistically
resorption injuries are very high and the significant.
situation is similar to other countries, too: The study was approved by the Ethics
Koreea [16], Sweden [17] and Belgium [18]. Commission of the University of Medicine and
The objective of the study was to identify Pharmacy of Craiova.
characteristic radiological aspects for the Dental chart of each patient utilized in the
different types of root resorption that could be study included the informed consent for dental
observed on digital panoramic radiography, research (a standardized form of informed
which could allow an easier diagnostic and consent used in the clinic).
treatment of root resorption.
Results
Material and Method 240 dental charts and digital panoramic
The retrospective study used the X-ray base radiographies of a group formed by 132 women
from the Oral Rehabilitation and Dental and 108 men, with a mean age of
Prosthetics Clinic of U.M.F. of Craiova to 41.32±11.21 years, were analyzed. 113 cases of
identify the most representative images for root resorption were identified (Table 1),
different types of root resorption. accounting for 47.08% frequency in the group
studied. 49.07% of men had root resorption
compared to 53.09% women in the study group.
Table 1. Root resorption distribution to gender groups

Gender EIRR ECRR ERRR IRR Total

Male 28 11 12 2 53
(11.66%) (4.58%) (5%) (0.83%) (49.07%)
Female 37* 15 5 3 60
(15.41%) (6.25%) (2.08%) (1,25%) (53.09%)
Total 65 26 17 5 113
(27.07%) (10.83%) (7.08%) (2.08%) (47.08%)

External inflammatory root resorption External cervical root resorption (ECRR) was
(EIRR) was the most encountered type of root identified in 10.83% of all studied cases, while
resorption, 27.07% of studied cases having this external replacement root resorption (ERRR)
type of root resorption (Table 1). was diagnosed in 7.08% of studied cases.
Internal root resorption (IRR) was the rarest type

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Iulia Roxana Marinescu et al. - Root Resorption Diagnostic: Role of Digital Panoramic Radiography

of root resorption, with only 5 cases, Age in the study group varied from 18 to
representing 2.08% from all studied cases 81 years old, with repartition of root resorption
(Table 1). cases on age groups as following: in age group
Most frequent type of root resorption in 18-30 years old RR cases accounted 10% from
women was EIRR, 15.41% from all studied all analyzed cases, in age group 31-65 years old
cases, significant more than in men (15.41%) RR cases accounted for 35% from all study
(Table 1). group and the people over 65 years old had the
ECRR was the less frequent, 4.58% in men fewest cases of root resorption, accounting for
and 6.25% in women. 2.08% from all study group (Table 2).
The results about ERRR show that it was
diagnosed in 2.08% from the studied cases in
women and had double value (5%) in men.

Table 2. Root resorption distribution to age groups

Age (years) EIRR ECRR ERRR IRR Total

18-30 10 2 11 1 24
(4.16%) (0.83%) (4.58%) (0.41%) (10%)
31-65 53 23 6 2 84*
(22.08%) (9.58%) (2.5%) (0.83%) (35%)
> 65 2 1 0 2 5
(0.83%) (0.41%) (0%) (0.83%) (2.08%)
Total 65 26 17 5 113
(27.08%) (10.83%) (7.08%) (2.08%) (47.08%)

Sixteen (6.67%) digital panoramic The root canal was visible, suggesting that
radiographies were selected, featuring the most resorption occurs from the outside towards the
interesting images of root resorption. inside of the root [4].
From these particular cases, EIRR was The following OPG image (Fig.1b) presented
present in 10 cases (Fig.1a,c,d; 2a,c,d; 3a,b,c; a right mandibular premolar (4.4) with a
and 4c), ERRR in 9 cases (Fig.1b; 2a,b,c,d; 3d; resorption lesion, without endodontic treatment:
and 4a,b,d), IRR in two cases (4a,c), and ECRR external replacement root resorption, a possible
in only one case (Fig.3b). consequence of the tooth overloading.
Figure 1 included 4 OPGs with the two most There was a radiotransparency area which
encountered types of root resorption: EIRR and coated the resorption lesion, which could be
ERRR. interpreted as the root resorption phenomenon
The first image (Fig.1a) presented the right occurred at a faster rate than the repair rate of
mandibular premolar (4.4) and the left inferior the bone.
canine (3.3) with external inflammatory root The classic radiological examination
resorption lesions. provided data only of the lesion located on the
None of the two teeth had endodontic proximal sides of the root.
treatment. The following two OPGs (Fig.1c,d) showed
The premolar certainly was necrotic, because two teeth (the left mandibular premolar and the
although it was covered with a metal crown, a right mandibular molar) with external
coronary destruction stretching to the cervical inflammatory resorption lesions and incorrect
area could be seen. endodontic treatment.
Radicular apex had a funnel shape due to the On both of the OPGs, an apical
resorption process; the alveolar bone showed a radiotransparency image specific to chronic
diffuse radiotransparency which appeared to be apical periodontitis could be seen, so, in these
the image of a chronic diffuse apical cases, root resorption was associated with
periodontitis. chronic apical periodontitis.
In these cases, the roots appear shorter than
normal, sometimes irregularly-shaped and
surrounded by a radiotransparent area.

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Fig.1. External radicular resorption (ERR) lesions: a) 3.3, 4.4 external inflammatory root resorption;
b) 4.4 external replacement root resorption; c) and d) 3.4, 4.6. external inflammatory root resorption

Figure 2 also included cases with EIRR and The tooth had no root treatment, the root
ERRR. canal was not radiological detectable and had a
Figure 2a showed the two right maxillary hard tissue resorption of about two-thirds of the
incisors 1.1, 1.2 with external replacement root root.
resorption lesions, consequent to orthodontic No radicular radiotransparent area or other
treatment. signs of apical periodontitis could be observed.
Teeth 1.5 and 1.6, with incorrect root canal The radiological image also showed a second
fillings and coronal-radicular restorations, part maxillary right premolar (1.5) with external
of a mesial cantilever bridge showed two inflammatory resorption, most likely a tooth
external inflammatory root resorption lesions. with pulp necrosis, without endodontic
On the second image of the figure (Fig.2b) a treatment.
replacement root resorption on the two Figure 2d revealed an external inflammatory
mandibles secondary molars (3.7, 4.7) could be root resorption lesion on the mesial root of
seen, as a consequence of the two wisdom teeth 3.6 and an external replacement resorption
in horizontal inclusion, with the crowns pushing aspect on 4.7 molar, due to the presence of the
towards the roots of the second molars. third molar which was bone impacted in an
The third image of this figure (Fig.2c) oblique position.
showed a right mandibular central incisor (4.1)
with external replacement root resorption.

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Fig.2. External root resorption lesions: a) 1.1, 1.2 external replacement root resorption and 1.5,
1.6 external inflammatory root resorption; b) 3.7, 4.7 external replacement radicular resorption;
c) 4.1 external replacement root resorption, 1.5 external inflammatory root resorption;
d) 3.6 external inflammatory root resorption; 4.7. external replacement root resorption

Figure 3 included cases with EIRR, ERRR upper incisor without root canal treatment but
and also ECRR. with pulp necrosis, and the right inferior first
The first image (Fig.3a) showed a right premolar with incorrect endodontic treatment.
inferior first molar (4.6) with an external The left mandibular first premolar (3.4), a
inflammatory resorption (EIR) lesion. root canal treatment, had a cervical resorption,
The tooth without endodontic treatment had a possibly by replacement of a part of the tooth
radioopacity in the pulp chamber, suggesting a root by bone tissue.
partial pulpotomy. Figure 3.c presented two external
The distal root was surrounded by a inflammatory root resorption lesions: first left
radiotransparent area, corresponding to a chronic mandibular premolar (3.4) and first right
marginal periodontitis. mandibular molar (4.6) with incomplete root
Interesting fact was that this patient had canal treatments.
several teeth with incomplete endodontic The last image of this figure (Fig.3d) showed
treatment, but without signs of apical two external replacement resorption lesions
periodontitis or root resorption. located on the second upper two premolars
Orthopantomographies from figure 3b and (1.5 and 2.5), overloaded by a bridge with distal
3c revealed several external root resorption extensions.
lesions: figure 3b showed two external The teeth showed no endodontic treatment
inflammatory resorption lesions: the lateral and apparently, they seemed vital.

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Fig.3. External radicular resorption lesions: a) 4.6 external inflammatory root resorption; b) 1.2, 4.4 external
inflammatory root resorption; 3.4 cervical root resorption; c) 3.4, 4.6 external inflammatory root resorption; d)
1.5, 2.5.external replacement root resorption

Figure 4 included cases with EIRR, ERRR the root canals, the apical third root resorption
and also IRR. and a significant area of periapical bone lysis
Figure 4a showed the radiological image of (radiotransparency).
the four maxillary incisors with external Clinically, this radiological image could be
replacement resorptive injuries, as a interpreted as of a molar with pulp necrosis,
consequence of the orthodontic treatment. internal and external inflammatory root
Their apexes had an amputated look and the resorption injuries, associated with a
central incisors also showed some irregularities well-defined chronic apical periodontitis.
of the root canals, suggesting the association The first left mandibular molar could not be
with internal inflammatory resorption lesions. considered as having resorptive lesions, but
The image from figure 4b showed an external rather could be seen as a tooth with massive
replacement root resorption of the tooth destruction of the hard tissue, which in the future
3.6, more obvious on the distal root, which has would be removed from its socket, as a
been replaced more than a half by alveolar bone. consequence of the slow extrusion mechanism,
The tooth had a large coronary filling and no associated with progressive destruction of the
endodontic treatment. tooth.
The OPG from figure 4c showed a Figure 4d presented the radiographic image
combination of internal inflammatory radicular of a 3.8 molar with external replacement
resorption with external inflammatory root resorption, so advanced that the molar appeared
resorption of a right second mandible molar to be completely amputated and replaced by
(4.7) without endodontic treatment. alveolar bone, as a result of the osteoblasts
Radiological, it could be noticed: a tooth with repair attempt.
an occlusal carious process and traces of filling The tooth was the distal pillar of a five
material on the bottom of the cavity, without elements dental bridge, which probably
being able to tell if the pulp chamber was open, constituted an overloading of the molar, in time.
an increased volume of the pulp chamber and of

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Iulia Roxana Marinescu et al. - Root Resorption Diagnostic: Role of Digital Panoramic Radiography

Fig.4. External and internal radicular resorption lesions: a) 1.2, 1.1, 2.1, 2.2 external replacement root
resorption and internal inflammatory root resorption; b) 3.6 external replacement root resorption;
c) 4.7 internal inflammatory root resorption, associated with external inflammatory root resorption;
d) 3.8 external replacement root resorption

specific to chronic apical periodontitis, so, in

Discussions these cases, root resorption was associated with
The resorption process may be self-limiting chronic apical periodontitis.
and may go clinically undetected but, once Other studies [26,5,27,11] also confirmed
initiated, if it is supported by infection and/or that external inflammatory RR was commonly
pressure, the destruction of the hard dental found in teeth with pulp necrosis and appeared
tissues will continue and the tooth may become in almost all teeth with chronic apical
irrecoverable [4]. periodontitis.
The largest number of teeth with root Due to the bi-dimensional aspect of
resorption was diagnosed in the age group of conventional radiographs, EIR could be detected
31-65 years, 35%, followed by 10% cases in the only if it was located on the approximate sides
group of young people under 30 and by 2% in of the root; resorptive lesions on the vestibular
the elderly over 65 years of age. or oral sides of the roots could only be detected
The percentage was less than reported by a by a CT scan [4].
study [19] in the Indian population (46.8%), but According to Patel and Saberi [4], there was
greater than 1.7-27.1 reported by others authors no classical radiological appearance for external
[20,21,22,1]. inflammatory resorption lesion, the aspect
EIRR was the most encountered type of root depending on the age of the lesion: recent
resorption found, 57.52% from the cases with resorptions were radio transparent, and the
RR, similar to another study published before by oldest appeared marbled, suggesting the attempt
our group, over 50%, most prevalent in the to repair the root structure [9,28].
middle age adults group [1]. The EIRR treatment consists of debridement
Most authors [23] found no relationship and preparation of the root canal, accompanied
between gender and RR, although Brezniak and by abundant irrigation with EDTA and sodium
Wasserstein [24,25] considered that women hypochlorite, given that it is an infection
were more prone to idiopathic RR. induced resorption [29] and in some cases,
Our research indicated that root resorption therapeutic pastes can also be used, such as
was predominant in women (53.09%) than in Ledermix, inside the root canal, whose
males (49.07%). corticosteroids and antibiotics act on clastic cells
Many of the teeth with RR from this study [30].
showed an apical radiotransparency image

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The cervical resorption diagnosed on the left Regarding the internal replacement root
mandibular first premolar (3.4), from resorption, the root surface had a "cloudy" or
figure 3b respected the pathognomonic aspect of spotted look, because of the hard tissue
the cervical resorption, visibility of the shape of radiopaque inclusions and the root canal looked
the root canal through the lesion, indicating that distorted and expanded. [4].
it originated from the outside of the root [4]. The treatment of this type of resorption
The treatment depends on the location of the consists in the preparation of the root canal
lesion on the tooth root and consists in curettage either up to the resorption level and expectation
of the resorptive tissue in the cavity and filling it for hard tissue repair or root preparation
with restorative material, when it is accessible, including the area with resorption and root canal
or surgical treatment with periodontal flap, filling [29,36].
curettage, filling of the defect and repositioning RR control and hard tissue formation
of the flap. [29,31]. stimulation could be achieved by using anti-
External replacement root resorption occurs clastic therapeutic agents (Ledermix) and
usually in teeth with severe luxation or abnormal calcium hydroxide or ProRoot MTA. [37].
trauma injuries [5,32,33]; this could explain the Patel and Saberi [4] also described the
situation of the central mandibular incisor in „apical transient breakdown”, which radiological
figure 2c, which, most likely has been mobilized showed an enlargement of the periapical space
in the past, but has remained in its socket. with apical discontinuity of the lamina dura.
Subsequently, in the remodeling process, This form occurred in teeth suffering from
osteoblastic activity could replace absent root mild or moderate trauma, and returned to normal
dentine with alveolar bone [26,5,34]. radiological appearance within one year.
External replacement root resorption seen in In fact, this lesion was an inflammatory
figures 2a, 2b, 2d occurred due to included teeth, external resorption and included a short
tumours, orthodontic treatments [35,5,31]; it resorption phase followed by a short repair
ceased with the removal of the cause (in this phase.
situation, after the extraction of the third Root resorption is usually diagnosed on
included molar) and the root surface have been orthopantomographies, with advantages such as
repaired with radicular cementum [5,6]. low radiation exposure, entire dental arch view,
The treatment of this type of RR is based on but also disadvantages caused by magnification
the tooth's response to vitality tests, which is errors or overlapping of the dental structures,
usually delayed; even if absent, is not an which could lead to an underestimation of the
indication for endodontic treatment in the extent of root resorption lesions.
absence of other clinical seeds. If the tooth is in The OPG exam is largely used in Romania,
a favorable position, it should not intervene as a routine radiography and it is based on the
immediately because the replacement resorption ALARA radiation protection principles: it uses
proceeds at a slow rate, although the possibility an acceptable radiation dose compared to a
of tooth ankylosis should be monitored in time series of periapical radiographies and less than
[29]. CBCT exam. Gavala et al. [38,39] stated that the
The internal RR lesions described in figures risk of radiation associated with panoramic
4a, located on the maxillary central incisors and radiography was still uncertain, although the
in figure 4c, on the lower right second molar absorbed doses were low.
were similar with Patel and Saberi’s [4] In our country, the panoramic radiography is
description of the internal inflammatory root a highly recommended complementary exam
resorption appearance, as a symmetrical, round and the situation is similar to other countries,
or oval radiolucency, located on the root surface. too: Koreea [16], Sweden [17] and Belgium
In practice, images deviated frequently from this [18], therefore, the chances of finding radicular
pattern. resorption injuries are very high.
An X-ray performed by parallax technique In Koreea, panoramic radiography was
could bring clarification about these injuries included in the national health check-up
which often could be confused with external program and it was an effective complementary
cervical root resorption, in teeth with more than exam to oral examinations [16].
one root. It has enough diagnostic accuracy in dental
CBCT was the most appropriate exam in this caries, periodontal diseases and other lesions and
situation. the radiation dose is lower than traditional full-
mouth periapical radiography [40].

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In Sweden, 61% of the dentists had access to performed and conventional X-rays have been
panoramic radiology techniques, especially with taken and evaluated [9,46].
a direct digital sensor, compared to around 8% As for any device emitting ionizing radiation,
who had access to CBCT [17] and in Belgium, the benefits of CBCT scanning must outweigh
76% of the dentists had access to a panoramic the risks [47].
unit and one in five to a CBCT, almost all This is especially important in children and
panoramic units having digital detectors. [18]. adolescents who are more sensitive to the
It is clear that digital panoramic radiography potential effects of the ionizing radiation [48].
is more used than CBCT, therefore, the chances The ALARA principle (as low as reasonably
of finding radicular resorption injuries are achievable) should be considered in all cases.
obviously higher. A CBCT recommendation should be
OPGs, however, show a 20% overestimation considered only if the additional information
of external radicular resorption lesions, from the reconstituted three-dimensional images
compared to periapical radiographies [19,41,42]. will contribute to the diagnosis and/or
A study [14] on the accuracy of external RR improvement of the management of a tooth with
detection using panoramic radiographs an endodontic problem.
compared to tomosynthetically reconstructed The CBCT exam can assess the nature of the
panoramic radiography (TPAN) diagnosis, lesion, including root perforations and whether
which is “a form of limited angle tomography the lesion can be surgically or non-surgically
that produces section, or ‘slice,’ images from a treated [29].
series of projection images acquired as the x-ray CBCT with FOV (limited field of view)
tube moves over a prescribed path” [43], could be considered in situations such as:
concluded that TPAN is slightly more accurate diagnosis of the radiographic features of the
for the root resorption detection than regular periapical pathology when there are
digital panoramic radiography. contradictory signs and/or symptoms
The same study quoted another [12] saying (non-specific), confirmation of the local
that panoramic radiography was not a useful pathology which is not related to the teeth,
investigation in RR diagnosis. assessment and/or management of complex
Ahuja [44] and Saccomanno [12] concluded dento-alveolar trauma, complications of the
that periapical radiographs were more efficient endodontic treatment (for example, root
in assessing RR, compared to panoramic perforations) and, of course, in the evaluation
radiographs, where the root resorption seemed and/or management of root resorption injuries.
more pronounced and the difference in
magnification was responsible for. Conclusions
In 2014, Patel and Durak [27] set out several Root resorption is commonly diagnosed with
aspects regarding the role of CBCT examination OPGs, having low cost advantages, visualization
in the assessment of resorption lesions, which of the entire dental arch, but also disadvantages
means that the root resorption diagnosis was caused by magnification errors or overlapping of
established based on conventional radiography, the dental structures, which can lead to an
but the CBCT exam was the one that could bring underestimation of the extent of root resorption
clear data on the extent and location of the lesions.
lesions. Digital panoramic radiography could be a
CBCT should not be used for routine useful tool for accidentally detecting root
screening and it should only be indicated when resorption and knowing about the radiological
conventional radiographs offered a limitation of appearance of different types of root resorption
information and additional details needed to be could allow a faster diagnosis.
identified [45]. Still, the CBCT may be recommended in
CBCT exam is also recommended for some cases to confirm the diagnosis.
monitoring these lesions, but only after a proper
clinical and radiological assessment. CBCT Acknowledgment
indications were stipulated by the Iulia Roxana Marinescu, Veronica Mercuţ
recommendations of the European Endodontic and Sanda Mihaela Popescu equally contributed
Society [27]. to the manuscript.
A CBCT scan could be considered only after
a complete clinical examination has been

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References 17. Svenson B, Ståhlnacke K, Karlsson R, Fält A.

Dentists' use of digital radiographic techniques:
1. Bănică AC, Marinescu IR, Gheorghe DN, Trușcă Part II-extraoral radiography: a questionnaire
AG, Drăghici EC, Mercuț V, Popescu SM. Root study of Swedish dentists. Acta Odontol Scand,
resorption prevalence in adults from Dolj county, 2019, 77(2):150-157.
Romania-a radiological evidence. Romanian 18. Snel R, Van De Maele E, Politis C, Jacobs R.
Journal of Oral Rehabilitation, 2018, 10(4):170- Digital dental radiology in Belgium: a nationwide
179. survey. Dentomaxillofac Radiol, 2018,
2. Levin MD, Jong G. The Use of CBCT in the 47(8):20180045.
Diagnosis and Management of Root Resorption, in 19. Agarwal MSS, Copra SS, Kumar P, Jayan BB,
M. Fayad, B.R. Johnson (eds.), 3D Imaging in Nehra K, Sharma M. A radiographic study of
Endodontics, Springer International Publishing external apical root resorption in patients treated
Switzerland 2016, 131-143. with single-phase fixed orthodontic therapy,
3. Estrela C, Bueno MR, Gonc AH, et al. Method to Medical Journal Armed Forces, India, 2016, 72:8-
evaluate inflammatory root resorption by using 16.
cone beam computed tomography. J Endod, 20. De Shields RWD. A study of root resorbtion in
2009, 35:1491-1497. treated class II, division I malocclusion. Angle
4. Patel S, Saberi N., The ins and outs of root Orthod, 1969; 39:231-245.
resorption, British Dental Journal, 2018, 224(9): 21. Hollender L, Ronnerman A, Thilander B, Root
691-699. resorption, marginal bone support and clinical
5. Patel S, Pitt Ford T. Is the resorption external or crown length in orthodontically treated patients.
internal? Dent Update, 2007, 34: 218-229. Eur J Orthod, 1980, 2(4):197-205.
6. Andreasen JO. Luxation of permanent teeth due 22. Martins DR, Tibola D, Janson G, Maria FRT.
to trauma. A clinical and radiographic follow-up Effects of intrusion combined with anterior
study of 189 injured teeth. Scand J Dental Res, retraction on apical root resorption. Eur J Orthod,
1970, 78(3):273-286. 2012, 34(2):170-175.
7. Benítez MB, Chiera CM, Jacobo MI. 23. Brudvik P, Rygh P. Transition and determinants of
Reabsorciones dentarias: un problema para el orthodontic root resorption-repair sequence.
diagnóstico, el tratamiento y el pronóstico. Claves European Journal of Orthodontics, 1995, 17(3):
Odontol, 2002, 8(50):10-13. 177-188.
8. Fuss Z, Tsesis I, Lin S. Root resorption-diagnosis, 24. Brezniak N, Wasserstein A. Root resorption after
classification and treatment choices based on orthodontic treatment: Part 1. Literature review.
stimulation factors. Dent Traumatol, 2003, American Journal of Orthodontics and Dentofacial
19(4):175-182. Orthopedics, 1993, 103(1):62-66.
9. Patel S, Kanagasingam S, Pitt Ford T. External 25. Brezniak N, Wasserstein A. Root resorption after
cervical resorption: a review. J Endod, 2009, orthodontic treatment: Part 2. Literature review.
35(5):616-625. American Journal of Orthodontics and Dentofacial
10. Bruno Oliveira de Aguiar Santos, Diego Santiago Orthopedics, 1993, 103(2):138-146.
de Mendonça, Denise Lins de Sousa, et al. Root 26. Tronstad L. Root resorption aetiology, terminology
resorption after dental traumas: classification and and clinical manifestations. Endod Dent
clinical, radiographic and histologic aspects, 2011, Traumatol, 1988, 4:241-252.
8(4):439-445. 27. Patel S., C. Durack, F. Abella, M. Roig, H.
11. Heithersay G S. Management of tooth resorption. Shemesh, P. Lambrechts & K. Lemberg,
Aust Dent J, 2007, 52(Suppl 1):105-121. European Society of Endodontology position
12. Saccomanno S, Passarelli PC, Oliva B, Grippaudo statement: The use of CBCT in Endodontics.
C. Comparison between Two Radiological International Endodontic Journal, 2014, 47:502-
Methods for Assessment of Tooth Root 504.
Resorption: An In Vitro Study. Hindawi BioMed 28. Hithersay G S. Clinical, radiologic and
Research International Volume, 2018, 5152172. histopathologic features of invasive cervical
13. Dudic A, Giannopoulou C, Leuzinger M, Kiliaridis resorption. Quintessence Int, 1999, 30:27-37.
S. Detection of apical root resorption after 29. Bansode PV, Pathak D.S, Wavdhane M. B.,
orthodontic treatment by using panoramic Priyanka P. Birage. Root Resorption and It’s
radiography and cone-beam computed Management: a Review Article. IOSR Journal of
tomography of super-high resolution. Am J Orthod Dental and Medical Sciences (IOSR-JDMS), 2019,
Dentofacial Orthop, 2009, 135(4):434-437. 18(1):63-69.
14. Rahmel S, Schulze RKW. Accuracy in Detecting 30. Abbott PV, Heithersay GS, Hume WR. The
Artificial Root Resorption in Panoramic release and diffusion through human coronal
Radiography versus Tomosynthetic Panoramic dentine in vitro of triamcinolone and
Radiographs. J Endod, 2019, 45(5):634-639. demeclocycline from Ledermix Paste.Endod Dent
15. Lima TF, Gamba TO, Zaia AA, Soares AJ. Traumatol, 1989, 5:92-97.
Evaluation of cone beam computed tomography 31. Gunraj M N. Dental root resorption. Oral Surg Oral
and periapical radiography in the diagnosis of root Med Oral Pathol Oral Radiol Endod, 1999, 88:
resorption. Aust Dent J, 2016, 61(4):425-431. 647-653.
16. Kweon HH, Lee JH, Youk TM, Lee BA, Kim YT. 32. Hammarstöm L, Pierce A M, Blomlöf L, Feiglin B,
Panoramic radiography can be an effective Lindskog S. Tooth avulsion and replantation - a
diagnostic tool adjunctive to oral examinations in review. Endod Dent Traumatol, 1986, 2:1-8.
the national health checkup program. J 33. Barrett E J, Kenny D J. Avulsed permanent teeth:
Periodontal Implant Sci, 2018, 48(5):317-325. a review of the literature and treatment guidelines.
Endodont Dent Traumatol,1997, 13:153-163.

10.12865/CHSJ.45.02.05 165
 Iulia Roxana Marinescu et al. - Root Resorption Diagnostic: Role of Digital Panoramic Radiography

34. Lindskog S, Pierce A M, Blomlöf L, Hammarström 43. Dobbins JT. Tomosynthesis imaging: at a
L. The role of the necrotic periodontal membrane translational crossroads. Med Phys, 2009,
in cementum resorption and ankylosis. Endod 36:1956-1967.
Dent Traumatol, 1985, 1:96-101. 44. Ahuja PD, Mhaske SP, Mishra G, Bhardwaj A,
35. Trope M. Root resorption due to dental trauma. Dwivedi R, Mangalekar SB. Assessment of Root
Endod Topics, 2002, 1:79-100. Resorption and Root Shape by Periapical and
36. Buchanan S. ProSystem GT: design, technique, Panoramic Radiographs: A Comparative Study. J
and advantages. Endod Topics, 2005, 10:168- Contemp Dent Pract, 2017, 18(6):479-483.
175. 45. Ahmed HM. Guidelines to enhance the
37. Koh ET, Torabinejad M, Pitt-Ford TR, Brady K, interpretation of two-dimensional periapical
McDonald F. Mineral trioxide aggregrate radiographic images in endodontics. Eur J Gen
stimulates a biological response in human Dent, 2015, 4:106-112.
osteoblasts. J Biomed Mater Res, 1997, 5:432- 46. SEDENTEXCT (2012) European Commission,
439. Radiation Protection N 172: Cone beam CT for
38. Małgorzata W, Jerzy O, Absorbed doses for dental and maxillofacial radiology. Evidence based
patients undergoing panoramic radiography, guidelines. Available at:
cephalometric radiography and CBCT. http://www.sedentexct.eu/files/radiation_protection
International Journal of Occupational Medicine _172.pdf [Accessed 21.04. 2019].
and Environmental Health, 2017, 30(5):705-713. 47. ICRP Publication 103: The 2007
39. Gavala S, Donta C, Tsiklakis K, Boziami A, recommendations of the International Commission
Kamenopoulou V, Stamatakis HC. Radiation dose on Radiological Protection. Annals of the ICRP.
reduction in direct digital panoramic radiography. Available at:
Eur J Radiol, 2009, 71:42-48. http://www.icrp.org/docs/ICRP_Publication_103-
40. Choi JW. Assessment of panoramic radiography Annals_of_the_ICRP_37(2-4)-Free_extract.pdf
as a national oral examination tool: review of the [Accessed 15.04. 2019].
literature. Imaging Sci Dent, 2011, 41(1):1-6. 48. Theodorakou C, Walker A, Horner K, Pauwels R,
41. Langland OE, Langlais RP, McDavid WD, Bogaerts R, Jacobs R. Estimation of paediatric
DelBalso AM. Panoramic radiography, 2nd ed organ and effective doses from dental cone beam
Philadelphia, PA: Lea &Febiger, 1989, 8-75. CT using anthropomorphic phantoms. The British
42. Taylor NG, Jones AG, Are anterior occlusal Journal of Radiology, 2012, 85:153-160.
radiographs indicated to supplement panoramic
radiography during an orthodontic assessment.
BR Dent J, 1995, 179:377-381.

Corresponding Author: Alexandra Carina Bănică, Faculty of Dentistry,

University of Medicine and Pharmacy of Craiova, Petru Rares str, no 2-4,
e-mail: karinabanica@yahoo.com

166 10.12865/CHSJ.45.02.05

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