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Root resorption of the permanent teeth involves an elaborate interaction among inflammatory cells resulting in loss of dental hard tissues. This report describes three clinical cases where idiopathic root resorption occurred in wind instrument playing patients. These patients produce adequate non-orthodontic forces, while playing their instruments, to expose their teeth to root resorbing force. Careful clinical monitoring of patients' teeth should be undertaken, as the additive effects of orthodontic treatment and musical habits are unknown.
CPD/Clinical Relevance: This paper advises that questioning about wind instrument playing during case history-taking would be beneficial to clinicians. Furthermore, careful clinical monitoring of these patients' teeth during orthodontic treatment should be undertaken.
Article
Root resorption involves the loss of the hard dental tissues cementum and dentine.1 Physiologic root resorption associated with primary teeth is desirable as it results in exfoliation of the teeth, thereby allowing eruption of the permanent successors. In the permanent dentition root resorption may be followed by repair, but understandably is unfavourable as it can result in irreversible damage or eventual tooth loss.2
Classically, root resorption has been classified by its location in relation to the root surface, ie internal or external resorption. External root resorption can be further classified into surface resorption, external inflammatory resorption, external replacement resorption, external cervical resorption, and transient apical breakdown.3 Internal root resorption is a relatively rare occurrence, and is often confused with external cervical resorption.4,5,6,7
A number of aetiologies have been implicated in root resorption:8,9,10,11,12,13,14
Trauma;
Pathology;
Eruption of neighbouring teeth;
Reimplantation of teeth;
Fixed appliance orthodontic treatment;
Intracoronal bleaching;
Heredity;
Parafunctional habits.
Historically, there has been an assumption that forces produced in playing wind instruments have an influence on the dentition.15,16 This speculation has been divided into whether these forces were beneficial in correcting orthodontic malocclusions or had detrimental effects.17,18,19 The effect on the hard tissues is dependant on the application of the instrument to the mouth, called an embouchure, and the force produced playing the instrument. An embouchure is use of the instrument player's facial oral muscles and the manner of application of the lips and teeth to the mouthpiece of the musical wind instrument.20 There are several sub types, and it takes long-term commitment and practice by the player to be completely proficient in its formation and use. Embouchure variations mean that there is a multitude of soft tissue applications to differing mouthpieces.
However, reviewing the literature reveals no reports on root morphological changes of the teeth of wind instrument players. The purpose of this paper is to present three cases of radiographic apical root resorption in wind instrument players and the management of their particular cases.
Case report 1
An 18-year-old girl was referred to the Orthodontic Department of the Glasgow Dental Hospital and School by her orthodontic specialist practitioner as a result of a recent yellow discoloration of the upper left permanent central incisor (UL1) and the shortened radiographic appearance of both the upper permanent incisor roots (Figure 1). Her medical history was unremarkable.
Figure 1. Periapical radiographs of (a) UR1 and (b) UL1 showing patient in fixed appliances with moderate root resorption and blunt apices. These radiographs were taken two weeks after commencing fixed appliances.
Previous dental history was significant for removable orthodontic functional twinblock treatment six years previously. This reduced her overjet and was discontinued after six months of a night-time retention regimen. She returned to her orthodontic specialist practitioner aged 17, complaining of recurrence of her overjet. Orthodontic treatment involved extraction of upper first permanent premolars and fixed appliance therapy. Following only two weeks of treatment during the initial levelling and aligning phase, discoloration of tooth UL1 was noted. There was no history of dental trauma. Social history revealed that the patient had played the oboe for four years, practising regularly on a daily basis.
Clinical examination revealed an unrestored, well-maintained permanent dentition, with all four upper permanent incisors normal to clinical testing with no signs of pathology. Periapical radiographs showed pulp canal obliteration and significant external apical root resorption (Figure 1). Orthodontic treatment was discontinued and the preferred treatment option was to restore the premolar spaces with resin-retained bridgework. This had the advantage of both good aesthetics and avoiding further orthodontic treatment, which may increase the risk of root resorption.
Case report 2
A 15-year-old girl had fallen down at school while holding her trumpet in her mouth. She attended her general dental practitioner (GDP) immediately, and although she complained of no symptoms, examination revealed very slight mobility of the upper permanent incisors and a palatal composite splint was placed. An initial diagnosis of luxation was made and she was seen in the Child Dental Health Department for further assessment one week later. Her medical history was unremarkable but dental history revealed trauma to the upper deciduous incisors at the age of six. The GDP's records showed that these teeth were displaced but not avulsed. Social history revealed that she had played the trumpet since the age of six and currently plays in an orchestra, with significant regular practice.
Clinical examination revealed an unrestored well-maintained permanent dentition with the anterior teeth exhibiting very slight mobility. The teeth responded normally to clinical testing and there were no signs of pathology. Periapical radiographs showed that both upper permanent central incisors (UR1, UL1) had severely shortened roots, with evidence of the remnants of the previous acid etch splint (Figure 2). The degree of external apical root resorption could not be attributed to the recent trauma, or the previous deciduous trauma, although theoretically the first trauma may have initiated premature root end closure of the upper permanent incisors.
The patient was concerned about the mobility of her teeth and how this would impact on her trumpet playing. An upper pressure formed thermoplastic appliance of 1 mm thickness was constructed (Erkodur®, Erkodent, Pfalzgrafenweiler, Germany) to stabilize the anterior teeth while playing to minimize any further resorption. Furthermore, she is on long-term review at the Child Dental Health Department to monitor if the root resorption is progressing.
Figure 2. Periapical radiographs of (a) UR1 and (b) UL1 showing patient with severe root resorption, blunt apices and remnants of composite adhesive used for splinting the teeth placed by the GDP. The radiographs were taken one week after the traumatic incident.
Case report 3
An 11½-year-old female attended her general dental practitioner immediately after a clash of heads in the playground at school. Examination revealed very slight mobility of the maxillary permanent central incisors (UR1, UL1) and periapical radiographs taken at that visit revealed the roots of both these teeth to be far shorter than the lateral incisors. The GDP referred the patient to the Child Dental Health department, and she was seen within a week.
Clinical examination revealed an unrestored, well-maintained permanent dentition with the exception of third molars. Her oral hygiene was excellent and she had had a 2 mm midline diastema between the upper permanent central incisors, which was unchanged following the traumatic incident. Clinical examination of the upper permanent incisors (UR1, UL1) was normal, but again very slight mobility of these teeth was noted. Periapical radiographs confirmed that both upper central incisors had severe root resorption, having lost half of their root length in comparison to the normally sized lateral incisors (Figure 3). No pathology was visible and the appearance resembled external apical root resorption.
Figure 3. Periapical radiographs of (a) UR1 and (b) UL1 showing patient with severe root resorption and blunt apices. The radiographs were taken one week after the traumatic incident.
The patient confirmed that she had begun playing the trumpet two years previously and had been practising on a daily basis since then. From the extensive history ascertained, this was the only activity in which the patient could have been exerting forces on her upper permanent incisors. The patient was keen to continue playing the trumpet and hence a thermoplastic upper pressure formed appliance was constructed (Figure 4). She is able to wear this while playing the trumpet with no obvious detrimental effect on her musical ability. Finally, she is on long-term review at the Child Dental Health Department, to monitor if the root resorption is progressing.
Figure 4. Thermoplastic upper pressure formed appliance in situ. Patients wear this when playing their wind instrument with no detrimental effects on ability.
Discussion
There has been a classification of wind instrument mouthpieces, initially developed for the unproven beneficial effects in certain malocclusions. However, the categorization is useful as it illustrates the embouchure.21
Class A – All cup-shaped mouthpieces, as in the trumpet, trombone, tuba, all horns, and brasses;
Class B – Single-reed mouthpieces, as in the clarinet and the saxophone;
Class C – Double-reed mouthpieces, as in the oboe and bassoon;
Class D – Mouthpieces with a small aperture or opening at the head, as in the flute and piccolo.
Instruments differ widely in mouthpiece diameter and pitch, and hence there is a range in mouthpiece forces and lip tensions required to produce a sound. Cross-sectional and longitudinal studies investigating wind instruments and the dentition have looked at mainly orthodontic clinical signs including: incisor classification, malocclusion, overjet, overbite and centreline. These have provided conflicting results, with the majority of studies concluding that long-term wind instrument playing may have some effect on the dentition, but is generally inconclusive.22,23,24
Moreover, these studies were undertaken in growing populations with varied musical experience, and time duration playing instruments was poorly quantified. Outcome measures were chronological study models, and hence static occlusions.25 Radiographic assessments were lateral cephalometric radiographs, and again looking at cephalometric changes rather than root morphology.26,27 A study looking at orthodontic study casts concluded that, though playing a wind instrument did not significantly influence the position of anterior teeth or was an aetiological factor in malocclusion development, playing a brass instrument with a large cup-shaped mouthpiece may predispose to buccal crossbite development.28
The embouchure of a wind instrument involves the exerting of forces on the soft and hard tissues. However, the size, direction and manner of forces produced are dynamic and complex. Quantifying these forces while the instrument is being played has concentrated on measuring activity of the muscles concerned, pressure in the oral cavity, and mouthpiece forces.29,30,31 Trumpet playing forces shown by an intra-oral device ranged from 10–50 Newtons (100–500 grams), being dependant on the note played, amount and duration of force and proficiency of the musician.32 Removable orthodontic appliances generally require 30 g of force to tip teeth, whereas fixed appliances need up to 100 g of force to move the teeth bodily.
Any device constructed to measure wind instrument forces, whether attached to the mouthpiece or intra-oral, may impede either embouchure or tone formation. The actual distribution of mouthpiece forces and lip tension forces acting on the hard or soft tissues are unknown, but lip tension may be of major importance in stressing the incisors during brass instrument playing.32,33 Moreover, upper permanent central incisors have exhibited horizontal deflections of up to 100 µm during wind instrument playing.34
Orthodontically induced inflammatory root resorption has been implicated with: continuous vibratory forces and intermittent forces; and vibratory forces causing occlusal trauma.35,36,37 There are several tooth movements: tipping, translation, rotation, intrusion and extrusion, with intrusive force application being found to increase orthodontically induced inflammatory root resorption rates significantly compared with controls.36,37 Fixed appliance orthodontic treatment has been well documented to cause iatrogenic damage of root resorption, but there is no evidence of this at present with removable appliances.38
Conventional dental panoramic radiographic investigations are used to assess root morphology and dimensions prior to orthodontic treatment. However, this may be hindered in the anterior maxillary region because of the focal trough, which is relatively narrow in the incisor region. Therefore, the apices and associated structures of these teeth may be out of focus or even invisible.39 Routine periapical radiographs for orthodontic assessment is unjustified, unless case history or clinical examination suggest pathology or abnormality.40,41,42 However, current guidelines do not consider habits as a reason for intra-oral radiographic examination. The extensive radiographic root resorption displayed in the case histories are unlikely to be due to the fixed appliances (Case 1) or the traumatic episodes (Cases 2 and 3) as follow-up radiographs were taken within two and one week, respectively; rapidly progressing root resorption occurs over several months rather than days.43
The Clinical Standards Committee of the British Orthodontic Society has produced an advice sheet with respect to braces and wind instruments for patients. It discusses both removal and fixed appliances, explaining that orthodontic treatment may affect patients' ability to practise and perform. It advises patients to arrange fitting of an orthodontic appliance at a time that avoids important music exams, auditions or performances. It concludes that there will be some temporary effect on their musical performance including: dry mouth, soft tissue trauma and the inability to achieve certain high notes. However, with practise and motivation most wind instrument players adjust to wearing braces.44
Conclusion
Wind instrument playing produces adequate forces, tooth deflection and time required for an environment to expose the teeth to non-physiological orthodontic forces. It could be speculated that instrument players, who have been playing and practising over many years, produce vibratory forces within the periodontium. This mimics oscillating orthodontic movements, increasing the risk of root resorption. Therefore, additional questioning about musical wind instrument playing during case history-taking would be beneficial to clinicians. Furthermore, careful clinical monitoring of these patients during their orthodontic treatment should be undertaken, as the additive effects of orthodontic forces and their musical habit may increase the risk of root resorption.
