Follow-up periapical and panoramic radiographs obtained in March 2026 confirmed complete healing of the surgical sites, stable bone levels, and no further progression of root resorption (Fig. 5 and 6). Orthognathic surgery was discussed as a future option should the patient wish to address the residual skeletal discrepancy. Discussion The most instructive aspect of this case is the distribution of resorption. EARR from orthodontic forces typically affects teeth under active mechanical loading, most often maxillary incisors. In this case, the most severely affected teeth were the mandibular second molars, which carried no brackets and were not in the direct mechanical field. That pattern is the clinical fingerprint of cyst-associated resorption— chronic inflammatory pressure from the expanding lesion activating osteoclastic activity at adjacent root surfaces, independent of any applied force. This does not mean that orthodontic forces played no role. Genetic susceptibility, including polymorphisms in inflammatory mediators such as IL-1β, likely contributed to the generalized irregular root morphology noted at baseline. But the pronounced resorption on unbracketed teeth, contiguous with the cystic lesions and confirmed by histopathology, implicates the cysts as the dominant driver in those teeth. Clinicians should recognize this pattern—when resorption appears in unexpected locations, the question is not only “how much force?” but “is there a pathological process that we haven’t fully accounted for?” The clinical presentation in this case, a large, fluctuant tender buccal swelling discovered at a routine recall, is a reminder that odontogenic pathology often surfaces not in emergency settings but in the chair of general dentists. The threemonth recall schedule, implemented specifically because of this patient’s high caries risk and poor compliance, brought this finding to light when it did. Had the patient been on a standard six-month recall, the lesion may have expanded substantially further before detection. Poor compliance added complexity throughout the treatment plan. Bracket failures, inadequate hygiene and inconsistent elastic wear each independently eroded the treatment trajectory. Managing these behavioural factors while simultaneously navigating a surgical complication required repeated recalibration of expectations, with the patient, the family and across the treating team. The decision to conclude treatment early was clinically justified. Continuing fixed appliances in the face of significant root resorption, particularly on teeth with already guarded prognosis, would have risked further compromise of teeth that remain functional. Accepting a less than ideal occlusal result in exchange for preserving tooth vitality is a trade-off that evidence and clinical judgment both support. Conclusion This case makes a practical point for any clinician managing complex orthodontic patients—root resorption in teeth outside the expected mechanical field should prompt investigation for underlying pathology, not reassurance that forces are within normal limits. Routine radiographic monitoring, a low threshold for CBCT when conventional imaging is ambiguous, and timely referral to an oral and maxillofacial surgeon are the tools that allow early intervention, before a manageable lesion becomes an irreversible complication. Equally, this case illustrates the value of structured recall in high-risk patients. The three-month hygiene schedule that was in place for compliance and caries management was the same mechanism that caught a developing cyst before it caused further damage. In complex orthodontic cases, recall frequency is not only a hygiene decision, it is a surveillance strategy. Orthodontic success is not always measured by the occlusion achieved. Sometimes it is measured by the teeth preserved. The clinical presentation in this case, a large, fluctuant tender buccal swelling discovered at a routine recall, is a reminder that odontogenic pathology often surfaces not in emergency settings but in the chair of general dentists. 33 Issue 4 | 2026 | Supporting Your Practice
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