Original Article

Canine retraction and anchorage loss

Self-ligating versus conventional brackets in a randomized
split-mouth study
Andre da Costa Monini
a
; Luiz Gonzaga Gandini Ju nior
b
; Renato Parsekian Martins
c
;
Alexandre Prota sio Vianna
a
ABSTRACT
Objective: To evaluate the velocity of canine retraction, anchorage loss and changes on canine
and first molar inclinations using self-ligating and conventional brackets.
Materials and Methods: Twenty-five adults with Class I malocclusion and a treatment plan
involving extractions of four first premolars were selected for this randomized split-mouth control
trial. Patients had either conventional or self-ligating brackets bonded to maxillary canines
randomly. Retraction was accomplished using 100-g nickel-titanium closed coil springs, which
were reactivated every 4 weeks. Oblique radiographs were taken before and after canine retraction
was completed, and the cephalograms were superimposed on stable structures of the maxilla.
Cephalometric points were digitized twice by a blinded operator for error control, and the following
landmarks were collected: canine cusp and apex horizontal changes, molar cusp and apex
horizontal changes, and angulation changes in canines and molars. The blinded data, which were
normally distributed, were analyzed through paired t-tests for group differences.
Results: No differences were found between the two groups for all variables tested.
Conclusions: Both brackets showed the same velocity of canine retraction and loss of
anteroposterior anchorage of the molars. No changes were found between brackets regarding
the inclination of canines and first molars. (Angle Orthod. 0000;00:000000.)
KEY WORDS: Canine retraction; Anchorage; Self-ligating brackets; Tooth movement rate
INTRODUCTION
Several in vitro studies have reported lower friction
levels when self-ligating brackets (SLB) were com-
pared to conventional brackets (CB).
18
It would be
logical, therefore, to assume that spaces could be
closed faster when SLB are used, since it is known that
friction could influence movement rates. Controver-
sially, recent systematic reviews failed to report the
superiority of SLB over CB when tooth movement
velocity was assessed,
9,10
challenging what logically
would make sense. Additionally, several randomized
clinical trials using SLB have been conducted,
1019
and
it has been suggested
20
that more clinical trials are
needed to assess tooth velocity during space closure
when SLB and CB are compared.
Canine retraction is probably the most common
clinical situation where sliding mechanics is used
to move a tooth over a relatively large distance.
Therefore, it would be interesting to evaluate the
superiority of one bracket over another regarding
friction, but to date only three studies have compared
the velocity of canine retraction using SLB and
CB,
11,14,16
and their results are controversial. Two
14,16
have failed to find differences between those brackets,
while the remaining
11
favored CBs. Even though the
design of the latter study
11
allowed a more complete
evaluation since full canine retraction was evaluated,
measurements were taken directly in the mouth and
a
PhD student, Faculdade de Odontologia de Araraquara,
Universidade Estadual Paulista, UNESP, Araraquara, SP, Brazil.
b
Professor, Faculdade de Odontologia de Araraquara, Uni-
versidade Estadual Paulista, UNESP, Araraquara, SP, Brazil;
Adjunct Clinical Professor, Baylor College of Dentistry, Dallas,
Tex, and Saint Louis University, St Louis, Mo.
c
Private practice, Araquara SP, Brazil and Faculdade de
Odontologia de Araraquara, Universidade Estadual Paulista,
UNESP, Araraquara, SP, Brazil.
Corresponding author: Dr Luiz Gonzaga Gandini Ju nior, Av
Casemiro Perez, 560, Vila Harmonia, Araraquara, Sa o Paulo,
CEP 14802-600, Brazil
(e-mail: luizgandini@uol.com.br)
Accepted: January 2014. Submitted: October 2013.
Published Online: March 4, 2014
G
0000 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/100813-743.1 1 Angle Orthodontist, Vol 00, No 0, 0000
rounded to the half millimeter, which could explain the
small differences found. Additionally, no information on
tipping was collected, and differences in tipping could
explain the differences found.
Another claim regarding SLB, involves the belief that
they would allow less anteroposterior (AP) anchorage
loss of the molars during space closure. This idea
comes from the theory that less friction would allow
lighter forces to retract anterior teeth and, therefore,
suboptimal forces would be applied to the posterior
teeth.
21
Three clinical trials have examined this
hypothesis,
14,22,23
but only one evaluated the loss of
AP anchorage during canine retraction and only over a
period of 12 weeks.
14
Three months may not be
enough to detect differences between brackets, and a
longer period of evaluation could be desirable.
Thus, the aim of this study was to assess possible
differences in canine retraction velocity, as well as
changes in tipping, and the amount of AP anchorage
loss during maxillary canine retraction, using CBand SLB.
MATERIALS AND METHODS
Sample size was calculated using the PS: Power and
Sample Size Calculation software, version 3.0.43
Table 1. Sample Characteristics
Mean age in T1, y 23.32 6 5.08
Age range, y 17.6635.49
Gender Female Male Total
16 9 25
Figure 1. Flow diagram of the progress through the phases of study.
2 MONINI, GANDINI JR, MARTINS, VIANNA
Angle Orthodontist, Vol 00, No 0, 0000
(Vanderbilt University, Nashville, TN) available at http://
www.mc.vanderbilt.edu/prevmed/ps/index.htm. Based
on estimated differences between groups of 0.2 mm
per month and on a standard deviation of 0.3 mm,
14
a
sample size of 25 patients per group was calculated for
an a of .05 and a power of 90%.
Twenty-five Class I biprotrusive adult patients
requiring four first premolar extractions, with arch
length discrepancy below 4 mm, were selected for
the study out of 52 patients who sought treatment at
the Araraquara School of Dentistry (Table 1). Three
patients did not attend the initial screening, and 24
were excluded due to tooth loss or arch length
discrepancy above 4 mm. The universitys institutional
review board approved this research, and the patients
signed an informed consent agreeing to participate in
the study. Patients were allocated into five groups, with
five patients in each; a block randomization was done
to determine which canine, right or left, would have the
SLB or CB bonded. Figure 1 depicts the flow diagram
of the progress through the phases of a parallel-
randomized trial of two groups.
Conventional 0.022-inch straight-wire brackets
(Ovation, GAC, Bohemia, NY) were bonded to the
upper second premolars, and incisors and tubes were
soldered to bands of the first and second molars.
Through block randomization, one maxillary canine
was bonded with a 0.022-inch SLB (In-Ovation R,
GAC), while the other received a 0.022-inch CB
(Ovation, GAC). Leveling and aligning was conducted
conventionally until a 0.020-inch stainless steel (SS)
wire could be passively inserted into the brackets.
Retraction was undertaken on 0.020-inch SS arch-
wires with tight fit omega loops tied to the first molars.
Second premolars and first and second molars were
tied together with ligature wire, which were also used
to tie the canines CB to the archwire. No auxiliary
devices such as transpalatal arches, headgear, or
elastics were used. Nickel-titanium closed coil springs
(CCS) of 100 g (GAC) were activated for 17 mm and
secured from the hooks of first molars to the hooks of
the canine brackets with ligature wires. The CCS were
adjusted to the same activation every 4 to 5 weeks.
Oblique cephalometric radiographs at 45u were
taken from right and left sides (T1) at 7 to 14 days
before the extractions and after total canine retraction
(T2). All 25 patients reached the T2 phase without
bracket debonds or CCS breakage.
The tracings were hand drawn with a 0.3-mm
mechanical pencil on tracing paper by one operator.
Two horizontal reference points were marked (Fig-
ure 2; Table 2) over the functional occlusal plane
traced in T1 in order to determine the horizontal
reference line (HRL). Point 1 was located in the
anterior region of the tracing, and point 2 was in the
posterior region of the tracing. A third point was
marked above the orbit contour and posterior to the
tracing to determine a vertical reference line (VRL)
perpendicular to HRL.
Four points were marked on each of the right and left
radiographs: (MC) and (MA) and (CC) and (CA)
Figure 2. Tracing with anatomic cephalometric landmarks and
reference points as described in Table 2.
Figure 3. Partial superimposition of T1 and T2. The superimposed
stable structures of the maxillary bone complex, the three reference
points, and the lines used to measure the horizontal displacement of
the teeth can be seen.
Table 2. Description of Cephalometric Landmarks and Reference
Points Identified on the 45u Lateral Tracing
Points and Cephalometric
Landmarks Description
Point 1 Anterior reference point
Point 2 Posterior reference point
Point 3 Posterior and superior maxillary ref-
erence point
MC Mesiobuccal cusp of maxillary first
molar
MA Mesiobuccal root apex of maxillary
first molar
CC Cusp of maxillary canine
CA Root apex of maxillary canine
SELF-LIGATING VERSUS CONVENTIONAL BRACKETS 3
Angle Orthodontist, Vol 00, No 0, 0000
(Table 2). All anatomic landmarks and points were
digitized on the software DentoFacial Planner Plus
(DFP version 2.0, Toronto, ON, Canada).
T1 and T2 tracings were superimposed using the
best fit of maxillary bone structures, following the
internal anterior maxillary cortex at the contralateral
canine, posterior contour of the infrazygomatic crest,
nasal cavity floor, and anterior lower orbit bone contour
(Figure 3).
24
The three reference points were then
transferred from T1 to T2.
The distances, parallel to HRL, from the points CC,
CA, MC, and CA to VRL were transferred to a
Microsoft Excel, (Microsoft Office Excel 9.0, Redmond,
WA, USA) spreadsheet where T2 values were
subtracted from T1 values. These calculations allowed
the measurement of the total amount of canine
retraction, at the cusp and at the apex, and measure-
ment of its velocity, by dividing the total amount of
retraction by the number of days for total space closure
on each side. The amount of AP loss of anchorage of
the molar cusps and apices was also calculated
similarly.
The angle formed by the tooth long axis, determined
by the cusp and apex points and HRL, was measured
in T1 and T2. This allowed an assessment of the
changes that occurred on tooth angulations also by
subtracting T2 from T1 (Table 2).
A single blinded examiner traced all radiographs and
superimposed and digitized them. Each digitalization
was repeated after 30 days for method error analysis
and also for the use of average measurements. Error
analysis was done though a paired t-test, which
evaluated systematic error and was complemented
by the Dahlberg formula, which evaluated random
error. No significant differences were found on the
paired t-test between the first and second digitalization
times, which confirmed the absence of systematic
error, while the Dahlberg formula showed random
errors ranging from 0.21 mm to 0.36 mm and from
0.77u to 1.28u.
Statistics were conducted with the software Statis-
tical Package for Social Sciences, SPSS, version 16.0
(SPSS, Chicago, IL, USA). All variables were normally
distributed according to kurtosis and skewness stan-
dard error comparisons; thus, paired t-tests were used
to detect differences between groups.
RESULTS
The canine crowns were retracted 0.71 and 0.72 mm
per month, and apices were retracted 0.22 and
0.24 mm per month, for SLB and CB, respectively
(Tables 3 and 4). Total retraction of the canine crowns
was 6.92 and 6.97 mm, while the total retraction of the
apices was 2.24 and 2.43 mm, for the SLB and CB
groups, respectively. Molars were protracted 1.28 mm
in the SLB group and 1.24 mm in the CB group, while
their apices were protracted 0.60 mm in the SLB group
and 0.52 mm in the CB group. Total time for space
closure took 10.86 months and 10.70 months for the
SLB and CB groups, respectively. No significant
differences were found between the groups for any
of the variables tested (Tables 5 and 6).
DISCUSSION
No differences were found between SLB and CB in
the velocity of canine retraction. To date, only three
clinical studies (Table 7) have compared the velocity of
retraction of maxillary canines with SLB and CB,
11,14,16
and even though different methods were employed,
Table 3. Means, Standard Deviations, and Significance of the Comparisons Between Groups
a
for the Variables Tested Monthly (28 Days)
Variable SLB Group (SD) CB Group (SD) P
Canine crown retraction, mm 0.71 (0.29) 0.72 (0.26) .965
Canine root apex retraction, mm 0.22 (0.27) 0.24 (0.22) .809
Total canine crown retraction, mm 6.92 (1.66) 6.97 (1.81) .924
Total canine apex retraction, mm 2.24 (2.70) 2.43 (2.10) .756
Total molar crown protraction, mm 1.28 (1.10) 1.24 (1.36) .919
Total molar apex protraction, mm 0.60 (1.11) 0.52 (1.33) .806
Time taken for total space closure, mo 10.86 (3.32) 10.70 (3.34) .788
a
SLB indicates self-ligating brackets; CB, conventional brackets.
Table 4. Average Changes
a
and Standard Deviations for Canine and Molar Inclinations in Both Groups
b
and Significance of the
Differences Found
Aspect SLB Mean Grade (SD) CB Mean Grade (SD) P
Changes on canine long axis 10.89 (6.25) 10.15 (4.75) .616
Changes on molar long axis 22.28 (3.20) 22.29 (2.42) .993
a
Positive values indicate distal inclination and negative values indicate mesial inclination.
b
SLB indicates self-ligating brackets; CB, conventional brackets.
4 MONINI, GANDINI JR, MARTINS, VIANNA
Angle Orthodontist, Vol 00, No 0, 0000
the current results were similar to two of them.
14,16
The
remaining study
11
identified a higher velocity of
retraction for CB and hypothesized that the differences
found were due to differences in the widths of the
brackets. We tried to control that variable by using SLB
and CB from the same manufacturer and of very similar
widths (2.9 mm and 3.4 mm, respectively), and even
then no differences were found. However, there was a
wide range of responses among patients, as well as
different responses within patients (Figure 4).
2527
On
the other hand, we found a lower velocity of canine
retraction compared to other studies.
11,14,16
Two factors
may have contributed to that finding: the adult sample,
which may show slower velocity of movement,
28,29
and
the force level (100 g), which could have been
suboptimal for the friction developed by a high-diameter
wire (0.020-inch).
11,14,26
There was no difference in the loss of AP anchorage
of the molar crowns between SLBand CV. Compared to
total retraction, we found a retraction to loss-of-
anchorage ratio of 5.4:1 for the SLB and 5.6:1 for the
CB. Only one other study
14
has compared the loss of
anchorage during canine retraction between SLB and
CB, and it also reported no differences between bracket
types. The ratio of retraction to loss of anchorage was
slightly lower than ours (4:1 and 4.3:1 for SLB and CB,
respectively), but the time of evaluation in that study
was only 8 weeks. Two other papers that have
compared SLB and CB found a greater anchorage loss
compared to our study. One
23
reported ratios of 1.3:1
and 1:1 for SLB and CB, respectively, while the other
22
found low ratios of 0.19:1 for both SLB and CB, but
those papers evaluated total space closure as opposed
to canine retraction only.
There was no difference in the tipping of the canines
and molars when the bracket types were compared.
Only one
16
of the articles comparing SLB and CB
during canine retraction evaluated this variable and
also found no difference. Tipping should always be
assessed when studying space closure because
differences might confound the apparent velocity of
movements since tipping is generally associated with
faster movement than translation.
3032
In order to
control this variable in the current study, all teeth were
aligned and leveled up to a .020-inch SS wire before
extractions took place. This provided a standardization
of the initial position of the teeth before canine
retraction was initiated and thus avoided differences
in the initial position of the canines which could have
influenced the rate of movement.
33
The use of a round
SS wire with low second order clearance (0.020-inch
wire in a 0.022-inch slot) combined with a relatively low
force (100 g) was chosen to provide maximum canine
translation
34
and less crown tipping. After total retrac-
tion, canine crowns moved distally more than the
apices did, resulting in 10u to 11u of change in the
canine long axes. The same occurred with the molars,
but the change was approximately 2u. This difference
in tipping between canines and molars can be
explained by the smaller second order clearance of
molar tubes compared to canine brackets due to the
difference in width.
Table 5. Mean Differences, Standard Deviations, Standard Errors of the Mean, and 95% Confidence Intervals of the Difference Between SLB
and CB
a
Variable Mean SD SEM
95% CI
P Lower Upper
Canine crown retraction/mo, mm 0.003 0.37 0.073 20.148 0.154 .965
Canine root apex retraction/ mo, mm 0.015 0.32 0.063 20.115 0.146 .809
Total canine crown retraction, mm 0.046 2.39 0.478 20.941 1.033 .924
Total canine apex retraction, mm 0.198 3.14 0.629 21.101 1.497 .756
Total molar crown protraction, mm 0.040 1.93 0.387 20.759 0.839 .919
Total molar apex protraction, mm 0.084 1.69 0.338 20.615 0.783 .806
Time taken for total space closure, mo 0.157 2.88 0.577 21.035 1.349 .788
a
SLB indicates self-ligating brackets; CB, conventional brackets.
Table 6. Mean Differences, Standard Deviations, Standard Errors
of the Mean, and 95% Confidence Interval of the Difference Between
SLB and CB for Canine and Molar Inclinations
a
Variable Mean SD SEM
95% CI
P Lower Upper
Changes in
canine long
axis
0.740 7.28 1.457 22.268 3.748 .616
Changes in
molar long
axis
0.006 3.36 0.672 21.381 1.393 .993
a
SLB indicates self-ligating brackets; CB, conventional brackets.
Table 7. Data From Articles on Maxillary Canine Retraction
Velocity Comparing Self-Ligating Brackets (SLB) and Conventional
Brackets (CB)
Reference SLB, mm/mo CB, mm/mo P
Mezomo et al.
14
0.90 0.84 .356
Burrow
11
1.00 1.17 .0001
Oz et al.
16
1.83 1.89 .77
Present study 0.71 0.72 .931
SELF-LIGATING VERSUS CONVENTIONAL BRACKETS 5
Angle Orthodontist, Vol 00, No 0, 0000
An a priori sample size calculation was done for this
research. A sample size of 25 was calculated using a
significance of 0.05, a power of 90%, a difference 0.2 mm
per month (considered by the authors to be relevant),
and a standard deviation of 0.3 mm per month, which
was selected from the literature.
14
The post hoc test of
our data, however, showed a power of only 5.2% to rule
out a type II error with the small difference found
(0.01 mm per month). Even though we had a small
sample size to rule out differences of 0.01 mm per
month, we believe that from a clinical standpoint those
differences would be clinically insignificant.
The results of this study demonstrated that bracket
type does not influence velocity of tooth movement,
but individual variation might. If the patients tested
were divided into two groups based on the movement
rate, for comparison of the fast (above average) and
slow (below average) movers, a significant differ-
ence of 0.304 mm per month in the rate of canine
retraction would be observed (Table 8). This difference
is much higher than the nonsignificant difference found
when the bracket type groups were compared or,
assuming that a type II error occurred, 30 times higher
when compared to the difference of 0.01 mm per
month between SLB and CB. In another words, the
rate of canine movement seems to be influenced by
individual biological responses of patients, rather than
by bracket type. Without management of the biological
responses that occur after a force is applied to a tooth,
it would be very difficult to observe a faster velocity of
tooth movement in the future.
3539
Based on the results of this study, in a given
population, no significant difference in the rate of tooth
movement is likely to be found between groups with
different bracket types. On the other hand, it is not
possible to predict accurately the time required for
tooth retraction in individual patients due to the great
amount of variability observed.
CONCLUSIONS
When comparing SLB and CB:
N retraction velocities of the maxillary canines were
similar;
N anchorage loss during maxillary canine retraction
was similar; and
N inclination changes on maxillary canines and molars
were similar.
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