CLINICAL Journal of Orthodontics, Vol.

00, 2015, 1–9

Controlled canine retraction using orthodontic

mini-implants coupled with bondable powerarms
Richard Cousley
Peterborough City Hospital, UK

Many patients present with a substantial amount of anterior dental crowding, necessitating canine retraction prior
to incisor alignment. Conventional biomechanics typically requires anchorage reinforcement and risks distal tipping
of the canine crown and a delay before incisor alignment. However, it is now possible to produce controlled canine
retraction without anchorage loss, even with narrow, flexible archwires in situ. This enables simultaneous
alignment of displaced incisors. This technique involves a combination of orthodontic mini-implants (OMIs) and a
powerarm bonded directly on either the labial or palatal surface of the target tooth, as described in this paper.

Key words: Orthodontic mini-implant, TAD, orthodontic anchorage, canine powerarm, bodily tooth movement

Received 31 March 2015; accepted 05 June 2015

Introduction In conventional straight wire treatment, the bio-

It is widely recognized that orthodontic mini-implants
(OMIs), also known as mini-screws, micro-implants and
Temporary Anchorage Devices (TADs), provide stable
anchorage for the application of traction in all three
planes of space and directions (Cousley, 2013; Cousley
and Sandler, 2015). Consequently, the focus of clinical
innovation has evolved in recent years beyond insertion
and stability issues to include the development of cus-
tomized techniques and biomechanics for each OMI-
related clinical scenario. For example, OMI anchorage is
very effective during en masse retraction of the six an-
terior teeth, especially when direct traction is applied to
anterior powerarms (Kuroda et al., 2009; Koyama et al.,
2011; Davoody et al., 2012; Al-Sibaie and Hajeer, 2014;
Upadhyay et al., 2008, 2014). These elongated hooks
(Fig. 1) act as vertical extensions of the fixed appliance
such that the retractive force acts closer to the centre of
resistance of the labial teeth, producing more effective
bodily movement than when it is applied to either short
hooks or the anterior brackets (Upadhyay et al., 2014).
In this situation, the powerarms are typically crimped
onto a rigid archwire, e.g. a 0.019|0.0250 stainless steel
wire (where 0.021|0.028 bracket slots are used).
However, some patients present with substantial
crowding of the anterior teeth, which necessitates canine
retraction prior to incisor alignment (and retraction).
What are the optimum fixed appliance and OMI bio-
mechanics in such cases for initial canine retraction
(before a full working archwire is inserted)?
mechanics set-up of canine retraction/distalisation
(typically into a premolar extraction space) involves the
application of traction from a molar hook to either the
canine bracket or a Kobyashi hook. A relatively narrow
(e.g. 0.0180) round stainless steel archwire is often used
during this phase in order to reduce the canine bracket’s
resistance to sliding. However, incomplete engagement
of the bracket slot means that the canine may undergo a
cycle of distal tipping and archwire binding, resulting
in both increased resistance to sliding and poor control
of both canine angulation and rotation. Incisor align-
ment is undertaken as a separate phase once canine
distalisation has created sufficient space in the labial
segment. Notably, indirect anchorage of the maxillary
molars by mid-palatal OMIs does not alter the canine
distalisation biomechanics since the traction is still
applied from buccal molar hooks and hence adjacent to
the archwire level. Therefore, with both conventional
and indirect anchorage retraction methods the control
of canine distalisation movements relates to the mode of
traction and archwire features, not the anchorage
component.
The use of buccal alveolar OMIs has been shown, in a
randomized clinical trial, to avoid anchorage loss during
canine retraction (Sharma et al., 2012). However, direct
traction to the canine bracket includes a vertical force
vector since the OMI head is at an apical level relative to
the bracket and archwire. Consequently, if this traction
is applied to a non-rigid archwire then the vertical vector

Address for correspondence: Richard Cousley,

Peterborough City Hospital, UK.
Email: Richard.Cousley@pbh-tr.nhs.uk.
# 2015 British Orthodontic Society DOI 10.1179/1465313315Y.0000000014
 2 Cousley
Figure 1 Bilateral orthodontic mini-implants (OMIs) and
crimpable powerarms being used, with coil spring trac-
tion, for en masse retraction of the anterior maxillary
teeth
accentuates distal tipping of the canine, resulting in a
‘rollercoaster’ effect on the buccal teeth (Fig. 2). If the
traction is applied with a rigid (e.g. 0.019|0.0250
stainless steel) archwire in situ then molar intrusion and
development of a posterior openbite may occur, or
alternatively the rate of canine distalisation may be very
slow because of excessive archwire resistance and
bracket-wire binding (Fig. 3).
These vertical side-effects may be minimized by
moving the mesial point of traction application in an
apical direction. This creates a horizontal force vector
(parallel to the occlusal plane), both reducing the ver-
tical vector problems and promoting bodily movement
of the canine. This concept was first demonstrated by
Yadav and Seghal (2011) who soldered a hollow stain-
less steel tube onto a canine bracket hook to create a
single tooth powerarm. However, steel tubing is poten-
tially weak and flexible compared to a stainless steel wire
of the same external diameter. Consequently, modifi-
cation of a canine bracket to create a more robust canine
powerarm may be achieved by welding a piece of rigid
steel wire onto the bracket hook (Fig. 4). While this
provides a single tooth powerarm, it has the dis-
advantage that the modified bracket needs to be bonded
either at the initial bond-up or as a replacement bracket
at the start of canine retraction. In addition, this bracket
modification may need to be prepared in advance by an
orthodontic technician, and a straight shaft design car-
ries a risk of the traction auxiliary slipping coronally
towards the bracket (unless a composite or crimpable
stop is added to the powerarm).
A more customized approach involves the fabrication
of single tooth bondable powerarms for the right and
left sides, respectively. These may be bonded to canine
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Figure 2 (a) Elastomeric traction applied directly to a
canine bracket, following first premolar extraction, with
a flexible archwire in place. (b) Distal tipping of the
canine, and intrusion of the adjacent second premolar
and first molar teeth is evident
crowns, solely for the period of OMI-anchored canine
retraction, either labially adjacent to a standard ortho-
dontic bracket or on the palatal crown surface.
This bondable powerarm is formed by cutting the
crimpable base off a commercially available powerarm
(the version illustrated here is distributed by DB
Orthodontics Ltd, UK; www.dborthodontics.co.uk).
The sectioned end of this powerarm is then welded onto
a narrow curved base, such as a bondable cleat (Fig. 5).
The small base size means that the powerarm can be
bonded onto any fully erupted canine crown in the
occluso-gingival space adjacent to an existing bracket.
If necessary, the canine bracket may be bonded at a
relatively coronal level to provide sufficient space for the
powerarm base. This offset bracket height also has
the advantage of relative intrusion of the canine and the
subsequent avoidance of occlusal interferences during its
retraction. This is irrespective of bracket type provided
that any pre-existing bracket hook does not prevent
placement of the auxiliary base.
 JO 2015 Clinical
Figure 3 Oblique elastomeric traction applied directly to
the canine bracket (a), then a Kobyashi hook on the
canine bracket (b), with a 0.019 £ 0.025 steel archwire in
place
It is also easy to adapt the shape of this type of sig-
moid powerarm, ideally prior to bonding. For example,
the addition of a buccal offset may be beneficial to avoid
impingement on the adjacent gingival margin, while an
inward curvature of the distal portion of the hook
avoids irritation of the opposing cheek tissues. Notably,
when a pre-fabricated crimpable powerarm is being
modified then remember that these are sold for a specific
side/quadrant. Therefore, the right crimpable powerarm
version is used for the upper right and lower left buccal
canine surfaces, and the upper left palatal surface.
Conversely, a standard left powerarm is used to produce
a bondable version for the upper left and lower right
canine buccal surfaces, and the right palatal surface.The
author has also trialled the alternative option of orien-
tating the powerarm’s base in an axial direction so that
it may be bonded distal to the canine bracket (Fig. 6a,b).
However, this approach was observed to result in disto-
palatal rotation of the canine, and the traction auxiliary
Controlled mini-implant canine retraction 3
Figure 4 (a) A canine powerarm welded to a conven-
tional bracket hook, in the patient shown in Fig. 3, with
direct elastomeric traction applied. (b) 9 weeks later the
left canine had been retracted into a Class I position, and
was stabilized with a steel ligature. The lower arch was
also bonded
impinged on the buccal mucosa causing it to ulcerate
(Fig. 6c,d). Therefore, the gingival part of an individual
crown appears to be the optimal site for bondable
powerarms on the buccal face of teeth.
Case reports
The following cases illustrate the usefulness of this
combination of OMI anchorage and a single tooth
powerarm for rapid, controlled retraction of canine
teeth during the initial alignment and levelling phase,
and as a secondary application later in treatment. These
teeth were seen to distalise with mainly bodily, rather
than tipping, movements even when flexible, narrow
archwires were in situ, and without the occurrence of
vertical side-effects in the buccal segment during this
phase. In addition, the first case demonstrates that it is
feasible to perform simultaneous alignment of adjacent
 4 Cousley
Figure 5 (a) The bondable base and crimpable power-
arm used to fabricate a bondable powerarm, as shown in
(b) adjacent to a powerarm hook welded onto a canine
bracket
incisors early during treatment, using an auxiliary
‘piggy-back’ nickel titanium (niti) archwire. This is
possible because powerarm retraction only requires the
maximum of a 0.0180 diameter steel base archwire,
leaving space for an auxiliary wire (with in
0.021|0.0250 slot brackets).
Case 1
A 17-year-old male patient presented with a Class III
malocclusion on a severe Class III skeletal relationship,
with severe maxillary arch crowding, buccal exclusion of
the upper left canine, and a substantial shift of the upper
centreline to the left side (Fig. 7a–c). The orthognathic
treatment plan involved pre-surgical relief of crowding,
orthodontic decompensation, centreline correction, and
then bimaxillary surgery. Treatment commenced with
extraction of the maxillary first premolar teeth and
placement of pre-adjusted fixed appliances, beginning
with the lower arch. The upper arch treatment was
Clinical JO 2015
complicated by fracture of the upper right premolar
root, involving a delay in treatment and loss of buccal
cortical plate during its surgical removal. The latter then
caused an increased resistance to the root movement of
the upper right canine. The maxillary lateral incisors
were excluded at bond-up. The angulation of the second
premolar brackets was altered with additional mesial tip
in order to tip their roots mesially and hence increase the
adjacent interproximal space.
After 7 months of orthodontic treatment an OMI,
with 1.5 mm diameter and 9 mm body length (Infini-
tasTM, DB Orthodontics Ltd, UK; www.infinitas-mini-
implant.com), was inserted bilaterally in a buccal
alveolar site mesial to the first molars. They were loaded
immediately with approximately 50 g of force, using
elastomeric chain attached to the canine brackets. A
single tooth powerarm was bonded to the right maxil-
lary canine 6 weeks later, a 0.0180 steel archwire inser-
ted, and elastomeric traction auxiliaries applied directly
to both the powerarm and the left canine bracket (Fig.
7d,e). After 3 months of traction, the anchorage
requirements on the left side had resolved and the left
OMI was explanted. At the same time, both maxillary
lateral incisors were bonded and a 0.0120 niti archwire
was fully ligated (Fig. 7f,g). Traction was also continued
to the right canine powerarm. A 0.0180 niti archwire was
inserted 8 weeks later (Fig. 7h,i). Simultaneous canine
retraction, and alignment and levelling of the maxillary
arch progressed over the following 3 months until a
0.019|0.0250 stainless steel archwire was placed (Fig.
7j). A panoramic radiograph at this stage showed that
the maxillary canine teeth had maintained their original
angulation, despite their retraction with flexible arch-
wires in place (Fig. 7k).Bimaxillary orthognathic surgery
was performed after 16 months of treatment, then both
the powerarm and right mini-implant were removed
1 month post-operatively (Fig. 7l) since the final phase
of centreline correction and space closure could afford
some anchorage loss prior to the debond stage (Fig. 7m,
n). The need for long-term occlusal settling of the post-
operative molar openbites was accepted since the patient
was moving to university and demonstrated sub-optimal
compliance with settling elastics prior to debond.
Case 2
This 17-year-old female originally presented with a Class
III malocclusion (Fig. 8a), on a Class III skeletal re-
lationship, with an increased maxillo-mandibular planes
angle (MMPA), an associated tenuous overbite and
centreline discrepancies. She had undergone 14 months
of pre-surgical orthodontics, including OMI-assisted
intrusion of the maxillary molars to reduce the MMPA
(Fig. 8b), then a mandibular setback osteotomy.
 JO 2015 Clinical Controlled mini-implant canine retraction 5

Figure 6 (a,b) Photographs of an adult female who presented with a Class II division one malocclusion with moderate
anterior maxillary arch crowding. The maxillary first premolars have been extracted. Elastomeric traction has been
applied from the buccal orthodontic mini-implants (OMIs) to powerarms bonded distal to the maxillary canine brackets.
(c) Both powerarms have been replaced with shorter ones bonded on the gingival aspect of the canine bracket, to
prevent continued mucosal trauma from the traction auxiliary’s position. Elastomeric traction was applied with a 0.018
niti archwire in place at this stage. (d) The canines are rotated disto-palatally and the archwire is not fully seated in the
canine brackets

Notably, a maxillary osteotomy was avoided because
the maxillary molar intrusion treatment effectively
reduced the vertical skeletal discrepancy. However, the
decision on the need for upper arch extraction(s) was
post poned because the full effects of molar intrusion
were not readily predictable with this novel treatment
and the extraction pattern could readily be confirmed at
the stage of pre-surgery records.
Pre-operatively it was noted that the patient had a
residual shift of the maxillary centreline to the right side.
It was decided to perform a symmetrical mandibular
setback osteotomy, to ensure that the mandibular cen-
treline was correct, and then rectify the upper centreline
discrepancy post-operatively. The options considered
were to extract an upper left quadrant tooth (at the
orthognathic surgery episode); or use asymmetric elastic
traction (which would have the side-effect of altering the
lower centreline), or use traction from one of the existing
OMIs. It was agreed to use the latter approach, but
noting that traction to a standard anterior powerarm
(on the buccal side of the dentition) was not feasible
since the OMIs were in palatal alveolar sites. Indirect
traction would have involved connecting a rigid wire
between the OMI head and an adjacent anchor tooth.
As anticipated in the orthognathic planning process,
post-operatively the upper centreline was positioned
to the right of the lower one, and the left canine
relationship was a half unit Class II (Fig. 8c,d).
6 Cousley Clinical JO 2015
 JO 2015 Clinical Controlled mini-implant canine retraction 7

Figure 7 Pre-treatment photographs showing a Class III malocclusion, severe anterior maxillary crowding and upper
centreline shift to the left side (a,b). (c) Distal angulation of the maxillary canines is evident on the initial panoramic
radiograph. (d,e) Elastomeric traction applied to a bondable powerarm on the right side and directly to the left canine
bracket, with a 0.018 steel archwire in situ. Alveolar necking is evident in the right edentulous site. (f,g) 8 weeks later
the upper lateral incisors have been bonded. Right canine retraction continues with a 0.012 niti archwire fully engaged.
(h,i) Traction continues simultaneous to incisor alignment using a 0.018 niti archwire. (j) A 0.019 £ 0.025 steel archwire
and a discoloured passive elastomeric in place pre-operatively. The right canine relationship is a full unit Class III and
there are residual maxillary arch spaces. (k) The pre-osteotomy panoramic radiograph shows that the maxillary canine
angulations have been unaltered during retraction, despite the right alveolar necking problem. (l) The right mini-
implant was explanted, and bracket repositioning performed 4 weeks post-operatively, prior to final space closure and
then debonding (m,n)
 8 Cousley Clinical JO 2015

Figure 8 Pre-treatment (a) and pre-operative (b) photographs of the Class III malocclusion and centreline discrepancies.
(c,d) Post-operative photographs showing a Class I incisor relationship, with an upper centreline shift to the right and a
left Class II canine relationship. (e) Elastomeric traction applied to a bondable powerarm on the left canine’s palatal
surface. (f– h) The Class II and centreline discrepancies have been corrected, and the powerarm and OMIs removed. (i,j)
The occlusion at debond
 JO 2015
Therefore, elastomeric traction was applied 2 months
after surgery, from the left OMI to a single-tooth pow-
erarm bonded palatally on the upper left canine crown
(Fig. 8e). This powerarm required minimal contouring
of its shape to avoid both palatal soft tissue contact and
tongue interference. A 0.019|0.0250 steel archwire
was in place and the upper left canine bracket ligated
with a ‘figure of eight’ elastomeric ring. A Class I
canine relationship and coincident centrelines were
achieved after 5 months of traction and the OMIs were
then removed (Fig. 8f–h). The patient was debonded
6 weeks later, after a total treatment time of 24 months
(Fig. 8i,j).
Discussion
The two cases described here demonstrate that a com-
bination of OMI anchorage and single-tooth, bondable
powerarms provides a simple and effective means of
optimizing bodily movement of canine teeth in high
anchorage cases. Vertical side-effects, such as the roller-
coaster intrusion of buccal segment teeth, are avoided
even when traction is applied with flexible archwires in
situ. This technique also offers flexibility in the timing
and application of the traction since these powerarms
may be bonded either on a canine crown’s buccal surface
adjacent to a fixed appliance bracket, or on its palatal
surface, at any stage of treatment. The most likely ap-
plication for buccal bonded powerarms is where patients
are being treated with labially bonded fixed appliances
and buccal OMIs. The use of palatal powerarms is
suitable for cases with palatally sited OMIs, but possibly
not for patients with lingual fixed appliances, since
there may be insufficient space on the palatal surfaces
for both attachments. Therefore, the combination of
buccal OMIs and single-tooth buccal powerarms may
also be applied to treatments where there are no labial
fixed appliances. This would be the case with lingual
orthodontics and orthodontic aligner treatments.
Clinical Controlled mini-implant canine retraction 9
Indeed, the latter scenario has recently been demon-
strated by Cousley and Sandler (2015) where traction
was applied from a buccal OMI to a bondable canine
powerarm.
Disclaimer statements
Contributors The author is the sole contributor.
Funding None.
Conflicts of interest The author has a financial interest
in the Infinitas™ mini-implant system.
Ethics approval None.
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