Shukla, Gupta, Singh, Verma, and Dwivedi: Various methods of canine retraction in premolar extraction space: A case series


Introduction

Orthodontics as a specialty has its long run of existence and every time it comes through various profound and revolutionary changes in terms of diagnosis, treatment planning, biological and biomechanical applications. In contemporary orthodontics, retraction of teeth after extraction of premolars is an essential part of orthodontic treatment.1 Single-step-enmass retraction of 6 anterior teeth at once or two-step procedure in which canine has to retract first followed by retraction of 4 incisors are the most common routines to close the space created by the extraction of premolars.2 There is a number of methods those can be employed for the above said purpose. In modern orthodontics, solutions are available in the form of friction and frictionless mechanics.3 The frictional method includes the use of elastomeric materials, active tie-backs, coil springs (NiTi/ SS-stainless steel/ Elgiloy-Co-Cr-Ni) while frictionless method utilizes different configuration of loops or retraction spring made up of materials like TMA (β-titanium), SS, or elgiloy.4, 5, 6 Retraction via these methods required 4 to 5 months for full retraction of canine and almost always consume anchorage when used with conventional anchorage units like posterior teeth or enhancement of anchorage with palatal or lingual arches, that is why now a day TADs (Temporary Anchorage Devices/Miniscrews) are popular choice to facilitate retraction in terms of reducing anchorage loss.7 Total orthodontic treatment time is usually an average of about 20-24 months or even more and this is the most common reason that patient may lose confidence, motivation, and compliance towards the treatment procedures. Due to longer treatment time, researchers are now focusing to accelerate the tooth movement via the application of different invasive (Corticotomy, PAOO- Periodontally Accelerated Osteogenic Orthodontics, Peizocision, Dental/Dentoalveolar distraction), minimal invasive micro-osteo-perforations (MOPs) or non-invasive procedures (low level laser, vibrations, pulsed electromagnetic field, drugs and supplements).8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 This article aims to provide the literature review of various methods of canine retraction followed by a report of 10 cases, focusing on canine retraction via various method available.

Review of Literature

Ray D Robinson was the first to introduce loop for retraction purposes long back during Angle era.21 Open and closed vertical loop came in existence around the year 1933 and later on became an integral part of edgewise mechanics.22 Segmental arch technique under frictionless mechanics was popularized by Burstone et al.6 The material of choice was TMA for construction of T loop, which is based on the application of differential moments between teeth. Differential moments are required to achieve particular tooth movement. These differential moments are classified as alpha (anterior) and beta (posterior) moments. Differential moments are used for obtaining differential anchorage, force system, and root movement.6 The PG retraction spring is another popular spring based on segmental arch mechanics, can be made from 0.016” x 0.022” stainless steel wire or TMA.23 Opus 70 loop is a closing loop design based on Castigliano's theorem for the derivation of moment to force ratio, best suited in continuous SS or TMA archwire. The opus loop works better than the other loops in most instances for both the centered and off-centered placements.24 A mushroom loop was fabricated by Nanda and It is similar to the design of T loop except that its apical area is curved.25 Location, moment generated, and spring characteristics of a closing loop are the three basic properties, which decide the performance of the loop.26 Effect of gable bends on loop was study by a researcher and it was concluded that first and second order gable bends in stainless steel triangular loops have uncoupled effects on the clinically critical M/F.27 It is a proven fact that T loop design results in force system closer to those required for translation while vertical loops produce higher forces but much lower M/F ratio at maximum activation that is not useful to carry out the translation.28

Bennett and Mclaughlin popularized the use of Active tie back (elastomeric module with ligature) for retraction during the development of their well known MBT philosophy.4 Activation of elastic module twice to their size can produce a force of up to 100 gram. Tie back has to be replaced every 5 to 6 weeks until full retraction of canine achieved.5 Elastomeric Chains are a convenient choice for sliding mechanics and commercially available in configurations of closed, short and long filament chains. E chains are easy to apply, relatively inexpensive, and no patient cooperation needed for insertion but rapid force degradation, relaxation, staining, and deformation are the major drawbacks.29 E chains has to be replaced in every 4 weeks or less.30 Closed coil springs produce more predictable and constant force than elastics. SS coils have high load deflection rate as compared to Ni-Ti coil springs. Ni-Ti close coil springs are efficient on constant production of force and useful to produce more consistent space closure than elastics. Coil springs are available in different sizes (eg. 6, 9, and 12mm) and their extension depends upon manufacturer’s recommendation.5 Just like elastics, these springs are also quick and easy to apply without patient co-operation. Major issues with sliding mechanics are the occurrence of friction and binding due to improper angulation of canine bracket to wire that leads to the production of unwanted forces.31 Rare earth magnets (e.g.- Parylene coated neodymium-iron boron=Nd2Fe14P) are less popular method for retraction of canine.32

An invasive procedure known as Dental Distraction was first performed by Liou, and Huang 13 for the purpose of rapid canine retraction. A different technique called Dento-Alveolar Distraction (DAD) for acceleration of canine distalization by performing osteotomies around the canines and achieved rapid tooth movement.14 This surgical technique did not rely on the stretching and widening of PDL thus prevents overloading and stress accumulation in the periodontal tissues. As DO is an extensive surgical procedure, further efforts have been made to refine the procedure which is less invasive to the patient. A new micro-invasive technique called micro-osteo-perforation has been introduced which literally translates to puncturing bone and stimulates cytokines activity which has been well scientifically proven. When an orthodontist creates micro-osteo-perforations in the alveolar bone, cytokines cascade is activated, resulting in a marked increase in osteoclast activity and bone remodeling. MOP can be completed inminutes and does not require advanced training. It causes less discomfort to the patients when compared to other surgical methods of accelerating tooth movement.15, 33 Periodontally Accelerated Osteogenic Orthodontics (PAOO) is a method to stimulate RAP (Regional Acceleratory Phenomenon) via conventional corticotomy and use of bone graft material.11 An alternative limited invasive procedure is known as Piezocision technique described in 2009 by Dibart et al.12 It combines cuts in the bone through the gingiva with a piezoelectric knife to create of submucosal tunnels for bone substitute material. According to the author, it is necessary to go through the entire cortical layer and reach the cancellous bone to stimulate RAP.12

Figure 1

Canine retraction via different methods: Case 1- NiTi coil spring; Case 2- SS coil spring; Case 3- canine retraction via PG spring; Case 4- canine retraction via T loop; Case 5- canine retraction via NiTi coil spring attached to sliding hook and anchorage enhancement from TADs; Case 6- canine retraction via E chain utilizing absolute anchorage from TADs; Case 7- canine retraction via active tie back; Case 8- canine retraction via E chain; Case 9- canine retraction via DAD procedure; Case 10- canine retraction via NiTi coil facilitated with MOPs

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/a483ba4c-9e12-4bcb-8a72-f00a79b1ec4aimage1.jpeg
Figure 2

Measurement of distopalatal rotation of canine from pre and post retraction cast

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/a483ba4c-9e12-4bcb-8a72-f00a79b1ec4aimage2.png
Figure 3

Pre and post retraction lateral cephalogram, and OPG radiographs (also used for measurement of distal tipping of retracted canines)

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/a483ba4c-9e12-4bcb-8a72-f00a79b1ec4aimage3.png
Figure 4

Amount of molar anchorage loss measured from superimposition of pre and post retraction lateral cephalogram tracings

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/a483ba4c-9e12-4bcb-8a72-f00a79b1ec4aimage4.png
Table 1

Report of 10 cases of canine retraction via various methods

Case report

Age/ Sex

Retraction Method

Full closure (days)

Anchorage loss (mm)

Case 1

15/F

Niti coil

128

1.7

Case 2

17/M

SS coil

137

2

Case 3

19/F

PG spring

112

1.3

Case 4

16/F

T loop

118

1.4

Case 5

16/M

STN*

102

0

Case 6

15/F

TADE*

100

0

Case 7

16/F

ATB*

148

2.3

Case 8

18/M

E chain

142

2.1

Case 9

16/F

DAD*

12

1

Case 10

18/F

MOPs*

84

1.1

[i] STN- Sliding Hook+TAD+NITICOIL; TADE- TAD+E Chain; ATB- Active Tie Back; DAD- Dentoalveolar Distraction; MOPs-Micro Osteo Perforations

Table 2

Result after comparison of various methods with respect to different factors

Factors

Results

Rate of canine retraction

DAD>MOPs>STN>TADE>PG spring>Tloop>Niticoil>S Scoil>Echain>ATB

Anchorage loss

ATB>Echain>SScoil>niticoil> Tloop>PGspring>MOPs>DAD> TADE=STN

Commercially available AcceleDent device (OrthoAccel Technologies, USA) may generate a vibration of 0.25 N and a frequency of 30 Hz. In a study with AcceleDent device, it was shown that rapid retraction of canines with skeletal anchorage increased by 48.1% compared to the control group (1.16 mm vs 0.79 mm/month).34 Using electric toothbrush massage as a source of stimuli for 15 min a day at a frequency of 125 Hz leads to the acceleration of distal movement of canine (37.7% greater than in the control group).35 Photo-biomodulation technique involves the exposure of tissues to the effects of a therapeutic wavelength (600–1200 nm).36 Therapy with light can be divided into 2 basic types: low-intensity lasers (LIL), producing coherent light, and light-emitting diodes (LED), which are sources of incoherent light.37

Case Series

This case series is the presentation of 10 cases (age ranges from 15y to 19y) of canine retraction in premolar extraction space performed by 10 different methods of retractions to the patients enrolled in the Department of Orthodontics-Faculty of Dental Sciences at Banaras Hindu University. Although all the 4 canines retracted simultaneously after premolar extraction but only right maxillary canine is chosen for the comparison purpose. Mean right maxillary premolar extraction space was 6.4 mm. Each subject had 0.022x0.028 inch Victory (3M-Unitek) orthodontic brackets bonded. Active canine retraction did not commence until a 0.019x0.025-inch stainless steel archwire was engaged. Canine retractions consider being completed when canine contacted with the 2nd premolar (timing for root uprighting movement not calculated). Follow-ups were done after 3 weeks for each case except DAD, which is followed every day. Rate of canine retraction, and molar anchorage loss was noted in relation to right maxillary cuspid. Rotation of canine measures from the pre and post retraction dental casts as the angle formed between a line through the distal and mesial contact points of the canine, and the midpalatal raphe. Angulations (distal tip) are measured in orthopantomogram as the intersection of the midline and a line extending from the apex to crown tip of canine and compare it with the initial value. Loss of anchorage was determined from the superimposition of initial and post retraction lateral cephalogram tracings.

Discussion

Presented case series provide the valuable data regarding the rate of canine retraction, distopalatal canine rotation with respect to mid-palatine raphe, distal tipping of canine (angulation) with respect to the midline, and loss of molar anchorage when various canine retraction method employed. The mean force applied was 150±30 gms that is in the range with the study of Quinn, and Yoshikawa:38 Rate of canine retraction or any other tooth/teeth depends upon several factors. For example, alveolar bone density, hyalinization adjacent to the root area subjected to excess mechanical forces, or optimal force application produce frontal resorptions, as well as the magnitude of force applied.39, 40 Different methodology of force application are there in the literature to maximize the speed of orthodontic treatment via biologically sound response. When we used constant force (9mm) NiTi coil spring with conventional anchorage (Nance button) for cuspid retraction, the canine contacted the second premolar in 128 days and produces 1.7 mm of molar anchorage loss, 4 degree distoplalatal rotation and distal tipping of canine that is consistent with other studies reported.7, 41 When NiTi coil spring was used with sliding hook and absolute anchorage (TADs), canine retraction completed in 102 days with no anchorage loss and less angulation and rotational changes of canine. Same result was observed when TAD is used with E chain except for larger rotational and angular changes. Results with TADs are consistent with the study reported by Thiruvenktachari B et al. 7 The T-loop with a symmetric shape could be used to achieve a moment differential. Position of T loop was determined according to recommendation of Kuhlberg and Burnstone. 42 PG retraction spring was better in providing rotational control than T loop but no significant difference was there in terms of rate of canine retraction, angular changes and anchorage loss. Canine retraction was completed in 12 days via DAD procedure leaving a 4.5 degree distal tipping, 3 degree rotation and around 1 mm molar anchorage loss that is consistent with the study reported by Kurt et al and other. 43, 14 Canine retraction was increased when facilitated with MOPs but not as much as reported by Alikhani et al. and Sivarajan et al. 15, 44 Contradictory to above no significant increase in rate of canine retraction was observed by Amira et al and Alkebsi et al. 33, 45 Rate of canine retraction with the help of E chain and Active tie back was slower than the other method utilized and costs higher molar anchorage along with more rotational and angular changes were observed. Anchorage loss has occurred during canine retraction via all the methods employed except those facilitated with TADs. Geron et al 46 suggested that the majority of molar anchorage loss does not occur during canine retraction (33%), rather during incisor retraction when the Nance appliance is removed (67%) with a mean of 3.9±2.3 mm by the end of orthodontic treatment in patients treated with extraction of upper first premolars.

Conclusion

Fastest canine retraction was achieved by maximal invasive DAD procedure. MOPs ranks first in terms of rate of canine retraction in which minimal invasion is involved. Canine retractions, in which anchorage was taken from TADs rank best in terms of anchorage control. Minimal canine rotation was occurred in canine retraction with the help of PG spring. Minimal tipping was observed when canine retraction facilitates with MOPs. E chain and active tie back ranks worst in terms of all the said factors involved. The biggest limitation of the above presentation is that only one case was there under a particular method of canine retraction and so that results came after direct comparison should be taken carefully for any consideration.

Clinical Significance

Canine retractions facilitated with Micro-osteo perforation and temporary anchorage devices gave best result in terms of time taken for retraction and preservation of molar anchorage so use of these techniques would be beneficial during fixed orthodontic treatment. Use of active tie back and elastomeric chain should be better avoided during orthodontic treatment.

References

1 

AE Erdinc RS Nanda E Isiksal Relapse of anterior crowding in patients treated with extraction and nonextraction of premolarsAm J Orthod Dentofacial Orthop2006129677584

2 

G Janson MCA Busato JFC Henriques MR DeFreitas LMA DeFreitas Alignment stability in class II malocclusion treated with 2- and 4-premolar extraction protocolsAm J Orthod Dentofacial Orthop2006130218995

3 

K Hayashi J Uechi M Marata I Mizoguchi Comparison of maxillary canine retraction with sliding mechanics and a retraction spring: a three dimensional analysis based on a midpalatal orthodontic implantEur J Orthod20042665859

4 

Mc Lauglin Benett Trevisi Systemized Orthodontic Treatment MechanicsMosby Elsevier200124977

5 

RHA Samuels SJ Rodge LH Mair A comparison of the rate of space closure using a nickel-titanium spring and an elastic module: A clinical studyAm J Orthod Dentofacial Orthop199310354647

6 

CJ Burstone HA Koenig Optimizing anterior and canine retractionAm J Orthod1976701119

7 

B Thiruvenktachari A Pavithranand K Rajasigamani HM Kyung Comparison and measurement of the amount of anchorage loss of the molars with and without the use of implant anchorage during canine retractionAm J Orthod Dentofacial Orthop200612945514

8 

FR Beckwith RJ Ackerman CM Cobb DE Tira An evaluation of factors affecting the duration of orthodontic treatmentAm J Orthod Dentofacial Orthop1999115443947

9 

H Köle Surgical operations of the alveolar ridge to correct occlusal abnormalitiesOral Surg Oral Med Oral Pathol195912551529

10 

P Mehra F Brugnami A Caiazzo Orthodontically Driven Corticotomy: Tissue Engineering to Enhance Orthodontic and Multidisciplinary TreatmentJohn Wiley & SonsHoboken, NJ2014

11 

WM Wilcko T Wilcko JE Bouquot DJ Ferguson Rapid orthodontics with alveolar reshaping: Two case reports of decrowdingInt J Periodontics Restorative Dent2001211919

12 

S Dibart E I Keser F Brugnami A Caiazzo Orthodontically Driven Corticotomy: Tissue Engineering to Enhance Orthodontic and Multidisciplinary TreatmentJohn Wiley & SonsHoboken, NJ2014

13 

EJW Liou S Huang Rapid canine retraction through the distraction of the periodontal ligamentAm J Orthod Dentofac Orthop199811437281

14 

RS Kişnişci H Işeri HH Tüz AT Altug Dentoalveolar Distraction Osteogenesis for Rapid Orthodontic Canine RetractionJ Oral Maxillofac Surg200260438994

15 

M Alikhani M Raptis B Zoldan C Sangsuwon YB Lee B Alyami Effect of micro-osteoperforations on the rate of tooth movementAm J Orthod Dentofacial Orthop2013144563948

16 

S Fujita M Yamaguchi T Utsunomiya H Yamamoto K Kasai Lowenergy laser stimulates tooth movement velocity via expression of RANK and RANKLOrthod Craniofac Res200811314355

17 

M Nishimura M Chiba T Ohashi M Sato Y Shimizu K Igarashi Periodontal tissue activation by vibration: Intermittent stimulation by resonance vibration accelerates experimental tooth movement in ratsAm J Orthod Dentofacial Orthop2008133457283

18 

MA Darendeliler A Zea G Shen H Zoellner Effects of pulsed electromagnetic field vibration on tooth movement induced by magnetic and mechanical forces: A preliminary studyAust Dent J20075242827

19 

S Alansari C Sangsuwon T Vongthongleur R Kwal Mc Teo YB Teo Biological principles behind accelerated tooth movementSemin Orthod201521315161

20 

T Kouskoura C Katsaros SV Gunten The Potential Use of Pharmacological Agents to Modulate Orthodontic Tooth Movement (OTM)Front Physiol201786710.3389/fphys.2017.00067

21 

RD Robinson A system of positive and painless tooth movementInt J Orthodontia1915110497509

22 

MM Stoner JT Lindquist The edgewise appliance today. Current orthodontic concepts and techniquesWB Saunders CompanyPhiladelphia1969

23 

P Gjessing Biomechanical Design and Clinical Evaluation of a New Canine Retraction SpringAm J Orthod Dentofac Orthop19858735362

24 

RE Siatkowski Continuous arch wire closing loop design, optimization, and verificationAm J Orthod Dentofacial Orthop19971124393402

25 

R Nanda Esthetic and Biomechanical Strategies for Clinical OrthodonticsWB Saunders2005194210

26 

WR Proffit HW Fields DM Sarver Contemporary orthodonticsElsevier Health Sciences2006

27 

TR Katona YP Le J Chen The effects of first-and second-order gable bends on forces and moments generated by triangular loopsAm J Orthod Dentofacial Orthop20061291549

28 

DW Raboud MG Faulkner AW Lipsett DL Haberstock Three-dimensional effects in retraction appliance designAm J Orthod Dentofacial Orthop199711237892

29 

AL Sonis EVD Plas A Gianelly A comparison of elastomeric auxiliaries versus elastic thread on premolar extraction site closure: An in vivo studyAm J Orthod1986891738

30 

C Nattrass AJ Ireland The Effect of Environmental Factors on Elastomeric Chain and Nickel Titanium Coil SpringsEur J Orthod19982016976

31 

V Dixon MJ Read KD O'Brien HV Worthington NA Mandall A randomized clinical trial to compare three methods of orthodontic space closureJ Orthod200229131610.1093/ortho/29.1.31

32 

J Daskalogiannakis KR McLachlan Canine Retraction with Rare Earth Magnets: An Investigation into the Validity of the Constant Force HypothesisAm J Orthod Dentofacial Orthop1996109548995

33 

AA Aboalnaga MMS Fayed NA El-Ashmawi SA Soliman Effect of micro-osteoperforation on the rate of canine retraction: a split-mouth randomized controlled trialProg Orthod20192012110.1186/s40510-019-0274-0

34 

P Dubravko A Ravikumar R Vishnu PT Gakunga Cyclic loading (vibration) accelerates tooth movement in orthodontic patients: A doubleblind, randomized controlled trialSemin Orthod201521318794

35 

C Leethanakul S Suamphan S Jitpukdeebodintra U Thongudomporn C Charoemratrote Vibratory stimulation increases interleukin-1 beta secretion during orthodontic tooth movementAngle Orthod20168617480

36 

AZ Nahas SA Samara TA Rastegar-Lari Decrowding of lower anterior segment with and without photobiomodulation: A single center, randomized clinical trialLasers Med Sci201732112935

37 

YA Vladimirov AN Osipov GI Klebanov Photobiological principles of therapeutic applications of laser radiationBiochemistry (Mosc)20046918190

38 

RS Quinn DK Yoshikawa A reassessment of force magnitude in orthodonticsAm J Orthod198583325260

39 

K Reitan Clinical and histological observation on tooth movement during and after orthodontic treatmentAm J Orthod1967531072145

40 

T Graber R Vanarsdall Orthodontics, Current Principles and TechniquesMo: MosbySt Louis19942156

41 

Duration and Anchorage Management of Canine Retraction with Bodily Versus Tipping MechanicsAngle Orthod200878195100

42 

B Kuhlberg T-loop position and anchorage controlAm J Orthod Dentofacial Orthop19971121128

43 

G Kurt H Is¸eri R Kişnişçi Ö Özkaynak Rate of tooth movement and dentoskeletal effects of rapid canine retraction by dentoalveolar distraction osteogenesis: A prospective studyAm J Orthod Dentofacial Orthop201715222043

44 

S Sivarajan JG Doss SN Papageorgiou MT Cobourne MC Wey Miniimplant supported canine retraction with micro-osteoperforation: A split-mouth exploratory randomized clinical trialAngle Orthod20198921839

45 

A Alkebsi E Al-Maaitah H Al-Shorman EA Alhaija Three-dimensional assessment of the effect of micro-osteoperforations on the rate of tooth movement during canine retraction in adults with Class II malocclusion: A randomized controlled clinical trialAm J Orthod Dentofac Orthop2018153677185

46 

S Geron N Shpack S Kandos M Davidovitch AD Vardimon Anchorage loss-a multifactorial responseAngle Orthod20037367307



jats-html.xsl

© This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


  • Article highlights
  • Article tables
  • Article images

Article History

Received : 21-06-2021

Accepted : 15-12-2021

Available online : 28-12-2021


View Article

PDF File   Full Text Article


Copyright permission

Get article permission for commercial use

Downlaod

PDF File   XML File   ePub File


Digital Object Identifier (DOI)

Article DOI

https://doi.org/10.18231/j.ijohd.2021.062


Article Metrics






Article Access statistics

Viewed: 97

PDF Downloaded: 36



Open Abstract (Increase article citation) Wiki in hindi