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Canine retraction: A comparison of two preadjusted

bracket systems
Lawrence P. Lotzof, DDS," Howard A. Fine, DMD, MMSc, b and
George J. Cisneros, DMD, MMSc
Bronx, N. Y.

Before the 1970s, Begg and Edgewise appliances were the most commonly used appliances in
orthodontics. With the introduction of preadjusted appliances, many have made claims of
superiority. These claims are often unsubstantiated, as few, if any, have ever been tested in a
controlled, prospective in vivo study. The purpose of this study was to compare the time required to
retract canine teeth by using two different preadjusted bracket systems (Tip-Edge, TP Orthodontics,
LaPorte, Ind., versus A-Company straight wire, Johnson and Johnson, San Diego, Calif.) in a human
sample. Anchorage loss as a result of this movement was also evaluated. A sample of 12 patients
was randomly selected from the new patient pool at the postgraduate orthodontic clinic of
Montefiore Medical Center. All patients required the removal of first premolars in one or both arches
as a part of their orthodontic treatment. The rate of retraction and anchorage loss were evaluated.
Paired t tests were performed separately for the rates of retraction and anchorage loss. The mean
rates of retraction were 1.88 mm per 3-week period and 1.63 mm per 3-week period for the
Tip-Edge and A-Company brackets, respectively. There was no statistically significant difference in
the rates (/9 > 0.05). The mean anchorage loss was 1.71 mm for the Tip-Edge bracket, and 2.33
mm for the straight wire bracket. The difference in the amount of anchorage loss was inconclusive
as the sample size was too small (power was 10%). (Am J Orthod Dentofac Orthop
1996;110:191-6.)

Orthodontic
clinicians t h r o u g h o u t t h e
y e a r s have t o u t e d t h e a d v a n t a g e s o f v a r i o u s a p p l i a n c e systems. 1-9 C e n t r a l to m a n y o f t h e i r a r g u m e n t s
is t h e efficiency o f t o o t h m o v e m e n t intrinsic to t h e
b r a c k e t design. M o r e o v e r , in r e c e n t years, scientific
s t u d i e s have f u r t h e r m i t i g a t e d t h e s i t u a t i o n by
d o c u m e n t i n g t h a t b r a c k e t d e s i g n is o n e o f several
v a r i a b l e s c a p a b l e o f effecting t o o t h m o v e m e n t . 1-13
With the introduction of preadjusted appliances,
few, if any, have ever b e e n t e s t e d in a c o n t r o l l e d
study.
T h e p u r p o s e o f this study was to c o m p a r e t h e
r a t e o f r e t r a c t i o n a n d a n c h o r a g e loss with two
d i f f e r e n t p r e a d j u s t e d b r a c k e t systems ( T i p - E d g e ,
T P O r t h o d o n t i c s , L a P o r t e , Ind., v e r s u s A - C o m p a n y
s t r a i g h t wire, J o h n s o n a n d J o h n s o n , San Diego,
Calif.) in a h u m a n s a m p l e .
From the Montefiore Medical Center-Albert Einstein College of
Medicine.
aln private practice,San Diego, Calif..
bAssistantDirector,Department of Dentistry,Divisionof Orthodontics.
CDirector,Divisionof Orthodontics;AssociateProfessor,Pediatric Dentistry and Orthodontics.
Reprint requests to: Dr. GeorgeJ. Cisneros,Director,Divisionof Orthodontics, Montefiore Medical Center-Albert Einstein College of Medicine, 111 E. 210st St., Bronx, NY 10467-2490.
Copyright 1996 by the AmericanAssociationof Orthodontists.
0889-5406/96/$5.00 + 0 8/1/62496

MATERIALS AND METHODS


A sample of 12 patients were randomly selected from
the new patient pool at the postgraduate orthodontic
clinic of Montefiore Medical Center. There were five
boys and seven girls, ranging in age from 12 to 15 years
old, with a mean of 14 years for the boys and a mean of
13 years for the girls. From the patients selected, six had
Class I malocclusions and six had Class II, Division 1
malocclusions.
The inclusion criteria for the study were as follows:
1. A minimum dental age of 12 years.
2. All teeth mesial to the second molars were to be
fully erupted before commencement of the study.
3. Canine retraction of at least 3 mm would be
required.
4. Total treatment time for canine retraction estimated to be less than 6 months.
The exclusion criteria were as follows:
1. Patients with oral manifestations of disease (e.g.,
cysts ) or a chronic debilitating disease.
2. Loss of periodontal support greater than 10%
before treatment.
3. Treatment would be terminated on signs and
symptoms of excessive pain, root resorption or
devitalization of maxillary or mandibular canines.

191

192

Loztof Fine, and Cisneros


4. Noncooperative patients, e.g., poor oral hygiene
and missing an excessive number of appointments.

All patients and their parent(s) were advised of the


purpose of this study, and the patient and one parent or
guardian signed a consent form. No patient who was
approached for enrollment refused to participate. All
patients who were offered the chance to participate
accepted the offer.

Determining rate of retraction


The rate of retraction was defined as the distance
travelled, divided by the time required to complete space
closure. This was recorded in millimeters per interval.
An interval was defined as a 3-week period. All patients
required the removal of first premolars in one or both
arches as a part of their orthodontic treatment. Each
subject received two different brackets placed on opposite canine teeth within the same arch. The canine
brackets used in the study were the preadjusted TipEdge bracket and the preadjusted A-Company straight
wire twin bracket, Roth prescription. The Tip-Edge canine bracket placement (left versus right side) was randomly assigned according to a randomization schedule
provided by the Department of Biostatistics. It should be
noted that the teeth assigned to the Tip-Edge appliance
were only tipped and not uprighted during this study.
The remaining teeth were bracketed with A-Company
preadjusted straight wire twin brackets (Roth prescription). The canines were retracted with elastic chain
(A-Company, Force-A) extending from the first molars to
the canine brackets. Class I mechanics were used with a
force level of 200 gm. The force was applied by the same
operator, to be as close to the selected value and rechecked minimizing operator error. The force was measured at each appointment with a Dial-Type Dynameter
stress and tension gauge (Dentarum, New Town, Pa.).
Patients were seen at 3-week intervals until retraction
was completed. A continuous, passively fitted 0.018-inch
stainless steel arch wire was used for canine retraction.
Severely crowded arches were initially aligned and leveled as required with 0.016-inch nickel titanium before
the placement of the 0.018-inch stainless steel wire.
Measurements of retraction and anchorage loss were not
made until after this leveling procedure was completed in
these patients. The canines were ligated to the arch wire
during retraction with elastomeric chain. The widths of
the extraction spaces were measured, and space closure
and time of retraction were recorded.
It was not known exactly when canine retraction was
completed within an interval. Thus the midpoint of the
last interval was declared as the endpoint of retraction.
Therefore the last interval was recorded as a half interval
for each canine and noted as the endpoint. Measurements were performed by direct-technique from stone
casts obtained before and at the completion of retraction

American Journal of Orthodontics and Dentofacial Orthopedics


August 1996

for each canine. Measurements for both the rate of


retraction were recorded twice on two separate days with
a digital vernier caliper. The measurements to 0.05 mm
were recorded by the same operator. The landmarks
used in measuring the teeth were consistent for both the
rate and the anchorage loss (Fig. 1).

Determining anchorage loss


Anchorage loss was recorded as the amount of movement in millimeters that occurred in the direction opposite to the direction of the applied resistance. Direct cast
measurements were used rather than radiographs. This
method was considered to be easier and accurate, and
did not subject patients to excessive radiation exposure.
In this study, anchorage loss was determined in the
maxillary arch only. This arch was selected because the
anterior palatal vault could be used as a stable reference
point, 14 whereas the mandibular arch precluded the use
of a stable reference point with stone models.
A total of 10 maxillary arches were used for the
determination of the anchorage loss. To measure the
movement of each canine and molar, an acrylic palatal
plug was made for each maxillary arch (Fig. 1). This plug
could thus be transferred from initial cast to the final cast
on the same patient. The plug was fabricated from acrylic
with reference wires (0.021 x 0.025-inch stainless steel)
embedded in the acrylic that extended to the cusp tips of
the canines and to the central fossa of the first molars.
The initial model was used to make the plug, which was
then fitted to the final model on completion of retraction
of both canines. This superimposition allowed for the
direct observation of the amount of molar protraction
(anchorage loss) and canine retraction. Measurement
criteria were the same as for the rate of retraction.

Statistics
A sample size of 12 patients assured an 80% statistical power to detect a difference of 0.25 mm per 3-week
period for the rate of retraction. Each subject acted as
their own control. Retraction in either the maxilla or the
mandible counted as one source of data.
Paired t tests were performed independently for the
difference of the rates of retraction and anchorage loss.
Significance was determined at the 0.05 level. A power
analysis was performed accessing the sample size.

RESULTS
T a b l e I s u m m a r i z e s t h e t i m e r e q u i r e d for retraction. T h e m a x i m u m t i m e interval for b o t h
b r a c k e t systems was 7.5 intervals a n d t h e m i n i m u m
was 1.5 intervals. T h e m e a n for t h e T i p - E d g e
b r a c k e t was 3.58 intervals, a n d for t h e straight wire
A - C o m p a n y b r a c k e t 3.92 intervals.
Table II summarizes the distance of retraction

American Journal of Orthodontics and Dentofacial Orthopedics


Volume 110, No. 2

L o z t o f Fine, a n d Cisneros

193

REFERENCEPOINTS

Fig. 1. Anchorage loss determination: (A) Initial model with palatal plug and reference wires
extending to cusp tips of canines and to central fossa of molars, (B) Final model with palatal plug
denoting amount of canine retraction and anchorage loss. (C) Enlargement illustrating anchorage
loss as distance between central fossa and reference wire.
Table II. Distance of retraction

Table I. Time required for retraction


Variable

Maximum

Median

Minimum

Mean

Variable

Maximurn

Median

Minimum

Mean

TE time (intervals*)
SW time (intervals*)

12
12

7.5
7.5

3.5
3.5

1.5
1,5

3.58
3.92

TE distance (ram)
SW distance (ram)

12
12

8.26
7.92

5.90
5.37

3.30
3.22

5.69
5.58

"1 interval - 3 weeks.

TE, Tip-Edge; SW, straight wire,

for both bracket systems. The maximum distance


travelled by the Tip-Edge bracket was 8.26 mm and
for the straight wire A-Company bracket 7.92 ram.
The minimum distance travelled was 3.30 mm and
3.22 mm, respectively, whereas the mean distance
was 5.69 mm and 5.58 mm, respectively.
Table Ill and Fig. 2 summarize the rate of
retraction. The maximum rate for the Tip-Edge
bracket was 4.18 ram/interval and for the straight

wire bracket 3.76 mm/interval. The minimum rate


was 0.94 ram/interval for the Tip-Edge bracket, and
0.92 ram/interval for the straight wire bracket, The
mean was 1.88 mm/interval and 1.63 ram/interval,
respectively. The average difference in the rates of
retraction was 0.25 ram/interval, There was no
statistically significant difference in the rates between Tip-Edge and straight wire (p > 0.05).
Table IV and Fig. 3 summarize the anchorage
loss. The Tip-Edge bracket maximum loss was 3.24

194

Loztof Fine, and Cisneros

American Journal of Orthodontics and Dentofacial Orthopedics

August 1996
4.5

4-

A4.5N
4C
H 3.5O
R 3-

3.5RATE
OF
RETRACTION

32.52-

(mm./interval)

A 2.5G
E 2-

1.510.5-

L
O

Tip Edge

Straightwire

1.5:
1-

S 0.5S
0c
(rnm.)

APPLIANCE TYPE

Tip Edge

Strak htwire

APPLIANCE TYPE

LEGEND
LEGEND

==MEAN
A=MINIMUM
T=MAXIMUM

Fig. 2. Rate of retraction by appliance type. Rate of retraction was faster for Tip-Edge appliance but not statistically significant.

Table III. Rate of retraction

Variable

Maximum Median I Minimum

12
12
12

4.18
3.76
1.27

1.46
1.50
0.19

0.94
0.92
-0.39

Fig. 3. Anchorage loss by appliance type. There was more


anchorage loss on straight wire side but not statistically
significant.

Mean

TE rate (mm/interval)
SW rate (mm/interval)
Rate difference (TE
rate - SW rate)

IN=MEAN
&=MINIMUM
T=MAXlMUM

1.88
1.63
0.25

A
n

h
0

Table IV. Anchorage loss

Variable

Maximum

I
I

a
Median

Minimum

Mean

T E anchorage
loss (mm)
SW anchorage
loss (mm)
Difference in

10

3.24

1.82

0.29

1.71

10

3.96

2.67

0.00

2.33

10

1.28

- 0.16

- 1.06

0.04

anchor age
loss (ram)

3.02.5-

1.5-

1.0-

0
S

I
m

2.0-

g
e

mm with a minimum of 0.29 mm and a mean of


1.71 mm. The A-Company straight wire bracket
had a maximum anchorage loss of 3.96 mm, a
minimum loss of 0 mm, and a mean loss of 2.33
mm. The mean difference was 0.04 mm. The difference in the amount of anchorage loss was also
not statistically significant (_/9 > 0.05).
Figs. 4 and 5 graphically depict the correlation
of anchorage loss and rate of retraction for the
Tip-Edge and A-Company straight wire brackets,
respectively. There was no statistically significant
correlation between anchorage loss and the rate of
retraction for either bracket system.

3.5

0.50.0
0.5

1.0

1.5

2.0

2.5

3.0

Rate

of

3.5

Retraction

Fig. 4. Anchorage loss versus rate of retraction for Tip-Edge


appliances. Anchorage Loss measured in millimeters; Rate of
Retraction measured in millimeters per interval.

DISCUSSION

Notable weaknesses of former studies in this


area have included the use of multiple operators
(variability) and sample size (lacking statistical sig-

American Journal of Orthodontics and Dentofacial Orthopedics


Volume 110, No. 2

nificance). By realizing the difficulties of clinical


research, we controlled several parameters in our
study. Ours was a prospective study performed by a
single operator. The brackets were randomly assigned eliminating any operator bias, and each
patient received both brackets. Although the
sample size was 12 patients, this was determined to
be adequate to detect a difference of 0.25 mm per
3-week period in this study (80% probability of
detecting a difference between the brackets for the
rate of retraction).
The results indicated that there was variability
among the subjects. This was noted with the time
intervals, the rate of retraction, and the anchorage
loss. The importance of biologic response and the
individual variation in tissue reaction was reported
by Reitan. 1~ Hixon et al. 16'17 agreed with Reitan 1~ in
that the individual variation in metabolic response
was so great, it overwhelmed any differences
caused by the force magnitude. They concluded
that there was a large variation between patients,
which precludes the formulation of simple theories
regarding force and anchorage. 17 Their results indicated that the variable metabolic response and
not the magnitude of the force accounted for the
major source of variation. It is generally considered
valid that higher forces produce more rapid movement than lighter forces, probably only within the
individual patient. 17
The force selected for retraction in our study
was 200 gm. The force magnitude selected was
mentioned by some authors as being light. 18'19
Quinn and Yoshikawa 2 estimated that a force
between 100 and 200 gm would be efficient for
canine retraction. Hixon et al. 16 stated that when
total forces of 300 gm or less are applied, the
average rate of tooth movement increased as the
load per unit area of the periodontal ligament
(PDL) increased, no matter whether a tooth was
being tipped or bodily moved. Reitan 15 stated that
the initial force application should be light, because
this produces desirable biologic effects. These
lighter forces will produce less extensive hyalinized
tissue that can be readily replaced by cellular
elements. He stated that an appropriate force of
150 to 250 gm for maxillary canines, and 100 and
200 gm for mandibular canines should be used for
translatory movement.
The force level recommended for tipping movements would be in the range of 50 to 70 gm. 2~ Some
may believe it was inappropriate to use a similar
force system for both bracket designs. This is understandable since Begg and Tip-Edge mechanics

Loztof,, Fine, and Cisneros

4.0

3.5-

c
h

3.0-

o
r
a

2.5-

1.5-

1.0-

195

2.0I

0.5-

L
o
s
e

0.0-0.5

I
1.0

'

Rate

I
1.5

of

'

2.0

'

2.5

Retraction

Fig, 5, Anchorage loss versus rate of retraction for the straight


wire appliance. Anchorage Loss measured in millimeters; Rate
of Retraction measured in millimeters per interval.

use these lower force levels. One should note that


the initial force applied in our study decayed to a
lighter force over the 3-week period. Force degradation of the elastomeric chains was not evaluated
in this study. In the Begg technique, even though
the force levels are less, they are constant as
elastics are applied several times daily. One could
speculate that over a period of 3 weeks the force
systems are equivalent. The force level used was
deemed to be a compromise between both systems.
Niti coils used in future studies may well provide
more predictable force control.
Depending on the type of tooth movement,
different biologic responses may be seen. The TipEdge bracket initially allows pure tipping that can
result in cell-free areas at the crest and apex of the
tooth being moved. These hyalinized areas can slow
tooth movement, and cause an unequal stress distribution. 15'18'2 Conversely, Reitan 15 reported that
during translatory movement, force distribution is
evenly displaced and therefore it is less likely that
hyalinized areas would form. The axial inclination
of the canines was not evaluated in this study,
which should be a consideration for future studies.
It would be better to extend treatment time to
finish uprighting. A common side effect occurring
with both brackets was the rotation of the canine
during retraction.
Anchorage loss was a secondary question inves-

196

Loztof,, Fine, and Cisneros

tigated in this study. The anchorage loss results


were inconclusive, and there was no statistically
significant difference at (p > 0.05) level. A power
analysis was conducted to determine the power of
the t test. Given the sample size used, there was
only a 10% chance of detecting a difference between brackets. Therefore one cannot detect a
difference with the sample size used. To resolve the
issue of anchorage loss without data to support
these findings was difficult. Another experiment
would have to be conducted to measure anchorage
loss with an adequate sample size. However, looking at the raw numbers, there appears to be a
clinical difference. The A - C o m p a n y bracket had a
mean loss of 2.33 mm, whereas the Tip-Edge
bracket had a mean loss of 1.71 mm.
A correlation was performed for the average
anchorage loss and rate of retraction for both
bracket systems (Figs. 4 and 5). O n e can observe no
correlation for either bracket. Outliers were eliminated from the equations and another correlation
was conducted. The results were the same for the
Tip-Edge bracket, but values increased in the
straight wire group. These figures are not included,
but suggest a possible source for further investigation.
CONCLUSION

The development of preadjusted appliances has dramatically changed the way orthodontics is taught and
practiced today. The appointments are shorter and the
amount of wire bending has decreased dramatically. One
must not fail to realize that we are dealing with a biologic
system, and that each person responds in a variable
fashion, regardless of the type of appliance used. Teeth
do not have the ability to recognize the type of appliance
being used. Manufacturers constantly imply that there

American Journal of Orthodontics and Dentofacial Orthopedics


August 1996

are differences in appliances and claim appliance superiority with no valid research. Preadjusted appliances and
super elastic wires may have revolutionized orthodontics
as we know it today, but we do not seem to alter the
biologic response with these new appliances. In essence,
the body and how it responds to orthodontic manipulation still governs overall treatment time.

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