CLINICIAN’S CORNER

Analysis of temporary skeletal anchorage

devices used for en-masse retraction:
A preliminary study
Seong-Hun Kim,a Young-Suk Hwang,b Andre Ferreira,c and Kyu-Rhim Chungd
Uijongbu and Seoul, Korea, and Birmingham, Ala

Introduction: The aim of this preliminary study was to analyze the results of en-masse incisor and canine re-
traction with temporary skeletal anchorage devices (TSADs) as the exclusive source of anchorage. Methods:
A retrospective clinical investigation supported by preliminary case reports was performed comparing pre-
treatment cephalometric radiographs with those taken after en-masse retraction of the 6 anterior teeth.
The sample consisted of 17 nongrowing patients with an average age of 24.4 6 3.71 years. The average re-
traction period was 13.94 6 5.37 months. No brackets or bands were placed on the posterior dentition during
retraction. A total of 34 TSADs were used as the only source of anchorage. Thirty sand-blasted, large-grit,
and acid-etched C-implants and 4 miniplates with tubes were used. These TSADs were designed to with-
stand heavy and dynamic retraction forces applied to the maxillary anterior dentition, thereby eliminating
the need for bonded or banded anchor teeth. The cephalometric radiographs were analyzed for differences
between pretreatment and postretraction variables that included skeletal, dental, and soft-tissue relation-
ships. Results: Significant incisor and canine retraction was achieved in all patients. During the retraction pe-
riod, the posterior teeth showed a tendency for extrusion and mesial tipping. Conclusions: En-masse
retraction of the 6 anterior teeth can be accomplished by using TSADs as the only source of anchorage. Max-
imum anchorage was achieved without appliances in the posterior dentition. (Am J Orthod Dentofacial Orthop
2009;136:268-76)

V
arious treatment techniques and biomechanical
approaches have been suggested over the past
decades to achieve en-masse retraction of ante-
rior teeth with minimal or no anchorage loss.1,2 Anchor-
age has been classified based on the magnitude of
mesial movement of the posterior teeth during anterior
retraction.2 Maximum anchorage should result in mini-
mal movement of the posterior teeth. Minimal anchor-
age results in extraction space closure primarily by
mesial movement of the posterior teeth. Moderate an-
a
Assistant professor, Division of Orthodontics, Department of Dentistry,
Catholic University of Korea, Uijongbu St. Mary’s Hospital, Uijongbu, Korea.
b
Private practice, Seoul, Korea.
c
Assistant professor, Department of Orthodontics, University of Alabama,
Birmingham, Ala.
d
President, Korean Society of Speedy Orthodontics, Seoul, Korea.
Partly supported by the Korean Society of Speedy Orthodontics and the alumni
fund of the Department of Dentistry and Graduate School of Clinical Dental
Science, Catholic University of Korea.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Seong-Hun Kim, Division of Orthodontics, Department of
Dentistry, Catholic University of Korea, Uijongbu St. Mary’s Hospital, 65-1
Geumoh-dong, Uijeongbu, Gyeonggi-do 480-717, South Korea; e-mail,
bravortho@catholic.ac.kr.
Submitted, June 2007; revised and accepted, August 2007.
0889-5406/$36.00
Copyright Ó 2009 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.08.023
268
chorage is often described as reciprocal movement of
anterior and posterior teeth into the extraction sites.
When extractions are planned to relieve crowding or
reduce incisor protrusion, anchorage control assumes
a central role in the selection of a biomechanical ap-
proach.3 Auxiliary appliances such as headgears, transpa-
latal arches, and Nance buttons have been used to achieve
maximum anchorage. The disadvantages of these appli-
ances might be the need for several laboratory steps and
significant patient compliance. Intra-arch mechanics
with differential moments have been proposed as alterna-
tives for anchorage control.4-6 Although limited or no pa-
tient cooperation is required, the significant chair-side
time and the increased difficulty of patient hygiene are
disadvantages of this biomechanical approach.7
More recently, implants have been suggested as an
alternative method for anchorage control.8-18 Most
articles describing the use of implants for temporary
skeletal anchorage incorporate them into traditional
biomechanical schemes such as sliding mechanics.12-18
However, sliding efficiency might be adversely affected
from friction on bracket slots and tubes. We believe that
a better system combines temporary skeletal anchorage
devices (TSADs) with light continuous forces, the
ability to control tooth movement, minimum friction,
and no need for patient compliance.
American Journal of Orthodontics and Dentofacial Orthopedics Kim et al 269
Volume 136, Number 2

Table I. Demographic distribution of the subjects

Malocclusion Retraction Finishing Treatment
Subject Sex Age class Extraction Type of appliance period method period

1 M 28 y 3 mo I #14,24,34,44 CI 15 mo FA 19 mo
2 F 20 y 8 mo II #14,24,34,44 CI 14 mo No 14 mo
3 F 24 y 5 mo I #14,24,34,44 CI 19 mo TP 21 mo
4 F 22 y 1 mo I #14,24,34,44 CI 8 mo FA 13 mo
5 F 22 y II #14,24,35,45 CI 19 mo TP 20 mo
6 F 31 y 5 mo I #14,24,34,44 CI 12 mo No 12 mo
7 F 27 y 2 mo II #14,24,34,44 CI 11 mo FA 16 mo
8 F 22 y 6 mo I #14,24,35,45 CI 15 mo No 15 mo
9 F 19 y II #14,24,35,44 CI 6 mo FA 12 mo
10 F 23 y 4 mo I #14,24,34,44 CI 10 mo FA 14 mo
11 F 30 y I #14,24,34,44 CI 12 mo FA 14 mo
12 F 29 y 2 mo I #14,24,34,44 CI 8 mo FA 14 mo
13 F 23 y 11 mo I #14,24,34,44 CI 23 mo TP 24 mo
14 F 23 y 1 mo II #14,24,36,46 CI 21 mo FA 23 mo
15 F 25 y 8 mo I #14,24,34,44 CI 12 mo FA 15 mo
16 F 19 y I #14,24,34,44 CT 23 mo No 23 mo
17 F 23 y II #14,24,35,45 CT 9 mo No 10.5 mo

F, Female; M, male; CI, C-implant; CT, C-tube; No, no orthodontic appliance; TP, tooth positioner; FA, fixed orthodontic appliance.

In a recent reports, TSADs were used as the only
source of anchorage for en-masse retraction of the 6 max-
illary anterior teeth.19-21 No appliances were placed in the
maxillary or mandibular posterior dentition. The TSADs
used by Chung et al21 were designed to accommodate
archwires that could slide during retraction and resist
the force levels necessary for various applications. The
authors claimed that the absence of appliances on the pos-
terior teeth did not preclude controlled tooth movement.
Furthermore, they claimed high efficiency because of
low friction and fewer periodontal problems because of
the hygienic nature of the system.11,19-21
The aim of this study was to evaluate the treatment
effects of specially designed TSADs as the sole source
of anchorage during en-masse retraction of the 6 maxil-
lary anterior teeth after extraction of the premolars. A
secondary objective was to analyze the behavior of the
posterior dentition during the anterior retraction phase
of treatment.
MATERIAL AND METHODS
Retrospective data were obtained from pretreatment
and postretraction lateral cephalograms of 17 patients
who met the following criteria: nongrowing, treatment
plan included maxillary and mandibular premolar ex-
tractions, maximum anchorage was required, TSADs
were used as the sole source of anchorage, and no appli-
ances were placed in the maxillary posterior dentition
during the retraction phase of treatment.
The subject’s ages at treatment start, the duration of
active treatment, and the numbers of subjects are shown
in Table I The sample included 16 women and 1 man.
Their mean age at the start of the treatment was 24.4
6 3.71 years (range, 19-31.41 years). Their most com-
mon complaint was anterior dental protrusion. Eleven
subjects had cephalometric values that indicated Class
I bimaxillary dentoalveolar protrusion, and 6 had a Class
II skeletal pattern. The subjects had a wide range of
space deficiency, but crowding was not recorded in
this study. One patient had the mandibular first molars
extracted instead of the mandibular premolars because
of the severely compromised condition of her teeth.
Therefore, cephalometric measurements for the man-
dibular molar position were excluded in this patient.
All patients were treated by 2 clinicians (K.S.H. and
C.K.R.) at Uijongbu St Mary’s Hospital in Korea.
This preliminary report and the associated data were re-
viewed by the Institutional Review Board at Uijongbu
St Mary’s Hospital Catholic Medical Center of the
Catholic University of Korea.
The TSADs used in this study (Fig 1, A)—C-im-
plants (C-implant Company, Seoul, Korea)—are sand-
blasted, large-grit, and acid-etched (SLA) surface
treated mini-implants. The implant size is 1.8 mm in di-
ameter and 8.5 mm in length; it has 2 parts: a screw and
a head.20 Thirty mini-implants were placed in the inter-
septal bone between the maxillary second premolars and
first molars. Initial loading was 4 weeks after placement.
In 2 cases of narrow interdental space and extended max-
illary sinus, 4 miniplates with tubes (C-tube, Gebrüder
Martin GmbH, Tuttlingen, Germany) were placed. No
C-implants were used in these 2 subjects (Fig 1, B
and C).21
270 Kim et al American Journal of Orthodontics and Dentofacial Orthopedics
August 2009

Fig 1. TADs used in this study: A, SLA surface-treated

C-implant; B and C, miniplate with tube (C-tube).

TSAD-dependent en-masse retraction is the novel

treatment approach presented here, called ‘‘biocreative
therapy’’ (Fig 2). Our objective was to achieve indepen-
dent en-masse retraction of the anterior teeth while avoid-
ing the use of orthodontic appliances in the posterior
segments during the retraction period.22 This concept
evolved because partially osseointegrated mini-implants
or plates can easily endure multi-directional heavy forces
even while supporting orthodontic archwires.21,22 Fig 2. TSAD-dependent en-masse retraction mechanics
In 17 patients, 0.022-in preadjusted edgewise (biocreative therapy): A and B, type A mechanics, with
brackets were placed on the maxillary 6 anterior teeth no appliances on the posterior dentition; C and D, type B
(Fig 2, C and D). Full appliances were placed in the man- mechanics, with no appliances on the maxillary posterior
dibular arch. During initial alignment, 2.5-oz elastics or dentition; E and F, type C mechanics, with fixed appliances
elastic chains delivering 0.7 N of force were applied to on all posterior dentition. Anterior retraction and maxillary
the canines. The canines were retracted while the 4 max- posterior intrusion were performed simultaneously.
illary anterior teeth were aligned. En-masse retraction of
ence plane, with forward movement of the centroid
the maxillary anterior teeth began once a 0.016 3 0.022-
point assigned a positive value. Vertical movement of
in stainless steel archwire was placed. Elastics were
the maxillary first molars was determined from palatal
applied directly to the brackets because uprighting of
plane superimpositions. Anteroposterior movement of
the incisors was desired (Fig 2, C). An 0.018 3 0.025-
the mandibular teeth was assessed by measuring the dis-
in stainless steel archwire with soldered hooks was
tance from the centroid point to the mandibular lingual
used for retraction when torque control was needed
cortex, whereas vertical movement was determined
(Fig 2, D). Closed nickel-titanium springs (1.2 N) or
from superimposition on the mandibular plane (MP).
4.5 oz elastics were used for en-masse retraction. Once
Angular changes were assessed by measuring the long
it was achieved, short-term fixed appliances, tooth posi-
axe’s inclination of the maxillary first molars to the
tioners, or clear aligners were used for finishing.
sella-nasion line (SN) and the mandibular first molar’s
Cephalometric headfilms were analyzed. Soft-tis-
long axes to the MP. The cephalometric measurements
sue, skeletal, and dental measurements were made as re-
we used are shown in Figures 3 and 4.
ported by Park et al16 and Gosh and Nanda.23 When
there were double images, a midpoint was used. Poste-
rior dental linear measurements used the centroid point: Statistical analysis
the midpoint on a horizontal line between the greatest The means and standard deviations for the 19 variables
mesial and distal convexity of the crowns. were calculated. Pretreatment to postretraction changes
To determine the amount of horizontal movement of for each variable were analyzed with paired t tests. To eval-
the maxillary teeth, the pterygoid vertical plane (PTV) uate tracing and measurement errors, the experimental
determined by Enlow et al24 was used. The PTV line procedures of the records of 17 patients (34 sets of cepha-
was transferred from the pretreatment tracing to the lograms) were repeated 3 weeks later.25 Results of the
postretraction tracing, providing a consistent reference Pearson correlation coefficient, used to compare the sec-
plane. Anteroposterior movement of the maxillary first ond measurement to the first for each variable, showed
molars was measured perpendicular to the PTV refer- above 0.98 at the 95% confidence interval.
American Journal of Orthodontics and Dentofacial Orthopedics Kim et al 271
Volume 136, Number 2

Fig 3. Soft-tissue and skeletal cephalometric analysis: 1, upper lip to E-line; 2, lower lip to E-line;
3, SN to palatal plane angle (SN-PP); 4, SN-anatomic occlusal plane angle (SN-Occ); 5, SN to man-
dibular plane angle (SN-Mn); 6, pterygoid vertical plane to A point (PTV-A); 7, pterygoid vertical plane
to B point (PTV-B); 8, lower anterior face height (LAFH; ANS-Me).

Table II.Comparisons of cephalometric measurements

before treatment (T1) and after retraction (T2)
T1 T2
Significance
Mean 95% CI Mean 95% CI T2– T1

Soft tissue
‡
Upper lip 2.12 1.34–2.9 0.25 0.47–0.98
to E-line
‡
Lower lip 4.4 3.5–5.3 1.69 0.87–2.52
to E-line
Skeletal
SN-PP 10.39 9.19–11.59 10.43 9.27–11.59
SN-Occ 20.17 18.20–22.14 20.79 18.70–22.88
‡
SN-Mn 40.55 38.03–43.06 41.09 38.58–43.60
PTV-A 48.48 47.16–49.79 48.45 47.21–49.70
PTV-B 43.16 40.89–45.43 42.69 40.50–44.89 *
Fig 4. Dental cephalometric analysis, angular and linear ANS-Me 77.11 75.01–79.21 78.25 76.11–80.38 †

measurements: 1, SN to maxilliary incisor angle (SN-U1); Dental

2, SN to maxillary first molar angle (SN-U6); 3, mandibu- angular
‡
lar plane to mandibular incisor angle (MP-L1); 4, mandib- SN-U1 108.9 105.1–112.6 93.52 89.80–97.25
†
ular plane to mandibular first molar angle (MP-L6); SN-U6 70.09 67.58–72.61 72.10 69.29–74.92
‡
MP-L1 98.64 95.66–101.6 86.78 83.53–90.03
5, pterygoid vertical plane to maxillary incisor tip dis- ‡
MP-L6 81.16 79.95–82.38 77.49 75.91–79.06
tance (PTV-U1); 6, pterygoid vertical plane to maxillary
Dental
first molar centroids distance (PTV-U6); 7, palatal plane linear
to maxillary incisor tip distance (PP-U1); 8, palatal plane PTV-U1 58.91 56.98–60.84 53.06 51.34–54.79 ‡

to maxillary first molar centroids distance (PP-U6); PTV-U6 22.35 20.93–23.77 23.09 21.67–24.50 †

9, mandibular lingual cortex to mandibular first molar PP-U1 32.58 31.47–33.68 33.21 32.26–34.15
†
centroids (LC-L6); 10, mandibular plane to mandibular PP-U6 22.12 21.11–23.14 22.85 21.84–23.86
†
incisor tip (MP-L1); 11, mandibular plane to mandibular LC-L6 15.79 14.34–17.25 13.89 12.15–15.63
first molar centroids (MP-L6). MP-L1 48.88 47.09–50.68 48.18 46.38–49.97 *
†
MP-L6 33.98 32.78–35.18 34.72 33.48–35.96

*P \0.05; †P \0.01; ‡P \0.001.

RESULTS
The mean retraction period was 13.94 6 5.61 and significant changes in the soft-tissue, skeletal, and
months, and the mean overall treatment time was dental measurements between pretreatment and postre-
16.44 6 4.31 months. The means, standard deviations, traction are listed in Table II.
272 Kim et al
Fig 5. Pretreatment photographs and panoramic radiogram.
A statistically significant difference was found be-
tween the pretreatment and postretraction measure-
ments in the anterior dentition. SN to maxillary incisor
(SN-U1) angle and mandibular incisor to MP angle
(MP-L1) decreased significantly (P \0.001) after en-
masse retraction (–15.33 6 6.85 and –11.85 6 6.06 ,
respectively). Soft-tissue changes were also significant,
whereas the upper and lower lips to E-line moved poste-
riorly –1.87 6 0.91 mm and –2.75 6 1.80 mm, respec-
tively. The maxillary molars showed mesial movement
(PTV-U6, 0.74 6 1.01 mm; P \0.01), extrusion (PP-
U6, 0.72 6 0.91 mm; P \0.01), and mesial tipping
(SN-U6, 2.01 6 2.28 ; P \0.05). The mandibular
molars showed slight extrusion during en-masse retrac-
tion (MP-L6, 0.86 6 0.92 mm; P \0.01).
CASE REPORT
A woman, aged 23 years 4 months, complained of
poor facial harmony and misalignment with a high max-
American Journal of Orthodontics and Dentofacial Orthopedics
August 2009
illary canine. The clinical examination showed anterior
protrusion, midline discrepancy, anterior crossbite of
the maxillary lateral incisors, and a Class II left canine
relationship (Fig 5). Radiographic examination showed
a skeletal Class I relationship with bimaxillary dentoal-
veolar protrusion (Fig 5, I). Based on the patient’s
complaints, and the clinical and cephalometric find-
ings, the following treatment plan was formulated:
(1) implantation of 2 C-implants (1.8-mm diameter,
8.5-mm length) between the maxillary second premo-
lar and first molar; (2) extraction of the first premolars
and placement of maxillary anterior and full mandibu-
lar fixed appliances; (3) C-implants used for maxillary
anterior retraction and as hooks for Class III intermax-
illary elastics; and (4) finishing and detailing with fixed
appliances.
Brackets were attached to the maxillary anterior and
mandibular dentition, and a 0.016 3 0.022-in stainless
steel utility archwire was used to retract the maxillary
anterior dentition. This archwire was bent for vertical
American Journal of Orthodontics and Dentofacial Orthopedics Kim et al 273
Volume 136, Number 2

Fig 6. Progress intraoral photographs: A-C, 1 month after treatment; D-F, 6 months after treatment;
G-I, 11 months after treatment; J-L, 13 months after treatment.

correction of the maxillary right canine during anterior DISCUSSION

retraction (Fig 6, A-C). Class I and Class III elastics
from the C-implants were used for en-masse retraction
(Fig 6, D-F). Full retraction of the maxillary anterior
dentition was performed (Fig 6, G-I). After 14 months
of active treatment, all fixed appliances were debonded,
and fixed retainers were placed in both arches. Based on
the cephalometric analysis and clinical examination, we
deemed the results to be acceptable. The patient was
pleased with the treatment result despite the overre-
tracted dentition and incomplete extraction space clo-
sure (Figs 7, 8, and 9).
The technique described here is the result of several
years of observation and clinical application of TSADs.
When compared with previously published retraction
methods, the mechanics in this report are different be-
cause the posterior teeth are not bracketed or
bonded.12-18 The mean retraction period was 13.94 6
5.61 months. The mean overall treatment time was
16.44 6 4.31 months. The periods for fixed appliances
were also relatively short, averaging 4.1 months. Usu-
ally, fixed appliances are applied for a short time to
the posterior dentition during the finishing stages to
274 Kim et al American Journal of Orthodontics and Dentofacial Orthopedics
August 2009

Fig 7. Posttreatment photographs and panoramic radiogram.

Fig 8. Lateral cephalograms: A, pretreatment and B, before debonding.

improve the occlusal relationship and achieve better in- with arch length discrepancies less than 1 mm required
terdigitation. No posterior appliances were used in 5 tooth positioners or clear aligners, and 9 patients had
subjects, who had complete extraction space closure posterior teeth bonded to achieve ideal occlusion. Post-
and reasonable occlusal relationships. Three patients treatment measurements were not included in this study,
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 136, Number 2
Fig 9. Superimposed tracings: pretreatment (black) and
posttreatment (red).
since the primary focus was to evaluate the effect of
en-masse retraction by using TSADs exclusively.
Osseointegration is the direct structural and func-
tional connection between living bone and the surface
of a load-carrying implant. Clinically, it means ankylo-
sis of the implant-bone interface.26 Osseointegration
can be useful in an orthodontic mini-implant when re-
sistance to rotational force is needed. A mini-implant
that aids orthodontic treatment requires a relatively little
bone-to-implant contact.
The retention portion of the C-implant has a higher
osseointegration potential27-32 compared with smooth
titanium mini-implants and is better able to resist the ro-
tational tendency during heavy dynamic loads.20,32 Oh
et al,30 in an animal study, compared the removal torque
value between SLA C-implants and smooth titanium
ones. After 6 weeks of loading, the SLA group had
a higher mean removal torque value (8.29 Ncm) than
the smooth group (3.34 Ncm), and histologic analysis
showed greater new bone formation along the screw
in the SLA group. Ko et al31 also found significantly
higher removal torque values in the SLA group than
in machined group, even though the implants were re-
moved and reimplanted.
The human histologic and histomorphometric find-
ings of Seo et al32 of retrieved SLA C-implants showed
52.6% of mean bone-to-implant contact, excluding the
upper smooth-surfaced 2-mm portion of the mini-
implant, and called it a partially osseointegrated mini-
implant. The authors believed that the increased
osseointegration potential of the C-implant was because
of its surface characteristics and the placement protocol
that allowed it to heal for 4 to 6 weeks before loading.
In a cephalometric study of zygomatic miniscrews,
Liou et al33 concluded that miniscrews are stable an-
Kim et al 275
chorage for orthodontic tooth movement but do not re-
main absolutely stationary like an endosseous implant
throughout orthodontic loading. In our study, we did
not examine whether the C-implants remained fixed or
whether they moved mesially during the treatment
period.
Even though the sample size was small (n 5 17), this
study showed statistically and clinically significant re-
sults in anterior tooth movement supported exclusively
by TADs. The maxillary and mandibular first molars
showed statistically significant horizontal and vertical
movements. The mesial drifting of the posterior denti-
tion was less than 1 mm vertically and 1 mm horizon-
tally. Although a direct comparison cannot be made,
this amount of horizontal movement is similar to other
studies in which anterior teeth were retracted with other
means of maximum anchorage.5,34 The MP angle
opened slightly as a result of the combined maxillary
and mandibular vertical movement of the molars. In
this study, we performed intra-arch retraction in the man-
dible as shown in the case report. This might affect the
mesial movement of the mandibular molars and the set-
tling of the maxillary molars to the opposing dentition.
Some clinicians might have concerns about this
technique, since there is no control over the posterior
dentition during the retraction phase of treatment. How-
ever, all subjects in this study required only minor treat-
ment after anterior retraction. Postretraction treatment
aimed to coordinate arch forms and detail the occlusion.
The ability to align and retract the anterior dentition
in a maximum-anchorage environment without the sup-
port of the posterior teeth is a novel approach. This tech-
nique requires minimal patient compliance and could
decrease treatment time. Canine retraction, alignment
of anterior teeth, and en-masse retraction are accom-
plished with adequate torque control at an early stage
of treatment. The latter is accomplished by directing
the retraction forces to soldered lever arms, creating bet-
ter moment-to-force ratios.
This technique might have the additional benefit of
decreasing periodontal disease because of the difficulty
of cleaning orthodontic appliances. In cases of peri-
odontal disease in which anchorage is provided by the
posterior teeth, the mobility and the periodontal condi-
tion of the anchor teeth can deteriorate.35,36
Further studies are needed to determine the treat-
ment effects of en-masse retraction with TADs based
on skeletal pattern and posttreatment stability.
CONCLUSIONS
Based on the findings of this preliminary report, we
concluded the following.
276 Kim et al
1. The TSADs used in this study can resist the forces
required for en-masse retraction of the 6 anterior
teeth.
2. Statistically and clinically significant anterior
retraction was achieved without posterior appli-
ances.
3. The anchorage loss observed in this study was com-
parable with traditional methods of achieving max-
imum anchorage.
We thank Shin-Jae Lee, Department of Orthodon-
tics, School of Dentistry, Seoul National University,
for assistance in preparing the manuscript.
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