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ORIGINAL ARTICLE

Experimental determination of optimal force system required for control of anterior tooth movement in sliding mechanics
SheauSoon Sia,a Tatsunori Shibazaki,b Yoshiyuki Koga,c and Noriaki Yoshidad Kuala Lumpur, Malaysia, and Nagasaki, Japan Introduction: This study was designed to determine the optimum vertical height of the retraction force on the power arm that is required for efcient anterior tooth retraction during space closure with sliding mechanics. Methods: Three adults (1 man, 2 women) with Angle Class II Division 1 malocclusions were selected for this study. In each subject, the maxillary right central incisor was the target tooth. Initial tooth displacements of that tooth wth sliding mechanics with various heights of retraction forces were measured in vivo by a 2-point 3-dimensional displacement magnetic sensor device. The tooths motion trajectories on the midsagittal plane were studied. Results: The location of the center of rotation of the target tooth varied according to the different heights of the retraction forces. Controlled anterior tooth movement (ie, lingual-crown tipping, lingual-root movement) can be predicted, simulated, or even manipulated by different heights of retraction forces on the power arm in the sliding mechanics force system. A power arm length of 3 to 5 mm is estimated to produce controlled lingual-crown tipping (with the apex as the center of rotation) for efcient anterior tooth retraction during sliding space closure in adults with Angle Class II Division 1 malocclusion. Conclusions: Knowing and applying the correct height of retraction force on the power arm is the key to efcient anterior tooth retraction. (Am J Orthod Dentofacial Orthop 2009;135:36-41)

or years, orthodontists have searched for an efcient force system that can work quickly, accurately, and effectively to shorten treatment time. A sliding mechanics force system might be an answer if we know how to control and manipulate the force system well. From the Andrews straight wire appliance1,2 to the McLaughlin, Bennett, Trevesi appliance,3 sliding mechanics force systems have been widely used, mainly for anterior tooth retraction during space closure in orthodontic treatment. Accurate control of the anterior teeth during space closure in sliding mechanics is essential to the success of orthodontic treatment. During sliding mechanics retraction, various vertical heights of retraction forces can be freely adjusted by soldering different lengths of power arms (sliding hooks) to an archwire. Therefore,
Private practice, Kuala, Lumpur, Malaysia. Tutor, Department of Orthodontics, School of Dentistry, University of Nagasaki, Japan. c Assistant professor, Department of Orthodontics, School of Dentistry, University of Nagasaki, Japan. d Professor and chairman, Department of Orthodontics, School of Dentistry, University of Nagasaki, Japan. Reprint requests to: SheauSoon Sia, Sia Orthodontic Dental Specialist Clinic, No. 5-1, Jalan Metro Perdana Barat 1, Taman Usahawan Kepong, 52100 Kuala Lumpur, Malaysia; e-mail, s_s_sia@yahoo.com. Submitted, November 2006; revised and accepted, January 2007. 0889-5406/$36.00 Copyright 2009 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2007.01.034
b a

the force system for the desired tooth movement can be simply applied.4,5 Nonetheless, have we ever wondered what should be the optimum height of the retraction force on the power arm for retraction with sliding mechanics? Is it important that the height level on the power arm is a few millimeters shorter or longer? We often overlook these important factors and just guess the height. This is because the mechanical conditions for achieving accurate control of the anterior teeth during space closure in sliding mechanics are still unknown. Guidelines on force system, force magnitude, and force vector in sliding mechanics are not yet established. Many authors have investigated the location of the center of rotation or the center of resistance of teeth; most studies were carried out in vitro with mathematical or physical models6-9 and nite element models.10,11 Human autopsy materials and dry skulls, for example, were used by Burstone et al,12 Dermaut et al,13 Pedersen et al,14 Van den Bulcke et al15 in their experiments. However, the major limitation of such studies was that the biomechanical properties of the periodontal ligament (PDL) might have changed considerably in dry skulls and autopsy materials, even though the PDL had been completely replaced by a synthetic substance that was claimed to have similar characteristics as the PDL.15 Thus, the results of these analyses were incon-

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sistent and subject to interpretation because most models could not sufciently approximate anatomic conditions. These disadvantages could be avoided by placing a magnetic sensor device in the oral cavity for measuring tooth displacement in vivo. This system was developed and tested previously by Yoshida et al.16 The purpose of this study was to determine the location of the center of rotation of the maxillary central incisor subjected to retraction forces applied at different vertical heights in human subjects in vivo and to discuss its clinical application to efcient anterior tooth retraction in a sliding mechanics force system.
MATERIAL AND METHODS

Fig 1. Diagram of 2-point 3D magnetic sensor device system for measuring initial tooth displacement.

Three patients, 1 man and 2 women, were selected for this investigation. They gave informed consent, and the research protocols were approved by the authorities at Nagasaki University in Japan. The selection criteria for those patients were Angle Class II Division 1 malocclusion, good and normal periodontal conditions, orthodontic treatment with both maxillary rst premolars extracted, and the target tooth was the maxillary right central incisor. For measuring 3-dimensional (3D) displacements of target tooth, a 2-point 3D displacement magnetic sensor device was constructed and calibrated before the intraoral setting. This magnetic sensor device was described previously and will be only summarized here.16,17 The main part of the system was composed of 2 magnets and 16 magnetic sensors to measure motion with 5 degrees of freedom. A diagram of the system is shown in Figure 1. The device included 2 sets of magnets and magnetic sensors. Each set consisted of an aluminum housing, with 8 magnetic sensors aligned in a cubic array around a magnet. When the device was placed into the oral cavity, 2 sets of magnets and magnetic sensors were placed labially and palatally to the maxillary right central incisor, respectively. The device was rigidly xed to the posterior teeth by a splint. The 2 magnets were placed in the center of each aluminum housing and attached to the maxillary right central incisor by aluminum rods. For the main archwire, 0.018-in slot brackets and 0.016 0.022-in cobalt-chromium alloy wires were used. The power arms were soldered directly to an archwire bilaterally mesial to the canines to simulate en-masse retraction of the anterior teeth in the clinical situation. The power arms were perpendicular and apical to the occlusal plane. Each power arm contained 6 small hooks. The rst hook was set 4.5 mm apical to the incisal edge, corresponding to the slot bracket. It

was followed by 5 more hooks, set in the apical direction from the bracket position at intervals of 2 mm. Retraction forces of 1.5 N were applied parallel to the archwire. The titanium miniplates (Orthoanchor SMAP system, Dentsply-Sankin, Tokyo, Japan) implanted in the bilateral zygomatic processes were used as anchorage for retraction of the anterior teeth. These implants were capped with preformed metal attachments with 6 hooks (posterior attachments). The vertical heights of the hooks on the posterior attachments were similar to the vertical heights of the hooks on the anterior power arms. Precalibrated closed-coil springs were hooked between the posterior attachments and the anterior power arms bilaterally at the same height of the hooks and parallel to the archwire. The posterior attachment height was changed in tandem with the height on the anterior power arm. Vertical distances from the closedcoil spring to the archwire were measured at several reference points during the experiment to keep the force vector parallel to the archwire for every height level of force application. The rst loading level at hook 1 was 0 mm, corresponding to the bracket position. The second loading level, for hook 2, was 2 mm from the bracket position. The loading process was continued until hook 6 (10 mm from the bracket position). Three sets of measurements were made for each subject and averaged. Initial tooth movements with sliding mechanics at various heights of retraction forces were measured in vivo, as shown in Figure 2. Displacements of the 2 magnets were determined by the magnetic sensors in real time. The tooth movements projected on the midsagittal plane were calculated from the displacements of the 2 magnets, because these movements are clinically important when anterior teeth are retracted. The locations of the center of rotation in relation to various heights of retraction forces (power arm lengths) were analyzed.

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Fig 2. Initial tooth displacements under sliding mechanics with various heights of retraction forces were measured by the magnetic sensor device in vivo.

According to Burstone,5 tooth movement is best described simply by the location of the tooths center of rotation as a rotation axis. This is because it is difcult to express the type of tooth movement precisely with classications such as tipping, translation, intrusion, extrusion, rotation, and their combinations, because the actual tooth movement involves innite combinations of these classications. The coordinates of the center of rotation were calculated as the intersection of 2 lines coincident with the extensions of the tooth axis before and after displacement. The process of calculation was explained previously by Yoshida et al.16,17
RESULTS

The locations of the center of rotation from the incisal edge, along the target tooth axis, were plotted against the height of the retraction force on the power arm and are shown in Figure 3 for our 3 subjects. Generally, Figure 3 demonstrates that the location of the center of rotation (along the tooth axis) varies in accordance with different heights of retraction forces. When the retraction force was applied at hook 1, which corresponded to the bracket position, the center of rotation was approximately at the middle of its tooth length. The center of rotation shifted toward the apex when the retraction force was applied at hook 3 (4 mm from the bracket position). When the force was applied at hook 4 (6 mm from the bracket position), the center of rotation was located apically far into the maxillary alveolar bone. However, there was a sudden change of the pattern when the force was applied at hook 5 (8 mm from the bracket position); the center of rotation was observed in a reverse direction and was located at the incisal edge of the target tooths crown. When the force was applied at hook 6 (10 mm from the bracket

Fig 3. Right, Location of the center of rotation plotted along the target tooth axis corresponding to the height of the retraction force on the power arm. Left, Relationship between the height of the retraction force on the power arm and the location of the center of rotation from the incisal edge. Arrows show the estimated height of the retraction force on the power arm required to achieve controlled lingual-crown tipping (center of rotation at apex) and controlled lingual-root movement (center of rotation at incisal edge) in our 3 subjects.

position), the center of rotation moved apically again and was approximately at the cervical line region. An innity range was observed between hooks 4 and 5. All subjects had almost the same pattern of consis-

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tency, as shown in Figure 3. Similarly, the same innity range between hooks 4 and 5 (6-8 mm from the bracket position) was also noticed among the 3 subjects. Retrospectively, one might estimate the height of the retraction force required (length of the power arm) if the center of rotation was at the apex. Figure 3 shows that the lengths of the power arm required to have the center of rotation at the apex for the 3 subjects were 4.0, 4.0, and 4.2 mm. Likewise, if the center of rotation was at the incisal edge, the length of the power arm could be estimated: ie, when the line intersected the x-axis (when the distance of the center of rotation to the incisal edge is 0 mm, or y 0). Figue 3 shows that the lengths of the power arm required to have the center of rotation at the incisal edge were 9.3, 8.9, and 9.4 mm for the 3 subjects.
DISCUSSION

moved apically from the center of the root as the height of force application was raised toward the apex. When the height of force application rose above the center of resistance, the center of rotation was coronal to the tooths crown; thus, the direction of tooth movement changed from lingual crown tipping to labial crown tipping at this level. This also claried to us that, in sliding mechanics, when we guess the length of the power arm (height of retraction force), sometimes it works as we want it to, but sometimes it does not. Clinically, 2 common scenarios during conventional anterior tooth retraction (ie, closing-loop mechanics) are the following: 1. For Angle Class II Division 1 patients, excessive (uncontrolled) lingual-crown tipping and unwanted labial root movement of the incisors often cause fenestration of the labial part of alveolar bone iatrogenically and root resorption (Fig 4). 2. For Angle Class II Division 2 patients, the additional step of crown-labial proclination of the incisor crown rst (to tilt the root lingually) before the second step of retraction, which is the real anterior tooth retraction. Either problem will cause orthodontists to spend more chair time to correct the excessive or unwanted movement during anterior tooth retraction. Eventually, these problems will not only prolong the treatment time, but also increase the costs and expose the tooth to redundant movements, traumatic forces, and additional risks of root resorption.21,22 Our results, however, gave some important clues (clinical applications) on how to avoid these undesirable tooth movements during anterior tooth retraction. 1. When the center of rotation was located at the root apex, the required height of the retraction force on the power arm was estimated to be 3 to 5 mm apical to the bracket position. Thus, controlled lingualcrown tipping (around the root apex as the point of rotation) would be expected. Clinically, this type of retraction movement is favorable for the treatment of patients with Angle Class II Division 1 malocclusion, as shown in Figure 5. This could minimize or prevent the unwanted labial root movement of the incisor as mentioned above. In conventional space-closing mechanics (ie, closing-loop mechanics), the center of rotation always remains approximately at the center of the root when the loop was activated. This is because the activated force vector could act only on the bracket level. If this undesirable incisor labial root movement occurs, an extra

Although only 3 subjects were studied because of the practical difculties in the experiment setup, the results were consistent among them. The coefcients of variation of the values for 9 measurements were less than 5.8%. Therefore, the reproducibility of the measurements of tooth movement was considered acceptable. Even though a 0.022-in bracket slot is preferred for sliding mechanics and an 0.018-in bracket slot is commonly used in closing-loop mechanics, an 0.018-in slot appliance and a 0.016 0.022-in cobalt-chromium alloy wire were chosen in this study mainly because they are the standard appliances at our institution.18 Furthermore, the frictional properties between the bracket slot and the archwire were not emphasized in this study because they were unlikely to inuence the properties of force vector (vertical height of retraction force) on the power arm during retraction with sliding mechanics.19,20 The location of the center of rotation of the target tooth varied according to the different heights of the retraction forces. As the height of force application was shifted apically, the center of rotation also displaced almost exponentially in the same direction. An innity range between hooks 4 and 5 (6-8 mm from the bracket position) was noticed in all 3 subjectsie, the location of the center of resistance. No tooth rotation but bodily translation movement would occur at this level as shown in previous studies of Burstone,5 Burstone and Pryputniewicz,6 Tanne et al,10 and Yoshida et al.17 On applying force on hook 5, the center of rotation was noticed to move coronally to the crown of the tooth. This was relatively in good agreement with the theoretical analyses by Burstone5 and Burstone and Pryputniewicz.6 They showed that the center of rotation

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Fig 4. Uncontrolled tipping can cause fenestration of the alveolar bone during anterior tooth retraction.

Fig 5. Estimated height of the retraction force on the power arm for efcient anterior tooth retraction with sliding mechanics in Angle Class II malocclusion patients.

step of treatment (palatal root torque) is required, and eventually this would increase treatment time. 2. When the center of rotation was located at incisal edge, the required height of the retraction force on the power arm was estimated to be 8 to 10 mm apical to the bracket position. Thus, controlled lingual-root movement of the retracting incisor (around its incisal edge as the point of rotation) would be expected. Clinically, this retraction movement is favorable for the treatment of patients with Angle Class II Division 2 malocclusion, as shown in Figure 5. In the treatment of Angle Class II

Division 2 patients, it is difcult to perform anterior retraction movement directly at the beginning step, because this will only aggravate the condition and tilt the crown even more lingually. Usually, an additional step of labial crown proclination is required before, as mentioned above. The advantage of the power arm in sliding mechanics is that it can directly transfer the force vector to the root rather than to the bracket (ie, closing-loop mechanics) for lingual-root movement, with the incisor edge as the center of rotation. Consequently, this will shorten treatment time by skipping the additional step of

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labial-crown proclination and might perform the real anterior retraction step directly. In addition, the location of the center of rotation in relation to a given height of retraction force also varied among our 3 subjects. Anatomy parameters such as length and shape of root, width of the PDL, palatal alveolar bone height, and physical properties of periodontal tissue might contribute to these differences. The height of the retraction force (power arm length) is not the only variable to consider during anterior sliding space closure. In clinical practice, sometimes it seems unlikely that the positions of both attachments (anterior power arm and posterior attachment) could be selected ideally to produce a force vector that is parallel to the archwire. Therefore, another interesting topic to investigate further would be the retraction forces applied at an angle to the archwire plane (eg, using the molar bracket hook as the posterior attachment).
CONCLUSIONS

The height of the retraction force on the power arm could modify the location of the center of rotation of the anterior teeth during anterior space closure with sliding mechanics. Thus, to know and apply the correct height of the retraction force on the power arm is the key to efcient anterior tooth retraction. It was estimated that, during anterior tooth retraction in Angle Class II Division 1 malocclusion patients, controlled lingual-crown tipping could be achieved by attaching a power arm of 3 to 5 mm in length (height of retraction force) with sliding mechanics.
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