Documente Academic
Documente Profesional
Documente Cultură
18
only a few studies have examined patients with minimal arch length deficiencies requiring maximum anterior retraction. Burstone9 suggested that how anchorage
is managed, not the mere extraction of teeth, determines
the magnitude of anterior dental reduction and the
resulting change in lip position. Williams and Hosila10
found that, in patients whose 4 first premolars were
extracted, only 66.5% of the available extraction space
was taken up by retraction of the anterior segment.
Creekmore11 stated that, as a rule of thumb, when first
premolars are extracted, one can expect the posterior
teeth to move forward approximately one third of the
space, leaving two thirds of the space for relief of
crowding and incisor retraction. In this scenario, maximum anchorage of the posterior teeth assumes importance in not only allowing the anterior teeth to be
retracted to their greatest extent but also increasing the
chances of straightening the profile by reducing the
convexity of the face.
With the introduction of dental implants,12 miniplates,13 and microscrews14-16 as anchorage units, it is
now possible to obtain absolute anchorage of the
posterior teeth and close the extraction spaces completely by anterior tooth retraction. However, there still
seems to be little accurate scientific evidence pertaining
to the treatment effects of skeletal anchorage in these
patients. Most treatment assessments were based on
either clinicians observations in their day-to-day practices (case reports14-16) or anecdotal clinical observations. It can be misleading to base future practice
decisions on such evidence.
Our purposes in this study were to investigate and
compare the dentoskeletal and soft-tissue treatment
effects with mini-implants as anchor units in bialveolar
dental protrusion patients requiring extraction of 4 first
premolars and maximum retraction of anterior teeth
with patients treated with conventional methods of
anchorage reinforcement. Additionally, the time taken
for space closure was compared.
MATERIAL AND METHODS
Upadhyay et al 19
20 Upadhyay et al
Upadhyay et al 21
larger than 5% was considered statistically not significant. The statistical significance was determined at the
0.1%, 1%, and 5% levels of confidence.
All cephalometric measurements were repeated 5
weeks later by the same examiner. If there was a
difference between the 2 measurements, a third reading
was made, and the aberrant one was discarded. The
mean of the 2 closest was used in the calculations.
Additionally, the paired-samples t test was applied to
the 2 closest measurements of each variable. The
difference between the first and the second measurements of the 72 radiographs was insignificant (P
0.05). Correlation analysis applied to the same measurement showed the highest r value of 0.952 for the
SNB angle and lowest r value of 0.906 for inferior
sulcus to E-line.
RESULTS
22 Upadhyay et al
Upadhyay et al 23
24 Upadhyay et al
Table I.
G2 (n 18)
Measurement
Mean
SD
Mean
SD
P value
Significance
Age at T1 (y)
Duration of retraction (mo) (T2-T1)
17.61
8.61
3.56
2.2
17.38
9.94
2.89
2.44
0.838
0.094
NS
NS
Comparison of morphologic characteristics of the patients treated with mini-implants (G1) and without (G2)
at T1
G1 (n 18)
Skeletal measurements
SNA ()
SNB ()
ANB ()
Go-Gn-SN ()
UFH (N-ANS) (mm)
LFH (ANS-Me) (mm)
UFH/LFH (%) (mm)
PFH (S-Go) (mm)
TAFH (N-Me) (mm)
PFH/TAFH (%)
Pog-Sv (mm)
Dental measurements
U1-SN ()
IMPA ()
U1-L1 ()
U6-PP (mm)
U6-Sv (mm)
L6-MP (mm)
L6-Sv (mm)
U1-Sv (mm)
L1-Sv (mm)
Soft-tissue measurements
G-Sn-Pg ()
Nasolabial angle ()
Labiomental angle ()
Sv-Nt (mm)
E-lineLs (mm)
E-lineLi (mm)
E-lineSs (mm)
E-lineSi (mm)
G2 (n 18)
Mean
SD
Mean
SD
P value
Significance
82.67
78
4.67
30.78
48.94
67.44
72.94
75.44
116.11
65.47
64
2.57
3.82
2.38
6.92
2.5
4
6.38
7.01
4.1
5.04
8.03
80.45
76.67
4.67
31.28
51.56
64.78
80.1
75.94
116.44
65.23
59
3.6
2.22
1.68
7.09
1.89
4.17
7.03
4.68
3.63
5.38
5.71
0.3243
0.3512
1
0.8318
0.0013
0.0585
0.003
0.8031
0.7979
0.8939
0.0393
NS
NS
NS
NS
113
98.56
112.67
21.78
50.56
32
50.78
80.22
75.44
7.19
6.81
9.13
1.06
5.88
2.66
6.94
6.86
6.91
115.83
104.72
103.22
21.44
44.44
31
44.78
76.44
71.44
4.16
9.52
7.26
1.89
4.42
3.46
5.08
3.73
4.68
0.1595
0.0327
0.0016
0.5189
0.0013
0.3385
0.0059
0.0501
0.051
NS
*
18.67
92.11
114.33
98.67
1.39
5.83
9.39
3
6.53
10.69
19.31
6.63
1.84
2.47
0.76
2.54
19.33
103.44
109.78
97.11
0.11
4
9.38
3.44
3.94
16
21.31
2.93
1.57
1.46
1.45
1.2
0.7134
0.0182
0.5062
0.372
0.0129
0.0114
0.973
0.5197
NS
*
NS
NS
*
*
NS
NS
NS
NS
NS
NS
*
NS
NS
NS
NS
Upadhyay et al 25
Table III.
Skeletal measurements
SNA ()
SNB ()
ANB ()
Go-Gn-SN ()
UFH (N-ANS) (mm)
LFH (ANS-Me) (mm)
UFH/LFH (%)
PFH (S-Go) (mm)
TAFH (N-Me) (mm)
PFH/TAFH (%)
Pog-Sv (mm)
Dental measurements
U1-SN ()
IMPA ()
U1-L1 ()
U6-PP (mm)
U6-Sv (mm)
L6-MP (mm)
L6-Sv (mm)
U1-Sv (mm)
L1-Sv (mm)
Soft-tissue measurements
G-Sn-Pg ()
Nasolabial angle ()
Labiomental angle ()
Sv-Nt (mm)
E-lineLs (mm)
E-lineLi (mm)
E-lineSs (mm)
ElineSi (mm)
T2
Mean
SD
Mean
SD
P value
Significance
84.67
80
4.67
30.78
48.94
67.44
72.94
75.44
116.11
65.47
64
2.57
3.82
2.38
6.92
2.5
4
6.38
7.01
4.1
5.04
8.03
84.44
80.56
4
29.67
49.56
66
75.17
76.72
115.44
66.94
65.33
2.96
4.29
1.94
6.6
2.79
4.31
6.59
7.09
4.31
5.46
8.56
0.4299
0.0135
0.0037
0.0168
0.0063
0.0006
0.0086
0.0007
0.0967
0.0053
0.007
NS
*
113
98.56
112.67
21.78
50.56
32
50.78
80.22
75.44
7.19
6.81
9.13
1.06
5.88
2.66
6.94
6.86
6.91
97.89
84.33
141.11
21.56
49.78
31.25
49.89
73
69.39
7.22
6.89
6.76
1.1
6.11
2.17
7.12
7.01
6.87
0
0
0
0.1631
0.026
0.0151
0.007
0
0
18.67
92.11
114.33
98.67
1.39
5.83
9.39
3
6.53
10.69
19.31
6.63
1.84
2.47
0.76
2.54
16.33
103.78
118
99.56
1.5
1.06
9.89
5.06
6.08
11.67
19.7
6.88
1.85
2.18
0.58
2.48
0
0
0.2362
0.0456
0
0
0.0066
0
NS
NS
*
NS
*
institute by modifying surgical micro-screws routinely used to stabilize plates in the facial bones and
fracture reduction surgeries. To adapt these screws to
our needs (ie, for attachment of nickel-titanium coil
springs), we modified the shape of the head and made
the neck slightly longer.
Contrary to previous reports, we found no significant shortening of treatment time in patients treated
with mini-implants (P 0.05) (Table I).14 A possible
explanation could be that, in the G1 patients, closure of
extraction space was completely done by distalization
of anterior teeth; in the G2 patients, due to anchorage
loss, there was simultaneous movement of anterior and
posterior teeth into the extraction space. However,
treatment time depends not only on the rate of tooth
movement but also on other variables, such as mechanics, patient cooperation, and parent or patient motivation. These variables were not controlled in this study,
and it was assumed that patient cooperation and motivation in both groups were the same.
26 Upadhyay et al
Table IV.
Skeletal measurements
SNA ()
SNB ()
ANB ()
Go-Gn-SN ()
UFH (N-ANS) (mm)
LFH (ANS-Me) (mm)
UFH/LFH (%)
PFH (S-Go) (mm)
TAFH (N- Me) (mm)
PFH/TAFH (%)
Pog-Sv (mm)
Dental measurements
U1-SN ()
IMPA ()
U1-L1 ()
U6-PP (mm)
U6-Sv (mm)
L6-MP (mm)
L6-Sv (mm)
U1-Sv (mm)
L1-Sv (mm)
Soft-tissue measurements
G-Sn-Pg ()
Nasolabial angle ()
Labiomental angle ()
Sv-Nt (mm)
E-lineLs (mm)
E-lineLi (mm)
E-lineSs (mm)
E-lineSi (mm)
T2
Mean
SD
Mean
SD
P value
Significance
81.33
76.67
4.67
31.28
51.56
64.78
80.1
75.94
116.44
65.23
59
3.6
2.22
1.68
7.09
1.89
4.17
7.03
4.68
3.63
5.38
5.71
80.89
77.23
4.67
31.56
51.67
65.33
79.71
76.22
117.56
64.93
58.33
3.74
2.14
1.68
6.82
2.9
5.11
8.86
4.11
4.34
4.97
5.64
0.1037
0.0347
1
0.5457
0.8061
0.1806
0.6811
0.3958
0.0013
0.2947
0.1209
NS
*
NS
NS
NS
NS
NS
NS
115.83
104.72
103.22
21.44
44.44
31
44.78
76.44
71.44
4.16
9.52
7.26
1.89
4.42
3.46
5.08
3.73
4.68
99
94
128
22.11
47.67
32.22
47.44
70.11
66.89
7.62
7.64
9.57
1.97
4.5
3.78
4.15
4.1
4.48
0
0
0
0.0293
0
0.0046
0.0001
0
0
19.33
103.44
109.78
97.11
0.11
4
9.38
3.44
3.94
16
21.31
2.93
1.57
1.46
1.45
1.2
18.17
108.44
114.67
97.22
2.67
0.89
10.29
5.29
3.29
14.1
12.2
2.73
0.49
2.08
1.54
1.54
0.019
0
0.1686
0.4299
0
0
0
0.0002
NS
NS
NS
NS
Dentoskeletal effects
Upadhyay et al 27
Table V.
Skeletal measurements
SNA ()
SNB ()
ANB ()
Go-Gn-SN ()
UFH (N-ANS) (mm)
LFH (ANS-Me) (mm)
UFH/LFH (%)
PFH (S-Go) (mm)
TAFH (N-Me) (mm)
PFH/TAFH (%)
Pog-Sv (mm)
Dental measurements
U1-SN ()
IMPA ()
U1-L1 ()
U6-PP (mm)
U6-Sv (mm)
L6-MP (mm)
L6-Sv (mm)
U1-Sv (mm)
L1-Sv (mm)
Soft-tissue measurements
G-Sn-Pg ()
Nasolabial angle ()
Labiomental angle ()
Sv-Nt (mm)
E-lineLs (mm)
E-lineLi (mm)
E-lineSs (mm)
E-lineSi (mm)
G2 (n 18)
Mean
SD
Mean
SD
P value
Significance
0.22
0.56
0.67
1.11
0.61
1.44
2.22
1.28
0.67
1.48
1.33
1.17
0.86
0.84
1.78
0.83
1.46
3.17
1.31
1.61
1.96
1.85
0.44
0.78
0
0.28
0.11
0.56
0.39
0.28
1.11
0.3
0.67
1.1
1.44
0.49
1.91
1.89
1.69
3.95
1.35
1.23
1.18
1.73
0.5598
0.0022
0.007
0.0306
0.315
0.0006
0.036
0.0308
0.0008
0.0027
0.002
NS
13.11
14.22
28.44
0.22
0.78
0.75
0.89
7.22
6.06
6.57
3.75
7.34
0.65
1.35
0.84
1.23
2.07
1.76
16.83
10.72
24.78
0.67
3.22
1.22
2.67
6.33
4.56
9.2
5.58
10.4
1.19
1.06
1.59
2.11
2.57
1.46
0.1724
0.035
0.2311
0.0097
0
0
0
0.2608
0.0088
NS
*
NS
2.33
11.67
3.67
0.89
2.89
4.78
0.5
2.06
1.37
5.94
12.67
0.9
1.3
1.33
0.69
1.34
1.17
5
4.89
0.11
2.56
3.11
0.33
1.06
1.91
3.36
14.43
0.58
1.29
1.02
3.18
2.31
0.0435
0.0003
0.7887
0.0045
0.4461
0.0002
0.2911
0.1231
*
NS
*
*
NS
NS
NS
NS
NS
28 Upadhyay et al
been more accurate if the pretreatment axial inclinations of the incisors in both the groups had been
identical. Although 1 to 2 mm of anchorage loss is
clinically acceptable, higher amounts can be detrimental to the overall efficiency of the treatment, especially
when anchorage demand is critical. We believe that
mini-implants are better suited for patients who require
high or maximum anchorage, especially for vertical
growth patterns.
Soft-tissue changes
The purpose of this study was to compare the treatment effects of mini-implants as anchorage units in
bialveolar dental protrusion patients requiring maximum
retraction of anterior teeth to similar patients treated
conventionally. Favorable and greater levels of skeletal
and dental changes were observed in the bialveolar dental
protrusion patients treated with mini-implants as anchor
units than with conventional methods. However, the
soft-tissue response, although greater in G1, was variable.
The following conclusions can be drawn from this
study.
1. Mini-implants placed in maxillary and mandibular
interradicular bone provided absolute anchorage for
en-masse retraction of anterior teeth.
2. The success rate of the mini-implants was 93%. Of
the 72 implants used, only 5 came loose.
3. The time taken for retraction might be less for
patients treated with mini-implants, but, in this
study, the results were not statistically or clinically
significant.
4. The molars were distalized and intruded in G1; in
G2, there were significant levels of anchorage loss
in both the horizontal and vertical directions.
Upadhyay et al 29
18. Zierhut EC, Joondeph DR, rtun J, Little RM. Long-term profile
changes associated with successfully treated extraction and
nonextraction Class II Division 1 malocclusions. Angle Orthod
2000;70:208-19.
19. Isaacson JR, Isaacson RJ, Speidel TM, Worms FW. Extreme
variation in vertical facial growth and associated variation in
skeletal and dental relations. Angle Orthod 1971;41:219-29.
20. Aras A. Vertical changes following orthodontic extraction treatment
in skeletal open bite subjects. Eur J Orthod 2002;24:407-16.
21. Schudy FF. The control of vertical overbite in clinical orthodontics. Angle Orthod 1968;38:19-39.
22. Sassouni V, Nanda S. Analysis of dentofacial vertical proportions. Am J Orthod 1964;50:801-23.
23. Staggers JA. A comparison of results of second molar and first
premolar extraction treatment. Am J Orthod Dentofacial Orthop
1990;98:430-6.
24. Hans MG, Groisser G, Damon C, Amberman D, Nelson S,
Paloma JM. Cephalometric changes in overbite and vertical
facial height after removal of 4 first molars or first premolars.
Am J Orthod Dentofacial Orthop 2006;130:183-8.
25. Cusimano C, McLaughlin RP, Zernik JH. Effects of first bicuspid
extractions on facial height in high-angle cases. J Clin Orthod
1993;27:594-8.
26. Kuhn RJ. Control of anterior vertical dimension and proper
selection of extraoral anchorage. Angle Orthod 1968;38:
340-9.
27. Kocadereli I. The effect of first premolar extraction on vertical
dimension. Am J Orthod Dentofacial Orthop 1999;116:41-5.
28. Kim TK, Kim JT, Mah J, Yaung WS, Baek SH. First or second
premolar extraction effects on facial vertical dimensions. Angle
Orthod 2005;75:177-82.
29. Ziegler P, Ingervall B. A clinical study of maxillary canine
retraction with a retraction spring and with sliding mechanics.
Am J Orthod Dentofacial Orthop 1989;95:99-106.
30. Thiruvenkatachari B, Pavithranand A, Rajasigamani K, Kyung
HM. Comparison and measurement of the amount of anchorage
loss of the molars with and without the use of implant anchorage
during canine retraction. Am J Orthod Dentofacial Orthop
2006;129:551-4.
31. Baker RW, Guay AH, Peterson HW. Current concepts of
anchorage management. Angle Orthod 1972;42:129-38.
32. Gjessing P. Biomechanical design and clinical evaluation of new
canine-retraction spring. Am J Orthod 1985;87:353-62.
33. Peck S, Peck L, Kataja M. Skeletal asymmetry in esthetically
pleasing faces. Angle Orthod 1991;61:43-8.
34. Bowman SJ. More than lip service: facial esthetics in orthodontics. J Am Dent Assoc 1999;130:1173-81.
35. Prahl-Andersen B, Ligthelm-Bakker AS, Wattel E, Nanda R.
Adolescent growth changes in soft tissue profile. Am J Orthod
Dentofacial Orthop 1995;107:476-83.
36. Zylinski CG, Nanda RS, Kapila S. Analysis of soft tissue facial
profile in white males. Am J Orthod Dentofacial Orthop 1992;
101:514-8.
37. Oliver BM. The influence of lip thickness and strain on upper lip
response to incisor retraction. Am J Orthod 1982;82:141-9.
38. Lo FD, Hunter WS. Changes in nasolabial angle related to
maxillary incisor retraction. Am J Orthod 1982;82:384-91.
39. Wisth J. Soft tissue response to upper incisor retraction in boys.
Br J Orthod 1974;1:199-204.
40. Hillesund E, Fjeld D, Zachrisson BU. Reliability of soft-tissue
profile in cephalometrics. Am J Orthod 1978;74:537-50.
29.e1 Upadhyay et al
APPENDIX
Item
Description
Introduction, background
Methods, participants
2
3
Interventions
Objectives
Outcomes
5
6
Sample size
Randomizationsequence
generation
Randomizationallocation
concealment
Randomizationimplementation
10
Blinding (masking)
11
Statistical methods
12
13
Recruitment
Baseline data
Numbers analyzed
14
15
16
17
Ancillary analyses
18
Adverse events
19
Interpretation
20
Generalizability
Overall evidence
21
22
Reported on page
18
18, 19
19
19, 20
19
19-21
19, 20
19
19
19
19
21
19, 20
19,24 (Tables I and II)
19, 20, flow chart (Fig 1)
21
28
25-28