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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 188-193

Assessment of anchorage loss with conventional versus contemporary method of intraoral anchorage: A prospective clinical study


1 Dental Centre, Jaipur, India
2 Department of Dental Surgery and Oral Health Sciences, Armed Forces Medical College, Pune, Maharashtra, India
3 Air Force Institute of Dental Sciences, Bengaluru, Karnataka, India
4 Naval Dental Centre, Visakhapatna, India
5 Department of Community Medicine, Armed Forces Medical College, Pune, India

Date of Submission28-May-2021
Date of Acceptance18-Jun-2021
Date of Web Publication23-Aug-2021

Correspondence Address:
Rajneesh Kumar Joshi
Department of Community Medicine, Armed Forces Medical College, Pune
India
Sanjeev Datana
Department of Dental Surgery and Oral Health Sciences, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrr.jdrr_55_21

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  Abstract 


Background: Anchorage control is a major concern in the design of orthodontic treatment planning. Even the best known methods to reinforce the anchorage result in taxing of the anchor unit. Control of anchorage is primarily important in “critical anchorage” situations where no anchor loss is acceptable. Temporary anchorage devices (TADs) offer to solve one of our greatest dilemmas of “anchorage control” and have been compared in this study with conventional intraoral anchorage in situ. Materials and Methods: The study involved a total of 60 subjects; 26 males and 34 females with a mean age of 16.7 years having Angle's Class I malocclusion with severe crowding who were divided randomly into two groups; Group A - TADs and Group B - Nance palatal button (NPB) for anchorage preparation. Amount of anchor loss was determined at maxillary first molar using the pre- and post-treatment lateral cephalograms. Results: The mean range of difference between pre- and post-values of the maxillary molar position in Group A was 0.02–0.09 mm (P = 0.005) and in Group B was 1.18–1.26 mm (P = 0.0001). Hence, the anchorage loss during the initial phase of leveling and alignment was approximately 1.22 mm with the use of NPB and minimal when TADs were placed and engaged before leveling and alignment. Conclusion: Minimal mesial movement of the maxillary first molars was observed when TADs were placed and engaged before leveling and alignment, thus proving their efficacy in maximum anchorage situations.

Keywords: Contemporary anchorage, contemporary anchorage, micro-implants, Nance palatal button, temporary anchorage devices


How to cite this article:
Nakra O, Datana S, Walia B S, Soni P, Joshi RK. Assessment of anchorage loss with conventional versus contemporary method of intraoral anchorage: A prospective clinical study. J Dent Res Rev 2021;8:188-93

How to cite this URL:
Nakra O, Datana S, Walia B S, Soni P, Joshi RK. Assessment of anchorage loss with conventional versus contemporary method of intraoral anchorage: A prospective clinical study. J Dent Res Rev [serial online] 2021 [cited 2021 Dec 4];8:188-93. Available from: https://www.jdrr.org/text.asp?2021/8/3/188/324419




  Introduction Top


”Anchorage control” has been the most challenging part for the orthodontist since the practice of orthodontics. Control of anchorage is primarily important in “critical anchorage” situations, where no undesirable movement of the anchorage unit is acceptable.[1] Anchorage can be provided by extraoral as well as intraoral methods. However, patient compliance is a major factor for success in extraoral anchorage, and also, its use in adolescent patients is limited owing to work schedules, social commitments, and social stigma attached.[2] Intraoral methods such as grouping of teeth, transpalatal arch (TPA) or the Nance palatal button (NPB), and skeletal anchors have been widely used to provide anchorage in various situations of orthodontic mechanotherapy. These methods however have not been able to provide stable anchorage due to their inherent side effects.[3]

The quest for search for an ideal intraoral anchorage device has led orthodontists to micro-implants or temporary anchorage devices (TADs), which offer to solve one of the greatest dilemmas of “anchorage control.”[4],[5] In conventional orthodontics, intraoral anchorage is prepared with NPB and is frequently encountered with loss of anchorage, which may be undesirable.

Hence, the purpose of this prospective study was to check the efficiency of contemporary method of anchorage preparation with TADs (micro-implants) compared with conventional Nance button method of anchorage enhancement during initial leveling/alignment and retraction of maxillary canine, in the management of severe crowding Class I malocclusions.

Aim

The aim of the study is to compare the efficiency of TADs (micro-implants) supported intraoral anchorage with conventional NPB method of anchorage enhancement during initial leveling/alignment and retraction of maxillary canine in the management of severe crowding malocclusions.


  Materials and Methods Top


This is an in vivo study with study population that included the patients attending the outpatient department (OPD) of orthodontics and dentofacial orthopedics. Sixty patients were invited to participate in the study after screening of 76 patients who were enrolled over the period of time [Figure 1]. Sample size was calculated for an effect size of one (the minimum difference between two groups to be detected is 0.2 mm with standard deviation [SD] of 0.2 mm in both groups); with alpha error of 1% and power of 90%, the sample size comes out to be 30 in each group. Necessary ethical clearance was obtained from the institutional ethical committee (IEC/Apr/2018 dated April 20, 2018), and written consent was obtained from the patients.
Figure 1: Patient allocation flowchart

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Inclusion criteria

Patients were included in the study, if he/she satisfied the following inclusion criteria:

  1. Angle's Class I molar relation (ANB = 2°–4°)
  2. Crowding more than 6 mm in the maxilla
  3. Permanent dentition
  4. Requiring extractions of maxillary first premolars
  5. Absence of any systemic illness affecting bone metabolism.


Exclusion criteria

Patients were excluded from the study if he/she had:

  1. History of orthodontic treatment
  2. Missing any permanent maxillary teeth (other than third molar)
  3. Poor periodontal support
  4. Cleft lip and palate
  5. Craniofacial syndromes.


A total of 60 subjects (26 males and 34 females) with a mean age of 16.7 years were invited for the study after taking informed consent. Patients were divided randomly into two groups by making them pick up a chit. The two groups were:

  • Group A – TADs (micro-implants)
  • Group B – NPB group.


Standard pretreatment records (T1) were made, patients underwent thorough oral prophylaxis, and therapeutic extractions of the maxillary first premolars were carried out in the maxillary arch as per the treatment plan. 0.022” × 0.028” Preadjusted edgewise appliance (PEA), McLaughlin Bennett Trevisi (MBT) prescription was bonded for all patients. Alignment and leveling was done with the help of 0.014”/0.016” NiTi archwire followed by 0.016” × 0.022” NiTi, 0.017” × 0.025” SS, and finally a 0.019” × 0.025” SS archwire which was used during canine retraction. For Group A, TADs, i.e., titanium micro-implant with diameter 1.3 mm and length 7 mm (Dentos, India Pvt. Ltd.), were placed for anchorage preparation, while for Group B, Taylor-made NPB using 0.9-mm stainless steel wire soldered to the maxillary first molar bands was used for anchorage preparation. TADs were placed between maxillary first molar and the second premolar, and care was taken that TADs should not be inserted above the level of attached gingiva into mobile alveolar mucosa as failure rates are more.[2] Cotton tweezers was used to confirm the stability; gentle lateral force was applied on the head of micro-implants. Intraoral periapical (IOPA) radiographs were taken to confirm the position of the TADs. Patients were recalled after 14 days of insertion of TADs for loading. A laceback in a 0.010” SS ligature wire was engaged from a hole available in the head of the TAD to the power arm of the canine bracket on each side, which was tightened enough so as not to produce discomfort to the patient. Following the leveling and alignment and the archwire being 0.019” × 0.025” SS, “active tiebacks” were engaged from the TADs to the canine hook to provide a light continuous force of around 150 g for the purpose of canine retraction [Figure 2]. Canines on either side were retracted sufficiently to allow alignment of incisors. It was at this stage of treatment (T2) that lateral cephalogram was recorded for each case.

For Group B, band transfer was done and a 0.9-mm SS wire was soldered and self-cure acrylic was used to fabricate a NPB. The assembly fabricated was cemented using glass ionomer cement. Routine procedure for bonding was carried out, and the same archwire sequence was followed as in the case of Group A. Following completion of leveling and alignment and the archwire being 0.019” ×0.025” SS, “active tiebacks” were engaged from the molar tube hook to the canine hook to provide a continuous force of 150 g for the purpose of canine retraction [Figure 2]. Canines on either side were retracted sufficiently to allow alignment of incisors. It was at this stage of treatment (T2) that lateral cephalogram was recorded for each case.
Figure 2: Clinical photographs: (a) Canine retraction in Group A (mini-implants), (b) Nance palatal button in situ, (c) canine retraction in Group B

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The anchorage loss was checked on the cephalograms recorded [Figure 3]. Pretreatment (T1) and posttreatment (T2) cephalograms were traced manually by an independent investigator who was not a part of clinical team of the study. To determine the amount of anchor loss (horizontal movement of the maxillary first molar), a perpendicular was dropped from Sella (point S) to the occlusal line perpendicular (OLp)[6] and the linear distance between the perpendicular and the mesial contact point of the maxillary permanent first molar was calculated.
Figure 3: Anchorage loss calculation on lateral cephalogram

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Statistical analysis

The data on categorical variables is shown as n (% of cases) and the data on continuous variables are presented as mean and SD. The cephalometric variables were summarized by calculating mean, SD, and 95% confidence interval. Paired t-test was used for comparison of changes within the group after treatment. In the entire study, the P < 0.05 was considered to be statistically significant. All the hypotheses were formulated using two-tailed alternatives against each null hypothesis (hypothesis of no difference). Comparison of pre- and post-treatment values which extrapolates to anchorage loss in two groups was done by using independent sample's t-test. P < 0.05 was considered statistically significant. R software version 3.1.0 (R Core Team, New Zealand) was used for statistical analysis. All results are shown in tabular as well as in graphical format.

Intra- and inter-operator agreement

Fifteen randomly selected lateral cephalograms were reassessed after 1 week by the same and another trained operator, to ascertain intra- and inter-operator bias. The Intraclass correlation (ICC) analysis for measurements carried out on lateral cephalogram had significantly higher ICC values, i.e., 0.895 for intra-operator and 0.826 for inter-operator agreement (P < 0.001), which indicate statistically significant intra- and inter-operator agreement.


  Results Top


Seventy-six patients from the waiting list as well as routine OPD were screened for eligibility over 6 months to obtain the sample of 60 patients for the present study. Sixty subjects fulfilling the criteria, consented to take part in the study, including 26 males and 34 females with a mean age of 16.7 years, were included. There were no drop-outs during the study, and thus, all sixty were evaluated to obtain the results.

Position of the maxillary first molar was calculated on cephalograms as linear distance between mesial contact point (ms) of maxillary first molar and the perpendicular (OLp) from sella (point S) on occlusion plane. This linear distance in pretreatment cephalogram in Group A ranged from 43.3 to 47.3 mm with a mean value of 45.51 mm (SD ± 1.03) and in Group B ranged from 43.5 to 47.3 mm with a mean value of 45.27 mm (SD ± 1.11) [Table 1] and [Figure 4]. Posttreatment results showed the same measurements ranged between 43.4 and 47.3 mm, with a mean value of 45.57 mm (SD ± 1.02) in Group A, and between 44.8 and 48.5 mm, with a mean value of 46.49 mm (SD ± 1.09) in Group B [Table 1] and [Figure 5].
Table 1: Mean linear measurement

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Figure 4: Pretreatment distance, occlusal line perpendicular to mesial contact point first maxillary molar in Group A and Group B

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Figure 5: Posttreatment distance, occlusal line perpendicular to mesial contact point first maxillary molar in Group A and Group B

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The range of difference between pre- and post-values of molar position in Group A is 0.02–0.09 mm which is statistically significant (P = 0.005). Similarly, the range of difference between pre- and post-values of molar position in Group B is 1.18–1.26 mm which is highly statistically significant (P = 0.0001) [Table 2] and [Figure 6]. Comparing the change in measurements between the two groups posttreatment, Group B shows a significantly (P = 0.001) greater change compared to Group A [Table 2] and [Figure 6].
Table 2: Mean anchorage loss in both groups

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Figure 6: Anchorage loss in Group A and Group B

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  Discussion Top


Orthodontic implants (micro-implants) or TADs have been a part of contemporary orthodontic treatment planning for conservation of anchorage. Although the concept of metal components for orthodontic anchorage dates back to around 1940s, it was popularized when some of the landmark animal studies initially by Gainsforth and Higley.[7] Several researchers have used micro-implants/mini-screws for orthodontic anchorage at various sites intraorally for different malocclusions. Studies with micro-implants positioned between the roots of the second premolar and the first molar have shown successful retraction of canines or entire anterior segment.[8],[9],[10],[11],[12],[13]

Smith and Storey[14] showed that 5%–50% of the total extraction space can be taken up by an anchor unit made up of the first molar and the second premolar, when used to retract a canine. This loss of anchorage may not be desirable in cases with critical anchorage. In such situations, the use of TADs (micro-implants) seems to be a promising option of anchorage preparation for different types of malocclusions and the same has been proved to be successful for carrying various tooth movements.[12],[15],[16],[17],[18],[19],[20]

Although there are numerous studies that rotate around the potential, success, and failures of TADs, as stated earlier, there are a very few studies that too in the form of case reports or pilot studies which have reviewed the topic in discussion. One of them is by Thiruvenkatachari et al.,[21] who did a pilot study to compare and measure the amount of anchorage loss of the molars with and without the use of implant anchorage during canine retraction after completion of the leveling and alignment phase. Their results showed no anchorage loss occurred in the implant-retained side but reported a mean amount of 1.6 mm mesial movement of the molar in the nonmicro-implant side. They concluded that titanium micro-implants could function as simple and efficient anchors for canine retraction when maximum anchorage is desired, a finding which is similar to our study.

Another study similar to ours is a randomized controlled trial done by Sharma et al.,[22] who compared mesial movement of upper first molars during initial phase of leveling and alignment, including maxillary canine retraction using a PEA having anchorage reinforcement by a TPA or mini-screw implant. In their study, authors have used indirect anchorage, i.e. engaged the second premolars with a passive 0.010” SS ligature wire to the implant, whereas in the present study, direct method of engagement of implants to the canines in the form of laceback has been used, and both methods are well documented. Previous study has used pterygoid vertical plane as a reference plane to measure the anchor loss, whereas in our study, occlusal line perpendicular (OLp) has been used, due to ease of construction and owing to the identification of anterior margin of pterygoid process which might not be easy in some cases. Sharma et al. in their study noted minimal mesial movement of the maxillary first molars with mini-screw implants compared to approximately 2.5 mm of mesial movement of the maxillary first molars when using a TPA. This is similar to the findings of our study as far as the implant-based sample is concerned, although anchor loss with NPB was found to be less in our study than that found by Sharma et al., with mean being 1.22 mm. The variation in results can be due to two reasons: one that present study did not evaluate anchor loss during entire canine retraction and another that the Nance button has been found to provide a better anchorage control than TPA.[23]

The retraction of canines was not completed in the extraction spaces but stopped at a point where retraction was sufficient to resolve the crowding and create a group of anteriors, which were then retracted en masse. Furthermore, the study was aimed at finding the anchorage loss during the initial phase, i.e., “leveling and alignment,” which included the canine retraction to an extent that it allows decrowding of anteriors, a finding where the literature was silent at the time study was planned and even remains grey till date. However, this also helped us complete the study faster and prevent any dropouts.

It will be beneficial to evaluate the anchor loss during the remaining treatment, i.e. the en masse retraction of anteriors, and thus evaluate the total anchor loss. This will help compare the anchorage requirements during initial and final phase of treatment.


  Conclusion Top


The anchorage loss during the initial phase of leveling and alignment was studied at the mesial contact point of the maxillary first molars for the two groups, which was recorded to be approximately 1.22 mm with the use of NPB; however, it was minimal when TADs were placed and engaged before leveling and alignment. Hence, it can be concluded that TADs (micro-implants) should be considered as a good option in clinical situations demanding absolute anchorage during the initial phase of leveling and alignment.

Ethical clearance

IEC/Dental/2018/165.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rajesh M, Kishore M, Shetty KS. Comparison of anchorage loss following initial leveling and aligning using ROTH and MBT prescription – A clinical prospective study. J Int Oral Health 2014;6:16-21.  Back to cited text no. 1
    
2.
Dalessandri D, Salgarello S, Dalessandri M, Lazzaroni E, Piancino M, Paganelli C, et al. Determinants for success rates of temporary anchorage devices in orthodontics: A meta-analysis (n>50). Eur J Orthod 2014;36:303-13.  Back to cited text no. 2
    
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Malhotra A, Mangla R, Dua VS, Kannan S, Arora N, Singh AK. A clinical comparative study using anchorage from mini-implants and conventional anchorage methods to retract anterior teeth. J Family Med Prim Care 2021;10:468-74.  Back to cited text no. 3
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Tian H, Xie C, Lin M, Yang H, Ren A. Effectiveness of orthodontic temporary anchorage devices in canine retraction and anchorage preservation during the two-step technique: A systematic review and meta-analysis. BMC Oral Health 2020;20:278.  Back to cited text no. 4
    
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Antoszewska J, Papadopoulos MA, Park HS, Ludwig B. Five-year experience with orthodontic miniscrew implants: A retrospective investigation of factors influencing success rates. Am J Orthod Dentofacial Orthop 2009;136:158.e1-10.  Back to cited text no. 5
    
6.
Pancherz H. The mechanism of Class II correction in Herbst appliance treatment. A cephalometric investigation. Am J Orthod 1982;82:104-13.  Back to cited text no. 6
    
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Gainsforth BL, Higley LB. A study of orthodontic anchorage possibilities. Am J Orthod Oral Surg 1945;31:406-17.  Back to cited text no. 7
    
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Park HS, Bae SM, Kyung HM, Sung JH. Microimplant anchorage for treatment of skeletal class I bialveolar protrusion. J Clin Orthod 2001;35:417-22.  Back to cited text no. 8
    
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Lee JS, Park HS, Kyung HM. Microimplant anchorage for lingual treatment of a skeletal class II malocclusion. J Clin Orthod 2001;35:643-7.  Back to cited text no. 9
    
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Bae SM, Park HS, Kyung HM, Kwon OW, Sung JH. Clinical application of micro-implant anchorage. J Clin Orthod 2002;36:298-302.  Back to cited text no. 10
    
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Kyung HM, Park HS, Bae SM, Sung JH, Kim H. Development of orthodontic micro-implants for intra-oral anchorage. J Clin Orthod 2003;37:321-5.  Back to cited text no. 11
    
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Chung KR, Nelson G, Kim SH, Kook YA. Severe bidentoalveolar protrusion treated with orthodontic microimplant-dependent en-masse retraction. Am J Orthod Dentofacial Orthop 2007;132:105-15.  Back to cited text no. 12
    
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Garfinkle JS, Cunningham LL Jr., Beeman CS, Kluemper GT, Hicks EP, Kim MO. Evaluation of orthodontic mini-implant anchorage in premolar extraction therapy in adolescents. Am J Orthod Dentofacial Orthop 2008;133:642-53.  Back to cited text no. 13
    
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Smith R, Storey E. The importance of force in orthodontics: The design of cuspid retraction springs. Aust Dent J1952;56:291-304.  Back to cited text no. 14
    
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Herman RJ, Currier GF, Miyake A. Mini-implant anchorage for maxillary canine retraction: A pilot study. Am J Orthod Dentofacial Orthop 2006;130:228-35.  Back to cited text no. 15
    
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Kuroda S, Sugawara Y, Deguchi T, Kyung HM, Takano-Yamamoto T. Clinical use of miniscrew implants as orthodontic anchorage: Success rates and postoperative discomfort. Am J Orthod Dentofacial Orthop 2007;131:9-15.  Back to cited text no. 16
    
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Garfinkle JS, Cunningham LL Jr., Beeman CS, Kluemper GT, Hicks EP, Kim MO. Evaluation of orthodontic mini-implant anchorage in premolar extraction therapy in adolescents. Am J Orthod Dentofacial Orthop 2008;133:642-53.  Back to cited text no. 17
    
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Motoyoshi M, Uemura M, Ono A, Okazaki K, Shigeeda T, Shimizu N. Factors affecting the long-term stability of orthodontic mini-implants. Am J Orthod Dentofacial Orthop 2010;137:588.e1-5.  Back to cited text no. 18
    
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Stivaros N, Lowe C, Dandy N, Doherty B, Mandall NA. A randomized clinical trial to compare the Goshgarian and Nance palatal arch. Eur J Orthod 2010;32:171-6.  Back to cited text no. 19
    
20.
Papageorgiou SN, Zogakis IP, Papadopoulos MA. Failure rates and associated risk factors of orthodontic miniscrew implants: A meta-analysis. Am J Orthod Dentofacial Orthop 2012;142:577-95.  Back to cited text no. 20
    
21.
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.  Back to cited text no. 21
    
22.
Sharma M, Sharma V, Khanna B. Mini-screw implant or transpalatal arch-mediated anchorage reinforcement during canine retraction: A randomized clinical trial. J Orthod 2012;39:102-10.  Back to cited text no. 22
    
23.
Sandler J, Murray A, Thiruvenkatachari B, Gutierrez R, Speight P, O'Brien K. Effectiveness of 3 methods of anchorage reinforcement for maximum anchorage in adolescents: A 3-arm multicenter randomized clinical trial. Am J Orthod Dentofacial Orthop 2014;146:10-20.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2]



 

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