ORIGINAL ARTICLE

Displacement pattern of the maxillary arch depending on miniscrew position in sliding mechanics
Kee-Joon Lee,a Young-Chel Park,b Chung-Ju Hwang,b Young-Jae Kim,c Tae-Hyun Choi,d Hyun-Mi Yoo,e and Seung-Hyun Kyunge Seoul, Korea

Introduction: This clinical study was performed to evaluate the anteroposterior and vertical displacement patterns of the maxillary teeth in sliding mechanics depending on the position of interradicular miniscrews after the extraction of premolars. Methods: Thirty-six women requiring maximum incisor retraction because of bialveolar protrusion were divided into 2 groups: group A (n 5 18), miniscrew between the premolar and the molar, and group B (n 5 18), miniscrew between the premolars. Cephalometric measurements for skeletal and dental changes were made before and after space closure. Results: In both groups, signicant incisor retraction with intrusion of the root apex was noted, with no signicant change in the rst molar position. Group B displayed signicantly greater intrusion at both the incisal tip (1.59 6 1.53 mm) and the root apex (2.89 6 1.59 mm) than did group A. In spite of the mean reduction of the vertical skeletal measurements, we failed to nd signicant skeletal changes. Conclusions: Miniscrews provided rm anchorage for anterior retraction. Selection of the placement site appeared to be an important determinant for the resultant displacement pattern of the incisor segment. Discriminative intrusion or retraction might be obtained via strategic miniscrew positioning. (Am J Orthod Dentofacial Orthop 2011;140:224-32)

onocortical miniscrew-type temporary anchorage devices have become appliances of choice for securing anchorage in clinical orthodontics. The main orthodontic problems that demand maximum anchorage for premolar extraction include severe crowding and protrusion, which are frequent in many ethnic groups.1-4 Anterior retraction is performed with specic strategies that involve vertical control and specied tooth movement types, considering the patients preferences.5 Clinicians are frequently concerned about

a Associate professor, Department of Orthodontics, Oral Science Research Center, Institute of Craniofacial Deformity, Yonsei University, Seoul, Korea. b Professor, Department of Orthodontics, Yonsei University, Seoul, Korea. c Instructor, Department of Orthodontics, Yonsei University, Seoul, Korea. d Resident, Department of Orthodontics, Yonsei University, Seoul, Korea. e Associate professor, Department of Orthodontics, Samsung Medical Center, Seoul, Korea. The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article. Supported by the Korea Research Foundation Grant funded by the Korean Government (KRF- 313-2008-2-E00550). Reprint requests to: Seung-Hyun Kyung, Department of Orthodontics, Institute of Oral Health Science, Samsung Medical Center, 50, Ilwon-Dong, Kangnam-Ku, Seoul 135-710, Korea; e-mail, kaustin@smc.samsung.co.kr. Submitted, November 2009; revised and accepted, May 2010. 0889-5406/$36.00 Copyright 2011 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2010.05.020

vertical control of the incisors when a patient has vertical esthetic problemsie, a deepbite or a gummy smile.6 Although the clinical effectiveness of miniscrews as anchorage devices has already been shown elsewhere, the effects of varying placement sites on the pattern of anterior tooth movement has not been studied much.2,7 Compared with others such as implants and onplants, a major strength of the miniscrew is the variety of placement sites that can be used.8-10 Several authors have demonstrated miniscrew placement at the interradicular space between the second premolar and the rst molar for retraction of the anterior segment after premolar extraction.10-13 The subapical area is preferred for intrusion of the incisors.14 Selection of the placement site is based on the common sense that the amount of anteroposterior or vertical force vector might affect the displacement pattern of the segment. The line of force is thus determined by simply connecting the line between the miniscrew head and the attachment hooks on the wire, and it is obvious that varying miniscrew positions would create different force vectors.15 Considering the popularity of sliding mechanics with continuous wire, the following biomechanical characteristics need to be considered to better understand the mechanism of tooth movement in miniscrew sliding mechanics.16

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Table I. Comparison of pretreatment age and treatment duration between groups

Group A (n 5 18) Variable Age at T1 (y) Duration of retraction (T1-T0) (mo) Overall treatment time (mo) Miniscrewarchwire distance (mm) Line of force-archwire angle ( ) NS, Not signicant. *P \0.05. Mean 22.25 10.35 22.35 8.21 12.55 SD 5.36 2.33 5.53 1.61 3.73 Group B (n 5 18) Mean 22.10 11.15 24.32 8.30 18.87 SD 5.73 3.51 7.03 1.95 6.80 Signicance NS NS NS NS *

Unlike the reciprocal attraction between the anterior and posterior segments along the main archwire in conventional sliding mechanics, the elastic force from the miniscrew head does not primarily affect the posterior segment. Hence, it might not be necessary to put gable or compensatory bends in the archwire. A plain archwire would be adequate for the stabilization of the posterior segment in miniscrew sliding mechanics. Therefore, with a plain archwire, the line of force passing below the center of resistance of the anterior segment might lead to rotational movement of the incisor segment, possibly causing an increase in overbite. In contrast, since miniscrews placed in the alveolar bone normally have an intrusive component of force, the resultant incisor position is questioned.12 Additionally, subsequent displacement of the posterior segment might follow the movement of the anterior segment because of the connection of the 2 segments along a continuous archwire.11,17 In spite of ample clinical reports in the literature, investigations of the effect of miniscrew position on the movement pattern of the anterior and posterior segments are scarce, especially with regard to vertical effects. Due to the limited predictability of the biomechanical behavior of continuous wire on a theoretical basis, actual movement of the anterior and posterior segments needs to be investigated in clinical circumstances.18 The aims of this study were to compare the clinical effects of a single line of force from 2 miniscrew positions in patients with bialveolar protrusion and thus to provide useful clinical information on appropriate selection of placement sites for intentional control of retraction and intrusion in extraction patients.
MATERIAL AND METHODS

The subjects were selected from the patients who visited the orthodontic departments at either Yonsei University Dental Hospital or Samsung Medical Center, Seoul, Korea, between 2004 and 2006, with the chief complaint of lip protrusion (Table I). Since the authors carried out an intention-to-treat analysis, all patients

were included in the analysis regardless of treatment outcome, by an investigator (Y.J.K.) who had not been informed of the purpose of this study: (1) skeletal Class I or mild Class II patients when 4 premolars were indicated to be extracted because of protrusion, (2) interincisal angle smaller than 115 , (3) well-aligned maxillary and mandibular incisors with minimal crowding of less than 3 mm, (4) normal or moderately excessive overjet (2 mm \overject \6 mm), (5) permanent dentition with no missing or malformed tooth, and (6) cervical vertebrae maturation index of 6, indicating cessation of active growth, according to Franchi et al.19 A total of 36 women (mean age, 22.17 6 5.54 years) who met above inclusion criteria were selected and then further divided into 2 groups depending on the miniscrew position as described below (Table I). All patients were treated with preadjusted edgewise appliances with the Roth prescription (Tomy, Tokyo, Japan) and an 0.018 3 0.025-in slot. In the maxilla, all rst and second molars were bonded with molar tubes instead of bands for accuracy of the cephalometric measurements. After the initial bonding, tapered miniscrews with either 1.8-mm diameter and 7.0-mm length of the thread part (Orlus No 18107; Ortholution, Seoul, Korea) or 2.5-mm diameter and 7.0-mm length (Orthoplant 2507T; BioMaterials Korea Inc, Seoul, Korea) were placed between the maxillary second premolar and the rst molar in group A (n 5 18), or between the rst and second premolars in group B (n 5 18), under inltration anesthesia (Fig 1). The miniscrews were placed only by 2 experienced operators (K.J.L. and S.H.K.). In the mandible, reciprocal attraction with elastic chains between the archwire hooks and either the rst or second molar tube, depending on the molar relationship, was used. Plain 0.016 3 0.022-in stainless steel rectangular archwires were placed in both arches including the second molars. Short crimpable hooks (TP Orthodontics, LaPorte, Ind) or soldered hooks were attached distally to the lateral incisor (Fig 2). A retraction force of 150 g was given by the elastic chains (Ormco, Glendora, Calif), and the chains were renewed every 4 weeks. In both

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Fig 1. Schematic gures of the appliance setups: A, group A; B, group B.

Fig 2. Intraoral photographs with miniscrews: A, group A, and B, group B. before retraction.

groups, space closure was performed independently in each arch, and the use of intermaxillary elastics was avoided to eliminate possible extrusive effects on the anterior segment. After space closure, vertical up-anddown elastics in the posterior segment were used for nal settling of the occlusion. Cephalometric lms were taken before (T0) and after (T1) space closure so that the effects of the vertical elastics could be eliminated. At T0 and T1, standardized digital lateral cephalograms were taken by using the Cranex31 Ceph (Soredex, Milwaukee, Wis). V-Ceph software (version 3.5; Cybermed, Seoul, Korea) was used to obtain the cephalometric measurements. The radiographic magnication of the cephalograms was standardized at 100% actual size, with a 100-mm metal ruler image captured in the digital lm as the reference. A reconstructed occlusal plane (OP) was made by rotating the palatal plane (PP) at ANS (OP0 ) by the initial OP-PP angle, and by rotating the mandibular plane (MP) at menton by the initial OP-MP angle (OP00 ). A perpendicular line to the OP0 line passing sella (SV) was used as the vertical reference plane. The anteroposterior and vertical distances of the incisors and the rst molars in

each arch were measured. Cephalometric landmarks and planes, angular measurements, linear measurements, and abbreviations used in this study are summarized in Figures 3 and 4.
Statistical analysis

All statistical analyses were performed with SPSS software (version 14.0; SPSS, Chicago, Ill). Cephalometric measurements were made with the V-Ceph software by an examiner who was unaware of the purpose of the study (T.H.C.). With a 2-week interval, all cephalometric digitizing and analyses were repeated by the same examiner. Intraexaminer reliability was assessed by paired samples t tests between the 2 sets of measurements, and no signicant differences between them were found. Correlation between paired measurements was examined, with the highest coefcient for SNA (0.977) and the lowest for the SN-OP angle (0.912). The mean and the standard deviation for each cephalometric variable were determined in each group. The Kolmogorov-Smirnov method was used to conrm the normal distribution of the measurements. A 2-tailed paired t test was then used to determine the signicance of the treatment changes (T1-T0) in the groups. An

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Fig 3. Cephalometric landmarks and planes used in this study. A, Cephalometric landmarks: 1, sella (S); 2, nasion (N); 3, anterior nasal spine (ANS); 4, point A; 5, point B; 6, menton (Me); 7, gonion (Go); 8, incisal tip of the upper central incisors (U1t); 9, root apex of the upper central incisors (U1r); 10, mesial cusp tip of the upper rst molars (U6t); 11, mesial root apex of the upper rst molars (U6r); 12, incisal tip of the lower central incisors (L1t); 13, root apex of the lower central incisors (L1r); 14, mesial cusp tip of the lower rst molars (L6t); 15, mesial root apex of the lower rst molars (L6r). B, Cephalometric planes: OP, occlusal plane; OP 0 , maxillary horizontal reference plane on ANS parallel to the OP); OP 00 , mandibular horizontal plane on Me parallel to occlusal plane; SV, vertical reference plane on S perpendicular to the OP.

unpaired t test determined the differences of the 2 groups between T0 and T1. Correlation coefcients between the amounts of retraction and other variables were also obtained. The statistical signicance was determined at the 5% level of condence.
RESULTS

Of the 72 miniscrews placed in the 36 subjects, 4 miniscrews failed during retraction (2 in group A, 2 in group B), resulting in a 94.4% overall success rate. In the failure cases, retraction was transitionally discontinued for 2 to 3 months, and the miniscrews were replaced in the same interradicular area, with some clearance from the original site. None of the replaced miniscrews failed; hence, the failures were considered to have little inuence on the results. At T0, the 2 groups were similar in both the anteroposterior and vertical skeletal measurements. The mean SN-MP angle was larger in group B, but there was no statistical signicance. At the end of retraction, both groups had signicant decreases in SNA and SNB, implicating possible alveolar bone remodeling around Points A and B according to the posterior movement of the incisors. The signicant

reduction in the ANB angle was attributed to the greater reduction in the SNA than in the SNB. The occlusal plane angle signicantly increased during retraction in group A. No statistical signicance was found between the 2 groups in any skeletal measurement (Table II). Before retraction, there was no signicant difference in the dental measurements between the groups except for the maxillary incisor angle, which was greater in group B. Retraction of the incisors at both the incisal tip and the root apex in the maxilla and the mandible (U1t-SV, U1r-SV, L1t-SV, L1r-SV) was signicant in both groups. Maxillary molar movement was not signicant during retraction (U6t-SV, U6r-SV), whereas signicant mesial displacement was noted in the mandible. Intrusion of the incisal tip (U1t-OP0 ) was signicant in group B, and intrusion of the root apex was signicant in both groups (U1r-OP0 ). The mandibular incisors displayed signicant retraction in both groups but no signicant vertical displacement. Overbite and overjet were reduced in both groups, with a signicant change in overjet in group B (Table III). In both groups, signicant positive correlations were found between the amount of incisor intrusion and the change in the OP. Correlations between maxillary incisor

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Fig 4. Angular and linear measurements. A, Angular measurements: I, SNA angle; II, SNB angle; III, ANB angle; IV, U1 to PP; V, IMPA; VI, OP to SN; VII, SN to MP; linear measurements: 1, posterior facial height (PFH); 2, anterior facial height (AFH). B, Linear measurements: 3, U1t-OP0 , vertical position of U1t; 4, U1r-OP0 , vertical position of U1r; 5, U6t-OP0 , vertical position of U6t; 6, U6r-OP0 , vertical position of U6r; 7, U1t-SV, horizontal position of U1t; 8, U1r-SV, horizontal position of U1r; 9, U6t-SV, horizontal position of U6t; 10, U6r-SV, horizontal position of U6r; 11, L1t-OP00 , vertical position of L1t; 12, L1r-OP00 , vertical position of L1r; 13, L6t-OP00 , vertical position of L6t; 14, L6r-OP00 , vertical position of L6r; 15, L1t-SV, horizontal position of L1t; 16, L1r-SV, horizontal position of L1r; 17, L6t-SV, horizontal position of L6t; 18, L6r-SV, horizontal position of L6r; overbite, vertical overlap between incisor tips; overjet, horizontal overlap between incisor tips.

intrusion and maxillary molar intrusion, and between maxillary incisor intrusion and SN-MP angle were found in group B (Table IV).
DISCUSSION

Both the anteroposterior and the vertical positions of the maxillary incisors are crucial for facial esthetics. For example, active intrusion of the incisors is indicated in patients with a gummy smile, whereas subjects with a reverse smile arc might need extrusion of the maxillary incisors.20-22 Anterior retraction after premolar extraction can be performed by using either friction or frictionless mechanics. Previous experiments have demonstrated that the sliding mechanics might lead to uncontrolled tipping or extrusion of the anterior segment.23,24 An A-type T-loop generates an intrusive force in the anterior segment and an extrusive force in the posterior segment during retraction of the incisors.25 Similarly, an intrusion arch could cause signicant anterior aring and extrusion of the molars.26 Extrusive forces on the posterior segment can be detrimental, especially in a hyperdivergent face. Hence,

reliable retraction mechanics that induce controlled intrusion and retraction in the anterior segment without signicant extrusion of the posterior segment might be favored in dealing with vertical problems such as a hyperdivergent face or a gummy smile. For this reason, we measured the displacements of the rst molars and the incisors. Both premolar-molar and premolar-premolar interradicular areas have been shown to be relatively safe for miniscrew placement.8,13 The difference in the placement site caused signicant differences in the angle of the line of force, but not in the mean height of the miniscrews relative to the archwire, possibly due to the limited height of the keratinized gingiva (Table I, Fig 5). The success rate of the miniscrews in this study was 94.4%, which was relatively higher than in previous reports.27,28 Relevant reasons include placement by experienced operators, adult subjects, and a miniscrew diameter of 1.8 mm or 2.5 mm.27 To minimize the variations in linear measurements, only female subjects were chosen. In view of the changes in the rst molar, these results support previous ndings.11,12 In both groups, mesial

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Table II. Skeletal measurements before retraction (T0) and changes during retraction in each group (T1-T0)
T0 Group A Variable SNA ( ) SNB ( ) ANB ( ) SN-MP ( ) AFH (mm) PFH (mm) SN-OP ( ) Mean 81.72 77.55 3.58 36.41 130.62 83.67 18.79 SD 4.01 3.52 2.07 5.55 6.13 6.03 3.96 Group B Mean 81.33 75.99 4.83 39.66 132.80 82.73 20.65 SD 3.23 2.78 1.71 5.50 3.72 5.51 5.13 Signicance NS NS NS NS NS NS NS Mean 0.89 0.34 0.55 0.14 0.38 0.34 1.36 Group A SD 0.20 0.69 0.94 0.75 1.40 0.94 1.25 Signicance y * * NS NS NS * Mean 1.83 0.83 1.01 0.35 0.68 0.03 0.07 T1-T0 Group B SD 2.09 1.02 1.60 0.94 1.33 0.75 2.20 Signicance * * * NS NS NS NS Signicance NS NS NS NS NS NS NS

NS, Not signicant. *P \0.05; yP \0.01.

Table III. Dental measurements before retraction (T0) and changes during retraction (T1-T0) in each group
T0 Group A Variable U1t-SV (mm) U1r-SV (mm) U6t-SV (mm) U6r-SV (mm) L1t-SV (mm) L1r-SV (mm) L6t-SV (mm) L6r-SV (mm) U1-PP ( ) IMPA ( ) U1t-OP0 (mm) U1r-OP0 (mm) U6t-OP0 (mm) U6r-OP0 (mm) L1t-O00 (mm) L1r-O00 (mm) L6t-O00 (mm) L6r-O00 (mm) Overbite (mm) Overjet (mm) Mean 91.78 75.28 55.41 55.11 86.45 77.43 58.08 52.80 119.48 103.83 30.92 10.57 30.45 12.07 43.97 24.78 43.09 24.15 2.77 3.66 SD 6.44 4.06 3.90 3.98 5.39 6.34 4.25 5.26 4.52 3.54 2.36 2.37 2.55 2.78 3.12 2.29 3.68 2.31 2.11 2.54 Group B Mean 93.25 76.45 57.01 57.60 88.24 76.42 60.34 53.04 115.86 100.06 31.33 11.44 31.39 13.35 45.24 24.88 42.77 23.77 3.44 4.36 SD 5.60 4.90 4.60 3.55 5.84 6.14 4.44 5.16 5.61 6.73 2.47 3.42 2.05 2.89 2.77 1.99 2.44 2.55 2.34 2.77 Signicance NS NS NS NS NS NS NS NS * NS NS NS NS NS NS NS NS NS NS NS Mean 7.20 2.66 0.70 0.45 5.85 1.85 1.94 2.04 9.89 10.18 0.25 1.80 0.24 0.35 0.34 0.77 0.35 0.80 0.67 0.94 Group A SD 1.58 1.45 1.25 1.58 1.71 1.39 1.48 1.67 5.18 5.29 1.51 1.45 0.78 0.74 1.06 1.70 1.27 1.69 1.74 1.45 Signicance y y NS NS y y * y y y NS y NS NS NS NS NS NS NS NS Mean 7.32 3.20 0.80 0.45 5.71 1.94 2.01 2.09 10.74 7.42 1.59 2.89 0.44 0.55 0.99 0.45 0.60 0.95 1.33 1.98 T1-T0 Group B SD 2.04 2.91 1.41 1.55 2.64 1.77 1.85 2.58 6.09 7.84 1.53 1.59 1.24 1.45 1.34 1.54 1.07 1.44 1.66 2.03 Signicance y y NS NS y y * * y y y y NS NS NS NS NS NS NS * Signicance NS NS NS NS NS NS NS NS NS NS y y NS NS NS NS NS NS NS NS

NS, Not signicant. *P \0.05; yP \0.01.

movement of the maxillary molars was less than 1.0 mm at both the cusp tip and the root apex (P .0.05), whereas the mandibular molars signicantly moved mesially. However, this movement of the mandibular molars did not affect the treatment outcome, since many subjects had slight Class II molar relationships at the beginning. Minute intrusions of the maxillary molars in both groups (U6t-OP0 , U6r-OP0 ) were noted, with no statistical signicance. This suggests that, in miniscrew sliding mechanics, the displacement of the anterior segment

possibly affects the posterior segment because of the continuity of the archwire. Furthermore, intentional movement of the whole dentition might be possible by increasing the number of miniscrews in the arch, although a single miniscrew is supposed to be adequate for movement of the tooth segment,29,30 as in part shown by Yamada et al.31 In terms of anteroposterior movement, maximum retraction of the incisors was obtained in both groups. The amount of incisor axis reduction in both groups appears to reect the bracket-wire play. Between 0.018 3

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Table IV. Correlation coefcients between variables in each group

U1t-SV Group A U1t-SV R Signicance U1t-OP0 R Signicance Group B U1t-SV R Signicance U1t-OP0 R Signicance U1t-PP U6t-PP U6-PP OP-PP SN-MP

0.08

0.21

0.07

0.10

0.22

0.08

0.22

0.03

0.59 *

0.29

0.07

0.21

0.06

0.06

0.25

0.07

0.19

0.41 *

0.66 *

0.40 *

*P \0.05; R, correlation coefcient.

Fig 5. Schematic diagrams of displacement patterns: A, group A; B, group B.

0.025-in slot and 0.016 3 0.022-in rectangular wire, the play was reported as 9.3 , which is close to the inclination change in this study.32 Second-order bends in the archwire, such as a V-bend, might reduce the lingual inclination of the incisors. However, their effects on the arch length and the vertical dimension are largely unpredictable.33 Control of incisor inclination could therefore be better performed by either using overtorqued incisor brackets or giving extra torque on the wire, not necessarily with a second-order bend in the wire. An interesting nding in this study was the differences in the movement patterns of the incisors between the groups (Fig 5). The vertical position of the incisal tip

relative to the reconstructed OP (OP0 ) did not signicantly change during retraction in group A, but it was signicantly reduced in group B. However, signicant intrusion in the root apex level in group A implies a considerable amount of intrusion at the center of resistance.34 According to this nding, iatrogenic bite deepening during anterior retraction by the "draw-bridge effect" can be prevented or minimized, eliminating the possible need for additional intrusive mechanics during retraction. Signicantly greater incisor intrusion at both the incisal edge and the root apex in group B appeared to be attributed to the greater vertical angulation of the line of force than that in group A. The vertical displacement of the incisor tip was shown to be associated with the level of horizontal load. Choy et al35 proposed a functional axis representing the shift of the center of rotation in response to various horizontal force levels. The center of rotation is formed at the mesiogingival area of the anterior segment by a line of force close to the center of resistance, resulting in minimal extrusion of the incisal edge; this was relevant to the intrusion in group B. However, the experiment indicated only an initial displacement pattern, and the overall changes therefore should be interpreted on a clinical basis. The dynamics of sliding mechanics combined with miniscrews are demonstrated in Figure 6. Since the line of force is located below the center of resistance of the incisor segment when a short hook was used in the wire, the initial response appeared to be rotation of the incisor.24 Additionally, deformation of the wire and friction of the wire would also affect the initial displacement pattern of the incisors.24,36 Depending on the elasticity of the archwire and the force degradation of the elastomeric chains, it is probable that the initial

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Taken together, it could be claimed that the displacement pattern of the anterior segment was explainable according to the relationship between the linear force by the miniscrew and the incisor segment. The pattern of tooth movement is associated with the line of force formed by the position of the miniscrew. Consequently, simultaneous intrusion and retraction were feasible by modifying the miniscrew position or, alternatively, by changing the points of attachment. Further investigations on the dynamics of tooth movement, including bracketslot size, archwire stiffness, friction, and tissue reactions, are needed for comprehensive understanding of the responses to the various forces introduced by miniscrews.
CONCLUSIONS Fig 6. Schematic diagrams of the dynamics of tooth movement in sliding mechanics with miniscrews.

displacement of the incisor segment affects the posterior segment.37 A constant heavy force along a stiff archwire would subsequently displace the posterior segment, as described by Jung and Kim.17 In contrast, because of the degradation of the elastic force, it is likely that the incisor segment will be repositioned at the original archwire level by the rebound of the wire (Fig 6, B). It was therefore presumed that the resultant incisor position might be largely determined by the constancy of the force, the stiffness of the archwire, and the direction of the line of force. The mandibular incisal edge was remarkably retracted but did not demonstrate a signicant vertical change. In spite of the tendency toward reduction in the vertical position of the molar and the other skeletal vertical measurements including SN-MP and AFH, we failed to show any signicance in the vertical skeletal change. Vertical skeletal change related to extraction of teeth can be realistic only in patients with an open bite extending to the posterior teeth.38 Even extraction of the second premolars did not effectively reduce the vertical dimension compared with rst premolar extractions.39 However, Upadhyay et al11 reported signicant reductions in the vertical dimension (SN-Go-Gn) in groups with mini-implants in their randomized clinical trial. One major difference was that miniscrews were not used in the mandibles in our study. Orthodontic miniscrews placed in the mandibular arch might have induced a signicant vertical skeletal change; this was the limitation of this study that focused mainly on the maxillary arch. However, one must be prepared for these intrusive effects and related vertical changes in the arch and also the skeletal pattern, as has been shown in anecdotal case reports.40

In this study, we aimed to evaluate the anteroposterior and the vertical displacement pattern of the maxillary anterior and posterior segments in sliding mechanics according to the positions of interradicular miniscrews. The ndings are summarized as follows. 1. Both groups had sufcient anchorage reinforcement for maximum anterior retraction amounts of 7.20 mm in group A and 7.32 mm in group B. The ANB angle was signicantly decreased in both groups, with no group difference. In group A, the vertical position of the incisal edge did not change signicantly during the retraction period. In group B, signicantly greater intrusion (1.59 mm) was found compared with group A. Neither group displayed signicant changes in skeletal vertical dimensions.

2.

3.

According to the results, simultaneous intrusion and retraction can be effectively obtained by using miniscrews between the premolars in extraction patients, without any intervention of the intrusive mechanics.
REFERENCES 1. Park HS, Yoon DY, Park CS, Jeoung SH. Treatment effects and anchorage potential of sliding mechanics with titanium screws compared with the Tweed-Merrield technique. Am J Orthod Dentofacial Orthop 2008;133:593-600. 2. Park HS, Bae SM, Kyung HM, Sung JH. Micro-implant anchorage for treatment of skeletal Class I bialveolar protrusion. J Clin Orthod 2001;35:417-22. 3. Park YC, Chu JH, Choi YJ, Choi NC. Extraction space closure with vacuum-formed splints and miniscrew anchorage. J Clin Orthod 2005;39:76-9. 4. Liu YH, Ding WH, Liu J, Li Q. Comparison of the differences in cephalometric parameters after active orthodontic treatment applying mini-screw implants or transpalatal arches in adult patients with bialveolar dental protrusion. J Oral Rehabil 2009;36:687-95. 5. Ioi H, Nakata S, Nakasima A, Counts AL. Anteroposterior lip positions of the most-favored Japanese facial proles. Am J Orthod Dentofacial Orthop 2005;128:206-11.

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6. Burstone CR. Deep overbite correction by intrusion. Am J Orthod 1977;72:1-22. 7. Creekmore TD, Eklund MK. The possibility of skeletal anchorage. J Clin Orthod 1983;17:266-9. 8. Poggio PM, Incorvati C, Velo S, Carano A. Safe zones: a guide for miniscrew positioning in the maxillary and mandibular arch. Angle Orthod 2006;76:191-7. 9. Lee JS, Kim DH, Park YC, Kyung SH, Kim TK. The efcient use of midpalatal miniscrew implants. Angle Orthod 2004;74:711-4. 10. Kim HJ, Yun HS, Park HD, Kim DH, Park YC. Soft-tissue and cortical-bone thickness at orthodontic implant sites. Am J Orthod Dentofacial Orthop 2006;130:177-82. 11. Upadhyay M, Yadav S, Nagaraj K, Patil S. Treatment effects of mini-implants for en-masse retraction of anterior teeth in bialveolar dental protrusion patients: a randomized controlled trial. Am J Orthod Dentofacial Orthop 2008;134:18-29. 12. Upadhyay M, Yadav S, Patil S. Mini-implant anchorage for en-masse retraction of maxillary anterior teeth: a clinical cephalometric study. Am J Orthod Dentofacial Orthop 2008;134:803-10. 13. Lee KJ, Joo E, Kim KD, Lee JS, Park YC, Yu HS. Computed tomographic analysis of tooth-bearing alveolar bone for orthodontic miniscrew placement. Am J Orthod Dentofacial Orthop 2009; 135:486-94. 14. Kanomi R. Mini-implant for orthodontic anchorage. J Clin Orthod 1997;31:763-7. 15. Smith RJ, Burstone CJ. Mechanics of tooth movement. Am J Orthod 1984;85:294-307. 16. Park HS, Kwon OW, Sung JH. Microscrew implant anchorage sliding mechanics. World J Orthod 2005;6:265-74. 17. Jung MH, Kim TW. Biomechanical considerations in treatment with miniscrew anchorage. Part 1: the sagittal plane. J Clin Orthod 2008;42:79-83. 18. Burstone CJ, Koenig HA. Force systems from an ideal arch. Am J Orthod 1974;65:270-89. 19. Franchi L, Baccetti T, McNamara JA Jr. Mandibular growth as related to cervical vertebral maturation and body height. Am J Orthod Dentofacial Orthop 2000;118:335-40. 20. Hwang WS, Hur MS, Hu KS, Song WC, Koh KS, Baik HS, et al. Surface anatomy of the lip elevator muscles for the treatment of gummy smile using botulinum toxin. Angle Orthod 2009;79:70-7. 21. Kim TW, Kim H, Lee SJ. Correction of deep overbite and gummy smile by using a mini-implant with a segmented wire in a growing Class II Division 2 patient. Am J Orthod Dentofacial Orthop 2006; 130:676-85. 22. Isaacson RJ, Lindauer SJ. Closing anterior open bites: the extrusion arch. Semin Orthod 2001;7:34-41. 23. Rhee JN, Chun YS, Row J. A comparison between friction and frictionless mechanics with a new typodont simulation system. Am J Orthod Dentofacial Orthop 2001;119:292-9. 24. Tominaga JY, Tanaka M, Koga Y, Gonzales C, Kobayashi M, Yoshida N. Optimal loading conditions for controlled movement

25. 26.

27.

28.

29.

30. 31.

32. 33.

34.

35.

36.

37.

38.

39.

40.

of anterior teeth in sliding mechanics. Angle Orthod 2009;79: 1102-7. Melsen B, Fotis V, Burstone CJ. Vertical force considerations in differential space closure. J Clin Orthod 1990;24:678-83. van Steenbergen E, Burstone CJ, Prahl-Andersen B, Aartman IH. Inuence of buccal segment size on prevention of side effects from incisor intrusion. Am J Orthod Dentofacial Orthop 2006; 129:658-65. Miyawaki S, Koyama I, Inoue M, Mishima K, Sugahara T, Takano-Yamamoto T. Factors associated with the stability of titanium screws placed in the posterior region for orthodontic anchorage. Am J Orthod Dentofacial Orthop 2003;124:373-8. 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. Kuroda S, Katayama A, Takano-Yamamoto T. Severe anterior open-bite case treated using titanium screw anchorage. Angle Orthod 2004;74:558-67. Park HS, Lee SK, Kwon OW. Group distal movement of teeth using microscrew implant anchorage. Angle Orthod 2005;75:602-9. Yamada K, Kuroda S, Deguchi T, Takano-Yamamoto T, Yamashiro T. Distal movement of maxillary molars using miniscrew anchorage in the buccal interradicular region. Angle Orthod 2009; 79:78-84. Creekmore TD. Dr. Thomas D. Creekmore on torque. J Clin Orthod 1979;13:305-10. Clifford PM, Orr JF, Burden DJ. The effects of increasing the reverse curve of Spee in a lower archwire examined using a dynamic photo-elastic gelatine model. Eur J Orthod 1999;21:213-22. van Steenbergen E, Burstone CJ, Prahl-Andersen B, Aartman IH. The relation between the point of force application and aring of the anterior segment. Angle Orthod 2005;75:730-5. Choy K, Kim KH, Burstone CJ. Initial changes of centres of rotation of the anterior segment in response to horizontal forces. Eur J Orthod 2006;28:471-4. Kusy RP, Whitley JQ, Prewitt MJ. Comparison of the frictional coefcients for selected archwire-bracket slot combinations in the dry and wet states. Angle Orthod 1991;61:293-302. De Genova DC, McInnes-Ledoux P, Weinberg R, Shaye R. Force degradation of orthodontic elastomeric chainsa product comparison study. Am J Orthod 1985;87:377-84. Aras A. Vertical changes following orthodontic extraction treatment in skeletal open bite subjects. Eur J Orthod 2002;24: 407-16. Kim TK, Kim JT, Mah J, Yang WS, Baek SH. First or second premolar extraction effects on facial vertical dimension. Angle Orthod 2005;75:177-82. Paik CH, Woo YJ, Boyd RL. Treatment of an adult patient with vertical maxillary excess using miniscrew xation. J Clin Orthod 2003; 37:423-8.

August 2011  Vol 140  Issue 2

American Journal of Orthodontics and Dentofacial Orthopedics