CLINICAL TECHNIQUES

T-loop spring vs ricketts maxillary canine

retractor in canine retraction efficacy and
anchorage loss control: A cone-beam
computed tomography study
Mariam M. Masaes,a Ahmad S. Burhan,a Mohamed Youssef,a and Fehmieh R. Nawayab
Damascus, Syria

This study aimed to compare the Burstone technique using the T-loop spring (TLS) and Ricketts maxillary
canine retractor (RMCR) in canine retraction efficacy and anchorage loss control using cone-beam com-
puted tomography. Data was taken from 31 patients with maxillary canine retraction using either the Bur-
stone technique, in which an off-centered TLS was applied (TLS group, n = 14), or Ricketts technique, in
which the RMCR was applied (RMCR group, n = 17). Cone-beam computed tomography images were
obtained before and after retraction. The evaluated outcomes were the vertical and sagittal movement
amounts of the centers of resistance, the tipping, the rotation, and the buccolingual inclination of both
canine and molar, in addition to the amount of root resorption of the canine. Using the TLS demonstrated
a significantly greater amount of canine retraction and intrusion (P = 0.003; P = 0.002) and fewer degrees
of mesial-out rotation (P = 0.004) than the RMCR. No significant differences in canine tipping and inclina-
tion were found. The difference in root resorption was also insignificant. No significant differences were
found in molar linear and angular movement changes, except for the anteroposterior tipping direction
(P <0.001). The molar protracted bodily with the TLS and tipped mesially with the RMCR. The TLS can
control the sagittal canine movement more effectively than the RMCR, whereas the RMCR can better
control the canine movement vertically. Both springs can cause a similar and significant amount of canine
root resorption. The molar tends to tip distally when the TLS is used, and it tips mesially when the
RMCR is used, with a significant difference between the methods. (Am J Orthod Dentofacial Orthop Clin
Companion 2022;2:26–40)

a
Department of Orthodontics, Faculty of Dentistry, Damascus
University, Damascus, Syria.
b
Department of Pediatric Dentistry, Faculty of Dentistry, Syrian
Private University, Damascus, Syria.
All authors have completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest, and none were
reported.
The present retrospective study obtained ethical approval
from the Ethics Committee at the Ministry of Higher Education
in Syria. (No. 3100). Because of the retrospective nature of the
present study, no informed written consents were obtained
from patients or parents.
Address correspondence to: Mariam M. Masaes, Depart-
ment of Orthodontics, Faculty of Dentistry, Damascus Uni-
versity, Mazzeh, Highway, Damascus, Syria; e-mail,
memo8a1992@outlook.com
M axillary canine retraction after first premolars
extraction is one of the most common treatment
strategies in orthodontics. Two main systems
have been introduced for extraction space closure: sliding
mechanics using coils or elastics and nonsliding mechanics
using loops. Nonsliding mechanics can overcome friction,
which is one of the most problematic phenomena in slid-
ing. Space closure in frictionless mechanics can be
achieved by either a looped continuous archwire or the
segmented (or sectional) arch technique. In the continu-
ous technique, the loop is bent on the main nonbroken
archwire; it is then formed around the whole dental arch
and connects brackets on adjacent teeth, and each tooth
moves around its center of rotation.1 The looped continu-
ous archwire is advantageous for incisors and en-mass
retraction, whereas segmental and sectional springs are

26 AJO-DO CLINICAL COMPANION


preferable for separate canine retraction. Many segmental
and sectional springs for canine distalization have been
described and tested in the literature2-5; among them, 2
common springs have undergone extensive clinical use:
the T-loop spring (TLS)6 and the Ricketts maxillary canine
retractor (RMCR).7
In the context of the segmented arch technique, Bur-
stone introduced the TLS6; this spring retracts the canine
or the active unit leaning on the reactive (anchor) one,
whereas it does not necessarily connect brackets and
tubes on adjacent teeth. To deliver constant light forces
with reasonable control over the anchor unit, the wire of
the TLS differs in size and material from those connecting
teeth in each unit. The TLS is fabricated by 0.017 £ 0.025-
in beta-titanium wire (TMA). According to Kuhlberg and
Burstone,8 clinicians can achieve differential space closure
by altering this preactivated symmetrical loop position or
making the residual moments (preactivation) bends asym-
metric (differential moments strategy). The TLS has fre-
quently been tested clinically in prospective controlled
trials compared with either other springs9-13 or with sliding
mechanics14; it is the standard spring that can be custom-
ized and used clinically to apply specific force systems.15-17
Canine root resorption during retraction with the TLS has
been evaluated in 2 clinical studies.14,17
Unlike the TLS, the RMCR is a sectional arch spring.18
Without arch segmentation, the RMCR retracts the canine
leaning directly on the premolar and then the molar con-
necting, in turn, brackets and tubes on adjacent teeth
using one continuous wire. The RMCR is fabricated with a
0.016 £ 0.016-in cobalt-chromium alloy wire (blue Elgiloy).
Anchorage cannot be controlled by altering the RMCR posi-
tion because of the small interbracket distance; thus, Rick-
etts indicated the need to apply a buccal root torque
(cortical bone anchorage system) to reduce the mesial molar
drifting during retraction and to delay its movement by plac-
ing its roots against the laminated and cortical bone.7
The RMCR was evaluated clinically in 2 studies that
compared sliding mechanics19,20; it has also been used
while detecting the best force magnitude for canine retrac-
tion21 and evaluating the effect of laser therapy in acceler-
ating canine distalization.22 Regarding the anchorage
control using the cortical bone anchorage system, accord-
ing to Ricketts, it has only been tested clinically compared
with the straight-wire in 1 previous study.23
Most relevant studies that have tested the TLS and
RMCR applied the springs without considering the compre-
hensive list of related techniques. Furthermore, those pre-
vious studies have depended on clinically evaluated
outcomes or 2-dimensional records assessments, thus lim-
iting the movement description and making it difficult to
evaluate the spring efficacy. Both devices are commonly
used in clinical practice, and the precise resulting canine
and molar movement are critical points to judge their effi-
cacy at the first stage of retraction (in individual canine
February 2022, Vol 2, Issue 1
Masaes et al.
retraction). Therefore, this study aimed to compare the
TLS and RMCR when each was used in its prescribed envi-
ronment and applied as advised in the original techniques,
using a 3-dimensional (3D) records assessment which is
generally more advanced in precision and accuracy than a
2-dimensional assessment.24,25
To meet the research purpose, we used cone-beam
computed tomography (CBCT) in a retrospective study to
compare 2 different techniques in canine retraction: the
Burstone technique using TLS and the Ricketts technique
using Ricketts maxillary canine retractor. The first outcome
was the quality of the canine retraction, it was assessed by
evaluating the canine center of resistance movement sagi-
tally and vertically, the 3D canine angulation changes, and
the amount of root resorption. The second outcome was
the quality of molar anchorage control which was also
assessed by evaluating the molar center of resistance
movement and its angular changes. The null hypothesis
was that there is no significant difference between the TLS
and the RMCR in the quality of canine movement control
and molar anchorage control.
MATERIAL AND METHODS
The present retrospective study obtained ethical
approval from the Ethics Committee at the Ministry of
Higher Education in Syria (No. 3100).
CBCT images of 41 patients who had undergone maxil-
lary first premolars extraction and canine retraction by
either the TLS or the RMCR between August 2018 and
March 2020 and had acquired 2 CBCT images before
retraction (T0) and after ending retraction of both left and
right canines (T1) were obtained from the archives of the
Department of Orthodontics, Faculty of Dental Medicine,
Damascus University. The inclusion criteria were: (1) aged
between 14 and 23 years, (2) having a bilateral Class II mal-
occlusion which only needs maxillary first premolars
extraction and actual canines retraction (a minimum of a
half cusp Class II canine relationship), (3) a full permanent
dentition, (4) overjet >4 mm and <8 mm, (5) a skeletal
Class I or Class II malocclusion (2°< ANB <9°), and (6) nor-
mal or long anterior facial height (N-S-Pog, 64°-68°; MM,
25°-31°). Exclusion criteria were: (1) the presence of a max-
illary canine with excessive malposition or rotation, (2) the
need to extract mandibular premolars, and (3) skeletal
deepbite or decreased anterior facial height. The effect
size was calculated depending on the mean and standard
deviation of the canine retraction variable derived from a
previous study. It was used to calculate the total sample
size.19 The statistical power of >85%, a significance level
of 0.05, and a (1:1) allocation ratio gave a total of 28
patients at an effect size of 1.19. The final sample size was
31 patients: 14 for the TLS (mean age, 17.32 § 2.18 years; 2
males, 12 females) and 17 for the RMCR (mean age 17.60 §
2.74 years; 4 males, 13 females). Moreover, the mean dura-
tion between T0 and T1 was 5.80 § 1.13 months for the
27
Masaes et al.

Table I. Descriptive statistics and intergroup comparisons for the main characteristics of both groups (independent t test and chi-
square test)

Main characteristics TLS RMCR P value

Sex 0.517

Male: n (%) 2 (14.3) 4 (23.5)

Female: n (%) 12 (85.7) 13 (76.5)

Age (y) 17.32 § 2.18 17.60 § 2.74 0.206

Minimum 14 14.5

Maximum 21 22.2

ANB (°) 8.00 § 1.83 8.20 § 1.42 0.728

MM (°) 30.28 § 4.8 30.52 § 2.91 0.863

Y-axis (°) 71.21 § 2.60 70.21 § 1.42 0.219

U1-SN (°) 107.07 § 4.42 104.41 § 3.74 0.080

L1-GoMe (°) 101.21 § 6.17 98.88 § 3.19 0.186

Crowding (-) (mm)

Maxillary arch 2.31 § 1.93 3.28 § 1.50 0.150

Mandibular arch 1.39 § 1.33 1.30 §1.09 0.839

Time needed to achieve a Class I 5.92 § 1.75 5.26 § 1.10 0.209

canine occlusion (mo)
S.Dis3 (mm) 40.18 § 2.31 40.87 § 2.52 0.440

Tip3 (°) 90.07 § 4.03 96.57 § 4.15 0.740

Rot3 (°) 32.16 § 3.50 35.85 § 8.57 0.143

V.Dis3 (mm) 10.44 § 2.19 10.87 § 1.99 0.578

Trq3 (°) 102.37 § 4.19 104.85 § 5.07 0.155

Time interval between T0 and T1 6.64 § 2.16 5.82 § 1.13 0.217

CBCT records (mo)
Minimum 4 4

Maximum 11 8
TLS, T-loop spring; RMCR, Ricketts maxillary canine retractor; n, sample size; S.Dis3, the sagittal position of the canine center of resistance; Rot3,
canine rotation; Tip3, canine tipping; V.Dis3, the vertical position of the canine center of resistance; Trq3, canine torque / inclination; T0, before retrac-
tion; T1, after achieving a Class I canine relationship at both sides.

whole sample, whereas the time needed to achieve a Class
I canine relationship was 5.92 § 1.75 months for the TLS
and 5.26 § 1.10 months for the RMCR. Descriptive statistics
and intergroup comparisons regarding the baseline data
are shown in Table I. These characteristics were similar
across both groups, indicating adequate intergroup com-
parability. Because of the retrospective nature of the pres-
ent study, no informed written consents were obtained
from patients or parents.
A span of 1-2 weeks was allotted after extraction of the
maxillary first premolars, after which time the orthodontic
appliances were applied by the principal researcher (M.M.M).
Six differences were identified between the 2 techniques
when their springs were applied: (1) the bracket prescrip-
tion and dimensions, (2) the need to level and align the
posterior unit, (3) the dimensions and material of the wire
used to form the spring, (4) the spring type (segmented vs.
sectional arch type), the companion anchorage style and
the resulting stress distribution pattern on posteriors, (5)
the preactivation (residual moment bends shape and
amount), and (6) the spring activation amount. These dif-
ferences will be described in detail for each technique.
The maxillary first molars were banded with an edge-
wise tube with a 0.022-in slot height. Four edgewise

28 AJO-DO CLINICAL COMPANION


Fig 1. Passive T-loop dimensions.
brackets with a 0.022-in slot height were bonded on the
canines and second premolars. The molars and premolars
were then held as a segment using a welded transpalatal
arch (TPA) with 0.8 mm of stainless steel (SS) wire size and
0.019 £ 0.025-in SS buccally-inserted wire that was
secured with a ligature wire on each side. This was done
without any preliminary leveling and alignment.
The TLS was fabricated from a 0.017 £ 0.025-in TMA
wire (no. 3524, American Orthodontics, Sheboygan, Wis),
with the standard dimensions described by Burstone (Fig
1).8 The residual moment bends were 40° for antitip and
60° for antirotation in each horizontal arm,26 with a smooth
curvature shape.26,27 The TLS was engaged in the auxiliary
molar tube and canine bracket and placed 2 mm off-center
toward the posterior after being activated 6 mm (approxi-
mately 345 g of activation applied force8) (Fig 2).
The maxillary first molars were banded with an edge-
wise tube with 0.018-in slot height before the symmetrical
buccal root torque was applied using an SS TPA with a
Fig 2. A, Lateral view of the TLS used in this study; B, Occlusal view.
February 2022, Vol 2, Issue 1
Masaes et al.
0.8 mm round wire size. The torque bends were then
applied, whereby each end of the TPA was 10 mm occlusal
of the lingual sheath while the counterpart end was
inserted. Next, 4 brackets of Ricketts’ prescription with a
0.018-in slot height were bonded on the canines and sec-
ond premolars. Finally, posterior leveling and alignment
were required before the RMCR could be applied.
The RMCR was formed by 0.016 £ 0.016-in blue Elgiloy
wire (no. 3524, American Orthodontics). Because no spe-
cific standard dimensions were described in the literature,
the author had to determine the spring dimensions. An
appropriate small spring size was chosen using approxi-
mately 70 mm of wire length (Fig 3) to fulfill the fit; the
spring had 45° of antitip and antirotation V-shaped bends
on each horizontal arm.7 It was located as mesially as pos-
sible, with 3 mm of activation amount (approximately
150 g of activation force7) (Fig 4).
All 31 patients had a monthly check-up visit to ensure
the amount of activation. The reactivation was performed
by the investigator (M.M.M) only for the applied forces by
cinching-back on the first molar; this was done by recover-
ing the deactivation amount when it reached ≥ 1 mm to
keep the forces as constant as possible. Because it was
impractical to remove the springs and ensure the set of
preactivation amounts monthly, the applied moments
were never reactivated. If a patient had 1 canine that
reached a Class I occlusion before the peer, a passive
open box-shaped SS wire was implemented to secure the
canine with the molar until the peer reached a Class I
occlusion.
The quality of canine retraction was assessed by evalu-
ating the canine’s center of resistance (CRs3) movement,
the canine’s angulation changes, and the amount of root
resorption. The quality of anchorage control was assessed
by evaluating the molar’s center of resistance (CRs6)
movement and its angular changes.
The first CBCT scan was obtained immediately at T0,
and the second was obtained at T1. All CBCT images
were obtained from the scanner-console PaX-i3D Green
(Vatech, Hwaseong-si, Gyeonggi-do, South Korea) in a
29
Masaes et al.

Fig 3. Activated Ricketts spring dimensions.

15 £ 15-cm field of view with a 0.25 mm3 voxel size and
9 seconds of exposure time. The device settings were
98 kV and 10.2 mA.
The measurement was assessed using 3D CD Viewer
Ver. 1.2.6.27 software (Vatech) by the investigator (M.M.
M), in a similar vein to Wilson et al.28
To calculate the outcome measures, 6 dental and 3
skeletal constant reference points and lines were deter-
mined and drawn. The dental points and lines were as
follows:
1. The long and the horizontal axes of the canines and
their centers of resistances (Fig 5): to draw the long
axis and to measure the canine length, the image was
oriented according to a line passing through the crown
tip and the apex tip in the coronal and sagittal planes,
and according to the great buccolingual width in the
axial plane. The line perpendicular to the great bucco-
lingual width was considered the horizontal axis. The
CRs3 measures 40% of the distance between the root
apex and the alveolar margin, starting with the alveolar
margin29; this was initially determined vertically in both
sagittal and coronal planes and was positioned axially
into the center of the pulp canal. The distance between
the CRs3 and the crown tip in T0 records was saved
for each canine in each patient to redefine the same
CRs3 in T1 records, yielding the investigator partially
blinded to the CBCT patient’s name and time points.
2. The long and the horizontal axes of the molars and
their centers of resistances (Fig 6): the long axis was

Fig 4. A, Lateral view of the Ricketts spring used in this study; B, Occlusal view.

30 AJO-DO CLINICAL COMPANION

 Masaes et al.

Fig 5. CBCT image orientation to draw the canine long axis (canine length determination) in both (A) sagittal and (B) coronal planes
and the horizontal axis in (C) the axial plane. The CRs3 was marked by an arrow. The midlines between the lines of the mesial and
distal alveolar margins are marked in (A) the sagittal plane, and between the lines of the buccal and lingual ones in (B) the coronal
plane was used to determine the CRs3. It was initially marked twice (once in each plane), and the average position was adopted to
represent the final location of the CRs3 (C), thus locating the adopted CRs3 in the center of the pulp canal in the axial plane.

determined after the image was oriented according to
a line passing through the trifurcation and the buccal
groove in the sagittal plane and the trifurcation and
the central pit in the coronal plane; simultaneously,
the orientation was determined according to a line
passing through the distolingual groove and the buc-
cal groove in the axial plane. The axis perpendicular
to the line passing through the distolingual groove
and the buccal groove in the axial plane was consid-
ered horizontal. The CRs6 was marked at the trifurca-
tion in the axial and sagittal planes.
The skeletal reference lines involved the following
(Fig 7):
The ANS-PNS line (in the sagittal and axial planes), the
PNS line (which is the line perpendicular to ANS-PNS in
PNS [in the axial plane]), and the orbital line (in the coro-
nal plane); were all drawn after the image was oriented
according to them. The linear and angular measurements
and the variables of both canine and molar were obtained
by measuring the lengths and angles explained in Table II
and shown in Figs 8 and 9.

Fig 6. CBCT image orientation to draw the long axis of the molar in the (A) coronal and (B) the sagittal planes and the horizontal axis
in (C) the axial plane. The CRs6 was marked by arrows in (B) the sagittal plane and (D) the axial plane.

February 2022, Vol 2, Issue 1 31

Masaes et al.

Fig 7. A, Drawing the palatal line (ANS-PNS) and the PNS line in the axial plane; B, The orbital line was drawn in the coronal plane,
and the 3D view of the skull was utilized in aiding the assessor to orient the image precisely to draw that line in the coronal plane.

Table II. The outcomes variables and the obtained linear and angular measurements

Outcomes (measurements’ values changes Measurements obtained from the CBCT Planes
between T0 and T1) images at each time point
The quality of canine retraction
The sagittal movement amount of the canine The sagittal distances between the CRs3 and Axial plane
(S.Dis3) the PNS line
Canine’s rotation change (Rot3) The rotation angle between the horizontal axis Axial plane
of the canine and the ANS-PNS line
Canine’s tipping change (Tip3) The tipping angle between the long axis of the Sagittal plane
canine and the ANS-PNS line
The vertical movement amount of the canine The vertical distance from the CRs3 to the ANS- Sagittal plane
(V.Dis3) PNS line
Canine’s inclination change (Trq3) The inclination angle between the canine long Coronal plane
axis and the orbital line
Canine’s root resorption (Rt3) The entire canine length: the distance from the Sagittal and
tip of the crown to the apex tip coronal planes
The quality of anchorage control
The sagittal movement amount of the molar The sagittal distance between the CRs6 and a Axial plane
(S.Dis6) line perpendicular to ANS-PNS in PNS
Molar’s rotation change (Rot6) The rotation angles between the horizontal axis Axial plane
of the molar and the ANS-PNS line
Molar’s tipping change (Tip6) The tipping angle between the long axis of the Sagittal plane
molar and the ANS-PNS line
The vertical movement amount of the molar The vertical distance from the CRs6 to the ANS- Sagittal plane
(V.Dis6) PNS line
Molar’s inclination change (Trq6) The inclination angle between the molar long Coronal planes
axis and the orbital line
ANS, anterior nasal spine; PNS, posterior nasal spine.

32 AJO-DO CLINICAL COMPANION

 Masaes et al.

Fig 8. The canine linear and angular measurements: A, The distance from the CRs3 (arrow) to the PNS line (S.Dis3), the angle
between the horizontal axis and ANS-PNS (Rot3), and the tipping angle of the canine (Tip3); B, The vertical distance of CRs3 relative
to ANS-PNS line (V.Dis3); and C, The buccolingual inclination of the canine relative to the orbital line (Trq3).

Because of the existence of the TPA, which integrates
both the right and left sides into 1 unit in each group, we
decided to average the right- and left-side values for all
the measurements (baseline data are included) and the
outcomes variables (except the root resorption values).
Three weeks after the first measurement was recorded,
all measurements were repeated for 20% of the total (T0
and T1) CBCT images. The intraexaminer reliability was
tested using the intraclass correlation coefficient test,
which ranged from 0.90 to 0.99 for all measurements. No
significant systematic difference between the first and the
repeated measurements was demonstrated using a paired
t test (P >0.05).
pretreatment and posttreatment measurements. Changes
between T0 and T1 were distributed normally for all varia-
bles except the root resorption amount of the canine in
the RMCR group. The following analyses were performed:
(1) a paired t test was used to detect any significant differ-
ences between left- and right-side values, planning to
average their values (canine length values were not
included); (2) a paired t test was used to detect intragroup
differences in linear and angular measurements; (3) an
independent sample t test was used to evaluate intergroup
differences in all linear and angular changes, except in
regard to the root resorption of the canine, for which the
Mann-Whitney test was used.

Statistical analysis RESULTS

SPSS (version 25, IBM Corp, Armonk, NY, 2017) was No significant differences were detected using the
used to perform all statistical analyses. The Kolmogorov- paired t test between the right and left sides, except for in
Smirnov test detected the normal distribution for all the amount of canine retraction in the RMCR group

Fig 9. The molar linear and angular measurements: A, The distance from the CRs6 to the PNS Line (S.Dis6), the rotation angle of the
molar (Rot6),and the tipping angle of the molar (Tip6); B, The vertical distance from CRs6 to ANS-PNS (V.Dis6); and C, The
buccolingual inclination of the molar relative to the orbital line (Trq6).

February 2022, Vol 2, Issue 1 33

Masaes et al.
Fig 10. Means of linear and angular measurements of the canine and molar at T0 and T1 for each group: A, Canine measurements for
the TLS group; B, Canine measurements for the RMCR group; C, Molar measurements for the TLS group; and D, molar measurements
for the RMCR group.
(P = 0.035) and the T0 and T1 molar rotation values in the
TLS group (P = 0.001 and P = 0.015, respectively).
Canine linear and angular measurements for each
group at T0 and T1 are shown in Fig 10, A and B. In both
the TLS and RMCR groups, the CRs3 was significantly
retracted (P <0.001) and associated with significant distal
tipping (P <0.001) and mesial-out rotation (P = 0.009 and
P <0.001, respectively) (Fig 11). The TLS group had signifi-
cantly more CRs3 retraction (P = 0.003) and less canine
rotation (P = 0.004) and insignificantly less canine tipping
than the RMCR group (P = 0.136) (Table III).
The canine also intruded significantly (P <0.001,
P = 0.001), but with an insignificant buccolingual inclina-
tion change in both groups (P = 0.124, P = 0.756) (Fig 12).
The intrusion was significantly greater in the TLS
(P = 0.002). The inclination was buccally for the TLS and
lingually for the RMCR with insignificant differences
(P = 0.104) (Table III).
The canine length decreased significantly after retrac-
tion by both springs in both sagittal and coronal planes
(P <0.001) (Fig 13), but the difference in this reduction
between the 2 groups was insignificant (P = 0.529 sagit-
tally, P = 0.515 coronally) (Table III).
Molar linear and angular measurements for each group
at T0 and T1 are shown in Fig 10, C and D. The CRs6 signifi-
cantly protracted in both groups (P <0.001). The molar in
the TLS group exhibited insignificant distal tipping
34
(P = 0.562) but exhibited significant anterior tipping in the
RMCR group (P <0.001). The rotation was insignificant in
both groups (P = 0.586, P = 0.338) (Fig 11), and the differ-
ence between the groups in the sagittal plane was only sig-
nificant in tipping changes (P <0.001) (Table III).
The molar extruded and inclined lingually insignificantly
in TLS (P = 0.209, P = 0.287) and significantly in RMCR
(P = 0.010, P = 0.008) (Fig 11). The differences between
the 2 were insignificant in the extrusion amount
(P = 0.088) and in the lingual inclination change
(P = 0.537) (Table III).
DISCUSSION
The present study compares the efficacy of 2 different
techniques for space closure: the Burstone technique using
the off-centered TLS (differential moments strategy in the
segmented arch technique) and the Ricketts technique
using the RMCR (as a sectional arch spring) combined with
the cortical bone anchorage system. We investigated some
linear and angular changes for canine and molar within
and between groups using CBCT scans. Regarding the
forces and moments applied, the springs were bent pre-
cisely as both Burstone and Ricketts clinically recom-
mended. Because the included patients were all selected
to have a well-aligned maxillary arch, the bodily movement
for both canine and molar was preferable to obtain, but
investigating this movement was not an objective of this
AJO-DO CLINICAL COMPANION
 Masaes et al.

Fig 11. Mean differences between T0 and T1 for each group in measurements: A and D, The sagittal distances from the centers of
resistance of the canine and molar to the PNS line (S.Dis3 and S.Dis6); B and E, The rotation angle of the canine and molar relative to
ANS-PNS (Rot3 and Rot6); C and F, The tipping angles of the canine and molar relative to the ANS-PNS (Tip3 and Tip6).

study. Accordingly, the load system of each spring was not
individually calculated for each tooth using a finite element
analysis to gain an objective specific desirable moment-to-
force (M/F) ratio, which meant that the retraction mechan-
ics were not entirely equal for all patients within each
group at the starting point, leading to some risk of bias.
This was also true during retraction: the changeable 3D
position of the canine and molar and the decreasing inter-
bracket distance change the initial loads acting on those
teeth; when a tooth is already inclined mesially, the intru-
sion forces resulting from the balanced couple are likely to
decrease the possibility of distal tipping, and vice versa.
The decreasing interbracket distance (the decreasing
length of the spring’s horizontal arms) changes the applied
initial loads by gradually increasing the applied M/F ratio
and the force to deflection rate (F/D) during retraction.26
However, the study subjects were all almost similarly
exposed to that load system-related error as they all had a
well-aligned maxillary arch, similar protocols of activation
and preactivation, and similar baseline data. Thus, the
results we obtained can still be clinically generalized.
Finally, because the canine was retracted separately with-
out involving the incisors, the current results of the quality
of anchorage control are particularly related to the first
stage of treatment; after incisors retraction is achieved, a
future additional anchorage loss will be expected, making
the molar-related results provisional.
Both the TLS and the RMCR produced a small but signif-
icant CRs3 movement, which is associated with significant
distal tipping and mesial-out rotation. With the TLS, the
tipping and rotation were caused by the activation force
level, which was relatively excessive (350 g of force) and
not proportional to the gradually deformed moments. The
tipping and rotation may also have resulted from the
spring location and its reactivation protocol,8 which
located the residual moment bends too far posteriorly.
However, with the RMCR, the force magnitude of 150 g of
force was ideal.21 As a result, the tipping and rotation were

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Masaes et al.

Table III. Intergroup comparisons of change in molar and canine linear and angular measurements.

TLS RMCR Differences

Variables n Mean § SD n Mean § SD Mean P value

The quality of canine retraction
S.Dis3 (mm) 14 1.85 § 0.64 17 1.10 § 0.63 0.75 0.003*

Tip3 (°) 8.06 § 3.66 10.19 § 3.99 2.12 0.136

Rot3 (°) 5.71 § 6.95 14.99 § 9.24 9.28 0.004*

V.Dis3 (mm) 1.26 § 0.69 0.52 § 0.52 0.73 0.002*

Trq3 (°) 2.95 § 6.72 0.30 § 3.98 3.25 0.104

Sagittal Rt3 (mm) 28 0.51 § 0.50 34 0.62 § 0.59 0.11 0.529

Coronal Rt3 (mm) 0.60 § 0.34 0.59 § 0.50 0.01 0.515

The quality of anchorage control

S.Dis6 (mm) 14 1.40 § 0.89 17 1.20 § 0.65 0.20 0.476

Tip6 (°) 0.56 § 3.55 4.63 § 2.13 5.19 <0.001*

Rot6 (°) 0.52 § 3.53 1.15 § 4.82 1.68 0.286

V.Dis6 (mm) 0.12 § 0.33 0.49 § 0.69 0.37 0.088

Trq6 (°) 0.86 § 2.90 1.40 § 1.90 0.54 0.537

TLS, T-loop spring; RMCR, Ricketts maxillary canine retractor; n, sample size; S.Dis, sagittal movement amount; Tip, tipping; Rot, rotation; V.Dis, verti-
cal movement amount; Trq, torque/buccolingual inclination; Rt, root resorption amount; 3,canine; 6, molar.
* statistically significant.

mainly caused by insufficient moments; in other words, the
low-strength wire used (blue Elgiloy) reduced the amount
of the moments once the spring was engaged. Further-
more, both springs had only a force reactivation process,
whereas moments never reactivated, making the forces
considerably more constant than the moments, which suf-
fered a gradual deformation over time.11,30
In the sagittal plane, canine retraction using the TLS
produced a superior movement pattern than that seen in
the RMCR; that is, the amount of CRs3 movement was sig-
nificantly greater, whereas the tipping and rotation
degrees were smaller. The M/F ratio was higher during
retraction using the TLS, ascribing to the alloy property dif-
ferences between both springs. More specifically, the
cobalt-chromium alloy outweighs the beta-titanium in
formability,31 at the cost of yield strength and ultimate
yield strength26,32; thus, the RMCR could expose to more
deformation and more residual moment reductions once
the RMCR is applied and during deactivation. However, the
strength of the TLS wire can keep the residual moments
more constant during deactivation, and the smooth curva-
ture bends, which themselves can generate a greater M/F
ratio.27 One must also acknowledge the role of the wire-
bracket interference in controlling the tooth movement;
the play of the TLS wire into its bracket is less than that of
the RMCR wire.
All previously reported results showed much greater val-
ues of amounts of canine retraction using the TLS (3.22 §
1.41 mm,9 2.13 § 0.47 mm13) or the RMCR (3.62 § 0.19 mm,19
3.24 mm21). These differences may be attributed to using the
tip of the canine crown as a standard representative reference
point in those studies, which is not sufficient to describe the
actual tooth movement. Although the CRs were the reference
point, the actual and more representative point in the current
study.26
Tipping degrees that resulted from the TLS in this study
were similar to those seen in a previous study,12 but other
previous trials have reported lower tipping degrees.11,13 A
possible reason for this disparity could be the smaller acti-
vation amount relative to the great residual moments
employed in those trials, producing a higher M/F ratio.
This study reported observations regarding the mesial-
out rotation for the TLS that were similar to those reported
in Davis et al,13 but less than that seen in Maheta and
Sable,12 in which only 30° of antirotation bend for each arm
was applied, as opposed to 60° in our study. Only 1 previ-
ous study has shed light on canine tipping and rotation
using the RMCR; Hayashi et al19 demonstrated smaller tip-
ping degrees but much higher rotation amount than our
results, but they used only a 2-month follow-up period,
smaller degrees of the applied moments, more constant
forces, and limited sample size.

36 AJO-DO CLINICAL COMPANION

 Masaes et al.

Fig 12. Mean differences between T0 and T1 for each group in measurements: A and D, The vertical distances from the centers
of resistance of the canine and molar to the PNS line (V.Dis3 and V.Dis6); B and E, The buccolingual inclination angle of the
canine relative to the orbital line (Trq3); and C and F, The buccolingual inclination angle of the molar relative to the orbital
line (Trq6).

Fig 13. Mean differences between T0 and T1 in canine length (root resorption amount) (Rt3) sagittally and coronally: A, In the TLS
group and B, In the RMCR group.

February 2022, Vol 2, Issue 1 37

Masaes et al.
The CRs3 was intruded significantly after ending retrac-
tion by both springs; such intrusion is generally ascribed
to the difference in moments acting on the posterior and
anterior units. These differential moments are the applied
residual moments of the TLS. For the RMCR, the differential
moments are not the residual moments but rather the
moments of the applied forces; the RMCR’s alloy proper-
ties have minimized the effects of its residual moments.
The intrusion movement was greater after ending retrac-
tion by the TLS, indicating greater differences in moments.
The initial location of the TLS and the reactivation protocol
placed the residual moment bends too far to the posterior,
which made the difference in moments more pronounced,
increasing not only the intrusive-extrusive force intensity8
but also the buccolingual forces resulting from the differ-
ential antirotation moments. The resultant vector of those
intrusive and lingual forces acting on the canine was likely
to be almost parallel to its long axis, which can reduce
the expected buccal inclination, making it insignificant.
With the RMCR, the difference in moments of forces
resulted in canine intrusion; these moments were almost
similar; the small difference between them might have
been due to the greater distance between the CRs and
the line of force application at the canine relative to that at
the molar. Typically, the greater the intrusive force magni-
tude, the greater the amount of buccal inclination that
might occur; this can explain why slightly greater buccal
inclination was observed when the TLS was applied.
The results we obtained regarding the intrusive canine
movement using the TLS were consistent with those of
Martins et al,9 who similarly showed that the canine
intruded but to a lesser extent than that seen in our study.
In their study, the evaluated point was the tip of the crown
rather than the center of resistance. No other study has
discussed the resulting vertical canine movement after
retraction with the RMCR; however, Hayashi et al20
detected an insignificant buccal inclination of 0.11° § 3.27,
which almost agreed with the result we obtained regarding
the insignificant buccolingual change.
In both groups, canines underwent a significant length
decrease. A retraction lasting longer than 4 months can
cause definite resorption ≥0.5 mm17; however, this resorp-
tion amount can be clinically considered too small after
approximately 5-6 months of retraction.
It seems that the larger amount of intrusion and retrac-
tion in the TLS group did not make a significant difference
to root resorption relative to the RMCR amount. We cannot
ignore the evident difference in the number of canines
included in each arm and the undetected movement of the
root apex that did or did not move significantly more in
one of each; indeed, these are important points to discuss
when comprehensively evaluating the root resorption dif-
ference between groups.
The resorption amount caused by TLS in the present
study was more than that found by Makhlouf et al14; in
38
their study, the shorter follow-up period and the limited
sample size may have contributed to the difference in
resorption results.
There was no difference in the molar CRs protraction
movement between the groups. In contrast, the molar
angular direction was contradictory, indicating a different
type of movement. Using the TLS almost produced a bodily
protraction, whereas the RMCR caused significant mesial
tipping; this suggests that utilizing the cortical anchorage
system in combination with the RMCR did not improve the
sagittal posterior anchorage much as the differential
moments produced by the off-centered TLS. This was likely
because the TLS produced a higher M/F ratio than the
RMCR. In the TLS, the rigid wires stabilize the posterior
unit so that the stress is evenly distributed; therefore, the
maximum stress level at the reactive unit is low; in the
RMCR, though, the Elgiloy wire alone cannot stabilize the
posterior unit, and the stress level on posteriors is rela-
tively higher. Moreover, the initial location and nature of
the reactivation allowed the TLS to generate higher
moments on posteriors, resulting in a higher M/F ratio; this
comes in addition to the TLS alloy properties, which made
the residual moments bends more resistant to deformation
than those of the RMCR.
Our results concerning insignificant molar distal tipping
in the TLS group coincide with Al-Hadlaq et al33; they
detect a small distal molar crown movement, confirming
molar distal tipping. In contrast, Martins et al9 demon-
strated a controlled tipping movement for the molar; in
their study, the location, the V-shape, and the amount of
the tip-back bend resulted in a low M/F ratio posteriorly.
Other TLS- and RMCR-related studies13,21 also showed the
anterior molar crown movement of different amounts from
the molar’s center of resistance movement detected in this
study. Given that they did not investigate the associated
tipping changes, the type of molar movement could not be
recognized, and their results cannot be compared. Regard-
ing the cortical anchorage, the amount of anterior maxil-
lary molar movement we detected in the RMCR group is
approximately half of that found by Urias and Mostafa23
when they studied the mesial drifting amount of the man-
dibular first molar (1.4 mm vs 3.1 mm, respectively). The
molar movement in their study was demonstrated after
ending retraction of both canines and incisors; in addition,
they used a 0.016 £ 0.016-in SS utility arch rather than an
inserted TPA to move the roots into the cortical bone.
Extrusion of molars is expected as a result of the bal-
anced couple, especially in the TLS group, in which the
moment’s differential was greater than that in the RMCR
group; nonetheless, the significant extrusion was only
demonstrated in the RMCR group. It seems that the rigid
soldered TPA and the large anchored unit in the TLS group
produced a superior stress distribution pattern and an
extra vertical anchorage control than that in the RMCR
group, in which the TPA was inserted, and the posteriors
AJO-DO CLINICAL COMPANION

were connected continuously together with the canine via
the spring wire only. In addition, the initial posterior level-
ing and alignment may have also played a role in molar
extrusion. Combined with the applied buccal root torque,
these extruding forces resulted in a significant lingual
molar inclination.
Meanwhile, Martins et al9 demonstrated an intrusion
molar vertical movement of 0.27 § 0.48 mm when using
TLS; however, this result was insignificant and coincided
with our present result.
According to the findings of our study, both TLS and
RMCR, in their current design, can satisfactorily retract the
mesially tipped and mesially in-rotated canines, whereas
the TLS may also be used in patients with Class II maloc-
clusion, which are associated with hypererupted maxillary
incisors. However, there is still room for improvement.
Clinicians can achieve a superior movement pattern after
considering some design-related adjustments. For the TLS,
the activation amount should be reduced (less than 6 mm)
to decrease the applied forces, whereas, for the RMCR, the
residual moments should be reactivated simultaneously
with each activation. Alternatively, in both springs, elon-
gating time intervals among activations will allow the force
to drop and the M/F ratio to increase gradually and spon-
taneously.
CONCLUSIONS
Regarding the canine retraction efficacy:
1. The TLS retracts more and controls the canine rotation
more than the RMCR; however, the canine intrudes
less when the RMCR is used.
2. There are no significant differences between the
springs regarding tipping, inclination, and root resorp-
tion of the canine.
Regarding the anchorage loss control:
1. The molar tends to tip distally when the TLS is used,
and it tips mesially when the RMCR is used.
2. There are no differences between the springs regard-
ing molar protraction, rotation, extrusion, or buccolin-
gual inclination.
ACKNOWLEDGMENT
The author would like to thank Dr Zeinab Dianat for her
contribution to the blinding process.
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