ORIGINAL ARTICLE

A radiographic comparison of apical root resorption after

orthodontic treatment with 3 different fixed appliance techniques

Guilherme R. P. Janson, DDS, MSc, PhD, MRCDC,a Graziela de Luca Canto, DDS, MSc,b
Décio Rodrigues Martins, DDS, MSc, PhD,c José Fernando Castanha Henriques,c DDS, MSc, PhD,
and Marcos Roberto de Freitas, DDS, MSc, PhDd
São Paulo, Bauru, Brazil

Apical root resorption is an undesirable, but frequent side effect of orthodontic treatment, and therefore improve-
ments in orthodontic techniques and materials are in constant development to decrease it. One of the most
recently developed orthodontic techniques is the Bioefficient Therapy that uses contemporary orthodontic mate-
rials. Therefore, the primary objective of this study was to compare the amount of root resorption after ortho-
dontic treatment between the simplified standard edgewise technique (group 1), the edgewise straight wire sys-
tem (group 2), and the Bioefficient Therapy (group 3). It was also the purpose of this investigation to evaluate
the amount of root resorption in the whole sample studied and the prevalence of root resorption in the upper and
lower incisors. Thus, periapical radiographs were obtained with the long cone paralleling technique for the upper
and lower incisors from 30 patients for each group. Root resorption was ranked by scores by 2 examiners who
had an excellent intra and interexaminer calibration by Kendall concordance coefficient. Results of the Kruskal-
Wallis test demonstrated that group 3 (Bioefficient Therapy) presented less root resorption than the others. It
was speculated that the factors responsible for the lesser resorption in this technique were the use of heat-acti-
vated and superelastic wires with the bracket design in this technique as well as the use of a smaller rectangu-
lar stainless steel wire (0.018 × 0.025 inch) in a 0.022 × 0.028 inch slot during incisor retraction and the finish-
ing stages, as compared to the other techniques. Considering the whole sample, there was no root resorption
in 2.25% of the analyzed teeth. There was only a slight resorption in 42.56%, a moderate resorption in 53.37%,
an accentuated resorption in 1.40% and an extreme root resorption in only 0.42% of the teeth. The prevalence
of resorption for each incisor indicated, in decreasing order, a greater resorption for the upper centrals, followed
by the upper laterals, lower centrals, and lastly the lower lateral incisors. (Am J Orthod Dentofacial Orthop
1999;118:262-73)

nable to eliminate the patient’s intrinsic factors
U that may predispose to root resorption, the ortho-
dontists are constantly improving materials and tech-
niques to minimize this undesirable treatment side
effect. In 1963 the first nickel-titanium alloy was
developed 1 and was first used in Orthodontics in
1971.2 Twenty-two years later the new superelastic
nickel-titanium wires that deliver light and continu-
This article is based on research submitted by Dr. Graziela de Luca Canto in
partial fulfillment of the requirements for the degree of Master of Science in
Orthodontics, University of São Paulo at Bauru Dental School.
From the Department of Orthodontics. Bauru Dental School. University of
São Paulo.
aAssociate Professor.
bOrthodontic Graduate Student.
cFull Professor.
dAssociate Professor and Head.
Reprint requests to: Dr Guilherme R. P. Janson, Department of Orthodontics,
Bauru Dental School, University of São Paulo, Alameda Otavio Pinheiro
Brisolla 9-75, Bauru - SP - 17043-101, Brazil; e-mail, jansong@travelnet.com.br
Submitted October 1998, and accepted March 1999.
Copyright © 2000 by the American Association of Orthodontists.
0889-5406/2000/$12.00 + 0 8/1/99136
doi:10.1067/mod.2000.99136
262
ous forces with large amounts of activation and
for long periods of time were developed in China3
and Japan.4
Concurrently with wire evolution the brackets were
also improved to take advantage of the quality of these
new materials, in reducing the force magnitude applied
to the teeth. In 1995, Viazis5,6 introduced triangular
brackets, with an increased interslot distance to
decrease even more the forces delivered by the new
generation of nickel-titanium wires and consequently
to provide a more biologic orthodontic intervention
with less discomfort to the patient. The use of this
bracket system with the heat-activated, superelastic,
nickel-titanium rectangular (or square) wires (Bioforce
Ionguard, GAC International, Inc, New York) was
called bioefficient therapy.5,6 Nevertheless, there is no
investigation concerning the resorption potential of
these new materials and techniques. Therefore, the pri-
mary objective of this study was to compare the
amount of root resorption after orthodontic treatment
between the Simplified Standard Edgewise Technique
American Journal of Orthodontics and Dentofacial Orthopedics Janson et al 263
Volume 118, Number 3

Table I. Initial and final overjet, overbite, and anteroposterior positions of the upper and lower incisors

Groups Mean Minimum Maximum Mean Minimum Maximum

Overjet
Group 1 5.51 –2.00 12.00 3.11 2.00 5.50
Group 2 5.53 –2.00 10.00 2.93 1.00 5.00
Group 3 4.39 1.00 7.00 2.86 2.00 4.00
Overbite
Group 1 3.43 –1.00 7.00 2.23 1.00 4.00
Group 2 3.25 –4.00 7.00 2.28 1.00 4.00
Group 3 3.41 –1.00 6.00 2.17 1.00 4.00
1-NA
Group 1 6.63 3.00 12.00 5.66 2.00 9.50
Group 2 6.76 3.00 12.00 5.43 2.00 10.00
Group 3 5.51 3.00 9.00 4.12 –1.00 9.00
1-NB
Group 1 6.58 2.00 10.50 6.76 2.00 11.00
Group 2 6.36 2.00 13.00 5.86 2.00 11.00
Group 3 6.68 2.00 9.50 5.65 2.00 9.00

Group 1, standard; group 2, straight wire; group 3, bioefficient.

(group 1), the Edgewise Straight Wire System (group
2), and the Bioefficient Therapy5,6 (group 3). It was
also the purpose of this investigation to compare the
amount of root resorption in the whole sample studied,
and the prevalence of root resorption in the upper and
lower incisors.
MATERIAL AND METHODS
Material
Ninety patients were used in this study, with an age
range between 10 years 1 month and 26 years 10
months, regardless of race, sex, and type of malocclu-
sion. Patients that presented apical root resorption or
endodontic treatment at the pretreatment stage were
excluded from the sample, as well as patients whose
orthodontic records were incomplete. Poor quality
radiographs were also eliminated. None of the patients
were retreatment cases.
Group 1 consisted of 30 patients treated with the
Simplified Edgewise Technique at the orthodontic
clinic at Bauru Dental School, University of São Paulo.
Eleven were female and 19 were male, with a mean age
of 13.92 years (age range, 10.08 to 26.83 years) at the
beginning of treatment. The malocclusion types con-
sisted of 12 Class I, 16 Class II Division 1, 1 Class II
Division 2, and 1 Class III. Eleven cases were treated
with 4 extractions, 3 with extraction of 3 teeth, 1 with
extraction of only 2 teeth, and 15 without extractions.
The mean treatment time was 29.13 months. The Sim-
plified Standard Edgewise Technique is characterized
by the use of 0.022 × 0.028 inch conventional brackets
(Morelli, Sorocaba, Brazil) associated with an extrao-
ral headgear and a lip bumper to reinforce anchorage
for the upper and lower teeth, respectively, when nec-
essary. There is no anchorage preparation. The usual
wire sequence begins with a 0.015 inch twist-flex or
0.016 nitinol wire, followed by 0.016, 0.018, 0.020,
and finally a 0.021 × 0.025 inch stainless steel wire
(Unitek, Monrovia, Calif). In extraction cases, the
canines are initially retracted only a small amount to
allow space for leveling and aligning of the anterior
teeth. The anterior teeth are retracted en masse with the
rectangular wire, after leveling and aligning. To
accomplish this, the dimensions of the rectangular wire
are electrolytically reduced in the posterior segments to
reduce the friction forces with the brackets and tubes.
The retraction of the canines and of the anterior teeth
are performed with elastic chains. Deep overbites are
usually corrected by reversing and accentuating the
curve of Spee of the stainless steel arch wires from the
beginning, until an overcorrection is obtained. This
overcorrection is maintained by accentuating and
reversing the curve of Spee in the rectangular wire as
well. The mean amount of overjet, overbite, and the
anteroposterior position of the upper and lower incisors
of the 3 groups, at the beginning and at the end of treat-
ment are illustrated in Table I.
Group 2 consisted of 30 patients treated with the
Roth (Lancer Orthodontics Inc, San Marcos, Calif)
Edgewise Straight Wire System at the orthodontic
clinic at Baura Dental School, University of São Paulo.
Fifteen were female and 15 were male, with a mean
age of 14.18 years (age range from 10.91 to 26 years)
at the beginning of treatment. Seven cases were Class I,
264 Janson et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2000

Fig 1. Score system of Levander and Malmgren (redrawn from Levander and Malmgren16) grade 0,
absence of root resorption; grade 1, mild resorption, root with its normal length and only an irregular
contour; grade 2, moderate resorption, small area of root loss with the apex exhibiting an almost
straight contour; grade 3, accentuated resorption, loss of almost one third of root length; grade 4,
extreme resorption, loss of more than one third of the root length.

19 Class II Division 1, 2 Class II Division 2, and 2 Class
III malocclusion types. Thirteen cases were treated with
4 extractions, five with extraction of only 2 teeth, and
12 without extractions. The mean treatment time was
19.26 months. The brackets had 0.022 × 0.028 inch
slots and the wire sequence and mechanics are similar
to the Simplified Standard Edgewise Technique, begin-
ning with a 0.015 inch twist-flex or 0.016 nitinol wire,
followed by 0.016, 0.018, 0.020, and finally a 0.021 ×
0.025 inch stainless steel wire (Unitek). To reinforce
anchorage, an extraoral headgear and a lip bumper are
used for the upper and lower teeth, respectively, when
necessary.
Group 3 consisted of 30 patients treated with the
Bioefficient Therapy (GAC International). Nineteen
were treated at the orthodontic clinic at Baura Dental
School, University of São Paulo, and 11 were treated in a
private practice. The malocclusion types consisted of 13
Class I, 10 Class II Division 1, 6 Class II Division 2, and
1 Class III. Fourteen were female and 16 were male, with
a mean age of 14.29 years (age range, 10.41 to 23.66
years) at the beginning of treatment. Fifteen cases were
treated with 4 extractions, 6 with extraction of 2 teeth, 1
with only 1 extraction, and 8 without extractions. The
mean treatment time was 18.93 months. The brackets had
0.022 × 0.028 inch slots and the wire sequence begins
with a 0.020 × 0.020 inch Bioforce Ionguard (GAC
International) followed by a 0.018 × 0.025 inch stainless
steel arch wire (Unitek). In extraction cases, the canines
are completely retracted into the extraction spaces with
superelastic retraction springs on the 0.020 × 0.020 inch
Bioforce Ionguard arch wire. After leveling and aligning
and retraction of the canines, the 0.018 × 0.025 inch
stainless steel arch wire is inserted and the incisors are
retracted on this wire with superelastic retraction springs.
Extraoral headgear and lip bumper can also be used to
reinforce anchorage for the upper and lower teeth,
respectively. The use of these anchorage reinforcement
devices can be reduced when the second molars are
included in the mechanics. Deep overbites are corrected
with the stainless steel rectangular arch wire with reverse
and accentuated curve of Spee, until an overcorrection is
obtained.
To quantify resorption, periapical posttreatment
radiographs of the upper and lower incisors, totaling
712 teeth, were examined. The decision to work with
only the incisors was reached because they are the
teeth subjected to greater movement during treatment,
primarily in extraction cases and because most
authors7-15 agree that they are more frequently and
intensely resorbed during treatment.
The other records were used to determine patient’s
sex and age at the beginning of therapy, the type of
treatment undertaken (with or without extractions) and
the orthodontic technique that was used.
Methods
The posttreatment periapical radiographs of the
patients treated at the University were obtained by a
single operator with the DABI 70 Spectro 1070X x-ray
machine, set up for 70 kV, 10 mA, and an exposure
time of 1 second, with the long cone paralleling tech-
nique. Kodak Ektaspeed EP 21 films were used, and
the angles were obtained by an intraoral XCP (Rinn-
Dentisply) positioner. The radiographs of the private
practice patients were obtained by 2 different operators
with the same type of positioner mentioned above,
with a Yoshida X 70F x-ray machine, set up for 70KVP
and 15 mA, using the same technique. Kodak DF 58
films were used and exposed for 0.9 second. All radi-
ographs were processed automatically.
Standardization of the radiographs taken by differ-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 118, Number 3
ent operators was not a concern because resorption was
evaluated by the score system of Levander and Malm-
gren16 that classifies it into 5 grades (Fig 1). The radio-
graphic analysis was blind and was performed by 2
examiners with a magnifying glass. The resorption
grade of each tooth was recorded on each patient’s
chart. Other information, such as age, sex, technique
used and whether the treatment was conducted with or
without extractions, was recorded on the chart later.
Error study
• Intraexaminer error. Thirty teeth were randomly
selected (10 from each group) and remeasured by
the same examiner (examiner A). The repeated mea-
surements were tested by the Kendall coefficient of
concordance that demonstrated an excellent level of
intraexaminer agreement (Table II).
• Interexaminer error. The 180 radiographs were eval-
uated by 2 examiners and the level of agreement
between examiners A and B was tested by Kendall’s
coefficient of concordance. Results were similar to
the intraexaminer calibration, showing a statistically
high level of agreement between the examiners as
shown on Table III. Therefore it was not necessary
to use the measurements of examiner B. They were
only used to test the precision of examiner A’s mea-
surements.
Statistical Analysis
The amount of root resorption between the three
orthodontic techniques was compared by means of the
Kruskal-Wallis nonparametric test. Because some
patients in group 3 were treated in a private practice, it
was decided to evaluate whether there was a difference
in the amount of resorption between patients treated in
the University and those treated in the private practice,
within group 3, with the Mann-Whitney test.
Because of the inherent difficulties in standardizing
the groups with respect to the type of malocclusion, at
the beginning of treatment the amount of extractions in
each group was compared to assist in interpreting the
results. This comparison was performed by the analy-
sis of variance (F test).
Descriptive statistics were used to evaluate the per-
centage of root resorption in the whole sample and the
prevalence of resorption in each incisor was evaluated
by the Kruskal-Wallis test.
RESULTS
Comparisons Between the Groups
Amount of resorption. The comparison of the amount
of root resorption observed in the 3 groups demonstrated
that group 3 presented, on average, less resorption than
groups 1 and 2 and that the amount of resorption among
Janson et al 265
Table II. Intraexaminer error
Group Coefficient value P
1 0.934 <.0001
2 0.828 <.0001
3 0.958 <.0001
Total 0.912 <.0001
Table III. Interexaminer error
Group Coefficient value P
1 0.846 <.0001
2 0.909 <.0001
3 0.898 <.0001
Table IV.Comparison of the amount of resorption
between the 3 groups (Kruskal-Wallis test, T = 45.25, P
< .0001)
Groups Mean post (P < .01)
1 156.5
2 156.0
3 79.5
Statistically equivalent.
these last two were similar (Table IV, Fig 2).
Results of the amount of resorption analysis within
group 3 among patients treated in the University or in
a private practice indicated that the subgroup treated in
private practice presented less resorption than those
treated in the University (Table V, Fig 3). Because
there was a difference between the two subgroups, it
was decided to compare the other two groups (groups
1 and 2) with the subgroup treated in the University, by
means of the Kruskal-Wallis test. Results of this com-
parison showed that the first 2 groups presented more
resorption than the subgroup treated in the University
(Table VI, Fig 4).
Amount of extractions (complementary evaluation).
The amount of extractions, evaluated through the
analysis of variance, was not statistically different
between the groups (Tables VII and VIII). Group 1
had, on average, 1.79 teeth extracted; group 2, 2.06,
and group 3, 2.43 (Fig 5). It should be noticed that
group 3 had the largest amount of extractions, although
this difference was not statistically significant.
Amount of Root Resorption Consequent to Ortho-
dontic Treatment
From the 90 cases of the sample, 712 teeth were
analyzed: 355 in the maxilla and 357 in the mandible.
Of the total, 16 (2.25%) did not present any root
resorption (grade 0), 303 (42.56%) presented only a
266 Janson et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2000

Fig 2. Comparison of amount of resorption in 3 groups.

Fig 3. Comparison of the resorption amount within group 3: patients treated in the University or in a private practice.

mild resorption (grade 1), 380 (53.37%) presented Generally, it could be observed that the most
moderate resorption (grade 2), 10 (1.40%) had accen- resorbed teeth were the upper central incisors, fol-
tuated resorption (grade 3), and only 3 (0.42%) pre- lowed by the upper laterals, lower central incisors, and
sented extreme resorption (grade 4) (Fig 6). lastly the lower lateral incisors (Fig 7).

Prevalence of Resorption in the Incisors (Kruskal- DISCUSSION

Wallis test) Sample Selection And Method
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 118, Number 3
In samples consisting of patients treated by different
professionals several variables should be considered. It is
very difficult to obtain groups large enough and treated
by a single operator with three different techniques. The
Bioefficient Therapy was only recently introduced,5,6 and
therefore it would be practically impossible that a single
professional would have 30 cases concluded with this
technique and two other groups of 30 cases treated with
the Simplified Standard Edgewise Technique and the
Edgewise Straight Wire System at the time this project
was being conducted. As Krogman17 stated: “In research
perfection may be the goal, but adequacy is the most use-
ful standard.” Furthermore, there are other works14,15,18-
20 in the literature that were conducted with samples from
different sources that stated that this factor should not
interfere with the results.
The method of periapical radiographs is the best for
clinical studies of apical root resorption and therefore
is used by the great majority of authors.11,13,14,16,20-30
Periapical radiographs are much superior to the
panoramic, occlusal, and the lateral cephalometric radi-
ographs for studying root structures, primarily when
obtained with the long cone paralleling technique.31
This technique provides less radiation to the patient
when radiographing the upper and lower incisors,
causes less image distortion; the superimposition errors
are also smaller when compared with the panoramic
and cephalometric radiographs. The reduction in radia-
tion to the patient is particularly important for children,
adolescents, and young adults, who are more radiosen-
sitive than adults, because of the fast-growing organs,
position of the thyroid, and the longer time for the radi-
ation effects to become apparent.31 The automatic film
processing enabled a standardization of the radiographs
regarding density and contrast, with a consequent sim-
ilar brightness.
Subjective methods, such as the presently used
method of Levander and Malmgren,16 are predomi-
nantly used in root resorption studies* following tooth
movement, in contrast to other methods that quantified
resorption by comparing measurements obtained in
radiographs before and after treatment,9,18,22,25,26,30
and therefore they seem to be very reliable. Their pri-
mary advantage is that they are not dependent on stan-
dardization of the initial radiographs. In the present
study, the intraexaminer and interexaminer errors
demonstrated an excellent concordance level between
the examiners, attesting to the precision of the evalua-
tion (Tables II and III).
Amount of Resorption
*7,10-12,14-16,19,20,23,27-29,32,33.
Janson et al 267
Table V. Comparison of the resorption amount within
group 3, between patients treated in the University or in
a private practice (Mann-Whitney test, U = 4913, U’ =
4798, P = .0019)
University Private practice
Mean post 76 42
Median 45 35.5
Table VI. Comparison of the resorption amount between
groups 1, 2, and the University subgroup of group 3
(Kruskal-Wallis test, T = 18.28, P = .001)
Groups Mean post (P < .01)
1 161
2 160.5
3 (University subgroup) 116.5
Statistically equivalent.
Comparison between the groups. The most impor-
tant result was that root resorption was not greater in
the group treated with the Bioefficient Therapy when
compared with the other groups. One could think that
the introduction of a rectangular wire in the initial
treatment stages, such as recommended in this tech-
nique, would lead to an increased root resorption.
However, it was shown that the smaller resorption
amount in the group treated with the Bioefficient Ther-
apy could be due to the biocompatibility of the new
orthodontic wires and brackets.
When the types of malocclusions in the groups are
compared, it can be seen that there is some similarity.
The amount of Class I in the Standard Edgewise Tech-
nique group is similar to that in the Bioefficient Ther-
apy group and the number of Class III cases is also sim-
ilar among all three groups. Group 3 had only a smaller
amount of Class II Division 1 cases than the other 2
groups, but on the other hand, it had more Class II Divi-
sion 2 cases. Regarding the resorption potential, Class
II Division 2 cases present higher risks because of the
intrusion mechanics necessary to correct the anterior
overbite characteristic of these cases, as previously
reported,22,23,32,34 and also the labial torque to correct
the incisors’ palatal inclination. Therefore an even
greater resorption would be expected in this group.
Table I shows the mean amount of overjet and over-
bite of the groups. It can be seen that the overjet in
group 3 is a little bit more than 1 mm less than the other
two groups in the beginning and that the amount of
change is approximately 1 mm less as well. Therefore it
could be speculated that the difference in resorption
level between group 3 and the others could be based on
the difference in the amount of correction of the over-
268 Janson et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2000

Fig 4. Comparison of resorption amount between groups 1, 2, and the University subgroup of group 3.

Comparison of the amount of extractions

Table VII. of group 3 experienced more retraction than the other
between the 3 groups (analysis of variance-F test) groups. Therefore, if resorption is associated with the
Variable F P amount of tooth movement as has been suggested in
some studies,32,35 then this would be a factor contribut-
Amount of extractions 0.898 Ns ing to a larger resorption in this group as compared to
the others. The lower incisor anteroposterior positions
of group I before and after treatment show that there
Table VIII. Mean amount of extractions in each group
was a small mean proclination of these teeth instead of
Group Amount of extractions SD retraction. The reason for this might be that there were
1 1.79 1.93 many nonextraction cases in this group that may have
2 2.06 1.85 experienced some labial movement of the incisors.
3 2.43 1.73 Therefore, when the mean anteroposterior movement
was calculated, the amount of retraction of the extrac-
tion cases was not greater then the proclination of the
jet, as it has been shown to be associated with a greater incisors experienced by the nonextraction cases.
risk of resorption.32 However, the amount of overbite in Retrospectively, the balanced effects of the maloc-
the 3 groups is very similar, as well as the changes that clusion types, amount of overjet, overbite, and retrac-
occurred with treatment that would therefore lead to a tion of the incisors in the groups would tend to lead to
similar resorption amount in the groups. It is interesting more resorption in group 3 and therefore could not
to mention that the mechanics used for the overbite cor- explain the obtained results.
rection in the 3 groups was very similar, accentuating Another factor worth considering for the resorption
and reversing the curve of Spee in the upper and lower level is the treatment time. In this regard, it may be
arch wires, respectively. speculated that the longer treatment time in group 1
The cephalometric measurements regarding upper might have contributed to the greater resorption found
and lower incisors mean retraction of the groups is also in this group, as it has been shown to be an aggravat-
presented in Table I. Although the use of 1-NA and 1- ing factor for root resorption.34,36,37 However, resorp-
NB is not ideal to evaluate the retraction of these teeth, tion was very similar between groups 1 and 2 (Table
it gives an idea of the amount of movement experienced IV), suggesting that other factors might have influ-
by them. It can be seen that the upper and lower incisors enced the difference with group 3.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 118, Number 3
Fig 5. Comparison of amount of extractions in 3 groups.
Although there are few studies comparing techniques
that use superelastic wires, some remarks are worth
mentioning in regard to the lesser resorption level found
in group 3. In 1993, Miura38 stated that the discovery of
the “super-elastic” properties of NiTi alloy wires and its
use in osteoclast recruitment, is a significant scientific
breakthrough for the orthodontic specialty, establishing a
new standard of biologic treatment in clinical orthodon-
tics. The superelastic wires produce a more biologic
action, with less discomfort to the patient.5,6 Shape
memory, heat activation, superelasticity, differential
force, and coating with nitrogen ions of these wires com-
bined with the bracket design of the Bioefficient Ther-
apy makes orthodontic treatment very comfortable for
the patient even when a rectangular wire is inserted in
the initial treatment phases. In the Simplified Standard
Edgewise Technique and in the Edgewise Straight Wire
System, the stainless steel round and rectangular wires
tend to apply heavier forces to the teeth, in addition to
presenting greater friction with the brackets.39 In order
to overcome this friction, larger retraction forces are nec-
essary39 that can increase the resorption risk and dis-
comfort to the patient.5 These techniques also use a
0.021 × 0.025 inch rectangular stainless steel wire for
retraction of the anterior teeth, that is larger than the
0.018 × 0.025 inch stainless steel wire used in the Bio-
efficient Therapy. Because the brackets of the 3 systems
present 0.022 × 0.028 inch slots, the forces delivered in
Janson et al 269
the first 2 systems are greater than in the Bioefficient
Therapy. This factor could also account for the greater
resorption in groups 1 and 2. In addition, because the
majority of the edgewise techniques use a continuous
arch wire, teeth leveling is performed in an indiscrimi-
nate manner so that the lateral incisor receives the same
force that the canine does. The heat-activated, super-
elastic Bioforce Ionguard wires present differential
forces, with 80g in the anterior and 320g in the posterior
segment, to move teeth without overloading them.5,6
To increase the wire length between the brackets
and consequently reduce even further the force applied
by the arch wire, it is necessary to have a large interslot
distance. Therefore it is evident that a single bracket
would be more efficient than a twin bracket. The Bioef-
ficient Therapy triangular bracket is single and provides
an increase in the interslot distance that consequently
allows an increase in the interslot arch wire length and
a greater flexibility, whereas its design still ensures an
efficient tooth movement with good control of tip and
rotation. In 1955, Quintanilla et al40 compared the fric-
tion of these brackets5,6 with others commercially avail-
able (Roth, Shoulder, Synergy, Standard twin, Lang sin-
gle) and found that they needed a lesser force to
produce the initial tooth movement. In some cases
(Viazis versus Lang single), the friction was up to 10
times less. In 1996, LaFerla41 confirmed that these
brackets present less friction compared with others such
270 Janson et al
Fig 6. Percentage of resorption in the examined teeth (n = 712).
as Lewis, Elan, Minitwin, Twin, Spirit, and Lumina. He
also claimed that the design of the brackets facilitated
the sliding mechanics because of the ligation method:
the bracket elbows keep the elastic ligatures away from
the arch wire, decreasing the resistance to sliding. The
is different from the conventional brackets in which the
ligatures are tightly tied, increasing friction and hinder-
ing tooth movement. The action of the triangular brack-
ets, associated with the heat activated superelastic wires
and the use of 0.018 × 0.025 inch rectangular stainless
steel wires in accessories with 0.022 × 0.028 inch slots
seem to have been at least partially responsible for the
lesser root resorption after orthodontic treatment,
observed in group 3 (Bioefficient Therapy).
Other accessories may have also contributed to the
reduced resorption found in the group treated with the
Bioefficient Therapy. The superelastic retraction
springs apply a constant force of 150g as opposed to the
elastic chains that present a decreasing force with time.5
This light and continuous force might have contributed
to the lesser resorption found in this group as well.
When the resorption level of patients within group
3 who had been treated in a private practice (subgroup
PP) were compared with those who had been treated in
the University (subgroup UNI) the results demon-
strated that the former presented less root resorption
than the latter (Table V, Fig 3). The possible cause of
this difference could be the greater clinical experience
of the private clinician, compared with the clinical
skills of graduate orthodontic students in the Univer-
sity. It should also be considered that the University
patients were treated by 9 students. It is evident that a
neophyte is more prone to introduce collateral effects
in the orthodontic mechanics than an experienced pro-
fessional. These collateral effects may then induce
more resorption as was observed.
American Journal of Orthodontics and Dentofacial Orthopedics
September 2000
In view of these results, one could speculate that
the fact that some of the patients in group 3 had been
treated in a private practice might have accounted for
the smaller resorption amount when compared with
groups 1 and 2 for the same reason already mentioned.
Therefore, to discard this possibility, the University
subgroup of group 3 was then compared to groups 1
and 2, although the number of patients in the Univer-
sity subgroup was only 19 subjects and not ideal for
statistical purposes. However, it was considered valu-
able as a complementary evaluation. The results of this
evaluation showed that the University subgroup also
presented less resorption than the other groups, sug-
gesting that the smaller resorption level of group 3, in
comparison with the others, could be the result of dif-
ferences in the orthodontic technique used and not dif-
ferences in professional skills (Table VI, Fig 4).
Amount of Extractions in the Groups
Selecting compatible groups according to the type of
malocclusion presented earlier for treatment, the type of
orthodontic treatment, and the amount of extractions to
be performed is very difficult. With respect to the types
of malocclusion and treatment performed, the subjects
were randomly selected and yet yielded quite similar
amounts of malocclusion types in each group, as already
mentioned. Considering that extraction cases usually
imply larger tooth movements to correct the malocclu-
sions and that this could implicate in a greater resorption
potential,32,35 the amount of extractions in the groups
was compared. The results in Tables VII and VIII and
Fig 5 show that the amount of extractions was statisti-
cally similar among the groups, and consequently, the
differences in resorption levels cannot be explained by
dissimilarities in the amount of tooth movement
between the groups on the basis of the amount of extrac-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 118, Number 3
Fig 7. Mean resorption scores for each incisor in 3 groups (ICI, upper central incisor; ULI, upper lateral incisor; LCI,
lower central incisor; LLI, lower lateral incisor).
tions. Although there were no statistically significant dif-
ferences in the amount of extractions among the groups,
it can be observed that there was a tendency toward an
increase, from group 1 to group 3 (Table VIII). When
Tables I and VIII are compared, it can be observed that
the amount of retrusion of the incisors is proportional to
the amount of extractions in each group. Therefore ana-
lyzing the amount of tooth movement based on the
amount of extractions is compatible to the analysis in
relation to the anteroposterior movement of the incisors.
Because no statistical comparison of the amount of
retrusion of the incisors among the groups was con-
ducted, the numbers only show a tendency for a greater
retraction of these teeth in group 3.
Amount of Root Resorption Consequent to Ortho-
dontic Treatment
From the total sample of teeth (n = 712), only 2.25%
showed no root involvement (grade 0), 42.56% pre-
sented only an apical blunting (grade 1), and 53.37%
presented moderate resorption (grade 2) (Fig 6). It was
also evident that resorption consequent to treatment is
rarely accentuated (grade 3) or extreme (grade 4) as
only 1.82% of the teeth presented this amount of resorp-
tion. These results are similar to those of Beck and Har-
ris32 who observed resorption in 62% of the incisors and
considered “resorbed teeth” to be only those presenting
with grades 2, 3, or 4, which in this work would add up
to 55.90%. Maybe this difference of almost 6% is asso-
ciated with the orthodontic techniques used, as Beck
Janson et al 271
and Harris32 used edgewise and Begg. The results are
also similar to those of Remington,19 Kaley and
Phillips,12 and Desields33 and present small differences
from those of Levander and Malmgren16 who found
accentuated resorption in 17% of the teeth. However,
these numbers might have been aggravated because
their sample consisted only of upper incisors that are
the most resorbed teeth during treatment.7-15 Neverthe-
less, the results of the present study that apical root
resorption during orthodontic treatment is rarely
extreme agree with most of the authors.12,19,24,33
Prevalence of Resorption in the Incisors
The prevalence of resorption in the incisors was
similar to that reported in the literature,7,8,11,12,14,29,32
that is, in a decreasing order, a larger resorption of the
upper central incisors, followed by the upper lateral
incisors, lower central incisors, and lastly the lower lat-
eral incisors. This helps to substantiate the precision of
the method used in the present investigation (Fig. 7).
CLINICAL CONSIDERATIONS
The most important consequence of these results is
that orthodontic mechanics can be simplified with the
new orthodontic materials, by obtaining 3-dimensional
control of tooth movement with a superelastic, heat-
activated rectangular wire from the beginning of treat-
ment, and that this will not cause more resorption than
usual. Therefore this will require less chair time for the
practitioner and provide more comfort for the patient.
272 Janson et al
However, other studies have to be done in order to con-
firm this tendency as well as to better elucidate any
advantages of this new technology. Histologic studies
of tissue changes consequent to tooth movement with
these appliances are necessary.
CONCLUSIONS
1. Treatment with the Bioefficient Therapy did not
produce an increase in the amount of root resorp-
tion. In fact, group 3 (Bioefficient Therapy) pre-
sented even less root resorption than group 1 (Sim-
plified Standard Edgewise Technique) and group 2
(Edgewise Straight Wire System). It was speculated
that the factors responsible for the smaller resorp-
tion in this technique were the use of heat activated
and superelastic wires with the bracket design in
this technique as well as the use of a smaller rectan-
gular stainless steel wire (0.018 × 0.025 inch) in a
0.022 × 0.028 inch slot during incisor retraction and
the finishing stages, as compared to the other tech-
niques.
2. From all the teeth examined, 2.25% did not have
root involvement; 42.56% had only a mild resorp-
tion; 53.37% had moderate resorption; 1.40% had
accentuated resorption; and only 0.42% had extreme
resorption.
3. The teeth that presented more root resorption were,
in decreasing order, the upper central incisors, the
upper lateral incisors, the lower central incisors, and
lastly, the lower lateral incisors.
We would like to acknowledge Dr Luis Carlos de
Mesquita Cabral for his kindness in permitting the use
of his patients’ data and CNPQ (Brazilian National
Research Foundation) for its support.
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