SHORT COMMUNICATION

Comparison and measurement of the amount

of anchorage loss of the molars with and
without the use of implant anchorage during
canine retraction
Badri Thiruvenkatachari,a A. Pavithranand,b K. Rajasigamani,c and Hee Moon Kyungd
Tamil Nadu, India, and Daegu, South Korea

Introduction: The purpose of this study was to compare and measure the amount of anchorage loss with
titanium microimplants and conventional molar anchorage during canine retraction. Methods: Subjects for
this study comprised 10 orthodontic patients (7 women, 3 men) with a mean age of 19.6 years (range, 18 to
25 years), who had therapeutic extraction of all first premolars. After leveling and aligning, titanium
microimplants 1.3 mm in diameter and 9 mm in length were placed between the roots of the second
premolars and the first molars. Implants were placed in the maxillary and mandibular arches on 1 side in 8
patients and in the maxilla only in 2 patients. A brass wire guide and an intraoral periapical radiograph were
used to determine the implant positions. After 15 days, the implants and the molars were loaded with
closed-coil springs for canine retraction. Lateral cephalograms were taken before and after retraction, and
the tracings were superimposed to assess anchorage loss. The amount of molar anchorage loss was
measured from pterygoid vertical in the maxilla and sella-nasion perpendicular in the mandible. Results:
Mean anchorage losses were 1.60 mm in the maxilla and 1.70 mm in the mandible on the molar anchorage
side; no anchorage loss occurred on the implant side. Conclusions: Titanium microimplants can function as
simple and efficient anchors for canine retraction when maximum anchorage is desired. (Am J Orthod
Dentofacial Orthop 2006;129:551-4)

A
ttempts to correct crowded, irregular, or pro-
truding teeth go back to at least 1000 BC.1 In
1728, the French pioneer, Fauchard, introduced
the first appliance and noted that, to exert mechanical
pressure by means of an apparatus, sufficient resistance
to the force must be exerted. Today, anchorage control
is a major concern in the design of orthodontic appli-
ances. Various techniques to reinforce anchorage have
been devised and used in orthodontic practice. However,
even some of the best-known intraoral appliances—
palatal or lingual bars, the Nance holding arch, and
intermaxillary elastics— have undesirable side effects,
a
Department of Orthodontics, Rajah Muthiah Dental College and Hospital,
Annamalai University, Tamil Nadu, India.
b
Lecturer, Department of Orthodontics, Rajah Muthiah Dental College and
Hospital, Annamalai University, Tamil Nadu, India.
c
Professor and head, Department of Orthodontics, Rajah Muthiah Dental
College and Hospital, Annamalai University, Tamil Nadu, India.
d
Chair, Department of Orthodontics, Dental School, Kyungpook National
University, Daegu, South Korea.
Reprint requests to: Dr Badri Thiruvenkatachari, Orthodontic Research Unit,
3rd floor, Coupland III Building, School of Dentistry, University of Manchester,
High Cambridge St, Manchester, M15 6FH United Kingdom; e-mail, badri_
chari@yahoo.com.
Submitted, April 2005; revised and accepted, September 2005.
0889-5406/$32.00
Copyright © 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.12.014
including protrusion, extrusion, and tipping of some
teeth.
The introduction of extradental intraoral anchorage
was a welcome event. A new type of intraoral extra-
dental anchorage, the titanium microimplant, has been
developed. This implant can be used as an alternative to
conventional molar anchorage. Designed specifically
for orthodontic use, it has a small diameter and a
button-like head with a small hole that accepts ligatures
and elastomers. The microimplant can be placed in
many areas in the maxilla and the mandible that were
previously unavailable, including between the roots of
adjacent teeth.
The purposes of this pilot study were to determine
the anchorage potential of titanium microimplants for
retraction of canines during space closure, and to
compare and measure the amount of anchorage loss of
the molars with and without implants during canine
retraction.
MATERIAL AND METHODS
This study was performed with patients at the Depart-
ment of Orthodontics, Annamalai University, Tamil
Nadu, India. The study design was reviewed and approved
551
552 Thiruvenkatachari et al American Journal of Orthodontics and Dentofacial Orthopedics
April 2006

by the Institutional Review Board. Ten patients (7

women, 3 men), with a mean age of 19.6 years (range,
16-21 years) were chosen based on the following
criteria: (1) comprehensive medical and dental history
ruling out any systemic illness; (2) therapeutic extrac-
tion of first premolars required; (3) aligning and level-
ing phases completed; and (4) maximum anchorage,
with 75% to 100% of space closure used for retraction
of anterior segments.2 All selected patients had arch-
length basal bone discrepancies of more than 5 mm.
Patients with Angle Class I malocclusions and ANB
angles of 2° to 4° were selected for implant placement
in both the maxilla and the mandible; patients with
Class II malocclusions and ANB angles greater than 5°
had implants placed only in the maxilla, as a part of
camouflage treatment. No anchorage preservation meth-
ods were undertaken for any patient.
After initial leveling and aligning, informed consent
was obtained from the patients before placing the im-
plants. Routine blood studies were done to rule out any
blood dyscrasias. The implants were positioned at the
maximum thickness of interdental bone, between the roots Fig 1. Cephalometric tracings, pre- (A) and postretrac-
of the second premolar and the first molar, on the selected tion (B) of the canine.
quadrants.3,4
Orthodontic forces were applied 15 days after
implant placement. Nickel-titanium closed-coil springs was measured by taking a stable landmark in the cranium
with a force of 100 g were stretched between the as the reference.
implant and the canine on the implant anchored side, For the maxillary measurements, the lateral cepha-
and between the molar and the canine on the molar lometric tracings taken before and after canine retrac-
anchored side. The period of study ranged from 4 to 6 tion were superimposed along the palatal plane regis-
months. tered at anterior nasal spine.5 In addition to the
Two sets of records were taken. The first was taken superimposition, the horizontal distance from pterygoid
before implant placement and the other when the canine vertical to the distal surface of the first molar on both
retraction was considered complete in accordance with sides was calculated to measure anchorage loss.5
the treatment plan for that patient. These included study For the mandibular measurements, the tracings
models, cephalometric radiographs, orthopantomograms, were superimposed by registering on the best fit of the
and photographs. anterosuperior border of the chin, the inner cortical
To differentiate between the right and left molars on structures of the inferior surface of symphysis, and the
the lateral cephalogram, a 0.017 ⫻ 0.025-in stainless mandibular canal.6 The horizontal distance from sella
steel wire was shaped in the form of an “L” with 0.5 cm vertical to the distal surface of the first molars on both
of vertical length and 1 cm of horizontal length. The sides was also calculated, at the beginning and end of
horizontal portion was inserted from the mesial side of canine retraction.7
the buccal tube and cinched behind the tube (so that it The data obtained were subjected to statistical
would not slip out of the tube) on the right side. On the analysis. The mean, standard error, and standard devi-
left side, the wire was inserted from the distal surface of ation were tabulated. The Student t test was used to
the buccal tube and cinched mesially to differentiate the determine the level of significance and the correlation
right and left molars on the lateral cephalogram. Care of anchorage loss in the maxilla and the mandible, and
was taken to make the vertical segment of the L-shaped between the sexes.
wires abut the buccal tubes to minimize errors during
superimposition. RESULTS
Molar anchorage loss was determined by superim- At the end of the study, the canines were retracted
posing the lateral cephalometric tracings before and successfully on both implant and nonimplant sides in
after retraction (Fig), and mesial movement of the molars all subjects.
American Journal of Orthodontics and Dentofacial Orthopedics Thiruvenkatachari et al 553
Volume 129, Number 4

Table I. Anchorage loss in each subject

Maxilla Mandible

Anchorage loss (mm) Anchorage loss (mm)

Age (y)
Subject and sex Implant side Nonimplant side Months Implant side Nonimplant side Months

1 21/F
2 18/M
3 16/F
4 21/F
5 19/F
6 20/M
7 21/F
8 21/F
9 20/F
10 19/M
0 1.5 5 0 2 5
0 1.5 4 0 1.5 4
0 2 5 0 1.5 5
0 2 5 0 2 6
0 2 4.5 0 2 4.5
0 1.5 4.5 0 1.5 5
0 1.5 5 0 1.5 5
0 1.5 4 0 1.5 5.5
0 1 4.5
0 1.5 5.5

Table II. Mean anchorage loss in men and women popularized when, in animal studies, Roberts et al8,9 and
Sex n Mean (mm) SD SE of mean
Turley et al10 showed good implant stability. Similar
results were achieved later in humans by Roberts et al11
Maxilla Combined 10 1.60 .3536 .1250 and Odman et al.12 Kanomi13 and Costa et al14 intro-
M 3 1.50 .0000 .0000 duced microimplants and miniscrews for orthodontic
F 7 1.67 .4082 .1667
Mandible Combined 8 1.70 .2739 .1118
anchorage. Specially designed orthodontic implants
M 3 1.50 .0000 .0000 were placed in various locations.11,13-17 Studies with
F 5 1.88 .2500 .1250 microimplants positioned between the roots of the
M, Male; F, female. second premolar and the first molar have shown suc-
cessful retraction of the entire anterior segment with
nickel-titanium coil springs.3,18
The superimpositions showed that anchorage loss
This study was aimed at evaluating the anchorage
occurred on the nonimplant side; this was evident with
loss encountered during canine retraction, with and
the mesial migration of that molar; anchorage loss did
without implants. Storey and Smith19 showed that 5%
not occur on the implant side, and no mesial movement
to 50% of the total extraction space can be taken up by
was noted there (Fig).
an anchor unit made up of the first molar and the second
Anchorage loss was less than 20% on the molar-
premolar when used to retract a canine. Aronsen et al20
anchored side; this was acceptable for the subjects
selected. Anchorage loss in this study ranged from 1 to showed anchorage losses of 2.4 mm in 1 monkey and
2 mm with means of 1.6 mm in the maxilla and 1.7 mm 1.4 mm in another. The results of these previously studies
in the mandible (Table I). Statistical analyses showed a matched the results of our human study, in which anchor-
significant anchorage loss in both the maxilla and the age losses of 1.6 mm in the maxilla and 1.7 mm in the
mandible, but the amounts were independent and did mandible were observed on the side where the molars
not differ by sex (Table II). were used as anchorage.
All implants were stable throughout treatment. No Relatively few studies have measured the amount of
damage was registered in any implant under the condi- anchorage loss during canine retraction in humans, and
tions of orthodontic loading. Implant deformation was not there are no studies measuring anchorage loss with
observed in any implants. One patient had peri-implant implant-assisted canine retraction. In this study, an
inflammation, perhaps due to improper oral hygiene. The attempt was made to evaluate the anchorage loss by
inflammation subsided uneventfully with proper oral- using more than 1 variable: by superimposing and by
hygiene measures. measuring the amount of anchor loss (L-shaped wires
as reference points) in the lateral cephalogram before
DISCUSSION and after retraction.
Advances in implant dentistry have made it possible The most important result of this investigation is
to use implants for anchorage in adult orthodontic that all loaded implants retained stability throughout the
patients. Although the concept of metal components for period of continuously applied orthodontic mesiodistal
orthodontic anchorage dates back to at least 1945, it was force. The implants were nearly immobile; this is by
554 Thiruvenkatachari et al
definition a rigid orthodontic anchoring system. The
same conclusions were drawn by Roberts et al,8,9
Turley et al,10 and Southard et al21 in trials in which
force was applied for a maximum of 16 weeks. How-
ever, implant size, implant location, magnitude of
applied force, biomechanical force system, and dura-
tion of orthodontic force application differed from our
study. Miyawaki et al22 reported that implants with a
diameter of less than 1 mm in the buccal alveolar bone
for orthodontic anchorage are less stable. In our study,
titanium microimplants were 1.3 mm in diameter.
En-masse retraction was observed on the implant
side in a few patients. The reason for this could be the
increase in vertical vector of the retractive force applied
from the implant to the canine whereby some binding
of the archwire to the bracket might have prevented the
free sliding of the canine over the archwire, and the
force thereby was transmitted to the archwire, causing
the en-masse retraction.
At the end of the study, the asymmetric anchorage
loss was managed by allowing mesial movement of the
molars on the implant side.
CONCLUSIONS
This study showed mesial movement of molars in
the nonimplant side and no movement on implant side.
It can be concluded that, with proper patient and
implant selection, implants as anchorage for retraction
of canines can be incorporated into orthodontic prac-
tices with complete success.
REFERENCES
1. Proffit WR, Fields HW, Ackerman JL, Bailey LT, Tulloch JF.
Contemporary orthodontics. St Louis: Mosby; 2000.
2. Nanda R. Biomechanics in clinical orthodontics. Philadelphia:
W. B. Saunders; 1997. p. 157.
3. Park HS, Bae SM, Kyung HN, Sung JH. Micro-implant anchor-
age for treatment of skeletal Class I bialveolar protrusion. J Clin
Orthod 2001;35:417-22.
4. Park HS, Bae SM, Kyung HM, Sung JH. Simultaneous incisor
retraction and distal molar movement with micro-implant an-
chorage (MIA). World J Orthod 2004;5:164-71.
5. Jacobson PA, Sadowsky L. Superimposition of cephalometric
radiographs. Chicago: Quintessence; 1995. p. 165-74.
American Journal of Orthodontics and Dentofacial Orthopedics
April 2006
6. Bjork. Prediction of mandibular growth rotation. Am J Orthod
1969;75:39-53.
7. Pancherz H, Ruf S, Kohlhas P. “Effective condylar growth” and
chin position changes in Herbst treatment: a cephalometric
roentgenographic long-term study. Am J Orthod Dentofacial
Orthop 1998;114:437-46.
8. Roberts WE, Smith RK, Zilberman Y, Mozsary PG, Smith RS.
Osseous adaptation to continuous loading of rigid endosseus
implants. Am J Orthod 1984;86:95-111.
9. Roberts WE, Helm FR, Marshall KJ, Gongloff RK. Rigid
endossous implants for orthodontic and orthopedic anchorage.
Angle Orthod 1989;58:257-62.
10. Turley PK, Shapiro PA, Moffett BC. The loading of bioglass-
coated aluminum oxide implants to produce sutural expansion of
maxillary complex in the pigtail monkey (Macaca nemestrina).
Arch Oral Biol 1980;25:459-69.
11. Roberts WE, Marshall KJ, Mozsary PG. Rigid endosseous
implant utilized as anchorage to protract molars and close an
atropic extraction site. Angle Orthod 1990;60:135-52.
12. Odman J, Lekholm U, Jemt T, Thilander B. Osseointegrated
implants as orthodontic anchorage in the treatment of partially
edentulous adult patients. Eur J Orthod 1994;16:187-201.
13. Kanomi R. Mini-implants for orthodontic anchorage. J Clin
Orthod 1997;31:763-7.
14. Costa A, Raffaini M, Melsen B. Microscrews as orthodontic
anchorage. Int J Adult Orthod Orthognath Surg 1998;13:201-9.
15. Block MS, Hoffman DR. A new device for absolute anchorage
for orthodontics. Am J Orthod Dentofacial Orthop 1995;107:
251-8.
16. Higuchi KW, Slack JM. The use of titanium fixtures to facilitate
orthodontic tooth movement. Int J Oral Maxillofac Implants
1991;6:338-44.
17. Lee JS, Park HS, Kyung HM. Micro-implant anchorage for
lingual treatment of a skeletal Class II malocclusion. J Clin
Orthod 2001;35:643-7.
18. Kyung HM, Park MS, Bae SM, Sung VH, Bongkim IL. Devel-
opment of orthodontic micro-implants for intraoral anchorage.
J Clin Orthod 2003;37:321-8.
19. Storey E, Smith R. Force in orthodontics and its relations to tooth
movement. Aust J Dent 1952;56:11-8.
20. Aronson SL, Nordenran A, Anneroth G. Titanium implant
anchorage in orthodontic treatment: an experimental investiga-
tion in monkeys. Eur J Orthod 1990;12:414-9.
21. Southard TE, Buckley MJ, Spivey JD, Krizan KE, Casco JS.
Intrusion anchorage potential of teeth versus rigid endosseous
implants: a clinical and radiographic evaluation. Am J Orthod
Dentofacial Orthop 1995;107:115-20.
22. Miyawaki S, Koyama I, Inoue M, Mishima K, Sugahara T,
Yamamoto TT. 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.