SYSTEMATIC REVIEW

Optimal force magnitude for bodily

orthodontic tooth movement with fixed
appliances: A systematic review
Christina I. Theodorou,a Anne Marie Kuijpers-Jagtman,b,c Ewald M. Bronkhorst,d and Frank A. D. T. G. Wagenere
Nijmegen and Groningen, The Netherlands, and Jakarta, Indonesia

Introduction: There is a high degree of uncertainty regarding the appropriate force level that should be applied
during orthodontic tooth movement (OTM). As a result, orthodontic treatments may take longer than necessary,
leading to unwanted side effects. This review aimed to identify an optimal force range with the rate of OTM as the
primary outcome. External apical root resorption and pain were evaluated as secondary outcomes, and the in-
fluence of growth was examined. Methods: Five electronic databases were searched (MEDLINE [via PubMed],
Embase [via OVID], Cochrane Library, CINAHL, and Web of Science) with no publication date or language re-
strictions. Inclusion eligibility screening, quality assessment, and data extraction were performed by 3 investiga-
tors. Each retrieved record was assessed by 2 observers independently. Only randomized controlled trials and
randomized split-mouth studies were included. Results: A total of 12 articles satisfied the inclusion criteria—two
randomized controlled trials and 10 randomized split-mouth studies. Only 1 study showed a low risk of bias,
whereas the remaining 11 were unclear. The qualitative analysis showed that forces between 50 cN and
250 cN produced a similar OTM rate; forces .250 cN yielded a slightly higher rate but were accompanied by
adverse effects. Because of considerable heterogeneity in methodology, clinical diversity with varying forces
between 18 cN and 360 cN, and poor statistical reporting, a meta-analysis was deemed inappropriate.
Conclusions: Forces between 50 cN and 100 cN seem optimal for OTM, patient comfort and potentially exhibit
fewer side effects. Nevertheless, careful data interpretation is necessary because of the lack of strong evidence.
Protocol registration: PROSPERO CRD42016039985. (Am J Orthod Dentofacial Orthop 2019;156:582-92)

A
n optimal force magnitude for orthodontic an appropriate orthodontic force, a tooth could be
tooth movement (OTM) has been described as moved through the alveolar bone, as a result of remod-
the lightest force providing a maximum or a eling of the periodontal ligament (PDL) and the bone per
near-maximum response.1 This would mean that with se.2 However, if the force level were to be set higher, the
risk of side effects, such as external apical root resorption
(EARR), uncontrolled tipping, and increased hyaliniza-
a
Department of Dentistry - Orthodontics and Craniofacial Biology, Radboud
tion, most likely would be enhanced, always at the
Institute for Health Sciences, Radboud University Medical Center, Nijmegen,
The Netherlands. expense of patient comfort and clinical efficiency.3-5
b
Department of Orthodontics, University Medical Center Groningen, Groningen, Hyalinization is with undoubtedly inevitable in OTM.
The Netherlands.
c However, if the force magnitude against the tooth is
Faculty of Dentistry, Universitas Indonesia, Jakarta, Indonesia.
d
Department of Dentistry, Radboud Institute for Health Sciences, Radboud Uni- great enough to completely cut off the blood supply to
versity Medical Center, Nijmegen, The Netherlands. an area within the PDL, then it de facto becomes avas-
e
Department of Dentistry - Orthodontics and Craniofacial Biology, Radboud
cular. The larger the hyalinized area, the longer the delay
Institute for Molecular Life Sciences, Radboud University Medical Center, Nijme-
gen, The Netherlands. in initiation of OTM, as differentiation of osteoclasts
All authors have completed and submitted the ICMJE Form for Disclosure of Po- within the PDL is not possible, and thus, the process of
tential Conflicts of Interest, and none were reported.
undermining resorption cannot take place until a
Funding: This research did not receive any specific grant from funding agencies
in the public, commercial, or non-profit sectors. much later stage.1
Address correspondence to: Christina I. Theodorou, Department of Dentistry - Even though the exact biological mechanisms that
Orthodontics and Craniofacial Biology, Radboud University Medical Centre, Phi-
determine OTM are not yet fully elucidated, force
lips van Leydenlaan 25, 6525EX Nijmegen, The Netherlands; e-mail,
orthodontie@radboudumc.nl. magnitude has an important role to play. Other factors,
Submitted, November 2018; revised and accepted, May 2019. including orthodontic force duration, growth, medica-
0889-5406/$36.00
tion intake, and individual environmental and genetic
Ó 2019 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2019.05.011 variability are also of significant substance.6-8

582
Theodorou et al 583

Therefore, OTM is a highly complex process, a fact that is 4. Outcome: rate of OTM was examined as a primary
frequently forgotten in an era of accelerated outcome, EARR and pain were assessed as
orthodontics. secondary outcomes, and the influence of growth
In the past, there has been considerable interest in was also evaluated.
comparing orthodontic force magnitudes, especially in 5. Study design: randomized controlled trials (RCTs)
animals.7-9 Regardless, interspecies differences seem to and randomized split-mouth studies.
apply for the regulation of various genes in animals
Studies concerning accelerated orthodontics and
and humans, which could be critical for the translation
the use of drugs influencing OTM or bone metabolism
of animal findings into clinical applications. Hence,
were excluded. Studies were also excluded when sub-
simple extrapolation of preclinical data toward the
jects had craniofacial anomalies or an active peri-
human setting is not always possible.
odontal disease or had previously undergone an
The only previous systematic review on this topic
orthodontic treatment.
published in 2003, concluded that there was no evidence
regarding an optimal force level for OTM.5 However, it
Information sources and search strategy
did not meet the current standards for systematic re-
views and included both animal and human studies. In A comprehensive search strategy was performed in
addition, the included studies were not of high quality the following electronic databases in collaboration
and showed clinical and methodological heterogeneity. with an experienced health science librarian on July 3,
Since then, further human randomized studies have 2016: MEDLINE (via PubMed), Embase (via OVID), Co-
been published, and thus, the present systematic review chrane Library, CINAHL and Web of Science. Grey liter-
provides an update of the previous one but with a focus ature was not included in our search.
on human studies. The search strategy was limited to humans, with no
This review aimed to identify an optimal force range language or publication date restrictions. The search
by comparing the rate of tooth movement in humans terms were developed for MEDLINE and modified
undergoing orthodontic treatment with full fixed appli- accordingly for the aforementioned databases. Table I
ances using different quantified force magnitudes. The illustrates the details of the MEDLINE and Embase
rate of OTM was evaluated as a primary outcome, searches.
whereas EARR and pain were assessed as secondary out-
comes. The influence of growth was also examined. Study selection
Three investigators were involved in the study selec-
MATERIAL AND METHODS tion process (A.K., C.T., and F.W.). Each retrieved record
Protocol and registration was assessed by 2 observers. The selection process was
carried out using Covidence (Veritas Health Innovation,
This systematic review was registered at PROSPERO Melbourne, Australia. Available at https://www.
under the unique ID number CRD42016039985 and re- covidence.org), a Web-based software platform that
ported according to Preferred Reporting Items for Sys- streamlines the production of systematic reviews. The
tematic Reviews and Meta-Analyses guidelines.10 first screening was on title and abstract. Titles and ab-
Details of the protocol can be found at: www.crd.york. stracts that did not meet the predefined eligibility criteria
ac.uk/prospero. were excluded, and the resulting articles were carefully
evaluated and judged based on their full texts by all au-
Eligibility criteria thors. Furthermore, the reference lists of the selected
A PICOS question was formulated to aid the selection studies were hand-searched to identify any additional
of eligible studies. The eligibility criteria were as follows: relevant studies. Authors were contacted if information
was lacking or unclear. All doubts and disagreements
1. Population: human subjects with a permanent
were resolved in consensus by all investigators, and the
dentition of any sex and ethnicity.
corresponding authors were contacted when additional
2. Intervention: orthodontic treatment with fixed ap-
or clarifying information was needed.
pliances, using a quantified force (as determined
per study) applied bodily in a mesiodistal direction. Data items and collection
3. Control: no treatment or intervention with a
different quantified force (as determined per study) A customized data extraction form was developed on
applied bodily in a mesiodistal direction. Covidence to record the following:

American Journal of Orthodontics and Dentofacial Orthopedics November 2019  Vol 156  Issue 5
584 Theodorou et al

Table I. MEDLINE and Embase search strategies http://www.ncbi.nlm.nih.gov/pubmed/advanced

Search group MEDLINE search term
1 “Tooth Movement”[Mesh]) OR Tooth Mov*[tiab]
2 (“Stress, Mechanical”[Mesh] OR “Dental Stress Analysis”[Mesh] OR “Biomechanical Phenomena”[Mesh] OR “Pressure”
[Mesh:NoExp] OR Force*[tiab] OR Pressure*[tiab] OR Stress*[tiab])
3 #1 AND #2 (“Tooth Movement”[Mesh]) OR Tooth Movement[tiab]) AND (“Stress, Mechanical”[Mesh] OR “Dental Stress
Analysis”[Mesh] OR “Biomechanical Phenomena”[Mesh] OR “Pressure”[Mesh:NoExp] OR Force*[tiab] OR Pressure*[tiab]
OR Stress*[tiab])
4 (Orthodont*[tw] AND (“Tooth Movement”[Mesh] OR movement[Mesh] OR “Orthodontic Space Closure”[Mesh] OR
((Tooth[tiab] OR teeth[tiab] OR dental[tiab] OR “Tooth”[Mesh:NoExp] OR “Bicuspid”[Mesh] OR “Cuspid”[Mesh]
OR “Incisor”[Mesh] OR “Molar”[Mesh] OR Bicuspid*[tiab] OR Cuspid*[tiab] OR Incisor*[tiab] OR Molar*[tiab] OR
canine*[tiab] OR premolar*[tiab]) AND (Mov*[tiab] OR displacement*[tiab] OR shift*[tiab]))) AND (“Stress, Mechanical”
[Mesh] OR “Dental Stress Analysis”[Mesh] OR “Biomechanical Phenomena”[Mesh] OR “Pressure”[Mesh:NoExp] OR
Force*[tiab] OR Pressure*[tiab] OR Stress*[tiab]))
5 #3 OR #4 ((“Tooth Movement”[Mesh]) OR Tooth Movement[tiab]) AND (“Stress, Mechanical”[Mesh] OR “Dental Stress
Analysis”[Mesh] OR “Biomechanical Phenomena”[Mesh] OR “Pressure”[Mesh:NoExp] OR Force*[tiab] OR Pressure*[tiab]
OR Stress*[tiab])) OR ((Orthodont*[tw] AND (“Tooth Movement”[Mesh] OR movement[Mesh] OR “Orthodontic Space
Closure”[Mesh] OR ((Tooth[tiab] OR teeth[tiab] OR dental[tiab] OR “Tooth”[Mesh:NoExp] OR “Bicuspid”[Mesh]
OR “Cuspid”[Mesh] OR “Incisor”[Mesh] OR “Molar”[Mesh] OR Bicuspid*[tiab] OR Cuspid*[tiab] OR Incisor*[tiab] OR
Molar*[tiab] OR canine*[tiab] OR premolar*[tiab]) AND (Mov*[tiab] OR displacement*[tiab] OR shift*[tiab]))) AND
(“Stress, Mechanical”[Mesh] OR “Dental Stress Analysis”[Mesh] OR “Biomechanical Phenomena”[Mesh] OR
“Pressure”[Mesh:NoExp] OR Force*[tiab] OR Pressure*[tiab] OR Stress*[tiab])))
6 (animals[mesh] NOT humans[mesh])
7 #5 NOT #6 ((“Tooth Movement”[Mesh]) OR Tooth Movement[tiab]) AND (“Stress, Mechanical”[Mesh] OR “Dental Stress
Analysis”[Mesh] OR “Biomechanical Phenomena”[Mesh] OR “Pressure”[Mesh:NoExp] OR Force*[tiab] OR Pressure*[tiab]
OR Stress*[tiab])) OR ((Orthodont*[tw] AND (“Tooth Movement”[Mesh] OR movement[Mesh] OR “Orthodontic Space
Closure”[Mesh] OR ((Tooth[tiab] OR teeth[tiab] OR dental[tiab] OR “Tooth”[Mesh:NoExp] OR “Bicuspid”[Mesh]
OR “Cuspid”[Mesh] OR “Incisor”[Mesh] OR “Molar”[Mesh] OR Bicuspid*[tiab] OR Cuspid*[tiab] OR Incisor*[tiab] OR
Molar*[tiab] OR canine*[tiab] OR premolar*[tiab]) AND (Mov*[tiab] OR displacement*[tiab] OR shift*[tiab]))) AND
(“Stress, Mechanical”[Mesh] OR “Dental Stress Analysis”[Mesh] OR “Biomechanical Phenomena”[Mesh]
OR “Pressure”[Mesh:NoExp] OR Force*[tiab] OR Pressure*[tiab] OR Stress*[tiab]))) NOT ((animals[mesh] NOT humans[mesh])
Search group Embase search term
1 exp orthodontics/
2 orthodontic$.ti,ab,kw.
3 ((tooth or teeth or Bicuspid* or Cuspid* or Incisor* or Molar* or canine* or premolar*) and mov$).ti,ab,kw.
4 1 OR 2
5 3 AND 4
6 mechanical stress/or biomechanics/or ”pressure and tension”/or pressure/or (Force* or Pressure* or Stress*).ti,ab,kw.
7 5 AND 6
8 1 OR 2 OR 3
9 8 AND 6

1. Study identification (authors, publication year, as a score (range, 0-3), and pain was also defined as a
setting, and country) score (range, 0-100) based on the visual analog scale.
2. Study design Before data extraction, our customized form was
3. Sample characteristics (inclusion and exclusion pilot-tested on 10 articles to identify data that were
criteria, sample size, sex, mean age, and growth sta- potentially missing from the form and adapted accord-
tus) ingly.
4. Intervention and control group details (initial force
magnitude in cN, site of force application, type of Risk of bias assessment in individual studies
appliance used for force application and reactiva- The risk of bias (high, unclear, low) for the RCTs and
tion of the appliance, method of measuring force randomized split-mouth studies was evaluated by pairs
magnitude and tooth movement, duration of the of observers on Covidence using the Cochrane Collabo-
experiment and the amount of OTM) ration risk of bias tool, as described in the Cochrane
5. Outcome (OTM rate, EARR, and pain) Handbook for Systematic Reviews of Interventions.11
The rate of OTM was defined as millimeters per week, Seven criteria were analyzed to grade the risk of bias
EARR was determined per study either in millimeters or for each study, including random sequence generation,

November 2019  Vol 156  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Theodorou et al 585

Iden fica on
Records iden fied through Addi onal records iden fied
database searching through other sources
(n =12255) (n = 1)

Records a er duplicates removed

(n = 8347)
Screening

Records screened Records excluded

(n = 8347) (n = 8220)

Full-text ar cles assessed Full-text ar cles excluded, with

Eligibility

for eligibility reasons (n = 115)

(n = 127)
Did not meet inclusion criteria for
• study design (n = 45)
• interven on (n =16)
Studies included in • comparator (n = 5)
qualita ve synthesis • outcome (n = 31)
(n = 12)
Compiled results from Iwasaki et al.
2017 used instead (n = 6)
Included

Studies included in Not found (n = 9)

quan ta ve synthesis
(meta-analysis) Non-human subjects (n = 2)
(n = 0)
No author response, excluded to
avoid overes ma on of results (n = 1)

Fig 1. PRISMA flow diagram.

allocation concealment, blinding of participants and sample size used. A remaining total of 12 articles, two
personnel, blinding of assessors, incomplete outcome RCTs,20,21 and 10 randomized split-mouth
data, selective reporting of outcomes, and other poten- studies,18,22-30 met the inclusion criteria of this review
tial sources of bias. In case of disagreement, the third and were used in the final qualitative analysis. The
investigator assessed the paper, and all disagreements selection process is summarized in Figure 1, and the
were resolved between the 3 observers. main characteristics of the included studies are shown
in Table II.
RESULTS
Risk of bias within studies
Study selection and characteristics
All included studies were assessed for risk of bias
A total of 12,255 articles were identified by database
(Fig 2). One RCT20 showed an unambiguous low risk
searching, and 1 article was included by hand search. Af-
of bias, whereas the remaining studies had an unclear
ter duplicate removal, 8347 studies underwent title and
risk of bias.18,21-27,29,30 Tests for the risk of bias across
abstract screening, 127 studies underwent full-text
studies were not undertaken.
screening, and 115 articles were excluded. Among these
115 articles, 6 were excluded upon author recommenda-
Results of individual studies
tion,12-17 and 1 article from the same author group was
included instead. This article comprised the compiled The outcomes of all individual studies are summa-
results of the 6 articles previously described.18 Another rized in Tables III and IV. Because of considerable het-
article was excluded19 to avoid result overestimation, erogeneity in methodology, clinical diversity, and poor
as the author failed to reply to an e-mail regarding the statistical reporting, data synthesis was not possible,

American Journal of Orthodontics and Dentofacial Orthopedics November 2019  Vol 156  Issue 5
November 2019  Vol 156  Issue 5

586
Table II. Main characteristics of the included studies
Control/intervention
Intervention: force (cN), force (cN), appliance Study
Study, setting and Sample size, appliance used and used and reactivation Site (jaw, side, Method for measuring duration,
country, and method sex, age (SD) reactivation (if applicable) (if applicable) tooth moved) force and OTM Outcome wk (SD)
Megat Abdul Wahab et al23 n 5 19 100 cN 150 cN Max Force: correx gauge Rate of OTM 5
(2014) academic, Malaysia sex: 14 F, 5 M, NiTi spring reactivation: NA NiTi spring reactivation: NA R or L OTM: digital caliper
Split mouth RCT age: 16-28 Canine
Ariffin et al25 (2013) n 5 12 100 cN 150 cN Max Force: correx gauge Rate of OTM 5
academic, Malaysia sex: NM NiTi spring reactivation: NA NiTi spring reactivation: NA R or L OTM: digital caliper
Split-mouth RCT age: 19.7 (5.0) Canine
Bokas and Woods26 (2006) n 5 12 200 cN 200 cN Max Force: NiTi spring and EC Rate of OTM 8, 12, 16
academic, Australia sex: 6 F, 6 M NiTi spring reactivation: 28 d EC reactivation: 28 d R or L activated from passive
Split-mouth RCT age: 13-14.5 Canine position to 9 mm and 20 mm,
respectively (following the
manufacturer's
recommendation).
Confirmed intraorally 3 times
using a customized caliper
OTM: space closure assessed
American Journal of Orthodontics and Dentofacial Orthopedics

on digital dental casts. Also

confirmed directly on the
study models with a needle
point and digital calipers
Falkensammer et al20 n 5 12 200 cN No control Man Force: NA Rate of OTM 16
(2014) academic, Austria sex: 8 F, 4 M Superelastic coil spring R or L OTM: Measured using
Parallel-group RCT age: 26.6 (13.5) reactivation: NA 2nd molar defined landmarks
on scanned dental casts
Keng et al27 (2012) private n 5 12 150 cN 150 cN Max Force: both closing loops Rate of OTM 8-24
practice & academic, sex: 6 F, 6 M TMA T-loop reactivation: NiTi T-loop reactivation: R or L activated by 3 mm, as
New Zealand age: 13.3-20.1 at 3 mm (if necessary) at 3 mm (if necessary) Canine measured by a dial caliper
Split-mouth RCT OTM: rate of space closure
based on the amount of
space closure achieved
per month as measured
on the upper dental casts
Luppanapornlarp et al28 n 5 16 50 cN 150 cN Max Force: calibrated orthodontic Rate of OTM 8
(2010) academic, sex: 14 F, 2 M NiTi spring reactivation: NA NiTi spring reactivation: NA R or L force gauge Pain
Thailand age: 18-24 Canine OTM: on dental casts
Split-mouth RCT using a measuring

Theodorou et al
microscope
 American Journal of Orthodontics and Dentofacial Orthopedics

Theodorou et al
Table II. Continued

Control/intervention
Intervention: force (cN), force (cN), appliance Study
Study, setting and Sample size, appliance used and used and reactivation Site (jaw, side, Method for measuring duration,
country, and method sex, age (SD) reactivation (if applicable) (if applicable) tooth moved) force and OTM Outcome wk (SD)
Megat Abdul Wahab et al22 n 5 12 100 cN 150 cN Max Force: correx gauge Rate of OTM 5
(2013) academic, sex: F NiTi spring reactivation: NA NiTi spring reactivation: NA R or L OTM: digital caliper EARR
Malaysia age: 24.7 (3.0) Canine
Split-mouth RCT
Norman et al21 (2016) n 5 15 200 cN 226.8 cN Max/Man Force: both stretched not Rate of OTM NA
academic, UK sex: 8 F, 7 M NiTi spring reactivation: SS spring reactivation: R and/or L more than twice their
Parallel-group RCT age: 16.3 (3.1) as necessary as necessary Canine length (according to
n 5 15 manufacturer's
sex: 9 F, 6 M recommendations)
age: 16.0 (2.0) OTM: digital calipers
Samuels et al29 (1998) n 5 18 100 cN 200 cN Max or Man Force: springs stretched Rate of OTM 27
academic, UK sex: 12 F, 6 M NiTi spring reactivation: NA NiTi spring reactivation: NA R or L between 3 mm and 15 mm
Split-mouth RCT age: 9.8-24.1 Canine (according to manufacturer's
recommendations)
OTM: measured using defined
landmarks on a dental
cast with a Reflex microscope
Wahab et al24 (2015) n 5 19 100 cN 150 cN Max Force: correx gauge Rate of OTM 5
academic, Malaysia sex: 13 F, 6 M NiTi spring reactivation: NA NiTi spring reactivation: NA R or L OTM: digital caliper EARR
Split-mouth RCT age: 21.3 (3.3) Canine
Yee et al30 (2009) n 5 14 50 cN 300 cN Max Force: elongation 200% Rate of OTM 12
academic, Australia sex: 9 F, 5 M NiTi spring reactivation: NiTi spring reactivation: R or L and 500% of its activation
Split-mouth RCT age: 13.0-19.5 not needed not needed Canine OTM: intraoral and
maxillary cast measurements
Iwasaki et al18 (2017) n 5 56 Intervention 1: Max force: NA Rate of OTM 12 (8)
academic, United States sex: G: 19 F, 17 M 18 cN NiTi spring; reactivation: NA R or L OTM: 3D measurement
November 2019  Vol 156  Issue 5

Split-mouth RCT NG: 8 F, 2 M Intervention 2: Canine on dental cast

age: G 13.5 (1.7) 60 cN NiTi spring; reactivation: NA
NG 19.2 (5.3) Intervention 3:
120 cN NiTi spring; reactivation: NA
Intervention 4:
240 cN NiTi spring; reactivation: NA
Intervention 5:
360 cN NiTi spring; reactivation: NA
F, Females; M, males; NA, not available; NiTi, nickel titanium; EC, elastomeric chain; TMA, beta titanium; SS, stainless steel; NM, not mentioned; Max: maxilla; Man, mandible; R, right; L, left; NG,
nongrower; G, grower.

587
588 Theodorou et al

Blinding of par cipants and personnel

Blinding of outcome assessment

Selec ve outcome repor ng

Incomplete outcome data
Alloca on concealment
Sequence genera on

Other sources of bias

Abdul Wahab 2014 23
+ ? ? ? + + +

25
Ariffin 2013
+ ? ? ? + + +

Bokas 2006 26
? ? ? + ? + +

Falkensammer 2014 20
+ + + + + + +

Iwasaki 2017 18
? ? ? ? + + +

Keng 2012 27
? ? - + + + +

Luppanapornlarp 2010 28
? ? ? ? + + +

22
Megat Abdul Wahab 2013
+ ? ? ? + + +

21
Norman 2016
+ + + + ? + +

Samuels 1998 29
? ? ? ? ? + ?

Wahab 2015 24
+ ? ? ? ? + +

Yee 2009 30
? ? ? ? + + +

+
Low risk of bias

Unclear risk of bias

?
High risk of bias
-

Fig 2. Risk of bias summary outlining judgment of risk of bias items for studies included in the qualita-
tive synthesis.

and thus, a meta-analysis was considered inappro- cN-250 cN), and very high (250 cN-400 cN). The
priate. rate of OTM ranged between 0.23 and 0.44 mm/wk
for the low force group, 0.16 and 0.47 mm/wk for
the moderate force group, 0.1 and 0.46 mm/wk for
Rate of OTM the high force group, and 0.34 and 0.49 mm/wk for
The rate of OTM was measured in all studies18,20-30 the very high force group.
(Table III), and the force magnitude used varied be- Four studies22-25 that compared 100 cN with 150 cN
tween 18 cN and 360 cN. For ease of description, forces favored the higher range; however, of these, only
the forces were categorized in 4 groups: low in 2 studies,22,25 the difference in the rate of OTM was
(\100 cN), moderate (100 cN-150 cN), high (150 found to be statistically significant (P \ 0.05). Iwasaki

November 2019  Vol 156  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Theodorou et al 589

Table III. Results of individual studies for the rate of OTM

Study Force (cN) and appliance used Amount OTM, mm (SD) Rate OTM (mm/week) P value
Abdul Wahab et al23 (2014) 100 cN, NiTi spring NA 0.30 (0.09) .0.05
150 cN, NiTi spring 0.40 (0.10)
Ariffin et al25 (2013) 100 cN, NiTi spring 1.85 (0.27) 0.37 (0.05) \0.05
150 cN, NiTi spring 2.36 (0.28) 0.47 (0.05)
Bokas and Woods26 (2006) 200 cN, NiTi spring NA 0.46 0.011
200 cN, EC 0.42
Falkensammer et al20 (2014) 200 cN, Superelastic coil spring 1.6 (0.4) 0.1 (0.02) 0.16
Iwasaki et al18 (2017) 18 cN, NiTi spring 2.82 (1.20) 0.23 (0.10) 0.01
60 cN, NiTi spring 3.36 (1.70) 0.33 (0.14)
120 cN, NiTi spring 5.38 (0.99) 0.44 (0.08)
240 cN, NiTi spring 5.47 (1.39) 0.45 (0.11)
360 cN, NiTi spring 5.96 (1.80) 0.49 (0.15)
Keng et al27 (2012) 150 cN, TMA T-loop NA 0.21 (0.08) 0.07
150 cN, NiTi T-loop 0.22 (0.11)
Luppanapornlarp et al28 (2010) 50 cN, NiTi spring 1.13 (0.63) 0.14 (0.08) .0.05
150 cN, NiTi spring 1.28 (0.70) 0.16 (0.09)
Megat Abdul Wahab et al22 (2013) 100 cN, NiTi spring 1.57 (0.44) 0.30 (0.09) 0.04
150 cN, NiTi spring 2.10 (0.50) 0.40 (0.10)
Norman et al21 (2016) 200 cN, NiTi spring 3.42 (1.79) 0.14 (0.06) 0.76
226.8 cN, SS spring 3.25 (1.28) 0.21 (0.09)
Samuels et al29 (1998) 100 cN, NiTi spring NA 0.16 0.000
200 cN, NiTi spring 0.24
Wahab et al24 (2015) 100 cN, NiTi spring 1.24 (0.29) 0.46 (0.04) .0.05
150 cN, NiTi spring 1.36 (0.39) 0.47 (0.05)
Yee et al30 (2009) 50 cN, NiTi spring 1.69 (0.58) 0.14 (0.04) \0.001
300 cN, NiTi spring 4.10 (1.68) 0.34 (0.14)
NiTi, Nickel titanium; NA, not available; EC, elastomeric chain; TMA, beta titanium; SS, stainless steel.

et al18 assessed 5 different force magnitudes (ie, 18, 60, EARR

120, 240, and 360 cN), showing an optimal force range EARR was examined in 2 studies from the same
between 120 cN and 240 cN, as well as more distopalatal author group.22,24 Abdul Wahab et al23 used the
rotations with forces of 360 cN. One study28 compared methods reported by Liou and Huang (score range,
50 cN with 150 cN and found no significant difference 0-3) to assess apical and lateral root resorption (RR)
in the rate of OTM between the experimental groups on periapical radiographs taken at baseline, 5 weeks,
(P .0.05). Another study29 examined the difference be- and 6 months after maxillary canine retraction. No
tween the rates of space closure for 150 cN and 200 cN RR was detected around the canines of either the
and noted no significant difference. However, Yee test or control teeth between the 100 cN and
et al,30 reported that the initial OTM was not related to 150 cN forces. In the study by Wahab et al,24 periap-
force magnitude. Nevertheless, during the later periods ical radiographs of maxillary canines were taken before
of the study, higher rates of OTM, as well as increased orthodontic appliance placement (R1), before canine
anchorage loss and loss of rotation canine control retraction (R2), and 5 weeks after canine retraction
were observed at the 300 cN vs 50 cN (P \0.05). (R3). The tooth lengths were subsequently measured
The remaining studies compared the same forces or a on the radiographs in millimeters using digital calipers,
very similar range of force magnitudes and used and EARR was calculated from the difference between
different materials for applying the force21,26,27 or the tooth lengths at the 3 radiographic time points. In
used extracorporeal shock-wave therapy in 1 group.20 addition, they found no sign of EARR at R1, minimal
The influence of growth on the rate of OTM was only signs of EARR at R2, and at R3, the 150 cN force
evaluated by Iwasaki et al,12 who found that the overall showed more pronounced EARR (1.42 6 0.13, stan-
speed of tooth movement was 1.5-fold faster in growing dard deviation [SD]) compared with the 100 cN force
subjects compared with nongrowing subjects (0.89 6 0.04, SD), although the difference was not
(P 5 0.001). statistically significant (P .0.05).

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590 Theodorou et al

Table IV. Results of Luppanapornlarp et al. for pain (VAS)

1 hour 24 hours 1 week 1 month 2 months
Force Mean 6 SD (mm) Mean 6 SD (mm) Mean 6 SD (mm) Mean 6 SD (mm) Mean 6 SD (mm)
50 cN 12.24 6 15.33 20.24 6 24.11 8.05 6 12.18 9.44 6 19.06 10.97 6 18.50
150 cN 18.84 6 18.19 35.15 6 16.89 8.09 6 10.84 10.45 6 16.79 15.03 6 22.02

Pain In the 2003 review,5 12 different human studies were

Pain was assessed in the study by Luppanapornlarp included from the current systematic review. This differ-
et al,28 (Table IV), who found a significant difference be- ence can be attributed to our strict inclusion criteria that
tween the 50 cN and 150 cN groups at 24 hours were set with a limitation to RCTs and randomized split-
(P \0.01). However, the pain intensity was reduced to- mouth studies. Even though split-mouth studies are
ward the end of the experiment. Overall, the 50 cN group known to exhibit a carry-across effect, the risk was
showed less pain than the 150 cN group throughout the assessed as unlikely for this type of orthodontic clinical
study period of 2 months. trials and, therefore, were included in this review.
It must be noted that force magnitude from a mecha-
Additional analysis nobiological point of view should be clearly expressed as
a pressure unit in Pa rather than cN. Once stress is
A meta-analysis was considered for the studies
applied on a tooth and distributed per unit area, the
comparing low (\100 cN) to high (.150 cN) forces.
tooth moves within its socket, leading to PDL strain at
There were 7 split-mouth design studies18,19,22-25,28,30
a cellular level. However, it is feasibly impossible to mea-
that met these criteria, and the opportunity to perform
sure stress and strain within the PDL of a loaded tooth.
a meta-analysis was examined. Quantitative analysis re-
Therefore, forces applied directly to the tooth are
quires information regarding the precision of the overall
measured instead.2,5
outcome (ie, the difference in the rate of OTM between
The force magnitudes used in the included studies
the given forces). In a split-mouth design setup, the SD
were applied to canines, with the exception of 1 study.20
of the difference in the rate of OTM cannot be calculated
In the study of Falkensammer et al,20 the mandibular
from the SD reported for the rate of OTM of individual
second molar was mesialized with a 200 cN force and
forces, as tooth movement is correlated within patients.
was included in our review as it fulfilled our eligibility
Therefore, at least 1 of the following should have been
criteria. The forces in all included studies ranged be-
reported in a study to be considered for a meta-
tween 18 cN and 360 cN, and according to the qualita-
analysis: (1) the P value of the difference in the rate of
tive analysis, forces between 50 cN and 250 cN
OTM; (2) a 95% confidence interval for that difference;
produced a similar rate of OTM (0.1 mm/wk-
or (3) the SD or standard error of the difference. Of the 7
0.47 mm/wk), whereas, forces .250 cN produced a
split-mouth design studies, only 1 met these criteria.22
higher rate of OTM (0.34 mm/wk-0.49 mm/wk). The
Attempts made to contact the authors regarding the
studies that used high or very high forces in 1 of their
missing information, where possible, were unsuccessful.
intervention groups18,28,30 reported more unwanted
Thus, with 6 of 7 studies lacking statistical precision, a
side effects, such as loss of canine rotation control,
meta-analysis was deemed inappropriate.
anchorage loss, and pain. However, the strength of
evidence regarding the primary outcome was
DISCUSSION
considered weak to moderate, as most articles had an
Summary of evidence unclear status for allocation concealment, blinding of
There has been considerable interest in the past in participants and personnel, and blinding of outcome
comparing orthodontic force magnitudes, with a previ- assessment (Fig 2). Furthermore, a positive correlation
ously published systematic review5 indicating that the ev- was found between growth and the rate of OTM. Iwa-
idence is insufficient regarding an optimal force range. saki et al18 reported a 1.5-fold difference between
Fifteen years later, upon deciding to update the previously growers and nongrowers, although the evidence was re-
published review, 12 human studies were identified (10 garded as weak because of the unclear risk of selection,
randomized split-mouth designs18,22-30 and 2 RCTs20,21). performance, and detection bias.
The rate of OTM was measured in all 12 studies,18,20-30 Regarding the study of Falkensammer et al,20 one
whereas the influence of growth was assessed in 1 might speculate that a 200 cN force may not be suffi-
article.18 In addition, EARR22,24 was investigated in 2 cient for bodily movement of a mandibular molar given
studies, and pain was examined in 1 study.28 that its root surface area is much larger than that of a

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Theodorou et al 591

canine. The rate of OTM in this study was data, as research regarding an optimal force magnitude
0.1 6 0.02 mm/wk, which is relatively low compared for OTM is scarce. This type of study design has received
with the other included studies using a 200 cN force increased popularity in the past decades, as a smaller
on canines with the rate of OTM ranging from 0.14 to sample size is required compared with a parallel-group
0.46 mm/wk. design,31 thereby making a clinical trial easier to
With respect to the secondary outcomes of this sys- conduct.
tematic review, Megat Abdul Wahab et al22 did not Furthermore, the different appliances used for tooth
detect any EARR when comparing 100 cN with 150 cN movement in the included studies could have influenced
in the study of 2013 and found no statistically signifi- the rate of OTM, leading to a confounding effect and a
cant difference in the study of 2015.24 Megat Abdul Wa- potential limitation at outcome level.
hab et al22 tried measuring lateral RR; however, this
cannot be performed based on a periapical radiograph. CONCLUSIONS
Regarding pain, Luppanapornlarp et al28 showed that
Based on this systematic review, we concluded the
the lower force group (50 cN) had less pain than the
following:
higher force group (150 cN) throughout the experiment.
Nonetheless, the strength of evidence for both secondary 1. There is weak to moderate evidence showing that
outcomes was considered weak as the number of articles forces ranging between 50 cN and 100 cN are
reporting on EARR and pain was insufficient to lead to a optimal for the rate of OTM, patient comfort, and
solid conclusion. potentially exhibit fewer side effects.
In consideration of the above-mentioned findings, 2. No sound conclusions can be drawn regarding EARR
practitioners must keep in mind that patient comfort and pain because of the limited amount of evidence.
should prevail during orthodontic treatment and that 3. Weak, but statistically significant evidence, suggests
lack of evidence regarding an optimal force range that growth increases the rate of OTM.
does not give clinicians carte blanche to use high
Based on the results of this systematic review, more
forces, which could eventually lead to unwanted side
robust and well-designed RCTs are needed to enable a
effects such as pain, EARR, and tipping of teeth dur-
future meta-analysis to identify an optimal force range.
ing OTM.
It is widely accepted that the rate of OTM is influ-
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