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Anchorage loss - A multifactorial response

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 Original Article

Anchorage Loss—A Multifactorial Response

Silvia Geron, DMD, MSca; Nir Shpack, DMD, MScb; Samouil Kandos, DMDc;
Moshe Davidovitch, DMDa; Alexander D. Vardimon, DMDd

Abstract: Anchorage loss (AL) is a potential side effect of orthodontic mechanotherapy. In the present
study, it is defined as the amount of mesial movement of the upper first permanent molar during premolar
extraction space closure. In addition, AL is described as a multifactorial response in relation to the ex-
traction site, appliance type, age, crowding, and overjet. For this study, 87 university clinic and private
practice subjects, who were defined as maximum anchorage cases and had undergone bilateral maxillary
premolar extractions, were divided into four groups according to extraction site (first vs second premolars),
mechanics (lingual vs labial edgewise appliances), and age (adolescents vs adults). Overjet and crowding
were examined from the overall sample. Data were collected from serial lateral cephalograms and dental
casts. The results showed that as the severity of dental crowding increased, AL significantly decreased (r
⫽ ⫺0.66, P ⫽ .001). Labial edgewise appliances demonstrated a significantly greater AL than did lingual
edgewise appliances (1.15 ⫾ 2.06 mm, P ⬍ .05). A greater, though not statistically significant, AL was
found in adults than in adolescents (0.73 ⫾ 1.43 mm). There was a slight nonsignificant increase in AL
between maxillary second compared with first premolar extractions (0.51 ⫾ 1.33 mm). Overjet was weakly
correlated to AL. These results suggest that AL is a multifactorial response and that the five examined
factors can be divided into primary (crowding, mechanics) and secondary factors (age, extraction site,
overjet), in declining order of importance. (Angle Orthod 2003;73:730–737.)
Key Words: Anchorage; Lingual orthodontics; Age; Extraction

INTRODUCTION fore, adjunct appliances, such as the Nance holding arch,

transpalatal bar, and extraoral traction, are often used to
Anchorage is the resistance to unwanted tooth move- augment molar anchorage. The use of multiple teeth at the
ment1,2 and is commonly described as the desired reaction anchorage segment to form a large counterbalancing unit
of posterior teeth to space closure mechanotherapy to and the application of differential moments have also been
achieve treatment goals, ie, minimum, medium, maximum described as methods to stabilize molar position.3–5
anchorage.3 Anchorage loss (AL) is a reciprocal reaction Factors such as malocclusion, type and extent of tooth
that could obstruct the success of orthodontic treatment by movement (bodily/tipping), root angulation and length,
complicating the anteroposterior correction of the maloc- missing teeth, intraoral/extraoral mechanics, patient com-
clusion and possibly detracting from facial esthetics. A ma- pliance, crowding, overjet, extraction site, alveolar bone
jor concern when correcting severe crowding, excessive contour, interarch interdigitation, skeletal pattern, third mo-
overjet, and bimaxillary protrusion is control of AL. There- lars, and pathology (ie, ankylosis, periodontitis) affect AL.
Most of the AL studies focus on biomechanical solutions.4–10
a
Clinical Instructor, Department of Orthodontics, The Maurice and For example, a greater AL was demonstrated with nonslid-
Gabriela Goldschleger School of Dental Medicine, Tel Aviv Univer- ing mechanics when the Gjessing spring was evaluated.6
sity, Tel Aviv, Israel. Tip-edge brackets showed less but not significant AL than
b
Senior Clinical Instructor, Department of Orthodontics, The Mau-
rice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv straight wire brackets (1.71 vs 2.33 mm).7 Differential mo-
University, Tel Aviv, Israel. ments have been reported to reduce AL by 0.6–0.7 mm.4,5
c
Private practice, Thessalonki, Greece. When maximum anchorage is required, AL was greater in
d
Chairman, Department of Orthodontics, The Maurice and Gabrie- Class I (0.60 mm) than in Class II (0.28 mm) malocclu-
la Goldschleger School of Dental Medicine, Tel Aviv University, Tel
sions.4
Aviv, Israel.
Corresponding author: Silvia Geron, DMD, MSc, Orthodontic De- AL has also been referred to as the extent of incisor
partment, Tel Aviv University, Tel Aviv, Israel 69978 protraction (1.8–2 mm) following molar distalization with
(e-mail: jgeron@zahav.net.il). repelling magnets or nickel titanium open coil springs8,9
Accepted: February 2003. Submitted: October 2002. supported by a Nance appliance or the second premolar (1.6

2003 by The EH Angle Education and Research Foundation, Inc. mm). However, minimal incisor anchorage loss (0.92) has

Angle Orthodontist, Vol 73, No 6, 2003 730

ANCHORAGE LOSS—A MULTIFACTORIAL RESPONSE 731

been reported when the pendulum appliance was used.10 MATERIALS AND METHODS
Molar AL had occurred supported with an implant in the
The files of 211 subjects treated in the Tel Aviv Univer-
center of the anterior palate (0.7–1.1 mm), but this was
sity’s clinic and private practices were examined for ade-
probably caused by deformation of the transpalatal bars that
quacy of diagnostic records. From these, a study sample
linked the implant to the maxillary molars.11
consisting of 87 Class I and Class II subjects was found.
The concept of a well-interdigitated occlusion acting to
Subjects were treated with either lingual (n ⫽ 25) or labial
enhance molar anchorage is an accepted dogma. Therefore,
edgewise appliances (n ⫽ 62). All lingually treated subjects
it could be hypothesized that the posterior disocclusion
were nongrowing, whereas 20 of the labially treated sub-
caused by the anterior bite plane effect of a lingual appli-
jects were nongrowing as determined by chronological age
ance might negate this. Thus, the decision to extract is more
and normal growth curves. All subjects had undergone or-
frequent when lingual brackets are applied in the maxillary
thodontic treatment, which included extraction of two max-
arch.12 Lingual archwires are more rigid because of the illary first or second premolars. If only maxillary premolars
smaller interbracket distance.13 were extracted, treatment goals included Class I canine re-
Extraction site is another factor that affects AL. Studies lationship and Class II molar occlusion. Seven subjects
conducted on the effect of the Begg appliance show that from the lingual group also had mandibular second pre-
the maxillary molar occupies 33.5% of the extraction site molars extracted, making their treatment goals include both
with first premolar extractions and 50.4% with first molar a Class I canine and molar relationship.
extractions.14 Creekmore15 found that the posterior teeth oc- All subjects were defined as maximum anchorage cases,
cupy one-third to one-half of the extraction space in first requiring minimal or no anterior movement of the molars
and second premolar extractions, respectively. Furthermore, during space closure. Patients were included if the sum of
in another study,16 no significant difference in AL was their maxillary dental crowding plus double the amount of
found between first or second maxillary premolar extrac- overjet together was greater than or equal to 11 mm
tions (4.3 vs 4.5 mm). However, when maxillary first pre-
molars were extracted in conjunction with mandibular first [crowding ⫹ (2 ⫻ overjet) ⬎11 mm],
or second premolars, AL of the maxillary molars was great- ie, overjet varied from two to 13 mm and crowding varied
er when the mandibular second premolars were extracted from one to 10 mm.
(3.7 vs 4.7 mm).16 The sample was divided into four groups.
Dental crowding and its relationship to AL provide the
first sign that it is a multifactorial response. Second pre- • G1—Nongrowing subjects treated with maxillary first
molar extraction, rather than first, is carried out far more premolar extractions and lingual appliances (n ⫽ 12, age
often in cases with less crowding. This choice has been 24.8 ⫾ 5.57 years).
related to greater molar mesial movement.17 Additionally, • G2—Nongrowing subjects treated with maxillary second
the maxillary chordal arch length (distance from mesial premolar extractions and lingual appliances (n ⫽ 13, age
contact point of the first molar to the contact point of the 24.4 ⫾ 5.99 years).
central incisors) was reported to decrease in extraction cas- • G3—Nongrowing subjects treated with maxillary first
es by 11.3 mm according to Ong and Woods16 and by 8.3 premolar extractions and labial appliances (n ⫽ 20, age
mm as reported by Luppanapornlarp and Johnston.18 This 20.09 ⫾ 5.43 years).
difference corresponds to greater crowding found in the lat- • G4—Growing subjects treated with maxillary first pre-
ter (5.8 mm) than in the former study (3.5 mm). molar extractions and labial appliances (n ⫽ 42, mean
The effect of patient age on AL has not been widely age 12.6 ⫾ 1.99 years).
reported. Growing patients (12.5 years) experience 2.52 Comparisons were made such that when one factor (ex-
mm of AL, whereas nongrowing patients (27.6 years) show traction site, mechanics, or age) was examined using a
an anchorage gain of 0.20 mm. The molar relationship is paired group comparison, the other two factors were non-
corrected by mandibular growth in the adolescent group variable. Crowding and overjet were evaluated from the
(70%) and by maintaining maxillary molar position in the paired-groups and the overall sample.
adult group.19 The labial subjects were treated with 0.022 ⫻ 0.028-inch
It would appear that AL is seemingly dependent on more preadjusted brackets (Victory System, 3M Unitek, Monro-
than one factor, which, up to now, has been investigated via, CA), according to a standardized maximum anchorage
separately. The objectives of this study were to examine the control regimen. The regimen included space closure by
contribution of five such factors: extraction site (first vs individual (sliding) canine retraction followed by en masse
second premolars), mechanics (lingual vs labial technique), incisor retraction carried out on a 0.017 ⫻ 0.025-inch stain-
age (growing vs nongrowing patients), crowding, and over- less steel archwire containing Bull-loops activated one mm
jet and to determine their relative contributions to AL (pri- every four weeks and producing an initial force of 150 g
mary vs secondary AL factors). per side. Archwires were preactivated with tip-back bends

Angle Orthodontist, Vol 73, No 6, 2003

732 GERON, SHPACK, KANDOS, DAVIDOVITCH, VARDIMON

immediately distal to the premolar bracket. All subjects

treated with labial appliances were instructed to wear a cer-
vical headgear, containing an elevated long outer bow, 12
hours daily. For the remainder of the day, subjects were
instructed to wear Class II elastics (3/16-inch medium de-
livering 70–100 g).20 Compliance was verified by clinical
observation of molar position.
All lingual subjects were treated with bidimensional21 or-
thodontics using preadjusted brackets with a 0.018 ⫻
0.025-inch archwire slot from canine-to-canine and an
0.022 ⫻ 0.028-inch slot in the posterior dentition (Ormco
Corp, Glendora, CA). These brackets were oriented and
bonded using a lingual jig method.22 Treatment was admin-
istered according to a standardized maximum anchorage
control regimen in which the second molars were included
in all cases and no headgear was used. Space closure was
accomplished by en masse sliding retraction of the anterior
teeth using intraarch orthodontic elastomeric chains, pro-
ducing initial forces of 150–200 g per side, approximately
50 g for each tooth. The elastic chain was replaced every
six weeks. All subjects treated with lingual appliances were
instructed to wear Class II elastics (3/16- or 1/8-inch me-
dium delivering 70–100 g) for eight hours a day.20 Space
closure was accomplished using a 0.016 ⫻ 0.022-inch FIGURE 1. The distance of the distal contact point of the maxillary
stainless steel archwires preactivated with compensating first molar to the occlusal line perpendicular (OLp) was measured
from pre- and posttreatment cephalometric radiographs, and the dif-
curves (exaggerated Curve of Spee in the maxillary arch
ference (post ⫺ pre) was defined as anchorage loss.
wire and a reverse curve in the mandibular arch wire). Lin-
gual space closure was carried out by en masse retraction
of the six anterior teeth to avoid opening unaesthetic an-
terior spaces during the canine retraction phase. ruga point and the mesial contact point of the first molar
In the lingual cases, the decision to extract first or second were demarcated on the right and left quadrants, and the
premolars was based on the severity of anterior crowding. midpalatal raphe was used to construct a median reference
Anterior crowding greater than six mm inclined toward first line. The referenced casts were photocopied at 200% en-
premolar extraction. Whenever possible the second pre- largement. The distance (d) between the projections of the
molar was the tooth of choice to maximize esthetics (the two points to the median reference line was measured for
extraction site is more visible in lingual treatment) and to the right (dR) and left (dL) quadrants and averaged (Figure
prevent the inset bend of the archwire distal to the canine 2). The difference between pretreatment ‘‘d’’ and posttreat-
from interfering with space closure. ment ‘‘d’’ was defined as AL. Overjet was measured from
the upper and lower dental casts in occlusion. Crowding
Radiographic assessment
was measured as the amount of overlap between teeth.27
Serial lateral cephalograms were superimposed according
to the method of Pancherz24 (Figure 1). The pre- and post-
Statistics
treatment difference of the distal contact point of the max-
illary first molar to a line perpendicular to the occlusal
An analysis of variance with repeated measures was per-
plane through sella (OLp) corresponds to the amount of the
formed to determine statistically significant (P ⬍ .05) dif-
mesial (⫹) or distal (⫺) movement of the maxillary first
molar. This includes maxillary growth that occurred in G4. ferences between the examined groups for three AL factors
In this group, the net AL was calculated by subtracting an (extraction site, mechanics, and age). Pearson’s correlation
average annual amount of maxillary horizontal growth (0.5 tests examined whether initial crowding and overjet corre-
mm/year for the females and 0.9 mm/year for the lated with the amount of AL.
males).25,26
RESULTS
Dental cast assessment
Dental casts were measured according to the method de- The sex of the individuals was excluded as an AL factor
scribed by Ziegler and Ingervall6 (Figure 2). The posterior because no dimorphism was found (P ⫽ .397).

Angle Orthodontist, Vol 73, No 6, 2003

ANCHORAGE LOSS—A MULTIFACTORIAL RESPONSE 733

FIGURE 2. (a) Pretreatment dental cast; the distance d was defined as the length between the projection of mesial contact point of the first
molar and the projection of the most medial point of the posterior ruga along the midpalatal line. (b) The distance d of the posttreatment dental
cast is shorter because of mesial displacement of the first molar and distal migration of the palatal rugae.

TABLE 1. AL for First (G1) Versus Second (G2) Premolar Extraction

OLp-M1 OLp-M1 OLp-M1
Group n Age (y) Before (mm) After (mm) Difference (mm)
Cephalogram
G1 13 24.8 ⫾ 5.7 49.6 ⫾ 9.4 51.4 ⫾ 9.4 1.8 ⫾ 1.4
G2 13 24.4 ⫾ 5.9 45.7 ⫾ 9.6 48.0 ⫾ 9.9 2.4 ⫾ 1.3
P 0.874 0.299 0.372 0.332
Dental cast
G1 13 7.2 ⫾ 2.9 4.8 ⫾ 2.4 2.4 ⫾ 1.9
G2 10 6.9 ⫾ 2.0 4.0 ⫾ 2.3 2.9 ⫾ 1.6
P 0.771 0.404 0.332

Extraction site—first (G1) vs second (G2) when measured from dental casts, was 2.4 ⫾ 1.9 mm for
premolar extractions G1 and 3.9 ⫾ 2.7 mm for G3 (Table 2).
AL was significantly greater in the labial appliance group
AL, as measured from the cephalometric radiographs,
than in the lingual group when measured from cephalo-
was 1.8 ⫾ 1.4 mm for G1 and 2.4 ⫾ 1.3 mm for G2. AL,
metric radiographs (P ⬍ .05) but was not significantly
measured from the dental casts, was 2.4 ⫾ 1.9 mm for G1
greater when measured from dental casts. The other two
and 2.9 ⫾ 1.6 mm for G2 (Table 1).
AL factors tested, ie, age (nongrowing) and extraction site
Thus, AL with second premolar extractions was 0.5 ⫾
(upper first premolar) were similar in these groups.
1.3 mm greater as measured from the cephalometric radio-
graphs and 0.5 ⫾ 1.7 mm greater when measured from the
dental casts. The other two AL factors tested, ie, mechanics Age—nongrowing (G3) vs growing (G4) subjects
(lingual appliances) and age (nongrowing) were similar in
The AL, as measured from cephalometric radiographs,
these groups.
was 3.0 ⫾ 1.4 mm for G3 and 3.5 ⫾ 1.6 mm for G4. AL,
as measured from dental casts, was 3.9 ⫾ 2.3 mm for G3
Mechanics—lingual (G1) vs labial (G3)
and 4.1 ⫾ 2.3 mm for G4 (Table 3).
edgewise appliances
Thus, the G4 growing patients showed a greater but not
AL, when measured from the cephalometric radiographs, significantly greater AL than the G3 nongrowing patients
was 1.8 ⫾ 1.4 mm for G1 and 3.0 ⫾ 1.4 mm for G3. AL, with cephalometric measurements and with dental casts.

Angle Orthodontist, Vol 73, No 6, 2003

734 GERON, SHPACK, KANDOS, DAVIDOVITCH, VARDIMON

TABLE 2. AL for Lingual (G1) Versus Labial (G3) Edgewise Appliance

OLp-M1 OLp-M1 OLp-M1
Group n Age (y) Before (mm) After (mm) Difference (mm)
Cephalogram
G1 13 24.8 ⫾ 5.7 49.6 ⫾ 9.4 51.4 ⫾ 9.4 1.84 ⫾ 1.4
G3 15 20.0 ⫾ 5.4 49.2 ⫾ 12.5 52.3 ⫾ 12.7 3.0 ⫾ 1.4
P 0.25 0.923 0.865 0.042*
Dental cast
G1 13 7.2 ⫾ 2.9 4.8 ⫾ 2.4 2.4 ⫾ 1.9
G3 11 9.2 ⫾ 2.8 5.3 ⫾ 3.9 3.9 ⫾ 2.7
P 0.097 0.696 0.084

TABLE 3. AL for Growing (G4) Versus Non-growing (G3) Subjects

OLp-M1 OLp-M1 OLp-M1
Group n Age (y) Before (mm) After (mm) Difference (mm)
Cephalogram
G4 33 12.7 ⫾ 2.0 48.3 ⫾ 10.0 51.8 ⫾ 10.2 3.5 ⫾ 1.6
G3 15 20.0 ⫾ 5.4 49.2 ⫾ 12.5 52.2 ⫾ 12.7 3.0 ⫾ 1.4
P 0.0001 0.793 0.919 0.275
Dental cast
G4 19 9.2 ⫾ 3.5 5.1 ⫾ 3.1 4.1 ⫾ 2.3
G3 11 9.2 ⫾ 2.8 5.3 ⫾ 3.9 3.9 ⫾ 2.3
P 0.994 0.869 0.802

TABLE 4. Comparison of Overjet and Crowding in Relation to the Three AL Factors

Site of Extraction Mechanics Age
G1 G2 P G1 G3 P G4 G3 P
Overjet (mm) 4.1 ⫾ 2.7 5.0 ⫾ 2.8 0.832 4.1 ⫾ 2.7 5.5 ⫾ 2.6 0.948 5.4 ⫾ 2.5 5.5 ⫾ 2.3 0.995
Crowding (mm) 7.4 ⫾ 1.8 6.6 ⫾ 1.6 0.743 7.4 ⫾ 1.8 6.7 ⫾ 4.2 0.776 6.2 ⫾ 3.7 6.7 ⫾ 2.0 0.876

However, after accounting for the maxillary growth expe-

rienced by G4, the net mean AL of G4 was less than that
of G3, with no significant net difference. The other two AL
factors tested, ie, mechanics (labial edgewise appliances)
and extraction site (first premolar) were similar in these two
groups.

Overjet and crowding

Overjet and crowding were compared using ANOVA be-

tween the three-paired groups of the previously examined
AL factors. These comparisons were not significant (Table
4). Pearson’s correlation test was performed between initial
crowding or overjet and AL for the whole sample. A sig-
nificant inverse correlation was found between initial
crowding and AL for both cephalometric and dental cast
measurements (Figure 3; Table 5). The correlation was par-
ticularly high for the cephalometric data (r ⫽ ⫺0.66, P ⫽
.001). Crowding and overjet were significantly but indi-
rectly and weakly correlated (r ⫽ ⫺0.28, P ⫽ .009) (Table FIGURE 3. An inverse correlation developed between initial crowd-
5). ing and anchorage loss measured from cephalometric radiographs.

Angle Orthodontist, Vol 73, No 6, 2003

ANCHORAGE LOSS—A MULTIFACTORIAL RESPONSE 735

TABLE 5. Correlation for Initial Crowding and Overjet Versus AL, and Crowding Versus Overjet
Anchorage Loss Anchorage Loss
n Cephalogram n Dental Cast n Crowding
Crowding 75 r ⫽ ⫺0.66, P ⫽ .001 53 r ⫽ ⫺0.31, P ⫽ .026
Overjet 75 r ⫽ 0.27, P ⫽ .021 53 r ⫽ ⫺0.11, P ⫽ .449 90 r ⫽ ⫺0.28, P ⫽ .009

DISCUSSION traction site is a secondary AL factor is probably a valid

deduction with regard to maxillary premolars.
The extent of AL was consistently greater when mea-
sured from dental casts than from cephalometric radio-
graphs by 0.5–0.6 mm, probably because of posterior dis- Mechanics—lingual vs labial
placement of the rugae as the anterior teeth were retracted edgewise appliances
(Figure 2). Thus, posttreatment d (Figure 2b) decreased be-
The choice of a labial or lingual edgewise appliance
cause of molar mesial movement and posterior displace-
demonstrated the greatest AL difference of all two-group
ment of the rugae. Consequently, pretreatment (Figure 2a)
comparisons. Cephalometric comparisons (AL ⫽ 1.2 ⫾ 2.1
minus posttreatment d (Figure 2b) increased. Thus, dental
mm, P ⬍ .05) suggest that this factor plays a more clini-
cast measurements do not reflect pure molar mesial dis-
cally relevant role in controlling AL than the extraction site
placement. In addition, in selecting the most anterior ruga
or patient age. The finding that the lingual edgewise tech-
as a reference point, the extent of its posterior displacement
nique demonstrated lower AL suggests that this factor
was greater than that found for the most posterior ruga,
should be studied more closely. The theory of Alexander
probably because of its proximity to the retracted incisors.
et al12 that disocclusion of the posterior teeth due to the bite
These results conflict with studies claiming that the palatal
plane built into the maxillary incisor brackets of the lingual
rugae are stable landmarks28,29 but are in agreement with
technique decreases resistance to AL is not supported by
other studies that report similar findings.30,31 The cephalo-
the present findings. Engagement of second molars in the
metric method is more reliable because the reference point
lingual archwire probably enhanced anchorage, which sup-
(OLp) is located posterior to the examined molar.
ports the theory of Storey relating anchorage resistance to
root surface areas. Freeman,33 who calculated this resis-
Extraction site—first vs second
tance, found that the ‘‘anchorage value’’ (AV) of the max-
premolar extraction
illary six anterior teeth (AVa ⫽ 1412) almost equaled that
The long-held dogma that greater AL occurs when sec- of the posterior teeth (AVp ⫽ 1574) when the second mo-
ond rather than first premolars are extracted14,15,17,32 was lars were excluded but was almost half when the second
weakly supported by the present study. AL was only 0.5 molars were included (AVp ⫽ 2474).2,33 However, in G3
mm greater with second premolar extractions when as- subjects, wearing a headgear was expected to offer greater
sessed either from cephalometric radiographs or from den- resistance than inclusion of second molars; but poor patient
tal casts. However, this was not significant, suggesting that compliance related to age (20 ⫾ 5.43 years) could explain
the location of the premolar extraction site cannot be con- some of the greater AL displayed by these subjects.
sidered a major AL factor. Statistically, the nonsignificant Kurz and Bennett13 suggest that the smaller arch perim-
difference between the two groups could be related to the eter increases the rigidity of lingual archwires, which may
relative small sample size in this comparison, although the increase anchorage control during retraction. The larger slot
high P value suggests a reliable nonsignificant AL differ- size of the posterior lingual attachments provides an almost
ence between the first and second premolar extraction op- frictionless sliding retraction with no energy burning.21,34
tions. Nevertheless, the present finding is supported by Ong Takemoto36 suggests that the anchorage value of posterior
and Woods,16 who reported a 0.2-mm difference. Williams teeth in the lingual technique is higher than that in the labial
and Hosila14 compared extraction sites mainly in the lower technique because of the nearness of the lingual brackets
jaw and reported a difference in AL in second vs first pre- to the center of tooth resistance. Additionally, the direction
molar extractions (1.0 mm), which was twice that found in of forces during space closure with lingual appliances cre-
the present study (0.5 mm). ates a buccal root torque and distal rotation of the molar
More molar mesial movement in both first and second crown, which produces cortical bone anchorage.
premolar extractions was reported by Saelens and De Smit17 The average traction force was 75 and 50 g per anterior
(4.4 and 5.3 mm, respectively) compared with the present tooth, in the labial and lingual techniques, respectively. Ad-
study (1.8 and 2.4 mm, respectively). This could be related ditionally, because the lingual retraction force is generated
to the use of lingual appliances that contributed to a reduc- by elastomeric chains, their force decay is more than 50%
tion in molar mesial migration. However, because mechan- in four weeks.36,37 This means that the average force applied
ics was a nonvariable parameter, the inference that the ex- during the six-week period (interval between lingual ses-

Angle Orthodontist, Vol 73, No 6, 2003

736 GERON, SHPACK, KANDOS, DAVIDOVITCH, VARDIMON

sions) was about 25 g per tooth. This suggests that, on crowded (⬃4 mm) and a severely crowded (⬃10 mm) sub-
average, during appointment intervals, the retraction force ject was two mm (Figure 3). This suggests that crowding
was threefold lower in the lingual than in the labial tech- was more relevant than mechanics as the key AL factor.
nique.
The combination of bidimensional orthodontics with its CONCLUSIONS
inherent less friction during sliding mechanics, with light
The hypothesis that AL is a multifactorial response was
orthodontic forces for space closure, the inclusion of the
supported by the present study. Although only five AL fac-
second molar in the anchorage unit, and the placement of
tors were examined, a regulatory reaction was found. Pri-
exaggerated curves in both archwires, together appears to
mary AL factors (crowding and mechanics) affected AL
be a very efficient method for anchorage preservation. This
more significantly than did secondary AL factors (age, ex-
seems to hold true even in severe Class II cases, regardless
traction site, and overjet). A pattern of influence was found,
of whether first or second premolars are chosen for extrac-
where crowding (inverted influence, ie, the greater the arch
tion.
length deficiency, the lower the AL) was superior to me-
chanics (primary AL factors), and extraction site was more
Age—growing vs nongrowing patients
influential than age and overjet (secondary AL factors).
Greater AL was found in the adult group when postero- The desire to minimize AL is of major concern because
anterior maxillary growth was compared with the adoles- residual overjet, noncusp fossa relationships, and deep bite
cent group. However, the difference between the groups are affected. The study suggests that incorporation of the
(0.7 ⫾ 1.4 mm) was not significant, which suggests that second molars in the anchorage strategy, low retraction
age, as an AL factor, was secondary to choice of appliance. forces, and frictionless mechanics are superior to the con-
Nevertheless, a significantly greater AL was found in the ventional anchorage means such as headgear or non en
adult group of the present study (3.0 ⫾ 1.4 mm) compared masse retraction.
with the findings of Harris et al,19 who reported only a
minor AL (0.2 mm), which suggests that this factor merits ACKNOWLEDGMENTS
further study. It should be mentioned that in the latter The authors thank Ms Ilana Gelerenter TAU Statistic Center for
study,19 this difference is explained by the fact that the adult statistical analysis, Ms Anna Bahar for graphical help, and Ms Rita
subjects wore Class II elastics for a longer time. In the Lazar for editorial assistance.
present study, both age groups wore elastics for similar pe-
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