Root Shortening With Three Methods of Upper Front Teeth Retraction

Orthodontic camouflage treatment of adult patients with Class II Division 1 malocclusion frequently involves extraction of the maxillary first premolars followed by retraction of the upper anterior teeth. Temporary orthodontic miniscrews can provide skeletal anchorage during this stage and allow the six maxillary anterior teeth to be retracted together as one unit. Although these mechanics are widely used, the anterior teeth remain exposed to orthodontic forces during both the initial leveling and alignment phase and the subsequent retraction phase. External apical root resorption is therefore an important biological safety outcome that should be evaluated throughout treatment rather than only after space closure has been completed.

This single-center, three-arm, parallel-group randomized clinical trial was conducted at the Department of Orthodontics, Faculty of Dentistry, Damascus University. Sixty adult patients with Class II Division 1 malocclusion who required extraction-based orthodontic camouflage treatment were allocated equally to one of three treatment groups: a bidimensional bracket group, a hybrid dual-section archwire group, or a conventional sliding mechanics group.

The three approaches differed in the relationship between the anterior brackets and the working archwire. The bidimensional approach used smaller anterior bracket slots with larger posterior slots. The hybrid dual-section approach used a customized archwire with different anterior and posterior cross-sections, while the conventional group used a continuous archwire with a uniform cross-section. These mechanical differences may influence archwire engagement, force expression, and the distribution of forces applied to the roots of the maxillary anterior teeth. Their possible effect on external apical root resorption therefore required direct clinical comparison.

All participants underwent bilateral extraction of the maxillary first premolars, fixed-appliance leveling and alignment, and miniscrew-supported en-masse retraction of the six maxillary anterior teeth. The same general treatment stages and skeletal anchorage concept were used in all groups, while the bracket-slot and archwire configurations varied according to group allocation. Retraction continued until an acceptable overjet and a Class I canine relationship were achieved. Participants were reviewed regularly throughout treatment, and miniscrew-related or other treatment-associated adverse events were recorded.

Digital panoramic radiographs were obtained before orthodontic treatment, at the end of leveling and alignment immediately before retraction, and after completion of en-masse retraction. The maxillary central incisors, lateral incisors, and canines on both sides were assessed individually. Crown length was used as a stable reference to correct for differences in radiographic magnification between time points.

The study was designed to determine whether the three treatment approaches were associated with different amounts of external apical root resorption and to identify the treatment phase during which root shortening occurred. Resorption was therefore evaluated separately during leveling and alignment, during en-masse retraction, and across the complete observation period. This phase-specific design was intended to avoid attributing all root changes detected at the end of retraction to the retraction mechanics alone.

Inclusion criteria

• Adults aged 18-30 years.
• Class II Division 1 dental malocclusion according to Angle classification
• Mild-to-moderate skeletal Class II discrepancy, with an ANB angle greater than 4° and not exceeding 7°.
• Overjet ranging from 5 to 9 mm.
• Presence of all six maxillary anterior teeth.
• Maxillary anterior teeth fully erupted and with complete root formation.

Exclusion criteria

• Patients with previous orthodontic treatment.
• Missing permanent maxillary teeth.
• Active periodontal disease.
• History of trauma to any maxillary anterior tooth.
• Previous endodontic treatment of any maxillary anterior tooth.
• Periapical pathology involving any maxillary anterior tooth.
• Extensive coronal restorations that could interfere with crown-length measurement.
• Radiographic evidence of pre-existing root resorption before orthodontic treatment.