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National Journal of Maxillofacial Surgery
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Table of Contents
Year : 2022  |  Volume : 13  |  Issue : 3  |  Page : 390-397  

Comparative study of different distraction rates in separate retractions of canine: Randomized control trial

1 Department of Orthodontics, Faculty of Dental Science, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of OMFS, Faculty of Dental Science, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission27-Jun-2021
Date of Acceptance20-Oct-2021
Date of Web Publication10-Dec-2022

Correspondence Address:
Dr. P Subash
Department of Orthodontics, Faculty of Dental Science, Banaras Hindu University, Varanasi, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njms.njms_430_21

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Introduction: Orthodontic treatment typically lasts 18–24 months, but depending on the conditions, it can take a longer duration. In recent years, accelerated orthodontics has been the subject of extensive research to shorten the duration of treatment. In distraction osteogenesis (DO), the surgically created joints are slowly and controllably displaced over time by gradual traction. This results in simultaneous growth of soft tissues and bone volumes at the osteotomy site. The DO field is currently experiencing a modern surge of research and development that has been able to implement numerous innovative and revolutionary distraction systems. In this study, we are comparing two different rates of dentoalveolar distraction.
Materials and Methods: With the use of custom-made distractors, we will compare the different ranges of activation of distractors and their dental effects. Participants are separated into two groups based on 0.4 mm/day activation and 0.5 mm/day activation.
Results: During the study period, the average tooth movement rate for Group 1 was 0.52 mm and for Group 2 was 0.58 mm. Group 1 completed canine distraction in 11.42 ± 1.81 days and Group 2 in 10.05 ± 1.68 days.
Conclusions: Retraction days decreased in Group 2, due to increased activation of the distractor. The anchorage loss in Group 2 was higher than that in Group 1, which was 1.39 mm lower. Unlike decreased activation, the mean tooth movement of Group 1 is higher than Group 2.

Keywords: Accelerated tooth movement, custom-made distractor, distraction osteogenesis, rate of tooth movement, surgically assisted tooth movement

How to cite this article:
Parihar AV, Verma S, Subash P, Singh AK. Comparative study of different distraction rates in separate retractions of canine: Randomized control trial. Natl J Maxillofac Surg 2022;13:390-7

How to cite this URL:
Parihar AV, Verma S, Subash P, Singh AK. Comparative study of different distraction rates in separate retractions of canine: Randomized control trial. Natl J Maxillofac Surg [serial online] 2022 [cited 2023 Jan 27];13:390-7. Available from: https://www.njms.in/text.asp?2022/13/3/390/363074

   Introduction Top

Conventionally, orthodontic tooth movement is done through the application of light, continuous, and controlled forces. The treatment usually ranges from 18 to 24 months, depending on the condition the duration increases too. The accelerated orthodontic treatment in recent years undergoing robust research to lessen the duration. The prolonged treatment time associated with comprehensive fixed orthodontic treatment is of concern from both patient and practitioner viewpoints because of increased risk of white spot lesions, dental caries, periodontal problems, external apical root resorption (EARR), and decreased patient compliance.[1] Segal et al.[2] in their meta-analysis, comprising studies on external root resorption, found that treatment is one of the major factors leading to EARR, and duration of treatment is directly proportional to extent of root resorption observed in orthodontic patients. The attempt to reduce the treatment time associated with fixed orthodontic treatment is largely based on increasing the rate at which the tooth moves under the orthodontic forces, and clinicians have been striving toward the development of such strategies. The first attempt to fasten the orthodontic tooth movement has been made as early as the 1890s, but the underlying biological phenomenon was not so clear at the time. According to Merill and Pedersen, L C Brain and G Cunnigham were the first to provide reports on surgical methodologies to fasten the correction of malocclusion.[3] This technique of surgical acceleration of orthodontic tooth movement was called corticotomy. The work of Herald Frost revolutionized the biological understanding of accelerated orthodontics. He explained that in response to local noxious stimulus, there is faster tissue formation as compared to the normal regeneration process and named it is as regional acceleratory phenomenon.[4] Ferguson et al. advocated a newer surgical technique to accelerate orthodontic tooth movement, which became very popular and formed the mainstay of accelerated orthodontics in the early years of the 21st century.[5] This technique and procedure laid the foundation of accelerated orthodontics. As Köle[6] proposed in 1959, interdental corticotomies could be used to reposition the tooth orthodontically.

Distraction osteogenesis (DO) involves gradual, controlled displacement of surgically created fractures (subperiosteal osteotomy) by incremental traction[7] resulting in simultaneous expansion of soft tissue and bone volume due to mechanical stretching through the osteotomy site. Modern research and development in the field of DO have led to the implementation of numerous innovative and revolutionary distraction systems. A wide variety of intraoral distractors are now available and engineered to be small and compact with increased patient comfort and acceptance. This paved the way to further investigate the technique for application in influencing the rate and vector of tooth movement. Liou and Huang[8] first investigated and applied this concept to orthodontic tooth movement and performed rapid canine retraction and termed it as dental distraction. Later investigations validated that this rapid movement is a form of DO of the periodontal ligament which acts as “sutures” between alveolar bone and tooth with similar osteogenic potential.[9] Clinical validation of this technique investigated in recent years[10] showed that this technique and procedure reduced net orthodontic treatment time. The technique was later substantiated with follow-up and a large number of cases have been treated successfully with the shorter orthodontic treatment time period (Kinsinci and Isrie 2011, Gokemon Kurt 2017).[11],[12]

Most of the studies have done dentoalveolar distraction (DAD) for canines in comparison with conventional or accelerated orthodontic tooth movement phenomena. No studies have compared the efficacy by differing the range of activation of distraction in the patient. In our present study, we compared the different ranges of activation of distraction and intended to choose the best one of it.

Aim and objective

This study aims to compare the different ranges of activation of distractors and their dental effect while using custom-made distractors. The null hypothesis tested was that there is no difference in dental effects induced by distractor on different activation.

   Materials and Methods Top

Trial design

The study was a single-centered, parallel-group, two arms randomized comparative clinical trial on DAD between two groups. This study was conducted over a three-year time period. The study is approved by Institutional Ethical Board by the university with registration number Dean/2018/EC/376. This study was also registered with the Clinical Trial Registry of India (CTRI) Registration Number: CTRI/2018/12/016793. This report was designed according to the Consolidated Standard of Reporting Trials (CONSORT) statement [Figure 1].
Figure 1: Consort Flow Diagram

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The study was carried out in the orthodontics department. All the participants recruited were new patients and reported to the outpatient department between January 2016 and June of 2017.

Inclusion criteria

Adolescent and adult patients aged 16 years and above were selected for the study. Patients with overjet >6 mm and requiring first premolar extraction for correction were selected [Table 1].
Table 1: Inclusion and exclusion criteria for the selection of sample

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Exclusion criteria

Patients who have previously done orthodontic treatment and patients with systemic disease and the craniofacial syndrome were excluded from the study.


In the study group, the patients and their parents were informed about the proposed treatment plan involving a maxillary surgical procedure, and informed consent was obtained from each patient before the DAD procedure. The computed tomography (Denta) scan of each patient was evaluated for possibilities of cases in which the apex of canine and first premolar root was closely situated near the antrum and floor of the maxillary sinus lining. The customized banding was done for molar and canine with 0.06 × 0.180” and 0.15 × 0.004” inches, respectively, and the impression was made. The impression was poured with a hard dental stone, and the distractor was soldered to the canine and first molar band and checked for fit and tolerance in the clinical setting, the distractor was positioned as high as possible on the buccal side to minimize tipping.

All patients underwent the procedure under local anesthesia. A horizontal mucosal incision 2–2.5 cm long was made parallel to the gingival margin of the canine and bicuspid teeth. Subperiosteal elevation was carried out to expose the canine and the first premolar root region. A vertical osteotomy cut was made on the anterior and posterior aspect of the canine tooth to be distracted using a stamping method on the alveolar bone with a small round carbide bur under copious irrigation. The proximity of the neighboring tooth dictated the depth and location of the cortical holes. The osteotomy was continued and curved apically, passing 3–5 mm from the apex, which could readily be identified in the alveolar bone. A thin, tapered fissure bur was then used to connect the holes around the canine root. Fine osteotome was then introduced and advanced in the coronal direction. The first premolar region buccal cortical shelves were carefully removed through the extraction socket using large, round burs between the bone cut at the distal canine region anteriorly and the second premolar posteriorly. The bone apical to the extraction socket and conceivable bony interferences at the buccal aspect that may be encountered during the distraction process were eliminated or smoothed between the canine and the second premolar teeth with preservation of palatal or lingual cortical shelves.

Osteotomes in appropriate sizes were then used along the anterior aspect of the canine tooth to split the surrounding spongy bone around its root of of the lingual or palatal cortex and neighboring teeth. Irrigation was done with saline and the wound was closed in a single mucosal layer with an absorbable suture.

The distraction device was fitted and cemented to the first molar and canine teeth at the end of the surgical procedure. Based on the systematic review by Sadhana Swaraj et al.,[13] bioactive glass cement is used to cement the appliance. Parihar et al.[14] conducted a meta-analysis and proved GIC is more effective in reducing white spot lesions too. DAD was started on the day of the surgery and continued at a rate of 0.4 mm twice a day.

The panoramic radiographs (Epsilon OPG EP-Dento HD) and IOPA were taken before and after completion of canine retraction in all three groups with a standardized patient's position. According to Ursi et al.,[15] 781,990 reference points and reference planes formed to mesial and distal tipping of canine and molar in OPG. A total of four angular measurements were made with these points and planes and analyzed by a one-way ANOVA test. Stuart and Michael's guidelines take all IOPA. Kruskal–Wallis test was performed on data obtained by using scale described by Liou and Huang.[8]

Before and after canine retraction, models were made and assessed for the rate of canine distraction and posterior anchorage loss by determining the location of maxillary raphe by using two predetermined reference points as described by Haas and Cisneros and Hoggan and Sadowsky.[16],[17] The perpendicular distances from the cusp tip of the upper canine and the mesiobuccal cusp tip of the first molars to the reference line were measured.

All patients participating in the study were observed for vitality, and then, the corresponding number on the scale was registered by electrical vitality test (Waldent Electric pulp tester) performed before starting the procedure and after 6 months after completion of canine retraction procedure among all groups. The number obtained from the suspected tooth was compared to the intact tooth (before the procedure). Each tooth was assessed two times by different observers [Figure 2].
Figure 2: Pulp vitality testing using Electric Pulp Test (EPT)

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Sample size

A clinically significant difference in two independent means of the rate of tooth movement was considered with an effect size of 1.4658065 and the power of the study is 80% with a significant difference P of 0.05. A total sample of 14 was therefore required (7 per group). As the procedure is highly invasive, the total sample was kept at 45 cases for potential attrition, based on the expected 10% dropout rate.[16]

Randomization and allocation concealment

The randomization was carried out using computer-generated random sequence numbers with an allocation ratio of 1:1 in both the groups. Once the patient consents to the distraction treatment, allocation concealment was reached by using sequentially numbered, opaque, sealed cover with a group to which the patient is allocated.


The blinding was not possible for the operator, as he has to activate the distractor. To minimize the outcome bias, all the outcomes (OPG, IOPA, Models, and Cast) were measured by an independent researcher who was blinded from the beginning of the study.

Primary Outcome

The primary outcome was the rate of canine retraction with both the distraction in terms of days from the fitting of distractor to the complete distraction of canine.

Secondary outcome

The secondary outcome measures were anchorage loss of molars, root resorption and tipping of canine before and after canine distraction, vitality, pain perception, and compliance of the patient.

Statistical analysis

Simple descriptive statistics were used for baseline demographic and clinical data. The repeatability of the angular changes, root changes, and anchorage loss was assessed in a patient model and on 10 randomly chosen radiographs. The intraclass correlation coefficient showed excellent reliability between groups. The samples within the group were assessed using paired-samples t-tests. All statistical analyses were completed using SPSS software for Windows (version 22.0; IBM, Armonk, NY, USA).

A significant level of 0.05 was used. The Fisher's exact test is used for validating root resorption in apical and lateral.

   Results Top

Participant flow

Forty-five patients were randomized in total. The number of samples in this study is kept high as the procedure is highly invasive expecting a high dropout of around 10%. Three patients in Group 1 and 2 patients in Group 2 discontinued and conventional treatment was done further. A CONSORT diagram showing the flow of participants through the study is given in the figure.

Baseline data

The baseline characteristics for age, sex, ethnicity, and the mean overjet were similar in both groups and are given in [Table 2].
Table 2: Baseline characteristics of study groups

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Numbers analyzed for each outcome, estimation, and precision

The paired t-test within the same group showed highly significant values (P < 0.05) in the table. The comparison of changes between both groups showed significant values for the rate of canine retraction, anchorage loss, tipping/angular changes in canine, and distraction time. The root resorption value in the Fisher's exact test is not significant in both apical and lateral areas.


No harm was observed or reported from the participants in the study.

   Discussion Top

Main findings in the context of existing evidence, Interpretation

This was the first study to assess the effect of the difference in activation of distraction range, i.e., 0.4 and 0.5 mm (0.1 mm increment) in two different groups [Table 3], [Table 4], [Table 5]. As the distraction is maximally invasive to the patient, and not preferable, patient motivation plays the main role. The study may have an important influence in clinical practice in deciding optimum activation range and pro-cons of increased activation in terms of functional impairment, duration of the appliance wearing, and compliance.
Table 3: Comparison of change in variables within 0.4 group

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Table 4: Comparison of change in variables within 0.5 group

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Table 5: Comparison of change in variables between 0.4 and 0.5 groups

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In our present study, the rate of tooth movement in Group 1 was 0.52 mm/day and Group 2 was 0.58 mm/day which is in accordance with Gokmen Kurt et al.[12] in which tooth movement was 0.67 ± 0.14 mm per day, whereas Sukurica et al.,[18] Karkare Kharkar et al.,[19] and Naveen Kumar et al.[20] also showed similar kinds of findings [Figure 3] and [Figure 4].
Figure 3: Group 1 undergoing 0.52 mm/day activation

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Figure 4: Group 2 undergoing 0.58 mm/day activation

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In our present study, the Group 1 completed canine distraction in 11.42 ± 1.81 days and Group 2 in 10.05 ± 1.68 days. Gokmen Kurt, Iseri et al.,[12] Kharkar et al.,[18] and Sukurica et al.[17] showed similar kinds of results through the activation ranges vary with studies. Reha S et al.[21] did the first distraction for the tooth movement and observed 0.5–0.8 mm movement per day with the total canine retraction achieved in 8–14 days. The study achieved the canine distraction earlier than our study, the reason is contributed due to increased activation of 0.8 mm/day.

The anchorage loss has been an important factor to be considered, unwanted tooth movement in molar for Group 1 is −0.97, and Group 2 is −1.39. Group 2 shows more anchorage loss while distraction with a similar condition. Both the groups' anchorage was enhanced with Nance palatal arch or transpalatal arch in maxilla during canine distraction. The findings were similar and in accordance with Yusuf Sukuricaa[18] who noted 0–3 mm anchorage loss with a mean value of 1.2 ± 0.83 mm. The contrary findings were seen in studies Reha S. et al.,[21] HalukIseri et al.,[12] V. R. Kharkar,[19] and Shashidhara Kamath Kateel et al.[22] who noted no significant anchorage loss in the molar during distraction without anchorage control mechanisms. The reason behind the huge differences in anchorage loss might be attributed to bone conditions.

In our study, the distal movement of the canine occurs by a combination of tipping and translation, the tipping of canine in Group 1 is −10.10 ± 6.56 and Group 2 is −14.35 ± 5.26. Similar findings were noted by Haluk et al.[12] who showed −13.15 (±4.65°). Yusuf Sukurica et al.[16] noted very little tipping while distraction (9.1) which was less than our finding, the reason might attribute to the usage of hyrax screw instead of the customized distractor. Yusuf et al.[18] used hyrax to do distraction by modification.

No tooth was nonvital before the start of treatment in any procedure in Group 1 and Group 2. The tooth was in a state of shock after the distraction, so immediately after the procedure, it might yield false-negative findings. The vitality test was repeated 6 months after the procedure, some of the teeth showed a tingling sensation, and followed by another 6 months (i.e., 1 year after the distraction), all the teeth reacted normally. The vitality of the teeth in both the groups was preserved. This was in accordance with the systematic review by Verma et al.s[23] where the vitality was not affected and also results were not reliable while undergoing orthodontic treatment.

The root resorption in Group 2 of the present study shows negligible root resorption (score 0) in 10 patients and (Score 1) in 9 patients, whereas Group 1 shows negligible root resorption in 9 patients (score 0) and irregularities in root surface in 10 patients (score 1). There is no statistically significant difference between Group 1 and Group 2. There is no significant root resorption during distraction in both the groups [Table 6]. The findings were similar to the findings of Yusuf Sukurica et al.,[18] they also noted no significant findings in root resorption.
Table 6: Comparison of root resorption apical lateral

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The procedure was highly invasive and a high rate of dropout was reported. The procedure needs continuous monitoring on a daily basis for the whole duration of distraction. The attrition of the sample is more; hence, the power of the study is reduced.

   Conclusions Top

Based on in comparison to Group 1 (0.4 mm) and Group 2 (0.5 mm), the following interpretations can be made

  1. The decreased mean number of days for retraction in Group 2, because of increased activation of the distractor
  2. Increased anchorage loss in Group 2 with a mean of −1.39 mm and in Group 1 has less anchorage
  3. In contrast to decreased activation mean tooth movement of Group 1 is higher than Group 2
  4. Group 2 has increased mesial tipping of canine and distal tipping of the molars than the Group 1
  5. The vitality is of no significant difference in both Group 1 and Group 2
  6. The root resorption in Group 2 is more in lateral aspect and Group 1 has more cervical root resorption.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Segal GR, Schiffman PH, Tuncay OC. Meta analysis of the treatment-related factors of external apical root resorption. Orthod Craniofac Res 2004;7:71-8.  Back to cited text no. 2
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Shenava S, Nayak UK, Bhaskar V, Nayak A. Accelerated orthodontics – A review. Int J Scient Study 2014;1:35-9.  Back to cited text no. 4
Ferguson DJ, Wilcko MT, Wilcko WM, Makki L. scope of treatment with periodontally accelerated osteogenic orthodontics therapy. Semoin Orthod 2015;21:175-86.  Back to cited text no. 5
Köle H. Surgical operations on the alveolar ridge to correct occlusal abnormalities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1959;12:515-29.  Back to cited text no. 6
Ilizarov GA. The principles of the Ilizarov method. Bull Hosp Joint Dis Orthop Inst 1988;48:1-11.  Back to cited text no. 7
Liou EJ, Huang S. Rapid canine retraction through distraction of the periodontal ligament. Am J Orthod Dentofac Orthop 1998;114:372-81.  Back to cited text no. 8
Liou EJ, Figueroa AA, Polley JW. Rapid orthodontic tooth movement into newly distracted bone after mandibular distraction osteogenesis in a canine model. Am J Orthod Dentofacial Orthop 2000;117:391-8.  Back to cited text no. 9
Sayin S, Bengi AO, Gürton AU, Ortakoğlu K. Rapid canine distalization using distraction of the periodontal ligament: A preliminary clinical validation of the original technique. Angle Orthod 2004;74:304-15.  Back to cited text no. 10
Kisnisci RS, Iseri H. Dentoalveolar transport osteodistraction and canine distalization. J Oral Maxillofac Surg 2011;69:763-70.  Back to cited text no. 11
Kurt G, İşeri H, Kişnişçi R, Özkaynak Ö. Rate of tooth movement and dentoskeletal effects of rapid canine retraction by dentoalveolar distraction osteogenesis: A prospective study. Am J Orthod Dentofacial Orthop 2017;152:204-13.  Back to cited text no. 12
Swaraj S, Prasanth K, Verma S, Parihar A, Chaturvedi T. Efficacious materials in minimizing white spot lesion in orthodontics: A systematic review. Int J Orthod (Milwaukee, Wis.) 2018;29:49.  Back to cited text no. 13
Parihar A, Swaraj S, Verma S, Chaturvedi T, Mishra R. Efficacy of various agents in reducing white spot lesions around orthodontic brackets: A meta-analysis. Int J Orthod (Milwaukee, Wis.) 2019;30:71-8.  Back to cited text no. 14
Ursi WJ, Almeida RR, Tavano O, Henriques JF. Assessment of mesiodistal axial inclination through panoramic radiography. J Clin Orthod 1990;24:166-73.  Back to cited text no. 15
Haas SE, Cisneros GJ. The goshgariantranspalatal bar a clinical and an experimental investigation. Semin Orthod 2000;6:98-105.  Back to cited text no. 16
Hoggan BR, Sadowsky C. The use of palatal rugae for the assessment of anteroposterior tooth movements. Am J Orthod Dentofacial Orthop 2001;119:482-8.  Back to cited text no. 17
Sukuricaa Y, Karaman A, Gürel HG, Dolanmaz D. Rapid canine distalization through segmental alveolar distraction osteogenesis. Angle Orthod 2007;77:226-36.  Back to cited text no. 18
Kharkar VR, Kotrashetti SM, Kulkarni P. Comparative evaluation of dento-alveolar distraction and periodontal distraction assisted rapid retraction of the maxillary canine: A pilot study. Int J Oral Maxillofac Surg 2010;39:1074-9.  Back to cited text no. 19
Kumar N, Prashantha GS, Raika S, Ranganath K, Mathew S, Nambiar S. Dento-alveolar distraction osteogenesis for rapid orthodontic canine retraction. J Int Oral Health 2013;5:31-41.  Back to cited text no. 20
Kişnişci RS, Işeri H, Tüz HH, Altug AT. Dentoalveolar distraction osteogenesis for rapid orthodontic canine retraction. J Oral Maxillofac Surg 2002;60:389-94.  Back to cited text no. 21
Kateel SK, Agarwal A, Kharae G, Nautiyal VP, Jyoti A, Prasad PN. A comparative study of canine retraction by distraction of the periodontal ligament and dentoalveolar distraction methods. J Maxillofac Oral Surg 2016;15:144-55.  Back to cited text no. 22
Verma S, Chaturvedi T, Sharma V, Swaraj S, Prasanth K, Parihar A. Appraisal of minimally invasive MOP and maxillary invasive DAD surgical procedures in the acceleration of tooth movement: A systematic review. Int J Orthod (Milwaukee, Wis.) 2019;30:43-52.  Back to cited text no. 23


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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