ONLINE ONLY

Factors controlling anterior torque with

C-implants depend on en-masse retraction
without posterior appliances: Biocreative
therapy type II technique
Sung-Seo Mo,a Seong-Hun Kim,b Sang-Jin Sung,c Kyu-Rhim Chung,d Youn-Sic Chun,e Yoon-Ah Kook,f
and Gerald Nelsong
Seoul, Korea, and San Francisco, Calif

Introduction: Our objective was to evaluate the factors that affect effective torque control during en-masse
anterior retraction by using intrusion overlay archwire and partially osseointegrated C-implants as the
exclusive sources of anchorage without posterior bonded or banded attachments. Methods: Base models
were constructed from a dental study model. No brackets or bands were placed on the posterior maxillary dentition during retraction. Different heights of the anterior retraction hooks to the working segment archwire and different intrusion forces with an overlay archwire placed in the 0.8-mm diameter hole of the C-implant were applied
to generate torque on the anterior segment of the teeth. The amount of tooth displacement after nite element
analysis was exaggerated 70 times and compared with tooth axis graphs of the central and lateral incisors and
the canine. Results: The height of the anterior retraction hook and the amount of intrusion force had a combined
effect on the labial crown torque applied to the incisors during en-masse retraction. The difference of anterior
retraction hook length highly affected the torque control and also induced a tendency for canine extrusion.
Conclusions: Three-dimensional en-masse retraction of the anterior teeth as an independent segment can
be accomplished by using partially osseointegrated C-implants as the only source of anchorage, an intrusion
overlay archwire, and a retraction hook (biocreative therapy type II technique). (Am J Orthod Dentofacial
Orthop 2011;139:e183-e191)

Associate professor, Division of Orthodontics, Department of Dentistry, Catholic

University of Korea, Seoul, Korea.
b
Associate professor, Department of Orthodontics, College of Dentistry, Kyung
Hee University, Seoul, Korea.
c
Associate professor and chairman, Division of Orthodontics, Department of
Dentistry, University of Ulsan, College of Medicine, Asan Medical Center, Seoul,
Korea.
d
President, Korean Society of Speedy Orthodontics, Seoul, Korea.
e
Professor and chairman, Division of Orthodontics, Department of Dentistry,
Ehwa Womans University Mokdong Hospital, Seoul, Korea.
f
Professor and chairman, Division of Orthodontics, Department of Dentistry,
Catholic University of Korea, Seoul, Korea.
g
Clinical professor, Division of Orthodontics, University of California at San
Francisco.
The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article.
Supported by a grant from Kyung Hee University in 2010 (KHU-20100696).
Reprint requests to: Seong-Hun Kim, Department of Orthodontics, College of
Dentistry, Kyung Hee University, #1 Hoegi-dong, Dongdaemun-gu, Seoul
130-701, Republic of Korea; e-mail, bravortho@hanmail.net.
Submitted, April 2010; revised and accepted, September 2010.
0889-5406/$36.00
Copyright 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.09.023

n biocreative therapy (C-therapy), torque control

requires special consideration, since one is retracting
the anterior teeth in a segment unattached to the
posterior teeth.1,2 This concept was developed because
partially osseointegrated mini-implants or plates can
easily endure multi-directional heavy forces even when
they support orthodontic archwires.3-6 In C-therapy, it
is possible to retract the anterior segment independently
by directly placing the wire into the hole of the
mini-implant.1,2,7,8 When retracting against dental
anchorage, or against indirect miniscrew anchorage,
actual intrusion vectors on the anterior teeth are hard
to achieve without unwanted reactive forces affecting
the posterior dental units. With the biocreative
approach, true intrusion vectors without side effects
are possible, since the osseointegrated C-implant or
the C-plate is secure against rotational moments.1,2
The posterior teeth can be left intact. We reported
previous nite element analysis (FEA) studies using the
biocreative therapy type I technique, demonstrating
3-dimensional (3D) anterior retraction with gable
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Fig 1. Biocreative therapy type II technique: A, intraoral photograph of intrusion overlay NiTi wire
application on the segmented archwire with a very short hook (woman, age 22 years); B, after treatment; C, intraoral photograph of intrusion overlay NiTi wire application on the segmented archwire
with a long hook (woman, age 26 years); D, after treatment.

bends and an anterior retraction hook (ARH).9 For patients

with a deepbite tendency in the anterior segment, we have
addressed a weak point of the type I technique by an applying intrusion force with an overlay archwire applied to the
anterior segment. We called this the biocreative therapy
type II technique. This is an improved method of applying
the segmented intrusion arch technique of Burstone.10
Two common orthodontic biomechanical systems today are the use of a continuous archwire (eg, straightwire appliance) and segmented archwires (Burstones
segmented arch technique).10-12 Straight-wire appliance
techniques are not technique sensitive but have limited applications for some tooth movements. Segmented archwire
techniques enable more effective and accurate tooth
movements by using mechanically determinate force
systems by separating the anterior and posterior segments.
These systems require a better understanding of the
biomechanics involved. Problems of anchorage loss in segmented arch systems are resolved with temporary skeletal
anchorage devices.13 Chung et al1,2,7,8 introduced the
technique that uses minimum orthodontic hardware and
minimizes side effects by replacing the posterior
appliance segments with the partially osteointegrated
C-implant. This benecial protocol is only possible if the
mini-implant will not loosen in response to the heavy or
dynamic forces that would be necessary. The C-implant
(sandblasted, large-grit, acid-etched mini-implant) will
allow the application of a nickel-titanium (NiTi) reverse
curve of Spee overlay archwire, which will apply a moment
to the mini-implant but not loosen the screw.1,2 This

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intrusion overlay wire produces forces that control both

the torque and the vertical position of the incisor
segment (Fig 1). The size of overlay NiTi archwire can be
changed easily. To date, there are no studies of the factors
involved in the control of anterior torque by this technique.
Clinical studies and case reports have described the technique.2 In this study, we constructed a 3D nite element
model of the maxillary teeth, periodontal ligament (PDL),
and alveolar bone after extracting the rst premolars.
After placement of the orthodontic mini-implant with
the 0.8-mm hole between the second premolar and the
rst molar, and 8 mm apical to the expected bracket
position, we applied an intrusion force using a reversecurved NiTi archwire from a C-implant head to the point
between the central incisors to the segmented archwire
of the 6 anterior teeth using the mini-implant as a posterior
orthodontic tube. We simulated the effect on torque control using different heights of retraction hooks located
between the lateral incisor and the canine, and different
amounts of intrusion force on the NiTi overlay archwire.
MATERIAL AND METHODS

For the nite-element model, we obtained the tooth

outline forms through the 3D laser scanning of a maxillary
right dentition from a dental study model (base model)
(model-i21D-400G, Nissin Dental Products, Kyoto,
Japan) of an adult with normal occlusion. Using the
micro-arch bracket (Tomy, Tokyo, Japan), we aligned
and leveled using a broad arch form (Ormco, Glendora,
Calif) and referred to previous studies for inclination and

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Table I. Mechanical properties of each material

Periodontal ligament
Alveolar bone
Teeth
Stainless steel

Youngs modulus (MPa)

5.0E-02
2.0E103
2.0E104
2.0E105

Poissons ratio
0.49
0.30
0.30
0.30

Table II. Comparison of ARH length and intrusion

force on z-axis displacement
Intrusion force (g)
Tooth
Central
incisor

Lateral
incisor

Canine

Hook
length
1 mm Root apex

70
2.78E-02

80
2.69E-02

90
2.60E-02

Incisal edge
4 mm Root apex
Incisal edge
7 mm Root apex
Incisal edge
10 mm Root apex
Incisal edge
1 mm Root apex

1.89E-03
2.70E-02
2.03E-02
2.84E-02
3.82E-02
2.93E-02
5.63E-02
1.91E-02

7.91E-03
2.64E-02
2.61E-02
2.77E-02
4.42E-02
2.86E-02
6.23E-02
1.91E-02

1.39E-02
2.57E-02
3.21E-02
2.70E-02
5.01E-02
2.79E-02
6.83E-02
1.91E-02

Incisal edge 1.18E-02 8.92E-03 6.08E-03

4 mm Root apex
1.58E-02 1.57E-02 1.57E-02
Incisal edge 1.89E-03 8.32E-04 3.54E-03
7 mm Root apex
1.17E-02 1.16E-02 1.16E-02
Incisal edge 6.24E-03 8.95E-03 1.17E-02
10 mm Root apex
7.46E-03 7.40E-03 7.33E-03
Incisal edge 1.46E-02 1.73E-02 2.00E-02
1 mm Root apex
1.95E-02 1.89E-02 1.83E-02
Incisal edge 1.52E-02 1.47E-02 1.43E-02
4 mm Root apex
1.40E-02 1.34E-02 1.28E-02
Incisal edge 3.80E-02 3.75E-02 3.70E-02
7 mm Root apex
7.36E-03 6.73E-03 6.10E-03
Incisal edge 5.97E-02 5.92E-02 5.88E-02
10 mm Root apex
5.21E-04 1.09E-04 7.39E-04
Incisal edge 8.07E-02 8.03E-02 7.98E-02

Positive gures mean tooth intrusion; negative gures mean extrusion.

Fig 2. Three-dimensional nite element mesh: A and B,

lateral views of the maxillary dentition and the PDL; C, lateral views of teeth, PDL, alveolar bone of the maxillary
dentition, and C-implant head; D, lateral views of intrusion
force application.

angulation.11,12,14 We did not add a curve of Spee or

a curve of Wilson (Fig 2, A), and the thickness of the PDL
was assumed to be uniform (0.25 mm) (Fig 2, B).15,16
The alveolar bone crest was constructed to follow
the cementoenamel junction curvature 1 mm apical
to the cementoenamel junction.17 The 3D nite element
model included 12 teeth, a space for the missing rst
premolars periodontal space, and alveolar bone, and
was bilaterally symmetrical (Fig 2, C). In the base model,

the distance from the incisal edge of the maxillary central

incisor to the bracket slot (perpendicular to the occlusal
plane) was 4.5 mm, 11 mm labial to the cementoenamel
junction, and 11.8 mm to the labial alveolar crest. In the
nite element model, teeth, alveolar bones, brackets,
periodontal spaces, the C-implant, and the archwire
were constructed with ne tetrahedron solid elements;
the teeth and brackets were connected without interference, and each tooth contacted the next at the contact
point as individual elements (Fig 2, D). In this study, teeth,
alveolar bones, and periodontal spaces were assumed to
be isoparametric and homogeneous linear elastic bodies;
the material properties of the elements were Youngs
modulus and Poissons ratio according to previous studies
(Table I).18-20 In the system studies, we construct the

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Fig 3. Changes of the axes of the maxillary anterior teeth according to the length of ARH and magnitude of the intrusion force. Solid line, before; dotted line, after the applicatioin of force; B, central incisor; ,, lateral incisor; O, mandibular canine end mean midincisal point or cusp tip, upper end mean
root apex); IF, intrusion force; ARH, anterior retraction hook. The displacement of teeth was magnied
70 times. The movement of the maxillary central incisor was controlled tipping with a short hook (1 mm).
When a longer hook was used, more root movement, and proclination of the anterior teeth, and more
extrusion of a canine were observed.

x-axis as the in-out direction, the y-axis as the labiolingual direction, and the z-axis as the upper-lower direction, and dened 1x as the left central incisor direction,
1y as the labial direction, 1z as the apical direction,
and x-y as the occlusal plane of the teeth.
The anterior segmented archwire was modeled by
using a 3D beam element (ANSYS beam 4, Swanson
Analysis System, Canonsburg, Pa) with the cross section
of 0.016 3 0.022-in stainless steel. The archwire hook
(0.019 3 0.025-in stainless steel) was set at the midpoint between the lateral incisor bracket and the
canine bracket bilaterally. The osseointegration-based
C-implant with an 0.8-mm diameter hole on the head
part (Cimplant, Seoul, Korea) was placed between the
maxillary rst molar and the second premolar, and
8 mm apically to the expected bracket position.

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We assumed that there were no gaps between the

bracket and the archwire at the central incisor, lateral
incisor, and canine and carried out the nonlinear analysis, allowing the gap element between the archwire and
the 0.8-mm diameter hole of the C-implant head. The
intrusion force can be applied to 1 point between the
central incisors or 2 points between a central incisor
and a lateral incisor; in this study, we applied the intrusion force to 1 point between the central incisors. The retraction force was applied via ARH between a lateral
incisor and a canine. The retraction force was 150 g between the ARH and the C-implant head, and the lengths
of hooks were 1 mm (very short), 4 mm (short), 7 mm
(standard), and 10 mm (long). We measured the intrusion forces by using 3 curved NiTi wire sizes (0.016 3
0.022-in, 0.017 3 0.025-in, and 0.019 3 0.025-in)

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Fig 4. Comparison of the vertical effects (z-axis) of the ARH and intrusion forces in the 3D nite element model (mm); IF, intrusion force; ARH, anterior retraction hook; negative value, mean extrusion;
positive value, mean intrusion. When longer ARH and greater intrusion forces were applied, more proclination or less linguoversion of the maxillary central incisor was observed. Accordingly, the intrusion
of the maxillary central incisor was increased.

(G&H Wire, Franklin, Ind) according to the intraoral

condition of patients and obtained 70, 80, and 90 g, respectively. The intrusive force was applied between the
right and left central incisors in the 1z direction as in
a 1-piece intrusion archwire. The boundary condition
for holding the maxillary model was the top of the model
base connected to the maxilla. There was signicant
clearance in the 0.8-mm hole of the C-implant head,
so friction for all 3 wires was low. The differences in friction between the wire sizes were not signicant. The
graphs are labeled with the forces produced as measured
on the physical models (Fig 3). The tooth displacements
were marked by applying the x, y, and z coordinates at
the midpoint of the incisal edges of the central incisor
and lateral incisor, the cusp tip of canine, and each
tooths root apex.
For the FEA, ANSYS (version 11, Swanson Analysis
System), the universal nite element program, was

used on a workstation (HP XW6400, Hewlett-Packard,

Palo Alto, Calif).
RESULTS

We observed the tooth displacement pattern on the

z-axis (Table II, Figs 3 and 4) based on the movement
of the maxillary central incisal edges. The amount of
intrusion increased as the intrusion force increased
and the length of the hook increased. Because the
force system introduces a slight counterclockwise
moment to the anterior dental segment, we noticed
some canine extrusion, which decreased with
a heavier intrusion force and increased with a longer
hook arm.
For the tooth displacement pattern on the y-axis
(Table III, Fig 5), when we applied 70 g of force, the maxillary central incisors tipped lingually with the 1-mm
hook group, moved almost bodily in the 4-mm group,

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Table III. Comparison of ARH length and intrusion on y-axis displacement

Intrusion force (g)
Tooth
Central incisor

Hook
length
1 mm
4 mm
7 mm
10 mm

Lateral incisor

1 mm
4 mm
7 mm
10 mm

Canine

1 mm
4 mm
7 mm
10 mm

Root apex
Incisal edge
Root apex
Incisal edge
Root apex
Incisal edge
Root apex
Incisal edge
Root apex
Incisal edge
Root apex
Incisal edge
Root apex
Incisal edge
Root apex
Incisal edge
Root apex
Incisal edge
Root apex
Incisal edge
Root apex
Incisal edge
Root apex
Incisal edge

70
1.33E-02
4.31E-02
2.45E-02
2.64E-02
3.55E-02
1.27E-02
4.65E-02
1.82E-03
1.44E-03
3.98E-02
9.81E-03
2.29E-02
2.03E-02
6.03E-03
3.08E-02
1.13E-02
8.62E-03
4.45E-02
1.39E-02
5.42E-02
1.88E-02
6.15E-02
2.35E-02
6.79E-02

80
1.74E-02
3.75E-02
2.83E-02
2.12E-02
3.95E-02
7.39E-03
5.05E-02
7.15E-03
8.40E-04
3.64E-02
1.21E-02
1.96E-02
2.26E-02
2.71E-03
3.30E-02
1.46E-02
7.75E-03
4.22E-02
1.30E-02
5.17E-02
1.80E-02
5.90E-02
2.26E-02
6.54E-02

90
2.14E-02
3.19E-02
3.23E-02
1.59E-02
4.34E-02
2.06E-03
5.45E-02
1.25E-02
3.12E-03
3.31E-02
1.43E-02
1.63E-02
2.48E-02
5.98E-04
3.52E-02
1.79E-02
6.88E-03
3.98E-02
1.22E-02
4.92E-02
1.71E-02
5.66E-02
2.17E-02
6.30E-02

Positive gures mean tooth proclination; negative gures mean retraction.

and displayed a root-retraction pattern in the 10-mm

group. As the intrusion force increased, the amount of
coronal retraction decreased, and root retraction increased. The canine crown tipped distally, and this
tipping pattern increased as the hook length increased.
DISCUSSION

In en-masse retraction after the usual extraction of

premolars, adjustment of the retraction hook length is
recommended to control loss of torque from linguoversion of the anterior teeth during their retraction,
and thick wires are recommended to minimize bite
deepening and torque loss from vertical bowing of
the main archwires.21,22 But improvement of bite
deepening and control of torque loss can be
obtained with restriction in a patient having enmasse retraction.
C-therapy, which is the subject of this study, has advantages that can minimize unwanted tooth movement
in the posterior teeth and maintain the occlusal relationship of the posterior area and good oral hygiene by
minimally bonding braces to molars and premolars. On
the other hand, more effort to control anterior tooth
movement is needed with C-therapy.1,2,7,8

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Unlike mechanical locked mini-implants,23,24 the

C-implant used in C-therapy can resist the rotational
force and be removed easily because of its partial
osteointegration.3-6 With this feature, biocreative
therapy type II mechanics can be used after completion
of anterior intrusion and decrowding.1,9 Instead of an
intrusion arch, a 0.016 3 0.022-in stainless steel
utility archwire is placed from the anterior segment
into the implant tube, and distinct gable bends are
used to generate an anterior torque moment on the
anterior segment of the teeth to provide bodily
movement during en-masse retraction. Biocreative therapy type II can be the other method to control the anterior teeth.2 This technique allows application of bodily
retraction and early intrusion even in a patient with
deepbite. Since the length of the ARH affects the quality
of the tooth-movement pattern, the ARH can be adjusted to t the goals of retraction. That is, we can use
the 1-mm ARH for controlled tipping in ared incisors,
the 4-mm ARH for bodily movement, and the 7-mm or
10-mm ARH for root retraction. A longer ARH allows
a little more extrusion of the canine during retraction.
Biocreative therapy type II shows features of the
3-piece intrusion archwire. Biocreative therapy type II

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Fig 5. Comparison of the sagittal effects (y-axis) of the ARH and intrusion forces in the 3D nite element mode (mm); IF, intrusion force; ARH, anterior retraction hook; negative value, mean lingual or
posterior movement; positive value, mean labial or anterior movement. When longer ARH and greater
intrusion force were applied, less linguoversion and further proclination of the central incisor crown
were observed.

can control various patterns of tooth movement through

the combination of intrusion force, retraction force, and
length of the ARH. In this study, intrusion forces of 70,
80, and 90 g generated by 0.016 3 0.022-in, 0.017 3
0.025-in, and 0.019 3 0.025-in reverse-curved NiTi
wires for patients various intraoral conditions were applied, retraction forces were xed to 150 g, and the
length of the ARH was 1, 4, 7, or 10 mm. The toothmovement patterns for the anterior 6-tooth segment
were evaluated in these conditions. A recent study
showed the center of resistance to be located 13.5 mm
posteriorly and 9 mm superiorly from the center of the
archwire, similar to the estimation of Melsen et al.25-28
In another study, the center of resistance of the 6
maxillary anterior teeth is known to be located 13.5
mm apically and 14 mm posteriorly from the central
incisal edge.22 If retraction and intrusion force are applied to the 1-mm ARH, the result is controlled lingual
tipping of the segment (Fig 6, A) because the clockwise

moment that is equal to the magnitude of the retraction

force multiplied by the perpendicular distance of the line
of action of the force to the center of resistance exceeds
the counterclockwise moment that is equal to the magnitude of the intrusion force multiplied by the perpendicular distance of the line of action of the force to
a center of resistance. When a retraction force is applied
to the 4-mm ARH, the clockwise and counterclockwise
moments are neutralized, and bodily movement occurs
(Fig 6, B). When retraction forces are applied to hooks
with arms longer than 4 mm, the sum of the moments
rotates the segment counterclockwise so that incisor torque and intrusion are increased, and the canines extrude
(Fig 6, C). In the C-therapy type II technique, 1 to 4 mm
ARH are recommended for anterior retraction in a patient
who needs maxillary rst premolar extractions. Although
the retraction forces were uniform in this study, a force
similar to that of the 3-piece intrusion archwire of Burstone10 will occur if the retraction forces are decreased;

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of temporary skeletal anchorage devices. When using

this technique, one must consider the center of resistance of the anterior segment to retraction in each patient. Root length, bone levels, pretreatment incisor
inclination, and close monitoring of the effects of force
application are all important considerations.
CONCLUSIONS

Based on the ndings of this study, we concluded the

following.
1.

2.

3.

Fig 6. Schematic representation of the biocreative therapy type II technique. A black dot indicates the center of
resistance (CR). Dotted lines indicate intrusion force
(blue line) and retraction force (red line). Solid arrows express the moments (force times the distance between
force and CR) that originated from 2 forces. A, 1-mm
hook (short): when the intrusion force and its moment
(blue) are constant, the clockwise moments generated
from the distance between the red dotted line and the
CR are greater, so that the group of 6 anterior teeth
inclines lingually. B, 4-mm hook: the distance between
the red dotted line and the CR is shorter than for the
1-mm hook, and the decreased clockwise moment is neutralized with a counterclockwise moment, so that the
group of 6 anterior teeth translates. C, 7 and 10 mm hooks
(long): the retraction force nearly passes by the CR, and
a clockwise moment is not generated as a result, so
that the group of 6 anterior teeth ares, and a canine
extrudes.

this might be suited for intrusion of the anterior segment. Therefore, further study seems necessary. The
technique described here resulted from several years of
experience and observation of the clinical application

February 2011  Vol 139  Issue 2

Finite element studies demonstrated that variations

of the height of the ARH and the amount of intrusion force produced measurable effects on the inclination and vertical position of the incisors during
en-masse retraction.
With a 70-g intrusion force and a 1-mm high hook,
the maxillary central incisors displaced lingually in
a controlled tipping pattern. Increasing the hook
height to 4 mm produced almost bodily movement,
and, in the 10-mm group, root retraction was
produced ahead of the crowns. As intrusion force increased, the amount of coronal retraction decreased,
and root retraction increased. Higher intrusion
forces and longer retraction hooks also caused
increased incisor intrusion and canine extrusion.
Three-dimension controlled en-masse retraction of
the 6 anterior teeth as an independent unit can be
accomplished by using partially osseointegrated
C-implants as the only source of anchorage, a NiTi
intrusion overlay archwire, and a retraction hook
(biocreative therapy type II technique).

We thank Ki-Joon Lee, Department of Orthodontics,

Youn-Sei University, for FEM model construction and
Jin-Kyung Lee, Division of Orthodontics, Department
of Dentistry, Catholic University of Korea, Yoido St.
Marys Hospital, for editing the manuscript.
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American Journal of Orthodontics and Dentofacial Orthopedics

February 2011  Vol 139  Issue 2