Original Article

Comprehensive comparison of canine retraction using NiTi closed coil

springs vs elastomeric chains:
A split-mouth randomized controlled trial
Haya A. Barsouma; Hend S. ElSayedb; Fouad A. El Sharabyc; Juan Martin Palomod; Yehya A.
Mostafae

ABSTRACT
Objectives: To compare canine retraction using NiTi closed coil springs vs elastomeric chains
comprehensively in a split-mouth randomized controlled trial.
Materials and Methods: The canines in 64 quadrants were randomly retracted into the first
premolar extraction spaces using NiTi closed coil springs or elastomeric chains, in the maxilla and
mandible. The retraction force was 150 g. Cone beam computed tomography scans and study
models were obtained before the start of canine retraction and 6 months later. The rate and total
amount of canine retraction, canine rotation, tipping, and root resorption were evaluated. A visual
analogue scale was used to evaluate patients’ pain experience.
Results: The two methods were statistically similar for dental changes, rate of canine retraction,
and root resorption. However, patients reported significantly more days of pain with the elastomeric
chain compared to the NiTi closed coil springs.
Conclusions: Within the constraints of the current study, using either NiTi closed coil springs or
elastomeric chains as force delivery systems for canine retraction results in no significant difference
in the rate of canine retraction, tipping, rotation, or root resorption. Pain experience during retraction
using elastomeric chains is more significant yet needs further investigation. (Angle Orthod.
2021;91:441–448.)
KEY WORDS: Canine retraction; Coil springs; Elastomeric chains; Root resorption; Pain

a
Resident, Department of Orthodontics and Dentofacial INTRODUCTION
Orthopedics, Faculty of Dentistry, Future University in Egypt,
Cairo, Egypt. Canine retraction and space closure is considered
b
Associate Professor, Department of Orthodontics & Pediatric the most time-consuming phase in orthodontic treat-
Dentistry, Oral and Dental Research Division, National Research
Centre, Giza, Egypt; and Adjunct Assistant Professor, Depart- ment.1 Acceleration of this step would reduce overall
ment of Epidemiology & Health Promotion, College of Dentistry, treatment time, improve patient cooperation, and
New York University, New York, NY, USA. decrease possible negative side effects.2,3
c
Associate Professor, Department of Orthodontics and Manipulation of tooth biomechanics1,4 and tissue
Dentofacial Orthopedics, Faculty of Dentistry, Cairo University,
Cairo, Egypt.
reaction5 have been widely attempted to reduce
d
Professor and Orthodontic Residency Director. Case West- treatment duration. Additionally, the rate and safety of
ern Reserve University School of Dental Medicine, Cleveland, different canine retraction methods6 and different force
OH, USA. systems7,8 have been intensely investigated.
e
Professor and Chairman, Department of Orthodontics and
The use of sliding mechanics for canine retraction
Dentofacial Orthopedics, Faculty of Dentistry, Future University
in Egypt, Cairo, Egypt. has been frequently reported in the literature.9 This
Corresponding author: Fouad A. El Sharaby, BDS, MSc, PhD, method reduces the chairside time compared to loop
MOrth, FDS (RCSEd), Department of Orthodontics and Dento- fabrication. Despite the fact that tooth movement along
facial Orthopedics, Faculty of Dentistry, Cairo University, 11 El the arch wire is highly predictable, friction between the
Sarayat St., El Manial, Cairo, Egypt
(e-mail: [email protected]) brackets and arch wires may bring about some
limitation to the tooth movement.10
Accepted: January 2021. Submitted: November 2020.
Published Online: February 17, 2021 The wide use of NiTi coil springs for canine retraction
Ó 2021 by The EH Angle Education and Research Foundation, can be attributed to their relatively constant force
Inc. delivery,11 hence, reducing the number of appliance

DOI: 10.2319/110620-916.1 441 Angle Orthodontist, Vol 91, No 4, 2021

442 BARSOUM, ELSAYED, EL SHARABY, PALOMO, MOSTAFA

Figure 2. Retraction of a maxillary canine using an elastomeric

chain.

Figure 1. NiTi closed coil spring attached to the vertical power arm
and the TAD. Participants, Eligibility Criteria, and Settings
Thirty-five consecutive patients seeking orthodontic
reactivations. On the other hand, elastomeric chains treatment were screened. The inclusion criteria were
deliver an interrupted force that provides periods of rest patients with a full permanent dentition (not necessarily
allowing for regeneration and better tolerance of the including third molars), patients indicated for bilateral
supporting tissues.12,13 Its main weakness is the first premolar extractions, and canine retraction in at
absorption of oral fluids leading to biodegradation least the maxillary arch with maximum anchorage
and rapid force decay with a consequent need for required. Patients who reported any systemic disease
frequent reactivation.14 or medication interfering with bone metabolism or
Although the efficacy of coil springs and elastomeric patients with severe skeletal discrepancies indicated
chains has been studied frequently, few randomized for orthognathic treatment were excluded from the
controlled trials have compared the two methods for study. Other exclusion criteria included pregnancy,
canine retraction directly.15–19 A recent systematic patients with craniofacial deformities, or periodontal
review and meta-analysis20 compared the efficacy disease.
and side effects of power chains and coil springs for Conventional 0.022-inch Roth prescription brackets
space closure. The results showed a similar rate of were used for all teeth except the second molars. The
retraction and insufficient data to compare side effects canines were bonded with vertical slot brackets
like pain, root resorption, and patient discomfort. (American Orthodontics, Sheboygan, Wis). The poste-
The aim of the present study was to compare the rior segment was aligned while bypassing the incisors,
rate of canine retraction using NiTi closed coil springs reaching 0.017- by 0.025-inch stainless steel wires.
and elastomeric chains comprehensively in orthodon- Vertical power arms, 8 mm in length, were fabricated
tic patients requiring first premolar extraction and and inserted into the vertical slots of the canine
maximum anchorage. The null hypothesis assumed brackets. Temporary anchorage devices (3M Unitek
that there would be no difference in the rate of canine TAD, St. Paul, Minn., 8 by 1.6 mm) were placed
retraction between the two methods. Other side between the roots of the second premolar and first
effects were considered, including rotation, tipping, molars in the maxilla and mandible (Figure 1). Patients
root resorption, anchorage loss, as well as associated were then referred for first premolar extractions and
pain. canine retraction was initiated within 2 weeks.

MATERIALS AND METHODS Interventions and Outcomes

Trial Design A NiTi closed coil spring (6 mm; Ormco, Orange,

Calif.) was used for canine retraction on one side
This split-mouth randomized controlled trial was (Figure 1), while elastomeric chain (American Ortho-
conducted at the Orthodontic Outpatient Clinic, Future dontics) was used on the contralateral side (Figure 2).
University in Egypt, Egypt, between January 2018 Both force delivery systems were extended between
and February 2019. The Institutional Review Board at the inserted temporary anchorage devices (TADs) and
FUE approved the study in April, 2017. Patients and the vertical power arms of the canine brackets. The
parents who agreed to join the trial signed consent retraction force was adjusted to 150 g using digital
forms at the start of treatment. force gauge. A ligature wire was used to attach the coil

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RETRACTION USING SPRINGS VS ELASTOMERIC CHAINS 443

Figure 3. The canine and molar measurements and the orientation of the digital models for superimposition using the reference planes.

spring to the TAD if the force exceeded 150 g. During A cone beam computed tomography (CBCT) scan
monthly follow-up visits, the force delivered by the coil (Acteon X-mind Trium CBCT machine, La Ciotat,
spring was measured and adjusted while the power France) was obtained before the start of canine
chain was replaced to maintain constant force delivery. retraction and 6 months later. In accordance with the
Seven maxillary dental impressions were taken for ALARA (as low as responsibly achievable) guide-
each patient: immediately before canine retraction and lines,21 a medium CBCT field of view was used. The
every 4 weeks for 6 months. Digital models were digital imaging and communications in medicine
obtained through laser scanning of plaster models (DICOM) images were imported into Invivo Dental 5
using the R500 3Shape scanner (3Shape, Copenha- software (version 5.3.1, Company, Santa Clara, Calif.)
gen, Denmark). Sagittal, horizontal, and frontal refer- and 3D images were constructed (Figure 4).
ence planes were constructed to orient the pre- The pre- and post-retraction CBCTs were compared.
retraction digital models and superimpose them on The total amount of canine retraction and canine
the medial points of the third rugae (Figure 3). rotation was measured using the same landmarks
Measurements were taken using 3Shape Analyzer used for the analysis of the digital models. Canine
computer software (3Shape). All measurements were tipping was calculated as the change in the angle
calculated as the difference between the pre-retraction between the long axis, from cusp tip to root apex, and
model (M0) and the model taken at the end of 6 months the frontal plane. Root resorption was measured as the
of retraction (M6). Total canine retraction was repre- difference in the length of the canines from the cusp
sented by the perpendicular distance from the canine tips to the root apices.
cusp tip to the frontal plane. Likewise, the mesial drift of The patients reported the presence or absence of
the maxillary first molar was measured from the dental pain for the first 10 days after each activation.
mesiobuccal cusp tip to the frontal plane. Canine The patients were asked to record the intensity of the
rotation was measured as the angle between the pain on a 100 mm visual analogue scale.22
projected line connecting the mesial and distal contact Intrarater reliability was evaluated by remeasuring
points of each canine and the frontal plane. six randomly selected digital models and CBCTs and

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444 BARSOUM, ELSAYED, EL SHARABY, PALOMO, MOSTAFA

Figure 4. CBCT image orientation on the reference planes.

another investigator measured these records for compare the mean differences of the two groups for
interrater reliability. monthly and overall canine retraction rate as well as
overall dental change at the end of 6 months. The
Sample Size Calculation Mann-Whitney test was applied to compare the pain
A priori sample size was determined from the data intensity across the two groups. The number of days
reported by Dixon et al.13 using the G*Power software. with pain for the first 10 days after each activation were
Twenty-eight observations were required in each group described by proportions and percentages and com-
for a study power of 0.8 and an 0.05 alpha error. pared using the Z score test. Tests were two tailed and
the significance level was set at P , .05.
Random Sequence Generation and Blinding
RESULTS
In Microsoft Office Excel Mac (version 16.24; Micro-
soft, Redmond, Wash.), the right quadrants in 32 The progress of patient selection and recruitment is
arches were equally and randomly assigned to one of shown in Figure 5. The CBCT for one patient was
the two interventions. The contralateral quadrant distorted causing some missing data. These measure-
received the other intervention. The allocation ratio ments were statistically imputed.
was 1:1. Intra- and interobserver agreement for angular and
It was not possible to mask the patients or the linear measurements on the CBCT and digital models
orthodontist providing the treatment. However, the was 0.99 (intraclass correlation coefficient).
outcome assessor was masked to the intervention. There was no statistical difference between the
groups for monthly canine retraction rate. The average
Statistical Analysis and Data Presentation monthly rate was 0.79 6 0.138 mm and 0.86 6 0.14
The data were analyzed using SPSS (version 17, mm for the NiTi coil spring and the elastomeric chain,
Chicago, Ill.), Descriptive statistics were reported for all respectively (Table 1). The total amount of retraction
outcomes. The Shapiro-Wilk test evaluated data for pooled maxillary and mandibular canines was 4.44
normality. All variables except pain followed a Gauss- 6 2.22 mm and 4.33 6 1.31 mm for the NiTi coil spring
ian distribution. Independent t-test was used to and the elastomeric chain groups, respectively (Table

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RETRACTION USING SPRINGS VS ELASTOMERIC CHAINS 445

Figure 5. CONSORT flow chart of patients throughout the trial.

Table 1. Comparison of Monthly and Total Canine Retraction Between the NiTi Coil Spring and Elastomeric Chain Groups Over 6 Months
(Digital Models)a
Coil Spring Elastomeric Chain 95% CI
Time Interval n Mean (SD) n Mean (SD) MD (SD) Lower Upper t P Value
M0-M1 18 0.80 (0.87) 18 1.09 (0.71) 0.29 (0.26) 0.83 0.25 1.09 .28169
M1-M2 18 0.95 (0.65) 18 0.95 (0.70) 0.00 (0.22) 0.46 0.45 0.01 .99411
M2-M3 18 0.81 (0.47) 18 0.81 (0.52) 0.00 (0.17) 0.34 0.34 0.00 .99736
M3-M4 18 0.68 (0.96) 18 0.83 (0.60) 0.15 (0.27) 0.69 0.39 0.57 .57224
M4-M5 18 0.94 (0.80) 18 0.63 (0.59) 0.31 (0.23) 0.17 0.78 1.32 .19665
M5-M6 18 0.56 (0.50) 18 0.86 (0.55) 0.30 (0.18) 0.66 0.05 1.72 .09376
M0-M6 18 4.73 (1.64) 18 5.17 (1.71) 0.44 (0.56) 1.57 0.70 0.78 .43893
a
CI indicates confidence interval; M, month; MD, mean difference; M0, baseline; n, sample size; SD, standard deviation.

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446 BARSOUM, ELSAYED, EL SHARABY, PALOMO, MOSTAFA

Table 2. Change Within the NiTi Coil Spring and Elastomeric Chain Groups at 6 Months of Canine Retractiona
Coil Spring Elastomeric Chain
Time
Outcome Interval n Mean SD MD (SD) P Value n Mean SD MD (SD) P Value
^ Max. Canine rotation M0 18 34.72 8.46 7.18 (13.80) .04125* 18 33.98 9.43 9.79 (13.85) .01010*
M6 18 27.54 13.99 18 24.19 9.65
^ Max. 1st Molar drift M0 18 30.85 3.62 0.29 (0.78) .13635 18 32.32 2.38 0.13 (0.97) .59368
M6 18 30.56 3.25 18 32.19 2.50
Canine retraction (mm) M0 32 11.32 2.81 4.44 (2.22) ,.001* 32 11.34 2.44 4.33 (1.31) ,.001*
M6 32 6.89 3.24 32 7.01 2.78
Canine rotation (8) M0 32 45.60 11.70 12.66 (11.45) ,.001* 32 45.39 12.64 12.30 (11.67) ,.001*
M6 32 58.26 12.95 32 57.69 9.49
Canine tipping (8) M0 32 20.13 6.34 6.21 (5.21) ,.001* 32 20.60 6.97 6.59 (3.79) ,.001*
M6 32 13.92 7.33 32 14.02 8.10
Canine root length (mm) M0 32 26.14 2.44 0.76 (1.14) .00109* 32 26.24 2.28 0.82 (0.72) ,.001*
M6 32 25.39 2.70 32 25.42 2.50
a
Max indicates maxilla; MD, mean difference; n, sample size; SD, standard deviation; ^Digital models, M0: baseline, M6: at 6 months of
canine retraction; *, statistical significance.

2), while it was 4.73 6 1.64 mm and 5.17 6 1.71 mm of retraction, the percent of closed extraction spaces
for the maxillary canine retraction (Table 1). within a given period of time, as well as weekly,
At 6 months, the groups were similar for canine monthly, and overall retraction rate have been mea-
tipping, rotation, and root resorption as well as for sured. The mean differences for the monthly rates
maxillary first molar mesial drift (Table 3). reported by Nightingale and Jones,8 Bokas and
No statistical difference between the groups was Woods,15 Khanmasjedi et al.,16 Talwar and Bhat,17
reported for pain intensity. However, patients in the coil Davidovic et al.,23 and Chaudhari and Tarvade19 were
spring group reported significantly less days with pain
0.05, 0.17, 0.23, 0.28, 0.21, and 0.25 mm, respectively.
(Table 4). About 70% of patients reported pain only for
In the current study, the difference between the two
the first 2 months.
groups (0.02 mm) was the smallest compared to
DISCUSSION previous studies, which ranged between 0.05 mm
and 0.28 mm. However, previous results consistently
Many previous studies have evaluated the rate of demonstrated that the differences were not clinically
canine retraction.15,17 23 The lack of evidence to support a significant. This can be explained by the similar
single, fast method with minimal unwanted tooth move-
biologic response of the periodontium despite the
ment and discomfort has been reported.6 Hence, there
different methods of force application.
was a recommendation for further studies with more
methodological rigor and patient-related outcomes.20 The rate of canine retraction in the present study
Sliding mechanics has been shown to be a was similar to that reported by Chaudhari and
controlled and predictable method of space closure. Tarvade19 and Dixon et al.13 for the coil spring (0.81
Coil springs and elastomeric chains have been used in 6 0.51 mm) and the elastomeric chain (0.58 6 0.3
a multitude of studies. Yet, only eight primary mm). The highest rates of retraction were reported by
studies8,13,15–19,23 compared the efficacy of coil springs Bokas and Woods15 (1.85 mm) and Khanmasjedi et
and elastomeric chains for canine retraction and space al.16 (1.67 6 0.39 mm) for the coil spring group and
closure. Various outcomes including the total distance 1.68 mm and 1.89 6 0.36 mm for the elastomeric

Table 3. Descriptive Statistics and Comparisons of Change at 6 Months to Baseline Between the NiTi Coil Spring and Elastomeric Chain
Groupsa
Coil Spring Elastomeric Chain 95% CI
Time
Outcome Interval n Mean (SD) n Mean (SD) MD (SD) Lower Upper t P Value
^ Max. Canine rotation (8) M0-M6 18 7.18 (13.80) 18 9.79 (13.85) 2.61 (4.68) 6.90 12.12 0.56 .58034
^ Max. 1st Molar drift (mm) M0-M6 18 0.29 (0.78) 18 0.13 (0.97) 0.16 (0.30) 0.76 0.44 0.53 .59680
Canine retraction (mm) M0-M6 32 4.44 (2.22) 32 4.33 (1.31) 0.11 (0.47) 1.05 0.83 0.23 .81898
Canine rotation (8) M0-M6 32 12.66 (11.45) 32 12.30 (11.67) 0.36 (2.99) 5.62 6.34 0.12 .90461
Canine tipping (8) M0-M6 32 6.21 (5.21) 32 6.59 (3.79) 0.38 (1.19) 2.01 2.76 0.32 .75302
Canine root length (mm) M0-M6 32 0.76 (1.14) 32 0.82 (0.72) 0.06 (0.25) 0.43 0.55 0.24 .80770
a
CI indicates confidence interval; Max, maxilla; MD, mean difference; n, sample size; SD, standard deviation; ^Digital models, M0: baseline,
M6: at 6 months of canine retraction.

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RETRACTION USING SPRINGS VS ELASTOMERIC CHAINS 447

Table 4. Descriptive statistics and comparison of pain intensity and number of days with pain between the NiTi coil spring and elastomeric chain
groupsa
Pain Intensity Days with Reported Pain
Median IQ Mann-Whitney U-test Z Score Test P value Percent Z Score Test P value
NiTi coil spring 16.00 22.00 1581.50 1.49 .13587 2.23 2.97 .00295
Elastomeric chain 23.50 41.75 3.70
a
IQ indicates inter-quartile.

chain, respectively. Similar rates were produced with previous systematic review24 (0.3–12.83 mm) for tooth
different arch wire diameters.15–17 movement with conventional brackets. Although the
Force magnitudes ranging between 50 and 300 g elastomeric chains produced intermittent forces, there
have been used effectively in canine retraction.1,9,10 was no difference in the amount of root resorption
Most clinicians activate the spring to produce 100–250 between the two groups. This may be explained by the
g according to the manufacturers’ instructions for most findings of Nightingale and Jones,8 in which the
NiTi closed coil springs. difference between force biodegradation in the two
For elastomeric chains, some investigators recom- groups was not as significant as generally expected.
mended the use of higher initial forces to compensate Pain was investigated using the visual analogue
for the loss of elasticity and force biodegradation. scale,22 which has been validated and is commonly
Nightingale and Jones8 reported that biodegradation used for patient reported outcomes. The severity of pain
was clinically much lower than the amounts expected. was similar between the two groups. Yet, patients
Greater initial forces (300–450 g) were associated with
reported significantly fewer days of pain in the quadrants
more force biodegradation and were not correlated to
in which NiTi coil springs were used for retraction. Since
the amount of canine retraction.8
the retraction force systems were similar for both
In the current study, all patients required maximum
methods, this may have been due to less activation
retraction of the anterior segment and TADs were used
for direct anchorage. The average mesial drift of the adjustments required by the coil spring. However, due to
posterior segment was ,0.05 mm during 6 months in the subjective25 and variable nature of pain, further
both groups (Table 2). These results were similar to investigations are needed for conclusive results.
those reported by Al Suleiman and Shehadah18 using An attempt was made to reduce performance and
miniscrews. The use of TADs as direct anchorage assessor bias. One clinician treated all the patients
during canine retraction is often advocated for patients with a similar protocol except for the method of
requiring maximum anchorage. retraction. The retraction force was standardized using
During tooth movement, force application away from a gauge. It was not possible to mask patients to the
the center of resistance results in unwanted tipping and retraction methods. Nevertheless, this had no impact
rotation. The correction of side effects could prolong on the results as retraction did not rely on patient
the overall treatment time. These outcomes should be cooperation. On the other hand, the outcome assessor
considered in relation to the rate of canine retraction was masked to the intervention and assessed de-
and space closure. identified digital models and CBCTs.
In this study, canine tipping was similar between the The changes in the maxillary arches were measured
two methods. The amount of tipping was significantly on digital models scanned from dental casts. Lemos et
reduced by using the vertical power arm. Tipping was al.26 reported the accuracy and reliability of the 3Shape
less than that observed by Al Suleiman and Sheha- scanners used in this study.
dah.18 Yet the position of the power arm caused cheek
CBCTs were used to assess changes in the
lacerations related to the coil springs in two mandibular
mandible due to the difficulty in superimposing
quadrants. Canine rotations in the present study were
subsequent models. Baumgaertel et al.27 showed that
almost four times (Table 2) the amount reported by Al
Suleiman and Shehadah18 at 3.438 6 1.38 and 3.328 6 measurements constructed from CBCT scans were
1.42 for the coil spring and elastomeric chain, accurate and reliable. After the ALARA guideline,21 the
respectively. CBCT scans were taken using a medium field of view
Pain and root resorption have been associated with where images were confined to the borders of the
orthodontic tooth movement. These outcomes have not upper and lower arches.
been investigated in studies comparing NiTi closed coil Unlike other studies comparing the NiTi closed coil
springs and elastomeric chains for canine retraction. In spring and the elastomeric chain, this study investigat-
the current study, the amount of root resorption ed all relevant outcomes to allow a comprehensive
observed was in agreement with the results of a comparison regarding efficiency and adverse effects.

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448 BARSOUM, ELSAYED, EL SHARABY, PALOMO, MOSTAFA

CONCLUSIONS 13. Dixon V, Read M, O’Brien K, Worthington H, Mandall N. A

randomized clinical trial to compare three methods of
 There was no clinical or statistical difference in orthodontic space closure. J Orthod. 2002;29:31–36.
canine retraction rate, tipping, rotation, or root 14. Halimi A, Benyahia H, Doukkali A, Azeroual MF, Zaoui F. A
resorption between the NiTi closed coil spring and systematic review of force decay in orthodontic elastomeric
the elastomeric chains to recommend one method power chains. Int Orthod. 2012;10:223–240.
over the other. 15. Bokas J, Woods M. A clinical comparison between nickel
 Significantly fewer days with pain were reported for titanium springs and elastomeric chains. Aust Orthod J.
2006;22:39–46.
the NiTi closed coil spring. Further studies are
16. Khanemasjedi M, Moradinejad M, Javidi P, Niknam O,
needed to investigate this finding.
Jahromi NH, Rakhshan V. Efficacy of elastic memory chains
versus nickel–titanium coil springs in canine retraction: a
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