I1945 7103 93 1 33
I1945 7103 93 1 33
I1945 7103 93 1 33
ABSTRACT
Objectives: To evaluate the success rate, treatment duration, and pain perceived during forced
eruption of maxillary palatally impacted canines using the K9 and Ballista springs.
Materials and Methods: Thirty unilateral palatal canine impactions of moderate and difficult
category as determined by KPG index (score between 10 and 19) were enrolled. Group 1
comprised canine impactions managed with K9 springs, and Group 2 comprised Ballista springs.
Block randomization and opaque sealed envelopes were used for allocation. The success rate and
treatment duration (application of force to ligation of the impacted canine into the initial alignment
archwire) were recorded. Pain perception was evaluated on a 10-point visual analogue scale (VAS)
and modified McGill Pain Questionnaire. Chi-square test and Mann-Whitney U-test were used to
compare the groups.
Results: The success rate for eruption of palatally impacted canines was 100%. The average
treatment duration was 296.13 6 96.45 days and 311.93 6 94.34 days, respectively for Group 1
and Group 2. VAS scale scores for pain were greater for Group 2 compared to Group1, and the
differences were statistically significant at all time intervals except at T1. The frequency of none and
mild pain was significantly greater at all time intervals in both groups.
Conclusions: The impacted canines of moderate and difficult category were erupted with a 100%
success rate and similar treatment duration with both interventions. The pain scores of Ballista
springs were greater after 24 hours of force application. (Angle Orthod. 2022;93:33–40.)
KEY WORDS: K9 spring; Ballista spring; Palatally impacted canines
first permanent molars to provide the anchorage and pain experienced. ‘‘Failure’’ of canine eruption was
required against forces created by torsion in the spring. considered when the impacted canine did not show
The patients were followed for 12 months and were any sign of eruption in the oral cavity for 9 months of
evaluated for ‘‘success or failure,’’ treatment duration, follow-up. Treatment duration was defined as ‘‘time-
span between orthodontic force application and ligation
of the erupted canine into the initial alignment arch-
wire.’’
A 10-point visual analogue scale (VAS) and modified
McGill Pain Questionnaire (MMPQ)18,19 was used to
evaluate pain at six observation periods: 1 hour (T1),
24 hours (T2), 48 hours (T3), 1 week (T4), 1 month
(T5), and 3 months (T6) after orthodontic force
application. All patients were examined every 4 weeks
to evaluate eruption of the canine for 12 months of
follow-up (Figure 3).
Randomization
The impacted maxillary canines were allocated to
the two groups using block randomization with a block
size of six each. Computer software-generated ran-
domization codes were used. Opaque sealed enve-
lopes with sequential numbers were used for allocation
concealment. Operator and subject blinding were not
possible because of the nature of the intervention. The
data were coded and presented to the blinded
evaluator for analysis.
Statistical Analysis
Statistical Package for Social Sciences (Windows,
version 25.0. Armonk, NY: IBM Corp.) software was
Figure 3. (a) VAS; (b) MMPQ questionnaire for Pain Perception. used for analyses. Continuous data were presented as
mean 6 SD, and categorical data as frequency the oral cavity within 9 months. The average treatment
(percentage). Shapiro-Wilk / Kolmogorov-Smirnov test duration for eruption and ligation of the impacted
DISCUSSION
This clinical trial involved palatally impacted canines
with similar severity of ‘‘moderate’’ and ‘‘difficult’’
categories according to KPG index17 scores between
10 and 19. They were exposed surgically using the
window technique with cautery in all cases. In a
systematic review, Parkin et al. reported no differences
in clinical outcome observed using either closed or
open technique for exposure of palatally impacted
canines.20 Naoumova et al. showed that the number of
appointments and active duration of traction was
Figure 4. CONSORT diagram. significantly shorter with an open technique.21
Table 2. Comparison of Treatment Duration and Success Rate for Management of Palatally Impacted Maxillary Canine With Two Different
Intervention Mechanicsa
Group 1 vs
Group 1 (n ¼ 15) Group 2 (n ¼ 15) Total (n ¼ 30) Group 2 (P Value)
Mean 6 SD Treatment Duration (d) 296.13 6 96.45 311.93 6 94.34 304.03 6 94.08 .27 (NS)
Success 15 15 30 1.000 (NS)
Failure 0 0 0 1.000 (NS)
a
NS indicates nonsignificant; SD, standard deviation.
* P .05 is statistically significant; ** P .01 is statistically highly significant; *** P .001 is statistically very highly significant.
Table 4. Mean Score of Each Question of Modified McGill Pain Questionnaire-Short Form (MMPQ-SF) at Different Timepointsa
T1 T2 T3
Group 1 Group 2 Group 1 Group 2 Group 1 Group 2
(n ¼ 15) (n ¼ 15) P (n ¼ 15) (n ¼ 15) P (n ¼ 15) (n ¼ 15) P
(Mean 6 SD) (Mean 6 SD) Value (Mean 6 SD) (Mean 6 SD) Value (Mean 6 SD) (Mean 6 SD) Value
Q1 1.53 6 0.74 1.93 6 1.16 .26 1.20 6 0.94 1.47 6 1.24 .58 0.60 6 0.74 1.13 6 0.91 .10
Q2 1.13 6 0.74 0.87 6 0.99 .21 1.20 6 0.86 1.07 6 0.46 .47 0.80 6 0.77 0.93 6 0.26 .41
Q3 1.20 6 0.77 1.13 6 0.52 .67 1.33 6 0.82 0.93 6 0.46 .08 0.73 6 0.88 0.93 6 0.46 .31
Q4 0.33 6 0.72 0.47 6 0.74 .49 0.47 6 0.64 0.40 6 0.51 .88 0.33 6 0.62 0.40 6 0.51 .54
Q5 1.20 6 1.08 0.73 6 0.70 .24 0.93 6 0.79 0.53 6 0.52 .16 0.80 6 0.68 0.53 6 0.52 .28
Q6 0.60 6 0.74 0.53 6 0.74 .76 0.13 6 0.35 0.67 6 0.72 .01** 0.13 6 0.35 0.67 6 0.72 .02*
of ‘‘severe pain’’ experienced was ‘‘pressure’’ and the K9 spring group. The mild to moderate degree of all
‘‘uncomfortable’’ with 17.3% and 12% reporting, re- pain types (Q1 to Q15) were perceived in both
spectively, among group 2 (Ballista spring) (Figure 3), intervention groups. Hence, it is inferred that sense of
whereas 5.3% of the patients experienced ‘‘pressure’’ ‘‘pressure’’ and ‘‘discomfort’’ were the most severe
and another 5.3% reported being ‘‘uncomfortable’’ in types of pain experienced after forced orthodontic
Figure 5. Categorical distribution of Modified McGill Pain Questionnaire-SF in Group 1 and Group 2 at different timepoints.
0.07 6 0.26 0.53 6 0.74 .03* 0.00 6 0.00 0.40 6 0.51 .007** as the treatment progressed.
0.40 6 0.74 0.80 6 0.68 .07 0.13 6 0.35 0.33 6 0.49 .20
0.20 6 0.41 0.47 6 0.52 .13 0.13 6 0.35 0.13 6 0.35 1.00
The frequency of none and mild pain was more
1.13 6 0.83 0.67 6 0.72 .12 0.80 6 0.68 0.60 6 0.51 .43 prevalent at all timepoints and increased from T1 to T5.
0.67 6 0.90 0.67 6 0.72 .82 0.33 6 0.72 0.67 6 0.49 .04*
0.47 6 0.83 0.40 6 0.51 .76 0.40 6 0.74 0.33 6 0.49 .89
0.60 6 0.91 0.20 6 0.41 .26 0.47 6 0.74 0.00 6 0.00 .01** ACKNOWLEDGMENT
0.47 6 0.83 0.27 6 0.70 .40 0.27 6 0.70 0.00 6 0.00 .15
6.07 6 6.89 8.27 6 6.15 .17 3.73 6 5.52 4.27 6 2.74 .13 The trial was funded as an Intramural Project by Postgraduate
Institute of Medical Education and Research, Chandigarh.
Figure 6. Categorical distribution of pain type and its severity (MMPQ-SF) in Group 1 and Group 2 at different timepoints.
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