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OriginalArticle
ASSESSMENTOFEXTERNALROOTRESORPTIONARADIOGRAPHICSTUDY
1Capt. Sandeep Kasana, 2Ritesh Singla Assistant Professor, 2Keluskar K.M, 2Nishu

Singla, 2Vaishali

keluskar
1ArmyDentalCorps,IndianArmedForces,India.
2DepartmentofOrthodonticsManipalCollegeofDentalSciences,ManipalUniversity,Manipal,Karnataka,India.

Correspondence:RiteshSingla, AssistantProfessor,DepartmentofOrthodonticsManipalCollegeofDentalSciences,
ManipalUniversity,Manipal,Karnataka,India.Email :riteshsingla83@yahoo.com
ReceivedJan18,2014RevisedFeb23,2014AcceptedMar28,2014

ABSTRACT
Introduction:Contemporaryorthodonticshasattainedahighdegreeofproficiency,undoubtedlyduetothevaluabletechnical
refinementsaswellasinnovationsinthefieldofmaterialsusedinorthodontics.Inspiteofsuchadvancestakingplaceinallaspectsof
orthodontics,externalapicalrootresorption(earr),particularlyintheregionofupperincisors,isanalmostubiquitousconsequenceof
orthodontictreatmentandhasbeenconcernofclinicians.Yet,notwithstandingourspeciality'sheightenedconcerninthepresenteraof
medicallitigiousness,thefundamentalcauseoftreatmentassociatedrootresorptionremainsunknown,andthemagnitudeofresorption
to be anticipated after specific clinical manoeuvres is almost entirely unpredictable. The ability to identify the small proportion of
patientsatriskofsevereapicalrootresorptionbeforeorearlyintreatmentmay,therefore,beofclinicalsignificance.
AimsAndObjectives:1)Tocheckfortheincidenceofexternalapicalrootresorptionduringactiveorthodontictreatment.
2) To quantify the amount of external apical root resorption in maxillary incisors during retraction phase of active orthodontic
treatment using frictional and frictionless mechanics. 3) To evaluate the contribution of gender, duration of retraction and type of
mechanicsusedforretractiontoexternalapicalrootresorption.

Methodology:Atotalof50subjectsundergoingorthodontictreatmentwithpreadjustededgewiseapplianceusingeitherRoth
orMBTprescriptionwereincluded.Thesubjectsweredividedinto2groups.1)fgrouppatientstreatedwithfrictionalmechanicsfor
retraction(36subjects:agebetween1327years)2)flgrouppatientstreatedwithfrictionlessmechanicsforretraction(14subjects:
agebetween1423years).Radiographsofthepatients`maxillarypermanentcentralandlateralincisorsweretakenattwostages:t1at
the start of the retraction and t2 at the end of the retraction with long cone paralleling technique. The crown and root length was
measuredinthepreretraction(t1)andpostretraction(t2)radiographsusingthervgsoftware(kodakdentalimaging).Usingasimple
mathematical formula the amount of external apical root resorption was calculated. Statistical analysis was done using paired and
unpairedttests.
Results: Therewasstatisticallysignificantdifferenceinmeanrootresorptionbetweenthefrictionandfrictionless groups in
bothcentralandlateralincisors.Therewasstatisticallysignificantdifferenceinpercentagerootresorptionbetweenmalesandfemales
inbothfandflgroups(p<.05).Themalepatientsinboththegroups(f,fl)showedlessamountofrootresorptioni.e.0.740.18mm
thanfemalesi.e.0.890.1mmrespectively.Theaverageamountofrootresorptionat4,5and6monthsoftreatmentdurationwas
0.92 0.31, 0.96 0.22, 1.30 0.31 respectively, indicating an increase in root resorption with treatment duration. There was
statisticallysignificantdifferencebetween4and6monthsbetween5and6monthsbutnostatisticallysignificantdifferencewasseen
between4and5months.
Conclusions:Therewasavisibleamountofrootresorptionduringretractionphaseoffixedorthodonticmechanotherapy.The
maximumresorptionwasseeninlateralincisorswhencomparedtocentralincisors.Themeanpercentageresorptioninlateralincisors
was 6.66% in comparison to 4.03% in central incisors. The root resorption seen was more in teeth which were retracted using
frictionless mechanics than the teeth in which friction mechanics was used with a statistically significant difference between them.
There was a significant increase in root resorption with increase in the treatment duration.There was an increased amount of root
resorptioninfemalesthaninmales.
KeyWords:Externalapicalrootresorption,Retraction,Frictionmechanics,Frictionlessmechanics,Radiovisiographs.
INTRODUCTION
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Contemporaryorthodonticshasattainedahighdegreeofproficiency,undoubtedlyduetothevaluabletechnicalrefinementsas
wellasinnovationsinthefieldofmaterialsusedinorthodontics.Thebasisforsuchimprovisationsisincreasedmechanicalefficiency,
betterandstableresults,reducedoperatorworkloadandidealbiologicalresponse.Inspiteofsuchadvancestakingplaceinallaspects
of orthodontics, External apical root resorption (EARR), particularly in the region of upper incisors, is an almost ubiquitous
consequence of orthodontic treatment and has been a concern of clinicians since the early reports of Bates[1], Ottenluigi[2] and
Ketcham[3].Yet,notwithstandingourspecialty'sheightenedconcerninthepresenteraofmedicallitigiousness,thefundamentalcauseof
treatment associated root resorption remains unknown, and the magnitude of resorption to be anticipated after specific clinical
maneuversisalmostentirelyunpredictable.
Intheseveralinvestigationsdoneinthepast,thereareconsiderabledifferencesinthetypeofteethexamined,samplesizes [4,5],
duration of followup [6,7], type of tooth movement,measurement methods, and patient characteristics. Some investigators have
assessedEARRqualitativelyfromperiapicalradiographsanddescribeditsseveritybasedonsubjectivescoringsystems [610],whereas
inotherstudies,EARRhasbeendefinedquantitativelyfromcephalometricimages[5,1114] orfromstandardperiapicalradiographswith
thelongconeparallelingtechnique[4,1518].Thereforecomparisonofthestudiescitedinliteratureisdifficult.
Althoughtheresorptionprocessstopsoncetheactiveapplianceisremoved[19],severelyresorbedteethmaybelostprematurely
in patients who are also susceptible to marginal periodontal breakdown. In addition, teeth with abnormally short roots may not be
suitableasfuturebridgeabutments.Theabilitytoidentifythesmallproportionofpatientsatriskofsevereapicalrootresorptionbefore
orearlyintreatmentmay,therefore,beofclinicalsignificance.Further,amountofexternalapicalrootresorptionisalsoaffectedbythe
timedurationandgenderasquotedbymanystudies[9,20].
Retractionisausualprocedurethatiscarriedoutinquiteamanycasesrequiringorthodontictherapyandthisstageofactive
orthodontic treatment has been shown to be associated with external apical root resorption.There are mainly two methods used for
retractionthatisfrictionandfrictionlessmechanics.Thefrictionmechanicsmainly utilizes the use of NiTi coil springs, elastics etc
whereasthefrictionless mechanics involves the use of loops such as Tloops, KSIR arch, Teardrop loop etc. However not many
studieshavebeendoneontheeffectofthetwomechanics(FrictionandFrictionless)onexternalapicalrootresorption.
ThustheprimaryaimofthisstudywasfocusedonmeasuringtheamountofEARRofthemaxillaryincisorsduringretraction
stageofactiveorthodontictreatmentusingfrictionalandfrictionlessmechanicsandtoevaluateitsclinical significance.A secondary
attempt was made with the same sample to examine the relationship between the maxillary incisor root resorption and treatment
variablessuchasthegender,durationofretractionandtypeofmechanicsusedforretraction.

AimsandObjectives
Thestudywasconductedwiththefollowingaimsandobjectives:
Tocheckfortheincidenceofexternalapicalrootresorptionduringactiveorthodontictreatment.
To quantify the amount of external apical root resorption in maxillary incisors during retraction phase of active orthodontic
treatmentusingfrictionalandfrictionlessmechanics.
Tocomparethecontributionoftypeofmechanicsusedforretractiontoexternalapicalrootresorption.
Toevaluateandcomparethecontributionofgendertoexternalapicalrootresorption.
Toevaluateandcomparethecontributionofdurationofretractiontoexternalapicalrootresorption.

METHODOLOGY
SourceOfData:
Patients undergoing orthodontic treatment with preadjusted edgewise appliance using either Roth or MBT prescription at
DepartmentofOrthodonticsandDentofacialOrthopedics,KLEVishwanathKattiInstituteofDentalSciences.

Method:
InclusionCriteria:
Patientsrequiringfixedactiveorthodontictreatment.
Patientswithsoundperiodontalsupport.

ExclusionCriteria:
Patientswithprevioushistoryoforthodontictreatment.
Patientswithcrownfractureorincisaledgeabrasion.
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Patientwithhistoryoftraumatoanteriorteeth.
Thestudysamplewasdividedinto2groupsbasedonthemechanicsusedforretraction:
FgroupPatientstreatedwithfrictionalmechanicsforretraction.Thisgroupcomprisedof36patients.
FLgroupPatientstreatedwithfrictionlessmechanicsforretraction.Thegroupcomprisedof14patients.
Theretractioninfrictiongroupwasdonebyusingelasticswhileinfrictionlessgroup,retractionwasdonebyusingcontinuous
archloops,mainlyTloopsandutilityarch.Thedurationofretractionvariedfrom46monthsinboththegroups.
Radiographsweretakenattwostages:
T1radiographtakenatthestartoftheretraction.
T2radiographtakenattheendoftheretraction.
Preretraction(T1)andpostretraction(T2)digitalizedintraoralperiapicalradiographofthepatients`maxillarypermanentcentral
andlateralincisorsweretakenwithlongconeparallelingtechniquebyasingleoperator.Thecorrectangulationwasobtainedbyanintra
oralXCPfilmholderattachedtotheconeofintraoralradiographmachine(Figure2&3),XMindSatelecImagingwithsettingsvoltage
70kvp, current 8mA and exposure time of 0.2 seconds and digitalized by RVG5000 Kodak (Figure 1),in Department of Oral
Medicine,DiagnosisandRadiology.
Thecrownandrootlengthofthemaxillarycentralandlateralincisorswasmeasuredinthepreretraction(T1)andpostretraction
(T2)radiographsusingthemeasurementoptionintheRVGsoftware.(Figure4and5)
Theteethweremeasuredintwoparts:
IncisaledgetoCEJ(C)
CEJtotheapex(R)
Usingasimplemathematicalformulatheamountofexternalapicalrootresorptionwascalculated.
Firsttheactualrootlength(rootlengthpostretractionifnoexternalapicalrootresorptionwouldhaveoccurredduringretraction)
wascalculatedusingtheformula:

ACTUALROOTLENGTH(RA)=C2XR1/C1
C1IncisaledgetoCEJ(T1)
C2IncisaledgetoCEJ(T2)
R1CEJtotheapex(T1)
RARootlengthatT2 ifnorootresorptionwouldhaveoccurredduringretraction
Further the amount of root resorption was calculated by subtracting the root length (R2) measured in the post retraction
radiograph(T2)fromtheactualrootlength(RA)calculatedasmentionedabove.

AMOUNTOFROOTRESORPTION(DIFFERENCE)=RAR2
RARootlengthatT2 ifnorootresorptionwouldhaveoccurredduringretraction
R2CEJtotheapex(T2)
Finallythepercentageofamountofrootresorptionwascalculatedfromtherootlengthpreretraction(R1).

PERCENTAGEOFROOTRESORPTION=AMOUNTOFROOTRESORPTIONX100/R1
STATISTICALANALYSIS
Meanamountofrootresorptioninfrictional(F)andfrictionless(FL)groupswerecomparedusingunpairedttest.
Meanamountofrootresorptioninmalesandfemaleswerecomparedusingunpairedttest.
CorrelationbetweendurationofretractionandrootresorptionwasdonebyKarlPearson`scorrelationcoefficientprocedure.

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FIGURE1IntraoralPeriapicalRadiographMachine(XMindSatelec)

FIGURE2DigitalIOPARadiographSensor(KodakRVG5000)andXCPfilmholder

FIGURE3Positioningofintraoralperiapicalradiographbyparallellingtechnique

FIGURE4DigitalImagingSoftwareShowingPreretractionandPostretractionRadiographicImages(Kodak)

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FIGURE5DigitalImagingSoftwareShowingMeasurementofIncisors(Kodak)

RESULTS
TheMeanandSDvaluesofrootlengthinpreretractionstageincentralincisorsandlateralincisorsin groups F and FL are
summarizedintables1and2.MeanandSDvaluesofrootresorptionincentralincisorsandlateralincisorsingroupsFandFLare
givenintables3and4.
Thepatientsinfrictiongroup(F)onradiographicevaluationofrootapicesshowedanaveragemeanroot resorption of 0.9
0.25forlateralincisorsand0.700.21mmforcentralincisors.Thepatientsinfrictionlessgroup(FL)onradiographicevaluationof
rootapicesshowedanaveragemeanrootresorptionof1.080.11mmforlateralincisorsand0.840.08mmforthecentralincisors.
Thepercentageofrootresorptionwithrespecttooriginalrootlengthwascalculated.(Table5and6).Therewasstatisticallysignificant
differenceinmeanrootresorptionbetweenthefrictionandfrictionlessgroupsinbothcentralandlateralincisors(p<0.05).(Table7)
Thecontributionofgendertorootresorptionwasalsoevaluated.Therewasstatisticallysignificantdifferenceinpercentageroot
resorptionbetweenmalesandfemalesinbothFandFLgroups(p<.05).Themalepatientsinboththegroups(F,FL)showedless
amountofrootresorptioni.e0.740.18mmthanfemalesi.e0.890.1mmrespectively.(Table8)Thedurationoftreatmentvaried
between46months.Theaverageamountofrootresorptionat4,5and6monthsoftreatmentdurationwas0.920.31mm,0.96
0.22 mm, 1.30 0.31 mm respectively, indicating an increase in root resorption with treatment duration. There was statistically
significantdifferencebetween4and6monthsbetween5and6monthsbutnostatisticallysignificantdifferencewasseenbetween4
and5months.(Table9)
Table1:MeanandSDvaluesofrootlengthinpreretractionstageinleftandrightcentralincisorsandlateralincisorsingroups
FandFL.

Table2:MeanandSDvaluesofrootlengthinpreretractionstageincentralincisorandlateralincisorsingroupsFandFL.

Table3:MeanandSDvaluesofrootresorptioninleftandrightcentralincisorsandlateralincisorsingroupsFandFL.

Table4:MeanandSDvaluesofrootresorptionincentralincisorandlateralincisorsingroupsFandFL.

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Table5:Percentageofrootresorptionfrompreretractionstagerootlengthinleftandrightcentralincisorsandlateralincisorsin
groupsFandFL.

Table6:Percentageofrootresorptionfrompreretractionstagerootlengthaccordingtogroupsandincisors

Graph1:Comparisonofrootresorptioninfrictionandfrictionlessgroupsinvariousteeth

Table7:Comparisonofrootresorptioninfrictionandfrictionlessgroupincentralincisorandlateralincisorsbyunpairedttest

*p<0.05
Table8:Comparisonofrootresorptioninmaleandfemalesinallteethbyunpairedttest

*p<0.05
Graph2:Comparisonofrootresorptioninmaleandfemalesinallteeth

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Table9:Comparisonofrootresorptionat4th,5th&6thmonthofretractionbyANOVAtest
Graph3:Comparisonofrootresorptionat4th,5th&6thmonthofretractionbyANOVAtest

Discussion
Externalapicalrootresorption(EARR)isacommoniatrogenicconsequenceoforthodontictreatment.Variousfactorscausing
root resorption of permanent teeth are physiologic tooth movement, adjacent impacted tooth pressure, periapical or periodontal
inflammation,toothimplantationorreplantation,continuousocclusaltrauma,tumorsorcysts,metabolicorsystemicdisturbances,local
functionalorbehavioralproblems,idiopathicfactorsandorthodontictreatment[2123].
Theorthodonticliteraturecontainsmanyreportsofclinicalandlaboratoryinvestigationsofrootresorption.Enormousresearch
investigating the causeandeffect relationship between root resorption and orthodontic treatment has also been published. These
studiesindicatedthatmultiplefactorsareinvolvedinrootresorptionsuchasgeneticandsystemicfactors,genderandtoothmovement
type,magnitudeoforthodonticforce,durationandtypeofforce.Theyhavealsocategorizedtheseriskfactorsaspatientrelatedand
treatmentrelatedfactors[9,20].
Evaluation of the vulnerability of specific teeth to the resorption process in the literature, has resulted in common agreement
amongauthorsthatthemaxillaryincisorsaretheteeththatarethemostsusceptibletotheprocess[24,25].
Thetypeofforcesappliedinfrictionandfrictionlessgroupsdifferfromeachotherwhichmightaffecttheamountofresorption
inorthodonticallytreatedcases[26].Howevernotmanystudieshavebeendonetocomparetheeffectoftheseretractionmechanicson
externalapicalrootresorption.
Thus, in this study orthodontically induced apical root resorption during retraction stage of treatment was studied. The teeth
selected were maxillary incisors since they exhibit maximum resorption as supported by various studies done by Oppenheim,
DeShieldsRW[9,27].
Preretraction(T1)andpostretraction(T2)digitalizedintraoralperiapicalradiographofthepatients`maxillarypermanentcentral
andlateralincisorsweretakenwithlongconeparallelingtechniquebyasingleoperatortoeliminatebias.
Radiographsarecommonlyusedasadiagnosticaidforrootresorption.Radiographicdetectionofapicalrootshorteningrequires
acertaindegreeofresorption[28].Itisdifficulttodevelopastandardizedtechniquetocomparethesameteethatdifferenttimes.Tooth
movementmakesitmoredifficulttoassesstheexactamountofrootlossespeciallywhenthetoothistorquedortipped.Conventional
radiographs are ineffective in assessing buccal and lingual root resorption. Several radiographic techniques used include periapical
bisectingangle,periapicalparalleling,orthopantomogram,cephalogramandlaminogram[28].
Digitized intra oral periapical radiographs, with a paralleling technique, were used to study root resorption in this study. The
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radiographsweredigitalizedbyRVG5000Kodaksoftware.Thedigitalizedphotographsallowedforgreaterprecisionascomparedto
conventionalperiapicalradiographs.Further,thereislessexposuretoradiationindigitalradiographs.Thisisinaccordancetostudies
donebyDinaalSudani,E.Arana,L.MartiBonmati[29].
Despiteitslimitations,theradiographictechniquethathasthemostfavorablebenefittoriskratioindetectingandevaluatingthe
degreeofapicalrootmateriallossistheperiapicaltechnique[30].Itprovidesthemostappropriateinformationwithleastirradiationto
the patient when used for teeth that are most likely to exhibit blunting of roots that is maxillary and mandibular incisors [24]. The
periapical technique provides less distortion and superimposition errors compared with the orthopantomogram or the lateral
cephalogram. By using the periapical technique for selected roots, up to 4 films enable absorption of lower radiation doses by
radiosensitivetissues of the head and neck, according to measurements on the skin, compared with orthopantomogram or lateral
headfilm [31,32]. This is of great advantage in children, adolescents and young adults whose radio sensitivity is higher than that of
adultsbecauseofrapidgrowthoforgans,thyroidpositionandlongerdurationfortheeffectsofradiationtobeapparent[31].
Howeverperiapicalradiographsincludeprojectionerrors.Tocompensateorcorrecttheseerrors,variousgeometricandalgebraic
methods have been used by various authors. Some authors used a customized jig for detection of root resorption [7]. A group of
researchers studied the effects of change in angulation between the tooth and film on the length of the image of a tooth model, to
referencepointsonthetoothforcalculatingrootlengths.Fiveamalgamdotswereplacedonanacrylicmodelofamaxillaryincisor.
Resultsindicatedthatangularchangesbetweenthetoothandfilmaffectthemeasuredtoothlength.Themidpointbetweenthemesial
CEJanddistalCEJwasthebestreferencepointformeasuringrootlength [33].Thus,inthepresentstudy,measurementsweremade
fromthemidpointofincisaledgetothemidpointbetweenthemesialCEJanddistalCEJandfromtheapextothemidpointbetweenthe
mesialCEJanddistalCEJ.Themeasurementsweredonewithmeasuringoptioninthesoftware.Theteethweremeasuredintwoparts:
incisaledgetoCEJ(C)andCEJtotheapex(R)tomeasurethecrownlengthandrootlengthatpreretractionandpostretractionphases.
Inthisstudy,theformulausedformathematicalcorrectionofmagnificationandtodetecttheamountofapicalrootresorption
was:ActualRootLength(RA)=C2XR1/C1AmountofRootResorption(Difference)=RAR2.
(C1IncisalEdgetoCEJ(T1),C2IncisalEdgetoCEJ(T2),R1CEJtotheApex(T1),R2CEJtotheApex(T2),RARoot
LengthatT2 ifnorootresorptionwouldhaveoccurredduringalignment).
An equation was given by Linge L and Linge B [17] in which root length measurements in pre treatment and post retention
radiographswerecorrectedforenlargementdifferences,revealingthevaluesofapicalrootresorption in individual maxillary incisor
teeth.Similarradiographicmagnificationerrorsweremathematicallycorrectedbyotherinvestigatorstostudyorthodonticallyinduced
apicalrootresorption[34,35].
In the present study, external apical root resorption was seen in all cases. This is in keeping with other studies done by
OttolenguiR,KetchamAH[2,3]whichstatesthatrootresorptionoccursduringactiveorthodontictreatment.
Controversyexistsregardingwhichincisorsresorbthemost:thecentralsorthelaterals?Somestudieshavereportedthatcentral
incisorsweremoresusceptibletotheprocess [3638]whileothershavefavoredthelateralincisors [25, 39, 40]. Inthepresentstudythe
maximumresorptionwasseeninlateralincisorswhencomparedtocentralincisors.Themeanpercentageresorptioninlateralincisors
was6.66%incomparisonto4.03%incentralincisors.
Therootresorptionseenwasmoreinteethwhich were retracted using frictionless mechanics than the teeth in which friction
mechanicswasusedwithastatisticallysignificantdifferencebetweenthem.Thiscouldbeduetothecontinuousforcethatisapplied
when loops (frictionless) are used for retraction. Moreover, the direction of force cannot be controlled in cases of frictionless
mechanicswhichresultsinjigglingmovementsthathaveshowntocausegreateramountofrootresorption.Thisisinaccordanceto
literaturebyNaphthaliBrezniak[33] andVarunKalra[41].
Inthepresentstudy,significantlygreateramountofrootresorptionwasseeninfemalesthaninmales.Thisisinaccordancewith
studiesdonebyLevanderandMalmgren[9], Kjaer[20]andHoriuchietal.[42].However,theresultsofpresentstudyarecontrarytothe
studiesdonebyRemingtonDNetal [43]and Sameshima and Sinclair [25]which stated that resorption occurs more in males than in
females. However, Harris et al [44], Linge and Linge [17] and Parker and Harris [45] have found nocorrelation between EARR and
gender. There is speculation about the difference in level of hormonal titres as being the causative factor of gender predilection of
EARR[46].Howeverthereisnoconclusiveevidenceregardingthisfinding.
Inthepresentstudy,therewasincreaseinEARRasthedurationofactiveorthodontictreatmentincreasedfrom4to6months.
ThemeanEARRat4months,5monthsand6monthswere0.9214,0.9650,1.3063respectivelywithstatisticallysignificantdifference
between5and6months,and4and6months.However,nosignificantdifferencewasseenbetween4and5months.
TheamountandpatternofEARRmayvarywithlongertreatmentdurationshencefurtherstudieswithlongerfollowupperiods
withlargersamplesizeandthreedimensionaldiagnosticaidslikecomputedtomographycouldbeofgreatvalue.

Conclusion
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Therewasavisibleamountofrootresorptionduringretractionphaseoffixedorthodonticmechanotherapy.
Themaximumresorptionwasseeninlateralincisorswhencomparedtocentralincisors.The mean percentage resorption in
lateralincisorswas6.66%incomparisonto4.03%incentralincisors.
Therootresorptionseenwasmoreinteethwhichwereretractedusingfrictionlessmechanicsthantheteethinwhichfriction
mechanicswasusedwithastatisticallysignificantdifferencebetweenthem.
Therewasasignificantincreaseinrootresorptionwithincreaseinthetreatmentduration.
Therewasanincreasedamountofrootresorptioninfemalesthaninmales.
There is a need for more efficacious treatment mechanics which can apply lower level of forces during retraction phase of
activeorthodontics.

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