Original Article

Relative anchorage loss under reciprocal anchorage in mandibular

premolar extraction cases treated with clear aligners
Zhenxing Tanga; Weichang Chenb; Li Meic; Ehab A. Abdulghanid; Zhihe Zhaoe; Yu Lie

ABSTRACT

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Objectives: To compare mandibular relative anchorage loss (RAL) under reciprocal anchorage
between first and second premolar extraction cases in bimaxillary protrusion mild crowding cases
treated using clear aligner therapy (CAT).
Materials and Methods: Adult patients who met the following criteria were included: treated using
CAT with bilateral mandibular premolar extractions and space closure using intra-arch reciprocal
anchorage. RAL was defined as the percent molar mesial movement relative to the sum of molar
mesial plus canine distal movement. Movements of the mandibular central incisor (L1), canine (L3),
and first molar (L6) were measured based on superimposition of the pre- and post-treatment
dentition and jaw models.
Results: Among the 60 mandibular extraction quadrants, 38 had lower first premolar (L4) and 22
had lower second premolar (L5) extracted. L6 mesial movement was 2.01 6 1.11 mm with RAL of
25% in the L4 extraction group vs 3.25 6 1.19 mm with RAL of 40% in the L5 extraction group (P ,
.001). Tooth movement efficacy was 43% for L1 occlusogingival movement, 75% for L1
buccolingual inclination, 60% for L3 occlusogingival movement, and 53% for L3 mesiodistal
angulation. L1 had unwanted extrusion and lingual crown torquing whereas L3 had unwanted
extrusion and distal crown tipping, on which the power ridges or attachments had little preventive
effect.
Conclusions: The average mandibular reciprocal RAL is 25% or 40% for extraction of L4 or L5,
respectively, in CAT cases. A RAL-based treatment planning workflow is proposed for CAT
extraction cases. (Angle Orthod. 2023;93:375–381.)
KEY WORDS: Clear aligner; Invisalign; Anchorage; Extraction treatment; Tooth movement efficacy

INTRODUCTION ment experience, reduced number of appointments,

and less negative impact on oral hygiene.1,2 CAT was
Clear aligner therapy (CAT) has become increas- initially indicated for nonextraction cases due to its
ingly popular due to its advantages over conventional limitation in controlling root movement.3,4 More recently,
fixed orthodontics, such as a more comfortable treat- it has also been used with extraction cases, thanks to

a
Postgraduate Student, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of
Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
b
Undergraduate Student, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China
Hospital of Stomatology, Sichuan University, Chengdu, China.
c
Associate Professor, Discipline of Orthodontics, Department of Oral Sciences, Faculty of Dentistry, University of Otago, Dunedin,
New Zealand.
d
Researcher, Department of Orthodontics and Dentofacial Orthopedics, College of Dentistry, Thamar University, Dhamar, Yemen;
and Postgraduate Student, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of
Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
e
Professor, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Orthodontics,
West China Hospital of Stomatology, Sichuan University, Chengdu, China.
Corresponding author: Dr Yu Li, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases,
Department of Orthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, 610041, China
(e-mail: yuli@scu.edu.cn)
Accepted: February 2023. Submitted: October 2022.
Published Online: March 29, 2023
Ó 2023 by The EH Angle Education and Research Foundation, Inc.

DOI: 10.2319/102222-727.1 375 Angle Orthodontist, Vol 93, No 4, 2023

376 TANG, CHEN, MEI, ABDULGHANI, ZHAO, LI

development of new aligner materials, attachment MATERIALS AND METHODS

designs, and staging of tooth movement.5–7
Anchorage is important for extraction cases and it Samples
can be classified according to the manner of force The determination of sample size was based on a
application, jaws involved, site of anchorage, number previous study,15 which investigated the molar mesial
of anchorage units, or anchorage demands.8 Among movement in mandibular premolar extraction cases. A
them, reciprocal anchorage refers to the desired sample size of 10 per group was needed with type I
movement of two segments with equal and opposite error at 0.05 and type II error at 0.20 (80% power)
forces.8 In premolar extraction cases, when retraction based on one-sided two-sample t-test. A total of 342
of the anterior segment and mesial movement of the patients who began CAT during the years 2016–2020,

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posterior segment are desired, the two segments move by the same orthodontist, were screened for eligibility.
in opposite directions, taking the form of reciprocal After applying the inclusion and exclusion criteria, 30
anchorage. For a specific case with reciprocal anchor- patients were included in the study, comprising seven
age, extraction of the second premolar may result in males and 23 females, with an average age of 27.2 6
greater mesial movement of the molar than would be 6.4 (range: 20–45 years). Permission to perform this
expected with extraction of the first premolar, as the study was approved by the Ethics Committee of the
ratio of the posterior vs anterior units is smaller when West China Hospital of Stomatology, Sichuan Univer-
the second premolar is extracted. Therefore, knowl- sity (WCHSIRB-CT-2022-160).
edge of the difference in posterior anchorage loss The inclusion criteria were: (1) adult patients with a
under reciprocal anchorage after extraction of the first clinical diagnosis of bimaxillary dentoalveolar protrusion
or second premolar can help clinicians choose the who underwent CAT (Invisalign, Align Technology, San
optimal extraction plan. Jose, CA), (2) the mandibular arch involved 14 teeth
Posterior anchorage loss is usually measured as (37–47) with the third molars missing or extracted before
amount of first molar mesial movement. With conven- treatment, (3) less than 2 mm crowding in each
tional fixed orthodontic appliances, average mesial mandibular quadrant, (4) treatment involving extraction
movement of the mandibular molars ranged from 2.14 of one mandibular premolar on each side, (5) the
to 4.16 mm in first premolar extraction cases,9–15 and mandibular extraction space was closed with only intra-
from 3.30 to 4.93 mm in second premolar extraction arch reciprocal anchorage and no other form of
cases.14–18 In CAT, after first premolar extraction, the anchorage (inter-arch elastics or temporary anchorage
mandibular first molar moved forward by an average of devices [TADs]), (6) completion of the first series of
1.66 mm.7 Though evaluating anchorage loss with clear aligners without midcourse correction, and (7) full
molar mesial movement is straightforward, it does not records available for pre- and post-treatment (when the
take into account the total space involved. Therefore, in first series of aligners were finished); records included
the present study, relative anchorage loss (RAL) was the cone-beam computed tomography (CBCT) images
used as another indicator to describe anchorage and intra-oral scans. The exclusion criteria were: (1)
capacity, meaning the percentage of molar mesial treatment combined with fixed appliances, (2) treatment
movement relative to the sum of molar mesial combined with orthognathic surgery, and (3) severe
movement plus canine distal movement during extrac- alveolar bone atrophy or root resorption. The reason for
tion space closure. The RAL under intra-arch recipro- including mild rather than moderate or severe crowding
cal anchorage may also be referred to as ‘‘reciprocal cases was so that the cases would thus have maximum
RAL.’’ residual extraction spaces after resolving crowding,
Studies on tooth movement efficacy of CAT, which could best represent reciprocal anchorage during
representing the capacity to achieve the predicted space closure.26 The diagnosis of bimaxillary dentoal-
clinical outcome, are of great significance. Most such veolar protrusion was made based on photographic and
studies included nonextraction cases only,19–25 but cephalometric assessment, including incisor protrusion
the conclusions drawn from nonextraction cases and increased lip procumbence.27 All patients changed
should not be extrapolated to extraction cases. A aligners every 10 days. The average treatment time of
the first series of aligners was 20.2 6 6.5 months. After
few studies 4,6,7,19 compared the discrepancy between
collection of the records needed for the present study,
the actual and virtual outcomes in CAT extraction
all the included patients continued their treatment with at
cases; however, none of them reported the efficacy
least one refinement.
of tooth movement. Therefore, the primary aim of this
study was to investigate reciprocal RAL in mandib-
3D Model Measurements
ular premolar extraction cases treated with CAT, and
the secondary aim was to analyze the efficacy of The 3D dental models included the intra-oral pre-
tooth movement. and post-treatment scans, and the predicted post-

Angle Orthodontist, Vol 93, No 4, 2023

RELATIVE ANCHORAGE LOSS UNDER RECIPROCAL ANCHORAGE 377

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Figure 1. Superimposition of the digital dentition models derived from ClinCheck software and the jaw models reconstructed from CBCT data. (A)
Superimposition of the pre-treatment dentition model and jaw model based on crown surfaces of all teeth; (B) Superimposition of the achieved
post-treatment dentition model and jaw model based on crown surfaces of all teeth; (C) Superimposition of the pre-treatment and post-treatment
jaw models based on the mandibular basal bone; (D) Final superimposition of the pre-treatment (green), predicted post-treatment (blue) and
achieved post-treatment (purple) mandibular dentition models.

treatment dentition models in the ClinCheck software planes, passing through the proximal contact point of
(Align Technology, San Jose, CA). The 3D jaw models the central incisors.
were derived from the CBCT reconstruction using Tooth movements, including anteroposterior move-
Mimics software (version 21.0; Materialise, Leuven, ment, occlusogingival movement, mesiodistal angula-
Belgium). Superimposition of the 3D models (Figure 1) tion, buccolingual inclination, and rotation, were
was performed with Geomagic Studio (version 12.0, measured for every lower central incisor (L1), canine
Geomagic, Rock Hill, SC) as described by Dai et al.7 A (L3), and first molar (L6). The L6 mesial movement was
measured as the length between the projected points
3D coordinate system (Figure 2A) was established for
of the pre- and post-treatment first molar mesial buccal
tooth movement measurement. The mesial buccal
cusp tips on the transverse plane. The L3 distal
cusps of bilateral first molars and the proximal contact
movement was quantified similarly (Figure 2B). The
point of bilateral central incisors on the predicted post- relative anchorage loss (RAL) was defined as the
treatment dentition model were used to fit the percentage of L6 mesial movement to the total
transverse plane (xy plane); the coronal plane (xz extraction space closed (the sum of L6 mesialization
plane) was the plane perpendicular to the transverse and L3 distalization). All other tooth movement
plane, passing through mesial buccal cusps of bilateral measurements were conducted in the same manner
first molars; the midsagittal plane (yz plane) was the as described in the literature,6,7 and repeated by the
plane perpendicular to the transverse and coronal same operator after a 1-week interval.

Angle Orthodontist, Vol 93, No 4, 2023

378 TANG, CHEN, MEI, ABDULGHANI, ZHAO, LI

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Figure 2. The measurement of anteroposterior tooth movement. (A) Establishment of the three-dimensional coordinate system based on
anatomical landmarks on the predicted post-treatment dentition model. (B) Measurement of mandibular first molar mesial movement (yellow) and
canine distal movement (red) in the xy plane.

Statistical Analysis RESULTS

All statistical analyses were performed with Stata For repeated measurements, the Pearson correla-
software (version 15.0; Stata Corporation, College tion coefficients and the Bland-Altman analysis showed
Station, TX). Pearson correlation coefficients and excellent intra-operator agreement (Table 1). Among
Bland-Altman analyses were used to evaluate intra- the 60 mandibular extraction quadrants, 38 quadrants
operator agreement. Independent t-tests were used to had L4 extraction, and 22 quadrants had L5 extraction.
compare anteroposterior movement and RAL between The characteristics of attachments and power ridges
the lower first premolar (L4) extraction quadrants and used on mandibular teeth are summarized in Table 2.
the lower second premolar (L5) extraction quadrants. Table 3 compares the achieved anteroposterior
movement and RAL between the L4 and L5 extraction
Paired t-test was used to compare the achieved and
groups. The amount of L1 retraction and L3 distaliza-
predicted tooth movements. For those variables with
tion in the L4 extraction group was greater than that in
statistically significant differences (except anteropos-
the L5 extraction group (P , .05); the amount of L6
terior movement), stepwise regression analysis was
mesial movement in the L4 extraction group (2.01 6
used to explore the influence of predicted tooth
1.11 mm) was significantly less than that in the L5
movement, power ridges, and attachment types on extraction group (3.25 6 1.19 mm); and the RAL was
achieved tooth movement. Tooth movement efficacy 25 6 13% in the L4 extraction group vs 40 6 15% in
was calculated as the coefficient of corresponding the L5 extraction group (P , .001).
predicted tooth movement of the regression models. Table 4 shows the comparison between the predict-
Statistical significance was set at P , .05. ed and achieved tooth movements. Compared with
predicted, the L1 had 2.36 6 1.19 mm more occlusal
Table 1. Pearson’s Correlation Coefficients (r) and Results of movement and 12.30 6 5.208 more lingual crown
Bland-Altman Analyses for Intra-Operator Agreementa
95% Limits of Table 2. Power Ridges and Attachments Used on Different
Measurement r Difference Agreement Mandibular Teeth
APM 0.997 0.016 6 0.170 0.349–0.316 Teeth Attachment/Power Ridge
OGM 0.993 0.006 6 0.157 0.302–0.315
MDA 0.998 0.048 6 0.574 1.077–1.173 L1 Power ridge None Total
BLI 0.997 0.207 6 0.707 1.179–1.594 11 49 60
Rotation 0.998 0.002 6 0.834 1.633–1.636 L3 Rectangular attachment Optimized attachment Total
22 38 60
a
APM indicates anteroposterior movement; BLI, buccolingual L6 Rectangular attachment Optimized attachment Total
inclination; MDA, mesiodistal angulation; OGM, occlusogingival 43 17 60
movement.

Angle Orthodontist, Vol 93, No 4, 2023

RELATIVE ANCHORAGE LOSS UNDER RECIPROCAL ANCHORAGE 379

Table 3. Achieved Anteroposterior Movement and Relative Table 4. Predicted and Achieved Tooth Movementa
Anchorage Loss in Different Groupsa
Measurement Predicted Achieved Difference P*
Measurement L4 Extraction L5 Extraction Difference P*
APM
L1_APM 5.02 6 1.36 4.11 6 1.58 0.91 .028 L1 5.16 6 1.73 4.70 6 1.49 0.45 6 1.51 .023
L3_APM 5.86 6 1.32 4.97 6 1.41 0.90 .017 L3 5.69 6 1.53 5.55 6 1.41 0.14 6 2.01 .585
L6_APM 2.01 6 1.11 3.25 6 1.19 1.23 ,.001 L6 1.55 6 1.16 2.45 6 1.27 0.90 6 1.38 ,.001
RAL 0.25 6 0.13 0.40 6 0.15 0.14 ,.001 OGM
L1 1.73 6 1.13 0.64 6 1.11 2.36 6 1.19 ,.001
a
APM indicates anteroposterior movement; þ, retraction of central
incisors, distalization of canines, and mesialization of first molars; , L3 0.82 6 1.12 0.22 6 1.21 1.04 6 1.11 ,.001
protrusion of central incisors, mesialization of canines, and L6 0.19 6 1.31 0.27 6 0.55 0.08 6 1.43 .657
distalization of first molars. RALindicates relative anchorage loss. MDA
* Independent t-test, significant at P , .05. L1 0.74 6 5.41 0.69 6 4.54 0.05 6 3.14 .900

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L3 1.00 6 10.76 11.33 6 8.52 10.33 6 8.13 ,.001
L6 3.02 6 8.38 2.23 6 9.16 0.79 6 8.46 .473
torquing, whereas the L3 had 1.04 6 1.11 mm more BLI
occlusal movement and 10.33 6 8.138 more distal L1 2.46 6 6.29 14.76 6 7.21 12.30 6 5.20 ,.001
crown tipping. In addition, the achieved L6 mesializa- L3 1.59 6 8.00 1.42 6 12.67 0.17 6 10.03 .897
tion was 0.90 6 1.38 mm larger than the amount L6 1.59 6 4.89 0.09 6 6.02 1.67 6 7.39 .085
Rotation
predicted (P , .001).
L1 5.70 6 13.90 4.74 6 12.44 0.97 6 8.18 .365
Stepwise regression analysis (Table 5) showed that L3 0.84 6 16.17 0.82 6 16.47 0.01 6 7.69 .988
the efficacy of different tooth movements varied: 42.8% L6 2.00 6 4.54 2.70 6 5.34 0.70 6 3.74 .150
for the L1 occlusogingival movement, 74.8% for the L1 a
APM indicates anteroposterior movement; þ, retraction of central
buccolingual inclination, 60.1% for the L3 occlusogin- incisors, distalization of canines, and mesialization of first molars; ,
gival movement, and 52.8% for the L3 mesiodistal protrusion of central incisors, mesialization of canines, and
distalization of first molars. BLI indicates buccolingual inclination; þ,
angulation. As shown in the regression model, the lingual crown torque; , labial/buccal crown torque. þ, retraction of
power ridges had no significant effect on the L1 central incisors, distalization of canines, and mesialization of first
buccolingual inclination, and the use of optimized or molars; , protrusion of central incisors, mesialization of canines, and
distalization of first molars. MDA indicates mesiodistal angulation; þ,
rectangular attachments had no significant effect on distal crown tipping; , mesial crown tipping. OGM indicates
the L3 mesiodistal angulation. occlusogingival movement; þ, extrusion; , intrusion. Rotation: þ,
distal-lingual rotation; , mesial-lingual rotation.
* Paired t-test, significant at P , .05.
DISCUSSION
It is controversial in the literature whether mandibular additional anchorage (Figure 3). First, the orthodontist
anchorage loss varies between different premolar sets the incisor position objective (IPO) and develops a
extraction patterns in fixed orthodontics. Some studies tentative extraction plan, based upon which a tentative
found significantly greater molar mesial movement in dental setup is made in the digital orthodontic software,
L5 than L4 extraction patients,14,15,28 whereas others such as ClinCheck. Then, the orthodontist measures
found no significant difference.16,29 It should be noted the predicted RAL and compares it with the average
that most of these studies involved intermaxillary reciprocal RAL value. If the predicted RAL is close to
elastics rather than intra-arch reciprocal anchorage the reciprocal RAL, the tentative extraction plan is
exclusively, except for one study conducted by Kim et justified; otherwise, it should be modified, either by
al.,15 which found that the L6 moved mesially by 2.14 supplementing additional posterior or anterior anchor-
mm in the L4 extraction cases and by 3.62 mm in the age, or by changing to a new extraction plan that better
L5 extraction cases. The present study is the first to matches the predicted RAL with the reciprocal RAL.
compare anchorage loss between L4 and L5 extraction Previous studies superimposed the pre- and post-
patterns in CAT. Based on the sample observed in the treatment dentition models using regional superimpo-
present study, L6 mesial movement was 2.01 6 1.11 sition on molars21 or global dentition alignment,23 which
mm with RAL of 25% in the L4 extraction group, were not applicable in the present study because the
significantly less than the 3.25 6 1.19 mm with RAL of arch length and form were changed in the extraction
40% in the L5 extraction group (Table 3). It also cases. Due to the stability of mandibular basal bone in
seemed that the mandibular posterior anchorage loss adults, registration of the pre- and post-treatment
in CAT was smaller than that in fixed appliances, CBCT jaw models was used to measure mandibular
though the sample in the present study might not be tooth movement in the present study. Such an
completely comparable to the sample evaluated by approach for registration has been previously validat-
Kim et al.15 ed,7 with the caution in mind that multiple superimpo-
A RAL based workflow is recommended to deter- sition operations might result in accumulation of
mine the optimal extraction site and the need for measurement errors.

Angle Orthodontist, Vol 93, No 4, 2023

380 TANG, CHEN, MEI, ABDULGHANI, ZHAO, LI

Table 5. Results of Stepwise Regression Analysisa

DV IV Coef. Std. Err. t P . jtj* 95% CI R2
L1_OGM b
L1_OGM c
0.428 0.116 3.68 .001 0.195–0.660 0.190
_cons 1.376 0.239 5.76 ,.001 0.897–1.854
L1_BLIb L1_APMc 1.244 0.359 3.47 .001 0.525–1.964 0.620
L1_BLIc 0.748 0.099 7.55 ,.001 0.550–0.946
_cons 6.502 1.917 3.39 .001 2.663–10.342
L3_OGMb L1-BLIc 0.057 0.020 2.85 .006 0.017–0.097 0.387
L3-OGMc 0.601 0.112 5.36 ,.001 0.247–0.894
_cons 0.571 0.162 3.53 ,.001 0.247–0.894
L3_MDAb L3_MDAc 0.528 0.077 6.82 ,.001 0.373–0.683 0.445
_cons 10.802 0.830 13.02 ,.001 9.141–12.463

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a
APM indicates anteroposterior movement; BLI, buccolingual inclination; coef, coefficient; DV, dependent variable; IV, independent variable;
MDA, mesiodistal angulation; OGM, occlusogingival movement; Std. Err., standard error.
b
Achieved tooth movement.
c
Predicted tooth movement.
* Stepwise regression analysis; significant at P , .05.

In the present study, the efficacy of occlusogingival did any type of attachment on the L3 mesiodistal
movement of the L1 and L3 was 43% and 60%, angulation (Table 5). Thus, clear aligners seem to lack
respectively (Table 5). The L1 and L3 extruded though sufficient control for maintaining incisor torque and
they were designed to intrude (Table 4). Relative canine angulation during anterior retraction, even with
extrusion caused by poor control and tipping of teeth power ridges or attachments.
into the extraction site during anterior retraction may This study had some limitations. First, although
account for these results.30 The L1 had an average of strict inclusion criteria were set in the present study,
12.30 6 5.208 more lingual crown torquing and the L3 there still might be some confounding factors, such as
had 10.33 6 8.138 more distal crown tipping (Table 4), vertical skeletal pattern variations. Second, when
which is consistent with a previous study.7 The power applying the RAL value in a specific case, anatomical
ridge is claimed to facilitate incisor torque control and features should also be considered, especially alve-
optimized attachments are supposed to improve olar bone width. Additionally, only Invisalign cases
control of canine tipping. Nevertheless, according to were included to reduce bias, and future studies on
the stepwise regression model, the power ridge had no the same topic may involve other brands of clear
significant effect on the L1 buccolingual inclination, nor aligners.

Figure 3. Flow chart for the RAL-based extraction treatment planning scheme in digital orthodontics.

Angle Orthodontist, Vol 93, No 4, 2023

RELATIVE ANCHORAGE LOSS UNDER RECIPROCAL ANCHORAGE 381

CONCLUSIONS 13. Upadhyay M, Yadav S, Nagaraj K, Patil S. Treatment effects

of mini-implants for en-masse retraction of anterior teeth in
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L4 extraction and 40% for L5 extraction in CAT. trolled trial. Am J Orthod Dentofacial Orthop. 2008;134(1):
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appropriate extraction treatment plan with improved 14. George SM, Campbell PM, Tadlock LP, Schneiderman E,
precision. Buschang PH. Keys to Class II correction: a comparison of 2
extraction protocols. Am J Orthod Dentofacial Orthop. 2021;
 The L1 had unwanted extrusion and lingual crown
159(3):333–342.
torquing, whereas the L3 had unwanted extrusion 15. Kim TK, Kim JT, Mah J, Yang WS, Baek SH. First or second
and distal crown tipping during anterior retraction; premolar extraction effects on facial vertical dimension.
power ridges or attachments had little effect on Angle Orthod. 2005;75(2):177–182.

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preventing this from occurring. 16. Wang Y, Yu H, Jiang C, et al. Vertical changes in Class I
malocclusion between 2 different extraction patterns. Saudi
Med J. 2013;34(3):302–306.
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Angle Orthodontist, Vol 93, No 4, 2023