Evaluation of SARDAC Technique During En-Masse

Retraction in Lingual
Orthodontics
Ahmed Kandil a, *, Sherif A. Al Kordy b , Dalia El Boghdadyc , Amr Labibb , Winfried Harzer d , Christoph Bourauel e

Department of Orthodontics, Misr International University, Cairo,

Egypt
Department of Orthodontics, Cairo University, Cairo, Egypt
Faculty of Dentistry, Cairo University, Egypt
Department of Orthodontics, University of Dresden, Dresden,
Germany
Department of Oral Technology, University of Bonn, Bonn, Germany
 Changing Landscape of Orthodontics

01 The risk of not keeping pace 02 Our profession is changing in a

with the new techniques and fast pace nowadays more than
customer needs are best ever before.
illustrated by the “Nokia” story.

03 The way we treat our patients 04 Nokia did not keep up with the
changes with every new smart phone companies like
invention, technique or even a iPhone and Samsung which
new software. eventually lead to Nokia been
overtaken by Microsoft.
Shift towards Customized and
Invisible Appliances
● The profession of orthodontics is shifting more
towards the customized and invisible appliances.

● Lingual orthodontics developed a lot over the last

decades to become able to treat most if not all
sorts of malocclusions with great accuracy.

● A relatively recent study comparing two

customized bracket systems, Incognito (Lingual)
and Insignia (Labial) found that the Incognito
treatment system was more efficacious than
Insignia in many aspects.

● However, not every clinician can gain access to a

fully customized digital lingual appliance.
 Importance of Skill in Using Over the Shelf
Lingual Brackets

01 Orthodontists frequently extract 02 Having enough knowledge and

the first premolars to correct skill to use over the shelf lingual
the protrusion in the anterior brackets to get satisfactory
segment, like in cases of class II clinical result is mandatory for
division 1 and bimaxillary any orthodontist who wants to
dentoalveolar protrusion. keep up with the changes in our
practice.
03 One of the most difficult issues 04
in lingual orthodontics is torque Applying proper biomechanics,
control during en masse with respect to the CR, is
retraction. essential to avoid undesirable
torque loss during anterior
segment retraction.
Biomechanical Differences between
Lingual and Labial Orthodontics
● Loss of torque control during maxillary anterior
segment retraction is more likely to occur
when using lingual orthodontic appliances
compared to labial orthodontics.
● Hence, it is very important to understand the
biomechanical differences between lingual and
labial orthodontics to achieve better treatment
outcomes.
 Introduction

Lingual tooth anatomy is

more versatile and
complex compared to the
01
labial
02 Changes in bracket
position can lead to
extensive and
unpredictable changes in
tooth position and torque
Vectors of forces are 03
directed lingually to the
center of resistance (CR) of
each tooth
Difficulties in
Torque Control
● Distance between the point of force application
and CR is different in lingual and labial
appliances
● This influences the magnitude of the moments
of forces leading to difficulty in torque control
Bodily Retraction

01 SARDAC technique utilizes TADS and lever arms for

space closure after extraction

02 Two methods for bodily retraction: applying a moment

at the bracket slot or using a lever arm

03 Temporary Anchorage Devices (TADS) provide absolute

anchorage for better control on tooth movement
 SARDAC Technique

SARDAC stands for

Skeletal Anchorage, Right
direction of the forces,
01
Absolute control of the
tooth movement
02 Introduced by Pablo
Echarri in 2012

Utilizes TADS and lever arms 03

of different lengths for
desired tooth movements in
lingual orthodontics
Determining Line of
Force Action

01 Proper alignment of lever arm and TAD with

the CR achieves en-masse retraction with
torque and vertical control

02 The height of the TAD and the length of the

lever arm determine the direction of the line
of force action

03 Line of force action affects torque and

vertical movement of the anterior segment
during en-masse retraction
Aim of the Study

The aim of the study was to test the

predictability of the SARDAC technique in
controlling torque and vertical movement of
the anterior segment during en-masse
retraction in lingual orthodontics.
Materials and methods study design

The Orthodontic Measurement and Simulation System (OMSS) was used for in vitro
evaluation of the SARDAC technique, following the protocols done by previous
studies.8−10

The CR of the frontal tooth segment was chosen to be 7 mm apical and distal to the
crest of the interproximal bone level between the central incisors, measured
perpendicular to the occlusal plane16-18 (that was 12 mm apical to the bracket slot).

Nine mm closing coil springs (Ortho Technology, USA) were used to apply the force
that was kept at 1.5 N per side.
Materials and methods
The torque and the vertical
movements acting on the
anterior segment were
recorded at 3 mm of
displacement during en-
masse retraction.

A control and six different

force setups were tested as
shown in Table 1.

In setup 1A (Fig. 1A), the

force was applied between
the 15 mm arm and the
para-median screw.

In setup 1B (Fig. 1B), the

force was applied between
the 15 mm arm and the inter
radicular screw.
In setup 1C (Fig. 1C), the force was applied between the 15 mm arm and the first molar bracket.

In setup 2A (Fig. 2A), the force was applied between the 12 mm arm and the para median screw.

In setup 2B (Fig. 2B), the force was applied between the 12 mm arm and the inter radicular screw.

In setup 2C (Fig. 2C), the force was applied between the 12 mm arm and the first molar bracket.

In the control setup (Fig. 3), the force was applied between the canine bracket and molar bracket.
 In setup 1A (Fig. 1A), the force
was applied between the 15 mm
arm and the para-median screw.
In setup 1B (Fig. 1B), the force was applied between the 15 mm arm
and the inter radicular screw.
In setup 1C (Fig. 1C),
the force was applied
between the 15 mm
arm and the first molar
bracket.
 In setup 2A (Fig. 2A), the force was
applied between the 12 mm arm and
the para median screw.
 In setup 2B (Fig. 2B), the force
was applied between the 12 mm
arm and the inter radicular screw.
In setup 2C (Fig. 2C), the force was
applied between the 12 mm arm and
the first molar bracket.
 In the control
setup (Fig. 3), the
force was applied
between the
canine bracket and
molar bracket.
 Each force
setup was The averages of
repeated five the readings
times, with a were used for
new coil spring the analysis.
used for each.
Orthodontic measurement and simulation system
evaluation
The Frasaco
model was
mounted on
the
Orthodontic
Measurement
and Simulation
System
(OMSS) (Fig.
4A), for
experimental
testing at the
Biomechanics
lab, Faculty of
Dentistry,
University of
Bonn,
The anterior segment of the cast was fixed by
two screws to the mobile part of the machine
which contained a sensor and motor,
connected to a computer.

The posterior segment of the cast was

attached to the nonmobile part of the machine.

The Nickel Titanium (NiTi) coil spring was

attached between the anterior and posterior
segments, then the machine was given the
order to start the simulation.
 The sensor recorded the direction and
the amount of forces applied and The computer recorded the direction of
accordingly the motor moved the anterior movement of the anterior segment in the
segment until the retraction force reached three planes of space every 0.01 mm.
zero denoting the end of the simulation.
Materials
The lingual brackets (Lingual Brackets, ORJ, China) with a 0.018
inch slot for the anterior teeth and a 0.022 inch slot for the posterior
teeth were bonded on the palatal side of the maxillary teeth of a
Frasaco model.
The Frasaco model was fabricated at the Biomechanics lab, Faculty of Dentistry,
University of Bonn, Germany.
A straight stainless-steel wire 0.43 × 0.64 mm (0.017”x0.025”) was customized in a
mushroom shaped arch form.
Two inter- radicular mini-screws of 10 mm length and 2 mm diameter (HUBIT, Korea) were
attached on each side of the arch, between the first and second molar teeth from the palatal
side at a distance of 7 mm from the gingival margin.

Another two mini-screws were attached lateral to the median palatine suture.15
The first premolar tooth with its bone on each side was then cut out from the model to allow for en-masse retraction.

Two multi-hooked lever arms (speed system Orthodontics, Canada) were welded together to create a 15 mm lever arm.

The new customized lever arms were welded to the wire distal to the lateral incisors bilaterally.

The anterior teeth were ligated together above the wire as one segment.

The first molar and second premolar on each side were also ligated together (Fig. 4B).

After finishing all the tests, the model was cut into two halves at the dental midline to create the illustrative figures.
Statistical Analysis in SPSS

● Statistical analysis was performed using SPSS (version 20)

● Quantitative variables were described using mean, standard deviation,
range, standard error, and 95% confidence interval of the mean
● The ShapiroWilk test of normality was used to test the normality
hypothesis of all quantitative variables
● Comparison with the control setup was carried out using Dunnett t test
(Table 2)
● All variables were found to be normally distributed, allowing the use of
parametric tests
One Way ANOVA and Bonferroni
Method
● One Way Analysis of Variance
(ANOVA) was used to test the
difference of means among all
setups
● Bonferroni method was used for
multiple comparisons (Tables 3)
● Significance level was considered at
P < 0.05
● Two tailed tests were assumed
throughout the analysis for all
statistical tests
RESULTS
RESULTS
RESULTS
RESULTS
DISCUSSION

Upon analyzing the resultant torque produced by each mechanical setup (Fig. 5),
the control setup where the force was applied between the canine bracket and
first molar bracket (Fig. 2B) showed the highest amount of torque loss because
the anterior point of force application (the canine bracket) was more coronal to
CR,5 compared to the lever arms.

This resulted in leaving only the rectangular wire in the bracket slot to counteract
the tendency for torque loss during retraction which was not enough. These
results were in agreement with Degushi et al.20
For the experimental setups, it was found that when the
posterior anchor unit was the same, the taller the lever
arm, the higher the palatal root torque produced.

Setup 1A showed higher palatal root torque than 2A,

similarly setup 1B showed higher palatal root torque than
2B and 1C was higher than 2C.

This was because when the length of the lever-arm increased, the
point of force application moved more apical away from CR
creating more palatal root torque.
 Group 1C (where the force was applied
from the 15 mm lever-arm to the first
molar tube) was the only one that
showed statistically significant difference
compared to the control group. These
findings correspond to the theory
mentioned by Aravind et al.21.
 The inter-radicular mini-
screw groups showed the
least palatal root torque
(Group 2B even showed
slight torque loss).
The steeper the line of force action in relation to the occlusal plane, the
higher the produced palatal root torque.

That was apparent in setup 1C which showed the highest palatal root
torque among all the groups, where the force was applied between the
15 mm lever-arm and the molar tube creating a steep line of force action
in relation to the occlusal plane.

This setup could be used when extreme torque control is needed during
retraction of the maxillary incisors like in the camouflage treatment of
class II division 2 cases after the extraction of the maxillary first
premolars.
 Regarding the vertical movements (Fig. 6), none of
the setups showed statistically significant difference
compared to the reference one, which could be due
to the increased effective stiffness of the wires in
lingual orthodontics as compared to labial
orthodontics because of the reduced arch perimeter
in the former leading to a better vertical control
compared to labial orthodontics.
Case report

A female patient aged 21 years old presented a visibly protruded and incompetent lips.

The chief complaint was that she felt that her front teeth were protruded.

The extraoral and intraoral photos (Fig. 7) showed a convex profile, incompetent lips, molar
and canine class I bilaterally, normal overjet and overbite.

However, the lateral cephalometric measurements (Fig. 8) showed very mild skeletal class 2
and proclined maxillary and mandibular anterior teeth along with protruded lips (Table 6).
Treatment objectives

The goal of the treatment was to correct

the protrusion in the lips and dentition by
extracting the four first premolars and en-
masse retraction using fixed lingual
orthodontic appliance and absolute
anchorage by mini-screws.
Treatment progress

A lingual appliance (Lingual brackets, ORJ, China) with bi-dimensional brackets

(Slot 0.018 inch for anterior teeth, 0.022 inch slot for posterior teeth) was used.

Lab Procedure: -

The lingual appliance was customized by combining Kommon base technique and
Hiro technique (Fig. 9).
Kommon base technique
● Kommon base is a precise bonding system for lingual orthodontic appliances.
It has a large base which provides excellent and accurate fit of the bracket on
the lingual tooth anatomy. It also provides increased bond strength due to its
increased surface area. Kommon base has a self- positioning shape so it
does not require transfer tray.24
Hiro technique

The Hiro system was created by Toshiaki Hiro and improved by Kyoto
Takemoto and Giuseppe Scuzzo.

In this system no special equipment was required.

The setup model was sectioned, aligned to the desired final occlusion.

Brackets were positioned on the set-up model with the help of a full-sized
rigid rectangular arch wire 0.017 × 0.025 inches.25
Steps

Accurate rubber base impressions were taken then disinfected, washed and dried with air.

The models were poured with hard plaster.

Setup was fabricated on a simple hinge articulator. The teeth were separated with its roots using dental stones
and discs. The setup was fabricated into the final occlusion anticipated after the treatment with the maxillary and
mandibular first premolars removed then the setup was finished with wax.

An ideal mushroom shaped arch wire following the lingual arch form was using 0.017 × 0.025 inch stainless steel
wire. This wire later was used during the retraction phase.
The lingual brackets were attached to the wire using elastic modules. On the cast, the position of each bracket
was adjusted at the center of the tooth and at the gingival one third in order not to interfere with the occlusion or
cause speech difficulties.

Once each bracket position was adjusted, the wire with the attached brackets were removed from the cast.

The model then was soaked in water and liquid soap for 4 hours. The soap forms a layer of separation that is
thinner and easier to remove than the dental separating medium.

The cast was left to dry on a towel for 30 minutes then the lingual surfaces of the teeth were gently dried with a
tissue.
The desired areas of the lingual surfaces of the teeth were then covered with
flowable composite with medium consistency and left uncured to form the
Kommon base. The idea is to have most of the lingual surface covered.
 Bond was applied to the bracket bases followed by the
same flowable composite resin used for the Kommon bases.
The wire with the brackets was seated again in place on the
cast. The composite then was light cured. Now we have a
Kommon base customized with the needed torque, tip and
buccolingual position of each tooth
Bonding Technique

1. At the visit of bonding, the wire with the engaged brackets were removed from
the cast and the excess composite was trimmed from the Kommon bases.
The elastic modules were cut by a hot instrument. The brackets with their
bases were separated from the arch wire and the bases were cleaned by the
air water syringe and alcohol to remove any soap attached to the base. By
reaching this step, the brackets were ready for bonding.
2. At the time of bonding, a proper cheek and tongue retractors were used. The
lingual surfaces of the teeth were etched, the etch was rinsed then the teeth
surfaces were dried. A thin layer of bond was added to the teeth surfaces
then cured.
4. A thin layer of bond and flowable composite were added to the bracket bases
(Not extending to the area covering the incisal edges of the anterior teeth to
facilitate their removal after bonding as they are used only to guide the
brackets to their precise position).
5. The brackets were bonded one by one to ensure accurate positioning of each
bracket and meticulous removal of excess composite before curing.
6. The composite covering the incisal edges was removed by a finishing stone.
The composite on the occlusal surfaces of the molars was left to act as bite
raisers to protect the maxillary lingual brackets from the occlusal forces.
7. An initial mushroom shaped 0.12-inch NiTi wire was applied and engaged
using elastic modules.
Follow up visits:

1. The patient was seen on monthly basis to upgrade the wires.

2. The leveling and alignment stage of the upper and lower arches was
considered completed when a 0.017 × 0.025-inch stainless-steel arch wire
could be placed passively.
3. Once leveling and alignment stage was completed, the patient was referred to
perform a pre-retraction lateral cephalometric radiograph.
4. Two mini-screws (Hubit,Korea) of 10 mm in length were placed at the palatal
bone between the maxillary first and second molars to be used for direct
anchorage. Another two mini-screws of the same type were inserted in the
mandibular buccal bone between the first and second molars to be used for
indirect anchorage
5. After insertion of the mini-screws, the patient was referred to extract the four
first premolars.
6. En masse retraction of the lower arch was started first to create enough overjet
for the retraction of maxillary anterior teeth using a power chain attached from
the first molar tubes to the canine brackets bilaterally.
7. For the maxillary arch, two power arms (14 mm in length) were soldered to the
main arch wire between the lateral incisor and the canine bilaterally. The power
arms were fabricated from 0.9 mm dental stainless-steel orthodontic wire to be
rigid enough to resist deformation when the force was applied (Fig. 10).
8. The maxillary six anterior teeth were secured together by a ligature wire above
the main arch wire
10. NiTi coil springs were extended from the screw head to the hooks bilaterally.
10 A force of 150 N was applied for each side. A force gauge was used to
maintain the force constant all over the retraction phase.
11. Retraction was considered finished when the canines contacted the second
premolars.
12. Following retraction of the anterior segment, the patient was referred to the
same radiology center to acquire the final lateral cephalometric radiograph to
assess the inclination of anterior teeth as well as the changes in soft tissue
post-retraction.
13. Custom made buttons were fabricated and bonded as needed on the labial
side to be used for settling using 1/8 inch intra oral elastics.
● In the extra oral and intraoral photos (Fig. 12), it is possible to see an
improvement in the profile.
● The lips became more competent and were retracted.
● The molar and canine relations were maintained class I on both sides.
● Finally, the protrusion of the anterior teeth was corrected and that was the
chief complaint.
● Normal over jet and over bite were maintained and the retraction of the
maxillary anterior teeth was completed without loss of torque.
 The antero-posterior skeletal relation
The cephalometric analysis (Fig. 13
was maintained the same. FMA angle
and Table 6) indicated retraction of
was reduced by 2 degrees. The
both upper and lower lips in relation
maxillary and mandibular incisors
to E-plane and increase in the
were retroclined and the interincisal
nasolabial angle.
angle was increased.
Recommendations
Precise Kommon base customization and fabrication is mandatory
to minimize or eliminate the need for finishing at the end of
treatment.

Proper isolation during bonding is necessary to minimize debonding

of the lingual brackets.

Follow the prescribed sequence of wires by the manufacturer to

allow for passive insertion of the rigid stainless steel arch wire before
retraction.

During retraction phase, use the largest possible rigid stainless steel
arch wire to avoid bowing in the dental arches and avoid the
development of lateral open bite.
 Always adopt en-masse
retraction with lingual
Use light force during orthodontic appliances
because esthetics during the
retraction (150 N per
treatment is a major concern
side for the maxillary for the patient and
arch) to avoid development of a space
unnecessary loss of between the canines and
torque. incisors is not acceptable

During retraction of the

maxillary anterior teeth
using lingual orthodontic
appliance, use rigid
power arms to translate
the point of force
application apical to
CRE.
Limitation

It is an in vitro study
which could not
simulate all the clinical
factors controlling
tooth movement.
Conclusion

The SARDAC technique is predictable in controlling the torque and vertical

movement during en-masse retraction in lingual orthodontics.

The amount of difference in the torque produced due to changing the lever arm length
and the position of the posterior anchor units, were not statistically significant; except for
the setup including the 15 mm lever arm, and the first molar bracket as the posterior
anchor unit.

This setup produced the highest palatal root torque.

Setup 2C showed the highest amount of extrusion while setups 1A and 2A showed the
highest amounts of intrusion.
REFERENCES
1. Vaid Nikhilesh R. Digital Technologies in Orhodontics − An update. Seminars in Orthodontics; 2018.
2. G.Awad Mirna, Skander Elouse, Ashley Smith, Vaid Nikhilesh, Makki Laith, Ferguson
Donald J. Accuracy of Digital Predictions with CAD/CAM Labial and Lingual Appliances:
A retrospective Cohort Study. Seminars in Orthodontics; 2018.
3. Kim J, Kim S, Kook Y, Chung K, Nelson G. Analysis of lingual en masse retraction combining a C-lingual retractor and a palatal plate. Angle Orthodont. 2011:81.
4. Sifakakis I, Pandis N, Makou M, Eliades T, Katsaros C, Bourauel C. A comparative
assessment of torque generated by lingual and conventional brackets. Eur J Orthodont.
2013 Jun 1;35(3):375–380.
5. Liang W, Rong Q, Lin J, Xu B. Torque control of the maxillary incisors in lingual and labial
orthodontics: A 3-dimensional finite element analysis. AJO-DO. 2009;135(3):316–322.
6. Das SK. Simplified manual setup and customization by resin core indirect bonding
technique: Lingual orthodontics on your own. J Indian Orthod Soc. 2016;50(4):23–32.
7. Scuzzo G, Takemoto K. Biomechanics and comparative biomechanics in Invisible
Orthodontics- Current Concepts and Solutions in Lingual Orthodontics. Quintessence
Germany;. 2003:55-59 p.
8. Geron S, Romano R, Brosh T. Vertical forces in labial and lingual orthodontics applied
on maxillary incisors- a theoretical approach. Angle Orthodont. 2004;74(2):195–201.
9. Smith RJ, Burstone CJ. Mechanics of tooth movement. AJO-DO. 1984;85(4):294–307.
10. Gjessing P. A universal retraction spring. J Clin Orthodont. 1994;28:222–242.
11. Hong R, Heo J, Ha Y. Lever-arm and mini-implant system for anterior torque control during retraction in lingual orthodontic treatment. Angle Orthodont. 2005;75(1):129–141.
12. Nanda R, Uribe F, Yadav S. Temporary Anchorage Devices in Orthodontics. Elsevier; 2020.
13. Pablo Echarri. Ortodontica. y microimplantes, Tecnica completa paso a paso. Ripano S.A
(Madrid); 2012.
14. Rafi Romano. Lingual and Esthetic Orthodontics. Quintessence United Kingdom.
2011:429–460.
15. Fayed M, Pazera P, Katsaros C. Optimal sites for orthodontic mini-implant placement
assessed by cone beam computed tomography. Angle Orthodont. 2010;80(5):939–951.
16. Vanden Bulcke MM, Burstone CJ, Sachdeva RCL. Dermaut LR. Location of the centers
of resistance for anterior teeth during re- traction using the laser reflection technique.
AJO-DO. 1987;91:375–384.
17. Yoshida N, Jost- Brinkmann PG, Koga Y, Mimaki N, Kobayashi K. Experimental evaluation of initial tooth displacement center of resistance and center of rotation under
the influence of an orthodontic force. AJO-DO. 2001;120:190–197.
18. Penderson E, Isidor F, Gjessing P, Andersen K. Location of center of resistance for maxillary anterior teeth measured on human autopsy material. Eur J Orthodont. 1991;13
(6):452–458.
19. Bourauel C, Drescher D, Their M. An Experimental apparatus for the simulation of
three-dimensional movements in orthodontics. Biomed Eng. 1992;14(5):371–378.
20. Deguchi T, Terao F, Aonuma T, Kataoka T, Sugawara Y, Yamashiro T. Outcome assessment of lingual and labial appliances compared with cephalometric analysis, peer
assessment rating, and objective grading system in Angle Class II extraction cases.
Angle Orthodont. 2023;85(3):400–407. 201.
21. Aravind M, Shivaprakash G, Ramesh G. Torque control in lingual orthodontics. Orthodont Art Pract Dentofac Enhance. 2013;14(1):186–196.
22. Park JH, Kook YA, Kojima Y, Yun S, Chae JM. Palatal en-masse retraction of segmented maxillary anterior teeth: A finite element study. The Korean Journal of. Orthodontics. 2019;49(3):188.
23. Feng Y, Kong WD, Cen W, Zhong Zhou X, Zhang W, Li
THANKS