THE ‘ROLLER COASTER EFFECT’ IN
PREMOLAR EXTRACTION CASES: CLEAR
ALIGNERS VS. STRAIGHT-WIRE APPLIANCE
Yuran Qian1, Zhenxing Tang2, Yao Chen1, Wanzhong Song3, Zhihe Zhao1, Wei Zheng4,
Yu Li1,
European Journal of Orthodontics,
Volume 47, Issue 1,
January 2025
INTRODUCTION
• In orthodontic treatment with premolar extractions, controlling torque with the anterior teeth
during retraction has always been of interest to orthodontists because retraction sometimes
induces adverse effects such as failure of anterior torque expression or extrusion of the
anterior teeth.
• When using heavy force on a flexible archwire to retract anterior teeth leads to a condition
known as “Roller coaster effect (RCE)”
• retroclination and extrusion of the incisors
• distal tipping of the canines
• mesial tipping of the posterior teeth
• posterior open bite due to premature contact of the anterior teeth.
CAUSES:
• Applying heavy elastic force either vertical or anteroposterior on a light archwire
( round NITI) wire
• Anchorage loss
• Improper ligation method
PREVENTION:
• Avoid heavy forces during initial appointments
• Anchorage preparation early in the treatment
• Proper ligation technique using ligature wire
• Space closure on heavy rectangular stainless steel wire only
• The RCE is unfavorable, which not only ruins the treatment results, but also largely
prolongs the treatment duration.
• As the RCE manifests with bending of the dental arch around the extraction site upon the
closing force, it could be quantified with the intersection angle between the anterior
occlusal plane (AOP) and the posterior occlusal plane (POP).
AIM
• The study aimed to propose a straightforward
indicator to quantify the severity of RCE and
to comparatively investigate the RCE in
premolar extraction cases treated with SWA or
CAT based on this indicator.
• Investigate the potential influencing factors
for possible association of RCE in the
extraction cases treated with CAT.
MATERIALS AND METHODS
• Study examined cases involving extraction of bilateral first premolars in the maxillary
or mandibular arch, treated by the same orthodontist in the Department of Orthodontics,
West China Hospital of Stomatology.
• The cases were brought into the SWA group or the CAT group according to the
technique used.
• Permission to perform this study was approved by the Ethics Committee of the West
China Hospital of Stomatology, Sichuan University.
• Informed consent was obtained from all the subjects before the inclusion procedure.
• The sample size calculation was based on the primary outcome post-treatment bending
angle of occlusal plane (BAOP) values.
• And the size determination was based on a pilot investigation, which included 10 maxillary
and 10 mandibular dentitions receiving SWA treatment.
• A minimal sample size of 16 and 18 was needed for the maxillary and mandibular groups,
respectively, with type I error at 0.05, and type II error at 0.20 (statistic power at 0.8),
based on two-sample t-test.
Inclusion criteria:
(i) adult patients (age ≥18 years before treatment and ≤35 years after treatment) who
finished orthodontic treatment in 2018–2023
(ii) full permanent dentition except the third molars before treatment
(iii) protrusion treated with extraction of bilateral first premolars in the upper and/or
lower arch (some cases had both arches included, while other cases had only the upper or
lower arch included)
(iv) pre- and post-treatment lateral cephalograms available. Notably, in the SWA group,
the ‘post-treatment’ time point was set at finish of the entire treatment, while in the CAT
group, it was set at completion of the first series of aligners (less than three sets of aligners
left before refinement).
Exclusion criteria:
(i) severe crowding (more than 8 mm) in the premolar extraction dental arch
(ii) mini-screws, transpalatal arch, or other additional anchorage devices used during
treatment
(iii) presence of severe alveolar bone atrophy or apical root resorption either before or
after treatment
(iv) premature termination of the first-phase CAT treatment due to severe off-aligner or
other reasons.
• Patients in the SWA group received Damon Q brackets (Ormco, California, USA).
• The teeth were aligned and leveled by changing the archwires sequentially, and the space
was closed using sliding mechanics on stainless-steel archwires of 0.018 × 0.025 inch.
• The archwires were bent with reverse-curve of Spee for the lower dentition and exaggerated
compensating curve for the upper dentition.
• Patients in the CAT group received Invisalign (Align Technology, California, USA) or
Angelalign (EA Medical Instruments, Shanghai, China).
• The dental set-up of each case was routinely adjusted by the orthodontists to finish with
overbite of 0 mm, a tactic potentially mitigating the RCE.
• The attachments and staging were given by the technicians with minor modifications by the
orthodontist when appropriate.
• The first-phase was routinely asked to finish within 50–60 aligners.
• All the patients changed aligners every 10 days, with a daily wearing time of at least 20
hours.
• Pre- and post-treatment lateral cephalograms were taken using a standardized approach.
• The landmarking and measurement were conducted by the same operator using the
SmartOrtho software (Sichuan University, Chengdu, China) in duplicates with 1-month
interval.
• The two measurements were averaged for further analysis.
In this study, a novel indicator was proposed to quantify the ‘roller coaster effect’, namely the
BAOP (Fig. 2). On the cephalograms, the line crossing the mesial contact point of the second
premolar and the edge of the central incisor represents the AOP; the line crossing the mesial
contact point of the second premolar and the distal contact point of the first molar, represents
the POP. Thus, the occlusal intersection angle between AOP and POP is referred to as BAOP
(°), which is usually an obtuse angle. Self-evidently, smaller post-treatment BAOP indicates
more severe RCE.
STATISTICAL ANALYSIS
• SPSS Statistical 21.0 (Statistical Package for the Social Sciences, SPSS Inc., Chicago, IL,
USA) was used to analyze the data.
• Intra-class correlation coefficient (ICC) test was used to evaluate the repeatability of the
measurer. Shapiro-Wilk and Levene testes were used to assess the normality and variance
homogeneity.
• An independent t-test was used to compare indicators between the SWA and CAT groups.
• Multiple linear regression was used to analyze the potential influencing factors of the post-
treatment BAOP in the CAT group.
• For all the tests, P < .05 was set to be statistically significant.
RESULTS
DISCUSSION
• In protrusion and premolar extraction cases, the unwelcome ‘roller coaster effect’ ruins the
treatment outcome and prolongs the treatment duration.
• For the sample collection, the premolar extraction cases with non-severe crowding were
included.
• With regard to the termination points of observation in this study, the post-treatment time
point in the CAT group was set as completion of the first series of aligners but not end of the
entire treatment.
• The reason was that once severe RCE occurred in the first-phase of CAT, lengthy refinement
would be almost inevitable, and mini-screws or even archwires may well be utilized for
rescuing the RCE.
• In contrast, prevention or alleviation of the RCE was incorporated in the leveling and
space closure processes in SWA, with no distinct ‘first phase’ of space closure such as in
CAT. Therefore, it was reasonable and feasible to compare the first-phase duration in CAT
with the overall treatment duration in SWA in this study, as no additional anchorage
devices were used in either of the groups.
• The RCE can be attributed to the space-closing force that does not directly pass the
resistance centers of the anterior and posterior segments, and consequently a moment
leading to inward rotation of the two segments.
• The clear aligner has much lower stiffness compared to the stainless-steel wire [7, 11],
which makes it less resistant to the force bending the arch.
• In addition, the thick stainless-steel wire fixed in the bonded brackets can create effective
counter-moment, while clear aligners are removable, which weakens its control of the
teeth.
• during the SWA treatment, corrective approaches like reverse-curve bending of the
archwire can be applied at ease to mitigate the RCE.
• however, such tactic of appliance activation does not work as well in the aligner, as its
elastic limit is much lower.
• Hence, lack of appliance activation potential has been underscored as a limitation of clear
aligners compared to fixed appliances .
• the POP remained unchanged in the both dentitions in the CAT group, and the decrease of
BAOP was all attributed to steepening of the AOP (P < .01).
• Although non-extraction CAT cases demonstrated similar performance in correcting deep
bite compared to SWA [18], overbite correction with clear aligners were not as effective as
that achieved with fixed appliances in premolar extraction cases .
• timely use of mini-screw anchorage should be considered for anterior vertical control in
premolar extraction CAT cases to prevent or mitigate the RCE .
• the mandibular canine crown length was positively correlated with the post-CAT mandibular
BAOP, indicating that longer mandibular canine crown may mitigate the mandibular RCE.
Crown length affects the area wrapped by the clear aligner, which in turn affects the force
exerted on the teeth to control tooth movement. Moreover, the canines may serve the pivot in
leveling of the mandibular dental arch.
• When the canine crowns are shorter, the aligners may have weaker control over the anterior
teeth, potentially leading to more severe RCE.
• It therefore underscores the importance of gingivectomy before intraoral scanning, when
a patient has gingival hyperplasia leading to short clinical crown, especially in the
canines.
CRITICAL APRAISAL
• Firstly, all the measurements were performed on two-dimensional cephalograms with intrinsic
inaccuracy.
• Secondly, the cases that couldn’t complete the first-phase aligner treatment due to terrible off-
tracking were not included in the sample, which would underestimate the severity of RCE in
the CAT group to some extent. Thirdly, only 6 potential variables were involved in the
multiple regression analysis due to the sample size.
REVIEW OF LITERATURE
TREATMENT OUTCOME COMPARISON OF INVISALIGN VS
FIXED APPLIANCE TREATMENT IN FIRST PREMOLAR
EXTRACTION PATIENTS
AIM: This study compared the dentitional changes after Invisalign and conventional orthodontic
treatment with 4 first premolar extractions.
Methods: This retrospective study included 57 patients whose orthodontic treatment involved
the extraction of 4 first premolars because of bialveolar protrusion.
A total of 27 patients were treated with Invisalign (mean age, 25.5 ± 5.2 years) and 30 patients
with the fixed appliance (mean age, 24.4 ± 5.8 years).
• The angular and linear changes of the maxillary and mandibular central incisors, second
premolars, first molars, and second molars were measured from the recordings on the basis of
the lateral cephalograms taken before and after treatment.
• The angular changes of the canines and second premolars were measured using panoramic
radiographs.
• Results:
• The overbite and interincisal angle increased significantly in the Invisalign group compared
with in the conventional fixed appliance group (P <0.05).
• The maxillary central incisors showed increased lingual tipping in the Invisalign group (P
<0.05), whereas there was no statistically significant difference in the angular change of the
mandibular incisors between groups (P >0.05).
• The maxillary first and second molars showed mesial tipping in the Invisalign group (P
<0.05). The maxillary second premolars, first and second molars, and the mandibular
second molars showed mesial movement in the Invisalign group (P <0.05).
Conclusions:
• The Invisalign group showed more statistically significant lingual tipping of the maxillary
central incisors, distal tipping of the maxillary canines, and mesial tipping of the maxillary
first and second molars after maximum retraction of the anterior teeth compared with the
fixed appliance group.
• AIM: The objective was to compare the root parallelism in extraction cases treated with
clear aligners vs. those treated with fixed appliances by measuring the differences per
extraction site and to access the root-movement control capacity of both orthodontic
appliances.
• METHODS: A retrospective study was conducted on cases in which the first premolars
were extracted, treated by clear aligner appliance (“Invisalign” system, 28 patients) or
fixed appliance (30 patients).
• The angulations of the tooth axis (canines, the second premolars, the first molars, and the
second molars) were measured to analyze and compare the difference in root parallelism
between the two orthodontic appliances.
• The percentage of root parallelism between the canine and second premolar in both groups
had no significant difference.
• the fixed appliance might have a greater range in root angulation adjustment than the aligner.
• In the angulation categories, the aligner mainly showed root apical divergence, while the
fixed appliance mainly showed root apical convergence.
• The dental crown of the molars was mainly non tipping in both groups, but the dental crown
of the maxillary molars had a tendency toward mesial inclination.
Conclusion:
• The same root parallelism and root inclination were obtained in tooth extraction cases whether
treated by clear aligners or fixed appliances. This study provides clinicians with more
information on the performance of clear aligners and fixed appliances.
CONCLUSION
[Link] is proposed as a straightforward indicator to quantify the ‘roller coaster effect’ in
premolar extraction cases, which can be used in future relevant studies.
2. In premolar extraction cases, CAT undergoes more severe ‘roller coaster effect’ at
completion of its first-phase treatment compared to SWA at the end of its treatment, both in the
maxillary and mandibular dentitions. Particular attention should be paid to timely enhanced
anterior vertical control in such cases treated with CAT.
3. Longer mandibular canine crown may mitigate mandibular ‘roller coaster effect’ in CAT,
underscoring the necessity of gingivectomy to manage gingival hyperplasia before intraoral
scanning.
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