الفهرس 
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Abstract
The current study was a Randomized Controlled Trial (RCT) that was performed to investigate three-dimensionally the effects of en-masse anterior retraction using the labial biocreative therapy technique on the skeletal, dentoalveolar and soft tissue levels as compared with the lingual biocreative therapy. In addition, the effect of treatment on the oral health related quality of life (OHRQoL) and patient satisfaction from treatment was evaluated.
A sample size of 24 patients was selected and randomly divided into two groups, twelve each; group 1, Labial Biocreative therapy group (n=12, 20.5 + 2.1 years) and group 2; Lingual Biocreative therapy group (n=12, 21.1 + 2.5 years). All patients were in the full permanent dentition stage (excluding third molars) and had upper dentoalveolar protrusion in need for extraction of the upper first premolars and retraction of the maxillary anterior teeth with maximum anchorage.
In the labial biocreative therapy group, only the upper six anterior teeth were bracketed and retracted en-masse by applying retraction force (200 gm per side) from Nickel Titanium (Ni-Ti) closing coil springs between 10-mm retraction hooks crimped anteriorly to the archwire distal to the lateral incisors and bracket head miniscrews posteriorly. An overlay reverse curve wire (0.016 × 0.022-inch NiTi) was ligated anteriorly (one-point contact) onto the wire at the midline between the two central incisors.
In the lingual biocreative therapy group, En-masse retraction of the six anterior teeth was accomplished using a lingual retractor bonded on to the lingual surface of the upper six anterior teeth, C-palatal plate fixed near the median palatal suture with 3 microscrews, and Nickel Titanium (Ni-Ti) closing coil springs to apply a force of 200 g per side (total 400 g) directly from the C-plate to the lingual retractor. Retraction hooks (10 mm long) were located between the central and lateral incisors.
For both groups, Retraction was stopped when a class I canine relationship was achieved, and a good incisor relationship was obtained. Cone beam computed tomography scan was taken for every patient before starting the
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retraction procedure and immediately after retraction using iCAT® CBCT scanner. A custom made three-dimensional analysis, whose intra and interobserver reliability were assessed, was performed to measure the skeletal, dento-alveolar and soft tissue effects in the two groups. Patient satisfaction from treatment and the effect of treatment on the OHRQoL was evaluated using a questionnaire (Appendix III) at the end of the retraction phase in both groups.
Paired t-test was performed to compare between the pre- and post-treatment CBCT measurements within the labial and lingual groups of all the variables measured. For not normally distributed variables, Wilcoxon signed rank test was applied. Independent sample t test was performed for comparing the mean treatment changes between the two groups. For the OHIP-TSQ, frequency and percent values were calculated for every question for both groups. Independent sample t test was conducted to assess differences between the two groups. Fischer exact test was then used to compare the answers of the two groups to each question separately. from the results of statistical analysis, and within the limitations of this study, the following conclusions could be drawn:
1. Using the labial biocreative therapy with a 10-mm anterior retraction hook, anterior retraction with good torque control, vertical control, and anchorage control were achieved.
2. Using the lingual biocreative therapy, good vertical control, and anchorage control were achieved. However, regarding torque control, anterior retraction was predominantly controlled tipping.
3. In the lingual group, clockwise rotation of the entire anterior segment occurred caused by the clockwise moment of the retraction force passing incisal to the centre of resistance of the anterior segment. This caused significant distal tipping and intrusion of the canine. Furthermore, significant differences between the two groups were found for the labiolingual inclination of the central and lateral incisors. The inclination of the
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incisor was reduced more (i.e. more lingual tipping, mean difference 5.85 + 1.85˚) occurred in the lingual group as compared to the labial group.
4. Significant improvement in the facial profile was achieved in both groups. Significant upper and lower lip retraction as well as reduction of the nasolabial angle and inter-labial gap were evident in both groups.
5. Oral impacts were commonly experienced during both labial and lingual biocreative therapies with no statistically significant differences between the two groups. Patients treated with labial biocreative therapy were more annoyed by the appearance of the appliance and were more likely to be embarrassed compared to those treated by the lingual biocreative technique. Both groups had similar levels of treatment satisfaction.
6. The mean retraction duration for the labial group was 12.3 + 2.72 months and 11.93 + 3.17 months in the lingual group. No statistically significant differences in duration of the retraction phase were found between the two groups.
7. Both labial and lingual biocreative therapy techniques offered the following advantages:
o Effective en-masse retraction of the anterior segment. This avoids unesthetic spaces distal to the lateral incisors and shortens treatment time. o Effective vertical control of the anterior segment and avoiding bite deepening during retraction. o Good anchorage control (No anchorage loss). o Single point force application, ability to control force magnitude and line of action. o No friction is introduced, which allows precise calibration and accurate tooth movements. o Posterior teeth are not bonded or banded. The occlusion is maintained. o Patients reported no adverse effects on speech, oral hygiene measures, and quality of life in both groups.