bioengineering

Article
Investigation of Forces and Moments during Orthodontic Tooth
Intrusion Using Robot Orthodontic Measurement and
Simulation System (ROSS)
Corinna L. Seidel * , Julian Lipp, Benedikt Dotzer , Mila Janjic Rankovic, Matthias Mertmann,
Andrea Wichelhaus and Hisham Sabbagh

Department of Orthodontics and Dentofacial Orthopedics, University Hospital, LMU Munich, Goethestrasse 70,
80336 Munich, Germany; [email protected] (J.L.); [email protected] (M.J.R.);
[email protected] (M.M.); [email protected] (A.W.);
[email protected] (H.S.)
* Correspondence: [email protected]

Abstract: The Robot Orthodontic Measurement and Simulation System (ROSS) is a novel biomechan-
ical, dynamic, self-regulating setup for the simulation of tooth movement. The intrusion of the front
teeth with forces greater than 0.5 N poses a risk for orthodontic-induced inflammatory root resorption
(OIIRR). The aim was to investigate forces and moments during simulated tooth intrusion using ROSS.
Five specimens of sixteen unmodified NiTi archwires and seven NiTi archwires with intrusion steps
from different manufacturers (Forestadent, Ormco, Dentsply Sirona) with a 0.01200 /0.01400 /0.01600
wire dimension were tested. Overall, a higher wire dimension correlated with greater intrusive forces
Fz (0.01200 : 0.561–0.690 N; 0.01400 : 0.996–1.321 N; 0.01600 : 1.44–2.254 N) and protruding moments Mx
(0.01200 : −2.65 to −3.922 Nmm; 0.01400 : −4.753 to −7.384 Nmm; 0.01600 : −5.556 to −11.466 Nmm)
during the simulated intrusion of a 1.6 mm-extruded upper incisor. However, the ‘intrusion efficiency’
parameter was greater for smaller wire dimensions. Modification with intrusion steps led to an
overcompensation of the intrusion distance; however, it led to a severe increase in Fz and Mx , e.g.,
Citation: Seidel, C.L.; Lipp, J.; Dotzer, the Sentalloy 0.01600 medium (Dentsply Sirona) exerted 2.891 N and −19.437 Nmm. To reduce the
B.; Janjic Rankovic, M.; Mertmann, risk for OIIRR, 0.01400 NiTi archwires can be applied for initial aligning (without vertical challenges),
M.; Wichelhaus, A.; Sabbagh, H.
and intrusion steps for the vertical levelling of extruded teeth should be bent in the initial archwire,
Investigation of Forces and Moments
i.e., 0.01200 NiTi.
during Orthodontic Tooth Intrusion
Using Robot Orthodontic
Keywords: nickel-titanium; NiTi archwires; initial levelling and aligning; intrusion; intrusion
Measurement and Simulation System
steps; orthodontic materials; biomechanical orthodontic simulation; orthodontic tooth movement;
(ROSS). Bioengineering 2023, 10, 1356.
https://doi.org/10.3390/
force control
bioengineering10121356

Academic Editor: Yanqi Yang

Received: 18 October 2023

1. Introduction
Revised: 22 November 2023 The orthodontic intrusion of the front teeth with fixed appliances can be necessary to
Accepted: 23 November 2023 correct deep bites [1]; yet, orthodontically induced inflammatory root resorptions (OIIRRs)
Published: 25 November 2023 are the most undesired side effect [2] with an incidence up to 90% during treatment with
fixed appliances [3–7]. A recent systematic review summarized how the incidence and
severity of OIIRR correlate with high forces, tooth intrusion, the application of torque,
the retraction of the front teeth as well as orthodontic treatment with enhanced duration,
Copyright: © 2023 by the authors.
premolar extractions, or long distances of tooth movement [2]. Furthermore, OIIRRs were
Licensee MDPI, Basel, Switzerland.
shown to correlate with genetic predisposition [8] and the adaptability of tissue [9–12].
This article is an open access article
distributed under the terms and
Moreover, the maxillary front teeth are susceptible to OIIRRs [13–16]. Adequate forces and
conditions of the Creative Commons
moments during orthodontic tooth movement (OTM) have to be differentiated clearly and
Attribution (CC BY) license (https://
are dependent on several factors like (I) tooth type and the size of the root surface (incisors,
creativecommons.org/licenses/by/ canines, premolars, molars), (II) the type of tooth movement (tipping, translational, torque),
4.0/). (III) the duration of force application (continuous, intermittent as well as IV) and age and

Bioengineering 2023, 10, 1356. https://doi.org/10.3390/bioengineering10121356 https://www.mdpi.com/journal/bioengineering

Bioengineering 2023, 10, 1356 2 of 18

health condition [1]. While axial and short-term forces of up to 300 Newtons (N) can be
compensated, forces of solely 1 N can lead to OIIRR if applied non-axially and for a longer
duration [17]. Reitan et al. defined forces for each tooth type depending on the type of tooth
movement varying between 20 centi Newtons (cN) for the extrusion of the front teeth and
245 cN for the translational movement of canines toward the end of treatment [18]. Further,
a moderate force application of 10–50 cN was shown to be more effective, while leading to
fewer side effects [19–21]. Intrusive forces induce the apical compression of the periodontal
ligament, which is associated with enhanced risk for OIIRR. Faltin et al. showed that
continuous forces of 50 cN applied during the intrusion of premolars can lead to OIIRR [22].
In accordance with histological studies [18–23], orthodontic forces used for tooth intrusion
should range between 0.1 and 0.3 N [1]. Orthodontic tooth intrusion can be performed
during levelling and aligning with standard nickel-titanium (NiTi) archwires [24] or with
modified NiTi archwires and intrusion steps [25]. In daily practice, orthodontists can modify
wires using cold forming with pliers or heat treatment using a direct electric resistance
heater, such as the Memory-MakerTM (Forestadent, Pforzheim, Germany) [26]; however,
the quality of the steps depends on the individual manual and technical accuracy. Heat
treatment with a furnace using defined annealing temperatures and annealing durations for
the thermal programming of NiTi archwires is preferred to ensure comparable experimental
conditions [27].
Forces and moments during OTM have been intensively studied, e.g., using the
three-point bending test [27–30]. However, due to its limited transferability to clinical
in vivo situations, the three-point bending test is mainly used for orthodontic material
science [31]. Hence, several new biomechanical simulation setups have been developed in
recent decades. Bourauel et al. presented the Orthodontic Measurement and Simulation
System (OMSS), a software-based setup with two force–moment-sensors and the ability
to investigate force-controlled orthodontic tooth movements three-dimensionally [32],
which has been used to address several research questions [33,34]. Friedrich et al. first
described an in vivo setup to investigate forces exerted by orthodontic appliances using a
force–moment-sensor adapted to a separable bracket, though without reproducible results
and limited dimensionality [35]. Wichelhaus and Sander et al. developed a biomechanical
three-dimensional test setup with two force–moment sensors and a thermal chamber,
that was able to analyse forces and moments considering four degrees of freedom [36].
Fuck et al. designed the Robotic Measurement System (RMS), which was able to analyse
forces and moments during initial orthodontic tooth movement regarding six degrees of
freedom [37]. The Orthodontic Simulator (OSIM) was invented by Badawi et al. with
14 force–moment sensors for each tooth; yet, the use of several sensors led to feedback
effects, and solely one-dimensional deviations could be analysed [38]. The Orthodontic
Force Tester (OFT) was implemented by Chen et al. using two sensors to measure the
forces and moments affecting adjacent teeth during space closure; however, this setup also
faced problems with side effects, e.g., activation in the distal direction led to unwanted
tooth deflections and, therefore, potentially distorted measurement forces [39,40]. Perrey
et al. used OMSS to analyse the impact of different bracket types and archwire qualities
on forces and moments during OTM [41,42]. Further, Finite Element Methods (FEM) were
established using the digital simulation of OTM without mechanical test setups [43,44]. The
conventional mechanical test setups were compared to FEM by Hayashi et al., presenting
comparable results for both techniques [45]. Lately, the Robot Orthodontic Measurement
and Simulation System (ROSS), consisting of a precision robot, a force–torque sensor, a
thermal chamber, and a test tooth, was introduced to investigate the forces and moments
exerted during intrusive, rotational, and angular tooth movement [24].
The aim of this study was to investigate forces and moments during the simulated
intrusion of extruded front teeth using ROSS exerted by sixteen commercially available NiTi
archwires with different wire dimensions and the following two therapeutic approaches:
vertical levelling using (I) standard NiTi archwires and (II) modified NiTi archwires with
intrusion steps. To ensure comparability, we developed an intrusion step shape setting
Bioengineering 2023, 10, 1356 3 of 18

Bioengineering 2023, 10, 1356 3 of 18

archwires with intrusion steps. To ensure comparability, we developed an intrusion step
shape setting tool using Computer-Aided Design (CAD). The overarching goal was to ex-
perimentally identify wires exerting the most adequate forces and moments for the ortho-
tool using Computer-Aided Design (CAD). The overarching goal was to experimentally
dontic intrusion of the front teeth to reduce the risk of OIIRR.
identify wires exerting the most adequate forces and moments for the orthodontic intrusion
of the front teeth to reduce the risk of OIIRR.
2. Materials and Methods
2.1.
2. Robot Orthodontic
Materials and MethodsMeasurement and Simulation System
2.1. Robot Orthodontic
The Robot Measurement
Orthodontic and Simulation
Measurement System System (ROSS) was developed
and Simulation
in the
The Biomechanics Laboratory
Robot Orthodontic of the Department
Measurement of Orthodontics
and Simulation and Dentofacial
System (ROSS) was developed Or-
thopedics
in of the LMULaboratory
the Biomechanics Universityof Hospital [24]. It consists
the Department of a precision
of Orthodontics androbot KUKA KR
Dentofacial Or-
5-sixx R650
thopedics of (KUKA
the LMU Roboter GmbH,
University Germany,
Hospital Gersthofen),
[24]. It consists of aan FTS Nano
precision robot17 KUKA
SI-12-0.12
KR
force–torque
5-sixx sensor (ATI
R650 (KUKA Industrial
Roboter GmbH, Automation,
Gersthofen, USA, North Carolina,
Germany), Apex),17a test
an FTS Nano tooth
SI-12-0.12
on a high-strength
force–torque sensor titanium alloy Kavo
(ATI Industrial Typodont
Automation, model
Apex, NC,adapted
USA), ato SAM
test tooth® Axiosplit
on a high- ®

mounting plates (SAM Präzisionstechnik GmbH, Germany,

strength titanium alloy Kavo Typodont model adapted to SAM Axiosplit mounting ®
Gauting) (Figure ® 1a) and a
thermal
plates chamber
(SAM with a temperature
Präzisionstechnik GmbH,controller REX-C100(Figure
Gauting, Germany) PID (RKC Instrument
1a) and a thermal Inc., Ja-
cham-
pan,with
ber Ibaraki), ensuring test
a temperature conditions
controller of 37.0 PID
REX-C100 ± 0.5(RKC
°C [24]. An upperInc.,
Instrument central incisor
Japan, (11)
Ibaraki),
ensuring
was modifiedtest conditions
with bonded of 37.0 ± 0.5
active ◦ C [24]. An
self-ligating, and upper centralwire
a straight incisor (11) with
bracket was modified
an MBT
with bondedand
prescription active self-ligating,
0.022″ and aForestadent,
slot (Bioquick, straight wire bracket with
Germany, an MBT
Pforzheim) prescription
applying pas-
and 00 slot (Bioquick, Forestadent, Germany, Pforzheim) applying passive pre-bent
sive 0.022
pre-bent 0.021″ × 0.025″ steel wire for the positioning of the bracket. The spatial coor-
0.021 00 × 0.02500 steel wire for the positioning of the bracket. The spatial coordinate sys-
dinate system was used for the test sensor; hence, x-, y-, and z-axis presented the mesi-
tem wasorovestibular,
odistal, used for the test
andsensor;
verticalhence,
axis ofthethex-, y-, andslot.
bracket z-axis presented
Since the mesiodistal,
the intrusion of 11 was
orovestibular, and vertical
investigated, mainly axis of the
Fz (positive bracket
values slot. Sinceforces;
= intrusive the intrusion
negativeof 11 was investigated,
values = extrusive
mainly Fz (positive
forces) and values
Mx (positive = intrusive
values forces;
= retruding negativenegative
moments; values =values
extrusive forces) andmo-
= protruding Mx
(positive
ments) were values = retruding
of interest, whilemoments;
data in allnegative values
translational and = rotational
protrudingdirections
moments) werewere of
col-
interest,
lected. while data in all translational and rotational directions were collected.

Figure 1.
Figure 1. Visualisation
Visualisation of
of the
the high-strength
high-strength titanium
titanium alloy
alloy Kavo
Kavo Typodont
Typodont model
model adapted
adaptedto toSAM
SAM®
®

Axiosplit®® mounting plates (SAM Präzisionstechnik GmbH, Gauting, Germany) and the test tooth
Axiosplit mounting plates (SAM Präzisionstechnik GmbH, Gauting, Germany) and the test tooth in
in (a) an extruded position and (b) intruded position after orthodontic tooth intrusion using Sental-
(a)
loyan extruded
0.012″ position and
NiTi archwire (b) intruded
(Dentsply Sirona,position after
York, PA, orthodontic
USA) tooth intrusion
with intrusion using Sentalloy
steps. Graphical presen-
0.012 00 NiTi archwire (Dentsply Sirona, York, PA, USA) with intrusion steps. Graphical presentation of
tation of (c) the intrusion step template and (d) the CAD design for the fabrication of the tool. The
(c) the intrusion
counterpart step
of the template
shape and
setting (d)isthe
tool notCAD
showndesign
here.for thetool
The fabrication of thewas
temperature tool.controlled
The counterpart
via an
internal
of Ni-CrNi
the shape thermocouple
setting tool is not located in close
shown here. proximity
The to the sample
tool temperature was(position is marked
controlled by the
via an internal
white arrow
Ni-CrNi in (c)).
thermocouple located in close proximity to the sample (position is marked by the white
arrow in (c)).
2.2. Experimental Setup and Measurement Simulation
2.2. Experimental Setup and Measurement Simulation
The test setup comprised the following two stages:
The test setup comprised the following two stages:
1. Position the test tooth adapted to the force–torque sensor in the ideal position accord-
1. ingPosition
to thethe test tooth
KAVO adapted
typodont to the
model force–torque
using a silicone sensor in the The
impression. idealdeflection
position accord-
of the
test tooth in the extruded, pathologic starting position is obtained (extrusionofdis-
ing to the KAVO typodont model using a silicone impression. The deflection the
test tooth in the extruded, pathologic starting position
tance: 1.6 mm), and the test archwire is inserted (Figure 1a). is obtained (extrusion distance:
2. The1.6 mm), and the
automatic andtest archwire
gradual is inserted
transfer of the (Figure 1a).
test tooth using force control (pre-defined
2. in The automatic and gradual transfer of the test
LabView) toward its final position is achieved, which tooth using force control
is defined (pre-defined
as forces and mo-
in LabView) toward its final position is achieved, which is
ments approaching zero (Figure 1b). As the measured intrusion distance did notdefined as forces and
moments approaching zero (Figure 1b). As the measured intrusion distance did
not reach 1.6 mm for each investigated wire, a reference distance was defined as
0.8 mm for statistical evaluation to ensure the data points for each wire and the
Bioengineering 2023, 10, 1356 4 of 18

comparability of data. The LabView software (LabView 2012 Version 12.03f3) by the
manufacturer National Instruments (NI, Austin, TX, USA) was used for closed-loop
force control using virtual instruments (VI) and processes based on mathematical
algorithms. The force–torque sensor measured forces and moments, continuously
adding up to thousands of data points for each sample. Afterward, the test wire was
removed, and the sensor was reset for the next test series.
Five wire samples from each of the following NiTi archwires were tested in inde-
pendent test cycles: 0.01200 /0.01400 /0.01600 Biostarter (Forestadent, Germany, Pforzheim),
0.01200 /0.01400 /0.01600 Align XF (Ormco, Brea, CA, USA), 0.01200 /0.01400 /0.01600 Copperloy
(Dentsply Sirona, York, PA, USA), 0.01400 /0.01600 Sentalloy Light (Dentsply Sirona, York,
PA, USA); 0.01200 /0.01400 /0.01600 Sentalloy Medium (Dentsply Sirona, York, PA, USA),
0.01400 /0.01600 Sentalloy Heavy (Dentsply Sirona, York, PA, USA). Moreover, five additional
wire samples of all Sentalloy wires were modified with intrusion steps and tested. To ensure
the reproducibility of the intrusion step, an intrusion step template was designed using
CAD and manufactured using stainless steel (Figure 1c,d). The intrusion step was 1.2 mm
high and 9 mm wide in accordance with the width of the test tooth. The heat treatment
of the NiTi wire was performed using the Heraeus K 750/1 furnace (Heraeus GmbH,
Germany, Hanau) with a chamber temperature of 550 ◦ C and an annealing duration of
16 min. To ensure the exact annealing temperature inside the tool, a Ni-CrNi thermocouple
was applied to the tool in very close proximity to the wire.

2.3. Statistics
Descriptive statistics were generated using SPSS Statistics 26 (IBM, USA, NY, Armonk)
and Microsoft Excel 2016 (Microsoft Corporation, USA, Washington, Redmond). Graphical
presentation was performed using OriginProm Version 2020 (Origin-Lab Corporation,
Northampton, MA, USA). A power analysis was performed to verify an adequate, quan-
titative sample size. Variance analyses were performed using the Kruskal–Wallis test.
Differences were considered significant with p-values ≤ 0.05.

3. Results
3.1. Comparison of Different Wire Dimensions of NiTi Archwires by the Same Manufacturer
without Intrusion Steps
As for Forestadent wires, the initial intrusive forces (Fz ) increased with larger wire
dimensions with a peak of 1.578 N for Biostarter 0.01600 archwires (Table 1). Accordingly,
higher wire dimensions presented greater initial protruding moments (Mx ) with a maxi-
mum of −7.261 Nmm for Biostarter 0.01600 archwires (Table 1). Similar intrusion distances
were seen for Biostarter 0.01200 and 0.01400 archwires, while 0.01600 archwires reached higher
distances of 1.281 mm.
Bioengineering 2023, 10, 1356 5 of 18

Table 1. Initial intrusive forces Fz [N], initial protruding moments Mx [Nmm] and the achieved
intrusion distances [mm] are given for all measured straight NiTi archwires and for modified NiTi
archwires with intrusion steps.

Fz [N] Mx [Nmm] z [mm]

Manufacturer Wire and Dimension [Inch]
MV MV MV
SD SD SD
0.561 −2.649 1.089
Biostarter 0.01200
±0.079 ±0.268 ±0.134
1.074 −4.753 1.049
Forestadent Biostarter 0.01400
±0.068 ±0.174 ±0.067
1.578 −7.261 1.281
Biostarter 0.01600
±0.105 ±0.391 ±0.085
0.690 −3.922 0.985
AlignXF 0.01200
±0.035 ±0.159 ±0.059
1.321 −7.384 1.133
Ormco AlignXF 0.01400
±0.103 ±0.482 ±0.040
2.180 −11.466 1.141
AlignXF 0.01600
±0.261 ±0.634 ±0.146
1.126 −4.810 0.998
Copperloy 0.01400
±0.081 ±0.497 ±0.030
Dentsply Sirona
1.853 −5.556 1.031
Copperloy 0.01600
±0.506 ±3.748 ±0.086
0.621 −3.524 0.956
Sentalloy 0.01200 medium
±0.073 ±0.425 ±0.052
0.996 −5.011 0.937
Sentalloy 0.01400 light
±0.071 ±0.448 ±0.186
1.175 −5.623 1.058
Sentalloy 0.01400 medium
±0.072 ±0.574 ±0.051
Dentsply Sirona 1.292 −6.627 1.130
Sentalloy 0.01400 heavy
±0.083 ±0.048 ±0.042
1.442 −6.781 1.135
Sentalloy 0.01600 light
±0.127 ±0.937 ±0.172
1.637 −9.609 1.087
Sentalloy 0.01600 medium
±0.328 ±0.871 ±0.015
2.254 −10.047 1.177
Sentalloy 0.01600 heavy
±0.174 ±1.046 ±0.130
1.066 −7.264 2.205
Sentalloy 0.01200 medium with IS
±0.112 ±0.857 ±0.265
1.319 −7.083 2.226
Sentalloy 0.01400 light with IS
±0.121 ±1.200 ±0.048
1.722 −10.342 2.572
Sentalloy 0.01400 medium with IS
±0.195 ±3.985 ±0.050
Dentsply Sirona 2.102 −13.731 2.473
Sentalloy 0.01400 heavy with IS
±0.065 ±2.884 ±0.108
2.029 −10.235 2.505
Sentalloy 0.01600 light with IS
±0.132 ±1.647 ±0.067
2.891 −19.437 2.691
Sentalloy 0.01600 medium with IS
±0.227 ±6.198 ±0.083
2.981 −15.887 2.620
Sentalloy 0.01600 heavy with IS
±0.186 ±0.891 ±0.148
MV = mean value, SD = standard deviation, N = Newton, Nmm = Newton millimeter, mm = millimeter,
IS = intrusion step.
Bioengineering 2023, 10, 1356 6 of 18

With regard to Ormco wires, increasing intrusive forces, protruding moments, and
intrusion distances were found for AlignXF archwires with an increasing wire diameter
(Table 1). AlignXF 0.01600 demonstrated the second-highest intrusive forces (Fz = 2.180 N)
and the highest protruding moments (Mx = −11.466 Nmm) in comparison to other manufac-
turers. The differences between the smallest and greatest wire dimensions were 1.490 N for
intrusive forces, 7.544 Nmm for protruding moments and 0.156 mm for intrusion distances,
which is in accordance with other manufacturers.
Regarding Dentsply Sirona wires, initial intrusive forces, protruding moments, and
intrusion distances were greater with higher wire dimensions (Table 1). Copperloy 0.01600
archwires presented higher intrusive forces (Fz = 1.853 N), protruding moments
(Mx = −5.556 Nmm), and intrusion distances (z = 1.031 mm) compared to Copperloy
0.01400 . Sentalloy 0.01200 medium archwires reached mean initial forces Fz of 0.621 N, while
Sentalloy 0.01600 heavy showed the highest initial intrusive forces of 2.254 N, which is
three times higher compared to the Sentalloy 0.01200 medium. Similarly, the protruding
moments of Sentalloy 0.01600 heavy archwires reached almost three times higher values
(Mx = −10,047 Nmm) compared to the Sentalloy 0.01200 medium. The intrusion distances
were enhanced with a higher wire dimension except for Sentalloy 0.01200 medium with
greater distances than Sentalloy 0.01400 light. The maximum difference between the intru-
sion distances was 0.240 mm, which is similar to other manufacturers.
Taken together, Biostarter 0.01600 (Forestadent) archwires reached the highest intrusion
distances, while the initial intrusive forces were second lowest compared to 0.01600 archwires
by other manufacturers (Figure 2). Biostarter 0.01200 archwires presented low mean initial
forces (Fz = 0.561 N) and moments (Mx = −2.649 Nmm) with similar curve progressions
for the five investigated wires (Figure 2a,b). An accumulation of the measured values
was found at the end of the test sequence since only marginal tooth movement was seen
(Figure 2a,b). The initial intrusive forces of Biostarter 0.01400 archwires were almost twice
as high as 0.01200 archwires (Fz = 1.074 N), and the force curves deviated further from
each other (Figure 2c). Yet, similar curve shapes were seen for the protruding moments
of Biostarter 0.01400 archwires with a mean initial moment of Mx = −4.753 Nmm and a
cluster toward the end of the measurement, indicating the short-term inversion of the
direction of motion (Figure 2d). The initial intrusive forces of Biostarter 0.01600 archwires
(Fz = 1.578 N) were 0.5 N higher than those of 0.01400 archwires and 1 N larger compared
to 0.01200 archwires, respectively (Figure 2e). The force curve progressions were similar,
with moderate diversification and greater flattening with a cumulation of values toward
the end (Figure 2e). Mean protruding moments of Mx = −7.261 Nmm were found for
Biostarter 0.01600 archwires, and the curve shapes were steeper with distinct curvatures and
a clustering of data at the end (Figure 2f).
Bioengineering 2023, 10, 1356 7 of 18
Bioengineering 2023, 10, 1356 7 of 18

Figure 2. Initial intrusive forces Fz [N] in relation to the intrusion distance z [mm] (a,c,e) and the
Figure 2. Initial intrusive forces Fz [N] in relation to the intrusion distance z [mm] (a,c,e) and the
protruding moments Mx [Nmm] in relation to the intrusion distance z [mm] (b,d,f) are given for
protruding
Forestadentmoments
BiostarterMNiTi
x [Nmm] in relation
archwires withouttointrusion
the intrusion distance
steps and z [mm] wire
all measured (b,d,f) are given
samples. for
Each
Forestadent Biostarter NiTi archwires without intrusion steps and all
sample (1–5) is presented using a colour scheme given next to the figures. measured wire samples. Each
sample (1–5) is presented using a colour scheme given next to the figures.
Bioengineering 2023, 10, 1356 8 of 18

3.2. Comparison of Tooth Intrusion Results with 0.01200 , 0.01400 and 0.01600 NiTi Archwires
without Intrusion Steps
Considering 0.01200 NiTi archwires, no significant differences were found between
wires by different manufacturers regarding initial intrusive forces and the gradient of the
initial forces along the reference distance of 0.8 mm (Figure 3a). However, AlignXF 0.01200
showed
Bioengineering significantly
2023, 10, 1356 higher initial protruding moments compared to Biostarter 0.012 9 of00 18

(p = 0.004) as well as the greater ascent of protruding moments (p = 0.022) (Figure 3b).
These initial differences of around 1 Nmm converged toward the end of the reference
and variations between the configuration as declared by the manufacturer (‘heavy’ vs.
distance (Figure 3b). ‘medium’ vs. ‘light’) and the actual force/moment output by the archwire.

Figure 3. Initial intrusive

Figureforces Fzintrusive
3. Initial [N] (a,c,e) and
forces protruding
Fz [N] momentsmoments
(a,c,e) and protruding Mx [Nmm] (b,d,f)
Mx [Nmm] regarding
(b,d,f) regarding
the reference distance of 0.8 mm are given for all measured 0.012″ NiTi archwires and (a,b) 0.014″
the reference distance of 0.8 mm are given for all measured 0.01200 NiTi archwires and (a,b) 0.01400
NiTi archwires (c,d) and 0.01600 NiTi archwires (e,f) without intrusion steps. The averaged curves
with superimposed best fit straight lines are given.
Bioengineering 2023, 10, 1356 9 of 18

Regarding 0.01400 NiTi archwires, most wires by different manufacturers presented

no differences regarding the initial intrusive forces, and no significant differences were
found considering the ascent of initial forces along the reference distance. Only signifi-
cant lower initial intrusive forces were seen for Sentalloy light 0.01400 compared to both
Sentalloy heavy 0.01400 (p = 0.006) as well as AlignXF 0.01400 (p = 0.005) (Figure 3c). The
initial protruding moments of AlignXF 0.01400 archwires were significantly higher com-
pared to Sentalloy light 0.01400 (p = 0.016), Copperloy 0.01400 (p = 0.013) and Biostarter
0.01400 (p = 0.002) (Figure 3d). Considering the gradient of the protruding moments, some
couples of investigated 0.01400 wires were largely congruent along the reference distance,
e.g., AlignXF 0.01400 and Sentalloy 0.01400 heavy. Biostarter 0.01400 , Copperloy 0.01400 and
Sentalloy 0.01400 presented similarities at the beginning of the experiment; however, these
varied toward the end. Some wires presented significant differences considering the ascent
of protruding moments, e.g., Copperloy 0.01400 and AlignXF 0.01400 (p = 0.002) as well as
Biostarter 0.01400 and AlignXF 0.01400 (p = 0.008).
As for 0.01600 NiTi archwires by different manufacturers, significantly lower initial
intrusive forces were solely found for Sentalloy light 0.01600 compared to AlignXF 0.01600
(p = 0.032) and Sentalloy heavy 0.01600 (p = 0.013) (Figure 3e). Considering the gradient
of initial intrusive forces along the reference line, most wires presented no differences.
However, significant differences were seen comparing Biostarter 0.01600 with AlignXF
0.01600 (p = 0.034) and Sentalloy heavy 0.01600 (p = 0.016) depicted by the force curve of
Biostarter 0.01600 intersecting those of AlignXF 0.01600 and Sentalloy heavy 0.01600 after a
0.65 mm intrusion distance (Figure 3e). Greater variety was found regarding the initial
protruding moment and its gradient along the reference line. Align XF presented the
highest initial protruding moment (Mx = −11,466 Nmm), which was significantly higher
compared to Biostarter 0.01600 (p = 0.024), Copperloy 0.01600 (p = 0.004), and Sentalloy light
0.01600 (p = 0.004). The curves of the protruding moments presented great differences up to
5 Nmm at the beginning and converged toward the end (Figure 3f). Significant differences
regarding the ascent of the protruding moments were found for AlignXF 0.01600 compared
to Biostarter 0.01600 (p = 0.007), Copperloy 0.01600 (p = 0.034) and Sentalloy light 0.01600
(p = 0.038).

3.3. Comparison of Forces and Moments of Straight NiTi Archwires Compared to Archwires with
Intrusion Steps
The same measurements as those presented above for straight wires were performed
for archwires with intrusion steps; however, this was conducted solely for the following
wires of the manufacturer Dentsply Sirona: Sentalloy 0.01200 medium, Sentalloy 0.01400 light,
Sentalloy 0.01400 medium, Sentalloy 0.01400 heavy, Sentalloy 0.01600 light, Sentalloy 0.01600
medium and Sentalloy 0.01600 heavy. Overall, archwires with intrusion steps presented
higher initial intrusive forces Fz and protruding moments Mx compared to archwires
without steps considering the same wire dimension (Table 1) (Figure 4). The increase in
the force ranged from 0.3 N (Sentalloy 0.01400 light) up to 1.2 N (Sentalloy 0.01600 medium).
Notably, the highest increase in the protruding moment was found for Sentalloy 0.01600
medium with intrusion steps (Mx = −19.437 Nmm), which were twice as high as Sentalloy
0.01600 medium without steps (Mx = −9.609 Nmm). Notably, the modification of NiTi
archwires with intrusion steps was accompanied by greater intrusion distances z compared
to NiTi archwires without steps (Table 1, Figure 4). The achieved intrusion distances z for
all measured NiTi archwires with intrusion steps ranged between 2.205 mm and 2.620 mm
and were even higher than the aspired intrusion distance of 1.6 mm (Table 1).
 Bioengineering 2023, 10, 1356 10 of 18

Bioengineering 2023, 10, 1356 10 of 18

NiTi archwires (c,d) and 0.016″ NiTi archwires (e,f) without intrusion steps. The averaged curves
with superimposed best fit straight lines are given.

Figure 4.
4. Initial
Initialintrusive
intrusiveforces
forcesFzF[N] in relation to the intrusion distance z [mm] (a) and the pro-
Figure z [N] in relation to the intrusion distance z [mm] (a) and the
truding moments Mx [Nmm] in relation to the intrusion distance z [mm] (b) are given for Dentsply
protruding moments Mx [Nmm] in relation to the intrusion distance z [mm] (b) are given for Dentsply
Sirona Sentalloy 0.012″, 0.014″ and 0.016″ medium NiTi archwires with and without intrusion steps.
Sirona Sentalloy 0.01200 , 0.01400 and 0.01600 medium NiTi archwires with and without intrusion steps.
Table 2. Presentation of the force and moment gradient along the intrusion reference distance of 0.8
According to straight wires without steps, archwires with intrusion steps showed
mm for selected unmodified archwires (Biostarter 0.012″, Sentalloy 0.016″ heavy) and NiTi arch-
greater initial intrusive forces with an increasing wire dimension. Furthermore, a higher
wires without intrusion steps (Sentalloy 0.012″ medium, Sentalloy 0.016″ heavy). Intrusive forces
configuration
along the z-axisas(Fdeclared by the manufacturer (‘heavy’ vs. ‘medium’ vs. ‘light’) regarding
z [N]) and protruding moments along the x-axis are given (Mx [Nmm]).
the same wire dimension was accompanied by an increase in the force and moment in most
cases (Tables 1 and0.016″
2). Sentalloy Sentalloy 0.012″ 00 Medium Sentalloy 0.016″ Heavy
Biostarter 0.012″ Sentalloy Heavy heavy 0.014 showed 00
significantly greater initial forces
Intrusion with Intrusion Steps with
and moments compared to Sentalloy light 0.014 (Fz : p = 0.001; Mx : p = 0.027) as well asIntrusion Steps
Distance Fz [N] Sentalloy medium [N] 00 compared to Sentalloy
Fz 0.016 Fz [N] light 0.01600 archwiresF(F z [N]
z : p = 0.04; Mx :
00
[mm] MV p = 0.003), while Sentalloy
MV heavy 0.016 solely MV presented significantly higher MV initial forces
00
SD compared to Sentalloy SD light 0.016 (p = 0.014).SD Interestingly, archwires with SDa smaller wire
0.561 dimension but higher
2.254 configuration (‘heavy’ vs.
1.066 ‘medium’ vs. ‘light’) sometimes
2.981 showed
0.000 greater forces or moments compared to archwires with larger wire dimensions yet a lower
±0.079 ±0.174 ±0.112 ±0.186
00
0.475 configuration: Sentalloy
1.887 0.014 in configuration 1.032 ‘heavy’ presented higher2.775 initial forces and
0.025 moments compared to Sentalloy 0.01600 light (Fz = 2.102 N vs. 2.029 N; Mx = −13.731 Nmm
±0.066 ±0.126 ±0.075 ±0.110
vs. −10.235 Nmm) and the Sentalloy 0.01200 medium showed higher initial moments
0.453 1.860 1.021 2.739
0.050 compared to Sentalloy 0.014 light (Mx = −7.264 Nmm vs. −7.083 Nmm). The highest
±0.044 ±0.105 ±0.119 ±0.090
protruding moment for the measured archwires with intrusion steps was found for the
0.444 Sentalloy 0.01600 ‘medium’
1.796 (Mx = −19.437 Nmm) and was even larger2.773
1.023 than compared
0.075
±0.035 to Sentalloy 0.016±0.143
00 ‘heavy’ (M = −15.887 Nmm). ±0.080 This might be explained ±0.081by the great
x
0.416 standard deviation 1.778
from the initial protruding 0.994moment of the Sentalloy 2.818
0.016 ‘medium’
0.100
±0.036 (±6.198 Nmm) and ±0.219 ±0.088
variations between the configuration as declared by the manufacturer±0.065
0.406 (‘heavy’ vs. ‘medium’
1.508vs. ‘light’) and the actual 0.953 force/moment output by 2.705
the archwire.
0.150
±0.045 Compared to ±0.142
NiTi archwires without steps ±0.091presenting initial intrusive ±0.139forces Fz be-
1.396 0.01200 ) and 2.25 N (Sentalloy
0.384 tween 0.56 N (Biostarter 0.933 0.01600 heavy), NiTi archwires with
2.584
0.200 00
±0.019 intrusion steps presented
±0.095 intrusive forces F between
±0.072
z 1.07 N (Sentalloy ±0.132 medium)
0.012
00
0.323 and 2.98 N (Sentalloy
1.1480.016 heavy) (Table 2). 0.837Regarding the force and moment 2.411 gradient,
0.400
±0.026 forces and moments ±0.056decreased during the dynamic ±0.084 intrusion of the test tooth ±0.091regardless of
0.133 a modification with intrusion
0.607 steps (Table 2).0.686 2.180
0.800
±0.016 ±0.030 ±0.111 ±0.104
distance Mx [Nmm] Mx [Nmm] Mx [Nmm] Mx [Nmm]
[mm] MV MV MV MV
Bioengineering 2023, 10, 1356 11 of 18

Table 2. Presentation of the force and moment gradient along the intrusion reference distance of 0.8
mm for selected unmodified archwires (Biostarter 0.01200 , Sentalloy 0.01600 heavy) and NiTi archwires
without intrusion steps (Sentalloy 0.01200 medium, Sentalloy 0.01600 heavy). Intrusive forces along the
z-axis (Fz [N]) and protruding moments along the x-axis are given (Mx [Nmm]).

Sentalloy 0.01600 Sentalloy 0.01200 Medium Sentalloy 0.01600 Heavy

Biostarter 0.01200
Intrusion Heavy with Intrusion Steps with Intrusion Steps
Distance Fz [N] Fz [N] Fz [N] Fz [N]
[mm]
MV MV MV MV
SD SD SD SD
0.561 2.254 1.066 2.981
0.000
±0.079 ±0.174 ±0.112 ±0.186
0.475 1.887 1.032 2.775
0.025
±0.066 ±0.126 ±0.075 ±0.110
0.453 1.860 1.021 2.739
0.050
±0.044 ±0.105 ±0.119 ±0.090
0.444 1.796 1.023 2.773
0.075
±0.035 ±0.143 ±0.080 ±0.081
0.416 1.778 0.994 2.818
0.100
±0.036 ±0.219 ±0.088 ±0.065
0.406 1.508 0.953 2.705
0.150
±0.045 ±0.142 ±0.091 ±0.139
0.384 1.396 0.933 2.584
0.200
±0.019 ±0.095 ±0.072 ±0.132
0.323 1.148 0.837 2.411
0.400
±0.026 ±0.056 ±0.084 ±0.091
0.133 0.607 0.686 2.180
0.800
±0.016 ±0.030 ±0.111 ±0.104
Mx [Nmm] Mx [Nmm] Mx [Nmm] Mx [Nmm]
distance
[mm] MV MV MV MV
SD SD SD SD
−2.649 −11.466 −7.264 −15.887
0.000
±0.268 ±0.634 ±0.857 ±0.891
−2.755 −11.918 −7.266 −16.832
0.025
±0.465 ±0.427 ±0.932 ±0.554
−2.599 −11.122 −7.055 −16.263
0.050
±0.517 ±0.455 ±0.565 ±0.670
−2.552 −10.286 −6.672 −15.128
0.075
±0.265 ±0.331 ±0.839 ±0.968
−2.570 −9.584 −6.562 −14.046
0.100
±0.419 ±0.801 ±0.982 ±1.484
−2.362 −9.470 −6.189 −14.843
0.150
±0.322 ±0.224 ±0.690 ±0.417
−2.061 −8.310 −6.394 −14.253
0.200
±0.245 ±0.814 ±0.756 ±1.512
−1.773 −7.226 −5.781 −12.222
0.400
±0.285 ±0.664 ±1.024 ±0.960
−0.141 −2.604 −4.326 −10.722
0.800
±0.126 ±0.851 ±0.973 ±0.716
Bioengineering 2023, 10, 1356 12 of 18

4. Discussion
In the present study, forces and moments during simulated initial orthodontic tooth
intrusion were investigated using the force-controlled biomechanical test standard ROSS.
The overarching goal of the present investigations was to compare NiTi archwires from
different manufacturers, material compositions, and diameters in order to identify arch-
wires that provide suitable forces and moments. Furthermore, the effect of intrusion steps
of 1.2 mm on the modulation of the force was studied.
As for the methodology, the focus of the experimental setup was the establishment
of a self-regulating dynamic test stand based on a robotic system. Extensive program
development work was performed to enable this automatic test setup comprising, e.g.,
the identification of ‘feedback parameters’. This included the allocation of a movement
amplitude to the attached forces and moments, which was used by the robot to move the
tooth in order to reduce forces and moments most effectively. As the tooth morphology
determines the resistance to the movement, these feedback parameters must be evaluated
for each tooth type. The parameters found in our test stand might be helpful for future
studies using this software for the advancement of this type of experimental setup. An
upper incisor was chosen for clinical reasons as this tooth type was found to have an
enhanced risk for OIIRR [13–16], and upper incisors often require vertical levelling at
the beginning of the treatment, e.g., in deep bite cases with elongated upper incisors [1].
Thermal treatment was used for the modification of wires with intrusion steps at a height
of 1.2 mm. This height was chosen since a minimal value of 1.2 mm could be achieved
in clinical practice using pliers and heat treatment by, e.g., using the Memory-MakerTM
(Forestadent, Pforzheim, Germany) [26]. The archwires were manually positioned into the
stainless steel intrusion tool, and the lid was bolted afterward according to a published
technique [27]. The height of the intrusion step was subsequently verified using a caliper.
To enable the comparability of data and data points for each wire, a reference distance of
0.8 mm (50% of the intrusion distance) was chosen. The averaged curves of the measured
five samples for each wire with superimposed best-fit straight lines were chosen to allow
better comparability of the gradient. After an initial drop, the slope of the force, as well as
the moment curves, presented a rather linear progression (Figure 2). The initial drop for
the first movement interval (0.5 mm) is a typical irregularity, as found in other biomechan-
ical simulation setups [46]. Moreover, the superimposed best-fit straight lines suggest a
rather linear correlation between the force, moment, and intrusion distance, which is only
applicable to a limited degree.
Regarding initial forces, we found that 0.01200 NiTi archwires without steps exerted
intrusive forces ranging from 0.561 N to 0.690 N and showed no significant differences
regarding the manufacturers. The modification of 0.01200 NiTi archwires with a 1.2 mm
intrusion step increased the intrusive force up to 1.066 N. Regarding 0.01400 NiTi archwires,
intrusive forces ranging from 0.996 N (Sentalloy light 0.01400 , Dentsply Sirona) to 1.321 N
(AlignXF 0.01400 , Ormco) were found with significant differences between the manufac-
turers. The modification of 0.01400 NiTi archwires enhanced initial forces up to 1.319 N
(Sentalloy light 0.01400 , Dentsply Sirona) and 2.102 N (Sentalloy heavy 0.01400 , Dentsply
Sirona). Whereas most recent studies investigating orthodontic forces are not comparable
with our results due to their biomechanical setup [32–34,41,47], Perrey et al. detected initial
forces of up to 3.5 N ranging between 0.2 N and 3.5 N for 0.01400 archwires and a 0.02200
slot [41], which is partly in accordance with our results, yet, with a greater range. Con-
sidering 0.01600 NiTi archwires, we detected initial forces ranging from 1.442 N (Sentalloy
light 0.01600 , Dentsply Sirona) to 2.254 N (Sentalloy heavy 0.01600 , Dentsply Sirona) with
significant differences between manufacturers. In accordance with a previous study using
ROSS, it was found that 0.01600 NiTi archwires produced excessive force when applied
for the levelling of a tooth extruded by 1.6 mm [24]. Step bends applied in 0.01600 NiTi
archwires led to force levels between 2.029 N (Sentalloy light 0.01600 , Dentsply Sirona) and
2.981 N (Sentalloy heavy 0.01600 , Dentsply Sirona), which could lead to severe OIIRR when
applied clinically [22].
Bioengineering 2023, 10, 1356 13 of 18

In our study, the force was applied anterior to the centre of resistance, resulting
in a protruding moment around the x-axis, which was accompanied by a palatal root
torque [1,31]. The initial protruding moments Mx measured in our study ranged between
−2.65 Nmm (Biostarter 0.01200 , Forestadent) and −11.466 Nmm (AlignXF 0.01600 , Ormco) for
unmodified NiTi archwires. The lowest moment values were seen for 0.01200 NiTi archwires
ranging from −2.65 Nmm (Biostarter 0.01200 , Forestadent) to −3.922 Nmm (AlignXF 0.01200 ,
Ormco). A 0.01400 wire dimension showed higher values from −4.753 Nmm to (Biostarter
0.01400 , Forestadent) to −7.384 Nmm (AlignXF 0.01400 , Ormco) and 0.01600 presented a range
from −5.556 (Copperloy 0.01600 , Dentsply Sirona) up to −11.466 Nmm (AlignXF 0.01600 ,
Ormco). The moment levels detected by Perrey et al. (range between 8 Nmm and 35 Nmm
for 0.01400 archwires and a 0.02200 slot [41]) were significantly higher than our results—even
0.01600 archwires did not reach 35 Nmm in our study. NiTi archwires with intrusion steps
presented even greater values ranging between −7.26 Nmm (Sentalloy 0.01200 medium,
Dentsply Sirona) and −15.89 Nmm (Sentalloy 0.01600 heavy, Dentsply Sirona). An increased
risk for OIIRR was also found when continuous moments between 3 Nmm and 6 Nmm
led to the capillary blood pressure being transcended when applied during orthodontic
treatment [48].
During the simulated intrusion, none of the investigated archwires without steps,
regardless of the manufacturer and respective diameter, reached the full intrusion dis-
tance of 1.6 mm (archwires without intrusion steps). NiTi archwires with a smaller wire
dimension generally reached slightly lower intrusion distances compared to larger wire
dimensions, e.g., Sentalloy 0.014 light achieved 59% of the aspired intrusion distance and
Bioengineering 2023, 10, 1356 Sentalloy 0.01600 light reached 71%, respectively (Figure 5). Three exceptions were 13 noted
of 18
when comparing the archwires of different material compositions, e.g., the Sentalloy 0.01400
light produced lower forces than the Sentalloy 0.01200 medium, and the Sentalloy 0.01600
medium produced lower forces 00 Sentalloy heavy (Figure 5). All measured
0.016″ medium produced lowerthan thethan
forces 0.014the 0.014″ Sentalloy heavy (Figure 5). All
archwires
measured with intrusion
archwires with steps of 1.2steps
intrusion mmof exceeded
1.2 mm the intrusion
exceeded distance distance
the intrusion of 1.6 mm, e.g.,
of 1.6
the Sentalloy 0.012 00 medium with IS achieved 138% and the Sentalloy 0.01600 medium with
mm, e.g., the Sentalloy 0.012″medium with IS achieved 138% and the Sentalloy 0.016″ me-
IS reached
dium with168%, respectively
IS reached (Figure 5). Adding
168%, respectively (Figure the intrusionthe
5). Adding step height to
intrusion theheight
step intrusion
to
distance, a maximum intrusion distance of 2.8 mm can be expected
the intrusion distance, a maximum intrusion distance of 2.8 mm can be expected for arch- for archwires with
intrusion
wires with steps; yet, while
intrusion steps;allyet,
analysed
while allarchwires
analysed with steps exceeded
archwires with steps1.2exceeded
mm, none1.2 ofmm,
them
reached a 2.8 mm intrusion distance (Figure 5).
none of them reached a 2.8 mm intrusion distance (Figure 5).

Figure 5. The achieved intrusion distance z [mm] and percentual intrusion [%] is given for all meas-
Figure 5. The achieved intrusion distance z [mm] and percentual intrusion [%] is given for all
ured NiTi archwires without and with intrusion steps. A red horizontal line is given to visualize the
measured
intrusion NiTi archwires
distance without
(1.6 mm) and aand with
blue intrusion
dotted steps. line
horizontal A red horizontal
visualizes theline
sumis given
of thetointrusion
visualize
the intrusion
distance and distance
height of(1.6
the mm) and astep.
intrusion blue dotted horizontal line visualizes the sum of the intrusion
distance and height of the intrusion step.
The reason that the aspired intrusion distance was not reached by any investigated
The reason
archwire can be that the aspired
explained by theintrusion
results ofdistance wasasnot
this study, thereached by any approached
forces already investigated
archwire can be
zero at lower explained
intrusion by the results
distances. of this study,
For example, as the forces
the intrusive already
force F approached
z of the Biostarter
zero at lower intrusion distances. For example, the intrusive force F z
0.012″ archwire approached 0 N after an intrusion distance of only approximatelyof the Biostarter
1 mm
(Figure 2). The force control of ROSS is programmed such that the robot reduces the ap-
plied forces and moments made by motions in the sense of a simulated tooth movement.
As the applied forces approached zero, the amount of the remaining force vector became
so small that the biomechanical setup was unable to cause a further reduction in the force,
Bioengineering 2023, 10, 1356 14 of 18

0.01200 archwire approached 0 N after an intrusion distance of only approximately 1 mm

(Figure 2). The force control of ROSS is programmed such that the robot reduces the applied
forces and moments made by motions in the sense of a simulated tooth movement. As the
applied forces approached zero, the amount of the remaining force vector became so small
that the biomechanical setup was unable to cause a further reduction in the force, which
also explains the noise or the sudden occurrence of enlarged value fluctuations in this
range (Figure 2). This result corresponds to clinical observations during orthodontic tooth
movement, as archwires of small diameters (e.g., 0.01200 ) cannot level all vertical deviations,
and, therefore, clinicians subsequently use higher archwire dimensions for further vertical
alignment [49]. However, the “intrusion efficiency”, i.e., the amount of possible intrusion
Bioengineering 2023, 10, 1356 14 of 18
distance vs. the Fz of smaller wire dimensions, is significantly higher compared to larger
wire dimensions in general (Figure 6).

Figure6.6.Intrusive
Figure Intrusiveforce
forceFzFzand
andpossible
possibleintrusion
intrusiondistance
distanceasasa afunction
functionofofthe
thewire
wirediameter
diameterandand
manufacturer. Smaller wire diameters deliver smaller forces, but the intrusion distance
manufacturer. Smaller wire diameters deliver smaller forces, but the intrusion distance is in theisrange
in the
range compared
compared to largertowire
larger wire
sizes sizes
and muchand muchintrusion
higher higher intrusion
forces. forces.

From Figure 6, it is
The application ofclear that across
an intrusion stepmore or less all
modulated thesuppliers, smaller in
forces, resulting diameters still
greater intru-
deliver significant intrusion distances even though the amount of intrusion
sion distances z (Figure 5). In addition, the disproportion between the slot size and the forces are only
inarchwire
the rangedimensions
of 25–30% maycompared to the larger-sized
have influenced wires.intrusion
the achieved The yellow columns
distances. InintheFigure
present6
indicate this conclusion,
study, NiTi archwires withand the tendencyof
dimensions of0.012″/0.014″/0.016″
the “intrusion efficiency” is very clear.with
were investigated This a
finding
standardmay be attributed
bracket to the
with a slot increased
size of 0.022″. play in the bracket
However, slot, thusinleading
the difference to a reduced
play between 0.012″
frictional force between the archwire and slot [50,51]. For clinical
and 0.016″ archwires is solely 0.05 mm; hence, the impact of the wire play is probably use, this means that
smaller wire sizes with delivered intrusive forces far below 1 N may
irrelevant with respect to the dimensions studied. Another aspect to be considered is the still lead to sufficient
intrusion
effect of results by reducing
the applied thermal thetreatment.
risk of root Evenresorption.
though the heat treatment has been con-
The application of an intrusion step
ducted under sufficiently controlled conditions using modulated the forces, resulting
a stainless in tool
steel greaterwithintrusion
an inte-
distances z (Figure 5). sensor
grated temperature In addition,
and an theairdisproportion
convection furnace between the only
with slot size and the
minimal archwire
temperature
dimensions
gradients, themayoriginal
have influenced
manufacturers’ the achieved intrusion distances.
thermomechanical treatmentInofthe thepresent study,
NiTi material
NiTi archwires with dimensions of 0.012 00 /0.01400 /0.01600 were investigated with a standard
may have been disturbed, and, 00therefore, the force-deflection behaviour in the bending 00 and
of
bracket with a slot
the 00heat-treated size of 0.022
archwires could. differ
However, from the the difference
as- supplied in material
play between 0.012though
[27]. Even
0.016 archwires
clinically is solely 0.05
not applicable, the mm;
chosen hence, the impactprocess
shape-setting of the wire play
is still is probably
considered irrelevant
the most ap-
with respect to the dimensions studied. Another aspect to be considered
propriate as it delivers the highest possible reproducibility of all the available shape-set- is the effect of
the applied thermal treatment. Even though the heat treatment has been conducted under
ting methods.
sufficiently controlled conditions using a stainless steel tool with an integrated temperature
Another interesting material aspect concluded from the present data is that the addi-
sensor and an air convection furnace with only minimal temperature gradients, the original
tion of copper in NiTi alloys (Copperloy 0.014″ and 0.016″) does not reduce forces and
manufacturers’ thermomechanical treatment of the NiTi material may have been disturbed,
moments to the expected extent. It is well known from the literature that Cu reduces the
and, therefore, the force-deflection behaviour in the bending of the heat-treated archwires
plateau stresses of NiTi alloys by changing the sequence of the martensitic transformation
could differ from the as- supplied material [27]. Even though clinically not applicable,
from B2->R > B19′ (monoclinic) toward B2->B19 (orthorhombic) [52] leading to reduced
plateau stresses combined with narrower stress hysteresis. In the case of the presented
research, the effect of the thermomechanical treatment of binary NiTi seems to be more or
less equivalent to alloying with Cu: the 0.014″ Copperloy wire delivers about identical Fz
values as the binary Sentalloy medium of the same dimension (1.126 N vs. 1.175 N). Fur-
thermore, the 0.016″ Sentalloy medium shows even lower forces compared to the Copper-
Bioengineering 2023, 10, 1356 15 of 18

the chosen shape-setting process is still considered the most appropriate as it delivers the
highest possible reproducibility of all the available shape-setting methods.
Another interesting material aspect concluded from the present data is that the ad-
dition of copper in NiTi alloys (Copperloy 0.01400 and 0.01600 ) does not reduce forces and
moments to the expected extent. It is well known from the literature that Cu reduces the
plateau stresses of NiTi alloys by changing the sequence of the martensitic transformation
from B2->R > B190 (monoclinic) toward B2->B19 (orthorhombic) [52] leading to reduced
plateau stresses combined with narrower stress hysteresis. In the case of the presented re-
search, the effect of the thermomechanical treatment of binary NiTi seems to be more or less
equivalent to alloying with Cu: the 0.01400 Copperloy wire delivers about identical Fz values
as the binary Sentalloy medium of the same dimension (1.126 N vs. 1.175 N). Furthermore,
the 0.01600 Sentalloy medium shows even lower forces compared to the Copperloy wire
(1.637 N vs. 1.853 N), giving rise to the conclusion that the thermomechanical treatment of
binary NiTi may be as efficient for the adjustment of plateau stresses as alloying with Cu.
Considering the limitations of this study, the brackets were positioned manually, and
the tooth was placed into the physiological position in the Kavo Typodont using a silicone
tray, both depending on the practitioner’s skills with possible tolerances. For future trials,
digital positioning trays are being considered. Furthermore, the results of the present study
were presented as data acting in the centre of resistance (CoR), which was defined as a static
point in this experimental setup. However, it was shown that, clinically, the changes in CoR
during tooth movement in a clinical in vivo situation depend on tooth morphology, the
periodontal ligament, and attached alveolar bone level [1,53]. Further, the CoRot changes
during tooth movement depending on the distance between the applied force and the
CoR [54–56]. Future in vitro trials could consider the dynamic relocation of the CoR and
CoRot. Even though the results are not directly transferrable to the clinical in vivo situation
due to the missing periodontal ligament and alveolar bone, some relevant conclusions are
being delivered.
Regarding clinical implementations, the application of heavy forces during tooth intru-
sion can lead to apical compression with an increased risk of OIIRR. It was shown that the
intrusion of single-rooted premolars did not lead to severe OIIRR when continuous forces of
50 cN were applied for 4 weeks. By contrast, the application of continuous intrusive forces
of 100 cN for 4 weeks was accompanied by severe OIIRR, especially in the apical region of
the root [22]. Intrusive forces no greater than 0.5 N were recommended for the intrusion
of single-rooted teeth [1]. Taken together, unmodified 0.01200 NiTi archwires present ideal
initial intrusive forces and moments when applied to the vertical aligning of extruded
single-rooted teeth. 0.01400 NiTi archwires are clinically applicable for levelling and aligning
when not applied to excessively extruded single-rooted teeth. NiTi archwires with intrusion
steps even achieved an overcorrection with greater achieved intrusion distances (>1.6 mm)
compared to NiTi archwires without steps not reaching the full intrusion distance. This
overcorrection is a consequence of significantly higher forces Fz and moments Mx exerted
by NiTi archwires with steps compared to unmodified NiTi archwires. Hence, the mod-
ification of wires with steps could be used to increase the transmission of the force and
moments of orthodontic-fixed appliances, e.g., for vertical overcompensation when a larger
diameter archwire cannot be placed due to the position of other teeth. Due to the high
forces exerted by NiTi archwires with IS, the use of steps should be considered carefully to
avoid OIIRR or a loss of anchorage [1,57–60]. Taken together, intrusion steps should solely
be applied in initial levelling archwires, i.e., 0.01200 NiTi archwires for the intrusion of lower
incisors and 0.01400 NiTi archwires for upper incisors.

5. Conclusions
The measured intrusive forces and protruding moments during the vertical alignment
of an extruded tooth (1.6 mm) exceeded the limit values recommended in the literature to
avoid OIIRR for all 0.01600 NiTi archwires and for some measured 0.01400 NiTi archwires.
Even simulated tooth intrusion with 0.01200 NiTi archwires presented forces and moments
Bioengineering 2023, 10, 1356 16 of 18

close to the limit value for OIIRR. Hence, a critical evaluation is recommended as to whether
NiTi archwires with dimensions greater than 0.01200 should be applied for initial orthodontic
tooth intrusion. Overall, increasing the wire dimension was accompanied by increasing the
force and moment levels. Furthermore, differences were found regarding 0.01400 and 0.01600
archwires regarding different manufacturers (but not for 0.01200 dimensions). Sentalloy
light 0.01400 /0.01600 from Dentsply Sirona presented significantly smaller intrusive forces
and protruding moments compared to AlignXF 0.01400 /0.01600 from Ormco. Biostarter
0.01600 from Forestadent showed the highest intrusion distance accompanied by the second
lowest Fz compared to other 0.01600 archwires found; yet, these force levels are still too high
for the vertical alignment of extruded teeth. The choice of the manufacturer seems to be of
subordinate importance regarding smaller wire dimensions, yet might gain importance
when greater wire dimensions are used. The modification of NiTi archwires with intrusion
steps increased and, in some cases, even doubled the measured intrusive forces and
protruding moments while leading to an overcompensation of the intrusion distance.
Therefore, the modification of archwires with steps can be a therapeutic, effective tool
for orthodontic tooth intrusion. Since intrusive forces up to 2.981 N and moments up to
−19.437 Nmm were found after the modification of 0.01600 NiTi archwires with intrusion
steps, the choice of the wire dimension is crucial. To avoid OIIRR, intrusion steps should
be bent in initial levelling archwires, i.e., 0.01200 NiTi archwires, for the intrusion of the
extruded single-rooted tooth.

Author Contributions: Conceptualisation, A.W.; methodology, A.W., C.L.S. and H.S.; formal anal-
ysis, J.L., C.L.S. and H.S.; investigation, J.L., C.L.S. and H.S.; resources, A.W.; data curation, J.L.;
writing—original draft preparation, C.L.S. and H.S.; writing—review and editing, M.M., M.J.R. and
A.W., C.L.S. and H.S.; visualisation, M.M., J.L., B.D., C.L.S. and H.S.; supervision, A.W.; project
administration, A.W. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author. The data are not publicly available.
Acknowledgments: The authors would like to thank the manufacturers for supplying the orthodontic
wires used in this study.
Conflicts of Interest: The authors declare no conflict of interest.

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