accelerated orthodontic tooth movement

Accelerated Orthodontic Tooth Movement: In Light of Evidence

Presenter: Dr. Aisha Khoja Supervisors: Dr. Fida

Dr. Attiya

Biomechanical approach

Physiological/mechanical approach

Pharmacological approach

Surgical-assisted approach

Surgery-simulated approach

POSSIBLE APPROACHES

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• No steel/elastomeric ligatures• Frictional force of ligatures ( O configuration)= 50 g• Reduced friction- especially passive design• Less force required for tooth movement• More physiological in terms of PDL vascular supply• More alveolar bone generation, greater expansion, less

proclination of anterior teeth, less need for extractions

Kapur et al: • Friction per bracket with Ni-Ti archwires-41g under conventional

ligation and 15g with Damon system• For SS wires: 61g (conventional); 3.6g (self ligating)

BIOMECHANICAL APPROACHSelf Ligating Bracket System

• Despite low friction, do not perform faster alignment/ space closure

• They are narrower than conventional brackets- effect of binding due to tipping is greater- increased resistance

• Short chair side time and less incisor proclination (1.5 degree)

Self Ligating Brackets- Current Evidence

BIOMECHANICAL APPROACH


1.Chen SS et al. Systemic review of self ligating brackets. Am J Orthod Dentofacial Orthop.2010;137:726e1:726e18

2. Fleming PS, Johal A. Self ligating brackets in orthodontics. A systemic review. Angle Orthod.2010;80:575-84

Beeson et al & Davidovitch et al:• Direct current : 7 volts & 15 microamperes• Anode : pressure side; Cathode: tension side• Degree of bone formation and resorption at electrically treated

pressure & tension side was higher• Increase osteoblasts, PDL cells, osteoclasts

Mechanism: • Direct current generate local response to increase AB turnover

Disadvantages:• The device and battery providing electric current were bulky

1. Direct Electric Current Stimulation: Evidence

PHYSIOLOGICAL/ MECHANICAL APPROACH


Beesan DC, Jhonston LE, Wisotzky J. Effect of constant currents on orthodontic tooth movement in cat. J Dent Res 1975;54:251-54

Davidovitch Z et al. Electric currents, bone remodelling and orthodontic tooth movment. Am J Orthod.1980;77:33-47

• Used clinically (2009)• It utilizes glucose as a fuel and enzymes as catalyst• Placed on the gingiva near the alveolar bone • Small size /minimal tissue injury

Disadvantage:• Short life time• Poor power density

Enzymatic Micro battery


• Electric potentials can be created by applying force to a tooth resulting in bending of bone and generation of piezoelectric charges

• The charges are created when stress is applied and released • Vibration could be used to apply and release forces at rapid rate• AcceleDent vibratory system : High frequency vibration (30Hz) for

20 min/day

Mechanism:• Stimulate cell proliferation and maturation to allow faster bone

remodeling

Endogenous Piezoelectric stimulation


• Prospective RCT: 45 patient , Random allocation for use of AcceleDent appliance

• NiTi coil spring was attached from canine and distally to TSAD• Distance checked b/w TSAD and distal of canine bracket – every 4 wks• 39 completed the trial and reported 38% (0.29mm/wk) faster tooth

movement compared to control (0.21mm/wk)

Discussion:• Lack of blinding & measurement method may affect the outcome• TSAD can drift under orthodontic loading-1.5mm• Vibration may results in accelerated drift of TSAD

Conclusion:Future research needed

Endogenous Piezoelectric stimulation: Evidence


AcceleDent website.http//accledent.com/images/uploads/AcceleDent + increases+the Rate of Orthodontic tooth movement Results of a RCT Final for Print November 14 2011.pdf Accessed 20 May 2012

• Gallium-aluminium-arsenide Irradiation• Wavelength: 630-860nm energy , energy 4.5-6 J/cm2• Minimally invasive, simple and safe to apply

Mechanism:• Increase in ATP at localized site - induce cells to undergo a remodeling

process due to an elevated metabolic activity• Increase in vascular activity contribute to rapid turnover of bone

Evidence:• Controversial• Few studies reported positive result, few no effect and some reported

retarded tooth movement

Low-Level Laser Therapy: Evidence


Youssef M et al. Low energy laser irradiation therapy during orthodontic tooth movement. A preliminary stud. Lasers Med Sci 2008;23:27-33

Limpanichkul et al. Effects of low laser therapy on rate of orthodontic tooth movement. Orthod Craniofac Res. 2006;9:38-43

• Light with 800-850nm wavelength (just above the visible light spectrum) penetrates cheeks and soft tissues over AB

• 97% light lost , 3% excite intracellular enzymes and increase cellular activity in PDL and bone

• Increase blood flow and may enhance tooth movement

Advantage: • Can be adjusted to apply light to only anterior teeth, whole arch or

posterior teeth

LLL therapy: Photo-biomodulation (Biolux)


• Corticosteroids

• PG’s

• Growth Hormone

• Parathyroid hormone

• Active form of Vitamin D

• Relaxin

PHARMACOLOGIC APPROACH

Mechanism:• PGE2 – an important mediator of bone remodeling under

mechanical force (increase cAMP & cGMP)

Yamaseki &Harell et al: • Experiment on animal model found application of orthodontic force

– increase in PG’s synthesis- stimulate osteoclastic bone resorption

• Injections of PGE1 and PGE2 into gingival tissues near first molar – increase rate of tooth movement

Prostglandins: Evidence



Yamaseki K et al. Prostaglandin as a mediator of bone resoprtion induced by experimental tooth movement in monkeys. J Dent Res. 1982;61:1444-1446

• Following LA, 0.1 ml of a 0.01% PGE1 solution in saline was injected submucosally at pressure side

• Rate of canine retraction- 1.6 fold increase

Disadvantages:• Injection were repeated at weakly intervals• Severe pain after injections

Protaglandins: Clinical trials



Speilmann T et al. Acceleration of orthodontically induced tooth movement through the local application of prostaglandin (PGE1). Schweiz Monatsschr Zahnmed 1989;99:162-165

• Insulin family of structurally related hormone• Produced during pregnancy

Mechanism: • Increase rate of degradation of extracellular fibrous C.T (stimulate

collagenase)• Increase bone resorption via increase in TNF and IL-1B secretion

Relaxin

PHARMACOLOGICAL APPROACH

Kristiansson P et al. Does human relaxin-2 affect peripheral blood mononuclear cells to increase inflammatory mediators in pathological bone loss?.Ann N Y Acad Sci.2005;1041:317-9

Stewart Dr et al. Use of Relaxin in orthodontics. Ann N Y Ascad Sci.2005 1041:379-387

• Vitamin D and PTH regulate the amount of calcium and phosphorus levels

• Vitamin D receptors – present on osteoblasts but also in osteoclast precursors and in active osteoclasts

Collins and Sinclair et al (1988)• Intraligamentary injections of vitamin D metabolite- increase in

the number of osteoclasts and amount of tooth movement during canine retraction with light forces

• Stimulatory action of vitamin D on osteoblasts can help stabilize orthodontic tooth movement.

Vitamin D ( 1,25 Dihydroxycholecalciferol)

PHARMACOLOGICAL APPROACH


• Rapid canine retraction through distraction of the PDL

• Rapid canine retraction through distraction of dento-alveolus

• Corticotomy assisted rapid tooth movement

• Corticision/Peizocision

SURGICAL-ASSISTED APPROACH

Mechanism:• Incorporation of a surgical procedure on interseptal bone distal to

canine the time of extraction of first premolar, resistance is reduced

• Rapid canine retraction through distraction (stretching) of PDL• This approach is based on distraction osteogenesis• Pressure side: Canine-interseptal bone complex transported

distally inside the socket • Tension side: PDL distraction leading to osteogenesis

1.Rapid canine retraction via PDL distraction


Rapid canine retraction through distraction of PDL

Procedure• At the time of extraction of

1st pm, socket is deepened to the same depth as canine with a 4mm round carbide bur

• 1mm carbide fissure bur- to make two vertical grooves, running from socket bottom to the alveolar crest, on the MB and ML corners

• These grooves are joined obliquely toward the base of interseptal bone

Liou EJ, Haung CS. Rapid canine retraction through distraction of periodontal ligament. Am J Orthod Dentofacial Orthop. 1998;114: 372-383

Technique:• Mucoperiosteal flap reflected• Cortical holes made in alveolar bone from canine to 2nd pm curving

apically to pass 3-5mm from apex• Connect the holes with tapering fissure• First premolar is extracted and buccal bone removed• Large osteotomes are used to mobilize the whole segment• Distraction : after 3 days of surgery• Activation of distractor: twice/day in morning and evening• 0.8mm/day• Can also be used to bring ankylosed tooth into positionDisadvantage:• Aggressive and complicated

Rapid canine retraction through dento-alveolar distraction


Kisniscu RS et al. Dentoalveolar distraction osteogenesis for rapid canine retraction. J Oral Maxillfac Surgery 2002. 60:389-394

• Local injury to the alveolar process reduces resistance to tooth movement and generate RAP

• First described in 1892 (fitzpatrick Barry)

Indications:• Resolve crowding and shorten treatment time• Accelerate canine retraction• Enhance post-orthodontic stability• Facilitate eruption of impacted teeth• Molar intrusion and open bite correction• Molar distalization

Kole’s technique: • Flap raised, vertical cuts facially and lingually between and under teeth

that did not penetrate all the way (only cortex)• Reduce resistance enhances en bloc movement of entire alveolar

segment

Corticotomy assisted orthodontic tooth movement


• Accelerated osteogenic orthdontics (AOO) /periodontally accelerated osteogenic orthodontics

Technique:• Full thickness flaps are reflected carefully beyond the apices to

allow decortication around apices• Corticotomy cuts are made in the form of lines and dots• Small circular depressions were placed in facial surface of bone

over maxillary anterior teeth• Bio-absorbable graft is placed (demineralized freeze dried bone)• Tooth movement- should be started after a weak • Tooth movement should be completed within 3-4 months

Advantages of graft:• Reduces bone dehiscence/ fenestrations especially when lower incisors are advanced• Good healing of alveolar bone

Wilcodontics


Micr0perforation:• Screws placed in gingiva b/w interproximal AB and removed• Enough to accelerate RAP

Piezocision:Minimally invasive flapless procedure combining microincisions, peizoelectric incisions & selective tunneling that allows for hard and soft tissue grafting

Advantages:• Minimally discomfort• Enhanced periodontium (added grafting)

Modified corticotomy



• Minimal surgical intervention• No flap is raised, No tunneling of hard or soft tissue graft not given

Indications:• To resolve anterior crowding• Anterior open bite

Technique:• Insert the surgical blade interproximally and parallel to occlusal plane 2-3

mm apical from the tip of the papilla • Tap blade with a mallet to a depth of approximately 8mm• Change the angle of the blade to approximately 45 degrees apically and tap

the blade to incise to a depth of 10mm to 12mm• The goal is to cut the cancellous bone between the roots to 50% to 75% of the

root length• Apply orthodontic forces immediately• See the patient every two weeks; forcibly mobilizing the teeth to induce

minor trauma to extend the effect.

Corticision



• Recent advancement: surgical blade is replaced by piezoelectric puncture

• Punctures rather than incisions penetrate gingiva, cortical bone, cancellous bone

Advantages:• Patient friendly• Less discomfort

• Evidence still needs further investigation

Corticision


Park YG. Patient friendly orthodontics to accelerate tooth movement. Presented at the 23rd Annual conference of Taiwan Association of orthodontics. 2011. Taichung, Taiwan.

• Autologous platelet rich plasma can simulate the effects induced by bone surgery

• Platelets contain growth factors PDGF,TGF, EGF’s and other components that regulate and stimulate wound healing and amplify osteogenesis

Technique:• 0.9ml of LA injected in the labial and lingual mucosa of anterior teeth• 0.7ml of PRP injected in labial and lingual attached gingiva from

canine to canine (immediately after bonding)• Acetaminophen given to control post-injection pain• The rate of orthodontic alignment was faster than compared to

controls

SURGERY SIMULATED APPROACHSubmucosal Injections of PRP

Liou EJ et al. Submucosal injection of platelet rich plasma accelerates orthodontic tooth movement. Am J Orthod Dentofacial Orthop (in press).

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