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Biology of Tooth Movement

Terminology
o Compression (Leading) Side: the side of the tooth that it is moving toward where PDL
fibers and blood vessels are compressed
Bone is resorbed in this area
Very high cellular component to this side (osteoclasts), some inflammation too
Takes about 4-6 hours to initiate a cellular response within the PDL space, and
2-5 days to initiate bone remodeling
o Tension (Trailing) Side: side of the tooth that it is moving away from where PDL fibers
are stretched and blood vessels area dilated
Bone is laid down in the area (osteoblasts lay down osteoid and fibroblasts lay
down cartilage). Transitional/bundle bone is created
Much less cells in this area
Timing lags behind resorption, so the PDL looks wider in this area
Tooth movement is driven by a healthy PDL
o Teeth without a healthy PDL space wont move orthodontically (ankyloses, implants,
etc.)
o Normal PDL
0.5 mm thick
Full of collagenous fiber bundles
Cellular elements
Tissues fluids
Vascular and neural elements
o PDL response to normal function
Intermittent/heavy forces (from occlusion, 1 second or less)
Fluids and ligaments stabilize against gross displacement
Alveolar bone bends a little
Acts as a shock absorber
Light/steady forces (soft tissue pressure)
Can lead to minor tooth movement (no pain involved)
Physiological tooth movement
o Eruption of teeth (juvenile/adult equilibration)
o Mesial drift
o Soft tissue imbalance (tongue thrust)
o It is a normal, very slow process (years). Primarily a periodontal phenomenon, and its
not associated with inflammation
Orthodontic tooth movement (OTM)
o Mechanically induced, and occurs rapidly (weeks-months)
o Primarily a periodontal phenomenon
o Principles of OTM
Light-prolonged pressures (50-350 grams)
Tooth moves
Bone around the tooth can be remodeled (like sutures) with higher pressure
(500-750 grams). This is done with a functional appliance like head gear
Often associated with some inflammation/pain (unavoidable)
o 2 types of bone remodeling
Frontal resorption: bone is resorbed on the frontal surface of the lamina dura
Occurs in regions of light forces PDL is partially compressed and the
blood flow is reduced, but not cut off
Osteoclasts are derived from the PDL blood vessels
Survival of most cells within the PDL, and its relatively painless
Movement happens relatively quickly (as quick as 2 days)
Undermining Resorption: bone is resorbed from the trabecular bone on the
back side of the lamina dura
Occurs in regions of heavy forces PDL is compressed to the point of
blood vessels being closed off, leading to necrosis
The PDL necrosis and becomes much more homogenized histologically,
called hyalinization
Osteoclasts come from blood supply in the trabecular bone and travel
to the back side of the lamina dura
Typically associated with more pain, due to PDL ischemia/necrosis
Takes more time for teeth to move, due to the delayed initiation and
need to wait for the lamina dura to resorb from the back side to where
the teeth can move.
o Can take up to 5 days for movement to start
Basically impossible to prevent this from happening in some areas with
ortho. Try to minimize
o Timing
Takes about 4-6 hours to initiate a cellular response with the PDL space.
Patients must wear a removable appliance for at least 4-6 hours/day to
get OTM
Generally you want double this time though, so 8-12 hours/day
Takes 2-5 days to initiate bone remodeling (depending on pressure level)
2-3 weeks between activations/adjustments by the orthodontist
Plateau phase: 2-14 days before lamina dura is resorbed. Tooth remains
relatively non-mobile
After the plateau phase, tooth movement becomes very constant, but if
pressure is lost it will stabilize and patient will go through another plateau phase
Keep ortho recalls at 3-6 weeks to keep teeth steadily moving, try and
prevent a plateau phase
o Tissue changes
Enamel no effect
Cementum localized perforations, repaired with cementum
More resistant to resorption than dentin
Dentin resorption in areas of cementum perforation possible
More affected by resorption than cementum.
Areas of resorption are filled in with cementum
Pulp modest and transient inflammation
Potentially a tooth with a history of trauma could lose vitality
Endo treated teeth can be moved like normal teeth
PDL
Compression of blood vessels/fibers on the leading side
Dilation of blood vessels/stretching of fibers on the trailing side
Increased metabolic activity
Inflammation speeds up tooth movement (regional acceleratory
phenomenon (RAP))
Bone
Alveolar bone is remodeled in zones of compression
Bone is deposited in zones of tension
Alveolar bone follows erupted/extruded teeth
Presence of active periodontal disease combined with OTM = rapid
bone loss (inflammation)
o Orthodontic root resorption: resorption of the cementum and sometimes underlying
dentin in teeth moved orthodontically
likely occurs in all teeth to some extent
Most common on maxillary anteriors (3% vs. less than 1%)
Factors that control remodeling
o Bone density (age, site of movement)
o Anatomical location (Mx vs. Mn)
o Cortical vs trabecular bone
o Force application
o Type of tooth movement
o Medications
Force application
o Duration and decay (all forces decay at some point, which is why adjustments are
needed)
Continuous forces never declines to 0
NiTi coil springs
Interrupted forces declines to 0 with recovery periods before being adjusted
Power chain
Intermittent forces continually placed in and out, and eventually declines to 0
Removable appliances (head gear, elastics)
o Force duration
Minimum of 4-6 hours per day to initiate
No tooth movement if less time is applied
The longer the force is applied, the more the teeth will move
o Force magnitude
In the range of 20 to 350 grams
Varies with the type of tooth movement
Tipping (35-60) vs Translation/bodily movement (70-120)
Rotation (35-60)
Extrusion (35-60) vs intrusion (10-20)
Light continuous forces area currently considered to be the most effective in
inducing tooth movement
Heavy forces cause damages and often fail to increase tooth movement
Increased risk of root resorption as well
Medication effect on OTM
o Prostaglandins and vitamin D can increase OTM
o Short term use of NSAIDs for acute pain has no relevance, but long-term use is expected
to decrease OTM
Acetaminophen may be better recommended vs ibuprofen
o Medications that can depress OTM
Bisphosphonates
Prostaglandin inhibitors
Tricyclin antidepressants
Antiarrhythmic agents
Antimalarial drugs
Anticonvulsants
Tetracyclines
Theories for initiation of bone remodeling
o Frost theory (Mechanostat) strain threshold/fluid flow with osteocytes/canaliculi leads
to the initiation of osteoclastic resorption
o Classic orthodontic bone remodeling theory
Bio-electric Theory (Piezoelectric)
Electrical signals are sent in streaming potentials
Occurs during the initial movement
Bending the alveolar bone during normal chewing sends these signals,
which help maintain the bone
Pressure-Tension theory
PDL compression decreases oxygen levels within the PDL
PDL stretching maintains or increases blood flow
Chemical messengers are sent based on the oxygen levels
Both probably play a role combined in OTM