Professional Documents
Culture Documents
CONTENTS
1- Introduction
2-The periodontium
• Gingiva
• Cementum
• Periodontal ligament
• Alveolar bone
5- Bilological considerations
8-Hyalinisation
15-Piezoelectric theory
17-Pressure-Tension theory
18-Orthodontic force
19-Clinical considerations
20-Factors affecting tooth movement
24-Conclusion
25-References
INTRODUCTION
Gingiva
Periodontal ligament
Cementum
Alveolar bone
PERIODONTAL LIGAMENT
Soft, specialized, unique connective tissue
Situated b/w the cementum covering the root of the tooth & the bone forming the
socket wall
Width ranges from 0.15 to 0.38 mm which varies with the location of the tooth and
the age of the patient
Principle function is to support teeth in their sockets and at the same time permit
them to withstand the considerable masticatory forces
Horizontal group
Oblique group
Apical group
Interradicular group
CEMENTUM
Functions of cementum
Primary function – furnish a medium for attachment of collagen fibers that bind the
tooth to the alveolar bone.
ALVEOLAR BONE
That bone of the jaws which contains the sockets for the teeth is known as alveolar
bone.
Consists of
A central spongiosa
bone lining the alveolus referred to as the bundle bone (provides attachment for the
PDL fiber bundles)
1)Immature Bone:
Woven Bone: Relatively weak, disorganized and poorly mineralized. The first
bone formed in response to orthodontic loading usually is the woven type.
2)Mature Bone :
Lamellar Bone:
The full strength of lamellar bone that supports an orthodontically moved tooth is
not achieved until approximately 1 year after completion of active treatment.
Composite Bone:
An osseous tissue formed by the deposition of lamellar bone within a woven bone
lattice.
“Every change in the form and function of bone or of their function alone is followed by
certain definite changes in their internal architecture, and equally definite alteration in
their external conformation, in accordance with mathematical laws.”
Both trabecular and cortical bone grow, adapt, and turn over by means of two
fundamentally distinct mechanisms: Modeling and Remodeling. Because bone is a
relatively rigid material, incapable of internal expansion or contraction, changes in
osseous structure are via cell-mediated resorption and formation. In Bone modeling,
independent sites of resorption and formation change the form (i.e., shape or size or
both) of a bone. In other words it is a process of uncoupled resorption and formation.
In bone remodeling a specific, coupled sequence of resorption and formation occurs to
replace previously existing bone. Bone modeling is the dominant process of facial
growth and adaptations to applied loads such as head gear, RPE, and functional
appliances. Modeling changes can be seen on cephalometric tracings, but remodeling
events are apparent only at the microscopic level.
Celsus- first advocated about use of mechanical forces to evoke tooth movement
Reiten (1951) & Kvam (1971) carried out a series of experiments on dogs and
human subjects to determine the tissue reaction during tooth movement and
discovered changes in the cellular level including the phenomenon of hyalinization.
During masticatory function, the teeth and PDL structures are subjected to heavy
intermittent forces tooth contacts last for 1 second or less ; forces are quite heavy ,
ranging from 1-2kg while soft substances are being chewed , up to as much as 50 kg
against a more resistant object.
When a tooth is subjected to such type of heavy load ,quick displacement of the
tooth within PDL space is prevented by incompressible tissue fluid present in PDL
space. Instead the force is transmitted to the alveolar bone, which bends in response.
Eruption
Drifting
Periodontal Pathology
No great difference exists between the tissue reactions observed in physiologic and
those observed in orthodontic tooth movement.
However, since the teeth are moved more rapidly during treatment as compared to
physiologic tooth movement, the tissue changes elicited during orthodontic forces are
consequently more marked and extensive. (Rygh and Brudvik 1995).
Storey & Smith (1952)-observed same finding in their experiments
Proffit (2007), Ren et al (2003)-suggested that optimal force may differ for each
tooth and for each individual patient.
If the duration of movement is divided into an initial and a secondary period, direct
bone resorption is found notably in the secondary period, when the hyalinized tissue
has disappeared after undermining bone resorption. During the crucial stage of
initial application of force, the tissue reveals a glass like appearance in light
microscopy, termed hyalinization.
Hyalinization:
• A hyalinized zone is a local cell free area of over compressed periodontal tissue.
The conventional pathologic process of hyalinization is an irreversible one; however,
hyalinization of the periodontal ligament is a reversible process.
Presence of hyalinised area indicates that the ligament is non functional and
therefore bone resorption cannot occur.
Greater the forces, the wider are the area of hyalinization and smaller
hyalinization area when less force is used.
Frontal Resorption-
When forces applied are within physiological limits, resorption is seen in alveolar
plate immediately adjacent to ligament . This kind of resorption is known as Frontal
Resorption.
Undermining Resorption
Storey inferred from his animal studies and graphed analyses that,
“In general, each curve has three phases: the first, where rapid movement takes
place through the periodontal ligament space; the second, where movement occurs
relatively slowly, or not at all, with the heaviest forces; and finally a stage where
teeth begin to move rapidly……”
• According to Reitan , this is the plateau or hyalinization stage in which little or no tooth
movement occurs.
• It is characterized by cell free zones on the pressure side of the root and undermining
resorption on the periodontal side of the alveolar wall.
This stage usually lasts from 1-3 weeks.
SIGNALING MOLECULES
Role of PGE1 and E2 in stimulating bone resorption (klein & raisz 1970,Lee 1990)
Cyclic GMP action mediated through cGMP dependent protein kinase plays key
role in synthesis of nucleic acids and proteins (Davidovitch,1995)
VITAMIN D
These are the basis of the two major theories of Orthodontic tooth movement-
• Most accepted theory of tooth movement,relies on chemical rather than electric signals as
the stimulus for cellular differentiation and tooth movement.Sustained pressure causes
tooth to shift position within the periodontal space.
• Schwarz hypothesized that the “PDL space is a continuous hydrostatic system, and forces
applied to this environment by means of mastication or orthodontic appliances create a
hydrostatic pressure that would be, in accordance with Pascal's law, transmitted equally
to all regions of the PDL’’.
• The area of periodontium in the direction of tooth movement is under pressure while the
area opposite to tooth movement is under tension.
• On the "tension" side, cell replication is said to increase because of the stimulation
afforded by the stretching of the fibre bundles of the periodontal ligament (PDL), thus
causing bone deposition.
• In terms of fibre content, the PDL on the "pressure" side is said to display
disorganization and diminution of fibre production, while on the "tension" side,
fibre production is said to be stimulated
2-PIEZOELECTRIC THEORY
• example-
• Collagen
• Hydroxyapetite crystal
• Hence a rhythmic activity would produce a constant interplay of electric signals, whereas
occasional application and release of force would produce only occasional electric signals
• Quick decay rate-when a force is applied, piezoelectric signal is produced. This electric
charge quickly dies away to zero even though the force is maintained
• When the force is released, electron flow in the opposite direction is seen
• When force of greater magnitude and duration is applied , interstitial fluid in the PDL
space gets squeezed out and moves towards the apex and cervical margins and results in
decreased tooth movement.This effect is known as Squeeze film effect by Bien.
• Osteocalcin
• Osteonectin
• Osteopontin
• RANKL (receptor activator of nuclear factor kappa B ligand )
• Macrophage colony stimulating factor ( M-CSF )
• osteoprotegerin (OPG)
• - Receptor activator of nuclear factor kappa ligand (RANKL) and Osteoprotegerin
(OPG) are regulators of bone metabolism
• Expression of RANKL and OPG in human PDL cells was measured by Zhang et al
(2004)
• In response to orthodontic force, Opn mRNA is elevated within the tissue by 12hrs
and can be demonstrated at 48hrs by in situ hybridization in >50% of osteoclasts
and >87% of osteocytes in the interdental septum of maxillary molars (JBMR-
1999).
• Vit D3 down regulated the expression of OPG and upregulated the expression of
RANKL
CLINICAL CONSIDERATIONS
• Force
• Drugs/medications
• Systemic diseases
• Age of Patient
• Continuous
• Interrupted
• Intermittent
CONTINUOUS FORCE-
INTERMITTENT FORCE
• An active orthodontic force that decays to zero magnitude or nearly so prior to the
next appointment.
INTERRUPTED FORCE
• Direct injection of prostaglandin into the PDL has shown to increase the rate of
tooth movement ( Painful )
• Play an important role in the cascade of signals that lead to tooth movement
NSAIDS
• NSAIDS are effective orthodontic analgesics, but they may reduce the rate of tooth
movement, and they should not be administered for long periods of time to
orthodontic patients.
• Several other drugs can affect prostaglandin level and therefore could affect the
response to orthodontic tooth movement
• Eg-Amytryptiline,Quinine,Procaine
• These results indicate that oral Misoprostol can be used to enhance the rate of
tooth movement with less risk of increased root resorption than PGE2.
Osteoporosis
• A problem faced by many post menopausal Females & also aging individuals of
both sexes
• Medication
Bisphosphonates
• They are synthetic analogues of pyrophosphate that bind to hydroxyapatite in bone.
• Eg. Alendronate
• Physicians of older women on these drugs and who require orthodontic treatment
should be consulted regarding the possibility of switching over to estrogen, at least
temporarily.
• Methyl Xanthines
1-Cardiovascular diseases
• Infective endocarditis
2-Bleeding Disorders
• Haemophilia
• Neutropenia
• Polycythemia vera
• Anaemia
• Thallasemia
3-Haematological malignancies(Leukemia)
4-Respiratory disorders
• Asthma
• OSA
• Cystic fibrosis
• Arthritis
• Bone tumors
6-Endocrinal disorders
• Diabetes Mellitus
• Hypothyroidism
• Estrogen
7-Nervous system
• Epilepsy
• Psychiatric disorder
It is of prime importance to include a detailed medical history of the patient during the
diagnosis phase of the orthodontic treatment.
A sound knowledge of the effect of different regularly used drugs and systemic diseases
will aid the clinician to take the required precautions and in turn make the orthodontic
treatment as efficient as possible
SURGICAL ENHANCEMENT
In 19th century Hullihan , the pioneer American oral surgeon experimented with
moving teeth after making cuts in alveolar bone
In mid century German surgeon Kole revived the idea that cuts between teeth could
produce faster tooth movement
Surgical Techniques
More recently, rapid tooth movement after corticotomy has come to be viewed as a
demineralization/remineralization phenomenon that produces a regional acceleration of
bone remodeling that allows faster tooth movement rather than movements of blocks
that contains teeth as done previously
It uses light with an 800-850 nm wavelength that penetrates soft tissue and “infuses
light energy directly into the basal bone’’.
1-Gingival Inflammation: The initial and most important factor causing gingival
inflammation is bacterial plaque at the gingival margin. Patients with fixed
appliances have increased retention sites for microbial samples and therefore
significantly higher total numbers of Strep. mutans and Lactobacilli.
A greater plaque index; tendency for bleeding; increased pocket depth and greater
interproximal loss of attachment have been observed more frequently for molars
with orthodontic bands
2-Root resorption
Orthodontic force application - evoke excessive resorption of root cementum,
proceeding into the dentin, eventually shortening the root length—a process called
root resorption.
Ottolengui (1914) and Ketcham (1927) - first to report severe root resorption
associated with orthodontic tooth movement.
Jarabak and Fizzell - analyzing the effect of force systems during mechanotherapy -
concluded that the magnitude of an orthodontic force and rigid fixation of the
archwire to the brackets could be considered the most important factors
predisposing a tooth to the root resorption
Cemental /surface resorption : where only the outer layers are resorbed, to be fully
regenerated or remodeled later .
Dentinal resorption : with repair, where the cementum and the outer layers of dentin
are resorbed, and are repaired along with morphological alterations .
Circumferential root resorption : where full resorption of the hard tissue components of
the root apex occurs, resulting in root shortening.
3-Pulpal reactions
Some reports suggested permanent damage to pulpal tissue from orthodontic force,
but others claimed no significant long-lasting effects on the dental pulp.
Labart et al demonstrated increased pulpal respiration rate in rat incisor pulp (1-2
times more than controls),orthodontic stress for 72 hours
Mostafa et al : congested and dilated blood vessels, and edema of pulpal tissue in
their histologic observations.
Compressed gingiva in extraction sites (between teeth that have moved together)
can produce a long-lasting epithelial fold, or invagination.
Surrounding connective tissue- loss of collagen, mechanical forces employed can
cause sub lethal damage and stimulates hyperplasia
may aggravate a pre-existing plaque induced gingival lesion and cause loss of
alveolar bone and periodontal attachment.
Experimental studies in the Beagle dogs also have shown that it is possible for
orthodontic tipping forces to shift a supragingivally located plaque into a sub
gingival position, resulting in the formation of infrabony pockets. (JCP 1977)
5-Marginal Bone Recession: It is the displacement of the soft tissue margin, apical to
the CEJ, with subsequent exposure of the root surface. This is associated with
localized plaque induced inflammatory lesions and sometimes in combination with
orthodontic therapy.
With respect to orthodontic treatment, this implies that as long as tooth is moved
exclusively within the envelope of the alveolar process, the risk of harmful side
effects in the marginal tissue is minimal, irrespective of the dimensions and quality
of the soft tissue (JCP 1981,87).]
POSTTREATMENT STABILITY
Not all orthodontically achieved changes remain stable, although the question of
relapse is related to the objective of treatment.
CONCLUSION
Rapid advances in all biological fields have enabled us to better understand the
mechanisms involved in orthodontic tooth movement.
This growing body of knowledge illuminate useful paths in clinical orthodontics and
assist us in identifying and discarding harmful methods of mechanotherapy and also
will move orthodontics closer to the goal of being optimal, where teeth are moved
efficiently, without causing discomfort to the patient or damage to the teeth and
their supporting tissues.
REFERENCES
Schwarz AM. Tissue changes incident to orthodontic tooth movement. Int J Orthod
1932;18: 331-52.
Proffit WR. Biologic basis of orthodontic therapy. In: Proffit WR, Fields HW,
editors. Contemporary orthodontics. 4TH ed. St Louis: Mosby; 2009
Farrar JN. Irregularities of the teeth and their correction. Vol 1.New York:
DeVinne Press; 1888. p. 658.
Grimm FM. Bone bending, a feature of orthodontic tooth movement. Am J Orthod
1972;62:384-93.