ORIGINAL CLINICAL ARTICLE

Rapid canine retraction through distraction of the periodontal

ligament

Eric JW Liou, DDS, MS,a and C. Shing Huang, DDS, PhDb

Taipei, Taiwan

The process of osteogenesis in the periodontal ligament during orthodontic tooth movement is similar to the
osteogenesis in the midpalatal suture during rapid palatal expansion. A new concept of “distracting the
periodontal ligament” is proposed to elicit rapid canine retraction in 3 weeks. It is called dental distraction.
Fifteen orthodontic patients (26 canines, including 15 uppers and 11 lowers) who needed canine retraction
and first premolar extraction were included. At the time of first premolar extraction, the interseptal bone
distal to the canine was undermined with a bone bur, grooving vertically inside the extraction socket along
the buccal and lingual sides and extending obliquely toward the socket base. Then, a tooth-borne, custom-
made, intraoral distraction device was placed to distract the canine distally into the extraction space. It was
activated 0.5 to 1.0 mm/day immediately after the extraction. The anchor units were the second premolar
and first molar. Cephalometric and periapical x-rays were taken before and after the canine retraction. Both
the upper and lower canines were distracted bodily 6.5 mm into the extraction space within 3 weeks. New
alveolar bone was generated and remodeled rapidly in the mesial periodontal ligament of the canine during
and after the distraction. It became mature and indistinguishable from the native alveolar bone 3 months
after distraction. During the distraction, 73% of the first molars did not move mesially and 27% of them
moved less than 0.5 mm mesially within 3 weeks. The radiographic examination revealed that apical or
lateral surface root resorption of the canine was minimal. No periodontal defect or endodontic lesion was
observed throughout and after distraction. We concluded that the periodontal ligament could be rapidly
distracted without complications. The rapid orthodontic tooth movement through distracting the periodontal
ligament cannot be emulated by current conventional orthodontic concepts and methods. (Am J Orthod
Dentofacial Orthop 1998;114:372-82)

Distraction osteogenesis is a process of tracted transversely through the midpalatal suture 1

growing new bone by mechanical stretching of the pre-
existing bone tissue. The most common technique in
distraction osteogenesis is mechanical stretching of the
reparative bone tissue by a distraction device through
an osteotomy or corticotomy site.1-4 With this tech-
nique, new bone is generated in the gap of osteotomy or
corticotomy at the approximate rate of 1 mm per day.
Another well-known modality of distraction osteo-
genesis is through a suture, such as in rapid palatal
expansion.5 In this technique, the hard palate is dis-
This article was partially presented in the 55th annual meeting of the American
Cleft Palate-Craniofacial Association, Baltimore, Maryland, April 20-25, 1998,
and the 98th annual session of the American Association of Orthodontists, Dal-
las, Texas, May 16-20, 1998.
aAttending orthodontist in the Department of Craniofacial Dentistry, and Cran-
iofacial Center, Chang Gung Memorial Hospital, Taipei, Taiwan.
bHead of the Department of Craniofacial Dentistry, Chang Gung Memorial Hos-
pital, Taipei, Taiwan, and associate professor, Chang Gung Medical College,
Chang Gung University, Taipei, Taiwan.
Reprint requests to: Eric JW Liou, DDS, MS, Department of Craniofacial Den-
tistry, Chang Gung Memorial Hospital, 199 Tung-Hwa N. Rd., Taipei, 105, Tai-
wan; e-mail: lioueric@ms19.hinet.net
Copyright © 1998 by the American Association of Orthodontists.
0889-5406/98/$5.00 + 0 8/1/93510
372
mm per day. Another example is midface distraction
through the sutures in the growing animals.6 The new
bone grows in the distracted midfacial sutures.
Orthodontic tooth movement is a process in which
a mechanical force is applied to induce alveolar bone
resorption on the pressure side, and alveolar bone
deposition on the tension side.7-9 On the tension side,
the periodontal ligament is stretched (distracted) fol-
lowed by alveolar bone deposition (osteogenesis). The
periodontal ligament is a “suture” between alveolar
bone and tooth. The process of osteogenesis in the peri-
odontal ligament during orthodontic tooth movement is
similar to that in the midpalatal suture during rapid
palatal expansion, or to that in the midface sutures in
the growing animal during midface distraction. The
major difference is the rate of osteogenesis.
The regular rate of osteogenesis in orthodontic
tooth movement during canine retraction is about 1 mm
per month, which is much slower than that in distrac-
tion osteogenesis. However, it has been shown that by
orthodontically moving a tooth into the fibrous bone
tissue just created by distraction osteogenesis in a
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 114, Number 4
Fig 1. Canine distraction device is placed close to cen-
ter of resistance of canine to achieve bodily movement.
canine model,10 the rate of the orthodontic tooth move-
ment could be as much as 1.2 mm per week in the
mandible.11
We hypothesized that periodontal ligament can be
distracted just like the midpalatal suture in rapid palatal
expansion. In this study, a new technique of rapid
canine retraction through distracting the periodontal
ligament with a distraction device is presented. We call
this new technique dental distraction.
MATERIAL AND METHODS
Fifteen consecutive orthodontic patients (8 females
and 7 males) who needed canine retraction and first
premolar extraction either in the mandible or maxilla
were included. Their ages ranged from 10 to 19 years
old. Twenty-six canine distractions, including 15 upper
and 11 lower canines, were carried out with custom-
made, tooth-borne, intraoral distraction devices.
Clinical Procedures
In each case, a fixed orthodontic appliance was
placed before the first premolar extraction. The tooth
to be distracted was a canine, and the first molar and
second premolar were the anchor units. A 0.051 inch
wire oriented vertically was soldered on the buccal
side of the canine band and a lingual cleat was welded
on the lingual side. A buccal vertical sheath and a lin-
gual cleat were soldered on the molar band (Fig 1). No
arch wire or active appliance was placed on the second
premolar or first molar before the first premolar
extraction.
Right after the first premolar extraction, the inter-
septal bone distal to the canine was undermined with a
bone bur, grooving vertically inside the extraction
socket, along the buccal and lingual sides, and extend-
ing obliquely toward the base of the interseptal bone to
Liou and Huang 373
Fig 2. Surgical techniques for undermining interseptal
bone distal to canine. No cuts are performed on buccal
and lingual plates. Note depth and position of undermin-
ing grooves.
weaken its resistance. The interseptal bone was not cut
through mesiodistally toward the canine (Fig 2). The
depth of the undermining grooves was dependent on
the thickness of the interseptal bone, as revealed on the
periapical films.
A custom-made intraoral distraction device (Fig 1)
was delivered for canine distraction right after the first
premolar extraction. It was activated 0.5 to 1 mm/day
right after the extraction until the canine was distracted
into the desired position and amount. Power chains
were placed on the lingual side between the canine and
the first molar to prevent rotation of the canine during
distraction (Fig 1). The patients were seen every week
during the distraction process.
Records and Data Analysis
The distance between the contact points of the
canine and lateral incisor (amount of distraction) was
recorded to 0.1 mm with a sliding caliper (Dentaurum,
Germany) right after extraction and every week until
retraction was complete. Lateral cephalometric radi-
ographs were taken right before the first premolar
extraction (T1) and after the completion of the canine
distraction (T2). The cephalometric radiographs were
traced and the maxillae were superimposed on their
anatomic best fits for the amount of mesial movement
of the first molar (loss of the anchorage) from T1 to
T2. Periapical films of the canines and first molars
were taken right before the first premolar extraction,
weekly until completion of the canine distractions
(retraction), and monthly for 3 months. They were
evaluated for the changes in the periodontal ligaments,
alveolar bone deposition and resorption, and root
resorption of the canines and first molars during the
canine distraction.
The periapical films of the canines right before the
first premolar extractions and at the end of the canine
distractions (in the third week after initiating the dis-
374 Liou and Huang American Journal of Orthodontics and Dentofacial Orthopedics
October 1998

Fig 3. Mandibular canine distraction in 16-year-old male. A, Clinical photograph right after first pre-
molar extraction. Note canine relationship was class III. B, Periapical radiograph just before the first
premolar extraction. C, Canine was distracted distally 6.9 mm after 3 weeks of distraction. Note elim-
ination of extraction wound and new keratinized gingival tissue created by canine distraction between
canine and lateral incisor. D, Periapical radiograph of canine after 3 weeks of distraction. Note bodi-
ly movement, no apical root resorption on apex of canine, rapid new bone formation in distracted
periodontal ligament, and elimination of extraction socket. E, Periapical radiograph of first molar after
3 weeks of distraction. On tension side, periodontal ligament and lamina dura became 0.5 mm wider,
the probable amount of mesial movement of first molar (loss of anchorage).

traction) were both projected on a screen and magni-
fied by 10. They were assessed for apical root and lat-
eral surface root resorption in each canine distraction
by five well-trained orthodontists. The apical root
resorption was assessed by the following scores12:
0 = No apical root resorption
1 = Slight blunting of the canine root apex
2 = Moderate resorption of the root apex beyond
blunting and up to one fourth of the root
length
American Journal of Orthodontics and Dentofacial Orthopedics Liou and Huang 375
Volume 114, Number 4

Fig 4. Maxillary canine distraction in 15-year-old male. A, Clinical photograph immediately after first premolar extrac-
tion. B, Periapical radiograph right before extraction. C, Canine was distracted distally 6.5 mm after 3 weeks of dis-
traction. Note elimination of extraction wound and new keratinized gingival tissue created by distraction between canine
and lateral incisor. D, Periapical radiograph of canine after 3 weeks of distraction. Note bodily movement, no apical root
resorption on apex of canine, rapid new bone formation in distracted periodontal ligament, and elimination of extrac-
tion socket. E, Periapical radiograph of first molar after 3 weeks of distraction. On tension side, widening of periodon-
tal ligament and lamina dura was less than 0.5 mm.

Table I. Accumulative amount of canine distractions and mesial movement of first molars
Maxillary (N = 15) Mandibular (N = 11)
Tooth movement (mm) Canine First molar Canine First molar P*

First week 2.4 ± 0.8 — 2.8 ± 1.1 — NS

Second week 4.6 ± 1.1 — 5.2 ± 1.0 — NS
Third week 6.5 ± 0.7 0.1 ± 0.2 6.6 ± 0.4 0.2 ± 0.2 NS

*ANOVA comparison between the maxillary and mandibular canines and between the maxillary and mandibular first molars.
376 Liou and Huang
Fig 5. Accumulative amount of maxillary and mandibular
canine distractions in 3 weeks.
3 = Excessive resorption of the root apex beyond
one fourth of the root length
The lateral root resorption on the distal side of the
canine root was assessed according to the following
scores:
0 = Smooth lateral root surface and periodontal
ligament
1 = Slightly irregular lateral root surface; not beyond
one third of the dentine width between the distal
side periodontal ligament and pulp chamber
2 = Moderate irregular lateral root surface beyond
one third and up to two thirds of the dentine
width between the distal side periodontal liga-
ment and pulp chamber
3 = Excessive irregularity of the lateral root surface
beyond two thirds of the dentine width between
the distal side periodontal ligament and pulp
chamber
Pulp vitality tests of those 26 distracted canines and
the lateral incisors and second premolars beside the
distracted canines were recorded with an electronic
pulp tester (Parkell). They were tested on the palatal or
lingual surfaces before placing any orthodontic appli-
ance and at least 1 month after the canine distraction.
All the arch wires and/or distractors were removed dur-
ing the pulp vitality tests.
RESULTS
All the patients reported no severe pain, but some
reported slight discomfort when the distraction device
became tight after activation. The discomfort lasted for
10 to 15 seconds only. One of the patients complained
about thermal sensitivity during the second week of
distraction in one of her four distracting canines.
Rapid Canine Distraction in 3 Weeks
Clinically and radiographically, although some
canines tipped slightly after the distraction, most of the
American Journal of Orthodontics and Dentofacial Orthopedics
October 1998
Fig 6. Interseptal bone distal to canine closely followed
canine distraction.
canines were moved bodily. The roots of the canines
were parallel to the long axis of the second premolars
after the distraction (Figs 3 and 4). Both the upper and
lower canines were distracted distally into the first pre-
molar extraction sockets 6.5 to 6.6 mm in 3 weeks (T1
to T2) (Table I and Fig 5). The rate of tooth movement
per week was not significantly different between the
maxillary and mandibular canines (Table I).
The native interseptal bone distal to the canine was
bent and brought into the extraction socket (trans-
port)(Fig 6). It closely followed the canine distraction
and eventually contacted the interseptal bone mesial to
the second premolar (docking).
Minimal Loss of the Anchorage
The average mesial movement of the first molars
was less than 0.5 mm in 3 weeks (T1 to T2). Seventy-
three percent of the first molars did not move mesially,
and 27% of them moved mesially less than 0.5 mm on
the cephalometric superimposition (Fig 7). The average
mesial movement was 0.1 mm in the maxillary first
molars, and 0.2 mm in the mandibular first molars,
respectively (Table I). In some of the first molars, the
periodontal ligament and lamina dura on the tension side
widened slightly at the end of distraction (the third
week), as revealed on the periapical films (Figs 3 and 4).
Minimal Root Resorption
On the periapical radiographs, the apical or lateral
surface root resorption was minimal for both the max-
American Journal of Orthodontics and Dentofacial Orthopedics Liou and Huang 377
Volume 114, Number 4

Fig 7. Frequency of mesial movement for first molars.

illary and mandibular canines. For the apical root

resorption, most of them had no root resorption (score
0) or only lightly blunting of the apex (score 1) after 3
weeks of distraction. For the lateral surface root resorp-
tion, most of them had no root resorption (score 0) or
only slightly irregular root surface (score 1) after 3
weeks of distraction (Fig 8).

Rapid Osteogenesis in the Distracted Periodontal

Ligament
The radiographic changes of the periodontal liga-
ments on the mesial side of the canines could be clas-
sified into five stages, from the initiation of the distrac- Fig 8. Frequency of apical root resorption scores (A)
tion to the complete remodeling of the new alveolar and lateral surface root resorption scores (B) for maxil-
bone (Fig 9). lary and mandibular canines.
Stage 1. Stretching and widening of the periodontal
ligament. This was in the first week after initiating ually decreasing radiodensity, initiating from the
the distraction. Bone formation was not evident in native lamina dura toward the canine. It eventually
this stage. would become the new lamina dura on the mesial
side of the canine. The radiodensity of the remod-
Stage 2. Active growing of striated bone (new bone
eling striated bone was similar to the cancellous
spicules) in the distracted periodontal ligament. This
alveolar bone. The native lamina dura disappeared
occurred during the second week after the initiation
gradually.
to the end of distraction. Striated bone was growing
actively in the distracted periodontal ligament. Stage 5. Maturation of the striated bone was 3
months after completing the distraction. The native
Stage 3. Recovery of the distracted periodontal lig-
lamina dura disappeared and the new lamina dura
ament. This occurred in the first to fourth week after
was of normal thickness. On the radiographs, the
completing the distraction. The striated bone
interseptal bone between the lateral incisor and the
became denser, gradually extending from the distal
canine was indistinguishable from the other inter-
lamina dura (native lamina dura) of the interseptal
septal bones.
bone, distal to the lateral incisor, toward the canine.
The distracted periodontal ligament gradually Reaction to Pulp Vitality Tester
decreased in width and back to normal. The radi-
Before placing the fixed orthodontic appliance, all
ographic characteristics of the striated bone created
the teeth tested positively to the electronic pulp tester.
by the distraction were similar to a cortical bone or
All of them were still under orthodontic forces when
thickened lamina dura.
the second pulp vitality tests were performed. After
Stage 4. Remodeling of the striated bone occurred canine distraction, 5 of the 15 upper distracted canines
from the fourth week to the third month after com- and 4 of the 11 lower distracted canines reacted posi-
pleting the distraction. The striated bone had grad- tively to the electronic pulp tester. None of the second
378 Liou and Huang American Journal of Orthodontics and Dentofacial Orthopedics
October 1998

Fig 9. Staging of radiographic changes of periodontal ligament during and after canine distraction. A, Stage 1, stretch-
ing periodontal ligament. B, Stage 2, active bone growth. C, Stage 3, recovery of distracted periodontal ligament. D,
Stage 4, remodeling of striated bone. E, Stage 5, maturation of striated bone. (See text for details.)

premolars tested reacted positively after canine distrac-
tion. Four of the 15 upper lateral incisors and 2 of the
11 lower lateral incisors reacted positively after canine
distraction.
DISCUSSION
In this study, we have successfully demonstrated
that periodontal ligament can be distracted just like the
midpalatal suture in rapid palatal expansion, and the
canine can be retracted rapidly with the use of this
concept. However several questions still have to be
discussed.
Why was the mesial movement of the first molar
minimal? After the initial tooth movement by a light or
heavy orthodontic force, a lag period of minimal tooth
movement persists for approximately 2 to 3 weeks
before tooth movement again proceeds.12-16 In this
study, the canine distraction was completed while the
first molar was still in its lag period or just initiating
its mesial movement.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 114, Number 4
The periodontal ligament is essentially a hydrostat-
ic system maintained by blood pressure of the capillary
bed. A force in excess of 26 g/cm2 was estimated to
strangulate the periodontal tissues, forcing the tooth
into physical contact with the alveolar bone and caus-
ing necrosis.17,18 The initial obstacle to orthodontic
tooth movement is the necessary elimination of the
necrotic (hyalinizing) tissues by undermining resorp-
tion.7-9 The elimination of the hyalinizing tissues takes
2 to 3 weeks, which is the lag period.15
Any technique that takes longer than 3 weeks to
retract a canine will result in loss of anchorage.
Because not only the canine but also the anchor unit
will move to each other after the lag period. The aver-
age time of a canine retraction takes 4 to 6 months
according to the anchorage needs. However, the anchor
unit also will move forward accordingly (loss of
anchorage). The best way to avoid losing anchorage is
to move the canine before the anchor unit moves.
Why was the root resorption minimal? External
root resorption is initiated 2 to 3 weeks after the ortho-
dontic force is applied and may continue for the dura-
tion of force application.19-22 In this study, the canine
distraction was completed within 3 weeks while the
root resorption was just initiating.
It is generally accepted that a certain degree of root
resorption will occur in patients undergoing orthodon-
tic treatment and a variety of conditions may be relat-
ed to the root resorption. An association between the
increased root resorption and the duration of the
applied force has been reported.23-26 The duration of
the applied force is an aggravating factor for the root
resorption, and it is regarded as a more critical factor
than the magnitude of the force,23,27 especially in con-
nection with long treatment periods.28 The best way to
minimize the root resorption induced by orthodontic
tooth movement is to complete the tooth movement in
a short duration or even before initiation of root
resorption.
Why can the canine be distracted so fast while the
first molar was still in the lag period? The orthodontic
tooth movement is faster and root surface resorption is
less in an alveolar bone with loose bone trabeculae and
less bone resistance.29-32 In this study, the canine was
distracted into an extraction socket that has not been
refilled by solid bone tissue.
After tooth extraction, regenerative bone tissue will
refill the extraction socket in 3 weeks and become
resistant and solid in 3 months.33 If the canine is not
retracted across the first premolar extraction socket in
the first 3 weeks, the rate of tooth movement will slow
down, root surface resorption will increase, and the
anchor unit will start to move forward.
Liou and Huang 379
Before the extraction socket becomes resistant and
solid, especially in the first 3 weeks after the first pre-
molar tooth extraction, the interseptal bone distal to the
canine is the only significant obstacle in the way of the
canine distraction. To elicit a rapid canine retraction
with minimal undermining resorption and lag period, it
has to be removed, weakened, or bent into the socket.
In this study, the interseptal bone distal to the canine
was undermined surgically to weaken its strength. It
was bent by the distraction and it closely followed the
tooth movement.
Since the nineteenth century, it has been proposed
that one of the mechanisms of orthodontic tooth move-
ment is the bending of alveolar bone.34,35 Angle36
claimed in 1907 that the first and principle response to
orthodontic force was the bending of the alveolar
process. He illustrated the bending of alveolar bone by
noting that the bony septum closely followed a moving
tooth, which was exactly the same as we observed in
this study. Epker and Frost37,38 concluded that the alve-
olar wall assumed to be under pressure might actually
be under tension from the strain resulting from bone
deflection. Baumrind39 and Grimm40 observed that
flexion of the alveolar bone results in recruitment of
osteoclasts and osteoblasts on the tension and pressure
sides. Picton41 demonstrated that the bending of the
alveolar bone could constitute as much as 25% of the
initial tooth movement.
To keep bending the interseptal bone distal to the
canine and carrying it with tooth movement, an ortho-
dontic force has to be heavy enough. However, a light
continuous force generated by the conventional ortho-
dontic appliances may be not strong enough to keep
bending the interseptal bone. In this article, we suc-
cessfully demonstrated that by using a distraction
appliance and undermining the interseptal bone surgi-
cally, the interseptal bone bends and moves along with
the canine into the extraction socket. The root resorp-
tion and lag period of the canine were minimized or
even eliminated.
Distraction Osteogenesis in the Periodontal
Ligament
In this study, the periodontal ligaments of the
canines were distracted 6 to 7 mm in 3 weeks. Some of
the ligaments could even be torn during the canine dis-
traction. However, they healed completely 1 month
after completing the distraction, and the new bone cre-
ated became radiographically mature in 3 months.
None of the cases reported severe pain and no
infrabony defect was observed radiographically and
clinically.
The healing process and osteogenesis of the dis-
380 Liou and Huang
tracted periodontal ligament were similar to those in
the midpalatal suture during rapid palatal expansion
and in the mandibular distraction as well. The dis-
tracted midpalatal suture was filled with disorganized
fibrous connective tissue, and it ossified rapidly and
ultimately regained a normal appearance.42 The min-
eral content within the suture rose rapidly during the
first month after the completion of the distraction,
and the process of mineralization has become fairly
well established 3 months after the completion of dis-
traction.43
In mandibular distraction,44-46 the distraction gap
was radiolucent in the beginning, and gradually filled
with striated bone. It took about 10 weeks for the stri-
ated bone to fill the gap completely in mandibular dis-
traction, but it was 4 weeks in the canine distraction.
The striated bone took 5 to 6 months for remodeling
and was still less radiodense than the native mandible,
even 1 year after distraction,47 but it took only 3
months for canine distraction.
The process of new bone maturation in canine dis-
traction was faster than that in mandibular distraction
osteogenesis. Liou et al48 also found that the new bone
created by the rapid orthodontic tooth movement
matured faster than the new bone created by mandibu-
lar distraction. Radiographically, the new bone matura-
tion in the distracted periodontal ligament was more
similar to the midpalatal suture in rapid palatal expan-
sion. However, it still needs histologic studies to com-
pletely analyze the mechanism and healing process of
canine distraction.
Pulp Vitality, Root Ankylosis?
It is generally accepted that pulp vitality tests are
not reliable when the tested tooth is undergoing ortho-
dontic movement. The effects of distraction on pulp
vitality of the canines cannot be accurately determined
by the electronic pulp tester. Laser Doppler flowmetry
may be a more reliable method in detecting blood flow
in the pulp tissues of those teeth under distraction.
Except for some minimal root resorption, we have not
observed any endodontic and periodontal lesions clin-
ically or radiographically. In an animal study done in
the Craniofacial Center, University of Illinois at
Chicago, Liou et al11 demonstrated that the pulp is still
vital, even though the tooth was moved rapidly at the
rate of 1.2 mm per week. Similarly, it has also been
shown that the inferior alveolar nerve and blood ves-
sels also regenerate in a short period after mandibular
distraction.49,50
We have not observed root ankylosis since using
canine distraction. The canines responded to orthodon-
tic forces after the distraction and the periodontal liga-
American Journal of Orthodontics and Dentofacial Orthopedics
October 1998
ments are patent. However, the long-term effects of
canine distraction (rapid canine retraction) are current-
ly not well known and need close monitoring.
CONCLUSION AND CLINICAL IMPLICATION
The periodontal ligament can be distracted just like
the midpalatal suture in rapid palatal expansion. By
using this concept, canines can be distracted distally
6.5 mm in 3 weeks without significant complication.
However, the clinical techniques and procedures in
canine distraction still need to be refined. The long-
term effects on root resorption, subsequent develop-
ment of a developing root, pulp vitality, periodontal tis-
sues, and possible root ankylosis of the canine should
be closely monitored.
This new concept and technique is best used on
those cases whose anterior teeth are severely crowded
or protruded. The canines can be distracted rapidly, and
almost all of the extraction space can be used for ante-
rior dental alignment or retraction. After distraction,
the anterior tooth retraction can be rapid as well, while
the new bone tissues distal to the lateral incisors are
still fibrous. In addition to orthodontic tooth move-
ment, we might possibly use this new concept and
technique to generate new bone and keratinized gingi-
val tissue for treating periodontal disease.
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19. Reitan K. Initial tissue behavior during apical root resorption. Angle Orthod 1974;44:
68-82.
20. Williams S. A histomorphometric study of orthodontically induced root resorption.
Eur J Orthod 1984;6:35-47.
21. Engstrom C, Granstrom G, Thilander B. Effect of orthodontic force on periodontal tis-
sue metabolism: a histological and biochemical in normal and hypocalcemic young
rat. Am J Orthod Dentofacial Orthop 1988;93:468-95.
22. Kurol J, Owman-Moll P, Lundgren D. Time-related root resorption after application of
a controlled continuous orthodontic force. Am J Orthod Dentofacial Orthop 1996;110:
303-10.
23. Harry MR, Sims MR. Root resorption in bicuspid intrusion: a scanning electron
microscope study. Angle Orthod 1982;52:235-58.
24. Kvam E. Scanning electron microscopy of tissue changes on the pressure surface of
human premolars following tooth movement. Scand J Dent Res 1972;80:357-68.
25. Goz G, Rakosi T. Die apikal Wurzelresorption unter kieferorthopadischer Behandlung.
Fortshr Kieferorthop 1989;50:196-206.
26. McFadden WM, Engstrom C, Engstrom H, Anholm JM. A study of relationship
between incisor intrusion and root shortening. Am J Orthod Dentofacial Orthop
1989;96:390-6.
27. Stenvik A, Mjor I. Pulp and dentine reactions to experimental tooth intrusion: a histo-
logical study of the initial changes. Am J Orthod 1970;57:370-85.
28. Vardimon AD, Graber TM, Voss LR, Lenke J. Determinants controlling iatrogenic
external root resorptions and repair during and palatal expansion. Angle Orthod
1991;61:113-22.
29. Midgett RJ, Shaye R, Fruge JF. The effect of altered bone metabolism on orthodontic
tooth movement. Am J Orthod 1981;80:256-62.
30. Goldie RS, King GJ. Root resorption and tooth movement in orthodontically treated,
calcium deficient, and lactating rats. Am J Orthod 1984;85:424-30.
31. Collins MK, Sinclair PM. The local use of vitamin D to increase the rate of orthodon-
tic tooth movement. Am J Orthod Dentofacial Orthop 1988;94:278-84.
32. Ashcraft MB, Southard KA, Tolley EA. The effect of corticosteroid-induced osteo-
porosis on orthodontic tooth movement. Am J Orthod Dentofacial Orthop 1992;102:
310-9.
33. Avery JK. V. Structure of periodontium: wound healing. In: Avery JK, ed. Oral devel-
opment and histology. Baltimore: William & Wilkins, 1987. p. 282-92.
Discussion
Alvaro A. Figueroa, DDS, MS,a,b John W. Polley, MDa
Chicago, Ill
In this clinical study, the authors have demonstrated
that it is possible to rapidly move teeth into extraction
spaces after minor surgical scoring of the interseptal
bone at the time of the dental extractions. A custom-
made, rigid, segmental, tooth-borne appliance was used
to rapidly retract the canines at the rate of 2.2 mm per
week. The anchorage units (first molar and second pre-
molars) were able to withstand the retraction force with
minimal anchorage loss. The authors reported no clini-
cal and radiographic evidence of root and gingival dam-
age as a result of the rapid tooth movement.
The authors of this study are to be commended as it
is very likely that their innovative approach may revo-
lutionize orthodontic treatment. They have used the
aCraniofacial Center
bDepartment of Orthodontics, University of Illinois at Chicago.
Liou and Huang 381
34. Kingsley Norman. Treatise on oral deformities as a branch of mechanical surgery.
New York: Appleton & Company; 1880.
35. Farrar JN. A treatise on the irregularities of teeth their corrections,AQ4 Vol. 2. New
York: DeVinne Press; 1888. p. 758.
36. Angle EH. Treatment of malocclusion of the teeth, 7th Ed. Philadelphia: SS White
Dental Manufacturing Company; 1907. Chap. 6.
37. Epker BN, Frost HM. Correlation of bone resorption and formulation with the physi-
cal behavior of loaded bone. J Dent Res 1965;44:33-41.
38. Epker BN, Frost HM. Biomechanical control of bone growth and development: a his-
tological and tetracycline study. J Dent Res 1966;45:364-71.
39. Baumrind S. A reconsideration of the propriety of the pressure-tension hypothesis.
Am J Orthod 1969;55:12-22.
40. Grimm FM. Bone bending, a feature of orthodontic tooth movement. Am J Orthod
1972;62:384-93.
41. Picton DCA. On the part played by the socket in toot support. Arch Oral Biol
1965;10:945-55.
42. Cleall JF, Bayne DJ, Posen JM, Subtelney JD. Expansion of the midpalatal suture in
the monkey. Angle Orthod 1965;35:23-35.
43. Ekstrom C, Henrikson CO, Jensen R. Mineralization in the midpalatal suture after
orthodontic expansion. Am J Orthod 1977;71:449-55.
44. Costantino PD, Shybut G, Friedman CD, Pelzer HJ, Masimi M, Shindo ML, Sisson
GA. Segmental mandibular regeneration by distraction osteogenesis. Arch Otolaryn-
gol Head Neck Surg 1990; 116:535-45.
45. Karp NS, McCarthy JG, Schreiber JS, Sissons HA, Throne CHM. Membranous bone
lengthening: a serial histological study. Annals Plast Surg 1992;29:2-7.
46. Karaharju-Suvanto T, Karaharju EO, Ranta R. Mandibular distraction: an experimen-
tal study on sheep. J Craniomaxillofac Surg 1990;18:280-3.
47. Costantino PD, Friedman CD, Shindo ML, Houston CG, Sisson GA. Experimental
mandibular regrowth by distraction osteogenesis: long term results. Arch Otolaryngol
Head Neck Surg 1993;119:511-6.
48. Liou EJW, Figueroa AA, Polley JW. The effects of orthodontic tooth movement on the
distraction osteogenesis. International Symposium on Distraction Osteogenesis in
Cranio-Maxillofacial Surgery, Stuttgart, Germany, September 11-13, 1997.
49. Block MS, Daire J, Stover J, Matthews M. Changes in the inferior alveolar nerve fol-
lowing mandibular lengthening in the dog using distraction osteogenesis. J Oral Max-
illofac Surg 1993;51:652-60.
50. Ganey TM, Klotch DW, Sasse J, Ogden JA, Garcia T. Basement membrane of blood
vessels during distraction osteogenesis. Clinical Orthopaedics and Related Research
1994;301:132-8.
knowledge and experience gained in the field of dis-
traction osteogenesis and have applied it to orthodon-
tics. Their work is based on a pilot canine study in
which teeth were rapidly moved orthodontically into
new bone created after distracting the osteotomized
body of the mandible.1,2
The authors rightly have pointed out that orthodon-
tic tooth movement is essentially distraction of the peri-
odontal fibers (tension side) and transport of the
tooth/alveolar bone complex with subsequent osteogen-
esis. They have also brought to our attention the fact
that rapid maxillary expansion is another variant of the
distraction osteogenesis concept. In an innovative fash-
ion, they have incorporated a simple, noninvasive “cor-
ticotomy” of the alveolar bone at the time of premolar
extraction to allow for “bending or transport” of the
alveolar-tooth complex into the extraction space. This
approach is based on principles of distraction used in
382 Liou and Huang
the long bones and craniofacial bones, such as the
mandible and maxilla. On the pressure side, the trans-
ported alveolar bone-tooth complex brings its own
bone into the extraction space with osteogenic potential
and minimal pressure on the preserved alveolar bone.
On the tension side, it appears that the periodontal lig-
ament is able to withstand the rapid rate of movement
with stretching of the periodontal fibers, followed by
osteogenesis and ossification.
Distraction osteogenesis is a procedure that was
used as early as 1905 by Codivilla in Bologna, Italy3
and later popularized by the clinical and research stud-
ies of Ilizarov in Russia.4-6 In 1992, distraction osteo-
genesis was first applied to the human mandible by
McCarthy et al,7 and since then it has been applied to
all the bones of the craniofacial skeleton, including the
midface and maxilla.8-12 Liou and Huang have now
applied this concept to orthodontic tooth movement.
Of course, the widespread application of this
approach awaits further follow-up in which issues con-
cerning tooth vitality, periodontal attachment levels,
and periodontal health of the rapidly moved teeth
should be investigated. The application of this tech-
nique may have appeal for those treating adult patients,
in which treatment time is a strong factor toward treat-
ment acceptance. Further, this technique may have
application in those cases with periodontal compromise
as it may assist in osteogenesis and regeneration of lost
alveolar bone. On the other hand, case selection may be
limited to those teeth well-aligned within the alveolar
ridge (not crowded) cases requiring extraction, ie,
bimaxillary dentoalveolar protrusion. Rapid movement
of canines labially positioned may compromise their
thin labial plate and soft tissue attachment.
Various other applications are also viable, such as
rapid movement of the four anterior teeth into the
newly created bone after rapid retraction of the canines.
Also the application of “minor” ostectomies and osteo-
tomies distal to the lateral incisors facilitate “en masse”
American Journal of Orthodontics and Dentofacial Orthopedics
October 1998
retraction of the anterior incisors both in the maxilla
and mandible. Another important application may be in
those teeth that are impacted in which osteotomies and
ostectomies can be performed around the tooth, fol-
lowed by rapid orthodontic tooth movement. Further, it
will be important to know if this approach can be
applied to multirooted teeth for either anterior or pos-
terior movement.
Finally, refinements in the surgical technique, such
as the use of corticotomies versus full osteotomies and
the applicability of the technique in those teeth close to
the mandibular dental nerve, should be considered. The
use of new biomechanical principles and orthodontic
appliances to maintain control of the rapid tooth move-
ment awaits further development before the routine
application of this innovative and exciting approach.
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osteogenesis [Abstract 182]. American Cleft Palate-Craniofacial Association. 55th
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