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168]

Review Article

Periodontically accelerated orthodontic

tooth movement: A narrative review
Karan Sharma, Puneet Batra, Saurabh Sonar, Amit Srivastava,
Sreevatsan Raghavan

Department of Abstract:
Orthodontics, Institute Adult orthodontics has gained widespread acceptance recently with the introduction of more esthetic options for
of Dental Studies the patient. The major deterrent that remains is the prolonged treatment time associated with comprehensive
and Technologies, orthodontic treatment. The objective of this paper is to present a review of techniques, which could be employed
Modinagar, by the orthodontist in conjunction with a periodontist to enhance the rate of orthodontic tooth movement. The
Uttar Pradesh, India biological rationale and clinical manipulation have been discussed with a brief review of the current literature
about these techniques. The interdisciplinary approach involving the orthodontist and the periodontist can benefit
the patient by affording them with reduced treatment time.
Key words:
Alveolar process/surgery, cortical bone/surgery, malocclusion/therapy, osteogenesis, tooth movement
techniques/methods

INTRODUCTION osteoperforations can be utilized in a regular

clinical setup without the need for general

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Website:
T he demand, as well as acceptance of
orthodontic treatment by the adult population,
has increased considerably, with the availability
www.jisponline.com
of more esthetic options for the patients to choose
DOI: from, the problem of bulky steel brackets more
10.4103/jisp.jisp_207_18
or less has been addressed. The other reason
Quick Response Code: most commonly cited for reluctance to accept
the orthodontic treatment is the long duration
of the treatment. A recent systematic review
has indicated that a comprehensive orthodontic
treatment takes <2 years to be completed. [1]
Patients expect a shorter duration of treatment
time of about 6–12 months.[2]
Many authors have described methods to reduce
the overall treatment time for comprehensive
orthodontic treatment. These methods can be
broadly classified into nonsurgical methods and
surgical methods.
Nonsurgical methods include the use of limited
orthodontic treatment, self‑ligating brackets,[3,4]
customized appliance, [5,6] medication, [7‑11]
Address for
correspondence:
microvibrations, [12] low‑intensity laser, [13]
Dr. Karan Sharma, photobiomodulation,[14] electromagnetic fields,[15]
and direct electrical currents.[16]
Department of
Orthodontics, Institute
of Dental Studies and Surgical methods include
Technologies, Modinagar,
micro-osteoperforations, [17] piezocision, [18]
Uttar Pradesh, India.
corticotomies, [19] osteotomies/periodontal
E‑mail: dr.sharmakaran@
gmail.com
ligament (PDL) distraction,[20] surgery first.[21]
Submission: 29‑03‑2018 Out of the surgical methods outlined,
Accepted: 09‑07‑2018 corticotomies, piezocision and micro
© 2018 Indian Society of Periodontology | Published by Wolters Kluwer ‑ Medknow 5
anesthesia. These may prove to be a clinical
tool which is readily available to the clinician
to accelerate the tooth movement and decrease
the overall treatment time, without the need for
additional inventory. Following is a biological
rationale and a brief narrative about three
procedures.
BIOLOGIC RATIONALE
Bone is a dynamic tissue, and it reacts to the
external load put on it by modifying its internal
as well as external structure. [22] The cellular
components within the bone play an intricate
role by complex interactions between them
to bring about the above‑said changes. These
cellular components within the bony tissue
are osteocytes, osteoblasts, and osteoclast.
Osteoblasts line the bone surface and secrete the
organic bone matrix (Osteoid), which then gets
calcified. Mature osteoblasts which get trapped
in this calcified matrix turn into osteocytes. These
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How to cite this article: Sharma K, Batra P,
Sonar S, Srivastava A, Raghavan S. Periodontically
accelerated orthodontic tooth movement: A narrative
review. J Indian Soc Periodontol 2019;23:5-11.
[Downloaded free from http://www.jisponline.com on Sunday, August 16, 2020, IP: 122.173.96.168]
Sharma, et al.: Periodontically accelerated orthodontic tooth movement
osteocytes function as a sensor of mechanical load on the bone
and initiate bone remodeling involving both the osteoblasts
and osteoclasts. This bone remodeling is an essential aspect
of orthodontic tooth movement, any attempt to accelerate the
orthodontic tooth movement is centered around modifying
this remodeling process.
Research in the field of orthodontic tooth movement has
revealed that osteoclastic activity is the rate‑limiting step,
which determines the rate of orthodontic tooth movement. Any
attempt to increase the rate of orthodontic tooth movement
should be focused around osteoclast and on the various
processes by which osteoclast are recruited and differentiated
to initiate bone resorption.[23]
Inflammatory markers like cytokines play an important role in
osteoclast recruitment and differentiation, any process leading
to an increase in the levels of these proinflammatory markers
may increase the rate of tooth movement. There are different
methods described in the literature to increase the levels of
cytokines locally.[24‑26]
The levels of the cytokines can be increased by locally
injecting them at the site of orthodontic tooth movement,
but this method is not conducive at a clinical level as these
inflammatory markers have a very short half‑life, when injected
and disintegrate before any useful clinical tooth movement
can occur.[27]
Another method to raise the levels of these cytokines locally
is to induce microtrauma within the bone and the PDL.
Procedures such as corticotomy, piezocision and micro‑osteo
perforations (MOP) are employed to induce trauma, which
in turn increase the levels of pro‑inflammatory markers such
as tumor necrosis factor alpha, interlukin (IL)‑1, IL‑6 locally.
These procedures can be utilized in a clinical set up to increase
the rate of tooth movement temporally.[28]
The concept of the inflammatory cascade and its role in wound
healing led to the development of corticotomy facilitated tooth
movement by L C Bryan in 1893. It was later re‑introduced by
Kole in 1959 for rapid movement of the tooth.[29] His method
involved osteotomy cuts being placed subapically into the full
alveolus to cause bodily tooth movement after application of
orthodontic forces. Due to its invasive nature and the amount
of surgical trauma, the patient acceptance of this method was
limited.
Wilcko et  al.[30] reported two cases of de‑crowding with the
use of corticotomy cuts extending into the cortical bone
plates barely entering the medullary space. The biological
response to iatrogenic injury with corticotomy results from
“Regionally Accelerated Phenomenon” (RAP)[31] as described
by Frost, is seen as a consequence of the inflammation of the
wound area. This is characterized by transient functional
osteopenia followed by accelerated bone turnover over the
course of time. The decreased mineral density allows for easier
orthodontic movement of teeth during the remodeling and
healing. RAP is said to typically peak till about 1–2 months
and lasts about 4 months postsurgery. It is regulated by the
RANK‑RANKL/OPG axis where osteoclast accumulation
takes place in the direction of the movement of the tooth and
6 Journal of Indian Society of Periodontology - Volume 23, Issue 1, January-February 2019
new bone formation at the tension side of the tooth.[32‑34] New
bone mineralization takes place at about 20–55 days, where the
fibrous tissue is later replaced by bone.[35]
CORTICOTOMIES
Wilcko combined the refined corticotomy‑facilitated orthodontic
technique with alveolar augmentation and named the
orthodontic and periodontal aspects of this procedure the
accelerated osteogenic orthodontics (AOO) technique, and more
recently, the periodontally AOO surgical technique, respectively.
Case selection
PAOO can be utilized to treat Class I cases having
moderate‑to‑severe crowding, mild‑to‑moderate Class II and
Class III cases and patients requiring unilateral expansion.
A close interaction between the orthodontist and the
periodontist is required. Areas requiring corticotomies are
defined, and teeth which are going to serve as anchor teeth
are delineated earlier. Any adjunct procedure which might
be required along with the corticotomies, for example, free
gingival grafts should also be planned beforehand to reduce
any further surgical trauma to the patient.
Orthodontic strap up should be planned carefully as the
application of orthodontic force should not be delayed >2 weeks
after the surgery.
Procedure
Generally, the orthodontic appliance is placed 1 week before
the surgical procedure and subsequent orthodontic visits are
planned at a 2‑week interval.
The surgical procedure could be performed under general or
local anesthesia as required. Full‑thickness flaps are raised
labially and lingually [Figure 1]. Including or excluding the
interdental papilla in the flap depends on the preference of
the surgeon. Interdental papilla on the lingual side between
the maxillary central incisors are usually not included in the
flap as the presence of the nasopalatine foramen in that region
prevents any osteotomy to be performed in that region. In
addition, vertical releasing incisions can be used and are
usually placed one tooth away from the intended area of the
osteotomy. Adequate flap reflection should be done till area
near the apices of the teeth. Sometimes, a full‑thickness flap
in the coronal portion and a split thickness flap in the apical
portions maybe raised to ensure a tensionless closure of the
flap after the surgical procedure.
A high‑speed handpiece with a No 1 or No 2‑round bur,
physio dispenser, and piezoelectric knife can be utilized for
decortication. Vertical grooves are made in the inter‑radicular
portion of the alveolar bone, extending from 2 to 3 mm from
the crest of the alveolar bone and going 2 mm apical to the root
apices. Decortication is done on both the labial/buccal and
palatal/lingual aspects. The vertical osteotomies are connected
with circular osteotomies [Figure 2]. Care should be taken to
avoid any neurovascular structures.
As recommended by Wilcko, all the areas undergoing
decortication require a bone graft, with the decorticated surface
acting as a scaffold for the graft material. The amount and
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Sharma, et al.: Periodontically accelerated orthodontic tooth movement
Figure 1: Full thickness flap reflected
Figure 3: Interrupted sutures placed
Figure 5: Micro-osteoperforations being done
direction of tooth movement anticipated and pretreatment
thickness of existing alveolar bone determine the amount of
graft. Usually, 0.25–0.5 ml of graft material is required per tooth.
Autogenous bone, allograft, xenograft, or a combination of
these can be utilized with barrier membranes usually not being
required. The flaps are sutured back making sure that there is
no tension present. Interrupted sutures with a nonresorbable
material are preferred [Figure 3].
Journal of Indian Society of Periodontology - Volume 23, Issue 1, January-February 2019 7
Figure 2: Corticotomy cuts placed
Figure 4: PROPEL device
Various studies in orthodontic patients have addressed the
efficacy of corticotomy in accelerating the tooth movement
in an orthodontic patient. Bhat et al. have demonstrated the
effectiveness of this procedure in published case reports.[36] The
studies by Mohammed et al.[37] in 2011 and Al‑Naoum et al.[38] in
2014 both have concluded that corticotomy‑assisted accelerated
tooth movement may be a viable treatment option for adults
seeking orthodontic treatment. A systematic review[39] in
2013 compared five different methods used for accelerating
orthodontic tooth movement (low‑level laser therapy,
corticotomy, electrical current, pulsed electromagnetic fields,
and dentoalveolar or periodontal distraction). The authors
concluded that among the five methods, corticotomy was the
most reliable and safe method to accelerate tooth movement
hence reducing the overall treatment time. Two systematic
reviews one in 2014[40] and another in 2018[41] corroborated with
the above‑mentioned statement; however, more recently the
Cochrane review[42] and a meta‑analysis[43] on the same subject
suggested that the level of evidence in support of corticotomy
and surgically‑assisted accelerated tooth movement was low
and well‑designed studies were required to make definitive
evidence‑based decisions. Therefore, to summarize, while
there are suggestions regarding corticotomy in being effective
in accelerating orthodontic tooth movement; further research
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Sharma, et al.: Periodontically accelerated orthodontic tooth movement
is needed to justify it as a clinical tool which could be used
regularly.
Piezocision
An alternative to the conventional corticotomies is piezocision,
which is a conservative procedure that does not involve raising
a full‑thickness flap. Due to this reason, patients readily
accept this procedure in place of a conventional corticotomy.
An animal histological study conducted has revealed that
RAP due to piezocision may be greater than conventional
corticotomy because of the use of Piezosurgery knife at
specific vibrations.[44] This could be due to the additive effect
of the osteocytes’ response to micro‑vibrations created by the
ultrasonic handpiece at specific settings.
Procedure
Similar to corticotomy, the orthodontic appliance should be
in position 1 week before the piezocision. A mid‑level vertical
incision is placed on the buccal and the interdental aspect to
facilitate the insertion of the piezoelectric knife. A 3‑mm deep
piezoelectric corticotomy is done through the vertical incision. It is
essential that the bony cut should pass through the cortical bone
and be deep enough to reach the medullary bone. The incision
is closed using interrupted sutures of a nonresorbable material.
The patient is then seen by the orthodontist after every 2 weeks.
While the literature regarding the efficacy of piezocision is
limited, a few case reports[45] (Pakhare VV) and well‑designed
randomized controlled trials[46] have given a favorable view
for the procedure, with a reduction of about 43% in the total
treatment time being reported. Similarly, another study[47]
reported that piezocision‑assisted distalization accelerates
tooth movement and decreases anchorage loss. However, a
few authors have compared corticotomy and piezocision, with
the results favoring corticotomy in being the more effective
method.[48] As with corticotomies, a recent systematic review,[49]
indicated weak evidence in support of piezocision.
MICRO‑OSTEOPERFORATIONS
MOP is the least invasive procedure which is undertaken to
increase the rate of orthodontic tooth movement. Without the
need of reflecting a full thickness flap, as required in conventional
corticotomy or incisions as required in piezocision, the MOPs
can be used to induce microtrauma to the alveolar bone, thus
producing RAP which in turn accelerates the rate of tooth
movement. The MOPs can be done by the treating orthodontist
without the requirement of additional health‑care professional,
thus reducing the overall cost of the procedure for the patient.
A Consortium for Translational Orthodontic Research,
New York University College of Dentistry, New York, in
collaboration with the Department of Developmental Biology,
Harvard School of Dental Medicine, Boston has advocated this
technique. The New  York University  (NYU) filled a patent
on micro‑perforations. Propel orthodontics Inc., licensed
this patent from NYU and developed a tool to facilitate the
procedure.[50]
Procedure
MOPs are done only before the initiation of the intended
tooth movement. After informed consent has been signed, the
8 Journal of Indian Society of Periodontology - Volume 23, Issue 1, January-February 2019
area where the MOPs are to be done is infiltrated by a local
anesthetic agent. The location of the MOPs is very critical to get
the maximum benefit. The MOPs should be close to the target
tooth. To get increased recruitment of osteoclasts (catabolic
effect), deep perforations are required (5–7 mm), whereas if
increased recruitment of osteoblasts is required (Anabolic
effect) then shallow perforations (1 mm) spread over a large
area is required.
Positioning of the micro‑osteoperforations
The MOPs should be placed in the attached gingiva to 1 mm
apical to the mucogingival junction. Clinically, the height of
the MOPs is dependent on the required tooth movement,
movements like torquing and intrusion might require MOPs
higher up in alveolar ridges near the apices of the teeth,
this might require vertical stab incisions in areas above the
mucogingival junction to avoid incisions in the movable
mucosa the MOPs can be placed obliquely so that the
perforation start in the attached gingiva but move apically in
an oblique fashion.
For deeper perforation, which is required for a catabolic effect,
the position of the root is very important to avoid any trauma
to the root surface. MOPs are required on both the mesial and
the distal portion of the target tooth.
In general, the MOPs are made on the buccal aspect avoiding
the lingual mucosa which is generally thinner than the
buccal mucosa. MOPs are required on the lingual aspect; if
the clinical situation requires so, contra angled handpieces
can be employed. In some cases where the residual ridge
has atrophied, MOPs will be required on the crest of the
residual alveolar ridge in addition to the buccal and the
lingual aspect.
Number and depth of the micro‑osteoperforations
Increasing the number of the MOPs is a potent method to
increase the catabolic effect of the MOPs. In a clinical scenario
placing 2‑4 MOPs per site is enough to initiate the catabolic
effect. Some sites may not permit increasing the number of
MOPs, in such cases increasing the depth of the MOPs can
compensate. MOPs of 5–7 mm can be placed to increase the
catabolic effect.
Clinical manipulation
1. The patient is asked to rinse with 15 ml of chlorhexidine
for 30 s
2. The area intended for MOPs is identified, and the area is
anesthetized by local infiltration
3. A sterile MOP device (PROPEL, Excel orthodontics) [Figure 4]
is used to perform the perforations. The PROPEL device has
markings for 3 mm, 5 mm, and 7 mm of lengths for varying
lengths of disposable tips that would be used according to
the depth of the MOP required
4. The desired length is set, and perforations are performed
on the cortical plate by gentle rotational movement until
the desired depth has been reached [Figure 5]
5. The MOP device is removed by rotational movements
6. Ideally, bleeding is not observed after MOP, but slight
bleeding might occur for some patients. If bleeding does
occur, normal hemostatic measures are enough to control
the bleeding
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Sharma, et al.: Periodontically accelerated orthodontic tooth movement
7. The treating orthodontist should inform the patient, that
slight discomfort is normal after the perforations. Analgesics
are usually not required after MOP but if pain control is
required acetaminophen can be prescribed. Nonsteroidal
anti‑inflammatory drugs are usually contraindicated as
their effect might inhibit the catabolic effect of the MOP
8. Chlorhexidine rinses are not required after the perforations,
but if the patient has poor oral hygiene, chlorhexidine rinses
can be initiated to prevent any postoperative complications.
Frequency of micro‑osteoperforation
For catabolic effect 3–5 repetitions of deep perforations are
required and for anabolic effect shallow perforations are
continued to enhance bone formation until the tooth movement
has been completed.
Orthodontic forces in a conventional set up are activated after
every 21 days, but in patients receiving MOPs to enhance
the rate of tooth movement, reactivation of the orthodontic
appliance is done after 2 weeks only. Application of orthodontic
forces leads to the secretion of cytokines locally; frequent
reactivation prevents any drop in the levels of cytokines which
are already saturated after the MOPs.
Saturation of the biological response
The accelerated response seen after inducing trauma to the
bone remains for a limited period, and saturation of the
biological response occurs after which the bone has to be
traumatized again to elicit the acceleration in tooth movement.
With procedures such as corticotomy and piezocision there
is a period of 4–6 months after which the saturation of
the biological response occurs. With MOP, this saturation
period is of around 28 days. The procedure thus has to be
repeated because of this reduced window of accelerated tooth
movement with MOP.
Force Magnitudes with micro‑osteoperforation
As seen earlier the perforations have to be repeated after
28 days to keep the RAP activated with MOP. Repeated
perforations lead to a decrease in the bone density of that
particular area. As a result, the saturation point increases thus
orthodontic forces of heavier magnitude can be tolerated by the
patient, which lead to increase in the rate of tooth movement.
The status of the literature regarding the effectiveness of MOPs
as a procedure to increase the rate of tooth movement is not
very conclusive. The initial few studies, which discuss the
effectiveness of the procedure, have been animal studies.[28,51]
Human trials on this have been done by the researchers at the
university where this procedure was patented and licensed to a
company for the development of a commercial product.[17] Bias
cannot be ruled out when discussing the results of the study.
A split‑mouth micro‑computed tomography study conducted
recently has shown that patients undergoing MOPs might
have a greater mean volumetric root loss when compared to
the control side.[52] Recently, a controlled trial assessing the
efficacy of MOPs as a technique was done, it concluded that
MOPs were not effective in accelerating orthodontic tooth
movement.[53] Further research is needed to clear the ambiguity
regarding the effectiveness of MOPs in accelerating orthodontic
tooth movement.
Journal of Indian Society of Periodontology - Volume 23, Issue 1, January-February 2019 9
Disadvantages of the surgical methods
1. Surgical morbidity associated with the procedures
2. Increased cost of the procedure has to be borne by the
patient
3. If not carried out properly chances of damage to the roots
of adjacent teeth
4. Chances of pain, infection, and swelling after the procedure
if proper hygiene is not maintained.
CONCLUSION
Increase in the rate of orthodontic tooth movement facilitated
surgically could be used to reduce the overall treatment time
for comprehensive Orthodontic treatment. Though the increase
is temporary in nature because of the biological saturation
point (after which the RAP reduces), a significant reduction in
the treatment time could be brought about. Procedures such
as corticotomy and piezocision may have a RAP for around
4–6 months during which acceleration in the tooth movement
might occur. As for MOP, the RAP lasts around 28 days after
which the procedure has to be repeated. The current literature
indicates that these procedures might be capable of reducing
the overall treatment time, further controlled trials are required
to raise the level of the evidence in support so that these
procedures could be used routinely with prescribed practice
guidelines.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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