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Kantarci A, Will L, Yen S (eds): Tooth Movement. Front Oral Biol. Basel, Karger, 2016, vol 18, pp 28–35
DOI: 10.1159/000351897
Kantarci A, Will L, Yen S (eds): Tooth Movement. Front Oral Biol. Basel, Karger, 2016, vol 18, pp 28–35
DOI: 10.1159/000351897
Change in bone mass
+
– Remodeling
Modeling
0 50 1,500 3,000 ı
Fig. 1. The mechanostat for dentists. The upper part shows the graph of bone activities in relation to the mechanical
history. The four mechanical usage windows are described in the text. Bone turnover is increased with negative bone
balance (–) in the disuse windows, as in edentulous areas. Bone balance is maintained in the adapted and in the mild
overload windows, with a tendency towards new bone formation via surface hypertrophy, as shown in cases of den-
tal implants. New bone formation and increased activation of BMUs is seen in the pathological overload windows, as
following the application of an orthodontic load with woven bone formation. In the lower part of the figure, histo-
logical sections showing an atrophic mandibular human specimen, a histological section of a human mandible with
load-bearing teeth, a section of a dental implant and the surrounding alveolar bone, and a section of maxillary alveo-
lar bone of rat showing (yellow marks) increased formation of woven bone following the application of an orthodon-
tic load (with permission from Libra Ortodonzia and reprinted from Verna et al. [29], with permission from Elsevier).
In the so-called ‘disuse windows’ strains are be- areas (fig. 1). In the so-called ‘adapted window’
low 50 με, well below the physiological range. the typical bone strain ranges between 50 and
BMU formation in this window increases with 1,500 με, with normal formation of BMU and bal-
negative bone balance occurrence and conse- ance between resorption and formation. This is
quent weakening of bone. No microdamage or the case of the alveolar bone with healthy peri-
RAP occurs at this strain level. The case of disuse odontium loaded by teeth (fig. 1).
atrophy following immobilization is the typical In the so-called ‘mild overload windows’ the
clinical situation reflecting unloading of bone. peak bone strain ranges from 1,500 to about 3,000
The related clinical situation for dentists is seen in με. The creation of BMU stays near the normal,
the alveolar ridge atrophy observed in edentulous no RAP occurs, while little new microdamage
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Univ. of California Santa Barbara
30 Verna
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Kantarci A, Will L, Yen S (eds): Tooth Movement. Front Oral Biol. Basel, Karger, 2016, vol 18, pp 28–35
DOI: 10.1159/000351897
arises. The generation of a macro- and a conse- situated in the ‘traditional’ compressive area is
quent microcrack is considered a triggering fac- loaded significantly less than the bone on the ten-
tor for the initiation of a remodeling cycle, whose sion side. Both compressive and tensile strains are
role it is to avoid the accumulation of cracks and present in the area from which the tooth is mov-
the consequent mechanical failure [4, 9, 10]. ing and no tension and very little compressive
However, the remodeling ensures an efficient re- strains are present in the bone in the direction of
moval of fatigue damage, and bone structural in- the force [12]. In the areas from which the tooth
tegrity is maintained. When the peak strain ex- is moving, the tensile stresses produced by the
ceeds 2,500 με, subperiosteal hypertrophy builds pulling of the PDL fibers are transformed into
bone mass to reduce the surface strain. In the case compressive hoop stresses similarly to the prin-
of alveolar bone, an example is the dental implant, ciple of the roman arch. Therefore, both tensile
where bone adapts to the new mechanical pat- and compressive stresses coexist on the ‘tension’
tern. Formation drift at this bone strain level usu- side. On the ‘pressure’ side the fibers of the PDL
ally results in lamellar bone (fig. 1). become curled up, and practically no stresses are
In the ‘pathological overload window’, bone is transferred onto the alveolar wall (fig. 2). Conse-
repetitively loaded at strains which are above quently, the hoop stresses are low as well, and the
3,000 με. BMU formation increases and the RAP overall stress concentration becomes much lower
occurs, consequently increasing bone turnover as on the ‘tension’ side. It seems therefore that the
rate. The newly formed bone is woven bone, and generally accepted concept, which suggests that
the risk of anarchic bone resorption occurs. Fa- compression leads to bone resorption and that
tigue damage accumulates more rapidly than it tension leads to bone formation, is questionable,
can be repaired, and the bone is at risk for stress and a more reasonable biological model seems to
fracture. It is the case of bone weakened by a cyst be the one involving loading/nonloading of the
or tumors. The mass and orientation of bone alveolar support structures. In a loading history
seems therefore to be molded through disuse at- perspective [13], this situation can be associated
rophy and overload hypertrophy [11]. It is inter- with the disuse window, when bone senses a de-
esting to consider the mechanical loading of the creased mechanical loading. Bone turnover in-
alveolar bone that occurs via the application of an creases, and resorption activities will prevail
orthodontic force bone in the light of the bone (fig. 2). However, this represents the very first ini-
strain history and Frost’s mechanostat theory. tiation of the bony reaction.
The mechanical loading has traditionally been Further application of an orthodontic load
described as compression and tension, the atten- generates bone reactions that lead to an adapta-
tion being commonly focused on the stress and tion to the new mechanical environment, achiev-
strain distribution within the viscoelastic struc- ing progressive balance between resorption and
ture of the periodontal ligament. However, the formation, as in the ‘adapted and mild overload
deformation of the periodontal ligament (PDL) windows’ (fig. 2). This ensures tooth movement
does not mirror the deformation that occurs in with bone, i.e. the movement of the tooth sur-
the surrounding bone. A finite element study has rounded by the alveolar bone.
shown that the transfer mechanism of orthodon- When sustained mechanical load is applied by
tic loads through the alveolar supporting struc- some orthodontic appliance, the ‘pathological
tures cannot be explained in terms of compres- overload window’ may be reached. Hyalinization
sion and tension. Considering the properties of of the PDL, ischemia-induced necrosis of the lin-
the PDL as nonlinear, tension was more predom- ing cells and microdamage of the bone in the di-
inant than compression, and the alveolar bone rection of the force will lead to increased BMU
198.143.33.33 - 3/8/2016 10:21:51 AM
Univ. of California Santa Barbara
Kantarci A, Will L, Yen S (eds): Tooth Movement. Front Oral Biol. Basel, Karger, 2016, vol 18, pp 28–35
DOI: 10.1159/000351897
Change in bone mass
+
– Remodeling
Modeling
0 50 1,500 3,000 ı
Fig. 2. The loading history of the alveolar bone following the application of an orthodontic load. For the description
of the strain windows, see figure 1. At the very initial stage, the tension of the periodontal fibers in the direction of the
force decreases, as schematized in the lower left pictures. The sudden change in loading activates the BMUs, as in a
disuse window. Tooth movement occurs with the surrounding alveolar bone in the adapted and in the mild overload
window. Bone-resorptive and -formative activities are in balance. The lower middle picture is a histological section of
a tooth whose PDL space is thinner in the direction of the force and wider on the opposite side. In green, the related
bone formation activities are presented: small amounts of bone formation in the direction of the force and large
amounts on the opposite side. In the pathological overload window, a clear RAP is observed in the direction of the
force. Here a horizontal section of a mandibular tooth of a monkey shows woven bone ahead of the tooth in the di-
rection of the force (with permission of Libra Ortodonzia, and the E.H. Angle Education and Research Foundation).
32 Verna
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Kantarci A, Will L, Yen S (eds): Tooth Movement. Front Oral Biol. Basel, Karger, 2016, vol 18, pp 28–35
DOI: 10.1159/000351897
Fig. 3. Alkaline (a) and acid (c) phos-
phatase staining of an interradicular
area of a rat molar after the applica-
tion of an orthodontic load of 25 g
for 2 weeks. The 10-μm-thick sec-
tions are taken consecutively.
Please observe the positive staining
for both anabolic (a) and catabolic
(c) activities, supporting the pres-
ence of a RAP after the application
a b
of an orthodontic load. The microra-
diographic image of the same sam-
ples (b) reveals decreased bone
density and the formation of woven
bone. The intensity of vowen bone
formation activities is detected by
the uptake of tetracycline labeling,
as depicted in d (with permission
from Libra Ortodonzia and the
c d
Italian Society of Orthodontics).
Kantarci A, Will L, Yen S (eds): Tooth Movement. Front Oral Biol. Basel, Karger, 2016, vol 18, pp 28–35
DOI: 10.1159/000351897
mechanism of the RAP may occur less effectively movement observed under high turnover condi-
with a higher risk for lack of balance between re- tions [31].
sorption and formation. Orthodontic tooth movement can therefore be
Some nonmechanical factors (genes, hor- seen as a modified skeletal wound healing and ad-
mones, vitamins, minerals, drugs and other aptation, typified by an increased bone remodel-
agents) seem to be able to modify the minimum ing response in addition to an elevated formation
effective strain thresholds listed above, thus ex- of woven bone. In this perspective, the biological
plaining the onset of some diseases [30]. This may principle of the RAP is exploited in surgically fa-
also be the explanation of the accelerated tooth cilitated orthodontics [32].
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Kantarci A, Will L, Yen S (eds): Tooth Movement. Front Oral Biol. Basel, Karger, 2016, vol 18, pp 28–35
DOI: 10.1159/000351897
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Kantarci A, Will L, Yen S (eds): Tooth Movement. Front Oral Biol. Basel, Karger, 2016, vol 18, pp 28–35
DOI: 10.1159/000351897