CRITICAL REVIEWS IN ORAL BIOLOGY & MEDICINE
V. Krishnan1* and Z. Davidovitch2
1
Department of Orthodontics, Rajas Dental College,
Tirunelveli District, Tamilnadu, India; and 2Department
of Orthodontics, Case Western Reserve University,
Cleveland, OH, USA; *corresponding author, Gourivilasam,
Kudappanakunnu PO, Trivandrum, Kerala State—695043,
India, vikrishnan@yahoo.com
J Dent Res 88(7):597-608, 2009
Abstract
Orthodontic forces deform the extracellular matrix
and activate cells of the paradental tissues, facili­
tating tooth movement. Discoveries in mechano­
biology have illuminated sequential cellular and
molecular events, such as signal generation and
transduction, cytoskeletal re-organization, gene
expression, differentiation, proliferation, synthesis
and secretion of specific products, and apoptosis.
Orthodontists work in a unique biological environ­
ment, wherein applied forces engender remodeling
of both mineralized and non-mineralized paraden­
tal tissues, including the associated blood vessels
and neural elements. This review aims at identify­
ing events that affect the sequence, timing, and
significance of factors that determine the nature of
the biological response of each paradental tissue to
orthodontic force. The results of this literature
review emphasize the fact that mechanoresponses
and inflammation are both essential for achieving
tooth movement clinically. If both are working in
concert, orthodontists might be able to accelerate
or decelerate tooth movement by adding adjuvant
methods, whether physical, chemical, or surgical.
Key words: tooth movement, cellular mechano­
transduction, extracellular matrix, cytoskeleton,
nucleic acids, osteocytes, fibroblasts, angiogenesis,
mechanoreceptors.
DOI: 10.1177/0022034509338914
Received August 22, 2008; Last revision November 20,
2008; Accepted December 11, 2008
On a Path to Unfolding the
Biological Mechanisms of
Orthodontic Tooth Movement
INTRODUCTION
T
he generation and propagation of signaling cascades and associated tissue
remodeling in response to applied mechanical loads form the central theme of
orthodontic tooth movement. All cell types are capable of reacting when subjected
to mechanical stimuli of either intracellular or extracellular origin (Hamill and
Martinac, 2001; Schwartz and DeSimone, 2008). The main challenges encoun­
tered by researchers have been to elucidate the intricate details of the conversion of
mechanical forces into biochemical signals, to identify the cellular parts involved
in this process, to highlight the signaling pathways, and, ultimately, to determine how
the response mechanisms are activated, leading to tissue remodeling that facilitates
the movement of teeth to different, more desirable locations in the dental arch.
Orthodontic forces affect the extracellular matrix (ECM) and the cells of the
dental pulp, periodontal ligament (PDL), alveolar bone, and gingiva. These
effects are both physical and biochemical in nature, and are frequently inter­
twined and interdependent. Recognition of these intimate associations and the
realization of their importance in defining the details of the biological response
to applied mechanical loads in vitro and in vivo have been reflected lately by a
great increase in the number of articles focusing on this subject (Krishnan and
Davidovitch, 2006a; Masella and Meister, 2006; Henneman et al., 2008; Wise
and King, 2008). The authors of all these reviews seem to believe that an
expanded understanding of these associations may be meritorious for the ortho­
dontist, as well as for his/her patients. For example, a recent review (Henneman
et al., 2008) has listed tissue and cellular responses to mechanical force applica­
tion in the following order: (1) matrix strain and fluid flow, (2) cell strain,
(3) cell activation and differentiation, and (4) tissue remodeling. However, that
article concentrated on alveolar bone and PDL cells, largely ignoring other para­
dental tissues known to respond to orthodontic forces.
In contrast, this article is aimed at expanding the overview of the orthodon­
tic tooth movement process, by delineating reactions occurring in mineralized
(alveolar bone) and non-mineralized (PDL and gingiva) paradental tissues,
and their associated neurovascular networks. It presents known information
about the mechanism of cell signaling in response to mechanical loading,
including mechanosensing, transduction, and cellular responses. Furthermore,
the various components of this ECM/cellular interrelated chain of responses
are presented in an organized sequence, highlighting the links between clinical
events and knowledge derived from basic research.
EXTRACELLULAR MATRIX REMODELING
Application of external mechanical loads to teeth may alter the effects of
gravitational and internal forces acting on resident cells, leading to changes in
gene expression, and production of proteins that ultimately alter the structure
597
598  Krishnan & Davidovitch J Dent Res 88(7) 2009
and function of the ECM, as well as the jaw bones. The most
important ECM macromolecules in determining its mechanical
properties are collagen (the most abundant molecule), proteo­
glycans, laminin, fibronectin, elastin, and hyaluronic acid. These
molecules bind to cell adhesion foci, consisting mainly of inte­
grins, to transfer the signals intracellularly (Li et al., 2008;
Schwartz and DeSimone, 2008; Wells, 2008; Kong and Vazquez,
2009). Thus, ECMs can be considered to be multi-component
tissues that enable internal and external mechanical strains
to effect changes in organ structure and function, through
mechanotransduction.
THE CONCEPT OF TENSEGRITY
The structure and shape of cells are determined by 3 cytoskeletal
molecular structures—microfilaments, microtubules, and inter­
mediate filaments—which link the nucleus to the cell-surface
adhesion receptors. Since microfilaments are chemically
attached to proteins in the cellular and nuclear membranes, they
are ideal candidates for transfer of tractional forces from inside
the cell. These mechanical signals are transferred to the ECM
through integrins, and to adjacent cells through cadherins, and
are resisted and balanced by the same attachment entities. This
physiological pre-existing tensile stress in the cell is known as
‘tensegrity’ (tension-dependent cellular integrity), and is consid­
ered to be essential for the normal function of cells, tissues, and
organs, as well as for proper growth and survival. In the absence
of this internal tension, cells often undergo apoptosis (Ingber,
2006, 2008). The physical properties of the ECM also plays a
significant role in cell behavior, by determining the transmission
of stress from the outside to the inside of the cell. According to
the tensegrity model of Ingber, a stiffer cytoskeleton is advanta­
geous in sensing external mechanical loading, in contrast to a
completely relaxed cytoskeleton. The cells are more sensitive to
dynamic changes in mechanical stress when the effective exter­
nal and internal stresses are similar in magnitude. In contrast,
the cells in a completely relaxed state are unable to sense an
external stress, because it is not matched by an internal counter-
stress (Anastasi et al., 2008).
MINERALIZED TISSUE RESPONSES
TO APPLIED MECHANICAL LOADS
Alveolar Bone Osteocytes as Mechanosensors
Bone cells (osteoblasts, osteoclasts, and osteocytes) are sensi­
tive to their mechanical environment, and their adaptive response
can alter both the mass and the morphology of bones (Rubin
et al., 2006). The important role played by these bone cells,
especially osteocytes, as part of mechanosensing or transducing
mechanisms in response to applied mechanical stress, has been
detailed in the literature (Bonewald, 2007; Y Wang et al., 2007;
Robling et al., 2008). Osteocytes are connected to each other
and to cells of the bone surface by cytoplasmic processes or
dendrites. Within a few minutes of the onset of mechanical loading,
glucose 6-phosphate dehydrogenase (a marker of cell metabolism)
is elevated in osteocytes (Dodds et al., 1993), and an increase in
c-FOS mRNA is observed within 2 hrs (Kawata and Mikuni-
Takagaki, 1998). Soon thereafter, by 4 hrs, transforming growth
factor β and insulin-like growth factor mRNA expression are
increased (Wildemann et al., 2004). Research reports demon­
strating increases in osteocyte-specific markers have also been
published, including E11/gp3.8 (Zhang et al., 2006), dentin
matrix protein 1 (found in a tooth movement model) (Gluhak-
Heinrich et al., 2003), MEPE (Gluhak-Heinrich et al., 2007),
and sclerostin (Robling et al., 2008). Anabolic signals, such as
nitric oxide, prostaglandins, and ATP, are released within sec­
onds of osteocyte loading (Bakker et al., 2001). All these signals
activate bone-surface cells and osteoblasts, by the network of
cell-cell communications. It was proposed recently that the
Wnt/β-catenin pathway initiates, while the SOST/sclerostin
pathway inhibits, new bone formation. Osteocytes are the only
cells secreting sclerostin—the product of the SOST gene.
Sclerostin potently antagonizes and negatively regulates several
members of the bone morphogenetic protein (BMP) family of
proteins, and also binds to LRP5/LRP6, preventing canonical
Wnt signaling. Both BMPs and Wnts are critical for osteoblas­
togenesis, since they provide the initial and essential stimulus
for the commitment of multipotential mesenchymal progenitors
to the osteoblast lineage (Canalis et al., 2003; Li et al., 2005).
This makes sclerostin a likely candidate as an osteocyte-derived
regulator of osteoblast function (Tatsumi et al., 2007). It was
reported recently (Robling et al., 2008) that SOST transcripts
and sclerostin protein levels were dramatically reduced by
mechanical loading.
The fluid flow hypothesis, describing a mechanism by which
osteocytes respond to mechanical forces, states that locally
evoked strain derived from the displacement of fluid in the
canaliculi is very important (Goulet et al., 2008). When loading
occurs, interstitial fluid is squeezed through the thin layer of
non-mineralized matrix surrounding the cell bodies and cell
processes, resulting in local strain at the cell membrane and
activation of the affected osteocytes (Weinbaum et al., 1994; Y
Wang et al., 2007; Goulet et al., 2008). Osteocytes may also
send signals for activation of the bone resorption cascade
through expression of activator for NF-κB ligand (RANKL),
secretion of macrophage colony-stimulating factors (M-CSF),
and through their own apoptosis at the sites of micro-damage or
-cracks (Verborgt et al., 2002; Bonewald, 2007). Gene expres­
sion analysis suggests that osteocytes control osteoclast differ­
entiation indirectly through modulation of RANKL expression
in osteoblasts. In addition, humoral factors produced and
released through canaliculi into the bone marrow may regulate
the differentiation and activity of osteoclasts (Tatsumi et al.,
2007). It has been reported that monocytes are differentiated to
osteoclasts in the presence of RANKL and M-CSF (Narducci
and Nicolin, 2009). It is therefore reasonable to conclude that
osteocytes act as chief mechanosensors in bone, which has been
recently confirmed by targeted ablation of osteocytes in a mouse
model (Tatsumi et al., 2007).
Alveolar Bone Remodeling in Response to Strain
Applied mechanical stress causes flow of bone interstitial fluid,
evoking shear stress in the mineralized ECM and deformation of
the alveolar bone osteocytes in the lacunae and of the dendrites
in the canaliculae (Fig. 1). This deformation perturbs the integ­
rin molecules, which act as a tethering protein, opening
J Dent Res 88(7) 2009 Orthodontic Tooth Movement   599

hemichannels in strained osteocytes, allowing for the release of

prostaglandins and facilitating mechanotransduction (Y Wang
et al., 2007; Philips et al., 2008; Schwartz and DeSimone,
2008). Mechanical forces alter the metabolic state of osteocytes,
which in turn secrete osteotropic factors, such as MLO-Y4,
capable of stimulating surface-lining osteoblasts (Heino et al.,
2004). The importance of physical contacts between osteocytes
and surface-lining osteoblasts through gap junction intercellular
communications, formed by members of a family of proteins
known as Connexins (Cx), for a proper bone-forming response
has been stressed (Taylor et al., 2007). Researchers have
detected an increase in the release of PGE2, modulated by hemi­
channels formed by Cx43, enhancing osteoblastic activity as
part of alveolar bone response to mechanical loading (Cherian
et al., 2005; Gluhak-Heinrich et al., 2006). The outcomes of all
these structural modifications are profound changes in cytoskel­
etal organization, as evidenced by increases in alpha actin
(29%), filamin (185%), and vimentin (15%) (Jackson et al.,
2008), altering the metabolic state of the cell, activating signal­
ing molecules inside the cellular cytoplasm, as well as extracel­
lular nucleotides (i.e., ATP and UTP). This promotes a significant
stimulation of Runx2 DNA-binding activity via a mechanism
involving protein kinase C and distinct mitogen-activated pro­
tein kinase cascades (Costessi et al., 2005). Up-regulation
(BMP2, BMP6, ALP, SOX9, MSX1, and VEGFA) and down-
regulation (BMP4 and EGF) of some osteogenic specific genes
in response to cyclic tensile forces have been reported (Wescott
et al., 2007). Time-dependent up-regulation of osterix, an
osteoblast-specific transcription factor, which enhanced alkaline
phosphatase activity, and the mRNA expression of all osteo­
genic marker genes (osteopontin, bone sialoprotein, osteocalcin,
Figure 1. The sequence of bone remodeling stages during orthodontic
and collagen) have been observed (Zhao et al., 2008). The treatment. The roles played by osteocytes, osteoblasts, and osteoclasts
secreted bone matrix proteins consist of type I collagen (about are illustrated.
90% of the organic matrix), which provides strength, structure,
and elasticity to mature bone tissue. Type I collagen also regu­
lates expression/secretion of other non-collagenous proteins, inducing osteoclast recruitment and function, is initiated by
such as osteocalcin, osteopontin, osteonectin, and bone sialopro­ TNF-α (Andrade et al., 2007). The important role of M-CSF in
tein. It is apparent that bone formation is coordinated by the osteoclastogenesis, mediated by TNF-α in response to orthodon­
expression of many molecules, such as growth factors, tran­ tic force application, has been demonstrated (Kitaura et al.,
scription factors, and anti-inflammatory cytokines. Committed 2008). These findings strongly suggest that TNF-α plays a piv­
osteoblasts induce/stimulate osteoclastogenesis through the otal role in the bone resorption process that facilitates orthodon­
RANK/RANKL/OPG pathway, or become highly differentiated tic tooth movement.
cells, persisting for a very long period of time inside the bone Bone degradation and terminal osteoclastogenesis require
matrix as osteocytes (Canalis, 2005). physical contact between osteoclasts and bone matrix. Once dif­
In physiologic conditions, RANKL is released only by osteo­ ferentiated, the capacity of a matrix osteoclast to resorb bone
blasts, but in cases of inflammation (e.g., rheumatoid arthritis, depends on its ability to synthesize and mobilize a series of
orthodontic tooth movement, periodontitis), these molecules are degradative enzymes. The way osteoclasts perform the bone
produced in abundance by T-lymphocytes (Kawai et al., 2006). degradation process has been well-reviewed, and readers are
In addition to RANKL, TNF-α has also been shown to promote referred to these excellent articles for details (Teitelbaum and
osteoclastogenesis in conditions of inflammatory osteolysis Ross, 2003; Teitelbaum, 2007; Kreja et al., 2008).
(Horowitz et al., 2001). This effect is achieved either by stimu­
lation of RANKL release from osteoblasts, or through direct
activation of osteoclast precursors. TNF-α apparently induces NON-MINERALIZED TISSUE RESPONSES
basal osteoclastogenesis via TNF receptor type 1 (p55), while TO MECHANICAL LOADING
suppressing it via TNF receptor type 2 (p75), as has been
Fibroblasts as Mechanosensors and Transducers
demonstrated in a tooth movement model (Abu-Amer et al.,
2000). Synthesis of other inflammatory mediators and chemo­ The changes elaborated in connective tissues in response
kines such as RANTES/CCL5 and MCP-1/CCL2, capable of to mechanical loading are largely mediated through ­fibroblasts.
600  Krishnan & Davidovitch J Dent Res 88(7) 2009
Figure 2. The responses of periodontal ligament fibroblasts to orthodon-
tic forces.
Fibroblasts are considered to be mechanoresponsive, in that
the mechanical signals transmitted from the ECM via integrin
receptors influence their morphology, cytoskeletal organiza­
tion, proliferation, differentiation, and gene expression (JH
Wang et al., 2007). Proteins located at focal adhesion kinases
(FAK) in the inner cell surface act as strain gauges that
‘sense’ stress from the ECM, as well as strain generated by
cytoskeletal re-organization. These stretch-induced confor­
mational changes might expose previously hidden phospho­
rylation sites (Wang et al., 2001; Smith et al., 2007; Li et al.,
2008). These newly modified sites are recognized by other
signaling molecules (growth factors and cytokines), which
in turn activate small GTPases of the Rho and Ras families,
which have multiple effects on cytoskeletal dynamics, gene
transcription, and cell division and differentiation (Jaffe and
Hall, 2005). Thus, focal adhesions, together with the actin
cytoskeleton, have been suggested to serve as mechanosen­
sors in ­fibroblasts.
Fibroblasts in the Mechanically Stressed
Periodontal Ligament
Various investigators studied the mechanoresponse by gene
expression in PDL fibroblasts (He et al., 2004; Kim et al.,
2007; Ritter et al., 2007). PDL fibroblasts exist in an active
mechanical environment, filling the gap between the dental root
­
cementum and the alveolar bone, and are periodically subjected
to compressive, tensile, and shearing forces of both short (during
mastication) and long duration (during orthodontic treatment).
In the PDL, integrin binds to fibronectin in the ECM and to
talin intracellularly, as part of establishing a signal transduction
pathway (Sandy, 1998). Applied mechanical forces stretch the
fibronectin molecules in ECM at sites of PDL tension, straight­
ening the initial nodular assembly with quaternary structure, and
unfolding fibronectin type III molecules. The signals transferred
to the inside of the fibroblast result in re-organization of the
cell’s cytoskeleton, leading to changes in cell shape and mobil­
ity, induction of gene expression in the nucleus, and secretion
of newly synthesized proteins, such as fibronectin and collagen
(Smith et al., 2007). A quantity of these newly synthesized colla­
gen fibers is incorporated into the newly formed osteoid, whereas
the rest are embedded in the PDL to form new Sharpey’s fibers
(Meikle, 2006). It has been demonstrated that, after orthodontic
force application, the density of cells expressing positive signals
for type I collagen mRNA is greater in the PDL in tension sites,
followed by expression of type XII collagen (Nakagawa et al.,
1994). Synthesis of all other collagen types has also been dem­
onstrated (types III, V, and VI) in both tension and compression
sites (Bumann et al., 1997). With recognition of several binding
sites, the response of fibronectin to mechanical force is impor­
tant in the mechanosensing and transduction pathway, leading to
ECM remodeling (Smith et al., 2007; Katanosaka et al., 2008).
Degradation of collagen and other macromolecules in the ECM
as part of the force-induced PDL remodeling is performed by
several enzymes, such as serine proteases, aspartate proteases,
cysteine proteases, and the matrix metalloproteinases (MMPs;
collagenase, gelatinase, and stromelysin). Specific up-regulation
of MMP-8 and -13 mRNA in PDL compression and tension
sites during orthodontic tooth movement has been demonstrated
(Takahashi et al., 2003), stressing the role of ECM degradation
in the remodeling process (Fig. 2).
Gingival Fibroblasts and Mechanical Forces
Gingival fibroblasts play an important role in determining tissue
architecture, by virtue of their attachment to the acellular
cementum in the cervical part of the dental root, and to the gin­
gival fibrous matrix at the other end of the fibers (Danciu et al.,
2004; Grünheid and Zentner, 2005). It has been proposed that if
there is any disruption in the chemico-physical connectivity of
the marginal gingiva to the dental root, the intracellular tensile
forces of gingival fibroblasts are abruptly lowered, changing the
balanced physiological strains existing in the cells (tensegrity)
(Binderman et al., 2002, 2007). In response, molecular changes
may occur, activating propagation of intracellular messengers
that start remodeling responses in the gingiva, as well as in the
alveolar bone. In this situation, the marginal gingiva acts as a
mechanosensor apparatus, recognizing and responding to abrupt
modifications in physical stimuli. Once intracellular and cell-
ECM strains are lowered, a molecular signaling pathway, with a
local release of ATP, and up-regulation of a specific p2x4
purinoreceptor in the gingival fibroblasts are initiated. These
events lead to an increase in intracellular calcium influx, trans­
ducing extracellular signals to the interior, and subsequently to
the genome (Fig. 3).
J Dent Res 88(7) 2009 Orthodontic Tooth Movement   601

Blood Vessel Re-organization and Neovascularization

in Orthodontic Tooth Movement
Blood vessels in the PDL, which provide gases and nutrients
required for all metabolic activities of their surrounding tissues,
in health and disease, are active participants in the tissue remod­
eling associated with orthodontic treatment. Furthermore, these
vessels usher immune cells into the strained PDL, extending a
helping hand for their role in the tissue-remodeling process.
They also permit migration into the strained paradental tissues
of hormones and a variety of molecules derived from food and
drugs consumed by the individual. All these molecules—those
that originate from native paradental cells or migratory leuko­
cytes, or from remote endocrine glands, or from consumed
nutrients and drugs—may have profound and long-lasting
effects on the nature of the force-induced tissue remodeling and
the degree of success of orthodontic treatment (Krishnan and
Davidovitch, 2006b).
The ECM surrounding the vessels provides critical support
for the vascular endothelium. Adhesion of the endothelial cell to
the ECM is required for its proliferation, migration, morphogen­
esis, survival, and blood vessel stabilization, to maintain tissue
viability and neovascularization (Davis and Senger, 2005).
During angiogenesis, with the help of the ECM (which serves
as a three-dimensional malleable scaffold), proliferating and
migrating endothelial cells organize to form new three-
dimensional capillary networks. By generating mechanical con­
tractile forces within the ECM, endothelial cells, which acquire
Figure 3. The gingival fibroblastic activity in response to orthodontic
shape changes with the help of the COL1A1 gene, establish
forces.
tension-based guidance pathways that allow them to form inter­
connected cords (Shyy and Chien, 2002; Chien, 2008). A colla­
transmission electron-microscopic observations, Anastasi et al.
gen type I gene is involved in acquiring shape changes by the
(2008) showed a reduction in the number of blood vessels after 72
endothelial cells. Over the course of several days, intercon­
hrs of treatment and an increase in their number after 7 days of
nected cords mature to form hollow tubes through a process
treatment. Modifications of immunofluorescence staining pat­
involving the development and coalescence of intracellular
terns of tested proteins revealed angiogenesis and reparative pro­
vacuoles (Zhou et al., 2006). The key angiogenic cytokine, vas­
cesses, along with thickening of fibrillar matrix, as a defensive
cular endothelial growth factor (VEGF), which induces sprout­
reply to mechanical stress. Through a quantitative representation
ing angiogenesis, also induces microvascular endothelial cells to
of PDL vascular reactions in rats, Ren et al. (2008) discovered
express integrins (Nör et al., 1999). The sequence of neovascu­
that prolonged force applications lead to increased vascularity,
larization steps is outlined below (Davies and Senger, 2005):
which is age-related. In young rats, increased numbers of both
small and large blood vessels were found, while adult rats exhib­
• Collagen type I ligation to integrins in endothelial cells ited an increase in the number of only small blood vessels. These
suppresses cAMP, thereby suppressing activity of cAMP- results confirm earlier findings on the responses of blood vessels
mediated protein kinase A (PKA). to applied mechanical forces, typified by increased permeability,
• PKA activity suppression leads to a marked induction of which enhances fluid extravasation from capillaries into the inter­
actin polymerization, leading to the formation of promi­ stitial space (Cooper and Sims, 1989; Lew, 1989).
nent stress fibers and endothelial cell contractility.
• Endothelial cell organization into multicellular pre-capil-
Neural Responses to Mechanical Forces
lary cords with activation of Src kinases and GTPase Rho
through interaction with integrins, which also results in Innervations of dental and paradental tissues are mainly constituted
cord formation. by neurons that originate in the trigeminal ganglia (located in the
cervical and middle root areas) and mesencephalic trigeminal
Applied mechanical stresses develop strain and activate signal­ nucleus (apical periodontal area). The nerve endings consist mainly
ing pathways, mainly through integrin-dependent mechanisms, fol­ of mechanoreceptors (Ruffini-like endings) and nociceptors. Under
lowed by actin polymerization, activation of type I collagen genes, normal physiological conditions, these receptors remain quiescent,
neovascularization, and remodeling of blood vessels (Fig. 4). The but contain various neuropeptides, such as calcitonin gene-related
entire process is self-limiting, once sufficient changes are obtained peptide (CGRP) and substance P (SP) (Norevall et al., 1995;
to nourish the associated structures. With the help of light and Vandevska-Radunovic, 1999; Hall et al., 2001; Yamaguchi et al.,
602  Krishnan & Davidovitch J Dent Res 88(7) 2009
Figure 4. Blood vessel response to orthodontic forces.
2004). Orthodontic tooth movement alters the neutral state of both
mechanoreceptors and nociceptive PDL nerve fibers (Fig. 5),
effecting the release of biologically active proteins, leading to local
neurogenic inflammation and the release of neuropeptides such as
CGRP and SP (Nicolay et al., 1991; Norevall et al., 1995;
Vandevska-Radunovic, 1999). Since most PDL neurons are
wrapped around blood vessels, including capillaries, endothelial
cells are probably the first to interact with neuropeptides, which in
turn bind circulating leukocytes, facilitating their migration from
the capillaries. Chemokines activate integrins on the leukocyte cell
surface to promote firm adhesion. The migration of leukocytes by
the chemoattractant gradient and their arrival in the PDL signify the
onset of an acute inflammation, which is essential for tooth move­
ment into newer locations (Middleton et al., 2002). Signaling mol­
ecules released by these migrating leukocytes (cytokines, growth
factors, and colony-stimulating factors) interact with various dental
and paradental cells and stimulate them to initiate and sustain the
tissue remodeling (Yamaguchi et al., 2004). Monocytes, lympho­
cytes, and mast cells express receptors for neuropeptides, which
transduce signals intracellularly and evoke cellular responses, such
as cytokine release, production of other neuropeptides, changes in
the expression of mediators, or direct release of inflammatory
mediators (Yamaguchi et al., 2004; Lee et al., 2007). Moreover,
CGRP and SP also serve as vasodilators, increasing vascular per­
meability, flow, and plasma extravasations. Often, this plasma
contains molecules derived from the diet, medications, remedies,
drugs, hormones, and inflammatory mediators that originated in
remote diseased organs, which might influence the course of
mechanotherapy, by virtue of their interaction with cells (Krishnan
and Davidovitch, 2006b).
In addition to this peripheral action, the affected neurons
rel­ease neurotransmitters centrally, in the trigeminal nucleus,
causing pain shortly after appliance activations in persons
undergoing ortho­­don­tic treatment (Krishnan, 2007). The short
delay in the onset of pain is due to the initial resistance of the
tissue fluids. The gradual move­ment of these fluids from areas
of com­­­­­pression to zones of tension facilitates the development
of ECM strain and the entire process of ­mechanotransduction.
Cellular and Molecular Behavior in Sites of PDL Tension
and Compression
Orthodontic forces (continuous, interrupted, or intermittent) cre­
ate strains in the teeth and paradental tissues. These strains are
not uniform throughout the applied region,
but rather develop a ‘quilt’ of areas where
tension or compression prevails, creating
favorable conditions for tissue remodeling.
Great clinical interest exists regarding the
behavior of cells in these strained locations,
since it determines the orthodontic treat­
ment outcome. An insight into this puzzle
may be obtained from investigations on the
responses of paradental cells to conditions
of tension, compression, or torque. It has
been reported that PDL cells respond differ­
ently to tensile and compressive strains, in
terms of synthesis and degradation of ECM
components (He et al., 2004). A 10% com­
pressive strain (0.5 Hz) decreased collagen (COL1A1) mRNA,
type I collagen, and fibronectin levels in these cells. In contrast,
a 10% tensile strain increased COL1A1 mRNA, MMP2 mRNA,
and TIMP2 mRNA. At the same time, tensile forces result in the
synthesis of similar levels of both MMP and TIMP, promoting
anabolic activity, whereas synthesis of MMP is increased under
compressive loads without a change in TIMP, thus promoting
degradation. Recently, an increase in type I collagen immunofluo­
rescence staining intensity was demonstrated in PDL pressure
sites, while tension sites displayed a diminution of staining after
72 hrs of treatment. Type IV collagen staining was reduced in
both sites, increasing gradually after 7 days of treatment (Anastasi
et al., 2008).
Orthodontic forces induce an aseptic inflammatory response,
rather than a reaction to an invasion by micro-organisms through
a wound. Nonetheless, the classic signs of inflammation (red­
ness, swelling, pain, and reduced function) are similar in both
cases. Inflammatory cytokines produced by leukocytes, plate­
lets, and native cells, which include lymphocyte- and monocyte-
derived factors, colony-stimulating factors, growth factors, and
chemotactic chemokines, are often involved in tissue reactions
associated with orthodontic forces (Ren and Vissink, 2008). In
periodontal tissues, cytokines are produced by immune cells,
fibroblasts, and osteoblasts, and participate in regular tissue
turnover and in induced bone-remodeling events (Mundy, 1992).
Both these procedures are mediated by pro- as well as anti-
inflammatory cytokines under the influence of distinct cytokine
subsets (Andrade et al., 2007; Maeda et al., 2007). Elevated
levels of IL-1β, SP, and PGE2 in gingival crevicular fluid from
both compression and tension sites of moving teeth have been
identified, with higher concentrations found in tension sites
(Dudic et al., 2006). Recently, the differential expression patterns
of 3 cytokines (TGF-β, IL-10, and TNF-α) in PDL compression
and tension sites during tooth movement have been reported
(Ren and Vissink, 2008). An augmented expression pattern for
TGF-β mRNA has been reported at sites of both PDL compres­
sion and tension, which induces proliferation and chemotaxis of
PDL cells, up-regulates COL-I, recruits osteoblast precursors,
inducing their differentiation, down-regulates MMPs, and up-
regulates TIMPs, enhancing production of bone matrix proteins
(Ignotz et al., 1987). In areas of compression, TGF-β inhibits
recruitment of osteoclast precursor cells, suppressing osteoclas­
tic activity (Kanaan and Kanaan, 2006). Compression-site PDL
cells have been reported to express increased amounts of TNF-α,
J Dent Res 88(7) 2009 Orthodontic Tooth Movement   603

which stimulate the production of MMPs, elevating the levels of

RANKL to be directly involved in bone resorption (Andrade
et al., 2007). In contrast, simultaneous up-regulation of
OPG and down-regulation of RANKL expression by the anti-
inflammatory cytokine IL-10 inhibit bone resorption (Ren and
Vissink, 2008). The dual role of cytokines in the remodeling of
mineralized and non-mineralized connective tissues can be
described as that of a pro-inflammatory cytokine, such as IL-1
and TNF-α, which promotes resorption and inhibits apposition,
while anti-inflammatory cytokines promote apposition and
inhibit resorption.
Chemokines, the superfamily of chemotactic cytokines, are
small structurally related heparin-binding proteins classified
into 4 subfamilies based on the configuration of cysteine resi­
dues near the N-terminal, depending on whether the first 2
cysteines are separated (CXC, CX3C) or not (CC, C). They are
synthesized by a variety of cell types, such as endothelial, epi­
thelial, and stromal cells, fibroblasts, mast cells, bone cells, and
leukocytes. Functionally, chemokines are divided into homeo­
static and inflammatory molecules, which target all types of
leukocytes and lymphocytes through their binding to selective
G-protein-coupled receptors. The activation of these receptors
triggers several intracellular signaling pathways, resulting in
re-organization of the cytoskeleton and cell adhesion, causing
cells to extend pseudopodia and crawl up the chemoattractant
gradient (Terricabras et al., 2004). Chemokine-driven cell Figure 5. Neural response to orthodontic forces.
migration is thought to be an important step in orthodontic-
force-induced paradental tissue remodeling, especially in bone
remodeling and angiogenic events (Krishnan and Davidovitch, PF4, CXCL9/Mig, CXCL10/IL-10, CXCL11/I-TAC, and
2006a; Masella and Meister, 2006; Meikle, 2006). Osteoclast CXCL14/BRAK) activities associated with any sort of chronic
precursors express chemokine receptors such as CCR2 and inflammation (Rosenkilde and Schwartz, 2004). Hence, chemo­
CCR5 and signals provided by chemokines, such as CCL2/ kines appear to emerge as important factors, in more than one
MCP-1, CCL3/MIP-1α, and CXCL12/SDF-1, which are essen­ way, in the remodeling of tissues subsequent to the application
tial for the differentiation of osteoclast progenitors into mature of orthodontic forces.
osteoclasts. High expression patterns have been demonstrated It can be concluded that orthodontic forces are capable
for MCP-1, CCL5/RANTES, and MIP-2 in bone resorption of creating aseptic and transitory inflammation at both PDL
areas associated with PDL compression (Alhashimi et al., 1999; ­compression and tension sites. Although a clear-cut microscopic
Garlet et al., 2008). Osteoblasts also express receptors, such as and/or computerized tomographic demarcation between areas
CXCR4, CXCR5, and CCR5, which function by binding to under compression and tension is not always possible, because
specific chemokines, such as SDF-1 and BCA-1/CXCL13, these zones often overlap (Melsen et al., 2007), the bulk of
resulting in proliferation and type I collagen mRNA expression research outcomes to date points to the fact that the reaction at
(Lisignoli et al., 2006). Moreover, osteoblasts can secrete each of these areas differs clearly on the molecular and cellular
chemokines such as MCP-1, SDF-1 (involved in bone remodel­ levels. Future research will continue to increase our knowledge
ing), KC/CXCL1, LIX/CXCL5, CINC-1/CXCL1, and BCA-1/ about this dichotomy.
CXCL13 (involved in the recruitment of different leukocytes) in
response to mechanical force application. These findings sug­
HOW DO TEETH MOVE ORTHODONTICALLY?
gest an interesting role for osteoblasts in the development of
aseptic inflammatory reaction in the PDL following orthodontic Orthodontic forces strain ECM and cells of the alveolar bone,
force application (Garlet et al., 2008). Chemokines, the known PDL, gingiva, and associated blood vessels and neural elements,
regulators of cell-trafficking and tissue remodeling, play a cru­ the initial effect of which is physical in nature, followed closely
cial role in the migration of cells into specific organs and tissues by a biological response. This interaction generates profound
(Rossi and Zlotnik, 2000). In this capacity, chemokines initiate changes in the structure and function of the ECM, cell mem­
signal transduction events, leading to other biological processes brane, cytoskeletal elements, nucleus, and several other cyto­
such as angiogenesis, cell proliferation, apoptosis, and host plasmic organelles that synthesize and mobilize a variety of
defense (Silva et al., 2007). Chemokines of the CXC family are molecules inside and outside the cells (Kerrigan et al., 2000;
unique in promoting angiogenic (CXCL1/GROα, CXCL2/ Masella and Meister, 2006; Meikle, 2006). Cell adhesion mole­
GROβ, CXCL3/GROγ, CXCL5/ENA 78, CXCL6/GCP-2, cules, like the integrins, transmit tensile, compressive, and shear
CXCL7/NAP-2, and CXCL8/IL-8) and angiostatic (CXCL4/ stresses directly from the ECM into the cell and vice versa, and
604  Krishnan & Davidovitch J Dent Res 88(7) 2009
Figure 6. The sequence followed by cells and tissues in mechanosensing, transduc-
tion, and response.
are considered essential for cellular survival, growth, and mobil­
ity. This transmission helps to maintain the cells in active form
(tensegrity), capable of responding rapidly to various mechani­
cal, physical, and other challenges. Mechanosensing is a process
by which cells sense structural changes in the ECM, caused by
external mechanical loading. This sensing triggers biochemical
reactions that generate energy, in addition to the energy pro­
vided by the mechanical load, required for the response to the
elevated environmental demands (Apodaca, 2002; Poirier and
Iglesias, 2007).
Each cellular system in paradental tissues is equipped with
mechanosensors; thus, each mechanical stimulus may activate
multiple mechanosensors, followed by downstream cellular
events. Subsequent changes in cytoskeletal protein structure and
function propagate the signaling process into the nucleus by a
process known as mechanotransduction, defined as the process
by which mechanical energy is converted to bio­
chemical and/or electrical signals. In addition, signal­
ing proteins generated in the cell cytoplasm, such as
hedgehog and transforming growth factors, as well as
calcium ions, reach the nuclear matrix and, ultimately,
the genome. The outcome of the entire chain of events
is enhanced or suppressed gene expression, transfer­
ring the signal back to the cytoplasm through mRNAs,
reaching the ribosomes, generating protein synthesis
and secretion, mitosis, cell motility, and programmed
cell death (Hamill and Martinac, 2001; Silver and
Siperko, 2003; Masella and Meister, 2006) (Fig. 6).
The unique feature of this scheme in orthodontics
is the interaction between various tissues, both min­
eralized and non-mineralized, and their associated
neuro­vascular elements, for effecting tooth move­
ment. For such an event to happen, remodeling of var­
ious tissues—performed by cells of the alveolar bone
(osteoblasts, osteoclasts, and osteocytes), PDL, and
gingival fibroblasts, blood vessels (endothelial cells),
and neural tissues (dendritic and neural cells)—must
occur. Additional cell types essential to the body’s
response to applied mechanical loads are derivatives
of the immune system (inflammatory cells and osteo­
clast progenitors). Each of these tissues follows its
own response pattern, as far as the mechanosensing,
transduction, and response mechanisms are concerned
(Fig. 7) (Krishnan and Davidovitch, 2006a; Masella
and Meister, 2006; Meikle, 2006; Henneman et al.,
2008; Wise and King, 2008).
Orthodontic for­ces bend the alveolar bone, and
compress and stretch the PDL. Consequently, there will
be an alteration in the electrical neu­­­trality of the alveo­
lar bone, as the compressed PDL becomes the site of
intense bone resorp­tion, while stretched PDL areas
interface with sites of active osteogenesis. Osteo­­cytes
are key participants in this process, being acu­tely sensi­
tive and responsive to applied mechanical loads. Their
elaborate network of cellular projections facilitates
com­munications with neighboring osteo­cytes, as well
as with alveolar bone surface-lining cells and bone
marrow cavity cells. Osteoblasts, which maintain direct
contact with osteocytes, respond to these signals and initiate
appositional changes. The activated osteoblasts proceed to convey
signals to approaching osteoclasts, enticing these cells to start
resorbing the alveolar bone, and informing them on the proper
time to cease their resorptive activities. The origin of osteoclasts
for bone resorption is attributed to either conversion of mono­
cytes/macrophages or migration of progenitor cells from alveolar
bone marrow cavities to the strained PDL (Xie et al., 2008).
Important components of this osteocyte→osteoblast→osteoclast
chain are PGs, TNF-α, and the RANK/RANKL/OPG system.
Gingival and periodontal fibroblasts play different roles in
paradental tissue remodeling. While PDL fibroblasts are pre­
dominantly involved in the synthesis and degradation of their
own ECM, gingival fibroblasts participate in bone remodeling
events. Up-regulation of 85 genes and down-regulation of 23
genes associated with protein synthesis in the PDL have been
J Dent Res 88(7) 2009 Orthodontic Tooth Movement   605
Figure 7. The sequence of orthodontic tooth movement, illustrating the roles played by mineralized and non-mineralized tissues along with the
associated blood vessels and neural elements.
identified (de Araujo et al., 2007). Diminution of collagen pro­
duction (type I and IV) in the compressed PDL has been
reported, as well as increased type IV collagen production at
PDL tension sites after 72 hrs of force application (Anastasi
et al., 2008).
The role played by blood vessels in orthodontic tooth move­
ment has received much recent attention. Angiogenesis and
remodeling of existing blood vessels help them adapt to the new
environment created by mechanical forces. An initial reduction
and a later increase in the number of PDL blood vessels follow­
ing orthodontic force application have been reported (Anastasi
et al., 2008; Ren et al., 2008). These blood vessels play a major
role in the mechanical force-induced aseptic inflammation by
acting as sources of cytokines and chemokines. Increased
expression of IL-1β, IL-1 receptor, IL-6, IL-6 receptor, IL-8
receptor, IL-11, and TNF-α has been demonstrated in the com­
pressed PDL, confirming the presence of aseptic inflammation
(Koyama et al., 2008). Substance P, CGRP, VIP, and other
released neurotransmitters interact with endothelial cells of the
paradental capillary network, enticing them to bind circulating
leukocytes, promoting their migration into the paradental ECM.
Upon entering these tissues, the migratory leukocytes produce
ample amounts of chemokines (Andrade et al., 2007; Maeda
et al., 2007) and cytokines (Yamaguchi et al., 2006, 2008).
Along with the cytokines produced by the native paradental
cells (fibroblasts and osteoblasts), they evoke and maintain the
remodeling events of the PDL and alveolar bone (Garlet et al.,
2007). The released neuropeptides also act centrally to produce
pain, which in turn restricts the use of the jaws and teeth by the
individual, whether for mastication or speech. These reduced
movements of contraction and relaxation of the PDL might pro­
voke a loss of transmission of mechanical stresses to the liga­
ment, delaying the cellular responses due to the state of
inactivity and loss of tensegrity. Increasing the magnitude and
606  Krishnan & Davidovitch J Dent Res 88(7) 2009
frequency of functional force application to orthodontically
treated teeth may restore the pace of tooth movement during
these painful periods. A similar effect can be achieved by
physical, chemical, or surgical means. This phenomenon further
emphasizes the fact that physical forces of gravity, hemody­
namic stresses, and movement play a critical role in tissues,
since the cells use tensegrity architecture for their structural
organization (Anastasi et al., 2008).
It can be concluded that orthodontic tooth movement is pro­
duced by mechanical means that evoke biological responses.
These two entities, mechanics and biology, act in concert to
produce desirable and predictable alterations in the form and
function of the dento-alveolar complex. The actual performers
of this force-induced remodeling are the native cells of the
treated teeth and their surrounding tissues. Other important cel­
lular participants in this remodeling process are derivatives of
the neuro-vascular and immune systems. Cells and tissues use
mechanosensing, transduction, and response phenomena to
respond to applied mechanical forces. This reaction is typified
by the aseptic inflammatory reaction, which is initially acute,
becoming chronic a few days after the activation of the ortho­
dontic appliance. Acute inflammation is re-introduced to the
paradental tissues each time the appliance is reactivated. Hence,
it may be suggested that mechanoresponse and inflammation are
both essential for achieving the clinical effect of tooth move­
ment. If both mechanisms indeed unfold in concert, orthodon­
tists might be able to accelerate the velocity of tooth movement
by utilizing additional external stimuli, whether physical, chem­
ical, or surgical. Knowledge pertaining to the subject of mechan­
ics and biology in orthodontics is expanding constantly, creating
an ever-stronger basis for success in the clinical realm.
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