The Biologic Basis of Orthodontic Therapy:

Orthodontic treatment is based on the principle that if prolonged pressure is applied to a tooth, tooth
movement will occur as the bone around the tooth remodels

Bone is selectively removed in some areas and added in others

the tooth moves through the bone carrying its attachment apparatus with it, as the socket of the tooth
migrates

bony response is mediated by the periodontal ligament, tooth movement is primarily a periodontal
ligament phenomenon.

Forces applied to the teeth can also affect the pattern of bone apposition and resorption at sites distant
from the teeth, particularly the sutures of the maxilla and bony surfaces on both sides of the
temporomandibular (TM) joint. In addition

the biologic response to orthodontic therapy includes not only the response of the periodontal ligament
but also the response of growing areas distant from the dentition

Periodontal and Bone Response to Normal Function:

Periodontal Ligament Structure and Function

 Each tooth is attached to and separated from the adjacent alveolar bone by a heavy collagenous
supporting structure, the periodontal ligament (PDL).
 Under normal circumstances, the PDL occupies a space approximately 0.5 mm in width around
all parts of the root.
 By far the major component of the ligament is a network of parallel collagenous fibers, inserting
into cementum of the root surface on one side and into a relatively dense bony plate, the lamina
dura, on the other side. These supporting fibers run at an angle, attaching farther apically on the
tooth than on the adjacent alveolar bone. This arrangement, of course, resists the displacement
of the tooth expected during normal function.
 Although most of the PDL space is taken up with the collagenous fiber bundles that constitute
the ligamentous attachment, two other major components of the ligament must be considered.
These are (1) the cellular elements, including mesenchymal cells of various types along with
vascular and neural elements, and (2) the tissue fluids, Both play an important role in normal
function and in making orthodontic tooth movement possible
 The principal cellular elements in the PDL are undifferentiated mesenchymal cells and their
progeny in the form of fibroblasts and osteoblasts
 The collagen of the ligament is constantly being remodeled and renewed during normal function
 The same cells can serve as both fibroblasts, producing new collagenous matrix materials, and
fibroclasts, destroying previously produced collagen
 The collagen of the ligament. the bony socket and the cementum of the root is constantly being
remodeled and renewed during normal function
 Remodeling and recontouring of the bony socket and the cementum of the root is also
constantly being carried out, though on a smaller scale, as a response to normal function
 Bone and cementum are removed by specialized osteoclasts and cementoclasts
  the osteoblasts and cementoblasts that produce bone and cementum.
 Although the PDL is not highly vascular, it does contain blood vessels and cells from the vascular
system. Nerve endings are also found within the ligament(e unmyelinated free endings
associated with perception of pain and the more complex receptors associated with pressure
and positional information (proprioception))
 the PDL space is filled with fluid; this fluid is the same as that found in all other tissues,
ultimately derived from the vascular system

Functions:

Supporting teeth===collagenous fiber bundle

Micromovements===fluid from vascular system

Resorbtion and apposition of bone===osteobalsts and osteoclasts

Note: ankylosed teeth that has a fully or partilly abcent PDL cant be treated orthodontically bcz they are
not able to be moved

Response to Normal Function

 During masticatory function, the teeth and periodontal structures are subjected to intermittent
heavy forces.
 Tooth contacts last for 1 second or less; forces are quite heavy, ranging from 1 or 2 kg while soft
substances are being chewed, up to as much as 50 kg against a more resistant object.
 When a tooth is subjected to heavy loads of this type, quick displacement of the tooth within
the PDL space is prevented by the incompressible tissue fluid. Instead, the force is transmitted
to the alveolar bone, which bends in response.
 The body of the mandible bends as the mouth is opened and closed, even without heavy
masticatory loads
 Bone bending in response to normal function generates piezoelectric currents (Figure 8-2) that
appear to be an important stimulus to skeletal regeneration and repair
 Very little of the fluid within the PDL space is squeezed out during the first second of pressure
application
 Pain is normally felt after 3 to 5 seconds of heavy force application, indicating that the fluids are
expressed and crushing pressure is applied against the PDL in this amount of time
 Although the PDL is beautifully adapted to resist forces of short duration, it rapidly loses its
adaptive capability as the tissue fluids are squeezed out of its confined area.
 Orthodontic tooth movement is made possible by the application of prolonged forces. In
addition, light prolonged forces in the natural environment—forces from the lips, cheeks, or
tongue resting against the teeth—have the same potential as orthodontic forces to cause the
teeth to move to a different location

Physiologic Response to Heavy Pressure Against a Tooth

 <1 second: PDL fluid incompressible, alveolar bone bends, piezoelectric signal generated
 1-2s PDL fluid expressed, tooth moves within PDL space
  3-5s PDL fluid squeezed out, tissues compressed; immediate pain if pressure is heavy

Role of the Periodontal Ligament in Eruption and Stabilization of the Teeth

 The phenomenon of tooth eruption makes it plain that forces generated within the PDL itself
can produce tooth movement. After a tooth emerges into the mouth, further eruption depends
on metabolic events within the PDL
 A tooth whose antagonist has been extracted will often begin to erupt again after many years of
apparent quiescence.
 The continuing presence of this mechanism indicates that it may produce not only eruption of
the teeth under appropriate circumstances but also active stabilization of the teeth against
prolonged forces of light magnitude

Periodontal Ligament and Bone Response to Sustained Force

 The response to sustained force against the teeth is a function of force magnitude: heavy forces
lead to rapidly developing pain, necrosis of cellular elements within the PDL, and the
phenomenon of “undermining resorption” of alveolar bone near the affected tooth.
 Lighter forces are compatible with survival of cells within the PDL and a remodeling of the tooth
socket by a relatively painless “frontal resorption” of the tooth socket

Biologic Control of Tooth Movement

 Two possible control elements, biologic electricity and pressure-tension in the PDL that affects
blood flow The bioelectric theory relates tooth movement at least in part to changes in bone
metabolism controlled by biologic electricity that are produced by light pressure against the
teeth. The pressure–tension theory relates tooth movement to cellular changes produced by
chemical messengers, traditionally thought to be generated by alterations in blood flow through
the PDL.

Biologic Electricity
 Electric signals that might initiate tooth movement initially were thought to be piezoelectric.
 Piezoelectricity is a phenomenon observed in many crystalline materials in which a deformation
of the crystal structure produces a flow of electric current as electrons are displaced from one
part of the crystal lattice to another
 Ions in the fluids that bathe living bone interact with the complex electric field generated when
the bone bends, causing electric signals in the form of volts as well as temperature changes. As a
result, there will be currents in the extracellular fluids
 The small voltages that are observed are called the “streaming potential.” These voltages,
though different from piezoelectric current flows, have in common their rapid onset and
alteration as changing stresses are placed on the bone.
 stress-generated signals are important in the general maintenance of the skeleton. Without
such signals, bone mineral is lost and general skeletal atrophy ensues
 Signals generated by the bending of alveolar bone during normal chewing almost surely are
important for maintenance of the bone around the teeth
  On the other hand, sustained force of the type used to induce orthodontic tooth movement
does not produce prominent stress generated signals. As long as the force is sustained, nothing
happens

Pressure–Tension in Periodontal Ligament

 The pressure–tension theory, the classic theory of tooth movement, relies on chemical rather
than electric signals as the stimulus for cellular differentiation and ultimately tooth movement.
 Chemical messengers are important in the cascade of events that lead to remodeling of alveolar
bone and tooth movement, and both mechanical compression of tissues and changes in blood
flow can cause their release
 There is no doubt that sustained pressure against a tooth causes the tooth to shift position
within the PDL space, compressing the ligament in some areas while stretching it in others.
 The mechanical effects on cells within the ligament cause the release of cytokines,
prostaglandins, and other chemical messengers.
 In addition, blood flow is decreased where the PDL is compressed, while it is maintained or
increased where the PDL is under tension. These alterations in blood flow also quickly create
changes in the chemical environment. For instance, oxygen levels certainly would fall in the
compressed area and carbon dioxide (CO2) levels would increase, while the reverse might occur
on the tension side.
 These chemical changes, acting either directly or by stimulating the release of other biologically
active agents, then stimulate cellular differentiation and activity.

Effects of Force Magnitude

 The heavier the sustained pressure, the greater should be the reduction in blood flow through
compressed areas of the PDL, up to the point that the vessels are totally collapsed and no
further blood flows
 When light but prolonged force is applied to a tooth, blood flow through the partially
compressed PDL decreases as soon as fluids are expressed from the PDL space, and the tooth
moves in its socket. Within a few hours at most, the resulting change in the chemical
environment produces a different pattern of cellular activity.
 If a removable appliance is worn less than 4 to 6 hours per day, it will produce no orthodontic
effects. Above this duration threshold, tooth movement does occur.
 For a tooth to move, osteoclasts must be formed so that they can remove bone from the area
adjacent to the compressed part of the PDL. Osteoblasts also are needed to form new bone on
the tension side and remodel resorbed areas on the pressure side. Prostaglandins have the
interesting property of stimulating both osteoclastic and osteoblastic activity
 in clinical orthodontics it is difficult to avoid pressure that produces at least some avascular
areas in the PDL, and it has been suggested that releasing pressure against a tooth at intervals,
while maintaining the pressure for enough hours to produce the biologic response, could help in
maintaining tissue vitality. This seems to be the mechanism by which chewing on a plastic wafer
or chewing gum after orthodontic force is applied reduces pain—chewing force briefly displaces
the tooth and allows a spurt of blood into compressed areas, thereby reducing the size of
necrotic areas in the PDL.
  undermining resorption: osteoclasts appear within the adjacent bone marrow spaces and begin
an attack on the underside of the bone immediately adjacent to the necrotic PDL area

Effects of Force Distribution and Types of Tooth Movement

 it is apparent that the optimum force levels for orthodontic tooth movement should be just high
enough to stimulate cellular activity without completely occluding blood vessels in the PDL
 The simplest form of orthodontic movement is tipping. Tipping movements are produced when
a single force is applied against the crown of a tooth
 Maximum pressure in the PDL is created at the alveolar crest and at the root apex. Progressively
less pressure is created as the center of resistance is approached, and there is minimum
pressure at that point.
 In tipping, only one-half of the PDL area that could be loaded
 pressure decreases to zero at the center of resistance
 Translation or bodily movement of a tooth requires that the PDL space be loaded uniformly
from alveolar crest to apex, creating a rectangular loading diagram. Twice as much force applied
to the crown of the tooth would be required to produce the same pressure within the PDL for
bodily movement as compared with tipping
 forces to produce rotation of a tooth around its long axis could be much larger than those to
produce other tooth movements, since the force could be distributed over the entire PDL rather
than over a narrow vertical strip
 Extrusion and intrusion are also special cases. Extrusive movements ideally would produce no
areas of compression within the PDL, only tension
 Light force is required for intrusion because the force will be concentrated in a small area at the
tooth apex

Optimum Forces for Orthodontic Tooth Movement

 Tipping 35-60/ Bodily movement (translation) 70-120 /Root uprighting 50-100 /Rotation 35-60/
Extrusion 35-60/ Intrusion 10-20

Effects of Force Duration and Force Decay

 It does mean that the force must be present for a considerable percentage of the time, certainly
hours rather than minutes per day
 Continuous forces, produced by fixed appliances that are not affected by what the patient does,
produce more tooth movement than removable appliances unless the removable appliance is
present almost all the time
 orthodontic force duration is classified by the rate of decay as: •Continuous—force maintained
at some appreciable fraction of the original from one patient visit to the next •Interrupted—
force levels decline to zero between activations