Accelerated Orthodontic Tooth Movement:

In Light of Evidence
Presenter:
Supervisors:

Dr. Aisha Khoja

Dr. Fida
Dr. Attiya

POSSIBLE APPROACHES
Biomechanical approach
Physiological/mechanical approach
Pharmacological approach
Surgical-assisted approach
Surgery-simulated approach

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BIOMECHANICAL APPROACH
Self Ligating Bracket System

No steel/elastomeric ligatures
Frictional force of ligatures ( O configuration)= 50 g
Reduced friction- especially passive design
Less force required for tooth movement
More physiological in terms of PDL vascular supply
More alveolar bone generation, greater expansion, less proclination of
anterior teeth, less need for extractions

Kapur et al:
Friction per bracket with Ni-Ti archwires-41g under conventional ligation and
15g with Damon system
For SS wires: 61g (conventional); 3.6g (self ligating)

BIOMECHANICAL APPROACH
Self Ligating Brackets- Current Evidence

Despite low friction, do not perform faster alignment/ space closure

They are narrower than conventional brackets- effect of binding due to

tipping is greater- increased resistance

Short chair side time and less incisor proclination (1.5 degree)

1.Chen SS et al. Systemic

Orthop.2010;137:726e1:726e18

review

of

self

ligating

brackets.

Am

Orthod

Dentofacial

2. Fleming PS, Johal A. Self ligating brackets in orthodontics. A systemic review. Angle
Orthod.2010;80:575-84

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PHYSIOLOGICAL/ MECHANICAL APPROACH

1. Direct Electric Current Stimulation: Evidence
Beeson et al & Davidovitch et al:
Direct current : 7 volts & 15 microamperes
Anode : pressure side; Cathode: tension side
Degree of bone formation and resorption at electrically treated pressure &
tension side was higher
Increase osteoblasts, PDL cells, osteoclasts
Mechanism:
Direct current generate local response to increase AB turnover
Disadvantages:
The device and battery providing electric current were bulky
Beesan DC, Jhonston LE, Wisotzky J. Effect of constant currents on orthodontic tooth movement in
cat. J Dent Res 1975;54:251-54
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icon to add picture
Davidovitch
Z et al. Electric currents, bone remodelling and orthodontic tooth movment. Am J

Orthod.1980;77:33-47

PHYSIOLOGICAL/ MECHANICAL APPROACH

Enzymatic Micro battery

Used clinically (2009)

It utilizes glucose as a fuel and enzymes as catalyst
Placed on the gingiva near the alveolar bone
Small size /minimal tissue injury

Disadvantage:
Short life time
Poor power density

PHYSIOLOGICAL/ MECHANICAL APPROACH

Endogenous Piezoelectric stimulation

Electric potentials can be created by applying force to a tooth resulting in

bending of bone and generation of piezoelectric charges
The charges are created when stress is applied and released
Vibration could be used to apply and release forces at rapid rate
AcceleDent vibratory system : High frequency vibration (30Hz) for 20
min/day

Mechanism:
Stimulate cell proliferation and maturation to allow faster bone remodeling

PHYSIOLOGICAL/ MECHANICAL APPROACH

Endogenous Piezoelectric stimulation: Evidence

Prospective RCT: 45 patient , Random allocation for use of AcceleDent

appliance
NiTi coil spring was attached from canine and distally to TSAD
Distance checked b/w TSAD and distal of canine bracket every 4 wks
39 completed the trial and reported 38% (0.29mm/wk) faster tooth
movement compared to control (0.21mm/wk)

Discussion:
Lack of blinding & measurement method may affect the outcome
TSAD can drift under orthodontic loading-1.5mm
Vibration may results in accelerated drift of TSAD
Conclusion:
Future research needed

AcceleDent website.http//accledent.com/images/uploads/AcceleDent + increases+the Rate of Orthodontic

tooth movement Results of a RCT Final for Print November 14 2011.pdf Accessed 20 May 2012

PHYSIOLOGICAL/ MECHANICAL APPROACH

Low-Level Laser Therapy: Evidence

Gallium-aluminium-arsenide Irradiation
Wavelength: 630-860nm energy , energy 4.5-6 J/cm2
Minimally invasive, simple and safe to apply

Mechanism:
Increase in ATP at localized site - induce cells to undergo a remodeling process
due to an elevated metabolic activity
Increase in vascular activity contribute to rapid turnover of bone
Evidence:
Controversial
Few studies reported positive result, few no effect and some reported retarded
tooth movement
Youssef M et al. Low energy laser irradiation therapy during orthodontic tooth movement. A preliminary
stud. Lasers Med Sci 2008;23:27-33
Limpanichkul et al. Effects of low laser therapy on rate of orthodontic tooth movement. Orthod Craniofac
Res. 2006;9:38-43

PHYSIOLOGICAL/ MECHANICAL APPROACH

LLL therapy: Photo-biomodulation (Biolux)

Light with 800-850nm wavelength (just above the visible light spectrum)
penetrates cheeks and soft tissues over AB
97% light lost , 3% excite intracellular enzymes and increase cellular activity
in PDL and bone
Increase blood flow and may enhance tooth movement

Advantage:
Can be adjusted to apply light to only anterior teeth, whole arch or posterior
teeth

PHARMACOLOGIC APPROACH
Corticosteroids
PGs
Growth Hormone
Parathyroid hormone
Active form of Vitamin D
Relaxin

PHARMACOLOGIC APPROACH
Prostglandins: Evidence
Mechanism:
PGE2 an important mediator of bone remodeling under mechanical force
(increase cAMP & cGMP)
Yamaseki &Harell et al:
Experiment on animal model found application of orthodontic force
increase in PGs synthesis- stimulate osteoclastic bone resorption

Injections of PGE1 and PGE2 into gingival tissues near first molar increase
rate of tooth movement

Yamaseki K et al. Prostaglandin as a mediator of bone resoprtion induced by experimental

tooth movement in monkeys. J Dent Res. 1982;61:1444-1446
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PHARMACOLOGIC APPROACH
Protaglandins: Clinical trials

Following LA, 0.1 ml of a 0.01% PGE1 solution in saline was injected

submucosally at pressure side
Rate of canine retraction- 1.6 fold increase

Disadvantages:
Injection were repeated at weakly intervals
Severe pain after injections

Speilmann T et al. Acceleration of orthodontically induced tooth movement through the local
application of prostaglandin (PGE1). Schweiz Monatsschr Zahnmed 1989;99:162-165
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PHARMACOLOGICAL APPROACH
Relaxin

Insulin family of structurally related hormone

Produced during pregnancy

Mechanism:
Increase rate of degradation of extracellular fibrous C.T (stimulate
collagenase)
Increase bone resorption via increase in TNF and IL-1B secretion

Kristiansson P et al. Does human relaxin-2 affect peripheral blood mononuclear cells to increase
inflammatory mediators in pathological bone loss?.Ann N Y Acad Sci.2005;1041:317-9
Stewart Dr et al. Use of Relaxin in orthodontics. Ann N Y Ascad Sci.2005 1041:379-387

PHARMACOLOGICAL APPROACH
Vitamin D ( 1,25 Dihydroxycholecalciferol)

Vitamin D and PTH regulate the amount of calcium and phosphorus levels
Vitamin D receptors present on osteoblasts but also in osteoclast precursors
and in active osteoclasts

Collins and Sinclair et al (1988)

Intraligamentary injections of vitamin D metabolite- increase in the number
of osteoclasts and amount of tooth movement during canine retraction with
light forces
Stimulatory action of vitamin D on osteoblasts can help stabilize orthodontic
tooth movement.

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SURGICAL-ASSISTED APPROACH

Rapid canine retraction through distraction of the PDL

Rapid canine retraction through distraction of dento-alveolus

Corticotomy assisted rapid tooth movement

Corticision/Peizocision

SURGICAL-ASSISTED APPROACH
1.Rapid canine retraction via PDL distraction
Mechanism:

Incorporation of a surgical procedure on interseptal bone distal to canine the

time of extraction of first premolar, resistance is reduced
Rapid canine retraction through distraction (stretching) of PDL
This approach is based on distraction osteogenesis
Pressure side: Canine-interseptal bone complex transported distally inside
the socket
Tension side: PDL distraction leading to osteogenesis

Rapid canine retraction through distraction of PDL

Procedure
Procedure
At the time of extraction of 1st
pm, socket is deepened to the
same depth as canine with a
4mm round carbide bur

1mm carbide fissure bur- to

make two vertical grooves,
running from socket bottom to
the alveolar crest, on the MB and
ML corners

These grooves are joined

obliquely toward the base of
interseptal bone

Liou EJ, Haung CS. Rapid canine retraction through distraction of periodontal ligament. Am J
Orthod Dentofacial Orthop. 1998;114: 372-383

SURGICAL-ASSISTED APPROACH
Rapid canine retraction through dento-alveolar distraction
Technique:
Mucoperiosteal flap reflected
Cortical holes made in alveolar bone from canine to 2nd pm curving apically to
pass 3-5mm from apex
Connect the holes with tapering fissure
First premolar is extracted and buccal bone removed
Large osteotomes are used to mobilize the whole segment
Distraction : after 3 days of surgery
Activation of distractor: twice/day in morning and evening
0.8mm/day
Can also be used to bring ankylosed tooth into position
Disadvantage:
Aggressive and complicated

Kisniscu RS et al. Dentoalveolar distraction osteogenesis for rapid canine retraction. J Oral
Maxillfac Surgery 2002. 60:389-394

SURGICAL-ASSISTED APPROACH
Corticotomy assisted orthodontic tooth movement

Local injury to the alveolar process reduces resistance to tooth movement and
generate RAP
First described in 1892 (fitzpatrick Barry)

Indications:
Resolve crowding and shorten treatment time
Accelerate canine retraction
Enhance post-orthodontic stability
Facilitate eruption of impacted teeth
Molar intrusion and open bite correction
Molar distalization
Koles technique:
Flap raised, vertical cuts facially and lingually between and under teeth that did
not penetrate all the way (only cortex)
Reduce resistance enhances en bloc movement of entire alveolar segment

SURGICAL-ASSISTED APPROACH
Wilcodontics

Accelerated osteogenic orthdontics (AOO) /periodontally accelerated

osteogenic orthodontics

Technique:
Full thickness flaps are reflected carefully beyond the apices to allow
decortication around apices
Corticotomy cuts are made in the form of lines and dots
Small circular depressions were placed in facial surface of bone over
maxillary anterior teeth
Bio-absorbable graft is placed (demineralized freeze dried bone)
Tooth movement- should be started after a weak
Tooth movement should be completed within 3-4 months
Advantages of graft:
Reduces bone dehiscence/ fenestrations especially when
lower incisors are advanced
Good healing of alveolar bone

SURGICAL-ASSISTED APPROACH
Modified corticotomy
Micr0perforation:
Screws placed in gingiva b/w interproximal AB and removed
Enough to accelerate RAP
Piezocision:
Minimally invasive flapless procedure combining microincisions, peizoelectric
incisions & selective tunneling that allows for hard and soft tissue grafting
Advantages:
Minimally discomfort
Enhanced periodontium (added grafting)

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SURGICAL-ASSISTED APPROACH
Corticision

Minimal surgical intervention

No flap is raised, No tunneling of hard or soft tissue
graft not given

Indications:
To resolve anterior crowding
Anterior open bite
Technique:
Insert the surgical blade interproximally and parallel to occlusal plane 2-3 mm apical
from the tip of the papilla
Tap blade with a mallet to a depth of approximately 8mm
Change the angle of the blade to approximately 45 degrees apically and tap the blade to
incise to a depth of 10mm to 12mm
The goal is to cut the cancellous bone between the roots to 50% to 75% of the root length
Apply orthodontic forces immediately
See the patient every two weeks; forcibly mobilizing the teeth to induce minor trauma to
extend the effect.

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SURGICAL-ASSISTED APPROACH
Corticision

Recent advancement: surgical blade is replaced by piezoelectric puncture

Punctures rather than incisions penetrate gingiva, cortical bone, cancellous
bone

Advantages:
Patient friendly
Less discomfort

Evidence still needs further investigation

Park YG. Patient friendly orthodontics to accelerate tooth movement. Presented at the 23rd
Annual conference of Taiwan Association of orthodontics. 2011. Taichung, Taiwan.

SURGERY SIMULATED APPROACH

Submucosal Injections of PRP

Autologous platelet rich plasma can simulate the effects

induced by bone surgery

Platelets contain growth factors PDGF,TGF, EGFs and other components

that regulate and stimulate wound healing and amplify osteogenesis

Technique:
0.9ml of LA injected in the labial and lingual mucosa of anterior teeth
0.7ml of PRP injected in labial and lingual attached gingiva from canine to
canine (immediately after bonding)
Acetaminophen given to control post-injection pain
The rate of orthodontic alignment was faster than compared to controls

Liou EJ et al. Submucosal injection of platelet rich plasma accelerates orthodontic tooth
movement. Am J Orthod Dentofacial Orthop (in press).

THANK YOU!