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Roberts Harry2004 PDF
Roberts Harry2004 PDF
PRACTICE
IN BRIEF
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The osteoblast is the pivotal cell in bone remodelling and the link between the osteoblast and
osteoclast recruitment and activation is now established
Excessive orthodontic forces cause inefficient tooth movement and adverse tissue reactions
The mechanisms which prevent root resorption are not fully understood but it remains a
consequence of any orthodontic treatment. The extent and degree of root resorption cannot
be predicted but some indicators are available
11
Orthodontics. Part 11: Orthodontic tooth movement
D. Roberts-Harry1 and J. Sandy2 NOW AVAILABLE VERIFIABLE
AS A BDJ BOOK CPD PAPER
Orthodontic tooth movement is dependent on efficient remodelling of bone. The cell-cell interactions are now more fully understood
and the links between osteoblasts and osteoclasts appear to be governed by the production and responses of osteoprotegerin ligand.
The theories of orthodontic tooth movement remain speculative but the histological documentation is unequivocal.
A periodontal ligament placed under pressure will result in bone resorption whereas a periodontal ligament under tension results in
bone formation. This phenomenon may be applicable to the generation of new bone in relation to limb lengthening and cranial-
suture distraction. It must be remembered that orthodontic tooth movement will result in root resorption at the microscopic level in
every case. Usually this repairs but some root characteristics apparent on radiographs before treatment begins may be indicative of
likely root resorption. Some orthodontic procedures (such as fixed appliances) are also known to cause root resorption.
The histological changes which occur when odontal ligament is not functioning normally.
ORTHODONTICS forces are applied to teeth are well documented The ligament itself undergoes remodelling and
1. Who needs (Figs 1 and 2). Teeth appear to lie in a position of the role of matrix metalloproteinases (MMPs)
orthodontics? balance between the tongue and lips or cheeks. together with their natural inhibitors, tissue
2. Patient assessment and This zone is not completely neutral since tongue inhibitors of metalloproteinases (TIMPs) are
examination I forces are usually slightly greater than the lips or clearly of importance.1
3. Patient assessment and cheeks. The periodontal ligament is thought to Osteocytes (osteoblasts incorporated into
examination II have an intrinsic force which has to be overcome mineralized bone matrix) are situated in a rigid
4. Treatment planning before teeth move. A notable feature of peri- matrix and are thus ideally positioned to detect
5. Appliance choices odontal disease, where this intrinsic force is lost, changes in mechanical stresses. They could
6. Risks in orthodontic is splaying, drifting and spacing of teeth. Simi- signal to surface lining osteoblasts and thus
treatment larly, if there is excessive tongue activity or bone formation and indeed bone resorption
7. Fact and fantasy in destruction of the lips or cheeks (as in cancrum may result. There is now good understanding of
orthodontics oris) then the teeth will drift. key mechanisms in bone resorption and forma-
Very low forces are capable of moving teeth. tion. Bone is formed by osteoblasts which also
8. Extractions in
Classically, ideal forces in orthodontic tooth have a role in bone resorption. It is the
orthodontics
movement are those which just overcome capil- osteoblast which has receptors for many of the
9. Anchorage control and
lary blood pressure. In this situation bone hormones and growth factors which stimulate
distal movement
resorption is seen on the pressure side and bone bone turnover.
10. Impacted teeth deposition on the tension side. Teeth rarely By contrast, the osteoclast which resorbs
11. Orthodontic tooth move in this ideal way. Usually force is not mineralised tissue, responds to very few direct
movement applied evenly and teeth move by a series of tip- hormone actions. Most of the classic agents
12. Combined orthodontic ping and uprighting movements. In some areas which have direct effects on osteoclasts have
treatment excessive pressure results in hyalanization inhibitory actions. For example, Calcitonin and
where the cellular component of the periodontal prostaglandin E2 will inhibit osteoclasts from
ligament disappears. The hyalanized zone resorbing calcified matrices.
1*Consultant Orthodontist, Orthodontic assumes a ground glass appearance but this The recruitment and activation of osteo-
Department, Leeds Dental Institute,
Clarendon Way, Leeds LS2 9LU;
returns to normal once the pressure is reduced clasts to sites of resorption comes from the
2Professor of Orthodontics, Division of and the periodontal ligament repopulated with osteoblast when the latter cell is stimulated
Child Dental Health, University of Bristol normal cells. In this situation a different type of by various hormones. The signal link from
Dental School, Lower Maudlin Street, resorption is seen whereby osteoclasts appear to osteoblasts has recently been identified as
Bristol BS1 2LY;
*Correspondence to: D. Roberts-Harry ‘undermine’ bone rather than resorbing at the osteoprotegerin (OPG) and the ligand (OPGL).
E-mail: robertsharry@btinternet.com ‘frontal’ edge (Fig. 3). They both potently inhibit and stimulate
Mechanically induced remodelling is not respectively, osteoclast differentiation. Fur-
Refereed Paper
doi:10.1038/sj.bdj.4811129 fully understood. The role of the periodontal thermore, OPGL appears to have direct effects
© British Dental Journal 2004; 196: ligament has been questioned since tooth on stimulating mature osteoclasts into activi-
391–394 movement can still occur even where the peri- ty. If OPGL is injected into mice there is an
PRACTICE
Fig. 1 Pressure side of a tooth being moved. The very vascular Fig. 2 This is a tension site where the bone adjacent to the
periodontal ligament has cementum on one side and bone on the periodontal ligament has surface lining osteoblasts and no sign of
other where frontal resorption is occurring. Osteoclasts can be seen any osteoclasts. New bone is laid down as the tooth moves
in their lacunae resorbing bone on it's ‘frontal edge’
PRACTICE
• Magnetic fields alone have little, if any, effect method, known as distraction osteogenesis,
on tissues can be used in any situation where it is hoped
• Pulsed magnetic fields (which induce electric that new bone will be generated. Originally
fields) can increase the rate and amount of this was described in Russia where many sol-
tooth movement diers returning from war faced the problem of
• When an orthodontic force is applied, the non-union limb fractures. Initially attempts
tooth is displaced many times more than the were made to induce new bone formation by Tension results in
periodontal ligament width. Bone bending compressing bone ends. It was only when a bone formation, this
must therefore occur in order to account for patient inadvertently turned the screw for can be used to
the tooth movement over and above the width compression of bone ends in the wrong direc-
of the periodontal ligament tion that it was noted excessive new bone for- generate new bone
• Physically distorting dry bone produces mation was seen where bone ends were dis- for digit lengthening
piezoelectric forces which have been implicat- tracted rather than compressed. or suture distraction
ed in tooth movement. Piezoelectric forces are This may also have application in patients
those charges which develop as a consequence whose sutures fuse prematurely (craniosynos-
of distorting any crystalline structure. The toses such as Crouzon's or Aperts Syndrome).
magnitude of the charges is very small and In this situation continued growth of the brain
there is some doubt whether they are suffi- results in a characteristic appearance of the
cient to induce cellular change. cranium but more importantly the eyes
• It must also be remembered that in hydrated become protuberant with possible damage to
tissues, streaming potential and nerve impuls- the optic nerve. Treatment involves surgically
es produce larger electrical fields and thus it is opening the prematurely fused sutures and
unlikely that piezoelectric forces alone are burring out to enable normal brain growth. If
responsible for tooth movement.2 distraction forces are applied prior to this early
fusion then bony infill could occur at a con-
A wider application of the phenomenon of trolled rate. The phenomenon of pressure
mechanically induced bone remodelling is resulting in bone loss is also seen in pathologi-
seen where sutures are stretched. In young cal lesions. Much work was done to examine
orthodontic patients the midline palatal pressures within cystic lesions and to equate
suture can be split using rapid maxillary this with the rate of bone destruction. It is now
expansion techniques. The resulting tension recognised that cytokines and bone resorbing
generates new bone which fills in between the factors produced by cystic and malignant
distracted maxillary shelves. A similar tech- lesions are more likely to be responsible for the
nique is also used to lengthen limbs. This associated bone resorption.
Fig. 3 This is an area of excessive pressure Fig. 4 Area of root resorption associated with
where the periodontal ligament has been orthodontic tooth movement. The apex of
crushed or ‘hylanized’ and the periodontal the tooth has a large excavation of the root
ligament has lost its structure. There is a large surface and this is typical of excessive
cell lying in a lacunae behind the frontal edge tipping forces that are placed on the apices
which is probably an area of undermining of the teeth
resorption
PRACTICE