SYSTEMATIC REVIEW

Effects of vibrational devices on

orthodontic tooth movement:
A systematic review
Aljazi Aljabaa,a Khalid Almoammar,a Abdullah Aldrees,a and Greg Huangb
Riyadh, Saudi Arabia, and Seattle, Wash

Introduction: The aim of this systematic review was to investigate the ability of vibrational devices to increase
the rate of orthodontic tooth movement or reduce pain associated with orthodontic treatment. Methods: An elec-
tronic search for relevant randomized controlled trials (RCTs) was conducted using Medline via OVID (January
1, 1966, through March 30, 2018), and EMBASE, PubMed, and the Cochrane Central Register of Controlled Tri-
als until August 2017. Hand searching of selected orthodontic journals was also undertaken. Results: Through
the electronic searches, 152 titles and abstracts were identified. From these, 10 articles were retrieved for re-
view, and 4 of these met the inclusion criteria. Two additional articles were identified by hand searching. This
resulted in 6 studies from 5 separate randomized controlled trials that were included in this systematic review.
One RCT reported increased tooth movement with vibrational devices, but the other 4 RCTs reported no differ-
ence. Three studies investigated the effect of vibrational devices on pain reduction and found no effect.
Conclusions: The ability of vibrational forces to increase the rate of tooth movement and reduce pain in orthodon-
tic patients has been studied in several RCTs. The results from all but 1 of the included studies indicate no advan-
tage from the use of vibrational devices during orthodontic treatment. Future studies should focus on total
treatment duration, the mechanism by which vibration may speed up tooth movement, and the use of vibration
with aligners. Funding: No funding was received for this review. (Am J Orthod Dentofacial Orthop
2018;154:768-79)

T
he duration of orthodontic treatment is an impor-
tant factor for both orthodontists and their pa-
tients. Shorter treatment time may reduce the
risk of caries, root resorption, and periodontal break-
down, and most patients desire shorter treatment times
simply because of the inconvenience and esthetics of
orthodontic appliances.1 For all these reasons, both
patients and orthodontists would prefer the shortest
treatment time possible. Different methods have been
tried to accelerate tooth movement, such as low-
energy laser irradiation,2 magnetic fields,3 and pharma-
cologic intervention using prostaglandin E2 and vitamin
D.4,5 However, these methods were sometimes
associated with undesirable side effects, such as severe
a
Division of Orthodontics, Department of Pediatric Dentistry and Orthodontics,
College of Dentistry, King Saud University, Riyadh, Saudi Arabia.
b
Department of Orthodontics, University of Washington, Seattle.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Aljazi Aljabaa, 8357 al buhayrat-ar rahmaniyah,
Riyadh 12343-3664, Saudi Arabia; e-mail, dr_aljazi@hotmail.com.
Submitted, April 2018; revised and accepted, July 2018.
0889-5406/$36.00
Ó 2018 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2018.07.012
768
root resorption and local pain.6 Corticotomy-facilitated
orthodontics has also been proposed as a method to
enhance tooth movement, but it is associated with po-
tential morbidity related to the surgery, high cost, and
limited clinical evidence.7
The rate of tooth movement is a primary factor in
determining treatment time, and this mainly depends
on the rate of alveolar bone remodeling. Two hypotheses
of alveolar bone remodeling are piezoelectricity gener-
ated in the alveolar bone and pressure-tension in the
periodontal ligament.8 In piezoelectricity, applied forces
generate an electrical charge that induces the osteogenic
response.9 Since the piezoelectric charges are created
only when stress is applied and released, Shapiro et al10
suggested that orthodontic forces applied to enhance
the rate of tooth movement should not be continuous.
Therefore, vibrational devices may be suitable for initi-
ating stress-induced charges by rapidly applying an inter-
mittent force. It has also been suggested that vibrational
devices enhance tooth movement by reducing frictional
resistance to sliding (stick-slip phenomena) between
brackets and archwires.11,12 Another advantage of
using vibrational devices that has been proposed is pain
reduction after orthodontic adjustment.13-15
Aljabaa et al
For the above-mentioned advantages, 2 devices that
have been or are available commercially provide cyclic
forces directly to the teeth during orthodontic treat-
ment: AcceleDent (OrthoAccel Technologies, Bellaire,
Tex) and Tooth Masseuse (no longer available). Accele-
Dent is a small, rechargeable device consisting of an acti-
vator and a removable mouthpiece, and it provides a
vibrational force of 0.2 N at 30 Hz. The Tooth Masseuse
provided a 111-Hz vibrational frequency and 0.06 N of
force.16 For both devices, patients are (or were) in-
structed to use them for 20 minutes per day by gently
biting on the vibrating plastic wafer. Additional vibra-
tion devices have been introduced to the market
recently, with similar forces and vibrational frequencies.
Orthodontic tooth movement and vibrational devices
were studied in animal models with promising results in
some reports.17-19 A study on Wistar rats with a
resonance vibration for 8 minutes per day found 15%
more tooth movement in the intervention group
compared with the control group.17 Another study
found that application of vibrational forces to Macaca
fuscata monkeys for 1.5 hours per day over 3 weeks
increased tooth movement 1.3 to 1.4 times more than
a static loading force.19 However, recent animal studies
have not found faster tooth movement with vibrational
devices.20,21 Kalajizic et al20 studied the effect of cyclic
forces (.04 N and 30 Hz) applied twice a week for 10 mi-
nutes on the rate of tooth movement on 26 female
Sprague-Dawley rats. They noticed that tooth move-
ment was inhibited after application of the cyclical
forces. Another study was performed on 64 mice that
were divided into 2 groups, control and experimental.
The experimental group received low-frequency me-
chanical vibration at 5, 10, or 20 Hz for 2 weeks, and
no difference was observed in tooth movement
compared with the control group.21 A recent review
article mentioned the conflicting findings in animal
studies and suggested that the rationale for vibration
to increase the rate of tooth movement seems contradic-
tory if the primary effects are anabolic.22 A Cochrane re-
view on nonsurgical adjunctive interventions to
accelerate tooth movement was published in 2015; at
that time, only 2 randomized controlled trials (RCTs)
were identified. Both studies were judged to have a
high risk for bias and showed no conclusive positive ef-
fect of vibrational devices on tooth movement.23-25
Another systematic review, published late in 2017,
included both RCTs and controlled clinical trials.26 The
authors reported that there may be weak evidence that
vibration could be effective for accelerating canine
retraction, but not for accelerating alignment. Since
that time, several additional studies on vibration have
American Journal of Orthodontics and Dentofacial Orthopedics
769
been published, leading us to undertake this systematic
review.
Objective
The aim of this systematic review was to investigate
the ability of vibrational devices to increase the rate of
tooth movement or reduce pain associated with ortho-
dontic treatment.
MATERIAL AND METHODS
The PRISMA checklist was used as a guideline for
conducting this systematic review.
Eligibility criteria
The following inclusion criteria were used: (1) type of
studies: RCTs; (2) participants: orthodontic patients,
aged 11 years and older; (3) types of interventions:
vibrational devices to accelerate tooth movement; and
(4) comparisons: intervention vs no intervention or com-
parisons of 2 or more interventions.
Outcomes
The primary outcome was the rate of tooth move-
ment, as measured by various methods, including rate
of space closure, rate of tooth alignment, or rate of
change in arch perimeter. The secondary outcome was
reduction of pain associated with orthodontic tooth
movement, using measures such as a visual analog scale
(VAS), a validated questionnaire, or a patient interview.
Information sources, search strategy, and study
selection
Electronic and hand searches were used to identify all
studies, regardless of language.
An electronic search was conducted using Medline
via OVID (January 1, 1966, through March 1, 2018), EM-
BASE, PubMed, and the Cochrane Central Register of
Controlled Trials through March 2018. The search strat-
egy is listed in Table I.
A hand search also was undertaken to identify rele-
vant studies from the following journals: American
Journal of Orthodontics & Dentofacial Orthopedics,
Angle Orthodontist, European Journal of Orthodontics,
and Journal of Orthodontics.
When needed, the authors of the included studies
were contacted by the review authors to obtain further
information about additional or unpublished studies
that were eligible for inclusion in the review.
December 2018  Vol 154  Issue 6
770
Table I. Search methodology for electronic systematic
review
Search engine
Embase
Section A: Tooth movement
1. [exp movement/or exp tooth movement]
2. Orthodontic Device.mp.
3. alignment.mp.
4. tooth.mp.
5. 1 AND 2 AND 3
Section B: Orthodontic cyclic load (vibration)
6. “Orthodontics”.mp.
7. cyclic load.mp.
8. vibration force.mp.
9. Acceledent.mp.
10. Tooth Massuse
11. 5 OR 6 OR 7 OR 8 OR 9
Combine A and B
12. 5 AND 11
Limited to human
PubMed
(”Orthodontic Appliances”[Mesh] OR vibrat* OR vibrational forces
OR Acceledent) AND (tooth movement* OR orthodontic tooth
movement*).
Web of Science and Cochrane Library
(tooth movement* OR orthodontic tooth movement*) AND
(Acceledent* OR vibrat*).
Study selection and data extraction
Two review authors (A.A., K.A.) identified potentially
relevant studies independently by screening the titles
and abstracts resulting from the searches. The full text
of each potentially relevant study was obtained, and in-
clusion was assessed independently and in duplicate. In
case of disagreement regarding the inclusion or exclu-
sion of a study, it was resolved by discussion or referred
to a third reviewer (G.H.). The full data extraction was
independently performed by 2 reviewers using a specif-
ically designed data-extraction form. The form was pi-
loted, and the interrater agreement was tested using
the Cohen kappa statistics (kappa value 5 0.88) indi-
cating very good agreement. The primary data extracted
from each study were (1) author, journal name, and year
of publication; (2) sample size; (3) number of subjects in
the intervention group and type of intervention; (4)
number of subjects in the control group; (5) mean age;
(6) treatment type; (7) outcome measures; (8) duration
of follow up; (9) results; and (10) conclusions.
Quality assessment and risk of bias of the selected
studies
Independent quality assessment of the included
studies was performed (Table II). Risk of bias was
December 2018  Vol 154  Issue 6
Aljabaa et al
assessed using Cochrane Collaboration's tool for assess-
ing risk of bias: http://handbook.cochrane.org/
chapter_8/
8_5_the_cochrane_collaborations_tool_for_assessing_
risk_of_bias.htm.
For the overall risk of bias (Table III), the studies were
categorized according to the following.
1. Low risk of bias (plausible bias unlikely to seriously
alter the results) if all criteria were met.
2. Unclear risk of bias (plausible bias that raises some
doubt about the results) if at least 1 criterion was as-
sessed as having an unclear risk.
3. High risk of bias (plausible bias that seriously
weakens confidence in the results) if at least 1 crite-
rion was assessed assessed as having a high risk.
Statistical analysis
Meta-analysis was not performed due to the hetero-
geneity of the devices, techniques, and outcomes
measured in each study. Since there were only 5 separate
trials included in this systematic review, each study will
be assessed and discussed separately.
RESULTS
Through electronic searches, 152 titles and abstracts
were identified. From these, 10 were retrieved for review,
and 4 met the criteria for inclusion. The excluded
studies, with the reason for exclusion, are listed in
Table IV.
Another 2 studies were identified via hand searching,
resulting in a total of 6 studies in this systematic review
(Fig). The characteristics and outcomes of these studies
are summarized in Table V. We briefly describe each of
the 6 studies below.
Miles et al,24 in the first RCT on vibration devices in
orthodontics, evaluated the rate of tooth movement
and the pain experienced by orthodontic patients asso-
ciated with the use of the Tooth Masseuse. The sample
size was 66 patients (26 boys, 40 girls), with an age
range of 11.1 to 15.7 years, who underwent nonextrac-
tion fixed appliance therapy. They were randomly
divided into 2 groups: the experimental subjects who
were instructed to use the vibrational device for 20 mi-
nutes daily (or more if desired), and the control subjects,
who received no vibrational device. The study duration
was 10 weeks, and the archwires used in both groups
were 0.014-in thermal nickel-titanium. The measured
outcomes were tooth movement using the irregularity
index and pain using a VAS score. The tooth movements
were assessed by taking impressions at the initial
American Journal of Orthodontics and Dentofacial Orthopedics
Aljabaa et al
Table II. Assessment of risk of bias
Article
Miles et al24 (Australian Orthodontic Journal, 2012)
Random sequence generation
Allocation concealment
Blinding of participants and personnel
Blinding of outcome assessment
Incomplete outcome data addressed
Selective reporting
Other bias
Pavlin et al25 (Seminars in Orthodontics, 2015)
Random sequence generation
Allocation concealment
Blinding of participants and personnel
Blinding of outcome assessment
Incomplete outcome data addressed
Selective reporting
Other bias
Woodhouse et al16 (Journal of Dental Research, 2015)
Random sequence generation
Allocation concealment
Blinding of participants and personnel
Blinding of outcome assessment
Incomplete outcome data addressed
Selective reporting
Other bias
American Journal of Orthodontics and Dentofacial Orthopedics
771
Judgment Support for judgment
Unclear Quote: “Patients who met the inclusion criteria (Figure 1) were randomly assigned in
blocks of 6 to ensure even numbers in the control and experimental groups.”
Did not mention how the randomization was performed.
Unclear Method of concealment was not addressed
High risk Clinician and investigator were blinded, but not participants.
Quote: “The clinician was blinded to the study participants at all appointments.”
Low risk Quote: “Identification numbers were assigned to the models prior to measurement to
ensure blinding. The irregularity index was measured by one of the authors (PM). After
data collection was complete, the model numbers were matched back to the
corresponding patients.” “A staff member who was blinded to the study groups and
trained in the use of a micrometer measured the VAS data.”
Unclear Dropout patients were reported, but the reasons were not mentioned. Also, did not
mention how missing data from dropouts was managed.
Low risk All planned outcomes reported.
The protocol was not published.
Unclear risk Source of funding was not mentioned.
Low risk Quote: “Subjects were randomly allocated to either the AcceleDent or. . . . A third-party
vendor provided a computer-generated randomization schedule with a block size
of 4“
Low risk Quote: “Each subject was assigned to the next of the 48 pre-specified numbers for four
stratification combinations and the allocation key was kept locked outside the clinic”
Low risk Quote: “both the investigators and the subjects remained blinded to treatment”
Unclear risk Quote from abstract: “All care providers, investigators, and patients were blinded to
intervention assignment.” (The primary author confirmed via personal
communication that all investigators, providers, and patients were blinded, but this
made it unclear why the study was called a double-blinded, rather than a triple-
blinded, study.)
Low risk Dropout patients were reported and the reasons were mentioned. Intention-to-treat
analysis was done.
Low risk Selective reporting of outcomes:
All outcomes outlined in the study registration were reported in the full article.
Selective reporting of data: no suggestion of incomplete reporting of data
High risk Journal not considered peer-reviewed. The study was sponsored by OrthoAccel. The
primary author is a consultant for OrthoAccel.
Low risk Quote: “The randomization sequence was generated using GraphPad online software”
Low risk Quote: “allocation undertaken centrally at King's College London, independently from
the clinical operators after recruitment (allocation concealment)”
Unclear risk Not specifically mentioned in this article, but a follow-up article stated “subjects and
treating clinicians were aware of treatment group allocations”
Low risk Quote: “Dental casts were coded so that measurements were undertaken blind”
Low risk Dropout patients were reported, and the reason was mentioned
Low risk Selective reporting of outcomes: Trial was registered at ClinicalTrials.gov
Selective reporting of data: no suggestion of incomplete reporting of data
Low risk Quote: “We are grateful to OrthoAccel Technologies, who graciously agreed to
participate in this prospective investigation and provide functional and sham
AcceleDent units. This investigation was undertaken independently from OrthoAccel
Technologies Inc. The authors received no financial support and declare no potential
conflicts of interest with respect to the authorship and/or publication of this article.
December 2018  Vol 154  Issue 6
772 Aljabaa et al

Table II. Continued

Article Judgment Support for judgment

Miles and Fisher (American Journal of Orthodontics & Dentofacial Orthopedics, 2016)27
Random sequence generation Low risk Quote: “Randomization was performed using permuted blocks of 10 randomly
generated numbers with the random generation function in Excel”
Allocation concealment Low risk Quote: “the numbers were sealed in opaque envelopes and shuffled by a staff member”
Blinding of participants and personnel Low risk Quote: “Patients were aware of their treatment group. The operator was blinded to the
group assignment, and the model assessor (E.F.) was blinded to the treatment group
and the model time point”
Blinding of outcome assessment Low risk Quote: “The same person (E.F.) blinded to the patient group measured the visual analog
scale data using a digital caliper”
Incomplete outcome data addressed Low risk All randomized patients were accounted for
Selective reporting Unclear risk Selective reporting of outcomes: insufficient information to permit judgment
Selective reporting of data: no suggestion of incomplete reporting of data
Other bias Low risk Study appears to be free of other sources of bias
Katchooi et al34 (American Journal of Orthodontics & Dentofacial Orthopedics, 2018)
Random sequence generation Low risk Quote: “A block stratified randomization scheme was used in this study. Stratification
was achieved by generating a separate block for each combination of age (older than
45 vs younger than 45 years) and sex covariates”
Allocation concealment Low risk Quote: “Subjects were assigned to the appropriate block of covariates using a random
number sequence in separate blocks of 2 to ensure that equal numbers of subjects
would receive the active and control devices.”
Blinding of participants and personnel Low risk Quote: “this was a triple blinded study, in which the subjects, investigators, and assessors
were all blinded to the treatment arms
Blinding of outcome assessment Low risk Quote: “A blinded examiner assessed all digital casts and abstracted data from the
questionnaires. Likewise, our statistician was blinded to the study arms throughout
the statistical analyses”
Incomplete outcome data addressed Low risk Dropout patients were reported, and the reasons were mentioned.
Selective reporting Low risk Selective reporting of outcomes: Trial was registered at ClinicalTrials.gov
Selective reporting of data: no suggestion of incomplete reporting of data
Other bias Unclear risk The study was sponsored by OrthoAccel
35
DiBiase et al (American Journal of Orthodontics & Dentofacial Orthopedics, 2018)*
Random sequence generation Low risk Quote: “The randomization sequence was generated using GraphPad online software”
Allocation concealment Low risk Quote: “allocation undertaken centrally at King's College London, independently from
the clinical operators after recruitment (allocation concealment)”
Blinding of participants and personnel Unclear risk Quote: “subjects and treating clinicians were aware of treatment group allocations”
Blinding of outcome assessment Low risk Quote: “Dental casts were coded so that all measurements were undertaken blindly. All
dental cast linear measurements were carried out blindly by 1 investigator (M.A.). PAR
scoring was also conducted blindly for all dental casts by a calibrated examiner (Y.K.)”
Incomplete outcome data addressed Low risk Dropout patients were reported, and the reason was mentioned.
Selective reporting Low risk Selective reporting of outcomes: trial was registered at ClinicalTrials.gov
Selective reporting of data: no suggestion of incomplete reporting of data
Other bias Low risk Study appears to be free of other sources of bias.
*This article reports outcomes from the completion of the study of Woodhouse et al16 from 2015.

placement of the brackets, 5 weeks, 8 weeks, and
10 weeks. Pain scores were measured by asking the pa-
tients to record the level of pain on a VAS scale at 5 time
points: immediately after placement of brackets, 6 to
8 hours later, and 1 day, 3 days, and 7 days after place-
ment of the brackets. The results of the study showed
no advantage from using the Tooth Masseuse to accel-
erate tooth movement or reduce pain. This study was
judged to have a high risk of bias since the participants
were not blinded (Table II).
The second included study was a single-center, dou-
ble-blinded RCT.25 Forty-five subjects who were 12 to
40 years old and required maxillary first premolar extrac-
tions, were randomly assigned to an AcceleDent group or
a control group. The control group received a disabled
vibrational device. Stratified randomization was used
to ensure that patients' ages (12-19 vs 20-40 years)
and method of space closure (canines separately vs en-
masse retraction) were equally distributed. Temporary
anchorage devices were inserted to ensure maximum

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Aljabaa et al 773

Table III. Overall risk of bias of the included studies

Entry Low risk of bias Unclear risk of bias High risk of bias
Miles et al24 (Australian Orthodontic Journal, 2012) U
Pavlin et al25 (Seminars in Orthodontics, 2015) U
Woodhouse et al16 (Journal of Dental Research, 2015) U
Miles and Fisher27 (American Journal of Orthodontics & Dentofacial U
Orthopedics, 2016)
Katchooi et al34 (American Journal of Orthodontics & Dentofacial U
Orthopedics, 2018)
DiBiase et al35 (American Journal of Orthodontics & Dentofacial U
Orthopedics, 2018)*

*This article reports outcomes from the completion of the study of Woodhouse et al16 study from 2015.

Table IV. Excluded studies with the reason for exclusion

Author
Kau et al28 (2010)
Nemiri et al29 (2013)
Boman30 (2014)
Huang et al31 (2014)
Singh et al32 (2017)
Takano-Yamamoto
et al33 (2017)
Title Reason for exclusion
The clinical evaluation of a novel cyclical force generating device in Uncontrolled clinical trial
orthodontics.
Acceleration of tooth movement during orthodontic treatment—a frontier in Review article
orthodontics
The effect of vibration on the rate of leveling and alignment. Retrospective nonrandomized
study
Accelerated orthodontic tooth movement: molecular mechanisms Review article
Accelerated orthodontic tooth movement: a review Review article
Synergistic acceleration of experimental tooth movement by supplementary Animal study
high-frequency vibration applied with a static force in rats

maxillary anchorage. The patients were asked to use the
AcceleDent devices for 20 minutes per day, and a log
book was used to measure patient compliance with the
appliance. Space closure was directly measured in the
patients’ mouths, and they were instructed to use the
appliances until space closure was achieved. The results
indicated significantly increased tooth movement in the
AcceleDent group (1.16 mm/month) compared with the
control group (0.79 mm/month), P 5 0.05. This study
was judged to have a high risk of bias, because the jour-
nal is not considered to be peer reviewed, and the pri-
mary author was a consultant for OrthoAccel during
the development, performance, and reporting of the
trial. Additionally, OrthoAccel was the sponsor of the
trial.
Woodhouse et al16 randomly allocated 81 patients
undergoing fixed appliance therapy into 3 groups; an
AcceleDent group, an AcceleDent sham group, and a
no-device group. The average age of the patients was
14.1 6 1.7 years, and all participants had first premolar
extractions before treatment began. The primary
outcome measure was the initial rate of tooth alignment,
and the secondary outcome was the time required to
achieve complete alignment. Little's irregularity index
was used to measure alignment on dental casts taken
at baseline, initial alignment (ready for 0.018-in
nickel-titanium), and final alignment (ready for
0.019 3 0.025-in stainless steel). The patients were in-
structed to use the devices for 20 minutes per day until
final alignment was achieved. The average time from
baseline to final alignment was 209 6 65 days. The au-
thors concluded that vibrational forces did not increase
the rate of tooth movement. This study was judged to
have an unclear risk of bias in the category of blinding
of participants.
Miles and Fisher27 evaluated the effect of AcceleDent
on anterior arch perimeter using Little's irregularity in-
dex and the amount of discomfort using a VAS scale.
The sample size was 40 patients with an average age
of 12.8 6 1.3 years, who had fixed orthodontic treat-
ment with maxillary first premolar extractions. They
were randomly allocated to the AcceleDent group (20
patients) and instructed to use the device for 20 minutes
per day, or a control group without a vibrational device.
Impressions of the mandibular anterior teeth were taken
at the start of treatment, 5 weeks, 8 weeks, and 10 weeks.
The patients were instructed to record the level of pain at
the beginning of treatment, 6 to 8 hours later, and at
24 hours, 3 days, and 7 days. The primary outcome of
the study was change in the mandibular anterior arch
perimeter over 10 weeks; the secondary outcomes were
changes in the mandibular arch irregularity index over

American Journal of Orthodontics and Dentofacial Orthopedics December 2018  Vol 154  Issue 6
774
Fig. PRISMA flow diagram.
10 weeks and the amount of discomfort and analgesics
used during the first week of treatment. There were no
significant differences in anterior arch perimeter, Little's
irregularity index, or amount of discomfort between the
AcceleDent group and the control group. There was less
use of analgesics in the AcceleDent group in the first
24 hours compared with the control group (P \ 0.01).
This study was judged to have an unclear risk of bias
because there was insufficient information to permit
assessment of selective reporting of outcomes.
Katchooi et al34 conducted a multicenter RCT to eval-
uate the effect of the AcceleDent device on orthodontic
tooth movement using aligners. Twenty-seven adult or-
thodontic patients with a mean age of 33.0 1 11.1 years
who were beginning their Invisalign treatment were
randomly allocated to either an AcceleDent or a sham
group. Patients in both groups were instructed to use
December 2018  Vol 154  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Aljabaa et al
the device for 20 minutes per day. The primary outcome
was the ability to complete the initial set of aligners us-
ing a 1-week change interval for the aligners. The sec-
ondary outcome was the anterior tooth alignment
using Little's irregularity index, measured at the begin-
ning and end of treatment. Also, aligner compliance
and oral health-related quality of life were evaluated at
baseline, midpoint, and end of treatment. Pain levels
were assessed twice with a 1-week pain survey during
the initial and middle aligner stages. No significant dif-
ference was found between the 2 groups in the percent-
ages of subjects who successfully completed their initial
series of aligners with a 1-week change regimen (P 5 1).
No significant differences were found in the incisor ir-
regularity index and compliance between the 2 groups.
Pain levels were lower in the AcceleDent group only on
day 3 of the first set of aligners. This study was judged
 American Journal of Orthodontics and Dentofacial Orthopedics

Aljabaa et al
Table V. Characteristics of the included studies
Vibrational Control Total
Author, year, appliance group sample Mean age Treatment type Outcome
journal group (n, sex) (n, sex) size (n) (y) (duration) measures Results Conclusion
Miles et al24 Tooth Control (33) 66 11.1-15.7 Nonextraction Little's Time point Control Experimental There was no early
(Australian Masseuse (14 M, 19 F) treatment irregularity mean (SD) mean (SD) improvement in
Orthodontic (33) (patients were index, pain T0 (initial) 4.9 (2.5) 6.2 (3.7) crowding and
Journal, 2012) (12 M, 21 F) instructed to use reduction T1 (5 weeks) 2.7 (1.4) 3.1 (2.1) no reduced pain
the device for (VAS score) T2 (8 weeks) 1.9 (1.0) 2.4 (1.3) among patients
10 weeks) T3 (10 weeks) 1.6 (0.9) 2.1 (1.1) using Tooth
VAS scores (0-100 mm scale) Masseuse
T0 (initial) 8.1 (12.3) 12.4 (13.3)
T1 (6-8 hours after 39.6 (25.8) 40.4 (20.8)
placement)
T2 (1 day after 47.6 (24.5) 41.5 (27.2)
placement)
T3 (3 days after 19.9 (15.5) 18.8 (18.5)
placement)
T4 (7 days after 5.5 (7.8) 4.0 (6.3)
placement)

Pavlin et al25 Acceledent Sham control 45 12-40 Extraction of Tooth Average rate of tooth movement (mm/month) Patients using
(Seminars in device (23) device (22) maxillary first movement ITT analysis Sham control Acceledent Acceledent had
Orthodontics, (sexes not (sexes not premolar and directly device (n 5 22) (n 5 23) an increased
2015) reported) reported) maximum measured Mean (SE) 0.79 (0.150) 1.16 (0.153) rate of tooth
anchorage with in patient's Mean difference 0.37 (0.217) movement
TADs (patients mouth P value 0.05 compared to the
were instructed to Average rate of tooth movement (mm/month) control
use the vibration PP analysis Sham control Acceledent group
device until space device (n 5 18) (n 5 21)
closed) Mean (SE) 0.89 (0.118) 1.25 (0.117)
Mean difference 0.36 (0.181)
P value 0.02
Woodhouse et al16 Acceledent Accel-sham 81 14.1 Extraction of The outcomes Time point Sham mean Fixed mean Accel mean No evidence that
(Journal of device (29) (25), fixed mandibular first measured were change, mm change, mm change, mm supplemental
Dental (sexes not only (27) premolars time to initial (mean time) (mean time) (mean time) vibrational
December 2018  Vol 154  Issue 6

Research, reported) (sexes not (patients were alignment and Baseline to 5.9 mm 5.7 mm 5.5 mm force with an
2015) reported) instructed to wear time to overall initial (59.8 days) (61.0 days) (56.3 days) AcceleDent
the appliances alignment, alignment device can
until final using Little's (59 6 25 days) increase the
alignment irregularity initial alignment 2.2 mm 3 mm 2.8 mm rate of initial
achieved). index to final (158 days) (139 days) (155 days) tooth alignment
alignment or reduce the
(150 6 62.5 time required
days) to achieve
Baseline to final 7.6 mm 8.6 mm 8.4 mm final alignment
alignment (217.5 days) (200.7 days) (210.2 days)
(209 6 65
days)

775
December 2018  Vol 154  Issue 6

776
Table V. Continued

Vibrational Control Total

Author, year, appliance group sample Mean age Treatment type Outcome
journal group (n, sex) (n, sex) size (n) (y) (duration) measures Results Conclusion

Miles and Fisher27 Acceledent Control 40 12.8 years Extraction of 2 Anterior arch Anterior arch perimeter No significant
(American Journal device (20) group (20) 6 1.3 maxillary perimeter, Time point No Acceledent Acceledent P value effect of
of Orthodontics (14 F, 6 M) (12 F, 8 M) premolars only Little's median median Acceledent on
& Dentofacial (study time was irregularity Baseline 36.5 mm 37.1 mm 0.85 mandibular
Orthopedics, 2016) 10 weeks) index, 5 weeks 37.3 mm 37.1 mm 0.84 arch perimeter,
discomfort 8 weeks 37.9 mm 37.6 mm 0.56 irregularity
(VAS score) 10 weeks 37.8 mm 37.7 mm 0.67 index, or
Little's irregularity index the level of
Baseline 4.4 mm 3.9 mm 0.46 discomfort.
5 weeks 2.0 mm 2.0 mm 0.80
8 weeks 1.7 mm 1.8 mm 0.70
10 weeks 1.5 mm 1.7 mm 0.65
Discomfort VAS
Baseline 9.5 mm 8.0 mm 0.84
6 hours 46.0 mm 46.3 mm 0.96
24 hours 54.0 mm 50.5 mm 0.75
3 days 22.1 mm 21.5 mm 0.98
American Journal of Orthodontics and Dentofacial Orthopedics

7 days 2.1 mm 2.6 mm 0.57

Katchooi et al34 Acceledent Aura Sham 26 33.0 Patients treated with Percentages of Subjects who completed their initial series of aligners, No significant
(American device (13) Acceledent 6 11.8 Invisalign fewer subjects who using a 1-week change, effect of using
Journal of (6 M, 7F) device (13) than 25 sets of completed their Sham Acceledent Acceledent P value Acceledent
Orthodontics (6 M, 7 F) aligners (patients initial series n (%) n (%) device on
& Dentofacial were instructed to of aligners, Completed 11 (85%) 10 (77%) 1 ability to
Orthopedics, use the device using a 1-week Not completed 2 (15%) 3 (23%) complete a
2018) once/day during change, Little's irregularity index (maxilla) series of
their treatment maxillary and Time point Sham Acceledent Acceledent P value aligners,
with aligners) mandibular Mean Mean tooth
Little's Baseline 5.45 mm 5.77 mm 0.68 movement,
irregularity Final 2.09 mm 2.20 mm 0.75 pain or oral
index, Little's irregularity index (mandible) health related
compliance Baseline 5.23 mm 5.23 mm 1.00 quality of life
using timers in Final 1.49 mm 1.67 mm 0.49 when used with
the Self-reported aligner uses in hours/day invisalign
AcceleDent First 3 weeks 21.0 20.6 0.89
devices, Midpoint 20.6 20.3 0.72
Additionally, 3 weeks
QoL and pain Final 3 weeks 20.8 20.3 0.53
levels Pain levels by treatment group
questionnaires. Baseline 21.6 15.3 0.27
questionnaire
Midpoint 13.0 10.8 0.51

Aljabaa et al
questionnaire
Aljabaa et al 777

to have an unclear risk of bias since it was sponsored by

final treatment
rate, treatment

breakage, and
space-closure
Conclusion

mandibular
OrthoAccel.
vibrational
No benefit of

outcome.
duration,
terms of
force in
The sixth article35 reported on the completion of
the previously reported study of Woodhouse et al.16
Space closure began after insertion of .019 3 .025-
in stainless steel wire using 9-mm nickel-titanium
coil springs. Collection of data was done at 4 time
P value

0.61

0.42

0.07

0.13
0.95
0.60
0.91
points: start of mandibular space closure (T1), first visit
after initiation of space closure (T2), end of space
median

closure in the mandibular arch (T3), and completion

20.45
Accel

0.82

0.82

14.5

28.0
2.0
3.0
of treatment on removal of the fixed appliances. The
primary outcome measured was the initial rate of space
closure in the mandibular arch, and the secondary out-
median

17.64
Fixed

0.95

0.76

11.0

29.0
2.0
3.0 comes included overall rate of mandibular arch space
Results

closure (mm/month), overall treatment duration

(months), overall number of visits, number of appli-
median

ance breakages, and both absolute and relative per-

Sham

16.73
0.89

0.68

11.0

27.0
2.0
3.0

centages of reduction in the Peer Assessment Rating

during treatment. The mean time periods were
68 6 28 days from T1 to T2 and 172 6 79 days
from T1 to T3. The median rate of initial mandibular
PAR improvement
closure rate
Monthly space

arch space closure was 0.89 mm per month across

Breakages (n)
(mm/mo)

(mm/mo)

duration
of space

Treatment
Initial rate

closure

PAR at T4
T1-T2

T1-T3

the randomized subjects, with no significant differ-

Outcome

(mo)
Visits

ences among groups. No significant differences among

groups were identified for any secondary outcomes.
visits, appliance

(PAR) reduction
closure, overall

breakages and
space closure,

The authors found that the rate of space closure was

mandibular

mandibular
measures
Outcome

number of
arch space

treatment.
Initial rate of

treatment
duration,

significantly influenced by sex, extraction category in

rate of

during

the maxillary arch, and amount of initial space to be

closed.
instructed to wear

closure achieved).
mandibular first
Treatment type

the appliances
(patients were
(duration)

until space
Extraction of

premolars

DISCUSSION
Acceleration of tooth movement and reduction of or-
thodontic treatment duration have great importance to
patients and orthodontists. Vibration is an attractive
Mean age

14.1

noninvasive option with several commercially available

(y)

devices. Many patients are currently using these devices

with the expectation that their teeth will move faster.
size (n)
sample
Total

81

However, animal studies have not demonstrated a clear

mechanism by which vibration induces faster tooth
movement, and clinical studies have reported mixed
(25), fixed
Control

(n, sex)

findings. Therefore, a systematic review assessing the

group

reported)
only (27)
Accel-sham

(sexes not

clinical evidence has high importance. At this time, there

do not appear to be any clear advantages for rate of
tooth movement, total treatment time, and pain reduc-
group (n, sex)
Vibrational

device (29)
appliance

reported)
Acceledent

tion from vibrational devices.

(sexes not
Table V. Continued

The best evidence on vibration and orthodontic ther-

apy consists of the 5 RCTs identified in this systematic
review. One RCT reported increased tooth movement,25
but 5 reports from 4 RCTs reported no differ-
& Dentofacial
Orthodontics

Orthopedics,
DiBiase et al35
Author, year,

Journal of
(American

ence.16,24,27,34,35 No study was judged to have a low

2018)

risk of bias, and the study that reported an increased

journal

rate of tooth movement was judged to have a high risk

American Journal of Orthodontics and Dentofacial Orthopedics December 2018  Vol 154  Issue 6
778
of bias. Although the domains that are typically assessed
for bias are relatively well accepted, this systematic
review highlights some challenges with assigning an
overall risk of bias to a particular trial. For example,
the study of Miles et al24 was judged to have a high
risk of bias, since the control participants did not receive
a sham device; therefore, they were not blinded to their
study arm. It is possible that this may have had an effect
on their VAS scores for pain. The RCT of Pavlin et al25
was published in a journal that historically has not
used formal peer reviews, and the lead author stated
that he was a consultant for OrthoAccel. Additionally,
this study was sponsored by OrthoAccel. Although these
factors do not necessarily discredit a study, taken collec-
tively it is difficult to ignore the potential for bias. The
other studies were judged to have an unclear risk of
bias. The studies by Woodhouse et al16 and DiBiase
et al35 were judged to have unclear risks of bias because
1 group did not receive a sham device and was not
blinded to the intervention. The RCT of Miles and
Fisher27 was not registered, making it difficult to assess
selective reporting. The RCT of Katchooi et al34 received
an unclear risk of bias rating due to sponsorship by Or-
thoAccel. Based on the current Cochrane risk of bias
guidelines, judging even 1 domain of the 7 total do-
mains as having an unclear risk or a high risk automat-
ically places the entire study into that “risk of bias”
category.36
We searched ClinicalTrials.gov for additional ran-
domized trials investigating the AcceleDent device and
found that several trials are currently underway or
recently completed. These include “Accelerated Invisa-
lign therapy in conjunction with AcceleDentÒ Aura”
and “Effect of AcceleDentÒ Aura on orthodontic tooth
movement with aligners.” Biting on the wafers of the vi-
bration devices for 20 minutes a day could function as a
seating device for the aligners, similar to “chewies” that
are given to patients to bite on to assist seating. This ac-
tion could be completely independent of the vibratory
force; therefore, RCTs investigating vibration with
aligners should have sham devices that are used in a
similar manner as the active devices. Otherwise, the
benefit attributed to vibration could be partially or
wholly due to the seating effect obtained by biting on
the wafer.
As with all systematic reviews, there are strengths and
limitations to this one. With respect to strengths, we fol-
lowed the PRISMA checklist and used the Cochrane
guidelines for assessing bias. We also searched for active
and recently completed trials registered at ClinicalTrials.
gov; these studies can be included in future updates of
this systematic review.
December 2018  Vol 154  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Aljabaa et al
Limitations
The heterogeneity of the devices used (1 RCT used
the Tooth Masseuse, and the 4 other RCTs used the first
or second generation AcceleDent devices) and the het-
erogeneity of the outcomes and the type of orthodontic
appliances (4 trials used fixed orthodontic appliances,
and 1 study used aligners) are limitations. Also, some tri-
als used active controls, whereas others did not use a
control device. Additionally, the ultimate goal is to
reduce overall treatment time, and only 1 current RCT
assessed this outcome. We hope that this systematic re-
view will assist future investigators with the design and
conduct of studies assessing vibrational devices; if
similar outcomes are used, meta-analysis may be
possible.
CONCLUSIONS
The ability of vibrational forces to increase the rate of
tooth movement and to reduce pain among orthodontic
patients has been studied in several RCTs. The results
from all but 1 RCT indicate no advantage from using
vibrational devices during orthodontic treatment. Future
studies should focus on total treatment duration, the
mechanism by which vibration may speed up tooth
movement, and the use of vibration with aligners.
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