ACCELERATED

ORTHODONTIC
TOOTH
MOVEMENT
 CONTENTS
• INTRODUCTION
• VARIOUS METHODS:
• BIOLOGICAL METHODS
• DEVICE ASSISTED TREATMENT
• SURGICAL APPROCH
• CLINICAL APPLICATION FOR FUTURE
 INTRODUCTION
• Number of attempts to create different approaches both
preclinically and clinically in order to achieve quicker
results.
• Orthodontic tooth movement= mechanical stimuli

remodelling of alveolar bone and PDL

• Bone remodelling= bone resorption on pressure side + bone

formation on tension site
 Accelerated tooth movement

Biological Device Assisted Surgical

approach treatment approach
 BIOLOGICAL APPROACH

Cytokines Prostaglandin Vitamin D3 PTH Relaxin

 EFFECT OF CYTOKINES ON TOOTH
MOVEMENT
• High concentration of cytokines such as interleukins
IL-1, IL-2, IL-3 IL-6, IL-8, and tumor necrosis factor
alpha (TNF) - play major role in bone remodeling.

• Interleukin-1 (IL-1) stimulates osteoclast function

through receptor on osteoclasts.

• Mechanical stress due to orthodontic treatment

increased production of prostaglandin PGE and IL-1
beta in periodontal ligaments.
 EFFECT OF CYTOKINES ON TOOTH
MOVEMENT
• RANKL- membrane-bound protein on osteoblasts
that bind to RANK on osteoclasts and causes
osteoclastogenesis.

• Osteoprotegerin (OPG) competes with RANKL in

binding to osteoclast to inhibit osteoclastogenesis.

• Process of bone remodeling- balance between

(RANKL-RANK) system and OPG compound.
 PROSTAGLANDIN EFFECT ON
TOOTH MOVEMENT
• PGs are local autocrine/paracrine lipid inflammatory
factors also regulate bone remodeling.
• Several animal experiments: local application of
PGE1, PGE2, or analogs of PGE1, PGE2, or
thromboxane A2 increase speed of orthodontic tooth
movement.
• Local submucosal injection of PGE1 in human
patients- successful in accelerating tooth movement
by 1.6-fold.
 EFFECT OF VITAMIN D3 ON TOOTH
MOVEMENT
• 1,25 dihydroxycholecalciferol- hormonal form of
vitamin D and plays an important role in calcium
homeostasis with calcitonin and parathyroid hormone
(PTH).
• Also acts on bone cells to increase bone remodeling.
• Animal studies: local injection of 1,25 dihydroxy
vitamin D3 accelerated orthodontic tooth movement
by about 1.2- to 2.5-fold.
 EFFECT OF VITAMIN D3 ON TOOTH
MOVEMENT
• Histologic examination- 1,25 dihydroxy vitamin D3
stimulates formation of osteoclasts in dose-dependent
manner, synergizing with mechanical force and
causes significantly more alveolar bone resorption.
• Osteoblast formation and bone formation also
elevated- presenting more balanced effect of 1,25
dihydroxy vitamin D3 on bone volume.
 PTH EFFECT ON TOOTH MOVEMENT

• Major hormone regulating bone remodeling and

calcium homeostasis.
• Elevates serum calcium concentration by both
stimulating bone resorption and up-regulating
calcium reabsorption and enzyme 25-hydroxy D3 1-
alpha-hydroxylase in kidneys.
• Animal studies shown that continuous global infusion
or chronic local injection of parathyroid hormone
accelerated orthodontic tooth movement- 1.6- to 2-
fold, and significantly increased osteoclast numbers.
 PTH EFFECT ON TOOTH MOVEMENT

• Shown to accelerate orthodontic tooth movement on

rats. (Soma S 1999)

• Locally injected PTH induces local bone resorption,

and it is more advantageous to give PTH locally
rather than systemically. (Yamamoto T 1990)
RELAXIN EFFECT ON TOOTH MOVEMENT

• Relaxin- hormone- helps during childbirth by

widening of pubic ligaments in females
• Suggested to be present in cranial suture and PDL.
• Role of relaxin: remodeling of soft tissue rather than
remodeling of bone.
• Increases collagen in tension site and decreases it in
compression site during orthodontic movement.
RELAXIN EFFECT ON TOOTH MOVEMENT

• Human relaxin does not accelerate orthodontic tooth

movement in rats, but can reduce level of PDL
organization and mechanical strength of PDL and
increase tooth mobility. (Madan MS AJODO 2007)

• Remodeling of PDL by relaxin might reduce rate

of relapse after orthodontic treatment.
 DEVICE ASSISTED TREATMENT

Cyclic Force Direct Electric Low Level Laser

Device Current Therapy (LLLT)
 DEVICE ASSISTED TREATMENT

• Concept of using physical approaches came from idea

that applying orthodontic forces causes bone bending
(bone bending theory) and bioelectrical potential
develops.
• Concave site will be negatively charged attracting
osteoblasts
• Convex site will be positively charged attracting
osteoclasts.
• Zengo (AJO 1974) in his measurements on dog
alveolar bone.
 DEVICE ASSISTED TREATMENT

• Bioelectrical potential is created when there is

application of discontinuous forces which leads to
idea of trying cyclic forces and vibrations.

• Applying vibrations for different duration per day,

accelerated tooth movements between 15% and 30%
in animal experiments.
 CYCLIC FORCE DEVICE EFFECT ON
TOOTH MOVEMENT

• 2 to 3 mm/month of tooth movement can be

achieved.
• Vibration rate- 20 to 30 Hz and used for 20 min/day.

(Kau CH. 2011)

 DIRECT ELECTRIC CURRENT EFFECT
ON TOOTH MOVEMENT

• This technique tested only on animals by applying

direct current to anode at pressure sites and cathode
at tension sites (by 7 V)- generating local responses
and acceleration of bone remodeling.

• Difficult to be tested clinically:

1. Bulkiness of devices
2. Source of electricity
 LOW LEVEL LASER THERAPY (LLLT)

• Photobiomodulation or low level laser therapy

(LLLT)- one of most promising approaches today.
• Laser-
1. Biostimulatory effect on bone regeneration, shown
in midpalatal suture during rapid palatal expansion
2. Stimulates bone regeneration after bone fractures
and extraction site
 LOW LEVEL LASER THERAPY (LLLT)

• Laser light stimulates proliferation of osteoclast,

osteoblast, and fibroblasts.
• Affects bone remodeling and accelerates tooth
movement.
• By production of ATP and activation of cytochrome C
• Low-energy laser irradiation enhances velocity of
tooth movement via RANK/RANKL and macrophage
colony-stimulating factor and its receptor expression.
 LOW LEVEL LASER THERAPY (LLLT)

• Laser wavelength of 800 nm and output power

of 0.25 mW- significant stimulation of bone
metabolism, rapid ossification, and also
acceleration of tooth movement to 1.5-fold in rat
experiments.
 SURGICAL APPROACH

Interseptal
Corticotomy Piezocision
Alveolar
and Osteotomy Technique
Surgery
INTERSEPTAL ALVEOLAR SURGERY

• Interseptal alveolar surgery or distraction osteogenesis is

divided into
1. Distraction of PDL
2. Distraction of dentoalveolar bone

• Example of both is rapid canine distraction.

• Concept of distraction osteogenesis came from early studies of
limb lengthening.

• Also from surgical treatments of craniofacial skeletal dysplasia,

this concept later adapted in relation to rapid tooth movement.
INTERSEPTAL ALVEOLAR SURGERY

Rapid Canine Distraction of PDL:

• Interseptal bone distal to canine is undermined surgically at

same time of extraction of first premolars.
• This reduce resistance on pressure site.
• Compact bone is replaced by woven bone.
• Tooth movement is easier and quicker due to reduced
resistance of bone.
• These rapid movements are during initial phases of tooth
movement especially in first week.
INTERSEPTAL ALVEOLAR SURGERY

Rapid Canine Distraction of PDL:

• Interseptal bone undermined 1 to 1.5 mm in thickness distal to

canine after extraction of first premolar.
• Socket deepened by round bur to length of canine.
• Retraction of canine is done by activation of intraoral device
directly after surgery.
• It takes almost 3 weeks to achieve 6 to 7 mm of full retraction
of canine to socket of extracted first premolars.
INTERSEPTAL ALVEOLAR SURGERY

Rapid canine distraction of dentoalveolar bone

• Done by same principle of distraction of PDL

• With addition of more dissection and osteotomies performed
at vestibule.

• Both techniques accelerated tooth movement with no evidence

of significant root resorption, ankylosis, and root fracture.
 CORTICOTOMY AND OSTEOTOMY

• Osteotomy- when segment of bone is cut into medullary bone

and is separated and then moved as a unit.

• Corticotomy- Only cortical bone is cut and perforated but not

medullary bone, suggesting that this will reduce resistance of
cortical bone and accelerate tooth movements.

• Was first tried in orthodontics by Kole (1959), where tooth

movements were achieved between 6 and 12 months.
 CORTICOTOMY AND OSTEOTOMY
• In 2001 Wilcko: acceleration of tooth movement is not due to
bony block movement as postulated by Kole.

• Rather process of bone remodeling at surgical site, which was

called regional acceleratory phenomenon (RAP).

• Developed patent techniques: Accelerated osteogenic

orthodontics (AOO) and periodontal accelerated osteogenic
orthodontics.

• Modification of RAP was done by adding bioabsorbable grafting

material over injured bone to enhance healing.
 CORTICOTOMY AND OSTEOTOMY
• This technique is reported to have postoperative stability and
improved retention.

• Negativity of these surgical techniques:

1. Invasiveness and
2. Acceleration only in first 3 to 4 months and it declines with
time to same level of controls.
 PIEZOCISION TECHNIQUE

• Dibart (2010)- first to apply Piezocision technique which

starts with primary incision placed on buccal gingiva followed
by incisions by Piezo surgical knife to buccal cortex.

• Did not cause any periodontal damage.

• It can be used with Invisalign, which leads to better aesthetic

appearance and less treatment time.
 CLINICAL APPLICATION FOR FUTURE
• Administration of certain molecules- promising results;
for example, cytokine, PTH, vitamin D, and
RANKL/RANK/OPG system play an important role in
bone remodeling and tooth movement.
• In physical approach, low level laser therapy most
promising method; however, contradictory results shown:
1. Due to different energies, duration, and experimental
design.
2. Most of these experiments done in only few weeks,
which is very short time to notice any side effects.
 CLINICAL APPLICATION FOR FUTURE
• Surgical approach most clinically used and most tested
with known predictions and stable results.
• Invasive, aggressive, and costly.
• Patients not open to ideas involving surgery unless it is
only option that is needed to have a good occlusion.
• Piezocision technique is one of newest techniques in
accelerating tooth movement, and has good clinical
outcome and is considered least invasive in surgical
approach.