Tissue Reaction Lecture 1 Dr. Hala Sept

Biological Mechanisms of orthodontic tooth
movement
By Dr. Hala Munir Abdel Majeed

Professor of Orthodontics
Future University
Date Title
18 October Periodontal and Bone Response to Normal
Function
25 October Bone Remodelling
1 November Optimal orthodontic force & phases of

orthodontic tooth movement
8 November Theories of orthodontic tooth movement
15 November Inflammatory mediators in orthodontic tooth

movement
22 November Midterm Exam

29 November Acceleration of tooth movement (Non surgical)
6 December Acceleration of tooth movement (Surgical)
13 December Drug effects on the response to orthodontic force
20 December Deleterious effects of orthodontic force

27 December
Course Outline
Part I
Periodontal and Bone Response to Normal Function
Part II.
Periodontal Ligament and Bone Response to sustained force
Part III
Deleterious Effects of Orthodontic force
Course Outline
Part I:
1. Periodontal and Bone Response to Normal Function:
a. Periodontal Ligament structure and Function

b. Bone structure and function
c. Response to Normal Function
d . Role of the periodontal Ligament in eruption and stabilization of teeth.
Part II.
Periodontal Ligament and Bone Response to sustained force:
a. Biological control of tooth movement.

b. Effects of magnitude, distribution and duration on the Response to Orthodontic
Force
c. Bone remodeling
d. Optimal Orthodontic force, phases of tooth movement
e. Theories of orthodontic tooth movement
f. Inflammatory mediators in orthodontic tooth movement
g. Acceleration of tooth movement
h. Drug Effects on the Response to Orthodontic Force
Part III
1. Deleterious Effects of Orthodontic force:
Part I:
1. Periodontal and Bone Response to Normal Function:
a. Peridodontal Ligament structure and Function

b. Bone structure and function
d. Role of the periodontal Ligament in Eruption and stabilization of
teeth
Orthodontic Tooth Movement
Orthodontic treatment is based on the principle that if prolonged pressure is applied to a tooth,
tooth movement will occur as bone around the tooth remodels.
The tooth moves through the bone carrying its attachment apparatus with it as the socket of the
tooth migrates. Because the bony response is mediated by the periodontal ligament,
Tooth movement is primarily a periodontal ligament phenomenon
According to Proffit “Orthodontic tooth movement is the result of a biological

response to interference in the physiological equilibrium of the dentofacial
complex by an externally applied force.”
Orthodontic tooth movement (OTM) is facilitated by remodeling of the dental

and paradental tissues which, when exposed to varying degrees of
Magnitude, frequency and duration of mechanical Loading which expresses
extensive physical and chemical changes.
a. 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.
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.
A fluid-filled chamber with retentive but porous
walls could be a description of a shock absorber,
and in normal function, the fluid allows the PDL
space to play just this role.
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.
a. Periodontal Ligament Structure and Function:
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.
Both components play

an important role in
normal function &OTM
• Vascular and neural elements:

• Although the PDL is not highly vascular, it does contain:
• * blood vessels and cells from the vascular system.
• Nerve endings:
• Unmyelinated free nerve fibers (Nociceptors) responsible for pain perception
• Mechanoreceptors (proprioceptors) for pressure sensation.
• Extracellular matrix (ECM) Component:

• The extracellular matrix (ECM):
Collagen, proteoglycans, laminin, and fibronectin embedded
in a hydrated polysaccharide gel
functions as a medium regulating PDL cellular identity, position, proliferation.
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.
b. Bone Structure and Function
Bone is a hard tissue composed of a collagen matrix impregnated with mineral salts. As
well as providing the foundation of the musculoskeletal system in most vertebrates, it
serves as a storage site for many important elements, especially calcium.
Bone consists of three principle components:

● An extracellular matrix, consisting predominantly
of: * Type I collagen
* a variety of Proteoglycans and bone-specific
proteins;
● Inorganic mineral, which makes up approximately 67% of bone by weight and

consists mainly of:
calcium and phosphate in the form of hydroxyapatite crystals;
● Cells, which include:

* Osteoblasts responsible for laying down and mineralizing the bone matrix;
• Osteocytes, which are osteoblasts that have become enveloped by bone as it
• mineralizes,
* Osteoclasts, which are large multinucleate cells derived from haematopoetic
precursors within the circulation that resorb bone.
●There is close intercellular communication between osteoblasts and

osteocytes, the main function of this osteoblast–osteocyte complex being to
maintain integrity of the bone matrix.
During masticatory function, the teeth and

periodontal structures are subjected to
intermittent heavy forces. Tooth contacts last for I
second or less; forces are quite heavy, ranging
from I or 2kg.
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.
Bone bending in response to normal

function generates piezoelectric currents
that appear to be an important stimulus to
skeletal regeneration and repair.
d. Role of periodontal ligament in Eruption and
Stabilization
c. Role of periodontal ligament in eruption and
stabilization
Prolonged force, even of low magnitude, produces

a different Physiologic response remodeling
of the adjacent bone.
c. Role of periodontal ligament in eruption and stabilization
The eruption mechanism appears to depend on metabolic events within the

PDL, including formation, cross-linkage and maturational shortening of
collagen fibers.
This process continues, although at a reduced rate, into adult life.
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.
It is observed that light

prolonged pressures against
the teeth are not in perfect
balance.
The ability of the PDL to generate a force and thereby contribute to the set of forces
that determine the equilibrium situation, probably explains this.
The current concept is that active stabilization can overcome prolonged forces of a few
grams at most, perhaps up to the 5 to 10gm/cm often observed as the magnitude of
unbalanced soft tissue resting pressures.
Resting pressure from the lips, cheeks and tongue

are usually not balanced.
In lower incisor region, tongue pressure is greater
than lip pressure.
While, in the upper incisor area, lip pressure is greater.
Consequently active stabilization is produced by
.metabolic events in the PDL
Part II
Periodontal Ligament and Bone Response to Sustained
Force
Part II
Force
1.Biological Control of Tooth Movement:

a. Biological electricity
b. Pressure Tension effects in Periodontal Ligament
2. Effects of magnitude, distribution and duration on the Response to

Orthodontic Force:
a. Effect of Force Magnitude
b. Effect of Force Distribution and types of OTM
c. Effects of Force Duration & Decay
i. Continuous Force
ii. Interrupted Force
iii. Intermittent Force
Part II
Force
1. Biological control of tooth movement:

a. Biological electricity
b. Pressure Tension effects in Periodontal Ligament
a. Biological Control of Tooth Movement:
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.
In orthodontic practice, the objective is to produce tooth movement as much as possible

by frontal resorption, recognizing that some areas of PDL necrosis and undermining
resorption will probably occur despite efforts to prevent this.
The biologic control mechanisms that lead from the stimulus of sustained force
application to the response of orthodontic tooth movement.
Two possible control elements:
1. Biologic electricity and;
2. Pressure-tension in the PDL that affects blood flow' are contrasted in
the Two major theories of orthodontic tooth movement.
1. Biologic electricity
The bioelectric theory relates tooth movement at least in part to

changes in bone metabolism controlled by the electric signals that are
produced when alveolar bone flexes and bends.
1. Biologic electricity
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.
Bone mineral is a crystal structure with piezoelectric properties, collagen itself

is piezoelectric.
Piezoelectric signals have two unusual characteristics: Calcium hydroxyapatite
(1) a quick decay rate (i.e., when a force is applied a piezoelectric signal is created in crystals
response that quickly dies away to zero even though the force is maintained) and
(2) the production of an equivalent signal, opposite in direction, when the force is
released.
2. Pressure-Tension
Theory
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.
Pressure and tension within the PDL, by reducing
(pressure) or increasing (tension) the diameter of
blood vessels in the ligament space, could certainly
alter blood flow.
2. Pressure-Tension
Theory
2. Pressure-Tension
Theory
The two theories are neither incompatible nor

mutually exclusive.
From a contemporary perspective, it appears that
both mechanisms may play a part in the
biologic control of tooth movements.
Part II
2. Effects of magnitude, distribution and duration on the Response
to Orthodontic Force:

b. Effect of Force Distribution and types of OTM
i. Continuous Force
Part II
Force
2. Effects of force magnitude on the Response to Orthodontic

Force:
2. Effects on the Response to Orthodontic Force:
Light Force
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 (i.e., in a few seconds).
Within a few hours at most, the resulting change in the chemical environment produces
a different pattern of cellular activity.
Light Force
Animal experiments have shown that increased levels of cyclic adenosine

monophosphate (AMP), the "second messenger" for many important cellular
functions including differentiation, appear after about 4 hours of sustained
pressure.
Light Force
Experiments have shown that prostaglandin and

interleukin-1 beta levels increase within the PDL within
a short time after the application of pressure, and it is
clear now that prostaglandin E is an important mediator
of the cellular response. Changes in cell shape probably Prostaglandin release
play a role. may be a primary
There is some evidence that prostaglandins are rather than a
released when cells are mechanically deformed. secondary response
to pressure
Light Force
It is likely that mobilization of membrane

phospholipids, which leads to the formation of
inositol phosphates, is another pathway
toward the eventual cellular response.
Other chemical messengers, particularly
members of the cytokine family but also nitric
oxide (NO) and other regulators of cellular
activity, also are involved.
Light Force
Cells appear in two waves: The first wave may be derived from a local cell population, while
others (the larger second wave) are brought in from distant areas via blood flow.
These cells attack the adjacent lamina dura, removing bone in the process of "frontal
resorption," and tooth movement begins soon thereafter.
Light Force
At the same time, but lagging somewhat behind so that the PDL space becomes enlarged, osteoblasts
(recruited locally from progenitor cells in the PDL) form bone on the tension side and begin remodeling
activity on the pressure side.
Heavy Force
If the sustained force against the tooth is great enough to totally occlude
blood vessels and cut off the blood supply to an area within the PDL.
When this happens, a sterile necrosis ensues within the compressed
area.
Heavy Force
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.
Heavy Force
Heavy force leads to complete occlusion of blood vessels leading to PDL cell death.
The histologic appearance as the cells disappear, an avascular area in the PDL traditionally has been
referred to as hyalinized. It represents the inevitable loss of all cells when the blood supply is
totally cut off.
Heavy Force
• Remodeling of bone bordering the necrotic area of the PDL ….. cells derived from adjacent undamaged areas.
• After a delay of several days, cellular invasion of necrotic (hyalinized) area.
• Osteoclasts appear within the adjacent bone marrow spaces and attacking on the underside of the bone
immediately adjacent to the necrotic PDL area (undermining resorption) .
 A delay in stimulating differentiation of cells within the marrow spaces.

 A considerable thickness of bone must be removed from the underside before any TM can take
place.
HEAVY LIGHT
FORCES FORCES
In clinical practice, tooth movement usually proceeds in a more stepwise fashion because of the areas
of undermining resorption.
Even with light forces, small avascular areas are likely to develop in the PDL& TM will be delayed until
these can be removed by undermining resorption.
Part II /
Part II
Agenda
Periodontal Ligament and Bone Response to Sustained Force

b. Effect of Force Distribution & types of OTM
Manner Direction Magnitude Duration

Manner Magnitude Duration
The PDL response is determined not by force alone, but by force per unit area, or pressure.
Because the distribution of force within the PDL, and therefore the pressure, differs with
different types of tooth movement, it is necessary to specify the type of tooth movement as
well as the amount of force in discussing optimum force levels for orthodontic purposes.
Tipping Tooth
Movement
Application of a single force to the crown of a tooth creates rotation around a point approximately
halfway down the root. Heavy pressure is felt at the root apex and at the crest of the alveolar bone,
but pressure decreases to zero at the center of resistance. The loading diagram therefore consists of
two triangles.
Tipping Tooth
Movement
In tipping, only one-half the PDL area is loaded covering half the total PDL area.
Pressure in the two areas where it is concentrated is high in relation to the force
applied to the crown. For this reason, forces used to tip teeth must be kept quite
low where tipping forces should not exceed approximately 50gm.
Tipping Tooth
Movement
In tipping tooth movement,

(Mc/Mf = 0), the tooth rotates
around the center of resistance
(Pure tipping).
The ratio between the moment produced by the force applied to move
a tooth (Mf) and the counterbalancing moment produced by the couple
used to control root position (Mc) determines the type of tooth
movement.
Controlled
Tipping
movement
As the moment to force ratio increases (0<Mc/Mf<1), the center of

rotation is displaced further away from the center of resistance
producing what is called controlled tipping.
Bodily When Mc/Mf=1, the center of

movement rotation is displaced to infinity
and bodily movement
(translation) occurs.
Bodily movement, the root apex and crown move in the same direction the same amount.
It requires that the periodontal ligament 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 periodontal ligament for bodily
movement as compared with tipping (70-120gms).
Rotation tooth
movement
It is essentially impossible to apply a rotational force so that the tooth

does not tip in its socket, and when this happens, an area of compression
is created just as in any other tipping movement. For this reason,
appropriate forces for rotation are similar to those for tipping (50-
100gms)
Extrusion tooth
movement
Extrusive movements ideally would produce no areas of compression within

the PDL, only tension. Since if the tooth tipped while being extruded, areas of
compression would be created. Even if compressed areas could be avoided heavy
forces in pure tension would be undesirable. Extrusive forces, like rotation,
should be of about the same magnitude as those for tipping (35-60gms)
Intrusion tooth
movement
As with extrusion, the tooth probably
will tip somewhat as it is intruded, but
the loading diagram nevertheless will
show high force concentration at the
apex.
When a tooth is intruded, the force is concentrated over a small

area at the apex. For this reason, extremely light forces are
needed to produce appropriate pressure within the periodontal
ligament during intrusion (10-20gms).
Torque tooth
movement
Movement of the root without movement of the crown. If Mc/Mf>1,

the center of rotation is displaced incisally and the root apex will move
more than the crown, producing torque.
Part II
Periodontal Ligament and Bone Response to Sustained Force

i. Continuous Force
2. Effectson the Response to Orthodontic Force:
c. Effects of Force Duration and Decay
i. Continuous Force
Orthodontic Force duration is classified by the

rate of decay
ii. Interrupted Force (Dissipating)
Both continuous and
interrupted forces can be
produced by fixed appliances
that are constantly present.
When tooth movement occurs, force levels
iii. Intermittent Force: will decrease as they would with a fixed
appliance (i.e., the intermittent force can also
become interrupted between adjustments of
the appliance.
force levels decline
Heavy
Intermittent
force levels decline Heavy

continuous
forces are to
Heavy forces are physiologically acceptable, only if force be avoided
levels decline so that there is a period of repair and
regeneration before the next activation, or if the force A heavy continuous force
decreases at least to the point that no second and third can be quite destructive
rounds of undermining resorption occur. to both the periodontal
structures and the tooth
itself.
Experience has shown that orthodontic appliances should not be

reactivated more frequently than at 3-week intervals. A 4- to 6-week
appointment cycle is more typical in clinical practice.

Tissue Reaction Lecture 1 Dr. Hala Sept

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Tissue Reaction Lecture 1 Dr. Hala Sept

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Biological Mechanisms of orthodontic tooth

By Dr. Hala Munir Abdel Majeed

1 November Optimal orthodontic force & phases of

8 November Theories of orthodontic tooth movement

15 November Inflammatory mediators in orthodontic tooth

22 November Midterm Exam

20 December Deleterious effects of orthodontic force

a. Periodontal Ligament structure and Function

a. Biological control of tooth movement.

a. Peridodontal Ligament structure and Function

According to Proffit “Orthodontic tooth movement is the result of a biological

Orthodontic tooth movement (OTM) is facilitated by remodeling of the dental

Each tooth is attached to and

The PDL space is filled with fluid; this fluid is the

The major component of the ligament is a

Both components play

• Vascular and neural elements:

• Extracellular matrix (ECM) Component:

Remodeling and recontouring of the bony socket and the cementum of

Bone consists of three principle components:

● Inorganic mineral, which makes up approximately 67% of bone by weight and

● Cells, which include:

●There is close intercellular communication between osteoblasts and

During masticatory function, the teeth and

When a tooth is subjected to heavy loads of this type, quick

Bone bending in response to normal

Prolonged force, even of low magnitude, produces

The eruption mechanism appears to depend on metabolic events within the

The continuing presence of this mechanism indicates

It is observed that light

Resting pressure from the lips, cheeks and tongue

1.Biological Control of Tooth Movement:

2. Effects of magnitude, distribution and duration on the Response to

1. Biological control of tooth movement:

In orthodontic practice, the objective is to produce tooth movement as much as possible

The bioelectric theory relates tooth movement at least in part to

Bone mineral is a crystal structure with piezoelectric properties, collagen itself

The Pressure-tension theory relates tooth movement

The two theories are neither incompatible nor

a. Effect of Force Magnitude

2. Effects of force magnitude on the Response to Orthodontic

Animal experiments have shown that increased levels of cyclic adenosine

Experiments have shown that prostaglandin and

It is likely that mobilization of membrane

In clinical orthodontics it is difficult to avoid

 A delay in stimulating differentiation of cells within the marrow spaces.

2. Effects on the Response to Orthodontic Force:

Manner Direction Magnitude Duration

Manner Magnitude Duration

In tipping tooth movement,

As the moment to force ratio increases (0<Mc/Mf<1), the center of

Bodily When Mc/Mf=1, the center of

It is essentially impossible to apply a rotational force so that the tooth

Extrusive movements ideally would produce no areas of compression within

When a tooth is intruded, the force is concentrated over a small

Movement of the root without movement of the crown. If Mc/Mf>1,

2. Effects on the Response to Orthodontic Force:

Orthodontic Force duration is classified by the

force levels decline

force levels decline Heavy

Experience has shown that orthodontic appliances should not be

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