Reviews

Methods of accelerating orthodontic tooth movement:

A review of contemporary literature
Metody przyspieszania ortodontycznego przesuwania zębów
– przegląd współczesnego piśmiennictwa
Alicja Kacprzak1,A–D,F, Adrian Strzecki2,A–F

1
Students’ Scientific Association of Orthodontics, Medical University of Lodz, Poland
2
Department of Orthodontics, Medical University of Lodz, Poland

A – research concept and design; B – collection and/or assembly of data; C – data analysis and interpretation;
D – writing the article; E – critical revision of the article; F – final approval of the article

Dental and Medical Problems, ISSN 1644-387X (print), ISSN 2300-9020 (online) Dent Med Probl. 2018;55(2):197–206

Address for correspondence

Alicja Kacprzak
Abstract
E-mail: [email protected] Technological progress and the introduction of  modern therapeutic methods are constantly changing
contemporary orthodontics. More and more orthodontic patients are working adults, who expect
Funding sources
None declared
satisfactory therapeutic effects as soon as possible, increasing the importance of methods accelerating tooth
movement. The aim of this study was to review the current literature regarding methods of accelerating
Conflict of interest tooth movement and reducing the duration of the active phase of therapy. The literature was collected
None declared from the PubMed and EBSCO databases using “accelerated orthodontic tooth movement” as the search key
words. The methods described were categorized as conservative and surgical. The pharmacological agents
used in conservative treatment, such as growth hormone, parathyroid hormone, thyroxine, and vitamin D,
are especially worth mentioning. They stimulate osteoclasts to increase resorption through a  variety
Received on January 11, 2018
Reviewed on April 6, 2018 of mechanisms. Effective methods also include physical stimuli, e.g., vibrations or photobiomodulation.
Accepted on May 11, 2018 Most studies describing the effects of pharmacological agents were based on animal subjects and they
may therefore lack clinical relevancy. Corticotomy and its modifications based on the regional acceleratory
phenomenon (RAP) might prove to be a  useful augmentation of  orthodontic treatment, especially in
adults, including patients with periodontal disease.
Key words: orthodontics, corticotomy, accelerated tooth movement
Słowa kluczowe: ortodoncja, kortykotomia, przyspieszone przesuwanie zębów

DOI
10.17219/dmp/90989

Copyright
© 2018 by Wroclaw Medical University
and Polish Dental Society
This is an article distributed under the terms of the
Creative Commons Attribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
198 A. Kacprzak, A. Strzecki. Accelerating orthodontic treatment: A review

The dream of  a beautiful smile is currently not dif- Growth hormone
ficult to fulfill, as interdisciplinary treatment involving
prosthetic, surgical, periodontal, and orthodontic pro- Growth hormone (GH), also called somatotropin,
cedures makes successful esthetic effects possible in the is secreted by the anterior lobe of the pituitary gland.
majority of  cases. Among these methods, orthodontics It has a stimulating effect on bone growth and remodel-
have a  fundamental disadvantage: prolonged therapy ing, and a deficiency results in pituitary dwarfism. The
time. Depending on the kind and severity of  the defect, action of GH is based directly on increases in the pro-
as well as the general condition of  the patient, compre- liferation and differentiation of osteoblasts, as well as
hensive treatment lasts on average close to 2 years.1 This on induction of protein synthesis and mineralization.5
has a  negative impact on the patient’s compliance with Ribeiro et al. assessed the modifying effect of growth
braces requiring strict control of  meals consumed, spe- hormone on the pace of tooth movement during exper-
cial attention to hygiene, and regular appointments at imental orthodontic treatment in rats.6 In their study,
the orthodontist’s office. On the clinical level, long-term individuals from the experimental group were admin-
therapy may lead to iatrogenic complications, including istered daily subcutaneous doses of  growth hormone
demineralization of  enamel, tooth decay, inflammation of  ≈ 0.033  mg/kg, analogous to the dose used in hu-
and recession of  gums, damage to the periodontium, or mans. A  day after the 1st dose was administered,
root resorption.2 In light of contemporary literature, us- a nickel-titanium spring was fixed between the incisor
ing increased force to accelerate the movement of  teeth and the right 1st molar, exerting a force of 30 g. Growth
is discouraged due to possible hyalinization of  the peri- hormone accelerated bone resorption (in the experi-
odontal fibers and undermining resorption, leading to mental group the highest number of  osteoclasts was
delayed movement.3 It is therefore necessary to affect the recorded as early as on the 3rd day, which was twice as
surroundings of the tooth that ensure its stable position high as in the control group on day 7), but it also de-
in the neutral zone − the alveolar bone. Tooth movement layed angiogenesis. This suggested that the activation
takes place with the simultaneous cooperation of osteo- of  a  device should be less frequent after GH admin-
clasts in the pressure zone (which leads to resorption) and istration. There are even recommendations to begin
osteoblasts in the pulling zone (the apposition process). orthodontic therapy 12–24  months after GH admin-
An important role is also played by periodontal ligaments, istration, because only then will somatotropin stimu-
which, while acting as a “force absorber”, also play the role late the process of bone formation.7 As GH reduces the
of specific receptors associated with the sympathetic sys- synchronization between resorption and bone appo-
tem.3 Methods of accelerating tooth movement are based sition, this is not a  method of  high potential clinical
on stimulating biological tissue response, i.e., enhanced relevancy.
metabolism and accelerated bone remodeling. On the ba-
sis of the level of invasiveness, the methods encountered Parathormone
in the scientific literature can be divided into conservative
methods and those based on surgical intervention. Parathormone (PTH) is a compound secreted by the
parathyroid gland which binds to receptors on osteo-
blasts, activating them and leading to the expression
Conservative methods of insulin-like growth factor 1 (IGF-1; somatomedin).
This results in the proliferation of  osteoblasts and,
The application of pharmacological agents with the participation of the RANK ligand, osteoclast
activation.8 Depending on the frequency of  adminis-
At the cellular level, the predominance of  osteoclast tration, PTH may stimulate bone formation (intermit-
activity over osteoblasts is responsible for bone resorp- tent therapy) or its resorption (exposure longer than
tion. It occurs as a result of the intensification of the in- 1–2 years).9 Two 12-day studies in rats confirmed that
flammatory process in the periodontal and connective intermittent administration of  PTH accelerated the
tissue of the gum. Mature osteoclasts can be stimulated mesialization of  the 1st molar 1.6  times after admin-
by pro-inflammatory signals coming from periopatho- istration of a dose of 0.25 μg/100 g b.w. into the sub-
gens (LPS Gram-negative bacteria), fibroblasts (MMP-1, periosteal area and 1.4 times as a result of subcutane-
MMP-2, MMP-3), macrophages (IL-1β, IL-6, TNFα, ous administration of  4  μg/100  g  m.c.10,11 However,
PGE2), or Th lymphocytes (IL-6, IL-11, IL-17). Another another study by the same authors does not confirm
pathway of  bone resorption is based on the mechanism the efficacy of  intermittent therapy.12 Long-term re-
of  osteoblast and cell-precursor differentiation towards search on the superiority of  this method over other
osteoclasts. This is an effect of the nuclear factor kappa protocols is needed, as well as clinical trials. Never-
B  receptor (RANK) system and the receptor activator theless, it is important to consider chronic PTH intake
of  nuclear factor kappa-Β ligand (RANKL) competing when planning orthodontic treatment, e.g., in cases
with osteoprotegerin (OPG).4 of severe osteoporosis.9,13
Dent Med Probl. 2018;55(2):197–206 199

Vitamin D ism it is recommended to activate the device less fre-

quently, whereas for patients with hyperthyroidism,
Another agent that may affect tooth movement is a longer retention period is recommended.24
vitamin D. 1,25-dihydroxycholecalciferol is the most
active metabolite of this vitamin. It mainly has an ana- Beta 2-adrenergic agonist
bolic effect on the bone tissue (to a  small extent also
catabolic).14 Similarly to PTH, sub-periosteal admin- There is a very specific periodontal microenvironment
istration of  vitamin D enhances the activity and pro- between the tooth and the bone that requires further de-
liferation of osteoblasts.15 These properties prompted scription. It consists of  collagen fibers, cells and tissue
researchers to design animal experiments attempting fluid acting as a force absorber. The ligaments are strong-
to modify the course of  orthodontic treatment. Col- ly innervated: they contribute to the transmission of pain,
lins et al. used calcitriol dissolved in DMSO (dimeth- modification of the immune response and bone remod-
ylsulfoxide) − a compound that readily penetrates cell eling.25 During orthodontic treatment mechanical force
membranes, as well as has a high solubility coefficient acting on the tooth is transmitted to these ligaments.
for vitamin D) − administered daily into the perios- Periodontal cells stimulate the biological response (e.g.,
teum.16,17 After 3 weeks, the retraction range of the ca- by increasing the amount of Y-neuropeptide-containing
nines was 60% higher compared to the control group. fiber, substance P or calcitonin gene-related peptide).26
Other researchers came to similar conclusions, this This is confirmed by the impossibility of moving ankylot-
time testing the action of  this vitamin on rats. They ic teeth, which are deprived of periodontal fibers due to
noticed an increased number of  both osteoclasts and direct connection with the bone. Periodontal ligaments
osteoblasts.18–20 Kawakami and Takano-Yamamoto are formed from the cranial neural crest differentiating in
emphasized the continuation of  intensified remod- embryonic stem cells.27 Due to their origins, they express
eling during the retention period as well.19 In turn, β2-adrenergic receptors and, through the RANK recep-
Kale et al. observed that distalization of the maxillary tor system, stimulate osteoblasts to undergo osteoclas-
incisors increased by 23%.20 In a few clinical trials, ac- togenesis.28
celeration of  orthodontic tooth movement was also The available studies involving β2-adrenergic agonists
demonstrated.21 After a daily oral dose of 0.25 μg of vi- are based on direct evidence (stimulation of  receptors
tamin D, the mean difference in the retraction move- with agonists, e.g., isoproterenol) or indirect observations
ment between the experimental group and the control (similar inhibition of the sympathetic system after using
group (who underwent orthodontic therapy without propranolol). Takeda et al., using isoproterenol, induced
supplementation) was 1  mm/60  days. However, the an osteoclastogenic response in mice.29 According to
use of a very low dose of the supplement in the study Kondo et al., by inhibiting the sympathetic system with
appears to be questionable (10 IU vs the daily recom- the butaxamine, bone loss was limited and tooth move-
mendations of 1000–2000 IU). ment slowed down.30 Kondo et al. also made intraperi-
toneal injections of propranolol, isoproterenol or (in the
Thyroxine control group) saline solution, and blockages or stimula-
tions confirmed their thesis.30 More invasive tests on rats
Thyroxine administration is a  recommended form were performed by Cao et al.31 After performing gan-
of  hypothyroidism treatment. It increases bone re- glionectomies of the upper cervical ganglion, they noted
modeling and stimulates resorption, which contributes a decrease in osteoclast differentiation and limited tooth
to a  decrease in bone density. This is probably due to movement. Yamashiro et al., in an animal model of  ex-
the increased concentration of  interleukin  1 (IL-1), perimental tooth movement, noted a  lack of  significant
which stimulates the formation of  osteoclasts and the changes in bone remodeling after transection of the lower
resorption process.14 Animal studies confirm acceler- alveolar nerve.26
ated tooth movement after administration of this sub- In conclusion, despite the presence of  many experi-
stance.22–24 Seifi et al. observed 0.45 mm of movement ments related to β2-adrenomimetics, one cannot over-
after 21  days in their experimental group, compared look the fact that there are no clinical trials that provide
to 0.23  mm in the control group.22 Additionally, they significant scientific evidence.
detected cumulative effects of  concomitant adminis-
tration of  thyroxine and prostaglandine  E2 (0.74  mm Physical stimuli
of  movement). However, Shirazi et al. noticed much
less root resorption after thyroxine-assisted orthodon- Studies on the acceleration of teeth movement describ-
tic treatment.23 Despite the lack of  clinical trials, the ing stimuli which increase the metabolism of tissues were
presence of  metabolic diseases related to the thyroid investigated. The mechanisms of  the most of  them are
gland should be taken into consideration when plan- not fully understood, but there is considerable evidence
ning orthodontic treatment. In cases of  hypothyroid- of their beneficial effects.
200 A. Kacprzak, A. Strzecki. Accelerating orthodontic treatment: A review

Electromagnetic fields Vibrations

Electromagnetic fields have a  proven effect on cell Rubin et al. have proven that vibrations increase the re-
membrane permeability.3 They can be divided into modeling rate and the overall reconstruction of the long
static magnetic fields (SMF) and pulsed electromag- bones − a phenomenon used in the prevention of osteo-
netic fields (PEMF). Both types have been used in gen- porosis.50 In addition, by comparing the effects of cyclic
eral medicine for many years. A SMF can contribute to and static forces in experiments on animal models (cra-
the healing process after an osteotomy, can stimulate nial sutures and the periosteum of  the long bones), an
bone remodeling, or prevent bone volume decrease improvement in bone formation and an increase in orth-
after surgical intervention or implantation.32–34 In the odontic tooth movement was observed.51–53 Initial clinical
field of orthodontics, it has been used for many years trials have shown promising results. Dubravko et al. used
as an element supporting active therapy or even as an the AcceleDent device (OrthoAccel Technologies, Inc.,
independent procedure. It may be of  certain clinical Bellaire, USA) to generate a vibration of 0.25 N and a fre-
benefit during space closure, intrusion, forced extru- quency of 30 Hz.54 It was possible to accelerate the distal-
sion of impacted teeth, and palatal expansion.35–38 An ization of canines with skeletal anchorage by 48.1% com-
analysis of the few available animal studies concludes pared to the control group (1.16 mm vs 0.79 mm/month).
that in order to accelerate tooth movement, a  field Other reports have also confirmed the accelerating effect
with a flux density of 460 mT should be used.39,40 Saka- of  vibrations.55 This time, the source of  the stimuli was
ta et al. came to this conclusion analyzing the previ- electric toothbrush massage for 15 min a day (a frequen-
ous experiment of Tengku et al., who, while using the cy of  125  Hz). Within 3 months, a  2.85 mm distal axial
intensity of 10 mT, did not observe clinically satisfac- movement of  the canines was obtained (37.7% greater
tory results.39,40 A PEMF, by stimulating osteoblasts to than in the control group). Those authors additionally
proliferate and differentiate, as well as increasing the investigated the concentration of IL-1β in fluid collected
production of alkaline phosphatase and regulating cal- from the gingival pocket, which, as a  factor stimulating
cium metabolism, can improve the treatment of bone the expression of RANKL, can be a good indicator of the
fractures, osteonecrosis and osteoporosis, among effectiveness of orthodontic movement.56,57 On the pres-
other things.32,41–45 According to Bassett’s research, sure side, the concentration of the cytokine in the study
therapeutic application of  magnetic fields results in group was on average more than 6 times higher than in
the creation of  cellular tension similar to that which the fluid collected from the control group. Contrary to
is induced during mechanical deformation of the bone expectations, acceleration was not confirmed by studies
(e.g., during the movement of the teeth).46 Studies on in mice in which orthodontic forces were applied to the
a rat model have shown that the support of active orth- 1st molars and low frequency vibrations (5, 10 and 20 Hz)
odontic elements operating with a force of about 20 g, were used.58 Furthermore, the latest randomized clinical
both using a PEMF of 1.8 mT (or 1.5 mT) and a Nd-Fe-B trials call into question the chances of significantly short-
magnet (neodymium), increases the distance a  tooth ening the time of orthodontic treatment by administering
can be moved.47,48 Stark and Sinclair and Showkat- vibrations.59,60
bakhsh et al. also confirmed the accelerating action
of PEMF.32,49 The clinical trial by Showkatbakhsh et al., Photobiomodulation
assessed the distalization of  the canine after 1st pre-
molar extraction, using a  removable PEMF-gener- This technique can be characterized by a very limited in-
ating device with an intensity of  0.5  mT and a  fre- vasiveness. It involves the exposure of tissues to the effects
quency of  1  Hz.49 After 6  months, the difference in of red light of a therapeutic wavelength (600–1200 nm).61
movements between the test and control groups was These wavelengths reduce absorption of the light by he-
1.57 ±0.83  mm. Dogru et al. performed an experi- moglobin and water and allow it to reach the deeper soft
ment on rats comparing a PEMF to a sinusoidal field.48 tissue and the alveolar bone.62 The resulting stimulation
In both cases, they observed positive effects. However, may have potentially positive effects on the production
the authors pointed out that due to differences in size of  adenosine triphosphate (ATP).63 On the other hand,
and physiology, predicted results on the human body increasing the activity of  cells leads to increased bone
should be extrapolated with caution. Information re- metabolism in situ, which creates favorable conditions
garding the lag phase in orthodontic tooth movement for the movement of teeth.64 Therapy with light can be
(the phase of clearing hyalinized fibers from the pres- divided into 2 basic types: low-intensity lasers (LIL),
sure zone) is also important. It can be hypothesized producing coherent light, and light-emitting diodes
that electromagnetic field therapy can shorten the lag (LED), which are sources of incoherent light.65 There are
phase (due, among other things, to earlier formation no publications regarding the superiority of  one above
and removal of hyalinized tissue).39,40,47 the other. What is more, most authors agree that the cel-
lular response depends primarily on the wavelength and
Dent Med Probl. 2018;55(2):197–206 201

the dose of  light, not on its source.66 Only Fujita et al. compared to fixed braces.79 Buschang et al. reached sim-
noted more favorable results in LIL therapy, and Vinck ilar conclusions: in a study of 150 patients with incisor
et al. found that an LED source creates more favorable crowding under 5 mm (the study group), they noted that
conditions for cell growth in green light.67,68 Numerous the duration of  therapy was reduced by 5.5 months.81
studies on this subject can be found in the literature, on However, despite shorter treatment and less frequent
both animal and clinical models. Most of them indicate visits, they point out that aligner therapy is much more
a  significant increase in the speed of  tooth movement. expensive and requires more experience. On the other
In these studies gallium-aluminum-arsenide (Ga-Al-As) hand, Hennessy et al. did not notice a difference between
lasers were used, and the length of light wave was on the length of the treatment of mandible incisor crowd-
average 820 nm. The challenge was to determine the ing with the Invisalign system and with a  fixed labial
optimal energy dose.61,70,72,75 Goulart et al. achieved ac- appliance.82 In summary, the use of clear thermoplastic
celeration as a result of a combined dose of 5.25 J/cm2, aligners, despite their presence and growing popularity
but noted that increasing it to 35 J/cm2 could have the in orthodontic clinics, requires further research in terms
opposite effect.69 This thesis was confirmed by sev- of accelerating the movement of teeth.
eral researchers, including some studies applying irra- Self-ligating brackets are also worth mentioning.
diations of  100  mW.61–70 Animal studies have adopted The 1st brackets of this type were created by Stolzenberg
a  methodology focusing on determining remodeling over 70 years ago.83 The aim was to reduce the friction
efficiency, the RANK/RANKL system, and the expres- between the arch and the bracket, which is increased by
sion of fibronectin and type I collagen.67,71,72 In addition ligatures (both elastic and metallic). According to some
to standard tooth movements, Saito and Shimizu were researchers, reducing it improved the effectiveness of the
able to accelerate bone regeneration after suture open- “sliding mechanism” used during tooth rotation, correc-
ing during expansion of  the palate in rats.73 Youssef tion of  angulation and closing spaces.84 It does not af-
et al., after 6 months of research on a group of 15 adults, fect bone remodeling, but only changes the distribution
achieved an almost 2-fold acceleration of canine retrac- of  forces that the orthodontist uses during treatment.
tion.70 Nahas et al. investigated the effects of the Ortho- In addition, despite manufacturers’ assurances of shorter
Pulse device (Biolux Research Ltd., Vancouver, Canada) treatment times, numerous studies have reported the op-
in patients with Little’s irregularity index in the range posite, detecting no significant differences between the
of 2–10 mm.61 Satisfactory results were obtained in the duration of  active therapy with the use of  conventional
research group after an average of 68.3 days (compared and self-ligating devices.85,86
with 87.8 days in the control group), which shortened
the treatment time by 22%. Acceleration has also been
reported in a few randomized clinical trials.74–76 Never- Surgical methods
theless, Marquezan et al., during an experiment on an
animal model, despite an increased number of  osteo- Surgical methods are more invasive, but also signifi-
clasts on the pressure zone side, did not notice an in- cantly broaden the scope of  therapeutic options. They
creased dental shift macroscopically.77 Chung et al. came are used primarily when the remaining methods are in-
to a similar conclusion after observing 11 patients for 3 sufficient, i.e., mainly after the period of  growth is fin-
months.79 To sum up, due to the differences in the pro- ished. They are characterized by surgical intervention to
tocols of the experiments conducted, further research is the bone tissue, which is more susceptible to the action
needed, focusing, among other things, on harmonizing of orthodontic forces while undergoing remodeling after
the radiation dose. traumatization.

Clear aligners and self-ligating brackets Corticotomy

In the literature, only a few studies can be found ana- The aim of corticotomy is to cut the cortical layer of al-
lyzing the acceleration of  the movement of  teeth using veolar bone in order to induce local temporary osteope-
clear aligners and self-ligating brackets. It should also nia. Over the last several decades, it has undergone nu-
be noted that research based on histological evidence merous modifications. The origins of  the method date
is lacking. Conclusions can be drawn based only on back to the end of the 19th century; however, Köle, who
the differences in therapy duration and cases assessed discussed the procedure in 1959, is considered the pio-
using various indices, such as the peer assessment rat- neer of corticotomy.87,88 According to his claims, cortical
ing (PAR) or the objective grading system (OGS).79,80 bone is the main obstacle to the orthodontic movement
Gu et al. found the Invisalign system (Align Technology of teeth. This theory, referring to osteotomy, was to a cer-
Inc., San Jose, USA) to be advantageous in correcting tain extent rejected in 1983, when Frost discovered the
minor orthodontic defects; the duration of  treatment regional acceleratory phenomenon (RAP), and in 1994
with the same effects was 30% (5.7 months) shorter Yaffe et al. introduced this concept to periodontal lit-
202 A. Kacprzak, A. Strzecki. Accelerating orthodontic treatment: A review

lier retraction of  the muco-periosteal flap, can be made

with traditional rotational tools or a  piezoelectric knife.
Dibart et al. recommend the use of the latter, due to lim-
ited traumatization of tissues, greater precision of execu-
tion, and more extensive bone demineralization, which
induces prolonged RAP.92 To avoid interfering with the
bone remodeling process, non-steroidal anti-inflamma-
tory drugs (NSAIDs) should not be administered. Initially
(in the first 3–7 days) the pain can severely affect the pa-
tient’s well-being. Tooth brushing should be neglected
for a week. An alternative is to rinse the mouth with an
antiseptic solution (e.g., chlorhexidine). After this period,
the 1st activation of the braces can be performed. It is im-
portant that during the demineralization of the bones, the
patient appears regularly for frequent visits.92

Periodontally accelerated osteogenic

orthodontics
Described by Wilcko et al. in 2001, the technique re-
ferred to as periodontally accelerated osteogenic ortho-
dontics (PAOO) or accelerated osteogenic orthodontics
(AOO) is a  combination of  conventional corticotomy
with the implantation of bone graft material.93 After ana-
lyzing high-resolution computed tomography (CT) scans,
Wilcko et al. observed the process of remodeling remin-
eralization and demineralization of  the bone and dem-
onstrated its relationship with the RAP, as described
earlier.93 After retraction of the muco-periosteal flap and
incisions in selected areas, allogenic frozen and dried
material is placed in the scars. It is very important that
it is fully biocompatible. Otherwise, only the extension
Fig. 1. The regional acceleratory phenomenon (RAP) − a phenomenon of  the epithelial attachment can be observed, leading to
described by H. Frost in 1983, involving the temporary reduction of bone the accumulation of bacteria, which in turn may result in
density as a result of harmful stimulus. I – The release of pro-inflammatory
cytokines activating osteoclast progenitor cells as a result of harmful abscess formation and bone loss.94 Insertion of  the ma-
stimuli. II – Bone resorption caused by the action of mature osteoclasts. terial allows bone density and mass to increase. This is
Bone density decreases by 10–50 times, making tissue much more particularly important in adults, who have much lower
susceptible to the action of orthodontic forces. III – Arrangement of the
resorbed tissue by macrophages. IV – The inflow of osteoblasts. Bone
regenerative bone capacity than children. The main goal
remineralization with teeth in new positions after 4 months is to surround the teeth on each side, while eliminating
fenestration and bone dehiscence. This increases the pos-
sible range of  tooth movement, the apical base and the
erature (Fig. 1).89,90 Small harmful stimuli (such as shal- arch envelope, and minimizes gum recessions, relapses
low bone incisions) activate the RANK/RANKL system. and the need for extraction.95 One indication is the pres-
In “weakened” bone tissue, 10–50 times faster remodeling ence of shortened roots, which could become shorter dur-
is expected. This effect lasts for about 4 months (though it ing traditional treatment.96 Wilcko et al. presented many
can last up to 6–24 months), with peak efficiency reached cases demonstrating the effectiveness of  the method in
1 or 2 months after surgery.91 Due to the nature of  the accelerating the movement of teeth while improving the
surgery, which involves a  high risk of  infection, antibi- condition of periodontal tissues.97,98
otic protection is vital. Only local anesthesia is required.
The field of the procedure depends on the defect: vertical Piezocision
incisions are made between the roots of the teeth, hori-
zontally, 2–3 mm above the apices, in order not to dam- To initiate the RAP phenomenon, one needs to perform
age the bundles. The advantage of the method lies in the a cut to the cortical layer of bone. In the traditional tech-
creation of a more stable anchorage, not involving teeth/ nique, this stage is preceded by the detachment of the mu-
arches in the procedure. The brackets of the fixed appli- co-periosteal flap. This increases the risk of  discomfort
ance are bonded before the surgery. The cuts, after ear- and postoperative pain. Park et al. and Kim et al. proposed
Dent Med Probl. 2018;55(2):197–206 203

performing the procedure without the flap retraction, but the treatment of  post-traumatic ankylosis is also worth
directly through the gum.99,100 An alternative combining considering. Małyszko et al. published a case of post-trau-
limited invasiveness, enhanced precision and treatment matic intrusion of  tooth 11 complicated with ankylosis
of periodontal problems is piezosurgery (the piezocision and resistant to other methods of traditional orthodontic
technique), described in 2009 by Dibart et al.101 It com- treatment.113 The application of  bone incisions with the
bines cuts in the bone through the gingiva with a piezo- intraocular luxation resulted in a positive effect, i.e., tooth
electric knife to create of  submucosal tunnels for bone- extrusion. The role of corticotomy in clinical orthodon-
substitute material. The orientation incisions are made tics seems to be constantly growing and is currently one
with a  scalpel, then a  piezoelectric knife is used with of the most frequently used methods to shorten the time
a marker indicating the working depth (according to the of orthodontic treatment.
author, it is necessary to go through the entire cortical
layer and reach the cancellous bone to stimulate RAP).
Particular caution should be exercised in the area of in- Combined methods
terdental papillae and between roots located close to each
other. Tunneling can be performed in areas of  gingival Considering the different mechanisms of action of con-
recession, dehiscences or fenestrations. In the anterior servative and surgical methods, the question arises: Would
part of the mandible, due to the small width of the teeth, the combination of both prove even more efficient? Refer-
incisions between the lateral and central incisors can be ring to this hypothesis, Kim et al. conducted a study com-
omitted. Active elements of the device are activated every bining cortical bone incision (also referred to as cortici-
2 weeks, starting 2 weeks after the procedure. sion) and radiation.114 The experiment involved 12 dogs
divided into 4 groups: a control group (only orthodontic
Micro-osteoperforations force was used), a  group undergoing photobiostimula-
tion, a group undergoing surgical treatment, and a group
This is another treatment modality based on the RAP.102 in which both of these methods were implemented. In the
The goal is to further minimize soft tissue damage. Perfo- groups involving the surgical procedure, incisions were
rations are made in the bone through the mucous mem- made near the 2nd maxillary premolars (for the purpose
brane, with the aim of  accelerating orthodontic move- of  their mesialization after the extraction of  the 1st pre-
ment. Micro-osteoperforations can also be combined with molars). A diode laser with a wavelength of 808 nm was
standard corticotomy or the PAOO technique. The device used as the source of  photobiostimulation. Contrary to
used during the treatment was designed by Propel Ortho- expectations, the group covered by both treatment meth-
dontics (Ossing, USA).103 It is intended for single use only. ods showed less acceleration than the groups undergoing
It perforates both the attached gingiva and the mucous each treatment separately. Moreover, within 8 weeks after
membrane. Clinically, the use of micro-osteoperforations the procedure, the dental movement in the group exposed
significantly increases the expression of cytokines, which to both methods was comparable to the control group (in
leads to a 60% shorter treatment time compared to a con- which only orthodontic forces were used). Considering
trol group, and 2.3 times faster retraction of  canines.102 the regenerative effect of  light irradiation, it can be as-
The procedure itself is described as effective, convenient, sumed that the laser significantly accelerated bone healing
and less invasive than standard corticotomy.104 and thus led to the elimination of the RAP. The available
Corticotomy and other attempts at surgical accelera- literature also describes 2 cases in which corticotomy and
tion of tooth movement are documented in a large num- Smiletech polyvinyl overlays (Ortodontica Italia, Rome,
ber of scientific publications. Despite the different levels Italy) were used. Cassetta et al. described the therapy
of  invasiveness, they have similar effectiveness, which of 2 patients with moderate crowding (the 1st with class I,
was confirmed in a comparative study by Librizzi et al.105 the 2nd with class II).115,116 The treatment was completed
It can be assumed that this is the effect of the same mech- with a satisfactory effect after 2 months (in the class I pa-
anism of  action (inducing the RAP). Experiments con- tient) and after 8 months (in the class II patient). Howev-
ducted on an animal model show both a shorter therapy er, attention should be paid to the low power of scientific
time and increased remodeling occurring within the can- evidence (no control group; only a  case report) and the
cellous bone.106–108 Similar results were obtained during possible bias of the conducted study.
the treatment of  mild crowding (a study on 24 patients
resulted in a  47% shorter treatment time), orthodontic
extrusion of  palatally impacted canines (6 patients) and Conclusions
retroinclination of  upper incisors with sufficient bone
support.109–111 Al-Naoum et al., in a group of 30 patients, The contemporary literature presents many methods
obtained an average speed of  0.74  mm/week (compared of accelerating tooth movement during orthodontic treat-
to 0.2  mm/week on the control side) during retraction ment, but a significant number of them, especially those us-
of canines.112 The potential usefulness of corticotomy in ing pharmacological agents, are supported by rather limited
204 A. Kacprzak, A. Strzecki. Accelerating orthodontic treatment: A review

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