Accelerated orthodontics.pptx

Outline
• Introduction
• Theories of tooth movement
• Overview of the biology of tooth movement
• Methods of accelerated tooth movements
• Pharmacological methods
• Surgical methods
• Physical methods
• Conclusion
• References
2

Introduction
Orthodontic treatment
involves the
reorganization of
skeletal and dental
tissues. Treatment
duration however, is one
of the main concerns of
patients undergoing
fixed orthodontics
treatment.
01
This period orthodontic
treatment (usually 2-3
years) in such cases
has several drawbacks
to the patients such as
increased predisposition
to root resorption, dental
caries and gingival
hyperplasia, etc.
02
Consequently,
researchers have
therefore introduced few
methods to accelerate
the velocity of the tooth
movement without any
drawbacks.
03
3

• These kinds of methods used in orthodontics are
known as accelerated orthodontics.
• Accelerated orthodontics could be possible by
mechanical stimulation or device assisted therapy,
surgical therapy and by the use of pharmacological
agents.
4

Theories of tooth movement
• Alveolar bone resorption and deposition during orthodontic tooth movement is a
cell mediated process regulated by various factors.
• However, the mechanisms involved in conversion of Orthodontic force into biologic
activity are not completely understood
• And the two possible control elements that form two major theories of orthodontic
tooth are:
1. Bio-electric theory
2. Pressure tension theory (PDL)
5

Overview of the biology of tooth
movement
Prolonged pressure to a tooth resulting in tooth movement due to bone remodeling
around the tooth.
This bone remodeling is a highly regulated process that is coordinated by bone
resorption by osteoclasts and new bone formation by osteoblasts.
6
Mechanism involved in OTM include, sterile inflammation-mediated osteoclasto-
genesis on the compression side and tensile force-induced osteogenesis on the
tension side.

Key cell types that participate in mediating the response to OTM include periodontal ligament
fibroblasts, mesenchymal stem cells, osteoblasts, osteocytes, and osteoclasts.
Intercellular signals that stimulate cellular processes needed for orthodontic tooth movement include
receptor activator of nuclear factor- κB ligand (RANKL), tumor necrosis factor-α (TNF-
α),transforming growth factor beta (TGF-β), and bone morphogenetic proteins.
7
Several intracellular signaling pathways and mechanosensors including ion channels transduce
mechanical force into biochemical signals that stimulate formation of osteoclasts or osteoblasts.

Methods of
accelerate
d tooth
movement
s
8
We can categorise the
methods of
accelerated tooth
movement into the
following categories:
Pharmacolo
gical
methods
Surgical
methods
Physical
methods
8

Pharmacologic
al methods
There are a number of researches on pharmacological
agents that act as biomodulators for increased
orthodontic tooth movement. These are examples of
such include:
• Prostaglandin E2 and Prostaglandin E1
• Misoprostol
• 1,25-Dihydroxycholecalciferol
• Parathyroid hormones
• Intravenous immunoglobulins
9
Orthodontic forces cause fluid movement in the
periodontal ligament space and distortion of the bone
matrix and cells. There is release of molecules which
initiate bone remodelling for tooth movement.

Prostaglandin
s
Prostaglandins (PGs) are inflammatory mediator and a
paracrine hormone that acts on nearby cells; it stimulates
bone resorption by increasing directly the number of
osteoclasts.
Animal studies have shown that both PGE1 and PGE2
increase tooth movement and facilitate bone resorption.
Camacho and Velásquez Cujar conducted a study that
showed that it required repeated injections due to its short
half-life.
10

It is usually administered submucosally with injections
given into the gingiva near the first molar
Following L.A administration 0.1ml of PGE1 solution in
saline is injected submucosally.
Various experiments have shown that injections of
exogenous PGE2 over an extended period of time caused
accelerated tooth movements.
Furthermore, the acceleration rate was not affected by
single or multiple injections or between different
concentrations of the injected PGE2.
11

However, root resorption was very clearly related to the
different concentrations and number of injections given.
It has also been shown that the administration of PGE2 in
the presence of calcium stabilizes root resorption while
accelerating tooth movement.
Furthermore, chemically produced PGE2 has been
studied in human trials with split-mouth experiments in the
first premolar extraction cases. In these experiments the
rate of distal retraction of canines was 1.6-fold faster than
the control side.
12

Disadvantages
• Injections are given at weekly intervals.
• Severe pain after injections.
• To minimise this, local injection of PGE1 an analogue misoprostol was tried out
and It was seen that it was effective in increasing orthodontic tooth movement
with less pain.
13

Figure 1. Injection of a
biomodulator in the
periodontium.
Photo credits: google 14

Calcitriol or 1,25-dihydroxycholecalciferol which is the most active metabolite of
vitamin D acts in a similar fashion to parathyroid hormones by facilitating
osteoblastic proliferation and function.
Route of administration: Intraligamentry injections of calcitriol increases the number
of osteoclasts and amount of tooth movement during canine retraction with light
forces.
15
Calcitriol

16
It acts directly on osteoblasts and on osteoclasts indirectly by binding to the PTH type 1
receptor on osteoblast that causes the expression of insulin like growth factor 1.
There is promotion of osteoblastogenesis and receptor activator for nuclear factor κ B ligand
(RANKL) which induces osteoclast activation.
PTH facilitates bone remodelling in intermittent treatment by enhancing activities of osteoblasts
and osteoclasts.
May be administered locally at the subperiosteum and systemically
Parathyroid hormone (PTH)

Surgical
methods
17
• Bichlmayr in 1931, put forward a surgical technique with
orthodontic appliances for rapid correction of severe maxillary
protrusion.
• First, wedges of bone were removed to reduce the volume for
which the roots of the maxillary anterior teeth would require for
retraction.
• Kӧle further looked into this technique in 1959 by including
special movements for crossbite correction and space closure.
• He believed that he was able to move bony blocks using the
crowns of teeth as handles as the blocks were connected by
only less-dense medullary bone.

• Regional acceleratory phenomenon
• Corticotomy
• Intraseptal alveolar surgery
• Corticision
• Piezocision
• Microosteoperforations(MOP)
18
Various surgical methods exist, and they include:

Regional acceleratory phenomenon (RAP).
• The basis for surgical acceleration came to being
following the introduction of regional acceleratory
phenomenon (RAP).
• This procedure which enables rapid tooth movement is
due to a healing event that was described by Frost
and termed as regional acceleratory phenomenon
(RAP).
• It is the acceleration of the normal regional healing
process from the original injury.
• It usually occurs after osteotomy, fractures,
arthrodesis and bone-grafting procedures. There might
be involvement and activation of precursor cells
required for healing at the injury site.
19

• RAP can increase both soft and hard tissue healing
processes by two- to tenfold. It usually starts in the first
few days of injury, peaks at the first or second month
and may last for 3–4 months.
• The concept ot RAP would prevail for several years
until 2001 when Wilcko et al. introduced a method that
increases the alveolar bone volume after orthodontic
treatment by using bone grafts consisting of
decalcified freeze-dried bone allograft (DFDBA).
• It combines corticotomy surgery and alveolar bone
grafting and was referred to as accelerated osteogenic
orthodontics or recently termed as periodontally
accelerated osteogenic orthodontics (PAOO).
20

• The PAOO is an amalgamation of selective
decortications and facilitated orthodontic techniques
along with alveolar augmentation.
• This technique decreases the treatment time to 33%
the time of conventional treatment duration in
orthodontics. This concept was based on a technique
that’s similar to that of the preveiously described
regional acceleratory phenomena (RAP).
21

Figure 2. The modified periodontally accelerated osteogenic orthodontics (PAOO) augmented
corticotomy in the lower anterior alveolar region
22
Photo credits: google

23
A corticotomy is defined as a surgical procedure whereby only the cortical bone is cut,
perforated, or mechanically altered without any alteration in the medullary bone.
Procedure:
• Elevation of full thickness of buccal and/or lingual mucoperiosteal flaps.
• Positioning the corticotomy cuts using piezosurgical aurnamenterium or micromotor under
irrigation and it is followed by placement of a graft material, in required sites to enhance the
thickness of the bone
Corticotomy

Indications
1. Resolve Crowding and Shorten Treatment Time
• Several authors have described cases in which moderate
and severe crowding was treated without extraction by
corticotomy within shorter periods of time.
2. Accelerate Canine Retraction after Premolar Extraction
• Canine retraction after premolar extraction is a lengthy
step during the extraction stage of orthodontic treatment.
Corticotomy accelerated canine retraction in animal
studies resulting in a faster retraction when compared to
conventional orthodontic retraction.
3. Enhance Post-Orthodontic Stability
• Stability after orthodontic treatment may be a challenge.
Corticotomy-assisted orthodontics favours stability due to
the increased turnover of tissues adjacent to the surgical
site.
24

Contraindications
• Patients with active periodontal disease or gingival
recession are not good candidates for corticotomy-
assisted orthodontic treatments.
• Patients with severe class III maloclussion
25

Advantages
• Corticotomy procedure causes minimal changes in the periodontal attachment apparatus
• It has been proven successfully by many authors to accelerate tooth movement.
• Bone can be augmented; thereby preventing periodontal defects.
26

Disadvantages
• Expensive and invasive procedure.
• Chances of damage to adjacent vital structures.
• Presence of postoperative pain and swelling.
• Chances of infection or avascularnecrosis.
• Low acceptance by the patient.
27

28
Corticocision is a procedure in which a reinforced scalpel is used to make a vertical incision in
the interdental region that penetrates the cortical bone. In this way, the regional acceleratory
phenomenon would be induced in a manner similar to corticotomy in a less invasive way
Procedure:
• The surgical technique consists of infiltrative anesthesia followed by incision with a blade
number 15, which has the necessary stiffness to allow penetration into the vestibular
cortical.
• The inclination of 900 should be maintained relative to the alveolus and the extent of the
incision ranges from below the interdental papilla to 1mm above the mucogingival junction
of each dentition.
Corticocision

29
As the cervical incision is extended the blade is forced into the medullary bone and must be
withdrawn without pivoting to prevent injury to the lips.
The original technique recommends the incision could also be done palatally or linguall, in this,
even greater care should be taken regarding the tongue. case
Indications: to resolve anterior crowding and open bite.

30
Is defined as a flapless, minimally invasive surgical procedure designed to help achieve rapid
orthodontic tooth movement.
Procedure:
• Involves microincisions which are confined to the buccal side that allows the use of
piezoelectric knife and selective tunnelling which enables hard and soft tissue grafting.
Piezocision is usually done a week after orthodontic appliance placement and it involves
vertical incisions made buccally and interproximally.
Piezocision

31
The mid portion of the incision between the roots enables the piezoelectric knife to be inserted.
A piezotome is then inserted in the gingival openings that were made and piezoelectrical
corticotomy of 3 mm is made. Hard or soft tissue grafts can then be added via a tunnelling
procedure.
Since it is much more minimally invasive than corticotomy, it is having high degree of patient
acceptance, short surgical time and has less postoperative discomfort.

Indications
1. Correction of deep bite
2. Correction of Open bite
3. Prevention of Mucogingival defects
4. Rapid adult orthodontic treatment
5. Simultaneous correction of osseous and mucogingival
defects
32

Advantages
• It is minimally invasive hence more tolerated by patients
• May be used to correct both hard and soft tissue defects.
• Minimal post operative swelling and pain.
33

Contraindications
• Medically compromised patients
• Mixed Dentition
• Non-Compliant patients
• Ankylosed teeth
• Piezocision must not be used if the patient has a
pacemaker or any other active implants.
34

36
Is a procedure used to further reduce the amount of invasive nature of surgical intervention. It
involves the creation of small pinhole-sized perforations are created within the alveolar bone
surrounding the dentition.
This initiates cytokine release to call in osteoclasts to increase bone resorption. Thus,
acceleration of tooth movement occurs during orthodontic treatment.
Procedure:
• The site of perforation is within the attached gingiva and close to the target teeth on the
mesial and distal aspect of the roots of the teeth which will be moved.
• Involves microincisions which are confined to the buccal side that allows the use of
piezoelectric knife and selective tunnelling which enables hard and soft tissue grafting.
Micro-osteoperforation

37
The most favourable place for placement of the perforation is the buccal cortical plate but
lingual plate can also be approached with a contra-angled appliance.
Two to four perforations of about 0.025mm are made with depths of 3–7 mm into the bone
using a round bur and a handpiece.
In 2013, Alikhani et al. showed that MOP increased expression of cytokines for osteoclast
differentiation, increased canine retraction, reduced orthodontic treatment by 62% with mild
discomfort in patients.
Their human clinical trial found distalisation was twice as much with MOP than the forces alone.

Advantages
• Studies are still being carried out to assess its effects in the long term, as well as
investigations on the MOPs method such as number of perforations required.
38
Limitation
• Reduced post-op pain.
• Increased patient compliance as the procedure is minimally invasive, comfortable, and
safe.
• Capable of reducing orthodontic treatment time by 62%.

Figure 4. Microosteoperforations
(applied around the target tooth)
39

Physical
methods
Despite all the attempts in making surgical methods being
minimally invasive, they still remain as an invasive procedure.
This had led to discoveries in other tools that can accelerate
tooth movement during orthodontic treatment.
The concept of using physical approaches came from the idea
that applying orthodontic forces causes bone bending (bone
bending theory) and bioelectrical potential develops.
The concave site will be negatively charged attracting
osteoblasts and the convex site will be positively charged
attracting osteoclasts.
The most common physical methods used in the present day
are:
• Vibratory stimulus
• Low level laser therapy
• Low-intensity pulsed ultrasound
• Direct electric current
• Pulsed electromagnetic field
41

42
Bone has the ability to respond to the mechanical stimuli that is applied to it as a mechanism to
withstand functional activity.
Ortho Accel Technologies introduced a novel device named AcceleDenttm device. The device
has an activator and a mouthpiece.
Procedure:
• The patient bites on the mouthpiece component when in use and the activator which is
extraorally positioned generates and transmits vibrations to the teeth.
Vibratory stimulus

43
It can provide 0.2 N of vibration at 30 Hz for 20 minutes. It was fabricated to work in tandem
with existing bracket systems and not replace them.
The device produces cyclic forces to move teeth within the alveolus via accelerated bone
remodelling.
Pavlin et al in 2015 showed low-level cyclic loading with AcceleDent increased the rate of
orthodontic movement

Figure 6. AcceleDent device.
44

45
Photo biomodulation or low-level laser therapy (LLLT) is one of the most promising approaches
today. Laser light stimulates the proliferation of osteoclast, osteoblast and fibroblasts, and
thereby affects bone remodeling and accelerates tooth movement.
The mechanism involved in the acceleration of tooth movement is by the production of ATP
and activation of cytochrome C [48] and improve the velocity of tooth movement via
RANK/RANKL and the macrophage colony-stimulating factor and its receptor expression.
Other than accelerating tooth movement, LLLT can enhance stability of orthodontic mini-
implants, reduce post-adjustment pain, and induce bone growth in midpalatal suture area
following rapid maxillary expansion.
Studies done by Fujita et al. and Yamaguchi et al. showed that LLLT enhances
osteoclastogenesis on the compressed side of teeth being moved.
Low-level laser therapy

46
LLLT stimulates bone formation on the tension side. Kim et al. observed osteopontin
localisation in the periodontal tissue in their study subjects, indicating LLLT may stimulate
osteogenesis as well in orthodontic treatment.
Although several findings show LLLT stimulates osteoblast and osteoclast function, further
studies are still required to optimise the effect of LLLT on tooth movement.

Figure 7. Low-level laser therapy.
47

48
Apart from physical agents, low-intensity pulsed ultrasound (LIPUS) has also been suggested.
It uses mechanical energy which passes through the tissues as acoustic pressure waves
Procedure:
• An electric appliance that provides direct electric current placed in the extracted tooth
region, bio electric potentials are generated, causing local responses and acceleration of
bone modelling.
This procedure was performed by some researchers on living animals and found to be effective
in tooth movement.
Subsequently, Kim et al performed a clinical trial on humans and found 30% acceleration of
tooth movement when compared to conventional technique.
Low-intensity pulsed
ultrasound(LIPUS)

49
Recent studies on LIPUS using animal models by Xue et al. showed that there is induction of
alveolar bone remodelling.
The remodelling occurred due to an increase in the gene expression of HGF/Runx2/BMP-2
signalling pathway with LIPUS.
This led to an increase in the velocity of tooth movement during orthodontic treatment.
El-Bialy et al. observed that LIPUS may reduce the root resorption that was orthodontically-
induced by deposition of dentin and cementum to create a preventive layer from root
resorption.

Figure 8. Low-intensity pulsed
ultrasound(LIPUS) device
50

51
Electrical current have been tested experimentally on the animal models and have shown
ATOM. Direct current or electrical currents generated piezoelectrically thereby enhance the
OTM.
This leads to biochemical changes at molecular and cellular levels. It can increase the healing
of both soft tissue and hard tissue.
LIPUS is usually used at frequency pulses of 1.5 MHz with 200 μs pulse width, which is
repeated at 1KHz for 20 minutes a day with an intensity of 30 mW/cm2
Direct electric current

Conclusion
Over the years, the methods of reducing treatment time has risen along with its’ demand.
The options that are available on the orthodontist’s plate are numerous ranging from
surgical means to device assisted methods.
However, more studies still need to be done particularly for newly emerging methods and
also to obtain a clearer understanding on the methods that already exist.
At present, the clinician should use all the knowledge available at present, for deciding
which treatment option is best for the patient, to meet the healthcare needs of the patient
and achieving an optimum treatment outcome.
52

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Orthodontics 31 http://dx.doi.org/10.5772/intechopen.80915 54

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