This document discusses various methods for accelerating orthodontic tooth movement. It begins with an introduction describing how orthodontic treatment involves reorganizing skeletal and dental tissues, but can take 2-3 years, which has drawbacks for patients. It then covers theories of tooth movement and the biology behind orthodontic tooth movement. The main methods discussed are pharmacological methods using substances like prostaglandins, misoprostol, vitamin D, parathyroid hormone and relaxin. Surgical methods like corticotomy, piezocision, corticision and micro-osteoperforations are also summarized. Physical methods like vibratory stimulus, low level laser therapy and low-intensity pulsed ultrasound are briefly

1. Accelerated Orthodontics
In Light Of Evidence
Dr. Maria Shahid
PGT Orthodontics

2. OUTLINE
• Introduction
• Overview of biology of tooth movement
• Regional Acceleratory Phenomenon
• Methods of accelerated tooth movement
• Pharmacological methods
• Surgical methods
• Physical methods
• Surgery Stimulated Approach

3. Introduction
Orthodontic treatment
involves
reorganization of
skeletal and dental
tissues.
Treatment duration is
one of the main
concerns of patients
undergoing this
treatment
The increased periods
(usually 2-3 years)
comes with several
drawbacks to the
patients such as
increased pre-
disposition to root
resorption, dental
caries, gingival
hyperplasia etc.
Consequently, In an
attempt to produce
faster tooth
movement,
numerous methods
of accelerating tooth
movement have been
introduced over the
years without
potential drawbacks

4. Theories of tooth movement
• Alveolar bone resorption and deposition during OTM 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
• There are two major theories:
1. Bio-electric theory
2. Pressure tension theory

5. Overview of biology of tooth movement
Prolonged pressure to a
tooth resulting in tooth
movement due to bone
remodeling around tooth
This bone remodeling is a
highly regulated process
that is coordinated by bone
resorption by osteoclasts
and new bone formation by
osteoblasts
Mechanism involved in OTM
includes osteoclastogenesis on
the compression side and force
induced osteogenesis on the
tension side

6. Methods of accelerated tooth
movement
• We can categorize the methods as follows:
A. Pharmacological methods
B. Surgical methods
C. Physical methods
D. Surgery Simulated Approach

7. Pharmacological methods
A. Prostaglandin E2 and Prostaglandin E1
B. Misoprostol
C. 1,25-Dihydroxycholecalciferol
D. Parathyroid hormone
E. Relaxin

8. Prostaglandin E2 and Prostaglandin E1
• Phospholipids Arachidonic acid PG E2
• Increases cAMP and cGMP
• Often-tested substance to increase orthodontic tooth
movement
• Short half life
• Requires repeated injections

9. • Yamasaki et al
• Routine canine retraction was carried out and PGE1
was applied only on one side, which resulted in 1.6-
fold faster movement on the treated side.
• Reference: Yamasaki K, Shibata Y, Imai S, Tani Y, Shibasaki Y,
Fukuhara T. Clinical application of prostaglandin E1 (PGE1)
upon orthodontic tooth movement. Am J Orthod 1984; 85:
508-518

10. Canine distal movement by tied back open coil spring

11. Showing canine distal movement at 0 days, 1 month, 3
months and 7 months

12. CLINICAL TRIALS
• Spielmann et al
• Assess the effect of PGE1 on tooth movement
• The method consisted of local administration of anesthesia
0.1 mL of 0.01% (w/v) PGE1 solution which was injected
under the palatal mucoperiosteum to the test tooth.
• 0.1 mL saline palatal to the contralateral control tooth.

13. • Injections were repeated at weekly intervals.
• The experimental teeth moved 3 times faster than the control
teeth without any pathological changes.
• Reference: Spielmann T, Wieslander L, Hefti AF. Acceleration
of orthodontically induced tooth movement through the local
application of prostaglandin (PGE1). Schweiz Monatsschr
Zahnmed 1989; 99: 162-165

14. Prostaglandin E1
• Even minimal amounts of PGE1 injection cause significant increase
in tooth movement
• Side Effect: Causes hyperalgesia
Misoprostol (analogue)
Injection of inflammatory biomodulators in the
periodontium

15. Parathyroid hormone (PTH)
• Acts directly on osteoblasts
• Indirectly on osteoclasts by binding to the PTH type 1
receptor
• Causes the expression of insulin like growth factor 1
• There is promotion of osteoblastogenesis and receptor
activator for (RANKL) which induces osteoclast activation

16. Parathyroid hormone (PTH)
• Facilitates bone remodeling in intermittent treatment by
enhancing activities of osteoblasts and osteoclasts
• According to the study of Shirazi et al, 1999 PTH hormone
administration in rats not only increased the speed of tooth
movement, but also reduced the extent of root resorption.

17. Relaxin
• Insulin family of structurally related hormone
Mechanism:
1. Increases rate of degradation of extracellular connective
tissue
2. Increases bone resorption by an increase in TNF and IL-1B
secretion
Reference: Stewart Dr et al. Use of Relaxin in orthodontics.
Ann N Y Ascad Sci. 2005 1041:379-387

18. Vitamin D
• Intraligamentous injections of a vitamin D metabolite caused
an increase in the number of osteoclasts and a larger tooth
movement, during canine retraction with light forces.
• Reference: Collins k, Sinclair M; The local use- of vitamin D
to increase the rate of orthodontic tooth movement; Am J
Orthod Dentofac Orthop 1988;94:278-84.)

19. Surgical methods
• Periodontally accelerated osteogenic orthodontics
• Piezocision
• Corticision
• Corticotomy assisted rapid tooth movement
• Micro-osteoperforations
• Distraction of the dentoalveolus
• Distraction of the periodontal ligament

20. Regional acceleratory phenomenon
(RAP)
• Regional Acceleratory
Phenomena (RAP) is tissue
reaction to a noxious stimulus,
that increases healing
capacities of affected tissues
• By enhancing the various
healing stages, this
phenomenon makes healing
occur 2–10 times faster than
normal physiologic healing
(Frost, 1983).

21. Regional acceleratory phenomenon
(RAP)
• Inducing RAP as a wound-healing
process is the basis for all
surgically assisted methods of
rapid tooth movement.
• Simply stated, when bone is
surgically irritated, a wound is
created. This wound initiates a
localized inflammatory response.
Due to the presence of the
inflammatory markers,
osteoclasts migrate to the area
and cause bone resorption.

22. Surgical methods
• Periodontally accelerated osteogenic orthodontics (PAOO):
• Wilckodontics: This method is a local response to a lethal
stimulus that describes a process of tissue formation faster
than the usual regeneration process.
• Increases the alveolar bone volume after orthodontic
treatment by using bone grafts consisting of decalcified freeze-
dried bone allograft (DFDBA).

23. Inter-septal alveolar surgery
• Involves controlled and gradual displacement of surgically
created osteotomy cuts which is termed as sub-periosteal
osteotomy.
Distraction of
periodontal
ligament
Distraction of the
dentoalveolar
bone
2 types

24. Rapid canine retraction by distraction of
the periodontal ligament
Procedure:
• Following extraction of
premolar, socket is deepened to
same depth as the canine
• A 1mm carbide fissure bur is
used to make 2 vertical grooves
on the MB and ML corners of
the socket
• These grooves are then joined
obliquely towards the base of
the interseptal bone

26. Rapid canine retraction by distraction of the
periodontal ligament
• A tooth-borne, custom
made, intraoral distraction
device is placed to distract
the canine distally into the
extraction space
• The anchor units are the
second premolar and first
molar
• This approach is based on
distraction osteogenesis
Canine distraction device is placed close to center
of resistance of canine to achieve bodily movement

27. Rapid canine retraction by distraction of
the periodontal ligament
• Staging of radiographic changes of periodontal ligament
during and after canine distraction:
• Stage 1: Stretching of the
periodontal ligament

28. Stage 2: Active bone growth
Stage 3: Recovery of distracted
periodontal ligament

29. Stage 4: Remodeling of striated
bone
Stage 5: Maturation of striated
bone
Reference: Liou J, Huang S; Rapid canine retraction through distraction of the periodontal
ligament; Am J Orthod Dentofacial Orthop 1998;114:372-82

30. Rapid canine retraction through
dentoalveolar distraction
• Same principle as distraction of PDL
• More osteotomies performed at vestibule
Technique:
• Mucoperiosteal flap reflected
• Cortical holes made in alveolar bone from canine to 2nd premolar
curving apically to pass 3-5mm from apex
• Connect the holes with tapering fissure bur
• 1st premolar is extracted and buccal bone is removed

31. • Large osteotomies are used to mobilize the whole segment
• Distraction: after 3 days of surgery
• Activation of distractor: twice/day in morning and evening
• 0.8mm per day

32. Rapid canine retraction through
dentoalveolar distraction
Can also be used to bring ankylosed tooth into position
Disadvantages:
• Aggressive and complicated
• Reference: Kisniscu RS et al; Dentoalveolar Distraction
Osteogenesis for Rapid Orthodontic Canine Retraction; J Oral
Maxillofac Surg 60:389-394, 2002

34. Surgically Assisted Approach
Corticotomy:
A corticotomy is defined as a surgical procedure
whereby only the cortical bone is cut, perforated, or
mechanically altered without any involvement in the
medullary bone.
Reference: Adusumilli S, Yalamanchi L, Yalamanchili PS (2014)
Periodontally accelerated osteogenic orthodontics͗; An
interdisciplinary approach for faster orthodontic therapy. J
Pharm Bioallied Sci 1: 2-5.

35. Corticotomy
Procedure:
• Elevation of full thickness
mucoperiosteal flap
• Positioning the corticotomy
cuts using piezosurgical
instruments or micro motor
under irrigation
• Followed by placement of a
graft material, in required
sites to enhance the
thickness of the bone

36. Corticotomy
Advantages:
1. Bone can be augmented and periodontal defects would
be avoided.
2. Minimal changes in the periodontal attachment
apparatus.
3. Minimal treatment duration and increased rate of tooth
movement.
4. Less root resorption

37. Corticotomy
Disadvantages:
1. Expensive and invasive procedure
2. May cause postoperative pain and swelling
3. Low acceptance by the patient
Indications:
1. Accelerate tooth movement
2. Enhance post orthodontic stability
3. Facilitates eruption of impacted teeth
4. Molar distalization

38. Piezocision
• Dibart et al in 2009 introduced a
flapless method of corticotomy,
using piezosurgery
• Minimally invasive procedure

39. Piezocision
• Procedure: Micro incisions limited to buccal gingiva that allow
use of a piezoelectric knife to give osseous cuts to the buccal
cortex and initiate RAP without involving palatal or lingual
cortex

40. Piezocision
Advantages:
• Minimally invasive
• Better patient acceptance
• Allows a rapid correction without the drawbacks of
conventional corticotomy procedures in severe malocclusion
cases.
• Enhanced periodontium (added grafting)
Disadvantages:
• Risk of root damage, as incisions and corticotomies are
“blindly” done.

41. Corticision
• Minimal surgical intervention
• No flap raised
• No tunneling is performed
• No graft placed

42. Corticision
Procedure:
• Insert surgical blade interproximally,
parallel to occlusal plane, 2-3mm apical to
papilla
• Tap blade with a mallet to depth of 8mm
• Change the angle of the blade to approx 45
degrees apically
• Tap the blade again to incise to a depth of
10-12mm
• The goal is to cut cancellous bone between
the roots to 50-75% of root length
• Apply orthodontic forces immediately
• See patient every 2 weeks

43. Corticision
Indications:
• To resolve anterior crowding
• Anterior open bite
Advantages:
• Patient friendly
• Less discomfort

44. Corticision
• Recent advancement: Surgical blade has been replaced by
piezoelectric puncture
• Punctures are done instead of incisions to penetrate gingiva,
cortical and cancellous bone

45. Micro-osteoperforations
• Least invasive procedure
• Device called PropelTM is used
• This device comes as ready-to-use sterile disposable device
• Alveolocentesis

46. Micro-osteoperforations
Positioning of the micro-osteoperforations:
• Placed in the attached gingiva to 1 mm apical to the
mucogingival junction

47. Micro-osteoperforations
• MOPs are required on both the
mesial and the distal portion of
the target tooth
• In general, MOPs are made on
the buccal aspect
• They can be made on the lingual
mucosa with contra angled hand
pieces
• In case of atrophied residual
ridge, they can be made on
buccal, lingual aspect as well as
crest of ridge

48. Micro-osteoperforations
• To get increased recruitment of
osteoclasts (catabolic effect), deep
perforations are required (5–7 mm)
• If increased recruitment of osteoblasts
is required (Anabolic effect) then
shallow perforations (1 mm) spread
over a large area is required

49. Application of MOPs in the buccal
cortical plate.
Height of application of MOPs should
be limited to the attached gingiva for
patient comfort.
a) Height of application of MOPs
around anterior teeth
b) Application of MOPs around
posterior teeth may have different
distribution and number, as
determined by root proximity,
accessibility, and width of attached
gingiva

50. Step-by-step performance of MOPs in the anterior area. A) Application of topical anesthetic, b)
application of local anesthetic, c) application of MOPs, d) attached gingiva right after application of MOPs

51. Physical Methods
• Vibratory stimulus
• Low level laser therapy
• Low-intensity pulsed ultrasound

52. Vibratory Stimulus
AcceleDent device
• Portable
• Has an activator and a mouthpiece
• Patient bites on the mouthpiece
component when in use
• Activator is extra orally positioned
and generates and transmits
vibrations to the teeth
• It can provide 0.2 N of vibration at 30
Hz for 20 minutes
• Has to be worn for 20 minutes a day

53. Low level laser therapy
• Photobiomodulation
• Through either lasers or light
emitting diodes
• Utilize a near-infrared
wavelength of approximately
600-1000 nm
• Range of 730-850 nm being
viewed as most appropriate for
photobiostimulatory effects

54. Low level laser therapy
Cellular and Molecular
Mechanisms of
Photobiostimulation:
• Laser light stimulates the
proliferation of osteoclast,
osteoblast and fibroblasts
• MOA: increased production of
ATP and accelerating tooth
movement via RANK/RANKL and
macrophage colony stimulating
factor

55. Patient presented as a class III with complete anterior and posterior crossbite

56. Surgery Simulated Approach
Sub-mucosal injections of platelet
rich plasma (PRP):
• PRP can simulate the effects
induced by bone surgery
• Platelets contain growth factors
and other components that
simulate wound healing and
osteogenesis
Technique:
• 0.9 ml of LA injected in the labial
and lingual mucosa of teeth

57. Surgery Simulated Approach
• 0.7ml of PRP injected in labial and lingual attached gingiva
• The rate of orthodontic alignment is faster than controls
Reference: Liou EJ et al; Submucosal injection of platelet rich plasma accelerates
orthodontic tooth movement; Am J Orthod Dentofacial Orthop

59. Sub-mucosal injections of platelet rich
plasma (PRP)
• The blood is separated into
its three basic components:
• The RBCs are discarded, and the
remaining buffy coat and PPP are
collected and centrifuged again at
3000 rpm for 8 min
• After the second centrifugation,
the PPP is removed until 4 ml
remained, and then the remaining
PPP is mixed with the buffy coat to
become PRP

60. Sub-mucosal injections of platelet rich
plasma (PRP)
• A single injection of PRP lasts for 5-6 months clinically
• Fastest rate of acceleration is between 2nd to 4th month
Applied regimen for different purposes is as follows:
• Single injection of PRP for leveling and alignment
• 1 injection at the start and another boost 6 months after, for the
purpose of anterior retraction
• 1 injection at the start and another boost 6 months after, for the
purpose of protraction of posterior teeth

61. Sub-mucosal injections of platelet rich
plasma (PRP)
Effect on root resorption:
• No research or data found on the effect of PRP on root
resorption under orthodontic force

62. REFERENCES
• Fischer TJ (2007) orthodontic treatment acceleration with corticotomy-assisted
exposure of palatally impacted canines. Angle Orthod 77: 417-420
• Shenava S , Nayak U S , Bhaskar V , Nayak A; Accelerated Orthodontics – A
Review
• Unnam D, Singaraju GS, Mandava P, Reddy GV, Mallineni SK, Nuvvula S;
Accelerated Orthodontics An overview; J Dent Craniofac Res Vol.3 No.1:4
• Sharma K, Batra P, Sonar S, Raghavan S; Periodontically accelerated orthodontic
tooth movement: A narrative review; J Indian Soc Periodontol; 2019 Jan-Feb;
23(1): 5–11
• Shailesh Shenava, US Krishna Nayak, Vivek Bhaskar, Arjun Nayak.
"Accelerated Orthodontics – A Review". International Journal of
Scientific Study. 2014;1(5):35-39
• Mangal U; Influence of platelet rich plasma on orthodontic tooth
movement; A Review