This study compared biochemical changes between rapid and conventional orthodontic tooth movement. 30 patients undergoing fixed orthodontic treatment were divided into two groups - one receiving conventional treatment and the other receiving micro-osteoperforations to accelerate tooth movement. Gingival crevicular fluid was collected from both groups at various time intervals and analyzed for levels of interleukin-1 and osteocalcin. The results showed significantly higher levels of both biomarkers at the micro-osteoperforated sites, indicating rapid orthodontic tooth movement was achieved through increased biological responses to force application.

1. BIOCHEMICAL CHANGES
BETWEEN RAPID AND
CONVENTIONAL
ORTHODONTIC TOOTH
MOVEMENT: A
COMPARATIVE STUDY
UNDER THE GUIDANCE OF
DR. MRIDULA TREHAN

2. Introduction

3.  Tooth movement by orthodontic force
application results as the bone
remodeling occurs when prolonged
pressure is applied to a tooth.
 Remodelling changes in paradental
tissues are considered essential in
effecting orthodontic tooth movement.
 Orthodontic force generates
mechanical stress which results in
creation of tissue strain leading to
extracellular matrix and cellular
changes in the paradental tissues.

4.  Duration of orthodontic treatment differs from
patient to patient, and is largely based on
individual characteristics, on an average it
extends from 21 to 27 months for non-extraction
treatment and 25 to 35 months for extraction
corrections.
 The rate of tooth movement can be increased by
application of mechanics which accelerates the
orthodontic tooth movement.
 Such mechanics has received more attention
recently as it speeds up tooth movement from its
usual rate of 0.8 mm to 1.2 mm per month.

5.  Extended treatment duration is one of the leading hindrance in
pursuing orthodontic treatment for adult patients.
 An active area of research in orthodontics today is the
introduction of various treatment methods to decrease treatment
time without compromising the treatment outcome.
 Prolonged treatment duration of about 2 to 3 years can lead to
complications such as external root resorption, periodontal
problems along with problem in patient compliance.

6.  Rapid advances in all biological fields have enabled
clinicians to better understand the mechanisms involved in
orthodontic tooth movement.
 For enhancing the rate of orthodontic tooth movement,
orthodontists are constantly striving towards developing
potential strategy.

7.  Various approaches are used in orthodontics to accelerate the
orthodontic tooth movement and to reduce the treatment duration.
 The methods used to accelerate orthodontic tooth movement are
broadly classified as surgical methods, device assisted therapy and
drugs.

8.  Surgical methods include corticotomy, periodontally accelerated
osteogenic orthodontics, piezocision, micro-osteoperforation,
interseptal alveolar surgery, corticision, surgery first approach which
are based on Regional Acceleratory Phenomenon (RAP).
 Device assisted therapy includes low level laser therapy, cyclic
vibrations, electric currents, electromagnetic field, LED device,
therapeutic ultrasound, self-ligating brackets etc.
 The most commonly used pharmacological agents to enhance
orthodontic tooth movement are Parathyroid hormone, Vitamin D3,
Prostaglandin and Relaxin.

9. Corticotomy
 In corticotomy, only cortical bone is surgically altered
without any alteration in the medullary bone.
 Vertical grooves extending from crest of alveolar bone
upto 2mm apical to root apices are made in the inter-
radicular alveolar bone using high-speed handpiece.

10. Periodontally accelerated osteogenic
orthodontics
 Periodontally accelerated osteogenic orthodontics is same
as corticotomy.
 Bone grafts are used which increases the limit of tooth
movement and decreases the need for extraction.
Hence rapid recovery and alveolar reshaping is reported
with the procedure.

11. Piezocision
 Piezocision is a minimally invasive approach
that involves micro-incisions, piezoelectric
incisions and selective tunneling for grafting.
 Vercelloti and Podesta (2007) advocated the
conventional flap elevations followed by the
use of piezosurgery for enhancing the tooth
movement.
 Patient’s acceptance for the technique is less
as discomfort after surgery is more due to the
invasive nature.

12. Micro-osteoperforations (MOP)
 Micro-osteoperforations (MOP)
are the procedures done on
alveolar bone which enhances the
expression of inflammatory
markers leading to increase in the
number of osteoclast and rate of
tooth movement.
 The procedure is also known as
alveocentesis.

13. Interseptal alveolar surgery
 Interseptal alveolar surgery works on the principle of
distraction osteogenesis in which the interseptal bone
distal to the tooth to be moved is surgically undermined.

14. Corticision
 Corticision is also called as minimally invasive rapid
orthodontics (MIRO) was introduced by Kim J, Park YG,
Kang SG (2009).
 Corticision is a technique in which a reinforced scalpel and
a mallet are used to cut the bone through the gingiva
without resecting the mucoperiosteal flap.

15. Surgery first approach
 Surgery first approach is the procedure which can be performed
in individuals with severe dento-facial deformity requiring
orthognathic surgery.
 Surgery first approach shortens the prolonged decompensation
phase of orthognathic surgery.

16. Low-level laser therapy
 Low-level laser therapy (LLLT) stimulates the
multiplication of bone cells and thereby increases bone
remodeling and accelerates tooth movement.

17. Cyclic vibrations
 Cyclic vibrations are methods in which mechanical
radiations create light alternating forces on the teeth.
 The initial response of cells to mechanical stress in vitro
appears within 30 minutes.

18. Electric current
 Electric current of 15µA is reported to increase the
osteoclast accumulation on compression site and osteoblast
accumulation on tension site in cats which accelerates the
amount of bone turnover and hence increases the
orthodontic tooth movement.

19. Electromagnetic field
 Electromagnetic field increases the orthodontic tooth
movement by decreasing the lag phase.
 A study conducted by Showkatbakhsh and co-workers
exposed patients to 1 Hz of electric current and found that
the rate of canine retraction was increased on application
of pulsed electromagnetic field.

20. Intraoral LED device
 An intraoral LED device named Biolux utilizes
light of 800-850 nm wavelength which can
penetrate the soft tissue and gets directly infused
into the bone tissue.
 The photochemical interaction of light with
tissue, can cause excitation of intracellular
enzymes and increase cellular activity in the
PDL and bone thus increasing the rate of bone
remodelling and tooth movement.

21. Low-intensity therapeutic pulsed
ultrasound
 A low-intensity therapeutic pulsed ultrasound increases the
orthodontic tooth movement by increasing blood flow in the PDL
thereby increasing bone remodelling and tooth movement and also
decreases root resorption.

22. Prostaglandins
 Prostaglandins are known group of inflammatory
mediators.
 Prostaglandins directly stimulate the osteoclasts and
increase bone resorption and hence increase the rate of
orthodontic tooth movement.

23. Parathyroid hormone (PTH)
 Parathyroid hormone (PTH) maintains
calcium level and bone turnover.
 PTH increases the serum calcium
concentration by enhancing calcium
resorption from small intestine.

24. Vitamin D and PTH
 Vitamin D and PTH increases
calcium reabsorption in the human
body.
 The calcium is reabsorbed from
small intestine with the active
configuration of vitamin D which
is 1,25 di-hydroxy vitamin D3.

25. Relaxin
 Relaxin is an insulin which influences many physiological processes
such as collagen turnover, angiogenesis and antifibrosis both in males
and females.
 Relaxin increases collagen in the tension site and decreases it in the
compression site.
 Randomised controlled trial on humans have not shown any major
advantage of using Relaxin for accelerating orthodontic tooth
movement.

26. Gingival crevicular fluid (GCF)
 Gingival crevicular fluid (GCF) is an osmotically mediated
inflammatory exudate in the gingival sulcus.
 GCF is an important predictor in orthodontic tooth movement.
 Various biomarkers found in GCF are Interleukin (IL), Tumor
necrosis factor alfa (TNF-alfa), Prostaglandin E2 (PGE2),
Osteocalcin (OC), Osteoprotegerin (OPG), Receptor activator of
nuclear NF-kappa (RANKL), Transforming growth factor-beta 1
(TGF-1), Alkaline phosphatase (ALP), Aspartate aminotransferase
(AST), Interleukin-1 (IL-1), Interferon-gamma (IF-gamma) and
others.

27.  There are three methods to collect GCF:
1. The first one is gingival washing technique in which GCF is
introduced in Hank’s balanced solution, an isotonic solution, with fixed
volume. The GCF is diluted which consists of cells and plasma protein
as soluble constituents.
2. In second method, capillary tube with specific diameter is inserted
into entrance of the gingival crevice and capillary action is the principle
behind the fluid migration into the tube.
3. Third method is commonly used in which absorbent filter paper are
used. For GCF collection, the paper strips are left in situ into the
gingival crevice for 5 to 60 seconds.

28.  Till date, few studies have been performed for the evaluation of
biochemical changes of Osteocalcin and Interleukin-1 during
Orthodontic tooth movement.
 This study was aimed at comparing the changes at Biochemical level
(IL-1 and Osteocalcin) between Rapid and Conventional Orthodontic
tooth Movement.

29. Aim and
Objectives

30. Aim
 To compare changes at Biochemical level (IL-1
and Osteocalcin) between Rapid and Conventional
Orthodontic tooth Movement.

31. Objectives
1. To study the Biochemical changes in Conventional Orthodontic tooth
movement.
2. To study the Biochemical changes in Rapid Orthodontic tooth
movement.
3. To compare the changes at Biochemical level between Rapid and
Conventional Orthodontic tooth Movement.

32. Materials and method

33.  A split mouth study was conducted on thirty patients undergoing
fixed orthodontic treatment (MBT 0.022 x 0.028 inch slot) requiring
all four first premolar extraction.
 All patients visiting the Department of Orthodontics and Dentofacial
Orthopaedics of Nims Dental College and Hospital, Jaipur, who
fulfilled the inclusion criteria were included in the study. Prior to the
conduction of the study, approval was taken from the Institutional
Ethics Committee and informed consent was taken from the patients.

34. INCLUSION CRITERIA
1. Patients requiring fixed appliance therapy involving extraction of all
maxillary first premolars.
2. Patients with no signs or symptoms of temporomandibular joint
disorder.
3. Patients with no use of anti-inflammatory and antibiotic drugs.
4. Patients with no grossly decayed or congenitally missing teeth except
third molars.
5. Patients with no history of systemic illness.
6. Patients with healthy periodontal tissue and well controlled
periodontal health.

35. EXCLUSION CRITERIA
1. Patients who have undergone long term corticosteroid
therapy.
2. Patients under medications that slow down bone
metabolism such as bisphosphonates and NSAIDS.
3. Patients with probing depth value greater than 3 mm in all
the teeth.
4. Patients not willing to participate in the study.

36. ARMAMENTERIUM
1. Local anesthesia (lidocaine
hydrochloride 2% with epinephrine
1:100,000)
2. Micro osteoperforation tool (Pitkar)
3. 2ml Syringe with 24 gauge needle
4. 0.2% Chlorhexidine oral rinse solution
5. MBT bracket kit of 0.022 x 0.028 inch
slot (Sapphire)
6. Etching gel, 37%phophoric acid
(Prime)
7. Ortho solo primer bond (Ormco)
8. Enlight light cure Adhesive (Ormco)
9. Periodontal probe (API)
10. 3 µL Calibrated volumetric
microcapillary pipette

37.  Before commencement of the study, patients were instructed to maintain good
oral hygiene throughout the treatment.
 After extraction of both the maxillary 1st premolars, 0.022 x 0.028-inch MBT
brackets were bonded to the teeth.
 Initial alignment and leveling was carried out and 0.019 X 0.025” stainless
steel archwire was ligated for 4 weeks.

38. SURGICAL PROCEDURE
 The surgical procedure was performed under local
anesthesia (2% lignocaine with 1:100,000 adrenalin).
 Micro osteoperforation device was held against the
gingiva while keeping the tissue taut.
 Three micro osteoperforations each were performed
distal to the maxillary canine and mesial to second
premolar.
 Type 1 Active tie backs were given immediately on
both the sites of the arch after completion of the
surgical procedure.

39. GINGIVAL CREVICULAR FLUID COLLECTION AND
ENZYME-LINKED IMMUNOSORBENT ASSAY
 GCF was collected before the micro osteoperforation (T0), at day 3
(T1), at day 7 (T2) and at 4 weeks (T3) of initiating canine retraction
from the distal gingival crevice of maxillary canine from both the
sites of the arch.
 Before initiating the process of GCF collection, the gingival area was
dried with an air syringe, supra gingival plaque was removed and
isolated with cotton rolls in order to minimize the contamination from
saliva.

40.  The tip of the 3 µL Calibrated volumetric microcapillary pipette was
placed into gingival crevice for 5 minutes at distal of the maxillary
canine.
 GCF from the crevice migrates into the tube by capillary action.
 A standardized volume of 3 mL GCF was collected using the
calibration on the micropipette.
 Atraumatic collection of GCF was ensured.

41.  Samples contaminated with blood or saliva were excluded from
the study.
 Quantitative analysis of IL-1 and Osteocalcin in GCF sample
were assessed.
 The optical density of samples was calculated using a fully
automated enzyme linked immunosorbent assay reader.

42. STATISTICAL ANALYSIS
 The data collected was entered in Microsoft Excel and subjected to
statistical analysis using Statistical Package for Social Sciences
(SPSS, IBM version 21.0).
 The data was evaluated using IBM SPSS version 21 for Windows.
 One-way ANOVA followed by Bonferroni post hoc tests were used
for determining statistical significance between expressions of
Biochemical marker levels at different time intervals.

43. Results

44. The present study was carried out to compare changes at
Biochemical Level (IL-1 and Osteocalcin) between Conventional
and Micro-osteoperforation site in Orthodontic tooth Movement.
The results are based on analysis of 30 patients by evaluating the
level of IL-1 and Osteocalcin in GCF.

45. Table 1 and Graph 1 shows the level of IL-1 at the conventional and Micro osteoperforation site.
Except for the comparison between baseline values, all other comparisons yielded statistically very highly significant results,
indicating that the level of IL-1 was always higher at the micro osteoperforation site.

46. Table 2 and Graph 2 shows the level of Osteocalcin at the conventional and Micro osteoperforation site at different time
intervals.
Except for the comparison between baseline values all other comparisons yielded statistically significant results, indicating that
the level of Osteocalcin was always higher at the micro osteoperforation site.

47. Discussion

48.  In orthodontics, patients usually complain regarding long
treatment duration of about 2-3 years.
 To accelerate orthodontic tooth movement and reduce the
treatment duration, various approaches are used in orthodontics.
 In adults, surgical approach is used for accelerating orthodontic
tooth movement.
 Various drugs are available for accelerating orthodontic tooth
movement, but they have other side effects.

49.  Device-assisted approach for faster tooth movement
requires patient cooperation.
 Therefore surgical approach is the safest approach for
accelerating orthodontic tooth movement.
 Surgical techniques for accelerating orthodontic tooth
movement are invasive in nature.
 Hence, a new technique has been developed known as
‘micro osteoperforation’(2010).

50.  This in-vivo study was undertaken with 30 patients undergoing fixed
orthodontic treatment after maxillary first premolar extraction.
 Three micro osteoperforations each were performed distal to the
maxillary canine and mesial to second premolar.
 Type 1 Active tie backs were given immediately on both the sites of
the arch after completion of the procedure.
 The level of IL-1 and Osteocalcin was assessed in GCF between
Conventional and Micro osteoperforation site during orthodontic
tooth movement.

51.  The levels of IL-1 from both the conventional and micro
osteoperforation sites are provided in table 1.
 One-way ANOVA result yielded statistically significant change
between different time intervals.
 At conventional site, significant elevation in the level of IL-1 was
observed on day 3 (T1) as compared to baseline (T0). A gradual
decrease in the level was observed on day 7 (T3) and at four weeks
(T4).

52.  At micro osteoperforation site, sudden increase in the level of
IL-1 was observed on day 3 (T1) as compared to baseline (T0). A
gradual decrease in the level of IL-1 was observed on day 7 (T3)
and at four weeks (T4).
 The level of IL-1 was always higher at micro osteoperforation site
as compared to conventional site at different time intervals except
for the comparison between the baseline values.
 Similar results were found by Yamaguchi et al. (2021),Alikhani
et al. (2015) and Teixeira et al. (2010).
 Their results show that IL-1 level in GCF was significantly higher
in micro osteoperforation site.

53.  The levels of Osteocalcin from both the conventional and micro
osteoperforation sites are provided in Table 2.
 One-way ANOVA result yielded statistically significant change
between different time intervals.
 At conventional site, gradual increase in the level of Osteocalcin
was observed at day 3 (T1) as compared to baseline (T0). The
level of Osteocalcin showed a peak value at day 7 (T3). A gradual
decrease in the level was observed after four weeks (T4).

54.  At micro osteoperforation site, the level of Osteocalcin was increased
on day 3 (T1) and day 7 (T2) as compared to baseline. The level of
Osteocalcin showed a peak value after 4 weeks (T3).
 The level of Osteocalcin was always higher at micro osteoperforation
site as compared to conventional site at different time intervals except
for the comparison between the baseline values.

55.  The same results were found in the study conducted by
Hashimoto et al. (2001). They reported that on administration of
Osteocalcin, orthodontic tooth movement was accelerated due to
enhancement of osteoclastogenesis on the pressure side.
 Holland (2018) found that Osteocalcin level was highest in PDL
at day 4 of orthodontic tooth movement. Their results show that the
level of Osteocalcin in GCF was significantly higher in experimental
group than in the control group.

56.  In contrast to the results of the present study, Ozdemir et al.
(2005)73 reported decrease in the level of Osteocalcin in GCF
during orthodontic intrusion of maxillary premolar teeth.

57. Conclusion

58.  The study was intended to compare the biochemical changes
between rapid and conventional orthodontic tooth movement.
The following conclusions can be drawn from the study:
1. The levels of bone-resorbing IL-1 peaked at the third day in
both conventional and micro osteoperforation site.
2. The levels of Osteocalcin peaked at 4th week in micro
osteoperforation site whereas in 7th day in conventional side.
3. Statistically significant elevated levels of IL-1 and
Osteocalcin were seen in micro osteoperforation site
compared to conventional site.

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