Non-surgical adjunctive interventions for accelerating tooth movement in patients undergoing fixed orthodontic treatment by Ahmed El-Angbawi, Grant T McIntyre, Padhraig S Fleming, David R Bearn ppt

1. Literature review

2. Type of study Cochrane Database of Systematic Reviews
Authors
Ahmed El-Angbawi, Grant T McIntyre, Padhraig S Fleming,
David R Bearn
Date of publication 2016
Name of Journal www.cochranelibrary.com

3. Where to find Systematic Reviews?
 ADA Center for Evidence-Based Dentistry.
 Cochrane Database of Systematic Reviews.
 PubMed.
 Evidence Based Dentistry Journal.
 Journal of Evidence-Based Dental Practice.
 Trip Database.

4. What are Cochrane Reviews?
 Cochrane Reviews are systematic reviews of primary research in human health care
and health policy, and are internationally recognized as the highest standard
in evidence-based health care.
 They investigate the effects of interventions for prevention, treatment and
rehabilitation.
 They assess the accuracy of a diagnostic test for a given condition in a specific patient
group and setting.

5. What is the difference between Pubmed and Cochrane?
 PubMed: an unfiltered source of primary literature comprises all different kinds of
publication types occurring in academic journals (23 million references).
 The Cochrane Library: a pre-filtered source which offers access to either synthesized
publication types or critically appraised and carefully selected references. (800,000
references).

6. Outlines:
 BACKGROUND
 OBJECTIVES
 METHODS
 RESULTS
 1st PAPER
 2nd PAPER
 DISCUSSION
 AUTHORS’ CONCLUSIONS

7.  BACKGROUND
 More than a quarter of adolescents classified as being in need of orthodontic treatment (Migale
2009; Mtaya 2009; Tausche 2004).
 Effective orthodontic treatment is accomplished by delivering planned treatment goals over the
shortest time possible, with minimal biological side effects and high levels of patient satisfaction.
 The majority of comprehensive treatment taking approximately 24 months to complete
(Mavreas 2008).
 Accelerating the rate of tooth movement may help to:
1. Reduce the duration of orthodontic treatment.
2. Reduce associated unwanted effects including root resorption and enamel demineralization.

8. Description of the intervention:
 The proposed non-surgical adjunctive interventions to accelerate orthodontic tooth movement
include:
I. Low energy laser radiation.
II. Intermittent resonance vibration.
III. Pulsed electromagnetic waves.
IV. Chewing gum or muscle exercise.
V. Pharmacological methods.
VI. Novel methods as they are described by authors.

9. How the intervention might work?
 Such interventions can act as a bio-stimulus to increase the activity of bone cells
(Tortamano 2009).
 The increased bone remodeling rate can increase the rate of tooth movement (short
duration treatment time)
Why it is important to do this review?
 They provides the orthodontic clinician with evidence about the effectiveness and safety
of non-surgical adjunctive interventions for accelerating orthodontic tooth movement.

10. OBJECTIVES:
To assess the effect of non-surgical adjunctive interventions on the rate of
orthodontic tooth movement and the overall duration of treatment.

11. • METHODS
Criteria for considering studies for this review:
o We included randomized controlled trials (RCTs) of people receiving orthodontic
treatment using fixed appliances along with non-surgical adjunctive interventions to
accelerate tooth movement.
o We excluded non-parallel design studies (for example, split-mouth) as we regarded them
as inappropriate for assessment of the effects of this type of intervention.
• Types of studies

12. • METHODS
Criteria for considering studies for this review
• Types of participants
o We included studies of individuals of any age or gender, receiving orthodontic treatment
with fixed appliances with non-surgical interventions to accelerate tooth movement.
o We excluded studies that included patients who were treated with orthognathic surgery,
participants with cleft lip or palate, or with other craniofacial syndromes or deformities.

13. o Active interventions:
Any form of fixed appliance orthodontic treatment incorporating the use of non-surgical adjunctive
interventions for accelerating orthodontic tooth movement.
o Control:
Any form of fixed appliance orthodontic treatment without the use of non-surgical adjunctive
interventions.
Criteria for considering studies for this review :
• Types of interventions
METHODS

14. Criteria for considering studies for this review
• Types of outcome measures
Primary outcomes Secondary outcomes
 Rate of tooth movement determined by
millimeters.
 Duration of active orthodontic treatment, number
of visits ,and duration of appointments.
 Improvement in occlusion.
 Patient centered outcomes.
 Harms arising during the course of orthodontic treatment.
 Prolonged stability of treatment outcome.
 Cost of treatment.
 Safety of the adjunctive intervention.
METHODS

15.  They searched the following databases
 The Cochrane Oral Health Group’s Trials Register.
 The Cochrane Central Register of Controlled Trials.
 MEDLINE via OVID.
 EMBASE via OVID.
 LILACS via BIREME.
 Meta Register of Controlled Trials (mRCT).
 US National Institutes of Health Register.
 World Health Organization International Clinical Trials Registry Platform Search Portal.
 They checked the reference to ask for details of additional published and unpublished trials.
 There were no restrictions regarding language or date of publication.
Search methods for identification of studies:
METHODS

16. METHODS
o Assessments were made independently by multiple authors.
o Excluded several published and ongoing studies because they were split- mouth studies.
Data collection and analysis
• Selection of studies:

17. METHODS
o We assessed the following domains as being at low, high or unclear risk of bias:
 Random sequence generation (selection bias).
 Allocation concealment (selection bias).
 Blinding of participants and personnel (performance bias).
 Blinding of outcome assessors (detection bias).
 Incomplete outcome data addressed (attrition bias).
 Selective outcome reporting (reporting bias).
 Other bias.
Data collection and analysis
• Assessment of risk of bias in included studies

18. METHODS
o They calculated mean differences (MD) with 95% confidence intervals (CI) for continuous data, and
risk ratios (RR) with 95% CI for dichotomous data.
o We contacted the corresponding authors of trials for original data where necessary.
Data collection and analysis
• Assessment of risk of bias in included studies
• Measures of treatment effect
o We categorized and reported the overall risk of bias of each included study according to the following:
 Low risk of bias (plausible bias unlikely to seriously alter the results)
 Unclear risk of bias (plausible bias that raises some doubt about the results)
 hHigh risk of bias (plausible bias that seriously weakens confidence in the results)

19. METHODS
 We had planned to carry out meta-analyses where there were studies of similar comparisons reporting
the same outcomes.
 We had planned to use the fixed effect model for meta-analyses. However, meta-analysis was not
possible.
 We used additional tables to present the results from the included studies.
Data collection and analysis
• Data synthesis:

20. o Using GRADEPro software, they produced Summary of findings for the main comparison for the
following outcomes, listed by priority:
1. Rate of tooth movement.
2. Duration of orthodontic treatment, number of visits during active treatment.
3. Improvement in occlusion.
4. Patient centered outcomes: impact of fixed appliances on daily life, quality of life and pain
experience.
5. Harm arising during the course of orthodontic treatment.
Data collection and analysis
• Presentation of main results
METHODS

21. RESULTS
• Included studies
o We included two studies in this review, reported in three
publications (Miles 2012; Pavlin 2015).
o The two studies were designed to assess the influence of
vibrational appliances as an adjunctive intervention on the
rate of tooth movement.
o Both studies obtained ethical approval prior to
commencement of the studies and recruitment of
participants.
o Excluded several published and ongoing studies because they
were split- mouth studies.

22. 1st PAPER

23. The effects of a vibrational appliance on tooth movement and patient
discomfort: a prospective randomized clinical trial
Miles P, Smith H, Weyant R, Rinchuse DJ.
Australian Orthodontic Journal 2012; 28(2):213–8. [PUBMED: 23304970]

24. Allocation: Randomized controlled trial.
Participants: 66 participants (40 F, 26 M) with fixed orthodontic appliance 0.018 inch bracket slot
system.
 Age: 11 to 15 years old.
 Mean age: 13 years old.
 Non-extraction treatment plan in the lower arch.
 No impacted or Unerupted teeth.
 Participants living close to the orthodontic practice.
Setting: the treatment was carried out by a single specialist orthodontist in private orthodontic practice
in Australia.
Dropouts: 2 out of 66 participants did not complete the trial. The authors did not mention the reasons.
Objective: to assess The effects of a vibrational appliance on tooth movement and patient discomfort.
Miles 2012

25.  Initial alignment of the lower anterior teeth using 0.018 bracket slot system brackets and 0.014-inch
nickel titanium arch wire for 10 weeks.
 Intervention: The vibration appliance (Tooth Masseuse), which provided a vibrational frequency of
11 Hz and 0.06 N (~6.1 g), was applied immediately after the initial arch wire was placed.
 The participants were instructed to use the vibrational appliance daily for 20 minutes each session.
 Control: treated with initial arch wire only.
Miles 2012
Interventions:

27. Miles 2012
Outcomes
Primary outcome Secondary outcome
The amount of tooth alignment measured by the
reduction in the irregularity, using Little’s
Irregularity Index.
Pain and discomfort levels using visual analogue
system during teeth alignment at 5 different time
points.
 Immediately
 5 weeks
 8 weeks
 10 weeks
 Immediately
 6 to 8 hours
 1 day
 3 days
 7 days

28. They assessed as being at high risk of bias.
• Randomization and Allocation:
Unclear risk of selection bias.
 No mention of how the randomization was created.
 No mention of allocation method.
• Blinding:
high risk of performance bias.
 The clinician was blinded, the participants were not blinded
to the type of intervention to which they were allocated.
Low risk of detection bias
 The outcome investigator was blinded during data collection.
Miles 2012
Risk of bias

29. They assessed as being at high risk of bias.
• Incomplete outcome data
Unclear risk of attrition bias.
 For the rate of orthodontic tooth movement outcome, 2
participants out of 66 were lost to follow-up.
 For the discomfort and pain outcome, there were 8
 dropouts out of 66 study participants.
 No mention of how missing data from participants who
dropped out were dealt with.
• Selective reporting
Low risk of reporting bias.
 The study protocol was not available. However, the outcomes
listed in the ’Methods’ section were comparable to the
reported results.
Miles 2012
Risk of bias

30. They assessed as being at high risk of bias.
• Other potential sources of bias
Unclear risk of other bias.
 It was unclear whether the authors had planned to assess
pain and discomfort for both arches or the lower arch only.
Miles 2012
Risk of bias

31. • The rate of anterior mandibular tooth movement during the alignment stage (primary outcome).
 By measuring the reduction in the LII score over 5, 8 and 10 weeks.
 The reduction in the LII score was higher in the intervention group
 0.9 mm at 5 weeks
 0.3 mm at 8 weeks
 0.7 mm at 10 weeks
 No statistical tests were provided for the comparison between the two groups. However, based on
the confidence intervals calculated, we concluded that there was no statistical difference between
the two groups.
Miles 2012
Effects of interventions:

32. • The Patient centred outcome: Pain and discomfort (secondary outcome)
 By recording the level of discomfort at five different time points using a 100 mm visual analogue
scale.
 It was noted that pain and discomfort increased after six to eight hours after arch wire placement
and dropped again after seven days, with minimal difference between the intervention and the
control group.
 No statistical tests were provided for the comparison between the two groups.however, based on the
confidence intervals calculated, we concluded that there was no statistical difference between the
two groups
Miles 2012
Effects of interventions:

33. 2nd PAPER

34. Cyclic loading (vibration) accelerates tooth movement in orthodontic
patients: A double-blind, randomized controlled trial
Dubravko Pavlin, Ravikumar Anthony, Vishnu Raj, and Peter T. Gakunga
Seminars in Orthodontics, Vol 21, No 3 (September), 2015: pp 187–194

35. Allocation: Randomized controlled trial.
Setting: the treatment was carried out by orthodontic residents under supervision of
faculty members of University of Texas, United States of America.
Objective: to assess The effects of a vibrational appliance on tooth movement and
adverse effects during treatment.
Pavlin 2015

36. Participants: 45 participants (28 F, 17 M)
 Age: 12 to 40 years old.
 Mean age: 21.4 years old.
 Inclusion criteria
 Permanent dentition.
 Participants had maxillary first premolars extracted as part of the orthodontic treatment.
 Minimum of 3 mm of extraction space closed by moving the maxillary canine distally.
 Good oral hygiene and compliance.
 Exclusion criteria
 Any compromised medical or dental condition.
 Participant currently involved in any other study.
 Use of bisphosphonates.
 Pregnant females.
 All participants received standard orthodontic treatment and temporary anchorage devices for tooth movement
and space closure.
Dropouts: 9 out of 45 participants did not complete the trial.
Pavlin 2015

37. • One intervention group and one control group
 Intervention: OrthoAccel device provides a light vibration at 0.25 Newtons and 30 Hz frequency
for 20 minutes daily.
 Control: Inactive device that is held in the mouth for 20 minutes a day.
Pavlin 2015
Interventions:

39. • Primary outcome
The rate of orthodontic movement of a maxillary canine tooth to close an extraction space for an average
of 22 weeks.
• Secondary outcome
Adverse effects during treatment.
Pavlin 2015
Outcomes

40. They assessed as being at high risk of bias.
• Randomization and Allocation:
Low risk of selection bias.
 Clearly mentioned the randomization procedure.
High risk of selection bias.
 No mention of allocation method.
• Blinding:
Low risk of performance bias.
 The clinician and participants were blinded to the type of
intervention as the control group participants were given a
sham device.
Low risk of detection bias.
 The outcome investigator was blinded during data collection.
Pavlin 2015
Risk of bias

41. They assessed as being at high risk of bias.
• Incomplete outcome data
Low risk of attrition bias.
 9 participants out of 45 (20%) were lost to follow-up
 However, the authors accounted for the missing data by
applying Intention-to-treat analysis.
• Selective reporting
Low risk of reporting bias.
 All outcomes outlined in the study registration were
reported in the full article in a peer-reviewed journal.
Pavlin 2015
Risk of bias

42. They assessed as being at high risk of bias.
• Other potential sources of bias
High risk of other bias.
 It was sponsored by OrthoAccel Technologies Inc.
 There was a time limited agreement between the principal
investigators and the sponsor to review results before
release to the public.
 In this study the space closure was done by using either en
masse retraction or canine retraction and that was
according to sample stratification during the randomisation
process. The author did not report the outcome of each
group separately.
Pavlin 2015
Risk of bias

43. • The rate of canine distalization during the space closure stage (primary outcome)
 The mean rate of tooth movement in the control group was 0.79 mm/month.
 The mean rate of orthodontic tooth movement in the intervention groups was 0.37 mm/ month
higher.
 Statistical tests were provided for the comparison between the two groups (statistically significant P =
0.05)
 However, based on the confidence intervals calculated for the mean differences, we concluded that
there was no statistical difference between the two groups. In addition, the reported mean difference
was considered to be clinically insignificant.
Pavlin 2015
Effects of interventions:

44. • Harms arising during the course of orthodontic treatment (secondary outcome)
 No serious adverse effects were reported in both groups.
 A similar number of minimal non serious adverse effects were reported in both groups.
 The non-serious adverse effects included
 Gastrointestinal disorders.
 General disorders.
 Injury.
 Poisoning and procedural complications.
 Musculoskeletal and connective tissue disorders.
 Nervous system disorders.
 Respiratory, thoracic and mediastinal disorders.
Pavlin 2015
Effects of interventions:

45. DISCUSSION
• Miles 2012
Rate of tooth movement
Miles 2012 Pavlin 2015
 The finding of the difference in reduction of Little’s
Irregularity Index (LII) is difficult to interpret due to the
pretreatment difference between the two groups.
 The intervention group having a higher initial LII and
therefore greater possibility for a reduction to be
achieved.
 It was reported no significant advantage in the use of
vibrational appliances.
 It is important to mention that the study didn’t present a
mean difference that we deemed to be of clinical
significance for the duration investigated.
o It was reported the mean rate of orthodontic tooth
movement in the intervention groups was 0.37 mm/
month higher.
o It was demonstrated that vibrational appliances could
increase the rate of canine distalization during
extraction space closure.
o It is important to mention that the study didn’t present a
mean difference that we deemed to be of clinical
significance for the duration investigated.

46. Pain and discomfort during treatment
Miles 2012 Pavlin 2015
o It was reported no advantage in the use of
a vibrational appliance in reducing pain
and discomfort during the first week of
fixed orthodontic appliance treatment.
o It did not investigate pain and discomfort
during treatment.

47. Harms during treatment
Miles 2012 Pavlin 2015
o It did not measure harms. o It was reported no increase in the adverse
effects due to the use of a vibrational
appliances.

48.  Currently, the evidence for non-surgical adjunctive interventions to increase the rate of
tooth movement is incomplete.
 All the data for light vibrational forces is at high risk of bias.
 The reported outcomes cannot be considered to be representative of the entire
orthodontic treatment duration.
Overall completeness and applicability of evidence

49. o The overall quality of the evidence is therefore considered to be very low.
Quality of the evidence
Potential biases in the review process
 Broad search strategy was done with no language restrictions.
 Assessments were made independently by multiple authors.
 Excluded several published and ongoing studies because they were split- mouth studies.
 Believe that the potential cross-over effects of this design introduces a great risk of bias.

50.  Long 2013 (RCTs and controlled clinical trials), suggested that low-level laser therapy is safe but
unable to accelerate orthodontic tooth movement.
 Gkantidis 2014 (RCTs and controlled clinical trials), reported that there is moderate to weak
evidence that non-surgical interventions (low energy laser, photobiomodulation or pulsed
electromagnetic fields) can accelerate tooth movement.
 Kalemaj 2015 (RCTs including split- mouth design), reported that there is some evidence that
low-level laser therapy can accelerate orthodontic tooth movement to a limited clinically
insignificant degree.
Agreements and disagreements with other studies or reviews

51. AUTHORS’ CONCLUSIONS

52. Implications for practice Implications for research
 There is insufficient evidence to conclude whether
or not there is a positive effect of non-surgical
adjunctive methods to accelerate tooth movement.
 The results of the current studies do not reach
either statistical or clinical significance and are at
high risk of bias.
 There is a clear need for well-designed and reported
randomized clinical studies for non-surgical
adjunctive methods to accelerate tooth movement.
 They would recommend that split-mouth designs
are avoided due to cross-over effects.
 Future studies need to have sufficient number of
participants to detect any clinically and statistically
significant differences.

53. Post-orthodontic Periodontal Treatment
After orthodontic treatment, the patient should remain on a 3 month periodontal maintenance program.
A nightguard is indicated to control parafunction and can also be used as a post-orthodontic retainer.
Occlusal adjustment to diminish any fremitus from lateral interferences
Take a new set of periapical radiographs.
It takes at least 6 months after band removal for adequate bone remodeling and cessation of mobility.