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
TOOTH MOVEMENT
Force
 Application
 Elimination
 Effects of Force
 On bone and teeth
 Tension  Bone Formation  Osteoblasts
 Compression  Bone Resorption  Osteoclasts
 Magnitude of Force
 > 7-8 grams
 Duration of Force
 > 4-6 hours

Types of Forces
 Continuous
 Light sustained forces from NiTi wires and springs
 Interrupted
 A wire that gets deactivated between appointments
 Intermittent
 Removable appliances


Effects of Drugs on
Orthodontic Tooth
Movement

STEROIDS
NSAIDS

Relaxin
 Pregnancy Hormones
 Destroyes Collagen
 Helps in softening / dilatation of cervix
 Increased rate of Orthodontic Tooth Movement

Prostaglandin Inhibitors
 NSAIDS
 STEROIDS
 Slow down tooth movement

Paracetamol
 COX 3 Inhibitor
 Analgesic
 Antipyretic
 But not anti-inflammatory
 Does not effect the rate of tooth movement

Other drugs
 Tricyclic Antidepressants
 Antiarrythmic agents
 Antimalarials
 Phenytoin
 Statins
 Tetracyclines

Osteoporosis
 Estrogen Replacement Therapy
 Reduced production of PG and IL-1 and IL-6
 Reduced rate of remodeling
 ESTROGEN – Uterine Cancers
 ESTROGEN + PROGESTERONE – Breast Cancers
 Estrogen Receptor Modulator (Anti-cancer?)
 Raloxifine
 Tamoxifine
 Bisphosphonates

BISPHOSPHONATES
 Can be
 Nitrogenous
 Non-nitrogenous
 Binds to Hydroxyapatite
 Slows down tooth movement
 Long half life
 In months and years

BISPHOSPHONATES
 Can be
 Nitrogenous
 Non-nitrogenous
 Binds to Hydroxyapatite
 Slows down tooth movement
 Long half life
 In months and years

Bisphosphonates
 Risks Involved
 Osteonecrosis
 Slow tooth movement

 A challenging task?
 Benefits of reduced treatment time
 Risks involved
ENHANCING ORTHODONITC
TOOTH MOVEMENT

 Biomechanical approach
 Physiological/mechanical approach
 Pharmacological approach
 Surgical-assisted approach
 Surgery-simulated approach
METHODS OF ENHANCHING
TOOTH MOVEMENT

 Self-ligating brackets:
 Frictional force of ligatures ( O configuration)= 50 g
 Reduced friction- especially passive design
 Less force - more physiological
 More alveolar bone generation, greater expansion, less
proclination of anterior teeth, less need for extractions
 Kapur et al:
 Friction per bracket
 with Ni-Ti archwires
 41g (conventional)
 15g (self ligating)
 For SS wires:
 61g (conventional)
 3.6g (self ligating)
BIOMECHANICAL APPROACH

 Self-ligating brackets:
 Despite low friction, do not perform faster alignment/ space
closure
 Narrower than conventional brackets – More Tipping – More
Binding
 Short chair side time and less incisor proclination (1.5 degree)
1. Chen SS et al. Systemic review of self ligating brackets. Am J Orthod Dentofacial
Orthop.2010;137:726e1:726e18.
2. Fleming PS, Johal A. Self ligating brackets in orthodontics. A systemic review. Angle
Orthod.2010;80:575-84.
BIOMECHANICAL APPROACH

 Direct Electric Current Stimulation:
 Direct current : 7 volts & 15 microamperes
 Anode : Pressure side; Cathode: tension side
 More bone formation and resorption at electrically treated sites
 Increase osteoblasts, PDL cells, osteoclasts
 Mechanism:
 Direct current generate local response to increase alveolar bone turnover
 Disadvantages:
 The device and battery providing electric current are bulky
 No clinical application has been reported
1. Beesan DC, Jhonston LE, Wisotzky J. Effect of constant currents on orthodontic tooth movement
in cat. J Dent Res 1975;54:251-54
2. Davidovitch Z et al. Electric currents, bone remodelling and orthodontic tooth movment. Am J
Orthod.1980;77:33-47
PHYSIOLOGICAL APPROACH

 Endogenous Piezoelectric Stimulation
 Electric potentials are created by force application
 The charges are created when stress is applied and released
 Vibration could be used to apply and release forces at rapid
rate
 Mechanism:
 Stimulate cell proliferation and maturation to allow faster bone
remodeling
 AcceleDent vibratory system:
 High frequency vibration (30Hz) for 20 min/day
PHYSIOLOGICAL APPROACH

 Endogenous Piezoelectric Stimulation
 Prospective RCT: 45 patient , Random allocation for use of AcceleDent
appliance
 NiTi coil spring was attached from canine and distally to TSAD
 38% (0.29mm/wk) faster tooth movement compared to control (0.21mm/wk)
 Discussion:
 Lack of blinding & measurement method may affect the outcome
 TSAD can drift under orthodontic loading-1.5mm
 Vibration may results in accelerated drift of TSAD
 AcceleDent website.http//accledent.com/images/uploads/AcceleDent + increases+the
Rate of Orthodontic tooth movement Results of a RCT Final for Print November 14
2011.pdf Accessed 20 May 2012
PHYSIOLOGICAL APPROACH

 Low-Level Laser Therapy (LLLT):
 Gallium-Aluminium-Arsenide Irradiation
 Wavelength: 630-860 nm; Energy: 4.5-6 J/cm2
 Minimally invasive, simple and safe to apply
 Mechanism:
 Increase in ATP at localized site - induce cells to undergo a
remodeling process due to an elevated metabolic activity
 Increase in vascular activity contribute to rapid turnover of bone
 Evidence:
 Few studies reported positive result, few no effect and some reported
retarded tooth movement
PHYSIOLOGICAL APPROACH
 Youssef M et al. Low energy laser irradiation therapy during orthodontic tooth movement. A
preliminary stud. Lasers Med Sci 2008;23:27-33
 Limpanichkul et al. Effects of low laser therapy on rate of orthodontic tooth movement. Orthod
Craniofac Res. 2006;9:38-43

 Photo-biomodulation (Biolux)
 Light with 800-850nm wavelength
 Penetrates cheeks and soft tissues over alveolar bone
 97% light lost , 3% excite intracellular enzymes and increase cellular
activity in PDL and bone
 Increase blood flow and may enhance tooth movement
 Advantage:
 Can be adjusted according to anchorage requirements
PHYSIOLOGICAL APPROACH

 Corticosteroids
 PG’s
 Growth Hormone
 Parathyroid hormone
 Active form of Vitamin D
 Relaxin
PHARMACOLOGICAL APPROACH

 Prostglandins:
 Mechanism:
 PGE2 – an important mediator of bone remodeling under mechanical force
 Increase cAMP and cGMP
 Yamaseki & Harell et al:
 Experiment on animal model found application of orthodontic force – increase
in PG’s synthesis- stimulate osteoclastic bone resorption
 Injections of PGE1 and PGE2 into gingival tissues near first molar – increase
rate of tooth movement
PHARMACOLOGICAL APPROACH
 Yamaseki K et al. Prostaglandin as a mediator of bone resoprtion induced by experimental tooth
movement in monkeys. J Dent Res. 1982;61:1444-1446

 Protaglandins:
 Clinical application:
 Following LA, 0.1 ml of a 0.01% PGE1 solution in saline was injected
submucosally at pressure side
 Rate of canine retraction- 1.6 fold increase
 Disadvantages:
 Injection were repeated at weakly intervals
 Severe pain after injections
PHARMACOLOGICAL APPROACH
 Speilmann T et al. Acceleration of orthodontically induced tooth movement through the local
application of prostaglandin (PGE1). Schweiz Monatsschr Zahnmed 1989;99:162-165

 Relaxin
 Insulin family of structurally related hormone
 Produced during pregnancy
 Mechanism:
 Increase rate of degradation of collagen (stimulate collagenase)
 Increase bone resorption via increase in TNF and IL-1B secretion
PHARMACOLOGICAL APPROACH
 Kristiansson P et al. Does human relaxin-2 affect peripheral blood mononuclear cells to increase
inflammatory mediators in pathological bone loss?.Ann N Y Acad Sci.2005;1041:317-9
 Stewart Dr et al. Use of Relaxin in orthodontics. Ann N Y Ascad Sci.2005 1041:379-387

 Vitamin D ( 1,25 Dihydroxycholecalciferol)
 Vitamin D and PTH regulate the amount of calcium and phosphorus levels
 Vitamin D receptors – present on osteoblasts but also in osteoclast precursors
and in active osteoclasts
 Collins and Sinclair et al (1988)
 Intraligamentary injections of vitamin D metabolite- increase in the number of
osteoclasts and amount of tooth movement during canine retraction with light
forces
 Stimulatory action of vitamin D on osteoblasts can help stabilize orthodontic
tooth movement
PHARMACOLOGICAL APPROACH

 PDL Distraction
 Rapid canine retraction through
distraction of dento-alveolus
 Corticotomy assisted rapid tooth
movement
 Corticision/Peizocision
SURGICAL-ASSISTED APPROACH

 Rapid canine retraction via PDL distraction
 Mechanism:
 Incorporation of a surgical cuts on interseptal bone distal to canine at
the time of extraction of first premolar
 Rapid canine retraction through distraction (stretching) of PDL
 Pressure side: Canine-interseptal bone complex transported distally
inside the socket
 Tension side: PDL distraction leading to osteogenesis
SURGICAL-ASSISTED APPROACH

PDL DISTRACTION
 Procedure
 At the time of extraction of 1st pm,
socket is deepened to the same
depth as canine with a 4mm
round carbide bur
 Interseptal bone is reduced to 1.0-
1.5mm
 A custom made distraction
appliance is delivered
immediately after extraction
 Rate of activation:
 0.5mm-1mm/day
 Liou EJ, Haung CS. Rapid canine retraction through distraction of periodontal ligament. Am J Orthod
Dentofacial Orthop. 1998;114: 372-383

 Dento-alveolar Distraction
 Surgical Technique:
 Mucoperiosteal flap reflected
 Cortical holes made in alveolar bone curving apically to pass 3-5mm from
apex
 Connect the holes with tapering fissure
 Large osteotomes are used to mobilize the whole segment
 Distraction: after 3 days of surgery
 Activation of distractor: twice/day in morning and evening
 0.8mm/day
 Can also be used to bring ankylosed tooth into position
 Disadvantage:
 Aggressive and complicated
SURGICAL-ASSISTED APPROACH
 Kisniscu RS et al. Dentoalveolar distraction osteogenesis for rapid canine retraction. J Oral Maxillfac
Surgery 2002. 60:389-394

 RAP
 Increased rate of orthodontic tooth movement
 Increased remodelling
 Transient osteopenia
Regional Acceleratory Phenomenon

 Corticotomy Assisted Tooth Movement
 Local injury to the alveolar process reduces resistance to tooth movement
and generate RAP
 Indications:
 Resolve crowding and shorten treatment time
 Accelerate canine retraction
 Enhance post-orthodontic stability
 Facilitate eruption of impacted teeth
 Molar intrusion and open bite correction
 Molar distalization
 Kole’s technique:
 Flap raised, vertical cuts facially and lingually between and under teeth
that did not penetrate all the way (only cortex)
SURGICAL-ASSISTED APPROACH

 Wilcodontics
 Accelerated osteogenic orthdontics (AOO)
 Periodontally accelerated osteogenic orthodontics (PAOO)
 Technique:
 Full thickness flaps are reflected carefully beyond the apices to allow
decortication around apices
 Corticotomy cuts are made in the form of lines and dots
 Small circular depressions are placed in facial surface of bone over
maxillary anterior teeth
 Bio-absorbable graft is placed (demineralized freeze dried bone)
 Tooth movement- should be started after a weak
 Tooth movement should be completed within 3-4 months
SURGICAL-ASSISTED APPROACH


 Wilcodontics
 Advantages of graft:
 Reduces bone dehiscence/ fenestrations
especially when lower incisors are
advanced
 Good healing of alveolar bone
SURGICAL-ASSISTED APPROACH

 MODIFIED CORTICOTOMIES:
 Micro-osteoperforation:
 Screws placed in gingiva b/w interproximal alveolar bone and removed
 Enough to accelerate RAP
 Advantages:
 Minimally discomfort
 Enhanced periodontium
SURGICAL-ASSISTED APPROACH

 Piezocision:
 Minimally invasive flapless
procedure combining peizoelectric
incisions & selective tunneling
 Allows for hard and soft tissue
grafting
 Indications:
 To resolve anterior crowding
 Anterior open bite
 Advantages:
 Patient friendly
 Less discomfort
SURGICAL-ASSISTED APPROACH
Park YG. Patient friendly orthodontics to accelerate tooth movement. Presented at the 23rd Annual
conference of Taiwan Association of orthodontics. 2011. Taichung, Taiwan.

 Corticision:
 Aim to cut interradicular bone to 50% to 75% of the root length
 Technique:
 Insert sepcial surgical blade interproximally and parallel to occlusal
plane 2-3 mm apical from the tip of the papilla
 Tap blade with a mallet to a depth of approximately 8mm
 Change the angle of the blade to approximately 45 degrees apically
and tap the blade to incise to a depth of 10mm to 12mm
 Apply orthodontic forces immediately
 Activation every two weeks
 Extra force to induce minor trauma and to extend the effect
SURGICAL-ASSISTED APPROACH

 Submucosal Injections of PRP
 Autologous Platelet Rich Plasma
(PRP) can simulate effects of bone
surgery
 PRP contain 5% RBC’s, 1% WBC’s,
and 94% platelets
 Platelets contain growth factors PDGF,
TGF and other components that regulate
and stimulate wound healing and
amplify osteogenesis
SURGERY SIMULATED
APPROACH

 Submucosal Injections of PRP
 Technique:
 0.7ml of PRP injected in labial and lingual attached gingiva from
canine to canine (immediately after bonding)
 Acetaminophen given to control post-injection pain
 Rate of orthodontic alignment faster than controls
 Liou EJ et al. Submucosal injection of platelet rich plasma accelerates orthodontic tooth
movement. Am J Orthod Dentofacial Orthop (in press).
SURGERY SIMULATED
APPROACH

 In general, all these techniques had draw backs and
uncertainties that made them not commonly used
clinically.
 However, there has been a rapid increase in the interest
levels of product companies to enhance orthodontic
tooth movement.
 These new approaches have the potential to be the next
frontier for orthodontics and its resources.
CONCLUSION
THANK YOU

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biology of tooth movement ii

  • 1.
  • 2.  TOOTH MOVEMENT Force  Application  Elimination  Effects of Force  On bone and teeth  Tension  Bone Formation  Osteoblasts  Compression  Bone Resorption  Osteoclasts  Magnitude of Force  > 7-8 grams  Duration of Force  > 4-6 hours
  • 3.  Types of Forces  Continuous  Light sustained forces from NiTi wires and springs  Interrupted  A wire that gets deactivated between appointments  Intermittent  Removable appliances
  • 4.
  • 5.  Effects of Drugs on Orthodontic Tooth Movement
  • 7.  Relaxin  Pregnancy Hormones  Destroyes Collagen  Helps in softening / dilatation of cervix  Increased rate of Orthodontic Tooth Movement
  • 8.  Prostaglandin Inhibitors  NSAIDS  STEROIDS  Slow down tooth movement
  • 9.  Paracetamol  COX 3 Inhibitor  Analgesic  Antipyretic  But not anti-inflammatory  Does not effect the rate of tooth movement
  • 10.  Other drugs  Tricyclic Antidepressants  Antiarrythmic agents  Antimalarials  Phenytoin  Statins  Tetracyclines
  • 11.  Osteoporosis  Estrogen Replacement Therapy  Reduced production of PG and IL-1 and IL-6  Reduced rate of remodeling  ESTROGEN – Uterine Cancers  ESTROGEN + PROGESTERONE – Breast Cancers  Estrogen Receptor Modulator (Anti-cancer?)  Raloxifine  Tamoxifine  Bisphosphonates
  • 12.  BISPHOSPHONATES  Can be  Nitrogenous  Non-nitrogenous  Binds to Hydroxyapatite  Slows down tooth movement  Long half life  In months and years
  • 13.  BISPHOSPHONATES  Can be  Nitrogenous  Non-nitrogenous  Binds to Hydroxyapatite  Slows down tooth movement  Long half life  In months and years
  • 14.  Bisphosphonates  Risks Involved  Osteonecrosis  Slow tooth movement
  • 15.
  • 16.   A challenging task?  Benefits of reduced treatment time  Risks involved ENHANCING ORTHODONITC TOOTH MOVEMENT
  • 17.   Biomechanical approach  Physiological/mechanical approach  Pharmacological approach  Surgical-assisted approach  Surgery-simulated approach METHODS OF ENHANCHING TOOTH MOVEMENT
  • 18.   Self-ligating brackets:  Frictional force of ligatures ( O configuration)= 50 g  Reduced friction- especially passive design  Less force - more physiological  More alveolar bone generation, greater expansion, less proclination of anterior teeth, less need for extractions  Kapur et al:  Friction per bracket  with Ni-Ti archwires  41g (conventional)  15g (self ligating)  For SS wires:  61g (conventional)  3.6g (self ligating) BIOMECHANICAL APPROACH
  • 19.   Self-ligating brackets:  Despite low friction, do not perform faster alignment/ space closure  Narrower than conventional brackets – More Tipping – More Binding  Short chair side time and less incisor proclination (1.5 degree) 1. Chen SS et al. Systemic review of self ligating brackets. Am J Orthod Dentofacial Orthop.2010;137:726e1:726e18. 2. Fleming PS, Johal A. Self ligating brackets in orthodontics. A systemic review. Angle Orthod.2010;80:575-84. BIOMECHANICAL APPROACH
  • 20.   Direct Electric Current Stimulation:  Direct current : 7 volts & 15 microamperes  Anode : Pressure side; Cathode: tension side  More bone formation and resorption at electrically treated sites  Increase osteoblasts, PDL cells, osteoclasts  Mechanism:  Direct current generate local response to increase alveolar bone turnover  Disadvantages:  The device and battery providing electric current are bulky  No clinical application has been reported 1. Beesan DC, Jhonston LE, Wisotzky J. Effect of constant currents on orthodontic tooth movement in cat. J Dent Res 1975;54:251-54 2. Davidovitch Z et al. Electric currents, bone remodelling and orthodontic tooth movment. Am J Orthod.1980;77:33-47 PHYSIOLOGICAL APPROACH
  • 21.   Endogenous Piezoelectric Stimulation  Electric potentials are created by force application  The charges are created when stress is applied and released  Vibration could be used to apply and release forces at rapid rate  Mechanism:  Stimulate cell proliferation and maturation to allow faster bone remodeling  AcceleDent vibratory system:  High frequency vibration (30Hz) for 20 min/day PHYSIOLOGICAL APPROACH
  • 22.   Endogenous Piezoelectric Stimulation  Prospective RCT: 45 patient , Random allocation for use of AcceleDent appliance  NiTi coil spring was attached from canine and distally to TSAD  38% (0.29mm/wk) faster tooth movement compared to control (0.21mm/wk)  Discussion:  Lack of blinding & measurement method may affect the outcome  TSAD can drift under orthodontic loading-1.5mm  Vibration may results in accelerated drift of TSAD  AcceleDent website.http//accledent.com/images/uploads/AcceleDent + increases+the Rate of Orthodontic tooth movement Results of a RCT Final for Print November 14 2011.pdf Accessed 20 May 2012 PHYSIOLOGICAL APPROACH
  • 23.   Low-Level Laser Therapy (LLLT):  Gallium-Aluminium-Arsenide Irradiation  Wavelength: 630-860 nm; Energy: 4.5-6 J/cm2  Minimally invasive, simple and safe to apply  Mechanism:  Increase in ATP at localized site - induce cells to undergo a remodeling process due to an elevated metabolic activity  Increase in vascular activity contribute to rapid turnover of bone  Evidence:  Few studies reported positive result, few no effect and some reported retarded tooth movement PHYSIOLOGICAL APPROACH  Youssef M et al. Low energy laser irradiation therapy during orthodontic tooth movement. A preliminary stud. Lasers Med Sci 2008;23:27-33  Limpanichkul et al. Effects of low laser therapy on rate of orthodontic tooth movement. Orthod Craniofac Res. 2006;9:38-43
  • 24.   Photo-biomodulation (Biolux)  Light with 800-850nm wavelength  Penetrates cheeks and soft tissues over alveolar bone  97% light lost , 3% excite intracellular enzymes and increase cellular activity in PDL and bone  Increase blood flow and may enhance tooth movement  Advantage:  Can be adjusted according to anchorage requirements PHYSIOLOGICAL APPROACH
  • 25.   Corticosteroids  PG’s  Growth Hormone  Parathyroid hormone  Active form of Vitamin D  Relaxin PHARMACOLOGICAL APPROACH
  • 26.   Prostglandins:  Mechanism:  PGE2 – an important mediator of bone remodeling under mechanical force  Increase cAMP and cGMP  Yamaseki & Harell et al:  Experiment on animal model found application of orthodontic force – increase in PG’s synthesis- stimulate osteoclastic bone resorption  Injections of PGE1 and PGE2 into gingival tissues near first molar – increase rate of tooth movement PHARMACOLOGICAL APPROACH  Yamaseki K et al. Prostaglandin as a mediator of bone resoprtion induced by experimental tooth movement in monkeys. J Dent Res. 1982;61:1444-1446
  • 27.   Protaglandins:  Clinical application:  Following LA, 0.1 ml of a 0.01% PGE1 solution in saline was injected submucosally at pressure side  Rate of canine retraction- 1.6 fold increase  Disadvantages:  Injection were repeated at weakly intervals  Severe pain after injections PHARMACOLOGICAL APPROACH  Speilmann T et al. Acceleration of orthodontically induced tooth movement through the local application of prostaglandin (PGE1). Schweiz Monatsschr Zahnmed 1989;99:162-165
  • 28.   Relaxin  Insulin family of structurally related hormone  Produced during pregnancy  Mechanism:  Increase rate of degradation of collagen (stimulate collagenase)  Increase bone resorption via increase in TNF and IL-1B secretion PHARMACOLOGICAL APPROACH  Kristiansson P et al. Does human relaxin-2 affect peripheral blood mononuclear cells to increase inflammatory mediators in pathological bone loss?.Ann N Y Acad Sci.2005;1041:317-9  Stewart Dr et al. Use of Relaxin in orthodontics. Ann N Y Ascad Sci.2005 1041:379-387
  • 29.   Vitamin D ( 1,25 Dihydroxycholecalciferol)  Vitamin D and PTH regulate the amount of calcium and phosphorus levels  Vitamin D receptors – present on osteoblasts but also in osteoclast precursors and in active osteoclasts  Collins and Sinclair et al (1988)  Intraligamentary injections of vitamin D metabolite- increase in the number of osteoclasts and amount of tooth movement during canine retraction with light forces  Stimulatory action of vitamin D on osteoblasts can help stabilize orthodontic tooth movement PHARMACOLOGICAL APPROACH
  • 30.   PDL Distraction  Rapid canine retraction through distraction of dento-alveolus  Corticotomy assisted rapid tooth movement  Corticision/Peizocision SURGICAL-ASSISTED APPROACH
  • 31.   Rapid canine retraction via PDL distraction  Mechanism:  Incorporation of a surgical cuts on interseptal bone distal to canine at the time of extraction of first premolar  Rapid canine retraction through distraction (stretching) of PDL  Pressure side: Canine-interseptal bone complex transported distally inside the socket  Tension side: PDL distraction leading to osteogenesis SURGICAL-ASSISTED APPROACH
  • 32.  PDL DISTRACTION  Procedure  At the time of extraction of 1st pm, socket is deepened to the same depth as canine with a 4mm round carbide bur  Interseptal bone is reduced to 1.0- 1.5mm  A custom made distraction appliance is delivered immediately after extraction  Rate of activation:  0.5mm-1mm/day  Liou EJ, Haung CS. Rapid canine retraction through distraction of periodontal ligament. Am J Orthod Dentofacial Orthop. 1998;114: 372-383
  • 33.   Dento-alveolar Distraction  Surgical Technique:  Mucoperiosteal flap reflected  Cortical holes made in alveolar bone curving apically to pass 3-5mm from apex  Connect the holes with tapering fissure  Large osteotomes are used to mobilize the whole segment  Distraction: after 3 days of surgery  Activation of distractor: twice/day in morning and evening  0.8mm/day  Can also be used to bring ankylosed tooth into position  Disadvantage:  Aggressive and complicated SURGICAL-ASSISTED APPROACH  Kisniscu RS et al. Dentoalveolar distraction osteogenesis for rapid canine retraction. J Oral Maxillfac Surgery 2002. 60:389-394
  • 34.   RAP  Increased rate of orthodontic tooth movement  Increased remodelling  Transient osteopenia Regional Acceleratory Phenomenon
  • 35.   Corticotomy Assisted Tooth Movement  Local injury to the alveolar process reduces resistance to tooth movement and generate RAP  Indications:  Resolve crowding and shorten treatment time  Accelerate canine retraction  Enhance post-orthodontic stability  Facilitate eruption of impacted teeth  Molar intrusion and open bite correction  Molar distalization  Kole’s technique:  Flap raised, vertical cuts facially and lingually between and under teeth that did not penetrate all the way (only cortex) SURGICAL-ASSISTED APPROACH
  • 36.   Wilcodontics  Accelerated osteogenic orthdontics (AOO)  Periodontally accelerated osteogenic orthodontics (PAOO)  Technique:  Full thickness flaps are reflected carefully beyond the apices to allow decortication around apices  Corticotomy cuts are made in the form of lines and dots  Small circular depressions are placed in facial surface of bone over maxillary anterior teeth  Bio-absorbable graft is placed (demineralized freeze dried bone)  Tooth movement- should be started after a weak  Tooth movement should be completed within 3-4 months SURGICAL-ASSISTED APPROACH
  • 37.
  • 38.   Wilcodontics  Advantages of graft:  Reduces bone dehiscence/ fenestrations especially when lower incisors are advanced  Good healing of alveolar bone SURGICAL-ASSISTED APPROACH
  • 39.   MODIFIED CORTICOTOMIES:  Micro-osteoperforation:  Screws placed in gingiva b/w interproximal alveolar bone and removed  Enough to accelerate RAP  Advantages:  Minimally discomfort  Enhanced periodontium SURGICAL-ASSISTED APPROACH
  • 40.   Piezocision:  Minimally invasive flapless procedure combining peizoelectric incisions & selective tunneling  Allows for hard and soft tissue grafting  Indications:  To resolve anterior crowding  Anterior open bite  Advantages:  Patient friendly  Less discomfort SURGICAL-ASSISTED APPROACH Park YG. Patient friendly orthodontics to accelerate tooth movement. Presented at the 23rd Annual conference of Taiwan Association of orthodontics. 2011. Taichung, Taiwan.
  • 41.   Corticision:  Aim to cut interradicular bone to 50% to 75% of the root length  Technique:  Insert sepcial surgical blade interproximally and parallel to occlusal plane 2-3 mm apical from the tip of the papilla  Tap blade with a mallet to a depth of approximately 8mm  Change the angle of the blade to approximately 45 degrees apically and tap the blade to incise to a depth of 10mm to 12mm  Apply orthodontic forces immediately  Activation every two weeks  Extra force to induce minor trauma and to extend the effect SURGICAL-ASSISTED APPROACH
  • 42.   Submucosal Injections of PRP  Autologous Platelet Rich Plasma (PRP) can simulate effects of bone surgery  PRP contain 5% RBC’s, 1% WBC’s, and 94% platelets  Platelets contain growth factors PDGF, TGF and other components that regulate and stimulate wound healing and amplify osteogenesis SURGERY SIMULATED APPROACH
  • 43.   Submucosal Injections of PRP  Technique:  0.7ml of PRP injected in labial and lingual attached gingiva from canine to canine (immediately after bonding)  Acetaminophen given to control post-injection pain  Rate of orthodontic alignment faster than controls  Liou EJ et al. Submucosal injection of platelet rich plasma accelerates orthodontic tooth movement. Am J Orthod Dentofacial Orthop (in press). SURGERY SIMULATED APPROACH
  • 44.   In general, all these techniques had draw backs and uncertainties that made them not commonly used clinically.  However, there has been a rapid increase in the interest levels of product companies to enhance orthodontic tooth movement.  These new approaches have the potential to be the next frontier for orthodontics and its resources. CONCLUSION

Editor's Notes

  1. among adults plus increasing risks of caries, gingival recession, and root resorption.
  2. Self ligating brackets have gained popularity in recent years. The first self ligating bracket the Russell attachment was introduced by Stolzenberg in 1935 to enhance clinical efficiency during ligation time. Subsequently, some other brackets were introduced such as Edgelock, Mobil-Lock, SPEED, Activa. The claim of reduced friction with self ligating brackets is often cited as primary advantage over conventional bracket system. Self ligating brackets are divided into two main categories active and passive, Active have spring clip that stores energy to press against the archwire for rotation and torque control. On the other hand the passive have a slide that can be closed which do not encroach on the slot lumen Self ligating brackets are proposed to have the potential advantages of producing more physiologically harmonious tooth movement by not overpowering the musculature and interrupting the blood supply, Therefore more AB generation, greater expansion, , less proclination of anterior teeth and less need for extractions.
  3. The use of minute direct electric current has only been used experimentally in cats. No clinical application has been reported. The direct electric current used was 7 volts and 15 MA. The anode was placed at the pressure side and cathode was placed at the tension side of the moving teeth.
  4. It has been suggested that these forces should not be continous because the peizoelectric charges are created when the stress to bone is applied and release. . Theoritically, vibration could be used to apply and release forces at rapid rate, which could create these stress induced electrical charges.
  5. A prospective RCT examined 45 patients requiring extraction of maxillary first premolar for crowding, The patients were randomly allocated to use either the AcceleDent viratory appliance for 20 min/day Although the TSAD may be expected to be a stable landmark, TSAD can drift 1.5mm under orthodontic loading which can affect the measure rate of movement.
  6. The most frequently used LLLT for the purpose of potentially accelerating tooth movement is gallium-aluminium-arsenide laser irradiation According to literature, laser is capable of activating pre-osteoclasts frm PDL to become mature but does not induce bone marrow cells to differentiate into new preostroclasts fast enough It seems that when pre-osteoclasts in the PDL comes to an end, the affect of laser in process of bone reserption is inexpressive, In this way, laser is ideally recommended only at the initial period of force application
  7. Certain enogenous agents such as inflammaatory mediators like cytokines and PG’s and hormones have been used exogenously in an attempt to accelerate tooth movement . However, only PG’s and relaxin have been tested clinically without any obvious adverse and systemic effects
  8. Prostaglandins are a group of chemical messengers belonging to a family of hormones called eicosonoids. Application of orthodontic force cause increase synthesis of PG’s which in turn stimulate osteoclastic bone turnover
  9. Few clinical studies are available. Although, local injections of PGE2 has demonstrated its clinical effectiveness in accelerating tooth movement however its clinical applications is limited
  10. Relaxin influences many other physiological processes such as collagen turnover, angiogenesis and antifibrosis. Instead of increasing bone turnover, relaxin increase the rate of degradation of extracellular fibrous connective tissue Relaxin might be used as an adjuvant to orthodontic therapy, during or after tooth movement, for promotion of stability, for rapid remodeling of gingival tissue during extraction space closure, for orthopedic expansion in non - growing patients, by reducing the tension of the stretched soft tissue envelope, particularly the expanded palatal mucosa, after orthognathic surgery.
  11. Surgical-assosted accelerated tooth movement is currently the most effective technique experimentally and clinically in accelerating tooth movement
  12. This technique is beneficial in treating adult patients in whom treatment duration is the deciding factor towards acceptance of treatment. The rate of tooth movement in adults is slower than adolescents. Two basic components are encountered during orthodontic tooth movment are PDL and AB In the initial stages of tooth movment, Young modulus (stiffness) of PDL is higher in adults leading in delay in early stages of tooth movement. However, Young modulus decreases markedly 4-7 days after application of orthodontic force and does not last through the entire period of orthodontic tooth movement.
  13. Banding and bonding are performed before extraction of first pm. A segment of Ni-Ti archwires is placed on anterior teeth for intial alignment and activation of PDL cells. The period of predistraction phase was 1-2 months. The surgery is perfomed inside the extraction socket without raising a flap The length of canine can be obtained from CBCT A custom made distraction appliance is deleivred immediately after extraction and surgical procedures. It is activated at a rate of 0.5mm-1mm/day right after the surgery until canine is distracted into desired position
  14. Transport dentoalveolar segment includes canine, the buccal cortex, underlying spongy bone that underlies canine root The palatal /lingual cortical plate and bone at the apex of canine remains intact.
  15. Frost found a diret correlation between the severity of bone corticotomy and the intensity of the healing response leadingto accelerated bone turnover at the surgical site. RAP is a temporary stage of localized soft and hard tissue remodelling that resulted in rebuilding of the injured sitesto normal state through recruitment of osteoclasts and osteoblasts vi intercellular mediator mechanisms
  16. Wilco’s technique (Wilcodontics): Accelerated osteogenic orthdontics (AOO) /periodontally accelerated osteogenic orthodontics Selective decortication in form of lines and points is performed over all the teeth to be moved A resorbable graft is placed Orthodontic tooth movement started after a weak Bone remodelling after corticotomy could be accelrated for 2-4 months
  17. Wilco’s technique (Wilcodontics): Accelerated osteogenic orthdontics (AOO) /periodontally accelerated osteogenic orthodontics Selective decortication in form of lines and points is performed over all the teeth to be moved A resorbable graft is placed Orthodontic tooth movement started after a weak Bone remodelling after corticotomy could be accelrated for 2-4 months
  18. This technique combines micro-incisions limited to the buccal gingiva that allow the use of a piezoelectric knife to give osseous cuts to the buccal cortex and initiate the regional acceleratory phenomenon (RAP)[6,7] without involving palatal or lingual cortex. The procedure allows for rapid tooth movement without the downside of an extensive and traumatic surgical approach while maintaining the clinical benefit of a bone or soft-tissue grafting concomitant with atunnel approach.
  19. This technique combines micro-incisions limited to the buccal gingiva that allow the use of a piezoelectric knife to give osseous cuts to the buccal cortex and initiate the regional acceleratory phenomenon (RAP)[6,7] without involving palatal or lingual cortex. The procedure allows for rapid tooth movement without the downside of an extensive and traumatic surgical approach while maintaining the clinical benefit of a bone or soft-tissue grafting concomitant with atunnel approach.
  20. Conrticision was introduced as a supplemental dentoalveolar surgery in orthodontic therapy to achieve accelerated tooth movement with minimal surgical intervention This manual manipulation involves the interception of llamellation process of woven bone at the incision site and provides repeated micodamage,
  21. Any procedure involving bone surgery is invasive and aggressive. How can the effects of bone surgery be simulated without surgery? Local injections of cytokines and hormones has similar effect as that of bone surgery but it is not clinically practical because of its systemic effects and need for frequent injections. PRP contain 5% RBC’s, 1% WBC’s, and 94% platelets that accelerate soft tissue healing and amplify osteogenesis Injection of PRP submucosally , the platelets first adhere and aggregate layer by layer on the surface of collagen, the extrinsic and intrinsic pathways of hemostasis intiate to generate thrombin ,platelets clots lay down layer by layer above the periosteum and then the growth factors relase and infiltrate into the periosteum gradually.
  22. Any procedure involving bone surgery is invasive and aggressive. How can the effects of bone surgery be simulated without surgery? Local injections of cytokines and hormones has similar effect as that of bone surgery but it is not clinically practical because of its systemic effects and need for frequent injections. PRP contain 5% RBC’s, 1% WBC’s, and 94% platelets that accelerate soft tissue healing and amplify osteogenesis Injection of PRP submucosally , the platelets first adhere and aggregate layer by layer on the surface of collagen, the extrinsic and intrinsic pathways of hemostasis intiate to generate thrombin ,platelets clots lay down layer by layer above the periosteum and then the growth factors relase and infiltrate into the periosteum gradually.