ACCELERATED ORTHODONTICS

CONTENTS

• INTRODUCTION
• DIRECT ELECTRIC CURRENT STIMULATION
• ENZYMATIC MICRO BATTERY
• ULTRASOUND
• LOW LEVEL LIGHT THERAPY
• PROSTAGLANDINS
• 1,25- DIHYDROXYCHOLECALCIFEROL
• PARATHYROID HORMONE
• L- THYROXINE
• RELAXIN
• OSTEOCALCIN
• SUBMUCOSAL INJECTION OF PLASMA RICH PROTEIN
• GENE THERAPY
• RAPID CANINE DISTRACTION THROUGH DISTRACTION OF PDL
• RAPID CANINE DISTRACTION THROUGH DENTOALVEOLAR DISTRACTION
• OSTEOTOMY AND CORTICOTOMY
• CORTICISION
• PIEZOCISION
• MICRO-OSTEOPERFORRATION
• REGIONAL ACCELERATORY PHENOMENON
• AOO/PAOO
• STAGES OF WOUND HEALING
• references
 INTRODUCTION
• The duration of orthodontic treatment is the primary concern
of most patients. Unfortunately, long orthodontic treatment
time poses several disadvantages like higher predisposition to
dental caries, gingival recession and root resorption.
• Therefore this increases the demand to fi nd the best method
to increase rate of tooth movement with the least possible
disadvantages.
• Conventional orthodontic procedure is slow and orthodontic
treatment times can range anywhere between 12-48 months.
By enhancing the body’s response to these forces, tooth
movement can be accelerated. Many methods are available to
accelerate tooth movement, such as surgical methods ,
mechanical/ physical stimulation methods , drugs, magnets
etc. These methods have been successfully proven to reduce
treatment times by up to 70%
 ELECTRIC CURRENT STIMULATION

• Cellular activation occurs in or through the cell membrane

which involves fluxes of ions, such as Ca2+, Mg2+, Na+, K+, Cl-
and inorganic phosphate1-3 as well as activation of the
membrane-bound enzymes adenylate cyclase and guanylate
cyclase.
• Within the membrane, these enzymes act upon their
respective substrates, adenosine triphosphate (ATP) and
guanosine triphosphate (GTP), to produce adenosine 3’, 5’-
monophosphate (cyclic AMP, CAMP) and guanosine 3’, 5’-
monophosphate (cyclic GMP, cGMP).
• These latter substances, together with Ca2+, are considered
to be the intracellular “second messengers” which mediate
the effects of external stimuli on their target cells. All three
substances serve as co-factors in enzymatic phosphorylation
reactions.
• The bulk of evidence showing that cyclic nucleotides are
involved in bone remodeling has emerged from experiments.
• The average increase in cAMP level (+60 per cent) suggested
that mechanical forces may not be optimal bone and PDL cell
activators.
• That observation supported assumptions by clinical researchers
who had thought that orthodontic tooth movement might be
enhanced by supplementing the mechanical forces with other
agents capable of affecting bone cells that could accelerate
orthodontic tooth movement is like electricity .
• Since the early observation of Fukada is that electric potentials
are generated by the application of force to bone, many
investigators used external electricity to enhance osteogenesis
(for instance, in fractured bones in experimental animals and
man) It was demonstrated that when electrodes are placed into
bone osteogenesis will occur around the negative electrode.
• Osteogenesis has been found to occur in response to the
application of electric currents to bone.
• Direct current : 7 volts & 15 microamperes
• Anode : pressure side; Cathode: tension side
• Degree of bone formation and resorption at electrically
treated pressure & tension side was higher
 ENZYMATIC MICRO BATTERY

• An enzymatic micro-battery, which is placed on the gingiva

near the alveolar bone, might be a possible electrical power
source for accelerating orthodontic tooth movement.
• These devices use organic compounds (glucose) as the fuel,
are noninvasive, and are not osseointegrated .
• After application of dc in this fashion, the electric device can
be easily re- moved. Due to the very small size of these
devices, the procedure can be done with no tissue injury.
DISADVANTAGES
• Short life time
• Poor power density
 ULTRASOUND

• Low-intensity pulsed ultrasound (LIPUS) stimulation is a

clinically established, widely used and FDA approved
intervention for accelerating bone growth .

• LIPUS which generally uses frequencies varying between 0.5 -

1.5 MHz frequency pulses (with a pulse width of 200 µs) and
intensity output of 30 mW/cm2 ,5-20 minutes per day.
• LIPUS is a form of physical energy that can be delivered into
living tissues as acoustic intensity waves.

• LIPUS accelerates the differentiation pathway of

mesenchymal stem cells in the osteogenic lineage via
activated phosphorylation of MAPK (mitogen-activated
protein kinase) pathways, up-regulation of cyclo-oxygenase-2
(COX-2), prostaglandin E2 (PGE2), altering the OPG/RANKL
ratio in the microenvironment , and stimulating the
production of bone morphogenetic protein
•It has also been shown that LIPUS stimulation accelerates
OTM by increasing osteoclast number and activity, probably by
enhancing the expression of RANKL on the pressure sites.
• Studies have hypothesized that resonance vibration might
prevent blood flow obstruction and hyalinization at the
compression sites.
 LOW LEVEL LIGHT THERAPY

• Photobiomodulation (PBM), also known as low-level light

therapy (LLLT), attempts to use low energy lasers or light-
emitting diodes (LED) to modify cellular biology by exposure
to light in the red to near-infrared (NIR) range (600–1000 nm)
• At the cellular level, NIR exposure is thought to activate the
primary mitochondrial photoacceptor of light, cytochrome c
oxidase (COX). COX activation results in various cellular
responses, including increased mitochondrial ATP production.
Increased ATP levels may accelerate bone remodeling through
overall elevation of metabolic activity. LLLT may also promote
angiogenesis, increasing the blood supply necessary for
remodeling.
Shaughnessy et al: 2016
• Study conducted with orthodontic 19 subjects.

•The PBM device exposed the buccal side of the gums to near-
infrared light with a continuous 850-nm wavelength, generating an
average daily energy density of 9.5 J/cm2.

•Patients received an average of 3.8 min of buccal-only treatment

per arch per day, using an average power density of 42 mW/cm2

•Findings suggest that intraoral PBM could be used to decrease

anterior alignment treatment time, which could consequently
decrease full orthodontic treatment time.
 LOW INTENSITY LASERS

• The term "laser" originated as an acronym for "light

amplification by stimulated emission of radiation".
• It is a device that emits light through a process of optical
amplification based on the stimulated emission of
electromagnetic radiation.
• The low-intensity laser (also known as soft laser, cold laser or
laser therapy) does not have a destructive potential.
• Its photobiomodulation mechanism of action penetrates
tissues and stimulates cellular metabolism, bone remodeling
and tooth movement
• Biomodulatory effects of laser are based on Arndt–Schulz law.
According to this law, a small dose of any substance/drug has
a stimulating effect, whereas higher dose is inhibitory.

• Different low-energy laser modalities have been used in

different doses and in various treatment protocols, including
helium-neon (632.8 nm wavelength) and semiconductor
lasers (emitting light in the range of 780–950 nm), gallium-
aluminum -arsenide (GaAlAs) (805 ± 25 nm wavelength) and
gallium-arsenide (904 nm wavelength).

• LILT Increases ATP at localized site of application and induces

cells to undergo a remodeling process due to an elevated
metabolic activity. Increase in vascular activity contribute to
rapid turnover of bone.
LOCAL ADMINISTRATION OF BIOMODULATORS
 PROSTAGALDINS

• Prostaglandins (PGs) are an interesting group of

multifunctional regulators during orthodontic tooth
movement. These lipids are synthesized by arachidonic acid by
the sequential actions of cyclooxygenase (COX) and respective
synthases.
• PGs are released in response to various stimuli and have
multiple physiological effects, two of which include the
amplification of the effects of cytokines and bone metabolism,
largely due to COX-2 induction.
• PGs have the ability to recruit inflammatory cells and enhance
the expression of inflammation-related genes.
• Furthermore, they can either facilitate or suppress tissue
remodeling and regulate bone metabolism, stimulating both
bone resorption and deposition.

• Among the PGs that had been found to affect bone

metabolism (E 1 ,E 2 , A 1 and F 2α ), PGE 2 is the one that
stimulates osteoblastic cell differentiation and new bone
formation, coupling bone resorption in vitro.
• Local submucosal injections of PGE 1 in patients were also
successful in accelerating orthodontic tooth movement by
1.6-fold .
• Orthodontic tooth movement is impaired by nonsteroidal
anti-inflammatory drugs, the compounds that inhibit the COX-
1 and COX-2 enzymes that catalyze the rate-limiting step of PG
formation
• The main side effect associated with local injection of PGs is
hyperalgesia, due to the release of noxious agents such as
histamine, bradykinin, serotonin, acetylcholine and substance
P, from nerve endings both peripherally and centrally
 1,25-DIHYDROXYCHOLECALCIFEROL

• Another agent that has been identified as an important factor

in orthodontic tooth movement is 1,25-
dihydroxycholecalciferol (1,25-DHCC).
• This agent is a biologically active form of vitamin D and has a
potent role in calcium homeostasis.
• A decrease in the serum calcium level stimulates secretion of
PTH, which in turn increases the excretion of PO4 -3,
reabsorption of Ca 2+ from the kidneys, and hydroxylation of
25hydroxycholecaliferol to 1,25-DHCC.
• The latter molecule has been shown to be a potent stimulator
of bone resorption by inducing differentiation of osteoclasts
from their precursors.
• It is also implicated in increasing the activity of existing
osteoclasts. In addition to bone-resorbing activity, 1,25-DHCC
is known to stimulate bone mineralization and osteoblastic
cell differentiation in a dose-dependent manner.
 PARATHYROID HORMONE
• Parathyroid hormone (PTH) is the major hormone regulating
bone remodeling and calcium homeostasis. By increasing the
concentration of calcium in the blood, it stimulates bone
resorption.
• The effect of PTH on orthodontic tooth movement has been
studied in rats.
• A significant stimulation of the rate of orthodontic tooth
movement by exogenous PTH administration appeared to
occur in a dose-dependent manner.
• However, this effect was only visible when the hormone was
more or less continuously applied, either by systemic infusion
or frequent local delivery

• It is well known that chronic elevation of PTH leads to

pathological changes in multiple organs,especially the kidneys
and bones
• Thyroid hormones play an imperative role in the regulation of
cellular metabolism, proliferation and differentiation.
 L -THYROXINE

• L -Thyroxine is a synthetic thyroid hormone that is chemically

identical to thyroxine, which is naturally secreted by the
thyroid gland.

• The possible effect of L-thyroxine on orthodontic tooth

movement has also been examined in a relevant study on
rats. The results showed that administration of 20 μg/kg
i.p./day L -thyroxine significantly increased the amount of
orthodontic tooth movement.
• The extent of root resorption as seen from scanning electron
micrographs appeared to decrease with thyroxine
administration.

• Because of the fact that thyroxine medication can lead to

osteoporosis, the seriousness of safety issues regarding its use
for orthodontic purposes is quite high.
 OSTEOCALCIN
• Osteocalcin (OC) is the most abundant noncollagenous matrix
protein in bone .
• Because of its strong capacity to associate with Ca 2+ and
hydroxyapatite, OC is a negative regulator for mineral
apposition and bone formation .
• In addition, OC is proposed to be a chemoattractant for
progenitor/mature osteoclasts .
• In studies in rats, it was demonstrated that local injections of
purified rat OC accelerated the rate and increased the total
amount of tooth movement. Histological examination
revealed that this acceleration of tooth movement was
caused by an enhanced recruitment of osteoclasts.
 RELAXIN
• Relaxin is a hormone in the insulin/relaxin family of
structurally related hormones.

• Relaxin was shown to have a role in connective-tissue

regulation by enhancing collagen turnover.25 In-vitro data
show that relaxin disorganizes and loosens the arrangement
of the PDL from the tooth to the bone surface, and dissolves
Sharpey's fiber insertions of the PDL.26 These relaxin effects
might weaken the mechanical strength of the PDL, resulting in
a more fragile and looser PDL over the short term.
 GENE THERAPY
• Animal studies demonstrated that transfer of RANKL gene to
periodontal tissue activated osteoclastogenesis and
accelerated OTM without producing any systemic effects.
• Local OPG gene transfer significantly inhibited RANKL-
mediated osteoclastogenesis in the periodontium caused by
experimental tooth movement.
 RAPID CANINE DISTRACTION THROUGH
DISTRACTION OF PDL

• The process of osteogenesis in the periodontal

ligament during orthodontic tooth movement
is similar to the osteogenesis in the midpalatal
suture during rapid palatal expansion.
• A concept of “distracting the periodontal
ligament” is proposed to elicit rapid canine
retraction in 3 weeks. It is called dental
distraction.
• Fifteen orthodontic patients (26 canines, including
15 uppers and 11 lowers) who needed canine
retraction and first premolar extraction were
included.
• At the time of first premolar extraction, the
interseptal bone distal to the canine was
undermined with a bone bur, grooving vertically
inside the extraction socket along the buccal and
lingual sides and extending obliquely toward the
socket base.
• Then, a tooth-borne, custom- made, intraoral distraction
device was placed to distract the canine distally into the
extraction space. It was activated 0.5 to 1.0 mm/day
immediately after the extraction. The anchor units were the
second premolar and first molar.
• Both the upper and lower canines were distracted bodily 6.5
mm into the extraction space within 3 weeks.
• New alveolar bone was generated and remodeled rapidly in
the mesial periodontal ligament of the canine during and after
the distraction. It became mature and indistinguishable from
the native alveolar bone 3 months after distraction.
 RAPID CANINE RETRACTION THROUGH DENTO-ALVEOLAR
DISTRACTION

Technique:
• Mucoperiosteal flap reflected.
• Cortical holes made in alveolar bone from canine to 2nd pm
curving apically to pass 3-5mm from apex.
• Holes were connected with stainless steel round bur.
• First premolar is extracted and buccal cortical bone removed
with preservation of palatal cortical shelves and the
interdental bone.
• Fine osteotomes were used along the mesial aspect of the
dentoalveolar segment to split the surrounding spongy
bone around its root off of the palatal cortex and neigh-
boring teeth.
• Two days latency period was observed, and then the
distractor was activated. Rate of distraction was 0.5
mm/day with the rhythm of distraction being 4 times a
day.
• Can also be used to bring ankylosed tooth into position
Disadvantage:
• Aggressive and complicated
 OSTEOTOMY AND CORTICOTOMY

• Osteotomy- surgical cut through both cortical and medullary

bone.
• Corticotomy -Barry N. Fitzpatrick (1979)
• Linear cutting of the cortical plates about a tooth or groups of
teeth, provides mobilization compatible with a dramatic
shortening of the orthodontic treatment time
• Corticotomy relies entirely on a direct medullary blood flow to
ensure vitality of the dental pulp and for this reason is not
recommended where there are large lateral,antero-posterior,
or vertical movements of the teeth
• Surgical access to the cortex on each side of the tooth is required
in corticotomy and is achieved by full gingival flaps; this deprives
the bone and teeth of the vascular input from the periosteum and
muscle and places complete reliance on medullary blood flow.
• In this vascular sense the procedure is thus safer in the maxilla
and perhaps should only be considered in patients aged less than
20 years.
Kole’s technique: (1959)
• Flap raised, vertical cuts facially and lingually between and under
teeth that did not penetrate all the way (only cortex)
• Reduce resistance enhances en bloc movement of entire alveolar
segment
 CORTICISION
• corticision- a reinforced scalpel is used as a thin chisel to
separate the interproximal cortices transmucosally, without a
flap reflection.
• The armamentarium involves a reinforced scalpel (No. 15T)
and an ordinary scalpel holder as well as a surgical mallet.
• After infiltration anesthesia, position the scalpel on the
interradicular attached gingiva at an inclination of 45–60° to
the long axis of the tooth to be moved, and insert it gradually
into the bone marrow by tapping the scalpel holder with the
surgical mallet, passing through the overlying gingiva and
cortical bone, and into the cancellous bone.
• The vertical cut leaves 5 mm of the papillary gingiva to avoid
bone loss of the alveolar crest and consequent development
of the ‘black triangle’ and damage of the adjacent dental root.
• The depth of alveolar penetration with the scalpel is about 10
mm for the sake of beneficial cancellous bone osteotomy,
which is expected to generate new blood vessels and enhance
trabecular bone remodeling.
• Since the length of the vertical cut in the interradicular
attached gingiva is not necessarily the entire root length, 2/3
of the root length is sufficient to evoke rapid tooth
movement.
• After the Corticision receives its sufficient vertical cut, pull out
the scalpel with a gentle swing motion
 PIEZOSICION
• Minimally invasive procedure.
• This approach combines microincisions to the buccal gingiva
that allow for the use of the piezoelectric knife instead of
scalpel and mallet to decorticate the alveolar bone to initiate
the regional acceleratory phenomenon.
• Although it is minimally invasive, it also has the advantage of
allowing for hard-tissue or soft-tissue grafting via selective
tunneling to correct gingival recessions or bone deficiencies in
patients
 MICRO-OSTEOPERFORATIONS

Microperforation:
• Perforations placed in gingiva between interproximal alveolar bone and
removed
• Enough to accelerate RAP
•1.5mm width and 2 to 3 mm average depth
REGIONAL ACCEELRATORY PHENOMENON
• HAROLD FROST 1983
• It is a tissue reaction to a noxious stimulus that increases the
healing capacities of the affected tissue.
• There is an increased activation of the basic multicellular units
in alveolar bone at cellular level.
• It is characterized by production of woven bone with the
typical unorganized pattern that will later be reorganized into
lamellar bone at later stage.
 PAOO/AOO- wilcko(1995)
Regional acceleratory phenomenon- HAROLD FROST(1983)
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 were placed in facial surface of bone over
maxillary anterior teeth
• Bio-absorbable graft is placed (0.25 to 0.5 ml)
• Tooth movement- should be started after a week
• Tooth movement should be completed within 3-4 months
Advantages of graft:
• Reduces bone dehiscence/ fenestrations especially when
lower incisors are advanced
• Good healing of alveolar bone
 STAGES OF WOUND HEALING
• INFLAMMATORY STAGE: The inflammatory stage begins the
moment the tissue injury occurs and lasts for 3-5days. It has
vascular and a cellular phase.

• FIBROBLASTIC STAGE: Strands of fibrin derived from the blood

coagulation, forms latticework on which fibroblasts are laid.
Fibrblasts produce tropocollagen which undergoes cross linking
to produce collagen.

• REMODELLING STAGE: This is the final stage of wound repair.

Previously laid collagen is replaced by new collagen fibres
oriented in a such a way to resist forces on the wound
 SUBMUCOSAL INJECTIONS OF PRP
• Autologous platelet rich plasma can simulate the effects
induced by bone surgery
• Platelets contain growth factors that regulate and stimulate
wound healing and amplify osteogenesis
Technique:
• 0.9ml of LA injected in the labial and lingual mucosa of anterior
teeth
• 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
• The rate of orthodontic alignment was faster than compared to
controls
 references
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• SURGICAL OPERATIONS ON THE ALVEOLAR RIDGE TO CORRECT OCCLUSAL
ABNORMALITIES Heinrich Kole, M.D., Gmz, Austria