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Acceleration of Tooth Movement in Orthodontics: A Review of Literature

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6 International Medical Journal Vol. 28, Supplement No. 1, pp. 6 - 10 , June 2021
DENTISTRY

Acceleration of Tooth Movement in Orthodontics: A Review of

Literature

Nuha F. Abbas1), Noor R. Al-Hasani2), Ali I. Ibrahim3)

ABSTRACT
Objectives: The demand for orthodontic treatment is nowadays increasing significantly for aesthetic improvement and to
correct various kinds of malocclusion, yet the prolonged treatment time remains the main obstacle. This review aimed to demon-
strate various orthodontic techniques and highlight the evidence-based successful approaches used for acceleration of orthodon-
tic tooth movement.
Materials and Methods: Data and sources of information pertaining to accelerated orthodontic tooth movement premised on
English-written articles were searched using electronic databases including Google Scholar, Scopus, PubMed and MEDLINE.
Results: This review demonstrated the availability of different surgical and non-surgical methods to enhance tooth move-
ment, with a wide range of advantages and disadvantages.
Conclusions: Although literature is replete with accelerating techniques, there are still uncertainties and unanswered ques-
tions towards most of these techniques and, hence, further research is needed to support the evidence for the enhancement of
orthodontic tooth movement.

KEY WORDS
tooth acceleration, orthodontic treatment, enhanced orthodontic movement

INTRODUCTION dence-based successful techniques used for acceleration of orthodontic

tooth movement, and evaluate the hard and soft tissue responses to the
various methods advocated in the literature.
Orthodontic treatment is often described as a lengthy procedure
since the average time for a successful orthodontic treatment ranges
between 18 to 24 months1). Prolonged orthodontic treatment involves PERIODONTAL AND BONE RESPONSE TO OTM
many disadvantages such as psychosocial effects on the patients, white
spot lesions, permanent enamel damage, gingival recession, and root
resorption2,3). Therefore, methods of accelerating orthodontic tooth During OTM, many changes occur in the tooth supporting tissues
movement (OTM) aim at shortening the treatment duration and mini- depending on amount, direction, and duration of the force applied, as
mizing these adverse effects. well as the age and growth status of the patient. The orthodontic treat-
Researchers have examined whether it is feasible to move a tooth ment is based on the principle that if prolonged light pressure is applied
faster than rates achieved by using conventional methods. Most attempts to a tooth, tooth movement occurs as the bone around the tooth remod-
to accelerate tooth movement can broadly be categorized into surgical els. The bone is selectively removed in some area (compression site)
and non-surgical approaches4). An increase in knowledge and develop- and added to other areas (tension site) resulting in tooth movement.
ment of the alveolar topography has been the main aid in acceleration of Because bone response is mediated by periodontal ligament, tooth
orthodontic tooth movement. Corticotomies and multiple tooth osteoto- movement is primarily a periodontal ligament (PDL) phenomenon
mies have been the main surgical ways to assist rapid tooth movement5). expressed by alterations in blood flow through PDL as the flow decreas-
Other surgical methods include micro-osteoperforations, piezocision, es on the compression side and increases on the tension side (Figure 1)8).
and periodontal ligament (PDL) distraction. Although many surgical The use of a light force is valuable as the application of excessive forces
techniques have shown to yield promising outcomes, the limited appli- causes pressure on the PDL and investing bone leading to diminished
cation was due to their invasiveness6,7). blood supply and bone necrosis9). This is followed by delayed tooth
Non-surgical methods include the use of self-ligating brackets, med- movement for few weeks until osteoclastic differentiation within adja-
ications, microvibrations, low-intensity laser, photobiomodulation, elec- cent bone marrow space induces "undermining resorption" that removes
tromagnetic fields, and direct electrical currents7). Debate is ongoing the lamina dura next to the compressed PDL10)
whether surgical or non-surgical methods are clinically effective in pro-
ducing faster rates of OTM as compared with the conventional tech-
niques. Therefore, this paper aims to review and highlight the evi-

Received on March 31, 2021 and accepted on April 30, 2021

1) Dentist at Ministry of Health
Baghdad, Iraq
2) Lecturer, Dept. of Basic Sciences, College of Dentistry, University of Baghdad
Baghdad, Iraq
3) Professor, Dept. of Orthodontics, College of Dentistry, University of Baghdad
Baghdad, Iraq
Correspondence to: Ali I. Ibrahim
(e-mail: [email protected])

C 2021 Japan University of Health Sciences

& Japan International Cultural Exchange Foundation
 Abbas N. F. et al. 7

RATE OF ORTHODONTIC TOOTH MOVEMENT bers of PGE2 alone caused root resorption, while the administration of
PGE2 with calcium stabilized root resorption with acceleration of
OTM22,23).
Research has shown that the rate of biological tooth movement fol- D) Parathyroid Hormone (PTH) is secreted by parathyroid gland
lowing an optimal mechanical force application is about 1.0 - 1.5 mm in and plays a significant role in influencing bone remodeling and serum
4 - 5 weeks12). Tooth movement can occur at different rates and individu- calcium level; by increasing the concentration of calcium in the blood, it
als show different responses to treatment depending on many factors stimulates bone resorption16). It has been shown that it is more advanta-
including magnitude and duration of force, quality of bone trabeculae, geous to administer PTH locally than systemically as local injection
patient age, number and shape of roots and type of tooth movement. The causes local bone resorption, and the slow-release application is effi-
response to orthodontic force is expected to be delayed in elderly cient as this keeps the local concentration of PTH for a long time.
patients compared to growing children due to the less dense alveolar Chronic elevation of PTH leads to pathological effects on the kidneys
bone and more cellular PDL in the children13). In addition, teeth in the and bones; consequently, the safety and efficiency of this factor in
maxillary arch are more responsive to orthodontics than those of the accelerating orthodontic movement need to be further investigated16).
mandible because the maxilla is primarily composed of trabecular bone, E) Thyroxin and Calcitonin are hormones released by thyroid
which exhibits faster resorption than dense cortical bone. The rate of gland, which play an important role in regulation and reabsorption of
tooth movement is also affected by the type of movement as teeth move calcium. It has been demonstrated that locally injected Thyroxin
faster by tipping than by translation14). increased the rate of tooth movement by activating osteoclasts18).
F) Relaxin is a naturally occurring hormone with a primary func-
tion of widening the pubic ligaments during childbirth and has many
METHODS OF ACCELERATION OF OTM other functions such as collagen turnover, angiogenesis and anti-fibrosis
effects. It is thought that relaxin might accelerate orthodontic tooth
movement through inducing alterations in the PDL24). Local administra-
tion of human relaxin in rats accelerated OTM rate, but at the expense
of inducing changes in the level of PDL organization and reducing its
Non-surgical methods for the acceleration of OTM mechanical strength with a marked increase in tooth mobility16).
These techniques have always been preferred by both the clinicians G) 1,25 dihydroxycholecalciferol (Vitamin D3 or Calcitriol) is a
and the patients. All these approaches have shown acceptable outcomes biologically active form of vitamin D and plays an important role in cal-
with varying degrees of success. cium homeostasis25). The first in vivo study to examine the effect of
locally injected calcitriol in accelerating OTM was conducted on
humans by accelerating canine distalization. On clinical efficacy basis,
1. Biological approach the dose of 25 pg calcitriol produced about 51% faster rate compared to
control side, while each of the 15 pg and 40 pg doses resulted in about
This includes chemical substances, neurotransmitters, and medica- 10% accelerated OTM. In addition, the periapical radiographs did not
tions. Many of these factors have been involved in OTM acceleration show any damaging effect of calcitriol to the surrounding tissues22). A
research and the effect of their local and/or systemic administration has comparison between local injection of vitamin D and PGE2 in two dif-
been tested, mainly in animal models, with variable results. ferent groups of rats showed no significant difference in acceleration
between the two agents. However, the number of osteoblasts on the
pressure side in the group injected with vitamin D was greater than in
I) Systemic/Local Administration of Biological Substances and Hormones the PGE2 group. This indicates that vitamin D may be more effective in
bone turnover26).
These factors work by stimulating the activity of osteoclasts either
indirectly, by stimulating the expression of RANKL on osteoblasts, or II) Neurotransmitters
directly by affecting osteoclast and osteoblast functions. However, these
factors are rapidly flushed by blood circulation so daily systemic admin- The neurons originating from trigeminal ganglion supply dental and
istration or daily injection is needed, necessitating several doses per periodontal tissues. These neurons contain many neuropeptides such as
day15). These factors include:- substance P, Calcitonin gene-related peptide (CGRP) and vasoactive
intestinal polypeptide (VIP); all these neurons are passive under neutral
A) Epidermal Growth Factor (EGF) is a small polypeptide growth conditions. Mechanical force application during orthodontic treatment
factor found in a variety of tissues (kidney, submandibular glands) and induces the release of active proteins, which in turn cause local inflam-
body fluids (saliva, amniotic fluid) that primarily stimulate proliferation mation and release of these neuropeptides18). These neuropeptides can
and differentiation of epithelial and mesenchymal cells15). It has been increase the vascular permeability and affect the bone remodeling
demonstrated that EGF has catabolic effects on bone. An organ culture directly20).
study found that administrating a high dose of EGF to rats caused an
elevation of osteoclahstic cell density on the trabecular bone surface and
stimulated bone resorption16). Local injection of EGF (encapsulated in III) Medications
liposomes) into the root furcation region of the maxillary left first molar
after elastic band insertion induced greater osteoclasts recruitment15). The medications that influence OTM are divided into four main cat-
B) Cytokines are soluble, small proteins that are produced by egories:-
immune system cells, which modulate the cellular activity and play an
important role in the bone remodeling processes in vivo17). The inflam- A) Non-steroidal anti-inflammatory drugs (NSAIDs) are used to
matory cells that produce cytokines are osteoblast, fibroblast, endotheli- overcome the pain and discomfort following application of mechanical
al cells and macrophages18). Cytokines, particularly Interleukin-1 alpha force to the teeth during orthodontic treatment. The mechanism of
and 1 beta, Tumor Necrosis Factor, Gamma Interferon have been impli- action of these drugs is inhibition of the prostaglandins (PGs) synthesis
cated in the mediation of bone remodeling process in vitro19). The first since the latter are responsible for hyperalgesia. Although chemically
experimental evidence was that after the application of a tipping force, disparate, they produce therapeutic effects by ability to inhibit the activ-
Interleukin --- 1 was found in the periodontal tissues of cat canine teeth. ity of Cyclooxygenase enzymes (COX-1, COX-2)27). Many studies were
RANKL, which is a membrane-bound protein on the osteoblasts, is a conducted to investigate the effects of NSAIDs on OTM, with the con-
cytokine involved also in the acceleration of OTM that binds to the sistent findings of reducing the rate of OTM. However, these effects
RANK on the osteoclasts and causes osteoclastogenesis20). were premised on short-term administrations; moreover, the results var-
C) Prostaglandins are lipid autacoids synthesized by arachidonic ied depending on the dose and frequency of administration of these
acid by the action of cyclooxygenase (COX)21). drugs18). It has been reported that the NSAIDs slow the tooth movement
Prostaglandin E is one of the most widely studied agents in animal because they inhibit the inflammatory reaction produced by PGs. The
and clinical models, which reported that prostaglandin E1 (PGE1) and whole process is controlled by inhibition of cyclooxygenase (COX)
prostaglandin E2 (PGE2) stimulated bone resorption, directly acting on activity, leading to altered vascular and extravascular matrix remodel-
osteoclasts22). Previous studies have shown that injections of exogenous ing, causing a reduction in the rate of tooth movement28).
PGE2 over an extended period of time accelerated OTM. However, it B) Acetaminophen (Paracetamol) is not involved under NSAIDs
was found that the local injection of different concentrations and num- and lacks anti-inflammatory effects, though it has almost a similar
8 Acceleration of Tooth Movement in Orthodontics

the formation of new bone is slowed in a treated patient, they decrease

the stability of both tooth movement and orthodontic treatment out-
come28).
D) Bisphosphonates (BPNs) have a direct effect on calcium homeo-
stasis and bone metabolism. Studies have shown that BPNs have an
inhibitory effect on orthodontic tooth movement, thus delay the tooth
movement. On the other hand, topical application of BPNs could be
helpful in anchoring and retaining teeth under orthodontic treatment28).

2. Device-assisted treatment

This depends on the idea that applying orthodontic forces causes

bone bending and a bioelectrical potential develops. This approach
includes:-

A) Direct light electric current. It has been demonstrated that elec-

tric current application (about 20 μA for 5 h daily) was capable of accel-
erating orthodontic tooth movement. It was reported that external elec-
tricity enhances osteogenesis around the negative electrode when the
current level is between 5 and 20 μA, while resorption of bone may
occur around the positive electrode (anode)16). However, the use of this
method is less popular than other methods as the existing evidence is
insufficient to support whether electrical current could be effective in
accelerating OTM with safety in humans.
B) Low level laser therapy (LLLT). The advantages of this meth-
od are non-invasiveness, ease of use, and localized action. Studies have
shown that LLLT increases osteoblastic activity, vascularization, and
organization of collagen fibers29). It enhances the proliferation of osteo-
clasts, osteoblasts and fibroblasts, thus affects bone remodeling and
Figure 1: Biological response to orthodontic force11). accelerates tooth movement by the production of ATP and activation of
cytochrome C. Aluminum-gallium-arsenide (Al-Ga-As) diode lasers are
most currently used for these interventions and have a deep tissue pene-
tration in comparison to other modalities, hence providing the clinicians
with a suitable penetrative instrument with great efficiency and minimal
side effects16).
A recent clinical study showed that the laser wavelength in a contin-
uous wave mode at 800 nm with an output of 0.25 mW and exposure of
10 s accelerated tooth movement at 1.3 fold30). However, more research
is needed to establish the most efficient protocol that would enhance the
effect and reduce the frequency of irradiation sessions.
C) Resonance vibration. The application of resonance vibration
(60 Hz) to the first molars in rats for 8 minutes per a week during ortho-
dontic movement increased tooth movement by 15% compared with the
controls by stimulating expression of RANKL and osteoclastic differen-
tiation in the PDL. There was no collateral damage to the periodontal
tissues or root resorption of the treated teeth due to the natural frequen-
cy of the vibration applied31). In another study, the combination of light
orthodontic force with vibratory stimuli using an electric toothbrush
Figure 2: Corticotomy cuts10). enhanced secretion of IL-1β in gingival crevicular fluid, bone resorption
activity, and accelerated tooth movement32). However, the use of ultra-
sonic vibration was associated with certain hazards as it may cause ther-
mal damage to the dental pulp16).
D) Static or pulsed magnetic field. Histological analyses have
shown that magnetic fields influence and activate the alveolar bone
remodeling. Hyalinization in the PDL was decreased in the presence of
static magnetic field, which also contributed to accelerated tooth move-
ment16). In a study conducted on 10 orthodontic patients who needed
canine retraction, the canines were exposed to a pulsed electromagnetic
field (1 Hz) after extraction of first premolars, canine retraction was
accelerated 1.57 ± 0.83 mm more than the control group33). However,
another study showed that the magnetic Field increased root resorption
of the treated teeth and increased width of the PDL, raising concerns
about the effectiveness and safety of this method34).

SURGICAL METHODS FOR THE ACCELERATION

Figure 3: Micro-osteoperforations through alveolar bone7)
OF OTM

These techniques are clinically effective and have been used for
chemical structure. Studies have shown that there is no significant adult patients, as the bone turnover increased after bone grafting, frac-
adverse effect of paracetamol on rate of OTM, hence, it can be consid- ture, and osteotomy. These techniques include:-
ered as the most commonly used and safe drug for pain management
during orthodontic treatment18). Inter-septal alveolar surgery. This surgical approach is called dis-
C) Corticosteroids have been shown to have an inhibitory effect on traction osteogenesis, which involves distraction of PDL or distraction
bone formation. They may increase tooth movement rate, and because of the dentoalveolar bone. For rapid canine retraction (after the
extraction of the first premolar), the interseptal bone distal to the canine
 Abbas N. F. et al. 9

is undermined 1 to 1.5 mm in thickness and the socket is deepened to been tested in different studies. Kawasaki and Shimizu (2000) reported
the length of the canine. The retraction of the canine is carried out by that orthodontic movement of low-intensity laser-irradiated rat teeth was
the activation of an intraoral device directly after the surgery. In this 30% faster than that of the teeth in a control non-irradiated group of
concept, the compact bone is replaced by the woven bone and tooth rats41). Clinical studies in humans have also revealed a significantly posi-
movement is easier and quicker due to the reduced resistance of the tive effect of low-intensity laser radiation on the acceleration of
bone35). It has been reported that this technique accelerates tooth move- OTM39,42) However, more research is needed to establish the most effi-
ment without causing significant root resorption, ankylosis or root frac- cient protocol that would enhance the effect and reduce the frequency of
ture. However, some results showed concerns regarding the vitality of irradiation sessions.
the retracted canines after six months of retraction35). The surgical approach provides favorable long-term effect and can
Osteotomy and corticotomy. Osteotomy is defined as a surgical be utilized in a regular clinical setup without the need for general anes-
cut involving both the cortical and trabecular bones. Corticotomy, on the thesia. Surgical intervention or corticotomy was successfully used for
other hand, is a surgical cut (Figure 2) through the cortical bone only, rapid canine retraction without increasing the risk of root resorption and
perforated or mechanically altered in a controlled surgical manner36). localized osteoporosis5). Nevertheless, the invasive nature of these tech-
The surgical cuts are conducted by using micromotor under irrigation, niques, possible injury to vital tissues, and the cost limited their popular
or piezosurgical instruments30). use. Corticotomy complications include whitening of the gingiva after
In a study that involved surgical holes technique for canine distal- reflection of large flaps and fenestration of incisor roots after labial
ization, it was shown that the corticotomy-assisted canine distalization movement of these teeth, which may take place even after placing par-
demonstrated 42.6% greater net canine distalization than the non-surgi- ticulate bone grafts. The invasiveness of the corticotomy procedures
cal side5). It has been reported that traditional vertical and horizontal constituted a serious drawback for their widespread acceptance among
osteotomies impose an increased risk of postoperative tooth devitaliza- orthodontists and patients. Therefore, more conservative flapless corti-
tion or even bone necrosis, depending on the severity of injury to the cotomy-restricted techniques are recommended10). It has also been
trabecular bone. There is also an increased risk of periodontal damage, reported that vertical and horizontal osteotomies increase the risk of
mainly in cases in which the interradicular space is less than 2 mm36). postoperative tooth devitalization or even bone necrosis, depending on
Corticotomy is one of the most common surgical procedures that is used the severity of injury to the trabecular bone. There is also an increased
to reduce orthodontic treatment time as the surgical cut through the cor- risk of PDL damage, mainly in cases in which the interradicular space is
tical bone rather than medullary bone reduces the resistance of the corti- less than 2 mm39).
cal bone and accelerates tooth movement. Piezoincision seems to be less discomforting method compared to
Piezocision. Piezocision-assisted orthodontics is an innovative, other surgical procedures and this might render them more commonly
minimally invasive surgical procedure designed to accelerate OTM used procedures in future35). However, evidence is needed to investigate
while correcting/preventing mucogingival defects by adding bone and/ its suitability for different age groups and examine the potential long-
or soft tissues36). Advantages are minimum invasiveness and better term side effects. The piezocision procedure that initiates the regional
patient compliance. Disadvantages are risks of damaging roots, as inci- acceleratory phenomenon may increase the iatrogenic root resorption
sions and corticotomies are conducted blindly30). when used in conjunction with orthodontic forces. Piezocision applied
Micro-osteoperforations (MOP) (Figure 3). In a single center, close to the roots may cause iatrogenic damage to the neighboring roots
single-blinded study to investigate this procedure on humans, it was and should be used with caution43).
found that MOPs significantly increased the rate of canine retraction 2.3 Finally, more studies and investigations on humans are mandatory
fold compared to the control group by increasing the expression of cyto- to understand all aspects and nature of mechanisms behind the accelera-
kines and chemokines, which are known to recruit osteoclast precursors tion of OTM by either enhancing the effectiveness of existing methods
and stimulate osteoclastic differentiation37). or developing new techniques with a higher clinical efficiency, lowest
side effects, cost-benefit and more comfortable to the patient.

DISCUSSION
CONCLUSIONS
Nowadays, the majority of orthodontic patients are demanding for a
safer and shorter orthodontic treatment duration, especially when con- 1. Successful finishing of orthodontic treatment within a short peri-
sidering adult orthodontics38). Success achieved from foremost trials od of time is still a relatively new horizon. Decisions on which method
encouraged the development of various surgical and non-surgical tech- to be used depend largely on the orthodontist's preference, patient's
niques, with emphasis to minimize the adverse effects. acceptance and willingness; taking into consideration the cost, age and
The rate of OTM is determined by bone remodeling, which is a general health status of the patient.
result of inflammatory processes in response to application of orthodon- 2. The most recent and the least invasive methods like lasers,
tic forces. Increasing the applied force in order to accelerate OTM is mechanical vibration, piezocision and microosteoperforations provide
proven useless because this approach led to many adverse effects favorable results with a minimal side effect, unlike the aggressive surgi-
including ankylosis, arrested tooth movement within the alveolar bone cal methods that accelerate tooth movement effectively but induce unfa-
and root resorption rather than tooth motion acceleration. Alternatively, vorable effects locally or systemically.
research was directed towards introducing local mediators or injuries to 3. Randomized controlled studies are required to compare between
the alveolar bone in an attempt to reduce orthodontic treatment time. different methods and identify the best techniques to shorten orthodon-
The systemic administration of medicines/chemical substances carries tic treatment time with minimal potential side effects.
the risk of systemic side effects18,39).
Being less invasive, non-surgical methods represent the most prefer-
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