What are the best methods to accelerate tooth movement?

Various devices, such as those that employ vibration (AcceleDent^®, OrthoAccel Technologies, acceledent.com; VPro5, Propel Ortho­dontics, propelorthodontics.com) or low-level light (OrthoPulse™, Biolux Research, bioluxresearch.com), have been introduced to accelerate orthodontic treatment. Although significant research has been done on cellular and animal models showing acceleration of healing, as well as studies that have shown animal and human bone fractures can heal faster with vibrational therapy and/or light, very little controlled human-subject clinical data are available to support their efficacy for acceleration of orthodontic tooth movement other than case reports. Essentially, they increase the energy field to speed the cellular responses of the tissue that is undergoing remodeling associated with tooth movement. Several controlled clinical trials of vibration have not demonstrated measurable acceleration of tooth movement with fixed appliances, so I do not recommend them for fixed appliances. No clear evidence for or against the use of these devices exists for clear-aligner therapy.

Another area of acceleration of orthodontic treatment is found with microperforations via the Propel system. The idea is to create several small wounds designed to increase the cellular activity around the chosen teeth. Several animal studies and one study conducted on canine retraction in humans have shown that these microperforations can speed movement for a 4-month period by as much as 30% to 40%. Unfortunately, most clinical treatments require multiple sessions of microperforations because of the length of the treatments. I have found this approach generally allows for faster clear-aligner treatment by changing the aligners more frequently, in as little as 5 days per aligner.

Excellent animal and human scientific evidence is available showing a corticotomy using a vertical interproximal perforation with a low-heat, reciprocating saw can accelerate orthodontic tooth movement by as much as 50% with a sustained effect for as long as 6 to 8 months. I have used this procedure successfully in a few cases in which I have had difficulty with space closure in an extraction space closure or in closing longstanding edentulous-ridge situations. A variation to this approach is to do a surgical ridge augmentation with a membrane and bone graft in an edentulous area, and then close the space.

The final type of accelerated orthodontic treatment that I use somewhat routinely is to perform surgery first when orthographic surgery is indicated. This procedure has been well documented in animal studies and in case reports. Many times orthodontic treatment can be done with a 60% or even higher reduction in treatment time. The biggest problem with this method is that the immediate postoperative occlusion is frequently composed of only a few tooth contacts, which may be uncomfortable for the patient until the occlusion is established.

My overall advice is to stay on the conservative side when suggesting procedures to patients. I am hopeful that the most conservative methods, such as vibration and low-level light, can be further documented. Probably the best news for speeding treatment is the recently released study from Invisalign (invisalign.com) that clear aligners can generally be changed in 7 days instead of the previously recommended 14 days. In my practice, this has allowed me to perform Invisalign treatment more efficiently with less treatment time. Further studies will be needed, however, to find out if the patient’s age or type of tooth movement are factors that might require a longer time of wear beyond 7 days.

The search for accelerated tooth movement in orthodontics has been a “holy grail” of sorts for both orthodontists and patients. We in orthodontics know that for a modality to be successful, it needs enough biologic force to move a tooth, yet protect the periodontal membrane from compression necrosis. In my practice, I have tried passive self-ligation brackets, light therapy, manual osteoperforations (MOPs), and vibration.

Using MOPs with Propel Orthodontics’ Excellerator™ series drivers has been the most effective method I have found to accelerate tooth movement. Increasing cytokine production around a tooth enhances osteoclast activity and hastens the rate of bone remodeling. MOPs create the inflammatory response that stimulates this process. Applying orthodontic force immediately after MOPs enables teeth to move easier and faster.

Before beginning MOPs, I use a topical anesthetic comprised of 10% lidocaine, 10% prilocaine, 4% tetracaine, and 2% phenylephrine to eliminate the risk for discomfort. I perform one MOP between each tooth, typically about 3 mm deep and approximately 1 mm deeper for posterior areas. It is not necessary to deeply penetrate the alveolar bone; just breaching the cortical wall is sufficient.

I have switched from a hand driver to the electric power driver, which makes the process easier to control, quicker, and more comfortable for the patient. For patients who still have discomfort, I recommend prescribing acetaminophen post application, as I would with my typical orthodontic cases.

As a result of using MOPs in conjunction with appropriate orthodontic therapy, my patients are completing treatment 4 months to 6 months faster than I ordinarily would expect. MOPs facilitate tooth movement for stubborn teeth and lead to more efficient movement for space closure. One outstanding example of the acceleration capabilities of MOPs occurred for a patient with a very narrow bite and exostosis on her upper gingival tissue. Even though tooth movement for this type of dentition would have been difficult, she wanted to finish treatment in 1 year. I started MOPs at the beginning of treatment and performed MOPs every 12 weeks. We were thrilled to be able to achieve our goals on this challenging case in 1 year. With tori on the upper arch, some clinicians think the teeth cannot be moved or the results will be compromised. But this case had successful results using MOPs in conjunction with the mechanics of the Damon® System (Ormco, Ormco.com) and passive self-ligation.

Patients appreciate achieving an esthetically pleasing smile in a relatively short time, and decreasing treatment time by 4 to 6 months in a biologically effective way through MOPs is significant for both the patient and doctor.

In the past few years, a significant increase in the number of modalities has become available to accelerate tooth movement. All these techniques are reported to induce bone remodeling and increase cytokine activity. They range from the use of injections and surgical stimuli to vibrational therapy and even the use of photobiomodulation (PBM). In combination with light orthodontic forces, all of these modalities have created interest and a debate as to which is the most effective.

Accelerating tooth movement is not a new concept; in the 1970s, Wilckodontics^®, now known as accelerated osteogenic orthodontics (AOO), was developed as a surgical technique to accelerate tooth movement. Piezocision™ is another surgical procedure, but a major drawback with both of these is that they are invasive and can involve significant postoperative discomfort and additional follow-up visits.

In an effort to find a less-invasive procedure, Propel has been developed using single-use screws to make MOPs. Propel can be used easily by numbing the gingiva and making MOPs directly through the keratinized gingiva and mucosa. Similar to AOO and Piezocision, Propel increases cytokine activity, thereby increasing bone remodeling. I find using Propel and making MOPs appears to be the most effective in shortening treatment time and making difficult tooth movements easier and more predictable.

There have also been advancements in noninvasive modalities that would be more widely accepted by patients and could accelerate tooth movement. Vibrational therapy has also been shown to enhance bone remodeling and has been demonstrated to help seat clear aligners, in addition to increasing blood flow to the teeth thereby decreasing pain. In my experience, using vibrational therapy is extremely effective in expediting molar intrusion and is superior to other techniques or appliances when treating patients with an open bite. Often, these hyperdivergent patients with skeletal open bites have weaker muscles of mastication, and vibrational therapy helps to seat the aligners and intrude the posterior teeth.

Compliance is imperative for clinical success in these cases because the patients need to use these devices for 5 to 20 minutes every day. Careful patient selection is needed; for example, patients who have hypodivergent cases typically tend to clench and can intrude posterior teeth, leading to a posterior open bite.

Another noninvasive appliance that is available is Biolux Research’s OrthoPulse. The OrthoPulse device utilizes PBM by directing continuous, near-infrared LEDs to the gingivae surrounding the dental roots. This noninvasive approach using lower-level light therapy has been shown to accelerate tooth movement with no resorption or other adverse effects. It is used for 5 minutes on each arch and has also been shown to reduce discomfort associated with orthodontic tooth movement. Of all the appliances, this is the most costly to the patient, which could be an obstacle for use. However, patients report the least amount of pain, and using this device also helps make difficult movements such as rotation more predictable and quicker.

Robert L. Boyd, DDS
Frederick T. West Professor and Chair
Orthodontics Department
Arthur A. Dugoni School of Dentistry
University of the Pacific
San Francisco, California

Stuart L. Frost, DDS
Associate Clinical Professor
Orthodontics Department
Arthur A. Dugoni School of Dentistry
University of the Pacific
San Francisco, California
Private Practice
Mesa, Arizona

Bella Shen Garnett, DMD, MMSc
Associate Clinical Professor
Orthodontics Department
Arthur A. Dugoni School of Dentistry
University of the Pacific
San Francisco, California
Private Practice
San Francisco, California