Dr Ross McDowall talks about Accelerated Orthodontics In A Post-pandemic World

Accelerated orthodontics has been a hot topic in our world over recent years, attracting much attention from dental companies and investors. Shorter treatment times, as well as appealing to patient’s desires, will help to reduce the risks of decalcification, gingival recession and root resorption.

“Just push harder” I am often told. Our days at Dental School, however, tell us that increasing the force applied to a tooth risks hyalinization of the periodontal fibres and undermining resorption, leading to delayed movement. Techniques used to accelerate tooth movement are therefore aimed at enhancing the rate of the alveolar bone remodelling process, whilst maintaining normal orthodontic forces.

Currently on the dental market, we have three modalities at our disposal:

Microvibration

Bending alveolar bone to produce an electric charge, piezoelectricity, is thought to trigger an osteogenic response that will enhance the remodelling process. It is also believed that these electric charges will only occur when force is pulsated and not continuous. This is the science behind the AcceleDent® vibrational appliance. The patient bites on a rubber interdental bite surface for 20 minutes each day, throughout treatment.

Photobiomodulation

Low energy lasers or light-emitting diodes emitting red to near-infrared light have been shown to modify cellular biology. In particular, the production of adenosine triphosphate (ATP) is increased, which in turn increases the activity of the cells required for remodelling and tooth movement. OrthoPulse® is the first widely available device that utilises this technology. Similar to a mouthguard, the patient wears the device for 10 minutes per day, throughout treatment.

Micro-osteoperforations

Creating shallow perforations or cuts to the cortical alveolar bone in an attempt to speed-up orthodontic treatment was first reported in the literature back in 1893. When bone is irritated surgically, an inflammation cascade is initiated which causes increased activity of osteoclasts and osteoblasts, which in turn is thought to trigger faster tooth movement. This process is known as Regional Acceleratory Phenomenon (RAP).

Traditionally, corticotomies have been invasive requiring the raising of a full thickness mucoperiosteal flap. Techniques have, however, evolved to become more conservative and patient friendly. One example is micro-osteoperforation, where the mucosa and bone adjacent to the teeth to be moved are perforated. PROPEL Orthodontics have produced manual and power Excellerator® drivers to achieve this. RAP is believed to subside after 2-3 months and therefore for these surgical techniques to be clinically meaningful, the procedure likely needs repeating at regular intervals.

So what does the scientific literature say about accelerated orthodontics, are these evidenced based techniques? More and more research is emerging in the form of randomised controlled trials, allowing for systematic reviews and meta-analyses. Navigating through the maze of available research, my interpretation is that there is currently a lack of high level evidence in support of the non-surgical methods, but that high level evidence is now emerging in support of the surgical methods; with reported reductions in treatment time of 1-3 months. This of course has to be offset against the extra cost and invasiveness to the patient.

Before changing my practice in the post-pandemic world and reaching for my surgical kit or investing in new gadgets, I will wait for further high level evidence. I need greater confidence that these techniques will truly result in a clinically meaningful treatment time reduction for my patients. As a wise orthodontic Professor once told me, the greatest impact on treatment time and efficiency comes from within, the treatment plans you make and the mechanics you choose. I think he is right!