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2015 AAO Annual Session May 15 - 19, 2015

San Francisco Acceleratingorthodontic tooth movement

Young Guk ParkKyung Hee University, Seoul

Corticision®

Day 1 immediately after corticisionDay 1 immediately after corticision

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06-16-20083mos after corticision

08-08-20084.8mos after corticision

12-24-2008 finishing at 9 mos

03-06-2009debonding at 11 mos

1 year old cat, Corticision at distal to canine

Park YG, Angle Orthod 2009Radiogram of tissue block, 29dCorticision Group, mobileDistinct radiolucent line (unhealed corticision gap)

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R R

H

Ortho only Corticision

7 dcompression side, 21 d, HE, X40

The woven bone formation was foundalong the resorbed bone surface,

tension side, 21 d, HE, X40

Surgical gap was filled with new bone. Overlying soft tissue was recovered.

Histomorphometry(Fluorescent microphotographs )

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group B

group C

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While mean apposition rate of control group(group A) showed peak value on day 21 following 14 days of low value, the rate of experimental group represented earlier peak value on day 14(A). There was no remarkable difference of accumulated apposition area between group B and group C, and accumulated mean apposition area of ‘Corticision’ group on day 28 days was observed 3.5-fold higher than that of control group(B).

Mean apposition rate(A) and accumulated apposition area(B). July 2014

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sound biological milieuwith tooth in bone

Efficiency & EffectivenessSafety…of tooth movement ?

Ahn, HY Angle Orthod. 2013, DOI 1-.2319/041812-325.1 Ahn, HW, Angle Orthod 2013,

Max Central Incisor Max Lateral Incisor Max Canine

EBP

Evidence-based Practice(EBP)Evidence-based Practice(EBP)Sacket DL, Evidence-based Practice:-”is integration of best research evidence with clinical expertise and

patient values”Accelerating Tooth

Movement

Cytokinetic, Electric, Surgical, etc…

Light accelerated Orthodontics

Treatment Duration

Evidence –based practice ; PICO

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Photobiomodulation: Light Accelerated Orthodontics to Reduce Treatment Duration

Uribe F, AJODO 2014

• Orthodontists (n=683)• Adolescent patients (n=200) • Their parents (n= 200)• Adult patients (n=50)

Keim, et al. 2014

“…Accelerated treatment techniques were listed on the questionnaire for the first time. About 26% of the respondents reported some use of these methods in the previous year, with a median six cases treated.

Although a number of techniques were used, the most common were AcceleDent (used routinely or occasionally by 62% of the practices performing accelerated treatment)…’’

Non-invasive methodVs.

Surgical method

Long , Systematic review, AO, 2013

Low-level laser therapySafe but unable to accelerate

CorticotomyEffective and safe

Electrical currentCurrent evidence does not reveal

Pulsed electromagnetic fieldsCurrent evidence does not reveal

Dentoalv. or perio. distractionPromising but lacks convincing evidence

Non-invasive ATM, Current clinical studies at KHU

Orthodontic force Bone remodeling

Adjunctive surgicalCorticisionPiezocisionCorticotomyOsteotomyPuncture

Non-Invasive mechanical★ Photobiomodulation

(LLLT / LED)★ VibrationUltrasound

Electrical StimulationStatic magnetic field

Appliance

PharmacologicPTH

Vit D3OPG

RANKLThyroxine

Prostaglandins

Accelerated Tooth Movement

RAP

VibrationClinical trials in KHU

Photobiomodulation

The effects of vibration on the rate of orthodontic tooth movement during alignment

The effects of LED PBM on the rate of orthodontic tooth movement during space closure

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PhotobiomodulationWhat is the photobiomodulation ?

Development of photobiomodulation studies on ATM

Current clinical studies of photobiomodulation in prgress

Vibration

What is the vibration ?

Development of vibration studies on ATM

Current clinical studies of vibration in progress

Accelerating tooth movement by Non-Invasive Devices

Increased loading

ExerciseOrthodontic Treatment

Reduced loading

Long-term bed restZero Gravity

Skeletal homeostasis and bone formation

Bone Metabolism

Mechanostat theory

Frost. 1960

100

1,000

10,000

0.1 1 10 100 1,000 10,000 1,000,000Number of daily loading cycles

Microstrain

Resorption

Formation

Maintenance

Bone mass is maintained under⋯⋯.

4 cycles per day of 2,000 microstrain

100 cycles per day of1,000 microstrain

Hundreds of 1,000 cycles of<10 microstrain

Rubin, et al. 2002

100

1,000

10,000

0.1 1 10 100 1,000 10,000 1,000,000Number of daily loading cycles

Microstrain

Resorption

Formation

Maintenance

4 cycles per day of 2000 microstrain

100 cycles,1000 microstrain

Hundreds of thousands of cycles, <10 microstrain

Rubin, et al. 2002

The extremely low level (< 10 microstrain), high frequency

(20-50 Hz) mechanical strains are as effective to maintain the

skeleton as the bigger strains typically associated with vigorous

activity (>2,000 microstrain).

Bone mass is maintained under⋯⋯.

Osteogenic potential of HFLM force

Cyclic forces have been proven to alter physiological

responses in long bones⋯

Increased rate of fracture healing

Increased cellular signaling to enhance bone density

Vibration & bone metabolism

Vibration

Roberts WE, Seminars in Orthodontics 2006

Activates mechanoreceptors in bone cells

Stimulates molecules that regulate OBs and OCs

Increases the anabolic activity of bone tissue

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X40, Copyright Park YG, Kyung Hee University, Seoul

Osteoblast proliferation

Osteoblast activation

from bone marrow stromal cells

(BMSCs)

Vibration

Osteoblast proliferation

Osteoblast activationfrom PDL stem cells

(PDLSCs) Zhang 2012

Mauney, et al. 2004Zhou, et al. 2011

Development of vibration studies on ATM

Animal studies

Consistent results of increased bone remodeling andaccelerated tooth movement using vibration.

Animal studies

Animal studies, vibration

Increased bone metabolism w/ tooth movement

Development of vibration on ATM

Clinical studies

Findings from human studies

Alignment

Extraction space closure

No clinically relevant root resorption

Satisfied with treatment

Easy to use

Reduce pain

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Current clinical study of vibration on ATM

KHU clinical study in progress

Vibration Study design

Inclusion criteria

① Littles Irregularity Index:

Non-extraction group : 4~7mm

Extraction group : > 8mm (Upper 1st premolar extraction)

② Good oral hygiene

③ No radiographic evidence of periodontal diseases

Grouping

• Group A (n=15): Non extraction, Home use (AcceleDent™, 25 gram, 30 Hz, 20 min/day)

• Group B (n=15): Extraction, Home use (AcceleDent™, 25 gram, 30 Hz, 20 min/day)

• Group C (n=15): Non extraction, Control Orthodontic only and No Vibration

• Group D (n=15): Extraction, ControlOrthodontic only and No Vibration

Study design

AcceleDent™

• Impression at every visit during alignment (every 3wks)

• Irregularity measurement : distance from contact point to

adjacent tooth contact point (Sum of UR3 to UL3)

Assessment

Result

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Litt

le index

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m)

Mean rate : 1.43 mm/mo.

PhotobiomodulationWhat is the photobiomodulation ?

Development of photobiomodulation on ATM

Current clinical studies in progress

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What is the Photobiomodulation?

Biostimulatory effect

- Light in the red to near infrared (NIR) range (600 -1000 nm) generated by low energy laser or light-emitting diode (LED) arrays

- Such photobiomodulation has been observed to increase mitochondrial metabolism, facilitate wound healing and promote angiogenesis⋯”

Biostimulatory effect of photobiomodulation, Zhang 2009

LLLT, LED

Kana JS, et al. 1981Mester E, et al. 1978, 1985

Wound healing

Anti-inflammation

Pain reduction

Fibroblast and chondroblast proliferationCollagen synthesis

Nerve regeneration

Bone regeneration- Fracture Healing, ATM

Abergel RP, et al. 1984Balboni GC, et al. 1986

Anders JJ, et al. 1993

BoultonM, et al. 1986SoudryM, et al. 1988

Van BH, et al. 1992Schultz RJ, et al. 1985

Mester E, et al. 1985Mohammadreza S, et al.

2007Albertini R, et al. 2007

Shimizu,et al. 1995Turhani D,et al. 2006

Biostimulatory effect of photobiomodulationwith LLLT

600-950 nm

Cellular Photoreceptor

Wound healingTissue repair

Prevention of tissue death

Relief of inflammationPain, edemaAcute injuries

Chronic diseases

Neurogenic painNeurological problems

Acupuncture

Biostimulatory effect of photobiomodulation, Hamblin 2006

ATP ↑

Cell activity ↑

Bone / PDL remodeling ↑

Accelerate tooth movement

Photobiomodulation

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In press at Seminars in Orthodontics, ed by Mani Alikhani

What is the Photobiomodulation?

Low level laser & LED

Laser LED

Wavelength constant Monochromatic Nearly monochromatic

Coherence Coherent Incoherent

Directionality High directionality Low directionality

Ease of use Complex Easier

Cost Higher cost Lower cost

http://www.hitlights.com/media/catalog/product/i/l/illusion-led-strip-rrft1000-40rgbd-_1.jpg

Low level laser & LED

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Laser, Complex for use

Chair time is required,

Operator must be trained,Time consuming,

Caution when used by layperson.

Ease of useComplex vs Easier

Advantage/DisadvantageSelective site vs whole arch,

Once a week application,

Ease of useComplex vs Easier

LED is Easy & safe

Application to a larger area of the body surface with fewer side effects

Layperson is able to use easily

Area of pin point positioning may not be an issue

Low level laser LED• Higher cost• Time consuming• Repeatability and positioning

may be an issue.• Chair time is required.• Operator must be trained.• Application to a pin point area

• Lower cost• Shorter treatment duration• Repeatability and positioning

may not be an issue.• Easy to use• Safe to use• Fewer side effects• Application to a larger area of

the body surface

Low level laser & LED, Karu 2005

Development of photobiomodulation on ATM

Molecular & cellular response to photobiomodulation

Development of photobiomodulation on ATM

Animal & Clinical studies, from LLLT to LED

Carvalho-Lobato, SR, 2014

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Systematic Review of LLLT by Carvalho-Lobato, et al. 2014

It remains unclear⋯determining dose limits that produce desired biological effect towards reduction of the orthodontic treatment time

5 human studies(canine traction)11 studies in rats(1st premolar traction)

4 human studies / 8 animal studiesshowed statistically significant changes. Development of photobiomodulation on ATM

Animal studies

LLLT(2000~)

LED(2008~)

Animal studies from LLLT to LED

Development of photobiomodulation on ATM

Human Subjects clinical studies

Human subjects clinical studies from LLLT to LED

LLLT(2004~)

LED(2013~)

Current clinical studies of PBM on ATM

clinical studies in progress

Photobiomodulation, Light Accelerated Orthodontics

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Photobiomodulation, Light accelerated orthodontics Clinical studies in progress

Investigator / Institution Status / Enrolled

Clinical TrialsFocus of Study

TS1,5 Tim Shaughnessy Suwanee, GA, USA

Completed(n=11 of 11)

Pilot: Non-extraction. Alignment and total Tx time. (CTB and SLB) Adolescent & Adult. Submitted for publication. Under review

TS2 Tim Shaughnessy Suwanee, GA, USAUniv Alabama and Forsyth Institute, USA

IP (n=26 of 30)

RCT Pivotal: Non-extraction. Alignment and total Tx time, Root integrity & Pain evaluation. Sham Controls. (CTB) Adolescent.

EUC2 Said Samara & Don Ferguson European Univesity College Dubai, UAE

Completed (n=60 of 60)

RCT: Extraction. Velocity of space closure in en-masse retraction. (Passive SLB) Adolescent & Adult. Manuscript in preparation.

MC Peerapong SantiwongMahidol Univ. Bankok, Thailand

IP (n=42 of 45)

RCT: Non-Extraction. Alignment and total Tx time. Bone Quality and Root integrity eval CBCT (Passive SLB) Adult and Adolescent.

TS3 Tim Shaughnessy Suwanee, GA, USA

IP (n=25 of 30)

Case series. Total Tx time. Adolescents and Adults. (Mixed brackets and mechanics)

KHU1 Young Guk ParkKyung Hee U, Korea

IP (n=40 of 45)

RCT: Effect of OrthoPulseTM on the rate of en-masse retraction 6 anterior teeth

Investigator / Institution Status / Enrolled

Clinical TrialsFocus of Study

BX8 Marc Lemchen, NYC, NYTito Norris, San Antonio, TXTim Shaughnessy, Suwanee, GA

IP (n=55 of

100)

Case Series: Beta OrthoPulseTMevaluation and assess clinical effectiveness.

TD1/TD2Todd Dickerson, Phoenix, AZ

Completed (n=12 of 12)

Pilot Study: Efficacy of OrthoPulseTM and Invisalign® treatments. Cross-over design.

TD3 Todd Dickerson, Phoenix, AZ

IP (n=4 of 10)

RCT: Effect of OrthopulseTM on aligner change rate during invisalign® treatment. Corss-over design.

TD4Todd Dickerson, Phoenix, AZ

IP (n=2 of 28)

RCT: Effect of OrthopulseTM on total invisalign® treatment time.

UAB2Chung How Kau. University of Alabama at Birmingham, AL

IP (n=0 of 40)

RCT: Effect of OrthopulseTM on treatment timeline with clear aligners.

EUC3Don Ferguson et al. European University College Dubai, UAE

IP (n=0 of 40)

RCT Pivotal: Non-extraction. Alignment and total Tx time, Root integrity & Pain evaluation. Sham Controls. (CTB) Adolescent.

Photobiomodulation, Light accelerated orthodontics Clinical studies in progress

Measure Group Arch N Mean SD Min Max Difference P Value

Alignment Rates

Control 10 0.44 0.2 0.19 0.83

186.3% 0.0002intraoral 18 1.27 0.53 0.24 2.06

Days to Alignment

Control 10 104 55 42 204

53.6% 0.0049intraoral 18 48 39 17 164

Starting LIIControl 10 5.77 1.57 3.70 8.80

26.0% N.Sintraoral 18 7.27 2.99 3.72 14.58

OrthoPulseTM treated arches exhibit significantly faster alignment rates (186% faster), and reduces days to alignment by over 50% when compared to conventional methods. Shaughnessy, et al.(submitted for publication)

PhotobiomodulationStudy agenda; Intra-oral photobiomodulation for tooth alignment

Current clinical studies of PBM on ATM

Clinical study at KHU, Seoul

Photobiomodulation, Light Accelerated Orthodontics

• Experimental group: (n=30)

Group I (n=15) – application 3min

Group II (n=15) – application 6min

• Control group(group III, n=15)

• En masse retraction

• 19X25 SS

• OrthopulseTM (850nm, 60mW/cm2)

• Tooth movement rate

Evaluate the effect of PBM by intraoral LED device(OrthoPulseTM, Biolux, Canada)appliance on the rate of tooth movement.

The specific aims of the study are:

• To verify the efficacy of PBM on the rate of en-masse retraction of the 6 anterior teeth in extraction cases.

• To establish the optimal clinical protocol of PBM by the intraoral LED device for accelerating tooth movement.

Study objectives

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Inclusion criteria

① Skeletal, dental Class I with bialveolar protrusion

② Age over 12 YO with permanent dentition, no gender discrimination

③ Upper first bicuspid extraction

④ Mmaximum to absolute anchorage

No radiographic evidence of bone loss and/or periodontal conditions

Study sample

PBM; OrthoPulseTM, 60mW/Cm2

•Group I (n=15): Home use of PBM Group

Orthodontic force and Application of PBM for 3 min/day

• Group II (n=15): Home use of PBM Group

Orthodontic force andApplication of PBM for 5 min/day

•Group III (n=15): Control Group, Orthodontic force only

Study design, PBM; OrthoPulseTM, 60mW/Cm2

Taking study model at every visit during space closure,

and measure the amount of TM

Measurement

Lateral headfilms before and after space closure, and

measure the amount incisor movement.

Measurement

Pt value MeanDIVERGENCY

SUM(°) 402.6 391.8

PFH/AFH(%) 64.7 68.5

OP-FH(°) 13.2 8.3

MP-FH(°) 33.2 23.5

Maxilla-Mandible Relation

ANB (°) 4.2 2.3

AB-FH (°) 81.8 80.6

APDI(°) 82.9 85.6

MAXILLA

SNA(°) 81.2 82.1

N perp-Pt.A (mm) 0.7 0.4

MANDIBLE

SNB(°) 77.0 79.8

N perp-Pog(mm) -9.2 -2.2

DENTURE

IIA(°) 112.6 124.1

U1-FH(°) 118.6 116.2

IMPA(°) 95.7 96.3

U6-PP(mm) 27.0 25.4

ANS-U1 tip(mm) 30.9 29.3

U1 exposure (mm) 2.2 2.3

SOFT TISSUENasolabial A(°) 97.3 90.4

Upper lip to E-Plane -1.4 -0.8Lower lip to E-Plane 3.4 0.5

Upper LIP THICKNESS 13.1 12.2

Lower LIP THICKNESS 14.9 13.6

U pharyngeal width 16.5 17.4L pharyngeal width 16.6 11.3

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Mean rate : 1.15 mm/mos.

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Pt value MeanDIVERGENCY

SUM(°) 399.9 391.8

PFH/AFH(%) 62.1 68.5

OP-FH(°) 7.4 8.3

MP-FH(°) 28.8 23.5

Maxilla-Mandible Relation

ANB (°) -0.3 2.3

AB-FH (°) 84.0 80.6

APDI(°) 92.1 85.6

MAXILLASNA(°) 75.9 82.1

N perp-Pt.A (mm) -3.4 0.4

MANDIBLESNB(°) 76.3 79.8

N perp-Pog(mm) -7.6 -2.2

DENTUREIIA(°) 111.4 124.1

U1-FH(°) 126.1 116.2

IMPA(°) 93.8 96.3

U6-PP(mm) 24.5 25.4

ANS-U1 tip(mm) 25.8 29.3

U1 exposure (mm) 1.6 2.3

SOFT TISSUENasolabial A(°) 72.4 90.4

Upper lip to E-Plane 0.9 -0.8Lower lip to E-Plane 3.9 0.5

Upper LIP THICKNESS 10.0 12.2

Lower LIP THICKNESS 13.0 13.6

U pharyngeal width 16.2 17.4L pharyngeal width 9.4 11.3

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Mean rate : 0.48 mm/mos.

47% increased

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Comparison of tooth movement rate

Group I (3min.) Group III (control)

0.88 mm/mos. 0.60 mm/mos.

Mean rate :

Conclusion

Light-accelerated orthodontics shows ⋯;

promise in producing noninvasive stimulation of the dentoalveolar

complex with cytochrome oxidase C mediated ATP production in the

mitochondrial cells.

Cytochrome oxidase C mediated ATP production is upregulated

2-fold by infrared light. During the tooth movement, higher ATP

availability helps cells turnover more efficiently, leading to an

increased remodeling process and acceleraed tooth movement.

Photobiomodulation,

as an alternative treatment option

to surgical approaches for accelerated tooth movement.

Guidelines - Intensity

- Duration

- Dose

- Frequency

- Interaction with other treatment modality

Young Guk Park, DMD,MSD,PhD,MBA,FICD.Professor of Orthodontics

Dean, Kyung Hee University School of Dentistry, Seoul

Thank You…!