A perspective in accelerated

orthodontics with aligner treatment

Kenji Ojima, and Chung How Kau

Aligner therapy is now a mainstay treatment alternative in Orthodontics.

Many patients specically request for aligner treatment at an Orthodontic
practice. One drawback to the treatment is the time for each aligner sequence
to be worn. This is normally about two weeks for each sequence for each
patient. This article describes two adjunctive therapies to be used with
Aligner treatment and describes the general modes of action. (Semin Orthod
2017; 23:7682.) & 2017 Elsevier Inc. All rights reserved.

Introduction treatment.9,10 The most notable orthodontic

advance in the last decade has been the intro-
rthodontic treatment is in much demand
O globally, and is practiced in just about every
country, developed or developing. To move the
duction of digitally fabricated aligners to move the
teeth in small, progressive sequences.
All these optimizations, innovations, and
teeth, the highly trained orthodontists employ
advances share one common goalreduction in
the aid of a variety of carefully prescribed bio-
treatment time.11 A signicant capability of the
mechanical forces systems. In the United States
digital revolution is creation of a virtual roadmap to
alone, 2.5 million children receive orthodontic
the desired outcome.1 It is a highly sophisticated
treatment annually, and the demand by adults is
process where they aid the clinician by simulating
still on the increase.
tooth movements or alerting pitfalls. Despite their
As the understanding of orthodontists become
excellent software, algorithms, and visual impact,
better and the appliances more precise invariably,
they are criticized for not taking into consideration
the focus of the clinician has shifted to improve-
the biological determinants of tooth movement.
ments in treatment efciency.1 Over the last
The second approach to improve treatment
25 years, main innovations were in the
efciency utilizes the biological response of teeth
biomaterial and biomechanical characteristics at
to mechanical stimuli. A number of possible
the level of wire and bracket interface.2 Newer
methods have been suggested and some early
systems have made signicant improvements in
research haveyielded much promise.12
the bracket technologies. Some principal
examples of these newer systems are friction
free self-ligating brackets and temporary anchor-
age devices.3,4 Additional advances are in the Clear aligners
initial alignment wire properties5,6 and in the
robotic wire systems.7,8 It will stand to reason to Currently, the largest provider of aligners is
argue these most excellent innovations have Invisalign (Align Technology, Inc., Santa Clara,
reached their peak and any further advancement CA). It is the rst mass produced custom-made
can result only in minimal impact in the length of healthcare product. It has proven to be a good
product of a good business idea and model, and
customer support. It has shocked the system, as
Smile Innovation Orthodontics, Tokyo, Japan; Japan Academy of
Aligner Orthodontics, Japan; Department of Orthodontics, School of
the orthodontist had to retool and broaden his
Dentistry, University of Alabama Birmingham, Birmingham, AL. ways of thinking and knowing more about the
Address correspondence to Chung How Kau, BDS, MScD, MBA, periodontal tissues of moving teeth. The intro-
PhD, MOrthEdin, FDSGlas, FAMS(Ortho), FFDIre, FDSEdin, ABO, duction of the Invisalign appliance is said to have
Cert (Ortho), Department of Orthodontics, School of Dentistry,
instigated its population among the adults, with
University of Alabama Birmingham, Suite 305, 1919 7th Avenue
South, Birmingham, AL 35294. E-mail: ckau@uab.edu consequent increase in the number of adult
& 2017 Elsevier Inc. All rights reserved.
patients. Lately, it has also become a popular
1073-8746/12/1801-$30.00/0 choice of appliance among the older teenagers.
http://dx.doi.org/10.1053/j.sodo.2016.10.002 To many patients, clear aligners are perceived as

Seminars in Orthodontics, Vol 23, No 1, 2017: pp 7682 76

 Accelerated orthodontics with aligner treatment 77

more tolerable than ceramic brackets and metal in the periodontal ligament (PDL) differentiate
brackets. into compression-associated osteoclasts and
Clear aligners have many advantages; a few tension-associated osteoblasts.17
practical ones are esthetics, hygiene, and time Once tooth movement is initiated, genes
management in the orthodontic ofce. Yet, the controlling osteogenesis are upregulated. Many
aligner treatment took some time to be widely genes act to release proteins that create a cascade
accepted mostly due to uncertainties of its of events. Some of these proteins include TF
potential to perform. It was an unknown entity, Cbfa1, bone morphogenetic proteins (BMPs),18
and 2005 systematic review of clear aligners, the transforming growth factor-beta (TGF-), and
authors were not able to nd enough evidence to growth factors. These series of events lead to
issue precise guidelines regarding Invisalign resorption and deposition of bone, which ulti-
treatment because of the lack of published mately lead to tooth movement. Obviously, all
clinical trials.13,14 Today, aligners account for this is consequent to force delivery to the tooth.
about 1520% of the global orthodontic market
share. In an ever-evolving world where the con-
sumers of orthodontic treatment dictate a lot Methods to enhance tooth movement
more than ever, led to a changing orthodontic
Clinically, three main methods of enhancing
specialty that continues to adapt itself.
tooth movement (ETM) proposed: chemical-led
There are some drawbacks to aligner use. One
interactions, surgery, and device-assisted thera-
of these is the appliance's efciency. Many
pies.11 The chemical-led interventions have been
orthodontists believe that the rate-limiting step is
proposed as a mechanism and fall into four
the aligner change regime (currently 14 days)
major groups.15 The rst group involves
and therefore if methods could be used to
endothelial growth factors and VEGF for
accelerate the biology it would enhance the rate
regulating angiogenesis. The second involves
of tooth movement and shorten the aligner
osteoclast precursors, such as osteocalcin. And
change intervals.
the third group engages bone resorptive factors
like RANKL, leukotrienes, and macrophage
Biology of tooth movement colony-stimulating factors. Studies in these
areas are limited and varied; it makes the
The biology of tooth movement is a very complex
understanding of these mechanisms difcult.
process and not fully understood.15 Indeed
A number of surgical techniques have been
numerous biological mechanisms must kick-in
describedtraditional osteotomies (for patients
before tooth movement can occur. It has been
with dentofacial deformities) and corticotomies.
suggested that ve microenvironments are
In this group, corticotomy may be the most
altered by orthodontic force: extracellular
popular procedure.19,20 It is a procedure where
matrix, cell membrane, cytoskeleton, nuclear
protein, and the genome.16 Additionally
suggested that gene activation (or suppression)
is the point at which input becomes output,
leading to the necessary changes in the ve
environments.
There are four schools of thought of tooth
movement: pressure/tension, biomechanical,
piezoelectric, and hydrodynamic theories. It is
difcult here to go into a detailed account of
each theory, but it is important to note that there
is no single unifying theory for tooth movement.
Some have postulated that within the rst second
of orthodontic treatment, some bone bending
occurs which leads to a piezoelectric phenom-
enon.2 As the duration of the applied force
increases, the force-subjected progenitor cells Figure 1. OrthoPulse I/O device.
78 Ojima and Kau

Figure 2. (A) With Class I malocclusion with anterior crossbite. (B) Completion of orthodontic treatment with
aligners and OrthoPulse device.

surgical aps are reected around the dentoal-
veolar complex to selectively perform buccal and
lingual decortications. The wound sites are often
packed with new bone or bony substitutes.
Without waiting for complete healing, active
orthodontic forces are applied immediately.
Published reports, however, have been equivocal
in success and lesser outcomes.21 The only
positive nding in these reports was that right
after the surgical intervention, teeth did move
faster for a brief moment, and returned to
normal tooth movement rate.22 Based on these
reports, surgery, though briey effective, needs
to be carefully planned with the orthodontic
protocol and precisely timed for maximum
effect. It should be noted that these surgical
techniques have never been studied in the
randomized clinical trial format.
The third category of biologically enhanced
orthodontic tooth movement requires device-
assisted therapy (DAT).12 The suggested DAT
systems are low-level light therapy (LLLT),
electrical currents, cyclic forces, and resonance
vibration.12 We present here, two methods of
 Accelerated orthodontics with aligner treatment
DAT. One method uses photobiomodulation
and the other cyclical forces.
Photobiomodulation or light-accelerated
orthodontics (LAO)
Light-accelerated orthodontics is an inter-
vention technique that falls within the scope of
photobiomodulation or low-level light therapy
(LLLT). The term photobiomodulation or LAO
is favored in this publication as the specic
wavelength range, intensity, and light pene-
tration are very specic.12
Photobiomodulation is an emerging area of
science that shows promise to produce a non-
invasive stimulation of cellular activity in the
dentoalveolar complex.23 It has been postulated
that photobiomodulation may affect the cytochrome
oxidase-c activity in ATP production by the
mitochondria. This enzyme is responsive to light.
Its function is upregulated by the right wavelength
of light, most commonly in the infrared
spectrum.24 Oron et al. reported a two-fold
increase in ATP production with LLLT treat-
ment. Increased ATP production may be assumed
to increase intracellular metabolic activity and
remodeling of periodontal tissues. During tooth
movement, an increase in ATP may help cells to
complete their tasks more rapidly or turnover
more efciently, which could lead to an increased
remodeling processaccelerated tooth move-
ment. It may also be postulated that LAO increases
the vascular activity in the targeted site. Vascular
activity is a determinant of tissue remodeling.
A number of clinical case series have showed an
enhanced effect with photobiomodulation.12 In
canine retraction studies, Youssef et al.25 and also
Cruz et al.26 have shown the effects of laser
treatment as increased velocity and decreased pain.
Device description. The OrthoPulse intraoral
(iO) LED device is a low-level laser phototherapy
device intended to provide stimulation to accel-
erate orthodontic tooth movement of teeth and
to reduce the overall treatment timeline (Fig. 1).
The OrthoPulse iO LED employs a near-infrared
wavelength of 850 nm, which is safe for tissue
contact and very low-level power (less than
50 mW/cm2). All light treatment is administered
intraorally, and other than potentially accelerat-
ing the treatment time, at no point are the
normal orthodontic treatments, procedures, or
79
equipment need to be altered to accommodate
the application. The device is designed to comply
with the lamp safety standard (IEC 62471:2006),
and with the general medical electrical family of
standards (60601-1, 3rd ed.). The OrthoPulse
device has FDA clearance in the United States
and Europe.
The OrthoPulse iO LED is designed as an
intraoral appliance, similar to a plastic sports
mouthguard, with LED technology embedded
into the mouthguard on a exible circuit. Light is
directed toward the alveolar surface when the
appliance is in the mouth. It facilitates light
treatment of the anterior segment during ortho-
dontic treatment. The intraoral appliance is
designed to treat one arch (upper or lower),
and is reversible by the patient to treat the other
arch. The device is worn for 5 min in each arch
and has shown much potential to affect the rate
of tooth movement.27
This 26-year-old male with the chief complaint
of anterior crowding, requested to be treated
with aligners. The patient was diagnosed with
a Class I malocclusion and anterior crossbite
on the lateral incisors (Fig. 2A). Routine
aligner records were obtained and treatment
was planned with the ClinCheck software.
Altogether, 31 aligners were planned and
issued. In a usual protocol, aligner trays would
have been changed every 2 weeks resulting in 62
Figure 3. Acceledent Aura device.
80 Ojima and Kau

Figure 4. (A) Patient with Class IID1 Malocclusion. (B) Series of pictures showing distal movement of the buccal
segment and anterior correction. (C) Completion of orthodontic treatment with aligners and Accelerant device.
 Accelerated orthodontics with aligner treatment
weeks or 16 months of treatment. The patient was
offered the aid of Photobiomodulation, and
he accepted. OrthoPulse I/O device was
dispensed with the instructions, which were to
use the device in conjunction with the Invisalign
appliances. The protocol was 5-min applications
in each arch throughout the treatment. Com-
pliance was high for both the OrthoPulse and
Invisalign. As a result, the aligners were changed
every 3 days. The total treatment time was
4 months or 16 weeks (Fig. 2B).
Cyclical forces
Device description. AcceleDents Aura, devel-
oped by OrthoAccel Technologies, Inc.
(OrthoAccel), consists of a mouthpiece and
activator assembly that provides a light vibration
to the teeth (Fig. 3). Combined with the doctor's
diagnosis and prescription for orthodontic care,
AcceleDents Aura claims to make orthodontic
treatment progress faster.
The exact mechanism of how it affects biology
is not fully understood. However, it has been
reported that the device generates small vibra-
tions called micropulses, which perturb the
periodontal tissues for accelerated tooth move-
ment. The device is used by inserting the
mouthpiece around the existing orthodontic
appliances and turning on the activator for
20 min or less every day. AcceleDents Aura has
been proven safe in clinical trials and is cleared
by the FDA as a Class II medical device.
This 27-year-old female was interested in
orthodontic treatment to reduce her severe
overjet. She wanted to be treated with aligners.
Her diagnosis was Class I div 1 with increased
overjet. Routine aligner records were obtained
and treatment planned with the ClinCheck
software. Her needs were extensive because it
required extractions and distaization of teeth in
the buccal segments (Fig. 4).
In her treatment 76 aligners were planned and
issued. In a usual protocol, aligner trays would
have been changed every 2 weeks resulting in 38
months or 152 weeks of treatment. Cyclical forces
using the Acceledent Aura device was recom-
mended to the patient and the patient accepted
the device. It was used together with aligners
and applied 20 min per day throughout the
treatment.
81
Compliance was high for both the Acceledent
and Invisalign Appliance. As a result, the aligners
were changed every 4 days. The total treatment
time was 13 months or 52 weeks.
Discussion
The two cases presented in this article may not be
representative of all things possible and certainly
does not qualify for an evidence based study.
Notwithstanding these meager numbers, the
ability to change the aligner trays at such a high
frequency represented in some ways, the ability
to create tooth movement at a rate not seen
before. At present, it seems like the photo-
biomodulation device has a slight advantage over
the cyclical force device. The rate of change of
tray was improved by 1 or 2 days.
The case selection between a cyclical force
device versus photobiomodulation device was made
purely on the need to distalize the buccal segments.
At present, only the Acceledent device has the
ability to incorporate beyond the rst molars.
Conclusion
Biological therapies are constantly being devel-
oped in orthodontics. These two methods repre-
sent some of the many types of biology-modifying
devices that may be used in orthodontics. Much
more research and innovation is still required to
fully comprehend the biological mechanism for
these types of devices.
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