10/3/2014

‫حيدر‬.‫د‬
‫الزريجاوي‬
Biology of Orthodontic Tooth movement

Introduction:

O rthodontic tooth movement is a unique process where a solid object (tooth)

is made to move through a solid medium (bone). Orthodontic treatment is
based on the principle that if prolonged pressure is applied to a tooth, tooth
movement will occur as the bone around the tooth remodels. Because the
periodontal ligament mediates the bony response, tooth movement is primarily a
periodontal ligament phenomenon.

Periodontal Ligament Structure and Function

During tooth movement, changes in the periodontium (i.e. gingiva,

alveolar bone, periodontal ligament and root cementum) occur. These
changes depend on magnitude, direction and duration the force.

Under normal circumstances, the PDL occupies a space

approximately 0.5 mm in width around all parts of the root.

The major components of the PD ligament are:

1. Collagenous fiber bundles.

2. The cellular elements, including Mesenchymal cells of various
types along with vascular and neural elements.
3. The tissue fluids.

Collagenous fiber bundles, a network of parallel collagenous fibers,

are inserting into cementum of the root surface on one side and into a relatively
dense bony plate, the lamina dura, on the other side.

The principal cellular elements in the PDL are undifferentiated Mesenchymal

cells and their progeny in the form of fibroblasts and osteoblasts. The collagen

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of the ligament is constantly being remodeled and renewed during normal

function. The same cells can serve as fibroblasts in producing new collagenous
matrix materials, and fibroclasts in destroying previously produced collagen.
New bone probably is formed by osteoblasts while the old is removed by the
osteoclasts.

PDL space is filled with fluid; this fluid is the same as that found in all other
tissues, ultimately derived from the vascular system. It allows the PDL to play a
shock absorber role.

The PDL in addition to it's cushioning action against sudden blows and it's role
in eruption and mediating sensory response, is also vital in the process of
orthodontic tooth movement.

Theories of Orthodontic Tooth Movement

Orthodontic tooth movement is a response of a sustained force application. For

this movement to occur, there are two possible control elements, the electrical
signals as in (Bioelectrical Theory) and chemical signals as in (Pressure-Tension
Theory).

Bioelectrical (Piezoelectric) Theory

It relates tooth movement at least in part to changes in bone metabolism

controlled by the electric signals that are produced when alveolar bone flexes
and bends. Electric signals that might initiate tooth movement initially were
thought to be piezoelectric*. When the force is applied on a tooth, the adjacent
alveolar bone bends, leading to deformation of crystalline structure in the bone
(like the hydroxyapatite crystals and collagen), and this produce a piezoelectric
signals which act as a stimulus for cellular differentiation and ultimately tooth
movement.

*Piezoelectricity is a phenomenon observed in many crystalline materials in

which a deformation of the crystal structure produces a flow of electric current
as electrons are displaced from one part of the crystal lattice to another.

On application of a force on a tooth

 Areas of concavity  negative charges  bone
deposition.
 Areas of convexity  positive charges  bone
resorption.

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Piezoelectric signals have two unusual characteristics:

 Quick decay rate.
 When the force is released, the electrons flow in
the opposite direction.

On one hand, there is no longer any doubt that stress-

generated signals are important in the general
maintenance of the skeleton. Without such signals,
bone mineral is lost and general skeletal atrophy ensues. Signals generated by
the bending of alveolar bone during normal chewing almost surely are important
for maintenance of the bone around the teeth.
On the other hand, sustained force of the type used to induce orthodontic tooth
movement does not produce prominent stress-generated signals. When the force
is applied, a brief signal is created; when it is removed, the reverse signal
appears. As long as the force is sustained, nothing happens. Therefore according
this theory, the stress-generated signals to be effective in producing the bone
remodeling associated with orthodontic tooth movement, a vibrating application
of force would be advantageous.

Deformation
Alveolar Bone Electric
Of Crystalline
Bends Signals
Structure

Cellular Changes in
Tooth
Differentiation Bone
Movement
Metabolism

Pressure- Tension Theory

The pressure-tension theory, the classic theory of tooth movement, relies on
chemical rather than electric signals as the stimulus for cellular differentiation
and ultimately tooth movement. There is no doubt that chemical messengers are
important in the cascade of events that lead to remodeling of alveolar bone and
tooth movement.

In this theory, an alteration in blood flow within the PDL is produced by the
sustained pressure that causes the tooth to shift position within the PDL space,

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compressing the ligament in some areas while stretching it in others. Blood flow
is decreased where the PDL is compressed, while it usually is maintained or
increased where the PDL is under tension. If regions of the PDL are
overstretched, blood flow may be decreased transiently. Alterations in blood
flow quickly create changes in the chemical environment. For instance, oxygen
levels certainly would fall in the compressed area, but might increase on the
tension side, and the relative proportions of other metabolites would also change
in a matter of minutes. These chemical changes, acting either directly or by
stimulating the release of other biologically active agents, then would stimulate
cellular differentiation and activity. In essence, this view of tooth movement
shows three stages:

1) Alterations in blood flow associated with pressure within the PDL.

2) The formation and/or release of chemical messengers.
3) Activation of cells.

Change in
Sustained Alteration In Oxygen Level &
Pressure Blood Flow Other
Metabolites

Stimulate
Chemical
Tooth Movement Cellular
Messengers
Differentiation

BONE RESORPTION (osteoclastic activity) takes place at the side of the

PDL where there is PRESSURE

BONE FORMATION (osteoblastic activity) takes place at the side where

there is TENSION

Secondary remodeling changes: Bony

changes also takes place elsewhere to
maintain the width or thickness of alveolar
bone.

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Phases of Tooth Movement

Clinically, orthodontic tooth movement passes through three distinct phases:

INITIAL PHASE

The initial phase of tooth movement is immediately seen following the

application of a force on a tooth. The phase is characterized by a sudden
displacement of the tooth within its socket. The movement of the tooth into the
periodontal space and the bending of the alveolar bone probably cause it. The
extent of movement achieved is nearly same for both light and heavy forces.

LAG PHASE

The lag phase is characterized by very little or no tooth movement. It is the

phase where the cellular components around the area of interest get activated to
cause tooth movement. The lag phase is longer if high forces are applied as the
area of hyalinization created is large and the resorption is Undermining.

Shorter duration of the lag phase is noticed for lighter forces. There is very little,
if any area of hyalinization and frontal resorption is noticed.

POST-LAG PHASE

This phase is characterized by the removal of the hyalinized tissue and tooth
movement. The movement is mediated by osteoclasts and there is either direct
(frontal) resorption of the bony surface facing the periodontal ligament or
Undermining bone resorption.

The Characteristics of Orthodontic Force

These includes both the magnitude and duration of applied force on the teeth.

Effect of Force magnitude

Physiological response of the tooth to the force differs according to force

magnitude if it was heavy or light as following:

A- Light Continues Force

When light but prolonged force is applied to a tooth, blood flow through the
partially compressed PDL decreases as soon as fluids are expressed from the
PDL space and the tooth moves in its socket (i.e., in a few seconds). Within a
few hours at most, the resulting change in the chemical environment produces a

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different pattern of cellular activity. Animal experiments have shown that

increased levels of cyclic adenosine monophosphate (AMP), the "second
messenger" for many important cellular functions including differentiation,
appear after about 4 hours of sustained pressure. This amount of time to produce
a response correlates rather well with the human response to removable
appliances. If a removable appliance is worn less than 4 to 6 hours per day, it
will produce no orthodontic effects. Above this duration threshold, tooth
movement does occur.
The tooth movement occurs when the osteoclasts are formed directly along the
bone surface in the area adjacent to the compressed part of the PDL. Such a
reaction called "frontal resorption" and it is obtained when the PDL be
compressed only to a certain extent (so as not to occlude the capillaries) and
must cause little or ideally no hyalinization. This is only possible when forces
are close to the capillary pulse pressure. The Osteoblasts also are needed to form
new bone on the tension side and remodel resorbed areas on the pressure side.
With frontal resorption, a steady attack on the outer surface of the lamina dura
results in smooth continuous tooth movement.

B- Heavy Continuous Force

The course of events is different if the sustained force against the tooth is great
enough to totally occlude blood vessels and cut off the blood supply to an area
within the PDL. When this happens, a sterile necrosis of cellular elements within
the PDL, which becomes nonfunctional. Because of the histological appearance
of the cells in the region (which lose their distinct structure, the nuclei may
shrink and/or disappear) the avascular area has been referred to as "hyalinized".
Remodeling of bone bordering the necrotic area of the PDL will be
accomplished by cells derived from adjacent undamaged areas.

After a delay of several days, cellular elements

begin to invade the necrotic (hyalinized) area.
More importantly, osteoclasts appear within the
adjacent bone marrow spaces and begin an attack
on the underside of the bone immediately adjacent
to the necrotic PDL area. This process is
appropriately described as "undermining
resorption", since the attack is from the underside
of the lamina dura.

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The delay in tooth movement is caused first by a delay in stimulating

differentiation of cells within the marrow spaces, and second, because a
considerable thickness of bone must be removed from the underside before any
tooth movement can take place. At that point, the tooth "jumps" to a new
position, and if heavy force is maintained, there will again be a delay until a
second round of undermining resorption can occur.

Effect of Force Duration

The key to producing orthodontic tooth movement is the application of sustained

force. There is a threshold for force duration in humans in the (4-8 hour) range,
and that increasingly effective tooth movement is produced if force is
maintained for longer durations. Continuous forces, produced by fixed
appliances that are not affected by what the patient does, produce more tooth
movement than removable appliances unless the removable appliance is present
almost all the time.

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Orthodontic force duration is classified by the rate of decay as:

•Continuous-Force maintained at some appreciable

fraction of the original from one patient visit to the next.

•Interrupted-Force levels decline to zero between

activations.

Both continuous and interrupted forces can be produced

by fixed appliances that are constantly present.

•Intermittent-Force levels decline abruptly to zero

intermittently, when the orthodontic appliance is
removed by the patient or perhaps when a fixed
appliance is temporarily deactivated, and then return to
the original level some time later. When tooth movement
occurs, force levels will decrease as they would with a
fixed appliance (i.e., the intermittent force can also
become interrupted between adjustments of the
appliance). Intermittent forces are produced by all patient-activated appliances,
such as removable plates, headgear, and elastics.

Deleterious Effects of Orthodontic Force

Effect on the pulp:

 Modest and transient inflammatory response within the pulp, at least at

the beginning of tooth movement, with no long-term significance.
 A large enough abrupt movement of root apex could sever the blood
vessels entering the pulp canal, and loss of vitality results.

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Effect on root structure:

 Root remodeling is constant feature of orthodontic tooth movement, but

permanent loss of root structure would occur only if repair did not replace
the initially resorbed cementum.
 According to some studies, endodontically treated teeth are slightly more
prone to root resorption during orthodontic than are teeth with normal
vitality.
 High than average resorption can be anticipated if the teeth have:
Distorted root form.
History of trauma.
Root apices in contact with cortical bone.
Excessive force during orthodontic treatment. particularly if heavy
continuous force are used.

Effect on alveolar bone height:

 Excessive loss of crestal bone height is almost never seen as a

complication of orthodontic tooth movement.
 Almost never exceed 1mm, greater changes at extraction sites.

Mobility:

 Radiographically, it can be observed that the periodontal ligament space

widens during orthodontic tooth movement.
 Heavier the orthodontic force, greater the amount of undermining
resorption expected leading to greater mobility.
 If a tooth become extremely mobile during orthodontic treatment, all
force should be discontinued until the mobility decreases to moderate
level.

Pain:

 Pain of any type involves a great deal of individual variation.

 Pain is related to the development of ischemic areas in the PDL. Hence,
higher force, more pain.
 If light forces are used, the amount of pain experienced by patients can be
decreased having them engaged in repeated chewing during the first 8
hours after the orthodontic appliance is activated.

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