Widescreen (16:9)

Guided By

Dr. Hariprasad MDS Prepared By

Dr. Sarath MDS
Dr. Shaji MDS JEAN MICHAEL
Dr. Yohan Varghese MDS, PhD Final Year - RDC
JM 1
 Physiologic Tooth Movement
It is the naturally occurring tooth movements
that take place during and after tooth eruption

1. Tooth eruption
2. Migration or drift of teeth
3. Changes in tooth position during mastication
JM 2
 Tooth Eruption
Axial or occlusal movement of
the tooth from its developmental
position within the jaw to its
functional position in the occlusal
plane

JM 3
 Theories Of Tooth Eruption
• Vascular pressure theory
• Root formation
• Bone Remodeling
• Periodontal ligament traction
This theory states that the periodontal ligament is rich in fibroblasts
that contain contractile tissue. The contraction of these periodontal
fibers (mainly the oblique group) result in tooth eruption.

JM 4
 Migration Or Drift Of Teeth
• Teeth have the ability to drift through the alveolar
bone
• Human teeth have a tendency to migrate in mesial
or occlusal direction
• This maintains the inter-proximal and occlusal
contact
• Aided by bone resorption and deposition by
osteoclasts and osteoblasts respectively
JM 5
• Mesial - due to proximal caries
(loss of tooth structure)

• Occlusal - Due to premature

exfoliation or absence of opposing
tooth (supra-eruption)

JM 6
Tooth Movement During Mastication
• Normal force of mastication – 1 to 50 kg
• It occurs in cycles of 1 second duration
• Teeth exhibit slight movement within the socket
and return to their original position on withdrawal
of the force
• Whenever the force is sustained for more than 1
second, periodontal fluid is squeezed out & pain is
felt as the tooth is displaced within the periodontal
space JM 7
PERIODONTIUM

JM 8
JM 9
• Thickness of normal PDL – 0.5 mm
• Collagenous fibres of PDL connects
the cementum and lamina dura
• The fibers run at an angle attaching
farther apically on the tooth than on
the adjacent alveolar bone
• PDL space is filled with fluid derived
from vascular system
JM 10
Periodontal Ligament

JM 11
 Cellular Elements in the PDL
• Fibroblasts – produce and destroys collagen fibers
• Osteoblasts –produce new bone
• Osteoclasts – aids in bone resorption
• Cementoblasts – forms new cementum
• Cementoclasts – removes cementum
• PDL is vascular and contains nerve endings which
aid in proprioception
JM 12
JM 13
FIBROBLAST

JM 14
OSTEOCYTE

JM 15
OSTEOBLASTS

JM 16
OSTEOCLASTS

JM 17
• Is orthodontic movement possible for a tooth that
has undergone endodontic treatment ?

YES (the PDL is intact in this case)

• Is it possible to move an ankylosed tooth ?

NO (here there is complete absence of the PDL)

JM 18
 Piezoelectric Effect
• When a force is applied to a
crystalline structure (like bone or
collagen), a flow of current is
produced that quickly dies away
• When the force is released, an
opposite current flow is
observed
• The piezoelectric effect results
from migration of electrons
within the crystal lattice
JM 19
 Response to Normal Function
• Teeth and periodontal structures are subjected to
forces up to 50 kg during mastication
• Force is transmitted to the alveolar bone which
bends in response
• Generation of piezoelectric currents
• It acts as an important stimulus to skeletal
regeneration and repair resulting in adaptation of
bony architecture to functional demands
JM 20
 Response to Continuous Pressure
• < 1 second: Fluid in the PDL is incompressible

• 1 – 2 seconds: PDL fluid expressed, Tooth moves

within PDL space

• 3 – 5 seconds: PDL fluid squeezed out, Tissue

compressed and immediate pain is felt if force is
heavy JM 21
Force for Orthodontic Tooth Movement
• Forces that bring about orthodontic tooth movement
are continuous and should have a minimum
magnitude (threshold)
• Below this threshold limit, the PDL has the ability to
stabilize the tooth by active metabolism
• The minimum pressure required is 5 to 10 gm/cm2
(current concept)
JM 22
 Resting Pressure from Lip & Tongue
• Upper Anteriors
Force exerted by LIP > Tongue
• Lower Anteriors
Force exerted by TONGUE > LIP
• Teeth remain stable in their position as the
unbalanced forces acting on them, are below the
threshold limit tolerated by the metabolism in PDL
JM 23
Magnitude of Force VS Tooth Movement

JM 24
ORTHODONTIC TOOTH MOVEMENT

JM 25
Modes of Orthodontic Tooth Movement
Forces created by orthodontic appliances bring about
tooth movement by 2 mechanisms.

• FRONTAL Resorption
• UNDERMINING Resorption

JM 26
Frontal Resorption
• Accomplished by Light Orthodontic Forces
• least painful
• least harmful to the periodontium
• Most desirable

JM 27
Undermining Resorption
• Caused by Heavy Orthodontic Forces
• Painful
• More harmful to the periodontium
• Occurs in a small scale even in the most careful
orthodontic treatment
• The dentist should always try to minimize this
JM 28
 Role of Piezoelectric Current
• Piezoelectric currents produced on application of
force on tooth and alveolar bone dies off quickly and
play little role in orthodontic tooth movement
• Orthodontic tooth movement requires sustained
forces which does not produce continuous
piezoelectric current
• But these signals which are produced while normal
chewing are required for proper maintenance of
normal bony architectureJM 29
 The Pressure – Tension Theory
• When force is applied on the tooth, PDL is
compressed on one side and stretched on the other
side
• Blood flow is decreased on the pressure side where
PDL is compressed
• Blood flow is increased on the tension side where
PDL is stretched
JM 30
• The process of initiation of tooth movement has 3
stages
1. Alternation of blood flow associated with
pressure within the PDL
2. The formation and release of chemical
messengers
3. Activation of cells which causes deposition and
resorption of bone
JM 31
• 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
JM 32
Maintenance of Thickness of Alveolar Bone
• In an ideal treatment, the attachment level is
maintained
• Resorption and deposition of bone maintains its
thickness in the facial and lingual side irrespective
of the type of movement the tooth has undergone
on the alveolar bone

JM 33
 Chemical Regulation of OTM
• Within the 1st hour
Increase in ProstaglandinE & Interleukin – 1
Increase in Cytokines & Nitric oxide (NO)
• After 4 hours of pressure application
Increase in cAMP (chemical mediator for differentiation)

PROSTAGLADINS can stimulate formation of both OSTEOBLAST & OSTEOCLAST

JM 34
 • It takes a minimum of 4 to 6
hours of continuous force
to initiate orthodontic
tooth movement
• So removable appliance
worn for less than this
minimum period of time is
of no use
Maximum efficiency is obtained if the appliance is worn for 24/7

JM 35
 Types of Orthodonic Forces

• LIGHT Force – Frontal resorption

• HEAVY Force – undermining resorption

JM 36
Effect of Magnitude of Force on PDL

JM 37
Application Of Continuous Light Force
• < 1 second: PDL fluid is incompressible, alveolar
bone bends, piezoelectric signal generated

• 1 – 3 seconds: PDL fluid expressed & tooth moves

within the socket

• 3 – 5 seconds: Blood vessels within PDL partially

compressed on pressure side & dilated on tension
side. PDL fibers and cells are mechanically distorted
JM 38
• Minutes: Blood flow altered & oxygen tension begins
to change. Prostaglandins and cytokines released
• Hours: Metabolic changes ocures. Chemical
messengers affects cellular activity. Enzyme levels
change
• 4 Hours: Iincreased cAMP levels are detectable &
cellular differentiation begins within PDL
• 2 Days: Tooth movement begins as osteoclasts &
osteoblasts remodel bony socket
JM 39
No pressure – Normal perfusion of blood vessels

JM 40
Light pressure – blood vessels constricted

JM 41
Tension side – Fibers stretched & Vessels open wide

JM 42
 Result of Continuous Light Force
• Osteoclasts initiates resorption of lamina dura from
the side of PDL
• The osteoclasts arrive in 2 waves
1st wave derived from the PDL itself
2nd wave (larger) from distant areas via blood flow
• All these events lead to FRONTAL RESORPTION

JM 43
Application of Continuous Heavy Force
• < 1 second: PDL fluid is incompressible, alveolar
bone bends, piezoelectric signal generated

• 1 – 3 seconds: PDL fluid expressed & tooth moves

within the socket

• 3 – 5 seconds: Blood vessels with in PDL occlude

on the pressure side
JM 44
• Minutes: Blood flow gets cut off to compressed
PDL area
• Hours: Cell death in compressed area
• 3 to 5 days: Cell differentiation in adjacent marrow
spaces; undermining resorption begins
• 7 to 14 days: Undermining resorption removes
lamina dura adjacent to compressed PDL & tooth
movement occurs
JM 45
Heavy Pressure – Blood flow totally cut off

JM 46
Compressed PDL after Sterile Necrosis

JM 47
 Cellular Changes
• Loss of blood flow causes sterile necrosis of the PDL
• A “Hyalinized” area devoid of cells and vasculature
develops
• Osteoclasts appear within the adjacent bone marrow
spaces and begins an attack on the underside of the
bone immediately adjacent to the necrotic PDL area
• An initial delay in tooth movement ocures
JM 48
• This delay is due to 2 reasons
• The delay in stimulating differentiation of cells
within the marrow space
• A considerable thickness of bone has to be
removed from the underside before any tooth
movement can take place

JM 49
Undermining Resorption

JM 50
Frontal Resorption VS Undermining Resorption

JM 51
 Centre Of Resistance

• It is the point on the tooth when a single force is

passed through it, would bring about its translation
along the line of action of the force
JM 52
• Factors affecting Centre of Resistance
1. Number of roots
2. Degree of Alveolar Bone loss
3. Degree of Root Resorption
JM 53
 ANCHORAGE
• It is the Resistance to Unwanted Tooth Movement

Or

• It is the nature and degree of resistance to displacement

offered by an anatomic unit for the purpose of effecting
tooth movement

JM 54
 Absolute Anchorage

1. Appliances gaining anchorage from extraoral

structures – Extraoral appliances (eg – Head Gear)
JM 55
2. Titanium screws implanted into the alveolar
bone through the gingiva to act as anchorage
JM 56
 Intraoral Anchorage

• Anchorage value of a tooth is proportional to the

surface area of the root
• The tooth with larger root surface area requires
greater force to move

JM 57
Anchorage Value Of Each Tooth

JM 58
• Teeth that are ANKYLOSED or DILACERATED are
very good sources of anchorage
JM 59
 Different Types of OTM

CONTROLLED UNCONTROLLED BODILY MOVEMENT

TIPPING TIPPING

JM 60
ROTATION ROOT
UPRIGHTING

JM 61
INTRUSION EXTRUSION

JM 62
 Optimum Forces For OTMs
TYPE OF MOVEMENT FORCE REQUIRED (gm)
Tipping 35-60
Bodily movement (translation) 70-120
Root uprighting 50-100
Rotation 35-60
Extrusion 35-60
Intrusion 10-20

JM 63
 Forces Delivered by Appliances

• Continuous Force (ideal spring)

• Interrupted Force (removable active plates)
• Intermittent Force (removable appliances)

JM 64
Continuous Force

JM 65
Interrupted Force

JM 66
Intermittent Force

JM 67
Deleterious Effects of Orthodontic Force
• Pain
• Allergic reactions
• Mobility
• Gingival Inflammation
• Loss of vitality of pulp
• Root Resorption

JM 68
 Pain
• If appropriate force (not heavy) is applied, the patient
feels little pain immediately
• Pain develops after several hours
• The patient feels mild aching sensation and the teeth
are quite sensitive to pressure
• The pain usually lasts for 2 – 4 days and disappears
until the appliance is reactivated
JM 69
• For most of the patients, the pain associated with the
initial activation of the appliance is most severe
• Pain is due to the development of ischemic areas in
the PDL
• The pain is directly proportional to the area of PDL
that has undergone sterile necrosis (hyalinization)
• So heavier forces produce larger areas of hyalinization
and greater pain
• Pain can be managed using analgesics like
ACETAMINOPHEN
JM 70
 Allergic Reactions
• Some patients may develop allergic reactions to
Stainless steel which contains NICKEL
• Allergic reactions manifest as widespread
erythema and swelling of oral tissue which
develops 1 – 2 days after starting the treatment
• In such patients, Stainless steel appliances
(brackets, bands, wires etc) should be substituted
with TITANIUM appliances
JM 71
 Mobility
• Mobility is due to
– Widening of PDL space during orthodontic
treatment
– Temporary disorganization of the fibers in the PDL

• Moderate increase in mobility is an expected

response of orthodontic treatment
JM 72
• Heavier Force causes greater degree of Undermining
Resorption which leads to Excessive mobility
• Excessive mobility indicates that there is heavy force
acting on the tooth
• If the tooth becomes extremely mobile, force should
be discontinued until the mobility decreases to
moderate levels
• Excessive mobility will usually correct itself without
permanent damage
JM 73
 Insults to the Pulp
• There will be a modest inflammatory response
within the pulp at the beginning of the treatment
• It may cause an initial mild pulpitis which has no
long term significance

JM 74
 Loss of Vitality of Pulp
• Loss of vitality may be encountered if there is
– History of previous trauma to the tooth
– Poor control of orthodontic forces
• Heavy forces cause abrupt movement of root apex
causing obstruction of the blood flow to the pulp
• Relatively heavy forces applied for intrusion can also
give rise to the same situation
JM 75
 Root Resorption
• Cementum adjacent to the hayalinized PDL undergo
resorption by cementoclast cells
• This can progress to the extend of dentin destruction
• Once orthodontic forces are removed, repair occurs
by the deposition of new cementum in the area of
previous destruction
• Dentin once lost will not be replaced
JM 76
Craters of Root Resorption in Dentin

JM 77
 Types of Resorption
• Slight Blunting
• Moderate resorption – up to ¼ of the root length
• Severe resorption – more than ¼ of the root length
• Moderate Generalized Resorption
• Severe Generalized Resorption
• Severe Localized Resorption

JM 78
Slight Blunting

JM 79
Moderate Resorption

JM 80
Severe Resorption

JM 81
 Moderate Generalized Resorption
• Most of the teeth show some loss of root length
• Greater in patients whose treatment duration
was longer
• Shortening of root length is more for maxillary
incisors
• In most cases, this type of resorption is clinically
insignificant
JM 82
 Severe Generalized Resorption
• This is mostly of unknown etiology
• In case of patients with thyroid deficiency, chances
of developing severe generalized resorption is high
• To prevent this, thyroid supplementation is
indicated

JM 83
 Severe Localized Resorption
• Caused by excessive forces and prolonged
duration of treatment
• Risk of severe resorption is much greater for
maxillary incisors
• Very high risk is noted if roots of maxillary
incisors are forced against the lingual cortical
plate
JM 84
Effect of DRUGS on OTM

JM 85
 Drugs which Enhance OTM

• Vitamin D administration

• Direct injection of Prostaglandin into PDL

(disadvantage – It is very painful)

JM 86
 Synthesis of Prostaglandins

CORTICOSTEROIDS NSAIDS

ARACHIDONIC
PHOSPHOLIPIDS PROSTAGLADINS
ACID

JM 87
 Drugs which Impede OMT
• BISPHOSPHONATES – for Osteoporosis
– Alendronate
• PROSTAGLADIN INHIBITORS
– Indomethacin
• TETRACYCLINES
– Doxycycline
JM 88
• TRICYCLIC ANTIDEPRESSANTS
– Doxepine
– Imipramine
• ANTIARRHYTHMIC agents
– Procaine
• ANTIMALARIALS Drugs
– Quinine
– Chloroquine
JM 89
 Patient with Osteoporosis
• This condition is encountered in case of post-
menopausal females
• The patient may be using BISPHOSPHONATES which
binds to Hydroxyapatite in bone and inhibits
Osteoclast mediated Bone Resorption
• BEFORE ORTHODONTIC TREATMENT,
– Consult the patient’s physician and temporarily
switch to estrogen therapy (Evista)
JM 90
Pain killers – Do they Inhibit OTM ?
• Common analgesics used during treatment
– IBUPROFEN
NSAIDS
– ASPIRIN
• At the dose level used during orthodontic
treatment, they do not impede tooth movement
• Acetaminophen is a better option as it is a centrally
acting agent which does not reduce inflammation
JM 91
Prostaglandin Inhibitors in Microspheres
• If Prostaglandin Inhibitors were placed in mini-
spheres and could be maintained in the sulcus
around tooth (like antibiotics in periodontal
therapy) which has to serve as anchorage, the
efficiency of the orthodontic treatment can be
improved.

JM 92
 Conclusion
• A dentist should thoroughly understand the biological
factors and principles behind Orthodontic Tooth
Movement. He should achieve the desired aesthetic
and functional result using the optimum amount of
force. He should also give consideration to the health
of the periodontium and thus try to minimize the
deleterious effects of the treatment.

JM 93
 REFERENCE

• Contemporary Orthodontics 4/e

• Orban’s Oral Histology and Embryology 11/e
• Ten Cate’s Oral Histology 7/e
• Orthodontics – The Art and Science 4/e

JM 94