2015-04-14

2015 AAO Annual Session

May 15 - 19, 2015
San Francisco Accelerating
orthodontic tooth movement

Young Guk Park

Kyung Hee University, Seoul

Day 1 immediately after corticision

Corticision

1
 2015-04-14

08-08-2008
06-16-2008
4.8mos after
3mos after corticision
corticision

12-24-2008 03-06-2009
finishing at 9 mos debonding at 11 mos

Park YG, Angle Orthod 2009

Radiogram of tissue block, 29d
Corticision Group, mobile
1 year old cat, Corticision at distal to canine Distinct radiolucent line (unhealed corticision gap)

2
 2015-04-14

7d
compression side, 21 d, HE, X40

R R
H

Ortho only The woven bone formation was found

Corticision
along the resorbed bone surface,

tension side, 21 d, HE, X40

Histomorphometry(Fluorescent microphotographs )

Surgical gap was filled with new bone.

Overlying soft tissue was recovered.

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

0.12 0.3
Accumulated apposition area (mm2/mm)

gr ou p A gr ou p A
Apposition velocity (mm2/mm/day)

gr ou p B gr ou p B
0.1 gr ou p C 0.25 gr ou p C

0.08 0.2

0.06 0.15

0.04 0.1

0.02 0.05

0 0
7 14 21 28 7 14 21 28
A B
Experimental period (days) Experimental period (days)

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).

3
 2015-04-14

Efficiency & Effectiveness

Safetyof tooth movement ?

sound biological milieu

with tooth in bone

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

Max Central Incisor Max Lateral Incisor Max Canine

Evidence-based Practice(EBP) Evidence based practice ; PICO

Sacket DL, Evidence-based Practice:
-is integration of best research evidence with clinical expertise and Accelerating Tooth
patient values Movement

Light accelerated
Orthodontics

Cytokinetic,
EBP
Electric, Surgical, etc

Treatment Duration

4
 2015-04-14

Photobiomodulation: Uribe F, AJODO 2014

Light Accelerated Orthodontics
to Reduce Treatment Duration
Orthodontists (n=683)
Adolescent patients (n=200)
Their parents (n= 200)
Adult patients (n=50)

Long , Systematic review, AO, 2013

Non-invasive method
Vs. Low-level laser therapy
Safe but unable to accelerate
Surgical method Corticotomy
Effective and safe
Electrical current
Accelerated treatment techniques were Current evidence does not reveal
listed on the questionnaire for the first time. Pulsed electromagnetic fields
About 26% of the respondents reported some use of these Current evidence does not reveal
methods in the previous year, with a median six cases Dentoalv. or perio. distraction
treated. Promising but lacks convincing evidence

Although a number of techniques were used, the most

common were AcceleDent (used routinely or
occasionally by 62% of the practices performing accelerated
treatment)

Keim, et al. 2014

Clinical trials in KHU

Non-invasive ATM, Current clinical studies at KHU Vibration Photobiomodulation

Orthodontic force
The effects of vibration on the rate of The effects of LED PBM on the rate of
orthodontic tooth movement orthodontic tooth movement
Accelerated Tooth during alignment during space closure
Bone remodeling
Movement

RAP

Adjunctive surgical Pharmacologic Non-Invasive mechanical

Corticision PTH Photobiomodulation
Piezocision Vit D3 (LLLT / LED)
Corticotomy OPG Vibration
Osteotomy RANKL Ultrasound
Puncture Electrical Stimulation
Thyroxine
Static magnetic field
Prostaglandins Appliance

5
 2015-04-14

Frost. 1960

Accelerating tooth movement by Non-Invasive Devices Bone Metabolism

Mechanostat theory
What is the vibration ?

Development of vibration studies on ATM

Vibration
Current clinical studies of vibration in progress

What is the photobiomodulation ? Increased loading Reduced loading

Photobiomodulation Development of photobiomodulation studies on ATM Exercise Long-term bed rest
Orthodontic Treatment Zero Gravity
Current clinical studies of photobiomodulation in prgress

Skeletal homeostasis and bone formation

Rubin, et al. 2002

Bone mass is maintained under. Bone mass is maintained under.
Microstrain Microstrain
10,000 10,000

4 cycles per day of 4 cycles per day of 2000

Formation Formation
2,000 microstrain microstrain
1,000 1,000 low level (< 10 microstrain), high frequency
The extremely
100 cycles per day of 100 cycles,
1,000 microstrain (20-50 Hz) mechanical strains are as effective to maintain the
1000 microstrain
skeleton as the bigger strains typically associated with vigorous
Maintenance Maintenance
Resorption activity (>2,000 microstrain). Resorption
100 100

Hundreds of 1,000 cycles of Hundreds of thousands of

<10 microstrain cycles, <10 microstrain

0.1 1 10 100 1,000 10,000 1,000,000 0.1 1 10 100 1,000 10,000 1,000,000
Number of daily loading cycles Number of daily loading cycles
Rubin, et al. 2002

Vibration & bone metabolism

Osteogenic potential of HFLM force

Cyclic forces have been proven to alter physiological Activates mechanoreceptors in bone cells
responses in long bones Vibration
Stimulates molecules that regulate OBs and OCs
Increases the anabolic activity of bone tissue

Increased rate of fracture healing

Increased cellular signaling to enhance bone density

Roberts WE, Seminars in Orthodontics 2006

6
 2015-04-14

X40, Copyright Park YG, Kyung Hee University, Seoul

Mauney, et al. 2004

Zhou, et al. 2011

from bone marrow Osteoblast proliferation

stromal cells
Osteoblast activation
(BMSCs)
Development of vibration studies on ATM

Vibration Animal studies

Osteoblast proliferation
from PDL stem cells
(PDLSCs) Osteoblast activation
Zhang 2012

Animal studies

Animal studies, vibration

Increased bone metabolism w/ tooth movement

Consistent results of increased bone remodeling and

accelerated tooth movement using vibration.

Findings from human studies

Alignment
Extraction space closure
No clinically relevant root resorption
Development of vibration on ATM
Satisfied with treatment
Clinical studies Easy to use
Reduce pain

7
 2015-04-14

Vibration Study design

Inclusion criteria
Littles Irregularity Index:
Current clinical study of vibration on ATM Non-extraction group : 4~7mm
KHU clinical study in progress Extraction group : > 8mm (Upper 1st premolar extraction)
Good oral hygiene
No radiographic evidence of periodontal diseases

Study design Assessment

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, Control
Orthodontic only and No Vibration Impression at every visit during alignment (every 3wks)

Irregularity measurement : distance from contact point to

AcceleDent adjacent tooth contact point (Sum of UR3 to UL3)

Result
12

10
Little index (mm)

8
Mean rate : 1.43 mm/mo.
6 What is the photobiomodulation ?
Photobiomodulation Development of photobiomodulation on ATM
4

Current clinical studies in progress

2

0
0 week 1 week 3 weeks 6 weeks 9 weeks 12 weeks 15 weeks

8
 2015-04-14

Biostimulatory effect of photobiomodulation, Zhang 2009

LLLT, LED

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

What is the Photobiomodulation? - Such photobiomodulation has been observed to increase

mitochondrial metabolism, facilitate wound healing and promote
Biostimulatory effect angiogenesis

Biostimulatory effect of photobiomodulation with LLLT Biostimulatory effect of photobiomodulation, Hamblin 2006

Wound healing Kana JS, et al. 1981

Mester E, et al. 1978, 1985
600-950 nm
Mester E, et al. 1985
Anti-inflammation Mohammadreza S, et al.
2007
Albertini R, et al. 2007
Shimizu,et al. 1995
Pain reduction Turhani D,et al. 2006
Cellular
Boulton M, et al. 1986 Photoreceptor
Fibroblast and chondroblast proliferation Soudry M, et al. 1988
Van BH, et al. 1992
Collagen synthesis Schultz RJ, et al. 1985

Abergel RP, et al. 1984 Wound healing Relief of inflammation Neurogenic pain
Balboni GC, et al. 1986
Tissue repair Pain, edema Neurological problems
Nerve regeneration Acupuncture
Prevention of tissue death Acute injuries
Anders JJ, et al. 1993 Chronic diseases
Bone regeneration
- Fracture Healing, ATM

Photobiomodulation

ATP

Cell activity

Bone / PDL remodeling

Accelerate tooth movement

9
 2015-04-14

In press at Seminars in Orthodontics, ed by Mani Alikhani

Low level laser & LED

Laser LED
Wavelength constant Monochromatic Nearly monochromatic
What is the Photobiomodulation?
Coherence Coherent Incoherent

Low level laser & LED 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

10
 2015-04-14

Ease of use Ease of use

Complex vs Easier Complex vs Easier

Laser, Complex for use LED is Easy & safe

Chair time is required,
Operator must be trained, Application to a larger area of the body surface with fewer side effects
Time consuming,
Layperson is able to use easily
Caution when used by layperson.
Area of pin point positioning may not be an issue

Advantage/Disadvantage
Selective site vs whole arch,
Once a week application,

Low level laser & LED, Karu 2005

Low level laser LED

Higher cost Lower cost
Time consuming Shorter treatment duration
Repeatability and positioning Repeatability and positioning
may be an issue. may not be an issue.
Development of photobiomodulation on ATM
Chair time is required. Easy to use
Operator must be trained. Safe to use Molecular & cellular response to photobiomodulation
Application to a pin point area Fewer side effects
Application to a larger area of
the body surface

Carvalho-Lobato, SR, 2014

Development of photobiomodulation on ATM

Animal & Clinical studies, from LLLT to LED

11
 2015-04-14

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

5 human studies(canine traction)

11 studies in rats(1st premolar traction)

4 human studies / 8 animal studies

showed statistically significant changes. Development of photobiomodulation on ATM
Animal studies
It remains unclear
determining dose limits that produce desired biological
effect towards reduction of the orthodontic treatment time

Animal studies from LLLT to LED

LLLT
(2000~)

Development of photobiomodulation on ATM

Human Subjects clinical studies

LED
(2008~)

Human subjects clinical studies from LLLT to LED

Photobiomodulation, Light Accelerated Orthodontics

LLLT
(2004~)

Current clinical studies of PBM on ATM

clinical studies in progress

LED
(2013~)

12
 2015-04-14

Photobiomodulation, Light accelerated orthodontics Photobiomodulation, Light accelerated orthodontics

Clinical studies in progress Clinical studies in progress

Status / Clinical Trials

Status / Clinical Trials Investigator / Institution
Investigator / Institution Enrolled Focus of Study
Enrolled Focus of Study
BX8 Case Series: Beta OrthoPulseTM evaluation and assess clinical
TS1,5 Tim Shaughnessy Completed Pilot: Non-extraction. Alignment and total Tx time. (CTB and SLB) Marc Lemchen, NYC, NY IP effectiveness.
Suwanee, GA, USA (n=11 of 11) Adolescent & Adult. Submitted for publication. Under review Tito Norris, San Antonio, TX (n=55 of
TS2 Tim Shaughnessy RCT Pivotal: Non-extraction. Alignment and total Tx time, Root Tim Shaughnessy, Suwanee, 100)
Suwanee, GA, USA IP integrity & Pain evaluation. Sham Controls. (CTB) Adolescent. GA
Univ Alabama and Forsyth (n=26 of 30) TD1/TD2 Completed Pilot Study: Efficacy of OrthoPulseTM and Invisalign treatments.
Institute, USA Todd Dickerson, Phoenix, AZ (n=12 of 12) Cross-over design.
EUC2 Said Samara & Don RCT: Extraction. Velocity of space closure in en-masse retraction. TD3 IP RCT: Effect of OrthopulseTM on aligner change rate during
Ferguson Completed (Passive SLB) Adolescent & Adult. Manuscript in preparation. Todd Dickerson, Phoenix, AZ (n=4 of 10) invisalign treatment. Corss-over design.
European Univesity College (n=60 of 60)
Dubai, UAE TD4 IP RCT: Effect of OrthopulseTM on total invisalign treatment time.
MC Peerapong Santiwong RCT: Non-Extraction. Alignment and total Tx time. Bone Quality Todd Dickerson, Phoenix, AZ (n=2 of 28)
IP
Mahidol Univ. Bankok, and Root integrity eval CBCT (Passive SLB) Adult and Adolescent.
(n=42 of 45) UAB2 RCT: Effect of OrthopulseTM on treatment timeline with clear
Thailand IP
Chung How Kau. University of aligners.
(n=0 of 40)
TS3 Tim Shaughnessy IP Case series. Total Tx time. Adolescents and Adults. (Mixed Alabama at Birmingham, AL
Suwanee, GA, USA (n=25 of 30) brackets and mechanics)
EUC3 RCT Pivotal: Non-extraction. Alignment and total Tx time, Root
Don Ferguson et al. IP integrity & Pain evaluation. Sham Controls. (CTB) Adolescent.
KHU1 Young Guk Park IP RCT: Effect of OrthoPulseTM on the rate of en-masse retraction 6
European University College (n=0 of 40)
Kyung Hee U, Korea (n=40 of 45) anterior teeth
Dubai, UAE

Photobiomodulation Photobiomodulation, Light Accelerated Orthodontics

Study agenda; Intra-oral photobiomodulation for tooth alignment

Arch
Measure Group Mean SD Min Max Difference P Value
N

Control 10 0.44 0.2 0.19 0.83

Alignment
Rates 186.3% 0.0002
intraoral 18 1.27 0.53 0.24 2.06

Days to
Control 10 104 55 42 204 Current clinical studies of PBM on ATM
Alignment 53.6% 0.0049
intraoral 18 48 39 17 164 Clinical study at KHU, Seoul
Control 10 5.77 1.57 3.70 8.80
Starting LII 26.0% N.S
intraoral 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)

Study objectives

Experimental group: (n=30)

Group I (n=15) application 3min
Evaluate the effect of PBM by intraoral LED device(OrthoPulseTM, Biolux,
Canada)appliance on the rate of tooth movement.
Group II (n=15) application 6min
Control group(group III, n=15)
The specific aims of the study are:
En masse retraction
19X25 SS To verify the efficacy of PBM on the rate of en-masse retraction
OrthopulseTM (850nm, 60mW/cm2) of the 6 anterior teeth in extraction cases.
Tooth movement rate
To establish the optimal clinical protocol of PBM by the intraoral LED
device for accelerating tooth movement.

13
 2015-04-14

Study sample Study design, PBM; OrthoPulseTM, 60mW/Cm2

PBM; OrthoPulseTM, 60mW/Cm2

Inclusion criteria
Group I (n=15): Home use of PBM Group
Skeletal, dental Class I with bialveolar protrusion
Orthodontic force and Application of PBM for 3 min/day
Age over 12 YO with permanent dentition, no gender discrimination
Upper first bicuspid extraction
Mmaximum to absolute anchorage Group II (n=15): Home use of PBM Group
No radiographic evidence of bone loss and/or periodontal conditions Orthodontic force andApplication of PBM for 5 min/day

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

Measurement Measurement

Taking study model at every visit during space closure,

Lateral headfilms before and after space closure, and
and measure the amount of TM
measure the amount incisor movement.

Pt value Mean
DIVERGENCY
SUM() 402.6 391.8
PFH/AFH(%) 64.7 68.5 1.6
OP-FH() 13.2 8.3
Mean rate : 1.15 mm/mos.
MP-FH() 33.2 23.5
Maxilla-Mandible Relation 1.4
ANB () 4.2 2.3
Movement distance (mm)

AB-FH () 81.8 80.6

APDI() 82.9 85.6
1.2
MAXILLA
SNA() 81.2 82.1 1
N perp-Pt.A (mm) 0.7 0.4
MANDIBLE
SNB() 77.0 79.8 0.8
N perp-Pog(mm) -9.2 -2.2
DENTURE
IIA() 112.6 124.1 0.6
U1-FH() 118.6 116.2

0.4
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 0.2

SOFT TISSUE
Nasolabial A() 97.3 90.4
Upper lip to E-Plane -1.4 -0.8 0
Lower lip to E-Plane 3.4 0.5
1st 2nd 3rd 4th (mos.)
Upper LIP THICKNESS 13.1 12.2
Lower LIP THICKNESS 14.9 13.6
U pharyngeal width 16.5 17.4
L pharyngeal width 16.6 11.3

14
 2015-04-14

Pt value Mean
0.9
DIVERGENCY
SUM() 399.9 391.8
PFH/AFH(%) 62.1 68.5 0.8
OP-FH() 7.4 8.3 Mean rate : 0.48 mm/mos.
MP-FH() 28.8 23.5
Maxilla-Mandible Relation 0.7
ANB () -0.3 2.3

Movement distance (mm)

AB-FH () 84.0 80.6
APDI() 92.1 85.6 0.6
MAXILLA
SNA() 75.9 82.1
N perp-Pt.A (mm) -3.4 0.4 0.5
MANDIBLE
SNB() 76.3 79.8
N perp-Pog(mm) -7.6 -2.2 0.4
DENTURE
IIA() 111.4 124.1
U1-FH() 126.1 116.2
0.3
IMPA() 93.8 96.3
U6-PP(mm) 24.5 25.4
ANS-U1 tip(mm) 25.8 29.3
0.2
U1 exposure (mm) 1.6 2.3
SOFT TISSUE
Nasolabial A()
Upper lip to E-Plane
72.4
0.9
90.4
-0.8
0.1
Lower lip to E-Plane 3.9 0.5
Upper LIP THICKNESS 10.0 12.2
Lower LIP THICKNESS 13.0 13.6
0
U pharyngeal width 16.2 17.4 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th
L pharyngeal width 9.4 11.3
(mos.)

Conclusion
Comparison of tooth movement rate
1.2 Light-accelerated orthodontics shows ;
Movement distance (mm)

1 promise in producing noninvasive stimulation of the dentoalveolar

Group I (3min.) Group III (control)
0.8
complex with cytochrome oxidase C mediated ATP production in the
0.6
mitochondrial cells.
0.4
Mean rate :
0.2 0.88 mm/mos. Cytochrome oxidase C mediated ATP production is upregulated
0 0.60 mm/mos.
1st mos. 2nd mos. 3rd mos. 4th mos. 5th mos. 6th mos. 7th mos. 2-fold by infrared light. During the tooth movement, higher ATP
availability helps cells turnover more efficiently, leading to an

47% increased increased remodeling process and acceleraed tooth movement.

Photobiomodulation,
as an alternative treatment option Thank You!
to surgical approaches for accelerated tooth movement.

Guidelines
- Intensity
- Duration
Young Guk Park, DMD,MSD,PhD,MBA,FICD.
- Dose Professor of Orthodontics
Dean, Kyung Hee University School of Dentistry, Seoul
- Frequency
- Interaction with other treatment modality

15