Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
2015-04-14
1
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
2015-04-14
2
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)
2015-04-14
3
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 )
0
0.02
0.04
0.06
0.08
0.1
0.12
7 14 21 28
Experimental period (days)
Ap
po
sitio
n ve
loci
ty (
mm
2/m
m/d
ay)
group A
group B
group C
A
0
0.05
0.1
0.15
0.2
0.25
0.3
7 14 21 28
Experimental period (days)
Acc
umul
ate
d a
ppo
sitio
n ar
ea (
mm
2/m
m)
group A
group B
group C
B
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
2015-04-14
4
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
2015-04-14
5
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
2015-04-14
6
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
2015-04-14
7
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
2015-04-14
8
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
0
2
4
6
8
10
12
0 week 1 week 3 weeks 6 weeks 9 weeks 12 weeks 15 weeks
Litt
le index
(m
m)
Mean rate : 1.43 mm/mo.
PhotobiomodulationWhat is the photobiomodulation ?
Development of photobiomodulation on ATM
Current clinical studies in progress
2015-04-14
9
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
2015-04-14
10
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
2015-04-14
11
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
2015-04-14
12
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
2015-04-14
13
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
2015-04-14
14
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
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1st 2nd 3rd 4th (mos.)
Move
men
t dis
tance
(m
m)
Mean rate : 1.15 mm/mos.
2015-04-14
15
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
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th
(mos.)
Move
men
t dis
tance
(m
m)
Mean rate : 0.48 mm/mos.
47% increased
0
0.2
0.4
0.6
0.8
1
1.2
1st mos. 2nd mos. 3rd mos. 4th mos. 5th mos. 6th mos. 7th mos.
Move
men
t dis
tance
(m
m)
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…!