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Review Article

Rapid orthodontics
Bhagyalakshmi A, Avinash BS1, Nitin V Muralidhar
Departments of Orthodontics and 1Periodontology, JSS Dental College and Hospital, Mysore, Karnataka, India

ABSTRACT
Every orthodontic patient requires that the treatment be completed in a short duration. During orthodontic treatment, wearing of orthodontic braces, besides being unaesthetic will also restrict patients from eating certain food; it would also make it difficult for patient to maintain good oral hygiene. Because of these reasons many patients decline for orthodontic treatment. But recently there are many techniques in orthodontics like distraction osteogenesis, corticotomy, etc. where treatment can be completed in a very short duration when compared to conventional treatment. This article discusses one of such technique known as Wilkodontics which helps in faster orthodontic tooth movement, thus helping the clinician to complete the treatment at the earliest.

This faster tooth movement was believed to be due to the reduced resistance of the cortical bonebysurgicalprocedure. Orthopaedist Harold Frost termed this as the regional acceleratory phenomenon (RAP). [2,3] In RAP there is temporary burst of localized soft and hard tissue remodeling (i.e., regeneration) which rebuilds the bone back to its normal state.[4] As early as the 1950s, periodontists began using a corticotomy technique to increase the rate of tooth movement. The inclusion of grafting procedure makes it possible to simultaneously augment and reshape the supporting alveolar bone.[5] Recent animal studies have added more evidence to the effect of corticotomy-assisted orthodontic tooth movement (CAOT). Ren etal,[6] evaluated the effects of alveolar interseptal corticotomy and extraction on orthodontic tooth movement in beagles. The tooth on the experimental side moved more rapidly than the tooth on the control side, without any associated root resorption or irreversible pulp injury. In addition, active and extensive bone remodeling around the moved tooth was shown. Mostafa etal,[7] reporteda doubled rate of tooth movement after corticotomy in dogs and attributed this to the observed increase in bone turnover and the regional acceleratory phenomenon. In another animal study using corticotomy-assisted orthodontic treatment, the third premolar was mesialized significantly faster than the control side in 12dogs. Corticotomy was found to increasetooth movement for at least 2weeks after the surgery and to limit the hyalinization of the periodontal ligaments on the alveolar wall to the first week after corticotomy. This was also attributed to a rapid alveolar bone reaction.[8] Two recent histological studies were conducted to evaluate
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Key words: Corticotomy, regional acceleratory

phenomenon, wilkodontics

INTRODUCTION
One of the most important reasons why patients are reluctant to wear orthodontic appliance is its longer duration of treatment. Wearing braces can be a nuisance and many potential patients decline needed orthodontic work just because of the lengthy treatment times and choose to have the multitude of appointments that are required. While new wire and bracket technologies have reduced treatment times, yet many patients require that treatment be still faster. This article will discuss on a treatment approach that drastically reduces orthodontic treatment duration.

CORTICOTOMY-ASSISTED ORTHODONTICS
Corticotomy has been used in many of the orthodontic treatment or orthognathic surgery. Kole reported combining orthodontics with corticotomy surgery and completed the active tooth movement in adult orthodontic cases in 6--12weeks.[1]
Address for correspondence: Dr. Bhagyalakshmi A, Department of Orthodontics, JSS Dental College and Hospital, Mysore, Karnataka-570015, India. E-mail:drbhagya_la@yahoo.co.in

Website: www.ijhas.in

DOI: 10.4103/2278-344X.96406

International Journal of Health & Allied Sciences Vol. 1 Issue 1 Jan-Mar 2012

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tissue response to decortication. [9,10] Sebaoun etal, [9] evaluated the response of alveolar bone to a selective alveolar decortication in a rat model in terms of time and proximity to the site of decortication without attempting any type of tooth movement. This study demonstrated an increased turnover of alveolar spongiosa as a response to alveolar decortication. Three weeks after surgery, the catabolic activity (osteoclast count) and anabolic activity (apposition rate) were three times greater, calcified spongiosa decreased by twofold and PDL surface increased by twofold. This dramatic increase in bone turnover decreased to a steady state by the 11thweek after surgery. The observed effect of corticotomy was localized to the area immediately adjacent to the decortication cuts. In the other histological study, Wang etal,[10] explained the sequence of events occurring after corticotomy in rats. CAOT was compared to osteotomy-assisted tooth movement and to controls. Corticotomy was found to produce bone resorption around the moving teeth by day21 after surgery and the area refilled with bone after 60days. This confirms the occurrence of reversible osteopenia during CAOT. This combination of corticotomy facilitated orthodontic treatment and periodontal alveolar augmentation has been termed as the accelerated osteogenic orthodontics (AOO) procedure. (The AOO appliances and the method of the accelerated osteogenic orthodontics procedure are patented by Wilkodontics, Erie, PA, USA.)

mandibular bands and brackets with nickel titanium (Niti) wires are placed. Sulcular incisions are placed both labially and lingually using 12B Bard Parker blade all around the maxillary and mandibular teeth except palatally between maxillary central incisors. Vertical releasing incisions are generally not required but if a thick layer of grafting material is required it may be given. Afull thickness flap is elevated both lingually and labially beyond the apices of the teeth taking care not to disturb the neurovascular bundles. Selective partial decortication is done on the labial and lingual aspects of maxillary and mandibular anterior teeth and premolars. Decortication is not done on molars as it wouldbe used as anchorage units. The decorticaton is accomplished with circumscribing corticotomy cuts outlining the roots of the teeth and small round corticotomy perforations where possible. The corticotomy cuts and perforations are made with No.2 round long shank round bur in a high speed handpiece with copious water irrigation and extended only barely into the medullary bone. The interradicualar vertical corticotomy cuts should be 2mm apical to the alveolar crest and extended 2-3mm beyond the apices of the teeth, where they are connected with a scalloped horizontal connecting corticotomy cut. Once this is done bone grafting is followed. An established resorbable grafting mixture for osseous augmentation consisting of approximately equal amounts by volume of demineralized freezed dried bone allograft (DFDBA) and bovine bone can be used. The DFDBA and bovine bone are mixed dry and then wet with clindamycin phosphate/sterile water solution just prior to placement. The mixture is then spread over the partially decorticated bone both labially and lingually. On an average the layer of graft material should 2--3mm thick. The full thickness flap are then returned to their original position and sutured into place with interrupted loop suture. Postsurgically the patient is prescribed antibiotics and analgesics. Analgesics should be stopped as soon as possible and NSAIDs should not be taken until the orthodontic treatment is completed. Scaling will be done 1month following the surgery and the importance of good oral hygiene should be reinforced. The first orthodontic adjustment will be performed approximately 2weeks following the surgery. Thereafter every 2weeks interval orthodontic adjustment is done until the treatment is completed.

WILKODONTICS
Wilkodontics TM -also known as accelerated osteogenic orthodontics (AOO) TM-is a relatively new treatment in the orthodontic realm. This technique has roots in orthopedics, dating back to the early 1900s. Only recently was it modified to assist in orthodontic tooth movement. Wilkodontics or the AOO procedure was developed by DrsThomas and William Wilko, of Erie, PA in 1995. Thomas Wilko is a periodontist in practice for more than 25years, and his brother William Wilko, is an orthodontist in practice for more than 18years. Both were interested in methods of growing bone called distraction osteogenesis and regional accelerated phenomenon (RAP), and modified these methods to work orthodontically with limited trauma to the surgical site.

HOW DOES IT WORK?

Following decorticomy, RAP potentiates tissue reorganization and healing by way of a transient burst of localized hard
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CLINICAL PROCEDURE
A week before the AOO procedure maxillary and

International Journal of Health & Allied Sciences Vol. 1 Issue 1 Jan-Mar 2012

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and soft tissue remodeling.[11] The bone goes through a phase known as osteopenia, where its mineral content is temporarily decreased. The tissues of the alveolar bone release rich deposits of calcium, and a new bone begins to mineralize in about 20-55days. While the alveolar bone is in this transient state, the tooth movement will be faster as the bone is softer and there is less resistance to the orthodontic forces. This accelerated remodeling is influenced by bone density and the hyalinization of the periodontal ligament.[12,13] Yaffe etal,[4] found that in the initial phases of RAP, there will be an increase in cortical bone porosity because of increased osteoclastic activity and speculated that bone dehiscence might occur after periodontal surgery in an area where cortical bone is initially thin. Pfeifer[14] also found increased osteoclastic activity along the PDL surface following surgery. There is strong indirect evidence that the physiologic events associated with RAP following surgery, i.e., calcium depletion and diminished bone densities, result in rapid tooth movement. Ostoclasts are capable of demineralizing bone via a proton pump.[15] Research has shown that once the alveolar bone heals additional alveolar bone forms. So after AOO, the alveolar bone is apparently not only as strong as it was before the procedure but there is actually more of it which is advantageous if the profile of the patient needs to be built up to improve the facial esthetics.

CONCLUSION
By combining the talents of the periodontist and the orthodontist, a viable and a safe orthodontic treatment can be completed in a fraction of the time required for conventional orthodontics. However, the orthodontic clinician must be aware that dental anchorage changes as a consequence of alveolar osteopenia.

REFERENCES
1. 2. 3. 4. Kole H. Surgical operations on the alveolar ridge to correct occlusal abnormalities. Oral Surg Oral Med Oral Pathol 1959;12:515-29. Frost HM. The biology of fracture healing. An overview for clinicians. PartI. Clin Orthop Relat Res 1989;248:283-93. Frost HM. The biology of fracture healing. An overview for clinicians. PartII. Clin Orthop Relat Res 1989;248:294-309. Yaffe A, Fine N, Binderman I. Regional accelerated phenomenon in the mandible following mucoperiosteal flap surgery. J Periodontol 1994;65:79-83. Wilcko MW, Wilcko MT, Bouquot JE, Ferguson DJ. Rapid orthodontics with alveolar reshaping: Two case reports of decrowding. Int J Periodontics Restorative Dent 2001;21:9-19. Ren A, Lv T, Kang N, Chen Y, Bai D. Rapid orthodontic tooth movement aided by alveolar surgery in beagles. Am J Orthod Dentofacial Orthop 2007;131:160.e1-10. Mostafa YA, Mohamed Salah Fayed M, Mehanni S, ElBokle NN, HeiderAM. Comparison of corticotomy-facilitated vs standard tooth-movement techniques in dogs with miniscrews as anchor units. Am J Orthod Dentofacial Orthop 2009;136:5707. Iino S, Sakoda S, Ito G, Nishimori T, Ikeda T, Miyawaki S. Acceleration of orthodontic tooth movement by alveolar corticotomy in the dog. Am J Orthod Dentofacial Orthop 2007;131:448.e18. Sebaoun JD, Kantarci A, Turner JW, Carvalho RS, Van Dyke TE, Ferguson DJ. Modeling of trabecular bone and lamina dura following selective alveolar decortication in rats. JPeriodontol 2008;79:167988. Wang L, Lee W, Lei DL, Liu YP, Yamashita DD, Yen SL. Tisssue responses in corticotomy-and osteotomy-assisted tooth movements in rats: histology and immunostaining. Am J Orthod Dentofacial Orthop 2009;136:770.e1-11; discussion 770-1. Shih MS, Norrdin RW. Regional acceleration of remodeling during healing of bone defects in beagles of various ages. Bone 1985;6:377-9. Verna C, Melsen B. Tissue reaction to orthodontic tooth movement in different bone turnover conditions. Orthod Craniofac Res 2003;6:155-63. von Bohl V, Maltha JC, Von den Hoff JW, KuijpersJagtman AM. Focal hyalinization during experimental tooth movement in beagle dogs. Am J Orthod Dentofacial Orthop 2004;125:61523. Pfeifer JS. The reaction of alveolar bone to flap procedures in man. Periodontics 1965;20:135-40. Dziak R. Biochemical and molecular mediators of bone metabolism. JPeriodontol 1993;64(5Suppl):40715. Wilcko MT, Wilcko WM, Bissada NF. An evidence-based analysis of periodontally accelerated orthodontic and osteogentic techniques: a synthesis of scientific perspectives. Semin Orthod 2008;14:30516. Hajji SS. The influence of accelerated osteogenic response on mandibular decrowding (Thesis) St Louis: St Louis University, 2000. Machado I. Root resorption with and without Corticotomy-facilitated orthodontics (Thesis). St Lousis: St Louis University; 2002.

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ADVANTAGES OF AOO
1. Duration of orthodontic treatment is reduced. 2. Less likelihood of root resorption. 3. Comparable tooth movements are accomplished in 2weeks as compared to 6-to 8-week intervals of conventional orthodontics.[16] 4. AOO procedure can be used to cover preexisting bony fenestrations over the root prominences. 5. An increase in cephalometric point A and point B area.[17,18] 6. In certain situations, the additional alveolar bone can also provide improved lip posture. 7. An improvement in the structural integrity of the periodontium.

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DISADVANTAGES OF AOO
1. Expensive procedure. 2. It is mildly invasive procedure and like all surgeries, it has its risks. 3. Pain and swelling with possible infection.

How to cite this article: Bhagyalakshmi A, Avinash BS, Muralidhar NV. Rapid orthodontics. Int J Health Allied Sci 2012;1:2-4. Source of Support: Nil, Conflict of Interest: None declared

International Journal of Health & Allied Sciences Vol. 1 Issue 1 Jan-Mar 2012