Clin Dent Rev (2018)2:4

https://doi.org/10.1007/s41894-017-0013-1

TECHNIQUES

Micro-osteoperforations in accelerated orthodontics

C. Sangsuwon1,2 S. Alansari1,3 J. Nervina2 C. C. Teixeira2

M. Alikhani1,3,4

Received: 6 November 2017 / Accepted: 8 November 2017

 Springer International Publishing AG, part of Springer Nature 2017

Abstract Micro-osteoperforation (MOPs) is a procedure based on sound bone

biology principles that has been developed to address the growing demand for rapid
orthodontic treatment, especially by adult patients. This is a safe, minimally inva-
sive technique that can be used in conjunction with any orthodontic appliances, not
only to accelerate tooth movement, but in many other clinical situations, namely to
change the type of tooth movement or create differential anchorage. Here we
summarize MOPs indications and describe all of the steps required for safe and
comfortable application of MOPs during orthodontic therapy.

Keywords Accelerated
Orthodontics
Tooth movement
Micro-osteoperforations

(MOPs)
Techniques
Clinical application

Quick reference/description

Micro-osteoperforation (MOPs) is a procedure in orthodontics in which small

pinhole perforations are created in the bone around the teeth to accelerate the rate of
tooth movement during orthodontic treatment. This procedure activates the release
of cytokines that in turn recruit osteoclasts to the area to increase the rate of bone
resorption. Due to activation of osteoclasts and temporarily reduction in bone

& M. Alikhani
Mani_Alikhani@hsdm.harvard.edu
1
Consortium for Translational Orthodontic Research (CTOR), Hoboken, NJ, USA
2
Department of Orthodontics, New York University College of Dentistry, New York, NY, USA
3
The Forsyth Institute, Cambridge, MA, USA
4
Advanced Graduate Education Program in Orthodontics, Department of Developmental
Biology, Harvard School of Dental Medicine, Boston, MA, USA

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density, the application of MOPs is not limited to accelerated tooth movement and
can be used in many different clinical scenarios where, due to dense cortical bone,
orthodontic treatment previously was not possible or could not produce optimal
results (Table 1). This procedure is designed to serve as a complement to any
orthodontic appliance, including fixed appliances (braces), clear aligners, or
removable appliances such as expanders, distalizers, among others.

Indications

Micro-osteoperforations are very easy to apply during a routine orthodontic visit.

However, clinicians should carefully plan MOPs application to facilitate the
movement that they are trying to accomplish at each visit, taking into consideration
anchorage needs, type of movement, bone anatomy, etc.

Procedure

The MOPs procedure may be completed by the dentist/orthodontist as dictated by

the clinical needs, with minor discomfort or complications to the patients, following
the steps described below.

Step I: medical and dental history

A complete medical and dental history of the patient should be obtained.

Information regarding allergy to any component(s) of local anesthetics,

Table 1 Clinical applications of micro-osteoperforation, a procedure that can be used to facilitate and
accomplish different types of movements and corrections
Objectives Clinical applications

Accelerating tooth movement Different stages of adult treatment

Facilitating root movement/bodily
movement
Movement into deficient alveolar
bone
Differential anchorage
Decreased possibility of root
resorption
Expansion in adults and asymmetric
expansion
Uprighting/intrusion/extrusion/root torque/closure of large space
Closure of old extraction space
Reducing bone density around teeth to be moved, while
preserving anchorage unit
Reducing bone density and duration of exposure to osteoclasts
Facilitate dental expansion in adults with less possibility of
recession
Asymmetric change in biological response to facilitate
asymmetric expansion

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Table 2 Medical conditions that may contraindicate the use of Micro-osteoperforation and/or may
require medical clearance before the procedure
General medical conditions Specific contraindications

Cardiovascular problems Angina pectoris

Myocardial Infarction
Coronary artery bypass grafting
Stroke
Dysrhythmias
Congestive heart failure
Pulmonary problems Chronic obstructive pulmonary disease
Severe asthma
Renal problems Renal dialysis
Renal transplant
Hepatic disorders Impaired liver function
Endocrine disorders Diabetes mellitus
Adrenal insufficiency
Hyperthyroidism
Hematologic problems Hereditary coagulopathies
Therapeutic anticoagulation
Neurologic disorders Seizure disorders
Alcoholism
Pregnancy

consumption of tobacco or excessive alcohol or any other condition, such as

uncontrolled diabetes, that may contraindicate MOPs should be obtained (Table 2).

Step II: informed consent

Patient informed consent should be obtained prior to performing MOPs. The

consent form should include possible side effects of the minor surgical procedure
(Fig. 1).

Step III: patient evaluation

Intraoral examination of the area should be performed. The length and thickness of
the attached gingiva, health of the periodontium, closeness of the frenum, distance
between teeth and their inclination, and accessibility of the area of interest for
performing MOPs should be evaluated.
The quality of the bone, location of the sinus, proximity of the inferior alveolar
nerve, distance between the roots, and length of the roots should be evaluated in the
panoramic radiograph just prior to MOPs application. Radiographs taken within
6 months prior to MOPs treatment can be used for evaluation.

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Fig. 1 Sample of consent form for application of micro-osteoperforations (MOPs)

Before initiating the MOPs procedure, the location, number, and depth of the
MOPs should be carefully planned. Below are some guidelines to help the clinician
with this planning.

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Location

Area of application

The maximum effect can be obtained when MOPs are applied close to the target
teeth and far from the anchor teeth. MOPs are done usually in the buccal surface
between the roots, on the alveolar ridge (in case of extraction) or, if needed, in the
lingual surface between the roots (Fig. 2).
If the mechanical design provides precise force application in a certain direction,
MOPs should be applied around the target tooth to encourage more bone remodeling
(Fig. 3a).
It is possible to encourage movement in the desired direction by focusing the
MOPs application in one direction, compensating for mechanical shortcomings in
guiding precise movement (Fig. 3b).

Height

The superior and inferior limits of MOPs can be determined in relation to the
mucogingival junction (MGJ). MOPs should be placed within the attached gingiva
to 1 mm apical to the MGJ (Fig. 4). When a resistance toward root movement is
observed, MOPs are placed more apically.

Fig. 2 Area of application of MOPs for catabolic stimulation. To harness the bone resorption effects of
MOPs, perforations are located mesial and distal of the target tooth in the area of the attached gingiva

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Fig. 3 Strategic application of MOPs based on desired direction of movement. In some setups, such as
the use of an overlay wire, the direction of movement is dictated by the wire and is difficult to control by
the clinician. MOPs can be applied around the target tooth for buccal movement in the direction of the
blue arrow (a). However, application of unilateral MOPs facilitates displacement in one particular
direction (shown by blue arrow) and allows the clinician to have better control on the direction of
movement (b)

Mesiodistal position

Root location and angulation should be considered while performing MOPs. MOPs
should be applied mesial and distal to the root of the tooth to be moved.

Buccal/lingual placement

Micro-osteoperforations can be applied in both buccal and lingual cortical plates.

The buccal cortical plate is the most favorable place for placement of MOPs.
However, when the lingual cortical plate affects the movement of the tooth, MOPs

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Fig. 4 Application of MOPs in

the buccal cortical plate. Height
of application of MOPs should
be limited to the attached
gingiva for patient comfort.
a Height of application of MOPs
around anterior teeth,
b application of MOPs around
posterior teeth may have
different distribution and
number, as determined by root
proximity, accessibility, and
width of attached gingiva

can be applied in the lingual plate. In this regard, contra-angle appliances are used to
facilitate MOPs application in the lingual plate (Fig. 5).
In cases where bone resorption significantly decreased the width and height of
alveolar bone, thereby decreasing buccal and lingual cortical bone, MOPs can be
applied on top of the ridge.

Number and depth of MOPs

Usually two to four perforations per site are ideal. However, when the higher
number of MOPs is not possible, perforation depth can be increased to compensate
for the smaller number of perforations.
The thickness of soft tissue and cortical plate should be considered when
deciding how deep to perforate the cortical plate. In general, MOPs with penetration
depths of 37 mm into the bone is recommended.

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Fig. 5 Contra-angle devices

(manual or rotary) for access to
the lingual cortical plates and
the posterior buccal cortical
surfaces. They also facilitate
perforation of thick bone that
may resist the use of handheld
devices

Step IV: MOPs tools and setup

All tools should be available and accessible before the procedure is initiated. To
perform MOPs, the following instruments and materials are recommended:
MOPs tool
Chlorhexidine oral rinse solution
Gauze/cotton rolls
Cheek retractor
Topical and local anesthesia
Carpule syringe and needle gauge
College plier and mouth mirror
Periodontal probe
Suction and water syringe

Step V: MOPs procedure

The following protocol is used to perform the MOPs procedure:

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Fig. 6 Step-by-step performance of MOPs in the anterior area. a Application of topical anesthetic,
b application of local anesthetic, c application of MOPs, d attached gingiva right after application of
MOPs

Ask the patient to rinse his/her mouth with 15 ml of chlorhexidine oral solution
for 30 s.
Select the area of MOPs application. Use a lip/cheek retractor for clear access.
To eliminate excess saliva and dry the location, wipe the area with a wet gauze
or cotton roll.
Apply topical anesthesia on the area planned for anesthetic injection and leave
for 12 min.
Start local infiltration with fine needle tip. The amount of anesthesia for one
location is about one fourth carpule or less. Wait a few minutes after the injection
and use a probe or explorer to check if the area is sufficiently anesthetized.
Set up sterile MOPs tool with a disposable tip set to the appropriate length, and
gently perforate the cortical plate in the area of interest with a light
stable rotation movement. Remove the tool gently by rotating in the opposite
direction after perforation reaches the set depth (Fig. 6).
Slight bleeding is normal and can be stopped using wet gauze/cotton pressed on
the MOPs site.
Evaluate the area.

Step VI: MOPs postoperative care

In case of discomfort patient is advised to take pain medication, such as

acetaminophen. Anti-inflammatory medication (such as non-steroid anti-

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inflammatory drugs) should not be prescribed as such drugs inhibit the inflammatory
effect of MOPs, thereby rendering the procedure ineffective.
In case of poor oral hygiene or in patients with compromised health,
chlorhexidine rinses are recommended. Advise the patient not to change their
brushing and flossing habits in the area where MOPs have been applied.

Pitfalls and complications

Due to the reduced bone density and the accelerated tooth movement induced by
MOPs, clinicians should carefully plan their mechanics to avoid unwanted
movement or side effects of their force system. We recommend restricting the
application of MOPs to the teeth to be moved or after the space has been created for
those movements. In addition, reuse of the MOPs tool is not recommended and can
increase the possibility of infection.

Further reading

1. Sangsuwon C, Alansari S, Lee YB, Nervina J, and Alikhani M (2017) Step-by-step guide for
performing micro-osteoperforations. In: Alikhani M (ed) Clinical guide to accelerated orthodontics:
with a focus on micro-osteoperforations. Springer Internal Publishing, Cham, pp 99116. https://doi.
org/10.1007/978-3-319-43401-8_6
2. Alikhani M, Raptis M, Zolden B, Sangsuwon C, Lee YB, Alyami B, Corpodian C, Barrera LM, Khoo
E, Teixeira CC (2013) Effect of micro-perforations on the rate of tooth movement in human. Am J
Orthod Dentofac Orthop 144(5):639648 (PMID: 24182579)
3. Alikhani M, Alyami B, Lee IS, Almoammar S, Vongthongleur T, Alikhani M, Alansari S, Sangsuwon
C, Chou MY, Khoo E, Boskey A, Teixeira CC (2015) Saturation in biological response to orthodontic
forces and its effect on rate of tooth movement. Orthod Craniofac Res 18[Suppl 1]:817. https://doi.
org/10.1111/ocr.12090
4. Alikhani M, Alansari S, Sangsuwon C, Alikhani M, Chou MY, Alyami B, Nervina JM, Teixeira CC
(2015) Micro-Osteoperforations: minimally Invasive Accelerated Tooth Movement. Seminar in
Orthodontics 21(3):162169

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