acclerated orthodontics.pptx

Orthodontics has been developing greatly in achieving the desired results both clinically and technically.

Today, it is still very challenging to reduce the duration of orthodontic treatments.

It is one of the common deterents that the orthodontist faces and it causes irritation among adults plus increasing risks of caries, gingival recession, and root resorption.
A number of attempts have been made to create different approaches both preclinically and clinically in order to achieve quicker results, but still there are a lot of uncertainties and unanswered questions towards most of these techniques.

1. DEPARTMENT OF ORTHODONTICS AND DENTOFACIAL ORTHOPAEDICS

2. ACCELERATED ORTHODONTICS 2 Prepared under the guidance of Prof. (Dr.) Mohammad Mushtaq HOD & GUIDE PRESENTED BY: DR. MONIKA CHIB POSTGRADUATE STUDENT

3. CONTENTS Introduction Historical Perspective Biological principles behind accelerated tooth movement Methods Of Accelerating Tooth Movement Surgical approach Corticotomy facilitated Osteotomy facilitated 3

4. 4 Other proposed approaches Biological approach Cytokines Prostaglandin Vitamin D3 PTH Piezocision technique Micro- osteoperforation Device-assisted treatment Cyclical force device effect on tooth movement. Direct electric current effect on tooth movement. Photobiostimulation Conclusion References

5. Various terms used: 5 SFOT: Surgically Facilitated Othodontics Therapy CAOT: Corticotomy Assisted Orthodontic Treatment PAOO: Periodontally Accelerated Osteogenic Orthodontics AOO: Accelerated Osteogenic Orthodontics WO: Wilckodontics / WilckoOrthodontics SAD: Selective Alveolar Decortication RAP: Regional Acceleratory Phenomenon

6. 6 DO: Distraction Osteogenesis RCR: Rapid Canine Retraction PD: Periodontal Distraction DD: Dental Distraction/ Interdental Distraction DAD: Dentoalveolar Distraction TDAD: Transport Dentoalveolar Distraction SF-RTM: Surgically Facilitated Rapid Tooth Movement

7. INTRODUCTION Orthodontics has been developing greatly in achieving the desired results both clinically and technically. Today, it is still very challenging to reduce the duration of orthodontic treatments. It is one of the common deterents that the orthodontist faces and it causes irritation among adults plus increasing risks of caries, gingival recession, and root resorption . 7

8. 8 A number of attempts have been made to create different approaches both preclinically and clinically in order to achieve quicker results, but still there are a lot of uncertainties and unanswered questions towards most of these techniques.

9. HISTORICAL PERSPECTIVE 9 The concept of corticotomy was introduced by Hullihan in 1892. Farrar : first to report the use of his “positive system”, a specialised screw to retract canine into the first premolar extraction space Codivilla (1905) : performed first limb lengthening using external skeletal traction after an oblique osteotomy of the femur. Ilizarov (1951) : Russian orthopaedic Surgeon who developed a single stage procedure to lengthen long bones and subsequently developed and popularised DO.

10. 10 Snyder(1973) : used Ilizarov’s technique to perform mandibular lengthening by gradual distraction in canine model. McCarthy(1992) : first used the principles of distraction osteogenesis in the craniofacial skeleton - performed lengthening of human mandible. Eric Liou & Huang(1998) : introduced the concept of DO in tooth movement Ferguson & Wilcko (2000) : affirmed that by moving teeth through a surgical healing site, tensional stress on the teeth act in a synergistic manner with the growth factors and redefine local bone mass

11. DIFFERENT APPROACHES TO ACCELERATE THE RATE OF TOOTH MOVEMENT 11 All theories agree that osteoclast activation is the main rate-controlling factor in orthodontic tooth movement!

12. METHODS OF ACCELERATING TOOTH MOVEMENT 12

13. SURGICAL APPROACH 13

14. 14

15. 15 CORTICOTOMY ASSISTED ORTHODONTIC TOOTH MOVEMENT

16. 16 Corticotomy is one of the surgical procedures that is commonly used in which only the cortical bone is cut and perforated but not the medullary bone, suggesting that this will reduce the resistance of the cortical bone and accelerate tooth movements. It was tried in orthodontics by Kole , where movements were achieved between 6 and 12 months. Grenerson used it for open bite treatment.

17. INDICATIONS 17 Adult patients requiring shorter treatment time. Patients requiring high anchorage control. Resolve crowding and shorten treatment time Accelerate canine retraction after premolar extraction. Facilitate eruption of impacted teeth. Molar intrusion and open bite correction. Patient with alveolar bone volume deficiency Dentoalveolar discrepancies such as severe crowding. Corticotomy assisted expansion (CAE) to treat maxillary deficiency in adults. Enhance post-orthodontic stability.

18. CONTRAINDICATIONS 18 Patients showing any sign of active periodontal disease Individuals with inadequately treated endodontic problems Patients making prolonged use of corticosteroids Persons who are taking any medications that slow down bone metabolism, such as bisphosphonates and NSAIDs. Non-compliant patient.

19. BIOLOGICAL BASIS 19 TRANSIENT ALVEOLAR OSTEOPENIA

20. REGIONAL ACCELERATORY PHENOMENON 20 Healing and remodeling are the natural responses following injury and surgery. Harold frost observed the correlation between degree of injury and intensity of physiological healing response. The greater the insult, the more accelerated and intense is the regional healing response.

21. 21

22. SURGICAL TECHNIQUE 22 Flap design Full thickness flap is elevated towards the coronal aspect and partial thickness flap towards the apical portion to avoid tension at the time of closure.

23. 23 2. Decortication Corticotomies are done in mid interdental areas, using no 2 carbide bur .

24. 24 3. Bone Graft Commonly de- proteinized bovine bone, decalcified freeze dried bone allograft and autogenous bone grafts are used.

25. 25 4. Primary closure For predictable bone augmentation, flap should be closed without excessive tension. Flap is usually sutured at the mid line in the interproximal areas followed by other areas.

26. 26 ADVANTAGES Faster tooth movement results in shorter treatment duration and therefore, reduces patient burnout. Increases the envelope of tooth movement. Enhanced post-orthodontic stability due to loss of tissue memory from high tissue turnover of the periodontium Repairs pre-existing alveolar dehiscence by increasing the post treatment alveolar volume and covers vital root surfaces Reduces root resorption facilitates eruption of impacted teeth Alleviates the need for extraction in some patients through bone extension Reduced appliance adjustment plan Usually performed as an outpatient procedure, therefore, risk of nosocomial infection is reduced.

27. 27 DISADVANTAGES Invasive procedure leading to high morbidity. Chances of damage to adjacent vital structures. Postoperative pain and swelling. Chances of infection or avascular necrosis. Low acceptance by the patient. Recession and loss of attached gingiva

28. 28

29. SELECTIVE ALVEOLAR DECORTICATION 29 A full thickness mucoperiosteal flap is carefully reflected beyond the apices of the teeth to allow adequate decortication . Selective circumscribing coritcotomy cuts are performed both labially and lingually around the teeth to be moved. This elicits regional acceleratory phenomenon. Flaps are then, repositioned and sutured into place.

30. WILCKODONTICS/PAOO 30 Combination of SAD in a linear or punctate pattern supplemented with a bone graft.

31. OSTEOTOMY ASSOCIATED TOOTH MOVEMENT 31

32. 32 Osteotomy is defined as a surgical cut through both the cortical and trabecular bones. This term is frequently used when describing the creation of bone segments. In orthodontics, osteotomies have been used to enhance and accelerate tooth movement. Cunningham in 1983 used mesial and distal interseptal osteotomies to reposition palatally inclined maxillary teeth and stabilized them in correct occlusion with wire ligatures or metal splints.

33. 33 In the 1950s, Kole introduced his ‘bony block’ technique, a surgical procedure involving both osteotomy and corticotomy to accelerate orthodontic tooth movement, based on the concept that teeth move faster when the resistance exerted by the surrounding cortical bone is reduced via a surgical procedure.

34. BIOLOGICAL BASIS 34

35. 35

36. DISTRACTION OF PDL 36 In the rapid canine distraction of PDL, the interseptal bone distal to the canine is undermined surgically at the same time of extraction of the first premolars, thus, this will reduce the resistance on the pressure site. In this concept the compact bone is replaced by the woven bone, and tooth movement is easier and quicker due to reduced resistance of the bone.

37. 37 In this technique the interseptal bone is undermined 1 to 1.5 mm in thickness distal to the canine after the extraction of the first premolar, and the socket is deepened by a round bur to the length of the canine. The retraction of the canine is done by the activation of an intraoral device directly after the surgery. Liou and Huang. Rapid canine retraction through distraction of the periodontal ligament. Am J Orthod Dentofacial Orthop 1998;114:372-82.

38. DISTRACTION THROUGH DENTO-ALVEOLAR DISTRACTION 38 This procedure was used as early as 1905 by Codivilla and later popularized by the clinical and research studies of Ilizarov . Rapid canine distraction of the dentoalveolar bone is done by the same principle of the distraction of PDL, with the addition of more osteotomies performed at the vestibule.

39. 39 A vertical osteotomy was made on the anterior aspect of the canine tooth to be distracted posteriorly with a small, round, carbide bur under copious irrigation

40. 40 The osteotomy is continued and curved apically, passing 3 to 5 mm from the apex, which could readily be identified in the alveolar bone. A vertical osteotomy was made in a similar manner along the posterior aspect of the canine tooth. The first premolar was extracted at this stage, and the buccal bone was carefully removed through the extraction socket using large, round burs between the bone cut at the distal canine region anteriorly and the second premolar posteriorly .

41. 41 The distraction device was fitted and cemented to the first molar and canine teeth at the end of the surgical procedure. Dentoalveolar distraction was started on the day of the surgery and continued at a rate of 0.4 mm twice a day.

42. RATE OF TOOTH MOVEMENT 42 PDL Distraction : average time taken is 17-22 days. {The native interseptal bone is bent and brought into the extraction socket[TRANSPORT] followed by canine distraction and eventually contact with the interseptal bone mesial to second premolar [DOCKING]} Dentoalveolar Distraction : average time taken is 8-14 days. { neither buccal nor apical bone nor the palatal bone interferes with the tooth movement}

43. TYPE OF TOOTH MOVEMENT 43 Combination of tipping and translation in both techniques. In interdental distraction, some tipping may occur due to the resistance offered by the interseptal bone adjacent to the apex of canine.

44. ANCHOR LOSS 44 When used judiciously, should not induce anchorage loss in sagittal and vertical dimensions. After tooth extraction, healing tissue fills the extraction socket which becomes resistant and compact in about 3 months. If the canine is not retracted across the first premolar socket in the first 3 weeks , the rate of tooth movement slows down, the likelihood of external root resorption increases and the anchor unit may move mesially .

45. 45 The aim of the dental distraction is to complete the retraction of the canines during this period only, before the first molars can move mesially thus preventing anchor loss.

46. ADVANTAGES 46 Rapid retraction of canine leading to shorter treatment time. Minimal loss of anchorage Elimination of need of additional anchorage support

47. DISADVANTAGES 47 Invasive procedure Patient discomfort associated with the bulk of the distractor Difficulty in maintaining oral hygiene Demands excellent patient compliance Reactivation of the distractor device Technique sensitive

48. OTHER PROPOSED APPROACHES 48

49. BIOLOGICAL 49 Cytokines Prostaglandins Vitamin D3 PTH

50. CYTOKINES 50 Cytokines family includes IL-1, Tumor necrosis factors, colony stimulating factors and Growth factors. Prominent cytokines that show demonstrated effects on bone remodeling are IL-I β, IL-6, TNF-alpha (TNF- α), GM-CSF and M-CSF. These cytokines have been shown to stimulate bone resorption and induce osteoclast proliferation. M-CSF is the most potent in stimulating bone-marrow cells to produce osteoclasts .

51. 51 High concentration of cytokines such as interleukins IL-1, IL-2, IL-3 IL-6, IL-8, and tumor necrosis factor alpha (TNF) were found to play a major role in bone remodeling ; Mechanical stress due to orthodontic treatment increased the production of prostaglandin PGE and IL-1 beta in the periodontal ligaments The experiments were done on cats where one canine was tipped distally by 80 g of force from hours to days, then immunohistochemistry and microphotometry experiments where done to measure the intensity of PGE and IL-1 beta which was found to be highest on the tension.

52. 52 Other cytokines which are also involved in the acceleration of tooth movement are RANKL, which is a membrane-bound protein on the osteoblasts that bind to the RANK on the osteoclasts and causes osteoclastogenesis . On the other hand, osteoprotegerin (OPG) competes with RANKL in binding to osteoclast to inhibit osteoclastogenesis . The process of bone remodeling is a balance between (RANKL-RANK) system and OPG compound.

53. 53 Juvenile teeth move faster than adults, which is due to the lower amount of RANKL/ OPG ratio in the gingival crevicular fluid (GCF) in adult patients measured by the enzyme-linked immunosorbent assay method. Also a correlation was found among RANK, OPG, and root resorption during orthodontic teeth movement, and patients with root resorption produced a large amount of RANKL in the compressed site

54. PROSTAGLANDIN EFFECT ON TOOTH MOVEMENT 54 Prostaglandins (PGs) are inflammatory mediator and a paracrine hormone that acts on nearby cells; it stimulates bone resorption by directly increasing the number of osteoclasts . Experiments have shown that injections of exogenous PGE2 over an extended period of time caused acceleration of tooth movements in rats

55. 55 Chemically produced PGE2 has been studied in human trials in the first premolar extraction cases. In these experiments the rate of distal retraction of canines was 1.6-fold faster than the control side

56. EFFECT OF VITAMIN D3 ON TOOTH MOVEMENT 56 1,25 dihydroxycholecalciferol is a hormonal form of vitamin D and plays an important role in calcium homeostasis with calcitonin and parathyroid hormone. Vitamin D metabolite was injected on the PDL of cats for several weeks; it was found that vitamin D had accelerated tooth movement at 60% more than the control group due to the increase of osteoclasts on the pressure site as detected histologically .

57. 57 A comparison between local injection of vitamin D and PGEs on two different groups of rats was also investigated. It was found that there is no significant difference in acceleration between the two groups. However, the number of osteoblasts on the pressure side which was injected by vitamin D was greater than on the PGE2 side. This indicates that vitamin D may be more effective in bone turnover Kale S, Kocadereli I, Atilla P, Asan E. Comparison of the effects of 1,25 dihydroxycholecalciferol and prostaglandin E2 on orthodontic tooth movement. Am J Orthod Dentofacial Orthop . 2004; 125(5):607–14

58. PTH EFFECT ON TOOTH MOVEMENT 58 PTH has been shown to accelerate orthodontic tooth movement on rats, which was studied by continuous infusion and the molars were moved 2- to 3-fold faster mesially by orthodontic coil spring. Some studies have shown that locally injected PTH induces local bone resorption , and it is more advantageous to give PTH locally rather than systemically

59. 59 The development of a slow-release application that keeps the local concentration of PTH for a long time is very efficient. The daily injection of PTH dissolved in gel medium allowed a slow release which caused 1.6-fold faster acceleration of teeth compared to daily injection of PTH dissolved in saline solution which did not cause any acceleration.

60. RELAXIN EFFECT ON TOOTH MOVEMENT 60 Relaxin is a hormone that helps during childbirth by widening of the pubic ligaments in females and is suggested to be present in cranial sutures and PDL. It causes soft tissue remodeling rather than bone remodeling. It increases collagen in the tension site and decreases it in compression site during orthodontic tooth movement.

61. 61 It can reduce the level of PDL organization and mechanical strength of PDL and increase tooth mobility. The remodeling of PDL by relaxin might also reduce the rate of relapse after orthodontic treatment.

62. DRUGS EFFECT ON TOOTH MOVEMENT 62 At present, drugs that stimulate tooth movement are unlikely to be encountered , although efforts to produce them continue. A major problem is how they would be applied to the local area where an effect on tooth movement is desired. For example, direct injection of Prostaglandin into the PDL has been shown to increase the tooth rate of tooth movement, but this is quite painful (a bee sting) and not very practical.

63. PIEZOCISION TECHNIQUE 63

64. 64

65. 65 Dibart in 2009 was among the first to apply the Piezocision technique which starts with primary incision placed on the buccal gingiva followed by incisions by Piezo surgical knife to the buccal cortex and initiate the regional acceleratory phenomenon without involving palatal or lingual cortex. Piezocision can also be combined with Invisalign in selected cases to produce outcomes that are less time consuming as well as satisfies patient’s desire of aesthetic appliance

66. TECHNIQUE 66 A small vertical incision is made buccally and interproximally . This mid-level incision, between the roots of the teeth will allow for the insertion of the piezoelectric knife. The tip of the Piezotome is inserted in the gingival openings previously made and a 3 mm deep piezoelectrical corticotomy is done.

67. 67 The decortication has to pass the cortical layer and reach the medullary bone to get the full effect of the regional acceleratory phenomenon (RAP). In the areas with thin or little gingiva (recessions) or with thin or no cortical buccal bone ( dehiscences , fenestrations), hard and/or soft tissue grafts can be added.

68. 68 The patient is seen every one or two weeks after surgery by the orthodontist in order to change aligners or activate wires and take advantage of the temporary demineralization phase created by Piezocision . This results in faster tooth movement and early completion of treatment. After the 5th or 6th month of treatment, the tooth movement appears to slow down

69. 69 Piezocision can now be defined as another tool for creating differential anchorage. It has been shown that the density of the bone around the Piezocision cut is less, the anchorage values of the teeth at the decortication site would be different. Piezocision can be done selectively around the teeth that are going to be moved and the anchorage values of these teeth can be decreased. Therefore the need for additional anchorage devices can be eliminated by designing the alveolar decortication according to the desired tooth movements.

70. CLINICAL APPLICATIONS 70 Generalized : If the correction of the malocclusion requires moving all of the teeth in both maxilla and mandible at the same time. Localized : If the malocclusion affects only one part of the dentition or one arch (i.e. An anterior crowding case with a perfect posterior occlusion, single tooth extrusions intrusions, etc.) Sequential : If the correction of the malocclusion requires a “staged” approach, where selected areas or segment of the arch are being demineralized at different times during orthodontic treatment to help achieve specific results.

71. INDICATIONS 71 Class I malocclusions with moderate to severe crowding (extraction and non extraction) Selected Class II malocclusions (end-on) Selected Class III malocclusions (dental) Correction of deep bite, correction of open bite Distalization of molars Rapid adult orthodontic treatment Orthodontic treatment with clear aligners, Rapid intrusion and extrusion of teeth

72. CONTRA-INDICATIONS: 72 Medically compromised patients Patients taking drugs modifying normal bone physiology (i.e. biphosphonates ) Bone pathology Ankylosed teeth Non-compliant patients Patient and/or operator having a pacemaker or any other active implant. Potential Problems: Root injury, infection, mucogingival defects

73. 73 The major disadvantage of piezocision technique is risk of root damage as incisions and corticotomies are blindly done. To reduce the risk of root damage, Jorge et al in 2013, suggested a method called MIRO ( Minimally Invasive Rapid Orthodontic Procedure) by using metal wire as a guide to placement of the incisions and subsequently the corticotomy cuts.

74. MICRO-OSTEOPERFORATIONS 74

75. 75 Micro-trauma in the form of micro- osteoperforations (MOPs) will amplify the expression of inflammatory markers that are normally expressed during orthodontic treatment and that this amplified response will accelerate both bone resorption and tooth movement. In human subjects, MOPs increased the rate of canine retraction concomitant with increased TNF and IL-1 levels in gingival crevicular fluid. It typically involves incisions in the interproximal gingiva so that reflecting flaps is not necessary and less extensive cuts in the bone.

76. PROPEL 76 Based on microperforation , in which screws like those used for skeletal anchorage are placed through gingiva into interproximal alveolar bone and then removed. 3 such perforations in each interproximal area are enough to generate a regional acceleration of bone remodeling and, thereby, produce faster tooth movement.

77. 77 In this study, rate of tooth movement was compared in 3 groups: control that only received orthodontic force (O), O + 1MOP group that in addition to orthodontic force received 1 MOP between canine and second premolar, and O + 4 MOP group that in addition to orthodontic force receive 4 MOPs in the same position. At different time points after canine retraction, the rate of tooth movement and levels of inflammatory marker IL1-α were evaluated as described before. Alikhani , Mani et al. Micro- osteoperforations : Minimally invasive accelerated tooth movement Seminars in Orthodontics 2015 Volume 21 , Issue 3 , 162 - 169

78. 78 In response to 4 MOPs, IL1-α activity in the gingival crevicular fluid increased 5 fold when compared with O group, 24 hours after MOPs procedure and coil activation, and 3.5 fold after 28 days. 4 MOPs were able to increase the rate of more than 2 folds , while no significant difference between O group and O + 1 MOP group was observed. Alikhani , Mani et al. Micro- osteoperforations : Minimally invasive accelerated tooth movement Seminars in Orthodontics 2015 Volume 21 , Issue 3 , 162 - 169

79. 79 These results demonstrate a direct relation between the magnitude of the trauma to the alveolar bone and activation of inflammatory markers, and therefore, the rate of tooth movement Alikhani , Mani et al. Micro- osteoperforations : Minimally invasive accelerated tooth movement Seminars in Orthodontics 2015 Volume 21 , Issue 3 , 162 - 169

80. DEVICE-ASSISTED TREATMENT 80 Cyclical force device effect on tooth movement. Direct electric current effect on tooth movement. Photobiostimulation

81. CYCLICAL FORCE DEVICE EFFECT ON TOOTH MOVEMENT. 81 Low-level mechanical oscillatory signals (vibrations) have been shown to increase the rate of remodeling in mechanical loaded long bones. Dynamic loading improves bone formation and increases orthodontic tooth movement compared to a static force.

82. AcceleDent device 82 AcceleDent is a  device that uses soft pulse technology and cyclic forces to accelerate the movement of teeth. Based on delivery of high high frequency vibration (30 Hz) to the teeth for approx. 20 minutes per day. Rationale is to stimulate cell differentiation and maturation, so that bone remodeling occurs more quickly..

83. DIRECT ELECTRIC CURRENT EFFECT ON TOOTH MOVEMENT 83

84. 84 Another approach is to use direct electric current. This technique was tested only on animals by applying direct current to the anode at the pressure sites and cathode at the tension sites (by 7 V), thus, generating local responses and acceleration of bone remodeling . The bulk of the devices and the source of electricity made it difficult to be tested clinically

85. LOW LEVEL LASER THERAPY 85

86. 86 Also known as photobiostimulation . Photobiostimulation refers to the alterations, produced by relatively low levels of irradiation, in chemical, physical, and metabolic processes in target tissues with little or no temperature changes.

87. 87 Photobiomodulation or low level laser therapy (LLLT) is one of the most promising approaches today. Laser has a biostimulatory effect on bone regeneration, which has been shown in the midpalatal suture during rapid palatal expansion and also stimulates bone regeneration after bone fractures and extraction site

88. 88 Two photobiostimulation modalities: LOW-LEVEL LIGHT EMITTING LASERS (LLLT) LIGHT EMITTING DIODES (LED) Both types of applications utilize a near-infrared wavelength of approximately 600-1000 nm, with a range of 730-850 nm being viewed as most appropriate for photobiostimulatory effects. The relatively narrow wavelength range allows for greater absorption by target tissues

89. 89 Photobiostimulation is not associated with any harmful effects on the periodontium and teeth. The mechanism involved is by the production of ATP and activation of cytochrome C that low energy laser irradiation enhanced the velocity of tooth movement via RANK/RANKL and the macrophage colony stimulating factor and its receptor expression.

90. Biolux OrthoPulse 90 OrthoPulse is device that uses low levels of light energy to stimulate the bone surrounding the roots and facilitates tooth movement which may reduce treatment time for braces or clear aligners. Uses light with 800-850 nm wavelength. Can be adjusted to apply light to only the anterior teeth, the whole arch or only the posterior teeth.

91. CONCLUSION 91 Tooth acceleration phenomenon is still a relatively new horizon and researchers have yet to seek a single most ideal and prudent technique for the patient. The surgical techniques have most of the human trials and also show very favorable and long term effects adding to the stability and retention of the orthodontic therapy. However the invasiveness and cost of these might make it little less viable option for the patients.

92. 92 Microsteoperforation , Piezocision on the other hand are the least discomforting among all the surgical procedures and this will make them more commonly used procedures in future. Yet at the same time any of these techniques once adapted depending upon clinician’s choice and patient’s preference; can prove to be immensely beneficial in reducing orthodontic treatment time.

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94. 94 Abhijith Shettya ; Anand K. Patil ; Ameet R.; Prabhdeep K. Sandhu . Local infiltration of Vitamin D3 does not accelerate orthodontic tooth movement in humans. Angle Orthodontist 2014 Liou and Huang. Rapid canine retraction through distraction of the periodontal ligament. Am J Orthod Dentofacial Orthop 1998;114:372-82. Xiao, Yu, Sun, and Yeweng.Rapid Canine Retraction by Distraction of the Periodontal Ligament. JCO MARCH 2016. Sukurica Y, Karaman A, Gurel HG, Dolanmaz D. Rapid canine distalization through segmental alveolar distraction osteogenesis . Angle Orthod . 2007; 77(2):226–36. Kurt, Gokmen   Iseri , Haluk,Kisnisci , Reha ;  Ozkaynak , Ozkan . Rate of tooth movement and dentoskeletal effects of rapid canine retraction by dentoalveolar distraction osteogenesis : A prospective study. Am J Orthod Dentofacial Orthop 2017;152:204-13.

95. 95 Almpani K,Kantarci A. Surgical Methods for the Acceleration of the Orthodontic Tooth Movement.Front Oral Biol 2016. Oliveira D, Oliveira B. F, Rodrigo VS. Alveolar corticotomies in orthodontics: Indications and effects on tooth movement. Dental Press J Orthod 2010 July-Aug;15(4):144-57. Verna C. Regional Acceleratory Phenomenon. Front Oral Biol . 2016;18:28-35.  Nisha N. et al. Wilckodontics - A Magical Wand for Rapid Success-A Review. Annals of International Medical and Dental Research, Vol (1), Issue (3) Shrikanth B. et al. Methods of Accelerating orthodontic treatment – A Review. Journal of Applied Dental and Medical Sciences. Volume 2 Issue 1 January - March 2016. Dibart , Serge et al. Piezocision ™-assisted orthodontics: Past, present, and future. Seminars in Orthodontics , Volume 21 , Issue 3 , 170 - 175

96. 96 Mittal S.K.,Sharma R, Singla A. Piezocision Assisted Orthodontics: A new approach to accelerated orthodontic tooth movement. Journal of Innovative Dentistry, Vol 1, Issue1, Jan-April 2011 Alikhani , Mani et al. Micro- osteoperforations : Minimally invasive accelerated tooth movement Seminars in Orthodontics 2015 Volume 21 , Issue 3 , 162 – 169 Pavlin , Dubravko et al.Cyclic loading (vibration) accelerates tooth movement in orthodontic patients: A double-blind, randomized controlled trial. Seminars in Orthodontics , Volume 21 , Issue 3 , 187 – 194 Chung, Sean et al. Photobiostimulation as a modality to accelerate orthodontic tooth movement.Seminars in Orthodontics 2015 Volume 21 , Issue 3 , 195 – 202. Kolahi J,  Abrishami M,  Davidovitch Z. Microfabricated biocatalytic fuel cells: a new approach to accelerating the orthodontic tooth movement. Med Hypotheses 2009 Sep;73(3):340-1

97. THANK YOU