Histology and physiology of tooth movement

Principles of orthodontic treatment :

If prolonged pressure is applied to a tooth, it will move as bone around it

remodels(so there should be a prolonged continuous force in order to move a tooth {46hours}). Tooth moves through the bone carrying its attachment apparatus with

it(alveolar bone socket migration).

Tooth movement is primarily a PDL phenomenon.

PDL Structures
Major component: Network of parallel collagenous fibers. Minor components: Cellular elements Vascular elements Neural elements Tissue fluids (allows PDL to act as shock absorber in normal function )

Response to normal function

Mastication:Why teeth do not move during mastication or swallowing? Because of :
Tooth contacts are for < 1 sec. Intermittent heavy forces ( 1 kg for soft food & 50 kg for more resistant object) Displacement of tooth within PDL is prevented by the incompressible tissue fluid. Force is transmitted to alveolar bone bending (bone crystals arrangement will be changed) (Piezoelectric signal that appears to stimulate skeletal regeneration & repair).

PDL is beautifully adapted to resist forces < 1 sec, however:

If the pressure against the tooth is maintained (>1sec), the PDL fluid is rapidly squeezed out Pain occurs as it's squeezed against the adjacent bone (crushing).
Orthodontic | Histology and Physiology of tooth movement| Dr. Emad Al Maaitah| Scripted by: Mohamed Al-Esayi 1

 Prolonged force, even of low magnitude, produces remodeling(e.g. thump sucking): This allows orthodontic tooth movement. Also explains why prolonged light forces from lips, tongue etc has potential to move teeth (Equilibrium theory). Check the figure on slide number 7 for the cells that involved in the tooth movement (fibroblast, osteoblast & osteoclast are the three most important) *osteoclast are present in the blood-stream not the PDL, it attend when stimulated.

Theories of tooth movement

I. --Tooth movement still unknown Bioelectric theory (Proffit): Relates tooth movement to change in bone metabolism (bio) controlled by electric signals produced when alveolar bone flexes and bends. Bone and collagen are crystalline structures and as a result of structural deformation, piezoelectric signals arise. Its limitations: o Quick decay rate of the signal, how? o Production of equivalent but opposite in direction signals when forces released It is suggested that the force does not produce prominent stressgenerated signals so it has little to do with orthodontic tooth movement. **So this theory later on has been rejected** II. Pressure-tension theory (profit):

It's the most acceptable theory***

Orthodontic | Histology and Physiology of tooth movement| Dr. Emad Al Maaitah| Scripted by: Mohamed Al-Esayi 2

 Relates tooth movement to chemical messengers generated by alterations of blood flow through PDL. Pressure leads to tooth movement within PDL and then alteration in blood flow: Reduced flow in pressure side (vasoconstriction) Increased flow in tension side (vasodilation) Result in : a) Changes in chemical environment i.e. O2 levels b) Formation / release of chemical messengers c) Activation of cells (fibroblasts/fibroclasts) III. Biomechanical theory:(sandy-1993) Relates tooth movement to mechanical distortion of cell membrane. Mechanical distorting a cell membrane activates phospholipase A2 make arachidonic acid available for the action of cyclo& lipoxygenase enzyme (cox1&2) produce prostaglandin (PGs) PGs feed back onto the cell membrane binding to receptors which then stimulate 2nd messengers and elicit a cell response. Cells under tension are flattened and show anabolic effects (synthesis), whereas cells under pressure side are rounded and show catabolic changes

Heavy and light forces

Now, based on the pressure-tension theory; Light prolonged force cause decrease in blood flow through partially compressed PDL vessels This leads to production of cAMP, IL-1and PGs(these all are inflammatory mediators) which cause differentiation and stimulation of osteoclastic activity Leads to frontal resorption (from inside) with removal of bone from the lamina dura and bone deposition on the tension side
Orthodontic | Histology and Physiology of tooth movement| Dr. Emad Al Maaitah| Scripted by: Mohamed Al-Esayi 3

 Heavy force completely occludes the blood vessels and an area of sterile necrosis develops (Hyalinised zone) (called hyalinised because it looks like glass no cells/vessels) Cells eventually invade the necrotic area and osteoclasts commence resorption of bone adjacent to this area from outside (Undermining resorption) It needs around {7-14 days} for movement to commence due to:
o Delay in differentiation of cells o Time required to fully resorb bone from underneath and the necrotic tissue

So
When PDL necrosis is avoided there is further efficiency in tooth movement and less pain for pt. and less root resorption risk. However, this is an unattainable ideal when continuous forces are used which may lead to sterile necrosis because of the differentiation of the surface area of each tooth. Clinically tooth movement is in astepwise fashion with some inevitable area of PDL necrosis. Optimal force should be high enough to allow tooth movement and stimulate cellular activity without completely occluding the blood vessel in PDL and low enough to not to cause sterile necrosis. Nickel-titanium archwire provide these low forces.

Types of tooth movements

tipping

bodily movement
intrusion

rotation

torque

extrusion
4

Orthodontic | Histology and Physiology of tooth movement| Dr. Emad Al Maaitah| Scripted by: Mohamed Al-Esayi

Tipping
In tipping there is a center of rotation(at the junction between the apical 3rd and middle 3rd of the root) that the tooth will move around it depend on the force direction, bucco-lingually or mesio-distally In tipping the force is single, when the force applied to the tooth the crown will start to move and the root too but in the opposite-way causing opposing pressure and tension areas

In regards to tipping the arising question is what is the recommended optimal force level for tipping movement? Here since it's again difficult to measure this on human beings, we have evidence that is obtained from "expert opinions". For example, Proffit suggested that the needed force per gram is 35gm for incisors and 60gm for molars whereas, Burston suggested it was 50gm for incisors and 70gm for molars. Lee however, stated that a force is only needed for the canine which is of 200gm

Orthodontic | Histology and Physiology of tooth movement| Dr. Emad Al Maaitah| Scripted by: Mohamed Al-Esayi

But the one mainly used or sought for is Proffit's suggested recommended optimal force

Bodily movement
When we spoke of the tipping movement in definition it was "the movement of the crown in one direction and the movement of the apex of the root in the opposite direction". Bodily movement is "the movement of both the crown and the root apex into the same direction by the same amount of force". This happens when two forces are applied to the crown which is not like tipping where only one force was applied. The PDLs in this case will be loaded uniformly i.e. a complete side will have pressure and the other complete side will have tension (unlike tipping) and this means that twice as much force that is required for tipping can be applied (unlike tipping where we applied only half the force, 35gm, but now we can apply the complete force of 70gm) Proffit here suggested a force of 70-120gm for incisors and 350-500gm for molars and the reason for the obvious change in suggested force was because molars have more than one root and there will be uniform loading for each root individually.

Rotation
What does rotation mean? Simply, "when you apply two forces in opposite directions you will have rotation". For example for an incisor, when you apply a force from the mesial side, palatally and another force from the distal side buccally, it will cause its rotation. So, we need two forces of the same magnitude but in opposite directions. You must remember though that it is impossible to have rotation without causing a slight tipping in the process. Since tipping is inventible we'd apply the same force of suggested tipping which Proffit allocated to be 35-60gm.
Orthodontic | Histology and Physiology of tooth movement| Dr. Emad Al Maaitah| Scripted by: Mohamed Al-Esayi 6

Torque
Let us suppose that we have an upper incisor that is anteriorly positioned and we want to move the root without causing a tipping movement. This is where a torque movement comes into play where we move the crown using force couple without moving the root. We could, also using torque, move the root when the crown is stable. In this case since the force is greater that of tipping it shall be 50-100gm according to Proffit.

Extrusion
Do you expect the extrusion to have a pressure area? If I were to extrude a tooth where the pressure would lay? There would normally be no pressure. There would be pressure however if the force of extrusion is parallel to the long access of the tooth itself but we usually fit the brackets on the labial aspect of teeth thereby causing the extrusion but again there is no running from causing tipping therefore producing small areas of pressure. It is the forces applied from the buccal side that produces some tipping and the force allocated for that is 35-60gm. Thus extrusion ideally produces pure tension or tensile forces and no areas of compression within the PDL. It also brings the alveolar bone with it which is a very important point to note as to if you were to make an implant for example, if you had a grossly decayed upper incisor that cannot be restored via post crown the treatment plan will include an implant but as a result of the decay the pt. will have bone resorption leaving an insufficient amount for bone for an implant so the practitioner will either add a bone graft or performs and RCT for the remaining
Orthodontic | Histology and Physiology of tooth movement| Dr. Emad Al Maaitah| Scripted by: Mohamed Al-Esayi 7

root to remove the infection and then orthodontically extrude the root to bring the bone with itas if you were generating bone from the same patient.

Intrusion
"It is intruding the tooth within its socket". So the pressure will mainly be concentrated around the apex of the root and since the apex is a small area the force needed will be low to which Proffit allocated 10-20gm. During the intrusion movement it has been reported that root resorption risk is high and that is why you need to keep the fore exerted as low as possible.

Adverse effects of excessive forces

We mention earlier light and heavy forces. If your force is heavy you shall face problems with mobility caused by; 1. undermining resorption that widens the PDL 2. large amounts of bone resorption and 3. The PDL as a result becomes disorganized Another problem is pain as heavy forces is commonly associated with pain. There are two types of pain as a result of orthodontic treatment; 1. Immediate pain due to excessive heavy force 2. Light force Pain that started 2-4 hours after the treatment and lasted for 1-2 days So the features of an ideal force include; No immediate pain Pain starts several hours later informs of mild aching and sensitivity to pressure
Orthodontic | Histology and Physiology of tooth movement| Dr. Emad Al Maaitah| Scripted by: Mohamed Al-Esayi 8

 It should last for 2-4 days post treatment However excessive force causes immediate pain due to ischemic necrosis, mild pulpitis after force is applied but is it rare to have pulp necrosis as a result of orthodontic treatment, hyperemia, and only inflammation around the apex because the necrosis caused is sterile. Another adverse effect is the root resorption. Out of the many types of root resorption, surface root resorption is the one occurring here which can be seen histologically but not on the X-ray. This surface root resorption caused by the orthodontic treatment will be remodeled later on once the force is removed or becomes too light. However, if the force is heavy and continuous there will be no time for cementum remodeling and this may eventually result in root resorption. Finally, alveolar bone loss and mainly the crestal alveolar bone loss which is the interdental alveolar crest. The resorption here is in terms of 0.5-1mm in the extraction space which is the maximum loss you could get as a result of an orthodontic treatment unless there is a preexisting active periodontal disease. This means that "it is contraindicated to start an orthodontic treatment for a patient with an active periodontal disease". You may start the disease after stabilizing the periodontal disease. THE END.

Orthodontic | Histology and Physiology of tooth movement| Dr. Emad Al Maaitah| Scripted by: Mohamed Al-Esayi