By Dr.

Arti Kripalani
Part I P.G.
K.M.Shah Dental College
 Introduction
 Periodontal ligament
 Physiologic tooth movement
 Optimum orthodontic force
 Types of forces
 Histology of tooth movement
 Hyalinization
 Phases of tooth movement
 Theories of tooth movement
 Orthodontic treatment is based on the principle that if
prolonged pressure is applied to a tooth, tooth
movement will occur as the bone around the tooth
remodels.

 Bone is selectively removed in some areas and added

in others.
 The tooth moves through the bone carrying its
attachment apparatus with it, as the socket of the tooth
migrates.

 Because the bony response is mediated by the

periodontal ligament, tooth movement is primarily a
periodontal ligament phenomenon.
 During masticatory function, the teeth
and periodontal structures are subjected
to intermittent heavy forces.

 Tooth contacts last for 1 second or less.

 Forces are quite heavy, ranging from 1 or 2 kg while soft

substance are chewed up to as much as 50 kg against a
more resistant object.
 Naturally occurring tooth movements that take place
during and after tooth eruption.

This include:
A)Tooth Eruption.
B)Migration or drift of teeth.
C)Changes in tooth position during mastication.
Tooth eruption is the axial movement of tooth from its
developmental position in the jaw to its final position
in the oral cavity.
a)Blood pressure theory:
The tissue around the developing end of the root is highly
vascular.
This vascular pressure is believed to cause the axial
movement of teeth.

b)Root Growth:
The apical growth of roots result in an axially directed
force that brings about the eruption of teeth.
This theory was rejected.

c)Periodontal traction theory:

The periodontal ligament is rich in fibroblasts that contain
contractile tissue.
The contraction of these periodontal fibers (mainly the
oblique group of fibers) results in axial movement of the
tooth.
d)Hammock ligament theory:
According to Sicher, a band of fibrous tissue exists below
the root apex spanning from one side of alveolar wall to
other.

This fibrous tissue appears to form a network below the

developing root and is rich in fluid droplets.

The developing root forces itself against this band of

tissue, which in turn applies an occlusally directed force on
tooth.
 Refers to minor changes in tooth position observed
after eruption.

 Human dentition shows a natural tendency to move in

a mesial & occlusal direction.

 Usually a result of proximal and occlusal wear of teeth,

to maintain inter-proximal and occlusal contact.

 This was pointed out for the first time by Stein and
Weinmann.
 Physiologic tooth migration usually is related to mesiodistal
movements. However, the teeth also exhibit a continued
eruption, even after full emergence, accompanying the
growth in height of the alveolar processes.

 Studies of craniofacial dimensions have demonstrated that

significant changes occur in human beings even during
adulthood (Bjork A, Skieller V, 1983).
 During mastication ,the teeth and PDL structures are
subjected to intermittent heavy forces which occurs in
cycles of one second or less and may range from 1-50
kg based on the type of food being masticated.
 Is one which moves teeth most rapidly in the desired
direction ,with the least possible damage to tissue and
with minimum patient discomfort.

 Schwarz defined it as the force leading to a change in

tissue pressure ,that approximated the capillary vessel
& blood pressure. Thus preventing their occlusion in
the compressed PDL.
 Below the optimal level cause no reaction in PDL.

 Forces exceeding optimal level would lead to areas of

tissue necrosis.
 Schwarz’s definition was slightly modified by
Oppenheim who advocated the use of lightest force
capable of bringing about tooth movement.

 Oppenheim and Schwarz following extensive studies

stated that the optimum force is equivalent to the
capillary pulse pressure which is 20-25 gm/sq.cm of
root surface area.
 Produce rapid tooth movement.
 Minimal patient discomfort.
 The lag phase of tooth movement is minimal.
 No marked mobility of the teeth being moved.
The vitality of the tooth and supporting PDL is
maintained.
 Initiates maximum cellular response.
 Produces direct or frontal resorption.
 Continuous force : the force magnitude
is maintained at almost the same level
in the period between two activations.

 Interrupted force : declines to zero

between activations.

 Intermittent force : falls to zero when

the appliance is removed and return to
original level on re insertion.
 Classic histologic research about tooth movement by
Sandstedt, Oppenheim and Schwarz led to the
hypothesis that a tooth moves in the periodontal space
by generating a ‘pressure side’ and a ‘tension side.’

 Later ultrastructural studies by Rygh (1972) and

Brudvik and Rygh (1994), gave a very detailed
description of events.

 The findings of the above research have been

meticulously summarized by Krishnan and
Davidovitch (2006).
Changes following application of light forces:

Changes on pressure side:

 The PDL gets compressed to almost 1/3rd of it’s original

thickness.

 A marked increase in the vascularity of PDL on this side is

observed due to increase in capillary blood supply.

 This increase in blood supply helps in mobilization of cells

such as fibroblasts and osteoclasts.

 When forces applied are within physiologic limits,the

resorption is seen in alveolar plate immediately adjacent to the
ligament.This kind of resorption is called frontal resorption.
Changes on tension side:

 PDL stretched.
 Distance between alveolar process & tooth is widened.
 Increased vascularity.
 Mobilization of fibroblasts & osteoblasts.
 Osteoid is laid down by osteoblast in PDL immediately
adjacent to lamina dura.
 Lightly calcified bone mature to form woven bone.
Secondary remodelling changes:
 Bony changes also takes place elsewhere to maintain the width
or thickness of alveolar bone. These changes are called
secondary remodeling changes.

For eg:-If a tooth is being moved in a lingual direction there is

compensatory deposition of new bone on the outerside of the
lingual alveolar bony plate and also a compensatory resorption
on the labial side of the labial alveolar bone.

This is to maintain the thickness of the supporting alveolar

process .
On the pressure side :-

 Root closely approximates the lamina dura .

 Compresses the PDL and leads to occlusion of blood vessels.
 The PDL is hence deprived of its nutritional supply leading to
regressive changes called hyalinization .
 Undermining/Rearward resorption occurs in the adjacent
marrow spaces and alveolar plate below, behind & above the
hyalinized zone.
On the tension side:-

 Over stretched PDL .

 Tearing of blood vessels & ischaemia.
 Extreme forces applied net increase in osteoclastic activity
and tooth loosened in socket.
 Is orthodontic movement possible for a tooth that has
undergone endodontic treatment ?

 Is it possible to move an ankylosed tooth ?

 Form of tissue degeneration characterized by formation
of a clear, eosinophilic homogenous substance.
 Denotes a compressed and locally degenerated PDL.
 Reversible process.
 Occurs in almost all forms of orthodontic tooth
movement but the areas are wider when the force
applied is extreme.
 Gradual shrinkage of PDL fibres.
 Cellular structures become indistinct.
 Collagenous tissues gradually unite
into a more or less cell free mass.
 break down of blood vessel walls
leading to spilling of their contents.
 Osteoclasts are formed after a period
of 20-30 hrs.
 The presence of hyalinised zone indicates that the
ligament is non-functional and therefore bone
resorption cannot occur.

 The tooth is hence not capable of further movement

until the local damaged tissue has been removed and
the adjacent alveolar bone resorbs .
 2 mechanism:-

1. By osteoclasts differentiating in the peripheral intact

PDL membrane and in the adjacent marrow spaces.

2. Invasion of cells and blood vessels from the

periphery of the compressed zone by which necrotic
tissue is removed by enzymatic action and
phagocytosis
 Greater the forces wider is the area of hyalinization.
Thus larger areas of the ligament becomes
functionless, thereby showing larger areas of rearward
resorption.

 If lighter forces are used, the hyalinised zone is

smaller and a larger area of functioning ligament is
available and frontal resorption predominates.

 The location and extent of hyalinised tissue largely

depends upon nature of tooth movement.
 Tipping – close to alveolar crest.

 Excessive force during tipping- two areas, one on

apical region and other in marginal area.

 Bodily- closer to middle portion of root.

Authors: Journal: Level of Aim and Result and Conclusion:
evidence: objectives:

S. H. EJO 2012 4 To study and assess A rapid transposition

Jónsdóttir, the biomechanical during the first few
E. B. W. behaviour of the seconds was found.
hyalinized
Giesen and However, it was
periodontal ligament
J. C. Maltha in experimental significantly less for
orthodontic tooth hyalinized than for non-
movement hyalinized PDL.

The hyalinized tissue

offers resistance to tooth
movement and it is
proportional to the
degree of hyalinization.
Burstone categorize the stages as:-
 Initial phase
 Lag phase
 Post lag phase
 Rapid tooth movement is observed over a short distance which
then stops.

 Represents displacement of tooth in PDL membrane space and

probably bending of alveolar bone .

 Both light and heavy forces displace the tooth to same extent .

 Between 0.4 to 0.9mm usually occurs in a weeks time.

 Little or no tooth movement occurs .

 Formation of hyalinized tissue .

 Extent upto 2-3 weeks but may at times be as long as

10 weeks.
 Tooth movement progresses rapidly as the hyalinized
zone is removed and bone undergoes resorption .

 Osteoclasts are found over a larger surface area.

 If the duration of the movement is divided into an initial and a
secondary period, direct bone resorption is found in the secondary
period, when the hyalinized tissue has disappeared after
undermining bone resorption.
 Study by Pilon et al performed on beagles,
divided the curve of tooth movement into 4 phases:

 The first phase lasts 24 hrs to 2 days and represents the

initial movement of the tooth inside its bony socket.
 Second phase when the tooth movement stops for 20 to 30
days.
 After the removal of necrotic tissue formed during the
second phase , tooth movement is accelerated in the third
phase and continues into the fourth linear phase.
1. The pressure-tension theory
2. Bone bending & piezoelectric theory
3. Blood flow/fluid dynamic theory
 Classic histologic research about tooth movement by
Sandsted (1904),Oppenheim (1911) and Schwarz
(1932) led them to hypothesize that a tooth moves in
the periodontal space by generating a “pressure side”
and a “tension side.”

 According to them, areas of pressure show bone

resorption while areas of tension show bone
deposition.
 Farrar was the first to suggest, in 1888, that alveolar
bone bending plays a pivotal role in orthodontic tooth
movement.

 This hypothesis was later confirmed with the

experiments of Baumrind in rats and Grimm in
humans.
 Piezo-electricity is a phenomenon observed in many
crystalline materials in which deformation of the
crystal structure produces a flow of electric current.

 As a result, displacement of electrons from one part of

the crystal lattice to the other.

 A small electric current is generated & bone is

mechanically regenerated and repaired.
The possible source of electric current are :-

1. Collagen.
2. Hydroxyapetite.
3. Collagen hydroxyapetite interface.
4. Mucopolysaccharide.
 As long as the force is maintained ,the crystal structure is
stable & no further electric effect is observed.

 When the force is released the crystals return to their

original shape & reverse flow of electrons is observed.

 This rhythmic activity produces a constant interplay of

electric signals .
 Quick decay rate
 When the force is released electrons flow in the opposite
direction.

On application of a force on a tooth ,

 Areas of concavity  negative charges  bone deposition.
 Areas of convexity  +ve charges and  bone resorption.
 It was proposed by Bien in 1966.

Acc. to this theory:

“Tooth movement occurs as a result of alterations in fluid
dynamics in the PDL.”

There are three interacting fluid systems in the PDL:

1. Vascular system
2. Cellular system
3. Interstitial fluid system
 These fluids in confined periodontal space create a unique
hydrodynamic condition.

ORTHODONTIC FORCE

compression of PDL

Occlusion of blood vessels on pressure side

and dilation on tension side

formation of aneurysms
 Fluid is squeezed out of vessel wall

O2 level falls in compressed area and rises on tension side

metabolite changes take place

change in chemical environment stimulates release of chemical

messengers

They stimulate cellular differentiation into Osteoblasts and Osteoclasts

Bone Remodeling takes place.

 Growth
Genes Proteins
factors
• Bone • C-fos • Integrin
morphogenetic • C-jun • gamma
proteins (BMP) • Egr-1 carboxyglutamic
• Transforming • Cbfa1 acid (GLA) protein
growth factor (TGF (Runx2/OSF2)
β- I and II)
• Osterix
• Insulin-like growth
factor (IGF-I and
II),
• Platelet derived
growth factor
(PDGF)
• Fibroblast growth
factor (FGF)
Cytokines (tumor necrosis factor [TNF], interleukin-1 alpha, 6-alpha
[I]), macrophage colony stimulating factor (M-CSF), granulocyte,
macrophage colony stimulating factor (GM-CSF) and prostaglandin
(PGE2).
Osteoclast differentiation is also mediated by the interaction of
two molecules produced by osteoblasts, namely osteoprotegrin
(OPG) and RANK ligand (RANKL) Receptor activator of nuclear
factor kappa B ligand
 At the “Biology of tooth movement” conference held at
Formington in Nov.,1986 it was suggested that the ans
was likely to be found in the field of CYTOKINE
biology.

 According to this hypothesis,formation and resorption

depends upon:
1) the cytokines
2) the functional state of available target cells.
 The cytokines are defined as short range soluble
mediators released from cells which modulate the
activity of other cells.

 Includes interleukines, interferons, chemotactic

factors,tumor necrotic factors,colony stimulating
factors and assorted growth factors.
Q) How do cytokines mediate mechanically induced
bone remodelling ?

A) Osteoblasts have receptors for prostaglandins, PTH,

Vit D but osteoclasts don’t have.
It is cytokine that transmits signals from osteoblasts to
osteoclasts.
Cytokines either activate osteoclasts or promote
differentiation of the precursor cells.
Secondly, osteoblasts produce collagenase enzyme that
resorbs osteoid.
Osteoclasts cannot resorb bone untill the surface
osteoid layer is removed.
 Although cytokine is a potent stimulator of bone
resorption,it can also stimulate osteoblast proliferation.

 Therefore, whether resorption or formation, depends

upon the cytokines and functional state of the available
target cells.

 Tooth movement ultimately depends on specific

activation of bone precursor cells ( osteoprogenitors)
which form osteoblasts and osteoclasts.
  First messengers
• Interleukin-1, Interleukin-6, Interleukin-11, Tumor necrosis factor, Osteoclast
differentiating factor, Bone formation Interleukin-4, Interleukin-13, Interleukin-
Cytokines 18, Interferon, Osteoprotegrin

• Insulin-like growth factors I & II , Transforming growth factor ,

Fibroblast growth factor, Platelet derived growth factor , Connective
Growth tissue growth factors
factors

• Polypeptides, Parathyroid hormones , Calcitonin, Insulin, Growth

hormone , Steroid, 1,25, dihydroxy vitamin D3, Glucocorticoids , Sex
Hormones steroids ,Thyroid hormones
 • M-CSF
Colony-
• G-CSF
stimulating • GM-CSF
factors

• Prostaglandins
• Leukotriens
Others • Nitric oxide
 Von Euler (1934) – prostate fluid.
 Imp role in stimulating bone resorption.
 One of the chief mediators of inflammation cause an
increase in intracellular cAMP and Ca++ accumulation.
 Cell membrane phospholipid
phospholipase- A

ARACHIDONIC ACID

Cyclo-oxygenase lipo-oxygenase
pathway pathway

PG2 thromoxane leukotrienes HETE

 Davidovitch and Shanfeld,
Davidovitch et al., Yamasaki et al. (first reported
human study, 1982-83),Lee et al., Selinkale et al. and
many others.

 Mohammed et al injected PG inhibitor, leukotriene

inhibitor and both together, in rats and performed tooth
movement.
 substance P
 vasoactive intestinal polypeptide (VIP)
 calcitonin gene related peptide (CGRP).

 Davidovitch et al demonstrated that incubation of

substance P in vitro significantly increased the
concentration of cAMP in the cells and of PGE2 in the
medium within 1 minute.
Authors: Journal: Level of Aim and Result and Conclusion:
evidence: objectives:

Davidovitch Dental clinic of 4 To test the Administration of SP and

et al N.American hypothesis that IL-1 beta to human PDL
1988 tissue remodeling fibroblasts in vitro for 1 to
during orthodontic 60 minutes resulted in
tooth movement is significant increases in the
modulated by factors levels of the intracellular
derived from the "second messenger" cAMP,
nervous and vascular as well as of PGE2.
systems.
This tend to support the
hypothesis that
neurotransmitters and
cytokines play a regulatory
role in orthodontic force-
induced alveolar bone
remodeling.
 Three distinct isoforms of NOS are:
- a neuronal form (nNOS),
- an endothelial form (eNOS),
- an inducible form (iNOS).

 Both nNOS and eNOS are constitutively expressed

and are collectively referred to as constitutive NOS
enzymes (eNOS).

 It was found that iNOS plays a role in the

response of periodontal tissue to orthodontic force.
 1. NO activates guanylyl cyclase in periodontal
ligament fibroblasts, leading to an increased level of
cGMP. This second messenger in cell cytoplasm raises
lysosome membrane permeability, leading to
exocytosis of lysosome content resulting in resorption
of organic and mineral elements of bone.

 2. Nitric oxide synthesizes prostaglandins by direct

activation of cyclo-oxygenase.

 3. Nitric oxide influences the function of osteoclastic

differentiation and osteoblast function.
1) strain sensitive ion channels and shear stress receptors
in cell membrane:
 calcium and potassium channels.
 Channel gating may be caused by direct mechanical
perturbation or secondarily by the activation of stretch
sensitive phospholipase C or D.
 They respond to mechanical strain by causing in and
out movement of ions, creating changes in the electric
potential.
 These changes enable the signal to be propagated
intracellularly.
2)Signal transduction by integrins and focal
adhesions
 Sutherland and Rall established the second-messenger
basis for hormone actions in 1958.

 They proposed that the first messenger binds to a

specific receptor on the cell membrane and produces an
intracellular chemical second messenger.

 This second messenger then interacts with cellular

enzymes which evokes a response.

- cAMP
- cGMP
- IP3
 The receptor activator of nuclear factor kappa B ligand
(RANKL), its decoy receptor (RANK) and
osteoprotegrin (OPG) were found to play important
roles in regulation of bone metabolism.

 Evidences suggest osteoblast itself regulates the

differentiation of osteoclast.

 The talk between an osteoblast and osteoclast is

accomplished through an osteoblast membrane bond
RANKL which can interact with osteoclast precursors
to cause them to differentiate into osteoclasts.

 Another membrane bond molecule and its bonding

ligand OPG can develop to block RANKL and prevent
osteoclast formation.
 Extensivestudies done by Alhashimi et al., Aihara et
al., Kanzaki et al.,and Yamaguchi et al. have
demonstrated that RANKL promotes osteoclastogenesis
while OPG inhibits this effect.
 One of the most distinctive features of bone
remodeling of both cortical and trabecular bone is the
precise coupling of bone resorption and formation.

 The A-R-F process is similar for all types of bone

remodeling; the multicellular unit for a trabecular bone
surface is essentially a hemisection of the
cutting/filling cone for cortical bone.
 (1) bone microdamage results in release of inflammatory
cytokines (prostaglandins, interleukin 1-, and so on) and
exposure of mineralized collagen to extracellular fluid.

 (2) T cells, attracted by the inflammatory cytokines and

exposed mineralized collagen, produce the ligand RANKL,
which induces osteoclastogenesis

 (3) preosteoclasts from circulating blood have RANK

receptors, which are activated by the RANKL to from
osteoclasts

 (4) as bone is resorbed, growth factors are released that

stimulate preosteoclasts to produce OPG which then retract
from the bone surface.
 (5) mononuclear cells move in and coat the scalloped
resorbed surface with cementing substance (green)

 (6) perivascular osteogenic cells migrate through the

low cell density zone and differentiate to preosteoblasts
that then divide and form two osteoblasts each.

 (7) osteoblasts form new bone, filling the resorption

cavity and completing the turnover process.
1. Effect on the pulp
 Heavy intrusive force can sever the blood vessels as they
enter the root apex and that can affect the tooth vitality.

2. Effects on the root structure

 Some root remodeling constantly occurs during orthodontic
tooth movement.
 But permanent root loss ( root resorption) occurs if:
there are conical roots with pointed apices,
dilacerated / distorted root form,
excessive force over prolonged period,
root apices in contact with cortical bone,
history of trauma.
3. Mobility

PDL usually widens during orthodontic treatment

hence some mobility of teeth is unavoidable during
orthodontic treatment.
Heavy sustained O.F. results into greater amount of
undermining resorption and thereby greater mobility.
If tooth becomes excessively mobile during treatment,
all
forces should be discontinued for time being till
mobility reduces.
4. Pain

Pain during orthodontic treatment occurs due to development

of ischemic areas in the PDL.

Heavier forces will cause more pain.

Upon activation using light forces can also produce pain for
few hours to few days.
This also greatly depends upon individual pain threshold.

If patient is engaged in repeated chewing during initial 8 hrs.

after activation the pain can be reduced.

Excessive pain during activation is an indication of too heavy

force which should be avoided.
 Orthodontic tooth movement consequent t application
of force is outcome of complex chain of events,
eventually leading to bone resorption and bone
formation.

 What signals the ‘cells’ in periodontium to perceive

orthodontic force to transform into bone forming and
bone resorbing cells is not yet fully understood.

 Future research in the field of molecular biology is

expected to unfol many more secretes of this
phenomenon.