2019, Number 4
Factors that influence the alteration of orthodontic movement. Bibliographic review
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Language: English/Spanish [Versión en español]
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Page: 267-275
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ABSTRACT
Introduction: Prolonged forces push the tooth against the socket and generates the onset of bone remodeling. Orthodontic mobilization is achieved with prolonged and gentle forces. Improper handling of orthodontic forces influences movement limitation as a factor. Background: Forces on the teeth are expressed in the tissue; this reaction forms and reabsorbs facilitating tooth displacement; in the tissue environment there are influences to the biological response, among these the characteristics of the alveolar bone, tooth morphology; in addition to factors of direction, duration and intensity of the forces. Objective: Evidence the factors that alter the movement. Purpose: to inform the reader about the factors that can alter the dental movement and how they influence. Material and methods: The present investigation was based on an exhaustive search of scientific articles, both in Internet databases: PubMed, EBSCO, JCO and ScienceDirect, Medigraphic among others, as printed material, making a selection of 30 reviews, taking as criteria keywords that related to the subject as, movement biology, orthodontics, ligament alterations, and excluding those that were unrelated, the search period includes the year 2005-2018. Results: The factors that affect the dental movements are: medicines such as ibuprofen, indomethacin, factors such as age, periodontal biotype, ankylosis and dental malposition. Conclusion: Orthodontic movements are altered by different factors; such as the consumption of anti-inflammatory drugs that alter the normal inflammatory process. Evaluate the DX of ankylated teeth as it is an important factor in the decision-making process in the application, magnitude and direction of forces that achieve an ideal movement.INTRODUCTION
The attachment and protective periodontium undergoes tissue changes in response to the dynamics of orthodontic movement, and this response must be properly understood in order to investigate the external and internal factors that can alter ideal orthodontic movement.1
This ideal movement involves the use and control of forces in parameters of magnitude, frequency and duration, as these are what will trigger bone remodeling.2
Extrinsic factors such as medications that act chemically in the molecular inflammatory response and inhibition of the bone remodelling process have been proven. Another clear example of the limitation of movement is dental ankylosis, the patient's age and periodontal pathology.3
The purpose of this research is to inform the reader about the factors that can alter dental movement and how they influence it, like anti-inflammatory drugs, the age of the patient, among others.
BackgroundAccording to Proffit (2014), the concept of tooth movement comprises three phases: pressure and tension in the periodontal ligament leading to alterations in blood flow; formation or release of chemical mediators and cell activation.2
Basically, if prolonged pressure is applied to a tooth, tooth movement will occur due to bone remodelling of the surrounding bone.4
The periodontal ligament is adapted to forces of short duration, when the forces are prolonged, the push of the tooth against the alveolus generates the onset of bone remodelling, even if the force is not very intense. Orthodontic mobilization is achieved with prolonged and gentle forces.4
According to Proffit,1-3 the lips, tongue and cheeks are muscular structures that generate forces on the teeth, although the pressures are not usually balanced, they do not move the teeth due to the compensation made by the periodontal ligament with its metabolic effect.
Theoretical frameworkBone is selectively resorbed from some areas and new bone is regenerated in another area, the tooth moves through the bone carrying with it its anchorage apparatus as the tooth socket migrates. Thus the movement is a phenomenon of this ligament.5
There are two theories that explain the mechanism by which light forces are able to provide the movement of the teeth:
- 1. Pressure-voltage theory based on the work of Sandstedt 1904 and Oppenheim 1911.
- 2. Piezoelectricity theory.3
Pressure-voltage theory
Refers to cellular changes produced by the action of chemical substances that originate when the blood flow adjacent to the tooth is altered during tooth movement due to the reduction or increase in the diameter of blood vessels. Relates tooth movement to biochemical responses of cells and extracellular components of the periodontal ligament and alveolar bone.3
Piezoelectricity theoryThis attributes tooth movement to changes in bone metabolism that are controlled by electrical signals generated when the alveolar bone is flexed and deformed by the application of a force. The electrical signals modify the bone remodelling on which tooth movement depends.3
The chemical mediators involved in bone remodelling during the application of orthodontic forces could be divided into five groups.
- 1. Cyclic nucleotides: these include cyclic 3',5' adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP) both of which are described as second messengers as they mediate external stimuli and convert them, after a series of intracellular events, into cellular response, i.e. protein synthesis, cell division, etc.6
- 2. Arachidonic acid (AA) metabolite: arachidonic acid is a polyunsaturated fatty acid found in the phospholipids of the cell membrane of almost every cell in the human body. Its metabolism occurs via two pathways named after the enzymes that initiate the reaction via, the oxygenase cycle that gives rise to prostaglandins, and the lipoxygenase pathway that gives rise to the formation of leukotrienes.5
- Both substances are involved in different inflammatory processes, fever, pain etc. However, prostaglandins seem to act by producing an increase in intracellular cAMP and have also been shown to stimulate bone resorption.7
- 3. Neuropeptides: these are potentially retroactive mediators, and although there are a large number of them, only substance p and vasoactive intestinal polypeptides (VIP) directly affect bone cells through their action on the vascular apparatus. These neuropeptides are stored in the nerve endings of periodontal tissues and are released into the extracellular space after the application of orthodontic force.8
- 4. Cytokines: these are local mediators generally released by cells of the immune system in response to stimuli produced by a variety of agents. A large number of them have been described, but it has been determined that interleukins 1-alpha and interleukins 1-beta intervene fundamentally in the process of bone resorption. Together with tumour necrosis factors, they appear to stimulate fibroblast collagen production, accelerate the arachidonic acid mechanism, and globally mediate bone resorption.9
- 5. Endocrine mediators: Here we refer to the main regulators of bone metabolism, i.e. those hormones that are responsible for maintaining serum calcium homeostasis. These are parathyroid hormone, vitamin D (through its active metabolite) and calcitonin.10
Drugs
A patient undergoing orthodontic treatment may be taking medication, but those that reach bone tissue via the bloodstream are the ones that can affect orthodontic treatment.11
The most common group of drugs used during orthodontic therapy are Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control after the application of forces to the teeth.11
The anti-inflammatory effect of this group is the result of blocking the synthesis of prostaglandins from arachidonic acid by inhibiting the enzyme cyclooxygenase.12 Clinical and animal studies have identified the role of prostaglandins in the process of bone resorption, determining that they have a direct action in increasing the number and size of osteoclasts and in stimulating their resorptive activity. This is why the use of NSAIDs for pain control in orthodontics has been questioned in recent years, because they would not only have a positive effect on pain management after orthodontic activations, but could also affect the sequence of tooth movement, by inhibiting or at least reducing the relationship between inflammation and the bone resorption process, decreasing the range of tooth movement.12
Paracetamol is one of the most widely used drugs for safe and effective pain control, acting by decreasing cyclooxygenase products, preferably in the central nervous system, without significantly altering peripheral prostaglandin secretion. Experimental animal studies have concluded that the use of paracetamol would not alter bone remodelling, i.e. it would have no effect on tooth movement range. Corticosteroids are related to the control of carbohydrate, lipid and protein metabolism, but they also have anti-inflammatory properties.13
AgeThe periodontal ligament in the child has a high rate of fibrillar turnover, the collagen fibres are thinner and there is a greater number of cells, making the periodontal tissues in young individuals react more quickly to orthodontic loading, unlike the response of adult periodontal tissues. This is due to the physiological changes that periodontal tissue undergoes in the adult, where the alveolar bone is less vascularised and the medullary spaces acquire more adipose tissue. With increasing age, cellular activity decreases, and tissues become richer in collagen, affecting the response of adult tissues to orthodontic forces. The child is in a proliferative stage, and presents a spongy alveolar bone, with large and numerous medullary spaces, abundant vascular flow, and maximum remodelling potential.13
MATERIAL AND METHODS
Theoretical bibliographic study: a search was carried out in the electronic platforms PubMed, EBSCO, JCO, ScienceDirect and Medigraphic where 30 scientific articles were chosen as background for the determination of the functioning of the dynamics of orthodontic movement and the main alterations that can affect this movement.
The following inclusion and exclusion criteria were used to select the scientific articles.
Inclusion and exclusion criteria- 1. Articles published between the years 2005 to 2018 and directly related to the topic orthodontic movement are included.
- 2. Articles published below the year 2005 and not related to orthodontic movement are excluded.
After the literature review, the results were organized with explanatory wording.
RESULTS
The literature review was conducted with 30 articles that specified the main factors that alter movement during orthodontic treatment.
Among them were the pharmacological chemical mediators, such as indomethacin which has anti-inflammatory, analgesic and antipyretic properties. This drug has potent inhibitors of prostaglandins, leukocytes and motility of alveolar bone resorption thus leading to loss of adherence of periodontal fibres thereby affecting the bone remodelling necessary for tooth movement.14
Ibuprofen, in experimental studies, shows the inhibition of the production of prostaglandins of the E series in the periodontal ligament and consequently the movement is decreased.14
Glucocorticoids largely inhibit inflammatory responses of the body and the activity of osteoblasts by stimulating osteoclast activity and thus decreasing bone formation and resorption.14
Age is a determining factor in orthodontic movement; there are differences between the periodontium of the adult and the child, which will define the complexity of the movement with increasing age.15,16
In adults, cellular activity decreases and tissues become richer in collagen, affecting the tissue response to orthodontic forces. On the other hand, the alveolar bone in children presents large and numerous medullary spaces with a high response to remodeling.15
Assessment of the condition of the periodontium (gingival width and gingival biotype) before starting orthodontic treatment will make it possible to predict the evolution of any periodontal and mucogingival pathology that may be altered.17
The ideal movement in orthodontics. A retrospective study of 100 patients found that teeth with little keratinised gingiva before orthodontic treatment did not form new gingiva after treatment, and found a 6.1% incidence of complete loss of keratinised gingiva in teeth with less than 2 mm of keratinised gingiva.16,17
Periodontal disease and tooth loss are the main triggers for the phenomenon of pathological migration of dental structures and in turn create dental malpositions forming protrusion, diastemas, molar inclination with posterior collapse and decreased vertical dimension of the lower third.9-11
Holmberg et al, Garcidueñas et al, and Vega M et al. prospect their studies that the diminished periodontium has no consequence in the alteration of orthodontic movement if a proper philosophy of biomechanics is applied, otherwise the orthodontic movement would be altered and not ideal.9-11
Another factor that alters dental movement is dentoalveolar ankylosis in the primary dentition, which is a frequent alteration, presenting a multifactorial aetiology, which generates fusion between the tooth and the alveolar bone due to obliteration of the periodontal ligament, causing the grams of force necessary for ideal movement to increase.12-13
The treatment decision should be based on clinical and radiographic findings, the severity of the infraocclusion, the root development of the permanent successor and the occlusal repercussions of each patient, which is why early diagnosis and treatment are of great importance to minimise the aforementioned alterations.14
DISCUSSION
Recognition of the tissue processes and normal aspects of the stomatognathic system in the face of orthodontic movement is of utmost importance in order to understand the effect of the factors that can alter this dynamic mechanism.15
Dawson mentions that among the causal agents capable of initiating the deterioration of the Stomatognathic System are microorganisms and forces. In this sense, if one wants to understand how a disease evolves, one must first understand the physiological aspects related to normal function.15
Soldevilla L, who determines the normal appearance of the periodontal ligament and alveolar bone against light orthodontic forces.16
Rodriguez O et al. describes the morphofunctional changes in the periodontium associated with tooth movement due to orthodontic treatment, which involve biochemical, histological and physiological processes.17
Therefore, it is possible to investigate that drugs that express their activity at the tissue level tend to alter the bone remodelling response to orthodontic movement.3
As described by Peña Claudia et al. in the action related to the effects of anti-inflammatory drugs during movement, they inhibit the activation of cyclooxygenase and thus the primary mechanism of this movement, inflammation.3
Another important factor to take into account is the age of the patient, since a young periodontium presents better characteristics to the inflammatory response, in agreement with Vargas del Valle P et al. who describes age as a factor to take into account in dental movement and Moreno M, in his bibliographic review of orthodontic tooth movement: modifying factors and tissue alterations.18,19
An alteration factor specific to the tooth such as ankylosis is considered a determinant in the limitation of movement in orthodontics that should be evaluated before starting any treatment to determine the ideal load of force and direction, as well as Silva B. et al, who determines that the epithelial remains of Malassez play an important role in the maintenance of the periodontal ligament and the prevention of ankylosis, and who investigate the recommendations in the diagnosis and evaluation of the treatment plan.20
With the advent of technology, a contributing factor in tooth movement has become dramatically evident. The low frequency therapeutic laser has been shown to increase dental movement by 30%, making it a favourable alternative; Holmberg P et al. determined the advantages Use of laser therapy in pain control in orthodontics the advantages in pain management and repair in bone remodelling, González R et al. determined the advantages of the laser in some dental movements and the benefit in ankylosed teeth.21-24
Muscle activity should be evaluated, as it plays an important role in limiting movement in a hyperactive and hypertonic maxillary, mandibular and perioral musculature. Also described by Andrew Pepicelli et al.25,26
Finally, Ayala MA et al, evaluated patients with frequent systemic diseases and orthodontics, and mentions that the most frequent diseases are diabetes, hypertension, immunological, syndromes and disabilities, stressing the importance of an adequate treatment plan and planning of any type of pathology, since for example a disability can affect oral hygiene and in turn degrade the strength of a module or chain, decreasing the expression of forces and thus altering the ideal orthodontic movement.27
CONCLUSIONS
Orthodontic movements are altered by different factors; among the most common is during the consumption of anti-inflammatory drugs such as ibuprofen and ampicillin, by altering the normal inflammatory process leading to a deficiency of microscopic bone remodelling.
It is of utmost importance to evaluate the diagnosis of ankylosed parts as it is an important factor in making decisions on the application, magnitude and direction of forces that achieve ideal movement.
As has been described, age plays an important role in movement, the older the periodontium, the greater the complexity in the movement.
Finally, technology shows the implementation of low frequency laser therapy to aid movement and reduce pain in orthodontics.
REFERENCES
AFFILIATIONS
1 Médico residente de Posgrado de Ortodoncia. Instituto Mexicano de Ortodoncia. México.
2 Ortodoncista. Docente. Instituto Mexicano de Ortodoncia. México.
CORRESPONDENCE
Andersson A Niño Charry. E-mail: andersson.nino@imo.edu.mxReceived: Marzo 2020. Accepted: Agosto 2020.