Can we speed up orthodontic treatment?
Can we make teeth move faster? A summary of current evidence
There is no doubt that all orthodontists would like to speed up orthodontic treatment, as shorter treatment times would clearly benefit our patients. Over the past five years several methods to speed up treatment have been developed and in this post I’m going to discuss my interpretation of the current state of the evidence.
I shall start by dividing these methods into those involving appliances (mostly wire and brackets) and those that aim to modify the biology of tooth movement.
Brackets and wires
I have already outlined the previous research into modifications of wires and brackets (particularly self-ligation) in these posts.
It appears that none of these modifications lead to increased efficiency of tooth movement and we could speculate that the effect of the operator and treatment plan may have a greater effect on treatment timing and success. It is also clear that the teeth do not recognise any particular type of “magic” bracket that we may use.
Biology of tooth movement
The other approach that has been taken to speed up treatment is to attempt to modify the biological factors. This is an entirely logical approach and a large amount of research is currently underway to evaluate these developments. Importantly, little of this research has been subject to peer review and published.
I have already devoted several blog posts to discussing the effects of vibration on tooth movement. In summary, it appears that evidence in support of the effect of vibratory force on influencing tooth movement is lacking. There is one small-scale trial that suggests a small increase in tooth movement. This was funded by Acceledent and run by a consultant to Acceledent and published in Seminars in Orthodontics. My feeling was that this was significantly flawed. The other study was larger, carried out by an independent team and published in the high-profile Journal of Dental Research. They concluded that Acceledent did not increase tooth movement. I have discussed the trials in these previous postings.
The other approach is to carry out minor surgical procedures to accelerate tooth movement and the evidence underpinning this intervention has been summarised in a recently published Cochrane systematic review. This done by a team based at The Royal London Dental School, in Whitechapel, London, UK and Corfu, Greece. Whitechapel is the area of London famous for Jack the Ripper and Corfu is a beautiful Greek Island.
Fleming PS, Fedorowicz Z, Johal A, El-Angbawi A, Pandis N
Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD010572. DOI: 10.1002/14651858.CD010572.pub2.
This was a Cochrane review so we can assume that it is of high quality because of the requirements of Cochrane editorial policy. I have covered how to read systematic reviews previously in this post. How to read a systematic review
What did they do?
They set out to evaluate the effect of surgically assisted orthodontics on the duration and outcome of orthodontic treatment. They used standard systematic review methodology when they searched the literature, identified the papers, applying the selection criteria, data extraction and evaluation of bias.
What did they find?
After an extensive literature search and exclusion of many studies, they selected 4 randomised trials that involved a total of only 57 patients. The interventions that were evaluated were essentially variants of corticotomy and micro osteoperforation. They pointed out that it was very unfortunate that no study followed patients to the end of their treatment. As a result, they could not answer their primary question.
The results of these trials were confined to the rate of retraction of canine teeth. While this does measure tooth movement, this is only for one phase of treatment and we must consider that this is only a surrogate measure for total tooth movement.
They found that tooth movement was slightly quicker with surgically assisted orthodontics over a period of one month. The mean difference was 0.61mm (CI 0.49-0.72).
They also pointed out that the studies were not of high quality and were subject to various forms of bias.
Overall, they concluded that there was limited research that underpins this treatment but there may be some promise in these new methods. New research needs to be carried out before these methods can be widely accepted.
What did I think?
I thought that this was a good detailed review that identified that surgically assisted orthodontics may have some potential. However, it is important for us to consider that the most important outcome, from a clinical point of view, is the total treatment duration and this was not evaluated by any of the studies.
I also thought that it was important to find that the differences that they detected in tooth movements were small. I am not sure how this would translate to a complete course of treatment.
We must also evaluate these findings with respect to the risks of treatment, for example, pain and discomfort and the overall cost of treatment. My feeling is that at present there is still a lack of evidence on whether this intervention is clinically effective.
I think that, currently, there is no real evidence to support the use of self ligating brackets, “space age” wires, vibratory force and surgical techniques with the aim of increasing the speed of tooth movement. As a result, we should wait until current trials are published, before we can recommend this treatment to our patients.
Unfortunately, these techniques are being widely promoted in the absence of evidence. It is clear to me that if practitioners want to use these techniques they need to inform patients that the evidence is weak or lacking. It is then the patients decision on whether they wish to undergo this type of treatment with the increased costs and potential risks.