November 02, 2015

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.

Self ligation: Another nail in the coffin?

Self ligation: more nails in the coffin

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.

Lets talk about AcceleDent

AcceleDent again. Cyclic vibration accelerates tooth movement: A clinical trial

Ground Hog day? AcceleDent again! Vibrational force has no effect on tooth movement a new trial

AcceleDent: The advertising has started!

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.

 

Surgical adjunctive procedures for accelerating orthodontic treatment

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.

Summary

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.

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Have your say!

  1. Avatar

    Thanks again. Agree on all points. I use SLAs almost exclusively for convenience – not speed. It is a management decision, not a biological decision (I still put colours on the top 6 on request). No modules on the lower and no wire ligs at all (hated removing them with blunt lig cutters at 4 pm)

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    Hi Kevin,
    Nice picture of Corfu!
    BW
    Nick

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    Sir,
    How about LOW LEVEL LASER THERAPY to increase tooth movement?…
    http://www.ncbi.nlm.nih.gov/pubmed/17361391

    • Avatar

      Well spotted omission.
      The problem with all the LLLT laser studies are one of standardising energy applied/protocols and wavelengths. Therefore even though the study you mention is one of many that points to LLLT potentially accelerating tooth movement, none of the studies have a large enough sample size on their own (even though LLLT lend itself to double blinded RCT well) and the issue of energy protocols and wavelengths means pooling the studies is impossible as almost all the papers on the subject measure energy applied differently and then do not have enough information on application protocols themselves.

      In my practice we use LLLT for pain relief during ortho treatment, the result is instantaneous reduction in discomfort, we will often apply LLLT before adjustments on sensitive patients or a very malpositioned tooth that we need to put a bit more pressure on to engage the wire in the bracket… my anecdotal observation is that LLLT works well. From a tooth acceleration perspective its just not practical to get patients in every few days to apply LLLT, and thats not just us (I delegate it to a nurse on a non-production chair) patients really are not able to come in every 3 days.

      • Avatar

        Thanks for the interesting comments and it would be really great if someone would carry out some high quality research on these methods. I would really like to see a simple method that would speed up tooth movement and reduce discomfort

  4. Avatar

    What do you think about caffeine to speed up orthodontic treatment ?

    I’m 22, started orthodontic treatment in the beginning of 2015, and it’s almost over. Class II malocclusion with something like 1cm+ of space. I drink lot’s of coffee.

  5. Avatar

    I agree with all your discussion , but i can not deny that me myself i get a feeling that self ligating brackets increase the first phase of treatment , the alignment and even can get better result in space gaining .
    I know it is not a controlled trial but atleast i feel more satisfied .
    Dear Dr , would like to get your opinion in the low level laser for the same purpose , would you consider to get such a device to your clinic , or we should consider waiting 🙂

  6. Avatar

    Thank you for your blog which as usual acts as a catalyst for stimulating thought and some discussion. It is clear I and many others enjoy the opportunity to read your opinions on “hot topics”.

    With regard to the present one maybe a distinction should be made between FASTER TOOTH MOVEMENT and FASTER ORTHODONTIC TREATMENT.
    There appears to be minimal chance of meaningfully accelerating tooth movement itself. However what about discussing better protocols that maximise treatment efficiencies and lead to faster overall treatment.
    For example ;
    1. Avoiding round tripping.
    2. Using Mechanical treatment efficiencies that allow for continual (gentle) tooth movement rather than a start/stop cycle of force application. Such as;
    a. Avoid bracket debonds by ensuring good secure initial bond technique.
    b. Immediate repair of bracket failures to avoid time loss.
    c. Customise appointment intervals to individual patients (there is a large variation in how fast different individuals teeth move). Also customise appointment intervals to the different stages of treatment. ( initial alignment stages = longer intervals etc).
    While these points e.g.. good bond technique, might be taken for granted in academic papers, in the real world these points are often overlooked. I am sure others could add a host of tips like these that might lead to “faster treatment” rather than “faster tooth movement”.

    Kevin, It is clear that you have made your mind up on self-ligating appliances – they are a waste of space !! Could I stand up a little in their defence. No question on speed of treatment, they are NOT any faster. (I proved this to myself years ago with my own tinpot study/audit – Orthodontic update 2012 vol 5. no 1). But I do believe there is a question mark in two other areas.
    1. Anchorage demand may be less when using self ligating appliances because of lower friction forces for sliding mechanics. How the devil do you design a study to measure it ???
    2. A reduction in the overall number of appointments is possible. Because of the secure ligation and highly flexible low force wires this allows longer appointment intervals. The same amount of tooth movement is achieved with less wire changes.
    kind regards Peter Ollivere

    • Avatar

      Hi Peter, Sorry for the delay in getting back to you. I have been recovering from cervical spine surgery. I agree with most of what you say! Your points on technique are very relevant and I cannot help wondering that the effects of the operator, in terms of technique and skill, are probably a greater effect than the choice of appliance. I’m very aware of this in my own practice, where several years ago I decided that I will increase the time of my appointments through each patient. Subjectively, I seem to be finishing them more quickly and to a higher standard. But this is only a sample of one!

      As regards self ligating brackets, I actually quite like them. My main problem is the claims that are made about them without evidence. I cannot help feeling that there must be something to them, particularly as the design of the bracket insurers complete ligation of the wire at every visit. Nevertheless, the studies are showing no difference and this may well be due to the effect of the operators carrying out the treatment on both groups of patients to the highest standards, as you have mentioned in the first part of your post. I hope all this makes sense

      Best wishes Kevin

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    Kevin, hope you are continuing to heal from your surgery and that you will soon be able to fully return to your work. From the evidence, it seems many of the biological approaches to accelerate orthodontic treatment leave much to be desired. One feature not mentioned is the extra cost and patient trauma.

    Larry

    • Avatar

      Hi Larry, Sorry for the delay in getting back to you but I’ve had to take it easy following my surgery. I’m pretty much back to normal so I am now catching up. You are completely correct. Whenever we are evaluating a new treatment is essential that a cost effectiveness analysis is carried out. I’ve posted a blog today on pain reduction with AcceleDent and while the authors suggest there is an effect they have not really compared the pain reduction with the effectiveness or the cost of simple methods such as over-the-counter analgesics. I think it will take awhile for orthodontic researches to take some aspects of prospective trial methodology on board.

      Best wishes Kevin

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