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Revue de la littrature

Review of the Literature

2009. CEO. dit par / Published by Elsevier Masson SAS. Tous droits rservs/All rights reserved

La force lgre et le dplacement orthodontique : revue critique


Light forces and orthodontic displacement: a critical review
Fatima ZAOUI

Rsum
La force lgre ou optimale constitue actuellement le centre dintrt de nombreuses recherches cliniques. travers la littrature, lexistence dune corrlation positive entre force lgre et vitesse de dplacement est souvent admise. Aujourdhui, le consensus nest ni universel ni scientifique et lexistence dun niveau de force optimum est toujours soumis discussions comme en tmoignent de nombreuses publications. Avec les nouvelles techniques danalyses scientifiques et lavance de la recherche en biologie et en gntique, il est ncessaire de reconsidrer ces points de vue, tant sur le plan biologique que mcanique, des transformations cellulaires et molculaires expliquant la cascade dvnements qui aboutissent au dplacement orthodontique sans dommage tissulaire. Le but de cet article est de rapporter les donnes rcentes de la bioadaptabilit des dents et du parodonte aux systmes de forces orthodontiques pour mieux comprendre la physiologie et la physiopathologie, passage incontournable pour optimiser les moyens thrapeutiques et matriser la dure du traitement souvent juge longue.

Summary
Light or optimal forces are currently the focus of many clinical studies. In the literature, a positive correlation between light forces and speed of displacement is often acknowledged. Now, the consensus is neither total nor scientific and the existence of an optimum force level is still the center of discussion, as witnessed by numerous publications. With the new scientific analysis techniques and the advances made in biological and genetic research, we need to rethink these viewpoints from both the biological and mechanical standpoints since cellular and molecular transformations account for the series of events leading up to damage-free orthodontic displacement. The aim of this paper is to report on recent data regarding the bio-adaptability of teeth and periodontium to orthodontic forces systems in order to enhance our understanding of the physiology and physiopathology involved. Such understanding is a must if we are to optimize our treatment arsenal and achieve greater control of treatment times which are frequently judged excessive.

Mots-cls
Physiologie du desmodonte. Remodelage osseux. Force mcanique. Mouvement orthodontique.

Key-words
Physiology of the periodontium. Bone remodeling. Mechanical force. Orthodontic movement.

DCD, SQODF, Professeur de lenseignement suprieur, service dODF, Facult de mdecine dentaire de Rabat, Universit Mohammed V Souissi, Maroc.

Correspondances et tirs part / Correspondence and reprints: F. ZAOUI, DCD, SQODF, Professeur de lenseignement suprieur, service dODF, Facult de mdecine dentaire de Rabat, Universit Mohammed V Souissi, Maroc. e-mail : zaoui@fmdrabat.ac.ma

International Orthodontics 2009 ; 7 : 3-13

Fatima ZAOUI

Introduction
Les dents se dplacent travers los alvolaire soit dans un processus normal, soit sous une contrainte orthodontique. Les tudes ralises avant le XXe sicle ont tent principalement danalyser les changements histologiques des dents et des tissus parodontaux au cours du mouvement orthodontique (MO). Les tissus dentaires impliqus sont la pulpe dentaire, le desmodonte, los alvolaire, la gencive et le systme vasculaire. Ces constituants participent aux changements adaptatifs et rpondent par des ractions rapides dans les tapes initiales de la mcanique orthodontique. Cependant, ces variables ne peuvent tre directement influences par le clinicien alors que lintensit, la dure et la localisation de la force peuvent ltre.

Introduction
Teeth move through the alveolar bone either in response to a natural process or when obliged to do so orthodontically. Studies conducted prior to the 20th century were mainly aimed at analysing the histological movement of teeth and of the periodontium during orthodontic movement (OM). The dental tissues involved are: tooth pulp, the periodontium, alveolar bone, the gingiva, and the vascular system. All are affected by the need for adaptation and respond rapidly in the early stages of orthodontic mechanics. However, the clinician has no direct control over these variables whereas the intensity, duration and location of the force can be controled.

Le mouvement orthodontique : 100 ans aprs Sandstedt


La thorie du mouvement orthodontique (MO) a t publie pour la premire fois par Sandstedt en 1905. Depuis cette poque, une littrature fournie [1] a tent dexpliquer les vnements cellulaires et molculaires sous leffet des contraintes mcaniques : Reitan en 1951, Story et Smith en 1952, Baumrind en 1969, Hixon en 1970, Davidovitch en 1991, Sandy en 1993, Melsen en 2001, etc. Les images cliniques du MO sont rsumes en trois phases : une phase initiale o MO est instantan (dplacement dans lespace desmodontal), une phase o aucun MO nest visible (zone dapoptose cellulaire) et une phase de dplacement linaire et rapide (la dent se dplace) (fig. 1). Reitan (1951) a dfini une zone de compression, une zone hyaline et une zone de tension. Il a attir lattention sur la complexit de la rponse orthodontique selon le type et lintensit de la force

Orthodontic movement: Sandstedt, a hundred years on


The theory of orthodontic movement (OM) was first published by Sandstedt in 1905. Since then, the abundant literature on the topic (1) has attempted to account for the cellular and molecular responses to mechanical stress: Reitan in 1951, Story and Smith in 1952, Baumrind in 1969, Hixon in 1970, Davidovitch in 1991, Sandy in 1993 and Melsen in 2001, etc. The clinical depiction of OM can be summed up in three phases: an initial phase in which OM occurs instantly (displacement within the periodontal space), a phase during which no OM is observed (cellular apoptosis phase) and a rapid linear displacement phase (the tooth is displaced) (fig. 1). Reitan (1951) defined an area of compression, a hyaline area and an area of tension. He drew attention to the complex nature of the orthodontic response according to the type and intensity of

Fig. 1 : Trois phases de dplacement orthodontique.


Fig. 1: Three stages of orthodontic displacement.

International Orthodontics 2009 ; 7 : 3-13

La force lgre et le dplacement orthodontique : revue critique


Light forces and orthodontic displacement: a critical review

applique, la mcanique utilise et les variations individuelles du patient. Il a prcis que la zone hyaline est plus frquente dans le mouvement de version que dans le mouvement de translation. Ces zones sont frquentes avec des forces continues de 30 g et des forces intermittentes de 70 100 g. Il a not que la rsorption des zones de ncrose se fait au bout de 2 4 semaines (fig. 2). Story et Smith (1952) ont dfini le concept des forces diffrentielles et lintervalle des forces optimales qui peuvent produire une vitesse de dplacement rapide. Hixon (1970) a trouv que la vitesse de rtraction recommande par Story et Smith est variable dun individu lautre. Ceci ninvalide pas le concept, mais prcise que la force optimale est diffrente pour chaque individu et que finalement, lintensit de la force est lune des nombreuses variables affectant la vitesse de dplacement.
a

the force applied, the mechanics used and the patients individual characteristics. He stressed that the hyaline area is more frequently found in cases involving tipping rather than translational movement. These areas are frequently observed with continuous forces of 30g and intermittent forces of 70 to 100g. He noted that the resorption of the necrotic areas occurs after 2 to 4 weeks (fig. 2). Story and Smith (1952) defined the concept of differential forces and the interval of the optimal forces capable of producing rapid displacement. Hixon (1970) found that the speed of retraction recommended by Story and Smith varied from one individual to another. This did not invalidate the basic concept but claimed that optimal force can differ from one individual to another and that, in the end, force intensity constitutes one of the many variables acting upon displacement rate.

Fig. 2 a-c : Les zones de tension et de compression lors du MO : B (os), PDL (desmodonte) activit cellulaire intense gauche et apoptose cellulaire droite et T (dent) [7].
Fig. 2 a-c: Tension and compression areas during OM: B (bone), PDL intense cell activity on the left and cell apoptosis on the right and at T (tooth) [7].

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Fatima ZAOUI

Melsen (2007) [2] a remis en question le concept des forces diffrentielles et des surfaces radiculaires dans le calcul de lancrage. Elle insiste sur la qualit de los le long de la racine et linclinaison de la racine : lancrage ne dpend pas de la longueur radiculaire mais de la morphologie et de la physiologie de los (fig. 3). Bien (1966) : Le desmodonte, centre initiateur des ractions biologiques, est constitu de trois liquides distincts mais qui interagissent : le systme vasculaire, les cellules et les fibres parodontales ainsi que les fluides interstitiels. Ces liquides absorbent le choc des fonctions. La pression momentane cre des forces brusques, cependant les pressions occlusales (1 500 g/cm2) nentranent pas lclatement de la membrane parodontale et nont pas dimpact sur los autour de la dent. Le desmondonte, de par sa composition htrogne, se comporte diffremment dans la distribution du stress et des contraintes au niveau de la dent et de los. De ce fait, il ne peut tre considr comme tissu homogne et linaire pour les tudes de biomcanique telles que celles dcrites par Burstone. Baumrind et Buck (1969) ont rapport que la prolifration de lactivit mtabolique augmente et les protines synthtases diminuent dans les cts tension et compression. Cette observation les a amens se poser la question de savoir sil existe une diffrence significative entre les zones de tension et les zones de compression, en termes dactivit biologique (fig. 4). Robert (1974) a not une grande activit mtabolique dans les 2 heures qui suivent lapplication de la force, suggrant que, sous leffet de contraintes mcaniques, les cellules du desmodonte sont principalement ostogniques. Les fibroblastes du desmodonte sont fonctionnellement htrognes et contiennent des cellules capables de donner des ostoblastes relis la matrice protinique (ostopontin, phosphatase alcalines et sialoprotines).

Melsen (2007) [2] raised doubts regarding the concept of differential forces and of root surfaces when calculating anchorage. She emphasized the quality of bone along the root and on bone inclination claiming that: anchorage is dependent not upon root length but upon bone morphology and physiology (fig. 3). Bien (1966): the periodontium is where biological responses are initiated. It comprises three distinct interacting fluids: the vascular system, cells and the periodontal fibers and interstitial fluids. These fluids absorb the shocks resulting from function. Momentary pressure creates abrupt forces. However, this occlusal pressure (1500 mg/cm2) does not rupture the periodontal membrane and has no impact on the bone surrounding teeth. On account of its heterogeneous nature, the periodontium behaves differently regarding the distribution of stresses and strains at tooth and bone level. Consequently, it cannot be considered to constitute a homogeneous and linear tissue in the context of biomechanical studies such as those described by Burstone. Baumrind and Buck (1969) reported that the proliferation of metabolic activity increases and that the synthetase proteins diminish on the side experiencing tension and compression. This observation led them to raise the question of whether there is a significant difference between the tension areas and the compression areas as regards biological activity (fig. 4). Robert (1974) observed considerable metabolic activity within two hours of force application suggesting that periodontal cells, when subjected to mechanical stress, are principally osteogenic. Periodontal fibroblasts are functionally heterogenic and contain cells which can give osteoblasts connected to the protein matrix (osteopontin, alkaline phosphatase and sialoproteins).

Fig. 3 : Cartographie osseuse 3D ; noter les irrgularits des racines et de los et

la diffrence de lpaisseur de los tout le long de la racine, la surface de desmodonte ne peut pas tre linaire [2]. Fig. 3: 3D bone map. Note the irregularities on roots and bone and the varying
thickness of the bone along the entire length of the root. The periodontal surface cannot be linear. [2].

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La force lgre et le dplacement orthodontique : revue critique


Light forces and orthodontic displacement: a critical review

Fig. 4 : La ttracycline colorie en jaune et orange la formation de los ; noter la no-formation de los ct tension (T) mais aussi du ct compression (C). ce niveau, les zones de rsorption et de formation sont difficilement dlimites [14].
Fig. 4: Tetracycline stains bone formation yellow and orange. Note new bone formation on tension side (T) as well as on the compression side (C). At this level, areas of resorption and formation are difficult to distinguish. [14].

Heller et Nanda (1979) se sont intresss au ct tension pour vrifier lhypothse selon laquelle les fibres de collagne du desmodonte entraneraient un stimulus dostognse. Ils sont arrivs la conclusion que, lorsque la dent est soumise des forces continues, les fibres principales du desmodonte subissent des tensions significatives ou transfrent les forces directement los alvolaire, par lintermdiaire des fibres de Sharpey, en crant des zones de contrainte loignes.

Heller and Nanda (1979) studied the tension side in order to verify a hypothesis whereby periodontal collagen fibers trigger an osteogenic stimulus. They reached the conclusion that when continuous forces are applied to the tooth the main periodontal fibers are subjected to high levels of tension or transfer the forces directly to the alveolar bone via the Sharpey fibers, thus creating remote stress areas.

Le mouvement orthodontique : 15 ans aprs Frost


Frost a mis laccent sur les deux phnomnes qui constituent lessentiel du turnover osseux : le modelage et le remodelage [3]. Le modelage est caractris soit par lostognse, soit par la rsorption. Ces phnomnes sont spcifiques de certaines priodes de la vie et sigent sur des surfaces osseuses particulires. Le modelage est lorigine du changement de la forme et de la taille des structures des tissus durs. Le remodelage est un processus physiologique obligatoire pour maintenir lintgrit de los et de la racine dentaire. Ce processus cyclique est une rponse pour rparer et renouveler le squelette tout au long de la vie. Le cycle de remodelage est compos dactivation, de rsorption, dinversion et de formation. Les vnements qui se produisent au niveau compression du MO, sapparentent au cycle de remodelage (King 2001). Les dommages tissulaires au niveau du site de compression suggrent que le remodelage est le processus osseux prvalant au niveau des sites en compression.

Orthodontic movement: 15 years after Frost


Frost stressed the two phenomena which account for the bulk of bone turnover: modeling and remodeling [3]. Modeling is characterized either by osteogenesis or by resorption. These phenomena occur at specific periods of an individuals life and affect a limited number of bone surfaces. Modeling gives rise to a change in shape and size of the hard tissue structures. Remodeling is a mandatory physiological process aimed at preserving bone and tooth root integrity. This cyclical process is designed to permit lifelong skeletal repair and renewal. The remodelling cycle consists of activation, resorption, inversion and formation. The events occurring during OM compression bear resemblances with the remodelling cycle (King, 2001). Tissue damage at compression sites suggests that remodelling is the main bone process at the compression sites.

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Fatima ZAOUI

Frost a aussi dcrit le phnomne de densit osseuse appel Reginnal Accelatory Phenomen (RAP) [4] associ au mouvement dentaire, la chirurgie orthognathique et aux corticotomies. Il a dcrit aussi certains profils physiopathologiques qui peuvent causer un dsordre du remodelage : lostoporose, la maladie de Paget et la rsorption radiculaire. A partir de ce contexte physiopathologique, le remodelage peut largir ou limiter les options orthodontiques dans la gestion des malocclusions. Le MO exige une srie coordonne dvnements qui permettent los de continuer sadapter aux nouvelles positions des dents et au micro-traumatismes des forces masticatoires. Lapprciation de ces vnements nest pas seulement capitale pour comprendre le droulement des processus, mais aussi pour dvelopper les moyens aptes contrler les ractions pouvant acclrer le MO sans risque de rsorption radiculaire. Cest dans ce sens que plusieurs auteurs ont tent de dterminer une corrlation entre force lgres et vitesse de dplacement. Melsen (1999) [5] : Lobservation du comportement de los audel du mur alvolaire a retenu lattention de cet auteur. Les rsultats dune tude sur des singes aprs 11 semaines de traction orthodontique, a montr que la densit de los adjacent (dans la direction du MO) a significativement augment et que sur le mur alvolaire au contact de la dent, la rsorption directe est visible sur toute la surface de la dent. Aprs 11 semaines de traction, laugmentation de la densit indique le phnomne dacclration rapide (RAP Rapid accelatory phenomen). Lexplication fournie par lauteur est que les charges supportes par les dents sont transfres los alvolaire au travers du desmodonte encore hyalinis. Dans cette tude, lobservation confirme que la charge orthodontique peut mener la formation dos dans la direction de la force, cette densit osseuse peut alors ralentir la vitesse de dplacement orthodontique, mme quand la rsorption directe a dj commenc (fig. 5). Cette constatation a t rapporte par Deguchi en 2008 partir dune tude histomorphomtrique montrant une diminution du volume osseux et une activation de la rsorption aux stades prcoces du MO. Cependant, une augmentation de la formation osseuse est ncessaire pour le maintien du volume osseux durant le MO. Une lvation significative du taux de formation osseuse a t observe de 200 % du ct tension et de 100 150 % du ct compression. Cette formation est observe dans les tapes ultrieures partir de 12 semaines. ce stade, le MO est caractris par le RAP manifestant ainsi la capacit du squelette sadapter et cicatriser la suite de traumas mcaniques. Lintensit de la force na quun rle subordonn. Le facteur apparemment dterminant est le degr dhyalinisation du desmodonte lors de lapplication de la force ainsi que la vitesse dlimination des zones ncrotiques, elle-mme sous la dpendance de la forme de distribution des contraintes dans les tissus parodontaux et de la morphologie de los. Cette morphologie est actuellement tudie par lanalyse des lments finis non linaires. En conclusion, le MO peut se produire rapidement ou lentement dune part selon des caractristiques physiques des forces appliques et dautre part selon limportance de la rponse biologique

Frost also described the bone density phenomenon known as Regional Acceleratory Phenomenon (RAP) [4] which is associated with dental movement, orthognathic surgery and corticotomies. He also described certain physiopathological profiles which can lead to remodelling disorders: osteoporosis, Pagets disease and root resorption. In this physiopathological context, remodelling can either extend or limit the orthodontic options available for the management of malocclusions. OM requires a coordinated sequence of events enabling bone to continue adapting to new dental positions and to micro-traumas due to masticatory forces. Evaluation of these events is not only essential for an understanding of the processes involved but is also useful for the development of means capable of controling the reactions which could accelerate OM without risk of root resorption. Several authors have worked along these lines in order to determine a correlation between light forces and speed of displacement. Melsen (1999) [5]. This author focused his observations on bone behavior beyond the alveolar wall. A study in monkeys after 11 weeks of orthodontic traction revealed that density of adjacent bone (in the direction of OM) had increased significantly and that there was evidence of direct resorption on the alveolar wall in contact with the tooth and over the entire dental surface. Increased density following 11 weeks of traction points to the RAP phenomenon. The explanation advanced by the author was that the loads borne by teeth are transferred to the alveolar bone through the still hyalinized periodontium. In this study, observations confirmed that the orthodontic load can trigger the formation of bone in the direction of the force. This bone density can then slow down orthodontic displacement, even when direct resorption has already begun (fig. 5).

This observation was reported by Deguchi in 2008 following a histomorphometric study which showed decreased bone volume and activation of resorption during the early stages of OM. However, increased bone formation is necessary for the preservation of bone volume during OM. A significant 200% increase in the rate of bone formation was observed on the tension side and a 100% to 150% increase on the compression side. This bone formation was observed during the later phases following week 12. At this stage of OM, the RAP demonstrated the ability of the skeleton to adapt and to heal itself following mechanical traumas. The level of force plays only a secondary role. Apparently, the determining factors are the degree of periodontal hyalinization during force application and the speed with which necrotic areas are eliminated, a process which is itself dependent on the stress distribution patterns within the periodontal tissues and on bone morphology. Research into bone morphology using non-linear finished elements analysis is currently ongoing. In conclusion, OM can occur quickly or slowly depending, on the one hand, on the physical characteristics of the applied forces and, on the other, on the degree of periodontal biological response and bone density

International Orthodontics 2009 ; 7 : 3-13

La force lgre et le dplacement orthodontique : revue critique


Light forces and orthodontic displacement: a critical review

Fig. 5 : Les zones roses reprsentent la rsorption directe qui dplace la dent vers les zones de densit osseuse nouvellement formes aprs application des forces, ce qui peut retarder le MO [2].
Fig. 5: The pink areas indicate direct resorption which displaces the tooth towards areas of newly-formed bone following application of force. This can retard OM. [2].

du desmodonte, de la densit osseuse et du mtabolisme capable dliminer les zones ncrotiques. Von Bhl (2004) [7] a donn plus de lumire sur les zones hyalines responsables du retard du MO. Limportance de ces zones est en rapport avec les irrgularits de los alvolaire comme les a identifies la microtomographie. Les tudes histologiques ralises chez le chien rvlent que lhyalinisation localise peut expliquer les variations individuelles, facteur dterminant de la vitesse de dplacement. Enfin, lextension des zones hyalines se dfinit comme tant en relation avec lintensit de la force mais non pas avec la vitesse de dplacement. Melsen (2007) a remis en question plusieurs notions et notamment, les forces lgres et la vitesse de dplacement, les surfaces radiculaires et leur implication dans valuation de lancrage et surtout les classiques zones de tension et zone de compression [2, 8]. La microtomographie informatise (prcision de la cartographie osseuse) et les logiciels 3D (explication des contraintes par lanalyse des lments finis non linaires) ont permis danalyser la ralit des vnements qui se produisent ds lapplication de la force mcanique : 1. Les rsultats rapports par certains auteurs dmontrent que la mme vitesse est observe avec diffrents niveaux de force. Les tudes sur lanimal et sur lhomme concluent que les variations de la vitesse de dplacement sont principalement lies lindividu plutt quau niveau de force applique. 2. Sur le plan histologique, la formation dos existe aussi bien du ct tension que du ct compression, et il est impossible de dlimiter les territoires en formation et ceux en rsorption. De plus la rsorption indirecte nest pas une raction la force, mais une tentative dlimination de la zone hyaline. Par consquent,

and on whether the metabolism is able to eliminate areas of necrosis. Von Bhl (2004) [7] shed more light on the hyalinized areas responsible for delayed OM. The extent of these areas is related to irregularities in the alveolar bone, as identified by microtomography. Histological studies performed on dogs revealed that localized hyalinization can explain individual variations, an important factor governing the rate of displacement. Finally, extension of the hyalinized areas is described as being related to the level of force but not to the rate of displacement. Melsen (2007) questioned several ideas, particularly those relative to light forces and displacement rate, root surfaces and their involvement in anchorage assessment and, above all, the traditionally recognized areas of tension and compression [2, 8] Computerized microtomography (providing accurate bone mapping) and 3D software (explaining stress by means of non-linear finite elements analysis) have made it possible to determine what really occurs during these events when mechanical force is applied: 1. The results reported by some authors demonstrate that the same rate is observed with different levels of force. Studies on animals and on men have concluded that variations in displacement rate are mainly related to the individual rather than to the force applied. 2. From the histological point of view, bone formation occurs both on the tension and on the compression sides and it is impossible to distinguish which areas are forming and which are resorbing bone. Moreover, indirect resorption is not a response to force but an attempt to eliminate the hyalinization. Conse-

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Fatima ZAOUI

lappellation zone exclusivement en tension et zone exclusivement en rsorption nest plus valable pour expliquer le MO. 3. Sur le plan mcanique, le centre de rsistance est dynamique et se situe 40 % de la longueur de la racine. Il dpend de lanatomie de la dent, du desmodonte et de los environnant mais surtout, de la micro anatomie de los diffrent niveau et de lintensit de la force (Cattaneo 2008) [9]. Deguchi (2008) [6] sest intress la diffrence de vitesse de dplacement entre les dents maxillaires et les dents mandibulaires. Durant 12 semaines de dplacement, la quantit de MO est nettement plus significative au maxillaire qu la mandibule. Ceci sexplique principalement par laugmentation de 10 % du turnover au niveau du maxillaire par rapport la mandibule. Cette tude suggre que, non seulement la diffrence de lanatomie osseuse mais aussi la rponse physiologique, sont lorigine des rponses diffrentes des dents maxillaires et mandibulaires aux sollicitations des forces mcaniques.

quently, when attempting to account for OM, we are no longer justified to think in terms of areas being entirely characterized by tension or by compression. 3. From the mechanical perspective, the center of resistance is dynamic being located 40% along the length of the root. This center of resistance varies according to tooth anatomy, the periodontium and the surrounding bone but, above all, to the microanatomy of the tooth at different levels and to force intensity (Cattaneo 2008) [9]. Deguchi (2008) [6] investigated the difference between the displacement rates of maxillary and mandibular teeth. Over 12 months of displacement, the amount of OM is considerably greater in the upper as opposed to the lower arch. This can be accounted for chiefly by the 10% increase in turnover of the maxilla as compared with the mandible. This study suggests that the contrasting response rates of maxillary and mandibular teeth to mechanical force are the result of both different bone anatomy and of physiological response.

La force lgre acclre-t-elle le dplacement orthodontique ?


La rponse est loin dtre affirmative et les raisons voques sont de trois ordres : les variations individuelles, la rigueur scientifique du diagnostic et les perspectives thrapeutiques.

Do light forces speed up orthodontic movement?


The answer to this is far being a clear yes, and for three different kinds of reason: individual variations, the scientific exactness of diagnoses and treatment prospects.

Lapproche individuelle
La typologie osseuse concerne ltendue des zones osseuses denses, la qualit de los noform et la vitesse dlimination des zones ncrotiques. En effet, lapparition de cette zone nest pas limite dans un intervalle de temps, mais elle constitue un processus continu tout au long du dplacement dentaire. Sa frquence dpend des irrgularits de la surface radiculaire, mais aussi de la qualit de los. La vitesse de llimination de la zone hyaline est tributaire du mtabolisme de los et du desmodonte. Ces facteurs dterminent la vitesse du dplacement dentaire. Ce mtabolisme est influenc par le profil physiologique (ge, hormone, le comportement du patient vis--vis de la douleur, etc.) mais aussi par les profils physiopathologiques (ostoporose, maladie de Paget, insuffisance rnale, etc.). Les mdications prescrites dans ces pathologies chroniques peuvent entraner des interactions avec le MO. En effet, leur emploi peut acclrer ou retarder le mouvement dentaire do la ncessit de connatre lhistoire mdicale des patients [4, 6, 8].

The individual approach


Bone typology comprises the extent of the areas of dense bone, the quality of newly-formed bone, and the speed with which necrotic areas are removed. Necrotic build-up is not restricted to a given time period but rather constitutes an ongoing process throughout tooth displacement. The frequency with which it occurs is dependent upon the irregularities present at the root surface as well as to the quality of the bone. The time taken to eliminate the hyalinized area is dependent on the metabolism of both the bone and the peridontium. These factors determine the rate of tooth displacement. This metabolism is impacted by the physiological profile (age, hormones, patient pain threshold etc.) as well as by physiopathological considerations (osteoporosis, Pagets disease, kidney failure etc.). The drugs prescribed to treat these chronic pathologies can have an effect upon OM, either accelerating or delaying it. Hence, the need to be informed of the patients medical history [4, 6, 8].

Lapproche diagnostique
Pour dterminer la relation de cause effet entre force et vitesse, il est raisonnable dutiliser des variables mesurables. Mais comment peut-on mesurer la force optimale pour chaque dent, chaque instant, chaque inclinaison et pour chaque patient ? De

The diagnostic approach


In order to determine the causal relation between force and displacement rate, it would be wise to use measurable variables. But how can we measure the optimal force for each tooth at every second, for every inclination and for all patients? Likewise, how

10

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La force lgre et le dplacement orthodontique : revue critique


Light forces and orthodontic displacement: a critical review

mme, comment peut-on mesurer le MO ? Ces deux interrogations ont remis en question la validit des rsultats dj publis [10]. Actuellement, lamlioration des mthodes pour mesurer les forces en temps rel par lanalyse des lments finis non linaires base sur une cartographie osseuse prcise, tente de rsoudre lquation de la force optimale. Cependant, ce procd de simulation nest pas capable de dterminer les systmes de forces et peut encore moins prdire la rponse biologique [9, 10]. Pour ce qui est de la vitesse de dplacement dentaire, le monitorage par les biomarqueurs constitue une voie intressante du diagnostic biologique. En effet, les biomarqueurs dosent le niveau des mdiateurs de linflammation dans le fluide gingival aprs lapplication de la force, ce qui tmoigne dune grande activit ostoclastognique (Nistiji et al, 2006). Nanmoins de nombreuses tudes sont ncessaires pour approfondir les recherches et spcifier les cytokines dues au dplacement orthodontique et celles dues linflammation parodontale. En attendant le perfectionnement de ces outils de monitorage pour dmontrer la relation de cause effet, il est raisonnable de considrer la force lgre comme un adjectif qualitatif.

can we measure OM? These two queries have placed in question the validity of previously published data [10]. Currently, improved methods for measuring forces in real time using non-linear finite elements analysis based on accurate bone cartography are helping to solve the optimal force equation. However, this simulation process cannot calculate force systems and is even less capable of predicting biological responses [9, 10]. Regarding tooth displacement rates, the adoption of biomarkers for monitoring purposes is a useful biological diagnosis approach. Biomarkers record the level of the inflammation mediators in the gingival fluid after force application, revealing intense osteoclastogenic activity (Nistji et al., 2006). Nonetheless a lot more research is required in order to distinguish cytokines released following orthodontic displacement from those resulting from periodontal inflammation. Until such time as these monitoring tools are enhanced sufficiently to demonstrate a causal relationship, it is reasonable to consider that the jury is still out regarding light forces.

Lapproche thrapeutique
De nombreuses recherches se sont orientes vers ladministration de substance pour acclrer le MO : cest lapproche pharmacologique qui vient supporter la mcanique pour aller toujours plus vite. Certains chercheurs ont utilis les signaux biomcaniques pour amliorer le MO et raccourcir la dure du traitement ; dautres ont prfr utiliser certaines drogues chimiques pour renforcer lancrage ou stabiliser les rsultats biologiquement. Le succs de la rgulation du MO est orient vers le contrle de lactivit ostoclastique, car laltration du nombre des ostoclastes est fortement corrle aux mouvements orthodontiques. Ladministration des cytokines et des prostaglandines amliore le MO ainsi que certains mtabolites de la vitamine D. Cependant, ces substances ont un effet similaire sur lodontoclaste. Par consquent, lorsquon inhibe la rsorption radiculaire, on limite le MO et lorsquon acclre le MO, on augmente le risque de rsorption radiculaire. loppos, certaines recherches rvlent que ladministration danti-inflammatoires non stroidiens pour soulager les douleurs et rduire linconfort aprs une activation orthodontique (aspirine, Ibuprophen, indomtacin et clodronate : Liuet et al, 2006) peuvent compromettre le MO par inhibition des mdiateurs de linflammation. Il en rsulte un blocage de lactivit biologique et un allongement de la dure du traitement, mme si leur activit est rduite de moiti au bout de 24 36 heures. Ces mdicaments ont par ailleurs une action sur la rduction de la rsorption radiculaire (Krishnan 2006) [11]. Dans le rpertoire des mdicaments consomms par les patients surtout adultes, prennent place les biphosphonates (Actonel, Fusamax et Zometa) pour traiter lostoporose. Ces mdicaments inhibent les ostoclastes et bloquent langiognse. Chez ces patients, le dplacement dentaire se trouve limit voire arrt. Lorsque ces mdicaments sont administrs pendant une longue

The therapeutic approach


Lots of studies looked into the administration of various substances designed to accelerate OM, pharmacology being used to support mechanics in an attempt to proceed more quickly. Some investigators have used biomechanical signals to improve OM and thus shorten treatment time. Others have preferred chemical drugs to enhance anchorage or to stabilize results by biological means. Successful OM regulation is aimed at controlling osteoclastic activity since changes in the number of osteoclasts present are strongly correlated with orthodontic movement. The administration of cytokines and prostoglandins improves OM, as do certain vitamin D metabolites. However, these substances have a similar effect on odontoclasts. Hence, while root resorption is inhibited, so is OM; and when OM is accelerated, so too the risk of root resorption increases. In contrast, some studies have revealed that the adminstration of non-steroidal anti-inflammatories to relieve pain and reduce discomfort following orthodontic activation (aspirin, Ibuprophen, indometacin and clodronate: Liuet et al., 2006) can compromise OM by inhibiting the inflammation mediators. As a result, biological activity is impeded and treatment time is prolonged even if the activity of these substances is reduced by half after 24 to 36 hours. Moreover, these drugs have an impact on the reduction of root resorption (Krishnan, 2006) [11]. Among the medications taken by patients, particularly adults, one finds biphosphonates (Actonel, Fusamax and Zometa) which are prescribed for osteoporosis. These drugs inhibit osteoclasts and impede angiogenesis. In these patients, tooth displacement is restricted or even completely arrested. When these drugs are administered over a long period, they can give rise to maxillary

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Fatima ZAOUI

priode, ils peuvent entraner des osteoncroses maxillaires et mandibulaires. Ces ncroses sont induites par des gestes chirurgicaux et en particulier les extractions dentaires ou dautres thrapeutiques dentaires. En orthodontie, il est alors recommand de traiter ces patients sans extractions et en privilgiant le stripping ou lexpansion. Dans certains cas, labstention orthodontique est conseille [12, 13]. Lorthodontiste doit rester vigilant et bien valuer le rapport bnfice/risque du traitement lorsquil sagit de terrain sensible.

and mandibular osteonecrosis. These osteonecrotic episodes of are triggered by surgical procedures, notably tooth extractions or other forms of dental treatment. In orthodontics, it is advisable therefore to treat these patients without extractions and to prefer stripping or expansion. In some cases, it is wiser to refrain from orthodontic treatment [12, 13]. The orthodontist must be on the alert and fully assess the benefit/risk ratio when dealing with sensitive cases.

Conclusion
Lhorloge biologique
Rduire la dure dun traitement orthodontique par mdication, laser faible dose ou encore corticotomie, ne peut enfreindre les lois de la biologie, elles-mmes obissant aux commandes gntiques, Laccent est souvent mis sur lactivation des ostoclastes dont les mcanismes sont plus ou moins dfinis. Le MO est un quilibre entre ostoclaste et ostoblaste et ce dernier est encore moins accessible au contrle par les mthodologies de recherche [10, 14]. La rsorption de los peut tre choisie mais lapposition est subie. Frost a prcis que la rsorption est plus rapide que la formation. Chez lhomme, il faut 29 jours pour rsorber une cavit de 200 250 , 134 jours (4 mois) pour la remplir dos cortical et 151 jours (5 mois) pour de los trabculaire [4]. Cependant, le mcanisme de coordination entre lactivit ostoclastique et ostoblastique reste encore mal connu. Le challenge des avances scientifiques et des innovations technologiques va certainement transformer lorthodontie 3D en orthodontie 4D , lorsque les mcanismes gntiques seront identifis et intgrs au projet thrapeutique pour contrler la direction, la nature et la vitesse du dplacement orthodontique [15].

Conclusion
The biological clock
The use of drugs, low-dose laser treatment or corticotomies in order to reduce treatment time must not breach the laws of biology, which are themselves governed by genetic factors. Importance is often given to the activation of osteoclasts, the mechanisms of which have been more or less defined. OM results from a balance between osteoclasts and osteoblasts, and the latter are now even more difficult to check using research techniques [10, 14]. Bone resorption is a process one may choose, but the apposition process is impossible to control. Frost observed that resorption occurs more quickly than formation. In man, it takes 29 days for a cavity to resorb by 200 to 250 , 134 days (4 months) to fill it with cortical bone and 151 days (5 months) with trabecular bone [4]. However, the mechanism which coordinates osteoclastic and osteoblastic activity is still not clearly understood. Scientific progress and technological innovations will undoubtedly transform 3d orthodontics into 4d orthodontics once we have identified the genetic mechanisms involved and incorporated them into our treatment plans in order control the direction, nature and rate of orthodontic displacement [15].

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International Orthodontics 2009 ; 7 : 3-13

La force lgre et le dplacement orthodontique : revue critique


Light forces and orthodontic displacement: a critical review

Rfrences/References
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Meikle MC. The tissue, cellular, and molecular regulation of orthodontic tooth movement: 100 years after Carl Sandstedt. Eur J Orthod 2006 Jun;28(3):221-40. Melsen B, Cattaneo P, Dalstra M, Kraft D. The importance of force levels in relation to tooth movement. Seminars in Orthodontics 2007;(13):220-233. Roberts EW, Epker NB, Burr DB, Hartsfield JK, Roberts JR , Roberts J. Remodeling of mineralized tissues, Part I: the Frost Legacy, Semin Orthod 2006;12:216-237. Roberts EW, Epker NB, Burr DB, Hartsfield JK, Roberts JR , Roberts J. Remodeling of mineralized tissues, Part II: control and physiopathology. Semin Orthod 2006;12:238-253. Melsen B. Biological reaction of alveolar bone to orthodontic tooth movement. Angle Orthod 1999 Apr;69(2):151-8. Deguchi T, Takano-Yamamoto T, Yabuuchi T, Ando R, Roberts WE, Garetto LP. Histomorphometric evaluation of alveolar bone turnover between the maxilla and the mandible during experimental tooth movement in dogs. Am J Orthod Dentofacial Orthop 2008 Jun;133(6):889-897. von Bhl M, Maltha JC, Von den Hoff JW, Kuijpers-Jagtman AM. Focal hyalinization during experimental tooth movement in beagle dogs. Am J Orthod Dentofacial Orthop 2004 May;125(5): 615-623. von Bhl M, Maltha J, Von den Hoff H, Kuijpers-Jagtman AM. Changes in the periodontal ligament after experimental tooth movement using high and low continuous forces in beagle dogs. Angle Orthod 2004 Feb;74(1):16-25. Cattaneo PM, Dalstra M, Melsen B. Moment-to-force ratio, center of rotation, and force level: a finite element study predicting their interdependency for simulated orthodontic loading regimens. Am J Orthod Dentofacial Orthop 2008 May;133(5):681-719. Pompermaier Garlet T, Coelho U, Repeke CE, Silva JS, Queiroz Cunha F, Pompermaier Garlet G. Differential expression of osteoblast and osteoclast chemoattractants in compression and tension sides during orthodontic movement. Cytokine 2008 June;42:330-335. Krishnan V, Davidovitch Z. Cellular, molecular, and tissue-level reactions to orthodontic force. Am J Orthod Dentofacial Orthop 2006 Apr;129(4):469.e1-32. Zahrowski JJ. Bisphosphonate treatment: an orthodontic concern calling for a proactive approach. Am J Orthod Dentofacial Orthop 2007 Mar;131(3):311-320. Krishnan V, Davidovitch Z. The effect of drugs on orthodontic tooth movement. Orthod Craniofac Res 2006 Nov;9(4):163-171. Wise GE, King GJ. Mechanisms of tooth eruption and orthodontic tooth movement. J Dent Res 2008 May;87(5):414-434. Iwasaki LR, Crouch LD, Nickel JC. Genetic factors and tooth movement. Semin Orthod 2008; 14:135-145.

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