Micro-osteoperforations in accelerated orthodontics · PDF filechange the type of tooth movement or create differential anchorage. ... Uprighting/intrusion/extrusion/root torque/closure

TECHNIQUES

Micro-osteoperforations in accelerated orthodontics

C. Sangsuwon1,2 • S. Alansari1,3 • J. Nervina2 • C. C. Teixeira2 •

M. Alikhani1,3,4

Received: 6 November 2017 / Accepted: 8 November 2017

� Springer International Publishing AG, part of Springer Nature 2017

Abstract Micro-osteoperforation (MOPs) is a procedure based on sound bone

biology principles that has been developed to address the growing demand for rapid

orthodontic treatment, especially by adult patients. This is a safe, minimally inva-

sive technique that can be used in conjunction with any orthodontic appliances, not

only to accelerate tooth movement, but in many other clinical situations, namely to

change the type of tooth movement or create differential anchorage. Here we

summarize MOPs indications and describe all of the steps required for safe and

comfortable application of MOPs during orthodontic therapy.

Keywords Accelerated � Orthodontics � Tooth movement �Micro-osteoperforations

(MOPs) � Techniques � Clinical application

Quick reference/description

Micro-osteoperforation (MOPs) is a procedure in orthodontics in which small

pinhole perforations are created in the bone around the teeth to accelerate the rate of

tooth movement during orthodontic treatment. This procedure activates the release

of cytokines that in turn recruit osteoclasts to the area to increase the rate of bone

resorption. Due to activation of osteoclasts and temporarily reduction in bone

& M. Alikhani

[email protected]

1 Consortium for Translational Orthodontic Research (CTOR), Hoboken, NJ, USA

2 Department of Orthodontics, New York University College of Dentistry, New York, NY, USA

3 The Forsyth Institute, Cambridge, MA, USA

4 Advanced Graduate Education Program in Orthodontics, Department of Developmental

Biology, Harvard School of Dental Medicine, Boston, MA, USA

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https://doi.org/10.1007/s41894-017-0013-1

density, the application of MOPs is not limited to accelerated tooth movement and

can be used in many different clinical scenarios where, due to dense cortical bone,

orthodontic treatment previously was not possible or could not produce optimal

results (Table 1). This procedure is designed to serve as a complement to any

orthodontic appliance, including fixed appliances (braces), clear aligners, or

removable appliances such as expanders, distalizers, among others.

Indications

Micro-osteoperforations are very easy to apply during a routine orthodontic visit.

However, clinicians should carefully plan MOPs application to facilitate the

movement that they are trying to accomplish at each visit, taking into consideration

anchorage needs, type of movement, bone anatomy, etc.

Procedure

The MOPs procedure may be completed by the dentist/orthodontist as dictated by

the clinical needs, with minor discomfort or complications to the patients, following

the steps described below.

Step I: medical and dental history

A complete medical and dental history of the patient should be obtained.

Information regarding allergy to any component(s) of local anesthetics,

Table 1 Clinical applications of micro-osteoperforation, a procedure that can be used to facilitate and

accomplish different types of movements and corrections

Objectives Clinical applications

Accelerating tooth movement Different stages of adult treatment

Facilitating root movement/bodily

movement

Uprighting/intrusion/extrusion/root torque/closure of large space

Movement into deficient alveolar

bone

Closure of old extraction space

Differential anchorage Reducing bone density around teeth to be moved, while

preserving anchorage unit

Decreased possibility of root

resorption

Reducing bone density and duration of exposure to osteoclasts

Expansion in adults and asymmetric

expansion

Facilitate dental expansion in adults with less possibility of

recession

Asymmetric change in biological response to facilitate

asymmetric expansion

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consumption of tobacco or excessive alcohol or any other condition, such as

uncontrolled diabetes, that may contraindicate MOPs should be obtained (Table 2).

Step II: informed consent

Patient informed consent should be obtained prior to performing MOPs. The

consent form should include possible side effects of the minor surgical procedure

(Fig. 1).

Step III: patient evaluation

Intraoral examination of the area should be performed. The length and thickness of

the attached gingiva, health of the periodontium, closeness of the frenum, distance

between teeth and their inclination, and accessibility of the area of interest for

performing MOPs should be evaluated.

The quality of the bone, location of the sinus, proximity of the inferior alveolar

nerve, distance between the roots, and length of the roots should be evaluated in the

panoramic radiograph just prior to MOPs application. Radiographs taken within

6 months prior to MOPs treatment can be used for evaluation.

Table 2 Medical conditions that may contraindicate the use of Micro-osteoperforation and/or may

require medical clearance before the procedure

General medical conditions Specific contraindications

Cardiovascular problems Angina pectoris

Myocardial Infarction

Coronary artery bypass grafting

Stroke

Dysrhythmias

Congestive heart failure

Pulmonary problems Chronic obstructive pulmonary disease

Severe asthma

Renal problems Renal dialysis

Renal transplant

Hepatic disorders Impaired liver function

Endocrine disorders Diabetes mellitus

Adrenal insufficiency

Hyperthyroidism

Hematologic problems Hereditary coagulopathies

Therapeutic anticoagulation

Neurologic disorders Seizure disorders

Alcoholism

Pregnancy

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Before initiating the MOPs procedure, the location, number, and depth of the

MOPs should be carefully planned. Below are some guidelines to help the clinician

with this planning.

Fig. 1 Sample of consent form for application of micro-osteoperforations (MOPs)

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Location

Area of application

The maximum effect can be obtained when MOPs are applied close to the target

teeth and far from the anchor teeth. MOPs are done usually in the buccal surface

between the roots, on the alveolar ridge (in case of extraction) or, if needed, in the

lingual surface between the roots (Fig. 2).

If the mechanical design provides precise force application in a certain direction,

MOPs should be applied around the target tooth to encourage more bone remodeling

(Fig. 3a).

It is possible to encourage movement in the desired direction by focusing the

MOPs application in one direction, compensating for mechanical shortcomings in

guiding precise movement (Fig. 3b).

Height

The superior and inferior limits of MOPs can be determined in relation to the

mucogingival junction (MGJ). MOPs should be placed within the attached gingiva

to 1 mm apical to the MGJ (Fig. 4). When a resistance toward root movement is

observed, MOPs are placed more apically.

Fig. 2 Area of application of MOPs for catabolic stimulation. To harness the bone resorption effects ofMOPs, perforations are located mesial and distal of the target tooth in the area of the attached gingiva

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Mesiodistal position

Root location and angulation should be considered while performing MOPs. MOPs

should be applied mesial and distal to the root of the tooth to be moved.

Buccal/lingual placement

Micro-osteoperforations can be applied in both buccal and lingual cortical plates.

The buccal cortical plate is the most favorable place for placement of MOPs.

However, when the lingual cortical plate affects the movement of the tooth, MOPs

Fig. 3 Strategic application of MOPs based on desired direction of movement. In some setups, such asthe use of an overlay wire, the direction of movement is dictated by the wire and is difficult to control bythe clinician. MOPs can be applied around the target tooth for buccal movement in the direction of theblue arrow (a). However, application of unilateral MOPs facilitates displacement in one particulardirection (shown by blue arrow) and allows the clinician to have better control on the direction ofmovement (b)

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can be applied in the lingual plate. In this regard, contra-angle appliances are used to

facilitate MOPs application in the lingual plate (Fig. 5).

In cases where bone resorption significantly decreased the width and height of

alveolar bone, thereby decreasing buccal and lingual cortical bone, MOPs can be

applied on top of the ridge.

Number and depth of MOPs

Usually two to four perforations per site are ideal. However, when the higher

number of MOPs is not possible, perforation depth can be increased to compensate

for the smaller number of perforations.

The thickness of soft tissue and cortical plate should be considered when

deciding how deep to perforate the cortical plate. In general, MOPs with penetration

depths of 3–7 mm into the bone is recommended.

Fig. 4 Application of MOPs inthe buccal cortical plate. Heightof application of MOPs shouldbe limited to the attachedgingiva for patient comfort.a Height of application of MOPsaround anterior teeth,b application of MOPs aroundposterior teeth may havedifferent distribution andnumber, as determined by rootproximity, accessibility, andwidth of attached gingiva

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Step IV: MOPs tools and setup

All tools should be available and accessible before the procedure is initiated. To

perform MOPs, the following instruments and materials are recommended:

• MOPs tool

• Chlorhexidine oral rinse solution

• Gauze/cotton rolls

• Cheek retractor

• Topical and local anesthesia

• Carpule syringe and needle gauge

• College plier and mouth mirror

• Periodontal probe

• Suction and water syringe

Step V: MOPs procedure

The following protocol is used to perform the MOPs procedure:

Fig. 5 Contra-angle devices(manual or rotary) for access tothe lingual cortical plates andthe posterior buccal corticalsurfaces. They also facilitateperforation of thick bone thatmay resist the use of handhelddevices

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• Ask the patient to rinse his/her mouth with 15 ml of chlorhexidine oral solution

for 30 s.

• Select the area of MOPs application. Use a lip/cheek retractor for clear access.

• To eliminate excess saliva and dry the location, wipe the area with a wet gauze

or cotton roll.

• Apply topical anesthesia on the area planned for anesthetic injection and leave

for 1–2 min.

• Start local infiltration with fine needle tip. The amount of anesthesia for one

location is about one fourth carpule or less. Wait a few minutes after the injection

and use a probe or explorer to check if the area is sufficiently anesthetized.

• Set up sterile MOPs tool with a disposable tip set to the appropriate length, and

gently perforate the cortical plate in the area of interest with a light

stable rotation movement. Remove the tool gently by rotating in the opposite

direction after perforation reaches the set depth (Fig. 6).

• Slight bleeding is normal and can be stopped using wet gauze/cotton pressed on

the MOPs site.

• Evaluate the area.

Step VI: MOPs postoperative care

In case of discomfort patient is advised to take pain medication, such as

acetaminophen. Anti-inflammatory medication (such as non-steroid anti-

Fig. 6 Step-by-step performance of MOPs in the anterior area. a Application of topical anesthetic,b application of local anesthetic, c application of MOPs, d attached gingiva right after application ofMOPs

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inflammatory drugs) should not be prescribed as such drugs inhibit the inflammatory

effect of MOPs, thereby rendering the procedure ineffective.

In case of poor oral hygiene or in patients with compromised health,

chlorhexidine rinses are recommended. Advise the patient not to change their

brushing and flossing habits in the area where MOPs have been applied.

Pitfalls and complications

Due to the reduced bone density and the accelerated tooth movement induced by

MOPs, clinicians should carefully plan their mechanics to avoid unwanted

movement or side effects of their force system. We recommend restricting the

application of MOPs to the teeth to be moved or after the space has been created for

those movements. In addition, reuse of the MOPs tool is not recommended and can

increase the possibility of infection.

Further reading

1. Sangsuwon C, Alansari S, Lee YB, Nervina J, and Alikhani M (2017) Step-by-step guide for

performing micro-osteoperforations. In: Alikhani M (ed) Clinical guide to accelerated orthodontics:

with a focus on micro-osteoperforations. Springer Internal Publishing, Cham, pp 99–116. https://doi.

org/10.1007/978-3-319-43401-8_6

2. Alikhani M, Raptis M, Zolden B, Sangsuwon C, Lee YB, Alyami B, Corpodian C, Barrera LM, Khoo

E, Teixeira CC (2013) Effect of micro-perforations on the rate of tooth movement in human. Am J

Orthod Dentofac Orthop 144(5):639–648 (PMID: 24182579)

3. Alikhani M, Alyami B, Lee IS, Almoammar S, Vongthongleur T, Alikhani M, Alansari S, Sangsuwon

C, Chou MY, Khoo E, Boskey A, Teixeira CC (2015) Saturation in biological response to orthodontic

forces and its effect on rate of tooth movement. Orthod Craniofac Res 18[Suppl 1]:8–17. https://doi.

org/10.1111/ocr.12090

4. Alikhani M, Alansari S, Sangsuwon C, Alikhani M, Chou MY, Alyami B, Nervina JM, Teixeira CC

(2015) Micro-Osteoperforations: minimally Invasive Accelerated Tooth Movement. Seminar in

Orthodontics 21(3):162–169

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