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O ver the past few years, clinicians have increasingly used accelerated orthodontic treatment modalities. Currently, over 400,000 manual osteo-perforations (MOPs) have been performed and are believed to have contributed significant value to orthodontic treatments. 1-6 Nonetheless, some practitioners remain reluctant to offer adjunctive treatment to their patients or feel that MOPs are too invasive. However, many professionals have regarded pulse vibration technology as a reasonable and less invasive alternative to MOPs. The number of patients who accept MOP treatment is impressive, especially adults and teens between the ages of 15-19-years old and anxious to shorten their treatment times. More importantly, some patients have expressed interest in reducing their time in treatment but were unwilling to undergo MOPs. For these patients, pulse vibration devices may present a viable alternative. The potential benefits of pulse vibration in orthodontics With so many physiologic systems demonstrating sensitivity to specific ranges of vibration frequency (i.e., diges- tion, hearing, breathing, sight, etc.), it would seem logical that bone would also respond to a range of vibrational frequen- cies. A number of studies have described the potential benefits of pulse vibration in orthodontic tooth movement: 1. non-pharmacological analgesic effects 7 2. enhanced clear aligner fit 3. accelerated tooth movement 4. promotion of stability in orthodontic retention 8 Non-pharmacological analgesic effects The non-pharmacologic analgesic effects diminish the discomfort associ- ated with both fixed appliance delivery/ adjustment and with new clear aligner delivery/exchange. Lobre, et al., reported a significant decrease in pain in a random- ized clinical trial of fixed appliance patients using a low-frequency vibration device when compared with controls. However, the study did not include a sham device to evaluate a placebo effect. Regardless, clinicians have reported that their patients have experienced a significant decrease in pain and increased appliance comfort when they included pulse vibration. Clear aligner fit Clinicians understand the importance of continuous, exacting fit in aligner treat- ment. Continuation of aligner exchange with improper tracking can undermine effective tooth movement. This results in aberrant and unanticipated tooth move- ment and prolonged treatment, which frustrates patients and doctors. Pulse vibration devices may enhance tracking and tooth movement, assuming patients cooperate and doctors use correct aligner protocol. Moreover, pulse vibration has prevented potential tracking issues gener- ated when patients wear aligners less than the prescribed time. This benefits patients, as successful tracking is fundamental to accelerated aligner exchange and reduces treatment time significantly. Tooth movement Reports of accelerated tooth movement with pulse vibration have been equivocal. Animal research (rats and rabbits) has shown that vibrating forces can cause separation of cranial sutures, induce cranial growth, and accelerate tooth movement (rats). 10-14 The manufacturer of the first-to-market pulse vibrator operating at a low frequency of 30 HZ; 25g, used these animal studies to vali- date its claim for accelerated tooth move- ment. Using a low-frequency pulse vibration prototype in 2009, Kau, et al., 15 reported accelerated tooth movement in both arches of 14 patients. In a more recent retrospec- tive study, Bowman 16 reported statistical in arch leveling in a group of patients with fixed appliances treated with low-frequency pulse vibrations in contrast to a group of control patients. The clinician, however, determined the degree of leveling subjectively without any objective calibration. A company that produces a low-frequency vibratory device funded a randomized, controlled clinical trial with 45 patients, and the authors reported statistically significant tooth movement and canine retraction compared to patients using a sham device. 17 Recently in a randomized clinical trial using a low-frequency vibratory device, Woodhouse, et al., 18 studied its effect on tooth alignment of 81 premolar extraction patients with fixed appliances. This study found no evidence of acceleration in tooth alignment compared to control patients. Yadav, et al., 19 investigated low-frequency mechanical vibration in the tooth movement of mice and found no significant accelera- tion in movement at frequencies of 5, 10, and 20 Hz. Significantly, Kalajzic, et al., 20 evaluated vibrational forces (30Hz, 0.4N) in a study of movement in 26 rat molars (n=9), and concluded that tooth movement was significantly inhibited by the application of cyclical forces at this frequency, possibly due to a decrease in the number of osteo- clasts. They suggested that cyclical forces may cause contrary effects depending upon force magnitude, the frequency of vibration (HZ level), or the point of application. In a review of vibrational therapy effects on tooth movement, Lala²¹ hypothesized that vibration may require a significantly higher frequency to cause consistently accelerated tooth movement. By citing studies by Judex and Rubin²² and Alikhani, et al.,²³ that found Pulse vibration technology in orthodontic treatment Dr. Gary Brigham presents a viable alternative to accelerate orthodontic treatment Gary Brigham, DDS, MSD, earned his doctorate at Case Western Reserve University, where he also received his certificate in orthodontics and a master’s degree in Immunology. He was awarded the Harry Sicher Award from the AAO for his graduate research and served as an Assistant Professor of Pediatric Medicine at the Center for Craniofacial Anomalies at the University of Illinois at the Medical Center in Chicago. He has lectured throughout the United States for Align Technology since 2004 and is the recipient of Align’s first award for service to the orthodontic profession. Dr. Brigham currently serves as an Adjunct Professor of Orthodontics in the orthodontic graduate program at the A.T. Still School of Dentistry and Oral Health, where he is the dedicated Invisalign ® instructor. He maintains a full-time practice in Scottsdale, Arizona. Disclosure: This article may describe uses of osteo perforation in general and/or an ExcelleratorTM series driver specifically that have not received 510(k) - clearance or premarket approval from FDA. Propel Orthodontics markets the VPro5 as a high frequency vibration aligner seater. This article may describe uses of high frequency vibration technology in general and/or the VPro5 specifically that are outside of our labeling. Propel Orthodontics provided financial support to the author. CLINICAL / PEER REVIEWED Reprint from Orthodontic Practice US Volume 7 Number 5
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  • Over the past few years, clinicians have increasingly used accelerated orthodontic treatment modalities. Currently, over 400,000 manual osteo-perforations (MOPs) have been performed and are believed to have contributed significant value to orthodontic treatments.1-6 Nonetheless, some practitioners remain reluctant to offer adjunctive treatment to their patients or feel that MOPs are too invasive. However, many professionals have regarded pulse vibration technology as a reasonable and less invasive alternative to MOPs.

    The number of patients who accept MOP treatment is impressive, especially adults and teens between the ages of 15-19-years old and anxious to shorten their treatment times. More importantly, some patients have expressed interest in reducing their time in treatment but were unwilling to undergo MOPs. For these patients, pulse vibration devices may present a viable alternative.

    The potential benefits of pulse vibration in orthodontics

    With so many physiologic systems demonstrating sensitivity to specific ranges of vibration frequency (i.e., diges-tion, hearing, breathing, sight, etc.), it would seem logical that bone would also respond to a range of vibrational frequen-cies. A number of studies have described the potential benefits of pulse vibration in orthodontic tooth movement:

    1. non-pharmacological analgesic effects7

    2. enhanced clear aligner fit3. accelerated tooth movement4. promotion of stability in orthodontic

    retention8

    Non-pharmacological analgesic effects

    The non-pharmacologic analgesic effects diminish the discomfort associ-ated with both fixed appliance delivery/adjustment and with new clear aligner delivery/exchange. Lobre, et al., reported a significant decrease in pain in a random-ized clinical trial of fixed appliance patients using a low-frequency vibration device when compared with controls. However, the study did not include a sham device to evaluate a placebo effect. Regardless, clinicians have reported that their patients have experienced a significant decrease in pain and increased appliance comfort when they included pulse vibration.

    Clear aligner fit

    Clinicians understand the importance of continuous, exacting fit in aligner treat-ment. Continuation of aligner exchange with improper tracking can undermine effective tooth movement. This results in aberrant and unanticipated tooth move-ment and prolonged treatment, which frustrates patients and doctors. Pulse vibration devices may enhance tracking and tooth movement, assuming patients cooperate and doctors use correct aligner protocol. Moreover, pulse vibration has prevented potential tracking issues gener-ated when patients wear aligners less than the prescribed time. This benefits patients, as successful tracking is fundamental to accelerated aligner exchange and reduces treatment time significantly.

    Tooth movement

    Reports of accelerated tooth movement with pulse vibration have been equivocal. Animal research (rats and rabbits) has shown

    that vibrating forces can cause separation of cranial sutures, induce cranial growth, and accelerate tooth movement (rats).10-14 The manufacturer of the first-to-market pulse vibrator operating at a low frequency of 30 HZ; 25g, used these animal studies to vali-date its claim for accelerated tooth move-ment. Using a low-frequency pulse vibration prototype in 2009, Kau, et al.,15 reported accelerated tooth movement in both arches of 14 patients. In a more recent retrospec-tive study, Bowman16 reported statistical in arch leveling in a group of patients with fixed appliances treated with low-frequency pulse vibrations in contrast to a group of control patients. The clinician, however, determined the degree of leveling subjectively without any objective calibration. A company that produces a low-frequency vibratory device funded a randomized, controlled clinical trial with 45 patients, and the authors reported statistically significant tooth movement and canine retraction compared to patients using a sham device.17

    Recently in a randomized clinical trial using a low-frequency vibratory device, Woodhouse, et al.,18 studied its effect on tooth alignment of 81 premolar extraction patients with fixed appliances. This study found no evidence of acceleration in tooth alignment compared to control patients. Yadav, et al.,19 investigated low-frequency mechanical vibration in the tooth movement of mice and found no significant accelera-tion in movement at frequencies of 5, 10, and 20 Hz. Significantly, Kalajzic, et al.,20 evaluated vibrational forces (30Hz, 0.4N) in a study of movement in 26 rat molars (n=9), and concluded that tooth movement was significantly inhibited by the application of cyclical forces at this frequency, possibly due to a decrease in the number of osteo-clasts. They suggested that cyclical forces may cause contrary effects depending upon force magnitude, the frequency of vibration (HZ level), or the point of application.

    In a review of vibrational therapy effects on tooth movement, Lala hypothesized that vibration may require a significantly higher frequency to cause consistently accelerated tooth movement. By citing studies by Judex and Rubin and Alikhani, et al., that found

    Pulse vibration technology in orthodontic treatment

    Dr. Gary Brigham presents a viable alternative to accelerate orthodontic treatment

    Gary Brigham, DDS, MSD, earned his doctorate at Case Western Reserve University, where he also received his certificate in orthodontics and a masters degree in Immunology. He was awarded the Harry Sicher Award from the AAO for his graduate research and served as an Assistant Professor of Pediatric Medicine at the Center for Craniofacial Anomalies at the University of Illinois at the Medical Center in Chicago. He has lectured throughout the United States for Align Technology since 2004 and is the recipient of Aligns first award for service to the orthodontic profession. Dr. Brigham currently serves as an Adjunct Professor of Orthodontics in the orthodontic graduate program at the A.T. Still School of Dentistry and Oral Health, where he is the dedicated Invisalign

    instructor. He maintains a full-time practice in Scottsdale, Arizona.

    Disclosure: This article may describe uses of osteo perforation in general and/or an ExcelleratorTM series driver specifically that have not received 510(k) - clearance or premarket approval from FDA. Propel Orthodontics markets the VPro5 as a high frequency vibration aligner seater. This article may describe uses of high frequency vibration technology in general and/or the VPro5 specifically that are outside of our labeling. Propel Orthodontics provided financial support to the author.

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    Reprint from Orthodontic Practice US Volume 7 Number 5

  • greater osteogenic effects at higher frequen-cies of vibration, Lala arbitrarily defined low frequency as any vibration at or below 45 HZ and high frequency as any vibration at or higher than 90 HZ.

    Nishimura, et al., used a resonant frequency of 60 HZ on maxillary molars and reported an acceleration of tooth movement with vibration. Additionally, Leethanakul, et al.,24 reported significant acceleration o f canine retraction in 15 patients following first premolar extractions. Using high-frequency electric toothbrushes (125 HZ) applied to the canines, they also noted a threefold increase in IL-1, a cytokine protein associated with osteoclastic activity.

    Stability in orthodontic retentionResults of some research suggest

    that pulse vibration may have a stabilizing effect for orthodontic retention. Low vibra-tion frequency (5, 10, and 20 HZ) has been found to increase bone volume factor and collagen tissue density in periodontal liga-ments,19 while Rubin, et al.,25 have reported low level vibration frequency (15-90 HZ) as strongly anabolic, which increases the quan-tity and quality of bone volume in sheep.

    Pulse vibration devices in ortho-dontics

    Clinicians currently use one of two prin-cipal pulse vibration devices now available. One, a low-frequency device (Figure 1), and the other, a high-frequency mechanism. The low-frequency device vibrates at 30HZ, and 0.25 N and recommends that patients use the vibratory device continuously for 20 minutes daily to affect the accelerated tooth movement.

    The high-frequency option (Figure 2) vibrates at 120 HZ and 0.3G, and the manufacturer recommends that patients

    Figures 5-7: Patient is showing excellent tracking. Patient is currently at aligner 20 out of 34, exchanging aligners every 5 days with high-frequency treatment using VPro5 Aligners in: Note excellent tracking at aligner No. 20

    Figure 1: Low-frequency device (30 HZ; .25N) Figure 2: High-frequency device (120 HZ; 0.3G)

    Figures 3-4: Class I malocclusion characterized by open extraction sites and significant maxillary incisor protrusion. Post-treatment. Patient initiated high-frequency treatment using VPro5 at aligner 6 and exchanged aligners every 7 days rather than every 14 days from that point forward. Total 24 aligners. Total treatment time 7 months 1 week

    Both clinical trials and experience suggest that

    pulse vibrational orthodontic devices may have a

    role in orthodontic therapy.

    2 Orthodontic practice Volume 7 Number 5

    CLINICAL / PEER REVIEWED

  • use the device for only 5 minutes each day for the indication of achieving proper aligner seating. Some preliminary research suggests that high-frequency vibratory devices may accelerate tooth movement.22-24

    The high-frequency vibrator initially starts at a lower frequency and rapidly increases to the 120 HZ. The low-frequency device vibrates at 30 HZ immediately.

    Independent, randomized, controlled trials have not yet established the efficacy of these appliances. Nevertheless, the website for the low-frequency vibrator along with testimonials by clinicians claims significantly reduced treatment times when patients use them with either fixed appliances or aligners. Additionally, numerous clinicians and patients attest to the relief of patient discomfort with the use of pulse vibration.

    ConclusionBone resorption remains a critical factor

    in tooth movement, and increasing studies indicate that low-frequency pulse vibra-tion has an anabolic effect that accelerates tooth movement. This has caused some researchers to speculate that accelerated tooth movement would require pulse vibra-tion to also accelerate the catabolic phase of bone remodeling. Light orthodontic forces are needed in conjunction with vibration to effect accelerated movements, and research has shown that light forces with the applica-tion of vibration enhances the secretion of IL-1, one of the pro-inflammatory cytokines associated with bone resorption. Thus, clini-cians might hypothesize that pulse vibration may also increase the secretion of a host of pro-inflammatory cytokines that facilitate bone resorption. Moreover, this cascade of cytokines could simultaneously stimulate a reactionary secretion of modulating glyco-proteins that constrain cytokine activity and stimulate osteoblastic activity in response to osteoclasis.

    Some clinicians, including myself, have begun incorporating both MOPs and high-frequency vibration (many times simultane-ously) to accelerate treatment. The intent is to use MOPs on the more difficult move-ments, and high-frequency vibration to improve aligner seating.

    Both clinical trials and experience suggest that pulse vibrational orthodontic devices may have a role in orthodontic therapy. Pulse vibration appears to have a non-pharmacological analgesic effect, which reduces patient discomfort. Additionally,

    these devices have a potential for accel-erating treatment and reducing treatment time, particularly when used in aligner treat-ment. However, the molecular and cellular mechanisms by which various pulse vibra-tion frequencies become anabolic or cata-bolic remain unidentified. Most importantly, the ultimate effectiveness of pulse vibration remains largely dependent upon patient compliance, as do the other features of orthodontic therapy. Additional research regarding the most effective frequencies, or

    range of frequencies to produce the desired clinical effects is necessary.

    While there is scientific evidence that vibration produces a dynamic force to assist in remodeling bone, it may be of benefit in orthodontic treatment with aligners simply by providing consistently well seated aligners. After using these devices with patients, I would encourage clinicians to familiarize themselves with the research and experi-ence with pulse vibration, and consider how these might benefit their patients. OP

    Figure 8

    REFERENCES

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    2. Nicozisis J. Accelerated orthodontics through micro-osteoper-foration. Orthodontic Practice US. 2013; 4(3):56-57.

    3. Shipley TS. The use of Propel to increase aligner progression. Orthodontic Practice US. 2014;5(2):52-56.

    4. Shipley TS. Proactive treatment with Propel. Orthodontic Prac-tice US. 2015;6(2):38-39.

    5. Boschken DR. Increasing case acceptance and practice differ-entiation with Propel. Orthodontic Practice US. 2015;6(4):36-37.

    6. Brigham G. The Propel System: the next generation orth-odontic disruptor. Orthodontic Practice US. 2015;6(5)36-38.

    7. Rubin C, Judex S, Qin YX. Lowlevel mechanical signals and their potential as a non-pharmacological intervention for osteo-porosis. Age Ageing. 2006; 35(suppl): ii32-ii36.

    8. Zhang C, Zhang L, Xu X, Duan P, Wu H. Mechanical vibration may be a novel adjuvant approach to promoting stability and retention following orthodontic treatment. Dent. Hypotheses. 2014;5(3):98-102.

    9. Lobre WD, Callegari BJ, Gardner G, Marsh CM, Bush AC, Dunn WJ. Pain control in orthodontics using a micropulse vibration device: a randomized clinical trial. Angle Orthod. 2016;86(4):625-630.

    10. Kopher RA, Mao JJ. Suture growth modulated by the oscilla-tory component of micromechanical strain. J Bone Miner Res. 2003;18(3): 521-528.

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    13. Kopher RA, Nudera JA, Wang X, OGrady K, Mao JJ. Expres-sion of in vivo mechanical strain upon different wave forms of exogenous forces in rabbit craniofacial sutures. Ann Biomed Eng. 2003;31(9):1125-1131.

    14. Nishimura M, Chiba M, Ohashi T, et al. Periodontal tissue activation by vibration: intermittent stimulation by resonance vibration accelerates experimental tooth movement in rats. Am J Orthod Dentofacial Orthop. 2008;133(4):572-583.

    15. Kau CH, Nguyen JT, English JD. The clinical evaluation of a novel cyclical force generating device in orthodontics. Orth-odontic Practice US. 2010;1(1):10-15.

    16. Bowman SJ. The effect of vibration on the rate of leveling and alignment. J Clin Orthod. 2014; 48(11):678-688.

    17. Pavlin D, Anthony R, Raj V, Gakunga PT. Cyclic loading (vibra-tion) accelerates tooth movement in orthodontic patients: a double-blind, randomized controlled trial. Semin Orthod. 2015;219(3):187-194.

    18. Woodhouse NR, DiBiase AT, Johnson N, et al. Supplemental vibrational force during orthodontic alignment: a randomized trial. J Dent Res. 2015; 94(5): 682-689.

    19. Yadav S, Dobie T, Assefnia A, Gupta H, Kalajzic Z, Nanda R. Effect of low-frequency mechanical vibration on orth-odontic tooth movement. Am J Orthod Dentofacial Orthop. 2015;148(3):440-449.

    20. Kalajzic Z, Polusa EB, Utreja A, et al. Effect of cyclical forces on the periodontal ligament and alveolar bone remodeling during orthodontic tooth movement. Angle Orthod. 2014; 84(2):297-303.

    21. Lala A. Vibration therapy in orthodontics: Realizing the benefits. Ortho. 2016; 1(1):24-27.

    22. Judex S, Rubin CT. Is bone formation induced by high -frequency mechanical signals modulated by muscle activity? J Musculoskeletal Neuronal Interact. 2010;10(1):3-11.

    23. Alikhani M, Khoo E, Alyami B, et al. Osteogenic effect of high-frequency acceleration on alveolar bone. J Dent Res. 2012;91(4):413-419.

    24. Leethanakul C, Suamphan S, Jitpukdeebodintra S, Thongu-dompom U, Charoemratrote C. Vibratory stimulation increases interleukin-1 beta secretion during orthodontic tooth move-ment. Angle Orthod. 2015;85;(5):74-80.

    25. Rubin C, Turner AS, Mller R, et al. Quantity and quality of trabecular bone in the femur are enhanced by a strongly anabolic, noninvasive mechanical interaction. J Bone Miner Res. 2002;17(2):349-357.

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