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
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
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
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.
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
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
Pulse vibration technology in orthodontic treatment
Dr. Gary Brigham presents a viable alternative to accelerate
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
instructor. He maintains a full-time practice in Scottsdale,
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.
L / PE
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
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
Stability in orthodontic retentionResults of some research
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
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
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
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
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.
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,
range of frequencies to produce the desired clinical effects is
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
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