FEATURE This article has been peer reviewed.

Appraisal of Minimally Invasive MOP and Maxillary Invasive DAD

Surgical Procedures in the Acceleration of Tooth Movement: A
Systematic Review

By Shivam Verma, MDS; Ajit V Parihar, BDS, MDS; TP Chaturvedi MDS, PhD; Kavin Prasanth, MDS; Sadhana
Swaraj, MDS; Vipul Kumar Sharma, MDS

Abstract: Introduction: The prolonged treatment time has been a constant deterrent for patients as they feel that it would be
inconvenient to have orthodontic appliances in the oral cavity for such a long duration of time. Therefore, it is the responsibility of
orthodontists to improve and implement procedures that can accelerate tooth movement. There are various approaches like biological, device-
assisted, and surgical approaches to fasten the tooth movement. The purpose of this study is to compare the rates of tooth movement with regard
to treatment time for both distraction osteogenesis and micro osteoperforation and simultaneously discuss the merits and demerits of both the
procedures. Materials and methods: Our search strategy for this review was cross-disciplinary and included randomized clinical trials on
distraction osteogenesis and micro osteoperforation. All the original research articles, review articles, published bibliographies and relevant
citations related to rapid tooth movement were checked for relevant information and used in this review. After excluding all the irrelevant
data with careful screening, 18 full-text articles were selected which included 12 articles related to distraction osteogenesis and six articles
related to micro osteoperforation. Results and Conclusion: There is a reduction in the duration of treatment time due to increase rate of tooth
movement with both dentoalveolar distraction osteogenesis and microosteoperforation where DO resulted in total retraction of canine in 8-14
days, and MOP increased the rate of tooth movement by 2-3 fold when compared to conventional tooth movement. There was no appreciable
anchorage loss, canine tipping, root resorption, and ankyloses associated with DO, whereas further studies were needed with regard to MOP.

ntroduction on humans which showed better desirable results of decreased

The comprehensive orthodontic treatment with
fixed mechanotherapy is an imperative part of the
branch of orthodontics and dentofacial orthopedics
to correct malocclusion and its associated
problems. The normal orthodontic treatment time is usually an
average of about 20-24 months.1, 2 This prolonged treatment
time has been a constant deterrent for the patients, as they feel
that it would be inconvenient to have orthodontic appliances in
the oral cavity for such a long duration of time. The prolonged
treatment time has several adverse effects like white spot
lesions, dental caries, periodontal problems, external apical root
resorption (EARR), and decreased patient compliance. It is
often more problematic in adults patients in whom the esthetics
during the treatment are of more concern owing to social
obligations. Therefore, it is the responsibility of orthodontists
to improve and implement procedures that can accelerate tooth
movement.
Various attempts have been made in recent years to
create different approaches to reduce the treatment time
without compromising the treatment result. They can be
broadly classified into biological, device-assisted, and surgical
approaches. The biological and device-assisted approaches have
experimented in animals, and further research is ongoing to
achieve better results in humans. Surgical approaches were done
treatment time. It is the safest method for accelerating tooth
movement.
Brain and Cunningham,3 were the first to provide reports
on surgical methodologies to accelerate the correction of
malocclusion. They advocated cutting the alveolar cortical
plates around the teeth, which decrease the bony resistance and
mobilize the teeth for immediate movement. Kole 4 described the
creation of cuts in the bone after raising the flap, as a method to
fasten the tooth movement. Liou and Huang5 first investigated
and applied this concept to orthodontic tooth movement and
performed rapid canine retraction and termed this as dental
distraction. It is the form of distraction osteogenesis of the
periodontal ligament which acts as a suture between alveolar
bone and tooth. Sayin et al.6 investigated this technique, and
he substantiated that this technique reduced net orthodontic
treatment time. Iseri et al.7 and Kisnisci et al.8 used a different
technique called dentoalveolar distraction (DAD) for rapid
canine distalization by performing osteotomies around the
canines and achieved accelerated tooth movement. This surgical
technique did not rely on the stretching and widening of
PDL, thus prevents overloading and stress accumulation in the
periodontal tissues.
Distraction osteogenesis (DO) involves gradual, controlled
displacement of surgically created fractures (subperiosteal

IJO  VOL. 30  NO. 2  SUMMER 2019 43

                                          Figure- I: Flow diagram of the included studies  Materials And Methods
Our search strategy for the review
 
Records identified through the data base  was cross-disciplinary and included
  Identification  searching (n=1667)  randomized clinical trials on distraction
 
CENTRAL (Cochrane library): n=9  osteogenesis and micro osteoperforation.
Embase   : n=506  All the original research articles, review
  Pub med : n=78  articles, published bibliographies, and
Scopus    : n=94  relevant citations related to rapid tooth
 
Google scholar : n=751 
movement were checked for relevant
  Web of science : n=309 
Clinical trials     : n=4 
information and used in this review.
  The initial electronic search was
ICTRP                 : n=16 
  performed in November 2018 with
no limitations with regard to time and
 
language. The search for the articles
Additional record identified 
  Records after duplicate  was made on the topic of dentoalveolar
through the other sources (n=0) 
  removed  (n=833)  distraction osteogenesis and micro
osteoperforation in the following
  Citations excluded by title, 
databases: Medline, EMBASE, Scopus,
mainly as irrelevant to study 
Screening 

  subjects (n=708) 
Cochrane Library, PubMed, Google
Abstracts assessed for  Scholar, Science Direct and Web of
 
eligibility  (n=125)  Science. Details of the electronic search
Articles excluded by abstract 
  strategy are provided in Figure 1. The
reading (n=107) 
  Animal studies (n=27)  reference lists of selected papers and
Case reports (n=23)  relevant reviews were screened for any
  Book chapters (n=17) 
possible related studies which may have
Technique descriptions (n=19) 
  not been discovered by the electronic
Reviews (n=9) 
Full texts articles (n=18) 
  Irrelevant studies  (n=12)  web-based search. The initial search
resulted in a total of 1,450 articles
 
Included 

related to dentoalveolar distraction

  and 217 articles related to micro
  12 article canine distraction  osteoperforation
osteogenesis and 6 articles for  Eligibility criteria: Exclusion
  micro‐osteoperforation  and inclusion criteria were employed
  with reference to the Study design,
Participants, Interventions,
 
Comparisons, and Outcomes.
osteotomy) by incremental traction,9 resulting in simultaneous expansion of soft tissue Study design: In-vivo randomized
and bone volume due to mechanical stretching through the osteotomy site. Modern controlled trials (RCTs) were selected for
research and development in the field of DO have led to the implementation of the study.
numerous innovative and revolutionary distraction systems. A wide variety of intra-oral Participants: Healthy patients, both
distractors are now available with increased patient comfort and acceptance. This paved males and females of any age and type
the way to further investigate the technique for applications in influencing the rate and of malocclusion, of any ethnic group
vector of tooth movement. who received orthodontic treatment
As DO is an extensive surgical procedure, further efforts have been made to refine with fixed orthodontic appliances were
the procedure which is less invasive to the patient. A new micro-invasive technique included.
called micro-osteoperforation, also called alveocentesis has been introduced which Type of interventions: Any type
literally translates to puncturing bone and stimulating cytokines activity which has been of orthodontic treatment with fixed
scientifically well proven.10, 11 When an orthodontist creates micro-osteoperforation appliances (the need to extract teeth
in the alveolar bone, a cytokines cascade is activated, resulting in a marked increase in the context of treatment) assisted
in osteoclast activity and bone remodeling. When an orthodontic force is applied by surgical techniques for accelerating
immediately following micro-osteoperforation, the teeth will move toward the tension orthodontic tooth movement (i.e.,
side and pass easily through the remodeled area. MOP can be completed in minutes and micro-osteoperforation and distraction
does not require advanced training. It causes less discomfort to patients when compared osteogenesis) was used.
to other surgical methods of accelerating tooth movement. Comparisons: Patients receiving
The purpose of the present study is to compare the rates of tooth movement with conventional orthodontic treatment
regard to treatment time for both distraction osteogenesis and micro osteoperforation as with fixed appliances (without any
well as simultaneously discuss the merits and demerits of both procedures. additional intervention to accelerate
tooth movement).

44 IJO  VOL. 30  NO. 2  SUMMER 2019

Outcomes:
Primary outcome: the rate of tooth movement (RTM) in
relation to the time that would give an idea about the efficacy of
the non-invasive surgical procedure
Secondary outcomes: Adverse side effects such as patient-
reported outcomes (pain, discomfort, oral-health-related
quality of life, alteration in mastication, other experiences, and
satisfaction), gingival and periodontal complications including
(gingival recession, loss of attachment, depth of probing, bone
resorption), loss of anchorage and unwanted tooth movement
(tipping, torquing, rotation) iatrogenic harm to teeth (e.g.,
tooth vitality loss, root resorption) stability of treatment in the
long term
Data collection: The full-text assessment was done for
all papers which appeared to be relevant, and the study design,
participants, intervention method, outcomes, advantages, and
disadvantages associated with both techniques were extracted
from each study. Papers were excluded when they did not fulfill
one or more of the inclusion criteria. Corresponding authors
were e-mailed for clarification of queries in the available data.
Results
Description of studies:
The steps and procedures involved in the electronic search
were represented in Figure 1. After excluding the article with
the irrelevant data by careful screening, 18 full-text articles
were selected which included 12 articles related to distraction
osteogenesis and six articles related to micro osteoperforation.
The details of the included studies and their quality assessment
were presented in Table 1, 2, and 3.
Description of Interventions
Dento-alveolar distraction osteogenesis: Various authors
have made randomized clinical trial on distraction osteogenesis
for rapid canine retraction and evaluated the rate of tooth
movement, anchorage loss, tipping of canine, root resorption,
and tooth vitality associated with it. The various results obtained
with the various studies are included in Table 1. The procedure
involved retraction of canine with the intra-oral distractor either
in the maxilla or mandible or both unilaterally or bilaterally. An
intraoral device for dentoalveolar DO was custom made. The
device is made up of stainless steel and contains a distraction
screw and guidance bars. The device was soldered to the canine
and first molar bands on the plaster model and checked for fit
and tolerance in the clinical setting. It was also made with a
conventional hyrax screw which was modified and soldered to
the canine and first molar bands.
Surgery was performed on an outpatient basis with the
patient under local anesthesia or sometimes with sedation. A
horizontal mucosal incision 2- 2.5 cm long was made parallel
to the gingival margin of the canine and bicuspid teeth well
beyond the depth of the vestibule. Subperiosteal elevations were
carried out to expose the canine root and first premolar region.
A vertical osteotomy was made on the anterior aspect of the
canine tooth to be distracted posteriorly using multiple cortical
holes made on the alveolar bone with a small, round carbide bur
under copious irrigation. The depth and the location of cortical
holes were made according to the proximity of neighboring
IJO  VOL. 30  NO. 2  SUMMER 2019
tooth. The osteotomy was continued and curved apically passing
3- 5 mm from the apex which could readily be identified in
the alveolar bone. A vertical osteotomy was made in a similar
manner along the posterior aspect of the canine tooth.
The first premolar was extracted and the buccal bone
removed between the outlined bone cut at the distal canine
region anteriorly and the second premolar posteriorly. Larger
osteotomes were used to fully mobilize the alveolar segment
that included the canine by fracturing the surrounding spongy
bone around its root of the lingual or palatal cortex. The
palatal shelf was preserved, but the apical bone near the sinus
wall was removed leaving the sinus membrane intact to avoid
interferences during active distraction process.
The transport alveolar segment that included the canine
also included the buccal cortex and the underlying spongy bone
that envelopes the canine root, leaving the intact palatal cortical
plate and the bone around the apex of canine. The incision was
closed with absorbable sutures and antibiotics and NSAIDs were
prescribed for five days. The distractor was cemented on the
canine and the first molar immediately after the surgery and the
distraction initiated within three days of surgery.
Micro-osteoperforation:
The procedure involves the retraction of the canine by
adjunctive minimal invasive therapy, i.e. micro-osteoperforation
either in the maxilla and mandible or both. A treatment device
for micro-osteoperforation may be a Propel orthodontic device
or hand screw-driver; both are frequently and alternatively
used by different authors at different time. The device has the
ability to puncture bone, with adjustable depth dial (0, 3, 5, 7
mm) and an indicating arrow on the device, or in some studies,
a rubber stopper has been used with hand screw-driver for
indicating depth.
Surgery was performed on an outpatient basis under
local anesthesia. Patients rinsed their mouths with 15 ml
chlorhexidine solution for 30 sections. Excess saliva was
removed with wet gauze or cotton roll. Topical anesthesia was
applied for 1-2 minutes, and after a few minutes, a probe was
used for proprioceptive feedback, and care was taken to avoid
nerve or root proximity. Using a sterile tool with disposable
tips or screws measuring approximately 1.5 mm wide and 3-5
mm deep, 2-3 holes were gently perforated in the cortical plate
between the canine and premolar region into the attached
gingiva 1 mm apical to the mucogingival junction with the
distance of 3 mm to each other.
The device was removed gently by rotating in the opposite
direction after perforation reached the set depth. Slight bleeding
is to be expected which can be stopped by using gauze/cotton
press on the MOPs site. The canine retraction was started at the
same time with NiTi closed coil springs (100-200gm) force on
experimental and control sides in both jaws by using temporary
anchorage device or molar anchorage.
Results of Interventions – Distraction Osteogenesis:
The various results obtained with various studies are
mentioned in Table 2. The rate of tooth movement observed was
about 0.5 to 0.8 mm per day with the total canine retraction
achieved in 8-14 days. The degree of activation of the distraction
45
46
Table-I: Various studies related to rapid orthodontics tooth movement with distraction osteogenesis in human subjects

Participants/ Rate/ Rhythm Anchorage Tipping Canine/ Root Vitality

Study Technique Device
Sample Size Duration Loss (MM) H/V Molar resorption

11 participants Horizontal mucosal

One distraction NAD (IOPA, color
Kişnişci et al, 8 (13 –18 years) incision with vertical 0.8 mm per day 0 mm (method
screw and two _ NAD (IOPA) discoloration,
(2002) JOMS. Maxilla- 8 osteotomy curved 8-12 days. not mentioned)
guidance bars vitality tests)
Mandible-2 apically
0.51±0.93mm (H)
Horizontal mucosal 0.8 mm/ day NAD (Root
12 10 participants One distraction 0.19± 0.31mm(V) 13.15±4.65
Iseri et al, , (2005) incision with vertical (2 times a day resorption NAD (electronic
(13-25 yrs.) screw and two Statistically (°RC/LC)
AJODO. osteotomy curved 10.05± 2.01days scale Sharpe digital pulp tester)
Maxilla 20 guidance bars insignificant (Lateral ceph)
apically 8-14 days et al)
Lateral ceph
Horizontal mucosal
Gürgan et al,18 18 participants One distraction 0.8mm/ day
incision with vertical
(2005) Eur J (13 – 25 yrs.) screw and two (2 times/ day) 0 mm -- NAD (IOPA) NAD (IOPA)
osteotomies curved
Orthod. Maxilla - 36 guidance bars 8 -14 days
apically
Conventional
Crevicular & 0.5mm/ day 0.0±9.1 (°RC/
19 8 participants hyrax screw 1.2±0.83mm (H) 7/20 are vital
Sukurica et al, vertical releasing (2 times/ day) LC)
(Avg. 18.5 modified with (model analysis- Insigni-ficant Electronic vitality
(2007) Angle incisions, with 12-28 days. No tipping in
yrs). Maxilla & bands soldered by location of (IOPA) tests.
Orthod. vertical & horizontal Mean 14.65± molars
Mandible. on the arms of maxillary raphe) No sign of pain or
osteotomies 3.49 OPG
the screw. discoloration
Distraction 10.61±0.29
Horizontal mucosal 0.32±0.043mm(H)
20 6 participants screw with 0.5mm/ day (°RC)10.65 ±0.22
Kharkar et al, . incision with vertical 0.55± 0.035mm(V) NAD NAD
(Avg. 20 yrs.) sliding rod (4 times/ day) (°LC)
(2010) OOOOE. osteotomies curved Cephalo-metric (IOPA) Electric pulp tester
Maxilla - 12 activated by 12- 13 days Cephalo-metric
apically measure-ments
screw wrench measurements
DAD: Horizontal Distraction .0.5mm/day NAD
6 participants
21 mucosal incision screw with (4 times/ day) 0.32±0.031mm(H) 10.61±0.29(°RC) IOPA (6days,
Kharkar et al, . (17–22 yrs.)
with vertical sliding rod DD:12-13 0.55±0.032mm(V) 10.61±0.22(°LC) 1 month, 3 NAD
(2010) IJOMS. Maxilla -12
osteotomies curved activated by days Lateral ceph Lateral ceph months, 6
apically screw wrench months)
Transport DAD with
73 participants NAD Insignificant
Kisnisci et al, 22 horizontal mucosal One distraction 0.8mm/ day
Maxilla/ (root (Electronic digital
(2011) J Oral incision with vertical screw and two (2 times/ day) 0 mm ---
Mandible resorption pulp tester)
MaxillofacSurg osteotomies curved guidance bars 9-14 days
scale)
apically
Contd---Table-1

IJO  VOL. 30  NO. 2  SUMMER 2019

 screw varied according to the various

discoloration or

(electrical pulp

Electronic pulp
5 out of 6 teeth
Electrical pulp

Electrical and
thermal pulp
authors and is mentioned in Table

vital (after 3
Insignificant
Vitality

4/10 are

months)

are vital
tester)
1. The anchorage loss was observed

tester

tester

NAD
pain

tests
No
with cephalometric measurements
from pre and post distraction lateral
cephalograms and pre and post
models with the location of the canine
scale by Liou
Insignificant

Sharpe root
according to the location of maxillary
and Huang
and lateral
resorption

resorption

resorption
Apical

scale
Root

raphe.12-14 The anchorage loss proved to

NAD
---

---
be statistically insignificant, and so the
anchorage control was appropriate.
The change in canine and molar
inclination was described in Table 1

14.88+_3.15°(RC/
Tipping Canine/

12±14.8 (° R/LC)

LC)1.19+_1.16°
Lateral ceph

Lateral ceph
11.48°± 4.37°
and model which was measured with the OPG

(Molar)
Molar

and cephalometric measurements.

OPG
---

The root resorption was primarily

checked with the IOPA radiographs
with several measures like Sharpe et
al.15 root resorption scale, and apical
Model analysis
No anchorage
0.50± 0.688mm

and lateral root resorption scale by Liou

Loss (MM) H/V

0.5±0.5mm(V)
0.80±0.63mm
Lateral ceph

Lateral ceph

Lateral ceph
Anchorage

and model

1.98±1.16

0.69±1.03
and Huang.5 There was no significant

mm(V)
mm(H)
loss
(H)

(H)

changes in the root morphology and

no significant root resorption. The
tooth was checked for any pain or
discoloration after DO, and the vitality
0.75 mm/ day

14+_2.45 days

was checked by electronic and thermal

3 quarter turn
Rate/ Rhythm

11.8±1.3 days
0.8 mm/ day
Twice a day

0.8mm/day
12-16 days

0.67± 0.14
8-14 days

mm/day
Duration

pulp testers. There was no significant

/day

difference in the tooth vitality, but

some studies showed that the tooth
did not respond after DO. But the
electronic pulp vitality tests were usually
on the arms of the

on the arms of the

on the arms of the

not reliable during orthodontic tooth

bands soldered

bands soldered

bands soldered
Custom made

unidirectio-nal
distractor with
Conventional

Conventional

Conventional
modified with

modified with

modified with
moving shaft
hyrax screw

hyrax screw

hyrax screw

NAD=No abnormality detected, RC/LC=Right Left canine, H/V=Horizontal Vertical

movement, and so further investigations

Device

screw.

screw.

screw.

were needed in terms of pulp vitality in

patients subjected to DO.
The periodontal surveys were done
on the distracted tooth with Silness and
Loe indices which showed statistically
preservation of sinus
incision with vertical

incision with vertical

incision with vertical

Crevicular mucosal
Horizontal mucosal

Horizontal mucosal
osteotomy curved

osteotomy curved

osteotomy curved

osteotomy curved
Complete vertical

insignificant changes.16, 17 The

apically with
& horizontal

dentoalveolar distraction osteogenesis

membrane
Technique

apically

apically

apically

was also compared with periodontal

distraction osteogenesis by Kharkar et
al.21 and Kateel et al.25 which showed
that dental distraction is superior to
periodontal distraction in all areas of
assessment.
19 participants
(Avg. 18.5 yrs.)

(15.8±1.96 yrs.)
7 participants

5 participants

8 participants
Sample Size

(Avg. 13 yrs.)

(14-30 years)
Participants/

Mandible 6
Maxilla 14

Maxilla 10

Maxilla 36
Maxilla 8

Results of Interventions – Micro

osteoperforation:
The various results obtained with
various studies were mentioned in Table
2 and 3. The studies by Alikhani et
Surg (Apr- June 2016)

et al,26 (Am J Orthod

Allwin Benjamin Raj

(J. Maxillofac. Oral

dentofacial orthop
et al,24( 2013 J Ind
et al,23 (2013) J Int

al., Bushra et al., and Masood et al.27-29

Naveen Kumar

15(2) : 144-155

GÖkmen Kurt
Kateel et al, 25
Oral Health).

Orthod Soc.

showed that the rate of tooth movement

(2017).
Study

associated with micro osteoperforation

increased 2-3 fold when compared
with the conventional method of tooth
movement. Sonal Attri et al.32 also

IJO  VOL. 30  NO. 2  SUMMER 2019 47

Table-II: Various studies related to rapid orthodontic tooth movement with micro-osteoperforation technique in human

Participants/ Rate/Rhythm Tipping of

Study Study Design Technique
Sample Size Duration Canine
MOP in between canine
and premolar region
20 participants (19.5- Not
with 2-3 mm depth and Increase 2-3 (62%)
Mani Alikhani et Single center, 33.1 years age) (10 statistically
1.5 mm wide. folds relative to
al, 27(2013) single blinded, experimental and 10 significant
Device–Propel conventional frictional
AJO-DO RCT control group) Maxillary (0.2mm)
orthodontic mechanics.
arch included. p < 0.05
Closed Coil spring
100gm
Increase 2 folds relative
MOP in between canine
Bushra Naeem Single center, 30 participants (15-28 to conventional
and premolar region
Khan et al,28 single blinded, years age M/F) maxillary frictional mechanics.
with 3 mm depth
(2018) OHMD RCT arch included MOP 2.04±0.699 mm
_
WMOP 1.02±0.22mm
Increase 2
folds relative to
Masood MOP in between canine
20 participants (18-33 conventional frictional
Feizbakhsh Single-blinded, and premolar region
years age) mechanics. WMOP
et al,29 (2018) prospective with 2-3 mm depth and
Maxillary and Max. 0.74±0.69mm
Journal of World split-mouth 1.5 mm wide
mandibular arch WMOP Mnd. 0.53±
Federation of clinical trial Device – Hand screw
included 0.41 mm MOP Max. _
Orthodontics driver
1.36±0.49 mm, MOP
Mnd 1.24± 0.42 mm
Amal Alkebsi Split mouth 32 participants (18-33 No statically significant
et al,30 (2018) randomized years age M/F) Maxillary difference between
AJO-DO clinical trial arch included WMOPs and MOPs _
MOP in between canine Statistically significant
30 participants (mean
SarithaSivarajana Single center and premolar region increased canine
age 22.2±3.72 years
et al, 31 split mouth with 3 mm depth and retraction rate of
M/F) Maxillary and
(2018) Angle randomized 1.6 mm wide. about 1.15mm on
mandibular arch
Orthodontist clinical trial Device – Hand screw MOPs side than _
included
driver WMOPs
MOP in between canine
60 participants (13-20 Statistically significant
SonalAttri et al, 2 arm parallel, & premolar region with
years M/F) Maxillary increased in rate of
32
(2018) Journal randomized 3 mm depth and 1.6
and mandibular arch tooth movement in
of Orthodontics clinical trial mm wide. Device – _
included MOPs
sPropel accelerator

RCT=Randomized control trial, WMOPs= without micro-osteoperforation, MOP=With Micro-Osteoperforation / F= Male/ Female

reported that there is a significant difference in tooth movement
between MOP side and the control side. Sarita et al. reported
that there is an only small difference in the rate of tooth
movement (1.10mm) between the MOP side and the control
side. The study by Amol et al.30 totally contraindicated the above
studies, as MOP had no effect on the rate of tooth movement,
anchorage loss, tipping, root resorption, and gingival status of
the patient, but this study had the shortcoming that the study
duration was only three months and undertaken by only one
clinician in a single center at a university.
There is an increase in the activity levels of cytokines and
chemokines in the region of micro osteoperforation.10, 11 There
was no reliable records on changes in root resorption, anchorage
loss, periodontal status, and tipping associated with MOPs.
Regarding pain perception, various studies proved that minimal
discomfort was observed post-procedure in the MOP region
which were statistically insignificant.
Discussion
Distraction osteogenesis:
Reha S et al.7, 22 presented a technique to reduce the
overall orthodontic treatment time by means of dentoalveolar
distraction osteogenesis. He observed that the distraction
rate and the device were well tolerated by all patients and no
anchorage loss in the second premolar and first molar teeth, root
resorption, dental ankylosis, discoloration, or loss of vitality was
detected. He did not use any specific method to measure the
anchorage loss. The ankylosis, root resorption, and tooth vitality

48 IJO  VOL. 30  NO. 2  SUMMER 2019

 Table- III: Timetable of events during various studies

Mani Alikhani Bushra Naeem Khan Masood Amal Alkebsi Saritha Sivarajana Sonal Attri et al, 32
TIME/ STEPS et al, 27 (2013) et al, 28 (2018) OHMD Feizbakhsh et al,29 et al, 30 (2018) et al, 31 (2018) (2018) Journal of
AJO-DO (2018) JWFO AJODO Angle Orthodontist Orthodontics

Extraction of 1st premolars in ü Only in upper arch ü ü ü ü

both arch (0 months) after leveling &
alignment (0-6
months)

Leveling and aligning+ ü ü ü ü ü ü

canine retraction(0-6

IJO  VOL. 30  NO. 2  SUMMER 2019

months )

Phase 1 impression and cast ü ü ü ü û ü

model before MOPs (6th
months)

Manual Evaluation of tooth ü ü ü ü ü û

movement following MOPs
(6-7 months)

Phase 2 impression cast and ü ü ü ü û ü

models 28 days after MOPs

Monitoring tooth movement û û û ü û ü

by other methods (6-7 mths)

Monitoring oral hygiene ü ü û ü û ü

Pain and discomfort ü û û ü ü ü

evaluation

Evaluation of other Inflammatory markers û û Anchorage loss, û û

biological markers and cytokines & Root resorption,
secondary outcomes interleukins & Tipping are
& TNF-α assessed.

MOPs = micro-osteoperforation,ü = procedure has

49
were checked with the IOPA and OPG radiographs, and the
vitality was further checked with vitality tests after distraction. In
2011, he compared both conventional and orthognathic patients
in which DO was used to reduce orthodontic treatment time
and to treat wide alveolar clefts with compromised soft tissue to
facilitate the optimal outcome. He found that the DO reduced
the treatment time without any significant complications, and
the canine retraction was achieved in 8-14 days.
Iseri’s et al.12 conducted distraction osteogenesis technique
on ten patients and found that full retraction of the canines was
achieved in a mean time of 10.05 (±2.01) days. The anchorage
teeth were able to withstand the retraction forces with minimal
anchorage loss. The mean change in canine inclination was
13.15°±4.65°, anterior face height, and mandibular plane
angle increased, and overjet decreased significantly at the end
of dentoalveolar distraction. No clinical and radiographic
evidence of complications, such as root fracture, root resorption,
ankylosis, periodontal problems, and soft tissue dehiscence, was
observed. Patients had minimal-to-moderate discomfort after
the surgery.
Gürgan et al18 conducted a study to evaluate the alterations
that occurred in the gingival dimensions of canine teeth
following dentoalveolar distraction (DAD) during a 12 month
follow up period. Full retraction of the canines was achieved in
10.36 ± 1.93 days (range 8–14 days) at a rate of 0.8 mm/day
using a custom-made intraoral rigid tooth-borne distraction
device. Before surgery (pre-DAD), immediately after removal of
the device (post-DAD), and at 1, 6, and 12 months post-DAD,
the plaque index (PI), gingival index (GI), pocket depth (PD)
and width of keratinized gingiva were recorded, and the width
of the attached gingiva was calculated; significant differences
were found between pre- and post-DAD for PD measurements
for all sites, with the highest difference at the distal site. The
palatal sites likewise showed significant differences but not
buccal sites. The width of keratinized gingiva also showed no
significant change during the follow-up period, while the width
of the attached gingiva was significant only between the pre- and
post-DAD periods. This study showed no unfavorable long-term
effects on the gingival tissues of rapidly retracted canine teeth.
Sukuricaa et al.19 conducted a study to examine the changes
in the periodontal tissues surrounding canines to evaluate the
displacement of the canine and first molar teeth, to assess the
effects of the procedure on the pulpal vitality of the canines,
and to determine the amount of root resorption in retracted
canines following DAD in first premolar extraction cases. The
distraction procedure was completed in 12-28 days (mean 14.65
± 3.49). The anchorage loss ranged from 0 -3 mm (mean 1.2
±0.83). The distal displacement of the canines ranged from
3- 8 mm (mean 5.35 ± 1.22). The canines showed a mean of
9.1° distal tipping, whereas there was no statistically significant
change in the axial inclinations of first molars after distraction.
Kharkar et al.20, 21 conducted a pilot study to make the
comparative evaluation of dentoalveolar distraction and
periodontal distraction assisted rapid retraction of the maxillary
canine. The patients were assessed at regular intervals with intra-
oral periapical radiographs and lateral cephalograms for gauging
the time required for retraction, canine tipping, anchorage loss,
50
and external root resorption. Results showed that dentoalveolar
distraction was superior to periodontal distraction in all areas of
assessment. He also conducted another study in the same year to
evaluate the time required for canine distraction, canine tipping,
anchorage loss, and root resorption using intraoral radiographs
and lateral cephalograms. The vitality of the canine was also
evaluated using an electric pulp tester. The time taken was 12.5
± 0.50 days with a minimal amount of tipping an acceptable
amount of anchorage loss. All the teeth were vital with no
evidence of root resorption.
Kumar et al.23 conducted a study on segmental alveolar
distraction in first premolar extraction cases, to evaluate the
displacement of the canine and first molar teeth, to assess the
effects of the procedure on the pulpal vitality of the canines,
and to determine the amount of root resorption in retracted
canines. The mean distal retraction of canines was 7.262 ±
0.4864 mm. The mean distraction procedure was completed
in 14.60 ±1.536 days. The duration of retraction was less for
mandibular canine compared to the maxillary canine. The
mean posterior anchorage loss was mean 0.50±0.688 mm. The
amount of root resorption that occurred during distraction was
clinically insignificant. None of the teeth reacted negatively to
the electrical vitality test that was performed six months after the
completion of the distraction procedure. There was no clinical
sign of discoloration or pulpal pain in any tooth.
Raj et al.24 conducted a clinical study on distraction
osteogenesis. The effects of dentoalveolar distraction on the
dentofacial structures, the dental changes that have been
produced by dentoalveolar distraction, and the vitality of
the distracted canine immediately after distraction, and three
months post distraction using pulp vitality test were evaluated.
The mean anchorage loss was 0.08±0.63 mm. The mean distal
displacement of the canine was 6.65±1.08 mm. The mean
change in the canine inclination of 12±14.8 degrees at the end
of the distraction period was statistically significant. There was a
significant difference both in the axial inclinations of distracted
canines and in the axial inclination of first molars. Electrical
vitality tests showed a delayed response in four teeth and no
response in six teeth after three months of DAD.
Kateel et al.25 conducted a study to assess and evaluate
canine retraction by the two methods of distraction osteogenesis-
periodontal ligament distraction and dentoalveolar distraction.
The distraction procedure was completed in 15.38 ± 1.51 days
on the side of periodontal ligament distraction while it took
14.50 ± 2.45 days on the side of dentoalveolar distraction. No
significant anchorage loss was seen on both sides. An angulation
change of 14.94 ± 7.58_ was observed in canine inclination on
periodontal distraction side while the change of 14.88± 3.15 was
seen on the dentoalveolar distraction side. The study concluded
that no significant differences in the various parameters were
found between both the techniques of canine retraction by
distraction osteogenesis while reducing orthodontic treatment
duration by 6–9 months without any unfavorable short-term
effects on the periodontium.
Kurt et al.26 conducted a study to test whether the duration
of orthodontic treatment can be significantly reduced by
accelerating canine retraction using dentoalveolar distraction
IJO  VOL. 30  NO. 2  SUMMER 2019
(DAD). Results showed that the canine retraction was 7.9±1.4
mm in 11.8 ±1.3 days, and canine distal tipping was 11.4±4.3
after DAD; the canines were distalized 5.2±2.0 mm and
tipped 13.6±9.5 in the DG. The rates of the posterior canine
movement were 0.6± 0.1 mm per day after DAD and 0.03
± 0.01 mm per day in the DG. No significant first molar
anchorage loss was observed after DAD, although the DG
showed some vertical and sagittal first molar movement. This
showed that the DAD can reduce the duration of orthodontic
treatment time by accelerating canine retraction in extraction
patients without undesirable side effects.
Micro-osteoperforation:
Alikhani et al.27 investigated the effect of micro-
osteoperforations on the rate of tooth movement and the
expression of inflammatory markers. Results showed that
micro-osteoperforations significantly increased the rate of tooth
movement by 2.3-fold. The activity of inflammatory markers
was measured in gingival crevicular fluid using an antibody-
based protein assay. There was a significant increase in cytokine
and chemokine levels on the MOP side where the activity levels
of cytokine IL1α and IL1β were 5.0 and 3.6 times higher than
before retraction on the MOP side. The patients did not report
significant pain or discomfort during or after the procedure, or
any other complications.
Khan et al.28 conducted a randomized control trial to
evaluate the effect of micro-osteoperforations on the rate of
tooth movement. By using miniscrews as anchorage, the canine
retraction was initiated via powerchain. The rate of tooth
movement after micro osteoperforations was 2.04 mm per four
weeks. Root resorption and inflammatory markers had not been
evaluated in this study.
Feizbakhsh et al.29 evaluated the effectiveness of micro-
osteoperforation technique for rapid canine retraction. Results
showed that micro-osteoperforation significantly increased the
rate of tooth movement by more than twofold when compared
with the control group. However, comparing the differences in
the rate of tooth movement between maxillary and mandibular
canine retraction, in both interventional and control side
yielded insignificant results (p > 0.05). Root resorption and
inflammatory markers had not been evaluated in this study.
Alkebsi et al.30 investigated the effect of micro-
osteoperforations (MOPs) on the rate of tooth movement.
There was no statistically significant difference in the rates of
tooth movement between the MOP and the control sides at all
times. There were also no differences in anchorage loss, rotation,
tipping, root resorption, plaque index, periodontal index, and
pain perception between the MOP and control sides at any time
point. MOP had no effect on patients’ daily lives except for a
feeling of swelling on the first day, and the level of satisfaction
and degree of easiness of the procedure were high.
Sivarajana et al.31 investigated using a split-mouth
randomized clinical design, the effect of micro-osteoperforation
(MOP) on mini-implant supported canine retraction using fixed
appliances. The mean overall canine retraction was 4.16 (1.62)
mm with MOP and 3.06 (1.64) mm without MOP over a 16
week period of observation. There were only small differences
in tooth movement when intervals of 4, 8, 12-week MOP
IJO  VOL. 30  NO. 2  SUMMER 2019
were used. Moderate pain was associated with MOP at 4-week
interval while only mild pain was perceived at intervals of eight
and 12 weeks. The study concluded that MOP can increase
overall mini-implant supported canine retraction over a 16-
week period of observation, but this difference is unlikely to be
clinically significant.
Attri et al.32 investigated the influence of micro-
osteoperforation (MOP) on the rate of orthodontic tooth
movement and pain perception with fixed appliances. There was
a statistically significant increase in the rate of tooth movement
in the MOP group (p<0.05). The pain perception was measured
using a visual analogue scale (VAS) of 10 mm. MOP appears to
enhance the rate of tooth movement with no differences in pain
perception.
Conclusion
There is a reduction in the duration of treatment time due
to an increased rate of tooth movement with both dentoalveolar
distraction osteogenesis and micro-osteoperforation where
DO result in total retraction of canine in 8-14 days, and
MOP increased the rate of tooth movement by 2-3 fold when
compared to conventional tooth movement. There was no
appreciable anchorage loss, canine tipping, root resorption. and
ankyloses associated with DO, whereas further studies were
needed with regard to MOP.
The pulp vitality was not affected with DO in most teeth,
but further studies are needed to understand the changes in
tooth vitality, as most of the pulp vitality tests were not reliable
during orthodontic tooth movement. Since DAD and MOP
can reduce the duration of orthodontic treatment time by
accelerating canine retraction in extraction patients without
undesirable side effects, there were some drawbacks associated
with them which included the need for the specific surgical
procedure, supervised activation protocol, need for special
devices, and its knowledge of the application.
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