Clin Dent Rev (2018)2:4 https://doi.org/10.1007/s41894-017-0013-1 TECHNIQUES Micro-osteoperforations in accelerated orthodontics C. Sangsuwon 1,2 S. Alansari 1,3 J. Nervina 2 C. C. Teixeira 2 M. Alikhani 1,3,4 Received: 6 November 2017 / Accepted: 8 November 2017 Ó 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 invasive 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 Mani_Alikhani@hsdm.harvard.edu 1 2 3 4 Consortium for Translational Orthodontic Research (CTOR), Hoboken, NJ, USA Department of Orthodontics, New York University College of Dentistry, New York, NY, USA The Forsyth Institute, Cambridge, MA, USA Advanced Graduate Education Program in Orthodontics, Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA, USA
4 Page 2 of 10 Clin Dent Rev (2018)2:4 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 Accelerating tooth movement Facilitating root movement/bodily movement Movement into deficient alveolar bone Differential anchorage Decreased possibility of root resorption Expansion in adults and asymmetric expansion Clinical applications Different stages of adult treatment Uprighting/intrusion/extrusion/root torque/closure of large space Closure of old extraction space Reducing bone density around teeth to be moved, while preserving anchorage unit Reducing bone density and duration of exposure to osteoclasts Facilitate dental expansion in adults with less possibility of recession Asymmetric change in biological response to facilitate asymmetric expansion
Clin Dent Rev (2018)2:4 Page 3 of 104 Table 2 Medical conditions that may contraindicate the use of Micro-osteoperforation and/or may require medical clearance before the procedure General medical conditions Cardiovascular problems Pulmonary problems Renal problems Hepatic disorders Endocrine disorders Hematologic problems Neurologic disorders Pregnancy Specific contraindications Angina pectoris Myocardial Infarction Coronary artery bypass grafting Stroke Dysrhythmias Congestive heart failure Chronic obstructive pulmonary disease Severe asthma Renal dialysis Renal transplant Impaired liver function Diabetes mellitus Adrenal insufficiency Hyperthyroidism Hereditary coagulopathies Therapeutic anticoagulation Seizure disorders Alcoholism 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.
4 Page 4 of 10 Clin Dent Rev (2018)2:4 Fig. 1 Sample of consent form for application of micro-osteoperforations (MOPs) 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.
Clin Dent Rev (2018)2:4 Page 5 of 104 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 of MOPs, perforations are located mesial and distal of the target tooth in the area of the attached gingiva
4 Page 6 of 10 Clin Dent Rev (2018)2:4 Fig. 3 Strategic application of MOPs based on desired direction of movement. In some setups, such as the use of an overlay wire, the direction of movement is dictated by the wire and is difficult to control by the clinician. MOPs can be applied around the target tooth for buccal movement in the direction of the blue arrow (a). However, application of unilateral MOPs facilitates displacement in one particular direction (shown by blue arrow) and allows the clinician to have better control on the direction of movement (b) 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
Clin Dent Rev (2018)2:4 Page 7 of 104 Fig. 4 Application of MOPs in the buccal cortical plate. Height of application of MOPs should be limited to the attached gingiva for patient comfort. a Height of application of MOPs around anterior teeth, b application of MOPs around posterior teeth may have different distribution and number, as determined by root proximity, accessibility, and width of attached gingiva 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.
4 Page 8 of 10 Clin Dent Rev (2018)2:4 Fig. 5 Contra-angle devices (manual or rotary) for access to the lingual cortical plates and the posterior buccal cortical surfaces. They also facilitate perforation of thick bone that may resist the use of handheld devices 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:
Clin Dent Rev (2018)2:4 Page 9 of 104 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 of MOPs 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-
4 Page 10 of 10 Clin Dent Rev (2018)2:4 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