Manual Osteoperforation and High-Frequency Vibration by Bruce McFarlane, DMD, BScD, MCID, FRCD(C)

Abstract
Certain orthodontic movements are, by nature, slow and time-consuming, especially in adults and older adolescents. These include such movements as guiding impacted teeth, large space closures, expansion and difficult de-rotations.

• Manual osteoperforation (MOP) is a method of potentially accelerating orthodontic tooth movement. In my practice, when I add acceleration proactively or when tough tooth movements arise during the course of fixed or aligner orthodontics, I look to MOPs.
• High-frequency vibration (HFV) can aid aligner seating and help ensure more consistent tracking with clear aligner treatments.
• The combination of MOPs to treat stubborn cases and HFV for aligner seating is showing promise. In the following cases, I utilized MOPs to aid the orthodontic movement:
  • Case 1: An exposed impacted canine treated with MOPs.
  • Case 2: Expansion with clear aligners treated with MOPs and HFV.
  • Case 3: A lateral open bite that was not closing treated with MOPs.
  • Case 4: A case of eruption failure made possible to treat with MOPs.

Case studies
I have found MOP to be an adjunct to orthodontic appliances and aligners for potentially aiding tooth movement in appropriate cases (Figs. 1 and 2).1 HFV can be used with an aligner seater with five-minute daily use by the patient (Fig. 3). Both techniques are now incorporated in my practices.

Attention now turns to using these techniques on difficult orthodontic cases with braces or clear aligners. The list of these malocclusions is long and includes impacted teeth that are not emerging efficiently, transverse expansion, open bites that are not closing, and teeth that are failing to erupt. Traditional treatment options in these cases—Wilckodontics, luxation, osteotomy and extraction, for example—are often considerably invasive, risky and expensive. "Saving" the case with techniques that are less invasive is therefore a most desirable intention.

When addressing difficult cases, I perform more MOP and often perforate as apically as possible because the tooth stubbornness is often located well along the root. The advantage of the MOP system, in my opinion, is that treatment can be targeted to and localized in the area of most need.

Case 1
Impacted canine
A 15-year-old patient presented with an impacted upper right canine that was surgically exposed after six months in braces (Figs. 4–6).

Eight months beyond the exposure time, the canine had emerged but was not moving anymore and was instead acting as an anchor to the surrounding teeth (Fig. 7). MOP was performed around the offending root and neighboring ones (Fig. 8). Four weeks later, some progress was observed (Fig. 9). Four months later, MOP was applied again and extended mesial to the lateral incisor (Fig. 10). Two months after the second MOP session, the case was back on track without luxation or further surgery (Fig. 11).

At 21 months, the patient still required some finishing.

Case 2
Maxillary transverse expansion
Clear aligners are extremely effective with certain patients and less predictable with others. In the latter group: Maxillary transverse expansion in an adult is an often-required maneuver, albeit a tough one.

The 37-year-old patient had previously been through traditional braces and two-jaw surgery. She had since experienced some relapse, and her right buccal segment was in full cross bite. She wanted correction, but did not want to go back into braces (Fig. 12). The Clincheck predicted full correction, but it was going to be difficult to achieve clinically (Fig. 13).

After four weeks of Invisalign alone, with one-week aligner intervals, MOP and HFV (for aligner seating) were added (Figs. 14 and 15). At one month and two months post-MOP the transverse improvement was realized (Figs. 16 and 17).

Case 3
A lateral open bite closes with MOP
Patient is a 55-year-old female who has never had occlusal contacts on her right side (Figs. 18 and 19). Braces were initiated and MOP was applied to the upper right buccal segment at six months (Fig. 20). At four weeks post-MOP, contact was established (Fig. 21a). At 12 weeks post-MOP, the occlusion is being detailed (Fig. 21b).

Case 4
Failure of eruption in a teen
Patient is a 15-year-old female who presented with some unerupted upper right premolar teeth and an occlusal plane cant. Her mother was wary, because she had experienced a similar problem as an adult, with difficult and complex treatment to address it. The previous orthodontist had tried, to no avail, the correct conservative measures to allow natural eruption (Figs. 22–24).

Fixed orthodontics were initiated in the three quadrants that were successfully erupting, but not in the upper right quadrant. MOP was administered on the mesial and distal of the unerupting premolars at one month (Fig. 25).

Two , three and four months post-MOP: Some eruption was occuring (Figs. 26–28). At four months MOP was repeated to ensure continued eruption with braces and elastics.

In summary, the use of MOP and HFV in my practice has, in my opinion, been quite valuable.

References
1. Alikhani M, Raptis M, Zoldan B, Sangsuwon C, Lee YB, Alyami B, Corpodian C, Barrera LM, Alansari S, Khoo E, Teixeira C. "Effect of micro-osteoperforations on the rate of tooth movement,"American Journal of Orthodontics and Dentofacial Orthopedics. 2013;144(5):639-648

Disclaimer: This article may describe uses of osteoperforation in general and/or an Excellerator series driver specifically that has 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 its labeling.