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Dr. Vaibhav Nepalia et al. / IJRID Volume 4 Issue 3 May.-June. 2014
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Review- article
INTERNATIONAL JOURNAL OF RESEARCH IN DENTISTRY
ACCELERATED OSTEOGENIC ORTHODONTICS: A REVIEW
Dr. Arun Ramani, Dr. Vaibhav Nepalia, Dr. Gunjan Singh
Jaipur Dental College, Jaipur rajasthan
Received: 13 Apr. 2014; Revised: 23May 2014; Accepted: 16 June. 2014; Available online: 5 July 2014
ABSTRACT
Wilckodontics – also known as Accelerated Osteogenic Orthodontics (AOO) – is a relatively new treatment in the orthodontic
realm. It promises to radically shorten the time of treatment with a dental surgical procedure. This technique has roots in
orthopedics, dating back to the early 1900s. Only recently was it modified to assist in orthodontic therapy.
INTRODUCTION
Currently, many adult patients are seeking orthodontic treatment. However, successful orthodontic treatment can be
difficult when treating adult patients because dentoalveolar development ceases after adolescence. The average
orthodontic treatment time for adults is considerably longer than for adolescent patients, ranging from 18.7 to 31 months.
It is also more likely for adult patients to experience root resorption because of an aplastic, narrow, and less vascular
periodontal membrane, as well as denser, avascular, and aplastic bone. Surgically assisted orthodontic tooth movement
has been used since the 1800s.
HISTORICAL REVIEW
The nature of orthodontic tooth movement needs to be revisited for research to develop a novel treatment method
combining selective alveolar decortications alveolar augmentation and orthodontic treatment. The method of
Periodontally Accelerated Osteogenic Orthodontics (PAOO) is patented by “Wilckodontics” based on the emerging
concepts of Wilcko brothers [1].
Surgically asssisted orthodontic tooth movement has been used since the 1800’s. In 1893, Cunningham presented
“Luxation, or the immediate method in the treatment of irregular teeth” at the International Dental Congress in Chicago.
Corticotomy facilitated tooth movement was first described by LC Bryan in 1893 published in the textbook by SH
Guiliford. It was Henrich Kole’s publication in 1959, however that set the stage for evolution of corticotomy facilitated
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Dr. Vaibhav Nepalia et al. / IJRID Volume 4 Issue 3 May.-June. 2014
Dr. Vaibhav Nepalia et al. / IJRID Volume 4 Issue 3 May.-June. 2014
orthodontics [2]. Kole believed that it was the continuity and thickness of the denser layer of cortical bone that offered the
most resistance to tooth movement. He theorized that by disrupting the continuity of this cortical layer of bone, he was
actually creating and moving blocks of bone in which teeth were embedded. He postulated this theory as “bony block
movement” [3].
Bell and Levy published the first experimental study of alveolar corticotomy in 49 monkeys in 1972. They described a
model of vertical interdental corticotomy that should have been considered an osteotomy, because they mobilized all
dento-osseus segments [4].
Further, Duker investigated the effect of corticotomy on tooth vitality and the marginal periodontium in beagle dogs. His
results supported the idea of preserving the marginal crest bone in relation to interdental cuts. The cuts must always be left
at least 2 mm short of the alveolar crestal bone level [5].
BIOMECHANICS OF WILCKODONTICS
Regional Acceleratory Phenomenon (RAP)
Orthopedist Herald Frost recognized that surgical wounding of osseous tissue results in striking reorganizing activity
adjacent to the site of injury (in osseous/ soft tissue surgery). He collectively termed this cascade of physiologic healing
events –“The Regional acceleratory phenomenon” (RAP) [6,7]. The RAP is a local response of tissues to noxious stimuli
by which tissue regenerates faster than normal in a regional regeneration/remodeling process [8]. This response varies
directly in duration, size, and intensity with the magnitude of the stimulus. The duration of RAP depends on the type of
tissue, and usually lasts about four months in human bone. This phenomenon causes bone healing to occur 10-50 times
faster than normal bone turnover [9].
The healing phases of RAP have been studied in the rat tibia. There is an initial stage of woven bone formation, which
begins in the periosteal area and then extends to medullary bone, reaching its maximal thickness on day seven. This
cortical bridge of woven bone is a fundamental component of RAP, providing mechanical stability of bone after injury.
From day seven, the woven bone in the cortical area begins to undergo remodeling to lamellar bone, but woven bone in
the medullary area undergoes resorption, which means transitory local osteopenia. It seems that medullary bone needs to
be reorganized and rebuilt after establishment of the new structure of cortical bone, and to adapt to the reestablishment of
cortical integrity (three weeks in rats). There is also a systemic acceleratory phenomenon (SAP) of osteogenesis due to
systemic release of humoral factors [9].
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Dr. Vaibhav Nepalia et al. / IJRID Volume 4 Issue 3 May.-June. 2014
In human long bones, following surgical injury, RAP begins within a few days, usually peaks at 1-2 months, and may take
from 6 to 24 months to subside completely [7]. RAP results in a decrease in regional bone density (osteopenia) in healthy
tissues, whereas the volume of bone matrix remains constant [6]. Orthodontic force application alone is a stimulant
sufficient to trigger mild RAP activity. But when tooth movement is combined with selective decortication, RAP is
maximized [9]. However, in 2001 Wilcko et al., revisited the original technique of bony block movement with some
modifications. They attempted two cases with severely crowded dental arches, and speculated that the dynamics of
physiologic tooth movement in patients who underwent selective decortication might be due to a demineralizationremineralization process rather than bony block movement. They suggested that this process would manifest as a part of
RAP that involves the alveolar bone after being exposed to injury (corticotomy) and during active tooth movement [6].
PAOO Procedures
PAOO is an outpatient procedure done in the office of Periodontist or an oral surgeon. Usually, braces are put
on a few days before the PAOO procedure.
A full thickness mucoperiosteal flap is reflected under local anesthesia, after an intra crevicular incision that connects the
releasing incisions buccally and lingually [10].The flap is reflected beyond the apices of the teeth [11].
Vertical corticotomy cuts are performed with round burs with water irrigation and in between roots from the distal of
second premolars to the distal of the opposing second premolars on both arches. These vertical cuts were extended
approximately 2 mm past the apices of the teeth and connected with horizontal corticotomy cuts. The vertical corticotomy
cuts stopped about 2 mm short of the alveolar crests. Both corticotomy cuts and perforations were extended through the
entire thickness of the cortical plate, just barely into the cancellous bone [11]
According to Dr. Wilcko, pain relievers like Ibuprofen are not recommended, since they are NSAIDs (Non-Steroid AntiInflammatory Drugs). NSAIDs can interfere with the production of prostaglandin hormone in body and slow down the
bone growth process which is vital to PAOO. In addition, NSAIDs given during the first 24 hours following trauma
(surgical or otherwise) inhibit clotting. Therefore, one should not take NSAIDs on a regular basis before or after
undergoing PAOO surgery.
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Dr. Vaibhav Nepalia et al. / IJRID Volume 4 Issue 3 May.-June. 2014
ORTHODONTIC ADJUSTMENTS AFTER THE SURGERY
After completing the procedure, orthodontist adjusts the braces about every two weeks. Depending on your case, you will
wear braces from 3 months up to about 9 months. After the braces are removed, retainer must be used for at least six
months.
Pros and Cons of AOO Surgery
Pros:

less time than traditional orthodontics

less likelihood of root resorption

History of relapse has been very low

There is less need for appliances and headgear (depending on the case)

In the eight years since AOO was first applied, the patients’ outcomes were good and have remained stable

The technique has its roots in proven orthopedic research and treatments

Both metal or ceramic brackets can be used.
Cons:

It is an expensive procedure.

It is a mildly invasive surgical procedure, and like all surgeries, it has risks of some pain, swelling and possibility
of infection.
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
Patients who take NSAIDs on a regular basis or have other chronic health problems cannot be treated.

It does not lend itself useful to Class III malocclusion cases.
Dr. Vaibhav Nepalia et al. / IJRID Volume 4 Issue 3 May.-June. 2014
Dr. Vaibhav Nepalia et al. / IJRID Volume 4 Issue 3 May.-June. 2014
CONCLUSION
Wilckodontics the new synergy of orthodontics interplaying with periodontics on the same bony platform has made adult
orthodontics a reality. This credit goes to the regional accelerated phenomenon due to transient osteopenia. This tissue
response elicited was proved to be beneficial in the treatment of clinical situations like decrowding, molar intrusion etc.
So, ACS is effective at accelerating tooth movement. But it is inappropriate to conclude that it reduces orthodontic
treatment time without assessing treatment quality. The significance of bone grafting along with corticotomy is yet to be
evaluated in RCT’s. However, review of literature could not reveal any established guidelines for selection of osteotomy
or corticotomy though the later proved to be advantageous. Thus, understanding the biomechanics of bone remodelling
may increase the clinical applications of corticotomy facilitated orthodontics with or without alveolar augmentation.
Wilckodontics can be an attractive treatment option and be a “win-win” situation for both the doctor and patient if
research attempts to relieve this clinical dilemma.
REFERENCES
1. Hajji SS. The influence of accelerated osteogenic response on mandibular de-crowding [thesis]. St Louis: St Louis
Univ; 2000.
2.
Köle H. Surgical operations of the alveolar ridge to correct occlusal abnormalities. Oral Surg Oral Med Oral
Pathol. 1959; 12: 515-29.
3.
Kole H. Surgical operations on the alveolar ridge to correct occlusal abnormalities. Oral Surg Oral Med Oral
Pathol. 1959; 12: 413-20.
4. Bell WH, Levy BM. Revascularization and bone healing after maxillary corticotomies. J Oral Surg. 1972; 30:
640–8.
5.
Duker J. Experimental animal research into segmental alveolar movement after corticotomy. J Maxillofac Surg.
1975; 3: 81–4.
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6.
Frost MH. The biology of fracture healing: An overview for clinicians Part I. Clin Ortho. 1989; 248: 283-93.
7.
Frost MH. The biology of fracture healing: An overview for clinicians Part II. Clin Ortho. 1989; 248: 294-309.
8.
Frost HM. The regional acceleratory phenomenon: a review. Henry Ford Hosp Med J. 1983; 31:3–9.
Dr. Vaibhav Nepalia et al. / IJRID Volume 4 Issue 3 May.-June. 2014
Dr. Vaibhav Nepalia et al. / IJRID Volume 4 Issue 3 May.-June. 2014
9.
Schilling T, Müller M, Minne HW, Ziegler R. Influence of inflammation-mediated osteopenia on the regional
acceleratory phenomenon and the systemic acceleratory phenomenon during healing of a bone defect in the rat.
Calcif Tissue Int. 1998; 63: 160–6.
10. Wilcko WM, Wilcko T, Bissada NF.An evidence based analysis of periodontally accelerated orthodontics and
osteogenic techniques.A synthesis of scientific perspective.Semin Orthod 2008;14:305-16
11. Wilcko WM, Wilcko MT,Rapid Orthodontics with alveolar reshaping.Two case reports of decrowding.Int J
Periodontics Restorative Dent2001;21:9-19
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