I was happy to see an article on surgically assisted orthodontic treatment in the September issue (Kim SH, Kook YA, Jeong DM, Lee W, Chung KR, Nelson G. Clinical application of accelerated osteogenic orthodontics and partially osseointegrated mini-implants for minor tooth movement. Am J Orthod Dentofacial Orthop 2009;136:431-9). Unfortunately, the article was a bit off the mark. It slipped through the review-process, as articles do from time to time, because too few reviewers understand the science or the clinical rationale.
Specifically, these authors were disappointed in the lackluster results of 7–9 months of treatment time. In my opinion, the authors deviated from a proven protocol and committed errors in their earnest but hapless sojourn into surgical orthopedics: (1) they did not need to graft the left molar site because there was sufficient bone in situ; (2) the corticotomy cuts (the preferred term is “selective alveolar decortication” or SAD) were too shallow to elicit the necessary mesenchymal stem cells and too coronal and too timid to induce the degree of therapeutic “trauma” necessary for intrusion; (3) the authors’ comments that heavy forces are necessary conflicts with both prior literature and their own words later in the article; and (4) their adjustments every 4 weeks were probably not frequent enough to perpetuate a therapeutic osteopenia or the so-called regional acceleratory phenomenon of Frost and Jee that derived principally from an engineered surgical trauma. Continued tensional stress altered in frequency and magnitude via the roots every 1 to 2 weeks maintains the osteopenic state and facilitates both accelerated tooth movement and a stable post-treatment phenotype. Constant force allows bone to adapt to an inactive “steady state” equilibrium. Monthly adjustments risk recalcification in midtreatment. In our office, we initiate biomechanics 5 minutes after the last suture is placed and make biomechanical adjustments every 1 to 2 weeks. This gives us tooth movement of 1 to 2 mm per week. Case Western Reserve University and the University of Southern California departments of periodontics know this and teach the accelerated osteogenic orthodontics (AOO) and periodontally accelerated osteogenic orthodontics (PAOO) protocols in their standard periodontics curriculum (AOO and PAOO and the terms these acronyms represent are trademarked by Wilckodontics Inc, Erie, Pa, for the sake of intellectual integrity and patient protection because the results are technique sensitive). However, they base their pedagogy on a thorough review of the literature of this evidence-based technique and we clinicians should do likewise.
I have been very successful with the AOO protocol for 7 years. Moreover, the underlying scientific principles upon which success is based are helpful in nearly all my patients to some degree. I am comfortable with AOO and PAOO, but I cringe at misapprehensions that earnest but inexperienced neophytes might bring to good bone tissue engineering science. In my private practice, we have received rave reviews from patients to an almost evangelistic degree. This however has been achieved only by assiduous research and collegial dialogue with peers. We must be good scholars before we can expect to be successful clinicians in surgical orthopedics. In sum, patients will perceive academic gravitas and appreciate progressive clinical innovation. However, that derived from being a good librarian before I was a successful clinician.
Despite these sentiments, I rest assured that in orthodontics we still have the opportunity for free speech, meaningful dialogue, and collaborative progress. For this I am grateful to my “NewThink” colleagues Professors Lysle E. Johnston Jr (University of Michigan), Nabil F. Bissada (Case Western Reserve University), and Hessam Nowzari (Univeristy of Southern California), who contribute to the synthesis in the style of the Western dialectic rendering the hybridization of diversified thought a better alternative to all its components.