**4.1. Micro-osteoperforation application techniques**

Micro-osteoperforation is an up-to-date method among the surgery-assisted techniques of accelerating tooth movement. Therefore, in the literature, there are studies in which different methods are used in order to create MOPs on alveolar bones.

We observe that low-speed handpiece and round bur combinations [11, 25] and mini-implants [12] are used within the animal studies which evaluate effects of MOPs on tooth movement and both methods are accepted as effective. Even if in a limited number of clinical trial; microosteoperforations are typically applied with a handheld disposable appliance designed by Propel Orthodontics (Ossining, NY). Propel is an appliance which is designed to apply alveocentesis procedure. The foremost part of the device which is like an orthodontic stainless steel screw is patented, allowing perforation of alveolar bone traumatically over keratinized gingiva and moving mucosa. Contrary to other rotatory devices, Propel was reported to have a slight effect on soft issue. It is a device which enables tissue remodeling and microosteoperforations between tooth roots over both stable and moving tissue of 1.5 mm diameter and 3, 5, and 7 mm depth without flap surgery in order to accelerate tooth movement. The appliance has an adjustable length and a light signal that turns on when the clinician achieved desired depth [5, 64]. Micro-osteoperforations, which are applied on the defined depth, reach to medullar bone from cortical bone increasing inflammatory mediators. The device was also reported not to cause soft tissue damage while enabling remodeling process [5].

While it is not always possible to create homogenous perforations of same size using microosteoperforation methods such as round burs, Propel device which is designed in order to form MOPs has not included in routine clinical use yet. Thus, mini-implants are considered more advantageous than other methods as they are included in clinical routine and frequently used by orthodontists for different purposes and easily tolerated by the patients. On the other hand, in the literature, there are limited studies in which mini-implant-facilitated micro-osteoperforations are carried out with human. Aksakalli et al. [66] applied three microosteoperforations distal to the canine teeth with miniscrews just before canine distalization period. In their case report, they reported that MOP method with miniscrews accelerated canine distalization in their 14-year-old male patient with class II malocclusion by almost 1.5-fold and also without harmful effects on root and periodontal structures. On the contrary, Alkebsi et al. [67] could not find any differences of anchorage loss, canine rotation, and tipping between the MOP and control sides in their randomized controlled clinical trial where they investigated the effectiveness of miniscrew-facilitated MOPs on the rate of canine distalization.

All of the methods are applied without a need for additional periodontal surgeries which is considered as a significant advantage but additional clinical studies are required in order to evaluate the efficiency of each technique and their advantages and disadvantages over each other in detail.

#### **4.2. Advantages of micro-osteoperforation over other surgical techniques**

bone remodeling process that was activated by applying orthodontic tooth movement and micro-osteoperforations on the atrophic ridge could be different. The researchers, who created atrophic alveolar ridge model on eight beagle dogs, evaluated tooth movement rates and atrophic alveolar ridge area on the sides with and without osteoperforations in their study which they planned via split mouth design. Micro-CT based histomorphometry analysis similar to the previous studies suggested that osteoperforations accelerated tooth movement with a decrease in bone density without any differences in atrophic ridge volume. This up-to-date finding can be evaluated as an indicator that the efficiency of micro-osteoperforations on bone remodeling is more related to resorption mechanism and

In the literature, there is a limited number of studies which evaluate the effects of microosteoperforations on tooth movement in human. Current studies indicate that microosteoperforation is a safe method that can accelerate tooth movement but it must be taken into consideration that several factors such as occlusal relations, movement type, applied mechanics, age and gender of the patient, oral hygiene, periodontal illnesses, alveolar bone loss, systemic diseases, and medication use effect tooth movement rate in human. Therefore, the efficiency of micro-osteoperforations must be evaluated with long-term studies in which study groups are standardized as much as possible considering these variable where different tooth movement types (distalization, intrusion, eruption of impacted tooth, etc.) and mechan-

Micro-osteoperforation is an up-to-date method among the surgery-assisted techniques of accelerating tooth movement. Therefore, in the literature, there are studies in which different

We observe that low-speed handpiece and round bur combinations [11, 25] and mini-implants [12] are used within the animal studies which evaluate effects of MOPs on tooth movement and both methods are accepted as effective. Even if in a limited number of clinical trial; microosteoperforations are typically applied with a handheld disposable appliance designed by Propel Orthodontics (Ossining, NY). Propel is an appliance which is designed to apply alveocentesis procedure. The foremost part of the device which is like an orthodontic stainless steel screw is patented, allowing perforation of alveolar bone traumatically over keratinized gingiva and moving mucosa. Contrary to other rotatory devices, Propel was reported to have a slight effect on soft issue. It is a device which enables tissue remodeling and microosteoperforations between tooth roots over both stable and moving tissue of 1.5 mm diameter and 3, 5, and 7 mm depth without flap surgery in order to accelerate tooth movement. The appliance has an adjustable length and a light signal that turns on when the clinician achieved desired depth [5, 64]. Micro-osteoperforations, which are applied on the defined depth, reach to medullar bone from cortical bone increasing inflammatory mediators. The device was also

reported not to cause soft tissue damage while enabling remodeling process [5].

While it is not always possible to create homogenous perforations of same size using microosteoperforation methods such as round burs, Propel device which is designed in order to

osteoclast activation.

84 Current Approaches in Orthodontics

ics are applied containing more sample numbers.

**4.1. Micro-osteoperforation application techniques**

methods are used in order to create MOPs on alveolar bones.

When micro-osteoperforations are compared with several surgical techniques, which are proved to accelerate tooth movement, they are considered as more advantageous because they are less invasive with no need for removing flaps eliminating possible side effects of the surgery [4, 5]. Additionally, all techniques which make use of micro-osteoperforation do not include an invasive surgical procedure represent that they are easily applicable in the clinics by the orthodontists and can be added to clinical routine. Patients did not report any pain or discomfort in the clinical studies with micro-osteoperforations which shows that it is easily accepted and tolerated by the patients who are under orthodontic treatment [5, 64]. These advantages also enable the micro-osteoperforations to be periodically repeated until the desired results are achieved [4, 64].
