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ORIGINAL ARTICLE

apid canine retraction and orthodonticreatment with dentoalveolar distractionsteogenesis

aluk Iseri,a Reha Kisnisci,b Nurettin Bzizi,c and Hakan Tüzd

nkara, Turkey

urpose: Duration of treatment is one of the things orthodontic patients complain about most. To shortenreatment time, a new technique of rapid canine retraction through distraction osteogenesis was introduced.he effects of dentoalveolar distraction on the dentofacial structures are presented in this article. Material:he study sample consisted of 20 maxillary canines in 10 growing or adult subjects (mean age, 16.53 years;ange, 13.08-25.67 years). First premolars were extracted, the dentoalveolar distraction surgical procedureerformed, and a custom-made intraoral, rigid, tooth-borne distraction device was placed. The canines wereoved rapidly into the extraction sites in 8 to 14 days, at a rate of 0.8 mm per day. Results: Full retraction

f the canines was achieved in a mean time of 10.05 (�2.01) days. The anchorage teeth were able toithstand the retraction forces with minimal anchorage loss. The mean change in canine inclination was3.15° � 4.65°, anterior face height and mandibular plane angle increased, and overjet decreasedignificantly at the end of dentoalveolar distraction. No clinical and radiographic evidence of complications,uch as root fracture, root resorption, ankylosis, periodontal problems, and soft tissue dehiscence, wasbserved. Patients had minimal to moderate discomfort after the surgery. Conclusions: The dentoalveolaristraction technique is an innovative method that reduces overall orthodontic treatment time by nearly 50%,
ith no unfavorable effects on surrounding structures. (Am J Orthod Dentofacial Orthop 2005;127:533-41)
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istraction osteogenesis was used as early as1905 by Codivilla1 and was later popularizedby the clinical and research studies of Ilizarov2

n Russia. Distraction osteogenesis was performed inhe human mandible by Guerrero3 in 1990 and Mc-arthy et al4 in 1992. Since then, it has been applied toarious bones of the craniofacial skeleton.

Most orthodontic patients have some crowding.lthough nonextraction treatment has become popularuring the last decade, many patients do need extrac-ions.5 The first phase of treatment for premolar extrac-ion patients is distal movement of the canines. Withonventional orthodontic treatment techniques, bio-ogic tooth movement can be achieved,6,7 but theanine retraction phase usually lasts 6 to 8 months.xtraoral or intraoral anchorage mechanics are required

o maintain the space obtained during canine distaliza-

rom the School of Dentistry, University of Ankara, Ankara, Turkey.Professor and chairman, Department of Orthodontics.Professor, Department of Oral and Maxillofacial Surgery.Research assistant, Department of Orthodontics.Research assistant, Department of Oral and Maxillofacial Surgery.eprint requests to: Dr Haluk Iseri, Ankara Universitesi, Dis Hekimligiakültesi, Ortodonti Anabilim Dalı, Besevler, Ankara 06500, Turkey; e-mail,

[email protected], June 2003; revised and accepted, January 2004.889-5406/$30.00opyright © 2005 by the American Association of Orthodontists.

goi:10.1016/j.ajodo.2004.01.022

ion, particularly when maximum anchorage is re-uired. Therefore, under normal circumstances, con-entional treatment with fixed appliances is likely toast 20 to 24 months. The duration of orthodonticreatment is one of the things that orthodontic patientsomplain about most—especially adult patients. Toddress this problem, a technique of rapid canineetraction in which the concepts of distraction osteo-enesis are used has been developed: dentoalveolaristraction (DAD). In this technique, which has beenescribed and used by Is eri et al8 and Kis nisci et al,9

steotomies surrounding the canines are made tochieve rapid movement of the canines in the dentoal-eolar segment, in compliance with the principles ofistraction osteogenesis. The purpose of this study waso examine the effect of the DAD technique on dento-acial structures.

ATERIAL AND METHODS

Class I or II patients who needed orthodonticreatment with fixed appliances and tooth extractionsere selected for this study. All patients were in theermanent dentition and had moderate to severe crowd-ng or increased overjet at the start of treatment. Thetudy sample consisted of 20 maxillary canines in 10
rowing or adult subjects (6 female, 4 male). Because
533

American Journal of Orthodontics and Dentofacial OrthopedicsMay 2005

534 Iseri et al

the treatment involved surgery, only subjects aged 13years or older were included. The initial mean age was16.53 years (range, 13.08-25.67 years).

A custom-made, rigid, tooth-borne intraoral distrac-tion device was designed for DAD and rapid toothmovement (Fig 1). The device is made of stainless steeland has a distraction screw and 2 guidance bars. Thepatient or parent turns the screw clockwise with aspecial apparatus, and this moves the canine distally.

The device is placed after a surgical procedure,described below, that includes extraction of the firstpremolars. No other appliances are placed on thesecond premolars or the incisors during the distractionprocedure.

The treatment procedure was explained in detail toall patients and parents, and informed consent wasobtained before surgery. This research project wasapproved by the ethics committee at the University ofAnkara (Turkey).

Surgical procedure

Surgery was performed on an outpatient basis, withthe patient under local anesthesia, sometimes supple-mented with sedation. The procedure was describedpreviously by Kis nisci et al.9 Briefly, a horizontalmucosal incision was made parallel to the gingivalmargin of the canine and the premolar beyond the depthof the vestibule. Cortical holes were made in thealveolar bone with a small, round, carbide bur (Fig 2)from the canine to the second premolar, curving api-cally to pass 3 to 5 mm from the apex. A thin, tapered,fissure bur was used to connect the holes around theroot. Fine osteotomes were advanced in the coronaldirection. The first premolar was extracted and thebuccal bone removed between the outlined bone cut atthe distal canine region anteriorly and the secondpremolar posteriorly (Fig 2). Larger osteotomes wereused to fully mobilize the alveolar segment that in-cluded the canine by fracturing the surrounding spon-gious bone around its root off the lingual or palatalcortex. The buccal and apical bone through the extrac-tion socket and the possible bony interferences at thebuccal aspect that might be encountered during thedistraction process were eliminated or smoothed be-tween the canine and the second premolar, preservingpalatal or lingual cortical shelves. The palatal shelf waspreserved, but the apical bone near the sinus wall wasremoved, leaving the sinus membrane intact to avoidinterferences during the active distraction process. Os-teotomes along the anterior aspect of the canine wereused to split the surrounding bone around its root fromthe palatal or lingual cortex and neighboring teeth. The
transport dentoalveolar segment that includes the ca-
nine also includes the buccal cortex and the underlyingspongy bone that envelopes the canine root, leaving anintact lingual or palatinal cortical plate and the bonearound the apex of the canine.

The incision was closed with absorbable sutures,and an antibiotic and a nonsteroidal anti-inflammatorydrug were prescribed for 5 days. The surgical procedurelasted approximately 30 minutes for each canine.9

Distraction protocol and dentoalveolar distraction

For the 10 patients in the study, the distractor wascemented on the canine and the first molar immediatelyafter the surgery. To ensure that the alveolar segmentcarrying the canine was fully mobilized intraopera-tively, the device was activated several millimeters andset back to its original position.

Distraction was initiated within 3 days after sur-gery. The distractor was activated twice per day, in themorning and in the evening, for a total of 0.8 mm perday. Immediately after the canine retraction was com-pleted, fixed orthodontic appliance treatment was initi-ated, and the leveling stage was started in both dentalarches. Ligatures were placed under the archwire be-

Fig 1. Dentoalveolar distraction device in place. Canineand molar bands are fabricated, and distractor is sol-dered to bands on cast.

Fig 2. Intraoral view of surgical site. A, Corticotomy; B,extraction socket of first premolar. Dentoalveolar seg-ment will be used as transport unit to carry maxillarycanine posteriorly.

tween the distracted canine and the first molar and kept

American Journal of Orthodontics and Dentofacial OrthopedicsVolume 127, Number 5

Iseri et al 535

at least 3 months after the DAD procedure. Periapicalradiographs of the canines and first molars and pan-oramic films were taken at the start and end of thedistraction procedure to evaluate root structures. Rootresorption was evaluated with a root resorption scale,modified from Sharpe et al,10 as follows: S0 � noapical root resorption; S1 � widening of periodontalligament (PDL) space at the root apex; S2 � moderateblunting of the root apex (up to one third of the rootlength); S3 � severe blunting of the root apex (beyondone third of the root length). Pulp vitality was evaluatedand recorded with an electronic digital pulp tester. Allteeth subjected to pulp vitality test (canines, incisors,second premolars, first molars) were cleaned and testedon the buccal surfaces.

Cephalometric analysis

Lateral cephalometric films were obtained understandardized conditions (the film-focus distance was155 cm, and the distance from the midsagittal plane tofilm was 12.5 cm). Twelve anatomic reference pointswere digitized (Fig 3), and the following dentoskeletalvariables were measured: s n ss (°): the angle betweensella, nasion, and subspinale (maxillary prognathism);NSL/NL (°): nasal plane angle in relation to the anteriorcranial base; s n sm (°): mandibular prognathism;NSL/ML (°): mandibular inclination in relation to theanterior cranial base; ss n sm (°): sagittal intermaxillaryrelationship; n me (mm): upper face height; overbite(mm): vertical distance between the incisal edges of themost prominent maxillary and mandibular central inci-sors; overjet (mm): sagittal distance between the incisaledges of the most prominent maxillary and mandibularcentral incisors; NSL/can (°): canine inclination—anglebetween the long axis of the canines in relation to theanterior cranial base (NSL); NSL-is (mm): verticalposition of the maxillary incisors in relation to the NSL;NSL-ms (mm): vertical position of the maxillary firstmolars in relation to the NSL; NSLv-is (mm): sagittalposition of the maxillary incisors in relation to theNSLv; and NSLv-ms (mm): sagittal position of themaxillary first molars in relation to the NSLv.

Measurements were performed vertically from themidpoint of the incisal edge of the maxillary centralincisors and from the tip of the mesiobuccal cusp of themaxillary first molars to the NSL and NSLv referenceplanes.

Initial descriptive statistics were calculated, and thechanges obtained by DAD were evaluated statisticallywith the paired t test. The reliability of the measure-ments was examined (previously described else-
where11) according to the formula described by Win-
ner.12 The reliability of the canine inclination was alsomeasured and found to be high (r � 0.89).

RESULTS

Tables I and II show the mean rate and duration ofdistraction, mean posterior anchorage loss (NSLv-ms),and mean change in canine inclination (NSL/can). Thecanines moved into the socket of the extracted firstpremolars, in compliance with distraction osteogenesisprinciples. The distraction procedure was completed in8 to 14 days (mean, 10.05 � 2.01 days) at a rate of 0.8mm per day (Fig 4). The canines were fully retracted,and the anchorage teeth (first molars and second pre-molars) were able to withstand the retraction forces

Fig 3. Reference points and planes used in study. s,sella; n, nasion; sp, anterior nasal spine; pm, posteriornasal spine; ss, A point; is, incisal edge of maxillarycentral incisor; uct, most inferior point of maxillarycanine tubercule; uca, root apex of maxillary canine;ms, most anterior-inferior point of maxillary first molar;sm, B point; me, menton; go, gonion; NSL, s-n linerepresents anterior cranial base as horizontal referenceplane; NSLv, vertical reference plane perpendicular toNSL at s; NL, sp-pm reference line represents nasalplane; ML, me-go reference line represents mandibularplane.

with minimal anchorage loss (Fig 5). The mean sagittal


536 Iseri et al

(NSLv-ms) and vertical (NSL-ms) anchorage loss was0.19 mm and 0.51 mm, respectively, during rapiddistraction of the canines, and these were statisticallyinsignificant. The distal displacement of the canineswas mainly a combination of tipping and translation,with a mean change in canine inclination of 13.15°(�4.65°) at the end of the distraction period (Table II)(Fig 6). In addition, anterior face height (n me) andmandibular plane angle (NSL/ML) increased and over-jet decreased significantly during the distraction period(P � .05, P � .01). No significant changes wereobserved in the other measurements.

Clinical and radiographic examination showed noevidence of complications, such as root fracture, rootresorption, ankylosis, and soft tissue dehiscence, inany patient. No apical root resorption (S0) wasdetected in any subject at the start or at the end ofdentoalveolar distraction (Fig 7). Patients reportedminimal to moderate discomfort, especially duringthe first 2 days after surgery, and edema was ob-served in some patients (Fig 8).

Before the start of treatment, pulp vitality wastested with an electronic pulp tester. All teeth reactedpositivly, with the exception of a right maxillary centralincisor in a patient who had previously had root canaltherapy. At the end of the dentoalveolar distractionprocedure and during the fixed appliance orthodontictreatment, no reliable reactions to the pulp test wereachieved in the study subjects.

DISCUSSION

Orthodontic tooth movement is a process wherebythe application of a force induces bone resorption onthe pressure side and bone apposition on the tensionside.6,7 Classically, the rate of orthodontic tooth move-ment depends on the magnitude and duration of theforce,6 the number and shape of the roots, the quality ofthe bony trabecula, the patient’s response, and thepatient’s compliance. The rate of biologic tooth move-ment with optimum mechanical force is approximately1 to 1.5 mm in 4 to 5 weeks.13 Therefore, in maximum

Table I. Survey of age and duration of dentoalveolardistraction for study sample*

Mean SD Minimum Maximum

Age, start of distraction (y) 16.53 3.76 13.08 25.67Duration of distraction (d) 10.05 2.01 8 14Rate of distraction (mm/d) 0.8

SD, standard deviation.*10 subjects, 20 canines.

anchorage premolar extraction cases, canine distaliza-

tion usually takes 6 to 9 months, contributing to anoverall treatment time of 1.5 to 2 years. The duration oforthodontic treatment is one of the issues patientscomplain about most, especially adult patients.

Many attempts have been made to shorten ortho-dontic tooth movement.14-16 Liou and Huang16 reporteda rapid canine retraction technique involving distrac-tion of the PDL after extraction of the first premolars.The method was described as an innovative approach;however, refinements in the surgical technique, such asthe use of corticotomies versus full osteotomies and theapplicability of the technique to teeth close to themandibular dental nerve, were suggested.17 Is eri et al8

and Kis nisci et al9 described and clinically used a newtechnique for rapid retraction of the canines, the DAD.With this technique, horizontal and vertical osteotomiessurrounding the canines are made to achieve rapidmovement of the canines in the dentoalveolar segment,in compliance with the principles of distraction osteo-genesis.

Ten patients with Class I or II malocclusion withmoderate to severe crowding were selected for thisstudy. Two patients had Class II Division 1 malocclu-sions, and 1 had an open bite. The maxillary andmandibular canines were moved rapidly into the cavityof the extracted first premolars, following a surgicalprocedure that lasted about 30 minutes for each ca-nine.9 Vertical corticotomies were performed aroundthe root of the canine, and the spongy bone around itwas split. With this surgical technique, the dentoalveo-lus could be used as a bone transport segment for rapidposterior movement of the canines. The surgical tech-nique does not rely on streching and widening of thePDL, which prevents overloading and stress accumu-lation in the periodontal tissues. Moreover, neither thebuccal or the apical bone through the extraction site northe palatal cortical plate interfered with the movementof the canine-dentoalveolus segment during the distrac-tion procedure because of the surgical procedure andthe distal movement vector of the canine along theguidance burs of the dentoalveolar distractor throughthe extraction cavity. All patients tolerated the surgeryand the device after the surgery. Fixed applianceorthodontic treatment was started immediately after thetermination of canine distraction in all patients.18

The term physiologic tooth movement designates,primarily, the slight tipping of the tooth in its socketand, secondarily, the changes in tooth position thatoccur during and after tooth eruption.19 In fact, there isbasically no great difference between the tissue reac-tions observed in physiologic tooth movement andthose observed in orthodontic tooth movement. How-
ever, because the teeth are moved more rapidly during

ted in


Iseri et al 537

treatment, the tissue changes elicited by orthodonticforces are more marked and extensive. It has beenassumed that application of force will result in hyalin-ization caused partly by anatomic and partly by me-chanical factors.20 The hyalinization period usuallylasts 2 or 3 weeks,19 and tooth movement continues ata rate of 1 to 1.5 mm in 4 to 5 weeks.13 On the otherhand, with the custom-made, rigid, tooth-borne distrac-tion device, the canines were retracted at a rate of 0.8mm per day and moved into the socket of the extractedfirst premolars in compliance with distraction osteogen-

Table II. Dentoskeletal changes with dentoalveolar dist

Start of distract

Maxillary measurementss n ss (°) 77.58 � 4.0NSL/NL (°) 8.90 � 3.1

Mandibular measurementss n sm (°) 73.57 � 2.3NSL/ML (°) 37.94 � 5.8

Maxillo-mandibular measurementsss n sm (°) 4.10 � 2.4n me (mm) 127.00 � 8.1Overbite (mm) 3.19 � 2.0Overjet (mm) 5.83 � 4.1

Dentoalveoler measurementsNSL/can (°) 93.85 � 9.8NSL-is (mm) 84.39 � 3.8NSL-ms (mm) 72.63 � 3.6NSLv-is (mm) 101.31 � 5.4NSLv-ms (mm) 63.01 � 7.9

Data are presented as mean � SD.*P � .05; **P � .01; ***P � .001.

Fig 4. Dentoalveolar distraction of maxillary ca(case 1801). Full distraction of canines comple

esis principles. The mean distraction time was 10 days

(canines were retracted until they came into contact withthe second premolars), and the distraction procedure wascompleted in 8 to 14 days. This is the most rapidmovement of a tooth demonstrated in the literature.13,16

Although every attempt was made to achieve bodilymovement of the canines with distraction osteogenesis(the distractor was designed with 2 guidance bars andplaced as high as possible on the buccal side of theteeth), a significant amount of tipping of the canineswas observed (Table II). Therefore, the distal displace-ment of the canines was mainly a combination of

n of canines

End of distraction Difference (t test)

77.60 � 4.11 0.05 � 0.549.38 � 2.45 0.49 � 1.28

73.29 � 2.41 �0.29 � 0.6338.61 � 5.91 0.67 � 0.80*

4.65 � 2.73 0.54 � 0.97128.00 � 8.15 0.99 � 0.57**

2.71 � 1.64 �0.48 � 1.205.50 � 4.08 �0.34 � 0.44*

84.20 � 5.92 13.15 � 4.65**84.68 � 4.08 0.29 � 0.6273.14 � 3.77 0.51 � 0.93

101.31 � 5.41 �0.01 � 1.0162.82 � 7.91 0.19 � 0.31

from start to end of distraction, occlusal views11 days.

ractio

ion

81

14

3266

26203

nines

tipping and translation.


538 Iseri et al

Fig 5. Dentoalveolar distraction of maxillary molars, from start (before surgery) to end (after removalof destraction device), lateral views of 2 patients. Anchorage teeth (first molars and second
premolars) withstood retraction forces almost without anchorage loss.
Fig 6. Radiographic appearance of maxillary canines before and after dentoalveolar distraction in2 patients. Canines were retracted with combination of tipping and translation. New bone formationin distraction sites was achieved after dentoalveolar distraction during fixed appliance orthodontic
treatment.


Iseri et al 539

Full retraction of the canines was achieved, and theanchorage teeth (first molars and second premolars)were able to withstand the retraction forces with min-imal anchorage loss. The mean sagittal and verticalanchorage losses were 0.19 mm and 0.51 mm, respec-tively, during rapid distraction of the canines. In fact,the mandibular plane angle (NSL/ML) and anterior face

Fig 7. Radiographic appearance of maxillary caninesbefore and 12 months after dentoalveolar distraction(case 0700). No radiographic evidence of complica-tions, such as root fracture, root resorption, or ank-lylosis.

height (n me) were increased slightly (0.67° � 0.80°

and 0.99 � 0.57 mm, respectively), which might berelated to the insignificant amount of extrusion of themaxillary first molars (0.51 � 0.93 mm). Therefore,one should consider the vertical anchorage loss of themaxillary first molars, especially in patients with openbite or tendency to open bite treated with DAD. In apreviously published study16 demonstrating rapid ca-nine retraction with the PDL distraction technique, the

Fig 8. Extraoral view at start of DAD (top) and after 5(middle) and 9 (bottom) days. Edema was observed insome patients.

average mesial movement of the first molars was less


540 Iseri et al

than 0.5 mm in 3 weeks; however, no data regarding thevertical posterior anchorage loss were presented.

After extraction of the first premolars and rapidretraction of the canines into the socket, a significantspontaneous decrease in overjet was observed. Thismight be expected by taking into account the recentlydistracted fibrous new bone tissue just behind theincisors. Another observation of this study was rapidmovement of the lateral incisors into the newly gener-ated fibrous bone tissue after DAD. Liou et al18

demonstrated in mature beagles that the best time toinitiate tooth movement was immediately after distrac-tion, when the edentulous space is still fibrous and boneformation is just starting; they suggested that toothmovement should be initiated when the osteogenicactivity brought about by the distraction process isactive, the new bone is still fibrous, and the trabeculaenot well developed. Our clinical observations supportthe findings of that experimental study and mightprovide an example to relieve severe dental crowdingand overjet in an extremely short time. However,systematic clinical and experimental research studiesare still needed.

No clinical and radiographic evidence of complica-tions, such as root fracture, root resorption, ankylosis,and soft tissue dehiscence, was observed in any of thepatients. Although the fundamental causes of treat-ment-associated root resorption are still poorly under-stood, and the magnitude of resorption is almost unpre-dictable, an association between the duration of theapplied force and increased root resorption has beenreported.21 It is generally accepted that the best way tominimize root resorption is to complete the toothmovement in a short time. Root resorption begins 2 to3 weeks after the orthodontic force is applied and cancontinue for the duration of force application.21-23 Fullretraction of the canines with DAD occured in 8 to 14days in our study, an extremely short time for rootresorption to begin.

Although no meaningful findings were achievedwith the electronic pulp tester, we still think that thedistracted canines preserved their pulp vitality at theend of dentoalveolar distraction. The pulp-vitality testis not a reliable technique when performed duringorthodontic tooth movement.16 Moreover, no colorchange was observed in any teeth during the observa-tion period of this study. Block et al24 demonstratedthat the inferior alveolar nerve and blood vesselsregenerate a short time after mandibular distraction.Findings of our study indicate that the distal movementof the canines is a combination of tipping and transla-tion. This means that the crown moves more than the
root apex, and, similar to the neurovascular bundle in
mandibular distraction, the pulp tissues of the teeth willremain vital under controlled rapid stretching. There-fore, observed tipping of the canines might be anadvantage with regard to pulp vitality during rapidtooth movement with DAD. However, further investi-gation of pulp vitality is needed in patients subjected torapid tooth movement with dentoalveolar distraction.

CONCLUSIONS

Distraction osteogenesis for rapid orthodontic toothmovement is a promising technique. With DAD, ca-nines can be fully retracted in 8 to 14 days. Thefollowing older adolescent and adult patients couldbenefit from the technique: those with complianceproblems; those with moderate or severe crowding;those with Class II malocclusions with overjet; thosewith bimaxillary dental protrusion; orthognathic sur-gery patients who need dental decompensation; andthose with small root-shape malformations, short roots,periodontal problems, or ankylosed teeth. With theDAD technique, anchorage teeth can withstand theretraction forces with no anchorage loss and withoutclinical or radiographic evidence of complications,such as root fracture, root resorption, ankylosis, perio-dontal problems, and soft tissue dehiscence. The DADtechnique reduces orthodontic treatment duration by 6to 9 months in patients who need extraction, with noneed for an extraoral or intraoral anchorage devices andwith not unfavorable short-term effects in the periodon-tal tissues and surrounding structures.

REFERENCES

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3. Guerrero C. Expansion mandibular quirurgica. Rev Venez Ortod1990;1-2:48-50.

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6. Reitan K. Clinical and histological observations on tooth move-ment during and after orthodontic treatment. Am J Orthod1967;53:721-45.

7. Rygh P. Elimination of hyalinized periodontal tissues associatedwith orthodontic tooth movement. Scand J Dent Res 1974;80:57-73.

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9. Kisnisci R, Iseri H, Tüz H, Altug A. Dentoalveolar distractionosteogenesis for rapid orthodontic canine retraction. J Oral
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11. Arat M, Iseri H. Orthodontic and orthopaedic approach in thetreatment of skeletal open bite. Eur J Orthod 1992;14:207-15.

12. Winner BJ. Statistical principles in experimental design. NewYork: McGraw Hill; 1971.

13. Pilon JJGM, Kuijpersa-Jagtman AM, Maltha JC. Magnitude oforthodontic forces and rate of bodily tooth movement, anexperimental study in beagle dogs. Am J Orthod DentofacialOrthop 1996;110:16-23.

14. Davidovitch Z, Finkelson MD, Steigman S, Shanfield FL, Mont-gomery PC, Korostaff E. Electric currents, bone remodeling andorthodontic tooth movement. I. The effect of electric currents onperiodontal cyclic nucleotides. Am J Orthod 1980;77:14-32.

15. Davidovitch Z, Finkelson MD, Steigman S, Shanfield FL, Mont-gomery PC, Korostaff E. Electric currents, bone remodeling andorthodontic tooth movement. II. Increase in rate of tooth move-ment and periodontal cyclic nucleotide levels by combined forceand electric currents. Am J Orthod 1980;77:33-47.

16. Liou EJW, Huang CS. Rapid canine retraction through distrac-tion of the periodontal ligament. Am J Orthod Dentofacial

17. Figuera AA, Polley JW. Discussion. Am J Orthod DentofacialOrthop 1998;114:381-2.

18. Liou EJW, Figueroa AA, Polley JW. Rapid orthodontic toothmovement into newly distracted bone after mandibular distrac-tion osteogenesis in a canine model. Am J Orthod DentofacialOrthop 2000;117:391-8.

19. Reitan K. Initial tissue behaviour during apical root resorption.Angle Orthod 1974;44:68-82.

20. Reitan K. Biomechanical principles and reactions. In: GraberTM, Swain BF, editors. Current principles and techniques. SaintLouis: C.V. Mosby; 1985. p. 108-23.

21. Reitan K. Tissue behavior during orthodontic tooth movement.Am J Orthod 1960;46:881-900.

22. Williams S. A histomorphometric study of orthodontically in-duced root resorption. Eur J Orthod 1984;6:35-47.

23. Kurol J, Owman-Moll P, Lundgren D. Time-related root resorp-tion after application of a controlled continuous orthodonticforce. Am J Orthod Dentofacial Orthop 1996;110:303-10.

24. Block MS, Daire J, Stover J, Matthews M. Changes in theinferior alveolar nerve following mandibular lengthening in thedog using distraction osteogenesis. J Oral Maxillofac Surg

Orthop 1998;114:372-81. 1993;52:652-60.

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Pi is 0889540604010029