Citation
Effect of Acceledent Aura on Orthodontic Tooth Movement with Aligners

Material Information

Title:
Effect of Acceledent Aura on Orthodontic Tooth Movement with Aligners a Pilot Study
Creator:
Mazzuoccolo, Aylin M
Place of Publication:
[Gainesville, Fla.]
Florida
Publisher:
University of Florida
Publication Date:
Language:
english
Physical Description:
1 online resource (55 p.)

Thesis/Dissertation Information

Degree:
Master's ( M.S.)
Degree Grantor:
University of Florida
Degree Disciplines:
Dental Sciences
Dentistry
Committee Chair:
WHEELER,TIMOTHY T
Committee Co-Chair:
MCGORRAY,SUSAN P
Committee Members:
RODY,WELLINGTON JOSE,JR
Graduation Date:
5/2/2015

Subjects

Subjects / Keywords:
Biological markers ( jstor )
Bones ( jstor )
Descriptive statistics ( jstor )
Gingival crevicular fluid ( jstor )
Orthodontics ( jstor )
Orthods ( jstor )
Osteoclasts ( jstor )
Teeth ( jstor )
Tooth movement ( jstor )
Vibration ( jstor )
Dentistry -- Dissertations, Academic -- UF
orthodontics
Genre:
bibliography ( marcgt )
theses ( marcgt )
government publication (state, provincial, terriorial, dependent) ( marcgt )
born-digital ( sobekcm )
Electronic Thesis or Dissertation
Dental Sciences thesis, M.S.

Notes

Abstract:
There are many variables that affect the rate of tooth movement. Preliminary data showed that the rate of tooth movement may be affected by variables such as age, sex, alveolar bone levels, tooth root length and alveolar bone quality. Our previous studies have shown, using two different force levels, that on average, only 55-60% of the attempted tooth movement could be achieved with aligners. The purpose of this pilot study was to establish appropriate methodology and to calibrate researchers in preparation of commencing the full clinical trial, which examines the amount of tooth movement achieved over time between subjects using a pulsation device known as AcceleDent Aura with those not using the device in conjunction with aligner treatment. During the pilot study, a total of 6 subjects were randomized to receive either the active device (n=3) or the sham device (n=3). Subjects were delivered 2 aligners over 4 weeks, with each aligner activated 0.5mm for a total movement of 1mm. Subjects were instructed to use the device daily for 20 minutes. Gingival crevicular fluid was collected at various time points to allow for analysis of biomarkers, cone beam CT was used to assess root length, bone levels, and bone quality, and 3Shape Trios digital impression scans were collected to allow for analysis of tooth movement. The accuracy and reliability of calculating tooth movement via Ortho Insight 3D software was confirmed with reliability measures ranging from 75% for initial time points up to 96% for later time points. GCF results suggested skewed distributions for IL-8, MMP-9, and osteocalcin. Symmetric distributions were noted for biomarkers RANKL, osteopontin, IL-6, MMP-3, M-CSF, and IFN-y, however, no trends in increasing or decreasing values were seen. Trends were noted for IL-1B, IL-1Ra, and OPG, which would support the literature regarding these biomarkers. Further analysis of these biomarkers will be conducted in the main study. Therefore, the primary objective of calibration of methods and procedures and assessing study feasibility prior to commencing the full study was achieved. ( en )
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis:
Thesis (M.S.)--University of Florida, 2015.
Local:
Adviser: WHEELER,TIMOTHY T.
Local:
Co-adviser: MCGORRAY,SUSAN P.
Electronic Access:
RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2016-05-31
Statement of Responsibility:
by Aylin M Mazzuoccolo.

Record Information

Source Institution:
UFRGP
Rights Management:
Applicable rights reserved.
Embargo Date:
5/31/2016
Classification:
LD1780 2015 ( lcc )

Downloads

This item has the following downloads:


Full Text

PAGE 1

EFFECT OF A CCELEDENT ® AURA ON ORTHODONTIC TOOTH MOVEMENT WITH ALIGNERS: A PILOT STUDY By AYLIN M. MAZZUOCCOLO A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMEN TS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2015

PAGE 2

© 2015 Aylin M. Mazzuoccolo

PAGE 3

To my husband and family for their endless encouragement

PAGE 4

4 ACKNOWLEDGMENTS T hank you t o my mentors, Dr. Ti mothy Wheeler, Dr. Wellington Rody, and Dr. Susan P. McGorray for your support and guidance through this process. Thank you t o my husband and family for your encouragement throughout dental school and residency . Additionally, t hank you to my all my residen cy instructors for your support and assistance throughout these past three years.

PAGE 5

5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 6 LIST OF FIGURES ................................ ................................ ................................ .......... 8 LIST OF ABBREVIATIONS ................................ ................................ ............................. 9 ABSTRACT ................................ ................................ ................................ ................... 10 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 12 Biology of Orthodontic Tooth Movement ................................ ................................ . 12 Forces Involved in OTM ................................ ................................ .......................... 14 Aligners and Tooth Move ment ................................ ................................ ................ 14 Pulsation and OTM ................................ ................................ ................................ . 16 Tooth Movement Model ................................ ................................ .......................... 17 Biomarker anal ysis in gingival crevicular fluid (GCF) ................................ .............. 17 2 MATERIALS AND METHODS ................................ ................................ ................ 19 Study Design ................................ ................................ ................................ .......... 19 Enrollment and Study Participation ................................ ................................ ......... 19 Collection of Data ................................ ................................ ................................ ... 21 Clinical Tooth Movement ................................ ................................ .................. 21 GCF Sampling ................................ ................................ ................................ .. 22 Bead based Immunoassay ................................ ................................ ............... 22 Statistical Analysis ................................ ................................ ................................ .. 24 3 RESULTS ................................ ................................ ................................ ............... 30 4 DISCUSSION ................................ ................................ ................................ ......... 43 5 CONCLUSIONS ................................ ................................ ................................ ..... 48 LIST OF REFERENCES ................................ ................................ ............................... 49 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 55

PAGE 6

6 LIST OF TABLES Table page 2 1 Outline of Inclusion and Exclusion Criteria. ................................ ........................ 25 2 2 Schedule of Pilot Study Events. ................................ ................................ .......... 26 3 1 Demographics of Subjects. ................................ ................................ ................. 35 3 2 Age of Subjects. ................................ ................................ ................................ . 35 3 3 Mean Tooth Movement (mm) Observed per Time point. ................................ .... 35 3 4 Cumulative Tooth Movement (mm) Observed for Sham Device. ........................ 35 3 5 Cumulative Tooth Movement (mm) Observed for Active Device. ....................... 35 3 6 P earson Correlation Coefficients to Correlate Tooth Movement over Time. ....... 36 3 7 Summary Statistics for IL 1 (pg/mL). ................................ ................................ . 36 3 8 Summary Statistics for IL 1Ra (pg/mL). ................................ .............................. 36 3 9 Summary Statistics for IL 1Ra) (pg/mL). ................................ ..... 37 3 1 0 Summary Statistics for RANKL (pg/mL). ................................ ............................ 37 3 11 Summary Statistics for OPG (pg/mL). ................................ ................................ 37 3 12 Summary Statistics for RANKL/ (RANKL + OPG) (pg/mL). ................................ 38 3 13 Summary Statistics for Osteocalcin (pg/mL). ................................ ...................... 38 3 14 Summary Statisti cs for Osteopontin (pg/mL). ................................ ..................... 38 3 15 Summary Statistics for IL 6 (pg/mL). ................................ ................................ .. 39 3 16 Summary Statistics for IL 8 (pg/mL). ................................ ................................ .. 39 3 17 Summary Statistics for MMP 3 (pg/mL). ................................ ............................. 39 3 18 Summary Statistics for MMP 9 (pg/mL). ................................ ............................. 40 3 19 Summary Statistics for M CSF (pg/mL). ................................ ............................. 40 3 20 Summary Statistics for IFN (pg/mL). ................................ ................................ 40

PAGE 7

7 3 21 Difference in Duplicated Measures to Determine Reliability of Measurement for Day 14. ................................ ................................ ................................ .......... 41 3 22 Difference in Duplicated Measures to Determine Reliability of Measurement for Day 28. ................................ ................................ ................................ .......... 41 3 23 Difference in Duplicated Measures to Determine Reliability of Measurement for Day 42. ................................ ................................ ................................ .......... 41 3 24 Difference in Duplicated Measures to Determine Reliability of Measurement for Day 56. ................................ ................................ ................................ .......... 41 3 25 Difference in Duplicated Measures to Determine Reliability of Measurement for Day 70. ................................ ................................ ................................ .......... 42 3 26 Difference in Duplicated Measures to Determine Reliability of Measurement for Day 84. ................................ ................................ ................................ .......... 42

PAGE 8

8 LIST OF FIGURES Figure page 2 1 AcceleDent® Aura Device ................................ ................................ .................. 27 2 2 Pilot Study Desig n Flow Diagram ................................ ................................ ....... 27 2 3 Identification of 3D Orthogonal Planes on Ortho Insight 3D. .............................. 28 2 4 Distance between Time P oints Calculated on Ortho Insight 3D ......................... 28 2 5 ................................ ................................ ................................ ................ 29 3 1 Mean Tooth Movement (mm) per Time point. ................................ .................... 42

PAGE 9

9 LIST OF ABBREVIATIONS AP Anterior Posterior CBCT Cone Beam Computed Tomography GCF Gingival Crevicular Fluid IFN Interferon Gamma IL Interleukin I L 1Ra Interleukin 1 Receptor Antagonist IRB Institutional Review Board M CSF Macrophage Colony Stimulating Factor MMP Matrix Metalloproteinase OPG Osteoprotegerin OTM Orthodontic Tooth Movement PDL Periodontal Ligament RANK Receptor Activat or of Nuclear Factor Kappa B RANKL Receptor Activator of Nuclear Factor Kappa B Ligand TNF Tumor Necrosis Factor Alpha VAS Visual Analogue Scale

PAGE 10

10 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science EFFECT OF ACCELED ENT ® AURA ON ORTHODONTIC TOOTH MOVEMENT WITH ALIGNERS: A PILOT STUDY By Aylin M. Mazzuoccolo May 2015 Chair: Timothy T. Wheeler Major: Dental Sciences Orthodontics There are many variables that affect the rate of tooth movement. Preliminary data sho wed that the rate of tooth movement may be affected by variabl es such as age, sex, alveolar bone levels, tooth root length and alveolar bone quality. Our previous studies have shown, using two different force levels, that on average, only 55 60% of the att empted tooth movement could be achieved with aligners . The purpose of this pilot study was to establish appropriate methodology and to calibra te researchers in preparation of commencing the full clinical trial, which examines the amount of tooth movement achieved over time between subjects using a puls ation device known as AcceleDent ® Aura with those not using the device in conjunction with aligner treatment . During the pilot study, a total of 6 subjects were randomized to receive either the active device (n=3) or the sham device (n=3). Subjects were delivered 2 aligners over 4 weeks, with each aligner activated 0.5mm for a total movement of 1mm. Subjects were instructed to use the device daily for 20 minutes. Gingival crevicular fluid was collected at various time points to allow for analysis of biomarkers, cone beam CT was used to assess root length, bone levels, and bone quality, and 3Shape Trios ® digital impression scans were collected to allow for anal ysis of tooth movement. The accuracy and

PAGE 11

11 reliab ility of calculating tooth movement via Ortho Insight 3D software was confirmed with reliability measures ranging from 75% for initial time points up to 96% for later time points . GCF results suggested skewed distributions for IL 8, MMP 9, and osteocalcin . Symmetric distributions were noted for biomarkers RANKL, osteopontin, IL 6, MMP 3, M CSF, and IFN , however , no trends in inc reasing or decreasing values were seen. Trends were noted for IL 1 , IL 1Ra , and OPG , which would support the literature regarding these biomarkers. Further analysis of these biomarkers will be conducted in the main study. T h e refore, the primary objective of calibration of method s and procedures and assessing study feasibility prior to commencing the full study was achieved .

PAGE 12

12 CHAPTER 1 INTRODUCTION Biology of Orthodontic Tooth Movement Orthodontic tooth movement (OTM) invol ves a sophisticated system of cellular mechanisms which ultimately control the rate at which teeth move. To understand the nature of OTM, first an understanding of the basis of bone remodeling must be acknowledged. Numerous literature reviews have been c ompiled to describe this topic in full detail 1 4 . Bone is a dynamic tissue, constantly undergoing remodeling and turnover to maintain integrity and strength, with an estimated 10% of bone material being replaced per year 5 . Osteoclasts, responsible for bone resorption, and osteoblasts, sp ecialized in bone formation, are the main two cellular components involved in bone remodeling and it is the interaction and communication between the two that allows bone remodeling to proceed. Orthodontic forces applied to teeth trigger cellular events t o promote bone remodeling, through the coupling of bone resorption and bone regeneration, allowing for OTM to occur 6 . With the application of orthodontic forces, an immediate strain is placed on the tooth su pporting tissues, with areas of compression and tension resulting. These strains on the periodontal ligament (PDL) result in changes in the vascularity and blood flow within the PDL, which results in a cascade of cellular components arriving to the area 7 , an increase in inflammation, and ultimately producing areas of resorption on the compression side and bone formation on the tension side 4 . The process of resorption begins with o st eoclastogenesi s, or the development of osteoclasts, through macrophage colony stimulating factor (M CSF) and the interaction of receptor activator of nuclear factor K B (RANK) and its ligand, RANKL. M CSF is

PAGE 13

13 required for the proliferation and differentiation of hematopo ietic stem cells of monocytic lineage into osteoclasts 8 and the lack of M CSF results in the absence of osteoclasts 9 . RANK on the membrane of pre osteoclasts binds to RANKL , thereby promoting osteoclast differentiation and maturation 3 . Therefore, RANKL , produced by osteoblasts, is also necessary for osteoclast differentiation. RANKL expression by bone lining cells is enhanced in the presence of various pro inflammatory cytokines including interl eukin (IL) 1 , IL 6 , IL 8 , thereby stimulating increased bone resorption 7 , 10 . Furthermore, osteoprotegerin (OPG), a competitive decoy receptor of RANK, binds to RANKL preventing the interaction between RANK and RANKL, and thereby resulting in a decrease of activated osteoclasts and subsequently decreased bone resorption 11 . By analyzing the ratio of RANKL to OPG, a determination of the extent of bone remodeling can be elucidated . Likewise, by comparing levels of various other bioma rker s of tooth movement, clinical findings may be supported by biologic results. Additional biomarkers used for such analysis include but are not limited to osteocalcin, which is secreted by osteoblasts and is an indicator of bone mineralization 12 , osteopontin, a structural protein that anchors osteoclasts to the bone matrix and is thereby an indicator of bone resorption 13 , and proteins of the matrix metalloproteinase family (MMPs), which not only degrade collagen and extracellular matrices, but also play a role in facilitating migration of osteoclasts toward sites of resorption 14 . The ensuing changes in bone metabolism after application of force thereby results in clinical o rthodontic tooth movement . OTM subsequently occurs in three phases; the initial phase where the tooth begins to move as the PDL space

PAGE 14

14 compresses, the lag phase where little to no tooth movement occurs as areas of hyalinization are removed, and the post lag phase, where tooth movement increases substantially 15 . These phases can be attributed to the cellular mechanisms simultaneously in process. Forces Involved in OTM Various attempts at determining the ideal orthodontic force to achieve optimum OTM without adverse effects on the tooth, surrounding tissues, and overall patient comfort have been conducted 16 . While it is generally accepted that light forces are more preferred over heavy forces, the precise range of what constitutes light versus heavy is controversial. Force l evels ranging from 18 1500cN have been reported in the literature 16 . Light forces tend to result in a more controllable and continuous movement as opposed to heavy forces, which produce larger areas of tissue necrosis resulting in increased regions of hyalinization subsequently showing an increased lag phase and an overall less desirable bone resorption process 15 , 17 . Due to the variability of tooth movements, tooth morphology, and patient specific variability including but not limited to changes in the center of resistance dependent on alveolar bone levels, an optimal force level is difficult and nearly impossible to determine 16 . Aligners and Tooth Movement Clear thermoplastic aligners to move teeth are available from several companies including Sp ecialty Appliances (Clear Image ® and AOA ( Red, White & Blue ® , Simpli 5 , Insignia Dentsply (MTM ® , an d Align Technology (Invisalign ® , Invisalign Teen ® , Invisalign Assist ® , Invisalign ® Exp ress 10, and Invisalign ® Express 5). Collectively, t hese systems for tooth movement utilize a

PAGE 15

15 series of clear aligners to facilitate tooth movement made from a polymeric material. By providing an esthetic alternative to traditional fixed appliances, alig ners have become a popular option by patients requesting orthodontic treatment. Additionally, aligner treatment has been attributed to a decreased risk of decay and periodontal disease, and thus may be an alternative treatment for patients with past perio dontal disease 18 . The aligners function optimall y by produc ing tooth movements in an anter oposterior (AP) direction and transverse dimension 19 . However, m any subjects who begin clear aligner treatment deviate from the programmed progression of aligners and require reevaluation, midcourse correction, and/or use of fixed applian ces to achieve treatment goals. Kravitz et al. 20 r eviewed results of 37 patients with a total of 401 teeth treated with clear aligners and compared predicted tooth movement to achieved tooth movement. The mean accuracy over all types of movement was only 41%. However, technology and techniques have improves since this study was conducted in 2009. I ncreasing the amount of tooth movement achieved is there fore a goal of aligner research and treatment. The general prescribed wear time to allow for aligner expression of the prescribed tooth movement is a twenty two hour interval per day for two weeks 21 . The majority of tooth movement prescribed has been shown to occur withi n the first week of aligner wear, however, there is still debate as to whether the second week will result in an increase in the tooth movement prescribed 18 , 22 . A randomized controlled clinical trial performed at UF in 2009 22 studied the effects and efficiency of OTM by inserting a fr esh aligner with the same prescription after one week of wear, replacing the previously worn aligner. The results showed that there is no added benefit of placing a fresh

PAGE 16

16 aligner with the same prescription after one week of wear instead of utilizing the same aligner for the two we ek period. This finding suggests that material fatigue and deactivation is not a rate limiting factor in the event of tooth movement. Pulsation and OTM Various methods of modulating bone architecture have been demonstrated to accelerate bone repair including low intensity pulsed electromagnetic fields, ultrasound, and mechanical loading 23 . Low level, high frequency strains on bone mass have been demonstrated to be anabolic to bone tissues 24 . Animal studies have shown that low magnitude high frequency strains, made through vibrations, can enhance bone formation in weight bearing areas of the skeletal frame work 24 , 25 . Whole body vibration for 2 minutes per day has been demonstrated to increase bone mass in the axia l skeleton in young women with low bone mass density 26 . Ultrasound has been used for the treatment of long bone fractures, resulting in increased angiogenesis 27 , increased blood flow velocity 28 , and increased protein synthesis in fibroblasts 29 . High frequency cyclic forces, both compressive and tensile, have shown to induce growth in c ranial sutures by increasing genes and gene products responsible for growth 30 . The application of resonance vibration in the rat model has shown to result in acceleration in OTM 31 , 32 , through heightened RANKL, thereby signifying increased osteoclast expression in the PDL 32 . The increase in RANKL expression is largely accredite d to the reaction of osteocytes, terminally differentiated osteoblasts embedded in a boney matrix during bone formation 33 . During vibration, bone microdamage triggers mechanoreceptors of osteocytes and sub sequentl y results in the amplification of RANKL 34 , 35 . In addition to enhanced rates of OTM , no subseque nt increase in periodontal damage, including root resorption, was shown in the rat model 32 .

PAGE 17

17 The AcceleDent ® Aura system (Figure 2 1) is a removable, handhel d device that delivers pulsating, low magnitude forces to the dentition in conjunction with both fixed and removable or thodontic treatment (OrthoAccel ® Technologies, Inc, Houston, TX). The patient bites on a mouthpiece after activating the device, which t hen delivers the vibration forces to the dentition. By utilizing the device for 20 minutes per day, OTM has been demonstrated to accelerate by stimulation of the PDL 36 , while simultaneously showing no increased risk of root resorption 37 . Therefore, this device may be a promising addition to the orthodontic armamentarium. However, there exists a lack of randomiz ed control trials on AcceleDent ® Aura in conjunction with aligner treatment , and consequently its clin ical significance cannot be fully understood at this time. Tooth Movement Model The human tooth movement model was initially developed in a 2005 study conducted at the University of Florida and previously described 22 , 38 . In the model, the movement of one anterior incisor is observed over time using intraoral digital scans of the teeth. Amount of tooth moveme nt of the one tooth is then determined by superi mposition on non moving teeth. While there were no significant results to report from this initial study, various observations regarding OTM and aligners were noted. These included an increased rate of OTM was observed during the first week of aligner wear, the full prescription of tooth movement of the aligners was not expressed, age of subjects had a positive correlation with OTM, and among individuals, OTM varied markedly 38 . Biomarker analysis in gingival crevicular fluid (GCF) Gingival crevicular fluid (GCF) is a serum transudate found in the gingival sulcus that can be collected at the gingival margin or wit hin the crevice of targeted teeth 39 , 40 .

PAGE 18

18 T he site specific nature of GCF, as opposed to saliva, means that it has great potential in containing factors which are specific for the periodontal tissues and may therefore be of diagnostic value to monitor bone remodeling and inflammation during OTM 41 , 42 . With over 100 biomarkers detectable in GCF, GCF analysis may provide a means of correlating protein expression to biologic processes and therefore offer biologic support to ba ck up clinical findings. P revious studies have shown that a variety of substances involved in OTM are diffused into the GCF including but not limited to RANKL 43 , 44 , OPG 43 , 44 , IL 1 45 , 46 , IL 1 Receptor antagonist (Ra) 46 , 47 , interferon (IFN) 48 50 , and M MPs 51 , 52 . Therefore, as soon as an association between clinical measures and biomarker levels in the GCF is established, the clinician may be able to manage orthodontic appliances and forces based on individual tissue responses in order to reduce the length of the orthodontic treatment without adverse side effects. We will be including this analysis to explore the possibility of identifying biomarkers in the GCF. Clinical Significance The number of patients seeking orthodontic treatment is increasing, with a large percentage of the increase coming from an adult population. There is little evidence of the ef fects of pulsation on OTM in association with aligner treatment . By understanding the benefits or limitations of pulsation as an adjuvant to orthodontic treatment, perhaps treatment with aligners may become more efficient, acceleration in OTM may occur, a nd overall orthodontic t reatment time may be shortened. Therefore the purpose of the present study was to calibrate study staff and person ne l , in addition to assessing the feasibility of the overall study, in preparation for a full cohort study investigat ing the effect of AcceleDent ® Aura on the rate of orthodontic tooth movement.

PAGE 19

19 CHAPTER 2 MATERIALS AND METHODS Study Design The design of the pilot study wa s modeled off of previous studies conducted by the same principal investigator (TTW) 22 , 38 , 53 . IRB approval was obtained to conduct a single center clin ical trial at the University of Florida Research Orthodontic Clinic. Participating subjects were between and including the ages of 18 40 who had need and intention to undergo orthodontic treatment. A preliminary sample of 6 subjects was randomized to rec eive align er treatment for 4 weeks with subject s receiving 2 aligners, each activated 0.5mm for a total anterior movement of 1.0mm as shown in Figure 2 1 . The first group of 3 subjects received aligner treatment in conjunction with the active AcceleDent ® Aura device whereas the second group of 3 subjects receive d aligner treatment along with a sham AcceleDent ® Aura device. Subjects were blinded to which device they received. Enrollment and Study Participation Participants were initially telephone scre ened and then scheduled for two preliminary screening visits. Inclusion and exclusion criteria, as outlined in Table 2 1, were utilized for subject selection. Preliminary Visit 1 was the Eligibility Visit, and was conducted to identify potential subjects with appropriate malocclusions and the correct number of maxillary teeth and to eliminate those with exclusionary medical conditions or intraoral problems. The subjects reviewed and signed the informed consent and study staff collected and reviewed medic al history and completed an intraoral clinical examination. Participants who were determined to be eligible based on this preliminary visit then proceeded with Preliminary Visit 2 : Screening Visit. The Screening Visit was

PAGE 20

20 used to fully determine a subjec completed: 3Shape Trios ® digital impression scans for preparation of aligners, intraoral and extraoral photographs, cone beam computed tomog raphy radiograph (CBCT), and gingival crevicular fluid (GCF) colle ction. A CBCT is a customary practice for orthodontic records at the University of Florida and was used for diagnostic purposes tudy . All women participating in the study were required to undergo a negative urine pregnancy test immediately prior to the imaging procedure. The principal investigator reviewed all subject information to confirm subject eligibility and once confirmed, subjects were assigned a study number and enrolled in the pilot study. Once the subject was accepted into the trial and the digital impression scan obtained, the right or left maxillary central incisor was selected as the target tooth. The selection w as based on the tar get tooth not being blocked by adjacent teeth to allow 1.0mm of anterior posterior movement. The initial digital impression scan was converted to a .stl file, which was then opened in 3Shape OrthoAnalyzer . After preparing each model, the target tooth was selected and moved digitally the prescribed amount of 0.50mm per aligner, for a total movement of 1mm over 2 aligners. Aligner fabrication was then completed by NorthStar Orthodontics, Inc. (Park Rapids, MN). Participants were info rmed that they were participating in a study utilizing a device that applies a mild vibration to the teeth to see if this would result in the teeth moving faster. Participants were told that two levels of vibration were being tested, one so slight that th ey might not feel the vibration. Sham devices with identical appearance

PAGE 21

21 and function, but without vibration, were used to blind the subjects and to serve as the control . Subjects were instructed to wear the aligners full time except for when eating, drin king, or brushing their teeth. They were also instructed to use their device daily for 20 consecutive minutes , and were asked to complete a daily diary recording the amount of time aligners were not worn each day, the start and stop time of the device usa ge, Visual Analogue Scale (VAS) pain index before and after device use, and medication usage. far along the line, in millimeters, the subject made their mark. Subjects were seen weekly where new digital impression scans and photos were taken, diaries were examined, collected, and new weekly diaries dispensed, and periodically, GCF collected. A summa ry of procedures and data collected at each study visit is outlined in Table 2 2. After completion of the pilot study, participant s were given the opportunity to continue with routine orthodontic treatment in the University of Florida Faculty Orthodonti c Clinic with the principal investigator (TTW). Collection of Data Clinical Tooth Movement Tooth movement was evaluated with weekly intraoral scans using a 3Shape Trios ® digital scanner at Days 7, 14, 21, and 28. Digital models were then imported into 3Shape OrthoAnalyzer and finally, Ortho Insight 3D. Anterio r posterior movement of the target tooth was measured by using the digital models and superimposing on posterior teeth. Using the Ortho Insight 3D software, three orthogonal reference planes wer e created from consistent posterior landmarks and used to determine the position of

PAGE 22

22 t he target tooth (Figure 2 2 ). The distance moved between time points was found by subtracting the position of the follow up scan from the previous scan (Figure 2 3). Thi s was done for each dimension. To find how much of the attempted movement was achieved, the ac tual movement vector is projected on the attempted movement vector onto attempted movement ) (Figure 2 4 ). The percent movement achieved was then calculated using the equation . GCF Sampling Samples of GCF were collected from the mesiofacial and distofacial surfaces of the target tooth at five time points: Preliminary Visit 2 (baseline 1), Day 0 (baseline 2), Day 7, Day 21, and Day 28 (study completion). GCF protocol followed previous studies by investigator WJR 42 , 46 . Prior to GCF collection, the target tooth was gently air dried and cotton roll isolated from saliva. GCF was collected with paper strips (Periopaper, Oraflow Inc, Plainview, NY) inserted for 60 seconds into the gingival sulcus at both the mesiofacial and distofacial of the target tooth. The fluid volume collected was immediately measured by a Periotron ® 8000 and then sealed in separate e ppendorf tubes and frozen at 80 o C. Bead based Immunoassay 100 µ l of phosphate buffered saline (PBS) was added to the Eppendorf tubes, which were then allowed to thaw at room temperature for approximately 30 minutes. The tubes were vortexed for 15 minutes and centri fuged for 10 minutes (1500 g, 40 o C) to elute proteins from the strip. Supernatant samples were analyzed using a multi analyte method by means of magnetic bead arrays, where specific antibod ies are

PAGE 23

23 coated onto microspheres sample of interest . In this study, four commercially available human magnetic bead based assays were customized to identify a panel of twelve biomarkers in GCF as follows: 1) A multiplex array for M CS F, IL 8, IL 16, IFN , IL 1 , MMP 3, MMP 9 and osteopontin (R&D systems, Minneapolis, MN), 2) A single plex kit for RANKL ( R&D systems, Minneapolis, MN , 3 ) A single plex assay for IL 1Ra ( R&D systems, Minneapolis, MN ), and 4) a multiplex kit for OPG and osteocalcin (EMD Mill ipore, Chicago IL). The a ssays were performed in 96 well . Briefly, microsphere beads coated with antibodies against the different target an alytes were added to the wells. Samples and standards were pipett ed into the wells and incubated overnight at 4°C. The wells were washed using a hand held magnet device. The plates were allowed to rest on the magnet for 60 seconds to allow complete settling of the magnetic beads. W ell contents were removed by gently decanting the plate in an appropriate waste receptacle and gently tapping on absorbent pads to remove residual liquid . A mixture of detection antib odies was added into each well. After incubation for 30 minutes, streptavidin conjugated to the fluorescent protein, R phycoerythrin (streptavidin RPE) was added to the beads and incubated for 30 min. After washing to remove the unbound reagents, sheath fluid (Luminex ® , MiraiBio, Alameda, CA) was added to the wells and the beads were resuspended on a plate sha ker for 5 minutes. Data were acquired with the use of instrumentation (Luminex ® 2 00TM, Millipore) and analyzed with software ( Xponen t software, Millipore Corporation ) using a 5 parameter logistic or spline curve fitting method for calculating cytokine/che mokines concentrations in samples . Concentrations are reported as pg/mL .

PAGE 24

24 Statistical Analysis Due to the nature of the pilot study, with a small sample size and therefore small statistical power, limited statistical analysis was completed. Descriptive st atistics were conducted along with two sample t tests with a p value less than 0.05 to analysis statistical significance for demographics and tooth movement between devices. Pearson correlation coefficients to examine the pattern of correlation of tooth m ovement over time were also conducted . Reliability coefficient test s were performed to determine the dependability of the procedure used to measure the amount of tooth movement , with scores over 0.90 indicated a high reliability . Descriptive statistics w ere also use d to assess consistency and trends with in the GCF data, and preliminary Wilcoxon two sample tests were used to assess any differences within the biomarkers between groups.

PAGE 25

25 Table 2 1. Outline of Inclusion and E xclu sion C riteria . Inclusion criteria 1. Males or females between and including the ages of 18 and 40 years old, desiring orthodontic treatment that could be completed within two years of treatment with either fixed appliances or aligner treatment. Subjects may have ha d previous orthodo ntic procedures . 2. Adult dentition with all upper anterior teeth present and any premolar and molar combination in the upper posterior of two teeth on each side . 3. At least one maxillary cent ral incisor that is positioned to allow anterio posterior (AP) moveme nt (crown tipping only) of 1.0mm. 4. Normal pulp vitality and healthy periodontal tissues as determined by intraoral exam ination . 5. Good health as determined by medical history. 6. Willingness and ability to comply with study procedures, attend study visits, and complete the study. 7. The ability to understand and sign a written informed consent form, which must be signed prior to initiation of study procedures. Exclusion Criteria 1. Severe malocclusions that would take longer than 2 years of treatment or require surgi cal intervention. 2. Significant periodontal disease (>3mm pocket depth or >1mm of recession on maxillary anterior teeth). 3. Active dental disease not under care of either a dentist or periodontist. 4. Chronic daily use of any nonsteroidal anti inflammatory medica tion, estrogen, calcitonin, or corticosteroids. 5. History of use or current use of any bisphosphonate medication or other medication for treatment of osteoporosis. 6. Current smoker (must not have smoked in the last six months). 7. Women must not be pregnant. Nega tive urine pregnancy tests prior to exposure to cone beam computed tomography (CBCT) imaging is required to verify pregnancy status. Dental x ray exposure with pregnant women has been questioned in potential association to pituitary and thyroid disorders a nd low birth weight in infants 54 . 8. Any condition or use of medication which in the opinion of the investigator interferes with the biology of tooth movement. 9. Any condition which in opinion of the investigator results in increased risk to the subject.

PAGE 26

26 Table 2 2. Schedule of Pilot Study Events . Event Prelim 1 Prelim 2 Day 0 Day 14 Day 7 & 21 Day 28 Informed consent 1 X In clusion/Exclusion X X Med history X Pregnancy Test X Intraoral exam X X X X X Pulp test X X Periodontal probing X X Max occlusal & frontal photos X X X Digital impression scan X X X X AcceleDent® Aura X X X VAS Pain Index X X X GCF collection X X X X Intraoral photos (complete set) X X Extraoral photos X X Cone beam imaging 2 , 3 X Dispense aligner & diary X X Collect aligner & diary X X Begin planned ortho tx X 1 Informed consent given prior to any diagnostic or baseline procedures related to the study were performed. 2 Cone beam imaging for orthodontic records is standard procedure at UF. 3 Women were required to produce a negative urine pregnancy test immediately prior to imagin g to confirm that that they were not pregnant.

PAGE 27

27 Figure 2 1. AcceleDent® Aura Device Figure 2 2. Pilot Study Design Flow Diagram

PAGE 28

28 Figure 2 3. Identification of 3D Orthogonal Planes on Ortho Insight 3D. Figure 2 4. Distance b etween Time Points Calculated on Ortho Insight 3D

PAGE 29

29 Figure 2

PAGE 30

30 CHAPTER 3 RESULTS As the primary objective o f the pilot study was calibra tion of methods and procedures, and due to varying time point collections ( data not collected on Day 21 for subject P2 due to holiday) and small sample size, a limited analysis of results was completed. Calibration of study methods and procedures by study staff was accomplished and a detail of these limited results follows. It should be noted again, however, th at due to the small sample size and therefore limited statistical power, these results should be viewed with cau tion and judgment of the efficacy o f AcceleDent ® Aura on the rate of orthodontic tooth movement with aligners should be postponed until results from the full cohort study are released. Subject demographic information is illustrated in Table 3 1 and Table 3 2. The average age of participa nts in the pilot study was 26.62 ( ±5) years with an equal number of males (50%) and females (50%). Orthodontic tooth movement between devices was not statistically significant for any of the time points as depicted in Table 3 3. Both devices showed less than 65% of the prescribed tooth movement achieved, with the sham device having 52% or 0.52mm of the prescribed 1mm tooth movement (Table 3 4) and the active device having 63% or 0.63mm of the prescribed 1mm tooth movement (Table 3 5 ). A diagrammatic repr esentation of tooth movement over time points is illustrated in Figure 3 1. While the active device resulted in a higher percentage of prescribed tooth movement, this was not statistically significant. Pearson correlation coefficients were run to determi ne if there was a correlation between tooth movements over time. As expected, measurements closer together were more highly correlated than time points father apart (Table 3 6). Within subject

PAGE 31

31 correlation will result in a crossover study with more power than a two group study design for a given sample size. Therefore, the correlation s observed in the pilot study were consistent with assumptions made to determine the sample size for the full cohort study. Summary statistics were run for each of the bio markers assayed (IL 1 , IL 1Ra , RANKL, OPG, osteocalcin, osteopontin , IL 6, IL 8, MMP 3, MMP 9, M CSF, and IFN ). Summary statistics for the ratios of IL 1 / ( IL 1 + IL 1Ra ) and RANKL / ( RANKL + OPG) were also analyzed to elucidate the levels of active IL 1 and RANKL in the GCF. Tables illustrating the summary stat istics can be seen in Tables 3 7 to 3 20 . Due to the small sample size, a decision to pool the GCF values together as opposed to active versus sham group was made to allow for comparison to determine reliable bi omarkers and to detect any trends seen in the results. Comparisons of mean and median values were examined to assess the distributions of the various biomarkers . Since mean and median values differed significantly, the data was considered nonparametric a nd therefore median values were utilized to examine the distributions . As seen in Table 3 1 6 and 3 1 8 , IL 8 and MMP 9 median values had extreme fluctuations, indicating th at these biomarkers did not have symmetric distributions in our GCF samples. Additi onally, while the values for osteocalcin were symmetric , li mitations with the design of the kits, which are designed to detect osteocalcin in serum, not GCF, resulted in a non reliable standard curve and therefore could not be utilized for interpretation. Furthermore, various biomarkers did have symmetric values although no trends were seen. These included RANKL, osteopontin, IL 6, MMP 3, M CSF, and IFN . While

PAGE 32

32 trends were not noted with these biomarkers, the symme t ric values indicate that they may stil l be useful for further GCF analysis in subsequent studies. Interesting findings were noted with the biomarkers IL 1 IL 1Ra , and OPG. IL 1 values increased at T2 (Day 7) which corresponds to 1 week after delivery of the first aligner (Table 3 7) . Ho wever, these values sharply decreased for T3 (Day 21) and T4 (Day 28). Values for IL 1Ra continuously decreased from T2 to T4 (Table 3 8) . These time points occurred during active tooth movement . In order to further explore this trend, a Wilcoxon two sa mple test was used to determine if there was a difference between the active and sham groups for IL 1Ra at different time points. Nevertheless, no statistically significant difference between the groups was found. Additionally , the values for the ratio o f IL 1 to IL 1Ra result in values of basically zero, and therefore are difficult to interpret. Moreover, the values of OPG decreased at T3 (Day 21) and T4 (Day 28), which would be expected to occur during tooth movement (Table 3 11) . However, this trend was not seen for T2, which would have been expected as well since it is an additional timepoint when active tooth movement was occurring. Nevertheless, this finding may be a result of the small sample size. Additionally, for biomarkers where mean and me dian values differed greatly, transformations may be needed or analyses that do not rely on normality of the data may be required. As previously stated, the primary objective of the pilot study was calibration of study methods and procedures. Therefore, to determine the validity of the procedures used to measure the amount of tooth movement, repeat measures and reliability tests were performed on five randomly selected digi tal models by the same operator . Data collected from the main study was also util ized in the reliability testing to increase

PAGE 33

33 assurance of measurement protocol . Repeat measurements of biweekly actual and projected tooth movement were completed for 5 randomly selected subjects. The results were summarized using descriptive statistics a nd a reliability coefficient was calculated for each timepoint. Actual 1 and actual 2 are the duplicated measures of the actual tooth movement. D Actual is the difference between Actual 1 and Actual 2, and AD Actual is the absolute value of the differenc e between Actual 1 and Actual 2. The same was conducted for the projec ted tooth movement. Tables 3 21 to 3 26 illustrate the summary statistics and the reliability coefficients. Reliability results for the actual tooth movement selected were fo und to b e 75% for Day 14, 85% for Day 28, 89% for Day 42, 96% for Day 56, 93% for Day 70, and 91% for Day 84. Reliability coefficients for all projected tooth movement remained over 92% for all time points. Generally, reliability scores greater than 0.90, or 90 % would indicate a high level of reliability. However, due to our small sample size, these values could be influenced by one or two values. An added objective of the pilot study was to assess the overall feasibility of the study. Factors including pati ent recruitment, patient retention, compliance, data collection and entry were determined to be practical and procedures were maintained for the main study. Conversely, some important implications were formulated from the pilot study. Initially, patients were planned to attend the clinic daily, Monday through Friday, in order for study staff to observe usage with the device. Additionally, more frequent scans were initially planned, with scans taking place on Mondays, Wednesdays, and Fridays. This was qu ickly deemed unnecessary and impractical and was therefore eliminated from the pilot study protocol, and subsequently from the main

PAGE 34

34 study protocol as well. Through the pilot study, an overall sense of practicability for the main study was achieved, and th erefore no changes were made for the main study protocol.

PAGE 35

35 Table 3 1. Demographics of Subjects . n Active Device Sham Device p Value Total 6 3 3 p = 1.000 (NS) Males 3 2 1 Females 3 1 2 Table 3 2. Age of Subjects . n Mean(yrs) Median (yrs) SD M in(yrs) Max(yrs) p Value Total 6 26.62 24.94 5 22.38 36.17 p = 0.696 (NS) Active Device 3 25.68 25.78 1.85 23.78 27.48 Sham Device 3 27.55 24.11 7.51 22.38 36.17 Table 3 3. Mean Tooth Movement (mm) Observed per Time poin t . Day 7 Day 14 Day 21 Day 2 8 Active Device 0.27 7 ± 0.153 0.293 ± 0.091 0.520 ± 0.173 0.633 ± 0.142 Sham Device 0.267 ± 0.093 0.283 ± 0.080 0.625 ± 0.078 0.523 ± 0.237 p Value 0.928 (NS) 0.893 (NS) 0.494 (NS) 0.528 (NS) Table 3 4. Cumulative Tooth Movement (mm) Observed for S ham Device . n Mean Median SD Min Max Day 7 3 0.267 0.240 0.0929 0.190 0.370 Day 14 3 0.283 0.290 0.0802 0.200 0.360 Day 21 2 0.625 0.625 0.0778 0.570 0.680 Day 28 3 0.523 0.650 0.237 0.250 0.670 Table 3 5. Cumulative Tooth Movement (mm) Observed fo r Active Device . n Mean Median SD Min Max Day 7 3 0.277 0.360 0.153 0.100 0.370 Day 14 3 0.293 0.330 0.0907 0.190 0.360 Day 21 3 0.520 0.560 0.173 0.330 0.670 Day 28 3 0.633 0.700 0.142 0.470 0.730

PAGE 36

36 T able 3 6. Pearson Correlation Coefficients to Cor relate Tooth Movement over Time . Table 3 7 . Summary Statistics fo r IL 1 (pg/mL) . n Median Mean SD Std Error Min Max T0 (baseline 1) 6 35.255 53.393 48.179 19.669 12.850 135.4 T1 (baseline 2/Day 0) 6 24.345 29.885 24.443 9.979 10.250 74.590 T2 (Day 7) 6 74.025 98.190 96.805 39.521 10.850 261.8 T3 (Day 21) 5 14.570 64.940 97.372 43.546 0.860 232.2 T4 (Day 28) 5 23.860 38.046 29.581 13.229 4.770 70.200 Table 3 8 . Summary Statistics for IL 1R a (pg/mL) . n Median Mean SD Std Error Min Max T0 (baseline 1) 6 25882 32336 32404 13229 913.5 77200 T1 (baseline 2/Day 0) 6 41945 49132 25763 10518 23987 85024 T2 (Day 7) 6 13133 15094 13770 5621.7 2006 39243 T3 (Day 21) 5 12199 13738 13253 5926.7 1612 36036 T4 (Day 28) 5 9053 13782 11884 5314.8 468.9 28237

PAGE 37

37 Table 3 9 . Summary Statistics for IL / ( IL 1Ra ) (pg/mL) . n Median Mean SD Std Error Min Max T0 (baseline 1) 6 0 0.005 0.00837 0.00342 0 0.02 T1 (baseline 2/Day 0) 6 0 0 0 0 0 0 T2 (Day 7) 6 0.015 0.0133 0.0121 0.00494 0 0.03 T3 (Day 21) 5 0 0.004 0.00548 0.00245 0 0.01 T4 (D ay 28) 5 0 0.012 0.0217 0.0097 0 0.05 Table 3 10 . Summary Statistics for RANKL (pg/mL) . n Median Mean SD Std Error Min Max T0 (baseline 1) 6 27.295 27.307 2.303 0.940 25.040 31.120 T1 (baseline 2/Day 0) 6 26.545 26.838 4.342 1.772 22.090 34.240 T2 ( Day 7) 6 25.040 26.337 4.348 1.775 22.090 34.240 T3 (Day 21) 5 23.560 24.498 4.274 1.912 18.210 29.580 T4 (Day 28) 5 23.560 24.158 1.691 0.756 22.090 26.540 Table 3 11 . Summary Statistics for OPG (pg/mL) . n Median Mean SD Std Error Min Max T0 (basel ine 1) 6 3.025 5.307 5.527 2.256 1.420 16.120 T1 (baseline 2/Day 0) 6 3.035 5.362 6.111 2.495 1.760 17.620 T2 (Day 7) 6 3.850 6.888 5.977 2.440 2.130 15.370 T3 (Day 21) 5 1.760 3.638 3.804 1.701 1.090 10.190 T4 (Day 28) 5 2.510 3.592 2.100 0.939 2.510 7.320

PAGE 38

38 Table 3 1 2 . Summary Statistics for RANKL/ (RANKL + OPG) (pg/mL) . n Median Mean SD Std Error Min Max T0 (baseline 1) 6 0.895 0.853 0.121 0.0494 0.620 0.950 T1 (baseline 2/Day 0) 6 0.900 0.847 0.142 0.0580 0.570 0.950 T2 (Day 7) 6 0.870 0.808 0.14 1 0.0576 0.610 0.930 T3 (Day 21) 5 0.930 0.874 0.115 0.0513 0.680 0.960 T4 (Day 28) 5 0.900 0.874 0.064 0.0286 0.760 0.910 Table 3 13 . Summary Statistics for Osteocalcin (pg/mL) . n Median Mean SD Std Error Min Max T0 (baseline 1) 6 111.0 110.3 12.053 4.921 93.32 122.1 T1 (baseline 2/Day 0) 6 113.2 113.6 5.351 2.185 104.30 119.9 T2 (Day 7) 6 124.4 122.0 22.939 9.365 82.52 147.2 T3 (Day 21) 5 106.5 114.6 13.985 6.255 104.30 135.8 T4 (Day 28) 5 108.7 109.7 13.579 6.073 91.14 128.9 Table 3 14 . Sum mary Statistics for Osteopontin (pg/mL) . n Median Mean SD Std Error Min Max T0 (baseline 1) 6 1180 1208.5 65.845 26.881 1144 1304 T1 (baseline 2/Day 0) 6 1195 1193.2 22.004 8.983 1165 1224 T2 (Day 7) 6 1175 1179.7 30.761 12.558 1144 1224 T3 (Day 21) 5 1144 1192.0 90.948 40.673 1122 1345 T4 (Day 28) 5 1205 1198.2 33.237 14.864 1165 1242

PAGE 39

39 Table 3 15 . Summary Statistics for IL 6 (pg/mL) . n Median Mean SD Std Error Min Max T0 (baseline 1) 6 1.160 1.178 0.124 0.0505 0.98 1.35 T1 (baseline 2/Day 0) 6 1.0 70 1.157 0.289 0.118 0.82 1.55 T2 (Day 7) 6 1.025 1.010 0.254 0.104 0.60 1.35 T3 (Day 21) 5 0.980 1.020 0.144 0.0642 0.82 1.16 T4 (Day 28) 5 1.070 1.070 0.090 0.0402 0.98 1.16 Table 3 16 . Summary Statistics for IL 8 (pg/mL) . n Median Mean SD Std Err or Min Max T0 (baseline 1) 6 123.8 132.4 108.9 44.471 18.27 311.0 T1 (baseline 2/Day 0) 6 57.035 138.6 216.7 88.481 5.98 575.8 T2 (Day 7) 6 181.5 604.5 892.4 364.3 3.44 2294.0 T3 (Day 21) 5 13.96 91.582 118.2 52.847 4.60 257.1 T4 (Day 28) 5 59.4 56.60 6 26.7 11.941 26.70 95.98 Table 3 17 . Summary Statistics for MMP 3 (pg/mL) . n Median Mean SD Std Error Min Max T0 (baseline 1) 6 2.480 2.495 0.568 0.232 1.580 3.070 T1 (baseline 2/Day 0) 6 2.105 4.438 5.528 2.257 1.750 15.680 T2 (Day 7) 6 2.290 3.21 2 1.578 0.664 1.920 5.240 T3 (Day 21) 5 2.110 2.208 0.778 0.348 1.580 3.480 T4 (Day 28) 5 1.920 2.402 1.385 0.620 1.260 4.790

PAGE 40

40 Table 3 18 . Summary Statistics for MMP 9 (pg/mL) . n Median Mean SD Std Error Min Max T0 (baseline 1) 6 5863.0 18041 26253 10 718 913.4 68599 T1 (baseline 2/Day 0) 6 7644.5 25996 40160 16395 1099 104441 T2 (Day 7) 6 10154 11351 11705 4778.5 684.5 25782 T3 (Day 21) 5 822.5 15405 30663 13713 91 70095 T4 (Day 28) 5 3562.0 10904 18000 8049.8 1033 42954 Table 3 19 . Summary Sta tistics for M CSF (pg/mL) . n Median Mean SD Std Error Min Max T0 (baseline 1) 6 55.35 60.948 23.441 9.570 38.23 103.3 T1 (baseline 2/Day 0) 6 55.31 58.058 9.465 3.864 50.89 76.14 T2 (Day 7) 6 55.310 55.440 8.394 3.427 42.350 64.39 T3 (Day 21) 5 48.72 5 6.114 15.055 6.733 42.350 78.54 T4 (Day 28) 5 59.810 58.666 11.334 5.069 42.350 69.04 Table 3 20 . Summary Statistics for IFN (pg/mL) . n Median Mean SD Std Error Min Max T0 (baseline 1) 6 2.69 2.923 0.945 0.386 2.010 4.770 T1 (baseline 2/Day 0) 6 3 .05 3.083 0.375 0.153 2.690 3.790 T2 (Day 7) 6 2.87 2.700 0.440 0.179 2.010 3.050 T3 (Day 21) 5 2.69 2.886 0.723 0.323 2.010 3.990 T4 (Day 28) 5 2.01 2.162 0.564 0.252 1.700 3.050

PAGE 41

41 Table 3 21 . Difference in Duplicated Measures to Determine Reliability of Measurement for Day 14 . N Median Mean SD Min Max D Actual 5 0.0100 0.0180 0.0409 0.0800 0.0300 AD Actual 5 0.0300 0.0300 0.0308 0 0.0800 D Projected 5 0.0200 0.0100 0.0515 0.0800 0.0300 AD Projected 5 0.0300 0.0420 0.0239 0.0200 0.0800 Relia bility Actual: 0.749 Projected: 0.917 Table 3 22 . Difference in Duplicated Measures to Determine Reliability of Measurement for Day 28 . n Median Mean SD Min Max D Actual 5 0.0300 0.0160 0.0744 0.1200 0.0700 AD Actual 5 0.0400 0.0600 0.0367 0.030 0 00.1200 D Projected 5 0.0100 0.0140 0.0472 0.0300 0.0800 AD Projected 5 0.0300 0.0380 0.0259 0.0100 0.0800 Reliability Actual: 0.851 Projected: 0.951 Table 3 23 . Difference in Duplicated Measures to Determine Reliability of Measurement for Day 42 . n Median Mean SD Min Max D Actual 5 0.0400 0.0340 0.0344 0.0800 0 AD Actual 5 0.0400 0.0340 0.0344 0 0.0800 D Projected 5 0 0.0220 0.0466 0.0900 0.0200 AD Projected 5 0.0200 0.0340 0.0365 0 0.0900 Reliability Actual: 0.892 Projected: 0.931 Table 3 24 . Difference in Duplicated Measures to Determine Relia bility of Measurement for Day 56 . n Median Mean SD Min Max D Actual 5 0.0300 0.0020 0.0497 0.0700 0.0400 AD Actual 5 0.0400 0.0420 0.0164 0.0300 0.0700 D Projected 5 0.0200 0.0160 0. 0522 0.0800 0.0500 AD Projected 5 0.0500 0.0440 0.0251 0.0200 0.0800 Reliability Actual: 0.959 Projected: 0.968

PAGE 42

42 Table 3 25. Difference in Duplicated Measures to Determine Reliability of Measurement for Day 70 . n Median Mean SD Min Max D Actual 5 0.0400 0.0460 0.0555 0.0400 0.1000 AD Actual 5 0.0400 0.0620 0.0303 0.0400 0.1000 D Projected 5 0.0400 0.0440 0.0230 0.0200 0.0800 AD Projected 5 0.0400 0.0440 0.0230 0.0200 0.0800 Reliability Actual: 0.930 Projected: 0.980 Table 3 26 . Difference in Duplicated Measures to Determine Reliability of Measurement for Day 84 . n Median Mean SD Min Max D Actual 5 0.05 00 0.044 0 0.0 336 0.0800 0.01 00 AD Actual 5 0.0 5 00 0.0 480 0.0 259 0 .0100 0.0800 D Projected 5 0.05 00 0.042 0 0.0 409 0. 09 00 0.02 00 A D Projected 5 0.05 00 0.050 0 0.02 74 0.0200 0.09 00 Reliability Actual: 0. 911 Projected: 0.9 91 Figure 3 1. Mean Tooth Movement (mm) per Time point. 0.633 mm 0.523 mm 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 Day 7 Day 14 Day 21 Day 28 Tooth Movement Achieved (mm) Mean Tooth Movement (mm) Per Time point Active Device Sham Device

PAGE 43

43 CHAPTER 4 DISCUSSION The rate of orthodontic tooth movement with aligners has been previously show n to result in less than 100% of the prescribed tooth movement 20 , 22 , 38 , 53 . Despite the usage of the AcceleDent ® Aura device , our results indicate a similar trend with the active device producing 63% of the prescribed tooth movement. Although the active de vice resulted in a higher percentage of prescribed tooth movement, this was not s tatistically significant. However, because of the small sample size and resultant small statistical power, the true statistical significance cannot be determined with the res ults of this pilot study. In the rat model evaluated by Nishimura et al . 32 , OTM was enhanced significantly by 15% when vibration was applied. In previous hum an studies conducted by Kau et al . 36 , 37 , usage of AcceleDent ® resulted in maxillary tooth movement of 3mm per month and mandibular tooth movement of 2.1mm per month. Unfortunately, the Kau et al . studies did not include a control group. In an unpublished prospective, randomized, blinded controlled trial at the University of Texas Health Science Center San Antonio, i t was determined that OTM increased by 106% during initial alignment and space closure increased by 38% in 23 premolar extraction patients 55 . The use of an AcceleDent ® device was found to increase the rate of orthodontic tooth movement during the leveling and alignment phase of the mandibular dentition by a statistically significant 30% 56 . These promising results from previous AcceleDent ® studi es should therefore indicate the need to further survey the results from the full cohort study. Thermoplastic aligners are traditi onally composed of polyethylene, polypropylene , or polyurethane. The aligners utilized in this study were made from Zendura ® , a polyurethane material made from high performing rigid engineering resin .

PAGE 44

44 Zendura ® advocates superior stress retention, crack and stain resistance, and exceptional tooth hugging capability for higher performance . However, the previous aligner studies conducted at the University of Florida utilized Invisalign ® aligners. While Invisalign ® aligners are also composed of polyurethane, they are a propriety material and therefore the full composition is unclear in the literature. The newest material introd uced by Invisalign ® , SmartTrack , advocates a lower initial insertion force and a longer working range and its effects on orthodontic tooth movement have previously been studied at the University of Florida 57 . Thermoplastic aligner thickness pla ys a role in the magnitude of fo rce delivered during OTM. In two studies comparing thermoplastic appliance thickness on the magnitude of force during tipping and rotation of a maxillary central incisor, Hahn et al . concluded that forces delivered by thick er appliance material were significantly higher than that of thinner appliance material 58 , 59 . Furthermore , thes e higher forces were larger than those stated in literature as ideal for tooth movement , at approximately 3 to 11 times higher 58 . Similarly, in a study conducted by Kohda et al . , aligners fabricated from a thicker material always produced significantly greater forces than aligners fabricated from a thinner material 60 . Kwon et al . concluded that thinner materi als can deliver a higher energy, or resilience, than thicker materials, and that thinner aligner material should be preferred over thicker aligner material 61 . As previously described, a light, continuous force is required for ideal tooth movement 15 , 17 with increasing fo rce resulting in increased rates of indirect bone resorption and subsequent slower rates of tooth movement 62 .

PAGE 45

45 The viscoelastic nature of thermoplastic aligners gives aligners the ability to adapt to the stresses and strains of the oral environment, however, this same property results in aligner fatigue over time 63 . Additionally, temperature, moisture, and humidity , features ubiquitous to the oral cavity, can result in changes to the aligners 64 , resulting in decreased tensile properties and stress relaxation. These changes can result in a reduced ability of the aligner to produce the correct force, and thereby m ay result in a reduction of prescribed tooth movement seen clinically 65 . While such characteristics are common to thermoplastic aligners in general, the different chemical composition of various aligner systems creates a varying degree of features spe cific to a single aligner system. Therefore, it is again important to note that the present stu dy was conducted utilizing a thermoplastic material, Zendura ® , which differs from the past UF aligner studies utilizing Invisalign ® aligners. Thus, the ability to compare the current study to the results of the previous aligner studies is limited, based on the various d ifferences between the aligner systems , including material composition and clinical characteristics. Previous studies have shown that the lev el of RANKL in GCF by osteoblasts, osteocytes, and fibroblasts in the PDL significantly increases as early as 3 hours after orthodontic force application 44 , 66 . Conversely, OPG levels in GCF have been shown to decrease as early as 1 hour after force application 67 . Compressive forces have also been shown to increase expression of M CSF by os teoblasts , thereby increasing proliferation of osteoclasts 68 . Furthermore , after 24 hours of orthodontic force application, GCF levels of IL 1 , IL 6, IL 8 and TNF are heightened 69 , 70 . Nishi mura et al . 32 demonstrated an increased expression of RANKL, osteoclast formation, and a subsequent acceleration of tooth movement by 15% of maxillary first mo lars in rats

PAGE 46

46 subjected to 8 minutes of resonance vibration per week. By comparing the levels of various biomarkers within the GCF , an understanding of the extent of bone remodeling occurring can be elucidated. Despite the reported abilities to detect the se biomarkers in the literature, within the current study, certain limitations resulted in a limited analysis of the data. Levels of IL 8, MMP 9, and osteocalcin were found to be unsymmetrical and therefore unreliable for analysis. Levels of RANKL, osteo pontin, IL 6, MMP 3, M CSF, and IFN were found to be symmetric , although no trends were identified. Despite the lack of trends, the regularity of these biomarkers indicates that they can be useful and reliable measures for future studies. Although not necessarily expected due to the sma ll sample size, a few promising trends were , however, uncovered. Levels of IL 1 increased one week after the first aligner activation of 0.5mm. In addition , levels of IL 1Ra decreased throughout active force application with the aligners. IL 1 , a pro inflammatory cytokine , shows potency in inducing osteoblasts to stimulate osteoclast activity, and thus enhances bone resorption 71 . Therefore, levels of IL 1 w ould be expected to increase during orthodontic force application, thereby promoting bone resorption required to facilitate tooth movement. The effects of IL 1 are restrained by its receptor antagonist cytokine, IL 1Ra. IL 1Ra binds to the IL 1 receptor s and subsequently blocks activation of IL 1 72 which consequently results in decreased activation of osteoclasts and therefore reduced bone resorption. Duri ng orthodontic force application, a reduction of IL 1Ra would indicate that more levels of active IL 1 are present with in the PDL , and therefore, higher levels of activated osteoclasts would result. The concentrations of IL 1 and IL 1Ra have been studie d extensively in the GCF of teeth subjected to orthodontic force 41 , 47 , 73 , 74 .

PAGE 47

47 While the results from the current study are promising, the fact that levels of IL 1 were not seen to continue increasing throughout the study is somewhat disappointing. However, this may be a result of the small sample size, and therefore it will be intriguing to compare the results of these biomarkers in the full cohort study. Additi onally, it will be interesting to compare the levels of these biomarkers between the active AcceleDent ® Aura group and the sham group to see if the differences are more pronounced with in the active group. Despite the limited results found in the current study, the primary objective of calibration of study methods and procedures was achieved. The continued goal of increasing efficiency and decreasing overall treatment time associated with orthodontics has resulted in the development of methods to acceler ate orthodontic tooth movement. Further research in this field may help implement methodology to provide improved clinical results and an overall enhanced patient experience.

PAGE 48

48 CHAPTER 5 CONCLUSIONS The primary objective of calibration of study method s and procedures by study staff was completed. This included calibration of a new tooth movement measurement protocol utilizing Ortho Insight 3D software, which was concluded to be both reliable and reproducible along with procedures to a nalyze various GC F biomarkers. Biomarker analysis indicated trends for IL 1 , IL 1Ra, and OPG, however, further elucidation of this data could not be determined due to the small sam ple size. Biomarkers IL 8, MMP 9 , and osteocalcin were determined to not be consistent, an d therefore may not be reliable for further research in future GCF studies. There were no statistically significant differences between the active AcceleDent ® Aura and the sham device in amount of tooth movement produced, however, due to the small sample size and therefore small statistical power, no differences were expected. While not statistically significant, aligner usage in conjugation with the active AcceleDent ® Aura device resulted in 63% of the prescribed amount of tooth movement while the sham d evice resulted in 52% of the prescribed tooth movement . Nevertheless , due to the small sample size, conclusions as to the efficacy of AcceleDent ® Aura with aligners should be withheld until full results from the cohort study are released. At the same tim e, it will be interesting to note any differences in VAS pain indexes and GCF biomarker trends between the two devices.

PAGE 49

49 LIST OF REFERENCES 1. Dolce C, Malone J, Wheeler T. Current Concepts in the Biology of Orth odontic Tooth Movement. Semin Orthod 2002;8:6 12. 2. Masella RS, Meister M. Current concepts in the biology of orthodontic tooth movement. Am J Orthod Dentofacial Orthop 2006;129(4):458 68. 3. Proff P, Romer P. The molecular mechanism behind bone remodel ling: a review. Clin Oral Investig 2009;13(4):355 62. 4. Wise GE, King GJ. Mechanisms of tooth eruption and orthodontic tooth movement. J Dent Res 2008;87(5):414 34. 5. Lerner UH. Bone remodeling in post menopausal osteoporosis. J Dent Res 2006;85(7):584 95. 6. Stabile AC, Stuani MB, Leite Panissi CR, Rocha MJ. Effects of short term acetaminophen and celecoxib treatment on orthodontic tooth movement and neuronal activation in rat. Brain Res Bull 2009;79(6):396 401. 7. Grant M, Wilson J, Rock P, Chapple I. Induction of cytokines, MMP9, TIMPs, RANKL and OPG during orthodontic tooth movement. Eur J Orthod 2013;35(5):644 51. 8. Fan X, Biskobing DM, Fan D, Hofstetter W, Rubin J. Macrophage colony stimulating factor down regulates MCSF receptor expression and entry of progenitors into the osteoclast lineage. J Bone Miner Res 1997;12(9):1387 95. 9. Wiktor Jedrzejczak W, Bartocci A, Ferrante AW, Jr., et al. Total absence of colony stimulating factor 1 in the macrophage deficient osteopetrotic (op/op) mouse. Pro c Natl Acad Sci U S A 1990;87(12):4828 32. 10. Ren Y, Vissink A. Cytokines in crevicular fluid and orthodontic tooth movement. Eur J Oral Sci 2008;116(2):89 97. 11. Theoleyre S, Wittrant Y, Tat SK, et al. The molecular triad OPG/RANK/RANKL: involvement i n the orchestration of pathophysiological bone remodeling. Cytokine Growth Factor Rev 2004;15(6):457 75. 12. Brennan Speranza TC, Conigrave AD. Osteocalcin: An Osteoblast Derived Polypeptide Hormone that Modulates Whole Body Energy Metabolism. Calcif Tiss ue Int 2014. 13. Reinholt FP, Hultenby K, Oldberg A, Heinegard D. Osteopontin -a possible anchor of osteoclasts to bone. Proc Natl Acad Sci U S A 1990;87(12):4473 5.

PAGE 50

50 14. Ishibashi O, Niwa S, Kadoyama K, Inui T. MMP 9 antisense oligodeoxynucleotide exerts an inhibitory effect on osteoclastic bone resorption by suppressing cell migration. Life Sci 2006;79(17):1657 60. 15. Reitan K. Clinical and histologic observations on tooth movement during and after orthodontic treatment. Am J Orthod 1967;53(10):721 45. 16. Ren Y, Maltha JC, Kuijpers Jagtman AM. Optimum force magnitude for orthodontic tooth movement: a systematic literature review. Angle Orthod 2003;73(1):86 92. 17. Storey E. The nature of tooth movement. Am J Orthod 1973;63(3):292 314. 18. Bollen A M, Huang G, King G, Hujoel P, Ma T. Activation time and material stiffness of sequential removable orthodontic appliances. Part 1: Ability to complete treatment. American Journal of Orthodontics and Dentofacial Orthopedics 2003;124(5):496 501. 19. Clements KM, Bollen A M, Huang G, et al. Activation time and material stiffness of sequential removable orthodontic appliances. Part 2: Dental improvements. American Journal of Orthodontics and Dentofacial Orthopedics 2003;124(5):502 08. 20. Kravitz ND, Kusnoto B, BeGole E, Obrez A, Agran B. How well does Invisalign work? A prospective clinical study evaluating the efficacy of tooth movement with Invisalign. Am J Orthod Dentofacial Orthop 2009;135(1):27 35. 21. Joffe L. Invisalign: early experiences. J Orthod 2003 ;30(4):348 52. 22. Drake CT, McGorray SP, Dolce C, Nair M, Wheeler TT. Orthodontic tooth movement with clear aligners. ISRN Dent 2012;2012:657973. 23. Pilla AA. Low intensity electromagnetic and mechanical modulation of bone growth and repair: are they e quivalent? J Orthop Sci 2002;7(3):420 8. 24. Rubin C, Turner AS, Muller R, et al. Quantity and quality of trabecular bone in the femur are enhanced by a strongly anabolic, noninvasive mechanical intervention. J Bone Miner Res 2002;17(2):349 57. 25. Rubin C, Turner AS, Bain S, Mallinckrodt C, McLeod K. Anabolism. Low mechanical signals strengthen long bones. Nature 2001;412(6847):603 4. 26. Gilsanz V, Wren TA, Sanchez M, et al. Low level, high frequency mechanical signals enhance musculoskeletal developme nt of young women with low BMD. J Bone Miner Res 2006;21(9):1464 74.

PAGE 51

51 27. Young SR, Dyson M. The effect of therapeutic ultrasound on angiogenesis. Ultrasound Med Biol 1990;16(3):261 9. 28. Fabrizio PA, Schmidt JA, Clemente FR, Lankiewicz LA, Levine ZA. Acu te effects of therapeutic ultrasound delivered at varying parameters on the blood flow velocity in a muscular distribution artery. J Orthop Sports Phys Ther 1996;24(5):294 302. 29. Doan N, Reher P, Meghji S, Harris M. In vitro effects of therapeutic ultra sound on cell proliferation, protein synthesis, and cytokine production by human fibroblasts, osteoblasts, and monocytes. J Oral Maxillofac Surg 1999;57(4):409 19; discussion 20. 30. Peptan AI, Lopez A, Kopher RA, Mao JJ. Responses of intramembranous bone and sutures upon in vivo cyclic tensile and compressive loading. Bone 2008;42(2):432 8. 31. Darendeliler MA, Zea A, Shen G, Zoellner H. Effects of pulsed electromagnetic field vibration on tooth movement induced by magnetic and mechanical forces: a preli minary study. Aust Dent J 2007;52(4):282 7. 32. Nishimura M, Chiba M, Ohashi T, et al. Periodontal tissue activation by vibration: intermittent stimulation by resonance vibration accelerates experimental tooth movement in rats. Am J Orthod Dentofacial Ort hop 2008;133(4):572 83. 33. Huang H, Williams RC, Kyrkanides S. Accelerated orthodontic tooth movement: Molecular mechanisms. Am J Orthod Dentofacial Orthop 2014;146(5):620 32. 34. Weinbaum S, Cowin SC, Zeng Y. A model for the excitation of osteocytes by mechanical loading induced bone fluid shear stresses. J Biomech 1994;27(3):339 60. 35. Kogianni G, Mann V, Noble BS. Apoptotic bodies convey activity capable of initiating osteo clastogenesis and localized bone destruction. J Bone Miner Res 2008;23(6):915 27. 36. Kau C, Nguyen J, English J. The clinical evaluation of a novel cyclical force generating device in orthodontics. Orthod Pract 2012;1(1):10 15. 37. Kau CH. A radiographi c analysis of tooth morphology following the use of a novel cyclical force device in orthodontics. Head Face Med 2011;7:14. 38. McGorray SP, Dolce C, Kramer S, Stewart D, Wheeler TT. A randomized, placebo controlled clinical trial on the effects of recomb inant human relaxin on tooth movement and short term stability. Am J Orthod Dentofacial Orthop 2012;141(2):196 203.

PAGE 52

52 39. Griffiths GS. Formation, collection and significance of gingival crevice fluid. Periodontol 2000 2003;31:32 42. 40. Rai B, Kharb S, Jai n R, Anand SC. Biomarkers of periodontitis in oral fluids. J Oral Sci 2008;50(1):53 6. 41. Iwasaki LR, Crouch LD, Tutor A, et al. Tooth movement and cytokines in gingival crevicular fluid and whole blood in growing and adult subjects. Am J Orthod Dentofac ial Orthop 2005;128(4):483 91. 42. Rody W, Iwasaki L, Krokhin O. Oral Fluid based Diagnostics and Applications in Orthodontics. Paper presented at: Taking Advantage of Emerging Technologies in Clinical Practice, 2012; Ann Arbor MI: University of Michigan. 43. Kawasaki K, Takahashi T, Yamaguchi M, Kasai K. Effects of aging on RANKL and OPG levels in gingival crevicular fluid during orthodontic tooth movement. Orthod Craniofac Res 2006;9(3):137 42. 44. Nishijima Y, Yamaguchi M, Kojima T, et al. Levels of R ANKL and OPG in gingival crevicular fluid during orthodontic tooth movement and effect of compression force on releases from periodontal ligament cells in vitro. Orthod Craniofac Res 2006;9(2):63 70. 45. Iwasaki LR, Chandler JR, Marx DB, Pandey JP, Nickel JC. IL 1 gene polymorphisms, secretion in gingival crevicular fluid, and speed of human orthodontic tooth movement. Orthod Craniofac Res 2009;12(2):129 40. 46. Rody WJ, Jr., Wijegunasinghe M, Wiltshire WA, Dufault B. Differences in the gingival crevicula r fluid composition between adults and adolescents undergoing orthodontic treatment. Angle Orthod 2014;84(1):120 6. 47. Iwasaki LR, Haack JE, Nickel JC, Reinhardt RA, Petro TM. Human interleukin 1 beta and interleukin 1 receptor antagonist secretion and v elocity of tooth movement. Arch Oral Biol 2001;46(2):185 9. 48. Rody WJ, Akhlaghi H, Akyalcin S, et al. Impact of orthodontic retainers on periodontal health status assessed by biomarkers in gingival crevicular fluid. Angle Orthod 2011;81(6):1083 89. 49. Rescala B, Rosalem W, Teles RP, et al. Immunologic and Microbiologic Profiles of Chronic and Aggressive Periodontitis Subjects. J Periodontol 2010;81(9):1308 16. 50. Mermut S, Bengi AO, Akin E, Kürkçü Gamma on Bone Remodeling during Experimental Tooth Movement. Angle Orthod 2007;77(1):135 41.

PAGE 53

53 51. Bildt MM, Bloemen M, Kuijpers Jagtman AM, Von den Hoff JW. Matrix metalloproteinases and tissue inhibitors of metalloprotei nases in gingival crevicular fluid during orthodontic tooth movement. Eur J Orthod 2009;31(5):529 35. 52. Capelli J, Jr., Kantarci A, Haffajee A, et al. Matrix metalloproteinases and chemokines in the gingival crevicular fluid during orthodontic tooth mov ement. Eur J Orthod 2011;33(6):705 11. 53. Chisari JR, McGorray SP, Nair M, Wheeler TT. Variables affecting orthodontic tooth movement with clear aligners. Am J Orthod Dentofacial Orthop 2014;145(4 Suppl):S82 91. 54. Ludlow JB, Ivanovic M. Comparative do simetry of dental CBCT devices and 64 slice CT for oral and maxillofacial radiology. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 2008;106(1):106 14. 55. Pavlin D. Modulation of tooth movement by vibratory forces. Paper p resented at: 41st Annual Moyers Symposium; March 9, 2014; University of Michigan, Ann Arbor. 56. Bowman SJ. The effect of vibration on the rate of leveling and alignment. Journal of Clinical Orthodontics 2014;48(11):678 88. 57. Patel ND. effect of aligne r material, duration, and force le vel on tooth movement. Gainesville, FL: University of Florida; 2014. 58. Hahn W, Dathe H, Fialka Fricke J, et al. Influence of thermoplastic appliance thickness on the magnitude of force delivered to a maxillary central incisor during tipping. Am J Orthod Dentofacial Orthop 2009;136(1):12 e1 7; discussion 12 3. 59. Hahn W, Engelke B, Jung K, et al. Initial forces and moments delivered by removable thermoplastic appliances during rotation of an upper central incisor. Angl e Orthod 2010;80(2):239 46. 60. Kohda N, Iijima M, Muguruma T, et al. Effects of mechanical properties of thermoplastic materials on the initial force of thermoplastic appliances. Angle Orthod 2013;83(3):476 83. 61. Kwon JS, Lee YK, Lim BS, Lim YK. Force delivery properties of thermoplastic orthodontic materials. Am J Orthod Dentofacial Orthop 2008;133(2):228 34; quiz 328 e1. 62. Proffit W. Contemporary orthodontics. St Louis: C.V. Mosby; 2000.

PAGE 54

54 63. Ryokawa H, Miyazaki Y, Fujishima A, Miyazaki T, Maki K. The mechanical properties of dental thermoplastic materials in a simulated intraoral environment. Orthodontic Waves 2006;65(2):64 72. 64. Servay T, Voelkel R, Schmiedberger H, Lehmann S. Thermal oxidation of the methylene diphenylene unit in MDI TPU. Poly mer 2000;41(14):5247 56. 65. Fang D, Zhang N, Chen H, Bai Y. Dynamic stress relaxation of orthodontic thermoplastic materials in a simulated oral environment. Dent Mater J 2013;32(6):946 51. 66. Brooks PJ, Nilforoushan D, Manolson MF, Simmons CA, Gong SG . Molecular markers of early orthodontic tooth movement. Angle Orthod 2009;79(6):1108 13. 67. Toygar HU, Kircelli BH, Bulut S, Sezgin N, Tasdelen B. Osteoprotegerin in gingival crevicular fluid under long term continuous orthodontic force application. Ang le Orthod 2008;78(6):988 93. 68. Sanuki R, Shionome C, Kuwabara A, et al. Compressive force induces osteoclast differentiation via prostaglandin E(2) production in MC3T3 E1 cells. Connect Tissue Res 2010;51(2):150 8. 69. Uematsu S, Mogi M, Deguchi T. Int erleukin (IL) 1 beta, IL 6, tumor necrosis factor alpha, epidermal growth factor, and beta 2 microglobulin levels are elevated in gingival crevicular fluid during human orthodontic tooth movement. J Dent Res 1996;75(1):562 7. 70. Ren Y, Hazemeijer H, de H aan B, Qu N, de Vos P. Cytokine profiles in crevicular fluid during orthodontic tooth movement of short and long durations. J Periodontol 2007;78(3):453 8. 71. Lerner UH, Modeer T, Krekmanova L, Claesson R, Rasmussen L. Gingival crevicular fluid from pati ents with periodontitis contains bone resorbing activity. Eur J Oral Sci 1998;106(3):778 87. 72. Dinarello CA. Interleukin 1, interleukin 1 receptors and interleukin 1 receptor antagonist. Int Rev Immunol 1998;16(5 6):457 99. 73. Iwasaki LR, Gibson CS, C rouch LD, et al. Speed of tooth movement is related to stress and IL 1 gene polymorphisms. Am J Orthod Dentofacial Orthop 2006;130(6):698 e1 9. 74. Lee K J, Park Y C, Yu H S, Choi S H, Yoo Y J. Effects of continuous and interrupted orthodontic force on in terleukin gingival crevicular fluid. American Journal of Orthodontics and Dentofacial Orthopedics 2004;125(2):168 77.

PAGE 55

55 BIOGRAPHICAL SKETCH Aylin M. Mazzuoccolo was born in Izmir, Turkey to her parents Sam and Cher yl Okcular. Her family relocated to Jacksonville, Florida shortly after she was born. Aylin lived in Jacksonville until 2004 where she next moved an hour and a half south to Gainesville to attend the University of Florida. In 2008, Aylin graduated with a BS in food science and human nutrition with an emphasis in nutritional sciences and immediately began dental school at the University of Florida. After completing her DMD degree, she was fortunate enough to be accepted into the UF Graduate Orthodontic pro gram to continue her training. Aylin and her husband, John, love spending time with their 8 year old Boston terrier Venice, watching Gator football and basketball, traveling, and spending time with family and friends.