Evaluation of the Effect of Full Thickness Mucoperiosteal Flap Versus Low Level Laser in Orthodontic Tooth Movement Acceleration
Phase: NA
Conditions: Mesial Movement of Teeth
Sponsor: Al-Azhar University

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Last Update 7/8/2019 
 
The Effect of Using FTMPF versus Low Level Laser Application on Orthodontic Tooth 
Movement Acceleration 
Mohsena A. Abdarazik1, Samir A. Ibrahim2 , James K. Hartsfield3 , Hatem H. AlAhmady4 
1.Assistant lectural at Orthodontics Department, Faculty of Dental Medicine for Girls, Al-Azhar 
University. 
2. Professor of Orthodontics, Faculty of Dental Medicine  for Girls, Al-Azhar University -Egypt. 
3. E. Preston Hicks Endowed, Professor of Orthodontics and Oral Health Research,  University of 
Kentucky- USA. 
4. Professor  and Head of Oral and Maxillofacial Surgery Department, Faculty of Dental Medicine for 
Girls, Al-Azhar University - Egypt 
 
 
 

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The Effect of Using FTMPF versus Low Level Laser Application on Orthodontic Tooth 
Movement Acceleration 
ABSTRACT 
PURPOSE: This study aimed to evaluate the effect of using full thickness mucoperiosteal flap 
(FTMPF) elevation only versus low level laser therapy (LLLT) on acceleration of orthodontic tooth 
movement. MATERIAL and METHODS: This study was a split mouth design study included 32 side 
according to sample size calculation. Those sides were divided into 2 groups. Group 1divided into 
(group 1a: 8 sides with FTMPF, group 1b:8 sides control). Group 2(group 2 a: 8 sides with LLLT, 
group 2b: 8 sides control). Extraction of the first maxillary premolars followed by canine retraction in 
the extraction space with maximum anchorage were indicated. FTMPF was elevated from the mesial 
interdental papilla of maxillary canine to the mesial interdental papilla of second maxillary premolar. 
LLLT was applied at 3,7,14,28.56 days of retraction. During retraction study model for all patients were 
taken at 2ed, 6th, 14th,16th weeks and at the end of retraction (I1,I2,I3,I4,I5 or overall interval). 3D laser 
scanning and digital superimposition was done to measure the rate of canine retraction and anchorage 
loss. RESULTS: Statistical analysis showed a significant difference in the mean distance moved by 
maxillary canine and weekly rate of retraction between the FTMPF and its control in I1, I2 and I5,and 
in I2,I3and I5 LLLT and its control. The total retraction time was significantly decreased in both 
FTMPF and LLLT in comparison to control. COCLUSIONS: FTMPF could accelerate orthodontic 
tooth movement with 25%, while LLLT could achieve 20% decrease with no significant difference 
between both techniques. 
Key wards: Acceleration, Full thickness mucoperiostreal flap, low level laser therapy. 
Paper extracted from Doctor thesis titled  " The Effect of Using Full Thickness Mucoperiosteal Flap 
versus Low Level Laser Application on Orthodontic Tooth Movement Acceleration" 
 
 

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INTRODUCTION 
    Today, a great increase of the population undergoes orthodontics treatment in order to bring about 
better occlusion, improved oral function as well as harmonized facial appearance (1). Owing to the fact 
that the metabolism in adults is much slower than those in younger patients the time taken for treatment 
in adults is significantly greater than that taken in adolescents (2-4). Studies on treatment time have found 
durations ranging from 21-27 months for non-extraction treatment and 25-35 months for extraction 
treatment (5-8). Much research has been done to quantify the rate of tooth movement possible, with most 
studies showing approximately 1 mm/month (9,10). 
           In the surgical approaches to accelerate orthodontic treatment, Regional Acceleratory 
Phenomenon (RAP) is a way to increase bone remodeling rates and decrease bone density. The RAP is 
a sequence of tissue reactions during healing of injured bone (11-14). Noxious stimuli include crushing 
injuries, fractures, and bone operations.  It occurs regionally in the anatomical sense, involves both hard 
and soft tissues (14). In corticotomies, the bone injury occurs in two ways. First by elevating a full-
thickness mucoperiosteal flap. Second, by cutting or perforating cortical bone. However, with the depth 
of damage in cortical bone ranging from 2 to 3 mm without flap elevation tooth movements were not 
accelerate orthodontic tooth movement because the RAP effects were limited to the cortical bone only 
(15,16). Former studies showed (17,18) that RAP is produced by elevation of a FTMPF so the rate of OTM 
increased approximately 24% to 31% because it decreases the amount and relatively  the density of the 
medullary bone by about 9% (18).  The decrease in bone volume fraction and density were small, less 
than previously shown to be associated with the RAP (19,20). 
      Laser is the acronym for “Light Amplification by Stimulated Emission of Radiation". Bone 
remodeling biomarkers assessment during laser irradiation could allow understanding of the mechanism 
of accelerated OTM with this novel approach (21). The effect of LLLT is photochemical not thermal 
which can be divided into primary and secondary responses.  Primary Response include absorption of 
photons of LLL by photoacceptor molecule (Cytochrome C oxidase) (22-24). It is an integral membrane 
protein of mitochondria; the excitation of this molecule with light energy increases the capacity of 
mitochondria to generate ATP (24). Increased ATP results in increased energy available for that cell’s 
metabolic processes. Moreover, the increase of Nitric Oxide (NO) alters the cell activity by increasing 
cell membrane permeability to calcium and other ions. Secondary responses include RNA and DNA 
synthesis, cell proliferation, release of the growth factors, increase in collagen synthesis, change in 
nerve conduction and neurotransmitter. A number of studies in the literature have shown cellular LLLT 
increases fibroblast proliferation and the quantity of osteoid tissue (25,26). Most of the clinical studies 
(27,28) used Ga–Al–As diode laser, showed a stimulating effect on OTM and inducing an increase of up 
to 30%.  
MATERIAL and METHODS: 
     This study included volunteer female patients (15-20 years old) from the clinic of orthodontics, 
Faculty of Dental Medicine for Girls, Al-Azhar University. All the patients who participated in this 
study were informed in simple language about the goals of the research and informed consent was 

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obtained from the patients and from one of the parents of those younger than 18 years before the study. 
The faculty Research Ethics Committee (REC) approval was obtained. 
   A split mouth study design was used (within each group a test side and control side). Sample size 
calculation using G Power software suggested a total  size 32 sides with 10% drop out rate form 16 
patients to be assigned randomly in allocation fashion 1: 1:1:1 as the following: 
Group 1: Group 1.a. Full thickness mucoperiosteal flap (8 sides)  and group 1.b. Control (8 sides) 
Group 2: Group 2.a. Low level laser application. (8 sides)      and   Group 2.b. Control.(8 sides). 
 Eligibility Criteria:  
 Inclusion Criteria: 
o Free of any syndromes affecting the head region or any craniofacial injuries. 
o No history of previous orthodontic treatment  
o All of the permanent dentition present excluding third molars. 
o Good oral hygiene before starting treatment. 
o Cases indicated for extraction of the maxillary first premolars and canine retraction into the 
extraction space with maximum anchorage. 
o Malocclusion cases that allow initial stage of leveling and alignment without extraction. 
 Exclusion Criteria: 
o Patients with systemic diseases especially bleeding disorders and osteoporosis. 
o History of administration of corticosteroids, exogenous hormones and non-steroidal anti-
inflammatory drugs (all drugs interfere with OTM). 
o Presence of previous history of oral surgeries in maxillary arch. 
    All the patients were examined clinically and following diagnostic case records were taken for every 
patient including a clinical examination chart, standardized photographs (extraoral & intraoral 
photographs), lateral cephalometric radiograph, panoramic radiograph and orthodontic study model. 
 
Study Design: This study included three phases: 
Phase I: Initial Orthodontic Treatment Phase 
Bonding and Banding: For all 16 patients the orthodontic treatment was started with installment of 
fixed orthodontic appliances to close the space that will be created after first premolar extraction and to 
restore an ideal occlusion and facial aesthetics.  
 Anchorage preparations: 1.4x8mm miniscrews were used to achieve maximum anchorage in all cases. 
At this point, the patients were ready for maxillary first premolar extraction.  
 Phase II: Intervention Phase: 
-Preoperative records included study model and periodontal pocket depth assessment. 
-Randomization: Randomized selection was done for patients that were treated with FTMPF (Full 
thickness mucopreiosteal flap) and other with LLLT (Low level laser thereby).  
- Extraction of first maxillary premolars: Extraction on the control side was done one week earlier than 
test side. The post extraction instructions were firm and clear not to use NSAIDs for analgesia, 
Paracetamol drugs were prescribed. 
Surgical Procedure (FTM PF Group): 
    A full thickness mucoperiosteal flap (FTMPF) was reflected on FTMPF side at the maxillary 
canine/premolar region by the same surgeon for all patients following the same procedures. 

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Disinfection for this area was done with Betadine. Subsequently, infiltration local anesthesia was 
injected on the canine-premolar region (buccal and palatal).  
 Flap design: 
      The canine root length was approximately detected digitally from the preoperative lateral 
cephalometric radiograph. Scalpel blade (number 15) was used to make the incision.  A free gingival 
sulcular incision was done from the distal surface of maxillary second premolar to the mesial side of the 
maxillary canine. A releasing oblique incision was done including the interdental papilla between 
maxillary canine and lateral incisor extending to the mucogingival junction just beyond the attached 
mucosa. The flap reflection extended beyond the canine root apex. A FTMPF reflection was done with 
mucoperiostal elevator. Free sulcus incision was done to allow elevation of palatal mucosa by tunneling 
technique on the palatal gingiva of maxillary canine. 
     Extraction of first maxillary premolar on this side was done using premolar extraction forceps. 
Irrigation and lavage with saline was done then tissue was reapproximated with simple interrupted 
sutures by 4-0 Prolyline. (Fig 1) 
  Canine retraction: 
    The same 0.016x0.022 Stainless Steel rectangular arch wire was inserted in the same day and canine 
retraction was immediately started. A NiTi closed coil spring (12mm) was used from the power arm 
mesial to upper canine to the miniscrews in both sides. A force gauge was used to ensure that the 
retraction force is within the physiological limits (150 g). 
- Low Level Laser Therapy Procedure (Group 2a): 
      LLLT was done using a diode soft laser (Epic X, BioLase, USA). It is a semiconductor diode soft 
laser. Active medium is In-Ga-As with 940nm wave length. LLLT protocol was using active laser tip 
(bleaching tip) 5w/cm2 output power with continuous radiation mode. All protective measures were 
taken. LLLT was done by the principal operator throughout the study with the following sequence 
3days after extraction, after 7 days, after 14 days, after 28 days, after 42 days, after 56 days 
 Measurements:     
      For all patients the rate of canine retraction was measured by measuring the distance moved by the 
maxillary canine through a series of 3D scanned study models and 3D superimposition. The distance 
Figure  1 : Flap design and elevation 

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was measured from the cusp tip of the maxillary canine to reference plane which was drawn just mesial 
to the 1st maxillary molar. In order to monitor the rate, study models were taken at T0 (just immediately 
before starting of retraction), T1 (At the 2nd week of retraction)(Interval 1),T2 (at the 6th week of 
retraction)( Interval2),T3 ( at the 14th week of retraction)( Interval3).T4 ( at the 16th week of retraction)( 
Interval4),T5 (at the end of retraction)( Overall Interval) 
Statistical analysis: 
     Values were presented as median (minimum – maximum), mean and standard deviation. As the data 
was nonparametric, the difference between the two techniques was evaluated by Mann-Whitney U test. 
While the difference between each technique and its control was assessed using Wilcoxon Signed 
Ranks test. All tests were bilateral and a P value of 5% was the limit of statistical significance. Analysis 
was performed by statistical package software IBM- SPSS version 21. 
 
RESULTS: 
      In the current study, the mean overall distance moved by maxillary canine by the end of retraction 
in FTMPF and its control side were {6.77mm (0.32), 6.70mm (0.35)} respectively. While in LLLT and 
its control were {6.88mm (0.24), 6.55mm (0.24)} respectively. There were a statistical significant 
differences in this distance in I1and I2. Moreover, there was a statistically significant difference 
between the mean distance moved by maxillary canine between I2 and I3 with a statistically significant 
difference in the overall distance in LLLT and its control. Subsequently, there were a statistically 
significant difference in this distance between FTMPF and LLLT in I 2 and I 3. (Table 1) 
Table1: Statistical comparison of the mean distance moved and difference in weekly rate maxillary of canine 
retraction between group 1a FTMPF and group 2a LLLT at different intervals by Mann-Whitney U test
 
Intervals 
Mean distance moved by maxillary canine FTMPF vs LLLT 
Mann-
Whitney U 
Wilcoxon W 
Z 
Asymp. Sig. (2-tailed) 
Exact Sig. [2*(1-tailed 
Sig.)] 
I1 
12.000 
48.000 
-1.862 
0.063 
0.072b 
I2 
2.500 
38.500 
-2.954 
0.003 
0.001b* 
I3 
5.500 
33.500 
-2.606 
0.009 
0.006b * 
I4 
27.000 
63.000 
-.116 
0.908 
0.955b 
I5 (Overall) 
25.000 
53.000 
-.347 
0.728 
0.779b 
 
Weekly rate of maxillary canine retraction FTMPF vs LLLT 
I1 
12.000 
48.000 
-1.862 
0.063 
0.072b 
I2 
2.500 
38.500 
-2.954 
0.003 
0.001b * 
I3 
5.500 
33.500 
-2.606 
0.009 
0.006b * 
I4 
27.000 
63.000 
-0.116 
0.908 
0.955b 
I5 (Overall) 
19.000 
55.000 
-1.042 
0.298 
0.336b 
a. Values with * are statistically significant with P value <0.05     b. Grouping Variable: Group         c. Not corrected for ties 
 
    Regarding each interval, there were statistically significant increase in I1 and I2.  The mean total 
weeks were needed to achieve full canine retraction {17.14 weeks (0.89)} in FTMPF and {22.42 

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weeks (0.97)} in control. While in LLLT and its control were {0.38mm/week (0.013)} and 
{0.28mm/week (0.01)} respectively. The mean total weeks were {17.87 weeks (0.83)} and its 
control {22.75 weeks (0.98)}. There was a statistically significant difference in the weekly rate of 
canine retraction in I2 and I3 between FTMPF and LLLT groups. (Table 1, Fig 2) (Table 2, Fig3) 
Table2: Statistical comparison of the difference in total number  of weeks needed to complete maxillary canine 
retraction between group 1a FTMPF and group 2a LLLT at different intervals by Mann-Whitney U test. 
Total Number of 
Weeks of Maxillary 
Canine Retraction 
FTMPF vs LLLT 
Mann-
Whitney U 
Wilcoxon W 
Z 
Asymp. Sig. 
(2-tailed) 
Exact Sig. [2*(1-
tailed Sig.)] 
16.500 
44.500 
-1.404 
0.160 
0.189b 
a. Values with * are statistically significant with P value <0.05    b. Grouping Variable: Group    c. Not corrected for ties. 
                    
 
 Figure 2: Line chart weekly rate of maxillary canine retraction between Group 1a FTMPF and Group 2a LLLT 
 
Figure 3: Bar chart showing mean total weeks for fullcanine retraction in FTMPF,LLLT and there control 
       The mean amount of mesial movement of 1st maxillary molar in FTMPF group and its control 
and LLLT and its control was {0.21mm (0.073), 0.26mm (0.13), 0.38mm (0.100), 0.36mm (0.076)} 
respectively. There was no statistical significant difference between those both groups. There was no 
statistical significant difference between those both groups. On the other hand, there was a 
statistically significant difference between the mean amount of mesial movement of 1st maxillary 
molar between FTMPF group and LLLT group; it was higher in the LLLT. In the current study, the 
amount of change in periodontal pocket depth average was assessed. In FTMPF group and its control 
was {0.13mm (0.20), -0.21mm (0.35)} respectively, with a statistically significant difference 
between FTMPF and its control. However, in LLLT ant its control group, t is {0.08mm (0.27), 
0.06mm (0.28)} respectively with no statistical significant difference in both groups. Also there were 
0
0.1
0.2
0.3
0.4
0.5
I 1
I 2
I 3
I 4
Overall
mm/week
Intervals
FTPF
LLLT
0
5
10
15
20
25
FTPF
LLLT
Control
FTPF
LLLT
Control

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no statistical significant difference in the mean average of periodontal pocket depth between FTMPF 
group and LLLT group.  
DISCUSSION: 
     The aim of the current study was to compare the acceleratory effect of a minimally invasive surgical 
technique in which only elevation of FTMPF with non-invasive technique as LLLT by evaluating the 
rate of canine retraction after using both techniques. According to literature there were no golden 
parameters for LLLT, a verity of different energy parameters (wave length, exposure time and mode 
radiation) were used 0.7j/cm2 (24), 5j/cm2 (27), 8j/cm2 (28) and 29j/cm2 (29). In the current study the total 
tissue energy was calculated according to manufacture recommendations 35j/cm2 in a continues mode 
for 100sec. The LLLT frequency of applications had also a great variability in the literatures. A 
previous study used LLLT at 0,3,7and 14 days then repeated it after every 21 days (28) and after 30 days 
(27). Another study (30) used 4 applications in the 1st month, then 2 applications per month for the end of 
canine retraction. Later study (29) apply LLLT at 0,7,14,21 days, then every 2weeks until the end of 
retraction. In the current study LLLT was applied at 0,7,14,24,48,56 days after starting retraction. 
      However, within every group, there were a statistical significant differences in the mean distance 
travelled by maxillary canine in I1 and I2 between the FTMPF and its control group. This finding is 
agreed with other studies which use any other minimal invasive surgical techniques. In those studies, 
it was clear that the acceleratory effect can be seen obviously in the first 4 weeks after procedure, 
then it effect begin to decrease or even disappear at 14 weeks duration (31,32) . In previous studies, 
which compare flap corticotomy to LLLT, the rate of canine retraction achieved on the corticotomy 
side was highest during the first 5 weeks and lowest at the 15th week which was corresponded to the 
current study results (29, 32, 33).  
       The highest rate in LLLT group of OTM was observed on the intervals (I2and I3) not earlier and 
not later. The peak of acceleration was seen at the first 10th week of retraction then it showed a sharp 
decrease after the 13th week of retraction. This is could be explained due to presence normal lag 
phase during OTM in order to remove the hyalinized bone to continue the canine retraction. 
Moreover, it could be due stoppage of LLLT application depending on the fact that the cellular 
response to laser therapy is dose dependent. Effectiveness of LLLT is believed that LLL is dose-
dependent and the force applied it can speed up or slow down biological processes depending on the 
fluency applied and the irradiation protocol, so there was a great difference in each study outcome 
(23,27,34). 
            Over the current study, there was a significant difference between FTMPF and LLLT groups 
in the weekly rate of canine retraction in I2 and I3. At I2 the FTMPF group has shown a higher 
weekly rate of canine retraction rather than the LLLT group, while in the I3 the LLLT group shown 
the higher weekly rate of canine retraction. These results were corresponded to former studies 
(27,29,30,35) findings. This could be explained as the RAP after FTMPF tend to start earlier than cellular 
stimulatory effect of LLLT.  
      In view of the current study, regarding the mean total weeks were needed to achieve full canine 
retraction, in FTMPF it showed a statistically significant decrease in the total retraction weeks which 

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were about 17.14 weeks versus 22.42 weeks in its control. Therefore, flap elevation increased the 
rate of tooth movement by approximately 25%. These results were in accordance with a former study 
that had showed the elevation of a full-thickness mucoperiosteal flap alone increases the rate of 
mesio-distal orthodontic tooth movement (18).   
         In LLLT, there was statistically significant decrease in the average total weeks for full canine. 
These results were in accordance with other previous studies regarding the concept only that LLLT 
accelerate the OTM but not in the amount of acceleration which may be due to different protocols were 
used for LLLT in every study (27).  
     However, comparing the FTMPF group with LLLT group, both interventions achieved a total 
decrease in treatment duration but with no statistically significant difference between both. 
Reviewing the literatures there was no similar study that evaluate the acceleratory effect of elevation 
of FTMPF alone on OTM in humans.  Moreover, there was no similar study that compare the 
FTMPF with LLLT using the same parameters. Clinically, FTMPF group showed about 25% 
decrease in the total time needed to achieve full canine retraction. While in LLLT group it showed 
about 20% decrease. These findings are in agreed with few of the former studies regarding 
acceleration but with different rates (18, 27, 28, 30). 
     There was a statistically significant difference between the mean amount of mesial movement of 
1st maxillary molar between FTMPF group and LLLT group, it was higher in the LLLT. This could 
be due to the extension of laser radiation effect to the 1st molar investing tissue as the LLLT was an 
area application rather than point application. This wasn't coordinate with a former study that had 
shown no statistically significant difference between Laser and surgical groups (29). 
      In the current study, the amount of change in periodontal pockets depth average for the maxillary 
canine were assessed in FTMPF group and its control. A statistically significant increase in the 
average periodontal pocket depth in FTMPF comparing to its control. This was agreed former study 
(28), while disagreed with other studies (29-32).     
CONCOLUSIONS 
      Within the limitation of this study and on the bases of the obtained results, a full thickness muco-
periosteal flap elevation (FTMPF) only could accelerate the rate of canine retraction clinically by 
25% of total conventional canine retraction time. A low level laser therapy (LLLT)application (within 
the parameters that was used in this study) could accelerate the rate of canine retraction clinically by 
20 % of the total conventional canine retraction time. Within Both techniques, there were no 
statistically significant difference on their effect on the rate of canine retraction. LLLT has showed 
more amount of molar anchorage loss (5%) than the FTMPF elevation (3%). Both techniques were 
safe regarding the periodontal health around the maxillary canine.  
REFERENCES 
1. Yina Li, Laura A. Jacox, Shannyn H. Little, Ching-Chang Ko, Kaohsiung. Review Article 
Orthodontic tooth movement: The biology and clinical implications J. Med. Sci. Res. 2018;34:207-
14. 

9 
 
2.  Mohammed M, Jawad A, Adam H, Mohammad K., Rozita H, Rumaizi S,. Effect of low level laser 
and low intensity by pulsed ultrasound therapy on bone remodeling during orthodontic tooth 
movement in rats. Prog Orthod. 2018;12: 10-9. 
3. Gurbax S, Raahat V S, Roopsirat K, Devinder P S. Accelerated Orthodontic Tooth Movement: A 
Review. Mod Res Dent. 2017;1:5-8. 
4. American Dental Association. The Future of Dentistry, pg. 81. Retreived 7/12/2005 at http:// 
www.ada.org/prof/resources/topics/futuredent/ future 2001. 
5. Skidmore KJ, Brook KJ, Thomson WM, Harding WJ. Factors influencing treatment time in 
orthodontic patients. Am J Orthod Dentofacial Orthop 2006;129:230-8. 
6. Fink DF, Smith RJ. The duration of orthodontic treatment. Am. J. Orthod. Dentofacial Orthop.  
1992;102:45-51. 
7.  Alger DW. Appointment frequency versus treatment time. Am. J. Orthod. Dentofacial Orthop.  
1988;94:436-439. 
8.  Popowich K, Nebbe B, Heo G, Glover KE, Major PW. Predictors for Class II treatment duration. 
Am. J. Orthod. Dentofacial Orthop.  2005;127:293-300. 
9. Boester CH, Johnston LE. A clinical investigation of the concepts of differential and optimal force 
in canine retraction. Angle Orthod 1974;44:113-9. 
10. Samuels RH, Rudge SJ, Mair LH. A comparison of the rate of space closure using a nickel-
titanium spring and an elastic module: a clinical study. Am J Orthod Dentofacial Orthop 
1993;103:464-7. 
11.  Gkantidis N. Effectiveness of non-conventional methods for accelerated orthodontic tooth 
movement: A systematic review and meta-analysis. J.Dent. 2014:5:1-20. 
12. Cano J, Campo J, Bonilla E, Colmenero C. Corticotomy-assisted orthodontics. J Clin Exp Dent 
2012;4:54-9. 
13. Mayur S., Rajkumar M., Harsh M, Harpreet S., Kunal A. Accelerated Orthodontics: A paradigm 
shift, J Indian Orthod Soc.  2017;3:64-8. 
14. Melsen B. Biological reaction of alveolar bone to orthodontic tooth movement. Angle Orthod 
1999;69:151-8. 
15. Safavi SM, Heidarpour M, Izadi SS, Heidarpour M. Effects of flapless bur decortications on 
movement velocity of dogs' teeth. Dent Res J.  2012;9:783-9. 
16. Swapp A, Campbell PM, Spears R, Buschang PH. Flapless cortical bone damage has no effect on 
medullary bone mesial to teeth being moved. Am J Orthod Dentofacial Orthop 2015;147:547-58.  
17. Yaffe A, Fine N, Binderman I. Regional accelerated phenomenon in the mandible following 
mucoperiosteal flap surgery. J Periodontol 1994;65:79-83. 
18. Owen KM, Campbell PM, Feng QJ, Dechow PC, Buschang PH. Elevation of a full-thickness 
mucoperiosteal flap alone accelerates orthodontic tooth movement. Am J Orthod Dentofacial Orthop 
2017;152:49-57. 
19. Lee W, Karapetyan G, Moats R, Yamashita DD, Moon HB, Ferguson DJ, et al. Corticotomy-
/osteotomy-assisted tooth movement micro CTs differ. J Dent Res 2008;87:861-7. 
20. Araújo MG, Lindhe J. Ridge alterations following tooth extraction with and without flap 
elevation: an experimental study in the dog. Clin Oral Implan Res 2009;20:545-9. 

10 
 
21. Alissa V, Ameet V. Revankar, Anand K. Patil. Low-level laser therapy increases interleukin-1b in 
gingival crevicular fluid and enhances the rate of orthodontic tooth movement. Am J Orthod 
Dentofacial Orthop. 2018: 1-12. 
22. Yoshida T, Yamaguchi M, Utsunomiya T, Kato M, Arai Y. Low-energy laser irradiation 
accelerates the velocity of tooth movement via stimulation of the alveolar bone remodeling. Orthod 
Cranio fac Res. 2009;12: 289-98.  
23. Kawasaki K, Shimizu N. Effects of low-energy laser irradiation on bone remodeling during 
experimental tooth movement in rats. Lasers Surg Med. 2000;26: 282-91.  
24. Karu TI, Afanas’eva NI. Cytochrome c oxidase as the primary photoacceptor upon laser exposure 
of cultured cells to visible and near IR-range light. Dokl Akad Nauk 1995;342: 693-5.  
25. Saito S, Shimizu N. Stimulatory effects of low‑power laser irradiation on bone regeneration in 
midpalatal suture during expansion in the rat. Am J Orthod Dentofacial Orthop 1997;111:525‑32. 
26. Angeletti P, Pereira MD, Gomes HC, Hino CT, Ferreira LM. Effect of low‑level laser therapy 
(GaAlAs) on bone regeneration in midpalatal anterior suture after surgically assisted rapid maxillary 
expansion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:38‑46. 
27. Cruz DR, Kohara EK, Ribeiro MS, Wetter NU. Effects of low intensity laser therapy on the 
orthodontic movement velocity of human teeth: a preliminary study. Lasers Surg Med 2004;35: 117-
20. 
28. Youssef M, Ashkar S, Hamade E, Gutknecht N, Lampert F, Mir M. The effect of low-level laser 
therapy during orthodontic movement: a preliminary study. Lasers Med Sci 2008;23:27-33. 
29. El-Ashmawi NM, Abd El-Ghafour M, Nasr S, Fayed MS, El-Beialy AR, Nasef E. Effect of 
surgical corticotomy versus low level laser therapy (LLLT) on the rate of canine retraction in 
orthodontic patients. Orthodontic Practice US.2018;5:1-11. 
30. Doshi-Mehta G, Bhad-Patil WA. Efficacy of low intensity laser therapy in reducing treatment 
time and orthodontic pain: A clinical investigation. Am J Orthod Dento facial Orthop 2012;141:289-
97. 
31. Eid FY, El-Kenany WA, El- Kalza AR. Effect of micro-osteoperforations on the rate of canine 
retraction; a split-mouth randomized controlled clinical trial Orthod J. 2017;52:57-64. 
32. Aboul SM, El-Beialy AR, El-Sayed KMF, Selim EMN, EL-Mangoury NH, Mostafa YA. 
Miniscrew implant-supported maxillary canine retraction with and without corticotomy- facilitated 
orthodontics. Am J Orhod Dentofacial Orhop. 2011;139:252-9. 
33. Alikhani M, Raptis M, Zoldan B. Effect of micro-osteoperforations on the rate of tooth 
movement. Am J Orthod Dentofacial Orthop. 2013;144:639-48. 
34. Marquezan M, Bolognese AM, Araujo MT. Effects of two low-intensity laser therapy protocols 
on experimental tooth movement. Photomed Laser Surg. 2010;28: 757-62. 
35. Arumughan S, Somaiah S., Muddaiah S., Shetty B.,  Reddy G.  Roopa S. A Comparison of the 
Rate of Retraction with Low-level Laser Therapy and Conventional Retraction Technique. Contemp 
Clin Dent. 2018; 9: 260–6. 
 
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