Journal of Oral Rehabilitation

Journal of Oral Rehabilitation 2017 44; 636–654

Review
Effectiveness of adjunctive interventions for accelerating
orthodontic tooth movement: a systematic review of
systematic reviews
J. YI* , J. XIAO†, H. LI†, Y. LI†, X. LI* & Z. ZHAO† *Department of Pediatric Dentistry, State Key
Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University,
Chengdu, and †Department of Orthodontics, State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases,
West China Hospital of Stomatology, Sichuan University, Chengdu, China

SUMMARY This study was aimed to summarise the efficacy of photobiomodulation, pulsed
published systematic reviews (SRs) that assess the electromagnetic field, interseptal bone reduction,
effects of adjunctive interventions on the two vibrational devices (Tooth Masseuse and
acceleration of orthodontic tooth movement Orthoaccel) and electrical current was of very low
(OTM). Electronic and manual searches were quality. Relaxin injections and extracorporeal
performed up to August 2016. Systematic reviews shock waves were reported to have no impact on
investigating the impact of adjunctive techniques OTM according to low- and very low-quality
on the promotion of OTM were included. The evidence, respectively. Based on currently
methodological quality of the included reviews available information, we conclude that low-
was evaluated using the A Measurement Tool to quality evidence indicates that LLLT (5 and
Assess Systematic Reviews (AMSTAR) scale. The 8 J cm 2) and corticotomy are effective to
quality of evidence for each intervention was promote OTM in the short term. Future high-
assessed using GRADE. The Jadad decision quality trials are required to determine the
algorithm was used to select a study to provide optimal protocols, as well as the long-term effects
body evidence from discordant reviews on the of LLLT and corticotomy, before warranting
same intervention. A total of 11 SRs were recommendations for orthodontics clinics.
included in this study. AMSTAR scores ranged KEYWORDS: orthodontics, tooth movement, alveolar
from 4 to 10 of 11. The quality of evidence ranged process, low-level light therapy, osteotomy, bone
from very low to low. The short-term (1– remodelling
3 months) effects of low-level laser therapy (LLLT,
5 and 8 J cm 2) and corticotomy were supported Accepted for publication 12 March 2017
by low-quality evidence. The evidence regarding

accumulate time-dependent side effects, such as exter-

Background
nal root resorption, caries and periodontal disease (3,
Orthodontic treatment duration, which is affected by 4). Thus, shortening the treatment duration is highly
numerous factors, including case severity, treatment desirable as it offers convenience and aesthetics and
plan, clinical proficiency and patient compliance, typi- reduces the likelihood of aforementioned adverse
cally ranges from 24 to 36 months in current clinical events to patients.
situations (1, 2). Time-consuming treatments not only It has been well recognised that orthodontic tooth
decrease the quality of life of patients but also movement (OTM) is achieved through a series of

© 2017 John Wiley & Sons Ltd doi: 10.1111/joor.12509

 ADJUNCTS FOR ACCELERATING OTM 637

biological events, including the remodelling of alveo- respectively. The search strategies are summarised in
lar bone, the periodontal ligament, the vasculature Appendix S1. No restrictions of language or publica-
and neural elements under the stimulus of orthodon- tion date were applied to the search process.
tic forces (5). To date, numerous novel adjunctive Moreover, a manual search was performed by
methods have been reported to accelerate this process reviewing the titles and abstracts of publications in
and shorten the treatment duration in clinical trials relevant journals and reference lists of included
and case reports (6). However, the clinical application studies.
of these techniques remains limited, a major reason of
which is the inconclusive results and unreliable
Study inclusion
methodology of the clinical research studies (7).
The conclusions provided by systematic reviews The inclusion criteria were as follows: (i) an SR or
(SRs) are regarded as the highest standard of scientific MA; (ii) the design of primary studies should be ran-
evidence because all results from clinical research on domised controlled trials (RCTs) or controlled clinical
a specific topic are pooled to generate evidence-based trials (CCTs); and (iii) the study should systematically
clinical practice recommendations (8). Moreover, SRs evaluate the effectiveness of adjunctive interventions
with meta-analysis (MA) could quantify the effective- that accelerate OTM. The exclusion criteria were as
ness of the interventions by calculating overall esti- follows: (i) narrative reviews; (ii) animal studies
mates of outcomes (9). Thus, SRs and MA are included; (iii) primary studies included cohort studies,
superior alternatives for practitioners who might case–control studies, case series, case reports or
encounter multiple investigations on the same clinical descriptive studies; and (iv) repeated publications.
question but differ in the reported results and Two reviewers (J.Y. and J.X.) independently assessed
conclusions. studies for inclusion or exclusion; disagreements were
Recently, several SRs and MAs focusing on inter- resolved through a discussion with a third reviewer to
ventions that accelerate OTM have been published. obtain a consensus (Y.L.).
Despite the promise that SRs and MAs could solve
the conflicting results of primary studies, different
Data extraction and analysis
conclusions among these publications have become
apparent due to variation in the quality of the pri- A standardised form was developed for data extraction
mary study, SR methodology and publication time. from the included studies. Two reviewers indepen-
This condition produces difficulties for clinicians in dently collected relevant information, including the
the evaluation of evidence and decision making name of the first author, the publication year, the
when several techniques have been reported to study design, the type of primary studies, interven-
accelerate OTM. tions, number of participants, outcomes, quality of
Therefore, we performed an SR of published SRs primary studies, results and conclusions. Disagree-
and MAs regarding adjunctive interventions that ments were resolved through mediation with a third
accelerate OTM to assess the methodological quality reviewer (Y.L.).
of these studies, grade the outcomes and summarise
the body of evidence based on current information.
Quality assessment of the included reviews

The methodological quality of recruited SRs was

Methods
assessed independently by two reviewers using the A
Measurement Tool to Assess Systematic Reviews
Search strategy
(AMSTAR) checklist. The AMSTAR checklist includes
The electronic literature search was conducted in 11 domains that appraise several critical steps of con-
databases including PubMed, Embase, Cochrane ducting an SR, including literature search and inclu-
Library and Scientific Electronic Library Online on sion, quality assessment of primary studies and
21 August 2016. We used a combination of Medical statistical analysis (10, 11). The methodological qual-
Subject Headings with relevant free text words to ity of an SR was scored as high (score ≥9), moderate
search in PubMed and optimised for each database, (score 5–8) or low (score ≤4). AMSTAR score

© 2017 John Wiley & Sons Ltd

638 J . Y I et al.

Fig. 1. PRISMA flow diagram for

the study selection process.

discrepancies were resolved by discussion with a third disagreement was resolved by reaching a consensus
reviewer. through discussion.

Quality assessment of the body evidence Results

The results and conclusions of SRs assessed as moder-
Search results
ate and high quality according to the AMSTAR check-
list were used to construct the whole body of A total of 496 records were identified through the ini-
evidence. GRADE was utilised to rate the quality of tial electronic and manual search. After removing
the evidence for each type of adjunctive technique duplicate studies, the titles and abstracts of the
(12). The GRADE approach determines the evidence remaining 464 records were screened, among which
level by assessing several methodological domains, 438 irrelevant citations were excluded. Full texts of
including risk of bias, inconsistency, indirectness, the 26 studies were retrieved and were evaluated
imprecision and publication bias (12). according to the inclusion and exclusion criteria.
Finally, 11 SRs were included in our review (15–25).
The detailed literature search process is presented in
Choice of the best body of evidence
Fig. 1 (PRISMA flow diagram). The information from
When an intervention was addressed by numerous the excluded records is summarised in Appendix S2.
SRs with discordance, the Jadad decision algorithm Cohen’s Kappa coefficient was calculated to assess the
was applied to choose the SR that provides the best measure of agreement in the literature search (26); a
body of evidence according to the currently available score of 0
89 was an indicator of low interobserver
studies (13, 14). The Jadad decision algorithm is bias (27).
designed to help decision makers select from discor-
dant reviews by confirming the sources of inconsis-
Characteristics of included reviews
tency on the basis of differences in the clinical
question, study selection, data extraction, quality The general information of included SRs is sum-
assessment of primary studies, data combinations and marised in Table 1. Three studies exclusively included
statistical analysis (13). The algorithmic assessment RCTs, whereas the other eight involved RCTs and
was performed by two reviewers independently. Any CCTs. More than half of the recruited SRs (6 of 11)

© 2017 John Wiley & Sons Ltd

 Table 1. Characteristics of included reviews

Type of primary Participants Quality of primary Authors’ conclusion

© 2017 John Wiley & Sons Ltd

Study Study design studies Interventions number Outcomes studies Results and comment

Long (2013)15 SR RCT (n = 7) LLLT (n = 4); 101 Primary: accumulative moved Cochrane collaboration LLLT: no significant differences C: LLLT is safe but
MA (on LLLT) CCT (n = 2) Corticotomy (n = 2); distance; movement rate; tool for assessing risk in tooth movement rate, unable to accelerate
Electrical stimulation Secondary: pain improvement; of bias: 2 low quality; periodontal health and root OTM; Corticotomy
(n = 1); anchorage loss; periodontal 5 medium quality; resorption between LLLT is safe and able to
Pulsed electromagnetic health; caries; pulp vitality; 2 high quality and control group. accelerate OTM;
field (n = 1); root resorption Corticotomy: faster movement Current evidence
Dentoalveolar rate in the corticotomy group. does not reveal
distraction No difference in anchorage whether electrical
vs. Periodontal loss and periodontal health. current and pulsed
Distraction (n = 1) Electrical current: significantly electromagnetic fields
improved accumulative are effective in
moved distance. accelerating OTM.
Pulsed electromagnetic field: dentoalveolar or
the accumulative moved distance periodontal distraction
was larger in the pulsed is promising in
electromagnetic field group. accelerating orthodontic
Dentoalveolar distraction (DD) tooth movement but
vs. periodontal distraction (PD): lacks convincing evidence.
the required time was Q: The results of this
significantly shorter in the DD SR must be interpreted
group than in the PD group with caution because
of several limitations,
including the small
number of high-quality
studies and limitation
of statistical pooling
due to clinical or
methodological
heterogeneity and
non-comparability
of outcome data

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Table 1. (continued)

Type of primary Participants Quality of primary Authors’ conclusion

Study Study design studies Interventions number Outcomes studies Results and comment
J . Y I et al.

Long (2015)16 SR RCT (n = 4) LLLT (n = 5) 374 Accumulated moved distance Cochrane collaboration The overall effect of LLLT on C: Weak evidence
MA (on LLLT) CCT (n = 1) tool for assessing risk accumulative moved distance suggests that LLLT at
of bias: 3 medium was significant at 1 month, the wavelength of
quality; 2 high quality while not at 2 and 3 month 780 nm, the fluence
However, substantial of 5 J cm 2 and/or
heterogeneity was detected. the output power of
Subgroup analysis showed 20 mW could accelerate
LLLT at the wavelength of OTM within 2 and
780 nm, the fluence of 3 months. However,
5 J cm 2 and/or the output the effectiveness of
power of 20 mW could LLLT at other parameters
accelerate orthodontic tooth cannot be determined
movement within 2 and due to insufficient data
3 months significantly or potential bias in this
meta-analysis. Moreover,
we cannot determine its
effectiveness within
1 month due to potential
measurement errors.
Q: The limitations of
this meta-analysis
included limited number
of included studies, low
quality of evidence, and
potential publication bias.
Thus, future studies with
high quality of evidence
are called for
Gkantidis (2014)17 SR RCT (n = 12) LLLT (n = 8) 354 Primary: OTM rate; Cochrane collaboration Corticotomy: Meta-analysis C: There is moderate
MA (on LLLT CCT (n = 6) Corticotomy (n = 7) accumulative moved distance; tool for assessing risk suggests higher tooth evidence on LLLT and
and corticotomy) Interseptal bone Secondary: patients’ of bias: 8 high risk;8 movement rate by 0
73 mm low evidence on
reduction (n = 1) quality of life; potential unclear risk;2 low risk month 1 with corticotomy vs. corticotomy regarding
Pulsed electromagnetic adverse effects the control technique for the their effectiveness in
fields (n = 1) first month of retraction acceleration of
Photobiomodulation LLLT: Meta-analysis suggests orthodontic tooth
(n = 1) higher tooth movement rate movement.
with LLLT vs. the control Q: The limitations of
technique the SR included the
interseptal bone reduction/ shortage of high-quality
pulsed electromagnetic fields/ studies, substantial
photobiomodulation: heterogeneity, the lack
The evidences are of cost-benefit analysis
limited and of very and the lack of data
low quality of entire treatment

(continued)

© 2017 John Wiley & Sons Ltd

 Table 1. (continued)

Type of primary Participants Quality of primary Authors’ conclusion

Study Study design studies Interventions number Outcomes studies Results and comment

Ge (2014)18 SR RCT (N = 6) LLLT 211 Primary: OTM rate Cochrane collaboration The accumulative moved C: This SR and

© 2017 John Wiley & Sons Ltd

MA (on CCT (N = 3) accumulative moved tool for assessing risk distance was statistically meta-analysis
corticotomy) distance; of bias: 5 moderate risk increased in the LLLT demonstrated that LLLT
Secondary: adverse event; of bias; 4 high risk of bias group in 7 days and might speed up the tooth
LLLT parameters 2 months. Marginal movement in orthodontic
significance was found treatment. Moreover, a
in 3 months. No difference relatively lower energy
was found in 1-month. density (2
5, 5, and
There was no evidence that 8 J cm 2) was seemingly
LLLT would do damage to more effective than 20
roots, alveolar bone and and 25 J cm 2, and even
periodontal tissues based higher ones, although the
on radiographs optimal dose remained
undetermined.
Q: The limitations of the
SR included the lack of
high-quality studies,
missing of data and
small samples
El-Angbawi SR RCT (n = 2) Tooth Masseuse (n = 1) 111 Primary: OTM rate; Cochrane collaboration Using the Tooth Masseuse for C: From the limited
(2014)19 Orthoaccel (n = 1) Secondary: pain perceptions; tool for assessing risk 20 min daily could promote evidence available,
unwanted side effects of bias: 2 high risk of bias the alignment of lower incisor it is not possible to
region over 10 weeks establish if the use
(not statistically significant) of vibrational forces
Using Orthoaccel for 20 min during treatment
daily produced a higher rate with fixed orthodontic
of maxillary canine distalisation appliances has a
in comparison with the control significant beneficial
group (marginal significant) or harmful effect on
Overall, the quality of the either the rate of
evidence was very low and orthodontic tooth
therefore we cannot rely movement or the
on the findings duration of treatment.
Q: The quality of
evidence was very low

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Table 1. (continued)
J . Y I et al.

Type of primary Participants Quality of primary Authors’ conclusion

Study Study design studies Interventions number Outcomes studies Results and comment

Kalemaj (2015)20 SR RCT (n = 15) Corticotomy (n = 6) 340 Primary: cumulative tooth Cochrane collaboration Corticotomy: accelerate OTM C: No firm
LLLT (n = 4) movement; rate and time tool for assessing risk during the first months after conclusions can be
Interseptal bone of tooth movement; of bias: 3 low risk of intervention, whereas the made on the efficacy
reduction (n = 1) Secondary: anchorage loss, bias; 6 moderate risk long-term effects are and benefit of the
Electrical current (n = 1) pain, periodontal health; of bias; 6 high risk questionable clinical use of
Relaxin injection (n = 1) bone/rot changes of bias LLLT: could accelerate OTM, corticotomy. The
Extracorporeal shock while the size of overall efficacy of LLLT on
waves (n = 1) benefits is quite small and accelerating OTM is
Pulsed electromagnetic therefore of no clinical not significant and
field (n = 1) relevance. the effect estimated
Interseptal bone reduction/ is not clinically relevant.
electrical-current devices/ The evidences suggesting
pulsed electromagnetic field: the benefit of interseptal
only research-based evidence bone reduction/electrical
suggest their efficacy in current/PEMF on OTM
enhancing OTM is only research-based
Extracorporeal shock and does not allow for
waves/relaxin injection: solid conclusions.
no significant effect on the Q: More high quality
rate of OTM clinical research is
required to estimate
the efficacy of
adjunctive
interventions on
accelerating OTM and
their potential clinical
use
Fleming (2015)21 SR RCT (n = 4) Corticotomy (n = 4) 57 Primary: overall duration Cochrane collaboration The MA od 4 studies suggest C: There is limited
MA (on of treatment; rate of OTM; tool for assessing risk corticotomy could accelerate amount of low quality
corticotomy) Secondary: periodontal of bias: 4 unclear risk the rate of OTM at 1 evidence concerning
health and inflammatory of bias (0
61 mm; 95%CI: the effectiveness of
response; pain experience 0
49–0
72) and 3 months surgical interventions
(2
03 mm; 95%CI: to accelerate OTM.
1
52–2
54) Q:further prospective
research concerning
the overall treatment
with longer follow-up
is required to confirm
any possible benefit

(continued)

© 2017 John Wiley & Sons Ltd

 Table 1. (continued)

Type of primary Participants Quality of primary Authors’ conclusion

Study Study design studies Interventions number Outcomes studies Results and comment

Patterson (2016)22 SR RCT (n = 6) Corticotomy (n = 14) 241 Primary: rate of OTM; Cochrane collaboration The corticotomy accelerate C: corticotomy can

© 2017 John Wiley & Sons Ltd

CCT (n = 8) Secondary: periodontium tool for assessing risk OTM compared to produce statistically
health; root resorption; of bias: 13 high risk of conventional OTM (from 1
3 and clinically
tooth vitality. bias; 1 unclear risk to 4 times); appear to have meaningful temporary
of bias no important adverse effects increases in the rate
on periodontal health, of OTM with minimal
root resorption and tooth side effects.
vitality Q: The body of the
evidence is generally
of a low quality
because of high risk
of bias of included
articles, and lack of
high-quality RCTs
Almeida (2016)24 SR RCT (n = 4) LLLT 73 Rate of OTM A revised checklist For the maxilla, there was C: There is no evidence
MA (on LLLT) CCT (n = 2) compressing 12 items: a statistically significant that laser therapy can
1 moderate quality; influence of the LLLT in accelerate the induced
5 high quality 3 months and, for the tooth movement.
mandible, in 1 month Q: The main limitation
of this meta-analysis is
caused by the limited
number of clinic
randomised trials in
well-designed humans,
in order to define the
optimal dose or density
Fernandez-Ferrer SR RCT (n = 11) Corticotomy 171 Not reported A simplified CONSORT All studies agree the C: Current evidences
(2016)23 CCT (n = 1) criteria: 5 high quality; corticotomy accelerates could not support the
7 medium quality OTM. Moreover, no corticotomy to be a
adverse effects on routine practice in
periodontal condition orthodontic clinics.
were found in the Q: The evidence is
short term not very strong since
the small sample sizes
in all cases and short
follow-up periods

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J . Y I et al.

Table 1. (continued)

Type of primary Participants Quality of primary Authors’ conclusion

Study Study design studies Interventions number Outcomes studies Results and comment

Sonesson (2017)25 SR RCT (n = 10) LLLT 637 Rate of OTM; The criteria of checklist The selected studies C: The quality of
CCT (n = 4) Pain perceptions for clinical trial of the reported promising evidence supporting
Swedish council on results for LLLT; LLLT to accelerate
Technology Assessment elevated acceleration orthodontic tooth
in Health care: 2 low of tooth movement movement is very
quality, 11 moderate and lower pain scores, low and low with
quality, 1 high quality than controls respect to modulate
acute pain.
Q: Future studies
should focus on the
consistency in study
design and conformity
of lase methods, to
determine whether
LLLT is an effective
method for
accelerating tooth
movement, or
modulating the
acute pain

SR, systematic review; MA, meta-analysis; LLLT, low-level laser therapy; OTM, orthodontic tooth movement; C, author’s conclusions; Q, authors’ comment on the quality of
review or evidence; RCT, randomised controlled trial.

© 2017 John Wiley & Sons Ltd

 ADJUNCTS FOR ACCELERATING OTM 645

were integrated into an MA. A total of 11 adjunctive LLLT and one review (21) on corticotomy were
techniques were addressed, including low-level laser selected.
therapy (LLLT), corticotomy, two commercial prod- There is evidence of low quality suggesting that
ucts with light vibrational forces (Tooth Masseuse and low-energy LLLT (5 and 8 J cm 2) could enhance the
Orthoaccel), electrical current, pulsed electromagnetic cumulative distance moved in 1 month (MD:
fields, interseptal bone reduction, photobiomodula- 0
72 mm; 95%CI: 0
42–1
06), 2 months (MD:
tion, extracorporeal shock wave, relaxin injection and 1
37 mm; 95%CI: 0
78–1
96) and 3 months (MD:
dentoalveolar/periodontal distraction. The primary 1
49 mm; 95%CI: 0
82–2
16), whereas high-energy
and secondary outcomes were the rate of tooth move- LLLT (20 and 25 J cm 2) could not (18). Very low-
ment or cumulative distance moved and adverse quality evidence revealed that LLLT reduced the pain
effects, such as root resorption, respectively, in most intensity within 1 month and caused no obvious
of the studies. adverse effects, such as root resorption or alveolar
bone height reduction (17).
Low-quality evidence suggested that a corticotomy
Methodological quality of the included reviews
could elicit more rapid tooth movement in 1 month
The AMSTAR scores with each question of the (MD: 0
61 mm; 95%CI: 0
49–0
72) and 3 months
included SRs are shown in Table 2. The kappa score (MD: 2
03 mm; 95%CI: 1
52–2
54)(21). Evidence of
regarding the agreement level was 0
92, suggesting very low quality indicated that a corticotomy had no
that the interobserver bias was low (27). The median significant effect on plaque index, probing depth,
AMSTAR score across the reviews was 6 (range 4–10). attachment loss or gingival recession (21).
Three studies were of high quality (score ≥9), six were Each of the interventions, except LLLT and cortico-
of moderate quality (score 5–8) and two were of low tomy, was only investigated by one primary study
quality (score ≤4) (Table 2). None of the included (Table 3). The evidence supporting the effectiveness
studies assessed the likelihood of publication bias. of photobiomodulation, pulsed electromagnetic field,
Only two Cochrane reviews provided the list of interseptal bone reduction, two commercial vibration
excluded studies. The key items that distinguished products (Tooth Masseuse and Orthoaccel) and elec-
studies with high AMSTAR scores included ‘a priori’ trical current on the acceleration of OTM were rated
design, a list of excluded studies and conclusions for- as very low (Table 3) (17, 19, 20). Reports of the inef-
mulated with a quality assessment of the primary fectiveness of relaxin injections and extracorporeal
studies. shock waves in the reduction of the treatment dura-
tion was of low and very low quality, respectively
(Table 3) (20).
Quality of evidence in included reviews

The overall quality of the evidence in the included

Discussion
studies was assessed using GRADE, and the results are
summarised in Table 3. The quality of the current evi- The currently available studies demonstrated conflict-
dence ranged from very low to low. The most fre- ing conclusions regarding the adjunctive interventions
quent reason for downgrading the quality was an for accelerating OTM. Thus, we systematically evalu-
unclear risk of bias. Nearly two-thirds of the evidence ated and summarised evidence of these interventions
was downgraded for imprecision, and half was down- from published SRs. The present review identified 11
graded for inconsistency (Table 3). SRs that addressed the effects of 11 adjunctive inter-
ventions on OTM.
Low-level laser therapy is a type of irradiation ther-
Effect of interventions
apy that does not induce an increase in temperature
To provide a definitive conclusion rather than a sim- in treated tissues (28). The best evidence regarding
ple narrative summary, the Jadad decision algorithm LLLT, which is of low quality, indicated that low-
was used to choose the best evidence when an inter- energy LLLT promotes tooth movement, whereas
vention was addressed by several discordant reviews high-energy LLLT could not (Fig. 2, Table 3) (18).
(13, 14). As shown in Fig. 2, two reviews (17, 18) on This conclusion is supported by another included SR

© 2017 John Wiley & Sons Ltd

 646
J . Y I et al.

Table 2. AMSTAR Criteria for included reviews

Long Long Gkantidis Ge El-Angbawi Kalemaj Fleming Patterson Almeida Fernandez-Ferrer Sonesson
(2013)15 (2015)16 (2014)17 (2014)18 (2015)19 (2015)20 (2015)21 (2016)22 (2016)24 (2016)23 (2017)25

Was an ‘a priori’ design provided? 0 0 1 0 1 0 1 0 1 0 0

Was there duplicate study 0 0 1 1 1 1 1 1 0 0 0
selection and data extraction?
Was a comprehensive literature 0 0 1 1 1 1 1 0 0 1 1
search performed?
Was the status of publication 1 1 1 0 1 0 1 1 1 0 0
(i.e. grey literature) used as
an inclusion criterion?
Was a list of studies (included and 0 0 0 0 1 0 1 0 0 0 0
excluded) provided?
Were the characteristics of the 1 1 1 1 1 1 1 1 1 1 1
included studies provided?
Was the scientific quality of the 1 1 1 1 1 1 1 1 1 0 1
included studies assessed and
documented?
Was the scientific quality of the 0 1 1 0 1 0 1 0 0 0 1
included studies used appropriately
in formulating conclusions?
Were the methods used to combine 1 1 1 1 1 1 1 1 1 1 1
the findings of studies appropriate?
Was the likelihood of publication 0 0 0 0 0 0 0 0 0 0 0
bias assessed?
Was the conflict of interest stated? 0 0 1 0 1 1 1 0 1 1 1
Total 4 5 9 5 10 6 10 5 6 4 6

1: yes; 0: no/cannot answer.

© 2017 John Wiley & Sons Ltd

 Table 3. Assessment of evidence quality using GRADE approach

Number of
Study participants

© 2017 John Wiley & Sons Ltd

Study Intervention Outcome type Effect estimates (studies) Conclusions GRADE

Long LLLT vs. no Accumulative moved MA MD: 0
54 mm 41 (3 studies) Cannot determine the effects ⊕⊝⊝⊝
(2015)16 intervention distance (1 month) (95%CI: 0
18–0
91) very low1a,2a,3a
Accumulative moved MA MD: 1
11 mm 21 (2 studies) LLLT (wavelength of 780 nm, ⊕⊕⊝⊝
distance (2 month) (95%CI: 0
91–1
31) at influence of 5 J cm 2, low1b,2a,3b,5
and/or the output power of
20 mW) could enhance OTM
Accumulative moved MA MD: 1
25 mm 10 (1 studies) LLLT (wavelength of 780 nm, ⊕⊕⊝⊝
distance (3 month) (95%CI: 0
68–1
82) at influence of 5 J cm 2, low1b,2a,3a,5
and/or the output power
of 20 mW) could enhance OTM
Gkantidis Corticotomy vs. no Rate of OTM (1 month) MA MD: 0
73 mm 23 (2 studies) Able to accelerate OTM ⊕⊕⊝⊝
(2014)17 intervention (95%CI: 0
28–1
19) low1c,3b
Pain (3 day and Narrative Not pooled 10 (1 study) No effect on pain intensity ⊕⊝⊝⊝
1 month) very low1c,3c
Periodontal health Narrative Not pooled 13 (1 study) Safe for periodontal health ⊕⊝⊝⊝
very low1c,3c
LLLT vs. no Rate of OTM MA MD: 0
42 mm 30 (2 studies) Able to accelerate OTM ⊕⊕⊝⊝
intervention (3–4
5 month) (95%CI: 0
26–0
57) low1d,3b
Pain Narrative Not pooled 20 (1 study) Reduce pain intensity ⊕⊝⊝⊝
very low1d,3c
Adverse effects Narrative Not pooled 10 (1 study) No effect on root resorption ⊕⊝⊝⊝
and alveolar bone height very low1d,3c
Photobiomodulation vs. Cumulative moved Narrative Not pooled 10 (1 study) Enable to accelerate OTM ⊕⊝⊝⊝
no intervention distance very low1i,3c
Pulsed electromagnetic Cumulative moved Narrative Not pooled 10 (1 study) Enable to accelerate OTM ⊕⊝⊝⊝
field distance very low1i,3c
vs. no intervention
Interseptal bone Rate of OTM Narrative Not pooled 18 (1 study) Enable to accelerate OTM ⊕⊝⊝⊝
reduction (3 months) very low1i,3c
vs. no intervention

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Table 3. (continued)
J . Y I et al.

Number of
Study participants
Study Intervention Outcome type Effect estimates (studies) Conclusions GRADE

18
Ge (2014) LLLT vs. no Accumulative moved MA MD: 0
19 mm 146 (3 studies) Able to accelerate OTM ⊕⊝⊝⊝
intervention distance (7 day) (95%CI: 0
02–0
37) very low1e,2a
Accumulative moved MA Low energy density: 42 (3 studies) LLLT (5 and 8 J cm 2) ⊕⊕⊝⊝
distance (1 month) MD: 0
74 mm could accelerate OTM, low1a,2a,3b,5
(95%CI: 0
42–1
06) but LLLT with higher
High energy density: energy density (20 and
MD: 0
16 mm 25 J cm 2) could not
(95%CI: 0
27
to 0
58)
Accumulative moved MA Low energy density: 65 (5 studies) LLLT (5 and 8 J cm 2) ⊕⊕⊝⊝
distance (2 month) MD: 1
37 mm could accelerate OTM, low1a,2a,3a,5
(95%CI: 0
78–1
96) but LLLT with higher
High energy density: energy density (20 and
MD: 0
01 mm 25 J cm 2) could not
(95%CI: 0
11
to 0
09)
Accumulative moved MA Low energy density: 42 (3 studies) LLLT (5 and 8 J cm 2) ⊕⊕⊝⊝
distance (3 month) MD: 1
49 mm could accelerate OTM, low1f,2a,3a,5
(95%CI: 0
82–2
16) but LLLT with higher
High energy density: energy density (20 and
MD: 0
17 mm 25 J cm 2) could not
(95%CI: 0
09
to 0
44)
Adverse effects Narrative Not pooled 68 (5 studies) Safe for periodontal tissue. ⊕⊕⊝⊝
low1a,2b
El-angbawi A vibration appliance Rate of OTM Narrative Not pooled 64 (1 study) Able to accelerate ⊕⊕⊝⊝⊝
(2015)19 (Tooth Masseuse) vs. OTM but not clinically very low1g,3d,4
no intervention important
Pain Narrative Not pooled 64 (1 study) No effect on pain intensity ⊕⊝⊝⊝
very low1g,3d,4
A vibration appliance Rate of OTM Narrative Not pooled 45 (1 study) Able to accelerate OTM ⊕⊝⊝⊝
(Orthoaccel) vs. but not clinically important very low1h,3d,4
no intervention Adverse effects Narrative Not pooled 45 (1 study) No obvious adverse effects ⊕⊝⊝⊝
very low1h,3d,4

(continued)

© 2017 John Wiley & Sons Ltd

 Table 3. (continued)

Number of
Study participants
Study Intervention Outcome type Effect estimates (studies) Conclusions GRADE

Kalemaj Corticotomy vs. Rate of OTM Narrative Not pooled 39 (3 studies) Able to accelerate ⊕⊕⊝⊝
(2015)20 no intervention (short-term OTM low1j,2c
1 month)
Rate of OTM Narrative Not pooled 60 (5 studies) Effects are ⊕⊕⊝⊝
(long-term controversial low1i,2c

© 2017 John Wiley & Sons Ltd

more than
1 month)
Adverse effects Narrative Not pooled 53 (3 studies) No obvious adverse ⊕⊕⊝⊝
effects low1a,2b
LLLT vs. no Rate of OTM Narrative Not pooled 63 (4 studies) Slightly accelerate OTM ⊕⊕⊝⊝
intervention but not clinical low1c,2b
important
Pain Narrative Not pooled 20 (1 study) Positive effect on ⊕⊝⊝⊝
pain release very low1f,3c
Interseptal bone Pate of OTM Narrative Not pooled 18 (1 study) Enable to accelerate ⊕⊝⊝⊝
reduction (3 months) OTM very low1i,3c
vs. no intervention
Electrical current vs. Accumulative moved Narrative Not pooled 7 (1 study) Enable to accelerate ⊕⊝⊝⊝
no intervention distance (4 weeks) OTM very low1i,3c
Extracorporeal shock Rate of OTM (4 months) Narrative Not pooled 13 (1 study) No effect on the rate of OTM ⊕⊝⊝⊝
waves vs. no intervention very low1i,3c
Pulsed electromagnetic Cumulative moved Narrative Not pooled 10 (1 study) Enable to accelerate ⊕⊝⊝⊝
field vs. no intervention distance OTM very low1i,3c
Relaxin injection Time for tooth Narrative Not pooled 39 (1 study) No effect on the rate ⊕⊕⊝⊝
movement of OTM low3c
Fleiming Corticotomy vs. Accumulative moved MA MD: 0
61 mm 51 (3 studies) Enable to accelerate ⊕⊕⊝⊝
(2015)21 no intervention distance (1 month) (95%CI: OTM low1k,2c
0
49–0
72)
Accumulative moved MA MD: 2
03 mm 31 (2 studes) Enable to accelerate ⊕⊕⊝⊝
distance (3 months) (95%CI: 1
42–2
54) OTM low1k,2c
Adverse effects Narrative Not pooled 13 (1 study) No significant effect on ⊕⊝⊝⊝
plaque index, probing very low1k,3c
depth, attachment loss
and gingival recession.
Patterson Corticotomy vs. Rate of OTM Narrative Not pooled 206 (11 studies) Able to accelerate OTM ⊕⊕⊝⊝
(2016)22 no intervention temporarily (lasting a low1i,2c
few months)
Periodontal health Narrative Not pooled 125 (9 studies) No important ⊕⊕⊝⊝
adverse effect low1i,2c
Root resorption Narrative Not pooled 59 (4 studes) No adverse effect ⊕⊕⊝⊝
low1k,2c
Tooth vitality Narrative Not pooled 36 (3 studies) No adverse effect ⊕⊝⊝⊝
very low1k,2c,3c

(continued)
ADJUNCTS FOR ACCELERATING OTM
649
 650

Table 3. (continued)

Number of
Study participants
J . Y I et al.

Study Intervention Outcome type Effect estimates (studies) Conclusions GRADE

Almeida LLLT vs. no Rate of OTM MA Maxilla: MD: 0
012 mm 31 (3 studies) LLLT increases the rate ⊕⊕⊝⊝
(2016)24 intervention (1 month) (95%CI: 0
296 to 0
959) of OTM in mandible, low1i,3b
Mandible:MD: 1
034 mm but not in maxilla.
(0
671–1
397)
Rate of OTM MA Maxilla:MD: 0
513 mm 42 (4 studies) No effect on rate ⊕⊕⊝⊝
(2 months) (95%CI: 0
226 to 1
252) of OTM low1i,3b
Mandible: MD: 0
143 mm
(95%CI: 0
798 to 0
512)
Rate of OTM MA Maxilla:MD: 0
332 mm 21 (2 studies) LLLT increases the rate ⊕⊕⊝⊝
(3 months) (95%CI: 0
072–0
591) of OTM in maxilla, low1i,3b
Mandible: MD: 0
373 mm but not in mandible.
(95%CI: 0
381 to 1
126)
Sonesson LLLT vs. no Rate of OTM Narrative Not pooled 60 (3 studies) Able to accelerate OTM ⊕⊝⊝⊝
(2017)25 intervention very low1e,2c
Pain Narrative Not pooled 617 (13 studies) Reduce pain intensity ⊕⊕⊝⊝
low1i,2c

OTM, orthodontic tooth movement; MA, meta-analysis.

1a
1CCT involved. Unclear randomisation procedures; Unclear whether outcome assessor blinded. Unclear blinding of participants. Downgraded for risk of bias by 1 level.
1b
Unclear randomisation procedures; Unclear blinding of participants. Downgraded for risk of bias by 1 level.
1c
Unclear randomisation procedures; Unclear blinding of participants, personnel and assessment. Downgraded for risk of bias by 1 level.
1d
Unclear randomisation, allocation concealment, and detection bias in one out of two studies. Downgraded for risk of bias by 1 level.
1e
Majority of the included studies (2 of 3) were controlled clinical trials. Unclear randomisation procedures, allocation concealment, assessment blinding and participant blinding. Downgraded for risk
of bias by 2 levels.
1f
Unclear random sequence generation, allocation concealment, incomplete outcome data and blinding of outcome assessment. Downgraded for risk of bias by 1 level.
1g
Unclear risk of allocation bias, performance bias and other source of bias. Downgraded for risk of bias for 1 level.
1h
Unclear risk of selection bias, detection bias, attrition bias, reporting bias. Downgraded for risk of bias for 1 level.
1i
Unclear risk of sequence generation, allocation concealment, blinding and incomplete outcome data. Downgraded for risk of bias for 1 level.
1j
Unclear risk of sequence generation and allocation concealment in 2 of the 3 studies. Downgraded for risk of bias for 1 level.
1k
Unclear risk of blinding of participants and personnel and outcome assessment. Downgraded for risk of bias for 1 level.
2a
High heterogeneity and no appropriate source explanations. Downgraded for inconsistency by 1 level.
2b
The measurement varied among the included studies. Downgraded for inconsistency by 1 level.
2c
The type of interventions and follow-ups varied among the included studies. Downgraded for inconsistency by 1 level.
3a
wide confidence interval. Downgraded for imprecision by 1 level.
3b
Total number of participants <50. Downgraded for imprecision by 1 level.
3c
Only 1 study with small number of participants (<50) was included. Downgraded for imprecision by 2 levels.
3d
Only 1 study was included. Downgraded for imprecision by 1 level.
4
Surrogate results. Downgraded for indirectness by 1 level.
5
Subgroup analysis based on LLLT parameters. Upgraded for dose-response gradient by 1 level.

© 2017 John Wiley & Sons Ltd

 ADJUNCTS FOR ACCELERATING OTM 651

Fig. 2. Flow diagram of the Jadad decision algorithm. [Colour figure can be viewed at wileyonlinelibrary.com]

that analysed the effects of LLLT using different proto- inconsistency and imprecision (Table 3). Notably, sub-
cols (16). Future research should investigate the opti- stantial differences in tooth movement types (space clo-
mal protocol of LLLT for the acceleration of OTM sure, canine retraction and alignment) and technique
using longer follow-ups. The magnitude of the effect procedures (traditional corticotomy, interseptal bone
sizes of LLLT was considered small to moderate reduction and micro-osteoperforations) exist among
(Table 3); thus, the clinical importance of LLLT imple- the primary studies (21). Therefore, the present evi-
mentation is questionable. The efficacy of LLLT in dence should be interpreted with caution given the
reducing orthodontic pain was reported with very small number of studies and high degree of hetero-
low-quality evidence (17), whereas only one dosage geneity. Future prospective clinical trials addressing the
of LLLT was investigated in the primary study (29). differences among corticotomy procedures with longer
Therefore, more RCTs investigating the effects of dif- follow-ups are required to verify this conclusion.
ferent LLLT protocols are needed to obtain more reli- Each of the other interventions was only investi-
able results. gated by a single clinical trial, which resulted in
According to the Jadad decision algorithm, a downgrading the quality of evidence on the basis of
Cochrane review (21) was selected to provide the opti- imprecision (Table 3). The ability of photobiomodula-
mal evidence of corticotomy efficacy (Fig. 2). This SR tion, pulsed electromagnetic field, interseptal bone
supported the effectiveness and safety of corticotomy in reduction, Tooth Masseuse, Orthoaccel and electrical
enhancing the velocity of tooth movement; however, current to reduce the treatment time was supported
the evidence quality was rated as low and very low and by evidence of very low quality (Table 3). Relaxin
was downgraded for an unclear risk of bias, injections and extracorporeal shock waves were

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652 J . Y I et al.

reported to have no effect on accelerating OTM based the excluded studies makes it difficult to explore the
on low and very low quality of evidence, respectively reasons for this variation (Table 2).
(Table 3). The available evidence is of very low qual- Because the AMSTAR checklist assesses several cho-
ity (except for relaxin injection, which was of low sen elements of reporting an SR rather than directly
quality), indicating the uncertainty with respect to evaluating the evidence, the GRADE approach was
current results (12). Thus, no recommendations can used to determine the overall quality of evidence. The
be made for clinical treatment regarding the afore- quality of evidence reported by included SRs ranged
mentioned techniques because of the limited number from very low to low. The most frequent reason for
of primary studies and participants. the evidence being downgraded is the unclear risk of
SRs included in this review have raised a common bias in the primary studies, including methodological
question regarding the clinical application of these flaws in randomisation procedures and blind methods
adjunctive interventions. Given that a certain adjunct (Table 3). Moreover, the evidence was also frequently
has been shown to accelerate OTM by synthesised downgraded for inconsistency and imprecision. This is
evidence, routine application in orthodontic clinics mainly caused by the different intervention protocols
remains a challenge. Using LLLT as an example, and the small number of primary studies and partici-
because current information indicates that LLLT- pants (Tables 1 and 3).
induced acceleration is sensitive to laser settings and Researchers should consider the results and implica-
could gradually decline (18), the optimal treatment tions of this review for conducting clinical trials and
timing, frequency and laser parameters should be SRs. First, the randomisation procedure and blind
carefully determined for clinical situations. However, method should be ensured in the design of future
the influence of patient characteristics such as age clinical trials. Second, the optimal protocol of a cer-
and gender with respect to LLLT protocol optimisation tain intervention should be explored by additional
remains unclear. Moreover, the cost-benefit ratio of studies comparing the effects of homogeneous inter-
LLLT for patients and clinicians needs more clarifica- vention with different protocols. Third, future studies
tion. Therefore, despite the promising results of clini- should investigate the long-term effects of these inter-
cal trials, the use of LLLT to accelerate tooth ventions and, in particular, the impact on the entire
movement remains limited. treatment. Fourth, the cost-benefit ratio of using
The AMSTAR scale is a validated tool that is widely adjunctive interventions for patients and clinicians
applied for the methodological quality assessment of should be investigated. Fifth, an SR should be con-
SRs (10). The average AMSTAR score of the included ducted strictly referring to the Cochrane handbook for
reviews is 6
3, indicating moderate overall quality. SRs of intervention (26) and Preferred Reporting
Among the 11 included SRs, no study satisfied the Items for Systematic Reviews and Meta-analysis
‘likelihood of publication bias’ criterion, which could (PRISMA) (31) to reduce methodological flaws.
be mainly caused by the scarcity of eligible primary The benefit of performing a SR of SRs is the abil-
studies and the weak statistical power of methods, ity to provide a wide-ranging perspective on avail-
such as funnel plots, when fewer than ten primary able techniques and a summary of current evidence.
studies are analysed (30). Additionally, the other However, several limitations exist in this study: (i)
items that were frequently unsatisfied included ‘was the primary study that was recently published could
an a priori design provided’ and ‘was a list of included be overlooked because only published SRs were
and excluded studies provided’. The a priori design included; (ii) more than one-third of the reviews
refers to the registered or predetermined protocol of neglected grey literature in their selection criteria,
performing SRs that could reduce the likelihood of SR which could restrict the analysis of the data source
duplication and prevent SRs from being changed by because unpublished literature could provide addi-
review author biases (10). Of the 11 included studies, tional evidence of ineffectiveness and potential side
only two Cochrane reviews provided the list of effects; (iii) we did not compare the efficacy or effect
excluded studies (19, 21). We noted a high variation size of different interventions because of the sub-
of included studies among the SRs with the same stantial methodological differences in the included
interventions and similar inclusion criteria in this studies. A network MA is needed to address these
review. Nevertheless, a lack of information regarding issues.

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 ADJUNCTS FOR ACCELERATING OTM 653

11. Shea BJ, Hamel C, Wells GA, Bouter LM, Kristjansson E,

Conclusion Grimshaw J et al. AMSTAR is a reliable and valid measure-
ment tool to assess the methodological quality of systematic
The present SR investigated the efficacy of adjunctive
reviews. J Clin Epidemiol. 2009;62:1013–1020.
interventions for accelerating OTM. Based on current 12. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y,
information, low-quality evidence suggested that LLLT Alonso-Coello P et al. GRADE: an emerging consensus on
and corticotomy are effective in promoting tooth rating quality of evidence and strength of recommendations.
movement, at least in the short term. There is clearly BMJ. 2008;336:924–926.
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more work to be performed to investigate the optimal
discordant systematic reviews. CMAJ. 1997;156:1411–1416.
protocols, as well as the long-term effects of LLLT and
14. Smith V, Devane D, Begley CM, Clarke M. Methodology in
corticotomy, and to evaluate other interventions. conducting a systematic review of systematic reviews of health-
care interventions. BMC Med Res Methodol. 2011;11:15.
15. Long H, Pyakurel U, Wang Y, Liao L, Zhou Y, Lai W. Inter-
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systematic review. Angle Orthod. 2013;83:164–171.
This work was supported by the National Natural 16. Long H, Zhou Y, Xue J, Liao L, Ye N, Jian F et al. The effec-
Science Foundation of China (Nos 11372202 and tiveness of low-level laser therapy in accelerating orthodon-
31470904), and the Orthodontic National Key Clinical tic tooth movement: a meta-analysis. Lasers Med Sci.
Specialty Construction Program of China, West China 2015;30:1161–1170.
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