Original Article

Low-level laser therapy effectiveness in accelerating

orthodontic tooth movement:
A randomized controlled clinical trial
Mohammad Moaffak A. AlSayed Hasana; Kinda Sultanb; Omar Hamadahc

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ABSTRACT
Objective: To evaluate the effectiveness of low-level laser therapy (LLLT) in accelerating
orthodontic tooth movement of crowded maxillary incisors.
Materials and Methods: This two-arm, parallel-group, randomized controlled trial involved 26
patients with severe to extreme maxillary incisors irregularity according to Little’s irregularity index,
indicating two first premolars extraction. Patients were randomly assigned to either the laser group
or the control group (13 each). Following premolars extraction, orthodontic treatment with fixed
appliances was initiated for both groups. Immediately after insertion of the first archwire, patients in
the laser group received a LLL dose from an 830-nm wavelength Ga-Al-As semiconductor laser
device with energy of 2 J/point. The laser was applied to each maxillary incisor’s root at four points
(two buccal, two palatal). Application was repeated on days 3, 7, 14, and then every 15 days
starting from the second month until the end of the leveling and alignment stage. Alignment
progress was evaluated on the study casts taken before inserting the first archwire (T0), after 1
month of treatment commencement (T1), after 2 months (T2), and at the end of the leveling and
alignment stage (T3). The outcome measures were the overall time needed for leveling and
alignment and the leveling and alignment improvement percentage.
Results: A statistically significant difference was found between the two groups in the overall
treatment time (P , .001) and the leveling and alignment improvement percentage at T1 (P ¼ .004)
and T2; (P ¼ .001).
Conclusion: LLLT is an effective method for accelerating orthodontic tooth movement. (Angle
Orthod. 2017;87:499–504)
KEY WORDS: Low-level laser therapy; Orthodontic tooth movement acceleration; Dental crowding;
Leveling and alignment

INTRODUCTION
a
Master’s Student, Department of Orthodontics and Dentofa- Dental crowding is considered the most common
cial Orthopaedics, Faculty of Dental Medicine, Damascus type of malocclusion. A survey stated that 78% of the
University, Damascus, Syria. American population have degrees of incisors irregu-
b
Senior Lecturer, Department of Orthodontics and Dentofacial
Orthopaedics, Faculty of Dental Medicine, Damascus University, larity, 15% of which is classified as severe to extreme.1
Damascus, Syria. Leveling and alignment of such cases may take up to 8
c
Senior Lecturer, Department of Oral Medicine, Faculty of months.2 In general, long orthodontic treatment time is
Dental Medicine, and Vice Dean, Higher Institute for Laser one of the main reasons patients refuse to undergo
Research and Applications, Damascus University, Damascus,
Syria.
treatment.3 It also has other disadvantages such as
Corresponding author: Dr Mohammad Moaffak A. AlSayed increased caries rates and root resorption.4 For these
Hasan, Department of Orthodontics and Dentofacial Orthopae- reasons, accelerating orthodontic tooth movement is
dics, Faculty of Dental Medicine, Damascus University, AlMaz- desirable to prevent those effects and encourage
zah Street, Damascus, Syria
(e-mail: drmoaffak89@gmail.com)
patients to undergo treatment. Several approaches
have been studied in an attempt to accelerate
Accepted: September 2016. Submitted: June 2016.
Published Online: November 21, 2016 orthodontic tooth movement, including local injection
Ó 2017 by The EH Angle Education and Research Foundation, of biological substances and surgical, mechanical, and
Inc. physical methods.5

DOI: 10.2319/062716-503.1 499 Angle Orthodontist, Vol 87, No 4, 2017

500 ALSAYED HASAN, SULTAN, HAMADAH

Recently, one of the physical methods, low-level and alignment of severely crowded incisors—assuming
laser therapy (LLLT), has proven to be effective in a 40% reduction in treatment time using LLLT—would be
inducing remodeling processes in the alveolar bone by 97.2 days. The standard deviation in the same study was
increasing osteoblast and osteoclast numbers, which 82.5 days. The statistical test to be used is a two-sample
leads to acceleration of orthodontic tooth movement.3,6 t-test with a statistical power of 80% and a significance
The application of LLLT in orthodontics has shown to level of 0.05. The given sample size was 26 patients (13
be effective in reducing orthodontic pain and in the per group).
photobiomodulation that might accelerate orthodontic
tooth movement.7,8 Several investigators have studied Participants
the use of LLLT in accelerating orthodontic tooth
Participants were recruited from patients attending
movement, most of them dealt with canine retraction

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the Department of Orthodontics and Dentofacial
cases.8,9 Some studies found laser effective while
Orthopaedics at Damascus University. Clinical exam-
others concluded the opposite.10,11 These conflicting
ination was done on 94 patients. Patients were
results may be explained by the difference in laser
considered eligible for the study if they met the
parameters used in each study regarding its type,
following inclusion criteria: aged between 16 and 24
application method, wavelength, dose of irradiation,
years, presence of all maxillary permanent teeth
and exposure time as these parameters relate directly
except third molars, moderate crowding (tooth-size–
to laser clinical results.6 Only three studies have
arch-length discrepancy of 3–5 mm) in the anterior
evaluated the LLL effect during leveling and alignment
maxilla with Little’s irregularity index (LII) of 7 mm or
of crowding cases.5,7,12 However, none of them was a
more—indicating extraction of two first premolars, the
randomized controlled trial (RCT), and they did not
feasibility of bonding brackets on all maxillary teeth, no
involve crowding cases with severe incisor irregularity.
previous orthodontic treatment, no systemic diseases,
Recent systematic reviews stated that there is a lack of
and good oral hygiene.
evidence regarding LLLT’s effectiveness in accelerat-
Exclusion criteria were patients with severe tooth
ing orthodontic tooth movement, so there is a need for
displacement (eg, ectopic canine) and those reporting
well-designed RCTs to determine the best protocols of
the use of medications throughout the study. Twenty-
laser parameters and present clear recommendations
six patients were selected to participate. The rights of
about its effects.10,11
patients were protected, and the purpose and methods
To the best of our knowledge, this is the first
of the study were completely explained to the patients
published RCT having the objective of evaluating LLLT
and parents; an informed consent was obtained from
effectiveness in accelerating leveling and alignment in
each.
dental crowding cases.

MATERIALS AND METHODS Randomization

Patients were assigned to a laser group or a control
Trial Design
group with an allocation ratio of 1:1 using a simple
This study is a two-arm, parallel-group, RCT randomization technique. Each patient was asked to
studying the effect of LLLT in accelerating tooth select a folded piece of paper from a box containing 26
movement in dental crowding cases. The CONSORT pieces of paper on 13 of which the word ‘‘laser’’ was
statement was used as a guide for this study.13 The written; on the other 13, the word ‘‘control’’ was written.
study was conducted in the Department of Orthodon- According to which piece was selected, the patient was
tics and Dentofacial Orthopaedics and Laser Research assigned to one of the two groups. The random
Unit at Damascus University between July 2015 and allocation sequence, participants’ enrollment, and
March 2016. Ethical approval was obtained from the assignment to intervention were done by the corre-
Ethics Committee at the Ministry of Higher Education in sponding author.
Syria (26106/SM). This RCT is registered in the Clinical
Trials database (NCT02568436). There is no funding Interventions
to be declared.
All 26 patients underwent conventional orthodontic
treatment with fixed appliances. Patients in the laser
Sample Size Calculation
group additionally underwent a LLL regimen through-
Sample size was calculated using the G*power 3.1.3 out the leveling and alignment stages.
program according to the following assumptions: de- Five to 7 days after first premolar extraction, fixed
pending on the results of a previous study2, The smallest orthodontic appliances of the MBT prescription and
clinically significant difference in time needed for leveling 0.022-inch slot height (American Orthodontics, Sheboy-

Angle Orthodontist, Vol 87, No 4, 2017

ACCELERATING TOOTH MOVEMENT WITH LOW-LEVEL LASER 501

Table 1. Laser Parameters Used in the Study

Active Medium Ga-Al-As
Emission type Continuous
Wavelength 830 nm
Dose of irradiation 2.25 J/cm2
Energy/point 2J
Output 150 mW
Exposure time/point 15 s
Application technique Direct contact
Laser sessions First mo: 4 (d 0, 3, 7, 14); starting
from the second mo: every 15 d
Laser classification 3B

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gan, Wisc) were bonded. Then a 0.014-inch NiTi
archwire (American Orthodontics) was inserted and tied
to each bracket in the maxillary arch using ligature wires.
Immediately after inserting the first archwire, a LLL dose
was applied for the laser group patients using an 830-nm
wavelength laser device (CMS Dental ApS, 55 Wilder-
Figure 1. Two illustrative cases representing treatment progress in
sgade, 1408 Copenhagen K, Denmark) with a 2.25-J/
the laser group (left panel) and the control group (right panel). LII:
cm2 irradiation dose. Laser device parameters are listed Little’s irregularity index; LAIP: Leveling and alignment improvement
in Table 1. The laser beam was applied to each root of percentage.
the six maxillary incisors roots. Each root was divided
into two halves: cervical and apical. The laser device tip sure was leveling and alignment improvement percent-
was applied to the center of each half, perpendicular to age (LAIP) of the maxillary teeth throughout the
the root and in direct contact with the mucosa from both leveling and alignment stage.
the buccal and palatal sides so that there were four To calculate outcome measures, a maxillary alginate
application points for each tooth with an exposure time of impression was taken to make study casts at four time
1 minute/tooth. The laser application was repeated on points: before insertion of the first archwire (T0), after 1
days 3, 7, and 14 after the first application and every 15 month of treatment commencement (T1), after 2
days starting from the second month until the leveling months (T2), and at the end of the leveling and
and the alignment stage was complete. Irradiation was alignment stage (T3), represented by final archwire
done by the corresponding author. insertion. LII was used to measure the change in tooth
alignment on the casts. It involved measuring the
Clinical Procedures horizontal linear distance among adjacent contact
For both groups, the archwire sequence used was points of the six anterior teeth. The sum of these five
0.014-inch NiTi followed by 0.016 3 0.016-inch and measurements gave the value of the index.14 LII was
0.017 3 0.025-inch NiTi, and finally 0.019 3 0.025-inch measured using a digital caliper (Insize, Insize Co,
stainless steel. Suzhou New District, China) to the nearest 0.01 mm by
Patients were evaluated every week starting from the corresponding author.
the second month. Wire progression was achieved OLAT was calculated by the number of days
only if there was less than a 0.5-mm change in tooth between T0 and T3. LAIP was calculated by dividing
movement within 2 weeks and the possibility of the amount of change in the LII value at a specific time
inserting the next archwire with full engagement into point (T1, T2, or T3; calculated by subtracting the LII
all brackets. Treatment was considered finished when value at T1, T2, or T3 from the LII value at T0) by Lll
LII was less than 1 mm, indicating complete alignment value at T0.
of the teeth and the feasibility of inserting the final
archwire passively into all brackets, indicating com- Error of the Method
plete leveling of the teeth (Figure 1).
To assess measurement reliability, 10 dental casts
(of the T1 casts) were randomly chosen, and LII was
Outcomes
remeasured 1 month after the first measurement.
The primary outcome measure was the overall time Reliability was evaluated using intraclass correlation
needed to complete leveling and aligning (OLAT) the (ICC), which gave a strong intraexaminer reliability
maxillary dental arch. The secondary outcome mea- (ICC ¼ 0.998), and the Dahlberg formula, which

Angle Orthodontist, Vol 87, No 4, 2017

502 ALSAYED HASAN, SULTAN, HAMADAH

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Figure 2. CONSORT flow diagram.

showed minimal error that does not affect the reliability control group (109.23 6 14.18 days); (P , .001), which
of the LII measurements. means a 26% decrease in overall treatment time.
Mean LAIP (Table 4) was significantly higher in the
Statistical Analysis laser group than in the control group at T1 and T2. At
T1, the percentage was 69.41 6 15.45% for the laser
Statistical Analysis was performed using the SPSS
group compared with 48.85 6 17.04% for the control
program version 20 (SPSS Inc, Chicago, Ill). The
group (P ¼ .004). At T2, the laser group LAIP was
Kolmogorov-Smirnov test was used to test normality of
89.42 6 7.16% compared with 71.71 6 16.18% for the
data distribution, which revealed normal distribution;
control group (P ¼ .001). No statistical significant
therefore, parametric tests were used. A two-sample t-
difference was found between the two groups at T3 (P
test was applied to evaluate the differences in OLAT
¼ .973).
and LAIP in each studied time point between the two
groups. Significance level was set at 0.05.
DISCUSSION
RESULTS This study aimed to evaluate the effectiveness of
LLLT in accelerating orthodontic tooth movement for
Patient flow through the study is illustrated in the
leveling and alignment of dental crowding cases. We
CONSORT flow diagram shown in Figure 2. Twenty-six
found that LLL accelerated leveling and alignment and
patients were recruited and allocated randomly to
reduced the overall time needed to achieve it by 26%.
either the laser group or the control group. No dropout
occurred, and complete follow-up and analysis were
Table 2. Sample Descriptive Statistics
achieved for all patients. Table 2 shows the descriptive
statistics of the sample regarding gender, age and Sex Initial LII* (mm) Age (y)
initial LII (at T0). N Male Female Mean SD Mean SD
Table 3 represents mean OLAT. A statistical Laser group 13 2 11 8.91 1.57 18.53 2.9
significance was found between the two groups. The Control group 13 4 9 10.8 2.29 21.61 2.63
laser group needed less mean time (81.23 6 15.29 Total sample 26 6 20 9.86 2.15 20.07 3.13
days) to complete leveling and alignment than did the * LII indicates Little’s irregularity index.

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ACCELERATING TOOTH MOVEMENT WITH LOW-LEVEL LASER 503

Table 3. Overall Leveling and Alignment Time (D) Table 4. Leveling and Alignment Improvement Percentage (%)
Min Max Mean SD P Value At T1 At T2 At T3
Laser group 57 106 81.23 15.29 Mean SD Mean SD Mean SD
Control group 85 141 109.23 14.18 ,.001*
Laser group 69.41 15.45 89.42 7.16 94.24 3.65
* Indicates significant. Control group 48.85 17.04 71.7 16.18 94.2 2.81
P value .004* .001* .973**
An 830-nm wavelength laser device was used in this * Indicates significant; **Nonsignificant.
study. This wavelength falls in the optimal range (600–
1000 nm),7 providing a proper photobiomodulation LAIP at T1 was 69.41 6 14.45% for the laser group
effect because it has a low absorbance coefficient in and 48.85 6 17.04% for the control group. These

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chromophores (ie, hemoglobin) and water that allows results indicate a 30% higher leveling rate for the laser
for proper penetration of the laser beam into the group. This percentage decreased to 20% at T2, with
tissues.15 Furthermore, previous studies with a similar LAIP of 89.42 6 7.16% for the laser group and 71.71
LLL wavelength found positive effects on orthodontic 6 16.18% for the control group. Results of this study
movement acceleration.8,12 agree with those of previous studies,8,9 which found a
The dose of irradiation has been reported as an decrease in the improvement rate throughout treat-
important laser parameter that affects orthodontic tooth ment. This decrease could be explained by the gradual
movement acceleration. No precise value has yet been decrease in the targeted tissues response to the laser
defined. However, Goulart stated that a lower irradia- over time and because most of the LAIP in the laser
tion dose value has a more positive effect.16 In this group occurred during the first month, meaning that no
study, a low dose of irradiation (2.25 J/cm2) was important development occurred toward the end of this
applied, which was effective in accelerating in accor- stage. No significant difference was found at T3 in
dance with the Sousa et al. study9 but contrary to the LAIP, which seems to be normal given that the main
Altan et al. study,17 which also used low irradiation factor to consider this stage finished was that LII was
doses. The other important parameter of LLLT is the less than 1 mm.
Two previous studies found that the movement
energy of the laser beam. Sousa et al. recommended
acceleration rate increased by 54%7 and more than
that for tooth movement acceleration it should range
100%5 between the laser group and the control group.
between 0.2 J and 2.2 J to be clinically effective.11 For
Those higher acceleration rates compared with this
that, an energy of 2 J/point was used in this study.
study’s findings might be explained by the fact that
Treatment progress was assessed every week
those studies applied LLL on a daily basis for a long
starting from the second month of treatment to ensure
application time each day utilizing complicated extra-
precise evaluation to avoid missing important changes
oral devices. However, this is not considered practical
in treatment, which could affect interpretation of the
for routine use in orthodontics compared with our
results. LII was used to assess treatment outcome protocol which applied the laser two or four times
measure regarding LAIP. It is simple, reproducible, and monthly with a LED-like portable device and an
considered to be an accurate and valid method of application time of 6 minutes/session.
measuring anterior arch-length discrepancy.18 Patients Doshi-Mehta and Bhad-Patil applied a similar proto-
with rotations or vertical discrepancies affecting LII col to evaluate the LLLT effect on accelerating canine
accuracy were excluded from participating in the retraction and found a 30% higher acceleration rate for
study.19 the laser group.8 Comparing the results of our study
Our results showed that overall treatment time was with theirs, considering two different phases of
81.23 6 15.29 days for the laser group and 109.23 6 treatment, and applying similar protocols with similar
14.18 days for the control group, which means that results, we conclude that the laser regimen and
laser application reduced leveling and alignment time parameters used in this study are effective; we
by about 26%. Camacho and Cujar found similar recommend them as proper parameters for laser
results with a 30% treatment time reduction.12 Howev- application in accelerating orthodontic tooth move-
er, they studied the whole treatment time until ment.
debonding of the fixed appliances, which may vary This study has some limitations: it was almost
between patients according to specific treatment impossible to obtain the same values of LII for the 26
needs. Also, the study involved cases with little patients at treatment commencement. However, we
crowding amount and pretreatment parameters be- tried to eliminate the effect of this factor by using the
tween the two groups were not adequately ad- improvement percentage for each patient (instead of
dressed.20 the LII value at each time point) as a criterion for

Angle Orthodontist, Vol 87, No 4, 2017

504 ALSAYED HASAN, SULTAN, HAMADAH

evaluating the development of each case. Besides, it is 6. Huang H, Williams RC, Kyrkanides S. Accelerated ortho-
difficult to control all the variables in the leveling and dontic tooth movement: molecular mechanisms. Am J
Orthod Dentofacial Orthop. 2014;146:620–632.
alignment stage as in other treatment stages (as
7. Shaughnessy T, Kantarci A, Kau CH, Skrenes D, Skrenes S,
canine retraction) because all teeth are involved in Ma D. Intraoral photobiomodulation-induced orthodontic
the movement. We tried to control that by recruiting tooth alignment: a preliminary study. BMC Oral Health.
cases with a close amount of initial crowding, 2016;16:3.
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weekly to avoid missing important changes in treat- laser therapy in reducing treatment time and orthodontic
pain: a clinical investigation. Am J Orthod Dentofacial
ment. Also, no blinding was applied to either operator
Orthop. 2012;141:289–297.
or patients, which sometimes risks bias. However, the 9. Sousa MV, Scanavini MA, Sannomiya EK, Velasco LG,
risk of bias was eliminated by randomizing patient

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 Low-level laser therapy, used with the described 14. Little RM. The irregularity index: a quantitative score of
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Angle Orthodontist, Vol 87, No 4, 2017

 Erratum

The authors’ names for Reference 12 in ‘‘Low-level laser therapy effectiveness in accelerating orthodontic
tooth movement: A randomized controlled clinical trial,’’ by Mohammad Moaffak A. AlSayed Hasan, Kinda
Sultan, and Omar Hamadah. Angle Orthod. 2017;87(4):499–504, were listed incorrectly. The reference should
read,

Dominguez A, Velásquez SA. Acceleration effect of orthodontic movement by application of low-intensity

laser. J Oral Laser Applications. 2010;10:99–105.

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125 Angle Orthodontist, Vol 88, No 1, 2018