Regional Acceleratory Phenomenon

Regional acceleratory phenomenon (RAP) is a sudden acceleration of normal tissue processes in reaction to noxious stimuli. It has been exploited in treatments such as the healing of atrophic or oligotrophic nonunions and surgically facilitated orthodontic therapy.

Background

In the early 1980s, American orthopedist Harold Frost published a review article detailing then known experiences with regional acceleratory phenomena, which can be caused by injuries such as fractures and burns, afflictions such as acute paralysis and arthritis, bone movement such as implant placement and orthodontics, as well as vitamin D, thyroxine, and electrical stimuli.[1][2][3][4][5][6] Once evoked, processes such as perfusion, the growth of skin, bone and other connective tissues, as well as their healing, turnover and remodeling can all accelerate beyond normal values.[7][8][9] More overt manifestations include warmness of an affected region, decreased bone density, and increased bone plasticity.[10] In rat tibia, more intense RAP was observed with deeper corticotomy.[11][12] RAP typically lasts four months but, in cases of branchial plexus injuries or severe burns, potentially over two years and predisposing the patient to hypercalciuria and genitourinary tract lithiasis.[13] If the causative stimuli were not removed, RAP may even persist indefinitely.[1]

Effects

The effects of regional acceleratory phenomenon can be positive or negative. A study in rabbits suggested that, following osteotomy, RAP contributed to a fivefold increase in new bone without a change in bone volume.[14] In tibial fractures, accelerated bone turnover allows the union of interfaces to occur typically within six months, compared to about twenty years for remodeling based on basic multicellular units (BMUs) alone.[15] On the other hand, increased collagen production due to RAP in rheumatoid arthritis or osteoid osteoma may lead to diffuse fibrosis and joint stiffening.[1]

Impaired RAP

Obtunded or absent RAP often accompanies sensory denervation.[16] In neuropathic soft tissue lesions, such as those in diabetics and certain frostbites, such impariment results in prolonged healing.[1] Similarly, against insults, Charcot joints display far less tissue responses such as edema, erythema, fibrosis, and bone production.[17][18] In late stage or some variants of rheumatoid arthritis, RAP may also be diminished; joints and ligaments become lax, allowing microscopic damages to accumulate leading to tendon rupture.[1]

Implications in research

Due to regional acceleratory phenomenon, repeated biopsies of the same bone may perturb the data being gathered.[1] Transient RAP may also mask the depressive effects of mechanical deloading on bone growth.[19] Experimental procedures may evoke RAP alongside other mechanical forces, such as when implanting hardware in a bone to measure the change in its diameter and porosity under mechanical compression, or when mechanically deloading bone by plate fixation, thereby yielding mixed results.[20][21][22][23]

Clinical uses

In dentistry

A 1994 study in rats found that the elevation of a mucoperiosteal flap is sufficient to induce RAP in the mandible.[24] In 2001, the Wilcko brothers reported that in two patients, accelerated tooth movement for orthodontics were achieved following partial decortication of the cortical plates and concomitant bone grafting; increased bone thickness and the covering of a previous bony fenestration were also observed.[25] Using similar techniques, the brothers went on to introduce periodontally accelerated osteogenic orthodontics (PAOO).[26] Corticision, a less invasive technique, introduces injury without the need for a flap reflection while still accelerating tooth movement.[27][28] Other recent innovations include the use of piezosurgery, micro-osteoperforation, vibrating devices, ultrasound, laser, or drugs to induce RAP.[29]

References
  1. Frost, Harold (1983-03-01). "The Regional Acceleratory Phenomenon: A Review". Henry Ford Hospital Medical Journal. 31 (1): 3–9. ISSN 0018-0416.
  2. Simmons, D. J.; Cohen, M. (1980-06-01). "Postfracture linear bone growth in rats: a diurnal rhythm". Clinical Orthopaedics and Related Research (149): 240–248. ISSN 1528-1132. PMID 7190883.
  3. Jenkins, D. H. R.; Cheng, D. H. F.; Hodgson, A. R. (1975-11-01). "Stimulation of bone growth by periosteal stripping". The Journal of Bone and Joint Surgery. British Volume. 57-B (4): 482–484. doi:10.1302/0301-620X.57B4.482. ISSN 0301-620X.
  4. Ring, P. A. (1957-11-16). "Shortening and paralysis in poliomyelitis". Lancet. 273 (7003): 980–983. doi:10.1016/s0140-6736(57)92003-2. ISSN 0140-6736. PMID 13482264.
  5. Uhthoff, Hk; Jaworski, Zf (1978-08-01). "Bone loss in response to long-term immobilisation". The Journal of Bone and Joint Surgery. British Volume. 60-B (3): 420–429. doi:10.1302/0301-620X.60B3.681422. ISSN 0301-620X. PMID 681422.
  6. Lee, Won (2018). "Corticotomy for orthodontic tooth movement". Journal of the Korean Association of Oral and Maxillofacial Surgeons. 44 (6): 251–258. doi:10.5125/jkaoms.2018.44.6.251. ISSN 2234-7550. PMC 6327016. PMID 30637238.
  7. Paradis, G R; Kelly, P J (1975-03-01). "Blood flow and mineral deposition in canine tibial fractures". The Journal of Bone and Joint Surgery, American Volume. 57 (2): 220–226. doi:10.2106/00004623-197557020-00015. ISSN 1535-1386. PMID 1112848.
  8. Karaharju, Eo; Ryoppy, Sa; Makinen, Rj (1976-02-01). "Remodelling by asymmetrical epiphysial growth. An experimental study in dogs". The Journal of Bone and Joint Surgery. British Volume. 58-B (1): 122–126. doi:10.1302/0301-620X.58B1.1270489. ISSN 0301-620X. PMID 1270489.
  9. Klein, L.; Dawson, M. H.; Heiple, K. G. (1977). "Turnover of collagen in the adult rat after denervation". The Journal of Bone and Joint Surgery. American Volume. 59 (8): 1065–1067. doi:10.2106/00004623-197759080-00011. ISSN 0021-9355. PMID 591537.
  10. Hughes, S; Khan, R; Davies, R; Lavender, P (1978-11-01). "The uptake by the canine tibia of the bone-scanning agent 99mTc-MDP before and after an osteotomy". The Journal of Bone and Joint Surgery. British Volume. 60-B (4): 579–582. doi:10.1302/0301-620X.60B4.711811. ISSN 0301-620X. PMID 711811.
  11. Kernitsky, Jeremy R.; Ohira, Taisuke; Shosho, Dhurata; Lim, June; Bamashmous, Abdullah; Dibart, Serge (2020-11-11). "Corticotomy depth and regional acceleratory phenomenon intensity:A preliminary study". The Angle Orthodontist. 91 (2): 206–212. doi:10.2319/041320-296.1. ISSN 0003-3219. PMC 8028476. PMID 33289837.
  12. "Regional acceleratory phenomenon (RAP)". Glossary Archive - ICOI. International Congress of Oral Implantologists.
  13. Minaire, P.; Meunier, P.; Edouard, C.; Bernard, J.; Courpron, P.; Bourret, J. (1974-12-01). "Quantitative histological data on disuse osteoporosis". Calcified Tissue Research. 17 (1): 57–73. doi:10.1007/BF02547214. ISSN 1432-0827. PMID 4451877. S2CID 21776796.
  14. Bogoch, E.; Gschwend, N.; Rahn, B.; Moran, E.; Perren, S. (1993). "Healing of cancellous bone osteotomy in rabbits—Part I: Regulation of bone volume and the regional acceleratory phenomenon in normal bone". Journal of Orthopaedic Research. 11 (2): 285–291. doi:10.1002/jor.1100110216. ISSN 1554-527X. PMID 8483041. S2CID 566481.
  15. Frost, Harold M. (2011-09-05). "Measurement of human bone formation by means of tetracycline labelling". Canadian Journal of Biochemistry and Physiology. 41: 31–42. doi:10.1139/y63-005. PMID 13945829.
  16. Bunch, W H; Deck, J D; Romer, J (1977-01-01). "The effect of denervation on bony overgrowth after below knee amputation in rats". Clinical Orthopaedics and Related Research (122): 333–339. ISSN 1528-1132. PMID 837617.
  17. Miller, Malcolm R.; Kasahara, Michiko (1963). "Observations on the innervation of human long bones". The Anatomical Record. 145 (1): 13–23. doi:10.1002/ar.1091450104. ISSN 1097-0185. S2CID 85005797.
  18. Duncan, Cp; Shim, Ss (1977-08-01). "J. Edouard Samson Address: the autonomic nerve supply of bone. An experimental study of the intraosseous adrenergic nervi vasorum in the rabbit". The Journal of Bone and Joint Surgery. British Volume. 59-B (3): 323–330. doi:10.1302/0301-620X.59B3.19482. ISSN 0301-620X. PMID 19482.
  19. Porter, RW (1978). "The effect of tension across a growing epiphysis". The Journal of Bone and Joint Surgery. British Volume. 60-B (2): 252–255. doi:10.1302/0301-620X.60B2.659475. ISSN 0301-620X. PMID 659475.
  20. Akeson, W. H.; Woo, S. L. Y.; Coutts, R. D.; Matthews, J. V.; Gonsalves, M.; Amiel, D. (1975-12-01). "Quantitative histological evaluation of early fracture healing of cortical bones immobilized by stainless steel and composite plates". Calcified Tissue Research. 19 (1): 27–37. doi:10.1007/BF02563988. ISSN 1432-0827. PMID 1201463. S2CID 1790295.
  21. Moyen, B J; Lahey, P J; Weinberg, E H; Harris, W H (1978-10-01). "Effects on intact femora of dogs of the application and removal of metal plates. A metabolic and structural study comparing stiffer and more flexible plates". The Journal of Bone and Joint Surgery, American Volume. 60 (7): 940–947. doi:10.2106/00004623-197860070-00012. ISSN 1535-1386. PMID 100500.
  22. Bradley, G. W.; McKenna, G. B.; Dunn, H. K.; Daniels, A. U.; Statton, W. O. (1979). "Effects of flexural rigidity of plates on bone healing". JBJS. 61 (6): 866–872. doi:10.2106/00004623-197961060-00010. ISSN 0021-9355.
  23. Tonino, Aj; Davidson, Cl; Klopper, Pj; Linclau, La (1976-02-01). "Protection from stress in bone and its effects. Experiments with stainless steel and plastic plates in dogs". The Journal of Bone and Joint Surgery. British Volume. 58-B (1): 107–113. doi:10.1302/0301-620X.58B1.1270486. ISSN 0301-620X. PMID 1270486.
  24. Yaffe, A.; Fine, N.; Binderman, I. (1994). "Regional accelerated phenomenon in the mandible following mucoperiosteal flap surgery". Journal of Periodontology. 65 (1): 79–83. doi:10.1902/jop.1994.65.1.79. ISSN 0022-3492. PMID 8133418.
  25. Wilcko, W. M.; Wilcko, T.; Bouquot, J. E.; Ferguson, D. J. (2001). "Rapid orthodontics with alveolar reshaping: two case reports of decrowding". The International Journal of Periodontics & Restorative Dentistry. 21 (1): 9–19. ISSN 0198-7569. PMID 11829041.
  26. Keser, Elif; Naini, Farhad B. (2022-01-05). "Accelerated orthodontic tooth movement: surgical techniques and the regional acceleratory phenomenon". Maxillofacial Plastic and Reconstructive Surgery. 44 (1): 1. doi:10.1186/s40902-021-00331-5. ISSN 2288-8101. PMC 8727645. PMID 34984554.
  27. Kim, Su-Jung; Park, Young-Guk; Kang, Seung-Goo (2009). "Effects of Corticision on paradental remodeling in orthodontic tooth movement". The Angle Orthodontist. 79 (2): 284–291. doi:10.2319/020308-60.1. ISSN 0003-3219. PMID 19216591.
  28. Park, Young Guk (2016). "Corticision: A Flapless Procedure to Accelerate Tooth Movement". Frontiers of Oral Biology. 18: 109–117. doi:10.1159/000351904. ISBN 978-3-318-05479-8. ISSN 1420-2433. PMID 26599124.
  29. Clark, R. L.; Schneider, M.; Mahmoudi, T.; Bashirelahi, N. (2017). "What every dentist and patient should know about accelerated orthodontic tooth movement" (PDF). General Dentistry. July/August 2018: 16–20.
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