Brief Summary of the Study

This study investigates the effects of locally administered vitamins C and E on orthodontic tooth movement during the initial stage of treatment. Orthodontic tooth movement relies on bone remodeling, which can be influenced by antioxidants like vitamins C and E. Vitamin C promotes collagen formation and osteoblast activity, while vitamin E has anti-inflammatory and antioxidant properties that may impact bone metabolism.

The study is a randomized clinical trial conducted in multiple clinics, where patients will be divided into three groups:

1. Control group - receives a saline injection.
2. Vitamin C group - receives a local injection of vitamin C.
3. Vitamin E group - receives a local injection of vitamin E.

Injections will be administered every two weeks for vitamin C and every month for vitamin E, for six months, while patients undergo orthodontic treatment with fixed appliances. Researchers will evaluate the rate of tooth movement, root resorption, pain perception, and patient experience. Additionally, biomarkers related to bone remodeling will be measured in gingival crevicular fluid at different time points.

The study aims to determine whether local administration of vitamins C or E enhances orthodontic tooth movement and elevate their effects on the orthodontic potential side effects like root resorption and pain. The findings may provide valuable insights into optimizing orthodontic treatment with the help of antioxidants.

This randomized clinical trial aims to investigate the effects of locally administered vitamins C and E on mandibular incisor crowding relief during the initial stage of orthodontic treatment. The study follows a multicenter, prospective, single-blinded, parallel-group design with equal randomization (1:1) and is conducted in private clinics and hospitals.

Study Rationale

Orthodontic tooth movement involves a complex biological process mediated by bone remodeling, which is regulated by mechanical forces and biochemical mediators. Oxidative stress and inflammatory responses play a significant role in the remodeling process. Vitamin C (ascorbic acid) and vitamin E (tocopherol) are known for their antioxidant properties and potential effects on bone metabolism, tissue healing, and inflammation modulation. This study aims to determine whether locally administered vitamins C and E can enhance orthodontic tooth movement, reduce adverse effects such as root resorption, and improve patient experience during treatment.

Study Objectives

The primary objective is to compare the effectiveness of vitamin C and vitamin E injections versus a saline control in mandibular incisor crowding relief over 24 weeks.

The secondary objectives include:

• Assessing the extent of apical root resorption using periapical radiographs.
• Evaluating pain perception using a Visual Analog Scale (VAS) during the first week after each archwire change.
• Measuring patient perception of treatment experience through a structured questionnaire.
• Analyzing levels of biomarkers associated with bone remodeling (RANKL, OPG, RUNX2) in gingival crevicular fluid (GCF) to determine the biological effects of the interventions.

Participant Selection

Eligible participants are patients aged 12 years and older with moderate to very severe mandibular anterior crowding (Little's Irregularity Index [LII]). Exclusion criteria include systemic diseases, prior orthodontic treatment, or the use of medications that could influence bone metabolism or inflammatory responses.

Intervention Groups

Participants will be randomly assigned to one of three groups:

1. Control Group: Receives saline injection.
2. Vitamin C Group: Receives intraepidermal injection of vitamin C (120 mg in 1.2 ml, divided among six mandibular anterior teeth).
3. Vitamin E Group: Receives intraepidermal injection of vitamin E (15mg in 0.1 ml, divided among six mandibular anterior teeth).

Injections are repeated biweekly for vitamin C and monthly for vitamin E, for a total of six months (24 weeks).

Orthodontic Treatment Protocol

All participants undergo standardized orthodontic treatment using MBT brackets (0.022-inch slot). The leveling and alignment phase follows a sequential archwire progression with CuNiTi archwires in the following sequence:

• 0.014-inch CuNiTi (initial 4 weeks)
• 0.016-inch CuNiTi (weeks 4-8)
• 0.018-inch CuNiTi (weeks 8-24)

No additional orthodontic interventions, such as interproximal reduction or extractions, will be performed during the study period.

Data Collection and Outcome Assessments

Data will be collected at multiple time points throughout the study:

1. Mandibular Incisor Crowding Relief

   • 3D-scanned digital models will be used to measure Little's Irregularity Index (LII) at baseline and every 4 weeks until week 24.

2. Root Resorption

   • Standardized periapical radiographs of mandibular anterior teeth will be taken at baseline, 8 weeks, and 24 weeks to evaluate root resorption.

3. Pain Perception

   • Participants will record pain intensity on a VAS scale (0-10) during the first week after each wire change (every 4 weeks).

4. Patient Perception

   • A structured questionnaire assessing comfort, esthetics, and perceived treatment progress will be administered at 8 weeks.

5. Biomarker Analysis

   • Gingival crevicular fluid (GCF) samples will be collected at baseline, 1 week, and 4 weeks. Levels of RANKL, OPG, and RUNX2 will be analyzed to assess changes in bone remodeling activity.

Statistical Analysis

Data will be analyzed using SPSS v26.Statistical methods include:

• Descriptive statistics (mean, standard deviation, frequency).
• Reliability analysis for measurement consistency.
• Inferential statistics, including paired and independent t-tests, analysis of variance (ANOVA), and regression models, to compare treatment effects.

A significance level of 0.05 will be used for hypothesis testing.

Study Oversight and Ethical Considerations

The study is self-funded and complies with ethical guidelines for human research. Ethical approval is pending from the appropriate review board. All participants (or their legal guardians) will provide informed consent before enrollment.

Potential Impact

This trial may provide valuable insights into the role of antioxidant therapy in orthodontic treatment. If vitamins C and E positively influence tooth movement and root integrity, their use could enhance treatment efficiency while minimizing complications. Findings may also contribute to a better understanding of bone remodeling mechanisms in response to mechanical forces.

Inclusion Criteria:

1. Patients aged 12 years and above, who are indicated for fixed appliance orthodontic treatment.
2. Patients with moderate to very severe crowding of the mandibular anterior teeth as per the Little's Irregularity Index (LII).
3. Treatment with or without two mandibular first premolars extraction. Presence of all the mandibular permanent teeth, except the third molars.

5. The overbite and overjet should not impede bracket placement on the mandibular anterior teeth.

Exclusion Criteria:

1. History of previous orthodontic intervention.
2. History of trauma or root resorption in the mandibular anterior teeth.
3. Presence of mandibular anterior teeth crowding of less than 4 mm (LII).
4. Existence of blocked-out teeth precluding engagement with the aligning archwire.
5. History of systemic diseases, especially diabetes and bone diseases.
6. Patients with periodontitis and obvious loss of tooth attachment according to Plaque and Bleeding on Probing indices.
7. Pregnant and lactating mothers.
8. Mouth breathing patients and smokers.
9. Healthy patients who have not used any medications (such as anti-inflammatory or antimicrobial drugs) or supplements (such as vitamins)

No additional parties are masked in this clinical trial beyond the participant, care provider, and outcomes assessor.