Rand Zakaria
Fifth year, Group 11The Evaluation of Corticotomy Compared to
Piezocision in Accelerating the Rate of Orthodontic
Tooth Movement
Master’s Thesis
Supervisor:
Prof. PhD. Arūnas Vasiliauskas
MEDICAL ACADEMY FACULTY OF ODONTOLOGY CLINIC OF ORTHODONTICS
The Evaluation of Corticotomy Compared to Piezocision in Accelerating the Rate of Orthodontic Tooth Movement
Master’s Thesis
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EVALUATION TABLE OF THE MASTER’S THESIS
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No. MT parts MT evaluation aspects
Compliance with MT requirements and evaluation Yes Partially No 1 Summary (0.5 point)
Is summary informative and in compliance with
the thesis content and requirements? 0.3 0.1 0
2 Are keywords in compliance with the thesis essence? 0.2 0.1 0
3
Introduc-tion, aim and tasks
(1 point)
Are the novelty, relevance and significance of the
work justified in the introduction of the thesis? 0.4 0.2 0 4 Are the problem, hypothesis, aim and tasks formed clearly and properly? 0.4 0.2 0
5 Are the aim and tasks interrelated? 0.2 0.1 0
6 Selection criteria of the studies, search methods and strategy (3.4 points)
Is the protocol of systemic review present? 0.6 0.3 0 7 Were the eligibility criteria of articles for the selected protocol determined (e.g., year,
language, publication condition, etc.) 0.4 0.2 0
8
Are all the information sources (databases with dates of coverage, contact with study authors to identify additional studies) described and is the last search day indicated?
0.2 0.1 0
9
Is the electronic search strategy described in such a way that it could be repeated (year of search, the last search day; keywords and their combinations; number of found and selected articles according to the combinations of keywords)?
0.4 0.1 0
10
Is the selection process of studies (screening, eligibility, included in systemic review or, if applicable, included in the meta-analysis) described?
0.4 0.2 0
11
Is the data extraction method from the articles (types of investigations, participants, interventions, analysed factors, indexes) described?
0.4 0.2 0
the risk of bias of individual studies and how this information is to be used in data synthesis, described?
14 Were the principal summary measures (risk ratio, difference in means) stated? 0.4 0.2 0
15 Systemiza-tion and analysis of data (2.2 points)
Is the number of studies screened: included upon assessment for eligibility and excluded upon giving the reasons in each stage of exclusion presented?
0.6 0.3 0
16
Are the characteristics of studies presented in the included articles, according to which the data were extracted (e.g., study size, follow-up period, type of respondents) presented?
0.6 0.3 0
17
Are the evaluations of beneficial or harmful outcomes for each study presented? (a) simple summary data for each intervention group; b) effect estimates and confidence intervals)
0.4 0.2 0
18 Are the extracted and systemized data from studies presented in the tables according to
individual tasks? 0.6 0.3 0
19
Discussion (1.4 points)
Are the main findings summarized and is their
relevance indicated? 0.4 0.2 0
20 Are the limitations of the performed systemic review discussed? 0.4 0.2 0 21 Does author present the interpretation of the results? 0.4 0.2 0 22
Conclusions (0.5 points)
Do the conclusions reflect the topic, aim and
tasks of the Master’s thesis? 0.2 0.1 0
23 Are the conclusions based on the analysed material? 0.2 0.1 0
24 Are the conclusions clear and laconic? 0.1 0.1 0
25
References (1 point)
Is the references list formed according to the
requirements? 0.4 0.2 0
26 Are the links of the references to the text correct? Are the literature sources cited
correctly and precisely? 0.2 0.1 0
27 Is the scientific level of references suitable for Master’s thesis? 0.2 0.1 0
28
Do the cited sources not older than 10 years old form at least 70% of sources, and the not older
than 5 years – at least 40%? 0.2 0.1 0
Additional sections, which may increase the collected number of points
29 Annexes Do the presented annexes help to understand the analysed topic? +0.2 +0.1 0
30 recommen-Practical dations
Are the practical recommendations suggested
analyses, meta-regression)?
32 Was meta-analysis applied? Are the selected statistical methods indicated? Are the results of
each meta-analysis presented? +2 +1 0
General requirements, non-compliance with which reduce the number of points
33
General require-ments
Is the thesis volume sufficient (excluding annexes)? 15-20 pages (-2 points) <15 pages (-5 points) 34 Is the thesis volume increased artificially? -2 points -1 point
35 Does the thesis structure satisfy the requirements of Master’s thesis? -1 point -2 points
36 Is the thesis written in correct language, scientifically, logically and
laconically? -0.5 point -1 points
37 Are there any grammatical, style or computer literacy-related mistakes? -2 points -1 points
38 Is text consistent, integral, and are the volumes of its structural parts
balanced? -0.2 point
-0.5 points 39 Amount of plagiarism in the thesis. (not evaluated) >20%
40
Is the content (names of sections and sub-sections and enumeration of pages) in compliance with the thesis structure and aims?
-0.2 point points -0.5
41
Are the names of the thesis parts in compliance with the text? Are the titles of sections and sub-sections
distinguished logically and correctly?
-0.2 point points -0.5
42 Are there explanations of the key terms and abbreviations (if needed)? -0.2 point points -0.5
43 Is the quality of the thesis typography (quality of printing, visual aids,
binding) good? -0.2 point
-0.5 points
*In total (maximum 10 points):
*Remark: the amount of collected points may exceed 10 points.
TABLE OF CONTENTS SUMMARY 1. INTRODUCTION...8-10 1.1 AIM...10 1.2 TASKS...10 1.3 HYPOTHESIS...10 ABBREVIATIONS...11
2. MATERIAL AND METHODS...12-16 2.1 FOCUS QUESTION... 12 2.2 TYPES OF PUBLICATION..……….………... 12 2.3 TYPES OF STUDIES.………….……….……...12 2.4 POPULATION...12 2.5 DATA COLLECTION..……...12 2.6 SEARCH STRATEGY.………...…12-13 2.7 SELECTION OF STUDIES ………...……14
2.8 INCLUSION AND EXCLUSION CRITERIA ….………...14
2.9 ASSESSMENT OF BIAS RISK...16
2.10 STATISTICAL ANALYSIS...16
3. RESULTS...17-28 3.1 STUDY SELECTION………...17
3.2 STUDY CHARACTERISTICS………..…...17-18 3.3 RISK OF BIAS WITHIN STUDIES………...18
3.4 SYSTEMIZATION OF DATA AND CHARACTERISTICS OF . STUDIES...19-20 3.5 EVALUATION OF DATA………...…….…………...21-22 3.6 INDIVIDUAL COMPARISON OF RESULTS BETWEEN SURGICAL ACCELERATION AND CONTROL GROUP…....25-26 3.7 META-ANALYSIS ………...26-27 3.8 COMPARISON BETWEEN CORTICOTOMY AND PIEZOCISION...27-28 4. DISCUSSION...28-32 4.1 DURATION OF TREATMENT………...31
4.2 ADVERSE EFFECT...31
4.3 ROOT RESORPTION...31
4.4 MOLAR ANCHORAGE LOSS...32
4.5 PAIN, DISCOMFORT AND SWELLING...32
5. LIMITATION ...32
6. CONCLUSION...33
SUMMARY
Introduction:
The purpose of this systematic review was to assess and to compare the effectiveness of corticotomy and piezocision in accelerating the rate of canine retraction and to evaluate which surgical method is the more superior one.
Materials and methods:
The searches and screening was done using five different databases: Pubmed, Biomed central, SAGE journals online, SpringerLink and Taylor & Francis. Only randomized clinical trials not older than 5 years were selected.
Results:
A total of 380 studies were initially identified, after applying the inclusion and exclusion criteria 8 eligible articles were finally selected. Corticotomy and piezocision both demonstrated a 1.5 to 2 times greater increase in the rate of canine retraction compared to their control groups. Corticotomy displayed higher values when compared to piezocision and the Meta-analysis conducted showed both methods to be significantly different to their corresponding control groups.
Conclusion
Corticotomy and piezocision showed significant effectiveness when compared to conventional orthodontic treatment groups. Corticotomy proved its superiority over the less invasive piezocision method in accelerating the rate of tooth movement. Nevertheless further investigations should be performed.
Keywords:
1. Introduction
Accelerating orthodontic tooth movement and reducing the original treatment time has gathered an immense interest amongst orthodontists and patients.[1] Patients going through conventional orthodontic treatment will normally face long treatment durations, which usually isn’t favoured. Furthermore, many patients express their need for a more rapid orthodontic treatment not only for aesthetic reasons, but also for social purposes. [2]
Many methods have been studied in the management of orthodontic tooth movement, these include surgical as well as nonsurgical approaches.
Drugs such as prostaglandin inhibitors and Relaxin(a hormone effective in increasing collagen breakdown) has shown minor significance in accelerating tooth movement and remain to this day impractical.[3]
The regional acceleratory phenomenon (RAP) explained by Frost is based upon the local response of the body to noxious stimulus. Once a stimulus of sufficient degree is made it evokes the regional acceleratory phenomenon and acceleration exceeding the normal values of both the hard and soft vital tissue processes initiates.
The consequent wound healing and local tissue defensive reaction causes a series of events in the body, the chief one including accelerated bone remodelling. [4]
The main constituent of orthodontic tooth movement is remodelling of the alveolar bone, the regional acceleratory phenomenon grants orthodontics the possibility of adapting the idea to increase the rate of tooth movement by causing local injury to the alveolar bone, successively generating a possible acceleration in tooth movement.
Therefor understanding this phenomenon permits one to understand the foundation to why local injury is a method in rapid tooth movement.
Corticotomy, piezocision and micro-perforation are all examples of surgical techniques used to cause regional injury to increase the rate of bone remodelling. [3]
The German surgeon Köle reintroduced Corticotomy in 1959 and indicated that a new approach could be adapted for the reduction of orthodontic treatment time.
This type of corticotomy was based upon a bone block technique.
This technique involved raising a mucoperiosteal flap and subsequently performing vertical osteotomies at inter-radicular sites and horizontal osteotomies at sub-apical sites.
The vertical and horizontal cuts allowed separation of small-sized bone blocks.[5]
Orthodontic appliance would then be activated using stiff arch-wires, the force would create greenstick fractures of surrounding bone and successively bring the teeth into alignment. Since the root apex did not move, Köle´s idea was built upon tipping the teeth into position rather than moving them bodily.
This surgical method was considered too invasive and was therefor not widely accepted, only till recently has corticotomy been revived and reintroduced in association with Frost’s regional accelerating phenomenon concept. This approach considered that the rate of dental movement was by virtue of a transient demineralization-mineralization process in the alveolar bone rather than movements of bone blocks containing the tooth.[3]
It has been reported that the effect of RAP reaches its highest point at 1-2 months and decreases thereafter. [6]
Although corticotomy had been described as being effective in accelerating tooth movement there are a number of reported side effects, mainly being loss of alveolar bone height and periodontal defects such as gingival stripping, whitening of the gingiva or fenestration of roots after moving the teeth labially. These complications are primarily created due to the aggressiveness of the procedure. [3]
Another concern involving orthodontic tooth movement into a premolar extraction space is molar anchorage loss. This mesial movement of the tooth is a reciprocal response to an extraction site and has the possibility to compromise not only the anteroposterior correction of the arch but also the overall aesthetics of the patient. [7]
Piezocision is a modified form of corticotomy. This technique doesn’t entail raising a flap and is therefor considered a less invasive method for accelerating orthodontic tooth movement.
It requires buccal micro-incisions, subsequently making cuts into the cortical bone and then entering the medullary bone interproximally using a piezoelectric knife. A tunnel approach could also be made if bone grafting is required. [3] A more extensive explanation regarding the surgical technique of both corticotomy and piezocision is described in Annex 1 and Annex 2.
Since the need for quicker orthodontic procedures are increasing, the various methods for accelerating the rate of tooth movement are being further explored each day. Corticotomy and piezocision have both proven to be efficient although not enough articles have investigated and compared the true extent of their acceleration efficiency, thus a true and competent foundation has yet to be made regarding these methods. [1-3]
1.1 AIM
The aim of this study was to evaluate the true extent and efficiency of corticotomy and piezocision compared to conventional orthodontic procedures in terms of accelerating the rate of canine distalization and subsequently drawing a comparison between the effectiveness of corticotomy to piezocision in accelerating orthodontic tooth movement.
1.2 Tasks
1. To compare corticotomy with piezocision in accelerating the rate of canine retraction
2. To compare the efficiency of corticotomy to conventional orthodontics in increasing the rate of orthodontic tooth movement
3. To compare the efficiency of piezocision to conventional orthodontics in increasing the rate of orthodontic tooth movement
1.3 Hypothesis
Abbreviations
Abbreviations and indices used in this systematic review to evaluate the rate of orthodontic tooth movement in piezocision and corticotomy is the following:
WMD - Weighted mean difference
RAP - Regional Acceleratory phenomenon RCT - Randomized controlled trial
OTM - Orthodontic tooth movement LLLT - Low level laser therapy LLL- Low level laser
PD - Probing depth
2. Materials and Methods
Ethics committee number: BEC-OF-112
2.1 Focus Question
The focus question was based upon the PICOS criteria (Patient, Intervention, Comparison, Outcomes and study type) and is presented in table 1.
Table 1 . PICOS table
Population (P) Healthy orthodontic patients requiring premolar extraction
Intervention (I) To evaluate the effectiveness in accelerating the rate of canine retraction
Comparison (C) Corticotomy compared to Piezocision
Outcomes (O) Does both method prove to be efficient in increasing the rate of tooth movement
Which method has the greatest rate of canine distalization
Study type (S) Randomized controlled trials
Focus Question Which method, corticotomy or piezocision have the greatest efficacy in accelerating orthodontic tooth movement?
2.2 Types of publication
The systematic review included human based articles in an English language.
2.3 Types of studies
The systematic review only included randomized controlled trials not older than 5 years, reporting about either method in relation to acceleration of rate of canine retraction.
2.4 Population
Healthy orthodontic patients requiring premolar extraction.
2.5 Data collection
Information and articles were collected from Pubmed, Biomed central, SAGE journals online, SpringerLink and Taylor & Francis databases.
2.6 Search strategy
The searches and screening of the electronic databases were searched from January 2016 up until December 2021. The main keywords included were Piezocision, Piezocision-facilitated
orthodontics, Corticotomy, Orthodontic corticotomy.
Databases with the option of using Boolean operators were used whenever possible during the search strategy, for the purpose of a more precise search with all the chief keywords included. Further details of the search strategy is presented in table 2.
Table 2. Search strategy Date of
Search
Database Keywords Results
2021-02-23 Pubmed (("Piezocision-Facilitated"[All Fields] AND "orthodontics"[All Fields])) OR "corticotomy"[All Fields]) OR "piezocision"[All Fields]) AND ([Filter]) AND (english[Filter]) AND (2016:2021[pdat]))
238
2021-02-23 BioMed
Central
Search #1 Orthodontic Corticotomy
Search #2 Piezocision 23 2021-02-23 SAGE Journals Online Search #1
[All corticotomy] AND [Article Type Research Article] AND
AND [Publication Date (01/01/2016 TO 12/31/2021)
Search #2
[All piezocision] AND [Article Type Research Article] AND [Publication Date (01/01/2016 TO 12/31/2021)
34
2021-02-23 SpringerLink Search #1
[All corticotomy]
AND [Language] English AND [Discipline] Dentistry AND [Content Type] Article AND [Publication Date] 2016 - 2021
Search #2
[All piezocision] AND [Language] English AND [Discipline] Dentistry AND [Content Type] Article AND [Publication Date] 2016 - 2021
53
2021-02-23 Taylor &
Francis
Search #1
[All: corticotomy] AND [Publication Date: (01/01/2016 TO 12/31/2021)]
Search #2
[All: piezocision] AND [Publication Date: (01/01/2016 TO 12/31/2021)]
2.7 Selection of studies
The title and abstract screening for article eligibility was based upon the following inclusion and exclusion criteria. Articles suitable to be included were then further evaluated by a detailed full-text reading. (Figure 1)
2.8 Inclusion and exclusion criteria
Inclusion criteria were:➢ Randomized controlled clinical trials not older than 5 years
➢ Healthy patients in need of orthodontic care, absent of any systemic diseases or drug use that could compromise the study
➢ Orthodontic participants undergoing premolar extraction ➢ Canine distalization
➢ Rate/velocity of canine retraction, total distance moved, periodontal parameters and molar anchorage loss
➢ English language articles
Exclusion criteria were:
➢ Outcomes not related to the aim
➢ Reviews, meta-analysis, commentaries, case series or single case studies ➢ Non-randomized clinical trials, qualitative studies, letters or literature reviews ➢ Animal studies
PUBMED
(n=238)
Fig 1. PRISMA flow diagram
Records identified through database searching (n = 380) Scr e e n in g In cl u d e d El ig ib ili ty Id e n ti fi cat
ion Additional records identified through other sources (n = 0)
Records after duplicates removed (n = 319)
Records screened (n = 319)
Records excluded (by abstract reading)
(n = 268)
Full-text articles assessed for eligibility (retrieved through hand
search (n = 51)
Full-text articles excluded, with reasons (n = 43) Irrelevant objective: 6 Unrelated outcome: 10 Molar protraction/intrusion/ mesialization: 3 Mass -retraction: 4 Non-extraction: 7 Study design: • Not a study: 1
2.9 Assessment of bias risk
The detailed evaluation of bias risk is presented in table 3. The quality of the selected articles was assessed according to the guidelines of Cochrane risk of bias tool for randomized clinical trials (Rob 2) and by following their provided full guidance document.
Table 3. Assessment of bias in included studies
2.10 Statistical analysis
Two Meta –analyses was utilized using the RevMan software (version 5.4), as seen in figure 2 and figure 3. The investigated outcomes were the velocity and amount of canine retraction (mm) for each month using either corticotomy or piezocision compared to their designated control group. A random-effects analysis model was implemented for the purpose of monitoring any unobserved heterogeneity between studies. The study confidence interval was set to 95%.
Heterogeneity was evaluated in percentage using chi-square test and I2 test with a high heterogeneity considered from 50% and above.
The p value ≤ 0.05 indicated whether there was any significant difference between the surgical procedure and its corresponding control group.
Study Randomization process Deviation from intended interventions Missing outcome data Measurement of the outcome Selection of the reported results Overall bias Aksakalli et al. 2016 [9]
Some concerns High risk High risk
Low risk Low risk High risk Abbas et al. 2016 [10] Some concerns High risk Some
concerns
Low risk Low risk High risk Jahanbakhshi et al.
2016 [11]
Some concerns High risk Some concerns
Low risk Low risk High risk Alfawal et al. 2018
[12]
Low risk Low risk Low risk Low risk Low risk Low risk Farid et al. 2019 [13] Low risk Low risk Low risk Low risk Some
concerns
Some concerns Raj et al. 2020 [14] Some concerns Some
concerns
Some concerns
High risk Low risk High risk Sharma et al. 2020 [15] Some concerns Low risk Low risk Low risk Some
concerns
Some concerns Alqadasi et al. 2020
[16]
3. Results
3.1 Study selection
Based upon the database results, the titles and abstracts were screened using the eligibility criteria. If any doubtfulness occurred regarding the relevancy of an article then the full text article was retrieved and examined further.
The article search provided 238 references in PUBMED, 23 references in BioMed Central, 34 references in SAGE Journals Online, 53 references in SpringerLink and 32 references in Taylor & Francis. After removal of duplicates 319 unique articles were left.
By screening the titles and abstracts of the articles, as well as implementing the exclusion criteria, it was concluded that 268 articles were rejected.
The remaining 51 articles were further evaluated based upon the full-text articles attained.
Data containing the characteristics of each article was extracted from the remaining relevant articles and placed into tables evaluating participants, interventions, comparison, outcomes and study design (PICOS). The information was then assessed and 43 ineligible articles were excluded which left 8 studies in total included in the qualitative search. Three articles were included in the
quantitative search.
3.2 Study characteristics
The data characteristics of eight studies are presented in table 4.
The collection of included corticotomy and piezocision studies had a benefit of all being randomized clinical controlled trials using a split mouth design to carry out the treatment. The included studies were published from 2016 to 2020 with ages between 14 to 30 years. The quantity of participant ranged from 10 to 20 patients for each study.
The majority of the studies placing orthodontic fixed appliance before the treatment procedure used the same size of bracket slot. A variety of arch- wire diameter sizes were used.
A force of 150g was selected for the retraction by essentially all but one included study [11], reporting a chosen retraction force of 200g instead. Two studies ([11,16] reported the use of mini-screws as anchorage and either elastomeric chains, canine retractors or NiTi closed coiled springs were used to distalize the canines.
from piezocision is the need for corticotomy to undergo a full flap reflection. Three studies [10,11,15] reported a buccal reflection only, while only one [13] reported a flap reflection done both buccally and palatally. Cortical indentations were subsequently done in all corticotomy studies using a round bur on the buccal wall only.
3.3 Risk of bias within studies.
3.4 Systemization of data and characteristics of studies
Relevant data and main characteristics of the included studies were collected and organized
Table 4. Characteristics of studies
Reference Sample size and age groups (Mean (SD)) Intervention Duration (Mean (SD))
Orthodontic fixed appliance Surgical procedure
Follow-ups
Aksakalli et al.
2016 [9] 10 patients 16.3 (2.4) y Piezocision 3.54 (0.81) mo ▪ Roth brackets 0.022-inch slots ▪ 0.016× 0.022-inch SS AW
▪ Elastomeric chains post-surgery (150g), replaced every 2 weeks
▪ Flapless with two buccal incisions made vertically and interproximally of canine. ▪ Incisions done 5 mm apical to mesial and distal
interdental papilla of tooth. ▪ Incision length 10 mm apically
▪ Piezotome 3 mm cortical alveolar incision depth
2- Week intervals Abbas et al. 2016 [10] 20 patients (10 P, 10 C) 15-25y Piezocision &
Corticotomy 3 mo ▪ Roth brackets 0.022-inch slots ▪ 0.016 × 0.022-inch SS AW
▪ NiTi closed-coil springs (150g, adjusted at 2-week intervals)
Corticotomy
▪ Buccal submarginal flap reflection and extended beyond canine apex
▪ Incision 4 mm apical to FGM
▪ Piezotome vertical bone cuts 2-3 mm below alveolar crest
▪ Cortical perforations along root length ▪ Mesial wall bundle bone removed from
extraction socket by piezotome Piezocision
▪ Vertical micro-incisions made below papillae on the buccal mucosa followed by cortical
perforations in interradicular space of canine ▪ Injury extended along canine root and 2 mm
beneath alveolar crest.
▪ Removal of bundle bone mesially in extraction socket using a piezotome
2- Week intervals
Jahanbakhshi et al.
2016 [11] 15 patients 25y Corticotomy 4 mo ▪ Brackets 0.018 – inch slot s ▪ Strap up on 2nd molar, mini-screw on buccal
segment
▪ Buccal flap reflected after sulcular and 2 vertical incisions
▪ With bur created vertical groove with 0.5–1 mm
SD- Standard deviation, SS- Stainless steel, AW- Arch wire, EC- Elastomeric Chains, SSW- Stainless steel wire, SW- Stainless wire, P- Piezocision, C- Corticotomy, FGM- Free gingival margin, MBT- brackets designed by McLaughlin, Bennett, and Trevesi, NiTi- Nickel Titanium, y- year, mo- month, wk- week,
Alfawal et al. 2018 [12]
17 Patients 15-27 y
Piezocision 4 mo ▪ MBT brackets 0.022-inch slots ▪ AW sequences: 0,014 inch NiTi or
0.016 inch NiTi (depending on crowding severity), 0,016 × 0,022 inch NiTi, 0,017 × 0,025 inch NiTi, 0,019 × 0,025 inch NiTi ▪ 0,019 × 0,025 inch SS AW post-surgery. ▪ NiTi closed-coil springs (150g adjusted at
2-week interval)
▪ Flapless
▪ Two buccal incisions 3-4 mm apical to interdental papilla and at equal distance from canine and 2nd premolar were made.
▪ Length of incision 10 mm.
▪ Vertical 3mm depth cortical cuts with piezotome.
2- Week intervals
Farid et al. 2019
[13] 16 patients 17–25y
Corticotomy 4 mo ▪ Roth brackets 0.022-inch slots ▪ Molar bands on 1st molar
▪ Trans-palatal arch on molar bands ▪ AW sequences: 0.014- inch NiTi, 0.016×
0.022- inch NiTi
0.017 × 0.025- inch SS AW ▪ NiTi closed-coil spring (150g)
▪ Incision and flap retraction bucally & palatally beyond canine root apex
▪ Round bur for 15 cortical perforations with 1-2 mm depth from distal wall of 2nd premolar to
mesial wall of canine
▪ Perforations made bilaterally on buccal and lingual walls.
2- Week intervals
Raj et al. 2020 [14] 20 Patients
23.18 (1.41) y Piezocision 3 mo ▪ Brackets ▪ 0.016× 0.022 inch SS AW ▪ NiTi coil spring (150g)
▪ Vertical incisions with 10 mm length, 5 mm apical to interdental papilla tip
▪ Piezotome for cortical incision depth of 3mm.
15 –day interval Sharma et al. 2020
[15] 17 patients 14.25 y Corticotomy 21 wk ▪ MBT brackets 0.022 inch slots ▪ Transpalatal arch and molar bands on 2nd
molar
▪ 0.016 × 0.022 inch SS AW ▪ NiTi coiled springs (150g)
▪ Buccal flap retracted and vertical groove along canine root length made distally through cortical bone
▪ Horizontal groove made apically 2 mm above apex of tooth
▪ Cortical indentations made over 1st extracted
molar socket.
3 –week interval
Alqadasi et al.
2020 [16] 11 Patients 15-40y Piezocision 3 mo ▪ MBT brackets 0.022- inch slots ▪ 0.018× 0.025- inch slot SS AW ▪ Self-drilling thread for anchorage ▪ NiTi coil spring (150g adjusted every 28
days)
▪ Cut with piezoelectric instrument made in middle of extraction site
▪ Cut made 3-5 mm deep, 3 mm long and 2 mm below alveolar ridge crest
After 2 wk of
3.5 Evaluation of data
The included studies were compared according to rate of canine retraction and control groups in table 5 and the outcomes for the OTM rate were summarized in table 6.
Table 5. Rate of canine retraction
Study Intervention Rate of canine retraction in intervention group
(Mean (SD)) mm
Rate of canine retraction in control group (Mean (SD)) mm Aksakalli et al.
2016 [9]
Piezocision Distance moved: ▪ 1st mo- 1.53 (0.67) ▪ 2nd mo- 2.90 (0.86) Distance moved: ▪ 1st mo -0.78 (0.24) ▪ 2nd mo -1.73 (0.72) Abbas et al. 2016 [10] Corticotomy and Piezocision Rate: Corticotomy: ▪ 4th wk- 0.6 (0.07) ▪ 8th wk- 0.78 (0.1) ▪ 12th wk- 1.22 (0.08) Piezocision: ▪ 4th wk- 0.50 (0.07) ▪ 8th wk- 0.70 (0.12) ▪ 12th wk -0.99 (0.10) Rate: Corticotomy: ▪ 4th wk- 0.34 0.08) ▪ 8th wk- 0.46 0.11) ▪ 12th wk- 0.58 (0.04) Piezocision: ▪ 4th wk- 0.30 (0.08) ▪ 8th wk- 0.45 (0.09) ▪ 12th wk -0.60 (0.04) Jahanbakhshi et al. 2016 [11] Corticotomy Rate: ▪ 1st mo- 2.2 (0.32) ▪ 2nd mo- 2 (0.15) ▪ 3rd mo-1.8 (0.22) ▪ 4th mo- 1.4 (0.19)
Overall mean rate: 1.8 (0.17) Rate: ▪ 1st mo- 1 (0.13) ▪ 2nd mo- 1.1 (0.23) ▪ 3rd mo-1.2 (0.25) ▪ 4th mo- 1.1 (0.12)
Overall mean rate: 1.1 (7.39) Alfawal et al. 2018 [12] Piezocision Rate: ▪ 1st mo- 1.65 (0.40) ▪ 2nd mo- 1.38 (0.32) ▪ 3rd mo- 1.10 (0.29) ▪ 4th mo- 0.87 (0.11) Overall rate: 1st- 4th mo- 1.19 (0.16) Rate: ▪ 1st mo- 0.83 (0.18) ▪ 2nd mo- 0.88 (0.14) ▪ 3rd mo- 0.98 (0.22) ▪ 4th mo- 0.94 (0.09) Overall rate: 1st- 4th mo- 0.9 (0.09) Farid et al. 2019 [13] Corticotomy Rate: ▪ 1st mo- 1.16 (0.67) ▪ 2nd mo- 0.82 (0.36) ▪ 3rd mo- 2.01 (1.37) ▪ 4th mo- 0.83 (1.03) ND
SD- Standard deviation, ND- No data, Mo-Month, wk- Week, d- Day, T1-T7- Time at 3 weeks interval, Net movement= Measurement from 3 months – Baseline measurement
Alqadasi et al. 2020 [16]
Piezocision Canine movement:
Table 6. Outcome summary of the orthodontic tooth movement (OTM) rate
Study Intervention Rate of OTM outcome
Aksakalli et al. 2016 [9] Piezocision Piezocision:
• Two times faster
• Piezocision side decreased to 1.37 mm for second month • Significant difference
Abbas et al. 2016 [10] Corticotomy and
Piezocision
• Corticotomy 1.5 to 2 times faster than control group • Piezocision 1.5 times faster than control group
• Piezocision and corticotomy both significantly different from control (P<0.001) • Corticotomy exhibited significantly greater rates of OTM compared to
Piezocision Jahanbakhshi et al.
2016 [11]
Corticotomy Corticotomy:
• Accelerated by 2 times for first and second month • Accelerated by 1.6 times during third month. • Significantly higher than control side (P<0.001) Alfawal et al. 2018 [12] Piezocision Piezocision:
• 2 times higher rate for first month • 1.5 times higher rate for second month
• Significantly higher rate first two months (P<0.001) Farid et al. 2019 [13] Corticotomy Corticotomy:
• Corticotomy compared to LLL showing no significant difference between them.
• Corticotomy remains preeminent. Raj et al. 2020 [14] Piezocision Piezocision:
• Statistically significant at all times (P<0.001) • 1.5 to 1.8 times faster
Sharma et al. 2020 [15] Corticotomy Corticotomy:
3.6 Individual comparison of results between surgical acceleration and control
group
The extracted values and outcome summaries from table 5 and table 6 of each study were evaluated. An individualization of results between each surgical method and its corresponding control group was then made.
Aksakalli [9] who performed a study on piezocision established that the amount of canine distance moved for the first and second month was 1.53 SD 0.67 mm and 2.90 SD 0.86 mm respectively. This meant that the total amount of canine movement decreased to 1.37 mm by the second month. Piezocision was compared to a control group that used conventional orthodontics, it was recognized that piezocision significantly resulted in twice the amount of acceleration compared to its opposing group.
Alfawal [12] similar to Aksakalli reported that piezocision had a significantly higher rate during the initial two months (P<0.001) compared to control group. The first month corresponded in a twice-increased amount of rate while the second month showed a 1.5 times greater rate of canine retraction. These numbers also coincided with a study made by Raj [14]
Raj [14] reported a 1.5 to 1.8 times faster rate of tooth movement using piezocision. This author assessed the chosen approach to be statistically significant at all times (P<0.001), compared to control group.
Alqadasi [16] had comparable outcomes to the previous piezocision studies and performed his trial similar to Aksakalli and Raj by measuring the distance moved for each month. Alqadasi also concluded that the initial two months were significantly different from the conventional control group (P<0.05) in terms of canine distalization rate.
Jahanbakshsi [11] performed and investigated buccal corticotomy, he found the result to be significantly higher than control side (P<0.001). Jahanbakshsi found that this surgical method increased the rate of orthodontic tooth movement by two times for the initial two months, his values for these months were also the highest amongst other corticotomy trials investigated in this article. The third month had a slight decrease, 1.6 times higher canine retraction acceleration was
presented.
Sharma [15] evaluated her results based upon a 3-week interval, which differed from the other included articles presenting results for each month or second week. Nevertheless her article found that corticotomy, similar to previous studies reported a highly significant difference (P<0.01) the first two months compared to the opposing control group.
Farid et al [13] study was limited and had no control group. It examined the efficacy of corticotomy and LLL and therefor provided measurement efficient in the comparison between the two surgical methods and not in contrast with control groups. Nevertheless it is important to note that Farid exhibited slightly questionable values compared to its other corticotomy cohorts.
3.7 Meta analysis
A meta-analysis was made for the purpose of examining the individual efficiency of each surgical method compared to its designated control group.
Two corticotomy-facilitated studies [10,11] were included in the meta-analysis, results were inputted and assessed for each month. The complete Meta – analysis for corticotomy is seen in Figure 2. The tooth movement for the initial month post-surgery proved to have a weighted mean difference of 0.73 mm/month (95% CI= -0.19 to 1.65, P=0.12), favouring the corticotomy group. Similarly, the second month showed equally promising results, with a statistically significant accumulative moved distance of 0.61 mm/month for the pooled weighted mean difference (95% CI= -0.11 to 1.11, P=0.04). This concludes that the surgical corticotomy procedure is superior to control.
The third month also crossed the line of no effect and had a weighted mean difference of 0.64 mm/month (95% CI= 0.58 to 0.69, P<0.00001). Comparable to the month prior, this final month proved to be statistically significant, therefore favouring the corticotomy group.
significant favouring corticotomy over control group. The meta-analysis also showed a high heterogeneity between studies I2 = 97%.
Two studies having measured the rate over the duration of 3 months [10,12] using piezocision were included in the meta-analysis, as seen in figure 3.
The first month presented the mean difference of canine distalization rate as 0.50 mm/month (95% CI=0.21 to 1.04, P=0.11), favouring the piezocision method.
The second and third month showed a weighted mean difference of 0.37 mm/month (95% CI=0.12 to 0.61, P=0.003) and 0.27 mm/month (95% CI=0.00 to 0.53, P=0.05) respectively.
Alike the initial one, these latter months revealed that piezocision was favoured over control group on the scale of treatment effect.
The overall outcome measure for all months presented a pooled mean difference of 0.36 mm/month (95% CI=0.23 to 0.50, p<0.00001) favouring piezocision and indicating a statistically significant difference in the movement rate. This analysis also exhibited high heterogeneity between studies I2 = 90%.
3.8 Comparison between corticotomy and piezocision
The primary outcome of this systematic review was to evaluate what surgical method was the most efficient in accelerating the rate of canine distalization. The outcome measurements of the included studies were therefor placed into intervals, for a better and easier overview of the acceleration efficiency of each method.
Three [10-13] of the studies using the corticotomy method reported a canine movement rate between 0.6 SD 0.07 to 2.2 SD 0.32 mm for the first month.
The study of Abbas et al. [10] had demonstrated the lowest number of corticotomy canine distalization rate amongst the three other studies during the first month, while Farid et al. [13] revealed a slightly higher number of 1.16 SD 0.67 mm. Jahanbakshshi et al. [11] showed the highest canine movement rate for that initial month.
The second month ranged between 0.78 SD 0.1 mm to 2 SD 0.15 mm.
Only two corticotomy articles [11,13] studied the rate over the course of 4 months. Their results ranged between 0.83 SD 1.03 mm to 1.4 SD 0.19 mm.
Two articles [10,12] compared the rate of canine retraction using piezocision. The first month revealed a movement rate between 0.50 SD 0.07 mm to 1.65 SD 0.40 mm, with Abbas et al. [10] study reporting the lowest value and Alfawal et al [12] reporting the highest rate of orthodontic tooth movement. The second month had a range between 0.7 SD 0.12 mm to 1.38 SD 0.32 mm. The piezocision studies for the third month reported similar values between 0.99 SD 0.1 mm to 1.10 SD 0.29 mm. Alfawal et al [12] was the only study including values for the forth month of rate retraction, his result being 0.87 SD 0.11mm.
4. Discussion
The main outcome in this review was whether corticotomy or piezocision had the highest capability in achieving the greatest acceleration of canine distalization.
Before evaluating this outcome, assessment of the two surgical methods were initially compared to their designated control groups to evaluate the extent of rate efficiency for each technique.
A major factor for the present increased interests and published literature in orthodontically related tooth acceleration has to do with the high demand of orthodontic treatment being hastened. Not only are patients requiring the treatment to be swift but they are also expecting the same outcome efficiency. [17]
It is important to note that procedures aiming to increase the rate of tooth movement essentially attempt to stimulate osteoclast activation and successively cause bone resorption, which triggers tooth movement. [17] Corticotomy and piezocision takes advantage of this RAP by adapting its concept to their methods. The results gathered in this systematic review and meta-analysis clearly demonstrates this phenomenon and correspondingly proves its accuracy. [18]
Four RCT [10,11,13,15] articles about corticotomy-facilitated orthodontics were included. Conclusions regarding the rate of each article compared to its control group revealed comparable results. All four articles reported a value between 1.5 to 2 times greater rate in retracting the canine compared to control group. These numbers were lower compared to a systematic review done by Viwattanatipa et al. [19], concluding that corticotomy was up to 1.5 to 4 times greater than control group. Additional to this review is one made by Patterson et al. [20], this author examined
One reason for the variety of values amongst the included articles in this systematic review might be the heterogeneity in the procedure. Compared to piezocision, the characteristics concerning the surgical aspects of the corticotomy procedure were diverse, furthermore the orthodontic appliances and sizes used were not entirely analogous. Another possible factor could be due to the difference in force application. Although only one study [11] applied a greater 200g-retraction force, the chance of causing a slight variation in the overall outcome values exists. In addition, this review excluded articles older than 5 years old and therefor older research done on these fields was not included. An article made in 2014 by Al-Naoum et al [21] concluded a 2-4 times higher rate of canine retraction, this study could possibly be the reason for the high interval set by other systematic reviews.
The corticotomy related meta-analysis was conducted on two articles [10,11]. The corticotomy group crossed the line of no effect in all 3 months, showing an overall significant difference in outcome and therefor favouring the corticotomy group over control. Heterogeneity was evaluated as very high in the first two months but remarkably enough had 0% heterogeneity in the third month. This could possibly be explained by looking at the measurements provided in the article by Abbas et al. [10]. While the outcome of nearly all included articles followed the regional acceleratory phenomenon, his values contradicted it. An important segment in this phenomenon explained by Frost [4] is the significance in mineralization and remineralisation of bone during the initial two months. This could possibly continue for up to 24 months [4] but it ultimately indicates that the rate of tooth movement should be at its highest during the initial months, not gradually increase and peak at 10-12 weeks as shown in the article by Abbas et al. [10]
These values create a high diversity in the first and second month in the meta-analysis,
Jahanbakhshi et al. [11], opposite to Abbas et al [10], show high values at first and a subsequent decrease after each month. This would help explain why heterogeneity proved to be high in the two early months. Taking this into consideration, it also would be reasonable to conclude that a 0% heterogeneity isn’t peculiar either during the third month. The measurement of Jahanbakhshi et al. [11] peaked at 2.2 mm/month for the first month while Abbas et al.[10] had 1.8 mm/month at its highest value during the third month. We could draw an assumption and find it comprehensible that as Jahanbakhshi´s [11] higher numbers decrease, Abbas et al. [10] values increase and an
control groups. These numbers are parallel with its comparator corticotomy. Türker et al [22] performed a study on piezocision and LLLT, this author found the highest peak in piezocision rate to be during the initial 4 weeks post-surgery, it also proved to be the only month showing a
statistical difference (P<0.001). This falls into place with our overall conclusion regarding this minimally invasive procedure. Also worth mentioning is the article by Viwattanatipa et al. [19] that compared two piezocision facilitated RCT articles and presented a matching conclusion of a 1.5 to 2 times greater rate of canine retraction compared to control group.
The meta-analysis done on 2 articles [10,12] for piezocision showed an overall high heterogeneity in all included month. The apparent variability in data was mentioned previously for corticotomy. Abbas et al. [10] article comparing both piezocision and corticotomy were considered beneficial in both of the meta-analysis and was therefor also included in this case. The concept we drew earlier is expected to be of benefit again in this circumstance. The low initial values provided in his RCT are questionable and do not follow RAP. Despite this, we cannot draw a true conclusion in regards to the values being incorrect. Numerous factors can play a role in the increase of heterogeneity.
The primary outcome was based upon a comparison between the two surgical methods corticotomy and piezocision. The first month yielded a range between 0.6 (SD 0.07) to 2.2 (SD 0.32) mm for corticotomy, whereas piezocision showed results values between 0.50 (SD 0.07) to 1.65 (SD 0.40) mm. These outcomes indicate that corticotomy show a greater amount of canine retraction rate as compared to piezocision.
The second month revealed an interval for corticotomy and piezocision between 0.78 (SD 0.1) to 2 (SD 0.15) mm and 0.7 (SD 0.12) to 1.38 (SD 0.32) mm respectively. Although the difference might not be substantial there is still a clear higher range in values for the former group than the latter.
The third month displayed outcomes between 1.22 (SD 0.08) to 2.01 (SD 1.37) mm for corticotomy and values between 0.99 (SD 0.1) to 1.10 (SD 0.29) mm for piezocision. These results also indicate a greater rate of tooth movement occurring after piezocision. The reason for these could be
multifactorial however since corticotomy is significantly more invasive and creates more
mechanical damage to the alveolar bone, consequently causing bone remodelling to increase the rate of repair [23], it would not be irrational to why corticotomy presents overall higher values.
results of 0.87 (SD 0.11) mm. The conclusion drawn here might not be similar to previously determined intervals but nevertheless corticotomy still proves to be superior over piezocision, presenting values almost 1.5 times greater.
4.1 Duration of treatment
The retraction of canine is known as the utmost extensive phase and therefore increases the overall orthodontic treatment time.
By increasing the rate of tooth movement, a decrease in treatment time could be achieved.
A piezocision article by Alfawal et al. [12] reported a significant 1.17-month decrease in the overall duration of canine retraction treatment, similarly Charavet [24] presented a 36% decrease in the overall treatment time by the use of piezocision-facilitated orthodontics.
Vargas et al. [25] concluded a total treatment decrease of 3-4 times by the use of corticotomy in orthodontic procedures.
4.2 Adverse effect
Two corticotomy related articles [10,15] both determined the periodontal effects to be of no significant difference between their corresponding control groups. This falls into agreement with a case series done on 20 patients by Sulewska et al [26]. Her results displayed no negative side effect in relation to treatment with corticotomy. Comparably Ferrer et al [23] came to the same conclusion in his systematic article, reporting no significant periodontal damage. Two included piezocision articles [9,10] reported no significant difference in the periodontal health post-surgery. Raj et al [14] came to a similar conclusion despite finding a slight increase in PD and RAL.
4.3 Root resorption
Three piezocision articles [10,14,16] reported results about root resorption. While two of them [14,16] concluded no significant root resorption existing between the surgical and conventional orthodontic treatment, one study [10] whose article consisted of both piezocision and corticotomy, presented no difference in root resorption when compared to each other, but a increased root resorption in both control group when compared to their respective surgical procedure. One piezocision-facilitated mass-retraction study done by Hatrom et al. [27] showed no significant difference in root resorption in either group.
4.4 Molar Anchorage loss
Nearly all included articles [10,15,12,13] that covered molar anchorage loss, reported no significant loss in relation to the surgical procedure. However Aksakalli et al. [9] concluded a decreased amount of anchorage loss in his article.
4.5 Pain, discomfort and swelling
Only one included corticotomy article by Sharma et al. [15] assessed pain, swelling and discomfort. She reported that the greater part of patients showed mild pain upon eating during the initial 24 hours and a subsequent pain decrease to 28.57% after 3 days. Moderate to severe swelling also occurred in 50% of patients after 3 days. The level of discomfort was regarded as mild to moderate for the initial 3 days. Gibreal et al [28] evaluated the pain and discomfort after piezocision-assisted flapless corticotomy, he concluded no significant difference in the level of pain or discomfort when compared to its control group. However swelling was regarded as significant during the first day assessment.
Similarly, an article by Charavet et al. [29] reported a high initial pain level after a completed piezocision procedure followed by a subsequent decrease in pain.
5. Limitations
The majority of the included articles were of low quality due to their high risk of bias. The amount of research samples were small and the ages went as low as 14 years old, which might have
contributed to diverse outcomes. Heterogeneity also proved to be very high in both meta-analysis, this could be due to several factors affecting the overall values of each compared article. Abbas et al. [10] article was used in both meta-analysis and were believed to have created some irregularity in heterogeneity. The reason behind this is due to his values failing to follow RAP. Farid et al. [13] also exhibited similar values to the previously mentioned article by peaking substantially in rate at the third month. The period of RAP is said to last up to 24 months, the highest follow up duration in our included articles were 21 weeks [15], the remainder of the studies observed outcomes over a period of 3-4 months. Thus it might be beneficial to include more longitudinal studies stretching over a greater amount of time to evaluate the true extent of each surgical method.
6. Conclusion
1. Corticotomy exhibited higher values of canine retraction rate amongst the included studies when compared to piezocision
2. Corticotomy achieved an overall 1.5 to 2 times greater rate of canine distalization when compared to control group
7. Practical recommendations
According to this systematic review corticotomy displayed higher rate of OTM values when compared to piezocision, despite this, it doesn’t translate to an automatic superiority over its comparator.
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Annex 1
Surgical protocol for corticotomy
The surgical procedure comprises of an initial incision made buccally and lingually, encompassing at least two to three teeth past the area to be treated. [30] Corticotomy involves raising a flap, the design of the flap is an arrangement of a full-thickness flap coronally with a split –thickness dissection apically. Following flap reflection is the elevation of the periosteal layer from the
alveolar bone. It is critical to elevate it with care for the purpose of not damaging any neurovascular bundles in the bone or alter muscle attachments. For aesthetic success it is also essential to leave interdental gingival tissue in place. [30,31]
The decortication can be done both labially and lingually by using either a No. 1 or No. 2 round diamond bur, or a piezoelectric knife on the alveolar bone. The vertical cuts are made 2-3 mm below the alveolar crest in the interradicular space, extending up to 2mm beyond the root apices. Cortical perforations can then be selectively placed in the alveolar bone. [30,31] (Fig 1)
Fig. 1 Vertical decortication after flap retraction [3]
Fig.2 Bone grafting with demineralized freeze-dried bone [3]
Annex 2
Surgical protocol for piezocision
Piezocision does not entail raising a flap. The technique initially involves vertical cuts made on the attached gingiva both buccally and interproximally. Both soft tissues and periosteum needs to be incised for the purpose of insertion of a piezoelectric knife. The tip of the knife is thereafter inserted and a 3 mm vertical and cortical cut is made. It is crucial not to interfere with the proximal papilla or the roots at this stage. [32] A tunnelling procedure can be added if bone grafting is desired. [3] The indication for this is usually in cases of thin gingiva or recession. This procedure comprises of the insertion of a periosteal elevator between the periosteum and alveolar bone via the vertical opening. A dissection is then carried out and a tunnel is created. The piezoelectric corticotomy is completed in the interradicular spaces, a graft slurry is subsequently placed into the tunnels using a syringe (Fig 1). The vertical mucosal and cortical incisions don’t require any suturing. If a tunnel technique has been prepared, a 5-0 chromic gut interrupted sutures or alternatively drops of cyanoacrylate glue are necessary. [3,32]
Fig. 1 A tunnelling procedure established (left picture) and bone
