Keser Et Al

Keser and Naini Maxillofacial Plastic and Reconstructive Surgery (2022) 44:1
https://doi.org/10.1186/s40902-021-00331-5
Maxillofacial Plastic and
Reconstructive Surgery
REVIEW Open Access
Accelerated orthodontic tooth movement:

surgical techniques and the regional
acceleratory phenomenon
Elif Keser1 and Farhad B. Naini2*
Abstract: Background: Techniques to accelerate tooth movement have been a topic of interest in orthodontics
over the past decade. As orthodontic treatment time is linked to potential detrimental effects, such as increased
decalcification, dental caries, root resorption, and gingival inflammation, the possibility of reducing treatment time
in orthodontics may provide multiple benefits to the patient. Another reason for the surge in interest in accelerated
tooth movement has been the increased interest in adult orthodontics.
Review: This review summarizes the different methods for surgical acceleration of orthodontic tooth movement. It
also describes the advantages and limitations of these techniques, including guidance for future investigations.
Conclusions: Optimization of the described techniques is still required, but some of the techniques appear to offer
the potential for accelerating orthodontic tooth movement and improving outcomes in well-selected cases.
Keywords: Regional acceleratory phenomenon, Microosteoperforations, Periodontally accelerated osteogenic
orthodontics (PAOO), Corticision, Piezocision
Background personally and professionally, with 75% reporting im-

The New York Times published an article in February provements in personal relationships or in their career,
2012 indicating a 58% increase in the number of Ameri- which they felt was due to their improved smiles.
can adults getting orthodontic treatment from 1994 to Ninety-two percent of the adults surveyed said they
2010, whereas there was only a 15% increase in the would recommend orthodontic treatment to other adults
number of patients under 18 years of age, during the [3]. A study conducted at the Eastman Dental Institute
same period. There has been a gradual increase in the in the UK found that the desire for dental alignment and
number of adults starting orthodontic treatment in the improved smile aesthetics were the primary motivating
USA, based on the results of orthodontic practice sur- factors for initiating treatment [4]. There are significant
veys [1]. The number of adults seeking orthodontic differences between the orthodontic treatment of adoles-
treatment appears to be on the increase in the UK as cents and adults. These are mainly related to psycho-
well [2]. A survey of the American Association of Ortho- logical and biological differences.
dontists (AAO) showed that the number of adult pa- Tayer [5] found that 33% of adult patients were dis-
tients increased by 16% in the period from 2012 to 2014, couraged from having orthodontic treatment due to the
and a 2013 study conducted for the AAO stated that length of treatment and the discomfort and inconveni-
adults who had orthodontic treatment by an orthodon- ence involved with having orthodontic appliances. A
tist had reported significant life improvements, both major concern for adult orthodontic patients is the pro-
longed length of treatment. Adults tend to desire a
shorter treatment time and demand more aesthetic ap-
* Correspondence: [email protected]
2 pliances [6, 7].
Kingston and St George’s Hospitals and St George’s Medical School,
Blackshaw Road, London SW17 0QT, UK
Full list of author information is available at the end of the article
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Keser and Naini Maxillofacial Plastic and Reconstructive Surgery (2022) 44:1 Page 2 of 21
The demand for more aesthetic appliances has been the bone volume through which root movement would
addressed by the use of clear aligners and lingual ortho- occur.
dontics. In the past decade, various techniques have The first English language paper describing a partial
been described to accelerate tooth movement, such as decortication of the alveolar bone to facilitate orthodon-
photobiomudulation, use of ultrasonic vibration, tic tooth movement was by Köle [10]. This formed the
pharmacological approaches, ultrasounds, microosteo- basis of the techniques employed today. This was due to
perforations (MOPs), periodontally accelerated osteo- the rationale that the primary resistance to tooth move-
genic orthodontics (PAOO), corticision, and piezocision. ment was from the bone cortex. This cortical layer takes
This article is a comprehensive narrative review, which longer to remodel than the trabecula of the spongiosa,
aims to summarize the surgical methods to accelerate and if its continuity is disrupted, orthodontic tooth
orthodontic tooth movement and review the main stud- movement can be completed much faster. Köle reflected
ies published in recent years on this topic. full-thickness flaps to expose the lingual and buccal al-
veolar bone. He then made interdental cuts through the
Search strategy cortical bone, but only slightly penetrating the medullary
The search strategy comprised the following: The Med- bone. Subapical horizontal cuts were undertaken as oste-
line, Scopus, Embase, and Web of Science databases otomies, connecting the interdental cuts, and penetrat-
were searched from 1985 to 2021 to identify all studies ing the full-thickness of the alveolus. This created a
using a number of terms. These included regional accel- block of bone, embedding one or more teeth, and sepa-
eratory phenomenon, RAP, accelerated orthodontics, rated from the rest of the alveolar bone by the cortical
microosteoperforations, micro-osteoperforations, peri- osteotomy. This was referred to as a “bony block
odontally accelerated osteogenic orthodontics (PAOO), movement”.
corticision, and piezocision. The Boolean operators In 1978, Generson et al. [11] published two cases using
“and” and “not” were used to focus the search. The fol- corticotomy with orthodontic treatment, stating that
lowing journals were also hand-searched from 2000 to there was a reduction in the treatment time. Gantes
2021: et al. [12] used Köle’s technique and the removal of cor-
American Journal of Orthodontics (and subsequent tices adjacent to an extraction site in five patients with
American Journal of Orthodontics and different malocclusion. The mean overall treatment
Dentofacial Orthopedics) times were 14.8 months in the corticotomy group and
Angle Orthodontist 28.3 months in the control group. The author analysed
British Journal of Orthodontics (and subsequent Jour- probing depths, plaque scores, and clinical attachment
nal of Orthodontics) levels, concluding that this surgery caused minimal
European Journal of Orthodontics changes in the periodontium. Suya [13] refined Köle’s
International Journal of Oral and Maxillofacial work and used “corticotomy-facilitated orthodontic” sur-
Surgery gical treatments on 395 patients. He used a supra-apical
International Journal of Periodontics and Restorative horizontal corticotomy cut instead of the horizontal
Dentistry osteotomy used in Köle’s procedure. The cases took 6 to
Journal of Clinical Orthodontics 12 months to complete. He observed that this procedure
Journal of Oral and Maxillofacial Surgery was less painful and produced less root resorption and
Journal of Periodontology relapse. He recommended completing the tooth move-
Seminars in Orthodontics ment in 3–4 months, as after this time, fusion of the
edges of the blocks of bone would begin.
Historical development of techniques
Corticotomy
The idea behind using surgery to accelerate tooth move- Dental distraction (dentoalveolar distraction
ment is not new. The origin of surgically accelerated osteogenesis)
tooth movement dates back towards the end of the nine- Liou and Huang [14] presented a concept of “distracting
teenth century, having been modified during the twenti- the periodontal ligament” to shorten the canine distaliza-
eth century. tion time to 3 weeks and called this concept “dental dis-
L.C. Bryan first described surgically assisted orthodon- traction”. This technique basically required modification
tic tooth movement in 1893 [8]. Later, in 1931, Bichl- of the extraction socket by undermining the interseptal
mayr [9] described a surgical procedure to accelerate the bone, distal to the canines, and using an intraoral dis-
correction of severe maxillary protrusion and reduce retraction device, which was activated 0.5–1 mm/day im-
lapse, for patients over 16 years of age. The technique mediately after the extraction. The rapid canine
consisted of removing wedges of bone in order to reduce retraction techniques require the use of a rigid
distraction device that can be activated 0.5–1 mm/day to undertaken, and calcein was included in the diet to mark
move the canines distally (Figs. 1, 2, and 3). the newly formed bone. At 4 weeks, he recorded newly
formed cancellous bone that obliterated the osteotomy
The regional acceleratory phenomenon gap, with a fivefold increase in new bone, without a
Regional acceleratory phenomenon (RAP) was defined change in bone volume. This was given an explanation
by Frost [15] as a “complex reaction of mammalian tis- of a local acceleration in bone remodelling.
sues to diverse noxious stimuli”. He stated that “The
phenomenon occurs regionally in the anatomical sense, RAP and tooth movement: a physiological
involves both soft and hard tissues, and is characterized concept
by an acceleration and domination of most ongoing nor- Periodontally accelerated osteogenic orthodontics
mal vital tissue processes. It may represent an “SOS” Yaffe et al. [17] were the first authors who described
mechanism which evolved to potentiate tissue healing RAP applied to the mandible, in 1994. They explored
and local tissue defensive reactions.” The intensity of its whether RAP occurs following mucoperiosteal flap sur-
response and the size of the affected region varies dir- gery in the jaw bone. They found that, in rats, the eleva-
ectly with the magnitude of the stimulus, although there tion of a mucoperiosteal flap is sufficient to create RAP.
is individual variability. The effect on the bone is a re- The RAP was observed as early as 10 days after surgery,
duction in regional bone density due to an increased re- peaked at 3 weeks, and was essentially completed by or
modelling space. Frost, who was an orthopaedic following 120 days. Both on the lingual and buccal as-
surgeon, also stated that a joint contracture, which was pects, the resorption was more prominent when a muco-
previously too rigid to respond to traction, can respond periosteal flap had been undertaken.
more readily during the 3 months or so following a In 2001, Wilcko and Wilcko [18] explained the accel-
major local bone operation, a phenomenon which sug- eration of the tooth movement in a different way. They
gests that the RAP rendered the capsular and related tis- concluded that the acceleration was due to the RAP.
sues more plastic for a time. They changed the understanding from the mechanical
Bogoch [16] used a rabbit model to investigate the concept of a “bony block movement” relating the corti-
RAP. An incomplete osteotomy of the condyle was cotomy effect, to a physiological concept, the RAP (de-
calcification/recalcification of the alveolus), which was
described by Frost. The Wilcko brothers introduced the
Periodontally Accelerated Osteogenic Orthodontics
(PAOO) technique, in which orthodontic forces were ap-
plied 1 week before the procedure, and also added bone
grafts after decortication. Both on the buccal and lingual
sides of the selected area, intrasulcular incisions were
made, a full-thickness flap was reflected and the cortico-
tomies were performed. The vertical incisions were lo-
cated between the teeth and connected apically, and
additional corticotomies were performed. Demineralized
freeze-dried bone allograft (DFDBA) and bovine graft
were placed and the flap was sutured (Fig. 4). The draw-
backs of this technique are:
1. The length of the procedure: the procedure on both

jaws can take 3–4 h to complete.
2. Due to the extent of the surgery postoperative
complications are common, such as swelling,
bruising, and pain.
3. Appearance of interproximal black triangles.
4. Due to the extent of the surgery, its clinical and
patient acceptance is low.
Corticision
Kim et al. [19] introduced the corticision technique as a
Fig. 1 Schematic representation of the surgical procedure for rapid
minimally invasive alternative to create surgical injury to
canine distraction (redrawn from Liou, 1998)
the bone without raising a flap. Kim et al. [19] and Park
Fig. 2 A rapid canine distraction device was designed by Drs. Keser and Pober (patent pending) to overcome some of the disadvantages of the
dental distractors
[20] use a reinforced scalpel and a mallet to go through 3. The possibility of breakages of the scalpel and risk
the gingiva and the cortical bone, without flap reflection. of injuries.
The surgical injury created in this manner is enough to
induce the RAP effect and accelerate the orthodontic
tooth movement. The advantage of this technique is the Piezocision
avoidance of a surgical flap, when compared with the Practitioners and patients often consider corticotomies
PAOO surgery. The drawbacks of this technique are: to be too invasive, therefore, their acceptance remains
low [21]. A new minimally invasive surgical approach
1. The inability to graft hard or soft tissues during the without flap elevation, called piezocision, was developed
procedure in order to correct and reinforce the to overcome this problem. First described in 2009 by
periodontium. Dibart [22], it combined the flapless approach of cortici-
2. The repeated malletting which may cause dizziness sion with the advantage of grafting offered by PAOO.
after the surgery. This technique combines buccal gingival micro-incisions
that allow the use of the piezoelectric knife to decorti-
cate the alveolar bone and thereby initiate the regional
accelerator phenomenon. The technique is minimally in-
vasive, but allows hard tissue and/or soft tissue grafting
via selective tunnelling, in order to correct gingival re-
cessions or bone deficiencies.
Piezoelectric surgery utilizes ultrasonic microvibra-
tions to ensure that only brittle mineralized tissue is cut
and soft tissues are spared, since cutting soft tissue re-
quires a frequency above 50 kHz. Because of its micro-
metrical and selective cut, a piezoelectric device allows
safe and precise osteotomies, without any osteonecrotic
damage [23, 24]. Piezoelectric surgery also obviates the
need for excessive force (Fig. 5a–c). Suturing is recom-
mended in all areas nowadays to limit scarring. There is
minimal patient discomfort. Other advantages of the
procedure are the grafting option and limited duration
of surgery. There is no need for flap elevation, and
therefore the surgical time is decreased, and the postop-
erative discomfort is minimal. The drawback of this
Fig. 3 Application of the Canine distractor. Activation begins technique is that since there is no flap reflection, the
immediately after the surgical procedure and activation is at a rate cuts are undertaken blindly. The use of navigation or
of 0.35 mm twice per day. Power chain is placed on the lingual surgical stents is considered to be beneficial to avoid in-
aspect to prevent rotation during the movement
juries to the roots.
Fig. 4 Wilcko and Wilcko PAOO. a Corticotomies, vertical lines and dots. b DFDBA placement
Micro-osteoperforations premolar extractions, in order to accelerate tooth move-

Also known as alveocentesis, micro-osteoperforations ment (Fig. 7). The drawbacks of the technique are:
is a novel technique introduced to accelerate tooth
movement, with minimal surgical intervention. It is a 1- The extent of the injury created to the bone is
minimally invasive procedure, as there is no flap ele- minimal and therefore the RAP effect may not be as
vation or incisions prior to the osteoperforations. long as it is intended.
Propel (Propel Orthodontics, USA) is an example of 2- It is a blind technique and pre-planning of the pos-
a device that can be used to create MOPs (Fig. 6). ition of the MOPs is crucial to avoid injury to the
The effectiveness of the technique in accelerating roots.
tooth movement is theoretically the amplification in 3- The inability to graft hard or soft tissues during the
the expression of inflammatory markers that are nor- procedure to correct and reinforce the
mally expressed during orthodontic tooth movement periodontium.
[25, 26].
Alikhani [25] used MOPs (Propel) in a clinical trial in
20 adults with Class II division 1 malocclusions. Three 4- It is time consuming especially in the mandible
flapless microperforations were performed under local because of the thick cortex and needs to be
anaesthesia distal to the canines, 6 months after the repeated frequently adding cost and chair time to
treatment.
Fig. 6 Propel device by Propel Orthodontics, USA. It has a surgical

tip 1.6 mm in diameter and a usable length of up to 7.0 mm
severe crowding who was 24 years old and a Class I case

with moderate to severe crowding who was 17 years old
were treated using PAOO. Orthodontic adjustments
were made at two-week intervals, approximately after
the surgery and the treatments were completed within 6
months and 2 weeks, which reduced treatment time by
75%. The first patient also required bone grafting, with
re-entry undertaken 15 months following surgery (8.5
months following debond). Clinical observation demon-
strated acceptable maintenance of the alveolar crest
height and an increased buccal bone thickness. Despite
the canine and premolars in this area being expanded
buccally by more than 3 mm, there had been an increase
in the buccolingual thickness of the overlying buccal
bone. The authors suggested that the rapid expansive
tooth movements with no significant apical root resorp-
tion may be attributed to the osteoclastic or catabolic
phase of the RAP. The conclusion was that cortico-
tomies resulted in transient osteoporosis, accelerating
tooth movement. The potential for grafting was an
Fig. 5 a Minimal vertical interproximal incisions on the buccal

aspect to provide access to the piezosurgical knife. b Corticotomies
are performed with a Piezoelectrical surgical knife (BS1 insert,
Piezotome, Satelec Acteon Group, Merignac, France) through the
gingival incision in the bone, with a depth of 3 mm to pass the
cortical plate. c Where bone grafting is needed a small periosteal
elevator is used to create a tunnel which will accommodate the
bone graft
Review of the Literature

There have been case reports, animal and clinical studies
published on all the above techniques, especially in the
past 10 years, due to the increased popularity of surgi-
cally accelerated orthodontics (Table 1).
Corticotomy/PAOO
Case reports
Fig. 7 Propel handheld disposable device used for MOPs
Wilcko and Wilcko [18] described the PAOO technique
(Alikhani, 2013)
with a report of two cases in 2001. A Class I case with
Table 1 Publications on surgically accelerated orthodontics in chronological order

Author(s) and Type of subjects Number Control group Procedure being assessed Type of
year of of and type publication
publication subjects
Liou and Huang, Human 15 No Rapid canine retraction/dental distraction Clinical
1998 [14] study
Wilcko and Human 2 None PAOO Case
Wilcko, 2001 [18] report—2
cases
Kisnisci et al., Human 11 No Rapid canine retraction/dental distraction Clinical
2002 [36] study
Bilodeau, 2003 Human 1 No Rapid canine retraction/dental distraction Case report
[35]
Iseri et al., 2005 Human 10 No Rapid canine retraction/dental distraction Clinical
[37] study
Lee et al., 2007 Human 65 Yes— Corticotomy, segmental osteotomy Clinical
[30] conventional study
orthodontics
Iino et al., 2007 Beagle dogs 12 Split mouth Corticotomy Animal
[32] design study
Nowzari et al., Human 1 None PAOO Case report
2008 [27]
cases
cases
KIm et al., 2009 Cat 16 Yes Corticision Animal
[19] study
Dibart et al., Human 1 None Piezocision Case report
2009 [22]
Mostafa et al., Beagle dogs 6 Split mouth Corticotomy Animal
2009 [33] design study
Sanjideh et al., Foxhound dogs 5 Split mouth Corticotomy Animal
Teixeira et al., Sprague-Dawley rats 48 Yes Soft tissue flap and osteoperforations Animal
2010 [55] study
About-Ela et al., Human 13 Split mouth Corticotomy Clinical
2011 design study
Keser and Human 1 None Piezocision Case report
Dibart, 2011 [40]
Keser and Human 1 None Piezocision Case report
Dibart, 2013 [41]
Alikhani et al., Human 20 Yes— Microosteoperforations Clinical
2013 [25] conventional study
orthodontics
Murphy et al., Wistar Rats 44 Yes Corticision Animal
2014 [38] study
Milano et al., Human 1 None Piezocision Case report
2014 [42]
Dibart et al., Sprague-Dawley rats 94 Yes Piezocision Animal
2014 [53] study
Murphy et al., Wistar rats 44 Yes Corticision Animal
2016 [39] study
Aksakalli et al., Human 10 Split mouth Piezocision Clinical
Table 1 Publications on surgically accelerated orthodontics in chronological order (Continued)

Author(s) and Type of subjects Number Control group Procedure being assessed Type of
year of of and type publication
publication subjects
Charavet et al., Human 24 Yes— Piezocision Clinical
orthodontics
Abbas et al., Human 20 Split mouth Two groups for canine retraction: corticotomy and Clinical
2016 [46] design piezocision study
Dibart et al., Ex-vivo calvarial bone 276 Yes Groups: piezoelectric knife, bur, handheld screw device Animal
2016 [68] organ culture—mice study
Uribe et al., Human 29 Yes— Piezotome-corticisions Clinical
orthodontics
Sugimori et al., Wistar Rats 50 yes— Microosteoperforations Animal
2018 [56] orthodontic study
force only
Alkebsi et al., Human 32 Yes— Microosteoperforations Clinical
orthodontics
Chan et al., 2018 Human 20 Yes— Microosteoperforations Clinical
orthodontics
Attri et al., 2018 Human 60 Yes— Microosteoperforations Clinical
orthodontics
Hou et al., 2019 Human 1 None Piezocision Case report
[43]
Strippoli et al., Human 24 Yes— Piezocision Clinical
2019 conventional study
orthodontics
Van Gemert Beagle dogs 13 Split mouth Microosteoperforations Animal
et al., 2019 [57] design study
Sivarajan et al., Human 30 Split mouth Microosteoperforations Clinical
Charavet et al., (Oncins France Strain 60 Yes— Piezocision Animal
2019 [54] A) Rats orthodontic study
force only
Hatrom et al., Human 26 Yes— Piezocision Clinical
orthodontics
Khlef et al., 2020 Human 40 No Two groups: corticotomy done by using piezoelectric knife Clinical
[52] with flap and piezocision( defined as flawless corticotomy) study
Hannequin et al., Human 1 None Corticotomy done by using piezoelectric knife with flap Case report
2020 [71]
Hatrom et al., Human 23 Yes— Piezocision Clinical
orthodontics
Alvarez et al., Human 36 Yes— Piezocision Clinical
orthodontics
Kernitsky et al., Sprague-Dawley rats 18 Yes Groups: deep and shallow piezoelectric decortications Animal
2021 [69] study
Sharon et al., Human 30 Yes— Microosteoperforations Clinical
orthodontics
important addition to corticotomy-facilitated orthodon- and anterior segmental osteotomy in the mandible; and
tics, especially in cases with preexisting defects. 16 with anterior segmental osteotomy in the maxilla and
Nowzari et al. [27] used the PAOO technique in a mandible. The mean treatment duration for the conven-
Class II division 2 case, aged 41 years, in order to accel- tional orthodontic group was the longest. The
erate orthodontic movement. Treatment was completed corticotomy-assisted orthodontic treatment can be ad-
in 8 months, with re-entry after 4 months. The maxillary vantageous for adult patients concerned with prolonged
and mandibular alveolar ridges maintained the original treatment duration. Anterior segmental osteotomy is
thickness and configuration, despite proclination of the recommended for bimaxillary dentoalveolar protrusion
incisors. They concluded that PAOO was an effective patients with increased gingival exposure on smiling,
treatment approach in adults, reducing both treatment skeletal prognathism, relatively normal incisor inclin-
time the risk of root resorption. ation, and relative deficiency in chin prominence.
Wilcko and Wilcko [28] presented two more cases Aboul-Ela et al. [31] compared miniscrew implant-
treated with PAOO, including the stability of the results supported maxillary canine retraction with and without
up to 8 years of retention, in 2009. The first patient had corticotomy-facilitated orthodontics in 13 adult patients
a Class I malocclusion with crowding of both arches and with Class II division 1 malocclusions. A split-mouth in-
severe maxillary arch constriction. This case was com- vestigation design was used. Canine retraction rate was
pleted in just over 6 months, with 8 mm of transverse two times faster on the test sides in the initial 2 months.
arch expansion. The second patient had moderate anter- It was 1.6 times faster in the third month and almost the
ior crowding. Her treatment time was 7 months. Both same (1.06 times higher) by the end of month 4. No sta-
patients showed thickening of the alveolar housing at re- tistically significant difference was found between pre-
entry, and all the dehiscences and fenestrations were operative and postoperative measurements in relation to
filled with bone. The authors stated that, “The acceler- probing depth, attachment loss, gingival recession, or
ated osteogenic orthodontics technique provides for effi- plaque index.
cient and stable orthodontic tooth movement.
Frequently, the teeth can be moved further in one third Animal studies
to one fourth the time required for traditional orthodon- Iino et al. [32] did a split-mouth study on twelve beagle
tics alone”. In the same year, Wilcko and Wilcko [29] dogs to measure tooth movement rate and the post-
published three more cases that required first premolar corticotomy bone reaction. Four second bicuspids were
extractions and canine retraction. The first case had a removed. A 16-week waiting period was given for
Class I molar relationship; maxillary first bicuspids and complete callus formation and mineralization prior to
mandibular canines extracted, and the PAOO surgery the corticotomy. It was found that movement was con-
followed. Her treatment time was 9 months. The other stant and faster, and the total amount of tooth move-
patient had bimaxillary protrusion with an 8-mm anter- ment on the experimental side was double. Root
ior open bite and moderate labial segment crowding. resorption was found after 4 and 8 weeks on the control
The first premolars were removed, the canines were side, but no root resorption was observed on the experi-
retracted, and treatment was completed in 9 months. mental side. Following the corticotomies, orthodontic
Another case presented with a Class II malocclusion. tooth movement increased for at least 2 weeks. The au-
Following PAOO surgery the treatment duration was 12 thors suggested that this may have been brought about
months. The authors’ conclusion was that the PAOO by rapid alveolar bone reaction in the bone marrow cav-
technique allowed teeth to be moved 2-3 times faster, 1/ ities, which led to less hyalinization of the periodontal
4 to 1/3 of the time required for orthodontic treatment, ligament on the alveolar wall.
and side effects of orthodontic movement such as root Mostafa et al. [33] investigated corticotomy-facilitated
resorption and relapse can be reduced with PAOO. orthodontic tooth movement using miniscrews on an
animal model. The maxillary second premolars of six
Human studies beagle dogs were removed. Miniscrews were inserted be-
Lee et al. [30] compared the treatment outcomes of tween the roots of the third premolars and the first mo-
orthodontic treatment only, anterior segmental osteot- lars bilaterally. Corticotomy was performed on the right
omy or corticotomy-assisted orthodontic treatment for side. Notches were placed on the two teeth allowing the
the management of bimaxillary dentoalveolar protrusion. distance between the first and third premolars to be
From the sample of 65 patients, 29 were treated with measured weekly, and histological samples were ac-
conventional orthodontics and anchorage reinforcement quired. They found that tooth movement was twice as
using a transpalatal arch with or without headgear. fast on the experimental side. Histology demonstrated
Twenty were treated with corticotomy-assisted ortho- greater activity and more extensive remodelling of the
dontic treatment with skeletal anchorage in the maxilla bone in the corticotomy group. This suggested that
accelerated tooth movement following corticotomy may concluded that the PDL could be rapidly distracted with-
be due to increased bone turnover, based on the RAP. out complications.
Sanjideh et al. [34] assessed the effect of corticotomy Kisnisci et al. [36] modified the rapid canine distrac-
on a dog model in a split-mouth study design. The au- tion by adding horizontal and vertical osteotomies sur-
thors investigated whether corticotomy procedures in- rounding the canines, in order to achieve rapid
crease tooth movement and the effects of a second movement in the dentoalveolar segment, in compliance
corticotomy procedure after 4 weeks on the rate of tooth with the principles of distraction osteogenesis. They
movement. Second premolars were extracted in the used dentoalveolar distraction on 11 patients. The first
upper arch and third premolars in the lower arch. One premolar was extracted, and the buccal bone was care-
upper and one lower quadrant had corticotomy only on fully removed. After mucosal incisions, cortical holes
the extraction day. Another upper quadrant had a sec- were made in the alveolar bone from the canine to the
ond procedure carried out 28 days later. The final quad- second premolar, curving apically to pass 3-5 mm from
rant was the control. Tooth movement on the test side the apex. The holes were connected round the root. Fine
was twice that of the control side after 56 days. The au- osteotomes were advanced coronally. Following the first
thors concluded that corticotomy significantly increased premolar extraction, the buccal bone was removed be-
orthodontic tooth movement. Performing a second cor- tween the outlined bone cut at the distal canine region
ticotomy procedure after four weeks maintained higher anteriorly and the second premolar posteriorly. Larger
rates of tooth movement over a longer duration. It also osteotomes were used to fully mobilize the alveolar seg-
produced greater overall tooth movement than perform- ment with the canine. The palatal shelf was preserved,
ing just one initial corticotomy, although the difference but the apical bone near the sinus wall was removed,
was small. Therefore, the second corticotomy procedure leaving the sinus membrane intact to avoid interferences
was not deemed to be justified. during the active distraction process. Osteotomes along
the anterior aspect of the canine were used to split the
surrounding bone around its root from the palatal or
Rapid canine retraction/dental distraction
lingual cortex and neighbouring teeth. The transport
Case report
dentoalveolar segment with the canine tooth also in-
Bilodeau published a case report in 2003 [35] demon-
cluded the buccal cortex and the underlying medullary
strating the application of dental distraction on a 37-
bone that envelopes the canine root, leaving an intact
year-old male. The dental distraction was used only on
lingual or palatal cortical plate and the bone around the
the upper left side; the patient was seen every three days
apex of the canine. Distraction was started the same day
during retraction. The canine retraction was completed
at the rate of 0.4 mm twice a day and continued until
in 25 days. He reported that the patient experienced no
adequate movement of the canine teeth was achieved.
discomfort with the device, and the tooth tested vital to
The authors reported good patient tolerance with the
ice at the end of the distraction.
distraction rate and the device. No root resorption, dis-
coloration, dental ankylosis, loss of vitality, or anchorage
Human studies loss in the second premolar and first molar teeth was
Liou and Huang [14] had 15 orthodontic patients (26 ca- detected.
nines, including 15 maxillary and 11 mandibular) requir- Iseri et al. [37] used ten subjects to study the dentoal-
ing first premolar extraction and canine retraction. veolar distraction of twenty maxillary canines. First pre-
Distal to the canine, the interseptal bone was under- molars were extracted, and the dentoalveolar distraction
mined with a bone bur, with grooves vertically inside the surgical procedure performed as described by Kisnisci,
extraction socket, along the buccal and lingual sides and and a custom-made intraoral, rigid, tooth-borne distrac-
extending obliquely towards the socket base (Fig. 1). An tion device was placed. The canines were moved rapidly
intraoral distraction device was placed to distract the ca- into the extraction sites in 8–14 days (rate of 0.8 mm/
nine distally into the extraction space. This was activated day). There was no clinical or radiographic evidence of
0.5-1.0 mm/day immediately after the extraction. The complications observed in any of the patients.
upper and lower canines were distracted bodily 6.5 mm
into the extraction space within 3 weeks. New alveolar Corticision
bone was generated and remodelled rapidly in the mesial Animal studies
periodontal ligament of the canine during and after the Kim et al. [19] evaluated the biologic effects of cortici-
distraction. Radiographic examination revealed that ap- sion on alveolar remodelling in orthodontic tooth move-
ical or lateral surface root resorption of the canine was ment using cats. Group A (control) had orthodontic
minimal. No periodontal defect or endodontic lesion force only. Group B had corticision and orthodontic
was observed throughout or after distraction. They forces. Group C had corticision together with
orthodontic forces and periodic mobilization. The cats of root craters were performed on maxillary first molars.
in the control group received no surgery. Each group The results suggested that corticision had a small and
was also divided into 4 subgroups, according to the force statistically insignificant effect in reducing root resorp-
application duration (7,14 ,21 and 28 days). The canines tion. No difference in root resorption was observed be-
were retracted with a 100g force, and the first and sec- tween 10 and 100 g of force measured by two-
ond molars were used for anchorage. The test groups (B dimensional histomorphometry or three-dimensional
and C) had corticision on the mesial and distal buccal, micro CT.
and distal-palatal aspects of the maxillary canines, using
a reinforced surgical blade and mallet for bone decorti- Piezocision
cation. In group C, mobilization was carried out imme- Case reports
diately following corticision. This was repeated every 3 Piezocision™ was first described by Dibart in 2009, in a
days. The authors observed extensive direct resorption case report [22]. The patient had a Class II division 2 in-
of the bundle bone with rapid removal of hyalinized tis- cisor relationship with slight maxillary retrusion. Piezo-
sue in group B, compared to the controls. The mean ap- cision™ was undertaken one week after the orthodontic
position area of new bone was 3.5 times higher in group appliances were placed. Ten vertical interproximal
B than in the control group at 28 days. There was no ob- microincisions were made in both jaws. Corticotomies of
vious root resorption or any other pathological change approximately 3-mm depth were made with a piezoelec-
in the corticision groups. There were no differences be- tric knife. The areas requiring expansion were tunnelled
tween groups B and C, suggesting periodic mobilization and bone grafts were placed. The treatment was com-
was not sufficient to increase RAP duration. The authors pleted in 17 weeks. The author concluded that piezoci-
explained that RAP can reduce the lag phase of tooth sion is a minimally invasive alternative to the PAOO,
movement by stimulating hyalinized tissue removal, with the total surgical time less than an hour. It was sug-
thereby resulting in reduced orthodontic treatment time. gested that the approach led to short orthodontic treat-
Murphy et al. [38] used two different force magnitudes ment time, minimal discomfort, and good patient
on the rate of tooth movement on rats. They assessed acceptance, as well as stronger periodontium, because of
the effects of corticision on alveolar bone remodelling 14 the added grafting (Fig. 8).
days following the start of orthodontic movement. Keser and Dibart [40] published a case report demon-
Forty-four rats were divided into four groups, receiving strating a case treated with an Invisalign appliance using
either a heavy 100g or a light 10g force, with or without piezocision to accelerate the treatment. The case report
corticision. The corticision procedure was performed at showed how to tackle the two major issues when it
appliance placement with force applied from the upper comes to adult orthodontics - the use of a discreet appli-
first molars to the central incisors. A week later spring ance in a timely manner. The authors illustrated how, in
reactivation was undertaken and corticision repeated in selected cases, piezocision combined with Invisalign
the corticision groups. The contralateral side was used treatment can be used to treat adults successfully. An-
as a control in every groups. Microcomputed tomo- other case report by Keser and Dibart [41] in 2013, used
graphic analysis was carried out on day 14 to assess sequential piezocision for Class III correction, signifi-
quantitatively for any bony changes and to evaluate the cantly reducing the treatment duration and the
tooth movement. Histomorphometric analysis was per- utilization of the RAP in a sequential manner helped
formed to evaluate osteoclastic activity and whether it with the complex tooth movement and anchorage re-
related to the changes in bone density. No significant quirements. The patient was 25 years of age, female,
differences in the microcomputed tomography data were with a Class III malocclusion, narrow maxilla and cross-
found. The authors concluded that, regardless of the bites of multiple teeth. She had 7.5 mm of upper crowd-
force magnitude, a flapless surgical insult in the mesio- ing and 2 mm crowding in the lower arch. The option to
palatal aspect of the first molar with a single-site cortici- have extractions in the upper arch and orthognathic sur-
sion was unable to induce clinical or histologic changes gery as the ideal treatment plan was provided, but the
after 2 weeks of orthodontic tooth movement. Histo- patient decided against it. Treatment was started by
logical analysis showed a significantly reduced bone vol- bracketing the maxillary arch and the piezocision was
ume fraction for the group with light loads compared performed. Only after 10 weeks, once the upper align-
with the other groups. ment was achieved, the orthodontic appliances were
Murphy et al. [39] repeated the experiment in 2016 to placed in the mandible and the lower jaw piezocision
assess the effect of corticision with different force mag- was undertaken. The orthodontic treatment was com-
nitudes on root resorption. Two-dimensional (histomor- pleted in 8 months. Fixed and removable retainers were
phometric) and three-dimensional (volumetric, micro- used. Piezocision was used successfully in a sequential
focus X-ray computed tomography [micro CT]) analysis manner to correct the Class III malocclusion.
Fig. 8 Case report (Dibart, 2009). a Pretreatment frontal view. b Post-treatment frontal view. c Tunnelling of areas to be grafted with bone. d
Bone grafting. e Sutures in place
A case report was published by Milano et al. [42] to extracted and canines were distalized. The initial stage
demonstrate the use of a surgical guide, to reduce the was alignment of the teeth. After the alignment was
risk with piezocision where there is close root proximity. complete, piezocision was performed on one side. Two
The authors demonstrated that the depth and location buccal vertical incisions were made, each approximately
of corticotomies can be precisely planned using a three- 10 mm, to create decortications at a depth of 3 mm.
dimensional model of the arch. A surgical guide can be Elastometric chains with a force of 150g were used for
fabricated and used to prevent damage to the dental distalization, adjustments were done every 2 weeks, and
roots. Another case was presented by Hou et al. [43] elastomeric chains were replaced at each appointment
where a 3D computer-assisted piezocision guide was until Class I canine relationship was achieved. Measure-
used to minimize the risk of surgical complications. The ments of movement were compared between the experi-
guide was designed as translucent for increased visibility, mental and control group before and after distalization,
rigid for enhanced support and porous for profuse intra- as were gingival scores and also mobility. Three-
operative irrigation. dimensional analysis of the study casts showed signifi-
Figure 9 a shows another design of a piezocision guide cant differences in tooth movement, less anchorage loss
that was used for a patient who was being treated with and greater canine distalization in the experimental
Invisalign (not published). Software was used to super- group. Also, the distalization time was shortened in the
impose the CBCT images of the patient and the guide experimental group. There was no difference between
design, to determine the position of the piezocision cuts the two groups for transversal changes, mobility or gin-
and the angulation of the piezoelectric knife in order to gival indices. They concluded that piezocision reduced
avoid any damage to the roots. The height of the cutting canine distalization time by half, and decreased the an-
holes was planned to be tall enough to prevent any wob- chorage loss for posterior teeth, and piezocision does
ble of the piezoelectric knife during the procedure. Irri- not have any adverse effects on periodontal health.
gation holes were present for water cooling. Using a Charavet et al. [45] compared conventional orthodon-
guide like this shortened the piezocision procedure time tic treatment to piezocision-assisted orthodontic treat-
and also made the positioning of the cuts extremely ac- ment in an adult group of patients with crowding.
curate and avoided any injuries to the roots (Fig 9b). Piezocisions were performed 1 week after the orthodon-
tic appliances were placed, and follow up appointments
Human studies were made every 2 weeks. The authors compared the
Aksakalli et al. [44] investigated the effectiveness of treatment duration, periodontal health, alveolar crest
piezocision in canine distalization in Class II patients. changes, analgesic intake in both groups. The treatment
They recorded the transverse changes, the post- time significantly reduced by 43%in the piezocision
distalization gingival status, and mobility scores in a group. Radiographic and periodontal parameters were
split-mouth design, where first maxillary premolars were similar following treatment in both groups, no increase
Fig. 9 a Piezocision surgical guide planning, showing the ideal angulation/insertion of the piezoelectric knife (design by Dr. Keser). b Application
of the surgical guide digitally created to guide piezocision surgery for a patient being treated by clear aligners
in root resorption was observed in either group. Scars reduce canine retraction duration and root resorption in
were observed in 50% of the patients in the piezocision adults. Corticotomy-facilitated orthodontics is 1.5-2
group. The piezocision group demonstrated higher pa- times faster than conventional orthodontics. Piezocision
tient satisfaction and smaller variations in the duration was 1.5 times faster than conventional orthodontics.
of treatment. The authors concluded that piezocision is Strippoli et al. [47] carried out a clinical trial to com-
an effective method in accelerating orthodontic tooth pare the duration of orthodontic treatment with peizoci-
movement. The risk of residual scarring should be kept sion versus conventional orthodontic treatment. They
in mind, especially in patients with a high smile line. Ab- also evaluated the safety of the piezocision and assessed
bas et al. [46] compared the efficiency of corticotomy fa- the inflammatory process, periodontal health and soft
cilitated orthodontics and piezocision in rapid canine tissue healing during the first 6 months in the piezoci-
retraction. They used a piezotome in both groups to cre- sion group. They found that the duration of treatment
ate the decortication. In the corticotomy side they re- was significantly decreased by 54%in the piezocision
moved the bundle of bone from the medial wall of the group compared with the conventional orthodontics
extraction socket of the premolar to decrease the resist- group. Most patients indicated that they would be will-
ance to tooth movement, in a similar fashion described ing to undergo a piezocision procedure again. Minimal
in rapid canine distraction by Liou in 1998 [14]. They effects on periodontal parameters were observed despite
concluded that both corticotomy-facilitated orthodontics the presence of some gingival scars. Although not statis-
and piezocision are effective treatment alternatives that tically significant, pro inflammatory markers showed
clinical peaks at 3–5 and 16 weeks following surgery. found in terms of skeletal, dental, and soft tissue vari-
These were in agreement with a systematic review by Yi ables, as well as the amount of external apical root re-
et al. [48] and confirmed that the piezocision-assisted sorption. They concluded that corticotomy-assisted en
orthodontic tooth movement can be considered to be a masse retraction, with or without flaps, led to improve-
safe procedure. Hatrom et al. [49] used a randomized ments in skeletal structures, facial profile and resulted in
controlled clinical trial to compare the en masse retrac- sufficient retraction of maxillary anterior teeth, and that
tion with or without piezocision, to assess the type of neither technique caused significant root resorption.
tooth movement. They also evaluated root integrity after
the retraction and recorded the pain levels. Piezocision Animal studies
cuts were carried out on the buccal aspect of the jaw Dibart et al. [53] used 94 rats to study the effects of
and in addition a piezotome was used to remove the piezocision on bone, with and without tooth movement.
bone from the extraction socket distal to the canine root The four groups were no active treatment, tooth move-
and palatal side of the socket. They concluded that ment only, piezocision only, and tooth movement with
piezocision enhanced the amount of en masse retraction piezocision. Alveolar bone histomorphometry after
by two times, with less root resorption; the piezocision piezocision was assessed, as were catabolic activity and
group showed a reduced amount of incisor tipping and extent of demineralization at various stages from 1 to 56
root resorption. Postoperative pain experienced by pa- days. An increase in the rate of bone resorption follow-
tients was moderate. The same group of investigators ing piezocision began on day 3 and continued to day 14,
published another study where they evaluated the pulp after which the movement of the teeth became the driv-
volume changes after piezocision-assisted tooth move- ing force for bone resorption. The increase in osteoclast
ment [50]. They used two groups of patients requiring numbers were significantly greater in the piezocision
orthodontic treatment with bilateral maxillary first pre- and tooth movement groups. The greatest level of osteo-
molar extractions and en masse retraction: 1- extraction clastic activity in the tooth movement only group was
with piezocision, 2- only extraction. At the end of the en on the third day, which decreased afterwards. The re-
masse retraction phase, pulp volume was significantly results showed that piezocision increases the rate of tooth
duced in all six anterior teeth in both groups. The de- movement and suggested that the increased osteoclastic
crease in pulp volume was not statistically different activity following decortication is extended by the syner-
between the groups. They also concluded that the degree gistic relationship between piezocision and orthodontic
of change in pulp volume did not appear to be related to tooth movement (Fig. 10). Charavet et al. [54] also used
the amount of root resorption. Alvarez et al. [51] com- rats to study the alveolar bone tissue response following
pared the extent of buccal bone defects and transverse piezocision to demonstrate the underlying biological
tooth movement of mandibular lateral segments in pa- mechanism. Sixty rats were randomly distributed be-
tients after orthodontic treatment with and without tween a control group (conventional tooth movement)
piezocision. The study sample consisted of 36 patients and an experimental group (piezocision-assisted tooth
with moderate mandibular anterior crowding. No signifi- movement). Tissue, cellular, and molecular analyses
cant differences were found in buccal dehiscences and were performed at 7, 28, and 42 days. The results
transverse tooth movement of the mandibular lateral showed that orthodontic tooth movement was 1.8 times
segments. In both groups dehiscences, buccal inclination faster in piezocision group at day 42. The bone volume
and arch width increased significantly at the end of the fraction was significantly decreased in the piezocision
treatment. The results were similar to those of Aksakalli group on day 7 and 28, but there was no difference on
et al. [37], who did not find any intercanine maxillary day 42. On day 7, the number of osteoclasts were signifi-
transverse differences between the piezocision group cantly higher in the piezocision group. There was no dif-
and control group when retracting canines after pre- ference between the two groups in the number of
molar extraction. osteoclasts involved in root resorption. This study dem-
In a recent randomized controlled clinical trial, Khlef onstrated the effectiveness of piezocision to accelerate
at al [52]. evaluated the efficacy of corticotomies, with tooth movement.
and without flaps, which were performed using a piezo-
electric knife. They had forty Class II division 1 patients Micro-osteoperforations
requiring maxillary first premolar extractions. One Animal studies
group was treated by flap elevation and using a piezo- Teixeira et al. [55] used rats to study the effects of osteo-
electric knife for decortications, and the other group was perforations using burs. The authors hypothesis was that
treated without a flap and piezoelectric corticotomies in stimulation of the expression of inflammatory cytokines,
en masse retraction by using miniscrews for anchorage. via osteoperforations of cortical bone, increases the rate
No significant differences between the groups were of bone remodelling and tooth movement. The
Fig. 10 Percentage of bone demineralization over time in the three experimental groups: piezocision alone (PS), piezocision and tooth
movement (PS+TM), tooth movement alone (TM) (from Dibart et al. [54].)
investigation used 48 Sprague-Dawley rats with four evident after 4 weeks. The principal effects do not ex-
groups: control, orthodontic force applied by a coil tend more than 1.5 mm from the MOP and normal
spring (O), orthodontic force with a soft tissue flap (OF, tabular healing occurs following MOP placement.
the flap was raised around the left first molar), or the
same as the OF group but with shallow perforation of Human studies
the cortical plate (OFP). This involved raising a soft tis- Alikhani [25] in 2013 investigated the effect of micro-
sue flap around the left first molar and three shallow osteoperforations (MOPs) on the rate of tooth move-
perforations, with a round bur, of 0.25 mm diameter and ment and on the expression of inflammatory markers.
depth, placed 5 mm mesial to the left first molar. The Twenty adults with Class II division 1 malocclusions
results showed that osteoperforations increase the rate were included in the study and divided into control and
of tooth movement, by increasing the rate of bone re- experimental groups. The experimental group received
modelling and general osteoporosity. The O and OF MOPs on one side of the maxilla, while the control
groups had a statistically lower expression of 21 cytokine group only had orthodontic treatment. All subjects had
receptors than the OFP group. Another animal study the maxillary first bicuspids removed. MOPs were done
from Japan that was undertaken by Sugimori [56] on rats after the levelling and alignment were completed and
focused on the inflammation, cell proliferation and the cases were ready for retraction. Three MOPs were
apoptosis of periodontal ligament cells. The experiment performed in the experimental group under local anaes-
period was 14 days and demonstrated that MOPs accel- thesia, distal to the canines, prior to the retraction
erated orthodontic tooth movement with a decreased undertaken with a disposable device (by PROPEL Ortho-
bone mineral density and bone volume/tissue volume ra- dontics, NY). Each perforation was 1.5 mm in width and
tio and an increased expression of THF-alpha and prolif- 2-3 mm in depth. Orthodontic force was applied with a
eration and apoptosis of compressed PDL cells. The coil spring connected from a TAD to a power arm on
authors concluded that MOPs may be effective in accel- the cuspid bracket. The study was concluded after 28
erating orthodontic tooth movement and reducing the days of canine retraction. Discomfort levels were pro-
traditional orthodontic treatment time. Van Gemert vided by the participants at different time points. There
et al. [57] used a split-mouth design on beagle dogs. was no difference between groups at any time point.
They wanted to determine how far the effects of MOPs After 24 h of canine retraction, the levels of chemokynes
can extend within the bone. They would quantify the increased significantly in both groups. In the control
damage caused and the short-term bony adaptations that group, by day 28, only IL-1 was still significantly higher
occur in and around the injury site. They used 13 beagle than before retraction. In the test group IL-1α and IL-1β
dogs and evaluations were performed 2 and 4 weeks levels were higher compared to before retraction. The
after MOPs. They concluded that the demineralization study model measurements at day 28 showed that ca-
effects of MOPs on bone are transient and are not nine retraction in the experimental group to be 2.3 times
higher compared to the control group. This was accom- this study were related to the RAP effect and that en-
panied by a significant increase in the inflammatory hanced alveolar bone turnover associated with an in-
markers. They concluded that MOPs are an effective creased osteoclastic activity was found to exacerbate the
and comfortable technique for the acceleration of tooth root resorption process [62, 63]. Also, it is possible that
movement. excessive localized activation of osteoclasts, as seen after
Alkebsi et al. [58] used a split-mouth design to investi- surgical procedures such as MOPs [55, 64], can lead to
gate the effect of MOPs on the rate of tooth movement. an increase in odontoclastic activity [62]. The authors
This randomized controlled trial used 32 patients who concluded that further research should be undertaken
needed maxillary first premolar extractions. Miniscrews on patients undergoing a full course of orthodontic
were used to support anchorage and for canine retrac- treatment and that repair of root resorption craters after
tion. Three MOPs were performed using miniscrews on MOPs should be investigated.
the buccal bone distal to the canines on the randomly Most recently, Shahrin et al. [65] investigated the ef-
selected side. They found no statistically significant dif- fectiveness of MOPs in overall time taken for alignment
ference in the rates of tooth movement between the of maxillary anterior crowding and evaluated the align-
MOP and the control sides at any time point. They con- ment improved percentage within 6 months between
cluded that three MOPs were not effective in accelerat- MOPs and cantor groups. They used 30 subjects with
ing tooth movement at any time point. Attri et al. [59] moderate upper labial segment crowding. All partici-
had 60 subjects requiring en-masse retraction following pants had their first premolars extracted. The interven-
first premolar extractions. The experimental group re- tion group received 3-mm-deep MOPs at monthly visits
ceived MOP distal to the canines, and they were com- until alignment was completed. There was no statisti-
pared with a control group treated with identical cally significant difference in the overall alignment dur-
brackets without MOP. They concluded that MOP ap- ation between the two groups. The authors concluded
pears to increase tooth movement rate, but with no dif- that MOPs are no more effective in accelerating initial
ference in the perception of pain. Monthly space closure orthodontic alignment than conventional treatment.
rate was 0.73 to 0.89 mm in the MOP group and 0.49 to This study was performed for the initial alignment phase
0.63 mm in the control group. Sivarajan et al. [60] used only.
30 subjects to assess the effect of MOPs in three differ-
ent canine retraction groups. Group 1: MOP 4-weekly
upper arch/8-weekly lower arch, Group 2: MOP 8- Discussion
weekly upper arch/12-weekly lower arch, and Group 3: There has been an increased interest in techniques to
MOP 12-weekly upper arch/4-weekly lower arch, with accelerate orthodontic tooth movement. The aim of this
measurements undertaken at 4-week intervals over 16 paper has been to present the different surgical tech-
weeks. Mean overall canine retraction was 4.16 mm with niques that have been developed to accelerate tooth
MOP and 3.06 mm without. All the MOP groups exhib- movement and review the pertinent literature about
ited significantly higher canine distalization than the these techniques.
control group. The subjects reported pain associated One of the main reasons behind accelerating ortho-
with MOP, with 60% classifying it as moderate and 15% dontic tooth movement is to address the patients’ desire
as severe. The main impact of this reported pain was re- for shorter treatment time in orthodontic appliances.
lated to chewing and speech. The authors concluded All the techniques described above have decreased
that MOP can increase overall mini-implant supported orthodontic treatment duration to some extent. Treat-
canine retraction over a 16-week period of observation, ment duration was reduced by one-third to a quarter of
but that this difference is unlikely to be clinically signifi- the expected time with the PAOO surgery [18], and by
cant. Chan et al. [61] looked into the effects of MOPs on half with piezocision surgery [45]. Rapid canine retrac-
orthodontic root resorption. In this prospective con- tion [14] reduced the canine retraction phase, which can
trolled trial, the authors used 20 subjects requiring ex- take an average of 6 months with routine appliance me-
traction of the upper first premolars as part of their chanics, to less than 1 month. The possibility of shorten-
orthodontic treatment. A 150g force was applied to both ing the treatment time may be particularly advantageous
premolars, and 5-mm depth MOPs were applied mesi- for adult orthodontic patients, both in terms of accept-
ally and distally in the mid-root region of the experi- ing orthodontic treatment, and accepting multidisciplin-
mental premolar. The premolars were extracted after 28 ary treatment plans, which may include pre-restorative
days and microcomputer tomography was used to meas- orthodontics. When adult patients are more willing to
ure the volumes of the root resorption craters. The re- go through orthodontic treatment to set the teeth in
sults showed greater orthodontic root resorption where their correct positions with pre-restorative orthodontics,
MOPs were applied. Some of the points mentioned in better restorative outcomes may be achieved.
The mechanism behind the accelerated tooth move- postoperative complications, such as bruising and pain,
ment has been discussed by various authors. Initially, it make the acceptance of the procedure low both by the
was described as a “bony block movement” [10]; later, patients and clinicians.
Wilcko and Wilcko [18] explained the acceleration of Corticision [19] was introduced to use the RAP effect
the tooth movement by the RAP, changing the previous for accelerating the tooth movement without the inva-
understanding of the acceleration of the movement from siveness of the PAOO. The flapless approach decreases
a “bony block movement” to the physiological concept the surgical time, the postoperative discomfort, and the
the “RAP”. Some of these procedures may also represent postoperative complications [19]. The main limitations
an alternative, albeit only in cases of mild skeletal dis- of this procedure are the inability to graft and the
crepancies, to orthognathic surgery in patients who are trauma caused by the malleting. This technique did not
not willing to undergo major procedures, by increasing seem to gain popularity over the years.
the scope of tooth movement [41]. The Piezocision™ procedure, introduced by Dibart
The effect of surgical techniques to accelerate ortho- [22], combined the advantages of PAOO™, which is the
dontic tooth movement on root resorption has been un- possibility of grafting, and corticision, which is a flapless
clear. It was suggested that one of the advantages of and thereby less invasive surgical procedure, and also
corticotomy-assisted orthodontics is the protection from added the benefits of using a piezoelectric knife instead
root resorption [28, 32, 39]. However, there have been of a bur for decortications. The surgical procedure is
contradictory findings on the effects of these techniques performed only on one side of the alveolus and the pro-
on root resorption [61, 66], especially in distinguishing cedure can be performed in a very short time, especially
the reason for the root resorption, i.e. whether root re- compared to PAOO, with minimal patient discomfort
sorption is the effect of the procedures on root surface and postoperative complications [22]. Healing, at the
remodelling or related to the improper use of the sur- clinical level, is suggested to be more predictable and
gery directly damaging the root. less painful [53]. The use of the piezoelectric knife en-
To overcome the risk of damaging the tooth structure sures that only mineralized tissue is cut and produces
and compromising tooth vitality, the latest technological precise osteotomies without osteonecrotic damage [23,
advancements can be used to create accurate surgical 24]. Human studies [44, 45] confirmed that piezocision
guides or can be used for navigation during the proce- decreased total orthodontic treatment time. As this ap-
dures. For each of the techniques, adequate preoperative proach does not require flap elevation and a relatively
imaging and planning is crucial to avoid any risks, espe- simple procedure, patients are more likely to have the
cially when there is close root proximity. The majority procedure done at different times for different parts of
of the publications on accelerated tooth movement using the jaw to meet specific mechanical requirements; there-
surgical techniques in the literature are predominantly fore, a sequential approach is possible to make most of
case reports and case series, with only a limited number the RAP effect [41]. The latest technological advances
of controlled trials having been published. Although it is make it possible to use surgical guides [42] or surgical
very difficult to make a direct comparison of the differ- navigation to increase the precision of the decortications
ent techniques using the available data, the literature and reduce the risk of damage to the roots. The possibil-
available sheds some light on the advantages and disad- ity of scarring has been pointed out as a minor possible
vantages of each procedure. Rapid canine retraction/ complication [47] of this technique, and suturing is rec-
dentoalveolar distraction [14, 36] only aimed to shorten ommended to avoid scarring; also, this should be dis-
a specific portion of the orthodontic treatment. This ap- cussed with the patient during the informed consent
proach did not become popular over the years, due to its process. The acceptance of the piezocision procedure is
limited application—only for canine retraction—and the shown to be considerably high compared to cortico-
need for a special distractor device. tomies [47]. It seems like as piezoelectric surgery is gain-
The PAOO, introduced by the Wilcko brothers, was ing more popularity amongst clinicians, piezocision has
shown to decrease the length of the orthodontic treat- also been gaining popularity.
ment up to 75% [29], while reducing unwanted effects, MOPs are the most recently introduced, relatively
such as root resorption [32]. PAOO has a significant ad- simple-to-use technique to accelerate tooth movement.
vantage which is the addition of bone augmentation dur- It is a minimally invasive flapless approach, but does not
ing the decortications, which may prevent the formation allow for grafting, which is similar to corticision. The de-
of new fenestrations and bone dehiscences [27], and al- vice used to make the MOPs is a simple handheld de-
lows for the treatment of pre-existent ones, while thick- vice, and there is no need for incisions. Careful planning
ening the alveolar housing [28]. The invasiveness of the of the location of the MOPs and the use of guides can
surgical procedure is the major disadvantage of PAOO. help to avoid root damage, as this is a flapless approach.
Also, the length of the procedure and common Patient discomfort and procedure time are much less
compared to the other procedures previously described. RAP effect. Previously, in 2017, Uribe et al. [70], pub-
The procedure may frequently require repeated applica- lished a randomized clinical trial to evaluate the effi-
tions, potentially adding to the cost and patient discom- ciency of piezotome-corticision-assisted orthodontics in
fort. In cases where the alveolar bone is thick and the alleviating mandibular anterior crowding. They used 29
effectiveness is a concern, other approaches such as patients treated with piezotome-corticision or traditional
PAOO™ or Piezocision™ should be considered for effect- orthodontics to correct mandibular crowding and found
ive decortication. no difference in the treatment time required to correct
A study published in 2014 evaluated clinician and pa- the crowding. However, on close inspection of their
tient interest in accelerated orthodontic treatment [67]. methodology, it is mentioned that a modification of the
Close to 70% of the orthodontists were interested in piezocision was used and the depth of the cortical inci-
adopting clinical procedures to reduce treatment time. sion was kept limited to 1 mm; therefore, the expected
Less invasive techniques had greater acceptability for RAP effect was not achieved. To determine if the depth
both the clinician and the patients. of corticotomy undertaken with the piezoelectric knife
PAOO, Corticision, Piezocision, and MOPs (Propel) could play a role in the intensity of the regional accelera-
use different instruments (bur, mallet, piezoelectric tory phenomenon (RAP), Kernitsky et al. [69] carried
knife, handheld screw device, etc.) for decortication. out a preliminary study. They compared the effect of
Dibart et al. [68] assessed and compared bone remodel- transcortical and intracortical penetration of the piezo-
ling activity using a calvarial bone model, between burs, electric cuts and demonstrated that the intensity of the
piezoelectric knives, and handheld screw devices, trying RAP in the rat is corticotomy depth dependent. They
to answer the question whether all corticotomies affect concluded that following a deep penetration with the
the bone in the same way. They used 6 groups: (a) cal- piezoelectric knife, passing the cortex and reaching the
varia + media only (negative control); (b) piezotome medullary space, the RAP is more intense. This gener-
sham injury, the piezotome with the BS1 insert was ates a higher level of osteoclastic activity and bone turn-
allowed to vibrate in media for five seconds with no in- over, compared with a shallower injury. This, in turn,
jury; (c) piezotome injury; (d) bur “sham” injury, the bur leads to more extensive bone demineralization, which
mounted on high-speed handpiece span in media for 5 s may have unique clinical applications in terms of speed
with no injury; (e) bur injury; (f) injury by hand held of tooth movement when combined with orthodontics.
screw perforation device. This is clinically relevant when decorticating the bone
A very surprising finding was that the sham piezotome during surgically facilitated orthodontic procedures.
group had high osteoclastic bone resorption, and osteo- As the techniques to accelerate orthodontic tooth
blastic differentiation and bone formation. This suggests movement are gaining popularity, there is more research
that vibration may be producing a similar response to being published on these techniques. A recent case re-
direct injury. The techniques induced varying degrees of port published in 2020 by Hannequin et al. [71] pre-
bone remodelling. In the bone resorption model, the sented the ortho-surgical treatment of a Class III
piezotome induced increased calcium release, TRAP ac- malocclusion treated with corticotomies using a piezo-
tivity, osteoclast differentiation, and bone resorption. electric knife for accelerated presurgical decompensation
Under bone formation conditions, the piezotome led to and clear aligners, followed by mandibular sagittal split
substantial levels of osteoblast differentiation with the osteotomy. The clinical follow-up of aligner-mediated
formation of new osteoid far exceeding those observed tooth movement, where aligners were changed every 4
with the bur and screw. The area of bone resorption and days, was managed with a patient-managed smartphone
formation was greatest in the piezotome group, which application (dental monitoring) allowing early intercep-
extended to the controlateral calvarial side, possibly tion and correction of minute orthodontic movement er-
resulting from the combined effect of injury and vibra- rors. The authors demonstrated the good use of the
tion. The bur injury group had significant remodelling dental monitoring technology when the accelerated rate
activity, which was limited to the injury region. The of the tooth movement requires very close follow-up.
handheld screw device injury resulted in the lowest Verna et al. [72] conducted a finite element study, which
amount of osteoclastic and osteoblastic activity. The au- concluded that surgical interventions may influence the
thors’ conclusion was that the piezotome had the great- amount and type of tooth movement. They suggested
est impact on bone resorption and formation. Their that the transitory osteopenia generated by the injury to
suggestion was that the high-frequency vibrations may accelerate tooth movement would allow the shift of the
intensify the response to injury. centre of rotation of the movement more apically,
A recent preliminary study by Kernitsky et al. [69] favouring larger tooth movement for the corticotomized
showed the importance of the depth of the corticotomies tooth, particularly for uncontrolled tipping. She et al.
to accelerate the tooth movement and obtain the desired [73] also used finite element analysis to show the
biomechanical effect of selective osteotomy and corticot- clear benefit from such research. Future research
omy on orthodontic molar uprighting and revealed how should concentrate on human trials, the results of
the different combinations of corticotomies had a bio- which will be directly applicable to human patients.
mechanical impact on orthodontic molar uprighting. Techniques to accelerate orthodontic tooth
They concluded the most extensive surgical approaches movement should be applied in selected cases when
resulted in increased tooth movement, which supports the benefits to the patient are clear. They should not
Frost’s [15] description of the RAP where the stimulus be applied without clear indications for their
magnitude determines the size of the affected region and benefits, which should always outweigh potential
the intensity of the response. risks or harms.
With all the surgical techniques to accelerate tooth Some of the techniques described are gaining
movement, it is important to keep in mind that as the popularity (MOPs, piezocision), whereas others
clinician can create a transient modification of the alveo- (rapid canine retraction, corticision) are not, due to
lus, more challenging movements may be achieved. limited applications, patient discomfort, or the
Therefore, it is not only the speed of the treatment that invasiveness of the technique.
potentially increases but also the possibility to success- Piezocision™ and PAOO™ have the advantage of
fully treat challenging adult patients [74]. grafting during the surgery, which allows for
It should be noted that the literature reviewed demon- improvement of the hard and soft tissues and
strated an absence of consistency in terminology and set preventing periodontal defects which might occur
protocols. When planning future investigations these due to a thin alveolar bone.
points should be considered, in addition to using long- Piezocision™, MOPs, and corticision are flapless
term clinical trials in humans to obtain a clearer under- approaches and are less invasive than PAOO™.
standing of these techniques and the underlying Mallet use in corticision is traumatic for the patient.
biophysiology. MOPs seem to be the least invasive application.
PAOO™ appears to be the most invasive approach.
Conclusions The use of the Piezoelectric knife appears to have a
Surgical techniques to accelerate tooth movements are greater impact on bone metabolism and creates a
not new. The journey of accelerated tooth movement greater response to injury when compared to other
that started as early as 1893 has been continuing with techniques.
constant advancement, gaining popularity in the last The depth of the injury created during these
decade, and the techniques have been evolving to reduce procedures has a direct effect on the intensity of the
the disadvantages and improve the acceptability of treat- RAP. Therefore, it plays a very important role in the
ment by patients and clinicians. Recently, there have effectiveness of the techniques.
been clinical modifications of corticotomies, with studies
Abbreviations
designed to compare the techniques where a flap was
MOPs: Micro-osteoperforations; PAOO: Periodontally accelerated osteogenic
raised versus a flapless procedure, and a significant trend orthodontics; PDL: Periodontal ligament; RAP: Regional acceleratory
to do the decortication with a piezoelectric knife instead phenomenon; TAD: Temporary anchorage device
of a bur. Efforts to minimize the trauma to the patient
Authors’ contributions
and the chair time are also important points being con- EK prepared the first draft of the review article, and EK and FBN contributed
sidered in the development of new techniques. Long- to the final manuscript. Both authors reviewed the final manuscript.
term controlled clinical trials in humans are required to
assess and compare the effectiveness of the different Availability of data and materials
Not applicable.
available techniques, their side effects, and long-term
results. Declarations
Some conclusions may be drawn from the limited
Ethics approval and consent to participate
number of studies available:
Not applicable.
The surgical techniques reviewed and described in Consent for publication

this article all accelerate orthodontic tooth Not applicable.
movement at different rates. It is not possible to
Competing interests
clearly compare the amount of reduction in The authors declare that they have no competing interests.
treatment time achieved by these different
techniques from the data available. Author details
1
Department of Orthodontics, Boston University Henry M. Goldman School
Aside from the obvious ethical implications of of Dental Medicine, Boston, USA. 2Kingston and St George’s Hospitals and St
animal experimentation, it is also difficult to see any George’s Medical School, Blackshaw Road, London SW17 0QT, UK.
Received: 19 October 2021 Accepted: 15 December 2021 24. Robiony M, Polini F, Costa F, Vercellotti T, Politi M (2004) Piezoelectric bone
cutting in multi piece maxillary osteotomies. Oral Maxillofac Surg 62(6):759–
761. https://doi.org/10.1016/j.joms.2004.01.010
25. Alikhani M, Raptis M, Zoldan B, Sangsuwon C, Lee YB, Alyami B, Corpodian
References C, Barrera LM, Alansari S, Khoo E, Teixeira C (2013) Effect of micro-
1. Keim RG, Gottlieb EL, Nelson AH, Vogels DS (2013) JCO orthodontic practice osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial
study. Part 1 Trends. J Clin Orthod 47(11):661–680 Orthop 144(5):639–648. https://doi.org/10.1016/j.ajodo.2013.06.017
2. Christensen L, Luther F (2015) Adults seeking orthodontic treatment: 26. Alikhani M, Alansari S, Sangsuwon C, Chou MY, Alyami B, Nervina JM,
expectations, periodontal and TMD issues. BDJ 218(3):111–117. https://doi. Teixeira C (2015) Micro-osteoperforations: minimally invasive accelerated
org/10.1038/sj.bdj.2015.46 tooth movement. Semin Orthod 21(3):162–169. https://doi.org/10.1053/j.
3. https://us.dental-tribune.com/news/adults-are-seeking-orthodontic-trea sodo.2015.06.002
tment-in-record-numbers/. Accessed Sept 2021.
27. Nowzari H, Yorita FK, Chang HC (2008) Periodontally accelerated osteogenic
4. Cedro MK, Moles DR, Hodges SJ (2010) Adult orthodontics-who’s doing
orthodontics combined with autogenous bone grafting. Compend Contin
what? J Orthod 37(2):107–117. https://doi.org/10.1179/14653121042966
Educ Dent 29:200–206 quiz 207, 218
5. Tayer BH, Burek MJ (1981) A survey of adults’ attitudes toward orthodontic
28. Wilcko MT, Wilcko WM, Pulver JJ, Bissada NF, Bouquot JE (2009) Accelerated
therapy. Am J Orthod 79(3):305–315. https://doi.org/10.1016/0002-9416(81
osteogenic orthodontics technique: a 1-stage surgically facilitated rapid
)90078-6
orthodontic technique with alveolar augmentation. J Oral Maxillofac Surg
6. Ong MMA, Wang HL (2002) Periodontic and orthodontic treatment in
67(10):2149–2159. https://doi.org/10.1016/j.joms.2009.04.095
adults. Am J Orthod Dentofacial Orthop 122(4):420–428. https://doi.org/10.1
29. Wilcko MT, Wilcko WM, Omniewski KB, Bouquot JE, Wilcko JM (2009) The
067/mod.2002.126597
Periodontally ‘Accelerated Osteogenic Orthodontics’TM (PAOOTM) technique:
7. Hassan AH, Amin HE (2010) Association of orthodontic treatment needs and
efficient space closing with either orthopedic or orthodontic forces. J
oral health-related quality of life in young adults. Am J Orthod Dentofacial
Implant Adv Clin Dent 1:45–63
Orthop 137(1):42–47. https://doi.org/10.1016/j.ajodo.2008.02.024
30. Lee JK, Chung KR, Baek SH (2007) Treatment outcomes of orthodontic
8. Guilford SH. Orthodontia, or malposition of the human teeth: its prevention
treatment, corticotomy-assisted orthodontic treatment, and anterior
and remedy. Spangler & Davis, 1893. APA.
segmental osteotomy for bimaxillary dentoalveolar protrusion. Plast
9. Bichlmayr A (1931) Chirurgische Kieferorthopaedie und das Verhalten des
Reconstr Surg 120(4):1027–1036. https://doi.org/10.1097/01.prs.0000277999.
Knochens und der Wurselspitzen nach derselben. Dtsch Zahnaerztl Wschr
01337.8b
34
31. Aboul-Ela SMBED, El-Beialy AR, El-Sayed KMF, Selim EMN, El-Mangoury NH,
10. Köle H (1959) Surgical operations on the alveolar ridge to correct occlusal
Mostafa YA (2011) Miniscrew implant-supported maxillary canine retraction
abnormalities. Oral Surg Oral Med Oral Pathol 12(5):515–529. https://doi.
with and without corticotomy-facilitated orthodontics. Am J Orthod
org/10.1016/0030-4220(59)90153-7
Dentofacial Orthop 139(2):252–259. https://doi.org/10.1016/j.ajodo.2009.04.028
11. Generson RM, Porter JM, Zell A, Stratigos GT (1978) Combined surgical and
orthodontic management of anterior open bite using corticotomy. J Oral 32. Iino S, Sakoda A, Ito G, Nishimori T, Ikeda T, Miyawaki S (2007) Acceleration
Surg 36(3):216–219 of orthodontic tooth movement by alveolar corticotomy in the dog. Am J
12. Gantes B, Rathbun E, Anholm M (1990) Effects on the periodontium Orthod Dentofacial Orthop 131:448.e1–448.e8. https://doi.org/10.1016/j.a
following corticotomy-facilitated orthodontics. Case reports. J Periodontol jodo.2006.08.014
61(4):234–238. https://doi.org/10.1902/jop.1990.61.4.234 33. Mostafa YA, Mohamed Salah Fayed M, Mehanni S, ElBokle NN, Heider AM
13. Suya H (1991) Corticotomy in orthodontics. In: Biological basics in (2009) Comparison of corticotomy-facilitated vs standard tooth-movement
orthodontic therapy 207–226. techniques in dogs with miniscrews as anchor units. Am J Orthod
14. Liou EJW, Huang CS (1998) Rapid canine retraction through distraction of Dentofacial Orthop 136(4):570–577. https://doi.org/10.1016/j.ajodo.2007.10.
the periodontal ligament. Am J Orthod Dentofacial Orthop 114(4):372–382. 052
https://doi.org/10.1016/s0889-5406(98)70181-7 34. Sanjideh PA, Rossouw PE, Campbell PM, Opperman LA, Buschang PH (2010)
15. Frost HM (1983) The regional acceleratory phenomenon: a review. Henry Tooth movements in foxhounds after one or two alveolar corticotomies.
Ford Hosp Med J. 31:3–9. (accessible at https://scholarlycommons.henryford. Eur J Orthod 32(1):106–113. https://doi.org/10.1093/ejo/cjp070
com/hfhmedjournal/vol31/iss1/2?utm_source=scholarlycommons.henryford. 35. Bilodeau JE (2003) Dental distraction for an adult patient. Am J Orthod
com%2Fhfhmedjournal%2Fvol31%2Fiss1%2F2&utm_medium=PDF&utm_ca Dentofacial Orthop 123:683–689. https://doi.org/10.1016/S0889-5406(03
mpaign=PDFCoverPages). Accessed Sept 2021. )00046-5
16. Bogoch E, Gschwend N, Rahn B, Moran E, Perren S (1993) Healing of 36. Kisnisci R, Iseri H, Tuz H, Altug A (2002) Dentoalveolar distraction
cancellous bone osteotomy in rabbits--Part I: Regulation of bone volume osteogenesis for rapid orthodontic canine retraction. J Oral Maxillofac Surg
and the regional acceleratory phenomenon in normal bone. J Orthop Res 60(4):389–394. https://doi.org/10.1053/joms.2002.31226
11(2):285–291. https://doi.org/10.1002/jor.1100110216 37. Iseri H, Kisnisci R, Bzizi N, Tuz H (2005) Rapid canine retraction and
17. Yaffe A, Fine N, Binderman I (1994) Regional accelerated phenomenon in orthodontic treatment with dentoalveolar distraction osteogenesis. Am J
the mandible following mucoperiosteal flap surgery. J Periodontol 65(1):79– Orthod 127(5):533–541. https://doi.org/10.1016/j.ajodo.2004.01.022
83. https://doi.org/10.1902/jop.1994.65.1.79 38. Murphy CA, Chandhoke T, Kalajzic Z, Flynn R, Utreja A, Wadhwa S, Nanda R,
18. Wilcko WM, Wilcko T, Bouquot JE, Ferguson DJ (2001) Rapid orthodontics Uribe F (2014) Effect of corticision and different force magnitudes on
with alveolar reshaping: two case reports of decrowding. Int J Periodontics orthodontic tooth movement in a rat model. Am J Orthod Dentofacial
Restorative Dent 21(1):9–19 Orthop 146(1):55–66. https://doi.org/10.1016/j.ajodo.2014.03.024
19. Kim SJ, Park YG, Kang SG (2009) Effects of corticision on paradental 39. Murphy CA, Kalajzic Z, Chandhoke T, Utreja A, Nanda R, Uribe F (2016) The
remodeling in orthodontic tooth movement. Angle Orthod 79(2):284–291. effect of corticision on root resorption with heavy and light forces. Angle
https://doi.org/10.2319/020308-60.1 Orthod 86(1):17–23. https://doi.org/10.2319/112514-843.1
20. Park YG (2016) Corticision: a flapless procedure to accelerate tooth 40. Keser EI, Dibart S (2011) Piezocision assisted Invisalign treatment. Compend
movement. Front Oral Biol 18:109–117. https://doi.org/10.1159/000351904 Contin Educ Dent (2):32, 46–48 50-51
21. Zawawi KH (2015) Patients’ acceptance of corticotomy-assisted 41. Keser EI, Dibart S (2013) Sequential piezocision: a novel approach to
orthodontics. Patient Prefer Adherence 9:1153–1158. https://doi.org/10.214 accelerated orthodontic treatment. Am J Orthod Dentofacial Orthop 144(6):
7/PPA.S89095 879–889. https://doi.org/10.1016/j.ajodo.2012.12.014
22. Dibart S, Sebaoun JD, Surmenian J (2009) Piezocision: a minimally invasive, 42. Milano F, Dibart S, Montesani L, Guerra L (2014) Computer-guided surgery
periodontally accelerated orthodontic tooth movement procedure. using the piezocision technique. Int J Periodon Restor Dentistry 34(4):523–
Compend Contin Educ Dent 30:342–344 346, 348–350 529. https://doi.org/10.11607/prd.1741
23. Kotrikova B, Wirtz R, Kremlin R, Blank J, Eggers G, Samiotis A, Muhling J 43. Hou HY, Li CH, Chen MC, Lin PY, Liu WC, Tsai YWC, Huang RY (2019) A
(2006) Piezosurgery- a new safe technique in cranial osteoclasts. Int J Oral novel 3D-printed computer- assisted piezocision guide for surgically
Maxillofac Surg 35(5):461–465. Epub 2006 Feb 24. https://doi.org/10.1016/j. facilitated orthodontics. Am J Orthod Dentofacial Orthop 155(4):584–591.
ijom.2005.12.006 https://doi.org/10.1016/j.ajodo.2018.11.010
44. Aksakalli S, Calik B, Kara B, Ezirganli S (2016) Accelerated tooth movement 60. Sivarajan S, Doss JG, Papageorgiou SN, Cobourne MT, Hey MC (2019) Mini-
with piezocision and its periodontal-transversal effects in patients with Class implant supported canine retraction with micro-osteoperforation: a split-
II malocclusion. Angle Orthod 86(1):59–65. https://doi.org/10.2319/012215-4 mouth randomised clinical trial. Angle Orthod 89(2):183–189. https://doi.
9.1 org/10.2319/011518-47.1
45. Charavet C, Lecloux G, Brewer A, Rompen E, Maes N, Limme M, Lambert F 61. Chan E, Dalci O, Petocz P, Papadopoulou AK, Darendeliler MA (2018)
(2016) Localized piezoelectric alveolar decortication for orthodontic Physical properties of root cementum: Part 26. Effects of micro-
treatment in adults: a randomized controlled trial. J Dent Res 95(9):1003– osteoperforations on orthodontic root resorption: a microcomputer
1009. https://doi.org/10.1177/0022034516645066 tomography study. Am J Orthod Dentofacial Orthop 153(2):204–213. https://
46. Abbas NH, Sabet NE, Hassan IT (2016) Evaluation of corticotomy-facilitated doi.org/10.1016/j.ajodo.2017.05.036
orthodontics and piezocision in rapid canine retraction. Am J Orthod 62. Wang Z, McCauley LK (2011) Osteoclasts and odontoclasts: signaling
Dentofacial Orthop 149(4):473–480. https://doi.org/10.1016/j.ajodo.2015.09. pathways to development and disease. Oral Dis 17(2):129–142. https://doi.
029 org/10.1111/j.1601-0825.2010.01718.x
47. Strippoli J, Durand R, Schnittbuhl M, Rompre P, Voyer R, Chandad F, Nishio 63. Engstrom C, Granstrom G, Thilander B (1988) Effect of orthodontic force on
C (2019) Piezocorticision assisted orthodontics: efficiency, safety, and long- periodontal tissue metabolism. A histologic and biochemical study in
term evaluation of the inflammatory process. Am J Orthod Dentofacial normal and hypocalcemic young rats. Am J Orthod Dentofacial Orthop
Orthop 155:662–669. https://doi.org/10.1016/j.ajodo.2018.06.013 93(6):486–495. https://doi.org/10.1016/0889-5406(88)90077-7
48. Yi J, Xiao J, Li Y, Zhao Z (2017) Efficacy of piezocision on accelerating 64. Tsai CY, Yang TK, Hsieh HY, Yang LY (2016) Comparison of the effects of
orthodontic tooth movement; A systematic review. Angle Orthod 87(4):491– micro-osteoperforation and corticision on the rate of orthodontic tooth
498. https://doi.org/10.2319/01191-751.1 movement in rats. Angle Orthod 86(4):558–564. https://doi.org/10.2319/052
49. Abdulkarim A Hatrom, Khalid H Zawawi, Reem M Al-Ali, Hanadi M Sabban, 015-343.1
Talal M Zahid, Ghassan A Al-Turki, Ali H Hassan (2020) Effect of piezocision 65. Shahrin A A , Ghani A H A , Norman N H (2021). Effectiveness of
corticotomy on en-masse retraction. Angle Orthod. 90:648-654. https://doi. microosteoperforations in accelerating alignment of maxillary anterior
org/10.2319/092719-615.1, 5 crowding in adults: a randomised controlled clinical trial, Am J Ortho
50. Hatrom AA, Howait MS, Zawawi KH, Al-Turki GA, Alansari RA, Almehayawi Dentofacial Orthop Advanced online access. https://www.ajodo.org/article/
NF, Alammari SH, Mohammed RA, Hassan AH (2021) Pulp volume changes S0889-5406(21)00486-8/fulltext https://doi.org/10.1016/j.ajodo.2021.04.021
after piezocision- assisted tooth movement: a randomised clinical trial. BMC 66. Patterson BM, Dalci O, Papadopoulou AK, Madukuri S, Mahon J, Petocz P,
Oral Health 21(1):28. https://doi.org/10.1186/s12903-020-01382-2 Spahr A, Darendeliler MA (2017) Effect of piezocision on root resorption
51. Alvarez MA, Mejia A, Alzate D, Rey D, Ioshida M, Aristizabal JF, Rios HF, associated with orthodontic force: a microcomputed tomography study.
Bellaiza-Cantillo W, Tirado M, Ruellas A, Cevidanes L (2021) Buccal bone Am J Orthod Dentofacial Orthop 151(1):53–62. https://doi.org/10.1016/j.a
defects and transversal tooth movement of mandibular lateral segments in jodo.2016.06.032
patients after orthodontic treatment with and without piezocision: a case 67. Uribe F, Padala S, Allareddy V, Nanda R (2014) Patients’, parents’, and
control retrospective study. Am J Orthod Dentofacial Orthop 159(3):e233– orthodontists’ perceptions of the need for and costs of additional
e243. https://doi.org/10.1016/j.ajodo.2020.08.017 procedures to reduce treatment time. Am J Ortho Dentofacial Orthop
52. Khlef HN, Hajeer MY, Ajaj MA, Heshmeh O, Youssef N, Mahaini L (2020) The 2014(145):S65–S73. https://doi.org/10.1016/j.ajodo.2013.12.015
effectiveness of traditional corticotomy vs flapless corticotomy in miniscrew 68. Dibart S, Alasmari A, Zanni O, Salih E (2016) Effect of corticotomies with
supported en-masse retraction of maxillary anterior teeth in patients with different instruments on cranial bone biology using an ex vivo calvarial
Class II Division 1 malocclusion: a single-centered, randomised controlled bone organ culture model system. Int J Periodontics Restorative Dent
clinical trial. Am J Orthod Dentofacial Orthop 158(6):e111–e120. https://doi. 36(Suppl):s123–s136. https://doi.org/10.11607/prd.2701
org/10.1016/j.ajodo.2020.08.008 69. Kernitsky JR, Ohira T, Shosho D, Lim J, Bamashmous A, Dibart S (2021)
53. Dibart S, Yee C, Surmenian J, Sebaoun JD, Baloul S, Goguet-Surmenian E, Corticotomy depth and regional accelerator phenomenon intensity: a
Kantarci A (2014) Tissue response during Piezocision-assisted tooth preliminary study. Angle Orthod 91(2):206-212. 10.2319/041320-296.1
movement: a histological study in rats. Eur J Orthod 36(4):457–464. https:// 70. Uribe F, Davoody L, Mehr R, Jayaratne YSN, Almas K, Sobue T, Allareddy V,
doi.org/10.1093/ejo/cjt079 Nanda R (2017) Efficiency of piezotome-corticision assisted orthodontics in
54. Charavet C, Van Hede D, Anania S, Maes N, Lambert F (2019) Multilevel alleviating mandibular anterior crowding-a randomized clinical trial. Eur J
biological responses following piezocision to accelerate orthodontic tooth Orthod 39(6):595–600. https://doi.org/10.1093/ejo/cjw091
movement: a study in rats. J World Fedf Orthodon 8(3):100–106. https://doi. 71. Hannequin R, Ouadi E, Racy E, Moreau N (2020) Clinical follow-up of
org/10.1016/j.ejwf.2019.07.002 corticotomy accelerated Invisalign orthodontic treatment with dental
55. Teixeira CC, Khoo E, Tran J, Chartres I, Liu Y, Thant LM, Khabensky I, Gary LP, monitoring. Am J Orthod Dentofacial Orthop 158(6):878–888. https://doi.
Cisneros G, Alikhani M (2010) Cytokine expression and accelerated tooth org/10.1016/j.ajodo.2019.06.025
movement. J Dent Res 89:1135–1141. https://doi.org/10.1177/00220345103 72. Verna C, Cattaneo PM, Dalstra M (2018) Corticotomy affects both the modus
73764 and magnitude of orthodontic tooth movement. Eur J Orthod 40(1):107–
56. Sugimori T, Yamaguchi M, Shimizu M, Kikuta J, Hikida T, Hikida M, Murakami 112. https://doi.org/10.1093/ejo/cjx041
Y, Suemitsu M, Kuyama K, Kasai K (2018) Micro-osteoperforations accelerate 73. She X, Deguchi T, Yao H, Zhou J (2021) Biomechanical effect of selective
orthodontic tooth movement by stimulating periodontal ligament cell osteotomy and corticotomy on orthodontic molar uprighting. Am J Orthod
cycles. Am J Orthod Dentofacial Orthop 154(6):788–796. https://doi.org/10.1 Dentofacial Orthop 160(2):292–301. https://doi.org/10.1016/j.ajodo.2020.06.
016/j.ajodo.2018.01.023 034
74. Dibart S, Keser E, Nelson D (2015) Piezocision assisted orthodontics: past,
57. Van Gemmert LN, Campbell PM, Opperman LA, Buschang PH (2019)
present, and future. Semin Orthod 21(3):170–175. https://doi.org/10.1053/J.
Localizing the osseous boundaries of micro-osteoperforations. Am J Orthod
SODO.2015.06.003
Dentofacial Orthop 155(6):779–790. https://doi.org/10.1016/j.ajodo.2018.07.
022
58. Alkebsi A, Al-Maaitah E, Al-Shorman H, Alhaija EA (2018) Three dimensional Publisher’s Note
assessment of the effect of micro-osteoperforations on the rate of tooth Springer Nature remains neutral with regard to jurisdictional claims in
movement during canine retraction in adults with Class II malocclusion: a published maps and institutional affiliations.
randomised controlled clinical trial. Am J Orthod Dentofacial Orthop 153(6):
771–785. https://doi.org/10.1016/j.ajodo.2017.11.026
59. Attri S, Mittal R, Batra P, Sonar S, Sharma K, Raghavan S, Rai KS (2018)
Comparison of rate of tooth movement and pain perception during
accelerated tooth movement associated with conventional fixed appliances
with micro-osteoperforations: a randomised controlled trial. J Orthod 45(4):
225–233. https://doi.org/10.1080/14653125.2018.1528746

Keser Et Al

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Keser and Naini Maxillofacial Plastic and Reconstructive Surgery (2022) 44:1

REVIEW Open Access

Accelerated orthodontic tooth movement:

Background personally and professionally, with 75% reporting im-

1. The length of the procedure: the procedure on both

Micro-osteoperforations premolar extractions, in order to accelerate tooth move-

Fig. 6 Propel device by Propel Orthodontics, USA. It has a surgical

severe crowding who was 24 years old and a Class I case

Fig. 5 a Minimal vertical interproximal incisions on the buccal

Review of the Literature

Table 1 Publications on surgically accelerated orthodontics in chronological order

Table 1 Publications on surgically accelerated orthodontics in chronological order (Continued)

The surgical techniques reviewed and described in Consent for publication

You might also like

Keser Et Al

Uploaded by

Copyright:

Available Formats

Keser Et Al

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

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Did you find this document useful?

Is this content inappropriate?

Copyright:

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Keser Et Al

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Copyright:

Available Formats

Keser and Naini Maxillofacial Plastic and Reconstructive Surgery (2022) 44:1

REVIEW Open Access

Accelerated orthodontic tooth movement:

Background personally and professionally, with 75% reporting im-

1. The length of the procedure: the procedure on both

Micro-osteoperforations premolar extractions, in order to accelerate tooth move-

Fig. 6 Propel device by Propel Orthodontics, USA. It has a surgical

severe crowding who was 24 years old and a Class I case

Fig. 5 a Minimal vertical interproximal incisions on the buccal

Review of the Literature

Table 1 Publications on surgically accelerated orthodontics in chronological order

Table 1 Publications on surgically accelerated orthodontics in chronological order (Continued)

 The surgical techniques reviewed and described in Consent for publication

You might also like

The surgical techniques reviewed and described in Consent for publication