|Year : 2021 | Volume
| Issue : 4 | Page : 360-364
Piezosurgical corticotomy for rapid orthodontic tooth movement – A case series
S Swarna Meenakshi, Sankari Malaiappan
Department of Periodontics, Saveetha Dental College, Saveetha University, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India
|Date of Submission||01-May-2020|
|Date of Decision||05-Oct-2020|
|Date of Acceptance||30-Nov-2020|
|Date of Web Publication||01-Jul-2021|
S Swarna Meenakshi
Department of Periodontics, Saveetha Dental College, Saveetha University, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Prolonged treatment duration is one of the main concerns of patients undergoing orthodontic treatment. In addition to the longer duration, there are several drawbacks such as increased predisposition to root resorption, caries, and gingival recession. Thus, clinicians are always on the lookout for better solutions or alternatives. This is where the technique of corticotomy came in. In the present study, two cases where a piezosurgical corticotomy was done for rapid tooth movement have been discussed. The entire treatment duration was about 7–8 months without any relapse or posttreatment complications.
Keywords: Inflammation, orthodontic tooth movement, osteogenic orthodontics, piezosurgery, regional acceleratory phenomenon
|How to cite this article:|
Meenakshi S S, Malaiappan S. Piezosurgical corticotomy for rapid orthodontic tooth movement – A case series. J Indian Soc Periodontol 2021;25:360-4
| Introduction|| |
Facial esthetics plays a significant role in determining self and social perceptions.
Optimal appearance is not just considered attractive but also more socially accepted by peers and others around., In particular, smile is considered to be the first thing someone notices in the face. Thus, it comes as no surprise that many patients are turning toward orthodontic treatment and shorter treatment duration has become a recurring request. This constant demand has paved the way for a number of surgical techniques to shorten the duration of orthodontic treatment and improve faster space closure and rapid movement of teeth. However, aggressive approaches to manipulate the bone to rapidly move may result in compromised periodontal health. Hence, a noninvasive yet powerful regulation of remodeling process of periodontium is necessary. The technique of corticotomy was introduced by Wilcko et al. in 2001. This technique involves selective decortication of the alveolar bone which in turn reduces the resistance offered by the thick alveolar housing to tooth movement and also initiates regional acceleratory phenomenon (RAP) which leads to a temporary burst of hard- and soft-tissue remodeling. Wilcko et al. named the procedure periodontally accelerated osteogenic orthodontics (PAOO).
Manual instruments such as chisel and mallet or motor-driven instruments such as airoters or micro-motors have been traditionally used for corticotomies. These tools are difficult to control in areas which require precise cuts and are densely mineralized. They produce frictional heat that may hinder the healing process, and are also capable of damaging soft tissues. To overcome these limitations, piezoelectric device was introduced to the field of periodontology. The vibratory movements are such that they do not cause any harm to the soft tissues, give precise cuts, and cause less or no postoperative discomfort for the patient. These devices have a wide variety of inserts that can be used in anatomically difficult areas as well, thereby improving the handling efficiency.
There is sufficient literature suggesting PAOO to have an edge over conventional orthodontic treatments in reducing the treatment duration. However, there is a scarcity in literature in modified PAOO done with piezosurgical device without the usage of bone grafts. Here, we discuss two cases where corticotomy was done using piezosurgery following a modified PAOO protocol.
| Case Report|| |
A 22-year-old female patient reported with a chief complaint of unesthetic appearance due to proclined upper teeth. Piezosurgical corticotomy procedure was planned after presurgical orthodontic alignment, followed by final orthodontic correction [Figure 1]. Before treatment commenced, the treatment protocol was explained to the patient, informed consent was taken, and ethical approval was obtained from the university's ethics board. Phase-I periodontal therapy comprising scaling and oral hygiene instructions was performed.
In the presurgical orthodontic treatment phase, strap-up was carried out using a preadjusted edgewise appliance system (MBT™ 0.022”). Initial leveling and aligning was done using preformed NiTi arch wires sequentially and finally stainless steel wires were given. The alignment was done until teeth were in good occlusion [Figure 2]. This phase took about 3 months after which piezosurgical corticotomy was scheduled.
In the corticotomy phase, the arch wires were removed to facilitate easier access in the maxillary arch. Aseptic protocol was followed throughout the surgical procedure. Presurgical mouth rinse with 0.12% chlorhexidine gluconate solution was advocated for 1 min. Local anesthesia was obtained with infiltrations from canine-to-canine region with 2% lignocaine at 1:200,000 concentration of adrenaline. Using No. 15 Bard parker surgical blade, crevicular and interdental incisions were given in the facial aspect from canine to canine. A full-thickness flap was reflected facially using a Molt's No. 9 periosteal elevator, following which vertical cuts were made in the interdental region from canine to canine, taking the elevations formed on the alveolar process by the convexity of the root as a guide. Vertical bone cuts with a depth of 2–2.5 mm were made using piezosurgical unit (ACTEON® Piezotome) using a crest split insert with adequate self-irrigation with saline [Figure 3]. The flap was approximated with continuous sling sutures [Figure 4]. Postoperative instructions were given and the patient was put on analgesic aceclofenac (100 mg) and paracetamol (500 mg) combination, twice daily for 3 days and antibiotic amoxicillin 500 mg thrice daily for 3 days. Chlorhexidine mouth rinse was prescribed twice daily for 2 weeks. Suture removal was done after 1 week. Orthodontic treatment was started postcorticotomy and the final outcome was achieved in a short duration – 2 months' time, whereas conventional orthodontic treatment would have been three times slower. The entire treatment modality including presurgical orthodontic treatment, corticotomy, and postsurgical orthodontic treatment took 8 months [Figure 5]. The postoperative complications were assessed radiographically with cone-beam computed tomography after orthodontic treatment and no bone loss was observed; clinically, there were no signs of mobility or loss of vitality in the tooth. There were no postoperative complications during the review phase.
A 19-year-old female patient reported with a chief complaint of unesthetic appearance due to proclined upper teeth. Planning of presurgical orthodontic treatment similar to that of case 1 was done [Figure 6] and [Figure 7].
In this case, corticotomy was done only for distalization of the canine(13). In the corticotomy phase, the arch wires were removed to facilitate easier access. Aseptic protocol was followed throughout the surgical procedure. Presurgical mouth rinse with 0.12% chlorhexidine gluconate solution was advocated for 1 min. Local anesthesia was obtained with infiltration of 2% lignocaine at 1:200,000 concentration of adrenaline. Using No. 15 Bard parker surgical blade, crevicular and interdental incision with a vertical release incision distal to 15 was given. A full-thickness flap was reflected facially using a Molt's No. 9 periosteal elevator, following which vertical cuts with 2–2.5 mm depth were made with the crest split insert of the piezosurgical unit in the [Figure 8]. The flap was approximated with simple interrupted sutures. Postoperative instructions were given, and the patient was put on analgesic aceclofenac (100 mg) and paracetamol (500 mg) combination, twice daily for 3 days and antibiotic amoxicillin 500 mg thrice daily for 3 days. Chlorhexidine mouth rinse was prescribed twice daily for 2 weeks. Suture removal was done after 1 week. Orthodontic treatment was started postcorticotomy and the final outcome was achieved in a short duration – 2 months' time. The entire treatment was completed in 6 months [Figure 9]. There were no postoperative complications during the review phase.
| Discussion|| |
According to the guidelines of the American Academy of Orthodontists, the ideal treatment time is said to be between 1.5 and 2 years. However, many a times, it is difficult to get the desired result in a short period of time, which becomes a huge burden to the patient as well as to the orthodontist.
Corticotomy has roots in orthopedics dating back to the early 1900s. In 1892, it was initially defined as a linear cutting technique in the cortical plates to mobilize the teeth for immediate movement. Later on, Köle introduced a surgical procedure involving both osteotomy and corticotomy, based on the concept that teeth move rapidly when the resistance exerted by the surrounding cortical bone is reduced. He further explained that this reduced resistance enhances an en bloc movement of the entire alveolar cortical segment when exposed to orthodontic forces. Frost found a direct correlation between the intensity of bone corticotomy or osteotomy and the degree of healing response, leading to accelerated bone turnover at the surgical site. He termed this “regional acceleratory phenomenon. Wilcko et al. developed a patented technique called accelerated osteogenic orthodontics or PAOO, which is similar to conventional corticotomy except that selective decortication is performed in the form of lines and points adjacent to the teeth that need to be moved.
Procedures like corticotomy modify the biology of the bone in such a way that they influence rapid movement of the teeth, thereby reducing the treatment duration. They are based on the principle of RAP. This RAP starts within few days of the procedure and attains peak at about 1–2 months. Another principle behind this is that it decorticates the bone, which results in transient osteopenia, thereby causing a temporary decrease in the mineral content. The immature bone offers decreased resistance to orthodontic forces and so the movement is rapid during this phase. This hypothesis is strongly backed by preclinical studies done by Ren et al. Mostafa et al. studied the orthodontic movement in dogs and reported that the rate of tooth movement doubled in the test site where corticotomy was done when compared to that of the control site where no corticotomy was performed.,
Piezosurgery was introduced in bone surgery as an alternative to rotary instruments. Piezoelectric surgery technique for corticotomies was introduced by Vercellotti and Podesta in 2004. The major advantage of this tool is that microvibrations allow a selective cut of only mineralized structures, creating minimal damage to the adjacent soft tissues. In a study by Farid et al., in dogs, corticotomy-facilitated orthodontics using piezosurgery versus rotary instruments was compared. They stated that the tooth movement was 1.6 times faster when rotary instruments were used compared to that of piezosurgery. They attributed it to the amount of trauma created by these rotary instruments and also noticed resorption of root and increased inflammation in the rotary group compared to that of the piezosurgery group which had better healing outcomes. However, from a clinician's perspective, the methodology that is quicker and less traumatic to the tissues is always preferred.
In both the cases, a piezosurgical approach was followed owing to the advantages of piezosurgery over conventional procedures, such as precise and micrometric cutting, minimal surgical trauma, less force with a greater control, and bleeding-free surgical site. Several clinicians have frequently encountered postoperative complications such as no vitality of the tooth, root resorption, delay in healing, and patient discomfort following the conventional approach of using micromotors for cuts.
Troiani et al. and Vercellotti and Podesta have observed similar findings and have noticed a rapid movement and reduction in the healing period with minimal or no postoperative discomfort., Various other authors like Fischer, Lee et al., and Shoreibah et al. have performed clinical trials using corticotomy-assisted canine retraction by means of piezosurgery and found a substantial reduction in treatment time by 28%–33% and a 2–3-fold increase in the velocity of tooth movement when compared to that of conventional means.,,
A study by Thind et al. compared PAOO with piezosurgery and surgical bur and observed that the treatment time had reduced in patients who underwent corticotomy with surgical bur compared to those who underwent piezosurgical corticotomy. However, there were some postoperative complications with surgical bur such as root resorption. Hajji reported similar outcomes in their study. Chung et al. in their histological study observed minimal cellular damage to bone margins by piezo.
Pakhare et al. in their case report stated that the entire treatment was completed in 5 months without any postoperative complications in the follow-up period of 1 year.
| Conclusion|| |
Based on the findings of these cases, it is evident that piezosurgery for corticotomy reduced the orthodontic treatment time as well as overcame the difficulties with conventional methods to reduce the overall treatment duration without any postoperative complications. In this fast-paced world, this is of prime importance as it gives result in no time and it could possibly reduce the apprehension that some patients have when they think of long-term orthodontic therapy. Now, with the regular use of piezosurgery, newer techniques such as flapless piezocision and micro-osteoperforations have been developed. However, even though they are noninvasive, based on the severity of the case, careful selection of the technique needs to be followed. From a clinician's perspective, piezosurgery is comparatively safe for corticotomies as soft issues are not injured, no additional irrigation is needed, clear and a bloodless field helps in proper visualization of the area, depth markings for adequate preparation, and adjustments could be made according to the bone density which improves the operator comfort and effectiveness.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]