AJODO 2013 - Effect of Piezopuncture on Tooth Movement and Bone Remodeling in Dogs

ORIGINAL ARTICLE

Effect of piezopuncture on tooth movement and bone remodeling in dogs Young-Seok Kim,a Su-Jung Kim,b Hyun-Joo Yoon,a Peter Joohak Lee,c Won Moon,d and Young-Guk Parke Seoul, Korea, and Los Angeles, Calif

Introduction: The aim of the study was to elucidate whether a newly developed, minimally invasive procedure, piezopuncture, would be a logical modification for accelerating tooth movement in the maxilla and the mandible. Methods: Ten beagle dogs were divided into 2 groups. Traditional orthodontic tooth movement was performed in the control group. In the experimental group, a piezotome was used to make cortical punctures penetrating the gingiva around the moving tooth. Measurements were made in weeks 1 through 6. Tooth movement and bone apposition rates from the histomorphometric analyses were evaluated by independent t tests. Results: The cumulative tooth movement distance was greater in the piezopuncture group than in the control group: 3.26fold in the maxilla and 2.45-fold in the mandible. Piezopuncture significantly accelerated the tooth movements at all observation times, and the acceleration was greatest during the first 2 weeks for the maxilla and the second week for the mandible. Anabolic activity was also increased by piezopuncture: 2.55-fold in the maxilla and 2.35-fold in the mandible. Conclusions: Based on the different effects of piezopuncture on the maxilla and the mandible, the results of a clinical trial of piezopuncture with optimized protocols might give orthodontists a therapeutic benefit for reducing treatment duration. (Am J Orthod Dentofacial Orthop 2013;144:23-31)

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arious surgical interventions on the periodontal tissues have been developed to accelerate orthodontic tooth movement. The degree of intentional surgical damage needed to evoke a long-lasting regional acceleratory phenomenon that is less prone to complications has been a topic of special interest. Fullthickness flap elevation with extensive decortications, including various modifications of corticotomies, are undoubtedly effective in increasing cellular activities related to tooth movement.1-3 The mechanism of accelerated tooth movement by a regional acceleratory phenomenon depends mainly on transient osteopenia a

Postgraduate student, School of Dentistry, Kyung Hee University, Seoul, Korea. Assistant professor, Department of Orthodontics, School of Dentistry, Kyung Hee University, Seoul, Korea. c Resident, Section of Orthodontics, School of Dentistry, University of California at Los Angeles, Calif. d Assistant professor, Section of Orthodontics, School of Dentistry, University of California at Los Angeles, Calif. e Professor and chair, Department of Orthodontics, School of Dentistry, Kyung Hee University, Seoul, Korea. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Supported by Korea Ministry of Education, Science and Technology (number 2009-0092562). Reprint requests to: Young-Guk Park, Department of Orthodontics, Kyung Hee University, School of Dentistry, 1 Hoegi-Dong, Seoul 130-701, Korea; e-mail, [email protected]. Submitted, February 2012; revised and accepted, January 2013. 0889-5406/$36.00 Copyright Ó 2013 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2013.01.022 b

by an accelerated demineralization-remineralization process, providing a more pliable environment,4 which is distinct from bony block movement in corticotomyfacilitated orthodontics1; therefore, development of a simple procedure just for cortical activation rather than cortical removal is required. Corticision (patent 0843344, class 10; Kyung Hee University, Seoul, Korea) was introduced as a minimally invasive alternative for cortical activation.5,6 A cortical incision made by malleting a reinforced scalpel to separate the interproximal cortices transmucosally was found to induce the regional acceleratory phenomenon effect for faster tooth movement in beagle dog experiments.5 To mitigate the patients' fear and discomfort from repeated malleting, Dibart et al7,8 suggested “piezocision,” a process that uses an ultrasonic tool to produce the incisions. This procedure combines piezoelectric cortical incisions with selective tunneling, which allows additional tissue grafting. To overcome the insufficiencies of these earlier procedures, we conceived a novel procedure for cortical activation that we called “piezopuncture.” In this procedure, an ultrasonic tool, a piezotome, is used to create multiple cortical punctures through the overlying gingiva. The concept of ultrasonic osteotomy is based on the socalled reciprocal piezo effect: voltage is applied to a polarized piezo ceramic to deform a piezoelectric crystal in the resultant electrical field; this creates alternating and perpendicular expansion and contraction of the material. 23

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Fig 1. Orthodontic force application: A, piezopuncture procedure: arrows indicate the direction of second premolar movement in each jaw; B, piezopuncture was performed on the mesiobuccal side of the second premolar, penetrating overlying gingiva into the cortical bone; white ring-like lesions were found around the puncture sites, showing no lethal damage on the soft tissues; C, nickeltitanium closed-coil springs were activated between the lever arms of the target teeth and the anchorage teeth. xxx, Specimen collection sites.

Because of its accurate and selective capability of cutting mineralized tissues without damaging adjacent soft tissues and nerves, ultrasonic osteotomes were first used in periapical oral surgery, including implantology9 and periodontology.10 These transmucosal manipulations of alveolar bone have minimized morbidity and achieved similar results to more aggressive procedures, including extensive flap elevation for rapid tooth movement.11,12 The aim of our study was to elucidate whether piezopuncture would elicit the regional acceleratory phenomenon and accelerate tooth movement without causing harmful tissue responses. The acceleration rates of tooth movement and bone remodeling were investigated and compared between the maxilla and the mandible. MATERIAL AND METHODS

Ten male beagles (age, 18-24 months; weight, 9-12 kg) were housed in separate cages supplied with a selfwashing system, air conditioning, and lighting according to the guidelines of the Institutional Animal Care and Use Committee, Kyung-Hee University Medical Center. The dogs were randomly divided into 2 groups: control (n 5 4) and piezopuncture (n 5 6). These groups were further divided into 3 subgroups based on the duration of force application: group I, 14 days (control, n 5 1; piezopuncture, n 5 2); group II, 28 days (control, n 5 1; piezopuncture, n 5 2); and group III, 42 days (control, n 5 2; piezopuncture, n 5 2). Each animal provided 4 specimens (1 each from the right and left sides of both jaws), and the maxillary and mandibular specimens (n 5 20 for each jaw) were randomly divided into 2 groups. Animals in the control group received orthodontic force alone, and the animals in the piezopuncture group received orthodontic force with piezopuncture. The animals were killed at 2, 4, and 6 weeks after the interventions.

July 2013 Vol 144 Issue 1

The target teeth in both arches were the second premolars; however, the anchorage teeth in each arch were selected differently because of anatomic limitation. In the maxillary arch, the second premolars were protracted against the canines as the anchorage, whereas the second premolars were retracted against the third premolars in the mandibular arch. Orthodontic buttons (Ormco, Orange, Calif) connected by a lever arm were bonded on the labial surfaces of all experimental teeth with Super-Bond C&B resin (Sun Medical, Shiga, Japan). A nickel-titanium closed-coil spring (Tomy International, Tokyo, Japan) was activated and ligated between the lever arms of the target teeth and the anchorage teeth. For reinforcing anchorages, resin bridges were constructed on the adjacent teeth. The orthodontic force by the appliance was 100 g at the beginning of the experiment. Tooth movement was allowed for 6 weeks. Force magnitude was measured using a force gauge (Haag-Streit, Koeniz, Switzerland) once a week with reactivation of the appliance to maintain a continuous force (Fig 1, A). For piezopuncture, a piezosurgical instrument with a sharp curved tip (Endo2 insert, ProUltra; Dentsply Maillefer, Ballaigues, Switzerland) was used to perform the cortical punctures penetrating the gingiva. The depth of cortical injury was 3 mm, by holding the tip perpendicular to the gingiva for 5 seconds under saline-solution irrigation. The setting selected for each puncture was in accordance with the manufacturer's recommendation. Piezopunctures were performed on the mesiobuccal, distobuccal, mesiolingual, and distolingual sides of the second premolars (Fig 1, B). Sixteen punctures were made on 1 target tooth. Gentamicin (7.5 mg/kg) was injected postoperatively for 3 days. Tooth brushing and daily hexamedine (Bukwang, Seoul, South Korea) irrigation were repeated during the postoperative care.

American Journal of Orthodontics and Dentofacial Orthopedics

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Table I. Accumulative distances of tooth movements in each group at 6 weeks after orthodontic force application Jaw Maxilla

Group Control (A)

Piezopuncture (B)

Mandible

Control (A)

Piezopuncture (B)

Beagle site A1-RT A1-LT A2-RT A2-LT Mean B1-RT B1-LT B2-RT B2-LT Mean P value A1-RT A1-LT A2-RT A2-LT Mean B1-RT B1-LT B2-RT B2-LT Mean P value

Second premolar movement, A (mm) 0.79 0.74 0.65 0.71 0.72 6 0.06 2.62 3.32 1.57 1.71 2.31 6 0.82 0.00054z 0.56 0.76 0.35 0.38 0.51 6 0.19 1.71 1.35 1.12 1.13 1.33 6 0.28 0.00041z

Anchor tooth movement, B (mm) 0.98 1.12 1.15 1.10 1.09 6 0.07 1.01 1.07 1.28 1.07 1.11 6 0.12 0.27102 0.38 0.59 0.28 0.35 0.40 6 0.13 0.31 0.56 0.58 0.39 0.46 6 0.13 0.55436

Ratio (A/B) 0.81 0.66 0.57 0.65 0.67 6 0.10 2.59 3.10 1.23 1.60 2.13 6 0.86 0.00215y 1.47 1.29 1.25 1.09 1.28 6 0.16 5.52 2.41 1.93 2.90 3.19 6 1.60 0.04373*

Independent t test was performed (mean 6 SD, *P \0.05; y \0.01; z \0.001). In the maxilla, the anchor tooth was canine; in the mandible, the anchor teeth were the third premolar and the first molar. A1, First control beagle; A2, second control beagle; B1, first piezopuncture beagle; B2, second piezopuncture beagle; RT, right side; LT, left side.

Tooth movement was measured by a digital caliper (Mitutoyo, Kawasaki, Japan) on the stone models once a week. In the maxillary arch, the distance from the mesial cervix of the third premolar to the mesial cervix of the moved second premolar was measured over time. In addition, the distance of canine retraction as an anchorage tooth was measured from the mesial cervix of the third premolar to consider the rate of tooth movement as the relative ratio. In the mandibular arch, the distance from the mesial cervix of the canine to the mesial cervix of the moved second premolar was measured, and the protracted distance of the anchored third premolar was also measured from the same reference. The relative values of the distance of the moved teeth divided by the distances of the anchorage teeth were compared between the groups. Histologic analysis was performed on the decalcified specimens at 2, 4, and 6 weeks. Tissue blocks including the second premolar with surrounding alveolar bone and the injury site were decalcified with 10% EDTA-2Na (pH 7.4) at 48 C for 30 days. The specimens were resected at 3 to 4 mm below the alveolar crest with thicknesses of 6 mm. The sections were stained with hematoxylin and eosin for descriptive histology. Quantitative histomorphometric analysis was done on the nondecalcified specimens of the dogs in the 6week groups. One experimental animal and 1 control

animal were randomly selected. They had been intramuscularly injected with 3 fluorochoromes as follows: oxytetracycline hydrochloride (yellow orange, 30 mg/ kg; Fluka Chemie AG, Buchs, Switzerland) at 24 hours before intervention and at 6 weeks after intervention; calcein (green, 10 mg/kg; Fluka Chemie AG) at 2 weeks after intervention; and alizarin red (red, 30 mg/kg; Fluka Chemie AG) at 4 weeks after intervention. Specimens were taken from 8 sampling sites in each jaw. These specimens were longitudinally sectioned parallel to the direction of orthodontic traction and examined under an ultraviolet fluorescence microscope (BH-2; Olympus, Tokyo, Japan) with an ultraviolet filter (l 5 515 nm). Microphotographs of all specimens were recorded using a digital CCD camera (PS30C ImageBase; Kappa Optronics, Gleichen, Germany). The outlines of labeled bones were traced from the photographs, and the distances between the labeled lines were measured with image analysis software (ImageBase Metreo 2.5; Kappa Optronics). Statistical analysis

Descriptive statistics were represented as means and standard deviations for all parameters in each group. The normality of the data was assessed with the Kolmogorov-Smirnov test. Statistical homogeneity was checked using the Levene test. Independent t tests



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Fig 2. Accumulated tooth movement distances and movement rates in the maxilla and the mandible.

were used to evaluate the intergroup differences of the mean tooth movement distances on the models and the mean accumulated new bone deposition measured by histomorphometric analysis. Values of P \0.05 were considered statistically significant. RESULTS

The mean cumulative distances of tooth movement for 6 weeks as well as the ratios of target tooth movement to anchorage loss were significantly increased in the piezopuncture groups as opposed to the control groups in both the maxilla and the mandible (Table I). The distance of the maxillary second premolar movement in the piezopuncture group (2.31 6 0.82 mm) was 3.26-fold greater than that in the control group (0.72 6 0.06 mm). The distance of the mandibular second premolar movement in the piezopuncture group (1.33 6 0.28 mm) was 2.45-fold greater than that in the control group (0.51 6 0.19 mm). There was no significant difference in the amount of anchorage tooth movement between the piezopuncture group (maxilla, 1.11 6 0.12 mm; mandible, 0.46 6 0.13 mm) and the control group (maxilla, 1.09 6 0.07 mm; mandible, 0.40 6 0.13 mm). The relative ratios of maxillary tooth movement were 2.15 6 0.98 in the piezopuncture


group and 0.66 6 0.02 in the control group. The ratios of mandibular tooth movement were 3.30 6 1.03 in the piezopuncture group and 1.35 6 0.75 in the control group. With respect to movement rate, the first 2 weeks in the maxilla and the second week in the mandible had the greatest movement (Fig 2). The weekly velocity of tooth movement in the piezopuncture group was larger than that in the control group at all observation times. The increasing pattern of the accumulated distances of tooth movement in the piezopuncture group showed no remarkable stagnation indicating the lag phase. Descriptive histologic findings on the compression sides of moving teeth are shown in Figure 3. At week 2, the periodontal ligament was compressed and locally degenerated into hyalinization in the control group, where no apparent resorptive findings on the alveolar surfaces were observed (Fig 3, A). In the piezopuncture group, osteoclasts with the resorption lacunae along the bone surfaces were seen near hyalinized areas of the periodontal ligament (Fig 3, B). At week 4, indirect resorption followed by the removal of the hyalinized periodontal ligament was found in the control group (Fig 3, C), whereas direct resorption by active boneresorbing cells continued in the piezopuncture group


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Fig 3. Microphotographs of periodontal tissues on the pressure sides of the second premolars: A, control group at 2 weeks; B, piezopuncture group at 2 weeks; C, control group at 4 weeks; D, piezopuncture group at 4 weeks; E, control group at 6 weeks; F, piezopuncture group at 6 weeks. The arrows indicate resorption lacunae with bone-resorbing cells along the compressed alveolar surface. In the control groups, hyalinization was found at 2 and 6 weeks, and indirect resorption was observed at 4 weeks. On the contrary, in the piezopuncture groups, direct bone resorption was evident at all observation times without remarkable hyalinization. B, Alveolar bone; P, periodontal ligament; R, root; H, hyalinization. Original magnification: 200 times.

(Fig 3, D). At week 6, the number and the activity of bone-resorbing cells were decreased, showing sparse resorption areas on the bone surface with focal hyalinization in the control group (Fig 3, E), whereas the findings of direct bony resorption with the cellular periodontal ligament were as before in the piezopuncture group (Fig 3, F). There were no recognizable differences of the time-dependent histologic responses between the maxilla and the mandible.

Fluorescent microscopic findings of anabolic bone remodeling on the tension sides of the moving teeth (Fig 4) showed correspondence with rate of tooth movement. The accumulated distance of newly mineralized bone apposition during 6 weeks was significantly greater in the piezopuncture group than in the control group (Table II). In the maxilla, the mean apposition length of the piezopuncture group was 2.55-fold greater than that of the control group. The distance between the first



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Fig 4. Fluorescent microphotographs of bone labels on the tension sides of the second premolars: A, maxillary bone apposition in the control group; B, maxillary apposition in the piezopuncture group; C, mandibular apposition in the control group; D, mandibular apposition in the piezopuncture group. Accumulated distances between the bone-labeled lines are significantly longer in the piezopuncture groups than in the control groups in both jaws. Earlier and larger responses to piezopuncture were observed in the maxilla compared with the mandible. Original magnification: 100 times.

Table II. Mean accumulated distances of new bone apposition in both arches indicated by fluorescence on the ten-

sion side Jaw Maxilla Mandible

Group Control Piezopuncture Control Piezopuncture

Weeks 0-2 (mm/wk) 44.44 6 30.27 122.89 6 23.12 35.18 6 13.02 98.56 6 24.58

Weeks 2-4 (mm /wk) 56.09 6 8.52 158.09 6 38.09 45.17 6 15.08 148.07 6 39.68

Weeks 4-6 (mm/wk) 78.35 6 7.31 116.00 6 17.25 25.55 6 7.34 123.18 6 6.60

Distances were measured from the nondecalcified specimens in the 6-week groups; 8 sampling sites in each jaw of 1 experimental animal and 1 control animal were randomly selected (means 6 SD were calculated from sampling sites of each jaw).

yellow line (oxytetracycline at 24 hours before intervention) and the red line (alizarin red at 4 weeks) was strikingly increased in the maxillary piezopuncture group. In the mandible, the mean apposition length in the piezopuncture group was 2.35-fold greater than that in the control group. The distance between the green line (calcein at 2 weeks) and the second yellow line (oxytetracycline at 6 weeks) was remarkably increased in the mandibular piezopuncture group. DISCUSSION

This beagle study shows that a newly developed supplemental procedure, piezopuncture, accelerated the rate of orthodontic tooth movement and the remodeling process of alveolar bone without causing collateral damage. Earlier and greater effects of piezopuncture were observed in the maxilla than in the mandible. Piezopuncture was developed to increase patient compliance by minimizing discomfort during and after


surgery, and to simplify the procedure for orthodontists. Piezopuncture uses a piezotome, which acts as a light ultrasonic scaler. Unlike the previous surgical interventions, piezopuncture eliminates the use bone malleting, which can be frightening to the patient, and the soft-tissue incision and suture.1-5 In contrast to corticision,5 such an approach for minimizing tissue damage, and the intensity and duration of the regional acceleratory phenomenon, might not be sufficient to function throughout the entire orthodontic treatment.13 However, this problem could be eliminated by repeated applications at regular intervals; this would be more favorable for the patients' convenience than more aggressive methods. The action mechanism of piezopuncture is based on the biologic concept of cortical activation rather than cortical removal.14 Most previous corticotomyfacilitated orthodontic treatments were designed to resect the cortical barrier, depending on the mechanical


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Fig 5. Mean apposition rates of newly mineralized bone on the tension sides of the second premolars. Peak velocity periods in the piezopuncture groups were at 2 to 4 weeks in both jaws, and the velocity in weeks 4 to 6 was higher in the mandible than in the maxilla.

concept of the cortex. The use of a minimal intervention to achieve an objective suggests a keen knowledge of the regional acceleratory phenomenon physiology and a respect for a discrete surgical technique. Garg15 emphasized that the regional acceleratory phenomenon is initiated mainly by trauma to the cortical bone. The cortex is regarded as a necessary matrix for rapid tooth movement, not an obstacle.3,15 Only cortical activation can increase osteoclastic activity around the periodontal ligament, facilitating bone turnover toward an osteoporotic state with less tissue resistance to tooth movement. Teixeira et al16 suggested that osteoperforation placed far from the tooth could accelerate the rate of tooth movement, reflected by an increased level of inflammatory cytokine expression, followed by extensive osteoporotic changes. In addition to this conceptual change, understanding the 2-sided characteristic of inflammation has enabled the continuous advancement of supplemental surgical techniques with minimal and conservative interventions. Piezosurgical incisions have been reported to be safe and effective in osseous surgeries, such as preprosthetic surgery, alveolar crest expansion, and sinus grafting.17-21 Because of its micrometric and selective cut, the piezosurgical knife is said to aid safe and precise osteotomies without osteonecrotic damage. Vercellotti and Podesta21 used a piezosurgical technique for periodontally accelerated orthodontic tooth movement. Dibart et al7,8 introduced piezocision as a modified method of corticision for rapid orthodontic tooth movement. Piezocision is different from piezopuncture in that it requires soft-tissue incisions with a blade and routine tissue grafting with the blinded tunneling technique. Grafting mimics the accelerated

osteogenic orthodontic treatments in the studies of Wilko et al2 and Murphy et al,3 which need to be discussed separately from cortical activation. Additionally, the previous evaluations on piezoelectricity for accelerating tooth movement, based on clinical reports, have not yet provided biologic evidence. This beagle experiment elucidated that the cortical activation by piezopuncture accelerated tooth movement significantly at each observation time. Since orthodontic tooth movement aims to restore the balance by remodeling the periodontal ligament, it is reasonable to assess the timing of bone apposition in conjunction with tooth movement.22 To explore the anabolic mechanism in response to tooth movement with cortical activation, it was prudent to analyze the fluorochromelabeled lines histomorphometrically. The rates of tooth movement in the control group showed no remarkable increase until 5 weeks after intervention, accompanied by increased rates of new bone apposition in 4 to 6 weeks. On the other hand, the piezopuncture group showed earlier acceleration of tooth movement in the first 2 weeks after intervention, followed by significantly increased rates of new bone apposition during later weeks. This acceleration of tooth movement could also be supported by different catabolic activities between the 2 groups, even though it was not based on quantitative analysis. Extensive hyalinization with little bone resorptive activity, indicating the biologic lag phase of tooth movement, was remarkable at 2 and 6 weeks in the control group, whereas direct bone resorption continued at all experimental periods in the piezopuncture group without evidence of a lag phase.23-25 The mechanism of bypassing the lag phase indicates less production and faster elimination of hyalinization, and



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it is mentioned in the study of Baloul et al22 about selective alveolar decortication; this corresponds to our results of a less invasive cortical puncture. The acceleration effect of piezopuncture was faster in the maxilla than in the mandible. Deguchi et al26 reported that orthodontic tooth movement progressed 2 weeks faster in the maxilla than in the mandible, and that higher rates of tooth movement in the maxilla were found at 4 through 6 weeks. In our study, piezopuncture-assisted tooth movement advanced 1 week faster in the maxilla than in the mandible. The piezopuncture group demonstrated a peak in tooth movement at weeks 1 and 2 in the maxilla and weeks 2 and 3 in the mandible, and peaks in bone apposition rate were at weeks 2 through 4 in the maxilla and weeks 2 through 6 in the mandible (Fig 5). Although the absolute amount of bone mass is stable during conventional tooth movement, even with highly dynamic metabolic activity, a transient osteoporotic state occurs during surgically facilitated tooth movement.2,22 Because of the differences of bone density and metabolism between the jaws, the maxillary teeth should be regarded as more sensitive to the regional acceleratory phenomenon by cortical activation than are the mandibular teeth. Nevertheless, the mean ratio of target tooth movement to the anchorage tooth movement was higher in the mandible than in the maxilla; this contradicts the result of comparing the distances of the target teeth themselves. This discrepancy can be explained because the mean amount of anchorage tooth movement was greater in the maxilla than in the mandible. This might imply that the accelerating effect of piezopuncture was more extensive to the anchorage part in the maxilla but was rather localized on the target tooth area in the mandible. It should be also considered that our beagle model included mesial movement of the maxillary second premolars and distal movement of the mandibular second premolars, depending on the different anchorage values. Tooth movement with or without surgical intervention is a combined process of osteoclastic and osteoblastic activities in response to external stimulation.27,28 It is not clear yet whether tooth movement by surgical stimulation follows the same mechanism as conventional tooth movement, or whether a different biologic pathway is involved. Nonetheless, a superior condition of surgically assisted tooth movement is that the tooth goes through the osteoporotic alveolar bone of a less tissue-resistant environment. We had presupposed that the biologic mechanisms underlying rapid tooth movement by cortical puncture would be similar to the previously reported demineralizationremineralization process of decortication.29 Although


we could not present molecular-biologic or genetic interactions related to the mechanism of accelerated tooth movement by piezopuncture, our preferential interest was to find the value of a newly developed and less invasive surgical modification. Piezopuncture proved to be effective to facilitate tooth movement, and the effect was greater and faster in the maxilla than in the mandible. Simultaneously, the regional acceleratory phenomenon effect was more extensive in the maxilla; hence, reinforcement of the anchorage part is needed in clinical applications. With further studies on the development of prolonged acceleration of tooth movement over time, the limitations of minimally invasive surgical procedures should be complemented and modified toward clinical efficiency. Based on the different acceleratory effects of piezopuncture on the maxilla and the mandible, a clinical trial of repeated piezopuncture with optimized application intervals and force adjustments would give orthodontists a great therapeutic benefit in the context of reducing treatment durations. CONCLUSIONS

This study introduced a novel periorthodontic technique, piezopuncture, which enables rapid tooth movement without damaging side effects. This technique involves puncturing of the cortical bone with a piezosurgical regimen. Piezopuncture was found to evoke rapid tooth movement by accelerating the rate of alveolar bone remodeling. The acceleration of orthodontic tooth movement associated with piezopuncture was explicated by increased bone turnover through the regional acceleratory phenomenon. Although further studies on the optimal power range of a piezosurgical device to induce a regional acceleratory phenomenon with orthodontic tooth movement are suggested for secure clinical applications, piezopuncture might have a great therapeutic benefit in the context of reducing treatment duration and also periodontal regeneration in its best extent. This development is expected to bring orthodontics closer to the goal of efficiency in tooth movement, without causing patient discomfort or damage to the teeth and their supporting tissues. REFERENCES 1. K€ole H. Surgical operations on the alveolar ridge to correct occlusal abnormalities. Oral Surg Oral Med Oral Pathol 1959; 12:515-29. 2. Wilcko MT, Wilcko WM, Pulver JJ, Bissada NF, Bouquot JE. Accelerated osteogenic orthodontics technique: a 1-stage surgically facilitated rapid orthodontic technique with alveolar augmentation. J Oral Maxillofac Surg 2009;67:2149-59.


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3. Murphy KG, Wilcko MT, Wilcko WM, Ferguson DJ. Periodontal accelerated osteogenic orthodontics: a description of the surgical technique. J Oral Maxillofac Surg 2009;67:2160-6. 4. Wilcko WM, Wilcko T, Bouquot JE, Ferguson DJ. Rapid orthodontics with alveolar reshaping: two case reports of decrowding. Int J Periodontics Restorative Dent 2001;21:9-19. 5. Kim SJ, Park YG, Kang SG. Effects of corticision on paradental remodeling in orthodontic tooth movement. Angle Orthod 2009;79: 284-91. 6. Kim SJ, Moon SU, Kang SG, Park YG. Effects of low-level laser therapy after corticision on tooth movement and paradental remodeling. Lasers Surg Med 2009;41:524-33. 7. Dibart S, Sebaoun JD, Surmenian J. Piezocision: a minimally invasive, periodontally accelerated orthodontic tooth movement procedure. Compend Contin Educ Dent 2009;30:342-4, 346, 348-50. 8. Dibart S, Surmenian J, Sebaoun JD, Montesani L. Rapid treatment of Class II malocclusion with piezocision: two case reports. Int J Periodont Rest Dent 2010;30:487-93. 9. Lea SC, Landini G, Walmsley AD. Ultrasonic scaler tip performance under various load conditions. J Clin Periodontol 2003;30:876-81. 10. Walmsley AD, Laird WR, Lumley PJ. Ultrasound in dentistry. Part 2—periodontology and endodontics. J Dent 1992;20:11-7. 11. Murphy NC. In vivo tissue engineering for orthodontists: a modest first step. In: Davidovitch Z, Mah J, Suthanarak S, editors. Biological mechanisms of tooth eruption, resorption and movement. Boston: Harvard Society for the Advancement of Orthodontics; 2006. 12. Murphy NC, Bissada NF, Davidovitch Z, Kucska S. Corticotomy and stem cell therapy for orthodontists and periodontists. In: Krishana V, Davidovitch Z, editors. Integrated clinical orthodontics. London, United Kingdom: Wiley-Blackwell; 2012. 13. Frost HM. The regional acceleratory phenomenon: a review. Henry Ford Hosp Med J 1983;31:3-9. 14. Germec D, Giray B, Kocadereli I, Enacar A. Lower incisor retraction with a modified corticotomy. Angle Orthod 2006;76:882-90. 15. Garg AK. The regional acceleratory phenomenon: an up-to-date rationale for bone decortication. Dent Implantol Update 1997; 8:63-4. 16. Teixeira CC, Khoo E, Tran J, Chartres I, Liu Y, Thant LM, et al. Cytokine expression and accelerated tooth movement. J Dent Res 2010;89:1135-41. 17. Vercellotti T, De Paoli S, Nevins M. The piezoelectric bony window osteotomy and sinus membrane elevation: introduction of a new

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AJODO 2013 - Effect of Piezopuncture on Tooth Movement and Bone Remodeling in Dogs

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