Sequential piezocision: A novel approach to accelerated ... · Sequential piezocision: A novel approach to ... correction of a Class III malocclusion, ... A novel approach to accelerated

CASE REPORT

Sequential piezocision: A novel approach toaccelerated orthodontic treatment

Elif I. Kesera and Serge Dibartb

Boston, Mass, and Istanbul, Turkey

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Piezocision-assisted orthodontic treatment is an innovative, minimally invasive surgical technique designed tohelp achieve rapid orthodontic tooth movement. Microsurgical interproximal openings are made in the buccalgingivae to let the piezoelectric knife create the bone injury that will lead to transient demineralization andsubsequent accelerated tooth movement. When this procedure was first described, cuts were made simulta-neously at the maxilla and the mandible. In recent years, the technique has evolved to a more staged approach,with selected areas or segments of the arch demineralized at different times during orthodontic treatment tohelp achieve specific results. The purpose of this article was to report the use of sequential piezocision in thecorrection of a Class III malocclusion, in a total treatment time of 8 months. (Am J Orthod Dentofacial Orthop2013;144:879-89)

During the last decade, orthodontic innovationshave changed and heightened clinicians' andpatients' expectations. Although recent advances

include appliances that are more acceptable to patients,especially to self-conscious adults, the length of ortho-dontic treatment is still a major concern. There havebeenmany attempts to shorten treatment time, includingrapid distraction of the canines1 and corticotomy-facilitated treatment.2-5 Corticotomy is an intentionalinjury to the cortical bone that was first described in1892 as a surgical approach to correct malocclusion.2

This procedure was later modified and popularized byKole,6 Suya,2 and Generson et al,7 as they referred tothe “bony block” mechanical movement concept. Theseattempts have demonstrated that a combined cor-ticotomy and osteotomy procedure could result in ashorter treatment time. In 2001, Wilcko et al5 revisitedtheir original technique, adding bone to increase the alve-olar thickness and allow tooth movement withoutcreating dehiscences. They defined their approach as

the Henry M. Goldman School of Dental Medicine, Boston University,n, Mass.nct assistant professor, Department of Orthodontics; private practice,ul, Turkey.ssor and chair, Department of Periodontology and Oral Biology.thors have completed and submitted the ICMJE Form for Disclosure oftial Conflicts of Interest, and none were reported.ss correspondence to: Serge Dibart, Department of Periodontology, Bostonrsity Henry M. Goldman School of Dental Medicine, 100 E Newton St,n, MA 02118; e-mail, [email protected], May 2011; revised and accepted, December 2012.5406/$36.00ight � 2013 by the American Association of Orthodontists./dx.doi.org/10.1016/j.ajodo.2012.12.014

accelerated osteogenic orthodontics. They suggestedthat toothmovement in patientswhounderwent selectivedecortication might be due to a demineralization-remineralization process. This observation is part of agreater event that is known in the orthopedic literatureas the regional acceleratory phenomenon, where adynamic healing process occurs at the site of the osseousinjury; the healing is proportional to the extent of the sur-gical insult.8-10 A recent publication has shown clearlythat this is the mechanism.11 A localized surge in osteo-clastic and osteoblastic activity results in a decrease inbone density and an increase in bone turnover. Theregional acceleratory phenomenon begins within a fewdays of the surgery and usually peaks in 1 to 2 months,and then slows down and disappears as remineralizationsets in.

Although effective and highly predictable, corticotomy-assisted orthodontic treatment is quite invasive becauseit requires extensive flap elevation and osseous surgery,which can cause postsurgical discomfort as well as variouspostoperative complications. Vercellotti and Podesta12

proposed the use of a piezoelectric knife instead of ahigh-speed surgical bur to decrease the surgical traumaand still achieve rapid tooth movement. Because of itsmicrometric and selective cut, a piezoelectric device pro-duces safe and precise osteotomies without osteone-crotic damage.13,14 In 2009, Kim et al15 introduced thecorticision technique as a minimally invasive alternativeto create a surgical injury to the bone without flap reflec-tion. In this technique, they used a reinforced scalpel anda mallet to go through the gingiva and cortical bone,without raising flaps. This surgical injury was deemed

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http://dx.doi.org/10.1016/j.ajodo.2012.12.014

Fig 1. Pretreatment extraoral photographs.

880 Keser and Dibart

enough to induce the regional acceleratory phenome-non effect and move the teeth rapidly during orthodon-tic treatment. This technique, although innovative, has afew major drawbacks: the inability to graft soft or hardtissues during the procedure to correct inadequaciesand reinforce the periodontium, and transient postsur-gical dizziness from the repeated malleting during thesurgery. In 2009, we proposed a new and minimallyinvasive procedure that we called “piezocision.”16 Thisapproach combines microincisions to the buccalgingivae that allow for the use of the piezoelectric knifeto decorticate the alveolar bone to initiate the regionalacceleratory phenomenon. Although it is minimallyinvasive, it also has the advantage of allowing forhard-tissue or soft-tissue grafting via selective tunnelingto correct gingival recessions or bone deficiencies in pa-tients.17

When this procedure was first described, the piezoci-sion cuts were made simultaneously in both arches tocorrect the malocclusion.16-18 In this case report, wepresent a new application of piezocision-assisted ortho-dontic treatment. Sequential piezocision is introduced asa tool to correct a Class III malocclusion in a total treat-ment time of 8 months.

DIAGNOSIS AND ETIOLOGY

A 25-year-old woman sought orthodontic treatmentwith chief complaints of misaligned teeth and an unfa-vorable smile. Her medical and family histories were notcontributory. She had a slightly concave profile with aprominent nose and chin (Fig 1).

The intraoral examination showed that she hadhealthy periodontal tissues and good oral hygiene. Hermaxilla was constricted. Her maxillary right second pre-molar, maxillary right canine, right and left lateral inci-sors, and maxillary left central incisor were in crossbite.

December 2013 � Vol 144 � Issue 6 American

She exhibited a Class III malocclusion with a narrowmaxilla (Fig 2). The space analysis done on the studymodels showed 7.5 mm of crowding in the maxillaryarch and 2 mm of crowding in the mandibular arch.The radiographic evaluation showed no visible pathol-ogies (Figs 3 and 4). She had composite fillings on themaxillary central incisors, maxillary left lateral incisor,and mandibular first molars.

The cephalometric analysis showed a skeletal Class IIIpattern with an ANB angle of �1.2� and a Wits value of�9 mm (Table). The SNB value was in the normal range(78.4�), showing that the slight Class III pattern was dueto the retracted position of the maxilla (SNA, 77.2�).IMPA and the angle axis of L1 to NB showed that themandibular incisors were upright.

TREATMENT OBJECTIVES

The treatment objectives for this patient were to cor-rect the crossbites, resolve the crowding in the maxillaryand mandibular arches, and achieve Class I molar andcanine relationships. Ideal overjet and overbite relation-ships were also desirable to improve the occlusion andfor anterior and lateral guidance. Other treatment objec-tives were to correct the incisor positions, maintainupper lip support for satisfactory facial harmony, andachieve favorable smile esthetics and profile.

TREATMENT ALTERNATIVES

Three treatment alternatives were presented to thepatient.

One alternative included extraction of the maxillaryfirst premolars to resolve the crowding and align themaxil-lary arch, andmaxillary advancement surgery to correct themalocclusion and theprofile. This optionwould correct thedental problems and significantly improve the facial

Journal of Orthodontics and Dentofacial Orthopedics

Fig 3. Pretreatment panoramic radiograph.

Fig 2. Pretreatment study models.

Keser and Dibart 881

profile. The patient was not willing to have orthognathicsurgery under any circumstances and expressed that herprimary concern was not to correct her facial appearance.Therefore, the surgical option was excluded.

Since the patient refused to have orthognathic sur-gery, extractions in the maxilla would create a moreprominent Class III pattern; hence, the option of extrac-tions to correct the crowding was eliminated.

Another alternative involved using surgically assistedrapid palatal expansion to create space to align themaxillary teeth and intermaxillary elastics to correctthe malocclusion.

When the patient expressed her concern regardingtreatment time, a third option was presented. This

American Journal of Orthodontics and Dentofacial Orthoped

option would use piezocision to shorten the treatmenttime and also to create a more pliable bone structureto expand the maxillary arch. The amount of crowdingin the maxillary arch was more than what could beresolved with expansion alone; therefore, interproximalreductions, especially on the teeth with the compositefillings, were also planned. Because the amount ofcorrection needed in the maxilla was more significantthan that in the mandible, a different therapeuticapproach, concomitant with the piezocisions, wasdevised. The piezocisions were planned in a sequentialmanner, starting with the maxillary arch; after correctionof the crossbites, the mandibular arch would be bondedand the mandibular piezocisions performed. The totaltreatment time for this option was estimated to be lessthan 1 year. The patient, refusing the orthognathic sur-gical treatment, decided to undergo piezocisions inconjunction with nonextraction treatment.

Rhinoplasty was also mentioned as another estheticintervention to complement her profile at the end ofthe treatment.

TREATMENT PROGRESS

Treatment was started by bonding the maxillary archonly, from second molar to second molar but excludingthe maxillary left lateral incisor because of the lack ofspace. A 0.014-in nickel-titanium alloy archwire wasplaced; bite-rising cones were placed on the mandibular

ics December 2013 � Vol 144 � Issue 6

Fig 4. Pretreatment cephalometric radiograph.

Table. Pretreatment and posttreatment cephalo-metric values

Cephalometric measurement Initial FinalSNA (�) 77.2 76.8SNB (�) 78.4 78ANB (�) �1.2 �1.2FMIA (�) 74 75FMA (�) 18 21IMPA (�) 88 84Wits appraisal (mm) �9 �6Interincisal angle (�) 135.2 130.2Angle axis of U1 to NA (�) 27.9 37.4Angle axis of U1 to SN (�) 105.1 114.2Angle axis of L1 to NB (�) 18.1 13.7Distance of U1 to NA (mm) 11 15Distance of L1 to NB (mm) 9 10


molars to open the bite and create the interocclusalspace for the crossbite corrections.

Piezocisions on the maxillary arch were done 9 daysafter the initial bracket placement. Local anesthesia wasgiven, and 6 vertical interproximal incisions were madewith a blade below the interdental papilla on the buccalaspect of themaxillamesial to the firstmolars, andmesialand distal to the canines. These incisions were minimal,just to give access to the piezosurgical knife (Satelec; Ac-teon Group, Merignac, France), which was then used tocreate the alveolar decortication through the gingivalopening to a depth of approximately 3 mm (Fig 5). A


prescription for a nonsteroidal anti-inflammatory drugwas given, and the patient was advised to rinse twice aday with chlorhexidine for a week. Because of the rapidand temporary demineralization that occurs after piezo-cision as a result of the regional acceleratory phenome-non effect, the orthodontic appointments werescheduled every 2 weeks instead of every 4 weeks. Thewire sizes progressed from 0.014-in nickel-titanium alloyto 0.016 3 0.022-in nickel-titanium alloy archwires forleveling and alignment. Once the crossbites were cor-rected, the bite opening cones on the mandibular molarswere removed. Two and a half months after the maxillarypiezocision, the mandible was bonded, and a 0.016-innickel-titanium alloy archwire was placed. Piezocisionson the mandible were done 2 weeks later. Six verticalinterproximal incisions were made in the same manneras described for the maxilla (Fig 6). The archwires pro-gressed from 0.016-in nickel-titanium alloy to 0.016 30.022-in stainless steel for leveling and alignment. ClassIII elastics were used to correct the Class III relationship.The orthodontic treatment was completed in 8 months.Fixed retainers were placed in both arches, and Hawleyplates were given for retention.

TREATMENT RESULTS

At the end of the orthodontic treatment, Class I can-ine and molar relationships were established. Maxillaryand mandibular crowding was resolved, ideal overjetand overbite were achieved, and the crossbites were


Fig 6. Piezocision in the mandible.

Fig 5. Piezocision in the maxilla.


corrected (Figs 7 and 8). The severe crowding in themaxilla was resolved by expanding the maxillary archand performing interproximal reductions; mandibularcrowding was resolved by interproximal reductions alone.There were no scars at the sites of the piezocision cuts. Amajor space problem in the maxillary arch was easilysolved after the piezocisions by expansion and interprox-imal reductions because of the more pliable bone createdby the piezocuts. Once the space issue was resolved andthemaxillary dentitionwas aligned, itwas easier to controlthe bite and achieve a Class I canine and molar relation-ship: hence the reason for bonding the mandibular denti-tion after the maxillary alignment. The improvement ofthe profile was significant. No pathology or root resorp-tion was detected on the posttreatment radiographs(Figs 9 and 10).

The posttreatment cephalometric analysis showed nomajor changes compared with the initial values (Table).The interincisal angle decreased from an initial valueof 135� to a final value of 130� because of the proclina-tion of the maxillary incisors at the end of the treatment.A slight increase of the FMA angle was observed becauseof the extrusive nature of the mechanics and intermax-illary elastics used (Fig 11). Although a favorable smilewas created and the patient was happy with the resultand the speed of the treatment, we noticed that betterpalatal crown torque could have been given to themaxillary left lateral incisor (Fig 7).

The mandibular first molars had extensive restora-tions with inadequate tooth forms and anatomies;therefore, the patient was referred to her general dentistfor retreatment of these teeth.


At 18 months posttreatment, the profile correctionappeared to be stable, and the maxillary expansion andmaxillary and mandibular arch forms remained stable(Fig 12). Although there was some relapse on the rightside, the canine relationship was Class I. The patientdid not have her mandibular first molars retreated duringthe 18 months after the orthodontic treatment. Noroot resorptions or pathologies were detected on the18-month posttreatment radiographs (Figs 13 and 14).A small relapse can be seen on the mandibular superim-positions of the posttreatment and 18-month posttreat-ment tracings (Fig 15). However, the maxillary teethremained stable.

DISCUSSION

A Class III malocclusion with a skeletal component isan orthodontic challenge, especially when a conservativeapproach is requested. An important factor for thesuccessful treatment of this malocclusion is the facialgrowth pattern. A reduced lower anterior face height,deep overbite, and passive lip seal, associatedwith a ClassIII malocclusion, have a better prognosis, becausetreatment-induced backward rotation of the mandiblewill assist in camouflaging the anteroposterior discrep-ancy. When an increased lower anterior face height isassociated with this malocclusion, surgical interventionis the treatment of choice, because any orthodonticallyinduced mandibular clockwise rotation will increasethe vertical facial dimensions and, consequently, causelip incompetence.19,20 For patients reluctant toundergo surgery or who are satisfied with their facial


Fig 7. Posttreatment extraoral and intraoral photographs.


appearance, an alternative is to treat with dentoalv-eolar compensation without correcting the underl-ying skeletal deformity. Since our patient refusedsurgery, the treatment approach was dentoalveolarcompensation. A major advantage was the decreasedvertical dimension, and this made the patient a goodcandidate for dentoalveolar compensation. Class IIIelastics were used to camouflage the anteroposteriordiscrepancy. Patient compliance in using the Class IIIelastics was crucial for success, and she was compliantwith the elastic wear. We achieved the Class IIIcorrection with intermaxillary elastics. The effectsof Class III elastics caused a small maxillary protrusion,and the mandible displayed a small retrusion, probablyconsequent to the backward and downward rotationthat this apical base experiences when Class III elasticsare used.20-22 These changes in the apical anteroposteriorposition contributed to the improvement in theirrelationship. The maxillary incisors were labially tipped,


and the mandibular incisors were lingually tipped. Thevertical component of the elastics produced smallextrusions of the maxillary molars and mandibularincisors (Table, Fig 11).

Evidently, an orthodontic-surgical approach couldhave produced greater skeletal correction of the ClassIII discrepancy, but the treatment should aim to solvethe patient's primary concerns.23-25

This patient had a significant amount of maxillarycrowding, with anterior crossbites and a Class III maloc-clusion. Since she refused orthognathic surgery, extrac-tions in the maxilla were not an option because thatwould have made nonsurgical correction impossible. Innonextraction treatment modalities, the resolution ofcrowding is usually achieved by distal movement ofthe posterior teeth, advancement of the anterior teeth,interproximal reduction, and transversal expansion.26

Interproximal enamel reduction (stripping) removescontrolled amounts of proximal enamel without


Fig 8. Posttreatment study models.

Fig 9. Posttreatment panoramic radiograph.

Fig 10. Posttreatment cephalometric radiograph.


damaging the teeth. This procedure, extensively investi-gated by many researchers, has undergone various tech-nological developments and become a widely usedclinical technique.27 Although stripping was introducedas an adjunctive treatment to resolve anterior crowding,Sheridan28 proposed its use in both the posterior andanterior segments to resolve crowding up to 10 mm.Thus, interproximal enamel reduction might be an alter-native treatment approach for space-gaining proceduressuch as arch expansion, distalization of the molars, pro-trusion of the incisors, and extractions in some patientswith moderate crowding and balanced profiles.29-31

However, the limitations (thin enamel and reducedproximal convexity) and complications (risk of toothsensitivity) of interproximal enamel reduction should


also be considered, because this is an irreversibleprocedure.32 Therefore, interproximal enamel reductionshould be used carefully with respect to the anat-omy and physiology of the teeth. Another concern aboutstripping is the long-term health of the teeth. A follow-up study showed that interdental enamel reduction inthe mandibular anterior region did not lead to dentalcaries, gingival recession, or alveolar bone loss over 10years.33 In this patient, crowding was resolved by a com-bination of expansion and interproximal stripping. The


Fig 11. Pretreatment and posttreatment superimpositions.


patient had composite fillings especially on the mesialand distal aspects of her anterior teeth; therefore, inter-proximal enamel reduction was done mostly from thefillings, creating no damage or adverse effects for thelong-term health of the teeth.

A recently described, minimally invasive surgicaltechnique (piezocision) is a novel tool in the armamen-tarium of the treating dental team. Piezocision-assisted orthodontic treatment speeds up the treatmentand increases the scope of tooth movement. This tech-nique also allows the placement of hard-tissue andsoft-tissue grafts in case of preexisting bony dehis-cences, fenestrations, thin buccal alveolar bones, ormucogingival defects.16,17 The concept is to accessthe alveolar buccal bone through microsurgicalinterproximal openings in the gingivae and use thedemineralization properties of the piezoelectric knifeto create the injury to the bone that will start theregional acceleratory phenomenon effect. When thebone is injured, a dynamic healing process occurs atthe site of the injury that is proportional to the extentof the surgical insult. The regional acceleratoryphenomenon effect can start as early as 24 hours (datanot shown), usually peaks in 1 to 2 months, and thenslows down and disappears as remineralization setsin.8-10 This dynamic process with its burst of localactivity (bone remodeling, surges in osteoclastic andosteoblastic activity) creates a transient osteopeniaresponsible for the rapid tooth movement becausethe teeth are moving in a more “pliable” environment.The judicious use of the localized demineralization


process to achieve a positive orthodontic outcomein a minimally invasive manner is the essence ofpiezocision. We are, in essence, using (and perhapsguiding) the physiologic response of the body to localinjury to help the dental team and the patient achievetheir therapeutic goals. In recent years, the techniquehas evolved from being used throughout the wholemouth in 1 surgical setting approximately 1 week afterthe initial bracket placement or the application of theorthodontic force to a staged approach, with selectedareas or segments of the arch demineralized atdifferent times during orthodontic treatment to helpachieve specific results.16-18 We called this approachsegmental or sequential piezocision. This case reportillustrates the sequential approach. The patient hadsevere maxillary crowding that required more toothmovement to correct the malocclusion, compared withthe mandible. She also had multiple crossbites causedby the skeletal discrepancy. Bonding both arches at thesame time would have created some buccal movementof the mandibular incisors, making it hard to controlthe overbite and correct the crossbites. Sincepiezocision creates a more pliable bone, the effects ofa nickel-titanium wire become exaggerated. Subse-quently, the decreased resistance created by the piez-ocision effect allows for faster buccal movement ofthe mandibular incisors; this compromises the controlof the overbite, especially in patients with anterior cross-bites. For this reason, the maxillary teeth were bondedinitially, piezocision was done in the maxillary arch,crowding was resolved, and the crossbites were


Fig 13. Posttreatment panoramic radiograph at 18months.

Fig 12. Posttreatment extraoral and intraoral photographs at 18 months.

Fig 14. Posttreatment cephalometric radiograph at 18months.


corrected. A rectangular stainless steel wire was placedon the maxilla with simultaneous bonding of themandibular arch. This was done 2.5 months after themaxillary piezocisions, when the regional acceleratoryphenomenon effect was at its peak, enhancing and com-plementing the effects of the Class III elastics in themaxilla.


In retrospect, the posterior alignment might havebeen better if the second and third molars had beenbanded or bracketed; also, a better palatal crown torque


Fig 15. Posttreatment and 18-months posttreatment superimpositions.


could have been given to the maxillary left lateral incisor(Fig 7).

At 18 months posttreatment, a small relapse canbe seen on the superimposed mandibular tracings(Fig 15). However, the maxillary teeth remained stable.The small relapse might have been prevented by keepingthe patient in heavy wires for another 3 months after theClass I relationship was achieved. Total treatment time infixed appliances has always been a major concern foradult patients. Accelerating the orthodontic treatmentis a major benefit for them. The active treatment timewas 8 months for our patient, but it might have beenmore stable if active retention was used and the fixedappliances were removed after stabilizing for a fewmore months. Even in that case, the overall treatmenttime would still be much shorter because of the use ofpiezocision.

Another compounding factor for the relapse was theless than ideal occlusal anatomy of the posterior teethleading to poor intercuspation and poor stability. Thepatient was referred to her general dentist to addressthe restorations of the posterior teeth, but she did nothave that treatment.

Because this patient's concern was primarily herdental and smile esthetics, we obtained the most fromthe orthodontic mechanics available to satisfy her needswithout orthognathic surgery. This case is unique inthat piezocision was used to assist and guide the ortho-dontic mechanics in a sequential manner, enhancingtheir affects and significantly decreasing the treatmenttime.


CONCLUSIONS

Piezocision is an innovative, minimally invasive tech-nique designed to achieve rapid orthodontic tooth move-ment without the downside of extensive and traumaticconventional surgical approaches. This new techniquecan be combined with various orthodontic treatment mo-dalities to satisfy today's adult patient population, andmodifications can be made to meet the specific mechan-ical requirements. This case report illustrates how piezo-cision can be used sequentially in selected patients toproduce outcomes that are both timely and satisfactory.

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