Accelerated orthodontic treatments with Piezocision: a mini invasive alternative to alveolar corticotomies

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1 English trnsltion from: Orthod Fr 2011;82: EDP Sciences, SFODF, 2011 DOI: /orthodfr/ Disponile en ligne sur : Originl rticle Accelerted orthodontic tretments with Piezocision: mini invsive lterntive to lveolr corticotomies Jen-Dvid M. SEBAOUN 1,2 *, Jérôme SURMENIAN 1,3, Serge DIBART 1 1 Deprtment of Periodontology, Boston University, 100 Est Newton Street, Boston MA 02118, Étts-Unis cours Jen Jurès, Grenole, Frnce 3 23 rue Alphonse Krr, Nice, Frnce (Received 9 Mrch 2011, ccepted 24 Mrch 2011) KEYWORDS: Corticotomy / Rpid orthodontics ABSTRACT An incresing numer of dult ptients re seeking orthodontic tretment nd short tretment time hs ecome recurring request. To meet their expecttions, numer of surgicl techniques hve een developed to ccelerte orthodontic tooth movement. However, these hve een found to e quite invsive. We re introducing here new, minimlly invsive flpless procedure, comining micro incisions, piezoelectric incisions nd selective tunneling tht llows for hrd- or soft-tissue grfting. Comined with proper tretment plnning nd good understnding of the iologicl events involved, this novel technique cn loclly mnipulte lveolr one metolism in order to otin rpid nd stle orthodontic results. Piezocision llows for rpid correction of severe mlocclusions without the drwcks of trumtic conventionl corticotomy procedures. 1. Introduction 1.1. Alveolr cortocotomies nd rpid orthodontic tretments An incresing numer of dult ptients re seeking orthodontic tretment nd short tretment time hs ecome recurring request. Significnt ccelertion in orthodontic tooth movement hs een extensively reported following lveolr corticotomies since the end of the 19th century. In 1959, Köle [9] descried surgicl procedure comining verticl inter-proximl corticl incisions with supicl horizontl osteotomy cut from the uccl to the pltl plte. The uthor explins tht rpid tooth movements oserved following the surgery re cused y wht he elieved to e ony lock movements more or less independent of ech other. Susequently, mny uthors pulish vrints of the technique where the supicl osteotomy ws removed nd where only superficil corticotomy incisions were relized. However, ll explined tht rpid * Corresponding uthor : jdseoun@gmil.com tooth movements were llowed y the ony lock movements concept [1, 4, 6, 20]. In 2001, Wilcko [25] introduced technique comining lveolr corticotomies nd one grfting to prevent the risk of dehiscence nd fenestrtion while incresing the scope of orthodontic corrections. In this conventionl pproch, corticl incisions circumscriing the roots re mde on oth the uccl nd pltl side following full thickness mucoperiostel flps (Fig. 1). The one grft is then plced fcing the teeth to e moved nd the flps re then repositioned nd sutured t the ppill. The uthors [18] further speculted tht the rpid orthodontic movements cliniclly oserved in ptients who underwent selective decortiction might e due to deminerliztion reminerliztion process rther thn ony lock movement Biologicl rtionls In 1981, the orthopedist Frost [5] oserved tht surgicl wounding of the one induces n incresed one turnover nd decresed one density in the immedite surrounding of the surgicl site (RAP, Regionl Accelertory Phenomenon). This post-surgicl stte of Article pulié pr EDP Sciences

2 312 Orthod Fr 2011;82: Figure 1 Conventionl lveolr corticotomy. Corticl incisions re mde using one ur following muco-periostel uccl nd pltl/ lingul flps. osteopeni is descried s trnsient condition, giving wy to complete remission of one density grdully s physiologicl heling progresses [7, 10]. Furthermore, mny studies underlined reltionship etween the rte of tooth movement nd the rte of lveolr one turnover. Vern [23], phrmcologiclly induced high or low rtes of one turnover nd demonstrted tht n incresed turnover is ssocited with displcement significntly fster. These results re consistent with those reported y Midgett [13] nd Ashcrft [2]. Recent niml studies hve confirmed the Wilcko hypothesis tht cliniclly oserved rpid tooth movement following corticotomy my e due to Frost s Regionl Accelertory Phenomenon nd not to the concept of movements known s ony locks. At the histologicl level, we reported in the rt reversile increse in one turnover following lveolr corticotomy [19]. Three weeks fter surgery, osteolstic nd osteoclcic ctivities were incresed y fctor of three nd returned to stedy stte vlues t eleven weeks postopertive. We lso noted tht these effects were limited to immedite environment of the surgicl site. Other uthors hve ssessed the qulity nd quntity of orthodontic movements following corticotomy in the niml model. Ren [17] oserved fster tooth movement ssocited with significnt increse in the rte of one turnover t the surgicl site fter corticotomy in the Begle dog. Mostf [14] reported twice fster tooth movements fter corticotomy in the dog nd lso ttriuted this effect to the incresed one remodeling oserved histologiclly nd to Regionl Accelertory Phenomenon (RAP). These findings re consistent with the work of Lino [12] for whom ccelerted movements re ssocited with rpid response in the one mrrow nd with lesser hyliniztion. Similr oservtions hve een reported in rts fter corticision (incresed resorption nd pposition) nd less hyliniztion [8]. Moreover, y compring orthodontic movement fter corticotomies to those otined fter osteotomies, Wng [24] nd Lee [11] confirmed the Regionl Accelertory Phenomenon (RAP) s the events responsile for rpid movements. Displcements y distrction osteogenesis re oserved in cses of osteotomies nd not following simple corticotomies thus refuting the concept of ony lock movements Alterntives to conventionl corticotomies Although effective, corticotomy techniques descried ove present significnt postopertive discomfort. The ggressive nture of these prticulr methods relted to the elevtion of muco-periostel flps nd to the length of the surgery rised reluctnce mong oth ptients nd dentl community. In ddition, ll the uthors mentioned ove performed the corticl incisions using one ur tht could potentilly dmge the roots of neighoring teeth (in cse of severe crowding in the nterior mndile). In 2006, Prk [15] introduced the corticision technique nd removed the need for flps elevtion y conducting their incisions directly through the gingiv using lde nd surgicl hmmer. While significntly reducing the durtion of the surgery, this technique does not provide the enefits of one grft of the Wilcko technique. In ddition, the highly ggressive use of the hmmer nd chisels in the mxill dds risk of enign proxysml positionl vertigo [16]. In 2007, Vercellotti [22] reported reduction of the orthodontic tretment time y 60 to 70% fter corticotomy performed y mens of piezosurgicl micro-sw. Due to their smll size nd their precision, piezoelectric cutting inserts relize precise osteotomies without the risk of osteonecrosis [21]. The uthor removed the lingul flp y performing only vestiulr incisions ut the elevtion of flp prior to the corticotomy ws mintined thus only reltively reducing surgicl time nd postopertive discomfort. To overcome the disdvntges of other corticotomy techniques, we re introducing [3], n innovtive, minimlly invsive, flpless procedure comining piezosurgicl corticl micro-incisions with selective tunneling tht llows for one or soft-tissue grfting.

3 Seoun J.D.M., Surmenin J., Dirt S. Accelerted orthodontic tretments with Piezocision Piezocizion: minimlly invsive technique of lveolr corticotomy 2.1. Initil periodontl exmintion nd mngement Figure 2 3D Imging (Cone em computed tomogrphy) for surgicl plnning. Preopertive rndering llows to loclize ntomicl risks nd to ssess the thickness of the corticl one nd the res of fenestrtions where one grft would e indicted. Piezocision technique ddressing primrily dult ptients, complete periodontl ssessment including periodontl proing nd full-mouth X- Rys must e conducted. Systemtic scling (nd root plning if indicted) must e performed prior to the surgery in order to remove ny inflmmtion tht could jeoprdize successfull heling. Any detected osseous lesion should e treted efore considering Piezocision procedure. Moreover, ecuse of the lck of mucoperiostel flp elevtion in the piezocision technique, we highly recommend the use of preopertive three-dimensionl imging (Cone Bem Computerized Tomogrphy) to locte res of root proximity s well s the mentl formen (Fig. 2). These imges lso llow the prctitioner to ssess the quntity nd loction of res where one grft would e indicted Surgery (Fig. 3) The surgery is performed under locl nesthesi, week following the plcement of the orthodontic pplince. Gingivl verticl incisions re mde interproximly elow the interdentl ppill using numer 15 lde nd kept s much s possile in the ttched gingiv. These incisions do not require to e extended (micro-incisions) ut they must cross the periosteum llowing the lde to come into contct with the lveolr one. Ultrsonic instrumenttion (BS1 insert Piezotome, Stelec Acteon Group Mérignc, Frnce) is then used to perform corticotomy cuts through the gingivl micro-incisions nd to depth of 3 mm. Note tht no suture is required except in res where one grft is plced. At the res requiring one ugmenttion, tunnel is performed y mens of n elevtor inserted etween the gingivl incisions to form sufficient spce for receiving the grft. The llogrft (Puros, Zimmer) is then plced nd the incision sutured (sorle sutures 5-0). Typiclly the grft is performed in cse of severe crowding in mndiulr nterior region. While only three gingivl incisions (etween the centrls nd distl to the lterls) re necessry for tunneling, we note tht the corticl incisions re mde etween ech tooth. When extrctions re indicted, they cn e mde during the intervention. As RAP otined y corticotomy is limited to the immedite proximity of the cuts [19], two corticl incisions should e performed fcing the extrction site to fcilitte rpid closure of the spce. Note tht ll of the incisions (nd the grft when required) re mde only ucclly. The lingul nd pltl pproches of conventionl corticotomies dispper. At the end of the procedure, the ptient is plced on ntiiotics, nonsteroidl nti-inflmmtory drugs nd mouthwshes contining chlorhexidine. Surgicl sites should e voided while rushing during the first postopertive week to llow hrmonious gingivl heling Orthodontic Follow-up After surgery, ptients re monitored every two weeks for their orthodontic djustments. The mjor orthodontic movements re otined within four months following the surgery emphsizing the trnsient nture of RAP. From our experience, it ppers

4 314 Orthod Fr 2011;82: c d e f g h i Figure 3 Surgery. () Micro-incisions re mde through the ttched gingiv. ( nd c) Bone is decorticted using the BS-1 insert (Piezotome, Stelec) to depth of 3 mm. (d) Three incisions re mde in the re needing one ugmenttion. (e) An elevtor is used to crete tunnel tht cn ccommodte the one grft. (f) The interproximl res re decorticted. (g) Insertion of the one grfting mteril. (h) The incisions re closed tightly with simple points (5.0). (i) Immedite post-surgicl view. Notice the minimlly invsive chrcter of the surgery. tht the mjority of cses re delt within rnge of 5 to 9 months depending on the severity of the initil mlocclusion. From periodontl stndpoint, ptients re monitored t one week postopertively nd then every month to ensure proper plque control nd reinforce necessry hygiene techniques (Fig. 4). 3. Clinicl pplictions 3.1. Indictions Creful selection of cses is decisive fctor on the clinicl success of this technique. Ptients should present stle periodontium without periodontl disese, not e ffected with locl or generl one disese or e sujected to tretment such s immunosuppressive or i-phosphonte. Motivtion nd coopertion of the ptient re essentil in Piezocision s in corticotomy ptients. In fct, the ternsient nture of RAP otined fter the surgery requires frequency of ppointments higher thn conventionl technique to chieve the mjor movements in the first months of tretment. From n orthodontic stndpoint, the idel cndidte for this procedure presents clss I or mild clss II ssocited with moderte to severe crowding. Severe deepites re lso corrected in timely mnner following Piezocision. In extrction cses, especilly in full Clss II ptients, the teeth will e extrcted during the surgery nd two to three corticl incisions will then e performed fcing the lveolus (Fig. 5).

5 Seoun J.D.M., Surmenin J., Dirt S. Accelerted orthodontic tretments with Piezocision 315 c d e f Figure 4 Periodontl follow-up of ptient in figure 3. ( nd ) Pre-tretment pnormic rdiogrph nd full mouth xrys to evlute one level nd root proximity for surgicl plnning. (c, d nd e) Heling ssessment one week post-piezocision. (f) Post-tretment pnormic rdiogrph for one level control. Note tht the wisdom teeth will e extrcted lter on. c Figure 5 Correction of Clss II y rpid cnine retrction fter Piezocision. () Two to three corticl incisions re mde fcing the socket of the extrcted tooth nd surrounding the teeth to e moved. () Before cnine retrction phse. (c) Four weeks following plcement of the retrction coils (300 g Sentlloy GAC ).

6 316 Orthod Fr 2011;82: Moreover, the procedure we re descriing cn e performed in segmentl mnner (pre-prosthetic intrusion, tretment of single rch...) or e incorported within comprehensive ortho-surgicl tretment pln llowing for rpid decompenstion of the rches prior to moving skeletl ses y orthognthic surgery. Finlly, the oserved ccelertion of orthodontic movements eing sed on loclized modifiction of one physiology, Piezocision my e ssocited with vrious orthodontic tretment techniques (uccl rces, lingul rces nd Invislign ) Advntges The technique descried here presents similr clinicl outcomes to those otined following conventionl corticotomy with the dvntges of eing shorter to perform, minimlly invsive nd much less trumtic for the ptient. Cliniclly we oserve decrese in the durtion of tretment equivlent to tht otined y corticotomy (Fig. 6). It ppers tht the mjority of even severe mlocclusions re resolved within 5 to 9 months. The ctive tretment times re therefore three times shorter thn those usully oserved fter conventionl tretment of similr mlocclusion. When comined with one grfting, Piezocision llows for n increse scope of tretment including llowing the correction of severe crowding without extrction. From technicl stndpoint, 45 min to 1 h is usully sufficient for complete surgery on oth the mxill nd mndiule with one grfting ginst three to four hours for trditionl techniques. Furthermore, if conventionl methods could e ssocited with some periodontl complictions (mild one loss nd prtil loss of interdentl ppill), it ppers tht not rising flp in the minimlly invsive technique voids those risks. Finlly we note tht the postopertive discomfort fter Piezocision is much lighter nd llows return to norml ctivities soon fter surgery. In our clinicl experience, we do not report mjor edem or hemtom of the fce s descried fter invsive corticotomies [6]. Postopertive pin is usully miniml nd well tolerted y ptients Disdvntges nd limittions of the technique Becuse of the lck of muco-periostel flp elevtion, corticl incisions my present risk of root dmge prticulrly in res of close root proximity. A risk lso exists t the mentl formen. A pnormic rdiogrph nd retrolveolr imges of those res re essentil to the preprtion of the surgery. The contriution of three-dimensionl imging compenste for the lck of direct vision of the ony structures (Fig. 2). Extr cre is lso required s to the loction of gingivl incisions. It is very importnt to keep t lest 2 mm from the gingivl mrgin to void the formtion of gingivl cleft. In ddition, for ptients presenting ethnic gingivl pigmenttion, soft tissue incisions cn crete cosmetic concern. In fct, ech incision my leve trce without proper repigmenttion, therey cusing cosmetic dmges in ptients with excessive gingivl disply. Those ptients must e wrned ginst potentil risk of post-opertive scrs. 4. Conclusion Piezocision is n innovtive, minimlly invsive, flpless procedure comining piezosurgicl corticl incisions with selective tunneling tht llows for one or soft-tissue grfting. This innovtive technique llows for the orthodontic correction of severe mlocclusions in less thn semester without the downside of the extensive nd trumtic surgicl pproches. It offers shorter surgicl time, miniml postopertive discomfort, high tolernce for ptients s well s n improved periodontium. The Piezocision revels itself s powerful tool in the rsenl of multidisciplinry dentl tem for our dult ptients. Figure 6 Ptient presenting Clss I mlocclusion ssocited with severe crowding (8 mm) nd 50% overite. Tretment completed in six months nd three weeks with mxillry nd mndiulr Piezocision from first molr to first molr coupled with one grft y tunneling in the inter-cnine region of the mndiule. Occlusl views: () efore tretment, () four months fter Piezocision, (c) six months nd three weeks fter Piezocision. Note tht the mjor movements re otined in the first months following the surgery.

7 Seoun J.D.M., Surmenin J., Dirt S. Accelerted orthodontic tretments with Piezocision c d e f g h i j k l m n o p 317

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