Art-4-Thonnart
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DENTOALVEOLAR SURGERY
CONTRIBUTION OF PIEZOCISION IN ORAL SURGERY:
Review Articles
THE EXAMPLE OF THE ACCELERATION OF
ORTHODONTIC MOVEMENTS
1a* 2b 2c
Thonnart François , Systermans Simon , Gilon Yves
¹Department of Plastic and Maxillofacial Surgery, CHU Liège, Belgium
²Department of Maxillofacial Surgery, ZOL Genk, Belgium
a
MD, DDS, Maxillofacial Surgery Resident; e-mail: francois-thonnart@hotmail.com; ORCIDiD: https://orcid.org/0000-0001-9382-8699
b
MD, DDS, PhD, Professor, Maxillofacial Surgeon; e-mail: yves.gilon@chuliege.be; ORCIDiD: https://orcid.org/0000-0002-1991-5951
c
MD, DDS, Maxillofacial Surgery Resident; e-mail: simon.systermans@chuliege.be; ORCIDiD: https://orcid.org/ 0000-0002-6740-8372
ABSTRACT https://doi.org/10.25241/stomaeduj.2021.8(3).art.4
Introduction Patients are more demanding of short or less invasive interventions. Piezocision responds well
to this demand, particularly in the case of piezo-guided corticotomy to accelerate orthodontic movements.
Different surgical approaches are described to shorten orthodontic procedures. Corticotomy is a surgical
process where osteotomies are realized at the level of the cortical part of the bone.
Objective The aim of this work is to review the contribution of piezocision in oral surgery, using as example
a review over the current results of piezocision on the acceleration of orthodontic movements.
Data sources The articles referenced and used in this article come from the PubMed database. The searched
keywords were "piezocision" alone or in combination with "orthodontics".
Study selection This search resulted in 44 available articles. Subsequently, 6 randomized controlled trials
were selected based on relevance, journal, and publication date. Four Randomized Controlled Trials and two
Controlled Clinical Trials were studied.
Data extraction The reviewer assessed each article for their relevance and methodology. The 6 studies
compared the time savings between conventional orthodontic treatment (control group) and orthodontic
treatment combined with piezocision surgery (test group).
Data synthesis Piezocision corticotomy reduces the operation and the postoperative period and increases
the acceptance of corticotomies and their indications.
KEYWORDS
Piezocision ; Orthodontics ; Corticotomy ; Oral Surgery ; Minimally Invasive.
1. INTRODUCTION cant exothermic reaction. The use of angled inserts
improves the visibility of the operating field.
Originally, piezosurgery was developed to allow Therefore, piezoelectric surgery is a safe, precise and
cutting hard structures without affecting soft struc- atraumatic technique.
tures, with an ultrasound instrumentation. Bone In our oral and maxillofacial surgery practice, the
cutting is performed by high frequency micromove- piezotome is currently taking an important place.
ments generated by the piezoelectric handpiece, It is particularly used in our department in pre-
the piezotome. The back and forth motion transmi- implant surgery for maxillary ridge expansion, open-
tted to a cutting insert creates a cutting effect. Over ing the bone windows during the sinus lift, during
the past decades, numerous scientific articles have ramic, symphyseal, tuberosal or cranial parietal har-
illustrated the numerous indications of piezocision vesting and during the lateralization surgery of the
in oral surgery, implant surgery, cranio-maxillofacial inferior alveolar nerve. The piezotome is also used
surgery and other surgical disciplines. The main in maxi-llofacial surgery for mandibulectomy and
advantages and characteristics of piezocision are costochondral harvesting (temporomandibular an-
the selective cutting of the bone without damaging kylosis treatment, rhinoplasties), and for free fibula
adjacent soft tissues such as vessels, nerves, mucous flaps. It is also used for condylectomies and compli-
membranes, but also to reach difficult access areas cated mandibular sagittal osteotomies with malpo-
via angled inserts compared to conventional instru- sition of the inferior alveolar nerve. In oral surgery,
mentation, and to cut without generating signifi- the piezotome is used in our practice for retrograde
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Thonnart F, Gilon Y, Systermans S. Contribution of piezocision in oral surgery: the example of the acceleration of orthodontic movements.
Stoma Edu J. 2021;8(3):184-188.
Received: July 05, 2021; Revised: July 22, 2021; Accepted: July 25, 2021; Published: August 02, 2021
*Corresponding author: Dr. François Thonnart, MD, DDS; Maxillo-Facial Surgery, Ziekenhuis Oost-Limburg, Rue de Spa 2/41, BE-Liège, 4020, Belgium
Tel.: +3242425260 ; Fax: +3243667061; e-mail: francois-thonnart@hotmail.com
Copyright: © 2021 the Editorial Council for the Stomatology Edu Journal.
184 Stoma Edu J. 2021;8(3):184-188 pISSN 2360-2406; eISSN 2502-0285
Contribution of piezocision in oral surgery
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endodontic surgeries, cyst removal but also to 3. RESULTS
Review Articles
accelerate orthodontic movements.
Orthodontics is a dental discipline that aims to Four Randomized Controlled Trials and two Controlled
correct the dental occlusion and/or the position- Clinical Trials were studied. The 6 studies compared
ing of the jaws and teeth, using various removable the time savings between conventional orthodontic
or fixed devices. The long duration of orthodontic
treatment (control group) and orthodontic treatment
treatments is one of the most common complaints
combined with piezocision surgery (test group).
of patients undergoing orthodontic treatment. In
addition, longer treatments can increase the risk of
complications such as caries, periodontal problems 3.1. Characteristics of the studies
and root resorption. The general information from the studies is summa-
Various surgical approaches have been described rized in Table 1. Of the 6 articles, 4 are RCT [3-4-6-8]
to accelerate tooth movement. Invasive procedures and 2 are CCT [5-7]. All studies included 131 patients.
such as corticotomies with periodontal flaps have Each study presented a group treated with electric
shown good results in decreasing treatment times in piezocision and another "control" group with conven-
orthodontics [1-2]. tional orthodontic movement. One study [5] compared
To reduce the invasiveness of corticotomies, a the efficacy of conventional corticotomy to piezoci-
minimally invasive surgical procedure has been sion. The studies by Uribe, Gibreal, and Charavet focus
introduced. This consists of making transmucosal
on tooth alignment, while the studies by Abbas and
cortical incisions without flaps using a piezotome.
Aksakalli investigate canine distalization in premolar
This technique involves micro-incisions and small
corticotomies. Localized decortication induces a extraction.
demineralization-remineralization process described
as regional acceleratory phenomenon (RAP). The 3.2. Orthondontic movements
induced corticotomy at the bone level is followed by The study by Charavet et al [6] showed a decrease
an increase in bone turnover and a decrease in bone of 43% in orthodontic time in the piezocision group
mineral. compared to the control group, compared to 59%
The aim of this work is to explain the contribution in the study [4]. The differences between the two
of piezocision in oral surgery through piezocision
groups in study [6] increased in time until full align-
corticotomy.
ment but decreased for final adjustments.
2. MATERIALS AND METHODS Study [3] showed no significant difference between
the two groups. The duration of canine distalization
The articles referenced and used in this article come in study [7] is reduced in the piezocision group.
from the Pubmed database. The searched keywords In addition, the study by Abbas et al [5] found a
were "piezocision" alone or in combination with higher rate of movement in the corticotomy group
"orthodontics". This search resulted in 44 available
compared with the piezocision group during weeks
articles. Subsequently, 6 randomized controlled
trials were selected based on relevance, journal, and 2,4,10,12 after surgery. The 2019 study by Charavet
publication date. Each study was conducted on et al [8] shows a 36% acceleration of treatment for
healthy patients and analyzed the effectiveness of the piezocision group compared with the control
piezocision on accelerating orthodontic movements. group.
Study name Study Number Group Intervention type Type of orthodontic Origins
type movements
Uribe (2013) [8] RCT n=29 Piezocision: M:6; W:10; age: 30 Piezocision: piezocision + orthodontic movement Anterior alignment due to USA
Control: M:6; W:7; age 29.4 Control: Orthodontic movement only crowding of the maxilla (3 to 3)
Gibreal (2019) [4] RCT n=34 Piezocision: n =17 Piezocision: piezocision + orthodontic movement Anterior alignment due to Syria
Control: n=17 Control: Orthodontic movement only crowding of the maxilla (3 to 3)
Abbas (2016) [5] CCT n=20 Group 1: n=10 Group 1: one-sided corticotomy with Distalization of a maxillary canine Egypt
Group 2: n=10 contralateral control group
Group 2: one-sided piezocision with contralateral
control group
Charavet (2016) [6] RCT n =24 Piezocision: n =12 Piezocision: piezocision + orthodontic movement Anterior alignment due to Belgium
Control: n=12 Control : Orthodontic movement only crowding of the upper and lower
jaws (3 to 3)
Aksakalli (2016) [7] CCT n =10 / Piezocision: piezocision + orthodontic movement Distalization of a maxillary canine Turkey
Control : Orthodontic movement only
Charavet (2019) [8] RCT n=24 Piezocision: n =12 Piezocision: piezocision + orthodontic movement Anterior alignment due to Belgium
Control: n=12 Control: Orthodontic movement only crowding of the upper and lower
jaws (3 to 3)
Table 3. Studies descriptions.
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A summary table (Table 2) compares the time gains 4. DISCUSSION
Review Articles
for the test groups versus the control groups.
The analysis of the results shows an acceleration of
Studies N Saves time in orthodontic treatment (%) orthodontic treatment in 5 of the 6 clinical trials ana-
Uribe, et al. 2017 [3] 41 Not significant
lyzed, ranging from 36 to 63% (Table 2). According to
Uribe et al. [3], the results of his study do not show a
Gibreal, et al. 2019 [4] 36 59%
significant difference in the time required to correct
Charavet, et al. 2019 [8] 24 43% a mandibular anterior crowding between the two
Charavet, et al. 2016 [6] 24 36% groups.
Abbas, et al. 2016 [5] 20 / The lack of significant time savings in orthodontic
Aksakalli, et al 2016 [7] 10 63% treatment in the Uribe et al. [3] study is probably
related to the surgical technique. Indeed, the
Table 2. Comparison of time savings according to the analyzed studies.
corticotomy is only 1 mm deep and 3 mm high, com-
3.3. Surgical approach pared to the 3 mm and 5 mm found in the studies of
The surgical protocol is based on a flapless piezoci- Charavet [6-8] and Gibreal [4].
sion procedure. This technique consists in making In addition, the studies by Charavet et al. and
vertical interproximal microincisions 4mm above Gibreal et al. perform 5 vertical incisions up to the
each papilla. The length of the incisions varies accor- canine-premolar interdental space while Uribe et al.
ding to the studies from 5 to 8mm [6-8] and 4mm perform 3 vertical incisions, stopping between the
[3]. After the incisions, the gingiva is elevated to vi- canine and lateral incisor. The difference between
sua-lize the bone and adjacent roots. A corticotomy the two RCTs by Charavet et al. may be explained by
line is then made with a piezoelectric instrument. the use of different Brackets system, CAD/CAM for
The line also varies according to the studies, from the 2019 study.
5mm long and 3mm deep for Charavet et al. [6-8] The study by Gibreal et al. shows a greater time gain
and 1mm deep for Uribe et Al [3]. The incisions are than the 2 studies by Charavet et al. The improve-
sutured with absorbable suture. ment in time gain for orthodontic tooth movements
observed is probably related to the severity of the
3.4. Periodontal parameters anterior crowding. In the Gibreal et al. study, severe
All periodontal parameters were comparable anterior crowding required prior extraction, which
between the piezocision and test groups at the end probably increased the RAP effect.
of the treatment in the studies[5-6-7-8]. Based on the results of the studies above and the
For 3 patients (2 in the control group and 1 in the test literature cited above, the effectiveness of bone
group) in the study [6], a non-significant increase decortication in accelerating tooth movement is
in recession was observed between the interval at progressive and effective for 3 months after surgery,
the beginning of the treatment and the end of the with greater effectiveness in the maxilla. This effec-
treatment. tiveness of piezocision is observed when the first
The studies by Charavet et al [6-8] investigated the arch is placed 1 to 2 weeks before surgery and when
visibility of vertical scars in the piezocision groups. the corticotomy is at least 3mm deep and 5 to 8mm
Study [6] observed persistent scarring in 50% of pa- long. In addition, the patient should be recalled
tients with piezocision. In 33% of cases, the scar was every 2 weeks to activate the fixed appliance if
as a punt and in 17% of cases, in the form of a line. possible because of the limited effect of the RAP [4].
The 2019 study shows a visible scar in 66% of the pa- A review of the literature by Mertens et al. [9] shows
tients treated with piezocision. interesting results of corticotomies depending on
the indications. All of them seem to go in the direc-
3.5. Root resorptions tion of an acceleration of dental movements. How-
Abbas et al [5] showed that there were no differences ever, few studies have been performed with a con-
in root resorptions between the corticotomy group trol group treated with fixed orthodontics, without
and the piezocision group. However, the contrala- surgery. Therefore, the number of reviews support-
teral control group shows greater root resorptions ing that the use of corticotomies reduces orthodon-
of the canine than the experimental groups (piezoci- tic treatment time is limited.
sion and corticotomy). According to Charavet et al. [6-8], there is a visible
Studies [6-8] do not show an increase in root resorp- scar (either punctiform or linear) in 50 to 66% of the
tions in each group. subjects who have undergone piezocision. There-
fore, upper jaw piezocision is not recommended for
3.6. Patient-centered outcomes patients with a gummy smile.
Study [6] did not show any significant differences be- Furthermore, an interradicular proximity of less than
tween the two groups consumption of paracetamol. 2 mm is a contraindication to corticotomy6. Means
The level of satisfaction was significantly higher such as CBCT, surgical guides [10] or retroalveolar
in the piezocision group compared to the control radiographs with opaque interradicular wires can be
group. used to avoid root effraction. These tools can also be
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used to prevent damage to anatomical structures effect of the piezotome is the main factor studied by
Review Articles
such as the maxillary sinus or the mental foramen. several authors [16], especially on the inferior alveo-
All periodontal parameters appeared to be stable lar nerve during sagittal osteotomy of the lower jaw.
in the different studies. However, 3 patients with Most studies report little or no nerve damage using
pre-existing oral recessions showed an increase in piezotomy surgery. Only one comparative study
recessions [8]. Therefore, mucogingival techniques finds less nerve disruption after inferior sagittal
combined or not with piezocision may be interesting osteotomy using conventional rotary handpiece
to prevent gingival recession. A bone grafting tech- instrumentation [16].
nique associated with piezocision was performed in
a study by Charavet and Lecloux [11]. This technique 5. CONCLUSION
has allowed a thickening of the vestibular bone in a
class II patient and thus prevented the aggravation Piezocision corticotomy seems to be an attrac-
of bone dehiscence and the appearance of gingival tive technique to reduce the time of orthodontic
recession. treatments. Compared to corticotomies, it reduces
According to the study by Angelo Troedban [12], the operation and the postoperative period and
the use of surgical ultrasound devices in reduction increases the acceptance of corticotomies and their
rhinoplasty has shown a decrease in postsurgical indications.
morbidity and significantly increases overall patient However, given the presence of vertical scars in more
satisfaction. Piezotome rhinoplasty could reduce than 50% of cases, it remains contraindicated in
the need for secondary corrective rhinoplasties, patients with a gummy smile.
and piezotomes could be the surgical instrument of These examples confirm the interest of piezosurgery
choice in facial hard tissue cosmetic surgery as they in oral and maxillofacial surgery, at a time when the
already are in oral surgery. demand for less invasive treatments is growing. The
Relating to preimplant sinus surgery, numer- indications for the piezotome are becoming more
ous studies [13-14] have shown a lower rate of and more extensive, which makes it an instrument of
Schneider's sinus membrane perforation using choice, indispensable in our practice.
piezoelectric instruments compared with conven-
tional rotary instrumentation. ACKNOWLEDGMENTS
In orthognathic surgery, most surgical trauma There are no conflicts of interest and no financial interests to be
occurs especially during osteotomy. Therefore, any disclosed.
surgical tool such as the piezotome that can pro-
vide a safe and precise cut is an excellent option. AUTHOR CONTRIBUTIONS
It has several disadvantages: reduced ability to cut FT, SS: wrote the manuscript in consultation with YG. All authors
dense bone, increased time to perform an osteoto- provided critical feedback and helped shape the research and the
my [15] and additional cost [16]. The neurosensory manuscript. YG: aided in interpreting the results.
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François THONNART
MD, DDS, Maxillofacial Surgery Resident
Department of Maxillofacial Surgery
ZOL Genk, Belgium
CV
Dr. François Thonnart is a resident in Oral and Maxillofacial Surgery at the University of Liège, Liège, Belgium. He has a clinical
focus on the head and neck oncology, orthognatic and dento-alveolar surgery. He currently works as resident in Ziekenhuis Oost
Limburg in Genk, Limburg, Belgium.
Questions
1. The effectiveness of piezocision is observed when:
qa. The first arch is placed 3 weeks after the surgery;
qb. The corticotomy is 3-4mm long;
qc. The corticotomy is minimum 3mm deep;
qd. The corticotomy is 1-2mm deep.
2. In Charavet's study, there is a visible scar after piezocision in:
qa. 50 to 66%;
qb. 35 to 45%;
qc. 0 to 10%;
qd. 95 to 100%.
3. The use of surgical ultrasound devices has shown:
qa. A higher rate of Schneider’s sinus membrane perforation;
qb. No increase in patient satisfaction for rhinoplasty;
qc. A decrease in postsurgical morbidity;
qd. It can increase the need for secondary corrective rhinoplasties.
4. Piezotome:
qa. Is not able to cut dense bone;
qb. Reduces the risk of nerve damage;
qc. Decreases the time to perform an osteotomy;
qd. Increases the time of orthodontic treatments.
188 Stoma Edu J. 2021;8(3): 184-188 pISSN 2360-2406; eISSN 2502-0285