ORIGINAL ARTICLE

Evaluation of corticotomy-facilitated
orthodontics and piezocision in rapid canine
retraction
Noha Hussein Abbas,a Noha Ezzat Sabet,b and Islam Tarek Hassanc
Cairo, Egypt

Introduction: The purpose of this study was to evaluate the efciency of corticotomy-facilitated orthodontics and
piezocision in rapid canine retraction. Methods: The sample consisted of 20 patients (15-25 years old) with
Class II Division 1 malocclusions. The suggested treatment plan was extraction of the maxillary rst premolars
with subsequent canine retraction. The sample was divided into 2 equal groups. In the rst group, 1 side of the
maxillary arch was randomly chosen for treatment with corticotomy, and in the second group, piezocision treatment was used. The contralateral sides of both groups served as the controls. Cuts and perforations were
performed with a piezotome, and canine retraction was initiated bilaterally in both groups with closed-coil
nickel-titanium springs that applied 150 g of force on each side. The following variables were examined over
a 3-month follow-up period: rate of canine crown tip, molar anchorage loss, canine rotation, canine
inclination, canine root resorption, plaque index, gingival index, probing depth, attachment level, and gingival
recession. The rate of canine crown tip was assessed every 2 weeks after the start of canine retraction at 6
time points. Results: The rates of canine crown tip were greater in the experimental sides than in the control
sides in both groups. Corticotomies produced greater rates of canine movement than did piezocision at 4
time points. Canine root resorption was greater in the control sides. The remaining studied variables exhibited
no differences between the control and the experimental sides. Conclusions: Corticotomy-facilitated orthodontics and piezocision are efcient treatment modalities for accelerating canine retraction. (Am J Orthod
Dentofacial Orthop 2016;149:473-80)

he long duration of orthodontic treatment is one

of the most frequent complaints of orthodontic
patients; it results from the use of traditional
mechanical forces to induce movement by stimulation
of resorption modeling in the paradental tissues.
Recently, it has been claimed that mechanical force is
not the only stimulus that can induce tooth movement.
The use of pharmaceutical,1,2 electromagnetic,3,4 laser,5
and surgical stimuli6-8 to accelerate orthodontic tooth
movement has attracted considerable scientic
interest. Over the years, several surgical techniques

From the Orthodontic Department, Faculty of Dentistry, Ain Shams University,

Cairo, Egypt.
a
Lecturer.
b
Professor.
c
Associate professor.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conicts of Interest, and none were reported.
Address correspondence to: Noha Hussein Abbas, 9 Hamouda Mahmoud St, Nasr
City, Cairo, Egypt; e-mail, dr_nohahussein@asfd.asu.edu.eg.
Submitted, March 2014; revised and accepted, September 2015.
0889-5406/$36.00
Copyright 2016 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.09.029

have been developed to reduce the overall treatment

time. Thus, the use of supplemental dentoalveolar
surgeries to accelerate tooth movement has been
recommended.
Distal canine movement is the core time-consuming
procedure for premolar extraction patients. Conventional techniques result in canine retraction rates of 0.5
to 1 mm per month, depending on the patient's age
and sex. Therefore, full canine retraction can require 5
to 9 months. Conventional treatments with xed
appliances are likely to require 1.5 to 2 years.
For rapid canine retraction, Liou and Huang6
proposed periodontal ligament distraction. Some
researchers have reported the use of dentoalveolar
distraction based on the principles of distraction
osteogenesis7; others have used selective alveolar
decortication and claimed that this procedure invokes
transient osteopenia.8 Modied surgical techniques
have been reported to be effective in reducing clinical
orthodontic treatment times.
Corticotomy or decortication simply refers to the
intentional cutting of cortical bone. The technique has
been claimed to dramatically reduce the treatment
473

Abbas, Sabet, and Hassan

474

time because the resistance of the dense cortical bone to

orthodontic tooth movement is eliminated.9-13 This
decreased resistance has been explained by the
underlying regional acceleratory phenomenon (RAP)
that occurs after a wound; RAP involves the
recruitment of osteoclasts and osteoblasts to the
injured site for wound healing, which leads to a
transient localized demineralization-remineralization
phenomenon in the bony alveolar housing.14
Moreover, it has been stated that corticotomyfacilitated orthodontics decreases the undesirable
adverse effects of orthodontic treatment including root
resorption and periodontal damage.11 The combination
of augmentation grafting with corticotomy increases
alveolar volume, which results in signicantly more
attached gingiva and aids the repair of alveolar cortical
bone fenestrations and dehiscences. The grafting increases the scope of orthodontic tooth movement
because it enables greater tooth movement into stable
positions.15 The main drawback of corticotomy is its
minimal acceptance by patients because of the aggressiveness of these procedures, which increase postoperative discomfort and the risk of complications.16
Corticision was introduced as a supplemental dentoalveolar surgery in orthodontic therapy to achieve
accelerated tooth movement with minimal surgical
intervention. Park et al,17 followed by Kim et al,18 introduced the corticision technique as a minimally invasive
alternative to the creation of surgical injuries to the
bone that do not involve ap reection. In this technique, the authors used a reinforced scalpel and a mallet
to pass through the gingiva and cortical bone without
raising a ap.
Thereafter, a piezosurgical knife was used to spare
the patient the stressful procedure of malletting; this
corticision procedure was termed piezocision. Piezocision is a new minimally invasive procedure in which a
microsurgical blade is used to make gingival microincisions, and piezoelectric incisions of the cortical alveolar
bone are then made with an ultrasonic piezosurgical
knife. This procedure has recently been reported to
be safe and effective in osseous surgeries, such as preprosthetic surgery, alveolar crest expansion, and sinus
grafting.19
Compared with conventional burs, the use of a piezoelectric knife enhances bone healing without causing osteonecrotic damage and facilitates the preservation of
root integrity because of its precise, selective cutting action.20 Furthermore, because the piezoelectric knife
works only on mineralized tissues, it spares the soft tissues and their blood supplies. Hard tissue or soft tissue
grafting can be combined with piezocision via selective
tunneling, which allows for the correction of gingival

April 2016  Vol 149  Issue 4

recessions and bone deciencies. This procedure is not

feasible with corticision. Piezocision has successfully
been used for the rapid treatment of Class II21 and Class
III22 patients and has been combined with lingual orthodontics23 and the Invisalign system24 to achieve both
esthetic and rapid treatment.
Because few studies have addressed the effects of
corticotomy and piezocision on canine retraction, this
study was performed to investigate the potentials of corticotomy and piezocision to accelerate canine retraction
and to compare these 2 techniques to determine whether
corticotomy can be replaced with the less-invasive piezocision. We also aimed to determine the types of canine
movement and any adverse effects that are associated
with these 2 techniques. The study was designed to
test the null hypothesis that the rates of canine retraction elicited by the conventional method, corticotomy,
and piezocision are the same.
MATERIAL AND METHODS

This study had approval from the ethical committee

of the faculty of dentistry of Ain Shams University, Cairo,
Egypt.
The sample consisted of 20 patients with full complements of permanent teeth that necessitated maxillary
rst premolar extractions and subsequent canine retractions. All patients fullled the following criteria: age, 15
to 25 years; Class II Division 1 malocclusion with mild or
no crowding; no previous orthodontic treatment; no
systemic disease that might have affected bone formation or density, such as osteoporosis, hyperparathyroidism, or vitamin D deciency; adequate oral hygiene;
probing depth values not exceeding 3 mm across the
entire dentition; adequate thickness of the attached
gingiva (1-2 mm); and no radiographic evidence of
bone loss. The patients were equally and randomly
divided into 2 groups: a corticotomy group in which corticotomy was randomly assigned to 1 side of the maxillary arch (experimental side), and a piezocision group in
which piezocision was randomly assigned to 1 side of the
maxillary arch (experimental side). The randomization
was performed with coin tosses to prevent selection
bias. The sides contralateral to the procedures served
as the controls in both groups.
The initial phase of leveling and alignment was rst
completed with a straight wire 0.022-in slot Roth appliance. On the day before the surgery, 1 maxillary premolar was randomly selected and extracted, and the other
premolar was extracted on the day of the surgery; this
procedure was implemented to spare the patient the
stress of having 2 bleeding sites at the same time and
the discomfort of a prolonged procedure.

American Journal of Orthodontics and Dentofacial Orthopedics

Abbas, Sabet, and Hassan

[F1-4/C]

[F2-4/C]

[F3-4/C]

Corticotomy entails ap reection followed by cuts

and perforations in the cortical bone. To preserve the
papillae, a submarginal ap was used, where the incision
was performed 4 mm apical to the free gingival margin.
A number 15 blade in a Bard Parker blade handle
(Paragon, Shefeld, United Kingdom) was used to
make a buccal incision that followed the contours of
the gingiva and extended from the mesial surface of
the maxillary lateral incisor to the mesial surface of the
maxillary second premolar. A vertical releasing incision
was then made, and a full-thickness mucoperiosteal
ap was elevated via a mucoperiosteal elevator; this
ap was extended beyond the apex of the canine. Using
a piezotome (VarioSurg3; NSK, Tokyo, Japan) (Fig 1),
bone activation was accomplished with vertical cuts
and perforations. The vertical cuts were made along
the mesial and distal aspects of the canine root starting
2 to 3 mm below the alveolar crest to protect the crestal
bone, and the perforations were made facially along the
length of the canine root (Fig 2). The depths of the holes
were conrmed by the drop felt when the cancellous
bone was reached. The piezotome was used to remove
the bundle bone from the mesial wall of the extraction
socket of the premolar to decrease the resistance to
tooth movement in the desired direction. Thereafter,
the ap was repositioned and sutured with nonresorbable 4-0 black silk with the interrupted technique.
Piezocision involves gingival microincisions and vertical cortical cuts without ap reection. Interproximal
incisions were made through the gingiva on the
mesiobuccal and distobuccal line angles of the canine
with a number 15 blade in a Bard Parker blade handle.
The incisions were made 2 mm below the papillae to
preserve the papillae. With the same piezotome, the
cortical alveolar incisions were created interproximally
(Fig 3). The surgical injury was made 2 mm short of
the alveolar crest to preserve the crestal bone and was
then extended to the entire length of the canine root.
The piezotome was used to remove the bundle bone
from the mesial wall of the extraction socket of the
premolar to decrease the resistance to tooth movement
in the desired direction. The incisions were then sutured
with nonresorbable 4-0 black silk with the interrupted
technique.
Based on the assumption that the RAP induced by the
buccal corticotomy would readily involve the noncorticotomized palatal side, the surgeries were performed
only on the buccal cortical plate of the bone to reduce
the operation time and the patients' postoperative
discomfort.8
In both groups, a 0.016 3 0.022-in stainless steel
wire was tied back immediately after the surgery, and
nickel-titanium closed-coil springs that applied 150 g

475

Fig 1. The piezotome used in this study.

Fig 2. Cortical perforations and vertical cuts in the buccal

cortical plate of the bone.

of pressure on each side were used for canine retraction.

Canine retraction began immediately after the surgery to
take advantage of the RAP induced by bone injury. The
coil springs were stretched between the canine and the
molar band hooks where the maxillary rst permanent
molar and second premolar were ligated together and
designated as the anchor unit (Fig 4). The retraction [F4-4/C]
force was measured using a strain gauge (Dentaurum,
Ispringen, Germany), and the force was calibrated for
readjustment at each visit (biweekly). The problem of
the transient nature of the RAP was managed by adjusting the orthodontic appliance every 2 weeks to use the
continuous mechanical stimulation of the teeth to prolong the osteopenic effect induced by the procedure.
The total follow-up period after the start of the
canine retraction was 3 months. Impressions were taken
every 2 weeks, and the casts were scanned using a

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Abbas, Sabet, and Hassan

476

Fig 5. A scanned cast showing the reference lines, the

midpalatine raphe (MPR) and the rugae line (RL) formed
by a projection from the most medial point on the third
right rugae. dc, The distance between the cusp tip of
the canine and the rugae line used to measure the anteroposterior canine movement; dm, the distance between
the mesial contact point of the rst permanent molar and
the rugae line used to measure molar movement; a, the
angle between the median raphe and the line through
the mesial and distal edges of the canine used to measure canine rotation.

Fig 3. Corticision lines.

assessed by evaluating the plaque index and the gingival

index according to the method of Loe26; moreover,
probing depth, attachment level, and gingival recession
were recorded.
Statistical analysis

Fig 4. Closed-coil nickel-titanium spring stretched between the canine and the anchor unit. A, Control side;
B, piezocision side.

[F5-4/C]

[F6-4/C]

atbed scanner. The anteroposterior crown tip movements of the canines were assessed at 6 time points
(T1-T6) with the method described by Ziegler and Ingervall.25 The casts were also used to assess the anchorage
loss of the rst molars and the canine rotation (Fig 5).
Cone-beam computed tomography scans taken before
and at the end of canine retraction were used to assess
the changes in canine inclination and canine root
resorption. The angle between the palatal plane and
the long axis of the canine was measured before and after canine retraction (Fig 6). Periodontal health was

April 2016  Vol 149  Issue 4

For the parametric variables, Student t tests were

used for comparisons between the 2 experimental sides
of the 2 studied groups, and paired t tests were used
to compare the experimental and control sides within
each group. For the nonparametric variables, MannWhitney U tests were used for comparisons of the 2
experimental sides of the 2 groups, and Wilcoxon signed
rank tests were used to compare the experimental and
control sides within each group. A repeated-measures
analysis of variance test was used to study the changes
in canine movement over time. Tukey post hoc tests
were used for pairwise comparisons between the
different periods when the analysis of variance test
showed signicant differences.
RESULTS

The rates of canine crown tip were greater (P \0.05)

in the experimental sides than in the control sides in
both groups (Table I). The corticotomy side exhibited
signicantly greater rates of canine crown tip than did
the piezocision side at T1, T2, T5, and T6 (Fig 7).
[F7-4/C]

American Journal of Orthodontics and Dentofacial Orthopedics

Abbas, Sabet, and Hassan

Fig 6. Cone-beam computed tomography sagittal section showing the angle between the palatal plane and
the long axis of the canine that was used to assess canine
inclination: A, before canine retraction; and B, after
canine retraction.

[F8-4/C]

Although canine crown tipping was observed in all

sides, there were no differences between the experimental and control sides or the 2 experimental sides in
canine inclination, canine rotation, or molar movement
(Table II), and no differences in any of the periodontal
readings (P .0.05) in either the corticotomy or the piezocision groups, as measured before the start of canine
retraction and 3 months after canine retraction.
Although there was no difference between the 2 experimental sides in canine root resorption, in both groups
the control side exhibited greater canine root resorption
than did the experimental side (Fig 8).
DISCUSSION

To address the demands of orthodontic patients

to decrease treatment time, corticotomy-facilitated

477

orthodontics (the most commonly used technique for

accelerating tooth movement) and piezocision
(a recently developed technique) were studied to assess
the advantages and disadvantages of each technique.
The rate of canine crown tip was signicantly greater
in the experimental side than in the control side during
the entire follow-up period. These ndings agree with
those of Wilcko et al,8 Lino et al,27 Ren et al,28 and
Moon et al,29 who reported that tooth movement velocity on the corticotomy side is twice as fast as that on the
control side.
The corticotomy group exhibited greater rates of
canine crown tip in the rst and third months than did
the piezocision group; these differences might be attributable to the more extensive surgery required for the
corticotomy procedure that might have enhanced the
RAP. This supposition agrees with the ndings of Frost30
and Wilcko et al,31 who demonstrated that the severity of
bone injury is directly correlated with the intensity of
bone healing and the rapidity of tooth movement.
The increase in the rate of canine crown tip as the
retraction proceeded can be explained by the ability of
the orthodontic force to prolong the RAP; ie, more
RAP is induced as the tooth moves, and this increases
the rate of canine movement.32 The acceleration of
canine retraction did not surpass the lag phase of molar
movement as occurs during periodontal distraction.
Consequently, the surgical procedures seemed to have
no effect on anchorage control.
The experimental sides exhibited less root resorption
than did the control sides; this is consistent with the
ndings of Generson et al,10 Suya,13 Wilcko and Wilcko,8
and Moon et al,29 who reported that teeth retain their
vitality without any evidence of resorption after corticotomy surgery. The increased osteoclastic activity and
decreased bone density that are associated with RAP
osteopenia decrease the likelihood of hyalinization necrosis and root resorption.27 In contrast, Gantes et al11
reported notable apical root resorption on periapical
radiographs associated with corticotomy-facilitated
orthodontics. However, the magnication errors and
2-dimensional limitations of periapical lm make
this technique inappropriate for estimations of root
resorption.
The use of a 0.016 3 0.022-in wire in a 0.022-in slot
might lead to uncontrolled tipping of the canines in all
sides. However, this study proved that neither canine
inclination nor rotation was different between the surgical and the conventional sides.
In contrast to the ndings of Lindhe,33 Bell and
Levy,34 and Yaffe et al,14 who reported slight interdental
bone losses, decreases in attached gingiva, and periodontal defects, we observed no signicant adverse

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Abbas, Sabet, and Hassan

478

Table I. Means, standard deviations, and results of paired t tests for comparisons between canine crown movement in

the experimental and control sides in the groups at 2-week intervals (T1-T6)
Corticotomy
Experimental
Period
2 wk (T1)
4 wk (T2)
6 wk (T3)
8 wk (T4)
10 wk (T5)
12 wk (T6)

Mean (mm)
0.5
0.6
0.7
0.78
0.94
1.22

Piezocision
Control

SD
0.07
0.07
0.12
0.1
0.05
0.08

Mean (mm)
0.24
0.34
0.42
0.46
0.52
0.58

Experimental
SD
0.05
0.08
0.08
0.11
0.04
0.04

Mean (mm)
0.40
0.50
0.60
0.70
0.84
0.99

Control
SD
0.07
0.07
0.12
0.12
0.05
0.10

Mean (mm)
0.25
0.30
0.40
0.45
0.55
0.60

SD
0.07
0.08
0.06
0.09
0.04
0.04

P value
\0.001*
\0.001*
\0.001*
\0.001*
\0.001*
\0.001*

*Signicant at P #0.05.

Fig 7. Mean canine movements of the experimental sides.

Table II. Means, standard deviations, and results of paired t tests for comparisons between molar movement, canine

rotation, and canine inclination in the experimental and control sides in the groups
Experimental

Molar movement (mm)

Canine rotation ( )
Canine inclination ( )

Side group
Corticotomy
Piezocision
Piezocision
Corticision
Corticotomy
Piezocision

Mean
2.99
3
0.65
0.7
2.75
2.89

Control
SD
0.55
0.38
0.47
0.35
1.16
1.2

Mean
3.13
3.25
0.5
0.58
2.1
2.23

SD
0.42
0.52
0.39
0.41
0.91
0.95

P value*
0.346
0.221
0.434
0.38
0.146
0.146

Measured before canine retraction and 3 months after canine retraction.

*Signicant at P \0.05.

effects on the periodontium after corticotomy. Our

observations agree with those of Gantes et al,11
Wilcko et al,8 and Lino et al.27 The following factors
augmented the preservation of the periodontium: (1)
the substitution of the conventional intrasulcular ap
design of the corticotomy surgery with the submarginal

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ap; (2) the start of the vertical cuts 2 to 3 mm below the

alveolar crest; (3) the manner of bone removal in which
the bone was only perforated, and the original bony
architecture remained intact; and (4) no heavy
orthodontic forces that might have induced extensive
bone resorption.

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Abbas, Sabet, and Hassan

479

Fig 8. Bar graph showing the comparisons between mean canine root resorptions of the experimental
and control sides of both groups.

The piezocision technique proposed here resulted in

clinical outcomes that were similar to those of the classic
decortication approach, but the piezocision technique
had the additional advantages of being minimally invasive, precise, and less traumatic for the patient. However,
this technique was time-consuming because of the
decreased cutting efciency of the piezotome blades
relative to conventional burs.
CONCLUSIONS

Corticotomy-facilitated orthodontics and piezocision

are effective treatment alternatives that decrease the
time required for canine retraction and decrease root
resorption in adults. Corticotomy-facilitated orthodontics is 1.5 to 2 times faster than conventional orthodontics. Piezocision was 1.5 times faster than conventional
orthodontics.
SUPPLEMENTARY DATA

Supplementary data related to this article can

be found at http://dx.doi.org/10.1016/j.ajodo.2015.09.
029.
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