Original Article

Comparison of the effectiveness of piezocision-aided canine retraction

augmented with micro-osteoperforation: a randomized controlled trial
Seerab Husaina; Shantha Sundarib

ABSTRACT

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Objective: To evaluate the effectiveness of micro-osteoperforation (MOP) on the rate of piezoci-
sion-aided canine retraction (CR).
Materials and Methods: The split-mouth study included 25 participants at the stage of com-
mencing CR. The participants received flapless piezocision bilaterally at T0 (0 months) and MOP
only on one side at T3 (3 months). The quadrant that received MOP at T3 served as the interven-
tion, whereas the other quadrant served as the control. The primary outcome was the rate of CR,
assessed using digital models. The angular change (AC) of the canine and the change in the
buccal cortical bone thickness (BCBT) from before to after CR were also assessed using cone
beam computed tomography.
Results: The rate of CR was 0.82 6 0.39 mm/month in the control quadrant vs 0.75 6 0.44 mm/
month in the intervention quadrant (P . .05). The AC of the canine was 2.00° 6 0.88° in the con-
trol quadrant vs 1.98° 6 0.86° in the intervention quadrant (P . .05). The crestal bone gain was
0.50 mm in the control quadrant vs 0.28 mm of bone loss in the intervention quadrant. The bone
thickness at a 3-mm height was increased by 0.11 mm in the control quadrant vs a 0.29-mm
decrease in the intervention quadrant. The bone thickness at a 6-mm height was decreased by
0.12 mm in the control quadrant vs a 0.15-mm decrease in the intervention quadrant. However,
none of the changes or group differences in bone height or thickness were statistically significant
(P . .05).
Conclusions: The periodic activation of a piezocision-aided CR site using MOP had no signifi-
cant positive effect on the rate of CR, angulation of the canine, or changes in BCBT. (Angle
Orthod. 2024;94:17–24.)
KEY WORDS: Interradicular mini-implant; Canine retraction; Piezocision; Micro-osteoperforation

INTRODUCTION
Orthodontic retraction is a complex procedure that
requires a complete understanding of biomechanics to
a
Postgraduate Student, Department of Orthodontics and bring about optimal space closure with minimal side
Dentofacial Orthopaedics, Saveetha Dental College and Hospital, effects.1 It is also the longest stage in orthodontic mech-
Saveetha Institute of Medical and Technical Sciences (SIMATS), anotherapy, taking as long as 20 months or even longer
Chennai, Tamil Nadu, India. in certain cases.2 A longer treatment duration brings the
b
Professor, Department of Orthodontics and Dentofacial
Orthopaedics, Saveetha Dental College and Hospital, Saveetha risk of patient fatigue, root resorption, white spot lesions,
Institute of Medical and Technical Sciences (SIMATS), Chennai, and pulpal and periodontal changes.3
Tamil Nadu, India. Acceleration of Orthodontic Tooth Movement (OTM)
Corresponding author: Dr Seerab Husain, Postgraduate, has been achieved through various means such as
Department of Orthodontics and Dentofacial Orthopaedics, pharmacological and physical/mechanical stimulation
Saveetha Dental College and Hospital, Saveetha Institute of
Medical and Technical Sciences (SIMATS), No 162, Poonamallee and surgical intervention.4 Pharmacological agents
High Road, Velappanchavadi, Chennai, Tamil Nadu 600077, India such as prostaglandin, relaxin, vitamin D3, platelet-rich
(e-mail: [email protected]) fibrin, and platelet-rich plasma have been used in sev-
Accepted: September 2023. Submitted: May 2023. eral studies to demonstrate the acceleration of OTM.5
Published Online: October 16, 2023 Physical methods of accelerating OTM involve the use of
Ó 2024 by The EH Angle Education and Research Foundation, Inc. low-level laser therapy, photobiomodulation, vibrations,

DOI: 10.2319/052323-370.1 17 Angle Orthodontist, Vol 94, No 1, 2024

18 HUSAIN, SUNDARI

and magnets. However, these modalities have shown guidelines (Figure 1). The study was approved by the
conflicting results, and the available evidence is of low Institutional Review Board and Human Ethical Committee
quality.5,6 of the Saveetha Institute of Medical and Technical Sci-
The concept of accelerated orthodontics is based ences (SIMATS) (SRB/SDC/ORTHO-1805/20/TH-01).
on the regional acceleratory phenomenon (RAP) by The trial was registered with the CTRI (identifier CTRI/
which any noxious stimulus or regional injury to a par- 2022/01/039275). Informed consent was obtained from
ticular site evokes the RAP. The intensity and site of the participants before the commencement of the study.
action of this phenomenon, however, are highly vari-
able among different individuals.7 Eligibility Criteria and Participant Preparation
In the late 1950s, Kole was the first to introduce the
Inclusion criteria:
concept of corticotomy in orthodontics to hasten

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OTM.8 Although corticotomy has been shown to have 1. Permanent dentition and age group of 18–35 years.
good results, it is an invasive surgical procedure that 2. Required fixed orthodontic treatment.
involves elevation of a mucoperiosteal flap.9 Piezoci- 3. Maximum anchorage requirement in the maxilla.
sion is a minimally invasive procedure that utilizes pie- 4. Bimaxillary protrusion and Class I malocclusion for
zoelectric incisions in the cortex to accelerate OTM.10 whom first premolars were extracted in both arches.
Several studies have reported the efficacy of piezoci- 5. Class II malocclusion for whom maxillary first pre-
sion in the acceleration of OTM and stated that a two- molars were extracted for camouflage treatment.
fold increase in the rate of OTM was observed.10,11
The most recent development in search of a mini- Exclusion criteria:
mally invasive procedure to accelerate OTM has been
micro-osteoperforation (MOP).12 MOPs are monocort- 1. Mixed dentition and under 18 years of age for
ical micropunctures placed at various depths in the whom adequate bone density would not have been
alveolar process to initiate the expression of inflamma- established.
tory markers to hasten the process of OTM.13,14 MOP 2. Missing teeth or abnormal tooth morphology.
has shown a 2.3-fold increase in the rate of OTM.12,14 3. History of orthodontic treatment.
However, recent human trials have shown conflicting 4. Systemic problem or bone pathology.
results regarding the effectiveness of MOP in the
acceleration of OTM.13,15 All of the participants were treated with a preadjusted
The acceleratory effect of these surgical and mini- edgewise appliance system: 3M Unitek Gemini metal
mally invasive procedures is believed to last for brackets (3M, Monrovia, Calif, USA), with a slot size of
about 4 months, during which the rate of OTM is 0.022 3 0.028 inches. The participants were recruited
increased.16 After this period, there is a need to after leveling and aligning to 0.019 3 0.025-inch stain-
reactivate the site for further acceleration of OTM. less steel archwires. All participants had a stainless steel
Hence, the aim of this study was to evaluate the self-drilling interradicular implant of 1.5 3 8 mm in diame-
effectiveness of MOP-augmented piezocision on the ter placed between the upper second premolar and the
rate of canine retraction (CR). first molar bilaterally. CBCT images of the maxillary arch
for each subject in natural head position, without arch-
Specific Objectives and Hypotheses wires, were taken 6 months apart at T0 (0 months) and
T6 (6 months) (Carestream 9600, Kodak CS imaging
The primary outcome of this study was to assess 8.0.18, Atlanta, Ga). The CBCT was standardized with a
the rate of CR using digital models. The secondary field of view of 8/5 mm, a tube current of 4 mA, a peak
outcome was to assess the buccal cortical bone thick- voltage of 120 kVp, and an exposure time of 15 seconds.
ness (BCBT) and the angular changes (ACs) of the
canine as observed with cone beam computed tomog- Piezocision at T0
raphy (CBCT). The null hypothesis was that there
would be no difference between the rates of CR All participants received flapless piezocision, admin-
assisted by piezocision with and without MOP. istered at T0, in the buccal cortical plate of the maxil-
lary first premolar extraction space bilaterally, using
MATERIALS AND METHODS Piezotome Solo (Satelec, Acteon Group, Merignac,
France). A Piezotome 2 BS1 slim bone surgery tip
Trial Design and Settings
was used to place a single vertical piezocision, of 5
This was a prospective, split-mouth, single-center, sin- mm in length and 5 mm in depth, starting 2 mm above
gle-blind, randomized controlled trial with a 1:1 allocation the alveolar crest (Figure 2). Postpiezocision, CR was
ratio according to the CONSORT statement reporting initiated on the same day using a 6-mm NiTi closed

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PACR AUGMENTED WITH MOP 19

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Figure 1. CONSORT flowchart.

coil spring. The magnitude of force was 150 g per side determined by the blinded opaque envelopes. MOP
as measured by a Dontrix tension gauge (Ortho Care, was administered using a sterile stainless steel mini-
West Yorkshire, UK) (Figure 3). implant of 1.5 3 8 mm in diameter. A periodontal
probe was used to measure the gingival thickness,
Intervention at T3 and a rubber stopper was used to demarcate the
amount of mini-implant depth that had to be pene-
At T3 (3 months), participants received the interven- trated transmucosally to achieve a 5-mm bone punc-
tion (MOP) in the quadrant selected based on the side ture. Under local anesthesia, 3 MOPs were placed in

Figure 2. Piezocision in the buccal cortical plate of the maxillary

first-premolar extraction space. Figure 3. CR using 6-mm NiTi coil springs.

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Figure 4. MOP placed using a mini-implant. Figure 6. Linear measurement derived from a constructed horizon-
tal plane bisecting the most convex portion of the canine.
the buccal cortical plate of the maxillary first premo-
lar extraction space. Each MOP was 5 mm deep Sample Size Calculation
and with an interval of 3 mm between each other
Sample size calculation was done using G*Power
(Figure 4).
Software Version 3.0.10 (Franz Faul, Universität Kiel,
Germany) software with a power of 90%. A sample
Measurements
size of 23 participants (n ¼ 23/group) was obtained.
Digital models were scanned using Trios 3Shape soft- An additional 2 participants (n ¼ 2/group) were added
ware (3shape A/S, Copenhagen, Denmark) at every to compensate for any attrition.
appointment. Three-point surface superimpositions of the
digital models were done at T0, T3, and T6 using the third
Random Sequence Generation and Blinding
rugae as a reliable landmark (Figure 5). The horizontal
cross-sectional view was used for linear measurement of Randomization was done with computer-generated
the rate of CR, derived from a constructed horizontal random numbers by using Random Allocation software
plane bisecting at the level of the most convex portions of 2.0 (Informer Technologies Inc, https://www.informer.
the canine and the second premolar (Figure 6). com). Allocation concealment was done using opaque
The AC of the canine was measured from the CBCT envelopes. Blinding of the patients and the operator was
images using Dolphin Imaging software version 11 (Dol- not possible because of the nature of the study. Blinding
phin Imaging & Management Solutions, Chatsworth, of the outcome assessor was done through data con-
Calif, USA) (Figure 7). The angular measurements were cealment during the assessment.
made using the long axis of the canine and palatal plane
as references. The BCBTs at T0 and T6 were measured
Interim Analyses
using RadiAnt Dicom Viewer software (Medixant,
Poznan, Poland). The canine was oriented by construct- An intent-to-treat analysis was done, so all of the
ing a vertical plane along the long axis of the canine and data for the participants regardless of the treatment
a Constructed Horizontal Plane (CHP) extending across outcome were included in the analysis. This consisted
the buccal and palatal Cementoenamel Junction (CEJ). of the analysis of all of the participants who were
The BCBT was measured at 3- and 6-mm heights entered into the trial for whom baseline data and final
from the CHP (Figure 8). records were available.

Figure 5. Three-point surface superimposition of the digital models at the third rugae. (A) At T3. (B) At T6. (C) Superimposition of the T3 and
T6 digital models.

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PACR AUGMENTED WITH MOP 21

Figure 7. AC in the canine from T0–T6 measured using the palatal plane Anterior Nasal Spine (ANS) - Posterior Nasal Spine (PNS) as the
reference plane and the long axis of the canine. (A) Right side. (B) Left side.

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Statistical Analysis and Data Presentation RESULTS
All of the statistical analyses were performed using Participant Flow
IBM SPSS software version 23 (IBM Corp, Armonk, Thirty patients (17 men and 13 women) with a mean
NY). The mean and standard deviation for each digital age of 24.6 6 5.7 years were assessed for eligibility,
model and radiographic variables were determined. among whom 5 were excluded. The intraoral quad-
For parametric statistical tests, independent or unpaired rants of these 25 patients were randomized in a 1:1
Student’s t tests were used for the rate of CR, AC, and ratio to either the MOP activation quadrant (interven-
BCBT. A confidence level larger than 5% was consid- tion quadrant) or the non-MOP activation quadrant
ered statistically not significant. The intraclass correla- (control quadrant). Two patients were lost to follow-up.
tion test was used to assess intra- and interobserver Inter- and intraobserver reliability showed excellent
agreement. correlation (intraclass correlation . 0.98).

Figure 8. BCBT measured at 3-mm and 6-mm heights using the long axis of the canine and buccolingual CEJ points used as the vertical and
horizontal reference planes.

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22 HUSAIN, SUNDARI

Table 1. Comparison of the Rates of Canine Retraction From T3 to T6 Between the Groups Treated Using Piezocision With and Without MOP
Group Number of Samples Mean Rate, mm/Month Standard Deviation P Value
Control—without MOP 25 0.82275 0.3965 .496
Intervention—with MOP 25 0.746 0.4485

Numbers Analyzed for Each Outcome has shown promising results in increasing the rate of
OTM.10,11 Although minimally invasive, the effect of
The control quadrant showed a mean CR rate of
piezocision has been reported to be short-lived and
0.82 6 0.39 mm per month. The intervention quadrant
requires periodic reactivation.7 Therefore, a minimally
showed a mean CR rate of 0.75 6 0.44 mm per
invasive procedure such as MOP could potentially be

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month. The difference between the control and inter-
used to augment the RAP in the piezocision site and
vention groups, however, was not statistically signifi-
further increase the rate of OTM for a longer duration.
cant (P ¼ .496) (Table 1). Evidence on the rate of CR with MOP has been con-
The control quadrant showed a mean AC of 2.00° 6 troversial. Several authors have conducted human tri-
0.88°. The intervention quadrant showed a mean AC als on MOP and reported a two- to threefold increase
of 1.98° 6 0.86°. The difference between the groups, in the rate of CR.12,19 Other authors using split-mouth
however, was not statistically significant (P ¼ .644) study designs reported that MOP did not increase the
(Table 2). rate of CR.13,20 A systematic review of MOP reported
The control quadrant showed a mean increase in that there was no significant increase in the rate of
the crestal bone height of 0.50 mm, which was not sta- OTM during short-term observation.15 The reason for
tistically significant (P ¼ .810). The bone thickness at such diverse results, however, has not been ade-
a 3-mm height from the CEJ was increased by 0.11 quately documented in any of these studies.
mm, which was not statistically significant (P ¼ .245). The results of this study showed that the overall
The bone thickness at a 6-mm height from the CEJ treatment changes in relation to the linear and angular
was decreased by 0.12 mm, which was also not statis- measurements as well as the BCBT changes were
tically significant (P ¼ .875). similar in both groups. Special attention was given to
The intervention quadrant showed a mean decrease the rate of individual CR from T3 to T6 since this was
in the crestal bone of 0.28 mm, which was not statisti- the time when the participants received the MOP.
cally significant (P ¼ .163). The bone thickness at a 3- From T3 to T6, there was no significant difference in
mm height from the CEJ was decreased by 0.29 mm, the rate of CR. Similar results were reported previ-
which was not statistically significant (P ¼ .964). The ously by Aboalnaga et al., who stated that the mean
bone thickness at a 6-mm height from the CEJ was rate of CR was 0.99 6 0.3 mm/month in both groups.13
decreased by 0.15 mm, which was also not statisti- Alkebsi et al. also reported no significant difference in
cally significant (P ¼ .664) (Table 3). the rate of CR in subjects receiving three MOPs.20
Fattori et al. showed that there was no significant dif-
Harms ference in the rate of OTM in participants receiving
No serious harms were observed. Some gingival MOP and also reported a negative impact on the oral
health–related quality of life.21 Alqadasi et al. reported
overgrowth and inflammation occurred, mainly due to
no significant difference in the rate of OTM with MOPs
irritation from the NiTi coil springs during individual CR.
at a 3-month interval.22 In their systematic review,
Sivarajan et al. reported on the inability of a single
DISCUSSION
application of MOP to accelerate OTM.15 However, it
Corticotomy has been considered to be the gold was also suggested that multiple applications of MOP
standard in increasing the rate of OTM. Several stud- could be effective in accelerating OTM over a longer
ies have consistently reported its effectiveness in has- observation period.15,19
tening OTM.17,18 However, it is still considered to be This study also showed no significant difference
an invasive procedure. As an alternative, piezocision in the AC of the canine in both groups. This was in

Table 2. Comparison of the Angular Changes of the Canine From T0 to T6 Between the Groups Treated Using Piezocision With and Without
MOP
Group Number of Samples Mean Degree Standard Deviation P Value
Control—without MOP 25 2.0040 0.83690 .644
Intervention—with MOP 25 1.9840 0.86152

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PACR AUGMENTED WITH MOP 23

Table 3. Comparison of the Changes in Buccal Cortical Bone Thickness in the Groups Treated Using Piezocision With and Without MOP
Between T0 and T6
Parameter Group Number of samples Mean Standard Deviation P Value
Control—Without MOP
Crestal bone height Pretreatment 25 1.9760 2.59898 .810
Posttreatment 25 1.4740 3.01905
Bone thickness at 3 mm from CEJ Pretreatment 25 0.7510 0.42270 .245
Posttreatment 25 0.8620 0.58021
Bone thickness at 6 mm from CEJ Pretreatment 25 0.6730 0.39536 .875
Posttreatment 25 0.5560 0.40330
Intervention—With MOP
Crestal bone height Pretreatment 25 2.37 2.552 .163
Posttreatment 25 2.65 3.205

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Bone thickness at 3 mm from CEJ Pretreatment 25 0.7490 0.51492 .964
Posttreatment 25 0.4600 0.43742
Bone thickness at 6 mm from CEJ Pretreatment 25 0.6540 0.48275 .664
Posttreatment 25 0.5060 0.34284

agreement with the results of other studies comparing CONCLUSIONS

MOP to a control group, which also showed no signifi- • There is no significant difference in the rate of piezo-
cant difference in the AC of the canine postretrac-
cision-aided CR with or without MOP.
tion.20,22 This could also be attributed to the fact that • There is no significant difference in the AC of the
CR was carried out on a rigid 0.019 3 0.025-inch stain-
canine postretraction.
less steel (SS) wire using a 0.022-inch slot McLaughlin, • There are no significant changes seen in the BCBT.
Bennett, Trevisi (MBT) prescription brackets, which
offered minimal allowance for tipping under controlled ACKNOWLEDGMENTS
gradual forces.
In terms of changes in BCBT, there was no significant We thank the director, Dr Deepak Nallaswamy; the Head
difference observed between the groups, indicating that of the Department, Dr Aravind Kumar; the anonymous
reviewers for their useful suggestions; and our colleagues
the changes in BCBT and crestal height were minimal.
for their undying support and encouragement throughout the
Agrawal et al., however, showed that there was a signifi-
course of this study.
cant increase in BCBT in the corticotomy as well as the
MOP groups.23 However, their study involved the place-
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