-
Effect of piezopuncture obone remodeling in dogs
Young-Seok Kim,a Su-Jung Kim,b Hyun-Joo Yoon,a PeterSeoul,
Korea, and Los Angeles, Calif
Introduction: The aim of the study was to elucidate
whethpiezopuncture, would be a logical modication for
acceleraMethods: Ten beagle dogs were divided into 2 groups. Trin
the control group. In the experimental group, a piezotomegingiva
around the moving tooth. Measurements were ma
s wethe popunreatalsoon tunc(Am
comthicincluundlatedaccephen
facilitated orthodontics1; therefore, development of
eeallyicaltoasonogm-tedl tones
activation that we called piezopuncture. In this proce-
resultant electrical eld; this creates alternating and per-
aPostgbAssisHee UcResid
All authors have completed and submitted the ICMJE Form for
Disclosure of Po-tential Conicts of Interest and none were
reported.
0889-5406/$36.00Copyright 2013 by the American Association of
Orthodontists.
ORIGINAL ARTICLEdure, an ultrasonic tool, a piezotome, is used
to createmultiple cortical punctures through the overlying
gingiva.The concept of ultrasonic osteotomy is based on the
so-called reciprocal piezo effect: voltage is applied to a
polar-ized piezo ceramic to deform a piezoelectric crystal in
the
Supported by Korea Ministry of Education, Science and Technology
(number2009-0092562).Reprint requests to: Young-Guk Park,
Department of Orthodontics, Kyung HeeUniversity, School of
Dentistry, 1 Hoegi-Dong, Seoul 130-701, Korea;
e-mail,[email protected], February 2012; revised and
accepted, January 2013.piezoelectric cortical incisions with
selective tunneling,which allows additional tissue grafting.
To overcome the insufciencies of these earlier proce-dures, we
conceived a novel procedure for cortical
at Los Angeles, Calif.dAssistant professor, Section of
Orthodontics, School of Dentistry, University ofCalifornia at Los
Angeles, Calif.eProfessor and chair, Department of Orthodontics,
School of Dentistry, KyungHee University, Seoul,
Korea.http:/plications has been a topic of special interest.
Full-kness ap elevation with extensive decortications,ding various
modications of corticotomies, areoubtedly effective in increasing
cellular activities re-
to tooth movement.1-3 The mechanism oflerated tooth movement by
a regional acceleratoryomenon depends mainly on transient
osteopenia
than cortical removal is required.Corticision (patent 0843344,
class 10; Kyung H
University, Seoul, Korea) was introduced as a miniminvasive
alternative for cortical activation.5,6 A cortincision made by
malleting a reinforced scalpelseparate the interproximal cortices
transmucosally wfound to induce the regional acceleratory
phenomeneffect for faster tooth movement in beagle dexperiments.5
To mitigate the patients' fear and discofort from repeated
malleting, Dibart et al7,8 suggespiezocision, a process that uses
an ultrasonic tooproduce the incisions. This procedure combi
raduate student, School of Dentistry, Kyung Hee University,
Seoul, Korea.tant professor, Department of Orthodontics, School of
Dentistry, Kyungniversity, Seoul, Korea.ent, Section of
Orthodontics, School of Dentistry, University of Californiaregional
acceleratory phenomenon that is less prone to a simple procedure
just for cortical activation ratherapposition rates from the
histomorphometric analysecumulative tooth movement distance was
greater infold in the maxilla and 2.45-fold in the mandible. Piezat
all observation times, and the acceleration was gsecond week for
the mandible. Anabolic activity wasand 2.35-fold in the mandible.
Conclusions: Basedand the mandible, the results of a clinical trial
of piezopa therapeutic benet for reducing treatment duration.
Various surgical interventions on the periodontaltissues have
been developed to accelerate ortho-dontic tooth movement. The
degree of inten-tional surgical damage needed to evoke a
long-lasting/dx.doi.org/10.1016/j.ajodo.2013.01.022n tooth movement
and
Joohak Lee,c Won Moon,d and Young-Guk Parke
er a newly developed, minimally invasive procedure,ting tooth
movement in the maxilla and the mandible.aditional orthodontic
tooth movement was performedwas used to make cortical punctures
penetrating thede in weeks 1 through 6. Tooth movement and bonere
evaluated by independent t tests. Results: Theiezopuncture group
than in the control group: 3.26-cture signicantly accelerated the
tooth movementsest during the rst 2 weeks for the maxilla and
theincreased by piezopuncture: 2.55-fold in the maxillahe different
effects of piezopuncture on the maxillature with optimized
protocols might give orthodontistsJ Orthod Dentofacial Orthop
2013;144:23-31)
by an accelerated demineralization-remineralizationprocess,
providing a more pliable environment,4 whichis distinct from bony
block movement in corticotomy-pendicular expansion and contraction
of the material.
23
-
unctuzopuingivg noen th
24 Kim et alBecause of its accurate and selective capability of
cuttingmineralized tissues without damaging adjacent soft tis-sues
and nerves, ultrasonic osteotomes were rst used inperiapical oral
surgery, including implantology9 and peri-odontology.10 These
transmucosal manipulations of alve-olar bone have minimized
morbidity and achieved similarresults tomore aggressive procedures,
including extensiveap elevation for rapid tooth movement.11,12
The aim of our study was to elucidate whether piezo-puncture
would elicit the regional acceleratory phenom-enon and accelerate
tooth movement without causingharmful tissue responses. The
acceleration rates of toothmovement and bone remodeling were
investigated andcompared between the maxilla and the mandible.
MATERIAL AND METHODS
Ten male beagles (age, 18-24 months; weight, 9-12
Fig 1. Orthodontic force application: A, piezopsecond premolar
movement in each jaw; B, pieof the second premolar, penetrating
overlying gwere found around the puncture sites, showintitanium
closed-coil springs were activated betweage teeth. xxx, Specimen
collection sites.kg) were housed in separate cages supplied with a
self-washing system, air conditioning, and lighting accord-ing to
the guidelines of the Institutional Animal Careand Use Committee,
Kyung-Hee University Medical Cen-ter. The dogs were randomly
divided into 2 groups: con-trol (n 5 4) and piezopuncture (n 5 6).
These groupswere further divided into 3 subgroups based on
theduration of force application: group I, 14 days (control,n5 1;
piezopuncture, n5 2); group II, 28 days (control,n 5 1;
piezopuncture, n 5 2); and group III, 42 days(control, n5 2;
piezopuncture, n5 2). Each animal pro-vided 4 specimens (1 each
from the right and left sides ofboth jaws), and the maxillary and
mandibular specimens(n 5 20 for each jaw) were randomly divided
into 2groups. Animals in the control group received orthodon-tic
force alone, and the animals in the piezopuncturegroup received
orthodontic force with piezopuncture.The animals were killed at 2,
4, and 6 weeks after theinterventions.
July 2013 Vol 144 Issue 1 AmericanThe target teeth in both
arches were the second pre-molars; however, the anchorage teeth in
each arch wereselected differently because of anatomic limitation.
Inthe maxillary arch, the second premolars were protractedagainst
the canines as the anchorage, whereas the sec-ond premolars were
retracted against the third premolarsin the mandibular arch.
Orthodontic buttons (Ormco,Orange, Calif) connected by a lever arm
were bondedon the labial surfaces of all experimental teeth
withSuper-Bond C&B resin (Sun Medical, Shiga, Japan).
Anickel-titanium closed-coil spring (Tomy International,Tokyo,
Japan) was activated and ligated between the le-ver arms of the
target teeth and the anchorage teeth. Forreinforcing anchorages,
resin bridges were constructedon the adjacent teeth. The
orthodontic force by the ap-pliance was 100 g at the beginning of
the experiment.Tooth movement was allowed for 6 weeks. Force
magni-
re procedure: arrows indicate the direction ofncture was
performed on the mesiobuccal sidea into the cortical bone; white
ring-like lesionslethal damage on the soft tissues; C, nickel-e
lever arms of the target teeth and the anchor-tude was measured
using a force gauge (Haag-Streit,Koeniz, Switzerland) once a week
with reactivation ofthe appliance to maintain a continuous force
(Fig 1, A).
For piezopuncture, a piezosurgical instrument witha sharp curved
tip (Endo2 insert, ProUltra; DentsplyMaillefer, Ballaigues,
Switzerland) was used to performthe cortical punctures penetrating
the gingiva. Thedepth of cortical injury was 3 mm, by holding the
tipperpendicular to the gingiva for 5 seconds undersaline-solution
irrigation. The setting selected for eachpuncture was in accordance
with the manufacturer'srecommendation. Piezopunctures were
performed onthe mesiobuccal, distobuccal, mesiolingual, and
disto-lingual sides of the second premolars (Fig 1, B).
Sixteenpunctures were made on 1 target tooth. Gentamicin(7.5 mg/kg)
was injected postoperatively for 3 days.Tooth brushing and daily
hexamedine (Bukwang, Seoul,South Korea) irrigation were repeated
during thepostoperative care.
Journal of Orthodontics and Dentofacial Orthopedics
-
each
move94516 0.022716 0.80054z
66586 0.115236 0.20041z
\0.00
cture
Kim et al 25Table I. Accumulative distances of tooth movements
in
Jaw Group Beagle site Second premolarMaxilla Control (A) A1-RT
0.7
A1-LT 0.7A2-RT 0.6A2-LT 0.7Mean 0.72
Piezopuncture (B) B1-RT 2.6B1-LT 3.3B2-RT 1.5B2-LT 1.7Mean 2.31P
value 0.0
Mandible Control (A) A1-RT 0.5A1-LT 0.7A2-RT 0.3A2-LT 0.3Mean
0.51
Piezopuncture (B) B1-RT 1.7B1-LT 1.3B2-RT 1.1B2-LT 1.1Mean 1.33P
value 0.0
Independent t test was performed (mean 6 SD, *P\0.05; y\0.01;
z
anchor teeth were the third premolar and the rst molar.A1, First
control beagle; A2, second control beagle; B1, rst piezopunTooth
movement was measured by a digital caliper(Mitutoyo, Kawasaki,
Japan) on the stone models oncea week. In the maxillary arch, the
distance from the me-sial cervix of the third premolar to the
mesial cervix of themoved second premolar was measured over time.
In ad-dition, the distance of canine retraction as an
anchoragetooth was measured from the mesial cervix of the
thirdpremolar to consider the rate of tooth movement asthe relative
ratio. In the mandibular arch, the distancefrom the mesial cervix
of the canine to the mesial cervixof the moved second premolar was
measured, and theprotracted distance of the anchored third premolar
wasalso measured from the same reference. The relativevalues of the
distance of the moved teeth divided bythe distances of the
anchorage teeth were compared be-tween the groups.
Histologic analysis was performed on the decalciedspecimens at
2, 4, and 6 weeks. Tissue blocks includingthe second premolar with
surrounding alveolar bone andthe injury site were decalcied with
10% EDTA-2Na (pH7.4) at 48C for 30 days. The specimens were
resected at3 to 4 mm below the alveolar crest with thicknesses of
6mm. The sections were stained with hematoxylin andeosin for
descriptive histology.
Quantitative histomorphometric analysis was doneon the
nondecalcied specimens of the dogs in the 6-week groups. One
experimental animal and 1 control
American Journal of Orthodontics and Dentofacial Orthopedgroup
at 6 weeks after orthodontic force application
ment, A (mm) Anchor tooth movement, B (mm) Ratio (A/B)0.98
0.811.12 0.661.15 0.571.10 0.65
6 1.09 6 0.07 0.67 6 0.101.01 2.591.07 3.101.28 1.231.07
1.60
2 1.11 6 0.12 2.13 6 0.860.27102 0.00215y
0.38 1.470.59 1.290.28 1.250.35 1.09
9 0.40 6 0.13 1.28 6 0.160.31 5.520.56 2.410.58 1.930.39
2.90
8 0.46 6 0.13 3.19 6 1.600.55436 0.04373*
1). In the maxilla, the anchor tooth was canine; in the
mandible, the
beagle; B2, second piezopuncture beagle; RT, right side; LT,
left side.animal were randomly selected. They had been
intra-muscularly injected with 3 uorochoromes as
follows:oxytetracycline hydrochloride (yellow orange, 30 mg/kg;
Fluka Chemie AG, Buchs, Switzerland) at 24 hoursbefore intervention
and at 6 weeks after intervention;calcein (green, 10 mg/kg; Fluka
Chemie AG) at 2 weeksafter intervention; and alizarin red (red, 30
mg/kg; FlukaChemie AG) at 4 weeks after intervention. Specimenswere
taken from 8 sampling sites in each jaw. Thesespecimens were
longitudinally sectioned parallel to thedirection of orthodontic
traction and examined underan ultraviolet uorescence microscope
(BH-2; Olympus,Tokyo, Japan) with an ultraviolet lter (l 5 515
nm).Microphotographs of all specimens were recorded usinga digital
CCD camera (PS30C ImageBase; Kappa Op-tronics, Gleichen, Germany).
The outlines of labeledbones were traced from the photographs, and
the dis-tances between the labeled lines were measured with im-age
analysis software (ImageBase Metreo 2.5; KappaOptronics).
Statistical analysis
Descriptive statistics were represented as means andstandard
deviations for all parameters in each group.The normality of the
data was assessed with theKolmogorov-Smirnov test. Statistical
homogeneity waschecked using the Levene test. Independent t
tests
ics July 2013 Vol 144 Issue 1
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26 Kim et alwere used to evaluate the intergroup differences of
themean tooth movement distances on the models andthe mean
accumulated new bone deposition measuredby histomorphometric
analysis. Values of P \0.05were considered statistically
signicant.
RESULTS
The mean cumulative distances of tooth movementfor 6 weeks as
well as the ratios of target tooth move-ment to anchorage loss were
signicantly increased inthe piezopuncture groups as opposed to the
controlgroups in both the maxilla and the mandible (TableI). The
distance of the maxillary second premolar move-ment in the
piezopuncture group (2.31 6 0.82 mm)was 3.26-fold greater than that
in the control group(0.72 6 0.06 mm). The distance of the
mandibular sec-ond premolar movement in the piezopuncture
group(1.33 6 0.28 mm) was 2.45-fold greater than that inthe control
group (0.51 6 0.19 mm). There was no sig-nicant difference in the
amount of anchorage toothmovement between the piezopuncture group
(maxilla,1.11 6 0.12 mm; mandible, 0.46 6 0.13 mm) andthe control
group (maxilla, 1.09 6 0.07 mm; mandible,0.40 6 0.13 mm). The
relative ratios of maxillary toothmovement were 2.15 6 0.98 in the
piezopuncture
Fig 2. Accumulated tooth movement distances and m
July 2013 Vol 144 Issue 1 Americangroup and 0.66 6 0.02 in the
control group. The ratiosof mandibular tooth movement were 3.30 6
1.03 inthe piezopuncture group and 1.35 6 0.75 in thecontrol
group.
With respect to movement rate, the rst 2 weeks inthe maxilla and
the second week in the mandible hadthe greatest movement (Fig 2).
The weekly velocity oftooth movement in the piezopuncture group was
largerthan that in the control group at all observation times.The
increasing pattern of the accumulated distances oftooth movement in
the piezopuncture group showedno remarkable stagnation indicating
the lag phase.
Descriptive histologic ndings on the compressionsides of moving
teeth are shown in Figure 3. At week2, the periodontal ligament was
compressed and locallydegenerated into hyalinization in the control
group,where no apparent resorptive ndings on the alveolarsurfaces
were observed (Fig 3, A). In the piezopuncturegroup, osteoclasts
with the resorption lacunae alongthe bone surfaces were seen near
hyalinized areas ofthe periodontal ligament (Fig 3, B). At week 4,
indirectresorption followed by the removal of the
hyalinizedperiodontal ligament was found in the control group(Fig
3, C), whereas direct resorption by active bone-resorbing cells
continued in the piezopuncture group
ovement rates in the maxilla and the mandible.
Journal of Orthodontics and Dentofacial Orthopedics
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Kim et al 27(Fig 3, D). At week 6, the number and the activity
ofbone-resorbing cells were decreased, showing sparse re-sorption
areas on the bone surface with focal hyaliniza-tion in the control
group (Fig 3, E), whereas the ndingsof direct bony resorption with
the cellular periodontalligament were as before in the
piezopuncture group(Fig 3, F). There were no recognizable
differences ofthe time-dependent histologic responses between
themaxilla and the mandible.
Fig 3. Microphotographs of periodontal tissues on thetrol group
at 2 weeks;B, piezopuncture group at 2 weegroup at 4 weeks; E,
control group at 6 weeks; F, piezoresorption lacunae with
bone-resorbing cells along tgroups, hyalinization was found at 2
and 6 weeks, anOn the contrary, in the piezopuncture groups,
directtimes without remarkable hyalinization. B, Alveolar botion.
Original magnication: 200 times.
American Journal of Orthodontics and Dentofacial
OrthopedFluorescent microscopic ndings of anabolic boneremodeling
on the tension sides of the moving teeth(Fig 4) showed
correspondence with rate of tooth move-ment. The accumulated
distance of newly mineralizedbone apposition during 6 weeks was
signicantly greaterin the piezopuncture group than in the control
group(Table II). In the maxilla, the mean apposition lengthof the
piezopuncture group was 2.55-fold greater thanthat of the control
group. The distance between the rst
pressure sides of the second premolars:A, con-ks;C, control
group at 4 weeks;D, piezopuncturepuncture group at 6 weeks. The
arrows indicatehe compressed alveolar surface. In the controld
indirect resorption was observed at 4 weeks.bone resorption was
evident at all observationne; P, periodontal ligament; R, root; H,
hyaliniza-
ics July 2013 Vol 144 Issue 1
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els o
28 Kim et alFig 4. Fluorescent microphotographs of bone
labyellow line (oxytetracycline at 24 hours before interven-tion)
and the red line (alizarin red at 4 weeks) was strik-ingly
increased in the maxillary piezopuncture group. Inthe mandible, the
mean apposition length in the piezo-puncture group was 2.35-fold
greater than that in thecontrol group. The distance between the
green line (cal-cein at 2 weeks) and the second yellow line
(oxytetracy-cline at 6 weeks) was remarkably increased in
themandibular piezopuncture group.
DISCUSSION
This beagle study shows that a newly developed sup-plemental
procedure, piezopuncture, accelerated therate of orthodontic tooth
movement and the remodelingprocess of alveolar bone without causing
collateral dam-age. Earlier and greater effects of piezopuncture
wereobserved in the maxilla than in the mandible.
Piezopuncture was developed to increase patientcompliance by
minimizing discomfort during and after
maxillary bone apposition in the control group; B, mamandibular
apposition in the control group; D, mandibcumulated distances
between the bone-labeled linegroups than in the control groups in
both jaws. Earlierserved in the maxilla compared with the mandible.
Or
Table II. Mean accumulated distances of new bone appositiosion
side
Jaw Group Weeks 0-2 (mm/wk)Maxilla Control 44.44 6 30.27
Piezopuncture 122.89 6 23.12Mandible Control 35.18 6 13.02
Piezopuncture 98.56 6 24.58
Distances were measured from the nondecalcied specimens in the
6-weekcontrol animal were randomly selected (means 6 SD were
calculated from s
July 2013 Vol 144 Issue 1 Americann the tension sides of the
second premolars: A,surgery, and to simplify the procedure for
orthodontists.Piezopuncture uses a piezotome, which acts as a light
ul-trasonic scaler. Unlike the previous surgical interven-tions,
piezopuncture eliminates the use bonemalleting, which can be
frightening to the patient, andthe soft-tissue incision and
suture.1-5 In contrast tocorticision,5 such an approach for
minimizing tissuedamage, and the intensity and duration of the
regionalacceleratory phenomenon, might not be sufcient tofunction
throughout the entire orthodontic treatment.13
However, this problem could be eliminated by
repeatedapplications at regular intervals; this would be more
fa-vorable for the patients' convenience than more aggres-sive
methods.
The action mechanism of piezopuncture is based onthe biologic
concept of cortical activation rather thancortical removal.14 Most
previous corticotomy-facilitated orthodontic treatments were
designed to re-sect the cortical barrier, depending on the
mechanical
xillary apposition in the piezopuncture group; C,ular apposition
in the piezopuncture group. Ac-s are signicantly longer in the
piezopunctureand larger responses to piezopuncture were ob-iginal
magnication: 100 times.
n in both arches indicated by uorescence on the ten-
Weeks 2-4 (mm /wk) Weeks 4-6 (mm/wk)56.09 6 8.52 78.35 6
7.31
158.09 6 38.09 116.00 6 17.2545.17 6 15.08 25.55 6 7.34
148.07 6 39.68 123.18 6 6.60
groups; 8 sampling sites in each jaw of 1 experimental animal
and 1ampling sites of each jaw).
Journal of Orthodontics and Dentofacial Orthopedics
-
d bos werthe m
Kim et al 29concept of the cortex. The use of a minimal
interventionto achieve an objective suggests a keen knowledge of
theregional acceleratory phenomenon physiology and a re-spect for a
discrete surgical technique. Garg15 empha-sized that the regional
acceleratory phenomenon isinitiated mainly by trauma to the
cortical bone. The cor-tex is regarded as a necessary matrix for
rapid toothmovement, not an obstacle.3,15 Only cortical
activationcan increase osteoclastic activity around theperiodontal
ligament, facilitating bone turnovertoward an osteoporotic state
with less tissue resistanceto tooth movement. Teixeira et al16
suggested that os-teoperforation placed far from the tooth could
acceler-
Fig 5. Mean apposition rates of newly mineralizePeak velocity
periods in the piezopuncture groupweeks 4 to 6 was higher in the
mandible than inate the rate of tooth movement, reected by
anincreased level of inammatory cytokine expression, fol-lowed by
extensive osteoporotic changes. In addition tothis conceptual
change, understanding the 2-sided char-acteristic of inammation has
enabled the continuousadvancement of supplemental surgical
techniques withminimal and conservative interventions.
Piezosurgical incisions have been reported to besafe and
effective in osseous surgeries, such as prepros-thetic surgery,
alveolar crest expansion, and sinusgrafting.17-21 Because of its
micrometric and selectivecut, the piezosurgical knife is said to
aid safe andprecise osteotomies without osteonecrotic
damage.Vercellotti and Podesta21 used a piezosurgical techniquefor
periodontally accelerated orthodontic tooth move-ment. Dibart et
al7,8 introduced piezocision asa modied method of corticision for
rapid orthodontictooth movement. Piezocision is different
frompiezopuncture in that it requires soft-tissue incisionswith a
blade and routine tissue grafting with the blindedtunneling
technique. Grafting mimics the accelerated
American Journal of Orthodontics and Dentofacial
Orthopedosteogenic orthodontic treatments in the studies ofWilko et
al2 and Murphy et al,3 which need to be dis-cussed separately from
cortical activation. Additionally,the previous evaluations on
piezoelectricity for acceler-ating tooth movement, based on
clinical reports, havenot yet provided biologic evidence.
This beagle experiment elucidated that the corticalactivation by
piezopuncture accelerated tooth move-ment signicantly at each
observation time. Since ortho-dontic tooth movement aims to restore
the balance byremodeling the periodontal ligament, it is
reasonableto assess the timing of bone apposition in
conjunctionwith tooth movement.22 To explore the anabolic
ne on the tension sides of the second premolars.e at 2 to 4
weeks in both jaws, and the velocity inaxilla.mechanism in response
to tooth movement with corticalactivation, it was prudent to
analyze the uorochrome-labeled lines histomorphometrically. The
rates of toothmovement in the control group showed no
remarkableincrease until 5 weeks after intervention, accompaniedby
increased rates of new bone apposition in 4 to 6weeks. On the other
hand, the piezopuncture groupshowed earlier acceleration of tooth
movement in therst 2 weeks after intervention, followed by
signicantlyincreased rates of new bone apposition during
laterweeks. This acceleration of tooth movement could alsobe
supported by different catabolic activities betweenthe 2 groups,
even though it was not based on quantita-tive analysis. Extensive
hyalinization with little bone re-sorptive activity, indicating the
biologic lag phase oftooth movement, was remarkable at 2 and 6
weeks inthe control group, whereas direct bone resorption
con-tinued at all experimental periods in the piezopuncturegroup
without evidence of a lag phase.23-25 Themechanism of bypassing the
lag phase indicates lessproduction and faster elimination of
hyalinization, and
ics July 2013 Vol 144 Issue 1
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be effective to facilitate tooth movement, and the effect
30 Kim et alit is mentioned in the study of Baloul et al22 about
selec-tive alveolar decortication; this corresponds to our re-sults
of a less invasive cortical puncture.
The acceleration effect of piezopuncture was faster inthe
maxilla than in the mandible. Deguchi et al26 re-ported that
orthodontic tooth movement progressed 2weeks faster in the maxilla
than in the mandible, andthat higher rates of tooth movement in the
maxillawere found at 4 through 6 weeks. In our
study,piezopuncture-assisted tooth movement advanced 1week faster
in the maxilla than in the mandible. The pie-zopuncture group
demonstrated a peak in tooth move-ment at weeks 1 and 2 in the
maxilla and weeks 2 and3 in the mandible, and peaks in bone
apposition ratewere at weeks 2 through 4 in the maxilla and weeks
2through 6 in the mandible (Fig 5). Although the absoluteamount of
bonemass is stable during conventional toothmovement, even with
highly dynamic metabolic activity,a transient osteoporotic state
occurs during surgically fa-cilitated tooth movement.2,22 Because
of the differencesof bone density and metabolism between the jaws,
themaxillary teeth should be regarded as more sensitive tothe
regional acceleratory phenomenon by corticalactivation than are the
mandibular teeth. Nevertheless,the mean ratio of target tooth
movement to theanchorage tooth movement was higher in the
mandiblethan in the maxilla; this contradicts the result
ofcomparing the distances of the target teeth themselves.This
discrepancy can be explained because the meanamount of anchorage
tooth movement was greater inthe maxilla than in the mandible. This
might imply thatthe accelerating effect of piezopuncture was
moreextensive to the anchorage part in the maxilla but wasrather
localized on the target tooth area in themandible. It should be
also considered that our beaglemodel included mesial movement of
the maxillarysecond premolars and distal movement of themandibular
second premolars, depending on thedifferent anchorage values.
Tooth movement with or without surgical interven-tion is a
combined process of osteoclastic and osteoblas-tic activities in
response to external stimulation.27,28 It isnot clear yet whether
tooth movement by surgicalstimulation follows the same mechanism
asconventional tooth movement, or whether a differentbiologic
pathway is involved. Nonetheless, a superiorcondition of surgically
assisted tooth movement is thatthe tooth goes through the
osteoporotic alveolar boneof a less tissue-resistant environment.
We had presup-posed that the biologic mechanisms underlying
rapidtooth movement by cortical puncture would be
similar to the previously reported
demineralization-remineralization process of decortication.29
Although
July 2013 Vol 144 Issue 1 Americanwas greater and faster in the
maxilla than in the mandi-ble. Simultaneously, the regional
acceleratory phenome-non effect was more extensive in the maxilla;
hence,reinforcement of the anchorage part is needed in
clinicalapplications.
With further studies on the development of pro-longed
acceleration of tooth movement over time, thelimitations of
minimally invasive surgical proceduresshould be complemented and
modied toward clinicalefciency. Based on the different acceleratory
effectsof piezopuncture on the maxilla and the mandible,a clinical
trial of repeated piezopuncture with optimizedapplication intervals
and force adjustments would giveorthodontists a great therapeutic
benet in the contextof reducing treatment durations.
CONCLUSIONS
This study introduced a novel periorthodontic tech-nique,
piezopuncture, which enables rapid tooth move-ment without damaging
side effects. This techniqueinvolves puncturing of the cortical
bone with a piezosur-gical regimen. Piezopuncture was found to
evoke rapidtooth movement by accelerating the rate of alveolarbone
remodeling. The acceleration of orthodontic toothmovement
associated with piezopuncture was expli-cated by increased bone
turnover through the regionalacceleratory phenomenon.
Although further studies on the optimal power rangeof a
piezosurgical device to induce a regional accelera-tory phenomenon
with orthodontic tooth movementare suggested for secure clinical
applications, piezo-puncture might have a great therapeutic benet
in thecontext of reducing treatment duration and also peri-odontal
regeneration in its best extent. This develop-ment is expected to
bring orthodontics closer to thegoal of efciency in tooth movement,
without causingpatient discomfort or damage to the teeth and their
sup-porting tissues.
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Periodontol2008;79:1679-88.ics July 2013 Vol 144 Issue 1
Effect of piezopuncture on tooth movement and bone remodeling in
dogsMaterial and methodsStatistical analysis
ResultsDiscussionConclusionsReferences