Periodontal Accelerated Osteogenic Orthodontics Technique for Rapid Orthodontic Tooth Movement: A Systematic Review.

AIM: The aim of this review was to analyze the data in the available literature regarding aspects of periodontally accelerated orthodontic therapy such as reduction in treatment time, variation in surgical techniques, and patient satisfaction.
MATERIALS AND METHODS: An internet-based search was performed for the articles published between January 2008 and August 2018 using keywords periodontal accelerated orthodontic tooth movement, corticotomy, bone grafting, tooth movement, and treatment duration. A total of 84 articles were obtained from MEDLINE and Embase search engines, of which 31 articles were eligible to be included for the systematic review.
RESULTS: On analysis, it was observed that the earlier studies were predominantly pertaining to case reports. In the later part of the decade considered in this review, it was observed that the emphasis was given to clinical and animal studies.
CONCLUSIONS: Most of the studies included in the review concluded that there was a significant reduction in orthodontic treatment duration using periodontal accelerated techniques compared to conventional orthodontic treatment.

INTRODUCTION

To achieve the orthodontic objectives of a functional and esthetic dentition, which most patients and clinicians desire for, orthodontic treatment must be performed. Orthodontic tooth movement can be brought by use of either fixed or removable appliances by applying different forces. Force when applied on to a tooth in a particular direction results in physiological tooth movement. Factors that play an important role in tooth movement are quality and quantity of force and treatment time. Along with this, knowledge about growth and development of dentofacial complex is essential. In today’s time, dental appearance is considered as an important feature while defining the facial appeal as it plays an important role in human social interactions.[1234] Recent reports have stated that there is a relationship between dental malocclusion, psychosocial well-being, and self-esteem.[5] In addition, current trend is that we have more of adult patients seeking ortho treatment in order to improve their facial appearance.[6789] It is estimated that the approximately 12–24 months is the time needed for comprehensive orthodontic treatment, which in turn depends upon severity, treatment plan, and individual characteristics. Prolonged treatment time means this can be an added risk factor for other dental problems such as root resorption, caries, and periodontal disease due to poor oral hygiene.[101112]

To reduce orthodontic treatment time due to patient demand, orthodontists have tried to accelerate tooth movement using various methods such as photobiomodulation,[13] pharmacological approaches,[14] and low-intensity laser irradiation.[15] Among all these procedures, surgical procedure, i.e., periodontally accelerated osteogenic orthodontics technique (PAOO), has widely been popularized[16] as it significantly reduced orthodontic treatment time.[1718]

What is periodontally accelerated osteogenic orthodontics?

It is a combination of periodontal and orthodontic treatment, which included surgical alveolar decortication followed by bone grafting and orthodontic treatment. The end results of this procedure lead to long-term improvement of the periodontium with reduction in orthodontic treatment time.[19] Name it decortication or corticotomy in simple terms, it means intentional cutting or injury of cortical bone.

Regional accelerating phenomenon (RAP) is the main biological mechanism behind the acceleration of orthodontic tooth movement, which was proven by most of the animal studies. RAP has been defined as a re-organization activity and physiologic event that happened next to the site of injury, resulting in regional reduction in bone density in the healthy tissue.[20]

The rationale behind this particular method comprises careful alveolar decortication, which is a form of periodontal tissue engineering causing transient osteopenia and high turnover adjacent to the injury site. Alveolar decortication initiates a healing response, the amount of which is directly related to the intensity and proximity of the surgical insult.

Historic view: L. C. Bryan (1892) was the first to treat malocclusion cases with the help of corticotomy procedure; later Heinrich Kole[11] reintroduced this procedure to correct malocclusion. Of late, Wilcko et al.[17] termed selective alveolar decortication combined with grafting and orthodontic treatment. They coined the term PAOO. Authors reported that 6–8 months were the time required to treat orthodontic cases with the help of PAOO surgery, which was quite faster than the conventional orthodontic treatment.[20]

Indications

It enhances alveolar bone volume and periodontium (i.e., correction of dehiscences and fenestrations).

Reduces treatment time (i.e., 3–4 times more rapid active orthodontic treatment).

Better posttreatment stability and a lesser amount of relapse.

Malocclusion treatment scope can be enhanced of (i.e., avoiding orthognathic surgery and extractions in selected cases).

Patient’s profile can be improved if needed.

Rapid recovery of impacted teeth (i.e., canines).

Contraindications

Thinner mandibular cortices

Patients with active periodontal disease or gingival recession

Palatal expansion

In the treatment of severe posterior cross-bite

Bimaxillary protrusion when accompanied with a gummy smile

Search strategy

This systematic review was conducted in the College of Dentistry, Gulf Medical University, Ajman, United Arab Emirates, between January 2008 and August 2018. A literature survey was conducted to identify all aspects of the studies that examined the effect, indications, and the biology of corticotomy. MEDLINE in process and other nonindexed citation, PubMed, and Embase reviews were searched. Keywords used included Periodontally Accelerated Orthodontic Tooth movement (PAOO), Corticotomy, Bone grafting, tooth movement, and treatment duration. Articles in the form of case reports, case series, and research studies were included in the review. Review articles were excluded. Only English language full-text articles were used as data source.

Eligibility criteria

Randomized controlled trials (RCTs), prospective controlled studies, and retrospective controlled trials were considered eligible to be included in the systematic review. The studies had to be in English language only, addressing at least some aspect of PAOO in both human and animals. Eligibility of potential studies was determined by reading the title and abstract of each article identified by the search, and then full texts of the articles were retrieved from the selected abstracts/titles. Two reviewers were assigned to review the full text of articles and were calibrated to use the review process adopted in this review. The data were categorized and tabulated into clinical studies [Table 1] and animal studies [Table 2].

Table 1

Clinical Studies

S.No	Authors	Study design	Case selection	Type of study	Study duration	Surgical procedure	Patient satisfaction	Conclusion
1	Thind et al.[21]	Case control study	Group I: 20 patients underwent PAOO treatment with surgical bur Group II: 20 patients underwent PAOO with piezocision	Orthodontic extraction space closure	Group I was 5 months and 2 weeks and for Group II was 7 months and 1 week	Study compared the effectiveness of corticotomy with surgical bur and piezocision	Not mentioned	Authors reported significant reduction in PAOO treatment duration with surgical bur on compared with PAOO piezosurgery in conventional orthodontic treatment
2	Brugnami et al.[22]	Retrospective analysis	Group I 79 patients corticotomy with bone graft and Group II surgically assisted orthodontics (corticotomy) without bone grafting	Decrowding and the patient sample included both Angle Class I and Class II malocclusion patients	Treatment time of 9 months	Corticotomy- facilitated orthodontic therapy with and without bone graft	Not mentioned	Authors concluded that corticotomy along with simultaneous bone grafting appears to be an effective technique to diminish the risk of marginal bone resorption and fenestration when a tooth is orthodontically inclined or moved toward, or even outside the cortical plane. In contrary corticotomy by itself, without concomitant bone grafting does not produce similar results
3	Addanki et al.[23]	Split-mouth study designed	16 patients were divided into 2 groups of 8 each	Angle’s Class I and Class II cases with first premolar extraction	Treatment time of 6 months	Buccal and palatal corticotomy compared with buccal corticotomy alone	Not mentioned	Authors reported that there was no significant difference in the duration of tooth between right and left arches with respect to bone density
4	Mahantesha et al.[24]	Case report	Two patients	Angle’s Class 1 malocclusion with maxillary protrusion of jaws	Time duration for first case was 4 months and second was for 5 months	Corticotomy was performed followed by placement of bone graft assisted with orthodontic treatment	Not mentioned	PAOO method in combination with selective decortications facilitated orthodontic technique and alveolar augmentation
5	Bahammam[25]	Single-masked clinical trial	33 orthodontic patients (20 women, 13 men; mean age 21.2 ± 1.43 (18– 27)	Treatment of adult patients with moderate crowding of the teeth	Duration of orthodontic treatment was markedly reduced for about 14 weeks in all groups	Study compared the effectiveness of a bovine-derived xenograft with that of bioactive glass when combined with PAOO	Not mentioned	PAOO decreases the duration of active treatment and reduces the risk of root resorption in adult patients. Use of a bovine- derived xenograft with modified corticotomy provided superior benefits in terms of increased bone density than did the use of bioactive glass
6	Awasthi et al.[26]	Case report	One patient	Anterior open bite and flared and spaced upper and lower incisors	The total treatment time was 41/2 with active period of 2 months	Orthodontic treatment combined with the modification in conventional wilckodontics technique	Not mentioned	The modified decortication technique reduced the treatment time to a considerable extent. The interdental spacing closed and optimum overjet and overbite was achieved
7	Charavet et al.[27]	RCT	24 adult patients	Adult patients presenting with mild overcrowdings	The overall treatment time was 7 months	Piezocision, which is a minimally invasive approach to corticotomy has been used in this study	Patient satisfaction was significantly better in the piezocision group than in the control group	The piezocision technique seemed to be effective in accelerating orthodontic tooth movement. No gingival recessions were observed. The risk of residual scars might limit the indications for piezocision in patients with a high smile line
8	Ahn et al.[28]	Case and control study	30 adult patients	30 Class III adult patients	Treatment time was 10.9 months in the control group and 8.7 months in the experimental group	Augmented corticotomy labial to the anterior mandibular roots: experimental group (with augmented corticotomy, n = 15) and control group (without augmented corticotomy, n = 15)	Not mentioned	Augmented corticotomy provided a favorable decompensation pattern of the mandibular incisors, preserving the periodontal structures surrounding the mandibular anterior teeth for skeletal Class III patients
9	Jahanbakhshi et al.[29]	Split-mouth design	15 adult female patients	Therapeutic need for extraction of maxillary first premolars and maximum canine retraction	Canine retraction was significantly higher on the corticotomy side than the control side by an average of 1.8 mm/month	Buccal corticotomy in accelerating maxillary canine retraction	Not mentioned	Corticotomy can accelerates the rate of orthodontic tooth movement about two times faster than conventional orthodontics and it is significant in early stages after surgical procedure
10	Munoz et al.[30]	A pilot prospective observational study	Cohort of 11 patients	Patients in need of orthodontic treatment	The average orthodontic treatment time was 9.3 months.	PAOO technique with leukocyte and platelet- rich fibrin (L-PRF) (incorporated into the graft and as covering membrane) was performed	Mild or moderate	L-PRF is simple and safe to use in PAOO. Combination with traditional bone grafts potentially accelerates wound healing and reduces postsurgical pain, inflammation, infection without interfering with tooth movement, and/ or postorthodontic stability, over a 2-year period
11	Abbas et al.[31]	Case and control study	20 patients (15– 25 years old)	Class II Division 1 malocclusions	Treatment time was for 12 weeks	Corticotomy- facilitated orthodontics (CFO) and piezocision in rapid canine retraction	Not mentioned	CFO and piezocision are efficient treatment modalities for accelerating canine retraction
12	Wu et al.[32]	Pilot study	Three young adult patients	Skeletal Class III surgical cases	The average total treatment time was 20.4 ± 2.4 months	After aligning and leveling the dental arches, a piezosurgical corticotomy was performed to the buccal aspect of the alveolar bone	Not mentioned	The facial aesthetics of three patients improved following multidisciplinary treatment. This approach may be an efficient method for the orthognathic patient who desires a reduced treatment time, but further clinical research is required
13	Sakthi et al.[33]	Case and Control study	40 adult patients	Bimaxillary protrusion requiring correction of bidental proclination	Average treatment time was 4 months	Corticotomy-assisted en masse orthodontic retraction	Not mentioned	The rate of retraction with study group was twice as faster when compared to the control group, accelerating during the first 2 months of retraction. There was better anchorage control with the undecorticated molar segment during the retraction period but was found to increase as time advanced.
14	Bhattacharya et al.[34]	RCT	Twenty patients (age>15 y)	Orthodontic treatment with upper anterior retraction in the extraction space of first premolar was selected	The mean time for the en masse retraction in the corticotomy group was found to be 131 ± 7.5 days, in comparison to 234 ± 9 days for the conventional technique	Corticotomy-assisted orthodontic tooth movement	Not mentioned	Alveolar corticotomies not only accelerates the orthodontic treatment but, also provides the advantage of increased alveolar width to support the teeth and overlying structures
15	Al-Naoum et al.[35]	Split-mouth design RCT	30 patients (15 males and 15 females)	Orthodontic treatment required canine retraction was included	Space closure was significantly faster on the experimental side than on the control side (mean = 0.74 mm/ week vs. 0.20 mm/ week between 1 week after and immediately after surgery	Corticotomy to facilitate tooth movement	50% and 30% of patients reporting severe pain at 1 and 3 days postoperatively	Alveolar corticotomy increased orthodontic tooth movement and was accompanied by moderate degrees of pain and discomfort
16	Krishnan et al.[36]		Patients between the age of 18 and 25 years	Retraction of anterior teeth	Average retraction time both maxillary and mandibular arches was of 9 weeks	Osteotomy with undermining of interseptal bone at the extraction site was performed	Not mentioned	This method of achieving faster en masse retraction immediately after extraction definitely reduced the initial retraction time. We recommend that such procedure must be carried out with appropriate anchorage conservation methods
17	Coscia et al.[37]		Fourteen patients (8 men, 6 women; mean age, 26.14 year)	Patients with surgical skeletal Class III	On average orthodontic treatment duration was of 8.23 ± 2.67 months	Augmented corticotomy plus accelerated orthodontic treatment	Not mentioned	This approach decreases the risk of the typical periodontal complications associated with traditional orthodontics, such as marginal bone loss and gingival recession
18	Yezdani [38]	Case report	29-year-old woman	Class I malocclusion and increased by dentoalveolar protrusion with increased spacing between the maxillary and mandibular incisors	Orthodontic treatment time was for 7 months	Selective alveolar decortication in conjunction with periodontal alveolar augmentation with a bone graft and rapid orthodontic tooth movement	Good	The rapid orthodontic tooth movement was attributed to the regional acceleratory phenomenon, triggered by selective alveolar decortication. The subsequent periodontal alveolar augmentation with the bone graft repaired the bony dehiscences and enhanced the bone volume and dramatically improved the patient’s soft tissue profile
19	Shoreibah et al.[39]	RCT	20 patients	Moderate crowding of the lower anterior teeth	Treatment duration 14–20 weeks	CFO	Not mentioned	CFO tooth movement using a further modified technique significantly reduces the total time of treatment
20	Choo et al.[40]		24 adults	With maxillary or bimaxillary protrusion	The average total treatment time was 20 months (range, 11–42 months).	Maxillary perisegmental corticotomy followed by the orthopedic en masse retraction against C-palatal miniplate anchorage	Not mentioned	Speedy surgical orthodontic treatment can be an effective modality for adults with severe maxillary protrusion
21	Wilcko and Wilko[1]	Case report	Two patients	Crowding and space closing	Treatment duration was 6 -7 months for two patients.	Orthodontics is combined with full-thickness flap reflection, selective alveolar decortication, ostectomy, and bone grafting	Not mentioned	The accelerated osteogenic orthodontics technique provides for efficient and stable orthodontic tooth movement
22	Nowzari et al.[41]	Case report	41-year-old man	With class II, division 2 crowded occlusion	Treatment time was 8 months	Use of particulate autogenous bone graft with the corticotomy- assisted rapid orthodontic procedure was carried out	Not mentioned	PAOO is an effective treatment approach in adults to decrease treatment time and reduce the risk of root resorption
23	Lee et al.[42]	Cohort study	65 Korean adult female patients	Bimaxillary dentoalveolar protrusion conditions	Treatment duration ranged between 14 and 27 months	Anterior segmental osteotomy, and corticotomy-assisted orthodontic treatment for resolution of bimaxillary dentoalveolar protrusion	Not mentioned	Orthodontic treatment or corticotomy- assisted orthodontic treatment is indicated for those with severe incisor proclination with normal basal bone position. Anterior segmental osteotomy is recommended for bimaxillary dentoalveolar protrusion patients with a gummy smile, basal bone prognathism, relatively normal incisor inclination, and relatively underdeveloped chin position

Table 2

Animal studies

S. No	Authors	Animals used for the study	Type of study	Methodology	Conclusion
1	Chen et al.[43]	40 rabbits	Split-mouth, randomized controlled experimental design	Left mandible was subjected to decortication- facilitated orthodontics, and right mandible underwent traditional orthodontics as a control. The animals were killed on the days 1, 3, 5, 7, and 14, after undergoing orthodontic procedures	Following alveolar decortication, osteoclastogenesis was initially induced to a greater degree than the new bone formation, which was thought to have caused a RAP. The amount of osteoclastogenesis in the decorticated alveolar bone was found to have two peaks, perhaps due to attenuated local resistance
2	Lee et al.[44]	Six male beagle dogs	Split-mouth, randomized controlled experimental design	Decortication was performed on the buccal bone surface of six male beagle dogs that were randomly assigned to receive grafts of deproteinized bovine bone mineral, irradiated cortical bone, or synthetic bone. Immediate orthodontic force was applied to the second and third premolars for buccal tipping for 6 weeks	All groups had considerable new bone formation on the pressure side. New bone formation on the buccal side and buccal plate formation in the coronal direction along the root surfaces were induced by the bone-derived and PDL-derived mesenchymal matrix, respectively. The angular change between groups was significantly different (P < 0.001). Augmented corticotomy using non-autogenous graft materials facilitated tooth movement without fenestrations and accelerated new bone formation on the pressure side
3	Ahn et al.[45]	20 beagles dogs	RCT	Surgical procedure: alveolar osteotomy alone (control) or osteotomy with bone graft (experimental group)	A bone graft into the surgical defect can not only allow immediate force application for accelerating orthodontic tooth movement with favorable periodontal regeneration, but also decrease the risk of inhibited orthodontic tooth movement in case of delayed force application after surgery.
4	Yuan et al.[46]	30 male adult Sprague-Dawley rats	Case and control study	Le Fort I osteotomies were performed on the left maxillas of one group. After surgery, a continuous force of 0.5 N was placed on the maxillary left first molar to move the tooth mesially. Other group served as controls were only orthodontic force was applies	Le Fort I osteotomy significantly accelerated the rate of orthodontic tooth movement. Histologically, more active and extensive bone remodeling was observed after osteotomy
5	Kim et al.[47]	Ten beagle dogs were divided into two groups.	Case and control study	Traditional orthodontic tooth movement was performed in the control group. In the experimental group, a piezotome was used to make cortical punctures penetrating the gingiva around the moving tooth	The cumulative tooth movement distance was greater in the piezopuncture group than in the control group: 3.26-fold in the maxilla and 2.45-fold in the mandible. Piezopuncture significantly accelerated the tooth movements at all observation times, and the acceleration was greatest during the first 2 weeks for the maxilla and the second week for the mandible. Anabolic activity was also increased by piezopuncture: 2.55-fold in the maxilla and 2.35-fold in the mandible
6	Baloul et al.[48]	114 Sprague- Dawley rats	RCT	Surgery was performed around the buccal and palatal aspects of the left maxillary first molar tooth and included five decortication dots on each side. Tooth movement was performed on the first molar using a 25-g Sentalloy spring	The data suggest that the alveolar decortication enhances the rate of tooth movement during the initial tooth displacement phase; this results in a coupled mechanism of bone resorption and bone formation during the earlier stages of treatment, and this mechanism underlies the rapid orthodontic tooth movement
7	Wang et al.[5]	36 rats were divided into 5 groups	RCT	Corticotomy	Corticotomy-assisted tooth movement produced transient bone resorption around the dental roots under tension; this was replaced by fibrous tissue after 21 days and by bone after 60 days
8	Sebaoun et al.[4]	36 healthy adult rats	Case and control study	Maxillary buccal and lingual cortical plates were injured in 36 healthy adult rats adjacent to the upper left first molars. Twenty-four animals were killed at 3, 7, or 11 weeks.	Selective alveolar decortication induced increased turnover of alveolar spongiosa, and the activity was localized; dramatic escalation of demineralization–remineralization dynamics is the likely biologic mechanism underlying rapid tooth movement following selective alveolar decortication

CONCLUSIONS

Due to the swift outcome of the treatment, adults shifting toward orthodontic treatment are more in number and forgo their taboos concerning the duration of treatment. PAOO is a technique that has many applications in the orthodontic treatment for adults because it helps to overcome many of the current limitations of conventional treatment, including lengthy duration, potential for periodontal complications, lack of growth, and the limited envelope of tooth movement. Further, randomized testing in humans is still necessary to confirm the claimed advantages of this technique and to evaluate the long-term effects of it. Interdisciplinary communication and proper coordination are essential for apt treatment planning and satisfying outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.