A new trial on making teeth move faster with Piezosurgery. You don’t always get want you want…

There are several new techniques that we can use to attempt to make teeth move faster. This new trial looks at the pretty invasive technique of piezosurgery.

Piezocision is a “minimally” invasive technique to accelerate tooth movement. This involves causing trauma to the alveolar bone during a course of orthodontic treatment. A team from Turkey and Massachusetts, USA did this study. The EJO published their paper.

Efficiency of piezosurgery technique in miniscrew supported en-masse retraction: a single-centre, randomized controlled trial

Nilüfer İrem Tunçer et al

European Journal of Orthodontics, 2017, 586–594

doi:10.1093/ejo/cjx015

These investigators wanted to study the effect of piezosurgery on the rate of overjet reduction using en masse mechanics with and without piezocision. They also looked at the effect of the intervention on various biomarkers. I will simply concentrate on the rate of tooth movement because I think that this is the most clinically relevant outcome.

What did they do?

They did a single centre parallel allocation 1:1 randomised clinical trial.

The PICO was:

Participants: 30 orthodontic patients aged 14 years old and above requiring upper and lower fixed appliance treatment with the extraction of four premolars

Intervention: Piezosurgery

Comparator: Treatment as usual, no piezosurgery

Outcome: En masse retraction rates of premolar space closure. The investigators measured this directly in the mouth using digital calipers at days 15, 30, 60, 90 and 120 after piezosurgery. This measurement was not blinded.

They also analysed cephalograms taken immediately before piezosurgery, after 28 days and at the end of space closure.

They did a clear sample size calculation and used a randomisation based on sealed envelopes. The patients selected the envelopes after they had agreed to take part in the study. The ceph data was blinded but the intra oral measurement of space closure was not.

Some readers may not be familiar with piezosurgery. This involves:

1          Giving a local anaesthetic

2          Making incisions in the buccal mucosa

3          Making bone cuts 3mm deep in the alveolar bone between all the anterior teeth

4          Stitching everything back again

5          Pain control advice, application of ice bags for 24 hours.

Here is a nice video of this on YouTube

To be honest I am not sure if this can be described as minimally invasive?

What did they find?

After they measured the rates of space closure and analysed many variables from the cephalograms, they found no difference between the groups. Importantly, they did not find any evidence that piezocision influenced the rate of tooth movement.

What did I think?

I thought that this trial was an interesting study. Unfortunately, there was a major problem with the blinding of data collection. It was not clear whether the person who measured the premolar spaces was blinded to treatment allocation. If the investigator was aware of the treatment allocation this study is at high risk of bias. I mailed the author about this and she confirmed that this was the case. She also pointed out that if they had taken study casts at all the data collection points this would have added to the experimental burden of the patients.

I have thought about this carefully and when I looked at the overjet reduction and molar movement from the cephalograms there was also no differences. As a result, I felt that we can conclude that there were no cephalometric differences in the effect of the interventions. There was an absence of evidence for the effect of piezosurgery.

In summary, my main thoughts are that there are issues with the methodology, particularly with blinding. However, piezocision does not look much fun for our patients. As a result, I would hope to see clear clinically significant effects for this intervention. This is not the case for this study.

I have also reviewed other studies on piezocision and they have all showed no or minimal effects.  I would not even think about doing this. Does anyone?

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  1. Kevin
    I do not really care if these techniques speed up or not premolar retraction. I am n=more interested in knowing if we could theoretically torque the roots with less force and fewer side effects by weakening the buccal plate. I think these experimental designs fail to address the real potential of these devices. There is more to orthodontics than canine retraction especially with the significant increase of adult orthodontics.

    • Please check the article below from JCO.
      Adult case with severe root torquing, and intrusion. No root resorption etc..
      Journal of clinical orthodontics
      CASE REPORT Sequential Piezocision in a Challenging Adult Case
      DONALD NELSON, DMD, SERGE DIBART, DMD
      VOLUME 48 : NUMBER 9 : PAGE 555 : Sep : 2014

  2. Kevin
    I do not really care if these techniques speed up or not premolar retraction. I am more interested in knowing if we could theoretically torque the roots with less force and fewer side effects by weakening the buccal plate. I think these experimental designs fail to address the real potential of these devices. There is more to orthodontics than canine retraction especially with the significant increase of adult orthodontics.

  3. I agree, this cannot be described as minimally invasive. The video doesn’t sell it, I don’t imagine any patient or parent would look at that and agree to treatment. It would need to drastically reduce treatment time, reliably, to make it a technique worth using. Considering the lack of evidence is it time for this technique to die?

    • Fun? Fun? Local anaesthetic/incisions in the buccal mucosa/3mm bone cuts between all the anterior teeth in a teenage patient – not my idea of fun! How about we try some coloured elastomeric ligatures?

  4. I would never tell to a patient of mine to do it! People, nowadays, are trying to discover the gender of the angels instead of develop all the good things that we already have! Tks for this Review Dr. O Brien!

  5. There is more than speeding up treatment. Just consider e.g. changing the biotype by combining piezosurgery with augmenting(GBR) of the bone in the direction of tooth movement. This will be benficial in expanding transverse, uprighting upper teeth in case of cl 3 correction and improve the bony envelope for lower anteriors in cl2 correction. All these items are of greater importance than the shorter tx time. Let us please focus in biological gain instead of reducing tx time.

  6. First of all, thank you Kevin for your effort. I think this is a good tecnique but need new study for have a convalidation. the truth is that Always you don’t have what you wont

  7. I agree with Kevin that the methodology needs a bit more attention – but that’s easier said that done. Altho’ it’s virtually impossible to blind the investigators from treatment allocation in this study, the results from cephalometrics cannot be relied upon since shape, size and location in 3D space cannot be accounted for. One way to approach this might be to take non-invasive digital scans – then trim the alveolar data so that only the tooth crowns remain. That might get over the potential measurement bias (if any) but I suspect that the rate of tooth movement is secondary to the rate of wound healing/bone remodeling in each subject, and based on complexity bone behavior is something that can’t be easily assessed.

  8. Hey Kevin,
    Have you ever looked at the SmileSonica device (Aevo system)? Their device accelerates tooth movement with Low Intensity Pulsed Ultrasound. I was a participant site in their study and I believe it was a well designed study. The device allows you to turn segments on/off as desired, which allowed for blinding of examiners. The results showed that space closure AVERAGED 30% faster (if my recollection is correct) and it eliminated root resorption in the treatment sites… might be of interest to you.

  9. Kevin has taken over from Lyle Johnson the mantle as the conscience of orthodontics. Thanks for popping another overblown technique bubble. What about risk of recession? Is that an issue with these Wilckodontics techniques?