Effect of Piezopuncture on Tooth

Movement and
Bone Remodeling in Dogs
By Kim et al. (AJODO July 2013)

Introduction

Various surgical interventions on the periodontal tissues have

been developed to accelerate orthodontic tooth movement.

Intentional surgical damage evokes a regional acceleratory

phenomenon that causes transient osteopenia by an accelerated
remodeling process.

Various modifications of corticotomies are effective in increasing

cellular activities related to tooth movement.

Corticision was introduced as a minimally invasive alternative for

cortical activation.

A cortical incision made by malleting a scalpel to separate the

interproximal

cortices

was

found

acceleratory phenomenon effect.

to

induce

the

regional

Piezopuncture is a procedure in which an ultrasonic tool, a

piezotome, is used to create multiple cortical punctures through
the overlying gingiva.

These transmucosal manipulations of alveolar bone have

minimized morbidity and achieved similar results to more
aggressive procedures, including extensive flap elevation for rapid
tooth movement.

Aim of Study

To determine whether piezopuncture would elicit the regional

acceleratory phenomenon and accelerate tooth movement without
causing harmful tissue responses.

To compare the acceleration rates of tooth movement and bone

remodeling between the maxilla and the mandible.

Materials & Method

Sample size: Ten male beagles (age, 18-24 months; weight, 9-12
kg)

The dogs were randomly divided into 2 groups: control (n = 4) and

piezopuncture (n = 6).

These groups were further divided into 3 sub-groups based on the

duration of force application: group I, 14 days; group II, 28 days;
and group III, 42 days.

Each animal provided 4 specimens (1 each from the right and left
sides of both jaws), and the maxillary and mandibular specimens
(n = 20 for each jaw) were randomly divided into 2 groups.

Target teeth = second premolars

Anchorage teeth

Maxillary arch Canine

Mandibular arch 3rd premolar

Orthodontic buttons connected by a lever arm were bonded on the

labial surfaces of all experimental teeth with Super-Bond C&B
resin (Sun Medical, Shiga, Japan).

A NiTi closed-coil spring (Tomy International, Tokyo, Japan) was

activated and ligated between the lever arms of the target teeth
and the anchorage teeth.

For reinforcing anchorages, resin bridges were constructed on the

adjacent teeth.

The orthodontic force by the appliance was 100 g at the beginning

of the experiment.

A piezosurgical instrument was used to perform the cortical

punctures penetrating the gingiva

The depth of cortical injury was 3 mm, by holding the tip

perpendicular to the gingiva for 5 seconds under saline-solution
irrigation.

Piezopunctures were performed on the MB, DB, ML, and DL sides

of the second premolars. Total Sixteen punctures were made on 1
target tooth.

Gentamicin (7.5 mg/kg) was injected postoperatively for 3 days.

Tooth brushing and daily hexamedine irrigation were repeated
during the postoperative care.

Tooth movement was measured by a digital caliper (Mitutoyo,

Kawasaki, Japan) on the stone models once a week.

Histologic analysis was performed on the decalcified specimens at

2, 4, and 6 weeks.

Quantitative histomorphometric analysis was done on the nondecalcified specimens of the dogs in the 6- week groups.

Microphotographs of all specimens were recorded using a digital

CCD camera (PS30C ImageBase; Kappa Optronics, Gleichen,
Germany).

The outlines of labeled bones were traced from the photographs,

and the distances between the labeled lines were measured with
image

analysis

Optronics).

software

(ImageBase

Metreo

2.5;

Kappa

Statistical analysis

Descriptive statistics were represented as means and standard

deviations for all parameters in each group.

The normality of the data was assessed with the KolmogorovSmirnov test.

Independent t tests were used to evaluate the intergroup

differences of the mean tooth movement distances on the models
and the mean accumulated new bone deposition measured by
histomorphometric analysis.

Results

The distance of the maxillary 2nd premolar movement in the

piezopuncture group was 3.26-fold greater than that in the control
group.

The distance of the mandibular 2nd premolar movement in the

piezopuncture group was 2.45-fold greater than that in the control
group.

There was no significant difference in the amount of anchorage

tooth movement between the piezopuncture group and the control
group.

With respect to movement rate, the first 2 weeks in the maxilla and
the second week in the mandible had the greatest movement.

The weekly velocity of tooth movement in the piezopuncture group

was larger than that in the control group at all observation times.

Histological findings (Compression sides of moving teeth )

At week 2,

Control group Compression and Hyalinization of PDL, with

no apparent resorptive findings on the alveolar surfaces.

Piezopuncture group Osteoclasts with the resorption

lacunae along the bone surfaces were seen near hyalinized
areas of the periodontal ligament .

At week 4,

Control group Indirect Resorption followed by the removal of

the hyalinized PDL.

Piezopuncture group Direct Resorption by active boneresorbing cells continued.

At week 6,

Control group The number and the activity of bone-resorbing

cells were decreased.

Piezopuncture group Direct bone resorption with the cellular

periodontal ligament continued.

Fluorescent Microscopic Findings(

On tension side)

The total distance of newly mineralized bone apposition during 6

weeks was significantly greater in the piezopuncture group than in
the control group.

In the maxilla, the mean apposition length of the piezopuncture

group was 2.55-fold greater than that of the control group.

In the mandible, the mean apposition length in the piezopuncture

group was 2.35-fold greater than that in the control group.

Discussion

Piezopuncture was developed to increase patient compliance by

minimizing discomfort during and after surgery, and to simplify the
procedure for orthodontists.

Piezopuncture eliminates the use bone malleting, which can be

frightening to the patient, and the soft-tissue incision and suture.

However, the intensity and duration of the regional acceleratory

phenomenon might not be sufficient to function throughout the
entire orthodontic treatment. This requires repeated applications at
regular intervals.

The action mechanism of piezopuncture is based on the biologic

concept of cortical activation rather than cortical removal.

Garg et al emphasized that the regional acceleratory phenomenon

is initiated mainly by trauma to the cortical bone.

Only cortical activation can increase osteoclastic activity around

the periodontal ligament, facilitating bone turnover toward an
osteoporotic state with less tissue resistance to tooth movement.

Piezosurgical incisions have been reported to be safe and

effective in osseous surgeries, such as preprosthetic surgery,
alveolar crest expansion, and sinus grafting.

Vercellotti et al used a piezosurgical technique for periodontally

accelerated orthodontic tooth movement.

Dibart et al introduced piezocision as a modified method of

corticision for rapid orthodontic tooth movement.

The rates of tooth movement in the control group showed no

remarkable increase until 5 weeks after intervention. On the other
hand, the piezopuncture group showed earlier acceleration of
tooth movement in the first 2 weeks after intervention.

The biologic lag phase of tooth movement is bypassed in

piezopuncture group, indicating less production and faster
elimination of hyalinized tissue.

The acceleration effect of piezopuncture was faster in the maxilla

than in the mandible.

Deguchi et al reported that orthodontic tooth movement

progressed 2 weeks faster in the maxilla than in the mandible.

This may be because of the differences of bone density and

metabolism between the jaws.

Conclusion

Piezopuncture was found to evoke rapid tooth movement by

accelerating the rate of alveolar bone remodeling.

Piezopuncture might have a great therapeutic benefit in the context

of reducing treatment duration and also periodontal regeneration.

This development is expected to bring orthodontics closer to the

goal of efficiency in tooth movement, without causing patient
discomfort or damage to the teeth and their supporting tissues.