Accepted Manuscript Corticotomies and Orthodontic Tooth Movement: A Systematic Review Braydon M. Patterson, BDSc, Oyku Dalci, DDS, PhD, M. Ali Darendeliler, BDS, PhD, Dip. Orth., Certif. Orth., Priv. Doc., MRACDS (Ortho), FICD, Alexandra K. Papadopoulou, DDS, MSc, Dipl. Specialty Orthod, PhD PII:

S0278-2391(15)01411-1

DOI:

10.1016/j.joms.2015.10.011

Reference:

YJOMS 57004

To appear in:

Journal of Oral and Maxillofacial Surgery

Received Date: 27 August 2015 Revised Date:

13 October 2015

Accepted Date: 15 October 2015

Please cite this article as: Patterson BM, Dalci O, Darendeliler MA, Papadopoulou AK, Corticotomies and Orthodontic Tooth Movement: A Systematic Review, Journal of Oral and Maxillofacial Surgery (2015), doi: 10.1016/j.joms.2015.10.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Corticotomies and Orthodontic Tooth Movement: A Systematic Review Authors: Braydon M. Patterson BDSc1, Oyku Dalci DDS, PhD2, M. Ali Darendeliler BDS, PhD, Dip. Orth., Certif. Orth., Priv. Doc., MRACDS (Ortho), FICD3, and Alexandra K. Papadopoulou DDS, MSc, Dipl. Specialty Orthod, PhD4.

1Postgraduate

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Student, Discipline of Orthodontics, Faculty of Dentistry, University of Sydney. Sydney Dental Hospital, Sydney South West Area Health Service, Sydney, Australia.

2Senior

Lecturer, Discipline of Orthodontics, Faculty of Dentistry, University of Sydney. Sydney Dental Hospital, Sydney South West Area Health Service, Sydney, Australia.

3Professor

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and chair, Discipline of Orthodontics, Faculty of Dentistry, University of Sydney. Sydney Dental Hospital, Sydney South West Area Health Service, Sydney, Australia.

4Senior

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Lecturer, Discipline of Orthodontics, Faculty of Dentistry, University of Sydney. Sydney Dental Hospital, Sydney South West Area Health Service, Sydney, Australia. Research Associate. Department of Oral Surgery and Implantology. Aristotle University of Thessaloniki, Thessaloniki, Greece.

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Address for Correspondence: Alexandra K. Papadopoulou, Discipline of Orthodontics, Faculty of Dentistry, University of Sydney, Sydney Dental Hospital, Level 2, 2 Chalmers St, Surry Hills, NSW 2010, Australia. Tel: +61 (2) 9351 8314 Fax: +61 (2) 9351 8336 E-mail: [email protected]

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Corticotomies and Orthodontic Tooth Movement: A Systematic Review Braydon M. Patterson BDSc, Oyku Dalci DDS, PhD, M. Ali Darendeliler BDS, PhD, Dip. Orth., Certif. Orth., Priv. Doc., MRACDS (Ortho), FICD, and Alexandra K. Papadopoulou DDS, MSc, Dipl. Specialty Orthod, PhD.

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Abstract: Purpose: A systematic review was conducted to examine the evidence for the effectiveness and safety of corticotomy-facilitated orthodontics. Methods:

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Electronic databases (Ovid Medline, EMBASE, Cochrane, SCOPUS, Web of

Science) were searched for articles that examined the rate of corticotomy-

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facilitated orthodontic tooth movement and its effects of the periodontium, root resorption and tooth vitality. Unpublished literature was searched electronically through ClinicalTrials.gov (www.clinicaltrials.gov) and the ISRCTN registry (www.controlled-trials.com). Relevant orthodontic journals and reference lists

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were also checked for eligible studies. Randomized clinical trials (RCTs) and controlled clinical trials (CCTs) were considered. Two article reviewers independently assessed the search results, screened the relevant articles,

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performed data extraction and evaluated the methodological quality of the

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studies. Results: Fourteen eligible articles were included in the review. This included six RCTs and eight CCTs. There was a statistically significant increase in the rate of tooth movement over controls for all of the different corticotomy techniques assessed. Some of the studies demonstrated that the acceleration in tooth movement was only temporary, lasting a few months. Corticotomy procedures did not seem to produce unwanted adverse effects on the periodontium, root resorption and tooth vitality. The quality of the body of evidence was regarded as low, due to the presence of multiple methodological

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ACCEPTED MANUSCRIPT issues, high risks of bias, and heterogeneity in the included articles. Conclusion: Corticotomy procedures were able to produce statistically and clinically significant temporary increases in the rate of orthodontic tooth movement with

needed to allow more definitive conclusions.

Introduction:

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minimal side effects. Additional high quality randomized clinical trials are

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The use of surgical alveolar corticotomies in orthodontic treatment has been discussed in the literature for over 100 years.1 Initially, the corticotomy

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procedures tended to focus on the sectioning of cortical alveolar bone blocks with associated teeth to allow surgically facilitated tooth movement. In 1959, Köle2 first described the use of corticotomies in the acceleration of orthodontic tooth movement. He believed that dense cortical bone was the main resistance to

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orthodontic tooth movement. His corticotomy procedure involved raising mucoperiosteal flaps and making full-length vertical corticotomy cuts on the

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buccal and lingual cortical alveolar bone of the teeth of interest. Horizontal osteotomy cuts were also made above the root apices. The cancellous bone was

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not involved in the corticotomy cuts. It was hypothesized that leaving intact cancellous bone allowed a continued supply of nutrition to the bone and teeth, as well as the prevention of unwanted sequelae such as root resorption, periodontal injury, and tooth devitalization. Subsequently, corticotomy techniques have been developed in the literature that have evolved and refined Köle’s traditional corticotomy technique. Studies have examined the simultaneous placement of bone grafting materials during the corticotomy procedure to enhance alveolar bone thickness.1, 3 Some

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ACCEPTED MANUSCRIPT researchers have developed techniques that avoid the raising of large buccal and lingual mucoperiosteal flaps by performing the corticotomy procedures through small vertical inter-radicular soft tissue incisions.4-6 Corticotomies were initially performed with surgical burs and handpieces, but recently other instruments

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have been successfully utilized to produce the corticotomy procedures such as piezosurgical tools,4, 7 lasers,8 disposable perforating devices9 and hardened

scalpel blades10. Variations on the size and design of the corticotomy cuts has

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also occurred, including the use of vertical inter-radicular cuts that only extend

partially along the length of the tooth roots,4, 6 or the use of small round cortical

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bone perforations instead of linear cuts.9, 11 These modifications to the corticotomy technique have allowed the procedure to become more conservative and less invasive for patients.

The biological mechanisms behind the acceleratory effect of corticotomies

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have previously been unclear. This related to a failure of understanding that a corticotomy procedure produced an altered physiological response via a regional

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acceleratory phenomenon effect (RAP), rather than an ‘en masse’ movement of teeth with alveolar bone blocks seen in osteotomy procedures.12 The term ‘RAP’

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was suggested by Frost,13-15 and refers to the situation where an injury to bone results in the acceleration of all of the processes involved in healing, including modelling, remodelling, cell turnover, perfusion, metabolism, inflammation and microdamage repair.16, 17 Recent literature has been able to show the relationship between RAP and corticotomy accelerated tooth movement.1, 3, 18, 19 Following a corticotomy, bone surrounding the roots of the teeth experiences a temporary demineralization/osteopenia. A higher level of cellular activity in terms of

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ACCEPTED MANUSCRIPT fibroblasts, osteoclasts, osteoblasts and cementoblasts in the periodontium, teeth and bony surfaces has been reported.20, 21 This results in more active and extensive bone and periodontal ligament remodelling on both the compression and tension side of teeth22, which allows teeth roots to rapidly move through the

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alveolar bone before it has the chance to remineralize.3, 21 This process differs

from the osteotomy, where cortical and cancellous bone is cut for the purpose of repositioning blocks of bone with associated teeth. The acceleratory effect of a

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corticotomy only has a finite period of bone ‘activation’. It has been suggested

that the RAP effect peaks at 1-2 months post-corticotomy, with a total duration

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usually extending for 2-4 months.1, 18, 23 However, studies have suggested that the RAP response can last for 6-24 months.24, 25

Corticotomies have been studied fairly extensively; however, many articles have tended to present only a single case or a handful of cases

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demonstrating the effectiveness and safety of the procedure. The reported rate of acceleration of tooth movement in human subjects has been suggested to be

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up to three times the normal rate of tooth movement,3, 4 with no increased risk of root resorption,26-28 tooth devitalization,6, 29 or adverse periodontal sequelae.28, However, the acceleration rate varies extensively, and this is likely due to

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30-32

factors such as different study designs, subject numbers, corticotomy procedure variations, force magnitudes, types of tooth movement with differing activation/reactivation regimes, and durations of force activation. Hence, it is the aim of this systematic review of the literature to assess: 1. The effectiveness of the corticotomy procedure in the acceleration of tooth movement when compared to conventional orthodontics.

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ACCEPTED MANUSCRIPT 2. Examine any adverse effects on the periodontium, root resorption, and tooth vitality.

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Material and Methods: Protocol Registration:

The study protocol was not registered. Due to the nature of this study

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being a systematic review, ethical approval was not required from the University

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of Sydney IRB.

Search Strategy:

Ovid Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), SCOPUS and Web of Science Core Collection databases were

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searched for literature until May 2015. Unpublished literature was searched electronically through ClinicalTrials.gov (www.clinicaltrials.gov) and the ISRCTN

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registry (www.controlled-trials.com) with key words including ‘corticotomy’,

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‘accelerated’, and ‘tooth movement’.

Table 1: Systematic Review Search Strategy

Eligibility Criteria:

The inclusion criteria for article eligibility in terms of study design included randomized clinical trials (RCTs), prospective and retrospective controlled clinical trials (CCTs). The exclusion criteria for study design included

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ACCEPTED MANUSCRIPT case reports, case series, descriptive studies, review articles, opinion pieces, abstracts only, and articles in languages other than English. Studies were only considered if participants were healthy human subjects with no prior orthodontic treatment. Animal studies were not included. There

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were no limitations set in terms of the type of malocclusion or orthodontic problem for the participants.

Eligible studies needed to focus their intervention on corticotomy-

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facilitated orthodontics only. Studies that examined other forms of surgically

accelerated tooth movement such as distraction osteogenesis or osteotomy were

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excluded.

A number of different corticotomy outcomes were examined: the rate of orthodontic tooth movement with corticotomy-facilitated orthodontic procedures, the effects on the periodontium, root resorption and tooth vitality.

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Ideally the outcomes needed to be examined either in comparison to a control group, or pre and post-treatment records where each subject served as their

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own control.

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Study Selection:

Following the results of the database searches, the titles and abstracts

were screened by two independent reviewers (B.M.P. and A.K.P.) using the eligibility criteria. If there was a lack of clarity in terms of the relevance of the article, then the full text was obtained and examined for eligibility. Full-length articles were only examined in further detail. The reference lists of any eligible articles were also manually examined for any further relevant literature.

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ACCEPTED MANUSCRIPT Data collection and items: Once the literature search results had been narrowed down to relevant articles, a data sheet was used on each eligible article to extract the necessary data. This was also performed independently by the two reviewers. The data

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sheet was a customized version of the Data Extraction Template for Cochrane

Reviews33 (Cochrane Consumers & Communication Review Group) (Appendix I). Following data collection, information for each study was organized into tables

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that examined participants, interventions, comparators, outcomes, and study

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design (PICOS).

Risk of bias:

The risk of bias for each article was assessed independently by the authors (B.M.P. and A.K.P.). Disagreements were discussed until a resolution was

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reached. Bias risk was carried out according to the guidelines of the Cochrane Risk of Bias Assessment Tool,34 and the Cochrane Quality Study Guide.35 These

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guides recommended the reporting of the following individual elements:

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1. Random sequence generation. 2. Allocation sequence concealment.

3. Blinding (outcome assessment). 4. Completeness of outcome data. 5. Selective outcome reporting. 6. Other sources of bias. Inconsistent medication use, corticotomy technique modifications and bone graft use were considered as other sources of bias that might have influenced the treatment outcomes.

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Each category was designated one of the following gradings: High, Low or Unclear risk of bias. Studies were deemed to be at the highest risk of bias if they were scored with a ‘high’ or ‘unclear’ risk of bias for the sequence generation or

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allocation concealment categories. This was based on growing evidence that

these factors were particularly important potential sources of bias in studies.35 Scores of low, medium and high quality were not given as a summary of the

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overall bias of individual studies, as this was discouraged by the Cochrane

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Systematic Review Handbook.34

Results: Study Selection:

The search strategy was able to find 241 references in Ovid Medline, 529

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references in Embase, 8 references in CENTRAL, 174 references in SCOPUS, 412 references in Web of Science, and 8 references from manual searching of

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reference lists. No unpublished studies were found. Once duplicate records had been removed, there were a total of 1053 unique search results. Following a

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review of titles and abstracts, the implementation of the exclusion criteria resulted in the removal of 1024 ineligible articles, leaving 29 references that were eligible for further assessment.

Figure 1: PRISMA Flow Chart

Full text articles for the 29 articles were then obtained and assessed via the aforementioned inclusion criteria. One article was excluded due to the

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ACCEPTED MANUSCRIPT language being other than English.36 One was excluded due to methodological issues,37 two were excluded as they focused on distraction osteogenesis as the method of intervention,7, 38 and four were not considered as they examined areas of corticotomy that did not address the outcomes that made up part of the

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review inclusion criteria.39-42 Seven articles that examined corticotomy were

excluded due to the studies not being randomized or controlled clinical trials.6, 4348

Ultimately, 14 articles were included in this review (Table 2).

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The eligible articles were then assessed for data extraction following

PICOS. Inter-reviewer consensus was high in terms of selecting eligible articles,

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data extraction and bias assessment.

Study Characteristics:

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Table 2: Study design of Included Studies

Within the 14 studies, six were randomized clinical trials (RCTs),9, 27, 31, 4951

and eight were demarcated as controlled clinical trials (CCTs).8, 26, 28, 30, 52-55

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Amongst the fourteen included studies, there were a total of 175

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participants that underwent a corticotomy procedure, with a total of 170 control participants (this included counting participants in split mouth studies). An a priori sample size calculation was performed in only three of the

included studies.9, 50, 53

Risk of bias: The results of the risk of bias assessment can be found in Table 3. Only two49, 50 of the six included RCTs were able to adequately address sequence

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ACCEPTED MANUSCRIPT generation (randomization). Randomization of participants was achieved by an envelope selection process,50 or coin toss.49 The other four RCTs9, 27, 31, 51 did not provide any description about the randomization process. For the CCTs, these were deemed to possess an inherently high risk of bias for sequence generation.

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Furthermore, none of the studies adequately addressed allocation concealment. In terms of blinding, only the blinding of outcomes (detection bias) was

possible in these studies, as the participants and operators (performance bias)

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could not be blinded from the corticotomy surgical intervention. Blinding of outcomes assessment was performed in only two studies.9, 51

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Most of the studies were able to address incomplete data outcome sufficiently. There were only a couple of studies that experienced attrition of subject numbers during the experimental period,27, 49 but they were considered to have a low risk of incomplete data reporting. None of the studies that

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experienced participant dropouts performed an Intention to treat analysis (ITT). Selective outcome reporting was generally not an issue in the body of

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evidence. Only two studies8, 54 did not provide detailed results for all of the primary and secondary outcomes that had been discussed in the material and

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methods.

Other sources of bias were present in some of the studies. Methodological

inconsistencies included studies that used bone grafting only in selected subjects from the corticotomy experimental group,55 the use of various post-operative medications,27, 28, 50 and the removal of bundle bone26, 30 or buccal and lingual cortical bone52 from the extraction sites during the corticotomy procedure.

Table 3: Risk of Bias Assessment

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Description of Interventions: All of the studies examined corticotomy procedures, but the various surgical interventions differed (Table 4). Most of the studies utilized traditional

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corticotomy procedures, where full thickness buccal, or buccal and palatal

mucoperiosteal flaps were raised, and vertical inter-radicular corticotomy cuts,

with joining horizontal subapical corticotomy cuts were performed.31, 52, 55 A few

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of the studies modified this corticotomy procedure by excluding the subapical corticotomy cut,27, 28, 53 by drilling multiple holes that penetrated the cortical

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plate instead of the linear cuts8, 49, 51, 54 or combining the commonly used corticotomy cuts with perforating holes.26, 50 More conservative techniques involved making vertical interproximal soft tissue incisions without raising soft tissue flaps. These studies used a piezosurgical instrument30 or a hard tissue

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laser8 to allow the corticotomy cuts to be performed through the soft tissue incisions. One study9 performed Micro-Osteo-Perforations into the cortical bone

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(MOPs) with a disposable device, without the need for soft tissue incisions. Bone allografts were placed only in some of the studies where the alveolar bone was

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considered thin.27, 31, 53, 55

Table 4: Description of Participants and Interventions

In the studies that had maxillary first premolars extracted, it was noted that the extractions were done either prior to the corticotomy procedure,8, 9, 50, 53, 54

or on the day of the surgery.26, 30, 31, 49, 52, 55

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ACCEPTED MANUSCRIPT Orthodontic appliances were placed prior to the corticotomy, which was likely due to convenience in bonding before surgery, and it would have allowed force application to occur immediately or soon after surgery. All studies involved

miniscrews,9, 49 or TPAs31, 50 as additional anchorage.

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the use of fixed appliances, with some using skeletal anchorage plates,44

In terms of orthodontic force, the studies had differing methods,

application times, force levels and durations. A lot of the studies used pre-

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calibrated NiTi closing coils,9, 26, 30, 31, 49, 50, 55 or elastomeric chain.8, 54 Some of the studies used only archwires to deliver force,27, 28, 43, 46 or other/not specified.6, 51,

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53

The time when forces were applied to the teeth varied among the different study designs. A number of the studies had force applied to the teeth immediately after the corticotomy surgical procedure.8, 9, 26-28, 30, 49, 50, 52, 54 The

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remaining studies tended to commence force application within two weeks of the corticotomy surgery.31, 44, 51, 53, 55 The application of force immediately/soon

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after surgery allowed the operators to maximize the period of accelerated tooth movement produced by the transient RAP effect.

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Force levels varied between studies, with forces ranging from as little as 60gms,51 up to 200-300gms.54, 55 Only some of the studies discussed their force reactivation protocols during the experimental period,9, 27, 28, 51, 53, 54 while the other studies either did not reactivate forces, or did not mention it. The duration of force application also varied significantly between the studies, with experimental periods ranging from as short as 4 weeks,9 to the duration required for space closure completion.31

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ACCEPTED MANUSCRIPT A large number of the included studies examined the rate of maxillary first premolar space closure either by canine retraction8, 9, 26, 30, 49, 50, 54 or en masse retraction of the anterior segment.31, 53, 55 Some of the studies examined the alignment of lower anterior teeth.27, 28 One study looked at the effect of

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corticotomy on maxillary canine extrusion.51 The remaining study did not use a homogenous treatment group.52

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Results of individual studies Rate of Tooth Movement:

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The corticotomy procedure produced a statistically significant increase in the rate of orthodontic tooth movement when compared to controls (Table 5). Out of the studies that examined the rate or duration of tooth movement, there were eleven that compared corticotomy and control groups that had

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conventional orthodontic therapy.9, 28, 31, 49-55 Al-Naoum, Hajeer and Al-Jundi50 performed a split mouth study that found corticotomy-activated canine teeth

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moved 2 - 4 times faster than controls over a 12 week period, with the fastest rate of tooth movement seen in the first 2 weeks. Bhattacharya et al31 found that

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with en masse retraction of maxillary anterior teeth, space closure in the corticotomy group took 131 ± 7.5 days, while the control group took 234 ± 9 days. This resulted in the corticotomy procedure accelerating tooth movement by 1.78 times. In the study by Sakthi et al,55 over a 4-month experimental period, the average rate of corticotomy-assisted en masse retraction was 1.8mm/month and 1.57mm/month in the maxilla and mandible, respectively. The control group managed to average 1.02mm/month and 0.87mm/month in the maxilla and mandible, respectively. Salman and Ali8 found that over a 6 week period, the net

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ACCEPTED MANUSCRIPT canine movement was an average of 1.63 mm on the corticotomy side, compared to an average distalisation of 0.82 mm on the control side. Wu et al53 also examined the rate of maxillary premolar space closure by en masse retraction. They found that in the corticotomy group, space closure took 5.52 ± 1.28 months.

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The control group took 14.17 ± 3.95 months, which was 8.65 ± 2.67 months

longer. The authors reported that there were no significant differences in the

amount of movement of anterior teeth and molars in the sagittal, vertical, and

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transverse dimensions between the groups. The split mouth study by Abed and Al-Bustani54 found that the corticotomy side demonstrated 42.6% more canine

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distalization than the control side over a one month period. Alikhani et al9 examined the effect of Micro-Osteo Perforations (MOPs) on the rate of tooth movement. Over a 4 week period, tooth movement was accelerated by 2.3 times when compared to controls. Shoreibah et al28 examined the time taken to align

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lower anterior teeth (3-5mm of crowding). In the corticotomy group, this took 17.5 weeks, as opposed to 49 weeks in the controls. Aboul-Ela et al49 found in

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their split mouth study that the corticotomy side experienced an acceleration of tooth movement of 2 times at 2 months, 1.6 times at 3 months, and 1.06 times at

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4 months. In a study that examined the rate of maxillary canine extrusion, Fischer51 found that the corticotomy procedure allowed canine extrusion at a rate of 1.06mm/mth. The control canines moved at 0.75mm/mth, meaning that corticotomy reduced treatment time by 28-33%. Finally, Gantes, Rathbun and Anholm52 found in their small group that corticotomy reduced treatment time by about 50% when compared to age and orthodontically matched controls. The corticotomy group took 14.8 months to complete treatment, whilst controls took 28.3 months. Overall, all of the studies highlighted that corticotomy procedures

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ACCEPTED MANUSCRIPT had the ability to enhance the rate of tooth movement 1.5-4 times that of conventional orthodontic therapy.

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Table 5: Outcomes of Included Studies

Periodontal Parameters:

There were nine studies that examined the effect of corticotomy on

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periodontal parameters. Out of those studies, four were RCTs27, 31, 49, 51 and five

were CCTs8, 28, 30, 52, 54. Overall, the corticotomy procedure did not appear to have

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any significant adverse sequelae on the periodontal health of the participants, including periodontal probing depths, plaque indices, gingival recession, clinical attachment levels and alveolar crestal bone heights. This was the case when compared to controls,8, 27, 28, 30, 49, 51, 54 and also when comparing pre and post-

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corticotomy-facilitated treatment parameters alone.52

In one of the studies where the bucco-lingual ridge thickness was examined pre and post-treatment,31 it found that with corticotomy, the ridge

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experienced a slight mean increase in thickness that was statistically significant.

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Two studies by Shoreibah et al27, 28 compared the bone density between corticotomy treated teeth and control teeth. In one of their studies, they found that at 6 months post-treatment, the corticotomy subjects had a smaller net reduction in alveolar bone density (-21.8%) than the non-corticotomy controls (37.2%).28 In their other study,27 it was found that when the corticotomy procedure was combined with a bone grafting procedure, at 6 months posttreatment, the net alveolar bone density was 25.85% greater than pre-treatment

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ACCEPTED MANUSCRIPT values. For the corticotomy only group, the net alveolar bone density was 17.59% less than pre-treatment values.

Root Resorption:

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The effects of corticotomy on the root resorption process were examined in four of the included studies.26-28, 52 Overall, root resorption in the corticotomy groups post-treatment was similar to controls. In two of the studies, it was found

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that root resorption was quantitatively less in the corticotomy group than in the control group.26, 28 In addition, none of the studies reported any iatrogenic root

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damage due to the corticotomy procedure.

Tooth Vitality:

Only a few the studies briefly discussed tooth vitality status pre and post-

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treatment.8, 52, 54 It was found that tooth vitality was not adversely affected by corticotomy-facilitated orthodontics. However, the methods of assessment were

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Discussion:

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generally not discussed in these studies.

Summary of Evidence:

Overall, the general consensus of the body of evidence in this systematic

review indicated that corticotomy procedures were able to accelerate orthodontic tooth movement to a clinically and statistically significant extent in the short term. The corticotomy procedures resulted in accelerations in movement that ranged from 1.5 times51 up to 4 times50 the normal rate of orthodontic tooth movement. There was a high level of study design

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ACCEPTED MANUSCRIPT heterogeneity amongst the corticotomy studies. Comparing rates of accelerated tooth movement between studies with different subject numbers and populations, surgical protocols, force levels, method of force application, and

quantitatively in the form of a meta-analysis.

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treatment durations meant that it was not possible to analyse the data

Only two of the studies49, 50 actually examined the rate of accelerated

tooth movement at regular intervals over a specified period of treatment. They

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found that although the acceleration of tooth movement was initially high, within the first few months the corticotomy procedures were accelerating tooth

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movement only at a slightly higher rate than conventional orthodontics. At 4 months, Aboul Ela et al49 found that the acceleration rate was only 1.06 times that of the controls. This could be explained by the RAP effect declining in intensity over the months following the corticotomy procedure.1, 18, 23 Studies

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that examined the acceleration of tooth movement over a longer period of time at regular intervals, and also the effect of repeating the corticotomy procedure

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on the acceleration of tooth movement over treatment would provide more clinically relevant information about the effect of the corticotomy procedure.

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Another factor that was not addressed in the included studies was followup and relapse. Two studies27, 28 followed subjects up to 6 months posttreatment,;however, relapse was not assessed. While some studies23, 56 have mentioned that corticotomy procedures resulted in less relapse than conventional orthodontics, properly designed clinical trials are needed to provide more substantial evidence to support these claims. Most of the included studies examined periodontal parameters before and after corticotomy-facilitated orthodontics.8, 27, 28, 30, 31, 49, 51, 52, 54 Although there

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ACCEPTED MANUSCRIPT were no reported adverse effects on the periodontium, only some of the studies used untreated controls when comparing periodontal parameters. Furthermore, none of the studies looked at periodontal parameters beyond the immediate post-experimental period.

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The effect of corticotomy procedures on root resorption was assessed in a few of the studies.26-28, 52 Overall, the consensus showed that corticotomy did not result in an increase in the amount of orthodontically induced inflammatory root

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resorption. The issue with most of the studies that assessed root resorption was that they were generally vague on their diagnostic methods: in terms of the

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method of taking radiographs and the assessment criteria. Furthermore, most of the studies only gave qualitative assessments of root resorption. Tooth vitality was briefly assessed in only three studies,8, 52, 54 and although there were no reported cases of loss of tooth vitality, only one study54

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provided information on the methods of diagnostic assessment, so it was not possible to draw comparisons between the studies.

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While some studies27, 28, 31 assessed bone density before and after corticotomy procedures, their radiographic assessment methods varied

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significantly. Furthermore, even though mild improvements in alveolar bone density and thickness were detected, it was noted that these studies had placed particulate bone allografts during the corticotomy procedure, which meant that it was difficult to assess the true effect of the corticotomy procedure on alveolar bone parameters. There was also no long-term follow-up of alveolar bone density and thickness, nor any form of histological assessment. The effect of the corticotomy procedure on anchorage was examined as a secondary outcome in a few of the studies.53-55 It has been postulated that the

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ACCEPTED MANUSCRIPT relative anchorage value of teeth that have not had a corticotomy procedure should increase when pitted against teeth that have been activated by corticotomy procedures.57 Two of the studies53, 54 found that there were no statistically significant differences in anchorage loss at the molars when

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comparing corticotomy and control groups, whilst the third study55 found that

there was a statistically significant reduction in anchorage loss in the molars for corticotomy subjects than control subjects (0.6mm in corticotomy subjects,

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1.8mm in control subjects). In these studies, the molars did not have a

corticotomy procedure performed, so this is important to consider when

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determining anchorage requirements in corticotomy cases.

There were only two studies that examined the degree of discomfort associated with corticotomy procedures.9, 50 Al Naoum, Hajeer and Al-Jundi50 reported that 50% of subjects were in extreme pain on eating one day after

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surgery. However, by day 7, there were no reports of extreme pain, and 66.6% of subjects reported no pain, or mild discomfort. Alikhani et al9 found that with

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micro-osteo-perforations (MOPs), despite discomfort being recorded by participants one day and 7 days after commencing canine retraction, there were

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no statistically significant differences between experimental and control groups. This was in accordance with another study that examined the effects of rotary surgical corticotomy and piezosurgical corticotomy procedures on Oral Health Related Quality of Life scores.39 Deterioration of the quality of life scores were noted 3 days after surgery, but the values almost returned to baseline 7 days post-surgery. Ileri et al41 published a study that examined the effect of a piezocision procedure on bacteraemia. Thirty participants had blood samples taken before,

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ACCEPTED MANUSCRIPT and 30-60 seconds following a piezocision procedure. They found no statistically significant difference between the preoperative and postoperative blood samples. However, while all participants did not demonstrate any transient bacteraemia in their pre-operative samples, three participants had positive

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bacteraemia results in their post-operative blood samples. This lead the authors to suggest that piezocision could lead to transient bacteraemia, and that the risk

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of infective endocarditis should be considered in at-risk patients.

Limitations:

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Overall, the body of the evidence was generally of a low quality due to the perceived high risk of bias in the included articles. Methodological issues associated with the body of evidence included a lack of adequate sequence generation and allocation concealment, failure to blind outcome assessors, and

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also other sources of bias that could have potentially confounded the results such as the use of post-operative medications, or use of bone grafts in only

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selected experimental subjects. Furthermore, out of the 14 included articles, only six were RCTs, with the remaining CCTs having inherently high risk of bias in

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terms of sequence generation and allocation Concealment. Due to the low quality of evidence, the results of this systematic review should be interpreted with caution.

The authors attempted to minimize bias in the review process. This was

achieved through independent evaluation of the results of the search strategy in terms of article eligibility, data extrapolation and risk of bias assessment. Furthermore, the use of the Cochrane Handbook for Systematic Reviews of Interventions58 and PRISMA guidelines59 allowed a thorough and logical

20

ACCEPTED MANUSCRIPT structure to the review process. However, inherent sources of bias were still present during the process. The search strategy only included articles that were written in English. Publication bias was also a potential issue. Published articles are more likely to report positive results that could influence the external

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validity of this systematic review. Some of the articles had poor study designs

when assessed with PICOS, which meant that bias might have been introduced during their assessments. Finally, some of the included studies were not RCTs,

Conclusions: Implications for Practice:

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which could have introduced bias into the review process.

The available body of literature for corticotomy-facilitated orthodontics currently provides a low quality of evidence to suggest that the corticotomy

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procedure results in an acceleration of orthodontic tooth movement. The included studies in the review process were able to demonstrate a statistically

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significant increase in the rate of tooth movement when compared with control groups. When examined temporally, the acceleration of tooth movement

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appeared to only last short-term, with rates of movement returning close to baseline after a few months. Corticotomy-facilitated orthodontic procedures did not appear to

increase the risk of adverse sequelae on the periodontium, tooth vitality or root resorption process when compared to normal orthodontic treatment.

Implications for Research:

21

ACCEPTED MANUSCRIPT The body of evidence was able to provide a qualitative indication that corticotomy procedures could increase the rate of tooth movement. Issues in study design, quality and heterogeneity of interventions prevented a quantitative assessment from being performed. It was also not possible to determine the

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superiority of one corticotomy technique over another. Over the past couple of years, there has been a noticeable increase in the number of clinical trials that

have examined the effects of corticotomy procedures on orthodontics. However,

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with the currently available literature only providing low levels of evidence,

there is a need for well-conducted research with less risk of bias, to allow more

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meaningful comparisons and conclusions. Future trials on corticotomyfacilitated orthodontics could increase subject numbers, improve randomization of participants, allocation concealment and blinding of outcome assessments to produce research that has a higher quality. Also, studies that quantified the

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period of accelerated tooth movement achieved with the corticotomy procedure, comparisons of differing corticotomy techniques, and long-term follow-up of

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outcomes such as periodontal parameters would provide more relevant

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information for evidence-based practice.

Acknowledgements:

The authors would like to Lajos Bordas from the Dentistry Library, University of Sydney for his valuable assistance in devising and implementing the search strategies.

22

ACCEPTED MANUSCRIPT References: 1.

Wilcko W, Ferguson D, Bouquot J, Wilcko M: Rapid orthodontic

decrowding with alveolar augmentation: case report. World J Orthod 4:197, 2003 Kole H: Surgical operations on the alveolar ridge to correct occlusal

RI PT

2.

abnormalities. Oral Surg Oral Med Oral Pathol 12:515, 1959 3.

Wilcko WM, Wilcko T, Bouquot JE, Ferguson DJ: Rapid orthodontics with

SC

alveolar reshaping: two case reports of decrowding. Int J Periodontics Restorative Dent 21:9, 2001

Dibart S, Sebaoun JD, Surmenian J: Piezocision: a minimally invasive,

M AN U

4.

periodontally accelerated orthodontic tooth movement procedure. Compend Contin Educ Dent 30:342, 2009 5.

Dibart S, Surmenian J, Sebaoun JD, Montesani L: Rapid treatment of Class

Dent 30:487, 2010

Hernandez-Alfaro F, Guijarro-Martinez R: Endoscopically assisted tunnel

EP

6.

TE D

II malocclusion with piezocision: two case reports. Int J Periodontics Restorative

approach for minimally invasive corticotomies: a preliminary report. J

7.

AC C

Periodontol 83:574, 2012

Vercellotti T, Podesta A: Orthodontic microsurgery: a new surgically

guided technique for dental movement. Int J Periodontics Restorative Dent 27:325, 2007 8.

Salman LH, Ali FA: Acceleration of canine movement by laser assisted

flapless corticotomy [An innovative approach in clinical orthodontics]. J Bagh College Dentistry 26:133, 2014

23

ACCEPTED MANUSCRIPT 9.

Alikhani M, Raptis M, Zoldan B, Sangsuwon C, Lee YB, Alyami B, Corpodian

C, Barrera LM, Alansari S, Khoo E, Teixeira C: Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop 144:639, 2013 10.

Kim SJ, Park YG, Kang SG: Effects of Corticision on paradental remodeling

11.

RI PT

in orthodontic tooth movement. Angle Orthod 79:284, 2009

Kim YS, Kim SJ, Yoon HJ, Lee PJ, Moon W, Park YG: Effect of piezopuncture

on tooth movement and bone remodeling in dogs. Am J Orthod Dentofacial

12.

SC

Orthop 144:23, 2013

Murphy NC, Bissada NF, Davidovitch Ze, Kucska S, Bergman RT, Dashe J,

M AN U

Enlow DH: Corticotomy and Tissue Engineering for Orthodontists: A Critical History and Commentary. Sem Orthod 18:295, 2012 13.

Frost HM: The regional acceleratory phenomenon: a review. Henry Ford

Hosp Med J 31:3, 1983

Frost HM: The biology of fracture healing. An overview for clinicians. Part

TE D

14.

II. Clin Orthop Relat Res 294, 1989

Frost HM: The biology of fracture healing. An overview for clinicians. Part

EP

15.

I. Clin Orthop Relat Res 283, 1989 Frost HM: Perspectives: bone's mechanical usage windows. Bone Miner

AC C

16.

19:257, 1992 17.

Frost HM: A 2003 update of bone physiology and Wolff's Law for

clinicians. Angle Orthod 74:3, 2004 18.

Buschang PH, Campbell PM, Ruso S: Accelerating Tooth Movement With

Corticotomies: Is It Possible and Desirable? Sem Orthod 18:286, 2012

24

ACCEPTED MANUSCRIPT 19.

Lee W, Karapetyan G, Moats R, Yamashita DD, Moon HB, Ferguson DJ, Yen

S: Corticotomy-/Osteotomy-assisted tooth movement microCTs differ. J Dent Res 87:861, 2008 20.

Cho KW, Cho SW, Oh CO, Ryu YK, Ohshima H, Jung HS: The effect of

21.

Cano J, Campo J, Bonilla E, Colmenero C: Corticotomy-assisted

orthodontics. J Clin Exp Dent 4:e54, 2012

Mostafa YA, Mohamed Salah Fayed M, Mehanni S, ElBokle NN, Heider AM:

SC

22.

RI PT

cortical activation on orthodontic tooth movement. Oral Dis 13:314, 2007

Comparison of corticotomy-facilitated vs standard tooth-movement techniques

M AN U

in dogs with miniscrews as anchor units. Am J Orthod Dentofacial Orthop 136:570, 2009 23.

Wilcko MT, Wilcko WM, Bissada NF: An evidence-based analysis of

periodontally accelerated orthodontic and osteogenic techniques: a synthesis of

24.

TE D

scientific perspectives. Sem Orthod 14:305, 2008 Frost HM: From Wolff's law to the Utah paradigm: insights about bone

25.

EP

physiology and its clinical applications. Anat Rec 262:398, 2001 Alghamdi AS: Corticotomy facilitated orthodontics: Review of a technique.

AC C

Saudi Dent J 22:1, 2010 26.

Abbas NH, Sabet NE, Hassan IT: Effect of corticotomy - facilitated

orthodontics on root resorption. Egypt Dent J 57:3039, 2011 27.

Shoreibah EA, Ibrahim SA, Attia MS, Diab MM: Clinical and radiographic

evaluation of bone grafting in corticotomy-facilitated orthodontics in adults. Journal Int Acad Periodontol 14:105, 2012

25

ACCEPTED MANUSCRIPT 28.

Shoreibah EA, Salama AE, Attia MS, Abu-Seida SM: Corticotomy-facilitated

orthodontics in adults using a further modified technique. Journal Int Acad Periodontol 14:97, 2012 29.

Germec D, Giray B, Kocadereli I, Enacar A: Lower incisor retraction with a

30.

RI PT

modified corticotomy. Angle Orthod 76:882, 2006

Abbas NH, Sabet NE, Hassan IT: The effect of using piezocision technique

in orthodontic tooth movement on the periodontal condition. Egypt Dent J

31.

SC

57:3047, 2011

Bhattacharya P, Bhattacharya H, Anjum A, Bhandari R, Agarwal DK, Gupta

M AN U

A, Ansar J: Assessment of Corticotomy Facilitated Tooth Movement and Changes in Alveolar Bone Thickness - A CT Scan Study. J Clin Diagn Res 8:ZC26, 2014 32.

Iino S, Sakoda S, Miyawaki S: An adult bimaxillary protrusion treated with

76:1074, 2006

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corticotomy-facilitated orthodontics and titanium miniplates. Angle Orthod

http://cccrg.cochrane.org/author-resources.

34.

Higgins JPT, Altman DG, Sterne JAC, (editors): Chapter 8: Assessing risk of

EP

33.

bias in included studies. . In: Higgins JPT, Green S (editors). Cochrane Handbook

AC C

for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration. Available from http://www.cochranehandbook.org. :187, 2011 35.

Ryan R, Hill S, Prictor M, McKenzie J: Study Quality Guide (ed. [May

2013]). http://cccrg.cochrane.org/author-resources Cochrane Consumers and Communication Review Group,

26

ACCEPTED MANUSCRIPT 36.

Wu JQ, Xu L, Liang C, Zou W, Bai YY, Jiang JH: [Class III surgical patients

facilitated by accelerated osteogenic orthodontic treatment]. Zhonghua Kou Qiang Yi Xue Za Zhi. 48:596, 2013 37.

Krishnan P, Shetty S, Husain A: An adjunctive minor surgical procedure

38.

RI PT

for increased rate of retraction. J Pharm Bioallied Sci 5:S39, 2013

Bertossi D, Vercellotti T, Podesta A, Nocini PF: Orthodontic microsurgery

for rapid dental repositioning in dental malpositions. J Oral Maxillofac Surg

39.

SC

69:747, 2011

Cassetta M, Di Carlo S, Giansanti M, Pompa V, Pompa G, Barbato E: The

M AN U

impact of osteotomy technique for corticotomy-assisted orthodontic treatment (CAOT) on oral health-related quality of life. Eur Rev Med Pharmacol Sci 16:1735, 2012 40.

Gulnahar Y, Huseyin Kosger H, Tutar Y: A comparison of piezosurgery and

Surg 42:508, 2013

Ileri Z, Akin M, Erdur EA, Dagi HT, Findik D: Bacteremia after piezocision.

EP

41.

TE D

conventional surgery by heat shock protein 70 expression. Int J Oral Maxillofac

Am J Orthod Dentofacial Orthop 146:430, 2014 Rajasekaran UB, Krishna Nayak US: Effect of prostaglandin E1 versus

AC C

42.

corticotomy on orthodontic tooth movement: an in vivo study. Indian J Dent Res 25:717, 2014 43.

Ahn HW, Lee DY, Park YG, Kim SH, Chung KR, Nelson G: Accelerated

decompensation of mandibular incisors in surgical skeletal class III patients by using augmented corticotomy: a preliminary study. Am J Orthod Dentofacial Orthop 142:199, 2012

27

ACCEPTED MANUSCRIPT 44.

Akay MC, Aras A, Gunbay T, Akyalcin S, Koyuncue BO: Enhanced effect of

combined treatment with corticotomy and skeletal anchorage in open bite correction. J Oral Maxillofac Surg 67:563, 2009 45.

Bhat SG, Singh V, Bhat MK: PAOO technique for the bimaxillary

46.

RI PT

protrusion: Perio-ortho interrelationship. J Indian Soc Periodontol 16:584, 2012 Coscia G, Coscia V, Peluso V, Addabbo F: Augmented corticotomy

combined with accelerated orthodontic forces in class III orthognathic patients:

SC

morphologic aspects of the mandibular anterior ridge with cone-beam computed tomography. J Oral Maxillofac Surg 71:1760 e1, 2013

Mostafa YA, El-Mangoury NH, Abou-El-Ezz AM, Heider AM: Maximizing

M AN U

47.

tissue response in selected subjects with anterior open bites. World J Orthod 10:187, 2009 48.

Yu H, Jiao F, Wang B, Shen SG: Piezoelectric decortication applied in

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periodontally accelerated osteogenic orthodontics. J Craniofac Surg 24:1750, 2013

Aboul-Ela SM, El-Beialy AR, El-Sayed KM, Selim EM, El-Mangoury NH,

EP

49.

Mostafa YA: Miniscrew implant-supported maxillary canine retraction with and

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without corticotomy-facilitated orthodontics. Am J Orthod Dentofacial Orthop 139:252, 2011 50.

Al-Naoum F, Hajeer MY, Al-Jundi A: Does alveolar corticotomy accelerate

orthodontic tooth movement when retracting upper canines? A split-mouth design randomized controlled trial. J Oral Maxillofac Surg 72:1880, 2014 51.

Fischer TJ: Orthodontic treatment acceleration with corticotomy-assisted

exposure of palatally impacted canines. Angle Orthod 77:417, 2007

28

ACCEPTED MANUSCRIPT 52.

Gantes B, Rathbun E, Anholm M: Effects on the periodontium following

corticotomy-facilitated orthodontics. Case reports. J Periodontol 61:234, 1990 53.

Wu J, Jiang J, Xu L, Liang C, Bai Y, Zou W: A pilot clinical study of Class III

treatments. Angle Orthod 27, 2014 54.

Abed SS, Al-Bustani AI: Corticotomy assisted orthodontic canine

retraction. J Bagh College Dentistry 25:160, 2013

Sakthi SV, Vikraman B, Shobana VR, Iyer SK, Krishnaswamy NR:

SC

55.

RI PT

surgical patients facilitated by improved accelerated osteogenic orthodontic

Corticotomy-assisted retraction: an outcome assessment. Indian J Dent Res

56.

M AN U

25:748, 2014

Wilcko MT, Wilcko WM, Pulver JJ, Bissada NF, Bouquot JE: Accelerated

osteogenic orthodontics technique: a 1-stage surgically facilitated rapid

67:2149, 2009 57.

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orthodontic technique with alveolar augmentation. J Oral Maxillofac Surg

Wilcko W, Wilcko MT: Accelerating tooth movement: the case for

58.

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corticotomy-induced orthodontics. Am J Orthod Dentofacial Orthop 144:4, 2013 Higgins JPT, Green S, (eds): Cochrane Handbook for Systematic Reviews

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of Interventions Version 5.1.0 (ed. [Updated March 2011]). http://www.cochrane-handbook.org, The Cochrane Collaboration, 2011, 59.

Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP,

Clarke M, Devereaux PJ, Kleijnen J, Moher D: The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 6:e1000100, 2009

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ACCEPTED MANUSCRIPT Figure and Table Legends: Figure 1: PRISMA flowchart for the systematic review literature selection

Table 1: Systematic review search strategies

Table 2: Study design parameters of included articles

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process

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Abbreviations: BD, Bone density; BOP, Bleeding on Probing; CCT, Controlled Clinical Trial; CBCT, Cone Beam Computed Tomograph; CT, Computed

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Tomograph; L, Mandibular arch; N/A, Study did not examine parameter; PA, Periapical radiograph; PDL, Periodontal Ligament; PDs, Probing Depths; RCT, Randomized Clinical Trial; U, Maxillary arch; 1-2, incisors; 3, canines; 4-5,

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premolars; 6-7, molars.

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Table 3: Risk of Bias assessment

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Low = Low risk of bias. High = High risk of bias. Unclear = Uncertain risk of bias

Table 4: Description of Participants and Interventions of the included studies Abbreviations: B+P, Buccal + Palatal; Cort., Corticotomy; DFDBA, Demineralized Freeze Dried Bone Allograft; FFA, Full Fixed Appliances; L, Mandibular arch; NiTi, Nickel Titanium; OTM, Orthodontic Tooth Movement; TADs, Temporary Anchorage Devices; TPA, Trans-palatal arch; U, Maxillary arch; 1-2, incisors; 3, canines; 4-5, premolars; 6-7, molars.

30

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Table 5: Outcomes of included studies Abbreviations: BD, Bone density; BOP, Bleeding on Probing; Cort., Corticotomy; L,

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Mandibular arch; N/A, Study did not examine parameter; OTM, Orthodontic

Tooth Movement; PA, Periapical radiograph; PDL, Periodontal Ligament; PDs, Probing Depths; RR, Root Resorption; SD, Standard deviation; SS, Statistically

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significant; U, Maxillary arch; 1-2, incisors; 3, canines; 4-5, premolars; 6-7,

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molars.

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ACCEPTED MANUSCRIPT Table 1: Search Strategy

CENTRAL SCOPUS

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Web of Science

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Embase

Search Strategy (tooth movement OR orthodontic tooth movement.mp. OR accelerated orthodontic tooth movement.mp.) AND (corticotomy.mp. OR corticotomies.mp. OR piezocision.mp. OR piezosurg$.mp. OR alveolar decort$.mp. OR alveolar surg$.mp. OR alveolar surgery.mp. OR osteotomy.mp. OR surg$ assisted tooth movement.mp. OR rapid tooth movement.mp. OR corticotomy facilitated orthod$.mp. OR regional acceleratory phenomenon.mp. OR regional accelerated phenomenon.mp. OR (RAP and orthod$).mp. OR accelerated osteogenic orthod$.mp. OR periodontally accelerated osteogenic orthod$.mp. OR piezotomy.mp. OR piezopuncture.mp. OR corticision.mp.). Limit to humans. (tooth movement OR orthodontic tooth movement OR accelerated orthodontic tooth movement) AND (corticotomy OR corticotomies OR piezocision OR piezosurg* OR alveolar decort* OR alveolar surg* OR alveolar surgery OR osteotomy OR surg* assisted tooth movement OR rapid tooth movement OR corticotomy facilitated orthod* OR regional acceleratory phenomenon OR regional accelerated phenomenon OR (RAP and orthod*) OR accelerated osteogenic orthod* OR periodontally accelerated osteogenic orthod* OR piezotomy OR piezopuncture OR corticision). Limit to humans. Same as Medline TITLE-ABS-KEY(("tooth movement" OR "orthodontic tooth movement" OR "accelerated orthodontic tooth movement") AND ("corticotomy" OR "corticotomies" OR "piezocision" OR "piezosurg*" OR "alveolar decort*" OR "alveolar surg*" OR "alveolar surgery" OR "surg* assisted tooth movement" OR "rapid tooth movement" OR "corticotomy facilitated orthod*" OR "regional acceleratory phenomenon" OR "regional accelerated phenomenon" OR ("RAP" AND "orthod*") OR "accelerated osteogenic orthod*" OR "periodontally accelerated osteogenic orthod*" OR "piezotomy" OR "piezopuncture" OR "corticision")). Limit to humans. Same as SCOPUS

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Database Medline

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Table 2: Study Design of Included Studies

Method Error Analysis Yes

Statistics used for data Yes

Yes, 10 subjects

No

Yes

CCT

Yes, 18 subjects

No

Yes

CCT

Split mouth study

No

Yes

Control group (no cort.) Split mouth study

Bhattacharya et al. 201431

RCT

Sakthi et al 201455

Salman, Ali 20148

Study Al Naoum et al. 201450

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Study Design RCT

Method of assessing Tooth Movement Digital calipers measured distance between U3 and U6 at weeks 0,1, 2, 4, 8, 12 weeks No measurement made, time to space closure measured.

Digital caliper measurements between U+L 3s and 5s on study models, once a month. Measured off study models taken pre and post-experimental period.

Method for Root Resorption N/A

Method for tooth vitality N/A

CTs taken before and after en masse retraction (cort. group only). Labiolingual thickness of alveolar bone of U anteriors measured at 3 levels N/A

N/A

N/A

N/A

N/A

Gingival sulcus depth of maxillary canines. PDL changes on PA radiographs at start and end of experiment.

N/A

Assessed, method not discussed

Method of assessing Periodontal Parameters N/A

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ACCEPTED MANUSCRIPT Yes, 12 subjects

Yes

Yes

Abed, AlBustani 201354

CCT

Split mouth study

No

Yes

Alikhani et al. 20139

RCT

Yes, 10 subjects

Yes

Yes

Shoreibah et al. 201228

CCT

Yes, 10 subjects

No

Yes

Preoperative levelling, alignment, and extraction space closure (T3– T1) assessed by scanned upper study models. Study models at start and end of experiment. Special acrylic splint used to measure b/w canine and 1st molar. Study models at start and end of experiment. Distance b/w U3 (at 3 points along the crown to assess type of movement) and U2 measured. Not mentioned

Shoreibah et al. 201227

RCT

Yes, 10 subjects (cort. Only group)

No

Yes

Not mentioned

Abbas et al. 201130

CCT

Split mouth study

No

Yes

Abbas et al. 201126

CCT

Split mouth study

No

Yes

Aboul-Ela et al. 201149

RCT

Split mouth study

No

Yes

Fischer 200751

RCT

Split mouth study

No

Gantes et al. 199052

CCT

Yes, 4 age and orthodontically matched subjects

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No

No

N/A

N/A

Perio pocket depths at start and end. BOP weekly. PA radiographs of maxillary canines taken at start and end to assess bone levels. N/A

N/A

Electronic pulp test: U3s, U5s, U6s.

N/A

N/A

Perio measurements were made with a William's probe. PA x-rays used to assess bone density (BD) via gray scale software.

Perio measurements were made with a William's probe. PA radiographs used to assess bone density (BD) via gray scale software.

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N/A

Study models were used to assess movement of the U3s and the U6s every 30 days. Initial upper study models used to measure the distance from the incisal tip of each canine to its final position in the arch. Time to treatment completion.

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Yes

N/A

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CCT

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Wu et al. 201453

Plaque index, gingival index, PDs, attachment level and gingival recession were assessed at start and end of U3 retraction. N/A

Plaque index, gingival index, PDs, attachment level, and gingival recession PDs of U3s canines compared at end of treatment. PA radiographs of U3s taken one year after treatment to compare bone levels. Plaque scores, PDs and attachment levels assessed. Used an electronic pressure sensitive probe. Pre and post-op PA radiographs.

Distance from CEJ to apex measured off PA radiographs Distance from CEJ to apex measured off PA radiographs N/A

N/A

CBCTs of upper arch at start and end of U3 retraction. N/A

N/A

N/A

N/A

Periapical radiographs

Assessed, method not discussed

Abbreviations: BD, Bone density; BOP, Bleeding on Probing; CCT, Controlled Clinical Trial; CBCT, Cone Beam Computed Tomograph; CT, Computed Tomograph; L, Mandibular arch; N/A, Study did not examine parameter; PA, Periapical radiograph; PDL, Periodontal Ligament; PDs, Probing Depths; RCT,

33

N/A

N/A

N/A

ACCEPTED MANUSCRIPT Randomized Clinical Trial; U, Maxillary arch; 1-2, incisors; 3, canines; 4-5, premolars; 6-7, molars.

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Table 3: Risk of Bias Assessment Allocation Concealment High

Blinding of Outcomes High

Incomplete Outcome Data Low

Selective Reporting Low

Other sources of Bias High

Unclear

Unclear

High

Low

Low

Unclear

Sakthi et al 201455

High

High

High

Low

Low

High

Salman, Ali 20148

High

High

High

Unclear

High

High

Wu et al. 201453

High

High

High

Low

Low

Unclear

Abed, Al-Bustani 201354

High

High

High

Low

High

Unclear

High

Low

Low

Low

Unclear

Alikhani et al. 20139

Unclear

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Bhattacharya et al. 201431

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Sequence Generation Low

Study Al Naoum et al. 201450

High

Unclear

High

Low

Low

High

Shoreibah et al. 201227

Unclear

Unclear

High

Low

Low

High

Abbas et al. 201130

High

Unclear

High

Low

Low

High

Abbas et al. 201126

High

Unclear

High

Low

Low

High

Aboul-Ela et al. 201149

Low

Unclear

High

Low

Low

Unclear

Fischer 200751 Gantes et al. 199052

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Shoreibah et al. 201228

Unclear

Low

Low

Low

Low

Unclear

High

High

High

Low

Low

High

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Low = Low risk of bias. High = High risk of bias. Unclear = Uncertain risk of bias

34

ACCEPTED MANUSCRIPT Table 4: Description of Participants and Interventions

Participants + age range

Orthodontic appliance/Force application

Al Naoum et al. 201450

30 subjects (20.04 yrs +/3.63 yrs). Power study.

Bhattacharya et al. 201431

20 subjects (15 to 25yrs)

Sakthi et al 201455

40 subjects (18-25yrs). Power study.

022 inch slot FFA. TPA for anchorage. 19x25 Steel wires. Retraction force: 120gm Sentalloy NiTi coils. Force applied immediately after cort. 022 inch slot brackets. 16x22 Steel wires. En masse retraction of anterior teeth with NiTi coils (250gm) 2 wks postsurgery. TPA anchorage. No reactivation of coils. 022 inch slot FFA. 19x25 Steel wires. En masse anterior retraction U+L arches with 250gm NiTi coil springs Force applied 5-7 days post-surgery.

Salman, Ali 20148

15 subjects (17-28yrs).

FFA. No details of wires used. Elastomeric chain used for canine retraction. No mention of force calibration or reactivation protocols.

24 subjects (18 to 30yrs). Power study.

022 inch slot FFA. 19x25 Steel wires. En masse retraction of U anterior teeth 2 weeks after cort. Adjustments every 4 weeks.

Alikhani et al. 20139

20 subjects (19.5 to 33.1 years). Power study.

Shoreibah et al. 201228

20 subjects (18.4 to 25.6 years)

Shoreibah et al. 201227

20 subjects (average age 24yrs 6mths). 3 withdrawals

Abbas et al. 201130

10 subjects (15 to 25yrs)

Abbas et al. 201126

10 subjects (15 to 25yrs)

Aboul-Ela et al. 201149

13 subjects (mean age 19yrs). Initial 15 pts, 2 excluded.

B + P flaps raised. Vertical inter-radicular and subapical corticotomy cuts buccal and palatal, from mesial surface of U4s of one side to the other side. DFDBA grafts placed. Extractions at same appointment. B + P flaps raised 3-3. Micromotor handpiece used for decortications. Vertical inter-radicular cuts were made, or corticotomy holes were placed if lacking space. Horizontal decortications connected the vertical cuts 2 mm beyond root apex. Performed 3-3. DFDBA placed only if needed. Soft tissue incisions made mesial and distal to maxillary canines by soft tissue laser on buccal side only. 4 circular holes were made mesially and distally, 2-3 mm apart. Each alveolar perforation was made with a hard tissue laser, approximately 1.5 mm in diameter and 3mm in depth. Premolars extracted prior. Buccal flaps only. Vertical inter-radicular corticotomy cuts from the mesial area of the right second premolar to the mesial area of the left second premolar. No horizontal corticotomy cuts. Bone graft placed on the decorticated areas for cort. subjects. Buccal side only, flap raised. 3-4 corticotomy holes 2mm apart (1.5mm diameter, 3mm deep to penetrate through the cortical bone) made along the bone mesially and distally adjacent to U3s. Premolars were extracted 6mths prior. No flaps raised. Three MOPs (Micro-Osteo Perforations) performed (in the left or right side) distal to the U3s before retraction using a disposable MOP device.

Until upper first premolar extraction spaces closed

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12-week experimental period. No follow-up.

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12 subjects (17-28 yrs)

FFA. 16x22 Steel wires with stops and tip back bends for U6s. 200gm power chain used to retract U3s, replaced weekly. 022 inch slot brackets. 16x22 Steel wires. U3 retraction achieved with 100gm NiTi coil springs connected from a TAD to a power arm on U3. Force was checked at each appt. 022 inch brackets, FFA. Tooth movement was initiated immediately after cort. Worked up to 19x25 Steel wires. Orthodontic adjustments every 2 weeks. 022 Roth brackets, FFA. Tooth movement was initiated immediately after cort. Worked up to 19x25 Steel wires. Orthodontic adjustments every 2 weeks.

AC C

Abed, AlBustani 201354

4 weeks post-exo. B + P flaps raised. Vertical interradicular and subapical corticotomy cuts buccal and palatal to U3s. Small corticotomy perforations were drilled in the buccal and palatal cortical bone.

TE D

Wu et al. 201453

Experimental Period

Corticotomy Intervention

EP

Study

022 inch brackets, FFA. 16x22 Steel wires. U3s retracted with precalibrated Sentalloy coil springs (150gms) immediately after surgery. 022 inch brackets, FFA. 16x22 Steel wires. U3s retracted with precalibrated Sentalloy coil springs (150gms) immediately after surgery. Fixed appliances. 16x22 Steel wires. TADs for U3s retraction. NiTi coils applying (150gms) on each side were used for retraction immediately after surgery.

Labial flaps raised from the distal surface L3 to other L3. Vertical inter-radicular corticotomy cuts performed. No horizontal corticotomy cuts. Antibiotics, analgesia and anti-edematous drugs used post-op. Labial flaps raised from the distal surface L3 to other L3. Vertical inter-radicular corticotomy cuts performed. No horizontal corticotomy cuts. Experimental group also had a bone graft placed. Antibiotics, analgesia and anti-edematous drugs used post-op. Premolars extracted on surgery day. Interproximal soft tissue incisions made mesial and distal to U3s. Piezosurgical inter-radicular full length cuts made interproximally and to a depth of 3mm. Bundle bone from the extraction socket next to the U3 removed. Premolars extracted on surgery day. Buccal flaps raised. Circumscribing corticotomy cuts and perforations performed facially along the length of U3 root with a piezotome. Bundle bone from the extraction socket next to the U3 removed. TADs were placed bilaterally between the U5 and U6. U4s extracted. Buccal flap raised. Corticotomy perforations were made extending from the U2 to U4 area. The depth of the holes approximated the width of the buccal cortical bone.

4 months. No followup.

6 weeks.

Duration of presurgical orthodontics: 12.519 months

One month. No follow-up.

4 weeks

From start to 6mths post-treatment.

From start to 6mths post-treatment.

Not specified. Until canines retracted into 1st premolar spaces. Not specified. Until canines retracted into 1st premolar spaces. 4 months

35

ACCEPTED MANUSCRIPT 6 subjects (11.1 to 12.9 yrs).

Gantes et al. 199052

9 subjects (21-32 yrs)

FFA. 2 weeks post surgery, an attachment placed on the impacted U3s. 60gms of force. 4-6 week intervals for adjustments reduced to 2 weeks when canine near final position. FFA placed prior to surgery. Orthodontic appliances were activated immediately after completion of the surgical procedures.

On the corticotomy side, a series of circular holes made along the bone mesial and distal adjacent to the canine were made. These holes extended into the edentulous area into which the tooth was to be moved.

Until canines were extruded into arch (38-78 weeks). 12 mths retention follow-up

B + P flaps raised. Vertical inter-radicular and subapical corticotomy cuts B + P. The teeth which had been planned for extraction were removed at this time. B + P cortical bone was removed over the extraction sites.

11-35 mths experiment. Treatment duration not specified.

RI PT

Fischer 200751

Abbreviations: B+P, Buccal + Palatal; Cort., Corticotomy; DFDBA, Demineralized Freeze Dried Bone Allograft; FFA, Full Fixed Appliances; L, Mandibular arch;

SC

NiTi, Nickel Titanium; OTM, Orthodontic Tooth Movement; TADs, Temporary

M AN U

Anchorage Devices; TPA, Trans-palatal arch; U, Maxillary arch; 1-2, incisors; 3, canines; 4-5, premolars; 6-7, molars.

Table 5: Outcomes of Included Studies

Bhattacharya et al. 201431

Sakthi et al 201455

Salman, Ali 20148

TE D

-From 0 weeks to 1 week: 0.739+/-0.365mm -From 1 week to 2 weeks: 0.455 +/-0.402mm -From 2 weeks to 4 weeks: 0.308+/-0.248mm -From 4 weeks to 8 weeks: 0.282+/-0.113mm -From 8 weeks to 12 weeks: 0.243+/-0.072mm Corticotomy group: Space closure took 130.50 days (SD 8.91). -This was SS faster than controls

Rate of Control OTM

-92.8% closure of the extraction space (7.05mm), average rate of U space closure of 1.8 mm/month. -91.6% closure of the extraction space (6.3mm), average rate of L space closure of 1.57 mm/month. An average of 1.63 mm of canine distalization was seen over 6wks.

Accelerated OTM rate

-From 0 weeks to 1 week: 0.201+/-0.149mm -From 1 week to 2 weeks: 0.105+/-0.115mm -From 2 weeks to 4 weeks: 0.095+/-0.161mm -From 4 weeks to 8 weeks: 0.124+/-0.061mm -From 8 weeks to 12 weeks: 0.080+/-0.060mm Control group: Space closure took 234.10 days (SD 7.37).

2-4 times. All differences were SS when compared with controls.

-54.5% closure of the extraction space (4.15mm), average rate of U space closure of 1.02 mm/month. -51.5% closure of the extraction space (3.5mm), average rate of L space closure of 0.87 mm/month. An average of 0.82mm of canine distalization was seen over 6wks.

1.7 times faster in the maxilla, 1.8 times faster in the mandible.

EP

Al Naoum et al. 201450

Rate of Corticotomy OTM

AC C

Study

1.78 times

2 times. This was SS.

RR Outcome

Tooth Vitality

N/A

N/A

N/A

Coronally, there was a 5.238.23% increase in alveolus. At mid-root, teeth 11, 12 and 22 had increases of 4.49%, 6.26% and 5.39%. Apically, teeth 11 and 21 increases of 5.61% and 3.04%. All values SS. N/A

N/A

N/A

N/A

N/A

Gingival sulcus depths around maxillary canines did not exceed 4mm pre or post-experiment. No pathological changes in PDL seen on PA radiographs.

N/A

No change

Perio Outcome

36

ACCEPTED MANUSCRIPT Cort. group space closure was 5.52 +/- 1.28 months. From T1 to T3, the rate of OTM was 0.30 +/- 0.13mm per month for central incisors and 0.43 +/0.11mm per month for U3s Surgical side: mean canine distalisation in one month was 1.74mm, SD 0.47. Stat. Significant.

Control group space closure was 14.17 +/- 3.95 months. From T1 to T3, the rate of OTM was 0.19 +/0.06mm/month for central incisors and 0.26 +/0.07mm/month for U3s Control side: mean canine distalisation in one month was 1.22mm, SD 0.40. Stat. Significant.

Data not provided

Data not provided

2.3 times

Mandibular alignment took 17.5 weeks

Mandibular alignment took 49 weeks

2.8 times

Shoreibah et al. 201227

Mandibular alignment in both groups ranged from 14-20 weeks with a mean of 17 weeks for cort. and bone graft

Mandibular alignment in both groups ranged from 14-20 weeks with a mean of 6.67 weeks for controls

Abbas et al. 201130

N/A

Abed, AlBustani 201354

Experimental side showed 42.6% greater canine distalisation than control side

N/A

N/A

N/A

Pre and post surgery depths did not exceed 2.5mm on either side. No SS changes in probing depths or BOP. PA x-rays showed no differences b/w sides in terms of appearance of alveolar bone. N/A

N/A

No change

N/A

N/A

No SS difference between the two groups in PDs. 6mths post-treatment, Cort. group had a decrease in PD of 1.86 ± 0.15 mm, controls had a net decrease of 1.70±0.32mm. There were no SS differences in the amount of change in BD. From beginning of treatment to 6mths posttreatment, cort. + bone graft had 21.8% less density than pretreatment values, while controls had 37.2% less density. No SS difference between the two groups in PDs. 6mths post-treatment, cort. + bone graft group had net decrease in PD of -1.559 ±0.164mm. Controls had net decrease of -1.427 ± 0.237 mm. 6mths posttreatment, BD was -17.59% less than pre-treatment in controls, while cort. + bone graft group were 25.85% more than pre-treatment value.

Cort. Group had a net decrease in root length of 1.5 ± 0.9 mm. Controls had a net decrease in root length of 1.7 ± 9.5mm.

N/A

No SS difference between two groups. Controls: decrease in root length of -0.056 mm ± 0.025, cort. + bone graft group: net decrease of 0.050mm±0. 026.

N/A

N/A

N/A

SS difference at 3 months postop. Cort. side: 0.6mm RR (SD 0.3). Controls: 1.5mm RR (SD 0.6). N/A

N/A

N/A

N/A

M AN U

SC

Alikhani et al. 20139 Shoreibah et al. 201228

Treatment time was SS reduced by 8.65 +/- 2.67 months for space closure.

RI PT

Wu et al. 201453

AC C

Abbas et al. 201126

EP

TE D

Nil

N/A

N/A

N/A

N/A

N/A

Aboul-Ela et al. 201149

-At one month: 1.89mm -At 2 months: 3.72mm -At 3 months: 4.79mm -At 4 months: 5.68mm -All values SS

-At one month: 0.75mm -At 2 months: 1.61mm -At 3 months: 2.54mm -At 4 months: 3.38mm

2nd month: 2 times. 3rd month: 1.6 times. 4th month: 1.06 times

Fischer 200751

The cort. canines moved at a rate of 1.06 mm/month (SS).

The control canines moved at a rate of 0.75 mm/month (SS).

Reduction in treatment time ranged from 28% to 33%.

No SS difference in plaque index, gingival index, PDs, attachment loss and gingival recession preoperatively and 3 months postoperatively N/A

No SS difference in plaque index, attachment loss, gingival recession, and PDs preop and at 4 months postop. Gingival index scores were higher on the operated side. No differences in PDs. No differences in bone levels when comparing sides.

37

N/A

ACCEPTED MANUSCRIPT Mean treatment time was 28.3 months for the control group.

Reduction in treatment time of 50%.

-Mean plaque scores were 27% prior to surgery, remained unchanged for 1 month, then decreased. -PDs were reduced by 0.2 mm (+0.1 to -0.4mm). -Attachment levels changed 0.2 mm or less. 88% of the sites had an attachment level which stayed within 1mm of the original value.

RR after treatment was mentioned, but not quantified or compared to controls.

RI PT

Mean treatment time was 14.8 months for cort. group.

Abbreviations: BD, Bone density; BOP, Bleeding on Probing; Cort., Corticotomy; L, Mandibular arch; N/A, Study did not examine parameter; OTM, Orthodontic

SC

Tooth Movement; PA, Periapical radiograph; PDL, Periodontal Ligament; PDs, Probing Depths; RR, Root Resorption; SD, Standard deviation; SS, Statistically

M AN U

significant; U, Maxillary arch; 1-2, incisors; 3, canines; 4-5, premolars; 6-7,

EP

TE D

molars.

AC C

Gantes et al. 199052

38

No change

ACCEPTED MANUSCRIPT

SC

AC C

EP

TE D

M AN U

Methods: • Aims of study: • Study design: • Methods of recruitment of participants: • Inclusion/exclusion criteria: • Method error analysis: • Adequate statistics: • Operator blinding in measurements: Participants: • Description: • Number: • Age: • Gender: • Withdrawals: Intervention: • Corticotomy protocol: • Orthodontic appliance: • Methods of measurement: • Treatment/Observation duration: • Details of secondary interventions: • Control group: Outcomes: • Rate of tooth movement: • Rate of acceleration of tooth movement: • Pain assessment: • Periodontal assessment: • Root resorption assessment: • Tooth vitality assessment: • Author’s conclusion:

RI PT

Appendix I: Customised Data Extraction Template

39

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT