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References

Turbill EA, Richmond S, Wright JL. The time-factor in orthodontics: what influences the duration of treatments in National Health Service practices?. Community Dent Oral Epidemiol. 2001; 29:62-72
Julien KC, Buschang PH, Campbell PM. Prevalence of white spot lesion formation during orthodontic treatment. Angle Orthod. 2013; 83:641-647 https://doi.org/10.2319/071712-584.1
The biology of fracture healing: an overview for clinicians. Part I. 1989. http://journals.lww.com/corr/Fulltext/1989/11000/The_Biology_of_Fracture_Healing__An_Overview_for.45.aspx
Frost HM. The biology of fracture healing: an overview for clinicians. Part II. Clin Orthop Relat Res. 1989; 248:294-309
Kole H. Surgical operations on the alveolar ridge to correct occlusal abnormalities. Oral Surg Oral Med Oral Pathol. 1959; 12:277-278
Murphy KG, Wilcko MT, Wilcko WM, Ferguson DJ. Periodontal accelerated osteogenic orthodontics: a description of the surgical technique. J Oral Maxillofac Surg. 2009; 67:2160-2166
Aboul-Ela SMBE-D, El-Beialy AR, El-Sayed KMF, Selim EMN, El-Mangoury NH, Mostafa YA. Miniscrew implant-supported maxillary canine retraction with and without corticotomy-facilitated orthodontics. Am J Orthod Dentofacial Orthop. 2011; 139:252-259
Wilcko WM, Wilcko T, Bouquot JE, Ferguson DJ. Rapid orthodontics with alveolar reshaping: two case reports of decrowding. Int J Periodontics Restorative Dent. 2001; 21:9-19
Wilcko MT, Wilcko WM, Pulver JJ, Bissada NF, Bouquot JE. Accelerated osteogenic orthodontics technique: a 1-stage surgically facilitated rapid orthodontic technique with alveolar augmentation. J Oral Maxillofac Surg. 2009; 67:2149-2159
Baloul SS, Gerstenfeld LC, Morgan EF, Carvalho RS, Van Dyke TE, Kantarci A. Mechanism of action and morphologic changes in the alveolar bone in response to selective alveolar decortication-facilitated tooth movement. Am J Orthod Dentofacial Orthop. 2011; 139:(4 Suppl)S83-101
Fischer TJ. Orthodontic treatment acceleration with corticotomy-assisted exposure of palatally impacted canines. Angle Orthod. 2007; 77:417-420
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. 2014; 72:1880-1889
Alikhani M, Raptis M, Zoldan B Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013; 144:639-648
Uribe F, Davoody L, Mehr R Efficiency of piezotome-corticision assisted orthodontics in alleviating mandibular anterior crowding – a randomized clinical trial. Eur J Orthod. 2017; 39:595-600
Gibreal O, Hajeer MY, Brad B. Efficacy of piezocision-based flapless corticotomy in the orthodontic correction of severely crowded lower anterior teeth: a randomized controlled trial. Eur J Orthod. 2019; 41:188-195
Wu J, Jiang J-H, Xu L, Liang C, Bai Y, Zou W. A pilot clinical study of Class III surgical patients facilitated by improved accelerated osteogenic orthodontic treatments. Angle Orthod. 2014; 85:616-624 https://doi.org/10.2319/032414-220.1
Makki L, Ferguson DJ, Wilcko MT Mandibular irregularity index stability following alveolar corticotomy and grafting: A 10-year preliminary study. Angle Orthod. 2015; 85:743-749 https://doi.org/10.2319/061714-439.1
Liou EJ, Huang CS. Rapid canine retraction through distraction of the periodontal ligament. Am J Orthod Dentofacial Orthop. 1998; 114:372-382
Leethanakul C, Kanokkulchai S, Pongpanich S, Leepong N, Charoemratrote C. Interseptal bone reduction on the rate of maxillary canine retraction. Angle Orthod. 2014; 84:839-845
Ohkubo K, Susami T, Mori Y Treatment of ankylosed maxillary central incisors by single-tooth dento-osseous osteotomy and alveolar bone distraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011; 111:561-567
Dolanmaz D, Karaman AI, Pampu AA, Topkara A. Orthodontic treatment of an ankylosed maxillary central incisor through osteogenic distraction. Angle Orthod. 2010; 80:391-395
You K-H, Min Y-S, Baik H-S. Treatment of ankylosed maxillary central incisors by segmental osteotomy with autogenous bone graft. Am J Orthod Dentofacial Orthop. 2012; 141:495-503
Fleming PS, Fedorowicz Z, Johal A, El-Angbawi A, Pandis N. Surgical adjunctive procedures for accelerating orthodontic treatment. Cochrane Database Syst Rev. 2015; (6)
Aksakalli S, Calik B, Kara B, Ezirganli S. Accelerated tooth movement with piezocision and its periodontal-transversal effects in patients with Class II malocclusion. Angle Orthod. 2016; 86:59-65 https://doi.org/10.2319/012215-49.1
Evaluation of corticotomy-facilitated orthodontics and piezocision in rapid canine retraction. 2016. http://www.sciencedirect.com/science/article/pii/S0889540615014031 (Accessed July 2, 2017)

Surgical Methods for Accelerating Orthodontic Tooth Movement

From Volume 13, Issue 4, October 2020 | Pages 170-179

Authors

Aman Ulhaq

BDS, MFDS, MSc, MOrth, FDOrth

Consultant in Orthodontics, Edinburgh Dental Institute, Edinburgh, UK

Articles by Aman Ulhaq

Emma McCrory

BDS, MFDS

Department of Orthodontics

Articles by Emma McCrory

Abstract

The ability to consistently reduce orthodontic treatment time without adverse outcomes would be an attractive prospect. Several surgical interventions have been described aimed at accelerating orthodontic tooth movement. The aim of this review is to identify and evaluate the current evidence available for surgically-assisted orthodontic tooth movement (OTM). The current evidence suggests that surgical procedures may increase the rate of tooth movement, however, this effect is short lived. Further reporting on total treatment time, and patient centred outcomes, would be beneficial in future studies.

CPD/Clinical Relevance: To explain surgical methods for accelerating orthodontic tooth movement.

Article

Aman Ulhaq

The ultimate challenge for orthodontists is to reduce treatment duration without compromising the result. Much of the current research is focusing on reducing treatment time and the methods employed can be broadly categorized into surgical and non-surgical methods. Efficient treatment can lead to reduced costs, both in the private and public healthcare settings.1 With reduced treatment times, there is likely to be a reduction in the risk of iatrogenic damage, namely enamel decalcification2 and root resorption, along with a likely increase in patient satisfaction. Furthermore, adult patients may be more inclined to accept orthodontic treatment if treatment duration could be shortened.

Surgical methods have been proposed to speed up OTM. These methods are mainly based on the principle of the Regional Acceleratory Phenomenon (RAP). The RAP was described by the Orthopaedic Surgeon Harold Frost.3,4 Surgical injury or intervention in the bony tissues results in remodelling activity in the adjacent hard and soft tissues. The resultant affect may be a more rapid rate of bone turnover, and a decrease in bone density, which would certainly be of interest to orthodontists. Surgical methods aiming to increase the rate of tooth movement include:

  • Corticotomy facilitated orthodontics (CFO);
  • Interseptal alveolar surgery;
  • Osteotomy/Distraction osteogenesis.

    • The aim of this article was to identify the various methods available to accelerate OTM and to evaluate the current evidence base available.

    Corticotomy facilitated orthodontics

    Corticotomy is defined as a surgical cut or an intentional surgical injury to cortical bone without penetrating the medullary bone. Kole was the first to introduce this concept into orthodontics.5 This procedure involved making vertical interdental cuts through the cortical bone, and horizontal osteotomy cuts subapically, thus mobilizing ‘blocks’ of bone. Different surgical techniques have been described. Flap design is aimed at allowing access to the alveolar bone to perform corticotomies, whilst also preserving gingival architecture. Murphy et al advocate a full thickness mucoperiosteal flap at the coronal aspect and a split thickness flap at the apical portion to mobilize the mucosa.6 Alternatively, a sub-marginal Luebke-Ochsenbein flap can be used which aims at retaining 2 mm of attached gingiva apical to the gingival sulcus.7 Corticotomies can be performed with a number 2 round bur or a piezoelectric knife with copious irrigation. In addition to this, allograft or xenograft material can be placed to augment the bone (Figures 1 and 2).8,9

    Figure 1. Alveolar corticotomies for the maxillary arch.
    Figure 2. Corticotomy cuts for lower incisor crowding.

    Alveolar corticotomy is likely to result in increased expression of osteoclastogenic cells and regulators. Increases in Receptor Activator of Nuclear Factor Kappa-B Ligand (RANKL), Macrophage Colony Stimulating Factor (M-CSF), as well as decreased bone volume and bone density, have been reported.10 Aboul-Ela et al7 conducted a split-mouth study for canine retraction with CFO. One side was randomly assigned to CFO and the results revealed a 2–3 fold increase in the rate of tooth movement compared to the control group over the first two months. The effects of CFO lasted for around 4 months, after which any difference in tooth movement is negligible. In another split-mouth study design,11 patients with bilateral palatally ectopic canines had these teeth surgically exposed. On the experimental canine corticotomy, holes were surgically drilled in the bony area into which the tooth was moved; the control side had a conventional surgical exposure. This study revealed a statistically significant difference in the rate of tooth movement (0.31 mm/month), however, the sample size of the study was only six patients. A larger split-mouth randomized clinical trial, assessing the rate of canine retraction in Class II division 1 cases, demonstrated that space closure was more than three times faster on the experimental side over the 4-week period following the corticotomies.12 Although the space closure remained significantly faster on the experimental side up to 12 weeks after the procedure, the rate of tooth movement had decreased in both groups. Micro-osteoperforations (Figure 3) have a similar effect to corticotomies. Alikhani et al also carried out a split-mouth study, which included 22 patients, with one side of the maxilla receiving three micro-osteoperforations approximately 1.5 mm wide and 2–3 mm deep for canine retraction and the contralateral side acting as an untreated control. Their results found a 2.3-fold increased rate in canine retraction over 28 days.13

    Figure 3. Micro-osteoperforations after palatal canine exposure.

    Flapless piezocision has shown varying results in how it affects the rate of tooth movement. Uribe et al14 showed no significant difference between the experimental and control group for time taken to achieve orthodontic tooth alignment. This study assessed mandibular alignment in a non-extraction group. Contrary to these findings, a further study assessed mandibular alignment after the extraction of first premolars and found a highly statistical and clinically significant difference, with alignment achieved in 53 days in the piezocision group compared to 131 days in the control group.15 The differences in the two studies could be due to the depth of the cuts made, as the former study used 1 mm cuts compared to 3 mm in the latter.

    The RAP may also be utilized in the ‘surgery-first approach’ for orthognathic cases.16 The osteotomy cuts and soft tissue flaps will result in an inflammatory response. In surgery-first cases, the surgery is carried out in the aligning phase of orthodontic treatment and thus has the potential to be more efficient.

    Stability and retention are important factors in orthodontics and much of the effort is placed on post-treatment methods to control relapse. However, there is some evidence that CFO, in addition to bone augmentation, may reduce relapse. A 10-year follow-up study has associated lower levels of post-treatment changes for CFO with bone augmentation, when compared with conventionally treated control groups.17 The results must be interpreted with caution as there were significant pre-treatment differences between the unmatched comparison groups. Table 1 summarizes studies investigating corticotomy and osteoperforations to accelerate OTM.


    Study Origin Design Sample Surgical Technique Orthodontic Procedures Rate of OTM Anchorage Loss Adverse effects Patient-centred outcomes
    Abbas et al, 201625 Egypt Split-mouth, controlled clinical trial. Randomization of experimental side only, but not the intervention itself. N=20. 10 Piezocision on one side vs control on contralateral side. 10Corticotomy on one side vs control on contralateral side Corticotomy: submarginal flap 4 mm apical to free gingival margin, vertical bony cuts and perforations to full depth of cortical bone. Piezocision: vertical alveolar cuts 2 mm apical to crestal bone along canine root length mesially and distally. Removal of cortical bone on mesial wall of premolar extraction socket. Maxillary canine retraction on 0.016 x 0.022 in SS archwire using nickel titanium closed coil springs with 150 g force Mean canine movement over 12 weeks: 1.22 mm corticotomy, 0.99 mm piezocision, 0.59 mm control. Mesial molar movement: Corticotomy 2.99 mm, Piezocision 3 mm, Control 3.19 mm No difference in Silness and Loe gingival index, periodontal probing depth, attachment level or gingival recession. Increased canine root resorption in control group compared to experimental groups Not reported
    Aboul-Ela et al, 20117 Egypt Split-mouth, randomized clinical trial N=13. 5 male, 8 female (additional 2 lost to follow-up). Mean age 19 years Maxillary first premolar extractions. Leubke-Ochsenbein flap from mesial surface of lateral incisor to mesial surface of maxillary second premolar. Corticotomy perforations with round bur to depth of cortical bone Nickel titanium closed coil springs with 150 g force to retract maxillary canines, with a mini-screw for direct anchorage. 0.016 x 0.022 in SS archwire Mean tooth movement after 4 months: Corticotomy group 5.68 mm, Control group 3.38 mm. Effect of corticotomy negligible after 4 months. No significant difference in anchorage loss due to the use of mini-screws No difference in plaque score, gingival recession, attachment loss, and probing depths between groups before and after treatment. Gingival index score significantly higher in the corticotomy side compared to control. Not reported
    Aksakalli et al, 201624 Turkey Split-mouth, randomized clinical trial N=10 (6 Female, 4 Male), Mean age 16.3 +/-2.4 years Maxillary first premolar extractions. Piezocision 3 mm depth, verticle cuts of 10 mm Maxillary canine retraction on 0.016 x 0.022 in SS archwire using elastomeric chain with 150 g force Piezocision group 1.53 mm and 2.90 mm in 1 month and 2 months, respectively. Control group 0.78 mm and 1.73 mm in 1 month and 2 months, respectively Mesial molar movement: Piezocision group 2.04 mm, Control group 3.01 No difference in Silness and Loe (ginigval) and Muhleman's (mobility) indices Not reported
    Alikhani et al, 201313 USA Two-arm, randomized controlled clinical trial N=20. Experimental group 5 males, 5 females (mean age 26.8 years), Control group 3 males, 7 females (mean age 24.7 years). Extraction of maxillary first premolars. Three micro-osteoperforations distal to the canines with the PROPEL device (PROPEL Orthodontics, Ossing, NY, USA) Canine retraction using 100 g force from nickel titanium closed coil springs. 2.3-fold increase in experimental group compared to control group. Not reported No difference in levels of cytokines between control and experimental group. No difference in pain and discomfort between control and experimental groups.
    Al-Naoum et al, 201412 Syria Split-mouth randomized clinical trial N=30. 15 males and 15 females. Mean age 20.04 +/- 3.63 years Extraction of maxillary first premolars followed by corticotomy procedures 4 weeks later. Horizontal and vertical corticotomy grooves placed buccally and palatally to canines. Approximately 20 corticotomy perforations placed, 2 mm bur to a depth of 2 mm. Fixed appliances, 0.019 x 0.025 in SS archwires. 120 g force from nickel titanium closed coil springs 2- to 4-fold difference between control and experimental group in rate of OTM. 0.16–0.54 mm/week difference in favour of experimental group. Velocity decreases over time. Not reported Not reported Subjective assessment of pain, discomfort and swelling. Decrease in moderate to severe numbers after days 5 and 7.
    Fischer, 200711 USA Split-mouth, randomized clinical trial N=6. 2 males, 4 females. Age range 11.1–12.9 years Surgical exposure of palatally ectopic canines. Experimental side had corticotomy perforations spaced 2 mm apart, with 1.5 mm round bur mesial and distal to canine extending to the line of the arch. 60 g orthodontic force used to align the canines on both sides. Corticotomy group 1.06 mm/month, control group 0.75 mm/month. 28–33% reduction in treatment time for treatment group versus control. Not reported No difference in periodontal probing depths (clinical) or bone levels (radiographic assessment) Not reported
    Gibreal et al, 201915 Syria Two-arm, randomized controlled clinical trial N=36. Control group 7 male, 10 female (mean age 20.35 +/- 2.17 years) and Experimental group 8 male, 9 female (mean age 20.20 +/- 1.79 years). Flapless piezocision cuts between the six anterior mandibular teeth. Cuts were 5–8 mm in length and 3 mm deep. Extraction of first premolars followed by bond up of stainless steel conventional ligation brackets. Archwire sequence was as follows: 0.014-inch, 0.016-inch, 0.016 × 0.022-inch NiTi, 0.017X 0.025-inch NiTi, and finally 0.019×0.025-inch stainless steel. Orthodontic alignment time: Piezocision group 53.53 +/-12.54 days, Control group 131.41 +/- 38.52 days Not reported Not reported Not reported
    Uribe et al, 201714 USA Two-arm, randomized controlled clinical trial N=29. Control group 6 male, 7 female (mean age 29.4 +/- 9.3 years) and experimental group 6 male, 10 female (mean age 30.0 +/-12.5 years). Three vertical incisions interproximally between mandibular canines and lateral incisors, and between the central incisors on the labial aspect of the mandible through the gingiva and the underlying bone. The soft tissue incisions were 4 mm in length. The depth of the piezotome-corticision was 1 mm Non-extraction treatment. Passive self-ligating brackets. Archwire sequence for both groups was 0.014-inch copper–nickel–titanium archwire for the first 2 visits followed by a 0.014 × 0.025-inch copper–nickel–titanium archwire until alignment. Orthodontic alignment time: Piezocision group 102.13 +/- 34.73 days, Control group 112.00 +/- 46.22 days. No significant difference Not reported No harm in either group Not reported
    Wu et al, 201416 China Controlled Clinical Trial N=24. 12 in experimental group (4 male, 8 female), 12 control (4 male, 8 female). Mean age 20.1 +/- 1.6 years experimental group, 20.6 +/- 2.0 years control group. Class III orthognathic cases. Maxillary first premolar extractions before treatment. Surgical procedures once alignment achieved. Full thickness mucoperiosteal flap. Piezo ultrasonic surgery unit for vertical bony corticotomy cuts in interradicular spaces from mesial of right maxillary second premolar to mesial of left second premolar. Bone augmentation using Cerasorb (Curasan, Durham, NC, USA) 0.019 x 0.025 in SS archwires. En masse retraction of anterior teeth. Alignment of arches to space closure of premolar extraction spaces was achieved on average 8.65 months faster (5.52 months experimental, 14.17 months control group) in experimental group. No difference between groups for mesial molar movement (2.17 mm in experimental group, 2.46 in control group) Not reported Not reported

    Interseptal alveolar surgery

    Canine retraction is anchorage demanding and can be a lengthy process, often requiring 6–9 months of treatment with conventional orthodontic mechanics. Mechanics that allow for rapid canine movement with minimal anchorage loss have been proposed in conjunction with dento-alveolar surgery. Following extraction of first premolars, the interseptal alveolar bone between the canine and first premolar is reduced and undermined to reduce the resistance to tooth movement (Figure 4).18 This method involves rapid distraction of the periodontal ligament of the canine tooth distally using a custom dental distraction device. The authors reported that canine retraction was complete in three weeks (6.5–6.6 mm distal movement), with only an average of 0.1–0.2 mm mesial movement of the first molars, resulting in minimal anchorage loss. Leethanakul et al performed the interseptal alveolar bone reduction from within the tooth socket of the extracted premolar.19 The interseptal bone distal to the canine was reduced to a thickness of approximately 1–1.5 mm.

    Figure 4. Interseptal alveolar surgery.

    In addition, the premolar extraction socket was deepened to the level of the canine apex. This study found that mini-implant supported canine retraction was significantly greater on the experimental side (1.8 mm/month) in comparison with the control (1.1 mm/month). Table 2 summarizes studies investigating interseptal alveolar surgery procedures.


    Study Origin Design Sample Surgical Technique Orthodontic Procedures Rate of OTM Anchorage Loss Adverse effects Patient-centred outcomes
    Leethanakul et al, 201419 Thailand Split-mouth, randomized clinical trial N=18, all female. Mean age 21.9 +/- 4.7 years Extraction of premolar only on control side. Extraction with interseptal bone reduction on the experimental side. Extraction socket deepened to length of canine apex, interradicular bone removed if present within socket, interseptal bone decreased to 1–1.5 mm thickness distal to canine. 3M Gemini brackets (3M Unitek, Monrovia, Cal, USA). 150 g force each on palatal and buccal sides with elastomeric chain 1.8 mm/month on experimental side, 1.1 mm/month on control side. Measured over 3-month period. Not reported Not reported Not reported
    Liou and Huang, 199818 Taiwan Case series N=15, 8 females and 7 males. Age range 10–19 years. Extraction of premolar. Reduction of interseptal bone distal to canine, extraction socket ‘expanded’ with vertical grooves on buccal and lingual sides. Custom made distraction device fitted to bands on the canines and first molar. Activated 0.5–1.0 mm/day. Power chain on lingual side to prevent rotation. Movement after 3 weeks: 6.5 mm +/- 0.7 mm for maxillary canines, 6.6 mm+/- 0.4 mm for mandibular canines. 0.1–0.2mm mesial movement of first molars. 72.7% molars showed no movement, 27.3 % had less than 0.5 mm mesial movement. 0% of patients experienced root resorption more than blunting of the apex. 3.8% of patients had lateral root resorption beyond 1/3 thickness of dentine. All canines reacted +ve to electric pulp test before distraction, only 35.6% reacted +ve after distraction No patient reported severe pain. 1 patient reported thermal sensitivity during distraction. Method of observation not reported.

    Segmental osteotomy/distraction osteogenesis

    Case reports have been presented documenting the use of these procedures in order to surgically reposition or distract teeth that have become ankylosed following intrusive injury.20,21,22 Vertical osteotomy cuts which taper towards the apical portion are united by a horizontal cut that is usually 4–5 mm above the apices of the affected teeth. The cuts are then deepened to the palatal cortex. Distraction of the segment involves the use of orthodontic forces using looped archwires to achieve the direction of movement required. The segment may also be surgically repositioned, and this is likely to require bone grafting if the segment is moved a significant distance.

    Adverse effects

    Although there appears to be promise in CFO, the results need to be viewed with caution due to the current evidence being of relatively low quality.23 Furthermore, few studies seem to report the possible disadvantages of surgical procedure. Increased levels of pain, swelling and discomfort in the surgical area may be reported by patients in the first few days.12 In another study which used the EXCELLERATOR (Propel Orthodontics, Ossining, NY, USA) handheld device to deliver the transmucosal corticotomy perforations, no difference in pain or discomfort was reported between the control and experimental side.13 The corticotomy procedure involves a mucoperiosteal flap and this may have an effect upon the post-operative periodontal condition. However, no difference in probing depth, gingival recession, attachment loss, or plaque index between pre- and post-operative recordings was reported in a study using a submarginal flap.7

    A decrease in the response to electric pulp testing was seen in canines that had rapid distraction.18 Although electric pulp testing may produce false negative results, almost two-thirds of the teeth tested experienced negative responses to the electric stimulus after canine distraction. Laser Doppler flowmetry could be used as a more valid estimate of pulp vitality.

    Although a reduced risk of root resorption with shorter treatment times is an advantage, caution must be expressed when considering ‘rapid’ movement of teeth. In the case of surgically-assisted treatment, this is achieved through decreased bone resistance, and not with excessive force levels. Liou and Huang18 assessed both apical and lateral root resorption of canines that had been retracted and found that only one patient experienced root resorption on the lateral surface that was beyond one-third the thickness of the dentine on the distal side. No patients experienced apical root resorption beyond that of apical blunting.

    Decreased resistance to tooth movement should be less anchorage demanding, however, most studies have not reported this as an outcome. Aksakalli et al24 showed that there was approximately 1 mm less mesial movement of the first molars when using surgically-assisted tooth movements compared to the control group. Liou and Huang18 demonstrated almost no anchorage loss, however, there was no control group in this study. Abbas et al25 showed no difference in anchorage loss between the surgical groups and the control group.

    Conclusion

  • Surgical methods to accelerate OTM have been described widely. Promising results have been observed with early studies showing accelerated tooth movement immediately after surgical intervention.
  • The effects of RAP appear to last up to approximately 4 months, therefore tooth movement must be initiated immediately to gain the full benefits of the surgical intervention.
  • Shorter recall intervals between orthodontic appointments may also allow maximum use of the accelerated tooth movement.
  • Additional surgical interventions to maintain accelerated tooth movement would be difficult to justify in clinical practice given the added morbidity and additional surgical costs.
  • Adverse effects must be borne in mind; pain and discomfort, periodontal condition post-surgery, root resorption and diminished pulp vitality.
  • There would be great benefit for future clinical trials to report all relevant outcomes, including patient-related measures, adverse effects, anchorage loss, rate of tooth movement, and total treatment time.