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Advances in cortical osteotomy of periodontal bone

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发表于 2018-9-16 16:15:12 | 显示全部楼层 |阅读模式
Advances in cortical osteotomy of periodontal bone
Clinical orthodontic treatment usually takes a long time. With more and more adult patients seeking orthodontic treatment, too long treatment cycle has become an obvious limiting factor. How to speed up orthodontic tooth movement to shorten the course of treatment has become a hot research topic both at home and abroad in recent years. At present, there are three main methods to accelerate orthodontic tooth movement: drug method, physical method and surgical method. Periodontal cortical osteotomy has been proven effective in clinical practice and basic research. Periodontal corticotomy is to incise only the cortex of the bone without injuring the cancellous substance and preserving the integrity of the medullary vessels and periosteum in the periodontal jaws.

Periodontal corticotomy is not only a way to accelerate tooth movement, but also a way to increase osteogenic potential. This article reviews the historical origin of periodontal corticotomy and its recent advances in surgical methods, providing a reference for the clinical application of periodontal corticotomy.
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 楼主| 发表于 2018-9-16 16:15:40 | 显示全部楼层
1. the historical origin and evolution of cortical periodontitis

It has been more than 100 years since surgery accelerated tooth movement was first proposed by Cunningham and Bryan in 1894. In 1921, inspired by immediate surgical reduction of dislocated teeth, Cohn-Stock suggested drilling through the lingual interdental cortex of the maxillary anterior teeth to make the teeth move more easily during orthodontic treatment, and suggested that this method was more suitable for adults. In 1959, Kole introduced the technology in detail. Since then, the technology has been paid attention by scholars. He believes that the main resistance to tooth movement is the cortical bone plate of the alveolar bone. By destroying its continuity, orthodontic treatment can be completed in a shorter time. Surgery included complete buccal-lingual vertical cortical osteotomy and subapical horizontal osteotomy to form a complete bone mass for movement. This method can make the teeth move to the desired position in 6-12 months, effectively accelerate the movement of orthodontic teeth, and no obvious root resorption, pulp vitality is normal. However, Kole technology has not been widely accepted because of its large trauma.

After 2001, Wilcko et al. combined periodontal corticotomy with bone grafting to create accelerated os-teogenic orthodontics (AOO), which was later renamed periodontal accelerated osteogenic orthodontics (PAOO). This technique is mainly through incision to move the buccal and lingual bone cortex around the tooth root, forming a linear and dotted bone wound, autologous bone or biomaterials transplanted to local bone weakness, the flap suture in place. This technique can reduce the orthodontic treatment time to one third of the traditional orthodontic treatment course, and ensure adequate periodontal support through bone grafting.

Wilcko et al. found that rapid tooth movement after periodontal corticotomy was caused by demineralization of bone around alveolar fossa. Therefore, Dr. Wilcko denied Kole's theory of bone movement and suggested that the theoretical basis for rapid tooth movement after cortical incision was related to regional acceleration phenomena (RAP).

RAP was first proposed by orthopaedic surgeon Frost. It can occur several days (2-3 days) after trauma and peaks at 1-2 months, usually lasting for 4 months. However, this effect will take 6-24 months to completely disappear. In 1994, Yaffe and other animal experiments showed that RAP could also occur on the jaws. RAP is a transient process of local demineralization and remineralization of alveolar bone. Alveolar bone near the surgical wound enters a transient and reversible state of osteopenia. Bone resorption and osteolysis occur immediately. During this catabolism, bone mineral density decreases, and the orthodontic force causes the bone matrix around the root and the bone collagen soft tissue matrix to move accordingly. During the subsequent remineralization process, new bone deposits are deposited, and the bony matrix is re mineralized to re wrap around the root.
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 楼主| 发表于 2018-9-16 16:15:52 | 显示全部楼层
2. progress in cortical osteotomy of periodontal bone

Over the years of development, periodontal corticotomy has gradually diversified, and the forms of gingival flap flap and incision are different. This article reviews the progress of periodontal corticotomy according to the different forms of flap and incision.

2.1 lip / tongue / palate flap.

This operation is a classical Wilcko operation. The buccal-palatal flap is followed by cortical osteotomy and perforation on the cortical bone. This method can produce sufficient RAP effect and sufficient space for bone grafting. However, the operation is traumatic and the patients feel uncomfortable. Bhattacharya et al. selected 20 patients (15-25 years old) to perform this operation between the bilateral maxillary first premolars, while extracting the maxillary first premolar, two weeks after the operation, until the maxillary first premolar extraction space closed; the results showed that the experimental group tooth movement rate was 1.78 times that of the control group, the crown and root alveolar bone mass increased. Add.

2.2 unilateral flap cortical incision

Single flap corticotomy (SFC) is an improved version of PAOO. It can accelerate the movement of teeth, provide sufficient space for bone grafting and reduce surgical trauma. It is routinely used in corticotomy.

2.2.1 cortical incision + drilling

Jahanbakhshi et al. Evaluated the effect of cortical osteotomy on maxillary canine distally. In this study, 15 adult female patients with maxillary first premolar extraction and maximum distal canine movement were selected. The buccal flaps of the maxillary first premolar were turned over and a 1 cm long, 0.5-1 mm deep groove was grinded in the distal and proximal middle of the maxillary canine and the second premolar respectively with a high-speed drill. Results On the corticotomy side, the canine distal movement rate was 1.8 mm per month on average, and 1.1 mm per month on the control side. The canine distal movement rate on the experimental side was significantly higher than that on the control side. Ma et al. introduced the "dumpling technique". This technique refers to making incisions at the gingiva-gingival junction, then separating the tissue layer by layer until the periosteum is separated from the bone surface, and then using ultrasonic bone knife to cut and perforate the bone cortex at the buccal side of the alveolar bone where bone graft is needed to reach the depth of bone marrow. The technique can effectively increase the vertical alveolar bone height and the horizontal alveolar bone thickness in patients with buccal defects in the lower anterior teeth.

2.2.2 only bone cortical incision.

Wu et al. conducted a clinical study on the preoperative orthodontic effect of cortical osteotomy in patients with Class III osteoarthritis. In this study, only buccal flap was used after the extraction of premolars. Vertical incision and bone grafting were made between the right second premolar and the left second premolar. Wang et al. also selected patients with Class III skeletal deformities and performed the same operation. The results also showed that cortical osteotomy can effectively assist preoperative orthodontic decompensation, and increase bone mass through bone grafting, without postoperative complications. Lu Jianfeng et al. formed a linear bone incision around the root of the target tooth to study the clinical effect of cortical incision in assisting the correction of lingual oblique molars. The results showed that cortical incision can effectively shorten the treatment time and reduce root resorption and other complications.

2.2.3 only bone cortical drilling.

This procedure has fewer clinical applications, but it can also speed up tooth movement. Abed et al. conducted clinical trials on 12 Angle II patients (17-28 years old) using this technique to study the effect of cortical perforation on canine distal movement. In this study, three to four cortical foramens (3 mm in depth, 1.5 mm in diameter, 2 mm in interval) were drilled in the proximal and distal region of the maxillary canine after buccal flap reversal. After one month of observation, the displacement of the experimental side was 42.6% higher than that of the control side. No periodontal damage was observed, and there was no change in alveolar bone and pulp vitality in the apical film.

2.3 no flap.

This technique is used to directly cut or perforate cortical bone without flap. In recent years, there are many clinical applications. It can accelerate the movement of teeth effectively, with less trauma, good periodontal tissue condition and aesthetics, and low postoperative discomfort. However, the method of bone grafting is tunnel bone grafting, and the space of bone grafting is insufficient. It is difficult to accurately grasp the position of bone grafting, which is not conducive to the patients who need a large number of bone grafts.

2.3.1 only bone cortical incision.

Aksakalli et al. selected 10 Angle Class II Class 1 patients. After extraction of the maxillary first premolar, one side of the incision with ultrasonic bone knife was 10 mm long and 3 mm deep in the proximal and distal of the maxillary canine. The other side was the control side. Results The distal movement speed of the canine on the experimental side was 1.58 times that of the control side. This operation was put forward by Dibart and so on in 2009. It is called Piezocision. Charavet et al. also selected 24 adults with mild crowding for clinical trials. They were divided into the traditional orthodontic group and the Piezocision assistant group. Results The total treatment time of the Piezocision assistant group was 43% less than that of the traditional orthodontic group. There was no obvious periodontal damage and root resorption. Cassetta et al. introduced a minimally invasive surgery in 2015. Preoperative computer-aided design combined with 3D printing technology was used to make the surgical guide plate. The position, length and depth of the incision were designed. The intraoperative use of ultrasound bone knife directly based on the guide plate for the cortical mini-incision can increase the accuracy of the operation, avoid the flap turning process and reduce the number of incisions. Surgical trauma, shortening operation time.
2.3.2 only bone cortical drilling.

Kim et al. put forward the method of piezopuncture, which is called piezopuncture without flap reversal and only with cortical bone perforation, and used this method in the experimental study of Beagle dogs, drilling around the moving teeth of the target. The results showed that the cumulative tooth movement distance of the experimental group was larger than that of the control group, maxilla was 3.26 times, and mandible was 2.45 times. Alikhani et al. used a disposable hand-held drilling device Propel (the device can adjust the length of the drilling, when the required depth is displayed when the light is on), and punched three tiny bone holes at the extraction of the first premolar, from the canine and the second premolar. The holes were 1.5 mm wide and 2-3 mm deep. The tooth movement rate was 2.3 times that of the control group and the control side. There was no significant difference in the tooth movement distance between the control group and the control side.

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 楼主| 发表于 2018-9-16 16:16:24 | 显示全部楼层
Operative comparison of 3. cortical osteotomy

3.1 effect on tooth movement velocity and bone remodeling

3.1.1 flap

There is no conclusion about the effect of flap on RAP effect. Yaffe et al think that the degree of RAP is related to the size of flap. Teixeira et al. designed experiments confirmed that most of the inflammatory factors in the flap + cortical perforation group showed the highest level, osteoclasts and bone remodeling activities were higher than the simple flap group, resulting in widespread osteoporosis and accelerated tooth movement. Generally speaking, the authors believe that flap flap surgery can produce a certain degree of RAP effect, but corticotomy produces a stronger and more extensive RAP effect. Binderman et al. believed that flap operation made most of the interdental fibers and gingival fibers separated from the crown of the root, on the one hand stimulated alveolar bone absorption, resulting in widened periodontal ligament space and accelerated tooth movement; on the other hand, it changed the memory of the physiological position of dentition, not easy to recur. This requires more experimental studies to fully understand its mechanisms and biological effects.

3.1.2 different types of cortical incision

Different types of incision, including linear incision, point incision and so on, in the final analysis is the different amount of bone destruction by surgery. Kurohama et al. assessed the relationship between bone loss during corticotomy and tooth movement, root resorption, and alveolar bone resorption. In this study, 10-week-old female Wistar rats were divided into 0.1 mm3 (punctate incision), 1.0 mm3 (linear incision) and 1.7 mm3 (circular incision) according to the amount of cortical incision. The results showed that the different amount of cortical incision had no significant effect on tooth movement distance and root resorption, but cortical incision had no significant effect on tooth movement distance and root resorption. The larger the amount, the greater the influence on the height of alveolar ridge after surgery, suggesting that corticotomy may affect the height of alveolar bone after orthodontic tooth movement.

Peron et al. selected 90 Wistar rats to compare the histological responses of Corticotomy (perforation of cortical bone after flap reversal) and Corticotomy (incision of cortical bone through the gingiva without flap reversal, direct hammering with the handle of the knife) to accelerate tooth movement. The results showed that Corticotomy was feasible in the early stage of tooth movement. To increase bone resorption, Corticision reduced hyaline degeneration, but did not increase the number of osteoclasts and bone resorption; both reduced the risk of root resorption. Abbas et al. studied the distal displacement velocity of canines in different operation methods. The results showed that the distal displacement velocity of canines in Corticotomy group was 1.5-2 times faster than that in control group, Piezocision group was 1.5 times faster than that in control group, Corticotomy group was faster than Piezocision group at 2, 4, 10 and 12 weeks.

Yang et al. simulated the distal canine movement after the extraction of the maxillary first premolar by establishing a three-dimensional finite element model of the maxilla. The results showed that the width of incision had no significant effect on tooth movement, but the position of incision had a significant effect on the effect of distal movement. The effect of canine distal movement was most obvious when continuous circular incision was used around canine. The movement of teeth including distal incisions is also larger than that of other cases. Pacheco et al. also used similar methods to analyze the results, and found that whether to make incisions in the extracted maxillary premolar area had no significant effect on canine distal movement. These studies suggest that surgery can simplify operation and reduce trauma. Trauma is not as small as possible.

Murphy et al. studied the effect of Corticision and the effect of different force values (light force 0.098 N, gravity 0.98 N) on tooth movement in Wistar rats. In this study, a flap-free incision was made near the middle palate where the teeth needed to be moved. The results showed that there was no difference in the rate of tooth movement between the experimental group and the control group.

To sum up, the trauma of corticotomy can not be too small or too large, in the direction of teeth need to move a certain amount of traumatic corticotomy, not only can effectively accelerate tooth movement, reduce periodontal tissue stress, but also reduce trauma, so that patients feel less uncomfortable.
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 楼主| 发表于 2018-9-16 16:16:40 | 显示全部楼层
3.2 influence on patients' perception and acceptance

Al-Naoum et al. used the classical buccal-palatal corticotomy for clinical trials. 50% of the patients had great pain on the first day after surgery and significantly relieved on the seventh day after surgery. 44% of the patients felt mild pain during the day (non-eating) of the first week after surgery, 56% felt moderate or severe pain and pain. The degree of pain relieved with time, and during the night sleep, the degree of pain was weak, will not affect the quality of sleep patients.

Studies have investigated the acceptance of corticotomy-assisted accelerated orthodontic treatment among adults seeking orthodontic treatment. Results Only 7.8% of the patients are willing to use corticotomy instead of tooth extraction. Most of the patients fear the operation process, pain and postoperative discomfort of corticotomy. Therefore, the acceptance of corticotomy is limited. The degree is low. It is undeniable that the greater surgical trauma will affect the degree of acceptance of patients to a certain extent, so corticotomy should ensure the accelerated effect of the premise, as far as possible to reduce surgical trauma, to reduce the cost of surgery and postoperative discomfort, and improve the degree of acceptance of patients.
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 楼主| 发表于 2018-9-16 16:17:04 | 显示全部楼层
Clinical application of 4. cortical osteotomy

The most minimally invasive cortical incision is still under way. In recent years, the mainstream surgical methods are PAO with buccal-palatal flap, SFC with unilateral flap and Piezocision without flap. Each has its advantages and disadvantages, and the indications are different. PAOO can effectively relieve moderate to severe dentition crowding, increase periodontal support, and can effectively assist the teeth near and far movement, conducive to the opening and closure of molar space, increase stability; its disadvantages are long operation time, trauma, easy to cause postoperative discomfort. SFC is a less invasive alternative to the more traumatic PAOO procedure and can effectively accelerate tooth movement.

Compared with non-flap Pezocision, SFC can implant soft and hard tissues better and stimulate RAP more adequately. The acceleration effect is better than Piezocision. Piezocision has the advantages of small trauma, short operation time, low postoperative discomfort, easy to be accepted by patients and effective in relieving mild to moderate congestion, but it is not the case for near to distal movement or lateral expansion of the bow. It is difficult or even impossible to locate the graft precisely under the attached gingiva. If the dentition is seriously congested and the alveolar bone is very thin, the Piezocision graft may not be sufficient. Through the analysis of the characteristics of these surgical procedures, we should consider the patient's malformation and the patient's requirements and acceptance, specific analysis of the specific situation, select the appropriate surgical procedures for patients.
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 楼主| 发表于 2018-9-16 16:17:19 | 显示全部楼层
5. conclusion

Periodontal corticotomy can assist orthodontic teeth to move quickly, efficiently and safely, but the invasiveness of the operation can not be avoided. It may cause pain, swelling and infection. Although in recent years a variety of surgical methods emerge in endlessly, but the development direction is unified, in the premise of ensuring the accelerated effect, as far as possible to simplify the operation, reduce surgical trauma, that is, minimally invasive. Periodontal corticotomy can not only accelerate the movement of teeth, but also enhance periodontal support by implant materials. Therefore, how to find a balance between minimally invasive surgery and adequate space for bone grafting is also an important factor to be considered in the development of surgery. When the clinical application of corticotomy accelerates tooth movement, it is necessary to analyze the specific situation and select the appropriate surgical method for patients. In the future, how to prolong the acceleration effect of corticotomy, regulate the acceleration time and cycle, and how to combine with drugs, vibration and laser will be the focus of research. More high-quality basic research and clinical randomized trials are needed to produce more definite conclusions.
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