ORIGINAL ARTICLE

Effect of piezopuncture on tooth movement and

bone remodeling in dogs
Young-Seok Kim,a Su-Jung Kim,b Hyun-Joo Yoon,a Peter Joohak Lee,c Won Moon,d and Young-Guk Parke
Seoul, Korea, and Los Angeles, Calif

Introduction: The aim of the study was to elucidate whether a newly developed, minimally invasive procedure,
piezopuncture, would be a logical modication for accelerating tooth movement in the maxilla and the mandible.
Methods: Ten beagle dogs were divided into 2 groups. Traditional orthodontic tooth movement was performed
in the control group. In the experimental group, a piezotome was used to make cortical punctures penetrating the
gingiva around the moving tooth. Measurements were made in weeks 1 through 6. Tooth movement and bone
apposition rates from the histomorphometric analyses were evaluated by independent t tests. Results: The
cumulative tooth movement distance was greater in the piezopuncture group than in the control group: 3.26fold in the maxilla and 2.45-fold in the mandible. Piezopuncture signicantly accelerated the tooth movements
at all observation times, and the acceleration was greatest during the rst 2 weeks for the maxilla and the
second week for the mandible. Anabolic activity was also increased by piezopuncture: 2.55-fold in the maxilla
and 2.35-fold in the mandible. Conclusions: Based on the different effects of piezopuncture on the maxilla
and the mandible, the results of a clinical trial of piezopuncture with optimized protocols might give orthodontists
a therapeutic benet for reducing treatment duration. (Am J Orthod Dentofacial Orthop 2013;144:23-31)

arious surgical interventions on the periodontal

tissues have been developed to accelerate orthodontic tooth movement. The degree of intentional surgical damage needed to evoke a long-lasting
regional acceleratory phenomenon that is less prone to
complications has been a topic of special interest. Fullthickness ap elevation with extensive decortications,
including various modications of corticotomies, are
undoubtedly effective in increasing cellular activities related to tooth movement.1-3 The mechanism of
accelerated tooth movement by a regional acceleratory
phenomenon depends mainly on transient osteopenia
a

Postgraduate student, School of Dentistry, Kyung Hee University, Seoul, Korea.

Assistant professor, Department of Orthodontics, School of Dentistry, Kyung
Hee University, Seoul, Korea.
c
Resident, Section of Orthodontics, School of Dentistry, University of California
at Los Angeles, Calif.
d
Assistant professor, Section of Orthodontics, School of Dentistry, University of
California at Los Angeles, Calif.
e
Professor and chair, Department of Orthodontics, School of Dentistry, Kyung
Hee University, Seoul, Korea.
All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conicts of Interest and none were reported.
Supported by Korea Ministry of Education, Science and Technology (number
2009-0092562).
Reprint requests to: Young-Guk Park, Department of Orthodontics, Kyung Hee
University, School of Dentistry, 1 Hoegi-Dong, Seoul 130-701, Korea; e-mail,
ygpark@khu.ac.kr.
Submitted, February 2012; revised and accepted, January 2013.
0889-5406/$36.00
Copyright 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.01.022
b

by an accelerated demineralization-remineralization
process, providing a more pliable environment,4 which
is distinct from bony block movement in corticotomyfacilitated orthodontics1; therefore, development of
a simple procedure just for cortical activation rather
than cortical removal is required.
Corticision (patent 0843344, class 10; Kyung Hee
University, Seoul, Korea) was introduced as a minimally
invasive alternative for cortical activation.5,6 A cortical
incision made by malleting a reinforced scalpel to
separate the interproximal cortices transmucosally was
found to induce the regional acceleratory phenomenon
effect for faster tooth movement in beagle dog
experiments.5 To mitigate the patients' fear and discomfort from repeated malleting, Dibart et al7,8 suggested
piezocision, a process that uses an ultrasonic tool to
produce the incisions. This procedure combines
piezoelectric cortical incisions with selective tunneling,
which allows additional tissue grafting.
To overcome the insufciencies of these earlier procedures, we conceived a novel procedure for cortical
activation that we called piezopuncture. In this procedure, an ultrasonic tool, a piezotome, is used to create
multiple cortical punctures through the overlying gingiva.
The concept of ultrasonic osteotomy is based on the socalled reciprocal piezo effect: voltage is applied to a polarized piezo ceramic to deform a piezoelectric crystal in the
resultant electrical eld; this creates alternating and perpendicular expansion and contraction of the material.
23

Kim et al

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Fig 1. Orthodontic force application: A, piezopuncture procedure: arrows indicate the direction of
second premolar movement in each jaw; B, piezopuncture was performed on the mesiobuccal side
of the second premolar, penetrating overlying gingiva into the cortical bone; white ring-like lesions
were found around the puncture sites, showing no lethal damage on the soft tissues; C, nickeltitanium closed-coil springs were activated between the lever arms of the target teeth and the anchorage teeth. xxx, Specimen collection sites.

Because of its accurate and selective capability of cutting

mineralized tissues without damaging adjacent soft tissues and nerves, ultrasonic osteotomes were rst used in
periapical oral surgery, including implantology9 and periodontology.10 These transmucosal manipulations of alveolar bone have minimized morbidity and achieved similar
results to more aggressive procedures, including extensive
ap elevation for rapid tooth movement.11,12
The aim of our study was to elucidate whether piezopuncture would elicit the regional acceleratory phenomenon and accelerate tooth movement without causing
harmful tissue responses. The acceleration rates of tooth
movement and bone remodeling were investigated and
compared between the maxilla and the mandible.
MATERIAL AND METHODS

Ten male beagles (age, 18-24 months; weight, 9-12

kg) were housed in separate cages supplied with a selfwashing system, air conditioning, and lighting according to the guidelines of the Institutional Animal Care
and Use Committee, Kyung-Hee University Medical Center. The dogs were randomly divided into 2 groups: control (n 5 4) and piezopuncture (n 5 6). These groups
were further divided into 3 subgroups based on the
duration of force application: group I, 14 days (control,
n 5 1; piezopuncture, n 5 2); group II, 28 days (control,
n 5 1; piezopuncture, n 5 2); and group III, 42 days
(control, n 5 2; piezopuncture, n 5 2). Each animal provided 4 specimens (1 each from the right and left sides of
both jaws), and the maxillary and mandibular specimens
(n 5 20 for each jaw) were randomly divided into 2
groups. Animals in the control group received orthodontic force alone, and the animals in the piezopuncture
group received orthodontic force with piezopuncture.
The animals were killed at 2, 4, and 6 weeks after the
interventions.

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The target teeth in both arches were the second premolars; however, the anchorage teeth in each arch were
selected differently because of anatomic limitation. In
the maxillary arch, the second premolars were protracted
against the canines as the anchorage, whereas the second premolars were retracted against the third premolars
in the mandibular arch. Orthodontic buttons (Ormco,
Orange, Calif) connected by a lever arm were bonded
on the labial surfaces of all experimental teeth with
Super-Bond C&B resin (Sun Medical, Shiga, Japan). A
nickel-titanium closed-coil spring (Tomy International,
Tokyo, Japan) was activated and ligated between the lever arms of the target teeth and the anchorage teeth. For
reinforcing anchorages, resin bridges were constructed
on the adjacent teeth. The orthodontic force by the appliance was 100 g at the beginning of the experiment.
Tooth movement was allowed for 6 weeks. Force magnitude was measured using a force gauge (Haag-Streit,
Koeniz, Switzerland) once a week with reactivation of
the appliance to maintain a continuous force (Fig 1, A).
For piezopuncture, a piezosurgical instrument with
a sharp curved tip (Endo2 insert, ProUltra; Dentsply
Maillefer, Ballaigues, Switzerland) was used to perform
the cortical punctures penetrating the gingiva. The
depth of cortical injury was 3 mm, by holding the tip
perpendicular to the gingiva for 5 seconds under
saline-solution irrigation. The setting selected for each
puncture was in accordance with the manufacturer's
recommendation. Piezopunctures were performed on
the mesiobuccal, distobuccal, mesiolingual, and distolingual sides of the second premolars (Fig 1, B). Sixteen
punctures were made on 1 target tooth. Gentamicin
(7.5 mg/kg) was injected postoperatively for 3 days.
Tooth brushing and daily hexamedine (Bukwang, Seoul,
South Korea) irrigation were repeated during the
postoperative care.

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Table I. Accumulative distances of tooth movements in each group at 6 weeks after orthodontic force application
Jaw
Maxilla

Group
Control (A)

Piezopuncture (B)

Mandible

Control (A)

Piezopuncture (B)

Beagle site
A1-RT
A1-LT
A2-RT
A2-LT
Mean
B1-RT
B1-LT
B2-RT
B2-LT
Mean
P value
A1-RT
A1-LT
A2-RT
A2-LT
Mean
B1-RT
B1-LT
B2-RT
B2-LT
Mean
P value

Second premolar movement, A (mm)

0.79
0.74
0.65
0.71
0.72 6 0.06
2.62
3.32
1.57
1.71
2.31 6 0.82
0.00054z
0.56
0.76
0.35
0.38
0.51 6 0.19
1.71
1.35
1.12
1.13
1.33 6 0.28
0.00041z

Anchor tooth movement, B (mm)

0.98
1.12
1.15
1.10
1.09 6 0.07
1.01
1.07
1.28
1.07
1.11 6 0.12
0.27102
0.38
0.59
0.28
0.35
0.40 6 0.13
0.31
0.56
0.58
0.39
0.46 6 0.13
0.55436

Ratio (A/B)
0.81
0.66
0.57
0.65
0.67 6 0.10
2.59
3.10
1.23
1.60
2.13 6 0.86
0.00215y
1.47
1.29
1.25
1.09
1.28 6 0.16
5.52
2.41
1.93
2.90
3.19 6 1.60
0.04373*

Independent t test was performed (mean 6 SD, *P \0.05; y \0.01; z \0.001). In the maxilla, the anchor tooth was canine; in the mandible, the
anchor teeth were the third premolar and the rst molar.
A1, First control beagle; A2, second control beagle; B1, rst piezopuncture beagle; B2, second piezopuncture beagle; RT, right side; LT, left side.

Tooth movement was measured by a digital caliper

(Mitutoyo, Kawasaki, Japan) on the stone models once
a week. In the maxillary arch, the distance from the mesial cervix of the third premolar to the mesial cervix of the
moved second premolar was measured over time. In addition, the distance of canine retraction as an anchorage
tooth was measured from the mesial cervix of the third
premolar to consider the rate of tooth movement as
the relative ratio. In the mandibular arch, the distance
from the mesial cervix of the canine to the mesial cervix
of the moved second premolar was measured, and the
protracted distance of the anchored third premolar was
also measured from the same reference. The relative
values of the distance of the moved teeth divided by
the distances of the anchorage teeth were compared between the groups.
Histologic analysis was performed on the decalcied
specimens at 2, 4, and 6 weeks. Tissue blocks including
the second premolar with surrounding alveolar bone and
the injury site were decalcied with 10% EDTA-2Na (pH
7.4) at 48 C for 30 days. The specimens were resected at
3 to 4 mm below the alveolar crest with thicknesses of 6
mm. The sections were stained with hematoxylin and
eosin for descriptive histology.
Quantitative histomorphometric analysis was done
on the nondecalcied specimens of the dogs in the 6week groups. One experimental animal and 1 control

animal were randomly selected. They had been intramuscularly injected with 3 uorochoromes as follows:
oxytetracycline hydrochloride (yellow orange, 30 mg/
kg; Fluka Chemie AG, Buchs, Switzerland) at 24 hours
before intervention and at 6 weeks after intervention;
calcein (green, 10 mg/kg; Fluka Chemie AG) at 2 weeks
after intervention; and alizarin red (red, 30 mg/kg; Fluka
Chemie AG) at 4 weeks after intervention. Specimens
were taken from 8 sampling sites in each jaw. These
specimens were longitudinally sectioned parallel to the
direction of orthodontic traction and examined under
an ultraviolet uorescence microscope (BH-2; Olympus,
Tokyo, Japan) with an ultraviolet lter (l 5 515 nm).
Microphotographs of all specimens were recorded using
a digital CCD camera (PS30C ImageBase; Kappa Optronics, Gleichen, Germany). The outlines of labeled
bones were traced from the photographs, and the distances between the labeled lines were measured with image analysis software (ImageBase Metreo 2.5; Kappa
Optronics).
Statistical analysis

Descriptive statistics were represented as means and

standard deviations for all parameters in each group.
The normality of the data was assessed with the
Kolmogorov-Smirnov test. Statistical homogeneity was
checked using the Levene test. Independent t tests

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Fig 2. Accumulated tooth movement distances and movement rates in the maxilla and the mandible.

were used to evaluate the intergroup differences of the

mean tooth movement distances on the models and
the mean accumulated new bone deposition measured
by histomorphometric analysis. Values of P \0.05
were considered statistically signicant.
RESULTS

The mean cumulative distances of tooth movement

for 6 weeks as well as the ratios of target tooth movement to anchorage loss were signicantly increased in
the piezopuncture groups as opposed to the control
groups in both the maxilla and the mandible (Table
I). The distance of the maxillary second premolar movement in the piezopuncture group (2.31 6 0.82 mm)
was 3.26-fold greater than that in the control group
(0.72 6 0.06 mm). The distance of the mandibular second premolar movement in the piezopuncture group
(1.33 6 0.28 mm) was 2.45-fold greater than that in
the control group (0.51 6 0.19 mm). There was no signicant difference in the amount of anchorage tooth
movement between the piezopuncture group (maxilla,
1.11 6 0.12 mm; mandible, 0.46 6 0.13 mm) and
the control group (maxilla, 1.09 6 0.07 mm; mandible,
0.40 6 0.13 mm). The relative ratios of maxillary tooth
movement were 2.15 6 0.98 in the piezopuncture

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group and 0.66 6 0.02 in the control group. The ratios

of mandibular tooth movement were 3.30 6 1.03 in
the piezopuncture group and 1.35 6 0.75 in the
control group.
With respect to movement rate, the rst 2 weeks in
the maxilla and the second week in the mandible had
the greatest movement (Fig 2). The weekly velocity of
tooth movement in the piezopuncture group was larger
than that in the control group at all observation times.
The increasing pattern of the accumulated distances of
tooth movement in the piezopuncture group showed
no remarkable stagnation indicating the lag phase.
Descriptive histologic ndings on the compression
sides of moving teeth are shown in Figure 3. At week
2, the periodontal ligament was compressed and locally
degenerated into hyalinization in the control group,
where no apparent resorptive ndings on the alveolar
surfaces were observed (Fig 3, A). In the piezopuncture
group, osteoclasts with the resorption lacunae along
the bone surfaces were seen near hyalinized areas of
the periodontal ligament (Fig 3, B). At week 4, indirect
resorption followed by the removal of the hyalinized
periodontal ligament was found in the control group
(Fig 3, C), whereas direct resorption by active boneresorbing cells continued in the piezopuncture group

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Fig 3. Microphotographs of periodontal tissues on the pressure sides of the second premolars: A, control group at 2 weeks; B, piezopuncture group at 2 weeks; C, control group at 4 weeks; D, piezopuncture
group at 4 weeks; E, control group at 6 weeks; F, piezopuncture group at 6 weeks. The arrows indicate
resorption lacunae with bone-resorbing cells along the compressed alveolar surface. In the control
groups, hyalinization was found at 2 and 6 weeks, and indirect resorption was observed at 4 weeks.
On the contrary, in the piezopuncture groups, direct bone resorption was evident at all observation
times without remarkable hyalinization. B, Alveolar bone; P, periodontal ligament; R, root; H, hyalinization. Original magnication: 200 times.

(Fig 3, D). At week 6, the number and the activity of

bone-resorbing cells were decreased, showing sparse resorption areas on the bone surface with focal hyalinization in the control group (Fig 3, E), whereas the ndings
of direct bony resorption with the cellular periodontal
ligament were as before in the piezopuncture group
(Fig 3, F). There were no recognizable differences of
the time-dependent histologic responses between the
maxilla and the mandible.

Fluorescent microscopic ndings of anabolic bone

remodeling on the tension sides of the moving teeth
(Fig 4) showed correspondence with rate of tooth movement. The accumulated distance of newly mineralized
bone apposition during 6 weeks was signicantly greater
in the piezopuncture group than in the control group
(Table II). In the maxilla, the mean apposition length
of the piezopuncture group was 2.55-fold greater than
that of the control group. The distance between the rst

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Fig 4. Fluorescent microphotographs of bone labels on the tension sides of the second premolars: A,
maxillary bone apposition in the control group; B, maxillary apposition in the piezopuncture group; C,
mandibular apposition in the control group; D, mandibular apposition in the piezopuncture group. Accumulated distances between the bone-labeled lines are signicantly longer in the piezopuncture
groups than in the control groups in both jaws. Earlier and larger responses to piezopuncture were observed in the maxilla compared with the mandible. Original magnication: 100 times.

Table II. Mean accumulated distances of new bone apposition in both arches indicated by uorescence on the ten-

sion side
Jaw
Maxilla
Mandible

Group
Control
Piezopuncture
Control
Piezopuncture

Weeks 0-2 (mm/wk)

44.44 6 30.27
122.89 6 23.12
35.18 6 13.02
98.56 6 24.58

Weeks 2-4 (mm /wk)

56.09 6 8.52
158.09 6 38.09
45.17 6 15.08
148.07 6 39.68

Weeks 4-6 (mm/wk)

78.35 6 7.31
116.00 6 17.25
25.55 6 7.34
123.18 6 6.60

Distances were measured from the nondecalcied specimens in the 6-week groups; 8 sampling sites in each jaw of 1 experimental animal and 1
control animal were randomly selected (means 6 SD were calculated from sampling sites of each jaw).

yellow line (oxytetracycline at 24 hours before intervention) and the red line (alizarin red at 4 weeks) was strikingly increased in the maxillary piezopuncture group. In
the mandible, the mean apposition length in the piezopuncture group was 2.35-fold greater than that in the
control group. The distance between the green line (calcein at 2 weeks) and the second yellow line (oxytetracycline at 6 weeks) was remarkably increased in the
mandibular piezopuncture group.
DISCUSSION

This beagle study shows that a newly developed supplemental procedure, piezopuncture, accelerated the
rate of orthodontic tooth movement and the remodeling
process of alveolar bone without causing collateral damage. Earlier and greater effects of piezopuncture were
observed in the maxilla than in the mandible.
Piezopuncture was developed to increase patient
compliance by minimizing discomfort during and after

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surgery, and to simplify the procedure for orthodontists.

Piezopuncture uses a piezotome, which acts as a light ultrasonic scaler. Unlike the previous surgical interventions, piezopuncture eliminates the use bone
malleting, which can be frightening to the patient, and
the soft-tissue incision and suture.1-5 In contrast to
corticision,5 such an approach for minimizing tissue
damage, and the intensity and duration of the regional
acceleratory phenomenon, might not be sufcient to
function throughout the entire orthodontic treatment.13
However, this problem could be eliminated by repeated
applications at regular intervals; this would be more favorable for the patients' convenience than more aggressive methods.
The action mechanism of piezopuncture is based on
the biologic concept of cortical activation rather than
cortical removal.14 Most previous corticotomyfacilitated orthodontic treatments were designed to resect the cortical barrier, depending on the mechanical

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Fig 5. Mean apposition rates of newly mineralized bone on the tension sides of the second premolars.
Peak velocity periods in the piezopuncture groups were at 2 to 4 weeks in both jaws, and the velocity in
weeks 4 to 6 was higher in the mandible than in the maxilla.

concept of the cortex. The use of a minimal intervention

to achieve an objective suggests a keen knowledge of the
regional acceleratory phenomenon physiology and a respect for a discrete surgical technique. Garg15 emphasized that the regional acceleratory phenomenon is
initiated mainly by trauma to the cortical bone. The cortex is regarded as a necessary matrix for rapid tooth
movement, not an obstacle.3,15 Only cortical activation
can increase osteoclastic activity around the
periodontal ligament, facilitating bone turnover
toward an osteoporotic state with less tissue resistance
to tooth movement. Teixeira et al16 suggested that osteoperforation placed far from the tooth could accelerate the rate of tooth movement, reected by an
increased level of inammatory cytokine expression, followed by extensive osteoporotic changes. In addition to
this conceptual change, understanding the 2-sided characteristic of inammation has enabled the continuous
advancement of supplemental surgical techniques with
minimal and conservative interventions.
Piezosurgical incisions have been reported to be
safe and effective in osseous surgeries, such as preprosthetic surgery, alveolar crest expansion, and sinus
grafting.17-21 Because of its micrometric and selective
cut, the piezosurgical knife is said to aid safe and
precise osteotomies without osteonecrotic damage.
Vercellotti and Podesta21 used a piezosurgical technique
for periodontally accelerated orthodontic tooth movement. Dibart et al7,8 introduced piezocision as
a modied method of corticision for rapid orthodontic
tooth movement. Piezocision is different from
piezopuncture in that it requires soft-tissue incisions
with a blade and routine tissue grafting with the blinded
tunneling technique. Grafting mimics the accelerated

osteogenic orthodontic treatments in the studies of

Wilko et al2 and Murphy et al,3 which need to be discussed separately from cortical activation. Additionally,
the previous evaluations on piezoelectricity for accelerating tooth movement, based on clinical reports, have
not yet provided biologic evidence.
This beagle experiment elucidated that the cortical
activation by piezopuncture accelerated tooth movement signicantly at each observation time. Since orthodontic tooth movement aims to restore the balance by
remodeling the periodontal ligament, it is reasonable
to assess the timing of bone apposition in conjunction
with tooth movement.22 To explore the anabolic
mechanism in response to tooth movement with cortical
activation, it was prudent to analyze the uorochromelabeled lines histomorphometrically. The rates of tooth
movement in the control group showed no remarkable
increase until 5 weeks after intervention, accompanied
by increased rates of new bone apposition in 4 to 6
weeks. On the other hand, the piezopuncture group
showed earlier acceleration of tooth movement in the
rst 2 weeks after intervention, followed by signicantly
increased rates of new bone apposition during later
weeks. This acceleration of tooth movement could also
be supported by different catabolic activities between
the 2 groups, even though it was not based on quantitative analysis. Extensive hyalinization with little bone resorptive activity, indicating the biologic lag phase of
tooth movement, was remarkable at 2 and 6 weeks in
the control group, whereas direct bone resorption continued at all experimental periods in the piezopuncture
group without evidence of a lag phase.23-25 The
mechanism of bypassing the lag phase indicates less
production and faster elimination of hyalinization, and

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it is mentioned in the study of Baloul et al22 about selective alveolar decortication; this corresponds to our results of a less invasive cortical puncture.
The acceleration effect of piezopuncture was faster in
the maxilla than in the mandible. Deguchi et al26 reported that orthodontic tooth movement progressed 2
weeks faster in the maxilla than in the mandible, and
that higher rates of tooth movement in the maxilla
were found at 4 through 6 weeks. In our study,
piezopuncture-assisted tooth movement advanced 1
week faster in the maxilla than in the mandible. The piezopuncture group demonstrated a peak in tooth movement at weeks 1 and 2 in the maxilla and weeks 2 and
3 in the mandible, and peaks in bone apposition rate
were at weeks 2 through 4 in the maxilla and weeks 2
through 6 in the mandible (Fig 5). Although the absolute
amount of bone mass is stable during conventional tooth
movement, even with highly dynamic metabolic activity,
a transient osteoporotic state occurs during surgically facilitated tooth movement.2,22 Because of the differences
of bone density and metabolism between the jaws, the
maxillary teeth should be regarded as more sensitive to
the regional acceleratory phenomenon by cortical
activation than are the mandibular teeth. Nevertheless,
the mean ratio of target tooth movement to the
anchorage tooth movement was higher in the mandible
than in the maxilla; this contradicts the result of
comparing the distances of the target teeth themselves.
This discrepancy can be explained because the mean
amount of anchorage tooth movement was greater in
the maxilla than in the mandible. This might imply that
the accelerating effect of piezopuncture was more
extensive to the anchorage part in the maxilla but was
rather localized on the target tooth area in the
mandible. It should be also considered that our beagle
model included mesial movement of the maxillary
second premolars and distal movement of the
mandibular second premolars, depending on the
different anchorage values.
Tooth movement with or without surgical intervention is a combined process of osteoclastic and osteoblastic activities in response to external stimulation.27,28 It is
not clear yet whether tooth movement by surgical
stimulation follows the same mechanism as
conventional tooth movement, or whether a different
biologic pathway is involved. Nonetheless, a superior
condition of surgically assisted tooth movement is that
the tooth goes through the osteoporotic alveolar bone
of a less tissue-resistant environment. We had presupposed that the biologic mechanisms underlying rapid
tooth movement by cortical puncture would be
similar to the previously reported demineralizationremineralization process of decortication.29 Although

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we could not present molecular-biologic or genetic interactions related to the mechanism of accelerated tooth
movement by piezopuncture, our preferential interest
was to nd the value of a newly developed and less invasive surgical modication. Piezopuncture proved to
be effective to facilitate tooth movement, and the effect
was greater and faster in the maxilla than in the mandible. Simultaneously, the regional acceleratory phenomenon effect was more extensive in the maxilla; hence,
reinforcement of the anchorage part is needed in clinical
applications.
With further studies on the development of prolonged acceleration of tooth movement over time, the
limitations of minimally invasive surgical procedures
should be complemented and modied toward clinical
efciency. Based on the different acceleratory effects
of piezopuncture on the maxilla and the mandible,
a clinical trial of repeated piezopuncture with optimized
application intervals and force adjustments would give
orthodontists a great therapeutic benet in the context
of reducing treatment durations.
CONCLUSIONS

This study introduced a novel periorthodontic technique, piezopuncture, which enables rapid tooth movement without damaging side effects. This technique
involves puncturing of the cortical bone with a piezosurgical regimen. Piezopuncture was found to evoke rapid
tooth movement by accelerating the rate of alveolar
bone remodeling. The acceleration of orthodontic tooth
movement associated with piezopuncture was explicated by increased bone turnover through the regional
acceleratory phenomenon.
Although further studies on the optimal power range
of a piezosurgical device to induce a regional acceleratory phenomenon with orthodontic tooth movement
are suggested for secure clinical applications, piezopuncture might have a great therapeutic benet in the
context of reducing treatment duration and also periodontal regeneration in its best extent. This development is expected to bring orthodontics closer to the
goal of efciency in tooth movement, without causing
patient discomfort or damage to the teeth and their supporting tissues.
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July 2013
Vol 144
Issue 1