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Full thickness mucoperiosteal flap, mop, piezotomy, corticotomy, lllt, prostaglandin, accelerated tooth movement, orthodontic, non-surgical, surgical
Doaa Tahsin Alfaylani, Mohammad Y. Hajir, Ahmad S. Burhan, Luai Mahahini, Khaldun Darwich, Ossama Aljabban
Cite this article as: Alfailany D, Hajeer MY, Burhan AS, et al. (May 27, 2022) Assessing the effectiveness of surgical and non-surgical interventions when used in combination with retainers to accelerate orthodontic tooth movement: a systematic review. Cure 14(5): e25381. doi:10.7759/cureus.25381
The purpose of this review was to evaluate the currently available evidence for the effectiveness of surgical and non-surgical acceleration methods and the side effects associated with these methods. Nine databases were searched: Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE®, Scopus®, PubMed®, Web of Science™, Google™ Scholar, Trip, OpenGrey and PQDT OPEN of pro-Quest®. ClinicalTrials.gov and the search portal of the International Clinical Trials Registry Platform (ICTRP) were reviewed to review current research and unpublished literature. Randomized controlled trials (RCTs) and controlled clinical trials (CCTs) of patients undergoing surgery (invasive or minimally invasive techniques) in combination with traditional fixed devices and compared with non-surgical interventions. The Cochrane Risk of Bias (RoB.2) instrument was used to assess RCTs, while the ROBINS-I instrument was used for CCT.
Four RCTs and two CCTs (154 patients) were included in this systematic review. Four trials found that surgical and non-surgical interventions had the same effect on accelerating orthodontic tooth movement (OTM). In contrast, surgery was more effective in the other two studies. A high degree of heterogeneity among the included studies precluded quantitative synthesis of results. Reported side effects associated with surgical and non-surgical interventions were similar.
There was ‘very low’ to ‘low’ evidence that surgical and non-surgical interventions were equally effective in accelerating orthodontic tooth movement with no difference in side effects. More high-quality clinical trials are needed to compare the effects of acceleration of the two modalities in different types of malocclusion.
The duration of treatment for any orthodontic intervention is one of the important factors that patients consider when making a decision [1]. For example, retraction of maximally anchored canines after extraction of upper premolars can take about 7 months, while the rate of bioorthodontic tooth movement (OTM) is approximately 1 mm per month, resulting in a total treatment time of approximately two years [2, 3] . Pain, discomfort, caries, gingival recession and root resorption are side effects that increase the duration of orthodontic treatment [4]. In addition, aesthetic and social reasons cause many patients to demand faster completion of orthodontic treatment [5]. Therefore, both orthodontists and patients seek to speed up the movement of teeth and reduce treatment time [6].
The method by which the movement of the teeth is accelerated depends on the activation of the biological tissue reaction. According to the degree of invasiveness, these methods can be divided into two groups: conservative (biological, physical, and biomechanical methods) and surgical methods [7].
Biological approaches include the use of pharmacological agents to increase tooth mobility in animal experiments and in humans. Many studies have shown efficacy against most of these substances such as cytokines, nuclear factor kappa-B ligand receptor activators/nuclear factor-kappa-B protein receptor activators (RANKL/RANK), prostaglandins, vitamin D, hormones such as parathyroid hormone (PTH). ) and osteocalcin, as well as injections of other substances such as relaxin, have not shown any accelerated efficacy [8].
Physical approaches are based on the use of apparatus therapy, including direct current [9], pulsed electromagnetic fields [10], vibration [11], and low-intensity laser therapy [12], which have shown promising results [8]. ]. Surgical methods are considered the most used and clinically proven and can significantly reduce the duration of treatment [13,14]. However, they rely on the “Regional Acceleration Phenomenon (RAP)” since the occurrence of surgical damage to the alveolar bone can temporarily accelerate OTM [15]. These surgical interventions include traditional corticotomy [16,17], interstitial alveolar bone surgery [18], accelerated osteogenic orthodontics [19], alveolar traction [13] and periodontal traction [20], compression electrotomy [14,21], cortical resection [19]. 22] and microperforation [23].
Several systematic reviews (SR) of randomized controlled trials (RCTs) have been published on the effectiveness of surgical and non-surgical interventions in accelerating OTM [24,25]. However, the superiority of surgery over non-surgical methods has not been proven. Therefore, this systematic review (SR) aimed to answer the following key review question: Which is more effective in accelerating orthodontic tooth movement when using fixed orthodontic appliances: surgical or non-surgical methods?
First, a pilot search was conducted on PubMed to ensure there were no similar SRs and to check all related articles before writing a final SR proposal. Later, two potentially effective trials were identified and evaluated. The registration of this SR protocol in the PROSPERO database has been completed (identification number: CRD42021274312). This SR was compiled in accordance with the Cochrane Handbook of Systematic Reviews of Interventions [26] and the Preferred Reporting Items of the Guidelines for Systematic Reviews and Meta-analysis (PRISMA) [27,28].
The study included healthy male and female patients undergoing fixed orthodontic treatment, regardless of age, type of malocclusion, or ethnicity, according to the Participant Intervention, Comparisons, Results, and Study Design (PICOS) model. Additional surgery (invasive or minimally invasive) to traditional fixed orthodontic treatment was considered. The study included patients who received fixed orthodontic treatment (OT) in combination with non-surgical interventions. These interventions may include pharmacological approaches (local or systemic) and physical approaches (laser irradiation, electrical current, pulsed electromagnetic fields (PEMF) and vibration).
The primary result of this criterion is the rate of tooth movement (RTM) or any similar indicator that can inform us about the effectiveness of surgical and non-surgical interventions. Secondary outcomes included adverse effects such as patient-reported outcomes (pain, discomfort, satisfaction, oral health-related quality of life, chewing difficulties, and other experiences), periodontal tissue-related outcomes as measured by the periodontal index ( PI), complications, Gingival Index (GI), loss of attachment (AT), gingival recession (GR), periodontal depth (PD), loss of support and unwanted tooth movement (tilting, twisting, rotation) or iatrogenic tooth trauma such as tooth loss Tooth Vitality, Root Resorption. Only two study designs were accepted – Randomized Controlled Trials (RCTs) and Controlled Clinical Trials (CCTs), written in English only, with no restrictions on the year of publication.
The following articles were excluded: retrospective studies, studies in languages ​​other than English, animal experiments, in vitro studies, case reports or case series reports, editorials, articles with reviews and white papers, personal opinions, trials without reported samples, no control group, or the presence of an untreated control group and an experimental group with less than 10 patients were studied by the finite element method.
An electronic search has been created on the following databases (August 2021, no time limit, English only): Cochrane Central Register of Controlled Trials, PubMed®, Scopus®, Web of Science™, EMBASE®, Google™ Scholar, Trip, OpenGrey (for identifying gray literature) and PQDT OPEN from pro-Quest® (for identifying papers and dissertations). The literature lists of selected articles were also checked for any potentially relevant trials that might not have been found by electronic searches on the Internet. At the same time, manual searches were carried out in the Journal of Angle Orthodontics, American Journal of Orthodontics and Dentofacial Orthopedics™, European Journal of Orthodontics and Orthodontics and Craniofacial Research. ClinicalTrials.gov and the World Health Organization’s International Clinical Trials Registry Platform (ICTRP) search portal conducted electronic checks to find unpublished trials or currently completed studies. More details on the e-search strategy are provided in Table 1.
RANKL: nuclear factor kappa-beta ligand receptor activator; RANK: nuclear factor kappa-beta ligand receptor activator
Two reviewers (DTA and MYH) independently assessed the suitability of the study, and in case of discrepancies, a third author (LM) was invited to make a decision. The first step consists of checking only the title and annotation. The second step for all studies was to rate the full text as relevant and filter for inclusion or when the title or abstract was unclear to help make a clear judgment. Articles were excluded if they did not meet one or more of the inclusion criteria. For further explanations or additional data, please write to the respective author. The same authors (DTA and MYH) independently extracted data from pilot and predefined data extraction tables. When the two lead reviewers disagreed, a third author (LM) was asked to help resolve them. The summary data table includes the following elements: general information about the article (name of the author, year of publication and background of the study); methods (study design, assessed group); participants (number of patients recruited, mean age and age range). , floor); Interventions (type of procedure, place of procedure, technical aspects of the procedure); Orthodontic characteristics (degree of malocclusion, type of orthodontic tooth movement, frequency of orthodontic adjustments, duration of observation); and Outcome measures (primary and secondary outcomes mentioned, methods of measurement, and reporting of statistically significant differences).
Two reviewers (DTA and MYH) assessed the risk of bias using the RoB-2 instrument for derived RCTs [29] and the ROBINS-I instrument for CCTs [30]. In case of disagreement, please consult one of the co-authors (ASB) to reach a solution. For randomized trials, we rated the following areas as “low risk”, “high risk” or “some problem of bias”: bias arising from the randomization process, bias due to deviations from the expected intervention (effects attributed to interventions; effects of adherence to interventions), bias due to missing outcome data, measurement bias, selection bias in reporting outcomes. The overall risk of bias for the selected studies was rated as follows: “Low risk of bias” if all domains were rated “low risk of bias”; “Some Concern” if at least one area was rated as “Some Concern” but not “High Risk of Bias in any area, High Risk of Bias: if at least one or more domains are rated as High Risk of Bias” or some concerns over multiple domains, which significantly reduces confidence in the results. Whereas, for non-randomized trials, we rated the following areas as low, moderate, and high risk: during the intervention (intervention classification bias); after intervention (bias due to deviations from expected intervention; bias due to lack of data; outcomes) measurement bias; reporting bias in the selection of results). The overall risk of bias for the selected studies was rated as follows: “Low risk of bias” if all domains were rated “low risk of bias”; “moderate risk of bias” if all domains were rated as “low or moderate risk of bias”. bias” “Serious risk of bias”; “Severe Risk of Bias” if at least one domain is rated “Severe Risk of Bias” but no Severe Risk of Bias in any domain, “Severe Risk of Bias” if at least one domain is rated “Severe risk of systematic error”; a study was considered “missing information” if there was no clear indication that the study was “significant or at significant risk of bias” and it was missing information in one or more key areas of bias. The reliability of the evidence was assessed according to the Guidelines Assessment, Development and Evaluation (GRADE) methodology, with results classified as high, moderate, low, or very low [31].
After an electronic search, a total of 1972 articles were identified and only one citation from other sources. After removing duplicates, 873 manuscripts were reviewed. Titles and abstracts were checked for eligibility and any studies that did not meet the eligibility criteria were rejected. As a result, an in-depth study of 11 potentially relevant documents was carried out. Five completed trials and five ongoing studies did not meet the inclusion criteria. Abstracts of articles excluded after full-text evaluation and the reasons for exclusion are given in the table in the appendix. Finally, six studies (four RCTs and two CCTs) were included in the SR [23,32–36]. The block diagram of PRISMA is shown in Figure 1.
The characteristics of the six included trials are shown in Tables 2 and 3 [23,32-36]. Only one trial of the protocol was identified; see Tables 4 and 5 for more information on this ongoing research project.
RCT: randomized clinical trial; NAC: non-accelerated control; SMD: split mouth design; MOPs: microosseous perforation; LLLT: low intensity laser therapy; CFO: orthodontics with corticotomy; FTMPF: full thickness mucoperiosteal flap; Exp: experimental; male: male; F: female; U3: upper canine; ED: energy density; RTM: tooth movement speed; TTM: tooth movement time; CTM: cumulative tooth movement; PICOS: participants, interventions, comparisons, results and study design
TADs: temporary anchor device; RTM: tooth movement speed; TTM: tooth movement time; CTM: cumulative tooth movement; EXP: experimental; NR: not reported; U3: upper canine; U6: upper first molar; SS: stainless steel; NiTi: nickel-titanium; MOPs: microbial bone perforation; LLLT: low intensity laser therapy; CFO: orthodontics with corticotomy; FTMPF: full thickness mucoperiosteal flap
NR: Not reported; WHO ICTRP: Search Portal of the WHO International Clinical Trials Registry Platform
This review included four completed RCTs23,32–34 and two CCTs35,36 involving 154 patients. Age range from 15 to 29 years old. One study included only female patients [32], while another study included fewer women than men [35]. There were more women than men in three studies [33,34,36]. Only one study did not provide a gender distribution [23].
Four of the included studies were split-port (SMD) designs [33–36] and two were composite (COMP) designs (parallel and split ports) [23,32]. In a composite design study, the operative side of the experimental group was compared with the non-operative side of other experimental groups, as the contralateral side of these groups did not experience any acceleration (only conventional orthodontic treatment) [23,32]. In the other four studies, this comparison was made directly without any non-accelerated control group [33-36].
Five studies compared surgery with physical intervention (i.e., low-intensity laser therapy {LILT}), and a sixth study compared surgery with medical intervention (i.e., prostaglandin E1). Surgical interventions range from overtly invasive (traditional corticotomy [33–35], FTMPF full thickness mucoperiosteal flap [32]) to minimally invasive interventions (minimal invasive procedures {MOPs} [23] and flapless piezotomy procedures [36]).
All studies found included patients requiring canine retraction after premolar extraction [23,32–36]. All included patients received extraction-based therapy. The canines were removed after the extraction of the first premolars of the upper jaw. Extraction was performed at the start of treatment until completion of leveling and leveling in three studies [23, 35, 36] and three others [32–34]. Follow-up assessments ranged from two weeks [34], three months [23,36], and four months [33] to completion of canine retraction [32,35]. In four studies [23, 33, 35, 36], the measurement of tooth movement was expressed as “tooth movement rate” (RTM), and in one study, “tooth movement time” (CTM) was expressed as “tooth movement”. “Time” (TTM). ) of two studies [32,35], one examined sRANKL concentrations [34]. Five studies used a temporary TAD anchor device [23,32–34,36], while a sixth study used reverse tip bending for fixation [35]. In terms of methods used to measure tooth velocity, one study used digital intraoral calipers [23], one study used ELISA technology to detect gingival sulcus fluid (GCF) samples [34], and two studies evaluated the use of an electronic digital cast. . casts a caliper [33,35], while two studies used 3D scanned study models to obtain measurements [32,36].
The risk of bias for inclusion in RCTs is shown in Figure 2, and the overall risk of bias for each domain is shown in Figure 3. All RCTs were rated as having “some concern for bias” [23,32-35]. “Some concerns about bias” is a key feature of RCTs. Bias due to deviations from expected interventions (intervention-related effects; intervention adherence effects) were the most suspect areas (i.e., “some concern” was present in 100% of the four studies). The risk of bias estimate for the CCT study is shown in Figure 4. These studies had a “low risk of bias”.
Figure based on data from Abdelhameed and Refai, 2018 [23], El-Ashmawi et al., 2018 [33], Sedky et al., 2019 [34], and Abdarazik et al., 2020 [32].
Surgical versus physical intervention: Five studies compared different types of surgery with low-intensity laser therapy (LILT) to accelerate canine retraction [23,32–34]. El-Ashmawy et al. The effects of “traditional corticotomy” versus “LLT” were evaluated in a cleft RCT [33]. Regarding canine retraction speed, no statistically significant difference was found between corticotomy and LILI sides at any point in the evaluation (mean 0.23 mm, 95% CI: -0.7 to 1.2, p = 0 .64).
Turker et al. evaluated the effect of piezocision and LILT on RTM in cleft TBI [36]. In the first month, the frequency of upper canine retraction on the LILI side was statistically higher than on the piezocision side (p = 0.002). However, no statistically significant difference was observed between the two sides at the second and third months of upper canine retraction, respectively (p = 0.377, p = 0.667). Considering the total evaluation time, the effects of LILI and Piezocisia on OTM were similar (p = 0.124), although LILI was more effective than the Piezocisia procedure in the first month.
Abdelhameed and Refai studied the effect of “MOPs” compared to “LLLT” and “MOPs+LLLT” on RTM in a composite design RCT [23]. They found an increase in the rate of upper canine retraction in the accelerated sides (“MOPs” as well as “LLLT”) when compared with the non-accelerated sides, with statistically significant differences at all assessment times (p< 0.05). They found an increase in the rate of upper canine retraction in the accelerated sides (“MOPs” as well as “LLLT”) when compared with the non-accelerated sides, with statistically significant differences at all assessment times (p< 0.05). Они обнаружили ускоренное увеличение скорости ретракции верхних клыков в боковых сторонах («MOPs», а также «LLLT») по сравнению с неускоренными боковыми ретракциями со статистически значимыми различиями во все времена оценки (p<0,05). They found an accelerated increase in the velocity of lateral retraction of the upper canines (“MOPs” as well as “LLLT”) compared to non-accelerated lateral retraction with statistically significant differences at all assessment times (p<0.05).他们发现，与非加速侧相比，加速侧（“MOPs”和“LLLT”）的上犬齿回缩率增加，在所有评估时间都有统计学显着差异（p<0.05）。 They found that, compared to the non-accelerated side, the upper canine teeth of the accelerated side (“MOPs” and “LLLT”) increased the reduction rate, and there was a statistically significant difference (p<0.05) at all evaluation times. Они обнаружили, что ретракция верхнего клыка была выше на стороне акселерации («MOPs» и «LLLT») по сравнению со стороной без акселерации со статистически значимой разницей (p<0,05) во все оцениваемые моменты времени. He found that upper limb retraction was higher on the side with acceleration (“MOPs” and “LLLT”) compared to the side without acceleration with a statistically significant difference (p<0.05) at all time points evaluated. Compared to the non-accelerating side, the retraction of the clavicle was accelerated by 1.6 and 1.3 times on the “SS” and “NILT” sides, respectively. In addition, they also demonstrated that the MOPs procedure was more effective than the LLLT procedure in accelerating the retraction of the upper clavicles, although the difference was not statistically significant. The high heterogeneity and differences in applied interventions between previous studies precluded a quantitative synthesis of data [23,33,36]. Abdalazik et al. A double-arm RCI with a composite design [32] evaluated the effect of a full-thickness mucoperiosteal flap (FTMPF height only with LLLT) on cumulative tooth movement (CTM) and tooth movement time (TTM). “Tooth movement time” when comparing the accelerated and non-accelerated sides, a significant reduction in the total time of tooth retraction was observed. In the whole study, there was no statistically significant difference between “FTMPF” and “LLLT” in terms of “cumulative tooth movement” (p = 0.728) and “tooth movement time” (p = 0.298). In addition, “FTMPF” and “LLLT” » can achieve 25% and 20% acceleration OTM respectively.
Seki et al. The effect of “traditional corticotomy” versus “LLT” on RANKL release during OTM in an RCT with orotomy was evaluated and compared [34]. The study reported that both corticotomy and LILI increased RANKL release during OTM, which directly affected bone remodeling and OTM rate. The bilateral difference was not statistically significant at 3 and 15 days post-intervention (p = 0.685 and p = 0.400, respectively). Differences in timing or method of evaluating outcomes prevented inclusion of the two previous studies in a meta-analysis [32,34].
Surgical and pharmacological interventions: Rajasekaran and Nayak evaluated the effect of corticotomy versus prostaglandin E1 injection on RTM and tooth movement time (TTM) in split-mouth CCT [35]. They demonstrated that corticotomy improved RTM better than prostaglandins, with a statistically significant difference (p = 0.003), since the mean RTM on the prostaglandin side was 0.36 ± 0.05 mm/week, while corticotomy was 0.40 ± 0 .04mm/perimeter. There were also differences in tooth movement time between the two interventions. The corticotomy group (13 weeks) had a shorter “tooth movement time” than the prostaglandin group (15 weeks). For more details, a summary of the quantitative findings from the main findings of each study is presented in Table 6.
RTM: tooth movement speed; TTM: tooth movement time; CTM: cumulative tooth movement; NAC: non-accelerated control; MOPs: microbial bone perforation; LLLT: low intensity laser therapy; CFO: orthodontics with corticotomy; FTMPF: full thickness mucoperiosteal flap; NR: not reported
Four studies assessed secondary outcomes [32,33,35,36]. Three studies assessed the loss of molar support [32,33,35]. Rajasekaran and Nayak found no statistically significant difference between corticotomy and prostaglandin groups (p = 0.67) [35]. El-Ashmawi et al. No statistically significant difference was found between corticotomy and the LLLT side at any time of assessment (MD 0.33 mm, 95% CI: -1.22-0.55, p = 0.45) [33] . Instead, Abdarazik et al. A statistically significant difference was reported between the FTMPF and LLLT groups, with the LLLT group being larger [32].
Pain and swelling were assessed in two included trials [33,35]. According to Rajasekaran and Nayak, patients reported mild swelling and pain during the first week on the corticotomy side [35]. In the case of prostaglandins, all patients experienced acute pain upon injection. In most patients, the intensity is high and lasts up to three days from the day of injection. However, El-Ashmawi et al. [33] reported that 70% of patients complained of swelling on the corticotomy side, while 10% had swelling on both the corticotomy side and the LILI side. Postoperative pain was noted by 85% of patients. The side of the corticotomy is more severe.
Rajasekaran and Nayak assessed the change in ridge height and root length and found no statistically significant difference between corticotomy and prostaglandin groups (p = 0.08) [35]. Depth of periodontal examination was assessed in only one study and found no statistically significant difference between FTMPF and LLLT [32].
Türker et al examined changes in canine and first molar angles and found no statistically significant difference in canine and first molar angles between the piezotomy side and the LLLT side during a three-month follow-up period [36].
The strength of evidence for orthodontic misalignment and side effects ranged from “very low” to “low” according to GRADE guidelines (Table 7). Reducing the strength of evidence is associated with the risk of bias [23,32,33,35,36], indirectness [23,32] and imprecision [23,32,33,35,36].
a, g Reduced risk of bias by one level (bias due to deviations from expected interventions, large loss to follow-up) and reduced imprecision by one level* [33].
c, f, i, j Risk of bias decreased by one level (non-randomized studies) and margin of error decreased by one level* [35].
d Reduce the risk of bias (due to deviation from expected interventions) by one level, indirectness by one level**, and imprecision by one level* [23].
e, h, k Reduce the risk of bias (bias associated with the randomization process, bias due to deviation from intended intervention) by one level, indirectness by one level**, and imprecision by one level* [32] .
CI: confidence interval; SMD: split port design; COMP: composite design; MD: mean difference; LLLT: low intensity laser therapy; FTMPF: full thickness mucoperiosteal flap
There has been a significant increase in research on the acceleration of orthodontic movement using various acceleration methods. Although surgical acceleration methods have been widely studied, non-surgical methods have also found their way into extensive research. Information and evidence that one acceleration method is better than another remains mixed.
According to this SR, there is no consensus among studies on the predominance of surgical or non-surgical approaches in accelerating OTM. Abdelhameed and Refai, Rajasekaran and Nayak found that in OTM, surgery was more effective than non-surgical intervention [23,35]. Instead, Türker et al. Non-surgical intervention proved to be more effective than surgical intervention during the first month of upper canine retraction [36]. However, considering the entire trial period, they found that the impact of surgical and non-surgical interventions on OTM was similar. In addition, Abdarazik et al., El-Ashmawi et al., and Sedki et al. noted that there was no difference between surgical and non-surgical interventions in terms of OTM acceleration [32-34].