988735 JOO Journal of OrthodonticsMheissen et al.

Clinical Section

Journal of Orthodontics

The effectiveness of surgical adjunctive 1­–16

https://doi.org/10.1177/1465312520988735
DOI: 10.1177/1465312520988735
© The Author(s) 2021
procedures in the acceleration of Article reuse guidelines:
sagepub.com/journals-permissions
orthodontic tooth movement: A journals.sagepub.com/home/joo

systematic review of systematic reviews

and meta-analysis

Samer Mheissen1 , Haris Khan2, Ahmad Saleem Alsafadi3

and Mohammed Almuzian4,5

Abstract
Objective: To identify and evaluate the body of the evidence regarding the effectiveness of surgical adjunctive proce-
dures (SAPs) in accelerating orthodontic tooth movement (OTM).
Data sources: Unrestricted search of three electronic databases and manual search up to 12 June 2020 were undertaken.
Data selection: All systematic reviews of randomised and non-randomised controlled trials that investigate the effec-
tiveness of the SAPs in accelerating OTM were included.
Data extraction: Study selection and data extraction were undertaken independently and in duplicate by two review-
ers. A random-effects model with a 95% confidence interval (CI) was generated for comparable outcomes. Two review-
ers assessed the quality of the included studies using AMSTAR2 and GRADE.
Results: Fourteen systematic reviews were included; however, four systematic reviews were assessed quantitatively.
Meta-analysis showed that mean difference (MD) of canine retraction rate, for the first month after SAPs, was mild
(MD = 0.65 mm/month). Compared to control, micro-osteoperforations (MOPs) statistically but temporally acceler-
ate lower canine retraction and en masse retraction by 0.25 mm/month and 0.31 mm/month, respectively. There was
no significant effect (P>0.05) in terms of molar anchorage loss (MAL) between control and MOP groups. Piezocision
non-significantly shortens the duration of en masse retraction (4.30 months, P>0.05), but significantly shortens incisors
retraction (101.64 days, P<0.001). MAL is mild but significantly less in the piezocision group compared to the control
group (MD = 0.53 mm, P=0.03). Low-level evidence showed that SAPs have no significant effect on root resorption or
periodontal health; however, piezocision is associated with transient acute inflammation and noticeable scars.
Conclusion: Low-level evidence concludes that SAPs accelerate OTMs and reduce treatment duration, but the accel-
eration is minor and transient. The effect on anchorage loss is variable and technique related. Side effects of SAPs are
transient, but some might be aesthetically noticeable. A cost-benefit analysis of SAPs should be considered while making
the treatment decision.

Keywords
surgical adjunctive procedures, micro-osteoperforation, piezocision, corticotomy, umbrella review

Date received: 3 August 2020; revised: 8 December 2020; accepted: 29 December 2020

1
F ormer instructor in Orthodontic Department, Syrian Ministry of Health, Private Practice, Damascus, Syria
2
CMH Institute of Dentistry Lahore, National University of Medical Sciences, Lahore, Pakistan
3
Department of Orthodontics, Faculty of Dentistry, Damascus University, Damascus, Syria
4
Private Clinic, Edinburgh UK
5
Department of Orthodontics, University of Edinburgh, Edinburgh, UK

Corresponding author:
Samer Mheissen, Former instructor in Orthodontic Department, Syrian Ministry of Health, Private Practice, Damascus, 00962, Syria.
Email: Mheissen@yahoo.com
2 Journal of Orthodontics 
Introduction
As orthodontic treatment improves oral health-related qual-
ity of life, particularly in adults (Javidi et al., 2017), the
demand for orthodontic treatment is on the rise (2018). On
average, comprehensive orthodontic treatments take 19.9
months (Tsichlaki et al., 2016). It has been shown that a
six-month increase in the duration of treatment could sig-
nificantly decline patients’ compliance by 23% (Bukhari
et al., 2016); therefore, short-term treatment is in demand
(Uribe et al., 2014). Moreover, an increase in the treatment
duration means increased direct and indirect costs of treat-
ment besides increasing the chances of iatrogenic damages
(Dindaroğlu and Doğan, 2016).
In conventional orthodontics, under optimal force, the
rate of biological orthodontic tooth movement (OTM) is
0.5–1 mm/month (Attri et al., 2018; Sivarajan et al., 2020).
Several approaches have been developed to harness OTM
including biological and physical modalities as well as sur-
gical adjunctive procedures (SAPs). SAPs activate local
inflammatory mediators, hence, optimise bone remodelling
and fasten OTM, a phenomenon known as regional accel-
eratory (RAP) (Vargas and Ocampo, 2016). Another princi-
ple of SAPs is the reduction of bone density at the region
where orthodontic tooth movement is desired, which in
turn might accelerate OTMs (Alikhani et al., 2013).
The most commonly advocated SAPs are corticotomy,
piezocision and micro-osteoperforation (MOPs), while cor-
ticision and interseptal alveolar surgeries are less com-
monly applied due to their invasiveness. Corticotomy, a
procedure of raising the mucoperiosteal flap combined with
inter-radicular osteotomies, was first reported by LC Bryan
in 1893 (Vargas and Ocampo, 2016) but only introduced to
orthodontists in 1959 (Kole, 1959). Piezosurgery was ini-
tially introduced by Vercellotti and Podesta, 2007), while
the flapless piezocision technique was put forward by
Dibart et al. (2009). Piezocision involves a flapless trans-
mucogingival bony cut which is performed using an ultra-
sonic micro-saw. In 2010, the first animal trial of the MOP
procedure was reported by Teixeira et al. (2010) followed
by a human trial in 2013 (Alikhani et al., 2013). MOPs
include flapless trans-gingival shallow bony perforations
(2–3 mm in depth and 1.5 mm in diameter); the procedure
can be performed using conventional orthodontic tempo-
rary anchorage devices (TADs) or by using a more sophis-
ticated device like PROPEL (Sivarajan et al., 2020).
Many systematic reviews have scrutinised the literature
to summarise the clinical effectiveness of different SAPs.
Some of these reviews (Alfawal et al., 2016; Fleming et al.,
2015; Fu et al., 2019) have similar findings, while others
(Shahabee et al., 2020; Sivarajan et al., 2020) have con-
flicted outcomes. Moreover, some of the recent reviews
combined the outcomes of different interventions in the
same meta-analysis (Dab et al., 2019; Fu et al., 2019). As
such, this systematic review of systematic reviews and
meta-analysis (umbrella review) aims to appraise critically
the body of systematic review evidence in the literature and
to establish a better understanding of the effectiveness of all
types of SAPs in accelerating OTM and to reanalyse the
outcome of the data comprehensively.
Methods
Protocol registration
The study protocol was registered in PROSPERO (refer-
ence no. CRD 42020191983).
Planning and reporting of the study were undertaken
according to PRISMA (Moher et al., 2009) and Cochrane
Guidelines for Systematic Reviews (Higgins et al., 2019;
Pollock et al., 2020).
Eligibility criteria
The inclusion criteria followed the PICOS approach as
follows:
•• Participants: orthodontic patients of any age or gen-
der with no systemic disease, cleft lip and/ palate nor
craniofacial deformities.
•• Intervention: any SAPs for the acceleration of OTM.
•• Comparison: no SAPs are adopted
•• Outcome measures: the primary outcomes were to
evaluate the rate of canine retraction, en masse inci-
sor retraction and the overall treatment duration
measured by the time. The secondary outcomes were
to assess the degree of root resorption, periodontal
indices, anchorage loss, bone density and thickness.
•• All systematic reviews, with or without meta-analy-
sis, for randomised and non-randomised controlled
trials were included. Studies that included partici-
pants who had distraction osteogenesis, surgical dis-
traction for skeletal deformities, surgical acceleration
prosecutes for maxillary expansion and non-surgical
acceleration procedures (such as laser, phototherapy,
drugs, plasma), were excluded. Moreover, literature
reviews, cases reports, case-control study, retrospec-
tive study design, animal studies and studies pub-
lished in languages other than English were excluded.
Search strategy
A comprehensive search using a combination of controlled
vocabulary (MeSH) and free-text terms was undertaken by
two reviewers (SM and ASA) to identify published system-
atic reviews. Three major electronic databases (Medline via
PubMed, Cochrane database and Scopus) were searched up
to 12 June 2020. A manual search was also carried out in
the four leading orthodontic journals (the American Journal
of Orthodontic and Dentofacial Orthopedics, the European
Journal of Orthodontics, the Journal of Orthodontics as
well as the Journal of Orthodontics and Craniofacial
Mheissen et al.
Research); this was combined with search in the reference
lists of the included systematic reviews. Grey literature
searching for unpublished data was carried out in the
ProQuest (https://www.proquest.com) and OpenGrey
Europe (http://www.opengrey.eu) websites. The search
results were exported to EndNote reference management
software (Version X9, Clarivate, Philadelphia, PA, USA)
for the removal of duplicates. The preplanned protocol
involved contacting the corresponding authors of selected
studies twice via email at consecutive weeks to clarify
study details or to supply raw data, if required.
Study selection
Two reviewers (SM and ASA) blindly and in duplicate
screened the title and abstract of the retrieved papers for the
eligibility criteria; any disagreement was resolved by dis-
cussion with another author (HK). Similarly, full texts of
the potentially eligible articles were reviewed indepen-
dently and in duplicate by two reviewers (SM and ASA)
before final inclusion; any disagreement was resolved by
discussion with the second author (HK). The scoping search
resulted in only 1485 studies in the PubMed database, so
the authors decided to use the filter of systematic reviews to
increase the precision of the search. Appendix 1 shows the
search strategy. Inter-reviewer agreement was tested using
the Kappa test. No restrictions were placed with regard to
gender, age, language or date of publication.
Data item and collection
Two reviewers (SM and ASA) independently extracted data
from the included reviews using a pre-standardised form.
Microsoft Word and Excel (Microsoft Corporation,
Redmond, WA, USA) were utilised for the management of
data extraction and completion of the report. The extracted
data included the authors’ names, year of publication, reg-
istration protocols, the search restrictions, risk of bias tool,
design of the primary studies, quality of the evidence, inter-
vention/ comparison arms, primary and secondary out-
comes, funding and declaration of conflicting interest.
Quality assessment of the included studies
Two reviewers (ASA and SM) independently assessed the
included systematic reviews using A Measurement Tool to
Assess Systematic Reviews (AMSTAR.2) checklist (Shea
et al., 2017). Each systematic review was categorised as:
high quality if there was no or only one non-critical weak-
ness; moderate quality if there was more than one non-criti-
cal weakness; low quality if there was one critical flaw; and
critically low quality if there was more than one critical flaw
(Shea et al., 2017). To improve the quality of assessment
and inter-agreement, the two reviewers (SM and ASA) ini-
tially assessed one review and discussed every point of
3
AMSTAR.2 grading of that review. The rest of the reviews
were evaluated; any disagreement between the assessors
was resolved by a discussion with the second and fourth
reviewers (HK and MA).
Choice of the best evidence
The authors included reviews with different SAP interven-
tions and outcomes. However, if more than one systematic
review addressed the same question, two reviewers (SM
and HK) applied the Jadad decision algorithm indepen-
dently to choose the best body of evidence (Jadad et al.,
1997) by comparing the search strategies, inclusion criteria,
and the quality of the primary trials. Any discrepancy
between the reviewers was resolved by a consultation with
the fourth reviewer (MA) to reach a consensus.
Summary measures and synthesis of results
Outcomes with close similarity were pooled quantitatively
using Review Manager (RevMan, version 5.3; The Nordic
Cochrane Centre, Copenhagen, Denmark). The mean dif-
ference (MD) and 95% confidence interval (CI) were used
to express the continuous data. Statistical heterogeneity
was tested using Tau2 and I2 statistics. A random-effect
model was adopted if I2 was more than 50%; otherwise, the
fixed-effect model was planned to be used. If the clinical
heterogeneity of the included studies was present, the find-
ings were described narratively. One reviewer (SM)
extracted the data from the included systematic reviews
(secondary studies); if this was not possible, the relevant
data from the primary studies (clinical trials) were also
retrieved.
Risk of bias across studies and additional
analyses
GRADE was used to summarise the quality of the evidence.
As different SAP interventions were included, the authors
planned to use subgroups analysis for every intervention in
meta-analysis. Similarly, sensitivity analysis was planned
by including the moderate- and high-quality trials for the
same outcome. If sufficient trials addressing the same inter-
vention and outcome were aggregated, it was planned to
test the publication bias using Egger’s linear regression test
(Egger et al., 1997) and by visually inspecting a generated
contour-enhanced funnel plot.
Results
Selection of studies
A search of electronic databases retrieved 131 articles with
no paper retrieved from the grey or manual searches. After
the removal of duplicates, 108 records remained. The initial
4 Journal of Orthodontics 
Figure 1. Flow chart for included systematic reviews.
screening of the titles and abstracts resulted in the exclu-
sion of an additional 78 articles. Full-text screening led to
the exclusion of 16 reviews; hence, 14 systematic reviews
were finally included (Figure 1). Most of the excluded stud-
ies did not meet the planned inclusion criteria, and one
study by Vannala et al. (2019) suffered from critical flaws
in reporting and the authors failed to respond to two pieces
of correspondence from the principal author (SM) one
week apart (Appendix 2). The selection of studies showed
a good agreement between reviewers (Kappa = 0.85).
Characteristics of the included reviews
This systematic review of systematic reviews included 9
quantitative reviews (systematic review with meta-analy-
sis) (Alfawal et al., 2016; Dab et al., 2019; Fleming et al.,
2015; Fu et al., 2019; Kamal et al., 2019; Mheissen et al.,
2020; Shahabee et al., 2020; Sivarajan et al., 2020; Zimmo
et al., 2018) and Five qualitative reviews (systematic review
with narrative-analysis) (Apalimova et al., 2020; Figueiredo
et al., 2019; Rekhi et al., 2020; Viwattanatipa and
Charnchairerk, 2018; Yi et al., 2017).
Eight studies (Alfawal et al., 2016; Fleming et al., 2015;
Kamal et al., 2019; Rekhi et al., 2020; Shahabee et al.,
2020; Sivarajan et al., 2020; Viwattanatipa and
Charnchairerk, 2018; Zimmo et al., 2018) included only
randomised controlled trials, while the rest included ran-
domised and non-randomised controlled trials. All of the
included reviews applied the Cochrane tool for randomised
controlled trials to assess the risk of bias of the primary
trails except one study (Rekhi et al., 2020) (Table 1).
Only one study (Kamal et al., 2019) investigated corti-
cotomy intervention, two studies (Shahabee et al., 2020;
Sivarajan et al., 2020) investigated MOPs and two studies
(Mheissen et al., 2020; Yi et al., 2017) tested piezocision
procedure, while the rest of the reviews studied more than
one SAP. All included reviews declared that there is no con-
flict of interest except one study (Yi et al., 2017) (Table 1).
Table 1. The characteristics of the included systematic reviews.
Author name, No. of Conflict
publication Search Search Date of trials and ROB Quality of age of Comparison Primary Secondary of
year Design Registration strategy restrictions search design tool evidence participants Intervention unit outcomes outcomes Outcomes Funding interest
Alfawal et al. SR/MA Pros ED (11) No LG Up to Jan RCT (4) ROB I Unclear All ages PS (2) PT (1) CR (3) PROMS, PI, CR rate higher NF NC
Mheissen et al.

(2016) + MS Rest 2016 ROB (4) MOP (1) SM (2) DC (1) RR by 0.65 mm in
IBR (1) SM+PT (1) 1 month
CR rate higher
by 1.41 mm in
2 months
Apalimova SR NR ED (4) + ENG only Up to Dec RCT (7) ROB I, By ROB All ages CO (6) SM (3) Rate of RR, bone No clear NF NC
et al. (2020) MS 2018 CCT (2) JADAD LROB (3), PS (4) PT (6) tooth density+ PI results due to
SCALE HROB (6) movement heterogeneity
By JADAD CR, DC CO increase CR
HROB (9) 2-4 time faster
Dab et al. SR/MA NR ED (4) LG Rest UP to Aug RCT (10) ROB I Very LQE All ages CO, SM (5) Bone Retraction Reduce NM NC
(2019) + grey NM 2018 CCT (2) ROBINS to LQE Ps, MOPs PT (7) thickness, time retraction time
literature I (Grade) bone by 2.80 months
GRADE HROB (6), density, RR,
Unclear PI, pain,
ROB (5), anchorage
LROB (1) loss
Figueiredo SR Pros ED (8) + English + Up to 30 RCT (7) ROB I LQE All ages PS, CO, CO SM (4) CR (3), ER RR, PI, CR rate M NC
et al. (2019) MS Spanish + March CCT (4) ROBINS (Grade) by LASER, PT (7) (1), DC (3), anchorage increased
Portuguese 2019 I Unclear Decision TD (3) loss, pain, TTT decreased
GRADE ROB (6), satisfaction (23%–43%)
LROB (1) DC duration
Serious (1) decreased 59%
Moderate
ROB (3)
Fleming et al. SR/ MA Coch ED (8) + No LG Up to 10 RCT (4) ROB I Unclear Adolescents CO (2) SM (4) Rate of PROMS, PI, 0.61 mm M NC
(2015) MS Rest Sep 2014 ROB (4) + adults MOPs (1) orthodontic anchorage more tooth
IBR (1) tooth loss, movement for
movement satisfaction, CR in 1 month
CR occlusion 2.03 mm
more tooth
movement for
CR in 3 months
Fu et al. SR/MA NR ED (5) + No Rest Up to Feb RCT (14) ROB I LQE All ages CO, PS, SM (7) Rate of Pain, PS + MOP M NC
(2019) MS for lg 2019 CCT (3) (Grade) Decision, PT (11) tooth discomfort, effective in
No Rest Self- HROB (2), Laser Pre and movement iatrogenic accel tooth
for Y control unclear (12), flapless Co, Post one time harm, PI, movement
(2) LROB (5) IBR group (1) CR (10), loss of
DC (5) anchorage,
stability
Kamal e tal. SR/ MA Pros ED (4) + Lg Res, Up to Nov RCT (5) ROB I Unclear Adults CO (5) PT (5) RR, PI, Treatment Non-significant NF NC
(2019) MS Only 2017 ROB (1), Bone duration for difference for
English Lg HROB (4) density CR the primary
outcomes
(Continued)
5
 6
Table 1. (Continued)
Author name, No. of Conflict
publication Search Search Date of trials and ROB Quality of age of Comparison Primary Secondary of
year Design Registration strategy restrictions search design tool evidence participants Intervention unit outcomes outcomes Outcomes Funding interest
Mheissen et al. SR/ MA Pros ED (6) + No LG Up to 20 RCT (12) ROB II LQE All ages PS SM (4) CR (4) RR, PI, Pain CR rate NF NC
(2020) MS Rest Nov 2019 CCT (2) ROBINS (Grade) PT (10) ER (2) increased by
I RCT: LROB DC (5) 0.57 mm/month
GRADE (1), Some ER time
concerns decreased by 4.3
(3), HROB months
(8) TTT decreased
CCT: by 101.64 days
Serious
ROB (2)
Rekhi et al. SR NR ED (6) LG NM UP to July RCT (9) Joanna Unclear All ages CO (7) SM (3) PI + bone NM Descriptive NF NC
(2020) 2018 Briggs ROB (9) PS (2) PT (6) resorption results

Shahabee et al. SR/ MA Pros ED (6) + NO LG Up to Feb RCT (6) ROB I LROB (1) All ages MOPs SM (4) Rate of Pain, RR Rate of CR NF NC
(2019) MS Rest 2019 MROB (5) PT (2) tooth increased 0.45
movement mm per month
CR (3 in for MOP
Max)
CR (3 in
Max +
Mand)
Sivarajan et al. SR/ MA Pros ED (6) + ENG only Up to June RCT (8) ROB I LROB (3) Adolescents MOPs SM (5) Rate of GR, RR, 0.01 mm NM NC
(2020) MS 2019 Unclear + adults PT (3) tooth Pain, less tooth
ROB (2) movement, Anchorage movement for
HROB (3) CR (4 in loss CR per month
Max)
CR (3 in
Max +
Mand)
ER(1)
Viwattanatipa SR Pros ED (5) + No Rest Up to July RCT (5) ROB I HROB (5) Adolescents CO (3), PS SM (5) CR PI, Pain, RR, CO 2 to 4 times NM NC
and MS for lg 2017 + adults (1), CO + Satisfaction faster
Charnchairerk Ps (1) Pc 1.5 to 2 times
(2018) faster
Yi et al. (2017) SR NR ED (5) + No LG Up to Oct RCT (2) ROB I HROB (1), Adolescents Ps, Co SM (2) Tooth RR, PI, There is effect M NM
MS Rest 2016 CCT (2) Unclear + adults PT (2) movement Pain and on acceleration,
ROB (3) velocity discomfort PI, pain and RR
CR (2) +
DC (1) +
TD (1)
Zimmo et al. SR/MA NR ED (2) + Only ENG Up to Dec RCT (8) ROB I LROB (1) + All ages CO (5) SM (7) CR PI, Gingival CR after 1 M NC
(2018) MS 2016 MROB (1) CO PS (1) PT (1) inflammation month (0.83
+ HROB CO by mm)
(6) LASER (1) CR after 2
MOPs (1) months (1.17
mm)
CR after 3
months (1.61
mm)

Accel, acceleration; CCT, controlled clinical trial; Co, corticotomy; Coch, Cochrane; COT, conventional orthodontic treatment; CR, canine retraction; DC, decrowding; ED, electronic database; ER, en masse retraction; HQE, high-
quality evidence; HROB, high risk of bias; IBR, interproximal bone reduction; LADC, lower anterior decrowding; Lg, language; LQE, low-quality evidence; LROB, low risk of bias; M, mentioned; MIS, minimally invasive surgery; MOP,
Journal of Orthodontics 

micro-osteoperforation; MQE, moderate-quality evidence; MS, manual search; NC, no conflict; NF, no funding; NM, not mentioned; NR, not registered; PD, periodontal distraction; PI, periodontal indices; PROM, patient-reported
outcome; Pros, Prospero; Ps, piezocision; PT, patient RCT, randomised controlled trial; Rest, restriction; ROB, risk of bias; RR, root resorption; SF, study filter; SM, split mouth; SR, systematic review; SR/MA, systematic review and
meta-analysis; TD, treatment duration; Y, year.
Mheissen et al.
The quality of the included reviews
A summary of the quality of the included reviews is given in
Table 2. Using AMSTAR 2, two studies (Dab et al., 2019; Fu
et al., 2019) were appraised as critically low-quality reviews,
seven studies (Alfawal et al., 2016; Apalimova et al., 2020;
Kamal et al., 2019; Shahabee et al., 2020; Sivarajan et al.,
2020; Zimmo et al., 2018, Yi et al., 2017)) were appraised as
low-quality reviews and five studies (Fleming et al., 2015;
Figueiredo et al., 2019; Mheissen et al., 2020; Rekhi et al.,
2020; Viwattanatipa and Charnchairerk, 2018) were
appraised as moderate-­quality reviews.
Eight reviews (Alfawal et al., 2016; Figueiredo et al.,
2019; Fleming et al., 2015; Kamal et al., 2019; Mheissen
et al., 2020; Shahabee et al., 2020; Sivarajan et al., 2020;
Viwattanatipa and Charnchairerk, 2018) registered their
prior protocols with registration bodies. Four of the
included reviews (Alfawal et al., 2016; Dab et al., 2019;
Fleming et al., 2015; Mheissen et al., 2020) provided a
justification of primary studies exclusion. All studies,
except the one by Dab et al. (2019) and Apalimova et al.
(2020), assessed the risk of bias of the primary non-ran-
domised controlled trials using a suitable tool. The
included reviews lack the reporting of the funding of the
primary clinical trials, which is a weakness in most, as
three of the included reviews (Dab et al. 2019; Sivarajan
et al. 2020; Viwattanatipa and Charnchairerk 2018) did
not provide the funding details and one study (Yi et al.,
2017) did not provide conflicts of interest details the
funding details. None of the included reviews provided
reporting about publication bias.
Choice of the best evidence
The authors found that many of the included reviews
addressed the same question about the effectiveness of
SAPs but differed in the inclusion criteria and search
strategy. As recycling the same trials in different system-
atic reviews introduced overlapping in the outcomes, the
authors applied the Jadad decision algorithm for choosing
the best body of evidence. Hence, only four reviews (Dab
et al., 2019; Mheissen et al., 2020; Sivarajan et al., 2020;
Zimmo et al., 2018) were included in the meta-analysis of
this umbrella review. Three of the included reviews
assessed the effectiveness of SAPs (corticotomy (Zimmo
et al., 2018), piezocision (Mheissen et al., 2020) and
MOPs (Sivarajan et al., 2020)) on OTM, while Dab et al.
(2019) studied the effect of SAPs on the periodontal
indexes and the bone density (Figure 2).
Synthesis of results
The results are summarised in Table 3 and Appendix 3.
7
Upper canine retraction
The available evidence comprised four piezocision trials, six
MOP trials and four corticotomy trials. The ­meta-­analysis of
this umbrella review reported a statistically significant MD for
upper canine retraction in the first month secondary to SAPs
(MD = 0.65 mm/month, 95% CI = 0.42–0.87, P < 0.00001,
14 trials, 328 participants, low quality) favouring the SAP
interventions; however, the statistical heterogeneity within the
subgroups was very high. Figure 3 shows the overall pooled
effect of all SAPs and subgroup analysis of each procedure.
Lower canine retraction
One of the included systematic review (Sivarajan et al.,
2020) included two trials that investigated MOP effects on
the OTM of the lower canines. It showed that the MD of the
lower canine retraction in the first four weeks secondary to
surgery was statistically significant (MD = 0.25, 95% CI =
0.19–0.32, P < 0.00001, two trials, 86 patients) favouring
the MOPs (Figure 4).
En masse retraction
One included systematic review by Mheissen et al. (2020)
found that the time required for en masse retraction in the
piezocision group was shorter but not statistically signifi-
cant in comparison to control (MD = 4.30 months, 95% CI
= 4.23 to –12.48, P = 0.32, two trials, very low quality, 54
patients). In contrast, another systematic review by
Sivarajan et al. (2020) concluded that MOPs provided sta-
tistically faster en masse retraction in the first month in
comparison to controls (MD = 0.31 mm/month, 95% CI =
0.22–0.39, P < 0.0001, one trial very low quality, 60
patients).
Upper incisor retraction
The included systematic review by Mheissen et al. (2020)
involved one primary trial that addressed the effect of pie-
zocision on the duration of upper incisor retraction; they
found that the piezocision harnessed upper incisor retrac-
tion by three weeks (27% shortening of the retraction time;
P < 0.001) when compared to the control group.
Overall treatment duration
One of the included systematic reviews (Mheissen et al.,
2020) pooled the effect of piezocision procedure on treat-
ment duration based on two primary trials that featured 45
participants, the reduction in the overall treatment duration
was statistically significant (MD = 101.64 days, 95% CI =
59.24–144.06, low quality, 45 patients) with a mean treat-
ment duration of 358 days in the control group.
 8
Table 2. A summary table for the quality of the included reviews in all domains of AMSTAR2 tool.

Funding ROB effect Authors’

Author name, Duplicate Duplicate List of Description Assessing of Results on the ROB Discussion funding
publication Inclusion Comprehensive in in data excluded of included risk of included statistical statistical in the for the Publication and COF Overall
year PICO Protocol criteria search selection extraction studies studies bias studies combination combination discussion heterogeneity bias reporting quality

Alfawal et al. Yes Partial Yes Partial yes Yes Yes Yes Partial yes Yes No No No Yes Yes No Yes Low
(2016) yes

Apalimova Yes No Yes Partial yes Yes No No Yes Yes No No meta- No meta- Yes Yes No meta- Yes Low
et al. (2020) (RCT), analysis analysis analysis
No
(CCT)

Dab et al. No No Yes No Yes Yes Yes Partial yes Yes No No No Yes No No Yes Critically
(2019) (RCT), low
No
(CCT)

Figueiredo Yes Partial Yes Partial yes Yes Yes No Yes Yes No No meta- No meta- Yes No No meta- Yes Moderate
et al. (2019) yes analysis analysis analysis

Fleming et al. Yes Yes Yes Partial yes Yes Yes Yes Yes Yes Yes Yes No Yes No No Yes Moderate
(2015)

Fu et al. Yes No Yes Partial yes Yes Yes No Partial yes Yes No Yes (RCT), No No Yes No Yes Critically
(2019) No (CCT) low

Kamal et al. Yes Yes Yes Partial yes No No No Partial yes Yes No Yes No No No No Yes Low
(2019)

Mheissen Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes No Yes Moderate
et al. (2020)

Rekhi et al. Yes No Yes Partial yes Yes Yes No Yes Yes No No meta- No meta- Yes Yes No meta- Yes Moderate
(2020) analysis analysis analysis

Shahabee Yes Yes No Partial yes Yes Yes No Yes Yes No Yes No No Yes No Yes Low
et al. (2019)

Sivarajan et al. Yes Yes Yes Yes Yes Yes No Partial yes Yes No No Yes Yes Yes No Yes Low
(2020)

Viwattanatipa Yes Yes Yes Partial yes Yes Yes No Partial yes Yes No No meta- No meta- Yes No No Yes Moderate
and analysis analysis
Charnchairerk
(2018)

Yi et al. Yes No No Yes Yes Yes No Yes Yes No No meta- No meta- Yes Yes No meta- Yes Low
(2017) analysis analysis analysis

Zimmo et al. Yes No Yes Partial yes Yes Yes No Partial yes Yes No Yes No No No No Yes Low
(2018)

CCT, controlled clinical trial; COF, conflict of interest; RCT, randomised controlled trial; ROB, risk of bias.
Journal of Orthodontics 
Mheissen et al.
Figure 2. Jadad algorithm for the best evidence selection.
Molar anchorage loss
One of the included systematic reviews (Mheissen et al.,
2020) quantitatively analysed the amount of molar
anchorage loss (MAL) based on the outcomes of three
primary studies; the pooled effect showed a statistically
higher degree of MAL in the control group than the pie-
zocision group (MD = 0.53 mm, 95% CI = 0.05–1.01, P
= 0.03). In contrast, the pooled effect of another system-
atic review (Sivarajan et al., 2020), which included three
trials, demonstrated no statistically significant difference
(P > 0.05) in the amount of MAL between MOPs and the
control group.
Adverse effects
Root resorption
One of the included systematic reviews (Mheissen et al.,
2020), which included four trials, narratively reported no
statistically significant effect of piezocision on the degree
of root resorption when compared to controls. Another
review that included one primary trial using MOPs
showed similar outcomes (Sivarajan et al., 2020). In addi-
tion, the review by Dab et al. (2019) quantitively found
that corticotomy has a minimal effect on root resorption
9
when compared to controls (MD = 0.24 mm, 95% CI =
0.49–0.96, three trials).
Periodontal indices
One of the included systematic reviews (Mheissen et al., 2020)
narratively reported that piezocision is associated with no sig-
nificant negative effect on the periodontal indices, mobility
score or the relative attachment level (RAL). However, piezo-
cision was associated with a high chance of developing an
acute inflammation when it is performed from the palatal
aspect. The same systematic review found that more than 50%
of those in the piezocision group have noticeable scars. On the
other hand, one of the included reviews (Sivarajan et al., 2020)
showed no statistically significant difference between the
MOP side and the control side regarding the probing depth, the
gingival index and the degree of gingival recession.
Bone density
One of the included reviews (Dab et al., 2019) with a low
level of evidence reported that the combined use of bone
graft with corticotomy significantly increases the buccal
bone thickness (MD = 0.68; 95% CI = 0.19–1.17, P =
0.006, two trials); however, the effect on bone density ratio
was not statistically significant (MD = 7.07%, 95%
CI = 3.24–17.38, P = 0.18, two trials).
10 Journal of Orthodontics 

Table 3. Summary of the results.

Intervention Treatment effect 95% CI No. of primary trials No. of events P value

Speed of upper canine retraction (mm/month)

All SAPs MD = 0.65 0.42–0.87 14 RCTs 532 <0.00001
Piezocision MD = 0.66 0.95–0.37 4 RCTs 114 <0.00001
MOPs MD = 0.45 0.88–0.02 6 RCTs 284 <0.00001
Corticotomy MD = 0.92 1.39–0.45 4 RCTs 134 <0.00001

Speed of lower canine retraction (mm/month)

MOPs MD = 0.25 0.19–0.32 2 RCTs 86 <0.00001

Duration of en masse retraction (months)

Piezocision MD = 4.30 4.23–12.48 2 (1 RCT, 1 CCT) 114 0.32

MOPs MD = 0.31 mm/month 0.22–0.39 1 RCT 60 <0.0001

Upper Incisor retraction (weeks)

Piezocision MD = 3.15 2.65–3.64 1 RCT 42 <0.001

Overall treatment duration (days)

Piezocision MD = 101.64 59.24–144.06 2 (1 RCT, 1 CCT) 45 <0.00001

Molars anchorage loss

Piezocision MD = 0.53 mm 0.05–1.01 3 RCTs 74 0.03

MOPs Described narratively 3 RCTs 82

Wide range of molar mesialisation (0.08–0.52) as
measured at crown level
Corticotomy MD 0.06mm –0.08 to –0.04 1 RCT 46 >0.05

Root resorption
Piezocision Described narratively 4 RCTs 54
Wide range of OIIRR
MOPs Described narratively 2 RCTs 50
no significant difference of OIIRR
Periodontal effects
Piezocision Described narratively 3 RCTs 211
No negative significant effect on periodontal indices,
mobility score or the relative attachment level
Corticotomy –0.14 mm Periodontal probing –0.45 to 0.17 3 RCTs 59 >0.05
depth
Piezocision –0.3 Gingival index –0.83 to 0.23 1 RCT 33 >0.05
Corticotomy MD = 0.68 mm 1.17–0.19 2 126 <0.05
Buccal bone thickness
Corticotomy 7.07% 3.24–17.38 2 RCTs 52 0.18
Bone density

CCT, controlled clinical trial; CI, confidence interval; MD, mean difference; MOP, micro-osteoperforation; RCT, randomised controlled trial;
SAP, surgical adjunctive procedure.
Mheissen et al. 11

Table 4. A summary table showing the quality of the evidence regarding different outcomes.

Surgical adjunctive procedure compared to conventional orthodontic for orthodontic tooth movement

Patient or population: Participants undergoing orthodontic tooth movement

Setting: Any
Intervention: Surgical adjunctive procedure
Comparison: Conventional orthodontic

No. of participants Certainty of the Anticipated absolute effects

(studies) evidence
Outcomes Follow-up (GRADE) MD (95% CI)

Upper canine 532 events, 328 ⨁⨁◯◯ 0.65 mm/month

retraction patients Low*† more
(14 RCTs) (0.42–0.87)

En masse 174 (2 RCTs, ⨁◯◯◯ Not pooled

retraction CCT) Very low†‡

Overall treatment 45 (1 RCT and 1 ⨁⨁◯◯ 101.64 lower

duration CCT) Low*† (59.23–144.06)

GRADE Working Group grades of evidence

High certainty: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: We are moderately confident in the effect estimate – the true effect is likely to be close to the estimate of
the effect, but there is a possibility that it is substantially different.
Low certainty: Our confidence in the effect estimate is limited – the true effect may be substantially different from the estimate
of the effect.
Very low certainty: We have very little confidence in the effect estimate – the true effect is likely to be substantially different
from the estimate of effect.

*The studies had limitations in design that were serious enough to downgrade the quality of evidence for this outcome.
†
There is an inconsistency across the studies which may have been serious enough to downgrade the quality of evidence for this outcome.
‡
The studies had serious limitations in the design.
CCT, clinical controlled trial; CI, confidence interval; MD, mean difference; RCT, randomised controlled trial.

Quality of the evidence cross studies
GRADE approach summary is given in Table 4. Most of the
evidence was graded as low-quality evidence due to incon-
sistency in the outcomes and the high risk of bias.
Additional analysis
Subgroup analysis of different SAPs is presented in Figure 3.
Based on the quality assessment of the included reviews,
low-quality primary trials were excluded from the meta-
analysis of upper canine retraction for sensitivity analysis.
However, the overall pooled effect dropped mildly but it
remains statistically significant (MD = 0.44 mm/month,
95% CI = 0.05–0.83, P = 0.03, five trials) (Figure 5).
Publication bias for every intervention was not possible
due to the small number of trials.
Discussion
Summary of evidence
The recent systematic review and meta-analysis in its
umbrella design showed that SAPs increased the rate of
upper canine retraction in the first month postoperatively
by 0.65 mm/month; sensitivity analysis confirmed the
pooled effect (0.44 mm/month).
Subgroup analysis showed that the acceleration of upper
canine retraction was higher in corticotomy followed by the
piezocision and MOP groups. As corticotomy is the most
invasive intervention of all techniques, it can be concluded
that the more injured the bone, the greater would be the
acceleration of tooth movement. Many secondary studies
(systematic reviews) (Alfawal et al., 2016; Fleming et al.,
2015; Fu et al., 2019; Shahabee et al., 2020) showed similar
findings but with small differences in the mean effect size
probably due to the differences in the inclusion criteria, the
search strategy and/ or the date of the search. For example,
three included reviews (Figueiredo et al., 2019; Viwattanatipa
and Charnchairerk, 2018; Yi et al., 2017) reported the results
descriptively for different SAPs, which may exaggerate the
effect size of the intervention due to the number and the
quality of the included trials. One review by Fu et al. (2019)
included only a flapless surgical technique and pooled more
than one SAP with a different follow-up in the same meta-
analysis without considering the subgroup analysis; this
may confound the estimate of the effect.
There is also a lack of information regarding the uses
of MOPs in accelerating the movement of lower canines.
12 Journal of Orthodontics 

Figure 3. Forest plot clarifying the canine retraction rate (mm/month) in the first month between surgical adjunctive
procedures and control with subgroups for three surgical adjunctive procedures in 14 randomised controlled trials.

Figure 4. Forest plot showing the mean difference between micro-osteoperforations and control regarding the lower canine
retraction rate in the first month in two randomised controlled trials.

Only one MOP review (Sivarajan et al., 2020) concluded
that the lower canine OTM rate was statistically higher in
the MOP group by 0.25 mm/month for the first month after
the intervention. However, this effect is clinically small and
less than the effect of MOPs on upper canine OTM; this
could be due to the fact that the structure, composition, den-
sity and geometry of the lower and upper alveolar bone are
different.
The effectiveness of SAPs on en masse retraction is
contradictory in the literature. Mheissen et al. (2020)
reported no statistically significant difference between the
piezocision group and the control group with a high level
of heterogeneity among the included primary trials (Tuncer
et al., 2017; Wu et al., 2015). On the other hand, a trial by
Wu et al. (2015) reported that piezocision significantly
fastens en masse retraction. It is important to notice that
the trial by Wu et al. (2015) was non-randomised, which
may increase the selection bias. Furthermore, the latter
study (Wu et al., 2015) adopted a full-thickness flap sup-
plemented by bone grafting to cover the exposed bone sec-
ondary to piezocision. Only one primary trial (Attri et al.,
2018), as reported by one included review (Sivarajan et al.,
2020), investigated the effect of MOPs on en masse retrac-
tion, and it was revealed that MOPs increased the en masse
retraction rate by 0.31 mm/month during the first month
after the intervention. This is a minimal effect when com-
pared with the total treatment duration (Mavreas and
Athanasiou, 2008). For maxillary incisors retraction, only
one review (Mheissen et al., 2020) suggested that using
piezopunctures from the palatal and labial aspects may
Mheissen et al.
decrease the incisors retraction duration by three weeks;
this effect is not clinically significant when compared with
the total treatment duration (Mavreas and Athanasiou,
2008). Most of the reviews (Figueiredo et al., 2019;
Fleming et al., 2015; Mheissen et al., 2020; Shahabee
et al., 2020; Sivarajan et al., 2020; Yi et al., 2017) reported
on the effectiveness of SAPs for the first two or three
months after intervention; it is also understandable that as
time passes, the effects of SAPs decrease. One review
reported no statistically significant difference between the
first and the second month for canine retraction after pie-
zocision (Mheissen et al., 2020). However, a systematic
review by Zimmo et al. (2018) reported more acceleration
in the second month rather than the first month, secondary
to corticotomy. Although there is a lack of data regarding
the cut-off point of regional acceleration phenomena
(RAP), it is important to notice that the findings of some
animal study (Yaffe et al., 1994) mirrored the observations
by Wilcko et al. (2008). These finding stated that bone
healing is completed in three months secondary to SAPs;
hence, the rate of OTMs might reverse to normal range
after almost two months.
For overall treatment duration, two trials (Charavet
et al., 2019; Yavuz et al., 2018) found that the piezocision
decreased the active treatment period by 101 days in
crowded cases, though these studies were suffering from a
high risk of bias due to methodological shortcomings. This
high risk of bias could decrease the certainty and increase
the subjectivity in the results (Savovic et al., 2018). Two
reviews (Mheissen et al., 2020; Sivarajan et al., 2020)
investigated the effect of SAPs on MAL during canine
retraction. MAL was significantly less in the piezocision
group when compared to the control group (Mheissen et al.,
2020). Meanwhile, there was no significant effect of MOPs
on MAL as reported by one review (Sivarajan et al., 2020);
therefore, the type of SAPs may play a crucial role for this
point.
There is a lack of good evidence on the effects of SAPs
on the root resorptions. Patterson et al. (2017) reported root
injuries on the premolar roots during bone punctures via
piezocision. Uribe et al. (2017), who applied 1-mm shallow
piezocision cuts to avoid root trauma, found no significant
effect on OTMs. Therefore, it can be suggested that deep-
cut SAPs are not very safe techniques and should be applied
with caution.
With regard to the periodontal parameters, there was no
evidence on the adverse effects of SAP on periodontal tis-
sues. The review by Dab et al. ( 2019) presented similar
periodontal outcomes between corticotomy and control
groups in the included trials. This might be because most
SAPs’ cuts and perforations do not involve gingival papilla,
free gingiva or the alveolar bone crest. However, it has been
reported that piezocision result in the scar tissues that may
cause aesthetic problems in patients with a high smile line.
Furthermore, there is low-level evidence suggesting that
13
bone grafting may increase the thickness of the buccal bone
(Dab et al., 2019). However, two reviews (Dab et al., 2019;
Kamal et al., 2019) that included different primary trials
found a non-significant effect of bone grafting on the bone
density. Therefore, the recent findings do not recommend
using SAPs with or without bone graft to increase bone
density.
Strengths and limitations
The major benefit of conducting an umbrella review is to
have a comprehensive overview and perspective on the cur-
rent evidence regarding the intervention and to detect the
certainty in the related evidence. The strength of this review
is the uses of AMSTAR 2 tool with GRADE approach, fol-
lowing a registered protocol with a robust methodology,
and a large number of patients.
It is important to acknowledge that there were several
limitations in the included reviews of this umbrella review.
The first was the heterogeneity in the clinical, methodo-
logical and statistical aspects of included reviews and their
primary clinical trials. The clinical heterogeneity refers to
the differences in the settings of the trial, orthodontic appli-
ances, wire dimensions, retraction modalities, surgical pro-
cedures and the degree of bone injury. The methodological
heterogeneity is related to the trials’ designs and the limita-
tions in the primary studies. All included reviews, except
one (Kamal et al., 2019), included split-mouth designs;
hence, the authors mostly neglect the proper sample size
and the correct statistical analysis for the within-person tri-
als (Pandis et al., 2017). The statistical heterogeneity can be
detected using subgroups analysis, and for our review, it
was similar across subgroups (Spineli and Pandis, 2020).
The second limitation was the low quality of the primary
studies; as the risk of bias of most of the primary trials was
appraised as high to unclear, that reduces the certainty in
the current evidence (Table 4). The risk of bias differences
between primary trials’ assessment may be due to the vari-
ation in the risk of bias tools, as ROB2 is more comprehen-
sive than ROB1 (Sterne et al., 2019).
The Cochrane Collaboration encourages researchers to
update the reviews rather than conducting a new review by
following Garner et al. (2016) guidelines. Therefore,
orthodontic journals are encouraged to pursue similar
guidelines for updating their reviews, as recycling existing
trials in new systematic reviews will produce overlapping
results without adding new information (Papageorgiou and
Eliades, 2019).
Although this review did not include the recent pri-
mary trials, it is important to state that the design of an
umbrella review focuses on the systematic reviews (sec-
ondary studies) rather than the primary trials. Moreover, it
is important to mention that there is a lack of information
regarding the financial cost for SAPs, which plays a cru-
cial role in decision-making in evidence-based practice.
14
Figure 5. Sensitivity analysis showing the effect of surgical adjunctive procedures in the low- and medium-quality trials.
Therefore, well-designed and robust randomised con-
trolled trials with large sample sizes and long-term fol-
low-up taking in consideration risks and cost versus
benefit of SAPs are recommended.
Conclusion
Low-level evidence concludes that the surgical adjunctive
procedures accelerate orthodontic tooth movement, but the
acceleration is minor and transient. For the upper canine
retraction, SAPs accelerate the tooth movement by 0.65 mm/
month for the first month. The more invasive the surgical pro-
cedures, the greater would be the tooth movement. There is
no conclusive evidence with regards to the effect of SAPs on
lower canine retraction, en masse retraction and overall treat-
ment duration. On the other hand, low-level evidence sug-
gested that SAPs have no clinically significant effects on
incisors retraction. Weak evidence suggested that SAPs have
minor adverse effects on roots and periodontal structures.
Although the cost of SAPs affects treatment decision, it was
not fully assessed by the literature.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Journal of Orthodontics 
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Samer Mheissen https://orcid.org/0000-0002-2129-8497
Supplemental material
Supplemental material for this article is available online.
References
(2018) The number of adults seeking orthodontic treatment in the UK con-
tinues to rise. Br Dent J 224: 847.
Alfawal AM, Hajeer MY, Ajaj MA, Hamadah O and Brad B (2016)
Effectiveness of minimally invasive surgical procedures in the accel-
eration of tooth movement: a systematic review and meta-analysis.
Prog Orthod 17: 33.
Alikhani M, Raptis M, Zoldan B, Sangsuwon C, Lee YB, Alyami B,
et al. (2013) Effect of micro-osteoperforations on the rate of tooth
movement. American Journal of Orthodontics and Dentofacial
Orthopedics 144: 639–648.
Apalimova A, Roselló À, Jané-Salas E, Arranz-Obispo C, Mari-Roig A
and Lopez-Lopez J (2020) Corticotomy in orthodontic treatment:
­systematic review. Heliyon 6: e04013.
Attri S, Mittal R, Batra P, Sonar S, Sharma K, Raghavan S, et al. (2018)
Comparison of rate of tooth movement and pain perception dur-
ing accelerated tooth movement associated with conventional fixed
Mheissen et al.
a­ppliances with micro-osteoperforations - a randomised controlled
trial. Journal of Orthodontics 45: 225–233.
Bukhari OM, Sohrabi K and Tavares M (2016) Factors affecting patients'
adherence to orthodontic appointments. American Journal of
Orthodontics and Denlofacial Orthopedics 149: 319–324.
Charavet C, Lecloux G, Jackers N, Albert A and Lambert F (2019)
Piezocision-assisted orthodontic treatment using CAD/CAM custom-
ized orthodontic appliances: a randomized controlled trial in adults.
European Journal of Orthodics 41: 495–501.
Dab S, Chen K and Flores-Mir C (2019) Short- and long-term potential
effects of accelerated osteogenic orthodontic treatment: A systematic
review and meta-analysis. Orthodontic Craniofacial Research 22:
61–68.
Dibart S, Sebaoun JD and Surmenian J (2009) Piezocision: a minimally
invasive, periodontally accelerated orthodontic tooth movement
procedure. Compendium of Continuing Education in Dentistry 30:
342–344, 346, 348–350.
Dindaroğlu F and Doğan S (2016) Root Resorption in Orthodontics.
Turkish Journal of Orthodontics 29: 103–108.
Egger M, Smith GD, Schneider M and Minder C (1997) Bias in
meta-analysis detected by a simple, graphical test. BMJ 315:
629–634.
Figueiredo DS, Houara RG, Pinto LM, Diniz AR, de Araujo VE, Thabane
L, et al. (2019) Effects of piezocision in orthodontic tooth movement:
A systematic review of comparative studies. Journal of Clinical and
Experimental Dentistry 11: e1078–e1092.
Fleming PS, Fedorowicz Z, Johal A, El-Angbawi A and Pandis N (2015)
Surgical adjunctive procedures for accelerating orthodontic treatment.
Cochrane Database of Systematic Reviews 2015: CD010572.
Fu T, Liu S, Zhao H, Cao M and Zhang R (2019) Effectiveness and Safety
of Minimally Invasive Orthodontic Tooth Movement Acceleration: A
Systematic Review and Meta-analysis. Journal of Dental Research
98: 1469–1479.
Garner P, Hopewell S, Chandler J, MacLehose H, Schunemann HJ,
Akl EA, et al. (2016) When and how to update systematic reviews:
consensus and checklist. BMJ 354: i3507.
Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ,
et al. (eds) (2019) Cochrane Handbook for Systematic Reviews of
Interventions version 6.0. Chichester: John Wiley & Sons.
Jadad AR, Cook DJ and Browman GP (1997) A guide to interpreting dis-
cordant systematic reviews. Canadian Medical Association Journal
156: 1411–1416.
Javidi H, Vettore M and Benson PE (2017) Does orthodontic treatment
before the age of 18 years improve oral health-related quality of
life? A systematic review and meta-analysis. American Journal of
Orthodontics and Denlofacial Orthopedics 151: 644–655.
Kamal AT, Malik DES, Fida M and Sukhia RH. (2019) Does periodon-
tally accelerated osteogenic orthodontics improve orthodontic treat-
ment outcome? A systematic review and meta-analysis. International
Orthodontics 17: 193–201.
Kole H (1959) Surgical operations on the alveolar ridge to correct occlusal
abnormalities. Oral Surgery Oral Medicine Oral Pathology 12: 413–
420 contd.
Mavreas D and Athanasiou AE (2008) Factors affecting the duration of
orthodontic treatment: a systematic review. European Journal of
Orthodics 30: 386–395.
Mheissen S, Khan H and Samawi S (2020) Is Piezocision effective in
accelerating orthodontic tooth movement: A systematic review and
meta-analysis. PLoS One 15: e0231492.
Moher D, Liberati A, Tetzlaff J, Altman DG and PRISMA Group (2009)
Preferred reporting items for systematic reviews and meta-­analyses:
the PRISMA statement. Journal of Clinical Epidemiology 62:
1006–1012.
Pandis N, Chung B, Scherer RW, Elbourne D and Altman DG (2017)
CONSORT 2010 statement: extension checklist for reporting within
person randomised trials. BMJ 357: j2835.
15
Papageorgiou SN and Eliades T (2019) Evidence-based orthodontics: Too
many systematic reviews, too few trials. Journal of Orthodontics 46:
9–12.
Patterson BM, Dalci O, Papadopoulou AK, Madukuri S, Mahon J,
Petocz P, et al. (2017) Effect of piezocision on root resorption asso-
ciated with orthodontic force: A microcomputed tomography study.
American Journal of Orthodontics and Dentofacial Orthopedics
151: 53–62.
Pollock M, Fernandes RM, Becker LA, Pieper D and Hartling L (2020)
Chapter V: Overviews of Reviews. In: Higgins JPT, Thomas J,
Chandler J, Cumpston M, Li T, Page MJ, et al. (eds) Cochrane
Handbook for Systematic Reviews of Interventions version 6.1.
Chichester: John Wiley & Sons.
Rekhi U, Catunda RQ and Gibson MP (2020) Surgically accelerated
orthodontic techniques and periodontal response: a systematic review.
European Journal of Orthodics. DOI: 10.1093/ejo/cjz103.
Savovic J, Turner RM, Mawdsley D, Jones HE, Beynon R, Higgins JPT,
et al. (2018) Association Between Risk-of-Bias Assessments and
Results of Randomized Trials in Cochrane Reviews: The ROBES Meta-
Epidemiologic Study. American Journal of Epidemiology 187: 1113–1122.
Shahabee M, Shafaee H, Abtahi M, Rangrazi A and Bardideh E (2020)
Effect of micro-osteoperforation on the rate of orthodontic tooth
movement-a systematic review and a meta-analysis. European
Journal of Orthodics 42: 211–221.
Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, et al. (2017)
AMSTAR 2: a critical appraisal tool for systematic reviews that
include randomised or non-randomised studies of healthcare interven-
tions, or both. BMJ 358: j4008.
Sivarajan S, Ringgingon LP, Fayed MMS and Wey MC (2020) The effect
of micro-osteoperforations on the rate of orthodontic tooth move-
ment: A systematic review and meta-analysis. American Journal of
Orthodontics and Dentofacial Orthopedics 157: 290–304.
Spineli LM and Pandis N (2020) Exploring heterogeneity in meta-analy-
sis: Subgroup analysis. Part 1. American Journal of Orthodontics and
Dentofacial Orthopedics 158: 302–304.
Sterne JAC, Savovic J, Page MJ, Elbers RG, Blencowe NS, Boutron I,
et al. (2019) RoB 2: a revised tool for assessing risk of bias in ran-
domised trials. BMJ 366: l4898.
Teixeira CC, Khoo E, Tran J, Chartres I, Liu Y, Thant LM, et al. (2010)
Cytokine expression and accelerated tooth movement. Journal of
Dental Research 89: 1135–1141.
Tsichlaki A, Chin SY, Pandis N and Fleming PS (2016) How long does
treatment with fixed orthodontic appliances last? A systematic review.
American Journal of Orthodontics and Dentofacial Orthopedics 149:
308–318.
Tuncer NI, Arman-Ozcirpici A, Oduncuoglu BF, Gocmen JS and Kantarci
A (2017) Efficiency of piezosurgery technique in miniscrew sup-
ported en-masse retraction: a single-centre, randomized controlled
trial. European Journal of Orthodontics 39: 586–594.
Uribe F, Davoody L, Mehr R, Jayaratne YSN, Almas K, Sobue T, et al.
(2017) Efficiency of piezotome-corticision assisted orthodontics in
alleviating mandibular anterior crowding-a randomized clinical trial.
European Journal of Orthodontics 39: 595–600.
Uribe F, Padala S, Allareddy V and Nanda R (2014) Patients’, parents’, and
orthodontists’ perceptions of the need for and costs of additional pro-
cedures to reduce treatment time. American Journal of Orthodontics
and Denlofacial Orthopedics 145: S65–73.
Vannala V, Katta A, Reddy MS, Shetty SR, Shetty RM and Khazi SS
(2019) Periodontal Accelerated Osteogenic Orthodontics Technique
for Rapid Orthodontic Tooth Movement: A Systematic Review.
Journal of Pharmacy & Bioallied Sciences 11(Suppl 2): S97–S106.
Vargas PO and Ocampo BRY (2016) Corticotomy: historical perspective.
Revista Odontológica Mexicana 20: e80–e90.
Vercellotti T and Podesta A (2007) Orthodontic microsurgery: a new surgi-
cally guided technique for dental movement. International Journal of
Periodontics & Restorative Dentitry 27: 325–331.
16
Viwattanatipa N and Charnchairerk S (2018) The effectiveness of corti-
cotomy and piezocision on canine retraction: A systematic review.
Korean Journal of Orthodontics 48: 200–211.
Wilcko MT, Wilcko WM and Bissada NF (2008) An Evidence-Based Analysis
of Periodontally Accelerated Orthodontic and Osteogenic Techniques: A
Synthesis of Scientific Perspectives. Seminars in Orthodontics 14: 305–316.
Wu J, Jiang J-H, Xu L, Liang C, Bai YY and Zou W (2015) A pilot clinical
study of Class III surgical patients facilitated by improved accelerated
osteogenic orthodontic treatments. Angle Orthodontics 85: 616–624.
Yaffe A, Fine N and Binderman I (1994) Regional accelerated phenom-
enon in the mandible following mucoperiosteal flap surgery. Journal
of Periodontol 65: 79–83.
Journal of Orthodontics 
Yavuz MC, Sunar O, Buyuk SK and Kantarci A (2018) Comparison of
piezocision and discision methods in orthodontic treatment. Progress
in Orthodontics 19: 44.
Yi J, Xiao J, Li Y, Li X and Zhao Z (2017) Efficacy of piezocision on
accelerating orthodontic tooth movement: A systematic review. Angle
Orthodontist 87: 491–498.
Zimmo N, Saleh MHA, Sinjab K, Wang C-W, Mandelaris G and
Wang H-L (2018) Corticotomy-Assisted Orthodontics for Canine
Distalization: A Systematic Review and Meta-Analysis of Clinical
Controlled Trials. International Academy of Periodontology 20:
153–162.