dentistry journal

Article
Management of a Facilitated Aesthetic Orthodontic
Treatment with Clear Aligners and Minimally
Invasive Corticotomy
Silvia Caruso 1 , Atanaz Darvizeh 2 , Stefano Zema 1 , Roberto Gatto 1 and Alessandro Nota 1,3, *
1 MeSVA, University of L’Aquila, 67100 L’Aquila AQ, Italy; silvia.caruso@univaq.it (S.C.);
stefanozemaz@libero.it (S.Z.); roberto.gatto@cc.univaq.it (R.G.)
2 IRCCS San Raffaele Hospital, 20132 Milan, Italy; atanazdarvizeh@gmail.com
3 Dental School, Vita-Salute San Raffaele University and IRCCS San Raffaele, 20132 Milan, Italy
* Correspondence: nota.alessandro@hsr.it




Received: 18 September 2019; Accepted: 12 February 2020; Published: 15 February 2020


Abstract: Accelerating orthodontic tooth movement has become a topical issue and the corticotomy
seems to be the only effective and safe technique reported in the literature. Simultaneously, aesthetic
orthodontic treatment with removable clear aligners has become commonly requested. The aim of
this paper is to illustrate the management of facilitated aesthetic orthodontic treatment, a combined
approach including piezocision corticotomy and clear aligners for orthodontic treatment. Orthodontic
planning for traditional clear aligners should be modified to take advantage of the corticotomy
technique in order to facilitate the most difficult orthodontic movements needed to achieve treatment
completion, where each aligner will be used for four days rather than 15 days for a total time of four
months. A corticotomy with a modified minimally invasive flapless piezocision technique should
be performed in both jaws at the same time, before the time window of the orthodontic treatment,
where the most difficult orthodontic movements are planned. Treatment planning where difficult
orthodontic movements, such as anterior open-bite closure and extraction space closure, are easily
managed with clear aligners and are presented as examples of facilitated aesthetic orthodontic
treatment application. The combination between aesthetic treatment with clear aligners and modified
piezocision corticotomy, if carefully planned, seems to represent a synergy that achieves the current
goals of orthodontic treatment. The primary objectives of this combination should be facilitating
difficult orthodontic movements and reducing treatment duration.

Keywords: orthodontic tooth movement; aesthetics; clear aligner appliances; cortical bone injuries;
removable orthodontic appliances

1. Introduction

1.1. Background
During the last few decades, accelerating orthodontic tooth movement has become a topical
issue [1] and there have been many attempts to shorten treatment duration, including surgical
procedures as well as skeletal anchorage [2] and orthodontic movement acceleration [3–5].
Among the different techniques described in the literature, the corticotomy seems to be the
only effective and safe technique for accelerating orthodontic tooth movement according to the
scientific literature [6]. A corticotomy is an intentional injury to the cortical bone that is able to
accelerate orthodontic tooth movement and dramatically reduce treatment times because it leads to a
biological process called regional acceleratory phenomenon (RAP), which is characterized by intensified

Dent. J. 2020, 8, 19; doi:10.3390/dj8010019 www.mdpi.com/journal/dentistry

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osteoclastic activity resulting in osteopenia and increased bone modeling. This reduces the resistance
of the dense cortical bone to orthodontic tooth movement, achieving more stable results [7–11].

1.2. Aim
Initially, this technique presented significant postoperative discomfort related to its aggressive
nature due to the elevation of the mucoperiosteal flaps and to the length of the surgical procedure [6,12].
Nevertheless, recently, the piezocision technique was introduced. This procedure entails small incisions,
minimal piezoelectric osseous cuts to the buccal cortex only, and bone or soft tissue grafting, performed
under local anesthesia through a tunnel approach [13,14] and overcoming most of the disadvantages
of traditional corticotomy.
Simultaneously, orthodontic treatment with removable clear aligners has become an increasingly
common treatment choice because of the increasing number of adult patients that desire aesthetic
and comfortable alternatives to conventional fixed appliances [10,15–17], or when there is a
temporomandibular joint disease and fixed appliances are not indicated [18,19]. Clear aligners
can also have a bite effect on the activity of the masticatory muscles [20].
Today, clear aligner treatment is also requested in children to treat cross-bites or other
malocclusions [21–23].
Aesthetics and treatment duration are generally the two main expectations for adult patients
when requesting orthodontic treatment. The aim of this study is to illustrate the management of a
combined approach with piezocision corticotomy and clear aligners for orthodontic treatment.

2. Case Reports

2.1. Subject Selection

In order to undergo facilitated aesthetic orthodontic treatment (FAOT), including applying a
corticotomy surgical technique or orthodontic clear aligners treatment (Invisalign, Align Technology,
San Josè, CA, USA), each subject should be carefully evaluated. A cone-beam computed tomography
should be added to the standard orthodontic examination (anamnesis, extraoral and intraoral
examination and photographs, dental casts, orthopantomography, cephalometry).
In particular, the following indications and contraindications to the surgical–orthodontic approach
should be checked.
Indication to FAOT are: healthy periodontium with absence of bleeding on probing, absence of
severe dental crowding, the need to perform difficult orthodontic movements with high risk of relapse
(i.e., distalization; open bite closure).
Contraindications to the surgical procedure are: root crowding, thin gingival biotype, active
periodontal disease, corticosteroid therapy, systemic or local contraindications to oral surgery.

2.2. Orthodontic Planning

Traditional planning for clear aligners should be modified to take advantage of the corticotomy
technique in order to facilitate the most difficult orthodontic movements needed to achieve treatment
completion. After performing polyvinylsiloxane or digital impressions of the dental arches and
sending it to the manufacturer, proper orthodontic planning using digital software (ClinCheck, Align
Technology, San Josè, CA, USA) should be performed and the orthodontist should identify the time
window in which the most difficult orthodontic movements have to be performed. The surgical
procedure should be planned and executed as the starting point of this period in which each aligner
will be used for 4 days rather than 14 days for a total time of 4 months.
Careful planning of the ideal attachments needed to correctly use the aligner to achieve these
movements is necessary. All subjects gave their informed consent for inclusion before they participated
in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol
was approved by the Ethics Committee of the University of L’Aquila (Document DR206/2013).
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2.3. Surgical Procedure

2.3. Surgical
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19 3 of 12
A corticotomy with a modified minimally invasive flapless piezocision technique should be
performed in both jaws at the same time before the time window of the orthodontic treatment as
2.3. Surgical Procedure
defined by the orthodontist. A one-shot antibiotic therapy with 2 g of amoxicillin/clavulanic acid
shouldA corticotomy
be administered with a1 modified
h before minimally
the surgical invasive flapless
procedure. piezocision technique
A preoperative should be
0.2% chlorhexidine
performed in both jaws at the same time before the time window of the orthodontic
mouthwash for 1 min should be done [24]. Next, local anesthesia should be administered, delivering treatment as defined
by the orthodontist.
articaine A one-shot1:100,000
4% with epinephrine antibioticby therapy
buccalwith 2 g of amoxicillin/clavulanic
infiltration. acid should
Interproximal corticotomy be
vertical
administered
micro-incisions 1 hshould
before be theextended
surgical procedure.
through theA entire
preoperative
thickness 0.2%of chlorhexidine mouthwash
the cortical layer, for
just barely
1penetrating
min shouldinto be done [24]. Next,
medullary bone,local
at a anesthesia should be administered,
depth of approximately 3 mm for an delivering articaine
approximate 4% of
length with
7–
epinephrine
8 mm only 1:100,000
on the jaw by buccal
buccalinfiltration.
side (Figure Interproximal
1). A soniccorticotomy vertical micro-incisions
device (SONICflex, KaVo EWL GmbH, should
be extended
Leutkirch, through is
Germany) the entire thickness
suggested of the
to perform thecortical
verticallayer,
cuts, just
using barely penetrating
appropriate into
inserts medullary
(SFS 101 and
bone, at a depth of approximately 3 mm for an approximate length of 7–8 mm
SFS 102, Komet Dental Brasseler, Lemgo, Germany) (Figure 2) with a thickness of 0.25 mm. After only on the jaw buccal
the
side (Figurethe
procedure, 1). areas
A sonic devicebe(SONICflex,
should compressedKaVo withEWL GmbH,
sterile Leutkirch,
dressing for 1 minGermany)
and thenis sutures
suggested to
with
perform the vertical cuts, using appropriate
Vicryl 5.0 thread are applied only if bleeding persists. inserts (SFS 101 and SFS 102, Komet Dental Brasseler,
Lemgo,TheGermany) (Figure 2)
day after surgery, thewith a thickness
patient should of 0.25using
begin mm. aAfter the procedure,
chlorhexidine the areas
mouthwash 0.2%should
twicebea
compressed
day for 6 days.with Nosterile
otherdressing foror1 analgesic
antibiotic min and then sutures
therapy with Vicryl
is needed. 5.0 thread
If sutures wereare applied
needed, only
they if
will
bleeding persists.
be removed at the first follow-up visit 7 days after surgery (Figure 3).

Figure 1.
Figure 1. Cone Beam Computed
Cone Beam Computed Tomography
Tomography (CBCT) image modified piezocision corticotomy
image of modified corticotomy
between 4-2 and 4-3.
between 4-2 and 4-3.

Figure 2.
2. Appropriate
Appropriatesonic
sonicinsert
insert
to to perform
perform thethe modified
modified piezocision
piezocision technique
technique (thickness:
(thickness: 0.25
0.25 mm).
mm).
The day after surgery, the patient should begin using a chlorhexidine mouthwash 0.2% twice a
day for 6 days. No other antibiotic or analgesic therapy is needed. If sutures were needed, they will be
removed at the first follow-up visit 7 days after surgery (Figure 3).
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Figure 3. Surgical procedure: (A) incision with a 15 blade; (B) cortical incision with sonic device and
Figure 3. Surgical procedure: (A) incision with a 15 blade; (B) cortical incision with sonic device and
with Vicryl
appropriate insert; (C) sutures with Vicryl 5.0
5.0 thread
thread are
areapplied
appliedonly
onlyififbleeding
bleedingpersists.
persists.
appropriate insert; (C) sutures with Vicryl 5.0 thread are applied only if bleeding persists.
2.3.1.
2.3.1. Example—Anterior Open-bite
Example—Anterior Open-bite
2.3.1. Example—Anterior Open-bite
A healthy 20-year-old
A healthy 20-year-oldman man camefor for anorthodontic
orthodonticassessment
assessment forfor an aesthetic improvement
A healthy 20-year-old mancame came foran an orthodontic assessment for anaesthetic
an aesthetic improvement
improvement of of
of his
hishis smile.
smile. The The extraoral examination revealedsatisfactory
satisfactoryfacial
facialproportions
proportionsand and aa good
good overall
smile. Theextraoral
extraoralexamination
examination revealed
revealed satisfactory facial proportions and overall
a good overall
aesthetic
aesthetic appearance.
appearance. All subjects gave their informed consent
consentforforinclusion before they participated in
aesthetic appearance.All Allsubjects
subjectsgave
gavetheir
their informed
informed consent for inclusion
inclusion before
before they
they participated
participated
the study.
in the study.
in the study.
The
The intraoral
intraoral analysis
analysisshowed
analysis showedaaamolar
showed molar
molarandand canine Class
and canine Class I relationship
relationshipon onboth
bothsides
sides with anterior
The intraoral canine ClassIIrelationship on both sides with
with anterior
anterior
open-bite
open-bite
open-bite on
onon 2-2
2-22-2(Figures 4 and
(Figures4 4and
(Figures 5),
and5), crowding
5),crowding
crowding and and light retroinclination
and light retroinclination
retroinclinationofofthe of the mandibular
themandibular
mandibular incisors;
incisors; 3- 3-
incisors;
3-4, 3-5,
4, 3-5,
4, 3-5, 4-4
4-44-4 and
andand 4-5
4-5 are
4-5are affected
areaffected
affectedbyby rotation
byrotation and
rotation and increased
and increased lingual
increased lingual torque.
lingualtorque.
torque.The The patient
Thepatient
patienthad had
had good
good
good oral
oral
oral
hygiene
hygiene
hygiene and
andandperiodontal health
periodontalhealth
periodontal except
healthexcept for
exceptfor the
for the presence
the presence
presence ofof some
of some
somelowlow gingival
lowgingival recessions.
gingivalrecessions.
recessions.

Figure4.4.Case
Figure Case1:1: initial
initial and final
final frontal
frontaland
andlateral
lateralphoto.
photo.
Figure 4. Case 1: initial and final frontal and lateral photo.

Figure
Figure 5. 5.Case
Case1:1:initial
initial(A,B)
(A,B)and
and final
final (C,D) superior
superiorand
andinferior
inferiorocclusal
occlusalarches photo.
arches photo.

Figure 5. Case 1: initial (A,B) and final (C,D) superior and inferior occlusal arches photo.
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Orthopantomography
Orthopantomography and
and cephalometry
cephalometry (Figure
(Figure 6)
6) were used for
were used for aa radiographic
radiographic evaluation
evaluation of
of
the case.
the case.

Figure
Figure 6.
6. Case
Figure 6. Case 1:
1: cephalometric
cephalometric image.
image.

The
The patient’s
patient’s desire
desire was
was to have aa pleasant
to have smile without
pleasant smile without applying both conventional
applying both conventional or or lingual
lingual
brackets
brackets because
because ofof their
their negative
negative impact
impact on aesthetics
on aesthetics
aesthetics andand comfort.
and comfort.
comfort. Thus,
Thus, thethe treatment
treatment objective
objective
was
was toto correct
correct the
the anterior
anterior open-bite
open-bite of of 2-2
2-2 and
and toto obtain
obtain aa correct
correct teeth
teeth alignment
alignment with
with an
an aesthetic
aesthetic
orthodontic treatment using clear
orthodontic treatment using clear aligners.aligners.
As the
As the adult
theadult open-bite
adultopen-bite closing
open-biteclosing
closing movement
movement
movement of
of 2-2 2-2
of is is
is difficult
2-2difficult and
and highly
and highly
difficult subjected
subjected
highly to
to relapse
to relapse
subjected [25,26],
relapse
[25,26],
[25,26], a combined corticotomy and aligners FAOT was planned to achieve this objective and reduce
a combineda combined corticotomy
corticotomy and and
aligners aligners
FAOT FAOT
was was
plannedplanned
to to
achieveachieve
this this objective
objective and and
reduce the
reduce
the
totaltotal orthodontic
orthodontic treatment
treatment time. time.
Cone Cone
Beam Beam
ComputedComputed Tomography
Tomography
the total orthodontic treatment time. Cone Beam Computed Tomography (CBCT) evaluation and(CBCT) (CBCT) evaluation
evaluation and and
proper
proper
proper aligners
aligners aligners were
were performed
were performed as part
performed as part
as of
parttheof the
the digital
ofdigital orthodontic
orthodontic
digital orthodontic plan.
plan.
plan.AnAn optimized
Anoptimized attachment
optimizedattachment
attachment waswas
positioned on the 2-2 to obtain the necessary extrusion and torque. In fact, the aligner can
positioned on the 2-2 to obtain
obtain the
the necessary
necessary extrusion
extrusion and
and torque.
torque. In
In fact, the aligner can apply
apply
perpendicular forces
perpendicular forces on
on the
the active
active surface
surface ofof these
these attachments
attachments thatthat determine
determine the the ideal
ideal extrusive
extrusive
movement of the anterior teeth (Figure 7). Optimized attachments were also placed on other elements
movement of the anterior teeth (Figure 7). Optimized
Optimized attachments were also placed on other elements
that
that needed
needed significant
significant rotations
rotations andand torque
and torque corrections.
torque corrections.
corrections.

Figure
Figure 7.
7. Case 1:
1: initial and
and final digital frontal
frontal and lateral images showing the adopted attachment
7. Case
Case initial
1: initial final
and digital
final digital and lateral
frontal andimages
lateralshowing
images the adoptedthe
showing attachment
adopted
placement.
placement. placement.
attachment

Before applying
Before applyingthe
applying thefirst
the firstaligner,
first aligner,the
aligner, thecorticotomy
the corticotomy
corticotomy was
waswasperformed
performed
performed distally and
distally
distally mesially
andand to
to 2-2
mesially
mesially toand
2-2 2-2
and
2-3
2-3 to
and 2-3facilitate
to facilitate the
to facilitate open-bite
the the open-bite
open-bite closure and
closure
closure andanddistally and
distally
distally andandmesially
mesially
mesially to
toto3-2,
3-2,3-3
3-2, 3-33-3and
and4-2
and 4-2that
4-2 that required
that required aa
required
difficult
difficult radicular
difficult radicular movement
radicularmovement
movementand and rotation
androtation
rotationin in
thethe
in mandibular
mandibular
the mandibular arch
arch (Figures
(Figures
arch 8–10).
8–10).
(Figures The The
8–10). corticotomy
corticotomy
The was
corticotomy
was performed
performed
was performed immediately
immediately before
beforebefore
immediately the
the first first
thealigner aligner was
was placed
first aligner placed because
becausebecause
was placed the
the difficult difficult
movements
the difficult movements
started
movements
started
with thewith
started the
the beginning
beginning
with of
of the
the orthodontic
of the orthodontic
beginning treatment
orthodontic treatment and
and the
and the planned
treatment the planned
whole
planned whole
whole orthodontic
orthodontic treatmenttreatment
orthodontic duration,
treatment
duration,
changing
duration, thechanging the
alignersthe
changing aligners
every 4 days,
aligners every 4 days,
was4ofdays,
every was
3 months of
and
was of 3 months
3 3months and
weeks instead 3 weeks instead
of 13 months
and 3 weeks of
of 13 months
13
instead (which would
months
(which
be would
the required
(which would be be the required
treatment treatment
time treatment
the required if changing time if changing
aligners
time every 14
if changing aligners every 14 days).
days).every 14 days).
aligners
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Figure8.8.Case
Figure Case1:1:modified
modified piezocision
modified piezocision corticotomy
corticotomydetail.
detail.

Figure
Figure 9. 9. Case1:1:photos
Case photosafter
after the
the surgical
surgical procedure;
procedure;sutures
sutureswith
withVicryl
Vicryl5.0
5.0thread were
thread applied
were only
applied only
Figure
where9. Case 1:
bleeding photos after
persisted.
where bleeding persisted. the surgical procedure; sutures with Vicryl 5.0 thread were applied only
where bleeding persisted.

Figure
Figure 10.10.Case
Case1:1: digital
digital sequential
sequential(up
(uptoto
down) detail
down) of the
detail of difficult radicular
the difficult movement
radicular of 3-2 and
movement of 3-2
4-2.
and 4-2.
Figure 10. Case 1: digital sequential (up to down) detail of the difficult radicular movement of 3-2 and
4-2.
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2.3.2. Example 2—Extraction

2.3.2. Example 2—Extraction Space
Space Closure
Closure
A healthy 38-year-old
A healthy 38-year-old man
man came
came in as he
in as he was
was interested
interested in
in an
an aesthetic
aesthetic improvement
improvement of of his smile
his smile
auspicating to an aesthetic orthodontic treatment option with clear aligners. The extraoral
auspicating to an aesthetic orthodontic treatment option with clear aligners. The extraoral examination
revealed satisfactory
examination revealedfacial proportions.
satisfactory facial proportions.
The intraoral analysis showed
The intraoral analysis showed a molar
a molar(2-6)(2-6)
and and
canine ClassClass
canine I relationship on bothon
I relationship sides,
bothabsence
sides,
of 1-6 and 3-6 and superior and inferior moderate crowding (Figures 11 and 12). The
absence of 1-6 and 3-6 and superior and inferior moderate crowding (Figures 11 and 12). The patient patient had
good oral hygiene
had good with absence
oral hygiene of bleeding
with absence on probing
of bleeding and gingival
on probing inflammation
and gingival but somebut
inflammation elements
some
showed moderate gingival recessions. Orthopantomography (Figure 13) and cephalometry
elements showed moderate gingival recessions. Orthopantomography (Figure 13) and cephalometry (Figure 14)
were used for a radiographic evaluation of the case.
(Figure 14) were used for a radiographic evaluation of the case.

Figure 11.
Figure 11. Case 2: initial
initial and
and final
final frontal and lateral photo.

12. Case 2: initial

Figure 12. initial (A,B)
(A,B) and
and final
final (C,D)
(C,D) superior and inferior occlusal arches photos.

Figure 13. Case

Case 2:
2: orthopantomography.
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Figure
Figure 14.
14. Case
Case 2:
2: cephalometric
cephalometric image.
image.
Figure14.
Figure 14. Case
Case 2: cephalometric
cephalometricimage.
image.
After
After aa CBCT
CBCT evaluation
evaluation and and an an accurate
accurate analysis
analysis on on the
the digital
digital software
software (Figure
(Figure 15),
15), the
the
After
treatment aobjective
After
treatment CBCT
objective
a CBCT evaluation
was to
evaluation
was andthe
to align
align an arches
and
the accuratebyanalysis
by
an accurate
arches on theondigital
aa distalization
analysis
distalization of the
ofthe software
first (Figuremesialization
first quadrant,
thedigital software
quadrant, 15), the 15),
(Figure treatment
mesialization of
of 1-
the 1-
7objective was
treatment to align
objective 16 the
was
and arches
to align
17) andby
the
aa distalization
arches by a of the first
distalization
proinclination of the ofquadrant,
the
inferior first mesialization
quadrant,
7 and 1-8 (Figures 16 and 17) and a proinclination of the inferior incisors. We planned to insert aa
and 1-8 (Figures incisors. We of 1-7
mesialization
planned to and
of 1-8
1-
insert
7 and
(Figures
dental
dental 1-8and
16
implant
implant(Figures
17)the
at
at 16
and
the 3-6aand
3-6 17) and a proinclination
proinclination
site.
site. of the inferiorofincisors.
the inferior incisors. to
We planned Weinsert
planned to insert
a dental a
implant
dental implant
at the 3-6 site. at the 3-6 site.

Figure
Figure
Figure 15.
15.Case
Figure15.
15. Case2:
Case
Case 2:initial
2:
2: initial and
initial
initial and final
and final
final digital
final digital
digital occlusal
digitalocclusal
occlusal images.
occlusalimages.
images.
images.

Figure
Figure 16. Case2:2:digital
16. digital sequential(left
(left to right)
right) detail of the facilitated space closure orthodontic
16. Case
Figure 16.
Figure 2: digital sequential
Case 2: sequential (left to
to right) detail
detail of the
of the
of facilitated
the facilitated space
facilitated space closure
space closure orthodontic
closure orthodontic
orthodontic
movement.
movement.
movement.
movement.

Figure 17. Case 2: digital lateral views before and after the space closure.
Figure 17. Case
Figure 17. Case 2:
2: digital
digital lateral
lateral views
views before
before and
and after
after the
the space
space closure.
closure.
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The
The vertically
vertically optimized attachment
optimized attachment was positioned
attachment was
was on 1-5
positioned on
on 1-5 to
to achieve
achieve an
an ideal
ideal distalization
distalization
The vertically optimized positioned 1-5 to achieve an ideal distalization
movement
movement and
and provide
provide anchorage
anchorage for
for the
the molar
molar mesialization
mesialization (Figure
(Figure 18).
18).
movement and provide anchorage for the molar mesialization (Figure 18).

Figure 18. Case

Figure 18.
18. Case 2: initial
Case 2: initial digital
initial digital frontal
digital frontal and
frontal and lateral images
and lateral images showing
showing the appropriate attachment
the appropriate
appropriate attachment
attachment
placement for achieving
placement for achieving the
achieving the space
the space closure.
space closure.
closure.

Before
Before applying
applying thethe aligner,
aligner, number
number 66 interdental
interdental corticotomy
interdental corticotomy incisions
corticotomy incisions were
were performed
performed in in the
the
first quadrant, starting from the distal site of the central incisor to the distal site of the second
first quadrant, starting from the distal site of the central incisor to the distal site of the second molar molar
(to
(to facilitate
facilitate the
the difficult
difficult molar
molar mesialization
molar mesialization and
mesialization and premolar
premolar distalization
distalization movements)
movements) and and in
in the
the
mandibular arch starting from the distal site of the lateral incisors to the mesial site of first
mandibular arch starting from the distal site of the lateral incisors to the mesial site of first premolars premolars
and between the
and between the central
central incisors
incisors (Figure
incisors (Figure 19).
(Figure 19). The
19). The case
case was
was completed
completed in in nine
nine months
months and
and three
three weeks
weeks
instead
instead of
instead of 19
of 19months
19 months and
months and three weeks
and three (which
three weeks
weeks (which would
(which would have been
would have the
have been required
been the time
the required for
required timechanging
time for aligners
for changing
changing
every
aligners14 days).
every 14 days).
aligners every 14 days).

Figure 19.
Figure 19. Case
19. Case2:2:
Case 2:photographs
photographs
photographs after
after
after the
thethe surgical
surgical
surgical procedure;
procedure;
procedure; sutures
sutures
sutures with Vicryl
with
with Vicryl Vicryl 5.0 were
5.0
5.0 thread thread
thread were
were
applied
applied
applied
only only where
onlybleeding
where bleeding
where bleeding persisted.
persisted.
persisted.

3. Discussion
3. Discussion
Reduced aesthetic
Reduced
Reduced aesthetic
aesthetic impact
impact and
andand
impact treatment
treatment duration
duration
treatment are the
theprincipal
are the current
duration are currentorthodontic
current principal expectations
principal orthodontic
orthodontic
expectations
for for most patients [15,27]. A corticotomy FAOT represents an ideal
expectations for most patients [15,27]. A corticotomy FAOT represents an ideal solutiongoals
most patients [15,27]. A corticotomy FAOT represents an ideal solution to achieve solution
these to achieve
to achieve
[1,10].
theseThe
these goals [1,10]. acceleratory phenomenon (RAP) induced by corticotomy is characterized by a
regional
goals [1,10].
The
transient regional
increase acceleratory
The regionalinacceleratory
bone turnover phenomenon (RAP)
and a decrease
phenomenon induced by
in trabecular
(RAP) induced by corticotomy
bone density that
corticotomy is lasts
is characterized by aa
approximately
characterized by
transient increase
transient increase inin bone
bone turnover
turnover and
and aa decrease
decrease in
in trabecular
trabecular bone
bone density
density that
that lasts
lasts approximately
approximately
four months [11,28]. During this time window, orthodontic movements are
four months [11,28]. During this time window, orthodontic movements are accelerated andaccelerated and achieve
achieve
more stable results [7–9].
more stable results [7–9].
Dent. J. 2020, 8, 19 10 of 12

four months [11,28]. During this time window, orthodontic movements are accelerated and achieve
more stable results [7–9].
Applying this technique to clear aligners therapy allows us to facilitate the most biomechanically
complicated movements that must be included in a time window of approximately 30 aligners. In fact,
after the surgical procedure, aligners can be changed after four days rather than 14, and this will
determine a significant total treatment time reduction of about 10 months because 30 aligners will
be changed in that time span instead of eight. It is possible to plan this time window to start with
the beginning of the whole treatment or to coincide with the starting point of difficult orthodontic
movements as shown in the example cases in this study. Furthermore, the cortical incisions will
be performed only in conjunction with the elements that are required to facilitate and accelerate
orthodontic movement or to increase the long-term stability of the obtained occlusal changes [7–9],
apparently increasing the predictability of the effect of the aligners. For this purpose, the accurate
choice of the composite attachments and digital workflow planning is fundamental to achieve the
planned movements by correctly expressing orthodontic forces on the correct elements [29].
The piezocision technique significantly reduced the disadvantages of traditional corticotomy that
presented significant postoperative discomfort [6,14]. By using a sonic device with inserts with a
minimal thickness and limiting the incisions to the selected areas, those contraindications are further
reduced, making the surgical procedure compatible with patient comfort.
Furthermore, orthodontic treatment with clear aligners guarantees better periodontal health
compared to fixed orthodontic appliances [30–34]. Despite this, oral hygiene and periodontal status
should be regularly checked after surgery and throughout the period of orthodontic movements [1,27],
particularly in patients that smoke [35].
It should be also stated that during the treatment, no adverse effects were reported and no negative
effects on the periodontal tissue were observed after the treatment.
Showing only clinical cases is obviously a limitation of the present study; indeed, the successful
results obtained are related to patient history and case selection and may not reflect the clinical outcomes
for all patients. Clinical studies should be published to analyze the impact of corticotomies in increasing
the predictability of orthodontic tooth movement, as the acceleration was already demonstrated [6].

4. Conclusions
The combination of aesthetic treatment with clear aligners and modified piezocision corticotomy,
if carefully planned, seems to represent a synergy that achieves the current goals of orthodontic treatment
with a satisfactory control of moderately difficult orthodontic movements. The primary objective of this
combination should be facilitating difficult and less predictable orthodontic movements and reducing
the treatment duration; simultaneously, the long term risk of relapse should be reduced. Clinical trials
should be conducted for a detailed study of the efficacy and limits of this combined technique.

Author Contributions: Conceptualization: S.C. and A.N.; Data curation: A.D. and A.N.; Formal analysis: S.C.,
A.D. and A.N.; Funding acquisition: R.G.; Investigation: S.C., S.Z. and A.N.; Methodology: S.C. and A.N.; Project
administration: S.C.; Software: S.C., S.Z. and A.N.; Supervision: R.G.; Visualization: R.G.; Writing—original
draft: S.C., S.Z. and A.N.; Writing—review and editing: A.D. and A.N. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.

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