https://doi.org/10.5125/jkaoms.2018.44.6.

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INVITED REVIEW ARTICLE pISSN 2234-7550·eISSN 2234-5930

Corticotomy for orthodontic tooth movement

Won Lee
Department of Dentistry, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Abstract (J Korean Assoc Oral Maxillofac Surg 2018;44:251-258)

Corticotomy was introduced as a surgical procedure to shorten orthodontic treatment time. Corticotomy removes the cortical bone that strongly resists
orthodontic force in the jaw and keeps the marrow bone to maintain blood circulation and continuity of bone tissues to reduce risk of necrosis and fa-
cilitate tooth movement. In the 21st century, the concept of regional acceleratory phenomenon was introduced and the development of the skeletal an-
chorage system using screw and plate enabled application of orthopedic force beyond conventional orthodontic force, so corticotomy has been applied
to more cases. Also, various modified methods of minimally invasive techniques have been introduced to reduce the patient’s discomfort due to surgi-
cal intervention and complications after surgery. We will review the history of corticotomy, its mechanism of action, and various modified procedures
and indications.

Key words: Corticotomy, Orthodontic tooth movement, Regional acceleratory phenomenon

[paper submitted 2018. 11. 21 / revised 2018. 11. 29 / accepted 2018. 11. 29]

I. Historical Background mies around teeth to be moved including periodontal tissue

and surrounding alveolar bone were performed, and the os-
One of the dental fields that has made great progress in the teotomized complex of the teeth and surrounding tissue was
modern era is orthodontics. However, orthodontic treatment transported to the desired position. Corticotomies for rapid
involves a lot of time and patient pain. Therefore, various tooth movement were introduced in 1959 by Köle in an effort
methods have been introduced to accelerate tooth movement to cut the alveolar bone and move a tooth. He practiced cor-
with stronger orthodontic force. A corticotomy is one of the ticotomies and osteotomies on various malocclusion cases.
representative methods for accelerating tooth movement Vertically, the cortical and marrow bone between the teeth
through invasive surgical treatment. were partially removed, and either a subapical horizontal cut
In order for tooth movement to occur, orthodontic force with alveolar bone cutting at a distance of 1 cm from the apex
must be applied to the teeth to evoke the biological action or only a cortical osteotomy excluding the marrow bone was
and response of the alveolar bone. If the force is too strong, performed. Köle2 reported no problems and no pocket forma-
problems will appear. Many studies have been performed to tion in pulp vitality testing performed 6 months later. He the-
overcome these issues. Methods for moving teeth through orized that tooth movement involved moving the block bone,
surgical techniques and the attendant biological mechanisms including the surrounding tissues. However, this method was
has recently been investigated again in various studies even not very widely used because of its surgical invasiveness.
though it has been studied for 100 years1. In the past, osteoto- Then, in order to overcome the disadvantages of a complete
resection of the alveolar bone, a treatment method was cre-
Won Lee ated to reduce resistance to tooth movement by removing
Dental Clinic, The Catholic University of Korea, Uijeongbu St. Mary’s only the cortical bone that resisted tooth movement2-4. Düker5
Hospital, 271 Cheonbo-ro, Uijeongbu 11765, Korea
TEL: +82-31-820-3574 FAX: +82-31-847-2894 reported that both the pulp and periodontium of the teeth in
E-mail: cmfs21@catholic.ac.kr beagle dogs were not damaged after corticotomy surgery
ORCID: https://orcid.org/0000-0002-6383-8754
based on Köle’s technique, and suggested a design that
CC This is an open-access article distributed under the terms of the Creative
Commons Attribution Non-Commercial License (http://creativecommons.org/ leaves at least 2 mm of bone at the level of the alveolar crest.
licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution,
and reproduction in any medium, provided the original work is properly cited. Many papers have been published since then, and all tooth
Copyright © 2018 The Korean Association of Oral and Maxillofacial Surgeons. All movement after corticotomies was believed to promote tooth
rights reserved.

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movement by eliminating the physical obstruction. However, periodontally accelerated osteogenic orthodontics (PAOO)
Wilcko et al.6 in 2001 introduced Frost’s regional accelerat- technique. It became known as “Wilckodontics” and was
ing phenomenon (RAP) concept. Tooth movement by corti- patented27. The Wilcko brothers introduced accelerated osteo-
cotomy was not caused by the movement of the bone block, genic orthodontics tooth movement (AOOTM) as a method
but by the demineralization-mineralization process around to accelerate tooth movement by selectively decorticating
the corticotomy. Wilcko et al.7 called it “bone matrix trans- the labial or lingual cortex6,7. They found that demineraliza-
portation”. Recently, interest in corticotomies has increased tion/remineralization of bone occurred ideally in younger
again, and the development of the skeletal anchorage system adolescents during tooth movement. However, in adult cases,
has enabled the application of orthodontic forces as strong as remineralization did not occur sufficiently28, so bone grafting
desired, which not only moves the teeth physiologically, but was performed at the site where the tooth would move to pro-
also facilitates tooth movement mechanically. Corticision8-10, vide alveolar housing during tooth movement7,29. Brugnami
piezocision11,12, micro-osteoperforation13,14, and discision15 et al.30 also extended the scope of conventional orthodontic
procedures have been used to perform corticotomies with treatment by corticotomy in combination with bone grafting,
minimal invasiveness. overcoming the limitations of traditional orthodontic treat-
ment.
II. Physiological Background von Böhl et al.31 found that in the beagle dog experiment,
small focal hyalinization occurred in the pressure side where
Frost16, an orthopedic surgeon, observed sudden reforma- orthodontic force was applied, and this phenomenon was
tion around the damaged area of bone and referred to this caused by a difference in tooth movement speed. Verna and
physiological reaction as a RAP, which resulted in a local Melsen32 noted that the rate of tooth movement was affected
transient burst of hard tissue. RAP is a reaction that occurs to by bone remodeling, bone density, and the hyalinized peri-
heal the damaged area not only in the hard tissue, but also in odontal ligament. Iino et al.33 reported decreased periodontal
soft tissues. In the case of hard bone tissue, the reaction in- ligament hyalinization in dogs who underwent corticotomies.
creases bone turnover and decreases bone density to promote The root resorption process continued until hyaline tissue dis-
bone healing. These tissue responses vary depending on the appeared34.
duration, strength, and size of the harmful stimulus. Shih and Verna et al.35 used finite element analysis (FEA) and stated
Norrdin17 showed a regional change in modeling and remod- that tooth movement after corticotomies decreased compres-
eling of bone defects in beagle dogs. Yaffe et al.18 reported sive stresses in the periodontal ligament and increased tensile
that a cascade of physiologic events occurred only at the cor- stresses. Ouejiaraphan et al.36 also reported that the center of
ticotomy area and that RAP occurred in the mandible of rats resistance was apically repositioned in the FEA of decorti-
even though only a mucoperiosteal flap was elevated. cated bone.
Lee et al.19 carried out corticotomies in the mandible of rats Medeiros et al.37 performed decortication to upright sec-
and observed demineralization/remineralization changes by ond molars in adults and studied the bone acquired from the
micro computed tomography, confirming that RAP occurred decorticated area using a trephine bur after 0 and 9 days. He
at the site of the corticotomy 3 weeks after the operation. reported that corticotomy surgeries inflicted reversible and
When RAP is initiated, the biological response is activated transient bone injury.
beyond the normal state. Bone metabolism, bone cell dif- The ossification created by surrounding osteoblasts and
ferentiation, progenitor cell activity, growth of bone and the jaw periosteum are main sources of osteogenic precursor
cartilage, and bone remodeling by bone multicellular units cells for osteogenesis38.
are affected by RAP20-22. In addition to trauma, RAP can be
caused by several stimuli including vitamin D, thyroxine, and III. Terminology
electrical stimuli23-25. In the maxilla and mandible, orthopedic
tooth movement as well as physical or infectious stimuli such Different terms may be used depending on the concept
as extractions, fractures, implant placement, and periodontitis when moving teeth using surgical procedures such as a corti-
may result in RAP26. cotomy.
In 2001, Wilcko et al.6 published the accelerated osteo- There are many terms for corticotomies for orthodontic
genic orthodontics (AOO) technique and then renamed it the treatment such as corticotomy-assisted orthodontic treatment

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(CAOT)39,40, AOO6,7,27,41,42, PAOO6,7,27,41-47, selective alveolar cal osteotomy site, and performing a corticotomy with a blind
decortication (SAD), surgically facilitated orthodontic thera- technique are performed to maximize the blood flow supply.
py (SFOT), and corticotomy-facilitated orthodontics (CFO) Sufficient saline irrigation and a gentle corticotomy would be
known as speedy orthodontics. The only difference is that helpful to minimize soft tissue damage and avoid necrosis of
SFOT, AOO, and PAOO involve bone grafting in addition the soft tissue after surgery.
to a corticotomy. In SFOT, both the corticotomy and bone The use of a piezoelectric surgical device can reduce soft
grafting procedures were performed in the direction of tooth tissue injuries. A high or low speed handpiece can be used.
movement rather than on both the buccal and lingual/palatal A round bur with a diameter of 2 to 4 mm is used to perform
surfaces48. the corticotomy with sufficient cooling saline. The bone is
Speedy orthodontics is defined as corticotomy-facilitated cut relatively shallow to the extent that the marrow bone is
orthodontic treatment that combines a corticotomy and ortho- exposed. The corticotomy is then divided into vertical and
pedic heavy force application on the anterior segment49-51. It horizontal parts. The vertical part must be performed care-
was demonstrated that a perisegmental corticotomy around fully so as not to damage the lateral side of the root from 2 to
the anterior segment could decrease the rigidity of the cortical 3 mm below the alveolar crest to the horizontal corticotomy
bone with bone-bending effects through heavy force applica- groove at the apical aspect.
tion on the corticotomized segment. The horizontal corticotomy is performed 3 to 5 mm away
from the lower part of the apical root between both vertical
IV. Conventional Corticotomy Technique grooves to prevent root damage. These osteotomies are per-
formed in both buccal and lingual cortical bone, and when the
Corticotomy in the alveolar bone refers to a method of thin- cortical bone is completely cut, a distal bone block is formed
ning the cortical bone without penetrating the marrow bone, containing only the teeth that are retained solely by the mar-
while an osteotomy of alveolar bone involves cutting through row bone. After the corticotomy, the flap is restored to its
the marrow bone from the cortex52. The corticotomy proce- original position and a suture is placed. The corticotomized
dure initially used handpieces and surgical burs, but various bone piece is fixed with arch wire and previously attached
devices such as a piezoelectric apparatus11,12,53-56, laser57, hard brackets. A periodontal pack can be applied for the reattach-
blade and hammer8-10,58, perforator14,59,60, and disc have gradu- ment of the elevated flap and to remove the dead space that
ally become more involved in order to reduce damage to the may cause infection and pain. The suture is removed 5 to 7
patient. In the case of corticotomy design, vertical corticoto- days after surgery.
mies between roots were carried out initially and the forma-
tion of grooves around the root using only a small round bur 2. AOO and PAOO
was used later61.
Local anesthesia is sufficient for corticotomies, but intra- A full-thickness flap is raised labially and lingually at the
venous sedation may be used for patient comfort. One-stage interdental papillae, except between the maxillary central
techniques are generally used, but two stages are used on oc- incisors. The flaps are raised beyond the apices of the teeth
casion. In the two-stage technique, alveolar bone is divided to avoid damaging the neurovascular complexes exiting the
into palatal and labial/buccal sections and corticotomized at alveolus. Corticotomy cuts and cortical bone perforations
two weeks intervals62. are performed to the malpositioned teeth using round burs6.
These cuts should not perforate the cancellous bone to avoid
1. One stage technique injury to any underlying structures. Particulate bone graft-
ing material is grafted onto the decorticated area. The flap
A vestibular incision is more advantageous in the blood is repositioned using nonresorbable suture materials. On the
circulation of the distal side and can reduce complications day of the operation, orthodontic forces should be applied to
caused by blood circulation disturbances to the distal bony the teeth. Increased osteoclastic activity results in temporary
fragment. The periosteum is elevated with a periosteal eleva- intrabony osteopenia for easy tooth movement6.
tor, and the buccal and lingual cortical bones are exposed
beyond the apical region of the corticotomy. At this time, tun-
neling of the lingual (or palatal) flap, elevating only the corti-

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V. Modified Corticotomy 4. Discision

1. Corticision Buyuk et al.15 introduced a method using a disc saw that

can be inserted into a handpiece because piezocision is dif-
Corticision means “cortical bone incision”. It is a mini- ficult to perform in orthodontic clinics where there are no
mally invasive periodontal procedure for accelerating tooth piezosurgery devices. To remove the cortical bone similar to
movement without flap elevation, but with an enhanced conventional piezocision, a disc saw is used below the inter-
turnover rate of the surrounding structures. The procedure in- dental papilla without incisions with blades. The cutting is
volves using a malleting scalpel through the cancellous bone carried out approximately 3 mm into the bone between the
and into cortical bone by approximately 10 mm and begins at roots. No suturing is performed. The orthodontic treatment is
5 mm below the papilla to preserve the papillary gingiva9. completed within 4 months without side effects such as root
resorption.
2. Piezocision
5. Laser-assisted flapless corticotomy
63
In 2007, Vercellotti and Podesta performed corticoto-
mies using conventional flap elevations and piezosurgery for It is a method for creating small perforations in the buc-
rapid tooth movement. After that, Dibart et al.11 reported on a cal gingiva without flap elevation using a laser such as the
method of performing only piezosurgery without flap eleva- ER:YAG laser. In comparison with piezocision, a similar de-
tion and named it “Piezocision”. gree of tooth movement was reported without side effects54.
This technique is performed with an interdental gingival in-
cision followed by a corticotomy with a piezoelectric appara- VI. Rate of Tooth Movement and
tus. If a bone graft is needed, it is performed after dissection Force Application
under the periosteum and the incision is sutured. Sutures are
not required if a bone graft is not performed. This method has Köle2 performed active orthodontic treatment for 6 to 12
the advantage of reducing tissue damage, but it requires more weeks after corticotomies and a retention appliance was worn
time than the conventional rotary device39. An endoscopically for 6 to 8 months to consolidate bone to prevent relapse af-
assisted tunnel approach may be used to reduce the number ter removal of the orthodontic appliance. The rate of tooth
of vertical incisions64. The rate of tooth movement was re- movement after corticotomies exhibited an average monthly
ported to be slightly slower than with a conventional corticot- rate that was twice as fast as that of the control side during
omy56. However, it was reported that the time required for the the first 2 months in the orthodontic patient with a decrease
anterior alignment of the mandibular dental arch was reduced in speed during the next two months37. Aboul-Ela et al.65 re-
by 59% in the experimental group when this procedure was ported that canine retraction after a corticotomy was 2-times
applied to alleviate crowding of the mandibular incisors53. faster in the first 2 months, 1.6 times in the 3rd month, and
1.06 times in the 4th month. When Alfawal et al.54 performed
3. Micro-osteoperforation piezocisions and laser-assisted flapless corticotomies, they
found that RAP was at its peak in the first month and dramat-
Micro-osteoperforation uses a handled appliance such as ically decreased in the second month due to the less invasive
Profel for osteo-perforation without flap elevation. Alikhani technique compared to conventional corticotomies. Abbas et
et al.59 divided twenty adults with Class II Division 1 maloc- al.56 reported that corticotomy-facilitated orthodontics exhib-
clusion into experimental and control groups, and micro- ited 1.5 to 2 times faster tooth movement compared to con-
osteoperforation was formed in the first premolar extraction ventional orthodontics. Gil et al.66 reported that corticotomy-
sockets of the experimental group. Micro-osteoperforation facilitated orthodontic cases required a shorter treatment
was formed 5 mm below the alveolar crest with three holes at period with an average of 8.85 months than conventional
the buccal surface of the extraction sockets. Each perforation orthodontic treatment, which took an average of 16.4 months.
is formed using a handheld appliance capable of adjusting Orthodontic forces were applied to the teeth and were
perforation widths to 1.5 mm with depths of 2 to 3 mm. divided into two groups. Many studies13,65,67-69 had forces ap-
plied to the teeth immediately after corticotomies. The other

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group70-74 was studied within 2 weeks after corticotomy. Krai- medications such as bisphosphonates and nonsteroidal anti-
wattanapong and Samruajbenjakun75 reported that the group inflammatory drugs6. Those who have been treated with ra-
with heavy force (50 g) application after corticotomy in rats diation therapy are unable to undergo a corticotomy because
experienced rapid tooth movement with no difference in al- of their reduced blood supply and less than ideal condition of
veolar bone change or root resorption compared to the group the surrounding soft tissue87.
with light force (10 g).
VIII. Complications
VII. Indications and Limitations
The side effects are controversial. Although interdental
Tooth movement using corticotomy can be applied in many bone loss, periodontal defects, and reduced attached gingiva
fields. Noh et al.76 reported good results in patients with were reported, Aboul-Ela et al.65 suggested that a flap design
severe bimaxillary protrusion by performing a wide-linear leaving two 2 mm of attached gingiva and relieving incisions
corticotomy with a palatal bone-borne type retractor and an- reduced the periodontal issue by providing vertical orienta-
terior segmental osteotomy instead of orthognathic surgery. tion without blocking blood flow. In the case of pain or dis-
However, cases where the bimaxillary protrusion is accompa- comfort, Al-Naoum et al.67 stated that the ingestion of food
nied with a gummy smile may benefit more from a segmental was painful for the first 2 days, but gradually decreased.
osteotomy77. Root resorption occurrence is known to be similar for both
Kim et al.78 reported that the tooth was moved to the de- corticotomy and noncorticotomy cases88. However, Chan et
sired position by performing a corticotomy and surgery to al.89 performed micro-perforations on the mesial and distal
expose multiple impacted maxillary teeth. Karthikeyan et aspects, provided a tipping force to the patient and extracted
al.79 treated a Class I malocclusion and open bite patient by premolars after four weeks. Forty-two percent more root re-
removing the bulky anterior cortical bone and intruding the sorption was observed compared to conventional orthodontic
anterior teeth. Corticotomies can also be used for canine re- tooth movement.
traction54,80, anterior teeth retraction, decrowding53,81, molar Murphy et al.58 reported that there was no difference in the
uprighting37, correction of a scissor bite82, and rapid maxillary volume of root resorption when light (10 g) or heavy forces
expansion. Lines83 introduced a method for the correction of (100 g) were applied after corticision.
a maxillary constriction that applied incisions on the lateral Corticotomy was not selected by patients because of their
walls of the maxillary sinus and mid-palatal sutures. Echchadi fear of surgery due to its invasiveness90.
et al.84 used piezo-bone perforations on the buccal alveolar
bone in young patients for maxillary expansion. Le et al.85 IX. Conclusion
showed that adjunctive buccal and palatal corticotomies on
the maxilla enhanced the outcomes of maxillary expansion in Although corticotomy is an invasive procedure, RAP ap-
adults by two and three folds. Ahn et al.86 performed orthog- pears to reduce the resistance of bone during tooth move-
nathic surgery on the mandible to correct upper incisors after ment, thereby shortening the period of orthodontic treatment
unilateral molar intrusion and occlusal plane canting correc- and minimizing adverse effects on teeth. It is believed that
tion. In addition, alveolar augmentation after corticotomies there will be a number of ways to speed up tooth movement
can increase the maxillary and/or mandibular bone-volume to without side effects while minimizing surgical invasiveness.
secure airway dimensions and prevent sleep disorders48.
Wilcko and Wilcko42 reported that ankylosed tooth or vital- Author’s Contributions
ity loss of the alveolar bone limited tooth movement. In case
of the PAOO, they suggested that patients who take cortico- W. L. wrote and approved the manuscript.
steroids which suppress inflammatory reactions were at a dis-
advantage because the periodontal ligament that mediates the Conflict of Interest
sterile inflammatory process is suppressed. In addition, it is
known that a corticotomy is not appropriate for patients with No potential conflict of interest relevant to this article was
active periodontal disease43, individuals with inadequately reported.
treated endodontic problems, and people who are taking any

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