Background <p>The need to shorten orthodontic treatment has led to the development of acceleration techniques, such as piezocision, a minimally invasive procedure that enhances tooth movement. Its effect on alignment, particularly in extraction versus non-extraction cases, remains unclear. This systematic review and meta-analysis aim to evaluate the efficacy of piezocision in accelerating the leveling and alignment of anterior teeth, with particular attention to its effects within different orthodontic treatment protocols, as well as its impact on overall treatment duration and postoperative pain.</p> Search methods <p>A thorough search was conducted up to December 2025 across the following databases: PubMed^®, the Cochrane Library, Scopus^®, Web of Science™, Embase^®, and Google™ Scholar.</p> Selection criteria <p>Included studies were only randomized, non-randomized, or cohort studies of patients with anterior crowding, comparing piezocision-assisted therapy to conventional treatment. Outcomes included alignment duration and overall treatment time, with some studies assessing postoperative pain as a secondary variable.</p> Data collection and analysis <p>Two reviewers independently extracted data and assessed the risk of bias. Meta-analyses were performed using RevMan 5.4 with random-effects models, heterogeneity was evaluated, and evidence certainty was graded using standard frameworks.</p> Results <p>Nine studies with 246 patients were included. Overall, piezocision reduced leveling and alignment time by 56.31 days (MD = -56.31; 95% CI: -74.00 to -38.63; <i>P</i> &lt; 0.00001) with high heterogeneity (I² = 86%). Subgroup analysis showed no significant reduction in non-extraction cases (MD = -24.06 days; 95% CI: -51.54 to 3.42; <i>P</i> = 0.09; I²=25%; Tau²= 154.96; very low certainty), whereas extraction cases had a significant reduction of 79.8 days after sensitivity analysis (MD = -79.8; 95% CI: -85.21 to -74.38; <i>P</i> &lt; 0.00001; I²=0%; Tau²= 0.00; high certainty). For overall treatment duration (3 studies), piezocision reduced time by 262.68 days (<i>P</i> = 0.002) but with low-certainty evidence and high heterogeneity (I²=93%). Evidence on postoperative pain was limited and of very low certainty.</p> Conclusions <p>Piezocision effectively accelerates leveling and alignment in extraction treatments, while the benefits in non-extraction cases are limited. Overall treatment reduction shows a trend but remains uncertain. The procedure is well-tolerated, though evidence on pain is scarce. High-quality trials are needed to confirm clinical value.</p> Trial registration <p>The protocol was registered in PROSPERO (CRD420251231974).</p>