Modern orthodontic treatments focus on comfort, aesthetics, function and efficiency, while prioritizing he patient’s quality of life during treatment [1].   Side effects such as pain, cavities, gum recession and prolonged treatment duration often motivate patients and orthodontists to seek faster tooth movement. Acceleration techniques are divided into non-surgical methods, like Low-Level Laser Therapy (LLLT) and vibration devices and surgical methods, such as micro-osteoperforations, which enhance bone remodeling and speed up tooth movement [2]. Since the 1890s, efforts have been made to accelerate tooth movement, which closely corresponds to Angle's groundbreaking work in contemporary orthodontics. Rapid orthodontics can now be performed using various approaches, including surgical and nonsurgical techniques. It has been effectively shown that these methods can reduce treatment duration by up to 70% [3]. In 2021, a study reported that 86.4% of participants preferred non-surgical accelerated orthodontic procedures, mainly to avoid anxiety, while surgical options were chosen to reduce treatment time. A statistically significant difference was found regarding opinions on time reduction when using accelerated modalities (p<0.001) [4]. Another 2021 study revealed 50.8% of orthodontists and 38.4% of patients favored customized appliances, while 49.2% of orthodontists and 38.1% of patients preferred vibration devices. Willingness to pay up to 40% more was noted among orthodontists and 20% among patients [5].   According to research conducted in 2019, 83% of participants thought orthodontic treatment took too long and 55.5% wanted it to take less than six months. FDA-approved vibrating devices came in second (40.5%), with customized wires being the most popular option (52.5%). Of the participants, 47.5% expressed a willingness to pay and 59% agreed with a charge increase of up to 40% for vibrating gadgets. There was a significant difference (p<0.05) between income and gender [6]. There is a lack of research in Saudi Arabia specifically exploring patient preferences between surgical and non-surgical accelerated orthodontic treatments. Existing studies often have small sample sizes and focus more on clinical outcomes than on patient-centered concerns like anxiety, cost and comfort. Factors such as perceived pain and psychological readiness remain underexplored. Given the rising demand for faster and more comfortable orthodontic care, it is essential to understand what influences patient choices to support more personalized and satisfactory treatment approaches.   The purpose of this study was to ascertain the opinions of patients and orthodontists on orthodontic treatment duration and methods for quickening the pace of tooth movement. Additionally, the study was designed to assess the most widely used acceleration technique selected by patients and orthodontists, as well as the amount of additional fees they are willing to spend [7].   Objectives This study aims to evaluate patient Knowledge, awareness and preferences for surgical and non-surgical accelerated orthodontic treatment options, to identify the main factors influencing acceptance, especially perceptions related to pain, cost and treatment duration.

Study Design and Setting This study utilized a cross-sectional design to assess patient awareness and preferences and acceptance of surgical versus nonsurgical approaches in accelerated orthodontic treatment. The cross-sectional design was chosen to collect data at a single point in from a Saudi population, allowing for the evaluation of current attitudes and preferences. The study was conducted at data collection took place over a period of 3 months, from September 2025 to December 2025. The setting provided access to a diverse group of patients currently undergoing or considering accelerated orthodontic treatment.   Subject: Participants, Recruitment and Sampling Procedure Participants in this study included male and female patients aged between 18 and 65 years who were undergoing or considering orthodontic treatment in dental clinics across Saudi Arabia. A sample recruiting approach relied on social media platforms such as X, Snapchat, Instagram, WhatsApp and Facebook.   Sample Size From September 2025 to December 2025 was the beginning of data collecting. Data collection involved a target sample of 384 patients (confidence level: 95%; margin of error: 5%). The sample size was estimated using the formula: n = P(1-P) * Zα 2 / d 2 with a 95% confidence level n = Calculated sample size Z = The z-value for the selected level of confidence (1- a) = 1.96 P = An estimated prevalence of knowledge. Q = (1- 0.50) = 50%, i.e., 0.50 D = The maximum acceptable error = 0.05 Therefore, the minimum target sample size (n = 384) was calculated using the formula: n = (1.96)2 X 0.50 X 0.50/(0.05) 2 = 384.   Inclusion and Exclusion Criteria Inclusion criteria were Saudi population, males and females aged between 18-65 years from all provinces of the Kingdom of Saudi Arabia, patients who are currently undergoing or planning to undergo orthodontic treatment and those who agree to participate in this study and complete the questionnaires.   Exclusion criteria were dental practitioners, patients under 18 years old, patients with chronic systemic diseases affecting oral or bone health and those unable or unwilling to provide informed consent.   Method for Data Collection, Instrument The questions were adapted from previously validated questionnaires in the literature. Data were collected through participants' responses to a self-administered questionnaire, which consisted of five main parts:   Part 1 involved the selection of each researcher's data collector number Part 2 provided a brief description of the study objectives, followed by a consent statement to ensure voluntary participation Part 3 collected demographic information, including age, gender, nationality, educational level and previous experience with orthodontic treatment Part 4 assessed participants' knowledge and awareness of accelerated orthodontic treatment options. This section covered both surgical and non-surgical methods, sources of information, perceived benefits, potential risks and factors influencing treatment choice-such as pain, duration and cost Part 5 explored participants’ preferences and acceptance of accelerated orthodontic treatments   Scoring System The questionnaire used in this study consists of a total of 33 statements, divided into three main sections. Six of these statements gather demographic information and are not scored. The remaining 27 items assess respondents' knowledge and awareness regarding surgical and non-surgical accelerated orthodontic treatment modalities and treatment preferences and acceptance. Specifically, three items measure knowledge, while eight assess awareness. Treatment preferences and acceptance consists of 16 statements. The scoring system is straightforward: each correct answer is awarded one point, while incorrect responses or answers marked as “I don’t know” receive zero points. For questions using Likert scales-whether dichotomous, three-point, or quality scales-the same scoring principle is applied.   The maximum possible score for the knowledge section is 3 points, while the awareness section has a maximum of 8 points, while the treatment preferences and acceptance section is 80 points. Resulting in a total possible score of 91 points. To interpret the scores, Bloom’s taxonomy cut-off levels are used. Overall scores are categorized for the knowledge-specific section, scores are further classified into low (1 points or zero), moderate (2 points) and high (3 points). Similarly, awareness levels are categorized as low (0-4 points), moderate (5-6 points) and high (7-8 points). Similarly for treatment preferences and acceptance section as low (less than 60%, 47 points or fewer) and moderate (60-79%, approximately 48-64 points) and high (80-100%, approximately more than 65 points).   Pilot Test The questionnaire was distributed to 15 individuals and asked to fill it. This was done to test the simplicity of the questionnaire and the feasibility of the study. Data from the pilot study were excluded from the final data of the study.   Analyzes and Entry Method The "Microsoft Office Excel Software" was utilized with Windows (2021) to enter the data into the device. The acquired data was then sent to the Statistical Package for the Social Sciences Software (SPSS) tool, version 21 (IBM SPSS Statistics for Microsoft Windows, Version 21.0), for statistical analysis. Descriptive statistics were used to summarize the numerical variables for baseline characteristics. For categorical variables, frequencies and percentages were calculated. The Chi-square test was used to identify associations between categorical variables.

Table 1 displays various demographic parameters of the participants with a total number of (652). The average age was 33.4±12.7 years and there was a comparatively balanced distribution of the age group. Most of them were female (61.7%). The sample was comprised of Saudi nationals 61.7%.   Table 1: Sociodemographic Characteristics of Participants (n = 652) Parameter No. Percentage Age (Mean: 33.4, STD: 12.7) 23 or less 135 20.7 24 to 26 133 20.4 27 to 29 137 21.0 30 to 45 106 16.3 46 or more 141 21.6 Gender Female 402 61.7 Male 250 38.3 Nationality Saudi 402 61.7 Non-Saudi 250 38.3 Educational level Elementary 2 .3 Intermediate 7 1.1 Secondary 101 15.5 Bachelor 465 71.3 Master's 47 7.2 Doctorate 30 4.6 Residential area Northern region 38 5.8 Southern region 239 36.7 Central region 62 9.5 Eastern region 64 9.8 Western region 249 38.2 Monthly income Less than 5,000 233 35.7 5,000–9,999 182 27.9 10,000–14,999 117 17.9 15,000 or above 120 18.4   Most of the participants were bachelors (71.3%), which shows that the population is educated. The major regions represented by the participants were the Western (38.2%) and Southern (36.7%). On income, more than a third indicated having a monthly income of below 5,000 with the rest of the population fairly spread out in the higher income brackets.   As shown in Figure 1, among 652 participants, pain was the main barrier to choosing surgical acceleration (37.3%), followed by fear (29.8%) and cost (12.7%). However, 18.9% reported no objection, while only 1.4% said that they have insufficient knowledge.     Figure 1: Illustrates Barriers to Surgical Method among Participants   Table 2 shows the knowledge and awareness about accelerated orthodontic treatment in terms of knowledge and preference of the participants. Most of the respondents were not undergoing or intending to undergo orthodontic treatment (64.6). Knowledge of the surgical acceleration techniques was moderate (47.7%) and the knowledge of the non-surgical ones was less (33.9%). On these conditions, more than half had a choice of non-surgical (55.1%), surgical (13.2%) and traditional (10.7%). The most significant consideration by 35.3% of participants was effectiveness and cost (28.4) and recovery time (27.6) were rated as important the least often. Most of them were not willing to undergo quick and excruciating procedures (64.3%) and were worried about pain after surgery (71.3%). On the other hand, 72.9 percent preferred slower and less painful non-surgical ones.   Table 2: Parameters Related to Knowledge and Awareness of Surgical Versus Nonsurgical Approaches in Accelerated Orthodontic Treatment (n = 652) Parameter No. Percent Do you currently have braces or are you planning orthodontic treatment? No 421 64.6 Yes 231 35.4 Have you ever heard of simple surgical methods that help speed up orthodontic treatment? (For example, making small incisions or scratches in the bone around the teeth to move them faster) No 341 52.3 Yes 311 47.7 Have you heard of non-surgical methods to speed up orthodontic treatment? (Such as laser or vibration devices) No 431 66.1 Yes 221 33.9 If it were possible to cut the duration of orthodontic treatment in half, which of these methods would you prefer? Traditional approach 70 10.7 Surgical approach 86 13.2 Non-surgical approach 359 55.1 It makes no difference to me 137 21.0 In terms of rating factors, choose the one that is most important to you: Pain 160 24.5 Cost 106 16.3 Effectiveness 230 35.3 Risk 84 12.9 Recovery time 72 11.0 In terms of rating factors, choose the one that is least important to you Pain 110 16.9 Cost 185 28.4 Effectiveness 72 11.0 Risk 105 16.1 Recovery time 180 27.6 If the surgical method was faster but caused more pain, would you agree to undergo it? No 419 64.3 Yes 233 35.7 If the non-surgical method is slower but less painful, would you prefer it? No 177 27.1 Yes 475 72.9 Do you have concerns about pain after surgical procedures? No 187 28.7 Yes 465 71.3 What prevents you from choosing the surgical method to speed up the healing process? Pain 243 37.3 Cost 83 12.7 Fear 194 29.8 I have no objection 123 18.9 I don't have enough knowledge 9 1.4 How willing are you to bear the additional cost for a treatment that reduces the orthodontic treatment time by 30%? Not willing to bear any additional cost 174 26.7 Willing to bear a small additional cost of 10% 251 38.5 Willing to bear a medium additional cost of 30% 168 25.8 Willing to bear a large additional cost of 50% 59 9.0   As shown in Figure 2, most participants (64.3%) agreed or strongly agreed that non-surgical accelerated orthodontic methods are preferred, while 26.5% were neutral and 9.2% disagreed.     Figure 2: Illustrates Participants Preference for Non-Surgical Methods for Accelerated Orthodontic Treatment   Table 3 below describes the preferences of the participants in terms of treatments to be used, cost and the perception of pain. There was also a strong inclination towards non-surgical acceleration methods with 64.3% agreeing with it or strongly agreeing. They were less willing to subject themselves to surgery so that only 41.5% agreed and 25.7% were opposed. Minimal intervention was preferred by most participants despite the length of treatment being prolonged (50.9%). The 61.2% decisions were made depending on the approach irrespective of the treatment effectiveness. The recommendation of the orthodontist was a significant factor and 75.4% agreed with it. Cost-related issues also mattered, with 56.9% of them only deciding to accelerate treatment when it is affordable and 47.2% of this group of users considering cost as a major factor.   Surgical pain was a source of concern and 65.5% of them expressed that they were concerned, whereas 64.3% of them stated that they avoid surgery because they are scared or because of complications.   Table 3: Participants’ Treatment Preferences, Cost Considerations and Pain and Discomfort Perception (n = 652) Parameter No. Percent I prefer non-surgical methods (lasers, vibration devices) for accelerated orthodontic treatment Strongly disagree 14 2.1 Disagree 46 7.1 Neutral 173 26.5 Agree 225 34.5 Strongly agree 194 29.8 I am willing to undergo surgical procedures (e.g., corticotomy, piezocision) if they significantly reduce treatment time Strongly disagree 48 7.4 Disagree 119 18.3 Neutral 214 32.8 Agree 158 24.2 Strongly agree 113 17.3 I would choose the least invasive method available, even if the treatment takes longer Strongly disagree 32 4.9 Disagree 69 10.6 Neutral 219 33.6 Agree 229 35.1 Strongly agree 103 15.8 I would choose a treatment based on its effectiveness regardless of whether it is surgical or non-surgical Strongly disagree 33 5.1 Disagree 71 10.9 Neutral 149 22.9 Agree 220 33.7 Strongly agree 179 27.5 My decision depends on the advice and recommendation of my orthodontist Strongly disagree 22 3.4 Disagree 44 6.7 Neutral 95 14.6 Agree 267 41.0 Strongly agree 224 34.4 I would only choose accelerated treatment if it is covered by insurance or is affordable Strongly disagree 21 3.2 Disagree 69 10.6 Neutral 191 29.3 Agree 213 32.7 Strongly agree 158 24.2 Cost is the most important factor influencing my treatment decision Strongly disagree 29 4.4 Disagree 117 17.9 Neutral 198 30.4 Agree 184 28.2 Strongly agree 124 19.0 I am concerned about the pain associated with surgical acceleration techniques Strongly disagree 25 3.8 Disagree 60 9.2 Neutral 140 21.5 Agree 259 39.7 Strongly agree 168 25.8 I would avoid surgical options due to fear of pain or complications Strongly disagree 27 4.1 Disagree 70 10.7 Neutral 136 20.9 Agree 238 36.5 Strongly agree 181 27.8 I believe non-surgical options are less painful and more comfortable Strongly disagree 25 3.8 Disagree 48 7.4 Neutral 124 19.0 Agree 276 42.3 Strongly agree 179 27.5   Table 4 indicates a high degree of interest in the shortening of orthodontic treatment period with 59.5% of the respondents agreeing or strongly agreeing with the importance of shortening treatment. Likewise, 56.8 would consider more invasive and 51.1 had no objection to a bit of discomfort to reduce the time of treatment. Although over 46.5% believed they had sufficient information to choose between both alternatives, only a significant percentage (78.4) of the respondents said they wanted to know more of the risks and benefits before making a final choice.   Table 4: Participants’ Treatment Duration and Decision-Making Confidence (n = 652) Parameter No. Percent Shortening orthodontic treatment time is important to me Strongly disagree 26 4.0 Disagree 88 13.5 Neutral 150 23.0 Agree 235 36.0 Strongly agree 153 23.5 I would choose a more invasive method if it reduced treatment time significantly Strongly disagree 22 3.4 Disagree 69 10.6 Neutral 191 29.3 Agree 236 36.2 Strongly agree 134 20.6 I am willing to accept some discomfort for a shorter overall treatment duration Strongly disagree 35 5.4 Disagree 108 16.6 Neutral 176 27.0 Agree 219 33.6 Strongly agree 114 17.5 I feel I have enough information to make a decision between surgical and non-surgical options Strongly disagree 23 3.5 Disagree 108 16.6 Neutral 218 33.4 Agree 202 31.0 Strongly agree 101 15.5 I would like to learn more about the risks and benefits of each acceleration method before deciding Strongly disagree 18 2.8 Disagree 37 5.7 Neutral 86 13.2 Agree 252 38.7 Strongly agree 259 39.7   Table 5 shows the score levels regarding knowledge of accelerated orthodontic approaches, with most participants demonstrating low knowledge (62.3%), while fewer participants showing moderate knowledge (29.3%) and only a small proportion showing high knowledge levels (8.4%).   Table 5: Shows Knowledge of Surgical Versus Nonsurgical Approaches in Accelerated Orthodontic Treatment Score Results Frequency Percent High knowledge level 55 8.4 Moderate knowledge level 191 29.3 Low knowledge level 406 62.3 Total 652 100.0   Table 6 shows the awareness level of accelerated orthodontic approaches, with most participants showing low awareness (74.5%), fewer having moderate awareness (23.6%) and only 1.8% showing high awareness.   Table 6: Shows Awareness of Surgical Versus Nonsurgical Approaches in Accelerated Orthodontic Treatment Score Results Frequency Percent High awareness level 12 1.8 Moderate awareness level 154 23.6 Low awareness level 486 74.5 Total 652 100.0   Table 7 shows treatment preferences and acceptance of accelerated orthodontic approaches, with most participants showing a moderate level (66.4%), followed by low (22.4%) and high levels (11.2%).   Table 7: Shows Treatment Preferences and Acceptance of Surgical Versus Nonsurgical Approaches in Accelerated Orthodontic Treatment Score Results Frequency Percent High level 73 11.2 Moderate level 433 66.4 Low level 146 22.4 Total 652 100.0   Table 8 shows that knowledge level of accelerated orthodontic treatment has statistically significant relation to gender (p = 0.001), age (p = 0.0001) and residential region (p = 0.0001). It also shows statistically insignificant relation to nationality, educational level and monthly income.   Table 8: Relation between Knowledge Level of Accelerated Orthodontic Treatment and Sociodemographic Characteristics Parameters Knowledge level Total (N = 652) P value High or moderate knowledge Low knowledge level Gender Female 131 271 402 0.001 53.3% 66.7% 61.7% Male 115 135 250 46.7% 33.3% 38.3% Age 23 or less 66 69 135 0.0001 26.8% 17.0% 20.7% 24 to 26 64 69 133 26.0% 17.0% 20.4% 27 to 29 70 67 137 28.5% 16.5% 21.0% 30 to 45 19 87 106 7.7% 21.4% 16.3% 46 or more 27 114 141 11.0% 28.1% 21.6% Nationality Saudi 235 374 609 0.089 95.5% 92.1% 93.4% Non-Saudi 11 32 43 4.5% 7.9% 6.6% Educational level Elementary 0 2 2 0.253 0.0% 0.5% 0.3% Intermediate 1 6 7 0.4% 1.5% 1.1% Secondary 42 59 101 17.1% 14.5% 15.5% Bachelor 181 284 465 73.6% 70.0% 71.3% Master's 14 33 47 5.7% 8.1% 7.2% Doctorate 8 22 30 3.3% 5.4% 4.6% Residential region Northern region 21 17 38 0.0001 8.5% 4.2% 5.8% Southern region 110 129 239 44.7% 31.8% 36.7% Central region 34 28 62 13.8% 6.9% 9.5% Eastern region 25 39 64 10.2% 9.6% 9.8% Western region 56 193 249 22.8% 47.5% 38.2% Monthly income Less than 5,000 94 139 233 0.082 38.2% 34.2% 35.7% 5,000–9,999 71 111 182 28.9% 27.3% 27.9% 10,000–14,999 48 69 117 19.5% 17.0% 17.9% 15,000 or above 33 87 120 13.4% 21.4% 18.4% *P value was considered significant if ≤0.05   Table 9 shows that awareness level of accelerated orthodontic treatment has statistically significant relation to age (p = 0.001) and monthly income (p = 0.005). It also shows statistically insignificant relation to gender, nationality, educational level and residential region.   Table 9: Awareness Level of Accelerated Orthodontic Treatment in Association with Sociodemographic Characteristics Parameters Awareness level Total (N = 652) P value High or moderate awareness Low awareness level Gender Female 112 290 402 0.074 67.5% 59.7% 61.7% Male 54 196 250 32.5% 40.3% 38.3% Age 23 or less 39 96 135 0.001 23.5% 19.8% 20.7% 24 to 26 25 108 133 15.1% 22.2% 20.4% 27 to 29 21 116 137 12.7% 23.9% 21.0% 30 to 45 34 72 106 20.5% 14.8% 16.3% 46 or more 47 94 141 28.3% 19.3% 21.6% Nationality Saudi 156 453 609 0.731 94.0% 93.2% 93.4% Non-Saudi 10 33 43 6.0% 6.8% 6.6% Educational level Elementary 0 2 2 0.063 0.0% 0.4% 0.3% Intermediate 0 7 7 0.0% 1.4% 1.1% Secondary 21 80 101 12.7% 16.5% 15.5% Bachelor 116 349 465 69.9% 71.8% 71.3% Master's 17 30 47 10.2% 6.2% 7.2% Doctorate 12 18 30 7.2% 3.7% 4.6% Residential region Northern region 6 32 38 0.085 3.6% 6.6% 5.8% Southern region 67 172 239 40.4% 35.4% 36.7% Central region 11 51 62 6.6% 10.5% 9.5% Eastern region 11 53 64 6.6% 10.9% 9.8% Western region 71 178 249 42.8% 36.6% 38.2% Monthly income Less than 5,000 61 172 233 0.005 36.7% 35.4% 35.7% 5,000–9,999 32 150 182 19.3% 30.9% 27.9% 10,000–14,999 30 87 117 18.1% 17.9% 17.9% 15,000 or above 43 77 120 25.9% 15.8% 18.4% *P value was considered significant if ≤0.05   Table 10 shows that acceptance level of accelerated orthodontic treatment has statistically significant relation to gender (p = 0.0001), age (p = 0.0001), nationality (p = 0.012), educational level (p = 0.001), residential region (p = 0.0001) and monthly income (p = 0.0001).   Table 10: Acceptance Level of Accelerated Orthodontic Treatment in Association with Sociodemographic Characteristics Parameters Acceptance level Total (N = 652) P value High or moderate level Low level Gender Female 332 70 402 0.0001 65.6% 47.9% 61.7% Male 174 76 250 34.4% 52.1% 38.3% Age 23 or less 124 11 135 0.0001 24.5% 7.5% 20.7% 24 to 26 90 43 133 17.8% 29.5% 20.4% 27 to 29 66 71 137 13.0% 48.6% 21.0% 30 to 45 100 6 106 19.8% 4.1% 16.3% Table 10: Continue Parameters Acceptance level Total (N = 652) P value High or moderate level Low level 46 or more 126 15 141 24.9% 10.3% 21.6% Nationality Saudi 466 143 609 0.012 92.1% 97.9% 93.4% Non-Saudi 40 3 43 7.9% 2.1% 6.6% Educational level Elementary 2 0 2 0.001 0.4% 0.0% 0.3% Intermediate 6 1 7 1.2% 0.7% 1.1% Secondary 64 37 101 12.6% 25.3% 15.5% Bachelor 364 101 465 71.9% 69.2% 71.3% Master's 42 5 47 8.3% 3.4% 7.2% Doctorate 28 2 30 5.5% 1.4% 4.6% Residential region Northern region 16 22 38 0.0001 3.2% 15.1% 5.8% Southern region 211 28 239 41.7% 19.2% 36.7% Central region 36 26 62 7.1% 17.8% 9.5% Eastern region 43 21 64 8.5% 14.4% 9.8% Western region 200 49 249 39.5% 33.6% 38.2% Monthly income Less than 5,000 202 31 233 0.0001 39.9% 21.2% 35.7% 5,000–9,999 129 53 182 25.5% 36.3% 27.9% 10,000–14,999 75 42 117 14.8% 28.8% 17.9% 15,000 or above 100 20 120 19.8% 13.7% 18.4% *P value was considered significant if ≤0.05

This study was conducted to determine the evaluation of the awareness of patients about surgical and non-surgical AAT modalities, preference of patients between these modalities, as well as the important factors in acceptance such as perceived pain, cost of treatment and estimated treatment duration. The research was done among 652 individuals of the Saudi Arabian population. The findings give important insights on patient-centered decision-making on accelerated orthodontics in this regional context.   Regarding patient preferences for treatment modalities, our findings showed a significant preference for non-surgical approaches as 55.1% of the participants preferred non-surgical acceleration methods over surgical approaches which were preferred by only 13.2% participants. This preference is in close accordance with past international research. Uzair et al. [8] reported that 86.4% of participants preferred to use the non-surgical accelerated orthodontic procedures, mainly for fear of anxiety and surgical options were selected mainly in reducing treatment time. Similarly, a systematic review of surgical and non-surgical methods for enhancing orthodontic tooth movement showed that of surgical methods, corticotomy showed the greatest acceleration potential and was highly invasive with substantial pain and discomfort [9]. On the other hand, non-surgical methods such as vibration and photobiomodulation were the most promising because of their non-invasive and effective [9]. Our results support these results and suggest that non-invasiveness is a foremost consideration in the choice of treatment for a patient and often surgical methods may have a quicker outcome.   The levels of knowledge among our sample were significantly lower than awareness level and 62.3% showed low knowledge and 8.4% showed high knowledge about accelerated orthodontic treatment approaches. This finding has particular importance for clinical practice. A study on evaluating patient-reported outcome measures with surgically-assisted acceleration of orthodontic treatment noted that the widespread introduction of surgically-assisted acceleration of orthodontic treatment requires careful evaluation of patient-reported outcomes prior to the introduction of any acceleration procedure [10]. The low knowledge levels in our study, therefore, suggest a critical need for better patient education about the different methods of acceleration, the mechanism of the different methods, the benefits and limitations of the different methods.   Pain appeared to be the most significant barrier to the selection of surgical techniques in our population with 37.3% of subjects reporting pain as the main deterrent followed by fear (29.8%) and cost (12.7%). These results are in line with past studies both in the Saudi Arabian context as well as globally. Linjawi and colleagues carried out a study in Saudi Arabia to assess patient perceptions on the reduction of orthodontic treatment period and found that pain and discomfort are major concerns affecting treatment decisions [11]. Another seminal study to examine patient acceptance of corticotomy assisted orthodontics found that fear from surgery (53.2%) was the most common reason for treatment refusal, followed closely by fear of pain (36.9%) [12]. The high prevalence of pain related concerns in our cohort (71.3% expressed concerns about pain after surgical procedures) suggests the importance of pre-operative counseling and anesthesia management in surgical acceleration protocols.   Interestingly, 72.9% of our participants preferred slower, less painful non-surgical methods to faster but more painful surgical options suggesting that treatment comfort takes precedence over treatment velocity to most patients. This finding is in line with the growing agreement in the literature in orthodontics towards less invasive acceleration techniques. Gabada and colleagues reviewed the area of accelerated orthodontics, noting that recent technological advances have radically changed the scope of orthodontic care, with non-invasive methods now providing clear benefits in terms of patient comfort, while simultaneously delivering meaningful acceleration [13].   Regarding the effectiveness factor, 35.3% of the participants identified effectiveness as the most important consideration in the choice of treatment methods, 28.4% considered cost and 27.6% considered recovery time as least important factors. These proportions reflect a patient population with a focus on clinical outcomes more than other considerations, but cost was an important secondary consideration. In a cross-sectional survey of young adult patients on their preferences for invasive and non-invasive methods of acceleration performed in Saudi Arabia about 47.5% of the sample population showed a willingness to pay extra fees, 59% of which agreed to pay an increase of 20% on the price of treatment for the FDA approved vibrating devices [11]. Our study showed similar trends with 38.5% being willing to pay small extra costs of 10 and 25.8% being willing to accept medium additional costs of 30% for treatment acceleration. This willingness to pay pattern can give valuable information to orthodontists who are developing accelerated treatment protocols for use in private practice settings.   The predominate influence of orthodontist recommendations on patient decision-making was apparent with 75.4% of the students in our cohort agreeing their treatment decisions are dependent on their orthodontist's advice. This places an emphasis on the importance of the dentist-patient relationship and the importance of evidence-based discussions about treatment options. Low level laser therapy is one particularly promising, non-surgical option. Recent research has shown that LLLT was significantly effective in reducing pain perception with patients receiving laser bio stimulations showing reduced pain intensity and lower pain duration than control groups [14]. Furthermore, several clinical trials have identified that a negative effect on periodontal health is not experienced with LLLT and that it can easily be incorporated into normal orthodontic protocols [15].   Cost considerations played a major role in treatment acceptance with 56.9% of respondents saying that they would only select accelerated treatment when it was affordable or covered by insurance. This finding highlights the inequities in access to healthcare and the need to develop cost-effective strategies for accelerating them. The Iraqi study of perception of orthodontists and patients to accelerated orthodontics has shown that most of the orthodontists have been willing to pay up to 40% of treatment income to purchase acceleration procedures, on the other hand, the patient has been generally willing to pay only 20% [16]. These financial considerations are particularly relevant in the Saudi Arabian context where as we noted in our demographic data, 35.7% of participants reported making less than 5000 SAR per month.   Regarding treatment duration preferences, 59.5% of the participants agreed that reducing orthodontic treatment time is important and 51.1% of them were fond of accepting some discomfort in order to have less overall treatment duration. However, a significant 78.4% wanted to have more information on risks and benefits of various methods of acceleration before making final treatment decisions. This finding suggests that although patients are influenced by time factors, they would like available, comprehensive and evidence-based information upon which to make truly educated decisions. A Cochrane systematic review on non-surgical adjunctive interventions for the acceleration of tooth movement stated that orthodontic treatment takes on average 20 months and acceleration may minimize undesirable effects such as root resorption, demineralization and decreased patient motivation [17].   The demographic relations between knowledge and acceptance levels showed that gender, age and residential region were statistically significant factors (p = 0.001, p = 0.0001 and p = 0.0001 respectively) in order to tailor patient education programs to these demographic characteristics. The fair to moderate degree of treatment preferences and acceptance in 66.4% of participants could indicate that although patients had a baseline interest in acceleration, information on the details and clinical experience may help to modify treatment preference to a higher acceptance level.   There are some important limitations of this study. First, the cross-sectional design gives a cross-section of preferences at one point in time and fails to reflect changes in attitudes over time. Second, the recruitment of participants on social media platforms may be associated with selection bias because people using these platforms may not be representative of the entire Saudi population. Third, the questionnaire was based on self-report, which can be vulnerable to self-reporting bias.

In conclusion, this study shows that Saudi Arabian patients show high preferences for accelerated orthodontic non-surgical methods, where pain perception and surgical anxiety are the determinants that determine its choice. While patient awareness of acceleration techniques is still less than ideal, willingness to pay for treatment acceleration in a significant percentage of the population exists. Future research should be aimed at developing patient education programs for specific concerns as identified in this study and assessing the long-term clinical outcome and patient satisfaction of different acceleration protocols in the Saudi Arabian setting.   Acknowledgement We acknowledge all volunteers who provided samples for this research.   Funding This study did not receive any funding from public, commercial, or non-profit funding agencies.   Conflicts of Interest The authors declare that there are no conflicts of interest.   Informed Consent Written informed consent was obtained from all study participants.   Data and Materials Availability All data generated or analyzed during this study are included in this published article.   Ethical Statement The study was fully explained to all participants and it was emphasized that participation was voluntary. Written informed consent was obtained from each participant prior to enrollment. All collected information was securely stored and used exclusively for research purposes.