International Journal of Dental and Health Sciences Review Article Volume 02,Issue 05

PIEZOSURGERY – A REVOLUTIONARY APPROACH IN PERIODONTAL Swyeta Jain Gupta1,Vivek Gautam2,Amit Gupta3 1.Senior Lecturer,Department of Periodontics and Implantology,I.T.S. Centre for Dental Studies and Research,Ghaziabad 2.MDS,Prosthodontics (Private Practitioner), Gautam Multispeciality Dental Clinic,P.N Plaza Complex,Below Bank Of India,Sigra,Varanasi,Uttar Pradesh ,India. 3.Senior Lecturer, Department of Oral and Maxillofacial Pathology and Microbiology,I.T.S. Dental College, Hospital and Research Centre,Greater Noida

ABSTRACT: Piezoelectric , also known as piezosurgery, is an osseous surgical technique first described by Vercellotti (2004) utilizing an innovative ultrasonic surgical apparatus, known as the Mectron piezosurgery device. Piezoelectric device is an innovative tool developed as an alternative to the mechanical and electrical instruments that are used in conventional oral surgical procedures. Because of its highly selective and accurate nature, with its cutting effect exclusively targeting hard tissue, its use may be extended to more complex oral surgical procedures, as well as to other interdisciplinary problems. It can be used for selective cutting of bone depending on bone mineralization, without damaging the adjacent soft tissue (e.g. vessels, nerves or mucosa), providing a clear visibility in the operating field, and cutting with sensitivity without the generation of heat. Hence, user must be knowledgable and trained enough to adapt their operating technique in order to utilize the advantages of piezosurgery. This review summarizes on the clinical importance of piezosurgery pertaining to its use in periodontal sugeries. Piezosurgery ensures the 3 ‘P’s that is predictability, less post operative pain and increased patient’s compliance in various disciples of dentistry. Keywords: Ultrasonic, microvibrations, piezoelectric, osteotomies, macrovibration.

INTRODUCTION:

In periodontics ultrasound has been periradicular osteotomy to extract an implicated since many years to remove ankylosed root of a maxillary canine. The tartar, debride root surfaces, and to implant positioned at the moment of the degranulate periodontal defects. In the extraction worked perfectly and this gave past few years ultrasonic powered devices rise to a series of experimental techniques have been developed that is using ultrasound for bone cutting.[1,2] revolutionizing periodontal surgeries and maxillofacial bone surgery. In 1997, The most convincing characteristics of Tomaso Vercellotti first introduced the piezoelectric bone surgery are low surgical idea to use an ultrasonic device for trauma, exceptional control during ablation fitted with a sharpened insert, surgery, and a quick healing response of such as a blade, to perform tissues. Clinical studies have demonstrated that the specificity of

*Corresponding Author Address: Dr Swyeta Jain Gupta Email: [email protected] Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 operation and the techniques employed possible to optimize surgical results even with piezoelectric bone surgery makes it in the most complex anatomical cases possible to advantageously exploit differences in hard and soft tissue The peizosurgery system consists of a anatomy. This not only increases main unit, peristaltic pump (for cooling treatment efficacy but it also improves and removal of blood and wastes), foot postoperative recovery and healing. switch, handpiece and tool inserts (flat, Ideally, surgical trauma should be blunt, scalpel and sharp saw tipped). The minimized to obtain the optimal healing, device can recognise changes in material which depends on gentle management of density and deactivate itself when a soft and hard tissues.[3] Surgery, by change is encountered, unlike definition, alters normal physiology by conventional tools. Piezosurgery uses a interrupting the vascular supply of tissues. modulated ultrasonic frequency to permit The extent of surgical invasiveness is highly precise and safe cutting of hard [7] extremely important for the quality of tissue. the most peculiar feature of the tissue healing and may affect whether piezoelectric device is selective cutting. wounds heal by repair or regeneration. The cutting of hard tissue with ultrasonic Indeed, when surgical trauma is kept to a vibrations that are formed by the bare minimum it generates enough piezoelectric effect was first described by [8] stimulation to favor healing mechanisms Catuna in 1953 and then by Volkov and [9] that lead to regeneration.[4,5] Shepeleva in 1974. In 1981, its application was described by Aro et al.[10] The Piezosurgery device was developed in orthopaedic surgery, and Horton et with the aim of enhancing the surgeon’s al.[11] in oral surgery. Although ability to perform meticulous bone piezosurgery cuts mineralized tissues such surgery, while reducing the risk of as bones, it does not cut soft tissues such intraoperative and postoperative as vessels, nerves and mucosa.[12] morbidity.[6] The philosophy behind the development of Piezoelectric bone Principle Surgery is based on two fundamental French physicists Jean and Marie Curie in concepts in bone microsurgery. The first is 1880 described the mechanism ‘Piezo minimally invasive surgery, which effect’ on which this device works. The improves tissue healing and reduces device operates at a frequency of 25-29 discomfort for the patient.. The second kHz, with the possibility of digital concept is surgical predictability, which modulation up to 30 kHz as a “boost” and increases treatment effectiveness. Indeed, an advanced oscillation control module the ease in controlling the instrument that introduces pauses in the high- during the operation combined with frequency vibrations. These pauses help reduced bleeding, the precision of the cut, to avoid heating of the bone and maintain and the excellent tissue healing make it optimum sectioning capacity.

1206

Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 Piezosurgery devices are fitted with a defined by the term ‘piezo’ derived from cooling irrigation system with 0 to 60 ‘piezein’, meaning pressure in Greek mL/min of variable sterile solution flow. language. The amplitude of the micro vibrations has to be kept in the range of 60-210 μm, at Mechanisms of action of piezoelectric [15] an ultrasonic power of up to 16 Watts.[13] devices Piezosurgery units are some 3 times more The cavitation effect of piezoelectric powerful than conventional ultrasonic surgery is crucial in bone surgery. units (5 Watts), which allows them to cut Cavitation is the formation and the highly mineralized cortical bone. The immediate implosion of cavities within a reduced range and the linearity of the liquid (i.e. small liquid-free zones, ‘bub- vibrations allow for precise control of bles’). These bubbles are formed as a cutting corresponding to a handpiece consequence of the forces that are acting power rating of 5W.[14] upon a liquid. It typically occurs when a The Piezosurgery device offers three liquid is subjected to a rapid change in specific therapeutic features attributable pressure, leading to the formation of to the microvibrations and to specific cavities within the liquid where the modulation of the ultrasound frequency. pressure is relatively low. In piezoelectric Firstly, it allows micrometric sectioning, surgery, the cavitation phenomenon offering superior precision in cutting and describes the process of vapourization, with no bone loss. Secondly, the bubble generation and subsequent implo- instrument selectively sections sion (growth and collapse of bubbles) into mineralized structures, without damaging many minute fractions of its original size the adjacent soft tissues, which remain (microscopic gas bubbles) that will occur intact even in the case of accidental in a flowing liquid as a result of the contact with the device. Lastly, the decrease and increase in pressure that is physical cavitation phenomenon produced caused by the ultrasonic vibrations. In ul- by the device ensures less bleeding. trasonic osteotomy, the cavitation phenomenon helps to maintain good Creation of piezoelectric effect and visibility in the operative field by dis- ultrasonic vibration persing a coolant fluid as an aerosol that causes the blood to essentially be washed The piezoelectric effect is the creation of away. Furthermore, the cavitation effect electrical tension on some crystal and will bring about haemostasis, which ceramic materials such as quarts to which results in a bloodless surgery. Walmsley et a mechanical pressure is subsequently al.[16] has suggested that the cavitation applied. The material in question will effect fragments the cell walls of bacteria, expand and then contract leading to an and therefore has an anti-bacterial ultrasonic vibration. Also known as efficiency. ‘pressure electrification’, it has been

1207

Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 Cutting characteristics of piezoelectric obtain the final bone shape. These inserts devices are specifically useful to prepare difficult and delicate structures such as sinus The cutting characteristics of piezosurgery window or access to nerve. Eg: Design no: are dependent upon the- OT5, OT-1, OT-4 and OP-4

Degree of bone mineralization (density)- Blunt Inserts: They have blunt, dull and The degree of bone mineralization rounded non cutting tip. These tips play determines the frequency of vibration (Hz) wonders in atraumatic elevation of the that the device should be set to for an sinus membrane for grafting procedures. effectively cutting the bone and has a positive correlation on cutting efficiency Insert Tip Color: Insert tips are color of piezosurgery. Low frequency of vibra- coded by either Gold or steel. Gold insert tions may be chosen in low mineralized tips are used to treat bone. It is obtained bone, whereas high frequency of by applying titanium nitride coating to vibrations, up to 30 Hz, may be chosen in improve the surface hardness which highly mineralized bone.15 In addition, further increases longevity of the insert alternating with pauses provides for tip. Steel is used to treat soft tissue or optimal cutting in highly mineralized delicate structures such as roots of teeth. bone. Pressure applied on the handpiece during The design of the insert- Inserts (Tips) can use- According to Claire et al.11 excessive vary in size, shape and material. Insert pressure on the piezosurgery insert led to design may impact on the level of power a reduction in oscillations and hence the (W) that should be set for an intended cutting ability. The results of their procedure. For the effective cutting of experimental study recommended that a highly mineralized bone with a saw- contact load of 150 g provide the greatest shaped insert, high power levels are depth of cut. required Speed of movements during use- Sharp inserts: The sharp edge of the Piezosurgery inserts should be moved instruments enable gentle and effective forwards and backwards continuously at a cut on the mineralised tissue. They are high speed with minimum pressure. Slow useful in osteotomy procedures like movements over the bone and excessive implant site preparation, osteoplasty and pressure on the handpiece will decrease other surgical techniques which require the micro-movements and cause an in- fine and well defined cut. Eg: Design No: crease in the bone temperature. OT-7, EX1,OP-3,IM2A and IM3P The frequency of ultrasonic vibrations Smoothening Inserts: They have diamond (Hz), the level of power (W) and the water surface coating which enables precise and spray are three adjustable settings that controlled work on bony structures to

1208

Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 should be set in accordance with the gingival sulcus between the space intended procedure.[10] occupied by periodontal ligament between the root and the socket. The Applications of Piezosurgery in periodontal fibres are cut upto or greater Periodontics than 10 mm. Thus when the most apical fibres are severed, the coronal portion is Routine scaling and root planning – not submitted to a violent‘rip’. Therefore, Piezosurgery can be used efficiently for in this way nearly atraumatic extraction the removal of supra and subgingival can be achieved.[18] calculus deposits and stains from teeth, periodontal pocket lavage with Traditional produce vigorous simultaneous ultrasonic tip movement, movements during tooth extraction which scaling and root planning. The causes forceful tearing of Sharpey’s fibres piezosurgery device can be used for soft- away from the bundle bone surrounding tissue debridement to remove the the socket. This causes disruption of blood secondary flap after incision through supply and trauma to the extraction retained periosteum. By altering the socket which in turn delays healing.[18] power setting and changing to a thin, tapered tip the piezosurgery device can be The use of piezosurgery has advantages in used to debride the field of residual soft procedures that require a meticulous tissue and for root surface scaling to preparation of a small bone or a piece of a certain thorough removal of calculus. tooth: for example, tooth sectioning of a Piezosurgery also permits planning of the tooth that has a close relationship with an root surfaces and the removal of important anatomical structure. In inflammatory tissues in periodontal working around the mandibular canal or operations.[17] maxillary sinus, piezosurgery may prevent nerve damage; even in the case of Osteoplasty and osteotomy accidental contact with the working insert tips. The piezosurgery device is used to develop positive, physiologic architecture Crown lengthening procedure of bone for pocket removal surgery.[17] The device enables for specific removal of Piezosurgery helps the dentist in achieving bone, with minimal risk of injury to better bone architecture with precise underlying root surfaces. Final smoothing cutting of bone during crown lengthening of root surfaces and bony margins using a procedures. specific ultrasonic insert, PP1, creates a [19,20] clean field, with ideal bony architecture Resective and regenerative surgery. ready for flap closure. Ultrasonic vibrating Piezosurgery has a vast array of ‘Syndesmotomes’ have recently been applications in dentoalveolar procedures developed tips for tooth and root involving periodontal surgical procedures extraction. The tip is inserted through 1209

Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 for e.g separating the tooth roots and corticotomy and micro- surgery. hemi-section. Piezosurgery has gained popularity among various applications in ridge augmentation Harvesting of autogenously bone grafts procedures. It was reported that it performs bone cutting with great Autogenous bone chips can be harvested precision, thus facilitating ridge from intra-oral sources with the use of augmentation and easy ridge expansion piezosurgery. In literature there is an (Palti and Hoch 2002).[24] disagreement with some authors favouring the use of piezosurgery with Ridge expansion is the surgical widening regards to the number of living cells, such of a bone ridge in the mouth to allow for [27], as osteocytes and others that the placement of dental implants. It leads scrutinize the use of piezosurgery owing to a shortened treatment time and to the lower percentage of living cells elimination of the issue of donor-site when compared with conventional tech- morbidity, as grafting is not required. [21,22] niques. Designed initially for augmentation in implant surgery, including sinus lifts and In harvesting of mandibular ramus block procedures such as ridge expansion bone graft [23] (Eggers, et al., 2004).[25] piezosurgery can In dental implantology procedures, the be used to cut the crestal and proximal mandibular ramus area is commonly facial cortices in a precise and tactile preferred as an autogenous bone graft. controlled manner. Motorized Mandibular bone block is usually used as are then used to widen the split ridge and an onlay graft with the aim of increasing create space. Using this technique the bone thickness. It has been suggested expansion of narrow, anatomically that the use of a piezoelectric device limiting, atrophic ridges can be done would provide distinct advantages in the creating space for immediate placement harvesting of a ramus graft. For of implants. The facial and lingual cortices piezosurgical bone cutting, a standard provide necessary support with vital saw-shaped insert is usually favoured in osteocytes for osteogenesis (Kelly and an easy to see area in comparison to a Flanagan, 2013).[26] dual-angled insert that is preferred in Distraction osteogenesis deep areas, especially for lower horizontal bone cutting during ramus bone graft A piezoelectric device is used to treat harvesting. alveolar bone defects and to provide for perfect osteotomy without palatal flap Alveolar decortication and corticotomy damage. Also, abundant vascularization and ridge augmentation from the palatal flap led to successful new Piezosurgery can be successfuly used for bone formation. Furthermore, performing alveolar decortications, Piezosurgery is a very convenient device

1210

Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 through which it is possible to get direct Robiony et al. (2007) [29] described the use visibility over entire osteotomies. The only of the piezosurgical instrument as a Limitation being the slightly longer time minimally invasive device, to allow required for the operation.[27] surgeons to perform all the steps of SARME under local anesthesia. Distraction osteogenesis is used to regain both hard and soft tissues without In a recent research Rana et al. (2013) [30] grafting. It is the biological process of new divided their 30 adult patients who were bone formation through the application of with an indication for SARME into two graduated tensile stress by incremental groups according to the treatment traction. With ridges that require four to modality performed. Patients of the first five millimeters of vertical height group were treated conventionally with augmentation, or where the overlying soft an oscillating saw, while patients of the tissue does not support osseous second group were treated with a augmentation, distraction osteogenesis is piezoelectrical saw. It was found that it is a useful treatment alternative, with possible to conduct a SARME with the piezosurgery being an effective tool for help of an ultrasonic-saw, piezosurgery. distraction osteotomies [27] Also it preserves the mucous membrane of the maxilla and is as effective and good With piezosurgery we can osteotomize as as the conventional method. The high precisely as possible due to its performance in terms of frequency and micrometric and linear vibrations, and power of the piezosurgical device allows it cause minimal damage to hard and soft to be used without the aid of any other [28] tissues. When performing distraction , and with the same atraumatic osteo-genesis in certain areas, it is effect on critical vascular structures. The essential to complete the osteotomies very low amount of bleeding observed delicately, because they are performed during surgery, lack of damage to the close to dental and periodontal structures, main vessels and reduction of and to soft tissues that provide postoperative consequences (hematomas vascularization. Piezosurgery permits ideal and swellings) for patients were striking. osteotomy preparation without flap damage, providing abundant In maxillary sinus bone grafting surgery: vascularization that leads to successful new bone formation. Also, it is possible to  Preparation of bone window get direct visibility over entire with lateral approach. osteotomies. slightly longer time is  Atraumatic dissection of required for the operation which is the sinus mucosa. lone limitation of this process.  Internal sinus floor elevation Piezosurgery for surgically-assisted rapid and sinus augmentation surgery maxillary expansion (SARME)

1211

Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 In maxillary sinus bone grafting surgery which brings the advantage of being able to touch the sinus lining without tearing it. Another intra-oral use of piezosurgery is in This eliminates the need to leave a thin [11] sinus bone grafting surgery . layer of bone around the window and tap Piezosurgery can be used during the it in (and thus further reduces the chance preparation of a bony window and in of perforation). atraumatic dissection of a sinus membrane with a lateral approach .Perfo- A blunt inverted cone tip can then be used ration of the sinus membrane is the most to raise the sinus lining, reducing the risk common complication of sinus bone of damage to the membrane even further. grafting and Wallace et al [31] reported In cases of sinus lift, studies have shown it that piezosurgery could minimize sinus can reduce the membrane perforation perforation rates. rate from 30% with the conventional approach to 7% with the piezosurgery. It was reported that the incidence of severe complications can be reduced and Le Fort I osteotomies the entire process can be completed during a single surgical procedure using a In severely atrophic alveolar ridges, both piezoelectric device and elevating the the maxilla and mandible can present a sinus membrane. jaw discrepancy, with a skeletal Class III tendency and a loss of vertical dimension Atrophy of the maxilla and progressive that may hinder treatment with dental pneumatization of the maxillary sinus can implants (Muñoz-Guerra, et al., 2009).[32] compromise implant placement in the Severe atrophy of the edentulous maxilla posterior maxilla. Atrophy can lead to can cause insufficient bone volume and an inadequate height, width, and quality of unfavorable vertical, transverse, and bone restricting ideal implant positioning sagittal relationship, due to the tri- and risking perforation of the sinus floor dimensional resorption pattern of long- (Muñoz-Guerra, et al., 2009).[32] There can term maxillary edentulism. often be as little as a few millimeters of bone between sinus and the oral cavity. Maxillary sinus augmentation and onlay grafting procedures can allow the Piezosurgery can be used as an alternative correction of bone defects, but are often or adjunct to standard instrumentation insufficient to correct severe maxillary during a sinus lift procedure (Figure 4). retrusion and increased interarch The sinus is accessed through a window distance. Le Fort I osteotomies allow for prepared in the lateral wall of the sinus, forward or downward repositioning of the conventionally made using a diamond bur maxilla to correct intermaxillary vertical and then infracturing of the bony window. and transverse discrepancies. Correction of osseous deficiencies using this However, a round piezosurgery tip may be technique permits ideal implant used to prepare the window instead, placement and creates a more natural soft 1212

Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 tissue profile that impacts on the overall surface ready for collection. Two surgical prosthodontic outcome.[33] tips are available for removal of cortical bone, eliminating the need for bone traps. The precise nature of piezosurgery For guided bone regeneration purposes provides exact, clean, and smooth cut these bone chips can be used all alone or geometries. This is an extremely in combination with other graft materials. important attribute, considering an Assessment of bone chips collected using atrophic maxilla is likely to present with a piezosurgery and conventional burs, thin and fragile bone structure that may established that no difference in the increase the risk of accidental fracture. detrimental effect on the viability and differentiation of cells occurs. The application of piezosurgery in these Piezosurgery was found to be more instances is advocated over other economical in regard to quantity of bone mechanical instruments because it harvested.[36] minimizes the chances of accidental damage (Muñoz-Guerra, et al., 2009). The Dental implantology risk to critical anatomical structures, such as the palatine nerve and artery, is also Peizosurgery has extensive minimized because the surgical action implementation in the field of stops when the piezosurgery insert comes implantology. It can be used in hard tissue into contact with demineralized procedures, such as implant site structures. preparation, alveolar ridge splitting and expansion, re-contouring of alveolar crest, However, it must be noted that the and ridge split, and in soft tissue success rate of implants placed in a procedures such as maxillary sinus lifting. reconstructed maxillae following a Le Fort Repositioning of mental nerve and also in I technique and bone grafting is harvesting bone chips for use in guided significantly lower than that of implants bone regeneration.[37] placed in an edentulous, but non- reconstructed, maxillae (Chiapasco, et al., With this technique, implant site 2007). Piezosurgery has also been used in preparation can be performed with a various other craniofacial surgical specifically designed set of piezosurgery procedures in addition to Le Fort inserts. Piezosurgical site preparation osteotomies, including calvarian bone enables for the selective enlargement of grafting and mandibular sagittal splits.[34] only one socket wall. This is called ‘differential ultrasonic socket Guided bone regeneration preparation’. Site prepared by piezosurgery provides the same primary Piezosurgery can also be used for stability and short-term survival rate of an harvesting bone chips, which are implant when compared with produced at the optimum grain size for conventional site-preparation techniques. effectiveness and remain on the bone

1213

Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 Stelzle et al.[38] emphasized that the Piezosurgery is efficient at preparing applied load on the handpiece may implant site osteotomies due to its increase the preparation speed but may selective cut, micro-streaming, and also increase the negative thermal effect cavitational effects, which preserve and on the bone. Therefore, during implant maintain the soft tissue — essential for site preparation a maximum load of 400g the overall healing and esthetics of the is recommended. implant.Micro-streaming is the continuous whirling movement of fluid created by a Piezosurgery is a predictable method that vibrating insert that favors a mechanical can be used to perform split-crest action of debris removal. Intraoperative procedures without the risk of bone visibility is enhanced with piezosurgery by thermo-necrosis; also it carries a reduced the implosion of gas bullae into blood risk of damage to the adjacent soft vessels during the osteotomy, which have tissues. Bone cutting efficiency is a hemostatic effect — the cavitational satisfactory with the current devices phenomenon (Sortino, et al., 2008).[40] because of the enhanced vibration power, especially in soft type IV bone. In Primary implant stability and osseo- implantology, piezosurgery can be used in integration are directly indicative of implant socket preparation, mental nerve implant prognosis. Primary implant repositioning, recontouring of alveolar stability can provide an early indication of crest, mobilisation of inferior alveolar future osseointegration. Authors have nerve and simultaneous implant suggested that there are no statistically placement and, immediate implant significant differences between primary placement after extraction.[39] implant stability provided by using the piezosurgery in comparison with a Piezosurgery with its symbolic role, conventional rotary unit. However, due to precisely helps in critical procedures like the study being ex vivo in nature and the alveolar ridge expansion which involves relatively small sample size, further separation of palatal and vestibular bone studies are recommended.[39] flaps and subsequent implant placement.[7] Sinus elevation with In a minipig model, bone healing at traditional burs is often allied with intervals of 1, 2, 4, and 8 weeks in sites complications such as perforation of prepared with piezosurgery was membrane, intra operative bleeding and compared to sites prepared with surgical trauma. To avoid such mishap, conventional . The study (Preti, et al., piezosurgical insert with blunt tip is useful 2007) concluded that piezosurgery was in atraumatic elevation of the membrane, more effective in stimulating implant followed by successful grafting osteogenesis, promoting more procedure.[40] osteoblastic activity around the implant sites compared to sites prepared conventionally with drills.

1214

Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 Another randomized control trial 20 μm to 200 μm, which is smaller than suggested that piezosurgery implant site the width achievable with rotary preparation has the potential to modify instruments,thus offering superior biological events during the osseo- precision in cutting accompanied with no integration process, resulting in a limited bone loss. decrease of implant stability quotient values and in an earlier shifting from a 2. Great control of the surgical device decreasing to an increasing stability The piezosurgical handpiece reaches its pattern in comparison with traditional highest efficiency when applying a load of drilling technique (Stacchi, et al., 2013).[41] 0.5 kg as compared to conventional drills Peri-mucositis, peri-implantitis, and thatmust be loaded with a force of 2 kg to calculus removal 3 kg.

Piezosurgery can be used in the treatment 3. Bleeding-free surgery site of peri-implantitis. It can be used for soft There is no bleeding of bone tissue when tissue debridement to remove the cutting with the ultrasound, and thus secondary flap after incision through provides good visibility of the operating retained periosteum. Using a thin tapered site and enables one to conduct the tip and altering the power setting, the procedure very precisely. The reason for piezo-surgery device can also be used to this is that the cavitation effect creates debride the field of residual soft tissue bubbles from the physiological salt and for root surface scaling to ensure solution and these lead to implosion and thorough removal of calculus. The generate the shock wave causing piezosurgery system also allows removal microcoagulation. of calculus from titanium osteosynthetic material quickly. Debris and infected bone 4. Selective cutting and minimal can be removed from implant surfaces operative invasion without damaging the implant.[29] This feature can also be beneficial when hard It reduces the risk of perforating the tissue has ingrown into screw slots, as it Schneider membrane due to the selective allows safe removal without damaging the cutting that is limited only to the screw itself to allow for screwdriver mineralized structures – bone. This is application . because of the ultrasonic frequencies that are used (25–29 kHz), as the hard tissues Advantages and soft tissues are cut at a different frequency. 1. Precise cutting and safety 5. Faster bone regeneration and healing The ultrasonic device implies micrometric process cutting that depends on the micro- oscillation of the handpiece. It varies from

1215

Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 Oxygen molecules released during cutting 4. Duration of the surgical procedure is have an antiseptic effect and ultrasound longer with the application of vibration stimulates cells’ metabolism. piezosurgery. Moreover, the lack of necro- sis in the cut area accelerates bone regeneration. Soft 5. For gaining experience with piezosur- tissue damage is not noticed. gery,more practice time might be required for clinicians. 6. No risk of emphysema Precautions The risk of subcutaneous emphysema is reduced due to the aerosol effect that the The piezosurgery technique immensely ultrasonic device produces unlike the lessens the risk of damaging soft tissues, effect of air-water spray generated be such as sinus floor membrane, nerves, and osteotomy with rotary instruments. vessels, but nevertheless precautions must be taken as the ultrasonic waves 7. Decrease in post-intervention pain have mechanical energy, and this energy can be converted into heat and pass into Owing to the action being less invasive adjacent tissues. For this reason the use of and producing less collateral tissue irrigation is essential, not only for the damage, it results in better healing. effect of cavitation, but also to avoid overheating. The intensity of the cooling 8. Reduced traumatic stress liquid can be adjusted depending on The device produces less noise and only different preparations. microvibrations in comparison with a Contraindications conventional motor, so the fear and psychological stress of the patient are There are no absolute contraindications, reduced. but one such is electrical pacemakers, in either the patient or the operator, which Disadvantages is a contraindication for piezosurgery. Age 1. The largest disadvantage of the factor is a relative contraindication for any procedure using the piezosurgery unit is surgery. the increased operation time that is Biological effects and bone response to required for bone preparation. piezosurgery 2. Not recommended in patients with Effect of mechanical instruments on the pacemakers. structure of bone and the viability of cells 3. Purchase of a device may initially be a is important in any type of osseous financial burden. surgery. Alterations in temperature is injurious to cells and may cause necrosis of bone.[42] Erikson et al.[43] showed that

1216

Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 local bone necrosis would occur in cases the concentration of bone morphogenic where the temperature exceeds 47°C for 1 protein (BMP-4), TGF beta-2, tumor minute due to the contact of rotating necrosis factor and interleukin-1, and tools. Piezosurgery not only selectively decreases some of the pro-inflammatory cuts the hard tissue but also produces the cytokines in the bone. Thus, neo haemostatic effect on the surrounding osteogenesis was proven to be tissue.[44] Because this technique consistently more active in cases where preserves the surrounding soft tissues, it piezosurgery is used. It has been observed can be applied in areas where bone is in that the critical temperature rises only close proximity to vital and delicate when the irrigation volume is as low as 20 structures such as nerves, blood vessels or ml per minute. Piezosurgery, therefore the sinus mucosa has a potential role in osseous surgery.[45]

Microtopographic and histomorphometric CONCLUSION: studies have shown that piezosurgery is preferred over other tools for harvesting The piezo device provides a great facility vital bone.[43,44] Perfect integrity of the during some surgical procedures, and osteotomized surfaces with a cut which is even to some extent becomes clean, regular and without imperfections indispensable. The ultrasound unit allows or pigmentation is achieved. The bone for precise removal of bone with minimal surface which was cut using the risk of injury to underlying soft tissues. It piezoelectric device showed no sign of allows a more successful and more lesions to the mineralized tissues and complication-free surgical result for a less presented live osteocytes with no sign of experienced surgeon that could be cellular suffering. Recently, Stubinger et especially beneficial for preparation of the al.[45] showed that autologous bone from Schneider membrane during sinus lift the zygomatico-maxillary region that had procedure or relocating or preparation of been harvested with a piezoelectric the inferior alveolar nerve. Not only does device, could be used in augmentation for it give minimal operative invasion, but stable and aesthetic placement of oral also it decreases post-intervention implant after a five months healing. intervention pain and reduces traumatic stress, accompanied with minimal Another histomorphological study reveals bleeding postoperatively. that the piezoelectric surgery increases

REFERENCES:

1. Vercellotti T. The piezoelectric bone 2. Kennedy JE, Ter Haar GR, Cranston surgery: New Paradigm. D. High intensity focused Quintessence Publisher.

1217

Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 ultrasound: Surgery of the future. Br transection and uniting of bone J Radiol. 2003;76: 590-9. tissue in orthopaedic surgery. 3. Maintz G. Animal experiments in Reconstr Surg Traumatol. 1974 the study of the effect of ultrasonic Jan;14:147–52. waves on bone regeneration. 10. Aro H, Kallioniemi H, Aho AJ, Strahlentherapie. 1950;82: 631-8. Kellokumpu-Lehtinen P. Ultrasonic 4. Vercellotti T, Majzoub Z, Trisi P. device in bone cutting. A histological Valente ML, Sabbini E, Cordioli G. and scanning electron microscopical Histologic evaluation of bone study. Acta Orthop Scand. 1981 response to Piezoelectric, surgical Feb;52(1):5–10. saw and osteotomies in the 11. Horton JE, Tarpley TM Jr, Jacoway rabbit calvaria. Int J oral and JR. Clinical applications of ultrasonic Maxillofac implants.(submitted). instrumentation in the surgical 5. Preti G, Martinasso G, Peirone B, removal of bone. Oral Surg Oral Navone R, Manzella C, Muzio G et al. Med Oral Pathol. 1981 Cytokines and Growth factors Mar;51(3):236–42. involved in the Osseointegration of 12. Schaeren S, Jaquiery C, Heberer M, oral titanium implants positioned Tolnay M, Vercellotti T, Martin I. using piezoelectric bone surgery Assessment of nerve damage using versus a drill technique: A pilot a novel ultrasonic device for bone study in minipigs. J Periodontol cutting. J Oral Maxillofac Surg. 2008 2007; 78:716-722. Mar;66(3):593–6 6. Eggers G, Klein, J, Blank, J Hassfeld, 13. Stübinger S, Kuttenberger J, Filippi S. Piezosurgery: an ultrasound A, Sader R, Zeilhofer HF. Intraoral device for cutting bone and its use piezosurgery: preliminary results of and limitations in maxillofacial a new technique. J Oral Maxillofac surgery. British Journal of Oral and Surg. 2005;63(9):1283-7. Maxillofacial Surgery 2004;42:451-3. 14. Robiony M, Polini F, Costa F, 7. Stübinger S, Kuttenberger J, Filippi Vercellotti T, Politi M. Piezoelectric A, Sader R, Zeilhofer HF. Intraoral bone cutting in multipiece maxillary piezosurgery: preliminary results of osteotomies, J Oral Maxillofac Surg. a new technique. J Oral Maxillofac 2004; 62:759-61. Surg. 2005;63(9):1283-7 15. Vercellotti T. Technological 8. Catuna MC. Sonic energy: A possible characteristics and clinical dental application. Preliminary indications of piezoelectric bone report of an ultrasonic cutting surgery. Minerva Stomatol. 2004 method. Ann Dent. 1953 May;53(5):207–14. Dec;112:256–60. 16. Walmsley AD, Laird WR, Williams 9. Volkov MV, Shepeleva IS. The use of AR. Dental plaque removal by ultrasonic instrumentation for the cavitational activity during

1218

Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 ultrasonic scaling. J Clin Periodontol. Presentation. 2nd Balkan 1988 Oct;15(9):539–43. Association of Maxillofacial 17. Sherman JA, Davies HT. Ultracision: Congress (BAMFS) and 5th Oral and the harmonic scalpel and its possible Maxillofacial Surgery Society uses in maxillofacial surgery. Br J (ACBID) Conference;2011 May 25– Oral MaxillofacSurg2000;38:530–2. 29; Antalya, Turkey. 18. Salami A, Vercellotti T, Mora R, 24. Palti, A. and T. Hoch (2002). "A Dellepiane M. Piezoelectric bone concept for the treatment of various surgery in otologic surgery. dental bone defects." Implant Dent Otolaryngol Head Neck Surg. 2011(1): 73-78. 2007;136(3):484–5. 25. Eggers G, Klein J, Blank J, Hassfeld S. 19. Peñarrocha Diago M, Ortega Piezosurgery: an ultrasound device Sánchez B, García Mira B et al. for cutting bone and its use and Evaluation of healing criteria for limitations in maxillofacial surgery. success after periapical surgery. Br J Oral Maxillofac Surg. Med Oral Patol Oral Cir Bucal. 2004;42(5):451-453. 2008;13:E143-7. 26. Kelly A, Flanagan D. Ridge expansion 20. Martí-Bowen E, Peñarrocha-Diago and immediate placement with M, García-Mira B. Periapical surgery piezosurgery and screw expanders using the ultrasound technique and in atrophic maxillary sites: two case silver amalgam retrograde filling. A reports. J Oral Implantol. study of 71 teeth with 100 canals. 2013;39(1):85-90. Med Oral Patol Oral Cir Bucal. 27. Lee HJ, Ahn MR, Sohn DS. 2005;10:E67-73. Piezoelectric distraction 21. Miron RJ, Gruber R, Hedbom E, Saul- osteogenesis in the atrophic acic N, Zhang Y, Sculean A, et al. maxillary anterior area: a case Impact of bone harvesting report. Implant Dent. techniques on cell viability and the 2007;16(3):227-234. release of growth factors of 28. Vercellotti T. Piezoelectric surgery in autografts. Clin Implant Dent Relat implantology: a case report — a new Res. 2012; Feb. piezoelectric ridge expansion 22. Happe A. Use of a piezoelectric technique. Int J Periodontics surgical device to harvest bone Restorative Dent. 2000;20(4):358- grafts from the mandibular ramus: 365. report of 40 cases. Int J Periodontics 29. Robiony, M., F. Polini, et al. Restorative Dent. 2007 "Ultrasonic bone cutting for Jun;27(3):241–9. surgically assisted rapid maxillary 23. Yaman Z, Suer BT. Clinical efficiency expansion (SARME) under local of piezoelectric devices for anaesthesia." Int J Oral Maxillofac harvesting of ramus bone graft. Surg 2007;36(3):267-9.

1219

Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 30. Rana, M., N. C. Gellrich, et al. 36. Landes CA, Stübinger S, Rieger J, "Evaluation of surgically assisted Williger B, Ha TK, Sader R. Critical rapid maxillary expansion with evaluation of piezoelectric piezosurgery versus oscillating saw osteotomy in orthognathic surgery: and chisel osteotomy - a operative technique, blood loss, randomized prospective trial." Trials time requirement, nerve and vessel 2013;14: 49. integrity. J Oral Maxillofac Surg. 31. Wallace SS, Mazor Z, Froum SJ, Cho 2008;66(4):657-674. SC, Tarnow DP. Schneiderian 37. Lazzara RJ. Immediate implant membrane perforation rate during placement into extraction sites: sinus elevation using piezosurgery: Surgical and restorative advantages. clinical results of 100 consecutive Int J Perio Rest Dent. 1989; 9(5) cases. Int J Periodont Rest Dent. :332–43. 2007;27(5):413-419. 38. Schaeren S, Jaquiery C, Heberer M, 32. Muñoz-Guerra MF, Naval-Gías L, Tolnay M, Vercellotti T, Martin I. Capote-Moreno A. Le Fort I Assessment of nerve damage using osteotomy, bilateral sinus lift, and a novel ultrasonic device for bone inlay bone-grafting for cutting. J Oral Maxillofac Surg. 2008 reconstruction in the severely Mar;66(3):593–6. atrophic maxilla: a new vision of the 39. Baker JA, Vora S, Bairam L, Kim HI, sandwich technique, using bone Davis EL, Andreana S. Piezoelectric scrapers and piezosurgery. J oral vs. conventional implant site Maxillofac Surg. 2009;67(3):613- preparation: ex vivo implant primary 618. stability. Clin Oral Implants Res. 33. Yaman Z, Suer BT. Piezoelectric 2012;23(4):433-437 surgery in oral and maxillofacial 40. Sortino F, Pedullà E, Masoli V. The surgery. Annals of Oral and piezoelectric and rotatory Maxillofacial Surgery. 2013;1(5):1-9. osteotomy technique in impacted 34. Vercellotti T, Paoli SD, Nevins M. third molar surgery: comparison of The piezoelectric bony window postoperative recovery. J Oral osteotomy and sinus membrane Maxillofac Surg. 2008;66(12):2444- elevation: introduction of a new 2448. technique for simplification of the 41. Stacchi C, Vercellotti T, Torelli L, sinus augmentation procedure. Int J Furlan F, Di Lenarda R. Changes in Perio Rest Dent. 2001;21:561–7. implant stability using different site 35. Vercellotti T, Pollack AS. A new bone preparation techniques: twist drills surgery device: sinus grafting and versus piezosurgery. a single- periodontal surgery. Compend blinded, randomized, controlled Contin Educ Dent. 2006;27(5):319- clinical trial. Clin Implant Dent Relat 325 Res 15(2):188-197

1220

Gupta S et al., Int J Dent Health Sci 2015; 2(5):1205-1221 42. Vercelotti T, Nevins ML, Kim DM, study in animals). Mediterranean Wada K, Schenk RK, Florellini JP. Journal of Surg Med. 2001;9:89-95. Osseous response following 45. Harder S, Wolfart S, Mehl C, Kern M. resective therapy with piezosurgery. Performance of Ultrasonic Devices Int J Perio Rest Dent. for Bone Surgery and Associated 2005;25(6):543-49. Intraosseous Temperature 43. Eriksson AR, Albrektsson T, Development. JOMI. 2009;24:484–9. Albrektsson B. Heat caused by drilling cortical bone. Temperature measured in vivo in patients and animals. Acta Orthop Scand 1984;55(6):629-31. 44. Vercelotti T, Crovace A, Palermo A, Molfetta A. The piezoelectric osteotomy in orthopaedics: clinical and histological evaluations (pilot

1221