Vishnu Dental college

Department of periodontics and implantology

Pedagogy on piezosurgery

CONTENTS

Introduction
What is piezosurgery?
History
Applications in dentistry
Advantages
Biological effects on bone cut by a piezoelectric device
Studies
Application of piezo in other fields
Conclusion
References

Presented by
R.Uday Bhaskar
9-7-16

INTRODUCTION:
Treatment success in implant dentistry, periodontology and oral surgery must take into
account precise biologic criteria. These criteria include using atraumatic surgical procedures;
limiting risks to surrounding tissues; and improving visibility, haemostasis and post-operative
conditions.
Most instruments available today do not allow clinicians to easily meet all of these
criteria. Manual instruments like burs, mallets and chisels, whilst effective in their direct action,
often introduce trauma to surrounding tissues that can prolong healing and affect overall
treatment success.
Manual instruments offer good control when used to remove small amounts of bone in
areas with relatively less dense mineralization. However, manual instruments are difficult to
control in cortical bone, particularly where precise osteotomies are essential. As a consequence,
they are mostly applied for gross cutting of larger bone segments.
Motor-driven instruments are often used when bone is very dense. Motor-driven
instruments transform electric or pneumatic energy into mechanical cutting action using the
sharpened edge of burs or saw blades. These instruments generate a significant amount of heat in
the cutting zone that must be minimized by water irrigation. Overheating of adjacent tissue may
alter or delay the healing response. Reduced rotational speed decreases not only frictional heat
but also cutting efficiency.
Motorized cutting tools also decrease tactile sensitivity. Slower rotational speed
necessitates increased manual pressure, which increases the macrovibration of the cutting tool
and farther diminishes sensitivity. This is particularly troublesome when cutting an area of dense
cortical bone into either trabecular bone or soft tissue, as when drilling an osteotomy above the
mandibular canal or preparing a lateral window for sinus grafting. The applied force necessary to
cut through the denser bone must be instantaneously released when encountering the less dense
tissue or the underlying structures may be damaged.

WHAT IS PIEZOSURGERY?
The Piezosurgery approach to hard tissue surgery was developed in the 1980s. It is
derived from the basic principles of piezoelectricity discovered by Jacques and Pierre Curie in
1988. The passage of an electric current across certain ceramics and crystals modifies them and
causes oscillations. Voltage applied to a polarised piezoceramic causes it to expand in the
direction of and contract perpendicular to polarity.
Horton and colleagues initially reported on bone removal with ultrasonically driven
instruments. Torrella and colleagues and Vercelotti 1998 took up this technology so-called
Piezosurgery (Piezosurgery by Mectron Medical Technology, Carasco, Italy) allows for
improved safety and precision for osteotomies and for optimum tissue healing

FEATURES:
Piezosurgery is a relatively new technique for osteotomy and osteoplasty that utilizes
ultrasonic vibration. The piezosurgery device is essentially an ultrasound machine with
modulated frequency and a controlled tip vibration range. The ultrasonic frequency is modulated
from 10, 30, and 60 cycles/s (Hz) to 29kHz. The low frequency enables cutting of mineralized
structures, not soft tissue. A frequency of 2529 kHz is used because the micromovements that
are created at this frequency (ranging between 60 to 210 m) cut only mineralised tissue;
neurovascular tissue and other soft tissue is cut at frequencies higher than 50 kHz. Piezoelectric
devices usually consist of a hand-piece and foot switch that are connected to the main power
unit. This has a holder for the hand piece, and contains irrigation fluids that create an adjustable
jet of 060 ml/minute through a peristaltic pump. It removes debris from the cutting area and
ensures precise cutting. It also maintains a blood-free operating area because of cavitation of the
irrigation solution, and gives greater visibility particularly in complex anatomical areas. Power
can be adjusted from 2.8 to 16W, with preset power settings for various types of bone density.
The piezosurgery tip vibrates within a range of 60-200 mm, which allows clean cutting with
precise incisions.
The Piezosurgery device has been developed to overcome the limits of precision and
intra-operatory safety existing in traditional bone cutting instruments. Piezosurgery allows the
clinician to obtain high predictability and low morbidity in bone surgery.
Utilising controlled three-dimensional ultrasound microvibrations, the Piezosurgery
technique opens up a new age for osteotomy and osteoplasty in implantology, periodontology,
endodontics and surgical orthodontics. Piezosurgery offers:
Micrometric cutting: Precise cutting actions with an excellent surgical tactile control;
Selective cutting: Minimizing the risk of adjacent soft tissue damage; and
Cavitation effect: offering maximum intra-operative visibility.
The cavitation effect is the result of vibrations 2-3mm from the tip of the instrument. The
air bubbles formed vibrate with their source, increase in size and explode. This phenomenon,
which has antibacterial properties, is called cavitation. It depends on the frequency not the
amplitude of the ultrasonic vibration.
The three key factors mentioned above means that Piezosurgery system surpasses any
instrument available today as a single tool that is indispensible in practice in areas of implant
dentistry, as well as periodontal surgical procedures and minor oral surgery.
HISTORY:
1997
mectron and Prof.Tomaso Vercellotti developed the idea of piezoelectric bone surgery
The main technological advancement is the adaption of ultrasound movement for bone
cutting
Mectron produces the first prototype devices for piezoelectric bone surgery

 first extraction treatments

1998
first lateral sinus lift treatments
1999
Prof.TomasoVercellotti introduced the name PIEZOSURGERY@ for the new method
first bone splitting treatments in the maxilla
2000
first bone splitting treatments in the mandible
first case studies about ridge expansion are published
mectron starts serial production of the PIEZOSURGERY device
2001
first crestal sinus lift treatments
PIEZOSURGERY I, the worldwide exclusive first unit of piezoelectric bone surgery,
is presented by mectron at IDS
over 20 inserts are already available
first study about sinus lift with PIEZOSURGERY presented
2002
development of periodontal resection surgeries
first bone block grafting treatments
2004
more powerful and better ergonomics mectron presents the 2nd generation of
thePIEZOSURGERY device
first orthodontic microsurgery treatments
2005
more than 30 scientific studies about PIEZO SURGERY are published
the first competitive units are launched
first implant site preparation treatments using PIEZOSURGERY
2007
mectron presents the innovative inserts for implant site preparation, at the same time the
first study about the inserts is published
2009
PIEZOSURGERY 3 the third generation is presented
The innovative qualities of the original mectron PIEZOSURGERY
Micrometric cutting action for maximum surgical precision and intra-operative
sensitivity
Selective cutting action for minimal damage to soft tissue, maximum safety for you and
your patients
Cavitation effect maximum intra-operative visibility and a blood-free surgical site are
further improved in PIEZOSURGERY 3.

The most effective device in the market becomes even more powerful, and at the same time it
becomes even simpler to use.
unique frequency range of 24-36 kHz for operating with highly complex inserts efficiently and
safely
FEEDBACK-SYSTEM
constant and optimal tuning of insert movement
29% increased sensitivity compared to PIEZOSURGERY II
automatically detects if more or less power is necessary and adjusts it accordingly
The ergonomics of PIEZOSURGERY 3 are ideal for daily use. With its simple handling it
offers utmost treatment security. Materials and surfaces are selected for easy cleaning,
disinfection and sterilization.
APPLICATIONS IN DENTISTRY:
Oral surgery
Extraction for immediate loading
Ankylotic tooth extraction
Dysgnatic surgery
Third molar/impacted tooth extraction
Distraction osteogenesis
Cystectomy
Implant explantation
Implantology
Lateral Sinus Lift, Crestal Sinus Lift
Implant site preparation
Ridge expansion
Lateralization of nerves
Bone chips harvesting
Bone block harvesting
Periodontal surgery
Root planing
Root debridement
Osteoplasty
Crown lengthening
Endodontic surgery
Root resection
Retrograde preparation of the root canal
Orthodontic surgery : Corticotomy
ADVANTAGES:

Piezosurgery Utilization: While many practitioners still employ handpieces and burs as
described above to prepare the initial osteotomy in the lateral wall of the alveolus, the use of
piezosurgery in place of burs offers a number of advantages.
These advantages include:
_ Greater tactile feedback as opposed to utilizing a handpiece with burs.
_ Greater control of bone preparation than with burs.
_ The lesser chance of soft tissue perforation utilizing piezosurgery as compared to a bur
technique.
_ A more superior osseous response, including a lesser degree of necrosis and decreased
morbidity, than when a bur is employed.
Better accessibility.
Compared with traditional rotary instrumentation, piezosurgery requires much less hand
pressure. This results in enhanced operator sensitivity and control, indicating that the clinician
can develop a better feel and precision for the cutting action because of microvibration of
cutting tip. The cut is safe because the ultrasonic frequency used does not cut soft tissue. The
cutting action is less invasive, producing less collateral tissue damage, which results in better
healing. Owing to its cavitation effect on physiological solutions (for example, blood),
piezosurgery creates a virtually bloodless surgical site that makes visibility in the working area
are much clearer than with conventional hone cutting instruments.
Unlike conventional burs and micro saws, piezosurgery inserts do not become hot, which again
reduces the risk of postoperative necrosis.
BIOLOGICAL EFFECTS ON BONE CUT BY A PIEZOELECTRIC DEVICE:
Stubinger 2006 et al showed that autologous bone from the zygomaticomaxillary region
that had been harvested with a piezoelectric device could be used in augmentation for stable and
aesthetic placements of oral implants after a 5-months healing.
In another histomorphological study by Preti 2007, porous titanium implants were
inserted into minipig tibias. The concentration of morphogenetic protein (BMP)-4; transforming
growth factor (TGF)- ; tumour necrosis factor-, and interleukin-1 and -10 were evaluated in
peri-implant osseous samples.
The analyses showed that neo-osteogenesis was consistently more active in bony samples from
implant sites that had been prepared using piezoelectric surgery, and there was an earlier increase
in BMP-4 and TGF- 2 proteins, and fewer pro-inflammatory cytokines in bone around the
implants.

In dentistry:

In dentistry, ultrasonic surgery became established in periodontology and endodontics after

initial reports by Catuna in 1953 on the use of high-frequency sound waves to cut hard dental
tissue. Ultrasonic oscillations can also be used to scale subgingival plaque, and to remove root
canal fillings and fractured instruments from root canals.
The removal of supra and sub gingival calculus deposits and stains from teeth,
periodontal pocket lavage with simultaneous ultrasonic tip movement, scaling, root planning and
crown lengthening, periodontal ostectomy and osteoplasty procedures requires careful removal
of small quantities of bone adjacent to exposed root surfaces to avoid damaging the tooth
surface. The piezosurgery device is used to develop positive, physiologic architecture of hone
support of the involved teeth.
The piezosurgery device can be used for soft-tissue debridement to remove the secondary
flap after incision through retained periosteum. By changing to a thin, tapered tip and altering the
power setting, the piezosurgery device can be used to debride the field of residual soft tissue and
for root surface scaling to ensure thorough removal of calculus.
Osteoplasty and ostectomy is performed using the piezosurgery device to create positive
architecture for pocket elimination surgery. The device allows for precise removal of bone, with
minimal risk of injury to underlying root surfaces. Final smoothing of root surfaces and bony
margins using a specific ultrasonic insert, PP1, creates a clean field, with ideal bony architecture
ready for flap closure. The piezosurgery device is used in bone grafting of an infrabony
periodontal defect.
Autogenous bone can be readily harvested from adjacent sites with minimal trauma and
therefore minimal postoperative effects. Implant site preparation, implant removal and bone
harvesting, hone grafting and sinus lifts can be done with much ease and less soft tissue trauma.
STUDIES:
Vercellotti 2000:
Performed ridge expansion of a very mineralized bone ridge (quality 1) of 2 to 3 mm in
thickness using piezosurgery. The fundamental idea on which piezoelectric surgery is based is
the use of a surgical force that is able to cut bone according to the requirements of the case, with
a powerful and precise energy and without excessive traumas or the risk of fracturing the ridge.
Vercellotti 2001:
Twenty-one piezoelectric bony window osteotomy and piezoelectric sinus membrane
elevations were performed on 15 patients using the appropriate surgical device (Mectron
Piezosurgery System). Only one perforation occurred during the osteotomy at the site of an
underwood septa, resulting in a 95% success rate. The average length of the window was 14 mm;
its height was 6 mm, and its thickness was 1.4 mm. The average time necessary for the
piezoelectric bony window osteotomy was approximately 3 minutes, while the piezoelectric
sinus membrane elevation required approximately 5 minutes.
Vercellotti 2005:

Studied the osseous response following resective therapy with piezosurgery. A

piezoelectric knife was compared with traditionally used diamond and carbide burs for the
purpose of ostectomy and osteoplasty. The histologic conclusion of this study in a dog model
showed that by day 56, the surgical sites treated by CB or DB evidenced a loss of bone, versus a
bone gain in the PS-treated sites. Thus, it appears that PS provided more favorable osseous repair
and remodeling than CB or DB when surgical ostectomy and osteoplasty procedures were
performed. Therefore, PS could be regarded as being efficacious for use in osseous surgery.
Wallace 2007:
He used a piezoelectric instrument for the sinus elevation procedure. Although new to the
United States, this approach has been used successfully in Europe for many years. The
membrane perforation rate in this series of 100 consecutive cases using the piezoelectric
technique has been reduced from the average reported rate of 30% with rotary instrumentation to
7%.
Furthermore, all perforations with the piezoelectric technique occurred during the hand
instrumentation phase and not with the piezoelectric inserts.
The following advantages have been shown in sinus elevation surgery using piezoelectric
techniques:
1. Reduced membrane perforation rate
2. Improved intraoperative visibility
3. Reduced intraoperative bleeding
4. Reduced surgical trauma
Blus et al. reported two perforations in 53 sinus elevations for a 3.8% perforation rate
using two different piezoelectric devices. In a report of 56 consecutive sinus elevations, Toscano
et al. reported a 3.6% perforation rate using piezoelective surgery.
Conflicting data were reported by Barone et al. who reported on 13 bilateral cases using
Piezosurgery on one side and a rotary diamond window preparation on the other as a withinpatient control. The perforation rate was 30% with Piezosurgery compared to 23% with the
diamond bur control. Barones results are contrary to other publications and the positive
experience with piezoelectric sinus elevation surgery at the New York University Department of
Periodontology and Implant Dentistry for the past 5 years.
Sohn 2007:
Piezoelectric Osteotomy for Intraoral Harvesting of Bone Blocks. Piezoelectric surgery
systems make micrometric bone cuts deep in the oral cavity, resulting in precise and easy-tocontrol osteotomies, in contrast to rotary burs or reciprocation saws. The small handpiece and
scalpel ease access to the oral cavity. The
In addition, this device reduces patient fear and stress during surgery performed under
local anesthesia because it makes much less noise and vibration than conventional rotary
instruments.

Metzger 2006 et al who compared the use of piezoelectric devices with convention burs
on soft and hard tissue for straightening or transposition of the inferior alveolar nerve in sheep.
Bovi 2005 reported mobilisation of the inferior alveolar nerve with simultaneous insertion of
implants. Both studies reported less damage to soft tissues, particularly neurovascular tissue
when using a piezoelectric device than conventional methods.

APPLICATION OF PIEZO IN OTHER FIELDS:

Robiony et al. 2007 used piezoelectric devices for rhinoplasty and avoided problem of
laceration to soft nasal tissue and damage to the principal vessels, such as the nasal angular
artery, and which may increase the risk of bleeding.
Salami et al. 2007 reported usage of piezoelectric devices on patients under general
anaesthesia undergoing ontological surgery such as; stapedotomy, antrotomy, posterior
tympanotomy, decompression of the facial nerve. In all cases the piezoelectric device allowed
rapid and easy intraoperative management, and precise cutting, particularly in critical anatomical
areas.
Schaller et al 2005 reported the successful use of piezoelectric surgery in the cranial base
and spine in children. He showed that the technique spared soft nerve tissue, was avoided
coagulative necrosis, improved the visualisation of the surgical field, and resulted in a more
precise cut.
Orthopaedic and hand surgery: A common problem in the removal of osteosynthetic
material is the formation of a callus that covers plates and screws and makes removal difficult.
Piezoelectric surgery allows the quick removal of callus from titanium osteosynthetic material,
particularly, from the slots of the screws without damaging them.
CONCLUSION:
Piezoelectric devices are an innovative ultrasonic technique for safe and effective
osteotomy or osteoplasty compared with traditional hard and soft tissue methods that use rotating
instruments because of the absence of macrovibrations, ease of use and control, and safer cutting,
particularly in complex anatomical areas. Its physical and mechanical properties have several
clinical advantages: precise cutting, sparing of vital neurovascular bundles, and better
visualisation of the surgical field. Piezoelectric bone surgery seems to be more efficient in the
first phases of bony healing; it induces an earlier increase in bone morphogenetic proteins,
controls the inflammatory process better, and stimulates remodelling of bone as early as 56 days
after treatment.
There are few limitations. Operating time for osteotomies is slightly longer than with traditional
saws, and increasing the working pressure impedes the vibration of devices that transform the
vibrational energy into heat, so tissues can be damaged. The technique can be difficult to learn.
REFERENCES:

1. Labanca M, Azzola F, Vinci R, Rodella LF .Piezoelectric surgery: Twenty years of use.

British Journal of Oral and Maxillofacial Surgery 2008;46:265269.
2. Nalbandian S. Piezosurgery techniquesin implant dentistry. Australasian Dental Practice
September/October 2011; 116-126.
3. Vercellotti T. Piezoelectric surgery in implantology:a case reporta new
piezoelectricridge expansion technique. IntJ Periodontics Restorative Dent 2000;20:359365.
4. Vercellotti T, De Paoli S, Nevins M. Thepiezoelectric bony window osteotomy andsinus
membrane elevation: Introductionof a new technique for simplification ofthe sinus
augmentation procedure. Int JPeriodontics Restorative Dent 2001;21:561567.
5. Vercellotti T, Nevins ML, Kim DM, et al.Osseous response following resective therapy
with piezosurgery. Int J PeriodonticsRestorative Dent 2005;25:543549.
6. Wallace SS, Mazor Z, Froum SJ, Cho SC, Tarnow DR.Schneiderian membrane
perforationrate during sinus elevation usingpiezosurgery: clinical results of 100
consecutive cases. Int J PeriodonticsRestorative Dent 2007;27:413419.
7. Reichwein A, Lambrecht JT, Schicho K, UndtG, Ewers R. Clinical Experience with
Piezosurgery. Distraction osteogenesis of the facial skeleton. B.C.Decker Inc. Chapter
19;229-231.
8. Sohn DS, Ahn MR, Lee WH, Yeo DS, Lim SY. Piezoelectric osteotomyfor intraoral
harvesting of bone blocks. Int J Periodontics Restorative Dent 2007; 27:12731.
9. Seshan H,Konuganti K, Zope S. Piezosurgery n periodontology andoral implantology.
Journal of Indian Society of Periodontology - Vol 13, Issue 3, Sep-Dec 2009: 155-156.

precautions
must be taken as the ultrasonic waves have mechanical energy, and this energy can be
converted into heat and pass into adjacent tissues. For this reason the use of irrigation is
essential, not only for the effect of cavitation, but also to avoid overheating.