J Oral Maxillofac Surg 63:1283-1287, 2005

Intraoral Piezosurgery: Preliminary Results of a New Technique

Stefan Stbinger, DDS,* Johannes Kuttenberger, MD, DDS, Andreas Filippi, DDS, Robert Sader, MD, DDS, and Hans-Florian Zeilhofer, MD, DDS
The piezosurgery instrument, developed in 1988, uses a modulated ultrasonic frequency that permits highly precise and safe cutting of hard tissue. Nerves, vessels, and soft tissue are not injured by the microvibrations (60 to 200 mm/sec), which are optimally adjusted to target only mineralized tissue. The selective and thermally harmless nature of the piezosurgery instrument results in a low bleeding tendency. In addition, the instrument can be used in operations requiring either local or general anesthesia. The precise nature of the instrument allows exact, clean, and smooth cut geometries during surgery. The difference in time requirement for surgical procedures using the piezosurgery instrument in comparison with the conventional drill is negligible. Postoperatively, excellent wound healing, with no nerve and soft tissue injuries, is observed. It is apparent that the range of application of piezosurgery is not limited to minor operations. 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 surgery cases, as well as to other interdisciplinary problems. 2005 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 63:1283-1287, 2005 Within the eld of dentistry, ultrasonics established itself mainly in periodontology1,2 and endodontics3 following the rst reports on the cutting effects of high-frequency sound waves on dental hard tissue by Catuna in 1953.4 In many cases, special scalers based on the so-called reciprocal piezo effect are used. This physical principle, also known as the indirect piezo effect, is generated by a deformation of a piezoelectric crystal in an electric eld. A voltage applied to a polarized piezo ceramic causes an expansion of the material in the direction of polarity and a contraction perpendicular to it. Ultrasonic oscillations can be used not only for scaling subgingival concrements and plaque, but also for removing root canal llings and fractured instruments from root canals.5 However, incidental treatment of adjacent hard substances cannot be entirely excluded from such procedures.6 Based on the experience gained with the ultrasonic scalpel, the application of focused ultrasound for noninvasive osteotomy,7 as well as the use of ultrasonic vibration drills in traumatology,8 the advantages of piezosurgery can also be used for intraoral osteotomy techniques. Because of the modulated ultrasonic frequency, which generates microvibrations of 60 to 200 mm/sec, mineralized tissue is exactly and smoothly cut while adjacent soft tissue and nerves remain unharmed.9 Piezosurgerys accuracy and selectivity render it superior to conventionally rotating instruments in operations where the area of interest is adjacent to nerves, such as when strongly displaced and impacted wisdom teeth are located in close proximity to the inferior alveolar nerve, in osteotomies performed close to the mental foramen, or in lateral nerve displacements. The advantages of the piezo osteotomy can also be applied to preimplantologic surgery for augmentative purposes. For example, sinus oor elevation carries a much lower risk of perforation or injury to the mucous membrane since soft tissue cannot be dam-

*Assistant, Clinic for Reconstructive Surgery, Division of Cranio and Maxillofacial Surgery, University Hospital Basel, Basel, Switzerland. Senior Physician, Clinic for Oral and Maxillofacial Surgery, Kantonsspital Luzern, Luzern, Switzerland. Senior Physician, Department of Oral Surgery, Oral Radiology and Oral Medicine, University of Basel, Basel, Switzerland. Senior Physician, Clinic for Reconstructive Surgery, Division of Cranio and Maxillofacial Surgery, University Hospital Basel, Basel, Switzerland. Professor, Clinic for Reconstructive Surgery, Division of Cranio and Maxillofacial Surgery, University Hospital Basel, Basel, Switzerland. Address correspondence and reprint requests to Dr Stbinger: University Hospital Basel, Reconstructive Surgery, Division of Cranio and Maxillofacial Surgery, Spitalstrasse 21, 4031 Basel, Basel Stadt, Switzerland; e-mail: sstuebinger@uhbs.ch
2005 American Association of Oral and Maxillofacial Surgeons

0278-2391/05/6309-0006$30.00/0 doi:10.1016/j.joms.2005.05.304

1283

1284

INTRAORAL PIEZOSURGERY

FIGURE 1. Clinical situation of the left mandibular with an obvious infraocclusion in the premolar region. Stbinger et al. Intraoral Piezosurgery. J Oral Maxillofac Surg 2005.

aged with this method. The following cases shows the protection of both nerves and soft tissue in this ultrasound-based surgical technique.

which the corticalis is weakened by the piezo instrument and then the teeth and surrounding spongiosa carefully mobilized, was planned. After local anesthesia, a marginal incision from the molar to the fronal region was performed. For purposes of relief, the cut was lengthened into the vestibule. After dissection of the mucoperiosteal ap, a thin osteotomy gap was created along the root of the rst premolar using the piezosurgery instrument. Similar to a vertical osteotomy performed distal to the premolar tooth, monocortical cuts reaching the lingual cortical plate were made between roots of the canine and rst premolar and the canine and second incisor. The apical transversal connecting osteotomy was dissected based on ultrasonic techniques in the area of the vestibular corticalis only (Fig 2). After weakening of the lingual cortical plate, the cortico-cancellous blocks, including the teeth, were subsequently carefully loosened in a vertical direction so that further orthodontic tooth movement could be performed postoperatively. The mental nerve was not touched or injured during the surgical manipulation.
CASE 2

Materials and Methods

A piezosurgery instrument manufactured by Mectron Medical Technology (Carasco, Italy) was used for the surgical interventions. The instrument operates with modulated ultrasound and can thus generate micromovements between 60 and 200 mm/sec. Physiological sodium chloride solution at a temperature of approximately 4C was used for irrigation. In all cases, the settings selected, mode boosted burst c and pump 5, for the individual cuts were in accordance with the manufacturers recommendations. The tips used for tooth extraction and bone surgery, as well as the new OT7 bone saw (Mectron Medical Technology), were attached to the hand piece of the instrument. Depending on the application, either a diamond-shaped tip for careful bone removal or a tip coated with titanium nitrate for cutting was used. For bone removal alone, the settings were changed to mode low and pump 3.

A 48-year-old woman was referred to our department for persistent pain in the left lower jaw. The patient stated that more than 30 years ago the rst molar on the right side had been extracted for caries and a fragment of the mesial root had been left in the mandible. Ten years ago, an attempt to remove the root fragment by conventional osteotomy using a rotating instrument was aborted because of the close proximity of the root fragment to the inferior alveolar nerve. Secondary to severe, persistent pain the patient elected to have another operation using a nerveprotecting piezo osteotomy under local anesthesia to remove the root fragment. After dissection of a ves-

Report of Cases
CASE 1

An 18-year-old woman was referred to our clinic for an infraocclusion in the left premolar area of the lower jaw (Fig 1). The patient had previously undergone an orthodontic procedure in which the canine and rst premolar on the left side could not be moved. Because the caudally displaced teeth were positioned in close proximity to the mental nerve, a traditional block osteotomy with distraction could not be performed. An alternative treatment method, in

FIGURE 2. Block osteotomy of the teeth. The mental nerve is clearly visible and is not injured by the piezosurgery device. Stbinger et al. Intraoral Piezosurgery. J Oral Maxillofac Surg 2005.

STBINGER ET AL

1285

FIGURE 3. The impacted mesial root fragment is carefully withdrawn with the help of the new ultrasonic technique. A special protection of the alveolar nerve is not necessary. Stbinger et al. Intraoral Piezosurgery. J Oral Maxillofac Surg 2005.

FIGURE 5. The vestibular bone window can be removed without any problems. However, the cyst follicle is traumatized by insertion of the chisel. Stbinger et al. Intraoral Piezosurgery. J Oral Maxillofac Surg 2005.

tibular mucoperiosteal ap, the piezosurgery instrument was used to cut a precisely dened bone window (Fig 3) in the area of the vestibular cortical plate, which provided access to the root remnant. After the removal of the bone lid, the bone window was extended mesially for improved access and view of the root fragment. Under these conditions, the root remnant was easily visualized and gently removed by circular piezo osteotomy (Fig 4). The inferior alveolar nerve and the surrounding soft tissues were not incidentally injured during the procedure.
CASE 3

woman initially underwent a procedure to extract an impacted wisdom tooth using a drill and piezo instrument. Afterward, an odontogenous cyst close to the location of the extracted wisdom tooth was removed from the region between the rst and second left molars. Similar to case 2, a vestibular bone window was prepared for extirpation of the cyst using piezosurgery (Fig 5). Because there is no cutting effect on soft tissue in ultrasonics-based surgery, the cyst follicle situated under the cortical surface was not transected. After the bony plate was lifted, the cyst was easily removed.
CASE 4

In a similar fashion to the case described above, piezosurgery can also be used for the removal of cysts close to the inferior alveolar nerve. A 35-year-old

A 66-year-old man with bilateral edentulous posterior maxilla was referred for implant treatment. Because of extensive alveolar bone loss, a bilateral sinus

FIGURE 4. The precise, safe, and exact piezosurgery allows predictable and sophisticated cut geometries. The sharp and clear edges of the bony block were hardly feasible with a conventional bur. Stbinger et al. Intraoral Piezosurgery. J Oral Maxillofac Surg 2005.

FIGURE 6. Osteotomy of the window. The clearly visible membrane is not harmed because of the selective and safe cut of piezosurgery. Stbinger et al. Intraoral Piezosurgery. J Oral Maxillofac Surg 2005.

1286

INTRAORAL PIEZOSURGERY

FIGURE 7. Harvesting of autologous bone chips for the sinus graft. Stbinger et al. Intraoral Piezosurgery. J Oral Maxillofac Surg 2005.

oor elevation was performed as a rst step using the piezosurgery technique. Under local anesthesia, a mucoperiosteal ap was raised and a rectangular bone window was cut with the piezosurgery device. The Schneiderian membrane was not violated during the dissection (Fig 6). Bone chips were harvested from the canine fossa with a special working tip (Fig 7). After elevating the maxillary sinus mucosa with manual instruments, the space created was lled with a mixture of harvested autogenous bone and Bio Oss (Fa Geistlich, Baden-Baden, Germany). The procedure was subsequently repeated on the other side of the maxilla.

Discussion
The routine use of ultrasonic scalers10 in periodontology has given rise to numerous studies analyzing possible complications and side effects of this treatment modality.11-13 One important question raised was whether treated tissue or the tissue adjacent to it remains capable of repair and regeneration after the application of high-frequency sound waves. It was shown that different ultrasonic amplitudes led to varying degrees of root surface destruction, which ultimately inuence the periodontal healing process.14 Proper selection of the settings thus plays a pivotal role because it not only inuences treatment efciency but also has a signicant role in the development of possible side effects in adjacent structures. Based on the experience from our cases, our clinical impression was that osteotomies performed with the piezosurgery instrument did not result in any visible injury to the adjacent soft tissues from the generated micromovements. This nding is caused by the piezo instruments modulated ultrasonic frequency, which removes only mineralized hard substance. A direct comparison with conventional piezo scalers is, there-

fore, not possible. It should, however, be noted that soft tissue structures, such as the mucous membrane of the maxillary sinus or a cyst follicle, may be perforated or injured by excessive mechanical force from the instrument tip. Careful operating technique remains critical. With regard to thermal damage of tissue structures after ultrasonics-based scaling, some authors describe a surface coagulation effect.15 However, wounds might heal faster if ultrasonic instruments were used.16 When using the piezo instrument in clinical applications, we did not observe any visible coagulation necroses in the area of hard or soft tissue. However, a pronounced temperature increase was noted in the area of the hand piece after a prolonged period of application. Therefore, it remains to be claried whether a transmitted thermal alteration of hard and soft tissue structures can be caused by intraoral piezosurgery. Because the instrument comes into the vicinity of or into direct contact with vital teeth in preimplantologic measures and in reconstructive periodontal surgery, thermal damage of the dental pulp, in principle, cannot be excluded.17 In such applications, the additional removal of dental hard tissue must be taken into consideration. The cutting effect on teeth is considerably lower when compared with bone. However, in our cases, cutting of dental substance was possible without any problems, contrary to the ndings of Lambrecht.18 Animal experiments19,20 conrm that scalers operated with an ultrasonic frequency of 20 kHz cause intravascular thrombus formation. Williams and Chater21 showed that the risk of thrombosis in pulp vessels is lower at a frequency of 25 kHz, but that the possibility of platelet aggregation in intrapulpar vessels continues to exist. In such a case, the tooth might nally be devitalized. The piezosurgery instrument used in our patients operates at a frequency of 20 kHz, which is exactly in the critical frequency range. Up to now, there has been only limited data on the effects of modulated high-frequency ultrasound on intraosseous blood vessels. Before the widespread use of piezosurgery for osteotomies, possible side effects such as thrombogenesis or impaired bony blood circulation need to be examined. One area for special concern is the poorly vascularized mandible, where thrombosis of its intraosseous vessels may lead to obvious clinical problems. Thus far, we have not encountered postoperative complications such as impaired wound healing or dry sockets. However, our experience is limited. Although ultrasonic osteotomies were rst described more than 20 years ago by Horton et al,22,23 this approach was not pursued for many years. It was

STBINGER ET AL

1287
11. Drisko CL, Cochran DL, Blieden T, et al: Research, Science and Therapy Committee of the American Academy of Periodontology Position paper: Sonic and ultrasonic scalers in periodontics. Research, Science and Therapy Committee of the American Academy of Periodontology. J Periodontol 71:1792, 2000 12. Trenter SC, Walmsley AD: Ultrasonic dental scaler: associated hazards. J Clin Periodontol 30:95, 2003 13. Kocher T, Plagmann HC: Heat propagation in dentin during instrumentation with different sonic scaler tips Quintessence Int 27:259, 1996 14. Chapple IL, Walmsley AD, Saxby MS, et al: Effect of instrument power setting during ultrasonic scaling upon treatment outcome. J Periodontol 66:756, 1995 15. Ewen, SJ: The ultrasonic wound - some observations. J Periodontol 32:315, 1961 16. Sanderson AD: Gingival curettage by hand and ultrasonic instruments: A histologic comparison. J Periodontol 37:279, 1966 17. Walmsley AD: Potential hazards of the dental ultrasonic descaler. Ultrasound Med Biol 14:15, 1988 18. Lambrecht TJ: Intraorale Piezo-chirurgie. Zahnzt Mitteil 1:36, 2004 19. Walmsley AD, Laird WR, Williams AR: Intra-vascular thrombosis associated with dental ultrasound. J Oral Pathol 16:256, 1987 20. Williams AR: Intravascular mural thrombi produced by acoustic microstreaming. Ultrasound Med Biol 3:191, 1977 21. Williams AR, Chater BV: Mammalian platelet damage in vitro by an ultrasonic therapeutic device. Arch Oral Biol 25:175, 1980 22. Horton JE, Tarpley TM Jr, Jacoway J: Clinical applications of ultrasonic instrumentation in the surgical removal of bone. Oral Surg Oral Med Oral Pathol 51:236, 1981 23. Horton JE, Tarpley TM Jr, Wood LD: The healing of surgical defects in alveolar bone produced with ultrasonic instrumentation, chisel, and rotary bur. Oral Surg Oral Med Oral Pathol 39:536, 1975 24. Vercellotti T: Piezoelectric surgery in implantology: A case reportA new piezoelectric ridge expansion technique. Int J Periodontics Restorative Dent 20:358, 2000 25. Vercellotti T, Crovace A, Palermo A, et al: The piezoelectric osteotomy in orthopaedic: Clinical and histological evaluations (pilot study in animals). Mediterranian J Surg Med 9:89, 2001

not until 2000 that Vercellotti et al24 renewed this approach for nerve and soft tissue protecting surgery. The results of piezosurgery in dentistry and veterinary medicine show promising possibilities25 that are conrmed by our clinical experience. Currently, longterm results following piezosurgery, which would allow for a critical evaluation of this new surgical method, are still lacking.

References
1. Lea SC, Landini G, Walmsley AD: Ultrasonic scaler tip performance under various load conditions. J Clin Periodontol 30: 876, 2003 2. Flemmig TF, Petersilka GJ, Mehl A, et al: The effect of working parameters on root substance removal using a piezoelectric ultrasonic scaler in vitro. J Clin Periodontol 25:158, 1998 3. Walmsley AD, Laird WR, Lumley PJ: Ultrasound in dentistry. Part 2 - Periodontology and endodontics. J Dent 20:11, 1992 4. Catuna MC: Sonic surgery. Ann Dent 12:100, 1953 5. Ward JR, Parashos P, Messer HH: Evaluation of an ultrasonic technique to remove fractured rotary nickel-titanium endodontic instruments from root canals: Clinical cases. J Endod 29:764, 2003 6. Walmsley AD, Walsh F, Laird WR, et al: Effects of cavitational activity on the root surface of teeth during ultrasonic scaling. J Clin Periodontol 17:306, 1990 7. Ishida S, Hata N, Azuma T, et al: Non-invasive osteotomy using focused ultrasound. In the Proceeding of the 16th International Congress and Exhibition, Computer Assisted Radiology and Surgery. Paris, France, 2002, pp 258-262 8. Kvashnin SE, Bosova EV, Grigorev AV: Investigation and development of ultrasonic vibrodrives for traumatology. Crit Rev Biomed Eng 29:520, 2001 9. Vercellotti T, De Paoli S, Nevins M: The piezoelectric bony window osteotomy and sinus membrane elevation: Introduction of a new technique for simplication of the sinus augmentation procedure. Int J Periodont Restor Dent 21:561, 2001 10. Busslinger A, Lampe K, Beuchat M, et al: A comparative in vitro study of a magnetostrictive and a piezoelectric ultrasonic scaling instrument J Clin Periodontol 28:642, 2001