Applications of Piezosurgery in Oral and Maxillofacial Surgery

Piezoelectric bone surgery is a relatively novel alternative to traditional bone cutting tools to overcome limitations in oral hard tissue surgery. It is a promising and improved technology for bone cutting that is meticulous and soft tissue-sparing, based on ultrasonic micro-vibrations [1].

Clinical applications of piezosurgery in oral and maxillofacial surgery are:

Dento-alveolar procedures

a) Root resection,

b) Hemi-section, root amputation,

c) Periodontal surgery (osseous bone contouring),

d) Apical resection and endodontic treatments,

e) Alveolar decortication and corticotomy,

f) Alveolar distraction,

g) Dental extractions,

h) Removal of impacted teeth (In and around the mandibular ca¬nal or maxillary sinus, piezosurgery helps prevent nerve damage, even in case of accidental contact with the working insert tips) [2].

Maxillary sinus surgeries

a) Preparation of bone window with lateral approach [3],

b) Sinus floor elevation,

c) Atraumatic sinus mucosa dissection [4].

The risk of perforating Schneiderian membrane is reduced from 30% to 7% during the osteotomy procedure for bone window confection or during membrane lifting [5].

Bone grafting

a) Harvest of intra-oral autogenous bone chips with a good number of viable osteocytes [6].

b) Mandibular ramus block bone graft as an onlay graft for increasing bone thickness [7].

c) Harvesting iliac block bone graft for jaw reconstruction.

d) Piezosurgery provides high precision and operating sensitivity and easy differentiation between cortical and cancellous bone while removing blocks of monocortical cancellous bone [8].

Dental Implantology

a) Implant socket preparation called ‘differen¬tial ultrasonic socket preparation’ is performed with selective enlargement of one socket wall [3].

b) Alveolar ridge splitting and expansion without the risk of thermo-necrosis of bone with reduced risk for adjacent soft tissues damage [9].

c) Re-contouring of alveolar crest with enhanced vibratory efficiency.

d) Mental nerve reposition.

e) Implant removal.

f) Maxillary sinus lifting [4].

g) Better primary stability and short-term survival rate of the implant.

Orthognathic surgeries

Like Sagittal split ramus osteotomies, Le Fort I osteotomies, and surgically assisted rapid maxillary expansion [10,11]. The operative time taken for remains the same with lesser blood loss especially in LeFort I osteotomies.

Enucleation of jaw cysts, Removal of odontogenic tumours, Jaw Resection

Piezo instruments enable cautious handling of the cystic lining without tearing the epithelial wall with careful removal of the surrounding thin cystic bone [12,13]. This has favourable implications of markedly reduced postoperative recurrence and complication rates. The resection of odontogenic tumors is also possible with piezosurgery, albeit time consuming.

Temporomandibular joint ankylosis and condylar hyperplasia osteotomy procedure with decreased risk of bone fracture as bones become elastic after osteotomy with ultrasonic intermediate vibration, minimizing complications like risk to the middle meningeal artery.

The main advantages of piezosurgery are

a) Enhanced patient comfort during procedures due to the absence of macro-vibrations,

b) Direct visibility of the surgical site from pressurized irrigation and cavitation effect,

c) Bone sectioning with micrometric sensitivity,

d) Haemostasis through direct cavitation effect,

e) Avoiding adjacent soft tissue damage [14],

f) Quicker bone healing-no thermal trauma, with earlier bone morphogenetic protein release,

g) No osteonecrosis as it avoids excessive temperature,

h) Precise and safe hard tissue cutting due to adaptation to the vibration frequency [15],

i) Harvested bone can be modified and shaped according to recipient site,

j) Less strength required for bony cuts as instruments are three times more powerful,

k) Better surgical control.

Disadvantages are

a) Contraindicated in patients with pacemakers,

b) Not cost effective,

c) Increased operative time,

d) Learning from experience curve for the technique,

e) Adequate dexterity and gentle touch is essential,

f) Pressure above certain limits impedes insert vibrations, decreasing efficiency,

g) Increase compared to traditional cutting instrument,

h) Difficulties in deeper osteotomy site like pterygomaxillary dysjunction,

i) Need regular sharpening/replacement-inserts get worn away and may break,

j) May cause thermal tissue damage.

Piezosurgery outweighs traditional instruments for bone cutting and its clinical and biological advantages contribute to improved bone health making it a highly effective tool in maxillofacial clinical practice.

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