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- DOI 10.18231/j.ijpi.2024.007
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Piezoelectric surgery - Gaining popularity in modern periodontics: A review
Introduction
Periodontal diseases are multifactorial infections caused by many bacterial species that interact with host tissues and cells, leading to the extensive release of inflammatory cytokines, chemokines, and mediators, which destroys the periodontal structures, including teeth supporting bone, leading to bony deformities.[1] This alteration in the normal physiologic bone pattern are corrected by various periodontal regenerative and reconstructive procedures.[1] Deformities in bone are corrected by osseous surgery for re-contouring the bone patterns. For many decades osseous surgery ware conventionally performed using hand and various rotary instruments. Using these conventional instruments, inappropriate force and heat generation during osseous surgery leads to fracture of the brittle bone, ultimately leading to alteration in standard physiologic bone patterns.[2], [3] In the recent past, innovative surgical techniques using piezoelectric device machines with regulated frequency, restrained tip vibration has been introduced in Periodontology and Oral Implantology assuring precise and productive methods in comparison to the conventional technique. It has gained popularity in very short duration due to wide variety of applications in both medical and dental surgeries. It has made the surgical procedures like bone incising (osteotomy) and bone shaping (osteoplasty) easier.[4]
Historical Aspects and Physics Involved in Piezosurgery
The word ‘’Piezo’’ originates from the greek word Piezein (to press tight, squeeze). Piezosurgery is basically based on the theory of "piezo-effect" i.e., changing the electrical field on crystalline structure.
The change of electrical field strength in the crystalline structure results in the production of ultrasonic vibrations. In 1880, Jacques Curie and Pierre Curie discovered piezoelectric while working as laboratory assistants at the faculty of science in Paris. They generated electrical charges by applying pressure to the crystals like tourmaline, quartz and Rochelle salts.[4], [5] In 1881, Gabriel Lippmann predicted the converse piezoelectric effect i.e. application of an electric field to the crystal materials causes the internal generation of a mechanical strain with the help of mathematical deduction from thermodynamic principles. In 1953, Catuna MC developed a drill with ultrasonic properties for cavity preparation on human teeth.[6] In 1957, Richman reported apicoectomies using an ultrasonic chisel for surgery without using slurry.[7] Demonstration to dissect the bone precisely using an ultrasonic blade was given by Mazzarow in 1960.[8] Mcfall et al., in 1961 compared healing with rotating instruments and an oscillating scalpel blade and concluded that there was no severe complications and wound healing was comparatively slower in the oscillating scalpel blade group.[9]
In 1980, Horton et al., conducted a study on alveolar bone in dogs comparing bone regeneration with rotating instruments and ultrasounds and concluded that regeneration of bone was better in ultrasonic group as compared to rotating instrument group, however smoother surface was appeared in rotating instrument group.[3] Torella et al., in 1998 reported the osteotomy procedures to lift the maxillary sinus was done by ultrasonic piezoelectric instruments.[10] Vercelloti T, in 1999, in collaboration with Mectron Spa invented piezoelectric bone surgery. Vercelloti T in 2000, published the first human clinical study using "piezoelectric bone surgery" maintaining the integrity of bone.[7], [11] In 2001, after bringing together (ultrasound and the piezo effect), the Piezosurgery® was introduced as a surgical tool.[8] This device was commercially approved in Germany in the year 2002.[4] In 2003, Vercelloti fabricated the optimal frequency methods for performing surgical procedures.[12], [13] In 2005, ultrasonics in the field of dentistry to perform different bone surgery was continued by the US Food and Drug Administration.[14]
Ideology of Piezoelectric Surgery
The doctrine behind the piezoelectric bone surgery is mostly based on two underlying concepts: [15], [16], [17], [18], [19]
Minimally invasive surgery
Improving the tissue healing and reducing the discomfort among patients; post-operative pain or swelling is much lower than the traditional technique.
Surgical predictability
Increases treatment effectiveness and ease of using the instrument during the surgery. Minor bleeding, accuracy in cutting, and magnificent tissue healing make it best to enhance surgical results despite being used in the most complex anatomical cases. The piezoelectric device produces ultrasonic vibration (25-29KHz frequency), an oscillation (60-120µm), and power up to 50W. This allows an adequate cutting of bone without damaging the soft tissue. [4] Applying electrical charges to the face of piezoelectric crystals result in crystal compression. In contrast, inverting the direction of electric charge results in expansion. When piezoelectric crystals like quartz or ceramic disk are placed under an alternating electric field, there is compression and expansion of the crystal, which produces a series of vibrations. [20]
These vibrations result in an oscillating shape change of the crystal at the frequency applied, which finally passes onto the working tip, also called inserts, where longitudinal movement occurs, resulting in the cutting of osseous tissue by the microscopic shattering of bone. [21] When this series of vibrations are conducted through a piezoelectric transducer, higher efficiency is obtained. The device uses a specifically engineered surgical instrument characterised by a surgical power that is three times higher than usual ultrasonic instruments. The piezoelectric device can be adjusted over various working frequency setting to perform different procedures. The ultrasonic waves allow the segregation of interface from solid-liquid through micro boiling phenomena called cavitation. This phenomenon occurs by implosion of the droplets causing release of energy as the water spray contacts. [22] This provides advantage in the surgical area by dispersing coolant as an aerosol, provide hemostasis resulting in the clear visibility in the surgical area. Cavitation also fragments bacterial cell walls. [23], [24], [25]
Components of Piezosurgery unit
Composed of
Main body
Main body is composed of touchpad (electronic), display screen, a peristaltic pump, a stand to hold the surgical handpiece,one stand to hold the bag of irrigation and different modes (roots and bone).
Handle
Piezoelectric ceramic discs inside handle generates ultrasonic waves.
Inserts tips
Based on the colour of tips [4], [22], [26]
Steel tips: For soft tissues or delicate structures, e.g. root of the teeth.
Gold tips: Used to treat bone. Titanium nitride is applied to increase the tips surface hardness.
Morphological-functional classification [27]The morphology represents the structural properties of the tips, while the functional description exemplify the cutting characteristics of the inserts:
Sharp- Cutting
Diamond coated - Abrasive
Rounded - Smoothing
Clinical classification (According to basic surgical technique).[27]
|
Osteotomy (OT) OT1 - OT2- OT3- OT 4- OT5- OT6- OT7- OT7S4 - OT7S3- OT8R/L |
Osteoplasty (OP) OP1 - OP2- OP3- OP4- OP5- OP6- OP7 |
|
Extraction (EX) EX1 - EX2 - EX3 |
Implant site preparation (IM) IM1 (OPs)- IM2A- IM2P- OT 4- IM3A- IM3P |
|
Orthodontic Microsurgery OT7S4- OT7S3 |
Sinus Lift OP3- OT1 (OPs)- EL1 - EL2- EL3 |
|
Implant site preparation (IM) IM1 (OPs)- IM2A- IM2P- OT 4- IM3A- IM3P |
Periodontal Surgery PS2 - OP5 - OP3 - OP3A- PP1 |
|
Endodontic Surgery OP3- PS2- EN1 - EN2- OP7 |
Ridge Expansion OT7- OT7S4- OP5 (IM1)- IM2- OT 4- IM3 |
Clinical applications
Periodontology
Supragingival and subgingival scaling:
Curettage.
Crown lengthening.
Resective surgery.
Bone harvest.
Implantology
Maxillary sinus lift
Ridge expansion
Inferior alveolar nerve laterization
Bone harvesting techniques
Perimucositis, periimplantitis, implant drill
Implant removal
Oral surgery
Dental extraction, including third molar extraction
Osteogenic distraction
Cyst removal
Endodontic surgery (apicoectomy)
Extraction of ankylosed teeth
TMJ ankylosis treatment
Orthodontic surgery- In Vilcodontics, PAOO (Periodontally accelerated osteogenic orthodontics).
Movement occurs and in that different width and depth of osteotomy has to be performed. (corticotomy).
Scaling (supra gingival and sub-gingival) and Curettage
The piezosurgery device with a vibrating tip is used for removing the debris and calculus from the teeth. Inserts are placed vertically parallel to the tooth's long axis and are moved continuously, providing better patient comfort and maximum calculus removal. The cavitation effect and micro-streaming disrupt the bacterial cell wall. [28] It can also efficiently remove diseased soft tissue by debridement of the pocket wall's epithelial lining, resulting in "micro-cauterisation" by using thin tapered tips and altered power settings. [29]
Surgical crown lengthening
This procedure is done to reposition the periodontal bone and soft tissues to a more apical position with appropriate biologic dimensions. Performing this technique using piezosurgery allows clinicians to efficiently reduce bone while preserving the root surface integrity. Ostectomy is performed while keeping the instruments parallel to the root, and there is no risk of damaging the root. Once the Osteotomy is completed, smoothing is performed parallel to the root surface and the bony micro-spicules are removed with the tip of the inserts. [30]
Maxillary sinus lifting
Maxillary sinus surgery for implant purposes enables the placement of an implant in the posterior maxilla when the crest of the bone is not sufficient. During conventional sinus lift procedures most common obstacle faced by clinician is the perforation of the Schneiderian membrane that leads to a communication between the oral cavity and maxillary sinus. This perforation increases the risk of sinusitis and infections. [31] Introduction of Piezosurgery in the maxillary sinus lift procedure abate the risk of Schneiderian membrane as the tips only cuts the mineralized tissues without damaging the soft tissue. [32] Maxillary sinus lift procedure using piezoelectric surgery shows approximately only 5% of membrane perforation, [33] whereas with rotary instrumentation varies between 5% and 56%.[34], [35]
Ridge Expansion Technique
The minimum width of an edentulous crest for placing a 4 mm diameter implant is 6 mm to obtain at least 1mm width of the buccal and lingual bone side. Narrow ridges are most frequently experienced by the clinician during placement of the dental implants. To overcome this, the ridge is expanded or splitted for expanding the bone to ease implant placement. [36] The ridge splitting of the mandible can also be done using conventional instruments but the risk of bone fracture as well as inferior alveolar damage is very high.[37], [38] To achieve ridge expansion with very less trauma the Piezosurgery unit is equipped with specific designed inserts that provides minimal fracture risk even in D1 type bone, where the chance of fracture is more. [38], [39], [40]
Harvesting autogenous bone graft
Autogenous bone graft is considered the “gold standard” for bone grafting procedures. Autogenous bone graft can be harvested as particulate or as a block grafts. Autogenous bone grafts are most commonly harvested from the ramus and body of the mandible, chin, symphysis, mandibular tori (if present) which shows good osteogenic properties, little resorption. Iliac crest, is considered for harvesting larger bone volumes. [36] The introduction of piezosurgery has further improvised the bone harvesting technique. Bone graft harvesting using a piezoelectric device showed greater short-term cell viability and slightly more new bone deposition and bone remodelling.[41] Piezosurgery utilises significantly less hand pressure than rotary instruments; hence precise cutting of bone is easily possible. [42], [43]
Inferior alveolar nerves lateralisation
In regions with significantly less visibility, performing the osteotomies with a tool that reduces the risk of nerve damage is essential. This goal can be possible with the Piezosurgery device due to its control, specialised tips and cavitation effect. [44] The specially designed tips of piezoelectric device precisely cuts allowing the lateral cortical bone over the neurovascular bundle. This procedure is performed to preserve and protect the nerve structure after nerve retraction and transposition. [45]
Removal of osseointegrated implants
Removal of an osseointegrated implant becomes utmost necessary for various reasons, including the undesirable position or primary esthetic concern, implant failures etc.
The osseointegrated implants (implant-bone interface) do not allow easy implant removal. Removal of such implants by conventional methods such as using burs, saw, chisel etc., have high risk of fracturing bone around the implants. The piezosurgical device have specially designed précised tips to remove osseointegrated implants. It makes easier for the surgeon as it improves efficacy and reduces trauma during the procedure.[36]
Contraindications of piezosurgery
Uncontrolled diabetic patients.
Patients with cardiopathy
Patients with pacemakers & ICD (Implantable Cardioverter Defibrillator)
On metal and ceramic crown and bridges.
Discussion
Piezosurgery is a new surgical technique in periodontology and oral implantology.[26] Piezosurgery instruments allow the clinician to perform more technique sensitive procedures which enabled better grip and, hence, increased precision while cutting. The cutting action is less invasive, leading very less collateral tissue damage.[27] Cavitation effect produced as the oscillating tip moves the irrigation fluid, there is a bloodless field of surgery and also fewer chances of postoperative necrosis. Due to the ultrasonic device's aerosol effect, hazard of developing subcutaneous emphysema is drastically reduced as compared to air-water spray released by rotary instruments for osteotomies.
Due to micro-vibrations, significantly less noise is produced when compared with a conventional motor system making less fear and reduces psychological stress among the patients. [28] Use of rotary instruments lead to high heat generations which are lethal to the cells and may cause tissue necrosis. [27] There have been many studies conducted for analysing the effects of piezoelectric surgery on the bone and the bone cells; not only is this piezoelectric technique is clinically effective, but histological and histo-morphometric observation on experimental animal models also indicated that postoperative wound healing and rate of bone formation and tissue response is more favourable compared to conventional bone cutting with diamond or carbide rotary instruments. [26], [29] Every coin has two sides. Piezosurgery is also associated with certain limitations. The use of irrigants helps in cavitation and avoids overheating. The intensity of the cooling liquid can be adjusted depending on different preparations. The cooling solution is used at 4 degrees centigrade. [30]
Conclusions
The Piezosurgery technique has numerous advantages over conventional surgical procedures. This technique allows the clinician to perform planned surgery in more efficient and predictable manner with minimum adverse effect. The use of Piezosurgery may increase treatment outcome, very less postoperative complications and an excellent healing. Piezosurgery due to specially designed tips and other properties has the future to revolutionize periodontal bone surgeries, implantology and redefine the concept of minimally invasive surgery in osteotomy and osteoplasty procedures. However, professional training and experienced guidance is required to achieve a better clinical skill enhancement.
Source of Funding
None.
Conflict of Interest
None.
References
- SC Holt, JL Ebersole. Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia: the "red complex", a prototype polybacterial pathogenic consortium in periodontitis. Periodontol 2000 2005. [Google Scholar] [Crossref]
- A Rashad, A Kaiser, N Prochnow, I Schmitz, E Hoffmann, P Haurer. Heat Production during different Ultrasonic and conventional osteotomy preparation for dental Implants. Clin Oral Implants Res 2011. [Google Scholar]
- JE Horton, TM Tarpley, LD Wood. The healing of surgical defects in alveolar bone produced with ultrasonic instrumentation, chisel, and rotary bur. Oral Surg Oral Med Oral Pathol 1975. [Google Scholar]
- M Thomas, U Akula, KK Ealla, N Gajjada. Piezosurgery: A boon for modern periodontics. J Int Soc Prev Community Dent 2017. [Google Scholar]
- M Labanca, F Azzola, R Vinci, LF Rodella. Piezoelectric surgery: Twenty years of use. Br J Oral Maxillofac Surg 2008. [Google Scholar]
- MC Catuna. Sonic Surgery. Ann Dent 1953. [Google Scholar]
- MJ Richman. The use of ultrasonics in root canal therapy and root resection. Med Dent J 1957. [Google Scholar]
- HB Mazarow. Bone repair after experimentally produced defects. J Oral Surg 1960. [Google Scholar]
- TA Mcfall, GM Yamane, GW Burnett. Comparison of cutting effect on bone of ultrasonic cutting device and rotary burs. J Oral Surg Anesth Hosp Dent Serv 1961. [Google Scholar]
- F Torrella, J Pitarch, G Cabanes, E Aniuta. Ultrasonic osteotomy for surgical approach of maxillary sinus: A technical note. Int J Oral Maxillofac Implants 1998. [Google Scholar]
- T Vercellotti. Piezoelectric surgery in implantology: a case report--a new piezoelectric ridge expansion technique. Int J Periodontics Restorative Dent 2000. [Google Scholar]
- LJ Walsh. Piezosurgery: An increasing role in dental hard tissue surgery. Aust Dent Pract 2007. [Google Scholar]
- CC Pereira, WC Gealh, L Meorin-Nogueira, IR Garcia-Júnior, R Okamoto. Piezosurgery applied to implant dentistry: clinical and biological aspects. J Oral Implantol 2014. [Google Scholar] [Crossref]
- J Thomas. piezoelectric ultrasonic bone surgery: Benefits for the interdisciplinary team and patients. Dent India 2008. [Google Scholar]
- LT Boioli, T Vercellotti, JF Tecucianu. La chirurgie piezoelectrique: Une alternative aux techniques classiques de chirurgie osseuse. lnf Dent 2004. [Google Scholar]
- JT Lambrecht. Intraoral piezo-surgery. Schweiz Monatsschr Zahnmed 2004. [Google Scholar]
- S Sivolella, M Berengo, M Scarin, F Mella, F Martinelli. Autogenous particulate bone collected with a piezoelectric surgical device and bone trap: a microbiological and histomorphometric study. Arch Oral Biol 2006. [Google Scholar]
- T Vercellotti. La Chirurgia Ossea Piezoelettrica. ll Dentista Moderno 2003. [Google Scholar]
- T Vercellotti. Technological characteristics and clinical indications of piezoelectric bone surgery. Minerva Stomatal 2004. [Google Scholar]
- Z Yaman, BT Suer. Piezoelectric surgery in oral and maxillofacial surgery. Ann Oral Maxillofac Surg 2013. [Google Scholar]
- P Leclercq, C Zenati, S Amr, DM Dohan. Ultrasonic bone cut part 1: State-of-art technologies and common applications. J Oral Maxillofac Surg 2008. [Google Scholar]
- H Aro, H Kallioniemi, AJ Aho, P Kellokumpu-Lehtinen. Ultrasonic device in bone cutting. A histological and scanning electron microscopical study. Acta Orthop Scand 1981. [Google Scholar]
- AM Mani, PP Marawar, S Amit, A Dalvi. Piezosurgery - A Review. Pravara Med Rev 2014. [Google Scholar]
- E Agarwal, SS Masamatti, A Kumar. Escalating Role of Piezosurgery in Dental Therapeutics. J Clin Diagn Res 2014. [Google Scholar]
- S Nalbandian. Piezosurgery techniques in implant dentistry. Aust Dent Pract 2011. [Google Scholar]
- CA Lands, S Stubinger, K Laudemann, J Rieger, R Sader. Bone harvesting at the anterior iliac crest using piezoosteotomy versus conventional open harvesting: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008. [Google Scholar]
- T Vercellotti. Characteristics of Piezosurgery Surgical Instruments. Essentials in piezosurgery: clinical advantages in dentistry 2009. [Google Scholar]
- AD Walmsley, WR Laird, AR Williams. Dental plaque removal by cavitational activity during ultrasonic scaling. J Clin Periodontol 1988. [Google Scholar]
- S Hema, K Kranti, Z Sameer. Piezosurgery in periodontology and oral implantology. J Indian Soc Periodontol 2009. [Google Scholar]
- JA Sherman, HT Davies. Ultracision: the harmonic scalpel and its possible uses in maxillofacial surgery. Br J Oral Maxillofac Surg 2000. [Google Scholar]
- M Al-Dajani. Recent trends in sinus lift surgery and their clinical implications. Clin Implant Dent Relat Res 2014. [Google Scholar]
- J Seoane, J López-Niño, L García-Caballero, J M Seoane-Romero, I Tomás, P Varela Centelles. Membrane perforation in sinus floor elevation - piezoelectric device versus conventional rotary instruments for osteotomy: an experimental study. Clin Implant Dent Relat Res 2013. [Google Scholar]
- T Vercellotti, S De Paoli, M Nevins. The piezoelectric bony window osteotomy and sinus membrane elevation: introduction of a new technique for simplification of the sinus augmentation procedure. Int J Periodontics Restorative Dent 2001. [Google Scholar]
- JP Van Den Bergh, CM Ten Bruggenkate, G Krekeler, DB Tuinzing. Sinusfloor elevation and grafting with autogenous iliac crest bone. Clin Oral Implants Res 1998. [Google Scholar]
- S Kasabah, J Krug, A Simůnek, MC Lecaro. Can we predict maxillary sinus mucosa perforation?. Acta Medica (Hradec Kralove) 2003. [Google Scholar]
- S Stübinger, A Stricker, B I Berg. Piezosurgery in implant dentistry. Clin Cosmet Investig Dent 2015. [Google Scholar]
- M Rahnama, L Czupkałło, L Czajkowski, J Grasza, J Wallner. The use of piezosurgery as an alternative method of minimally invasive surgery in the authors’ experience. Wideochir Inne Tech Maloinwazyjne 2013. [Google Scholar]
- F Brugnami, A Caiazzo, P Mehra. Piezosurgery-assisted, flapless split crest surgery for implant site preparation. J Maxillofac Oral Surg 2014. [Google Scholar]
- JG Rodriguez, RM Eldibany. Vertical splitting of the mandibular body as an alternative to inferior alveolar nerve lateralisation. Int J Oral Maxillofac Surg 2013. [Google Scholar]
- R Eldibany, JG Rodriguez. Immediate loading of one-piece implants in conjunction with a modified technique of inferior alveolar nerve lateralisation: 10 years follow-up. Craniomaxillofac Trauma Reconstr. 2014. [Google Scholar]
- S Mouraret, KS Houschyar, DJ Hunter. Cell viability after osteotomy and bone harvesting: comparison of piezoelectric surgery and conventional bur. Int J Oral Maxillofac Surg 2014. [Google Scholar]
- M Lakshmiganthan, S Gokulanathan, N Shanmugasundaram, R Daniel, S B Ramesh. Piezosurgical osteotomy for harvesting intraoral block bone graft. J Pharm Bioallied Sci 2012. [Google Scholar]
- M Bovi. Mobilization of the inferior alveolar nerve with simultaneous implant insertion: a new technique. Case report. Int J Periodontics Restorative Dent 2005. [Google Scholar]
- MC Metzger, KH Bormann, R Schoen, NC Gellrich, R Schmelzeisen. Inferior alveolar nerve transposition - an in vitro comparison between piezosurgery and conventional bur use. J Oral Implantol 2006. [Google Scholar]
- S Stübinger, C Landes, O Seitz, HF Zeilhofer, R Sader. Ultrasonic bone cutting in oral surgery: a review of 60 cases. Ultraschall Med 2008. [Google Scholar]
- Introduction
- Historical Aspects and Physics Involved in Piezosurgery
- Ideology of Piezoelectric Surgery
- Minimally invasive surgery
- Surgical predictability
- Components of Piezosurgery unit
- Inserts tips
- Clinical applications
- Scaling (supra gingival and sub-gingival) and Curettage
- Surgical crown lengthening
- Maxillary sinus lifting
- Ridge Expansion Technique
- Harvesting autogenous bone graft
- Inferior alveolar nerves lateralisation
- Removal of osseointegrated implants
- Contraindications of piezosurgery
- Discussion
- Conclusions
- Source of Funding
- Conflict of Interest