INSIGHTS OF PIEZOSURGERY- AN

INNOVATIVE SURGICAL METHOD IN THE

FIELD OF PERIODONTOLOGY

ISSN No: 2582-0559

To access & cite this article

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ABSTRACT

Periodontitis is the commonest diseases in the oral cavity. It is defined

as inflammation of the Periodontium and alveolar bone with periodontal

pocket formation, gingival recession, or both. The various Treatment

modalities include non-surgical and surgical methods, but the common

drawbacks of these methods are profuse bleeding, pain, and infection which

causes discomfort to the patient. To overcome this, in the era of modern

dentistry has an innovative surgical technique which was developed and

is referred as “Piezosurgery”. Piezosurgery is defined as a process that

utilizes piezoelectric vibrations in the application of cutting bone tissue. It

promotes rapid healing, reduces damages to osteocytes, and permits good

survival of bone cells during bone harvesting. It is extremely selective

and correct nature makes its path extended to interdisciplinary approaches.

This article discusses the new scope of piezoelectric surgery within the

field of Periodontology and Oral Implantology.

KEYWORDS:

Bone Harvesting, Cavitation, piezosurgery, ultrasonic

vibration.

Volume No: 9, Issue No: 2

Address for Correspondence:

Dr. K.K. Keerthana

Intern,

Department of Periodontology and Oral

Implantology,

Sri Venkateswara Dental College and Hospital

Off OMR road, Near Navalur, Thalambur,

Chennai-603103.

Email id: keerthanakrish.kk@gmail.com

Received

: 24.03.2022

Accepted

: 03.06.2022

First Published

: 21.06.2022

Published

: 27.06.2022

REVIEW ARTICLE

Dr. K.K. Keerthana, Dr. M.R. Keerthika, Dr. J. Kiruthika, Dr. U. Arunmozhi, Dr. R. Kadhiresan

Department of Periodontology and Oral Implantology,

Sri Venkateswara Dental College and Hospital, Off OMR road, Near Navalur, Thalambur, Chennai-603103.

DOI:1.37841/jidam_2022_V9_I2_04

Volume No: 9, Issue No: 2

Keerthana et al: Insights of piezosurgery

INTRODUCTION

The term “PIEZO” was derived from the Greek word “piezien”,

which means “Pressure”. Traditional surgical methods for the

treatment of periodontitis had quite a lot of drawbacks which

includes time-consuming procedure, overheating of adjacent

tissue, multiple instrumentations, delayed healing process, and

difficulty in maintaining a sterile surgical field. Localized bone

necrosis occurs when a temperature of more than 47 degree

Celsius was applied to the bone by the rotary instrument which

is a major complication of the conventional method. Harder

et al observed this rise in temperature was due to insufficient

irrigation as low as 20ml/min. To overcome this, Piezosurgery

was introduced, in which an internal irrigation system in the

piezoelectric device

(Fig 1) reduces the risk of post-operative

complications such as bone necrosis. It is a favourable method

for bone harvesting by using low-frequency ultrasonic micro-

vibrations. The absence of micro vibration makes the instrument

more feasible and permits greater intraoperative management.

Piezosurgery also decreases the chance of injuries to vital

structures like nerves and blood vessels

. Piezosurgery creates

a bloodless field throughout the surgical procedure that creates

a comfort zone for the patient. Piezoelectric surgery device

uses lower micro-vibrations that range from 60-200 micron/

second and ultrasonic frequency ranges from 24-36 kHz and

the power is approximately 5 W

. Nowadays, piezoelectric

surgery is considered a boon for modern periodontics, due to its

efficacy of handling delicate tissue is straightforward and avails

less risk to the patient

. Piezosurgery is also utilized in various

branches of dentistry like conservative dentistry, implantology,

periodontology, and oral and maxillofacial surgery.

Fig 1 : Piezoelectric device

REVIEW OF LITERATURE

In 1880,The Curie brothers ‘Jacque and Pierre’ discovered that

putting pressure on various materials like ceramics or bone,

created electricity which is known as the Piezo effect. In 1953,

Catuna & 1974 -Shepeleva delineated the cutting of hard tissue

with ultrasonic vibrations as piezoelectricity. In 1981- Aro et

al delineated Piezosurgery in orthopaedic surgery and Horton

et al in oral and maxillofacial surgery. In 1997-Mectron and

Tomaso Vercellotti developed piezoelectric bone surgery that

uses ultrasonic movements for bone cutting. Mectron created

the prototype device for Piezoelectric bone surgery with which

the primary extraction was performed. Tomaso Vercellotti

named this technique as PIEZO SURGERY in 1999. In

2001, Piezosurgery was introduced for use in dentistry and in

2002, Piezoelectric device was used in the field of dentistry

in Germany. Vercelloli in 2003 discovered the ideal frequency

for using the Piezoelectric device in various fields of dentistry

such as endodontic, orthopaedic, neurologic, periodontal, and

oral and maxillofacial surgeries. Mectron in 2004 developed the

second generation of piezosurgery device and in 2005, The US

Food and Drug Administration extended the use of ultrasonic

in dentistry to include bone surgery

. Sakkas et al in 2008

suggested that Piezosurgery allows a reduction of intraoperative

bleeding, creating better visibility of the surgical field

. The

third generation of piezosurgery was introduced in 2009 and

selective cutting made harvesting of bone possible without

encountering necrosis due overheating of the bone, and without

damaging nerves and vessels (Seshan et al., 2009, Crosetti et al.,

2009)

Piezosurgery (piezoelectric bone surgery) was used for

mandibular cyst enucleation that requires sensitive manipulation

(Kocyigit et al., 2012)

. Recently extraction of impacted lower

third molar results in more favourable outcomes when carried

out by piezosurgery technique

Piezoelectric surgery resulted

in improved quality of life of patients in the first week of post-

surgery with lower levels of pain and swelling as well as the

number of analgesics taken and better haemorrhage control

during surgery

INDICATIONS

• Supra and subgingival scaling and root planing

• Smoothening of the root surface

• Bone grafting

• Sinus lift preparation

• Implant site preparation

• Retrograde root canal preparation

• Apicoectomy

• Orthodontic surgeries.

CONTRAINDICATIONS

• Increased operating time

• Expense

• Learning curve

• Pacemakers and defibrillators

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Keerthana et al: Insights of piezosurgery

Parts of the Device: (Fig 2)

Fig 2: parts of piezoelectric device

BASE UNIT OR MAIN UNIT

The main unit consists of a Display, Electronic touchpad, Peristaltic pump, Holders.

THE ELECTRONIC TOUCHPAD CONSISTS OF THREE KEYS

Feature mode, Specific program, Flow of fluid from the cooling system

The irrigation fluid flows at the rate of 0-60 m/min through the peristaltic pump.

FEATURE MODE

It has two feature modes Root mode, Bone mode

ROOT MODE HAS TWO PROGRAMS

Endo program

This type of vibration is used in washing out the apical area of

the root canal in endodontic surgery.

Perio program

The program is characterized by an intermediate level of power,

The ultrasonic wave is transmitted through the transducer in

a continuous sinusoidal manner .this vibration is used in

periodontics for the root planing.

BONE MODE

It is characterized by extremely high ultrasonic power. It has

two selections:

Quality 1:cutting of cortical bone or high-density spongy bone

Quality 3: cutting low-density spongy bone

SPECIAL PROGRAM

It is characterized by a standard power level slightly lower than

bone mode. This special program is designed to form specific

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Keerthana et al: Insights of piezosurgery

types of inserts.

INSERT TIPS: (FIG 3)

Classifications of inserts tips:

Fig 3 : Insert tips

BASED ON THE COLOR OF THE TIPS

• Gold- used to treat bone, golden color is obtained by plating

titanium nitride to improve surface hardness.

• Steel – used to treat soft tissue

MORPHOLOGICAL FUNCTIONAL

CLASSIFICATION

• Sharp insert tips – for osteotomy and osteoplasty where fine

and well-defined cutting of bone is required.

• Smoothing insert tips – for precise and controlled cutting

effect during osteotomy.

• Blunt insert tips – In periodontics, these insert tips are used

for root planing.

CLINICAL CLASSIFICATION

• The clinical classification includes the inserts according to

basic surgical technique

• Osteotomy - OT1-OT2-OT3-OT4-OT5-OT6-OT7-OT7S4-

OT7S3-OT8R/L

• Osteoplasty-OP1-OP2-OP3-OP4-OP5-OP6-OP7-

• Implant site preparation –IM1-IM2A-IM2P OT4- IM3A-

IM3P-

• Sinus lift –OP3-OT1-EL1-EL2-EL3-

• The inserts for basic osteotomy, osteoplasty, and extraction

techniques are used in combination with each other for

different surgical protocols

MECHANISM OF ACTION

When driving an electric current from a generator, piezoelectric

ultrasonic frequency created over the piezoceramic rings results

in deformation. In dentistry, ultrasonic frequency ranges from

24-36 kHz with the capability of cutting minimal tissues. so

movement from the deformation of piezoceramic rings sets up a

vibration in the transducer that creates ultrasonic output. These

waves are transmitted to hand piece tips and inserts have resulted

in longitudinal movements leading to cutting of bony tissues.

Transducers in the piezoelectric element convert an electrical

signal into mechanical vibration and mechanical vibrations into

electrical signals. When an electric field is applied through the

material like Quartz (SiO2) and Barium titanate (BaTiO3) will

produce an electric field once the material changes dimensions

as a result of mechanical force. This can be referred to as

electrostriction

When the water spray contacts the inserts “CAVITATION’

occurs. Cavitation is that the micro boiling development

occurs once solid and liquid interface to rupture of molecular

cohesion in liquid and look of a zone of depression, crates

and forms bubbles about to implode. In osteotomy procedure,

this phenomenon maintains smart visibility within the field of

operation by coolant as an aerosol and provides haemostasis.

Cavitation shows antibacterial properties by fragmenting

bacterial walls. For optimum use and most potency, the

operators choose the accurate power based on site by applying

minor pressure in the tips and manage the irrigation process by

preventing overheating of tissue and decreases the possibility of

injury to the soft tissues

8,9

APPLICATION OF PIEZOELECTRIC

DEVICE IN THE FIELD OF DENTISTRY

PERIODONTOLOGY

• Supragingival and subgingival scaling and root planing.

• Periodontal pocket lavage

• Crown lengthening

• Soft tissue debridement

• Resective surgeries

• Regenerative surgeries- to obtain autogenous graft for the

treatment of periodontal intrabony defects.

• Implantology:

• For harvesting bone grafts

• Recipient site preparation for implant placement

• Osteotomy procedures

• Distraction osteogenesis

• Ridge expansion procedures

• Maxillary sinus elevation procedure

SINUS FLOOR ELEVATION

The sinus floor elevation is commonly used to augment and

enhance the insufficient maxillary posterior ridge for optimal

implant placement. The piezoelectric device plays a vital key

in sinus floor elevation. Piezosurgery decreases the chance of

perforation and separation of schneiderian membrane, is much

easier during lateral wall osteotomy

RIDGE EXPANSION PROCEDURE

The ridge splitting technique is indicated when there is an

Volume No: 9, Issue No: 2

Keerthana et al: Insights of piezosurgery

adequate height of bone and inadequate ridge thickness for

the placement of implant placement. While using conventional

techniques, it may take prolonged time for second-stage surgery

for implant placement and also high risk of soft tissue injuries,

but in case of Piezosurgery, gives us better visibility and control

which prevents the damage to adjacent structures and risk of

bone thermonecrosis

12,13

BONE GRAFT HARVESTING

Piezosurgery is commonly used to harvest bone grafts (bone

chips/bone blocks) from the mandibular ramus region. This

device uses ultrasonic micro-vibration to create an osteotome

with this micro-vibration, cutting off the selective bone is quite

possible. In addition, surgical access to the deep oral cavities

can be done more precisely using piezosurgery and also lowers

the chance of damage to adjacent vital soft tissues structures

such as nerves and vessels during bone graft harvesting

IMPLANT SITE PREPARATION

Implant site healing and ultimate Osseo integration of implant

are negatively influenced by the high temperature for rotary

instrument created during the site preparation, but with the use

of piezosurgery, although the trabecular bone and osteocytes

were still intact and found implant stability is higher with

piezosurgery

DISTRACTION OSTEOGENESIS

Distraction osteogenesis is indicated when there is a need for

a significant amount of bone augmentation or lengthening or

when the soft tissue around the bone doesn’t allow for osseous

augmentation. Distraction osteogenesis with a piezoelectric

device ensures the preservation of original bone structures

which favours the healing process due to its high healing

potential

2,15

DISCUSSION

In the past decades, osteotomy and osteoplasty were the

surgical treatment modalities for the treatment of periodontitis.

Shortcomings of these procedures were, post-operative pain,

infection, bleeding, etc. so in the era of modern dentistry, a

promising technique has come into light which is referred to

as “PIEZOSURGERY” also known as “PIEZOELECTRIC

SURGERY”. The piezoelectric effect is produced when there is

electric tension on ceramic material such as Quartz that results

in ultrasonic vibration. These vibrations are carried to vibrating

tips and as a result cavitation is produced

In 2018, Daniel Isaac et al, suggested that there is slight evidence

that implant stability can be improved when osteotomy is

performed with a piezoelectric device.

Vamsi lavu et al, in 2019, gave a case report which highlights

the application of contemporary technology of piezosurgery

for crown lengthening. the insert tips used in piezosurgery not

only reduce the bone but also preserve the tooth’s root surface

integrity. Thus it is a viable option to improve the aesthetic

appearance of the patient

Cynthia et al in 2021 whose study showed that the majority

of dental professionals had good awareness, knowledge, and

attitude about piezosurgery and they understand the advantage

of using piezo over other methods

Recently, In 2022, Saurabh S Simre et al concluded about

piezo guided corticotomy was effective in providing rapid

Orthodontic Tooth Movement with a profound reduction in

total treatment time and may be proposed as a suitable adjuvant

to conventional corticotomy having comparable postoperative

complications

LIMITATIONS

The following are the common disadvantages of a

piezoelectric device, dense bone cutting can take four

times longer than with rotary, expensive, technique

sensitive, frequent tip breakage, and tips get worn

out more rapidly.

CONCLUSION

The piezoelectric technique offers advantages such

as the minimal risk of injury to soft tissue, bloodless

surgical field, comfort and precision to the surgeon,

minimal post-operative pain, and fast healing. Even

though it is precise it has quite a small limitation like

increased operating time and technique sensitivity.

With this scientific evidence, it is wise to conclude

that Piezosurgery is truly an innovative osseous

surgical technique in the field of dentistry when

compared to traditional hard and soft tissue surgical

method that uses manual and rotary instruments.

FINANCIAL SUPPORT AND

SPONSORSHIP

Nil

CONFLICTS OF INTEREST

There are no conflicts of interest.

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