|Year : 2021 | Volume
| Issue : 2 | Page : 60-66
Piezosurgery – a sanctifying invention for osseous surgeries in periodontics and implant dentistry
Department of Periodontology, Sri Ramakrishna Dental College and Hospital, Coimbatore, Tamil Nadu, India
|Date of Submission||07-Sep-2020|
|Date of Decision||10-Jun-2021|
|Date of Acceptance||12-Jul-2021|
|Date of Web Publication||15-Sep-2021|
MDS, MBA Rajendran Poornima
Department of Periodontology, Sri Ramakrishna Dental College and Hospital, Coimbatore, 641 006, Tamil Nadu
Source of Support: None, Conflict of Interest: None
The use of various hard tissue cutting instruments like micromotors and carbide burs pose a certain disadvantage such as excessive heat generation, smear layer formation, difficulty in controlling the bleeding of the operating field, etc. These disadvantages not only increase the intraoperative time but also affects the overall prognosis of the treatment. At present, the use of power ultrasonics has gained popularity over conventional techniques for procedures involving hard tissues. It overcomes the various disadvantages of traditional instruments as well as provides increased precision, protection of both soft and hard tissues as well as hastens the healing after osseous surgeries. The present review article aims to highlight the impact created by the piezoelectric devices in various dental procedures, specifically periodontal and implant related therapies, its mechanism of action and the advantages over conventional osseous surgeries.
Keywords: implant therapy, osseous surgeries, piezosurgery
|How to cite this article:|
Poornima R. Piezosurgery – a sanctifying invention for osseous surgeries in periodontics and implant dentistry. Tanta Dent J 2021;18:60-6
|How to cite this URL:|
Poornima R. Piezosurgery – a sanctifying invention for osseous surgeries in periodontics and implant dentistry. Tanta Dent J [serial online] 2021 [cited 2021 Oct 19];18:60-6. Available from: http://www.tmj.eg.net/text.asp?2021/18/2/60/326039
| Introduction|| |
Ultrasound has been used for decades in the field of medicine and dentistry to cut the hard tissue . Until a few years ago, ultrasonic dental instruments were exclusively utilized to remove calculus on teeth through the vibrational movements of resonant inserts driven by magnetostrictive or piezoelectric ultrasonic transducers . In the 1980s, use of devices employing ultrasonic were well known for odontostomatologic surgery. The first attempt at using ultrasonic equipment in bone surgery showed good results in the cutting phase, but was not strong enough for performing osteotomy in the presence of highly mineralized bone or when the bone was thicker than 1 mm. Repeated application of these instruments did effect a cut, but was associated with an excessive increase in temperature including the risk of subsequent bone necrosis .
Use of micromotors could be very dangerous in close proximity to delicate anatomical structures such as vessels and nerves. Also the traditional motorized instruments generate macrovibrations which reduce the surgical safety. Therefore, in the last decade, a novel family of power ultrasonic devices has been successfully created to dissect hard tissue in various maxillofacial operations. This revolutionary surgical technique, known as piezosurgery was invented by Professor Vercellotti in 1998 and the article was published in the year 2000 . The piezosurgery device consists of a novel piezoelectric ultrasonic transducer powered by an ultrasonic generator capable of driving a range of resonant cutting inserts. This innovative device provides higher level of precision, safety and rapidity in recovery after bone surgery.
The cutting action of the piezoelectric drill is the result of linear microvibrations of an ultrasound nature with a range of only 60–200 μm in a longitudinal direction with control of surgical procedures in all anatomical situations. Thus piezosurgery can be simply stated as an equipment that comprises the versatility of a drill, particularly in performing curvilinear osteotomies .
The present article aims to review the use of piezosurgery in periodontics and implantology, its mechanism of action, the instrument, its biologic effects on the bone and its applications.
| Mechanism|| |
Jacques and Pierre Curie in 19th century introduced the concept of using microvibrations to achieve bone cutting . Decades later, these microvibrations, elicited by ultrasonic waves were then utilized in various field including medicine and dentistry.
The ultrasonic frequency, as the name implies, is a frequency above the audible range for humans, usually above 20 kHz. In dental applications the frequency range capable of cutting mineralized ranges from 24 to 36 kHz. With piezoelectric ultrasonics, the frequency is created by driving an electric current from a generator over piezoceramic rings, which leads to their deformation. The resulting movement from the deformation of the ring sets up a vibration in a transducer and/or amplifier, which creates the ultrasound output. These waves are then transmitted to the handpiece tip, also called an insert, where their longitudinal movement results in cutting of osseous tissue by microscopic shattering of the bone .
The conversion of electrical pulses to mechanical vibrations and the conversion of returned mechanical vibrations back into electrical energy is the basis for ultrasonic testing. The active element is the heart of the transducer as it converts the electrical energy to acoustic energy, and vice versa . The active element is basically a piece of polarized material (i.e., some parts of the molecule are positively charged, while other parts of the molecule are negatively charged) with electrodes attached to two of its opposite faces. When an electric field is applied across the material, the polarized molecules will align themselves with the electric field, resulting in induced dipoles within the molecular or crystal structure of the material. This alignment of molecules will cause the material to change dimensions. This phenomenon is known as electrostriction . In addition, a permanently polarized material such as quartz (SiO2) or barium titanate (BaTiO3) will produce an electric field when the material changes dimensions as a result of an imposed mechanical force. This phenomenon is known as the piezoelectric effect.
Subsequent to piezoelectric effect, cavitation occurs. Cavitation is a phenomenon occurring in liquids on any solid–liquid interface vibrating to an intermediate frequency. It corresponds to a rupture of the molecular cohesion in liquids and the appearance of zones of depression that fill up with vapor until they form bubbles that are about to implode .
| Instruments|| |
The equipment consists of a piezoelectric handpiece and a footswitch that are connected to the main unit, which supplies power and has holder for handpiece and irrigation fluids. The main unit comprises a platform (with a control panel that has a digital display and a keypad). This piezoelectric device (PED) is with a functional frequency of 25–29 kHz and the possibility of 30 Hz digital modulation. It also comprises a series of inserts of different forms with a linear vibration ranging from 60 to 200 μm. To complete the system, a peristaltic pump that irrigates any physiological solution such as saline is present. The peristaltic pump is for cooling with a jet of solution that is discharged from the insert with an adjustable flow of 0–60 ml/min and removes detritus from the cutting area. For cooling effect, the solution is refrigerated at 4°C. The power of the device is 5 W (ultrasonic scaler 2 W) .
Each part of the instrument is described below.
The piezosurgery unit is controlled solely by means of an interactive keyboard. Each command is shown on an easy-to-read display. There are two basic programs, BONE and ROOT. In the BONE program, it is possible to adapt the power to any of four levels depending upon bone quality. In the ROOT program, the power can be set to either PERIO or ENDO.
It has an automatic feedback system for constant control of the power of the ultrasounds, which can be adjusted in case of need. With this system, any interference present in the unit, in the handpiece or in the electronics are recognized and highlighted on the display. The CLEAN function is activated by pressing a button and the footswitch together to start the cleaning cycle of the unit's main tubes.
The surgical tray
The surgical tray contains all the components necessary for surgery utilizing the piezosurgery system.
The dynamometric wrench
The insert tips are tightened to the handpiece with the dynamometric wrench. The wrench applies a predefined force to obtain optimum energy transmission.
Liquid is drawn from a bag or bottle which hangs from the rod provided. All parts of the unit through which the liquid passes, including the handpiece cord and the handpiece itself, are fully sterilizable.
The peristaltic pump
The sterile tube is simply inserted into the pump which is then closed. The quantity of liquid may be adjusted using the continuous + and – buttons. The peristaltic pump is for cooling with jet of solution that discharges from the insert with an adjustable flow of 0–60 ml/min and removes detritus from cutting area. For cooling effect, the solution is refrigerated at 4°C.
The handpiece is connected permanently to the handpiece cord and the two are sterilized together. Each Piezosurgery unit comes with two handpieces. From a clinical point of view, the piezosurgery system offers three different power levels:
- Low mode indicated for apical endocanal cleaning, in orthodontic surgery.
- High mode, useful for cleaning and smoothing the radicular surface.
- Boosted mode, indicated in bone surgery, necessary in performing osteotomy and osteoplasty.
This modality of work is further divided into a, b, c, according to the modulation of the correct frequency for the quality of the bone that is to be treated. The ultrasonic bone surgery device differs from conventional tools by four parameters such as the generator frequencies, and insert's weight, hardness and form. Also, it is made of a generator of intermediate frequencies.
The generator is composed of three settings in frequency:
- The first setting passes on 29 000 Hz frequencies to the insert, enabling conventional detartrating when used with adequate inserts.
- The second setting uses 29 000 Hz modulated in 50 000 Hz every 30 ns to get a moderate cut effect. It remains insufficient for bone surgery, but is an excellent compromise for periodontal surgery.
- The third setting uses 29 000 Hz frequencies modulated in 50 000 Hz every 10 ns to obtain maximum cut effect. This setting is most interesting for us as it enables us to have a maximum resonance between piezoelectric chips of shaft and the inserts of corresponding weight. This allows for a maximum energetic output and optimum cut efficiency.
Inserts used are those whose vibrations can enter in resonance with the piezoelectric ceramic chips of the shaft. This resonance enables us to increase the energetic output, making the insert more efficient. Classification of inserts is provided in [Table 1].
| Clinical characteristics of ultrasonic cutting|| |
The primary clinical characteristics of the piezosurgery cutting action include microprecision, selective cutting, maximum visibility, and excellent healing.
Piezosurgery cuts mineralized tissues with microprecision. The cut is made by mechanical microvibrations at a linear range of about 80 μm and a frequency of 30 000 times a second. A sound wave is over modulated on this base frequency, which in turn generates a hammering action . During this process, very little heat is produced because the mechanical energy necessary to produce the microvibrations is very low. This action, along with the water spray, facilitates removal of bone debris. Piezoelectric osteotomies are easy to create, but it is important to recognize that the technique and instrument handling are different than the technique using a traditional handpiece with rotary instruments .
The piezosurgery insert is applied to the bone with a relatively light stroke similar to the smooth precision that is used to draw a picture. Heavy pressure or force is not required. Indeed, the pressure applied by the surgeon to the piezosurgery handpiece is much lower than the pressure typically applied to a rotary or oscillating type handpiece, which uses mechanical macrovibrations for cutting. This characteristic provides maximum control during surgery and makes this technique unique especially in areas with delicate anatomy .
Piezosurgery microvibrations are low frequency and selective for cutting mineralized tissue only. These microvibrations are physically unable to cut soft tissue. Clearly, the most significant benefit of this selective cutting property is the ability to preserve the integrity of soft tissues, such as the alveolar nerve, the infraorbital nerve, the maxillary sinus membrane, and the dura mater, while effectively cutting the mineralized tissue (bone) in close proximity to these tissues .
Piezosurgery creates a surgical field that is blood free during cutting because of its cavitation effect. Cavitation is a physical phenomenon that, from a clinical standpoint that happens with the nebulization of the saline solution. The slight hydro-pneumatic pressure applied by piezosurgery temporarily stops the bleeding from both hard and soft tissues . It is important for the liquid pump to be flowing properly and for the cutting action to be intermittent to maintain optimal surface microcirculation, especially for long surgical procedures. Tissue perfusion resumes shortly after cutting (and cavitation action) is stopped .
Postoperative healing after piezoelectric bone surgery is characterized by minimal swelling and little bleeding. Furthermore, postoperative morbidity is lower compared to traditional techniques .
| Piezoelectric inserts|| |
The cutting effect of the PEDs is delivered through various inserts. These inserts are specifically devised for various purposes in dentistry including periodontal and implant therapy needs.
Various insert tips used for different purposes are enlisted in [Table 2] and [Table 3].
|Table 2 Piezosurgery inserts used in various augmentation procedures and dental extraction|
Click here to view
|Table 3 Piezosurgery inserts used in various periodontal and implant procedures|
Click here to view
| Applications|| |
Soft tissue applications of piezosurgery devices
Ultrasonic instrument uses high frequency mechanical energy to offer the surgeon controlled and precise incision as well as hemostasis. The machine operates at 55 500 Hz and requires less energy than diathermy and laser. The instrument tip vibrates at amplitude of 50–100 μm. Vessels up to 2 mm in diameter may be sealed by cooptation with the blade before division. No special training or precautions are required before using the self-cleansing device. It produces considerably less smoke or smell than either diathermy or laser, which reduces the need for instrument exchanges or smoke evacuation. Resterilization of the harmonic scalpel will allow it to be used on any number of patients and appreciably reduce the procedure related expenses after initial outlay .
Hard tissue applications of piezosurgery devices are listed in [Table 4].
The use of piezosurgery in periodontal surgery simplifies and improves handling of soft and hard tissues . In resective periodontal surgery, for example, after raising the primary flap using a scaler-shaped insert (PS2) or an insert in the shape of a rounded scalpel (OP3) makes it easier to detach the secondary flap and remove inflammatory granulation tissue. This phase has little bleeding as the result of the cavitation of the saline solution (coolant). With the right inserts and power mode, the ultrasonic device facilitates effective scaling, debridement, and root planing. In particular, debridement with a special diamond-coated insert enables thorough cleaning even for interproximal bone defects .
The mechanical action of ultrasonic microvibrations, together with cavitation of the irrigation fluid eliminates bacteria, toxins, dead cells and debris, which creates a clean physiology for healing. Healing is improved by applying ultrasound to produce micropits at the base of the defect that activates cellular response of healing mechanisms. The result is that this technology reduces the invasiveness of traditional surgery by making the surgery faster and by ensuring thorough cleaning of the periodontium. It also favors tissue healing by utilizing bone removed in the osteoplasty procedure to graft osseous defects .
Moreover, the ability to work on the bone defect with magnifying systems makes it possible to exploit the benefits of piezosurgery microprecision in preparing the recipient site and stabilizing micrografts.
Crown lengthening with osseous reduction
Clinical crown lengthening is the most common periodontal surgical operation performed in otherwise healthy periodontium. The indication for this procedure is usually associated with a need or desire to expose more tooth structure because of short clinical crowns and/or loss of clinical tooth structure. The clinical crown lengthening technique entails performing a periradicular ostectomy of a few millimeters, which allows repositioning of the periodontal flap in a more apical position. The positive result obtained is that the health of the treated part is preserved even though the normal gingival morphology is altered .
The ostectomy is simple to perform using piezosurgery because control of the instrument during surgery is precise, even in very difficult proximity cases (piezosurgery OP3 insert). The root planing phase can be performed very effectively using blunt ultrasonic inserts (PP1 insert). Saline solution cavitation reduces bleeding during surgery and facilitates debridement of the surgical area. This effect is responsible for the excellent soft tissue healing which is always characterized by a light color and absence of edema. Furthermore, it is possible to effectively reduce the bone level while preserving root surface integrity.
Implant site preparation
Special piezosurgery inserts developed for bone perforation have enabled the development of a new technique for ultrasonic implant site preparation (UISP). The first advantage of UISP is related to the cutting characteristics of piezosurgery, which facilitate differential preparation of the cortical and cancellous bone.
The differential implant site preparation (DISP) technique can be used within the initial osteotomy site to correct the implant axis by selectively directing the cutting action in the desired direction . DISP can also be used in combination with twist drills to facilitate preservation of alveolar crestal bone while achieving maximum primary stability .
The second advantage of UISP is the fast clinical healing of both soft and hard tissue. The improved healing response observed at piezoelectric bone surgery-treated sites (compared to sites prepared with traditional drills) may be explained by differences in the level of bone morphogenetic proteins (BMPs), growth factors, and cytokines. It is assumed that the micronization of the bone reduces cut trauma while saline solution cavitation produces debridement of the osteotomy surfaces. This allows the preservation of a high number of BMPs and growth factors. These proteins are capable of increasing the mitosis of stromal stem cells and osteoblasts .
Sinus lift preparation
Approaches to sinus lift techniques typically involve the use of a lateral window or crestal osteotomy. The traditional technique using a high-speed rotary bur to remove bone runs a high risk of damaging the Schneiderian membrane, which often results in membrane perforation (∼14–56% incidence) ,. The surgical technique entails a lateral window osteotomy that traces the frame of the bony window, which is then removed. Lateral window osteotomy outline is created using a piezosurgery diamond-coated scalpel – OT1. Separation of the membrane from the inner wall is made using an inverted cone insert such as EL1 detaches the membrane around the perimeter of the bony window. This reduces membrane tension facilitating the separation and lifting of the membrane with piezoelectric or manual instruments. Once completely elevated, bone augmentation material is inserted and packed. The bony window is then closed with a collagen membrane.
Piezosurgery simplifies the sinus lift technique and increases the predictability due to its selective cutting action, which enables surgeons to maintain membrane integrity. This has resulted in a considerable reduction in patient morbidity in maxillary sinus surgery .
Horizontal alveolar ridge expansion is an extremely useful technique for increasing bone width and simultaneously placing implants in narrow ridges. The great advantage is that both augmentation and implant placement are accomplished in one surgical procedure. A possible disadvantage is that crestal bone loss may be greater in cases that begin with very narrow ridges. Piezosurgery is an indispensable tool used to create a horizontal osteotomy on the alveolar bone crest because of its precise cutting action .
The horizontal osteotomy is expanded in subsequent steps using piezoelectric inserts for ISP together with screw-type or fan-type expanders for increasing the diameter or section, respectively . Expanding a narrow ridge by the entire width for the planned implants may be challenging because of the density of cortical bone and limited elasticity. The need to expand or displace the buccal cortical bone can be reduced with rigorous application of DISP to the lingual cortical bone, which is generally thicker than the buccal cortical bone. DISP can be done using OT4 after the initial implant preparation with IM1. This is difficult to do with traditional twist drills because they cannot limit cutting to one side and tend to get displaced by areas of dense bone into areas of loose or missing bone. In fact, attempting to prepare the site with traditional drills can fracture the weaker, inelastic buccal cortical bone, making simultaneous implant placement impossible.
| Biological effects on bone cut by piezoelectric device|| |
The effect of mechanical instrument on structure of bone and viability of cells is important in regenerative surgery. Its effect on the cortical and cancellous bone and the surface roughness produced by different osteotomy techniques all have a strong biological effect on the bone and healing of the bone.
A PED vibrating in the ultrasonic frequency range was investigated in a study for its potential use in periodontal resective therapy. The rate of postoperative wound in a dog model following surgical ostectomy and osteoplasty was the marker used to compare the efficacy of this instrument (PED) with a commonly used carbide bur or a diamond bur. The results suggested that PED provided more favorable osseous repair and remodeling than carbide bur or diamond bur when surgical ostectomy and osteoplasty procedures were performed. Therefore, PED could be considered efficacious for the use in osseous surgery .
A study used biomolecular and histologic analyses to compare the osseintegration of porous implants positioned using traditional drills verses the piezoelectric bone surgery technique. Porous titanium implants were inserted into mini-pig tibias. Histomorphology and levels of BMP-4, transforming growth factor-β2, tumor necrosis factor-alpha, interleukin-1β, and interleukin-10 were evaluated in peri-implant osseous samples. Histomorphological analyses demonstrated that more inflammatory cells were present in samples from drilled sites. Also, neo-osteogenesis was consistently more active in bone samples from the implant sites that were prepared using piezoelectric bone surgery. It was also noted that bone around the implants treated with piezoelectric surgery technique showed an earlier increase in BMP-4 and transforming growth factor-β2 proteins as well as a reduction in proinflammatory cytokines .
Systematic review and meta-analysis in 2018 suggested that PED seem to be a feasible substitute to traditional drilling techniques for ISP . The only disadvantage noted was prolonged operating time associated with the use of PEDs, but both techniques were comparable in terms of the marginal bone level changes and the risk of implant failure. The satisfactory effect on the implant stability pattern associated to the use of PEDs on the certainty of immediate and early loading protocols has to be confirmed in future long term studies.
| Conclusion|| |
Piezoelectric surgery is the current and future trend for osseous surgeries pertaining to all fields of dentistry. In periodontics and implant dentistry, there are enough and more of evidence that suggests that piezosurgery not only aids in faster healing, but also improves the chances of achieving complete periodontal regeneration which is the ultimate goal of periodontal therapy.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]