Volume 5, Issue 10, October – 2020 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Piezoelectric Surgery: A Predictable and Painless

Approach in Periodontics
1. 2.
Dr. Uma Sudhakar Dr. Snophia Suresh
Professor and Head Professor
Department ofPeriodontics, Department ofPeriodontics,
Thai Moogambigai dental College Thai Moogambigai dental College
Chennai, India Chennai, India

3. 4.
Dr. C. Aruna Dr. S. Geerthigan
Undergraduate Student Undergraduate Student
Department of Periodontics, Department of Periodontics,
Thaimoogambigai Dental college, Thai Moogambigai dental College
Chennai, India Chennai, India

5.
Dr. R. Harini Priya
Undergraduate Student
Department of Periodontics
Thai Moogambigai dental College, Chennai, India

Abstract:- Dentistry, is an art in science and tranquilizer I. INTRODUCTION:

in medicine, has seen many challenging surgeries.
Procedures over years. In starting it began with using Over the last few decennary, there has been
the traditional tools. To overcome the disadvantage of expeditious development in dental surgical techniques,
the traditional tools, nowadays new device has been in simultaneously, by using hand instruments and rotary
rule such as, Piezosurgical device. It is one of the best instruments osseous surgery was performed. By using these
innovations in the modern dentistry, in periodontics it is kinds of burs, it requires external copious irrigation because
used in various applications such as bone grafting, of the heat production by these instruments. In addition to
curettage, crown lengthening, Ridge expansion, and in this pressure was also exerted in osseous surgeries. Fractures
many departments such as implantology, conservative and brittle bone also accompany with the pressure in
dentistry, oral and maxillofacial surgery. It leads to the osseous surgeries. To overcome these pressure and
safe and precise bone incision without damaging the limitations, a novel surgical technique was introduced term
associated structures. It creates the bloodless field PIEZOSURGERY, to reduce the injury occurring in
during the surgical procedures. In ostectomy and surrounding tissues. Piezosurgery was invented by professor
osteoplasty, it is widely in use. Healing process in VERCELLOTI in 1988[1]
piezosurgery is very shorter. It is safe to use for surgeons
and also creates the comfort zone to the patient. It is It is a technique of bone surgery which is gaining a
three times more powerful than the conventional major success in the dental field. It is used in the branch of
ultrasonic units. The piezosurgical device consists of a osteotomies, implantology, periodontology and many oral
novel piezoelectric ultrasonic transducer powered by an surgical procedures [2]
ultrasonic generator capable of driving a range of
resonant cutting inserts. Piezosurgery can be defined as piezosurgery plays a major role in bone surgeries and
a saw characterized by the versatility particularly in it fulfils the biological and technical criteria. Piezo surgery
perform osteoplasty and Ostectomies. This article aims is a safe method to use it does not damage the supporting
to review piezoelectric surgery and its role in and vital structures such as nerves, mucosa and vessels,
periodontics, it’s mechanism, equipment, applications, because it uses a low micro vibrations which range from 60-
ostectomy and osteoplasty tips finally advantages and 200 micro/sec, through internal irrigation mechanism it
disadvantages. removes debris, simultaneously it overcomes some
difficulties such as visibility by producing bloodless field
Keywords:- Piezosurgery, Ostectomy, Osteoplasty. during surgical procedures[3]

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Volume 5, Issue 10, October – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Nowadays piezo surgery plays a vital role because The different vibrating frequency of device is targeted
handling of delicate tissues can be performed with less risk for different action, the frequency of 25 to 29 khz can be
for the patient and it offers a new possibility to do minimally modulated with low frequency of 10hz to 70 hz and high
invasive osteotomies [4] frequency upto 30khz.Frequency <30 khz is targeted to cut
only mineralized tissue, and frequency more than 50 khz is
Piezosurgery is also called as piezo electric surgery. for cutting neurovascular and other soft tissues \Precision
Piezosurgery device is commonly an ultrasound machine cutcan be achieved with minimal pressure when using
with a correct modulatedfrequency and controlled tip with piezoelectric surgery in contrast to conventional micro-saws
vibration range [5] where high degree of pressure is required [11]

In this piezo surgery, the piezoelectric effect occurs

when the current is passed around a stack of crystals and
then it starts to vibrate at a moderate frequency. This
piezoelectric instrument produces an ultrasonic frequency
which ranges from 24 to 29KHZ [6]

The cutting characteristics of the piezosurgery mainly

depends on the pressure given, degree of mineralization, Fig 1:- Piezoelectric Instrument Design
design of insert being used and speed usage [7]
 Equipment:
II. MECHANISM OF ACTION: The first model of piezoelectric device was introduced
by Vercellotti et al [3] The principle of the device is that
“piezo” in Greek term “piezein” meaning pressure in, crystalline structure like quartz tends to change in shape
which denotes that piezoelectric device works on the when subjected to electric field, as the operating unit of
principle of” pressure electrification “that defines when piezoelectric device is between 25-50khz, crystals enclosed
electric tension is applied across certain materials, the in handpiece produces dimensional changes through passage
material expands and contracts by producing ultrasonic of electricity over the surface of crystals, producing osseous
vibrations [5]The materials that helps in performing these repair and remodeling when compared to carbide and
actions are Rochelle salts, quartz, and certain types of diamond burs [2]
ceramic [8]
The major characteristics that are essential for
The working mechanism of piezo includes it converts operating piezoelectric device is based on density of bone,
mechanical energy in the form of tension and compression design of insert, pressure of handpiece, speed of movement
into electric energy. and in addition to these, three adjustable settings frequency
of ultrasonic vibration, level of power, water spray is
Piezoelectric surgery provides certain features such as considered [7]
cavitation, heat, formation of bubbles, ultra-massage,
electric and acceleration. [7] The frequency of piezoelectric  BONE MINERALISATION (Density):
unit in which it is operated is 25-50khz.The ultrasonic The cutting efficiency of device is interrelated to level
waves can allow segmentation of interfaces from solid to of Mineralization of bone, higher the Mineralization of bone
solid by means of distinct vibration and solid -liquid by higher the setting range if frequency and vice versa in case
means of cavitation. of low mineralized bone. Frequency range for high
frequency is 30hz for cutting bone. Alternative pauses are
Piezoelectric ultrasonic frequency is created by provided for optimal cutting and prevention of lodges in
compelling an electric current from a generator over piezo- bone [7]
ceramic tings that leads to their deformation [9]
 Insert Design:
The term cavitation describes the process of Different types of design and shapes that are
vaporization, bubble formation and subsequent implosion Applicable for different procedure is tightened with the
into many fractions of its original size that occurs due to handpiece e.g. Saw-shaped insert [3]
decrease and increase in pressure as result of ultrasonic
vibration. [3]  Pressure:
Pressure exhibited by handpiece is related to bone
As the cavitation effect is attributed with anti-bacterial temperature, inserts should be moved with backwards and
efficiency, it fragments cell wall of bacteria. Thus, these forward at a high speed with minimum pressure, Depth of
phenomenon helps in ultrasonic osteotomy by dispersing about 150gms of load is essential for achieving maximum
coolantfluid which causes the blood to be washed away depth, Excessive pressure decreases oscillation and hence
thereby maintaining good visibility in operating field [10] the cutting ability [3]

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Volume 5, Issue 10, October – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
 Speed: holder and irrigating fluids of jet 0-60ml /min through
The tip of device is operated at controlled speed of 60- peristaltic pump for cooling and removal of debris. [2]
200mm/sec [14]. Decreased degree of speed is operated for
effective cutting. Speed and irrigation system are controlled  Inserts:
with + or - button on the control panel [3] The design and feature of inserts are developed by
Mectron Medical technology for different surgical needs [11]
III. PARTS OF THE INSTRUMENT:

The device unit is composed of main body and holder

for handpiece, inserts and irrigating coolant fluids

Fig 3: Insert Tips

Inserts are classified as titanium nitrate coating,

diamond coating,

 Titanium Nitrate Coating:

It is used in case of osteoplasty technique or for
harvesting bone chip. It is also advantageous because of its
cutting efficiency, Increased working life, Non-corrosive
Fig 2:- Piezosurgery Unit property [1]

 Main Body:  Diamond Coating:

The main body can be operated in various modes like These tips are very useful for operating near anatomic
root and bone modes with the electronic display. structure because it provides clinically less efficacious cut,
and safer near such structures [1]
 Root Mode:
In the root mode, the power can be opted between Classified as sharp insert tips, smooth insert tips, blunt
endo or perio modes [1] The vibration generated by selecting insert tips.
root mode are characterized by average ultrasonic power
without frequency over modulation [11] They are useful in procedure like thin bone osteotomy
or osteoplasty, preparing sinus window, elevating Schneider
 Endo Mode: membrane or lateralizing the nerve and root planning in
In this mode, transducer produces limited level of periodontics.
power as the electric tension applied is reduced, generating
insert oscillation by few microns [5]. These mechanical micro
vibrations are efficient in washing out the apical part of root
canal [11]

 Perio Mode:
Fig 4: Smooth Tips
This is the intermediate level between endo and bone
mode. The ultrasonic wave is transmitted through the
transducer in continuous sinusoidal manner characterized by
a frequency equal to the resonance frequency of insert used
[5]

 Bone Mode:
Fig 5: Sharp Tips
The vibration generated by selecting bone mode are
extremely high ultrasonic power than root mode [11] Based
on type of bone to be reduced, Quality 1 for cutting cortical
bone or high-density spongy bone. Quality 2 for cutting low
density spongy bone [5]

 Handle:
The ultrasonic waves generated by piezoceramic disks Fig 6: Blunt Tips
determines cutting actions [3]. Handpiece is provided with

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Volume 5, Issue 10, October – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
 Irrigation:  Resective Surgery:
The irrigating coolant fluids provided water spray The use of piezosurgery in periodontal surgery is very
removes debris and contributes blood free surgical area and much useful compared to the other devices because it is easy
offers great visibility in Operating field because of to handle and handling of the device is very much
cavitation effect if irrigation [3] convenient. After raising the primary flap in the resective
surgery this device makes it easier to accompany with the
IV. APPLICATION OF PIEZOSURGERY IN secondary flap and removing the inflammatory granulation
PERIODONTICS: tissue, this phase will cause a light bleeding but by using a
correct ultrasound vibration it doesn’t cause bleeding. Even
In periodontics piezo surgery is basically used in in an interproximal bone defects, with the help of the special
scaling procedures. It is also used for surgical procedures in diamond coated but it cleans very deeply. Healing is
periodontics such as osteotomy, osteoplasty, lengthening of improved very much by producing an ultrasound to provide
crown, resective surgery and regenerative surgery [3] a micropits at a base of the defect to produce a healing
mechanism [13]
Piezosurgery also used in bone harvesting procedures.
In other devices, rotating saws will cause damage to the  Ridge Expansion Procedure:
adjacent tissue structures and damage soft tissues such as For increasing the bone width and placing the implants
tongue and cheek and the incisions is more difficult in that in the narrow ridges, the horizontal alveolar ridge expansion
devices, whereas the piezosurgical devices is less sensitive is a useful procedure. For this piezosurgery is a vital key and
in nature and it does not produce damage to the adjacent useful device. Thus, playing a major role in this procedure.
tissue structures and soft tissues. The horizontal and vertical It creates a precise cutting action in it. In piezosurgical
incision is made without damaging the tissues and it creates device it has a screw or fan type expanders for increasing
a comfort zone to the patient. After the incision process in the diameter so it helps to expand the area in horizontal
piezo device it is used to remove the secondary flap. In the osteotomy procedure [13]
result of micro cauterization this device is used for debriding
the epithelial lining of the pocket wall. Piezosurgery is also  Bone Grafting:
used in sinus grafting procedures [11] By using the There are different types of ridge augmentation
piezosurgical device, it causes minimal or no trauma from procedures and a sufficient measure for this generation.
adjacent structures while doing autogenous bone graft Bone grafts result in a greater short-term cell viability and it
procedures [12] shows a new bone deposition and remodeling of the bone by
using the piezosurgery device. So, it is termed to be efficient
 Sinus Elevation: measure for bone grafting procedure. By comparing the
Perforation of membrane and surgical trauma will piezo surgical device and conventional. Piezo electric device
cause while doing sinus elevation procedures with normal shows a greater convenience because it is easy in precise
burs. So piezosurgical device is very much useful in such cutting, especially in bone grafting techniques. Piezosurgical
cases because it inserts a bur which is blunt tip, it is useful device will undergo the surgeries and remove grafts which is
in atraumatic elevation procedures such as grafting difficult to undergo surgery by many devices. In cases such
procedures. [3] as, lateral wall of the maxillary sinus. So, it is ease to handle
piezosurgical device [4]
 Scaling And Root Planing:
Cavitation removal is the process by which some  Nerve Lateralisation Procedure:
energy is required for the removal of deposits present in the Piezosurgery device is used in nerve lateralization or
teeth. And there is a MYTH believed that to remove the transposition procedure. This device has a precise cutting
calculus there has to beacontact between vibrating tip and efficiency so it is important in this procedure because, it
calculus is necessary, therefore, it is now accepted that the involves a surgery which is indicated in nerves such as
mechanical energy produced by the vibrating tip in the inferior alveolar nerve. In nerve regions an accurate
device along with the cavity is required for the deposit instrument only needed. so, piezo device is used nowadays.
removal. The piezosurgery ultrasonic scalar set is used in The piezosurgical device is invasive but very much safe
the deposit removal process. Compared to the conventional compared to other devices [1]
scalar set piezosurgical scalar set is believed to produces no
or less damage to the root surface [13]  Implant Site Preparation:
Piezosurgical device is efficient in the implant site
 Curettage: osteotomies because it only has a precise cutting efficiency
In the process of microcauterization, for debriding and microstreaming property. Because, it preserves a soft
pocket wall lining piezosurgical device is very much useful tissue. This device plays a major role in the esthetic and
and in cases of crown lenghtheing process in which bone is healing properties.While using the piezosurgical device
to be reduced, according to the patient’s convenient healing in implant site preparation will be done within two
structure to preserve a root integrity this device helps in to eight weeks compared to the usage of other devices. This
reducing into acquired size [1] device is very much effective compared with other device
because it stimulates the osteogenesis of implant, producing
osteoblastic activity around the implant sites. During the

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Volume 5, Issue 10, October – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
osseointegration process, this piezosurgical device produce a uncontrollable heat produced by this instrument it will break
potential to modify the biological events [1] or damage the tissue structures [13]

 Peri-Mucositis And Peri-Implantitis: With the piezosurgical device, the technique is

This device is used in the treatment of peri mucositis difficult to adapt and learn. It is difficult in practical
and peri implantitis procedures. After the incision of purposes. The operating time needed for bone preparation is
retained periosteum this device is used for the soft tissue increased so it will cause the pressure on patients [12]
debridement to remove the secondary flap [1]
Apart from periodontics piezosurgery is very much useful in The cutting depth is low and precision is caused due to
endodontics and oral and maxillofacial surgery. the vibrations. Intraoperative sensitivity will be caused [15]

 Advantage; It is unable to reach all the areas while doing a surgical

The main advantage of the piezosurgery is, it provides procedure. In some surgeries the additional instruments are
a supportive agent to the adjacent structuresand it also needed apart from the piezosurgical device. It causes
reduces a thermal damage to the bony surface whereas other thermal damage to the target tissues. In the applications of
devices will cause a major defect. In this procedure healing piezosurgery the duration is very much higher than the other
occurs rapidly because it does not produce any damage to devices in some surgeries. More practice time with this
the osteocytes. The design of the device is used in the areas device is needed for the clinicians [14]
where it is difficult to access. In first phase of bone healing
it becomes more efficient. Due to the reduced damage to Tip breakage will happen many times so stocking the
associated structures, it controls the inflammatory process tips is very much essential in this device. It some cases the
better than other devices. It is better than conventional device will be slow. Cutting the dense bone will take up to
therapy because remodeling occurs very much easy as 56 four times longer than with the other burs. Due to its thermal
days after the treatment [14] production the use of irrigation is very much essential to
avoid the thermal production [2]
In piezosurgery, hand pressure is less needed, easy to
access the indirect vision, and control is very much easier. The gentle touch and correct dexterity are needed with
During nerve lateralization procedures it causes less damage a different learning curve for this piezosurgical device. This
to blood vessels or no damage at all [15] device is not used in the patients with cardiopathy, metallic
crowns and uncontrolled diabetes mellitus [1]
It does not cause an emphysema risk during the
surgical procedures. Due to less hand pressure needed, the V. OSTECTOMY AND OSEOPLASTY TIPS:
control of the device is very much supportive during
surgeries, therefore the patient stress level will be reduced. By using this piezosurgical device, osteoplasty and
Compared to other devices it provides a blood free field.[5] ostectomy can be done which is used in creating positive
architecture for the pocket elimination surgery. This device
It contains a sterile coolant which provides a is used for the easy removal of bone, with no or minimal
contamination free zone. The major advantage of the risk to the underlying root surfaces and associated
surgery is, a good cutting action in a device thus it provides structures. Final step is smoothening of the root surface, it is
a good healing to the tissues [8] done using this piezosurgical device andbony margins is
done using this device with accurate ultrasonic insert, clean
while undergoing an osteotomy procedure field is done with the ideal bony architecture which is ready
piezosurgical device is the best device because it provides for flap closure [9]
good visibility to access. Due to its less invasive procedure
it provides a reduced post intervention pain. Compared to By using the SHARP INSERT TIPS in the piezo
other devices this device produces a less sound and it device, the ostectomy and osteoplasty can be done in cases
produces only micro vibrations during surgeries. This such as where fine and well-defined cutting of the bone is
piezosurgical device provides a highest efficiency when required. For precise and controlled cutting effect during the
applying a load of 0.5 kg. This device is three times more ostectomy procedure, the SMOOTHING INSERT TIPS is
powerful than the other devices. Due to this advantage of used. According to the basic surgical technique like
piezosurgery the psychological fear and stress is reduced to ostectomy and osteoplasty the clinical classification includes
the patients [13] the inserts such as sharp and smoothing tips. In ostectomy
(OT)-OT1-OT2-OT3-OT4-OT5-OT6-OT7-OT74-
 Disadvantage; OT7S3-OT8R/L is used and in osteoplasty (OP)-OP1-
The main disadvantage of the piezoelectric device is OP2-OP3-OP4-OP5-OP6-OP7 is used. The inserts used in
its increase in operating time when compared with the other the techniques of ostectomy and osteoplasty is used in the
traditional cutting instruments. This device is not used in the combination with each other for different surgical protocol.
pacemaker patients. In the deeper osteotome procedures it is Piezoelectrical devices is a safe and protective method in the
difficult with the piezosurgery device, as the increasing techniques such as ostectomy and osteoplasty compared
pressure while doing the procedure this pressure turns into with the other methods which uses a rotating instrument
heat. So, it is the major drawback in this device. By the because of the absence of macro vibrations [14] Nowadays

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Volume 5, Issue 10, October – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
piezosurgical device is used widely in the osteoplasty and VII. CONCLUSION:
ostectomy procedures. The morphological characteristics of
the ostectomy and osteoplasty is mainly depending on the Piezosurgical device is a safe, effective and precise to
tips and unit used in that procedure. [4] work on the tissues of bone. It is easy to handle by the
clinicians and due to the less damage to the associated
structure it gives comfort zone to the patient. In surgical
field it gives better visualization. Soft tissues were protected
using this piezosurgical device. The success rate in surgeries
is high using this device, as well as the prevention average
of the post operatory complications, without the increase of
the trans operatory surgery time.

Ostectomies and osteoplasties can be done without

much difficulties using this piezo device. Although there is a
great deal in the scientific research focuses on new products
Fig 7:- Osteotomy Insert Tips for tissue engineering and bone regeneration. The
importance of the minimal surgical trauma for bone healing
VI. DISCUSSION: is difficulty now a days. Piezosurgery is an innovative
ultrasonic technique which is much effective compared with
Piezosurgery is considered to be a great and safety the other soft tissue methods and traditional hard tissue
method in the bone surgery compared to the manual and methods that use rotating instruments because of the
motorized instruments. Piezosurgery device allows precise absence of macro vibrations. Piezosurgical device has the
cuts during osteotomy procedure. Piezosurgery device gives physical and mechanical properties such as sparing of vital,
the best result in the bone healing process. Piezosurgical neurovascular bundles and so, this device and this procedure
device helps in the bone saving in osteotomy sites. By using used by this device should be considered in the everyday
this device, blood loss during the surgeries can be reduced life.
by 25-30% due to the best visibility. The micrometric
vibration of tips is highly useful in the osteotomy procedures Piezosurgery ensures three P’s in it they are,
[16]
PREDICTABILITY, LESS POSTOPERATIVE PAIN,
AND INCREASED PATIENTS COMPLIANCE.
Piezosurgery reduces edema, pain, ecchymosis and Piezosurgical device is much effective in operative sensitive
Haemorrhage after the surgery and it increases the cases. In periodontics this device is used in various
satisfaction of the patient. Piezosurgery does not cause soft techniques such as, scaling and root planning, sinus
tissue injury. In postoperative period it was accompanied elevation, Bone Grafting, Ridge Expansion procedure,
with the less hemorrhage and ecchymosis [17] Nerve Laterization procedure, resective surgery, etc. Apart
from periodontics, this piezosurgical device is used in
This technology counts on the irrigating system coped various platforms such as oral medicine, oral and
with the handpiece, it prevents the borders of the osteotomy. maxillofacial surgery, conservative dentistry and
This, avoiding the periodontal injuries on the tissues. During prosthodontics.
the osteotomy procedures it has a low rate of bleeding. The
contraindications of the device are pacemaker patients and REFERENCES
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