Original Article

Piezo-osteotomy in orthognathic surgery: A comparative

clinical study
ABSTRACT
Background: After the clinical introduction of ultrasound scalpel in recent years, piezosurgery has become competitive with conventional
instruments in orthognathic procedures to reduce the operative and postoperative complications reported to occur in association with these
surgeries.
Aims: The aim of this prospective clinical study was to compare intraoperative and postoperative outcomes of both piezoelectric device and
the traditional bur technique in orthognathic surgery. Intraoperative bleeding time, operative time, postoperative swelling, and neurological
impairment were evaluated.
Materials and Methods: In this study, a split‑mouth technique was applied on ten patients requiring orthognathic surgery. To make the
osteotomy cuts, on the one side, piezo‑osteotome was used, and on the other side, conventional osteotomy bur was used.
Results: Duration of osteotomy was found to be greater with piezo osteotomy compared to bur osteotomy. Mild bleeding was observed with
piezosurgery. Postoperative swelling was greater on the side of piezosurgery compared to the bur side. Altered neurosensory activity was
found to be equal on the 1st day postoperatively, but the piezo side recovered faster compared to the bur side in the 1st month after surgery.
Conclusion: Piezoelectric device offers better advantages over the conventional bur in orthognathic surgery and hence can be considered
an alternative to the bur in some orthognathic procedures.

Keywords: Bilateral sagittal split osteotomy, jaw osteotomies, nerve impairment, orthognathic surgery, piezosurgery,
ultrasonic device

INTRODUCTION materials like quartz and Rochelle salts, it causes the materials
to expand and contract producing ultrasonic vibrations. This
In orthognathic surgeries, osteotomies are performed in close device uses ultrasonic vibration at 60–210 µm/s at 24–29 kHz
relationship with delicate anatomic structures. Saws, burs, to selectively remove the bone with minimum damage to the
and chisels are traditionally used for cutting bones. Although soft tissues such as blood vessels and nerves. In addition,
these instruments are highly effective, they can cause damage it provides excellent visibility due to its cavitation effect.[3‑6]
to the adjacent soft tissues and nerves. These rotating
instruments can be potentially injurious as the production of Harshitha Raj, Madhumati Singh,
Anjan Kumar Shah
excessively high temperatures can impair bone regeneration
Department of Oral and Maxillofacial Surgery, Rajarajeshwari
and result in bone necrosis.[1,2] Dental College and Hospital, Bengaluru, Karnataka, India

The need for less invasive surgery and greater precision Address for correspondence: Dr. Harshitha Raj,
No. 14, Ramohalli Cross, Mysore Road, Kumbalgodu,
compared to standard bur and saw encouraged the Bengaluru ‑ 560 074, Karnataka, India.
development of piezosurgery. Invented by Tomasso E‑mail: harshitha256@gmail.com

Vercelloti, piezosurgery works on the principle of “pressure Received: 13 April 2021, Revised: 24 July 2021,
Accepted: 13 September 2021, Published: 15 June 2022
electrification.” When electric tension is applied to certain

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DOI:
How to cite this article: Raj H, Singh M, Shah AK. Piezo-osteotomy in
10.4103/njms.njms_357_21 orthognathic surgery: A comparative clinical study. Natl J Maxillofac Surg
2022;13:276-82.

276 © 2022 National Journal of Maxillofacial Surgery | Published by Wolters Kluwer - Medknow
 Raj, et al.: Piezo v/s conventional bur technique in orthognathic surgery

Due to these benefits, piezosurgery has been become an The following parameters were used to evaluate the subjects
alternative tool and is increasingly used in orthognathic in the study:
surgeries.
Intraoperative assessment
This prospective study aims to evaluate the effects of • Bleeding during surgery was evaluated based on a
piezoelectric surgery compared to conventional burs in visual guide by Ali Algadiem et al.[7] which was created
orthognathic surgery. The objective of this study is to assess to aid the estimation of blood absorbed by gauze at
intraoperative bleeding, compare the operative time taken different percentages of calculation. The amount of
for piezotome and bur, and evaluate postoperative swelling blood loss in milliliter was correlated as mild (<500 ml),
and neurological impairment. moderate (500–1000 ml), and severe (>1000 ml)
• Surgical duration time was calculated in minutes from
MATERIALS AND METHODS the start of each osteotomy cut until the end of the
osteotomy with either piezo‑osteotome or conventional
The clinical study was conducted on a total of ten patients bur on the respective sides, and the mean was calculated.
who required orthognathic surgery. In this study, a standard
split‑mouth model was used. On the one side, piezo‑osteotome Postoperative assessment
was used, and on the contralateral side, conventional bur was • Postoperatively patients were evaluated on day 1,
used to make the osteotomy cuts. Each was randomly assigned 1 week, and 1 month
to the left or right side. All the surgeries were carried out • Postoperative facial swelling was assessed on day 1 and
by the same surgeon. Ethical clearance was obtained by the week 1 after surgery and using a modification of the
ethical committee before the commencement of the study. tape measure method by Gabka and Matsumura. In this
The patients were selected based on specific inclusion and method, linear distances were taken from the corner of
exclusion criteria. Ethical Clearance was obtained from Ethical the eye to the angle of the mandible (S1), from the tragus
Committee of Rajarajeshwari Dental College and Hospital of the ear to the corner of the mouth (S2), and the tragus
dated 27/11/2018 with Ref No: RRDCET/02OS/2018. of the ear to the soft‑tissue pogonion (S3). The sum of
these sizes was calculated as the facial dimension and
Patients between 16 and 40 years with skeletal dysmorphia used to measure the swelling level on the side of the bur
requiring orthognathic surgery were included in the and piezo
study. Skeletally immature patients, pregnant patients, • Nerve impairment was checked with pin pressure,
and medically compromised patients were excluded from brush directional discrimination, and static light touch.
the study. Prior to surgery, necessary consent was taken The patients were explained about the tests before
from the patients, which explained the procedure and performing them. The patients were told to relax,
any complications arising due to surgery. A detailed case close their eyelids, and sit in a semi‑reclining position.
history was recorded. General physical examination, routine The right and left sides were examined separately on the
hematological investigations, and preoperative radiographs lips, chin, upper lip, and cheeks. The patients were asked
such as lateral cephalograms, computed tomography (CT) to evaluate sensory recovery, and the grade of response
facial skeleton, and cone‑beam computed tomography were is shown as Grade 1 – absent sensation and anesthesia,
done. Preoperative orthodontic treatment, if needed, was Grade 2 – severely altered sensation and paresthesia,
performed for the correction of dental decompensation, Grade 3 – moderately altered or slightly reduced
which enabled occlusion coordination of both dental arches.
Following this, patients were operated under general
anesthesia with nasal intubation. For both maxillary and
mandibular osteotomies, following surgical exposure,
conventional osteotomy bur [Figure 1] was used to give the
osteotomy cut on the one side and piezo unit [Figure 2] was
used to give osteotomy cut on the other side.

Postoperatively as a standard protocol, antimicrobials such

as cefotaxime, metronidazole, and paracetamol as analgesics
were administered to the patients. Injection dexamethasone
8 mg was administered in tapering doses only during the
postoperative period for a maximum of 4 days. Figure 1: Conventional osteotome device (NSK)

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 Raj, et al.: Piezo v/s conventional bur technique in orthognathic surgery

sensation, Grade 4 – mildly reduced or subnormal 13.28 min (<0.001) [Figure 3]. Out of ten patients, three
sensation, and Grade 5 – normal sensation. patients had mild bleeding on the bur side and seven patients
had moderate bleeding. On the piezo side, eight patients
Statistical analysis had mild bleeding and only two patients had moderate
Statistical Package for Social Sciences (SPSS) for Windows, bleeding (P = 0.07) [Figure 4].
Version 22.0 Released 2013 (Armonk, NY: IBM Corp.) was
used to perform statistical analyses. Independent Student’s Postoperative paresthesia was assessed on day 1, week
t test was used to compare the mean scores for blood loss 1, and 1 month after surgery. On day 1, on the bur side,
and operative time between the piezo osteotomy and three patients were evaluated as Grade 2 and seven
bur osteotomy. Chi‑square/Fisher’s exact test was used to patients as Grade 3, whereas on the piezo side, four
compare the postoperative swelling and nerve impairment patients were assessed with Grade 3 and six patients
between the two groups at different time intervals. The with Grade 4 (P = 0.007). After 1 week postoperatively,
results were analysed by descriptive and analytic statistics. on the bur side, five patients were evaluated as Grade 3
A value of P < 0.05 was considered to be significant. and five patients as Grade 4. On the piezo side, four
patients were assessed with Grade 4 and six patients with
RESULTS Grade 5 (P = 0.004). After 1 month, it was observed that
on the bur side, five patients were evaluated as Grade 5,
A total of ten patients between the age groups of 16 and three patients as Grade 4, and two patients as Grade 3. On
40 years who required orthognathic surgery were included the piezo side, all ten (100%) patients were evaluated as
in the study [Table 1]. Out of the ten study participants, Grade 5 normal sensation (P = 0.04) [Figure 5]. Two patients
four were female and six were male. The mean age of the who underwent bimaxillary procedure and intraoral
participants was 20.40. Intraoperative clinical parameters
included in the study were the duration of osteotomy and
blood loss on each side. The postoperative parameters were
nerve impairment and swelling.

The mean duration of osteotomy with bur was 8.62 min,

whereas the mean duration with piezo‑osteotome is

Figure 3: Intraoperative duration of osteotomy comparing with bur and

Figure 2: Piezotome device, handpiece, and burs (Acteon) piezotome

Table 1: Clinical features and procedures performed

Case Age Gender Facial skeletal deformity Procedure Jaw Bur Piezo
1 19 Female Skeletal class II LeFort I with 5‑mm advancement and genioplasty Maxilla Right Left
2 18 Female Skeletal class II LeFort I with 5 mm with advancement genioplasty Maxilla Right Left
3 17 Male Maxillary hypoplasia LeFort I with 3‑mm posterior impaction Maxilla Left Right
4 17 Male Mandibular prognathism BSSO with 10‑mm setback Mandible Left Right
5 20 Male Mandibular prognathism IVRO with 10‑mm setback Mandible Left Right
6 29 Female Skeletal class III with maxillary hypoplasia BSSO with 8‑mm setback and genioplasty Mandible Right Left
7 20 Male Skeletal class III BSSO with 9‑mm setback Mandible Right Left
8 20 Male Maxillary hypoplasia LeFort 1 with 5‑mm advancement Maxilla Right Left
9 25 Female Skeletal class III BSSO with 6‑mm setback Mandible Left Right
10 19 Male Mandibular retrognathism BSSO with 7‑mm advancement Mandible Right Left
BSSO: Bilateral sagittal split osteotomy, IVRO: Intraoral vertical split osteotomy

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 Raj, et al.: Piezo v/s conventional bur technique in orthognathic surgery

vertical split osteotomy, respectively [Figures 6 and 7], During piezo‑osteotomy, the cut design was assessed,
had continued paresthesia up to 1 month after surgery which showed precise and neat cut edges compared to the
on the bur side. ragged and uneven edges with bur osteotomy [Figure 6].
The accurate cuts can be appreciated when piezotome
Postoperative swelling was measured on day 1 and was used for genioplasty along with bilateral sagittal split
1 week postoperatively. On postoperative day 1, the mean osteotomy (BSSO) in a case of skeletal class III [Figure 10].
measurement of swelling on the bur side was 12.78 cm,
whereas on the piezo side, it was 12.55 cm (P = 0.36). On the DISCUSSION
1st week after surgery, the mean measurement of swelling was
The increasing trend for minimally invasive surgery with
11.87 cm, and on the piezo side, it was 11.83 cm (P = 0.93)
more precision encouraged the development of piezoelectric
[Figure 8]. In most cases, mild swelling was observed on the
bur side for 1 week postoperatively [Figure 9].

Figure 5: Mean of paresthesia grading and recovery observed over the

Figure 4: Intraoperative blood loss between bur and piezo side follow‑up period

a b c

d e

f g h
Figure 6: Case of maxillary hypoplasia with mandibular prognathism. (a) Preoperative picture. (b) Procedure planned – 3‑mm maxillary advancement with
LeFort 1 and 10‑mm setback with bilateral sagittal split osteotomy. (c) Piezo‑osteotomy on the right side. (d) Bur osteotomy on the left side. (e) LeFort 1
osteotomy with piezo on the right and with bur on the left. (e) 3D printed orthognathic splint. (f and g) Persistent paresthesia present on the left side at
1 week and 1 month

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 Raj, et al.: Piezo v/s conventional bur technique in orthognathic surgery

a b
Figure 8: Comparison of mean values of swelling between bur side and
piezo side at different times of follow‑up

c d
Figure 7: Case of skeletal class III. (a) Preoperative profile. (b) Intraoral
vertical split osteotomy with 10‑mm setback. (c) 3D printed orthognathic
splint. (d) One month postoperatively a b

c d
a b

e f
c d Figure 10: Case of skeletal class III. (a) Preoperative. (b) Final
procedure – 6‑mm setback with bilateral sagittal split osteotomy with
4‑mm reduction genioplasty. (c) Bur osteotomy on the right side. (d)
Piezo‑osteotomy on the left side. (e) Genioplasty with piezo‑osteotomy. (f)
One month postoperative

surgery in orthognathic procedures, such as the BSSO, surgically

assisted rapid maxillary expansion, and LeFort I osteotomy.
This is a comparative study done on ten patients where a
e f split‑mouth technique is applied to compare the outcomes of
Figure 9: Case of skeletal class III deformity with maxillary hypoplasia. (a) piezo‑osteotome and conventional bur in orthognathic surgery.
Preoperative. (b) Procedure planned – 8‑mm mandibular setback with
bilateral sagittal split osteotomy. (c) Bur osteotomy on the right side. (d)
Piezo‑osteotomy on the left side. (e) 3D printed orthognathic splint. (f) In the present study, based on the parameters evaluated, the
Follow‑up after 1 week – swelling present only on the right side advantages of piezo were as follows:

280 National Journal of Maxillofacial Surgery / Volume 13 / Issue 2 / May-August 2022

 Raj, et al.: Piezo v/s conventional bur technique in orthognathic surgery

1. Reduced intraoperative bleeding with piezo‑osteotomy difference was significant 30 days after follow‑up. Many
compared to the osteotomy with the bur. Blood‑free studies have also reported a higher accuracy and cutting
surgical field enabled better visualization precision with the piezoelectric device when compared to
2. Better clinical outcomes in terms of neurosensory conventional burs or saws.[3,6] The cavitation effect seen
disturbances – most patients attained complete recovery on in piezosurgery causes the evacuation of the detritus to
the piezo side within a shorter duration than the bur side provide a clear surgical field.[6,8] Studies by Semper‑Hogg
3. The difference in postoperative swelling was not et al.[14] and Weber and Griffin[15] showed that administration
significant on both sides but faster resolution with piezo of dexamethasone either intraoperatively or postoperatively
usage compared to the bur. This could be due to the also has a significant effect on reduction on postoperative
administration of dexamethasone postoperatively in our swelling.
study
4. During piezo‑osteotomy, the cut design was precise, and Studies by Spinelli et al.[3] and Rossi et al.[13] have reported
neat cut edges were observed compared to the ragged a longer duration of the procedure with the piezo when
and uneven edges with bur osteotomy compared with the bur. It is reported that the duration of
5. Bone loss during piezo‑osteotomy cuts was less compared surgery with piezo‑osteotome takes 30%–50% longer than
to the bur osteotomy, which enabled proper interdigitation the conventional bur, especially when cutting through dense
of the segments with piezo‑osteotomy cuts. cortical bone.[12]

The main drawbacks observed were as follows: Overall, despite these shortcomings, the piezoelectric
1. Piezo‑osteotomy takes a longer duration compared to device offers better advantages over the conventional bur
the bur osteotomy increasing the overall operative time in orthognathic surgery and hence can be considered an
2. There is a slight reduction in cutting efficiency in the alternative to the bur in some procedures.
presence of dense cortical bone.
CONCLUSION
Similar observations were made in various studies in the
literature. Spinelli et al.[3] reported a significant reduction It was observed that piezosurgery offers several benefits over
in mean blood loss of 25% in piezosurgery compared to a conventional bur in orthognathic surgery: precise cutting,
traditional saw procedure. According to Bertossi et al.,[8] sparing of vital structures, and better visualization of the
piezosurgery provides more controlled bleeding than surgical field. It reduces blood loss and promotes better
conventional osteotomy. Due to the piezoelectric effect, the clinical outcomes with regard to neurosensory disturbance
distribution of cooling fluid and microvibrations provides a when compared to the use of conventional bur. However, it
blood‑free surgical field. has several limitations like prolonged duration of osteotomy,
thus increasing the surgical time. As our sample size is small,
The results in our study regarding neurosensory disturbances further studies are recommended to evaluate the outcomes
were in consensus with the literature. According to Beziat of orthognathic procedures with piezo‑osteotome. To
et al.,[9] faster recovery was observed on both sides by the conclude, piezoelectric devices provide an innovative, safe,
first postoperative week, but the percentage of sensation and effective osteotomy compared to rotating instruments
recovery was higher following ultrasound osteotomy. in orthognathic surgery.
Likewise, other studies have reported significant differences
after 3 months and 6 months postoperatively, but piezo Declaration of patient consent
surgery showed a lesser amount of neurosensory disturbance The authors declare that they have obtained consent from
compared to the conventional bur side.[10‑12] This is due to patients. Patients have given their consent for their images
preserving the soft tissues, including the perineurium of and other clinical information to be reported in the journal.
the nerve. Patients understand that their names will not be published
and due efforts will be made to conceal their identity but
Postoperative swelling is a common occurrence after anonymity cannot be guaranteed.
orthognathic surgery, and it is resolved after 2–3 weeks.[11]
Spinelli et al.[3] reported a majority of the patients recovered Financial support and sponsorship
within a week and the rest in the first postoperative month Nil.
and a decreased incidence of postoperative swelling with
piezoelectric surgery. Rossi et al.[13] reported less swelling Conflicts of interest
in the piezo side compared to the traditional saw, and the There are no conflicts of interest.
National Journal of Maxillofacial Surgery / Volume 13 / Issue 2 / May-August 2022 281
 Raj, et al.: Piezo v/s conventional bur technique in orthognathic surgery

REFERENCES 2013;24:1763‑6.
9. Beziat JL, Bera JC, Lavandier B, Gleizal A. Ultrasonic osteotomy as
a new technique in craniomaxillofacial surgery. Int J Oral Maxillofac
1. Köhnke R, Kolk A, Kluwe L, Ploder O. Piezosurgery for sagittal split
Surg 2007;36:493‑500.
osteotomy: Procedure duration and postoperative sensory perturbation.
10. Brockmeyer P, Hahn W, Fenge S, Moser N, Schliephake H,
J Oral Maxillofac Surg 2017;75:1941‑7.
Gruber RM. Reduced somatosensory impairment by piezosurgery
2. Robiony M, Polini F, Costa F, Vercellotti T, Politi M. Piezoelectric bone
during orthognathic surgery of the mandible. Oral Maxillofac Surg
cutting in multipiece maxillary osteotomies. J Oral Maxillofac Surg
2015;19:301‑7.
2004;62:759‑61.
11. Pagotto LE, de Santana Santos T, de Vasconcellos SJ, Santos JS,
3. Spinelli G, Lazzeri D, Conti M, Agostini T, Mannelli G. Comparison of
Martins‑Filho PR. Piezoelectric versus conventional techniques
piezosurgery and traditional saw in bimaxillary orthognathic surgery.
for orthognathic surgery: Systematic review and meta‑analysis.
J Craniomaxillofac Surg 2014;42:1211‑20. J Craniomaxillofac Surg 2017;45:1607‑13.
4. Agarwal E, Masamatti SS, Kumar A. Escalating role of piezosurgery in 12. Silva LF, Carvalho‑Reis EN, Bonardi JP, de Lima VN, Momesso GA,
dental therapeutics. J Clin Diagn Res 2014;8:ZE08‑11. Garcia‑Junior IR, et al. Comparison between piezoelectric surgery and
5. Eggers G, Klein J, Blank J, Hassfeld S. Piezosurgery: An ultrasound conventional saw in sagittal split osteotomies: A systematic review. Int
device for cutting bone and its use and limitations in maxillofacial J Oral Maxillofac Surg 2017;46:1000‑6.
surgery. Br J Oral Maxillofac Surg 2004;42:451‑3. 13. Rossi D, Romano M, Karanxha L, Baserga C, Russillo A, Taschieri S,
6. Landes CA, Stübinger S, Rieger J, Williger B, Ha TK, Sader R. Critical et al. Bimaxillary orthognathic surgery with a conventional saw
evaluation of piezoelectric osteotomy in orthognathic surgery: Operative compared with the piezoelectric technique: A longitudinal clinical study.
technique, blood loss, time requirement, nerve and vessel integrity. J Oral Br J Oral Maxillofac Surg 2018;56:698‑704.
Maxillofac Surg 2008;66:657‑74. 14. Semper‑Hogg W, Fuessinger MA, Dirlewanger TW, Cornelius CP,
7. Ali Algadiem E, Aleisa AA, Alsubaie HI, Buhlaiqah NR, Algadeeb JB, Metzger MC. The influence of dexamethasone on postoperative swelling
Alsneini HA. Blood loss estimation using gauze visual analogue. Trauma and neurosensory disturbances after orthognathic surgery: A randomized
Mon 2016;21:e34131. controlled clinical trial. Head Face Med 2017;13:19.
8. Bertossi D, Lucchese A, Albanese M, Turra M, Faccioni F, 15. Weber CR, Griffin JM. Evaluation of dexamethasone for reducing
Nocini P, et al. Piezosurgery versus conventional osteotomy in postoperative edema and inflammatory response after orthognathic
orthognathic surgery: A paradigm shift in treatment. J Craniofac Surg surgery. J Oral Maxillofac Surg 1994;52:35‑9.

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