Cytokines and Growth Factors Involved in the Osseointegration of Oral Titanium Implants Positioned Using Piezoelectric Bone Surgery Versus a Drill Technique: A Pilot Study in Minipigs

Cortical Piezo-Puncture as a Minimally Invasive Method for Reducing MiniScrew Implant Insertion Torque: A Preliminary in vitro Study

Objective

The objective of this study was to determine the effect of cortical piezo-puncture (CPP) on maximum insertion torque (MIT), maximum removal torque (MRT), and maximum axial load (MAL) during the insertion of self-drilling miniscrew implants (MSI), in an experimental model with proximal epiphysis of bovine tibia.

Materials and Methods

A comparative study was conducted using two groups of 20 self-drilling MSI inserted in intact bone (control group) and in bone with previous CPP (experimental group). MIT, MRT, and MAL of the 20 mini implants of each group were measured. Using SPSS software, Student’s t-test was applied to compare MIT and MRT and the U-test Mann–Whitney test was applied to compare MAL in both groups as well as Pearson and Spearman correlation.

Results

In the experimental group, average values of 12.85 (±4,32) Newton x centimeters (Ncm), 13.7 (±4,54) Ncm, and 22,474 (±895,95) gF for MIT, MRT, and MAL were found, respectively. In the control group, average values found for MIT, MRT, and MAL were 20.2 (±4,7) Ncm, 22.3 (±5,17) Ncm, and 4688,7 (±320,18) gF, respectively. Statistically significant differences were observed in MIT, MRT, and MAL between control and experimental groups (P < 0,001).

Conclusions

CPP before insertion of orthodontic MSI in bovine tibia significantly reduces MIT, MRT, and MAL.

Immediate Loading of Implant-Supported Single Crowns after Conventional and Ultrasonic Implant Site Preparation: A Multicenter Randomized Controlled Clinical Trial

Aim

To compare implant survival rate and marginal bone loss (MBL) of immediately loaded single implants inserted by using ultrasonic implant site preparation (UISP) (test) and conventional rotary instrumentation (control).

Methods

Two single implants were inserted for each patient: after randomization, test site was prepared by using an ultrasonic device (Piezosurgery Touch, Mectron, Italy) and control site was prepared by using the drills of the selected implant system (Premium AZT, Sweden & Martina, Italy), until reaching a final diameter of 3 mm in both groups. Identical implants (3.8x11.5 mm) were inserted in all sites at crestal level. Impressions were taken and screwed resin single crowns with platform-switched provisional abutments were delivered with 48 hours. Periapical radiographs were taken at provisional crown insertion (T0), 6 months (T1) and one year (T2) after prosthetic loading to measure MBL. All data were tested for normality and subsequently analyzed by paired samples t-test and forward multiple linear regression.

Results

Forty-eight patients were treated in six centers with the insertion of ninety-six implants (48 test; 48 control). Four implants in four patients failed within the first six months of healing (two in test group; two in control group; no difference between groups). Forty patients (age 60.1±10.7 years; 22 female, 18 male) were included in the final analysis. Mean MBL after six months of loading was 1.39±1.03 mm in the test group and 1.42±1.16 mm in the control group (p>0.05) and after one year was 1.92±1.14 mm and 2.14±1.55 mm in test and control, respectively (p>0.05).

Conclusions

No differences in survival rate and MBL were demonstrated between UISP and conventional site preparation with rotary instruments in immediately loaded dental implants: UISP, with its characteristics of enhanced surgical control and safety in proximity of delicate structures, may be used as a reliable alternative to the traditional drilling systems.

Neurosensory Disturbances After Bilateral Sagittal Split Osteotomy Using Piezoelectric Surgery: A Systematic Review

PURPOSE

The objective of the present systematic review was to test the hypothesis of no difference in neurosensory disturbances (NSDs) after bilateral sagittal split osteotomy (BSSO) with piezoelectric surgery compared with conventional techniques.

MATERIALS AND METHODS

A PubMed (Medline), Embase Library, and Cochrane Library search in combination with a manual search of relevant journals was conducted from January 2000 to November 2017. Randomized controlled trials and controlled trials in humans were considered. Primary outcome measures (assessment of neuro-sensitivity by subjective and objective evaluations) and secondary outcome measures (NSD risk factors, patient-reported outcome measures, complications, operating time, and intraoperative bleeding) were considered.

RESULTS

The search provided 241 studies of which 5 eligible studies were included. Meta-analysis was not possible because of considerable heterogeneity. Two studies were characterized by a moderate risk of bias and 3 were characterized by a high risk of bias. Piezoelectric surgery substantially decreased NSDs as evaluated by subjective tests. NSD after BSSO varied from 1.8 to 23.0% with piezoelectric surgery and from 7.3 to 52.0% with conventional techniques after 2 to 12 months. Furthermore, piezoelectric surgery seemed to considerably decrease the frequency of intraoperative bleeding in bimaxillary procedures and decrease the risk of an unfavorable split of the mandible and macroscopic damage of the inferior alveolar nerve.

CONCLUSIONS

The hypothesis of no difference in NSD after BSSO with piezoelectric surgery compared with conventional techniques could be neither confirmed nor rejected owing to insufficient knowledge. However, piezoelectric surgery seems to decrease the risk of NSDs after BSSO compared with conventional techniques. Long-term randomized controlled trials comparing the 2 treatment modalities by standardized subjective and objective electrophysiologic tests are needed before one treatment modality can be considered superior to another.

Minimally Invasive Approach Based on Pterygoid and Short Implants for Rehabilitation of an Extremely Atrophic Maxilla: Case Report

INTRODUCTION

Extremely atrophic maxillae can be considered the most important indication for three-dimensional maxillary reconstruction. Different bone-augmentation techniques have been suggested to accomplish this. This article illustrates a minimally invasive approach to rehabilitation of the extremely atrophic maxilla.

MATERIAL AND METHODS

A 63-year-old male patient was referred for restoration of his totally edentulous maxilla with a fixed full-arch implant-prosthetic rehabilitation. Four short implants in the premaxillary region and 2 longer implants in the pterygomaxillary regions were inserted with piezoelectric implant site preparation.

DISCUSSION

At the 1-year follow-up appointment, no clinical or radiographic changes in the soft-tissue contours or crestal bone levels were observed.

CONCLUSION

This surgical approach, based on the combination of short implants in the premaxillary regions and pterygoid implants in the pterygomaxillary regions, represents a way to shorten treatment timing, minimize the risk of surgical complications, and reduce patient discomfort and costs.

Correlation between Insertion Torque and Implant Stability Quotient in Tapered Implants with Knife-Edge Thread Design

Aim

To evaluate the correlation between insertion torque (IT) and implant stability quotient (ISQ) in tapered implants with knife-edge threads.

Methods

Seventy-five identical implants (Anyridge, Megagen) were inserted by using a surgical drilling unit with torque control and an integrated resonance frequency analysis module (Implantmed, W&H). IT (N/cm) and ISQ were recorded and implants were divided into three groups (n = 25) according to the IT: low (<30), medium (30 < IT < 50), and high torque (>50). ISQ difference among groups was assessed by Kruskal-Wallis test, followed by Bonferroni-corrected Mann–Whitney U-test for pairwise comparisons. The strength of the association between IT and ISQ was assessed by Spearman Rho correlation coefficient (α = 0.05).

Results

At the pairwise comparisons, a significant difference of ISQ values was demonstrated only between low torque and high torque groups. The strength of the association between IT and ISQ value was significant for both the entire sample and the medium torque group, while it was not significant in low and high torque groups.

Conclusions

For the investigated implant, ISQ and IT showed a positive correlation up to values around 50 N/cm: higher torques subject the bone-implant system to unnecessary biological and mechanical stress without additional benefits in terms of implant stability. This trial is registered with NCT03222219.

Comparative Evaluation of Cell Viability Immediately After Osteotomy for Implants With Drills and Piezosurgery: Immunohistochemistry Analysis

OBJECTIVE

To evaluate the effect of reusing drills and piezosurgery tips during implant osteotomy on immediate bone cell viability through immunohistochemical analysis.

MATERIALS AND METHODS

Six male rabbits were divided into 2 groups and then divided into 5 subgroups-correspond to drills and tips used 10, 20, 30, 40, and 50 times, respectively. All animals received 10 osteotomies in each tibia, by use of the classic drilling procedure in one group (G1) and the piezosurgery device in the other group (G2). For immunohistochemical technique were utilized the osteoprotegerin, RANKL, osteocalcin, and caspase 3. Control procedures were performed by omitting the primary antibodies (negative control).

RESULTS

Bone formation and resorption responses presented in more intense way during the piezosurgery. The expression of osteocalcin had become quite intense in piezosurgery groups, but with reduced immunostaining from the 30th osteotomy. The caspase 3 showed the viability of the osteoblast from the 20th osteotomy with piezosurgery and remained constant until the 50th.

CONCLUSION

Piezosurgery provides greater osteoblastic cell viability than the system of conventional drilling.

CLINICAL RELEVANCE

This study will provide data so that the authors can recycle the drills and tips for implant placement, thus enabling a better cell viability for osseointegration.

Piezoelectric versus conventional implant site preparation: A systematic review and meta-analysis

BACKGROUND

The use of a piezoelectric device (PED) for implant site preparation (ISP) has been introduced to overcome the limitations of using conventional drills (CDs). With little and inconsistent information in the literature regarding their efficiency for preparing implant osteotomies, the objective of this systematic review was to compare the use of CDs to PEDs for ISP with regard to implant stability values, marginal bone level changes, operating time, and dental implant failure rate.

METHODS

The systematic review was prepared according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The literature was searched for studies that assessed the use of CDs and PEDs for ISP. The Cochrane Collaboration risk of bias tool was used to evaluate the selected studies and meta-analyses were performed using statistical software.

RESULTS

A total of 755 citations were identified. Of these, 4 studies with 178 implant osteotomies in 80 participants were included. The pooled estimates for the implant stability showed significant differences between the 2 surgical techniques in favor of PEDs at baseline, 8 and 12 weeks. A statistically significant difference in the operating time was also shown between the 2 techniques with more time required using PED. The differences in marginal bone level changes or implant failure rate were not statistically significant.

CONCLUSIONS

With the limitations of this review in mind, PEDs appear to be a viable alternative to traditional drilling techniques for ISP. With the exception of prolonged operating time associated with the use of PEDs, both techniques were comparable in terms of the marginal bone level changes and the risk of implant failure. The favorable influence of the implant stability pattern related to the use of PEDs on the predictability of immediate and early loading protocols need to be confirmed in future studies.

Conventional Drilling Versus Piezosurgery for Implant Site Preparation: A Meta-Analysis

The aim of this study was to evaluate if the stability of dental implants varies between dental implants placed by piezosurgery compared with those placed by conventional drilling. An electronic search in MEDLINE, SCOPUS, and the Cochrane Library was undertaken until August 2016 and was supplemented by manual searches and by unpublished studies at OpenGray. Only randomized controlled clinical trials that reported implant site preparation with piezosurgery and with conventional drilling were considered eligible for inclusion in this review. Meta-analyses were performed to evaluate the impact of piezosurgery on implant stability. Of 456 references electronically retrieved, 3 were included in the qualitative analysis and quantitative synthesis. The pooled estimates suggest that there is no significant difference between piezosurgery and conventional drilling at baseline (weighted mean differences [WMD]: 2.20; 95% confidence interval [CI]: -5.09, 9.49; P = .55). At 90 days, the pooled estimates revealed a statistically significant difference (WMD: 3.63; 95% CI: 0.58, 6.67, P = .02) favoring piezosurgery. Implant stability may be slightly improved when osteotomy is performed by a piezoelectric device. More randomized controlled clinical trials are needed to confirm these findings.

Bone Scrapers Versus Piezoelectric Surgery in the Lateral Antrostomy for Sinus Floor Elevation

The purpose of this investigation is to evaluate 2 different methods for reducing cortical wall thickness in sinus floor augmentation surgery. A manual bone scraper was compared in terms of efficacy, speed, and safety to an ultrasonic insert for osteoplasty, in a randomized controlled clinical trial with a split-mouth design. Twenty-five patients with severe posterior maxillary atrophy were treated with bilateral sinus floor elevation with lateral approach. Antrostomies were randomly performed by eroding the cortical wall with a manual bone scraper (test site) or with an ultrasonic insert (control site) until the membrane was visible under a thin layer of bone, before outlining the window with a piezoelectric device. Occurrence of membrane perforation, laceration of vascular branches, and surgical time were recorded. Mean surgical time of the antrostomy in the test sites was 9'18", while in the control sites was 9'47". No significant differences were found in terms of surgical time, incidence of membrane perforation during antrostomy (4.3% in both groups), or other intraoperative complications between the 2 techniques. Both surgical approaches represent effective options for performing lateral antrostomies during sinus floor elevation procedures in a safe and predictable way.

Osseous outgrowth on the buccal maxilla associated with piezosurgery-assisted en-masse retraction: A case series

Piezoelectric surgery is a novel surgical approach used in orthodontic treatment for rapid tooth movement. This paper presents a case series wherein osseous outgrowths were observed in response to piezosurgery-assisted en-masse retraction. Sixteen patients requiring upper premolar extractions were treated with miniscrew-supported en-masse retraction and received minimally invasive decortication via piezosurgery. Computed tomography (CT) of the maxillary anterior region was performed to investigate the nature of the outgrowths. In 8 of the 16 patients, hemispheric or disc-shaped osseous outgrowths were observed on the sites where piezosurgery was performed during retraction. CT images revealed that these outgrowths were alveolar bone. This case series presents a previously unreported osseous response to piezosurgery-assisted tooth movement during orthodontic treatment. The response is mostly transient and is observed in 50% of the treated patients, suggesting a bone turnover that can be assessed clinically and radiographically.

Mobilization of malpositioned dental implant using segmental osteotomy: A case report

By increasing the number of replaced tooth with dental implants, the number of poorly positioned implants is also increased. In this article, we present our experience about a 48-year-old female who was referred to our department for resolving prosthetic problem regarding two malpositioned implants inserted in the upper jaw. The interocclusal space was insufficient and the two adjacent implants had excessive buccal angulation. To overcome these problems, segmental osteotomy of the alveolar bone containing two implants has been done. After palatal and apical repositioning of the bone block, rigid fixation was performed using a 4-hole miniplate and four 5mm monocortical screws. Two weeks after the procedure, a conventional fixed prosthesis was constructed with regard to the esthetic and functional aspects. During the two-year follow-up, the patient was satisfied with the result and there were no complications, such as alveolar bone necrosis, marginal bone loss, implant failure or infection.

Physics and Histologic Evaluation of Rotary, Ultrasonic, and Sonic Instruments

Rotary instruments (RIs) are the most commonly used to perform osteotomies in many fields of medicine. Owing to a new interest in performing a minimally invasive surgery, over last fifteen years new devices have been used in oral surgery such as ultrasonic instruments (UIs) and, lately, sonic instruments (SIs). Nowadays, bone preservation and regeneration are paramount in many clinical situations and, consequently, it is crucial to rely upon instruments, which cause the least tissue damage during the surgery. Concerning SIs, there is still few information about workload to be applied and related temperature increases; furthermore, there are no comparative in-vivo studies, which analyze the thermal and mechanical effects on bone. Thus, SIs have been compared with UIs and RIs in terms of heat generation, operating time, accuracy, and tissue damage. Decalcification and sectioning procedure resulted in no significant differences between the applied instruments in terms of bone damage. RIs resulted more efficient than UIs (P < 0.001), but demonstrated low accuracy (NRS 4.9), whereas SIs (P = 0.005) required more time to perform the osteotomy. The maximum temperature increase occurred in the ultrasonic group. Even though SI were the slowest, they have proved to be the most accurate (NRS 8.4) in comparison with UI (NRS 7.6) and RI (NRS 4.9). Within the limit of this study, sonic instruments could be considered a safe alternative to ultrasonic instruments.

Influence of Piezosurgery on Bone Healing around Titanium Implants: A Histological Study in Rats

The aim of this study was to evaluate histomorphometrically the influence of two techniques of dental implant site preparation on bone healing around titanium implants. Fifteen male Wistar rats (±300 g) were used in the study. Each tibia was randomly assigned to receive the implant site preparation either with a conventional drilling technique (control - DRILL group) or with a piezoelectric device (PIEZO group). The animals were sacrificed after 30 days and then the following histomorphometric parameters were evaluated (percentage) separately for cortical and cancellous regions: proportion of mineralized tissue (PMT) adjacent to implant threads (500 μm adjacent); bone area within the threads (BA) and bone-implant contact (BIC). The results demonstrated that there were no statistically significant differences between both groups for cancellous BIC (p>0.05) and cortical PMT (p>0.05). On the other hand, a higher percentage of BA was observed in the PIEZO group in the cortical (71.50±6.91 and 78.28±4.38 for DRILL and PIEZO groups, respectively; p<0.05) and cancellous regions (9.62±4.06 and 19.94±14.18 for DRILL and PIEZO groups, respectively; p<0.05). The piezosurgery also showed higher PMT values in the cancellous zone (9.35±5.54 and 18.72±13.21 for DRILL and PIEZO groups, respectively; p<0.05). However, the DRILL group presented better results for BIC in cortical region (80.42±10.88 and 70.25±16.93 for DRILL and PIEZO groups, respectively; p<0.05). In conclusion, for the implant site preparation, the piezosurgery was beneficial to bone healing rates in the cancellous bone region, while the drill technique produced better results in the cortical bone.

The effects of surgical preparation techniques and implant macro-geometry on primary stability: An in vitro study

Background

The attainment of a good primary stability is a necessary condition to ensure the success of osseointegration in implantology. In type IV cancellous bone, however, it is possible that a reduced primary stability can lead to an increased rate of failure. The aim of this study was therefore to determine, with the help of the resonance frequency (Osstell mentor), which technique of implant site preparation (piezo surgery, conventional, under-preparation, bone compaction, osteodistraction) and macro-geometry is able to improve implant stability in type IV cancellous bone.

Material and Methods

10 pig ribs were prepared with a surgical pre-drilled guide, calibrated for a correct implant positioning. On each rib, 5 implant sites (one for each technique) were prepared. Successively, 50 conical implants (Tekka Global D) were inserted and measured with the resonance frequency to evaluate the primary stability. Data collected were analyzed by analysis of variance (ANOVA) to test whether the Implant Stability Quotient (ISQ) values of the five techniques were significantly different.

Results

The results showed that no significant differences among the ISQ values of the five techniques used were found. Also, no significant differences in the macro-geometry of the two types of compared implants were observed. However, the macro-geometry of Tekka implants, characterized by a double condensing thread, seems to provide greater ISQ values than those of single thread implants when using the same technique.

Conclusions

In light of these preliminary data, it is conceivable that in cases of reduced stability, such as those occurring with a type IV bone, all means ameliorating the primary stability and accelerating the osseointegration can be utilized.

Key words:Implant primary stability, resonance frequency analysis, implant site preparation.

Treatment of medication-related osteonecrosis of the jaws (MRONJ) with ultrasonic piezoelectric bone surgery. A case series of 20 treated sites

PURPOSE

There is no consensus on how to successfully treat medication-related osteonecrosis of the jaws (MRONJ). We report here on the application of piezoelectric bone surgery to treat MRONJ in combination with antibiotherapy and on its possible benefit.

MATERIEL AND METHODS

A cohort of 18 consecutive patients has been treated for MRONJ; they involved 20 sites, 15 in the mandible, and five in the maxilla. Surgical removal of the necrotic areas and debridement was performed with a powerful piezoelectric surgery device (max 90 W) in combination with antibiotherapy.

RESULTS

All patients healed and obtained a complete soft tissue closure within 1 month. No recurrence of the symptoms was observed during the present follow-up (10-54 months).

CONCLUSION

We hypothesize that healing of all treated sites might have resulted from the synergic effect of bone ablation, biofilm alteration, and antibiotic administration. Biofilm alteration might have permitted a better access of antibiotics to the involved germs. These encouraging results warrant further studies on the use of ultrasonic surgery to treat MRONJ patients in order to confirm or refute the hypothesized effect.

Bone Healing Following Different Types of Osteotomy: Scanning Electron Microscopy (SEM) and Three-Dimensional SEM Analyses

The aim of the present study was to compare dynamics of the bone healing process after different types of osteotomies. In total, 24 Wistar rats were subjected to different types of osteotomy performed with standard steel bur, piezosurgery, contact, and non-contact Erbium:yttrium-aluminum-garnet (Er:YAG) laser ablation. The animals were randomly divided into four groups, to be euthanized immediately after the procedure, or at 1, 2, or 3 weeks after surgery. The obtained bone samples were analyzed by scanning electron microscopy (SEM). Immediately after surgery, there were significant differences in the appearance of the bone defects, with presence of bone fragments and debris after standard steel bur preparation, compared with the clean smooth walls and relatively sharp edges in all other groups. The initial bone formation in defects prepared by piezosurgery was observed to be the most rapid. After 3 weeks, all bone defects were completely restored; although, differences in the healing pattern were noted, with a modest initial delay in healing after laser preparation. The first stage of the bone healing process was delayed when contact and non-contact Er:YAG laser modes were used and accelerated by piezosurgery; however, the results after 3 weeks demonstrated similar restitution of defects in all tested groups.

Application of Ultrasonic Devices in Management of Periodontal Lesions - Bone Response in a Case of a Tooth with Poor Treatment Prognosis

BACKGROUND

Surgical treatment of odontogenic jaw cysts may include one of the following four basic methods: enucleation, marsupialization, staged combination of marsupialization and enucleation, or enucleation with curettage. Enucleation/cystectomy, alone or combined with other procedures, is the preferred choice of treatment.

OBJECTIVE

The aim of the case report was to present the outcome of an ultrasound-assistant periapical cystectomy in a frontal upper tooth with indications for extraction.

RESULTS

Postoperative recovery was uneventful. The functional result was satisfactory. On the follow-up X-rays a reduction of the intraosseous defect by a new bone formation could be observed.

CONCLUSION

We found ultrasonic surgery to be a promising approach for safe and effective odontogenic jaw cyst removal reducing the risk of its recurrence.

Rehabilitation with 4 zygomatic implants with a new surgical protocol using ultrasonic technique

When the residual bone crest cannot allow the placement of standard implants, the treatment for complete arch rehabilitation of severely atrophic maxillae can be performed with 4 zygomatic implants (ZIs) and immediate function with predictable results in terms of aesthetics, function, and comfort for the patient. However, even if ZIs' rehabilitations showed a good success rate, this surgery is difficult and need a skillful operator. Complications in this kind of rehabilitation are not uncommon; the main difficulties can be related to the reduced surgical visibility and instrument control in a critical anatomic area. All the surgical protocols described in the literature used drilling techniques. Furthermore, the use of ultrasonic instruments in implant surgery compared with drilling instruments have shown advantages in many aspects of surgical procedures, tissues management, enhancement of control, surgical visualization, and healing. The aim of this study was to report on the preliminary experience using ultrasound technique for ZIs surgery in terms of safety and technical improvement. Ten consecutive patients with severely atrophic maxilla have been treated with 4 ZIs and immediate complete arch acrylic resin provisional prostheses. The patients were followed up from 30 to 32 months evaluating implant success, prosthetic success, and patient satisfaction with a questionnaire. No implants were lost during the study period, with a 100% implant and prosthetic success rate. Within the limitations of this preliminary study, these data indicate that ultrasonic implant site preparation for ZIs can be a good alternative to the drilling technique and an improvement for the surgeon.

Piezosurgery in Bone Augmentation Procedures Previous to Dental Implant Surgery: A Review of the Literature

The piezosurgery has been used with increasing frequency and applicability by health professionals, especially those who deal with dental implants. The concept of piezoelectricity has emerged in the nineteenth century, but it was applied in oral surgery from 1988 by Tomaso Vercellotti. It consists of an ultrasonic device able to cut mineralized bone tissue, without injuring the adjacent soft tissue. It also has several advantages when compared to conventional techniques with drills and saws, such as the production of a precise, clean and low bleed bone cut that shows positive biological results. In dental implants surgery, it has been used for maxillary sinus lifting, removal of bone blocks, distraction osteogenesis, lateralization of the inferior alveolar nerve, split crest of alveolar ridge and even for dental implants placement. The purpose of this paper is to discuss the use of piezosurgery in bone augmentation procedures used previously to dental implants placement.

Piezosurgery in implant dentistry

Piezosurgery, or the use of piezoelectric devices, is being applied increasingly in oral and maxillofacial surgery. The main advantages of this technique are precise and selective cuttings, the avoidance of thermal damage, and the preservation of soft-tissue structures. Through the application of piezoelectric surgery, implant-site preparation, bone grafting, sinus-floor elevation, edentulous ridge splitting or the lateralization of the inferior alveolar nerve are very technically feasible. This clinical overview gives a short summary of the current literature and outlines the advantages and disadvantages of piezoelectric bone surgery in implant dentistry. Overall, piezoelectric surgery is superior to other methods that utilize mechanical instruments. Handling of delicate or compromised hard- and soft-tissue conditions can be performed with less risk for the patient. With respect to current and future innovative surgical concepts, piezoelectric surgery offers a wide range of new possibilities to perform customized and minimally invasive osteotomies.

Temperature and time variations during osteotomies performed with different piezosurgical devices: an in vitro study

AIM

The aim of this experimental in vitro study was to evaluate the effects of the piezoelectric device in temperature and time variations in standardized osteotomies performed with similar tip inserts in bovine bone blocks.

METHODS

Two different piezosurgical devices were used the OE-F15(®) (Osada Inc., Los Angeles, California, USA) and the Surgybone(®) (Silfradent Inc., Sofia, Forli Cesena, Italy). Serrated inserts with similar geometry were coupled with each device (ST94 insert/test A and P0700 insert/test B). Osteotomies 10 mm long and 3 mm deep were performed in bone blocks resembling type II (dense) and type IV (soft) bone densities with and without irrigation. Thermal changes and time variations were recorded. The effects of bone density, irrigation, and device on temperature changes and time necessary to accomplish the osteotomies were analyzed.

RESULTS

Thermal analysis showed significant higher temperatures during piezosurgery osteotomies in hard bone without irrigation (P < 0.05). The type of piezosurgical device did not influence thermal variations (P > 0.05). Time analysis showed that the mean time values necessary to perform osteotomies were shorter in soft bone than in dense bone (P < 0.05).

CONCLUSIONS

Within the limitations of this in vitro study, it may be concluded that the temperature increases more in piezosurgery osteotomies in dense bone without irrigation; the time to perform the osteotomy with piezosurgery is shorter in soft bone compared to hard bone; and the piezosurgical device have a minimal influence in the temperature and time variations when a similar tip design is used during piezosurgery osteotomies.

Piezoelectric Versus Conventional Rotary Techniques for Impacted Third Molar Extraction: A Meta-analysis of Randomized Controlled Trials

Impacted third molars are frequently encountered in clinical work. Surgical removal of impacted third molars is often required to prevent clinical symptoms. Traditional rotary cutting instruments are potentially injurious, and piezosurgery, as a new osteotomy technique, has been introduced in oral and maxillofacial surgery. No consistent conclusion has been reached regarding whether this new technique is associated with fewer or less severe postoperative sequelae after third molar extraction.The aim of this study was to compare piezosurgery with rotary osteotomy techniques, with regard to surgery time and the severity of postoperative sequelae, including pain, swelling, and trismus.We conducted a systematic literature search in the Cochrane Library, PubMed, Embase, and Google Scholar.The eligibility criteria of this study included the following: the patients were clearly diagnosed as having impacted mandibular third molars; the patients underwent piezosurgery osteotomy, and in the control group rotary osteotomy techniques, for removing impacted third molars; the outcomes of interest include surgery time, trismus, swelling or pain; the studies are randomized controlled trials.We used random-effects models to calculate the difference in the outcomes, and the corresponding 95% confidence interval. We calculated the weighted mean difference if the trials used the same measurement, and a standardized mean difference if otherwise.A total of seven studies met the eligibility criteria and were included in our analysis. Compared with rotary osteotomy, patients undergoing piezosurgery experienced longer surgery time (mean difference 4.13 minutes, 95% confidence interval 2.75-5.52, P < 0.0001). Patients receiving the piezoelectric technique had less swelling at postoperative days 1, 3, 5, and 7 (all Ps ≤0.023). Additionally, there was a trend of less postoperative pain and trismus in the piezosurgery groups.The number of included randomized controlled trials and the sample size of each trial were relatively small, double blinding was not possible, and cost analysis was unavailable due to a lack of data.Our meta-analysis indicates that although patients undergoing piezosurgery experienced longer surgery time, they had less postoperative swelling, indicating that piezosurgery is a promising alternative technique for extraction of impacted third molars.

Morphological characteristics of osteotomies using different piezosurgical devices. A scanning electron microscopic evaluation

PURPOSE

The objective of this study was to compare morphological characteristics of osteotomies performed by 6 Piezosurgical devices.

MATERIALS AND METHODS

The 6 Piezosurgical units were: (a) Piezotom, (b) SurgySonic, (c) Piezon Master Surgery, (d) VarioSurg, (e) Surgybone, and (f) Piezosurgery 3. Osteotomies on 9 freshly slaughtered cattle ribs (2 cuts by each unit, per rib) from the cortical (first cut at 5 mm) to the cancellous (second cut at 3 mm) bone layer were performed. The osteotomy margins were compared using scanning electron microscopy analysis. The cutting areas, osteotomy bottoms, and osteotomy margins were analyzed morphologically. Statistical evaluation of the 2 cuts regarding the design of the tips (a-d: tapered tool shanks, f: parallel tool shank) was performed by an unpaired t test.

RESULTS

Morphological characteristics were different for each Piezosurgical unit and each examined area. A significant difference (P = 0.0209) of the upper width of the first cut between tapered and parallel tips was shown.

CONCLUSIONS

The morphological characteristics of the produced Piezosurgical osteotomies vary and depend on the Piezosurgical unit and tip.

The effect of piezoelectric surgery implant osteotomy on radiological and molecular parameters of peri-implant crestal bone loss: a randomized, controlled, split-mouth trial

AIM

To evaluate the effect of piezoelectric surgery (PS) implant osteotomy on biochemical and radiological parameters of crestal bone (CB) loss.

MATERIAL AND METHODS

In this randomized, controlled, clinical study, 38 osteotomies were prepared with PS and drilling in the posterior maxilla in a split-mouth design. Implants were placed and left for non-submerged healing. Osteotomy time, insertion torque, pain perception, probing depth, and modified gingival and plaque indices were recorded. Peri-implant sulcular fluid (PISF) was collected from four sites of each implant at 2, 4, 8, 12, and 24 weeks. PISF samples were analyzed by ELISA for receptor activator of nuclear factor kappa-B-ligand (RANKL) and osteoprotegerin. CB loss was assessed on periapical radiographs at the 12th and on cone beam computed tomography (CBCT) at the 24th weeks. The influence of time and osteotomy method on biochemical and radiological parameters of CB loss employed statistical method of Brunner-Langer.

RESULTS

Osteotomy time for PS group was significantly longer than the drill group (P < 0.05). Pain perception that was lower in the PS than in the drill group depended on osteotomy method (P < 0.05). PS group had lower RANKL total amount than the drill group (P < 0.05). Mean CB loss on periapical radiographs at the 12th week for PS and drill groups were 0.11 and 0.18 mm, respectively (P > 0.05). At the 24th week, PS and drill groups showed 0.11 and 0.12 mm CB losses on CBCT, respectively (P > 0.05). However, CB loss values did not depend on osteotomy modality (P > 0.05).

CONCLUSION

PS may modify and reduce bone-destructive inflammatory response during implant osseointegration. Therefore, on the molecular level, it might be a less traumatic osteotomy modality than drilling although this was not reflected by CB loss values in the present study.

Understanding nonlinear vibration behaviours in high-power ultrasonic surgical devices

Ultrasonic surgical devices are increasingly used in oral, craniofacial and maxillofacial surgery to cut mineralized tissue, offering the surgeon high accuracy with minimal risk to nerve and vessel tissue. Power ultrasonic devices operate in resonance, requiring their length to be a half-wavelength or multiple-half-wavelength. For bone surgery, devices based on a half-wavelength have seen considerable success, but longer multiple-half-wavelength endoscopic devices have recently been proposed to widen the range of surgeries. To provide context for these developments, some examples of surgical procedures and the associated designs of ultrasonic cutting tips are presented. However, multiple-half-wavelength components, typical of endoscopic devices, have greater potential to exhibit nonlinear dynamic behaviours that have a highly detrimental effect on device performance. Through experimental characterization of the dynamic behaviour of endoscopic devices, it is demonstrated how geometrical features influence nonlinear dynamic responses. Period doubling, a known route to chaotic behaviour, is shown to be significantly influenced by the cutting tip shape, whereas the cutting tip has only a limited effect on Duffing-like responses, particularly the shape of the hysteresis curve, which is important for device stability. These findings underpin design, aiming to pave the way for a new generation of ultrasonic endoscopic surgical devices.

An alumina toughened zirconia composite for dental implant application: in vivo animal results

Ceramic materials are widely used for biomedical applications because of their remarkable biological and mechanical properties. Composites made of alumina and zirconia are particularly interesting owing to their higher toughness with respect to the monolithic materials. On this basis, the present study is focused on the in vivo behavior of alumina toughened zirconia (ATZ) dental implants treated with a hydrothermal process. A minipig model was implemented to assess the bone healing through histology and mRNA expression at different time points (8, 14, 28, and 56 days). The novel ATZ implant was compared to a titanium clinical standard. The implants were analyzed in terms of microstructure and surface roughness before in vivo tests. The most interesting result deals with a statistically significant higher digital histology index for ATZ implants with respect to titanium standard at 56 days, which is an unprecedented finding, to the authors' knowledge. Even if further investigations are needed before proposing the clinical use in humans, the tested material proved to be a promising candidate among the possible ceramic dental implants.

Piezosurgical treatment of crestal bone: quantitative comparison of post-extractive socket outcomes with those of traditional treatment

OBJECTIVE

The study aimed to quantitatively compare, for the first time, the clinical outcomes of crestal bone volume resorption in sockets undergoing traditional extraction technique (TET) or piezosurgical extraction technique (PET), also considering the influence of buccal plate thickness.

MATERIAL AND METHODS

In this prospective study, 19 sockets were randomly treated with TET, and 18 sockets were randomly treated with PET. Furthermore, patients were split into subgroup A, with buccal bone plate thickness (BPT) ≤1 mm, and subgroup B, with BPT>1 mm. Buccal (BCH) and palatal (PCH) cortex height, bucco-palatal ridge (BPR) width were monitored at tooth extraction and after the 4-month post-extractive period of natural healing.

RESULTS

After 4 months, BCH, PCH and BPR width decreased more in the TET than in the PET group, but only the BPR decrease was statistically significant (P = 0.034) after ANOVA test. In both TET and PET groups, all B subgroup patients showed a lower decrease than A subgroup patients for both BCH, PCH and BPR, statistically significant for PCH (P = 0.019) and BPR (P < 0.001) of TET group, and BPR (P = 0.002) of PET group, after ANOVA. Both A and B subgroups of PET showed a statistically significant lower decrease than the corresponding subgroups of TET, comparing A (P = 0.005) and B (P = 0.037) subgroups for BPR, after ANOVA.

CONCLUSIONS

With both thin and thick buccal plates, the piezosurgical extraction technique of teeth significantly decreases the horizontal resorption of the hard tissue ridge, but not the vertical resorption. Moreover, buccal plate thickness seems to be a key factor in post-extractive bone resorption: the thinner the buccal plate the greater the horizontal crestal bone loss.

[Comparative study bone tissue temperature changes by using conventional and piezosurgical methods in dental implantology]

The laboratory study compared thermal bone lesion by the formation of dental implant bed using traditional and piezosurgical method with varying degrees of irrigation. The study was carried out on cadaveric mandible and porcine mandible with preserved soft tissues. Implant bed was formed by Implantmed dispenser (W&H, Austria) and AstraTech drills (Sweden) according to standard clinical protocol or by piezosurgical device Implant Center (Satelec Acteon Group, France) with Intra Lift II (Satelec Acteon Group, Франция) and №1 scalpel tips with D1 power under minimal and maximal irrigation. The results showed that the formation of the bone bed was safe when using both conventional and piezosurgical method under copious irrigation. The possibility of bone tissue thermal damage increases when using minimum irrigation or no irrigation.

Piezosurgery: A new and safe technique for distraction osteogenesis in Pierre Robin sequence review of the literature and case report

INTRODUCTION

Pierre Robin sequence (PRS) is characterized by microgenia and retrognathia. Cleft palate and glossoptosis are frequently associated with airway obstruction and difficulty in swallowing. Distraction osteogenesis with micro-distractors has recently been considered as a surgical option during the neonatal age.

CASE PRESENTATION

A 6-week-old female with PRS underwent mandibular lengthening in neonatal age. Mandibular osteotomies were performed with the piezoelectric scalpel.

DISCUSSION

Piezosurgery represents an innovative technique as it offers the maxillofacial surgeon the opportunity to make precise bone cuts without damaging the soft tissue, minimizing the invasiveness of the surgical procedure, and the opportunity of working in a field which is almost totally blood free.

CONCLUSION

The use of a piezoelectric device to perform this kind of surgery provides clinical and surgical results which would be difficult with traditional instruments, not only for the patient's benefit but also for the surgeon's. Preservation of the original bony structure, especially of the cancellous bone, will benefit the bone healing process due to its high estrogenic potential.

Piezosurgery applied to implant dentistry: clinical and biological aspects

Piezosurgery is a new and modern technique of bone surgery in implantology. Selective cutting is possible for different ultrasonic frequencies acting only in hard tissues (mineralized), saving vital anatomical structures. With the piezoelectric osteotomy technique, receptor site preparation for implants, autogenous bone graft acquistition (particles and blocks), osteotomy for alveolar bone crest expansion, maxillary sinus lifting, and dental implant removal can be performed accurately and safely, providing excellent clinical and biological results, especially for osteocyte viability. The aim of this review was, through literature review, to present clinical applications of piezosurgery in implant dentistry and outline their advantages and disadvantages over conventional surgical systems. Moreover, this study addressed the biological aspects related to piezosurgery that differentiate it from those of bone tissue approaches. Overall, piezosurgery enables critical operations in simple and fully executable procedures; and effectively, areas that are difficult to access have less risk of soft tissue and neurovascular tissue damage via piezosurgery.

Piezosurgery versus conventional osteotomy in orthognathic surgery: a paradigm shift in treatment

The aim of the study was to compare in a randomized controlled clinical trial the use of the piezoelectric osteotomy as an alternative to the conventional approach in terms of surgery time, intraoperative blood loss, cut quality, nerve injury, and costs.One hundred ten patients who had orthognathic surgery procedures with bimaxillary osteotomy were divided into 2 groups: group A was treated with a piezosurgery device, and group B, with a reciprocating saw and bur.The piezosurgical bone osteotomy permitted individualized cut designs. The surgical time in group A was reduced, with a mean for the mandibular osteotomy (1 side) between 3 minutes 31 seconds and 5 minutes 2 seconds, whereas in group B, the surgical time was between 7 minutes 23 seconds and 10 minutes 22 seconds. The surgical time in group A for the Le Fort I osteotomy was between 5 minutes 17 seconds and 7 minutes 55 seconds in group A and between 8 minutes 38 seconds and 15 minutes 11 seconds in group B. All patients in group A had a low blood loss (<300 mL) versus patients of group B who had a medium to high blood loss (medium loss: 400 mL, high loss: >500 mL). Inferior alveolar nerve sensation was retained in 98.2% of group A versus 92.7% in group B at 6 months postoperative testing.Piezoelectric osteotomy reduced surgical time, blood loss, and inferior alveolar nerve injury in bimaxillary osteotomy. Absence of macrovibrations makes the instrument more manageable and easy to use and allows greater intraoperative control with higher safety in cutting in difficult anatomical regions.

Sub-crestal positioning of implants results in higher bony crest resorption: an experimental study in dogs

OBJECTIVE

To compare peri-implant soft- and hard-tissue integration at implants installed juxta- or sub-crestally. Furthermore, differences in the hard and soft peri-implant tissue dimensions at sites prepared with drills or sonic instruments were to be evaluated.

MATERIAL AND METHODS

Three months after tooth extraction in six dogs, recipient sites were prepared in both sides of the mandible using conventional drills or a sonic device (Sonosurgery(®)). Two implants with a 1.7-mm high-polished neck were installed, one with the rough/smooth surface interface placed at the level of the buccal bony crest (control) and the second placed 1.3 mm deeper (test). After 8 weeks of non-submerged healing, biopsies were harvested and ground sections prepared for histological evaluation.

RESULTS

The buccal distances between the abutment/fixture junction (AF) and the most coronal level of osseointegration (B) were 1.6 ± 0.6 and 2.4 ± 0.4 mm; between AF and the top of the bony crest (C), they were 1.4 ± 0.4 and 2.2 ± 0.2 mm at the test and control sites, respectively. The top of the peri-implant mucosa (PM) was located more coronally at the test (1.2 ± 0.6 mm) compared to the control sites (0.6 ± 0.5 mm). However, when the original position of the bony crest was taken into account, a higher bone loss and a more apical position of the peri-implant mucosa resulted at the test sites.

CONCLUSIONS

The placement of implants into a sub-crestal location resulted in a higher vertical buccal bone resorption and a more apical position of the peri-implant mucosa in relation to the level of the bony crest at implant installation. Moreover, peri-implant hard-tissue dimensions were similar at sites prepared with either drills or Sonosurgery(®).

Use of Piezosurgery for removal of retrovertebral body osteophytes in anterior cervical discectomy

BACKGROUND CONTEXT

The relatively new technique of Piezosurgery is based on microvibrations, generated by the piezoelectrical effect, which results in selective bone cutting with preservation of adjacent soft tissue.

PURPOSE

To study the applicability of Piezosurgery in anterior cervical discectomy with fusion (ACDF) surgery.

STUDY DESIGN/SETTING

Prospective clinical study at the neurosurgical department of the University of Freiburg, Germany.

PATIENT SAMPLE

Nine patients with cervical disc herniation and retrovertebral osteophytes who underwent ACDF surgery.

OUTCOME MEASURES

Piezosurgery was evaluated with respect to practicability, safety, preciseness of bone cutting, and preservation of adjacent neurovascular tissue. Pre- and postoperative clinical and radiological data were assessed.

METHODS

Piezosurgery was supportively used in ACDF in nine patients with either radiculopathy or myelopathy from disc herniation or ventral osteophytes. After discectomy, osteophytes were removed with Piezosurgery to decompress the spinal canal and the foramina. Angled inserts were used, allowing for cutting even retrovertebral osteophytes.

RESULTS

In all nine cases, Piezosurgery cut bone selectively with no damage to nerve roots, dura, or posterior longitudinal ligament. None of the patients experienced any new neurological deficit after the operation. The handling of the instrument was safe and the cut precise. Osteophytic spurs, even retrovertebral ones that generally only can be approached via corpectomies, could be safely removed because of the angled inserts through the disc space. Currently, a slightly prolonged operation time was observed for Piezosurgery. Furthermore, the design of the handpiece could be further improved to facilitate the intraoperative handling in ACDF.

CONCLUSIONS

Piezosurgery proved to be a useful and safe technique for selective bone cutting and removal of osteophytes with preservation of neuronal and soft tissue in ACDF. In particular, the angled inserts were effective in cutting bone spurs behind the adjacent vertebra which cannot be reached with conventional rotating burs.

Review of high-power ultrasound-industrial applications and measurement methods

Applications involving high-power ultrasound are expanding rapidly as ultrasonic intensification opportunities are identified in new fields. This is facilitated through new technological developments and an evolution of current systems to tackle challenging problems. It is therefore important to continually update both the scientific and commercial communities on current system performance and limitations. To achieve this objective, this paper addresses two key aspects of high-power ultrasonic systems. In the first part, the review of high-power applications focuses on industrial applications and documents the developing technology from its early cleaning applications through to the advanced sonochemistry, cutting, and water treatment applications used today. The second part provides a comprehensive overview of measurement techniques used in conjunction with high-power ultrasonic systems. This is an important and evolving field which enables design and process engineers to optimize the behavior and/or operation of key metrics of system performance, such as field distribution or cavitation intensity.

Healing at implant sites prepared conventionally or by means of Sonosurgery ®. An experimental study in dogs

OBJECTIVE

To compare peri-implant tissue healing at implants installed in sites prepared with conventional drills or a sonic device.

MATERIAL AND METHODS

In six Beagle dogs, the mandibular premolars and first molars were extracted bilaterally. After 3 months, full-thickness muco-periosteal flaps were elevated and recipient sites were prepared in both sides of the mandible. In the right side (control), the osteotomies were prepared using conventional drills, while, at the left side (test), a sonic device (Sonosurgery(®)) was used. Two implants were installed in each side of the mandible. After 8 weeks of non-submerged healing, biopsies were harvested and ground sections prepared for histological evaluation.

RESULTS

The time consumed for the osteotomies at the test was more than double compared to the conventional control sites. No statistically significant differences were found for any of the histological variables evaluated for hard and soft tissue dimensions. Although not statistically significant, slightly higher mineralized bone-to-implant contact was found at the test (65.4%) compared to the control (58.1) sites.

CONCLUSIONS

Similar healing characteristics in osseointegration and marginal hard tissue remodeling resulted at implants installed into osteotomies prepared with conventional drills or with the sonic instrument (Sonosurgery(®)).