A comparison of piezosurgery and conventional surgery by heat shock protein 70 expression

A comparative analysis of postoperative morbidity and alveolar bone regeneration following surgical extraction of ımpacted lower third molar teeth using piezosurgery and conventional ınstruments: a split-mouth clinical ınvestigation

BACKGROUND-OBJECTIVE(S)

This randomized, split-mouth study aimed to compare postoperative complications following the surgical extraction of impacted lower third molars using piezosurgery versus conventional rotary instruments.

MATERIALS AND METHODS

Twenty-one patients, aged 18-35 years, with bilaterally and symmetrically impacted lower third molars, were randomly assigned to undergo extraction using piezosurgery on one side and conventional rotary instruments on the other.

RESULTS

The piezosurgery method required a longer operation time. However, it resulted in quicker resolution of postoperative swelling by the 7th day compared to the conventional method, where swelling persisted longer. Mandibular angle-tragus measurements were significantly higher with the conventional method on the 1st, 3rd, and 7th postoperative days. Although mouth opening decreased significantly after piezosurgery, it returned to preoperative levels by the 7th day, outperforming the conventional method. Postoperative pain was notably higher with the conventional method during the first four days but showed no significant difference from the 5th day onward. Alveolar bone healing was significantly better with piezosurgery at the 3rd and 6th months. Temporary paresthesia occurred in one patient from the conventional group, resolving within four weeks. Neither method resulted in alveolar osteitis.

CONCLUSION(S)

Within the study's limitations, piezosurgery demonstrated a reduction in postoperative discomfort, suggesting its advantage in enhancing patient recovery following lower third molar extractions.

CLINICAL SIGNIFICANCE

Piezosurgery, when used appropriately, can reduce postoperative complications compared to conventional methods. Clinicians should be aware of its indications, benefits, and potential challenges. Trial registration This study was registered as a clinical trial to the ClinicalTrials.gov, and the registration ID is NCT06262841 ( https://clinicaltrials.gov/study/NCT06262841 ).

A Pilot Randomized Controlled Clinical Trial Comparing Piezo Versus Conventional Rotary Surgery for Removal of Impacted Mandibular Third Molars

Background: The extraction of impacted mandibular third molars is a frequent dental surgery, interfering with patients’ quality of life. Ultrasonic surgery is an alternative to osteotomy with conventional rotary instruments. This study compares postoperative signals and symptoms after extracting impacted mandibular third molars using ultrasonic surgery or conventional rotary osteotomy. Methods: A pilot randomized controlled clinical trial was conducted. Thirty patients were randomly divided into the test group (ultrasonic technique) and a control group (conventional rotatory technique). All surgeries were timed. Swelling parameters, trismus and paraesthesia were evaluated on the day of surgery and the third, fifth and seventh postoperative days. Intraoperative bleeding was evaluated during surgery. Postoperative pain was evaluated daily by the patient through a visual analogue scale and the number of ingested analgesics. Results: Pain, swelling and trismus present beneficial results with the ultrasonic technique but without statistical significance. Intraoperative bleeding was significantly lower with ultrasonic surgery (t(28) = 3.258; p = 0.003). Operating time was significantly higher in extractions involving osteotomy and cutting crown and roots either with the conventional technique (p = 0.020) or ultrasonic technique (p = 0.039). Regardless of the surgical difficulty, no statistically significant results were detected between techniques regarding the procedure duration. Conclusions: The beneficial postoperative signs and symptoms make ultrasonic surgery a favourable therapeutic option, especially when the integrity of noble anatomical structures is the most important risk factor. Further studies with larger samples are needed to support the use of piezosurgery as a valid option for impacted mandibular third molar extraction.

Evaluation of heat shock protein 70 and toll-like receptor 4 expression in gingival crevicular fluid in response to orthodontic forces

OBJECTIVES

The aim of this study was to assess the concentrations of heat shock protein 70 (HSP70) and toll-like receptor 4 (TLR4) during orthodontic tooth movement and to compare their levels with interleukin-1β (IL-1β), a well-known proinflammatory biomarker.

MATERIALS AND METHODS

This study consisted of 20 patients (8 males, 12 females; mean age 14.75 ± 2.34 years) who needed maxillary premolar extraction and segmental canine distalization. Concentrations of HSP70, TLR4, and IL-1β were examined before extraction (T1), at the 1st (T2), 4th (T3), 7th (T4), 14th (T5), and 30th (T6) days of canine retraction by enzyme-linked immunosorbent assay analysis of gingival crevicular fluid samples. Statistical analyses were performed with repeated measure ANOVA and Spearman's rank correlation coefficient analysis (p < 0.05).

RESULTS

HSP70 increased gradually from T1 to T6 and showed significant differences between T1-T6 and T2-T6 (T1:3.28 ± 0.92 ng/ml; T2:3.72 ± 0.66 ng/ml; T6:9.35 ± 2.45 ng/ml). The lowest TLR4 concentration was at T1, peaked at T3 and remained constant afterwards with significant differences between T1-T3, T1-T4, and T1-T6 (T1:0.71 ± 0.02 pg/ml; T3:1.04 ± 0.11 pg/ml; T4:0.95 ± 0.06 pg/ml; T6:1.00 ± 0.07 pg/ml). IL-1β increased from T1 to T6 with significant differences between T1-T4, T1-T5, and T1-T6 (T1:55.71 ± 5.48 pg/ml; T4:100.11 ± 16.92 pg/ml; T5:103.71 ± 23.19 pg/ml; T6:125.12 ± 22.04 pg/ml). The increase in HSP70 and TLR4 from T2-T3 showed a significant correlation (r = 0.598; p = 0.005).

CONCLUSIONS

The increased levels of HSP70, TLR4, and IL-1β show the contribution of these mediators to the inflammatory response from the early stages of orthodontic tooth movement.

CLINICAL RELEVANCE

The regulation of HSP70, TLR4, and/or IL-1β secretion during orthodontic force application could provide alterations for desired optimal tooth movement.

Bone Healing Evaluation Following Different Osteotomic Techniques in Animal Models: A Suitable Method for Clinical Insights

Osteotomy is a common step in oncological, reconstructive, and trauma surgery. Drilling and elevated temperature during osteotomy produce thermal osteonecrosis. Heat and associated mechanical damage during osteotomy can impair bone healing, with consequent failure of fracture fixation or dental implants. Several ex vivo studies on animal bone were recently focused on heating production during osteotomy with conventional drill and piezoelectric devices, particularly in endosseous dental implant sites. The current literature on bone drilling and osteotomic surface analysis is here reviewed and the dynamics of bone healing after osteotomy with traditional and piezoelectric devices are discussed. Moreover, the methodologies involved in the experimental osteotomy and clinical studies are compared, focusing on ex vivo and in vivo findings.

Bone microRNA-21 as surgical stress parameter is associated with third molar postoperative discomfort

OBJECTIVE

To evaluate an association between bone levels of inflammation/oxidative stress mediators and postoperative discomfort after third molar conventional or piezosurgery.

MATERIAL AND METHODS

Twenty-six subjects with bilaterally impacted mandibular third molars, who underwent either piezo or conventional surgery, were included in a split-mouth design study. MicroRNA-21 (miR-21) expression, interleukin-1 beta (IL-1β), and vascular endothelial growth factor (VEGF) proteins, as well as superoxide dismutase (SOD) activity in alveolar bone, were evaluated. Pain intensity, the first pain appearance, analgesic first use and total dose taken, trismus, and swelling were clinically recorded.

RESULTS

MiR-21 expression was higher while VEGF protein was lower in piezosurgery vs. conventional groups. The differences in IL-1β protein and SOD activity were not significant between groups. The pain intensity on the first day was significantly decreased in piezosurgery group. The first pain appearance and the first analgesic taken were reported sooner in conventional vs. piezosurgical group. Significantly pronounced trismus on the third day following conventional surgery was found. In conventional group, significantly increased trismus was observed on the third compared to the first postoperative day. MiR-21 showed significant correlation with the first pain appearance.

CONCLUSION

Delayed onset of less pronounced postoperative pain after piezosurgical vs. conventional extraction of impacted lower third molar was significantly associated with expression of bone miR-21.

CLINICAL RELEVANCE

Alveolar bone miR-21 may reflect surgical stress and is associated with third molar postoperative pain onset.

Piezoelectric bone surgery for impacted lower third molar extraction compared with conventional rotary instruments: a systematic review, meta-analysis, and trial sequential analysis

The aim of this study was to evaluate whether piezoelectric bone surgery (PBS) for impacted lower third molar extraction reduces the surgical time and risk of intra- and postoperative complications in comparison with conventional rotary instruments. This meta-analysis followed the PRISMA guidelines and was registered in the PROSPERO database. The PubMed, Embase, Scopus, and OpenGrey databases were screened for articles published from January 1, 1990 to December 31, 2018. Selection criteria included randomized controlled trials (RCTs) comparing PBS with conventional rotary instruments for impacted lower third molar extraction and reporting any of the clinical outcomes (intra- and postoperative complications and duration of surgery) for both groups. A risk of bias assessment was performed using the Cochrane Collaboration tool. A meta-analysis was performed, and the power of the meta-analytic findings was assessed by trial sequential analysis (TSA). Strong evidence suggests that PBS prolongs the duration of surgery and low evidence suggests that PBS reduces postoperative morbidity (pain and trismus) in comparison with rotary instruments. Data were insufficient to determine whether PBS reduces neurological complications and postoperative swelling in comparison with burs.

Randomized clinical study comparing Piezoelectric Surgery with conventional rotatory osteotomy in mandibular third molars surgeries

Purpose

The aim of this study was to evaluate the performance and to assess the postoperative sequel and quality of life after removal of impacted mandibular third molars using piezoelectric surgery compared with conventional rotatory osteotomy.

Patients and methods

A single blinded, randomized, control clinical study was performed. Sixty-three patients (44 males, 19 females) who presented with bilaterally asymptomatic impacted mandibular third molars were included in this analysis. Each patient was treated, at two separate sessions approximately 4 weeks apart, with a conventional rotatory hand piece on one side of the mandible and a piezoelectric device on the contralateral side. Patients were followed up on postoperative days 1, 3, 5, 7, and 15 to rate the pain, swelling and trismus. Inferior alveolar nerve paresthesia was evaluated up to 12 months postoperatively.

Results

The severity of the pain, trismus and swelling using the piezosurgery were significantly different from the rotary group. In both groups, pain was most intense and peaked during the first post-operative day, while swelling and trismus reached peak levels on the third postoperative day. The piezoelectric procedure resulted in a significantly longer procedural duration compared to the rotatory surgery (P < 0.001).

Conclusion

Piezoelectric surgery is considered a viable alternative technique compared to the conventional rotary systems and can improve a patient’s quality of life. Thus, piezoelectric surgery might be a preferred modality for patients undergoing complicated surgical extraction of impacted lower third molars.

Ultrasonic versus conventional gap arthroplasty for the release of ankylosis of temporomandibular joint: a prospective cohort study

The purpose of this study was to compare the clinical outcomes of ultrasonic surgery to the conventional bone cutting technique using bur and saw for the release of ankylosis of temporomandibular joint. We conducted a prospective cohort study on 25 patients with 38 ankylotic joints at Chinese PLA General Hospital from March 01, 2012 to March 01, 2016. Patients were followed up at least 2 years postoperatively. The primary outcome was the intraoperative blood loss per joint. The secondary outcome was the long-term (≥2 years) improvement of maximum mouth opening. The blood loss was significantly reduced in the ultrasonic group compared to the conventional group (107.3 ± 62.3 ml vs. 186.3 ± 92.6 ml, P = 0.019). The long-term improvements of maximum mouth opening were substantial and stable in both groups (33.5 ± 4.8 mm in the ultrasonic group vs. 29.2 ± 6 mm in the conventional group, P = 0.06). Multivariate linear regression analysis showed a significant association between blood loss and technique used (coefficient: 66.3, 95% confidence interval: 22.1,110.4, P = 0.006). The ultrasonic surgery was associated with less intraoperative blood loss when compared to the conventional method for the release of ankylosis of temporomandibular joint while providing a stable and comparable long-term improvement of maximum mouth opening.

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.

Influence of piezotomy and osteoperforation of the alveolar process on the rate of orthodontic tooth movement: a systematic review

OBJECTIVE

The minimally invasive procedures piezosurgical corticocision and osteoperforation have been advocated as methods to accelerate orthodontic tooth movement and to shorten treatment time, but without large-scale trauma of the periosteum and the bone. The aim of this study was to evaluate if there is evidence supporting these claims based on a systematic review of the literature.

MATERIALS AND METHODS

A search of PubMed and Google Scholar with the combined search terms "piezo*" and "tooth movement" was performed until May 2016. In addition, the keywords "osteoperforation" and "piezopuncture" were searched in both databases. All scientific articles were considered and examined for suitability by two scientists. Disagreements resolved by consensus. The first inclusion criterion was studies with human species. Second inclusion criterion the surgical procedure had to be performed transmucosally and without the elevation of a mucoperiosteal flap. Case series were also considered.

RESULTS

The Google Scholar search delivered 516, the PubMed search 60 references. A total of 36 human trials fulfilling the first inclusion criterion were identified. Among those, in only 13 publications was a transmucosal technique used (12 on piezosurgical corticocision and 1 on osteoperforation). Of the 13 articles, 9 represented case series and only 4 were clinical trials. In all four trials, an acceleration of the orthodontic treatment was reported. However, the extent of the acceleration was inconsistent and in one article it disappeared when assessing the overall orthodontic treatment.

CONCLUSION

Evidence for an acceleration of tooth movement in conjunction with the minimally invasive methods piezosurgical corticocision and osteoperforation of the alveolar process in humans is low.

Comparison of Radiofrequency and Electrocautery With Conventional Scalpel Incisions

PURPOSE

The disadvantages of conventional scalpels, including insufficient control of bleeding, prompted us to search for new alternative methods such as electrosurgery and radiosurgery. In this study, the conventional scalpel was compared with radiosurgery and electrosurgery for wound healing with assessment of lateral heat production, inflammation, and instrument performance.

MATERIALS AND METHODS

Incisions were made in the palatal mucosa of 42 Wistar rats using a scalpel, electrocautery instrument, or radiofrequency instrument. Postoperative hemostasis, tissue coagulation, and tissue sticking were measured, and pain evaluation through weight loss was recorded. Gingival biopsy specimens from the surgical area were obtained at the time of surgery and 2, 4, 7, and 14 days postoperatively and were evaluated immunohistochemically for inducible nitric oxide synthase and heat shock protein 70. Kruskal-Wallis, 1-way analysis of variance, and Mann-Whitney U tests were used for statistical evaluation.

RESULTS

The rats in the electrosurgery and radiosurgery groups had aggressively greater weight loss when compared with the scalpel group in the first 7 days. Hemostasis was better in the electrocautery group, tissue coagulation was greater in the radiofrequency group (P < .001), and tissue sticking was lesser in the scalpel group (P < .001) compared with the other groups. Inducible nitric oxide synthase expression and heat shock protein 70 expression were similar in all 3 groups.

CONCLUSIONS

Electrosurgery performed better regarding hemostasis, whereas a scalpel was superior in terms of tissue sticking and tissue coagulation. Radiosurgery was superior regarding hemostasis when compared with a conventional scalpel, but it was not as successful as electrosurgery.

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.

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.

Four osteotomy methods with piezosurgery to remove complicated mandibular third molars: a retrospective study

PURPOSE

Piezosurgery has been used widely in oral and maxillofacial surgery, but there has been no report systematically describing an osteotomy method with piezosurgery for complicated mandibular third molar removal. The aim of this study was to introduce 4 osteotomy methods using piezosurgery and evaluate their effects.

MATERIALS AND METHODS

A retrospective study was conducted of patients with a complicated impacted mandibular third molar requiring extraction. The predictor variable was the extraction technique. Four osteotomy methods using piezosurgery were tested according to different impaction types: method 1 involved complete bone removal; method 2 involved segmental bone removal; method 3 involved bone removal combined with tooth splitting; and method 4 involved block bone removal. Outcome variables were success rate, operative time, major complications (including nerve injury, mandible fracture, severe hematoma, or severe edema), and serious pyogenic infection. Data were analyzed using descriptive statistics.

RESULTS

The study was composed of 55 patients with 74 complicated impacted mandibular third molars. All impacted mandibular third molars were removed successfully. The average surgical time was 15 minutes (range, 8 to 26 minutes). Thirty-eight molars (51.4%) were extracted by method 1, 18 molars (24.3%) by method 2, 12 molars (16.2%) by method 3, and 6 molars (8.1%) by method 4. Two cases (2.7%) developed postoperative infections and recovered within 1 week using drainage and antibiotic administration.

CONCLUSION

The 4 osteotomy methods with piezosurgery provide effective ways of removing complicated impacted mandibular third molars.

Effects of a new piezoelectric device on periosteal microcirculation after subperiosteal preparation

INTRODUCTION

Subperiosteal preparation using a periosteal elevator leads to disturbances of local periosteal microcirculation. Soft-tissue damage can usually be considerably reduced using piezoelectric technology. For this reason, we investigated the effects of a novel piezoelectric device on local periosteal microcirculation and compared this approach with the conventional preparation of the periosteum using a periosteal elevator.

MATERIAL AND METHODS

A total of 20 Lewis rats were randomly assigned to one of two groups. Subperiosteal preparation was performed using either a piezoelectric device or a periosteal elevator. Intravital microscopy was performed immediately after the procedure as well as three and eight days postoperatively. Statistical analysis of microcirculatory parameters was performed offline using analysis of variance (ANOVA) on ranks (p<0.05).

RESULTS

At all time points investigated, intravital microscopy demonstrated significantly higher levels of periosteal perfusion in the group of rats that underwent piezosurgery than in the group of rats that underwent treatment with a periosteal elevator.

CONCLUSION

The use of a piezoelectric device for subperiosteal preparation is associated with better periosteal microcirculation than the use of a conventional periosteal elevator. As a result, piezoelectric devices can be expected to have a positive effect on bone metabolism.

Ablation of porcine bone tissue with an ultrashort pulsed laser (USPL) system

Ultrashort pulsed lasers (USPLs) represent a new generation of laser systems in the field of biophotonical applications. In terms of a pilot project, the study was carried out to evaluate the ablation parameters of bone tissue regarding the medical use of such a laser technology in dentistry. Specimens from ribs of freshly slaughtered pigs were assembled and irradiated with an USP Nd:YVO4 laser (pulse duration 8 ps at 1,064 nm with repetition rates between 50 and 500 kHz) using eligible average output powers in the range of 3.5-9 W and fluences between 1 and 2.5 J/cm(2). Square-shaped cavities of 1-mm edge length in the bone compacta were created employing a scanner system. Cavities were analyzed with an optical profilometer to determine the ablated volume. Ablation rate was calculated by the ablated volume and the recorded irradiation time by the scanner software. Additionally, samples were examined histologically to investigate side effects of the surrounding tissue. Formed cavities showed a precise and sharp-edged appearance in bone compacta. Optimized ablation rate of 5.2 mm(3)/min without any accompanying side effects was obtained with an average output power of 9 W, a pulse repetition rate of 500 kHz, and an applied fluence of 2.5 J/cm(2). Provided that the used laser system will be advanced and adjusted for clinical applications, the outcome of this study shows auspicious possibilities for the use of USPL systems in the preparation of bone tissue.

Subperiosteal preparation using a new piezoelectric device: a histological examination

Introduction: Subperiosteal preparation using a periosteal elevator leads to disturbances of local immunohistochemistry and periosteal histology due to a microtrauma. Usually soft-tissue damage can be considerably reduced by using piezoelectric technology. For this reason, the effects of a novel piezoelectric device on immunohistochemistry and periosteal histology were examined and compared to conventional preparation of the periosteum using a periosteal elevator.

Material and methods: Lewis rats were randomly assigned to one of five groups (n=50). Subperiosteal preparation was performed using either a piezoelectric device or a periosteal elevator. Immunohistochemical and histological analyses were performed immediately after preparation as well as three and eight days postoperatively. A statistical analysis of the histological colouring was performed offline using analysis of variance (ANOVA) on ranks (p<0.05).

Results: At all times, immunohistochemical and histological analysis demonstrated a significantly more homogenous tissue structure in the group of rats that underwent piezosurgery than in the group of rats that underwent treatment with a periosteal elevator.

Conclusion: The use of a piezoelectric device for subperiosteal preparation is associated with more harmonious immunohistochemical and histological results for the periosteum than the use of a conventional periosteal elevator. As a result, piezoelectric devices can be expected to have a positive effect primarily on soft tissue, in particular of the periosteal as well as on surrounding tissues.