Bone lid technique with piezosurgery to preserve inferior alveolar nerve

Loop-Neurorrhaphy Technique for Preventing Bone Resorption and Preserving Sensation in Mandibular Reconstruction

BACKGROUND

The aim of this study was to investigate whether using an innervated vascularized iliac bone flap could effectively prevent bone resorption and maintain sensory function in the lower lip.

METHODS

In the innervated group, the deep circumflex iliac artery and recipient vessels were anastomosed, with simultaneous microanastomosis of ilioinguinal nerve, mental nerve, and inferior alveolar nerve. Conversely, the control group underwent solely vascular anastomosis. Computed tomography was used to assess bone quality. Sensory recovery of the lower lip was recorded using 2-point discrimination and current perception threshold testing.

RESULTS

The study comprised a total of 40 subjects, with each group accounting for 20 participants, equally distributed in terms of gender. Hounsfield unit loss was significantly lower in the innervated group (13.26% ± 8.65%) as compared with the control group (37.98% ± 8.60%) ( P < 0.001). Moreover, 2-point discrimination values were lower in the innervated group (15.11 ± 8.39 mm) when compared with the control group (21.44 ± 7.24 mm) ( P = 0.02). The current perception threshold values for the innervated group were 176.19 ± 31.89, 64.21 ± 19.23, and 42.29 ± 18.96 at 2 kHz, 250 Hz, and 5 Hz, respectively, whereas in the control group, the current perception threshold values were 204.47 ± 36.99, 82.26 ± 27.29, and 58.89 ± 25.38 at 2 kHz, 250 Hz, and 5 Hz ( P = 0.02, P = 0.02, and P = 0.03, respectively).

CONCLUSION

The innervated vascularized iliac bone flap represents a safe and effective novel approach to preserving lower lip sensation and preventing bone resorption through functional mandibular reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Piezoelectric Device and Dynamic Navigation System Integration for Bone Window-Guided Surgery

INTRODUCTION

This study investigates the feasibility of integrating a piezoelectric device (PIEZO) into a dynamic navigation system (DNS) for bone-window guided surgery. It compares the accuracy and efficiency of PIEZO + DNS to PIEZO + Freehand (FH) procedure for bone-window cutting and root-end resection (RER).

METHODS

Forty-eight mandibular molars of 3D-printed surgical jaw models were divided into two groups: PIEZO + DNS (n = 24) and PIEZO + FH (n = 24). Cone-beam computed tomography scans were taken before and after the procedure. The procedure was virtually planned on X-guide software. The bone-window cutting and RER were conducted with a PIEZO under dynamic navigation in the PIEZO + DNS group and using the dental operating microscope in the PIEZO + FH group. The 2D- and 3D-accuracy deviations and angular deflection were measured for the bone window cut. The root length resected and resection angle were calculated. The bone window cut, RER, total operating time, and number of mishaps were recorded.

RESULTS

PIEZO + DNS was more accurate than PIEZO + FH for bone-window cutting, showing fewer 2D and 3D deviations and less angular deflection (P < .05). The resection angle was lower in the PIEZO + DNS (P < .05). The bone-window cut and total operating time were significantly reduced using a DNS (P < .05). There was no difference in the number of mishaps (P > .05).

CONCLUSIONS

Within the limitations of this in vitro study, the integration of a PIEZO into a DNS is feasible for bone-window guided surgery. The DNS improved the accuracy and efficiency of bone-window cutting.

The Temporary Mental Nerve Paresthesia as an Outcome of Dentigerous Cyst Removal during Preparation for Dental Implant Placement: A Case Report

The usage of xenograft material is widely used in almost all oral cavity bone defects for regenerative and reconstructive purposes. The presented xenograft usage in the following care report enabled good bone defect healing and enabled the preservation of affected premolars. It is quite common to use any possible variations of bone materials to ensure bone defect improved healing. In some cases, the scope of surgeries requires the removal of each cyst within close proximity to various nerves and vessels. The inferior alveolar, infraorbital, lingual, and mental nerves are those most commonly adjacent to most operating sites in jaw bones. The usage of some additional materials such as collagen sponges, bone substitutes, resorbable membranes, or other additional materials are useful in each bone defect reconstruction but should be handled with care, as described in the following case. Before planning their usage, it is important to perform each surgery with close cone beam computed tomography imaging, which is very helpful to establish the scope of each lesion and the proximity of vital structures. There are a lot of factors that might influence any possible nerve damage, especially the different nerve anatomical variations. Even factors including the subperiosteal preparation and compression of adjacent tissues might influence later nerve function. When the lesion is expanding through the buccal cortical plate and when soft tissue fluctuation is present, some special care is needed. Similar to the presented case, a limitation in crushing, blowing, or any irritation of nerve fibers improves later postoperative outcomes. When the wound and surrounding tissues are handled with care, a limited possibility of any damage or paresthesia can occur. When the nerve itself is damaged or cut, loss of function can be permanent. Immediately after or even prophylactic prescription 1–2 days before the surgery of Vitamin B with NSAIDs (Non-steroidal anti-inflammatory drugs) (or other additional supplementary medicaments can improve nerve function in time. Possible nerve damage can be divided into many etiological factors. A quite different situation arises when the nerve is pulled in by the cyst growth into the cyst wall. The presented case report describes the outcomes of a cyst removal from the mandibular basis and treatment modalities.

Piezosurgery Versus Conventional Method Alveoloplasty: A Comparative Study

Purpose

The conventional alveoloplasty approach which uses manual equipment results in more resorption of the underlying alveolar ridge that makes denture prosthesis unstable. The goal of this study was to compare results of piezosurgery alveoloplasty to those of conventional alveoloplasty.

Materials and Methods

This was an in-vivo comparative study consisting of ten edentulous individuals who needed alveoloplasty due to bilateral bony projection. On one side, a conventional alveoloplasty was performed with a bone rongeur and bone file, whereas the contralateral side was treated with a piezosurgery unit. The clinical parameters were analyzed using SPSS version 21 software including operating time, postoperative pain evaluation on day 3 and a healing on day 7.

Results

There was a statistically significant difference between the two groups in terms of outcome variables such as operating time, pain and healing. The Conventional group has a lower mean of operating time, a higher mean rank of VAS and a lower mean rank of healing index compared to the piezosurgery group.

Conclusion

Piezosurgery alveoloplasty not only lowers postoperative patient discomfort but also preserves alveolar bone integrity by not disrupting soft and hard tissue architecture thus allowing faster tissue healing and easier prosthesis replacement in the future.

The Bone Lid Technique in Oral and Maxillofacial Surgery: A Scoping Review

This scoping review aimed at reporting the outcomes of the bone lid technique in oral surgery in terms of bone healing, ridge preservation, and incidence of complications. Bone-cutting instruments and stabilization methods were also considered. PubMed, Scopus, and the Cochrane Register of Controlled Trials were searched using a combination of terms, including bone lid, bony window, piezosurgery, microsaw, cysts, endodontic surgery, impacted teeth, and maxillary sinus. A hand search was also performed. The last search was conducted on 30 November 2021. No date limitation was set. Searches were restricted to human clinical studies published in English. All types of study design were considered except reviews and case reports. After a two-step evaluation, 20 (2 randomized studies, 2 case-control studies, 3 cohort studies, 13 case series) out of 647 screened studies were included, reporting on 752 bone lid procedures. The bone lid technique was associated with favorable bone healing when compared to other methods, and with a very low incidence of major complications. Clinical indications, surgical procedures, study design, follow-up duration, and outcomes varied among the studies. Overall, favorable outcomes were reported using the bone lid approach, though evidence-based studies were scarce.

Comparison Between the Bone Lid Technique and the Traditional Technique in Surgical Treatment of the Posterior Mandibular Lesions: A Randomized Controlled Trial

Introduction

Cystic lesions of the jaws and the impacted teeth are two of the most common cases that require surgical intervention in oral and maxillofacial surgery; however, surgeons also frequently use a traditional technique that involves the removal of the buccal bone plate. This study was conducted to compare the clinical and radiologic outcomes of the bone lid technique and the traditional technique.

Methods

This randomized controlled trial included 20 patients who were randomly divided into two groups (n = 10 each): the T group, in which the lesions were accessed using the traditional technique with classical rotating instruments, and the BL group, in which the lesions were accessed with the bone lid technique performed using a piezoelectric device, with repositioning of the buccal bone plate. Operative time, pain, edema, inferior alveolar nerve injury, and bone defect healing were measured during clinical and radiological follow-ups at 24 h, 72 h, one week, one month, and six months after the surgery.

Results

Normal soft tissue and bone healing were observed in all cases except one case in the BL group. The T group had a shorter mean operative time than the BL group. In terms of pain, edema, and inferior alveolar nerve injury, the groups did not differ statistically significantly. The percentage of bone defect healing was significantly greater in the BL group than in the T group after six months of follow-up.

Conclusion

The bone lid technique performed using a piezoelectric device was effective and safe for managing lesions in the posterior mandibular region and was not associated with increased postoperative complications. The disadvantages of this technique include a longer operative time and the need for fixation tools in some cases. In contrast, this technique outperforms the traditional technique in terms of reducing bone loss and improving the healing of bone defects.

Present Status and Future Directions - Surgical Endodontics

Endodontic surgery encompasses several procedures for the treatment of teeth with a history of failed root canal treatment, such as root-end surgery, crown- and root resections, surgical perforation repair, and intentional replantation. Endodontic microsurgery is the evolution of the traditional apicoectomy techniques and incorporates high magnification, ultrasonic root-end preparation and root-end filling with biocompatible filling materials. Modern endodontic surgery uses the dental operating microscope, incorporates cone-beam computed tomography (CBCT) for preoperative diagnosis and treatment planning, and has adopted piezoelectric approaches to osteotomy and root manipulation. Crown- and root resection techniques have benefitted from the same technological advances. This review focuses on the current state of root-end surgery by comparing the techniques and materials applied during endodontic microsurgery to the most widely used earlier methods and materials. The most recent additions to the clinical protocol and technical improvements are discussed, and an outlook on future directions is given. While non-surgical retreatment remains the first choice to address most cases with a history of endodontic failure, modern endodontic microsurgery has become a predictable and minimally invasive alternative for the retention of natural teeth.

PRESS and Piezo MicroSurgery (Bony Lid): A Seven Year Evolution in a Residency Program Part 2: PRESS- defined site location

INTRODUCTION

Treatment of a failing endodontic procedure via microsurgical revision presents better outcomes due, in part, to the integration of the Surgical Operating Microscope (SOM) and CBCT into clinical practice. But challenges still remain with respect to the operational locations and the techniques required to address them. Posterior sites, with substantial cortical plate thicknesses and sensitive anatomy, present the dichotomy of visualization versus post-surgical regeneration of bone. The bony lid technique bridges the gap between these two concepts, and the application of Piezosurgery renders a precise and biocompatible osseous incision. The purpose of this paper is to outline, through Case reports, the progression of Piezo-Guided surgery in a resident setting.

METHODS

The first two evolutions of the technique utilized a surgeon-defined method for site location. This third and final evolution utilizes a digital workflow to virtually plan the surgical procedure, integrating STL and DICOM files to create 3-dimensional guides with exacting resection locations, levels, and angles. Export of the virtually planned guide in post-production generates the Precision Endodontic Surgical Stent (PRESS) to accurately define the site location and parameters of the procedure. All surgeries were executed using the Piezosurgical method with increasing levels of guidance and precision throughout the evolution process.

RESULTS

Each step in the technique implementation enabled the resident to assimilate a new technique and skill set while maintaining bone architecture and minimizing volume loss post-operatively. The patient benefits were an increase in intra-operative safety and post-operative comfort. The resident benefits were accelerated regeneration timetables, increase in the confidence level of the resident and number of scheduled posterior surgical procedures.

CONCLUSIONS

The progression from crude on-site measurements to elegant and precise surgical guides enabled the access and manipulations of difficult surgical sites without compromising visibility, post-operative osseous regeneration, or patient comfort.

Precise locating and cutting of the bone lid with a digital template during the treatment of large mandibular cysts: A case series study

The aim of the study was to investigate the efficacy and safety of a digital template in the bone lid technique during enucleation of large mandibular cysts. Six patients were enrolled in this study. Patients' preoperative CT data were collected to design and produce the digital templates. The bone lids were located and cut under the guidance of the digital templates, and then replanted and fixed following cyst enucleation. Postoperative clinical symptoms were observed and recorded from postoperative days 1-7. The follow-up visits were set at 3, 6, and 12 months. The cystic lesions were exactly and fully exposed without the need for secondary bone removal. The contours of the mandibles recovered well, with excellent sealing of the defects. Apart from one case with postoperative infection and one case with 2-month numbness of the lower lip, no other complications occurred. Six months after the surgery, patients' appearance and function were well-restored. A digital template in the bone lid technique during enucleation of large mandibular cysts was effective and safe.

Surgical techniques for the removal of mandibular wisdom teeth

BACKGROUND

Pathology relating to mandibular wisdom teeth is a frequent presentation to oral and maxillofacial surgeons, and surgical removal of mandibular wisdom teeth is a common operation. The indications for surgical removal of these teeth are alleviation of local pain, swelling and trismus, and also the prevention of spread of infection that may occasionally threaten life. Surgery is commonly associated with short-term postoperative pain, swelling and trismus. Less frequently, infection, dry socket (alveolar osteitis) and trigeminal nerve injuries may occur. This review focuses on the optimal methods in order to improve patient experience and minimise postoperative morbidity.

OBJECTIVES

To compare the relative benefits and risks of different techniques for surgical removal of mandibular wisdom teeth.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 8 July 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2019, Issue 6), MEDLINE Ovid (1946 to 8 July 2019), and Embase Ovid (1980 to 8 July 2019). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication.

SELECTION CRITERIA

Randomised controlled trials comparing different surgical techniques for the removal of mandibular wisdom teeth.

DATA COLLECTION AND ANALYSIS

Three review authors were involved in assessing the relevance of identified studies, evaluated the risk of bias in included studies and extracted data. We used risk ratios (RRs) for dichotomous data in parallel-group trials (or Peto odds ratios if the event rate was low), odds ratios (ORs) for dichotomous data in cross-over or split-mouth studies, and mean differences (MDs) for continuous data. We took into account the pairing of the split-mouth studies in our analyses, and combined parallel-group and split-mouth studies using the generic inverse-variance method. We used the fixed-effect model for three studies or fewer, and random-effects model for more than three studies.

MAIN RESULTS

We included 62 trials with 4643 participants. Several of the trials excluded individuals who were not in excellent health. We assessed 33 of the studies (53%) as being at high risk of bias and 29 as unclear. We report results for our primary outcomes below. Comparisons of different suturing techniques and of drain versus no drain did not report any of our primary outcomes. No studies provided useable data for any of our primary outcomes in relation to coronectomy. There is insufficient evidence to determine whether envelope or triangular flap designs led to more alveolar osteitis (OR 0.33, 95% confidence interval (CI) 0.09 to 1.23; 5 studies; low-certainty evidence), wound infection (OR 0.29, 95% CI 0.04 to 2.06; 2 studies; low-certainty evidence), or permanent altered tongue sensation (Peto OR 4.48, 95% CI 0.07 to 286.49; 1 study; very low-certainty evidence). In terms of other adverse effects, two studies reported wound dehiscence at up to 30 days after surgery, but found no difference in risk between interventions. There is insufficient evidence to determine whether the use of a lingual retractor affected the risk of permanent altered sensation compared to not using one (Peto OR 0.14, 95% CI 0.00 to 6.82; 1 study; very low-certainty evidence). None of our other primary outcomes were reported by studies included in this comparison. There is insufficient evidence to determine whether lingual split with chisel is better than a surgical hand-piece for bone removal in terms of wound infection (OR 1.00, 95% CI 0.31 to 3.21; 1 study; very low-certainty evidence). Alveolar osteitis, permanent altered sensation, and other adverse effects were not reported. There is insufficient evidence to determine whether there is any difference in alveolar osteitis according to irrigation method (mechanical versus manual: RR 0.33, 95% CI 0.01 to 8.09; 1 study) or irrigation volume (high versus low; RR 0.52, 95% CI 0.27 to 1.02; 1 study), or whether there is any difference in postoperative infection according to irrigation method (mechanical versus manual: RR 0.50, 95% CI 0.05 to 5.43; 1 study) or irrigation volume (low versus high; RR 0.17, 95% CI 0.02 to 1.37; 1 study) (all very low-certainty evidence). These studies did not report permanent altered sensation and adverse effects. There is insufficient evidence to determine whether primary or secondary wound closure led to more alveolar osteitis (RR 0.99, 95% CI 0.41 to 2.40; 3 studies; low-certainty evidence), wound infection (RR 4.77, 95% CI 0.24 to 96.34; 1 study; very low-certainty evidence), or adverse effects (bleeding) (RR 0.41, 95% CI 0.11 to 1.47; 1 study; very low-certainty evidence). These studies did not report permanent sensation changes. Placing platelet rich plasma (PRP) or platelet rich fibrin (PRF) in sockets may reduce the incidence of alveolar osteitis (OR 0.39, 95% CI 0.22 to 0.67; 2 studies), but the evidence is of low certainty. Our other primary outcomes were not reported.

AUTHORS' CONCLUSIONS

In this 2020 update, we added 27 new studies to the original 35 in the 2014 review. Unfortunately, even with the addition of these studies, we have been unable to draw many meaningful conclusions. The small number of trials evaluating each comparison and reporting our primary outcomes, along with methodological biases in the included trials, means that the body of evidence for each of the nine comparisons evaluated is of low or very low certainty. Participant populations in the trials may not be representative of the general population, or even the population undergoing third molar surgery. Many trials excluded individuals who were not in good health, and several excluded those with active infection or who had deep impactions of their third molars. Consequently, we are unable to make firm recommendations to surgeons to inform their techniques for removal of mandibular third molars. The evidence is uncertain, though we note that there is some limited evidence that placing PRP or PRF in sockets may reduce the incidence of dry socket. The evidence provided in this review may be used as a guide for surgeons when selecting and refining their surgical techniques. Ongoing studies may allow us to provide more definitive conclusions in the future.

Evaluation of accuracy and sensory outcomes of mandibular reconstruction using computer-assisted surgical simulation

PURPOSE

To introduce a modified protocol for mandibular reconstruction and evaluate the protocol using a standardized assessment method.

METHOD

This retrospective study involved a case series of nine patients who underwent mandibular reconstruction between 2015 and 2017. The modular protocol comprised three novel modifications in terms of computer-assisted surgical simulation (CASS); surgical template (ST), and surgical procedure. The standardized postoperative evaluation consisted of operation time, part comparison analysis (PCA), facial symmetry, and mechanical quantitative sensory testing.

RESULTS

The surgery successfully removed the affected mandible and preserved the inferior alveolar neurovascular bundle (IANB). PCA revealed that the mean error and standard deviation were 0.92 and 0.96 mm, respectively, for all mandibular surface sites. Follow-up results showed good facial symmetry, existence of sensation in lower lip, and no significant differences in pulp vitality between both sides (p = 0.181). Also, the results showed a reduction in the overall operating time.

CONCLUSION

The modified mandibular reconstruction method used in this study could repair lateral mandibular defects and preserve the sensory function of the chin and lower lip.

A Step-By-Step Technique for the Piezosurgical Removal of Fractured Implants

With the increasing popularity of dental implants, the removal of fractured implants has become a major challenge for clinicians. Several tools can be used for the removal of osseointegrated implants; however, few of these have the characteristics of easy control, selective cutting, and rapid healing. In this study, the authors describe a step-by-step technique for the removal of osseointegrated fractured implants via multiple peri-implant osteotomies performed using a piezoelectric device and appropriate inserts. All patients ended with primary wound closure without any soft tissue dehiscence and no healing problems during the postoperative period. As the use of ultrasonic inserts enables precise and selective cuts, piezosurgical implant removal is an attractive alternative to trephine burs or rotary drills.

Application of Digital Diagnosis and Treatment Technique in Benign Mandibular Diseases

PURPOSE

To explore the feasibility of preoperative planning for treatment of benign mandibular lesions (BML) using digital technologies such as three-dimensional (3D) reconstruction, measurement, visualization as well as image contrast and design of neural positioning protection template (NPPT) in combination with 3D printing technology in the BML diagnosis and treatment.

METHODS

The 3D models of BML and inferior alveolar nerves (IAN) of 10 BML patients were reconstructed based on their digital imaging and communications in medicine (DICOM) data using MIMICS16.0 software. The models were used to visualize lesions and nerve contrast measurement and guide design of personalized NPPT and osteotomy after operation modality was determined in order to achieve accurate, minimally invasive operation with shortened intraoperative time.

RESULTS

Intraoperative NPPT application could accurately locate lesions and their scope and assist osteotomy. The measurement results were consistent with those of preoperative reconstruction and measurement. The BML were curetted completely without damage IAN. The 10 BML patients had no numbness and other discomforts in the lower lip and mandibular teeth after operation.

CONCLUSIONS

The digital diagnosis and treatment technology is an effective method for functional treatment of BML patients and its application could achieve personalized, minimally invasive and precise treatment and save intraoperation time.

Bone Lid Technique Using a Piezoelectric Device for the Treatment of a Mandibular Bony Lesion

Different techniques for the enucleation of jaw cyst lesion in the oral and maxillofacial regions have been proposed, including the bone lid technique. The purpose of this case report is to describe the case of a cystic lesion, approached with the bone lid technique performed using a piezoelectric device, with an 8-month clinical and radiographic follow-up. A 14-year-old male patient was treated for a suspicious lesion detected on a panoramic radiograph. The concerned area was surgically accessed, and a radiographically predetermined bony window was drawn, and the beveled bony lid was removed. The underlying lesion was enucleated and sent for pathology as a routine procedure, and the removed bony lid was repositioned in situ and secured with a collagen tape. Healing was uneventful with limited swelling and reduced pain. A complete radiographic bone healing at the previously diseased site was confirmed with an 8-month cone beam computed tomography (CBCT) scan with no buccal bone resorption nor ridge collapse. The bone lid technique with a piezoelectric device was noninvasive and atraumatic in this case. Further studies are needed and could lead to the adaptation of this approach as a possible standard of care.

Protection of Inferior Alveolar Neurovascular Bundle in Alveolar Bone Operation

PURPOSE

The aim of this study was to investigate the protection of the inferior alveolar neurovascular bundle in alveolar bone operation in conditions such as chronic osteomyelitis and cementoma.

PATIENTS AND METHODS

The study enrolled 7 cases, 4 with chronic osteomyelitis and 3 with cementoma with pain. Computed tomography scan and 3-dimensional reconstruction were performed for the diseases. Data were processed by ProPlan CMF 1.3 software. The edge of lesion was defined and the inferior alveolar nerve was marked. Template was designed to guide the osteotomy line. Piezosurgery was used for osteotomy, with the avoidance of nerve canal. Current perception threshold (CPT) was performed to evaluate the nerve function after operation.

RESULTS

The CPT difference of the affected side before and after operation showed no statistically significant differences compared with that of the unaffected side (P = 0.0556).

CONCLUSIONS

Digital template protects the inferior alveolar neurovascular bundle with the aid of piezosurgery during alveolar bone resection, which obtained satisfying clinical results. As powerful assistive tools of functional surgery, digital template and piezosurgery achieve both the purposes of treatment and function.

Apicoectomy of maxillary anterior teeth through a piezoelectric bony-window osteotomy: two case reports introducing a new technique to preserve cortical bone

Two case reports describing a new technique of creating a repositionable piezoelectric bony window osteotomy during apicoectomy in order to preserve bone and act as an autologous graft for the surgical site are described. Endodontic microsurgery of anterior teeth with an intact cortical plate and large periapical lesion generally involves removal of a significant amount of healthy bone in order to enucleate the diseased tissue and manage root ends. In the reported cases, apicoectomy was performed on the lateral incisors of two patients. A piezoelectric device was used to create and elevate a bony window at the surgical site, instead of drilling and destroying bone while making an osteotomy with conventional burs. Routine microsurgical procedures - lesion enucleation, root-end resection, and filling - were carried out through this window preparation. The bony window was repositioned to the original site and the soft tissue sutured. The cases were re-evaluated clinically and radiographically after a period of 12 - 24 months. At follow-up, radiographic healing was observed. No additional grafting material was needed despite the extent of the lesions. The indication for this procedure is when teeth present with an intact or near-intact buccal cortical plate and a large apical lesion to preserve the bone and use it as an autologous graft.

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.

Reduced somatosensory impairment by piezosurgery during orthognathic surgery of the mandible

PURPOSE

This clinical trial aimed to test the hypothesis that piezosurgery causes reduced nerval irritations and, thus, reduced somatosensory impairment when used in orthognathic surgery of the mandible.

METHODS

To this end, 37 consecutive patients with Angle Class II and III malocclusion were treated using bilateral sagittal split osteotomies (BSSO) of the mandible. In a split mouth design, randomized one side of the mandible was operated using a conventional saw, while a piezosurgery device was used on the contralateral side. In order to test the individual qualities of somatosensory function, quantitative sensory testings (QSTs) were performed 1 month, 6 months and 1 year after surgery.

RESULTS

A comparison of the data using a two-way analysis of variance (ANOVA) revealed a significant reduction in postoperative impairment in warm detection threshold (WDT) (P = 0.046), a decreased dynamic mechanical allodynia (ALL) (P = 0.002) and a decreased vibration detection threshold (VDT) (P = 0.030) on the piezosurgery side of the mandible as opposed to the conventionally operated control side. In the remaining QSTs, minor deviations from the preoperative baseline conditions and a more rapid regression could be observed.

CONCLUSIONS

Piezosurgery caused reduced somatosensory impairment and a faster recovery of somatosensory functions in the present investigation.

Preservation of the inferior alveolar neurovascular bundle in the osteotomy of benign lesions of the mandible using a digital template

Our aim was to evaluate the effect of a digital template in the preservation of the inferior alveolar neurovascular bundle during osteotomy for benign lesions of the mandible in 6 patients who were treated with mandibular osteotomies during 2013. Computed tomographic (CT) data were imported into ProPlan CMF 1.4 software. The borders of the lesion and the inferior alveolar canal were marked, and a digital template designed to mark the borders, outline the canal, and guide the osteotomy. A mirror image of the unaffected mandible was used to make a stereolithographic model by a rapid prototyping technique to prefabricate the reconstruction plate for the bone graft. The accuracy of the designs and the templates was evaluated during operation and postoperatively by CT. The sensation of the skin was tested using a Neurometer® CPT (current perception threshold) sensory detector (Neurotron Inc, Baltimore USA) to evaluate the function of the preserved inferior alveolar neurovascular bundle during follow up. With the digital template it was possible to guide removal of the bony lesion while accurately protecting the neurovascular bundle. Follow up for a mean of 8 months (range 5 -12) showed good facial symmetry, a stable occlusion, and recovery of sensation in the lower lip on the affected side. We conclude that a digital template can successfully help the resection of benign lesions of the mandible while preserving the function of the inferior alveolar neurovascular bundle.

Rehabilitation With Implants After Bone Lid Surgery in the Posterior Mandible

Bone defects are often secondary to alveolar disease removal. Creating a bone lid with piezosurgery is a valid method to preserve the alveolar bone. A careful and precise osteotomy associated with a firm placement of the bone lid in its original position enables better bone healing, thus allowing for the delayed insertion of dental implants at the operated site with no need for any bone augmentation procedures. The aim of this technical note is to present the application of the bone lid surgery in the posterior mandible before dental implant rehabilitation.

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.

In vivo assessment of bone healing following Piezotome® ultrasonic instrumentation

PURPOSE

This pilot study evaluated the molecular, histologic, and radiographic healing of bone to instrumentation with piezoelectric or high speed rotary (R) devices over a 3-week healing period.

MATERIAL AND METHODS

Fourteen Sprague-Dawley rats (Charles River Laboratories International, Inc., Wilmington, MA, USA) underwent bilateral tibial osteotomies prepared in a randomized split-leg design using Piezotome® (P1) (Satelec Acteon, Merignac, France), Piezotome 2® (P2) (Satelec Acteon), High-speed R instrumentation, or sham surgery (S). At 1 week, an osteogenesis array was used to evaluate differences in gene expression while quantitative analysis assessed percentage bone fill (PBF) and bone mineral density (BMD) in the defect, peripheral, and distant regions at 3 weeks. Qualitative histologic evaluation of healing osteotomies was also performed at 3 weeks.

RESULTS

At 1 week, expression of 11 and 18 genes involved in bone healing was significantly (p < .05) lower following P1 and P2 instrumentation, respectively, relative to S whereas 16 and 4 genes were lower relative to R. No differences in PBF or BMD were detected between groups within the osteotomy defect. However, significant differences in PBF (p = .020) and BMD (p = .008) were noted along the peripheral region between P2 and R groups, being R the group with the lowest values. Histologically, smooth osteotomy margins were present following instrumentation using P1 or P2 relative to R.

CONCLUSIONS

Piezoelectric instrumentation favors preservation of bone adjacent to osteotomies while variations in gene expression suggest differences in healing rates due to surgical modality. Bone instrumented by piezoelectric surgery appears less detrimental to bone healing than high-speed R device.

The removal of a malpositioned implant in the anterior mandible using piezosurgery

In oral, cranio, and maxillofacial surgery, a close relationship among the bone, nerves, and blood vessels can be regularly observed. Surgical procedures for the removal of dental implants have the potential to cause vascular injury and bleeding in the floor of the mouth and internal anterior region of the mandible. Furthermore, conventional osteotomy techniques always require extensive protection of adjacent soft tissue because cutting is not limited to bone and could easily affect other tissues when applied improperly. We report the removal by means of piezosurgery of a malpositioned osseointegrated implant that had previously caused a sublingual hematoma during its insertion. The postoperative course was uneventful, no bleeding, infection, or hematoma formation was noted and the patient reported 100% resolution of all symptoms.

The effect of load on heat production, thermal effects and expenditure of time during implant site preparation - an experimental ex vivo comparison between piezosurgery and conventional drilling

OBJECTIVES

Piezoelectric surgery (PS) is meant to be a gentle osteotomy method. The aim of this study was to compare piezosurgical vs. conventional drilling methods for implant site preparation (ISP) - focusing on load-dependent thermal effect on hard tissue and the expenditure of ISP time.

MATERIALS AND METHODS

Three hundred and sixty ISP were performed on ex vivo pig heads using piezosurgery, spiral burs (SB) and trephine burs (TB). The load applied was increased from 0 to 1000 g in 100-g intervals. Temperature within the bone was measured with a thermocouple, and duration was recorded with a stop watch. Thermal effects were histomorphometrically analysed. Twelve ISPs per technique were performed at the lateral wall of the maxillary sinus.

RESULTS

PS yields the highest mean temperatures (48.6 ± 3.4°C) and thermal effects (200.7 ± 44.4 μm), both at 900-1000 g. Duration is reduced with a plus of load and significantly longer in either case for PS (P < 0.05). There is a correlation of the applied load with all other examined factors for PS and TB. Temperature and histological effects decrease for SB beyond 500 g.

CONCLUSIONS

PS yields significantly higher temperatures and thermal tissue alterations on load levels higher than 500 g and is significantly slower for ISP compared to SB and TB. For ISP with PS, a maximum load of 400 g should be maintained.

Technological advances in extraction techniques and outpatient oral surgery

There have been several exciting technological advances in extraction techniques and outpatient oral surgery within the last decade. A variety of new instruments and techniques are revolutionizing the fields of oral and maxillofacial surgery and dentistry. This article reviews the newer innovations in dentistry including the powered periotome, piezosurgery, the Physics Forceps, laser therapy, orthodontic techniques, and use of polyurethane foam.