Open Journal of Stomatology, 2011, 1, 179-184
doi:10.4236/ojst.2011.14027 Published Online December 2011 (http://www.SciRP.org/journal/ojst/ OJST ).
Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJST
Ultrasonic piezotome surgery: is it a benefit for our patients
and does it extend surgery time? A retrospective comparative
study on the removal of 100 impacted mandibular 3rd molars
Angelo Tr oedhan1, Andr eas Kurrek2, Marcel Wainwright3
1Center for Facial Esthetics, Vienna, Austria;
2Implantology Clinic Ratingen, Ratingen, Germany;
3Implantology Clinic Kaiserswerth, Dusseldorf, Germany.
Received 28 October 2011; revised 3 November 2011; accepted 9 December 2011.
ABSTRACT
Aim of the study was to evaluate if there is a constant
and significant reduction in traumaticity when mas-
sively traumatic oral surgical procedures such as the
removal of third molars are conducted with only ul-
trasonic surgical devices (Piezotomes) expressed in a
reduction of postsurgical pain and swelling on the
patient’s side since such clinical experiences by the
authors suggested this. Since oral surgeons criticize a
higher time consumption for surgeries with Piezoto-
mes also the objective time consumption was evalu-
ated and compared to the traditio nal methods. Mate-
rial and Methods: 56 female and male patients were
selected that already underwent a removal of an im-
pacted third mandibular molar on one side with rota-
ry instruments by bone destructive burring with a
still persisting comparable third mandibular molar
on the contralateral side complaining about recur-
rent pain episodes and were already documented for
pain and swelling before. The ultrasonic surgical re-
moval with the Piezotome was conducted with a buc-
cal osteotomy of the compacta lateral to the impacted
third molar, preservation of the resected compacta in
saline solution, removal of the third molar by single
or multiple dentotomy and full anatomical restitution
of the surgical site with the preserved buccal com-
pacta. The swelling was documented by kephalome-
try 24/48/72 hours and 1 week post surgery, the pain
index by the total consumption of ibuprofen-400 mg—
tablets. Lesions of the mandible nerve were docu-
mented. Netto surgery time was taken from the first
incision to the last suture of the procedure. Results: 6
patients had to be excluded from evaluation due to
incomplete post surgical follow up. A signifycant (***,
p > 0.999) decrease in pain and swelling of 50% was
detected both for the parameters swelling and pain
with Piezotome-surgery. No lesions of the mandible
nerve were detected with Piezotome surgery whereas
surgery with rotary instruments resulted in 16%
hypesthesia at least up to one week. Although netto
surgery time was approximately 50% longer when
done with the Piezotome at the beginning the time
consumption normalized with the growing experience
of the surgeons back to the time schedule when sur-
gery was performed with rotary instruments reveal-
ing no significant differences (-, p < 0.73). Conclu-
sions: The results of this retrospective study suggest
that Piezotome-surgery is superior in atraumaticity
and soft-tissue safety compared to traditional proce-
dures with burs and grants the patients significantly
less post surgical pain and swelling. Although—as it
is with all new surgical tools and protocols—sur-
gery time is longer at the beginning when purely
working with ultrasonic surgical devices time con-
sumption reduces to normal values after a learning
curve.
Keywords: Ultrasonic Surgery; Piezotome; Rotating In-
struments; Post Surgical Swelling; Post Surgical Pain;
Impacted Mandibular Third Molars; Osteotomy
1. INTRODUCTION
In the year 2004 a new surgical device was introduced to
oral and craniomaxillofacial surgery developed by Prof.
Tomaso Vercellotti derived from ultrasonic scalers used
in the everyday dental office. The “Piezosurgery”-device
(Mectron) had more oscillating force thus enabling the
surgeon to effectively work on bone and dentin [1].
Like ultrasonic scalers ultrasonic surgery devices os-
cillate between an average of 24 to 36 KHz and have an
energy output at the tip of 15 - 60 Watts.
In the year 2005 Satelec-ACTEON presented its “Pie-

A. T ro edhan et al. / Open Journal of Stomatology 1 (2011) 179-184 180
zotome” with enhanced oscillating behaviour such as a
responsive force-modulation and bi-directional force mo-
vement of the working tip promising enhanced working
speed.
Various histological st udies proved ult rasonic surgery to
be less traumatic to bone than conventional surgery with
rotating instruments thus enhancing and speeding up the
healing processes [2-4 ].
Basic working-tip-sets are common to all ultrasonic
surgery devices on the market: a tip-set for osteotomies
(micro-scissels, micro-saws), bone collection (rounded
and flat bone scrapers), diamond coated balls (1 - 2 mm),
a sinus-lift-set for lateral sinus-floor-elevations (diamond
coated bone-cutter, initial membrane elevator—“trum-
pet”, various non-cutting elevators), scalers for perio-
dontal surgery (sharp edged and diamond coated) and li-
gament cutters for tooth extraction.
A tip-set for the minimal-invasive hydrodynamic ul-
trasonic cavitational sinuslift (HUCSL-“INTRALIFT”)
was developed by the authors 2007 for Piezotome (Sa-
telec-ACTEON) [5].
Although the ad vantages of ultrasonic surgery such as
uncomparable atraumaticity and precision in surgery,
poor bleeding surgical site, lossless bone management [6]
and soft tissue preserva tion [7] as well as stimulating ef-
fects in bone healing [8] are widely accepted by oral and
craniomaxillofacial surgeons ultrasonic surgery is still
critiziced to be time consuming and lack ing a benefit for
the patient when used in the daily routine oral surgery.
To investigate th is critic closer the authors established
a study protocol to objectively quantify the benefit of ul-
trasonic Piezotome surgery for patients in daily routine
oral surgery and the average duration of surgical proce-
dures compared to conventional procedures with rotating
instruments (burs) since the authors observed a signify-
cant decrease in pain and swelling after completely swit-
ching all oral surgery procedures to ultrasonic surgical
devices completely abandoning burs in 2006.
2. MATERIAL AND METHODS
56 male and female patients at an age between 21 yr and
52 yr were selected for the retrospective study who al-
ready underwent the removal of an impacted third molar
and were already documented for pain, swelling and sur-
gery time on behalf of a prior study. Patients were ano-
nymized in the study protocol by assigning a number.
All patients had bilateral comparable mandibular im-
pacted third molars with the crown-root axis parallel or
at a maximum of 20 degrees ascending to the occlusal
plane of the mandible and regular developed second mo-
lars in occlusion (Figures 1-3).
Prior to surgery measure spots were marked with a
resorbable tattoo-ink for kephalometry in the skin adja-
cent the mandibular angle on both sides.
Figure 1. Schematic scheme for eligibility.
Figure 2. Bilateral horizontally impacted third molars.
Figure 3. Bilateral angulated impacted third molars.
Before anesthesia a protocolist assitant different from
the surgeon measured the skin-distance between the right
and left mandibular angle tatoo with a kephalometer and
noted it to the study protocol.
All patients already underwent the removal of one
impacted third molar on one side under local anesthesia
(6 - 8 ml Ultracain-forte) with conventional rotating in-
struments, periotomes, scissels and leverages (the “tradi-
tional” surgical procedure, Figure 4) in the years 2004-
2006 and were already documented by a protocol that
was then also followed for the current study.
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With the availability of ultrasonic surgical devices for
bone cutting from 2006 the contralateral impacted third
molar was removed using the Piezotome (Satelec-AC-
TEON, Figure 5) and one leverage only under local an-
esthesia (6 - 8 ml Ultracain forte)
To reduce ambient seasonal influences (ambient tem-
perature, humidity, daylight hours etc.) the ultrasonic
surgery was performed +/– 3 weeks of the date of the
prior surgery with rotating instruments.
Both surgical procedures were started with a 45˚ me-
sial-vertical mucoperiostal incision reaching the distal
face of the second molar in the mesio-distal line of the
crowns central fissure proceeding mesio-distal on the al-
veolar crest up to the ascending part of the mandible in
the retromolar trigonum (Figures 4 and 6)
Figure 4. Surgical protocol with rotary instruments: vast re-
moval of buccal compacta bone to reveal the crown, single or
multiple dentotomy, removal and wound closure.
Figure 5. Ultrasonic surgical device piezotome (center; Sate-
lec-ACTEON/France).
Figure 6. Surgical Protocol with Piezotome: almost lossless
osteotomy and luxation of the buccal bone compacta with BS 5
(bone scalpel), cutting of the periodontal ligaments with liga-
ment cutters LC 1-5, dentotomy, removal, reposition of the bu-
ccal bone compacta for anatomical correct reconstruction
Conventional surgery (Figure 4) with rotating instru-
ments was performed according to the valid surgical pro-
tocol prior to the introduction of ultrasonic Piezotome-
surgery: after preparing the mu coperiostal flap with a pe-
riostal elevator the alveolar crest and buccal compacta
was removed by milling with a 3-mm Tungsten Carbide
Bur (Meisinger) until the distal and buccal face of the
crown and the first one third of the root could be seen.
The horizontally impacted third molar was then cut in
two or more pieces in the area of the enamel-dentine-
margin with the Tungsten Carbide Bur, the crown or
multiple pieces of the crown removed with different lev-
erages, the roots mobilized with the periotome and—if
necessary again cut in two separate parts at the furcation
and finally removed with leverages.
Ultrasonic surgery (Figure 6) with the Piezotome was
performed as follows: the mucoperiostal flap was eleva-
ted with the BS4-tip (originally designed for Bone har-
vesting) and the alveolar crest and buccal compacta re-
sected as one bone block after osteotomy with the ultra-
sonic scissel BS5 and the micro-bone-saws BS1 and BS2
(Figure 7) thus revealing the distal and entire buccal face
of the crown and the bu ccal side s of the roots in their en-
tire length (Figure 8). The prepared bone block was kept
in saline solution for later anatomically correct recon-
struction of the surgical site. The crown was separated
from the roots by cutting the roots with the diamond-
coated ball-tip SL2, then both crown and roots mobilized
with the ligament-cutter LC 1 and removed with a lev-
erage (Figure 9). The surgical site was inspected for
clinically visible damages of the mandible nerve when
applicable (Figure 10). The osteotomed bone block was
reponed before wound closure to reconstruct the original
anatomy of the surgical site (Figure 11).
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A. T ro edhan et al. / Open Journal of Stomatology 1 (2011) 179-184 182
Figure 7. Almost lossless osteotomy and luxation of the buccal
compacta.
Figure 8. Cutting the periodontal ligament with Ligament Cut-
ters (LC) 1-5 followed by dentotomy.
Figur e 9 . Lux ation of the crown followed by removal of th e roots.
Figure 10. Inspection of the surgical site for lesions of the
mandible nerve (if applicable).
Figure 11. Reposition of the buccal compacta bone plate to
reconstruct the original anatomy. No osteosynthesis is needed
due to the almost lossless osteotomy cut, the angulated cut de-
sign providing “rest surfaces” and the precise refitting.
The time for the surgical procedure was taken from
the first mucoperiostal incision to the last suture to close
the wound by a standby assistant and noted in the study
protocol.
The patients were handed out two blister packs per 10
tablets of the analgetic Dexibuprofen 400 mg (“Seractil
forte”) and an antibiotic sh ielding with Clindamycin 300
mg 3 × 1/day 16 capsules after surgery. Unused analgetic
tablets had to be brought back and were counted by the
protocolist. All patients were advised to apply cool packs
and refrain from sport activities and heavy body work in
the first 72 hours after surgery.
The skin distance between the tattoo at the angle of
the mandible on the non surgery side and the utmost
swelling protrusion on the surgery side was measured
with a kephalometer by a protocolist assistant different
from the surgeon after 24 hr, 48 hr, 72 hr and one week
(+/–1 hr) and noted to the study protocol. The analgetic
tablets brought back by the patients were counted and
the usage noted to the study protocol.
Hypesthesia 1 week after surgery in the corresponding
lip-half was checked by the two-point discrimination-test
and noted—if occurred—to the study protocol.
From 56 patients 50 were included in the study. The
causes for the exclusion of 6 patients were: 1 patient did
not show up for kephalometry after 24 hours, 2 patients
had to be excluded since th ey failed the 24 hour +/– 1 hr
margin for kephalometry by more than 6 hours delay, 1
patient did not show up for kephalometry after 72 hr and
2 patients did n ot sho w up f or kep hal ometry after 1 week
thus lacking data for objective comparison.
3. RESULTS
The average mean value swelling of the patients face
undergoing surgery with rotating instruments measured
between the utmost lateral protrusion of the cheek on the
surgery side and the contralateral tattoo at the angle of
the mandible with the kephalometer resulted in a swell-
ing 24 hr +/– 1 hr post surgery of 44 mm, 48 hr +/– 1 hr
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49 mm, 72 hr +/– 1 hr 46 mm and after one week 5 mm
(Tables 1-4). In both groups no full anesthesia of th e corresponding mandible nerve was observed 1 week after surgery (0%).
The average mean value swelling of the patients face
undergoing surgery with the ultrasonic Piezotome-sur-
gical device measured between the utmost lateral protru-
sion of the cheek on the surgery side and the contralat-
eral tattoo at the angle of the mandible with the kepha-
lometer resulted in a swelling 24 hr s +/– 1 hr post surge-
ry of 20 mm, 48 hr +/– 1 hr 20 mm, 72 hrs +/– 1 hr 15
mm and after one week 1 mm (Tables 1 -4) which is a
significant (***, p > 0.999) reduction of 50% compared
to the procedure with rotary instruments.
In the rotary-instrument group 8 patients suffered from
hypesthesia in the corresponding lip at the check after 1
week (16%).
In the ultrasonic Piezotome-group no hypesthesia was
observed at the check after 1 week (0%).
While the time between the in itial mucoperiostal inci-
sion and wound closure by suture performed with rotat-
ing instruments was constantly at an average of 43 min-
utes (Table 6) surgery with the ultrasonic device initially
took a maximum of 72 minutes but constantly lowered
to also an average of 47 minutes (Table 6) finally show-
ing no significant (-, p < 0.73) time difference to proce-
dures with rotary instruments. This might be caused by
the fact that the surgeons working procedures in ultra-
sonic surgery undergoes a “learning-curve” since the sin-
gle surgical steps are different to the conventional tech-
nique with rotating instruments. With growing experi-
ence the handling of the ultrasonic device Piezotome is
constantly optimised.
Figure 12 shows the cumulated results of the swelling
kephalometry.
The mean value of the patients analgetic intake (De-
xibuprofen 400 mg) was 17 tablets in the group undergo-
ing surgery with rotating instruments (Table 5) and 8
tablets in the group und ergoing ultr asonic surgery (Table
5) which is a significant (***, p > 0.999) reduction of 50
% of the patient’s need for analgetics in the ultrasonic
Piezotome-surgery gr o up .
Figure 12. The cumulated results shown in a compiled graph.
Table 3. Comparison of facial edema 72 hr post surgery.
Table 1. Comparison of facial edema 24 hr post surgery.
Swelling after 24 hr (in mm) Rotary Instruments Piezotome
Mean Value 44.36 20.30
Max 61 41
Min 28 5
Stand. D e v. 7.3 7.99
Significance *** (p > 0.999)
Swelling after 72 hr (in mm) Rotary Instruments Piezotome
Mean Value 46.16 15.28
Max 67 38
Min 28 3
Stand. D e v. 7.72 6.40
Significance *** (p > 0.999)
Table 2. Comparison of facial edema 48 hr post surgery. Table 4. Comparison of facial edema 1 week post surgery
Swelling after 48 hr (in mm) Rotary Instruments Piezotome
Mean Value 49.38 20.54
Max 72 45
Min 34 5
Stand. D e v. 8.02 7.81
Significance *** (p > 0.999)
Swelling after 1 week (in mm)Ro tary Instruments Piezotome
Mean Value 4.7 1.02
Max 12 5
Min 0 0
Stand. D e v. 3.22 1.61
Significance *** (p > 0.999)
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A. T ro edhan et al. / Open Journal of Stomatology 1 (2011) 179-184 184
Table 5. Comparison of overall analgetic intake (ibuprofen 400
mg).
Analgetic intake (tablets) Rotary Instruments Piezotome
Mean Value 17.6 7.8
Max 20 15
Min 10 1
Stand. D e v. 3.05 3.17
Significance *** (p > 0.999)
Table 6. Comparison of duration of surgeries in minutes.
Surgery time (in minutes) Rotary Instruments Piezotome
Mean Value 42.86 46.84
Max 59 72
Min 28 29
Stand. D e v. 6.69 8.48
Significance - (p < 0,73)
While most of the time is lost with the ultrasonic sur-
gical device Piezotome in cutting the buccal compacta as
a precise bone block to reveal the impacted third molar
the fast and destructive milling away of th e cortical bone
with burs to reveal the third molar performs faster but
this time is regained by the perfectly visible and nearly
blood-free surgical site, the easiness of the separation of
the crown from the roots without fear to damage the man-
dible nerve and the easy luxation of the tooth fragments
out of it’s bone site with the ultrasonic ligament cutters.
4. DISCUSSION
The results of this study suggest that it can be stated as
proven that pure ultrasonic surgery procedures with its
nearly lossless and ultimate precise bone management
can completely replace conventional surgery techniques
with hand instruments, rotating instruments, periotomes
and most levers and dental pliers to the patient’s benefit.
With an average of 50% less swelling and 50% post
surgical pain reduction and the preservation of critical
soft tissues such as the mandible nerve ultrasonic sur-
gery furthermore reduces the need for additional anti-
inflammatory and swelling-reducing medication and ini-
tiates faster and better wound healing.
The immediate anatomically correct reconstruction of
the surgery site avoids long term inconveniences primar-
ily for the patient but also for the surgeon lacking the
necessity to treat these inconvenien ces.
Although the positive effects of application of low
frequency ultrasonic waves between 25 and 40 KHz on
the healing of soft and hard tissue on a histophysiologi-
cal and histomorphological level were already published
in various Scientific Journals the multiple effects of ul-
trasonic Piezotome surgery with the current and future
devices in oral and craniomax illofacial surgery have still
to be rese arched into d eep to identify the bio logical pro-
cesses on the molecular and humoral level that lead to
the clinical results of lesser swelling, pain reduction and
faster and complication -poor healing.
Ultrasonic Piezotome surgery—after a “learning cur-
ve” in handling the device and individually optimise and
economize the surgical procedures—does not consume
more time than conventional surgical techniques with
rotating instruments in the everyday surgical routine
such as teeth extractions, apisectomies, removal of im-
pacted teeth, periodontal surgery etc. and the individual
surgeon has no need to recalculate his or her time sched-
ule for routine surgical procedures in his/he r office.
On the other hand ultrasonic surgery allows almost
atraumatic and minimal invasive surgical procedures that
were unthinkable with traditional instruments (such as
transcrestal hydrodynamic ultrasonic sinuslifting, flap-
less crest splitting etc.) thus sp aring time, costs, pain and
complications to both the surgeon and the patient.
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