comparative evaluation of conventional and piezoelectric
TRANSCRIPT
Introduction
Bilateral sagittal split osteotomy (BSSO) is the most common
mandibular corrective operation for skeletal malocclusion. As
the mandibular body is moved by BSSO, there is a risk of
excessive operative bleeding. There is also a risk of
postoperative neurosensory damage to the inferior alveolar
nervebecause of the anatomical course of the mandibular
canal.[1]
Traditionally, rotary burs were considered a time-honoured
technique for ostectomy in maxillary and mandibular bone
removal. It inherently inflicts variable insult to the bone and
soft tissue due to overheating, causing a greater degree of
discomfort and protracted course of recovery. [2]
With the recent trends towards minimally invasive surgery, piezosurgery – a novel ostectomy technique was popularized in oral and maxillofacial surgery. The inserts employ micro-vibrations of the scalpel, maintained at a frequency of 24–29 kHz and amplitude alternating between 60 and 200 µm/s permitting a precise, safe and efficient ostectomy.The piezoelectric instrument selectively works on hard tissue, thus
Abstract:
Aim & Objective: Our aim was to compare the outcomes of piezoelectric surgery and conventional bur after Bilateral sagittal split osteotomy (BSSO). Piezoelectric surgical device is precise and safe than traditional bur in orthognathic surgery.Materials & Method: Fourteen consecutive patients who underwent BSSO procedures were involved in the study. In seven patients procedure was performed using traditionalbur, the remaining seven patient’s osteotomies by piezoelectric device. Intraoperative blood loss, procedure duration timeand nerve impairment were evaluated to compare the outcomes of these two procedures at 1day, 1week, 1month, 3months & 6months.Result: Compare to traditional mechanical surgery. Piezoosteotomy, showed statistically significant reduction in postoperative nerve impairment.Conclusion: The null hypothesis was rejected and our stated hypothesis proved strong, the use of piezoelectric of osteotomy found better than traditional bur. We believe that piezoelectric device allows surgeons to achieve better results overtraditional bur in terms of nerve impairment. This device represents a more precise and safer method to perform invasive surgicalprocedures such as BSSO However, use of traditional burshowed fast osteotomy eventually reducing procedural duration time but on the other hand in deeper incision and vascular areas, use of bur found to be more aggressive as compared to piezoelectric device.
Keywords: BSSO; Piezoelectric surgery; Traditional Bur; Nerve impairment
reducing the likelihood of inflicting iatrogenic trauma to surrounding tissues, including the mucosa and neurovascular structures. Investigators have promulgated piezosurgical devices as a safer and preferred alternative to conventional bur for ostectomies owing to favourable osseous response facilitating speedy recovery. [3-5]
In the present study we analysed the effect on postoperative
neurosensory damage when performed surgery by
conventional bur and piezoelectric device.
Clinical Research Paper
1 2 3 4SINGH K Y, SINGH K V, TIWARI R, THANVI G, 5 6MISHRA S, CHAUHAN B1-6Dept. of Oral and Maxillofacial Surgery, Mahatma Gandhi
Dental College and Hospital, Jaipur
Address for Correspondence : Dr. Yashpal Kunwar Singh
71- Adarsh Nagar, Sector-2, Bayana, Rajasthan
Email: [email protected]
Received : 15 Dec.2020, Published : 30 April 2021
Comparative evaluation of conventional and Piezoelectric Surgery in Sagittal Split Ramus Osteotomy- an in-vivo study
12 University Journal of Maxillofacial Surgery and Oral Sciences Official Publication of Aligarh Muslim University, Aligarh. India
Univ J Maxillofac Oral Sci. 2021; Vol. 1, Issue 1
Patients and Method
Patients
Surgical method:
Fourteen patients under went the orthognathic surgery in
Mahatma Gandhi University of Medical Science MGUMST
in between August 2019-August 2020. All the patients were
informed and signed consent form agreement. Patients had
presence of facial skeletal morphologic disturbances. The
patients with a history of facial trauma, facial reconstructive
surgery and previous orthognathic surgery were under
exclusion criteria of study. (Table-1)
In all patients we have used Epker technique for osteotomy. In
piezoelectric surgery we have made a groove in cortical bone
at anterior border of ramus without reaching bone marrow.
Then the tip of osteotome penetrated the grooves and cut the
complete cortical bone. The tip further penetrated the inner
portion of ramus cortical bone to separate cancellous bone
sagittally with osteotome.
In other group of patient the cortical bone was completely
severed using conventional bur and separated sagittally by
chisel mallet. Following sagittal separation of cortical bone
semirigid fixation was done with absorbable miniplate
(Super-FIXSOR®-MX, Takiron Co., Ltd., Osaka, Japan) or
titanium miniplate (Medicon Co., Ltd., Tuttlingen,
Germany). The patients selection for either group was
randomly done by operating surgeon.
All the operated patients were supplemented with vitamin
B12 methylcobalamin (Methycobal®, Eisai Co., Ltd. Tokyo,
Japan) 1500 _g/day 7 for early recovery from neuro sensory
disturbances of inferior alveolar nerve, most often occur in
extensive surgeries of mandible like BSSO. Vitamin
supplement was continued till complete recovery of neural
disturbance. The difference was evaluated on lateral
cephalogram with mesial cusp of mandibular first molar as a
reference point. (Fig1 & 2)
Pre-operative lateral profile of patient showing bilateral
mandibular prognathism
Pre-operative lateral cephalogram
Pre-operative Lateral profile with IMF
Fig-1 Pre-operative view
13 University Journal of Maxillofacial Surgery and Oral Sciences Official Publication of Aligarh Muslim University, Aligarh. India
Univ J Maxillofac Oral Sci. 2021; Vol. 1, Issue 1
Post-Operative OPG showing BSSO with plating
Post-operative clinical lateral profile showing reduced
mandibular prognathism
Fig-2 Post-operative view
The postoperative parameter was analysed in following
manner:
Nerve impairment was evaluated by the clinical neurosensory
test which was performed on 1day, 1week, 1month, 3months
& 6months on all the patients after surgery and were
compared with the normal nerve sensation recorded
preoperatively as a baseline. All tests were performed in an
entirely healthy surrounding when the patient was in a relaxed
posture and shoulderwith eyes closed in semi supine position.
Patients were explained about the test by performing on hand
(without sensory disturbance) and also about the grading
system of response. The evaluated reference points were chin
and inferior lip (vermilion) bilaterally. (6)
Radiographs and photograph of patients were taken pre and
post operatively for comparison after receiving the informed
consent from patients.
Mean SD and median were calculated for data variables.
Statistical analyses were performed using STATA (Stata
Corporation, College Station, TX, USA). A value of p < 0.05
was considered to be significant.
Statistical analysis;
14
Observation & Results
ANCOVA for analysis
Nerve impairment-
Grade of response in nerve sensitivity evaluation on each side
during subjective examination.
1. Absent sensation, anaesthesia
2. Severely altered sensation, paraesthesia
3. Moderately altered or slightly reduced sensation
4. Mildly reduced or subnormal sensation
5. Normal sensation
The post-operative evaluation on 1day, 1week, 1month,
3months and 6months for nerve sensitivity of patients treated
with traditional bur present prolonged nerve impairment till
6months and more. The piezoelectric device groupshowed
less injury to nerve as well as early recovery by
3months.(Table 2a &2b)
Table 2a- Postoperative Nerve sensitivity when use of
Traditional bur
(Number denote- number of patients i.e. in traditional bur on
1st post-op day 1 patient had mild reduction in nerve
sensitivity, 2 patients with moderately reduced sensation, 2
with severely reduced sensation and 1 patient has no
sensation. 3 patients were got normal sensation by 1 month
and 4 out of 7 patients had normal nerve sensation by
6months)
Table 2b- Postoperative Nerve sensitivity when use of
Piezoelectric
Grade Response:
University Journal of Maxillofacial Surgery and Oral Sciences Official Publication of Aligarh Muslim University, Aligarh. India
Univ J Maxillofac Oral Sci. 2021; Vol. 1, Issue 1
In piezoelectric group 4 out of 7 patients were having normal
nerve sensation on 1st post-operative day whereas in
traditional bur group only 1 patient had normal sensation on
1st post-operative day. Moreover, all the patients improved
by 1 month and completely recover by 6 months in
piezoelectric group, contrasting to traditional bur group
where only 4 patients were completely recovered, 1 patient
had mild reduced sensation and 2 had moderately reduced
sensations by 6 months.
Surgery with approximation of vital tissue do required more
attention and precision, negligence in either of this may raise
the incidence intra or post-operative complications following
surgery
In our study we have compared traditional bur with
piezoelectric device for osteotomy in BSSO surgery and
evaluated on the bases post-operative nerve impairment. The
results that have been concluded after statistical analysis
provedthepiezoelectric device as a better option over
traditional bur for osteotomy procedures specially in intimate
surgical procedures when having a close approximation with
vital structures, except in terms of duration of osteotomy
where traditional bur showed a significant faster cutting
efficiency than piezoelectric device.[7-9]
Precision-Piezoelectric device found to be more precise and
safer in dealing with neural structures, as the instrument work
at 25-35kHz frequency at which the surrounding soft tissues
just vibrates without getting severed and at this same
frequency the device cuts only the mineralized tissue which
dramatically reduced the trauma to neural and vascular
tissues. Soft tissues may get traumatised when they are
entrapped to adjacent bony structure hindering their
vibrations. [10-14]
Discussion:
15
During osteotomy the cutting was donetill the periphery of cortical bone and without penetrating the entire thickness of body of mandible body in a very controlled manner, preventing the mandibular canal. This has also been proved by other authors in their studies, that the direct contact of piezoelectric tip does not damage the nerves and vessels unless the excessive pressure is applied against these structures. [15] The piezoelectric device efficiencyhas also been assessed and practiced in neurosurgery where the parietal bone osteotomy could be safely achieved without rapture of the underlying dura matter.[16]
Piezoelectric device has advantages over the traditional technique by means of high precision, reduced blood loss and reduced nerve injury with early recovery. This overall reduces the post-operative soft and hard tissue complications and improves the prognosis of treatment. However, in terms of duration of procedure traditional bur perform faster osteotomy than piezoelectric device. This eventually reduced the chances of infections,which have been the thumb rule for allthe invasive procedures “Longer the procedure,higher the likelihood of acquiring infection” [17]
The prolonged time required for piezoelectric osteotomy can be improved by practicing and getting habitual with the device by performing few surgeries with it, as there is a learning curve for every newer technique which has to be followed for excellence.
So, from this study we would conclude that the use of ultrasonic device is safer and precise. We would recommend the use of piezoelectric device in cases with close proximity of vitals structures and have higher risk of soft and nerve tissue damage. Moreover, if the device operation is practiced and expertized it may completely replace the traditional bur in performing most of the surgeries.
Perhaps the part to be aware on is,piezoelectric cutting efficiency on dense bone which is low and may lead to breakage of tip of osteotome and piezoelectric effect on bone regeneration after surgery. This will require further studies for evaluation.
1. Patil C et al.Piezosurgery vs bur in impacted mandibular third molar surgery: Evaluation of postoperative sequelae; Journal of Oral Biology and Craniofacial Research 2019; (9): 259–262
2. Sortino F, Pedullà E, Masoli V. The piezoelectric and
rotatory osteotomy technique in impacted third molar
surgery: comparison of postoperative recovery. J Oral
Maxillofac Surg. 2008; Dec66(12):2444–2448.
Conclusion:
References:
University Journal of Maxillofacial Surgery and Oral Sciences Official Publication of Aligarh Muslim University, Aligarh. India
Univ J Maxillofac Oral Sci. 2021; Vol. 1, Issue 1
3. Angelo T, Mahmoud T Z. Is Piezoelectric Surgery the
New Gold-Standard in Oral Surgery and Implantology?
A Scientific Literature Review. Smile Dental Journal.
2016; (4): 11
4. Galié, M., Candotto, V., Elia, G., &Clauser, L. C.
Piezosurgery: A new and safe technique for distraction
osteogenesis in Pierre Robin sequence review of the
literature and case report. International Journal of
Surgery Case Reports. 2015;(6): 269–272.
5. Allan W, Williams ED, Kerawala CJ. Effects of repeated
drill use on temperature of bone during preparation for
osteosynthesis self-tapping screws. Br J Oral
MaxillofacSurg. 2005;43:314-9.
6. F BeziatJL, BeraJC, LavandierB, GleizalA. Ultrasonic
osteotomy as a new technique in cranio maxillofacial
surgery. Int J Oral Maxillofac Surg. 2007; 36(6):
493–500.
7. Rashad A et al. Practitioner experience with sonic
osteotomy compared to bur and ultra- sonic saw: a pilot
in vitro study. Int J Oral Maxillofac Surg. 2015; 44(2):
203–8.
8. LucasM, MathiesonA. Ultrasonic cutting for surgical
applications. In :Gallego- JuarezJA, GraffKF, editors.
Power Ultrasonics. (Chap.23), Cambridge: Wood- head
Publishing, Elsevier 2015;695–721.
9. SpinelliG, LazzeriD, ContiM, AgostiniT, MannelliG.
Comparison of piezo- surgery and traditional saw in
bimaxillary orthognathic surgery. J Craniomaxillofac
Surg. 2014; 42(7):1211–20.
10. Landes CA et al. Critical evaluation of piezoelectric
osteotomy in orthognathic surgery: operative technique,
blood loss, time requirement, nerve and vessel integrity. J
Oral Maxillofac Surg. 2008; 66(4):657–74.
11. vonSeeC, GellrichNC, RückerM, KokemüllerH,
KoberH, StöverE. Inves- tigation of perfusion in osseous
vessels in close vicinity to piezo-electric bone cutting. Br
J Oral Maxillofac Surg. 2012; 50(3):251–5.
12. VercellottiT, CrocaveA, PalermoA, MolfettaA. The
piezoelectric osteotomy in orthopedics: clinical and
histological evaluations (pilot study in animals).
Mediterr J Surg Med. 2001; 9:89–95.
13. O’DalyBJ, MorrisE, GavinGP, O’ByrneJM,
McGuinnessGB. High power low frequency ultrasound:
are view of tissue dissection and ablation in medicine and
surgery . J Mater Process Technol . 2008;
200(1–3):38–58.
16
14. LabancaM, AzzolaF, VinciR, RodellaLF. Piezoelectric
surgery: twenty years of use. Br J Oral Maxillofac Surg.
2008; 46(4): 265–9.
15. S c h a e r e n S , J a q u i é r y C , H e b e r e r M , T o l n a y M ,
VercellottiT,MartinI.Assessment of nerve damage using
a novel ultrasonic device for bone cutting. J Oral
MaxillofacSurg. 2008; 66:593–6.
16. Kotrikova B, Wirtz R, Krempien R, Blank J, Eggers G,
Samiotis A. Piezosurgery–a new safe technique in
cranial osteoplasty? Int J Oral Maxillofac Surg. 2006;
35:461–5.
17. Cheng, H et al. Prolonged operative duration is
associated with complications: a systematic review and
meta-analysis. Journal of Surgical Researc. 2018; 229:
134–144
University Journal of Maxillofacial Surgery and Oral Sciences Official Publication of Aligarh Muslim University, Aligarh. India
Univ J Maxillofac Oral Sci. 2021; Vol. 1, Issue 1