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The Power of Piezo: A Predictable and Painless Approach by Sandeep Singh, BDS, MS and Ashutosh Agarwal, BDS

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Introduction
Piezo surgery is a modern technique for osseous surgeries.

Selective cutting is possible for different ultrasonic frequencies acting only in hard tissues (mineralized), which saves vital anatomical structures.

A wide range of treatment modalities can be completed in almost all the fields of dental sciences with piezoelectric surgery, such as osteotomy, alveolar bone expansion, ridge splitting, pre-prosthetic surgeries, maxillary sinus lifting and more.

These procedures can be performed precisely and safely, providing exceptional clinical and biological results, specifically for osteocyte viability.

Piezo has many advantages over conventional approaches, and recent advancements in the field have brought the technique closer to the mainstream.

Piezo surgery enables challenging operations to be performed in simple and fully practical procedures. Areas that are difficult to reach have less danger of soft tissue and neurovascular tissue damage.

Piezoelectric surgeries were introduced in the 1950s, but with advancement in the dental sciences, they have taken a significant habitation in clinical practice.

Piezo surgery devices, patented under Piezosurgery Incorporated, produce specific ultrasound frequency modulation (22,000Hz—35,000Hz). They have been used in various treatment modalities and are considered a predictable, safe and painless approach. Piezo surgery devices are developed precisely for osseous surgery and have applications in various dental and medical specialties.

History
The term "piezo" originates from the Greek word piezein, and means "to press tight, squeeze."1 In 1880, physicists and brothers Jacques and Pierre Curie discovered what we now call piezoelectricity. Simply put, the brothers found that putting pressure on various crystals, ceramics or bone, created electricity.

Later, physicist and inventor Gabriel Lippmann found the converse piezoelectric effect. He demonstrated that if an electric field is applied to a crystal, the material will deform.2

These effects were further investigated by different scientists, and in 1953, Matthew C. Catuna published an article on the use of ultrasound on hard tissue.3

In the following decades, the application of ultrasonic vibrating technology for cutting mineralized tissue was demonstrated by different work groups.4

Almost another two decades passed before the first clinical study was published. In 1998, a technical note was published,5 and then in 2000, the first human clinical study about piezoelectric bone surgery was released.6

For the first time a case was reported on a split-ridge in which an edentulous bone was split evenly, despite its very narrow, knife-edge ridge. With other cutting instruments, it would not have been possible to keep the bone's integrity. In 2001, the Piezosurgery device was introduced, a tool that combined the ultrasound and the piezo effect.7

Principles and applications
The principle behind the piezoelectric effect is that the quartz vibrates when an electric current is applied. Transducers convert the vibrations generated in the quartz into oscillations of the working tip, which in this case, enables selective ablation of tissue in ultrasonic surgery.

Control over the surgery with piezo was effortless, as the force necessary to obtain a cut by the operator was much less as compared to conventional approaches. In fact, the micromotor action of the rotational burs required a supplemental force (increase in hand pressure on the device) to oppose the rotation of the instrument.

As a result, when a bur met structures of varying mineralization or soft tissues, there was a decrease in surgical sensitivity and an increase in hand pressure on the device.

Secondly, because the Piezosurgery insert vibrated within a width of 60mm to 200mm at a modulated ultrasonic frequency, an increase in temperature was avoided, which eliminated bone damage. In addition, the vibration frequency of piezo surgery was optimal for mineralized tissue and did not cut into the adjacent soft tissue, minimizing the risk of harming adjacent tissues.8

So far, piezo surgery can be used in oral and maxillofacial surgery, implantology, periodontology, orthodontics, and crown and bridge preparations. In addition, the surgery is useful in medical sciences in the fields of otorhinolaryngology, neurosurgery, ophthalmology, traumatology and orthopedics.

Main indications in dentistry9
In oral and maxillofacial surgery for atraumatic extractions, wisdom teeth exposure, periapical cyst debridement, pre-prosthetic surgery, inferior alveolar nerve decompression, etc.
  • In periodontology for root planing and bone recontouring, crown lengthening, etc.
  • In implantology for sinus lifts (direct and indirect), removal of fractured implants, bone-ridge augmentation, bone-graft harvesting (crestal, retromolar, chin or tori), etc.
  • In orthodontics for periodontal accelerated osteogenic orthodontics and orthognathic surgeries, etc.
  • In endodontic surgeries with many more uses and providing excellent clinical and biological results, especially for the osteocytes viability.
  • In prosthodontics, using special attachments for crown and bridge preparations, achieving precision in shoulder preparation and finishing, avoiding trauma, and preservation of adjacent soft tissue.
Advantages and advances
  1. Precision and safety.
  2. Absence of macro-vibrations together with modulated piezoelectric signal allows for smooth cut geometries in mineralized bone, while minimizing the risk to soft tissue (such as nerves, blood vessels, Schneiderian membrane and dura mater).
  3. Better visualization of surgical field.
  4. Irrigation and cavitation effects provide optimal visibility of the operative site, removes bone debris, and avoids temperature rise liable to cause tissue degradation.12
Every device always has some disadvantages. Piezo seems to overcome all other drawbacks, but unfortunately its operating time is significantly higher during osseous cutting when compared to conventional approaches.

Only a few studies have been published on the effect of the piezoelectric device concerning soft-tissue changes, including one that showed that the use of piezoelectric technology created less soft-tissue damage for subperiosteal preparation.

Dr. Dongseok Sohn recently introduced a hydrodynamic piezoelectric internal sinus elevation (HPISE) technique for sinus membrane elevation. Videos of the procedure can be found on YouTube and other sites.

After breaking the sinus floor with the round insert, a 2.8-mm-wide cylindrical carbide insert was used to enlarge the osteotomy site and elevate the sinus membrane using hydraulic pressure by internal irrigation at the same time.

The HPISE insert has a working tip height of 4mm and depth-indicating lines marked at 2mm intervals. Thus, it measures the exact residual bone height at each implant placement site.

Hydraulic pressure to the sinus membrane from internally irrigated sterile saline was applied until the sinus floor was penetrated with the HPISE tip. Subsequently, the insert was pushed a few millimeters over the sinus floor and then hydraulic pressure was applied again for 10 to 20 seconds to confirm the elevation of the sinus membrane at each implant placement site.10 Other doctors have introduced different approaches and different procedures. The scope of application in piezo surgery is wide and growing.

Conclusion
Preparation of natural teeth is a daily challenge for dentists, especially if the soft tissue is to be preserved. More specifically in the esthetic regions, like the maxillary anterior teeth, a sub-gingival preparation edge is very important. It is challenging to keep the marginal finish lines covered by marginal gingiva, and piezo may serve as an alternative to conventional approaches.

Piezo technology has come a long way since its introduction. With many advantages, piezo contributes to favorable osseous repair and remodeling in comparison to conventional approaches. This can be used as an interdisciplinary tool and may substantiate a favorable addition to the clinician's armamentarium.

References
  1. The Free Dictionary [homepage on the Internet]. Available from: http:// www.thefreedictionary.com. Accessed July 15, 2015.
  2. American Physical Society. This month in physics history: March 1880 — the Curie brothers discover piezoelectricity. 2014 http://www.aps.org/publications/apsnews/201403/physicshistory.cfm. Accessed July 10, 2015.
  3. Catuna MC. Sonic energy: a possible dental application, Preliminary report of an ultrasonic cutting method. Ann Dent. 1953;12:100—101.
  4. Mazorow HB. Bone repair after experimental produced defects. J Oral Surg Anesth Hosp Dent Serv. 1960;18:107—115.
  5. McFall TA, Yamane GM, Burnett GW. Comparison of the cutting effect on bone of an ultrasonic cutting device and rotary burs. J Oral Surg Anesth Hosp Dent Serv. 1961;19:200—209.
  6. Torrella F, Pitarch J, Cabanes G, Anitua E. Ultrasonic ostectomy for the surgical approach of the maxillary sinus: a technical note. Int J Oral Maxillofac Implants. 1998;13:697—700.
  7. Vercellotti T, Crovace A, Palermo A, Molfetta A. The piezoelectric osteotomy in orthopedics: clinical and histological evaluations (pilot study in animals). Mediterranean J Surg Med. 2001;9:89—95
  8. Australian Dental Practise; 2008 March; Tomaso Vercellotti,, Marc L. Nevins, David M. Kim, Myron Nevins Keisuke Wada, Robert Schenk,Joseph P Fiorellini
  9. Rev Stomatol Chir Maxillofac. 2007 Nov;108(5):431-40. Epub 2007 Oct 4
  10. Ji-Min Kim et al; Minimally Invasive Sinus Augmentation Using Ultrasonic Piezoelectric Vibration and Hydraulic Pressure: A Multicenter Retrospective Study; IMPLANT DENTISTRY /VOLUME 0, NUMBER 0 2012
  11. Vercellotti T, Crovace A, Palermo A, Molfetta A. The piezoelectric osteotomy in orthopedics: clinical and histological evaluations (pilot study in animals). Mediterranean J Surg Med. 2001;9:89—95
  12. Br J Oral Maxillofac Surg. 2008 Jun;46(4):265-9. doi: 10.1016/j.bjoms.2007.12.007. Epub 2008 Mar 14.
  13. Vercellotti T. Piezoelectric surgery in implantology: a case report — a new piezoelectric ridge expansion technique. Int J Periodontics Restorative Dent. 2000;20:358—365.
  14. Int J Oral Maxillofac Surg. 2011 May;40(5):451-7. doi:10.1016/j.ijom.2010.11.013. Epub 2010 Dec 19.


Dr. Sandeep Singh has been in private practice for the last 20 years. He received his master's degree in implantology from UCLA. Singh delivers lectures on national and international platforms. He holds many titles, including president of the World Academy of Piezoelectric Bone Surgery: South East Asia. He is also the director of Dental Health & Sciences at the Sam Higginbottom Institute of Agriculture, Technology and Sciences in Allahabad, India. Singh can be contacted at drsandeep13@hotmail.com

Dr. Ashutosh Agarwal is currently pursuing piezo surgery specialization in periodontology and implantology from Institute of Dental Sciences, Bareilly, UP, India.


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