|ORIGINAL ARTICLE - COMPARATIVE STUDY
|Year : 2018 | Volume
| Issue : 2 | Page : 181-187
Piezosurgery versus conventional method alveoloplasty
Khushal D Gangwani, Lakshmi Shetty, Deepak Kulkarni, Ratnadeepika Seshagiri, Ratima Chopra
Department of Oral and Maxillofacial Surgery, Dr. D. Y. Patil Vidyapeeth's, Dr. D. Y. Patil Dental College and Hospital, Pune, Maharashtra, India
|Date of Web Publication||26-Dec-2018|
Dr. Khushal D Gangwani
Sonigara Aangan Society, F-508, Near ISKCON Temple, Ravet, Pune - 412 101, Maharashtra
Purpose: Conventional alveoloplasty procedure using manual instruments results in higher resorption of the residual alveolar ridge, which is unsuitable for denture construction. The purpose of this study was to evaluate the effect of piezosurgery-assisted alveoloplasty using minimally invasive technique compared to that of the conventional technique. Materials and Methods: This was a comparative in vivo study. The study sample consisted of 35 edentulous patients with bilateral bony spicules requiring alveoloplasty. The primary outcome variables assessed were time required for alveoloplasty, postoperative pain using visual analogue scale (VAS), and postoperative healing using Landry, Turnbull, and Howley healing index. The differences between the outcome variables were statistically analyzed using paired t-test. Results: The participants consisted of 35 patients (25 men and 10 women; age range: 38–83 years) diagnosed with bilateral bony spicules on the edentulous alveolar ridge. There was a statistically highly significant difference between both groups with respect to the outcome variables such as time required, VAS at 2nd day, and healing index at 7th day with higher mean of time required (in sec), higher mean of VAS, and lower healing index for conventional group as compared to piezo group (P < 0.05). Conclusion: Alveoloplasty done using piezosurgery not only reduces patient's postoperative discomfort but also maintains the alveolar bone integrity by not disturbing the soft-tissue and hard-tissue architecture, allowing faster healing of tissues, which makes the future prosthesis replacement easier
Keywords: Alveoloplasty, minimally invasive, piezoelectric surgery, piezosurgery
|How to cite this article:|
Gangwani KD, Shetty L, Kulkarni D, Seshagiri R, Chopra R. Piezosurgery versus conventional method alveoloplasty. Ann Maxillofac Surg 2018;8:181-7
| Introduction|| |
A well-contoured smooth alveolar ridge is crucial for appropriate fabrication of complete or partial denture. While contouring the ridge, it is highly essential to remember that greater the excision of bone, higher will be resultant resorption. Therefore, the procedure of contouring should be limited to excision of the irregular sharp ridges and unfavorable undercuts which are unsuitable for denture construction. Hence, the goal of alveoloplasty is to gain favorable tissue support for the designed prosthesis, while conserving as much soft tissue and hard tissue as possible.
Alveoloplasty is a term for preprosthetic surgical procedure that involves smoothening of rough alveolar bone following extractions on the edentulous area or trimming of bulbous tuberosities, which creates deep undercuts. It is one of the most common surgical techniques used to prepare the alveolar ridges to procure a prosthesis. Historically, the procedure has been recognized from more than a century. A. T. Willard in 1853 advocated reduction of the alveolar ridge to bring about the complete proximity of soft tissues over the alveolus. Sir O. T. Dean first described “Intra-septal alveoloplasty” in the American Dental Association journal in 1936. Hence, this procedure also came to be known as Dean's alveoloplasty.
Technological advancement boldly gives the options to step aside, lead, or follow. Piezosurgery or piezoelectric bone surgery is a new innovative, assuring, precise system for removal of hard tissue, sparing the soft tissues. It works on the principle of ultrasonic vibrations.
Reports have been published of the use of this technology in dentistry in maxillary sinus elevation procedures,, bone harvesting,, expansion of alveolar crest, implantology,, periodontal surgery, orthognathic and maxillofacial surgery,,, and dental exposure and extractions. However, to the best of our knowledge, no studies until now have been published for the use of piezosurgery with the minimally invasive technique for alveoloplasty procedure.
Therefore, this study aims at evaluating the efficacy of alveoloplasty done with piezosurgery system compared with that of the conventional technique. The parameters to be compared between the two systems will be – the time required for the procedure, postoperative pain, and healing of the soft tissues.
| Materials and Methods|| |
Study design and sample
To address the research purpose, the authors designed and implemented a split-mouth in vivo study after receiving approval from the Institutional Review Board and Ethics Committee. The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all patients after they were given full written and verbal information regarding the study.
The study population comprised all edentulous patients with bilateral bony spicules on the alveolar ridge indicated for alveoloplasty who presented to the institute's dentistry outpatient department between January 1, 2016, and January 1, 2017. Patients with bilateral bony spicules with 2-mm maximal diameter on either side were included in this study. Patients with bleeding disorders, uncontrolled systemic comorbidities, unilateral bony spicules, and maximal bony spicule diameter exceeding 2 mm were excluded from the study.
In the recruited patients, using Sequentially Numbered Opaque Sealed Envelopes randomization technique, a site on which the piezo alveoloplasty to be performed was selected.
All the surgical procedures and postoperative assessments were performed by the same surgeon. Preoperatively, patients were required to gargle with 0.12% chlorhexidine mouthwash (Oradex) for a minute. After performing standard painting and draping of the site, local anesthetic (2% lignocaine hydrochloride with 1:200,000 Adrenaline) was injected in the mucobuccal fold over the prominent bony spicule region.
Once complete anesthesia of the planned surgical area was achieved, crestal and releasing incisions were taken, and the full thickness flap was reflected [Figure 1]. Bony contouring was accomplished with bone files, rongeurs forceps, or burs [Figure 2]. Digital palpation was used to determine the uniformity of the ridge. The flap was approximated and secured with nonresorbable suture (3-0 silk suture, Monodek®) [Figure 3]. The surgical procedure was timed from the first incision to the last suture.
On the other contralateral side of the arch, a stab incision was placed mesial or distal to the bony spicule using a surgical blade (No. 15) [Figure 4]. A small-sized tip periosteal elevator was passed underneath the stab incision, and subperiosteal tunneling was done until the prominent bony spicule was reached [Figure 5]. A Piezo blade of Rhomboid shape (EX-03, Dmetec Surgystar®, Korea) was then inserted through the subperiosteal tunnel up to the bony spicule. The piezo unit was switched on with frequency set at of 25–29 kHz in “boosted” mode with saline flow of 60 ml/min [Figure 6]. The bony spicule was shaved off carefully in a unidirectional motion of the piezo blade [Figure 7]. The motion was continued until the bony spicule was no longer digitally palpated. The time from the start of the incision till the end of alveoloplasty was noted.
Both the surgical procedures, conventional alveoloplasty, and alveoloplasty using piezosurgery were performed in the same surgical session.
Postoperatively, patients were prescribed an analgesic (500 mg of Aceclofenac 8 h for 5 days) and antibiotic (250 mg of amoxicillin every 8 h for 5 days). In case of amoxicillin allergy, erythromycin (250 mg every 8 h for 5 days) was prescribed. Choice of analgesic and antibiotic was based on the standard institutional protocol.
The postoperative pain at the operated site was assessed by visual analog scale (VAS) [Figure 8] on the second postoperative day (POD). Sutures were removed on the 7th POD and the healing was assessed using Landry et al. index [Table 1].
The obtained values were recorded, tabulated, and statistically evaluated.
| Results|| |
The participants consisted of 35 patients (25 men and 10 women; age range: 38–83 years, mean age: 60.8 years) diagnosed with bilateral bony spicules on the edentulous alveolar ridge.
Statistical package for the (SPSS) version 21.0 (SPSS, Inc, Mumbai, India) was used for the statistical analysis. There was no significant difference in patient age and size of the bony spicules. However, gender was noted to be a confounding factor because the male population predominated [Figure 9].
Descriptive statistics such as mean, standard deviation, frequency, and percentage of independent variables have been expressed. Intergroup comparison of outcome variables, such as time required for surgery, VAS score for pain assessment, and the healing index, was done using paired t-test where P < 0.05 was considered statistically significant.
There was a statistically highly significant difference between both groups with respect to outcome variables such as time required in seconds, VAS at 2nd day, and healing index at 7th day. It was observed that mean time required (in sec), and mean VAS was higher and mean healing index was lower for the conventional group as compared to piezo group [Table 2].
The patients in the piezo subgroup reported a significantly lower VAS score at the surgery site on POD 1, compared to the conventional subgroup. The mean VAS score was 2.74 for the conventional method and 0.94 for the piezosurgery method with the standard deviation of 1.2 and 0.7, respectively [Figure 10].
The reported operative time in the piezosurgery alveoloplasty subgroup was significantly less compared to the conventional site subgroup. The mean time required for the alveoloplasty by conventional method was 255.20 s and for the procedure by piezosurgery technique was 132.37 s with a standard deviation of 109.8 and 78.2, respectively [Figure 11].
The operative site in piezosurgery subgroup showed significantly better and faster healing compared to that in the conventional subgroup. The healing index by Landry et al. on the 7th POD for the conventional method was 3.11 and for the piezosurgery method was 4.31 with standard deviations being 0.71 and 0.67, respectively [Figure 12].
| Discussion|| |
Except for the extraction of natural teeth, the most commonly performed preprosthetic surgical procedure is alveolectomy or alveoloplasty.
Alveolectomy has been defined by Boucher in 1974 as “removal of a part of the alveolus by surgery.” In recent years, the term “Alveoloplasty” has been adopted to signify recontouring of the alveolar process rather than its removal. Thoma has stated that there is requirement of alveoloplasty in almost every patient who has undergone multiple extractions and may also be needed in those with single extraction. The goal for contouring the alveolar ridge is to gain favorable tissue support for the designed prosthesis while conserving as much soft tissue and hard tissue as possible.
Historically, alveoloplasty is known to the field of surgery for the past few decades. W. G. Beers in 1976 coined the phrase “heroic treatment of alveolectomy” in which large portions of alveolus were removed with cutting forceps. In 1905, W. Shearer advocated and elaborated on alveolectomy to eradicate gingival and alveolar pathosis and to serve as a foundation for the prosthodontist to prepare a denture. The problems of excessive bone resorption after alveolectomy were addressed when in 1936 Sir O. T. Dean published and revolutionized the process of alveoloplasty by introducing intraseptal alveoloplasty, a procedure he had been using for 20 years. Since then, there has not been any improvement or change in the procedure. Dean differed from other pioneers in the field of preprosthetic surgery in that he advocated the preservation of the labial cortex,preferring instead to sacrifice the interradicular medullary bone to achieve optimal alveolar ridge contour. Dean's intraseptal alveoloplasty was particularly well suited for immediate denture surgery. For the cases of extreme premaxillary protrusion, Obwegeser in 1966 suggested a modification of Dean's technique wherein both the palatal and labial cortices were fractured and repositioned.
In 1976, Michael and Barsoum studied the amount and duration of postoperative bone resorption and ridge contour changes in immediate denture patients using various surgical techniques such as: (1) simple extractions without additional surgery, (2) extractions with labial cortical alveolectomy, and (3) extractions with Dean's intraseptal alveolectomy. Using serial sagittal contour photographs of study casts and serial cephalometric radiographs of patients, they showed that the three techniques produced almost the same amount of bone resorption at the end of 3 months, but thereafter, the differences were noteworthy (with statistical significant difference). At the end of 6 and 12 months, the nonsurgical extractions had produced the least amount of bone resorption with a marked slowing of the rate by 6 months, whereas both alveoloplasty techniques resulted in continuing bone resorption.
Piezoelectric technique was introduced in oral surgery during the 1970s when Horton examined the recovery process of dogs that had undergone osteotomy. It works on the principle of piezoelectric effect, first reported in 1880 by Marie and Jean Curie that asserts that some crystals and ceramics change their shape when an electric current is sent across them, producing oscillations of ultrasonic frequency. There is amplification of vibrations with minimum pressure on hard tissue, which produces cavitation phenomenon, which is a mechanical cutting phenomenon occurring particularly on hard tissues.
The piezoelectric instrument develops a regulated ultrasonic frequency of 24–29 kHz, and a microvibration amplitude of 60–200 mm/s. Soft tissues remain unharmed at this frequency, but may also be damaged at frequencies above 50 kHz. Microstreaming and cavitation phenomenon are peculiar features of piezosurgery.
In bone microsurgery, two fundamental concepts principally govern the philosophy behind the development of piezoelectric bone surgery. The first being minimally invasive surgery in which the postoperative pain and swelling is much lower as compared to traditional techniques because of improved tissue healing, ultimately reducing patient discomfort. The second concept which increases the effectiveness of the treatment is surgical predictability. The development of piezoelectric bone surgery has indeed optimized the surgical results even in the most complex and unfavorable anatomical cases due to ease of controlling the instrument leading to reduced hemorrhages, precise cuts eventually producing excellent tissue healing.
Subperiosteal tunneling, a minimally invasive access procedure, was a technique used by Kim et al. in horizontal ridge augmentation procedure in which the authors prepared a subperiosteal cavity with a periosteal elevator, and a selection of bone graft materials was placed into the tunnel to augment the deficient alveolar ridge. A similar technique is used in this study to get access to the bony spicule and perform alveoloplasty using the contrangled piezo blade. The advantage of this minimally invasive sutureless technique is reduced healing time with lesser postoperative discomfort.
According to a prospective study by Waite and Cherala, the authors stated that tight closure over a large bony socket or defect does not facilitate drainage and oral hygiene. Suturing may create a one-way valve that allows food debris to enter the socket but not easily escape which may lead to local infection, inflammation, edema, clot necrosis, alveolar osteitis, and pain. A small flap left open without suturing may facilitate drainage, improve hygiene, and reduce the risk of pain associated with alveolar osteitis. Hence, we performed a sutureless alveoloplasty technique in our study.
In studies conducted by Sortino et al. and Goyal et al. comparing the efficacy of piezosurgery and conventional rotatory instruments for impacted mandibular third molar removal, the authors concluded that there was a reduction in postoperative pain, facial swelling, and trismus in piezosurgery group, while the operative time was higher in the same compared to the control group. However, in this study, the operative time in piezo group was lesser compared to control group owing to the lack of need for suturing of the minimally invasive incision.
Labanca et al. reported the advances in piezosurgery over the last 20 years and focused on its uses in different surgical areas. In oral and maxillofacial surgery, it has been used in orthognathic surgeries, rhinoplasties, and surgical extractions. After studying the use of piezosurgery in all these clinical scenarios, the authors concluded that piezoelectric surgery is an innovative technique for safe and effective osteotomy owing to the lack of macro vibrations, ease of use, and controlled and safe cutting. It seems to be more efficient in the first phases of bony healing, inducing an earlier increase in Bone Morphogenic Proteins (BMPs), controlling the inflammatory process better, and stimulating bony remodeling as early as 56 days after treatment. There are few limitations also which include slightly longer osteotomy time and increasing heat transmission due to increasing working pressure which can lead to tissue damage unless used carefully.
| Conclusion|| |
Among the various instruments and techniques used for alveoloplasty, piezosurgery using the minimally invasive incision has proved to be a better alternative by minimizing the operative time, reducing patient's discomfort, and accelerating the healing process. Therefore, this study justifies the use of piezosurgery in atraumatic alveoloplasty in all patients.
There are few limitations to this study. The sample size in the study is small. However, the findings were consistent across all patients. Studies using larger sample size are needed to establish the findings with higher statistical significance.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
[Table 1], [Table 2]