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Piezoelectric surgery in endodontics

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This Presentation describes about a newly introcuced minimally invasive "piezoelectric surgical unit".

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Piezoelectric surgery in endodontics

  1. 1. Applications of Piezoelectric Surgery in Endodontics Presented By : Dr. Arpit Viradiya Guided By : Dr. Karthik Reddy
  2. 2. Introduction • One goal of endodontic surgery is to treat apical periodontitis in cases in which healing has not occurred after nonsurgical retreatment or, in certain instances, after primary root canal therapy. • Such cases include patients with persistent or refractory intracanal infection after iatrogenic changes to canal anatomy or those with microorganisms in proximity to the constriction and apical foramen.
  3. 3. • Other indications include extraradicular infections, such as the presence of bacterial plaque on the apical root surface or bacteria within the lesion itself. • Advantages of modern surgical endodontic treatment include easier identification of root apices; smaller osteotomies; and shallower resection angles, which preserve cortical bone and root length. • Introduction of CBCT scanning is particularly useful for both diagnosis and treatment planning.
  4. 4. • It eliminates of the superimposition of anatomic structures, such as the zygomatic buttress, alveolar bone, maxillary sinus, and other roots, and helps in detection of the presence and dimensions of apical lesions and changes in apical bone density. • Although many published studies advocate the use of modern approaches, limited information is available on the applications of piezosurgery (piezoelectric bone surgery) in endodontic surgery.
  5. 5. • Piezosurgery is a meticulous and soft tissue– sparing system for bone cutting based on ultrasonic microvibrations. • Vercellotti et al pioneered its application in periodontal surgery. • Selective cutting is the most innovative feature of the piezoelectric surgery device. • Although piezosurgery cuts mineralized tissues such as bone, it does not cut soft tissues such as blood vessels, nerves, and mucosa.
  6. 6. • Indications for the use of piezosurgery devices are increasing in oral and maxillofacial surgery, as in other disciplines, such as endodontics. • Currently, piezoelectric instruments can be used at most stages of endodontic surgery, reducing the risk of damage to soft tissues.
  7. 7. Overview • Ultrasound is sound energy with a frequency above the range of human hearing, which is 20 kHz. • It is usually achieved either by magnetostriction or piezoelectricity. • In magnetostriction electric current passes through a wire coil in the handpiece, a magnetic field is created around the stack or rod transducer, causing it to constrict.
  8. 8. • Alternating current then produces an alternating magnetic field that causes the tip to vibrate. • Piezoelectric scaler units are based on the piezoelectric effect which was first described as “some ceramics and crystals deform when an electric current is passed across them, resulting in oscillations of ultrasonic frequency without producing heat.”
  9. 9. • The resultant vibration produces tip movement that is primarily linear in direction and generally allows only 2 sides of the tip to be active at any time. • Piezoelectric scaler units have some advantages over earlier magnetostrictive units because they offer more cycles per second. • The tips of these units work in a linear, back- and-forth, ‘‘piston-like’’motion, which is ideal for endodontics.
  10. 10. • Piezosurgery was introduced as an alternative to the traditional instrumentation used in oral bone surgery. • Piezosurgery is a new and innovative method that uses piezoelectric ultrasonic vibrations to perform precise and safe osteotomies. • It was developed in 1988 by the Italian oral surgeon Vercellotti to overcome the limitations of conventional bone surgery.
  11. 11. • The vibrations obtained are amplified and transferred to a vibration tip, which, when applied with slight pressure to bone tissue, results in a mechanical cutting effect that occurs exclusively in mineralized tissue. • Piezosurgery uses a specifically engineered surgical instrument approximately 3 times as powerful as a conventional ultrasonic instrument (a piezoelectric scaler unit).
  12. 12. • The unique feature of the piezosurgery technique is that cutting occurs when the tool is applied to mineralized tissue but stops when soft tissue is encountered. • The light handpiece pressure and integrated saline coolant spray of piezosurgery maintain a low temperature and allow clear visibility of the surgical site.
  13. 13. Bone-tissue Management • Piezosurgery is useful when bone must be cut close to important soft tissues, such as nerves, vessels, and the dura mater, or when mechanical or thermal injury must be avoided. • Trauma to the mental nerve caused by blunt dissection in this area can cause temporary paresthesia but is less likely to leave permanent injury.
  14. 14. • Schaeren et al concluded that direct exposure of a peripheral nerve to piezosurgery, even in the worst case scenario, does not dissect the nerve. • This makes piezosurgery a promising tool for osteotomy procedures in close proximity to nerves during endodontic surgery. • The cutting characteristics of piezosurgery depend on the degree of bone mineralization, the design of the insert, the pressure applied to the handpiece, and the speed of operation.
  15. 15. • Bone quality can be evaluated with CBCT and the appropriate power level is selected. • Piezosurgery requires only minimal pressure unlike conventional microsaws or drills. • Piezosurgery devices provide a clear surgical site; they maintain a blood-free field during bone cutting through an air-water cavitation effect. • Walmsley et al suggested that cavitation fragments bacterial cell walls and therefore has an antibacterial function.
  16. 16. • The Piezosurgery Insert OTS7-4 (Mectron) is effective for microsurgical applications, including osteotomy and root-end resection. • Convenient laser-etched markings at 7, 8.5, and 10 mm inform the clinician of the osteotomy depth.
  17. 17. Sagittal Axial Coronal
  18. 18. OT1 Insert 6 Months Osteotomy Root End Filling
  19. 19. Enucleation of Radicular Cysts • One important application of piezosurgery is in the enucleation of radicular cysts. • For enucleation of a lateral periodontal cyst, the Piezosurgery Retrosurgical Kit is available, which is specifically designed for endodontic surgery. • Diamond-coated inserts can be used to remove the bone lamina over the cyst, whereas dull, bellshaped inserts can be used for the dissection of the cyst epithelium from the bone.
  20. 20. • The use of piezosurgery in the treatment of jaw cysts is a new development, and few cases have been reported. • Atraumatic handling of soft tissues is required for the complete removal of cystic lesions and is technically comparable to handling the sinus membrane during sinus bone grafting. • The main advantage of enucleation is that it facilitates a pathologic examination of the entire cyst. • Another advantage is that total excisional biopsy treats the lesion appropriately.
  21. 21. • Yaman and Suer evaluated the performance of piezosurgery in removing odontogenic cysts. • They concluded that piezosurgery increased operation time but also markedly increased visibility in the operating field. • In cases in which cyst enucleation is necessary in difficult areas requiring delicate manipulation, the use of piezosurgery carries a lower risk of damage to vital structures, such as neurovascular tissues.
  22. 22. Dull – Bell Shaped Insert Dissection of cyst epithelium From bone Complete enucleation of cystCyst Removal
  23. 23. Root-end Resection • Minimization of the bevel angle during root resection is one of the most important developments in endodontic microsurgery. • The traditional technique uses a bevel angle of 45–60 to facilitate access and visibility when using large surgical instruments. • The modern technique uses a shallow bevel angle of 0–10 to expose fewer dentinal tubules.
  24. 24. • Several authors have shown that the type of instrument and cutting angle used directly relate to apical surface roughness and dentinal tubule exposure after root-end resection. • A Brazilian company developed chemical vapor deposition (CVD)-coated diamond tips adaptable for use with conventional ultrasound devices and marketed under the brand name CVDentus System.
  25. 25. • Bernardas et al compared an ultrasonic CVD- coated tip with high- and low-speed carbide burs for apicoectomy, evaluating resection time and analyzing root-end surfaces using SEM. • They concluded that ultrasonic root-end resection using the CVD-coated tip took longer and resulted in rougher surfaces than carbide burs at both high and low speeds.
  26. 26. • Some lasers can also be used for root-end resection and offer many advantages, including reduced discomfort and vibration, risk of contamination, and risk of trauma to adjacent tissues. • Moreover, the ‘‘no-touch’’ characteristic of laser methods results in a loss of tactile feedback to the operator, rendering it difficult to maintain conservative preparations.
  27. 27. • The piezosurgery insert OTS7-4 can also be used for root-end resection. • Few published studies have evaluated the use of both ultrasound and piezosurgery instruments for apicoectomy. • Further studies are necessary to determine the influence of root end resection techniques on apical healing after endodontic surgery.
  28. 28. Pre operative OP7 Insert OTS7 Insert
  29. 29. Root-end Cavity Preparation • Conventional root-end cavity preparation using rotary burs in a microhandpiece poses several problems for the clinician, such as difficult access to the root end, the inability to establish preparations parallel to the canal, and the risk of lingual perforation of the root. • Ultrasonic retrotips have shown many advantages over the traditional handpiece.
  30. 30. • The long axis of the tooth can be followed, thus preserving canal morphology, and apical cavities can be shaped more easily, safely, and with greater precision than with conventional handpieces. • Several studies on the use of ultrasonic retrotips also report improved cleaning of cavity walls compared with conventional instruments and reduced smear layer volume after root canal preparation.
  31. 31. EN1 Insert
  32. 32. • Diamond-coated retrotips produce quality root-end preparations faster and more effectively than stainless steel tips. • Comparisons of diamond-coated and smooth ultrasonic tips for root-end preparation by Peters et al revealed that a shorter preparation time was required with diamond- coated retrotips than with stainless steel tips.
  33. 33. • Recently, a new ultrasonic tip, JETip, has been introduced that features micro projections on its stainless steel surface. • Liu et al reported that JETip facilitated the rapid production of regular root end preparations. • several studies have shown the occurrence of dentinal cracks on resected root ends after retrograde preparation with ultrasonic retrotips.
  34. 34. • However, these in vitro studies had limitations. • Cadaveric studies have been undertaken to overcome these problems. • They showed that, when the pizoelectric tip oscillated with a constant vibration, the power level did not affect the incidence or type of dentin cracks.
  35. 35. Conclusions • Piezosurgery is a bone-cutting modality with rapidly increasing indications in different surgical fields, including endodontic surgery. • The main advantages of piezosurgery include protection of soft tissues, optimal visualization, decreased blood loss, reduced vibration and noise, increased comfort for the patient, and protection of tooth structures.
  36. 36. • Some disadvantages of piezosurgery include the initial financial burden, the long duration of the surgical procedure, and the fact that the instruction manuals of many piezoelectric units discourage use of these devices in patients with implanted cardiac pacemakers. • Further studies are necessary to determine the long-term success rate of this novel technique.
  37. 37. •THANK YOU

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