Applications of Piezoelectric
Surgery in Endodontics
Presented By : Dr. Arpit Viradiya
Guided By : Dr. Karthik Reddy
• 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
• 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.
• 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
• 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
• Piezosurgery is a meticulous and soft tissue–
sparing system for bone cutting based on
• Vercellotti et al pioneered its application in
• 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.
• 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.
• Ultrasound is sound energy with a frequency
above the range of human hearing, which is
• 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.
• Alternating current then produces an
alternating magnetic field that causes the tip
• 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.”
• 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
• Piezosurgery was introduced as an alternative
to the traditional instrumentation used in oral
• 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.
• 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).
• 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.
• 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
• Schaeren et al concluded that direct exposure
of a peripheral nerve to piezosurgery, even in
the worst case scenario, does not dissect the
• 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.
• 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
• Walmsley et al suggested that cavitation
fragments bacterial cell walls and therefore
has an antibacterial function.
• The Piezosurgery Insert
OTS7-4 (Mectron) is effective
osteotomy and root-end
• Convenient laser-etched
markings at 7, 8.5, and 10
mm inform the clinician of
the osteotomy depth.
Root End Filling
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.
• The use of piezosurgery in the treatment of jaw
cysts is a new development, and few cases have
• 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
• Another advantage is that total excisional biopsy
treats the lesion appropriately.
• Yaman and Suer evaluated the performance
of piezosurgery in removing odontogenic
• 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.
Dull – Bell Shaped Insert
Dissection of cyst epithelium
Complete enucleation of cystCyst Removal
• 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
• 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.
• 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
• 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.
• 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
• 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.
• 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.
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.
• 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
• 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.
• 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.
• Recently, a new ultrasonic tip, JETip,
has been introduced that features
micro projections on its stainless steel
• 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
• However, these in vitro studies had
• 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
• 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.
• 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