IJESCE- Comparidion of rotary and peizo surgical unit in third molar impaction: an original research

1. International Journal of Early Childhood Special Education (INT-JECS)
ISSN: 1308-5581 Vol 14, Issue 03 2022
814
COMPARISON OF ROTARY AND PIEZO-SURGICAL UNIT IN THIRD
MOLAR IMPACTION: AN ORIGINAL RESEARCH
1. Dr. Kannan Venugopal, Department of Oral and Maxillofacial Surgery, PMS College of Dental
Science and Research, Golden Hills, Vattapara, Trivandrum, Kerala. kannan7072003@gmail.com
2. Dr. Rahul VC Tiwari, OMFS, FOGS, (MHA), PhD Scholar, Dept of OMFS, Narsinhbhai Patel
Dental College and Hospital, Sankalchand Patel University, Visnagar, Gujarat,384315.
drrahulvctiwari@gmail.com
3. Dr Shilpa Sunil Khanna M.D.S, Department of Oral and Maxillofacial Surgery, Senior Lecturer,
Sri Ramakrishna Dental College and Hospital, Coimbatore , Tamil Nadu, 641006.
khannashilpa03@gmail.com
4. Dr. Heena Dixit Tiwari, BDS, PGDHHM, Final year Student, Master of Public Health,Parul
Univeristy, Limda, Waghodia, Vadodara, Gujrat, India.drheenatiwari@gmail.com
5. Dr. M L V SURYAMITHRA, Senior Lecturer, Department of Oral and Maxillofacial Surgery,
Mamata Institute of Dental Sciences, Hyderabad, Telangana. msuryamithra@gmail.com
6. Dr. MANOJ KUMAR KANTA, MDS, READER, DEPT OF MAXILLOFACIAL SURGERY,
GSL DENTAL COLLEGE AND HOSPITAL. kantamanojkumar@gmail.com
7. Dr Pritee Rajkumar Pandey, MDS, OMFS, DJ College of Dental Sciences & Research, Ajit
Mahal, Modinagar - Niwari Rd, Modinagar, Uttar Pradesh, India.Priteepandey1990@gmail.com
Corresponding Author: Dr. Kannan Venugopal, Department of Oral and Maxillofacial Surgery,
PMS College of Dental Science and Research, Golden Hills, Vattapara, Trivandrum, Kerala.
kannan7072003@gmail.com
ABSTRACT
Aim
The aim of this study was to compare the surgical outcome of third molar surgery using conventional rotary
handpiece and piezotome.
Methodology
This prospective study consisted of 20 medically fit patients between 18–40 years of age with bilateral impacted
mandibular third molars from both the genders. On one side surgical extraction was done using conventional
rotary technique and contra lateral side was treated using piezosurgery (split mouth study design). Statistical
analysis was done between these two techniques for patient satisfaction, duration of surgery, pain perception and
trismus.
Results
Piezoelectric surgery took more time than rotary, but patient satisfaction, pain, mouth opening was statistically
poor with conventional rotary technique.
Conclusion
Piezoelectric device is a promising, meticulous, innovative ultrasonic technique for safe and effective bone
removal when compared with rotary technique.
Keywords: Piezoelectric surgery, Rotary surgical technique, Surgical removal, Mandibular impacted third
molar.
INTRODUCTION
Third molar surgery is the most common procedure performed in oral and maxillofacial surgery practice.1
Some
of the most frequent complaints following third molar surgery, according to the work of Oikarinen 2
and Kim 3
,
are pain and trismus. Fisher showed that trismus and swelling are closely associated with acute inflammation
following third molar surgery. Inferior alveolar nerve injury is a well documented.4
complication of maxillofacial procedures such as third molar surgery.5
Susarla and Dodson stated that the
incidence of nerve damageranges from 1% to 22% and has become a common cause of litigation.6
Severaltherapeutic protocols have thus been evaluated to support improvements in thepostoperative period.7-9
Approximately 20% of the population has impacted teeth, where mandibular and maxillary third molars are the
most common.10
The highest incidence of impaction has been shown in mandibular wisdom teeth which may

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lead to pathologies like pericoronitis, periodontitis, second molars tooth-crown resorption, pain, cysts or
odontogenic tumors, and primary or secondary crowding of the dentition. Early removal of these teeth to
prevent the abovementioned problems is widely approved.11
Hard tissue cutting is a common procedure in the dental fields, especially during maxillofacial, oral, and
periodontal surgeries. Traditionally, rotating instruments like burs have been used for osseous surgery.
However, bone overheating and damage to adjacent tissues are disadvantages that are related to the use of
thesemethods.12
Piezoelectric surgery techniques have opened up a new age for osteotomy, osteoplasty and exodontia in
maxillofacial and oral surgery. As well as being selective, the micrometric cuts possible via these techniques
maximize surgical precision, resulting in minimal damage to soft tissue. In addition, the cavitation effect
provides maximum intraoperative visibility and a blood-free surgical site.
Its mechanism of action is based on the ability of certain ceramics and crystals to deform when an electric
current is passed across them, resulting in microvibration at ultrasonic frequency.13
A frequency of 25–30KHz,
from a nitride hardened or diamond-coated insert, allows for selective cut of bone tissue.14
Since its approval for
commercial use in 2002, it has been successfully utilized for many surgical procedures, such as maxillary sinus
lifting, autologous bone graft harvesting, bone splitting, lateralization of the inferior alveolar nerve, and
orthognathic and neurologic surgeries.15
Goyal et al. compared piezosurgery with the conventional rotary surgical technique and found that pain,
swelling, trismus, and healing were significantly decreased in the piezosurgery site.16
Moreover, a systematic
review and meta-analysis done by Jiang et al. compared piezosurgery and conventional rotary osteotomy
techniques in third molar extraction. They concluded that although the patients undergoing piezosurgery
experienced longer surgery time, they developed less swelling, less pain, and less postoperative trismus.17
Also, similar findings were concluded in the metaanalysis conducted by Al-Moraissi et al. in which there was a
significant reduction in postoperative sequelae (facial swelling, pain, and trismus) with the piezoelectric surgical
technique in third molar extraction, whereas their results showed that the duration of surgery and operating time
for third molar extraction were significantly shorter with conventional rotary instruments compared to the
piezoelectric surgical technique.18
AIM OF THE PRESENT STUDY
This study compares the two different instruments i.e. piezoelectric and rotary bur for removal of impacted
mandibular third molars for evaluating the time required, patient satisfaction of the procedure intra-operatively,
the severity of pain and mouth opening postoperatively.
METHODOLOGY
Sample size was determined to be 20 patients. All patients were informed about the study and consent was taken
for the same. Preoperative orthopantomogram and intraoral periapical radio figures were taken. The patients
were subjected to removal of impacted mandibular third molars using piezoelectric and rotary bur. The study
was conducted to compare surgical and post-surgical outcome of impacted third molar removal using
piezoelectric on one side and rotary bur on contralateral side. Internal ethics committee for human studies, of the
institution has approved this study. Intra-operatively, the time taken and patient satisfaction of the procedure
was evaluated. Post operatively, patients were evaluated for pain using a feedback form of visual analog scale
for a period of 7 days, mouth opening examined clinically on day 3, day 5 and day 7.
All the patients underwent surgical removal of impacted mandibular third molars. Full thickness mucoperiosteal
flap was raised and retracted using Austin’s retractor. On one side, bone was removed using rotary device with
#702 or #703 bur and constant irrigation was done using sterile isotonic saline solution to reduce the heat
generated during bone removal. After around 10 to 15 days, using SL 1, SL 2, & SL 3 burs, bone was removed
using piezoelectric device on contralateral side. Guttering technique was adapted on both the sides. The teeth
were removed in toto. The irregular bone and gingival margins were parried; the wound was irrigated with
sterile saline solution. Flaps were repositioned and sutured using 3-0 black braided silk. Post operatively, all
patients received amoxicillin 500 mg tid and diclofenac sodium 50 mg tid for 3 days. Postoperative instructions
were given and the sutures were removed on the 7th day.
Patient satisfaction of the individual procedure was evaluated intra-operatively and graded using a scale. Post-
operative pain was evaluated according to subjective analysis like VAS (visual analog scale).For mouth
opening, Inter-incisal distance is measured preoperatively, and postoperatively on day 3, day 5 and day 7.
RESULTS
Patients belong to age group 19 to 34 years, out of which 11 were males and 9 were females. Intra-operatively,
the time taken and patient satisfaction of the procedure was evaluated and post operatively, clinical assessment

3. International Journal of Early Childhood Special Education (INT-JECS)
ISSN: 1308-5581 Vol 14, Issue 03 2022
816
of mouth opening was done on day 3, day 5 and day 7, correlating with that of preoperative value. Pain was
evaluated subjectively using feedback form of visual analog scale for a period of 7 days.
The time taken for removal of impacted tooth using rotary bur was much less (25.15+ 6.74 min) compared to
that of piezoelectric device (50.30+ 20.51 min). (Table 1) Student t test (paired) was used for statistical analysis.
Patient satisfaction was evaluated using a grading scale and mixed results were obtained in terms of satisfaction
of the procedure. The mean of mouth opening on day 3, day 5 & day 7 was significantly better in the
piezoelectric group (p<0.01) as compared to rotary bur. (Table 2) On day 1 the pain was much less in
piezoelectric group as compared with rotary bur group with a p value of 0.03. From day 2 to day 6, there was
significant difference among the two groups at the level of p<0.01. On day 7 no significant difference was found
among the two groups. (Table 3)
Table 1- Comparison of time taken in minutes between piezoelectric and Rotary Surgery
Time taken Piezoelectric Rotary
Min-Max 15-88 15-41
Mean ± SD 50.30±20.51 25.15±6.74
95%CI 15.0-88.0 15.0-41.0
Table 2- Comparison of mean score mouth opening for procedure in two groups
Mouth opening score Piezoelectric Rotary P value
Pre-op 34.45±2.54 34.40±2.46 0.330
Day 3 31.75±3.11 27.75±2.92 <0.001
Day 5 32.95±3.09 30.75±3.18 <0.001
Day 7 33.70±2.94 33.00±2.82 <0.001
Table 3- Patient satisfaction using grading scale between Piezoelectric and Rotary bur
Patient satisfaction
grade
Piezoelectric
(n=20)
Rotary
(n=20)
P value
1: Very satisfied 6(30.0%) 8(40.0%) 0.298
2: Fairly satisfied 8(40.0%) 5(25.0%) 0.204
3: Fairly unsatisfied 6(30.0%) 7(35.0%) 0.392
4: very unsatisfied 0 0 -
DISCUSSION
In oral and maxillofacial surgery, impacted third molars are routinely extracted and invariably cause certain
degree of postoperative pain, swelling, and trismus. The severity of postoperative responses is correlated to the
“aggressiveness” of the procedure.[7] In 1975, Horton et al.[15] studied the effects of chisel, ultrasonic
instrument, and rotary bur used for osteotomy and compared their effect on postoperative wound healing and
reported that rotary burst was more
traumatizing to the bone. A favorable healing outcome was observed in chisel, followed by ultrasonic
instruments. In 1999, Prof. Tomaso Vercellotti, in collaboration with Mectron Spa, invented a new innovative
piezoelectric bone surgery technique.[16] The postoperative pain was evaluated based on VAS.
Other factors affecting pain and swelling are individual pain threshold, body response and type of wound. The
severity of pain might vary among individuals. The severity of trismus and swelling correlates with the degree
of trauma during the surgery. Thus, a risk of error is present when the case and control are different
individuals.12 The present study is a split-mouth study design in which the subjects are served as their own
controls.
Over a period of time surgical procedures have been modified to reduce intraoperative and postoperative
complications. The surgical method should be one with minimum complication.13 Initially bone removal was
done by using chisel and mallet. Later rotary instruments were introduced for cutting bone in maxillofacial
operations. Rotating instruments are potentially injurious due to excessive increase in the temperature during
osseeus drilling, which can produce marginal osteonecrosis and impair bony regeneration. Piezoelectric
techniques were developed in response to the need for greater precision and safety in bone surgery as compared
to that of manual and motorized instruments.

4. International Journal of Early Childhood Special Education (INT-JECS)
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The present study is done to compare two different instruments i.e., piezoelectric and rotary bur in surgical
removal of impacted molar tooth. Intraoperatively, time required and patient satisfaction was evaluated.
Postoperatively, mouth opening was measured clinically on day 3, day 5 and day 7 correlating with preoperative
values. Pain was evaluated using a feedback form of VAS for a period of 7 days.
Francesco Sortino et al. (2008) did a clinical study to compare postoperative outcome in surgical removal of
third molars treated by piezoelectric and by rotatory osteotomy technique. The study was concluded by saying
that piezoelectric osteotomy produced a reduced amount of trismus 24hrs after surgery, but a longer surgery
time was required when compared with the rotatory osteotomy technique.13
In piezoelectric group, 30% were very satisfied, 40% were fairly satisfied and 30% were fairly unsatisfied as
compared to rotary bur in which 40% were very satisfied, 25% were fairly satisfied and 35% were fairly
unsatisfied and amount of pain experienced by piezoelectric group was less as compared to rotary bur technique
over a period of 7 days and the mouth opening was much better in piezoelectric group as compared to rotary bur
group at the level of P<0.001.
CONCLUSION
We conclude piezoelectric instrument is better alternative for removal of impacted tooth than rotary instruments.
Extensive studies are required to be conducted for its different uses in osseous surgeries, so that its range of
applications can be widened.
REFERENCES
1. Tetsch, p., wagner, w., 1982. Operative extraction of wisdom teeth. Munich: Wolfe medical publications
ltd.
2. Oikarinen, k., rasanen, a., 1991. Complications of third molar surgery Among university students. J am coll
health, 39(6), 281-285.
3. Kim, j., choi, s., wang, s., kim, s., 2005. Minor complications after Mandibular third molar surgery: type,
incidence and possible prevention. Oral surg Oral med oral pathol oral radiol endod, 102.
4. Fisher, s.e., frame, j.w., rout, p.g.j., mcentegart, d.j., 1988. Factors affecting the onset and severity of pain
following the surgical removal of Unilateral impacted mandibular third molar teeth. Br dent j, 164, 351-
353.
5. Genu, p.r., vasconcelos, c.e., 2008. Influence of the tooth section Technique in alveolar nerve damage after
surgery of impacted lower third molars. Int j oral maxillofac surg, 37, 933-928.
6. Susarla, s.m., dodson, t.b., 2007. Preoperative computed tomography Imaging in the management of
impacted mandibular third molars. J oral Maxillofac surg, 65, 83-88.
7. G. Juodzbalys and P. Daugela, “Mandibular third molar impaction: review of literature and a proposal of a
classification,” Journal of Oral & Maxillofacial Research, vol. 4, no. 2, article e1, 2013.
8. S. Mansuri, A. Mujeeb, S. A. Hussain, and M. A. Z. Hussain, “Mandibular third molar impactions in male
adults: relationship Of Operative time and Types of impaction on inflammatory complications,” Journal of
International Oral Health, vol. 6, no. 2, pp. 9–15, 2014.
9. T. de Santana-Santos, J.-A. de Souza-Santos, P.-R. Martins- Filho, L.-C. da Silva, E.-D. de Oliveira e Silva,
and A.-C. Gomes, “Prediction of postoperative facial swelling, pain and trismus following third molar
surgery based on preoperative variables,” Medicina Oral, Patolog´ıa Oral y Cirug´ıa Bucal, vol. 18, no. 1,
pp. e65–e70, 2013.
10. C. H. Bui, E. B. Seldin, and T. B. Dodson, “Types, frequencies, and risk factors for complications after
third molar extraction,” Journal of Oral and Maxillofacial Surgery, vol. 61, no. 12, pp. 1379–1389, 2003.
11. P. Leclercq, C. Zenati, and D. M. Dohan, “Ultrasonic bone cut part 2: state-of-the-art specific clinical
applications,” Journal of Oral and Maxillofacial Surgery, vol. 66, no. 1, pp. 183–188, 2008.
12. A. Barone, S. Marconcini, L. Giacomelli, L. Rispoli, J. L. Calvo, and U. Covani, “A randomized clinical
evaluation of ultrasound bone surgery versus traditional rotary instruments in lower third molar extraction,”
Journal of Oral and Maxillofacial Surgery, vol. 68, no. 2, pp. 330–336, 2010.
13. A. Happe, “Use of a piezoelectric surgical device to harvest bone grafts from the mandibular ramus: report
of 40 cases,” International Journal of Periodontics and Restorative Dentistry, vol. 27, no. 3, pp. 241–249,
2007.
14. M. Danza, R. Guidi, and F. Carinci, “Comparison between implants inserted into piezo split and unsplit
alveolar crests,” Journal of Oral and Maxillofacial Surgery, vol. 67, no. 11, pp. 2460–2465, 2009.
15. C. A. Landes, S. St¨ubinger, J. Rieger, B. Williger, T. K. L. Ha, and R. Sader, “Critical evaluation of
piezoelectric osteotomy in orthognathic surgery: operative technique, blood loss, time requirement, nerve
and vessel integrity,” Journal of Oral and Maxillofacial Surgery, vol. 66, no. 4, pp. 657–674, 2008.

5. International Journal of Early Childhood Special Education (INT-JECS)
ISSN: 1308-5581 Vol 14, Issue 03 2022
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16. M. Goyal, K. Marya, A. Jhamb et al., “Comparative evaluation of surgical outcome after removal of
impacted mandibular third molars using a Piezotome or a conventional handpiece: A Prospective Study,”
British Journal of Oral and Maxillofacial Surgery, vol. 50, no. 6, pp. 556–561, 2012.
17. Q. Jiang, Y. Qiu, C. Yang, J. Yang, M. Chen, and Z. Zhang, “Piezoelectric versus conventional rotary
techniques for impacted thirdmolar extraction: a meta-analysis of randomized controlled trials,” Medicine,
vol. 94, no. 41, Article ID e1685, 2015.
18. E. A. Al-Moraissi, Y. A. Elmansi, Y. A. Al-Sharaee,A. E.Alrmali, and A. S. Alkhutari, “Does the
piezoelectric surgical technique produce fewer postoperative sequelae after lower third molar surgery than
conventional rotary instruments? A systematic review and meta analysis,” International Journal of Oral and
Maxillofacial Surgery, vol. 45, no. 3, pp. 383–391, 2016.