This document provides an overview of piezoelectric surgery and its applications in periodontics. It describes the equipment, mechanism of action involving ultrasonic cutting of bone through piezoelectric effects, and various applications including scaling and root planing, crown lengthening, bone grafting, ridge expansion, implant site preparation, and sinus lift procedures. Piezoelectric surgery allows for precise cutting of bone while minimizing damage to adjacent soft tissues.

1. Piezoelectric surgery
in periodontics
T.HUDSON JONATHAN
II ND YR MDS

2. CONTENTS
 Introduction
 Equipment
 Mechanism of action
 Applications
 Scaling and root planning
 Curettage
 Periodontal surgery
 Harvesting Bone blocks and
Bone grafting
 Ridge expansion
 Implant site preparation
 Sinus lift procedure
 Tooth extraction
 Advantages
 Disadvantages
 Conclusion
 References

3. INTRODUCTION
 Piezosurgery device is a sophisticated ultrasonic device, that can be used
for bone surgery in a variety of dental surgical procedures like periodontal
surgery, periapical surgery, removal of impacted teeth, in implant surgery
for facilitating bone ridge expansion, in bone regeneration techniques and
inferior dental nerve lateralization and trans positioning Diago et al 2008.
 This device is designed to cut or grind the bone without damaging the
adjacent soft tissues. The mechanism of this instrument is mainly based
by the “Piezo effect”.

4.  The instrument used for ultrasonic cutting of bone creates microvibrations
that are caused by piezoelectric effect was first described by French
physicists Pierre Curie and Marie Curie, in 1880.
 They were the first persons who had mentioned that in direct Piezo-Effect
certain crystals produce electrical current while under mechanical
pressure.
 This is the effect being used by the piezosurgery device in which the
electrical field is located in the handle of the saw.

5.  In 1999 Dr. Tomaso Vercelloti, invented
Piezoelectric bone surgery in collaboration with
Mectron Spa. In the United States, Vercellotti
first published on this topic in 2000.
 This technology has been used commercially in
Europe since 2000.
 In 2005, the US Food and Drug Administration
extended the use of ultrasonics in dentistry to
include bone surgery. Thomas J 2008

6. EQUIPMENT
 Piezoelectric device typically consist of handheld device (handpiece),
foot pedal, base unit. There are different-shaped inserts that correspond
to different applications that can be screwed into the handpiece.
 The insert tips are tightened to the handpiece with the dynamometric
wrench, applying a pre-defined force to obtain optimum energy
transmission.
 High-frequency oscillations of 24 000 and 29 500 Hz, modulated with a
low frequency between 10 and 60 Hz, enables efficient and controlled
use.

7.  The handpiece is controlled by a foot pedal with settings that could be
adjusted on the base unit. Main body has a display, an electronic touchpad,
a peristaltic pump, one stand for the handle another to hold the bag
containing irrigation fluid.

8.  All the parts of the unit through which the liquid passes, including the
handpiece cord and the handpiece itself, are fully sterilizable. Base unit is
controlled solely by means of the keyboard.
 The unit has a display that allows the operator to select either the Bone or
Root operating modes.
Bone mode
 It is used to cut bone with selections that are specific to bone type or
density. The selection recommended is:
 Quality 1 for cutting and removing small cortical bone fragments.
 Quality 2 for cutting and removing cancellous or spongy bone.

9. Root operating mode
 It is used to shape, debride, and smoothen the root surfaces.
 Root operating mode consists of two different programs.
• ENDO Program: the ultrasonic frequency is set at an ideal power level for
retrocanal and intracanal debridement after root canal treatment
• PERIO Program: the ultrasonic frequency without over modulation is set at
an ideal power level for scaling, debridement, and root planing.

10. The insert kits:
 PS inserts are classified based on their functional and clinical
characteristics.
Functional classification:
 The tips have been classified as sharp, smoothening and blunt tips.
 Sharp instruments: The sharp edge of the instruments enables gentle and
effective treatment of the bony structures, such as in osteotomy, implant
site pre-paration, osteoplasty techniques and or harvesting bone chips.

11.  Smoothening instruments: The smoothening instruments have diamond
surfaces enabling precise and controlled work on the bone structures.
Preparing for a sinus window or access to a nerve is possible.
 Blunt instruments: Are used for preparing the soft tissue. For elevating
schneiders membrane or for lateralizing nerves. In periodontology, these
tips are used for root planning.

12. Clinical classification:
 Clinical classification sorts the inserts according to basic surgical
techniques of osteotomy, osteoplasty and extraction.
 Identification codes
 OT: osteotomy
 OP: osteoplasty
 EX: extraction
 IM: implant site preparations.

13. INSTRUMENTS COLORS
 Gold: For all instruments used to treat
bone. The gold color of the instrument is
obtained by applying a coating of titanium
nitride to improve the surface hardness
which means a longer working life.
 Steel: For all instruments used to treat soft
tissue or delicate surfaces, such as the roots
of teeth.

14. MECHANISM OF ACTION
 Most dentists use ultrasonic scaler at some point in their careers to
help in removal of plaque and calculus from root structure.
 The ultrasonic (or ultrasound) frequency, as the name implies, is a
frequency above the audible range for humans, usually above 20 kHz.
 In dental applications, the frequency used ranges from 24 kHz to 36
kHz, the frequency range capable of cutting mineralized tissue.
Bhagat et.al ;Galore International Journal of Health Sciences and Research Vol.5; Issue: 1; January-March 2020

15.  With piezoelectric ultrasonic, the frequency is created by driving an
electric current from a generator over piezoceramic rings, which leads to
their deformation.
 The resulting movement from the deformation of the ring sets up a
vibration in a transducer and/or amplifier, which creates the ultrasound
output.

16.  These waves transmitted to the hand piece tip, where the longitudinal
movement results in cutting of osseous tissue by microscopic shattering of
bone.

17.  The conversion of electrical pulses to mechanical vibrations and the
conversion of returned mechanical vibrations back into electrical energy is
the basis for ultrasonic testing.
 The active element is the heart of the transducer as it converts the
electrical energy to acoustic energy, and vice versa.
 The active element is basically a piece of polarized material (i.e. some
parts of the molecule are positively charged, while other parts of the
molecule are negatively charged) with electrodes attached to two of its
opposite faces.

18.  When an electric field is applied across the material, the polarized
molecules will align themselves with the electric field, resulting in
induced dipoles within the molecular or crystal structure of the material.
 This alignment of molecules will cause the material to change dimensions.
This phenomenon is known as electrostriction.
 In addition, a permanently-polarized material such as quartz (SiO2) or
barium titanate (BaTiO3) will produce an electric field when the material
changes dimensions as a result of an imposed mechanical force. This
phenomenon is known as the piezoelectric effect.
NDT resource center. Piezoelectric transducer . Lowa state university: National science foundation; 2001

19.  The active element of most acoustic transducers used today is a
piezoelectric ceramic, which can be cut in various ways to produce
different wave modes.
 The first piezoceramic in general use was barium titanate which was
followed during the 1960's by lead zirconate titanate compositions,
which are now the most commonly employed ceramic for making
transducers.
 New materials such as piezo-polymers and composites are also being used
in some applications.

20. Applications
Soft Tissue Applications:
 Ultrasonic instrument uses high frequency mechanical energy to offer the
surgeon controlled and precise incision and haemostatis.
 The machine operates at 55,500 Hz and requires less energy than either
cutting diathermy or laser.
 The instrument tip vibrates at amplitude of 50 μm to 100 μm. Vessels up
to 2mm in diameter may be sealed by coaptation with the blade before
division.

21.  It produces considerably less smoke or smell than either diathermy or
laser, which reduces the need for instrument exchanges or smoke
evacuation.
 Resterilization of the harmonic scalpel will allow it to be used on any
number of patients and appreciably reduce the procedure related expenses
after initial outlay.
 The device has been successfully used in both open and laparoscopic
general surgical, gynecological procedures and for resections of squamous
cell carcinoma of the tongue. A clear, relatively bloodless field was
obtained with good visibility. Sherman et al 2000

22. Hard Tissue Applications: (Seshan et al 2009)
1. Cranial Osteoplasty
2. ENT surgery, neurosurgery, paediatric surgery and orthopaedics
3. Rhinoplasty
4. Otologic surgery
5. Orthodontic Applications
 Corticotomy
 Exposure of impacted canines
6. Oral surgery
 To treat TMJ ankylosis
 Nerve mobilization or nerve transposition procedures
 Atraumatic extractions and Cyst removal

23. 7. Periodontology
 Supragingival and subgingival scaling and root planning
 Periodontal pocket lavage
 Crown lengthening
 Soft tissue debridement
 Resective surgeries
 Regenerative surgeries - To obtain autogenous grafts for treatment of
periodontal intrabony defects.

24. 8. Implantology
 For harvesting Block (bone) grafts and eventually implant placement in
the recipient sites.
 Osteotomy procedures
 Distraction osteogenesis followed by Implant placement.
 Ridge Expansion and implant placement.
 Maxillary sinus elevation procedures
 Drilling hole in the bone for implant placement
 For insertion of implant.

25. Scaling and root planing
 Cavitation was assumed to be able to liberate some energy for the removal
of deposits.
 However, it has been found that using only the cavitation without the
touch of the vibrating tip is not sufficient to remove the calculus, and that
a direct contact between the vibrating tip and the calculus is necessary.
 Therefore, it is now accepted that the mechanical energy produced by the
vibrating tip (chipping action) along with cavitation is responsible for the
removal of deposits.

26.  The piezosurgery ultrasonic scaler set on function On/Mode Periodontics
(ROOT), with the insert PS1 and PP1, applied at a medium power of two
for 15 sec is used on all the surfaces for removal of deposits.

27.  Movements were parallel to the tooth axis and the working strokes were
perpendicular to the tooth axis.
 The piezoelectric device appears to produce better results in terms of
roughness and less damage to the root surface than the conventional
magnetostrictive ultrasonic scaler.
MG Newman, HH Takei, PR Klokkevold, FA Carranza. 11th ed. South Asia

28. Curettage:
 Piezosurgery device are used for the debridement of the epithelial lining
of the pocket wall resulting in microcauterization.
 Piezosurgery device can be used for efficient removal of diseased soft
tissue and removal of root calculus compared to manual instruments by
using thin tapered tips and altered power setting [Hema et al 2009].

29. Periodontal surgery
 The use of piezosurgery in periodontal surgery simplifies and improves
handling of soft and hard tissues.
 In resective periodontal surgery, for example, after raising the primary
flap with a traditional technique, using a scaler-shaped insert (PS2) or an
insert in the shape of a rounded scalpel (OP3) makes it easier to detach the
secondary flap and remove inflammatory granulation tissue.

30.  This phase has little bleeding as the result of the cavitation of the saline
solution (coolant). With the right inserts and power mode, the ultrasound
device facilitates effective scaling, debridement, and root planing.
 In particular, debridement with a special diamond-coated insert enables
thorough cleaning even for interproximal bone defects.
 The mechanical action of ultrasonic microvibrations, together with
cavitation of the irrigation fluid (pH neutral; isotonic saline solution)
eliminates bacteria, toxins, dead cells, and debris, which creates a clean
physiology for healing.

31.  Healing is improved by applying ultrasound to produce micropits at the
base of the defect to activate cellular response of healing mechanisms.
 The ability to work on the bone defect with magnifying systems makes it
possible to exploit the benefits of piezosurgery microprecision in
preparing the recipient site and stabilizing micrografts.
Carranza’s clinical periodontology-13th ed

32. Crown lengthening
 The goal is to reposition the periodontal bone and soft tissues to a more
apical position with appropriate biologic dimensions and minimal
periodontal inflammation.
 The crown lengthening technique performed with piezosurgery using
appropriate inserts makes it possible to effectively reduce bone while
preserving root surface integrity.

33.  The osteotomy is simple to perform using piezosurgery in direct contact
with the root surface because control of the instrument during surgery is
precise, even in very difficult proximity cases.
 The root planing phase can be performed very effectively using blunt
ultrasonic inserts [Sherman et al 2000].

34. Harvesting Bone blocks and Bone grafting
 Bone blocks harvested using traditional rotary cutting instruments to
reduce the width of the cortical bone by at least 1 mm circumferentially
and are unable to effectively cut the internal cancellous bone.
 So the block has to be detached using scalpels and this makes the margins
irregular. Subsequently, it becomes necessary to further reduce the block
width.

35.  Piezo surgery provides high precision and operating sensitivity and easy
differentiation between cortical and cancellous bone while removing
blocks of monocortical cancellous bone [Sohn et al 2007].
 Bone chips as big as 500μm are the basis of osteoconductive bone
regeneration. The piezo unit enables to gently scrub the bone surface to
obtain graft material in sufficient amount.

36.  As far as bone blocks are concerned, the donor beds might be situated in
the chin, iliac crest or oblique line of the mandible.
 Using this technique the easiness of the surgical procedure and smaller
entrance site are guaranteed . Happe 2007

37. Ridge expansion
 Horizontal alveolar ridge expansion is an extremely useful technique for
increasing bone width and simultaneously placing implants in narrow
ridges.
 The great advantage is that both augmentation and implant placement are
accomplished in one surgical procedure.
 Piezosurgery is an indispensable tool used to create a horizontal
osteotomy through the alveolar bone crest caused by its precise (narrow)
cutting action.

38.  In some cases (e.g., areas of dense bone with little elasticity), it may also
be necessary to make one or two vertical cuts in the alveolar bone to allow
ridge expansion.
 The horizontal osteotomy is expanded in subsequent steps using
piezoelectric inserts for implant site preparation together with screw-type
or fan-type expanders for increasing the diameter or section, respectively.

39. Implant site preparation
 As a new technique, implant site preparation can be performed with a
specifically designed set of piezosurgical inserts.
 Piezosurgical site preparation allows for the selective enlargement of only
one socket wall.
 This is called ‘differential ultrasonic socket preparation’ by Vercellotti.
Piezosurgical site preparation provides similar primary stability and short-
term survival rate of an implant when compared with conventional site-
preparation techniques.

40.  Stelzle et al 2012 emphasized that the applied load on the handpiece may
increase the preparation speed but it may also increase the negative
thermal effect on the bone.
 Therefore, it is recommended that a maximum load of 400 g is used
during implant site preparation.

41. Sinus lift procedure
 In 2000, a new technique was developed that entails cutting an antrostomy
(lateral window) using piezosurgery. This technique has greatly reduced
the risk of membrane perforation (approximately 5% to 7%).
 Wallace et al, reported the perforation rate was reduced from the average
of 30% with rotary instrumentation to only 7% with piezosurgery.
 Piezoelectric osteotomies cuts mineralized tissues without damage to the
schinderian membrane and piezoelectric elevators separate and raise the
membrane easily without perforation.

42.  There is no risk of damage to the adjacent structures. Cavitation cleans the
working area improving visibility [Wallace et al 2007].

43. Tooth extraction
 One of the main advantage of ultrasonic unit is
the ability to prepare the bony window in the
external cortex, which provides greater
accessibility to the root or impacted tooth with
limited loss of bone.
 Moreover, it enables one to replace the
removed bony piece in its original position to
improve the healing process and reduce the
regeneration period [Francoli et al 2004].

44. Advantages
• Piezoelectric bone surgery seems to be more efficient in the first phases of
bony healing; it induces an earlier increase in bone morphogenetic proteins,
controls the inflammatory process better, and stimulates remodelling of bone
as early as 56 days after treatment [Rahnama et al 2013]
• It provides faster bone regeneration and healing process
• Greater control of surgical device
• Selective cutting and minimal operative invasion
• Reduced traumatic stress
• Decreased post-intervention pain
• No risk of emphysema.

45. Disadvantages
• Increased operating time required for bone preparation
• Increased cost of the PS equipment as compared with the motor-driven or
manual instruments
• Longer operating time and increasing the working pressure impedes the
vibration of device that transforms the vibrational energy into heat, so tissues
can be damaged, therefore, the use of irrigation is essential not only for the
effect of cavitation but also to avoid overheating
• Moreover, the technique is difficult to learn [Deepa et al 2016].

46. Conclusion
 PS appears to be an advanced and conservative tool when compared with
existent traditional methods for the treatment of bone and soft tissues. It
has the ability to increase treatment effectiveness while improving
postoperative recovery and healing.
 Inspite of the fact that a great deal of scientific research focuses on new
products for tissue engineering and bone regeneration, the importance of
minimal surgical trauma for optional bone healing and regeneration
should not be overlooked.

47.  The effectiveness of PS has the potential to redefine the concept of
minimally invasive surgery in bone regeneration procedures and
implantology.

48. References
 Carranza’s clinical periodontology-13th ed
 Kshirsagar et al .Piezosurgery: Ultrasonic bone surgery in periodontics
and oral implantology- Review; International Journal of Applied Dental
Sciences 2015; 1(5): 19-22
 Mithlesh Bhagat et.al. Piezosurgery in periodontics;Galore International
Journal of Health Sciences and Research Vol.5; Issue: 1; January-March
2020
 Sakthi Devi et al. Piezosurgery In Periodontics-review ;International
Journal of Prosthodontics and Restorative Dentistry, April-June
2015;5(2):51-55

49.  Seshan et al. Piezosurgery in periodontology and oral implantology;
Journal of Indian Society of Periodontology - Vol 13, Issue 3, Sep-Dec
2009.
 Bhatnagara et al. Piezowave in periodontology and oral implantology -
an overview; Tanta Dental Journal, Volume 14 No. 1, January-March 2017

50. Thank you