Oral and Maxillofacial Surgery

https://doi.org/10.1007/s10006-019-00817-7

ORIGINAL ARTICLE

A prospective split-mouth clinical study: comparison of piezosurgery

and conventional rotary instruments in impacted third molar surgery
Dilek Menziletoglu 1 & Funda Basturk 1 & Bozkurt Kubilay Isik 1 & Alparslan Esen 1

Received: 24 June 2019 / Accepted: 12 November 2019

# Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Purpose Our purpose was to compare the effects of piezosurgery and conventional rotary instruments on postoperative pain,
swelling, trismus, and patients’ comfort after mandibular third molar surgery.
Methods Thirty patients (27 women and 3 men) with bilateral impacted mandibular third molars were included in this split-
mouth clinical study. Sixty impacted third molars were divided into a control group (n = 30), in which the osteotomies were
performed using a conventional rotary handpiece technique and an experimental group (n = 30), in which the osteotomies were
done by piezosurgery technique. Duration of the procedure was recorded. Postoperative pain was assessed using a visual
analogue scale (VAS). All the patients were given a form containing verbal rating scale for evaluating the swelling. Trismus
was evaluated using a caliper at maximum mouth opening (cm). In postoperative seventh day, patients were asked to fill a global
quality of life (QoL) scale as well.
Results There was no significant difference in postoperative pain, trismus, and swelling between control and experimental groups
(p > 0.05). However, time of the procedure increased in control group (p < 0.05).
Conclusion Piezosurgery is a safe way for performing the osteotomies during third molar surgery. However, regarding the
postoperative morbidity, it does not have an advantage over conventional rotary instruments. Piezosurgery took longer to
complete the osteotomy than the rotary handpiece technique.

Keywords Piezosurgery . Impacted third molar . Trismus . Pain

Introduction those efforts. Using different osteotomy techniques is one of

those strategies [11].
Removal of impacted third molars is one of the most per- Conventionally, rotary handpieces and burs are used for
formed oral surgical operations. Partially or fully impacted removing the bone over impacted third molars and other im-
third molars can be associated with pericoronitis, pain, pacted teeth as well. Piezosurgery has been suggested as an
odontogenic infections, trismus, cysts, or even tumors [1]. alternative for rotary instruments. This technology is used for
Postoperative complications such as pain, trismus, nerve elevating maxillary sinus floor, expanding alveolar crest, peri-
damage, bleeding, and dry socket can be encountered after odontal surgery, orthognathic surgery, cyst, and tumor remov-
surgical removal of these teeth [2]. Because these morbidities al [12].
affect the patient’s postoperative quality of life, surgeons have Our purpose was to compare the effects of piezosurgery
made attempts to decrease them [3]. Preoperative or postop- and conventional rotary instruments on postoperative pain,
erative use of antibiotics [4], platelet-rich plasma application swelling, trismus, and patients’ comfort after mandibular third
[5], cryotherapy [6], wound drainage [7], different flap tech- molar surgery.
niques [8], use of corticosteroids [9], or laser [10] are along

* Dilek Menziletoglu Method and materials

[email protected]
The study protocol was approved by the local ethics commit-
1
Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, tee (decision no: 2016/009). We planned a prospective and
Necmettin Erbakan University, Konya, Turkey split-mouth study. Thirty patients were randomly selected.
 Oral Maxillofac Surg

Inclusion criteria were being older than 18 of age, having and it was intended to evaluate their general well-being during
asymptomatic bilateral mesioangular impacted mandibular the first postoperative week [14].
third molar (Pell and Gregory class II, position B) fully cov- We used SigmaPlot 12.5 (Systat Software Inc., San Hose,
ered with the mucosa and bone and being otherwise medically CA) for statistical analyses. The data were tested for normality
healthy. Exclusion criteria were as follows: alcohol abuse, by using Shapiro-Wilk test. Wilcoxon test was used for com-
smoking, pregnancy, and the presence of acute severe paring pain, swelling, and QoL. MIO and DO were compared
periodontitis. with paired t-test. Significance level was set as .05.
Thirty patients aging between 18 and 26 (mean age 21.4 ±
2.44, 3 males and 27 females) included to the study. Maximal
interincisal opening (MIO) was noted before the surgery. One Results
side of the patients was randomly selected and labeled as
“experimental group,” and other side was accepted as “control There was no statistically significant difference experimental
group.” There was at least 1 month between two surgeries. and control groups (p > 0.05) regarding postoperative pain
All surgeries were done in conventional way and carried and swelling (Figs. 1 and 2).
out by the same surgeon. Before the surgery, patients used In the experimental group, preoperative MIO was 37.73 ±
10% povidone-iodine mouthwash for 1 min. Inferior alveolar 5.6 mm, and postoperative MIO was 34.83 ± 5.8 mm. In the
block and buccal anesthesia were performed with 2 mL of 4% control group, preoperative MIO was 38.13 ± 5.3 mm and
articain HCl and 1:200.000 epinephrine solution. A full- postoperative 33.93 ± 6.45 mm. Although the decrease in
thickness envelope flap with a vertical releasing incision was MIO was less in experimental group, the difference was not
reflected. In the control group, a conventional rotary statistically significant (p = 0.393) (Fig. 3)
handpiece and tungsten carbide burs were used under copious There was no significant difference between QoL of two
irrigation for removing the overlying bone. In the experimen- groups (mean values 77.33 ± 14.49 in experimental group and
tal group, piezosurgery (EMS, Piezon Master Surgery, 77.17 ± 13.63 in control group, p = 0.909).
Switzerland) was employed for the same purpose. In both The only significant difference was found between DO of
groups, after removal of the bone, tungsten carbide surgical two groups (14.03 ± 4.23 min in experimental group, 10.6 ±
burs were used for tooth sectioning. Extraction wounds were 2.74 min in control group, p < 0.01).
closed with 3-0 silk sutures. The time passed from flap eleva-
tion until suturing was recorded as “duration of the operation”
(DO). Discussion
The patients were postoperatively prescribed a 5-day
course of 100 mg flurbiprofen twice daily (Majezik, Sanovel In oral surgery, conventional tool for removing the bone is
İlaç, Istanbul, Turkey), 1 g amoxicillin twice daily (Largopen, rotary handpieces. Recently, piezosurgery technique has
Bilim İlaç, Istanbul, Turkey), and 0.12% chlorhexidine gluco- g a i n e d p o p u l a r i t y. I t u s e s u l t r a s o n i c f r e q u e n c y
nate antiseptic mouthwash every 8 h (Kloroben, Drogsan İlaç, microvibrations, and it has been considered as safe and effi-
Ankara, Turkey). They were invited after 1 week for removing cient [15]. Since it only affects mineralized structures, it has a
the sutures and postoperative assessment. “selective cutting” feature, and this makes it ideal for using in
During the first postoperative week, pain was self- osteotomy sites where vital structures should be protected.12
evaluated daily by using a visual analogue scale (VAS). This Since it does not produce extreme temperatures, it does not
scale was a 100-mm horizontal line drawn on a paper. The left interfere with healing of the bone [16], and constant irrigation
end of the line was marked as “no pain at all” and the right end system provides a clearer operation site [17]. However, it is
marked as “worst pain imaginable,” with no any other expres- also more time-consuming when compared with rotary instru-
sion on it. Patients would make a mark indicating their degree ments. [18].
of pain on this line. This mark was measured in millimeters Those differences between classical rotary handpiece and
and was labeled as “pain level.” piezosurgery techniques have led researchers to compare their
All the patients were given a form containing verbal rating effects on postoperative morbidity in third molar surgery. In a
scale ranging from 0 to 5, showing the degree of swelling, as randomized split-mouth study, pain, swelling, and trismus
described a previous study [13]. During the 1 week, swelling were found less in piezosurgery group, while duration of the
was also self-evaluated by the patients daily. operation was longer. [19]. Similar results were reported by
In postoperative seventh day, when the patients came for Arakji et al. [20]. and Al-Moraissi et al. [21]. In another study,
removing the sutures, MIO was measured to assess trismus. Goyal et al. extracted 40 impacted mandibular third molars,
On the same day, they were asked to fill a global quality of life and they also reported that postoperative pain, swelling, and
(QoL) scale as well. This scale contains numbers from 0 (ex- trismus were significantly reduced in piezosurgery [22].
tremely bad quality of life) to 100 (excellent quality of life), However, we found no significant differences between two
Oral Maxillofac Surg

Fig. 1 Pain scores on visual

analog scale

groups regarding postoperative pain, swelling, and trismus, created by the surgical instruments is not the single effective
which contradict with other reports in the literature [19–22]. factor on postoperative pain. The patient’s anxiety and percep-
We claim that prolonged operation time in piezosurgery tion of the pain, oral hygiene, alveolar osteitis development,
group might have reduced the benefits of the technique. and the surgeon’s skill and experience are also important.
Although a more atraumatic surgery can be done with the Because of the slow micrometric cutting in piezosurgery, it
piezosurgery, it requires an extended period of soft tissue re- takes more time to complete the osteotomy. This was also
traction, leading more edema and more swelling. There was previously reported in the literature [19, 20, 22, 25].
also no significant difference between two groups in postop- Additionally, when the operation site is not easily accessible,
erative trismus. This may be due to age factor. Our patients the tip of the piezosurgery handpiece may not be applied to the
were relatively younger, and their ages were fairly close to bone perpendicular, and that can cause the surgery to take
each other, which probably accelerated the healing process. even longer. Surgical difficulty and the patients’ age affect
Sivolella et al. reported similar results [23]. In a split-mouth duration of the operation [25]. In our study, age distribution
study performed in 26 patients, they found no significant dif- was relatively homogenous, and surgical difficulty of teeth
ferences between two groups in postoperative pain, swelling was similar to each other.
and trismus. Postoperative morbidities developing after third molar sur-
While Barone et al. [24] found piezosurgery to be more gery may have serious impact on the patient’s QoL [13].
favorable than rotary instruments regarding postoperative Different methods have been used for this purpose, but it is
swelling and trismus, they also showed that the postoperative challenging to obtain relevant results. [14, 26]. In our study,
pain between two groups was similar. Extraction trauma there was no significant difference between piezosurgery and

Fig. 2 Swelling scores in

piezosurgery group and rotary
group
 Oral Maxillofac Surg

Fig. 3 Preoperative and postoperative mean mouth opening values

rotary instruments groups regarding the QoL during postop- Statement of informed consent (optional) Informed consent was ob-
tained from all individual participants included in the study.
erative first week. In both groups, QoL scores were high
(77.33 ± 14.49 in piezosurgery group and 77.17 ± 13.63 in
rotary instruments group), which suggests both techniques
yielded acceptable outcomes.
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