Comparative evaluation of conventional and Piezoelectric ...

Introduction

Bilateral sagittal split osteotomy (BSSO) is the most common

mandibular corrective operation for skeletal malocclusion. As

the mandibular body is moved by BSSO, there is a risk of

excessive operative bleeding. There is also a risk of

postoperative neurosensory damage to the inferior alveolar

nervebecause of the anatomical course of the mandibular

canal.[1]

Traditionally, rotary burs were considered a time-honoured

technique for ostectomy in maxillary and mandibular bone

removal. It inherently inflicts variable insult to the bone and

soft tissue due to overheating, causing a greater degree of

discomfort and protracted course of recovery. [2]

With the recent trends towards minimally invasive surgery, piezosurgery – a novel ostectomy technique was popularized in oral and maxillofacial surgery. The inserts employ micro-vibrations of the scalpel, maintained at a frequency of 24–29 kHz and amplitude alternating between 60 and 200 µm/s permitting a precise, safe and efficient ostectomy.The piezoelectric instrument selectively works on hard tissue, thus

Abstract:

Aim & Objective: Our aim was to compare the outcomes of piezoelectric surgery and conventional bur after Bilateral sagittal split osteotomy (BSSO). Piezoelectric surgical device is precise and safe than traditional bur in orthognathic surgery.Materials & Method: Fourteen consecutive patients who underwent BSSO procedures were involved in the study. In seven patients procedure was performed using traditionalbur, the remaining seven patient’s osteotomies by piezoelectric device. Intraoperative blood loss, procedure duration timeand nerve impairment were evaluated to compare the outcomes of these two procedures at 1day, 1week, 1month, 3months & 6months.Result: Compare to traditional mechanical surgery. Piezoosteotomy, showed statistically significant reduction in postoperative nerve impairment.Conclusion: The null hypothesis was rejected and our stated hypothesis proved strong, the use of piezoelectric of osteotomy found better than traditional bur. We believe that piezoelectric device allows surgeons to achieve better results overtraditional bur in terms of nerve impairment. This device represents a more precise and safer method to perform invasive surgicalprocedures such as BSSO However, use of traditional burshowed fast osteotomy eventually reducing procedural duration time but on the other hand in deeper incision and vascular areas, use of bur found to be more aggressive as compared to piezoelectric device.

Keywords: BSSO; Piezoelectric surgery; Traditional Bur; Nerve impairment

reducing the likelihood of inflicting iatrogenic trauma to surrounding tissues, including the mucosa and neurovascular structures. Investigators have promulgated piezosurgical devices as a safer and preferred alternative to conventional bur for ostectomies owing to favourable osseous response facilitating speedy recovery. [3-5]

In the present study we analysed the effect on postoperative

neurosensory damage when performed surgery by

conventional bur and piezoelectric device.

Clinical Research Paper

1 2 3 4SINGH K Y, SINGH K V, TIWARI R, THANVI G, 5 6MISHRA S, CHAUHAN B1-6Dept. of Oral and Maxillofacial Surgery, Mahatma Gandhi

Dental College and Hospital, Jaipur

Address for Correspondence : Dr. Yashpal Kunwar Singh

71- Adarsh Nagar, Sector-2, Bayana, Rajasthan

Email: [email protected]

Received : 15 Dec.2020, Published : 30 April 2021

Comparative evaluation of conventional and Piezoelectric Surgery in Sagittal Split Ramus Osteotomy- an in-vivo study

12 University Journal of Maxillofacial Surgery and Oral Sciences Official Publication of Aligarh Muslim University, Aligarh. India

Univ J Maxillofac Oral Sci. 2021; Vol. 1, Issue 1

Patients and Method

Patients

Surgical method:

Fourteen patients under went the orthognathic surgery in

Mahatma Gandhi University of Medical Science MGUMST

in between August 2019-August 2020. All the patients were

informed and signed consent form agreement. Patients had

presence of facial skeletal morphologic disturbances. The

patients with a history of facial trauma, facial reconstructive

surgery and previous orthognathic surgery were under

exclusion criteria of study. (Table-1)

In all patients we have used Epker technique for osteotomy. In

piezoelectric surgery we have made a groove in cortical bone

at anterior border of ramus without reaching bone marrow.

Then the tip of osteotome penetrated the grooves and cut the

complete cortical bone. The tip further penetrated the inner

portion of ramus cortical bone to separate cancellous bone

sagittally with osteotome.

In other group of patient the cortical bone was completely

severed using conventional bur and separated sagittally by

chisel mallet. Following sagittal separation of cortical bone

semirigid fixation was done with absorbable miniplate

(Super-FIXSOR®-MX, Takiron Co., Ltd., Osaka, Japan) or

titanium miniplate (Medicon Co., Ltd., Tuttlingen,

Germany). The patients selection for either group was

randomly done by operating surgeon.

All the operated patients were supplemented with vitamin

B12 methylcobalamin (Methycobal®, Eisai Co., Ltd. Tokyo,

Japan) 1500 _g/day 7 for early recovery from neuro sensory

disturbances of inferior alveolar nerve, most often occur in

extensive surgeries of mandible like BSSO. Vitamin

supplement was continued till complete recovery of neural

disturbance. The difference was evaluated on lateral

cephalogram with mesial cusp of mandibular first molar as a

reference point. (Fig1 & 2)

Pre-operative lateral profile of patient showing bilateral

mandibular prognathism

Pre-operative lateral cephalogram

Pre-operative Lateral profile with IMF

Fig-1 Pre-operative view

13 University Journal of Maxillofacial Surgery and Oral Sciences Official Publication of Aligarh Muslim University, Aligarh. India


Post-Operative OPG showing BSSO with plating

Post-operative clinical lateral profile showing reduced

mandibular prognathism

Fig-2 Post-operative view

The postoperative parameter was analysed in following

manner:

Nerve impairment was evaluated by the clinical neurosensory

test which was performed on 1day, 1week, 1month, 3months

& 6months on all the patients after surgery and were

compared with the normal nerve sensation recorded

preoperatively as a baseline. All tests were performed in an

entirely healthy surrounding when the patient was in a relaxed

posture and shoulderwith eyes closed in semi supine position.

Patients were explained about the test by performing on hand

(without sensory disturbance) and also about the grading

system of response. The evaluated reference points were chin

and inferior lip (vermilion) bilaterally. (6)

Radiographs and photograph of patients were taken pre and

post operatively for comparison after receiving the informed

consent from patients.

Mean SD and median were calculated for data variables.

Statistical analyses were performed using STATA (Stata

Corporation, College Station, TX, USA). A value of p < 0.05

was considered to be significant.

Statistical analysis;

14

Observation & Results

ANCOVA for analysis

Nerve impairment-

Grade of response in nerve sensitivity evaluation on each side

during subjective examination.

1. Absent sensation, anaesthesia

2. Severely altered sensation, paraesthesia

3. Moderately altered or slightly reduced sensation

4. Mildly reduced or subnormal sensation

5. Normal sensation

The post-operative evaluation on 1day, 1week, 1month,

3months and 6months for nerve sensitivity of patients treated

with traditional bur present prolonged nerve impairment till

6months and more. The piezoelectric device groupshowed

less injury to nerve as well as early recovery by

3months.(Table 2a &2b)

Table 2a- Postoperative Nerve sensitivity when use of

Traditional bur

(Number denote- number of patients i.e. in traditional bur on

1st post-op day 1 patient had mild reduction in nerve

sensitivity, 2 patients with moderately reduced sensation, 2

with severely reduced sensation and 1 patient has no

sensation. 3 patients were got normal sensation by 1 month

and 4 out of 7 patients had normal nerve sensation by

6months)

Table 2b- Postoperative Nerve sensitivity when use of

Piezoelectric

Grade Response:

University Journal of Maxillofacial Surgery and Oral Sciences Official Publication of Aligarh Muslim University, Aligarh. India


In piezoelectric group 4 out of 7 patients were having normal

nerve sensation on 1st post-operative day whereas in

traditional bur group only 1 patient had normal sensation on

1st post-operative day. Moreover, all the patients improved

by 1 month and completely recover by 6 months in

piezoelectric group, contrasting to traditional bur group

where only 4 patients were completely recovered, 1 patient

had mild reduced sensation and 2 had moderately reduced

sensations by 6 months.

Surgery with approximation of vital tissue do required more

attention and precision, negligence in either of this may raise

the incidence intra or post-operative complications following

surgery

In our study we have compared traditional bur with

piezoelectric device for osteotomy in BSSO surgery and

evaluated on the bases post-operative nerve impairment. The

results that have been concluded after statistical analysis

provedthepiezoelectric device as a better option over

traditional bur for osteotomy procedures specially in intimate

surgical procedures when having a close approximation with

vital structures, except in terms of duration of osteotomy

where traditional bur showed a significant faster cutting

efficiency than piezoelectric device.[7-9]

Precision-Piezoelectric device found to be more precise and

safer in dealing with neural structures, as the instrument work

at 25-35kHz frequency at which the surrounding soft tissues

just vibrates without getting severed and at this same

frequency the device cuts only the mineralized tissue which

dramatically reduced the trauma to neural and vascular

tissues. Soft tissues may get traumatised when they are

entrapped to adjacent bony structure hindering their

vibrations. [10-14]

Discussion:

15

During osteotomy the cutting was donetill the periphery of cortical bone and without penetrating the entire thickness of body of mandible body in a very controlled manner, preventing the mandibular canal. This has also been proved by other authors in their studies, that the direct contact of piezoelectric tip does not damage the nerves and vessels unless the excessive pressure is applied against these structures. [15] The piezoelectric device efficiencyhas also been assessed and practiced in neurosurgery where the parietal bone osteotomy could be safely achieved without rapture of the underlying dura matter.[16]

Piezoelectric device has advantages over the traditional technique by means of high precision, reduced blood loss and reduced nerve injury with early recovery. This overall reduces the post-operative soft and hard tissue complications and improves the prognosis of treatment. However, in terms of duration of procedure traditional bur perform faster osteotomy than piezoelectric device. This eventually reduced the chances of infections,which have been the thumb rule for allthe invasive procedures “Longer the procedure,higher the likelihood of acquiring infection” [17]

The prolonged time required for piezoelectric osteotomy can be improved by practicing and getting habitual with the device by performing few surgeries with it, as there is a learning curve for every newer technique which has to be followed for excellence.

So, from this study we would conclude that the use of ultrasonic device is safer and precise. We would recommend the use of piezoelectric device in cases with close proximity of vitals structures and have higher risk of soft and nerve tissue damage. Moreover, if the device operation is practiced and expertized it may completely replace the traditional bur in performing most of the surgeries.

Perhaps the part to be aware on is,piezoelectric cutting efficiency on dense bone which is low and may lead to breakage of tip of osteotome and piezoelectric effect on bone regeneration after surgery. This will require further studies for evaluation.

1. Patil C et al.Piezosurgery vs bur in impacted mandibular third molar surgery: Evaluation of postoperative sequelae; Journal of Oral Biology and Craniofacial Research 2019; (9): 259–262

2. Sortino F, Pedullà E, Masoli V. The piezoelectric and

rotatory osteotomy technique in impacted third molar

surgery: comparison of postoperative recovery. J Oral

Maxillofac Surg. 2008; Dec66(12):2444–2448.

Conclusion:

References:



3. Angelo T, Mahmoud T Z. Is Piezoelectric Surgery the

New Gold-Standard in Oral Surgery and Implantology?

A Scientific Literature Review. Smile Dental Journal.

2016; (4): 11

4. Galié, M., Candotto, V., Elia, G., &Clauser, L. C.

Piezosurgery: A new and safe technique for distraction

osteogenesis in Pierre Robin sequence review of the

literature and case report. International Journal of

Surgery Case Reports. 2015;(6): 269–272.

5. Allan W, Williams ED, Kerawala CJ. Effects of repeated

drill use on temperature of bone during preparation for

osteosynthesis self-tapping screws. Br J Oral

MaxillofacSurg. 2005;43:314-9.

6. F BeziatJL, BeraJC, LavandierB, GleizalA. Ultrasonic

osteotomy as a new technique in cranio maxillofacial

surgery. Int J Oral Maxillofac Surg. 2007; 36(6):

493–500.

7. Rashad A et al. Practitioner experience with sonic

osteotomy compared to bur and ultrasonic saw: a pilot

in vitro study. Int J Oral Maxillofac Surg. 2015; 44(2):

203–8.

8. LucasM, MathiesonA. Ultrasonic cutting for surgical

applications. In :Gallego- JuarezJA, GraffKF, editors.

Power Ultrasonics. (Chap.23), Cambridge: Wood- head

Publishing, Elsevier 2015;695–721.

9. SpinelliG, LazzeriD, ContiM, AgostiniT, MannelliG.

Comparison of piezosurgery and traditional saw in

bimaxillary orthognathic surgery. J Craniomaxillofac

Surg. 2014; 42(7):1211–20.

10. Landes CA et al. Critical evaluation of piezoelectric

osteotomy in orthognathic surgery: operative technique,

blood loss, time requirement, nerve and vessel integrity. J

Oral Maxillofac Surg. 2008; 66(4):657–74.

11. vonSeeC, GellrichNC, RückerM, KokemüllerH,

KoberH, StöverE. Inves- tigation of perfusion in osseous

vessels in close vicinity to piezo-electric bone cutting. Br

J Oral Maxillofac Surg. 2012; 50(3):251–5.

12. VercellottiT, CrocaveA, PalermoA, MolfettaA. The

piezoelectric osteotomy in orthopedics: clinical and

histological evaluations (pilot study in animals).

Mediterr J Surg Med. 2001; 9:89–95.

13. O’DalyBJ, MorrisE, GavinGP, O’ByrneJM,

McGuinnessGB. High power low frequency ultrasound:

are view of tissue dissection and ablation in medicine and

surgery . J Mater Process Technol . 2008;

200(1–3):38–58.

16

14. LabancaM, AzzolaF, VinciR, RodellaLF. Piezoelectric

surgery: twenty years of use. Br J Oral Maxillofac Surg.

2008; 46(4): 265–9.

15. S c h a e r e n S , J a q u i é r y C , H e b e r e r M , T o l n a y M ,

VercellottiT,MartinI.Assessment of nerve damage using

a novel ultrasonic device for bone cutting. J Oral

MaxillofacSurg. 2008; 66:593–6.

16. Kotrikova B, Wirtz R, Krempien R, Blank J, Eggers G,

Samiotis A. Piezosurgery–a new safe technique in

cranial osteoplasty? Int J Oral Maxillofac Surg. 2006;

35:461–5.

17. Cheng, H et al. Prolonged operative duration is

associated with complications: a systematic review and

meta-analysis. Journal of Surgical Researc. 2018; 229:

134–144



Comparative evaluation of conventional and Piezoelectric ...

Documents

Transcript of Comparative evaluation of conventional and Piezoelectric ...