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CLINICAL & APPLICATION BOOKLET –PIEZOMED

ORAL SURGERY

IMPRESSUMTitle: Clinical and Application Booklet – PiezomedMedia type: Clinical user reportsContent: User reports from the medical field of oral surgeryPublisher: W&H Dentalwerk Bürmoos GmbHCopyright: W&H Dentalwerk Bürmoos GmbHImage copyrights for the clinical documentation are with the authorsResponsible for the content: W&H Dentalwerk Bürmoos GmbHEditorial coordination: Dr Jan H. Koch (www.dental-journalist.de)Basic design: Team BRANDCOM2nd edition 2019

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CONTENT

PREFACEWhat is the purpose of this booklet? .................................................................................. 6Statements from Piezomed users ................................................................................. 6 – 7Expertise of W&H in oral surgery ......................................................................................... 8W&H surgical devices .................................................................................................... 8 – 9Surgical straight and contra-angle handpieces ............................................................... 10Additional products .............................................................................................................. 10Piezoelectric surgery .................................................................................................. 11 – 15References ................................................................................................................... 16 – 17

CHAPTER 1A ........................................................................................................... 18 – 25Splitting and expansion of the alveolar process in preparation for tooth transplantation

CHAPTER 1B ........................................................................................................... 26 – 31Splitting and expansion of the alveolar ridge prior to implant placement

CHAPTER 2A ........................................................................................................... 32 – 38External sinus augmentation with delayed implant placement

CHAPTER 2B ........................................................................................................... 40 – 47External sinus augmentation with simultaneous implant placement

CHAPTER 3A ...........................................................................................................48 – 53Cystectomy, root-end resection and retrograde preparation of the root canal

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CHAPTER 4A ........................................................................................................... 54 – 59Extraction of teeth and root remnants

CHAPTER 4B ........................................................................................................... 60 – 67Surgical tooth extraction taking an impacted mandibular wisdom tooth as an example

CHAPTER 5A ........................................................................................................... 68 – 73Open periodontal debridement

CHAPTER 5B ............................................................................................................74 – 81Cleaning of contaminated implant surfaces and autologous defect augmentation

CHAPTER 6A ........................................................................................................... 82 – 89Piezoelectric implant site preparation for a maxillary prosthesis retained by 10 mm and 4 mm implants

CHAPTER 7A ...........................................................................................................90 – 99Piezosurgical implant bed preparation, internal sinus lift and implantation

PIEZOMED INSTRUMENTS B1, B2L / B2R ..........................................................................................................100 – 101B3, B4 .......................................................................................................................102 – 103B5, B6 ...................................................................................................................... 104 – 105B7, S1 ........................................................................................................................106 – 107S2, S3 ...................................................................................................................... 108 – 109S4, S5 .......................................................................................................................110 – 111R1D, R2LD / R2RD ................................................................................................... 112 – 113R3D, R4LD / R4RD ................................................................................................... 114 – 115

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CONTENT

P1, P2LD / P2RD ...................................................................................................... 116 – 117EX1, EX2 ...................................................................................................................118 – 119I1, I2A / I2P............................................................................................................... 120 – 121I3A / I3P, I4A / I4P ....................................................................................................122 – 123Z25P, Z35P ............................................................................................................... 124 – 125

HYGIENE AND MAINTENANCE Outline manual reprocessing: handpiece and cable .....................................................126Outline automatic reprocessing: handpiece and cable ................................................. 127Outline manual reprocessing: instrument .....................................................................128Outline automatic reprocessing: instrument ................................................................. 129

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WHAT IS THE PURPOSE OF THIS BOOKLET?

Oral surgery is a central aspect of modern dentistry, and that does not look set to change any time soon – even if it is possible to avoid or postpone many treatments nowadays by means of adequate preventive measures. If surgery is required, patients expect procedures to be as painless as possible. They should not take too long and should cause few postoperative complaints. Newer, minimally invasive methods make it easier to satisfy these requirements than was possible in the past.State-of-the-art piezosurgical systems like Piezomed by W&H represent a giant leap towards a new, atraumatic form of surgery. The device boasts a range of unique features and is an invaluable tool for a wide variety of indications, finding applications in bone surgery as well as in the fields of endodontics, prosthetics and periodontology. One particular feature of Piezomed consistently praised by its users is its high performance and efficiency (see statements).This booklet starts by examining the technical and clinical principles of piezoelectric surgery. Dentists and surgeons then report in detail on their experiences, offering handy tips and suggestions for routine clinical practice. Treatment scenarios offer newcomers to the field an overview of the most important indications. The overview is intended as a guide to ensure safety. Even experienced users will find useful suggestions for their day-to-day work. Then at the very least it will become clear why piezoelectric surgery should be a feature of every modern dental practice.

»USE THE PIEZOMED BRAVELY« – STATEMENTS FROM PIEZOMED USERS

»Use the Piezomed bravely because it is very safe to prepare the lateral window without damaging the membrane. I was surprised to see how safe it was when I started.«István Urbán, private practice in Budapest and Universities of Szeged, Hungary, and Loma Linda, USA

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PREFACE

»I have found many advantages of using the Piezomed, like precise cutting and greater speed in comparison with other piezosurgical devices. Another benefit is the secure procedure, which is important when students or trainees perform surgery.«Dragana Gabrić, University of Zagreb, Croatia

»Our academic mission is to test and clinically validate new devices which can make surgery less invasive for the patients – without jeopardising efficiency and efficacy for the surgical team. This new surgical device improves the features of piezoelectric surgery. It can make external sinus augmentation efficient, easy to perform and even faster compared to traditional methods. The new saw-like instruments are very thin and can preserve bone structure during the osteotomy.«Tiziano Testori, Universities of Milan and New York (NYU, USA), and Luca Fumagalli, University of Milan, Italy

»Piezo surgery is the better alternative to rotary instruments in my opinion. My patients mostly complain about the vibrations and noise of the instruments, which is exactly where Piezomed comes into its own: It is quiet and vibration-free. At the same time, it boasts a high performance and is thus quicker than other devices to date.«Jairo Martínez Vargas, private practice in San Pedro de Montes de Oca, National Clinic San Juan de Dios, Costa Rica

»As a periodontist I work with a group of orthodontists and prosthodontists, who are also convinced of the clinical relevance of piezosurgery. I have used W&H products in my practice for years and know their good quality. Both aspects gave me the motivation to test the Piezomed.«Kenji Hosoya, private practices in Mexico City and Tecamachalco, México

EXPERTISE OF W&H IN ORAL SURGERY

W&H, with its headquarters in Bürmoos near Salzburg, Austria, celebrated its 125th anniversary in 2015. With a whole host of ground-breaking innovations – for example, the first high-speed contra-angle handpieces, the first B class autoclaves for dentistry and the first self-generated LED illumination – W&H has long been a pioneer in the fields of dental handpieces and hygiene. The company has also been offering instruments for applications in oral and maxillofacial surgery for more than 30 years, including special straight and contra-angle handpieces, surgical and implantology motors and a piezosurgical device.

W&H develops its products in close cooperation with dentists and oral surgeons. The result is an optimal treatment setting, for both user and patient alike.As is true for the entire product range, W&H sets great store by innovation in the field of oral surgery. The aim is to keep abreast of the times with our users and to always stay one step ahead of our competition.

W&H SURGICAL DEVICES – SAFE, ERGONOMIC AND RELIABLE

The true hallmarks of W&H oral surgery instruments are their user safety, ergonomics and reliable quality. These qualities are ensured by extensive, standardized test reports in their development along with the use of only the most reliable materials. For example, all of our straight and contra-angle handpieces boast surfaces which are scratch-resistant and easy to clean. The short surgical motors and contra-angle handpieces offer an ergonomically ideal balance. All devices are easy to use.

Elcomed surgical deviceThe Elcomed surgical device was first presented to the public at the International Dental Show (IDS) in 1983. The device with its high-performance, sterilizable electric motor and clearly laid-out display has been continually updated over the years

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and still remains very successful today. An integrated pump supplies sterile saline solution to the surgical site and has proven very useful in routine clinical practice.

Implantmed implantology deviceIntroduced in 2001, the Implantmed implantology motor is particularly popular for its high power and ease of use. It is a market leader in the implantology motor segment and is also manufactured for a range of private label customers. All of Implantmed’s essential parameters are visible at a glance. The torque can be set and controlled precisely – even when threading for implant beds. The instruments can be operated clockwise or anticlockwise. In 2016, an updated device with impressive new features became available. These include an ultrashort and even more powerful motor, in combination with the straight and contra-angle handpieces full illumination of the treatment area, even in standby mode. Furthermore a wireless foot control as well as an optional module for implant stability measurement (Osstell ISQ) are available. The easy-to-use colour touch screen allows customized implantation workflows and is thus also ideal for larger practices and clinics.

Piezomed surgical deviceSince 2013 W&H has been supplying a state-of-the-art piezoelectrically operated surgical device. The Piezomed is characterized by its precise and gentle effect combined with high cutting performance.Thus it is trend-setting for minimally invasive surgery and is suitable for a wide range of indications.

Surgical straight and contra-angle handpiecesSpecial straight and contra-angle handpieces for oral surgery transfer power reliably to rotary instruments. Another significant feature of these devices is their high resistance to corrosion, even after prolonged exposure to saline solution (Neugebauer et al., 2008). In addition, oral surgical straight and contra-angle handpieces, thus the W&H instruments, can be dismantled and sterilized with ease.

PREFACE

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The hexagon chucking system for surgical milling cutters was patented by W&H and introduced in 2005. The Hexagon chucking system ensures optimal power transfer even at high torques. In contrast to standard contra-angle handpieces, this results in maximum protection of the rotary instruments. W&H introduced the first dental handpieces with internally generated LED illumination in 2007. As the light is generated by an integrated motor, the instruments are not dependent on lighted surgical motors. A number of W&H surgical handpieces are now available with LED illumination. Introduced in 2014, the WS-91 surgical handpiece is the first to combine the advantages of straight and contra-angle handpieces in one instrument. A 45° angle between the handle and bur improves both visibility and access, even far distal of the back molars. On the surgical contra-angle handpieces of the WS-56 and WS-75 ranges, the spray tubes can be attached on the left or right using spray clips.

Additional products > For repositioning osteotomy and bone harvesting saw handpieces and micro-saws

with sagittal, oscillating and reciprocal motion have been available since 2005. > The surgical suction device collects blood and bone fragments, effectively protecting

the vacuum pumps of treatment units (2007). > The Implantology Distance Control System (IDC) can be used for the positioning of

implants at the correct distance from each other or the adjacent tooth, the precise measurement of tooth gaps prior to implantation and placing implants in the desired position (2007).

> The W&H wireless prosthodontic screwdriver fixes implant prosthetic screws in place at the defined torque. As it can be used with just one hand, it requires less space in the oral cavity than ratchets and manual screwdrivers – a decisive ergonomic advantage since 2009.

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PIEZOELECTRIC SURGERY – WHAT MAKES THE METHOD RELEVANT?

The piezo principleThe piezoelectric effect was discovered in France in 1880 by Pierre and Jacques Curie. Certain quartzes and ceramics can be bent by exposing them to electrical charges. A good example of this is the quartz crystals used in timepieces. If this dimension change is amplified appropriately, it results in a high-frequency vibration.In dental applications, piezoceramic plates are stimulated to produce axial movements, which can then be transferred to an instrument. At a corresponding electric charge, this then oscillates in the inaudible ultrasonic range (micro-oscillation).

Depending on the frequency modulation and power settings of the drive unit, the instrument can then be used to complete defined tasks corresponding to its design. For example, they can include periodontal debridement and various forms of bone preparation. Beyond dentistry, piezoelectric surgery is also employed in oral and maxillofacial plastic surgery, ENT surgery and neurosurgery to name but a few.

The origins of piezoelectric surgeryEarly attempts at preparing bone with magnetostrictive ultrasonic technology failed as a result of poor performance and the destructive effect the technique had on the tissue (Vercellotti, 2009). Right up until the 1990s, experimental piezo devices employed in bone surgery still displayed inadequate cutting power and damaged the tissue by overheating it. For this reason, the Italian surgeon Dr Dr Tomaso Vercellotti, together with engineers, modified the frequency range. The intentional superimposing of low-frequency (10-60 Hz) over high-frequency (25-30 kHz) oscillation improved the cutting power of the piezosurgical devices introduced since 1999 even at low energy settings (Vercellotti, 2009).

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Whole new quality of bone surgeryThe micro-oscillation of piezosurgical instruments requires less pressure compared to micromotor-driven rotary instruments. The result is a well-balanced correlation between the oscillating speed and pressure exerted, which allows better control in bone surgery procedures (Vercellotti, 2009).Moreover, the extremely short (micro-oscillating) movements of the instrument permit highly precise and thus minimally invasive preparation of bone (Vercellotti, 2009). Overall, this is what creates the characteristic piezosurgical feel.

Better view thanks to cavitation effectYet another positive aspect of piezo surgery is the absence of bleeding thanks to the cavitation effect. The high-frequency ultrasound generates shock waves in the coolant, which has a microcoagulatory effect (Rahnama et al., 2013). The result is an improved view of the treatment site, which in turn increases the safety of the procedure (Schlee et al., 2006).

Selective cutting protects soft tissueOne of the impressive features of piezosurgical devices is their selective effect regarding hard and soft tissues. Whilst suitable instruments at corresponding power settings can remove or cut bone effectively, the soft tissue is not damaged when the same instruments are used correctly (Vercellotti, 2009). This property, in combination with the cavitation effect and the precise surgical approach, ensures more predictable results, even in complex operations.

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Bone harvesting and cell biologySpecial piezosurgical instruments allow minimally invasive harvesting of chips in the operating area. The good biocompatibility of this method is evident for example in the osteocyte survival rate (Chiriac et al., 2005). The expression of growth factors and the formation of immunocytes appear generally comparable with mechanical bone harvesting. Compared with rotary preparation, the particles acquired through piezosurgical bone chip harvesting are larger and display a better cell survival rate (von See et al., 2010).

Increased comfort for patients Treatment comfort tends to be higher when employing piezoelectric surgery for a number of reasons. For example, operation in the inaudible ultrasonic range reduces the noise-related stress for patients and also for the dental team compared with rotary instruments (Sohn et al., 2007). In addition, the uncomfortable macro vibration felt with rotary instruments is also not an issue with piezo instruments (Sohn et al., 2007). Furthermore, the soft tissue is preserved thanks to the selective effect of the piezoelectric surgery, which consequently makes it possible to avoid corresponding postoperative complaints. These clinical observations are all supported by high-quality studies. For example, according to one randomized study with a patient cohort of 80 individuals, the pain experienced after cyst enucleation was lower for piezo surgery than for rotary preparation (Pappalardo and Guarnieri, 2014). The same is also true of postoperative swelling according to the same study. In addition, in contrast to rotary preparation (8%), no cases of hypaesthesia were reported for the piezosurgical technique (Pappalardo and Guarnieri, 2014). A systematic review of lateral sinus lift operations also revealed a notable reduction in the occurrence of fenestrations and haemorrhage (Wallace et al., 2012).

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Piezoelectric surgery compared with other preparation methodsDepending on tissue quality and indication, bone preparation with piezosurgical instruments offers specific advantages. In general a very precise mode of operation can be named, for example, when cutting bone for block removal or splitting the alveolar process (bone splitting), both contribute to an improved implant site. The prerequisite is suitable reduced exertion of pressure (Stelzle et al., 2014). Together with the cavitation effect and when delicate piezosurgical instruments are used, the specific, low-pressure application ensures a slender osteotomy gap with precise margins and smooth bone surfaces (Maurer et al., 2008). Histological studies have shown that the latter can be beneficial to the healing process (Rullo et al., 2013). The cooling, which should be applied as close as possible to the tip of the instrument, also plays an important role.

Rotary instrumentsBased on clinical observations, rotary instruments can result in relatively broad osteotomy gaps in comparison (Rothamel et al., 2015). This is due to the fact that for technical reasons it is not possible to determine the optimal position of the initial gap. Shearing forces can also result in broader gaps in rotary preparation. In addition, rotary milling cutters and grinders can slip easily. Accordingly, there is a risk of adjacent anatomical structures like teeth, soft tissue and nerves being damaged (Rothamel et al., 2015).According to histological studies performed on animals, bone structures are better preserved when piezosurgical instruments are used than with other conventional methods (Lindemann’s cutting burs, micro-saws) (Maurer et al., 2008). This is attributed to the fact that it is easier to differentiate between cancellous and cortical bone when using piezoelectric surgery for preparation. The preparation surface was also significantly rougher following the use of Lindemann’s cutting bur compared with the two piezo instruments tested (Maurer et al., 2008).

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Micro-sawsIt can also be difficult to define a precise osteotomy line at the beginning of the preparation when working with oscillating micro-saws (Rothamel et al., 2015). Clinical experience reveals that there can be deviations between the planned and final trajectory of the gap, for which reason the bone ablation tends to be increased.

FOCUS ON PIEZO TECHNOLOGY AT W&HThe first time that W&H employed piezo technology was in a piezoelectric scalerin 2006. Its successor model Tigon+, which was launched in 2011, offers five preset programs, among others for prophylaxis and periodontal debridement. Water preheating and three different application modes allow patient-friendly treatments.W&H utilized its experience with piezo scalers to develop the Piezomed piezosurgical device (available since August 2013). Prof Dr Martin Lorenzoni and Prof Dr Christof Pertl (both from Graz, Austria) and the dentists with their own practices Dr Ulrich Fürst, an oral surgery consultant (Attnang-Puchheim, Austria), and Dr Mario Kirste, MSc, a specialist in implantology and oral surgery (Frankfurt (Oder), Germany), were just some of the specialists involved in its development.

Piezomed – features and advantagesThe corresponding piezosurgical instruments are automatically detected by the device and power levels are automatically assigned. This prevents overloading of the piezo instruments and increases the safety for both user and patient. Other advantages include:

> Coolant supply close to the application site > LED illumination (4x ring) > Customizability of all device settings

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REFERENCES

Chiriac, G., Herten, M., Schwarz, F., Rothamel, D. & Becker, J. (2005) Autogenous bone chips: influence of a new piezoelectric device (Piezosurgery) on chip morphology, cell viability and differentiation. J Clin Periodontol 32, 994-999. doi:CPE809 [pii]10.1111/j.1600-051X.2005.00809.x.Harder, S., Wolfart, S., Mehl, C. & Kern, M. (2009) Performance of ultrasonic devices for bone surgery and associated intraosseous temperature development. Int J Oral Maxillofac Implants 24, 484-490.Maurer, P., Kriwalsky, M. S., Block Veras, R., Vogel, J., Syrowatka, F. & Heiss, C. (2008) Micromorphometrical analysis of conventional osteotomy techniques and ultrasonic osteotomy at the rabbit skull. Clin Oral Implants Res 19, 570-575. doi:10.1111/j.1600-0501.2007.01516.x.Neugebauer, J., Karapetian, V., Lingohr, T., Scheer, M. & Zöller, J. (2008) Besondere Anforderungen an oralchirurgische Hand- und Winkelstücke. Oralchirurgie Journal, 38-41.Pappalardo, S. & Guarnieri, R. (2014) Randomized clinical study comparing piezosurgery and conventional rotatory surgery in mandibular cyst enucleation. J Craniomaxillofac Surg 42, e80-85. doi:10.1016/j.jcms.2013.06.013.Rahnama, M., Czupkallo, L., Czajkowski, L., Grasza, J. & Wallner, J. (2013) The use of piezosurgery as an alternative method of minimally invasive surgery in the authors' experience. Wideochir Inne Tech Malo Inwazyjne 8, 321-326. doi:10.5114/wiitm.2011.35144.Rothamel, D., Happe, A., Fienitz, T., Kreppel, M., Neugebauer, J. & Zöller, J. (2015) Piezosurgery - a universal principle for many indications. EDI Journal, 64-70.Rullo, R., Addabbo, F., Papaccio, G., D'Aquino, R. & Festa, V. M. (2013) Piezoelectric device vs. conventional rotative instruments in impacted third molar surgery: relationships between surgical difficulty and postoperative pain with histological evaluations. J Craniomaxillofac Surg 41, e33-38. doi:10.1016/j.jcms.2012.07.007.Schlee, M., Steigmann, M., Bratu, E. & Garg, A. K. (2006) Piezosurgery: basics and possibilities. Implant Dent 15, 334-340. doi:10.1097/01.id.0000247859.86693.ef.

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Sohn, D. S., Ahn, M. R., Lee, W. H., Yeo, D. S. & Lim, S. Y. (2007) Piezoelectric osteotomy for intraoral harvesting of bone blocks. Int J Periodontics Restorative Dent 27, 127-131.Stelzle, F., Frenkel, C., Riemann, M., Knipfer, C., Stockmann, P. & Nkenke, E. (2014) The effect of load on heat production, thermal effects and expenditure of time during implant site preparation - an experimental ex vivo comparison between piezosurgery and conventional drilling. Clin Oral Implants Res 25, e140-148. doi:10.1111/clr.12077.Vercellotti, T. (2009) Essentials in Piezosurgery: Clinical Advantages in Dentistry. Quintessence Publishing.von See, C., Rucker, M., Kampmann, A., Kokemuller, H., Bormann, K. H. & Gellrich, N. C. (2010) Comparison of different harvesting methods from the flat and long bones of rats. Br J Oral Maxillofac Surg 48, 607-612. doi:10.1016/j.bjoms.2009.09.012.Wallace, S. S., Tarnow, D. P., Froum, S. J., Cho, S. C., Zadeh, H. H., Stoupel, J., Del Fabbro, M. & Testori, T. (2012) Maxillary sinus elevation by lateral window approach: evolution of technology and technique. J Evid Based Dent Pract 12, 161-171. doi:10.1016/s1532-3382(12)70030-1.

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The transplantation of wisdom teeth with incomplete root development is a tried-and-tested alternative to the use of implants. For the tooth to be transplanted to have good changes of healing successfully, it needs to be preserved to the greatest possible extent during its removal from the alveolus – this is especially applicable to the periodontium. Piezosurgical instruments are optimally suited for this purpose and also for the preparation of the recipient site.

CHAPTER 1ASPLITTING AND EXPANSION OF THE ALVEOLAR PROCESSIN PREPARATION FOR TOOTH TRANSPLANTATION,BY ASST PROF PRIV DOZ DR GEORG D. STRBAC

Instruments for this case

Aim of Treatment

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Initial clinical situation following orthodontic realignment (X-ray cf. Fig. 10): Tooth 48 is yet to erupt and the alveolar ridge will require expansion at position 46 if it is to accept the transplant. Both measures can be performed as outpatient procedures.

In the next step the cortical bone of the crest is then prepared with the Piezomed B1 straight saw at a distance of 1.0 to 1.5 mm from the neighbouring teeth. The preparation is performed to a depth of max. 6 mm.

Following mobilization of a buccal mucoperiosteal flap, a relatively thin alveolar ridge is revealed in the area of tooth socket 46. This was then confirmed with a preoperative DVT scan. For the bone mobilization to buccal, the first step is to make fine markings of the basal and vertical regions using the diamond-coated Piezomed S2.

Taking the crestal preparation as the starting point, the Piezomed B2L angled saw is then used to make two vertical incisions through the buccal cortical bone down to a depth of 4 mm. The final step is to weaken the cortical bone in the basal region of the alveolar process through minimal preparation.

Clinical Case

A 19-year-old patient with an unremarkable medical history presented deep caries with endodontic involvement in tooth 46 necessitating the tooth’s extraction.Following orthodontic realignment of tooth 47, the treatment plan continues with autogenous transplantation of the third molar on the same side (tooth 48) to position 46. The root system of the donor tooth is not yet fully developed and so the conditions are ideal for successful revascularization in the alveolus at position 46.

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The crown of the unerupted tooth 48 is exposed down to its greatest circumference using the diamond-coated Piezomed S2 instrument. The tooth can now be extracted from its socket using diamond-coated forceps while preserving the periodontium as much as possible.

o The healing occurs in infraocclusion with the aim of promoting the healing process. Piezomed’s minimally invasive approach very likely made it possible to preserve the donor tooth’s periodontium intact.

Following minor apical expansion with the Piezomed S2 the tooth transplant can be placed in the new alveolus. Excess space around the transplant is filled with autologous bone harvested during piezosurgical exposure and extraction of tooth 48.

a As such, the natural eruption and spontaneous advancement to occlusion of the tooth is to be expected after approximately six months.

The atraumatically prepared, basally branched bone block is mobilized using special manual osteotomes and surgical chisels (augmentation/sinus lift set Memmingen, Stoma).

This step is performed with the utmost care and precision until the desired buccolingual dimension as determined preoperatively is reached. The newly formed alveolus is now ready to accept the donor tooth from position 48.

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Autogenous tooth transplantation (autotransplantation) of third molars – prognosis and state-of-the-artWisdom teeth, premolars and primary canines are best suited for tooth transplantation (1-3). Whereas premolars and primary canines are predominantly employed as replacements for traumatized anterior teeth, third molars are generally used to replace first molars which required extraction due to early destruction by caries. The average survival rate of transplanted teeth after up to 10 years is 81%; the risk of ankylosis is reported as 4.8% and that of other forms of root absorption as 4.0% (2, 4).The root development stage is a decisive factor in the success of transplantations. For this reason, wherever possible, teeth should be used where the apical foramen is still open and the roots should only have reached between two thirds and three quarters of their final length (stage 4-6 according to Moorees) (5). The primary consequence of this is whether the pulp is revascularized following the procedure and the function of the periodontium is preserved (6). The procedure can be performed in one or two phases; single-phase transplantations have proven successful in young patients (7).The space must be sufficiently large to mesiodistal to allow the transplanted tooth to grow into place. At the same time, the alveolar ridge must be sufficiently wide. This aspect can sometimes prove critical when replacing first molars with wisdom teeth. In addition, the distances between the transplant and the recipient bone bed must also be observed. The distance to the root surface should be approximately 0.5–1 mm and the distance from the apical tip to the alveolar floor approximately 2–3 mm (7).Another requirement for successful tooth transplants is the intact periodontium of the donor tooth (8-10). This requires the tooth to be extracted as atraumatically as possible, which can prove particularly difficult in cases with impacted third molars (cf. Chapter 4B: Surgical tooth extraction taking an impacted mandibular wisdom tooth as an example). At this point piezoelectric surgery comes into play, which is firstly used to remove the bone above the tooth – down to the greatest circumference of the crown – in a very precise and atraumatic fashion. The fine instruments and the cavitation effect ensure a good view, with the result that injuries can largely be avoided (patient example, Fig. 7) (11).In addition, there is the selective effect on hard tissues, with soft tissue being largely preserved, which is characteristic of piezo technology (12). When applied correctly, the result is an intact periodontium. If necessary, the alveolar space can be expanded with special piezosurgical instruments (for example with Piezomed EX1/EX2).

Description of technique

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However, this must be done extremely carefully and without the exertion of pressure, to be able to rule out resorption affecting the donor tooth.If it is not possible to transplant the tooth immediately, it must be stored in a physiological solution (Ringer's acetate solution, tooth rescue box) for the remainder of the preparation of the recipient site. In order to achieve optimal development of the roots following the transplantation, the target should be a slight infraocclusion (Fig. 8 to 10). If the primary stability is sufficient and the infraocclusion position advantageous, there is no need for splinting. The transplanted teeth are generally sufficiently fixed in place with standard sutures and a criss-cross suture over the occlusion. This ensures micromobility of the tooth and reduces the risk of ankylosis considerably (9).

Alveolar ridge splitting prior to tooth transplantations – clinical procedure with piezoelectric surgerySome basic principles concerning horizontal augmentation of the alveolar process can be found in Chapter 1B: Splitting and expansion of the alveolar ridge prior to implant placement. Below you can find more detailed information on the piezosurgical preparation of the bony recipient site prior to tooth transplantations.In order to achieve the dimensions outlined above for acceptance of the graft in the new alveolus, the safety distances already mentioned are taken into consideration in preoperative planning. This can be done in the planning software prior to the operation if a DVT scan is available. Alternatively, the tooth is measured extraorally by hand following its atraumatic extraction and then, if the preparation is already adequate, introduced directly into the prepared recipient site in the bone. If necessary, the site can be expanded using piezosurgical instruments. If the mesiodistal distance is too short, the enamel can be reduced slightly intra-operatively autologous to orthodontic stripping. The Piezomed S2 is well suited for this task.The alveolar ridge splitting is performed as usual with piezosurgical saws, which are available in very fine versions (Piezomed B6: 0.25 diameter, Piezomed B1, B2R/B2L: 0.5 mm). Lindemann’s cutting burs, in contrast, have a diameter of at least 1.6 mm (13). The patient example illustrates the mobilization of a basally branched bone block to buccal and the consequent creation of a generously dimensioned transplant site (Figs. 1 to 6). The procedure was performed in the Oral Surgery Clinic at the University Clinic of Dentistry Vienna.Compared with alveolar ridge splitting prior to an implantation (cf. Chapter 1B), the buccal mobilization of the recipient bone often has to be performed considerably more extensively

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The challenges of transplanting third molars to the site of prematurely lost first molars begin directly with the harvesting of the transplant. A minimally invasive and highly effective piezosurgical system can ensure here that the tooth is extracted as atraumatically as possible and, above all, that the periodontium is protected to the greatest extent possible. The exertion of minimal pressure and excellent cooling are also important. Both are ensured by Piezomed’s effective working approach and the location of the coolant supply in the direct vicinity of the application site.The efficiency of piezosurgical saws such as the Piezomed B1, B2R/B2L and B6/B7 is evident when it comes to preparation of the transplant site (cf. Chapter 5B: Cleaning of contaminated implant surfaces and autogenous defect augmentation). At the same time, the Piezomed’s characteristic working approach and the thin diameter of the instruments ensure minimally invasive preparation.The success of the procedure depends on a range of additional factors alongside the tissue-preserving approach. These include appropriate dimensioning of the transplant site, which along with existing micromobility permits healing in place without ankylosis and successful revascularization of the pulp. Correspondingly, a moderately infraocclusional position of the transplant without splinting has proved advantageous. All these factors combined improve the prognosis for complete development of the roots as well as physiological, periodontal healing and ultimately allow the tooth to move into position correctly.

Challenge of the procedure and benefits of the Piezomed

due to the three-dimensional size of the transplant. In addition to the crestal preparation (Fig. 3), the buccal region must also be suitably prepared to accommodate the donor tooth (Fig. 4). This can be done by weakening the cortical bone at the base of the alveolar process. If necessary the transplant site can be expanded apically using, for example, a piezosurgical diamond-coated instrument (Piezomed S2). The donor tooth can then be introduced into its new alveolus (Fig. 8).

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Asst Prof Priv Doz Dr Georg D. Strbac > Until 2004 Dental student at the Medical University of Vienna > 2004–2013 Research Associate, Department of Oral Surgery (Supervisor: Prof Georg Watzek, DMD), University Clinic of Dentistry Vienna, Medical University of Vienna

> 2013 Habilitation (Venia docendi) for Dental, Oral and Maxillofacial Medicine, Medical University of Vienna

> Since 2013 Assistant Medical Director, Assistant Professor with Tenure (Asst Prof), Senior Academic Assistant (Priv Doz), Department of Oral Surgery (Supervisor: Prof Christian Ulm, DMD), University Clinic of Dentistry Vienna, Medical University of Vienna

> Lecturer for numerous academic courses, postgraduate and specialized training sessions in Austria and abroad

> Numerous academic publications and book chapters > Registration of various patents, including for example the radiological mucous membrane marker and the dental surgical cooling system for the Medical University of Vienna

> 12 Austrian and international awards for academic presentations and publications including from the Austrian Society of Dental, Oral and Maxillofacial Medicine (ÖGZMK) and the European Association for Osseointegration (EAO)

Author information

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1. Lang B, Pohl Y, Filippi A. Transplantation von Zähnen. Schweiz Monatsschr Zahnmed 2003;113:1179-1199.2. Machado LA, do Nascimento RR, Ferreira DM, Mattos CT, Vilella OV. Long-term prognosis of tooth autotransplantation: a systematic review and meta-analysis. International journal of oral and maxillofacial surgery 2015.3. Moorees CF. Age variation of formation stages for ten permanent teeth. Journal of dental research 1963;42.4. Andreasen JO, Andreasen FM, Andreasen L. Textbook and Color Atlas of Traumatic Injuries to the Teeth, 4th Edition: Wiley, 2007.5. Schultze-Mosgau S, Neukam FW. Intentionelle Replantation, therapeutische Zahnluxation, Zahntransplantation. In: Reichert PA, Hausamen JE, Becker J, Neukam FW, Schliephake H, Schmelzeisen R (eds). book section. Berlin: Quintessenz, 2002:263-290.6. Akiyama Y, Fukuda H, Hashimoto K. A clinical and radiographic study of 25 autotransplanted third molars. J Oral Rehabil 1998;25:640-644.7. Bauss O, Engelke W, Fenske C, Schilke R, Schwestka-Polly R. Autotransplantation of immature third molars into edentulous and atrophied jaw sections. International journal of oral and maxillofacial surgery 2004;33:558-563.8. Mendes RA, Rocha G. Mandibular third molar autotransplantation–literature review with clinical cases. J Can Dent Assoc 2004;70:761-766.9. Schlee M, Steigmann M, Bratu E, Garg AK. Piezosurgery: basics and possibilities. Implant dentistry 2006;15:334-340.10. Vercellotti T. Essentials in Piezosurgery: Clinical Advantages in Dentistry: Quintessence Publishing, 2009.11. Rothamel D, Happe A, Fienitz T, Kreppel M, Neugebauer J, Zöller J. Piezosurgery – a universal principle for many indications. EDI Journal 2015:64-70.

References

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Ridge splitting and expansion is an effective and time-saving technique to develop sites in connection with implant placement. In order to prevent bone resorption the procedure should be as minimally invasive as possible. For this reason piezoelectric cutting with delicate instruments is the method of choice. Due to the minimal invasive design and controlled action of the device bone and soft tissue can be better preserved in comparison with conventional methods.

CHAPTER 1BSPLITTING AND EXPANSION OF THE ALVEOLAR RIDGE PRIOR TO IMPLANT PLACEMENT,BY ASST PROF DRAGANA GABRIĆ


Aim of Treatment

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Clinical Case

The reduced width of the implant site requires a horizontal bone management procedure (upper left: axial view, lower left: lateral view, upper right: transversal/coronar view, lower right: 3D reformation).

After buccal and oral preparation of a full thickness flap the ridge is ready for the splitting procedure.

The clinical baseline finding is a narrow edentulous ridge more than 5 years after tooth loss, combined with a reduced keratinized tissue width.

With the Piezomed B1 instrument the ridge is split along the alveolar crest.

In a 25-year-old male patient two implants are planned at positions 46 and 47. In order to allow insertion of 4.1 mm diameter implants the alveolar ridge is split with piezoelectric instruments and subsequently expanded with screws.

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Result of piezoelectric splitting prior to ridge expansion. A vertical releasing osteotomy has been prepared at the distal site (see Fig. 7).

Prior to implant placement expansion is accomplished with specific screws (Split Control, Meisinger).

After preparation of the implant bed with system-specific burs the 4.1 / 8.0 mm implants (Bone Level, Straumann) have been inserted. An implant drill was used to keep the gap open for insertion of the first implant.

Flaps are finally repositioned and sutured.

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Options for horizontal augmentation prior to implant placementThe thickness of bone around implants should be at least 1 mm, ideally 2–3 mm, especially on the buccal side (1). Concerning the hardware, in contrast to older recommendations, implants require a minimum diameter of only 3.3 mm (2). As a consequence, alveolar ridges with a width of less than approximately 6 mm at implant shoulder level should be augmented to allow insertion of implants with a good long-term prognosis (3).Lateral augmentation techniques include bone blocks (4), guided bone regeneration (GBR)(5), and also ridge splitting and expansion (6). Splitting of the alveolar ridge, which can be accomplished with an array of hand and mechanical instruments, has shown high implant survival and success rates (7). An additional alveolar ridge width of 3–4 mm can be achieved, most predictably in the more elastic maxillary bone.Ridge splitting and expansion can be performed in one stage, combined with simultaneous grafting of the area and submerged implant placement. In comparison with other procedures this saves time and is potentially less invasive. However, as the split bone laminae are often very thin a loss of buccal bone must be anticipated (7). Therefore additional buccal GBR measures may be indicated. Access to the site and crestal osteotomyBased on diagnostic data and case-specific implant planning an access flap is prepared. If a minimum residual ridge width of 2–3 mm is available the crestal osteotomy can be performed. Conventional surgical instruments for this procedure include micromotor-driven rotary carbide burs and rotary, sagittal, reciprocating or oscillating saws (micromotor, sonic). Due to their size rotary instruments are relatively traumatic, which is less than optimal in bone deficient sites (3).Due to their design and cutting action saws driven by micro motors or sonic devices may allow only limited access to the site, especially near natural teeth. The crestal (sagittal) osteotomy line should be prepared to a distance of 1.0 to 1.5 mm from the periodontium of neighboring teeth. Piezoelectric devices show a unique, well-controlled cutting action and have a minimal invasive instrument design. Therefore they are the technology of choice in a selective and sensitive ablation of calcified tissue. This applies also to the vertical release osteotomy on the buccal side, which requires delicate instruments and an optimal view over the surgical area. The crestal osteotomy is prepared as a function of the implant hardware and the expansion technique, in most


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Splitting and expansion of the crestal alveolar bone to allow placement of implants is a predictable procedure. However, care must be taken to preserve as much bone as possible and to use a minimal invasive cutting technique. Piezoelectric devices like the Piezomed cut bone in a highly effective manner. At the same time the specific cutting action of the device, exit of irrigant near the tip of the Piezomed instrument and the bright LED light allow optimal operative control and view over the surgical area.In the present clinical example the mandibular site was successfully split with a piezoelectric saw (Piezomed B1). Alternatively the finely-toothed and highly effective saws B6/B7 could have been used for the purpose. These precise instruments allow preparation of split lines with a width of only 0.25 mm (B6) and 0.5 mm (B1), respectively. As the mandibular bone of the young patient was relatively resilient it was possible to expand the site minimally invasive to accommodate two 4.1 mm implants.

Assistant Professor Dragana Gabrić, DMD, PhD > 2004 Doctor of Dental Medicine (DMD), University of Zagreb, 2005 Dean’s Award for Study Success

> 2006 Junior Assistant, 2010 Senior Assistant, Department of Oral Surgery, School of Dental Medicine, University of Zagreb

> 2007 Oral Surgeon Trainee, Department of Oral Surgery, Clinical Hospital Center Zagreb

Author information

cases to a depth corresponding to the implant length. The (distal and/or mesial) vertical release osteotomy should be long enough to prevent fracturing of the buccal bone, which is especially important in the less elastic mandibular bone (8). Ridge expansion and implant placementExpansion of the ridge can now be performed with dedicated instruments, which are available as hand osteotomes, chisels with graduation marks, or as expansion screws with increasing diameter (9). Additional horizontal expansion devices can be used for controlled alveolar ridge expansion. Implants are placed after defined osteotomic preparation of the implant bed(s) with specific kits of hand or mechanic (rotary or ultrasonic) instruments.


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1. Buser D, Chen ST, Weber HP, Belser UC. Early implant placement following single-tooth extraction in the esthetic zone: biologic rationale and surgical procedures. Int J Periodontics Restorative Dent 2008;28:441-451.2. Klein MO, Schiegnitz E, Al-Nawas B. Systematic review on success of narrow-diameter dental implants. The International journal of oral & maxillofacial implants 2014;29 Suppl:43-54.3. Vercellotti T. Essentials in Piezosurgery: Clinical Advantages in Dentistry: Quintessence Publishing, 2009.4. Nystrom E, Ahlqvist J, Kahnberg KE, Rosenquist JB. Autogenous onlay bone grafts fixed with screw implants for the treatment of severely resorbed maxillae. Radiographic evaluation of preoperative bone dimensions, postoperative bone loss, and changes in soft-tissue profile. International journal of oral and maxillofacial surgery 1996;25:351-359.5. Buser D, Bragger U, Lang NP, Nyman S. Regeneration and enlargement of jaw bone using guided tissue regeneration. Clinical oral implants research 1990;1:22-32.6. Simion M, Baldoni M, Zaffe D. Jawbone enlargement using immediate implant placement associated with a split-crest technique and guided tissue regeneration. Int J Periodontics Restorative Dent 1992;12:462-473.7. Bassetti MA, Bassetti RG, Bosshardt DD. The alveolar ridge splitting/expansion technique: a systematic review. Clinical oral implants research 2015.8. Vercellotti T. Piezoelectric surgery in implantology: a case report--a new piezoelectric ridge expansion technique. Int J Periodontics Restorative Dent 2000;20:358-365.9. Stricker A. Augmentationen in der oralen Implantologie. Bone splitting als Alternative zum Knochenblock. Der Freie Zahnarzt 2013:78-87.

References

> 2010 PhD, dissertation in the field of experimental laser bone surgery; 2011 Specialist in Oral Surgery, Department of Oral Surgery, Clinical Hospital Center Zagreb

> 2011 Associate Research Scientist, 2013 Senior Research Scientist, 2014 Assistant Professor and PhD Tutor, Department of Oral Surgery, School of Dental Medicine, University of Zagreb

> Author of numerous scientific papers and book chapters (medical genetics; dental implantology and bone augmentation surgical procedures; laser soft tissue surgery)

> Editorial board member of the Journal of Lasers, Optics & Photonics; review board member of several international scientific journals (e.g. Journal of Periodontology, Journal of Dentistry)

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During external grafting of the maxillary sinus the most important risk is perforation of the Schneiderian membrane. Clinicians, especially with limited experience, should therefore use the safest available techniques. In the procedure described below Professor Urbán utilizes spatula-formed or round piezoelectric instruments to prepare the outline of the lateral window. He does not detach the bone from the membrane, but infractures it and rotates it into the sinus using specialized piezoelectric instruments. Prior to delayed implant placement the sinus is augmented with a sagittal sandwich grafting technique.

CHAPTER 2AEXTERNAL SINUS AUGMENTATION WITH DELAYED IMPLANT PLACEMENT, BY PROF ISTVÁN URBÁN


Aim of Treatment

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After palatal incision and preparation of a full thickness flap the lateral bone fragment is completely prepared with the Piezomed S1. As the device is very safe the full preset power (80) can be used down to the membrane.

With the S5 (preset power 65) and specific hand instruments the membrane is further detached from the sinus wall as far as necessary. Together with the bone fragment the membrane is carefully moved in a cranial direction, which creates space for the graft material.

For initial detachment the membrane is mobilized from the marginal bone with the »elephant foot« (S3, preset power 65).

Finally the bony edges are smoothened with the Piezomed S5. The picture clearly shows how ample amounts of sterile rinsing solution are brought near to the surgical area.

Clinical Case

Patient 1: Preparation of the lateral window with a spatula-shaped piezoelectric diamond-coated instrument and grafting of the sinus floor in a 55-year-old female patient (delayed implant placement). IMPORTANT NOTE: For better visibility Figures 3, 4 and 6 were photographed without instrument irrigation.

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A resorbable collagen membrane is placed over the substitute material, then the graft is sutured. The implants were placed 6 months later.

Bovine bone substitute material is inserted medially and laterally in the area of the window.

The intermediate space where the implants will be placed is filled with autogenous bone particles. At the lateral aspect an additional layer of bone substitute material is placed.

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Note the rounded outline of the window. The outline of the lateral window can alternatively be prepared with the round Piezomed instrument S2 (preset power 65).

As in the first example the lateral bone fragment is rotated into the sinus. Please note the membrane, which has been detached and likewise moved cranially. As the membrane was very thin the surgeon had to use extreme care not to cause any perforations.

Patient 2: Preparation of the lateral window with a round piezoelectric instrument. The 45-year-old male patient will also receive delayed implants.

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Preparation of the lateral windowA full thickness periosteal flap is elevated in order to expose the lateral wall of the sinus. During preparation of the window the bony wall of the sinus is cut almost to the Schneiderian membrane, which should remain intact. The following specifically shaped diamond-coated Piezomed instruments can be used for this step:

> Spatula-shaped instrument S1 (Fig. 1 Patient 1) > Round instrument S2 (Fig. 1 Patient 2)

As in all piezoelectric procedures only little pressure should be used. Combined with the preset power these instruments allow safe and efficient preparation. The use of magnifying spectacles and optimal illumination is recommended throughout the procedure.

Detachment of the membraneThe next step is the detachment of the membrane from the marginal areas of the lateral window. This can be accomplished with the Piezomed instrument S3 (»elephant foot«) (Fig. 2). The membrane can be further detached from the sinus wall using the S4 (90° angulation) or the S5 (45° angulation). The membrane will then be rotated medially-cranially together with the bone fragment. Alternatively or additionally the author prefers self-developed sinus curettes of variable shapes and angulations (Impurban 16,26,36, HuFriedy). Sharp bony edges can finally be smoothened with the S4 or S5 instrument (Figs. 3–4).

Grafting using a resorbable membraneA sagittal sandwich layer bone graft is created with inorganic bovine-derived bone mineral (Bio-Oss®, Geistlich Biomaterials) and particulated autogenous bone, which can be harvested locally with a scraper (Figs. 5–6). The bone mineral is applied and packed to the medial wall of the sinus. Next the autogenous bone is applied and packed precisely cranial to the planned implant sites on the ridge. Then the autogenous bone layer is covered laterally with a final layer of bovine bone to restore the contour of the sinus wall. Finally a resorbable collagen membrane (Bio-Gide®, Geistlich Biomaterials) is applied to the area to protect the sinus windows (Fig. 7). The flaps are sutured with an expanded polytetrafluoroethylene (ePTFE) suture utilizing single interrupted and continuous sling sutures.


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The most significant risk of external maxillary sinus augmentation procedures is damage to the Schneiderian membrane (cf. patient case #2, Figs. 8-10). In this context the piezoelectric approach reduces the rate of intraoperative complications. Clinicians with limited experience should prepare the lateral window with either of the diamond-coated Piezomed instruments S1 or S2. These instruments are safe even at the preset power of 80, which allows to accomplish the procedure in relatively short time. Due to their selective cutting action these instruments cut efficiently while at the same time protecting the surrounding soft tissue including the membrane.


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István Urbán, DMD, MD, PhD > 1991 DMD degree and 1996 MD degree at Semmelweis University School of Medicine and Dentistry (Budapest, Hungary)

> 1992–1996 full time program in oral surgery at St. István Hospital (Budapest, Hungary); internship program in Periodontics at at the University of California Los Angeles (UCLA) (USA)

> 1999–2000 graduation from the Fellowship Program in Implant Dentistry at Loma Linda University (USA), since 2001 assistant professor teaching implant dentistry at Lomal Linda

> Licensed practitioner in the state of California (USA) and private practice in Budapest > 2012 PhD degree in Periodontology at the University of Szeged (Hungary); honorary professor at the University of Szeged.

> Dr Urbán has published scientific articles and text book chapters on bone regeneration and soft tissue reconstructive surgery around dental implants.

1. Urbán I, Caplanis N, Lozada JL. Simultaneous vertical guided bone regeneration and guided tissue regeneration in the posterior maxilla using recombinant human platelet-derived growth factor: a case report. J Oral Implantol 2009;35:251-256.2. Urbán IA, Lozada JL. A prospective study of implants placed in augmented sinuses with minimal and moderate residual crestal bone: results after 1 to 5 years. The International journal of oral & maxillofacial implants 2010;25:1203-1212.3. Urbán IA, Nagursky H, Church C, Lozada JL. Incidence, diagnosis, and treatment of sinus graft infection after sinus floor elevation: a clinical study. The International journal of oral & maxillofacial implants 2012;27:449-457.

Author information

References

40

External sinus augmentation procedures should be both safe and efficient. Concerning the preparation of the lateral window experienced surgeons will reach this objective using a new generation of thin saw-like piezoelectric instruments. In his clinical case Professor Tiziano Testori and coworkers present an advanced case with intra-operative extraction of an infaust tooth and simultaneous implant placement using computer guided surgery.

CHAPTER 2BEXTERNAL SINUS AUGMENTATION WITH SIMULTANEOUS IMPLANT PLACEMENT, BY PROF TIZIANO TESTORI AND DR LUCA FUMAGALLI


Aim of Treatment

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Preoperative planning of the maxillary sinus elevation combined with four simultaneous implants, including calculation of the graft volume needed.

After extraction of tooth 24 a mucoperiosteal flap is raised by a horizontal crestal incision which is intrasulcular in the cuspid area, and of a vertical joystick releasing incision mesial to the cuspid. The caudal outline of the antrostomy is prepared with a piezoelectric saw-like instrument (Piezomed B7).

Occlusal view of the edentulous area. The root of the first premolar is not in relation with the maxillary sinus and cannot be salvaged due to its poor endodontic and restorative prognosis.

In order to facilitate the removal of the bone fragment, the horizontal incision crosses the vertical one. The bone is carefully lifted and removed.

Clinical Case

Preparation of the lateral window with a piezoelectric saw and grafting of the sinus floor in a 56-year-old male patient (simultaneous implant placement). IMPORTANT NOTE: For better visibility Figures 3, 4 and 6 were photographed without instrument irrigation.

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The sinus membrane is then detached from the marginal part of the maxillary sinus wall using the dedicated «elephant foot» (S3, preset power 65). During the procedure in most cases the membrane will be detached without perforations.

The instrument is moved in a circular manner until the shaft touches the outer periphery of the window. Preservation of the periosteal layer and the small vessels up to this step can be noticed.

The medial detachment of the membrane is completed with a manual instrument.

o After placement of the implant, graft material is inserted.

A resorbable collagen membrane is placed over the sinus membrane prior to grafting.

a The bony window is replaced into the preoperative position. An additional buccal graft will be supplemented before suturing.

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External augmentation (elevation) of the maxillary sinus floor is a predictable procedure (1–4) which requires skill and good knowledge of anatomy. After the flap is raised a bony window called antrostomy is prepared in the lateral maxillary sinus wall. Size and position of the antrostomy depend on anatomical details, such as mesio-distal extension of the sinus and presence of septa and arteries. Other relevant factors which determine window preparation include number of implants to be placed and skill of the surgeon (5).Maxillary sinus floor augmentation procedures were historically accomplished using a combination of rotary and manual instruments. Due to its high cutting capability a tungsten carbide round bur was utilized for the initial antrostomy. Next a diamond-coated round bur was applied on a straight handpiece to refine the antrostomy and smoothen the sharp edges. However the rotary approach is extremely technique sensitive and complication-intensive since burs can enhance the risk of sinus membrane perforations and vessel damage, which may lead to intra-operative bleeding (6).

For preparation of the lateral window a number of different approaches have been suggested, including:1. preservation of the bone fragment, which is rotated into the sinus and used as part of the graft (cf. clinical case Professor Urbán)2. preservation of the bone, which is detached from the membrane and repositioned at the end of the procedure (cf. clinical case Prof Testori, Dr Fumagalli and coworkers)3. preservation of the bone, which is detached from the membrane and then particulated to serve as part of the graft material4. complete erosion of the lateral bone fragment starting from the surface (7)

Since the introduction of the piezoelectric approach the above mentioned complications have been reduced. The soft tissue in the operatory field will remain intact when a suitable surgical technique is used (8). More specifically, based on a case series, the risk

Description of technique (by Dr Luca Fumagalli and coworkers)*

* Luca Fumagalli1, Andrea Parenti1, Matteo Deflorian1, Matteo Capelli1, Francesco Zuffetti1, Riccardo Scaini1, Massimiliano Politi1, Fabio Galli11, Tiziano Testori2

1 Section of Implant Dentistry and Oral Rehabilitation (Head: Prof T. Testori), Dental Clinic, Department of Health Technologies, IRCCS Galeazzi Institute, University of Milan, Italy.2 Head of the Section of Implantology and Oral Rehabilitation, Department of Biomedical, Surgical and Dental Sciences, Dental Clinic, IRCCS Galeazzi Institute, University of Milan, Italy.

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of damaging the Schneiderian membrane is 7 % with piezoelectric surgery, in contrast to 30 % with rotary instruments (6). This effect appears most significant in dentists with only limited surgical experience (9). According to clinical observations and one recent systematic review there is also a lower incidence of post-operative swelling and an enhancement of healing in piezo surgery in comparison with rotary preparation of the sinus wall (10, 11). However this result was not shown in all studies (12). Moreover less vibration and noise is produced in comparison with rotary instruments or saws, which makes the piezoelectric procedure more comfortable for the patient (13).

Selection of instrumentsFrom a clinician’s point of view piezoelectric surgery has proven cleaner and more efficient in terms of precision and speed in comparison with other methods. According to the authors’ experience this is especially true when a new generation of thin saw-like instruments is used to prepare the antrostomy. Less experienced users may prefer specifically shaped diamond-coated piezoelectric instruments. Once the antrostomy has been performed an «elephant foot» is used for the initial detachment of the sinus membrane. This instrument reduces the incidence of perforations which mainly occur at this stage. Additional piezoelectric instruments are available to finalize the detachment procedure. However in most cases, following initial detachment the authors prefer dedicated manual instruments.

Preparation of the lateral windowAfter raising of a mucoperiosteal flap the complete antrostomy is prepared with a saw-like piezoelectric instrument (Piezomed B7) (Fig. 3). Unintentional contact of the instrument with the periosteal layer does not cause any damage to the sinus membrane. The periosteal layer and the small vessels in the area will remain intact in most cases (cf. Figs. 5 and 6). If the horizontal and vertical cuts cross each other at all four angles of the antrostomy the bone fragment can easily be removed (Fig. 4).

Detachment of the membraneThe initial detachment of the Schneiderian membrane is – because of the risk of perforation – usually the most difficult part. This applies especially when traditional rotary instruments are used for preparation of the window. Initial detachment is usually safe to perform with the «elephant foot», Piezomed S3 (Figs. 5–6). The instrument should be moved gently in a circular motion towards the bony walls of the antrostomy. The medial (internal) part of the membrane is then detached with a hand instrument (Fig. 7).

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Preparation of the lateral window can be time-consuming due to a thick external sinus wall, which can even consist of two cortical layers. The new saw-like instruments (Piezomed B6/B7) are very thin and therefore help to preserve valuable bone during the osteotomy. Moreover due to the precise cutting action of the instruments the bone fragment will be easier to reposition after grafting of the sinus. And finally with the use of bone there is no need to place a membrane. Most importantly sinus membrane perforations and vessel damage seldom occur due to the selective cutting action of the device. Detachment of the Schneiderian membrane from the marginal part of the window is the most critical phase of maxillary sinus augmentation. The cavitation effect and the special irrigation at the tip of the Piezomed S3 instrument help the operator in this initial phase of the procedure. In summary, with modern piezoelectric equipment and instruments external sinus augmentation can be efficient, easy to perform and even faster compared to traditional technique with rotary burs. This new surgical device improves the features of piezoelectric surgery.

Tiziano Testori, MD, DDS, FICD > 1981 MD, 1984 DDS degree and 1986 speciality degree in Orthodontics from the University of Milan (Italy)

> 1991 Fellowship at the Department of Oral Maxillo-Facial Surgery (Head: Philip J. Boyne), Loma Linda University (USA). 2000 Fellowship at the Division of Oral Maxillo-Facial Surgery (Head: Robert E. Marx), University of Miami (USA)


Author information

Grafting and implant placementA non cross-linked resorbable collagen membrane (Bio-Gide®, Geistlich Biomaterials) is placed over the periosteal layer of the sinus membrane prior to medial grafting with a inorganic bovine bone-derived mineral (Bio-Oss®, Geistlich Biomaterials) (Fig. 8). This is done in order to protect the membrane from accidental micro perforations. For the same reason a collagen sponge is temporarily inserted into the sinus prior to implant site preparation. After implant insertion the graft is completed with Bio-Oss® (Fig. 9) and the bony window is replaced in its preoperative position (Fig. 10). A bovine bone graft is also positioned outside the maxillary sinus to improve the volume on the buccal side of the implant area (not shown). Before suturing another collagen membrane is placed over the graft.

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> Currently Head of the Section of Implant Dentistry and Oral Rehabilitation, School of Dentistry (Chairman: Prof R.L. Weinstein), I.R.C.C.S. Galeazzi Institute, University of Milan; visiting Professor New York University (USA)

> Member of the Editorial Board of The International Journal of Oral and Maxillofacial Implants (IJOMI) and the European Journal of Oral Implantology (EJOI)

> Editor with R.L. Weinstein and S. Wallace of the book »Maxillary Sinus Surgery and Alternative Therapies«, Quintessence Publishing 2009; and with F. Galli and M. Del Fabbro of the book »Immediate loading: a new era in oral implantology«, Quintessence Publishing 2011

> Author of over 200 scientific articles in Italian and international journals.

Luca Fumagalli, DDS > 2001 DDS degree from the University of Milan (Italy) > Since 2002 coworker of Dr Tiziano Testori at the Section of Implant Dentistry and Oral Rehabilitation, School of Dentistry (Chairman: Prof R.L. Weinstein), I.R.C.C.S. Galeazzi Institute, University of Milan

> Active Member of the Italian Society of Oral Surgery and Implantology (SICOI); in 2008, member of the Scientific Committee of SICOI. Founding Member of A.I.S.G. (Advanced Implantology Study Group)

> Co-author with T. Testori, R.L. Weinstein and S. Wallace of the book »Maxillary Sinus Surgery and Alternative Therapies«, Quintessence Publishing 2009; and with T. Testori, F. Galli and M. Del Fabbro of the book »Immediate loading: a new era in oral implantology« Quintessence Publishing 2011

> Co-author of other Italian books on implant surgery and oral surgery; author of over 90 scientific articles in Italian and international journals.

1. Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation. J Clin Periodontol 2008;35:216-240.2. Jensen OT, Shulman LB, Block MS, Iacono VJ. Report of the Sinus Consensus Conference of 1996. The International journal of oral & maxillofacial implants 1998;13 Suppl:11-45.3. Del Fabbro M, Rosano G, Taschieri S. Implant survival rates after maxillary sinus augmentation. Eur J Oral Sci 2008;116:497-506.

References

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4. Del Fabbro M, Corbella S, Weinstein T, Ceresoli V, Taschieri S. Implant survival rates after osteotome-mediated maxillary sinus augmentation: a systematic review. Clin Implant Dent Relat Res 2012;14 Suppl 1:e159-168.5. Testori T, Weinstein RL, Taschieri S, Del Fabbro M. Risk factor analysis following maxillary sinus augmentation: a retrospective multicenter study. The International journal of oral & maxillofacial implants 2012;27:1170-1176.6. Wallace SS, Mazor Z, Froum SJ, Cho SC, Tarnow DP. Schneiderian membrane perforation rate during sinus elevation using piezosurgery: clinical results of 100 consecutive cases. Int J Periodontics Restorative Dent 2007;27:413-419.7. Stacchi C, Vercellotti T, Toschetti A, Speroni S, Salgarello S, Di Lenarda R. Intraoperative Complications during Sinus Floor Elevation Using Two Different Ultrasonic Approaches: A Two-Center, Randomized, Controlled Clinical Trial. Clinical implant dentistry and related research 2013.8. Vercellotti T. Essentials in Piezosurgery: Clinical Advantages in Dentistry: Quintessence Publishing, 2009.9. Seoane J, Lopez-Nino J, Garcia-Caballero L, Seoane-Romero JM, Tomas I, Varela-Centelles P. Membrane perforation in sinus floor elevation – piezoelectric device versus conventional rotary instruments for osteotomy: an experimental study. Clin Implant Dent Relat Res 2013;15:867-873.10. Delilbasi C, Gurler G. Comparison of piezosurgery and conventional rotative instruments in direct sinus lifting. Implant dentistry 2013;22:662-665.11. Wallace SS, Tarnow DP, Froum SJ, Cho SC, Zadeh HH, Stoupel J, et al. Maxillary sinus elevation by lateral window approach: evolution of technology and technique. The journal of evidence-based dental practice 2012;12:161-171.12. Rickert D, Vissink A, Slater JJ, Meijer HJ, Raghoebar GM. Comparison between conventional and piezoelectric surgical tools for maxillary sinus floor elevation. A randomized controlled clinical trial. Clinical implant dentistry and related research 2013;15:297-302.13. Schlee M, Steigmann M, Bratu E, Garg AK. Piezosurgery: basics and possibilities. Implant dentistry 2006;15:334-340.

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First of all endodontic surgery requires safe access to the periapical area and minimal injury to the hard or soft tissues. During access the diseased periapical tissue should be preserved for histopathological examination. Resection of the root tip and preparation of the apical part of the canal is then accomplished with effective, but delicate instruments, which produce smooth surfaces, for a tight endodontic seal. Piezoelectric instruments for osteotomy and a specific assortment of instruments for endodontic retrosurgery fulfill all of these requirements.

CHAPTER 3ACYSTECTOMY, ROOT-END RESECTION AND RETROGRADE PREPARATION OF THE ROOT CANAL,BY ASST PROF DRAGANA GABRIĆ


Aim of Treatment

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Due to pain and a persistent periapical translucency it was decided to retreat the tooth using retrograde microsurgery.

The cystic tissue has been exposed with a piezoelectric instrument (Piezomed S2).

After preparation of a marginal full thickness flap with a vertical releasing incision the outline of the cystic lesion is clearly visible. The cortical bone has been completely resorbed.

The diseased tissue specimen has been enucleated in toto, which makes histopathological examination easy.

Clinical Case

In a 23-year-old female patient the root canal of tooth 15 had been treated orthogradally 5 months before surgery.

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Periapical aspect of the diseased tooth, after near 90° beveling using a straight diamond-coated piezoelectric instrument (R1D). The bony defect is big enough for the use of resection and retro-preparation instruments.

With instrument R1D the root canal is prepared in a retrograde direction.

The canal is filled with mineral trioxide aggregate (MTA).

o The flaps are finally repositioned and sutured.

Situation after retrograde filling.

a The radiograph 2 months post-surgery shows significant ossification, indicating successful treatment of the cystic lesion.

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Microsurgical techniques have become the standard of care for the surgical management of endodontic complications (1, 2). When anamnesis and diagnostics have confirmed that a surgical (retro-)endodontic treatment is indicated the equipment of choice includes a microscope for optimal visualization of the surgical area. Moreover there is an array of specific hand and mechanical instruments suitable for soft tissue access, osteotomy, periapical soft tissue removal, root end preparation and obturation, and suturing (3, 4).

Access to the periapical site and cystectomyIn order to reduce bleeding a vertical releasing incision is prepared, in combination with a marginal or submarginal horizontal incision. The periapical area is identified (Fig. 2) and existing bone over the diseased tissue is cut (Fig. 3) with suitable instruments, e.g. with piezoelectric saws or with piezoelectric diamond-coated round or spatula-shaped instruments. As there may occur pathologies other than granulomae or cysts the periapical tissue should routinely be examined with histopathological methods. It is therefore important to preserve the tissue in toto during access to the apical area (5). The procedure can be compared with the management of the Schneiderian membrane in maxillary sinus grafting. For the same reason piezoelectric osteotomy has proven more successful than rotary preparation concerning epithelial perforation of the cystic tissue, bleeding (better visibility of surgical field), postoperative complications and recurrence of the cystic process (6–8). After piezoelectric access the cystic tissue can be carefully enucleated with hand instruments (Fig. 4).

Root-end resection and retrograde preparationUsing optimal magnification and, if necessary, methylene blue solution for detection of all details the most apical infected part (approximately 3 mm) of the root tip is ablated. This can be performed with rotary carbide burs in specially angulated micro-handpieces, or with dedicated ultrasonic diamond-coated instruments. In comparison with lasers, both options have proven less invasive and to produce more suitable surfaces for cellular attachment during tissue repair (9). Diamond-coated instruments for use in piezoelectric surgery devices are a third and relatively new option for the procedure (10).Finally, retrograde cavity preparation can be successfully performed with specific assortments of ultrasonic instruments. There is a number of different shapes and angulations available, which allow delicate enlargement of the apical canal. In comparison with rotary burs ultrasonic technology has proven safer in preservation of the canal shape. It also allows a more precise and better controlled preparation in the long axis of the


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In endodontic microsurgery it is important to preserve a maximum amount of hard and soft tissues, depending on the specific indication: 1. After soft tissue access bone should be prepared with minimum heat production to avoid tissue damage. This is ideally accomplished with piezoelectric devices which allow effective irrigation. With Piezomed instruments the coolant exits near the tip, close to the surgical area.2. The size of the defect produced by access osteotomy is critical for successful healing. Delicate piezoelectric instruments, e.g. the Piezomed B6/B7, S1 or S2, allow precise and minimal invasive cutting of the bone overlying the periapical lesion. The cavitation effect permits better control of bleeding and therefore enhanced visibility in comparison with rotary instruments.3. The selective cutting action of piezoelectric devices helps to preserve the integrity of the soft periapical cystic or granulation tissue, which is important for pathohistologic examination (5).4. Root-end resection was carried out with a piezoelectric instrument which is routinely used for retrograde root canal preparation. Depending on the defect size the B3 would also be suitable.5. The retrograde endodontic assortment of the Piezomed is shaped similar to ultrasonic inserts available for the same indication. The diamond-coated instruments R1D, R2RD/R2LD, R3D and R4RD/R4LD allow precise and minimal invasive retrograde preparation of the root canal, with high efficiency due to the powerful action of the device.

Assistant Professor Dragana Gabrić, DMD, PhD > 2004 Doctor of Dental Medicine (DMD), University of Zagreb, 2005 Dean’s Award for Study Success

> 2006 Junior Assistant, 2010 Senior Assistant, Department of Oral Surgery, School of Dental Medicine, University of Zagreb

> 2007 Oral Surgeon Trainee, Department of Oral Surgery, Clinical Hospital Center Zagreb > 2010 PhD, dissertation in the field of experimental laser bone surgery; 2011 Specialist in Oral Surgery, Department of Oral Surgery, Clinical Hospital Center Zagreb

> 2011 Associate Research Scientist, 2013 Senior Research Scientist, 2014 Assistant Professor and PhD Tutor, Department of Oral Surgery, School of Dental Medicine, University of Zagreb


Author information

canal, resulting in less perforations (11). Analogous to ultrasonic inserts assortments of piezosurgical instruments can be used for retrograde preparation (Fig. 6) (12).

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1. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. Journal of endodontics 2006;32:601-623.2. Setzer FC, Kohli MR, Shah SB, Karabucak B, Kim S. Outcome of endodontic surgery: a meta-analysis of the literature-Part 2: Comparison of endodontic microsurgical techniques with and without the use of higher magnification. Journal of endodontics 2012;38:1-10.3. Abella F, de Ribot J, Doria G, Duran-Sindreu F, Roig M. Applications of piezoelectric surgery in endodontic surgery: a literature review. Journal of endodontics 2014;40:325-332.4. Hargreaves KM, Cohen S. Cohen's Pathways of the Pulp, Tenth Edition. St. Louis: Mosby, 2011.5. Ellis EI. Surgical management of oral pathologic lesions; in: Contemporary Oral and Maxillofacial Surgery. In: Ellis EI, Hupp JR (eds). book section: Mosby, 2003:481-483.6. Kocyigit ID, Atil F, Alp YE, Tekin U, Tuz HH. Piezosurgery versus conventional surgery in radicular cyst enucleation. The Journal of craniofacial surgery 2012;23:1805-1808.7. Yaman Z, Suer BT. Clinical comparison of ultrasonic surgery and conventional surgical techniques for enucleating jaw cysts. International journal of oral and maxillofacial surgery 2013;42:1462-1468.8. Tortorici S, Difalco P, Caradonna L, Tete S. Traditional endodontic surgery versus modern technique: a 5-year controlled clinical trial. The Journal of craniofacial surgery 2014;25:804-807.9. Camargo Villela Berbert FL, de Faria-Junior NB, Tanomaru-Filho M, Guerreiro-Tanomaru JM, Bonetti-Filho I, Leonardo Rde T, et al. An in vitro evaluation of apicoectomies and retropreparations using different methods. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics 2010;110:e57-63.10. Pavlikova G, Foltan R, Horka M, Hanzelka T, Borunska H, Sedy J. Piezosurgery in oral and maxillofacial surgery. International journal of oral and maxillofacial surgery 2011;40:451-457.11. Gutmann JL, Pitt Ford TR. Management of the resected root end: a clinical review. International endodontic journal 1993;26:273-283.12. Del Fabbro M, Tsesis I, Rosano G, Bortolin M, Taschieri S. Scanning electron microscopic analysis of the integrity of the root-end surface after root-end management using a piezoelectric device: a cadaveric study. Journal of endodontics 2010;36:1693-1697.

References

> Author of numerous scientific papers and four book chapters (medical genetics; dental implantology and bone augmentation surgical procedures; laser soft tissue surgery)

> Editorial board member of the Journal of Lasers, Optics & Photonics; review board member of several international scientific journals (e.g. Journal of Periodontology, Journal of Dentistry)

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Following extractions, the alveolar bone should be preserved to the greatest extent possible for both implantological and prosthetic reasons. In the examples described below, the desmodontal space of molars not worth preserving was expanded using piezoelectric surgery. This was done by inserting the EX1 and EX2 instruments in an apical direction between the root surface and the alveolar bone. The teeth can then be extracted without any problem.

EXTRACTION OF TEETH AND ROOT REMNANTS,BY DR JAIRO MARTÍNEZ VARGAS


Aim of Treatment

CHAPTER 4A

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A 49-year-old patient presented with teeth 26 and 27 requiring removal due to deep caries (section of panoramic radiograph). Two implants are to be placed eight weeks after the procedure.

Leverage effects must be avoided.

The EX2 is used to expand the buccal desmodontal space of tooth 26 apically.

Application of the EX2 along the palatal surface of tooth 27.

Clinical Case

Patient 1: Removal of two maxillary molars not worth preserving in preparation for implant placement.

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The EX1 instrument, for example, is well suited for approximal surfaces and posterior transitions.

Cautious, horizontal (bucco-oral) motions are also required here.

Following the piezosurgical extraction of tooth 26, the alveolar bone structure is completely preserved.

A 40-year-old patient presented with an endondontically restored tooth 37 requiring removal. This was possibly causing healing problems in the region of an extended Keratocystic Odontogenic Tumor (KCOT) in region 38. Following reflection of mucoperiosteal flap, the desmondontal space was expanded with the EX1 (image shows integrated LED illumination).

The same proves possible for tooth 27. The wound is sutured and tooth 28 is available for anchoring the temporary prosthesis.

In this case, the EX2 was employed along the distal approximal surface. The marsupialized KCOT (black) can be seen distal of tooth 37. It was possible to remove the tooth without any problems and this had a positive effect on the healing process.

Patient 2: Extraction of an ankylosed mandibular molar not worth preserving, with soft tissue reflection.

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Piezosurgical tooth extraction represents the state-of-the-artTeeth which are not worth preserving, including ankylosed and fractured teeth and root remnants, are traditionally removed with mechanical elevators and forceps. The exertion of excessive pressure often results in soft tissue and alveolar bone in the area of the tooth socket being damaged. The result is trauma-related pain and wound healing problems. Moreover other soft tissues such as the cheek, tongue and even nerves (1) can also be considerably injured if instruments slip, in some cases. Yet another complication which occurs often in wisdom teeth extractions is fractures (2). Preparation of the alveolar bone with rotary instruments also results in tissue losses.

As a consequence of traumatic tooth extractions, the alveolar bone often reabsorbs far beyond its normal physiological extent (3). This can result, for example, in there being insufficient bone volume available for the insertion of implants. If a conventional prosthetic restoration is planned, an unfavourable vertical and horizontal alveolar process contour can significantly affect the result.Such undesirable consequences can largely be avoided by giving preference to minimally invasive extraction methods such as piezoelectric surgery (4, 5). Modern piezosurgical instruments have integrated cooling systems in direct vicinity of the instrument tip and are very effective despite their atraumatic approaches. In the case of ankylosed teeth, it can be advantageous to separate the clinical crown below the cementoenamel junction so as to allow easier access to the desmodontal space with the piezosurgical instruments (5). Another possibility for removing ankylosed teeth and tooth remnants is to separate them within the alveolus, for example with piezosurgical saws.

Piezosurgical tooth extraction – step by step This method requires flat instruments with similar designs to periotomes and a cutting edge. They are initially introduced into the gingival sulcus in operating mode until contact is made with the bone. From there, the instruments are advanced apically into the desmodontium until they reach the apical third, insofar as this is possible. For buccally, orally and posteriorly located approximal root surfaces, the EX2 instrument, which has a working surface angled at 90° to the shaft (cf. patient example 1, Figs. 2 to 4 and patient example 2, Fig. 2), is generally well suited.


The extraction of teeth not worth preserving with forceps, elevators and periotomes can not only be traumatic but also takes more time than is actually necessary. The atraumatic working principle of piezosurgical instruments offers great advantages in the author’s experience. For example, the axially oriented micro-movements of the instruments are advantageous for entry into and advancement within the desmodontal space. The angle at which the Piezomed EX1 and EX2 instruments are oriented to the crown creates an ideally shaped space between the bone and cementum. In the case of teeth with extensively curved crowns, molars especially, the instrument tip needs to be introduced slightly in the direction of the cementum. In this way, it is mainly superficial root substance which is removed, whereas the alveolar bone remains protected. If this technique is not successful, the clinical crown can be reduced or removed using suitable instruments. The piezosurgical instruments then penetrate the desmodontium in a straight line.With its automatic preset cooling at the instrument tip, the Piezomed system prevents tissue damage from overheating as occurs with other instruments. This makes a decisive contribution to atraumatic treatment and reduces postoperative complaints (6). At the same time, the Piezomed is highly efficient (7). For example, in the author’s experience, ankylosed anterior teeth can be removed in 2–3 minutes and just 10–15 minutes are required for molars depending on the situation. The author has not yet had to remove crowns from erupted teeth or separate the roots.The foot control of the Piezomed also makes it possible to adjust the instruments’ cutting performance. If time is of the essence, the dental surgeon can increase the instrument’s power setting, for example by using the boost function. This convenient power reserve can be used to accelerate the process if and as required.


The EX1 instrument is used approximally, for posterior buccal and oral surfaces and for line angles (cf. patient example 1, Figs. 5, 6 and patient example 2, Fig. 1).As soon as the desmodontal space in contact with the root surface has been expanded in a circle, the tooth can usually be extracted easily with extracting forceps or suitable elevators. If necessary, the roots are separated with a saw (e.g. B6 or B7) prior to the extraction. Depending on the situation, reflection of soft tissue may be practical (cf. patient example 2).

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Dr Jairo Martínez Vargas > 1986 Licence to practise dentistry, 1993 further training to become oral and maxillofacial surgeon (University of Heidelberg, Germany)

> Since 1988 Lecturer at the Dental School of the University of Costa Rica > Since 1994 private practice in San Pedro de Montes de Oca, Costa Rica > Director of the OMS department at the National Clinic San Juan de Dios, Costa Rica > Chief consultant for the journal of OMS and oral surgeons in Costa Rica > Numerous publications on, among other things, the topics of prophylactic antibiotic coverage, extractions in cases of neoplasia, guided bone regeneration (GBR) prior to implantations

1. Boffano P, Roccia F, Gallesio C. Lingual nerve deficit following mandibular third molar removal: review of the literature and medicolegal considerations. Oral surgery, oral medicine, oral pathology and oral radiology 2012;113:e10-18.2. Boffano P, Roccia F, Gallesio C, Berrone S. Pathological mandibular fractures: a review of the literature of the last two decades. Dental traumatology : official publication of International Association for Dental Traumatology 2013;29:185-196.3. Tan WL, Wong TLT, Wong MCM, Lang NP. A systematic review of post-extractional alveolar hard and soft tissue dimensional changes in humans. Clin Oral Implants Res 2012;23:1-21.4. Blus C, Szmukler-Moncler S, Khoury P, Orru G. Immediate implants placed in infected and noninfected sites after atraumatic tooth extraction and placement with ultrasonic bone surgery. Clin Implant Dent Relat Res 2015;17 Suppl 1:e287-297.5. Vercellotti T. Essentials in Piezosurgery: Clinical Advantages in Dentistry: Quintessence Publishing, 2009.6. Rullo R, Addabbo F, Papaccio G, D'Aquino R, Festa VM. Piezoelectric device vs. conventional rotative instruments in impacted third molar surgery: relationships between surgical difficulty and postoperative pain with histological evaluations. J Craniomaxillofac Surg 2013;41:e33-38.7. Harder S, Wolfart S, Mehl C, Kern M. Performance of ultrasonic devices for bone surgery and associated intraosseous temperature development. Int J Oral Maxillofac Implants 2009;24:484-490.

Author information

References

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Author information

References

The surgical extraction of unerupted and impacted teeth, for example the mandibular wisdom teeth, should entail as little stress for the patients as possible. This requirement can be satisfied very well with piezosurgical instruments, which, on the one hand, allow vibration-free and thus atraumatic treatment. On the other hand, this, like all surgical procedures, should be completed quickly, as it helps to reduce the development of complications.

Aim of Treatment

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CHAPTER 4BSURGICAL TOOTH EXTRACTION TAKING AN IMPACTED MANDIBULAR WISDOM TOOTH AS AN EXAMPLE,BY DR JAIRO MARTÍNEZ VARGAS


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A 24-year-old patient with nothing remarkable in his medical history presented with a partially erupted, horizontally displaced, mandibular wisdom tooth requiring removal to prevent pericoronal infections.

Piezomed display following insertion of the B7 saw (group 3, programme 1, boost function activated): The handpiece is connected to the device and the +/- keys pressed at the same time to activate the cooling system. The Piezomed detects the inserted instrument and regulates the power and coolant supply automatically.

The initial situation corresponds to a class B situation based on the Pell and Gregory classification: The third molar is at the height of (above and below) the cementoenamel junction of the second molar.

The surgical site around tooth 38 is exposed with a sulcular incision starting mesiobuccal of tooth 37 and a releasing incision distobuccal of 38 in the direction of the ascending ramus. The slender B7 piezosurgical saw is used to prepare a buccomarginal bone fragment down to the underlying wisdom tooth.

Clinical Case

Piezosurgical removal of a partially impacted, horizontally displaced, mandibular wisdom tooth.

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Following a second incision positioned further medially, the resulting bone shard is luxated with an osteotomy rasp and subsequently removed with forceps. This technique preserves the retromolar bone of the ascending ramus.

The B7 saw is used to separate the crown distally and buccoapically and a fragment created with two incisions (cf. Fig. 11).

This creates a sufficiently wide space for the insertion of the Bein elevator.

o The EX1 instrument expands the periodontal space to enable atraumatic elevation of the roots from the tooth socket. The integrated LED illumination of the Piezomed ensures excellent light conditions even in deeper areas (Note: The LED illumination was switched off for the remaining pictures for optimal setting of the camera flash).

The first crown fragment can now be removed.

a Removal of a root fragment with the Luer forceps.

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s An overview of all of the tooth fragments: distobuccal bone shard, buccal bone shard for the insertion of Bein elevator, crown fragment 1 (top row); crown fragments 2 and 3 (middle row); distal (cranial) and mesial (caudal) root (bottom row, from left to right).

d The wound area has healed well eight days after the surgery (situation following removal of sutures). The postoperative complaints were minimal.

Comparison of bone preparation methodsThe risk of complications in surgical tooth extractions is primarily decided by the patient’s age, surgical technique, number of teeth to be extracted and root anatomy (1). For example, the longer a procedure takes the more frequently postoperative complications are encountered (2). No studies confirm the advantages of a certain surgical technique over others based on randomized comparative studies (3). In contrast, a whole range of clinical observations speak in favour of piezosurgical bone preparation.The bone around unerupted, partially impacted and impacted teeth has traditionally been removed with rotary instruments, especially Lindemann’s cutting burs and round burs. The same instruments are also used for separating teeth and roots in their alveoli. Both procedures generate vibrations, which are unpleasant for the patient. Depending on the access possibility for the coolant, rotary instruments also generate higher temperatures, which put bone vitality at risk.This problem was not observed when piezosurgical instruments were employed in a comparative study (4), which could possibly be linked to the laminar flow of fluid in the operating field (5). In addition, compared with piezosurgical systems, rotary systems put relatively high postoperative stress on tissue, which can have negative consequences on the healing process (6).

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One additional advantage of piezosurgical instruments is their diameter, which can be between 0.25 (Piezomed B6/B7) and 0.5 mm (Piezomed B1, B2R/B2L), depending on the system. Lindemann’s cutting burs in contrast are at least 1.6 mm in diameter (7). This can result in too much bone being removed unnecessarily and the relative wound surface being correspondingly enlarged. Rotary instruments can also slip relatively easily. Based on clinical experience, their special, micro-oscillating approach means piezosurgical systems can be controlled better (7-9).

Extraction of impacted mandibular wisdom teeth – clinical procedure with piezoelectric surgeryOnce the operating site has been exposed with a suitable flap technique, the surrounding soft tissues are protected with suitable instruments as usual. Then, depending on the initial situation, the bone above the teeth to be extracted is removed, for example with the Piezomed B3 instrument. Alternatively, piezosurgical saws (Piezomed B1, B2R/B2L and B6/B7) are also suitable. They can be used to osteotomize larger or smaller bone fragments (shards) above the tooth, which can then be removed with elevators and forceps (patient example Figs. 4 and 5).Whereas a larger quantity of retromolar bone is usually removed with round head burs to expose the crown, it is largely possible to preserve retromolar bone when the piezosurgical method described here is used.The crown can also be split with piezoelectric saws and separated from the roots. If very fine instruments like the Piezomed B6/B7 are used, it may be necessary to create a sufficiently wide space for insertion of the Bein elevator by making two incisions (Figs. 6 to 8). Alternatively, it is also possible to use a combination of rotary milling cutters and piezosurgical instruments (8). If the crown of the wisdom tooth is located very deep, it can be fragmented using a saw again (cf. tooth fragments, Fig. 11).The periodontal space can be expanded with suitable piezosurgical instruments so as to allow the roots to be removed from the tooth socket as atraumatically as possible (Piezomed EX1/EX2 or B6/B7) (Figs. 9 and 10). Elevators and forceps can then be used as usual.

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The removal of impacted and displaced wisdom teeth is one of the most commonly performed surgical procedures in dentistry (10). At the same time, the wound infection rate is given at up to 17.8%, with the risk increasing in correlation to the patient’s age and use of tobacco (11). The roots of the second molar can be damaged especially in cases where the mandibular wisdom teeth are located very close to it (2). In addition, there is a possibility of increased sensitivity after the operation in the regions innervated by the lingual nerve and inferior alveolar nerve (12). All these risks speak in favour of a surgical technique which is as minimally invasive as possible and involves maximum bone preservation and low traumatizing preparation. As it was possible to demonstrate in the patient example, impacted third mandibular molars can be removed completely without the use of rotary instruments. This allows maximum preservation of bone substance, which should encourage healing. An additional, patient-related advantage is the lack of vibration and the low noise level with this procedure. As such, when performed under anaesthesia, the patient may barely notice the procedure in the best case. The patient presented here reported hardly any postoperative complaints and the wound healed without any problems (Fig. 12), thanks also to the perioperative medication (diclofenac and dexamethasone before and amoxicillin and diclofenac after the operation, plus additional rinsing with 0.2% CHX for 7 days).As the piezosurgical system used also works very efficiently, the procedure can be performed in a similar time to rotary instruments. Only the multiple fragmentation of the crown as performed in the patient example might have been completed more quickly if rotary instruments had been used. Nevertheless, it can be established that, with its high efficiency, the Piezomed device used will satisfy even impatient surgeons.


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Dr Jairo Martínez Vargas > 1986 Licence to practise dentistry, 1993 further training to become oral and maxillofacial surgeon (University of Heidelberg, Germany)

> Since 1988 Lecturer at the Dental School of the University of Costa Rica > Since 1994 private practice in San Pedro de Montes de Oca, Costa Rica > Director of the OMS department at the National Clinic San Juan de Dios, Costa Rica > Chief consultant for the journal of OMS and oral surgeons in Costa Rica > Numerous publications on, among other things, the topics of prophylactic antibiotic coverage, extractions in cases of neoplasia, guided bone regeneration (GBR) prior to implantations

Author information

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1. Akadiri OA, Obiechina AE. Assessment of difficulty in third molar surgery--a systematic review. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 2009;67:771-774.2. Strietzel FP, Reichart P. Wundheilung nach operativer Weisheitszahnentfernung. Evidenzgestützte Analyse (in German). Mund Kiefer Gesichtschir 2002;6.3. Dodson TB, Susarla SM. Impacted wisdom teeth. BMJ clinical evidence 2010;2010.4. Rullo R, Addabbo F, Papaccio G, D'Aquino R, Festa VM. Piezoelectric device vs. conventional rotative instruments in impacted third molar surgery: relationships between surgical difficulty and postoperative pain with histological evaluations. Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery 2013;41:e33-38.5. Grötz KA, Schmidt BL. Piezo-Chirurgie in der zahnärztlichen Chirurgie – Update 2011. Dtsch Zahnärztl Z 2011;66:432-439.6. Gulnahar Y, Huseyin Kosger H, Tutar Y. A comparison of piezosurgery and conventional surgery by heat shock protein 70 expression. International journal of oral and maxillofacial surgery 2013;42:508-510.7. Rothamel D, Happe A, Fienitz T, Kreppel M, Neugebauer J, Zöller J. Piezosurgery – a universal principle for many indications. EDI Journal 2015:64-70.8. Vercellotti T. Essentials in Piezosurgery: Clinical Advantages in Dentistry: Quintessence Publishing, 2009.9. Schlee M, Steigmann M, Bratu E, Garg AK. Piezosurgery: basics and possibilities. Implant dentistry 2006;15:334-340.10. Eklund SA, Pittman JL. Third-molar removal patterns in an insured population. J Am Dent Assoc 2001;132:469-475.11. Larsen PE. Alveolar osteitis after surgical removal of impacted mandibular third molars. Identification of the patient at risk. Oral Surg Oral Med Oral Pathol 1992;73:393-397.12. Eliav E, Gracely RH. Sensory changes in the territory of the lingual and inferior alveolar nerves following lower third molar extraction. Pain 1998;77:191-199.

References

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CHAPTER 5A

In open periodontal debridement critical factors include good access to the root surface and gentle but efficient calculus removal. Following instrumentation the surface should be clean and smooth, which helps to reduce microbial recolonization and enhances the attachment of connective and epithelial tissues. This can be successfully achieved with a selection of dedicated piezoelectric instruments designed to reach even into deep and narrow defects.

OPEN PERIODONTAL DEBRIDEMENT,BY DR KENJI HOSOYA


Aim of Treatment

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The orthograde radiograph shows proximal and interradicular bone loss around teeth 35, 36 and 37.

After preparation of a full thickness flap the deep intrabony defects are visible.

Mesial, mid and distal probing depths are 8–6–4 mm on the buccal side of tooth 35, and 6–5–4 mm on the lingual. The respective values for tooth 36 are 8–7–7 mm (buccal) and 8–6–6 mm (lingual), with furcation involvement class II. The picture shows mesiobuccal probing on tooth 35, with discrete bleeding.

The root surfaces are carefully smoothened with Piezomed instruments (picture shows P2RD). These instruments are used in the same way as the active parts of corresponding hand instruments (Gracey curettes). This means that the piezoelectric instruments should be used with gentle, extensive movements.

Clinical Case

In a 53-year-old female patient with severe chronic periodontitis guided tissue regenerative procedures were planned due to deep intrabony defects. Scaling and root planing was performed as an initial treatment prior to surgery in all four quadrants.

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Result of the finishing procedure on the mesial surface of tooth 35.

Debridement and finishing of the mesial root surface of tooth 36 with the P2RD instrument. The tip of the instrument must not be used as it would scratch the root surface. It is important to always work with efficient irrigation (picture taken without irrigation due to better visibility of the instrument).

The site is augmented with bovine bone-derived mineral. Subsequently a collagen membrane was placed and the site was sutured using 4–0 catgut (not shown).

o Radiograph 10 weeks after surgery, showing increased radiopacity in the GTR area.

Soft tissues are inflammation-free 10 weeks after surgery. Probing depths at this time point are 4–3–2 mm (buccal) and 4–2–2 mm (lingual) for tooth 35; and 4–3–3 mm (buccal) and 4–3–3 mm (lingual) for tooth 36. Clinically there is no furcation involvement detectable.

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Surgical debridement of periodontal defectsSurgical debridement of contaminated root surfaces can be indicated as an alternative to, or as an additional treatment following subgingival (non-surgical) scaling and root planing (1). Other indications include debridement in combination with a curettage of bony defects prior to (periodontal) guided tissue regenerative procedures. Finally debridement of exposed root surfaces should be performed after raising of flaps in connection with implant placement.

Surgical scaling and root planing can be carried out with an array of mechanical or hand instruments. Mechanical systems include sonic and ultrasonic scalers, and rotary or oscillating systems with diamond-coated and carbide instruments, respectively. According to the literature it is not clear if hand or power driven scalers produce rougher surfaces in non-surgical debridement (2–4). Moreover new designs of mechanical instruments have not proven superior to older ones (5).

Power driven devices may significantly speed up open debridement procedures in comparison with hand instruments. In this context, piezoelectric devices, which have originally been developed for bone surgery, are a relativley new option. In order to reach into narrow spaces – such as deep intrabony defects – piezoelectric instruments should have a slender and anatomically well adapted design. This is true for a set of two instruments shaped according to standard Gracey hand curettes. Another instrument has a straight delicate design for use on easier accessible root surfaces or treatment of periimplantitis.

Subgingival scaling and root planing (SRP) has proven successful as a preparation for guided tissue regeneration procedures (6). For access to the relevant sites the surgeon prepares modified Widman (Ramfjord) full thickness flaps, if possible without or with only minimal vertical release incisions (Figs. 3–4). Debridement can now be carried out with a set of two diamond-coated instruments which are angulated like Gracey curettes (Piezomed P2RD and P2LD). Due to their slim shape with corresponding transitions, adapted to mesial and distal root surfaces and line angles these instruments will efficiently clean even deep intrabony defects (Figs. 4 and 6).


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Alternatively a straight instrument (Piezomed P1) can be used, which reaches into the narrowest periodontal spaces and performs efficiently in deep subgingival pockets (oral and buccal, non-surgical use), or on flat accessible root surfaces (surgical). This instrument is also suitable for the open debridement of implant surfaces in the treatment of periimplantitis.

After cleaning of all surfaces the defect is augmented with a dedicated guided tissue regeneration technique, e.g. with a combination of bovine bone-derived mineral (Fig. 7) and an absorbable collagen membrane. Suturing is done according to standard techniques.

Analogous to subgingival scaling and root planing hand or power driven instruments can be used for open debridement of root surfaces. From a practical point of view hand instruments can be tiresome to use and may not reach all areas of deep and narrow intrabony defects. This can be relevant in primary or secondary open debridement or also when the site has to be prepared for guided tissue regenerative procedures.For all of these indications a set of piezoelectric instruments has proven efficient and at the same time gentle towards the tooth substance. As one option a set of diamond-coated instruments shaped like left and right Gracey curettes allows treatment of all proximal surfaces and line angles in a familiar way (Piezomed P2RD/P2LD). A complimentary uncoated straight instrument can be used for buccal or oral surfaces (Piezomed P1). The LED ring in the front side of the handpiece brings shadow-free light directly to the treatment area. Irrigation spray exits near the instrument’s area of activity, which allows efficient cooling.


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Dr Kenji Hosoya > 1992 DMD degree at the Intercontinental University School of Dentistry (México City, México) > 1994–1996 postgraduate program in Periodontics at Intercontinental University, with honorific mention

> 1996 license to teach at Intercontinental University > 1996–2012 Faculty member of the postgraduate program in Periodontics > 1997 Certified specialist, Mexican Council of Periodontology > Member of several national and international professional and scientific organizations > Co-author, with Dr Alejandro González Blanco, of the chapter »Periodontics« in the text book: Castellanos Suárez, Díaz Gúzman, Lee Gómez (editors). Medicine in Dentistry – management of patients with systemic disorders. (Manual Moderno publishing company, Colombia)

> Private practice focused on periodontics and dental implants in México City and Tecamachalco, México.

1. Miremadi SR, De Bruyn H, Steyaert H, Princen K, Sabzevar MM, Cosyn J. A randomized controlled trial on immediate surgery versus root planing in patients with advanced periodontal disease: a cost-effectiveness analysis. J Clin Periodontol 2014;41:164-171.2. Schlageter L, Rateitschak-Pluss EM, Schwarz JP. Root surface smoothness or roughness following open debridement. An in vivo study. J Clin Periodontol 1996;23:460-464.3. Drisko CL, Cochran DL, Blieden T, Bouwsma OJ, Cohen RE, Damoulis P, et al. Position paper: sonic and ultrasonic scalers in periodontics. Research, Science and Therapy Committee of the American Academy of Periodontology. Journal of periodontology 2000;71:1792-1801.4. Rosales-Leal JI, Flores AB, Contreras T, Bravo M, Cabrerizo-Vilchez MA, Mesa F. Effect of root planing on surface topography: an in-vivo randomized experimental trial. Journal of periodontal research 2015;50:205-210.5. Walmsley AD, Lea SC, Landini G, Moses AJ. Advances in power driven pocket/root instrumentation. J Clin Periodontol 2008;35:22-28.6. Aljateeli M, Koticha T, Bashutski J, Sugai JV, Braun TM, Giannobile WV, et al. Surgical periodontal therapy with and without initial scaling and root planing in the management of chronic periodontitis: a randomized clinical trial. J Clin Periodontol 2014;41:693-700.

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References

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CHAPTER 5B


Many periimplant defects need to be carefully cleaned surgically so as to stop infections and the associated further bone loss. This can be achieved reliably with slender piezosurgical instruments, which penetrate even deep, crevice-shaped defects thanks to their design. Following decontamination of the defect, it is possible to harvest autologous bone material for the subsequent augmentation atraumatically and efficiently using piezosurgical instruments too.

CLEANING OF CONTAMINATED IMPLANT SURFACES AND AUTOLOGOUS DEFECT AUGMENTATION,BY PD DR JÖRG NEUGEBAUER

Aim of Treatment

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An extensive defect secreting pus has formed around a ceramic implant (Frialit-1) inserted 26 years ago at position 22/23. The soft tissue findings were largely unremarkable.

The implant surface and the surrounding tissue are cleaned with a piezosurgical instrument (Piezomed EX2 or P1). The slender instrument can be inserted easily into the crevice-shaped defect. A releasing incision far from the defect (distally) was sufficient to expose the surgical field.

The tooth X-ray displays extensive bony defects on the mesial and distal aspects up to the apical third of the ovally shaped intraosseous part of the implant.

Following the cleaning, a photosensitizer is inserted into the defect, rinsed out with sterile saline solution and then activated with the corresponding low-energy diode laser (photodynamic therapy, aPDT, Helbo® Blue, bredent medical).

Clinical Case

Surgical decontamination of a periimplant defect around a ceramic implant at position 22/23 in a 47-year-old patient.

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A bone block is prepared with different piezosurgical saws (here B7) for the augmentation.

An angled saw is ideal for the basal section (here B2L).

The area of the defect is augmented using a mixture of bone particulate and bone chips harvested through rasping (not shown).

o Six months on, there is no indication of irritation. The buccal soft tissue has receded slightly. The surface of the implant and the denture can be kept clean easily with a soft brush.

The defect is then sutured. The sulcular incision employed to expose the defect preserved the peri-implant soft tissue to the greatest possible extent.

a Radiological findings following reconstructiveperiimplantitis therapy. It remains to be decided whether the marginal and periapical defects will subsequently be filled. The patient has not reported any complaints.

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Surgical decontamination in periimplant defectsSurgery is often indicated in order to prevent progressive bone loss in cases of periimplant defects and keep the implant free from infections (1). The infected tissue is removed and the surface of the implant cleaned. Manual and ultrasonic instruments with different materials and configurations or laser devices are recommended for this purpose. However, it has been shown that the cleaning effect of plastic and titanium curettes is suboptimal (2). In addition, their use is also very time-consuming. At the same time, the risk of damaging the surface of the implant by steel instruments is overestimated. It was also not possible to ascertain the superiority of different laser devices over other aids (3, 4). The use of piezosurgical instruments, which are also used for the removal of periodontal deposits, is a relatively new method. Antimicrobial photodynamic therapy (aPDT), which can be used to disinfect contaminated tissue and implant surfaces effectively, is also available as a complement to the mechanical removal of deposits (5, 6). The use of suitable low-energy diode lasers and photosensitizers reduces the numbers of pathological microorganisms and these systems also promote tissue regeneration and wound healing with their photobiological effect (7).In addition to cleaning and decontamination of the defect, augmentation with application of bone replacement material or guided bone regeneration may be indicated depending on the findings (8). As reossification can only be achieved very slowly when defects are regenerated with xenogenous material, augmentation with autogenous bone is recommended for extensive defects (9). This bone can be prepared atraumatically on all sides as a block with piezosurgical saws (patient example, Figs. 5 and 6).

Blocks harvested in this way are ultimately mobilized atraumatically without the exertion of excessive force, split with a diamond disc for additional lateral augmentation if necessary and converted partially or completely into particulate bone with a bone crusher (10). Alternatively or additionally, bone chips can be harvested through ablation with mechanical bone rasps, for example (11). However, compared with piezosurgical instruments, these instruments have proven to be less effective (12).


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Piezosurgical treatment of periimplant defects – step by stepFollowing surgical exposure of the periimplant defect, flat piezosurgical instruments such as the Piezomed P1 are used for the removal of periodontal deposits. Alternatively, slightly broader, flat instruments developed for the extraction of teeth have also proved practical (Piezomed EX1 and EX2). The instruments are inserted into the defect in contact with the surface of the implant or the infected bone (patient example, Fig. 3). This effectively cleans the implant and also atraumatically removes necrotic bone and granulation tissue in the periimplant defect.For efficient decontamination of the defect, photosensitizer (Helbo® Blue, bredent medical) is also applied, rinsed out with saline solution and activated with the specific laser light corresponding to the system for one minute after at least three minutes’ exposure time (Fig. 4). In order to avoid waiting time in the patient example, the activation is not performed until the bone block has been prepared. The photochemical reaction results in excited oxygen on the cell wall of the bacteria (singlet oxygen). The resulting lipid oxidation destroys the bacteria.For this bone-regeneration measure, a bone block is harvested from the Linea obliqua externa of the mandible with straight and angled piezosurgical saws (Piezomed B7 and B2L) (Figs. 5 and 6). This is then converted to particulate bone with a bone crusher and inserted into the defect along with bone chips harvested with a special piezosurgical instrument (Piezomed B5) as autologous augmentation material (Fig. 7). Following the suturing (Fig. 8) and a healing period of six months, the soft tissue showed no indications of irritation and the buccal tissue had receded slightly (Fig. 9). However, as the patient’s smile line is low, this does not affect the patient. Additionally, she can easily clean both the denture and the surface of the implant. The final X-ray reveals a reduced radiolucency (Fig. 10) in the distal region compared with the initial findings (cf. Fig. 2) as a result of the augmentation.

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If contaminated implant surfaces have a heavily retentive structure or deep threads, it can be very difficult to remove the infected tissue with manual instruments. This is especially true in the case of deep and crevice-shaped periimplant defects. The Piezomed EX2 instrument removes material very effectively and makes it possible to remove granulation tissue from the depths and the flanks of the thread safely and reliably. Alternatively, the Piezomed P1 instrument is well suited to even more sharply tapering defects.The cavitation effect of the piezoelectric drive reduces bleeding and ensures better views of the surgical site. In addition, the coolant supply close to the instrument tip ensures that the bone in the periimplant defect is not overheated. The bone block can be prepared very effectively with the Piezomed B7 and B2L saws and then mobilized easily. The high performance of the Piezomed device makes the preparation time similar to that of rotary systems. The clinical application is very safe and both hard and soft tissue are protected to the greatest possible extent. Bone material can also be harvested more efficiently with piezoelectric surgery than with manual bone rasps. For it to be possible to use them, it is generally necessary to mobilize a larger mucoperiosteal flap than is required for piezosurgical instruments. In addition, it has proven true that piezosurgical bone harvesting is comparable to mechanical methods in terms of the biological quality of the bone chips (13).The high-performance piezo surgery unit used thus made it possible to perform different treatment steps effectively in just one procedure.


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Privatdozent Dr Jörg Neugebauer > 1989 Licence to practise dentistry (University of Heidelberg, Germany) > 1990–2001 Dentist employed by the Friedrichsfeld implant manufacturing company (Mannheim, Germany), now Dentsply Implants, responsible for product development and clinical research

> 2001–2004 Further training to become dentist specializing in oral surgery (University of Cologne)

> 2005–2010 Assistant Medical Director of the Interdisciplinary Policlinic for Oral Surgery and Implant Dentistry and the Clinic and Policlinic for Oral and Maxillofacial Sugery (University of Cologne)

> 2009 Habilitation and title of Privatdozent (venia legendi) > Since 2010 Group practice Dres. Bayer, Kistler, Kistler & Elbertzhagen, lecturer at University of Cologne

> Research focuses: Reliability of implant treatment, antimicrobial photodynamic therapy, digital volume tomography, ceramic implants

> Numerous publications and presentations, co-author of the textbook "Cone Beam Volumetric Imaging in Dental, Oral and Maxillofacial Medicine", Quintessence Publishing

> Member and actively involved in numerous academic and scientific associations at home and abroad, including being Chairman of the Continuing Education Oversight Committee, Academy of Osseointegration, USA

1. Figuero E, Graziani F, Sanz I, Herrera D, Sanz M. Management of peri-implant mucositis and peri-implantitis. Periodontology 2000 2014;66:255-273.2. BDIZ EDI. Periimplantäre Entzündungen: Prävention, Diagnostik, Therapie. 10. Europäische Konsensuskonferenz (EuCC). 2015.3. Schwarz F, Papanicolau P, Rothamel D, Beck B, Herten M, Becker J. Influence of plaque biofilm removal on reestablishment of the biocompatibility of contaminated titanium surfaces. J Biomed Mater Res A 2006;77:437-444.

References

Author information

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4. Kotsakis GA, Konstantinidis I, Karoussis IK, Ma X, Chu H. Systematic review and meta-analysis of the effect of various laser wavelengths in the treatment of peri-implantitis. Journal of periodontology 2014;85:1203-1213.5. Mailoa J, Lin GH, Chan HL, MacEachern M, Wang HL. Clinical outcomes of using lasers for peri-implantitis surface detoxification: a systematic review and meta-analysis. Journal of periodontology 2014;85:1194-1202.6. Bassetti M, Schar D, Wicki B, Eick S, Ramseier CA, Arweiler NB, et al. Anti-infective therapy of peri-implantitis with adjunctive local drug delivery or photodynamic therapy: 12-month outcomes of a randomized controlled clinical trial. Clinical oral implants research 2014;25:279-287.7. Neugebauer J, Kistler S, Kistler F. Vermeidung der apikalen Periimplantitis bei der Sofortimplantation. Dentale Implantologie 2014;18:354-361.8. Chan HL, Lin GH, Suarez F, MacEachern M, Wang HL. Surgical management of peri-implantitis: a systematic review and meta-analysis of treatment outcomes. Journal of periodontology 2014;85:1027-1041.9. Khoshkam V, Chan HL, Lin GH, MacEachern MP, Monje A, Suarez F, et al. Reconstructive procedures for treating peri-implantitis: a systematic review. Journal of dental research 2013;92:131S-138S.10. Khoury F. Knochenaugmentation in der oralen Implantologie. Berlin: Quintessenz, 2009.11. Zaffe D, D'Avenia F. A novel bone scraper for intraoral harvesting: a device for filling small bone defects. Clin Oral Implants Res 2007;18:525-533.12. Sivolella S, Berengo M, Scarin M, Mella F, Martinelli F. Autogenous particulate bone collected with a piezo-electric surgical device and bone trap: a microbiological and histomorphometric study. Arch Oral Biol 2006;51:883-891.13. Chiriac G, Herten M, Schwarz F, Rothamel D, Becker J. Autogenous bone chips: influence of a new piezoelectric device (Piezosurgery) on chip morphology, cell viability and differentiation. J Clin Periodontol 2005;32:994-999.

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In edentulous patients implant-retained fixed prostheses improve mastication and quality of life. The present patient had only minimal posterior maxillary bone height due to resorption and extensive pneumatisation of the sinuses. The implant sites were prepared with a piezoelectric device and a new set of dedicated instruments. Two 10 mm and six 4 mm implants were placed to retain a bar-supported fixed CAD/CAM denture.

CHAPTER 6APIEZOELECTRIC IMPLANT SITE PREPARATION FOR A MAXILLARY PROSTHESIS RETAINED BY 10 MM AND 4 MM IMPLANTS, BY PROF DR DR JOSÉ LUIS CALVO GUIRADO, DDS, PHD/EU, PHD, MSC


Aim of Treatment

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Pre-operative view of the maxillary ridge, with implant positions marked with the aid of a surgical plastic template. Due to the low ridge super short posterior implants were planned.

Preparation with the ultrasonic marker instrument (Piezomed I1) is performed in an up and down movement, parallel to the long axis of the working part. The ideal power setting is 80, irrigation 100 % (Figures 3-5 without irrigation for better visibility).

After mid-crestal incision and preparation of mucoperiosteal flaps the implant positions are transferred to the bone. The oro-vestibular width of the ridges proves sufficient for placement of 4.1 mm diameter implants.

The next step is pilot enlargement with the Piezomed I2A/I2P instruments, which are applied in a rotary horizontal movement (not up and down). Both power setting and irrigation is 100 for all instruments of this type.

Clinical case

A 41-year-old patient without systemic particularities lost all her teeth due to periodontitis and caries and because she could not afford appropriate treatment. Finally she had to wear mucosa-supported full dentures in both jaws, with great masticatory difficulties due to the ill-fitting prostheses. When her economic situation improved the patient decided to have implants placed to support a bar-retained fixed CAD/CAM prosthesis in the mandible. Three years later it was time for a maxillary implant-supported denture of the same type.

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Implant stability is determined with a SmartPeg and the W&H ISQ Osstell module. All values are in the high range with a minimum of ISQ 69.

o A plastic template reveals sufficient space for the existing prosthesis to serve as a temporary restoration retained on the provisional implants.

After fixation of the gingiva former provisional implants are placed at positions 18, 12, 22 and 28.

a The post-operative panoramic radiograph shows all implants in appropriate positions, including the pterygoid provisional implants.

In this case the final diameter is achieved with the Piezomed I3A/I3P instruments. For the 10 mm implants at positions 11 and 21 sites are finalized with a 3.5 mm rotary drill in an implant motor (Implantmed).

A 10 mm tissue level implant is placed at position 21. The implant at position 11 and the three left posterior 4 mm implants are already in place.

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Options for implant site preparationPreparation of implant sites is traditionally performed with rotary instruments. Up-to-date implant motors ensure well-controlled cutting at low speed and defined torque values. The whole process can be documented electronically, including insertion torque and stability values of the implants (ISQ) in their final positions (W&H Osstell ISQ module for Implantmed). However, in challenging anatomical situations, e.g. with minimal bone volume and thin layer of cortical bone or when preparing close to the Schneiderian membrane, rotary preparation allows only limited operator sensitivity. This can lead to tissue damage including bone fenestration, sinus membrane laceration or nerve damage. Moreover, with rotary instruments, it is difficult to correct the initial axis of an implant site.

In contrast, ultrasonic bone preparation with piezo-electric devices has proven especially gentle to hard and soft tissues. One important reason is the specific cutting action, which is due to the high-frequency micro-oscillation of the instruments (1). This allows to prepare with superior tactile feeling and minimal pressure, for maximum control of surgical procedures (2). Micro-oscillation also causes a cavitation effect leading to micro-coagulation (3). Bleeding is thus reduced and visibility enhanced, also during implant site preparation.

Special aspects of piezoelectric preparationUltrasonic implant site preparation has been advocated for situations where delicate bone and soft tissues are endangered, e.g. in context with internal maxillary sinus augmentation (4). Another benefit is a favorable effect on osseointegration following piezoelectric preparation, which results in an earlier transition from primary to secondary implant stability (5, 6). This may be relevant in patients with non-optimal healing characteristics or when immediate or early loading is planned (4, 7).

In addition piezoelectric implant site preparation has proven successful in a wide range of indications. In a multi-center study involving 3,579 implants a high survival rate of almost 98 % was found 1-3 years after insertion (8). There were no complications related to the surgical protocol.


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Multiple implant site preparation in the maxilla – step by stepIn the present patient case piezoelectric preparation was carried out for a total of eight implant sites in an edentulous maxilla. Sinus augmentation was avoided with the aid of short implants, based on CBCT planning and a surgical template was used to transfer the planned positions to the alveolar ridge (Figs. 1 and 2). No smoothening of the bone was necessary prior to implant site preparation.

A flame-shaped, diamond-coated piezoelectric instrument (Piezomed I1) was used to mark the implant positions and for pilot preparation (Fig. 3). Care was taken to use an up and down movement, with reduced power, full irrigation and low pressure (below 300 g). Next a pilot instrument (Piezomed I2A/I2P) was used for the initial 2 mm diameter enlargement of the implant sites (Fig. 3), followed by a 3 mm instrument (Fig. 4). Instruments with a smaller angle (I2A/I3A/I4A) are indicated for anterior, instruments with a wider angle (I2P/I3P/I4P) for posterior sites. Laser marks at a distance of 2 mm allow precise preparation depths.

In case of dense bone the whole instrument sequence including the intermediate instruments Piezomed Z25P and Z35P should be used to widen the osteotomies before the next enlargement step with the I3A/P or I4A/P. The Z25P/Z35P have 2.5 mm and 3.5 mm working part diameters, respectively. They are also indicated for preparation near the sinus membrane in connection with internal augmentation procedures or when there is less than 4 mm of residual bone height. In the present patient the Z25P and Z35P were not used due to the relatively soft posterior bone, which was easily managed with the I3A/I3P instruments. However, to be on the safe side, the Z25P and Z35P should also be used in these situations.

The 10 mm long implant sites at positions 11 and 21 were finalized with a 4 mm diameter rotary drill dedicated for the implant system, in combination with a W&H WS-75 L surgical contra-angle handpiece and the W&H Implantmed implant motor. The reason for this instrument choice was the higher performance of rotary drills in the relatively hard bone (D2) in this area.

In contrast, for optimal primary stability and due to the soft bone the posterior sites for the 4 mm length/4.1 mm diameter implants were only prepared to a final 3 mm diameter using the Piezomed I3P instrument. Six short and two long transgingival implants were finally placed to osseointegrate for three months before impression (Figs. 6-10). The existing denture was retained on the four provisional implants (Fig. 8) as a temporary restoration.

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Special aspects of piezoelectric implant site preparationPiezoelectric preparation has been proven to enhance bone healing (3, 9-11), which results in improved bone formation and a higher bone density near the implant surface (12). As shown in a randomized controlled trial this may lead to an earlier increase of secondary implant stability, as compared to sites prepared with rotary instruments (6).

Another important aspect of piezoelectric preparation is an excellent operator sensitivity during preparation in small bone volumes, e.g. in case of resorbed ridges as in the present patient. Thin cortical bone layers, often found in anterior sites, are easier to detect with piezoelectric systems, leading to a less invasive preparation. The cooling system of the Piezomed, which ensures exit of the coolant near the tip of the instruments, allows effective irrigation of the surgical site. This avoids heat production, in combination with maximum effectivity. Last but not least piezoelectric preparation is free of macro vibration, which makes the procedure more convenient for patients in comparison with rotary systems (13).

For successful implant site preparation the power and irrigation settings should be carefully respected. This is true for both rotary and piezo-electric systems. Moreover, with piezo-electric devices, the pressure during preparation should be limited to a recommended value of less than 300 g (weight of a big chocolate bar). The chosen combined preparation procedure, with rotary finalization of the anterior implant sites in hard bone proved effective, while piezoelectric preparation was optimal for the posterior soft bone with low residual bone height.


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Prof Dr Dr José Luis Calvo Guirado, DDS, PhD/Eu, PhD, MSc > 1989 DDS degree at Universidad Nacional de Córdoba (Argentine) > 1991 PhD degree in Dentistry, Faculty of Health Sciences, Universidad Católica San Antonio de Murcia (UCAM) (Murcia, Spain)

> 2014 European PhD in Bioengineering in Biomaterials, Universidad Miguel Hernández (Elche, Spain)

> Full Professor, Department of Oral Surgery and Implant Dentistry, Faculty of Health Sciences, UCAM (Murcia, Spain)

> Chairman, International Dentistry Research Cathedra, Faculty of Health Sciences, UCAM (Murcia, Spain)

> Director, Murcia Biomaterials & Implants Research Group (MBIRG) > Director, Clinical and Experimental Research Group, Faculty of Health Sciences, UCAM (Murcia, Spain)

> Research Professor, Department of Prosthodontics and Digital Technologies, School of Dental Medicine, State University of New York at Stony Brook (USA)

> Visiting Professor, Faculty of Medicine and Dentistry, University of Belgrade (Serbia) > Visiting Professor, Catholic University de Córdoba (Argentine) > More than 300 scientific articles, 5 text books and 10 text book chapters published on bone regeneration and dental implants

1. Vercellotti T. Essentials in Piezosurgery: Clinical Advantages in Dentistry: Quintessence Publishing, 2009.2. Schlee M, Steigmann M, Bratu E, Garg AK. Piezosurgery: basics and possibilities. Implant dentistry 2006;15:334-340.3. Rahnama M, Czupkallo L, Czajkowski L, Grasza J, Wallner J. The use of piezosurgery as an alternative method of minimally invasive surgery in the authors' experience. Wideochirurgia i inne techniki malo inwazyjne = Videosurgery and other miniinvasive techniques / kwartalnik pod patronatem Sekcji Wideochirurgii TChP oraz Sekcji Chirurgii Bariatrycznej TChP 2013;8:321-326.

Author information

References

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4. Pellegrino G, Taraschi V, Vercellotti T, Ben-Nissan B, Marchetti C. Three-Dimensional Implant Positioning with a Piezosurgery Implant Site Preparation Technique and an Intraoral Surgical Navigation System: Case Report. The International journal of oral & maxillofacial implants 2017;32:e163-e165.5. da Silva Neto UT, Joly JC, Gehrke SA. Clinical analysis of the stability of dental implants after preparation of the site by conventional drilling or piezosurgery. The British journal of oral & maxillofacial surgery 2014;52:149-153.6. Stacchi C, Vercellotti T, Torelli L, Furlan F, Di Lenarda R. Changes in implant stability using different site preparation techniques: twist drills versus piezosurgery. A single-blinded, randomized, controlled clinical trial. Clinical implant dentistry and related research 2013;15:188-197.7. Scarano A. Traditional Postextractive Implant Site Preparation Compared with Pre-extractive Interradicular Implant Bed Preparation in the Mandibular Molar Region, Using an Ultrasonic Device: A Randomized Pilot Study. The International journal of oral & maxillofacial implants 2017;32:655-660.8. Vercellotti T, Stacchi C, Russo C, Rebaudi A, Vincenzi G, Pratella U, et al. Ultrasonic implant site preparation using piezosurgery: a multicenter case series study analyzing 3,579 implants with a 1- to 3-year follow-up. The International journal of periodontics & restorative dentistry 2014;34:11-18.9. Chiriac G, Herten M, Schwarz F, Rothamel D, Becker J. Autogenous bone chips: influence of a new piezoelectric device (Piezosurgery) on chip morphology, cell viability and differentiation. J Clin Periodontol 2005;32:994-999.10. Preti G, Martinasso G, Peirone B, Navone R, Manzella C, Muzio G, et al. Cytokines and growth factors involved in the osseointegration of oral titanium implants positioned using piezoelectric bone surgery versus a drill technique: a pilot study in minipigs. J Periodontol 2007;78:716-722.11. von See C, Rucker M, Kampmann A, Kokemuller H, Bormann KH, Gellrich NC. Comparison of different harvesting methods from the flat and long bones of rats. The British journal of oral & maxillofacial surgery 2010;48:607-612.12. Di Alberti L, Donnini F, Di Alberti C, Camerino M. A comparative study of bone densitometry during osseointegration: piezoelectric surgery versus rotary protocols. Quintessence Int 2010;41:639-644.13. Sohn DS, Ahn MR, Lee WH, Yeo DS, Lim SY. Piezoelectric osteotomy for intraoral harvesting of bone blocks. The International journal of periodontics & restorative dentistry 2007;27:127-131.

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Sinus floor augmentation with transalveolar access reduces postoperative discomfort compared to lateral fenestration. The use of piezosurgical systems offers additional technical and biological advantages. They eliminate unpleasant hammering with osteotomes and enable particularly atraumatic detachment of the Schneiderian membrane. In this case study, a newly introduced set of instruments is used for piezosurgical preparation of the implant bed and hydrodynamic lifting of the membrane.

CHAPTER 7APIEZOSURGICAL IMPLANT BED PREPARATION, INTERNAL SINUS LIFT AND IMPLANTATION, BY MARIO KIRSTE, DMD, MSC


Aim of Treatment

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Clinical findings before the procedure: the alveolar ridge has healed very well, including sufficiently wide, keratinised buccal gingiva. Due to the preceding history of inflammation, closed implant healing was planned. The intention was to mobilise the mucoperiosteal flap slightly palatally and buccally with a crestal incision (cf. Fig. 3 and 4).

The implant position was marked with the flame-shaped piezosurgical instrument I1 and the direction of the implant bed was established (power 100, coolant 80%). The implant bed was then widened using the I2A instrument (100/100%). The same instrument was used for small-scale removal of the cortical floor of the maxillary sinus. This was followed by initial detachment of the Schneiderian membrane with the Z25P instrument (reduce coolant to 50%). The depth markings enabled good orientation at all times.

The DVT showed adequate dimensions in each of the axial (left), lateral (top) and transverse views (right). The width of the alveolar process was relatively comfortable in the region of 16 and permitted the introduction of a 4.8 mm diameter implant. The mucosa of the maxillary sinus was still slightly thickened but to an acceptable degree.

The interim check shows the situation after initial preparation of the implant bed and detachment of the membrane, with approximately the following dimensions: diameter of the implant bed 2 mm, residual bone height above the maxillary sinus floor approx. 4 mm palatally and buccally, centrally at the subsequent implant position approx. 3 mm. The Schneiderian membrane is stretched 1.5-2 mm above the bony access.

Clinical case

A 49-year-old female patient, a non-smoker and with nothing remarkable in her general medical history, was referred to our oral surgery practice for surgical extraction of tooth 16 and subsequent implantation. The tooth had previously been treated endodontically several times without success. After the extraction, the patient experienced mild sinusitis trouble with the result that we initially waited six months before carrying out the planned measures.

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Schematic representation of the final membrane elevation with the Z35P instrument: the coolant supply around the instrument is indicated and also the cavity created under the membrane which is generally 1.2 to 3.5 cm3.

o Situation after insertion of the implant (length: 10 mm, prosthetic platform: 6.5 mm) immediately before suturing. The thread of the cover screw was coated with a small amount of 0.2% chlorhexidine gel for easier unscrewing later.

A special augmentative mixture is carefully placed apically into the area of the internal maxillary sinus ostium.

a A good six months later, after the definitive crown had been delivered, the X-ray check shows a largely homogeneous peri-implant hard tissue structure. The implant site had been opened with a soft tissue punch for impression taking and further prosthetic steps.

In the next step, the implant bed was widened to 3.0 mm with the I3A instrument (power 100, coolant 80%). The instrument removes the bone very effectively with axial up and down movements and without the application of pressure and levers. This is ensured via the crown gearing (sharp pilot hole cutting) and the ultrasonic piezo cavitation effect in conjunction with an oblique lateral coolant outlet. Here too, the depth marks reliably prevent the preparation from going too deep.

Then the Z35P instrument (diameter: 3.5 mm, diamond-coated front face) was inserted intermittently into the shaft of the implant bed in three to five applications and in each case activated with the settings 100/50%. This lifted the fibrous membrane to its final position. If an implant with a diameter of 3.8, 4.0 or 4.1 mm is planned, this is also the final piezosurgical preparation step.

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Comparison of lateral and transalveolar methods Where teeth are lost in the left posterior maxilla, a low residual bone height often requires augmentation of the maxillary sinus (sinus lift). To avoid this, where there is still adequate bone available, short implants which are only 6 mm long may also be successful (1, 2). However, current publications gave a less favourable prognosis for these implants than for longer ones after up to 5 years (3, 4).

With regard to the implant prognosis, transalveolar (internal) access and that via a lateral window show comparable results (5, 6). The augmentation volume achievable with the internal methods is largely determined by the anatomy of the maxillary sinus; long, narrow maxillary sinuses apparently being more favourable that those with flat floors (7, 8). DVT-based planning can contribute to the success (9).

According to a randomized study, the level of postoperative discomfort to be expected with the transalveolar procedure is less than with the lateral procedure (10). Due to their method of operation, piezosurgical systems offer additional advantages compared to rotary and manual instruments, for example, particularly atraumatic opening of the maxillary sinus with a suitable operating technique (11). A residual bone height of approximately 4 mm is required for this method laterally across the maxillary sinus floor, i.e. at the subsequent implant circumference, for an adequate cavitation effect (cf. Fig. 2, transverse view).

In the conventional transalveolar procedure using manual instruments, the procedure itself is considered to be more stressful than the lateral procedure (12), but this is most likely due to the hammering function of the osteotomes. With a suitable piezosurgical technique, access is very atraumatic and the Schneiderian membrane can be lifted hydrodynamically with the help of the cavitation effect (13). According to the author’s own research, the pressure necessary for this is 2.4 to 2.7 bar (14).

Transalveolar sinus lift with piezo surgery – step by stepThis principle is also used in the patient example described here. In addition to the clinical situation (Fig. 1), we use 3D planning to clarify the remaining pathology of the sinus epithelium and the available bone volume. This information is essential in order to assess whether an open or closed healing mode makes sense.


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The residual bone height of 3-4 mm at the planned implant position 16 means that the initial situation is not ideal (Fig. 2). We therefore planned a closed, single-stage approach. If doubts about the primary stability of the implant arise during the operation (measurement with Osstell), it is possible to switch to a two-stage approach at any time – i.e. first augmentation and then implantation.

Due to the previous inflammatory sinus problems, the patient was given 1.5 Mega IU penicillin one hour pre-operatively. After gentle preparation of the mucoperiosteal flap, the implant position was marked and initial preparation was carried out with the flame-shaped instrument I1. The metric marking enabled us to gauge the preparation depth at all times. At the same time, we did not allow the instrument I1 to penetrate to the depth determined pre-operatively: preparation was stopped when the first resistance was felt.

Instruments take over the workPiezosurgical instruments are used in a pressure-free up and down movement. The technique should be practised on a pig’s jaw before using it clinically. Lever or rotary movements should be avoided since this could break the instruments. Incorrect use can also result in the removal of too much bone in an inappropriate manner. The piezoelectric vibration alone produces the desired and very efficient cavitation. The illumination of the Piezomed instruments via the LED ring in the handpiece is unique in this form and provides the surgeon with a significantly improved view during the procedure.

The dental assistant has to aspirate well during use due to the considerable amount of spray. The instruments penetrate the bone very efficiently, even during shape-related expansion of the implant bed. We used the I2A instrument (diameter 2.0 mm) to perforate the sinus floor intermittently and on the smallest scale possible. This special way of working with the instruments ensures that the Schneiderian membrane is not damaged.

The next instrument is the cylindrical, diamond-coated front face Z25P (diameter 2.5 mm). The membrane is already lifted slightly with this due to the coolant supplied via the tip (Fig. 3). Again, intermittent use is important here, as is reducing the amount of coolant fluid to 50% otherwise the implant bed could be subject to too much pressure. Collagen fibres make up more than 70% of the Schneiderian membrane. Therefore, after detachment it cannot resume its initial position on the floor of the maxillary sinus and remains stretched a few millimetres above the intervention area.

95

Implant bed preparation and augmentationWe now checked the result of the first preparation sequence (Fig. 4). Another preparation step for the implant bed followed, this time with the I3A instrument (diameter 3.0 mm, Fig. 5). After this, in a similar manner to the Z25P, the hydraulic Z35P instrument (diameter 3.5 mm) completed the desired elevation of the Schneiderian membrane (Figs. 6 and 7).There must be no nose-blowing test. Instead, a Luer Lock syringe can be used to inject saline solution into the implant canal. If the fluid runs back intraorally, everything is fine. If it runs into the nasal cavity, treatment must be stopped or the damage that has occurred must be repaired with tissue fibrin glue and a lateral access created.

In our example, this was followed by further piezosurgical preparation of the implant bed using the I4A instrument (diameter 4.0 mm) and then finally with a rotary bur and shoulder milling cutter up to the implant diameter of 4.8 mm. Before inserting the implant, a mixture of synthetic biphasic bone substitute material (maxresorb®), platelet concentrate obtained from the patient’s own blood (L-PRF, both products: botiss biomaterials) and limited amounts of autogenous bone was prepared. This was applied under the membrane in the apical implant canal (Fig. 8).

The volume of the implant inserted subsequently must be taken into account when introducing the amount of augmentation material. The particle size of the bone substitute material is 0.8-1.6 mm. Smaller particles are difficult to apply, larger particles fuse too quickly and make application through the drilled shaft difficult. It is also important to distribute the mixture carefully laterally, mesially and distally.

Implantation and prosthetic restorationTo displace the augmentation material atraumatically, the implant was inserted very slowly by hand. In the process, we pushed the Schneiderian membrane in the cranial direction once again. The chosen implant version with a strong flare has the advantage that the implant cannot be screwed into the maxillary sinus.After introducing the cover screw (Fig. 9), we closed the surgical site with a continuous 3/0 PTFE suture (Coreflon). Due to the relatively large augmentation volume, the patient was administered 1.5 Mega IU penicillin and a gastric supplement (Symbiolact®, Symbiopharm) for five days postoperatively. She had no postoperative symptoms and could go back to work normally the next day. From the third postoperative day, she used nasal vapour baths and decongestant nose drops as a preventive measure.

96

Internal sinus floor augmentations are traditionally performed with manual instruments that have a hammering movement in combination with rotary implant bed preparation. In the author’s experience, modern piezosurgical systems make this procedure considerably less traumatic, the cavitation effect permits practically pressure-free use. On the one hand, the instruments are used for preparation of the implant bed and on the other hand for minimally invasive opening of the maxillary sinus floor and hydrodynamic elevation of the Schneiderian membrane (13).

In the example, this sequence ran smoothly although in the author’s practice the membrane is routinely elevated in two phases. Alternatively, the method specified by the manufacturer is suitable. In this case, the implant bed is first prepared and only then is the sinus floor opened on a small scale with the Z35P instrument. The result of the very atraumatic method is that the patient had no postoperative pain and was able go to work again the next day. In the author’s practice, this is true for 90% of patients. In the case study, the minimally invasive flap technique with relieving incision also contributed to this.

Adhere to settingsThe most time-consuming steps during the procedure were the provision and insertion of the augmentation material underneath the membrane. In contrast, with the system used it was possible to save time when carrying out preparation of the implant bed and hydrodynamic internal augmentation of the sinus floor. Due to very effective operation of the new instruments in conjunction with the Piezomed, a gentle, correct way of working is crucial for avoiding the removal of too much bone.


After two months, the surgical site was healed without irritation, the maxillary sinuses are asymptomatic. Six months after augmentation and before opening the implant site, the X-ray check showed a significant increase in opacity compared to the postoperative image as an indication of progressive ossification (Fig. 10). Sufficient soft tissue was punched for exposure in the referral clinic, the healing caps then remained in situ for another four weeks until the impression was taken. The prosthetic restoration was finally carried out with a metal-ceramic crown (Fig. 10).

97

In particular, incorrectly set values for power and coolant supply can lead to overheating of the instruments and therefore to overheating in the preparation site. Therefore, the manufacturer’s recommended settings should always be taken into account. This is very easy, as the device automatically recognises the instrument used in each case.

ConclusionThe new instruments for preparation of the implant bed and internal sinus lift have proven themselves very well. Careful diagnosis, planning and execution of the procedure are very likely to lead to successful augmentation and implant-based restoration.

Mario Kirste, DMD, MSc Implantology, specialist for periodontology > 1989 State examinations at the Humboldt University Berlin > 1989–1991 Assistant dentist at the Maxillofacial Surgery Hospital in Frankfurt (Oder) > 1991 Practice in Frankfurt (Oder), entry to dental implantology > 1992/93 Further training in periodontology with Prof Dr Wolfgang Krüger, University of Göttingen

> 1996 PhD on the topic “Assessment of treatment strategies for spontaneous intracerebral haematomas”, Humboldt University Berlin

> From 1997 Head of implantology courses for the Straumann company > 2004 Focus of activity on implantology (DGI) > 2007 Masters thesis to obtain an MSc Implantology at the Danube University Krems, Austria

> A large number of collaborations with science and the dental industry, including on the topics of hydrodynamic sinus lift using the balloon lift control technique [balloon-assisted sinus floor elevation], piezo surgery (Piezomed, for W&H) and sinus lift using mesenchymal stem cells

> Since 2015, independent delivery of implantology supervision and coaching programmes for dentists in Germany, Poland and Russia

Author information

98

1. Zadeh HH, Gulje F, Palmer PJ, Abrahamsson I, Chen S, Mahallati R, et al. Marginal bone level and survival of short and standard-length implants after 3 years: An Open Multi-Center Randomized Controlled Clinical Trial. Clinical oral implants research 2018.2. Thoma DS, Zeltner M, Husler J, Hammerle CH, Jung RE. EAO Supplement Working Group 4 - EAO CC 2015 Short implants versus sinus lifting with longer implants to restore the posterior maxilla: a systematic review. Clinical oral implants research 2015.3. Lemos CA, Ferro-Alves ML, Okamoto R, Mendonca MR, Pellizzer EP. Short dental implants versus standard dental implants placed in the posterior jaws: A systematic review and meta-analysis. J Dent 2016;47:8-17.4. Naenni N, Sahrmann P, Schmidlin PR, Attin T, Wiedemeier DB, Sapata V, et al. Five-Year Survival of Short Single-Tooth Implants (6 mm): A Randomized Controlled Clinical Trial. Journal of dental research 2018;97:887-892.5. Starch-Jensen T, Aludden H, Hallman M, Dahlin C, Christensen AE, Mordenfeld A. A systematic review and meta-analysis of long-term studies (five or more years) assessing maxillary sinus floor augmentation. International journal of oral and maxillofacial surgery 2018;47:103-116.6. Antonoglou GN, Stavropoulos A, Samara MD, Ioannidis A, Benic GI, Papageorgiou SN, et al. Clinical Performance of Dental Implants Following Sinus Floor Augmentation: A Systematic Review and Meta-Analysis of Clinical Trials with at Least 3 Years of Follow-up. The International journal of oral & maxillofacial implants 2018;33:e45-e65.7. Calin C, Petre A, Drafta S. Osteotome-mediated sinus floor elevation: a systematic review and meta-analysis. The International journal of oral & maxillofacial implants 2014;29:558-576.8. Stacchi C, Lombardi T, Ottonelli R, Berton F, Perinetti G, Traini T. New bone formation after transcrestal sinus floor elevation was influenced by sinus cavity dimensions: A prospective histologic and histomorphometric study. Clinical oral implants research 2018;29:465-479.9. Fornell J, Johansson LA, Bolin A, Isaksson S, Sennerby L. Flapless, CBCT-guided osteotome sinus floor elevation with simultaneous implant installation. I: radiographic examination and surgical technique. A prospective 1-year follow-up. Clinical oral implants research 2012;23:28-34.10. Farina R, Franceschetti G, Travaglini D, Consolo U, Minenna L, Schincaglia GP, et al. Morbidity following transcrestal and lateral sinus floor elevation: a randomized trial. J Clin Periodontol 2018.

Literatur References

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11. Rickert D, Vissink A, Slater JJ, Meijer HJ, Raghoebar GM. Comparison between conventional and piezoelectric surgical tools for maxillary sinus floor elevation. A randomized controlled clinical trial. Clinical implant dentistry and related research 2013;15:297-302.12. Al-Dajani M. Recent Trends in Sinus Lift Surgery and Their Clinical Implications. Clinical implant dentistry and related research 2014.13. Kuhl S, Kirmeier R, Platzer S, Bianco N, Jakse N, Payer M. Transcrestal maxillary sinus augmentation: Summers' versus a piezoelectric technique--an experimental cadaver study. Clinical oral implants research 2016;27:126-129.14. Kirste M. Das Ballon-Lift-Control-System (BLC) und die Elevation der Sinusbodenschleimhaut: Überlegungen, vorklinische und klinische Studien. Masterthese zur Erlangung des „Master of Science Implantologie“ (MSC). 2007.

100

34.4 mm

8 mm4.4 mm

B1

UseCutting bone, bone block harvesting, preparation for bone spreading

Special features Fine toothing

Work recommendation

The best, quickest results are achieved with slow forward and back movements with little exerted pressure

Signs of wear and tearTeeth worn down, tooth broken off, loss of power during treatment

Further details can be found in

Chapter 1

100

0.5

mm

100 100%Leistung_grün

Flüssigkeit_grün

© Dr Strbac

101

34.2 mm

3.8 mm4.3 mm

0.4

mm

B2L

B2R

UseCutting bone, horizontal incisions for bone block harvesting

Special features Angled, fine toothing

Work recommendation

The best, quickest results are achieved with slow forward and back movements with little exerted pressure

Signs of wear and tearTeeth worn down, tooth broken off, loss of power during treatment


Chapter 1


Flüssigkeit_grün

3.8 mm

© Dr Neugebauer

102

UseCollecting bone, scraping bone, modelling bone, removing inflamed tissue (cysts)

Special features Sharp, rounded working edge

Work recommendation

Reduce the coolant flow to 10-20% so as to prevent bone chips being rinsed away

Signs of wear and tearBlunt working edge, not possible to pick up bone chips, loss of power during treatment


Chapter 1


Flüssigkeit_grün

35 mm

B3

4 m

m

© Dr Neugebauer

103

0.6

mm

B4

UseSplitting the alveolar ridge, corticotomy

Special features Sharp cutting edge

Work recommendation

Maintain in constant motion to ensure sufficient cooling in the area of the split

Signs of wear and tear Blunt working edge, loss of power during treatment


Chapter 1

35.4 mm

2.8 mm


Flüssigkeit_grün

© Dr Gabric

104

UseCollecting bone, scraping bone, modelling bone, preparation for bone splitting

Special features Sharp, square working edge

Work recommendation

Low pressure, low power settings and reduced coolant flows allow efficient working

Signs of wear and tearBlunt working edge, not possible to pick up bone chips, loss of power during treatment


Chapter 1


Flüssigkeit_grün

32.1 mm

B5

3.2

mm

© Dr Neugebauer

105

UseFine saw incisions, bone block harvesting, separation of teeth, apical resection, bone splitting

Special featuresExtremely fine toothing, cuts enamel, very thin saw blades 0.25 mm

Work recommendation

Slow forward and back movements with little pressure exerted, direct insertion in the bone with minimal movement when preparing the bone cover for the apical resection

Signs of wear and tear Visible wear of saw teeth, loss of power during treatment


Chapter 1


Flüssigkeit_grün0.

25 m

m

B6

41.7 mm

4.3 mm

8 mm

© Dr Testori

106

UseFine saw incisions, bone block harvesting, separation of teeth, apical resection, bone splitting

Special featuresExtremely fine toothing, cuts enamel, very thin saw blade 0.30 mm

Work recommendation

Slow forward and back movements with little pressure exerted, direct insertion in the bone with minimal movement when preparing the bone cover for the apical resection

Signs of wear and tear Visible wear of saw teeth, loss of power during treatment


Chapter 1


Flüssigkeit_grün0.

3 m

m

B7

106

41.4 mm

10 mm

4.3 mm

© Dr Neugebauer

0.6

mm

107

UsePreparation of bone, preparation of window for direct sinus lift, crown margin extension

Special features 90 µm grain, rectangular surface

Work recommendation

The best, quickest results are achieved with slow movements with little exerted pressure

Signs of wear and tear Grain worn down, loss of power during treatment


Chapter 2


Flüssigkeit_grün

S1

35.4 mm

4 mm

© Dr Urbán

0.6

mm

108

UseWindow preparation for lateral sinus lift, crown margin extension

Special features 60 µm grain, sphere

Work recommendation

Forward and back movements always in axial direction of handpiece (like saws)



Chapter 2


Flüssigkeit_grün

1.7

mm

S2

108

36.2 mm

© Dr Urbán

109

UseAtraumatic detachment of mucous membrane of sinus, elevation of Schneiderian membrane

Special featuresCoolant fluid forms a protective film between the instrument and mucous membrane of sinus

Work recommendation

Slow movements without pressure along the junction between the bone and soft tissue

Signs of wear and tearNo wearing of materials, but material fatigue possible – evidenced by loss of power during treatment


Chapter 2


Flüssigkeit_grün

S3

35.9 mm

4.9 mm

© Dr Testori

110

Use Atraumatic elevation of Schneiderian membrane

Special features Blunt working edge, 90° angle

Work recommendation

The interior side of the working part should remain in contact with the bone at all times



Chapter 2

4 m

m

S4

110

30.3 mm

8 mm


Flüssigkeit_grün

© Dr Urbán

111

Use Atraumatic elevation of Schneiderian membrane

Special features Blunt working edge, 135° angle

Work recommendation

The interior side of the working part should remain in contact with the bone at all times



Chapter 2

4 m

m

S5

34.8 mm

10 mm


Flüssigkeit_grün

© Dr Urbán

112

37.4 mm

3.5 mmR1D

Use Retrograde root canal preparation

Special features Diamond-coated, 60 µm grain

Work recommendation

Prepare the root canal from retrograde without pressure and with continuous up-and-down movement



Chapter 3

112

0.5

mm


Flüssigkeit_grün

© Dr Gabrić

113

36.9 mm

0.5

mm

3.5 mm

R2LD

R2RD


Special features Diamond-coated, 60 µm grain, angled slightly left/right

Work recommendation




Chapter 3


Flüssigkeit_grün

© Dr Neugebauer

114

31.7 mm

0.5

mm

6 mm

R3D


Special features Diamond-coated, 60 µm grain, angled sharply

Work recommendation




Chapter 3

114


Flüssigkeit_grün

© Dr Neugebauer

0,5

mm

115

33.1 mm

3.5 mm

R4LD

R4RD


Special features Diamond-coated, 60 µm grain, angled slightly left/right

Work recommendation




Chapter 3


Flüssigkeit_grün

0.4

mm

© Dr Hirsch

116

UseRemoval of subgingival deposits, especially suitable for deep periodontal pockets

Special features Fine, long, non-cutting tip

Work recommendationRun along the tooth in constant movement without pressure

Signs of wear and tear Working part worn (shorter), loss of power during treatment


Chapter 5

116

34.8 mm

P1

0.6

mm

12 mm


Flüssigkeit_grün

© W&H

117

UsePeriodontal debridement, supportive treatment on medium-depth to deep pockets as well as furcations

Special features Diamond-coated, 60 µm grain, left/right angled

Work recommendationRun along the tooth in constant movement without pressure

Signs of wear and tear Working part worn (shorter), loss of power during treatment


Chapter 5

41.9 mm

P2LD8.1 mm

0.7

mm

P2RD


Flüssigkeit_grün

© Dr Hosoya

118

UseDetachment of the periodontium, allows tooth extraction with preservation of hard tissue

Special features Cutting instrument, buccal and lingual/palatal application

Work recommendation

Maintain in constant motion to ensure sufficient cooling in the gingival sulcus

Signs of wear and tearInstrument is difficult to move in the gingival sulcus, rounded edges


Chapter 4


Flüssigkeit_grün

118

33.4 mm

9 mm

EX1

0.5

mm

© Dr Vargas

119

UseDetachment of the periodontium, allows tooth extraction with preservation of hard tissue

Special features Cutting instrument, distal and mesial application

Work recommendation

Maintain in constant motion to ensure sufficient cooling in the gingival sulcus

Signs of wear and tearInstrument is difficult to move in the gingival sulcus, rounded edges


Chapter 4


Flüssigkeit_grün

32.8 mm

9 mm

EX2

© Dr Vargas

1.4

mm

120

34.6 mm

I1

0.5

mm

4 mm2 mm

© Dr Guirado

Use Initial pilot preparation with correct axial alignment

Special features Diamond-coated, 60 µm grain, depth mark, 60° angle

Work recommendation

Insert to the required depth in an up-and-down motion with little exerted pressure



Chapter 6

75 100 %

Flüssigkeit_grün

Leistung_grün

121

2 mm2 mm

38 mm

I2A

2 m

m

I2P

© Dr Guirado

Use Gradual preparation of the implant site

Special featuresCrown cutter-like working part with depth mark, anterior 20° angle, posterior 50° angle

Work recommendation

The best, quickest results are achieved with gentle left-and-right rotary movements with little exerted pressure

Signs of wear and tear Working part gets stuck, loss of power during treatment


Chapter 6

100 100 %

Flüssigkeit_grün

Leistung_grün

41.1 mm

122

2 mmI3A

I3P

© Dr Guirado



Work recommendation




Chapter 7

100 100 %

Flüssigkeit_grün

Leistung_grün

41.3 mm

38.6 mm

3 m

m

2 mm

123

I4A

I4P

© Dr Kirste



Work recommendation




Chapter 7

100 100 %

Flüssigkeit_grün

Leistung_grün

41.5 mm

2 mm4 mm

38.8 mm

4 m

m

124

40.6 mm

Z25P

2.5

mm

© Dr Kirste

UseAccess expansion, preparation of the entry opening for elevation of the Schneiderian membrane using cooling medium

Special featuresDiamond-coated, 90 µm grain, depth mark, central coolant duct, 50° angle

Work recommendation




Chapter 7

100 50 %

Flüssigkeit_grün

Leistung_grün

2 mm

1.1 mm

4 mm

125

40.6 mm

3.5

mm

Z35P

© Dr Kirste

UseAccess expansion, preparation of the entry opening for elevation of the Schneiderian membrane using cooling medium

Special featuresDiamond-coated, 90 µm grain, depth mark, central coolant duct, 50° angle

Work recommendation




Chapter 7

100 50 %

Flüssigkeit_grün

Leistung_grün

2 mm

1.6 mm

4 mm

126

HYGIENE AND MAINTENANCE

OUTLINE MANUAL REPROCESSING: HANDPIECE AND CABLE

Manual disinfection

RinsingFunctio

n test

Packing

Drying

Asse

mbl

y

Manual cleaning

Dismantling

Sterilization

Use

Pre-

disi

nfec

tion

at th

e pl

ace

of u

se

> Lisa > Class B as per

EN 13060

> Air gun > Dry all parts with air > Blow through coolant tube

> Seal2 **

> Complete Piezomed system

> Disinfectant wipes > VAD/DGHM-listed > Run rinsing function on device

> Unscrew the handpiece cap > Remove LED socket

> Handpiece without socket and cap

> LED socket > Handpiece cap > Motor holder

> Disinfectant wipes > VAD/DGHM-listed*

> Temperature <38°C > Demineralized water

> Assemble the handpiece > Connect LED socket to handpiece > Screw handpiece cap on

* Follow your local and national laws, directives, standards and guidelines for cleaning, disinfection and sterilization.** Seal2: The foil sealer creates a 12-mm wide seal in just two seconds.

127

OUTLINE AUTOMATIC REPROCESSING: HANDPIECE AND CABLE

Drying

Funct

ion te

st

Packing

Assembly

Preparation in washer/disinfector

Dismantling

Sterilization

Use

Pre-

disi

nfec

tion

at th

e pl

ace

of u

se


EN 13060

> Seal2


> Disinfectant wipes > VAD/DGHM-listed > Run rinsing function on device

> Unscrew the handpiece cap > Remove LED socket

> Reprocess in instrument tray

> Connect coolant tube up to washer/disinfector adaptor set

> LED socket > Handpiece cap > Motor holder

> Air gun > Dry all parts with air > Blow through coolant tube

> Assemble the handpiece: > Connect LED socket to handpiece > Screw handpiece cap on

128

OUTLINE MANUAL REPROCESSING: INSTRUMENT

Rinsing

Visual in

spec

tion

Packing

Drying

Manual cleaning and

disinfection in ultra

sonic bath

Sterilization

Use

Pre-

disi

nfec

tion

at th

e pl

ace

of u

se


EN 13060

> Seal2

> Eye > Magnifying glass


> Disinfectant wipes > VAD/DGHM-listed

> Instrument holders with Piezomed instruments

> Tip changer > Ultrasonic bath with

VAH-listed agent

> Air gun > Blow all parts dry

inside and outside

> Temperature <38°C > Demineralized water

HYGIENE AND MAINTENANCE

129

Drying

Packing

Preparation in washer/disinfector

Sterilization

Use

Pre-

disi

nfec

tion

at th

e pl

ace

of u

se


EN 13060

> Seal2


> Disinfectant wipes > VAD/DGHM-listed

> Use W&H washer/disinfector adaptor set

> Instrument holders > Tip changer

> Air gun > Blow all parts dry inside

and outside

OUTLINE AUTOMATIC REPROCESSING: INSTRUMENT

Visual in

spec

tion

> Eye > Magnifying glass

130

NOTES

20463 AEN Rev. 001 / 11.02.2019Subject to alterations

W&H Dentalwerk Bürmoos GmbH Ignaz-Glaser-Straße 53, Postfach 1 5111 Bürmoos, Austria t + 43 6274 6236-0 f + 43 6274 6236-55 [email protected] wh.com

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