- Email: [email protected]
Is the piezoelectric device the new standard for facial osteotomies?
Accepted Manuscript Title: Is the piezoelectric device the new standard for facial osteotomies? Author: Javier Gonz´alez Lagunas PII: DOI: Reference:
S2468-7855(17)30108-8 http://dx.doi.org/doi:10.1016/j.jormas.2017.06.009 JORMAS 63
To appear in: Received date: Revised date: Accepted date:
1-5-2017 11-6-2017 19-6-2017
Please cite this article as: Javier Gonz´alez Lagunas Is the piezoelectric device the new standard for facial osteotomies? (2017), http://dx.doi.org/10.1016/j.jormas.2017.06.009 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Is the piezoelectric device the new standard for facial osteotomies? Javier González Lagunas Department of Oral and Maxillofacial Surgery Hospital Quironsalud, Barcelona Plaza Alfonso Comín 5-7 08023 Barcelona, España
Ac ce pt e
d
M
an
us
cr
ip t
[email protected]
Page 1 of 11
Abstract Piezoelectric devices are commonly used in all areas of maxillofacial surgery. Initially applied in preprosthetic surgery, they have steadily become a common practice in major surgery of the facial skeleton, including maxillary and mandibular osteotomies, temporomandibular joint surgery, orbital surgery, craniofacial procedures and rhinoplasty. We will review the current medical literature and establish the "state of the
ip t
art" of piezosurgery in orthognathic surgery, TMJ surgery and rhinoplasty.
cr
Key words. piezosurgery, orthognathic surgery, temporomandibular joint disorders,
Ac ce pt e
d
M
an
us
rhinoplasty
Page 2 of 11
Oxford Dictionary defines Standard as "Something used as a measure, norm, or model in comparative evaluations". Other sources define it as "...something considered by an authority or by general consent as a basis of comparison; an approved model"
In this paper we will analyze some of the most frequent indications for piezoelectric devices in craniomaxillofacial surgery, specifically jaws osteotomies (orthognathic
ip t
surgery), TMJ surgery and rhinoplasty and decide if this particular technique could be
cr
considered as a new standard for these procedures
us
Introduction
The term ultrasound defines mechanical vibrations in frequencies above the human
an
upper audible limit, superior to 20Khz. Ultrasounds have a long history of applications in medicine. Apart from their role for diagnosis, they also play an important role in some therapeutic procedures. In 1950 they were firstly used to treat neuropathic and
M
muscular pains and also to improve bone healing. In dentistry, they were used in the
d
same decade to prepare cavities and to perform tartrectomies.
Ac ce pt e
Piezosurgery si superior to scapels because of its ability to cut when it micro-vibrates with an ultrasound frequency, and cut the bone, but do not affect the underlying soft tissues. It was developed in its surgical field by Dr Tomaso Vercelloti in Genova [1]. In fact the term Piezosurgery (R) is a trademark of an Italian company (Mectron, Italy®).
The soft tissues that contact the vibratory material are not injured, making the piezoelectric device as the ideal instrument to be used in the bordering territory between the soft tissues and the bone [2], thus reducing the risk of traumatizing the surrounding soft tissues. In this chapter we present the different applications of the piezoelectric devices in several extraoral osteotomies in the craniofacial region.
a. Basic sciences The piezoelectric scalpel takes advantage of the cutting ability of an instrument that micro-vibrates with the frequency of ultrasound. The piezoelectric effect was described by the Curies in 1880: certain crystals and ceramics acquire an electric polarization in
Page 3 of 11
response to mechanical stress. On the contrary, when these materials are subjected to an electric current, they deform: this is known as the inverse piezoelectric effect. In this type of surgery an ultrasonic transducer that includes a piezoelectric material is used. When passing an electric charge this material undergoes a mechanical change, so that it contracts and expands alternately. In addition it is added an intermediate frequency that causes the material to produce oscillations of average frequency and
ip t
finally ultrasonic waves. The generated vibrations are amplified and transferred to an insert that can induce the disorganization and fragmentation of different materials [2],
cr
due to the phenomenon of agitation.
These vibrations are expanded and transferred to a terminal, which exerts a mechanical
us
cutting effect on the mineralized tissue. The surgeon can adjust the vibration frequency, cutting capacity and irrigation flow rate. The frequency ranges from 25 to 30 kHz and
an
produces micro-vibrations of 60-210 microns in amplitude with a power at the tip of the terminal of about 5W. The system also includes an irrigation cannula that connects to the handpiece and whose volume is regulated by the surgeon. The intensity of the liquid
M
that cools the surgical bed can be adjusted between 0ml / min to 70ml / min. The soft tissues surrounding the insert are not damaged, thus reducing the risk of soft
Ac ce pt e
d
tissue injury.
b. Biological response of the tissues
From the outset, the piezoelectric scalpel demonstrated faster bone regeneration and healing, compared to results obtained with carbide or diamond drills [3]. Oxygen molecules released during cutting have an antiseptic effect and ultrasonic vibration stimulates cellular metabolism. Precision in the osteotomy allows the preservation of normal bone architecture, a factor that could contribute to accelerate bone regeneration. Some studies have also shown that bone extracted from osteotomies performed with a piezo device contained more vital bone and more osteocytes than bone obtained with usual methods.
Clinical applications
a. Osteotomies of the maxillary bones
Page 4 of 11
There have been many changes in orthognathic surgery in recent years, and one of the most relevant one is the use of less invasive cutting systems (instead of usual saws). Since its development, the piezoelectric scalpel has been used in the different types of orthognathic surgery for its precision and safety: Lefort 1 osteotomy, sagittal branch osteotomy (BSSO) (Fig.1), or mentoplasty [4]. The comparison with usual surgical saw
ip t
is in favor for the piezoelectric scalpel because it genders less bleeding, less postoperative swelling and less nervous morbidity [5-6]. A better control in osteotomies
cr
and a lower risk of bad splits has also been described [7].
us
In mandibular orthognathic surgery, the piezoelectric device has been used both in sagittal split osteotomy and intraoral vertical osteotomy. One of the main strengths of
an
this technique is the recovery of the sensitivity in the territory of the inferior dental nerve after surgery. Some reports showed an early recovery of the inferior alveolar nerve in less than 2 months. In a recent study, there was also a lower somatosensory
M
impairment in both thermal detection and in the detection of vibration, as well as a faster recovery of these functions [8]. Its efficiency on genioplasty has been also shown
Ac ce pt e
injuries.
d
[9-10], with less damage to the suprahyoid pedicle and comparable results in nerve
Cadaver studies in the upper jaw demonstrated the safety of the procedure in terms of mucosal and vessel integrity [4]. The low vibration of the instrument even allows that some type of osteotomies (Surgically Assisted Rapid Palatine Extension, or SARPE) were performed under local anesthesia, with good acceptance by the patient [11-12]. In Lefort 1 osteotomy, two important technical aspects improved by this technique are (a) the possibility of performing the pterygomaxillary osteotomy with minimal vascular risk, and (b) favoring the deinsertion of the nasal mucosa. In cases of segmental Lefort 1 osteotomies [13], vertical osteotomies are facilitated by the precision of the cut obtained.
Among the innovations introduced in recent years it is worth noting the navigation in the osteotomies performed with this technology.
Page 5 of 11
Regarding the duration of surgery, a longer duration is usually attributed for unimaxillary osteotomy [14], but Bertossi confirmed a shorter duration in cases of bimaxillary ostetomies [6].
b. Osteotomies in the TMJ (temporomandibular joint) area
ip t
During open surgery of the TMJ, different types of osteotomies are used to correct
articular problems: condylar-shave, eminectomy, condylectomy... (Fig.2). Classically,
cr
round burs, as well as fissure burs and high speed saws have been used. The piezoelectric scalpel was introduced in this area in 2006 [15]. Osteotomies in this area
us
are not free of vascular risk. The piezoelectric device allows a safe bony cut in the medial aspect of the condyle, thus reducing the risks for internal maxillary artery injury.
an
The same thing happens in the medial aspect of the articular eminence: if by accident the cranial cavity is penetrated, there is a severe risk of injuring the meningeal vessels. The condylectomy in cases of condylar hyperplasia [16-17] is another frequent
M
indication of TMJ bone surgery, in which the artery injury represents an important risk (Fig.2). This eventuality is especially important in cases of TMJ ankylosis (18), in
Ac ce pt e
d
which there is a severe deformation of the bony architecture.
c. Osteotomies in rhinoplasty
Rhinoplasty includes in many cases the practice of osteotomies, to treat defects of the bony pyramid (19). The control of the osteotomy that is done transcutaneously (Fig.3) or endonasally is not simple. The use of rotary instruments to perform the osteotomy is not usual. The ultrasonic scalpel offers a novel and precise option to perform the nasal osteotomy, respecting at the same time the underlying soft tissues [20-21]. Initially the use of the piezosurgery instrument did not offer any special advantage due to the lack of specific inserts and the poor power of the first platforms [22]. Nevertheless, the appearance of new inserts specifically designed for rhinoplasty, as well as the appearance of the new medical units, has given a new boost to this new application of piezosurgery [23]. The osteotomy with a piezoelectric device can be done without any assistant, in a continuous and constant way without turning to the use of the classical hammer and chisel. In addition, the preservation of the soft tissues improves
Page 6 of 11
the stability of the position of the bone fragments after the osteotomy. The results are a reduction of postoperative edema and ecchymosis and less pain [24].
Discussion
The piezoelectric technique allows minimally invasive interventions: the soft tissues
ip t
remain intact, the osteotomy produces no damage, the inflammation is less important,
cr
and consequently the healing is faster.
Advantages of the procedure include:
us
1. Preservation of the adjoining soft tissues, avoiding accidental injury during surgery [1-3].
an
2. Better control of the osteotomy line due to the physical properties of the device [7], which allows a micrometric cut, with little bone loss compared to the rotating material or the oscillating saws.
M
3. Exhaustive surgical bed. The phenomenon of cavitation [25] allows surgery with less bleeding: bubbles are created from the irrigation saline, which implode and generate
d
waves that produce a micro-coagulation. 4. Faster bone healing and regeneration.
Ac ce pt e
Oxygen molecules released during cutting have an antiseptic effect, and ultrasonic vibration stimulates cellular metabolism. The lack of necrosis in the osteotomy accelerates bone regeneration. Some studies have shown that bone extracted from osteotomies performed with a piezoelectric device contained more vital bone and more osteocytes [3].
5. From the patient point of view, the sensation of vibration disappears, which improves comfort and reduces the anxiety of the patient during surgery [11].
Complications derived directly from the piezoelectric surgery are infrequent. 1. Thermal lesion of the bone is a hypothetical complication of the technique, with the appearance of the so called "cavitations "[25]. It is mandatory to cool the tip to avoid this particular complication, so continuous irrigation as well as correct handling of the inserts are a must. 2. The most frequent complain is that the procedures are lengthy compared to cases operated using conventional saws. In our experience, this situation has been especially evident in nasal osteotomies, and to a lesser extent in cranial graft, but this lengthening
Page 7 of 11
of operating time has been insignificant in the TMJ procedures. In our experience with TMJ, the spongy features of the condyle head allow us to say that the time difference is insignificant. Logically this situation is more frequent when osteotomies are performed on compact and thick bone, for example during bilateral sagittal split osteotomies. However the increased power of the new piezotomes platforms for medical use reduces the operating
ip t
time making no differences with usual methods.
cr
Conclusions
us
The piezoelectric scalpel with the appropriate tip can be safely used in many of the osteotomies that are routinely performed in the maxillofacial skeleton. The technique
an
has already been sufficiently tested in most bone procedures performed in the head and neck. When answering the question that gives title to this paper we have to differentiate the 3 procedures.
M
In orthognathic cases, the main advantage of the piezoelectric “scalpel” is that it can precisely cut the hard tissues, without causing lesions in adjacent soft tissues. This is
d
especially important with the inferior alveolar nerve in BSSO, and with the vessels of
Ac ce pt e
the pterygoid area in Lefort 1 osteotomy. The visibility and manageability during the orthognathic procedures for the surgeon are excellent; the patient's perception is of less invasiveness and less morbidity so their acceptance is excellent, and finally the literature confirms a better and faster bone healing. With the new models of piezo devices, lack of power is not an issue anymore, and length of procedures is now comparable to usual techniques.
In the TMJ area, piezosurgery allows an accurate osteotomy that respects the vascular structures immediately behind the mandibular condyle and articular eminence. Visibility is enhanced, and due to the softness of the bone in the area, osteotomies are straightforward procedures. Finally, in the rhinoplasty cases accuracy of the osteotomy and respect to the soft tissues have also been observed, but the lack of visibility might still be an obstacle that prevents the popularization of the technique.
Page 8 of 11
References 1. Vercellotti T. Technological characteristics and clinical indications of piezoelectric bone surgery. Minerva Stomatol. 2004;53: 207-14. 2. Eggers G, Klein J, Blank J, Hassfeld S. Piezosurgery: an ultrasound device for cutting bone and its use and limitations in maxillofacial surgery. Br J Oral Maxillofac
ip t
Surg. 2004;42: 451-3. 3. Vercellotti T, Nevins ML, Kim DM, Nevins M, Wada K, Schenk RK et al. Osseous
cr
response following resective therapy with piezosurgery. Int J Periodontics Restorative Dent. 2005; 25:543-9.
us
4. Robiony M, Polini F, Costa F, Vercellotti T, Politi M. Piezoelectric bone cutting in multipiece maxillary osteotomies. J Oral Maxillofac Surg. 2004; 62: 759-61.
an
5. Spinelli G, Lazzeri D, Conti M, Agostini T, Mannelli G. Comparison of piezosurgery and traditional saw in bimaxillary orthognathic surgery. J Craniomaxillofac Surg.
M
2014;42:1211-20.
6. Bertossi D, Lucchese A, Albanese M, Turra M, Faccioni F, Nocini P et al.
d
Piezosurgery versus conventional osteotomy in orthognathic surgery: a paradigm shift
Ac ce pt e
in treatment. J Craniofac Surg. 2013;24:1763-6. 7.Gilles R, Couvreur T, Dammous S. Ultrasonic orthognathic surgery: enhancements to established osteotomies. Int J Oral Maxillofac Surg. 2013;42:981-7. 8. Brockmeyer P, Hahn W, Fenge S, Moser N, Schliephake H, Gruber RM. Reduced somatosensory impairment by piezosurgery during orthognathic surgery of the mandible. Oral Maxillofac Surg. 2015;19:301-7. 9.Kawase-Koga Y, Mori Y, Kanno Y, Hoshi K, Takato T. Short Lingual Osteotomy Using a Piezosurgery Ultrasonic Bone-Cutting Device During Sagittal Split Ramus Osteotomy. J Craniofac Surg. 2015 ; 26: 567-8.
10.Rullo R, Festa VM, Rullo F, Trosino O, Cerone V, Gasparro R et al. The Use of Piezosurgery in Genioplasty. J Craniofac Surg. 2016; 27:414-5. 11. Rana M, Gellrich NC, Rana M, Piffkó J, Kater W. Evaluation of surgically assisted rapid maxillary expansion with piezosurgery versus oscillating saw and chisel osteotomy - a randomized prospective trial. Trials. 2013;17;14:49.
Page 9 of 11
12. Robiony M, Polini F, Costa F, Zerman N, Politi M. Ultrasonic bone cutting for surgically assisted rapid maxillary expansion (SARME) under local anaesthesia. Int J Oral Maxillofac Surg. 2007;36:267-9 13. Olate S, Pozzer L, Unibazo A, Huentequeo-Molina C, Martinez F, de Moraes M. LeFort I segmented osteotomy experience with piezosurgery in orthognathic surgery.
ip t
Int J Clin Exp Med. 2014 ;7:2092-5 14. Beziat JL, Bera JC, Lavandier B, Gleizal A. The ultrasonic osteotomy as a new
cr
technique in craniomaxillofacial surgery. Int J Oral Maxillofac Surg 2007;36:493-500
15. Gonzalez Lagunas J, Mareque J, Raspall G. Piezosugery its role in TMJ surgery. J
us
Craniomaxfac Surg 2006; 34 (suppl 1) :220
16. Gonzalez Lagunas J, Mareque J. Piezosurgery its role in TMJ surgery. Italian J Oral
an
Maxillofac Surg 2008;19:119-121
17.. Chiarini L, Albanese M, Anesi A, Galzignato PF, Mortellaro C, Nocini P et al.
M
Surgical treatment of unilateral condylar hyperplasia with piezosurgery. J Craniofac Surg. 2014;25:808-10.
d
18. Jose A, Nagori SA, Virkhare A, Bhatt K, Bhutia O, Roychoudhury A. Piezoelectric osteoarthrectomy for management of ankylosis of the temporomandibular joint. Br J
Ac ce pt e
Oral Maxillofac Surg. 2014;52:624-8.
19. Robiony M, Toro C, Costa F, Sembronio S, Polini F, Politi M. Piezosurgery: a new method for osteotomies in rhinoplasty. J Craniofac Surg. 2007;18:1098-100. 20.. Tirelli G, Tofanelli M, Bullo F, Bianchi M, Robiony M. External osteotomy in rhinoplasty: Piezosurgery vs osteotome. Am J Otolaryngol. 2015;36:666-71. 21. Ghassemi A, Prescher A, Talebzadeh M, Hölzle F, Modabber A. Osteotomy of the nasal wall using a newly designed piezo scalpel--a cadaver study. J Oral Maxillofac Surg. 2013;71:2155
22. Gonzalez Lagunas J, Molina J, Mareque J. Aplicaciones extraorales del bisturí piezoeléctrico. Rev Esp Cirug Oral y Maxilofac 2009; 31: 26-31 23 Gerbault O, Daniel RK, Kosins AM. The Role of Piezoelectric Instrumentation in Rhinoplasty Surgery. Aesthet Surg J. 2016;36:21-34
Page 10 of 11
24. Taskin Ü, Batmaz T, Erdil M, Aydın S, Yuceba K. The comparison of edema and ecchymosis after piezoelectric and conventional osteotomy in rhinoplasty. Eur Arch Otorhinolaryngol. 2017;274 :861-5. 25. Brujan EA. The role of cavitation microjets in the therapeutic applications of
Ac ce pt e
d
M
an
us
cr
ip t
ultrasound. Ultrasound Med Biol 2004; 30: 381-7
Page 11 of 11
S2468-7855(17)30108-8 http://dx.doi.org/doi:10.1016/j.jormas.2017.06.009 JORMAS 63
To appear in: Received date: Revised date: Accepted date:
1-5-2017 11-6-2017 19-6-2017
Please cite this article as: Javier Gonz´alez Lagunas Is the piezoelectric device the new standard for facial osteotomies? (2017), http://dx.doi.org/10.1016/j.jormas.2017.06.009 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Is the piezoelectric device the new standard for facial osteotomies? Javier González Lagunas Department of Oral and Maxillofacial Surgery Hospital Quironsalud, Barcelona Plaza Alfonso Comín 5-7 08023 Barcelona, España
Ac ce pt e
d
M
an
us
cr
ip t
[email protected]
Page 1 of 11
Abstract Piezoelectric devices are commonly used in all areas of maxillofacial surgery. Initially applied in preprosthetic surgery, they have steadily become a common practice in major surgery of the facial skeleton, including maxillary and mandibular osteotomies, temporomandibular joint surgery, orbital surgery, craniofacial procedures and rhinoplasty. We will review the current medical literature and establish the "state of the
ip t
art" of piezosurgery in orthognathic surgery, TMJ surgery and rhinoplasty.
cr
Key words. piezosurgery, orthognathic surgery, temporomandibular joint disorders,
Ac ce pt e
d
M
an
us
rhinoplasty
Page 2 of 11
Oxford Dictionary defines Standard as "Something used as a measure, norm, or model in comparative evaluations". Other sources define it as "...something considered by an authority or by general consent as a basis of comparison; an approved model"
In this paper we will analyze some of the most frequent indications for piezoelectric devices in craniomaxillofacial surgery, specifically jaws osteotomies (orthognathic
ip t
surgery), TMJ surgery and rhinoplasty and decide if this particular technique could be
cr
considered as a new standard for these procedures
us
Introduction
The term ultrasound defines mechanical vibrations in frequencies above the human
an
upper audible limit, superior to 20Khz. Ultrasounds have a long history of applications in medicine. Apart from their role for diagnosis, they also play an important role in some therapeutic procedures. In 1950 they were firstly used to treat neuropathic and
M
muscular pains and also to improve bone healing. In dentistry, they were used in the
d
same decade to prepare cavities and to perform tartrectomies.
Ac ce pt e
Piezosurgery si superior to scapels because of its ability to cut when it micro-vibrates with an ultrasound frequency, and cut the bone, but do not affect the underlying soft tissues. It was developed in its surgical field by Dr Tomaso Vercelloti in Genova [1]. In fact the term Piezosurgery (R) is a trademark of an Italian company (Mectron, Italy®).
The soft tissues that contact the vibratory material are not injured, making the piezoelectric device as the ideal instrument to be used in the bordering territory between the soft tissues and the bone [2], thus reducing the risk of traumatizing the surrounding soft tissues. In this chapter we present the different applications of the piezoelectric devices in several extraoral osteotomies in the craniofacial region.
a. Basic sciences The piezoelectric scalpel takes advantage of the cutting ability of an instrument that micro-vibrates with the frequency of ultrasound. The piezoelectric effect was described by the Curies in 1880: certain crystals and ceramics acquire an electric polarization in
Page 3 of 11
response to mechanical stress. On the contrary, when these materials are subjected to an electric current, they deform: this is known as the inverse piezoelectric effect. In this type of surgery an ultrasonic transducer that includes a piezoelectric material is used. When passing an electric charge this material undergoes a mechanical change, so that it contracts and expands alternately. In addition it is added an intermediate frequency that causes the material to produce oscillations of average frequency and
ip t
finally ultrasonic waves. The generated vibrations are amplified and transferred to an insert that can induce the disorganization and fragmentation of different materials [2],
cr
due to the phenomenon of agitation.
These vibrations are expanded and transferred to a terminal, which exerts a mechanical
us
cutting effect on the mineralized tissue. The surgeon can adjust the vibration frequency, cutting capacity and irrigation flow rate. The frequency ranges from 25 to 30 kHz and
an
produces micro-vibrations of 60-210 microns in amplitude with a power at the tip of the terminal of about 5W. The system also includes an irrigation cannula that connects to the handpiece and whose volume is regulated by the surgeon. The intensity of the liquid
M
that cools the surgical bed can be adjusted between 0ml / min to 70ml / min. The soft tissues surrounding the insert are not damaged, thus reducing the risk of soft
Ac ce pt e
d
tissue injury.
b. Biological response of the tissues
From the outset, the piezoelectric scalpel demonstrated faster bone regeneration and healing, compared to results obtained with carbide or diamond drills [3]. Oxygen molecules released during cutting have an antiseptic effect and ultrasonic vibration stimulates cellular metabolism. Precision in the osteotomy allows the preservation of normal bone architecture, a factor that could contribute to accelerate bone regeneration. Some studies have also shown that bone extracted from osteotomies performed with a piezo device contained more vital bone and more osteocytes than bone obtained with usual methods.
Clinical applications
a. Osteotomies of the maxillary bones
Page 4 of 11
There have been many changes in orthognathic surgery in recent years, and one of the most relevant one is the use of less invasive cutting systems (instead of usual saws). Since its development, the piezoelectric scalpel has been used in the different types of orthognathic surgery for its precision and safety: Lefort 1 osteotomy, sagittal branch osteotomy (BSSO) (Fig.1), or mentoplasty [4]. The comparison with usual surgical saw
ip t
is in favor for the piezoelectric scalpel because it genders less bleeding, less postoperative swelling and less nervous morbidity [5-6]. A better control in osteotomies
cr
and a lower risk of bad splits has also been described [7].
us
In mandibular orthognathic surgery, the piezoelectric device has been used both in sagittal split osteotomy and intraoral vertical osteotomy. One of the main strengths of
an
this technique is the recovery of the sensitivity in the territory of the inferior dental nerve after surgery. Some reports showed an early recovery of the inferior alveolar nerve in less than 2 months. In a recent study, there was also a lower somatosensory
M
impairment in both thermal detection and in the detection of vibration, as well as a faster recovery of these functions [8]. Its efficiency on genioplasty has been also shown
Ac ce pt e
injuries.
d
[9-10], with less damage to the suprahyoid pedicle and comparable results in nerve
Cadaver studies in the upper jaw demonstrated the safety of the procedure in terms of mucosal and vessel integrity [4]. The low vibration of the instrument even allows that some type of osteotomies (Surgically Assisted Rapid Palatine Extension, or SARPE) were performed under local anesthesia, with good acceptance by the patient [11-12]. In Lefort 1 osteotomy, two important technical aspects improved by this technique are (a) the possibility of performing the pterygomaxillary osteotomy with minimal vascular risk, and (b) favoring the deinsertion of the nasal mucosa. In cases of segmental Lefort 1 osteotomies [13], vertical osteotomies are facilitated by the precision of the cut obtained.
Among the innovations introduced in recent years it is worth noting the navigation in the osteotomies performed with this technology.
Page 5 of 11
Regarding the duration of surgery, a longer duration is usually attributed for unimaxillary osteotomy [14], but Bertossi confirmed a shorter duration in cases of bimaxillary ostetomies [6].
b. Osteotomies in the TMJ (temporomandibular joint) area
ip t
During open surgery of the TMJ, different types of osteotomies are used to correct
articular problems: condylar-shave, eminectomy, condylectomy... (Fig.2). Classically,
cr
round burs, as well as fissure burs and high speed saws have been used. The piezoelectric scalpel was introduced in this area in 2006 [15]. Osteotomies in this area
us
are not free of vascular risk. The piezoelectric device allows a safe bony cut in the medial aspect of the condyle, thus reducing the risks for internal maxillary artery injury.
an
The same thing happens in the medial aspect of the articular eminence: if by accident the cranial cavity is penetrated, there is a severe risk of injuring the meningeal vessels. The condylectomy in cases of condylar hyperplasia [16-17] is another frequent
M
indication of TMJ bone surgery, in which the artery injury represents an important risk (Fig.2). This eventuality is especially important in cases of TMJ ankylosis (18), in
Ac ce pt e
d
which there is a severe deformation of the bony architecture.
c. Osteotomies in rhinoplasty
Rhinoplasty includes in many cases the practice of osteotomies, to treat defects of the bony pyramid (19). The control of the osteotomy that is done transcutaneously (Fig.3) or endonasally is not simple. The use of rotary instruments to perform the osteotomy is not usual. The ultrasonic scalpel offers a novel and precise option to perform the nasal osteotomy, respecting at the same time the underlying soft tissues [20-21]. Initially the use of the piezosurgery instrument did not offer any special advantage due to the lack of specific inserts and the poor power of the first platforms [22]. Nevertheless, the appearance of new inserts specifically designed for rhinoplasty, as well as the appearance of the new medical units, has given a new boost to this new application of piezosurgery [23]. The osteotomy with a piezoelectric device can be done without any assistant, in a continuous and constant way without turning to the use of the classical hammer and chisel. In addition, the preservation of the soft tissues improves
Page 6 of 11
the stability of the position of the bone fragments after the osteotomy. The results are a reduction of postoperative edema and ecchymosis and less pain [24].
Discussion
The piezoelectric technique allows minimally invasive interventions: the soft tissues
ip t
remain intact, the osteotomy produces no damage, the inflammation is less important,
cr
and consequently the healing is faster.
Advantages of the procedure include:
us
1. Preservation of the adjoining soft tissues, avoiding accidental injury during surgery [1-3].
an
2. Better control of the osteotomy line due to the physical properties of the device [7], which allows a micrometric cut, with little bone loss compared to the rotating material or the oscillating saws.
M
3. Exhaustive surgical bed. The phenomenon of cavitation [25] allows surgery with less bleeding: bubbles are created from the irrigation saline, which implode and generate
d
waves that produce a micro-coagulation. 4. Faster bone healing and regeneration.
Ac ce pt e
Oxygen molecules released during cutting have an antiseptic effect, and ultrasonic vibration stimulates cellular metabolism. The lack of necrosis in the osteotomy accelerates bone regeneration. Some studies have shown that bone extracted from osteotomies performed with a piezoelectric device contained more vital bone and more osteocytes [3].
5. From the patient point of view, the sensation of vibration disappears, which improves comfort and reduces the anxiety of the patient during surgery [11].
Complications derived directly from the piezoelectric surgery are infrequent. 1. Thermal lesion of the bone is a hypothetical complication of the technique, with the appearance of the so called "cavitations "[25]. It is mandatory to cool the tip to avoid this particular complication, so continuous irrigation as well as correct handling of the inserts are a must. 2. The most frequent complain is that the procedures are lengthy compared to cases operated using conventional saws. In our experience, this situation has been especially evident in nasal osteotomies, and to a lesser extent in cranial graft, but this lengthening
Page 7 of 11
of operating time has been insignificant in the TMJ procedures. In our experience with TMJ, the spongy features of the condyle head allow us to say that the time difference is insignificant. Logically this situation is more frequent when osteotomies are performed on compact and thick bone, for example during bilateral sagittal split osteotomies. However the increased power of the new piezotomes platforms for medical use reduces the operating
ip t
time making no differences with usual methods.
cr
Conclusions
us
The piezoelectric scalpel with the appropriate tip can be safely used in many of the osteotomies that are routinely performed in the maxillofacial skeleton. The technique
an
has already been sufficiently tested in most bone procedures performed in the head and neck. When answering the question that gives title to this paper we have to differentiate the 3 procedures.
M
In orthognathic cases, the main advantage of the piezoelectric “scalpel” is that it can precisely cut the hard tissues, without causing lesions in adjacent soft tissues. This is
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especially important with the inferior alveolar nerve in BSSO, and with the vessels of
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the pterygoid area in Lefort 1 osteotomy. The visibility and manageability during the orthognathic procedures for the surgeon are excellent; the patient's perception is of less invasiveness and less morbidity so their acceptance is excellent, and finally the literature confirms a better and faster bone healing. With the new models of piezo devices, lack of power is not an issue anymore, and length of procedures is now comparable to usual techniques.
In the TMJ area, piezosurgery allows an accurate osteotomy that respects the vascular structures immediately behind the mandibular condyle and articular eminence. Visibility is enhanced, and due to the softness of the bone in the area, osteotomies are straightforward procedures. Finally, in the rhinoplasty cases accuracy of the osteotomy and respect to the soft tissues have also been observed, but the lack of visibility might still be an obstacle that prevents the popularization of the technique.
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References 1. Vercellotti T. Technological characteristics and clinical indications of piezoelectric bone surgery. Minerva Stomatol. 2004;53: 207-14. 2. Eggers G, Klein J, Blank J, Hassfeld S. Piezosurgery: an ultrasound device for cutting bone and its use and limitations in maxillofacial surgery. Br J Oral Maxillofac
ip t
Surg. 2004;42: 451-3. 3. Vercellotti T, Nevins ML, Kim DM, Nevins M, Wada K, Schenk RK et al. Osseous
cr
response following resective therapy with piezosurgery. Int J Periodontics Restorative Dent. 2005; 25:543-9.
us
4. Robiony M, Polini F, Costa F, Vercellotti T, Politi M. Piezoelectric bone cutting in multipiece maxillary osteotomies. J Oral Maxillofac Surg. 2004; 62: 759-61.
an
5. Spinelli G, Lazzeri D, Conti M, Agostini T, Mannelli G. Comparison of piezosurgery and traditional saw in bimaxillary orthognathic surgery. J Craniomaxillofac Surg.
M
2014;42:1211-20.
6. Bertossi D, Lucchese A, Albanese M, Turra M, Faccioni F, Nocini P et al.
d
Piezosurgery versus conventional osteotomy in orthognathic surgery: a paradigm shift
Ac ce pt e
in treatment. J Craniofac Surg. 2013;24:1763-6. 7.Gilles R, Couvreur T, Dammous S. Ultrasonic orthognathic surgery: enhancements to established osteotomies. Int J Oral Maxillofac Surg. 2013;42:981-7. 8. Brockmeyer P, Hahn W, Fenge S, Moser N, Schliephake H, Gruber RM. Reduced somatosensory impairment by piezosurgery during orthognathic surgery of the mandible. Oral Maxillofac Surg. 2015;19:301-7. 9.Kawase-Koga Y, Mori Y, Kanno Y, Hoshi K, Takato T. Short Lingual Osteotomy Using a Piezosurgery Ultrasonic Bone-Cutting Device During Sagittal Split Ramus Osteotomy. J Craniofac Surg. 2015 ; 26: 567-8.
10.Rullo R, Festa VM, Rullo F, Trosino O, Cerone V, Gasparro R et al. The Use of Piezosurgery in Genioplasty. J Craniofac Surg. 2016; 27:414-5. 11. Rana M, Gellrich NC, Rana M, Piffkó J, Kater W. Evaluation of surgically assisted rapid maxillary expansion with piezosurgery versus oscillating saw and chisel osteotomy - a randomized prospective trial. Trials. 2013;17;14:49.
Page 9 of 11
12. Robiony M, Polini F, Costa F, Zerman N, Politi M. Ultrasonic bone cutting for surgically assisted rapid maxillary expansion (SARME) under local anaesthesia. Int J Oral Maxillofac Surg. 2007;36:267-9 13. Olate S, Pozzer L, Unibazo A, Huentequeo-Molina C, Martinez F, de Moraes M. LeFort I segmented osteotomy experience with piezosurgery in orthognathic surgery.
ip t
Int J Clin Exp Med. 2014 ;7:2092-5 14. Beziat JL, Bera JC, Lavandier B, Gleizal A. The ultrasonic osteotomy as a new
cr
technique in craniomaxillofacial surgery. Int J Oral Maxillofac Surg 2007;36:493-500
15. Gonzalez Lagunas J, Mareque J, Raspall G. Piezosugery its role in TMJ surgery. J
us
Craniomaxfac Surg 2006; 34 (suppl 1) :220
16. Gonzalez Lagunas J, Mareque J. Piezosurgery its role in TMJ surgery. Italian J Oral
an
Maxillofac Surg 2008;19:119-121
17.. Chiarini L, Albanese M, Anesi A, Galzignato PF, Mortellaro C, Nocini P et al.
M
Surgical treatment of unilateral condylar hyperplasia with piezosurgery. J Craniofac Surg. 2014;25:808-10.
d
18. Jose A, Nagori SA, Virkhare A, Bhatt K, Bhutia O, Roychoudhury A. Piezoelectric osteoarthrectomy for management of ankylosis of the temporomandibular joint. Br J
Ac ce pt e
Oral Maxillofac Surg. 2014;52:624-8.
19. Robiony M, Toro C, Costa F, Sembronio S, Polini F, Politi M. Piezosurgery: a new method for osteotomies in rhinoplasty. J Craniofac Surg. 2007;18:1098-100. 20.. Tirelli G, Tofanelli M, Bullo F, Bianchi M, Robiony M. External osteotomy in rhinoplasty: Piezosurgery vs osteotome. Am J Otolaryngol. 2015;36:666-71. 21. Ghassemi A, Prescher A, Talebzadeh M, Hölzle F, Modabber A. Osteotomy of the nasal wall using a newly designed piezo scalpel--a cadaver study. J Oral Maxillofac Surg. 2013;71:2155
22. Gonzalez Lagunas J, Molina J, Mareque J. Aplicaciones extraorales del bisturí piezoeléctrico. Rev Esp Cirug Oral y Maxilofac 2009; 31: 26-31 23 Gerbault O, Daniel RK, Kosins AM. The Role of Piezoelectric Instrumentation in Rhinoplasty Surgery. Aesthet Surg J. 2016;36:21-34
Page 10 of 11
24. Taskin Ü, Batmaz T, Erdil M, Aydın S, Yuceba K. The comparison of edema and ecchymosis after piezoelectric and conventional osteotomy in rhinoplasty. Eur Arch Otorhinolaryngol. 2017;274 :861-5. 25. Brujan EA. The role of cavitation microjets in the therapeutic applications of
Ac ce pt e
d
M
an
us
cr
ip t
ultrasound. Ultrasound Med Biol 2004; 30: 381-7
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