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British Journal of Oral and Maxillofacial Surgery xxx (2019) xxx–xxx

Alveolar repair after the use of piezosurgery in the removal

of lower third molars: a prospective clinical, randomised,
double-blind, split-mouth study
L. de Freitas Silva, E.N. Ribeiro de Carvalho Reis, B.C. Oliveira Souza, L.S. Egas,
A.M. Aranega, D. Ponzoni ∗
The Department of Surgery and Integrated Clinic, São Paulo State University (UNESP), School of Dentistry, Araçatuba, São Paulo, Brazil

Abstract

The objective of this study was to evaluate the use of piezosurgery for osteotomy and odontosection in the repair of the alveoli four months
after exodontia. Fifteen young patients who needed third molars extracted were included. During the extractions, one of the teeth was included
in the Piezo group, in which ultrasound motor tips were used in both procedures. The other tooth was removed with a conventional rotary
instrument. The values of density of the repair regions of the right and left third molars were compared using digital panoramic radiographs.
There were no significant differences (p > 0.05): piezo group mean (SD) 125.7 (15.4) and control group 126.7 (21.2). The bone density of the
alveoli after extraction of the lower third molars with rotary instruments and surgical ultrasound was similar in both groups.
© 2019 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Bone Density; exodontia; Osteotomy; Piezosurgery; Third Molar

Introduction tulous site that lead to a reduction in the size of the alveolar
ridge.2–4
The extraction of third molars is one of the most common The alveolar cavity closes between 10 and 20 weeks after
procedures done by oral and maxillofacial surgeons.1 After extraction,5,6 and the complete filling of the cavity with bone
exodontia, the healing process of the remaining alveolus can is radiographically visible between three and six months.7
be divided into three phases: inflammatory, proliferative, and The remodelling process can continue until a year after
modelling or remodelling.2 The inflammatory phase lasts two extraction.7,8 The healing rate of the dental alveolus is influ-
to three days, and consists of the formation of clots and the enced by individual biological differences, alveolar size, and
migration of inflammatory cells.2 The proliferative phase is the extent of trauma during the extraction.2
related to fibroplasia and the formation of bone, the latter Traditionally, rotating instruments have been used for
of which can be identified radiographically two weeks after operating on bones. However, they have drawbacks, such
extraction.2,3 The last phase, modelling and remodelling, as the overheating or fragmentation of bone, formation of
results in qualitative and quantitative changes in the eden- a smear layer during osteotomy, and damage to adjacent
tissues.9–11
Piezosurgery is a selective micrometric technique that uses
a defined ultrasound frequency (ranging from 24 to 32 kHz)
∗ Corresponding author at: José Bonifácio Street, n 1193, Vila Mendonça,
to cut the bone.12 The advantages of using it to extract third
Araçatuba, São Paulo 16015-050, Brazil. Tel.: +55 18 3636 3270/+55 18
99135 6561.
molars are the lower risks of postoperative pain, trismus,
E-mail address: dponzoni@foa.unesp.br (D. Ponzoni). oedema, and neurological complications.13–16 It has also

https://doi.org/10.1016/j.bjoms.2019.09.017
0266-4356/© 2019 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: L. de Freitas Silva, E.N. Ribeiro de Carvalho Reis, B.C. Oliveira Souza, et al.. Alveolar repair after the
use of piezosurgery in the removal of lower third molars: a prospective clinical, randomised, double-blind, split-mouth study. Br J Oral
Maxillofac Surg (2019), https://doi.org/10.1016/j.bjoms.2019.09.017
YBJOM-5800; No. of Pages 6
ARTICLE IN PRESS
2 L. de Freitas Silva, E.N. Ribeiro de Carvalho Reis, B.C. Oliveira Souza et al. / British Journal of Oral and Maxillofacial Surgery xxx (2019) xxx–xxx

been shown to cause less stress on the bones by evaluation of

the expression of heat shock protein 70 (Hsp70).17
Results of animal studies suggest that piezosurgery
promotes better bony healing after osteotomy than rotat-
ing instruments,9,18,19 and its main disadvantages are the
increases in operating time and cost.13–15,20
Because of the limited number of studies about the pro-
cess of bony healing after third molar extraction using
piezosurgery,21 our objective was to evaluate the density of
the healing bone. We used panoramic radiographs of patients
who had had lower third molars extracted using rotary instru-
ments and piezosurgical ultrasound.

Material and methods

This study was approved by the Research Ethics Committee

of the Faculty of Dentistry of Araçatuba – Unesp (CAAE
number 48607015.6.0000.5420). All patients signed consent
forms to authorise the study and the publication of the results,
which was in line with the medical and ethics protocols of
the Helsinki Declaration, 2013.22

Study design
Fig. 1. Control group. Osteotomy and dental section done with the drill in
The study comprised 15 patients between the ages of 18 high rotation.
and 30 years, with impacted or semi-impacted right and left
mandibular third molars that required osteotomy and odon-
the randomised instruction. During the procedures, a third
tectomy. Both teeth in each patient were of a similar level of
research worker randomised the instrument for the osteotomy
surgical difficulty (assessed using panoramic radiographs).
and odontectomy, according to the allocated group. The sec-
We decided that the third molars should be buried or par-
ond operation followed the result of the first randomisation.
tially buried in mandibular bone below the occlusal plane
The patients were evaluated four months after operation
of the second molar, or mesioangular that had a mesially
by a surgeon not concerned with the operation.19
leaned-in relation to the second molar axis according Pell
and Gregory’s classification (1937).23
Patients were excluded from the study if they were smok- Operation
ers, had periodontal disease or non-compensated systemic
disease, or were using medications.24 After intraoral and extraoral antisepsis, the patients were
To find out whether there was a difference between the anaesthetised using the inferior alveolar, lingual, and buccal
piezo and control groups the sample sizes were calculated nerve-block technique with 2% mepivacaine and 1:100.000
using the website http:www.lee.dante.br.25 The data used adrenaline (Mepiadre Nova DFL® ).
were extracted from the previous study14 (SD = 0.23; differ- For the control group, the procedure consisted of an Avel-
ence between the means 0.35). For a power of 80% and level lanal incision (linear incision in the distal region of the
of significance 5%, it would be necessary to use five sam- second molar, an intrasulcular incision in the buccal region
ples/group. To guarantee greater homogeneity, 15 patients of the second molar, and an oblique relaxing incision in
with two sites /patient were chosen, giving a split-mouth the mesiobuccal region of the second molar), detachment
analysis. with a Molt periosteal elevator No. 9 (Quinelato® ) (Fig. 1),
The teeth were removed during two operations for each osteotomy and odontectomy with a surgical burr 702 (KG
patient, with an interval of at least 15 days between. The same Sorensen® ) at high speed (KaVo Dental) under constant irri-
surgeon operated on both occasions. gation with saline solution (Fig. 1).
For each patient, one tooth was included in the con- In the Piezo group, the osteotomy and odontectomy were
ventional group (control) and the other in the piezo group carried out with surgical ultrasound (Piezosonic Driller® ,
(osteotomy and odontectomy with surgical ultrasound) Carapicuíba). The osteotomy was done in a rectangular shape
(n = 15 in each). The selection was randomised, and both eval- using the ES007R and ES007L tips (Fig. 2) with the objective
uator and patient were unaware of the technique used. The of partial removal of the buccal bone cortex. The bone block
allocation was obtained from sealed envelopes that contained was excised.9,19 The odontectomy was carried out with the

Please cite this article in press as: L. de Freitas Silva, E.N. Ribeiro de Carvalho Reis, B.C. Oliveira Souza, et al.. Alveolar repair after the
use of piezosurgery in the removal of lower third molars: a prospective clinical, randomised, double-blind, split-mouth study. Br J Oral
Maxillofac Surg (2019), https://doi.org/10.1016/j.bjoms.2019.09.017
YBJOM-5800; No. of Pages 6
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L. de Freitas Silva, E.N. Ribeiro de Carvalho Reis, B.C. Oliveira Souza et al. / British Journal of Oral and Maxillofacial Surgery xxx (2019) xxx–xxx 3

Table 1
Bone density of control and piezo groups.
Mean (SD) bone density (pixel)

Participant Piezo Control

1 99 (19.4) 125 (20.8)
2 108 (13.1) 143 (9.6)
3 139 (25.5) 161 (17.6)
4 124 (12.1) 84 (13.8)
5 143 (14.8) 149 (18.1)
6 113 (11.8) 111 (12.1)
7 136 (23.5) 115 (15.4)
8 143 (28.5) 113 (26.6)
Fig. 2. Piezo group. Use of surgical ultrasound in lower third molar surgery. 9 124 (17.2) 131 (10.1)
10 151 (19.7) 123 (13.1)
11 119 (22.7) 150 (29.6)
ES009 tip. The other steps of the extraction were similar to 12 139 (29.2) 98 (21.7)
13 112 (15.7) 129 (16.5)
those in the control group (Fig. 2). 14 112 (28.8) 147 (30.3)
The teeth were removed with the aid of dental extractors 15 123 (11.2) 130 (21.5)
and the wound sutured with 4/0 interrupted silk (Ethicon® ).
All patients were prescribed amoxicillin 500 mg orally
every eight hours for five days, non-steroidal anti- groups. For all tests, probabilities of less than 0.05 were
inflammatory nimesulide 100 mg every 12 hours for three considered significant.
days, sodium dipyrone 500 mg every six hours, and 0.12 %
chlorhexidine digluconate mouthwash twice daily for seven
days. Results
The suture was removed seven days postoperatively, and
at four months postoperatively each patient had a digital The mean bone densities obtained are shown in Table 1 (den-
panoramic radiograph. sity values that were obtained in selected alveolar areas on
panoramic radiographs).
There was no significant difference between the groups
Obtaining and analysing images
(p = 0.883). Ultrasound of the extraction sites of third molars
showed a mean (SD) bone density of 125.7 (15.4) PI and
All digital panoramic radiographs were obtained by the same
the surgical sites in which the teeth were removed by the
radiology technician. A panoramic PaX-iTM device (Vatech
conventional technique a mean of 126.7 (21.2).
Technology Ltd) was used at standardised image settings and
There were no complications postoperatively, and the
exposure times, and all images were stored in JPEG format.
surgical sites healed without complications such as infec-
The images were analysed using the Image Tool 3.0 soft-
tion, haemorrhage or dehiscence of the sutures. Trismus and
ware (UTHSCSA). The area of repair of the alveolar bone
oedema were no more than would be expected.
of the right and left third molar were individually selected
using a square, 1 cm2 in size, selection template (Fig. 3). In
the sequence, the images were analysed by considering the
Discussion
grey levels (pixel values). The pixel intensity, expressed as
PI, is a measure of density, ranging from zero (black) to 255
Currently, there is much concern regarding the process of
(white). For each measure, the histogram tool was selected
alveolar repair because the quantity and quality of bone are
to provide the mean density of each region (Figs. 4 and 5).
paramount.
Based on density data obtained on histogram, the control
Alveolar repair is completed by the formation and matura-
and piezo groups were compared by statistical analysis.26,27
tion of bony trabecula within the alveolus.1,3 The chronology
Bone density values of the repair region of left and right
of this formation can be influenced by several factors inher-
third molars were compared.
ent in the patient and the surgical technique used.3,5 It has
been suggested that the less traumatic the surgical technique,
Statistical analysis the better the quality of alveolar bone.4,7 We chose the sites
of the lower third molars for this study because these teeth
Data were tabulated and compared statistically using the are often selected for excision for different reasons and there-
SigmaPlotTM 14.0 statistical software (SigmaPlot Exact fore enabled the use of a control and study group in the same
Graphs and Data Analysis). Shapiro-Wilk normality test patient under similar conditions, which is rare with erupted
showed the homogeneity of data (p > 0.05). A paired t test was teeth. The choice of four months of observation was justified
used to compare the significance of the differences between by the fact that alveolar repair is already complete and the

Please cite this article in press as: L. de Freitas Silva, E.N. Ribeiro de Carvalho Reis, B.C. Oliveira Souza, et al.. Alveolar repair after the
use of piezosurgery in the removal of lower third molars: a prospective clinical, randomised, double-blind, split-mouth study. Br J Oral
Maxillofac Surg (2019), https://doi.org/10.1016/j.bjoms.2019.09.017
YBJOM-5800; No. of Pages 6
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4 L. de Freitas Silva, E.N. Ribeiro de Carvalho Reis, B.C. Oliveira Souza et al. / British Journal of Oral and Maxillofacial Surgery xxx (2019) xxx–xxx

Fig. 3. Selected area (in red) on a panoramic radiograph corresponding to the alveolar repair area on the right side.

Fig. 4. Histogram generated from the selected area.

Fig. 5. Screen-shot of table with the mean (SD) of the selected area.

trabecular bone is mature. In the event of a delay in repair, formation of bone in the surgical site and loss of height of
the mineral bone density of these sites would be different the alveolar bone crest occurred simultaneously during the
between the groups. Ideally, this tissue would be analysed first three months. The amount of bone lost was also almost
using a biopsy and histological analysis, but this would not unchanged from three to 12 months. We think, therefore, that
be ethical. the four-month postoperative period is ideal for observing
We followed a technique already published,26,27 in which alveolar repair (Tables 2 and 3).
postoperative radiographs, with periods ranging from three to Our study is a prospective, double-blind and split-mouth
six months, were used to evaluate the healing of surgical sites study, which reflects results that are reliable as the control and
after the extraction of mandibular third molars. The study by the test regimens were used in the same patients. This reduces
Schropp et al7 evaluated the alveolar healing of maxillary the chances of individual differences in healing. In addition,
and mandibular molars and premolars using intraoral radio- in the current review of publications, we found only one study
graphs for 12 months after extraction. They noted that the that evaluated the healing of the dental alveolus after the

Please cite this article in press as: L. de Freitas Silva, E.N. Ribeiro de Carvalho Reis, B.C. Oliveira Souza, et al.. Alveolar repair after the
use of piezosurgery in the removal of lower third molars: a prospective clinical, randomised, double-blind, split-mouth study. Br J Oral
Maxillofac Surg (2019), https://doi.org/10.1016/j.bjoms.2019.09.017
YBJOM-5800; No. of Pages 6
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L. de Freitas Silva, E.N. Ribeiro de Carvalho Reis, B.C. Oliveira Souza et al. / British Journal of Oral and Maxillofacial Surgery xxx (2019) xxx–xxx 5

Table 2 Panoramic radiographs showed that there were no signifi-

Bone density of control and piezo groups. cant differences in bone density. Anesi et al,9 Reside et al,19
Mean bone density (pixel) and Rullo et al20 found early bone repair after osteotomy
Participant Piezo Control was quicker when a piezoelectric device was used than with
1 99 125
a conventional rotary instrument. Protein expression was also
2 108 143 more advantageous to the bony tissue after extraction with the
3 139 161 piezo technique.17
4 124 84 However, Horton et al18 in a three to 90 days’ histolog-
5 143 149 ical analysis in dogs showed bony damage after the use of
6 113 111
7 136 115
surgical ultrasound, chisel and hammer, and rotating instru-
8 143 113 ments. The use of piezosurgery resulted in bony damage that
9 124 131 was similar to that of the chisel and hammer. The chisel and
10 151 123 hammer would be the best option for completing osteotomies
11 119 150 in exodontia, but it causes greater discomfort for the patient.
12 139 98
13 112 129
Piezosurgery is an important alternative that is associated
14 112 147 with less tissue damage, and is more comfortable for the
15 123 130 patient than rotating instruments and a chisel.

Table 3
Mean and standard deviation bone density of Control and Piezo groups. Conflict of interest
Group name No. Mean SD
We have no conflicts of interest.
Piezo 15 125.67 15.40
Control 15 126.67 21.17

Ethics statement/confirmation of patients’ permission

extraction of third molars with piezosurgery. Unfortunately,
one of the limitations of this study is the use of panoramic This study was approved by the Research Ethics Committee
radiographs for the evaluations, because the image presents of the Faculty of Dentistry of Araçatuba - Unesp (CAAE
some degree of magnification. However, because the objec- number 48607015.6.0000.5420). Patients’ permission was
tive of the study was to compare sites in the same patient, obtained.
using the same equipment and protocol for acquisition of
images, so this limitation does not affect the reliability of the
results found. Acknowledgment
Another limitation was that the postoperative evaluation
was done only after four months, and it might have been inter- Special thanks to Professor Leonardo Perez Faverani of the
esting if a radiograph had been taken during the first week Department of Surgery and Integrated Clinic of the School of
postoperatively. These data could be useful in evaluating if Dentistry of Araçatuba - UNESP for the statistical analysis
piezosurgery favours alveolar repair for this procedure at an of the data.
earlier time. The present study, however, fulfilled our objec-
tive of evaluating whether or not there was a difference in
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Please cite this article in press as: L. de Freitas Silva, E.N. Ribeiro de Carvalho Reis, B.C. Oliveira Souza, et al.. Alveolar repair after the
use of piezosurgery in the removal of lower third molars: a prospective clinical, randomised, double-blind, split-mouth study. Br J Oral
Maxillofac Surg (2019), https://doi.org/10.1016/j.bjoms.2019.09.017
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Please cite this article in press as: L. de Freitas Silva, E.N. Ribeiro de Carvalho Reis, B.C. Oliveira Souza, et al.. Alveolar repair after the
use of piezosurgery in the removal of lower third molars: a prospective clinical, randomised, double-blind, split-mouth study. Br J Oral
Maxillofac Surg (2019), https://doi.org/10.1016/j.bjoms.2019.09.017