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National Journal of Maxillofacial Surgery
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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
Comparative and clinical evaluation between piezoelectric and conventional rotary techniques for mandibular impacted third molar extraction

1 Department of Oral and Maxillofacial Surgery, Daswani Dental College and Research Centre, Kota, Rajasthan, India
2 Dr. Harvansh Singh Judge Institute of Dental Sciences and Hospital, Chandigarh, India
3 Department of Oral Medicine and Radiology, Bhojia Dental College and Hospital, Baddi, Himachal Pradesh, India

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Date of Submission01-Mar-2021
Date of Acceptance20-Jun-2021
Date of Web Publication26-May-2022


Purpose: The aim of this study was to evaluate and compare the operative and postoperative outcomes of the mandibular impacted third molar removal using piezoelectric technique and conventional rotary bur technique.
Settings: The study was conducted in the department of oral and maxillofacial surgery between January 1, 2019, and January 1, 2020.
Materials and Methods: Thirty patients, with an age of 18–40 years, with asymptomatic bilateral impacted mandibular third molars, were selected for the study and randomly surgical extraction was done either using piezoelectric or the conventional rotary bur technique on each site. The intraoperative time taken, postoperative pain, swelling, and trismus were assessed over a follow-up period of 7 days postoperatively.
Results: Study and control groups were compared using paired t-test. There was statistical significance in reduction of pain and swelling in the study group where the duration of surgery was increased in the study group.
Conclusion: Even if piezoelectric technique takes more time but can be used safely as another technique to conventional surgical method with surgical bur and handpiece for removal of impacted mandibular third molars.

Keywords: Osteotomy, piezosurgery, rotary, third molar

How to cite this URL:
Sharma AK, Gupta A, Pabari HP, Pathak SK, Odedra NH, Beniwal J, Arora KS. Comparative and clinical evaluation between piezoelectric and conventional rotary techniques for mandibular impacted third molar extraction. Natl J Maxillofac Surg [Epub ahead of print] [cited 2022 Dec 3]. Available from: https://www.njms.in/preprintarticle.asp?id=346014

   Introduction Top

Impacted molars square measure often encountered in clinical work, with a prevalence of 30%–60%.[1],[2],[3],[4] It has been well-documented that wedged third molars, either partial or complete, are related to many complications together with pericoronitis, regional pain, odontogenic abscesses, trismus, distal tooth decay, cysts, and tumors.[5],[6],[7],[8] The split bone technique was introduced by Ward in 1956;[9] chisels were the preferred instruments for bone removal. Another study[10] stated that the technique was more painful and most of the patients may not tolerate the jarring effect of chisel and mallet while operating under local anesthesia. Hence, it was preferable to opt for rotary instruments for bone removal and tooth sectioning for surgery under local anesthesia, but the use of rotatory osteotomy and oscillating saws results in irregular surfaces and marginal osteonecrosis due to the high temperature generated during osteotomy.[11],[12]

Piezotome is a new system for cutting bone with microvibration. The piezoelectric ultrasonic vibrations (25–30 khz) generate micrometric vibration ranging from 60 to 200 mm/s, because of its micrometric and selective cut, the piezoelectric device produces safe and precise osteotomies without any osteonecrosis damage. In this study, we carried out a mean clinical trial to compare piezosurgery with conventional rotary osteotomy techniques.

   Materials and Methods Top

The study was started after procuring the ethical approval from the ethical committee of the institute vide letter no. DDC/Acad/2018/1914 dated November 14, 2018. Thirty patients were selected conveniently, fulfilling the inclusion criteria from the outpatient clinic of oral and maxillofacial surgery department. Participants required removal of their bilateral impacted mandibular third molars were selected irrespective of sex, caste, and socioeconomic status. The study was conducted in our institution between January 1, 2019, and January 1, 2020. Since this is a split-mouth study design, each patient underwent two operations for removal of their bilateral impacted mandibular third molars operated by the same operator; the time between both was 2 weeks.

Patients were subdivided into two groups randomly of 30 patients in both the groups. Control group (C) patients were treated with rotary osteotomy technique and study group (S) patients were treated with piezoelectric osteotomy technique. To keep the study unbiased in regard to surgical expertise, only one surgeon performed all the cases in the present study. The study protocol was explained to the patient in detail and their consent was obtained.

Inclusion criteria

  • Healthy individuals between 18 and 40 years of age
  • Patients requiring bilateral extractions
  • Individuals having bilateral vertical, mesioangular, distoangular, or horizontal mandibular third molar impactions with the same class and position according to the Pell and Gregory classification
  • Subject willingness.

Exclusion criteria

  • Patients with bone diseases affecting bone healing
  • Patients with uncontrolled systemic conditions jeopardizing the surgery
  • Patients with any pathological conditions related to the site of surgery
  • Patients with infection around the lower third molar
  • Patients having habit of smoking tobacco
  • Pregnancy or lactation.


  • W and H Piezomed surgical unit
  • Micromotor surgical unit with straight handpiece and carbide surgical burs for osteotomy.


Preoperative evaluation of a patient was done which included proper case history, opening of mouth was evaluated using Vernier caliper, and facial measurement was obtained with thread as baseline measurements for assessment of edema, radiographic examination, and routine blood investigations were done.

The surgical procedure was carried out in an operating room under strict aseptic conditions. The surgeries were performed under local anesthesia (lignocaine 2% with epinephrine 1:200000). The nerve blocks used were inferior alveolar, lingual, and long buccal. For both sides, Standard Ward's Incision was given. After flap reflection in the study group (S), bone osteotomy was done, and the piezosurgery settings were regulated on bone removal program. Bone guttering around the impacted tooth was achieved using piezosurgery device [Figure 1] and specific tips distal to the second molar from the mesiobuccal line angle to the distobuccal aspect of the impacted tooth, then from the distobuccal to the distolingual aspects, splitting of tooth was done according to the impacted tooth, and then, tooth was removed by using a suitable elevator.
Figure 1: Bone guttering with piezomed

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And in the control group (C), bone guttering around the impacted tooth was achieved using the micromotor straight handpiece [Figure 2]. Tooth splitting and extraction was continued in a similar manner as the study side, followed by proper debridement of the socket and flap closure.
Figure 2: Bone guttering with micromotor and carbide bur

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All patients were given postoperative instructions following extractions and were prescribed Antibiotics and Analgesics. Assessment of patients was done at 3rd and 7th postoperative days based on the following parameters:

  1. Duration of surgery
  2. Pain Visual Analog Scale (VAS)
  3. Swelling
  4. Mouth opening.

Statistical analysis

The variables included in the study were tested for normality using Kolmogorov–Smirnov test. Since the data were randomly distributed, study and control groups were compared regarding the study variables using paired t-test. Initial values were compared in the same group, using paired t-test. The significance level was set at the 5% level. Statistical analysis was performed using IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. (Armonk, NY: IBM Corp.).

   Results Top

Duration of surgery was recorded in both the groups from the incision till the suturing. Significantly more time was required in the study than in the control group (mean = 30.76 and 19.60, P < 0.0001) [Table 1].
Table 1: Comparison of time taken for operation between study and control

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The mean postoperative pain after 1, 3 and 7 days, mean VAS scores in the study group was lower than that in the control group (mean in study = 3.56, 2.03 and 0.43 compared to mean in control = 2.8, 5.66 and 2.56). The change from 1 to 7 days was statistically significant in the study and control groups (P < 0.0001) for both [Table 2].
Table 2: Pain (Visual Analog Scale) at different interval of time periods

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Regarding postoperative swelling, significant differences existed between mean measurements indicating swelling after 3 and 7 days. On 3rd and 7th day, swelling was greater at (C) than an (S).

Maximum mouth opening was noted between the groups at different follow-up periods. Significant differences were calculated between mean measurements, indicating mouth opening at baseline and after 3 and 7 days (P= <0.0001, <0.0001, <0.0001). At baseline and after 3 and 7 days, mouth opening in the (C) sides was less than at (S) sides. The change from baseline to 7 days was statistically significant in the (S) or the (C) group (P < 0.0001) [Table 3].
Table 3: Comparison of trismus

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   Discussion Top

Surgical extraction of impacted mandibular third molar is one of the most common oral surgical procedures. The indications for its removal include recurrent pericoronitis, cellulitis, abscess, cysts and tumors, unrestorable caries, periodontal breakdown, and prophylactic removal.[13] However, surgery is frequently associated with many possible complications, such as postoperative pain, swelling, and trismus. Less commonly observed complications include infection, dry socket, trigeminal nerve injuries, and rarely, fracture of the mandible. The recent study by Mantovani et al.[14] showed the application of piezoelectric, ultrasonic vibrations in making precise and safe osteotomies. To improve the quality of life for patients, this work was carried out to evaluate the efficiency of piezosurgery versus conventional surgical technique in removal of the impacted mandibular third molar and postoperative complications after the mandibular third molar removal.

Surgical time

In this study, we performed a comparative study between two osteotomies techniques in impacted third molar extraction. We found that the mean duration of operation was longer in the piezosurgery group than in the control group. The mean time in piezosurgery was 30.76 min and the control group was 19.6 min. Our findings are in agreement with the other research articles[14],[15],[16],[17],[18],[19],[20],[21] who concluded that the duration of surgery and operating time for the third molar extraction were significantly shorter with the conventional rotary instruments compared to the piezoelectric surgical technique.

Pain, swelling, and trismus

Pain was evaluated using the VAS. The present study showed that there was a significant statistical difference between the study group and the control group from the second postoperative day till the seventh. Whereas the VAS mean score decreased in study group from 2.03 on the 3rd day after surgery to 0.43 on the 7th day, there was a reduction in VAS mean score from 5.66 on the 3rd postoperative day to 2.56 on the 7th in the control group. These results run parallel to Barone et al., Goyal et al., Piersanti et al., Arakji et al., and Liu et al.[ 22] where the authors tested the efficiency of piezosurgery versus the conventional technique in regard to pain using the same technique as this present work, namely the VAS. They also used another method for evaluating pain by recording the amount of analgesics taken after surgery and concluded that there is a significant difference between the two groups.[15],[22],[23],[24],[25] Furthermore, Mantovani et al.[14] conducted a similar study and evaluated pain. They concluded that the mean pain evaluation reported by patients who underwent tooth removal using piezosurgery was significantly lower than that reported after bur bone removal, reaching a statistical difference after 4 days. In all cases, they reported that postoperative pain evaluated on the VAS was greatest on the day of surgery and then decreased progressively daily until day 6 after surgery.

Furthermore, swelling and trismus were evaluated in our study. Trismus measures were recorded before the surgery, on the 3rd day, and 7th days. Regarding facial edema, it was calculated by taking the mean of sum of three measurements: the distance between the lateral corner of the eye and the angle of the mandible; the distance between tragus and the outer corner of the mouth; and the distance between tragus and soft tissue pogonion. It was taken into account the mean of sum of these measures. It was found that there is a significant difference between piezosurgery group and conventional handpiece and surgical bur technique and that the mean facial swelling in the study group varied from the 3rd day after surgery to the 7th day from 12.67 cm to 12.58 cm, whereas it varied from 12.8 cm to 13.23 cm in the control group.

Pappalard and Guarnieri[26] performed a comparative study between piezosurgery and conventional rotary surgery and deduced that swelling was significantly less in the piezosurgery group. Meanwhile, trismus was assessed. The results have shown a significant difference between the two groups: where the range of mouth opening varied from the baseline to the 7th day, from 42.36 mm to 47.7 mm in the study group, whereas the values recorded in the control group varied from 42.43 mm to 36.68 mm. These findings are similar to a study conducted by Sortino et al.[17] on 100 patients, 50 of whom were treated by the conventional method using the surgical bur and 50 using the piezosurgery. Mozzati et al.[27] have shown parallel results with this study, they conducted a study on 15 patients. It was observed that the range of mouth opening increased more significantly in their study group than in the control group. These results run parallel to the current study results. Moreover, Goyal et al.[15] while conducting a similar study on 40 patients, their study has shown that despite extended operating time, the trismus was significantly lower in the piezotome group.

One meta-analysis study showed that, although patients undergoing piezosurgery experienced longer surgery time, they had less postoperative swelling, indicating that piezosurgery is a promising alternative technique for extraction of impacted third molars.[28]

   Conclusion Top

Within the limitation of this study, it will be concluded that piezosurgery technique can be used as another technique to conventional surgical method with surgical bur and handpiece for removal of impacted mandibular third molars. It offers better healing, compartively reducing pain, range of mouth opening, and postoperative edema. The most drawback was the time of surgery since the surgical bur and handpiece were faster in the surgical time. Yet, increasing the operator's experience could diminish this gap. Although piezosurgery is fast being adopted for major surgical procedures, its cost remains one in each of the foremost reasons for its continued limited usage in minor oral surgery like impacted third molar removal. At the top, piezosurgery is way better than the conventional rotary technique, but furthermore studies are needed with larger sample size and longer follow-up period for better evaluation and more conclusive results.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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Correspondence Address:
Karandeep Singh Arora,
House No. 1078, Sector 19-B, Chandigarh - 160 019
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njms.njms_333_21


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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