Farag AS; Kellesarian SV; Javed F; Arany S; Malmstrom H

Research Article

J Dent & Oral Disord.2016; 2(3): 1015.

Efficacy of Piezosurgery versus Conventional Techniques in the Surgical Extraction of Third Molars: A Systematic Review

Farag AS*, Kellesarian SV, Javed F, Arany S and Malmstrom H

Department of General Dentistry, University of Rochester, USA

*Corresponding author: Farag AS, Department of General Dentistry, Eastman Institute for Oral Health, University of Rochester, USA

Received: March 31, 2016; Accepted: April 29, 2016; Published: May 02, 2016

Abstract

A limited number of studies have compared piezosurgery with conventional methods in extraction of impacted third molars. To date, no systematic review of the literature analyzing the efficacy of chisels, rotary instruments, and piezosurgery in the extraction of impacted third molars has been reported. The aim of the present study was to systematically review the efficacy of chisels, rotary instruments, and piezosurgery in the extraction of impacted third molars. To address the focused question, “Is there a difference in efficacy between piezosurgery and conventional techniques in extraction of impacted third molars?”, we searched indexed databases through February 2016 using various key words “piezosurgery”; “piezoelectric”; “impaction”; “third molars” and “extraction”. Letters to the editor, commentaries, historic reviews, and experimental studies were excluded. The pattern of the present systematic review was customized to primarily summarize the pertinent data. Thirteen studies were included with 1251 subjects. A discrepancy in the reported results and conclusions was observed in the included studies. From the literature reviewed, there seems to be no difference between using chisels, rotary instruments, or piezosurgery in efficiently extracting impacted third molars; however, further well-designed controlled clinical trials are needed in this regard. We conclude that selection of technique depends on operator preference.

Keywords: Piezosurgery; Third molar; Rotary instrument; Chisel; Extraction

Introduction

Surgical extraction of impacted third molars is commonly performed in dental practice [1]. A variety of complications might be encountered during or after surgical extraction of impacted third molars such as pain, swelling and trismus, dry socket, dysthesia due to trauma to either the Inferior Alveolar Nerve (IAN) or lingual nerve, infection, or even jaw fracture [2,3]. Many factors can contribute to the incidence or severity of post-operative complications such as flap design [4-6], osteotomy techniques [7,8] and operator experience [9]. It has been shown that the severity of postoperative pain and swelling is related to surgical difficulty or the degree of intraoperative tissue damage [10]. According to Strietzel et al. [11] age, duration of operation, primary or secondary wound closure, impaction type, and pathology associated with the third molar are predictors for the postoperative course.

Osteotomy is inevitable for the extraction of third molars that are partially and/or fully impacted in bone. Although surgical hand pieces with a carbide bur are commonly used to perform osteotomies during the removal of impacted third molars, a recent morphological analysis of bone samples has shown that a bur produces irregular surfaces and marginal osteonecrosis due to the high temperature generated during osteotomy [12]. A review by Sarikov et al. [2] mentioned that IAN trauma is a complication of surgery which uses conventional techniques with chisels and hand pieces. Nearly three decades ago Horton et al. [13] introduced the clinical use of ultrasonic inserts in the surgical removal of alveolar bone, where they histologically studied the effect of the ultrasonic cutting inserts on alveolar bone and concluded that ultrasonic inserts remove bone with ease and preciseness, resulting in minimal hemorrhage from surgical sites and improved healing with less postoperative complications. Furthermore, patients reported minimal discomfort during and following the surgical application of this instrumentation. Vercelloti et al. [14] reported that the piezoelectric device (piezosurgery) is effective for performing osteotomy for maxillary sinus graft. Since then piezosurgery has been widely used as an alternative to rotary instruments or chisels for osteotomy. Piezoelectric device has also been used in a variety of procedures: root canal treatments, smoothening and shaping bony edges, oral and cranio-maxillofacial surgeries. A technologic advantage of piezosurgery that it has a built-in alarm that will sound to warn the surgeon of excessive pressure or heat [15]. Moreover, Schaeren et al. [16]. reported that the chances of mutilation of the IAN are minimal even in the case of direct exposure of the nerve to the piezosurgery tip. Piezosurgery provides better visibility at the surgical site because it increases irrigation and distribution of the cooling system, which allows for blood to be washed away via a cavitation effect [17]. From the literature reviewed [9,18-29], we speculate that extraction of impacted third molars using piezosurgery is an efficient technique that reduces the incidence of postoperative complications, as compared to the use of rotary instruments.

To date, no systematic review of the literature analyzing the efficacy of chisels, rotary instruments, and piezosurgery in the extraction of impacted third molars has been yet reported. The aim of the present study was to systematically review the efficacy of chisels, rotary instruments, and piezosurgery in the extraction of impacted third molars.

Material and Methods

Focused question

Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a specific question was constructed according to the Participants, Interventions, Control, Outcomes (PICO) principle (Figure 1). The focused question, “Is there a difference between the efficacy of Piezosurgery and conventional techniques in the extraction of impacted third molars?” was addressed in this systematic review.

Figure 1: Article selection flow chart for the systematic review according to PRISMA guidelines.

    
    
    Figure 1: Article selection flow chart for the systematic review according to
PRISMA guidelines.

(P) Participants: It was essential for subjects to have undergone impacted third molars surgical extraction

(I) Types of interventions: The intervention of interest was surgical extraction of impacted third molars using a piezoelectric device.

(C) Control Intervention: Surgical extraction of impacted third molars was done using conventional techniques (rotary instruments or chisels).

(O) Outcome Measures: Procedure duration and postoperative complications (such as pain, swelling, trismus, infection, numbness… etc.) were recorded.

Eligibility criteria

The eligibility criteria were as follows: (a) Original studies (clinical studies); (b) inclusion of a control group (patients who had undergone impacted third molar surgical extractions by means of rotary instruments or chisels); and (c) intervention: patients who had undergone impacted third molar surgical extractions by piezosurgery. Letters to the editor, historic reviews, commentaries, case-series, and case-reports were excluded.

Literature search protocol

PubMed/Medline (National Library of Medicine, Washington, DC), EMBASE, Scopus, Web of Knowledge, and Google-Scholar databases were searched through February 2016 using different combinations of the following key words: “piezosurgery”; “piezoelectric”; “ultrasonic”; “ultrasound”; “third molars” and “extraction”. Titles and abstracts of studies identified using the above-described protocol were screened by two authors (ASF and SVK) and checked for agreement. Full-texts of studies judged by title and abstract to be relevant were read and independently evaluated for the stated eligibility criteria. Reference lists of potentially relevant original and review articles were hand-searched to identify any studies that could have remained unidentified in the previous step. Once again, the articles were checked for disagreement via discussion among the authors (Figure 1). The pattern of the present systematic review was customized to mainly summarize the relevant data.

The initial search yielded 31 studies. Eighteen studies, which did not fulfill the eligibility criteria, were excluded. In total, 13 clinical studies [9,18-29] were included and processed for data extraction.

Quality assessment

Quality assessment was performed in an attempt to increase the strength of the present systematic review. The 13 studies [9,18-29] that were included underwent a quality assessment with the Critical Appraisal Skills Program (CASP) Cohort Study Checklist [30]. The CASP tool uses a systematic approach based on 12 specific criteria, which are: 1) Study issue is clearly focused; 2) Cohort is recruited in an acceptable way; 3) Exposure (surgical procedure) is accurately measured; 4) Outcome (duration of the procedure and postoperative complications) is accurately measured; 5) Confounding factors are addressed; 6) Follow-up is long and complete; 7) Results are clear; 8) Results are precise; 9) Results are credible; 10) Results can be applied to the local population; 11) Results fit with available evidence; and 12) There are important clinical implications. Each criterion was given a response of either “Yes”, “No”, or “Cannot tell”. Each study could have a maximum score of 12. CASP scores were used to grade the methodological quality of each study assessed in the present systematic review.

General characteristics of the studies included

One case control study [25] and 12 clinical trials [9,18-24,26-29], of which three studies [18,19,22] were randomized clinical trials, 3 studies [9,26,27] were split mouth randomized clinical trials, and two studies [20,28] were crossover randomized clinical trials, included a total of 1251 study subjects. In all studies [9,18-29], both genders were included with an age range from 14 to 54 years. In all studies [9,18- 29] the number of subjects ranged from 10 to 300 patients (Table 1).

Table 1: Characteristics of the study.




  
    Author
    Study Design
    Age range (Mean)    years
    Study subjects N=    Number
    Gender M/F
    Study groups
  
  
    Barone et al. [18] 
    Randomized Clinical    Trial
    24-45 (31.2)
    N= 26
    14/12
    Piezo = 13
      Rotary = 13
  
  
    Bartuli et al. [19] 
    Randomized Clinical    Trial
    25-35 (31.4)
    N= 194
    102/90
    Piezo = 96
      Rotary = 96
  
  
    Chang et al. [20] 
    Randomized    Crossover Clinical Trial
    17- 29
    N=20
    18-Feb
    Piezo =10
      Rotary =10
  
  
    Gao,Y et al. [21] 
    Clinical Trial
    18-40 (29) years
    N=228
    130/98
    Piezo = 114
      Chisels =114
  
  
    Goyal et al. [22] 
    Randomized Clinical    Trial
    22-36 (29)
    N= 40
    24/16
    Piezo = 20
      Rotary = 20
  
  
    Guo Z et al. [23] 
    Clinical Trial
    20-30
    N=300
    189/111
    Chisels = 100
      Rotary =100
      Piezo =100
  
  
    Itro et al. [24] 
    Clinical Trial
    NA
    N= 140
    NA
    Piezo = 70 (35 Max-    35 Mand)
      Rotary =70 (35 Max-    35 Mand)
  
  
    Mantovani et al. [9] 
    Split-mouth    Randomized Clinical Trial
    NA (24±4.21)
    N=100
    41/59
    Piezo = 100
      Rotary =100
  
  
    Mozzati et al. [25] 
    Case Control
    18-34 (22.5)
    N=15
    8-Jul
    Piezo = 15
      Rotary = 15
  
  
    Piersanti et al. [26] 
    Split-mouth    Randomized Clinical Trial
    NA (22.4±2.3)
    N=10
    6-Apr
    Piezo = 10
      Rotary = 10
  
  
    Rullo et al. [27] 
    Prospective    split-mouth Randomized Clinical Trial
    18-54 (26.2)
    N= 52
    20/32
    Piezo = 52
      Rotary = 52
  
  
    Sivolella et al. [28] 
    Prospective Crossover    Randomized Clinical Trial
    14-18 (15.4±1.29)
    N=26
    16-Oct
    Piezo = 26
      Rotary =26
  
  
    Sortino et al.[29] 
    Clinical Trial
    (P)14-39 (23.26±6.62)
      (R)14-45 (24.36±6.23)
    N= 100
    46/54
    Piezo = 50
      Rotary = 50
  
  
    ^*Max: Maxillary; Mand: Mandibular



Table 1:  Characteristics of the study.

Characteristics of the surgical procedure

In all studies [9,18-29] impacted third molar extractions were done under local anesthesia with the use of a full thickness mucoperiosteal flap. In 12 studies [9,18-23,25-29] the duration of procedure was reported, which ranged from: 15.77±6.56 to 45±16 minutes for the piezosuregery group; 11.77±6.24 to 35±11 minutes for the rotary group; and 7.22±0.15 to 30±8.7 minutes for the chisel group.

Eight studies [9,18,19,22,25-28] reported use of pre-operative medications; six studies [9,18,19,22,26,27] used pre-operative antibiotics either 1 hour before the procedure or the day before the procedure and doses varied from 500mg amoxicillin to 2g of amoxicillin and clavulanic acid. In two studies [25,28] patients were instructed to use antiseptic mouth rinse (0.2% Chlorhexidine) 1 minute before the surgery.

Post-operative antibiotics were reported in 10 studies [9,18,19,21,25-29], in which five studies [9,18,19,22,26] amoxicillin and clavulanic acid were prescribed, and in two studies [27,28] amoxicillin was prescribed alone. Sortino et al. [29] prescribed intramuscular injections of 2g piperacillin, Yongbo et al. [21] prescribed a combination of acetylspiramycin and Metronidazole and Mozzati et al. [25] used an unspecified antibiotic.

Ten studies [9,18,19,22,25-29] reported the use of post-operative pain analgesics. Naproxen sodium was prescribed in two studies [9,18], Ibuprofen was prescribed in two studies [26,27], Paracetamol was prescribed in one study [19], Nimesulide was prescribed in one study [28], Diclofenac was injected intramuscularly in one study [29], and the type of analgesic was not reported in two studies [22,25].

In six studies [9,18,19,25,27,28] oral rinses were used post operatively, in which five studies [9,18,25,27,28] used Chlorohexidine 0.12% or 0.2% , and one study19 used a 50%-50% Peroxide mouthwash.

In all studies [9,18-29] the patients were followed from day 0 to post-operative day 90 (Table 2).

Table 2: Characteristics of the surgical procedure.




  
    Author
    Anesthesia
    Duration of    Procedure (min)
    Follow up time    (days)
    Medication preoperative
    Medication    post-operative
  
  
    Barone et al. [18] 
    NA
    (P) 34.3±7.4
      (R) 30.5±4.4
    1,3,5,7
    2g of    (Amoxicillin+Clavulanic Acid)1 hour before the surgical procedure
    1gm    (Amoxicillin+Clavulanic acid) 2/day for 5 days 550 mg of naproxen sodium,    when needed; and chlorhexidine mouthwash for 14 days.
  
  
    Bartuli et al. [19] 
    3% Mepivacaine    Without Epinephrine
    (P) 54.50
      (R) 32.73
    5,10,20,90
    -1gm    (Amoxicillin+Clavulanic Acid)
    -1gm    (Amoxicillin+Clavulanic acid) 2/day for 5 days
      -Paracetamol 1000mg
      -50%-50% H2O2+H2O
  
  
    Chang et al. [20] 
    NA
    NA
    1,2,3,4,5,6,7
    NA
    NA
  
  
    Gao,Y et al. [21] 
    Primacaine
    (P) 16±5.2
      (C) 30±8.7
    2-Jan
    NA
    Acetylspiramycin, metronidazole
  
  
    Goyal et al. [22] 
    2% Lignocaine
    (P) 45±16
      (R) 35±11
    0,1,3,5,7,15
    -625 mg    (Amoxicillin+Clavulanic Acid)
    -625 mg    (Amoxicillin+Clavulanic Acid) 3/day
      -Analgesic
  
  
    Guo Z et al. [23] 
    Primacaine
    (C) 7.22±0.15
      (P) 25.23±0.32
      (R)14.12±0.12
    1
    NA
    NA
  
  
    Itro et al. [24] 
    NA
    (P) 20
      (R) 15
    1,2,3,7
    NA
    NA
  
  
    Mantovani et al. [9] 
    Mepivacaine with    epinephrine
    (P)^*21.50±8.64
      ^*19.33±6.45
      ^*20.16±7.11
      (R)*18.75±5.87
      ^*16.52±5.22
      ^*18.74±5.96
    2,7,14,28
    -2gm    (Amoxicillin+Clavulanic Acid) 1 h before operation
    -2gm (Amoxicillin+Clavulanic    Acid)/day
      -Naproxen 550mg
      -0.12%    Chlorhexidine
  
  
    Mozzati et al. [25] 
    4% Articaine with    epinephrine
    (P) 33±5
      (R) 25±5
    7,14,30,90
    -No antimicrobial
      - Rinse with    Chlorhexidine 1 min before operation
    Antibiotic
      Anti-inflamatory
      Chlorhexidine 0.12%
  
  
    Piersanti et al. [26] 
    Mepivacaine with    Epinephrine
    (P) 36.8±10.6
      (R) 30.8±6.1
    1,2,3,4,5,6,7
    -2gm    (Amoxicillin+Clavulanic Acid) 1 h before operation
    -2gm    (Amoxicillin+Clavulanic Acid)/day
      -Ibuprofen 600mg
  
  
    Rullo et al. [27] 
    4% Articaine with    Epinephrine
    (P) ^*16.47±3.38
      ^*20.67±4.46
      (R) ^*18.34±4.42
      ^*28.73±5.46

    0,1,2,3,4,5,6
    500mg Amoxicillin    3/day 1 day before surgery
    500 mg Amoxicillin    for 6 days starting the day of surgery
      -Ibuprofen 600mg    3/day for 4 days
      - Chlorhexidine    0.12% for 7 days from day after surgery
  
  
    Sivolella et al. [28] 
    Mepivacaine
    (P) 15.77±6.56
      (R) 11.77±6.24
    30-Jul
    -Rinse with 0.2%    Chlorhexidine 1min before operation
    -Amoxicillin    50mg/kg 2/day for 6 days
      - Nimesulide 50mg    3/day as necessary
      -0.2% Chlorhexidine    3/day for 6 days
  
  
    Sortino et al.[29] 
    NA
    (P) 22.92
      (R) 17
    1
    NA
    Injection of 2 g    piperacillin and 75 mg diclofenac, twice daily byIM administration, for 4    days.
  
  
    ^*(P) Piezosurgery; (R) Rotary    instruments; (C) Chisels



Table 2:  Characteristics of the surgical procedure.

Post-operative outcomes and complications

Post-operative pain scores in the first days after surgery ranged from 3.55±1.43 to 5.97±2.14 in the piezosurgery group and 4.1±2.5 to 7.4±3.0 in the rotary group. Guo Z et al. [23] reported that mild pain was reported more frequently in the piezosurgery group compared to the chisel group, but moderate and severe pain were greater in the chisel group compared to the piezosurgery group.

In nine studies [9,18,20-22,25,26,28,29] there was no significant difference between piezosurgery and conventional techniques; in the study by Itro et al. [24] manifestation of post-operative swelling was greater in the conventional technique groups compared to the piezosurgry group.

On post-operative day 1, nine studies [18,20-22,24-26,28,29] reported trismus, which ranged from 11.15 to 38.2mm in the piezosurgery group and 14.76 to25.4mm in the rotary group. Yongbo et al. [21] reported that trismus was 17.86±10.11mm in the chisel group.

Post-operative infection or dry socket was only reported in five studies [9,19,23,25,28] ;post-operative infection or dry socket was greatest in the chisel group, followed by the rotary group, and was least in the piezosurgery group (Table 3).

Table 3: Post-operative outcomes and complications.




  
    Author
    Pain
    Duration of pain    (days)
    Severity of Pain
    Swelling
    Duration /severity    of swelling
    Trismus
    Numbness of lips    and tongue
    Infection/
      Dry socket
  
  
    Barone et al. [18] 
    Y
    7
    (P) 5.1±1.4 @ 1^st day
      (R) 5.3±1.5 @ 1^st day
    Y
    R>P @ 5^th day
    (P) 7^th day 38.5±3.7
      (R) 7^th day 35.6± 
    NA
    NA
  
  
    Bartuli et al. [19] 
    Y
    10
    (P) 5.97@ 5 days
      (R) 6.89@ 5 days
    NA
    NA
    NA
    NA
    -Exudates 3cases after    10 days
      -Infection 1 case    after 30 days
  
  
    Chang et al. [20] 
    
    (P) 2.2±1.2
      (R) 2.2±1.2
    (P) 4.1±2.3
      (R) 4.1±2.5
    Y
    (P) 3.6±1.9 days
      (R) 3.7±1.9 days
    P>R 2^nd day
    NA
    NA
  
  
    Gao,Y et al. [21] 
    Y
    2
    Mild pain P>C
      Moderate and severe    pan C>P
    Y
    (P) 42.20±10.12%
      (C) 66.36±11.65%
    (P) 12.72±8.23 mm
      (C) 7.86±10.11 mm
    NA
    NA
  
  
    Goyal et al. [22] 
    Y
    15
    (P) 1^st day 3.55(1.43)
      (R) 1^st day 6.45(1.19)
    Y
    (P) 3^rd day 11.44(0.49) cm
      (R)3^rd day 12.36(0.96) cm
    (P) 7^th day 4.48(0.81)
      (R) 15^th day 4.34(0.75)
    (P) 0
      (R) 1
    NA
  
  
    Guo Z et al. [23] 
    Y
    (C) 62.15±1.51 hours
      (R) 48.23±1.23 hours
      (P) 14.34±0.80 hours
    NA
    NA
    NA
    NA
     
      (C) 6
      (R) 2
      (P)0
    (C) 9
      (R) 2
      (P) 1
  
  
    Itro et al. [24] 
    NA
    NA
    NA
    Y
    (P) 1^st day 2.86mm
      (R) 1^st day 6.23mm
    (P) 1^st day 11.15mm
      (R) 1^st day 14.76mm
    NA
    NA
  
  
    Mantovani et al. [9] 
    Y
    7
    (P) 2^nd day 5.97±2.14
      (R) 2^nd day 6.09±2.08
    Y
    7^th day
      (P) 1.02
      (R) 1.10
    NA
    (P) 0
      (R) 1 temporary    numbness resolved after 4 weeks
    (P) 0
      (R) 2 Dry socket
  
  
    Mozzati et al. [25] 
    Y
    7
    R>P from day 1    to day 7
    Y
    R>P
    7^th day
      (P) 0
      (R) 1
    NA
    (P) 0
      (R) 1 Dry socket
  
  
    Piersanti et al. [26] 
    Y
    7
    (P) 5.5±3.0
      (R) 7.4±3.0
    Y
    7^th day
      (P) 2.75±0.23cm
      (R) 3.1±0.39cm
    2^nd day highest values
      R>P
    NA
    NA
  
  
    Rullo et al. [27] 
    Y
    6
    R>P day 0 simple    extractions
      P>R day 0 to day    6 for complex extractions
    NA
    NA
    NA
    NA
    NA
  
  
    Sivolella et al. [28] 
    Y
    30-Jul
    7^th day
      (P) 14 patients
      (R) 24 patients
      30^th day
      (P) 5 patients
      (R) 4 patients
    Y
    7^th day
      (P) 7 patients
      (R) 8 patients
      30^th day
      (P) 1 patient
      (R) 1 patient
    7^th day
      (P) 3.89(0.99)
      (R) 3.94(0.77)
      30^th day
      (P) 4.71(0.68)
      (R) 4.52(0.48)
    NA
    7^th day
      (P) 0
      (R) 1
      30^th day
      (P) 0
      (R) 2
  
  
    Sortino et al.[29] 
    Y
    NA
    NA
    Y
    (P) 4.22±3.21 cm
      (R) 7.04±3.45 cm
    (P) 12.52±7.99 mm
      (R) 16.76±9.11 mm
    NA
    NA
  
  
    ^*(P) Piezosurgery; (R) Rotary    instruments; (C) Chisels



Table 3:  Post-operative outcomes and complications.

Quality assessment of included studies

Quality assessment identified that all the studies were conducted on humans and the total quality score ranged from 8 to 11. On average, the quality of included studies on efficacy of piezosurgery compared to conventional techniques was good. The most common shortcomings among all studies were the short term, incomplete follow up of the groups and omission of confounding variables like smoking, which could limit the application of the study outcomes. Quality assessment of the individual studies is summarized in Table 4.

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Citation:Farag AS, Kellesarian SV, Javed F, Arany S and Malmstrom H. Efficacy of Piezosurgery versus Conventional Techniques in the Surgical Extraction of Third Molars: A Systematic Review. J Dent & Oral Disord. 2016; 2(3): 1015. ISSN:2572-7710

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