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71]

Original Article ‑ Comparative Study

Piezosurgery Versus Conventional Method Alveoloplasty

Khushal D. Gangwani, Lakshmi Shetty, Deepak Kulkarni, Ratnadeepika Seshagiri, Ratima Chopra
Department of Oral and Maxillofacial Surgery, Dr. D. Y. Patil Vidyapeeth’s, Dr. D. Y. Patil Dental College and Hospital, Pune, Maharashtra, India

Abstract
Purpose: Conventional alveoloplasty procedure using manual instruments results in higher resorption of the residual alveolar ridge,
which is unsuitable for denture construction. The purpose of this study was to evaluate the effect of piezosurgery‑assisted alveoloplasty
using minimally invasive technique compared to that of the conventional technique. Materials and Methods: This was a comparative
in vivo study. The study sample consisted of 35 edentulous patients with bilateral bony spicules requiring alveoloplasty. The primary
outcome variables assessed were time required for alveoloplasty, postoperative pain using visual analogue scale (VAS), and postoperative
healing using Landry, Turnbull, and Howley healing index. The differences between the outcome variables were statistically analyzed
using paired t‑test. Results: The participants consisted of 35 patients (25 men and 10 women; age range: 38–83 years) diagnosed
with bilateral bony spicules on the edentulous alveolar ridge. There was a statistically highly significant difference between both
groups with respect to the outcome variables such as time required, VAS at 2nd day, and healing index at 7th day with higher mean of
time required (in sec), higher mean of VAS, and lower healing index for conventional group as compared to piezo group (P < 0.05).
Conclusion: Alveoloplasty done using piezosurgery not only reduces patient’s postoperative discomfort but also maintains the alveolar
bone integrity by not disturbing the soft‑tissue and hard‑tissue architecture, allowing faster healing of tissues, which makes the future
prosthesis replacement easier

Keywords: Alveoloplasty, minimally invasive, piezoelectric surgery, piezosurgery

Introduction O. T. Dean first described “Intra‑septal alveoloplasty” in the

A well‑contoured smooth alveolar ridge is crucial for
appropriate fabrication of complete or partial denture. While
contouring the ridge, it is highly essential to remember
that greater the excision of bone, higher will be resultant
resorption.[1] Therefore, the procedure of contouring should be
limited to excision of the irregular sharp ridges and unfavorable
undercuts which are unsuitable for denture construction.
Hence, the goal of alveoloplasty is to gain favorable tissue
support for the designed prosthesis, while conserving as much
soft tissue and hard tissue as possible.
Alveoloplasty is a term for preprosthetic surgical procedure
that involves smoothening of rough alveolar bone following
extractions on the edentulous area or trimming of bulbous
tuberosities, which creates deep undercuts. It is one of the
most common surgical techniques used to prepare the alveolar
ridges to procure a prosthesis. Historically, the procedure has
been recognized from more than a century. A. T. Willard in
1853 advocated reduction of the alveolar ridge to bring about
the complete proximity of soft tissues over the alveolus.[2] Sir
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American Dental Association journal in 1936. Hence, this
procedure also came to be known as Dean’s alveoloplasty.[3]
Technological advancement boldly gives the options to step
aside, lead, or follow. Piezosurgery or piezoelectric bone
surgery is a new innovative, assuring, precise system for
removal of hard tissue, sparing the soft tissues. It works on
the principle of ultrasonic vibrations.
Reports have been published of the use of this technology
in dentistry in maxillary sinus elevation procedures,[4,5]
bone harvesting, [6,7] expansion of alveolar crest, [8]
implantology, [9,10] periodontal surgery, [11] orthognathic
and maxillofacial surgery,[12‑14] and dental exposure and
Address for correspondence: Dr. Khushal D. Gangwani,
Sonigara Aangan Society, F‑508, Near ISKCON Temple, Ravet,
Pune ‑ 412 101, Maharashtra, India.
E‑mail: khushalhkhr@gmail.com
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which
allows others to remix, tweak, and build upon the work non‑commercially, as long
as appropriate credit is given and the new creations are licensed under the identical
terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Gangwani KD, Shetty L, Kulkarni D, Seshagiri R,
10.4103/ams.ams_162_18 Chopra R. Piezosurgery versus conventional method alveoloplasty. Ann
Maxillofac Surg 2018;8:181-7.

© 2018 Annals of Maxillofacial Surgery | Published by Wolters Kluwer - Medknow 181

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Gangwani, et al.: Minimally invasive Piezo-alveoloplasty
extractions. [15] However, to the best of our knowledge,
no studies until now have been published for the use of
piezosurgery with the minimally invasive technique for
alveoloplasty procedure.
Therefore, this study aims at evaluating the efficacy of
alveoloplasty done with piezosurgery system compared with
that of the conventional technique. The parameters to be
compared between the two systems will be – the time required
for the procedure, postoperative pain, and healing of the soft
tissues.
Materials and Methods
Study design and sample
To address the research purpose, the authors designed
and implemented a split‑mouth in vivo study after
receiving approval from the Institutional Review Board
and Ethics Committee. The study was conducted in
accordance with the Declaration of Helsinki. Written
informed consent was obtained from all patients after they
were given full written and verbal information regarding the
study.
The study population comprised all edentulous patients
with bilateral bony spicules on the alveolar ridge indicated
for alveoloplasty who presented to the institute’s dentistry
outpatient department between January 1, 2016, and
January 1, 2017. Patients with bilateral bony spicules with
2‑mm maximal diameter on either side were included in
this study. Patients with bleeding disorders, uncontrolled
systemic comorbidities, unilateral bony spicules, and
maximal bony spicule diameter exceeding 2 mm were
excluded from the study.
Methodology
In the recruited patients, using Sequentially Numbered Opaque
Sealed Envelopes randomization technique, a site on which the
piezo alveoloplasty to be performed was selected.
All the surgical procedures and postoperative assessments
were performed by the same surgeon. Preoperatively,
patients were required to gargle with 0.12% chlorhexidine
mouthwash  (Oradex) for a minute. After performing
standard painting and draping of the site, local anesthetic
(2% lignocaine hydrochloride with 1:200,000 Adrenaline)
was injected in the mucobuccal fold over the prominent bony
spicule region.
Once complete anesthesia of the planned surgical area was
achieved, crestal and releasing incisions were taken, and the
full thickness flap was reflected [Figure 1]. Bony contouring
was accomplished with bone files, rongeurs forceps, or
burs [Figure 2]. Digital palpation was used to determine
the uniformity of the ridge. The flap was approximated
and secured with nonresorbable suture  (3‑0 silk suture,
Monodek®) [Figure 3]. The surgical procedure was timed from
the first incision to the last suture.
182 Annals of Maxillofacial Surgery  ¦  Volume 8  ¦  Issue 2  ¦  July-December 2018
On the other contralateral side of the arch, a stab incision was
placed mesial or distal to the bony spicule using a surgical
blade (No. 15) [Figure 4]. A small‑sized tip periosteal elevator
was passed underneath the stab incision, and subperiosteal
tunneling was done until the prominent bony spicule was
reached [Figure  5]. A Piezo blade of Rhomboid shape
(EX‑03, Dmetec Surgystar®, Korea) was then inserted through
the subperiosteal tunnel up to the bony spicule. The piezo
unit was switched on with frequency set at of 25–29 kHz in
“boosted” mode with saline flow of 60  ml/min [Figure  6].
The bony spicule was shaved off carefully in a unidirectional
motion of the piezo blade [Figure 7]. The motion was continued
until the bony spicule was no longer digitally palpated. The
time from the start of the incision till the end of alveoloplasty
was noted.
Both the surgical procedures, conventional alveoloplasty, and
alveoloplasty using piezosurgery were performed in the same
surgical session.
Postoperatively, patients were prescribed an analgesic
(500  mg of Aceclofenac 8 h for 5  days) and antibiotic
(250  mg of amoxicillin every 8  h for 5  days). In case of
amoxicillin allergy, erythromycin (250 mg every 8 h for 5 days)
was prescribed. Choice of analgesic and antibiotic was based
on the standard institutional protocol.
The postoperative pain at the operated site was assessed
by visual analog scale  (VAS)[16] [Figure 8] on the second
postoperative day  (POD). Sutures were removed on the
7th POD and the healing was assessed using Landry et al.
index[17] [Table 1].
The obtained values were recorded, tabulated, and statistically
evaluated.
Results
The participants consisted of 35  patients  (25 men and 10
women; age range: 38–83  years, mean age: 60.8  years)
diagnosed with bilateral bony spicules on the edentulous
alveolar ridge.
Statistical package for the (SPSS) version 21.0 (SPSS,
Inc, Mumbai, India) was used for the statistical analysis.
There was no significant difference in patient age and
size of the bony spicules. However, gender was noted
to be a confounding factor because the male population
predominated [Figure 9].
Descriptive statistics such as mean, standard deviation,
frequency, and percentage of independent variables
have been expressed. Intergroup comparison of outcome
variables, such as time required for surgery, VAS score for
pain assessment, and the healing index, was done using
paired t‑test where P <  0.05 was considered statistically
significant.
There was a statistically highly significant difference
between both groups with respect to outcome variables such
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Gangwani, et al.: Minimally invasive Piezo-alveoloplasty

Figure 1: Crestal incision along with releasing incisions Figure 2: Excision of bony spicule using rongeurs forceps

Figure 3: Closure with interrupted 3‑0 black silk Figure 4: Stab incision adjacent to the bony spicule

Figure 5: Subperiosteal tunneling

Figure 6: Piezo unit
as time required in seconds, VAS at 2  day, and healing
nd

index at 7th day. It was observed that mean time required (in Pain

sec), and mean VAS was higher and mean healing index The patients in the piezo subgroup reported a significantly
was lower for the conventional group as compared to piezo lower VAS score at the surgery site on POD 1, compared to the
group [Table 2]. conventional subgroup. The mean VAS score was 2.74 for the

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Gangwani, et al.: Minimally invasive Piezo-alveoloplasty
conventional method and 0.94 for the piezosurgery method with
the standard deviation of 1.2 and 0.7, respectively [Figure 10].
Operative time
The reported operative time in the piezosurgery
alveoloplasty subgroup was significantly less compared
to the conventional site subgroup. The mean time required
for the alveoloplasty by conventional method was
Figure 7: Alveoloplasty using piezo blade EX‑03
Figure 9: Gender distribution
Figure 11: Comparison of operative time
184
255.20 s and for the procedure by piezosurgery technique
was 132.37 s with a standard deviation of 109.8 and 78.2,
respectively [Figure 11].
Healing index
The operative site in piezosurgery subgroup showed
significantly better and faster healing compared to that in the
conventional subgroup. The healing index by Landry et al.[17] on
the 7th POD for the conventional method was 3.11 and for the
piezosurgery method was 4.31 with standard deviations being
0.71 and 0.67, respectively [Figure 12].
Discussion
Except for the extraction of natural teeth, the most commonly
performed preprosthetic surgical procedure is alveolectomy
or alveoloplasty.
Alveolectomy has been defined by Boucher in 1974 as
“removal of a part of the alveolus by surgery.”[1] In recent
Figure 8: Visual analog score
Figure 10: Comparison of visual analog scale
Figure 12: Comparison of postoperative healing
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Gangwani, et al.: Minimally invasive Piezo-alveoloplasty
years, the term “Alveoloplasty” has been adopted to signify
recontouring of the alveolar process rather than its removal.
Thoma has stated that there is requirement of alveoloplasty in
almost every patient who has undergone multiple extractions
and may also be needed in those with single extraction.[18] The
goal for contouring the alveolar ridge is to gain favorable tissue
support for the designed prosthesis while conserving as much
soft tissue and hard tissue as possible.[19]
Historically, alveoloplasty is known to the field of surgery
for the past few decades. W. G. Beers in 1976 coined the
phrase “heroic treatment of alveolectomy” in which large
portions of alveolus were removed with cutting forceps. In
1905, W. Shearer advocated and elaborated on alveolectomy
to eradicate gingival and alveolar pathosis and to serve as a
foundation for the prosthodontist to prepare a denture.[20] The
problems of excessive bone resorption after alveolectomy
were addressed when in 1936 Sir O. T. Dean published and
Table 1: Healing index (Landry, Turnbull and Howley)
HEALING INDEX CRITERIA
VERY POOR 1 Tissue color: more than 50% of gingivae red
Response to palpation :bleeding
Granulation tissue: present
Incision margin: not epithelialised, with loss
of epithelium beyond margins
Suppuration: present
POOR 2 Tissue color: more than 50% of gingivae red
Response to palpation: bleeding
Granulation tissue: present
Incision margin: not epitheliased with
connective tissue exposed.
GOOD 3 Tissue color: less than 50% of gingivae red
Response to palpation: no bleeding
Granulation tissue: none
Incision margin: no connective tissue
exposed
VERY GOOD 4 Tissue color: less than 25% of gingivae red
Response to palpation: no bleeding
Granulation tissue: none
Incision margin: no connective tissue
exposed
EXCELLENT 5 Tissue color: all gingivae pink
Response to palpation: no bleeding
Granulation tissue: none
Incision margin: no connective tissue exposed
Table 2: Comparison of outcome variables
Outcome variables Groups n Mean
Time required (Sec) Conventional 35 255.20
Piezo 35 132.37
VAS 2d Conventional 35 2.74
Piezo 35 0.94
Healing Index 7d Conventional 35 3.11
Piezo 35 4.31
**=Statistically highly significant difference (P<0.01)
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revolutionized the process of alveoloplasty by introducing
intraseptal alveoloplasty, a procedure he had been using for
20 years.[3] Since then, there has not been any improvement
or change in the procedure. Dean differed from other pioneers
in the field of preprosthetic surgery in that he advocated the
preservation of the labial cortex, preferring instead to sacrifice
the interradicular medullary bone to achieve optimal alveolar
ridge contour. Dean’s intraseptal alveoloplasty was particularly
well suited for immediate denture surgery. For the cases of
extreme premaxillary protrusion, Obwegeser in 1966 suggested
a modification of Dean’s technique wherein both the palatal
and labial cortices were fractured and repositioned.
In 1976, Michael and Barsoum[1] studied the amount and
duration of postoperative bone resorption and ridge contour
changes in immediate denture patients using various surgical
techniques such as: (1) simple extractions without additional
surgery,  (2) extractions with labial cortical alveolectomy,
and (3) extractions with Dean’s intraseptal alveolectomy. Using
serial sagittal contour photographs of study casts and serial
cephalometric radiographs of patients, they showed that the
three techniques produced almost the same amount of bone
resorption at the end of 3 months, but thereafter, the differences
were noteworthy  (with statistical significant difference). At
the end of 6 and 12 months, the nonsurgical extractions had
produced the least amount of bone resorption with a marked
slowing of the rate by 6 months, whereas both alveoloplasty
techniques resulted in continuing bone resorption.
Piezoelectric technique was introduced in oral surgery during
the 1970s when Horton examined the recovery process of dogs
that had undergone osteotomy.[21] It works on the principle of
piezoelectric effect, first reported in 1880 by Marie and Jean
Curie that asserts that some crystals and ceramics change their
shape when an electric current is sent across them, producing
oscillations of ultrasonic frequency. There is amplification
of vibrations with minimum pressure on hard tissue, which
produces cavitation phenomenon, which is a mechanical
cutting phenomenon occurring particularly on hard tissues.
The piezoelectric instrument develops a regulated ultrasonic
frequency of 24–29 kHz, and a microvibration amplitude of
60–200 mm/s. Soft tissues remain unharmed at this frequency,
but may also be damaged at frequencies above 50  kHz.
Microstreaming and cavitation phenomenon are peculiar
features of piezosurgery.
Std. deviation Std. error mean P of t-test
109.854 18.569 0.000**
78.258 13.228
1.221 0.206 0.000**
0.765 0.129
0.718 0.121 0.000**
0.676 0.114
185
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Gangwani, et al.: Minimally invasive Piezo-alveoloplasty
In bone microsurgery, two fundamental concepts principally
govern the philosophy behind the development of piezoelectric
bone surgery. The first being minimally invasive surgery in
which the postoperative pain and swelling is much lower
as compared to traditional techniques because of improved
tissue healing, ultimately reducing patient discomfort. The
second concept which increases the effectiveness of the
treatment is surgical predictability. The development of
piezoelectric bone surgery has indeed optimized the surgical
results even in the most complex and unfavorable anatomical
cases due to ease of controlling the instrument leading to
reduced hemorrhages, precise cuts eventually producing
excellent tissue healing.
Subperiosteal tunneling, a minimally invasive access
procedure, was a technique used by Kim et al. in horizontal
ridge augmentation procedure in which the authors prepared a
subperiosteal cavity with a periosteal elevator, and a selection
of bone graft materials was placed into the tunnel to augment
the deficient alveolar ridge.[22] A similar technique is used
in this study to get access to the bony spicule and perform
alveoloplasty using the contrangled piezo blade. The advantage
of this minimally invasive sutureless technique is reduced
healing time with lesser postoperative discomfort.
According to a prospective study by Waite and Cherala, the
authors stated that tight closure over a large bony socket
or defect does not facilitate drainage and oral hygiene.[23]
Suturing may create a one‑way valve that allows food debris
to enter the socket but not easily escape which may lead to
local infection, inflammation, edema, clot necrosis, alveolar
osteitis, and pain. A small flap left open without suturing may
facilitate drainage, improve hygiene, and reduce the risk of
pain associated with alveolar osteitis. Hence, we performed a
sutureless alveoloplasty technique in our study.
In studies conducted by Sortino et al.[15] and Goyal et al.[24]
comparing the efficacy of piezosurgery and conventional
rotatory instruments for impacted mandibular third molar
removal, the authors concluded that there was a reduction in
postoperative pain, facial swelling, and trismus in piezosurgery
group, while the operative time was higher in the same
compared to the control group. However, in this study, the
operative time in piezo group was lesser compared to control
group owing to the lack of need for suturing of the minimally
invasive incision.
Labanca et  al.[25] reported the advances in piezosurgery
over the last 20 years and focused on its uses in different
surgical areas. In oral and maxillofacial surgery, it has
been used in orthognathic surgeries, rhinoplasties, and
surgical extractions. After studying the use of piezosurgery
in all these clinical scenarios, the authors concluded that
piezoelectric surgery is an innovative technique for safe and
effective osteotomy owing to the lack of macro vibrations,
ease of use, and controlled and safe cutting. It seems to be
more efficient in the first phases of bony healing, inducing
an earlier increase in Bone Morphogenic Proteins (BMPs),
186 Annals of Maxillofacial Surgery  ¦  Volume 8  ¦  Issue 2  ¦  July-December 2018
controlling the inflammatory process better, and stimulating
bony remodeling as early as 56 days after treatment. There are
few limitations also which include slightly longer osteotomy
time and increasing heat transmission due to increasing
working pressure which can lead to tissue damage unless
used carefully.
Conclusion
Among the various instruments and techniques used for
alveoloplasty, piezosurgery using the minimally invasive
incision has proved to be a better alternative by minimizing the
operative time, reducing patient’s discomfort, and accelerating
the healing process. Therefore, this study justifies the use of
piezosurgery in atraumatic alveoloplasty in all patients.
There are few limitations to this study. The sample size in the
study is small. However, the findings were consistent across
all patients. Studies using larger sample size are needed to
establish the findings with higher statistical significance.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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