ORIGINAL ARTICLE
Third-Molar Extraction With Ultrasound Bone Surgery: A
Case-Control Study
Marco Mozzati, DDS,* Giorgia Gallesio, DDS,* Andrea Russo, DDS,† Giorgio Staiti, DDS,‡
and Carmen Mortellaro, MD, DDS§
Purpose: The aim of this case-control study was to evaluate the
postoperative period and healing between 2 surgical methods (tradi-
tional and ultrasound bone surgery) that are used for mandibular
third-molar extraction.
Patients and Methods: Fifteen patients with impaction of both of
the lower third molars and indications for their extractions were
used in this study. Bilateral-mandibular third-molar extractions were
performed at the same surgical time: traditional surgery with burrs
was used on 1 side (control site), and ultrasound surgery was used
on the other side (test [T] site). After surgery, the patients were ex-
amined at 7 and 14 days and at 1 and 3 months to evaluate tissue
healing. The following was assessed at every follow-up: pain, tris-
mus, swelling, and alveolar bone level.
Results: The study included 15 patients, and 30 mandibular third-
molar extractions were performed. We found only 1 postoperative com-
plication: 1 patient had alveolitis in the control site. Complete recoveries
without any complications were reported in all of the patients at the
T sites.
Conclusions: Complete recoveries without any complication were
reported in all patients at the T sites. The only disadvantage of the
piezoelectric technique was the length of operation time, which
was increased by approximately 8 minutes; however, this effect
was offset by reducing the morbidity.
Clinical Relevance: Our preliminary study showed that Piezosurgery
is an excellent tool for reducing the risk of complications and improv-
ing the postoperative period.
Key Words: Piezosurgery, bilateral-mandibular third-molar
extractions, low-speed rotary instruments, intraoperative visibility,
osteotomy, odontotomy
(J Craniofac Surg 2014;25: 856–859)
From the *SIOM Oral Surgery and Implantology Center, Turin, Italy;
†Trainer Oral Surgery Unit, Dentistry Section, Department of Clinical
Physiopathology, University of Turin, Turin, Italy; ‡Assistant Oral Sur-
gery Unit, University of Eastern Piedmont, Novara, Italy; and §Professor
of Stomatology and Oral Surgery, Department of Health Sciences “A.
Avogadro,” University of Eastern Piedmont, Novara, Italy.
Received January 14, 2014.
Accepted for publication January 25, 2014.
Address correspondence and reprint requests to Marco Mozzati, MD, DDS,
SIOM Srl Studio Medico Odontoiatrico, Corso Dante 64, 10126 Torino,
Italy; E-mail: marcomozzati@libero.it
The authors report no conflicts of interest.
Copyright © 2014 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000000825
856 The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
M andibular third-molar tooth extraction, which is frequently
unerupted,1 is the most common oral surgical procedure and
is often associated with intraoperative and postoperative complica-
tions. It may cause damage to hard and soft tissues that are adjacent
to the postextractive socket. In addition, the postoperative period is
frequently characterized by swelling and pain, which is sometimes
quite severe, and temporary, restricted mouth opening and mastica-
tory capabilities.2
Once a clear indication for a lower third-molar tooth extrac-
tion has been made, the surgeon devises a strategy to reduce the risk
of complications and to improve the postoperative healing. Some
studies have found that the severity of postoperative pain and swell-
ing seems to be related to the surgical difficulty or to the degree of
intraoperative tissue damage.3,4 Various proposals have been dis-
cussed over the years to reduce postoperative discomfort, such as
the use of a postoperative ice pack,5 postoperative administration
of antibiotics or cortisone,6 and osteotomies by low-speed rotary
instruments.7 As such, since 1988, some authors have proposed ul-
trasound bone surgery for performing osteotomies as an alternative
to traditional instruments.8 According to some experimental animal
studies, histologic and histomorphometric evidences of wound
healing and bone formation have demonstrated a better tissue re-
sponse to surgical trauma using Piezosurgery, as compared with
conventional bone-cutting techniques, such as diamond or carbide
rotary instruments.9,10 Piezoelectric surgery is very efficient be-
cause it is inert against soft tissues, including nerves and blood
vessels. Traditional burs and micro saws do not distinguish between
hard and soft tissues.11,12 In addition, the cavitation phenomenon
produces an important hemostatic effect to optimize intraoperative
visibility and permit great intraoperative visibility control, which
increases safety.13,14
The aim of this study was to evaluate the postoperative period
and healing between 2 surgical methods (traditional and ultrasound
bone surgery) that are used for mandibular third-molar extractions.
MATERIALS AND METHODS
This study was performed at the Dental School in Torino,
Italy, between January 2007 and January 2008. Fifteen patients
(8 women and 7 men) who were 18 to 35 years old had both lower
third molars impacted, and indications for their extractions were en-
tered into the study. The exclusion criteria were as follows: teeth
with acute infection, patients with systemic diseases, irradiation to
the head or neck region within 12 months of surgery, pregnancy,
poor oral hygiene, and poor motivation to return for follow-up
visits. We selected cases that showed similar, difficult surgical
conditions, such as location of the tooth compared with the jaw,
depth of inclusion, ramus relationship, number of roots, and rela-
tionship to the alveolar inferior nerve. All of the selected patients re-
quired an osteotomy and odontotomy in the context of the surgical
intervention. The mandibular third-molar extraction difficulty was
moderate (class II, level B), which was assessed using the clas-
sifications of Pell and Gregory.15
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
No patient had acute pericoronitis or severe periodontal dis-
ease at the time of surgery. Before entering the study, all patients
were visited, and an orthopantomography (OPT) and computed to-
mography (CT) scans were prescribed for the initial assessments.
In addition, they were informed about the nature of this study, and
they signed an informed consent form.
SURGICAL PROCEDURE
The patients were treated by the same surgeon with good
clinical expertise and the same assistant. All of the patients under-
went a radiologic examination, which included panoramic OPT and
a CT scan.
Bilateral-mandibular third-molar extractions were performed
at the same surgical time: traditional surgery was used on 1 side
with burs (control [C] site), and ultrasound surgery was used on
the other side (test [T] site) (Fig. 1). Patients rinsed with 0.12% of
chlorhexidine for 1 minute, and they were not given preoperative
antimicrobial or other drugs that might influence healing.
Surgery was performed under local anesthesia by nerve-
blocking agents to the inferior alveolar, lingual, and buccal nerves
with 4% of articaine chlorhydrate and epinephrine (1:100,000).
All third-molar extractions were performed by raising a full-thickness
mucoperiosteal flap. The surgeon used the same surgical approach
for both surgeries and only changed the instrument that was used.
After the mucoperiosteal flap reflection in the C sites, a burr was
used, and in the T sites, an ultrasound device was used (Piezosurgery,
Mectron SPA, Carasco, Italy). At the C sites, osteotomy was first
performed using a Lindemann-type burr on a straight handpiece
with constant irrigation, which was followed by odontotomy with
a tungsten carbide burr under abundant irrigation. At the T sites,
osteotomy was performed by OT3, and odontotomy was performed
by EX1 and EX2. All parts of the tooth were loosened with a lever
and removed. In all cases, 3-0 silk sutures were used for wound clo-
sure, and they were removed after 7 days. An icepack was then
applied to the surgical area for 6 hours after surgery, alternating
30 minutes on with 30 minutes off.
All patients were prescribed antibiotic and anti-inflammatory
medicines (1 g of amoxicillin and clavulanic acid every 12 hours on
the day of surgery for 6 days and 400 mg of nimesulide twice daily
for 3 days). Corticosteroids were not used in either the preoperative
or postoperative period. In addition, the same postoperative instruc-
tions were given to all patients, which included a soft, warm diet for
FIGURE 1. Bilateral-mandibular third-molar extractions were performed at the
same surgical time: traditional surgery was used on 1 side with burs (C site),
and ultrasound surgery was used on the other side (T site).
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Ultrasound in Oral Surgery
the first 24 hours; normal oral hygiene after the day after surgery;
and mouthwash with 0.12% of chlorhexidine twice daily.
The time it took for each single tooth extraction (starting from
the first incision to the last suture) and the number of complications
were registered.
EVALUATION PROCEDURE
After surgery, patients were visited at 7 and 14 days and at 1
and 3 months to evaluate tissue healing. At every follow-up, the fol-
lowing were assessed: pain, trismus, swelling, and alveolar bone
level. Pain was assessed for both postextraction sites on a 10-cm vi-
sual analog scale (VAS; 0 representing absence of pain and 10 indi-
cating the most severe pain). The pain was evaluated every day at
the same time starting at the patient's home 2 hours after the extrac-
tion (T1) until day 7 (T7) of the postoperative period, at which time
the sutures were removed. Trismus was evaluated by measuring the
distance (cm) between the mesial incisal corners of the upper and
lower right-central incisors at maximum mouth opening.16 Facial
swelling was evaluated using horizontal and vertical guides with a
flexible ruler and a vernier caliper and the control points.17 The fa-
cial measurements corresponded to the mentalis angle (Go) and 4 fa-
cial points indicating the angle of the mandible: (1) ear tragus (Tr),
(2) external canthus of the eye (Ca), (3) nose spine (Sp), and (4)
buccal commissure (Po). The facial swelling score was obtained
by dividing the measures made in the postoperative period (days
2–7) by the value for the preoperative period (T0). The methods
for assessing trismus and facial swelling are reliable and rapidly re-
producible, as shown by other publications with high impact factors.18
The alveolar bone levels in the T and C sites were measured with a
plastic ruler that was graduated in millimeters before the extractions
(T0) and 1 (T1) and 3 months (T2) after the extractions. The mea-
surements were performed at the center of the buccal face (because
it is involved during the surgical incision) and at the center of the distal
surface (site involved during the osteotomy) of the second molar. All
clinical evaluations were performed by the same operator, and the
results are interpreted in this context.
The T sites showed facial swelling that was slight (0–5 mm),
moderate (6–9 mm), and high (10–13 mm) in 80%, 15%, and 5% of
the cases, respectively.
After the tooth extractions, all subjects received a question-
naire about the comfort and psychologic approaches to the 2 types
of surgeries, and they were invited to fill it out. The patients were
asked which operation they considered more comfortable and the
reasons why. They also assessed precise parameters, such as swell-
ing, pain, and bleeding. Finally, they were asked about their prefer-
ence on the type of surgery if they could have chosen it before it
was performed. The questionnaires were collected when the patients
visited the hospital for suture removal on postoperative day 7.
RESULTS
The study included 15 patients (8 women and 7 men) with a
mean age of 22.5 years (range, 18–35 y). Thirty mandibular third-
molar extractions were performed in these patients. Presurgical
evaluations were performed using an OPT and a CT scan. The mean
(SD) times it took for the extractions using a rotary instrument or an
ultrasound device were 25 (5) and 33 (5) minutes, respectively.
Important indicators of postoperative reactions after third-
molar surgery include determining trismus, swelling, and pain. Trismus
was evaluated by the degree of mouth opening after tooth extrac-
tion. Mouth opening was reduced at both postextractive sites after
surgery. At 7 days only, 1 patient had trismus after alveolitis in the
C site. None of the participants expressed any difficulties in using
the VAS to quantify the pain. The mean reported pain was highest
on the day of the surgery and declined steadily for both sites
857
Mozzati et al The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
FIGURE 2. The VAS for pain measurement in Piezosurgery and control sites.
after the surgery. Pain was higher in the C sites compared with the
T sites (Fig. 2). Figure 2 shows the difference in facial swelling be-
tween the T and C sites. There was less swelling at the T sites com-
pared with the C sites, and the differences were significant for all
of the 4 measurements (Fig. 3A–D). The alveolar bone levels at
the T and C sites were measured before the extractions and at 1
and 3 months after the extractions (Fig. 4). After 7 days, 5 patients
showed a complete recovery at the T sites (33%), but only 2 patients
showed a complete recovery at the C sites (13%). Complete healing
was found after 1 month in 11 T sites (74%) and 8 C sites (53%).
After 3 months, all sockets at both sites were healed.
Patients respond more positively to ultrasound surgery com-
pared with traditional surgery in the surgical and postsurgical phases.
In this sample of 15 patients, 13 responded positively and preferred
FIGURE 3. Measures of facial swelling for Piezosurgery and control sites. Go-Tr,
mentalis angle-ear tragus; Go-Po, mentalis angle-buccal commissure; Go-Sp,
mentalis angle-nose spine; Go-Ca, mentalis angle-external canthal of the eye.
858
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
FIGURE 4. Measures of the alveolar bone level for Piezosurgery and control sites
(T0, before the extractions; T1, 1 month from the extractions; T2, 3 months
from the extractions).
using the Piezosurgery intraoperatively (86.8%), 1 patient preferred
the traditional surgery (6.6%), and another one did not have a prefer-
ence (6.6%). After follow-up, 11 patients confirmed that they pre-
ferred the ultrasound surgery (74%), 2 preferred the traditional
surgery (13%), and 2 had no preference (13%).
DISCUSSION
This study was conducted to evaluate traditional and ultra-
sound bone surgeries that are used for extracting third molars. Be-
cause the ability of the surgeon may influence the surgery outcome,
all third-molar extractions were performed by the same surgeon and
the same assistant.19 We found only 1 postoperative complication in
this study, and it included 1 patient having alveolitis in the C site.
Complete recoveries without any complication were reported in all
patients at the T sites. The only disadvantage of the piezoelectric tech-
nique was the length of operation time, which was increased by ap-
proximately 8 minutes; however, this effect was offset by reducing
the morbidity.
Similar to previous studies, an association was not found be-
tween the length of operation time and the severity of postoperative
discomfort.20 However, some authors have observed that longer in-
terventions are typically associated with increased levels of pain.10
Our study is in contrast to these findings because the VAS score
was higher in the C sites compared with the T sites, despite the
length of operation time. Facial swelling was reduced at the T sites
compared with the C sites. These results show a positive correlation
between postoperative swelling and pain, which confirms what
MacGregor and Heart21 observed in 1969. They found that postop-
erative pain tended to occur when swelling was also present.
Associations between the clinical investigation, measurements
of lateral soft-tissue profile alterations, and the VAS have been
assessed to determine the degree of inflammation due to operative
trauma, and they can be used to perform a complete postoperative
evaluation. As demonstrated by Berge,22 using the VAS to evaluate
pain may be valid, and it has been proven to be a reliable and sensitive
method for recording pain after oral surgery procedures. Furthermore,
the pain for both sites was most severe on the day of surgery in our
study. This is similar to a study by Fisher et al23 that showed that
97% of patients reported more severe pain on their first day of surgery.
The VAS score was lower at the T sites than at the C sites, and the ul-
trasound instrument was the preferred method for lower third-molar
extraction. In addition, the patients had less bleeding and swelling at
the T sites.
Extracting lower mandibular molars may cause a periodontal
defect on the distal surface of the second molar, resulting in an in-
creased probing depth. Kan et al24 showed a relatively high preva-
lence of deep, residual periodontal defects on the distal surface of
the mandibular second molar after a surgical extraction of the adja-
cent, impacted third molar, which is in accordance with previous
studies. Our study showed no statistically significant differences be-
tween the control group and the group treated with Piezosurgery.
However, horizontal or mesial angulation of the lower third molar
may benefit from ultrasound bond surgery and its cavitation proper-
ties because oxygenation of the sockets seems to reduce the risk of
increasing the probing depth.
© 2014 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
CONCLUSIONS
In conclusion, our preliminary study showed that Piezosurgery is
an excellent tool to reduce the risk of complications and to improve the
postoperative period. Furthermore, appropriate preoperative evaluations
of the patients are important factors for proper surgical planning.
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Ultrasound in Oral Surgery
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