J Oral Maxillofac Surg

68:330-336, 2010

A Randomized Clinical Evaluation of

Ultrasound Bone Surgery Versus
Traditional Rotary Instruments in Lower
Third Molar Extraction
Antonio Barone, DDS, PhD, MSc,* Simone Marconcini, DDS,†
Luca Giacomelli, DDS, PhD,‡ Lorena Rispoli, DDS,§
Josè Louis Calvo, DDS,储 and Ugo Covani, MD, DDS¶

Purpose: The purpose of this study was to investigate and compare, in a randomized and controlled
clinical trial, the use of ultrasound bone surgery devices and the use of rotary instruments in lower third
molar extractions.
Materials and Methods: We selected 26 patients (12 women and 14 men) for this study; the mean age
was 31.2 years (range, 24-45 years). A randomized clinical trial was planned. Patients in the control group
received treatment with the conventional rotary instruments; patients in the test group received
treatment with the ultrasound bone surgery tools. Twenty-six third molars were allocated to the test and
control groups according to a computer-generated randomization list. All the surgical procedures were
performed by the same surgeon. Pain, trismus, cheek swelling, and number of analgesics taken were
evaluated at baseline (before surgery) and at the first-, third-, fifth-, and seventh-day visits.
Results: Pain levels (evaluated on a visual analog scale) were higher in the control group when
compared with the ultrasonic group; however, no statistically significant differences were found. On the
contrary, the number of analgesics taken in the test group was significantly lower when compared with
the control group. The occurrence of trismus was significantly higher in the control group when
compared with the test group. The clinical values of cheek swelling were higher in the rotary group
when compared with the ultrasound group at the fifth-day visit.
Conclusion: This study showed that the use of ultrasound bone surgery for third molar extraction
significantly reduced the occurrence of postsurgical trismus, the occurrence of swelling, and the number
of analgesics taken after surgery.
© 2010 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 68:330-336, 2010

The surgical removal of impacted mandibular third
molars produces a significant degree of trauma to the
soft tissues and bony structures of the oral cavity,
potentially resulting in a significant inflammatory re-
action. The latter produces the usual postoperative
signs and symptoms of pain, edema, and limited
mouth opening due to muscle spasm.1,2 Although
these postoperative complications are not limited to
third molar surgery, their occurrence in the orofacial
area has physical, psychological, and esthetic path-
ways that might influence the patient’s quality of life.3
Perioperative administration of corticosteroids is a
pharmacologic approach that is commonly used to
reduce morbidity after third molar surgery by inhibit-

*Assistant Professor, Department of Oral Pathology and Medi-
cine, University of Genova, Genoa, Italy, and Istituto Stomatologico
Tirreno, Versilia Hospital, Lido di Camaiore, Italy.
†PhD Student, Department of Oral Pathology and Medicine,
University of Genova, Italy, and Istituto Stomatologico Tirreno,
Versilia Hospital, Lido di Camaiore, Italy.
‡Statistical Consultant, Istituto Stomatologico Tirreno, Versilia
Hospital, Lido di Camaiore, Italy.
§Visiting Fellow, Department of Prosthodontic, Dental School,
“La Sapienza” University, Rome, Italy.
储Assistant Professor, Department of Oral Implantology, Dental
School, University of Murcia, Murcia, Spain.
¶Full Professor, Department of Surgery, University of Pisa, Italy, and
Istituto Stomatologico Tirreno, Versilia Hospital, Lido di Camaiore, Italy.
Address correspondence and reprint requests to Dr Barone: Piazza
Diaz 10, 55041 Camaiore (Lu), Italy; e-mail: barosurg@gmail.com
© 2010 American Association of Oral and Maxillofacial Surgeons
0278-2391/10/6802-0016$36.00/0
doi:10.1016/j.joms.2009.03.053

330
BARONE ET AL
ing the body’s inflammatory response to trauma.
However, a recent meta-analysis suggested that the
administration of corticosteroids after third molar sur-
gery has a mild to moderate effect in reducing the
inflammatory symptoms up to 7 days after surgery.4 In
addition, the combination of corticosteroids and non-
steroidal anti-inflammatory drugs has also been shown
to be well suited for the treatment of postoperative
pain, trismus, and swelling after dental surgical pro-
cedures.5 Nonmedication methods used to minimize
tissue injury after third molar extraction include com-
pression, cryotherapy, and soft laser application.6,7
More recently, ultrasounds have been introduced in
many fields of surgery, such as tumor enucleation,
fragmentation of renal calculus, and lithotripsy of
gallbladder stones.8 Ultrasonic tools are of valuable
clinical use in reducing the risk of surgical trauma to
the adjacent tissues. In fact, ultrasonic dissection has
been classified as a tissue-selective technique that
might improve the efficiency of dissections and, at the
same time, reduce the morbidity rate resulting from
collateral iatrogenic injuries. Several authors have pro-
posed using piezoelectric surgical devices to perform
osteotomies and ostectomies as an alternative to ro-
tary instruments.9-11 Moreover, the wound healing
response after osteotomy showed a more favorable
osseous response with piezoelectric surgical devices
when compared with diamond or carbide burs.12
The aim of this study was to investigate and com-
pare, in a randomized controlled clinical trial, the use
of ultrasound bone surgery (UBS) devices and the use
of rotary instruments in the extraction of lower third
molars.
Materials and Methods
POPULATION
The patients were selected at Versilia Hospital, Lido
di Camaiore, Italy, between February and September
2008. All patients referred for lower third molar ex-
traction at Versilia Hospital who were systemically
healthy were candidates for inclusion in this study.
Patients were not included in the study if any of the
following criteria were present: patients with a his-
tory of systemic diseases that would contraindicate
surgical treatment, pregnant and lactating women,
patients in whom there was no need to raise the
mucoperiosteal flap to remove the third molar, and
patients who smoked more than 10 cigarettes per
day. Patients who smoked fewer than 10 cigarettes
per day were requested to stop smoking before and
after surgery; however, their compliance could not be
monitored.
The following criteria were used to select the pa-
tient population: the need for lower third molar ex-
331
traction, the necessity to raise a mucoperiosteal flap
because of a medium or deep level of inclusion and
limited or no space available in relation to the ramus,
and acceptance and signing of a consent form.
We selected 26 patients (12 women and 14 men)
for this study; the mean age was 31.2 years (range,
24-45 years). A randomized clinical trial was planned.
Thereafter radiographic examination such as ortho-
pantomography and computed tomography scans
were prescribed to evaluate the spatial relationship,
depth of inclusion, ramus relationship, and number of
roots, as well as the relationship with the alveolar
inferior nerve.
SURGICAL PROCEDURES
An independent evaluator allocated the patients
into the test and control groups according to a com-
puter-generated randomization list. All the surgical
procedures were performed by the same surgeon and
assistant with patients under local anesthesia in both
groups. In the control group (rotary instruments) a
full-thickness flap was incised on the buccal aspect of
the third molar and raised with a periosteal elevator to
expose the bone. A round bur in a straight handpiece
was used for bone removal. Where necessary, the
crown and root sectioning was performed with a
high-speed handpiece and fissure burs. In the test
group a UBS device (Resista, Verbania, Italy) was used
to perform the flap elevation and the bone removal
and to complete the necessary tooth/root sectioning
after the use of fissure burs (Fig 1). The UBS device
has a vibration frequency that ranges from 20 to 32
kHz, with a maximum ultrasonic power of 90 W.13
Thereafter the tooth/root fragments were removed
with an elevator in both groups. After tooth removal,
the extraction sockets were inspected, curetted for
granulation tissue removal, and flushed with sterile
saline solution. No. 4 resorbable sutures were used
for wound closure. An icepack was then applied to
the surgical area for at least 30 minutes.
All patients received 2 g of amoxicillin– clavulanic
acid 1 hour before the surgical procedure and 2 g/d
for the subsequent 5 days. Moreover, the same post-
operative instructions were given to all patients: soft
and cold diet for 24 hours; 550 mg of naproxen
sodium, when needed; and chlorhexidine mouth-
wash for 14 days.
The time necessary for the tooth extraction (start-
ing from the first incision to the last suture) as well as
the number of complications was registered.
EVALUATION PROCEDURE
Pain, trismus, and cheek swelling were evaluated at
baseline (before surgery) and at the first-, third-, fifth-,
and seventh-day visits postoperatively at approxi-
mately the same time of the day.
332 ULTRASOUNDS FOR LOWER THIRD MOLAR EXTRACTION

Table 1. PRESURGICAL CLINICAL EVALUATION FOR

TOOTH EXTRACTION IN CONTROL GROUP (13
LOWER THIRD MOLARS) AND TEST GROUP (13
LOWER THIRD MOLARS)

Preoperative Control Test

Variable Category Group Group

No. of roots Multiple 10/13 10/13

Singular 3/13 3/13
Incomplete — —
Spatial relationship Distoangular — —
Horizontal 2/13 2/13
Vertical 3/13 4/13
Mesioangular 8/13 7/13
Depth of inclusion Level A (high) — —
Level B (medium) 7/13 7/13
Level C (deep) 6/13 6/13
Class I (sufficient) 7/13 5/13
Ramus relationship/ Class II (reduced) 5/13 6/13
space available Class III (none) 1/13 2/13
Barone et al. Ultrasounds for Lower Third Molar Extraction.
J Oral Maxillofac Surg 2010.

Patients who had pain before surgery were not in-

FIGURE 1. A and B, Intraoperative views in UBS group.
Barone et al. Ultrasounds for Lower Third Molar Extraction.
J Oral Maxillofac Surg 2010.
Pain was assessed during the preoperative and post-
operative periods with a visual analog scale (VAS) of
10 units in combination with a graphic rating scale.14
On the VAS, the leftmost end represented absence of
pain (score of 0) and the rightmost end indicated the
most severe pain (score of 10). In addition, the num-
ber of consumed analgesic tablets was considered.
cluded in the study. Trismus was evaluated by mea-
suring the distance between the mesial incisal corners
of the upper and lower right central incisors at the
maximum mouth opening in centimeters, as de-
scribed by Ustun et al.15 Cheek thickness (swelling)
was measured with a standard caliper from the lingual
aspect of the midportion of the crown of the first
mandibular molar to the tangent of the cheek’s skin,
according to the study of Al-Khateeb and Nusair.16
The preoperative measurement was considered as the
baseline value. The difference between each postop-
erative evaluation and baseline indicated the cheek
swelling for that day.
The mean values and SDs were determined for each
parameter in the test and control groups. Comparison

FIGURE 2. Flow diagram of randomized clinical study comparing rotary instruments and UBS device for lower third molar extraction.
Barone et al. Ultrasounds for Lower Third Molar Extraction. J Oral Maxillofac Surg 2010.
BARONE ET AL
Time required
50.00
40.00
Time (min)
30.00
20.00
10.00
0.00
Ultrasonic Rotary
FIGURE 3. Mean time required for lower third molar extraction in
rotary group (control) and UBS group (test).
Barone et al. Ultrasounds for Lower Third Molar Extraction.
J Oral Maxillofac Surg 2010.
between the 2 groups was performed by use of a
Wilcoxon matched-pairs test. The value for statistical
significance was set at P less than .05 with Bonferroni
correction for multiple comparisons.
Results
A total of 26 patients who required lower third
molar extraction were included in this randomized
clinical study. Figure 2 shows the number of partici-
pants, the number of third molars assigned to treat-
ments, the follow-up period, and the number of lower
third molars in the analysis for each group. The con-
trol group included 7 men and 6 women, with a mean
age of 30.3 ⫾ 5.8 years. Lower third molar extraction
was performed because of a history of infection in 5
cases, caries in 5 cases, and prophylactic require-
ments in 3 cases. The test group included 7 men and
6 women, with a mean age of 32.2 ⫾ 6.7 years. Lower
third molar extraction was performed because of a
history of infection in 5 cases, caries in 3 cases, and
prophylactic requirements in 5 cases. The presurgical
clinical evaluations were performed on the pan-
oramic radiographs, and the findings are shown in
Table 1 for both the control and test groups. The
mean time necessary for flap elevation, bone removal,
and tooth extraction with the use of rotary instru-
ments (control group) was 30.5 ⫾ 4.4 minutes,
whereas with the UBS device (test group), it was
34.3 ⫾ 7.4 minutes. The difference between the
Table 2. PAIN SCORE ON VISUAL ANALOG SCALE FOR CONTROL (n ⴝ 13) AND TEST (n ⴝ 13) GROUPS
1 Day
Control group 5.3 ⫾ 1.5
Test group 5.1 ⫾ 1.4
P value ⬎.05
Barone et al. Ultrasounds for Lower Third Molar Extraction. J Oral Maxillofac Surg 2010.
333
Table 3. TOTAL NUMBER OF ANALGESIC DOSES IN
7 DAYS FOR CONTROL (n ⴝ 13) AND TEST (n ⴝ 13)
GROUPS
Mean SD
Control group (conventional instruments) 7.3* 1.3
Test group (UBS device) 3.6* 1.1
*P ⬍ .005.
Barone et al. Ultrasounds for Lower Third Molar Extraction.
J Oral Maxillofac Surg 2010.
groups was not statistically significant (Fig 3). The
level of pain felt by the patients (as evaluated on
the VAS) was higher in the rotary group when
compared with the UBS group; however, the statis-
tical comparison showed no significant differences
between the 2 groups (Table 2). Furthermore, the
number of analgesic doses taken in the test group
was significantly lower when compared with the
control group (Table 3).
Trismus was evaluated as the degree of mouth
opening after tooth extraction. The interincisal dis-
tance was significantly reduced for both groups after
surgery: the comparison between the rotary group
and the UBS group showed significantly higher values
for the test group at the first-, third-, and seventh-day
visits after surgery. At the fifth-day visit, the degree of
mouth opening was greater in the test group than in
the control group, even though a level of significant
difference was not reached (Table 4). The cheek
swelling in the postoperative period increased in the
control group as well as in the test group: the clinical
values were higher in the control group, even though
a level of significance was only observed at the fifth-
day visit (Fig 4). Evaluations at the third- and fifth-day
visits showed a gradual reduction in mean values of
cheek swelling, even if there were still higher values
for the control group (Table 5).
Discussion
This study was conducted to analyze and compare
the degree of postoperative discomfort signs and
symptoms with the use of UBS device and with the
use of rotary instruments in the extraction of lower
third molars (Fig 1).
3 Days 5 Days 7 Days
4.1 ⫾ 1.9 3.5 ⫾ 1.0 1.7 ⫾ 1.1
3.8 ⫾ 1.8 3.8 ⫾ 1.1 1.6 ⫾ 0.7
⬎.05 ⬎.05 ⬎.05
334
Table 4. MEAN MOUTH OPENING VALUES FOR CONTROL (n ⴝ 13) AND TEST (n ⴝ 13) GROUPS
Preoperatively
Control group (n ⫽ 13) (mm) 44.1 ⫾ 3.5
Test group (n ⫽ 13) (mm) 44.5 ⫾ 3.9
P value ⬍.05*
*Statistically significant difference between the 2 groups.
Barone et al. Ultrasounds for Lower Third Molar Extraction. J Oral Maxillofac Surg 2010.
The time required to perform the complete proce-
dure was longer in the test group (UBS) compared
with the control group (conventional instruments),
although the difference did not reach a level of sig-
nificance. The level of pain felt was evaluated based
on a VAS and the use of analgesics. The VAS score was
higher in the conventional instruments (control)
group than in the UBS (test) group, even if the
differences were not statistically significant. On the
other hand, the doses of analgesics taken in 7 days
after surgery were significantly higher in the con-
trol group than in the test group. This could indi-
cate that the absence of a significant difference in
pain reduction between the 2 groups was caused by
a higher consumption of pain-relieving medications
in the conventional instruments group than in the
UBS group. The evaluation of intraoral swelling is
heavily affected by observer bias and might fail to
show the effective edema because it involves 3-di-
mensional registration and intraoral swelling can
also manifest as facial edema.17 The mean differ-
ence in cheek swelling between the rotary (con-
trol) and UBS (test) groups in our study showed a
significantly higher value in the control group on
day 5, although the clinical values were higher in
the conventional instruments group for the entire
observation period. Significantly higher values were
6.00
5.00
4.00
Swelling (cm)
3.00
2.00
1.00
0.00
Baseline 1 day
FIGURE 4. Mean cheek swelling for lower third molar extraction in rotary group (control) and UBS group (test).
Barone et al. Ultrasounds for Lower Third Molar Extraction. J Oral Maxillofac Surg 2010.
ULTRASOUNDS FOR LOWER THIRD MOLAR EXTRACTION
1 Day 3 Days 5 Days 7 Days
20.5 ⫾ 3.3 19.3 ⫾ 3.9 34.0 ⫾ 4.1 35.6 ⫾ 4.5
24.8 ⫾ 4.5 23.3 ⫾ 5.3 36.2 ⫾ 3.7 38.5 ⫾ 3.7
⬍.05* ⬍.05* ⬎.05 ⬍.05*
observed in the UBS group at the first-, third-, and
seventh-day visits for postoperative interincisal
distance, which was used for the evaluation of
trismus.
Several studies reported potential risk indicators for
postoperative discomfort or extended recovery after
third molar surgery. The estimated incidence of clin-
ical complications varies depending on the method
used for their evaluation.18-21
The degree of surgical difficulty was evaluated
based on anatomic factors (depth of inclusion and
ramus relationship) and the position of the third mo-
lar as assessed on radiographic examination. This has
been reflected in the classifications of Pell and Greg-
ory22 and Winter.23 In our study all the included third
molars had a medium or deep level of inclusion and
limited or no space available in relation to the ramus.
These clinical conditions were considered criteria for
inclusion to reduce the risk of confounding factors and
to obtain adequate homogeneity between the 2 groups.
This evaluation is plausible given that the deeper the
impaction, the greater the likelihood of tissue distur-
bance. Tissue manipulation, large wounds, and the use
of handpieces may all cause complications during the
healing period.
Delayed clinical healing after third molar surgery
significantly increased the prevalence of delayed re-
Swelling
Ultrasonic
Rotary
3 days 5 days 7 days
BARONE ET AL
Table 5. MEAN DIFFERENCE IN CHEEK SWELLING
BETWEEN ROTARY (CONTROL) AND UBS (TEST)
GROUPS
Mean SD
Rotary vs Ultrasonic n (mm) (mm) P Value
Day 1 26 0.31 0.82 ⬎.05
Day 3 26 0.62 0.61 ⬎.05
Day 5 26 1.15 0.63 ⬍.05*
Day 7 26 0.37 0.45 ⬎.05
*Statistically significant.
Barone et al. Ultrasounds for Lower Third Molar Extraction.
J Oral Maxillofac Surg 2010.
covery in terms of quality of life and oral function.
The odds of a delay in health-related quality-of-life
outcomes as reported by Ruvo et al24 were double if
clinical healing was prolonged. The preoperative and
intraoperative risk factors for severe morbidity after
removal of a third molar were compared in a prospec-
tive study by Grossi et al1 with patients’ perceptions
of changes in their quality of life. The postoperative
symptom severity scale resulted in a valid and respon-
sive measure of the clinical severity of postoperative
discomfort.25
Findings from this study showed that UBS is an
alternative method to reduce morbidity and to im-
prove recovery after third molar surgery in patients
whose preoperative risk factors would predict surgi-
cal difficulty and/or delayed clinical recovery.21,26,27
Our findings, as supported by other authors, showed
no association between the length of operation time
and severity of postoperative discomfort.1,28,29 On the
other hand, some authors have reported a statistically
significant difference in pain evaluations depending
on the duration of surgery.30,31 Similarly, in a more
recent study the authors concluded that longer inter-
ventions were typically associated with increased lev-
els of pain.32 Another important factor to consider is
that in our study all the procedures were performed
by the same trained oral surgeon, and this should be
taken into account in our assessment of the relation-
ship between the duration of the intervention and
postoperative pain.
One limitation of this study is related to the study
design, which did not include more than one surgeon
performing the procedures. Therefore the population
in this study is not representative of the population of
all individuals who have undergone third molar ex-
traction because many of those individuals may have
had third molar extraction by surgeons with limited
experience. In consideration of the association be-
tween surgical experience and the duration of the
intervention, we would expect a lower duration than
in a study with a sample composed of a mixture of
providers with varied levels of training and experi-
335
ence. Another possible limitation of this study relates
to the sample size, which is limited and does not have
the statistical power to rule out the possibility of a
difference between the 2 groups. More extensive
studies need to be performed to support the equiva-
lence of experimental groups (test and control) and to
evaluate possible factors affecting the time required
for the intervention and rate of complications.
The UBS device operates with modulated ultra-
sound micromovements and with an oscillating fre-
quency of 29 and 32 kHz, making it specifically suit-
able for osteotomies but not soft tissue cutting.11,33
The accidental slipping of the titanium tips onto sur-
rounding soft tissue does not cause any injuries if only
a very small degree of pressure is adopted, as recom-
mended by the manufacturer.
Management of the ultrasonic flap through careful
tissue manipulation might explain our findings for
pain, swelling, and trismus. Moreover, the reduced
UBS micrometric oscillation amplitude allows for a
controlled performance of curved incisions for osteot-
omy.34,35 The advantage offered by the UBS device
during surgery is to allow for easy control of the
entire cutting procedure, increasing tactile control
and cutting precision.33-39 In addition, the oscillating
tip drives an irrigation solution, which allows for
higher visibility and the capability of evacuation of
detritus (via the cavitation effect) in the operating
field, as compared with conventional osteotomy burs.
In conclusion, this study indicates that the use of
UBS in the extraction of third molars significantly
reduced the occurrence of postsurgical trismus, the
occurrence of swelling, and the number of analgesics
taken after surgery.
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