Bone lid technique with piezosurgery to preserve inferior

alveolar nerve
Kagan Degerliyurt, DDS, PhD,a Volkan Akar, DDS, PhD,a Senem Denizci, DDS, PhD,a and
Ergun Yucel, DDS, PhD,b Ankara, Turkey
GAZI UNIVERSITY

The inferior alveolar nerve is at risk during surgical removal of impacted mandibular teeth and excision of
benign tumors of mandible. Manual and/or mechanical instruments used in the close proximity of delicate structures
do not allow the control of the cutting depth and can damage these structures by accidental contact. Piezoelectric
surgery is a new and innovative bone surgery technique using the microvibrations of special scalpels at ultrasonic
frequency so therefore soft tissue will not be damaged even upon accidental contact with the cutting tip. This article
presents an alternative technique that uses piezoelectricity to minimize trauma to the inferior alveolar nerve, vascular
tissues, or surrounding dental tissues. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:e1-e5)

The inferior alveolar nerve (IAN) is at risk during surgical

removal of impacted mandibular teeth and excision of
benign tumors of mandible.1 The results of studies show
that the risk of IAN injury associated with conventional
removal of mandibular third molars ranges from 1% to
22% and the injured nerve usually recovered spontane-
ously.2-10 Most of the studies reported a permanent injury
rate of the IAN as less than 1%.4,6-8,10,11
Manual and/or mechanical instruments used in the
close proximity of delicate structures (vascular, ner-
vous tissue) do not allow for control of the cutting
depth and can damage these delicate structures by ac-
cidental contact.12 Piezoelectric surgery is a new and
innovative bone surgery technique using the microvi-
brations of special scalpels at ultrasonic frequency;
Fig. 1. Preoperative dental panoramic radiography of Case 1.
therefore, soft tissue will not be damaged even upon
accidental contact with the cutting tip.12,13
A new bone lid technique with a piezoelectric de-
vice, which is described in this article, may be indicated CASE REPORT 1
considering its selective and soft tissue sparing abilities An 18-year-old female was referred to our department for
when a conventional operation requires extensive re- evaluation of bilateral mandibular unerupted second molars
moval of alveolar bone and/or performing surgery in and supernumerary premolars. A panoramic radiographic
close proximity to the IAN when there was an appre- showed bilateral unerupted, horizontally impacted, lower sec-
ciable risk of damage to the IAN by instrumentation. ond molars just below the lower first molars in close prox-
This article presents an alternative method that uses imity to the IAN and bilateral impacted mandibular third
piezoelectricity to minimize trauma to the IAN, vascu- molars distal to the supernumerary mandibular premolars
lar tissues, or surrounding dental tissues. (Fig. 1). Dental computerized tomography established that the
IAN bilaterally passed just inferior to the lower second mo-
lars (Fig. 2). The right mandibular impacted second molar
a
Former Resident, Gazi University, School of Dentistry, Department was removed and the left one was removed 1 month after the
of Oral and Maxillofacial Surgery, Ankara, Turkey. first operation.
b
Professor and Head, Gazi University, School of Dentistry, Depart-
ment of Oral and Maxillofacial Surgery, Ankara, Turkey.
Received for publication Jun 23, 2009; returned for revision Jul 27, CASE REPORT 2
2009; accepted for publication Aug 5, 2009. A 45-year-old woman was referred to our department for
1079-2104/$ - see front matter evaluation and treatment of persistent pain in left mandibular
© 2009 Published by Mosby, Inc. third molar region. The dental history of the patient revealed
doi:10.1016/j.tripleo.2009.08.006 that she had self-referred to another institution 2 years earlier

e1

e2 Degerliyurt et al.
Fig. 2. Preoperative cross-sectional dental CT views of Case 1. A, Left side of Case 1. B, Right side of Case 1. Note the
approximate relationship between inferior alveolar nerves and the lower second molars (arrows).
Fig. 3. Preoperative dental panoramic radiography of Case 2.
Note the approximate relationship of the inferior alveolar
nerve, the lower left second molar and the radiopaque lesion
surrounded with a comparable radiolucent halo (arrow).
when the pain first appeared. She mentioned an attempt to
remove an unknown lesion by conventional osteotomy using
a rotating instrument in the same institution and said the
operation was aborted because of the requirement of the
extensive amount of bone to be removed and close proximity
of the unknown lesion to the IAN. Intraoral examination
revealed no abnormalities and past medical history was un-
remarkable. A dental panoramic radiography revealed a ra-
diopaque lesion in close proximity to the root of the second
molar and IAN surrounded with a radiolucent halo. The lower
left second molar seemed to be intact in radiological exami-
nation (Fig. 3).
SURGICAL PROCEDURE
In regard to the extensive amount of bone that was
required to be removed to access the teeth or lesions,
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December 2009
the appreciable risk to the IAN or adjacent tissues and
high risk of intra- or postoperative fracture, it was
decided to use the piezosurgery device to cut and ele-
vate a precisely defined bone lid on the lateral cortex of
the mandible to provide access to the teeth and lesion
(Fig. 4).
All operations were performed under local anesthe-
sia. After achieving an IAN, lingual and buccal nerve
blocks, a full-thickness 3-cornered flap extending to the
ramus with an anterior vertical releasing incision was
reflected. The piezosurgery device was used for osteot-
omy to cut a precisely defined bony window in the
extended reflection area of underlying teeth or lesion on
the vestibular cortical plate of mandible that provided
access to the teeth or lesion (Fig. 5). The bone window
was elevated with the help of a curved osteotome. The
tooth or lesion was seen clearly and gently removed
either sectioning with piezosurgery or by circular piezo
osteotomy. There was no need to protect the IAN and
adjacent soft and/or dental tissues. The surgical field
was irrigated carefully to observe any injury to the IAN
or adjacent tissues. After the visual confirmation of an
undamaged IAN and adjacent tissues, the bone lid was
located to its former position (Fig. 6) and fixated with
absorbable mini-plates. The mucoperiosteal flap was
sutured with 3/0 silk sutures in an interrupted manner.
The healing was uneventful and none of the patients
complained about any sensory disturbances of IAN
postoperatively.
DISCUSSION
Conventional removal of deeply impacted lower mo-
lars and excision of the benign bony tumors located at
close proximity to the IAN would require extensive
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Volume 108, Number 6 Degerliyurt et al. e3

Fig. 4. Piezoelectric osteotomies in the extended reflection area of underlying teeth or lesion on the vestibular cortical plate of
mandible. A, Case 1. B, Case 2.

Fig. 5. Access to the teeth or lesion. A, Case 1. B, Case 2.

Fig. 6. The bone lids that were located to their former position. A, Case 1. B, Case 2.

removal of bone to allow access to the tooth or desired
area. Conventional techniques also give limited visibil-
ity and may cause damage to the IAN.2
The conventional direct surgical approaches are usu-
ally applicable to mandibular lesions and impacted
teeth above the IAN, but mandibular lesions and related
teeth in more distant locations such as posterior to the
canal in the ramus or inferior to the IAN may require
alternative techniques other than conventional methods.
Alling and Alling14 defined alternative techniques other
than through the dentoalveolar process to gain access to
remove lesions or impacted teeth in unusual locations
through the mandible. They described removal of the
body of the mandible lateral cortical bone to provide

e4 Degerliyurt et al.
access to the body of the mandible below and above the
IAN.14
The precise and selective surgical cut is extremely
important while performing surgery close to the IA
neurovascular bundle and/or the roots of adjacent teeth.
Traditional burs and micro saws do not distinguish hard
and soft tissue.15 Additionally, tools do tend to slip,
thus damaging adjacent tissue by accidental contact,
especially IAN. Piezoelectric surgery is a new innova-
tive technique to perform safe and effective bone sur-
geries using piezoelectric ultrasonic vibrations that only
cut bone and cause no soft tissue damage by ceasing the
surgical action when the scalpel contacts nonmineral-
ized tissues.2,16-18
The device generates an oscillation amplitude of 60
to 200 ␮m horizontally and 20 to 60 ␮m vertically.
When compared with oscillating micro saws, the oscil-
lation of the piezosurgery scalpel tip is very small,
which performs more precise and safe ostetomies.17
Surgical control of the device is effortless compared
with rotational burs or oscillating saws because there is
no need for a supplemental force to oppose rotation or
oscillation of the instrument.19 In addition, contrary to
micro saws and burs, ultrasonic vibrations break down
the irrigation liquid into very small particles that wash
away from the operation field, make it appear blood-
less, and permit great intraoperative visible control with
the consequent increase in safety, especially in anatom-
ically difficult areas.20
Assael21 stated that damage to the IAN during sur-
gery may result in neuromalike changes with fascicles,
epineural tissues, and axons mixed into the surrounding
scar tissue.21 Eriksson et al.22 reported that such an
interruption of the structures of a nerve would result in
proliferation of axons, a plausible pathophysiological
cause of paresthesia, dysesthesia, allodynia, and phan-
tom pain and it might develop into severe disabling
pain. In a study of Metzger et al.23 it was shown that the
epineurium became roughened without the deeper
structures being affected after piezosurgery for trans-
position of IAN and claimed the degree of injury was
lower than when using conventional rotary burs23;
however, in our cases our patients declared no alter-
ation of neurosensory function of the IAN after the
operations. Unfortunately, because the number of the
cases was very limited and in both operations only
piezosurgery was performed, it was not possible to
compare piezosurgery and conventional rotary burs
with respect to the damage of the IAN.
Removal of the body of the mandible lateral cortical
bone with piezoelectric instrumentation allows ade-
quate access to the required area, excellent visibility,
minimal bone loss, precise cutting ability, and enables
protection of the IAN by sparing the soft tissue when
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December 2009
osteotomy was performed blind. By means of the pre-
cise bone-cutting ability of the piezosurgery device and
minimal bone loss, it was easy to adapt the bone win-
dows to their former location and fixate them.
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changes of the inferior alveolar nerve and Gasserian ganglion kdegerliyurt@hotmail.com