Int. J. Oral Maxillofac. Surg.

2005; 34: 590–593

doi:10.1016/j.ijom.2005.06.006, available online at http://www.sciencedirect.com

Invited Technical Note

Technical Innovations

Ultrasonic surgery—an R. M. Gruber, F.-J. Kramer,

H.-A. Merten, H. Schliephake
Georgia Augusta University, Department of

alternative way in orthognathic Oral and Maxillofacial Surgery, Robert-Koch-

Strasse 40, 37099 Goettingen, Germany

surgery of the mandible

A pilot study
R. M. Gruber, F.-J. Kramer, H.-A. Merten, H. Schliephake: Ultrasonic surgery—an
alternative way in orthognathic surgery of the mandible. Int. J. Oral Maxillofac. Surg.
2005; 34: 590–593. # 2005 International Association of Oral and Maxillofacial
Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The aim of this report is to present preliminary results and experiences using
an ultrasonic bone-cutting device in bilateral sagittal split osteotomies of the
mandible (BSSRO) with particular attention to possible damages to the inferior
alveolar nerve (IAN). Seven patients with class II or class III malocclusion were
treated by BSSRO with a conventional combined orthognathic and surgical
approach. The osteotomy was carried out using an ultrasonic bone-cutting device.
Subjective neurosensory deficits of the inferior alveolar nerve were assessed on 14
sides. Compared to the conventional techniques using saws, chisels and burs, the use
of the ultrasonic device was more time-consuming, but the osteotomies were carried
out at a high level of precision. In addition, this procedure offered the advantage of a
blood-free surgical field and thus provided good control of the surgical procedure.
Subjective neurosensory disturbances of the IAN showed a continuous decrease
from 57.1% (eight sides) 2 months after the surgical procedure to 14.3% (2 sides)
after 5 months and to 7.1% 7 months after BSSRO. Within the seven patients of this
pilot study associated neurosensory disturbances were low. A possible advantage in
terms of nerve protection is subject to a prospective study. Accepted for publication 8 June 2005

Ultrasonic dissection is classified as a
tissue-selective dissection technique. The
tissue-specific selectivity is based on the
contents of water, the tensile strength and
the different power density of the tissues5.
Besides the advantage of creating an
almost blood-free surgical field by coagu-
lating small vessels, ultrasonic devices can
also allow for a selective and precise
procedure in bone cutting.
In the early 1950s high-frequency vibra-
tions were used in industry to cut heavy
materials12. A few years later the devel-
opment of ultrasonic scalers made ultra-
sound an important tool in dentistry
particularly for procedures in periodontol-
ogy and endodontology17. In 1955 VANG7
designed a vibrating surgical instrument
with a frequency of 6 kHz to 12 kHz gen-
erated by a micromotor. Three years later
in 1958, SHAFER7 generated ultrasound
with a piezo-electrical crystal for driving
the scalpel blade. Ultrasound has been
increasingly used in many fields in med-
icine, such as debulking of tumours, the
fragmentation of renal calculus and litho-
tripsy of gall bladder stones4,6. Several
surgeons reported very good results when
using ultrasonic osteotomes22. Referring
to cutting of bone tissue VOLKOV &

0901-5027/060590+04 $30.00/0 # 2005 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 Ultrasonic surgery—an alternative way in orthognathic surgery of the mandible
Table 1. Patients with sagittal retromolar split with the use of Piezosurgery1
Number Age, sex
1 21, f
2 18, f 5.0 mm (ant)
3 37, m 5.0 mm (ant)
4 16, f 6.0 mm (ant)
5 32, f r: 7.0 mm (ant)
6 36, m
7 24, f
SHEPELEVA22 concluded on the experience
of 311 surgical cases that ultrasonic
devices might hold some promise of sim-
plifying orthopaedic operations.
Despite its advantage in preventing
damage to adjacent soft tissues, a major
breakthrough of ultrasonic bone prepara-
tion has not happened yet.
In oral-, cranio- and maxillofacial sur-
gery a close relationship of bone, nerves
and blood vessels can be observed regu-
larly. Ultrasonic devices might be effec-
tive in minimizing the hazard of surgical
trauma to these adjacent tissues.
Particularly in elective orthognathic
surgery of the mandible protection of
the inferior alveolar nerve is important
to reduce surgical morbidity.
It would therefore be of interest to test
ultrasonic devices for the use in BSSRO in
mandibular set back or advancement pro-
cedures. The aim of this report is to pre-
sent preliminary results and experience
in using such a device in orthognathic
surgery of the mandible.
Material and methods
From February to June 2004, seven con-
secutive patients (five female and two
male; aged 16–37 years) six patients with
a class II malocclusion and one patient
with a class III malocclusion were treated
by BSSRO with a combined orthognathic
and surgical approach. Every BSSRO pro-
cedure was performed by the same opera-
tion team. Details of individual patients
are given in Table 1.
Ultrasound surgical device
BSSRO was carried out using the Mectron
Piezosurgery1 device (Mectron, Italy).
Ultrasonic vibrations were generated by
piezoelectricity with variable frequencies
from 25 kHz to 30 kHz, which resulted in
variations in cutting energy. The fre-
quency of this ultrasonic device was
adapted to the requirements of the manip-
ulation of mineralized tissue. Therefore,
the device worked with mineralized struc-
Advancement (ant) set back (post)
r: 7.0 mm (ant)
l: 7.0 mm (ant)
l: 1.5 mm (post)
3.0 mm (post)
r: 5.5 mm (post)
l: 2.5 mm (ant)
tures only and could prevent damage to
soft tissues18,21.
This device provided three different
power levels (low, high, boosted), the
highest of which was used in the present
study. The amplitude of the working tip
ranged from 60 mm to 200 mm. Copious
irrigation with 0.9% saline solution was
used during the entire procedure.
Surgical procedure
After an initial orthodontic therapy of at
least one year, a surgical procedure was
carried out according to the modified
osteotomy of HUNSUCK9. The medial sub-
periosteal preparations and dissections
were carefully performed in order to protect
the IAN bundle. A few millimetres cranial
above the mandibular foramen a groove
was created with a conventional bur. Sub-
sequently, the osteotomy was performed
using the ultrasonic device. The osteotomy
could be performed easily above the man-
dibular foramen with the insert tip OT2
(Fig. 1). The osteotomy on the anterior
crest of the ascending ramus and the ver-
tical osteotomy on the lateral aspect of the
mandible were completed with the insert
tip OT7 (Fig. 1 and Movie 1). Afterwards,
Fig. 1. Two different working tips of the ultrasonic device (OT2, OT7).
591
the osteotomy of the inferior border of the
mandible was finished with insert tip OT2.
After rigid fixation with miniplates,
elastic intermaxillary fixation with rubber
bands and an interocclusal splint was
applied for 5 days. The elastic tension
was reduced in the following 4 weeks.
Subjective neurosensory deficits of the
IAN were assessed at follow-up intervals
up to 7 months. Patients were interviewed
for the presence of numbness, tingling,
burning and electricity as well as for the
area of the affected skin region.
Results
The osteotomies were easy to carry out
with the ultrasonic device in combination
with the two different working tips. In the
cortical bone of the mandible the saw-like
working tip OT7 in combination with
high-energy mode (boosted) was very
effective. In one case the osteotomy of
the ascending ramus was difficult due to a
very short ramus and interference with the
maxillary alveolar process.
Due to the small vibration amplitude of
the working tip (60–200 mm) a narrow
osteotomy gap was created at high preci-
sion. There was no need to apply high
pressure. A sudden or poorly controlled
movement of the cutting device that is
known from the use of rotating instru-
ments did not occur.
The procedure was more time-consum-
ing than using saws and burs. Subsequent
splitting of the ramus was easily managed
with chisels.
A major advantage was the perfect
visibility and a nearly blood-free surgical
site during the osteotomy. All BSSRO
procedures could be performed without
a ‘‘bad split’’.
592 Gruber et al.
Movie 1. Surgical procedure using Piezosurgery1 ultrasonic device. Osteotomy of the ascend-
ing mandibula, the online version of this article shows an animated version of this image.
The reported subjective neurosensory
deficits are displayed in Fig. 2, showing
that the subjective neurosensory distur-
bances decreased to 57.1% (8 sides) of
all the 14 sides (seven patients) after 2
months. Fifty percent of the nerves
showed deficits after an interval of 4
months after surgery. Within the first 5
months after surgery the disturbances of
the IAN decreased to 14.3% (two sides).
Neurosensory deficits were characterized
by tingling paraesthesia. Seven months
after surgery only one patient reported a
full recovery of sensitivity but a ‘‘different
feeling’’ in the area of the left chin com-
pared with the right side (Fig. 2).
Discussion
Mandibular osteotomies are difficult to
perform in orthognathic surgery due to
Fig. 2. Percentage of nerve disturbance after different intervals (n = 7 patients).
the close relationship between the osteot-
omy lines and adjacent nerves and vessels.
The most frequent surgical morbidity
associated with a bilateral sagittal split
is the damage to the IAN. This complica-
tion might be caused by direct mechanical
injury during surgery, postoperative
oedema or by compression injury after
fixation11,15. NESARI et al.16 reported in a
recent study that most important factors
influencing postoperative nerve function
are the perioperative position of the IAN,
patient age and the method of fixation.
A recent evaluation of trigeminal soma-
tosensory-evoked potentials (TSEP) has
shown that damage to the inferior alveolar
nerve (IAN) during BSSRO procedures
was initiated during periosteal dissection
on the medial side of the ascending ramus
and was extended further after the sagittal
bone split and after fixation15. Moreover,
visible damage or transection of the IAN
during BSSRO procedures has been
reported by WESTERMARK et al.23 and LEIRA
& GILHUUS-MOE13.
The reported incidence of subjective
nerve disturbance after BSSRO ranged
from 67% to 100%, respectively3,24. Six
months after BSSRO 26% of the patients
claimed neurosensory disturbance as
reported by LEIRA & GILHUUS-MOE13,
whereas objective assessments revealed
only 8% of nerves with neurosensory dis-
turbance. The long term reported para-
esthesia of the alveolar nerve one year
after surgery is shown to range from to
4% to 17.3%1,19. JÄÄSKELÄINEN et al.10
found two different types of nerve injury:
a demyelinating type and an axonal type of
nerve injury. These two types showed
different periods of recovery. Most of
the demyelinating nerves showed a recov-
ery of function within the first 6 months
whereas the axonal type was characterized
by a prolonged and slow recovery.
Authors reported 50% IAN subjective dis-
turbances after 3 months. One year after
surgery 38% of patients showed a persist-
ing subjective nerve disturbance10.
The preliminary results of this report
investigating a short period of nerve
recovery might be explained by the two
injury types of JÄÄSKELÄINEN et al.10. The
use of the ultrasonic device during the
BSSRO might prevent a direct, axonal
injury of the IAN. The typical nerve dis-
turbance of the demyelinating type, which
is characterized by a quick recovery of the
function of the nerve within a few months
was seen at most patients.
In addition to the present results there
are reports about osteotomy procedures of
the maxilla such as multipiece maxillary
osteotomies with conventional cutting
tools which have been reported to run
the risk of a possible soft tissue damage
with an impairment of the nutritive blood
supply of bone, dental and periodontal
tissues14,18.
ROBIONY et al.18claimed that the multi-
piece maxillary osteotomy with Piezosur-
gery1 could prevent complications like
periodontal, dental or bone damage due
to a compromised blood supply.
Although ultrasonic bone surgery pre-
sents the decisive advantage of a selective
cut, GIRAUD et al.7 discussed three poten-
tial disadvantages: (1) high rise in tem-
perature; (2) lack of knowledge
concerning the medium and long term
effects; (3) fatigue failure of the osteotome
parts.
Ultrasound produces an increase in tem-
perature, which demands effective cool-
ing. As mentioned before, copious
 Ultrasonic surgery—an alternative way in orthognathic surgery of the mandible
irrigation was used during osteotomy but
further studies will be necessary to assess
the change of the intraosseous temperature
during the use of this device in the osteot-
omy of cortical bone.
Looking at the long-term effects, HOR-
8
TON et al. evaluated the influence of ultra-
sound on wound healing within a period of
more than 50 weeks in 1975. The healing
response following the use of the ultra-
sonic device was comparable to the heal-
ing response after the osteotomy with a
chisel. Authors reported that osteocytic
death occurred more often in the osteo-
tomies performed by the use of a bur and
the use of the ultrasonic device compared
to the use of chisels. Empty lacunae could
be seen up to a depth of 300 mm from the
cut surface. Defects produced with the
ultrasonic device healed within regular
limits and were comparable to the osteo-
tomies carried out with chisels or burs8.
With respect to the osteotomy the cavi-
tation phenomenon has been under discus-
sion to be responsible for the good
visibility of the surgical site due to a
cleansing effect of the microstream
towards the rigid boundary of the surface
of the bone2,20. The effect of cavitation on
cells of the adjacent tissue such as peri-
osteal cells or bone cells is still not fully
understood so that further studies and
investigations on this issue will be neces-
sary.
This preliminary clinical evaluation
suggests that ultrasonic bone cutting is
possible in orthognathic surgery at a high
level of safety and precision. Long-term
benefits regarding protection of neurosen-
sory functions remain to be shown.
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Address:
Rudolf Matthias Gruber
Georgia Augusta University
Department of Oral
and Maxillofacial Surgery
Robert-Koch-Strasse 40
37099 Goettingen
Germany
Tel: +49 551 392854
Fax: +49 551 392886
E-mail: r.gruber@med.uni-goettingen.de