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Postoperative evaluation of Er:YAG laser, piezosurgery, and rotary systems used for
osteotomy in mandibular third-molar extractions

Tayfun Civak, Tugba Ustun, Hanife Nuray Yilmaz, Bahar Gursoy

PII: S1010-5182(20)30246-8
DOI: https://doi.org/10.1016/j.jcms.2020.11.010
Reference: YJCMS 3559

To appear in: Journal of Cranio-Maxillo-Facial Surgery

Received Date: 11 September 2019

Revised Date: 4 August 2020
Accepted Date: 24 November 2020

Please cite this article as: Civak T, Ustun T, Yilmaz HN, Gursoy B, Postoperative evaluation of Er:YAG
laser, piezosurgery, and rotary systems used for osteotomy in mandibular third-molar extractions,
Journal of Cranio-Maxillofacial Surgery, https://doi.org/10.1016/j.jcms.2020.11.010.

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 Postoperative evaluation of Er:YAG laser, piezosurgery, and rotary systems used for

osteotomy in mandibular third-molar extractions

Tayfun Civaka, Tugba Ustunb, Hanife Nuray Yilmazc, Bahar Gursoyd

a
Oral and Maxillofacial Surgery, Istanbul Yeni Yuzyil University, Faculty of Dentistry,

Istanbul, Turkey
b
Orthodontist, Private Practice, Istanbul, Turkey
c
Department of Orthodontics, Marmara University, Faculty of Dentistry, Istanbul, Turkey

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Oral and Maxillofacial Surgery, University of Kyrenia, Faculty of Dentistry, Kyrenia,

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Cyprus
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Objective:
This study compared patient postoperative pain, swelling, and trismus after usage of rotary
instruments, piezosurgery, and Er: YAG lasers in mandibular third molar extraction.
Materials&Methods:
This prospective study was executed with class II and position B vertically impacted
mandibular third molars. Patients were divided into three groups according to the
osteotomy system used to remove retentive bone: rotary instruments, piezosurgery, and Er:
YAG laser. Postoperative pain was evaluated with VAS questionnaires at 12, 24, and 48 h,
and 7 days after procedures. Trismus was evaluated by measuring the distance between
maxillary and mandibular incisors at maximum mouth opening and comparing preoperative
to postoperative days 2 and 7. Analyses of swelling were done via a stereophotogrammetry
system. Operation times were measured using a digital stopwatch from the initial incision to
the final suture.
Results:

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There were no statistically significant differences between the groups in terms of pain,
trismus, and swelling (p>0.05). The pain persisted longer in the rotary instrument group 24 h

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later (0±1.3; p=0.001). Pain scores obtained after 48 h for the piezosurgery(1,81±2,29) and
rotary(2,2±2,12) group were observed at 24 h in the laser group(2,19±1,52). The mean
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operation time was highest using the laser (19,1±3,85 min.; p=0.001) and lowest using rotary
instruments (9,88±2,97 min.; p=0.001).
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Conclusion:
Piezosurgery and Er: YAG laser are good alternatives to rotary instrument systems in third
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molar extraction but both systems are slower than traditional rotary instruments.
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Figure 1

Figure 2

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VAS

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0
12th hour 24th hour 48th hour 7th day

Er:YAG Laser Piezosurgery Rotary

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Figure 3

Trismus
45
40
35
30
25
20
15
10
5
0
Day 0 2nd day 7th day

Er:YAG Laser Piezosurgery Rotary

Figure 4

Total operation duration (min)

25

20

15
Ort±SS

10

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ER:YAG Laser Piezosurgery Rotary

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Total op. Duration (min)

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 Postoperative Evaluation of Er:YAG Laser, piezosurgery, and rotary systems used for

osteotomy in mandibular third-molar extractions

ABSTRACT

Objective:

This study compared patient postoperative pain, swelling, and trismus after usage of rotary

instruments, piezosurgery, and Er:YAG lasers in mandibular third-molar extraction.

Materials and methods:

This prospective study was executed with class II and position B vertically impacted

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mandibular third molars. Patients were divided into three groups according to the osteotomy

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system used to remove retentive bone: rotary instruments, piezosurgery, and Er:YAG laser.
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Postoperative pain was evaluated using VAS questionnaires at 12 h, 24 h, 48 h, and 7 days
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after procedures. Trismus was evaluated by measuring the distance between the maxillary and
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mandibular incisors at maximum mouth opening, and comparing preoperative measurements

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with those for postoperative days 2 and 7. Analyses of swelling were carried out via a

stereophotogrammetry system. Operation times were measured using a digital stopwatch from
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the initial incision to the final suture.

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Results:

There were no statistically significant differences between the groups in terms of pain,

trismus, or swelling (p > 0.05). Pain persisted more in the rotary instrument group 24 h later

(0 ± 1.3; p = 0.001). The pain scores obtained after 48 h for the piezosurgery (1.81 ± 2.29)

and rotary (2.2 ± 2.12) groups were observed at 24 h in the laser group (2.19 ± 1.52). The

mean operation time was highest using the laser (19.1 ± 3.85 min; p = 0.001) and lowest using

rotary instruments (9.88 ± 2.97 min; p = 0.001).

Conclusion:
Piezosurgery and Er:YAG laser are good alternatives to rotary instrument systems in third-

molar extraction, but both systems are slower than traditional rotary instruments.

Keywords

Er:YAG laser; piezosurgery; stereophotogrammetry

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INTRODUCTION

Third-molar extractions are among the most common procedures performed by oral

and maxillofacial surgeons (Ghaeminia et al., 2015). Complications such as pain, swelling,

and trismus frequently occur afterwards, and can affect daily quality of life and activities in

the immediate recovery period (da Rocha Heras et al., 2020). A comfortable healing period is

possible by keeping surgical procedures minimally invasive and atraumatic (Engelke et al.,

2014).

Osteotomy and ostectomy are often needed to remove retentive bone around third

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molars in order to facilitate extractions (Rupprecht et al., 2003). It is essential to perform an

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atraumatic osteotomy to access teeth and promote healing (Ge et al., 2014). Rotary systems
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have been used for many years to accomplish this, but there are several problems that persist
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despite technological developments. These problems include bone debris accumulation,
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overheating of surrounding bone, with subsequent necrosis, vibration, and patient discomfort
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(Rashad et al., 2015).

New technologies and instruments have been introduced into oral and maxillofacial
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surgical procedures to eliminate these adverse effects and perform effective, safe, and
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atraumatic osteotomies. One of these innovative systems is the erbium (Er):YAG laser

system, which can effectively cut hard tissues, such as bone and teeth. There is also the

piezosurgical system, which can remove calcified bone tissue without harming the

surrounding soft tissues (Pavlíková et al., 2011; Rullo et al., 2013). This study aimed to

compare patients’ postoperative pain, swelling, and trismus after usage of rotary instruments,

piezosurgery, and Er:YAG lasers in mandibular third-molar extraction.

MATERIALS AND METHODS

 The study was conducted in accordance with the Declaration of Helsinki and approved

by the local research ethics committee (approval number 2016-57). Only patients with Pell

and Gregory class II and Winter class B vertically impacted asymptomatic mandibular third

molars were recruited. Patients with any systemic disease, excessive alcohol consumption,

drug allergies, or who were pregnant/lactating were excluded. All patients were asked to sign

a consent form after they were informed of the possible risks and benefits of the procedure,

postoperative recovery time, and possible complications.

Patients included in the study were randomly divided into three groups according to

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the type of osteotomy instrument used during third-molar extraction. In order to eliminate the

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selection bias, all patients were randomly assigned to groups using the block randomization
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method. Group A involved bone removal with a 1.6 mm diameter round bur at 40 000 rpm,
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with saline irrigation. For group B a piezosurgery instrument (Piezomed; W&H, Bürmoos,
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Austria) was used for bone removal on the P3 program at 90% power and 60% cooler setting,
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as recommended by the manufacturer, using the EX1 and EX2 blades. For group C, an

Er:YAG laser instrument (Fidelis Plus II; Fotona, Ljubljana, Slovenia) was used for
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osteotomy, in contact mode and with the following parameters: 250 mJ pulse energy, 20 Hz
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frequency, 5 W power, 8 air–4 water rating, and super-short pulse (SSP) duration. Study

groups are summarized in Table 1.

All surgical procedures were performed by the same operator using the same surgical

protocol for all groups, except for the osteotomy devices used. The inferior alveolar and

buccal nerves were anesthetized using 2.5% articaine (Ultracaine D-S forte 2 mL ampoule;

Sanofi Aventis) containing 1:100 000 epinephrine. A #15 scalpel was used to perform buccal

sulcular and retromolar relaxing incisions. A mucoperiostal flap was elevated and the alveolar

bone was exposed. Retentive bone was removed to the cemento-enamel junction using one of

the three different osteotomy devices. Impacted third molars were extracted with a Bein root
elevator, the socket was irrigated with saline, and hemostasis was achieved. Flaps were closed

with 3.0 silk sutures to achieve primary closure. All patients received antibiotics (amoxicillin

with clavulanic acid; 1000 mg every 12 h for 5 days, starting the day before surgery), an

analgesic (paracetamol; 500 mg every 12 h starting after surgery), and an antiseptic

mouthwash (chlorhexidine gluconate 0.12%; rinsing three times per day for 7 days, starting

the day after surgery). Postoperative care instructions were explained in detail and given to

patients in a written form.

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Evaluation

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Postoperative pain was assessed using a visual analogue scale (VAS). Patients were
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asked to score pain being felt between 0 (no pain) and 10 (most severe pain ever) at 12 h,
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24 h, 48 h, and 7 days after surgery. Trismus was evaluated by measuring the distance
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between the mandibular and maxillary incisors at maximum mouth opening, preoperatively
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and postoperatively at days 2 and 7.

Swelling was evaluated using a three-dimensional stereophotogrammetry system

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(3dMDFace; 3dMD, Atlanta, GA, USA), taking photographs preoperatively and on

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postoperative days 2 and 7. The system was calibrated by taking photographs of the

calibration board punctured at regular intervals from two different angles in accordance with

3dMD’s instructions. After calibration, patients were photographed in an upright sitting

position, presenting a centric relation and with lips slightly closed. The 3D photos were

transferred to the 3dMDPatient software and trimmed to eliminate extraneous data, such as

hair, auricles, and neck anatomy, which could compromise the analysis. The 3DMDVultus

program was used to perform superimpositions of preoperative and 48 h postoperative

images, and preoperative and 7 day postoperative images. The frontal eminence and nasion of

the forehead were considered as static reference points, and painted. Records were taken with
a margin of error < 0.5. A color histogram map was created to visually evaluate and measure

volumetric changes between the superimposed preoperative and postoperative images, where

increases and decreases in volume were shown in red and green, respectively. Areas with a

difference equal to or less than 0.2 mm (either increased or decreased facial swelling) were

considered as being not significant by the software, and were shown in blue. Red areas (i.e.

swelling areas) on the histogram were marked and automatically calculated in cubic

centimeters (Figure 1). Operation times were measured using a digital stopwatch, which was

started right before the initial incision and stopped right after the final suture.

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Statistical analysis for this study was performed using IBM SPSS Statistics v. 22 (IBM

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SPSS, Turkey). Correlations of parameters with normal distributions were evaluated using the
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Shapiro-Wilk test. In addition to the descriptive statistical methods (mean, standard deviation,
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frequency), a one-way Anova test was used to compare the quantitative data between the
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groups with a normal distribution. The Tukey HSD test was used to determine the group that
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caused the difference. The Kruskal–Wallis test was used for comparisons of non-normally

distributed parameters between groups, and the Mann–Whitney U test was used for
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determination of the group causing the difference.

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In the group comparisons for normal distribution parameters, variance analysis was

used for repeated measurements, and the Bonferroni test was used to determine the period that

caused the difference. Friedman and Wilcoxon sign tests were used for comparison of the

parameters that did not show normal distribution. A chi-square test was used to compare

qualitative data. The significance level was set at p < 0.05.

RESULTS

The study was conducted on 57 patients (23 males and 34 females) aged between 18

and 39 years (average age 24.3 ± 5.01 years). There were no statistically significant
differences in average age or sex distribution between the treatment groups (p > 0.05) (Table

2).

There were no statistically significant differences in pain scores between the treatment

groups for 12 h, 24 h, 48 h, or 7 days (p > 0.05). However, pain reported in the piezosurgery

group decreased significantly throughout the postoperative period (p = 0.001). In the Er:YAG

laser group, no significant decrease in pain was observed between 24 h and 48 h (p > 0.05). In

the group treated with rotary instruments, no significant pain decrease was observed between

12 h and 24 h (p > 0.05) (Table 3). There was a significant difference between all three groups

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in the average pain felt at 24 h compared with 12 h (p = 0.001). Multiple comparisons

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demonstrated that the average change in perceived pain at 24 h compared with 12 h in the
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rotary instrument treated group was significantly lower than for those treated with the laser (p
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= 0.001) or with piezosurgery (p = 0.009) (Table 4 and Figure 2).
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There were no significant differences in maximum mouth opening between the three
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groups (p > 0.05) (Table 5 and Figure 3). Trismus was decreased on day 2 compared with day

0, but had increased significantly on day 7 compared with day 2 in all groups (p = 0.001)
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(Table 6). There were no statistically significant differences in swelling between groups,
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which was recorded by volumetric evaluation on day 2 and day 7 (p > 0.05) (Table 7).

Interestingly, there were significant differences between the groups in durations of

procedure. In multiple comparison tests, the mean total operation time for the laser treatment

group was significantly longer than for the piezosurgery and rotary instrument groups. The

average time recorded to complete extractions via piezosurgery was significantly longer than

that recorded for procedures using rotary instruments (Figure 4).

DISCUSSION
 Osteotomy to remove retentive bone is one of the most critical components in third-

molar extractions. It is possible to provide patients with a more comfortable recovery period

by keeping tissue damage to a minimum (Esparza-Villalpando et al., 2016). New instrumental

systems that reduce alveolar bone morbidity have been introduced in recent years to improve

patient outcomes. In this study, we compared the effects of three different osteotomy systems

(rotary, piezosurgery, and Er:YAG laser) on postoperative recovery.

During an osteotomy, marginal osteonecrosis from overheating of the surrounding

bone is a detrimental iatrogenic complication that disrupts healing. Siroraj et al. (2016)

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compared the effects of two different osteotomy speeds (20 000 and 40 000 rpm) on

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peripheral bone and reported sharper alveolar bone margins, decreased thermal osteonecrosis,
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and decreased debris accumulation in osteotomies performed with high-speed hand pieces.
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Accordingly, we performed our osteotomy procedures with conventional burs at 40 000 rpm
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to minimize damage to bone.

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Clinical results in the literature reflect different outcomes for rotary instruments and

piezosurgery in third-molar extraction procedures. In our study, we found no differences

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between these two methods relating to trismus and swelling, but did observe a decrease in
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reported pain at 24 h compared with 12 h in patients treated with rotary instruments. Goyal et

al. (2012) reported more pain, swelling, and trismus after mandibular third-molar extraction

with conventional rotary osteotomy compared with piezosurgery. Postoperative swelling was

not significant using the tragus–pogonion measurements, but tragus–comissura labiorum

measurements were greater in those treated with rotary instruments. Unlike our study, theirs

also included impacted teeth in multiple positions and angulations, which may be the reason

for our different results.

Mantovani et al.’s (2014) split-mouth study evaluating piezosurgery in comparison

with rotary systems showed no differences in pain scores using a VAS on postoperative days
2 and 4, but noted significantly lower pain on postoperative day 6 in the piezosurgery-treated

group. The average surgical procedure was longer in the piezosurgery group, which was

consistent with our findings.

Our findings are also in line with those of Piersanti et al. (2014), who reported no

differences in pain and trismus between patients treated with piezosurgery or rotary systems.

However, contrary to our results, they reported significantly lower postoperative swelling 1

week after surgery in the piezosurgery group. In that study, swelling was measured from the

lingual aspect of the crown of the first mandibular molar to the tangent of the skin of the

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cheek, using calipers. In another study that used calipers to measure swelling, postoperative

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swelling and trismus were lower in the piezosurgery-treated group (Sortino et al., 2008).
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Surgical time in that study was still lower in the rotary group; however, unlike in our study,
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they evaluated trismus and swelling 24 h after surgery. We believe that our results differed
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from these earlier studies because we evaluated these parameters at later time points.
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Tsai et al. (2012) compared piezosurgery with rotary instrument systems in bilateral

symmetrical impacted mandibular or maxillary third-molar extractions. Pain, swelling, and

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mouth opening parameters of all patients were followed daily for 1 week postoperatively and
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showed no significant differences between the two treatment groups; we found similar results.

Sivolella et al. (2011) compared rotary and piezosurgery systems used on patients undergoing

germectomy for orthodontic reasons. Postoperative day 7 pain values measured with a VAS

and maximum mouth opening on days 7 and 30 were similar between the groups. The mean

operation time for germectomy was significantly increased using piezosurgery.

Current literature does not provide evidence that piezosurgery or rotary systems are

superior to the other in terms of pain, swelling, and trismus during third-molar extraction.

However, we can say that a great number of publications have reported no differences in pain

and trismus between the two systems. Significant differences in swelling are usually seen with
tragus–comissura labiorum measurements. A review by Al-Moraissi et al. (2016) reported

that piezosurgery significantly reduced the occurrence of postoperative sequelae (edema,

trismus, and pain) compared with the conventional rotary system during mandibular third-

molar extraction, but that the procedure required more time.

Animal and clinical studies that have examined the use of Er:YAG laser on bone are

quite limited in the literature. Panduric et al. (2012) compared the impact of conventional

drills and Er:YAG laser on porcine ribs using microscopy and histology, and reported that

more bone tissue was removed in the same amount of surgical time with the laser. In addition,

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cavities prepared with the laser were regular, with clear, sharp edges and knifelike cuts, unlike

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those created by the conventional drill, which exhibited irregular edges full of bone fragments

and fibrous debris.

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Strikingly, in an animal study that used the Er:YAG laser at clinically acceptable
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energy levels, thermal damage was still observed. Martins et al. (2011) compared bone
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healing after conventional bur and Er:YAG laser ostectomies. They noted thermal damage as

a thin layer at all applied energy values (300 mJ, 350 mJ, 400 mJ). Bone healing was faster
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when surgical burs were used, but after 90 days similar results were achieved between the
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groups. By contrast, Romeo et al. (2015) reported lower pain, edema, and trismus using the

Er:YAG laser system compared with rotary instruments in third-molar extraction.

Comparing the Er:YAG laser with rotary instruments during third-molar extraction,

Passi et al. (2013) reported no differences between the groups in terms of perceived pain, but

found that trismus continued longer in the laser-treated group and swelling was increased in

the rotary instrument group. Osteotomy times for the laser were reported to be twice as long

as when using rotary instruments. Although we found similar results concerning patient pain,

we believe that these differences in trismus and swelling were due to differences in the study
group distributions. Unlike our study, which included only vertically impacted teeth, Passi et

al. removed mesioangular, distoangular, and horizontally impacted teeth.

Abu-Seriah et al. (2004) compared the use of Er:YAG laser and rotary instrument

systems to remove partially erupted third molars. They observed no statistically significant

differences between the groups in postoperative pain, but noted that pain persisted for longer

periods in patients treated with rotary instruments. They also reported that trismus was more

common in the laser-treated group, possibly due to the extended surgical time. Their study

measured tragus–comissura labiorum and gonion–lateral cantus distances to evaluate swelling

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and found no differences between the groups. Our results were consistent with these pain and

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swelling results, whereas trismus incidence was higher in their study. This may be due to their
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use of the laser at a higher energy value (700 mJ) compared with ours (250 mJ).
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Swelling after third molar extraction is commonly evaluated by measuring the
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distances between chosen reference points on the face. Many researchers prefer this method
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because it is easy to perform, low cost, rapidly repeatable, noninvasive, and provides an

objective numerical value. The most frequently measured distances for postoperative swelling
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analyses are the tragus–comissura labiorum, tragus–lateral cantus, gonion–lateral cantus, and
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tragus–soft tissue pogonion (Amin and Laskin, 1983; Gallardo et al., 1990). Contour changes

in soft tissue can only be evaluated in two dimensions using this method. However, swelling

is a volumetric change, and the most accurate evaluation is possible only with three-

dimensional measurements. One of the major deficiencies of the above two–dimensional

measuring method is that it is limited to the cheek. Swelling that spreads in the lingual

direction and is reflected in the submandibular and sublingual regions cannot be evaluated

because it falls outside the reference points.

For our study, stereophotogrammetry was used to evaluate postoperative swelling.

This is a noninvasive technique that can be repeated and archived, requires minimal patient
cooperation to quickly obtain data, and is cost effective. Few studies have discussed the

efficiency of the clinical use of stereophotogrammetry because it is such a new technique.

Lübbers et al. (2010) reported that the precision and accuracy of the stereophotogrammetry

system are more than sufficient for clinical needs, and greater than those of other methods,

such as direct anthropometry and two-dimensional photography. Van der Meer et al. (2014)

created artificial swellings in the cheeks of individuals to measure facial swelling with a

stereophotogrammetry system at different time points, and reported that a 3dMD

stereophotogrammetry scanner is a valid and reliable tool for measuring volumetric changes

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in the facial contour and facial swelling.

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CONCLUSION
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Recently, the search for an alternative to rotary systems has increased in oral surgery.
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Following our study, we conclude that piezosurgery and Er:YAG laser systems do not have
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obvious superiority over rotary instruments in the early postoperative recovery period.

Postoperative swelling evaluations should now be performed using 3D measurement

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techniques. However, it is evident in the literature that more extensive research is needed on
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this subject.

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Figure captions
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Figure 1. (a) Histogram map showing the volumetric changes between two matching images.
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(b) Measurement of swelling difference between preoperative and postoperative 3D images.

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Figure 2.

Figure 3.
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Figure 4.
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Table 1: Study groups and properties of osteotomy systems used

Study groups Osteotomy system used for bone removal

Group A (n = 20) Rotary system
12 female, 8 male 40 000 rpm
1.6 mm steel round bur
External saline irrigation
Group B: (n = 21 ) Piezosurgery system
14 female, 7 male 90% power and 60% cooler
EX1 and EX 2 blades
(Piezomed, W&H, Austria)
Group C: (n = 16) ER:YAG laser system
8 female, 8 male 250 mJ pulse energy, 20 Hz frequency, 5 W power, 8
air/4 water rating, SSP (super short pulse) duration,

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R14 handpiece, 256-12 sapphire tip contact mode
(Fidelis Plus II, Fotona, Slovenia)

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Table 2: Age and gender evaluations between groups

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Er: YAG laser Piezosurgery Rotary p-value

Age (mean ± SD) 23.75 ± 4.92 24.47 ± 5.20 24.55 ± 5.10 0.8781
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Gender (n)
Male 8 7 8
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0.5922
Female 8 14 12
1
one-way ANOVA test; 2chi-square test
Table 3: Inter- and intragroup VAS evaluation
ER:YAG laser Piezosurgery Rotary
VAS mean ± SD mean ± SD mean ± SD p-value1
(median) (median) (median)
12th hour 4.19 ± 1.94 (4) 4.14 ± 2.5 (4) 3.55 ± 2.56 (3) 0.524
24th hour 2.19 ± 1.52 (3) 3 ± 2.21 (3) 3.55 ± 2.72 (2.5) 0.374
48th hour 1.88 ± 2 (1.5) 1.81 ± 2.29 (1) 2.2 ± 2.12 (2) 0.708
7th day 0.63 ± 1.31 (0) 0.62 ± 0.92 (0) 0.25 ± 0.72 (0) 0.251
2
p-value 0.001 0.001 0.001
12th hour–24th hour
0.001 0.011 1.000
p-value3
12th hour–48th hour
0.001 0.001 0.002
p-value3

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12th hour–7th day p-
0.001 0.001 0.001
value3

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24th hour–48th hour
0.273 0.012 0.001
p-value3
24th hour–7th day p- -p
0.003 0.001 0.001
value3
48th hour–7th day p-
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0.007 0.005 0.002
value3
1
Kruskal–Wallis test; 2Friedman test; 3 Wilcoxon sign test; p < 0.05
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Table 4: Intergroup evaluation of differences in VAS scores

ER:YAG laser Piezosurgery Rotary
p-
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VAS mean ± SD mean ± SD mean ± SD value1

(median) (median) (median)
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24th hour–12th hour −2 ± 1.37 (−2) −1.14 ± 1.68 (−1) 0 ± 1.3 (0) 0.001
−0.31 ± 1.35
48th hour–24th hour −1.19 ± 1.81 (−1) −1.35 ± 1.39 (−1) 0.156
(−0.5)
7th day–48th hour −1.25 ± 1.61 (−1) −1.19 ± 1.69 (0) −1.95 ± 2.09 (−2) 0.443
1
Kruskal–Wallis test; p < 0.05
Table 5: Intra and Inter group evaluation of trismus levels.
ER:YAG laser Piezosurgery Rotary
Trismus p-value1
mean ± SD mean ± SD mean ± SD
Day 0 37.22 ± 6.59 39.86 ± 6.08 35.25 ± 7.22 0.093
2nd day 23.59 ± 7.12 22.83 ± 7.64 19.68 ± 7.84 0.250
7th day 33.75 ± 7.26 29.17 ± 8.61 28.28 ± 8.18 0.113
2
p-value 0.001 0.001 0.001
Day 0–2nd day p-
0.001 0.001 0.001
value3
Day 0–7th day p-
0.002 0.001 0.001
value3
2nd day–7th day
0.001 0.001 0.001
p-value3
1
one-way ANOVA test; 2Varyans analysis for repeated measurements; 3Bonferroni tTest; p <

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0.05

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Table 6: Intergroup evaluation of differences in trismus levels
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ER:YAG laser Piezosurgery Rotary
Trismus p-value1
mean ± SD mean ± SD mean ± SD
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2nd day–day 0 −13.63 ± 6.59 −17.02 ± 8.48 −15.58 ± 5.94 0.365

7th day–2nd
10.16 ± 6.3 6.33 ± 5.67 8.6 ± 5.08 0.126
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day
1
one-way ANOVA test
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Table 7: Intergroup evaluation of preop/postop2 and preop/postop7 swelling

parameters
ER:YAG laser Piezosurgery Rotary
Volume difference p-value1
mean ± SD mean ± SD mean ± SD
Preop/postop 2nd
17.86 ± 9.49 24.93 ± 13.85 20.74 ± 13.41 0.245
day
Preop/postop 7th
2.35 ± 2.14 4.15 ± 3.72 2.63 ± 2.06 0.113
day
1
one-way ANOVA test