Piezosurgical bone-cutting technology reduces risk

of maxillectomy and mandibulectomy complications in dogs

Sydney L. Warshaw, VMD; Patrick C. Carney, DVM, PhD, DACVIM; Santiago Peralta, DVM, DAVDC, FF-AVDC-OMFS*;
Nadine Fiani, BVSc, DAVDC, FF-AVDC-OMFS*

Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY

*Corresponding authors: Drs. Peralta (sp888@cornell.edu) and Fiani (nf97@cornell.edu)
Received March 8, 2023
Accepted May 2, 2023
doi.org/10.2460/javma.23.03.0130

OBJECTIVE
To report the complication rate of dogs undergoing oral oncological surgery when using a bone-cutting piezoelec-
tric unit for osteotomies.
CLINICAL PRESENTATION AND PROCEDURES
Retrospective cohort evaluation of medical records from 2012 through 2022 for canine patients that underwent
mandibulectomy or maxillectomy for the treatment of oral neoplasia at the Companion Animal Hospital at Cornell
University. Cases were included if osteotomy was performed using a piezoelectric unit. Medical records were then
reviewed for documentation of intraoperative hemorrhage and administration of blood products.
RESULTS
41 maxillectomies and 57 mandibulectomies met the inclusion criteria (98 in total). Only 1 (1.02%) case was associ-
ated with excessive surgical bleeding requiring administration of blood products.
CLINICAL RELEVANCE
Results of this study show that intraoperative hemorrhage requiring the use of blood products during or immediately
after a mandibulectomy or maxillectomy is rare when using a piezoelectric unit to perform osteotomies, and is substan-
tially lower than that previously reported when using oscillating saws or other bone-cutting devices for maxillectomies.

M axillectomy and mandibulectomy are common

surgical procedures for the treatment of orofacial
tumors. The most common reported intraoperative
complication with these procedures is hemorrhage.1–4
This is particularly true for patients undergoing caudal
maxillectomy,4 as inadvertent trauma to the maxillary,
infraorbital, and sphenopalatine blood vessels can
occur during the osteotomy. Other complications
can occur in the immediate or convalescent postop-
erative period, including aspiration pneumonia, sur-
gical site dehiscence, oronasal fistula formation, and
sialocele formation.1,5–7
Intraoperative hemorrhage can impede visualiza-
tion of the surgical field. As a result, identification and
ligation of the injured vessels is difficult, prolonging
surgical times and potentially leading to life-threat-
ening blood loss. A 2018 report4 evaluating factors
associated with intraoperative complications in 193
dogs undergoing oncologic maxillectomies found
that 53.4% exhibited excessive surgical bleeding, of
which 42.7% required a blood transfusion for acute hy-
povolemic anemia. This was consistent with prior stud-
ies4,8,9 that reported 30% to 50% of dogs undergoing
maxillectomy required transfusion for profound intra-
operative hemorrhage. In contrast to maxillectomies,
however, a 2021 study1 found that 4 of 279 (1.4%)
dogs undergoing mandibulectomy required a blood
transfusion for acute hypovolemic anemia.1
Some authors have recommended performing
osteotomies rapidly to allow more time to apply
ligation to control bleeding, suggesting that ex-
cessive or profound hemorrhage is unavoidable.2,4
However, rapid identification of hemorrhage may
be difficult or impossible in locations where vessels
may retract into osseous recesses.10,11 Common ca-
rotid or external carotid arterial ligation has been
well documented in human medicine to stop active
hemorrhage during surgical procedures or to pre-
emptively prevent or reduce risk for surgical proce-
dures with a high risk of bleeding.2,10,11 Comparable
approaches have been proposed in veterinary med-
icine including preemptive ligation of the maxillary
and carotid arteries.2,11
Surgical instruments used to perform osteoto-
mies during maxillofacial surgery often include os-
cillating or sagittal bone saws, high-speed electrical

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and air-driven dental units, low-speed electrical
units, and osteotomes with mallets.2,3,5,12–24 What
these instruments have in common is indiscriminate
cutting of any hard or soft tissue in their path. The
speed at which these instruments cut bone may be
relatively quick, but secondary injury to local soft tis-
sues is increased.25
Another instrument that can be utilized for max-
illofacial surgery is the piezoelectric unit (Figure 1).
Piezoelectric surgery utilizes ultrasonic micro-oscil-
lations at a rate of 28 to 36 oscillations/s, which al-
lows the instrument to cut mineralized tissues with
precision while sparing the soft tissues.20,26–28 There
is low acoustic impact and high tactile sensitivity,
allowing for less pressure for effect and enabling
improved ergonomic handing of the instrument for
the operator.17,29 Simultaneous sterile irrigation also
rinses away blood to improve visibility and creates
an environment for cavitation that has the addi-
tional benefit of cauterizing small vessels.15,26,29 Hu-
man studies utilizing piezosurgery for maxillofacial
surgery have also reported improved postoperative
healing and patient comfort.19 Due to the technically
complex nature of oncologic maxillectomy and man-
dibulectomy and proximity to major vessels, piezo-
surgical units may be utilized for procedures that
have high risk of hemorrhage.
Few reports have systematically documented
the risks or benefits of using a piezoelectric unit to
perform osteotomies during maxillectomy and man-
dibulectomy in dogs.3,15 The purpose of this study
was to document the intraoperative complication
rate in patients undergoing oncologic maxillectomy
or mandibulectomy when using a piezoelectric unit
to perform osteotomies.
Materials and Methods
Medical records of dogs that underwent man-
dibulectomy or maxillectomy for the treatment of
oral neoplasia at the Companion Animal Hospital
at Cornell University between 2012 and 2022 were
evaluated. Dogs were included if osteotomies were
performed using a piezoelectric unit and complete
medical records up to and through the perioperative
period were available. The type of surgical procedure

Figure 1—Photographs illustrating the surgical setup of a piezosurgical unit with attached irrigation, handpiece, and
cutting tips (A), closeups of the digital screen (B), handpiece with a BS1 cutting tip (C), and bone-cutting kit (D).
Figure 1 was designed with the assistance of Carol Jennings, Multimedia Producer, from the College of Veterinary
Medicine at Cornell University.

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was categorized based on location of osteotomies
as previously described in the literature.5,30,31 Total
mandibulectomies were excluded because they do
not involve an osteotomy, while extended subtotal
mandibulectomy cases were excluded because the
mandibular artery is ligated prior to the osteotomy.32
Records were considered complete if they in-
cluded preanesthetic bloodwork (CBC and serum
biochemistry profile or point-of-care bloodwork for
patients < 7 years of age with benign tumors con-
firmed via histopathology), CT imaging of the head,
histopathologic diagnosis, surgical report, anesthet-
ic records, and immediate postoperative hospital
monitoring/treatment records. Point-of-care blood-
work included PCV, serum total protein, BUN, and
blood glucose. Advanced imaging of the head was
utilized to evaluate the extent of tumor invasion, de-
termine whether the tumor was resectable, and de-
sign the individual surgical protocol. Additional data
obtained included breed, age, sex, body weight, pa-
tient size, surgical time if available, and location and
extent of surgery.
Surgeries were performed following standard
techniques5,30,31 by either an American Veterinary
Dental College board-certified specialist or a closely
supervised specialist in training. Anesthesia was per-
formed under direct supervision of a board-certified
veterinary anesthesiologist. Ethics committee ap-
proval was not required for enrollment given the ret-
rospective nature of the study.
All records included were assessed for the pri-
mary complication of interest (ie, severe intraopera-
tive hemorrhage). Severe hemorrhage was differen-
tiated from routine surgical bleeding by subjective
documentation of nonroutine bleeding in the medi-
cal record and objective signs of acute hypovolemic
anemia including tachycardia, hypotension, para-
doxical bradycardia, and the need for administration
of blood products.
Records were evaluated for intraoperative admin-
istration of blood products due to severe hemorrhage,
and the need for administration of blood products
was compared based on whether the patient under-
went maxillectomy or mandibulectomy, the location
of surgery, tumor type, and size of the patient.
Statistical analysis
Continuous variables were assessed for normal-
ity via the Shapiro-Wilk test; approximately normally
distributed variables were reported as mean ± SD,
while nonnormal variables were reported via median,
range, and IQR. The Wilcoxon rank sum test was used
to compare group medians for nonnormal variables,
while Spearman rank correlation was used to exam-
ine the relationship between nonnormal continuous
variables. Simple logistic regression was used to de-
termine the association between continuous variables
and the presence or absence of complications, while
relative risks (RRs) and associated 95% CIs, along with
the χ2 test or Fisher’s exact test, were used to assess
the relationships between categorical variables. Mul-
tivariable linear regression and multivariable logistic
regression were performed using stepwise backward
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selection with a retention threshold of P < .2, with fi-
nal models checked for 2-way statistical interaction.
Significance was defined as P < .05. Normality of re-
siduals in linear regression was visually assessed via
inspection of normal QQ plots. The linearity of the
relationship between continuous predictors and the
logit of the response variable in logistic regression
was checked via the Box-Tidwell test. All statistical
testing was performed using commercial statistical
software (SAS version 9.4; SAS Institute Inc).
Results
Ninety-eight cases met the inclusion criteria,
representing 41 maxillectomies (41.84%) and 57
mandibulectomies (58.16%). Patient body weight
ranged from 2.6 to 70.5 kg (median, 28.05; IQR,
16.80). Patient age ranged from 6 months to 15
years (mean, 7.79 ± 3.15 years). Fifty-five (56.12%)
patients were male (49 castrated, 6 intact), and 43
(43.87%) patients were female (40 spayed, 3 intact).
A total of 33 breeds were identified; the most com-
mon were mixed-breed dogs (29 dogs [29.59%]),
followed by Labrador Retrievers (14 dogs [12.28%])
and Golden Retrievers (7 dogs [7.14%]).
Thirteen tumor types were represented, includ-
ing canine acanthomatous ameloblastoma (31 dogs
[31.63%]), oral squamous cell carcinoma (19 dogs
[19.39%]), peripheral odontogenic fibroma (12 dogs
[12.24%]), plasmacytoma (8 dogs [8.16%]), osteosar-
coma (8 dogs [8.16%]), multilobular tumor of bone
or osteochondrosarcoma (5 dogs [5.10%]), oral ma-
lignant melanoma (4 dogs [4.08%]), and fibrosarco-
ma (3 dogs [3.06%]). The remaining 8.19% consisted
of 4 undifferentiated sarcomas, 1 amyloid-producing
odontogenic tumor, 1 peripheral nerve sheath tumor,
and 1 undifferentiated carcinoma.
Of the patients that underwent maxillectomy
procedures, 16 (39.02%) were unilateral rostral, 9
(21.95%) were bilateral rostral, 3 (7.31%) were cen-
tral, and 13 (31.70%) were caudal. Of the patients
that underwent mandibulectomy procedures, 11
(19.29%) were unilateral rostral, 28 (49.12%) were
bilateral rostral, 6 (10.52%) were rim (marginal) exci-
sions, and 12 (21.05%) were subtotal.
Recorded surgical times for all 98 reported sur-
geries ranged from 0.58 to 6.58 hours (median, 2.46
hours; IQR, 1.58 hours). Surgical times for maxillec-
tomies ranged from 0.83 to 6.58 hours (median, 2.73
hours; IQR, 1.75 hours), and surgical times for man-
dibulectomies ranged from 0.58 to 5.58 hours (medi-
an, 2.41; IQR, 1.50 hours; Table 1). In univariable anal-
yses, surgical time did not differ significantly between
mandibulectomies and maxillectomies (Wilcoxon rank
sum P = .6019), nor was it significantly associated
with dog weight (Spearman rank correlation, 0.116;
P = .2703). The surgery time for caudal procedures,
including caudal maxillectomy and subtotal mandib-
ulectomy (range, 2.00 to 6.58 hours; median, 3.41;
IQR, 1.70), was significantly longer than that of more
rostral procedures (range, 0.58 to 5.70 hours; me-
dian, 2.20; IQR, 1.21; Wilcoxon rank sum P < .0001).
Multivariable linear regression predicting the natural
Table 1—The range of surgical times by anatomical lo- In univariable analyses, dogs undergoing max-
cation, demonstrating similar surgical times between illectomy were more likely to experience complica-
maxillectomy and mandibulectomy and significant in- tions within 24 hours compared with mandibulec-
crease in surgical time for the most caudal procedures. tomy (RR, 1.86 [95% CI, 1.25 to 2.76]), but were not
Unit of measurement is in hours. significantly more likely to have complications at the
Surgical location No. Median Range IQR 2-week recheck (RR, 0.84 [95% CI, 0.46 to 1.55]);
conversely, caudal location was not significantly as-
Maxillectomy 39a 2.73 0.83–6.58 1.75 sociated with complications within 24 hours (rostral
Unilateral rostral 16 2.13 0.83–4.98 1.46 vs caudal: RR, 0.77 [95% CI, 0.52 to 1.15]), but was
Bilateral rostral 8 2.08 1.00–3.95 1.19
Central 3 2.08 1.25–5.70 4.45 associated with complications at the 2-week recheck
Caudal 12 3.94 2.33–6.58 1.62 (RR, 0.52 [95% CI, 0.23 to 0.90]). Location, sex, neuter
Total 0 — — — status, age, and body weight were not significantly
associated with either 24-hour or 2-week complica-
Mandibulectomy 53b 2.41 0.58–5.58 1.5 tions. In multivariable logistic regression predicting
Unilateral rostral 11 2.33 1.50–4.25 0.75 the odds of complications within 24 hours by age,
Bilateral rostral 25 2.33 1.00–5.50 1.66
Rim excision 6 1.96 0.58–2.66 0.75 body weight, sex, neuter status, caudal versus rostral
Caudal 0 — — — location, and mandibulectomy versus maxillectomy,
Subtotal 11 3.25 2.00–5.58 1.33 the only significant predictor was mandibulectomy
aTwo dogs did not have surgical time recorded. bFour dogs
(OR, 0.23 vs maxillectomy [95% CI, 0.09 to 0.58];
did not have surgical time recorded. P = .0020), with body weight also retained (OR, 1.03
[95% CI, 0.99 to 1.07]; P = .1053). For complications
at the 2-week recheck, caudal location (OR, 3.32 vs
logarithm of surgical time by age, body weight, sex, rostral [95% CI, 1.07 to 10.30]; P = .0382) was the
neuter status, caudal vs rostral location, and mandib- sole remaining significant predictor, with age (OR,
ulectomy vs maxillectomy found that caudal location 0.89 [95% CI, 0.76 to 1.05]; P = .1574) also retained
(P < .0001) was retained in the model and was associ- in the model.
ated with a 64.33% increase in the length of surgery.
When evaluating for the complication of interest, 1
of 98 (1.02%) cases received blood products due to re-
Discussion
ported excessive surgical bleeding with corresponding In the 10-year period captured in the present
paradoxical bradycardia, premature ventricular beats, study, 1 of 98 (1.02%) cases of dogs undergoing on-
and acute drop in RBC level. Presurgical PCV was 55%, cologic maxillectomy or mandibulectomy required
intraoperative PCV was 24%, and postoperative PCV administration of blood products due to severe in-
(following a single unit of packed RBCs) was 36%. traoperative hemorrhage. Intraoperative hemor-
This patient was a large-breed (37.9-kg) 10-year-old rhage has been consistently reported as the most
spayed female Staffordshire Bull Terrier with a 5-cm- common complication during caudal maxillectomies,
long osteochondrosarcoma that was treated with a with transfusion rates ranging from 30% to 50%.2,4,8,9
caudal maxillectomy; surgical time was 3.58 hours. These observations, although inconsistent with our
Other complications were recorded when avail- findings, are unsurprising given the proximity of the
able and separated into categories for < 24 hours after osteotomy sites to the maxillary artery and its prom-
surgery and 2 weeks after surgery. Within 24 hours inent branches. The variety of surgical procedures
of surgery, 33 cases (34.02%) were documented to included represented the full spectrum of described
have facial/hemifacial swelling, of which 19 (57.57%) surgical techniques with the explicit exclusion of total
were classified as mild, 12 (36.36%) as moderate, and and extended subtotal mandibulectomy cases.5,30,31
2 (6.06%) as severe. Other documented 24-hour com- Additionally, patient age, size, breed, tumor type,
plications included lip entrapment in 2 dogs (2.06%), and tumor location described in the present data set
epistaxis in 10 dogs (10.30%), inappetence in 15 dogs were comparable to previous studies.1,2,4,5,8 While di-
(15.46%), drooling in 2 dogs (2.06%), and an intraop- rect comparison to previous studies is not ideal, the
erative iatrogenic fracture of a marginally resected variables noted here are similar to previous reports,
mandibular tumor that required immediate fracture with the exception of the cutting instrument. There-
repair in 1 dog (1.02%). Fifty cases (51.54%) had no fore, the notably low intraoperative hemorrhage rate
reported complications at the 2-week recheck, and 19 observed in this study was likely aided by the use of
cases (19.58%) were lost to follow-up. Eight (20%) of a piezoelectric surgical unit. However, other factors
the maxillectomy procedures developed lip entrap- such as appropriate case selection, familiarity with
ment that required no further intervention, 2 (4.87%) the anatomy, diagnostic imaging, surgical planning,
had intermittent sneezing episodes, and 1 (2.43%) had and skill all play an important role in the outcomes of
mild drooling. Three (5.26%) of the mandibulectomy these challenging surgeries.
procedures developed lip entrapment that required The single patient that received a blood transfu-
no further intervention; 7 (12.28%) had mandibular sion was 1 of 13 (7.69%) dogs that underwent a caudal
drift, of which 2 (28.57%) required additional proce- maxillectomy. The anesthetic record demonstrated
dures; and 8 (14.03%) had areas of dehiscence that paradoxical bradycardia. While this deviates from the
were managed medically. Of the 7 dogs with mandib- classic signs of tachycardia and hypotension typically
ular drift, 6 underwent subtotal mandibulectomies. seen in cases of acute hemorrhage, 1 possibility for

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this change is myocardial hypoxia as a result of acute
hypovolemic anemia. This would explain the brady-
cardia and ventricular beats as early indicators for the
need of packed RBCs.
For this study, careful surgical planning and use
of piezoelectric surgery were adequate in avoiding
significant hemorrhage. Prior reports have recom-
mended temporary or permanent carotid ligation,
which is not without its own inherent risks and com-
plications, including hemorrhage, prolonged surgical
time, and trauma to the vasosympathetic trunk, re-
current laryngeal nerve, and internal jugular vein.11
Postoperative sequelae can also include hematoma
formation, retinal damage, and cerebral ischemia.11
The most commonly used bone-cutting instru-
ment for maxillectomy and mandibulectomy pro-
cedures has traditionally been the oscillating saw,
although other rotary instruments as well as an os-
teotome and mallet have also been reported.2,4,8,9
The power osteotomy instruments convert electric
or air-driven energy into mechanical energy that
creates heat at the cutting surface, increasing risk of
osteonecrosis and local tissue damage.15,21 Typical-
ly, bone-cutting burs used in rotary handpieces are
thicker compared with piezoelectric tips, increasing
the volume of bone lost during osteotomies and in-
creasing the torque and drilling force needed to be
effective.21 These factors limit the design and preci-
sion of the osteotomy, are indiscriminate in the dam-
age inflicted to soft tissues in the vicinity, and reduce
tactile feedback to the operator.2,21,25,33,34
In human medicine, oral surgeons use piezoelec-
tric units to reduce the risk of intraoperative hemor-
rhage for many types of delicate maxillofacial pro-
cedures.12,16,20,26,35–40 Piezoelectric surgery utilizes
ultrasonic micro-oscillations at frequencies that cut
mineralized tissues and spare soft tissues.20,26–28 As
a result, piezoelectric surgical handpieces do not re-
quire much operator pressure for effect, allowing for
improved ergonomics, high tactile sensitivity, and
preservation of fine motor control of the handpiece,
which make this useful for cutting bone intimately as-
sociated with nerves and vessels such as that of the
jaw.15,17,25,29 Modern piezoelectric units also include a
cold LED light to enhance surgical field visualization
and continuous sterile saline irrigation that rinses de-
bris from the surgical site, avoids overheating, and
provides a solution for cavitation, which cauterizes
small vessels and provides a bactericidal effect.15,26
Piezoelectric tips are narrow and come in various
angles and lengths allowing for a variety of osteot-
omy designs, including semilunar and deeply angled
cuts.21,35,41 These factors allow for precise bone cut-
ting, reduced soft tissue damage, increased visibility,
and sterilization of the surgical site.3,14,16,26,36,42–46
Histomorphological studies have demonstrated
that piezoelectric surgery results in increased lo-
cal expression of bone morphogenic proteins and
transforming growth factor as well as decreased
inflammatory cytokines such as interleukin 1β for
better bone healing compared with conventional
surgery.18,21,26,38,47 Human studies19,29,48 describe
improved healing with up to 50% less postoperative
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swelling and patients requiring up to 50% less postop-
erative analgesia when osteotomies were performed
with a piezoelectric unit compared with when they
were performed with conventional oscillating saws.
One cited disadvantage of piezoelectric surgery
is relatively increased surgical time, with 1 study re-
porting that osteotomies in hard or cortical bone
take up to four times as long as traditional osteoto-
mies.12,13,15,41,49 However, a human medical study41
comparing conventional instrumentation with piezo-
electric surgery for impacted third premolar extrac-
tion found that the gap in surgical duration closed as
operators gained experience with piezosurgical units,
eventually reaching parity. Moreover, any prolonga-
tion of surgical time with a piezotome is arguably off-
set by the benefits associated with the lack of severe
hemorrhage, reduced costs and risks of blood prod-
uct administration, and improved surgical outcome.
When evaluating surgical time in the current co-
hort, both bivariant analysis and multivariable linear
regression found no significant difference between
maxillectomies and mandibulectomies; however,
surgical time for caudal surgeries was significantly
longer than that of more rostral surgeries. This find-
ing is expected, given that the complexity of the
anatomy caudally necessitates more delicate dissec-
tion, careful osteotomy, and closure.
Limitations for this study are consistent with its
retrospective nature. For example, case controls,
where a separate cohort of patients would have un-
dergone the same procedure using different cutting
instruments, would have been ideal. Given that cases
were collected from a teaching hospital setting over
a period of time, the skill level of the multiple opera-
tors varied, and this would likely have had an impact
on surgical time. To compensate, strict inclusion cri-
teria were used. Future studies using a prospective
approach should be considered to best delineate
complication rates when all variables, other than the
cutting instrument, are kept consistent.
Statistical analysis showed that maxillectomy
procedures were more likely to lead to complications
within the first 24 hours postoperatively than mandib-
ulectomies. However, this was not the case at 2 weeks
postoperatively. The complications noted within the
first 24 hours were mild and largely self-limiting.
When complications at the 2-week mark were as-
sessed, caudal procedures were found to be more
likely to lead to complications. This was particularly
true for caudal mandibulectomies, as they sometimes
resulted in significant mandibular drift necessitating
treatment of the ensuing occlusal trauma. Interest-
ingly, surgical site dehiscence has previously been
reported as being the most common complication
associated with maxillectomies, especially for caudal
procedures; in contrast, the most common sequelae
in the current study included lip entrapment, swell-
ing, and self-limiting epistaxis, with no surgical site
dehiscence reported.1,4 Eight of 57 cases (14.04%) un-
dergoing mandibulectomy had small areas of surgical
site dehiscence that did not require further surgical
intervention. It is difficult to discern the exact reasons
for lack of dehiscence in the maxillectomies included
in this study. However, a combination of careful surgi-
cal planning, good technique, and appropriate instru-
mentation likely contributed.
Results of this study show that intraoperative
hemorrhage requiring the use of blood product dur-
ing or immediately after a maxillectomy is rare when
using a piezoelectric unit to perform osteotomies
and is much lower than that previously reported. This
study also corroborates the results of previous stud-
ies that indicated intraoperative hemorrhage is rare
for mandibulectomies.
Acknowledgments
The authors have nothing to declare.
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