European Journal of Cardiovascular Medicine

Mandibular third molar impaction is one of the most common surgical conditions encountered in oral and maxillofacial practice. The removal of impacted third molars is often indicated due to pain, pericoronitis, caries, cystic changes, or orthodontic considerations. However, this procedure can be associated with several complications including postoperative pain, swelling, trismus, and, in some cases, sensory nerve disturbances, especially when conventional rotary instruments are used [1]. The surgical trauma involved in bone removal plays a crucial role in the development of these postoperative sequelae.

Conventional rotary instruments, specifically carbide burs attached to micromotor handpieces, have been used widely for osteotomy during third molar surgery. Although effective in cutting bone, burs operate through high-speed rotary motion that generates substantial heat and mechanical vibrations. These factors can cause microfractures in the bone and damage to adjacent soft tissues, resulting in increased postoperative inflammation and delayed healing [2]. Additionally, conventional burs can be difficult to control precisely near vital structures such as the inferior alveolar nerve, increasing the risk of nerve damage [3].

Piezoelectric surgery, also known as piezosurgery, has emerged as a modern alternative to conventional rotary instruments in various oral surgical procedures. It operates based on ultrasonic microvibrations that selectively cut mineralized tissues while preserving adjacent soft tissues such as blood vessels and nerves [4]. The piezo device allows precise bone cutting with minimal trauma and offers better visibility in the surgical field due to its cavitation effect. This has led to suggestions that piezo may reduce intraoperative complications and postoperative morbidity when compared to burs [5].

Several clinical studies have compared the efficiency and safety of piezoelectric surgery with conventional burs in third molar extractions. Most assessments focus on intraoperative duration, postoperative pain, swelling, trismus, and healing outcomes. Piezoelectric instruments are generally associated with reduced postoperative pain and swelling due to less aggressive bone cutting and less soft tissue trauma. However, they may increase the operative time when compared to burs, especially in dense cortical bone regions [6]. This trade-off between surgical precision and time efficiency is central to ongoing debates regarding the routine adoption of piezosurgery in third molar removal.

Furthermore, from a biological standpoint, the thermal and mechanical properties of piezosurgery seem to result in less cellular necrosis, improved osteogenesis, and more favorable healing dynamics. Some histological studies have demonstrated that piezoelectric devices maintain the vitality of the osteotomy site better than rotary instruments, which is an important consideration in cases requiring bone preservation, such as future implant placement [7]. Despite its advantages, the cost of piezoelectric units and the learning curve associated with their use remain limiting factors in widespread clinical adoption [8].

This comparative study aims to evaluate the efficiency of burs versus piezoelectric surgery in the extraction of impacted mandibular third molars by analyzing various clinical parameters such as operative time, postoperative pain, swelling, mouth opening limitation, and overall patient satisfaction. The objective is to provide evidence-based guidance on whether piezoelectric surgery offers a clinically significant advantage over the conventional bur technique in everyday oral surgical practice [9,10].

This prospective, comparative clinical study was conducted on patients requiring surgical removal of impacted mandibular third molars. Ethical clearance was obtained from the institutional review board prior to initiation. Informed consent was collected from all participants after explaining the nature of the study, potential risks, and benefits.

Study Design and Sample Selection

A total of 60 patients aged between 18 and 35 years, with mesioangular or horizontal impactions of mandibular third molars (classified as Class I or II, Position A or B based on Pell and Gregory classification), were selected and randomly allocated into two groups:

• Group A (n=30): Surgical extraction performed using conventional rotary burs.
• Group B (n=30): Surgical extraction performed using a piezoelectric surgical unit.

Inclusion criteria were:

• Presence of unilateral or bilateral impacted mandibular third molars.
• ASA I or II physical status (healthy or mild systemic disease).
• No history of acute infection, pericoronitis, or previous surgical attempt in the region.
• No systemic contraindications to oral surgery.

Exclusion criteria included:

• Severe trismus or limited mouth opening.
• Patients on anti-inflammatory or anticoagulant therapy.
• Pregnant or lactating women.
• Neurological disorders or history of nerve damage in the mandibular region.

Surgical Procedure

All surgeries were performed under local anesthesia (2% lignocaine with 1:80,000 adrenaline). A standard Ward’s incision was used in all cases. In Group A, bone removal was performed using a micromotor handpiece with straight surgical carbide burs under continuous saline irrigation. In Group B, a piezoelectric surgical unit with a bone-cutting tip was used for osteotomy under sterile saline irrigation.

Tooth sectioning was done as required in both groups. Closure was achieved using 3-0 silk sutures. The same experienced surgeon performed all procedures to eliminate inter-operator variability.

Postoperative Assessment Parameters

The following parameters were recorded:

• Operative Time (in minutes): From incision to placement of the final suture.
• Pain Score: Measured using a 10-point Visual Analog Scale (VAS) on postoperative Days 1, 3, and 7.
• Facial Swelling: Measured using standard facial reference points (tragus-pogonion and tragus-lateral canthus distances) preoperatively and on Days 1, 3, and 7.
• Mouth Opening: Interincisal distance was recorded preoperatively and postoperatively using a digital caliper.
• Postoperative Complications: Such as infection, dry socket, or nerve injury were noted.
• Patient Satisfaction: Recorded using a 5-point Likert scale on Day 7.

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using SPSS version 26.0. Continuous variables were expressed as mean ± standard deviation. Comparisons between groups were performed using the Student's t-test for continuous variables and the Chi-square test for categorical variables. A p-value < 0.05 was considered statistically significant

The study included 60 patients equally divided into Group A (Bur) and Group B (Piezotome). Baseline demographic characteristics (age and gender distribution) were statistically comparable between the two groups (p > 0.05), ensuring homogeneity of sample selection. The findings are summarized below:

Operative Time

The mean operative time was significantly shorter in Group A (Bur) than in Group B (Piezotome). Although piezosurgery offered better precision, it was slower due to the conservative bone cutting process.

Mean operative time:

• Group A:6 ± 3.4 minutes
• Group B:8 ± 4.2 minutes (p < 0.001)

Postoperative Pain (VAS Scores)

Pain was significantly lower in Group B on postoperative Day 3 and Day 7, indicating reduced soft tissue trauma with piezo use. However, Day 1 scores were comparable.

• Day 1: No significant difference
• Day 3 & Day 7: Group B showed significantly lower pain scores (p < 0.05)

Facial Swelling

Swelling was evaluated using linear facial measurements. Group B showed significantly less swelling on Day 3 and Day 7, suggesting better tissue preservation and healing.

Mouth Opening (Trismus)

Postoperative mouth opening was better maintained in Group B. Trismus was more evident in Group A, likely due to muscle trauma from heat and vibration caused by burs.

Table 1: Comparison of Operative Time Between Groups

Table 2: Visual Analog Scale (VAS) Pain Scores

Table 3: Postoperative Swelling Measurement (mm)

Table 4: Interincisal Mouth Opening (mm)

The present study aimed to compare the efficiency of conventional burs and piezoelectric devices in the surgical extraction of impacted mandibular third molars. Various parameters including operative time, postoperative pain, swelling, mouth opening, and patient comfort were assessed, revealing notable clinical differences between the two techniques.

One of the most prominent findings was that the mean operative time was significantly shorter in the bur group compared to the piezo group. This aligns with earlier observations that rotary instruments can cut bone more rapidly due to their aggressive mechanical action, making them more time-efficient in routine extractions [11]. However, this efficiency may come at the cost of greater surgical trauma, particularly due to thermal injury and vibration-induced soft tissue damage [12].

Despite the longer surgical duration, the piezoelectric group demonstrated significantly better postoperative outcomes. Patients in this group experienced lower pain scores on Days 3 and 7, suggesting that piezosurgery leads to reduced inflammatory response and soft tissue trauma [13]. These findings support the concept that piezosurgery’s selective bone-cutting ability, with minimal impact on surrounding soft tissues, contributes to decreased nociceptive stimuli and enhanced postoperative comfort [14].

Facial swelling is another important parameter indicating surgical trauma and inflammation. The piezo group consistently showed reduced swelling, particularly evident on Day 3. This can be attributed to the cavitation effect of piezoelectric instruments, which promotes better hemostasis and minimal disruption of the periosteum and soft tissues [15]. Comparable studies have demonstrated that piezo-assisted osteotomy preserves vascular integrity, contributing to quicker resolution of edema [16].

Trismus, reflected by decreased mouth opening, was significantly lower in the piezo group postoperatively. Reduced muscular trauma and minimal tissue retraction associated with piezosurgery may be responsible for better preservation of masticatory function [17]. The absence of rotary vibration also contributes to a lower degree of neuromuscular irritation in the surrounding tissue planes.

Another key point is the safety profile. Although this study did not report any complications, previous literature suggests that piezoelectric surgery significantly reduces the risk of inferior alveolar nerve injury due to its selective cutting mechanism and enhanced tactile feedback [18]. This feature is particularly advantageous in cases with close root proximity to the mandibular canal.

In terms of bone healing, several histological studies have shown that piezoelectric bone cutting results in a more organized and viable bone margin, which may enhance regenerative outcomes [19]. Though not directly assessed in this study, such healing benefits have long-term implications in cases requiring future implant placement or regenerative procedures in the same site.

The main limitation of piezosurgery remains the increased operative time and higher cost of equipment. However, the trade-off is improved patient-centered outcomes, including less pain, swelling, and faster return to function. Therefore, its utility may be especially justified in high-risk cases or in patients who prioritize minimal discomfort postoperatively [20].

This comparative study establishes that while bur-based osteotomy is faster, piezoelectric surgery provides superior postoperative outcomes in mandibular third molar extractions. Patients in the piezo group experienced significantly less pain, swelling, and trismus, with enhanced overall comfort and recovery. Although piezosurgery demands a longen r operative time and involves higher cost, its minimally invasive nature and improved healing profile make it an excellent alternative, especially in anatomically sensitive or patient-centered cases. The findings advocate for its selective integration into clinical practice where preservation of soft tissue, vascular integrity, and nerve safety is prioritized.

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