Clinical Success
in
Bone Surgery with
Ultrasonic Devices
Marie Grace Poblete-Michel, DMD, MSc, DCD
Jean-François Michel, DDS, PhD, DCD
Paris, Berlin, Chicago, Tokyo, London, Milan, Barcelona, Istanbul, Moscow, New Delhi, Prague, São Paulo and, Warsaw |
ISBN 978-2-912550-64-4
© 2009 Quintessence International
Quintessence International
11 bis, rue d’Aguesseau
75008 Paris
France
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.
Design: STDI, Lassay-les-Châteaux, France
Printing and Binding: EMD, Lassay-les-Châteaux, France
Printed in France
Marie Grace Poblete-Michel, DMD, MSc, DCD
Former Assistant Professor in Periodontology
College of Dentistry
University of the East
Manila, Philippines
Jean-François Michel, DDS, PhD, DCD
Master of Lectures in Periodontology
Academic and Clinical Chair
Department of Periodontology
Faculty of Dentistry
University of Rennes I Rennes,
France
Coauthors
Solenn Hourdin, DDS
Former University Hospital Assistant in Periodontology
Faculty of Dentistry
University of Rennes I
Rennes, France
Nadine Brodala, DDS, MSc
Clinical Assistant Professor
Department of Periodontology
School of Dentistry
University of North Carolina
Chapel Hill, North Carolina, USA
Gilles Gagnot, DDS, PhD
Former University Hospital Assistant in Periodontology
Faculty of Dentistry
University of Rennes I
Rennes, France
The authors wish to express their gratitude to:
Dr Jean-Marie Korbendau (Evreux, France) for sharing his vast scientific knowledge and for his guidance and help in editing this book.
Professor Hessam Nowzari (Department of Periodontology, University of Southern California, Los Angeles, CA, USA) for contributing his broad scientific competence, his advice, and his objective and innovative approach to periodontology that has guided our work through these years.
Drs Amir Aalam (Los Angeles, CA, USA) and Pascal Huet (Nantes, France) for generously contributing clinical case photographs.
Mr Robert Grégoire and Ms Violaine Tureau (Acteon Group, France) for their dedicated collaboration.
The Mectron, Esacrom, EMS, and NSK Companies (France) for their kind participation.
Mr Joseph Lelannic (Center of Scanning Electron Microscopy and Microanalysis, University of Rennes I, France) for working with us to create quality SEM images.
Professor Jean-François Gaudy (Faculty of Medicine, University of Paris V, France) and Mr Eric Berthon (Laboratory of Anatomy, University of Rennes I, France) for the photographs of anatomic specimens.
Dr Nicolas Bedhet (Rennes, France) for his collaboration and the extraoral grafts presented in this book.
Cover | |
Table of contents | |
Foreword | |
Introduction | |
1 | Ultrasounds: Medical and surgical applications |
Piezoelectricity | |
Different mechanisms of ultrasonic wave production | |
Advantages of ultrasound use in the practice of bone surgery | |
2 | Indications and contraindications for bone surgery in periodontology and implant dentistry |
Indications | |
Contraindications | |
3 | Ultrasonic-assisted bone surgery: Devices and instrumentation |
Objectives and characteristic requirements of an osteotome | |
Types of nonconventional osteotomes | |
Ultrasonic-assisted osteotomes | |
Advantages of ultrasonic-assisted osteotomes | |
Technology of current ultrasonic-assisted osteotomes | |
Clinical applications in oral surgery | |
4 | Preoperative evaluation and premedication |
Preoperative evaluation | |
Premedication | |
5 | Intraoral and extraoral donor sites in periodontal and implant surgery |
Intraoral donor sites | |
Extraoral donor sites | |
6 | Techniques – Clinical cases |
Treatment of periodontal and preimplant defects | |
Reconstruction of bone loss through the sinus cavity | |
Piezoperiotomy: Ultrasonic-assisted atraumatic tooth extraction | |
Conclusion | |
I am delighted to be asked to write the foreword for this impressive book on the use of ultrasonic devices for bone surgery. The authors are timely in presenting this information for clinicians who are active in periodontal, oral and maxillofacial, and implant surgery. The reader is thoughtfully instructed in this new technology such that one quickly develops an appreciation of the science behind the device and the possible clinical applications of the device. What comes through loud and clear throughout this book is that piezosurgery is a true advance in the surgical management of bony tissues. The book nicely illustrates the many applications of piezosurgery in periodontal, oral, and implant surgery. The book further helps the reader to examine and treatment plan various clinical situations. The inclusion of contraindications for piezosurgery should be useful to early learners of this technology and ensure appropriate planning and use. The section on intraoral and extraoral donor sites is a useful reminder for the experienced surgeon and an excellent guide for the developing surgeon. Cases are well used to teach the reader the nuances of piezosurgery techniques in a variety of clinical situations.
All in all, I view this book as a tremendous resource for surgeons, for residents in graduate training, and for students. As an academician involved in the day to day training of young dental students and residents, this book will be a wonderful resource for me in educating these individuals in surgical applications. As a practitioner, this book will teach me new techniques for managing a variety of osseous and implant surgical situations. Recognizing that the field of implant dentistry has exploded, it is timely to have surgical technologies such as ultrasonic devices to accompany the placement of dental implants. But recognizing that this area of dentistry is never content, I expect the advances in osseous surgery detailed in this book to be quickly followed by the next generation of ultrasonic devices. I look forward to the ever emerging new possibilities for improved and advanced patient care utilizing ultrasonic devices.
Ray C. Williams, DMD
Distinguished Professor and Chair,
Department of Periodontology
School of Dentistry
University of North Carolina
Chapel Hill, North Carolina, USA
Managing the periodontal environment is a permanent challenge for the periodontist. The periodontium is an entity wherein the superficial periodontium is closely related to the deep periodontium. The alveolar bone partially determines the stability of the periodontal attachment and thus contributes to the periodontal health as far as esthetics and function are concerned. Different techniques and surgical protocols have been proposed to treat bone loss, be it during periodontal disease, after extractions, infections, or trauma, or within the context of placing osseointegrated dental implants. Most of these protocols involve bone surgery techniques.
Success in the practice of bone surgery requires the evaluation of more than 50 criteria (Misch 1987). The essential criteria are of course the long-term stability of the tissues surrounding the implant(s), the absence of inflammation or infection, and the prosthodontic needs and expectations of the patient. The dental implant possibilities will then be subjected to the anatomic criteria of the bone in the concerned area. When there is a pre-existing bone defect, bone grafting should be considered. Bone resorption is a natural physiologic phenomenon after the loss of teeth. Local or general resorptions may be the result of pathologic processes such as the evolution of untreated aggressive periodontitis or an endodontic or endoperiodontal infection. In addidtion resorption may be of traumatic, tumoral, or iatrogenic origin, and the alveolar bone can also be partially or totally destroyed at the moment of the tooth extraction.
Studying the morphology of the bone defect is essential for selecting the method of reconstruction (Mattout and Mattout 2003). If the volume of the defect is significant, we need to use a technique that is osteoinductive (Misch et al, 1992). The progress on alloplastic materials, allogenic materials (Deep et al, 1989; Nique et al, 1987), and guided bone regeneration techniques (Buser et al, 1993; Nyman et al, 1990) has reached a relatively high level of predictability. However, compared with an autogenous bone graft, these techniques lack the capacity of healing and the ability to provide a predictable prognosis. From the biologic and immunologic points of view, autogenous bone has demonstrated its superiority over all other materials.
The treatment success in oral surgery, periodontology, and implant dentistry must take into account more precise biologic criteria. These criteria include: using atraumatic surgical procedures; limiting risks to the surrounding tissue; and improving visibility, hemostasis, and postoperative conditions. Most of the instruments available so far have allowed rapid sampling but have not met all of these criteria. As far as bone grafts are concerned, most of the cutting instruments are modifications of instruments used decades ago in oral and maxillofacial surgery, ie, manual and mechanical instruments like saws, burs, and/or mallets and chisels.
Nowadays, it seems desirable to have at one’s disposal precision instruments tailored to every aspect of periodontal and implant surgery of hard tissues. Moreover, the narrow access to the sites of the oral cavity, efforts by the practitioner, and trauma inflicted on the patient (immediate and mediate postoperative conditions) are difficulties that at present cannot be ignored. Piezosurgery is an innovative technical approach to hard tissue surgery that was developed in the 1980s. It was derived from the basic principles of “piezoelectricity,” which was discovered by Jacques and Pierre Curie in the late 19th century. The idea of being able to cut through the bone using ultrasounds has been published since the 1970s (Horton et al. 1975). This surgical technique is assisted by an ultrasonic modulated frequency allowing precise and safe cutting of hard tissue. The tip selectively cuts the mineralized tissues without cutting the soft tissues. It therefore limits the risk of damage to the bloodvessels and nerves during bone harvesting. Moreover, visibility is increased, owing to physiologic saline solution irrigation that flows at the working end of the tip. The piezoelectric surgery accordingly offers comfort, safety, and precision to the surgeon during delicate interventions. The surgical indications for powerful ultrasounds using a piezoelectric device differ from all other bone surgery techniques (eg, rotary instruments).
This more precise and less traumatic technique for the tissues has a learning curve that requires prior training in order to understand the perfect balance between the pressure exerted by the hand of the practitioner and the movement of the tip.
This book presents the practical applications of powerful ultrasonic devices through their technical and surgical aspects. It aims to inform practitioners on the indications, effects, and limitations of this technique by including new protocols. It also provides the guiding principles in using these devices for optimal clinical application. Finally, it presents clinical cases illustrating the proposed indications.
Bibliography
Buser D, Dula K, Belser U, Hort HP, Berthold H. Localized ridge augmentation using guided bone regeneration. I. Surgical procedure in the maxilla. Int J Periodontics Restorative Dent. 1993;13(1):29–45.
Deep ME, Hosny M, Sharawy M. Osteogenesis in composite grafts of allogenic demineralised bone powder and porous hydroxyapatite. J Oral Maxillofac Surg. 1989;47:50–56.
Horton JE, Tarpley TM, Wood LD. The healing of surgical defects in alveolar bone produced with ultrasonic instrumentation, chisel, and rotary bur. Oral Surg, Oral Med, Oral Patho, Oral Radio. 1975;39(4):536–546.
Mattout P, Mattout C. Les Thérapeutiques Parodontales et Implantaires. Paris: Quintessence International.
Misch CE. Patient dental medical implant evaluation form. Misch Implant Institute Dearborn, 1987.
Misch CM, Misch CE, Resnir RR, Ismail YH. Reconstruction of maxillary alveolar defects with mandibular symphysis grafts for dental implants: Preliminary procedural report. Int J Oral Maxillofac Impl. 1992;3(7):360–366.
Nique T, Fonseca RJ, Upton LG, Scott R. Particulate allogenic bone grafts into maxillary alveolar clefts in humans: A preliminary report. J Oral Maxillofac Surg. 1987;45:386–392.
Nyman S, Lang NP, Buser D, Brägger U. Bone regeneration adjacent to titanium dental implants using guided tissue regeneration: A report of two cases. Int J Oral Maxillofac Impl. 1990;13(1):29–45.
Ultrasounds: | |
Medical and surgical | |
Piezoelectricity
Ultrasounds are waves with a frequency higher than 20,000 Hz (ie, cycles per second). A large number of ultrasonic frequencies used in everyday life—such as those used in car alarms and other antitheft systems—are not perceptible to the human ear. Humans perceive frequencies between 20 and 20,000 Hz. Ultrasound is therefore inaudible to humans but audible to certain animals such as dogs, bats, and dolphins. Developed in the 1950s, ultrasound technology is now widely used in the fields of medicine, dentistry, metallurgy, and aviation, and by the navy. It is also used for fishing, cleaning, and remote controls (eg, automatic gates).
The ultrasonic wave displaces itself in a medium and transmits its energy to the particles encountered. Ultrasonic vibrations are waves that are (1) displaced in a longitudinal direction, (2) displaced in a medium, and (3) reflected and absorbed at the interface of the different surfaces encountered (Van Der Weijden 2007).
Different mechanisms of ultrasonic wave production