10.59987/ads/2012.2.64-68
The removal of impacted mandibular third molar is a common surgical procedure entailing some risk of complications, especially when the tooth and the inferior alveolar nerve and/or lingual cortical plate are in close proximity. A technique that can reduce the possibility of damage is the Ultra Sonic Bone Surgery. The aim of this report is to present a paradigmatic case of an impacted mandibular third molar closely associated with a complex odontoma, which was treated with the Ultrasonic Bone Surgery (UBS) device. This technique appeared to be a valid alternative to manual or mechanical treatment, strongly minimizing trauma to the inferior alveolar nerve, vascular tissues, or surrounding dental tissues.
application/pdf
1971-1441
164
2
en
I. Vozza
https://creativecommons.org/licenses/by-nc-nd/4.0
Annali di stomatologia
ultrasonic bone surgery
Ultrasonic bone surgery in the treatment of impacted lower third molar associated to a complex odontoma: a case report
Text.Serial.Journal
https://www.annalidistomatologia.eu/ads
3
Case Report
2022-08-17
2022-08-17
2012-06-01
2023-12-04
64-68
Ann Stomatol (Roma)
I. Vozza
2012
10.59987/ads/2012.2.64-68
64
1971-1441
2
ultrasonic bone surgery
en
68
Ultrasonic bone surgery in the treatment of impacted lower third molar associated to a complex odontoma: a case report
https://www.annalidistomatologia.eu/ads/article/download/164/147
3
                                                                                                          Case Report



Ultrasonic bone surgery in the treatment of impacted
lower third molar associated to a complex odontoma: a
case report




                                                                                           li
                                                                                        na
Maria Paola Cristalli, DDS, PhD1                             ture (4-5). Rare complications are brain abscess, epi-
Gerardo La Monaca, DDS, PhD1                                 dural abscess, benign paroxysmal positional vertigo,
Nicola Sgaramella, MD, DDS2                                  subcutaneous and tissue space emphysema, subdural




                                                                                     io
Iole Vozza, DDS, PhD1                                        emphysema, and herpes zoster syndrome (6). The in-
                                                             cidence of inferior alveolar nerve (IAN) injuries ranges
1
  Department of Oral and Maxillofacial Sciences, “Sapi-      from 0.41% to 8.1% for temporary decreases of sensitiv-




                                                                                  az
enza” University, Rome, Italy                                ity and from 0.014 % to 3.6% for prolonged signs and
2
  Department of Surgical Sciences, Foggia University,        symptoms (7). When the radiographic signs of proximity
Italy                                                        of the mandibular canal to the roots of the third molar
                                                             are present, the incidence of damage can be as high as




                                                                     n
                                                             35% (8).
Corresponding Author:                                        Risk factors also include advanced age, surgeon’s ex-




                                                                  er
Maria Paola Cristalli, DDS, PhD                              perience, the use of burs during bone removal or tooth
Department of Oral and Maxillofacial Sciences, Oral          sectioning, and surgical difficulty associated with deeply
Surgery Unit, “Sapienza” University of Rome                  impacted teeth, particularly if distal bone removal is re-
6, Caserta, St. 00161, Italy                                 quired (9,10).
Phone: +39 06 49976651
Fax: +39 06 44230811
E-mail: mariapaola.cristalli@uniroma1.it
                                           nt                Thus, any technique that could reduce the possibility of
                                                             these nerve damages is worthy of exploration: a good
                                                             example is the Ultra Sonic Bone Surgery (UBS). This
                                         iI
                                                             technique consists of inducing energetic micro-vibra-
                                                             tions with a frequency in the 20–32 kHz range, above
                                                             the audible spectrum. The vibrations are generated by
                                       on

Summary                                                      a transducer, which is electrically, piezo-electrically or
                                                             magnetically controlled. Piezo-electric materials vary in
The removal of impacted mandibular third molar is            size when they are submitted to an intense electric field,
a common surgical procedure entailing some risk of           typically in the 500-750 V/mm range. These deforma-
                               i


complications, especially when the tooth and the in-         tions can further transmit energetic micronic mechanical
                            iz


ferior alveolar nerve and/or lingual cortical plate are      forces to a tip vibrating up to amplitudes of 200µm. UBS
in close proximity. A technique that can reduce the          uses piezo-electrical transducers, because the generat-
possibility of damage is the Ultra Sonic Bone Sur-           ed movements are more energetic. Ultrasonically moved
               Ed




gery. The aim of this report is to present a paradig-        knives have the ability to cut hard tissues, like teeth and
matic case of an impacted mandibular third molar             bone. In contrast, soft tissues like gingiva, blood vessels,
closely associated with a complex odontoma, which            nerves and sinus membranes are preserved from injury
was treated with the Ultrasonic Bone Surgery (UBS)           because they vibrate with the tip. This makes UBS par-
device. This technique appeared to be a valid alter-         ticularly suitable for a broad spectrum of surgical appli-
native to manual or mechanical treatment, strongly           cations including apicectomy, bone block section, sinus
 IC




minimizing trauma to the inferior alveolar nerve,            lifting, split-crest, nerve lateralization, resective bone
vascular tissues, or surrounding dental tissues.             surgery, and biopsies (11). We present here a case of
                                                             a deeply located odontoma encompassing an impacted
C




Key words: lower third molar, odontoma, ultrasonic           left mandibular third molar in close proximity to the inferi-
bone surgery.                                                or alveolar nerve, which was treated by Ultrasonic Bone
                                                             Surgery (UBS) device.
©




Introduction
                                                             Case report
The extraction of the lower third molar is one of the most
frequent procedures in oral surgery (1). Common com-         A 40-year-old man was referred to the Oral Surgery Unit
plications following third molar surgery include sensory     - Department of Oral and Maxillofacial Sciences (Sapi-
nerve damage, alveolar osteitis, infection, or haemor-       enza University of Rome, Italy) for recurrent episodes
rhage during or after surgery (2,3). Less common com-        of infection and pain in the mandibular left third molar
plications are severe trismus, iatrogenic damage to the      region. Clinical examination revealed the presence of a
adjacent second molar, and iatrogenic mandibular frac-       partially impacted left mandibular third molar showing

64                                                                                  Annali di Stomatologia 2012; III (2): 64-68
Ultrasonic bone surgery in the treatment of impacted lower third molar associated to a complex odontoma: a case report



mild signs of gingival inflammation (plaque retention and
bleeding on probing), without deformations or swelling of
the region (Fig.1). The panoramic x-ray (Fig.2) revealed
the presence of two large dense radiopaque masses in
close association mesially and distally to the roots of the




                                                                                                     li
impacted tooth, consistent with the provisional diagno-
sis of complex odontoma. A computed tomography (CT)




                                                                                                  na
with the Dentascan program (Siemens Rs Somaton Vol-
ume Zoom Kv 120 mA 140; Siemens, Erlangen, Germa-
ny) (Figs. 3, 4), obtained in order to define the extension
of the lesion and the anatomical topography, showed an




                                                                                               io
intimate relationship between the inferior alveolar nerve
and the odontoma-tooth unit. Surgical removal of the
impacted third molar and the associated odontoma was




                                                                                            az
planned. The patient received a single dose of 2 g of
amoxicillin and clavulanic acid (Augmentin 1 g, GlaxoS-
                                                                     Figure 3 - Panorex CT scan obtained in order to define the exten-
mithKline, Verona, Italy) 1 h before surgery, together with          sion of the lesion and regional anatomical topography.
a single dose (100 mg) of non-steroidal anti-inflammato-




                                                                              n
ry drug (Nimesulide, Aulin, Hoffmann-La Roche, Basel,
Switzerland). Surgery was performed under local anes-




                                                                           er
thesia. Local anaesthesia was performed (2% mepiva-
caine with 1:100,000 epinephrine) by IAN block injection
and tissue infiltration. A mucoperiosteal buccal flap was
reflected and bone was removed on the mesial, buccal

                                                  nt
and distal aspect of the third molar area with the Ultra-
                                                iI
                                      i       on
                                   iz
                   Ed




                                                                     Figure 4 - Sagittal CT scan examination showing an intimate re-
                                                                     lationship between the inferior alveolar nerve and the odontoma-
                                                                     tooth unit.
 IC




                                                                     Sonic Bone Surgery UBS® device (Italia Medica, Milan,
Figure 1 - Clinical examination of the impacted left mandibular      Italy) (Fig.5). The same device was used to separate the
third molar showing mild signs of gingival inflammation.
                                                                     odontoma from the tooth. After sectioning, both the third
                                                                     molar and the associated lesion were gently removed
C




                                                                     using root elevators (Figs. 6, 7). The wound was care-
                                                                     fully irrigated and the flap was repositioned and sutured
                                                                     with 4.0 suture (Vicryl®, ETHICON GmbH, Germany)
                                                                     (Figs. 8, 9). On macroscopic examination, the masses
©




                                                                     appeared to be a complex odontoma (Fig. 10), and the
                                                                     histopathological examination confirmed this diagnosis
                                                                     (12). After surgery, amoxicillin and clavulanic acid (1 g
                                                                     twice a day for 1 week) and nimesulide (100 mg twice a
                                                                     day for 2 days, and then as needed) were prescribed to
                                                                     the patient. Immediate postoperative wound healing was
Figure 2 - Appearance of two large dense radiopaque masses           satisfactory, and the post-operative panoramic radio-
closely associated to the roots of the impacted lower third molar    graph showed the integrity of the mandibular canal (Fig.
at the orthopanoramic examination.                                   11). No symptoms or signs of neurosensory impairment

Annali di Stomatologia 2012; III (2): 64-68                                                                                        65
M. P. Cristalli et al.




                                                                                                   li
                                                                                                na
                                                                                             io
                                                                           n              az
Figure 5 - Mucoperiosteal buccal flap reflection and bone remov-   Figure 7 - The third molar sectioned and then removed using
al with the Ultrasonic Bone Surgery.




                                                                        er
                                                                   root elevators.




                                               nt
                                             iI
                                  i        on
                               iz
                   Ed




Figure 6 - The separation of the odontoma from the third molar     Figure 8 - The wound after third molar removal.
and its removal with the ultrasonic device.
 IC




of the innervated area, the inferior alveolar nerve, or the
lingual nerve could be detected.
We confirm that we have read the Helsinki Declaration
and have followed the guidelines concerning this report.
C




Discussion
©




The present case showed an impacted lower third molar
associated with a relatively large complex odontoma in
an intimate relationship with the inferior alveolar nerve
canal. Surgical technique seems to play a major role in
causing complications related to third molar extraction
(13). Thus, a careful operating technique and adequate
instruments may limit the occurrence of complications.
Here, the removal of the odontoma-tooth unit was car-
ried out by using an ultrasonic surgery device in order            Figure 9 - The flap repositioned and sutured.


66                                                                                         Annali di Stomatologia 2012; III (2): 64-68
Ultrasonic bone surgery in the treatment of impacted lower third molar associated to a complex odontoma: a case report



                                                                     seems similar (18) or even improved because piezoelec-
                                                                     tric bone surgery seems to induce an earlier increase
                                                                     in neo-osteogenesis, resulting in a more positive osse-
                                                                     ous response (19, 20). The latter may depend on the
                                                                     cavitation effect induced by ultrasonic cutting that allows




                                                                                                     li
                                                                     an effective cooling avoiding significant hyperthermia
                                                                     and coagulation damages to the surrounding area (21).




                                                                                                  na
                                                                     The same effect is responsible for a higher visibility dur-
                                                                     ing surgery compared to conventional instruments due
                                                                     to the evacuation of detritus with the aerosol formation
                                                                     (14). In the present case, the piezoelectric device used




                                                                                               io
                                                                     is the Ultra Sonic Bone Surgery UBS® (UBS). The vibra-
                                                                     tion frequency of UBS is in the 20-32 kHz range and the
                                                                     maximum ultrasound power is 90 W. Increased power of




                                                                                            az
                                                                     the ultrasonic vibration and a higher vibrating frequency
                                                                     may result in a higher cutting efficiency in hard bone.
                                                                     Therefore, less pressure on the working tip is required
                                                                     further reducing the risk of thermal damage to the bone.




                                                                              n
                                                                     High power also allows for good cutting in case there is
Figure 10 - The complex odontoma.                                    soft bone, since the softer the bone the higher the ul-




                                                                           er
                                                                     trasound power required (21). Finally, the decrease of
                                                                     post-surgical complications with the use of ultrasound
                                                                     bone surgery after lower third molar removal must be
                                                                     considered, as reported by different authors (22,23).

                                                  nt                 Conclusion
                                                iI
                                                                     The use of Ultrasound Bone Surgery in surgical cases,
                                                                     where risk for noble soft tissue damage is high, appears
                                              on

                                                                     to be a valid alternative technique confirming other lit-
                                                                     erature reports.
Figure 11 - The post-operative orthopanoramic radiographs
showing the integrity of the mandibular canal.
                                      i


                                                                     References
                                   iz


to reduce risk for inferior alveolar nerve damage. Ultra-
sonic surgery is a tissue-selective technique that allows              1. Marciani RD. Third molar removal: an overview of indica-
a micrometric, precise and smooth cut into mineralized                    tions, imaging, evaluation, and assessment of risk. Oral
                   Ed




tissue, while adjacent soft tissue such as nerves, ves-                   Maxillofac Surg Clin North Am. 2007 Feb; 19(1): 1-13.
sels, periosteum or Schneiderian membrane (in case                     2. Bui CH, Seldin EB, Dodson TB. Types, frequencies, and
of maxillary sinus surgery) remain uninjured, because                     risk factors for complications after third molar extraction. J
surgical action ceases when the device tips come in                       Oral Maxillofac Surg. 2003 Dec; 61(12): 1379-89.
contact with non-mineralized tissue (14,15). An in vitro               3. Malkawi Z, Al-Omiri MK, Khraisat A. Risk indicators of post-
study concerning inferior alveolar nerve transposition by
 IC




                                                                          operative complications following surgical extraction of
piezoelectric surgery showed that after surgery the epi-                  lower third molars. Med Princ Pract. 2011; 20(4): 321-5.
neurium became roughened without any damage to the                     4. Chrcanovic BR, Custódio AL. Considerations of mandibular
deeper structures (16). Compared to traditional surgery                   angle fractures during and after surgery for removal of third
C




by conventional burs or chisels, ultrasonic cutting pre-                  molars: a review of the literature. Oral Maxillofac Surg.
cision and selectivity constitute important advantages,                   2010 Jun; 14(2): 71-80.
particularly in those cases where the surgery target is in             5. Woldenberg Y, Gatot I, Bodner L. Iatrogenic mandibular
close relationship with noble soft tissue structures (17).                fracture associated with third molar removal. Can it be
©




As a result, even less experienced surgeons (though                       prevented? Med Oral Patol Oral Cir Bucal. 2007 Jan 1;
properly trained) can perform such procedure, since                       12(1): E70-2.
the learning curve with ultrasonic surgery technique is                6. Brauer HU. Unusual complications associated with third
strongly reduced compared to traditional surgery with ro-                 molar surgery: a systematic review. Quintessence Int.
tating instruments (15). Nevertheless, a careful surgical                 2009 Jul-Aug; 40(7): 565-72.
approach remains critical considering that soft tissue can             7. Renton T, McGurk M. Evaluation of factors predictive of
be damaged by excessive mechanical force while using                      lingual nerve injury in third molar surgery. Br J Oral Max-
the device. In addition, when compared with traditional                   illofac Surg. 2001 Dec; 39(6): 423-8.
surgery, bone healing following piezoelectric surgery                  8. Tay AB, Go WS. Effect of exposed inferior alveolar neuro-


Annali di Stomatologia 2012; III (2): 64-68                                                                                          67
M. P. Cristalli et al.



    vascular bundle during surgical removal of impacted lower          Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009
    third molars. J Oral Maxillofac Surg. 2004 May; 62(5): 592-        Dec; 108(6): e1-5.
    600.                                                           17. Chiriac G, Herten M, Schwarz F, Rothamel D, Becker J. Au-
 9. Tolstunov L. Lingual nerve vulnerability: risk analysis and        togenous bone chips: influence of a new piezoelectric de-
    case report. Compend Contin Educ Dent. 2007 Jan; 28(1):            vice (Piezosurgery) on chip morphology, cell viability and




                                                                                                   li
    28-31.                                                             differentiation. J Clin Periodontol. 2005 Sep; 32(9): 994-9.
10. Ziccardi VB, Zuniga JR. Nerve injuries after third molar       18. Preti G, Martinasso G, Peirone B et al. Cytokines and




                                                                                                na
    removal. Oral Maxillofac Surg Clin North Am. 2007 Feb;             growth factors involved in the osseointegration of oral tita-
    19(1): 105-15.                                                     nium implants positioned using piezoelectric bone surgery
11. Blus C, Szmukler-Moncler S, Vozza I, Rispoli L, Polastri           versus a drill technique: a pilot study in minipigs. J Peri-
    C. Split-crest and immediate implant placement with ultra-         odontol. 2007 Apr; 78(4): 716-22.




                                                                                             io
    sonic bone surgery (piezosurgery): 3-year follow-up of 180     19. Vercellotti T, Kim DM, Wada K, Fiorellini JP. Osseous re-
    treated implant sites. Quintessence Int. 2010 Jun; 41(6):          sponse following respective therapy with piezosurgery. Int
    463-9.                                                             J Periodontics Restorative Dent. 2005 Dec; 25(6): 543-9.




                                                                                          az
12. Philipsen HP, Reichart PA. Classification of odontogenic       20. Emam TA, Cuschieri A. How safe is high-power ultrasonic
    tumours. A historical review. J Oral Pathol Med. 2006 Oct;         dissection? Ann Surg. 2003 Feb; 237(2): 186-91.
    35(9): 525-9.                                                  21. Blus C, Szmukler-Moncler S. Split-crest and immediate
13. Brann CR, Brickley MR, Shepherd JP. Factors influencing            implant placement with ultra-sonic bone surgery: a 3-year




                                                                           n
    nerve damage during lower third molar surgery. Br Dent J.          life-table analysis with 230 treated sites. Clin Oral Implants
    1999 May 22; 186(10): 514-6.                                       Res. 2006 Dec; 17(6): 700-7.




                                                                        er
14. Barone A, Santini S, Marconcini S, Giacomelli L, Gherlone      22. Goyal M, Marya K, Jhamb A, Chawla S, Sonoo PR, Singh
    E, Covani U. Osteotomy and membrane elevation during               V, Aggarwal A. Comparative evaluation of surgical out-
    the maxillary sinus augmentation procedure. A compara-             come after removal of impacted mandibular third molars
    tive study: piezoelectric device vs. conventional rotative         using a Piezotome or a conventional handpiece: a pro-

    511-5.                                    nt
    instruments. Clin Oral Implants Res. 2008 May; 19 (5):

15. Schlee M, Steigmann M, Bratu E, Garg AK. Piezosurgery:
                                                                       spective study. Br J Oral Maxillofac Surg. 2011 Nov 14.
                                                                       [Epub ahead of print]
                                                                   23. Barone A, Marconcini S, Giacomelli L, Rispoli L, Calvo JL,
                                            iI
    Basics and Possibilities. Implant Dent. 2006 Dec; 15(4):           Covani U. A randomized clinical evaluation of ultrasound
    334-40.                                                            bone surgery versus traditional rotary instruments in lower
16. Degerliyurt K, Akar V, Denizci S, Yucel E. Bone lid tech-          third molar extraction. J Oral Maxillofac Surg. 2010 Feb;
                                          on

    nique with piezosurgery to preserve inferior alveolar nerve.       68(2): 330-6.
                                  i
                               iz
                   Ed
 IC
C
©




68                                                                                          Annali di Stomatologia 2012; III (2): 64-68
