REVIEW OF LITERATURE

(1)

“COMPARATIVE EVALUATION OF PIEZOSURGERY VERSUS CONVENTIONAL OSTEOTOMY IN SURGICAL REMOVAL OF

IMPACTED MANDIBULAR THIRD MOLAR”

Dissertation submitted to

THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY In partial fulfillment for the Degree of

MASTER OF DENTAL SURGERY

BRANCH III

ORAL AND MAXILLOFACIAL SURGERY 2017-2020

RAJAS DENTAL COLLEGE AND HOSPITAL

THIRURAJAPURAM, KAVALKINARU, TIRUNELVELI – 627 105.

DCI Recognition No. DE-3 (44) – 93/2246, dated 09/11/1993 Affiliated to The Tamil Nadu Dr. M.G.R. Medical University, Chennai.

(2)

CERTIFICATE BY THE GUIDE

This is to certify that this dissertation entitled “COMPARATIVE EVALUATION OF PIEZOSURGERY VERSUS CONVENTIONAL OSTEOTOMY IN SURGICAL REMOVAL OF IMPACTED MANDIBULAR THIRD MOLAR” is a bonafide research work done by Dr.Chandooorya.C under my guidance during her postgraduate study period between the year 2017– 2020.

This Dissertation is submitted to THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY, in partial fulfillment for the degree of MASTER OF DENTAL SURGERY in BRANCH III - ORAL AND MAXILLOFACIAL SURGERY. It has not been submitted partially or fully for the award of any other degree or diploma.

DATE: SIGNATURE OF THE GUIDE

PLACE: Kavalkinaru DR. DHINEKSH KUMAR. N MDS, MOMSRCPS, Professor,

Department of Oral and Maxillofacial Surgery, Rajas Dental College and Hospital,

Kavalkinaru, Tirunelveli-627105.

(3)

CERTIFICATE BY THE HEAD OF THE DEPARTMENT

This is to certify that this dissertation entitled “COMPARATIVE EVALUATION OF PIEZOSURGERY VERSUS CONVENTIONAL OSTEOTOMY IN SURGICAL REMOVAL OF IMPACTED MANDIBULAR THIRD MOLAR” is a bonafide research work done by Dr.Chandooorya.C under the guidance of DR. DHINEKSH KUMAR. N MDS, MOMSRCPS (GLASGOW), Professor, during her postgraduate study period between the year 2017– 2020.

This Dissertation is submitted to THE TAMILNADU Dr. M.G.R.

MEDICAL UNIVERSITY, in partial fulfilment for the degree of MASTER OF DENTAL SURGERY in BRANCH III - ORAL AND MAXILLOFACIAL SURGERY. It has not been submitted partially or fully for the award of any other degree or diploma.

DATE:

PLACE: Kavalkinaru

DR. I. PACKIYARAJ, MDS, Head of the Department,

Kavalkinaru, Tirunelveli-627105.

(4)

ENDORSEMENT BY HOD/PRINCIPAL/HEAD OF THE INSTITUTION

This is to certify that the dissertation entitled “Comparative evaluation of Piezosurgery versus Conventional osteotomy in surgical removal of impacted mandibular third molar” is a bonafide work done by Dr.Chandooorya.C under the guidance of Dr.Dhineksh Kumar. N MDS, MOMSRCPS (Glasgow), Professor, Department of Oral and Maxillofacial Surgery, Rajas Dental College and Hospital, Kavalkinaru, Tirunelveli-627105.

DATE: DR. ANISHA CYNTHIA SATHIASEKHAR, M.D.S,

PLACE: Kavalkinaru Principal,

Rajas Dental College and Hospital, Kavalkinaru, Tirunelveli-627105.

(5)

THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY CHENNAI

DECLARATION BY THE CANDIDATE

I hereby declare that the dissertation titled “Comparative evaluation of Piezosurgery versus Conventional osteotomy in surgical removal of impacted mandibular third molar” is a bonafide and genuine research work carried out by me under the guidance of Dr. Dhineksh Kumar. N MDS, MOMSRCPS (Glasgow), Professor, Department of Oral and Maxillofacial Surgery, Rajas Dental College and Hospital, Kavalkinaru, Tirunelveli-627105.

Date:

Place: Kavalkinaru

Dr.Chandoorya. C, Post Graduate Student,

Kavalkinaru, Tirunelveli-627 105.

(6)

PLAGIARISM CHECK CERTIFICATE

This is to certify that this dissertation work titled “Comparative evaluation of Piezosurgery versus Conventional osteotomy in surgical removal of impacted mandibular third molar” by the candidate Dr.Chandooorya.C with Registration number 241715201 is submitted for the award of Master of Dental Surgery in the Branch III - Oral and Maxillofacial Surgery. I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file has contents from introduction to conclusion pages and its result shows percentage of plagiarism in the dissertation.

DATE:

PLACE: Kavalkinaru

SIGNATURE OF THE GUIDE

DR. DHINEKSH KUMAR. N MDS, MOMSRCPS, Professor,

Kavalkinaru, Tirunelveli-627 105

(7)

(8)

(9)

ACKNOWLEDGEMENT

I thank THE ALMIGHTY for all of His blessings, strength, grace and guidance all throughout my life.

I consider this as a great privilege to express my honour and gratitude to my most respectedDr.I.Packiyaraj MDS, Head of the Department of Oral and Maxillofacial Surgery, for his keen interest, kind support, valuable advice and constant encouragement throughout the course of my work, as well as during my entire post – graduation course.

I sincerely thank my Guide Professor. Dr. Dhineksh Kumar. N MDS, MOMSRCPS (Glasgow) for the enlightenment in the surgical dexterityand for his valuable guidance throughout my work.I thank Reader Dr.Gen Morgan MDS, Senior lecturers Dr.Suresh MDS, Dr.Vimal Joseph Devadoss MDS, Dr. Venkata Krishnan MDS Department of Oral and Maxillofacial Surgery, for their inspiring guidance, valuable counsel and constant support during my study.

It is my pleasant privilege to extend my gratitude to our beloved chairman Dr. Jacob Raja, MDS for his support and encouragement throughout the period of the study.

It gives me immense pleasure to thank our Principal, Dr. Anisha Cynthia Sathiasekhar MDS, Vice Principal (Academics) Dr. Antony Selvi, MSc, PhD, Vice Principal (Administration) Dr. J. Johnson Raja MDS, Administrative director and the Members of the Ethical Committee and Review Board for the permission, help and guidance throughout the course.

I am grateful to my colleague Dr. Jenin N.T for his co-operation and support.

My sincere thanks to my junior colleagues Dr.Jebina Dennis and Dr.Saravanan for

(10)

their support. I also thank Dr.Vincy Flora and Dr. Augusta for their kind help. I extend my sincere thanks to my senior colleagues Dr.Kala Bagavathy, Dr.Priyanthi, Dr.Kavitha and Dr. Vimal Joseph Devdoss for their guidance.

I thank the photographer of Rajas Dental College and Hospital, Mr. Siva Subramani for his kind help in standard clinical photography. I would also like to thank all the non-teaching staff of the Department of Oral and Maxillofacial Surgery for the help and support.

I would also like to express my gratitude to my Family, for their understanding, endless patience and encouragement when it was most required. I dedicate this dissertation to my father Mr. S.Chandramouli, SBI & Mother Mrs. M.Viji, ICDS and to my brother C.Winston Vijay, ICICI for their encouragement and support.

Dr.Chandoorya.C

(11)

ABSTRACT

I ABSTRACT

TITLE OF THE STUDY: Comparative evaluation of Piezosurgery versus Conventional osteotomy in surgical removal of impacted mandibular third molar.

PURPOSE OF THE STUDY:

Surgical removal of impacted mandibular third molars are recommended as it poses problem with normal functioning. It can cause pericoronitis, regional pain, abscess, trismus, distal caries of second molar, periodontal pocket of the second molar, development of follicular cyst, crowding of lower incisor. Many methods of osteotomy techniques are used, which when used inadvertently may cause osteonecrosis and impair regeneration & healing. Horton et al was the first to propose the ultrasonic technique in oral surgery. An Italian oral surgeon Tomasso Vercellotti was the one who introduced piezosurgery in oral surgery. Piezosurgery is used for osteotomy as it works through micro vibrations at an ultrasonic frequency for effective and precise bone cutting. It is very much useful in place where vital structures are involved. It produces less heat generation than with conventional bur technique. It also produces a selective cutting of bone. The purpose of this split mouth, prospective study is to compare the efficiency and post-operative outcome between piezosurgery and conventional bur technique in surgical removal of impacted mandibular third molar.

AIM:

To compare piezosurgery and conventional bur method for bilateral surgical removal of impacted mandibular third molar.

(12)

ABSTRACT

II OBJECTIVES:

The objective of the study is to compare and evaluate the efficiency and post - operative outcome between two groups;

1. Conventional method (Bur technique) 2. Piezosurgery (Piezotome with osteotomy tips) The comparison is made on the following parameters:

PRIMARY PARAMETER (assessed during the surgical procedure)

 Duration of the operative surgical procedure (from start of the incision to removal of the tooth)

SECONDARY PARAMETERS (Evaluated on 1^st, 3rd & 7^th day post – operatively)

 Pain

 Swelling

 Dry socket

 Trismus

METHODOLOGY:

SAMPLE SIZE 10 patients

(13)

ABSTRACT

III INCLUSION CRITERIA

1. Impacted teeth with full root formation, persistent pericoronitis.

2. Patient’s requiring removal of bilateral impacted mandibular third molars, who visited Rajas dental college & Hospital, OMFS Department on a period of 2017 – 2019 was included in the study.

3. Patient’s age between 20 to 35 years.

EXCLUSION CRITERIA

1. Poor motivation to return for follow up visit

2. Patients with any systemic diseases like uncontrolled diabetes and blood disorders

3. Smokers 4. Alcoholics 5. Drug abusers

6. Patients with acute pericoronitis, abscess 7. Oral submucous fibrosis

8. Patient on immunosuppressive drugs 9. Patient who underwent Radiation therapy 10. Pregnancy

INVESTIGATION

 Intra – oral periapical radiograph (IOPA)

 Orthopantomograph (OPG)

(14)

ABSTRACT

IV PROCEDURE

(i) 10 patients who required bilateral surgical removal of impacted mandibular third molar were selected randomly and allocated in two groups based on randomized control trial.

(ii) Pell & Gregory, Winter’s classification & Quek’s modification, WAR lines were included in this study to classify the position of the third molar.

1. PELL & GREGORY CLASSIFICATION:

(A) Relation of the tooth to the ramus of the mandible

Class I: Sufficient amount of space between the ramus and distal surface of the second molar for accommodation of the mesiodistal diameter of the crown of the third molar.

Class II: The space between the ramus and the distal surface of the second molar is less than the mesiodistal diameter of the crown of the third molar.

Class III: All or most of the third molar is within the ramus of the mandible (B) Relative depth of the third molar in bone

Position A: The highest portion of the tooth on a level with or above the occlusal line.

Position B: The highest portion of the tooth below the occlusal line, but above the cervical line of the second molar.

Position C: The highest portion of the tooth on the level with or below the cervical line of the second molar.

(15)

ABSTRACT

V

(C) The position of the tooth in relation to the long axis of the second molar 1. Vertical

2. Horizontal 3. Mesioangular 4. Distoangular 5. Inverted

2. GEORGE WINTER’S CLASSIFICATION:

Based on the relationship of the long axis of the impacted mandibular third molar to the long axis of the second molar.

(i) Mesioangular - the long axis of the impacted third molar is inclined towards the second molar.

(ii) Distoangular - the long axis of the impacted third molar is angled distally or tilted backwards to the long axis of the second molar.

(iii) Horizontal - the long axis of the impacted third molar is perpendicular to the long axis of the second molar.

(iv) Vertical - the long axis of the impacted third molar is parallel to the long axis of the second molar.

(v) Buccal / lingual obliquity – In combination with the above angulation, the tooth can be buccally (tilted towards the cheek) or lingually (tilted towards the tongue) impacted.

(vi) Transverse– where the tooth is placed horizontally in cheek – tongue direction.

(vii) Inverted – the lines are inverted.

(16)

ABSTRACT

VI

3. QUEK’S MODIFICATION OF WINTER’S CLASSIFICATION:

Quek et al. Classification system uses orthodontic protractor to determine the angle formed between the intersected long axis of third and second molar. The classification of mandibular third molar impaction as follows.

a. Vertical (0°–10°)

b. Mesioangular (11°–79°) c. Horizontal (80°–100°) d. Distoangular (−11° to −79°) e. Others (−111° to −80°) 4. WAR (WINTER’S) LINES:

 Winter’s lines are colour coded.

 The first “white” line drawn along the occlusal surfaces of erupted mandibular molars and is extended posteriorly over the third molar region. This line corresponds to the axial inclination of the impacted third molar tooth.

 The second “amber” line drawn from the bone overlying distal surface of the third molar to the crest of interdental septum between second and first mandibular molars. This indicates the amount of alveolar bone covering the impacted tooth.

 The third or “red” line is used to measure the depth of the impacted tooth that lies within the mandible. It is a perpendicular line dropped from the “amber”

line to the imaginary point of application of an elevator which lies on the

(17)

ABSTRACT

VII

cemento-enamel (CEJ) junction on the mesial surface of the impacted mandibular tooth. (Figure 11)

(iii)Patients are evaluated based on the following parameters.

PRIMARY PARAMETER PIEZOSURGERY CONVENTIONAL BUR TECHNIQUE

Duration of the operative surgical procedure from start of the incision

to removal of tooth (in mns)

METHOD PIEZOSURGERY CONVENTIONAL BUR

TECHNIQUE

SECONDARY PARAMETERS

PRE OP

1

st

DAY 3

rd

DAY 7

th

DAY

PRE OP

1

st

DAY 3

rd

DAY 7

th

DAY Pain (VAS scale)

Swelling (4 facial reference point)

Dry socket (based on blum’s criteria)

Trismus (Measuring interincisal distance with a ruler [ in mm] )

(18)

ABSTRACT

VIII INSTRUMENTS

 Piezosurgery device (Piezotome) with special osteotomy tip US2, US3 designed for osteotomy.

 Conventional bur method with No 703 carbide straight fissure bur in surgical straight handpiece and micromotor at 35,000 rpm.

SURGICAL PROCEDURE

Local anaesthetic: Lignocaine hydrochloride 2% with 1:80,000 adrenaline Nerve block:

 Inferior alveolar nerve block (IANB)

 Long buccal nerve block

 Lingual nerve block Incision:

Ward’s & Modified Ward’s incision (Based on the requirement for exposure of impacted mandibular third molar)

Osteotomy method:

Done with Gillbe - Moore collar technique 1. PIEZOSURGERY GROUP:

 Bone removal with Piezosurgery osteotomy tip US2,US3 & Piezotome

 Fissure burs for sectioning of tooth

(19)

ABSTRACT

IX 2. CONVENTIONAL GROUP:

 Bone removal with No 703 carbide straight fissure bur in a straight handpiece with micromotor

 Fissure burs for sectioning of tooth

Wound closure:

Done with 3-0 black braided silk sutures.

STATISTICAL ANALYSIS:

 The obtained data was statistically analysed using independent “T” test for the duration of the surgical procedure, mouth opening and swelling.

 Pain was calculated by Mann Whitney test.

RESULTS:

Data obtained were analysed with SPSS software. Duration of the procedure is prolonged in piezosurgery group with statistically significant data. Pain and swelling reduced in piezosurgery group compared to conventional group. Mouth opening reduced in piezosurgery group due to longer duration of procedure and it was statistically significant. Dry socket was not observed in both groups. Dry socket was not evaluated statistically.

KEYWORDS: Piezosurgery, micrometric, precise, osteotomy, third molar impaction.

(20)

X TABLE OF CONTENTS

S.NO CONTENTS PAGE NO

1. INTRODUCTION

1

2. AIM & OBJECTIVES

5

3. REVIEW OF LITERATURE

6

4. MATERIALS & METHODS

16

5. CASE REPORT

33

6. RESULTS & STATISTICS

54

7. DISCUSSION

62

8. SUMMARY & CONCLUSION

75

9. BIBLIOGRAPHY

76

10. ANNEXURES

84

(21)

XI LIST OF FIGURES

FIGURE NO FIGURE PAGE NO

1. Wong – Baker Visual Analog Scale

19 2. Patient rating the VAS Scale

19 3. Assessment of facial swelling with description

20 4. Measurement of facial swelling from Gonion to Tragus

21 5. Measurement of facial swelling from Gonion to Lateral

canthus 21

6. Measurement of facial swelling from Gonion to Ala of

the nose 22

7. Measurement of facial swelling from Gonion to

Pogonion 22

8. Measurement of Mouth opening with scale & divider

23 9. WAR line – a diagrammatic representation

23 10. Surgical tray with Piezoelectric surgery unit and

piezoelectric osteotomy tips 26

11.

Surgical tray with Micromotor, handpiece and bur

27 12. Tooth 48 removal with Piezosurgery method

28 13. Tooth 38 removal with Conventional method

30 14. Pre – operative OPG of the patient

32 15. Post – operative OPG of the patient

32

(22)

XII LIST OF GRAPHS

GRAPH NO DESCRIPTION PAGE NO

1. Gender distribution of the study population 57

2. Age group of the study participants 57

3.

Duration of the surgical procedure ( Primary parameter) between two groups

58

4.

Evaluation of pain (secondary parameter) between two groups

58

5.

Evaluation of mouth opening (secondary parameter) between two groups

59

6.

Evaluation of swelling (secondary parameter) between two groups – Pre operative assessment

59

7.

Evaluation of swelling (secondary parameter) between two groups – Day 1 assessment

60

8.

60

9.

61

(23)

XIII LIST OF TABLES

TABLE NO DESCRIPTION PAGE NO

1. Case report of 10 patients

 Primary parameter

 Secondary parameter

33

2. Age of the study participant (Statistical report)

54

3. Duration of the procedure (Primary parameter)

- assessment in both groups ( Statistical report) 54

4. Pain ( Secondary parameter)

5. Mouth opening ( Secondary parameter) -

assessment in both groups( Statistical report) 55

6. Swelling (Secondary parameter)

(24)

XIV LIST OF ABBREVIATION

IOPA Intra Oral Periapical Radiograph OPG Orthopantomograph

WAR LINE White, Amber and Red Line

NSAID Non – Steroidal Anti Inflammatory Drug PRE - OP Pre - operative

POST - OP Post - operative VAS Visual analog scale SD Standard deviation

% Percentage

° Degree

LA Local anaesthesia

IANB Inferior alveolar nerve block

mm Millimeter

mns Minutes

No Number

rpm Revolutions per minute

(25)

INTRODUCTION

(26)

INTRODUCTION

Page 1 INTRODUCTION

Piezoelectric surgery also called piezosurgery is an innovative technique for atraumatic bony osteotomy which was invented and patented by an Italian Oral and Maxillofacial Surgeon Tomasso Vercellotti in the year 1988 in need for bone surgery with higher levels of precision, safety and rapidity in recovery. The word ‘piezo’

originates from a Greek word ‘Piezein’ which means ‘to press tight, sqeeze’. It was introduced in the field of dentistry in the year 1975 by Horton et al. The first reported human clinical study by Vercellotti was in 2000. This was based on a piezoelectric effect. First it was described in the year 1880by French physicists Jean and Marie Curie.

It utilizes ultrasonic frequency in the range of 24 to 29 kHz with amplitude of 60 to 210 micrometer. The principle behind piezosurgery is ultrasonic transduction that is acquired by ceramic contraction and expansion. The vibration is amplified and transferred to the insert tips which when applied upon bony structure with slight pressure produced effective mechanical cutting on mineralized structures. This low frequency provides a precise, selective micrometric osteotomy cuts only in the mineralized tissue.

Surgical removal of impacted third molar is a common procedure performed in Oral and Maxillofacial Surgery which can be easy to extremely difficult and dangerous. Impacted lower third molars pose difficulty during removal and also during their eruption. Impacted lower third molars can cause pain, trismus, pericoronitis, distal caries of lower second molar, cyst formation, bone resorption, tooth resorption, Temporomandibular joint pain and more serious complications like inferior alveolar nerve injury, paresthesia, hemorrhage, alveolar osteitis.

(27)

INTRODUCTION

Page 2 Few potential complications include infection, injury to adjacent teeth, fracture of the maxillary tuberosity, mandibular fracture, oro antral communication & fistula, periodontal pocket formation distal to second molar and displacement of tooth or root fragment into the soft tissue. Surgical removal is advised to avoid those complications.

The heat generated from high speed air driven handpiece lead to marginal osteonecrosis which impair regeneration & healing. The air driven handpiece can also cause subcutaneous emphysema.

So a technique should be used for surgical removal of impacted third molar which is efficient and superior to the conventional osteotomy method. The safe and minimally invasive method for osteotomy is piezosurgery particularly where the areas of interest is deeply impacted lower third molar which lies close proximity to the inferior alveolar nerve.

The main advantage of using piezosurgery is it does not injure the soft tissue, even in case of any accidental contact. It can be used safely in case of nerve lateralization, osteotomy closer to the dura, for harvesting autogenous bone graft from the skull cap and in case of close proximity to the nerves and vessels with absolute confidence. Since the frequency needed to cut the soft tissue is above 50 kHz piezosurgery is inert on the soft tissue. This is useful in impacted third molars when it is in close approximation with the inferior alveolar nerve. Piezosurgery tip vibrates in a range of 60 to 200 micrometer which equals the handpiece power rating of 45 W that provides efficient cutting.

Motor driven instruments transform the electric energy into mechanical cutting action using sharp edge of bur. This will generate significant amount of heat in

(28)

INTRODUCTION

Page 3 the cutting zone which should be decreased by water irrigation. Piezosurgery has an inbuilt coolant system that reduces the chance of thermal necrosis.

Piezosurgery due to its cavitation effect reduces intra and post - operative bleeding. Histological and histomorphometric studies done on animal studies show evidence of wound healing and bone formation with piezosurgery when compared to rotary instruments. It produces effective cut with less noise and vibration in contrast to the macrovibration and extreme noise in surgical saw and bur. However, if pressure is increased it results in overheating and breakage of piezoelectric tip.

This unit consists of handpiece, inserts kit, footswitch, control monitor, dynamometric wrench, and peristaltic pump. In the piezosurgery unit, holders are available for handpiece and irrigation fluids. All the parts of the unit through which the fluid passes are sterilizable. The insert tips are secured to the handpiece via dynamometric wrench with pre - defined force for optimum energy transmission. The control system is shown on the display. The coolant system is adjusted 0 to 60 ml/

minute which discharges jet of solution from the insert. This removes the detritus from the cutting area.

Different insert tips are available for various procedures. There are sharp, smoothening and blunt tips. Sharp tips are available for osteotomy and osteoplasty for a precise and safe cut. Smoothening tips are used for sinus window preparation; they are diamond coated for controlled work. Blunt tips are used for Schneiderian’s membrane elevation and nerve lateralization. Gold and steel colored piezoelectric tips are available. Procedure that involves bone are treated with gold tips and steel tips are used to treat soft tissue. The golden color of the tips is due to coating of titanium nitride. This improves the surface hardness and working life.

(29)

INTRODUCTION

Page 4 It is used for ridge augmentation, ridge expansion, apicectomy, tooth extraction, ankylotic tooth extraction mainly impaction, cyst removal, implant site preparation, implant removal, bone harvesting, bone grafting, sinus lift, orthodontic corticotomy, Orthognathic surgery, separation of pterygomaxillary junction without damaging the descending palatine artery and in distraction osteogenesis. Beziat et al used piezosurgery for palatal expansion after Lefort 1 osteotomy, bilateral sagittal split osteotomy, Lefort 3 in the management of Crouzon’s syndrome, segmental osteotomy, unicortical calvarial bone graft, removal of anterior and posterior frontal sinus to approach the orbital tumor and skull base tumor. With the help of piezosurgery the frequency and number of Schneiderian’s membrane perforation and laceration is lower.

(30)

AIM & OBJECTIVES

(31)

AIM & OBJECTIVES

Page 5 AIM & OBJECTIVES

AIM:

To compare piezosurgery and conventional bur method for surgical removal of the bilateral impacted mandibular third molar.

OBJECTIVES:

The objective of this clinical study is to compare and evaluate the efficiency and post-operative outcome between two groups;

1. Conventional method (Bur technique) 2. Piezosurgery (Piezotome with osteotomy tips)

The comparison is made on the following parameters:

PRIMARY PARAMETER (assessed during the surgical procedure)

 Duration of the operative surgical procedure (from start of the incision to removal of the tooth)

SECONDARY PARAMETERS (Evaluated on 1^st, 3rd & 7^th day post – operatively)

 Pain

 Swelling

 Dry socket

 Trismus

(32)

REVIEW OF LITERATURE

(33)

REVIEW OF LITERATURE

Page 6 REVIEW OF LITERATURE

1. Robiony et al in 2004, performed three piece maxillary osteotomy with piezosurgery and found it is superior to blind approach with saw and bur. It is very helpful in paramedian midline palatal osteotomy where the mucosa is very thin. The only limitation being slightly longer surgical time.

2. Georg Eggers et al in 2004, described about fronto – orbital advancement in children and mentioned that calvarial bone osteotomy was done without damaging the dura mater. In sinus lift procedure also the mucosa is not damaged.

This device is essential when cutting the thin bone in a more precise manner.

3. Vittorio Grenga et al in 2004, used piezoelectric surgery for palatally impacted canine and mentioned that piezosurgery is quieter than conventional device. It improves patient comfort because it avoids trauma associated with hammer and chisel.

4. Paolo Nordera et al in 2007, performed bilateral sagittal split osteotomy with piezosurgery scalpel with more precise osteotomy cuts. It is also used in performing craniotomy with safe and efficient cut without damaging the dura.

5. R. M. Gruber et al in 2005, did a pilot study on usage of ultrasonics in Orthognathic surgery. Bilateral sagittal split osteotomy was carried out with piezoelectric surgery. Results showed that in ultrasonic group osteotomy were done with high level of precision compared to conventional method like chisel &

bur and saw. There was also good control of the surgical procedure.

6. Stefan Stubinger et al in 2005, created a rectangular window on the buccal cortical bone in order to remove the retained root remnant which was attempted

(34)

Page 7 with conventional method. Root remnant was removed without injuring the inferior alveolar nerve.

7. Kotrikova et al in 2006, used Piezosurgery for cranial osteoplasty and stated that the ultrasonic microvibration allow selective cut only in the mineralized structure thereby preventing dural tear even in case of accidental contact.

8. Laurence J Walsh et al in 2007, reported increased use of piezosurgery in dental surgery. Piezosurgery device is three times more powerful than the conventional units. This is used in cutting of cortical bone. Piezosurgery requires adequate dexterity and gentle touch.

9. Praveen G et al in 2007, conducted a study which is about a comparison among lingual split, bur and split bone technique. This study showed usage of surgical bur resulted in higher degree of swelling.

10. J.L. Beziat et al in 2007, published a clinical study on use of ultrasonics in craniomaxillofacial surgery. LeFort 1 osteotomy with palatal expansion, bilateral sagittal split osteotomy, LeFort 3 osteotomy in case of Crouzon syndrome, unicortical calvarial bone grafting. For cases with orbital tumor, removal of the external orbital wall and anterior & posterior table of the frontal sinus were done with piezosurgery. In that study integrity of the soft tissue and surgical operative time were assessed. The overall surgical time is increased with no damage to the soft tissue, brain and inferior alveolar nerve.

11. M. Robiony et al in 2007, in his article which is on a surgically assisted rapid maxillary expansion with the use of ultrasonics mentioned that ultrasonic bone surgery is a feasible alternative to conventional bone surgery with precision and safety. Advantages with ultrasonic surgery include minimal risk to the palatine

(35)

Page 8 artery, minimal thermal damage to the bone, minimal intra operative bleeding and post - operative swelling.

12. Landes et al in 2008, performed Orthognathic surgery with piezoelectric tips and reported that during final separation of pterygomaxillary suture, nasal septal osteotomy and lateral nasal wall osteotomy additional use of chisel was necessary as the piezoelectric tip were not able to reach the desired position.

They also concluded that piezosurgery reduced blood loss and inferior alveolar nerve injury.

13. Francesco Sortino et al in 2008, compared the post - operative recovery between rotatory and piezoelectric method of third molar surgery and concluded that piezosurgery reduced swelling of the face and improved mouth opening. This procedure takes longer operating time when compared with rotatory method of osteotomy.

14. Stefan Schaeren et al in 2008, in his article mentioned that traditional instrument are highly effective but not selective for bone and thus can produce injury to the soft tissue and nerves.

15. Crosetti et al in 2009, endorsed piezosurgery is developed to overcome the limits of conventional instruments. Piezosurgery is used in recurrent extracranial meningioma where the line of osteotomy is continued beyond the limits of frontal sinus with exposure of dura mater. But dura mater was not damaged.

16. Hema Seshan et al in 2009, pointed out the use of piezosurgery in Implantology and mentioned that mechanical and motor driven instruments decrease the tactile sensation. Piezosurgery allows for selective bone removal. It is also used for implant site preparation, bone harvesting, sinus lift, bone grafting. It also reduces the risk of post - operative necrosis.

(36)

Page 9 17. Stefeno Sivolella et al in 2011, performed a randomized prospective crossover study in osteotomy of lower third molar germectomy and concluded that piezosurgery resulted in less patient discomfort when compared to conventional osteotomy method.

18. G. Pavlikova et al in 2011, in his research paper described the use of piezosurgery which is a soft tissue sparing and promising tool in distraction Osteogenesis, bone harvesting, inferior alveolar nerve decompression, sinus lift and for cyst removal. In this article he quoted that Crosetti et al used piezosurgery for removal of bone residues which are formed due to bisphosphonate therapy for carcinoma. Piezosurgery also decreased the amount of bone necrosis after the necrotic bone is removed.

19. D. Baldi et al in 2011, in his clinical paper discussed about the sinus floor elevation procedure using osteotome and piezoelectric surgery. Piezosurgery removed selective amount of bone without damaging the Schneiderian membrane. Piezosurgery is less traumatic and more comfortable for the surgeon.

20. Manoj Goyal et al in 2012, did a prospective study on evaluation of surgical outcome after lower impacted third molar surgical removal between piezosurgery and conventional osteotomy technique. Results suggested that piezotome is a valuable alternative in surgical removal of impacted third molar compared to conventional method. Piezotome provided better perception of quality of life.

21. Yaman et al in 2013, Piezosurgery produced clear surgical field because of pressurized irrigation and cavitation effect but cost is higher than the traditional and conventional method. Piezosurgery produced selective cutting of bone

(37)

Page 10 without soft tissue damage and micron sensitivity cutting without heat generation.

22. Rosario Rullo et al in 2013, compared piezoelectric surgery versus conventional method and compared the surgical difficulty, post - operative pain with histological evaluation. Piezoelectric device has the more designed line of osteotomy, no bone heat osteonecrosis with reduced cellular damage. Level of alkaline phosphatase was observed to be higher in the piezosurgery group with positive response for bone regeneration.

23. Luigi Piersanti et al in 2014, assessed the post - operative surgical outcome and discomfort following mandibular impacted third molar with piezosurgery and conventional method. Evaluation of the study showed that post - operative discomfort, swelling is less in piezosurgery group. It is also a safety method for procedures involving soft tissue, nerves and vessels.

24. Ge Jing et al in 2014, did a retrospective study on comparison of four methods for removal of impacted lower third molar with piezosurgery technique.

Complete bone removal for partially impacted tooth, segmental bone removal for fully impacted tooth, bone removal with tooth splitting for hypertrophied root and block bone removal for ankylosed tooth. All these four methods with piezosurgery tips were effective for osteotomy.

25. Edoardo Mantovani et al in 2014, did a split mouth randomized clinical trial on comparison of piezosurgery and conventional technique in removal of impacted third molar. In the piezosurgery group there was reduced level of pain and swelling reported. The duration of the procedure was reported to be higher in the piezosurgery group compared to the conventional group.

(38)

Page 11 26. Shakilahmed Nagori et al in 2014, did a study on autogenous third molar transplantation using piezosurgery. Atraumatic tooth removal was achieved with piezosurgery and the adjacent teeth showed positive for tooth vitality testing.

27. Anuroopa et al in 2014, in his review article mentioned that piezosurgery is a conservative and advanced tool for osteotomy with less intra and post - operative bleeding with which precise, micrometric and curvilinear cuts are possible with absolute confidence mainly in areas close proximity to nerves and vessels.

28. Giuseppe Spinelli et al in 2014 stated that compared to mechanical method of surgery piezoosteotomy resulted in less intra operative blood loss, swelling, hematoma and less post – operative nerve impairment but required more time.

This procedure is a less aggressive and safe method for surgery like LeFort 1 osteotomy.

29. Marco Mozzati et al in 2014, did a case control study on third molar surgical removal with conventional and piezosurgery and showed that piezosurgery is an excellent tool in decreasing the complication and improving the post - operative healing period.

30. Francesc Abella et al in 2014, in his literature review stated that cyst enucleation can be done in difficult areas requiring delicate manipulation with lower risk to vital structures. Piezosurgery is superior to conventional in terms of haemorrhage, epithelial perforation, post - operative complication.

31. Mani AM et al 2014, in his review described about the use of piezosurgery in ridge expansion with immediate implant placement. This new technique can be used for more complex oral surgical procedures.

(39)

Page 12 32. Qian Jiang et al in 2015, did a Meta - analysis on impacted third molar extraction with piezosurgery and conventional method and told that pain and facial swelling is reduced in piezosurgery. In case of implant osseointegration, piezosurgery induced bone morphogenetic protein and stimulated bone remodelling.

33. Lokman et al in 2015, in his research have mentioned that piezosurgery in combination with platelet rich fibrin reduced the number of analgesics taken and has positive outcome in terms of post - operative pain and swelling.

34. F.J. Kramer et al in 2015, in his research paper mentioned about the noise trauma produced in ultrasonic piezosurgery. The sound is transmitted through the bone conduction and it result in acoustic damage. Both conventional and piezoelectric osteotomy can produce hearing damage when applied over longer duration of time.

35. H. Mistry et al in 2015 did a comparative study on conventional and piezosurgery in Orthognathic surgery. Results showed that piezosurgery reduced the overall surgical time and protection to the soft tissue is achieved.

Piezosurgery reduced the patient morbidity.

36. K. Irem et al in 2015, did a study on classical technique and piezosurgery in surgical removal of impacted lower third molar. Piezosurgery produce a more selective and precise less aggressive osteotomy cuts with protection to the nerves and vessels.

37. Zhigui Ma et al in 2015, compared piezosurgery and traditional method in orthodontic traction of impacted third molar and concluded that piezoelectric surgery produced faster and efficient traction which are close to the inferior alveolar nerve without any neurological damage.

(40)

Page 13 38. Stefan Stubinger et al in 2015, conducted a review based search on piezosurgery and concluded that piezosurgery is superior to mechanical instrument in handling the delicate structures and considered possibility to perform minimally invasive osteotomy.

39. Hani Arakji et al in 2016, conducted a clinical study on comparison between conventional rotary and piezosurgery removal of impacted mandibular third molar. The study showed a significant statistical difference in reduction of pain and swelling. It improved the quality of life in decreasing the post – operative outcome. It also showed enhanced quality of bone within the socket and quantity of bone distal to the second molar. But there showed a statistically increased time with piezosurgery.

40. Badenoch Jones et al in 2016, conducted a systematic review and meta-analysis search from database and identified piezosurgery device caused less facial swelling, trismus and reduced risk of neurological complication. There was improved clinical healing response with longer operating time in piezosurgery.

41. Farag et al in 2016, reviewed the efficacy of piezosurgery and conventional technique in surgical extraction of third molar and the results showed pain was greater in the chisel group compared to piezosurgery and post – operative swelling was great in the conventional group compared to piezosurgery.

42. E.A. Al-Moraissi et al in 2016, did a systematic review and Meta - analysis and found that low bone injury was observed with piezosurgery group. Better haemostasis and low risk of edema was found. Piezosurgery causes less vibration to the soft tissue when compared to the macrovibration and overheating which is seen in conventional group.

(41)

Page 14 43. K. Bilginaylar et al in 2016, evaluated the effects of piezosurgery and platelet rich fibrin after impacted third molar removal and found the mean pain score, total number of analgesics taken, trismus and swelling were reduced in the piezosurgery group. Number of analgesics taken were reduced in the piezosurgery and conventional group when used along with the platelet rich fibrin.

44. Dhruvakumar Deepa et al in 2016, reviewed that piezosurgery is used for osteotomy, Implantology and oral surgical procedures with highly precise and safe osteotomy.

45. Marcelo Sirolli et al in 2016, did a histomorphometric animal study on evaluation of bone formation around titanium implant. They concluded that in cortical bone conventional method can be used. In cancellous region, piezosurgery can be used. Since the use of increased tip pressure with piezosurgery resulted in heat generation and necrosis. Piezosurgery produced less oscillation with preservation of original bone tissue.

46. Mathai Thomas et al in 2017 did a review study on piezosurgery and concluded that due to lack of macrovibration it gives more intra operative control. It can be used safely in more difficult anatomical region.

47. Basheer et al in 2017, conducted a comparative study and concluded that time duration was more with piezosurgery group. Pain increased with conventional group and mouth opening was better in piezosurgery group.

48. Bharat bhati et al in 2017, did a case control study and showed a statistically significant difference in pain among both groups. They concluded there is soft

(42)

Page 15 tissue protection, reduced blood loss, decreased vibration and noise and increased comfort for the patient.

49. Reddy et al in 2017, analysed the post - surgical consequences in lower third molar surgical extraction using piezosurgery and micromotor. They finalized more time duration with piezosurgery unit. Pain and swelling is reduced and faster increase in normal mouth opening.

50. Serpil Irem Kirli Topcu et al in 2018, did a comparative evaluation of piezosurgery and conventional technique and assessed the perioperative pain and anxiety. Piezosurgery technique provides more precise and less aggressive osteotomy. But there was no difference between the conventional and piezosurgery group in terms of pain and anxiety.

51. Dushyanth et al in 2019, did a comparative study on piezosurgery and conventional method for surgical removal of impacted lower third molar and in his study he concluded that piezosurgery takes more time and it is very expensive. The complication reported with piezosurgery is much lower like less post - operative pain and swelling. The great advantage of piezosurgery is its soft tissue protection.

(43)

MATERIALS & METHODS

(44)

MATERIALS & METHODS

Page 16 MATERIALS & METHODS

1. Patient selection and study design

Patients who visited Rajas dental college and hospital, Oral and Maxillofacial Surgery Department for bilateral surgical removal of impacted mandibular third molar was included in this study. The duration of the study took over a period of two years from 2017 – 2019. Among the 10 patients 6 male and 4 female patient participated in the study. The participant age group was from 20 to 33 years.

INCLUSION CRITERIA

 Impacted teeth with full root formation, persistent pericoronitis.

 Patient’s requiring removal of bilateral impacted mandibular third molars, who visited Rajas dental college & Hospital, OMFS Department on a period of 2017 – 2019 was included in the study.

 Patient’s age between 20 to 35 years.

EXCLUSION CRITERIA

 Poor motivation to return for follow up visit

 Patients with any systemic diseases like uncontrolled diabetes and blood disorders

 Smokers

 Alcoholics

 Drug abusers

 Patients with acute pericoronitis, abscess

(45)

MATERIALS & METHODS

Page 17

 Oral submucous fibrosis

 Patient on immunosuppressive drugs

 Patient who underwent Radiation therapy

 Pregnancy

INVESTIGATION

 Intra – oral periapical radiograph (IOPA)

 Orthopantomograph (OPG)

PROCEDURE

(i) 10 patients requiring bilateral surgical removal of impacted mandibular third molar were selected randomly and allocated in two groups based on randomized control trial.

 Ethical clearance obtained

 Informed consent obtained from patients.

(ii) Pell & Gregory, George winter’s classification & Quek’s modification, WAR lines was included in this study to classify the position of the third molar.

(iii)Patients are evaluated based on the following parameters.

(46)

MATERIALS & METHODS

Page 18 PRIMARY PARAMETER PIEZOSURGERY

Duration of the operative surgical procedure from start of the incision to removal of tooth

(in mns)

PIEZOSURGERY

CONVENTIONAL BUR TECHNIQUE

SECONDARY

PARAMETERS PRE OP

1

st

DAY 3

rd

DAY 7

th

DAY

PRE OP

1

st

DAY 3

rd

DAY 7

th

DAY

Pain (VAS scale)

Swelling (4 facial reference point)

Dry socket (based on blum’s criteria)

Trismus (Measuring interincisal distance with a ruler [ in mm] )

CONVENTIONAL BUR TECHNIQUE

METHOD

(47)

MATERIALS & METHODS

Page 19 Figure 2 - Patient rating the VAS Scale

Figure 1 - Wong – Baker Visual Analog Scale

(48)

MATERIALS & METHODS

Page 20 Figure 3 - Assessment of facial swelling with description

ASSESSMENT OF FACIAL SWELLING (WITH THE FACIAL REFERENCE POINT)

 Gonion to Tragus

 Gonion to Lateral canthus

 Gonion to ala of the nose

 Gonion to Pogonion Gonion - Go Tragus - T Lateral canthus - Lc Ala of the nose - Al Pogonion - Pg

Go

Pg Al T

Lc

(49)

MATERIALS & METHODS

Page 21 Figure 5 - Measurement of facial swelling

from Gonion to Lateral canthus Figure 4 - Measurement of facial swelling

from Gonion to Tragus

(50)

MATERIALS & METHODS

Page 22 Figure 6 - Measurement of facial swelling

from Gonion to Ala of the nose

Figure 7 - Measurement of facial swelling from Gonion to Pogonion

(51)

MATERIALS & METHODS

Page 23 Figure 8 - Measurement of Mouth opening with scale and

divider

Figure 9 - WAR line – a diagrammatic representation

MESIOANGULAR DISTOANGULAR

VERTICAL HORIZONTAL

WHITE LINE

AMBER LINE

RED LINE

POINT OF APPLICATION - CEMENTO ENAMEL JUNCTION

(52)

MATERIALS & METHODS

Page 24 2. Surgical instruments

Patients were selected with same degree of angulation and position of the impacted mandibular third molar on both the sides. Pre operatively IOPA and OPG were taken to assess the position of the third molar in relation to the inferior alveolar canal and the amount of bone removal required.

Sides were selected based on the random method. In the conventional group side, bone guttering was done with carbide straight fissure bur and tooth sectioning also with the same No 703 carbide fissure bur connected to the micromotor rotating at 35,00 rpm. In the opposite side, bone guttering was done with piezoelectric osteotomy tip US2, US3 in the piezotome. Tooth sectioning was done with No 703 carbide straight fissure bur.

3. Surgical procedure

Local anesthetic lignocaine hydrochloride 2% with vasoconstrictor adrenaline 1:80,000 concentration for haemostasis was used. Nerve blocks inferior alveolar nerve block, long buccal nerve block and lingual nerve block were used. Bite block (mouth props) were placed for adequate visibility, accessibility for instruments and for patient comfort. Depending upon the exposure needed Ward’s and modified Ward’s incision was placed with no 15 blade. Gillbe Moore collar technique was followed for bone guttering. Bone along the buccal and distal aspect of the impacted tooth was removed with piezotome with special osteotomy tip and No 703 carbide straight fissure bur accordingly. During bone guttering on the distolingual aspect care was taken to preserve the lingual nerve with a periosteal elevator. For both the group tooth sectioning was done with No 703 carbide straight fissure bur. The tooth was luxated and elevated from the socket with elevators or forceps. Wound debridement done with

(53)

MATERIALS & METHODS

Page 25 curette. Bone file used to smoothen the socket wall and interdental projection.

Copious saline irrigation was done to remove the bony spicules and detritus. Socket were inspected for any bone prominence or tooth remnants. Wound closure done with 3-0 black braided silk suture, simple interrupted suture.

4. Postoperative care

Post - operative instruction were given. Ice packs were provided. Antibiotic Amoxycillin 500 mg for three days thrice; metronidazole 400 mg for three days thrice were given. Anti-inflammatory drug aceclofenac with paracetamol combination was given twice for three days. Pantoprazole was given once for three days to prevent gastric irritation. Suture removal was done on the seventh day once the socket healed.

(54)

MATERIALS & METHODS

Page 26 Figure 10 - Surgical tray with Piezoelectric surgery unit & piezoelectric

osteotomy tips

 Piezoelectric osteotomy unit with Piezotome and special osteotomy tips, dynamometric wrench, peristaltic pump and inbuilt coolant system is shown in the figure.

 The osteotomy tip used for impaction is US2, US3.

(55)

MATERIALS & METHODS

Page 27 Figure 11 - Surgical tray with Micromotor, handpiece and bur

 Conventional bur technique for osteotomy is shown in the figure.

 Osteotomy done with micromotor and straight handpiece at 35,000 rpm.

 No 703 carbide straight fissure bur is used for bone removal.

(56)

MATERIALS & METHODS

Page 28 EXPOSURE OF TOOTH 48 WITH WARD’S INCISION AND

FULL THICKNESS MUCOPERIOSTEAL FLAP REFLECTION HORIZONTAL IMPACTION

48

FIGURE 12 - TOOTH 48 REMOVAL WITH PIEZOSURGERY METHOD

(57)

MATERIALS & METHODS

Page 29 TOOTH 48 REMOVAL WITH PIEZOSURGERY METHOD

PIEZOTOME AND OSTEOTOMY TIP US2 IN USE

SOCKET OF 48 AFTER TOOTH REMOVAL

SUTURE IN 48 REGION WITH BLACK BRAIDED SILK

(58)

MATERIALS & METHODS

Page 30 EXPOSURE OF TOOTH 38 WITH WARD’S INCISION AND

FULL THICKNESS MUCOPERIOSTEAL FLAP REFLECTION

ELEVATION OF THE TOOTH 38 FROM THE SOCKET AFTER OSTEOTOMY WITH CARBIDE BUR NO 703

FIGURE 13 - TOOTH 38 REMOVAL WITH CONVENTIONAL METHOD

(59)

MATERIALS & METHODS

Page 31 THE SOCKET OF 38 AFTER REMOVAL OF TOOTH WITH

CONVENTIONAL METHOD

SUTURE PLACED IN 38 REGION WITH BLACK BRAIDED SILK AFTER TOOTH REMOVAL

(60)

MATERIALS & METHODS

Page 32 Figure 14 - Pre – operative OPG of the patient

Figure 15 - Post – operative OPG of the patient

(61)

CASE REPORT

(62)

CASE REPORT

Page 33 CASE REPORT

CASE NO PATIENT DETAILS PAGE

NO

1. Basker 27 M, D /16475 34

2. Bright 24 M, C /44423 36

3. Irul raj 33 M, D /35690 38

4. Muthulakshmi 27 F, D / 32027 40

5. Muthuraj 24 M, C /9785 42

6. Pradeeksha 21 F, C /21134 44

7. Saba 21 F, C / 41491 46

8. Sahaya Vijesh 24 M, D / 16330 48

9. Sankar 20 M, D /27419 50

10.

Subarna 21 F, C /21134 52

(63)

CASE REPORT

Page 34 RAJAS DENTAL COLLEGE & HOSPITAL

DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY

PATIENT PROFORMA PATIENT NAME: Mr. Basker AGE/SEX : 27 Years / male OP.NO : D /16475 DATE : 18/06/2018 CONTACT NO : 8220709089 PLACE : Thenkasi

PRIMARY PARAMETER

PIEZOSURGERY CONVENTIONAL [BUR]

DURATION OF THE PROCEDURE (IN MNS)

38 mns 48 : Mesioangular 3 ml lignocaine 1: 80,000

14.05.19

30 mns 38 : Mesioangular 2.8 ml lignocaine 1:80,000

18.06.19

(64)

CASE REPORT

Page 35 SIGNATURE OF GUIDE:

SIGNATURE OF THE H.O.D:

SECONDARY

PARAMETERS DAY

PAIN(VISUAL ANALOG

SCALE)

DRY SOCKET (BASED ON

BLUM’S CRITERIA)

TRISMUS (INTERINCISAL

MOUTH OPENING WITH

RULER (IN MM)

SWELLING (BASED ON 4

FACIAL REFERENCE

POINT)

PIEZOSURGERY

PRE- OP

1 0 41 mm G-T:5.7 mm

G-L:10.4mm G-A:10.4mm G-M :10.3mm 1^st

DAY

3 0 41 mm G-T:5.7mm

G-L:10.6mm G-A:10.5mm G-M:10.5mm 3^rd

DAY

3 0 40 mm G-T:5.8mm

G-L:10.4mm G-A:10.5mm G-M:11mm 7^th

DAY

1 0 41 mm G-T: 5.7 mm

G-L : 10.4mm G-A : 10.4mm G-M:10.3mm

CONVENTIONAL BUR

TECHNIQUE

PRE- OP

8 0 41 mm G-T:5.7 mm

G-L:10.4mm G-A:10.4mm G-M :10.3mm 1^st

DAY

5 0 32 mm G-T:5.9mm

G-L:10.6mm G-A:10.5mm G-M:10.5mm 3^rd

DAY

3 0 33 mm G-T:6mm

G-L:10.9mm G-A:10.5mm G-M:11mm 7^th

DAY

2 0 35 mm G-T: 5.7 mm

G-L : 10.8mm G-A : 11mm G-M:10.3mm

(65)

CASE REPORT

PATIENT PROFORMA

PATIENT NAME : Mr. Bright AGE/SEX : 24 Years / male OP.NO : C /44423 DATE : 13/12/2018 CONTACT NO : 7639225741 PLACE : Thirukarankudy

PRIMARY

PARAMETER PIEZOSURGERY

CONVENTIONAL [BUR]

40 mns 48 : Distoangular 3 ml lignocaine 1: 80,000

09.01.19

35 mns 38 : Distoangular 3 ml lignocaine 1:80,000

03.12.18

(66)

CASE REPORT

Page 37 SIGNATURE OF GUIDE:

SIGNATURE OF THE H.O.D:

SECONDARY

PARAMETERS DAY

PAIN(VISUAL ANALOG

SCALE)

DRY SOCKET (BASED ON

BLUM’S CRITERIA)

TRISMUS (INTERINCISAL

MOUTH OPENING WITH

RULER (IN MM)

SWELLING (BASED ON 4

FACIAL REFERENCE

POINT)

PIEZOSURGERY

PRE- OP

0 Nil 44 mm G-T:6.5 mm

G-L:11.5 mm G-A:10.5 mm G-M :11.3 mm 1^st

DAY

G-L:11.5 mm G-A:10.6 mm G-M :11.3 mm 3^rd

DAY

G-L:11.5 mm G-A:10.5 mm G-M :11.3 mm 7^th

DAY

G-L:11.5 mm G-A:10.5 mm G-M :11.3 mm

CONVENTIONAL BUR

TECHNIQUE

PRE- OP

G-L:11.5 mm G-A:10.5 mm G-M :11.3 mm 1^st

DAY

G-L:11.7 mm G-A:10.5 mm G-M :11.4 mm 3^rd

DAY

G-L:11.6 mm G-A:10.5 mm G-M :11.3 mm 7^th

DAY

G-L:11.5 mm G-A:10.5 mm G-M :11.3 mm

(67)

CASE REPORT

PATIENT PROFORMA

PATIENT NAME: Mr. Irul raj AGE/SEX : 33 Years / male OP.NO : D /35690 DATE : 15/10/2019 CONTACT NO : 9688134349 PLACE : Tirunelveli

PRIMARY

PARAMETER PIEZOSURGERY

CONVENTIONAL [BUR]

60 mns 48 : Horizontal 3 ml lignocaine 1: 80,000

22.10.19

55 mns 38 : Horizontal 2.8 ml lignocaine 1:80,000

15.10.19