Piezo ultrasonic

oral surgery
 Contents
Synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
I-Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
1. Ultrasonics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
2. Piezoelectricity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
3. The contribution of piezoelectric generators to oral surgery . . . . . . . . . . . . .63
4. Selectivity of ultrasonic cutting effect . . . . . . . . . . . . . . . . . . . . . . . . . . .65
5. Hemostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66
6. Histology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

Acknowledgements II-Clinical applications of Piezotome . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

1. Diagnosis of bone loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68
2. Bone classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
This clinical booklet has been written with the guidance and backing of university 3. Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
lecturers and scientists, specialists and scientific consultants (Drs. S. GIRTHOFER, S. 4. Clinical procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
HOURDIN, P. MARIN and J-F. MICHEL). a. Autogenous bone graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
Our protocols, and the findings that support them, originate from university theses b. Sinus lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72
and international publications, which you will find referenced in the bibliography. 5. Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72
We have of course gained tremendous experience over the last thirty years from the
III-Ultrasonic instruments for surgery . . . . . . . . . . . . . . . . . . . . . . . . . . .73
dentists worldwide who, through their recommendations and advice, have
1. Osteotomy instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74
contributed to the improvement of our products.
Instrument sequence (ramus bone harvest) . . . . . . . . . . . . . . . . . . . . . . . .83
But our special thanks go to each Satelec user who shows faith in us, each time they
choose one of our products. 2. Instruments for sinus lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84
Instrument sequence (discarded vestibular bone window) . . . . . . . . . . . . . .91
Gilles Pierson Instrument sequence (preserved vestibular bone window) . . . . . . . . . . . . . .92
President 3. Syndesmotomy instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93
Instrument sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94

IV-Organization of technical environment . . . . . . . . . . . . . . . . . . . . . . . .95

1. Packaging of the generator and its accessories . . . . . . . . . . . . . . . . . . . . . .96
2. Operating zone organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96
3. Decontamination and re-packaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97

Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101

54
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102 55
 Synthesis Introduction
More SAFETY Because of a high healing potential of oral tissue and the absence of vital risk, except
• A selective cut (tissue distinction); only the bone is cut. No risk of soft tissue lesions. for some important systematic risk factors, oral surgery has for a long time been
• Fast healing (no tissue damage, sharpness of tip). content with basic instruments. However, the limited access to the operating site, the
efforts employed by the practitioner and the trauma left for the patient are
More PRECISION drawbacks which cannot be ignored.
• A neat and fine cut. At present, dental surgeons have two types of instrument to perform oral surgery
• Good visibility of the operative field from the spray system. surgery:
• Preserved tactile sense. • Manual instruments.
• Motorized instruments:
More COMFORT - with rotary movement,
• A powerful and silent device. - with sonic or ultrasonic vibrations.
• No overheating of the handpiece and no heating of the tip.
• An effortless cut. Piezotome™, Satelec® piezoelectric generator for pre-implant surgery, belongs to the
category motorized instruments with ultrasonic vibrations employing a piezoelectric
Principles transducer. It was designed with the objective to respond to the drawbacks
An efficient use of Satelec® ultrasonic tips encountered with traditional instruments. It allows the performance of delicate
1. The active part, in contact with the surface, is generally located operations such as osteotomies, osteoplasties, ridge expansions, syndesmotomies, or
on the last 2-3 millimeters of the tip. sinus lift.
2. Paintbrush movement: ultrasonics, piloted by the SP Newtron™ technology
require no pressure to be effective. A so-called "paintbrush" movement, where Until the beginning of the 90s, confronted by the problems of bone loss, generalists
smoothness and dexterity are the keywords, is preferred to obtain the desired preferred to avoid implantology procedures. Thanks to new materials and
atraumatic result. technologies, it is possible today to offer patients a credible alternative. Piezotome
3. Selective cut: the undeniable advantage of ultrasonic cutting resides in soft tissue offers comfort, safety and precision to the surgeon during delicate operations.
preservation.
This clinical booklet presents piezoelectric surgery under a technical as well as a
Main characteristics of the Piezotome surgical angle. It aims to explain to the practitioner the effects of this recent
• Two functioning modes: Piezotome is intended for pre-implant surgery technique by means of new protocols.
and Newtron for conventional treatments.
• Two connectors (automatic recognition of the connected handpiece:
Newtron or Piezotome).
• Two silent peristaltic pumps.
• A dual footswitch to control the device at distance.

56 57
 Foreword
Protocols and instrument sequences
given as recommendations in this
booklet are the fruit of our consultants’

Technology
experiments, developed during clinical
trials of Piezotome in • phase
(development) and phase (pre-
launching). It is up to each user to adapt
or modify them according to the case. Satelec®, inventor of the piezoelectric ultrasonic generator for
usage in dentistry, enters a new era by providing powerful
ultrasonics for oral surgery: Piezotome™.

58
1. Ultrasonics
Ultrasound is waves whose sound frequency is superior to 20 000 Hertz (vibrations per
second). Humans can hear waves between 20 and 20 000 Hertz. Ultrasound is thus
inaudible by humans but perceivable by certain animals such as dogs or dolphins.
Developed in the 50s, ultrasound is widely employed today, notably in the field of
instrumentation and medical imaging. Within the scope of Piezotome, the wave is
transmitted through a transducer and its tip.
The piezoelectric ultrasonic vibrations are constituted by waves which:
• Move longitudinally.
• Move in an environment.
• Are reflected and absorbed at the interface of various encountered surfaces (13).
An ultrasonic device as Piezotome consists of an electric generator controlled by a
dual footswitch, a handpiece and different tips to be screwed in.
2. Piezoelectricity
At present, the use of piezoelectric instruments in dentistry has become common and
their efficacy is demonstrated by different clinical studies.
The piezoelectric effect was discovered in 1880, by the physicists Pierre and Jacques
Curie, in collaboration with Gabriel Lippmann. According to these two French
researchers, the application of compressive forces on certain solid bodies would
generate an electric charge. The term «Piezo» is derived from the Greek verb
«piezein» which means to compress or squeeze or to press. The solid bodies that
possess such a property have crystalline structures such as quartz, tourmaline,
Seignette salt or baryum titanate. Today, quartz crystals have been abandoned and
piezoelectric handpieces are mainly constituted from ceramics of crystalline
structures.
60
Piezo effect can be explained as:
• Direct: the properties of certain solid bodies called piezoelectric (for example,
quartz or ceramic) to electrically polarize (movement of positive and negative
charges) under the effect of a mechanical force.
• Indirect: all the deformations (expansion or contraction) of certain bodies called
piezoelectric under the influence of polarization, from application of an electric
field.
Satelec® piezoelectric handpieces are thus subjected to either an indirect or direct
effect.
Electric current generates a deformation of piezo ceramic rings. The movement of
these pastilles leads to vibrations in the transducer’s axis. The amplifier, coupled
with a tip, increases the vibrational movements emitted by the piezo
ceramic rings. The tip thus vibrates in a longitudinal axis as
presented on the illustration (left). The vibrations’
amplitude is between 30-60 µm in Piezotome
mode. The counterweight deadens the
vibrations to the rear and optimizes
the electromechanical output.
61
 Piloted by SP Newtron™ technology, the most evolved patented electronics in the market, Piezotome
benefits from several instrument control systems: 3. The contribution of piezoelectric
generators to oral surgery
Auto-tuning
System
+ Push-Pull
System
+ Feed-Back
Principle
Instruments dedicated to pre-implant surgeries are becoming more and more
sophisticated. Here is a succinct analysis of various instruments sorted according to
their arrival on the market (2-3).

Automated and real-time
frequency adjustment in the 28
to 36 kHz range, according to
the tip’s acoustic response.
Effective restitution of the
tactile sense.
Push-Pull system, or perfect
and constant control of the
vibration amplitude of the
insert.
Preservation of fragile tissues.
Feedback principle, or constant
and instantaneous power
adaptation depending on the
resistance encountered by the
tip (couple).
For a light and precise
gesture, and an action without
useless fatigue.
Manual instruments remain effective but difficult to maneuver. They hinder the
visibility of the practitioner. Moreover, the efforts exercised during the operations are
considerable and their use remains very traumatizing for the patient. Among these
instruments, the most commonly employed are scalpels, mallets and surgical
osteotomes. They are still widely used in zones with easy access, but are often
associated to motorized instruments.
Motorized cutting tools transform their electrical or pneumatic energy into
mechanical energy, producing micro-vibrations on the bur or the bone saw. Various
movements of cutting were introduced such as circular and rectilinear movements.

= Cruise Control™
System
Burs activated by a micromotor force the practitioner to go against the couple from
the instrument rotation. Saws produce macro-vibrations which also have to be
controlled by the practitioner. The cutting feature of a saw does not allow the dental
surgeon to control its depth. It is thus preferable to finish this type of intervention by
manual instruments in order to avoid too much depth which might damage soft
tissues, nerves or membrane.
These three systems constitute The use of these instruments thus remains controversial (see tables below).
the Cruise Control System™,
allowing the clinician to be in
full control of the situation, in Bur cutting
total safety.
Advantages Disadvantages
Bur can be employed on almost all Cutting dependent on the force exercised by the practitioner (resulting in
types of bone. an increase of manual pressure).

Temperature rise is more related to the pressure exercised by the

Speed of action. practitioner than to the rotation speed (temperature harmful to the bone:
47°C for one minute) (7).

Reduced sensibility and precision of the practitioner due to the vibrations.

Dangerous when used close to soft tissues, inferior alveolar nerve and sinus
membrane.

Strong couple of the instrument makes it dangerous to stop, due to its

inertia.
62 63
 Saw cutting 4. Selectivity of ultrasonic cutting effect
Advantages Disadvantages
Cutting speed and linearity of the Cutting dependent on the force exercised by the practitioner (resulting in Owing to the selected frequencies ranging between 28 and 36 kHz, Piezotome is
saw-cutting line. an increase of manual pressure). active on hard tissue and restricts the risks of soft tissue lesions. The generator
Saw can be employed on almost all produces intermittent ultrasonic vibrations with weaker amplitude, called modulated
Reduced sensibility and precision of the practitioner due to the vibrations. piezo signal. This modulated signal in amplitude, automatically established during the
types of bone.
acts of pre-implant surgery, allows tissue relaxation and optimal cellular repair for a
Less control of cutting depth. neat cut and better healing. Finally, it guarantees an incision exempt from friction
and vibration.
Dangerous when used close to soft tissues, inferior alveolar nerve and sinus
membrane.

Saws cannot be employed in zones with difficult access.

Piezoelectricity in pre-implant and periodontal surgery provides much more comfort

and safety to the practitioner. Indeed, it allows elaborate, precise, fine, effortless
cutting without soft tissue lesions. Post-operative pain is slight and healing is fast.
Furthermore, the effort required to obtain a cutting line is much lower. Horton J-E
et al. (5-6) have demonstrated the advantages of ultrasonic tools, such as the
precision provided to the practitioner, the coagulating effect and the absence of
post-operative after effects.

A comparative study performed at Harvard University by Vercellotti T. (15) compares
the extent of bone healing after use of a piezoelectric instrument, a carbide bur and
a diamond bur during an ostectomy and osteoplasty on a dog, on the 14th, 28th and 56th
day after the procedure. At the 56th day, the sites operated with burs (carbide and
diamond) showed bone loss (0.37 and 0.83 mm respectively), whereas the sites
operated with piezoelectricity presented bone gain of 0.45 mm. This study thus
proves that the piezoelectric instrument generates bone repair more favorably than
burs during ostectomies and osteoplasties.
In particular, the study of Horton, Tarpley and Jacoway in 1981 (6) demonstrates the
cutting precision. Their robust tips associated with limited vibration amplitude,
enables very high precision cutting. Finally, the great maneuverability of the
handpiece, combined with the tips’ shape adapted to the anatomical situation,
facilitates the control of the most difficult treatment.

Surgical gesture during the use of Piezotome, a piezoelectric generator, is different

from other bone surgery techniques (for example, rotary instruments). Much more
precise and less traumatizing to tissue, this technique requires learning and training
to find the perfect balance between the practitioner’s gesture and the movement
speed of the tip.

64 65
5. Hemostasis
Due to its irrigation subject to cavitation, the Piezotome has a hemostatic effect on
the cutting surfaces (partially owing to the production of nascent oxygen). The
cavitation is characterized by the appearance of micro-bubbles when liquid comes
into contact with the tip further to ultrasonic vibrations. When imploding, the
cavitation bubbles have a caustic effect. This phenomenon allows achievement of
optimal visibility of the operative field, limits the blood extravasation, cleans the
working zones of bone debris and avoids temperature rise susceptible to tissue
degradation (12).

6. Histology
A histological study was performed in 2001 by T. Vercellotti, A. Crovace, A. Palermo,
Clinical applications
L. Molfetta (14) in order to observe tissue healing mechanisms after having performed
cutting lines with a piezoelectric device. Three orthopedic surgeries were carried out
of Piezotome
on dogs involving ulnar osteotomy, head and neck osteotomy and laminectomy. This
study demonstrated an absence of necrosis signs on the cutting surfaces. Developed by the Research and Development Department of
Furthermore, the presence of living osteocytes exhibited the weak trauma SATELEC®, Piezotome™ is a dental surgery device, an
engendered by this new technique. The macroscopic examinations showed the
neatness of cutting. Indeed, devoid of pigmentation or visible signs of necrosis, the
ultrasonic generator, designed for delicate operations such as
cutting surface is perfectly smooth. osteotomies, osteoplasties, ridge expansions, or sinus lift.

66
1. Diagnosis of bone loss 2. Bone classification
Above all, a general evaluation of the patient status is essential in order to identify In implantology, the identification of bone volume is mostly based on the classification
his/her previous medical history, physical and psychological needs. of Lekholm and Zarb (1985) who have listed four types of bone density (D):

Clinical investigation must be performed to evaluate the extent of bone loss by X-ray
D1 D2
(notably panoramic type), tomographies and scanners or three dimensional MRI
Very high bone High bone density
(Magnetic Resonance Imaging). The practitioner must evaluate bone height and its density and thick and thick cortical
density by radiography before treatment. cortical bone. bone.

According to the study of Harris D. in 1997 (4), bone resorption can have four
principal origins:
• Pathological (periodontal diseases, cysts, etc.).
• Surgical (extraction of embedded canine, apical resection). D3 D4
Intermediate bone Weak bone density, fine
• Congenital (micrognathy, oligodontia, clefts, etc.). or even absent cortical
density, thin cortical
• Physiological (tooth loss, age, pneumatisation of the maxillary sinus). bone and dense bone and spongy bone.
spongy bone.
Bone resorption is a constraint for implant insertion. However, disparities exist
because the anterior ridge resorption is four times faster in the mandible compared
to the maxilla (2). Bone resorption brings the crestal edge closer to the inferior
alveolar nerve in the mandible, and to the sinus cavities in the maxilla. For an implant
of 3.75 mm in diameter, the quantity of required minimal bone is 4 mm transversely
and 7 mm vertically (11). If the bone height is lower than 6-7 mm, a surgical operation
of type bone graft or sinus lift will be necessary for insertion of an implant. However, 3. Healing
the practitioner will have to encounter different obstacles such as: the inferior
alveolar nerve, the maxillary sinus or the nasal fossas according to the location of the Bone fracture leads inevitably to a trauma which activates a healing response. Within
future implant. the first four hours following the operation, the inflammatory reaction induces
vasodilation, plasma and leukocytes seepage and an appearance of inflammatory cells
contributing to phagocytosis of cellular and tissue debris (such as macrophages).
Simultaneously, at the healing site, angiogenesis or formation of a blood clot
(containing blood platelets) and new blood vessels can be observed. This
revascularization provides nutrition to cells, necessary for their development and
proliferation. It is thus particularly important during patient diagnosis, to make sure
of the good quality of vascularization. Finally, the weaker the mechanical trauma, the
faster the local circulation will be restored (8).

The use of piezoelectric instruments limits the development of trauma.

68 69
4. Clinical procedures Ramus bone harvest
Ramus bone is useful when small and average extent of bone is needed. Operative
consequences are simple and comparable to those of a wisdom tooth extraction.
a. Autogenous bone graft However, it is important to be careful not to hurt nerves, particularly the inferior
Autogenous bone remains the material of choice for bone graft operations. alveolar nerve.
Autogenous graft is defined when the graft is derived from the same patient, as donor
and recipient. Both surgical acts (harvest and graft placement), have to be done Advantages Disadvantages
during the same surgical session. The graft can be procured from various parts of the
Highly abundant spongy bone More comfortable general anesthesia
body where a dense cortical bone can be found: such as skull (parietal bone), hip (iliac
bone) or certain intraoral sites. Piezotome and its tips are specifically intended for Cortical bone of good thickness Difficulties of access
small to average harvests from intraoral sites. Operative consequence similar to that of the Risk of lesion to the inferior alveolar nerve:
third molar extractions obligatory scanner
Prior to all acts of harvesting or cutting of bone window, the practitioner gains access No esthetic impairment Specific surgical material
to the site by an incision and a flap elevation. It is then essential to preserve a good See reference (10).
visibility of the operative field and a good blood supply, by respecting anatomical
structures and avoiding unsightly scars. It is highly recommended to clean the bone
To favor an integration of graft on the recipient’s site, the practitioner has to
out of any trace of soft tissue before the use of tips. Because, as previously explained,
particularly control beforehand the presence of spongy bone, the stability and the
the tips cut only hard tissues and will not produce the expected effect in presence of
good integration of the graft. For that purpose, he/she is brought to perform
soft tissues. The suture is made by a wound closure without tension.
osteoplasties.

Chin bone harvest

Required qualities of the recipient site and the graft
The chin bone allows a bone harvest of about 2 cm wide and 3 cm long. The central
part is preserved in order not to modify the shape of the chin. This operation, Advantages Disadvantages
performed under local anesthesia, has only moderate operative consequences. Intact and free of any infectious lesion Cortico-spongy block
However, a risk of mobility disturbance of the chin muscles and nerve lesions, notably Existing bone skeleton (scaffold) Stability
labial and incisive, can occur following the operation. Presence of spongy bone allowing No space between the recipient site and the
osteosynthesis graft
Site preparation Graft preparation

See reference (10).

Advantages Disadvantages
Local anesthesia Limited bone quantity
Accessibility Less abundant spongy bone

Rapid healing Frequent loss of sensitivity of anterior teeth

Moderate post-operative pain Possible mucosal paresthesia

Limited swelling reaction
See reference (10).

70 71
 b. Sinus lift
The sinus cavity naturally tends to increase its volume with time (see illustration on
right). Furthermore, the extraction of a tooth situated in the maxillary sinus area
entails a loss of bone height (called pneumatisation of the sinus) and a loss of alveolar
bone. The placement of an implant in a bone
deficit zone can then lead to a membrane
perforation. The Schneider’s membrane acts
as an immune barrier responsible for the
maintenance of the healthy sinus. It is thus
necessary to perform a sinus lift by an
elevation of the membrane, then by an
integration of autogenous bone shavings
(harvested during bone window opening).

For this type of operation, the patient is put

under local anesthesia. A flap is then
performed and then opened on the antero-
lateral wall of the upper maxilla. Different
techniques of window cutting can be employed. However, considering the risks of
membrane perforation when turning the mobile or moving bone window inward into
the sinus (Tatum’s technique), it is recommended to remove and separate the whole
perimeter of bone window fragment.

Ultrasonic instruments
for surgery
5. Contraindications
For a favorable progress of the operation, it is important to verify the general status
of the patient. The contraindications are the same as for any surgical operation.
However, the use of devices with ultrasound is contraindicated for the bearers of
active implants (for both practitioner and patient) such as pacemakers. Furthermore,
certain diseases such as cardiopathy (heart disorders), diabetes, and bone diseases
and patients receiving radiotherapies can be a constraint for an implant placement.
Bone structure validation and circulatory evaluation of the patient are essential
elements to ensure efficient graft integration and healing.

72
1. Osteotomy instruments
Bone Surgery Kit™*, consisting of six ultrasonic tips, principally intended for
performing bone graft, allows cutting, excising and remodeling bone structures
without any risk of soft tissue lesions.

Protocol
Having noticed a bone deficit, the practitioner chooses his zone of intraoral harvest
(from chin or ramus bone) and performs a flap opening.

The recipient site must be exposed before harvesting the graft in order to measure
the bone deficit and anticipate the graft integration.

The saw BS1 marked at 3, 6 and 9 mm, creates the lines of osteotomy. The angled
forms of the BS2L and BS2R saws facilitate horizontal and vertical cuts during ramus
bone harvest. The precise and selective cut of these three saws limits any risk of soft
tissue lesions. The ultrasound favors the cleavage of the bone block and thus the
graft’s harvesting. The BS6 tip can be used to execute a fracture between the cortical
bone of the graft and its subjacent medullary tissues. The use of striking instruments
and its consequences for the patient is thus greatly limited.
Recommended modes Irrigation ml/min
The recipient site is then prepared, commonly called osteoplasty. The BS4 and BS6
tips allow to eliminate granulation tissue, to level the site (osteoplasty) and to collect
BS1 1 2 3 4 40-50
bone shavings to be later integrated into the bone filling material. The bone block is
then screwed in and the graft’s edges rounded off with the BS6 tip or the diamond BS2L 1 2 3 4 40-50
tips of the SL kit (SL1 or SL2). The bone filling is spread and the site is sutured. Healing
varies between 3 to 6 months.
BS2R 1 2 3 4 40-50
The BS5 tip is especially designed for delicate osteotomies (ridge expansion, pre-
marking during a sinus lift).
BS4 1 2 3 4 35-40
The following tip index charts specify the different clinical applications of each one.
BS5 1 2 3 4 35-40

BS6 1 2 3 4 35-40

*Osteotomy
74 75
Osteotomy Saw Saw Osteotomy

BS1 BS2L
Ultra-sharp saw, equipped with five specifically sharpened teeth, intended for the in- Left-angled bone saw with five teeth, used for cutting the ramus cortical bone.
depth cutting of very dense cortical bones. Tip height: 28 mm • Saw width: 4 mm • Saw thickness: 0.5 mm ± 0.05 mm.
Tip height: 28.9 mm • Saw width: 4 mm • Saw thickness: 0.5 mm ± 0.05 mm.

The laser-marker, placed at 3, 6 and 9 mm from its extremity, facilitates the evaluation This tip, specially adapted to the anatomical situation, facilitates the cut of ramus
of bone defect dimension and controls cutting depth. cortical bone. Left oriented, it is used to create vertical and horizontal osteotomy lines
This extremely sharp bone saw is particularly effective during chin and ramus bone on the patient’s right mandible.
harvest. Its deep cutting allows a rapid graft grasp. The cutting movement must be
vertical (marking the cutting line with the saw teeth) then linear, joining the pilot holes
created from the initial movement.

1 1
Recommended modes

Recommended modes

2 2
3 3
4 4
76 77
Irrigation ml/min 40-50 40-50 Irrigation ml/min
Osteotomy Saw Scalpel Osteotomy

BS2R BS4
Circular scalpel angled at 120°, for osteoplasty and harvesting of bone particles or chips.
Treatments: Ridge osteoplasty, periodontal surgery, cysts exeresis, etc.
Tip height: 32 mm.
Right-oriented bone saw with five teeth, used for cutting the ramus cortical bone.
Tip height: 28 mm • Saw width: 4 mm • Saw thickness: 0.5 mm ± 0.05 mm.
During bone graft, this tip shapes the recipient site (osteoplasty) in order to ensure the
graft stability facilitating its integration.
Used during sinus lift, it collects bone shavings of the vestibular bone window. The
This tip, specially adapted to the anatomical situation, facilitates the cut of ramus aspirated autogenous bone will be harvested in a bone filter to be integrated later into
cortical bone. Right oriented, it is used to create vertical and horizontal osteotomy lines the bone filling material.
on the patient’s left mandible. In the presence of cyst, the BS4 planes the site until the cystic follicle is perfectly
exposed.

1 1
Recommended modes

Recommended modes

2 2
3 3
4 4
78 79
Irrigation ml/min 40-50 35-40 Irrigation ml/min
Osteotomy Scalpel Scalpel Osteotomy

BS5 BS6
Flat scalpel for fine osteotomies. Curved scalpel particularly recommended for osteoplasty.
Treatments: Ridge expansion, thin osteotomy, distraction, preparation of buccal bone Treatments: remodeling, curettage and harvesting of bone chips.
flap on thick cortical terrain prior to sinus lift surgery. Tip height: 28 mm.
Tip height: 30 mm.

The ridge expansion technique, introduced for the first time by Bruschi and Scipioni in An osteoplasty tip, the BS6 cleans the recipient site, smoothens surface defects and
1990 (9), allows an implant placement in the ridges originally having deficient eliminates adhering periostium (fibrocellular layer) in order to best adapt the recipient
thickness. With use of the BS5, the practitioner separates vestibular and lingual (or site to the graft. It can serve for remodeling the graft to eliminate any secant or
palatal) cortical bone, then introduces immediately the implant between both cortical aggressive zone and to separate the cortical bone graft from subjacent medullary tissue
bones. After performing an optional osteoplasty to level the ridge’s surrounding, the during grasp of the graft. Finally, it levels the ridge surrounding during ridge expansions.
bone filling material is placed and then the site is sutured.
Sharpness and precision characteristics of the BS5 are undeniable advantages for
performing other numerous surgical acts. It can be used at the very beginning of the
surgery to perform a marking line during bone distraction or sinus lift.

Ridge expansion

Pre-marking of the bone window

1 1
Recommended modes

Recommended modes

2 2
3 3
4 4
80 81
Irrigation ml/min 35-40 35-40 Irrigation ml/min
 Instrument sequence
Ramus bone harvest

1 2
3 4
Bone Surgery kit

5 6
7 8
Ramus bone harvest and graft remodeling for filling
of bone deficit on tooth 11.

82 83
2. Instruments for sinus lift
The Sinus Lift™* kit, consisting of five ultrasonic tips, is specifically designed for sinus
lift.

The sinus cavity naturally tends to increase in volume with time. Having noticed the
bone deficit, the practitioner performs a local anesthesia and then a flap with a
scalpel.

The vestibular bone window is operated with the SL1 diamond tip by a horizontal
incision, followed by two vertical lines, then a second horizontal incision. The angles
of this window are then smoothed with the SL1 and/or the SL2 in order not to damage
the Schneider’s membrane.
Once the bone block is removed (see II, 4, b), the elevation of the membrane is
assured with the SL3 tip. It is introduced between the cortical bone and the
membrane (or the bone block, according to the method) and separates them
approximately 2.5 mm apart from the edge. The SL4 and SL5 tips are then used in
apical, mesial and then distal position to elevate the edges deeper. It is important
during this operation to keep good contact with the edges of the vestibular bone
window.
The filling of sinus is then performed by an autogenous bone graft. Autogenous bone Recommended modes Irrigation ml/min
shavings harvested during the operation can be mixed with biomaterials. The bone
filling material is then introduced into the bone window and over the whole site.
SL1 1 2 3 4 40-50
Before suturing the site, collagen or Gore-Tex® or even Vicryl® membranes can be
placed to protect and maintain the filling material. SL2 1 2 3 4 40-50
Finally, depending on the case, implants are inserted approximately three months
after the operation.
SL3 1 2 3 4 35-40
The following tip index charts specify the different clinical applications of each one.

SL4 1 2 3 4 35-40

SL5 1 2 3 4 35-40

*Sinus elevation
84 85
Sinus lift Diamond Diamond Sinus lift

SL1 SL2
Diamond-coated tip (90 µm) for vestibular bone window cut and for attenuation of sharp Diamond-coated ball tip (90 µm) for smoothing the vestibular bone window and precise
angles. osteoplasty.
Tip height: 30 mm. Ball diameter: 1.5 mm • Tip height: 34.5 mm.

This tip is used to perform bone incisions less aggressive than saws. It is recommended This diamond tip performs very fine bone incisions. It is intended for the vestibular bone
to be used during a vestibular bone window cut and attenuation of the sharp angles to window cut (of very thin bone) and precision osteoplasty. The SL2 remodels all the
protect the nearby anatomical structures. During its use, the practitioner has to secant bone zones likely to damage the Schneider’s membrane or the tissue surrounding
perform a constant (longitudinal) sweeping of the surface to be incised. The SL1 the graft. It cleans and refines alveolar bone after tooth extraction.
remodels all the secant bone zones susceptible to damage the Schneider’s membrane
or the tissues surrounding the graft.
The marking phase of the bone window can be possibly performed with the BS5.

1 1
Recommended modes

Recommended modes

2 2
3 3
4 4
86 87
Irrigation ml/min 40-50 40-50 Irrigation ml/min
Sinus lift Spatula Spatula Sinus lift

SL3 SL4
Plateau tip, non-cutting, served for Schneider’s membrane elevation on the window’s
edges. Non-cutting spatula, oriented at 90°, served for Schneider’s membrane elevation inside
Tip height: 31 mm • Plateau diameter: 5 mm. the sinus.
Tip height: 23.4 mm • Spatula diameter: 4 mm.

This non-cutting tip is intented for elevating the Schneider’s membrane approximately
by 2.5 mm on the window’s edges. During its use, it is essential to keep a permanent
contact between the membrane and the lining bone. Finally, in presence of a cyst, the
SL3 tip separates the cyst from the osseous wall of the cystic cavity.
This tip is intended for Schneider’s membrane elevation inside the sinus and for
disengagement of anatomical structures. During its use, the practitioner has to
permanently keep in touch with the bone edges. The elevation is undertaken at the
apical, mesial then distal part.
Finally, in presence of a cyst, the SL4 tip separates the cyst form the osseous wall of the
cystic cavity.

1
Modes préconisés

Modes préconisés

1
2 2
3 3
4 4
88 89
Irrigation ml/min 35-40 35-40 Irrigation ml/min
Sinus lift Spatula
Instrument sequence
Discarded vestibular bone window

SL5
Non-cutting spatula, oriented at 120°, used for Schneider’s membrane elevation inside
the sinus and for disengagement of anatomical structures.
Tip height: 31.5 mm • Spatula diameter: 4 mm.
1
This tip is used for Schneider’s membrane elevation inside the sinus and disengagement
of anatomical structures. During its use, the practitioner has to permanently keep in
contact with the bone edges. The elevation is undertaken at the apical, mesial then
distal part.
Finally, in presence of a cyst, the SL5 tip separates the cyst form the osseous wall of the
cystic cavity.

2 4
5 7
6
1
Recommended modes

2
The surgical principle of a sinus lift is as follows: cutting the
vestibular bone window, elevating the Schneider’s membrane,
3
filling and suturing the site.
4
90 Photos were taken during two operations. 91
Irrigation ml/min 35-40
 Instrument sequence 3. Syndesmotomy instruments
Preserved vestibular bone window
Scalpel Syndesmotomy

LC1
Scalpel for performing syndesmotomies and periradicular osteotomies.
Treatments: extraction of impacted teeth, removal of remaining root fragment.
Tip height: 26.3 mm.

This tip allows penetration with precaution and in depth, along the periodontal space
between the root and the alveolar bone. The practitioner has to make sweeping
movements. The ultrasonic micro-oscillations entail the resection of alveolar bone wall
without affecting peripheral tissues. The tip draws very thin trenches to finally facilitate
the tooth or root avulsion out of its alveolar bone.

1
Recommended modes

Swinging vestibular bone window towards Schneider’s 2

membrane during a sinus lift. 3
4
92 93
40-60 Irrigation ml/min
 Instrument sequence

2
Organization
of technical environment

3
Using the LC1 around the root to facilitate
the root avulsion.
94
1. Packaging of the generator
and its accessories
Delivered non-sterile, various packages (BS*, SL**) consist of a sterilization box, a
handpiece connected to its cord, a dynamometric wrench and a tips’ support. Before
performing an operation, it is thus necessary to operate a cycle of sterilization.
Dynamometric wrench
The dynamometric wrench allows tip changes as necessary. Having screwed the tip on
the handpiece’s transducer, the practitioner can interlock the wrench and tighten at
90° past abutment. The tips which cannot be integrated into the dynamometric
wrench will be changed by using the universal flat wrench (see illustration on the
right).

2. Operating zone organization

The generator Piezotome can be placed on a mobile Newtron Kart. The shelves
allow a combination of a piezoelectric generator and a high frequency
electrosurge (Servotome®) or a motor for implantology.

Piezotome connected to the electrical current can be equipped with one or 3. Decontamination and re-packaging
two handpieces. This device is equipped with two handpiece connection
cords. Depending on the needs, the practitioner can choose to connect to the After the operation, it is important to follow the procedure of decontamination and
device one or two handpieces of Piezotome™ or Newtron® type. re-packaging of the device as well as their accessories.
The irrigation line is connected to the handpiece, clipped with the cord, the
cassette placed in the pump and finally the perforator integrated with a The irrigation line must be purged in distilled water after each operation to eliminate
bottle or a pouch of sterile solution. The bottle is hung on the pole by a hook remaining physiological serum.
(three hooks are delivered with the device). Two pouches can be Accessories such as tips support, tips and wrench must be disinfected,
simultaneously placed on the pole with two hooks. The practitioner is decontaminated and sterilized.
thus allowed to operate with two handpieces under sterile irrigation.
The sterilization box can follow a process of physical (brushing) and chemical
Tips supports (detergent) cleaning. Furthermore, cassettes and trays can be placed in a mechanical
Prior to the operation, it is advised to place a bridge table above the patient. The cleaning device.
stainless steel support and its tips maintained by silicone rings facilitating their grip
can be easily decontaminated, sterilized and placed on this bridge table. The handpiece can be cleaned with disinfecting towelettes. Its extremity can be
completely unscrewed, facilitating access to and cleaning of the amplifier.
Handpiece support
It is also recommended to install the handpiece support on the bridge table.
The handpiece provided with its tip can be presented with the head at the top of the
support (1). At the end of the operation, the Piezotome handpiece can be introduced
upside-down on its support, over a kidney dish (2).

(1) (2)
96 97
*Bone Surgery, osteotomy
**Sinus Lift
Cycle of sterilization

98 99
 Maintenance Summary
1. Instruments and accessories Recommended modes Irrigation ml/min

Tips BS1 1 2 3 4 40-50

Wear of tips must be regularly verified by the user. A tip with dulled active part must
be changed. Diamond tips must be renewed when the active diamond part becomes
smooth and shiny. In anticipation of tip wear, it is recommended to sterilize a second
BS2L 1 2 3 4 40-50
tips kit in advance. Furthermore, to prolong their efficiency and precision, it is
important to avoid dropping them. BS2R 1 2 3 4 40-50
Piezotome handpiece
Before each operation, it is recommended to verify the integrity of the handpiece
cord.
BS4 1 2 3 4 35-40
Unscrewing the handpiece extremity allows access to the sealed joint as well as the
screw thread (zone of tip screwing) and thus allows checking for their wear status.
BS5 1 2 3 4 35-40
The sealed joint (reference E15019) ordered through your local retailer can be easily
changed.
Finally, you can, in case of loss or deterioration, order the hooks from your local BS6 1 2 3 4 35-40
retailer (reference E57348).
For further details, please refer to the relevant user’s manual.
SL1 1 2 3 4 40-50
2. Generator
After each operation, it is necessary to check the integrity of mains cables, the SL2 1 2 3 4 40-50
footswitch and handpieces. The whole generator and in particular the control panel
designed with anti-bacterial plastic material can be cleaned with disinfecting
towelettes. It is however important to quickly mop up liquids which might penetrate SL3 1 2 3 4 35-40
into chinks during the decontamination procedure.

SL4 1 2 3 4 35-40

SL5 1 2 3 4 35-40

LC1 1 2 3 4 40-60

100 For further details, please refer to Piezotome user's manual. 101
 References
1. Bonnet L., Alternatives aux greffes osseuses autogènes et comblements sinusiens en
chirurgie implantaire. Thèse, Université d’Auvergne Clermont-Ferrand I, Unité de Formation
et de Recherche d’Odontologie, 2001.
2. Gaphian F., Nichols K., La Piézochirurgie : ses apports en chirurgie buccale. Thèse, Université
de Rennes I, Unité de Formation et de Recherche d’Odontologie, 2005.
3. Giraud J-Y, Etude et mise en œuvre d’un ostéotome assisté par ultrasons. Thèse, Université
Paul Sabatier de Toulouse (Sciences), 1991.
4. Harris D. Advanced surgical procedures : bone augmentation. Dental Update. 1997, 24: 332-
37.
5. Horton JE, Tarpley TM, Wood LD., The healing of surgical defects in alveolar bone produced
with ultrasonic instrumentation, chisel and rotary bur. Oral Surgery, Oral Medicine, Oral
Pathology, Oral Radiology, and Endodontology. 1975, 39: 536-546, Elsevier.
6. Horton JE, Tarpley TM Jr, Jacoway JR, Clinical applications of ultrasonic instrumentation in
the surgical removal of bone. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology,
and Endodontology. 1981, 51(3): 236-242, Elsevier.
7. Kerawala C.J., Martin I.C., Allan W., Williams E.D., The effects of operator technique and
bur design on temperature during osseous preparation for ostheosynthesis self-tapping
screws. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology.
1999; 88: 145-150, Elsevier.
8. Sautier J.M., Loty C., Loty S. Biologie de la réparation osseuse. Information Dentaire, 1995,
n°38 : 2955 – 2960.
9. Scipioni A., Bruschi G. B., Technique d’élargissement de la crête édentée : Etude sur 5 ans.
International Journal of Periodontics & Restorative Dentistry., 1994, Vol.14, n°5 : 451-459.
10. Seban A., Bonnaud P., Deboise A., Greffe autogène préimplantaire dans le traitement des
insuffisances osseuses transversales du secteur antérieur maxillaire. Clinic 2004 – Vol.25,
N°10, Edition CdP.
11. Simon M, Baldoni M., Elargissement du matériel osseux de l’arcade par implantation
immédiate associée à un clivage de la crête et à la régénération tissulaire guidée.
International Journal of Periodontics & Restorative Dentistry, 1992, Vol.12, n°6 : 463-473.
12. Torella F., Pitarch J., Cabanes J, Anitua E: Ultrasonic ostectomy for the surgical approach
of the maxillary sinus: A technical note. International journal of oral & maxillofacial
implants, 1998, 13: 697-700.
13. Van der Weijden F., De stille kracht van Ultrasoon (The power of ultrasonics), 2005.
14. Vercellotti T, Crocave A., Palermo A., Molfetta A. The piezoelectric osteotomy in
orthopedics : clinical and histological evaluations (pilot study in animals). Mediterranean
Journal of Surgery and Medicine, 2001;9: 89-95.
15. Vercellotti T, Nevins ML, Kim DM, Nevins M, Wada K, Schenk RK, Fiorellini JP. Osseous
response following resective therapy with piezosurgery. International Journal of
Periodontics & Restorative Dentistry, 2005 (Dec), 25 (6):543-9.

102