ARTÍCULO CLÍNICO

 

Extraoral uses of a piezoelectric surgical cutting tool

Aplicaciones extraorales del bisturí piezoeléctrico

 

 

J. González Lagunas, J. Molina Montes, J. Mareque Bueno

Departamento de Cirugía Oral y Maxilofacial, Hospital Universitari Vall d'Hebron y Hospital Quirón, Barcelona. España

Correspondence

 

 

 

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ABSTRACT

We report our experience with the use of a piezoelectric surgical cutting tool in performing extraoral osteotomies. These indications have not been reported previously in the literature. In the last 6 months we have used this instrument to perform osteotomy on the temporomandibular condyle and articular eminence, to obtain grafts from the skull, and to perform osteotomy for rhinoplasty. This instrument can be used to makes an osteotomy cut without risk of injuring adjacent soft tissues. Its advantages and disadvantages are discussed in accordance with the procedure performed.

Key words: Temporomandibular joint; Rhinoplasty; Bone grafts; Ultrasound; Osteotomy.

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RESUMEN

Presentamos nuestra experiencia con el empleo de un bisturí piezoeleéctrico con el fin de efectuar diferentes osteotomias extraorales, Estas indicaciones no se han presentado previamente en la literatura. En lus últimos 6 meses hemos utilizado este intrumento para efectuar osteotomías en el cóndilo y en la eminencia articular, para tomar injerto de calota craneal y para realizar las osteotomias de la rinoplastia. Este instrumento permite una inea de osteotomia precisa sin el riesgo de lesionar los tejidos blandos vecinos. Se discuten las ventajas e inconvenientes del instrumento según el procedimiento realizado.

Palabras clave: Articulación temporomandibular; Rinoplastia; Injertos óseos; Ultrasonidos; Osteotomía.

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Introduction

"Piezosurgery" takes advantage of the cutting capacity of an instrument that vibrates at ultrasound frequency. The soft tissues that come into contact with the vibratory material are not injured, which makes the piezoelectric cutting tool an ideal instrument to use in limit between soft tissues and bone,¹ which reduces the risk of injuring adjacent soft tissues.

In the maxillofacial region, there is an intimate relation between bone and the local nerves and blood vessels. The technique has been used in a variety of intraoral and extraoral osteotomies in the maxillofacial territory to take advantage of its "selective" cutting capacity and to minimize surgical trauma to adjacent tissues. The aim of this article is to present our experience with new applications of a piezoelectric surgical cutting tool in various extraoral osteotomies in the craniofacial territory.

 

Material and method

The same instrument (Medical Mectron Technology, Italy) was used to perform the osteotomies on all the patients. High-frequency oscillation at 25-30 KHz is used to cut bone without affecting the adjacent soft tissues. The device is used at its maximum power level («bone special»). Profuse irrigation with saline solution was used throughout the procedure to keep the bone from overheating. A micro-saw (OT7) from the same manufacturer was used in every case.

Between April 2006 and December 2006, eight patients with problems of the temporomandibular joint who required different osteotomies were treated. The most common procedure performed was high condylectomy (Fig. 1), or condylar reshaping, and resection of the articular eminence (Fig. 2). In a case of craniofacial dysplasia, osteotomy of the zygomatic arch was performed to obtain access to the condyle.

In addition, in a case of secondary reconstruction of naso-orbital collapse, the region was repaired with parietal external cortical grafts that were obtained with a micro-saw insert connected to the piezoelectric surgical cutting tool (Fig. 3).

Finally, in a case of post-traumatic rhinoseptoplasty, the piezoelectric surgical cutting tool was used to make osteotomies through percutaneous incisions in the paranasal region (Fig. 4). The osteotomy had a "low-to-high" design.

 

Results

In all the patients operated on, the piezoelectric surgical instrument made it possible to perform an exact and safe osteotomy without visible lesions to the neighboring tissues. The osteotomies of the temporomandibular joint were simple. In most cases, only a periosteotome elevator was required to separate the osteotomized fragments. In the skull, it was simple and safe to obtain the bone graft, but the operating time was prolonged by the hardness of the parietal bone. During rhinoplasty, poor vision of the area and the hardness of the bone to be fractured made the procedure difficult. The operating time also was longer.

 

Discussion

In recent years, piezoelectric surgical cutting tools for the maxillofacial region have become popular.^1-4 Although they have been used fundamentally in intraoral techniques,^5-7 they also have been applied for different osteotomies of the facial area, including maxillary segmental osteotomy,⁸ mandibular osteotomy,⁹ and cranial osteoplasty.¹⁰

Piezoelectric surgery can be used to obtain most of the bone grafts made in the craniofacial region. Its cutting characteristics protect the adjacent soft tissues. Consequently, during the bone graft harvesting procedure, the sinus mucosa can be protected in the maxillary tuberosity, the mental nerve in grafts from the chin, the inferior alveolar nerve in grafts from the ascendant ramus, and the dura mater in grafts from the parietal bone.^11-14

We present the technique used to perform different osteotomies in the craniofacial region that have not been described previously in the literature.

The outer table of the parietal bone is a useful donor area for craniofacial surgeons, not only because of its easy accessibility, but also because of the low morbidity and disability of the procedure.^15-17 The bone is obtained from the thickest part, where the diploë has abundant cancellous bone. The main complication of the procedure is dural injury but, no morbidity occurs if the dura is not perforated.¹⁸ The piezoelectric surgical cutting tool has the advantage of preventing dural injury and avoiding the associated complications because it can be used both to cut selectively and without the surgeon having to apply pressure to the intervention site. In addition, the precision of the cut means that less bone substance is lost during osteotomy.

In the temporomandibular joint, the piezoelectric surgical device allows bone to be cut safely on the medial condylar aspect, thus reducing the risk of injuring the internal maxillary artery. In the medial part of the articular eminence, the risk of injuring meningeal vessels is reduced if the cranial cavity is penetrated accidentally. This eventuality is especially important in cases of temporomandibular ankylosis, in which there is severe deformation of the bone architecture.

In rhinoplasty, the osteotomy is one of the most critical stages of the procedure. Poor design or defective execution will result in deficient esthetic results and possible intra- or postoperative complications. Our usual practice is to perform the osteotomy using an extranasal approach with two or four paranasal incisions in which 3 mm chisels are introduced. This technique allows better operative control and is less traumatic. We used the same incisions to introduce the vibratory insert. Use of the piezoelectric cutting tool in rhinoplasty did not offer any special advantage from our viewpoint. The difficulty of access through the percutaneous incision complicates the refrigeration of the osteotomy zone and increases the risk of thermal injury to the bone. Since the risk of soft tissue injury is insignificant, the longer duration of the procedure does not justify replacing the classic chisel technique through the transcutaneous or endonasal approach. Nonetheless, we cannot rule out the possibility that using the instrument by an endonasal approach (which improves access for bone refrigeration) would be an option to consider.

The advantages of the procedure include its already mentioned innocuousness for soft tissues, which prevents accidental injury during surgery,³ and better control of the osteotomy due to the physical properties of the device.¹⁹ Complications derived directly from the piezoelectric surgical device are infrequent. These complications include thermal damage to the bone, our lack of knowledge of the long-term effects of the technique, and material fatigue.²⁰ The most frequent complaint is that procedures are more time-consuming than interventions performed with conventional cutting instruments. This occurred in our experience, especially in the nasal osteotomy and, to a lesser extent, in harvesting the skull graft, but it was insignificant in the procedures on the temporomandibular joint.

 

Conclusions

The piezoelectric surgical cutting tool, with the proper insert, can be used safely in many osteotomies that are performed routinely on the maxillofacial skeleton. We have reported here presented our experience with this instrument in the management of condylar hyperplasia, temporomandibular joint conditions requiring resection of the articular eminence, lateral osteotomy in rhinoplasty, and in harvesting skull grafts, all situations in which the use of this instrument has not been reported previously.

 

 

Correspondence:
Dr. Javier Gonzalez Lagunas
Hospital Quirón Barcelona
Plaza Alfono Comín 5-7
08023 Barcelona, España
Email: jgonzalez.bcn@quiron.es

Received: 05.06.07
Accepted: 16.06.08

 

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