British Journal of Oral and Maxillofacial Surgery (2004) 42, 451—453

SHORT COMMUNICATION

Piezosurgery® : an ultrasound device for cutting

bone and its use and limitations in maxillofacial
surgery
Georg Eggers*, Johannes Klein, Julia Blank, Stefan Hassfeld

Department of Oral and Cranio-Maxillofacial Surgery, Heidelberg University Hospital, Im Neuenheimer

Feld 400, 69120 Heidelberg, Germany
Accepted 30 April 2004

Available online 28 July 2004

KEYWORDS Summary Piezosurgery uses modulated ultrasonic vibration to allow controlled cut-
Piezosurgery; ting of bony structures. Delicate bony structures can be cut easily and with great
Maxillofacial surgery; precision, without destruction of soft tissue. We have found this device useful when
exact cutting of thin bones is essential. However, it is of only limited use in cutting
Bone cutting;
thick bones and in regions with limited access.
Ultrasonic vibration
© 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.

Introduction The equipment (Fig. 1) consists of a piezoelectric

Ultrasound has been used for decades to cut tissue,
and commercially available systems for ultrasonic
cutting of soft tissue are used in various medical
disciplines and environments.1,2 Ultrasonic cutting
of bone is feasible3 and alveolar bone that had been
cut ultrasonically healed uneventfully.4
Technique
Piezosurgery® (Mectron, Carasco, Italy) is a re-
cently developed system for cutting bone with mi-
crovibrations. These are created by the piezoelec-
tric effect: certain ceramics and crystals deform
when an electric current is passed across them,
resulting in oscillations of ultrasonic frequency.
*Corresponding author. Tel.: +49 6221 56 7332;
fax: +49 6221 56 4222.
E-mail address: georg.eggers@med.uni-heidelberg.de
(G. Eggers).
0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2004.04.006
handpiece and a foot switch that are connected to
a main unit, which supplies power and has holders
for the handpiece and irrigation fluids. It contains
a peristaltic pump for cooling with a jet of solution
that discharges from the insert with an adjustable
flow of 0—60 ml/min and removes detritus from the
cutting area. The settings of power and frequency
modulation of the device can be selected on a
control panel with a digital display and a keypad
according to the planned task. The unit uses a fre-
quency of 25—29 kHz. In ‘‘boosted’’ mode, a digital
modulation of this oscillation produces an alterna-
tion of high frequency vibrations with pauses at a
frequency of up to 30 Hz. This alternation prevents
the insert from impacting the bone and avoids
overheating while maintaining optimum cutting
capacity.5 For the handpiece several autoclavable
tooltips, called ‘‘inserts’’, are available (Fig. 2).
Some are coated with titanium or diamonds in var-
ious grades. The microvibrations that are created
in the piezoelectric handpiece cause the inserts
to move between 60 and 210 ␮m, providing the
452
Figure 1 The Mectron Piezosurgery system: (A) main
unit with panel (I), peristaltic pump (II), socket for con-
nector to handpiece (III); and (B) handpiece with saw
insert.
handpiece with power exceeding 5 W.5 The instru-
ment was originally designed for augmentation in
implant operations, including sinus lift6 and ridge
expansion.7 For the cutting of bone in maxillofacial
operations, the most efficient setting is boosted
mode with maximum irrigation. The handpiece is
guided over the bone firmly, but without excessive
force. The sound of the cutting can be used as
acoustic feedback for the force to be used. Dur-
ing operations, it is important to pay attention to
irrigation to avoid heating of the bone. After pro-
longed cutting the handpiece will warm and a short
pause may be advisable to let the handpiece cool
down.
Figure 2 A selection of available inserts, from left
to right: (A) flat scalpel, diamond tipped, titanium
nitride-coated surface; (B) cone compressor, flat, blunt;
(C) bone harvester, titanium nitride-coated surface;
and (D) sharp tipped saw, titanium nitride-coated
surface.
G. Eggers et al.
Procedures
In craniofacial surgery, we used the system in
fronto-orbital advancement operations in children.
We cut the calvarial bones in two stages. Firstly, we
cut the calvarium to remove parts for later repo-
sition. The cutting speed was dependent on the
thickness of the bone. When the bones were more
than about 3 mm wide, the cutting was slow but
precise and without laceration of the dura mater.
The tool was also used to cut the removed bone
before replantation. Here the system proved to be
particularly useful. It was possible, even in the thin
bone of a child’s calvarium, to cut the inner cor-
tical layer selectively without damaging the outer
cortical bone. The bone could then be bent into
shape before fixation with microplate osteosynthe-
sis without breaking. The number of fragments and
the amount of osteosynthetic material was there-
fore reduced, which saved time and reduced costs.
In sinus-lift operations it was easy to cut a bony
window into the maxilla without lacerating the mu-
cosa of the maxillary sinus. The cut was thin, which
Figure 3 Accurate osteotomy of the buccal cortical
bone of mandible in a case of apical odontoma: (A) cut-
ting the cortical bone with the Piezosurgery handpiece;
and (B) osteotomy completed.
Piezosurgery in maxillofacial surgery
Figure 4 Electron micrographs of bone surfaces after
different cutting devices, from left to right: (A) Piezo-
surgery; (B) Lindemann bone cutter; and (C) oscillating
saw.
reduced the loss of bony tissue. The mucosa could
be peeled off the bone with a cone compressor,
causing no damage. However, the access to the pos-
terior regions of a LeFort osteotomy of the maxilla
was extremely difficult.
A common problem in the surgical removal of os-
teosynthetic material is the formation of callus that
covers plates and screws and makes removal dif-
ficult. The Piezosurgery system allowed us to re-
move callus from titanium osteosynthetic material
quickly. In particular, it was possible to remove the
callus from the slots of screws without damaging
them. Screwdrivers could then be attached.
In osteotomies and biopsies of bone it was pos-
sible to place exact cuts at the desired location of
the bony surface. In particular, it was possible to
cut the bone between teeth precisely at the desired
angle (Fig. 3A and B). However, when deep cuts
into the bone were necessary, the system was less
efficient. While the cutting speed decreased tem-
peratures rose, so pauses were necessary to let the
system cool down. In these cases, the combination
of Piezosurgery for the initial incision and a chisel
for the final osteotomy of the bone was useful.
In cases where it is necessary to obtain autolo-
gous material to fill bony defects, such as in sinus
453
lift, a specially designed insert could be used to col-
lect material from the bone surface. When gently
moved over the surface, small deposits of bone par-
ticles accumulated on the surface and could eas-
ily be collected with a small curette. Currently, we
are doing an electron microscopic study in cadav-
eric bones, which suggests that the quality of cuts
by Piezosurgery compares favourably with those us-
ing conventional instruments (Fig. 4).
Discussion
The manufacturer claims that bone can be cut pre-
cisely without damage to soft tissue and with little
bleeding (Handbook, Mectron S.r.l., Carasco, Italy,
2002). The system fulfilled these promises for us.
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