ISSN: 2455-4634
International Journal of Oral and Craniofacial Science
Review Article       Open Access      Peer-Reviewed

Cutting bone with drills, burs, lasers and piezotomes: A comprehensive systematic review and recommendations for the clinician

Angelo Troedhan1*, Ziad Tarek Mahmoud2, Marcel Wainwright3 and Mohamed Moataz Khamis4

1Institute for Oral & Maxillofacial Surgery and Dentistry, General Hospital “Krankenhaus Hietzing” of the City of Vienna, Vienna
2Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Alexandria University, Egypt
3School of Dentistry, University of Seville, Spain
4Department of Prosthodontics, Faculty of Dentistry, Alexandria University, Egypt
*Corresponding author: Angelo Troedhan, Krankenhaus Hietzing, Institute for Oral & Maxillofacial Surgery and Dentistry, Wolkersbergenstraße 1, 1130 Vienna, Austria, Tel: 0043 664 5009246; Fax: 0043 1 544912821; Email:
Received: 29 July, 2017 | Accepted: 12 August, 2017 | Published: 14 August, 2017
Keywords: Oral surgery; Maxillofacial surgery; Cutting bone; Osteotomy; Lasers; Piezo-electric bone surgery; Piezotomes

Cite this as

Troedhan A, Mahmoud ZT, Wainwright M, Khamis MM (2017) Cutting bone with drills, burs, lasers and piezotomes: A comprehensive systematic review and recommendations for the clinician. Int J Oral Craniofac Sci 3(2): 020-033. DOI: 10.17352/2455-4634.000028

Background: New tools for bone-cutting were introduced to oral and maxillofacial surgery in the last decade, such as lasers and piezotomes.

Purpose: To evaluate most recent evidence, when surgical procedures performed with drills or burs are compared with laser- and/or piezotome-surgical procedures in experimental and clinical studies and to assess possible advantages of their use in daily practice.

Methods: A systematic search of various medical databases with specific keywords was performed, excluding studies published before 2006 for their possible invalidity by technological progress. Systematic reviews were assigned to Group 1, experimental studies ex vivo to Group 2, in vivo to Group 3 and clinical studies to Group 4. All studies in each of the groups 2 – 4 were appraised regarding their evidence, starting with a value of 0 for no evidence of advantages of lasers and/or piezotomes compared to rotary instruments, 1 for moderate evidence with verified clinical impact and 2 for strong evidence and significant clinical impact and statistically processed for their Evidence Value (EV) in each group and their Overall mean Evidence Value (OmEV).

Results: 129 studies were finally included for evaluation. Two systematic reviews concluded lack of evidence for lasers to be advantageous over burs/drills. Nine reviews for piezotomes reveal strong evidence piezotome-surgery to significantly reduce morbidity and to enhance soft-tissue preservation. Comparative experimental and clinical studies of burs/drills vs lasers revealed a low EV in Group 2 (EV:0,8), Group 3 (EV:0,5) and Group 4 (EV:0,5) with an OmEV of 0,6. Comparative studies burs/drills vs piezotomes resulted in a significant EV in all groups (Group 2: 1,4, Group 3: 1,3, Group 4: 1,59) with an OmEV of 1,4.

Conclusion: The results suggest too little evidence to establish lasers as an alternative to rotary instruments. Piezotomes seem to define a possible new gold-standard in bone cutting due to their improved bone-healing, almost bone-lossless and precise osteotomy design, precise depth-control, soft-tissue protection as well as reduced intrasurgical and post-surgical morbidity.


EL: Evidence Level; EV: Evidence Value; OmEV: Overall Evidence Value


Performing bone-cuts and bone-trepanations is the very basis of the Oral and Maxillofacial surgeon´s daily task and until recently were carried out exclusively with rotary instruments like drills and burs or slow-oscillating saws. Only in the last decade, new technologies evolved as commercially available and certified devices for bone cutting such as lasers and piezotomes. Drills, burs, lasers and piezotomes act fundamentally different in their physical mechanism of cutting bone.

Drills, burs, slow-oscillating saws

Driven by micro-motors or air-pressure-turbines, drills, burs and slow oscillating saws cause a mere mechanical ablation by hacking, crushing and shearing bone with serrated or diamond coated rotational hard-metal bodies of spherical, conical, cylindrical or saw-like shapes. The speed of action depends on the size and coarseness of the serrated surface (from macro-serration to diamond coating), speed of the handpiece and pressure exerted onto the bone, thus causing frictional heat, which might cause bone-necrosis [1]. Heat dissipation by water-beam cooling decreases significantly in surgical practice if the water-beam is not precisely adjusted to target exactly the cutting center of the bur, is blocked by soft-tissues or other surgical instruments, or is reflected by the adjacent bone-surfaces of the osteotomy line with increasing depth of the osteotomy or drill-hole [2].

Drills, burs or low-frequency oscillating instruments are difficult to handle when used on cortical and trabecular bone due to its procedural high physical torque-moment especially in the initial phase of the osteotomy-design on cortical bone. The more coarse the serration of the bur, the more difficult it is to design a perfect osteotomy-line or an anatomical precise drill hole for implant-placement especially for novices.

The major and unavoidable medical drawback of drills, burs and slow-oscillating saws is the enormous procedural bone loss due to the minimum necessary diameter of the instrument of at least 1,5 – 2 mm and the imprecision of the cut due to the high torque-moment, which has to be tamed by the hand of the surgeon as the author´s demonstration in vivo shows (Figure 1). Additional, there is a high risk of soft tissue injury to important anatomical structures such as the inferior alveolar nerve (IAN) [3] or maxillary sinus-membrane and deposition of metal shavings and bacterial contamination [4].


Compared to drills, burs and slow-oscillating saws, lasers act completely different on bone when performing bone cuts. Commercial available laser-devices for bone-cutting in dentistry and oral and maxillofacial surgery – commonly called “Erbium-laser”, “Neodymium-laser” and “Carbon-Dioxide-laser” - emit a coherent light-beam of a precisely defined wavelength in the invisible infrared spectrum of light. The invisible infrared heat beam is transmitted either by optical lenses, hollow tubes or quartz-fibers to the focus-spot on the bone, which typically has a diameter of 0,4 – 1,0 mm depending on the focus-mechanism, the precision of the quartz-fiber tip and distance of the laser-handpiece to the bone by divergence of the coherent infrared light beam [5].

Once the heat-beam hits the intra- and extracellular water-molecules in dentin (~20% H2O), cortical or trabecular bone (~20-30% H2O) and molecular composition of carbonated Hydroxyapatite (OH-, CO3, PO4, intercrystal free H2O), the heat is instantly almost fully absorbed (Figure 2) and leads to micro-explosions of vaporized superheated water vapor (“plasma plume”). The micro-explosions – heat energy transformed into kinetic acoustic energy - are well audible by the patient and surgeon by achieving up to 120 dB in bone [5] and by this enormous kinetic sound-pressure shock wave – called “photoacoustic effect” – ablates the bone by shattering the Hydroxyapatite crystals and disrupting collagen fibers. Physically it is a heat-induced cavitation-effect creating cavitation-bubbles (Figure 3). Once the water in bone-tissue is consumed, the heat energy cannot be transformed into kinetic sound-energy anymore and thus leads to carbonization and necrosis of the adjacent bone-layers [6], in case of dentin and enamel to vast cracks and unwanted separation of tissue-layers as the author´s investigations on freshly extracted teeth show (Figure 4). To reduce the risk of heat-induced bone-necrosis by lasers (especially in deeper osteotomies) and to deliver water to the osteotomy-site, a water-spray-coolant is mandatory although this might lead to unwanted patient´s body-liquid-splatter in the surgery room [5].

The efficacy of bone cuts with commonly used Erbium- or CO2-lasers depend on the precision and cleanliness of the focal-system (mirrors or quartz-fibers), the focus-spot-dimension and energy-density in the focus-spot and the pulse quality of the intermittent blasting laser-beam (to allow dispersion of the heated “laser-plume” carrying the debris and cooling of the osteotomy-site between the intermittent laser-pulses [6]). Furthermore, focal laser energy cannot and must not be increased above the threshold of the laser-specific bone-ablation-property since an increase would only lead to detrimental bone-necrosis and not to faster bone cutting [5,6].

Although osteotomies with lasers allow a precise osteotomy-design (since only the laser-beam should touch the bone) [7] with substantial less procedural bone loss compared to drills and burs (Figure 1) and disinfection of the surgical site itself [6] (but dispersion of possible infective agents in the oral cavity and OR-room [5]), a major drawback is still the complete lack of osteotomy-depth-control, haptic feedback and soft-tissue preservation [8].


Although on the macroscopic level piezoelectric surgical tools resemble drills, burs and slow-oscillating saws by their shape, their physical mechanism of action is merely mechanical only to the smallest part. Piezoelectric crystal rings - activated by electric current - initiate a precise unidirectional ultrasonic oscillation – especially in medical literature wrongly described as “vibrations” – at a rate of 28.000 – 36.000 modulated harmonic oscillations per second and a distance between 60 and 200 µm (Figure 5). Any rigid physical body oscillating at ultrasonic speed in liquids creates the physical phenomenon of the pressure-induced cavitation effect, which is very similar to the photoacoustic effect caused by infrared laser beams in liquids, but at significant lower temperatures [9]. Thus, the physical mechanism of cutting bone with Piezotomes is based on precise disruption of mineralized bone-components by harmonic acoustic shockwaves and cavitation – similar to ultrasonic kidney stone crushers – but completely preserves soft tissues from damage due to the ultrasonic frequency of the devices [10,11]. The pressure-induced cavitation effect - as demonstrated by the author´s investigations of various piezotome-surgical tips (Figure 6) - enhances the clean separation of mineralized tissue formations, enables a significant improved bone healing [10, 11], and – at lower power-settings – an improved and non-destructive dissection of soft-tissues [12] with improved postsurgical hemodynamic microcirculation [13].

Possible heat generation caused by the ultrasonic oscillating instrument is sufficiently counteracted by the applied cooling-liquid, which adheres to the working-tip at the surgical site due to acoustic resonance-adhesion as demonstrated by the author´s investigations (Figure 7). Only improper handling of or faulty constructed piezotomes might lead to increased intrabony heat-peaks (e.g. too high manual pressure by the surgeon, reduction of cooling saline-flow beyond required minimum, faulty constructed piezotomes causing irregular vibrations instead of harmonic, modulated oscillations of the working tip).

Piezotomes provide least procedural bone-loss (Figure 1) due to working tips of a cutting width of only 0,1 – 0,2 mm and allow a precise osteotomy-design comparable to lasers but with precise depth-control and least risk to damage soft-tissues due to the oscillation frequency-range.

The purpose of the systematic review was to evaluate most recent comparative evidence in ex vivo and in vivo experiments on micro molecular, microscopic and macroscopic level and comparative clinical results regarding patient morbidity, when surgical procedures performed with drills or burs are directly compared with laser- and/or piezotome-surgical procedures. Furthermore, the range of applicability, advantages and drawbacks of the different surgical tools were investigated to provide up-to-date evidence and recommendations to the clinician.

Material and Methods

Literature search strategies

The databases, indexes and search engines MEDLINE, PubMed, Cochrane Library, Scopus, Web of Science (ISI), Trip, Dentistry and Oral Science Source, DOAJ, NSLC, OAJSE, Index Copernicus and Google Scholar were used to identify references matching the keywords “osteotomy”, “bone”,“ cut”, “cutting”, “crest”, “alveolar ridge”, “bur”, “drill”, “rotary instruments”, “saw”, “laser”, “Er:*”, “Nd:*”, “CO2*”, “piezo”, “piezoelectric”, “ultrasonic”, “Piezosurgery”, “Piezotome” alone (Boolean operator “NEAR”) or in dual/triple combination by Boolean operators “AND” and “OR”.

All references matching the keywords, but were being published before the year 2006, were excluded to avoid inclusion of studies with experimental and technological outdated devices or already analyzed in published systematic reviews and meta-analysis.

The abstracts of the remaining retrieved reports then were thoroughly scanned and a set of criteria applied for their inclusion in the preliminary reference list.

Inclusion criteria

The abstracts were assigned to four thematically different groups:

Systematic reviews and meta-analyses of rotary instruments vs. laser and/or piezoelectric instruments.

Comparative experimental ex vivo studies of rotary instruments vs. laser and/or piezoelectric instruments.

Comparative experimental in vivo studies of rotary instruments vs. laser and/or piezoelectric instruments.

Comparative clinical studies (randomized controlled trials RCTs, prospective and retrospective) of rotary instruments vs. laser and/or piezoelectric instruments.

Exclusion criteria

All abstracts reporting case studies, general reviews, overviews, technical notes, expert opinions, non-comparative experimental and clinical studies or published in non-peer-review journals were excluded.

Critical appraisal

The included systematic reviews and studies were retrieved as full text, critically evaluated separately by each author regarding procedural flaws, inadequate study- or review-design or too many potential biases. In case a unanimous assessment by the authors could not be achieved, an independent referee evaluated the report or systematic review for in- or exclusion.

Statistical evaluation

All included reports in each of the groups 2 – 4 were appraised regarding their evidence, starting with a value of 0 for no evidence of advantages of lasers and/or Piezotomes compared to rotary instruments, 1 for moderate evidence with verified clinical impact and 2 for strong evidence and significant clinical impact. The evidence-values for each type of surgical tool-comparison were added and divided by the number of publications comparing rotary instruments with lasers and/or Piezotomes.

Primary outcome evaluation

To assess weak or strong evidence if the use of lasers and/or piezotomes has advantages regarding precision of bone cuts, improves bone healing and reduces post-surgical patient-morbidity when compared with traditional rotary instruments.

Secondary outcome evaluation

To assess applicability, indications and restrictions of lasers and/or piezotomes in the daily work of oral and maxillofacial surgeons when compared with traditional rotary instruments to give evidence-based recommendations to the clinician.


954 potential references were found in the databases of which 461 were published since 2006. 279 abstracts then had to be excluded in accordance with the exclusion-criteria. From the final 182 full-text publications 53 had to be excluded due to procedural flaws (e.g. imprecise study design with too many variables and/or wrong settings of the used devices), inadequate study design (e.g. primary outcome evaluation not focused on instrumentation-comparison bur vs laser and/or piezotome) and possible bias (e.g. product-related comparative studies with conflict of interest-background).

A total of 129 publications, meeting the inclusion-criteria and were agreed by all authors and the referee, were finally assigned to group 1-4 and group 2-4 for evidence-staging (Figure 8).

Group 1 (systematic reviews and meta-analyses)

Only two very recent systematic reviews were found comparing rotary instruments with lasers in general [14,15], pointing out that “additional research is necessary to evaluate different laser types with appropriate laser setting variables to increase ablation rates, with control of depth, change in bone type and damage to adjacent soft tissue “ [14] and “because of the lack of clinical studies, it is not possible to make a conclusive result whether there is superiority of laser osteotomy in clinical practice” [15].

Nine very recent systematic reviews comparing rotary instruments with piezotome-instrumentation focused on comparative clinical studies regarding specific surgical procedures such as alveolar crest-split technique [16], lateral maxillary sinus-floor elevation [17,18], acceleration of orthodontic tooth movement [19] and surgical removal of impacted third molars [20-24] and conclude piezotome-instrumentation to significantly reduce post-surgical morbidity (pain, swelling, trismus) but to prolong surgery-time and the need for further randomized clinical studies with a precise study-design.

No systematic reviews were found directly comparing rotary instruments with lasers and piezotomes or piezotomes with lasers.

Group 2 (experimental studies ex vivo)

Burs/drills vs lasers: Comparative ex vivo studies burs/drills vs laser [25-29] suffer from the heterogeneity of used laser-technology (Er:YAG, Er,Cr:YSGG - wavelength) and laser-settings (focus-spot-size/energy-density at focus-spot/laser-pulse-duration and –frequency). Ex vivo-studies are not comparable among each other, point out partly increased thermal bone necrosis depending on the power-settings, but state sharper and cleaner osteotomy lines with less debris when compared with rotary instruments. The evidence-value (EV) 0,8 (Table 1) indicates minor evidence of lasers to substantially improve bone-cutting procedures in oral & maxillofacial surgery.

Burs/drills vs piezotomes: EX VIVO comparisons between rotary instruments and piezotome-osteotomies [30-47] provide substantial evidence with possible high impact on clinical practice with an evidence value (EV) of 1,4 (Table 1). Although with piezotome-instrumentation there is still a risk of thermal bone-damage too (when used improperly), all comparative studies proved piezotome-osteotomies to lead to more precise, debris-free and less destructive bone-cuts as well as superior soft-tissue-preservation especially in the hands of novices in oral surgery.

Burs/drills vs lasers vs piezotomes: Only two studies were found investigating differences of microscopic osteotomy-morphology and temperature rise when burs, lasers and piezotomes [48, 49] are used to cut bone. One [49] revealed a minor procedural flaw in the piezotome-settings regarding flow-rate of saline-irrigation, which lead to a higher intrabony temperature-rise. Both studies present moderate evidence (EL=1, Table 1) and suggest advantages of Er:YAG-lasers over piezotome-instrumentation and burs, however pointing out comparable precise bone cuts with both lasers and piezotomes and the mandatory need of proper knowledge and training to handle lasers correctly in surgery.

Piezotomes vs Piezotomes

Five comparative studies investigate the cutting performance, osteotomy quality and intrabony temperature rise of different devices from different piezotome manufacturers [50-54], but were not rated for their evidence level since the small number of published studies, different settings and study designs do not allow a valid meta-analysis.

Group 3 (experimental studies in vivo)

Burs/drills vs lasers: Evaluation of evidence value in comparative in vivo studies [55-69] suffers mainly from the wide range of different laser-systems used (Er:YAG, Er,Cr:YSGG, CO2, femtolaser), laser-light delivery (free beam, optic fibers) and lack of standardized protocols regarding focus-spot energy-density, pulse-rate and pulse-frequency used. There is not even moderate evidence (EV: 0,5, Table 1) for lasers to provide superior cutting performance on micromorphologic, microscopic and clinical level in vivo and most authors point out thermal damages and thermal bone-necrosis in histologic investigations. However, these laser-induced thermal damages do not seem to influence the overall bone-healing when compared to rotary instruments.

Burs/drills vs piezotomes: With moderate to strong evidence (EL: 1,3; Table 1) and consecutive substantial clinical impact piezotomes seem to provide an improved bone-healing, proved on molecular-biologic, micromorphologic and histologic level in vivo, when compared to rotary instruments. Furthermore, a superior soft-tissue-preservation is reported compared to drills and burs [70-86].

Burs/drills vs lasers vs piezotomes: Only two published studies provide a direct comparison of rotary instruments against Er:YAG-laser and piezotomes of which one [87] describes a significant delay in bone-healing when laser was used and a faster bone healing with piezotome-instrumentation, whereas a comparative study comparing implant drill-sites [88] finds no significant differences between the osteotomy methods. Due to the small number of studies the Evidence Value (EV) is insignificant (0,3; Table 1).

Lasers vs piezotomes

Four published studies [89-92] suggest Er:YAG-lasers in non-contact application with a computerized scanning-handpiece to provide faster bone-healing in vivo than piezotome-instrumentation, but was equal when Er:YAG-laser was used in contact-mode. The evidence value of these studies is low with EV: 0,5 (Table 1).

Group 4 (Comparative Clinical Studies)

Burs/drills vs Laser: Only two comparative clinical studies were published until now [93,94], both comparing Er:YAG lasers with rotary instruments in surgical removal of impacted third molars, with only little evidence (EV: 0,5; Table 1) of clinical advantages of laser-use.

Burs/drills vs Piezotomes: A total of 48 comparative clinical studies investigated molecular-biologic, biomechanical, histologic, radiologic, bone-densitometric and periodontal differences in the short and long-term-outcome between the use of burs/drills and piezotomes [95-107] as well as short and long-term effects on intra- and post-surgical morbidity (intra-surgical amount of bleeding, post-surgical pain, swelling and/or trismus) [108-142].

Both morphologic and morbidity related clinical studies conclude with significant evidence (EV: 1,5, Table 1) piezotome-instrumentation to have a significant clinical impact on improved bone-healing, reduced intra-surgical blood-loss, superior soft-tissue-preservation (e.g. IAN, sinus-membrane, brain-tissue) and significantly reduced post-surgical morbidity (pain, swelling, trismus) not only in oral and maxillofacial surgery but also in cosmetic, ENT and neurosurgery. The learning curve is short and novices in oral and maxillofacial surgery achieve better results with piezotomes than with rotary instruments.

No clinical studies were found comparing burs/drills with lasers and piezotomes as well as lasers with piezotomes.

Overall evidence rating (Group 2,3 and 4; Overall mean Evidence Value - OmEV)

There is only minor evidence with questionable clinical impact that lasers might provide improved properties in bone-cutting when compared to burs/drills (OmEV: 0,6; Table 1) or piezotomes (OmEV: 0,5; Table 1) or both (OmEV: 0,7; Table 1).

Contrary, the use of piezotomes – also backed by the high number of experimental and clinical studies – seem to have a significant clinical impact on improved bone-healing, superior soft-tissue-preservation and reduced postsurgical morbidity with an OmEV of 1,4 (Table 1) when compared with rotary instruments.

(Table 2) gives an overview of evidence-based comparative properties of burs/drills, lasers and piezotomes with burs/drills as “baseline-values” as a descriptive result of this systematic review.


As in abdominal surgery traditional surgical procedures with large transabdominal skin-incisions are more and more replaced by minimal invasive endoscopic procedures with reduced intrasurgical complications and post-surgical morbidity, advanced laser- and ultrasonic-technology might replace traditional surgical techniques performed with burs, drills or slow oscillating instruments likewise in oral and maxillofacial surgery and implantology.

For the clinician the consideration to change from usual rotary instrumentation with traditional surgical protocols to new technologies for bone cutting with new surgical protocols needs solid experimental and clinical evidence to justify the investment of time and funds to introduce these technologies into the individual daily practice.

Although tissue-cutting lasers proved their benefits over scalpel-blades in almost all specialties of surgery, their beneficial application is mostly restricted to soft-tissue-surgery due to their heat-induced precise micrometric soft-tissue-ablation and blood-vessel-coagulation also in oral and maxillofacial surgery.

The application of mainly Er:YAG and/or Er,Cr:YSGG-lasers for surgical therapy of periimplantitis is discussed and applied to clinical practice as demonstrated by the author´s case-examples (Figure 9 A-C) but still lacking sufficient evidence to act superior compared to other surgical protocols [143].

The wide variety of available tissue-cutting laser-systems with different wavelengths (CO2-, Diode-, Nd:YAG-, Er:YAG-, Er,Cr:YSGG-, Hol:YAG- (Figure 10A), experimental Femtosecond- and Excimer-lasers) and high acquisition cost (40.000.- US$ and more) still lack clear evidence of “proof of concept”.

Although laser-systems for bone cutting in the current clinical routine can be narrowed down to CO2-, Er:YAG-, and Er,Cr:YSGG-laser-types (Figure 10A), contradictory published experimental ex vivo and in vivo results suggest an investment in current laser-technology for bone cutting doubtful.

A total of 2 systematic reviews and 32 publications of experimental and clinical studies since 2006 – meeting the selection criteria of this critical review - do not provide even basic information on and results of standardized procedures with laser-types sold for and used in oral and maxillofacial surgery.

Too many parameters for the optimum setup of bone cutting lasers of each wavelength have to be taken into account to improve their performance over rotary instruments and might be corrupted by currently available laser technology.

Aside the specific infrared heat-wavelength of a laser-type, the performance of lasers on bone depend substantially on the infrared-heat-energy-density in the focus-spot, the time-span this energy is delivered on this focus-spot (pulse-duration), the geometry of the laser-pulse (sloped versus rectangular pulse = Q-switch) and the frequency the laser-pulse is delivered onto the bone (Figure 10B). Second, the type of delivery system of the infrared laser beam vastly influences the performance on bone: optical lenses and mirrors cause a divergence of the laser beam, leading to an unprecise focus-spot with varying diameters, which in the course of clinical work might completely counteract the desired effects on bone and revert them into increased heat-induced bone-necrosis as reported (Figure 3).

Fiber optical delivery can reduce the focusing problem (but not completely eliminate it), but once the fiber touches the bone, heat-coagulated fibrous tissue clots the optical fiber and corrupts the clean delivery of the laser-beam onto the bone. The plasma-plume, the photoacoustic and cavitation-effect might also splinter the polished surface of the fiber when it is made of quartz glasses.

Most of these technical problems in the application of laser-beams on bone were not taken into account in most experimental and clinical studies, which might explain the contradictory results even with lasers of a single type (e.g. Er:YAG-lasers). The majority of studies report substantial heat-induced bone-necrosis compared to rotary instruments. The desired heat induced cavitation-effect, with its characteristic loud and intermittent knocking sound and least undesired thermal side effects, is generated only with a precise focus spot (Figure 3, Figure 10B).

For the clinician, the daily routine of bone-cutting close to delicate soft-tissue-structures such as sinus-membrane, trigeminal nerves and major intrabony blood-vessels, is the major challenge. The complete lack of any type of depth-control of the laser-beam and its ability to cut through soft-tissues faster than through bone might make a laser – beside the high acquisition-cost - the least instrument of choice for osteotomies in the daily routine, especially for novices.

The construction-principles of piezotomes are subject to tight technical parameters: the oscillation rate is restricted to 28.000 – 36.000 modulated harmonic oscillations per second (28 -36 KHz) and the distance of physical movement between 60 and 200 µm, to achieve the least risk of soft-tissue damage by frequency and working-tip-design. The separation or ablation of bone is also based on the cavitation-effect, but contrary to lasers is not heat-induced but pressure induced at much lower temperatures (Fig. 6). Heat induced bone-necrosis only occurs when no or too little continuous irrigation is supplied to the working tip, too high manual pressure is exerted onto the handpiece by the surgeon or a faulty constructed piezoelectric device for bone cutting generates irregular and uncoordinated vibrations instead of modulated harmonic oscillations.

Beside significant lower acquisition cost (starting with 8.000 US$) compared to lasers, the surgeons investment in time to get acquainted with piezotome-surgical protocols seems to be a matter of a few training hours as studies report. Novices in oral and maxillofacial surgery achieve better results with piezotomes than with rotary instruments when it comes to delicate procedures such as sinuslifting and IAN-lateralization as this systematic review revealed.

Microscopically the surfaces of bone cuts with piezotomes are as sharp and clean as reported for lasers, but with significant less or no procedural iatrogenic bone-loss due to scalpel-thin working-tips attached to the handpiece and without signs of heat-induced bone-necrosis. Like lasers, piezotomes allow an individual precise straight or curved design of any osteotomy, tuned to the needs of individual surgical procedures. Furthermore, the use of piezotomes for bone cutting seems to improve bone healing although the precise mechanism is not clear until now.

The ability to perform lossless bone cuts with superior soft tissue preservation lead to new bone-preserving surgical protocols for all kinds and subspecialties of oral implantology and oral and maxillofacial surgery, as demonstrated by the author´s case-examples (Figures 11-13).

Both technologies for bone cutting – lasers and piezotomes – are significantly technology-sensitive: since the precision of the desired physical effects cannot be observed by the surgeon (lasers: precise focus-spot without divergence, precise and stable energy-density on the focus-spot, laser-pulse-characteristic/Q-switch, mechanical resistive and optical clean optical fibers; piezotomes: harmonic modulated oscillations, verified cavitation-effect at the acting part of each sold tip) enormous care has to be taken when considering a purchase without proof of these effects by the manufacturer.

Since this systematic review includes the most current and multidisciplinary literature and was not restricted to oral and maxillofacial surgery, experimental and clinical studies recommend piezotomes to be introduced as superior bone cutting tool also in ENT-, cosmetic - and neurosurgery for their proven property to reduce intrasurgical blood-loss, superior soft-tissue preservation and significantly reduced post-surgical morbidity.

Due to the lack of larger clinical split-mouth studies with precise and standardized surgical protocols for burs, lasers and piezotomes, evidence of improved bone healing in the clinical routine - as proven in experimental studies- is limited and cannot be answered by this review.

From the patient´s point of view, any surgical instrument and procedure, that might significantly reduce intrasurgical iatrogenic or procedural complications as mentioned above, will always be preferred. For the patient, the use of piezotomes implies less risk of iatrogenic lesions of the inferior alveolar nerve, mental nerve, sinus-membrane and major blood vessels and provides a proven significant reduction of post-surgical sequelae (trism, pain, edema), allowing the patient to proceed with regular activities sooner after surgeries.


Lasers in their variety of available wavelengths and application modes still lack evidence to establish them as a viable alternative to rotary instruments. Substantial research and development efforts as well as experimental and clinical studies are needed to define standards regarding power-density, laser-pulse duration and frequency and consistent focusing on bone to achieve better results than with rotary instruments in the clinical routine. If technological developments can overcome the major disadvantages of lasers – the complete lack of depth-control of any osteotomy and unacceptable risk of iatrogenic soft-tissue lesions – seems doubtful.

Piezotomes seem to inhere the potential to establish the new gold standard in bone cutting in the oral and maxillofacial surgeon’s clinical routine. Backed by experimental and clinical studies, piezotomes provide least thermal side effects on bone, a smooth osteotomy surface, improved bone-healing, and almost bone-lossless and precise osteotomy design with superior depth-control and soft-tissue protection. The reduced intrasurgical blood loss and significant reduction of post-surgical morbidity - when compared with rotary instruments – suggest piezotomes to be the instrument of choice also from the patient´s point of view. However, also for piezotomes further studies have to be undertaken to shed light on the molecular biologic mechanisms of the improved bone healing and to further optimize the oscillation-characteristics.

  1. Möhlhenrich SC, Modabber A, Steiner T, Mitchell DA, Hölzle F (2015) Heat generation and drill wear during dental implant site preparation: Systematic review. Br J Oral Maxillofac Surg 53: 679–689. Link:
  2. Siegel SC, von Fraunhofer JA (1999) Irrigating solution and pressure effects on tooth sectioning with surgical burs. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 87: 552–556. Link:
  3. Rood JP (1992) Permanent damage to inferior alveolar and lingual nerves during the removal of impacted mandibular third molars. Comparison of two methods of bone removal. Br Dent J 172:108–110. Link:
  4. Hogg NJ, Morrison AD (2005) Resterilization of instruments used in a hospital-based oral and maxillofacial surgery clinic. J Can Dent Assoc 71: 179–82. Link:
  5. Parker S (2007) Surgical lasers and hard dental tissue. Br Dent J 202: 445–454. Link:
  6. Colucci V, do Amaral FL, Pecora JD, Palma-Dibb RG, Corona SA (2009) Water flow on erbium: yttrium–aluminum–garnet laser irradiation: effects on dental tissues. Lasers Med Sci 24: 811–818. Link:
  7. Kautzky M, Troedhan A, Susani M, Schenk P (1991) Infrared laser stapedotomy. Eur Arch Oto-Rhino-Laryngology 248: 449–451. Link:
  8. Moslemi N, Shahnaz A, Masoumi S, Torabi S, Akbari S (2017) Laser-Assisted Osteotomy for Implant Site Preparation. Implant Dent 26: 129–136. Link:
  9. Pavlíková G, Foltán R, Horká M, Hanzelka T, Borunská H, et al. (2011) Piezosurgery in oral and maxillofacial surgery. Int J Oral Maxillofac Surg 40: 451–457. Link:
  10. Pereira CCS, Gealh WC, Meorin-Nogueira L, Garcia-Júnior IR, Okamoto R (2014) Piezosurgery Applied to Implant Dentistry: Clinical and Biological Aspects. J Oral Implantol 40: 401–408. Link:
  11. Agarwal E, Masamatti SS, Kumar A (2014) Escalating role of piezosurgery in dental therapeutics. J Clin Diagnostic Res 8: ZE08-ZE11. Link:
  12. Troedhan AC, Kurrek A, Wainwright M, Jank S (2010) Hydrodynamic Ultrasonic Sinus Floor Elevation-An Experimental Study in Sheep. J Oral Maxillofac Surg 68:1 125–1130 Link:
  13. Stoetzer M, Felgenträger D, Kampmann A, Schumann P, Rücker M, et al. (2014) Effects of a new piezoelectric device on periosteal microcirculation after subperiosteal preparation. Microvasc Res 94: 114–118. Link:
  14. Rajitha Gunaratne GD, Khan R, Fick D, Robertson B, Dahotre N, et al. (2017) A review of the physiological and histological effects of laser osteotomy. J Med Eng Technol 41: 1–12. Link:
  15. Moslemi N, Shahnaz A, Masoumi S, Torabi S, Akbari S (2017) Laser-Assisted Osteotomy for Implant Site Preparation. Implant Dent 26: 129–136. Link:
  16. Waechter J, Leite FR, Nascimento GG, Carmo Filho LC, Faot F (2017) The split crest technique and dental implants: a systematic review and meta-analysis. Int J Oral Maxillofac Surg 46: 116–128. Link:
  17. Wallace SS, Tarnow DP, Froum SJ, Cho SC, Zadeh HH, et al. (2012) Maxillary sinus elevation by lateral window approach: Evolution of technology and technique. J Evid Based Dent Pract 12: 161–171. Link:
  18. Atieh M, Alsabeeha N, Tawse-Smith A, Faggion C, Duncan W (2015) Piezoelectric Surgery vs Rotary Instruments for Lateral Maxillary Sinus Floor Elevation: A Systematic Review and Meta-Analysis of Intra- and Postoperative Complications. Int J Oral Maxillofac Implants 30: 1262–1271. Link:
  19. Alfawal AMH, Hajeer MY, Ajaj MA, Hamadah O, Brad B (2016) Effectiveness of minimally invasive surgical procedures in the acceleration of tooth movement: a systematic review and meta-analysis. Prog Orthod 17: 33. Link:
  20. Jiang Q, Qiu Y, Yang C, Yang J, Chen M, et al. (2015) Piezoelectric Versus Conventional Rotary Techniques for Impacted Third Molar Extraction. Medicine (Baltimore) 94: e1685. Link:
  21. Badenoch-Jones EK, David M, Lincoln T (2016) Piezoelectric compared with conventional rotary osteotomy for the prevention of postoperative sequelae and complications after surgical extraction of mandibular third molars: a systematic review and meta-analysis. Br J Oral Maxillofac Surg 54: 1066–1079. Link:
  22. Al-Moraissi EA, Elmansi YA, Al-Sharaee YA, Alrmali AE, Alkhutari AS (2016) Does the piezoelectric surgical technique produce fewer postoperative sequelae after lower third molar surgery than conventional rotary instruments? A systematic review and meta analysis. Int J Oral Maxillofac Surg 45: 383–391. Link:
  23. Farag A, Kellesarian S, Javed F, Arany S, Malmstrom H (2016) Efficacy of Piezosurgery versus Conventional Techniques in the Surgical Extraction of Third Molars : A Systematic Review. J Dent 2: 1015. Link:
  24. Magesty RA, Galvão L, De Castro Martins C, Rocha CR, Santos DCRR, et al. (2017) Rotary Instrument or Piezoelectric for the Removal of Third Molars: a Meta-Analysis. J Maxillofac Oral Surg 16: 13–21. Link:
  25. Lee SY, Piao C, Heo SJ, Koak JY, Lee JH, et al. (2010) A comparison of bone bed preparation with laser and conventional drill on the relationship between implant stability quotient (ISQ) values and implant insertion variables. J Adv Prosthodont 2: 148–153. Link:
  26. de Oliveira GJ, Rodrigues CN, Perussi LR, Rastelli AN, Marcantonio RA, et al. (2016) Effects on Bone Tissue After Osteotomy with Different High-Energy Lasers: An Ex Vivo Study. Photomed Laser Surg 34: 291–296. Link:
  27. Zhang YX, Xie S, Zhan Z, Zhao H, Guo J, et al. (2010) Evaluation of Er, Cr: YSGG laser for hard tissue ablation: an in vitro study. Front Optoelectron China 3: 291–296. Link:
  28. Panduric DG, Juric IB, Music S, Molčanov K, Sušic M, et al. (2014) Morphological and Ultrastructural Comparative Analysis of Bone Tissue After Er:YAG Laser and Surgical Drill Osteotomy. Photomed Laser Surg 32: 401-408 Link:
  29. Pandurić DG, Bago I, Katanec D, Žabkar J, Miletić I, et al. (2012) Comparison of Er:YAG Laser and surgical drill for osteotomy in oral surgery: An experimental study. J Oral Maxillofac Surg 70: 2515–2521. Link:
  30. Simonetti M, Facco G, Barberis F, Signorini G, Capurro M, et al. (2013) Bone characteristics following osteotomy surgery : an in vitro SEM study comparing traditional Lindemann drill with sonic and ultrasonic instruments. Poseido J 1: 187–194. Link:
  31. Sagheb K, Kumar V V, Azaripour A, Walter C, Al-Nawas B, et al. (2017) Comparison of conventional twist drill protocol and piezosurgery for implant insertion: an ex vivo study on different bone types. Clin Oral Implants Res 28: 207–213. Link:
  32. Scarano A, Cappucci C, Mancino C, Iezzi G, Sinjiari B, et al. (2011) Comparison of Conventional Drills and Ultrasonic Osteotomy for Dental Implant Site Preparation : a Histological Analysis in Bovine Ribs. Eur J Inflamm 9: 85–89. Link:
  33. Stelzle F, Frenkel C, Riemann M, Knipfer C, Stockmann P, et al. (2014) The effect of load on heat production, thermal effects and expenditure of time during implant site preparation–an experimental ex vivo comparison between. Clin Oral Implants Res 25: e140–148. Link:
  34. Rashad A, Sadr-Eshkevari P, Heiland M, Smeets R, Prochnow N, et al. (2015) Practitioner experience with sonic osteotomy compared to bur and ultrasonic saw: A pilot in vitro study. Int J Oral Maxillofac Surg 44: 203–208. Link:
  35. Heinemann F, Hasan I, Kunert-Keil C, Götz W, Gedrange T, et al. (2012) Experimental and histological investigations of the bone using two different Oscillating Osteotomy techniques compared with conventional rotary osteotomy. Ann Anat 194: 165–170. Link:
  36. Catros S, Montaudon M, Bou C, Da Costa Noble R, Fricain JC, et al. (2015) Comparison of Conventional Transcrestal Sinus Lift and Ultrasound-Enhanced Transcrestal Hydrodynamic Cavitational Sinus Lift for the Filling of Subantral Space: A Human Cadaver Study. J Oral Implantol 41: 657–661. Link:
  37. Jank S, Kurrek A, Wainwright M, Bek VE, Troedhan A (2011) Rupture length of the sinus membrane after 1.2 mm puncture and surgical sinus elevation: An experimental animal cadaver study. Oral Surgery, Oral Med Oral Pathol Oral Radiol Endodontology 112: 568–572. Link:
  38. Rashad A, Sadr-Eshkevari P, Heiland M, Smeets R, Hanken H, et al. (2015) Intraosseous heat generation during sonic, ultrasonic and conventional osteotomy. J Cranio-Maxillofacial Surg 43: 1072–1077. Link:
  39. Rashad A, Sadr-Eshkevari P, Weuster M, Schmitz I, Prochnow N, et al. (2013) Material attrition and bone micromorphology after conventional and ultrasonic implant site preparation. Clin Oral Implants Res 24: 110–114. Link:
  40. Seoane J, Lopez-Nino J, Garcia-Caballero L, Seoane-Romero JM, Tomas I, et al. (2013) Membrane perforation in sinus floor elevation–piezoelectric device versus conventional rotary instruments for osteotomy: an experimental study. Clin Implant Dent Relat Res 15: 867–873. Link:
  41. Maurer P, Kriwalsky MS, Block Veras R, Vogel J, Syrowatka F, et al. (2008) Micromorphometrical analysis of conventional osteotomy techniques and ultrasonic osteotomy at the rabbit skull. Clin Oral Implants Res 19: 570–575. Link:
  42. Perfetti G, De Tullio I, Berardi D, Di Iorio D, Spoto G, et al. (2012) Micromorphometrical and histological analyses using two different oscillating osteotomy techniques compared with conventional rotary osteotomy. J Biol Regul Homeost Agents 26: 81–88. Link:
  43. Gandhi SA, Baker JA, Bairam L, Kim H-I, Davis EL, et al. (2014) Primary Stability Comparison Using Piezoelectric or Conventional Implant Site Preparation Systems in Cancellous Bone. Implant Dent 23: 79–84. Link:
  44. Kühl S, Kirmeier R, Platzer S, Bianco N, Jakse N, et al. (2016) Transcrestal maxillary sinus augmentation: Summers’ versus a piezoelectric technique - an experimental cadaver study. Clin Oral Implants Res 27: 126–129. Link:
  45. Scarano A, Iezzi G, Perroti V, Tete S, Staiti G, et al. (2014) Ultrasonic versus drills implant site preparation: a histologic analysis in bovine ribs. J Craniofac Surg 25: 814–817. Link:
  46. Rashad A, Sadr-Eshkevari P, Heiland M, Smeets R, Prochnow N, et al. (2015) Practitioner experience with sonic osteotomy compared to bur and ultrasonic saw: A pilot in vitro study. Int J Oral Maxillofac Surg 44: 203–208. Link:
  47. Llopet J, Montaudon M, Guillaud E, Ella B. (2014) Comparison of 2 Crestal Sinus Floor Lift Techniques Performed on Human Cadavers. Implant Dent 23: 626–632. Link:
  48. Romeo U, del Vecchio A, Palaia G, Tenore G, Visca P, et al. (2009) Bone damage induced by different cutting instruments - An in vitro study. Braz Dent J 20: 162–168. Link:
  49. Matys J, Flieger R, Dominiak M. (2016) Assessment of Temperature Rise and Time of Alveolar Ridge Splitting by Means of Er:YAG Laser, Piezosurgery, and Surgical Saw: An Ex Vivo Study. Biomed Res Int 2016: 8p. Link:
  50. Hollstein S, Hoffmann E, Vogel J, Heyroth F, Prochnow N, et al. (2012) Micromorphometrical analyses of five different ultrasonic osteotomy devices at the rabbit skull. Clin Oral Implants Res 23: 713–718. Link:
  51. Bauer SEM, Romanos GE (2014) Morphological Characteristics of Osteotomies Using Different Piezosurgical Devices. A Scanning Electron Microscopic Evaluation. Implant Dent 23: 334–342. Link:
  52. Delgado-Ruiz RA, Sacks D, Palermo A, Calvo-Guirado JL, Perez-Albacete C, et al. (2016) Temperature and time variations during osteotomies performed with different piezosurgical devices: an in vitro study. Clin Oral Implants Res 27: 1137–1143. Link:
  53. Harder S, Wolfart S, Mehl C, Kern M (2009) Performance of ultrasonic devices for bone surgery and associated intraosseous temperature development. Int J Oral Maxillofac Implants 24: 484–490. Link:
  54. Stacchi C, Berton F, Turco G, Franco M, Navarra CO, et al. (2016) Micromorphometric analysis of bone blocks harvested with eight different ultrasonic and sonic devices for osseous surgery. J Cranio-Maxillofacial Surg 44: 1143–1151. Link:
  55. Jung M-K, Kim S-G, Oh J-S, Jin S-C, Lee S-Y, et al. (2012) A Comparative Histological Study of Bone Healing in Rat Calvarial Defect Using the Erbium-Doped Yttrium Aluminum Garnet Laser and Rotary Instruments. Jpn J Appl Phys 51: 01AE02. Link:
  56. Kuttenberger JJ, Waibel A, Stübinger S, Werner M, Klasing M, et al. (2010) Bone healing of the sheep tibia shaft after carbon dioxide laser osteotomy: Histological results. Lasers Med Sci 25: 239–249. Link:
  57. Cloutier M, Girard B, Peel SAF, Wilson D, Sándor GKB, et al. (2010) Calvarial bone wound healing: A comparison between carbide and diamond drills, Er:YAG and Femtosecond lasers with or without BMP-7. Oral Surgery, Oral Med Oral Pathol Oral Radiol Endodontology 110: 720–728. Link:
  58. De Mello EDA, Pagnoncelli RM, Munin E, Filho MSA, De Mello GPS, et al. (2008) Comparative histological analysis of bone healing of standardized bone defects performed with the Er:YAG laser and steel burs. Lasers Med Sci 23: 253–260. Link:
  59. Perussi LR, Pavone C, De Oliveira GJPL, Cerri PS, Marcantonio RAC (2012) Effects of the Er,Cr:YSGG laser on bone and soft tissue in a rat model. Lasers Med Sci 27: 95–102. Link:
  60. Esteves JC, de Souza Faloni AP, Macedo PD, Nakata PB, Chierici Marcantonio RA, et al. (2016) Effects on Bone Repair of Osteotomy With Drills or With Erbium, Chromium: Yttrium-Scandium-Gallium-Garnet Laser: Histomorphometric and Immunohistochemical Study. J Periodontol 87: 452–460. Link:
  61. Akyol UK, Güngörmüs M (2010) Er: YAG laser ablation of bone in experimental diabetics. Photomed Laser Surg 28: 477–482. Link:
  62. Lo DD, MacKanos MA, Chung MT, Hyun JS, Montoro DT, et al. (2012) Femtosecond plasma mediated laser ablation has advantages over mechanical osteotomy of cranial bone. Lasers Surg Med 44: 805–814. Link:
  63. Akyol UK, Güngörmüs M, Gündogdu C, Erdem H (2009) Histologic Evaluation of the Effects of Er : YAG Laser on Bone Ablation. J Contemp Dent Pract 10: 1–7. Link:
  64. Salina S, Maiorana C, Iezzi G, Colombo A, Fontana F, et al. (2006) Histological evaluation, in rabbit tibiae, of osseointegration of mini-implants in sites prepared with Er:YAG laser versus sites prepared with traditional burs. J Long Term Eff Med Implants 16: 145–156. Link:
  65. Schwarz F, Olivier W, Herten M, Sager M, Chaker A, et al. (2007) Influence of implant bed preparation using an Er:YAG laser on the osseointegration of titanium implants: A histomorphometrical study in dogs. J Oral Rehabil 34: 273–281. Link:
  66. Martins GL (2011) Bone Healing After Bur and Er: YAG Laser Ostectomies. J Oral Maxillofac Surg 69: 1214–1220. Link:
  67. Kesler G, Shvero DK, Tov YS, Romanos G (2011) Platelet Derived Growth Factor Secretion and Bone Healing After Er:YAG Laser Bone Irradiation. J Oral Implantol [Internet] 37: 195–204. Link:
  68. Sotsuka Y, Nishimoto S, Tsumano T, Kawai K, Ishise H, et al. (2014) The dawn of computer-assisted robotic osteotomy with ytterbium-doped fiber laser. Lasers Med Sci 29: 1125–1129. Link:
  69. Kesler G (2006) Use of Er: YAG Laser to Improve Osseointegration of Titanium Alloy Implants — A Comparison of Bone Healing. Int J Oral Maxillofac Implants 21: 375–379. Link:
  70. Saulacic N, Bosshardt DD, Jensen SS, Miron RJ, Gruber R, et al. (2015) Impact of bone graft harvesting techniques on bone formation and graft resorption: A histomorphometric study in the mandibles of minipigs. Clin Oral Implants Res 26: 383–391. Link:
  71. Reside J, Everett E, Padilla R, Arce R, Miguez P, et al. (2015) In vivo assessment of bone healing following piezotome ultrasonic instrumentation. Clin Implant Dent Relat Res 17: 384–394. Link:
  72. Mouraret S, Houschyar KS, Hunter DJ, Smith AA, Jew OS, et al. (2014) Cell viability after osteotomy and bone harvesting: Comparison of piezoelectric surgery and conventional bur. Int J Oral Maxillofac Surg 43: 966–971. Link:
  73. Preti G, Martinasso G, Peirone B, Navone R, Manzella C, et al. (2007) Cytokines and Growth Factors Involved in the Osseointegration of Oral Titanium Implants Positioned Using Piezoelectric Bone Surgery Versus a Drill Technique: A Pilot Study in Minipigs. J Periodontol 78: 716–22 Link:
  74. Esteves J, Marcantonio Jr E, de Souza Faloni A, Rocha FR, Marcantonio R, et al. (2013) Dynamics of bone healing after osteotomy with piezosurgery or conventional drilling – histomorphometrical, immunohistochemical, and molecular analysis. J Transl Med 11: 221. Link:
  75. Macedo NL, Monteiro ASF, Sato TP, Macedo LGS (2015) The effect of piezosurgery with cvd tip in osteotomy in rat parietal bone: histologic and histomorphometric analysis. Brazilian Dent Sci 18: 81–87. Link:
  76. Yang B-E, Girod S (2014) Efficacy of Bone Healing in Calvarial Defects Using Piezoelectric Surgical Instruments. J Craniofac Surg 25: 149–153. Link:
  77. Danjo A, Yamashita Y, Aijima R, Katsuki T, Goto M (2015) Histological evaluation of the bone healing by osteotomy with ultrasonic osteotomy devices. Int J Oral Maxillofac Surg 44: e51. Link:
  78. Trisi P, Carlesi T, Colagiovanni M, Falco A, Bovi M, et al. (2011) Ultrasonic vs. drill osteotomy. A clinical and histologic study in the sheep mandible. J Osteol Biomater 2: 21–31. Link:
  79. Sirolli M, Mafra CES, dos Santos RAB, Saraiva L, Holzhausen M, et al. (2016) Influence of piezosurgery on bone healing around titanium implants: A histological study in rats. Braz Dent J 27:278–283. Link:
  80. Matsuda H, Furuya Y, Sasaki H, Takanashi T, Morioka T, et al. (2015) Comparison of surface morphology and healing in rat calvaria bone defects between ultrasonic surgical method and rotary cutting method. J Hard Tissue Biol 24: 267–276. Link:
  81. Bengazi F, Lang NP, Canciani E, Viganò P, Velez JU, et al. (2014) Osseointegration of implants with dendrimers surface characteristics installed conventionally or with Piezosurgery®. A comparative study in the dog. Clin Oral Implants Res 25: 10–5. Link:
  82. Vercellotti T, Nevins ML, Kim DM, Nevins M, Wada K, et al. (2006) Osseous response following resective therapy with piezosurgery. Int J Periodontics Restorative Dent 26: 543–549. Link:
  83. Pavliková G, Foltán R, Burian M, Horká E, Adámek S, et al. (2011) Piezosurgery prevents brain tissue damage: an experimental study on a new rat model. Int J Oral Maxillofac Surg 40: 840–844. Link:
  84. Avila Kfouri F, Duailibi MT, Bretos JLG, Carvalho AB, Pallos D, et al. (2014) Piezoelectric osteotomy for the placement of titanium implants in rabbits: Histomorphometry study. Clin Oral Implants Res 25: 1182–1188. Link:            
  85. Ma L, Stübinger S, Liu XL, Schneider UA, Lang NP (2013) Healing of osteotomy sites applying either piezosurgery or two conventional saw blades: A pilot study in rabbits. Int Orthop 37: 1597–1603. Link:
  86. Ma L, Mattheos N, Sun Y, Liu XL, Yip Chui Y, et al. (2015) Wound healing of osteotomy defects prepared with piezo or conventional surgical instruments: a pilot study in rabbits. J Investig Clin Dent 6: 211–220. Link:
  87. Blaskovic M, Gabric D, Coleman NJ, Slipper IJ, Mladenov M, et al. (2016) Bone healing following different types of osteotomy: Scanning electron microscopy (SEM) and three-dimensional SEM analyses. Microsc Microanal 22: 1170–1178. Link:
  88. Stübinger S, Biermeier K, Bächi B, Ferguson SJ, Sader R, et al. (2010) Comparison of Er: YAG laser, piezoelectric, and drill osteotomy for dental implant site preparation: a biomechanical and histological analysis in sheep. Lasers Surg Med 42: 652–661. Link:
  89. Gabrić D, Blašković M, Gjorgijevska E, Mladenov M, Tašič B, et al. (2016) Evaluation of bone healing after osteotomies prepared with Er:YAG laser in contact and noncontact modes and piezosurgery - An animal study. J Oral Maxillofac Surg 74: 18–28. Link:
  90. Baek KW, Deibel W, Marinov D, Griessen M, Dard M, et al. (2015) A comparative investigation of bone surface after cutting with mechanical tools and Er:YAG laser. Lasers Surg Med 47: 426–432. Link:
  91. Stübinger S, Nuss K, Pongratz M, Price J, Sader R, et al. (2010) Comparison of Er: YAG laser and piezoelectric osteotomy: An animal study in sheep. Lasers Surg Med 42: 743–751. Link:
  92. Gabric D (2015) Evaluation of bone healing after osteotomies prepared with Er: YAG laser and piezosurgery using laser profilometry–an animal study. Clin Oral Implants Res 26(S12): 9. Link:
  93. Passi D, Pal US, Mohammad S, Singh RK, Mehrotra D, et al. (2013) Laser vs bur for bone cutting in impacted mandibular third molar surgery: A randomized controlled trial. J Oral Biol Craniofac Res 3: 57–62. Link:
  94. Romeo U, Libotte F, Palaia G, Tenore G, Galanakis A, et al. (2015) Is erbium:yttrium-aluminum-garnet laser versus conventional rotary osteotomy better in the postoperative period for lower third molar surgery? Randomized split-mouth clinical study. J Oral Maxillofac Surg 73: 211–218. Link:
  95. Grauvogel J, Scheiwe C, Kaminsky J (2011) Use of Piezosurgery for internal auditory canal drilling in acoustic neuroma surgery. Acta Neurochir (Wien) 153: 1941–1947. Link:
  96. Di Alberti L, Donnini F, Di Alberti C, Camerino M (2010) A comparative study of bone densitometry during osseointegration: piezoelectric surgery versus rotary protocols. Quintessence Int 41: 639–644. Link:
  97. Da Silva Neto UT, Joly JC, Gehrke SA (2014) Clinical analysis of the stability of dental implants after preparation of the site by conventional drilling or piezosurgery. Br J Oral Maxillofac Surg 52: 149–153. Link:
  98. Spinelli G, Valente D, Mannelli G, Raffaini M, Arcuri F (2017) Surgical management of ankyloses of the temporomandibular joint by a piezoelectric device. J Cranio-Maxillofacial Surg 45: 441–448. Link:
  99. Stacchi C, Vercellotti T, Torelli L, Furlan F, Di Lenarda R (2013) Changes in implant stability using different site preparation techniques: Twist drills versus piezosurgery. A single-blinded, randomized, controlled clinical trial. Clin Implant Dent Relat Res 15: 188–197. Link:
  100. Canullo L, Penarrocha D, Penarrocha M, Rocio AG, Penarrocha-Diago M (2014) Piezoelectric vs. conventional drilling in implant site preparation: Pilot controlled randomized clinical trial with crossover design. Clin Oral Implants Res 25: 1336–1343. Link:
  101. Nguyen V, von Krockow N, Weigl P, Depprich R (2016) Lateral Alveolar Ridge Expansion in the Anterior Maxilla Using Piezoelectric Surgery for Immediate Implant Placement. Int J Oral Maxillofac Implants 31: 687–699. Link:
  102. Peker Tekdal G, Bostanci N, Belibasakis GN, Gürkan A (2016) The effect of piezoelectric surgery implant osteotomy on radiological and molecular parameters of peri-implant crestal bone loss: A randomized, controlled, split-mouth trial. Clin Oral Implants Res 27: 535–544. Link:
  103. Spinato S, Rebaudi A, Bernardello F, Bertoldi C, Zaffe D (2016) Piezosurgical treatment of crestal bone: Quantitative comparison of post-extractive socket outcomes with those of traditional treatment. Clin Oral Implants Res 27: 361–366. Link:
  104. Majewski P (2014) Piezoelectric Surgery in Autogenous Bone Block Grafts. Int J Periodontics Restorative Dent [Internet] 34: 355–363. Link:
  105. Tsai SJ, Chen YL, Chang HH, Shyu YC, Lin CP (2012) Effect of piezoelectric instruments on healing propensity of alveolar sockets following mandibular third molar extraction. J Dent Sci 7: 296–300. Link:
  106. Tete S, Vinci R, Zizzari V, Cingano L, Bollero R, et al. (2009) Evaluation of effects on bone tissue of different osteotomy techniques. J Craniofac Surg 20: 1424–1429. Link:
  107. Gülnahar Y, Hüseyin Köşger H, Tutar Y (2013) A comparison of piezosurgery and conventional surgery by heat shock protein 70 expression. Int J Oral Maxillofac Surg 42: 508–510. Link:
  108. Rullo R, Addabbo F, Papaccio G, D’Aquino R, Festa VM (2013) Piezoelectric device vs. conventional rotative instruments in impacted third molar surgery: Relationships between surgical difficulty and postoperative pain with histological evaluations. J Cranio-Maxillofacial Surg 41: e33–e38. Link:
  109. Mantovani E, Arduino PG, Schierano G, Ferrero L, Gallesio G, et al. (2014) A split-mouth randomized clinical trial to evaluate the performance of Piezosurgery compared with traditional technique in lower wisdom tooth removal. J Oral Maxillofac Surg 72: 1890–1897. Link:
  110. Altiparmak N, Soydan SS, Uckan S (2015) The effect of conventional surgery and piezoelectric surgery bone harvesting techniques on the donor site morbidity of the mandibular ramus and symphysis. Int J Oral Maxillofac Surg 44: 1131–1137. Link:
  111. Wei LIU (2013) Clinical value of ultrasonic osteotomy in pulling out impacted wisdom tooth in the lower mandible. Pract J Clin Med 3:37. Link:
  112. Goyal M, Marya K, Jhamb A, Chawla S, Sonoo PR, et al. (2012) Comparative evaluation of surgical outcome after removal of impacted mandibular third molars using a Piezotome or a conventional handpiece: A prospective study. Br J Oral Maxillofac Surg 50: 556–561. Link:
  113. Spinelli G, Lazzeri D, Conti M, Agostini T, Mannelli G (2014) Comparison of piezosurgery and traditional saw in bimaxillary orthognathic surgery. J Cranio-Maxillofacial Surg 42: 1211–1220. Link:
  114. Chang HH, Lee MS, Hsu YC, Tsai SJ, Lin CP (2015) Comparison of clinical parameters and environmental noise levels between regular surgery and piezosurgery for extraction of impacted third molars. J Formos Med Assoc 114: 929–935. Link:
  115. Crippa B, Salzano FA, Mora R, Dellepiane M, Salami A, et al. (2011) Comparison of postoperative pain: Piezoelectric device versus microdrill. Eur Arch Oto-Rhino-Laryngology 268: 1279–1282. Link:
  116. Shirota T, Kamatani T, Yamaguchi T, Ogura H, Maki K, et al. (2014) Effectiveness of piezoelectric surgery in reducing surgical complications after bilateral sagittal split osteotomy. Br J Oral Maxillofac Surg 52: 219–222. Link:
  117. Landes CA, Stübinger S, Ballon A, Sader R (2008) Piezoosteotomy in orthognathic surgery versus conventional saw and chisel osteotomy. Oral Maxillofac Surg 12: 139–147. Link:
  118. Li X, Yan-Fang D, Pei-Zhen H (2013) Application of piezosurgery in the extraction of mandibular impacted wisdom tooth close to neural tube and nursing care. J Qilu Nurs 12:15. Link:
  119. Gao Y, Lin Z, Rodella LF, Buffoli B, Wu X, et al. (2014) Piezoelectric ultrasonic bone surgery system in the extraction surgery of supernumerary teeth. J Cranio-Maxillofacial Surg 42: 1577–1582. Link:
  120. Troedhan A, Kurrek A, Wainwright M (2011) Ultrasonic piezotome surgery: is it a benefit for our patients and does it extend surgery time? A retrospective comparative study on the removal of 100 impacted mandibular 3rd molars. Open J Stomatol 1: 179–184. Link:
  121. Landes CA, Stübinger S, Ballon A, Sader R (2008) Piezoosteotomy in orthognathic surgery versus conventional saw and chisel osteotomy. Oral Maxillofac Surg 12: 139–147. Link:
  122. Monnazzi MS, Real Gabrielli MF, Passeri LA, Cabrini Gabrielli MA, Spin-Neto R, et al. (2014) Inferior alveolar nerve function after sagittal split osteotomy by reciprocating saw or piezosurgery instrument: Prospective double-blinded study. J Oral Maxillofac Surg 72: 1168–1172. Link:
  123. Piersanti L, Dilorenzo M, Monaco G, Marchetti C (2014) Piezosurgery or conventional rotatory instruments for inferior third molar extractions? J Oral Maxillofac Surg 72: 1647–1652. Link:
  124. Guo Z, Zhang H, Li Y, Li X, Liu Y, et al. (2012) Comparative study of complications among routine method,high speed turbine handpiece and piezosurgery device after extraction of impacted wisdom teeth. Shanghai Kou Qiang Yi Xue 21: 208–210. Link:
  125. Rana M, Gellrich N, Rana M, Piffkó J (2013) Evaluation of surgically assisted rapid maxillary expansion with piezosurgery versus oscillating saw and chisel osteotomy-a randomized prospective trial. Trials 14: 49. Link:
  126. Bertossi D, Lucchese A, Alabanese M, Turra M, Faccioni F, et al. (2013) Piezosurgery versus conventional osteotomy in orthognathic surgery: a paradigm shift in treatment. J Craniofac Surg 24: 1763–1766. Link:
  127. Troedhan A (2016) Piezotome Rhinoplasty Reduces Postsurgical Morbidity and Enhances Patient Satisfaction: A Multidisciplinary Clinical Study. J Oral Maxillofac Surg 74: 1659.e1-1659.e11. Link:
  128. Mistry FK, Hegde ND, Hegde MN (2016) Postsurgical consequences in lower third molar surgical extraction using micromotor and piezosurgery. Ann Maxillofac Surg 6: 251–259. Link:
  129. Sivolella S, Berengo M, Bressan E, Di Fiore A, Stellini E (2011) Osteotomy for lower third molar germectomy: Randomized prospective crossover clinical study comparing piezosurgery and conventional rotatory osteotomy. J Oral Maxillofac Surg 69: e15–23. Link:
  130. Felice P, Balercia A, Pistilli R, Tuci L, Barausse C, et al. (2016) Conventional drills versus ultrasonic preparation for placement of zygomatic implants: a 4-month post-loading split-mouth randomised controlled trial. Clin Oral Implants Res 27: 273. Link:
  131. Pappalardo S, Guarnieri R (2014) Randomized clinical study comparing piezosurgery and conventional rotatory surgery in mandibular cyst enucleation. J Cranio-Maxillofacial Surg 42: e80–e85. Link:
  132. Arakji H, Shokry M, Aboelsaad N (2016) Comparison of Piezosurgery and Conventional Rotary Instruments for Removal of Impacted Mandibular Third Molars: A Randomized Controlled Clinical and Radiographic Trial. Int J Dent 2016: 7p. Link:
  133. Tirelli G, Tofanelli M, Bullo F, Bianchi M, Robiony M (2015) External osteotomy in rhinoplasty: Piezosurgery vs osteotome. Am J Otolaryngol - Head Neck Med Surg 36: 666–671. Link:
  134. Delilbasi C, Gurler G (2013) Comparison of Piezosurgery and Conventional Rotative Instruments in Direct Sinus Lifting. Implant Dent 22: 662–5. Link:
  135. Spinelli G, Mannelli G, Zhang YX, Lazzeri D, Spacca B, et al. (2015) Complex craniofacial advancement in paediatric patients: Piezoelectric and traditional technique evaluation. J Cranio-Maxillofacial Surg 43: 1422–1427. Link:
  136. Mozzati M, Gallesio G, Russo A, Staiti G, Mortellaro C (2014) Third-Molar Extraction With Ultrasound Bone Surgery. J Craniofac Surg. 25: 856–859. Link:
  137. Gilles R, Couvreur T, Dammous S (2013) Ultrasonic orthognathic surgery: Enhancements to established osteotomies. Int J Oral Maxillofac Surg 42: 981–987. Link:
  138. Cassetta M, Di Carlo S, Giansanti M, Pompa V, Pompa G, et al. (2012) The impact of osteotomy technique for corticotomy-assisted orthodontic treatment (CAOT) on oral health-related quality of life. Eur Rev Med Pharmacol Sci 16: 1735–1740. Link:
  139. Toscano NJ, Holtzclaw D, Rosen PS (2010) The Effect of Piezoelectric Use on Open Sinus Lift Perforation: A Retrospective Evaluation of 56 Consecutively Treated Cases From Private Practices. J Periodontol 81: 167–171. Link:
  140. Peñarrocha-Diago M, Peñarrocha-Diago M, Sanchez-Recio C, Peñarrocha-Oltra D, Romero-Millán J (2012) Osteotomy in direct sinus lift. A comparative study of the rotary technique and ultrasound. Med Oral Patol Oral Cir Bucal 17: e457. Link:
  141. Barone A, Santini S, Marconcini S, Giacomelli L, Gherlone E, et al. (2008) Osteotomy and membrane elevation during the maxillary sinus augmentation procedure. Clin Oral Implants Res 19: 511–515. Link:
  142. Atari M, Chatakun P, Ortiz O, Mañes A, Gil-Recio C, et al. (2011) Viability of maxillary bone harvesting by using different osteotomy techniques. a pilot study. Histol Histopathol 26: 1575–1583. Link:
  143. Smeets R, Henningsen A, Jung O, Heiland M, Hammächer C, et al. (2014) Definition, etiology, prevention and treatment of peri-implantitis--a review. Head Face Med 10: 34. Link:
© 2017 Troedhan A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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