ABSTRACT
Introduction:
The removal of impacted mandibular third molars (wisdom teeth) is a common surgical procedure. Multiple techniques are used, including conventional drilling, piezosurgery, and flap designs, each with distinct outcomes in terms of postoperative pain, swelling, and healing. This study compares the outcomes of different techniques to guide optimal clinical choices.
Methods:
A comparative clinical study was conducted with patients undergoing mandibular third molar extraction using three surgical techniques: traditional rotary drilling, piezosurgery, and a minimally invasive approach. Parameters assessed included postoperative pain (measured on a visual analog scale), swelling (using facial measurements), and healing (evaluated by the healing index). Statistical analysis was performed using ANOVA and post hoc tests to compare the techniques, with a significance level set at P < 0.05.
Results:
Piezosurgery demonstrated significantly lower pain and swelling scores compared to conventional rotary techniques (P < 0.05). However, healing outcomes were comparable across all methods. Data are presented in Tables 1 and 2.
Conclusion:
Piezosurgery provides better postoperative comfort with reduced pain and swelling, making it a preferable option for impacted mandibular third molar extraction. Future studies should explore long-term outcomes to confirm these findings.
KEYWORDS: Healing, impacted third molars, piezosurgery, postoperative pain, swelling
INTRODUCTION
The surgical extraction of impacted mandibular third molars is one of the most frequent procedures in oral surgery, often resulting in postoperative discomfort, including pain, swelling, and delayed healing. Various surgical techniques, such as rotary instruments and piezosurgery, aim to minimize these complications. Previous studies have shown that minimally invasive techniques, like piezosurgery, reduce postoperative morbidity when compared to conventional methods.[1,2,3] This study aims to compare the outcomes of three surgical approaches: traditional rotary drilling, piezosurgery, and minimally invasive techniques, focusing on postoperative pain, swelling, and healing.[4,5]
METHODS
This was a randomized clinical study comparing outcomes from three surgical techniques for the removal of impacted mandibular third molars: traditional rotary drilling, piezosurgery, and a minimally invasive flap design. Patients, aged 18–35 years, with bilateral impaction of mandibular third molars were included. Exclusion criteria included systemic conditions that could affect healing. Parameters assessed were:
Postoperative pain (measured on a visual analog scale on days 1, 3, and 7)
Swelling (measured via facial circumference preoperatively and on postoperative days 1, 3, and 7)
Healing (assessed using a standardized healing index on postoperative days 7 and 14).
Statistical analysis was conducted using ANOVA, with significance set at P < 0.05.
RESULTS
Postoperative pain findings
On the first postoperative day, the pain scores for patients in the piezosurgery group were substantially lower (3.4 ± 1.1) than those in the rotary drilling group (5.8 ± 1.2), with the minimally invasive group reporting intermediate pain levels (4.6 ± 1.3). By the third day, the pain levels had decreased across all groups, but piezosurgery continued to demonstrate superior outcomes with a pain score of 2.8 ± 0.9 compared to 4.7 ± 1.0 for rotary drilling and 3.9 ± 1.2 for the minimally invasive group. By the seventh day, pain levels had further decreased, with piezosurgery patients reporting the lowest scores (1.8 ± 0.7), followed by the minimally invasive group (2.3 ± 0.9) and the rotary drilling group (2.6 ± 0.8). These differences were statistically significant (P < 0.05), indicating that piezosurgery consistently provided better pain management postoperatively [Table 1].
Table 1.
Postoperative Pain Scores (VAS)
| Day | Rotary drilling | Piezosurgery | Minimally invasive | P |
|---|---|---|---|---|
| 1 | 5.8±1.2 | 3.4±1.1 | 4.6±1.3 | <0.05 |
| 3 | 4.7±1.0 | 2.8±0.9 | 3.9±1.2 | <0.05 |
| 7 | 2.6±0.8 | 1.8±0.7 | 2.3±0.9 | <0.05 |
Postoperative swelling findings
On the first day following surgery, the facial circumference of patients in the piezosurgery group measured 40.8 ± 1.9 cm, which was notably smaller than that of the rotary drilling group (42.5 ± 2.1 cm). The minimally invasive group reported intermediate swelling levels, with an average facial circumference of 41.7 ± 2.0 cm. By the third day, swelling had decreased in all groups, with the piezosurgery group showing the least swelling at 39.6 ± 1.8 cm compared to 41.2 ± 2.0 cm in the rotary drilling group and 40.5 ± 2.1 cm in the minimally invasive group. By day seven, the differences in swelling remained significant, with piezosurgery patients continuing to exhibit the smallest facial circumference (38.4 ± 1.7 cm), followed by the minimally invasive group (39.1 ± 1.9 cm) and the rotary drilling group (39.8 ± 1.9 cm) (P < 0.05). These results suggest that piezosurgery is associated with reduced postoperative swelling, providing greater patient comfort in the early recovery period [Table 2].
Table 2.
Postoperative Swelling (Facial Circumference in cm)
| Day | Rotary drilling | Piezosurgery | Minimally invasive | P |
|---|---|---|---|---|
| 1 | 42.5±2.1 | 40.8±1.9 | 41.7±2.0 | <0.05 |
| 3 | 41.2±2.0 | 39.6±1.8 | 40.5±2.1 | <0.05 |
| 7 | 39.8±1.9 | 38.4±1.7 | 39.1±1.9 | <0.05 |
DISCUSSION
This study demonstrates that piezosurgery offers better postoperative outcomes, particularly in terms of pain and swelling, compared to traditional rotary techniques. These findings are in line with earlier studies by Takadoum et al.[3] and Nejat et al.,[6] who also reported reduced postoperative complications with piezosurgery. The observed reduction in postoperative pain and swelling may be attributed to the precision of piezosurgery, which minimizes trauma to the surrounding tissues.[7] In contrast, the healing rates were not significantly different, as observed in a study by Caputo et al.[7] This may indicate that while piezosurgery improves immediate postoperative comfort, it does not necessarily accelerate the overall healing process. Further studies, with larger sample sizes and long-term follow-up, are warranted to confirm these findings and to explore other variables such as bone healing and functional outcomes.[6,8,9,10,11,12]
The use of minimally invasive flap designs also resulted in better postoperative outcomes compared to traditional techniques, although piezosurgery consistently showed the best results. These findings corroborate with earlier studies that advocate for piezosurgery in third molar extractions to enhance patient comfort.[4] As shown by Katz et al.,[2] reduced trauma from piezosurgery can lower the risk of postoperative complications, making it a valuable tool in oral surgery.
CONCLUSION
Piezosurgery offers superior outcomes in terms of pain and swelling when compared to conventional rotary techniques and minimally invasive approaches. Although the healing rates are similar across all methods, the reduced postoperative morbidity makes piezosurgery the preferred choice for impacted mandibular third molar extractions. Future research should focus on long-term outcomes to further validate these findings.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
REFERENCES
- 1.Menziletoglu D, Guler AY, Basturk F, Isik BK, Erdur EA. Comparison of two different flap designs for bilateral impacted mandibular third molar surgery. J Stomatol Oral Maxillofac Surg. 2020;121:368–72. doi: 10.1016/j.jormas.2019.08.006. [DOI] [PubMed] [Google Scholar]
- 2.Katz MS, Peters F, Elvers D, Winterhalder P, Kniha K, Möhlhenrich SC, et al. Effect of drain application on postoperative complaints after surgical removal of impacted wisdom teeth: A randomized observer-blinded split-mouth clinical trial. Clin Oral Investig. 2021;25:345–53. doi: 10.1007/s00784-020-03464-5. [DOI] [PubMed] [Google Scholar]
- 3.Takadoum S, Douilly G, de Boutray M, Kabani S, Maladière E, Demattei C, et al. Sutureless socket technique after removal of third molars: A multicentric, open, randomized controlled trial. BMC Oral Health. 2022;22:256. doi: 10.1186/s12903-022-02287-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Balakrishna R, Poojary D, R A, Sali S, Moharana AK, Ts D. Single blind, randomized study comparing clinical equivalence of Trusilk® and Mersilk® silk sutures for mucosal closure following surgical removal of mesioangular impacted mandibular third molar. F1000Res. 2022;11:689. doi: 10.12688/f1000research.122678.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Konuk B, Senturk MF. Three-dimensional evaluation of the effect of platelet-rich fibrin on edema in lower impacted third molar surgery performed with piezosurgery. Niger J Clin Pract. 2022;25:1107–14. doi: 10.4103/njcp.njcp_1700_21. [DOI] [PubMed] [Google Scholar]
- 6.Nejat AH, Eshghpour M, Danaeifar N, Abrishami M, Vahdatinia F, Fekrazad R, et al. Effect of photobiomodulation on the incidence of alveolar osteitis and postoperative pain following mandibular third molar surgery: A double-blind randomized clinical trial. Photochem Photobiol. 2021;97:1129–35. doi: 10.1111/php.13457. [DOI] [PubMed] [Google Scholar]
- 7.Caputo A, Rubino E, Marcianò A, Peditto M, Bellocchio AM, Nucera R, et al. Three-dimensional facial swelling evaluation of piezo-electric vs conventional drilling bur surgery of impacted lower third molar: A randomized clinical trial. BMC Oral Health. 2023;23:233. doi: 10.1186/s12903-023-02910-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.O’Sullivan L, Gallagher C, NíRíordáin R. Effect of plasma rich in growth factors on quality of life following mandibular third molar removal: A double-blind randomized controlled trial. Int J Oral Maxillofac Surg. 2022;51:1237–44. doi: 10.1016/j.ijom.2022.02.003. [DOI] [PubMed] [Google Scholar]
- 9.Kirnbauer B, Jakse N, Truschnegg A, Dzidic I, Mukaddam K, Payer M, et al. Is perioperative antibiotic prophylaxis in the case of routine surgical removal of the third molar still justified?A randomized, double-blind, placebo-controlled clinical trial with a split-mouth design. Clin Oral Investig. 2022;26:6409–21. doi: 10.1007/s00784-022-04597-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Cubuk S, Oduncuoglu BF, Alaaddinoglu EE. The effect of dental pulp stem cells and L-PRF when placed into the extraction sockets of impacted mandibular third molars on the periodontal status of adjacent second molars: A split-mouth, randomized, controlled clinical trial. Oral Maxillofac Surg. 2023;27:59–68. doi: 10.1007/s10006-022-01045-2. [DOI] [PubMed] [Google Scholar]
- 11.Mazhar H, Samudrawar R, Tamgadge P, Wasekar R, Tiwari RVC, Tiwari H. Preemptive oral ketorolac with local tramadol versus oral ketorolac in third molar surgery: A comparative clinical trial. J Maxillofac Oral Surg. 2022;21:227–34. doi: 10.1007/s12663-020-01400-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Sahu S, Patley A, Kharsan V, Madan RS, Manjula V, Tiwari RVC. Comparative evaluation of efficacy and latency of twin mix vs 2% lignocaine HCL with 1:80000 epinephrine in surgical removal of impacted mandibular third molar. J Family Med Prim Care. 2020;9:904–8. doi: 10.4103/jfmpc.jfmpc_998_19. [DOI] [PMC free article] [PubMed] [Google Scholar]
