Title	Piezoelectric Surgery in Craniofacial Anomaly Reconstruction Improves Clinical Outcomes
Clinical Question	In patients with craniofacial anomalies such as cleft palate, does piezoelectric surgery compared to conventional techniques improve postoperative results?
Clinical Bottom Line	The use of piezoelectric scalpels in reconstruction of craniofacial anomalies has unique advantages over conventional techniques, namely less pain and adjacent tissue damage, while providing better esthetic outcomes. This newer technique has proven to be remarkably beneficial for both patient and surgeon when other events cause a need for craniofacial surgery, such as trauma. Yet, higher quality clinical evidence in long-term studies is needed to support current findings specifically for this patient group.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 32320977 Tsikopoulos/2020 347 patients undergoing lateral nasal osteotomies due to trauma Systematic review of randomized trials Key results Conventional osteotomy significantly increased the risk of intraoperative mucosal injury as compared to the piezoelectric technique (OR = 16.67). Favoring group P, eyelid edema as measured on a 4-grade visual scale on postoperative day 3 had an SMD = -0.65 (95% CI = -1.18, -0.12; p = 0.02; I² = 69%). Periorbital ecchymosis as measured on a 3-point scale on postop day 7 had an SMD = -0.52 (95% CI = -0.79, -0.24; p = 0.0003; I² = 71%). Postop pain as measured on a 10-point visual analog scale within the first 3 days had an SMD = -0.99 (CI = -1.78, -0.11; p = 0.01; I² = 49%). 30228982 Rullo/2018 20 patients age 18-24 years old undergoing secondary cleft surgery needing dental implant(s) Case Control Study Key results Postop bone graft volume at 8 months for group P was 1.03 cm³ (SD = 0.51 cm³); group C was 0.88 cm³ (SD = 0.46 cm³). Histology: transition between graft and host bone for group P was “well-organized and well-vascularized bone with a homogeneous appearance even at the level of the [transition] point;” and for group C was “mature bone but with less homogeneous points with the recipient site.” Measured on a 10-point visual analogue scale, postop day 3 pain at the donor site for group P was 3.18 (SD = 0.72); for group C was 4.41 (SD = 0.61). Postop day 3 pain at the receiving site for group P was 2.18 (SD = 0.63); for group C was 3.11 (SD = 0.51). Assessed using a 5-point scale created by Landry et al., soft tissue healing score range at 1 week postop for group P was 3.8-4.6; for group C, 3.1-4.2. 37229805 Thomson/2023 40 patients ages 16-44 years old undergoing secondary cleft rhinoplasty Case Control Study Key results Mean operative time for group P was 229 min; for group C, 217 min. The piezotome minimized soft tissue trauma with a unique atraumatic drilling process, even with more open dissections. This technique allowed for a greater graft harvest from the septal graft. Also, more fine bony adjustments were performed, yielding a better medialization of bony side walls. All of these findings in comparison to using the conventional osteotome provided more esthetic outcomes in these patients.
Evidence Search	piezoelectric AND (conventional OR traditional) AND (cleft OR craniofacial (deformities OR anomalies)); also looked through reference articles of articles found through method described.
Comments on The Evidence	Tsikopoulos et al. systematically reviewed the literature through August 2019. Three databases were searched (PubMed, CENTRAL, and Web of Science) along with ClinicalTrials.gov. PRISMA guidelines were followed, using specific key terms provided in their search. The Cochrane Collaboration’s risk bias tool was used to assess the quality of each trial. Only RCTs that had either low or unclear overall risk of bias on piezoelectric lateral osteotomy in rhinoplasty compared to conventional osteotomy were included. Moderate and substantial heterogeneity was seen in their results. Rullo et al. performed a retrospective analysis on 20 of their patients with orofacial clefts from 2014 to 2017 with half receiving bone grafts via piezoelectric surgery and the other half via a bur, all performed by the same surgeon. All patients in both groups had the same classification of cleft palate and were non-smokers that were evaluated with CBC, liver markers, and IgE to make sure they were in good overall health. The patients ranged in age from 18-24 years with 12 boys and 8 girls. Postoperative bone graft volume, histology of the graft-host bone transition, postop pain at 3 days at the donor and receiving sites, postop inflammation, and postop soft tissue healing at 1 week were all evaluated the same way for each patient. Radiographic and histologic follow-up at 8 months were performed. Thomson et al. performed a retrospective analysis on 40 of their patients with orofacial clefts undergoing secondary cleft rhinoplasty over a 5-year period via the same surgeon using either piezoelectric or conventional techniques. All data was collected in the same way via patients’ case notes and included demographics, cleft type, operative time, postoperative complications, and the need for revision or not. Follow-up averaged 10.7 months for the piezoelectric group and 21 months for the conventional group.
Applicability	The Tsikopoulos review showed that even with different patients across many studies, piezoelectric surgery has many benefits over conventional techniques. Although it focused on patients undergoing surgery because of trauma, the same tools were used in the same craniofacial region as would be used for craniofacial deformity reconstruction. Thus, this systematic review provides context as to why piezoelectric scalpels are being evaluated for use in new patient populations. Preferably, a 1-10 scale that the patients answered postoperatively asking about how much they liked the esthetics of the outcome would have been helpful to include, as this is an important component of these procedures that was not addressed. Significant differences in favor of piezoelectric surgery included decreased risk of intramucosal injury, postoperative eyelid edema, periorbital ecchymoses, and pain. The Rullo case-control study included a patient group with a narrow age range who all needed at least one dental implant. Bone volume was significantly improved when using the piezoelectric scalpel, although the amount was clinically minimal. Histologically, the transition between graft and host bone was improved, and postoperative pain in the donor and recipient site was significantly lower, as well as inflammation. They discussed how the technique has increased cutting safety in more difficult-to-access locations, minimizing trauma for patients while maximizing surgical control and generating a timelier healing response. The Thomson case-control study focused on patients undergoing secondary cleft surgery but with a broader age range. Although the mean operative time was on average 12 minutes longer with the piezoelectric technique, the scalpel minimized soft tissue trauma with a unique drilling process, even with a more open dissection. Also, finer bony adjustments when undergoing medialization of bony side walls were achieved, leading to better esthetic results. Overall, piezoelectric surgery in patients with craniofacial deformities is a technique to be considered, although more high-evidence research that is specific to this patient population is needed. Increased cost and a steep learning curve for the operator may hinder the adoption of this technology, but the increased control felt by the surgeon intraoperatively, as well as the decreased trauma to adjacent tissues and thus postoperative pain, may outweigh the costs.
Specialty	(Oral Surgery)
Keywords	Craniofacial deformities, clefts, piezoelectric, reconstruction
ID#	3561
Date of submission	06/08/2024
E-mail	hakalah@livemail.uthscsa.edu
Author	Houston Hakala
Co-author(s)	Nathan Yang
Co-author(s) e-mail	yangn@livemail.uthscsa.edu
Faculty mentor	Kelly C. Lemke, DDS, MS
Faculty mentor e-mail	lemkek@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available