Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Bone Flap Technique With Piezosurgery for Impacted Teeth Extraction and Bone Cysts Removal Without Additional Fixation Hu ¨seyin Akc ¸ay, DDS, PhD, Birkan Tatar, DDS, Keremcan Kuru, DDS, O ¨ zgu ¨r Go ¨zlu ¨klu ¨, DDS, and Murat Ulu, DDS, PhD Abstract: To explore a new surgical approach for impacted teeth extraction and cystectomy using piezosurgery that provides proper bone healing in normal anatomical structure without additional fixation and graft materials. In cases with intact and relatively thicker vestibular compact bone, a bone flap design was used with converging osteotomy lines made with piezosurgery tips which allow proper stabilization after enucleation or extraction. Procedure was performed in 10 patients with 9 to 36 months follow-up resulted in satisfactory healing without any complications. Comparing to traditional techniques, effective enucleation and accelerated bone regeneration are achieved, with reduced risk of complications, operation time, and costs. Key Words: Cystectomy, impacted tooth, osteotomy, piezosurgery I mpacted tooth removal is one of the most common oral surgical procedures performed due to the complexity of development and eruption process. 1 Special attention was paid to the positioning of mandibular third molars because of the close relation to the mandibular canal, sometimes exhibiting direct contact. 2 Odontogenic and nonodontogenic cysts are also common lesions in the maxillofacial region. 3 Inflammatory radicular and residual cysts are the most common forms of maxillofacial cysts. 4 Clinicians prefer a surgical technique include cystectomy, cystotomy or a staged combination of both depending on cyst dimensions, patient’s age, and relation to critical anatomic regions. 5 Partsch as ‘‘cystec- tomy’’ first described the treatment of cysts, consisted in enucle- ation of the cysts and watertight primary closure. The procedure is applied by complete removal of the cyst epithelium and primary closure of the cavity. 6 Enucleation can be more difficult and time consuming as a result of manipulation problems and the need of protecting nearby anatomic structures. 7,8 Sometimes enucleation treatment with large cavities may cause compromising mandibular strength and functions. 9 In recent years, authors have suggested the use of additional graft biomaterials in cyst cavity as a filling immediately after enucleation. Thus, bone regeneration was accelerated and soft tissue migration into cyst cavity was prevented. 10 In conventional techniques, a large bone window could be necessary for enough access to cyst cavity and an effective enucleation which causes soft tissue migration into cyst cavity that negates healing process and reduces the bone volume. Consequently, detailed augmentation procedures like titanium mesh and autogenous bone block were needed sometimes which increase the costs and risk of complica- tions such as infections and wound exposure. In cases of mandibular cysts with intact vestibular wall, osteotomy of access performed with piezosurgery is efficient for preserving vestibular bone block. In this technical report, we described a technique that soft tissue migration is prevented without any additional biomaterial. Rotating instruments and oscillating saws used in traditional techniques are highly effective in cutting bone tissue; however, these instruments are not selective for bone, so significant damage of surrounding soft tissues, especially nerves may occur. 10 Piezo- surgery is an encouraging, sensitive, and hard tissue selective system for osteotomies and may be considered convenient in interventions such as mandibular cyst operations which require gentle manipulation. 5 Using piezosurgery allows to perform thinner and more stable bone cuts compared to traditional systems. Piezo- surgery facilitates minimal intraoperative hemorrhage, providing a better vision of the surgical area and ensures to perform osteotomies through a selective cutting without any necrosis layer caused by overheating or neural damage. 11,12 Moreover, histologic and his- tomorphometric parameters of wound healing and bone regenera- tion in experimental animal models has shown that tissue response is more favorable in piezosurgery than it is in traditional bone- cutting methods with diamond or carbide rotary instruments. 13 In this technical report, we presented 3 cases which were treated with piezosurgery that allows to resect the vestibular bone flap as one block and to reconstruct the original anatomy of the surgical site, by the precise repositioning of the bone block before wound closure. Thus, bone regeneration was accelerated, soft tissue col- lapsed, and so large bone defects were prevented. METHODS A total of 10 systematically healthy patients were included in this study whom applied to Department of Oral and Maxillofacial Surgery of Izmir Katip C ¸ elebi University between February, 2014 and January, 2017. Their ages ranged between 19 and 62 years with an average age of 41. Three of the patients (2 females and 1 male) were suffering from impacted tooth in close proximity to the inferior alveolar nerve and 7 patients (3 females and 4 males) had a cystic bone lesion, the smallest lesion being 1.3 cm in diameter and the largest 6 cm. After regular examinations, cystic lesions and symptomatic impacted teeth were realized and referred to our Oral and Maxillo- facial Surgery Department. Initial radiologic examinations were performed with orthopantomograph. After large-sized cystic lesions or impacted teeth which have close relation with inferior alveolar nerve were realized, patients referred to cone-beam computed tomography (CBCT) for 3D evaluation of the surrounding bone structure that revealed radiolucencies extending longitudinally in mandible. After realizing that the vestibular compact bone was intact and thick enough, enucleation with vestibular approach of lesions by preserving vestibular bone block was decided. Same conservative technique was also used for impacted tooth extractions which were tend to cause loss of large amounts of bone structure. All patients were informed about surgical procedures and pos- sible complications, and their informed consents were taken. From the Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Izmir Katip Celebi University, Izmir, Turkey. Received June 6, 2018. Accepted for publication July 10, 2018. Address correspondence and reprint requests to Birkan Tatar, MD, Aydinlikevler mah Cemil Meric Cad IKCU Dis Hek Fak Agiz, Dis ve Cene Cerrahisi, 35640 Cigli/IZMIR, Turkey; E-mail: birkantatar@hotmail.com The authors report no conflicts of interest. Copyright # 2018 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000004913 BRIEF CLINICAL STUDIES The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2018 1