Piezosurgery for safe and efficient petrous bone cutting in cerebellopontine angle and petroclival meningioma surgery.

Intradural petrous bone drilling has become a widespread practice, providing extended exposure in the removal of cerebellopontine angle (CPA) or petroclival tumors. Adjacent neurovascular structures are at risk, however, when drilling is performed in this deep and narrow area. Hence, this study evaluates the use of Piezosurgery (PS) as a non-rotating tool for selective bone cutting in CPA surgery. A Piezosurgery® device was used in 36 patients who underwent microsurgery for extra-axial CPA or petroclival tumors in our Neurosurgical Department between 2013 and 2019. The clinical and radiological data were retrospectively analyzed. The use of PS was evaluated with respect to the intraoperative applicability and limitations as well as efficacy and safety of the procedure. Piezosurgical petrous bone cutting was successfully performed in the removal of meningiomas or extra-axial metastases arising from the dura of the petroclival region (21 patients) or petrous bone (15 patients). PS proved to be very helpful in the deep and narrow CPA region, considerably reducing the surgeon's distress toward bone removal in close proximity to cranial nerves and vessels in comparison to common rotating drills. The use of PS was safe without injuries to neurovascular structures. Gross total resection was achieved in 67% of petroclival and 100% of petrous bone tumors. Piezosurgery proved to be an effective and safe method for selective petrous bone cutting in CPA surgery avoiding rotating power and associated risks. This technique can particularly be recommended for bone cutting in close vicinity to critical neurovascular structures.

A comparison of piezo surgery osteotomies with conventional internal osteotomies as performed by trainee surgeons: a cadaveric study.

INTRODUCTION: Aesthetic rhinoplasty remains a challenging procedure with high expectations and narrow tolerance for errors. Considerable training is required to achieve controlled and reliable results. Use of the Piezotome is gaining popularity for performing the nasal osteotomies, a key step in rhinoplasty, where it is reported to improve precision and predictability and to keep tissue damage to a minimum. We compare the outcomes of conventional osteotomy techniques to piezosurgery in human cadavers as undertaken by surgical trainees. MATERIALS AND METHODS: Seven human cadavers were used and a total of 14 osteotomies were performed. Conventional osteotomies and piezosurgery were carried out each on one side of the cadaver. A number of fragments and a blinded assessment of the accuracy of the osteotomy compared with the preprocedure skin markings were carried out by two experienced rhinoplasty surgeons. The Mann-Whitney test for statistical analysis was used. RESULTS: The mean number of fragments was 1.57 in the piezosurgery osteotomy and 2.14 using conventional osteotomies. Four of seven piezosurgery osteotomies achieved an accuracy within 1mm. The conventional osteotomies as performed by the trainees showed a significant mismatch of more than 3mm in three of seven of cases. Accuracy within 1mm was achieved in one of seven cases. DISCUSSION: Piezosurgery offers a safe, reliable and precise method of performing lateral nasal osteotomies. This human cadaver study shows a high accuracy of osteotomy and fewer comminuted fractures using this technique compared with conventional osteotomy techniques.

Comparison of the use of piezosurgery expander and conventional instruments on primary implant stability.

OBJECTIVE: To compare the use of a piezosurgery expander and conventional chisel/osteotome on primary implant stability. MATERIALS AND METHODS: Twenty fresh ribs were divided into two main groups; group P and group C. In group P, bone expansion was performed using piezosurgery. In group C, bone expansion was performed using conventional chisel osteotomy. In both groups, the implants were inserted into the ribs after bone expansion. After implant placement, primary stability values were evaluated from the bucco-lingual (B-L) and mesio-distal (M-D) sides of the implant. RESULTS: The primary stability values on the B-L side of both implants in group P were significantly higher than in group C (P < 0.05). CONCLUSION: The use of piezo-expanders in the alveolar split technique has better effects on primary implant stability compared with the conventional technique.

Osteotomy in Genioplasty by Piezosurgery.

BACKGROUND: The chin is the most prominent and median sector of the lower third of the face giving harmony to nose and lips. The authors present the application of piezoelectric scalpel for the correction of different chin deformities. The distinctive characteristics of this device allow the authors to avoid or reduce the immediate genioplasty complications. METHODS: Fifty-five patients of defective chin have been treated from January 2006 to April 2008. Intraoral genioplasty was performed during the correction of dentofacial dysmorphisms or associated with nasal surgery. The authors used a piezoelectric cutting device to perform different osteotomies and if necessary, interpositional graft was used to stabilize bony segments. RESULTS: Piezosurgery has been associated with a fewer number of postoperative complications, especially as regard intraoperative bleeding, nerve injuries (immediate and late), hematomas and seromas, asymmetry (immediate and early). The mean time for completing the complete procedure of genioplasty with piezosurgery was almost the same compared with the saw and drill. CONCLUSION: Genioplasty represents one of the most common ancillary procedures and may be associated with corrective surgery of dentofacial dysmorphisms. Mental nerve injuries, asymmetries, intraoperative bleeding are the main immediate complications of genioplasty. Distinctive characteristics of ultrasonic piezoelectric osteotomy are selective cut of mineralized structure with less risk of vascular and nervous damage (microvibrations), intraoperative precision (thin cutting scalpel and no macrovibrations), blood free site (cavitation effect). In the authors' experience, piezoelectric scalpel, compared with saw and drill, enables them to reduce or avoid immediate complications of chin surgery, helping the surgeon to reach patients' satisfaction.

Removal of external ear canal exostoses by piezo surgery: a novel technique.

BACKGROUND: External auditory canal exostoses are known to occur in patients who engage in cold-water sports. Although the majority of patients with exostosis remain asymptomatic, larger lesions can cause wax impaction, conductive hearing loss and predispose to recurrent otitis externa. OBJECTIVE: A novel technique is described of using a piezo saw to excise exostoses that are symptomatic. The piezo saw is used to perform various procedures, but its use in removing exostoses has not been described in the literature. CONCLUSION: Excision of exostoses of the ear canal using a piezo saw is a safe technique and patients have a speedy recovery. This paper describes a new technique for removing exostoses.

Bimaxillary orthognathic surgery with a conventional saw compared with the piezoelectric technique: a longitudinal clinical study.

The only cutting technique used for osteotomies in orthognathic surgery for many years has been a saw, but recently piezoelectric surgery has been introduced as a possible alternative. The aim of this study was to find out if piezoelectric surgery can be more comfortable for patients having orthognathic surgery. A total of 25 patients with dentofacial deformities (seven male and 18 female), were treated from January 2016 to September 2017. In 11 patients, osteotomies were made using a conventional saw, while in 14 a piezoelectric device was used. The variables assessed were: operating time, postoperative swelling, postoperative pain, and cutaneous sensitivity of the upper and lower lips. The duration of operation for the piezosurgery group was significantly longer than that for controls, but the patients had less swelling at all follow-up visits, and the difference was significant at the 30-day follow-up (p=0.045). Those who had piezosurgery had significantly less pain at the three-day follow up (p=0.035). There was a significant difference in cutaneous sensitivity only for the right side of the upper lip and only at the one-day follow-up. We conclude that piezoelectric surgery offers some advantages in lessening swelling and the perception of pain after orthognathic surgery, but further investigations are required.

Heat Production and Drill Wear Following Osseous Resective Surgery: A Preliminary In Vitro SEM Study Comparing Piezosurgery and Conventional Drilling.

The aim of this pilot in vitro study was to evaluate material wear and temperature variations after using conventional rotating bur and piezosurgical insert for osseous resective surgery in bovine bone blocks under physiologic irrigation. Wear evaluation was carried out by measuring cutting time, and wear mechanisms were analyzed by scanning electron microscopy. Time analysis showed greater material wear and higher heat production with the piezoelectric insert. However, temperatures remained below values of clinical concern even after a cutting time of 20 minutes. Conversely, bone surface appeared irregular in shape with bone debris and signs of thermal damage on the bur-drilled surface, probably due to the more traumatic action of the diamond-coated bur.

Piezoelectric Surgery for Dorsal Spine.

BACKGROUND: Laminoplasty and laminectomy are 2 common surgical procedures used in treating degenerative and neoplastic diseases of the spinal canal. Routinely used instruments, such as the Kerrison rongeur and high-speed drill, can result in potentially serious complications, such as dural injury and thermal and mechanical damage to neurovascular structures. We adopted piezoelectric bone surgery, which permits a selective cut of mineralized tissues, to perform posterior procedures on the thoracic spine, where the relationship between bone and the spinal cord is critical. The aim of this article was to evaluate the use of piezoelectric surgery for performing dorsal spine laminectomy and laminoplasty. METHODS: The Mectron piezosurgery device was developed for cutting bone with microvibrations that are created by the piezoelectric effect. This instrument allows a safe and precise bone cut, and it is characterized by no heat generation, thus avoiding thermal injury to bone and soft tissues. We used this device to perform 8 laminoplasties for tumors of the dorsal spine and 2 laminectomies for thoracic spinal stenosis in 10 patients. RESULTS: There were no procedure-related intraoperative complications, such as dural injury or damage to neural structures. CONCLUSIONS: The piezoelectric device showed excellent results in terms of safety and precise bone cutting properties when performing posterior surgical procedures in the dorsal spine, where thermal injury produced by the conventionally used drill may damage the spinal cord closer to bony elements.

Comparative Study on the Cutting Effectiveness and Heat Generation of Rotary Instruments Versus Piezoelectric Surgery Tips Using Scanning Electron Microscopy and Thermal Analysis.

PURPOSE: The search for optimizing rehabilitation results with the use of osseointegrated implants has led oral surgeons to look for other technologies that can provide better predictability for treatments; however, effectiveness must be considered as well. This study aimed to compare temperature variation during preparation of implant surgical beds using conventional rotary implant burs versus ultrasonic tips and to study perforation effectiveness by analyzing the functional wear of both systems and the influence of such wear on the overheating of cortical bone. MATERIALS AND METHODS: This evaluation was made using thermocouples placed in fresh bovine cortical bone (femur) and connected to a data collector so that the recorded temperatures could provide the thermal behavior of both systems after repeated use of the burs and piezoelectric tips, to compare the wear and the loss of cutting efficiency. Scanning electron microscopy (SEM) was used to compare the topography of both systems' perforations. Biostatistics assays were performed comparing both techniques as well. RESULTS: The collected data and images showed that the wear of the burs and tips did not significantly influence the temperature variation, and the greatest variation occurred in the piezoelectric system for preparations of 13-mm depth. The SEM images show a different surface topography between both systems. While the burs cut the bone, showing a smooth surface, the piezoelectric tips condense the bone and present a rough surface. CONCLUSION: The use of either rotatory burs or piezoelectric tips generates a temperature that does not affect the tissue healing. Burs create a smooth surface, and piezoelectric tips show a more rough and condensed bone surface. The wear of both systems does not have a relevant increase in temperature after the preparation of 30 surgical beds.

MicroSaw and Piezosurgery in Harvesting Mandibular Bone Blocks from the Retromolar Region: A Randomized Split-Mouth Prospective Clinical Trial.

PURPOSE: The aim of this randomized prospective split-mouth clinical trial was to evaluate the outcome of bone block harvesting from the retromolar region using the MicroSaw and Piezosurgery. MATERIALS AND METHODS: Fifty-three patients for extensive bilateral bone grafting procedures with or without concomitant implant placement in the maxilla and/or mandible were scheduled. In each patient, bone blocks were harvested in the retromolar area within the external oblique ridge of the mandible. Using a randomized protocol, bone blocks were harvested with the MicroSaw and Piezosurgery either from the right or the left side. Clinical outcome parameters were the comparison of osteotomy time; volume of block graft; and clinical determination of intraoperative complications such as hemorrhage, nerve injury, pain, swelling, and healing of the donor site. RESULTS: The mean osteotomy time for harvesting including luxating a bone block was 5.63 (± 1.37) minutes using the MicroSaw and 16.47 (± 2.74) minutes using Piezosurgery (P < .05). A mean graft volume of 1.62 (± 0.27) cm3 was measured with the MicroSaw and 1.26 (± 0.27) cm3 with the piezoelectric surgical device (P < .05). No heavy bleeding at the donor site occurred in any of the cases. Complications due to injury of adjacent teeth or nerve lesion of the mandibular nerve were not observed in any cases. According to a scale, there was little postoperative pain with both instruments, and it decreased within 14 days postoperatively (P > .05). Swelling did not appear significantly different either (P > .05), and none of the donor sites showed primary healing complications. CONCLUSION: The data described in this randomized prospective split-mouth clinical trial indicate that the MicroSaw and Piezosurgery allowed efficient and safe bone block harvesting from the external oblique ridge. Clinically, concerning harvesting time and volume of the grafts, the MicroSaw performed significantly better, whereas pain, swelling, and healing did not appear to be considerably different. Given the improved visibility, precise cut geometries, and the margin of safety afforded by the MicroSaw and Piezosurgery, they are both instruments of choice when harvesting bone from the retromolar area.

Piezosurgery for Treatment of Large Recurrent Mandibular Osteoma.

BACKGROUND: Osteomas are infrequent benign bone tumors of uncertain etiology. They are usually situated at extremities and their occurrence in the jaws is relatively rare. There are 3 types of osteoma: central, peripheral, and extraskeletal. Preoperative presumptive diagnosis is performed by means of radiography using orthopantomographs, computerized tomographs, or cone beam scans. Treatment is surgical and consists of careful exeresis and curettage of the adjacent tissue. In recent years, piezoelectric surgery has been used to treat bone pathologies in the maxillofacial area, orthopedic surgery, and neurosurgery. When used for the exeresis of a bone lesion, the device minimizes risks and eliminates possible complications arising from affectation of the vascular and nerve structures close to the lesion. OBJECTIVE: This clinical report describes a peripheral mandibular osteoma situated in the left mandibular basilar which recurred 45 years after surgical treatment at another center. METHODS: For resection, the surgical approach followed the scar remaining from the earlier surgery and was performed using piezoelectric surgery. Surgery did not cause hemorrhagic complications, affect the sensitivity of the left labial menton, or cause paralysis of the lower lip. CONCLUSIONS: Based on the present patient, it may be concluded that mandibular osteoma treatment by means of piezoelectric surgery makes precise exeresis possible with less affectation of the important surrounding structures such as the inferior alveolar nerve and the marginal mandibular branch of the facial nerve.

Preservation of root cementum: a comparative evaluation of power-driven versus hand instruments.

OBJECTIVES: The purpose of this study was to evaluate the effects of three distinct periodontal treatment methods in comparison with hand instrumentation on residual cementum of periodontal diseased teeth. Cementum can influence the activities of periodontal cells and may play an important regulatory role in periodontal treatment. The ideal method for periodontal therapy involves removal of biofilm, calculus and endotoxin while preserving root cementum. MATERIAL AND METHODS: Forty-eight caries free, single-rooted teeth in patients diagnosed with severe chronic periodontitis were treated using four different methods prior to extraction. The teeth were instrumented subgingivally at one approximal site either by hand curettes (HC), piezoelectric ultrasonic scalers (U), piezoelectric ultrasonic scalers following air polishing (U + AP) or air polishing (AP) alone. Following extraction of teeth, instrumented and non-instrumented sites were analysed with a dissecting microscope and SEM for measurement of the amount of and surface characteristics of residual cementum. RESULTS: The percentage of coronal cementum remaining following subgingival instrumentation was 84% for U, 80% for U + AP, 94% for AP and 65% for HC. Although subgingival instrumentation of apical portions of the cementum demonstrated 6% less retained cementum in comparison with coronal portions, the amount of retained cementum with AP was still significantly greater than with HC. SEM results found the smoothest root surfaces were produced by the HC followed by the AP, while root surfaces instrumented by U or U + AP presented grooves and scratches. CONCLUSIONS: This study demonstrated that AP was superior to U devices in preserving cementum, whereas HC were the most effective instruments in removing cementum.

Comparación entre la piezocirugía y los instrumentos rotativos convencionales en la lateralización del nervio dentario inferior / Comparison between the piezosurgery and the conventional rotary surgery in the lateralization of the inferior alveolar nerve

Introducción: la rehabilitación de pacientes desdentados mandibulares posteriores con implantes osteointegrados, se vuelve difícil cuando la cresta alveolar presenta una atrofia severa debido al recorrido superficial del canal mandibular. La lateralización del nervio dentario inferior es una alternativa terapéutica que posibilita la colocación de implantes convencionales y cortos en esta región. Objetivo: comparar la facilidad, efectividad y seguridad de la técnica quirúrgica convencional, realizada con fresas quirúrgicas, y la piezocirugía en la lateralización del nervio dentario inferior. Presentación del caso: paciente con ausencia bilateral de los molares inferiores y cresta alveolar atrófica fue tratada mediante lateralización del nervio dentario inferior y colocación simultánea de implantes. En el lado izquierdo, la lateralización fue realizada con fresas y en el lado derecho, con motor piezoeléctrico. Fue posible observar que la piezocirugía facilitó la técnica quirúrgica, y consecuentemente disminuyó el tiempo operatorio. A la vez, produjo una osteotomía más regular y con menos sangrado, lo cual mejoró la visualización del campo operatorio. Finalmente, el daño neural inmediato fue menor en el lado tratado con motor piezoeléctrico y con recuperación más rápida. Después de 3 meses de seguimiento, los implantes en ambos lados no presentaban pérdida ósea. Conclusiones: el uso del motor piezoeléctrico trajo más beneficios durante la lateralización del nervio dentario inferior, por la simplificación de la técnica quirúrgica y la reducción del sangrado y del daño neural en comparación con el uso de fresas convencionales(AU)

Introduction: the rehabilitation of edentulous posterior mandibular patients with bone-integrated implants becomes difficult when the alveolar crest presents a severe atrophy due to the superficial course of the mandibular canal. The inferior alveolar nerve lateralization is a therapeutic alternative that allows the placement of conventional and short implants in this region. Objective: to compare the easiness, effectiveness, and safety of the conventional surgical technique, performed with surgical drills, and piezosurgery in the lateralization of the inferior alveolar nerve. Case presentation: a patient with bilateral absence of the lower molars and atrophic alveolar crest was treated by lateralization of the inferior alveolar nerve and simultaneous implant placement. On the left side, the lateralization was made with drills and on the right side, with an electric piezotome. It was possible to observe that the piezosurgery facilitated the surgical technique, and consequently decreased the operative time. At the same time, it produced a more regular osteotomy and with less bleeding, which improved the visualization of the operative field. Finally, the immediate neural damage was lower on the side treated with the electric piezotome and with faster recovery. After 3 months of follow-up, the implants on both sides did not show bone loss. Conclusions: the use of the electric piezotome brought more benefits during the lateralization of the inferior alveolar nerve, by the simplification of the surgical technique and the reduction of bleeding and neural damage in comparison with the use of conventional drills(AU)

Comparación entre la piezocirugía y los instrumentos rotativos convencionales en la lateralización del nervio dentario inferior / Comparison between the piezosurgery and the conventional rotary surgery in the lateralization of the inferior alveolar nerve

Introducción: la rehabilitación de pacientes desdentados mandibulares posteriores con implantes osteointegrados, se vuelve difícil cuando la cresta alveolar presenta una atrofia severa debido al recorrido superficial del canal mandibular. La lateralización del nervio dentario inferior es una alternativa terapéutica que posibilita la colocación de implantes convencionales y cortos en esta región. Objetivo: comparar la facilidad, efectividad y seguridad de la técnica quirúrgica convencional, realizada con fresas quirúrgicas, y la piezocirugía en la lateralización del nervio dentario inferior. Presentación del caso: paciente con ausencia bilateral de los molares inferiores y cresta alveolar atrófica fue tratada mediante lateralización del nervio dentario inferior y colocación simultánea de implantes. En el lado izquierdo, la lateralización fue realizada con fresas y en el lado derecho, con motor piezoeléctrico. Fue posible observar que la piezocirugía facilitó la técnica quirúrgica, y consecuentemente disminuyó el tiempo operatorio. A la vez, produjo una osteotomía más regular y con menos sangrado, lo cual mejoró la visualización del campo operatorio. Finalmente, el daño neural inmediato fue menor en el lado tratado con motor piezoeléctrico y con recuperación más rápida. Después de 3 meses de seguimiento, los implantes en ambos lados no presentaban pérdida ósea. Conclusiones: el uso del motor piezoeléctrico trajo más beneficios durante la lateralización del nervio dentario inferior, por la simplificación de la técnica quirúrgica y la reducción del sangrado y del daño neural en comparación con el uso de fresas convencionales(AU)

Introduction: the rehabilitation of edentulous posterior mandibular patients with bone-integrated implants becomes difficult when the alveolar crest presents a severe atrophy due to the superficial course of the mandibular canal. The inferior alveolar nerve lateralization is a therapeutic alternative that allows the placement of conventional and short implants in this region. Objective: to compare the easiness, effectiveness, and safety of the conventional surgical technique, performed with surgical drills, and piezosurgery in the lateralization of the inferior alveolar nerve. Case presentation: a patient with bilateral absence of the lower molars and atrophic alveolar crest was treated by lateralization of the inferior alveolar nerve and simultaneous implant placement. On the left side, the lateralization was made with drills and on the right side, with an electric piezotome. It was possible to observe that the piezosurgery facilitated the surgical technique, and consequently decreased the operative time. At the same time, it produced a more regular osteotomy and with less bleeding, which improved the visualization of the operative field. Finally, the immediate neural damage was lower on the side treated with the electric piezotome and with faster recovery. After 3 months of follow-up, the implants on both sides did not show bone loss. Conclusions: the use of the electric piezotome brought more benefits during the lateralization of the inferior alveolar nerve, by the simplification of the surgical technique and the reduction of bleeding and neural damage in comparison with the use of conventional drills(AU)

Comparison of clinical outcomes using a Piezosurgery device vs. a conventional osteotome for lateral osteotomy in rhinoplasty.

Our aim for this study was to evaluate and compare the clinical outcomes in patients who underwent lateral osteotomy with a Piezosurgery device or a conventional osteotome in open-technique rhinoplasty. This cohort trial involved 65 patients (36 women and 29 men; average age: 23.6 ± 5.71 yr) who underwent surgery between May 2015 and January 2016. Piezosurgery was used for lateral osteotomy in 32 patients, whereas 33 patients underwent conventional external osteotomy. These 2 groups were compared for duration of surgery, perioperative bleeding, postoperative edema, ecchymosis, pain, and patient satisfaction on the first and seventh postoperative days. The Piezosurgery group revealed significantly more favorable outcomes in terms of edema, ecchymosis, and hemorrhage on the first day postoperatively (p < 0.001 for all). Similarly, edema (p = 0.005) and ecchymosis (p < 0.001) on the seventh postoperative day also were better in the Piezosurgery group. Hemorrhage was similar in both groups on the seventh postoperative day (p = 0.67). The Piezosurgery group not only experienced less pain on the first postoperative day (p < 0.001), but these patients also were more satisfied with their results on both the first and seventh postoperative days. Results of the present study imply that Piezosurgery may be a promising, safe, and effective method for lateral osteotomy, a critical step in rhinoplasty. The time interval necessary for the learning curve is counteracted by the comfort and satisfaction of both patients and surgeons.

Intracanal temperature changes during bone preparations close to and penetrating the inferior alveolar canal: Drills versus piezosurgery.

PURPOSE: The aim of this in vitro study was to investigate temperature increases in the inferior alveolar canal (IAC), when different bone preparation methods approximate and penetrate the IAC. MATERIALS AND METHODS: In pig mandible, buccal bone removals were performed until the neurovascular bundle became visible. Temperatures were registered with thermocouple probes and with infrared thermometer. Preparations were performed with diamond drills (DD), tungsten carbide drills (TCD), piezoelectric diamond sphere (PT_D) and saw (PT_S) tips, and a combined preparation method was also performed whereby the superficial three-fourths of the bone was removed with TCD and the deepest one-fourth of the bone with PT_D (TCD + PT_D_7 °C) or PT_S (TCD + PT_S_7 °C), using cooled irrigation (7 °C). RESULTS: Preparations using room temperature irrigation caused significantly less heat on the bone surface than in the IAC. Piezosurgery in the IAC produced significantly higher temperatures (>13 °C) than the drills (<4 °C). Heat productions of the piezoelectric tips were reduced significantly by applying the combined bone removal methods. The speed of PT_S and TCD + PT_S_7 °C were comparable to the speed of TCD, whereas TCD + PT_D_7 °C was found to be significantly slower. CONCLUSION: The speed of piezosurgery is comparable to that of the drills; however, it produces the highest, potentially nerve-harming temperatures. To eliminate the heat consequences during piezosurgery in the IAC, the use of cooled irrigation at 7 °C and predrilling is recommended.

Piezosurgery in Modified Pterional Orbital Decompression Surgery in Graves Disease.

OBJECTIVE: Piezosurgery uses microvibrations to selectively cut bone, preserving the adjacent soft tissue. The present study evaluated the use of piezosurgery for bone removal in orbital decompression surgery in Graves disease via a modified pterional approach. METHODS: A piezosurgical device (Piezosurgery medical) was used in 14 patients (20 orbits) with Graves disease who underwent orbital decompression surgery in additional to drills and rongeurs for bone removal of the lateral orbital wall and orbital roof. The practicability, benefits, and drawbacks of this technique in orbital decompression surgery were recorded. Piezosurgery was evaluated with respect to safety, preciseness of bone cutting, and preservation of the adjacent dura and periorbita. Preoperative and postoperative clinical outcome data were assessed. RESULTS: The orbital decompression surgery was successful in all 20 orbits, with good clinical outcomes and no postoperative complications. Piezosurgery proved to be a safe tool, allowing selective bone cutting with no damage to the surrounding soft tissue structures. However, there were disadvantages concerning the intraoperative handling in the narrow space and the efficiency of bone removal was limited in the orbital decompression surgery compared with drills. CONCLUSIONS: Piezosurgery proved to be a useful tool in bone removal for orbital decompression in Graves disease. It is safe and easy to perform, without any danger of damage to adjacent tissue because of its selective bone-cutting properties. Nonetheless, further development of the device is necessary to overcome the disadvantages in intraoperative handling and the reduced bone removal rate.