Mallet and Chisel Versus Rotary Motor or Piezoelectric Instruments in the Removal of Impacted Third Molars: The Ideal Approach in the Primary Care Setting. A Narrative Review

Author

Dr. Althaaf Khan


Abstract

 Background and objective: Removal of impacted mandibular third molars is a routine procedure in which bone removal and tooth sectioning cause most of the surgical trauma. Three osteotomy approaches are in use: mallet and chisel, rotary handpiece and piezoelectric instruments. This review compares their evidence and identifies the most suitable approach for the primary care setting.

Methods: A narrative review of systematic reviews, meta-analyses and clinical comparative studies was undertaken. Literature was identified through targeted searches of PubMed-indexed, Cochrane and open-access sources up to October 2026. Outcomes were operating time, pain, swelling, trismus, nerve disturbance, alveolar osteitis and practical factors relevant to primary care.

Results: Meta-analyses show that piezoelectric surgery lengthens operating time, by about six minutes in one pooled estimate, and reduces swelling and trismus in the early postoperative period. Pain findings are heterogeneous and the underlying trials are of limited quality. Evidence for mallet and chisel comes from small, mostly older trials, and a Cochrane review could not show superiority over a surgical handpiece. Chisel techniques may shorten operating time and avoid aerosols, but the lingual split carries a risk of temporary lingual nerve disturbance and the method depends on operator training. No trial comparing chisel with piezoelectric instruments was identified.

Conclusion: In primary care, a rotary surgical handpiece with irrigation remains the practical default for routine impactions. Piezoelectric instruments are a reasonable adjunct where available and where the benefit justifies longer operating time. Mallet and chisel is best reserved for trained operators and carefully selected cases. Rigorous head-to-head randomised trials are needed.



Keywords

third molar; impacted tooth; piezosurgery; chisel and mallet; rotary instruments; primary dental care



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References


  1. Renton T, Smeeton N, McGurk M. Factors predictive of difficulty of mandibular third molar surgery. Br Dent J. 2001;190(11):607-10. doi:10.1038/sj.bdj.4801052
  2. Slade GD, Foy SP, Shugars DA, Phillips C, White RP Jr. The impact of third molar symptoms, pain, and swelling on oral health-related quality of life. J Oral Maxillofac Surg. 2004;62(9):1118-24. doi:10.1016/j.joms.2003.11.014
  3. Lago-Méndez L, Diniz-Freitas M, Senra-Rivera C, Gude-Sampedro F, Gándara Rey JM, García-García A. Relationship between surgical difficulty and postoperative pain in lower third molar extractions. J Oral Maxillofac Surg. 2007;65(5):979-83. doi:10.1016/j.joms.2006.06.281
  4. Pell GJ, Gregory GT. Impacted mandibular third molars: classification and modified technique for removal. Dent Dig. 1933;39:330-8.
  5. Ward TG. Split bone technique for removal of lower third molar. Br Dent J. 1956;101:297-301.
  6. Chien AT, Stehle NE, Karian BK. The use of chisels in the extraction of mandibular third molars: a technique that may prevent the aerosolization of severe acute respiratory syndrome coronavirus 2. J Oral Maxillofac Surg. 2021;79(6):1199-206. doi:10.1016/j.joms.2021.01.035
  7. Cicciù M, Stacchi C, Fiorillo L, Cervino G, Troiano G, Vercellotti T, et al. Piezoelectric bone surgery for impacted lower third molar extraction compared with conventional rotary instruments: a systematic review, meta-analysis, and trial sequential analysis. Int J Oral Maxillofac Surg. 2021;50(1):121-31. doi:10.1016/j.ijom.2020.03.008
  8. Jiang Q, Qiu Y, Yang J, Chen M, Zhang Z. Piezoelectric versus conventional rotary techniques for impacted third molar extraction: a meta-analysis of randomized controlled trials. Medicine (Baltimore). 2015;94(41):e1685. doi:10.1097/MD.0000000000001685
  9. Al-Moraissi EA, Elmansi YA, Al-Sharaee YA, Alrmali AE, Alkhutari AS. 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. 2016;45(3):383-91. doi:10.1016/j.ijom.2015.10.005
  10. Magesty RA, Galvão EL, Martins CC, dos Santos CRR, Falci SGM. Rotary instrument or piezoelectric for the removal of third molars: a meta-analysis. J Maxillofac Oral Surg. 2017;16(1):13-21. doi:10.1007/s12663-016-0938-y
  11. Liu J, et al. Piezosurgery vs conventional rotary instrument in the third molar surgery: a systematic review and meta-analysis of randomized controlled trials. J Dent Sci. 2018;13(4):342-9. doi:10.1016/j.jds.2016.09.006
  12. Steel B. Lingual split versus surgical bur technique in the extraction of impacted mandibular third molars: a systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;114:294. doi:10.1016/j.tripleo.2011.07.028
  13. Bailey E, Kashbour W, Shah N, Worthington HV, Renton TF, Coulthard P. Surgical techniques for the removal of mandibular wisdom teeth. Cochrane Database Syst Rev. 2020;7:CD004345. doi:10.1002/14651858.CD004345.pub3
  14. Baethge C, Goldbeck-Wood S, Mertens S. SANRA: a scale for the quality assessment of narrative review articles. Res Integr Peer Rev. 2019;4:5. doi:10.1186/s41073-019-0064-8
  15. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71
  16. Absi EG, Shepherd JP. A comparison of morbidity following the removal of lower third molars by the lingual split and surgical bur methods. Int J Oral Maxillofac Surg. 1993;22(3):149-53. doi:10.1016/S0901-5027(05)80240-1
  17. Praveen G, Rajesh P, Neelakandan R, Nandagopal C. Comparison of morbidity following the removal of mandibular third molar by lingual split, surgical bur and simplified split bone technique. Indian J Dent Res. 2007;18(1):15-8.
  18. Singh V, Alex K, Pradhan R, Mohammad S, Singh N. Techniques in the removal of impacted mandibular third molar: a comparative study. Eur J Gen Dent. 2013;2(1):25-30. doi:10.4103/2278-9626.106799
  19. Pichler JW, Beirne OR. Lingual flap retraction and prevention of lingual nerve damage associated with third molar surgery: a systematic review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91(4):395-401.
  20. Mantovani E, Arduino PG, Schierano G, Ferrero L, Gallesio G, Mozzati M, et al. 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. 2014;72(10):1890-7. doi:10.1016/j.joms.2014.05.002
  21. Menziletoglu D, Basturk F, Isik BK, Esen A. A prospective split-mouth clinical study: comparison of piezosurgery and conventional rotary instruments in impacted third molar surgery. Oral Maxillofac Surg. 2020;24(1).
  22. Gulnahar Y, Alpan AL. Comparison of postoperative morbidity between piezoelectric surgery and conventional rotary instruments in mandibular third molar surgery: a split-mouth clinical study. Med Oral Patol Oral Cir Bucal. 2021. doi:10.4317/medoral.24085
  23. Cantore S, Vieira e Silva FF, Bizzoca ME, Smimmo A, Lo Muzio L, et al. Enhancing lower third molar surgery: using the piezoelectric technique for superior postoperative outcomes and complication prevention. Dent J (Basel). 2024;12(11):353. doi:10.3390/dj12110353

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