|
 
 |
| REVIEW ARTICLE |
|
| Year : 2022 | Volume
: 3
| Issue : 2 | Page : 29-35 |
|
Conceptual approach to periodontal microsurgery: An insight
Riddhi Awasthi, Mohammad Jalaluddin, Urmi Agrawal, Dhirendra Kumar Singh
Department of Periodontics and Oral Implantology, Kalinga Institute of Dental Sciences, KIIT Deemed to be University, Bhubaneswar, Odisha, India
| Date of Submission | 20-Sep-2021 |
| Date of Acceptance | 19-Dec-2021 |
| Date of Web Publication | 9-Mar-2022 |
Correspondence Address:
Riddhi Awasthi
Department of Periodontology, Kalinga Institute of Dental Sciences, Campus 5, KIIT University, Patia, Bhubaneswar - 751 024, Odisha
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jpcdoh.jpcdoh_35_21
Periodontal treatment modalities have evolved since the 20th century. This era of periodontal treatment is progressing towards minimally invasive techniques. Nowadays, microscopes and surgical loupes are being used in different fields of dentistry. Periodontal surgeries like root coverage procedures, esthetic surgeries, scaling & root planing have also incorporated these methods for better esthetic results and patient compliance. Unlike in other fields of dentistry, there is more to be explored in the periodontal field with microsurgical methods. This article aims to discuss the evolution of periodontal treatment with microsurgical procedures and its principles. The literature concerning the efficacy of microsurgical approaches in treating periodontal diseases has been evaluated.
Keywords: Microscope, microsurgical princples, periodontal surgeries, surgical loupes
How to cite this article:
Awasthi R, Jalaluddin M, Agrawal U, Singh DK. Conceptual approach to periodontal microsurgery: An insight. J Prim Care Dent Oral Health 2022;3:29-35 |
How to cite this URL:
Awasthi R, Jalaluddin M, Agrawal U, Singh DK. Conceptual approach to periodontal microsurgery: An insight. J Prim Care Dent Oral Health [serial online] 2022 [cited 2022 May 27];3:29-35. Available from: http://www.jpcdoh.org/text.asp?2022/3/2/29/339307 |
| Introduction | |  |
With the advancement of technology, the approach to treat periodontal diseases is also evolving. New approaches and treatments have been described in the last few decades. This era of periodontal treatment is progressing toward minimally invasive techniques. The introduction of microsurgical periodontics is one step toward minimally invasive periodontal therapy.
The use of magnifying aids has bought beneficial alteration in end results of both nonsurgical and surgical periodontal therapies. Nowadays, microsurgery is applied to many of the operations in medical practice to a wide variety of treatment procedures in dental practice.[1],[2]
High-powered loupes and operating microscopes are being used as magnifying aids while periodontal therapy. Currently, the “criterion standard” of performing microsurgery is under the operating microscope in many periodontal therapies.[3]
Data availability of research studies concerning the efficacy of the microsurgical approach is scarce. Therefore, this article provides a brief insight into the periodontal therapies via microsurgical approach along with its principles, ergonomics, and instruments.
| History | | |
Microsurgery was first defined by Daniel in 1979,[4] as “surgery performed under magnification by the microscope.” In 1980, Serafin described microsurgery[5] as “a methodology – a modification and refinement of existing surgical techniques using magnification to improve visualization, with applications to all specialties.” Periodontal microsurgery[6] is the enhancement of surgical techniques made achievable by improving visual insight with the aid of a surgical microscope.
| Principles of Microsurgery | | |
Microsurgery features three important principles:[7]
- Motor skills improvisation, thus advancing surgical skill
- To emphasize on primary apposition of the wound edge so that passive wound closure can be achieved.
- The use of microsurgical instrumentation and suturing to reduce tissue trauma.
| Microsurgical Triad | | |
The advantages offered by microscopes to periodontists are illumination, magnification, and increased precision of surgical skills (Belcher 2001) [Figure 1]. The precision of surgical skills is facilitated by the collaboration of heightened illumination and amplified visual perception. Universally, these advantages are being referred to as the microsurgical triad.
| Ergonomics in Microsurgery | | |
Clinician posture
A microsurgeon must have an unperturbed state of mind, suitable body comfort and position, a well-supported hand, and a stable instrument-holding position [Figure 2].[8]
- Lower body: The surgeon must be seated upright with the legs extending forward and with both feet flat on the floor so that the calf of each leg forms a right angle to the thigh
- Upper body: The surgeon's head should be held in a comfortable upright position
- Hand rests: In microsurgery, the hand should be rested on a surface to avoid unwanted movements. Fingertips are only to be used. Efficient and economical movements should be made with an accord toward considerate motions
- Handgrips: Common precision grip used in microsurgery is the pen grip or internal precision grip, because of greater stability. Tripod effect of thumb, index, and middle fingers yields the best results.
Several factors can influence a surgeon's physiologic tremor, including anxiety, recent exercise, alcohol, smoking, caffeine, heavy meals, hypoglycemia, and medication usage.
Patient's positioning
Patient's head should be placed in the 12 o'clock position. For a right-handed person, a precise movement for suturing is from the 2 o'clock to the 7 o'clock position, and for a left-handed person, it is from the 10 o'clock to the 4 o'clock position [Figure 2].[8]
| Microsurgical Instruments | | |
[Figure 3]
Diagnostic instruments
Micromirrors with flexible neck are available in different shapes to provide improved illumination [Figure 4].
Microexplorers are specifically designed with a 90° bent 2 mm tip on the one end and 130° on the other. The short tip easily reaches inside the small boney crypt. Areas that are difficult to reach such as distal to the last molar can be accessed by micro-explorers and micro-mirrors. In cases of restricted mouth opening, these instruments can be used as diagnostic aids [Figure 5].
Surgical instruments
Incision and elevation (knives and elevators)
The commonly used knives in periodontal microsurgery are blade breaker, crescent, mini-crescent, and spoon knives [Figure 6]. Blade breaker can be used for placing internal bevel and external bevel incisions. Crescent knife is available with one-piece handles or as a removable blade. It can be used for placing crevicular incisions and in root coverage procedures. The spoon knife can track through the tissue adjacent to the bone because of its beveling on one side. It is frequently being used in microsurgical procedures to undermine tissue for the augmentation of a connective tissue graft.
The soft-tissue elevators are designed to elevate the gingiva and tissue from the underlying cortical bone with minimal trauma to the tissue. The one end of the instrument has a thin, sharp, triangular beak and the other end has a sharp, rounded beak that varies in size. This design allows the soft tissue to be elevated from the bone cleanly and completely [Figure 7].
Tissue retraction
Tissue retractors are available with various widths varying from 8 mm to14 mm in size. Retractors ensure easy flap reflection with good visibility and accessibility to the surgical site. Some retractors such as KimTrac retractors are specifically designed with serrated ends to precisely anchor against the cortical boney [Figure 8].
Osteotomy
A 45° surgical handpiece with a Lindemann bur is the instrument of choice for implant procedures (Brasseler NSK and Morita) [Figure 9]. It is designed to direct water onto the cutting surface by channeling it along the surface of the bur while the air is ejected through the back of the handpiece [Figure 9]. This reduces the chance of emphysema and pyemia and creates less splatter than a conventional handpiece. The handpiece's 45° angled head makes it easier to work in and visualize difficult-to-reach areas.
Curettage
Curettage instruments [Figure 10] include periodontal curettes and surgical curettes. Microcurettes aid in enhanced root planing with reduced trauma to soft tissue. It also facilitates better adaptation of curettes to the surface and precise debridement in less time.
Suturing instruments
Needles and sutures
The most common scissors used for microsurgical procedures are the Laschal microscissors, or any small-beaked scissors. The scissors along with the castroviejo needle holder help in easy management of 5-0 or 6-0 synthetic sutures and prevent inflammation and associated delayed healing.
The common curvatures of needles used in microsurgical procedures are three-eighths of an inch (10 mm) and one-half of an inch (12.7 mm). A specifically designed needle, i.e., spatula needle, is most commonly used in esthetic periodontal microsurgical procedures. It is 6.6 mm long and has a curvature of 140° [Figure 11]. The combination of a shallow needle tract and precise needle purchase of the tissue enables extremely accurate apposition and closure in periodontal mucogingival surgery.
The combination of using smaller needles, sutures, and magnification results in minimal dead space, closure with sufficient but appropriate tension, and immobilization of the wound.[9]
Microsurgical tying
Principles for microsurgical tying applicable to periodontal therapy are instrument grip, needle gripping, two-handed tying techniques, needle penetration, and suture guiding.[9]
Instrument grip
Pen grip grasp helps maintain the stability of microsurgical instruments [Figure 10].
Needle gripping
One-third from the eye of the needle is the preferred area for gripping the needle [Figure 12]. The needle in the needle holder should be pointed along the intended path. To ensure passive wound closure, the bite size should be approximately 1.5 times the tissue thickness.[10]
Needle penetration
Microsurgical suturing skills diverge from traditional surgical procedures. The needle should penetrate perpendicularly to the tissues and exit at uniform distances during microsurgeries [Figure 13].
Two-handed tying techniques
Instrument ties are used to tie knots under the microscope, with the dominant hand holding a microsurgical needle holder and the nondominant hand picking up microsurgical tissue.[8]
Suture guiding
Square knots have the best knot integrity, and a surgeon's knot followed by a square knot is the recommended knot combination. Additional ties to a knot increase its bulk rather than its strength or integrity.[11] A new suturing method based on both vertical and horizontal mattress sutures anchored at temporarily splinted interdental contact sites has recently been reported for appropriate soft-tissue harmonization and atraumatic displacement in minimally invasive periodontal surgery.[12]
Magnification systems can be of two types: [Table 1][8]
- Loupes
- Microscope.
Periodontal Microsurgical Procedures [Figure 14][8]
Improved visualization of root surface
The degree to which the root surface is debrided is a critical determinant of the periodontal treatment outcome (Lindhe et al., 1984). Magnifications can dramatically improve access and visibility in deep subgingival pockets, furcation, and interdental sites. It aids in the detection of materia alba, biofilm, or calculus adhering to the root surface and its removal from regions not evident to the human eyes.
Applications in mucogingival surgery
Mucogingival surgeries are technical and operator dependent which results in various treatment outcomes. Root coverage, frenectomy, vestibuloplasty, crown lengthening, and other periodontal plastic surgery procedures have significantly improved prognosis with less operational stress and distress, excellent postoperative esthetics, and appreciably faster recovery. For grafting procedures, early plasmatic diffusion aids in the survival of grafts in the initial phase. Accurate recipient and donor site preparation with less tissue and vascular damage, quicker and complete anastomosis of capillary buds, and faster recovery can be guaranteed by the microsurgical approach. This approach can also be used for technique sensitive procedures such as papilla reconstruction with excellent prognosis.
Minimally invasive surgical technique
Incorporation of microscopes or surgical loupes with minimally invasive surgical technique (MIST, Cortellini and Tonetti, 2007), modified papilla preservation technique (MPPT), and modified minimally invasive surgical technique (M-MIST by Cortellini and Tonetti 2009) have provided excellent esthetic results with favorable results in terms of probing pocket depth (PPD) reduction, gain in width of attached gingiva, clinical attachment level (CAL) gain bone regeneration, and others. Case reports (de Campos et al., 2006) and case-cohort studies (Cortellini and Tonetti 1999, 2007, and Francetti et al., 2004) have further validated the clinical advantages of the microsurgical technique for periodontal regeneration surgery.
Microsurgery in implant therapy
The microscopical approach can be used in all stages of implant surgery with greater precision. The microscope can be beneficial in visualizing the last threads of the implant for subcrestal placement, implant recovery with minimal trauma to adjacent tissues, management of peri-implantitis, visualization of the sinus membrane during sinus lift procedures, and minimizing the risk of perforations or tears.[26]
Various studies has been conducted on periodontal microsurgical procedures which are mentioned in [Table 2]. | Table 2: Research related to clinical applications of periodontal microsurgery
Click here to view |
| Conclusion | | |
Microsurgery offers new possibilities of minimally invasive treatment for periodontal therapy. It improves therapeutic results in terms of cosmetics, wound healing, discomfort to patient, and patient acceptance. It also helps in accessibility and visualization of difficult areas. The main reason for this is operating microscope helps in better diagnostic ability and enhances the treatment quality.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Shanelec DA, Tibbetts LS. A perspective on the future of periodontal microsurgery. Periodontol 2000 1996;11:58-64.  |
| 2. | Belcher JM. A perspective on periodontal microsurgery. Int J Periodontics Restorative Dent 2001;21:191-6. |
| 3. | Yadav VS, Salaria SK, Bhatia A, Yadav R. Periodontal microsurgery: Reaching new heights of precision. J Indian Soc Periodontol 2018;22:5-11. [ PUBMED] [Full text] |
| 4. | Daniel RK. Microsurgery: Through the looking glass. N Engl J Med 1979;300:1251-7. |
| 5. | Serafin D. Microsurgery: Past, present, and future. Plast Reconstr Surg 1980;66:781-5. |
| 6. | Tibbetts LS, Shanelec D. Periodontal microsurgery. Dent Clin North Am 1998;42:339-59. |
| 7. | Acland R. Practice Manual for Microvascular Surgery. 2 nd ed. St Louis: CV Mosby; 1989. |
| 8. | Tibbetts LS, Shanelec D. Principles and practice of periodontal microsurgery. Int J Microdent 2009;1:13-24. |
| 9. | Belcher J. Periodontal microsurgery. In: Dibart S, editor. Practical Periodontal Plastic Surgery. Bhubaneswar: Kalinga Institute of Dental Sciences; 2017. p. 13-20. |
| 10. | Price PB. Stress, strain and sutures. Ann Surg 1948;128:408-21. |
| 11. | Belcher JM. Periodontal microsurgery. In: Dibart S, Karima M, editors. Practical Periodontal Plastic Surgery. Oxford, USA: Blackwell Munksgaard; 2006. p. 15-22. |
| 12. | Ronco V, Dard M. A novel suturing approach for tissue displacement within minimally invasive periodontal plastic surgery. Clin Case Rep 2016;4:831-7. |
| 13. | Mamoun JS. A rationale for the use of high-powered magnification or microscopes in general dentistry. Gen Dent 2009;57:18-26. |
| 14. | Hegde R, Hegde V. Magnification-enhanced contemporary dentistry: Getting started. J Interdiscip Dent 2016;6:91-100. |
| 15. | Mamoun J. Use of high-magnification loupes or surgical operating microscope when performing prophylaxes, scaling or root planing procedures. N Y State Dent J 2013;79:48-52. |
| 16. | Penmetsa GS, Panda KD, Manthena AK, Korukonda RR, Gadde P. Evaluating the efficacy of different magnification variables during root planing procedure under a surgical operating microscope in chronic periodontitis: A randomized clinical trial. J Indian Soc Periodontol 2020;24:32-6. [ PUBMED] [Full text] |
| 17. | Sonika S, Esther Nalini H, Arun Kumar Prasad P, Renuka Devi R. Comparative evaluation of scaling and root planing with and without magnification loupe – A randomised controlled clinical trial. Int J Curr Adv Res 2019;08:19986-9. |
| 18. | Hegde R, Sumanth S, Padhye A. Microscope-enhanced periodontal therapy: A review and report of four cases. J Contemp Dent Pract 2009;10:E088-96. |
| 19. | Burkhardt R, Lang NP. Coverage of localized gingival recessions: Comparison of micro- and macrosurgical techniques. J Clin Periodontol 2005;32:287-93. |
| 20. | Francetti L, Del Fabbro M, Calace S, Testori T, Weinstein RL. Microsurgical treatment of gingival recession: A controlled clinical study. Int J Periodontics Restorative Dent 2005;25:181-8. |
| 21. | Andrade PF, Grisi MF, Marcaccini AM, Fernandes PG, Reino DM, Souza SL, et al. Comparison between micro- and macrosurgical techniques for the treatment of localized gingival recessions using coronally positioned flaps and enamel matrix derivative. J Periodontol 2010;81:1572-9. |
| 22. | Bittencourt S, Del Peloso Ribeiro E, Sallum EA, Nociti FH Jr., Casati MZ. Surgical microscope may enhance root coverage with subepithelial connective tissue graft: A randomized-controlled clinical trial. J Periodontol 2012;83:721-30. |
| 23. | Di Gianfilippo R, Wang IC, Steigmann L, Velasquez D, Wang HL, Chan HL. Efficacy of microsurgery and comparison to macrosurgery for gingival recession treatment: A systematic review with meta-analysis. Clin Oral Investig 2021;25:4269-80. |
| 24. | Ribeiro FV, Casarin RC, Palma MA, Júnior FH, Sallum EA, Casati MZ. Clinical and patient-centered outcomes after minimally invasive non-surgical or surgical approaches for the treatment of intrabony defects: A randomized clinical trial. J Periodontol 2011;82:1256-66. |
| 25. | Cortellini P, Tonetti MS. Microsurgical approach to periodontal regeneration. Initial evaluation in a case cohort. J Periodontol 2001;72:559-69. |
| 26. | Nasr HM. The use of dental operating microscope for retrieval of different types of fractured implant abutment screws: Case reports. Dentistry 2018;8:507. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
[Table 1], [Table 2]
|
Search Pubmed for