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Year : 2022  |  Volume : 3  |  Issue : 2  |  Page : 29-35

Conceptual approach to periodontal microsurgery: An insight

Department of Periodontics and Oral Implantology, Kalinga Institute of Dental Sciences, KIIT Deemed to be University, Bhubaneswar, Odisha, India

Date of Submission20-Sep-2021
Date of Acceptance19-Dec-2021
Date of Web Publication9-Mar-2022

Correspondence Address:
Riddhi Awasthi
Department of Periodontology, Kalinga Institute of Dental Sciences, Campus 5, KIIT University, Patia, Bhubaneswar - 751 024, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcdoh.jpcdoh_35_21

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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 Top

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 Top

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 Top

Microsurgery features three important principles:[7]

  1. Motor skills improvisation, thus advancing surgical skill
  2. To emphasize on primary apposition of the wound edge so that passive wound closure can be achieved.
  3. The use of microsurgical instrumentation and suturing to reduce tissue trauma.

  Microsurgical Triad Top

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.
Figure 1: Microsurgical triad

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  Ergonomics in Microsurgery Top

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]
Figure 2: Patient and surgeon positioning

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  1. 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
  2. Upper body: The surgeon's head should be held in a comfortable upright position
  3. 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
  4. 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 Top
[Figure 3]

Figure 3: Periodontal microsurgical instrument types

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Diagnostic instruments

Micromirrors with flexible neck are available in different shapes to provide improved illumination [Figure 4].
Figure 4: Micromirrors

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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].
Figure 5: Microexplorers

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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.
Figure 6: Blade-braker, crescent and spoon knives

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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].
Figure 7: Soft tissue elevators

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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].
Figure 8: Soft-tissue retractors

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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.
Figure 9: Handpiece with Bur

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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.
Figure 10: Curettes

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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.
Figure 11: Pen grasp grip

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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]
Figure 12: Needle grip

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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].
Figure 13: Entry and exit route of needle

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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]
Table 1: Types of magnification systems and its structural components

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  1. Loupes
  2. Microscope.

Periodontal Microsurgical Procedures [Figure 14][8]
Figure 14: Periodontal microsurgical procedures

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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

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  Conclusion Top

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


Conflicts of interest

There are no conflicts of interest.

  References Top

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Belcher JM. A perspective on periodontal microsurgery. Int J Periodontics Restorative Dent 2001;21:191-6.  Back to cited text no. 2
Yadav VS, Salaria SK, Bhatia A, Yadav R. Periodontal microsurgery: Reaching new heights of precision. J Indian Soc Periodontol 2018;22:5-11.  Back to cited text no. 3
[PUBMED]  [Full text]  
Daniel RK. Microsurgery: Through the looking glass. N Engl J Med 1979;300:1251-7.  Back to cited text no. 4
Serafin D. Microsurgery: Past, present, and future. Plast Reconstr Surg 1980;66:781-5.  Back to cited text no. 5
Tibbetts LS, Shanelec D. Periodontal microsurgery. Dent Clin North Am 1998;42:339-59.  Back to cited text no. 6
Acland R. Practice Manual for Microvascular Surgery. 2nd ed. St Louis: CV Mosby; 1989.  Back to cited text no. 7
Tibbetts LS, Shanelec D. Principles and practice of periodontal microsurgery. Int J Microdent 2009;1:13-24.  Back to cited text no. 8
Belcher J. Periodontal microsurgery. In: Dibart S, editor. Practical Periodontal Plastic Surgery. Bhubaneswar: Kalinga Institute of Dental Sciences; 2017. p. 13-20.  Back to cited text no. 9
Price PB. Stress, strain and sutures. Ann Surg 1948;128:408-21.  Back to cited text no. 10
Belcher JM. Periodontal microsurgery. In: Dibart S, Karima M, editors. Practical Periodontal Plastic Surgery. Oxford, USA: Blackwell Munksgaard; 2006. p. 15-22.  Back to cited text no. 11
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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.  Back to cited text no. 16
[PUBMED]  [Full text]  
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.  Back to cited text no. 17
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Burkhardt R, Lang NP. Coverage of localized gingival recessions: Comparison of micro- and macrosurgical techniques. J Clin Periodontol 2005;32:287-93.  Back to cited text no. 19
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.  Back to cited text no. 20
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.  Back to cited text no. 21
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.  Back to cited text no. 22
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.  Back to cited text no. 23
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.  Back to cited text no. 24
Cortellini P, Tonetti MS. Microsurgical approach to periodontal regeneration. Initial evaluation in a case cohort. J Periodontol 2001;72:559-69.  Back to cited text no. 25
Nasr HM. The use of dental operating microscope for retrieval of different types of fractured implant abutment screws: Case reports. Dentistry 2018;8:507.  Back to cited text no. 26


  [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]


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