PERIODONTAL

MICROSURGERY

Presented to Presented by
Dr Ashutosh Nirola BHAVYA SHARMA
Dr priyanka
Dr kanika SINGLA
DR.KANIKA
DR.SHIVANI
CONTENTS

INTRODUCTION

HISTORY

THE MICROSURGICAL TRIAD

MAGNIFYING LOUPES
• SIMPLE LOUPES
• COMPOUND LOUPES
• PRISM TELESCOPIC LOUPES
MAGNIFICATION RANGE OF SURGICAL LOUPES

THE OPERATING MICROSCOPE

PERIODONTAL MICROSURGERY

ROOT PREPARATION

SURGERY UNDER MAGNIFICATION

MICROSURGICAL INSTRUMENTS

MICROSURGERY IN MUCOGINGIVAL SURGERY

MICROSURGERY IN ROOT COVERAGE PROCEDURES

APPLICATION IN MANAGEMENT OF FLAPS

MICROSURGERY IN SINUS LIFT PROCEDURES & IMPLANT THERAPY

SUMMARY & CONCLUSION

REFERENCES
INTRODUCTION
Magnification is a tool to lessen the effects of
compromise in treatment modalities.

Microsurgery in general ,is not an independent

discipline, but is a technique that can be applied to
different surgical disciplines.

The principle upon which all microtreatment procedure

is based is the observation that hand can perform
remarkably intricate micromanipulations as long as
the eye can see the magnified field and it can be
interpreted by the mind.
HISTORY
 2800 yrs back Simple glass meniscus lenses
were described in Egypt.

1694, ANTON VON First compound lens

LEWENHOCK microscope

CARL NYLEN,1921, FATHER OF 1ST surgical operation with a

MICROSURGERY microscope to correct
otosclerotic deafness.

JACOBSON & SWAREZ,1960 Microsurgically modified

techniques in plastic &
transplantation surgery.

HARRY BUNCKE, 1964, 1st succesful

FATHER OF MODERN replantation(reattachment of
VASCULAR MICROSURGERY amputated body part)

TAMAI, 1993 Microscope for use in

Ophthalmology.
FIELDS OF APPLICATIONS

Otolaryngologists Microsurgery on the

small, delicate structures
of the inner ear or the
vocal cords
Ophthalmologists Remove cataracts,
perform corneal
transplants and treat
glaucoma
Urologists Reverse vasectomies

Gynaecologists Reverse tubal ligations

PERIODONTAL MICROSURGERY
 HISTORY
APOTHEKER & JAKO ,1978 first introduced the
microscope in dentistry

CARR, 1992 published an article

outlining the use of
surgical microscope during
endodontic procedure
SHANELEC & TIBBETTS presented a continuing
,1993 education course on
periodontal microsurgery
at the annual meeting of
AAP
RUBINSTEIN & KIM 1999, introduction of
2002 microendodontic
techniques
 DEFINITION
It was broadly defined as – “surgery performed under
magnification of 10x or more which is only possible by the
microscope.”
Daniel RK 1979

Serafin (1980) defined microsurgery as “a methodology–a

modification and refinement of existing surgical techniques
using magnification to improve visualization-that had
implications and applications to all specialities”.

Microsurgery is defined as a refinement in operative

technique by which visual acuity is increased using a
microscope at magnifications exceeding 10x.
(Tibbets LS 1991-1997)
Virtual cellular level >>>>
1 mm to 10 µm
THE MICROSURGICAL TRIAD
(KIM ET AL , 2001)

Illumination

Magnification Instruments
PHILOSOPHY OF PERIODONTAL
MICROSURGERY : 3 CORE VALUES

Enhanced
motor skill

Primary Minimal
passive tissue
wound trauma
closure
 ILLUMINATION
Fiber optic technology has revolutionized this
aspect of instrumentation and improved the method
of delivering and focusing light to specific areas.

Fiber optic sources of light can be attached to hand

pieces, scalers, instruments and magnification
loupes.
Fiber optic lighting is a standard feature of surgical
operating microscopes.
 Visual acquity

( best eye
sight can be Lightining nd
achieved at light density
light density of
1000cd /m2)
 MAGNIFICATION

Saemisch, a German ophthalmologist, introduced

simple binocular loupes to ophthalmic surgery in
1876, and since then, dentists also used the same in
operative dentistry.

Today a wide range of simple and complex magnifying

systems are available to dentists, allowing
improvement in the accuracy of their clinical skills.
An optimal vision is a stringent necessity in periodontal
practice.

Visualization of fine details is enhanced by ↑sing the

image size of the object, 2 ways:
1. By getting closer to the object
2. By magnification

, the clinical procedure which may only be performed

successfully with the use of magnification improving
precision, & hence the quality of work.
ASPECTS OF MAGNIFICATION THAT AFFECT
EQUIPMENT SELECTION:

Working distance: its the distance between our eye and

the working site.

Depth of field: it is the range over which we are able to

achieve visual resolution(discrimination).

Width of field: also called “field of view”, represent the

width and height of the area the practitioner sees while
using the magnification device.
 4% loss in
transmission

Antirefractive
coating
WORKING RANGE

Is the range within which the

object remain in focus
Basically there are two types of optical
magnification available to dentists:
Magnification Loupes
SIMPLE SINGLE-LENS
MAGNIFIERS (clip-
COMPOUND on,flip-up,jeweller’s
glasses)
PRISM MULTI-LENS
TELESCOPIC LOUPES

Operating Microscopes
KEPLERIAN OPTICS

EYE

LENSES

OBJECT
 SIMPLE LOUPES
Pair of single meniscus lenses.

Primitive magnifiers with limited capabilities.

Each lens  2 refracting surfaces.

Magnification can be increased by increasing lens

diameter & thickness.
meniscus lenses are convex-concave lenses.

They have one outward curved face and one

inward-curved face. If the outward curve is
sharper than the inward curve, the lens has a
positive focal length and acts as a magnifier.
DISADVANTAGES

Affected by spherical &

Size & weight constraints.
chromatic abberations.

This distorts the image

Impractical beyond 1.5 X
shape & colour of the
magnification.
object being viewed.
Diopter Magnification Disadvantage
??????
 COMPOUND
LOUPES

Compound loupes use converging multiple lenses with intervening

air spaces to gain additional refracting power, magnification,
working distance & depth of field.

Such loupes can be adjusted to clinical needs without excessive

increase in size or weight.

Compound lenses can be achromatic in addition to offering

substantially improved optical design.
COMPOUND LOUPE OPTICAL DIAGRAM
 SIMPLE LOUPE COMPOUND LOUPE

Pair of single meniscus Multielement lenses

lenses

Each lens limited to only 2 Multielement with

refracting surfaces, intervening air spaces to
gain additional refracting
surfaces.
Magnification can only ↑ by ↑sd by lengthening the
↑sing lens diameter & distance between the lenses
thickness. , avoiding excessive size &
wt.
Impractical beyond 1.5 X Optically insufficient
beyond 3X
Greatly affected by Can be achromatic
spherical & chromatic
abberations
PRISM LOUPES

The most optically advanced type of loupe magnification

presently available.

The loupes actually contain Schmidt/Roof-top prisms that

lengthen the light path through a series of mirror reflections
within the loupes, virtually folding the light so that the barrel
of the loupe can be shortened.

Recent innovationcoaxial fiberoptic lighting incorporated

in the lens element to improve illumination.
ADVANTAGES

Better Wider depths of

magnification. field.

Longer working Larger fields of

distances . view.
Binocular prism loupes
 LOUPE MAGNIFICATION

Loupes are capable of providing a wide range of magnification (1.5x

to 10x).

Less than 2x is insufficient for microsurgery where as more than

4.5x can be awkward due to narrow field size and depth of focus.

For most periodontal procedures in which magnification is needed,

loupes of 4x to 5x provide an effective combination of
magnification, field size and depth of focus.
DISADVANTAGES OF LOUPES

The eye must converge to view the

object.

Eye fatigue.

Eye strain.

Vision changes with prolonged

usage of poorly fitting loupes.
OPERATING MICROSCOPE

The operating microscope offers a flexibility and comfort

vastly superior to magnifying loupes.

More expensive & more difficult to use.

Operating microscope use the application of the magnifying

loupe in combination with a magnification changer and a
binocular viewing system, so that it employs parallel
binoculars for protection against eye strain & fatigue.
Operating microscope also incorporate fully coated optics with
achromatic lenses to provide the highest resolution and
most efficient illumination.

The most important advantage of the surgical operating

microscope is the ability of the clinician to easily change
the working magnification level .

Operating microscopes have a rotating variable

magnification element that may be changed easily to allow
the clinician to quickly adapt the magnification levels to
operative procedure demands.
Some operating microscope incorporates electronic zoom
optics for further convenience.

Depth of focus and field of view characteristics are

enhanced several fold.

For practical use in periodontics a surgical microscope must

have both maneuverability and stability.

Microscope mountings are available for ceiling, wall or floor;

inclinable eyepieces also lend flexibility to the clinical use of
the surgical microscope in periodontics.
Coaxial fiberoptic illumination produces an
adjustable bright, uniformly illuminated, circular spot
parallel to the viewing axis that is shadow free.

For documentation, beam –splitter camera

attachment is also available.
The beamsplitter allows the light path to be split allowing a video
camera, digital camera, or an assistant head to be attached to the
microscope. The most common beamsplitter used is a 50-50 / 20-80,
which means one side splits the light into 50% to the user’s eye and
50% to the digital camera. The 20-80 is 20% to the camera and 80%
to the user’s eye.
Although microscopes are capable of
much greater magnification, factors
greater than 20x are unnecessary
for dentistry.

For periodontics, optimal

magnification factors range from
5x to 12x.
 Wall mounted

Movable operating
microscope

Floor mounted

rrect posture with back &

arms supported
 ADVANTAGES OF OPERATING
MICROSCOPE

Greater operator eye comfort because of the parallel viewing

optics of the Galilean system.

Range of variable magnification.

Excellent coaxial fiberoptic illumination.

Countless accessories such as still and video cameras for case

documentation.
 ADVANTAGES OF LOUPES OVER
MICROSCOPE

Less expensive .

Easier to use .

Tend to be less cumbersome in the operating field.

Less likely to breech a clean operative field.

 DISADVANTAGES OF LOUPES OVER
MICROSCOPE

Lack of variable magnification.

Individual light source may be required.

Protective coating of antireflective material to

prevent loss of light transmitted is essential.
 BENEFITS OF DENTAL MICROSCOPE FOR
PERIODONTAL APPLICATIONS

Allows surgeon to minimize the size of the surgical site,

reducing patient discomfort and healing time.

Improves accuracy of microsurgical incisions and

suturing permitting precise tissue/tissue and tissue/tooth
approximation for primary wound healing.

Allows for better inspection and diagnosis of abnormal soft

tissue lesions of the gingiva, palate and mucosa.

Improves visualization of root surface and adjacent intra-

bony defects for definitive removal of calculus.
Aids identification of micro-inflammation during re-
evaluation following non-surgical therapy.

Permits micro-level osseous surgery facilitating bone removal

without nicking the root surface and allows for better
periodontal ligament preservation during ostectomy.

Permits accurate subepithelial placement and suturing of

membranes and sub epithelial connective tissue grafts.

Permits precise control of laser surgery on adjacent teeth

without injury to root or implant surfaces.

Permits accurate root amputations & hemisections.

Facilitates sinus lift procedures through direct visualization of
the sinus membrane during dissection.

Permits location of the PDL for atraumatic elevation of roots

and root tips during extraction with concurrent ridge
preservation/augmentation.

Provides upright working conditions, alleviating occupational

neck, back and shoulder problems.

Provides high – resolution video and 35 mm photography for

patient education, enhanced training, and insurance/ legal
documentation.
MICROSURGICAL
INSTRUMENTS
AS THE INSTRUMENTS ARE PRIMARILY MANIPULATED BY THE THUMB, INDEX AND
MIDDLE FINGER, THEIR HANDLES SHOULD BE ROUND, YET PROVIDE TRACTION SO
THAT FINELY CONTROLLED ROTATING MOVEMENTS CAN BE EXECUTED.
THE ROTATING MOVEMENT OF THE HAND FROM TWO O’CLOCK TO SEVEN O’CLOCK
(FOR RIGHT-HANDED PERSONS) IS THE MOST PRECISE MOVEMENT THE HUMAN BODY
IS ABLE TO PERFORM.
The instruments should be approximately 18 cm long and lie on the
saddle between the operator’s thumb and the index fi nger; they
should be slightly top-heavy to facilitate accurate handling
In order to avoid an unfavorable metallic glare under the light of the
microscope, the instruments often have a coloured coating surface.
The weight of each instrument should not exceed 15–20 g (0.15–0.20
N) in order to avoid hand and arm muscle fatigue.
The needle holder should be equipped with a precise working lock
that should not exceed a locking force of 50 g (0.5–N). High locking
forces generate tremor, and low locking forces reduce the feeling for
movement.
Appropriate sets of steel or titanium instruments for periodontal
surgery are available from different manufacturers.
When the needle holder jaws are closed, no light must pass through
the tips. Locks aid in the execution of controlled rotation movements on
the instrument handles without pressure.
The tips of the forceps should be approximately 1–2 mm apart,
when the instrument lies in the hand idly.
 Micro mirrors with sapphire
surfaces
Round (5mm) nd rectangular

Balanced instruments
 No. 15 microsurgical
scalpel blade
SMALLER INSTRUMENTS
Mini crescent
microsurgical blade
Several types of ophthalmic knives such as crescent,
lamellar, blade breaker sclera and spoon knife can be used in
the field of periodontics.

Ophthalmic knives offer the dual advantages of extreme

sharpness & minimal size.

Ophthalmic knives are chemically etched rather than ground, their

sharper blades produce a more precise wound edge.

Compared with the standard 15 blades commonly used in

periodontics, the smaller size of the ophthalmic knives facilitates
surgical work.
The crescent knife can be used for intrasulcular
procedures.

The knife is designed with a unilateral level & measures

2.4mm x 3.7mm.
It can be used in connective tissue graft procedures to
tunnel, to prepare the recipient site or to obtain the donor
graft.
The spoon knife is often used for
placement of connective tissue grafts
using sulcular, non-relief technique.

This knife is also beveled on one side,

thereby allowing the knife to track
through the tissue adjacent to bone.
OTHERS

Needle holders
Forceps Scissors
(for suturing)

Vascular clamps Irrigators (for Vessel dilators (for

(for controlling washing opening up the
bleeding) and structures in the cut end of a blood
clamp applicators surgical field) vessel)

Holders, pick-ups
Various standard
& standard needle
surgical tools
holder
Finer-tipped scissors are used for dissection, less fine for
suture cutting only.
Needle-holders used in microsurgery usually have
curved jaws as they provide positional advantage in
placing sutures. The jaw surfaces are flat and apposing.
Locking needle-holders are a disadvantage because of
the lurch incurred in locking and unlocking and are not
recommended.
Fine tipped vessel dilators with a round end profile may
be used to dilate vessel ends when there is spasm and a
fine (32g) irrigator tip are used for hydro dissection and
for washing blood out of the ends of cut vessels before it
clots and adheres to the endothelium.
Castroviejo needle holder
& Laschal micro scissors
 SUTURE MATERIALS

Conventional suturing usually requires gauges of 2-0 (0.3

mm) to 6-0 (0.07 mm). Conversely, gauges of 9-0 (0.03 mm)
to 12-0 (0.001 mm) are generally used for microsurgery.

Suture thread may be absorbable or non-absorbable, natural

or synthetic.

The type of suture thread used depends on the procedure and

tissue to be sutured.
The suture needle comes in various

- sizes (diameters and length)

- shapes (straight or curved)

- different point types (rounded, cutting, or blunt)

As in the case of suture thread, the type of needle used depends on

the procedure and tissue to be sutured; generally, needles with a
diameter of less than 0.15 mm are used for microsurgery.
 FACTORS TO CONSIDER IN THE
SELECTION OF A SUTURE NEEDLE

Chord length: the straight line- distance from the point of a

curved needle to the swage

Needle length: the distance measured along the radius of the

needle to the point to the end

Radius: The needle radius most commonly used Is the 3/8th

circle, but the 1/4th circle & ½ are also used

Diameter: The thickness or gauge of the needle wire

 SUTURE GEOMETRY

It consists of:

Needle angle of entry & exit of slightly less than 90°

Suture bite size of ~ 1.5 times the tissue thickness

Equal bite sizes on both sides of the wound

Needle passage perpendicular to the wound

 KNOT TYING

Knot tying is done using instrument ties with microsurgical needle

holder in the dominant hand & a microsurgical tissue pick up in
the non dominant hand

Only the working tips of the instrument are visible in the

microscopic field

Well tied micosurgical suture knots are stable & resist loosening
even under frictional loads

The art of microscopically tying a good surgeon’s knot, reef knot or

clinching knot can only be mastered by repeated lab practice under
the microscope
Proper wound codaptation &
suturing

Microsurgical reef knots

REEF KNOT
SURGEON “S KNOT
 IMPROVED ROOT VISUALIZATION

Lindhe and co-workers (1984) suggested that a critical

determinant of the success of periodontal therapy is the
thoroughness of Debridement of the root surface.

Visual access substantially improves the operator’s ability

to remove calculus.

Magnification can enhance the effectiveness of

periodontal calculus removal.
 MICROSURGERY IN MUCOGINGIVAL
SURGERY
Periodontal microsurgery has proven to be an effective means
of improving the predictability of gingival transplantation
procedures used in treating recession with less operative
trauma and discomfort.

Correct diagnosis with microsurgical techniques, makes

complete root coverage extremely predictable in Class I
and Class II marginal tissue recession.

The partial root coverage results achieved in Class III & Class
IV marginal recession with conventional surgery can also be
greatly enhanced through the use of microsurgery.
Microsurgery provides a predictable means of improving the
reliability of the three broad types of gingival
transplantation procedures used in treating gingival
recession

Vascularized graft – The high survival rate of the

vascularized graft is due to the retained blood supply from
base of the pedicle, which can be enhanced through
microsurgery.
Avascular graft – The lack of full root coverage predictability
with this procedure is due to the high degree of operator and
technique sensitivity. Microsurgery offers the possibility of
greatly enhanced results with the avascular graft.
 Papillary reconstruction.
MACROSCOPIC SURGERY

MICROSCOPIC SURGERY
MACROSCOPIC SURGERY

MICROSCOPIC SURGERY
Palatal donor site closure
MINIMALLY INVASIVE SURGERY (MIS)
FOR REGENERATION (HARREL ET AL.,
1999)

MIS is a surgical technique using very small incisions &

limited access approach indicated for performing
regenerative therapy in periodontal defects.

Visualization during MIS requires some form of

magnification and a light source that can be focused
into the surgical site.
 ADVANTAGES
Improvements in probing depths and CAL similar to
traditional techniques.

Better retention of graft material.

Improved retention of soft tissue height and contour.

Improved rate of healing.

Less post-op pain.

Improved patient acceptance.

 Cortellini & Microsurgical The use a
GTR & Case
Tonetti, MICROSURGICAL
series approachTECHNIQUE
was microsurgical
(2001) tested in approach was
procedures of GTR, associated with
in combination
with: simplified clinically important
papilla amounts of CAL
preservation flap gains and minimal
(<2mm), recessions
modified papilla
preservation flap
technique (>2mm)
and
crestal incision
(next to edentulous
area) depending on
the clinical
situation
MICROSURGERY AND (ENAMEL MATRIX
DERIVATIVES) EMDOGAIN® COMBINATION

Wachtel et al. Assessed the In terms of PPD

(2003) clinical effect of reduction and
the CAL gain, the
microsurgical combination
access flap and with EMD
EMD treatment application
with an appeared to be
emphasis on the superior to the
evaluation of microsurgical
early wound access flap
healing alone.
Cortellini & Tonetti EMD + MIST ( with Confirmed the
(2007) microsurgical previous positive
techniques). results, yeilding a
primary wound
closure of the
interdental tissues,
6 weeks , post –
operatively.

Fickl S et al. (2009) Evaluated the effect The combination of

of a microsurgical a microsurgical
approach for the access flap with
treatment of intra- EMD seemed to be
bony defects with superior to open
and without an flap debridement
enamel matrix in terms of PPD
derivative (EMD) reduction, CAL gain
and radiographic
bone fill.
MICROSURGERY IN ROOT COVERAGE
PROCEDURES

Evaluated the degree of vascularization of connective tissue

grafts by applying a microsurgical approach.

10 patients with bilateral Class I and II recessions at maxillary

canines - In split-mouth design.

Immediately after the surgical procedures, and after 3 and 7

days of healing, fluorescent angiograms were performed to
evaluate graft vascularization.

(Burkhardt et al,2005)
The percentage of root coverage both test and control sites
remained stable during the first year at 98% and 90%,
respectively.

The study clearly demonstrated that mucogingival surgical

procedures designed for the coverage of exposed root surfaces,
performed using a microsurgical approach, improved the
treatment outcomes substantially and to a clinically relevant
level when compared with the clinical performance under
routine macroscopic conditions.

(Burkhardt et al .,2005)
Luca Francetti et 16 cases treated Total gain was
al. (2004) – Case with a free rotated estimated at
series papilla autograft 97.03%.
technique
combined with
coronally
advanced flap
using Surgical
microscope at 4x -
8x magnification.
Luca Francetti et 24 recession cases The application of
al.(2005) of 2-5mm deep. magnification
They treated 12 gave better results
patients with as compared to
microscope and 12 conventional
without. method.
 Bittencourt S et al. Compared root Use of the surgical
(2009) coverage, microscope was
postoperative associated with
morbidity and additional clinical
esthetic outcomes of benefits in the
SCTG technique with treatment of teeth
or without the use of with gingival
a surgical recessions.
microscope

Latha TA et al. (2009) Evaluate the success Use of magnification

and predictability of in mucogingival
a rotated papillary surgery resulted in
pedicle graft in achieving a high
combination with degree of success and
the coronally predictability as well
advanced flap using as an excellent
surgical loupe (2.5X esthetic outcome.
magnification)
 PERIODONTAL ENDOSCOPY

The periodontal endoscope allows for subgingival

visualization of the root surface at magnifications of 24x to
48x.
This is accomplished through a 0.99 mm fiber optic bundle
that is a combination of a 10,000-pixel capture bundle
surrounded by multiple illumination fibers.
This fiber is delivered to the gingival margin coupled into an
instrument called an “explorer.” A single-use sterile
sheath isolates the fiber so it can be used repeatedly (average -
70 to 80 uses per fiber).
The captured image is relayed to a screen so that the user can
see “real time” video of the highly magnified environment
(approximately 3 mm on screen at a time).
PERIODONTAL ENDOSCOPY
TOMS - THREE DIMENSIONAL ON-SCREEN
MICROSURGERY SYSTEM

As an alternative to the operating microscope, advances in

video technology can now permit the surgeon to view a
micro-surgical field on a video monitor in three
dimensions without the necessity of physically
looking through the microscope eyepieces.
(Ralph JPM Franken)
 COMPONENTS OF TOMS

Two single chip videocameras (Sony XC-999) mounted

on custom fit eyepiece adapters .
A dual camera-controller.
A view/record image processor.
An VCR for optional recording.
A digital monitor .
A synchronizing signal emitter .
120 MHz shutter glasses
(stereo eye wear).
 MICROSURGERY IN SINUS LIFT
PROCEDURES & IMPLANT THERAPY
One of the novel applications of microsurgery is in the
sinus lift procedure. The surgical microscope can aid in
visualization of the sinus membrane.

A simple non-traumatic subantral sinus lift microsurgery

was presented by Steiner GG et al. (2010). This sinus lift
microsurgery resulted in a 97% implant success rate.
Improves visualization of implant sites with minimal space
between teeth and helps in evaluating the exact fit of
implant prosthetic components and the health of
marginal tissues around implant.

Permits fine dissection of the mandibular and mental

nerves for lateral displacement during mandibular implant
procedure.
 ERGONOMICS

The ergonomics of hand position and body posture is

closely related to the improved motor skills made
possible by a microsurgical approach to therapy. Studies
show that motor coordination is greatly improved when
surgeons use microsurgical instruments specifically
designed to employ a precision grip of the hand.
MICRO / MACRO SURGERY ???

Root
coverage

Pappilla
preservations
SUMMARY & CONCLUSION
 Microsurgery offers possibilities to improve
therapeutic results of various procedures.

A number of periodontal and implant reconstructive

procedures can be performed using minimally
invasive approaches.

Future comparative studies will produce the evidence

whether the use of the surgical microscope will further
increase surgical effectiveness and thus become an
indispensable part of periodontal surgical practice.
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Root Coverage With Subepithelial Connective Tissue Graft: A Randomized-
Controlled Clinical Trial. J Periodontol, Posted online on August 26, 2011.
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 Thank
you

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THANK YOU….