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Imperial Journal of Interdisciplinary Research (IJIR)

Vol-3, Issue-4, 2017

ISSN: 2454-1362,

Minimally Invasive Surgery - A Zenith

Forte In Periodontal Therapy
P. Sudhakar1, Satish. M2, Ramoji Rao M.V.3 &
Vidya Hiranmayi. K4
(M.D.S ,STUDENT), Department of Periodontics, Drs.S&NR Siddhartha Institute Of Dental
Sciences,Chinnaoutapalli, Gannavaram mandal ,Krishna District ,Andhra Pradesh, India.
(M.D.S,READER) Department of Periodontics, Drs.S&NR Siddhartha Institute Of Dental
Sciences, Chinnaoutapalli, Gannavaram mandal ,Krishna District ,Andhra Pradesh, India.
(M.D.S,PRINCIPAL & HOD) Department of Periodontics, Drs.S&NR Siddhartha Institute
Of Dental Sciences,Chinnaoutapalli, Gannavaram mandal ,Krishna District , Andhra Pradesh,
(M.D.S ,STUDENT) Department of Periodontics, Drs.S&NR Siddhartha Institute Of Dental
Sciences, Chinnaoutapalli, Gannavaram mandal ,Krishna District ,Andhra Pradesh, India.

Abstract : Performing minimally invasive surgical approach for periodontal regeneration would be one
procedure is enhanced by using microsurgical that allow access to the site to be regenerated
techniques. Periodontal microsurgery is the without extending the surgical incision into
refinement of basic surgical techniques made adjacent healthy areas1. In 1990, Wickham and
possible by the improvement in visual acuity gained Fitzpatric described the technique of using smaller
with the use of surgical microscope. In the last incisions as minimally invasive surgery3. The
decade, a special emphasis has been focused on the concept of minimally invasive surgery further
design and performance of surgical procedures for refined by Hunter and Sackier as the ability to
periodontal regeneration.. Minimally invasive miniature the operator eyes and extend his hands to
periodontal surgery can diminish the negative perform microscopic and macroscopic surgery4.
outcomes while increasing the efficacy of therapy. The application of minimally invasive surgery for
Minimally invasive periodontal surgery technique the treatment of periodontal attachment and bone
allows for minimization of soft tissue trauma and loss was first described by Harrel and Ress in
the removal of granulation tissue from periodontal 1995. Minimally invasive approach was later
defects using a much smaller surgical incision than modified to Modified Minimally invasive
that used in conventional surgical techniques. surgical technique (MMIST) in 2009 by
Further in order to improve surgical effectiveness, Cortenelli and Tonetti9. Main objective of the
the use of operating microscopes and minimal invasive treatment is minimizing trauma to
microsurgical instruments has been suggested. the tissues and still achieve a satisfactory
Future devices for performing minimally invasive therapeutic result. Microsurgery incorporates three
periodontal surgical procedures need to be easier different principles, That include improvement of
to use. motor skills to enhance the surgical ability of
operator, to obtain passive wound closure with
INTRODUCTION opposition of wound edges and reduce the tissue
trauma by using microsurgical instruments and
The aim of periodontal surgery has always been to suturing 5. The application of magnification to
alleviate or eliminate the degeneration associated periodontics promises to change clinical concepts
with progressive periodontal disease. In order to of periodontal surgical care. For these reasons
accomplish this goal, the access to the periodontal minimally invasive surgical procedures are
defect for debridement has been integral part of advantageous than conventional surgical
surgical therapy. Traditional surgical techniques procedures.5
used extensive flap procedures to access diseased
areas and treat the underlying bone damage1. With
the advent of more predictable regenerative REVIEW
therapy, the focus of periodontal surgery shifted The concept of minimally invasive surgery in the
from the removal of pocket walls to the re growth field of dentistry was introduced by Hareel and
and regeneration of lost tissue2. The ideal surgical Ress. Minimally invasive surgery (MIS) has been
defined as the ability to perform a procedure

Imperial Journal of Interdisciplinary Research (IJIR) Page 2149

Imperial Journal of Interdisciplinary Research (IJIR)
Vol-3, Issue-4, 2017
ISSN: 2454-1362,

through a substantially smaller surgical wound than eyesight can be achieved at a light density of 1000
had previously been necessary to accomplish the cd/m. At higher densities, visual acuity decreases.
same surgical goals. Minimal invasive surgical This, in turn, means that claims for optimal lighting
procedure is possible through the use of conditions have to be implemented. Visualization
magnifying instruments such has surgical of fine details is enhanced by increasing the image
microscope, surgical telescope, microsurgical size of the object. Image size can be increased in
instruments and materials6. There are three two ways
elements in microsurgery. These three elements 1. By getting closer to the objects
collectively called as microsurgical triad. It consists 2. By magnification. To see small objects in
of: operative field magnifying loupes can be used.
Magnification, Periodontal microsurgery is commonly performed
Illumination and at 10x to 20x magnification. In dentistry two basic
Microsurgical instruments7. types of magnification systems are commonly used:
Magnification: The first element of 2.Surgical microscope
microsurgical triad Loupes
An optimal vision is a stringent necessity in The most common magnification system used in
periodontal practice. Vision is a complex process dentistry is magnification loupes. Loupes are
that involves the cooperation of multiple links fundamentally two monocular microscopes, with
between the eye, the retina, the optic nerve and the side-by-side lenses, angled to focus on an object.
brain. Another important factor influencing visual The magnified image that is formed, has
acuity is the lighting. The relation between visual stereoscopic properties that are created by the use
acuity and light density is well established: a low of convergent lens systems. A convergent lens
light density decreases visual acuity. The best optical system is called as kaplerian optical system.



MICROSURGICAL TRAID It includes working distance, working range,

the use of convergent lens systems. A convergent convergence angle, field of view, Interpupillary
lens optical system is called as kaplerian optical distance and viewing angle.
system. Working distance
Principal optical features of loupes. The working distance is the distance measured
It includes working distance, working range, from the eye lense location to the object in vision.
convergence angle, field of view, Interpupillary Working range
distance and viewing angle. The working range (depth of field) is the range
Principal optical features of loupes. within which the object remains in focus.
Convergence angle

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Imperial Journal of Interdisciplinary Research (IJIR)
Vol-3, Issue-4, 2017
ISSN: 2454-1362,

The convergence angle is the pivotal angle aligning identical distance and angle.
the two oculars, such that they are pointing at the

Principal optical features of loupes spaces to gain additional refractory

surfaces. This allows increased
Field of view magnification with more favourable
The field of view is the linear size or working distance and depth of field.
angular extent of an object when viewed Magnification of compound loupes can be
through the telescopic system. increased by lengthen the distance
Interpupillary distance between lenses there by avoiding
The interpupillary distance depends on the excessive size and weight. These loupes
position of the eyes of each individual and are based on Galilean optical system and
is a key adjustment that allows long-term, allow a magnification of about2.5x.
routine use of loupes. Prism telescopic loupes
Viewing angle Prism loupes are the most optically advanced type
The viewing angle is the angular position of loupe magnification presently available. These
of the optics allowing for comfortable loupes actually contain Schmidt or roof-top prisms
working. that lengthen the light path through a series of
Three types of loupes are commonly used: mirror reflections within the loupe.They are
1. Simple loupes. superior to other loupes in terms of better
2. Compound loupes. magnification, wider depths of field, longer
3. Prism telescopic loupes. working distances and larger fields of view5.
Loupe Magnification
Simple loupes - Simple loupes consist of Wide ranges of magnifications are available in
a pair of single, positive, side-by-side loupes, ranging from 1.5x to 10x. Loupes with less
meniscus lenses. Each lens has two than 2x magnifications are usually inadequate for
refracting surfaces, with one occurring as the visual acuity necessary for microsurgery. For
light enters the lens and the other when it most periodontal procedures in which
leaves. Their magnification can only magnification is needed, loupes of 4X to 5X
increases by increasing lens diameter and provide an effective combination of magnification,
thickness. Its main advantage is that it is field size, and depth of focus5.
cost effective and light weight.5 Choice of Loupes
Compound loupes Before choosing a magnification system, different
Compound loupes use multiple loupes and appropriate time for a proper adjustment
converging lenses with intervening air have to be considered. Improperly adjusted loupes

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Imperial Journal of Interdisciplinary Research (IJIR)
Vol-3, Issue-4, 2017
ISSN: 2454-1362,

and the quality of the optics will influence the 2) A multitude of eye, neck, shoulder and back
performance. For the use in periodontal surgery, an problems that are common to dentists assuming a
adjustable, sealed prism loupe with high quality shorter working distance to increase visual acuity
coated lenses offering a magnification between 4x without magnification, may be eliminated by using
and 4.5x, either head band or front frame mounted, the surgical microscope.
with a suitable working distance and a large field of 3) Increasing the normal working distance by 6 to 8
view, seems to be instrument of choice5. inches has been shown to improve vastly the
Risks of the long-term use of magnification postural ergonomics and eye strain of industrial
Loupes are widely used for magnification their workers
major disadvantage is that the eyes must converge
to view an image. Individuals suffering from Benefits of Microscopes In Periodontics
convergence insufficiency, however, are potentially Operating microscopes offer three distinct
at risk when wearing loupes. Convergence advantages to the clinician: Illumination,
insufficiency occurs when the extrinsic eye muscles magnification and increased precision in the
responsible for turning the eyes medially delivery of surgical skills. Collectively, these
(convergence) appear to be weak in relation to the advantages are referred to as the microsurgical
muscles responsible for divergence (‘lazy eye’). In triad. The surgical operating microscope under
spite of this imbalance, the individual’s eyes magnification of 20x enhances visual acuity12. This
remain straight in all fields of gaze (compensation), leads to Increased precision in delivery of surgical
resulting in ‘strained eyes’. This can manifest itself skills, which results in more accurate incisions via
as headaches, eyestrain (pain), blurred vision, or smaller instrumentation, less trauma, and quicker
fatigue when engaged in extended periods of close post operative healing. Gentle handling of soft and
work. The condition most commonly occurs in hard tissues with the same universally accepted
teenagers and young adults, although it can occur surgical principles. Extreme and accurate wound
up to middle age. closure. Little damage as possible to the tissues and
Surgical microscope Ergonomic advantage.
The surgical microscope is a complicated system of Illumination: The second element of the
lenses that allows stereoscopic vision at a microsurgical triad
magnification of approximately 4–40x with an Since the beginning of the practice of dentistry,
excellent illumination of the working area. In dentists have recognized the importance of light in
contrast to loupes, the light beams fall parallel onto viewing their work. Most of the manufacturers
the retinas of the observer so that no eye offer collateral lighting systems or suitable fixing
convergence is necessary and the demand on the options. These systems may be helpful, particularly
lateral rectus muscles is minimal. The microscope for higher magnification in the range of 4X and
consists of the optical components, the lighting more loupes with larger field of view will have
unit, and a mounting system. To avoid an better illumination and brighter image than those
unfavorable vibration of the microscope during use, with narrower fields of view.
the latter should be firmly attached to the wall, the Fiber optic technology has improved the
ceiling or a floor stand. Mounted on the floor, the methods of focusing light on specific areas. Several
position of the microscope in the room must sources of fiber optic light can be attached to hand
provide easy and quick access. piece, instruments or loupes. Johnson et al
demonstrated that fiber optic illumination
The optical unit of the microscope includes the /transillumination is beneficial in removing
following components: deposits in moderate to deep periodontal pockets.
1. Magnification changer Fiber optic lighting is a standard feature of surgical
2. Objective lenses operating microscopes.
3. Binocular tubes
5. Lightning unit OF MICROSURGERY
6 Additional attach Proper instrumentation is fundamental for
microsurgical intervention. Microsurgical
Loupes Versus Operating Microscopes instruments are much smaller, often by tenfold.
Loupes and optical microscope have some common This creates a smaller surgical field with less injury
features which include : and bleeding. Microsurgical instrumentation can be
1) Both loupes and the operating microscope made with titanium or surgical stainless steel.
improve visual acuity and are beneficial in Titanium instruments tend to be lighter, but are
enhancing periodontist’s ergonomic comfort and more prone to deformation and are usually more
efficiency by increasing the optical working expensive. Appropriate sets of steel or titanium

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Imperial Journal of Interdisciplinary Research (IJIR)
Vol-3, Issue-4, 2017
ISSN: 2454-1362,

instruments for periodontal microsurgery are needle holding security. The presence of teeth in
available from different manufacturers. the tungsten carbide inserts provides the greatest
deterrent to either twisting or rotating of the needle
Internal Precision Grip between the needle holder jaws.
It is also called pen grip, which is ideal for Suture materials
microsurgical instrumentation. With this grip, the Suture material and technique are essential factors
external muscles of the hand, its flexors and to consider in microsurgery. The most popular
extensors, are relaxed to resist fatigue. As the technique for wound closure is the use of sutures
instruments are primarily manipulated by the that stabilize the wound margins sufficiently and
thumb, index and middle finger, their handles ensure proper closure over a defined period of time.
should be round, yet provide traction so that finely However, the penetration of a needle through the
controlled rotating movements can be executed. soft tissue in itself causes a trauma and the
The instruments should be approximately 18 cm presence of foreign materials in a wound may
long and lie on the saddle between the operator's significantly enhance the susceptibility to infection.
thumb and the index finger; they should be slightly Hence, it is obvious that needle and thread
top heavy to facilitate accurate handling. In order to characteristics influence wound healing and
avoid an unfavorable metallic glare under the light surgical outcome.
of the microscope, the instruments often have a Characteristics of the needle
colored coating surface. The weight of each The needle consists of a swage, body and tip and
instrument should not exceed 15–20 g (0.15–0.20 differs concerning material, length, size, tip
N) in order to avoid hand and arm muscle fatigue. configuration, body diameter, and the nature of
The needle holder should be equipped with a connection between needle and thread. In
precise working lock that should not exceed a atraumatic sutures, the thread is firmly connected to
locking force of 50 g (0.5–N). High locking forces the needle through a press-fit swage or stuck in a
generate tremor, and low locking forces reduce the laser-drilled hole. The body of the needle should be
feeling for movement. flattened to prevent twisting or rotating in the
A basic set of periodontal microsurgery comprises needle holder. In order to minimize tissue trauma in
1) Knives, periodontal microsurgery, the sharpest needles,
2) Micro scissors, reverse cutting needles with precision tips or
3) Anatomic and surgical forceps, spatula needle with micro tips are preferred . The
4) Needle holder, shape of the needle can be straight or bent to
5) Micro scalpel holder and various degrees. For periodontal microsurgery, the
6) Set of various elevator. 3/8” circular needle generally ensures optimum
Knives results.
These knives have their characteristic ability to There is a wide range of lengths, as measured along
create clean incisions to prepare the sharp flap the needle curvature from the tip to the proximal
margins for healing by primary intention. Using end of the needle lock. For papillary sutures in the
Castroviejo microsurgical scalpel, incisions are posterior area, needle lengths of 13–15 mm are
made at 90 degrees angles to the surface. appropriate. The same task in the front aspect
Magnification permits easy identification of ragged requires needle lengths of 10–12 mm, and for
wound edges for trimming and freshening. Various closing a buccal releasing incision, needle lengths
types of knives such as of 5–8 mm are adequate. To guarantee a
1. Blade Breaker Knife perpendicular penetration through the soft tissues
2. Crescent Knife without tearing, an asymptotic curved needle is
3. Mini crescent Knife advantageous in areas where narrow penetrations
4. Spoon Knife are required (e.g. margins of gingiva, bases of
5. Lamellar Knife papillae). To fulfill these prerequisites for ideal
6. Scleral Knife. wound closure, at least two different sutures are
Scissors used in most surgical interventions
The micro–vannas tissue scissors are used for
removal of small fragments of tissue. Characteristics of the suture material
The suture material may be either resorbable or
Needle Holders nonresorbable material. Within these two
In order to avoid sliding of the thread when tying categories, the materials can be further divided into
the knot, the tips of the forceps have flat surfaces or monofilament and polyfilament threads. The
can be finely coated with a diamond grain that bacterial load of the oral cavity demands attention
improves the security by which the needle holder in the choice of the suture material. Generally, in
holds a surgical needle. The configuration of the the oral cavity the wound healing process is
needle holder jaw has considerable influence on uneventful, hereby reducing the risk of infection

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Imperial Journal of Interdisciplinary Research (IJIR)
Vol-3, Issue-4, 2017
ISSN: 2454-1362,

caused by contamination of the thread. As REFERENCES

polyfilament threads are characterized by a high
capillarity, monofilament materials are to be
preferred. Pseudomonofilaments are coated
polyfilament threads with the aim of reducing 1. Harrel SK. A minimally invasive surgical
mechanical tissue trauma. During suturing the approach for periodontal regeneration. J
coating will break and the properties of the Periodontal 1999;70:1547-57.
pseudomonofilament thread then corresponds to 2. Nyman S, Gottlow J, Llindhe J,
that of the polyfilament threads . Additionally, Karring T, Wennstrom J. New
fragments of the coating may invade the attachment formation by guided tissue
surrounding tissues and elicit a foreign body regeneration. J Periodontol Res
reaction. 1987;22:252-254.
Resorbable sutures 3. Wickham, Fitzpatric JM. Minimally
Resorbable threads may be categorized as natural invasive surgery. J Periodontal
or synthetic. Natural threads (i.e. surgical gut) are 1990;71:721-722.
produced from intestinal mucosa of sheep or cattle. 4. Hunter JG, Sackier JM. Mlnimally
The twisted and polished thread loses its stability invasive surgery. J Periodontal 1993;12:3-
within 6–14 days by enzymatic breakdown. 6.
Histologic examinations confirmed the infl 5. Prabhati G. Periodontal microsurgery a
ammatory tissue reactions with a distinct infiltrate. review. J Dental and Medical sciences
For that reason, natural resorbable threads are 2014;13:12-17.
generally obsolete.Synthetic materials are 6. Fitzpatrick JM, Wickham JE.
advantageous due to their constant physical and Minimally invasive surgery. Br J Surg
biologic properties. The materials used belong to 1990;77:721-722.
the polyamides, the polyolefines or the polyesters 7. Jain R, Praveen K, Rakesh. Periodontal
and disintegrate by hydration into alcohol and acid. Microsurgery-Magnifying Facts,
Polyester threads are mechanically stable and, Maximizing Results. J Adv Med Dent Scie
based on their different hydrolytic properties, lose Res 2014;2:24-34.
their firmness in different, but constant times. A 8. Chirag S , Sameer S , Darshan .
50% reduction of breaking resistance can be Microsurgery in periodontics – Revisited.
expected after 2–3 weeks for polyglycolic acid and J Res Adv Dent 2012;1:22-24.
polyglactin threads, 4 weeks for polyglyconate, and 9. Harrel SK. A videoscope use in
5 weeks for polydioxanone threads. The threads are minimally invasive periodontal surgery. J
available in twisted, polyfilament forms, and Clinical Periodontol 2013;40:868-74.
monofilament forms for finer suture materials. The 10. Jan Lindhe Clinical periodontology and
capillary effect is limited and hardly exists for implant dentistry -5th edition.
polyglactin sutures. 11. Dannan A. Minimally invasive
periodontal therapy. J Indian soc
CONCLUSION 12. Takei H, Han T.J, Carranza F.A,
Kenney E. Flap technique for periodontal
Better devices to assist in visualizing small surgical bone implants. Papilla preservation
fields, better devices to prepare surgical sites, and technique. J Periodontol 1985; 56:204-
better instruments to aid in the placement of 210.
regenerative materials are all needed. Such 13. Cortellini P, Pini Prato G, Tonetti M.
advanced technologies, now ubiquitous across The modified papilla preservation tech-
medical-surgical disciplines. This is in contrast to nique. A new surgical approach for
periodontal practice where currently available interproximal regenerative procedures. J
minimally invasive surgical instruments are Periodontol 1995;06:261-266.
suboptimal modifications of instruments designed 14. Cortellini P, Pini Proto G, Tonetti M.
for large-field surgeries. Therefore, it seems to us The simplified papilla preservation flap. A
that for invasive periodontal surgical techniques to novel surgical approach for the
advance in parallel to advances in medicine, our management of soft tissues of in
specialty needs to embrace the possibility of new regenerative procedures. J Periodontol
technology. Otherwise, periodontics as a specialty 1993;64:261-268.
faces the ever-increasing risk of becoming 15. Anil Kapadia J, Surekha Y.
superfluous. Bhedasgoankar, Dilip Bhandari S.
Periodontal microsurgery: A case report. J
Ind Soc Periodontol 2013; 17;790-792.

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