includes various minimally invasive surgical techniques with recent advances in techniques

1. MINIMALLY INVASIVE
SURGICAL TECHNIQUES
(MIST)
Dr. Gulafsha. M
Post graduate
Dept of Periodontology

2. CONTENTS
INTRODUCTION
HISTORY
RATIONALE
FEATURES OF MINIMALLY INVASIVE PERIODONTAL SURGERY (MIPS)
- INCISION
- FLAP ELEVATION
- USE OF MICROSCOPE
- SUTURING
EFFICACY & EFFECTIVENESS OF MIPS
RECENT UPDATION
DISADVANTAGES OF MIPS
CONCLUSION
REFERENCES

3. • Conventional periodontal surgical therapies involve extensive tissue reflection resulting in morbidity
like thermal sensitivity, food impaction, and compromised esthetics.
• The clinical innovation in periodontal flap design and handling has radically changed surgical
approach, which has allowed a drastic reduction in wound failure when compared to conventional
flap approach.
INTRODUCTION

4. Data from controlled clinical trials and meta analyses from
systematic reviews demonstrate that minimal invasion
approaches provide added benefits in terms of clinical
attachment level gain and probing pocket depth reduction as
compared with access flap alone.
These include barrier membranes, demineralized freeze dried bone
allograft, a combination of barrier membranes and grafts and enamel
matrix derivative (EMD).

5. • In fact, flap dehiscence at regenerative sites is a frequent occurrence with barrier membranes, bone
grafts, combination of barriers and grafts and, to a lesser extent, with EMD.
• Exposure and thus contamination of the regenerative material is a critical issue because it has been
associated with reduced clinical outcomes.
• Thus, in order to further increase surgical effectiveness, the use of operating microscopes and
microsurgical instruments in terms of MIPS has been suggested.

6. MIPS technique allows for minimization of soft tissue trauma
and the removal of granulation tissue from periodontal
defects using a much smaller surgical incision than that used
in standard bone graft techniques.
MIPS can be used for patients who have many isolated
defects, so long as the incision at one site does not connect
with the incisions at other sites to become a continuous
incision.

7. HISTORY
• The term “minimally invasive surgery” was first coined by the general surgeons Filtzpatrick and
Wickham in 1990.
• The concept of “minimally invasive surgery (MIS)” is one such peculiar and innovative
approach which aims to produce minimal wounds, minimal flap reflection, and gentle
handling of the soft and hard tissues (Harrel et al. 2005).
• It was further explored by Hunter and Sackier in 1993. They defined minimally invasive
surgery as the ability to perform a traditional surgical procedure and achieve the same or
better outcomes utilizing a surgical opening that was smaller than the traditional surgical
access.

8. • MIS was first introduced into the periodontal field with intent
to treat multiple and isolated periodontal intrabony defects in
1995.
• Minimally invasive surgery for periodontal therapy was
introduced by Harrel SK in 1998.
• (1) minimal mesiodistal extension of periodontal flap,
• (2) minimal flap elevation to expose only 1 to 2 mm of alveolar bone,
• (3) to avoid placement of vertical incision, but if necessary confined within attached
gingiva and not extending beyond mucogingival junction, and
• (4) to avoid periosteal incision
OBJECTIVES

9. • The use of microscope in periodontal surgeries for better visualization
during manipulation and suturing of soft tissues was introduced by
Tibbetts and Shanelec.
• The techniques were then called as “periodontal microsurgeries”
mainly to address the techniques aided by a specific technology such as
microscopes.
• A broader term “minimally invasive periodontal surgery” (MIPS) was
introduced later to describe the smaller more precise surgical
techniques that are possible through the use of operating microscopes
and other technologies that are beginning to be available for the use in
periodontal surgery.

10. RATIONALE
Reduction of
surgical
trauma
Increase in
flap/wound
stability
Improvement
of primary
closure of the
wound
Reduction of
surgical chair
time
Minimization
of intra-
operative and
post-operative
patient
discomfort and
morbidity

11. FEATURES OF MIPS
INCISION
FLAP
ELEVATION
USE OF
MICROSCOPE
SUTURING

12. INCISION
• MIPS technique allows for minimization of soft tissue trauma and the
removal of granulation tissue from periodontal defects using a much smaller
surgical incision than that used in standard bone graft techniques.
• The incisions are designed to preserve as much of the soft tissue as possible.
It is started with intra-sulcular incisions surrounding the teeth adjacent to the
defect.
• These incisions are not connected across the interproximal tissue and should
be made as separate incisions to preserve the inter-proximal tissue.

13. • The 2 intrasulcular incisions are connected with a single horizontal incision that is
placed 2–3 mm from the crest of the papilla.
• When the surgery is being performed in an esthetic area, such as the maxillary
anterior, this horizontal incision will usually be placed on the palatal aspect of the
papilla. This will help to preserve the shape of the papilla as well as cover the
grafted site with soft tissue.
• In a nonesthetic area, the horizontal incision can be placed either buccally or
lingually as needed to better cover the grafted site with soft tissue.

14. The use of Tunnel Technique
(TT) in periodontal surgery is
considered an important element of
MIPS.
This technique is originated
primarily from the Envelope
Technique (ET) developed by
Raetzek in 1985 for the treatment
of single gingival recessions.
In the TT, intrasulcular incisions
are first initiated and then
followed by supraperiosteal
preparation of a tunnel through
the defect areas.
This will allow the transplantation
of subepithelial connective tissue
graft (SCTG) in the sulcular areas.

16. • Single Incision Technique (SIT), described by Hurzeler and Weng, for the extraction of SECTG
from the palate, is more preferable than using Trap Door Incision Technique (TDIT).
The Single-lncision Palatal Harvest Technique: A Strategy
for Esthetics and Patient Comfort Eduardo R. Lorenzana.
(lnt J Periodontics Restorative Dent 2000;20:297-305

17. Schematic illustration of the new modification for the single
incision palatal harvest technique.
A: Incision perpendicular to the palatal tissue until reaching
the bone in a horizontal direction.
B: Elevation of 1 to 2 mm of a full thickness flap.
C: Dissection of the partial thickness flap.
D: Graft harvesting from the flap.

18. The surgical access to the interdental papilla associated with the intrabony defects can be selected
among 3 different surgical approaches
Cortellini P. Minimally invasive surgical techniques in periodontal regeneration. Journal of Evidence Based Dental Practice.
2012 Sep 1;12(3):89-100.

19. FLAP ELEVATION
• In MIPS, the flaps are elevated utilizing sharp dissection only. This could be achieved by means of
Orban knives that have been reshaped to one third to one fourth of their original size.

20. The use of the small Orban knives will allow the blade to be placed into the previously made intrasulcular
incision and, with the tip of the knife angled toward the center of the papilla, perform a thinning and
undermining incision.

21. • The use of sharp dissection minimizes trauma to the flap and preserves much of the blood
supply to the soft tissue.
• When blunt dissection has been used to elevate MIPS flaps, obvious blanching of the
reflected tissue has been noted. This often leads to a darkened bruised appearance of the flap
at the time of closure.
• When this bruised appearance is present, an increased incidence of postsurgical flattening of
the papilla, interproximal cratering, and loss of soft tissue height is observed compared with
when only sharp dissection has been used.

22. • Specific surgical approaches have been reported to prevent
or reduce an excessive apical displacement of the gingival
margin in the treatment of periodontal defects.
• Takei et al. proposed a new surgical approach called the
papilla preservation technique.
PAPILLA PRESERVATION FLAP

24. • Cortellini et al. published a modification of Takei's technique as a
new approach for interproximal regenerative procedures called (the
modified papilla preservation technique) in 1995.
• A horizontal incision is performed on the buccal papillary tissue at the
base of the papilla. A full thickness palatal flap, which includes the
interdental papilla, is elevated.
• A buccal full thickness flap is elevated with vertical releasing
incisions and/or periosteal incisions, when needed.
• A barrier membrane is positioned to cover the defect. The interdental
tissues are repositioned and sutured to completely cover the
membrane.
MODIFIED PAPILLA PRESERVATION TECHNIQUE

25. This technique is applicable in wide interdental spaces (2 mm), especially in the anterior
dentition. This technique allows for achieving primary closure of the tissue and preserving the
papilla in 75% of cases.
A horizontal internal crossed mattress suture is placed beneath the mucoperiosteal flaps
between the base of the palatal papilla and the buccal flap. This suture relieves all the tension of
the flaps.
A second suture (vertical internal mattress suture) is placed between the buccal aspect of the
interproximal papilla and the most coronal portion of the buccal flap to ensure primary closure.

26. Cortellini et al.(1999)
proposed the simplified
papilla preservation flap
(SPPF).
A full thickness palatal
flap, including the papilla,
and a split thickness
buccal flap are then
elevated.
The interdental tissues
are positioned and
sutured to obtain primary
closure of the interdental
space. The SPPF is
applicable in narrow
interdental spaces (2
mm).
SIMPLIFIED PAPILLA
PRESERVATION TECHNIQUE

27. Whales tail technique
• Bianchi and Basseti in 2009 introduced a surgical
technique to preserve interdental tissue in guided tissue
regeneration known as a “whale’s tail” technique.
• It was used for the treatment of wide intrabony defects
in the esthetic zone involving the elevation of a large flap
from the buccal to the palatal side to allow accessibility
as well as visibility of the intrabony defect and to
perform GTR while maintaining interdental tissue over
grafting material.

28. MIS- (Harrel and Rees, 1995) aimed to produce minimal wounds,
minimal flap reflection, and gentle handling of the soft and hard
tissues, retention of the preoperative gingival position and to
minimize the occurrence of gingival recession architecture.
MIST- (Cortellini P and Tonetti MS, 2007) stressed the aspects of
wound and blood clot stability and primary wound closure for
blood clot protection and favourable esthetic outcome with
reduction in postsurgical contraction and morbidity.
M-MIST- (Cortellini P and Tonetti) additionally, incorporated the
concept of space provision for regeneration.

29. • MIST- used for treatment of multiple intrabony defects whereas,
• M-MIST- for isolated intrabony defects.
• The basic ideology behind MIST follows the concepts of MIS and in addition involves the application of
papilla preservation techniques with a microsurgical approach.
• The design of M-MIST allows both access to root surface instrumentation and minimization of flap
elevation through the elevation of the buccal flap alone. Enhances stability of blood clot and prevents the
collapse of the papilla into the defect thereby preserving more space for the regeneration to occur.

30. Minimally invasive surgical technique

31. Modified-Minimally invasive surgical technique

32. Selection of the regenerative material is based on the defect anatomy and on the flap design chosen
to expose the defect
Cortellini P. Minimally invasive surgical techniques in periodontal regeneration. Journal of Evidence Based Dental Practice.
2012 Sep 1;12(3):89-100.

33. TREATMENT OF GINGIVAL RECESSION WITH MIST
POUCH AND TUNNEL TECHNIQUE
PINHOLE TECHNIQUE
VISTA TECHNIQUE

34. The tunnel technique
• In 1994 Allen AL introduced the tunnel procedure for root coverage, it was
termed the supraperiosteal envelope.
• The tunnel technique has a minimally invasive nature since the interdental
papillae are left intact and vertical incisions are not performed which results in
better esthetics. This technique entailed the placement of a connective tissue
graft in the tunnel.
• Coronal advancement of the marginal tissue was then performed as a
modification to the tunnel technique, which allowed complete graft coverage.

35. The tunnel technique
This tunneling under the papillae and lateral extension of the pouch facilitate the passive coronal
advancement of the pouch, thus eliminating the need for vertical releasing incisions as well as
papillary incision

37. Pin hole technique
Reddy SS. Pinhole surgical technique for treatment of marginal tissue recession: A case series. J Indian Soc Periodontol
2017;21:507-11
Chao introduced
Pinhole technique for
Miller class I, II, and
III recession defects
and reported
favorable
predictability for root
coverage and defect
reduction up to 18
months follow up.

38. Vestibular Incision Subperiosteal Tunnel Access
(Vista Techniques)

39. NONINCISED PAPILLAE SURGICAL APPROACH
(NIPSA)
Moreno Rodriguez JA,Ortiz Ruiz AJ, Pardo Zamora G, Pecci-Lloret M, Caffesse RG. Connecive Tissue Grafts with Nonincised
Papillae Surgical Appoach for Periodontal Reconstruction in
Noncontained defects. International Journal of Periodontics &Restrorative Dentistry. 2019 Nov 1:39(6).

40. Visualization
USE OF MICROSCOPE
• The use of magnification and optimal illumination of the surgical field in MIPS greatly improves
the visual acuity and the control of the surgical instruments, making it possible to perform surgery
with reduced flap reflection.
• Thus, in order to further increase surgical effectiveness, the use of operating microscopes and
microsurgical instruments in terms of MIPS has been suggested, and the use of a microsurgical
approach in combination with different regenerative materials resulted in maintenance of primary
wound closure in more than 92% of the treated sites for the whole healing period.

41. Periodontal microsurgical techniques have been described by Tibbetts and
Shanelec

42. • During MIPS, it is often necessary to visualize the defect from several
angles to verify the debridement areas of the osseous defect or the root
surfaces.
• It is difficult to move a surgical microscope from one visualization angle to
another rapidly.

43. Head banded microscope
So that the easiest method to achieve a good magnification of the surgical field is a head banded microscope, which could
be placed on the head of the surgeon and can be easily directed during surgery. An appropriate lightening can be also
added to the headband.

45. • In order to guarantee atraumatic surgical approach in the MIPS, the use of miniaturized
operation instruments is considered to be of great importance.
Generally, a useful microsurgical tray for the routine use in MIPS should include:
• (1) microraspatorium
• (2) bone scraper
• (3) papilla elevatorium
• (4) microscalpel holder
• (5) needle holder
• (6) microscissor
• (7) dental microforceps.

48. Defect Debridement
• The granulation tissue is removed using a curette with its tip inserted vertically into the defect and its
shank held parallel to the long axis of the tooth.
• This will minimize the trauma to the flap. The ultrasonic scaler can be additionally used to break up the
granulation tissue into smaller fragments. A granulator can also be utilized to remove the remaining
granulation tissue. Final root planing and smoothening is accomplished with a highspeed surgical length
finishing bur.

49. SUTURING
• An important element of MIPS is the use of suitable microsuturing.
• This includes the materials to be used as well as the suturing technique itself.
From minimally invasive point of view, monofilament suturing materials are
atraumatic, whereas polyfilament suturing materials may carry the “wicking
action” and therefore contribute to wound contamination from saliva.

50.  In the anterior areas, it is recommended to use the vertical
mattress suture.
 In the premolar and/or molar areas, the use of modified
matress suture is a better choice. These techniques help
removing the collapse of gingiva and enhancing optimal
adaptation of wound edges.
 Continuous suturing may be achieved wherever releasing
incisions have been done.

51. Periodontal videoscope
• The term Videoscope assisted minimally invasive surgery (V-MIS) is
used to describe MIS performed with the aid of a videoscope.
• Proper visualization of the surgical site is of utmost importance in MIS.
Hence a videoscope comprising of a small digital camera was
developed.
• This camera when placed at the surgical site provides direct visualization
and greater magnification (Harrel et al. 2012, 2013).

52. • Harrel SK et al in 2014 conducted a study to evaluate residual defects
following non-surgical therapy consisting of root planing with local
anaesthetic.
• V-MIS was performed utilizing the videoscope for surgical visualization. Re-
evaluation, 6 months post-surgery, showed statistically significant
improvement in mean PPD and CAL (PPD 3.88±1.02 mm, CAL 4.04±1.38
mm) in 1, 2, and 3 wall defects.

54. ROBOT-ASSISTED MINIMALLY INVASIVE SURGERY (RMIS)
• Robot-assisted minimally invasive surgery (RMIS) promises to be a evolutionary step
towards refining MIS.
• It would greatly improve the accuracy and dexterity of a surgeon while minimizing
trauma to the patient.
• Robotically assisted minimally invasive surgery uses robotic arms to perform the
actual surgery on the patient.
• These arms can either be controlled by a telemanipulator or through computer control.

55.  In the telemanipulator approach, the surgeon performs the normal movements associated with
the surgery while the robotic arms replicate them onto the patient.
 The computer controlled approach allows the surgeon to use a computer to control the robotic
arms.
 However; clinical studies using RMIS have shown only marginal success.
 A major disadvantage includes large size footprints and cumbersome robotic arms.
 Due to feasibility constraints, long term studies using RMIS have not been conducted.

56. INDICATIONS
1. An ideal site for bone grafting using
MIPS is an ISOLATED, usually
interproximal defect that does not extend
significantly beyond interproximal site.
2. Less than ideal site is a defect that
extends to buccal and/or lingual from
interproximal area
3. Defects that border on an edentulous
area
4. MIPS can be used for patients who have
many isolated defects, so long as the
incision at one site does not connect
with incisions at other sites to become a
continuous incision.

57. Generalized horizontal bone loss or multiple interconnected vertical defects are thought to be
contraindicated for MIPS and are best handled with more traditional surgical approaches.
CONTRAINDICATIONS

58. ADVANTAGES
1. MIPS has a high potential for achieving and maintaining primary closure leading to less contamination from
oral environment
2. Soft-tissue height and contour are mostly preserved leading to minimal gingival recession meeting the demands
of patients and clinician in the esthetic zone. These distinguishing features of MIS might be attributed to decreased
tissue manipulation, lessened overall trauma, and enhanced blood supply to the surgical sites
3 This technique allows for minimization of soft-tissue trauma and removal of granulation tissue using much
smaller surgical incision than standard surgical procedure
4. Gentle handling of tissue leads to less postsurgical complications such as pain, swelling, and flap dehiscence.
5.. Uninvolved areas can be spared by decreasing surgical area span.

59. DISADVANTAGE
• According to Jaffray disadvantages of minimally invasive surgery, in general, are related
to the fact that
1. It requires special equipment
2. Specialist training is probably required
3. Some additional equipments could be more expensive
4. Some procedures may take longer than usual, compared with conventional surgeries.

63. REFERENCES
• Minimally invasive periodontal therapy -clinical techniques and visualization technology. Stephen K. Harrel, thomas G.
Wilson jr.
• Carranza’s clinical periodontology, 12th ed.
• Harrel sk. A minimally invasive surgical approach for periodontal regeneration: surgical technique and observations. J
periodontol. 1999;70:1547–1557.
• Cortellini p, tonetti ms. Minimally invasive surgical technique and enamel matrix derivative in intrabony defects . I: clinical
outcomes and morbidity. J clin periodontol. 2007;34:1082– 1088.
• Harrel sk, wilson tg jr, riverahidalgo f. A videoscope for use in minimally invasive periodontal surgery. J clin periodontol.
2013;40:868–874.
• Jan lindhe, clinical periodontology and implant dentistry, 5th ed.
• Aous dannan, minimally invasive periodontal therapy. J indian soc periodontol. 2011 octdec; 15(4): 338–343.
• Wickham j. Minimally invasive therapy. Health trends. 1991;23:6–9.
• Cortellini P. Minimally invasive surgical techniques in periodontal regeneration. Journal of Evidence Based Dental Practice.
2012 Sep 1;12(3):89-100.
• Moreno Rodriguez JA,Ortiz Ruiz AJ, Pardo Zamora G, Pecci-Lloret M, Caffesse RG. Connecive Tissue Grafts with
Nonincised Papillae Surgical Appoach for Periodontal Reconstruction in Noncontained defects. International Journal of
Periodontics &Restrorative Dentistry. 2019 Nov 1:39(6).

64. THANK YOU