role of microsurgery in periodontics

1. Microsurgery

2. Introduction
❯ Many new technologies are evolved to assist clinician and to enhance the
outcome of periodontal therapy. one among them is microsurgery
❯ microsurgery is defined as surgery performed under magnification of 10×or
more using a surgical microscope
where as periodontal microsurgery includes all the procedures done under
magnification starting from 2.5× onwards either using surgical loupes or microscope

3. ❯ The hallmarks of microsurgery are increased visual acuity
and improved manual dexterity when visibility
increased 10 fold ,motor movement precision is
increased from 1mm to 10 ųm
The techniques is used in periodontal plastic surgery, Guided
Tissue Regeneration, crown lenghting, dental implant placement
demand the clinical expertise beyond the normal visual acuity

4. Philosophy of periodontal microsurgery
❯ embraces 3 core values
❯ 1.enhanced motor skill for better surgical performance
❯ 》》》》This is accomplished through visual acuity and the use of
precise hand grip to improve accuracy and reduce tremor
❯ 2.minimal tissue trauma
❯ 》》》》this is accomplished through smaller incisions and
reduced surgical field
❯ 3.primary passive wound closure
❯ 》》》》this is accomplished by microsurgery to eliminate gaps
and dead spaces at the wound edge

5. ❯ in addition to the use of magnification and reliance on
atraumatic technique, it requires specially designed instruments to
minimize trauma
❯ Important characteristics to create clean incision that prepare
wounds for healing by primary intention
no:15 blade vs Opthalamic
blade
working tip of
conventional needle
holder vs McGregor
microsuturing forceps

6. Advantages
❯ ergonomic and body posture advantages occur
❯ neuromuscular fatigue and occupational skeletal pathology are
reduced
❯ motor skills are enhanced
❯ titanium instruments are used for the strength and lightness to
permit precise rotation
❯ can improve surgical performance
❯ helps in complete root debridement

7. Magnification systems
❯ dental loupes are most common systems of optical magnification
used in periodontics
❯ LOUPES are fundamentally dual monocular telescopes with side
by side lenses convergent to focus on operating field
A CONVERGENT LENS OPTICAL SYSTEM IS CALLED
AS KEPLERIAN OPTICAL SYSTEM _can result in eye
strain,fatigue,even pathologic vision changes after
prolonged use

8. ❯ 3 types of keplerian loupes are used they are
❯ 1.simple/Single _element loupes
❯ 2.Compound loupes
❯ 3.Prism telescopic loupes
❯ Each may differ from optical sophistication and individual design

9. Simple Loupes
❯ consists of a pair of single meniscus lenses
❯ primitive magnifiers with limited capabilities
❯ each lens is limited to only 2 retracting surfaces
❯ magnification can only increased by increasing lens diameter and thickness
❯ disadvantage: size and weight constraints make loupes impractical for
magnification beyond 1.5x
❯ greatly affected by spherical and chromatic abberation,this distorts the image
shape and color of objects viewed

11. Compound Loupes
❯ uses multi element lenses with intervening air spaces to gain
additional retracting surfaces ,thus allows magnification with
more favorable working distance and depth of field
❯ magnification can be increased by lenghting the distance b/w
lenses,thereby avoiding size and weight
❯ can be achromatic
❯ disadvantage:is optically ineffecient at magnifications above 3x

13. Prism Telescopic Loupes
❯ most advanced loupe optical magnification currently available is prism
telescopic loupe
❯ employ Schmidt or rooftop prisms to lenghten the light path through a series of
switchback mirrors b/w the lenses
❯ produced better magnification, wider depths of field,longer working distance
and larger field of view
❯ increased weight of loupes with magnification above 4x makes headband
mounting more comfortable and stable than eye_glass frame mounting
❯ RECENTLY COAXIAL FIBER OPTIC LIGHT IS INCORPORATED

15. magnification ranges of surgical loupes
❯ limited range of 1.5× to_6x
❯ less than 3x are inadequate surgical loupes providing
magnification of more than 4x are impractical because of small
field of view,excessive weight,shallow depth of focus
❯ for periodontal procedures prism telescopic loupes with
magnification 4x can provide adequate combination of
magnification
❯ however surgical microscope offers higher magnification and
superior optics compared to other loupes

16. surgical microscope
❯ Offers greater versatility than dental loupes,superior optics
❯ proficient use of microscope requires training and practice
❯ Surgical microscope used in dentistry employ Galilean optics,which has
binocular eyepieces joined by offset prisms,to establish a parallel optic axis and
without eye strain
❯ coated with achromatic lenses and high optical resolution and rotating
magnification element
❯ the working distance used range is 250_350mm
❯ used with lateral illumination or headlamps

17. ❯ documentation is important and surgical microscope Is an ideal
platform for periodontal pathologies and clinical procedures

18. esthetic periodontal microsurgery
❯ to reconstruct gingival tissue over denuded root is routine and
predictable using sub epithelial Connective Tissue grafting
❯ microsurgical closure of palatial donor site allows healing by
primary intention, thus reduces post operative pain
❯ principles of microsurgery:1.precise tailoring
❯ 2.delicate tissue manipulation
❯ 3.passive primary wound closure
❯

19. precise tailoring
❯ ability to make clear incision
❯ principles is to make incisions perpendicular to tissue
surface,creating "butt joint" edges that easily approximate for
wound edge stability and maintain blood supply patency
Delicate tissue manipulation
• gentle handling is necessary to reduce cellular injury and
subsequent necrosis ,inflammation
• also necessary to maintain tissue hydration and color to
maximize healing

20. passive primary wound closure
❯ final and critical element ,there is a specific geometry of the
suturing is required ,with the following 6 well defined components
❯ 1.Angle of entry and exit: should enter at 90°to tissue, passing
needle at an oblique angle cause tearing when knot is tied
❯ 2.bite size: ranges b/w 1 and 1.5 times the tissue thickness ,too
small cause tear the wound ,too large cause overriding of wound
❯ 3.direction of passage: perpendicular to the incisions line and
directs the suture force vectors at 90 ° and prevents lateral
dislocation at the wound edge

21. ❯ 4.Tension:minimal,gentle passage of suture in 90 degrees doesn't
cause tissue strangulation through ligation
❯ 5.symmetry:distance b/w bite sizes of wound edge should be
symmetrical as should the distance b/w sutures
❯ 6.frequency:smaller suture material and smaller bite size makes it
necessary to place more microsutures at the frequent intervals
along wound edges ,avoids stress breakage of sutures or tissue
tearing

22. microsurgical connective
tissue graft. Minimal trauma during
incisions, surgical manipulation and
suturing is accomplished after
microsurgical principles

23. Papilla
reconstruction
⇨
crown lenghting
⇨

24. microsurgical sutures
❯ size ranges from 6_0 to 9_0
❯ the size and shape of needle is essential for atraumatic passage of suture
❯ the needle diameter is slightly larger than the suture size
❯ the important component of needle design is the chord distance(lenght of a ,ine
drawn b/w the cutting point and swaged end),chord determines ease in passing
a suture b/w adjacent teeth
❯ the radius of the needle has an arc of 180° ,this determines the bite size and
angle of entry taken by needle

25. microsurgical knots
❯ Two basic knots are employed in microsurgery
❯ 1.English surgeon knot,composed of 2double loops thrown in opposite direction.
❯ 2.square or reef knot, composed of 2 single loops thrown in opposite direction
❯ 1. 1st thrown more likely to loosen,when performing 2nd thrown,making it easier to control tissue appositon
❯ 2. reef knot has more internal stability than other knot and ideal for primary wound closure(lies fast when tied
well),for this reasons it is employed in nautical applications
❯ As postsurgical edema occurs ,it opens slightly them becomes self locking
❯ It maintains wound edge support without ligation caused by excessive tension
• square knot • English surgeon knot

26. Conclusion
❯ Periodontal microsurgery includes all the procedures done magnification from
2.5×
❯ Advanced Periodontics has increasing need for clinical procedures that require
intricate surgical skills beyond the range of possibility with ordinary vision
❯ As Microsurgery has noted the extent which reduce incision size,less retraction
thus directly relating to reduced postoperative morbidity and rapid healing
❯ ergonomics, body posture,Visual acuity are maintained

27. ❯Thank-you