This document provides information on microsurgery and microsurgical instruments. It discusses the history of magnification in surgery and introduces microsurgery. Key aspects of microsurgery include enhanced visualization through a microscope and less traumatic tissue handling. The document then describes different types of magnification systems used, including loupes and surgical microscopes. It outlines the benefits of microscopes and characteristics of ideal surgical loupes. Microsurgical instruments are also introduced, including scalpels, needles, sutures, needle holders, and forceps. Proper storage of microinstruments is also mentioned.

2. • Deepu Mathews
• Associate Professor
• Malabar Dental College & Research Centre
• Manoor - Chekanoor Road, Manoor, Edappal,
Kerala 679582
• https://macity.edu.in/

3. • Microsurgery is defined as a refinement in operative
technique by which visual acuity is enhanced through
the use of the surgical operating microscope.
• In microsurgery, there is great reduction in surgical
damage to the tissues due to the excellent
visualization of the operative field through
microscope, this least traumatic surgical approach
being possible because of magnified surgical field
and enhanced dexterity of the surgeon leading to less
injury and more meticulous tissue handling.

4. HISTORICAL PERSPECTIVE
References to magnification date back 2,800 years, when
simple glass meniscus lenses were described in ancient
Egyptian writings.
In 1694, Amsterdam merchant Anton van Leeuwenhook
constructed the first compound-lens microscope.
Magnification for microsurgical procedures was
introduced to medicine during the late 1800s. In 1921, Carl
Nylen, who is considered the father of microsurgery,
first used the binocular microscope for ear surgery.

5. Apotheker & Jako first introduced the microscope to dentistry
in 1978.
In 1993, Shanelec & Tibbetts presented a continuing
education course on periodontal microsurgery at the annual
meeting of the American Academy of Periodontology.

6. Research demonstrates that root preparation is enhanced
when performed under illumination (Reinhardt et al.
1985). The surgical microscope provides fiber optic
lighting and magnification for calculus removal.
Burdhardt & Lang 2005 conducted a study that
performing root-coverage techniques microsurgically
versus macrosurgically microsurgery substantially
improved the vascularization of connective tissue grafts
and the percentage of additional root coverage

7. MAGNIFICATION SYSTEMS
• Basically, there are two types of optical magnification
available:
I. Magnifying loupes : Also called as Keplerian loupes
Types commonly employed in dentistry
• Simple loupes
• Compound loupes
• Prism telescopic loupes
II. Surgical microscope

8. Magnifying loupes
• Simple Loupes: Simple loupes consist of a pair of
single, side by side meniscus lenses. Each lens has
two refracting surfaces.
• Cost is the sole advantage of simple loupe.

9. • Disadvantages are
• a) They can distort the image of the object that is being
viewed;
• b) They have no practical dental application beyond a
magnification range of 1.5 diameter, where working
distances and depths of field are compromised.

11. • Compound Loupes: Compound loupes use
converging multiple lenses with intervening air spaces
to gain additional refracting power, magnification,
working distance and depth of field.
• Compound loupes are commonly mounted in or on eye
glasses. Multi element compound loupes become
optically inefficient at magnifications above 3.0
diameters.

13. Prism Telescopic Loupes
• These are the most optically advanced type of loupes.
These loupes employ rooftop prisms to lengthen the
light path.
• Advantages are :
• a) better magnification; b) wider depths of field; c)
longer working distance; and d) larger fields of view
than other loupes.
• The barrels of prism loupes are short to be mounted
on either eyeglass frames or headbands.

15. • However, the increased weight of prism telescopic
loupes with magnification above 3x makes headband
mounting more comfortable and stable than eyeglass
frame mounting.
Surgical Microscope
• The surgical microscope is a complicated system of
lenses that allow binocular viewing at a magnification of
approximately x4 to x40. It consists of the magnification
changer, lenses, lighting unit, binocular tubes and
eyepieces. It can be fixed to the floor or wall or ceiling.

19. Properties of ideal surgical loupes
•Light weight: No pressure is felt on the nose bridge while wearing these
loupes
•Advanced optic lenses: These have a clearer image, wider field of
view, sharper picture, and a greater depth of visual field
•Vertical and interpupillary adjustment: This enables the operation to be
performed with a comfortable posture.
•Magnification (range, 2.5 to 8 fold) and working distances (range,
14–22 inches)
•Mounting choice: Spectacle frames and headband
•Low cost
The usual magnification of loupes for a general dentist is 2.5 to 3.5 fold.
However, the magnification for a periodontist is 3.5 to 4.5 fold.

20. BENEFITS OF MICROSCOPE
The operating microscope offers three distinct
advantages to periodontist:
•Illumination,
•Magnification
•Increased precision of surgical skills (Belcher 2001).
The synergy of improved illumination and increased
visual acuity enables the increased precision of
surgical skills. Collectively, these advantages can be
referred to as the microsurgical triad.

22. • The advantages of microscopes over loupes is that of
greater comfort and same view can be shared on to a
monitor for teaching and a better team work, or even
record the surgery.
MICROSURGICAL INSTRUMENTS
• Design of Microinstruments : They should be
approximately 18 cm long. Their handles have cross -
sectional diameter to enhance rotary movements using
the precision grip. The weight of each instruments
should be a maximum of 15 to 20 g to avoid hand and
muscle fatigue. They are made up of titanium to reduce
weight and prevent magnetization.

23. Scalpel and blades:
• The knives most commonly used in periodontal
microsurgery are those used in ophthalmic surgery:
blade breaker, crescent, mini crescent, spoon, lamella,
and scleral knives Because ophthalmic knives are
chemically etched rather than ground, their sharper
blades produce a more precise wound edge.

25. • The blade-breaker knife has a handle onto which a
piece of an ophthalmic razor blade is affixed. This
allows for infinite angulations of the blade. This
knife is often used in place of a no. 15 blade.
• The crescent knife can be used for intrasulcular
procedures. It is available with one-piece handles or
as a removable blade. It can be used in connective
tissue graft procedures to obtain the donor graft, to
tunnel under tissue, and to prepare the recipient site.

26. • The spoon knife is beveled on one side, allowing the
knife to track through the tissue adjacent to bone. It is
frequently used in microsurgical procedures to
undermine tissue, enhancing the placement of a
connective tissue graft.
• Retractors and elevators have been downsized. Scissors
such as the micro–vannas tissue scissors are used
for removal of small fragments of tissue.

27. Sutures and Needles
• For suturing in microsurgery, microsutures from 8-0 to 11-0
are used. The largest sutures used in current microsurgical
techniques, 8-0 sutures, are often chosen for use by
novices; 9-0 sutures are used for 1- to 2-mm-vessel anas-
tomosis; 10-0 sutures are used to repair small arteries or veins
with a nerve diameter of less than 1 mm; and 11-0 sutures, the
least commonly used, are reserved for special situations.

28. • Reverse cutting needles with precision tips or spatula
needles with micro tips are preferred.
Reverse cutting needles have a greater degree of firmness
than round-body needles, which is advantageous for the
penetration of coarse gingiva.

29. • The most common curvature of needles used in dentistry
is three-eighths inch (10 mm) and one-half inch (12.7
mm),the former being the most common.
• A spatula needle, which is beneficial in periodontal
microsurgical procedures, is 6.6 mm long and has a
curvature of 140°. An accepted surgical practice is to use
the smallest suture possible to hold the mending tissue
adequately (Johnson & Johnson 1994)
• Bite size is 1.5 times the tissue thickness. Polypropylene,
is the optimum suture material for microsurgery.

31. Suture card
• This device used to practice suturing is made of
silicon rubber or plastic and divided into 16 squares.
Incisions are made on the silicon sheet in each
square.
• A total of more than 350 stitches can be made in
each suture card. Different sized sutures can be
practiced on this card to refine technique

35. Micro needle holder:
• The needle holder is used to grasp the needle,
pull it through the tissues, and tie knots. The
needle holder should be equipped with a precise
working lock that should not exceed a locking
force of 50g. High locking forces generate tremor
and reduce the feeling for the movement

36. • The needle holder is mainly manipulated by the
thumb, index, and middle fingers, similar to how a
pencil is held between the fingers.
• The appropriate needle-holder length depends on
the nature of the operation. The most commonly used
are 14 cm and 18 cm. The tips can be straight or
gently curved.
• Delicate tip (0.3 mm) is used for 8-0 and 10-0 sutures.
The needle holder with a 1-mm tip is used for 5-0 and
6-0 sutures.

37. Microscissors
• These are used for the dissection of tissues, blood
vessels, and nerves.
• The most commonly used micro scissors are 14 cm and
18 cm long. To manage the delicate part of the adventitial
tissues, 9-cm micro scissors are preferable.
• The tips of the scissor blades can be straight or
gently curved. Straight scissors cut sutures and trim the
adventitia of vessels or nerve endings. Curved scissors
dissect vessels and nerves.

38. Surgical and Anatomical forceps
• As an innovation, the surgical forceps is designed
as a combination instrument. It is an anatomical
forceps that converts into a surgical forceps at its
end. This combination enables mucosal flaps to be
seized and the thread to be knotted without a
change of instruments ·

39. • In order to avoid sliding of the thread when the tips of the
forceps have flat surfaces. The latter should be designed
fine and rough needles. When 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 1 to 2 mm apart when
the instrument lies in hand without any pressure.

40. Storage of instruments:
In order to prevent damage, microinstruments are stored in
a sterile container or tray.
The tips of the instruments must not touch each other during
sterilization procedures or transportation.

41. Position Of Surgeon
• A microsurgeon’s chair is required to provide proper
arm and hand support. The surgeon must be seated upright
with the legs extending forward and with both feet
flat on the floor.
• Support of the wrist is necessary to control or reduce
tremor. The surgeon’s head should be held in a comfortable
upright position. Proper ergonomics can help to prevent
neck and back injuries resulting from poor chairside habits.

43. • In microsurgery, the hand should either directly or
indirectly rest on an immovable surface or unwanted
movements will occur, only the fingertips move.
• Microsurgical instruments are most stable when held
like a writing instrument . Needles are best gripped
about two-thirds down from the end of the needle.

45. ROLE OF MICROSURGERY IN PERIODONTAL
PROCEDURES
• The reason microsurgery has gained acceptance among is
not due to the reduced morbidity but rather, the endpoint
appearance of microsurgery is simply superior to that of
conventional surgery. The difference is shown in cleaner
incisions, closer wound apposition, reduced hemorrhage
and reduced trauma of the surgical site

46. • In periodontal plastic surgery, the aesthetic and
functional results are equally important. Due to
microsurgical technique,optimal aesthetics can be
obtained in microgingival surgery
• Various microgingival surgical procedures are:
i. Tissue grafting procedure to correct gingival recession
a. Free epithelial grafting
b. Subepithelial connective tissue grafting
ii. Papilla reconstruction procedures

48. CONCLUSION
• Microsurgical periodontics requires a different
practitioner mindset. It is technique-sensitive and more
demanding than periodontal macrosurgery, but it results
in more rapid healing because it is less invasive and less
traumatic.

49. • The operating microscope allows the surgeon to
practice enhanced, precise, delicate surgical procedures
that have important healing processes and outcomes tor
patients.
• Periodontal microsurgery provide a natural evolution
in the progression of periodontics.