This document provides an overview of periodontal microsurgery. It begins with an introduction to microsurgery, discussing the rationale and historical background. It then covers principles of microsurgery including magnification systems, microsurgical instruments, and indications for periodontal microsurgery. The document discusses loupes, the surgical operating microscope, and three-dimensional on-screen microsurgery systems. It also covers hand control, microsurgical instruments including blades, scissors, and needles, and techniques for microsurgery.

1. PERIODONTAL MICROSURGERY
Dr. R. Dhivya – III yr PG Student
1

2.  Introduction
 Definition and terminologies
 Rationale for microsurgery
 Historical Background
 Principles of microsurgery
 Elements - Microsurgical Triad
 Clinical Philosophy
 Magnification Systems
 Hand control during microsurgery
 Microsurgical instruments
 Indications Of Periodontal Microsurgery
 Video
 Limitations of microsurgery
 Recent Advances
 Conclusion
 References
Contents
2

3. INTRODUCTION
LASERS
MICROSURGERY
LOCAL DRUG DELIVERY
IMPLANTOLOGY MUCOGINGIVAL SURGERY
TISSUE ENGINEERING
3

4. PERIODONTAL MICROSURGERY
 There has been a tremendous advancement in the medical and
dental fields to meet the patient’s expectations and to achieve
much desired therapeutic goals.
 Microsurgery is an advanced surgical technique in which the
normal vision is enhanced through magnification.
 The use of microsurgical instruments, improved view of root
surfaces permit more definitive removal of calculus and better
smoothness of root.
 Studies have demonstrated improved vascularization, enhanced
mobility of flaps, and hence, possibility of obtaining primary
wound closure, less post-operative discomfort, thus providing
better esthetic results. 4
“Events that spawn a paradigm begin with a vision.”

5. Definition and terminologies
 In 1979, Daniel RK defined microsurgery in broad terms as “Surgery performed under
magnification by the Microscope”.
 In 1980, Serafin described microsurgery as a methodology – “A modification and refinement
of existing surgical techniques using magnification to improve visualization, with applications
to all specialities.”
 Periodontal microsurgery is the refinement of basic surgical techniques made possible by the
improvement in visual acuity gained with the use of the surgical microscope - INT JOURNAL
OF MICRO DENT 2009
5

6. Rationale for microsurgery
Reduce the
amount of
trauma to
the tissue
Minimal
manipulation
of the tissue
Better blood
perfusion
and healing
is faster with
minimal scar
formation
Least
possible
trauma to
the graft
Less
bleeding
with clear
vision
Healing by
primary
intention
Patient
acceptance
6

7. Historical Background
• In 1694, Amsterdam merchant Anton van Leeuwenhook constructed the first compound lens microscope.
• Saemisch, a German ophthalmologist, introduced simple binocular loupes to ophthalmic surgery in 1876.
• In 1921, Carl Nylen, who is considered the father of microsurgery, first used a binocular
microscope for ear surgery.
• During 1950s, Barraquer began using the microscope for corneal surgery.
• Apotheker and Jako first introduced the microscope to dentistry in 1978.
• During 1992, Carr published an article outlining the use of the surgical microscope during
endodontic procedures.
• In 1993, Shanelec and Tibbetts presented a continuing education course on periodontal microsurgery
at the annual meeting of the American Academy of Periodontology.
7

8. Principles of microsurgery
Microsurgery incorporates three important principles :
Improvement of motor skills, thereby enhancing surgical ability.
An emphasis on passive wound closure with exact primary
apposition of the wound edge.
The application of microsurgical instrumentation and suturing
to reduce tissue trauma.
8

9. Elements of microsurgery
Microsurgical Triad– Kim et al (2001)
Magnification – Perceive two
closely lying objects
seperately
Illumination –
Visualization of fine details
Instruments – To perform
micro-surgeries
9

10. Clinical Philosophy
 Consistent application of the philosophy and techniques learned in basic microsurgery
education is necessary for the operator to attain a level of experience and competence
needed for various periodontal surgical procedures.
 Effective periodontal microsurgery allows the operator to consistently achieve clinical results
that were once thought to be unlikely.
 Becoming a clinically proficient periodontal microsurgeon requires a willingness to adopt
new values and ideas.
 The development of new thought patterns regarding surgical esthetics is necessary and
attention must be paid to microanatomy, tissue manipulation, and surgical craftsmanship
10

11. Magnification Systems
Loupes
Surgical
operating
Microscope
(SOM)
Three
dimensional on
– screen
microsurgery
system (TOMS)
Magnification system
11

12. Loupes
 Loupes are the most common form of magnification used in dentistry.
 Fundamentally, loupes are two monocular microscopes with side by- side lenses
that are angled to focus on an object.
 Surgical loupes for magnifi cation enable the clinician to experience the ergonomic
benefi ts of an increased working distance from viewing object as well as
improved visual acuity.
 The pattern of convergent lens system is called a Keplerian optical system.
 Three types of Keplerian loupes commonly used in periodontics are:
i) Simple loupes, ii) Compound loupes, and iii) Prism loupes.
12

13. Simple loupes
 Simple loupes are primitive magnifiers with limited capabilities, consisting of a
pair of single, positive, side-by-side meniscus lenses.
 The disadvantage of simple loupe is that they are highly subjected to spherical
and chromatic aberration, which distorts the image of the object that is being viewed.
 In spite of its cost advantages, the size and weight limitations make simple loupes
impractical for magnifi cation beyond 1.5 diameters.
Advantage
- Low cost.
Disadvantage
- Subjected to spherical and chromatic aberration, that ultimately distorts the
image and color of the object that is being viewed.
- Their size and weight limits the practical application in dentistry, which is
beyond magnifi cation range of 1.5 × diameters, hence distorting the image
13

14. compound loupes
• The compound loupes are commonly mounted in or on the eyeglasses and
can be adjusted to clinical needs without excessive increase in size or weight.
• Compound lenses can be achromatic (limits the effects of chromatic and
spherical aberration and brings two wavelengths into focus in the same plane),
which is an important feature for any magnifying loupe used in periodontics
periodontics.
Advantages
• Better magnifi cation
• Wider depths of field
• Longer working distances, and Larger fields of view
Disadvantages
• There is lack of variable magnifi cation.
• Individual light source may be required.
• Protective coating of anti-refl ective material to prevent loss of light transmitted 14

15. PRISM LOUPES
 These loupes produce superior magnification since they contain Schmidt
or roof-top prisms.
 Other technical advantages include: Better magnification, larger surgical
view with wider depths of field, and longer working distances.
 Furthermore, because of the shorter barrels of the prism loupes, these
loupes can be easily mounted on either eyeglass frames or head bands.
 The incorporation of coaxial fiber optic lights in prism telescopic loupes
has improved the operative site illumination to a greater extent.
15

16. Loupe magnification range
• The surgical loupes provide a wide range of magnification ×1.5 to ×10.
• In most of the periodontal procedures, prism telescopic loupes of 4x magnification, even though lower than
the operating surgical microscope, provide an effective combination of magnification, field of view, and
depth of focus.
• The major disadvantage of loupes is that the clinician’s eyes must converge to view on the operate field,
which can result in eye strain, fatigue, and even vision changes when poorly designed loupes are used.
• But, loupes are less expensive and initially easier to use.
16

17. Principal Optical features of Loupes
Working distance
Working Range
Convergence angle
Field of view
Interpupillary distance
Viewing angle
Choice of loupes
Text book of Lindhe – 5th Edition 17

18. Surgical operating microscope – som
“Pushing the boundaries of the possible in periodontics”
• Surgical microscope utilizes the ‘Galilean optical principles.’
• Optimal magnification factor for the periodontal surgery ranges from ×5 to ×12.
• The microscope mountings are available for ceiling, wall mount, or on the floor.
• Clinicians are not affected by the weight of the instrument or the challenges of
maintaining a stabilized field of vision since they are external to the body.
• Surgical microscope has both maneuverability and stability.
• The fiber optic technology has improved the methods of focusing light on specifi c areas.
• Documentation of periodontal pathology and procedures of all types and
video-documentation are also possible
18

19. System Components of Surgical Microscope
Magnification Changer
Eyepiece
Objective Lens / Fine focus
Binocular
Suspension system
Tiltable Viewing Tube
Tiltable Viewing tube
19

20. ERGONOMIC POSTURE POR OPTIMAL PERFORMANCE
20

21. Advantages of surgical microscope
- Greater operator eye comfort because of the parallel viewing optics of the
Galilean system as well as the range of variable magnification.
- Excellent coaxial fiber optic illumination
- Countless accessories such as still and video cameras for case documentaries
Disadvantages
- It is an expensive equipment.
21

22. Loupes Vs. Operating Microscope
Loupes Operating Microscopes
1.5x to 10x magnification 2.5x to 20x magnification
Need additional illumination for
magnifications of 4x or greater
Use excellent coaxial Fiber-optic
illumination, hence does not need
additional light source
Operator eye comfort is less as the eyes
must converge to view the image
High comfort as it has parallel
binoculars
Initially easy to use Basic training required to use surgical
microscope
Less expensive Main disadvantage is that these are
expensive
Cannot provide variable magnification Has the advantage of providing
variable magnifications 22

23. TOMS -Three Dimensional On-Screen Microsurgery System
• TOMS is a three dimentional system used for better visualization of
the surgical area through the monitor, so that direct viewing through
microscope can be avoided and thereby reduces eye strain.
• The system consists of two single chip video cameras mounted on to
the custom fit eyepiece adapters, a dual camera-controller, a record
image processor, a VCR for optional recording, digital monitor,
synchronizing signal emitter and 120 MHz shutter glasses.
• The greatest advantage is that they helps in providing a clear and
accurate sense of depth perception.
• Drawbacks 1. Technique sensitive 2. High cost 3. Restricted areas of
vision 4. Time consuming 5. Loss of visual reference points.
23

24. Hand control during microsurgery
HAND
CONTROL
HAND
GRIP
PHYSIOLOGIC
TREMOR
24

25. Hand control during microsurgery
Physiologic tremor
• Finger movements controlled by the long flexor and extensor muscles that move our fingers are relatively crude.
• Thus, active finger extensions, or flexions, are likely to be relatively crude.
• However, when the wrist is stabilized by resting on a flat surface, angled in a dorsi flection position at approximately 20
degrees, more accurate, finely controlled finger movement can be accomplished because of the reduction in muscle tremor
provided by this “platform.”
• In microsurgery, the hand should either directly or indirectly rest on an immovable surface or unwanted movements will occur.
• Only the fingertips move. All movements should be efficient and economical and should be made with a unity of effort toward
purposeful, deliberate motions.
• There are several factors that can influence a surgeon’s physiologic tremor, including anxiety, recent exercise, alcohol,
smoking, caffeine, heavy meals, hypoglycemia, and medication usage.
• To avoid these tremors, microsurgeons should have a relaxed mind,comfortable posture, well – supported hand and stable hold
on the instrument.
25

26. Hand grips
• Basic hand skills in the United States have been associated with and thought of as an
extension of penmanship.
• With the increased use of keyboards for computers and text messaging on mobile devices,
educational curricula no longer stress penmanship.
• This may play a role in the lack of basic hand skills in the “writing” or penmanship
position.
• The acquisition of poor ergonomic habits prior to and during dental education may increase
the time it takes for postgraduate residents to become proficient in microsurgery.
• The most commonly advocated precision grip for microsurgical procedures is the pen grip or
internal precision grip , which provides a greater stability in comparison to any other hand
grip due to the tripod formed by the fingers, while the middle finger holds the instrument.
• It is best to start with the pen grip until basic manipulations are mastered and more freehand
positions can be initiated.
26

27. Microsurgical instruments
27

28. Microsurgical instruments
Microsurgical Blade / knives
Microsurgical scissors
Microsurgical needle holders
Microsurgical needles
Microsurgical sutures
Microsurgical Knots
 Circular in cross section
15 cm in Length
The working tips are much smaller
Manufactured under magnification to high tolerances.
 Needle holders and tissue forceps are made of titanium.
 Resistant to distortion, non magnetized and are lighter.
 Shorter instruments with a rectangular cross-sectional design
are not ideal for microsurgery.
28

29. • These knives have their characteristic ability to create clean incisions
to prepare the sharp flap margins for healing by primary intention.
• Using Castroviejo microsurgical scalpel, incisions are made at 90
degrees angles to the surface.
• Magnification permits easy identification of ragged wound edges for
trimming and freshening.
• Various types of knives such as crescent, lamellar, blade breaker,
sclera, and spoon knife can be used.
• They offer the dual advantage of extreme sharpness and minimal size.
Microsurgical blade / knives
1- blade breaker;
2-crescent;
3-minicrescent;
4- 260° spoon;
5- lamella and
6- sclera
29

30. • Common characteristics of these knives are their extreme sharpness and
small size. This enables precise incisions and maneuvers in small areas .
• 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.
• 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.
Spoon knife shown
in sulcular
undermining
incision.
30

31. Microsurgical scissors
i. Micro scissors
ii. Extra fine micro scissors (straight)
iii. Extra fine micro scissors (curved)
- Scissors such as the micro–vannas tissue scissors are
used for removal of small fragments of tissue.
Microsurgical NEEDLE HOLDERS
 They are designed to hold the fine needles.
 They differ in the way they grasp the needle
- e.g. a grasp with flat surface if a flat needle is used.
The working tips of needle holder are much smaller
and are made up of Titanium 31

32. Microsurgical needles
Every surgical needle has three distinct elements :
1. The Point
2. The Body
3. The Attachment
The point :
It extends from the tip of the needle to the maximum cross section of the body of the
needle. It is designed to penetrate specific types of tissue.
There are several types :
Reverse cut – Minimal trauma and early regeneration of tissue
Taper point / Round needle – Minimal tissue cutting and Smallest puncture hole
Taper cut – Dense fibrous tissue and periosteum
Blunt Point needle- Dissect through the friable tissue rather than cut through them.
32

33. The body :
• It comprises slightly more than the middle third of the needle. This is the portion of the needle that is
grasped by the needle holder during suturing
• The size of the body as close as possible to the diameter of the suture material.
The Attachment :
• (Swaged end) is a method if attaching the needle and sutured together in a continuous unit that is
convenient to use and minimize tissue trauma.
• Significant size - ( 16 to 19 mm).
• Periodontists frequently use a reverse cutting needle
33

34. Factors to consider in selection of suture needles:
• 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 from the point to end.
• Radius : The distance from the center of the circle to the body of
the needle if the curvature of the needle were to make a full
circle.
• Diameter : The thickness or guage of the needle wire.
34

35. Microsurgical sutures
One of the three basic premises of microsurgery is
1. Attention to passive wound closure.
2. The desired result is exact primary apposition of the wound edge.
3. Ideally, the incisions should be almost invisible and closed with
precisely placed, small sutures with minimal tissue damage and no
bleeding
 An ideal suture material is sterile, easy to handle, minimally reactive
in tissue, resistant to shrinkage in tissues, and capable of holding
securely when knotted without fraying or cutting.
 Ideally, the needle and the suture material should be the same size.
35

36. • Suture size is stated numerically, as in 3-0 or 7-0.
• The larger the no. of zeros , the smaller the diameter of sutures.
• The smaller the size of the suture, the less tensile strength the
suture will have depending on the procedure being performed.
• Most Periodontal microsurgical suturing is done with sutures
ranging in size from 6-0 to 9-0.
• Suture bite size should be approximately 1.5 times the tissue
thickness to achieve proper wound approximation.
(top) 4-0 Vicryl on a FS-2 cutting needle;
(bottom) 6-0 polypropylene on a KV-11
taper cutting needle.
(top to bottom) 4-0 Vicryl, 6-0 polypropylene,
7-0 PDS-II, 8-0 nylon, 10-0 nylon.
36

37. • The suture of choice in microsurgery is a monofilament suture material such as polypropylene or
polydioxanone.
• These materials are bacteriostatic and noninflammatory, hold a knot extremely well, and are easily
removed.
• Monofilament materials are preferred as polyfilament threads are characterized by a high capillarity
and wicking effect.
• Suturing techniques are completely different in macrosurgery and microsurgery.
The geometry of microsurgical suturing consists of the following points:
• 1. Needle angle of entry and exit of slightly less than 90 degrees 2. Suture bite size of
approximately 1.5 times the tissue thickness 3. Equal bite sizes (symmetry) on both sides of the
wound 4. Needle passage perpendicular to the wound 37

38. Microsurgical knots
OLD PHRASE – “Watch one , Do one , Teach one”
 Two basic knots employed in microsurgery are the square knot or reef
knot and surgeon’s knot.
 The reef knot is composed of two single loops thrown in opposite
directions.
 It lies flat when tied well and is ideal for passive wound closure.
 As postsurgical edema occurs, the reef knot opens sightly then becomes
self-locking .
 The surgeon’s knot is composed of two double loops thrown in opposite
directions.
 The first double throw is less likely to loosen when performing the second
throw, making it is easier to control tissue apposition
38

39. INDICATIONS OF PERIODONTAL MICROSURGERY
Scaling and Root planing
Periodontal Flap surgery
Mucogingival Surgery
Ridge Augumentation
Sinus Lift Procedures
Crown Lengthening
Root Surface Conditioning
Interdental Papillary reconstruction
Entire Papilla Preservation Technique (EPP)
Minimal Invasive Surgical technique (MIST)
Implant Surgery
39

40. Scaling and root planing
• The critical determinant of the success of periodontal therapy is the
thoroughness of debridement of the root surface (Lindhe et al. 1984).
• Accessibility and visibility in deep subgingival pockets, furcation areas,
and interdental areas can remarkably be improved using magnifications
• It is clear that magnification around ×4–10 greatly improves the surgeon’s
ability to create a clean, smooth root surface.
• It can help to detect islands of biofilm, calculus, or material alba clinging
to the root surface and facilitate removal from areas which were normally
not visible to the naked eyes Lang et al - 2015
40

41. Periodontal Flap surgery
• Several authors have proposed the use of microsurgical approach for the
treatment of isolated or multiple intrabony defects.
• The advantages of microsurgical approach in regenerative therapy relate
to improved illumination and magnification of the surgical field that
permits proper access to and debridement of the intrabony defect with an
increased accuracy and minimal trauma.
• Furthermore, the competency to achieve and maintain a primary wound
closure minimizes bacterial contamination, and thereby provides more
favorable conditions for periodontal regeneration.
ADVANTAGE OF MICROSURGERY
• Minimal marginal tissue recession and thus Improved esthetics
• very limited intra and postoperative morbidity, high patient acceptance
and satisfaction
Cortellini and Tonetti 1999
41

42. • Harrel et al - 1999 in his study showed that probing depth reduction and clinical attachment level gain for the
regenerative procedures performed with microsurgical approach has been found similar to those achieved with
conventional surgical approach.
• Bunckle et al – 1995 in his study with enamel matrix proteins have shown that enamel matrix derivative could exert
better biologic activity in microsurgically treated sites because of reduced tissue trauma and vessel injury to
improve vascularization and achieve primary wound closure, which allows optimal retention of enamel matrix
derivatives.
• Liu et al – 2016 in his recent meta-analysis found no significant differences in treatment of intrabony defects treated
with minimally invasive periodontal surgery (MIPS) plus biomaterials and MIPS alone for the observed parameters
(probing depth, clinical attachment level, marginal recession, and radiographic bone fill), pointing out that costs
and benefits should be considered substantially while deciding a regenerative therapeutic modality.
• Isolated interproximal defects that are usually limited to interproximal site are considered ideal for bone grafting
with MIPS.
• Generalized horizontal bone loss and multiple interconnected intrabony defects are a contraindication for MIPS
and are best managed with more conventional surgical approaches 42

43. Mucogingival Surgery
• To achieve an excellent result in terms of both esthetics and function, it is fundamental to perform extremely fine
and accurate incisions, meticulous suturing to promote stabilization and immobilization of the graft and precise
closure of wound margins.
• Therefore, the use of surgical microscope in mucogingival therapy might be helpful for those sites where esthetics
demand complete and perfect coverage.
• Periodontal microsurgery performed by a trained and skilled surgeon offers an improved outcome of the root
coverage procedures.
advantage
• increased vascularization of the grafts,
• relatively better percentages of root coverage,
• a significant increase in width and thickness of keratinized tissue,
• an improved esthetic outcome,
• and decreased patient morbidity.
Free gingival graft
Double papilla flaps
Apical or coronal repositioned flaps
Connective tissue grafts
Pedicle or sliding flaps
43

44. FREE GINGIVAL GRAFT WITH PALATAL DONAR SITE CLOSURE
Hedge et al - 2009
44

45. Laterally positioned flap
- Zuchelli et al - 2004
LMCAF – with Loupe and
microsurgical instruments
as successful treatment
option in class III
Recession defect
45

46. Connective tissue graft and Double papilla
Shanelac et al - 2015
46

47. Ridge augumentation
Walter et al - 2008 47

48. Sinus Lift procedure
• One of the novel applications of
microsurgery is in the sinus lift procedure
with a success rate of 97%.
• The surgical microscope can aid indirect
visualization of the sinus membrane and
minimizes the risk of perforations.
• Incorporation of microsurgical techniques
for an improvement of altered sensation due
to implants encroaching on the inferior
alveolar nerve even without unscrewing them
has also been reported
Kumar et al - 2005
48

49. Crown Lengthening
• Although the comparative studies of Crown lengthening with microsurgical methods are limited, it seems logical to
substantiate the fact that magnification is beneficial in such procedures.
Tibettes et al - 2015
49

50. Root Surface Conditioning
• Furthermore, root preparation can be done with microultrasonic
instruments. The smaller size (about ) 0.2–0.6 mm in diameter) and
variable power settings (25,000)to more than 40,000 cycles per second)
of these instruments allows subgingival treatment in deep pockets with
less chances of overinstrumentation of the root surface.
• Moreover, these instruments have active working sides on all surfaces;
deliver ultrasonically activated lavage in the working area and can be
used with minimal water spray
• In conclusion, magnification improves the root surface debridement by
enhancing clinician’s ability to differentiate the calculus from tooth
surface and biofilm to the microscopic level, which reveals
morphological contours of both supragingival and subgingival tooth
surfaces and accurately procreates working end angles during
instrumentation
Lindhe et al - 1984
50

51. Interdental Papillary reconstruction
Microsurgical techniques have been developed to replace the lost interdental papilla, which can create
phonetic problems, saliva bubbles, and cosmetic deficiencies.
A papillary deficiency can be created through iatrogenic surgical removal, as part of tissue collapse
following extraction, with periodontal pocket elimination surgery,with periodontal bone loss and with
orthodontic separation of overlapped teeth.
 Success in the treatment of black triangle with periodontal microsurgery is a significant leap in the field
of perio-aesthetics, making it a realistic possibility.
Andrade et al - 2010
51

52. Entire Papilla Preservation Technique (EPP)
•Recently, a new microsurgical approach for periodontal
regeneration named “Entire Papilla Preservation Technique”
(EPP) has been described in literature.
•In this technique, an interdental tunnel is made through the
defect associated papilla by giving a beveled vertical releasing
incision in the buccal gingiva of the adjacent interdental space.
•After granulation tissue removal and root surface debridement,
regenerative materials such as bone grafts and enamel matrix
derivative are applied.
•Primary advantage of EPP technique is enhanced wound stability and
limited premature exposure of regenerative biomaterials
Aslan et al - 2017
52

53. Minimal Invasive Surgical technique (MIST)
• The minimally invasive surgical technique (MIST, Cortellini and Tonetti, 2007) is a
concept that was designed, especially for isolated intrabony defects for periodontal
regeneration.
• It is based on minimal reflection of very short buccal and lingual flaps with minimal
mesiodistal and coronoapical extensions, the aim being to expose the coronal edge of
the residual bone crest that include the defect-associated interdental papilla.
• Modified minimally invasive surgical technique (M-MIST) has been proposed by
Cortellini and Tonetti, 2009, for use in combination with enamel matrix derivatives
(amelogenins).
• The overall idea of the M-MIST is to provide a very small interdental access to the
defect only from the buccal side, following which the supracrestal interdental tissue is
dissected from the granulation tissue by means of a mini-blade, and regenerative
material of choice applied.
• Passive closure by internal mattress sutures is preferred 53

54. Implant Surgery
• Surgical microscope can be a valuable tool in implant dentistry.
• Different stages of implant treatment ranging from implant
placement to implant recovery and peri-implantitis management
may be accomplished with more precision under magnification.
• The microscope may be a valuable tool in visualizing the last
threads of the implant for subcrestal placement, implant
recovery with minimal trauma to adjacent tissues, management
of peri-implantitis, visualization of the sinus membrane during
sinus lift procedures, and minimizing the risk of perforations or
tears Shanelec et al - 2005
54

55. video
55

56. Drawbacks of microsurgery
• As we upgrade our surgical maneuvers with the aid of microsurgical concepts, there are a few shortcomings
of this modus operandi, which need to be considered prior to its application.
• It is much more demanding and technique-sensitive; the cost incurred to establish a microsurgical set up is
also high.
• Magnification systems used also pose some difficulties including restricted area of vision, loss of depth of
field as magnification increases, and loss of visual reference points.
• An experienced team approach mandates microsurgery and is time-consuming to develop.
• Physiologic tremor control for finer movements intra-operatively and a steep learning curve are required
for clinical proficiency.
56

57. RECENT ADVANCES IN MICROSCOPES
• Zeiss OPMI PROErgo
• Mechanical optical rotating assembly interface (MORA Interface)
• Periodontal endoscope
• Varioscope
• Infrared 800, flow 800, and blue 400 fluorescence
57

58. Conclusion
• Aesthetic preservation and improvement have become an integral part of today’s periodontal treatment.
• Evaluation of periodontal aesthetic procedures has driven largely by the patient’s increased awareness of and
desire for aesthetically pleasing smiles.
• Patients are demanding a youthful attractive smile that includes healthy gingiva with ideal contours and texture.
• Periodontal microsurgery is definitely a must for perio-aesthetics.
• The improved visual acuity provided by magnification opens a whole new world for those who make effort and take
time to become proficient in microsurgical principles and procedures.
• The promising periodontal microsurgery will provide new possibilities to improve the therapeutic results for
variety of periodontal surgeries. 58

59. Reference
 Textbook of periodontology – Carranza - 10th ed.
 Textbook of Periodontal Diseases: Basic Phenomena, Clinical Management, and Occlusal and Restorative
Interrelationships - Page and Schluger - 2nd ed.
 Cohen – Atlas of Cosmetic & Reconstructive periodontal Surgery – 2nd ed.
 Hall WB. Critical Decisions in Periodontogy - 4th edition.
 Tetbook of Periobasics: A textbook of periodontics and implantology – 5st Edition
 Francetti L, Del Fabbro M, Calace S, Testori T, Weinstein RL. Microsurgical treatment of gingival recession:
controlled clinical study. Int J Periodontics Restorative Dent 2005;25:181-8.
59

60. • Tibbetts LS, Shanelec D. Periodontal microsurgery. Dent Clin North Am 1988;42:339-59.
• Michaelides PL. Use of the operating microscope in dentistry. J Calif Dent Assoc 1996;24:45-50.
• Shanelec DA, Tibetts LS. A perspective on the future of periodontal microsurgery. Periodontol 2000 1996;11:58-
64.
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