Imperial Journal of Interdisciplinary Research (IJIR) Vol-3, Issue-4, 2017 ISSN: 2454-1362, http://www.onlinejournal.in

Minimally Invasive Surgery - A Zenith Forte In Periodontal Therapy

P. Sudhakar1, Satish. M2, Ramoji Rao M.V.3 & Vidya Hiranmayi. K4 1(M.D.S ,STUDENT), Department of Periodontics, Drs.S&NR Siddhartha Institute Of Dental Sciences,Chinnaoutapalli, Gannavaram mandal ,Krishna District ,Andhra Pradesh, India. 2(M.D.S,READER) Department of Periodontics, Drs.S&NR Siddhartha Institute Of Dental Sciences, Chinnaoutapalli, Gannavaram mandal ,Krishna District ,Andhra Pradesh, India. 3(M.D.S,PRINCIPAL & HOD) Department of Periodontics, Drs.S&NR Siddhartha Institute Of Dental Sciences,Chinnaoutapalli, Gannavaram mandal ,Krishna District , Andhra Pradesh, India. 4(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

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Imperial Journal of Interdisciplinary Research (IJIR) Vol-3, Issue-4, 2017 ISSN: 2454-1362, http://www.onlinejournal.in 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: 1.Loupes 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.

MAGNIFICATION

ILLUMINATION INSTRUMENTS

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, http://www.onlinejournal.in

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 are based on Galilean optical system and position of the eyes of each individual 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 magnification, wider depths of field, longer 2. Compound loupes. 5 3. Prism telescopic loupes. working distances and larger fields of view . 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 provide an effective combination of magnification, increases by increasing lens diameter and 5 thickness. Its main advantage is that it is field size, and depth of focus . 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, http://www.onlinejournal.in 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 4. Eyepieces INSTRUMENTS : THE THIRD ELEMENT 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 distance.

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Imperial Journal of Interdisciplinary Research (IJIR) Vol-3, Issue-4, 2017 ISSN: 2454-1362, http://www.onlinejournal.in 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, http://www.onlinejournal.in 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. 10. Jan Lindhe Clinical periodontology and monofilament forms for finer suture materials. The th capillary effect is limited and hardly exists for implant dentistry -5 edition. polyglactin sutures. 11. Dannan A. Minimally invasive periodontal therapy. J Indian soc periodontal.2011;15:338-43. 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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