IP International Journal of Periodontology and Implantology 2019;4(4):130–137 Content available at: iponlinejournal.com IP International Journal of Periodontology and Implantology Journal homepage: www.innovativepublication.com Review Article Minimally invasive surgery in periodontics - A review Archana Balakrishnan1, Lalitha Tanjore Arunachalam1,*, Uma Sudhakar1 1Dept. of Periodontics, Thai Moogambigai Dental College and Hospital, Chennai, Tamil Nadu, India ARTICLEINFO ABSTRACT Article history: Minimally invasive dentistry was introduced to preserve the dentitition and the surrounding structures as Received 01-12-2019 much as possible. In the periodontal scenario, this technique aims at smaller incisions, minimal trauma and Accepted 26-12-2019 exposure compared to the standard protocol. To accomplish this, optical acuity a well specially designed Available online 01-07-2020 instruments is required. It not only achieves good results but also saves time, and offers post-operative comfort to the patient. This review explores the history, and the use of minimally invasive surgery in periodontology and implant dentistry. © 2019 Published by Innovative Publication. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by/4.0/) 1. Introduction 2. History Minimally Invasive Surgery (MIS) is a surgical technique Dentistry borrowed micro surgery from medicine since that minimizes flap reflection and tissue trauma, resulting 1920s. From 1921-1960 microsurgery was utilized in stability of the blood clot within the wound site by in different specialties and achieved better results than maintenance of critical blood supply, tand hence reducing traditional surgery. In 1980 microsurgery was described postoperative shrinkage over time. Microsurgery is the by Serafin 2 as a methodology - a modification and a refined basic surgical technique that is made possible by refinement of recent surgical procedures. Surgeons have the improvement in visual acuity with the use of surgical always endeavoured to treat surgical sites atraumatically. microscope. It has been broadly defined by Daniel RK. In 1921, Carl Nylen, who is considered the father of (1979) 1 as surgical technique that is performed under microsurgery, used a primitive binocular microscope for magnification provided by operating microscope. ear surgery. Most dental treatments historically had been Periodontal microsurgery is defined as ’refinements in rendered with unaided eyes. Magnification in microsurgical existing basic surgical techniques that are made possible procedures were introduced in medicine during the late by the use of surgical microscope and subsequent improved nineteenth century. In 1694, Anton van Leeuwenhook, visual acuity’ (Shanelec 1992). The treatment philosophy an Amsterdam merchant constructed the first compound of micro surgery incorporates three principles: lens microscope. Periodontal microsurgery shares the attributes with medical microsurgery which will have a 1. Enhancing the surgical ability by improvement of positive influence on its professional acceptance. Saemisch, motor skills. a German ophthalmologist, introduced simple binocular 2. Exact primary apposition of the wound edge by loupes for an ophthalmic surgery in 1876. In 1950s, passive wound closure. Barraquer JI 3 began using the microscope in corneal 3. Application of micro surgical instruments and sutures surgeries. Apotheker and Jako first introduced the to reduce tissue trauma. microscope to dentistry in 1978. In 1979 Daniel described * Corresponding author. micro surgery as “surgery performed under magnification”. E-mail address: [email protected] (L. Tanjore Arunachalam). Over the past decade, the field of periodontology has https://doi.org/10.18231/j.ijpi.2019.028 2581-9836/© 2019 Innovative Publication, All rights reserved. 130 Balakrishnan, Tanjore Arunachalam and Sudhakar / IP International Journal of Periodontology and Implantology 2019;4(4):130–137131 seen increased surgical refinement in many procedures. magnification was first used. The art of dentistry is based on Periodontal microsurgery is the refinement of basic surgical precision. The human naked eye is capable of distinguishing techniques made possible by the improved visual acuity fine details, but a better accomplishment can be made enabled by the use of surgical microscope. In the last when an image is sharpened and enlarged. Microsurgery decade, a special emphasis has been focused on the design is an interesting concept in the minds of many dental and performance of surgical procedures for periodontal professionals, and yet there are inabilities by most clinicians regeneration. Specific surgical approaches have been to perform such procedures which shows the dental proposed to preserve the soft tissues and to reach a stable profession’s lack of understanding of what microsurgery can primary closure of the wound in order to seal the area truly accomplish. Periodontal microsurgery is a technique of regeneration from the oral environment. The micro by which visual acuity is increased using a microscope at vessel surgery revolutionized plastic and transplantation magnifications exceeding 10x. The introduction of loupes surgery was mainly developed by neurosurgeons Jacobsen and surgical operating microscopes along with the micro- & Suarez 1960. In 1990, Wickham and Fitzpatric described instruments has taken periodontal surgery to an altered level the techniques of using smaller incisions as “minimally of sophistication and has made the microsurgical approach invasive surgery”. Hunter and Sackier in 1993 refines the a stunning reality. Therefore this review highlights on concept of minimally invasive surgery, and described the application of Periodontal microsurgery in management of surgical approach as “the ability to miniaturize our eyes and flap, root coverage procedures, periodontal regeneration and extend our hands to perform microscopic and macroscopic recently added implant surgical procedures. operations in places that could previously be reached only by large incisions”. It is the refinement of basic surgical technique that is achieved by improvement in visual acuity gained with the In 1996, Shanelec and Tibbetts showed a continuing- use of the surgical microscope. education course on periodontal microsurgery at the annual meeting of the American Academy of Periodontology which The three elements, i.e. magnification, illumination, led to the development of centers devoted to teaching and refined surgical skills by instruments are called the periodontal microsurgery. A long term prospective study microsurgical triad (Belcher et al. 2001), 6 the by the same group reported on a two center study of 160 sites where MIS was used (Harrel, Wilson, & Nunn 2005). 4 improvement of which is a prerequisite for improved To lay more stress on wound and blood clot stability and accuracy in surgical interventions. Without anyone of these, primary wound closure for blood-clot protection, Cortellini microsurgery is not possible. and Tonetti 5 proposed the Minimally Invasive Surgical Technique (MIST) in 2007. Belcher 6 in 2001 summerized the benefits and potential usages of the surgical microscope 3.1. Hand grips in periodontal therapy. Cortellini and Tonetti 7 later improvised it further by incorporating the concept of space The most commonly used precision grip in microsurgery is provision for regeneration with the Modified Minimally the pen grip or internal precision grip in which the thumb Invasive Surgical Technique (M-MIST, Cortellini and and index and middle fingers are used as a tripod. In a Tonetti 2009). 7 The use of operating microscopes, three-digit grip, an instrument to be used is held exactly as Surgical telescopes (loupes) and microsurgical instruments a pen would be held when writing. The forearm should increased the surgical prognosis (Cortellini and Tonetti be slightly supine, positioning the knuckles away so that 2001, 2005). 8,9 These instruments provided magnification the ulnar border of hand, wrist, and the elbow are all well and optimal illumination of the surgical field thereby supported, allowing the weight of the hand to be on the ulnar improving the visual acuity. Trauma, orthognathic surgery, border. The middle finger should rest firmly and directly on sialoendoscopy, and Temporo Mandibular Joint (TMJ) either the working surface supporting the hand or indirectly disorders in oral and maxillofacial surgery are usually on the ring finger and the middle finger holds the instrument. performed with the support of the endoscopes. Application The thumb and index finger are so placed on the instrument of endoscopic techniques in various surgeries has been so that it contacts the underlying middle finger. A very fine approaching in deeper parts and still under experiment. control can be obtained when the instrument is held with an Onishi 10 in 1970, was the first to report arthroscopy of the internal precision grip and can be opened ad closed by will. human TMJ, and the first results were published by him If the middle finger is steady it will stabilize any tremor (Onishi, 1975). resulting from the thumb or index finger. The use of pen grip, relaxes the flexor and extensor muscles of the hand, 3. Principles that resists the fatigue, and as the intrinsic muscles that rotate the hand are well postured, the most accurate motion The proverb “you can do well what you see, if you see of which the hand is capable is obtained (e.g., rotational well what you do,” dates back to the 15th century when movement). 132Balakrishnan,