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MICROSURGERY: A BOON IN PERIODONTOLOGY

Article in International Dental & Medical Journal of Advanced Research · August 2016

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 Diksha Singhal and Anand Shinde. / International Journal of Advanced Dental Research, 2016;1(2):40-43.

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International Journal of Advanced Dental
Research

Journal homepage: www.mcmed.us/journal/ijadr

MICROSURGERY: A BOON IN PERIODONTOLOGY

Diksha Singhal* and Anand Shinde
Department of Periodontology, People’s College of Dental Sciences and Research Centre, Bhopal.

Corresponding Author:- Diksha Singhal

E-mail: [email protected]

Article Info ABSTRACT

Received 18/07/2016 Newer treatment modalities including new technology, instruments, and techniques enhance the skill
Revised 25/07/2016 of the clinician as well as ensure better results. Microsurgery is a minimally invasive technique that is
Accepted 9/08/2016 performed with the surgical microscope, instruments and suture materials. The increased motor skills,
minimal tissue trauma and passive wound closure forms the triad of the microsurgery. This review
Key words: briefs about the various magnifying systems and their working principles used in dentistry, in
Microsurgery, particular Periodontology.
Periodontology,
Trauma

INTRODUCTION
There has been a tremendous advancement in the Philosophy of Periodontal Microsurgery
medical and dental fields to meet the patient's expectations It embraces three core values viz.,
along with achieving desired therapeutic objectives. 1. Enhanced motor skills which is accomplished through
Microsurgery is an advanced surgical technique, which is improved visual acuity and the use of a precise hand grip.
defined as surgery performed under magnification of 10× 2. Minimal tissue trauma, which is accomplished through
or more performed under a surgical microscope [1-3]. This smaller incisions.
increases motor movement precision from 1mm to 10 μm 3. Primary passive wound closure. This is accomplished
[4]. The properties of microsurgery include increased by microsuturing.
visual acuity and improved manual dexterity [5].
History Magnification Systems
 Amsterdam merchant Anton van Leeuwenhook (1694) Magnifying Loupes
constructed the first compound lens microscope. The most common system of optical
 Saemisch (1876) introduced simple binocular loupes magnification used in Periodontics are dental loupes.2
to ophthalmic surgery. Loupes are basically dual monocular telescopes with side-
 Apotheker and Jako (1978) first introduced the by-side lenses. It is based on Keplerian optical system
microscope to dentistry [6] (Figure 1). The magnified image formed has stereoscopic
 Carr (1992) demonstrated the use of the surgical properties by virtue of their convergence [2,9,10]. Three
microscope during endodontic procedures [7]. types of Keplerian loupes used in periodontics include
 Shanelec and Tibbetts (1993) presented a continuing simple or single-element loupes, compound loupes, and
education course on periodontal microsurgery at the annual prism telescopic loupes.
meeting of the American Academy of Periodontology
[1,2,5,8, 9].

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Simple Loupes Microsurgical Knots

It consists of a pair of single meniscus lenses Two basic knots employed in microsurgery are
(Figure 2). Each lens has two refracting surfaces. The the square knot or reef knot and surgeon’s knot. The reef
magnification can be increased by increasing lens diameter knot is composed of two single loops thrown in opposite
and its thickness. Size and weight constraints make simple directions. It lies flat when tied well and is ideal for passive
loupes impractical for magnification beyond 1.5×. They wound closure. As postsurgical edema occurs, the reef knot
are greatly affected by spherical and chromatic aberration, opens sightly then becomes self-locking [2,11,12,16]. The
thus distorts the image shape and color of objects being surgeon’s knot is composed of two double loops thrown in
viewed [9, 11,12]. opposite directions. The first double throw is less likely to
loosen when performing the second throw, making it is
Compound Loupes easier to control tissue apposition [2].
They use multi-element lenses with intervening
air spaces to gain additional refracting surfaces (Figure 3) Microsurgical Needles
[13]. Magnification of compound loupes can be increased The needle diameter is ideally slightly larger than
by increasing the distance between lenses, thereby the suture size. Sutures used in microsurgery are swaged,
avoiding excessive size and weight. Compound lenses can making the needle and the suture continuous [2,17].
be achromatic and produces a color-correct image [14, 15].
However, compound loupes become optically inefficient at Microsurgical Sutures
magnifications above 3× [2,10]. The suture of choice in microsurgery is a
monofilament suture material such as polypropylene or
Prism Telescopic Loupes polydioxanone. These materials are bacteriostatic and
The most advanced loupe is the prism telescopic noninflammatory, hold a knot extremely well, and are
loupe. They use Schmidt or “rooftop” prisms and lengthen easily removed. Monofilament materials are preferred as
the light path through a series of switchback mirrors polyfilament threads are characterized by a high capillarity
between the lenses (Figure 4) [9-15]. They produce better and wicking effect. In periodontal microsurgery the suture
magnification, wider depths of field, longer working size ranges from 6-0 (diameter of a human hair) to 9-0
distances, and larger fields of view than other types of [1,2,11,12,17].
loupes. The magnification is increased upto 4×. Inclusion
of coaxial fiberoptic lighting has improved properties of Periodontal Microsurgery
illumination. The three basic microsurgical principles
comprises of precision tailoring, delicate tissue
The Surgical Microscope manipulation, and passive primary wound closure. The
Surgical microscopes employ Galilean optics, specific geometry of the suturing requirements includes:
which have binocular eyepieces joined by offset prisms 1. Angle of entry and angle of exit: The needle should
(Figure 5). They establish a parallel optical axis and permit penetrate the tissue at a 90-degree angle, perpendicular to
stereoscopic vision without eye convergence or eyestrain the tissue surface.
[1,2,4, 9]. They have coated achromatic lenses and high 2. Bite size: Bite size should be between 1 and 1.5 times
optical resolution. Depth-of-focus and field-of-view the tissue thickness.
characteristics are greatly enhanced. Mountings are 3. Direction of passage: needle must exit the opposing side
available for the ceiling, wall, or floor. Fiberoptic coaxial of the wound with a direction of passage perpendicular to
illumination is a major advantage as it eliminates shadows. the incision line.
Digital images can be captured using a beam splitter and 4. Tension: Suturing should be accomplished with minimal
camera attachment. A foot-control switch permits a tension.
surgeon to record, as the procedure unfolds, without 5. Symmetry: The distance between the bite sizes on either
interrupting surgery [1-4,9,11-12]. side of the wound edge should be the symmetrical as
should the distance between sutures.
Advantages Of Microsurgery 6. Frequency: Smaller suture material and smaller bite size
There are many advantages of microsurgery. makes it necessary to place more microsutures at frequent
Surgical decision making is enhanced as the quality and intervals along the wound edge [1,9,17]
quantity of visual data reaching the cerebral cortex is
increased [2]. It is ergonomic as well as reduced Microsurgical Indications In Periodontal Surgery
neuromuscular fatigue and occupational skeletal Ridge augmentation [2,17]
pathologies [1, 5]. The ability to create clean incisions Mucogingival surgeries [2,16-20]
prepares wounds for healing by primary intention Flap surgeries [1,2,17]
[5,9,11,12] It also minimizes gaps or voids at the wound Visualisation of root surfaces and calculus removal [1,2]
edges and encourages rapid healing with less postoperative Implant surgery [2,17,21,22]
inflammation and less pain [2,16].

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 Diksha Singhal and Anand Shinde. / International Journal of Advanced Dental Research, 2016;1(2):40-43.

Fig 1. Loupe Fig 2. Simple Loupe

Fig 3. Compound Loupe Fig 4. Prism Telescopic Loupe

Fig 5. Microscope

CONCLUSION Microsurgery facilitates enhanced vision and ergonomics,

The advent of microsurgery in the field of thus resulting in better therapeutic outcome.
Periodontology is a boon. The three basic philosophies, i.e.
enhanced motor skills, minimal tissue trauma and primary ACKNOWLEDGEMENT: None
wound closure are an important element of microsurgery.
The triad in periodontal microsurgery includes CONFLICT OF INTEREST:
illumination, magnification and increased precision. The authors declare that they have no conflict of interest.

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