recent advances in periodontal surgical technique

1. RECENT ADVANCES
IN PERIODONTAL
SURGICAL
TECHNOLOGY
BY –
DR.AANANYAA JHALDIYAL

2. CONTENTS
 INTRODUCTION
 MICROSURGERY
 PERIODONTAL MICROSURGERY
 MAGNIFICATION SYSTEMS
 LASERS IN PERIODONTICS

3. INTRODUCTION

4. This seminar discusses surgical advancement
in the following two areas –
1. Recent developments in the use of
magnification systems, especially periodontal
microsurgery.
1. Advances in the use of laser technology in
periodontal surgery & other areas of periodontal
therapy.

5. MICROSURGERY

6.  Microsurgery is defined as a refinement in
surgical technique by which visual acuity is
increased using a microscope at magnification
exceeding 10X.
Microsurgery is also an ergonomic methodology
in which surgical manipulations are improved
through better motor coordination.

7. MAGNIFICATION
SYSTEMS

8. Magnification improves the accuracy of clinical
and diagnostic skills.
 It requires the understanding of optical
principles that govern all magnification
systems.
 Magnification systems –
1. Magnifying loupes
2. Surgical microscope.

9. 1. Magnifying loupes
 Dental loupes are the most common system of
optical magnification used in periodontics.
 Loupes are fundamentally dual monocular
telescopes with side by side lenses convergent to
focus on the operative field.
 A convergent lens optical system is called a
keplerian optical system.

10.  Disadvantages of dental loupes-
1. Eyestrain
2. fatigue
3. Pathologic vision changes, especially after
prolonged use.
 Three types of keplerian loupes are used in
periodontics-
a) Simple or single element loupes
b) Compound loupes
c) Prism telescopic loupes

11.  Consist of a pair of single meniscus lenses.
 Primitive magnifiers
 Limited capabilities
 Each lens is limited to only 2 refracting
surfaces.
 Magnification increases by increasing lens
diameter and thickness.
Impractical for magnification beyond 1.5X
a ) S i m p l e l o u p e s

12. Disadvantage – they are greatly affected by
spherical & chromatic aberration, this distorts
the image shape & color of objects being viewed.
Fig- simple loupe

13. Use multi element lenses with intervening air
spaces to gain additional refracting surfaces.
Increased magnification with more favorable
working distance & depth of field.
Magnification can be increased by lengthening
the distance between lenses.
Improved optical performance
b ) C o m p o u n d l o u p e s

14. They can be achromatic lenses i.e consist of 2
glass lenses joined together with clear resin.
Optically insufficient at magnifications above
3X.
Fig- compound loupe

15. Most advanced loupe optical magnification .
Such loupes employ Schmidt or rooftop prisms
through a series of switchback mirrors between
the lenses.
Advantages-
1. Produce better magnification,
2. wider depths of field,
c ) P r i s m t e l e s c o p i c l o u p e s

16. 3. longer working distances,
4. larger field of view.
Fig: eye glass mounted prism loupe

17. Recent innovation in prism telescopic loupes
include- coaxial fiber optic lighting incorporated
in the lens element to improve illumination.
Fig : coaxial lighted prism loupe

18. Dental loupes – 1.5 to 1.6X
For some periodontal procedures, prism
telescopic loupes with magnification of 4X
provide an adequate combination of
magnification, field of view, & depth of focus.
Loupes providing magnification more than 4X
are impractical because of their small field of
view, shallow depth of focus & excessive weight.
M a g n i f i c a t i o n r a n g e o f s u r g i c a l
l o u p e s

19. 2. Surgical microscope
They provide higher magnification & superior
optical performance compared with dental
loupes.
It requires training & practice to gain
proficiency.
Surgical microscopes designed for dentistry
employ Galilean optics with binocular eyepieces
joined by offsetting prisms to establish parallel
optical axes.

20. Galilean optics- permits stereoscopic vision
without eye convergence, which aligns the eyes
as if they were focused on infinity & permits a
relaxed vision without eye strain or fatigue.
Advantage- it allows dentist to change
working magnification easily to a value
appropriate for a clinical task at hand.
Operating microscopes have a rotating variable
magnification element that changes
magnification to match surgical needs.

21.  Surgical microscopes have objective lenses with
various working distances. A useful range in
dentistry is 250 to 350mm.
For practical use in periodontics, the surgical
microscope must have both maneuverability &
stability.
Maneuverability must be sufficient to provide
visual access to the posterior region of the mouth
& to all anatomic structures addressed during
periodontal treatment.

22. Fiberoptic coaxial illumination is a major
advantage of the operating microscope over
surgical loupes. With coaxial lighting, no
shadows are produced. The surgeon can view
perfectly the deepest reaches of the oral cavity,
including the subgingival pockets & angular
bony defects.

23. Fig: surgical Fig: microscope camera
microscope & beam splitter

24. PERIODONTAL
MICROSURGERY

25. Periodontal microsurgery introduces the
potential for less invasive surgical approach in
periodontics.
This is exemplified by a decreased need for
vertical releasing incisions & greater use of
smaller surgical sites.
Reduced incision size & surgical retraction are
directly related to decreased postoperative pain &
rapid healing.

26. Root Preparation
Essential component of periodontal therapy.
Microscope enhanced vision in periodontics
permits more definitive root debridement.
Root debridement performed without
magnification was incomplete, when examined
with the aid of microscope, substantial deposits
remain.

27. Magnification greatly improves the surgeon’s
ability to create a clean, smooth root surface.
Magnification permits preparation of both hard
& soft tissue wound surfaces so that they may
be joined together according to the accepted
microsurgical principle of butt joint wound
approximation.
This encourages primary wound healing &
enhanced periodontal reconstruction.

28. Fig: magnified root planing

29. Surgery under microscope
Periodontal microsurgery is the natural
transition from conventional surgical principles
to a surgical ethic in which the microscope is
employed to permit the most accurate &
atraumatic handling of tissue to enhance wound
healing.

30. Microsurgical Instruments
Microsurgery requires specially constructed
instruments designed specifically to minimize
trauma.
An important characteristic of microsurgical
instruments is their ability to create clean incisions
that prepare wounds for healing by primary
intension.
Microsurgical incisions are established at a 90-
degree angle to the surface using ophthalmic
microsurgical scalpels.

31. For primary wound closure, microsutures in the
range of 6-0 to 9-0 are needed to approximate
the wound edges accurately.
Microsurgical wound apposition minimizes
gaps or voids at the wound edges & encourages
rapid healing with less postoperative
inflammation and less pain.
Fig: Castroviejo microsurgical
scalpel

32. Ergonomics
Studies show that motor coordination is greatly
improved when surgeons use microsurgical
instruments specifically designed to employ a
precision grip of the hand.
Microsurgical instruments are circular in cross-
section to permit rotational movements.
They are manufactured of titanium because of
its strength, lightness, & nonmagnetic
characteristics.

33. Conclusion
Microsurgery offers new opportunities for
periodontal surgery that can enhance the
therapeutic results for a variety of procedures.
Benefits includes-
1. Improved cosmetics
2. Rapid healing
3. Minimal discomfort
4. Enhanced patient acceptance.

34. LASERS IN
PERIODONTICS

35. LASER is an acronym for light amplification
by stimulated emission of radiation.
Lasers can concentrate light energy & exert a
strong effect, targeting tissue at an energy
level much lower than natural light.
The wavelength of a laser determines its
characteristics.

36. Once in contact with tissue, laser energy is
reflected, scattered, absorbed or transmitted to
the neighboring tissues.
Lasers most often used in dentistry are –
1. Neodymium: yttrium-aluminium-garnet
(Nd:YAG)
2. Carbon dioxide
3. Diode
4. Erbium:YAG
L a s e r a p p l i c a t i o n f o r p e r i o d o n t a l
t h e r a p y

37. Among many lasers available, high power
lasers, such as CO2, Nd:YAG, & diode lasers, can
be used in periodontics. Because of their excellent
soft tissue ablation & haemostatic
characteristics, the use of these lasers has been
approved for soft tissue management in
periodontal & oral surgery.
The use of these lasers in periodontics are–
1. gingivectomy,
2. frenectomy,
3. removal of melanin pigmentation
4. Removal of metal tattoos of gingiva

38. 6. Subgingival debridement & curettage
7. Removal of granulation tissue during flap
surgery
8. Osseous recontouring
9. Implant surgery
10.Maintenance of implants
11.Management of periimplantitis
1. Greater hemostasis
2. Bactericidal effect
3. Minimal wound contraction
A d v a n t a g e s o f l a s e r t r e a t m e n t

39. 1. Strong thermal side effects leading to
melting, cracking and carbonization of hard
tissues.
2. Excessive tissue destruction by direct ablation
3. Destruction of the attachment apparatus at the
bottom of pockets
4. Excessive ablation of root surface & gingival
tissue within periodontal pockets
5. Thermal injury to the root surface, gingival
tissue, pulp & bone tissue.
D i s a d v a n t a g e s o f l a s e r t r e a t m e n t

40. 1. Use glasses for eye protection
2. Prevent inadvertent irradiation
3. Protect the patients eyes, throat, & oral tissues
outside the target site
4. Use wet gauze packs to avoid reflection from
shiny metal surfaces
5. Ensure adequate high speed evacuation to
capture the laser plume.
P r e c a u t i o n s b e f o r e & a f t e r
i r r a d i a t i o n