RECENT ADVANCES IN PERIODONTAL

SURGICAL TECHNOLOGY

BY –DR.AANANYAA JHALDIYAL

CONTENTS INTRODUCTION

MICROSURGERY

PERIODONTAL MICROSURGERY

MAGNIFICATION SYSTEMS

LASERS IN PERIODONTICS

INTRODUCTION

This seminar discusses surgical advancement in the following two areas –

1. Recent developments in the use of magnification systems, especially periodontal microsurgery.

2. Advances in the use of laser technology in periodontal surgery & other areas of periodontal therapy.

MICROSURGERY

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.

MAGNIFICATION SYSTEMS

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 loupes2. Surgical microscope.

1. Magn i fy ing 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 .

Disadvantages of dental loupes-1. Eyestrain2. fatigue3. Pathologic vision changes, especially

after prolonged use.

Three types of keplerian loupes are used in periodontics-

a) Simple or single element loupesb) Compound loupesc) Prism telescopic loupes

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

Disadvantage – they are greatly affected by spherical & chromatic aberration, this distorts the image shape & color of objects being viewed.

Fig- simple loupe

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

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

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

3. longer working distances,4. larger field of view.

Fig: eye glass mounted prism loupe

Recent innovation in prism telescopic loupes include- coaxial fiber optic lighting incorporated in the lens element to improve illumination.

Fig : coaxial lighted prism loupe

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 fi 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

2. Surg ica l microscopeThey 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.

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.

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.

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.

Fig: surgical Fig: microscope camera

microscope & beam splitter

PERIODONTAL MICROSURGE

RY

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.

Root Preparat ionEssential 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.

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.

Fig: magnified root planing

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.

Microsurg i ca l I ns t rumentsMicrosurgery 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.

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

ErgonomicsStudies 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.

Conclusion Microsurgery offers new opportunities

for periodontal surgery that can enhance the therapeutic results for a variety of procedures.

Benefits includes-1. Improved cosmetics2. Rapid healing3. Minimal discomfort4. Enhanced patient acceptance.

LASERS IN PERIODONTICS

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.

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 dioxide3. Diode4. 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

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

6. Subgingival debridement & curettage7. Removal of granulation tissue during

flap surgery8. Osseous recontouring9. Implant surgery10.Maintenance of implants11.Management of periimplantitis

12.Greater hemostasis13.Bactericidal effect14.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

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

1. Use glasses for eye protection2. Prevent inadvertent irradiation3. Protect the patients eyes, throat, &

oral tissues outside the target site4. Use wet gauze packs to avoid

reflection from shiny metal surfaces5. 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