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R E V I E W

PRINCIPLES AND PRACTICE OF


PERIODONTAL MICROSURGERY
Leonard S. Tibbetts, DDS, MSD1
Dennis Shanelec, DDS2

Periodontal microsurgery is the refinement of basic surgical techniques made


possible by the improved visual acuity gained with the use of the surgical
microscope. In the hands of a trained and experienced clinician, microsurgery
offers enhanced outcomes not possible with traditional macrosurgery, especially
in terms of passive wound closure and reduced tissue trauma. This paper aims
to briefly review the basics of periodontal microsurgery, including the role and
instruments of magnification, hand positions, knot trying, clinical applications,
and microsurgery’s effect on esthetics. The improved visual acuity of
microsurgery provides significant advantages to those who take the time to
become proficient in microsurgical principles and procedures. INT J MICRODENT
2009;1:13–24

In the minds of many dental profes- as a methodology—a modification


sionals, microsurgery is an interesting and refinement of existing surgical
concept, and yet the inability of most techniques using magnification to
clinicians to perform such procedures improve visualization, with applica-
shows the dental profession’s lack of tions to all specialties. Regardless of
understanding of what microsurgery whether they are dentists, physicians,
truly encompasses. Dentistry has or veterinarians, all reconstructive
borrowed microscopic surgery from surgeons have the ability to use visu-
medicine, which dates back to ally enhanced surgical techniques.
1922.1,2 It behooves dentistry to pig- As a treatment philosophy, micro-
gyback on medical experience, rather surgery incorporates three important
than rediscover it. The purpose of principles5:
this paper is to provide a brief review
of what periodontal microsurgery 1.Improvement of motor skills,
entails: the role of magnification, thereby enhancing surgical ability
microsurgical instrumentation and 2.An emphasis on passive wound
design, the surgeon’s physiologic closure with exact primary apposi-
and physical status, posture, hand tion of the wound edge
positions, knot tying, appropriate 3.The application of microsurgical
applications, and the effects of micro- instrumentation and suturing to
surgery on esthetics. reduce tissue trauma
Periodontal microsurgery3 is the
1Private practice, Arlington, Texas. refinement of basic surgical tech- Most dental treatment, histori-
2Private practice, Santa Barbara, California. niques made possible by the cally, has been rendered with the
improvement in visual acuity gained unaided eye. Without the use of
Correspondence to: with the use of the surgical micro- visual magnification, such treatment
Dr Leonard S. Tibbetts scope. In 1979, Daniel1 defined is termed macroscopic. Treatment
916 West Mitchell Street microsurgery in broad terms as sur- rendered with visual enhancement
Arlington, TX 76016 gery performed under magnification supplied by the microscope is termed
Fax: 817 274 0872 by the microscope. In 1980, micro- microscopic. Improved outcomes
Email: lstibbetts@sbcglobal.net surgery was described by Serafin4 obtained from the use of microscopic

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periodontal surgical procedures have cate tissue handling, wound closure, and posture, a well-supported hand,
resulted in a shift toward periodontal and suturing require concentration and a stable instrument-holding posi-
microsurgery. Over the past two and practice. The development of tion. Attitude is also very important.5
decades, periodontics has seen new thought patterns regarding sur- Mental focus and patience during
increasing refinement of surgical pro- gical esthetics is necessary, and the procedure are important factors
cedures, requiring the development attention must be paid to micro- in maintaining precise motor control
of more intricate surgical and motor anatomy, tissue manipulation, and skills.
skills. The techniques used in peri- surgical craftsmanship. Physiologic tremor is usually asso-
odontal plastic surgery, guided tissue ciated with tension generated by the
regeneration, cosmetic restorative postural control “antigravity” mus-
crown lengthening, gingival augmen- cles.6 Since these muscles are a
tation procedures, soft and hard tissue major cause of tremor, a relaxed and
ridge augmentation, osseous resec- Effective periodontal proper seating posture is essential. A
tion, and dental implant placement microsurgery allows the microsurgeon’s chair is required to
demand clinical expertise beyond the operator to consistently provide proper arm and hand sup-
range of normal visual acuity. achieve clinical results port. The surgeon must be seated
Microsurgery represents an ampli- upright with the legs extending for-
fication of universally recognized sur- that were once thought ward and with both feet flat on the
gical principles in which gentle han- to be unlikely. floor so that the calf of each leg
dling of soft and hard tissues and forms a right angle to the thigh. Sup-
extremely accurate wound closure port of the ulnar surface of the fore-
are made possible through magnifi- arm and wrist is necessary to control
cation, allowing for well-planned and or reduce tremor. The surgeon’s
precisely executed surgical proce- head should be held in a comfort-
dures.6 The goal of the periodontist is HAND CONTROL able upright position (Fig 1). Proper
to cause as little damage as possible ergonomics can help to prevent neck
to tissues and to have healing occur Physiologic Tremor and back injuries resulting from poor
by primary rather than secondary For a basic understanding of the fine chairside habits. During a surgical
intention. Healing by secondary inten- finger movements necessary with procedure, patient and chair position
tion occurs when the wound edges the use of microscopic magnifica- must be adjusted to the surgeon
open and heal more slowly and with tion, some important aspects of and the microscope.
more inflammation as granulation hand function must be reviewed. In microsurgery, the hand should
tissue fills the wound. Microsurgery Finger movements controlled by the either directly or indirectly rest on
offers a more rapid and comfortable long flexor and extensor muscles an immovable surface or unwanted
healing phase for the patient. that move our fingers are relatively movements will occur. Only the fin-
crude. Thus, active finger extensions, gertips move. All movements should
or flexions, are likely to be relatively be efficient and economical, and
CLINICAL PHILOSOPHY crude. However, when the wrist is should be made with a unity of effort
stabilized by resting on a flat sur- toward purposeful, deliberate
Consistent application of the philos- face, angled in a dorsiflection position motions. There are several factors
ophy and techniques learned in basic at approximately 20 degrees, more that can influence a surgeon’s phys-
microsurgery education is necessary accurate, finely controlled finger iologic tremor, including anxiety,
for the operator to attain a level of movement can be accomplished recent exercise, alcohol, smoking,
experience and competence needed because of the reduction in muscle caffeine, heavy meals, hypoglycemia,
for various periodontal surgical proce- tremor provided by this “platform.”2,5 and medication usage.
dures.5 Effective periodontal micro- Physiologic tremor is the uncon-
surgery allows the operator to con- trolled movement arising from both
sistently achieve clinical results that the intended and unintended actions Hand Grips
were once thought to be unlikely. of our bodies. Awareness of its effect Basic hand skills in the United States
Becoming a clinically proficient peri- is magnified by visual enhancement. have been associated with and
odontal microsurgeon requires a will- During microsurgery, physiologic thought of as an extension of pen-
ingness to adopt new values and tremor manifests as a naturally manship. With the increased use of
ideas. Training with the microscope occurring unwanted hand and finger keyboards for computers and text
enhances the motor skills, which movement.4 To minimize tremors, a messaging on mobile devices, edu-
can translate to improved surgical microsurgeon must have a relaxed cational curricula no longer stress
skills. The methods of precise, deli- state of mind, good body comfort penmanship. This may play a role in

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Fig 1 Clinician seated at microscope with correct posture


and arms supported.

Fig 2 Precision grip.

the lack of basic hand skills in the the ulnar border. The middle finger accurate motion of which the hand is
“writing” or penmanship position. should rest firmly and directly on capable (eg, rotational movement8,9).
The acquisition of poor ergonomic either the working surface supporting It is best to start with the pen grip
habits prior to and during dental edu- the hand or indirectly on the ring fin- until basic manipulations are mas-
cation may increase the time it takes ger. With the tripod formed by the tered and more freehand positions
for postgraduate residents to fingers in the pen grip, the middle fin- can be initiated. Regardless of the
become proficient in microsurgery. ger holds the instrument. The thumb surgeon’s postural position, when
The most commonly used preci- and index finger are arranged on the the hands are in an unsupported
sion grip in microsurgery is the pen instrument into contact with the position or the operator’s breath is
grip or internal precision grip, which underlying middle finger. When an held, the whole body becomes rigid
gives greater stability than any other instrument is held with the internal when trying to perform precision
hand grip.2,7 In the three-digit grip, precision grip, the instrument can tasks. Accurate, exact hand move-
an instrument is held exactly as a be opened and closed with very fine ments with instruments of the cor-
pen would be held when writing. control. Any tremor resulting from rect length and design along with
The thumb and index and middle the thumb or index finger is mini- precision hand grips are crucial to
fingers are used as a tripod (Fig 2). mized by the contact with the sup- good microsurgical results.
The forearm should be slightly ported, steady middle finger. Using The microsurgeon’s position rela-
supine, positioning the knuckles the pen grip, the flexor and extensor tive to the patient is an important
away from you, so that the ulnar muscles of the hand are relaxed, consideration. When picturing an
border of your hand, wrist, and the resisting fatigue, while the intrinsic imaginary clock laying flat on the table
elbow are all well supported, allow- muscles that rotate the hand are in front of you, with the patient’s
ing the weight of the hand to be on well postured, resulting in the most head in the 12 o’clock position in

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Fig 3a Relative size of


microsurgical needle holders
and pick-ups and a standard
needle holder.

Fig 3b No. 15 scalpel


blade and mini-crescent
microsurgical blade.

a b

front of and perpendicular to your gical instruments are much smaller Loupes
chest, the most precise rotary sutur- than those of regular instruments Loupes are the most common form
ing movement for a right-handed (Figs 3a and 3b). To provide consis- of magnification used in dentistry.
person is from the 2 o’clock to the tent manipulation of tissues, nee- Fundamentally, loupes are two
7 o’clock position, while the most dles, and sutures, most microsurgical monocular microscopes with side-
precise movement for left-handed instruments are manufactured under by-side lenses that are angled to
people is from the 10 o’clock to the magnification to high tolerances. focus on an object. The magnified
4 o’clock position. Needle holders and tissue forceps image that is formed by the conver-
Once command in suturing from are made of titanium. Properly cared gent lens system has stereoscopic
the 2 o’clock to 7 o’clock position for, such instruments are resistant properties. The disadvantage of
is gained from repeated practice, to distortion from repeated use and loupes is that the eyes must con-
proficiency of the 10 to 4 position is sterilization, are nonmagnetized, and verge to view an image, which can
necessary. Persistent practice of are lighter than surgical stainless result in eyestrain, fatigue, and even
alternative positions around the entire steel instruments. Shorter instru- vision changes with prolonged use of
360-degree axis ultimately results in ments, as well as instruments with a poorly fitted loupes.13 Only two types
mastery of surgical skills necessary rectangular cross-sectional design, of loupes, compound and prism, are
to render successful microsurgical do not allow as precise manipula- commonly used in dentistry today.
treatment in all areas of the mouth. tion and therefore are not ideal for Both types employ convergent
microsurgery. optics, but may differ widely in
design and lens construction.
MICROSURGICAL
INSTRUMENTS MAGNIFICATION METHODS Compound loupes. To gain refract-
ing power, magnification, working
With microscopic magnification and Dentists have a wide range of simple distance, and depth of field, com-
the use of microsurgical instruments, and complex magnifying systems pound loupes use converging multi-
tissue trauma and bleeding can be that are available, including three ple lenses with intervening air
minimized. For high-precision move- types of magnification loupes10 and spaces. Such lenses can be adjusted
ment, microsurgical instruments the operating microscope.11 Both to clinical needs without excessive
must be approximately 15 cm in types of optical magnification have increase in size or weight. Com-
length. For an average-sized hand, advantages and limitations. The mode pound lenses can be achromatic.
this provides adequate length for an of magnification used is often based The lenses consist of two glass
instrument held in a pen grip to rest on the task to be accomplished and pieces bonded together with clear
in the web between the thumb and the operator’s experience level. resin. The specific density of each
index finger. There are also subtle Whether or not more magnification is piece counteracts the chromatic
design features for these instru- better must be weighed against the aberration of the adjacent piece,
ments that help accomplish the size of the viewing field and the making such lenses a desired feature
desired surgical results. Instruments depth of focus that occurs as magni- by dentists. Compound loupes are
should be circular in cross section fication is increased. Increases in commonly mounted in or on eye-
to allow for a smooth rotation move- magnification require proportionate glasses.
ment. The working tips of microsur- increases in field illumination.2,12

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Prism loupes. Prism loupes contain Fig 4 HD video


Schmidt or rooftop prisms that camera mount.
lengthen the light path through a
series of mirror reflections within
the loupes, virtually folding the light
so that the barrel of the loupe can be
shortened. These loupes are the
most optically advanced type of
loupe magnification presently obtain-
able. Prism loupes produce better
magnification, wider depths of field,
longer working distances, and larger
fields of view than other types of
loupes. The barrels of prism loupes
are short enough to be mounted on
either eyeglasses or a headband, but binoculars protect against eyestrain patient without magnification or with
at magnifications of 3.0 diameters and fatigue. Operating microscopes ill-fitted loupes, a multitude of eye,
or greater the increased weight often incorporate fully coated optics and neck, shoulder, and back problems
results in headband-mounted loupes achromatic lenses with high-resolu- become increasingly evident with
being more comfortable and stable tion and high-contrast stereoscopic age. Such problems may be reduced
than those mounted on glasses. To vision. Operating microscopes are or eliminated by using magnification.
obtain better optical characteristics designed on Galilean principles. A 6- to 8-inch increase in normal
and magnification than those achiev- When using the microscope, there working distance has been shown
able with prism loupes requires the must be an adequate working dis- to vastly improve postural ergonom-
use of the surgical microscope. tance between the microscope and ics and reduce eyestrain in industrial
the object being viewed for instru- workers.16
Loupe magnification. Loupes with ments to be used. For use in the The advantages of the operating
magnifications ranging from 1.5 to various areas of the mouth, the microscope include its versatility due
10 can be purchased from a num- microscope must have extensive to an extended range of variable
ber of vendors. Those with magnifi- horizontal and vertical maneuverabil- magnification from 2.5 to 20 and
cations of less than 4 are usually ity, whether it is mounted to a wall, to excellent coaxial fiber-optic,
inadequate for microdentistry or peri- ceiling, or floor stand. The addition of shadow-free illumination. An addi-
odontal microsurgery. For most peri- inclinable binocular eyepieces gives a tional advantage is the availability of
odontal procedures, loupes of 4 microscope great improvement in numerous accessories for digital still
to 5 provide increased visual acuity maneuverability. Surgical micro- and video image case documenta-
with an effective combination of scopes use coaxial fiber-optic illumi- tion (Fig 4). The greatest advantage,
magnification, field size, and depth of nation. This type of light produces an however, is increased operator eye
field. Loupes of 4.5 magnification adjustable, bright, uniformly illumi- comfort due to the parallel viewing
or greater need to be thoroughly nated, shadow-free, circular spot of optics provided by the Galilean sys-
evaluated before purchasing, as their light that is parallel to the optical tem. Conversely, the limitations of
depth of focus and narrow field size viewing axis. loupes include fixed magnification
can make them awkward to use. or a lack of magnification variability
Loupes Versus Operating and the potential need for additional
Operating Microscope Microscope light for magnification levels of 4.0
For the greatest flexibility and comfort There are a few advantages and dis- or greater. Loupes with large fields of
in optical magnification, the properly advantages to each system.14,15 view have brighter illumination and
equipped operating microscope is Loupes are less expensive and initially brighter images than those with nar-
vastly superior to magnifying loupes. easier to use. They are also less cum- rower fields of view. Brightness and
With instruction and practice, the bersome in the operating field and illumination can also be improved by
operating microscope can be simple less likely to breech a clean operating increasing the working distance.
to use. It is, however, much more field. Both loupes and the micro- When using loupes, each surface re-
expensive and initially more difficult to scope improve visual acuity and fraction that occurs through the lens
use. Operating microscopes com- ergonomic comfort and efficiency by results in a 4% loss of transmitted
bine the magnification of loupes with increasing the working distance. light unless antireflective coatings
a magnification changer and a binoc- When dentists assume a working are used. Antireflective coatings
ular viewing system. The parallel distance of 13 inches or less to the allow the lens to transmit light more

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Fig 5 Microsurgical palatal donor site


closure. (Courtesy of Dr Adriana McGregor.)

effectively. Compound and prism steep learning curve. Different mag- to successfully close the wound in a
loupes without antireflective coat- nifications are appropriate for vari- manner that promotes optimum
ings could have as much as a 50% ous stages of a procedure. For healing. To utilize microsurgical prin-
reduction in brightness. example, high magnification is used ciples requires knowledge of the tis-
After using magnification loupes for passing a suture needle through sue-healing characteristics and bio-
and the surgical microscopes for over tissue, and lower power is used to logic characteristics of the various
a decade and a half, the authors find pull the suture through the tissue suture materials being used. A
that the use of the microscope offers so that you can see the end of the suture material must be selected
many advantages over loupes. The suture as it approaches. Common that will retain its strength until the
difference is similar to comparing the sense dictates that it is important to wound heals sufficiently to withstand
use of a belt-driven handpiece versus use the lowest magnification level stress on its own. An ideal suture
an electric motor handpiece under a possible to accomplish each stage of material is sterile, easy to handle,
multitude of conditions. Both types of the procedure being performed. minimally reactive in tissue, resistant
handpiece can be used to prepare to shrinkage in tissues, and capable
teeth for restorative work or for surgi- of holding securely when knotted
cal procedures, but the latter is much SUTURES without fraying or cutting. Ideally,
more versatile and efficient. Like- the needle and the suture material
wise, both loupes and the operating One of the three basic premises of should be the same size. The only
microscope allow clinicians to per- microsurgery is attention to passive variable in an ideal suture material
form tasks not possible without wound closure.5 The desired result is is its size and tensile strength and
improved visual acuity; however, exact primary apposition of the the size and type of needle swaged
loupes cannot compare to the com- wound edge. Ideally, the incisions onto the material.
fort, versatility, illumination, and visual should be almost invisible and closed Essentially all sutures used in den-
acuity offered by the microscope. with precisely placed, small sutures tistry today are swaged, making the
Although magnification makes with minimal tissue damage and no suture and the needle a continuous
microsurgery possible, there are also bleeding (Fig 5). single unit. Size denotes the diameter
drawbacks, including: (1) a restricted With all of the surgical subspecial- of the suture material, and accepted
area of vision and loss of depth of ties, suture materials and techniques surgical protocol is to use the smallest
field as magnification increases, (2) have evolved to the point that diameter suture necessary to ade-
loss of visual reference points, (3) sutures are designed and developed quately hold the wound tissue
extra time needed to develop an for specific procedures. What has together. The smaller the suture mate-
experienced team approach for plan- been developed for medicine is sub- rial and needle used to pass through
ning and practice to avoid errors in sequently used in dentistry. The crite- the tissue, the less trauma will result.
positioning instruments and place- ria necessary for successful use of Suture size is stated numerically, as
ment of sutures, (4) accentuated suture materials are dependent on in 3-0 or 7-0. The larger the number
physiologic tremor that must be con- the surgical procedure to be per- of zeros, the smaller the diameter
trolled for fine movements, and (5) a formed and the factors necessary of the suture. The smaller the size of

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Fig 6a Different-sized sutures. (top) 4-0 Vicryl on a FS-2 Fig 6b (top to bottom) 4-0 Vicryl, 6-0 polypropylene,
cutting needle; (bottom) 6-0 polypropylene on a KV-11 taper 7-0 PDS-II, 8-0 nylon, 10-0 nylon.
cutting needle.

1 3
2

Fig 6c (left to right) 8-0 nylon, 7-0 polypropylene, Fig 7 Suture needle anatomy: 1, point; 2, body;
6-0 polypropylene, 4-0 Vicryl. 3, attachment.

the suture, the less tensile strength The point extends from the tip of ting is desired. The taper cut surgical
the suture will have depending on the needle to the maximum cross needle combines the reverse cutting
the procedure being performed. section of the body of the needle. It edge tip and taper point, with the
Most periodontal microsurgical sutur- is designed to penetrate specific three cutting edges extending approx-
ing is done with sutures ranging in types of tissue. There are several imately 1/32 inch back from the tip
size from 6-0 to 9-0 (Figs 6a to 6c). types of cutting needles, taper point before blending into the round taper
The most common suture used in needles, taper cut surgical needles, body. A taper cut needle is used for
macroscopic dentistry is a 4-0 suture and blunt point needles. Reverse cut- suturing through dense fibrous con-
on a three-eighths circle FS-2 reverse ting needles are frequently used in nective tissue and periosteum. Blunt
cutting needle. dentistry where minimal trauma and point needles are used to dissect
Sutures are also classified accord- early regeneration of tissue is desired. through friable tissues rather than
ing to the composition of the suture Since the third cutting edge of the cut through them.
strand (eg, monofilament, braided needle is located on the outer convex The body of the needle comprises
multifilament), surface characteris- curvature, the danger of a tissue slightly more than the middle third of
tics (coated or uncoated), and absorp- cutout is reduced. The hole left by the needle. This is the portion of the
tion properties (absorbable or non- the reverse cutting needle leaves a needle that is grasped by the needle
absorbable). wide wall of tissue against which the holder during suturing. The size of
suture is tied. Taper point needles or the body should be as close as possi-
Suture Needle Anatomy round needles pierce and spread the ble to the diameter of the suture
Every surgical needle has three dis- tissue without cutting it. They are material in microsurgical procedures.
tinct elements: the point, the body, used when the smallest possible The attachment (swaged end) is a
and the attachment (Fig 7).18 puncture hole and minimal tissue cut- method of attaching the needle and

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Fig 8a Proper wound coaptation Fig 8b Improper wound coaptation Fig 9 Properly tied microsurgical
and suturing. and suturing. reef knots.

suture together in a continuous unit Suture Geometry Knot Tying


that is convenient to use and mini- Suturing techniques are completely Suturing is a critical factor in peri-
mizes tissue trauma. different in macrosurgery and micro- odontal treatment success. Sutur-
Selection of an appropriate nee- surgery. With magnification, a sur- ing techniques and knot tying, how-
dle is dependent on where and how geon is able to scrutinize discrepan- ever, occupy only minimal time in
the suture will be used. Factors to cies that occur with macrosurgery dental education curricula, and are
consider in the selection of a suture and embrace a more efficient consequently learned according to
needle include: approach to wound closure. The the old phrase “watch one, do one,
microsurgical approach is dependent teach one.”
• Chord length: the straight-line dis- on careful, atraumatic entry incisions Macroscopic knot tying is done
tance from the point of a curved and dissection to allow passive with full visualization of the hands.
needle to the swage. wound closure. This is followed by The needle holder is held in the dom-
• Needle length: the distance wound closure using the fundamen- inant hand and the gloved fingertips
measured along the radius of the tal geometric approach, with the of the nondominant hand are used
needle from the point to end. goal of primary and passive wound to help place and tie sutures using
• Radius: the distance from the cen- closure. proprioception (ie, the unconscious
ter of the circle to the body of the The geometry of microsurgical perception of movement and spatial
needle if the curvature of the nee- suturing consists of the following orientation arising from within the
dle were to make a full circle. In points19: body).
dentistry, the needle radius most Knot tying using the microscope is
commonly used is the three-eighths 1.Needle angle of entry and exit of done using instrument ties, with a
circle, but the one-fourth circle and slightly less than 90 degrees microsurgical needle holder in the
one-half circle are also used. Such 2.Suture bite size of approximately dominant hand and a microsurgical
shapes require less space for 1.5 times the tissue thickness tissue pick-up in the nondominant
maneuvering than a straight needle. 3.Equal bite sizes (symmetry) on hand. Only the working tips of the
• Diameter: the thickness or gauge both sides of the wound instruments are visible in the micro-
of the needle wire. 4.Needle passage perpendicular to scopic field. Microsurgery is there-
the wound fore done by visual reference only, as
Microsurgery uses needles of a the breaking force of microsutures is
fine-gauge material that are small to Gentle coaptation of a wound often less than the human threshold
very small. Surgical needles are using the above geometric standards of touch. Microinjury to tissues also
designed for maximum needle prevents either incomplete wound occurs below the proprioceptive abil-
holder stability. Needle holder per- closure or overlapping of the wound. ity of the human hand. Well-tied
formance has a significant impact The results of geometric, perpendicu- microsurgical suture knots are stable
on the entire suturing procedure. lar suturing are uncomplicated and resist loosening, even under
The surgeon must have the utmost wound closure, as compared to functional loads.20 The art of micro-
control of the needle sitting in the when sutures pass across an inci- scopically tying a good surgeon’s
holder without the needle wobbling sion line at an oblique or an acute knot, a reef knot, or a cinching knot
as it is passed through the tissue. angle, resulting in dead spaces or can only be mastered with repeated
Therefore, the needle holder must microgaps with longer postoperative laboratory practice under the micro-
be appropriately sized for the needle healing (Figs 8a and 8b). scope (Fig 9).21
and suture selected.

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Fig 10 Microsurgery blades


compared to a 15C scalpel blade.

PERIODONTAL be a goal to avoid compromising the Esthetic Surgical Procedures


MICROSURGERY surgeon’s field of view. Controlling When attempting to restore gingival
homeostasis before wound closure esthetics, several periodontal plastic
Periodontal microsurgery is gener- prevents the formation of postoper- surgery procedures are helpful, includ-
ally associated with esthetic peri- ative hematomas. By adequately ing pedicle soft tissue grafts and free
odontal plastic surgery, because of closing a wound site with passive soft tissue grafts. The direction of
the intricate detail and small scale closure, dead space in the wound transfer of the pedicle graft deter-
of the work made possible by the is eliminated. mines whether it is divided into rota-
surgical microscope. Microsurgical Many of the procedures men- tional flaps (eg, laterally sliding flap,
principles also have application in tioned above use 5-0 to 7-0 sutures. papilla flap, or double papilla flap) or
more extensive periodontal surgical This is necessary because the chord advanced flaps without rotation or
procedures, including resective pro- length of the suture needle must be lateral movement (eg, coronally posi-
cedures, combined resective/peri- long enough to be passed inferior tioned flap). The pedicle soft tissue
odontal microsurgery and regenera- to the contact points of the teeth. graft combined with the use of a
tive procedures, extractions and ridge membrane barrier, according to the
preservation procedures, sinus aug- principles of guided tissue regenera-
mentations and repairs, biopsies, Periodontal Plastic Microsurgery tion, is also used as a treatment for
and larger soft tissue transfers. Such The term mucogingival surgery was root coverage. When using a guided
procedures utilize microsurgical introduced into the periodontal litera- tissue regeneration barrier, it is critical
instruments to make incisions that ture in the 1950s. The current termi- to maintain a space between the
are just long enough to afford access nology, periodontal plastic surgery, is barrier membrane and the root sur-
for operating space and exposure. defined as surgical procedures per- face for tissue regeneration.
Incisions should be clean and pre- formed to correct or eliminate To correct small areas of recession
cise, with as little trauma as possible. anatomic, developmental, or traumatic without invasive major flaps, careful
Appropriately designed and sized deformities of the gingiva or alveolar dissection and suturing can some-
microsurgical instruments produce mucosa.23 Periodontal plastic surgery times be used to place a graft (Figs
minimal tissue trauma and promote is an integral aspect of periodontal 11 and 12). Free soft tissue grafts
healing (Fig 10). Tissue should be education and practice. Knowledge can be performed as a full-thickness
handled very gently and as little as of medical microsurgery offers a view epithelialized soft tissue graft or a
possible. Retraction should be done as to what esthetic needs can be subepithelial connective tissue graft,
carefully to avoid excess pressure, realistically achieved while treating with the donor tissue for both proce-
since tissue tension can alter the periodontal problems. Improvement in dures usually taken from the palate. A
local physiologic state of the wound. esthetics is a major indication for peri- subepithelial connective tissue graft is
Achieving a bloodless field should odontal plastic surgery. normally harvested from the palate by

VOLUME 1 • 2009 21

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Tibbetts/Shanelec

a b

c d

Fig 11 Preoperative (a), graft being placed (b), sutured graft (c), and postoperative (d) views of connective tissue graft.
(Courtesy of Dr. Scott Kissel.)

a “trap door” approach,24,25 which is with both macrosurgery and micro- grafting, in the hands of the authors,
minimally invasive and heals rapidly. surgery (Fig 13). Autologous grafts is most predictable using autologous
Microsurgically transferring donor (ie, tissue borrowed from one area grafts because they revascularize
tissue removed from one area of the and then transferred to another area quickly. The two most reliable root
mouth to a new microsurgically pre- within the same individual28), homol- coverage techniques are the full-thick-
pared recipient site allows for cor- ogous grafts (ie, freeze-dried human ness gingival graft and subepithelial
rection of gingival esthetic prob- dermal allografts from different indi- connective tissue graft. Full-thickness
lems.26 Survival of the grafted tis- viduals of the same species), and gingival grafts do not offer as good a
sue, whether the procedure is done heterologous grafts (ie, bovine colla- color match as subepithelial connec-
macroscopically or microsurgically, is gen membranes from donors of a tive tissue grafts and produce a less
dependent on the recipient site hav- different species) can be used in root natural appearing result, but can usu-
ing a blood supply to restore circula- coverage procedures. Complete root ally restore narrow recession
tion to the transferred tissue.27 coverage of gingival recession is pre- defects.30 Wide recession defects
Attempting to graft over avascular dictably achievable in Miller Class I can more predictably be restored by
root surfaces is a unique challenge in and Class II defects. Only partial cov- subepithelial connective tissue grafts.
periodontics, but it has become more erage may be expected in Class III or
predictable, depending on the defect, Class IV29 defects. Root coverage

22 THE INTERNATIONAL JOURNAL OF MICRODENTISTRY

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Tibbetts/Shanelec

a b c
Fig 12 Preoperative (a), sutured connective tissue graft (b), and postoperative (c) views typical of other microsurgical procedures.
(Courtesy of Dr J. David Cross.)

Fig 13 Preoperative (a), 1-week post-


operative (b), and 2-week postoperative
(c) views of microsurgical guided tissue
regeneration procedure. (Courtesy of Dr
a Scott Kissell.)
c

Root Surface Conditioning based on histologic evidence and than periodontal macrosurgery, but it
Since root surface preparation others on empirical observation, but results in more rapid healing because
addresses how the soft tissue all are important for successful root it is less invasive and less traumatic.
attaches to the root of the tooth in coverage. The improved visual acuity and
root coverage surgery, it is of the ergonomics provide significant advan-
utmost importance; however, it is CONCLUSIONS tages to those who take the time
not within the scope of this article to to become proficient in microsurgical
discuss in detail. Suffice it to say, in Periodontal microsurgery has many principles and procedures. The oper-
an attempt to get new periodontal applications and benefits. As health ating microscope allows the surgeon
ligament attachment of a graft to care professionals and the public to practice enhanced, precise, deli-
the tooth with new cementum and become familiar with the benefits cate surgical procedures that have
Sharpey’s fibers, several methods of microsurgery, applications of this important healing processes and out-
of root preparation have been sug- philosophy in periodontics will likely comes for patients. Periodontal
gested,31–33 including mechanical become a treatment standard. Micro- microsurgery and periodontal plas-
root preparation, chemical root prepa- surgical periodontics requires a differ- tic microscopic surgery provide a
ration, and biologic root preparation. ent practitioner mindset. It is tech- natural evolution in the progression
The outcomes of some methods are nique-sensitive and more demanding of periodontics.

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