29

Microsurgery
A therapeutic revolution has taken place in general surgery requiring the retraining of thousands of surgeons and the retooling of their operating rooms. This change has come about owing to the acceptance of microscopic surgery in many areas of medicine, such as vascular, corneal, otologic, neurologic, gynecologic, and, in particular, laparoscopic and arthroscopic procedures. These procedures were a natural evolution of microsurgical advances and have become accepted as routine by the general public. Over the past decade, the field of periodontics has seen increasing surgical refinement of many procedures. Such refinements require more detailed surgical skills resulting from increased visual acuity. Consistent successful guided tissue regeneration, cosmetic crown lengthening, gingival augmentation procedures, soft and hard tissue ridge augmentation, osseous resection, and dental implants demand clinical expertise that challenges the technical skills of periodontists to the limits of and beyond the range of normal visual acuity. Periodontal microsurgery has thus evolved. Periodontal microsurgery is not a specific operation intended to replace traditional periodontal surgery but a methodology that improves all aspects of surgical techniques. Microsurgery is defined as refinements in existing basic surgical techniques that are made possible by the use of the surgical microscope with subsequent, significant improved visual acuity. Traditional macroscopic surgery or macrosurgery is defined as those surgical procedures performed with the unaided eye, without the assistance of magnification. Owing to the visual advantage gained with microsurgery, macrosurgery and microsurgery are not comparable. In macrosurgery, hand movements are guided proprioceptively, whereas in microsurgery, they are guided visually. These visually guided movements not only position the hands for the execution of prelearned movements but also through their entire range of motion, with visual feedback and midcourse corrections. Visually guided movements result in greater accuracy of hand movements, which are retrained with use and practice. Microscopically visually guided movements allow the periodontist to achieve clinical results once thought unlikely on a consistent basis. Optical magnification has, therefore, broadened the horizons of dentistry in general and periodontics in particular. Improvement in visual acuity, made possible through optical magnification, has become an integral part of modern dental practices.

Magnification Systems
A variety of simple and complex magnification systems are available to practitioners, ranging from simple loupes to prism telescopic loupes and, ultimately, to the surgical microscope. Each magnification system has specific advantages and limitations. When selecting which mode of magnification should be used for improved visual acuity, the task at hand must be considered. The assumption that more magnification is better must be weighed against the decrease in field of view and depth of focus that occurs as magnification increases (Figure 29-1). Therefore, an understanding of the optical principles that govern magnification is essential to the successful use of magnification in the clinical practice of dentistry. Microdentistry and periodontal microsurgery are acquired skills, requiring magnification, microsurgical instruments, intensive training, and frequent practice to achieve and maintain excellence.

Three types of keplerian loupes are commonly employed in dentistry: simple single-element loupes (Figures 29-3 and 29-4), compound loupes (Figures 29-5 and 29-6), and prism telescopic loupes (Figures 29-7 and 29-8). Each type may differ widely in optical sophistication and individual construction (Table 29-1). For most periodontal procedures performed using loupe magnification for increased preciseness, either compound or prism loupes, of 4 to 5 magnification, are used to provide the most effective combination of magnification, field size, and depth of focus.

Simple Loupes
Simple loupes consist of a pair of single, positive, side-by-side menicus lenses (see Figure 29-4). Such loupes are primitive magnifiers, with limited capabilities. Each lens has two refracting surfaces, with one occurring as light enters the lens and the other when it leaves. The magnification of simple loupes can be increased only by augmenting the lens diameter or thickness. Because of their size and weight limitations, they have no practical dental application beyond a magnification range of 1.5 diameters, where working distances and depths of field are compromised.

Magnifying Loupes
Surgical loupes are the most common system of optical magnification used in dentistry. Fundamentally, loupes are two monocular microscopes with side-by-side lenses converging to focus on the operative field. The magnified image is formed with stereoscopic properties by virtue of the convergent lenses. A convergent lens system is called a keplerian optical system (Figure 29-2).

Compound Loupes
Compound loupes (see Figure 29-6) are converging multiple lenses with intervening air spaces to gain additional refracting power, magnification, working distance, and depth of field. They are also achromatic (color correct), which is highly desirable. Size and weight are not significant

Eye Lenses of eye piece

Binocular objectives

Object

FIGURE 29-1 Magnifications (clockwise from upper left) 2, 4, 8, and 16.

FIGURE 29-2 Keplerian optics.

434 Advanced Surgical Procedures

FIGURE 29-3 Simple loupes.

FIGURE 29-4 Simple loupe optical diagram.

FIGURE 29-5 Compound loupes.

FIGURE 29-6 Compound loupe optical diagram.

FIGURE 29-7 Eyeglass-mounted prism loupes.

FIGURE 29-8 Prism loupe optical diagram.

problems for the 4 to 5 magnification commonly used in periodontics.

Operating Microscope
The surgical operating microscope is much more versatile and advantageous than magnifying loupes (Table 29-2). The microscope offers multiple flexibility in magnification optics and comfort (Figure 29-9). Operating microscopes suitable for use in periodontics use galilean optical principles (Figure 29-10). Such scopes use the application of the magnifying loupe in combination with a magnification changer and a binocular viewing system so that the scopes employ parallel binoculars for protection against eye strain and fatigue. They

should also incorporate fully coated optics and achromatic lenses, with high resolution and good contrast stereoscopic vision.

Prism Loupes
Prism loupes are the most optically advanced type of loupe magnification presently available (see Figure 29-8). Prism loupes contain Schmidt or rooftop prisms, which 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. Only the surgical microscope can provide better magnification and optical characteristics than prism loupes.
Table 29-1 Keplerian Loupes Type Simple Lens Single Maximum Usable Magnification 1.5

Maneuverability
For practical use in periodontics, a surgical microscope must have maneuverability, stability, and an adequate working distance for instrumentation. Microscope mountings play an important role in maneuverability and scope stability and are available for the ceiling, the wall, or a floor stand. Maneuverability must always be sufficient to meet the requirements of clinicians for increased visual accessibility to the various anatomic structures dealt with in periodontics. Inclinable eyepieces are an indispensable necessity for the maneuverability and flexibility necessary for the clinical use of the surgical microscope in periodontics. Because the optical characteristics of most manufacturers lenses are comparable, microscope maneuverability is often more important than optical characteristics in determining the appropriate microscope for periodontal procedures (Figures 29-11 and 29-12).

Advantages Simplicity

Disadvantages* Spherical (shape) and chromatic (color) distortions with increased size and weight increased magnifications Limited depth of field Limited field access Increased weight above 4

Compound Prism

Multiple Multiple

3.0 4.0

Increased magnification Higher magnification Wide depth of field Longer working distances Larger fields of view

Illumination
Illumination of the field is an important consideration. Periodontists are accustomed to lateral illumination from side-mounted dental lights. Clinicians who work with loupes often require a

*A major disadvantage of the design of keplerian loupes is that the clinicians eyes must converge to view the operative field. This can result in eye strain, fatigue, and even vision changes, especially after prolonged use of poorly fitted loupes.

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Table 29-2 Operating Microscope Type Lens Maximum Usable Magnification 420 Advantages Binocular eyepieces Parallel optical eyepieces permit relaxed stereoscopic viewing Achromatic (color stable) lenses High resolution Efficient illumination Increased depth of field Increased field of view Ability to easily change magnification Disadvantages Fixed positioning of patient High initial setup costs Limited site use to 6080%

Microscopic Multiple

FIGURE 29-12 Periodontal operatory equipped for microsurgery.

headlamp to compensate for the decreased amount of light passing through the loupes. Until recently, coaxial fiber optic illumination had been a major advantage of the operating microscope over surgical loupes. Coaxial lighting places the light source parallel to the optical axis via a prism beam splitter. With coaxial lighting, no shadows are produced, and the clinician can better view into the farthest reaches of the oral cavity, including into some subgingival pockets and angular defects. Improved visualization of root surface irregularities and deposits is possible. The clinician is often able to view aspects of both normal and abnormal periodontal anatomy never previously accessible. Clinical decisions can be made based on improved visual knowledge of altered anatomy rather than educated guesses. Coaxial lighting has also become available in prism telescopic loupes.

Documentation
Documentation of periodontal procedures has become increasingly important for both dentallegal reasons and for patient and professional education purposes. The surgical operating microscope is ideal for documenting periodontal

Eye Lenses of eye piece

Prism assembly Binocular objectives

procedures of all types: either 35 mm slides or digital photographs can be easily produced using a beam splitter camera attachment (Figure 29-13). With a foot-operated shutter control, the surgeon can compose the photographic field as the procedure unfolds without interrupting the surgical process for photography. An advantage of microscopic photography is that it represents the surgical field exactly as the surgeon sees it as opposed to a photographers view produced from a different angle while the surgeon works. Excellent video documentation is also available through the operating microscope using a video beam splitter attachment. High-resolution digital cameras with video and slide printers are currently replacing 35 mm camera photography in many microsurgical disciplines. High-resolution S-VHS recorders bring new capabilities for video recording of periodontal procedures for educational purposes.

Periodontal Microsurgery
In recent years, periodontics has witnessed increasing refinement and consistency of procedures, requiring progressively more intricate surgical skills. Regenerative and resective osseous surgery, periodontal plastic surgery, and dental implants demand clinical performance that challenges the technical skills of periodontists beyond the range of ordinary visual acuity.

Object

FIGURE 29-10 Galilean optics microscope diagram.

FIGURE 29-9 Operating microscope.

FIGURE 29-11 Microscope on a rotating mount.

FIGURE 29-13 Microscope camera and beam splitter.

436 Advanced Surgical Procedures

Periodontal microsurgery introduces the possibility for considerably less invasive surgical procedures in periodontics, exemplified by smaller, more precise surgical incisions for access and, consequently, less need for vertical releasing incisions. Periodontists, like other microsurgeons, have been surprised by the extent to which reduced incision size is directly related to reduced postoperative patient pain.

Conclusions
Viewing periodontal surgery under magnification cannot help but impress the clinician with the coarseness of conventional surgical manipulation. What appears to the unaided eye as gentle handling is revealed, under magnification, as gross crushing and tearing of delicate tissues. PeriodonFIGURE 29-14 Microsurgical instruments.

Advantages
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Less tissue trauma Less mobility Less patient anxiety Atraumatic tissue management Accurate primary wound closure Increased diagnostic skills Minimally invasive Improved cosmetic results Increased surgical quality Increased effectiveness of root dbridement results in greater predictability of a. Regeneration procedures b. Cosmetic procedures Improved documentation a. Video b. Slide c. Digital

A
FIGURE 29-15 Castroviejo microsurgical scalpel.

Disadvantages
1. Educational requirements a. Surgical technique b. Understanding of optics Long adjustment period for clinical proficiency Initial increased surgical time Higher patient cost Limited surgical access

2. 3. 4. 5.

Microsurgical Instruments
In addition to the use of magnification and reliance on atraumatic technique, microsurgery entails the use of specially constructed microsurgical instruments specifically designed to minimize trauma (Figures 29-14 and 29-15). An important characteristic of microsurgical instruments is their ability to create clean incisions to prepare the wound for healing by primary intention. Such incisions are established at 90 angles to the surface using a Castroviejo microsurgical scalpel (Figure 29-16). Magnification permits easy identification of ragged wound edges for trimming and freshening. To permit primary wound closure, microsutures in the range of 6-0 to 9-0 (Figure 29-17) with microsurgical needle holders are required to correctly approximate the wound edges (Figure 29-18). Microsurgical wound apposition minimizes gaps or voids at the wound edges, which encourages rapid healing, with less postoperative inflammation and less pain.

C
FIGURE 29-16 Microsutures and microinstruments at 10 magnification.

D
FIGURE 29-18 A, Suture practice on latex at 8 magnification. B, Suture practice on latex at 24 magnification. C, Suture practice on latex at 32 magnification. D, Suture practice on foliage (anthurium flower) at 32 magnification.

FIGURE 29-17 Sutures in human hair.

Microsurgery tists have attempted to treat the surgical site atraumatically to achieve primary wound closure. However, the limits of normal vision dictate the extent to which this goal is possible. For surgeons who perform periodontal surgery to continue to live up to their reputation of being experts in deftly handling soft and hard tissues, proficiency in periodontal microsurgery is a necessity. Periodontal surgery is a natural extension of conventional surgical principles by which magnification is employed to permit accurate and atraumatic handling of soft and hard tissues to enhance wound healing. Figures 29-19 to 29-21 illustrate periodontal surgery cases treated using microsurgical techniques.

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A1

B1

A2

B2

A3

B3
FIGURE 29-19 A, 1, Deep-wide gingival recession on maxillary cuspid. 2, Microsurgical subepithelial connective tissue graft 4 magnification. 3, Same case viewed at 20 magnification. 4, Final postoperative result. B, 1, Multiple areas of recession (central incisor and cuspid). 2, Microsurgical subepithelial connective tissue graft sutured with minimal trauma. 3, One-month postoperative result.

A4

438 Advanced Surgical Procedures

A1

A2

A3

B1

B2

B3

FIGURE 29-20 A, 1, Mucogingival frenum abnormality with slight recession. 2, Subepithelial microsurgery to reposition the frenum and augment attached gingiva with a connective tissue graft. 3, One-month postoperative result. B, 1, Multiple areas of gingival recession. 2, Mirosurgical subepithelial connective tissue graft with a coronally positioned flap. 3, Final result with 100% root coverage.

A1

A2

A3

B1

B2

B3

FIGURE 29-21 A, 1, Papilla reconstruction prior to surgery. 2, Microsurgical view of papillary reconstruction. 3, Papillary reconstruction completed. B, 1, Significant recession on the canine tooth. 2, Microsurgical subepithelial connective tissue graft coverage by a double-papilla flap. 3, Complete root coverage with a wide zone of keratinized gingiva, 3-month result.