Microsurgery in Periodontal and Implant Dentistry: Concepts and Applications

Foreword
A Tribute to Dennis A. Shanelec, DDS: The Father of Periodontal Microsurgery
Acknowledgments
Contents
Introduction to Microsurgery
1 Introduction
2 History of Operating Microscope in Medicine
3 History of Operating Microscope in Dentistry
4 History of OM in Periodontology and Implant Dentistry
5 Advantages of Using OM in Surgical Dentistry
6 Current Trends that Favor Using OM
7 Future Directions
8 Conclusion
9 Key Points
References
The Impact of a Minimally Invasive Approach on Oral Wound Healing
1 Introduction
2 An Overview of the Biological Pathways to Mucosal Wound Repair and Regeneration
2.1 Inflammation Phase (First Stage of Mucosal Wound Healing)
2.2 Proliferation Phase (Second Stage of Mucosal Wound Healing)
2.2.1 Epithelialization
2.2.2 Angiogenesis
2.2.3 Granulation Tissue Formation
2.3 Remodeling Phase (Third Stage of Mucosal Wound Healing)
3 Impact of the Microsurgical Technique on the Healing Process of Oral Mucosal Wounds: Clinical Results and Potential Triggers for Enhanced Healing
3.1 Scientific Evidence of Improved Outcomes After Periodontal Plastic Microsurgeries: Some Critical Comments about the Clinical Relevance of the Results
3.2 The Interconnectedness of the Microsurgical Technique with the Healing Process of Mucosal Wounds
3.2.1 Influence of Modified (Minimal-Invasive) Incision Designs on Wound Stability and Wound Integrity
3.2.2 Healing of Periodontal Wounds Created by Traditional, but Microsurgically Modified Flap Designs
4 How to Translate Findings from Basic Research into Clinical Success?
4.1 Incision Design and Wound Healing from a Histological and Physiological Perspective
4.2 Micromechanical Properties of the Extracellular Matrix of the Oral Mucosa and the Blood Clot after Wounding
4.2.1 Micromechanical Aspects of Oral Mucosal Tissues
4.2.2 Micromechanical Aspects of the Blood Clot during Healing
4.3 Microsurgically Controlled Instrument Handling and its Impact on Tissue Mechanotransduction
5 Closing Remarks
6 Key Points
References
Fundamentals of the Operating Microscope
1 Introduction
2 Magnification
3 Loupes
4 Loupes Versus Operating Microscope
5 Parts and Functions of a Surgical Microscope
5.1 The Body of the Microscope
5.1.1 Microscope Eyepieces
5.1.2 Binocular Tube Head
5.1.3 Co-Observation
5.1.4 Microscope Objective Lens
5.1.5 Microscope Magnification Changer or Zoom system
5.1.6 Focusing
5.2 Light Source
5.2.1 Illumination
5.2.2 Augmented Visualization
5.3 The Suspension System
5.4 Imaging Systems and Documentation Devices
6 Conclusions
7 Glossary
8 Key Points
References
Design and Ergonomics of Microsurgical Instruments
1 Introduction
2 From Touch Perception to Prehensile Skilled Movements in Periodontal Microsurgery
2.1 Anatomy and Neurophysiology of the Human Hand
2.2 Tactile Sensing and the Threshold Concept
2.3 Dynamic Touch and Precision Grips in Periodontal Microsurgery
3 Instrument Design
3.1 Ergonomics of Microsurgical Instrument Handles
3.1.1 Instrument Handle’s Shape and Size
3.1.2 Materials and Weight of Microsurgical Instruments
3.1.3 Fine Surface Texture and Roughness of the Instrument Handle
3.2 Influence of Surgical Gloves on Tactile Sensitivity, Finger Pad Friction, and Surgical Performance
3.2.1 Touch Sensation and Haptic Perception Thresholds
3.2.2 Fingerpad Friction and Grasp Force
3.2.3 Influence of Gloves on Surgical Performance
3.3 Instrument use and How it Affects Hand Representation in the Brain
4 Basic Set of Instruments for Periodontal Microsurgery
4.1 Description of Microsurgical Instruments
4.2 Sterilization Process and Caring for Microsurgical Instruments
5 Conclusions
6 Key Points
References
The Science and Art of Microsuturing
1 Introduction
2 Historical Background of Suture Materials, Needles/Evolution
3 Wound Closure: Principles
4 Armamentarium
5 Sutures and Needles
5.1 Suture Classification
5.2 Suture Biocompatibility
5.3 Needles
5.3.1 Needle Parts
5.3.2 Needle Designs/Geometry
5.3.3 Needle Color Innovations
6 The Geometry of Suturing
7 Knots
7.1 Knot Coding/Nomenclature
7.1.1 Square Knot
7.1.2 Slip Knot
7.1.3 Surgeon’s Knot
7.2 Knot Tying: Instrument Tie
7.3 Knot Failure
7.3.1 Slippage
7.3.2 Suture Cutting Through Tissue
7.3.3 Mechanical Damage
7.4 Biomechanical Properties and Performance
7.4.1 Vectoring/Angulation
7.4.2 Compression Zones/Frequency/Symmetry
7.4.3 Suture Tension on Soft Tissues
7.5 Suture Removal
8 Suturing Techniques
9 The Microsurgical Training Institute
10 Methods for Developing Suturing Technique and Practicing
10.1 Training Models and Exercises
10.1.1 Gauze
10.1.2 Newspaper
10.1.3 Needles
10.1.4 Egg
10.1.5 Eggplant
10.1.6 Tomato-Star
10.1.7 Grass Blade
10.1.8 Flower
10.1.9 Mushroom
10.1.10 Tissue Paper Box-Silicone/Resin Dental Model
10.1.11 Plastic Micro-tubing
10.1.12 Training Simulators
11 Conclusion
12 Key Points
References
Practical Considerations in Incorporating Microsurgery to Daily Workflow
1 Introduction
2 Principles of Ergonomics
2.1 Musculoskeletal Disorders Associated with Dentistry
2.2 Working Mistakes When Using the Microscope
3 Implementation Stages of OM in Periodontal and Implant Procedures
4 Fundamental Aspects of Microsurgical Incorporation (Fig. 3)
4.1 Frame of Mind
4.2 Comfort
4.3 Hand Support
4.4 Armamentarium
4.5 Assisting
5 Economy of Movement
5.1 Assisting Models
6 Positioning
6.1 Operator (Microsurgeon)
6.2 Assisting Team
6.3 Patient Position
7 Infection Control
8 Conclusions
9 Key Points
References
Microscope-Assisted Periodontal and Peri-implant Plastic Surgery
1 Introduction
2 Historical Background of Periodontal Microsurgery Compared with Conventional Mucogingival Interventions
3 Periodontal Phenotype
4 Gingival Recessions
5 Recession Classification
6 Incisions
6.1 Horizontal
6.2 Vertical
7 Flap Designs
7.1 Mucoperiosteal Flap (Total Thickness)
7.2 Mucosal Flap (Partial Thickness)
7.3 Combined Flap (Partial/Total/Partial Thickness)
8 Suture Techniques
8.1 Closing Sutures
8.2 Tension-Relieving Sutures
8.3 Combined Sutures (Closing and Tension-Relieving Sutures)
8.4 Suspension Sutures
8.5 Point-of-Contact Sling Sutures
8.6 Fixation Sutures
8.7 Insertion Sutures
9 Treatment of Single Gingival Recessions
9.1 Trapezoidal Flap (CAF with Vertical Incisions)
9.2 Laterally Moved CAF
9.3 CAF in Envelope Without Vertical Incision
9.4 Envelope Without Incision
9.5 Laterally Closed Tunnel for Isolated Mandibular Recession
10 Treatment of Multiple Gingival Recessions
10.1 CAF in Envelope
10.2 Modified Tunnel
11 Microscope-Assisted Autograft Harvesting
11.1 Trapdoor Technique
11.2 Envelope Technique
11.3 Connective Tissue Graft (De-epithelialized Epithelium)
12 Treating Non-carious Cervical Lesions Associated with Gingival Recessions Defects
12.1 Classification of Root Defects
12.2 Digitally Guided Root Coverage Predetermination: A Multidisciplinary Approach
12.3 Treatment Options
12.3.1 Class 1
12.3.2 Class 2
12.3.3 Class 3 (Option 1)
12.3.4 Class 3 (Option 2)
12.3.5 Class 4
12.4 Restorative Treatment
12.5 Surgical Treatment
12.6 Restorative Treatment
12.7 Surgical Treatment Plan (Right Side)
12.8 Surgical Treatment Plan (Left Side)
12.9 Mandibular Surgical Plan (Left Side)
12.10 Clinical Outcomes
12.11 Restorative Treatment
12.12 Surgical Treatment
12.13 Clinical Outcomes
13 Treatment of Peri-implant Soft Tissues Dehiscences/Deficiencies in the Esthetic Zone
13.1 Immediate Management During the Placement of Implants
13.2 Later Management on Rehabilitated Implants
13.3 Classification of Peri-implant Soft Tissues Defects
13.3.1 Multidisciplinary Approach
14 Conclusions
15 Key Points
References
Microscope-Assisted Laser Ablation of Gingival Pigmentation
1 Introduction: Gingival Pigmentation
2 Application of Lasers in Gingival Depigmentation
3 Er:YAG Laser-Assisted Gingival Depigmentation
3.1 Indication for Depigmentation of Gingiva
3.2 Characteristics of Er:YAG Laser
3.3 Ablation Mechanism and Thermal Effects
3.4 Soft Tissue Ablation and Wound Healing Following Er:YAG Laser Surgery
3.5 Advantages of Er:YAG Laser Microsurgery in Esthetic Gingival Procedures
3.6 Er:YAG Laser Irradiation Safety
4 Removal of Melanin Pigmentation
4.1 Procedures of Melanin Depigmentation Under Microscope
4.2 Wound Healing and Pain Perception
4.3 Clinical Cases
4.3.1 Case 1
4.3.2 Case 2
5 Removal of Metal Tattoo Pigmentation
5.1 Procedures of Metal Tattoo Depigmentation Under Microscope
5.2 Wound Healing and Pain Perception
5.3 Clinical Cases
5.3.1 Case 1
5.3.2 Case 2
6 Closing Remarks
7 Key Points
References
Microscope-Assisted Periodontal Regenerative Therapy
1 Introduction
1.1 Definition of Terms
1.2 Role of the OM and Microsurgical Instruments and Materials in Periodontal Regenerative Therapy (PRT)
2 Historical Background
2.1 Landmark Events in Periodontal Regenerative Therapy of Intrabony Defects
2.2 Landmark Events in Minimally Invasive Surgery of Intrabony Defects
2.3 Landmark Events in Regeneration of Furcation Defects
2.4 Landmark Events in Regeneration of Combined Intrabony and Furcation Defects
3 Principles Behind the Biologically Driven Paradigm
3.1 Setting the Ideal Condition for Periodontal Regenerative Microsurgery
3.1.1 Patient Preparation: Patient-Related Factors
3.1.2 Site Preparation: Site-Related Factors
3.2 Biologically Driven Flap Design and Selection of the Regenerative Strategy
3.2.1 Soft Tissue Architecture
3.2.2 Hard Tissue Architecture
3.2.3 Presurgical Assessment of the Hard and Soft Tissue Morphology
3.2.4 Biologic Foundation of Periodontal Regeneration
4 Microsurgical Phase: Treatment of Intrabony and Furcation Defects
4.1 Workflow During PRT Utilizing the Operating Microscope
4.2 The Biologically Driven Flap Design
4.3 Technical Tips: Flap Design, Defect Debridement, Biomaterial Application, Suturing
4.3.1 Intrabony Defects
4.3.2 Key-Hole Furcation Defects
4.3.3 Combined Intrabony and Furcation Defects
5 Errors Most Frequently Committed/Actions to Avoid
6 Postsurgical Protocols and Complications
7 Surgical and Postsurgical Patient Morbidity
8 Long-Term Outcomes of Regeneration
9 Summary
10 Key Points
References
Microscope-Assisted Preprosthetic Surgery
1 Introduction
2 Donor Site Evaluation and Harvesting Techniques for Free Gingival Graft (FGG)/Connective Tissue Graft (CTG)
3 Root Coverage Procedures: Recipient Site Consideration and Preparation
4 Preprosthetic Gingival Augmentation
5 Surgical Crown Lengthening
6 Papilla Reconstruction
7 Conclusion
8 Key Points
References
Microsurgery in Guided Bone Regeneration
1 Introduction
1.1 History of Guided Bone Regeneration
1.2 Development of Microscopic Surgery and its Application in Regenerative Bone Therapy
1.2.1 History
1.3 Importance of the Surgical Microscope in GBR
2 Biological Basis and Anatomical Consideration During Microscope-Assisted GBR
2.1 Ridge Deformity Classifications
2.2 Physiology of Bone Regeneration, Histology, and Participating Cells
2.3 Intra-Operative Visualization of Anatomical Structures
2.4 Anatomical Considerations for GBR
2.4.1 Anatomical Considerations: Musculature
Maxilla
Mandible
2.4.2 Anatomical Considerations: Vasculature
2.4.3 Anatomical Considerations: Innervation
3 Microsurgical Soft Tissue Management
3.1 Incision Design
3.2 Decision to Place Vertical Incisions
3.3 Steps in Flap Releasing: Layered Releasing Incision, Linear Incision, and Selectively Releasing Incision
3.3.1 Microsurgical reflection
4 Special Considerations in Material Selection and Placement
4.1 Selection and Management of Regenerative Materials and Their Combination in Microsurgery
4.2 Autologous Bone Graft, Allografts, Xenografts, and Membranes
4.2.1 Xenografts
4.2.2 Allografts
4.2.3 Mixed Grafts
4.3 Use of Resorbable and Non-resorbable Membranes
4.4 Use of Dermis Allograft as Membrane
4.5 Use of Biologics
4.6 Membrane-Fixation Microsurgical Techniques
5 Microsurgical Sutures Specific to Bone Regeneration
5.1 Microsurgical Knots [68]
5.2 Suspensory Suture Technique
5.3 Different Suturing Materials
6 Post Microsurgical Management
6.1 Postoperative Indications
6.2 Microsurgical Suture Removal
7 Microsurgical Management of Postoperative Complications
8 Soft Tissue Management and Vestibular Repositioning After Bone Regeneration
8.1 Vestibular Deepening
8.2 Connective Tissue Grafts for Increased Thickness
8.3 Soft Tissue Grafts to Increase Keratinized Tissue
8.4 Allografts, Xenografts, and Their Use
9 Ultra-Minimally Invasive GBR Techniques
10 Conclusion
11 Key Points
References
Microscope-Assisted Sinus Augmentation
1 Introduction
2 Keys to Success in Sinus Augmentation Procedures
2.1 Historical Background and the Current Trend of Sinus Augmentation Surgery
2.2 The Rationale for Microscope-Assisted Sinus Augmentation
3 Anatomical Considerations and Clinical Implications
3.1 Schneiderian Membrane
3.2 Sinus Walls: Floor, Medial-Lateral Wall Distance, Angle, Lateral Wall Thickness, Septum
3.3 Residual Ridge Height and Width
3.4 Vascular Supply
3.5 Innervation
4 Fundamental Principles of Endoscopy as a Minimally Invasive Approach for Antral Interventions
5 Presurgical Sinus Assessment: Diagnosing Pathological Conditions of the Maxillary Sinus
6 Pre-op Diagnosis, Planning, and Evaluation of Case Difficulty
7 Microscope-Assisted Lateral Sinus Augmentation
7.1 Lateral Sinus Augmentation
7.1.1 Potential Benefits and Advantages
7.1.2 Incision Design and Osteotomy Preparation
7.1.3 Schneiderian Membrane Examination and Management
7.1.4 Management of Schneiderian Membrane Perforation
8 Microscope-Assisted Vertical Sinus Augmentation
8.1 Potential Benefits and Advantages
8.2 Osteotomy Site Preparation
8.3 Detection of Schneiderian Membrane Perforation and Management
8.4 Bone Graft Application and Simultaneous Implant Placement
9 Conclusions
10 Key Points
11 Appendix
References
The Shanelec SMILE Technique: Immediate Microsurgical Implant and Provisional Restoration Placement in Anterior Esthetic Sites
1 Introduction
2 Immediate Implant Placement in the Maxillary Anterior Area
3 Case Presentation
4 Step 1: Implant Microsurgery
5 Steps 2, 3, 18, and 19: Preparation of Provisional Replication of the Failing Tooth
6 Steps 4–6: Extraction with Minimal Trauma and Socket Debridement
7 Step 7: Socket Drilling
8 Steps 8–13: Implant Placement
9 Steps 14–16: Osseous Grafting of the Buccal Socket Gap
10 Steps 17–24: Implant Provisional Crown
11 Steps 25 and 27: Advancing the Flap
12 Steps 26, 28, 29, 30, 31: Provisional Restoration Seating, Adjusting Occlusion, Postoperative Care
13 Step 32: Final Restoration
14 Step 33: Postoperative CAT Scan
15 Clinical Results and Discussion
16 Key Points
References
Microscope-Assisted Implant Complication Management
1 Implant Complications
2 Trans-Surgical Accident
3 Early Complications
3.1 Edema, Bleeding, Ecchymosis, and Hematoma
3.2 Mucosal Dehiscence
4 Late Complications
4.1 Mechanical Complications
4.2 Biological Complications
4.3 Esthetic Implant Complications
4.3.1 Implant Position and Prosthesis
4.3.2 Phenotype
4.3.3 Surgical Technique and Morphology of the Recession
4.3.4 Papilla Reconstruction
5 Conclusions
6 Key Points
References