Periodontal microsurgery: A case report.

The purpose of this article is to limelight the benefit of periodontal microsurgery in the surgical disciplines. It reviews the benefits and potential applications of magnification and microsurgery in the specialty of periodontics and a case report on microsurgical approach for free gingival graft surgery in the treatment of gingival recession. The increased demand for mucogingival esthetics has required the optimization of periodontal procedures. Microsurgery is a minimally invasive technique that is performed with the surgical microscope and adapted instruments and suture materials. Although this hardware and knowledge of various operations are necessary to achieve patient esthetic expectations, clinicians must be willing to undergo an extended period of systematic training to become familiar with novel operating procedures and instruments. This article describes the application of the surgical microscope to provide enhanced perioplastic treatment.

INTRODUCTION

The proverb “you can do well what you see, if you see well what you do,” dates back to the 15th century when magnification was first used. Certain dental procedures were performed with the aid of magnification in the late 1800's and the first microscope used in clinical procedures was introduced by Apotheker in 1981.[1] The use of magnification in clinical dentistry has become a standard since 1990, when its use became wide spread. The art of dentistry is based on precision. The human naked eye is capable of distinguishing fine details, but is no match for what can be accomplished when an image is sharpened and enlarged.[23]

Microsurgery has been introduced to the specialty of periodontics in 1992.[4] Since then the method is widely spread used in periodontics due to its three major advantage. First is enhancement of motor skills to improve surgical ability. This is evident in the smooth hand movements accomplished with increased precision and reduced tremor. Second is the decreased tissue trauma at the surgical site, which is apparent by the use of small instruments and a reduced surgical field. Third is the application of microsurgical principles to achieve passive and primary wound closure. The aim of microsurgery is to eliminate gaps and dead spaces at the wound edge to circumvent new tissue formation needed to fill surgical voids; hence, a painful and inflammatory phase of wound healing can then be avoided. Literature had recorded use of microsurgery, but its use and success in young patients is not well- documented.[4] The present case throws light on the free gingival graft techniques for covering gingival rescission performed under surgical microscope.

CASE REPORT

During periodontal examination of an 18-year-old female at the Department of Periodontics of Vasantdada Patil Dental College Sangli (M.H), it was found that there was inadequate attached gingiva on the labial aspect of mandibular right and left central incisor with the recession of 5 mm and 2 mm respectively. There was mild to moderate marginal gingival inflammation. The recession defect was classified as Class III for 41 and Class I with 31 (Miller classification) [Figure 1]. Patient's medical history was non-contributory and she had no complaints or discomfort. Since esthetics is of concern, it was decided to treat the site by autogenous free gingival grafting to achieve root coverage for both lower centrals and also to increase the width of attached gingiva. Patient agreed to this treatment plan and treatment was initiated with instructions for plaque control, followed by thorough scaling and root planning [Figure 2].

Figure 1

Pre-operative

Figure 2

After scaling and root planing

During the surgical appointment, after local anesthesia had been achieved, the exposed root was planned thoroughly with a Gracey 1-2 curette. With microsurgical approach using surgical microscope [Figure 3] the area on the right and left mandibular central incisor that was to receive the gingival graft was prepared by raising of a partial-thickness flap [Figure 4]; graft tissue (approximately 2 mm in thickness) was obtained from the palatal side at the level of the left premolars and first molar [Figure 5]. After obtaining graft, donor site was protected by an acrylic stent. The graft was sutured in place by means of interrupted sutures (6-0 ethicon sutures) at the coronal and apical corners. A basting-type of suture was also used to obtain good adaptation of the graft to the recipient site [Figure 6]. A non-eugenol periodontal dressing was applied to recipient site after covering the graft with aluminum foil [Figure 7]. The patient received routine postsurgical instructions, including a 0.12% of chlorhexidine mouth rinse twice daily along with 400 mg ibuprofen 3 times a day for 7 days. 1 week after the surgical procedure, the patient reported with no major problems; wound healing of the grafted sites and donor site was assessed weekly for the first 2 weeks. At the 12-week evaluation, there was a gain in attached gingiva around the right lower anterior [Figure 8]. Patient had no complaints about the treatment outcome and oral hygiene was reinforced at this appointment.

Figure 3

Microsurgical approach using surgical microscope

Figure 4

Preparation of the recipient site

Figure 5

Donor graft tissue was obtained from the palatal side

Figure 6

After suturing

Figure 7

Non-eugenol periodontal dressing was given

Figure 8

Post-operative after 12 weeks

DISCUSSION

There are two basic periodontal procedures in which periodontal plastic microsurgery may be applied: Those relative to the level of the dentogingival junction and those relative to the edentulous ridge. With regard to the dentogingival junction, microsurgery can be employed to add gingival tissue where it is absent or to remove gingival tissue where it is excessive. Periodontal plastic microsurgery of the edentulous ridge often involves the addition of bone and or soft tissue.[5]

Advantages of the microscope in periodontics

The surgical microscope allows high-level motor skills and accuracy in clinical care. At ×40 magnification, vascular microsurgeons routinely anastomose vessels with a diameter of <1 mm. At ×120 magnification, biologists perform sub-cellular operations on mitochondria and chromosomes. Periodontal microsurgery is commonly performed at ×10-20 magnification. Under magnification of ×20, accuracy of hand movement and visual resolution are drastically improved. Proprioceptive guidance is of little value under the microscope. Instead, visual guidance is used to accomplish mid-course correction of the hand to accomplish the finest movement with skill and dexterity. This means incisions are accurately mapped, flaps are elevated with minimal damage and the wound is closed precisely and without tension. For the patient this means that post-operative morbidity can be reduced.[678]

Microsurgery in periodontics

Microsurgery has gained acceptance among some periodontists because the end-point appearance of microsurgery is simply superior to that of conventional surgery. As much as knowledge plays a role in surgery, eventually it is a craft. Surgeons appreciate craftsmanship, especially when it rises to artistic levels greater than those possible with conventional surgery. With a little training, the periodontist can consistently produce more finely crafted work than the most gifted conventional surgeon. Periodontal surgery viewed under the microscope reveals the coarseness of most surgical manipulation. What appears as gentle handling of tissues is discovered to be gross crushing and tearing. The microscope is a tool that permits less traumatic and minimally invasive surgery. Using 6-0 to 9-0 micro-sutures allows more precise wound closure.[9] This encourages repair through primary healing, which is rapid and causes less formation of granulation or scar tissue. Wound healing studies show anastomosis of microsurgical wounds within 48 h. Periodontal microsurgery does not compete with conventional periodontal surgery. It is evolution of surgical techniques to permit reduced trauma. Its methodology improves existing surgical practice and introduces the possibility for better patient care to periodontics.[10]