|Year : 2017 | Volume
| Issue : 1 | Page : 24-29
Minimally invasive surgical techniques in periodontal regeneration
Swet Nisha1, Pratibha Shashikumar1, Gadupudi Salini Samyuktha2
1 Department of Periodontology and Oral Implantology, J. S. S. Dental College and Hospital, J. S. S. University, Mysore, Karnataka, India
2 Department of Public Health Dentistry, J. S. S. Dental College and Hospital, J. S. S. University, Mysore, Karnataka, India
|Date of Web Publication||3-Jul-2017|
Department of Periodontology Oral Implantology, Room No 9, J. S. S. Dental College and Hospital, S. S. Nagar, Bannimantap, Mysore - 570 015
Source of Support: None, Conflict of Interest: None
There are recent advances in periodontal surgical techniques, from resection to regeneration, the focus of surgical access has shifted to regeneration of lost tissues. To achieve goals of periodontal surgical therapy, minimal invasive surgery can be considered as a potential future for the treatment of periodontal disease with the concept of being minimal in our treatment approaches. This article reviews the various techniques, its applications, and future prospects of minimal invasive periodontal surgery.
Keywords: Minimal invasive periodontal surgery, minimally invasive surgery, periodontal regeneration
|How to cite this article:|
Nisha S, Shashikumar P, Samyuktha GS. Minimally invasive surgical techniques in periodontal regeneration. Int J Oral Health Sci 2017;7:24-9
| Introduction|| |
Surgery is a scary thing from the patient's perspective. Periodontal surgery targets access to the underlying bony defect, pocket elimination, periodontal regeneration, and maintenance of healthy periodontium. Traditional periodontal surgical procedures used extensive flap operation to access underlying disease area which causes bone exposure.
With advances in surgical procedures, there is a paradigm shift from periodontal resection to regeneration. Although periodontal resection remains surgical choice for definite pocket reduction, regeneration of lost periodontal tissues remains challenging to the clinician. Any surgical procedure should be easy to perform from operators side, less time taking, less pain and postoperative discomfort, less costly and more acceptable, and beneficial to the general population. Taking consideration to all these in 1995, the term minimally invasive surgery (MIS) was introduced in periodontology by Harrel and Ress, to minimize wounds and flap reflection.
The concept of minimal invasive surgery is being practiced for years in various field of medicine and surgery. Laparoscopic cholecystectomy, microsurgery of the eye, ear, nerve injury using surgical microscope has gained popularity. These procedures result in early wound healing, better patient acceptance.
MIS helps in handling hard and soft tissues gently during periodontal surgery. Isolated defects not extending beyond the interproximal site were considered ideal for this technique. Incisions were aimed at conserving the soft tissue as much as possible. In cases of multiple isolated defects, individual incisions for each site should be given.
Generalized periodontitis cases require quadrant surgery, long incision, and vertical releasing incision to gain access to deeper pockets. This results in postoperative soft tissue recession. The ideal surgical approach for periodontal regeneration would be one that allows access to the site to be regenerated without extending the surgical incision into adjacent healthy areas.
Taking this into account, the first technical proposal introduced in periodontal regenerative surgery was MIS. The authors suggested the use of MIS in combination with bone grafting material covered with a bioresorbable vicryl mesh to treat isolated and multiple intrabony defects. The technique consists of an initial intrasulcular incision around the teeth neighboring the defect, followed by an incision between the teeth, usually on the lingual aspect, to connect the preliminary intrasulcular ones. The papilla is sharply dissected from the underlying bone, and small buccal and lingual flaps are carefully reflected. The connective tissue within the osseous defect is dissected with a blade and removed with curettes and ultrasonic instruments, and the root is debrided. The authors suggested finalizing root planing with finishing burs. Root conditioning with citric acid is also suggested, followed by placement of decalcified freeze-dried bone allograft mixed with tetracycline hydrochloric acid to fill or slightly overfill the defect. The flap was sutured with vertical parallel mattress sutures to obtain primary closure.
Wickham and Fitzpatric 1999 described the techniques of using smaller incisions as “MIS.” Hunter and Sackier in 1993 described the minimal invasive approach as “the ability to miniaturize our eyes and extend our hands to perform microscopic and macroscopic operations in places that could previously be reached only by large incisions.”
Tibbetts and Shanelec 1994 described periodontal microsurgical technique and concentrated on soft tissue regeneration and augmentation using a surgical operating microscope.
| Minimally Invasive Surgical Approach for Periodontal Regeneration|| |
- Isolated, interproximal bone defect, not extending beyond the interproximal site 
- Periodontal defects that border on an edentulous area
- Periodontal defect that extend from buccal/lingual from interproximal site
- Multiple separate defect sites within a single quadrant.
- Generalized horizontal bone defect 
- Multiple interconnected vertical defects, walls.
General consideration for minimally invasive surgery
- All incisions are designed to conserve soft tissues
- Separate incisions are performed, continuous incisions are avoided
- Vertical releasing incisions are avoided
- Coverage of graft/membrane by soft tissue is achieved to promote periodontal regeneration, for example, if the bony defect is in esthetic areas, incision is given in palatal papilla 
- Tissues are reflected by sharp dissection or combination of blunt and sharp
- Adequate visualization of the procedure requires magnification and light source. Surgical microscope, loupes ×3.5 magnification can be used 
- Root surface debridement becomes difficult as minimal flap reflection is performed to preserve tissues. Mechanical debridement can be performed tip of curette inserted vertically and shank held parallel to the tooth surface. Ultrasonic scalers can be used to break the granulation tissues
- Placement of bone graft material – plastic plunger gun can be used for precise placement of graft material
- Interproximal site can be closed by vertical mattress sutures. 6-0 resorbable suture can be used.
| Minimally Invasive Periodontal Surgical Therapy: Techniques|| |
Cortellini and Tonetti proposed the minimally invasive surgical technique (MIST) in 2007. Later, they introduced the concept of space provision for regeneration with the modified MIST (M-MIST, Cortellini et al. 2009).
In the MIST approach, the defect-associated interdental papilla is accessed either with the simplified papilla preservation flap (SPPF) in narrow interdental spaces or the modified papilla preservation technique (MPPT), in large interdental spaces.
The SPPF is a diagonal incision traced as close as possible to the buccal side of the papilla col, whereas the MPPT is a horizontal incision traced on the buccal side of the papilla [Figure 1]. Intrasulcular incisions are performed from the interdental side to the buccal and lingual sides of the teeth neighboring the defect; tiny buccal and lingual flaps are elevated to expose the residual bone crest. Periosteal incisions are performed only if needed to improve flap reflection. The soft tissue is sharply dissected from the osseous defect and debridement and root planing are performed with a combination of mini-curettes and power air-driven instruments [Figure 2]. Ethylenediaminetetraacetic acid is applied to the air-dried root surface for 2 min and then carefully washed away, and enamel matrix derivative is applied on the air-dried root surface. The suturing approach is based on the use of a single internal mattress sutures [Figure 3].
Cortellini and Tonetti  proposed the application of a single MIS technique to treat multiple adjacent defects. The surgical modification includes an extension of the flap to all the teeth involved by osseous defects. The larger flap is minimally reflected in accordance with the previously described principles.
More recently, Cortellini and Tonetti  proposed M-MIST. The surgical approach consists of a tiny interdental access in which only buccal intrasulcular incisions are performed and connected with a buccal horizontal incision of the papilla performed as close as possible to the papilla tip.
The tiny buccal triangular flap is elevated to expose the residual buccal bone crest. The papillary tissues are left untouched, carefully preserving the supracrestal attachment apparatus to the root cement of the crest-associated tooth. Access to the defect is gained through the tiny buccal “window.” The soft tissue filling the defect (i.e., the so-called granulation tissue) is sharply dissected from the papillary supracrestal connective tissue and removed with mini-curettes.
Then, the root surface is carefully debrided with mini-curettes and power-driven air instruments avoiding any trauma to the supracrestal fibers of the defect-associated papilla. The palatal tissues are not surgically accessed. The suturing approach is based on the use of a single internal modified mattress suture. Additional sutures can be applied to further increase primary closure, when needed. M-MIST cannot be applied to all periodontal defects. Its limits are the access to the diseased root surface. Whenever a defect extending to the lingual/palatal side of a root is difficult to debride, the authors suggest raising the papilla and performing a MIST approach.
The MIS  and the MIST  include the elevation of the interdental papillary tissues to uncover the interdental space, gaining complete access to the intrabony defect, whereas the M-MIST  proposes an approach in which the access to the defect is gained through the elevation of a small buccal flap, without elevation of the interdental papilla.
Single-flap approach consists of a buccal envelope flap without vertical releasing incisions. Sulcular incisions are performed following the gingival margin of the teeth included in the surgical area. The mesiodistal extension of the flap is kept limited while ensuring access for defect debridement and placement of any bone biomaterial or membrane.
An oblique or horizontal, butt-joint incision is made after the profile of the underlying bone crest at the level of the interdental papilla overlying the intraosseous defect; the greater the distance from the tip of the papilla to the underlying bone crest, the more apical (i.e., close to the base of the papilla) the buccal incision in the interdental area.
At wound closure, a horizontal internal mattress suture was placed between the buccal flap and the base of the attached oral papilla coronal to the mucogingival junction to ensure repositioning of the buccal flap. For each defect, a microsurgical periosteal elevator was used to raise a flap on the buccal side only, leaving the oral portion of the interdental supracrestal soft tissues undetached. Root and defect debridement were performed using hand and ultrasonic instruments. At the completion of the surgical debridement, defects were left to fill with a blood clot. A second internal mattress suture (vertical or horizontal) was placed between the most coronal portion of the flap and the most coronal portion of the oral papilla to ensure wound closure for primary intention healing.
The recent meta-analysis suggested no significant difference in treatment of intra-bony defects between the MIS plus biomaterials group and the MIS alone group [Table 1] indicating that it is important to take costs and benefits into consideration when a decision is made about a therapeutic approach.
|Table 1: Overview of Minimally invasive surgical Techniques with clinical outcomes|
Click here to view
Summary of studies in a tabulate form is illustrated in [Table 1] providing an overview of different technique used in MIST with clinical outcomes.
Minimally invasive soft tissue grafting is predictable for root coverage procedures with advantage of (i) no surface incisions, thus no scarring; (ii) use of an allograft, which eliminates need for a palatal donor site; (iii) reduced patient discomfort; (iv) greater acceptance of treatment; and (v) ideal esthetics. Tunnel and pouch technique described by Allen includes minimal incision, soft tissue grafting, and precise suturing to gain optimal esthetic outcomes.
Advantages minimally invasive surgical techniques in periodontal regeneration
- Less postoperative pain
- Improvement in rate of healing 
- Chair time required to perform such a surgery is by far shorter than the chair time required for more conventional surgical approaches 
- Improved retention of soft height and contour
- Periodontal tissue regeneration
- Good patient acceptance.
- Technique sensitive
- MIS needs improved instruments for root and osseous defect debridement, “micro” versions of the instruments
- Cannot be universally applied, only in suitable cases technique can be performed.
| Videoscope Assisted Minimally Invasive Surgery || |
The term videoscope-assisted MIS (V-MIS) is used to describe MIS performed with the aid of a videoscope. Harrel et al. in 2014 conducted a study to evaluate residual defects following nonsurgical therapy consisting of root planing with local anesthetic. V-MIS was performed utilizing the videoscope for surgical visualization. Reevaluation, 6 months postsurgery, showed statistically significant improvement (P < 0.001) in mean probing pocket depth (PPD) and clinical attachment level (CAL) (PPD 3.88 ± 1.02 mm, CAL 4.04 ± 1.38 mm) in 1, 2, and 3 wall defects.
| Robot-Assisted Minimally Invasive Surgery|| |
Robotically assisted MIS uses end effectors and manipulators of the robotic arms to perform the actual surgery on the patient. These arms can either be controlled by a telemanipulator or through computer control. However, it is cumbersome to use, expensive, and needs expertise.
| Conclusion|| |
The future for improvements in periodontal therapy is virtually limitless. Proper case selection, flap design, equipment will be beneficial in evaluating the efficacy of MIS toward periodontal regeneration. Limitations in case selection, cost, and mastering the technique are issues to be faced in acceptance of this technique. Studies have shown limited patient morbidity and excellent clinical improvements with MIS. MIS has a future potential to become a mainstream and eventually, the dominant therapeutic approach. The combination of positive scientific evidence and advances in technology will allow rapid advancement in the field of minimal invasive surgery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]