Enhanced Visualization in Periodontal Therapy: A Clear Picture of Better Patient Care
Minimally Invasive Periodontal Therapy with Surgical Microscopy (Microsurgery)

Microsurgery is defined as surgical procedures performed under a microscope using specialized instrumentation to allow for manipulation of small structures and to avoid interruption of adjacent tissues as much as possible. The procedures themselves are a mixture of surgical science and art and can take many years of training to become proficient.⁷¹ Carl Nylen is considered to be the father of microsurgery and designed the first binocular microscope for use in medicine in 1921.²⁷ While other surgeons adopted the use of microscopes during surgery, its usefulness in complex treatments at sites with a minute scale was clearly demonstrated with Jacobsen and Suarez achieved complete patency after suturing blood vessels of < 1 mm in diameter during surgical anastomosis⁷² and surgical microscopes were first introduced to dentistry in 1978 by Apotherker and Jako.⁴² Given the minute scale on which surgical procedures are performed in periodontics, the addition of microsurgical techniques has challenges and advantages.

Generally, the traits associated with use of surgical stereomicroscopes are threefold: illumination, magnification, and increased precision in surgical skill delivery.⁷³ Illumination and magnification delivered by an external stereomicroscope offers the advantage that it allows significantly greater magnification when compared to loupes and the ability to deliver illumination directly to the surgical field. Unlike the use of the endoscope, minimally invasive surgical techniques with the use of surgical microscopy require elevation of gingival flaps to expose the working field, but this approach can allow for the utilization of minimal flap elevation and thus yield decreased post-operative healing time and discomfort. Lastly, due to the factors of magnification (generally between 5-12x for periodontal surgery) and the more delicate tissue manipulation, the use of microsurgical instrumentation and fine-gauge sutures are also a critical part of the armamentarium for periodontal microsurgery. The use of microsurgical instruments, such as ophthalmic knives, allows for small size and higher levels of precision and sharpness due to their method of preparation.⁷³ These factors, in turn, lead to a more even and exact wound edge which can be repositioned for more rapid post-operative healing.⁷³ In particular, debridement of defects for hard and soft tissue regeneration and periodontal mucogingival and aesthetic surgeries have been described as benefitting from the use of microsurgical techniques.^74-77 However, the limited field of view that is allowed via the stereomicroscope may limit the use of microsurgery for larger procedures and/or where depth perception is critical, such as dental implant placement.^74-77 While many of these reports are limited in nature, they should be critically evaluated and the benefit to clinical, aesthetic, and patient-reported outcomes thoroughly assessed.

This advanced armamentarium and the inevitable learning curve associated with acquiring new surgical skills may be a barrier to some practitioners, but can convey benefits for advanced surgical care including:^73-77

1. Increased accuracy and decreased extent of incisions and flap elevation, which can decrease unintended surgical trauma and improve post-operative healing and patient-perceived discomfort.
2. Enhanced observation of etiologic factors that may cause recurrent disease progression and the ability to be more meticulous in debridement of surgical sites to ensure improved surgical outcomes.
3. Improved visualization for surgical positioning of tissues, leading to more exacting outcomes after soft and hard tissue manipulation.
4. Decreased surgical manipulation and interruption of blood supply lessens the risk of tissue injury and necrosis and functional and esthetic compromise.
5. Facilitation of healing by primary rather than secondary intention, which decreases significant variability in treatment outcomes and reduces untoward surgical healing.