periodontal microsurgery (loupes, microscope).pptx

PERIODONTAL MICROSURGERY

1. Dr.P.S.Viola Esther Assistant Professor

2.  Microsurgery refers to a surgical procedure performed under a microscope.  It is based on the fact that the human hand, by appropriate training, is capable of performing finer movements than the naked eye is able to see.  Magnification is a tool to lessen the effects of compromise in treatment modalities. Introduction 

3.  In 1979, Daniel RK defined microsurgery in broad terms as “Surgery performed under magnification by the Microscope”. Definition 

4. Microsurgical Triad 

5.  Improvement of motor skills, thereby enhancing surgical ability  An emphasis on passive wound closure with exact primary apposition of the wound edge  The application of microsurgical instrumentation and suturing to reduce tissue trauma Principles 

6. Magnific a tion Methods Loupes Operating Microsc o pe Magnification Methods 

7.  Loupes are again of three types: Simple loupes Compound loupes Prism loupes  Only compound and prism loupes are used in dentistry today Loupes 

8. 

9.  Compound loupes use multiple converging lenses with intervening air spaces.  These lenses can be adjusted to clinical needs without excessive increase in size or weight  Compound loupes are mounted in or on eye glasses Compound Loupes 

10. Prism Loupes 

11. Operating Microscope 

12.  Loupes Operating Microscopes 1.5x to 10x magnification 2.5x to 20x magnification Need additional illumination for magnifications of 4x or greater Use excellent coaxial Fiber-optic illumination, hence does not need additional light source Operator eye comfort is less as the eyes must converge to view the image High comfort as it has parallel binoculars Initially easy to use Basic training required to use surgical microscope Less expensive Main disadvantage is that these are expensive Cannot provide variable magnification Has the advantage of providing variable magnifications Loupes Vs. Operating Microscope

13.  The microsurgical instruments are of 15cms length to provide adequate hand control Microsurgical Instruments  15 CM 10 CM The instruments are manufactured under magnification

14. The instruments are circular in cross section which allows for smooth rotation movements Instruments with rectangular cross-section and smaller instruments do not allow precise manipulation and therefore, are not ideal for microsurgery The working tips of microsurgical instruments are much smaller than those of regular instruments, approximately ten times smaller Working tip

15. Micro mirrors with  sapphire surfa c es Castroviejo needle holder & Laschal micro scissors Sutures size – 6.0, 7.0

16.  Cleaner incisions,  Closer wound apposition,  Reduced hemorrhage,  Reduced trauma at the surgical site.  Patient acceptance is more Advantages over Conventional Surgery 

17.  Periodontal plastic surgery,  Guided tissue regeneration,  Cosmetic restorative  Crown lengthening,  Gingival augmentation procedures,  Soft and hard tissue ridge augmentation,  Osseous resection,  Dental implant placement Clinical applications 

18.   Based on the microsurgical principles MIS(Minimally Invasive Surgery) was introduced  Further, MIST(Minimally Invasive Surgical Technique) followed by M-MIST(Modified M i n i mally I n vasive Sur g ica l T ech n ique ) were introduced.

19. 

20. Esthetic periodontal microsurgery Precise tailoring Delicate tissue handling Passive primary wound closure

21.  Microsurgery offers possibilities t o i m p r o v e therapeutic results of various procedures.  A number of periodontal and implant reconstructive procedures can be performed using minimally invasive approaches. Conclusion 

22. LASERS IN PERIODONTICS

23. INTRODUCTION L- L IGHT A- A MPLIFICATION by S- S TIMULATED E- E MISSION of R- R ADIATION

24. YESTERDAY…???

25. TODAY ….???

26. ORDINARY LIGHT LASER LIGHT Diffused White light- sum of visible colour of spectrum Monochromatic Coherent Collimation

27. PROPERTIES OF LASERS

28. CLASSIFICATION According to ANSI & OHSA standards lasers are classified as Class I : Low powered lasers that are safe to use. Class IIa : Low powered visible lasers that are hazardous only when viewed directly for longer than 1000 seconds. Class IIb : Low powered visible lasers that are hazardous when viewed for more than 0.25 seconds.

29. Class IIIa : Medium powered lasers & hazardous if viewed for less than 0.25 seconds without magnifying optics. Class IIIb : Medium powered lasers, hazardous when viewed directly. (dental application) Class IV : High powered lasers, that produce ocular skin and fire hazards.(dental application)

30. 3.Based on the penetration power of the beam: Hard tissue lasers : Erbium lasers. ( Er:YAG ) Soft tissue lasers : Diode, Nd:YAG,CO2 laser. 4.Based on the emission mode: Continuous wave mode Gated pulse mode Free running pulsed mode

31. 5.Based on the laser material used: Gas lasers : CO2, Argon, He-Ne lasers Liquid lasers: Dye lasers Solid state lasers: Ruby , Nd:YAG lasers Semiconductors: Gallium, Arsenide (diode laser).

32. Contact Tip is in contact with tissue. Concentrated delivery of laser energy. Tactile feedback is available Non- contact Tip is kept 0.5 to 1 mm away from tissue. Laser energy delivered at the surface is reduced. No feedback. Only visual. TYPES OF LASER

33. Focused : Laser beam hits tissue at its focal point- narrowest diameter. Cutting mode Defocused : Wider area of tissue affected as beam diameter increases. Ablative mode. TYPES OF LASER A target tissue absorbs the light. If it is well absorbed, the energy will explode the cell. This process is called as ablation

34. LASER EFFECTS ON TISSUES Reflection Transmission Scattering Absorption

35. Biopsy Bleaching Apicoectomy Dental composite curing Caries removal Root canal disinfection Pontic site preparation Teeth preparation Epulis fissuratum. Residual ridge modification. Impaction. Tori reduction. Soft tissue modification Orthodontic Practice. Removal of white lesions Haemangiomas Facial nerve surgery. APPLICATIONS IN DENTISTRY

36. CONVENTIONAL METHODS LASER Bleeding- surgical field. Suturing. Local anesthesia. Post-operative discomfort. Healing time. Post-operative complications. Periodontal dressings. Effective hemostasis. No sutures. (concept of tissue welding). Topical anesthetic- some procedures. Faster healing. Minimal/no post operative complications. Laser sterilization of wound site. Laser bandage.

37. APPLICATIONS IN PERIODONTICS : Initial non-surgical pocket therapy Frenectomy Gingivectomy Soft tissue grafting. De-epithelialization Removal of granulation tissue.

38. APPLICATIONS IN PERIODONTICS : Osseous recontouring. Crown lengthening. Second stage surgery- implants. Peri-implantitis. Operculectomy. LANAP Photodynamic therapy Biostimulation

39. 40-45 o C – Hyperthermia >65 o C - Protein denaturation & coagulation 70-90 o C - Tissue welding >100 o C - Vapourization >200 o C - Carbonization & charring LASER ON HARD TISSUES >47C – osseous resorption >60C - tissue necrosis LASER ON SOFT TISSUES

40. GINGIVAL SOFT TISSUE THERAPIES Gingivectomy. Gingivoplasty. Frenectomy/ frenotomy. Vestibuloplasty. Operculectomy. Depigmentation .

41. GINGIVECTOMY Increased Visualization sue to sealing of capillaries & lymphatics Nd : YAG & Diode lasers comonly used Non- inflamed . Fibrotic – More power needed Inflamed – less power needed. ( More Hb )

42. FRENECTOMY Predictable with laser because –Periosteal fenestration preventing re-attachment. Shorter healing period CO2 provides penetration depth of 5 -40 micrometer while Nd:YAG result in deeper penetration of 500 micrometers having risk of peri osteal damage.

43. OPERCULECTOMY Soft tissue laser used . Merit : Faster healing time Bactericidal effect.

44. GINGIVAL DEPIGMENTATION Principle : No Incision , It is the ability of melanin absorbing laser energy & lightning in colour. Nd : YAG & Diode laser used with low power to prevent unnecessary tissue penetration.

45. C. In addition, the bacteriocidal effects of Nd YAG laser plus intraoperative use of topical antibiotics are designed for the reduction of microbiotic pathogens (antisepsis)within the periodontal sulcus and surrounding tissues. A second pass with the 635µ/ sec “long pulse” laser finishes debriding the pocket D. Gingival tissue is compressed against the root surface to close the pocket and aid with formation and stabilization of a fibrin clot E. The wound is stabilised, the teeth are splinted and occlusal trauma is minimized to promote healing F. Oral hygiene is stressed and continued periodontal maintenance is scheduled. No probing is performed for at least 6 months LANAP –LASER ASSISTED NEW ATTACHMENT PROCEDURE The primary endpoint of LANAP is debridement of inflamed and infected connective tissue within the periodontal sulcus B. Removal of calcified plaque and calculus adherent to the root surface

46. Conventional method- tactile feel. Latest: Er YAG laser with fluorescent feedback system for calculus detection. Rationale: Difference in the fluorescence emission properties of calculus and dental hard tissue when subjected to irradiation with 655 nm diode laser . Commercially available as Key Laser III, Ka Vo, Germany SUBGINGIVAL CALCULUS DETECTION- UNIQUE APPLICATION FOR LASER

47. PHOTODYNAMIC THERAPY

48. Reduction of discomfort / pain (Kreisler MB et al 2004). Promotion of wound healing ( Qadri t et al 2005). Bone regeneration (Merli LA et al 2005). Suppression of inflammatory process. ( Qadri T et al 2005). Activation of gingival and periodontal ligament fibroblast (Kreisler M et al 2003), growth factor release (Saygun I et al 2007). Alteration of gene expression of inflammatory cytokines (Safavi SM et al 2007). Photo biostimulation (Garcia et al 2012) BIOSTIMULATION OF LOW LEVEL LASERS

49. LASERS USED: CO2 AND ERBIUM FAMILY Involves use of lasers for  calculus removal,  osseous surgery,  de-toxification of the root surface and bone,  granulation tissue removal Advantage of Laser: Better access in furcation areas, hemostasis, less postoperative discomfort, faster healing. SURGICAL POCKET THERAPY - LASERS

50. MANAGEMENT OPTIONS- Conventional- plastic curettes and antibiotics. New option- Laser Rationale:  Disinfection and de-contamination of implant surface.  Granulation tissue removal. LASERS USED: DIODE, CO2, ERBIUM FAMILY. LASERS CONTRA-INDICATED: ND:YAG (IMPLANT DAMAGE). IMPLANT THERAPY- MANAGEMENT OF PERIIMPLANTITIS

51. PRECAUTIONS Inspite of laser being an excellent tool , it has high risk of damage of irradiated tissue. Therapauetic lasers of less than 500 mW considered as low risk devices. Protective eye wear Rubber mouth gaurds to Protect mouth and gingiva Use of co2 lasers : silver foil between the teeth and gingiva Proper shielding of lips , eyes, pharynx and skin

52. ADVANTAGES OF LASER Wound heals more quickly and produce less scar tissue Ability to cut, coagulate or vaporize in a controlled manner Reduction in bleeding Sterilization of wound site Reduction in post-operative pain Minimal pain & swelling Less need for sutures Minimally invasive

53. ADVANTAGES OF LASER Reduction in operative time High patient acceptance Protein coagulum that is formed on the wound surface, thereby acting as a biologic dressing and sealing the ends of the sensory nerves – enhanced healing

54. DIS-ADVANTAGES Relatively high cost of the device A need for additional education( especially basic physics) Every wavelength has different properties and should be used based on that knowledge The need for implementation of safety measures.

55. CONCLUSION “ LASER IS AN EXCITNG FIELD WITH PROMISING POSSIBILTIES TO BE INVESTIGATED THAT MAY PROVE ITS FURTHER UTILITY IN PERIODONTICS.”