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1. Minimal invasiveness in Recession Coverage and Ridge Augumentation SARAAJ BHUVAN R

2. INTRODUCTION MINIMALLY INVASIVE SURGERY (MIS) PERIODONTAL PLASTIC SURGERY MINIMAL INVASIVENESS IN GINGIVAL RECESSION CAIRO’S CLASSIFICATION RATIONALE FOR MINIMALLY INVASIVE SURGERY IN RECESSION COVERAGE FACTORS INFLUENCE MINIMAL INVASIVENESS IN PPS C URRENT PROCEDURES AND RELATED OUTCOMES OF GINGIVAL AUGMENTATION PROCEDURES  SURGICAL STRATEGIES TO MINIMIZE THE INVASIVENESS OF ROOT COVERAGE PROCEDURES   ALLOGRAFTS AND REPLACEMENT BIOMATERIALS FOR MIS CLINICAL OUTCOMES FOR SINGLE AND MULTIPLE RECESSIONS TREATMENT AND RELATED MORBIDITY  

3. MINIMAL INVASIVENESS RIDGE AUGUMENTATION   MINIMALLY INVASIVE VERTICALRIDGE AUGUMENTATION   MODIFICATIONS TO CONVENTIONAL AUGMENTATION METHODS DIAGNOSTIC PHASE AND PATIENT PREPARATION MODIFICATION OF SURGICAL TECHNIQUES THE CORTICAL TENTING TECHNIQUE AND THE TENT POLE TECHNIQUE STAGED OR SIMULTANEOUS IMPLANT PLACEMENT TISSUE ENGINEERING AND CELL THERAPY T HREE-DIMENSIONAL BIOPRINTING. MINIMALLY INVASIVE IN HORIZONTAL AUGUMENTATION   SUBPERIOSTEAL MINIMALLY INVASIVE AESTHETIC RIDGE AUGMENTATION TECHNIQUE (SMART) CONCLUSION REFERENCE

4. INTRODUCTION Minimally invasive surgery has transformed the landscape of periodontics, especially in procedures targeting recession coverage and ridge augmentation.

The shift towards minimally invasive approaches has improved outcomes, shorter recovery times, and reduced post-operative discomfort for patients undergoing recession coverage and ridge augmentation procedures.

5. Minimally Invasive Surgery (MIS) Minimally Invasive Surgery (MIS) is defined as surgeries that encompass surgical techniques that limit the size of incision needed and so lessen wound healing time a associated pain, morbidity and risk of infection National Institute of Health

6. Periodontal Plastic Surgery MIS is often used synonymously with periodontal microsurgery which refers to refinement in surgical technique by which normal vision is enhanced through magnification.

7. GINGIVAL RECESSION Recession is exposure of root surface by an apical shift in the position of gingiva (CARRANZA ) Gingival Recession is defined as displacement of soft tissue margin apical to cementoenamel junction (CEJ) with exposure of root surface. (LINDHE)

8. CAIRO’S CLASSIFICATION OF GINGIVAL RECESSION Gingival recession with no loss of interproximal attachment. Interproximal CEJ is clinically not detectable at both mesial and distal aspects of the tooth RT 1

9. Gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment loss is less than or equal to the buccal attachment loss RT 2

10. Gingival recession associated with loss of interproximal attachment. The amount of interproximal attachment loss is greater than the buccal attachment loss RT 3

11. Minimal invasiveness in Recession Coverage

12. Rationale To minimize the extent of surgical trauma To limit the intra and post operative morbidity with lower incidence and severity of complications To eliminate or minimize the need for reconstructive devices through maximizing the inherent healing potential of treated lesion.

13. Factors influence minimal invasiveness in PPS

14. PROVIDER SURGICAL PROCEDURE BIOLOGICAL CONDITIONS-IMPACT ON WOUND HEALING

15. PROVIDER Cause for invasiveness??? Flap design with technical characeristics - alone ?? 75% 25% Decision-Making Communication Team work Technical Skills

16. NON TECHNICAL SKILLS Early recognition of surgeons’s cognitive biases and personality traits are crucial to optimize pre and intraoperative decisions and to prevent surgical errors including traumatic tissue manipulation. Singh H, Graber ML. Improving Diagnosis in Health Care--The Next Imperative for Patient Safety. N Engl J Med. 2015 Dec 24;373(26):2493-5. doi : 10.1056/NEJMp1512241. Epub 2015 Nov 11. PMID: 26559457.

17. T ECHNICAL SKILLS Technical performance of a surgeon does not improve much by clinical experience and increasing knowledge alone. Human factors as the field dealing with the interface between the surgeons' hand and the instrument handle is closely related to technical skills T he tactile feedback needed to control the application of physical forces to wound margins or to prevent the unwanted crushing effect of an occluding forceps on the delicate mucosal tissues.

18. Impact of residual flap tension on the amount of coverage of shallow gingival recessions, showed that Applied flap tensions in a very low range <1 g are compatible with complete coverages Residual mean tension of just 6.5g substantially lowered the probability for a complete root coverage.

19. SURGICAL PROCEDURES

20. BLOOD SUPPLY ANGIOGRAPHIC STUDIES ON HUMANS

21. FLAP TENSION

22. MICROMECHANICAL ASPECTS OF THE BLOOD CLOT DURING HEALING

23. C URRENT PROCEDURES AND RELATED OUTCOMES OF GINGIVAL AUGMENTATION PROCEDURES For decades, the presence of “ adequate” amount of attached gingival tissue was considered a key factor for maintenance of gingival health. A classical prospective study on dental students suggested that a minimal keratinized tissue (KT) threshold of 2 mm is necessary to prevent further periodontal breakdown.

24. Wennstrom's study confuted the paradigm that a “minimal” amount of gingiva by itself is necessary to prevent the progression of gingival recession. the replacement of the definition periodontal biotype with periodontal phenotype. 1. Thin periodontal biotypes are at greater risk for developing gingival recessions than thicker biotypes . 2. Inadequate oral hygiene measures, orthodontic treatments, and cervical restorations increase the risks for gingival recessions especially in the presence of thin periodontal phenotype

25. In a retrospective case–control study, the risk for the occurrence of gingival recessions was assessed on plaster models of 100 orthodontically treated patients compared with 120 untreated controls, showing that history of treatment was associated with higher risk of recession with a significant odds ratio of 4.48 . The most prevalent sites for recessions were at lower incisors, supporting the hypothesis that buccal tooth movements in the presence of a thin buccal bone may increase the risks of buccal gingival recessions

26. ADVANCED GRAFT MATERIALS

27. ADVANCED GRAFT MATERIALS - Partly epithelized FGG (PE‑FGG) Biological substitutes. -Placental allograft - Decellularized human dermis -Xenogeneic collagen matrix (XCM)

28. ALLOGRAFTS AND REPLACEMENT BIOMATERIALS FOR MINIMAL INVASIVE ROOT COVERAGE - In the 1990s, barrier membranes were commonly used under coronally advanced flaps (CAF) for single recession treatment. - Meta-analysis revealed wide variability in root coverage outcomes (mean 48%–87%) and high complication rates, especially with non- resorbable membranes. - Consequently, barrier membranes for root coverage are now considered obsolete in clinical practice. - Modern biomaterials like enamel matrix derivatives, acellular dermal matrix (ADM), and collagen matrix (CM) are extensively researched alternatives.

29. Bilayer collagen matrix (BCM), a xenogenic porcine bilayer collagen matrix composed of Type I and III collagen that has been extensively investigated in its use for gingival augmentation. In a total of 20 patients, Sanz et al. compared BCM to CTG for gingival augmentation at both teeth and implant sites, reporting no significant differences between the 2 procedures and approximately 2 mm of mean KT gain after 6 months. BCM was associated with lower patient morbidity

30. EMD plus CAF has been applied for root coverage procedure as well, supported by histological findings documenting the formation of new cementum in the apical part of the dehiscence with inserting collagen fibers . A meta-analysis on single recession treatment showed that EMD + CAF yielded better root coverage outcomes (mean root coverage 84%–94%) than CAF alone leading to minimal,even if significant, final increase in KT gain

31. For the first time, an autologous cell hyaluronic acid graft was applied by Pini Prato et al. for gingival augmentation. A small portion of gingiva (epithelium and connective tissue) was removed from each patient, placed in a nutritional medium, and sent to a laboratory where fibroblasts have been separated and cultivated. Subsequently, cells were cultured on a scaffold of fully esterified benzyl ester hyaluronic acid (HA). 2003

32. The obtained membrane was applied at the exposed periosteum of the treated teeth. Three months after surgery, an increased amount of KT (mean increase 2 mm) could be noticed, and the histological examination revealed a fully keratinized tissue

33. McGuire et al tested a tissue-engineered product with neonatal keratinocytes and fibroblasts versus FGG in a large multicenter study. After 6 months, the results showed that FGG generated more KT gain than the living cell construct (LCC). LCC provided better color match and texture with the adjacent gingiva. 2008

34. Minimally invasive surgical procedures -RC

35. VESTIBULAR INCISION SUBPERIOSTEAL TUNNEL ACCESS Miller class I, class II, and class III recession defects, M ultiple adjacent gingival recession defects E sthetic -zone defects S oft-tissue augmentations/enhancements around dental implants in the esthetic zone.

36. Does no detach papillae. Incision in mucosa facilitating the access. Easier detachment of the soft tissue ( subperiosteal ). Expensive biomaterial was used (membrane complex ( β- TCPhydrated with rhPDGFBB )).

37. PINHOLE TECHNIQUE Miller class I, class II, and class III multiple adjacent gingival recession defects, including in the esthetic zone.

38. Does not detach papillae. Incision in mucosa acilitating the access. Full thickness dissection (reduced risk of fenestration). - Collagen stripes placed (increase the cost due to the biomaterial). - Specific instruments to perform the technique.

39. MODIFIED VESTIBULAR INCISION SUBPERIOSTEAL TUNNEL ACCESS

40. Double vascular surfaces for revascularization of the graft. - Lower risk of graft necrosis and scarring. - Better capillary in growth. - Does not detach papillae. Access is only through the frenum area, “V-shaped” incision. - Simultaneous frenectomy . - Difficult level for thin phenotypes (risk of fenestration).

41. GUM DROP TECHNIQUE

42. Miller class I, class II, and class III multiple adjacent gingival recession defects, including in the esthetic zone.

43. Minimally invasive. Places holes in mucosa to permit the access. Reduced risk of fenestration full thickness tunnel ( subperiosteal access). Does not detach papillae Substitution of the “gold standard” (CTG) for the A-PRF and i -PRF. - Rapid resorption of the PRF compared with the CTG.

44. Guided Creeping Technique (GCT)

45. Guided Creeping Technique (GCT)

46. Designed to keep the junctional epithelium intact while moving the mucogingival tissue complex coronally To provide maximum graft protection and stability through narrow blind tunnel reflection with its undetached coronal junctional epithelial seal Limited reflection of soft tissue to be restricted only on tissues apical to the recession Maintenance of the junctional epithelial seal with no intrasulcular incision.

47. No coronal suturing  the blind tunnel is already biologically sealed coronally with the undetached junctional epithelium Contact Inhibition of Proliferation (CIP), which is the ability of cells to stop proliferation once the tissue reaches confluence and cell establish cell to cell contact (sensing pressure increase) which is the main mechanism of proliferation control

48. CONTRAINDICATION Recession defects ≤ 3 mm, More recession depth may not allow for maintenance of the junctional epithelial adherence. INDICATION

49. MIXED-THICKNESS TUNNEL ACCESS (MITT) THROUGH A LINEAR VERTICAL MUCOSAL INCISION

50. Vertical incision on the mucosa (around 1–2 mm apical to the MGJ), lateral to the papilla base (Figure 1D). From the MGJ, subperiosteal access to raise the full-thickness tunnel is performed (Figure 1I), involving one adjacent tooth, to keep the local vascularization. The access is subperiosteal , and it is essential to act gently in this stage

51. Not mandatory to perform an intrasulcular incision Technique applies full-detachment design in the keratinized gingiva region,  avoiding the risk of fenestration in case of thin tissue thickness and keeping a better vascularization; Reduced risk of post-operative scarring, No use of flaps, which brings more predictability for the esthetic result Use of a split-detachment design in the region apical to the MGJ improves the tissue mobility, keeping the vascularization; Minimal surgical trauma to the recipient area; Maintenance of the integrity of the involved papillae, Permits relative ease suturing while ensuring firm graft fixation

52. Necessary to have KTW remnants to obtain a better outcome; Tissue detachment through the vertical incision can present some difficulties to be implemented; shortened vestibule may be challenging Moderate level of technical sensitivity,

53. INFLUENCE OF MINIMAL INVASIVENESS ON ROOT COVERAGE PROCEDURE RESULTS

54. In the modern clinical scenario, there is an upward tendency to treat multiple gingival recession in 1 surgical session instead of staged single interventions. This was enabled through the high predictability of modern procedures that incorporate the aspects of minimal invasiveness, including elimination of vertical releasing

55. MINIMAL INVASIVENESS RIDGE AUGUMENTATION

56. Ridge augmentation is a dental procedure aimed at replacing lost bone in the residual ridge by grafting either natural or synthetic materials. It involves the placement of bone grafting materials to aid in the healing of osseous defects and to augment atrophic edentulous ridges, thereby facilitating the successful placement of dental implants.

57. L oss of tissue in the buccolingual direction with normalheight in the apical-coronal direction. L oss of the tissue in the apical-coronal direction, withnormal width in the buccolingual direction. A combination of Class I and Class II (loss of both height and width Seibert classification 1983

58. RATIONALE Minimally invasive surgery techniques are increasingly being explored for maxillo-mandibular bone regeneration and reconstruction. The goal is to achieve similar functional and aesthetic outcomes while minimizing patient discomfort and invasiveness.

59. MINIMALLY INVASIVE VERTICALRIDGE AUGUMENTATION

60. DIFFERENT BONE RECONSTRUCTIVE OR REGENERATIVE TECHNIQUES HAVE BEEN PROPOSED: (i) D istraction osteogenesis; (ii) M axillary sinus floor elevation; (iii) O nlay grafts with intra-oral and extraoral autogenous bone blocks; (iv) G uided bone regeneration with resorbableor nonresorbable membranes (polytetrafluoroethylene) in association or not with tenting screws; (v) P rotected bone regeneration with noncustomized or customized titanium meshes.

61. MODIFICATIONS TO CONVENTIONAL AUGMENTATION METHODS ( i ) Use of soft tissue expanders prior to bone grafting (ii) the cortical tenting technique
(iii) the split bone blocks technique (iv) the tunnel technique
(v) the computer-guided bone harvesting procedure (vi) the use of a three-dimensional–printed bone model to preshape or produce bone blocks or to preshape or produce customized titanium meshes (vii) the split-thickness flap design without vertical releasing incisions (viii) the vestibular shifted flap design
(ix) tissue engineering and cell therapy

62. DIAGNOSTIC PHASE AND PATIENT PREPARATION Evaluation of bone availability is one of the first steps that should be carried out to determine whether we need to perform a vertical bone augmentation procedure. To achieve success together with less invasiveness, vertical bone augmentation procedures should be performed by well-trained and experienced surgeons. The clinician should carefully follow each step with special attention during flap management and suturing, because it is crucial that the stabilized bone regenerative materials remain covered by the soft tissues.

63. MODIFICATION OF SURGICAL TECHNIQUES

64. D OUBLE-FLAP INCISION TECHNIQUE

65. The palatal flap eversion to couple the first 4-5 mm of the buccal flap may be difficult because of the characteristic dense connective tissue of the area, , the incision line is shifted towards the buccal side based on defect anatomy and the target of vertical bone augmentation; Palatal flap length extends at least 4 mm coronal to the bone graft level prior to wound closure. This approach may impact invasiveness because it is expected that the optimal adaptation of the inner faces of the flaps results in a lower risk of non primary wound healing. VESTIBULAR SHIFTED FLAP DESIGN

66. the invasiveness of vertical ridge augmentation interventions may be limited by reducing the number of surgical interventions, that is, placing implants simultaneously to the ridge augmentation. However, when evaluating the effectiveness of different vertical ridge augmentation procedures in a recent systematic review, the weighted mean effect of the simultaneous approach was 3.81 mm, while the staged approach achieved a weighted mean effect of 4.39 mm. graft/membrane exposures and postoperative infections may lead to a bacterial contamination of adjacent implant surfaces if a simultaneous technique is utilized and also in cases of simultaneous vertical ridge augmentation.

67. TISSUE ENGINEERING AND CELL THERAPY Growth factors incorporated in carriers, stimulation of selective production of growth factors using gene therapy, and the delivery of expanded cellular constructs have been developed for craniofacial regeneration, including vertical ridge augmentation.

68. T HREE-DIMENSIONAL BIOPRINTING The technology can produce objects with controlled morphology and an internal structure that has a highly similar structure to the human body. Currently, the technology is used in various aspects of tissue engineering and regenerative medicine applications, including hard and soft tissue printing, cartilage printing, skin printing, and tumorous tissue model printing.

69. FAC TORS INFLUENCING THE OUTCOMES OF VERTIC AL RIDGE AUGMENTATION PROCEDURES (PATIENT AND SITE RISK FACTORS)

70. MINIMALLY INVASIVE IN HORIZONTAL AUGUMENTATION

71. Histomorphometric analysis

72. CONCLUSION It seems like you're highlighting the advantages of minimally invasive surgery (MIS) for recession coverage and ridge augmentation, emphasizing reduced discomfort, faster healing, and minimal tissue trauma compared to traditional techniques. Indeed, MIS strives to emulate the success of modern laparoscopic approaches in achieving better patient outcomes through smaller incisions, reduced tissue damage, and quicker recovery times. This shift towards minimally invasive procedures represents a progressive step in periodontal therapy, promising improved patient experiences and outcomes.

73. REFERENCE BOOKS

74. KEY REFERENCES

75. KEY AUTHORS Istvan dr. Urban Francesco Cairo Eduardo Montero

76. REFERENCE Cairo F, Burkhardt R. Minimal invasiveness in gingival augmentation and root coverage procedures. Periodontology 2000. 2023 Feb;91(1):45-64. Urban I, Montero E, Sanz ‐Sánchez I, Palombo D, Monje A, Tommasato G, Chiapasco M. Minimal invasiveness in vertical ridge augmentation. Periodontology 2000. 2023 Feb;91(1):126-44. Lee EA. Subperiosteal minimally invasive aesthetic ridge augmentation technique (SMART): a new standard for bone reconstruction of the jaws. Int J Periodontics Restorative Dent. 2017 Mar 1;37(2):165-73.

77. Marques T, Santos NB, Sousa M, Fernandes JC, Fernandes GV. Mixed-Thickness Tunnel Access ( MiTT ) through a Linear Vertical Mucosal Incision for a Minimally Invasive Approach for Root Coverage Procedures in Anterior and Posterior Sites: Technical Description and Case Series with 1-Year Follow-Up. Dentistry Journal. 2023 Oct 7;11(10):235.