Minimally Invasive Periodontal Therapy

Clinical Techniques and Visualization Technology

Stephen K. Harrel, Thomas G. Wilson, Jr.

• Publisher: Wiley-Blackwell
• Year: 2014
• Print ISBN:
  9781118607626
• eBook ISBN:
  9781118953624
• Edition: 1
• Topic: Medicine
• Subtopic: Dentistry

The long-term success of periodontal therapy is dependent on proper diagnosis and removal of subgingival tooth-borne accretions in the form of calculus and bacteria. From a clinical perspective, better visualization during the diagnostic and therapeutic phases has been shown to yield better results compared to traditional approaches.

Minimally Invasive Periodontal Therapy evaluates the advantages of using minimal invasive techniques, the technologies available for enhancing visualization during minimally invasive therapy, and step-by-step illustrates the clinical use of each technique. Each chapter addresses the advantages and disadvantages of minimally invasive therapies, rationale for the approach, and the advantages and limitations of each of the current methods of improving visualization. The chapters then provide an evidence-based review of the technologies and procedures, and end with case studies for each visualization procedure, featuring clinical photographs.

1
Overview of Minimally Invasive Therapy

Stephen K. Harrel and Thomas G. Wilson Jr.

The definition of a minimally invasive procedure has been debated in medicine since the term was first coined in an editorial in the British Journal of Surgery in 1990 [1]. Initial descriptions of small incision surgeries were usually based on the method or instrument that was used to visualize the surgical site. Examples of this would be a microsurgical procedure where the surgical site was visualized using a surgical microscope or a laparoscopic procedure where the abdominal procedure was visualized using a laparoscopic endoscope. Because the technology being used for small incision surgery continued to evolve rapidly and often the instrumentation for visualization of a particular procedure changed over time, the term “minimally invasive surgery” was suggested. This is a more global term that need not be changed as the technology evolves. Over time, a definition was accepted which states that minimally invasive surgery is a surgical technique that uses smaller incisions to perform a surgical procedure that previously required larger incisions and achieves equal or superior results compared with the traditional surgical approach [2]. This definition separates the description of the surgical procedure from the technology used for visualizing the surgery. This broad-based definition is currently accepted in most medical fields.

A significant portion of this text will explore periodontal therapeutic approaches that are markedly different from traditional techniques. Some of these techniques clearly fit the medical definition of minimally invasive surgery. These include the surgical approaches where very small incisions using a videoscope are used to treat periodontal bone loss or to treat soft tissue deficiencies. Some of the techniques described do not fit the usually accepted definition of minimally invasive surgery. An example is closed gingival scaling and root planing using a dental endoscope. However, the editors feel that this procedure clearly belongs in the broader area of minimally invasive therapy.

The scientific documentation on minimally invasive techniques is approaching a critical mass. The number of papers that document very favorable results from minimally invasive surgical and nonsurgical periodontal procedures is increasing and have been generated from multiple sources. This is a critical factor for minimally invasive therapies to become a mainstream and, eventually, the dominant therapeutic approach. At the same time, the devices for performing MIS are becoming more widely available. This combination of positive scientific evidence and advances in technology will allow rapid advancement in the field.

This book briefly describes some of the early applications of this philosophy, how the technologies for performing minimally invasive procedures have evolved, and how the current techniques have reached their present form. The book also covers in detail the state of the art in minimally invasive periodontal therapy. This includes a description of the techniques, a discussion of the currently used technology, as well as clinical case studies. Chapter 10 explores possible futures for the treatment of periodontal disease that may take us far beyond our current concepts of what is “minimal” in our treatment approaches.

References

1. 1. Wickham, J. & Fitzpatric, J.M. (1990) Minimally invasive surgery [Editorial]. British Journal of Surgery, 77, 721–722.
2. 2. Hunter, J.G. & Sackier, J.M. (1993) Minimally invasive high tech surgery: Into the 21st century. In: J.G. Hunter & J.M. Sackier (eds), Minimally Invasive Surgery, pp. 3–6. McGraw-Hill, New York.

2
Visualization for Minimally Invasive Periodontal Therapy: An Overview

Stephen K. Harrel

The increasing popularity of minimally invasive procedures has been driven in part by advancements in technology that have allowed procedures to be performed through smaller access openings and by the reduced morbidity and improved efficacy seen as a result of these technologies. The most critical advancements in technology are in the area of visualization. The key to performing minimally invasive procedures is the ability to adequately see the site and, therefore, the ability to successfully complete the indicated surgical manipulations. With enhanced visualization, outcomes are improved.

Traditional closed subgingival scaling and root planing is the most frequently used approach for treating inflammatory periodontal diseases. This approach allows no direct visualization of the treatment site. Treatment end points are based on the tactile sense of the operator using various instruments. The operator is forced to determine by palpation alone if the root surface has been debrided of calculus and if root roughness has been removed. Because of a lack of a tactical “feel,” it is impossible for the operator to determine by palpation if any existing biofilm has been completely removed. The process of determining a clinically ideal end point is complicated by factors such as burnished calculus and various root anomalies that give a less-than-smooth feel to the root. While closed root planing has been shown to routinely improve periodontal health, it has also been shown that the end result is often a root surface with some residual calculus. It was found that root surfaces treated with these traditional methods when subsequently viewed either with the endoscope or the videoscope routinely reveal areas of retained calculus and biofilm. Thus, the lack of visualization in traditional closed approaches frequently results in subsequent periodontal breakdown and frequently leads to further treatment often including surgery.

Traditional periodontal surgery was developed to allow for access and visualization of the surgical site. One of the most commonly performed traditional periodontal surgical procedures is open-flap debridement. This approach allows for visualization of the root surface and periodontal defect. The incisions traditionally used to provide visualization often extend over many teeth and often include areas that have little or no periodontal damage. Elevation of these large flaps frequently leads to post-surgical root exposure, areas of food impaction, and thermal sensitivity as well as esthetic deformities.

Minimally invasive periodontal therapy is designed to access and visualize only the areas that require periodontal treatment using the smallest incision possible. This has been made possible by technologic advances for visualization without the necessity of large incisions and flap elevation. This chapter explores the options currently available for visualization. The advantages and disadvantages of each will be discussed.

Visualization for closed root planing procedures

The very nature of closed root planing demands that visualization of the treatment site uses a visualization technology that can be placed into an intact pocket without a surgical incision. To date, there is a single device, the periodontal endoscope which was developed in the 1990s, that will allow for this approach [1] (Figure 2.1). This endoscope consists of glass fibers contained within a plastic disposable sheath with a small stainless steel tube, and a sealed sapphire lens. The stainless steel tube is retained in a handheld dental instrument that allows the fibers and lens to be directed into the periodontal pocket without flap elevation. Some of the glass fibers direct light into the subgingival environment. Other glass fibers capture an image of this space. The image is returned to an external camera that displays it on a monitor. The operator can directly view the treatment area by looking at the monitor that allows them to determine the need for and efficacy of efforts to remove root-bound deposits.

Figure 2.1 The glass fiber endoscope for use in nonsurgical minimally invasive periodontal therapy is shown.

Source: Courtesy of Dr. John Kwan.

The currently available glass fiber endoscope is less than 1 mm in diameter. It contains several thousand individual optical glass fibers. It is considered flexible because some amount of bending and flexing is possible. However, care must be taken to avoid significant bending of the fibers to reduce the probability of fracture. Typically, even with care, some of the individual glass fibers will break with use. As fractures occur, there will be some degradation of the amount of light that reaches the surgical site, and the image returned to the external camera will be deg...

Table of contents

• Cover
• Title page
• Copyright page
• Contributors
• Introduction
• 1 Overview of Minimally Invasive Therapy
• 2 Visualization for Minimally Invasive Periodontal Therapy: An Overview
• 3 Ultrasonic Endoscopic Periodontal Debridement
• 4 Endoscope Use in Daily Hygiene Practice
• 5 The Use of the Dental Endoscope and Videoscope for Diagnosis and Treatment of Peri-Implant Diseases
• 6 Development of Minimally Invasive Periodontal Surgical Techniques
• 7 The MIS and V-MIS Surgical Procedure
• 8 Minimally Invasive Surgical Technique and Modified-MIST in Periodontal Regeneration
• 9 Minimally Invasive Soft Tissue Grafting
• 10 Future Potential for Minimally Invasive Periodontal Therapy
• Index
• Access the Companion Website
• End User License Agreement