Development of Minimally Invasive Periodontal Surgical Techniques










Minimally Invasive Periodontal Therapy: Clinical Techniques and Visualization Technology, First Edition.
Edited by Stephen K. Harrel and Thomas G. Wilson Jr.
© 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.
Companion Website: www.wiley.com/go/harrel/minimallyinvasive
77
6
All treatments for periodontal diseases are centered, at least in part, on the thorough
debridement of the root surfaces. Without the removal of plaque, biofilm, and
calculus from the root surfaces, most authorities agree that periodontal treatment
whether aimed at ameliorating the disease process or the regeneration of lost
periodontal tissue is doomed to failure. Bearing this goal in mind, all periodontal
surgical approaches are aimed at allowing the surgeon improved access and
visualization to debride root surfaces and the periodontal lesion.
Most authorities credit Widman and Neumann with the first descriptions of
periodontal surgery [1,2]. The surgery described involved large incisions to expose
the bone beyond the apex of the teeth, allowing for the debridement of root
surfaces and osseous defects. Often, it was recommended that the interproximal
bone be left exposed to allow for the formation of new interproximal tissue. This
surgical technique was aimed at pocket elimination. Everett credits Kirkland
with describing the first periodontal surgical procedures that were aimed at
regeneration and reattachment to the root surface [3]. Most traditional periodontal
surgical procedures are modifications of these early techniques.
Schluger was the first to described periodontal osseous surgery [4]. Osseous
surgery had many similarities to the original procedure described by Widman
but altered the treatment of the bone by reshaping the alveolar bone to include
the removal of existing osseous defects. Ramfjord described what he termed the
modified Widman procedure [5]. This procedure also had many of the elements
Development of Minimally
Invasive Periodontal Surgical
Techniques
Stephen K. Harrel

78 Minimally Invasive Periodontal Therapy
of the original Widman procedure but utilized a much more conservative flap
design and did not include the complete surgical removal of osseous defects.
Despite many strongly held opinions at the time these surgeries were current,
traditional periodontal flap surgery techniques whether aimed at pocket elimina-
tion or amelioration had many similarities. Most used large incisions that allowed
for the reflection of the tissue from around many teeth. Typically, the flap reflection
included all or most of the teeth in a quadrant to gain access to the underlying
defects. In addition, a frequent end point was some amount of apical positioning of
the gingival tissue.
The advent of surgery aimed at the regeneration of periodontal supporting
tissue began a change in periodontal surgical techniques that resulted in a move
toward minimally invasive periodontal surgery. Most credit Hyatt and Schallhorn
with the introduction of bone grafting techniques for periodontal regeneration [6].
The original surgical techniques for periodontal regeneration were very similar
to those that were in use at the time for pocket elimination procedures. As regen-
erative surgical techniques became established, the size of the surgical access
gradually became smaller and more localized. Often vertical releasing incisions
were used to allow for a more localized access to an area of bone loss. However,
relatively large localized flaps continue to remain the norm for most regenerative
periodontal procedures.
One of the first descriptions of a small flap procedure was termed “mini-flap” [7].
A mini-flap, by definition, was the reflection of the papilla to allow for better access for
root planing. The gingival papilla was reflected and root planing was performed with
the assistance of fiber optic illumination. The papillae were repositioned with pressure
from saline-soaked gauze only. No sutures were used. The mini-flap procedure was
viewed as an enhancement for root planing and as a method to fully remove sulcus
epithelium. The authors did not describe regeneration of periodontal supporting
tissue as a major goal of the treatment method. The 24-month post-operative data
indicated approximately 1.8 mm in improved calculated attachment level as well
as0.8 mm of gingival recession. This represented a moderate improvement over
the results obtained from traditional closed root planing without the use of the
mini-flaps.
The first description of a periodontal surgical procedure that was described as
minimally invasive was in 1995 [8]. The paper described a surgical instrument
that allowed for the debridement of periodontal defects through very small
access incisions. This minimally invasive technique was further developed over
the next several years as a surgical technique for periodontal regeneration using
bone grafts and other regenerative materials. The periodontal surgical technique
was described as Minimally Invasive Surgery for periodontal regeneration and is
referred to as MIS [9]. This technique and later modifications are fully described and
referenced in Chapter7. In 2007, another minimally invasive surgical technique for
periodontal regeneration was described. This technique was based on the papilla
preservation technique and was described as the Minimally Invasive Surgical
Technique and is referred to as MIST [10]. This technique and later modifications are
fully described and referenced in Chapter8. A minimally invasive approach for the

Development of Minimally Invasive Periodontal Surgical Techniques 79
treatment of soft tissue defects utilizing a tunnel procedure for the placement of
soft tissue grafts is described and referenced in Chapter9.
The current minimally invasive surgical techniques that utilize small incisions
for the treatment and regeneration of the destruction caused by periodontal
disease can be seen as the result of an evolution that has occurred over the entire
history of surgical periodontal treatment. Today, we are able to treat and regen-
erate periodontal destruction through surgical openings that would have been
unimaginable as little as 30 years ago. The data presented in Chapters 7, 8, and 9
indicate that not only are we able to obtain excellent regeneration that is very
stable over a long time period, but this regeneration is possible with much
reduced patient morbidity, and unaesthetic results are minimized or eliminated.
Improvements in technology for visualization are a major force in the ability to
perform minimally invasive periodontal regeneration. As technology continues
to improve, it is very likely that surgical access openings will continue to become
smaller and regenerative results are likely to improve. Some of the potential
future changes in minimally invasive periodontal techniques are discussed in
Chapter10.
References
1. Widman, L. (1918) The operative treatment of pyorrhea alveolaris. A new surgical
method. Sv. Tandl. Tidsk., December.
2. Neumann, R. (1920) Die Alveolarpyorrhoe und ihre Behandlung, 3rd edn. Hermann
Meusser, Berlin, Germany.
3. Everett, F.G., Waerhaug, J. & Widman, A. (1971) Leonard Widman: Surgical treatment
of pyorrhea alveolaris. Journal of Periodontology, 42, 571.
4. Schluger, S. (1949) Osseous resection: A basic principal in periodontal surgery. Oral
Surgery, Oral Medicine, Oral Pathology, 2, 361.
5. Ramfjord, S. & Nissle, R. (1974) The modified Widman flap. Journal of Periodontology,
45 (8), 601–607.
6. Schallhorn, R., Hiatt, W. & Boyce, W. (1970) Iliac transplants in periodontal therapy.
Journal of Periodontology, 41 (10), 566–580.
7. Reinhardt, R., Johnson, G. & Tussing, G. (1985) Root planing with interdental papilla
reflection and fiber optic illumination. Journal of Periodontology, 56, 721–726.
8. Harrel, S.K. & Rees, T.D. (1995) Granulation tissue removal in routine and minimally
invasive surgical procedures. Compendium of Continuing Education in Dentistry, 16,
960–967.
9. Harrel, S.K. (1998) A minimally invasive surgical approach for bone grafting. The
International Journal of Periodontics & Restorative Dentistry, 18, 161–169.
10. Cortellini, P. & Tonetti, M.S. (2007) Minimally invasive surgical technique and
enamel matrix derivative in intra-bony defects. I: Clinical outcomes and morbidity.
Journal of Clinical Periodontology, 34, 1082–1088.

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Minimally Invasive Periodontal Therapy: Clinical Techniques and Visualization Technology, First Edition. Edited by Stephen K. Harrel and Thomas G. Wilson Jr. © 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.Companion Website: www.wiley.com/go/harrel/minimallyinvasive776All treatments for periodontal diseases are centered, at least in part, on the thorough debridement of the root surfaces. Without the removal of plaque, biofilm, and calculus from the root surfaces, most authorities agree that periodontal treatment whether aimed at ameliorating the disease process or the regeneration of lost periodontal tissue is doomed to failure. Bearing this goal in mind, all periodontal surgical approaches are aimed at allowing the surgeon improved access and visualization to debride root surfaces and the periodontal lesion.Most authorities credit Widman and Neumann with the first descriptions of periodontal surgery [1,2]. The surgery described involved large incisions to expose the bone beyond the apex of the teeth, allowing for the debridement of root surfaces and osseous defects. Often, it was recommended that the interproximal bone be left exposed to allow for the formation of new interproximal tissue. This surgical technique was aimed at pocket elimination. Everett credits Kirkland with describing the first periodontal surgical procedures that were aimed at regeneration and reattachment to the root surface [3]. Most traditional periodontal surgical procedures are modifications of these early techniques.Schluger was the first to described periodontal osseous surgery [4]. Osseous surgery had many similarities to the original procedure described by Widman but altered the treatment of the bone by reshaping the alveolar bone to include the removal of existing osseous defects. Ramfjord described what he termed the modified Widman procedure [5]. This procedure also had many of the elements Development of Minimally Invasive Periodontal Surgical TechniquesStephen K. Harrel 78 Minimally Invasive Periodontal Therapyof the original Widman procedure but utilized a much more conservative flap design and did not include the complete surgical removal of osseous defects.Despite many strongly held opinions at the time these surgeries were current, traditional periodontal flap surgery techniques whether aimed at pocket elimina-tion or amelioration had many similarities. Most used large incisions that allowed for the reflection of the tissue from around many teeth. Typically, the flap reflection included all or most of the teeth in a quadrant to gain access to the underlying defects. In addition, a frequent end point was some amount of apical positioning of the gingival tissue.The advent of surgery aimed at the regeneration of periodontal supporting tissue began a change in periodontal surgical techniques that resulted in a move toward minimally invasive periodontal surgery. Most credit Hyatt and Schallhorn with the introduction of bone grafting techniques for periodontal regeneration [6]. The original surgical techniques for periodontal regeneration were very similar to those that were in use at the time for pocket elimination procedures. As regen-erative surgical techniques became established, the size of the surgical access gradually became smaller and more localized. Often vertical releasing incisions were used to allow for a more localized access to an area of bone loss. However, relatively large localized flaps continue to remain the norm for most regenerative periodontal procedures.One of the first descriptions of a small flap procedure was termed “mini-flap” [7]. A mini-flap, by definition, was the reflection of the papilla to allow for better access for root planing. The gingival papilla was reflected and root planing was performed with the assistance of fiber optic illumination. The papillae were repositioned with pressure from saline-soaked gauze only. No sutures were used. The mini-flap procedure was viewed as an enhancement for root planing and as a method to fully remove sulcus epithelium. The authors did not describe regeneration of periodontal supporting tissue as a major goal of the treatment method. The 24-month post-operative data indicated approximately 1.8 mm in improved calculated attachment level as well as0.8 mm of gingival recession. This represented a moderate improvement over the results obtained from traditional closed root planing without the use of the mini-flaps.The first description of a periodontal surgical procedure that was described as minimally invasive was in 1995 [8]. The paper described a surgical instrument that allowed for the debridement of periodontal defects through very small access incisions. This minimally invasive technique was further developed over the next several years as a surgical technique for periodontal regeneration using bone grafts and other regenerative materials. The periodontal surgical technique was described as Minimally Invasive Surgery for periodontal regeneration and is referred to as MIS [9]. This technique and later modifications are fully described and referenced in Chapter7. In 2007, another minimally invasive surgical technique for periodontal regeneration was described. This technique was based on the papilla preservation technique and was described as the Minimally Invasive Surgical Technique and is referred to as MIST [10]. This technique and later modifications are fully described and referenced in Chapter8. A minimally invasive approach for the Development of Minimally Invasive Periodontal Surgical Techniques 79treatment of soft tissue defects utilizing a tunnel procedure for the placement of soft tissue grafts is described and referenced in Chapter9.The current minimally invasive surgical techniques that utilize small incisions for the treatment and regeneration of the destruction caused by periodontal disease can be seen as the result of an evolution that has occurred over the entire history of surgical periodontal treatment. Today, we are able to treat and regen-erate periodontal destruction through surgical openings that would have been unimaginable as little as 30 years ago. The data presented in Chapters 7, 8, and 9 indicate that not only are we able to obtain excellent regeneration that is very stable over a long time period, but this regeneration is possible with much reduced patient morbidity, and unaesthetic results are minimized or eliminated. Improvements in technology for visualization are a major force in the ability to perform minimally invasive periodontal regeneration. As technology continues to improve, it is very likely that surgical access openings will continue to become smaller and regenerative results are likely to improve. Some of the potential future changes in minimally invasive periodontal techniques are discussed in Chapter10.References1. Widman, L. (1918) The operative treatment of pyorrhea alveolaris. A new surgical method. Sv. Tandl. Tidsk., December.2. Neumann, R. (1920) Die Alveolarpyorrhoe und ihre Behandlung, 3rd edn. Hermann Meusser, Berlin, Germany.3. Everett, F.G., Waerhaug, J. & Widman, A. (1971) Leonard Widman: Surgical treatment of pyorrhea alveolaris. Journal of Periodontology, 42, 571.4. Schluger, S. (1949) Osseous resection: A basic principal in periodontal surgery. Oral Surgery, Oral Medicine, Oral Pathology, 2, 361.5. Ramfjord, S. & Nissle, R. (1974) The modified Widman flap. Journal of Periodontology, 45 (8), 601–607.6. Schallhorn, R., Hiatt, W. & Boyce, W. (1970) Iliac transplants in periodontal therapy. Journal of Periodontology, 41 (10), 566–580.7. Reinhardt, R., Johnson, G. & Tussing, G. (1985) Root planing with interdental papilla reflection and fiber optic illumination. Journal of Periodontology, 56, 721–726.8. Harrel, S.K. & Rees, T.D. (1995) Granulation tissue removal in routine and minimally invasive surgical procedures. Compendium of Continuing Education in Dentistry, 16, 960–967.9. Harrel, S.K. (1998) A minimally invasive surgical approach for bone grafting. The International Journal of Periodontics & Restorative Dentistry, 18, 161–169.10. Cortellini, P. & Tonetti, M.S. (2007) Minimally invasive surgical technique and enamel matrix derivative in intra-bony defects. I: Clinical outcomes and morbidity. Journal of Clinical Periodontology, 34, 1082–1088.

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