Future Potential for Minimally Invasive Periodontal Therapy










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
165
10
Based on the enthusiastic acceptance of nonsurgical treatment and minimally
invasive surgery in medicine and dentistry, the future for the discipline in
periodontal treatment is bright. As improvements in visualization technology
come to the marketplace, a minimally invasive nonsurgical approach will likely
become the routine first step in periodontal therapy. With diligence and expert
application, many if not most periodontal therapy may likely be performed non-
surgically. However, for the foreseeable future, there will almost certainly remain
situations where surgical care will be necessary.
Goals and pitfalls of periodontal therapy
The basic tenants of periodontal therapy are unlikely to change no matter what
physical approach is taken. There is almost universal agreement that periodontal
diseases stem from the combination of microbiota and the body’s response to
these microbiota and their byproducts. Part of treatment will be to balance this
dynamic system to limit the insult to the tissue. At present, personal oral hygiene
is important to remove local etiologic factors, but we have very little influence on
the systemic response. Without the body’s defenses, we would rapidly lose teeth
from periodontal diseases, and yet much of the destruction from periodontal dis-
eases stems from this defense mechanism.
Future Potential for
Minimally Invasive
Periodontal Therapy
Stephen K. Harrel and Thomas G. Wilson Jr.

166 Minimally Invasive Periodontal Therapy
Periodontal therapy whether through a traditional approach or a minimally
invasive approach is a process of minimizing the risk factors for periodontal
destruction, repairing the destruction that has already occurred, and once we
have repaired the damage, to keep the process from reoccurring. At the heart of
our therapy is the debridement of the root, the reduction of the microbiological
load within the sulcus/pocket, and stimulating periodontal regeneration. This
chapter will look at how these goals may be addressed in the future through a
minimally invasive approach.
Nonsurgical therapy
There is a possibility that if the root surfaces could be completely debrided of
calculus and biofilm, then “spontaneous” regeneration of periodontal tissues
might result. When this is possible through a nonsurgical approach, surgical
periodontal treatment could cease to be a necessity. The problem is that using
traditional approaches in many instances, surgical access is currently necessary
for complete debridement. The major problem facing nonsurgical periodontal
therapy is the deficiencies in the current technology available for visualizing the
pocket. A third generation of the glass fiber endoscope is scheduled for the intro-
duction in the near future. This device will have the same basic technology as is
currently available but will give a much clearer image. As mentioned in Chapter2,
the next step in improvement will most likely be the development of a miniature
camera, similar to the one in the surgical videoscope but much smaller so that it
can be placed into the intact sulcus/pocket. This is a technology that is available
at this time but not currently economically practical. A videoscope for nonsur-
gical periodontal therapy will not change what is currently done with a glass
fiber endoscope; but due to improved visualization, it should make the therapy
much easier to perform.
Methods for the removal of root-borne deposits will also improve. One possible
approach would be a device to detect calculus that could be used in combination
with the videoscope. Wilson’s study on the near-universal association of calculus
with inflammation of the pocket wall clearly indicates that to be successful in our
treatments, we must do a better job of calculus removal. One of our problems
today is that we must rely on a less than perfect visual analysis of the root surface
to determine where the calculus is located. We need a detection device that can
differentiate between dentine, cementum, and calculus.
Once we know where the calculus is, we need to be able to remove it. The
instruments we have now are extremely crude for the level of cleaning that
needs to be performed. A small Gracey curette or traditional ultrasonic tip visu-
alized with the videoscope appears huge compared to the islands of calculus on
the root surface. The ideal would be an instrument that is associated with the
calculus detector. This would allow the instrument to locate and remove the
calculus while it was “in the sights.” Prototypes of lasers have shown some suc-
cess, but today’s lasers are hopelessly crude and often destructive. It is possible

Future Potential for Minimally Invasive Periodontal Therapy 167
that the laser energy could be generated in an electronic component at the tip of
the instrument. Within this same context would be a microultrasonic that sent
out a single burst of precision-guided energy. It is also possible that a form of
energy that is not currently used in dentistry might be applied. The hammer
effect of a piezoelectric crystal might also be possible. A dental piezoelectric
scaler applies energy to a crystal in the scaler handle that is attached to the shaft
of the scaler, and the energy is transferred to the tip of the scaler. It might be pos-
sible to apply a burst of current to a tiny peizo crystal at the end of a microprobe
that gave a direct hammer action to the calculus that has been located by the
detector probe. There is the potential for making this entire apparatus no larger
than a periodontal probe. Many methods are possible, but active research will be
necessary.
Surgical therapy
The anatomic configurations of root structure and bone loss will probably make
surgical intervention necessary for regeneration in the foreseeable future. This is
due to the inherent difficulty in accessing many of the sites where calculus forms
on the root surfaces. With the videoscope, it is possible to visualize and access
almost all areas of the root surfaces even when very small incisions are utilized.
However, the currently available videoscope is too large to visualize most furca-
tions that are more extensive than a class I; therefore, a smaller videoscope is
needed. An ideal instrument size for surgical minimally invasive procedures would
be approximately 0.5 mm in diameter. Again this is technically feasible at this time
but is impractical to create. There is a strong likelihood that these difficulties can be
overcome in the foreseeable future.
Minimally invasive surgery needs improved instruments for root and
osseous defect debridement. Using the videoscope, anatomic irregularities
and areas of calculus are visible that are normally impossible to see with other
methods of visualization. Removing this calculus is possible but difficult with
our current instrumentation. In addition, a new set of instruments for removal
or smoothing of anatomical defects is needed. The videoscope reveals grooves
and defects in cementum and dentine that have previously been unrecognized.
The source of these defects is unknown. No matter their cause, they are almost
always filled with calculus. Currently, the defects are removed with standard
hand instruments, diamond-coated ultrasonic tips, or rotary instruments. All of
these instruments are relatively crude and remove large amounts of apparently
healthy root structure in the process of removing the root defect. What is needed
is the development of instruments that can be applied in a much more selective
manner than those currently available. Logically, these would be “micro” ver-
sions of the instruments currently used. Looking further, it may be possible to
“heal” or fill in these defects with some variation of the methods currently
being used in the recalcification of early carious lesions. Because recalcification
technology for caries is itself in early development, the applicability of this or

168 Minimally Invasive Periodontal Therapy
other techniques to the problems encountered in periodontal therapy is currently
an unknown.
The removal of granulation tissue from periodontal defects through the small
access afforded by minimally invasive surgery is another area that needs particular
attention. Various mechanical instruments for the removal of granulation tissue
have been developed in the past, but none have been fully satisfactory at removing
tissue or were impractical for use with small incision techniques. These include
sharpened ultrasonic curettes, rotary instruments, and lasers. There is some
question as to how much granulation tissue needs to be removed for successful
regeneration. One of the reasons given for removing granulation tissue is that it
contains bacteria. While this is true, this can also be said for virtually all of the
tissue surrounding a periodontal lesion both before and immediately after surgery.
There is a good chance that to achieve healing, it is only necessary to remove
enough granulation tissue to allow for debridement of the root surface. As visuali-
zation devices become smaller, we may find that removal of large amounts of
granulation tissue becomes unnecessary.
Many regeneration techniques are well suited to the current minimally invasive
surgical techniques. All of the liquid or semiliquid biologic agents such as enamel
matrix proteins and recombinant bone morphogenic proteins are easily placed
through small access opening. The same is true for most bone grafting materials
that are in a granular form. The two current methods of regeneration that are not
suitable for a minimally invasive approach are membranes for guided tissue
regeneration and block grafting. The use of a block bone graft by its very nature
does not lend itself to a minimally invasive approach. The use of a membrane is
contraindicated where the incisions or flap reflection would have to be extended
to allow for the placement of the membrane. The inability to use a membrane is
not a major consideration because a membrane does not appear to be necessary
for regeneration when the blood supply to the surgical area is spared with the use
of minimally invasive surgery.
Goals for minimally invasive periodontal therapy
The long-term goals for minimally invasive periodontal therapy may well be a
hybrid between nonsurgical and surgical minimally invasive treatment. It is con-
ceivable that in the future, technology will allow for treatment of periodontal
disease using incisions that are less damaging than is currently caused by placing
a traditional curette into an intact periodontal pocket/sulcus. Such a minimally
invasive technique might consist of inserting two medium-sized needles into the
gingival tissue, possiblyone on the buccal and one on the lingual surface, and
then performing all manipulations through these needles. One needle would allow
for visualization; the other needle would allow for removal of calculus, smoothing
of the roots, and placement of regenerative materials. While such a technique might
be considered dreaming at this point, the technologic leap that is necessary to
accomplish this or some other similar technique is less of a leap than the one that

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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/minimallyinvasive16510Based on the enthusiastic acceptance of nonsurgical treatment and minimally invasive surgery in medicine and dentistry, the future for the discipline in periodontal treatment is bright. As improvements in visualization technology come to the marketplace, a minimally invasive nonsurgical approach will likely become the routine first step in periodontal therapy. With diligence and expert application, many if not most periodontal therapy may likely be performed non-surgically. However, for the foreseeable future, there will almost certainly remain situations where surgical care will be necessary.Goals and pitfalls of periodontal therapyThe basic tenants of periodontal therapy are unlikely to change no matter what physical approach is taken. There is almost universal agreement that periodontal diseases stem from the combination of microbiota and the body’s response to these microbiota and their byproducts. Part of treatment will be to balance this dynamic system to limit the insult to the tissue. At present, personal oral hygiene is important to remove local etiologic factors, but we have very little influence on the systemic response. Without the body’s defenses, we would rapidly lose teeth from periodontal diseases, and yet much of the destruction from periodontal dis-eases stems from this defense mechanism.Future Potential for Minimally Invasive Periodontal TherapyStephen K. Harrel and Thomas G. Wilson Jr. 166 Minimally Invasive Periodontal TherapyPeriodontal therapy whether through a traditional approach or a minimally invasive approach is a process of minimizing the risk factors for periodontal destruction, repairing the destruction that has already occurred, and once we have repaired the damage, to keep the process from reoccurring. At the heart of our therapy is the debridement of the root, the reduction of the microbiological load within the sulcus/pocket, and stimulating periodontal regeneration. This chapter will look at how these goals may be addressed in the future through a minimally invasive approach.Nonsurgical therapyThere is a possibility that if the root surfaces could be completely debrided of calculus and biofilm, then “spontaneous” regeneration of periodontal tissues might result. When this is possible through a nonsurgical approach, surgical periodontal treatment could cease to be a necessity. The problem is that using traditional approaches in many instances, surgical access is currently necessary for complete debridement. The major problem facing nonsurgical periodontal therapy is the deficiencies in the current technology available for visualizing the pocket. A third generation of the glass fiber endoscope is scheduled for the intro-duction in the near future. This device will have the same basic technology as is currently available but will give a much clearer image. As mentioned in Chapter2, the next step in improvement will most likely be the development of a miniature camera, similar to the one in the surgical videoscope but much smaller so that it can be placed into the intact sulcus/pocket. This is a technology that is available at this time but not currently economically practical. A videoscope for nonsur-gical periodontal therapy will not change what is currently done with a glass fiber endoscope; but due to improved visualization, it should make the therapy much easier to perform.Methods for the removal of root-borne deposits will also improve. One possible approach would be a device to detect calculus that could be used in combination with the videoscope. Wilson’s study on the near-universal association of calculus with inflammation of the pocket wall clearly indicates that to be successful in our treatments, we must do a better job of calculus removal. One of our problems today is that we must rely on a less than perfect visual analysis of the root surface to determine where the calculus is located. We need a detection device that can differentiate between dentine, cementum, and calculus.Once we know where the calculus is, we need to be able to remove it. The instruments we have now are extremely crude for the level of cleaning that needs to be performed. A small Gracey curette or traditional ultrasonic tip visu-alized with the videoscope appears huge compared to the islands of calculus on the root surface. The ideal would be an instrument that is associated with the calculus detector. This would allow the instrument to locate and remove the calculus while it was “in the sights.” Prototypes of lasers have shown some suc-cess, but today’s lasers are hopelessly crude and often destructive. It is possible Future Potential for Minimally Invasive Periodontal Therapy 167that the laser energy could be generated in an electronic component at the tip of the instrument. Within this same context would be a microultrasonic that sent out a single burst of precision-guided energy. It is also possible that a form of energy that is not currently used in dentistry might be applied. The hammer effect of a piezoelectric crystal might also be possible. A dental piezoelectric scaler applies energy to a crystal in the scaler handle that is attached to the shaft of the scaler, and the energy is transferred to the tip of the scaler. It might be pos-sible to apply a burst of current to a tiny peizo crystal at the end of a microprobe that gave a direct hammer action to the calculus that has been located by the detector probe. There is the potential for making this entire apparatus no larger than a periodontal probe. Many methods are possible, but active research will be necessary.Surgical therapyThe anatomic configurations of root structure and bone loss will probably make surgical intervention necessary for regeneration in the foreseeable future. This is due to the inherent difficulty in accessing many of the sites where calculus forms on the root surfaces. With the videoscope, it is possible to visualize and access almost all areas of the root surfaces even when very small incisions are utilized. However, the currently available videoscope is too large to visualize most furca-tions that are more extensive than a class I; therefore, a smaller videoscope is needed. An ideal instrument size for surgical minimally invasive procedures would be approximately 0.5 mm in diameter. Again this is technically feasible at this time but is impractical to create. There is a strong likelihood that these difficulties can be overcome in the foreseeable future.Minimally invasive surgery needs improved instruments for root and osseous defect debridement. Using the videoscope, anatomic irregularities and areas of calculus are visible that are normally impossible to see with other methods of visualization. Removing this calculus is possible but difficult with our current instrumentation. In addition, a new set of instruments for removal or smoothing of anatomical defects is needed. The videoscope reveals grooves and defects in cementum and dentine that have previously been unrecognized. The source of these defects is unknown. No matter their cause, they are almost always filled with calculus. Currently, the defects are removed with standard hand instruments, diamond-coated ultrasonic tips, or rotary instruments. All of these instruments are relatively crude and remove large amounts of apparently healthy root structure in the process of removing the root defect. What is needed is the development of instruments that can be applied in a much more selective manner than those currently available. Logically, these would be “micro” ver-sions of the instruments currently used. Looking further, it may be possible to “heal” or fill in these defects with some variation of the methods currently being used in the recalcification of early carious lesions. Because recalcification technology for caries is itself in early development, the applicability of this or 168 Minimally Invasive Periodontal Therapyother techniques to the problems encountered in periodontal therapy is currently an unknown.The removal of granulation tissue from periodontal defects through the small access afforded by minimally invasive surgery is another area that needs particular attention. Various mechanical instruments for the removal of granulation tissue have been developed in the past, but none have been fully satisfactory at removing tissue or were impractical for use with small incision techniques. These include sharpened ultrasonic curettes, rotary instruments, and lasers. There is some question as to how much granulation tissue needs to be removed for successful regeneration. One of the reasons given for removing granulation tissue is that it contains bacteria. While this is true, this can also be said for virtually all of the tissue surrounding a periodontal lesion both before and immediately after surgery. There is a good chance that to achieve healing, it is only necessary to remove enough granulation tissue to allow for debridement of the root surface. As visuali-zation devices become smaller, we may find that removal of large amounts of granulation tissue becomes unnecessary.Many regeneration techniques are well suited to the current minimally invasive surgical techniques. All of the liquid or semiliquid biologic agents such as enamel matrix proteins and recombinant bone morphogenic proteins are easily placed through small access opening. The same is true for most bone grafting materials that are in a granular form. The two current methods of regeneration that are not suitable for a minimally invasive approach are membranes for guided tissue regeneration and block grafting. The use of a block bone graft by its very nature does not lend itself to a minimally invasive approach. The use of a membrane is contraindicated where the incisions or flap reflection would have to be extended to allow for the placement of the membrane. The inability to use a membrane is not a major consideration because a membrane does not appear to be necessary for regeneration when the blood supply to the surgical area is spared with the use of minimally invasive surgery.Goals for minimally invasive periodontal therapyThe long-term goals for minimally invasive periodontal therapy may well be a hybrid between nonsurgical and surgical minimally invasive treatment. It is con-ceivable that in the future, technology will allow for treatment of periodontal disease using incisions that are less damaging than is currently caused by placing a traditional curette into an intact periodontal pocket/sulcus. Such a minimally invasive technique might consist of inserting two medium-sized needles into the gingival tissue, possiblyone on the buccal and one on the lingual surface, and then performing all manipulations through these needles. One needle would allow for visualization; the other needle would allow for removal of calculus, smoothing of the roots, and placement of regenerative materials. While such a technique might be considered dreaming at this point, the technologic leap that is necessary to accomplish this or some other similar technique is less of a leap than the one that Future Potential for Minimally Invasive Periodontal Therapy 169has brought us from a gingivectomy to a traditional approach for regenerative surgery. The technology that is now cutting edge for nonsurgical and surgical minimally invasive periodontal therapy will likely be viewed as crude in 30 years. The future for improvements in periodontal therapy is virtually limitless. The one thing that appears ensured is that procedures for treatment will become more effective and more minimally invasive. 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/minimallyinvasive171Note: Page numbers in italics refer to Figures; those in bold to TablesAllen Microsurgical Elevator, 153, 154AlloDerm, soft tissue grafting, 151alveolar ridge defect, 159–161, 160–161amelogeninsdelivery, 128minimally invasive surgical technique (MIST), 131, 133, 136modified MIST, 131, 132, 136as regenerative material, 128, 130American Academy of Periodontology (AAP), periodontal diseasecase type II-III (early-to-moderate), 39case type III-IV (moderate-to-severe), 48case type IV (advanced/severe), 43anesthetic-local vs. subgingival topicalanesthetic, 60Angles classification, class III bilateral, 39bone grafting techniques, 78, 103, 160, 168bruxism, 39CAF see coronally advanced flap (CAF)calculusin chronic inflammatory periodontal disease, 20deposition, cementoenamel junction, 22detection, 166–7forms, 20micro islands, 93, 93and probing depth, correlation, 22removal, 55–6on root surfaces see minimally invasive surgery (MIS)subgingival debridement procedures, 22Castroviejo Needle Holder, 156–7cementimplant, 61, 108–9peri-implantitis, 67peri-implant soft tissue, 67, 67problem, 69–70removal, 70Index 172 Indexcervical enamel projections (CEPs)Grade I, 32, 32–3Grade II, 32–3, 33Grade III, 32, 33chronic unacceptable probing depths, 61closed root planing, 3coronally advanced flap (CAF), 145–6demineratized cortical human bone allograft (DFDBA), 94–5, 95, 105, 115dental endoscopic techniquecervical enamel projections (CEPs)Grade I, 32, 32–3Grade II, 32–3, 33Grade III, 32, 33componentsBilumen construction, 18camera/LED/controller, 15, 16dental endoscope, 16–18, 17dual Luer–Lock connectors, 18, 18DV2 perioscopy system, 15, 16endoscopic explorer tissue retraction shield, 19, 19handpiece, 15, 16perioscopy system, 15, 17self-contained water delivery device, 19, 20single-use disposable endoscopic sheath, 18, 18dental endoscopy explorers, 31diamond-coated ultrasonic instruments, 31, 31ectopic enamel removal, 32enamel pearls, 34enamel projections, 32instructionexplorer and ultrasonic instrument, 35, 36medium-to-medium plus power, 35patient positioning, 35recommended training, 35in subgingival visualization, 35tray setup, 35microvisual full-mouth debridement, 29, 30two-handed technique, 27, 30ultrasonic powered instruments, 30–31“view, instrument and view” technique, 27dental endoscopy explorers, 31DFDBA see demineratized cortical human bone allograft (DFDBA)diamond-coated ultrasonic instrumentsmagnetostrictive diamond-coated ultrasonic inserts, 31, 31scalers, 107Diamond Safety Tip, 91–3, 92dual Luer–Lock connectors, 18, 18DV2 perioscopy systemcolor LCD video monitor, 15, 16master control unit (MCU) camera, 15ectopic enamel removal, 32, 34EDTA see ethylenediaminetetracetic acid(EDTA)enamel matrix derivative (EMD), 82, 94–5, 95, 105, 115enameloplasty, 34, 34enamel pearl, 34, 106, 107End-Cutting Intrasulcular Knife, 153, 154endoscope see also nonsurgical endoscopic treatmentadvantages, 55–6anesthetic-local vs. subgingival topical anesthetic, 60calculus removal, 55diagnostic, 60implants, 61, 62learning curvefield of vision recognition, 56Gutta percha (GP), 59healthy sulcus with enamel, 57inflamed adjacent soft tissue, 57mandibular molar furcation, 59nondominant hand training, 56open margin (OM), 59porcelain crown and root surface, 59soft tissue and root surface, 57, 58subgingival calculus, 58subgingival deposits removal, 56vertical fracture, 58void filling, 60limitations, 61–2in pocket probing depth, 60–61in sulcus at CEJ level, 56and videoscopeblue-gray biofilm, 67, 67bone loss, 68 Index 173cement, 67, 67, 69–70clinical and radiographic information gathering, 66“granulation” tissue removal, 66inflammatory lesion, 66mandibular second molar abutment, 71–2, 72maxillary left central incisor, 73, 73–4osseointegrated implant, 70, 71peri-implant diseases, 66–9periodic right-angle radiographs, 66probing depths, 70–1re-osseointegration, 67–8single-unit cemented fixed partialdenture, 70, 71subgingival calculus, 67swelling complaint, 70endoscopic explorer, 13ethylenediaminetetracetic acid (EDTA)calculus removal, 93, 94, 111, 115root preparation, 101, 104, 105, 153FGGs see free gingival grafts (FGGs)free gingival grafts (FGGs), 143–5gingivectomy, 145, 169implant(s)abutment interface, 70endoscope, 61, 62peri-implantitis infection, 37internal mattress suture, modified MIST, 128, 130, 133, 133, 135intrabony defectsclassification, 123first lower molar, 137minimally invasive surgical technique (MIST), 118, 131modified MIST, 118morphology and extension, 123pockets treatment, 122radiographic image, 124, 128, 130, 133, 134laser curettage, 38laser pocket disinfection, 38laser surgery, full-mouthazithromycin, 48implant placement, 48laser tip view, 48, 50periodontal charting, 51periodontal maintenance, 48periodontal probing depths, 48, 50post restorative bridge upper anterior 9-11, 48, 50pre-Tx perio charting, 48, 49pre-Tx X-rays upper anterior bridge 9-11, 48, 49radiograph, 48, 51ultrasonic endoscopic debridement, 48upper anterior bridge, pre-Tx photo, 48, 48loupes see surgical telescopes (loupes)luting agent, minimal, 70magnetostrictive diamond-coated ultrasonic inserts, 31, 31microvisual full-mouth debridement, 29, 30Miller Class l recession sites, 151“mini-flap”, 78minimally invasive periodontal therapygoals, 168–9microbiota combination, 165nonsurgical therapy, 166–7personal oral hygiene, 165risk factors minimization, 166surgical techniquesbone grafting techniques, 78interproximal bone, 77“mini-flap”, 78osseous surgery, 77periodontal tissue, regeneration, 77, 78pocket elimination/amelioration, 78root surfaces, debridement, 77vertical releasing incisions, 78Widman procedure, 77–8surgical therapy, 167–8minimally invasive soft tissue graftingadvantages, 157evolutioncoronally advanced flap (CAF), 145–6free gingival grafts (FGGs), 145gingivectomy, 145open vascular recipient bed, 145palatal donor tissue, 145root coverage, CTG procedure, 145–6 174 Indexminimally invasive soft tissue grafting (Cont’d)indicationsattached gingiva, 143–4complete root coverage, 144dense collagenous connective tissue, 144exposed roots coverage, 144free gingival grafts (FGGs), 144gain of keratinized tissue, 144mucogingival junction (MGJ), 143–4subepithelial connective tissue graft(CTG) procedure, 144tunnel techniqueallograft donor tissue, 151–3allograft placement, 156intrasulcular site preparation, 153postoperative care, 157recipient site preparation, 146–50root preparation, 153suturing, 156–7minimally invasive surgery (MIS), 82calculus on root surfacesEDTA, biomodification, 111irregularities, 112mechanical removal, 104mid-lingual surface, 109periodontal defect, deep calculus area, 110smooth “burnished” calculus, 110ultrasonic instruments and hand scalers, 111case selection, 83–6cement, on implants, 108, 109closed subgingival scaling, 82debridementbiomodification,EDTA, 93, 94, 101,104, 105calculus, micro islands, 93, 93defect, 90–91Diamond Safety Tip, 91–3, 92granulation tissue, removal, 90–91, 92magnification, 91, 92microcalculus removal, 93, 93ultrasonic scaler, 91–2Younger-Goode 7/8 curette blade, 91, 91enamel matrix derivative (EMD), 82granulation tissue removal, 100, 103, 104incision and flap designdisposable microsurgical knifes, 88, 90initial sulcular incisions, 87, 88interproximal defect visualization, 86, 86, 87, 87lingual access approaches, 86modified Orban knife, 87–8, 89, 90osseous defect, 86push-pull cutting capabilities, 87, 89routine pocket measurements, 86sulcular incisions, jointing, 87, 88“lines” on root surfaces, 112–113maxillary molar bifurcation defect, treatment, 114–115nonsurgical treatment, 83palatal incision, periodontal defect, 102periodontal defect, 99, 100periodontal regeneration, 78pocket probing depthand CAL, 82chart, 83, 84pocket probing depth, presurgical buccal view, 98, 98postoperative instructions, 97post surgery, surgical area buccal view, 101, 102presurgical lingual view, 99presurgical pocket probing depths, 82quadrant charting, 84, 85recession, 82regenerative materialsdemineratized cortical human bone allograft (DFDBA), 94–5, 95enamel matrix derivative (EMD), 94–5, 95flaps, soft tissue healing, 94–5guided tissue regeneration, 95periodontal regeneration, 94–5Vicryl mesh, 95root abnormalities and diagnosisbiomodification, 107decay, 107diamond-coated ultrasonic scalers, 107enamel pearl, 106, 107maxillary molar bifurcation defect, 105pulp chamber, 108root resorbtion, 106small incision surgery, 85 Index 175surgical principlesblood supply preservation, 82–3minimum traumatic damage, 83split thickness dissection, 83suturing, 83un-incised tissue, cyanotic appearance, 83suturingpapilla tissues coronal, 96–7, 974-0 plain collagen, 96vertical mattress suture, 96, 96, 97videoscope, 82visualization and magnification improvement, 86minimally invasive surgical technique (MIST) see also periodontal regenerationblood clot formation, 117–118buccal and the lingual intrasulcular incisionsamelogenins, regenerative materials, 131defect and residual bone crest, 126–8, 127–8EDTA application, 131flap mobility, 128–131, 129–30scaling and root planing, 131buccal horizontal cut, 125clinical indications and diagnostic proceduresflap design, 124, 125interproximal intrabony defect, 123intrabony defects, 123, 124local anesthetic, 123nonsurgical cause-related therapy, 121–2papilla preservation flap, 125periodontal evaluation, 121, 122periodontal probe, 123topographic extension around teeth, 123Cohort studies and randomized controlled clinical trials, 118–121, 119, 120defect-associated interdental papilla, 125edema, 138flap, primary closure, 138interdental space width, 125invasivity and patient side effects, 131lingual/palatal incision, 126mesio-distal extension, 126microblade role, 126modified MISTaggressive localized periodontitis, 131, 132–3attention, 133buccal “surgical window,” 133internal mattress suture, 133, 134–5operative microscope/magnifying lenses, 133modified papilla preservation technique (MPPT), 125, 126multiple intrabony defects treatment, 131papilla preservation technique, 78–9postoperative period and local side effects, 138postsurgical protocols, 137regeneration, 117–118root hypersensitivity, 138simplified papilla preservation flap (SPPF), 125, 126single modified internal mattress suture, 131supportive periodontal care programs, 117technical implications, 136minimally invasive therapy, 1–2MIST see minimally invasive surgical technique (MIST)modified MIST see minimally invasive surgical technique (MIST)modified papilla preservation technique (MPPT)minimally invasive surgical technique (MIST), 125, 126regeneration, 118mucogingival junction (MGJ), 143–4, 153nonsurgical endoscopic treatmentAAP case type IV (advanced/severe) periodontal disease, 43, 44adjunctive antimicrobial agents, 38bone loss to apex, pre-Tx radiograph, 43, 44doxycycline hyclate, 43gingivitis and periodontitis, 36inflammatory signs, clinical diagnosis, 37 176 Indexnonsurgical endoscopic treatment (Cont’d)local anesthesia, 43mechanical debridement, 37–8minocycline HCl placement, 44, 44objectives, 36peri-implantitis, 36–7peri-implant mucositis, 36periodontal disease treatment protocol, 38periodontal pathogens, 38pocketing, pre-treatment periodontal charting, 43radiographic bone repair, post treatment X-ray, 45systemic antibiotic therapy, 38topical anti-infective chemotherapeutics, 38ultrasonic endoscopic debridementperiodontal charting, 39, 42periodontal probing depths, 39post-Tx mandibular linguals, 39, 42post-Tx photo, 39, 41pretreatment panographic radiograph, 39pre-Tx periodontal charting, 39, 40pre-Tx photo facials, 39, 41ultrasonic scaling, under local anesthetic, 45–8nonsurgical sulcular debridement, 38palatal donorallograft, 151site, 151, 157, 159surgery, 151tissue, 144–6, 147palatal grafts see minimally invasive softtissue graftingperi-implant diseases, 36 see also endoscopeperi-implantitis, 36–7, 69peri-implant mucositis, 36, 67, 68–9periodontal disease treatment protocol, 38periodontal osseous surgery, 77–8periodontal regenerationblood clot formation, 117–118concepts, 118definition, 117demineratized cortical human bone allograft (DFDBA), 94–5, 95enamel matrix derivative (EMD), 94–5, 95flap designs, 118flaps, soft tissue healing, 94–5guided tissue regeneration, 95modified papilla preservation technique (MPPT), 118periodontal regeneration, 94–5regenerative material selection, 136, 137simplified papilla preservation flap (SPPF), 118Vicryl mesh, 95perioscopy systemCCD/LED camera, 15medical grade monitor, 15, 17piezo scalers, 61pocket elimination/amelioration, 78pocket probing depthchart, 84, 85dental implant and, 61endoscope, 60–61mean, 82periodontal disease examination, 23periodontal evaluation, 121presurgical, 82residual deep, 122subgingival calculus, 60–61pocket sterilization, 38root surfacescalculus onEDTA, biomodification, 111irregularities, 112mechanical removal, 104mid-lingual surface, 109periodontal defect, deep calculusarea, 110smooth burnished calculus, 110ultrasonic instruments andhandscalers, 111debridement, 77endoscopic evaluation, 22soft tissue and, 57, 58routine pocket measurements, 86sheath, single-use disposable endoscopic, 18, 18simplified papilla preservation flap (SPPF)minimally invasive surgical technique (MIST), 125, 126regeneration, 118 Index 177socket enhancement, 73, 73–4soft tissue grafting see minimally invasive soft tissue graftingsubepithelial connective tissue graft (CTG) procedure, 144surgical microscopefacial flap access, 9facial tissues handling, 9high magnification, 8inner ear surgery, 8installation, 8magnification and light, 9minimal disruption, 9MIST and M-MIST procedures, 8periodontal plastic surgeries, 9in posterior and lingual areas, 9refocus, patient movement, 9soft tissue grafts placement, 8suturing of tissues, 9surgical telescopes (loupes)advantages, 7disadvantages, 7–8focal length, 7halogen/LED light, 7integral light, 7magnification, 6range, 6–7surgical videoscope see also endoscopeblood and surgical debris, 10carbon fiber retractor, 10external camera, 9gas shielding device, 11, 11image transfer to monitor, 9kidney, nonsurgical exploration, 10modifications, 10periodontal defect, buccal/lingual aspect, 10root abnormalities and diagnosisbiomodification, 107decay, 107diamond-coated ultrasonic scalers, 107enamel pearl, 106, 107maxillary molar bifurcation defect, 105pulp chamber, 108root resorbtion, 106small incision surgeries, 11stainless steel tube, 9videoscope-assisted minimally invasive surgery (V-MIS), 10, 10, 11traditional scalers and ultrasonics, 61tunnel technique, soft tissue graftingallograft donor tissueacellular dermal matrix (ADM), 151advantage, 151AlloDerm, 151keratinized tissue gain, 151–3, 152limitation factors, 151Miller Class l recession sites, 151palatal donor site, 151allograft placement, 155, 156allografts, 146free gingival graft (FGG), 143intrasulcular site preparation, 153, 154palatal donor tissue, 146, 147postoperative care, 157recipient site preparation“biologic width”, 146disadvantages, 150interdental embrasure space, 148intrasulcular incisions, 146maxillary arch, root exposure, 148, 148papillary incisions, indications, 149, 149–50vertical incisions elimination, 150ridge augmentationalveolar ridge defect, 159–161, 160–161papillary areas and edentulous ridge areas, 159pediculated palatal connective tissue graft harvest, 158, 159rotated palatal pedicle graft technique, 158VIP-CT grafting technique, 158root coverage grafting, 146root preparation, 153, 154–5suturing, 156–7ultrasonic endoscopic periodontal debridementantibiotics, 23computerized charting program, 23, 27dental endoscopy, 14fiber-optic illumination, 14full-mouth laser surgery, 48–52 178 Indexultrasonic endoscopic periodontal debridement (Cont’d)indicationscomponents, 15–19DV2 perioscopy system, 15patients, 15magnifications, 14microvisual approach, 13minimally invasive procedures, 13nonsurgical endoscopic treatment selection, 36–9periodontal endoscope, 13perioscopy system, 14pocket probing depths, 23–6real-time video, 13subgingival environmentadvantage, 20blind scaling and root planing, 23bright fiber-optic illumination, 20calculus deposits removal, 20cementoenamel junction, calculus deposition, 22chronic inflammatory periodontal disease, 20, 23closed scaling and root planing, 22endoscope probe, 19factors affecting instrumentation, 21gingival wall, 19–20goal, 22hand instrumentation and ultrasonics combination, 22oral cavity, ecological niches, 22periodontal pathogens, 22residual calculus and probing depth, correlation, 22root surfaces, endoscopic evaluation, 22scaling and root planing, 19, 21, 22technique, endoscopic see dental endoscopic techniquetreatment and follow-upfifteen months post micro-ultrasonic, 27, 28post treatment X-ray, 27, 29post-Tx X-ray, 27, 30pretreatment X-ray, 27, 28, 29ultrasonic scaling, under local anestheticamoxicillin and metronidazole, 45periodontal charting, 45, 47pocket depths reduction, 48povidone-iodine application, 45pretreatment periodontal charting, 45, 46radiograph, 45, 46, 47Vascularized Interpositional Periosteal-Connective Tissue Graft (VIP-CT), 158Vicryl mesh, 95videoscope-assisted minimally invasive surgery (V-MIS), 10, 10, 11, 81–2 seealso minimally invasive surgery(MIS)visualization, minimally invasive periodontal therapyclosed root planing proceduresblood and debris removal, 6camera, 6clarity of image, 5–6glass fiber endoscope, 4, 4–5nonsurgical, 6periodontal endoscope, 4–5routine periodontal treatments, 5single-use sterile disposable sheath, 5, 5smaller fibers uses, 6periodontal surgery, 4root planing, 3subgingival scaling, 3surgical microscope, 8–9surgical telescopes (loupes), 6–8surgical videoscope, 9–11Widman procedure, 77–8Younger-Good 7/8 curetteallograft placement, 155, 156graft insertion, 155, 156granulation tissue removal, 91, 91, 100interdental alveolar crest elevation, 153, 154

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