The MIS and V-MIS Surgical Procedure










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
81
7
Introduction
Minimally invasive surgery (MIS) is based on the concept of using small incisions
to perform surgical procedures that have previously been performed through
larger surgical access openings. The term “minimally invasive surgery” was first
applied to periodontal surgical procedures in 1995 [1]. The procedure was
described as minimally invasive surgery or MIS. Several variations and tech-
niques for performing MIS have been described. These include the original MIS
approach that used surgical telescopes for visualization, a variation of this
approach using the glass fiber endoscope for visualization, and the most recently
described technique of Videoscope-Assisted MIS (V-MIS). Each of these tech-
niques is considered to be an MIS technique with each change in visualization
technology, thereby allowing for smaller incisions and greater magnification.
Following the initial description of MIS, the technique was further explored
in several case series published over the next five years [2–5]. These papers
reported excellent clinical results over an extended time period. The largest of
these case series had 194 surgical sites that were followed for 9–54 months. All
patients had closed scaling and root planing performed under local anesthetic at
least 6 week before the surgical procedure. At the time of surgery, the pockets to
be surgically treated ranged from 5 to 16 mm. The mean improvement in pocket
The MIS and V-MIS Surgical
Procedure
Stephen K. Harrel

82 Minimally Invasive Periodontal Therapy
probing depth was 4.58 mm, and the mean improvement in clinical attachment
level (CAL) was 4.87 mm. A detailed description of the technique for performing
MIS was published in 1999 [3].
Further research on MIS has been published more recently. A prospective
study of the use of MIS with enamel matrix derivative (EMD) was published
with 1-year data in 2005, and the 6-year data on the same cases published in 2010
[6,7]. These studies showed that there was a significant amount of improvement
in pocket probing depth and CAL when MIS was performed. A total of 160 sites
were treated with EMD using an MIS approach. The presurgical pocket probing
depths following closed subgingival scaling and root planing were 5 mm or
greater with a range of 5 mm–12 mm. At 1 year and at 6 years, the mean pocket
probing depths were 3.09 mm and 3.06 mm, respectively. The mean improve-
ment in CAL at 1 and 6 years post surgery was 3.33 mm and 3.36 mm, respec-
tively. All pocket probing depths were less than 4 mm at all reevaluations. One
ofthe most clinically significant findings in this study was the lack of clinically
detectable recession at both measurement intervals. Recession is a major concern
associated with all types of periodontal surgery. The lack of recession following
MIS is an important finding because it indicates that the risk of unaesthetic
gingival contours, food impaction, and thermal sensitivity is minimal following
MIS regenerative surgery.
Recently, a videoscope has been designed for use with MIS [8,9]. This video-
scope was described in Chapter 2. The use of the videoscope has allowed for
smaller surgical access openings when performing MIS, and the procedure is
described as Videoscope-Assisted Minimally Invasive Surgery V-MIS. A large
university based study of V-MIS indicates that there is a further improvement
over MIS when V-MIS is used. The mean presurgical pocket probing depths
following closed subgingival scaling and root planing were 5.23 mm with a
mean CAL of 5.86 mm and 0.82 mm of recession. At 6 months following V-MIS,
the mean pocket probing depth was 2.28 mm while all pocket probing depths
were less than 3 mm. There was an improvement in CAL of 3.00 mm. There was
also a small, but statistically significant, improvement in soft tissue height of
0.29 mm [10]. This study further emphasizes that the MIS and specifically the
V-MIS surgical technique yield good improvement in pocket probing depths and
CAL while not causing clinical and esthetic complications associated with reces-
sion. The surgical technique described in this chapter will be based on the V-MIS
approach to minimally invasive surgery.
Surgical principles
There are certain principles that guide all MIS procedures. The first is to preserve
as much blood supply to the periodontal tissues as possible. Preserving the blood
supply means that split thickness dissection is used for all flap reflection and a
periosteal elevator is never used. This is a critical aspect of MIS. A major source
of blood supply for the periodontal tissues is the periosteum. The reflection of
theperiosteum with a perosteal elevator significantly disturbs the blood supply

The MIS and V-MIS Surgical Procedure 83
to the gingival tissue and underlying bone. Care should be taken to leave the
periosteum intact. The bone should only be exposed within the defect itself. A
second principle of MIS is to cause minimum traumatic damage to the periodontal
tissue. In most traditional regenerative periodontal surgery, it is routine to make
large flaps and widely reflect the soft tissue from the bone. With MIS, care is
taken to use as small an incision as possible, use split thickness dissection to
reflect thesoft tissue only to the edge of the osseous defect, and to put as little
pressure on the tissue as possible. When successful, at closure the tissue should
have the appearance of the surrounding un-incised tissue and to not have a
bruised orcyanotic appearance. A third principle of MIS is to replace the soft
tissue at or above the presurgical height with no tension on the tissue. Suturing is
kept as simple as possible, and sutures are only placed at the base of the flap. The
thin coronal portion of the papilla is never penetrated with a needle as it is felt this
negatively impacts the blood supply to this thin vulnerable tissue. Instead of
suturing the papilla, the tissue is approximated and positioned coronally by finger
pressure on wet gauze. The use of the videoscope allows for smaller incisions and
flaps that do not have to be reflected to the extent necessary with other means of
visualization which aids closure of the tissue.
Steps in V-MIS or MIS
The surgical technique for MIS using either telescopes or a glass fiber endoscope
and V-MIS using a videoscope is similar in many ways. The following descrip-
tion will detail the use of a videoscope for V-MIS. The same steps can be followed
for MIS using surgical telescopes or a surgical microscope. With V-MIS, smaller
access incisions and less flap reflection can be used than with traditional MIS
surgical approaches. Major variations in technique necessitated by different
visualization technology will be noted in the steps as they are described.
Case selection
V-MIS/MIS is usually indicated for isolated defects. Standard nonsurgical
treatment (oral hygiene instruction, closed subgingival scaling and root plan-
ing, and occlusal adjustment where appropriate) should be performed prior to
making a decision on the type of surgical approach that may be necessary.
Often following nonsurgical treatment, a patient who initially presented with
generalized periodontal inflammation will instead present with most pocket
probing depths at an acceptable level for the maintenance of periodontal health.
However, there will frequently be isolated, usually interproximal, defects that
are 5 mm orgreater in pocket probing depth. (Figure7.1) The radiographs of
these areas should be carefully evaluated and a decision made whether bone
loss is present and if so are regenerative procedures indicated. If the defects are
localized and are adjacent to periodontally healthy tissue, these defects are the
ideal sites for using V-MIS.

84 Minimally Invasive Periodontal Therapy
In cases where the periodontal destruction is more generalized with many con-
tiguous areas of deeper pocket probing depths, it may not be possible to use a
minimally invasive approach as it has been described in the literature. (Figure7.2)
However, many of the principles described for use with minimally invasive sur-
gery such as smaller flaps and minimizing trauma to the tissue can still be used for
Figure 7.1 Charting of a quadrant where V-MIS is indicated. Pocket probing depth chart post
initial preparation indicating an isolated defect between the first and second molar. This isolated
defect is ideally indicated for a V-MIS/MIS approach.

The MIS and V-MIS Surgical Procedure 85
Figure 7.2 Charting of a quadrant where more generalized (non-V-MIS/MIS) surgery is
indicated. Pocket probing depth chart post initial preparation showing generalized defects
thatindicate the need for a more generalized surgical approach than V-MIS/MIS. Small incision
surgery and the use of the videoscope will be of benefit for this case, but more extensive
(longer) incisions will be necessary.

86 Minimally Invasive Periodontal Therapy
the treatment of more generalized periodontal damage despite the necessity for a
more extensive reflection of tissue. The videoscope because of its ability to provide
improved visualization and magnification can be very useful in performing these
more generalized (nonminimally invasive) surgical procedures.
Incision and flap design
The flap design for V-MIS/MIS procedures will vary with the location, extent
ofthe osseous defect, and visualization devices that are available. The presence of
an osseous defect can be diagnosed with routine pocket measurements, but the
extent of bone loss should be verified by bone sounding after the patient has been
anesthetized. Where possible, only a single lingual or palatal flap is used. Lingual
access and visualization is much easier when a videoscope is available. Lingual
access approaches are difficult to use when surgical telescopes or a surgical micro-
scope are used. These instruments give a straight view into the surgical field,
which means a mirror must be used with a lingual flap approach. By contrast, the
Figure 7.3 The videoscope is placed through a single MIS access flap on the palate allowing
for full visualization of the interproximal defect.

The MIS and V-MIS Surgical Procedure 87
videoscope can be placed directly into the lingual opening, which results in a clear
view of the surgical site. (Figures7.3 and 7.4)
Assuming an interproximal defect that does not extend beyond the line angles
of adjacent teeth, the first incision is placed in the intersulcular space from theline
angle of each tooth extending into the interproximal area. Care should be taken
to stay in the sulcus and not remove a collar of tissue with this incision (Figure7.5).
This requires that the blade be placed against the tooth and pushed to the base of
the defect. The blade should not be allowed to incise the tissue in the body of the
papilla, and care should be taken to not cross the body of the papilla with these
incisions. The second incision should be a horizontal (mesial-distal) incision
across the body of the papilla (Figure7.6). This incision should be placed relatively
high on the papilla but not extend into the area of the col. The col should be pre-
served in place if at all possible. Once the horizontal incision is made, a split-
thickness dissection is performed to create the access flap (Figure7.7). This should
be done only with sharp dissection. A periosteal elevator should never be used to
elevate this flap.
Various blades can be used for making these incisions. The following sugges-
tions for blades are those used by the author. The initial sulcular incisions are
made with a 12b blade (Figure7.8). This is a standard curved disposable scalpel
blade where both edges of the curve are sharpened. This blade has the advantage
of some rigidity and the ability to be utilized in a push–pull motion. This has been
Figure 7.4 The interproximal defect from Figure7.3 as visualized by the videoscope.

88 Minimally Invasive Periodontal Therapy
found to be very useful for the sulcular incisions. This blade may also be used to
make the horizontal incision across the body of the papilla. The sharp dissection
of the papilla is performed with a modified Orban knife. A standard Orban knife
is reduced in size by approximately one third of its width (Figure 7.9). The
rigidity of the Orban knife is very helpful for reflecting the flap because it allows
for a split thickness dissection as well as the ability to “pull” on the flap as the
incision is made. Other blades that may be helpful are the so-called microsur-
gical blades (Figure7.10). The size of these blades allows good access to small
spaces, but the blade’s lack of rigidity is often a significant impediment to their
use. These blades also tend to have a “spring” that causes the blade to move
suddenly when the blade “catches” on bone or calculus. This sudden movement
of the very sharp blade may damage the tissue.
Figure 7.6 An outline drawing of the incision jointing the two sulcular incisions across the
papilla. The two initial incisions are connected on the surface (buccal or lingual) where the
access flap will be elevated. This connecting incision is made apical to the col tissue. The col
tissue and the papilla on the nonsurgical side remain intact and are not elevated.
Figure 7.5 An outline drawing of the initial sulcular incisions. These initial incisions are made
in the sulcus of the teeth adjoining the periodontal defect. The incisions are kept strictly within
the sulcus by placing the blade against the adjacent root surface. No collar of tissue is removed
with this incision, and care is taken to not join the two incisions.

The MIS and V-MIS Surgical Procedure 89
If a videoscope is not available or if the osseous defect is extensive, it may be
advisable to create a buccal flap in addition to the lingual minimal access flap.
When telescopes or a surgical microscope is used, consideration can also be given
to using only a buccal approach. However, it should be borne in mind that
reflecting a buccal flap has a greater potential for visible gingival recession with
possible negative esthetic consequences.
Figure 7.7 (a) Outline drawing of using a modified Orban knife to reflect the access
flap.Theaccess flap is reflected with sharp dissection only leaving the periosteum in place
onthebone. A periosteal elevator should not be used. Because of its rigidity, a small Orban
knife is ideal for this step. (b) Clinical use of a modified Orban knife for the sharp
dissection.
(b)
(b)
Figure 7.8 Because of its push–pull cutting capabilities and its relative rigidity, a disposable
12b blade is ideal for making the initial sulcular incisions and the incision across the papilla.

90 Minimally Invasive Periodontal Therapy
Debridement
A through debridement of the periodontal defect and adjacent tooth is necessary
for optimal chances of regeneration. Debridement of the defect consists of two
parts. The first is the removal of granulation tissue. The second is the removal of
calculus, biofilm, and surface roughness from the root surface.
Figure 7.9 A standard Orban knife modified by reducing its width by approximately one third
is ideal for making the split thickness incision that is used to elevate the access flap. The rigidity
of this blade allows for the cutting of the tissue and also displacing flap for access.
Figure 7.10 Many disposable microsurgical knifes of different shapes are available, which can
be used for all the incisions used in V-MIS/MIS. Because the shafts of these knifes are very
flexible, they may not be ideal for some steps in making V-MIS/MIS incisions.

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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/minimallyinvasive817IntroductionMinimally invasive surgery (MIS) is based on the concept of using small incisions to perform surgical procedures that have previously been performed through larger surgical access openings. The term “minimally invasive surgery” was first applied to periodontal surgical procedures in 1995 [1]. The procedure was described as minimally invasive surgery or MIS. Several variations and tech-niques for performing MIS have been described. These include the original MIS approach that used surgical telescopes for visualization, a variation of this approach using the glass fiber endoscope for visualization, and the most recently described technique of Videoscope-Assisted MIS (V-MIS). Each of these tech-niques is considered to be an MIS technique with each change in visualization technology, thereby allowing for smaller incisions and greater magnification.Following the initial description of MIS, the technique was further explored in several case series published over the next five years [2–5]. These papers reported excellent clinical results over an extended time period. The largest of these case series had 194 surgical sites that were followed for 9–54 months. All patients had closed scaling and root planing performed under local anesthetic at least 6 week before the surgical procedure. At the time of surgery, the pockets to be surgically treated ranged from 5 to 16 mm. The mean improvement in pocket The MIS and V-MIS Surgical ProcedureStephen K. Harrel 82 Minimally Invasive Periodontal Therapyprobing depth was 4.58 mm, and the mean improvement in clinical attachment level (CAL) was 4.87 mm. A detailed description of the technique for performing MIS was published in 1999 [3].Further research on MIS has been published more recently. A prospective study of the use of MIS with enamel matrix derivative (EMD) was published with 1-year data in 2005, and the 6-year data on the same cases published in 2010 [6,7]. These studies showed that there was a significant amount of improvement in pocket probing depth and CAL when MIS was performed. A total of 160 sites were treated with EMD using an MIS approach. The presurgical pocket probing depths following closed subgingival scaling and root planing were 5 mm or greater with a range of 5 mm–12 mm. At 1 year and at 6 years, the mean pocket probing depths were 3.09 mm and 3.06 mm, respectively. The mean improve-ment in CAL at 1 and 6 years post surgery was 3.33 mm and 3.36 mm, respec-tively. All pocket probing depths were less than 4 mm at all reevaluations. One ofthe most clinically significant findings in this study was the lack of clinically detectable recession at both measurement intervals. Recession is a major concern associated with all types of periodontal surgery. The lack of recession following MIS is an important finding because it indicates that the risk of unaesthetic gingival contours, food impaction, and thermal sensitivity is minimal following MIS regenerative surgery.Recently, a videoscope has been designed for use with MIS [8,9]. This video-scope was described in Chapter 2. The use of the videoscope has allowed for smaller surgical access openings when performing MIS, and the procedure is described as Videoscope-Assisted Minimally Invasive Surgery V-MIS. A large university based study of V-MIS indicates that there is a further improvement over MIS when V-MIS is used. The mean presurgical pocket probing depths following closed subgingival scaling and root planing were 5.23 mm with a mean CAL of 5.86 mm and 0.82 mm of recession. At 6 months following V-MIS, the mean pocket probing depth was 2.28 mm while all pocket probing depths were less than 3 mm. There was an improvement in CAL of 3.00 mm. There was also a small, but statistically significant, improvement in soft tissue height of 0.29 mm [10]. This study further emphasizes that the MIS and specifically the V-MIS surgical technique yield good improvement in pocket probing depths and CAL while not causing clinical and esthetic complications associated with reces-sion. The surgical technique described in this chapter will be based on the V-MIS approach to minimally invasive surgery.Surgical principlesThere are certain principles that guide all MIS procedures. The first is to preserve as much blood supply to the periodontal tissues as possible. Preserving the blood supply means that split thickness dissection is used for all flap reflection and a periosteal elevator is never used. This is a critical aspect of MIS. A major source of blood supply for the periodontal tissues is the periosteum. The reflection of theperiosteum with a perosteal elevator significantly disturbs the blood supply The MIS and V-MIS Surgical Procedure 83to the gingival tissue and underlying bone. Care should be taken to leave the periosteum intact. The bone should only be exposed within the defect itself. A second principle of MIS is to cause minimum traumatic damage to the periodontal tissue. In most traditional regenerative periodontal surgery, it is routine to make large flaps and widely reflect the soft tissue from the bone. With MIS, care is taken to use as small an incision as possible, use split thickness dissection to reflect thesoft tissue only to the edge of the osseous defect, and to put as little pressure on the tissue as possible. When successful, at closure the tissue should have the appearance of the surrounding un-incised tissue and to not have a bruised orcyanotic appearance. A third principle of MIS is to replace the soft tissue at or above the presurgical height with no tension on the tissue. Suturing is kept as simple as possible, and sutures are only placed at the base of the flap. The thin coronal portion of the papilla is never penetrated with a needle as it is felt this negatively impacts the blood supply to this thin vulnerable tissue. Instead of suturing the papilla, the tissue is approximated and positioned coronally by finger pressure on wet gauze. The use of the videoscope allows for smaller incisions and flaps that do not have to be reflected to the extent necessary with other means of visualization which aids closure of the tissue.Steps in V-MIS or MISThe surgical technique for MIS using either telescopes or a glass fiber endoscope and V-MIS using a videoscope is similar in many ways. The following descrip-tion will detail the use of a videoscope for V-MIS. The same steps can be followed for MIS using surgical telescopes or a surgical microscope. With V-MIS, smaller access incisions and less flap reflection can be used than with traditional MIS surgical approaches. Major variations in technique necessitated by different visualization technology will be noted in the steps as they are described.Case selectionV-MIS/MIS is usually indicated for isolated defects. Standard nonsurgical treatment (oral hygiene instruction, closed subgingival scaling and root plan-ing, and occlusal adjustment where appropriate) should be performed prior to making a decision on the type of surgical approach that may be necessary. Often following nonsurgical treatment, a patient who initially presented with generalized periodontal inflammation will instead present with most pocket probing depths at an acceptable level for the maintenance of periodontal health. However, there will frequently be isolated, usually interproximal, defects that are 5 mm orgreater in pocket probing depth. (Figure7.1) The radiographs of these areas should be carefully evaluated and a decision made whether bone loss is present and if so are regenerative procedures indicated. If the defects are localized and are adjacent to periodontally healthy tissue, these defects are the ideal sites for using V-MIS. 84 Minimally Invasive Periodontal TherapyIn cases where the periodontal destruction is more generalized with many con-tiguous areas of deeper pocket probing depths, it may not be possible to use a minimally invasive approach as it has been described in the literature. (Figure7.2) However, many of the principles described for use with minimally invasive sur-gery such as smaller flaps and minimizing trauma to the tissue can still be used for Figure 7.1 Charting of a quadrant where V-MIS is indicated. Pocket probing depth chart post initial preparation indicating an isolated defect between the first and second molar. This isolated defect is ideally indicated for a V-MIS/MIS approach. The MIS and V-MIS Surgical Procedure 85Figure 7.2 Charting of a quadrant where more generalized (non-V-MIS/MIS) surgery is indicated. Pocket probing depth chart post initial preparation showing generalized defects thatindicate the need for a more generalized surgical approach than V-MIS/MIS. Small incision surgery and the use of the videoscope will be of benefit for this case, but more extensive (longer) incisions will be necessary. 86 Minimally Invasive Periodontal Therapythe treatment of more generalized periodontal damage despite the necessity for a more extensive reflection of tissue. The videoscope because of its ability to provide improved visualization and magnification can be very useful in performing these more generalized (nonminimally invasive) surgical procedures.Incision and flap designThe flap design for V-MIS/MIS procedures will vary with the location, extent ofthe osseous defect, and visualization devices that are available. The presence of an osseous defect can be diagnosed with routine pocket measurements, but the extent of bone loss should be verified by bone sounding after the patient has been anesthetized. Where possible, only a single lingual or palatal flap is used. Lingual access and visualization is much easier when a videoscope is available. Lingual access approaches are difficult to use when surgical telescopes or a surgical micro-scope are used. These instruments give a straight view into the surgical field, which means a mirror must be used with a lingual flap approach. By contrast, the Figure 7.3 The videoscope is placed through a single MIS access flap on the palate allowing for full visualization of the interproximal defect. The MIS and V-MIS Surgical Procedure 87videoscope can be placed directly into the lingual opening, which results in a clear view of the surgical site. (Figures7.3 and 7.4)Assuming an interproximal defect that does not extend beyond the line angles of adjacent teeth, the first incision is placed in the intersulcular space from theline angle of each tooth extending into the interproximal area. Care should be taken to stay in the sulcus and not remove a collar of tissue with this incision (Figure7.5). This requires that the blade be placed against the tooth and pushed to the base of the defect. The blade should not be allowed to incise the tissue in the body of the papilla, and care should be taken to not cross the body of the papilla with these incisions. The second incision should be a horizontal (mesial-distal) incision across the body of the papilla (Figure7.6). This incision should be placed relatively high on the papilla but not extend into the area of the col. The col should be pre-served in place if at all possible. Once the horizontal incision is made, a split-thickness dissection is performed to create the access flap (Figure7.7). This should be done only with sharp dissection. A periosteal elevator should never be used to elevate this flap.Various blades can be used for making these incisions. The following sugges-tions for blades are those used by the author. The initial sulcular incisions are made with a 12b blade (Figure7.8). This is a standard curved disposable scalpel blade where both edges of the curve are sharpened. This blade has the advantage of some rigidity and the ability to be utilized in a push–pull motion. This has been Figure 7.4 The interproximal defect from Figure7.3 as visualized by the videoscope. 88 Minimally Invasive Periodontal Therapyfound to be very useful for the sulcular incisions. This blade may also be used to make the horizontal incision across the body of the papilla. The sharp dissection of the papilla is performed with a modified Orban knife. A standard Orban knife is reduced in size by approximately one third of its width (Figure 7.9). The rigidity of the Orban knife is very helpful for reflecting the flap because it allows for a split thickness dissection as well as the ability to “pull” on the flap as the incision is made. Other blades that may be helpful are the so-called microsur-gical blades (Figure7.10). The size of these blades allows good access to small spaces, but the blade’s lack of rigidity is often a significant impediment to their use. These blades also tend to have a “spring” that causes the blade to move suddenly when the blade “catches” on bone or calculus. This sudden movement of the very sharp blade may damage the tissue.Figure 7.6 An outline drawing of the incision jointing the two sulcular incisions across the papilla. The two initial incisions are connected on the surface (buccal or lingual) where the access flap will be elevated. This connecting incision is made apical to the col tissue. The col tissue and the papilla on the nonsurgical side remain intact and are not elevated.Figure 7.5 An outline drawing of the initial sulcular incisions. These initial incisions are made in the sulcus of the teeth adjoining the periodontal defect. The incisions are kept strictly within the sulcus by placing the blade against the adjacent root surface. No collar of tissue is removed with this incision, and care is taken to not join the two incisions. The MIS and V-MIS Surgical Procedure 89If a videoscope is not available or if the osseous defect is extensive, it may be advisable to create a buccal flap in addition to the lingual minimal access flap. When telescopes or a surgical microscope is used, consideration can also be given to using only a buccal approach. However, it should be borne in mind that reflecting a buccal flap has a greater potential for visible gingival recession with possible negative esthetic consequences.Figure 7.7 (a) Outline drawing of using a modified Orban knife to reflect the access flap.Theaccess flap is reflected with sharp dissection only leaving the periosteum in place onthebone. A periosteal elevator should not be used. Because of its rigidity, a small Orban knife is ideal for this step. (b) Clinical use of a modified Orban knife for the sharp dissection.(b)(b)Figure 7.8 Because of its push–pull cutting capabilities and its relative rigidity, a disposable 12b blade is ideal for making the initial sulcular incisions and the incision across the papilla. 90 Minimally Invasive Periodontal TherapyDebridementA through debridement of the periodontal defect and adjacent tooth is necessary for optimal chances of regeneration. Debridement of the defect consists of two parts. The first is the removal of granulation tissue. The second is the removal of calculus, biofilm, and surface roughness from the root surface.Figure 7.9 A standard Orban knife modified by reducing its width by approximately one third is ideal for making the split thickness incision that is used to elevate the access flap. The rigidity of this blade allows for the cutting of the tissue and also displacing flap for access.Figure 7.10 Many disposable microsurgical knifes of different shapes are available, which can be used for all the incisions used in V-MIS/MIS. Because the shafts of these knifes are very flexible, they may not be ideal for some steps in making V-MIS/MIS incisions. The MIS and V-MIS Surgical Procedure 91The debridement of granulation tissue from the defect is performed using standard periodontal curettes. Larger curettes such as a Prichard curette are too large for use in most V-MIS procedures. Care should be taken to keep from plac-ing pressure on or folding the soft tissue flap while debriding the defect. This means that most traditional periodontal retractors are not suitable for use in MIS. If a videoscope is available, the rotating carbon fiber tissue retractor will adequately retract the V-MIS flap without causing damage to the soft tissue. If a videoscope is not available, great care should be taken to not apply excessive pressure when retracting the flap for visualization as this will damage the tissue and lead to postsurgical recession. The instrument most used for granulation tissue removal with V-MIS/MIS is a Younger-Goode 7–8 (Figure7.11). This is a relatively small instrument with a narrow shaft that can be used in a motion similar to a “spoon” used for the removal of decay. This motion is far less likely to place excess pressure on the minimal flap than will the standard root planing like motion used in traditional periodontal surgery. Other small curettes can also be used, but the prevention of damage to the soft tissue flap should be a goal throughout debridement.Classically, all granulation tissue is removed during periodontal surgery. With high magnification, this can become an extremely difficult job. This is especially true when the videoscope with 40+ magnification is used. The author’s goal is to remove as much granulation tissue as possible from next to the tooth and from the floor of the defect. The granulation tissue on the soft tissue walls (Figure7.12) is removed to a point that allows for visualization of the root surface, but the definitive removal of “all granulation tissue” is not pursued.The debridement of the root surface is usually started with an ultrasonic scaler. The Diamond Safety Tip (Vista Dental, Milwaukee, WI) is the preferred ultrasonic tip for this (Figure7.13). This tip brings the aggressiveness of a diamond ultra-sonic tip; but because the abrasive action of the diamond is limited, it can safely be used in small defects without risk of damaging the root surface. Following the Figure 7.11 The blade of a Younger-Goode 7/8 curette is ideal for the gross removal of granulation tissue from periodontal defect through the small MIS access opening. This curette can be utilized in a manner similar to an operative “spoon” instrument used to remove caries. 92 Minimally Invasive Periodontal TherapyFigure 7.12 Photo of a surgical defect with granulation tissue removed illustrating the intact col tissue and the unreflected buccal papilla. Granulation tissue is removed from the osseous defect and a “tunnel” is made under the unreflected papilla. Tags of granulation tissue remaining on the unreflected tissue and on the underside of the access flap are removed only to the extent necessary to visualize the defect.Figure 7.13 Initial debridement of the root surface is performed with an ultrasonic scaler. TheDiamond Safety Tip (Vista Dental) is preferred for this step. It allows for the rapid removal ofcalculus and roughness with the diamond abrasive, but it does not cause any damage of the root surface. The MIS and V-MIS Surgical Procedure 93use of an ultrasonic scaler, hand curettes, typically Graceys, are used for the mechanical removal of the remaining calculus. Care must be taken to clean and dry the surgical area before visualizing the root surface with the videoscope for remaining calculus. This drying is best accomplished by packing a strip ofdry gauze into the site and withdrawing the gauze just before placing the videoscope in place.With V-MIS, when the mechanically debrided root surface is observed with thevideoscope, there will often be “micro” islands of calculus remaining, which are not observable with telescopes or the surgical microscope (Figure7.14). These micro islands of calculus are usually not detectable with a periodontal probe. These small areas of calculus can be very difficult to remove by mechanical means. The use of biomodification with either ethylenediaminetetracetic acid (EDTA) or citric acid will usually remove all of the remaining islands of calculus (Figure7.15). The author feels this final removal of microcalculus is extremely important to the long-term results reported for MIS and V-MIS.Figure 7.14 Photo showing remaining islands of calculus following mechanical root debridement. After mechanical debridement of the root surface with ultrasonic and hand curettes, the videoscope will often reveal “micro islands” of calculus that remain on the rootsurface. 94 Minimally Invasive Periodontal TherapyRegenerative materialsMost of the MIS and V-MIS cases reported in the periodontal literature have used either enamel matrix derivative (EMD) alone or mixed with freeze-dried demineratized cortical human bone allograft (DFDBA). However, the author has performed V-MIS/MIS using only EMD, only DFDBA, and with no regener-ative material. The use of each of these approaches has led to similar excellent clinical results. Cortellini has reported that if the blood supply to the surgical site is well maintained, no regenerative materials are necessary with small incision surgery (MIST) [11,12]. The author agrees with this observation in many instances. This is probably most true when the lesion is relatively small and narrow and, therefore, supports the soft tissue. If the lesion is somewhat larger, the use of DFDBA, with or without EMD, will help support the flap and prevent it from sinking into the underlying defect. This seems to be beneficial in preventing recession and postsurgical esthetic problems. The use of EMD appears to speed the soft tissue healing of the flaps and has been associated with long-term sta-bility of periodontal regeneration. Based on these clinical considerations, the use Figure 7.15 The root surface shown in Figure7.14 after the use of ethylenediaminetetraacetic acid (EDTA). Note that the micro islands of calculus seen in Figure7.14 are no longer present. The MIS and V-MIS Surgical Procedure 95of EMD both on the root surface and mixed with DFDBA when flap support is needed seems to be an ideal approach (Figure7.16).The small opening used in V-MIS precludes the use of a membrane for cellular exclusion. One of the principles of guided tissue regeneration is to extend the occlusive membrane several millimeters beyond the edge of the osseous defect. This would negate much of the advantages gained from the use of small inci-sions. This extension also would necessitate the exposure of a considerable amount of bone with the subsequent loss of blood supply from the area denuded of periosteum. In the early descriptions of MIS, a technique was discussed in which a Vicryl mesh was placed over a bone graft in the osseous defect. This mesh material was dead soft with relatively large holes in the material. The Vicryl mesh was not placed for cellular exclusion but for stabilization of the bone graft and subsequent blood clot. The use of a Vicryl membrane has been discontinued with no apparent changes in clinical results. The author no longer recommends this step for MIS or V-MIS.Figure 7.16 Photo showing freeze-dried particulate bone graft material mixed with enamel matrix derivative (EMD) placed in the periodontal osseous defect. The use of a growth stimulator such as EMD in association with a material to support the flap such as freeze-dried demineralized human bone appears to be ideal for use in V-MIS/MIS regeneration. 96 Minimally Invasive Periodontal TherapySuturingA single suture is used for the typical closure of a V-MIS site. In most cases, the material used is either a 4-0 plain collagen or chromic suture. However, the exact suture material does not appear critical, but it should be strong enough to allow the tissue to be pulled firmly together and not be so small that it cuts through the tissue when tension is applied. A vertical mattress suture is placed at the base of papilla (Figure7.17). The suture is placed in this position so that tension can be placed on the suture without fear of damaging the papillary tissue in a manner that might cause postoperative recession. The suture at the base of the papilla will allow the body of the papilla to be pulled firmly together without damaging the thin and narrow tissue at the apex of the papilla. Suturing coronal to the base of the papilla, even with very small suture and fine needles, is avoided in order to not damage this vulnerable tissue. It is felt that this suturing technique that avoids trauma to the papillary tissue is one of the major reasons that no mean recession is reported following V-MIS/MIS.The papilla tissues coronal to the suture are approximated by placing saline-soaked gauze on the tissue and applying finger pressure (Figure 7.18). Where possible, the interproximal soft tissue is placed at or above the presurgical level. Figure 7.17 The access flap is closed with a simple vertical mattress suture placed at the base of the papilla. Sutures are not placed through the tip of the papilla in order to not damage the blood supply to this thin tissue. The MIS and V-MIS Surgical Procedure 97This will help minimize the possibility of postsurgical recession, which is one of the significant advantages of the V-MIS/MIS procedure.Postoperative instructionsPatients generally require only over-the-counter pain medication such as Ibuprofen or Acetaminophen following surgery. They are advised to avoid mechanical oral hygiene in the surgical area for 7–10 days and to use chlorhexidine mouth rinses twice a day. A 5–7 day course of broad spectrum antibiotic can be prescribed forpostsurgical use if the surgeon feels this is necessary. A moderately soft diet is recommended for 1 week following surgery.Most patients report little pain or other morbidity following MIS. Often, the patients will say they forget that surgery has been done and brush or chew routinely in the surgical area despite being advised not to do so. While this can certainly lead to complications, it is an indication that the patient has little discomfort following MIS.SummaryMinimally invasive surgery using the very small incisions of V-MIS or using the somewhat larger incisions of MIS has a proven track record of producing shallow pocket probing depths, improved attachment levels, clinically unde-tectable recession, and long-term stability of the improved results following surgery. In addition to these favorable clinical results, patient satisfaction with these procedures has been high. This is reflected in a lack of discomfort immediately following the surgical procedure, no food packing, or thermal Figure 7.18 After the base of the papilla has been closed with a vertical mattress suture, the tips of the papilla are approximated at or above the presurgical height with finger pressure only. 98 Minimally Invasive Periodontal Therapysensitivity following initial surgical healing, and minimum to no negative esthetic changes following surgery. The useof V-MIS/MIS where indicated for regeneration of damage from periodontal destruction is highly clinically predictable and is viewed very favorably by patients.The video link to Journal of Clinical Periodontology (Wiley) “pubcast” is available on the book companion website.Case Study 1A 53-year-old Caucasian female presented with chronic moderate-to-severe gen-eralized periodontal disease. Initial therapy consisted of oral hygiene instruc-tion,nonsurgical root planing with local anesthetic, and reevaluation at 6 weeks post root planing. At the time of reevaluation, most pocket probing depths had returned to an acceptable level of 4 m or less. However, multiple isolated inter-proximal sites with pocket probing depths of 5–8 mm remained. These sites were treated with V-MIS.Figure CS1 7.1 Presurgical buccal view of the surgical area. A pocket of 8+ mm remained interproximally between the first molar and second bicuspid, following initial therapy consisting of root planing with local anesthetic. The MIS and V-MIS Surgical Procedure 99Figure CS1 7.2 Presurgical lingual view of the surgical area pictured in Figure CS1 7.1.Figure CS1 7.3 Initial videoscope view of the periodontal defect. The defect was accessed using only a lingual MIS access incision. Figure CS1 7.4 Videoscope view of the periodontal defect showing the use of a Younger-Goode curette (arrow) to remove granulation tissue. Note the apparent vascular channel present in the bony wall of the periodontal defect.Figure CS1 7.5 Most of the granulation tissue has been removed, and the root surfaces have been mechanically debrided of all calculus visible with surgical loupes, and no roughness could be detected with a periodontal probe. When the lesion is visualized with the videoscope “micro” islands of calculus are visible (arrow). The MIS and V-MIS Surgical Procedure 101Figure CS1 7.6 The root surface has been treated with EDTA to biomodify the roots surface. The micro islands of calculus are no longer visible.Figure CS1 7.7 A buccal view of the surgical area at 6 month post surgery. 102 Minimally Invasive Periodontal TherapyCase Study 2 The patient is a 54-year-old man who presented with generalized moderate and locally severe periodontitis. He responded well to nonsurgical periodontal ther-apy consisting of root planing with local anesthetic. Most pocket probing depths returned to an acceptable level of 4 mm or less. Several sites continued tohave deeper pocket probing depth, gingival inflammation, and bleeding on probing. These areas were treated nonsurgically with the use of a periodontal endoscope Figure CS2 7.1 A V-MIS palatal incision is used to access the periodontal defect.Figure CS1 7.8 A lingual view of the surgical area at 6 months post surgery. No measurable recession is noted. The MIS and V-MIS Surgical Procedure 103Figure CS2 7.2 Videoscope view of the periodontal lesion with a portion of the granulation tissue removed. Note the calculus filled “depression” on the interproximal aspect of the distal tooth. All other root surfaces had been rendered calculus free by the two nonsurgical procedures.Figure CS2 7.3 Further granulation tissue and most of the calculus visible in Figure CS2 7.2 has been removed. Dark calculus extending to the level of the bone is now revealed.(Perioview). All areas responded well to this therapy with the excep tion of a single site between a maxillary first molar and second bicuspid. This site had a residual 7-mm pocket probing depth and continued bleeding on probing. The site was treated with V-MIS, bone grafting, and enamel matrix derivative. 104 Minimally Invasive Periodontal TherapyFigure CS2 7.4 All granulation tissue has been removed and the bony floor of the periodontal defect is visible. The depression on the root with remaining calculus is fully visible.Figure CS2 7.5 Mechanical removal of the remaining calculus being performed with a Gracey curette. Following mechanical removal of calculus, multiple micro islands of calculus were observed with the videoscope. EDTA was used to remove the remaining calculus and to biomodify the root surface. At six months post operative, the site has a pocket probing depth of 3 mm, no bleeding on probing, and no clinically detectable postsurgical gingival recession.Figure CS2 7.6 The root surface following the use of EDTA. At this point, EMD and DFDBA were placed in the defect and the access flap was closed.V-MIS GalleryDiagnosis and root abnormalities identified with the videoscopeFigure G7.1 Root resorbtion detected in a maxillary molar bifurcation defect. 106 Minimally Invasive Periodontal TherapyFigure G7.2 The root resorbtion noted in Figure G7.1, following clean out. At patient’s request, the lesion was filled with a glass ionomer and the lesion was bone grafted. At 9 months post surgery, the area had healed well.Figure G7.3 Enamel pearl located on the root surface approximately 2 mm apical to the CEJ. This root abnormality was smooth and undetectable to a periodontal probe prior to surgical access and the removal of the small amount of planed calculus that surrounded the enamel pearl. The MIS and V-MIS Surgical Procedure 107Figure G7.4 The root surface pictured in Figure G7.3, following the removal of the enamel pearl and root biomodification with EDTA. The pearl was removed with diamond-coated ultrasonic scalers and smoothed with a rotary carbide finishing burs.Figure G7.5 Root decay is noted apical to the CEJ. The instrument in the illustration is inserted into the area of decay. Figure G7.6 The pulp chamber has been opened and a fracture of the pulp chamber wall is verified with the videoscope. Based on this finding the tooth was extracted and the site prepared for an implant.Cement on implantsFigure G7.7 Excess cement at the base of an implant supported crown is identified by the use of the videoscope. Figure G7.8 The excess cement has been removed with the exception of a thin line at the crown margin (arrow). The surgical site has been prepared to attempt regeneration of bone and reattachment to the implant. The soft tissue will be positioned apical to the crown margin.Calculus on root surfacesFigure G7.9 An isolated area of calculus is visualized on the mid-lingual surface of the root. The remainder of the root had been planed free of calculus during closed root planing and the calculus shown was very smooth and undetectable with a probe when the root was palpated prior to surgery. Figure G7.10 Area of deep calculus visualized at the base of a large periodontal defect. Allsurrounding root surface had been planed smooth during nonsurgical root planing, but thedeepest area of the defect appeared untouched.Figure G7.11 A large area of smooth “burnished’ calculus is visualized on the distal root surface. The calculus had been planed smooth during many episodes of root planing over several years. Figure G7.12 The calculus seen in Figure G7.11 has been removed with ultrasonic instruments and hand scalers. Note that many micro islands of calculus remain.Figure G7.13 The root surface shown in Figure G7.12, following biomodification by the use of EDTA. Note that the micro islands of calculus are no longer present. Figure G7.14 A root surface exposed during V-MIS showing calculus present in many depressions on the root surface. The cause of these root irregularities is unknown.Figure G7.15 Multiple lines noted on the palatal root surface on a maxillary central incisor. When first noted, these lines were filled with dark calculus, and it was assumed the tooth was fractured. However, as the root was scaled it was determined that there were multiple linear depressions in the root surface. It is unknown if these depressions are natural or part of the disease process.“Lines” on root surfaces Figure G7.16 The root surface shown in Figure G7.15 after root planing with diamond ultrasonic scalers and hand curettes, followed by biomodification with citric acid. At 2 years post operative, the pocket probing depth had been reduced from 10 mm preoperatively to 3 mm post operative. Post-operative recession was approximately 1 mm.Figure G7.17 A single line filled with calculus is shown on the mesial root surface of a maxillary bicuspid. When the line was removed with a scaler, no fracture of the root could be detected. 114 Minimally Invasive Periodontal TherapyFigure G7.18 An interproximal periodontal lesion on the mesial of a maxillary molar with a class II bifurcation defect. Generalized sheet calculus is noted on the root surface and in the bifurcation.Treatment of a maxillary molar bifurcation defectFigure G7.19 Most of he granulation tissue has been removed from the bifurcation defect, and the root surface has had most of the calculus removed. The MIS and V-MIS Surgical Procedure 115References1. Harrel, S.K. & Rees T.D. (1995) Granulation tissue removal in routine and minimally invasive surgical procedures. Compendium of Continuing Education in Dentistry, 16, 960–967.2. Harrel, S.K. (1998) A minimally invasive surgical approach for bone grafting. The International Journal of Periodontics & Restorative Dentistry, 18, 161–169.3. Harrel, S.K. (1999) A minimally invasive surgical approach for periodontal regenera-tion: Surgical technique and observations. Journal of Periodontology, 70, 1547–1557.4. Harrel, S.K., Nunn, M. & Belling, C.M. (1999) Long-term results of a minimally invasive surgical approach for bone grafting. Journal of Periodontology, 70, 1558–1563.5. Harrel, S.K. & Wright, J.M. (2000) Treatment of periodontal destruction associated with a cemental tear using minimally invasive surgery. Journal of Periodontology, 71, 1761–1766.Figure G7.20 Removal of granulation tissue from the bifurcation and mechanical debridement of the root surface has been completed. The use of EDTA has removed the remaining micro islands of calculus. EMD and DFDBA were placed in the defect, including the bifurcation. At 3 years post operatively, the bifurcation defect cannot be probed. 116 Minimally Invasive Periodontal Therapy6. Harrel, S.K., Wilson, T.G. Jr. & Nunn, M.E. (2005) Prospective assessment of the use of enamel matrix derivative with minimally invasive surgery. Journal of Periodontology, 76, 380–384.7. Harrel, S.K., Wilson, T.G. Jr. & Nunn, M.E. (2010) Prospective assessment of the use of enamel matrix proteins with minimally invasive surgery: Six year results. Journal of Periodontology, 81, 435–444.8. Harrel, S.K., Wilson, T.G. Jr. & Rivera-Hidalgo, F. (2013) A videoscope for use in min-imally invasive periodontal surgery. Journal of Clinical Periodontology, 40, 868–874.9. Harrel, S.K., Hidalgo-Rivera, F. & Abraham, C. (2012) Tissue resistance to soft tissue emphysema during M 8. Journal of Contemporary Dental Practice, 13 (6), 886–891.10. Harrel, S.K., Abraham, C.M., Rivera-Hidalgo, F., Shulman, J. & Nunn, M. (2014) Videoscope-assisted minimally invasive periodontal surgery (V-MIS). Journal of Clinical Periodontology, DOI:10.1111.11. 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, 1082–1088.12. Cortellini, P. & Tonetti, M.S. (2009) Improved wound stability with a modified mini-mally invasive surgical technique in the regenerative treatment of isolated inter-dental intrabony defects. Journal of Clinical Periodontology, 36, 157–163.

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