Periodontology 2000, Vol.
1 1 , 1996, 58-64
Printed in Detininrk All riglirs reseriad
A perspective on the future of
periodontal microsurgery
A. S H A N E L E c & LEONARD
DENNIS S. TIBBETTS
The current pendulum of clinical opinion in some
areas of periodontal education and research has
swung away from traditional mechanical and sur-
gical therapy toward pharmaceutical treatment ap-
plications. Although periodontal surgery, as prac-
ticed today, may be relegated to a lesser role in the
future, the application of magnification to peri-
odontics promises to change clinical concepts of
periodontal surgical care. As recent developments
in medicine have shown, magnification and micro-
surgery can greatly impact clinical practice. Over
the past several years, a therapeutic revolution has
taken place in general surgery requiring the re-
training of tens of thousands of surgeons and the
retooling of their operating rooms (1). This star-
tling change has come about due to the acceptance
of microscopic and endoscopic surgical therapy,
particularly laproscopic removal of the gallbladder
and arthroscopic repair of the knee. These proce-
dures were a natural evolution of microsurgical ad-
vances that took place in the early 1970s and cul-
minated in modern medical microsurgery. Micro-
surgery today is applied to a variety of medical op-
erations ranging from limb replantation to coro-
nary artery bypass procedures (Fig. 1). In common
usage, “microsurgery” refers to a refinement in
surgical technique by which normal vision is en-
hanced through magnification (7). In a broader
sense, however, microsurgery implies an extension
of surgical principles by which gentle handling of
tissue and exceedingly accurate approximation of
the wound edges is of paramount importance. Al-
though microsurgery is an integral part of modern
medicine, surgeons did not rapidly accept it. Its be-
ginning dates to 1886, with the microscope of Ze-
hender-Westein, developed in Germany for oph-
thalmology. Many years passed before professor
Carl Nylen performed the first surgical operation
with a microscope in 1922 to correct otosclerotic
deafness (3). Despite early pioneers, it was not un-
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C o p y r i g h t 0 Munksgaard 1996
PERIODONTOLOGY 2000
ISSN 0906-6713
ti1 1952 that operating microscopes were commer-
cially available to surgeons (Fig. 2). By the mid-
1960s, surgical microscopy had become the stan-
dard of care in otological and ophthalmological
surgery (2). Today, magnification of some kind is
commonplace in virtually every area of surgical
and diagnostic medicine from neurology to urol-
ogy.
An important factor in recent public and
professional acceptance of microsurgery is the
significant decrease in morbidity. This now
relegates some operating room surgical
procedures, formerly requiring general anesthesia
and lengthy post-surgical hospital stays, to
outpatient procedures. The reduced trauma and
relative painlessness that microsurgery offers is an
appealing alternative to major surgery. Patients
may not fully understand the medical reasons for
their therapy, but they are firmly grounded in a
belief that medicine and technology should
advance in their behalf. They expect sound advice
and careful treatment and readily appreciate
advances that give more predictable, more
cosmetic and safer results, to say nothing of
lessening their inconvenience, anxiety and
discomfort. New technology is expected to cost
more, but when improved quality is perceived,
promotion on purely selfish grounds is less likely to
be imputed. For these reasons, the public and the
medical profession have wholeheartedly embraced
minimally invasive surgical procedures.
There is every reason to believe that the public
expects, will welcome and eventually demand
advancement in the technology and procedures
available for treating periodontal disease. A case in
point is the growth and acceptance of technical
diagnostics, nonsurgical mechanical therapies
and pharmaceutical therapies in periodontics.
Despite these advances in periodontics over the
past decade, much of the everyday practice of

Fig. 1. Periodontal microsurgery with prism loops.
Fig. 2, a, Surgical operating microscope.b. Dental surgeon
utilizing the operating microscope.
periodontics still involves surgically treating
periodontal anatomy altered by trauma or disease.
Aside from many potential promotional or
marketing advantages, periodontal microsurgery
offers an improvement in predictability, cosmetic
result, and patient comfort level over conventional
periodontal surgical procedures (9). This is
especially true of regenerative procedures that
apply materials and techniques that are difficult to
Future of periodontal microsurgery
Fig. 3. a. Evolution of microsurgery: macroscopic surgery.
b' Of microsurgery:metascopic c* Evolu-
tion of microsurgery: microscopic surgery.
use successfully and predictably within the
confines of normal vision. Today, patients
increasingly seek periodontists who will provide
therapy that goes beyond treating the bacterial
component of periodontal disease. Many envision
and expect an ideal of therapy that will improve
their appearance 'and function. They expect such
therapy to be administered with minimal trauma
and discomfort.
59
Shnnelec & Tibbetts
Fig. 4. a. Multiple areas of recession: maxillary central inci-
sor and cuspid. b. Microsurgical subepithelial connective
tissue graft sutured with minimal trauma. c. Postoperative
result at 1 month.
In periodontics today, microsurgery is in the
same position it occupied in medicine in the
recent past. Periodontal microsurgery shares the
attributes with medical microsurgery that will
positively influence its professional acceptance.
These include improved cosmetic results,
increased predictability, less pain and higher
patient acceptance. On the other hand, such
factors as insurance pressure and hospital peer
Fig. 5. a. Multiple areas of recession: mandibular lateral in-
cisor and cuspid. b. Microsurgical subepithelial connective
tissue graft sutured. c. Postoperative result at 1week show-
ing rapid healing. Note remaining undissolved suture over
bicuspid.
review are absent for periodontists. The public’s
acceptance of minimal invasive periodontal
microsurgery is a foregone conclusion. The
acceptance of microsurgery by periodontists,
however, is likely to hinge in a number of factors.
One will undoubtedly be the marketing advantage
that individual periodontists perceive in being the
first to offer this service to their dental community.
Another will be the increased patient acceptance of

periodontal microsurgery as compared with
conventional periodontal surgery. The marketing
factors aside, periodontists must eventually
recognize that the clinical benefits microsurgery
offers to patients outweigh the time and expense
necessary to learn the techniques. When
microsurgery eventually becomes accepted,
periodontists will begin to learn as much as
possible about the development and
enthusiastically adapt it to their practices. There is
reason to believe that microsurgery may be
accepted more rapidly than previous new clinical
developments in periodontics. First, the tenants of
atraumatic technique and primary wound closure
fundamental to microsurgery are already goals
accepted in principle by periodontists (Fig. 3). The
specialty is not faced with a conceptual revolution
in periodontal therapy but merely improving the
accuracy and gentleness of what is already being
done in everyday practice (11).Every periodontic
procedure today can benefit from being done more
carefully and gently (Fig. 4).Second, a substantial
number of periodontists have already adopted the
use of low magnification in their practices and
recognize its value. What is lacking today among
periodontists is an understanding that the
cognitive and motor skills currently used in their
surgeries can be retrained to function at much
higher levels of accuracy than was ever imagined.
Using x2O magnification, vascular microsurgeons
routinely anastomose vessels with a diameter of 1
mm or less. Using x120 magnification, cellular
biologists routinely perform subcellular operations
on mitochondria and chromosomes. Using
magnification in the range of x10-20, periodontists
can easily learn to increase the precision of their
motor skills from tolerances of 1-2 mm to as small
as 10 pm (personal communication, Shanelec &
Tibbetts, 1992). To accomplish this, it is necessary
to move outside the envelope of proprioceptively
guided hand movement into the arena of true
visually guided movement. As such, vision is not
used merely to localize and position the hand with
the movement itself carried out by pre-
programmed, proprioceptively guided, motor
events. Instead vision directly guides the hand
through its entire range of motion, using visual
sensory feedback to accomplish mid-course
corrections. Under magnification, not only are
such cognitive perceptual skills readily learnable,
but it is also possible to retrain the hand and arm
muscles to move in much smaller and more
Future of periodontal microsurgery
~ _ _ _
accurate incremental motion sequences. Provided
that the reprogrammed sequences are maintained
by occasional practice sessions, these more
accurate motor skills are added to the neurological
repertoire of movements available for use with
loops or even without magnification (Fig. 6).
Although such cognitive retraining and muscle
fiber reconditioning cannot be accomplished
without practice using a microscope, once
established, the new skills become an
indispensable resource available to execute the
fine motor movement required in microsurgical
technique (6) (Fig. 5). In a fully developed
microsurgical periodontal practice, perhaps 70-
80% of typical periodontal microsurgical
procedures could be performed with the surgical
microscope at x10-20. The remainder of the
procedure could be accomplished with loops
under x6-8 using enhanced motor skills learned
and conditioned during microsurgery training
sessions with a scope. Such enhanced motor skills
operating on the outer borders of distinct visual
acuity have been termed metascopic motor skills
(4, 8). With such metascopic skills, some
periodontal microsurgical procedures can be
performed acceptably under loops.
Another important reason why microsurgery is
likely to gain more rapid acceptance among
periodontists is unrelated to improved outcome or
lessened morbidity of the procedure. The end-
point visual appearance of the typical
microsurgical procedure is simply far superior to
the end-point appearance of conventional surgery
(10). In photographically documented cases, the
difference is not only self-evident but the
magnitude is startling (Fig. 7). As much as
judgment, knowledge and theory play a role in
surgical outcome, in the end surgery is a craft.
Surgeons cannot help but appreciate the result of
fine skill, especially when it appears to rise to
artistic levels as compared with conventional
surgery. The end-point appearance of
microsurgery and conventional surgery are simply
not comparable because of the remarkable
advantage that magnification offers the
microsurgeon (5). With even a little microsurgical
training, the average periodontist can consistently
produce more finely crafted work than the most
gifted conventional surgeon ever dreamed of.
Personal gratification to the surgeon in performing
more ideal work is a factor that cannot be
underestimated in its potential to speed the
61
Shanelec & Tibbetts

Fig. 6.a. Suture practice on latex at X8 magnification. b. Su-

ture practice on latex at X24 magnification. c. Suture prac-
tice on latex at X32 magnification. d. Suture practice on fo-
liage (Anthurium flower) at X32 magnification.
Fig. 7.a. Mucogingival frenum abnormality with slight re-
cession. b. Subepithelial microsurgery to reposition fre-
num and augment attached gingiva with connective tissue
graft. c. Postoperative result at 1 month.

62

Fig. 8. a. Preoperative wide and deep maxillary cuspid re-
cession. b. Subepithelial connective tissue graft microsur-
gically sutures: x4 magnification. c. Same case viewed at
x20 magnification.d. Postoperativeresult after 3 weeks.
acceptance and growth of microsurgery among
periodontists (Fig. 8).
How will a periodontist learn microsurgery?
Today, microsurgical training is incorporated in the
curriculum of most medical surgical residencies. It
even occupies a place in the pre-doctoral medical
curriculum, especially emergency medicine. Some
medical specialties, such as neurosurgery, have
become almost exclusively microsurgical, whereas
others require supplemental residency training to
Future of periodontal microsurgery
Fig. 9. a. Microsutures and microinstruments at X10 mag-
nification. b. Microsutures and microinstruments at X20
magnification.
Fig. 10. Periodontal operatoryequipped for microsurgery
develop the requisite skills. Nevertheless, it is well
established that microsurgery can be taught in
brief, well-organized laboratory workshops (12).
Training in periodontal microsurgery is
becoming available to periodontists. However,
microsurgery training is unlike other continuing
education courses offered. First, the courses must
be practical and not theoretical. Their primary
teaching focus should be on developing the
clinical skills that comprise good microsurgical
63
Shanelec & Tibbetts
technique. A curriculum requires at least two days
of intensive training with direct one-on-one
instruction to guide students’ skills from
introductory to advanced levels. Surgeons learn
best with a scalpel or suture in hand (Fig. 9). This is
how periodontal microsurgery must be taught.
Education through movement concentrates the
mind and raises the neurobiology of learning to
new levels of performance and new possibilities
for achievement. As we progress into the twenty-
first century, such learning methods will come to
occupy an increasingly important role in training
periodontists for microsurgery as it moves into the
mainstream of periodontal therapy (Fig. 10).
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