Minimally Invasive Periodontal Therapy
Minimally Invasive Periodontal Therapy
Visualization for Minimally Invasive Periodontal Therapy: An Overview
Stephen K. Harrel
The increasing popularity of minimally invasive procedures has been driven in part by advancements in technology that have allowed procedures to be performed through smaller access openings and by the reduced morbidity and improved efficacy seen as a result of these technologies. The most critical advancements in technology are in the area of visualization. The key to performing minimally invasive procedures is the ability to adequately see the site and, therefore, the ability to successfully complete the indicated surgical manipulations. With enhanced visualization, outcomes are improved.
Traditional closed subgingival scaling and root planing is the most frequently used approach for treating inflammatory periodontal diseases. This approach allows no direct visualization of the treatment site. Treatment end points are based on the tactile sense of the operator using various instruments. The operator is forced to determine by palpation alone if the root surface has been debrided of calculus and if root roughness has been removed. Because of a lack of a tactical "feel," it is impossible for the operator to determine by palpation if any existing biofilm has been completely removed. The process of determining a clinically ideal end point is complicated by factors such as burnished calculus and various root anomalies that give a less-than-smooth feel to the root. While closed root planing has been shown to routinely improve periodontal health, it has also been shown that the end result is often a root surface with some residual calculus. It was found that root surfaces treated with these traditional methods when subsequently viewed either with the endoscope or the videoscope routinely reveal areas of retained calculus and biofilm. Thus, the lack of visualization in traditional closed approaches frequently results in subsequent periodontal breakdown and frequently leads to further treatment often including surgery.
Traditional periodontal surgery was developed to allow for access and visualization of the surgical site. One of the most commonly performed traditional periodontal surgical procedures is open-flap debridement. This approach allows for visualization of the root surface and periodontal defect. The incisions traditionally used to provide visualization often extend over many teeth and often include areas that have little or no periodontal damage. Elevation of these large flaps frequently leads to post-surgical root exposure, areas of food impaction, and thermal sensitivity as well as esthetic deformities.
Minimally invasive periodontal therapy is designed to access and visualize only the areas that require periodontal treatment using the smallest incision possible. This has been made possible by technologic advances for visualization without the necessity of large incisions and flap elevation. This chapter explores the options currently available for visualization. The advantages and disadvantages of each will be discussed.
Visualization for closed root planing procedures
The very nature of closed root planing demands that visualization of the treatment site uses a visualization technology that can be placed into an intact pocket without a surgical incision. To date, there is a single device, the periodontal endoscope which was developed in the 1990s, that will allow for this approach  ( Figure 2.1 ). This endoscope consists of glass fibers contained within a plastic disposable sheath with a small stainless steel tube, and a sealed sapphire lens. The stainless steel tube is retained in a handheld dental instrument that allows the fibers and lens to be directed into the periodontal pocket without flap elevation. Some of the glass fibers direct light into the subgingival environment. Other gla