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Minimally invasive periodontal regeneration with the buccal approach: a systematic review and meta-analysis of clinical studies

Evidence-Based Dentistry volume 25, page 54 (2024)Cite this article

Subjects

Abstract

Objective

The aim of this study was to investigate clinical periodontal parameters after treatment using the Minimally Invasive Surgical Technique (MIST), Modified Minimally Invasive Surgical Technique (M-MIST), and/or any technique for papilla preservation, such as Entire Papilla Preservation (EPP), modified-papilla preservation technique (M-PPT), or simplified-papilla preservation technique (SPPT).

Methods

The focus question was “For patients with periodontal intrabony defects (P), what is the best minimally invasive regenerative approach (I), comparing MIST, M-MIST, and papilla preservation techniques’ outcomes (C) to improve PD, CAL, GR, and periodontal stability (O)?” An online search was conducted on PubMed, Cochrane Library, and Embase. Only randomized clinical trials and case series with a minimum of 10 enrolled patients were included. The risk of bias was evaluated using the Critical Appraisal tools in JBI Systematic Reviews. The meta-analysis compared the data obtained for the periodontal parameters analyzed, and the heterogeneity was verified.

Results

After the screening, nine articles were included. Seven studies applied MIST and its modifications; two used M-PPT, one SPPT, and one approached EPP. A general statistically significant PD reduction and CAL gain were noted between the groups, comparing baseline and follow-up for all articles, independently of the technique or materials used. Also, all studies showed a non-significant increase in the gingival recession. Four studies had a low risk of bias, four had a moderate risk, and only 1 had a high risk. Moderate heterogeneity was found in one analysis for CAL (65.73%); moderate and substantial heterogeneity was found in the PD results (71.91% and 89.19%); and no heterogeneity was found within all analyses for gingival recession (0%).

Conclusion

MIST, M-MIST, and papilla preservation techniques demonstrated their potential and efficacy to improve periodontal conditions of sites with intrabony defects with minimal morbidity.

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Fig. 1
Fig. 2: Clinical Attachment Loss (left) compared the baseline and outcome averages of the studies included per group; a general reduction can be observed, mainly when MIST and M-MIST are used.
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Data availability

All data is available within the manuscript.

References

  1. Lang NP. Focus on intrabony defects—conservative therapy. Periodontology. 2000;22:51–58.

    Article  CAS  Google Scholar 

  2. Farina R, Simonelli A, Rizzi A, Pramstraller M, Cucchi A, Trombelli L. Early postoperative healing following buccal single flap approach to access intraosseous periodontal defects. Clin Oral Investig. 2013;17:1573–83.

    Article  PubMed  Google Scholar 

  3. Harrel SK, Rees TD. Granulation tissue removal in routine and minimally invasive surgical procedures. Comp Cont Educ Dent. 1995;16:960–7.

    CAS  Google Scholar 

  4. Cortellini P, Tonetti MS. Improved wound stability with a modified minimally invasive surgical technique in the regenerative treatment of isolated interdental intrabony defects. J Clin Periodontol. 2009;36:157–63.

    Article  PubMed  Google Scholar 

  5. Aslan S, Buduneli N, Cortellini P. Reconstructive surgical treatment of isolated deep intrabony defects with guided tissue regeneration using entire papilla preservation technique: A prospective case series. J Periodontol. 2020;92:488–95.

    Article  PubMed  Google Scholar 

  6. Cortellini P, Tonetti MS. A minimally invasive surgical technique with an enamel matrix derivative in the regenerative treatment of intra-bony defects: a novel approach to limit morbidity. J Clin Periodontol. 2007;34:87–93. https://doi.org/10.1111/j.1600-051X.2006.01020.x

    Article  PubMed  Google Scholar 

  7. Rasperini G, Ricci G, Silvestri M. Surgical technique for treatment of infrabony defects with enamel matrix derivative (Emdogain): 3 case reports. Int J Periodontics Restorative Dent. 1999;19:578–87.

    CAS  PubMed  Google Scholar 

  8. Maia VTG, Kahn S, Souza AB, Fernandes GVO. Deepithelialized connective tissue graft and the remaining epithelial content after harvesting by the harris technique: a histological and morphometrical case series. Clin Adv Periodontics. 2021;11:150–4. https://doi.org/10.1002/cap.10151

    Article  PubMed  Google Scholar 

  9. Cortellini P, Tonetti MS. Microsurgical approach to periodontal regeneration. Initial evaluation in a case cohort. J Periodontol. 2001;72:559–69.

    Article  CAS  PubMed  Google Scholar 

  10. Cortellini P, Tonetti MS. Clinical performance of a regenerative strategy for intrabony defects. Scientific evidence and clinical experience. J Periodontol. 2005;76:341–50.

    Article  PubMed  Google Scholar 

  11. Kahn S, Araújo E, Tajra I, Dias AT, Souza AB, Chambrone L, et al. Histologic and histomorphometric analysis of connective tissue grafts harvested by the parallel incision method: a pilot randomized controlled trial comparing macro- and microsurgical approaches. Quint Int. 2021;52:772–8.

    Google Scholar 

  12. Kahn S, Oliveira LZ, Dias AT, Fernandes GVO. Clinical evaluation and biological understanding of the early step-by-step healing after periodontal microsurgery: A case report with PES analysis comparing initial and 31-day result. J Adv Periodontol Implant Dent. 2022;14:141–5. https://doi.org/10.34172/japid.2022.016

    Article  PubMed  PubMed Central  Google Scholar 

  13. Cortellini P, Pini Prato G, Tonetti MS. The modified papilla preservation technique. A new surgical approach for interproximal regenerative procedures. J Periodontol. 1995;66:261–6.

    Article  CAS  PubMed  Google Scholar 

  14. Cortellini P, Pini Prato G, Tonetti MS. The simplified papilla preservation flap. A novel surgical approach for the management of soft tissues in regenerative procedures. Int J Periodontics Restorative Dent. 1999;19:589–99.

    CAS  PubMed  Google Scholar 

  15. Aslan S, Buduneli N, Cortellini P. Entire papilla preservation technique in the regenerative treatment of deep intrabony defects: 1-year results. J Clin Periodontol. 2017;44:926–32.

    Article  CAS  PubMed  Google Scholar 

  16. Tibbetts LS, Shanelec D. Periodontal microsurgery. Dent Clin North Am. 1998;42:339–59.

    Article  CAS  PubMed  Google Scholar 

  17. Takei HH, Han TJ, Carranza FA Jr, Kenney EB, Lekovic V. Flap technique for periodontal bone implants. Papilla preservation technique. J Periodontol. 1985;56:204–10. https://doi.org/10.1902/jop.1985.56.4.204

    Article  CAS  PubMed  Google Scholar 

  18. Aslan S, Nurcan B, Cortellini P. Clinical outcomes of the entire papilla preservation technique with and without biomaterials in the treatment of isolated intrabony defects: A randomized controlled clinical trial. J Clin Periodontol. 2020;47:470–8.

    Article  CAS  PubMed  Google Scholar 

  19. Ochôa C, Castro F, Bulhosa JF, Manso C, Fernandes JCH, Fernandes GVO. Influence of the Probiotic L. reuteri on periodontal clinical parameters after nonsurgical treatment: a systematic review. Microorganisms. 2023;11:1449 https://doi.org/10.3390/microorganisms11061449

    Article  PubMed  PubMed Central  Google Scholar 

  20. Schincaglia GP, Hebert E, Farina R, Simonelli A, Trombelli L. Single versus double flap approach in periodontal regenerative treatment. J Clin Periodontol. 2015;42:557–66. https://doi.org/10.1111/jcpe.12409

    Article  CAS  PubMed  Google Scholar 

  21. Elsalam MGA, Elsamad AA, Elbarbary AM, Abuldahab OM. Evaluation of gain in clinical attachment and bone levels after treatment of patients with intra-bony defects by minimally invasive surgical technique versus open flap debridement: a randomized controlled clinical trial. Ain Shams Dental J. 2020;13:239–46.

    Google Scholar 

  22. Aimetti M, Ferrarotti F, Mariani GM, Romano F. A novel flapless approach versus minimally invasive surgery in periodontal regeneration with enamel matrix derivative proteins: a 24-month randomized controlled clinical trial. Clin Oral Invest. 2017;21:327–37. https://doi.org/10.1007/s00784-016-1795-2

    Article  Google Scholar 

  23. Cortellini P, Buti J, Pini Prato G, Tonetti MS. Periodontal regeneration compared with access flap surgery in human intra-bony defects 20-year follow-up of a randomized clinical trial: tooth retention, periodontitis recurrence and costs. J Clin Periodontol. 2017;44:58–66. https://doi.org/10.1111/jcpe.12638

    Article  PubMed  Google Scholar 

  24. Windisch P, Iorio-Siciliano V, Palkovics D, Ramaglia L, Blasi A, Sculean A. The role of surgical flap design (minimally invasive flap vs. extended flap with papilla preservation) on the healing of intrabony defects treated with an enamel matrix derivative: a 12-month two-center randomized controlled clinical trial. Clin Oral Investig. 2022;26:1811–21.

    Article  PubMed  Google Scholar 

  25. Liu B, Ouyang X, Kang J, Zhou S, Suo C, Xu L, et al. Efficacy of periodontal minimally invasive surgery with and without regenerative materials for treatment of intrabony defect: a randomized clinical trial. Clin Oral Investig. 2022;26:1613–23.

    Article  PubMed  Google Scholar 

  26. Ghezzi C, Ferrantino L, Bernardini L, Lencioni M, Masiero S. Minimally invasive surgical technique in periodontal regeneration: a randomized controlled clinical trial pilot study. Int J Periodontics Restorative Dent. 2016;36:475–82. https://doi.org/10.11607/prd.2550

    Article  PubMed  Google Scholar 

  27. Cosyn J, Cleymaet R, Hanselaer L, De Bruyn H. Regenerative periodontal therapy of infrabony defects using minimally invasive surgery and a collagen-enriched bovine-derived xenograft: a 1-year prospective study on clinical and aesthetic outcome. J Clin Periodontol. 2012;39:979–86. https://doi.org/10.1111/j.1600-051X.2012.01924.x

    Article  PubMed  Google Scholar 

  28. Harrel SK, Wilson TH Jr, Nunn ME. Prospective assessment of the use of enamel matrix proteins with minimally invasive surgery. J Periodontol. 2005;76:380–4. https://doi.org/10.1902/jop.2005.76.3.380

    Article  PubMed  Google Scholar 

  29. Riberio FV, Casarin RC, Junior FH, Sallum EA, Casati MZ. The role of enamel matrix proteins in minimally invasive surgery in treating intrabony defects in single-rooted teeth: a randomized clinical trial. J Periodontol. 2011;82:522–32. https://doi.org/10.1902/jop.2010.100454

    Article  Google Scholar 

  30. Cortellini P, Tonetti MS. Clinical concepts for regenerative therapy in intrabony defects. Periodontol 2000. 2015;68:202–307. https://doi.org/10.1111/prd12048

    Article  Google Scholar 

  31. Tonetti MS, Lang NP, Cortellini P, Suvan JE, Adriaens P, Dubravec D, et al. Enamel matrix proteins in the regenerative therapy of deep intrabony defects. A multicenter randomized controlled clinical trial. J Clin Periodontol. 2002;29:317–25. https://doi.org/10.1034/j.1600-051x.2002.290407.x

    Article  CAS  PubMed  Google Scholar 

  32. Siciliano VI, Andreuccetti G, Siciliano AI, Blasi A, Sculean T, Salvi GE. Clinical outcomes after treatment of non-contained intrabony defects with enamel matrix derivative or guided tissue regeneration: a 12-months randomized controlled clinical trial. J Periodontol. 2011;82:62–71. https://doi.org/10.1902/jop.2010.100144

    Article  PubMed  Google Scholar 

  33. Cortellini P, Tometti MS. Clinical and radiographic outcomes of modified minimally invasive surgical technique with and without regenerative materials: a randomized-controlled trial in intrabony defects. J Clin Periodontol. 2011;38:565–73. https://doi.org/10.1111/j.1600-051x2011.01705.x

    Article  Google Scholar 

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Author information

Authors and Affiliations

  1. Masters’ student, FCS, Universidade Fernando Pessoa, 4249-004, Porto, Portugal

    Elisa Pasqualini

  2. FP-I3ID, FCS, Universidade Fernando Pessoa, 4249-004, Porto, Portugal

    Filipe Castro

  3. Periodontics and Oral Medicine Department, University of Michigan School of Dentistry, Ann Arbor, MI, USA

    Denise Curado, Muhammad H. Saleh, Juliana Campos Hasse Fernandes & Gustavo Vicentis Oliveira Fernandes

  4. Private practice, Rio de Janeiro, Brazil

    Ana Martelete

  5. Department of Prosthodontics, Faculty of Stomatology, Yerevan State Medical University after Mkhitar Heratsi, Str. Koryun 2, Yerevan, 0025, Armenia

    Artak Heboyan

  6. A.T. Still University - Missouri School of Dentistry & Oral Health, St. Louis, MO, USA

    Gustavo Vicentis Oliveira Fernandes

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Contributions

EP, FC, DC, AM, AH, MHS, JCHF, and GVOF were responsible for the conceptualization and design of the project. EP, FC, and GVOF were responsible for the data collection. EP, FC, DC, AM, AH, MHS, JCHF, and GVOF were responsible for the analysis and interpretation of data. EP, FC, DC, AM, AH, MHS, JCHF, and GVOF participated in the investigation, data curation, and drafting of the manuscript and contributed to revising the manuscript. All authors have read and agreed to the published version of the manuscript.

Corresponding author

Correspondence to Gustavo Vicentis Oliveira Fernandes.

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Pasqualini, E., Castro, F., Curado, D. et al. Minimally invasive periodontal regeneration with the buccal approach: a systematic review and meta-analysis of clinical studies. Evid Based Dent 25, 54 (2024). https://doi.org/10.1038/s41432-023-00964-7

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