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Introduction: Periodontal regeneration of hopeless teeth represents a major concern for clinicians, especially when
these teeth are associated with the esthetic zone.
Case Presentation: The case presented describes a non-incised papillae surgical approach (NIPSA) to improve
regenerative parameters in hopeless teeth. After treatment of a mandibular right canine with severe periodontal bone
loss, clinical attachment loss to the apex, minimal keratinized tissue, and Class III mobility, there were important clinical
improvements with no marginal soft tissue shrinkage and minimal morbidity for the patient.
Conclusion: NIPSA represents a promising minimally invasive technique even in hopeless teeth, facilitating the
treatment of deep intrabony defects associated with high risk of soft tissue collapse and post-surgical soft tissue shrinkage.
Clin Adv Periodontics 2018;8:33–38.
Key Words: Periodontitis; reconstructive surgical procedures; regeneration; surgical flaps; surgical procedures.
34 Clinical Advances in Periodontics, Vol. 8, No. 1, March 2018 Periodontal Regeneration of Hopeless Teeth
C A S E R E P O R T
Case Management
A presurgical professional prophylaxis appointment was
completed 1 to 2 weeks before the surgical procedure,
with ultrasonic and mini-curet instrumenting only the first
2 to 3 mm of the pocket. No conventional scaling and root
planing (SRP) to the bottom of the pocket was done to
preserve any residual fibers attached and to avoid uninten-
tional curettage and prevent any possible shrinkage. The
FIGURE 4 Probing of the mesial bony defect is 11 mm from
canine was stabilized with a fiberglass splint to the lin- the soft tissue margin. There is an apical 4-mm 3-wall defect
gual aspects of the adjacent teeth. Surgery was performed extending coronally as a 1-wall defect. Intact maintenance of
with firm marginal tissues for manipulation, depicting the preoperative gingival architecture.
low or no inflammation (Fig. 1). Postoperative pain and
inflammation were controlled with 600 mg ibuprofen at
the beginning of the surgical procedure. The patient also
received 2 g of amoxicillin 1 hour before surgery. The
surgical area was anesthetized using articaine–epinephrine
1:100,000.
This surgical approach is specifically indicated as a
periodontal reconstructive procedure for interproximal
intrabony defects with the requirement of an extension to
the buccal aspect of the tooth. It is a papillae preservation
technique where the interdental papillae and marginal
tissues surrounding the defect must not be altered. A ×
3 magnifying loupe was used to increase visibility of the
surgical site. FIGURE 5 EMD applied on the defect. The marginal tissues
protect the clot, acting as a dome for the defect.
Only one apical horizontal incision was made on the
buccal mucosa, as far as possible from the interdental
papillae and marginal KT. A clear mapping of the limits
of the defect by bone sounding or CT scan is required
to place the horizontal incision on the cortical bone
and to recognize the defect in a three-dimensional (3D)
reconstruction (Fig. 2).
Mesio-distally, the incision extended enough to allow
correct visualization of the boundaries of the defect and,
with the help of magnification, provided access for treat-
ment through a minimal incision. The soft tissue was
Clinical Outcomes
Primary wound healing of the incision area and excel-
FIGURE 7 One week after surgery. Complete closure of the flap. lent state of the interdental papillae and marginal tissue
was observed 1 week after
surgery (Fig. 7). The patient
reported no pain or discomfort,
to the point that no postoperative
analgesic was needed. The
patient continued to be enrolled
in periodontal maintenance. A
CT scan at 18 months after
surgery showed new bone forma-
tion (Fig. 8), and the clinical
parameters (Fig. 9) reflected
complete resolution of the peri-
odontal defect; the tooth main-
tained positive vitality (Table 1).
At the 18-month maintenance
visit the splint was removed,
showing Class I mobility.
Discussion
The goal of periodontal
regeneration is the complete
resolution of intrabony defects,
with maximum CAL gain and
no alteration of the marginal
soft tissues. Modified MIST
(M-MIST) showed reduced post-
surgical REC of the interdental
FIGURE 8 Post-surgical CT scan at 18 months showing new bone formation. 8a Frontal view. 8b Bucco-
lingual aspect. 8c Horizontal view. 8d 3D reconstruction.
papillae.12 In M-MIST the
incision is performed in the
papilla area. The presence of a
to the root surface were removed carefully with mini- thin papilla at baseline and minimal thickness of KT
curets and power-driven instruments. The granulation would enormously increase the difficulty in the manage-
tissue attached to the base of the papillae was cut with ment of interdental tissues and may promote further REC.
a microblade and removed carefully. The flap design represents a very important parameter
EDTA was applied on the instrumented root surface for in any surgical procedure in which the stability of the
2 minutes, the area was carefully rinsed with saline, and marginal tissue and good revascularization during early
enamel matrix derivative (EMD)‡ was applied on the root, wound healing13 are essential to promote stable wound
which was kept as dry as possible (Fig. 5). The incision closure. Moreover, the flap design plays a very important
line was closed by 6/0 bioabsorbable sutures. Horizontal role in the success of the therapy, creating and maintaining
mattress sutures, placed 2 mm away from the borders, a stable space for the clot.
were used as the first line of closure, promoting connective NIPSA represents a new surgical approach for the man-
agement of soft tissues in periodontal surgery, maintaining
‡ Emdogain, Institute Straumann, Basel, Switzerland. the papillae and marginal tissues intact. The maintenance
36 Clinical Advances in Periodontics, Vol. 8, No. 1, March 2018 Periodontal Regeneration of Hopeless Teeth
C A S E R E P O R T
Clinical
Parameters Baseline 18 Months
PD (mm) 10 10 10 4 2 2 2 2
CAL (mm) 13 13 13 7 5 5 5 5
REC (mm) 3 3
Papilla mesial Papilla distal Papilla mesial Papilla distal
PH (mm) 2 2 2 2
KT (mm) 2 2
Vitality + +
Mobility Class III Class I
of the pocket were treated. At surgery with an apical and limited post-surgical tissue shrinkage with minimal
access, the defect was treated without altering ≈3 mm morbidity and ideal early wound healing, even in the
of the marginal tissue, debriding the granulation tissue case of a hopeless tooth. In spite of the anatomy of the
below and the rest of the epithelial cells of the pocket. non-containing defect (1-wall defect), NIPSA promoted
This approach looks at inhibiting the apical migration of a favorable environment creating and maintaining the
epithelial cells along the root surface in the early healing clot space, without the use of graft or barrier membrane,
period by the use of EMD as a barrier. resulting in the resolution of the defect with no alteration
The results of the present case report indicate that the of the papilla and marginal tissues.
use of NIPSA with EMD results in substantial CAL gain
Summary
Why is this case new This case report presents a new technique for periodontal regeneration,
information? with optimal results in a hopeless tooth.
What are the keys to successful Intrabony defect with absence of the buccal wall is a prerequisite for
management of this case? access and correct debridement of the defect.
The technique described is designed to preserve the papilla and
marginal soft tissues, preventing tissue collapse.
A complete diagnosis of the defect morphology is required; a CT scan is
a very useful diagnostic test.
What are the primary limitations The lingual aspect of the root had to be without direct vision.
to success in this case? Experience with periodontal regeneration is required to perform this
technique.
Acknowledgment
The authors report no conflicts of interest related to this
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