CASE REPORT

A New Papilla Preservation Technique for Periodontal Regeneration

of Severely Compromised Teeth
Jose A. Moreno Rodríguez∗ and Raúl G. Caffesse†

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.

Background apy represents a great challenge in teeth with hopeless

prognosis.3
Periodontal regenerative therapy aims at the recovery
Patients diagnosed with periodontitis are prone to be
of lost periodontal tissues due to disease. In the 1970s,
associated with a higher incidence of implant biologic
Hiatt et al.1 demonstrated the possibility of achieving new
complications and lower implant survival rates than peri-
attachment with new bone and new cementum formation.
odontally healthy patients.4 Not only peri-implantits is a
In the 1980s, Nyman et al.2 demonstrated the possibility
problem, but also the maintenance and treatment of other
of achieving new attachment in teeth with periodontal
biologic complications, such as buccal tissue dehiscence,
intrabony defects, with the application of what is known
increasing its complexity and morbidity for patients.5
today as guided tissue regeneration.
With the introduction of new biomaterials, minimally
In cases of periodontal loss, periodontal regenerative
invasive surgical techniques (MISTs) have been proposed
therapy must be the first treatment of choice, ahead of
for the regenerative treatment of deep intrabony defects,
dental implant rehabilitation. However, regenerative ther-
and their effectiveness has increased over time with the use
∗ Private of papilla preservation approaches.6 – 9 However, regener-
practice, Murcia, Spain
ative treatment is often associated with gingival margin
† Department of Periodontology, Complutense University of Madrid, and papilla recessions (RECs). The presence of reduced
Madrid, Spain keratinized tissue (KT), thin papillae, and/or thin biotype
represents risk factors during regenerative therapy for tis-
Received May 9, 2017; accepted July 5, 2017
sue manipulation and post-surgical tissue shrinkage with
doi: 10.1902/cap.2017.170033
unesthetic results.10

Clinical Advances in Periodontics, Vol. 8, No. 1, March 2018 33

C A S E R E P O R T

gains. However, the prognosis is much different in cases

with non-contained defects (1-wall defects) with deep PD,
Class II and Class III mobility, and other unfavorable
baseline situations.10 They represent a great challenge for
regeneration,3 with the risk of soft tissue collapse into
the defect, which would preclude the space maintenance
required for clot stabilization. Nonetheless, in these cases
the objective of treatment must be the same, that is, to
promote regeneration with minimal soft tissue shrinkage
and morbidity for the patient.
The case report presented in this article describes a
surgical approach to improve regenerative parameters in
a hopeless tooth with a deep intrabony defect with non-
containing topography affecting its buccal, lingual, mesial,
FIGURE 1 Presurgical probing. Paramarginal tissue shows mild and distal aspects. The basic principle of the technique is
chronic inflammation; however, the marginal tissue shows a the placement of only one buccal horizontal or oblique
fibrotic aspect ideal for surgery.
incision in the mucosa, as apically as possible from the
periodontal defect and the marginal tissues, and the rais-
Minimally invasive non-surgical techniques (MINSTs) ing of a mucoperiosteal flap coronally, which permits
were also successfully used for the treatment of intrabony apical access to the defect but leaves the marginal tissues
defects with the help of a microscope in cases with deep intact, acting as a “dome” for the protection of the clot.
pockets (6.35 ± 0.92 mm).11
In studies7,9,11 with MISTs or MINSTs, greater baseline
narrow defects, with deeper probing depths (PDs), and Clinical Presentation
2- or 3-wall defects (contained defects) may promote a A 40-year-old female former smoker presented to a pri-
more favorable situation for improvements in attachment vate practice in Murcia, Spain in 2012 with diagnosis of
acute periodontitis; after years of
treatment and maintenance, the
patient was stabilized with full-
mouth plaque and bleeding
scores of <10%. Under these
conditions, regenerative therapy
was suggested in residual deep
pockets where the MINST app-
roach did not resolve bleeding
on probing after years of
maintenance. The mandibular
right canine showed clinical
attachment level (CAL) of 13 mm
and PD of 10 mm on the buccal,
mesial, and lingual aspects; CAL
of 10 mm and PD of 7 mm
on the distal aspect; REC of 3
mm with loss of papilla height
(PH = 2 mm); reduced KT of
2 mm; and Class III mobility,
but with positive vitality
(Fig. 1). Computed tomography
(CT) scan revealed deep and
wide bone loss to the apex on
the buccal, mesial, and lingual
aspects (Fig. 2).
It was decided to use a non-
incised papillae surgical app-
roach (NIPSA),11 a novel
modified papillae preservation
FIGURE 2 CT scan: severe bone loss to the apex on the mesial, lingual, and vestibular aspects. 2a Frontal technique, because of the lack
view. 2b Bucco-lingual aspect. 2c Horizontal view. 2d 3D reconstruction. of KT, the risk of soft tissue

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

collapse into the defect, and post-surgical tissue shrinkage.

Written informed consent for periodontal surgery was
obtained from the patient. All clinical procedures were
performed in full accordance with the Declaration of
Helsinki and the Good Clinical Practice Guidelines

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

FIGURE 6 Double layer of suturing, sealing the incision area.

reflected apico-coronally by a full-thickness flap, exposing

FIGURE 3 Horizontal apical incision. Soft tissue reflected
apico-coronally shows granulation tissue filling the bony defect.
The marginal tissue remains unaltered.
the coronal limit of the intrabony component of the defect
(Fig. 3). The marginal tissue was kept unaltered. The
intrabony defect had a containing part – a 3-wall defect
at the bottom – that was extended coronally by a non-
containing part – a 1-wall defect (the proximal wall of the
adjacent tooth was maintained) (Fig. 4).
SRP was performed to maintain the attached fibers to
the cementum. The 2- to 3-mm root at the level of the
unaltered coronal marginal tissues was instrumented 1
week prior to SRP. Soft tissues that were not attached

Rodríguez, Caffesse Clinical Advances in Periodontics, Vol. 8, No. 1, March 2018 35

C A S E R E P O R T

tissue contact between both edges of the incision; single

interrupted sutures were placed as the second line of
closure (Fig. 6).
The patient was asked to refrain from using mechanical
oral hygiene measures for 4 weeks after surgery. During
this period, the patient was advised to rinse with 0.12%
chlorhexidine digluconate mouthrinse twice daily for
1 minute. Sutures were removed 1 week after surgery.

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

With techniques that involve the papillae and sulcus area

FIGURE 9 Healthy clinical tissues 18 months after surgery
(PD = 2 mm).
of the preoperative gingival architecture, preserving the
suprabony soft tissue attached to the lingual aspect and
adjacent teeth, is a great advantage; it means a dome
to protect the clot in the periodontal defect is estab-
lished, with better preservation of blood supply to the
marginal tissues. Suturing is facilitated, optimizing the
primary intention of closure of the wound and avoiding
contraction of the papillae. The dome helps to preserve the
stability of the clot even without the addition of grafting
materials or barrier membrane, in spite of the morphology
of the defect, which would not have prevented the collapse
of the marginal soft tissue. Other papillae preservation
techniques require the help of grafting materials on barrier
membranes to minimize collapse in severe periodontal
defects.
Complete closure of the flap during early wound healing
is a prerequisite for the success of regenerative therapy.12
with the incision, the perfect closure of the wound repre-
sents a great challenge on many occasions, such as when
the papillae are very thin and narrow or when adapting
the margin of a flap to a concave interproximal root
surface (Fig. 2d) or to a prominent convex buccal root in
the presence of minimal keratinized gingiva, where a soft
and thin tissue cannot guarantee stable adaptation. Not
dissecting the marginal tissue maintaining the papillae
intact assures the best closure in that critical area over
the periodontal defect. A unique incision apically from the
marginal tissues and bony crest has a number of advan-
tages. It is placed on healthy bone far away from the defect
and in elastic mucosa, facilitating the closure of the wound
by approaching the borders of the tissue at the line of inci-
sion and putting in intimate contact two connective tissue
surfaces by the horizontal mattress sutures, thus preclud-
ing early healing dehiscence affecting the marginal tissues.
NIPSA is indicated in cases where the buccal wall is
involved in the defect, allowing access to treatment. In
the present case reported, the advanced periodontal loss
required a thorough diagnosis. A CT scan provided the
morphology of the defect with precision. The absence of
a large portion of the buccal wall facilitated visibility and
instrumentation. However, the lingual aspect of the root
had to be without direct vision, as a routine conventional
SRP. NIPSA can also be applied to buccal molar furca-
tions, although further studies are needed to evaluate the
effect of various anatomic differences, such as the large
avascular root surface present in a furcation defect that
could result in the revascularization being compromised
with the type of apical incision used here.
In the present case, EMD was applied to favor regen-
eration in a hopeless situation; it may have played a very
important role. Human histology has demonstrated that
the application of EMD promotes the formation of new
cementum, new periodontal ligament, and new bone.14
It has been suggested that EMD may also provide
barrier function, inhibiting epithelial cell migration.15
With NIPSA, ≈1 week before surgery the first millimeters

TABLE 1 Clinical Parameters at Baseline and 18 Months After Surgery

Clinical
Parameters Baseline 18 Months

Mesial Buccal Lingual Distal Mesial Buccal Lingual Distal

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

Rodríguez, Caffesse Clinical Advances in Periodontics, Vol. 8, No. 1, March 2018 37

C A S E R E P O R T

of the pocket were treated. At surgery with an apical
access, the defect was treated without altering ≈3 mm
of the marginal tissue, debriding the granulation tissue
below and the rest of the epithelial cells of the pocket.
This approach looks at inhibiting the apical migration of
epithelial cells along the root surface in the early healing
period by the use of EMD as a barrier.
The results of the present case report indicate that the
use of NIPSA with EMD results in substantial CAL gain
and limited post-surgical tissue shrinkage with minimal
morbidity and ideal early wound healing, even in the
case of a hopeless tooth. In spite of the anatomy of the
non-containing defect (1-wall defect), NIPSA promoted
a favorable environment creating and maintaining the
clot space, without the use of graft or barrier membrane,
resulting in the resolution of the defect with no alteration
of the papilla and marginal tissues.

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
case report.
CORRESPONDENCE
Dr. Jose A. Moreno Rodríguez, C/Ctra de Granada n◦ 46, Caravaca de la
Cruz, 30400 Murcia, Spain. E-mail: joseantonio171087@gmail.com
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38 Clinical Advances in Periodontics, Vol. 8, No. 1, March 2018 Periodontal Regeneration of Hopeless Teeth