Hindawi

International Journal of Dentistry

Volume 2021, Article ID 2810264, 12 pages
https://doi.org/10.1155/2021/2810264

Review Article
Minimally Invasive Periodontology: A Treatment Philosophy and
Suggested Approach

Ethan Ng ,1 John Rong Hao Tay ,1 and Marianne Meng Ann Ong 1,2

1
Department of Restorative Dentistry, National Dental Centre Singapore, Singapore 168938, Singapore
2
Oral Health Academic Clinical Programme, Duke-NUS Medical School, Singapore 169857, Singapore

Correspondence should be addressed to Ethan Ng; [email protected]

Received 11 May 2021; Revised 9 June 2021; Accepted 15 June 2021; Published 23 June 2021

Academic Editor: Gaetano Isola

Copyright © 2021 Ethan Ng et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Severe periodontitis is a highly prevalent dental disease. With the advent of implant dentistry, teeth are often extracted and
replaced. Periodontal surgery, where indicated, could also result in increased trauma to the patient. This literature review discusses
different treatment modalities for periodontitis and proposes a treatment approach emphasizing maximum preservation of teeth
while minimizing morbidity to the patient. Scientific articles were retrieved from the MEDLINE/PubMed database up to January
2021 to identify appropriate articles that addressed the objectives of this review. This was supplemented with hand searching using
reference lists from relevant articles. As tooth prognostication does not have a high predictive value, a more conservative approach
in extracting teeth should be abided by. This may involve repeated rounds of nonsurgical periodontal therapy, and adjuncts such
as locally delivered statin gels and subantimicrobial-dose doxycycline appear to be effective. Periodontal surgery should not be
carried out at an early phase in therapy as improvements in nonsurgical therapy may be observed up to 12 months from initial
treatment. Periodontal surgery, where indicated, should also be minimally invasive, with periodontal regeneration being shown to
be effective over 20 years of follow-up. Biomarkers provide an opportunity for early detection of disease activity and personalised
treatment. Quality of life is proposed as an alternative end point to the traditional biomedical paradigm focused on the disease
state and clinical outcomes. In summary, minimally invasive therapy aims to preserve health and function of the natural dentition,
thus improving the quality of life for patients with periodontitis.

1. Introduction cytokines as biomarkers of periodontitis has utility in per-

sonalised dentistry, especially for the identification of
Periodontitis is a multifactorial and bidirectional inflam- higher-risk patients or nonresponders and to determine
matory disease initiated by the accumulation of microbial disease activity and progression [5].
deposits; nonresolving inflammation and individual sus- With a prevalence of 35% and 11.2%, respectively, un-
ceptibility likewise lead to an overgrowth of periodontal treated dental caries and severe periodontitis are two of the
pathobionts which also play a role in the progression of most common dental diseases [6, 7]. While their aetiologies
periodontitis [1]. Dysbiosis drives destructive inflammation may differ, both conditions involve establishing a dysbiotic
and perpetuates the disease, and inflammatory byproducts polymicrobial community influenced by host factors and
provide nutrients which selectively favour pathobionts and inflammation, whose activities converge to initiate the
worsen the extent of dysbiosis [2]. These factors codevelop in disease [8]. Both conditions may also result in tooth loss,
a reciprocally reinforced way, leading to a disease state in the which is associated with an impaired oral health-related
susceptible individual [3]. Since tissue damage may be at- quality of life [9]. Thus, the prevention and control of caries
tributed to the host inflammatory response, cytokines and periodontitis should be an aim of every dentist. The
represent an intermediate mechanism between bacteria and concept of minimally invasive dentistry is based on tissue
host-mediated tissue destruction [4]. The use of salivary preservation; preferably by prevention and early
2 International Journal of Dentistry

intervention and then by minimizing tissue loss should

intervention be required [10]? It is an evolving treatment Minimize tooth loss
Conservative extraction, dynamic
philosophy in healthcare based on scientific advances and a prognostication, periodontal
regeneration Minimize surgery
more recent focus on patient-reported outcome measures. In Antimicrobial adjuncts and host modulators,
cariology, this has taken the form of early diagnosis, extended reevaluations, minimal invasive
nonsurgical therapy, long-term nonsurgical
remineralization of early lesions, and minimally invasive therapy
cavity preparation techniques [11]. In periodontology, this
concept has focused mainly on surgical techniques that
minimize surgical trauma, thus optimizing wound healing
and reducing patient morbidity [12]. Therefore, this litera-
ture review aims to discuss periodontitis and different Minimize relapse
treatment modalities, with the purpose of integrating these Shared treatment goals,
facilitate compliance, early
into a holistic treatment approach which includes a patient’s detection, quality of life as
quality of life as an endpoint (Figure 1). The effectiveness of an endpoint

this approach is discussed in terms of clinical performance Figure 1: The minimally invasive approach to periodontology
and patient perception. involves three interlinked goals. This aims to minimize tooth loss at
the initial stage and minimize surgery by considering the use of
2. Materials and Methods adjuncts and appropriate evaluation periods. If indicated, regen-
erative surgery with a minimally invasive approach may improve
A literature search was conducted in MEDLINE/PubMed up attachment levels. Minimizing relapse will in turn minimize tooth
to January 2021 to identify appropriate articles for this re- loss and improve the quality of life.
view. A variety of MeSH terms and keywords were employed
in keyword/title/abstract searches, including minimally; prognosis is influenced not only by clinical and radiographic
invasive; minimally invasive surgical procedures; minimally findings but also by the control of modifiable behavioural
invasive non-surgical procedures; periodontics; periodon- risk factors and quality of received treatment [15, 16].
tology; periodontal disease; prognostication; tooth extrac- Furthermore, the clinician that assigns the prognosis and
tion; tooth loss; periodontal regeneration; non-surgical, performs the corresponding treatment dictates the outcome
adjunctive therapy; host modulators; anti-infective agents; of the tooth [17]. In a study of Norwegian dentists, a low
biomarkers; periodontal reviews; and periodontal mainte- forceps level (threshold for extraction) resulted in the re-
nance. The definition for a minimally invasive procedure was moval of 60% teeth with ≤50% periodontal support [18].
“any intervention described as minimally invasive.” Articles Some clinical guidelines have proposed that teeth with bone
were screened by title, abstract, and full text for relevance. loss >65% have a poor long-term survival, adding to the
Full-text examination was also carried out for studies with decision for extraction [19, 20]. However, the assignment of
insufficient information from the titles or abstracts to make a prognosis is complicated by a wide diversity of different
definitive decision. Related articles published in English, possible cases which a tooth prognostication system may not
reviews, meta-analyses, and clinical studies in humans were adequately address. The decision to extract teeth should also
included. Case reports, implant-associated surgeries (e.g., not be based on mobility alone. Since the predictive power of
sinus lift surgery, socket preservation, or bone grafting), soft a tooth with a prognosis other than “good” is approximately
tissue or other restorative dentistry procedures, and animal 50% [21], a more conservative approach in extracting teeth
and in vitro studies were excluded. The electronic search was ought to be followed. In support of this, long-term studies
supplemented by cross-checking the bibliographies from have demonstrated the retention of teeth with even a
identified articles. questionable prognosis and advanced furcation involvement
[22–24].
3. Minimizing Tooth Loss
Periodontitis is a major cause of tooth loss among adults; the
3.2. Periodontal Regeneration. Periodontal regeneration
downstream sequelae include loss of self-esteem, quality of
may be defined as “the restoration of lost or diminished
life, and masticatory dysfunction which may compromise
periodontal tissues, including the cementum, periodontal
nutrition and general health [13]. The 2017 World Work-
ligament, and alveolar bone [25]. If successful, it may in-
shop classification considers the number of teeth lost due to
crease periodontal support and remains the only modality
periodontitis as a stage defining the level of severity, with ≥5
that may result in regression of a periodontal stage [26].
teeth possibly leading to the need for complex rehabilitation
Recently, a systematic review reported that periodontal
[14]. Inherent in the process of tooth loss is the assignment
regeneration of intrabony defects resulted in improved at-
of tooth prognosis, which has traditionally been interpreted
tachment levels and a higher rate of tooth survival over a
as the probability of tooth mortality.
period of up to 20 years [27]. Furthermore, the treatment of
intrabony defects with guided tissue regeneration or with
3.1. Predictive Value of Tooth Prognostication. Various biomaterials such as enamel matrix derivative performs
classification systems exist, but it is unclear if any system is better than open flap debridement [28], and these results are
superior to the other. What is clear, however, is that tooth maintained in the long term, even in teeth with furcation
International Journal of Dentistry 3

involvement [29, 30]. Minimally invasive approaches to further elucidate its promising role in minimally invasive
periodontal regeneration have also shown to be effective periodontology [46–48].
over the long term and will be discussed later [31, 32]. Thus,
periodontal regeneration plays an important role in im-
4.2. Extended Reevaluations or Surgery? The efficacy of single
proving the prognosis of a tooth and should be attempted
or repeated rounds of debridement in improving periodontal
with a minimally invasive surgical approach when indicated.
status has been debated in the literature. In a study involving
severely advanced periodontitis patients, Badersten et al.
4. Minimizing the Need for Surgery observed that a single episode of instrumentation was effective
in treating deep periodontal pockets, compared to repeated
The presence of residual pockets ≥5 mm and a full-mouth instrumentation performed three times at intervals of two to
bleeding score >30% after nonsurgical therapy represents a four months [49]. Similarly, another study by Anderson et al.
risk factor for disease progression and tooth loss and stated that multiple episodes of instrumentation are inef-
therefore may be regarded as an incomplete periodontal fective, although in this study, the interval for additional
treatment outcome [33–35]. Persistent pockets are com- instrumentation was 24 hours apart [50]. The authors con-
monly perceived as requiring “additional therapy,” usually cluded that if calculus was not removed after one episode of
following a surgical course. A major advantage of surgical debridement, repeated instrumentation was unlikely to
therapy is visual access, and clinicians often fail to com- change that. However, more recent evidence from several
pletely debride roots of plaque and calculus, especially in the other studies supports clinically significant further reductions
presence of deep pocketing [36]. after the initial debridement, and they were more pronounced
An important prerequisite prior to any periodontal sur- for moderate and deep pockets [51–53].
gery is the optimization of patient plaque control. Successful Thus, it should be noted that the results of classic studies
outcomes are obtained in patients with good plaque control, such as Badersten et al. and Anderson et al. may not be
whereas periodontal surgery in plaque-infected dentitions generalized. Indeed, a single episode of scaling often does
results in disease recurrence and significant loss of further not result in complete removal of subgingival calculus, with
attachment [37, 38]. In addition, the maintenance of a high deeper pockets associated with less complete calculus re-
standard of oral hygiene is strongly associated with a good moval [54]. The quality of instrumentation is also dependent
regenerative outcome [39, 40]. The use of appropriate in- on the clinician skill and time allocated for the procedure.
terdental cleaning aids, antimicrobial adjuncts, and sessions Hence, treated areas should be reevaluated at an appropriate
of repeated instrumentation with oral hygiene reinforcement time after initial inflammation subsides, and reinstru-
may also possibly result in further probing pocket depth mentation was performed before considering periodontal
reductions in the nonsurgical phase [41], obviating the need surgery. Notably, it takes time for the periodontium to
for surgical therapy. remodel after a single round of nonsurgical periodontal
therapy. The traditional reevaluation of therapy at 8–12
weeks may mask the real potential of nonsurgical treatment
4.1. Use of Antimicrobial Adjuncts and Host Modulators.
as healing and maturation of the periodontium occur over
Periodontitis follows a polymicrobial model of community
the next 9–12 months [55–57]. Waiting for an extended
dysbiosis, and the transition to disease resembles ecological
period before surgery is also recommended to assess the
succession that culminates in a higher proportion of oral
patient’s compliance to recall appointments and plaque
pathobionts [42]. As nonresolving inflammation is thought
control before any surgical intervention is carried out [58].
to drive this conversion, the application of host modula-
tion, which refers to manipulation of the immune response
to prevent or ameliorate tissue damage, may facilitate an 4.3. Minimally Invasive Nonsurgical Therapy (MINST). A
environment that reverses dysbiosis and promotes repair minimally invasive approach to nonsurgical therapy was first
[2]. These topics were the subject of systematic reviews proposed by Ribeiro et al. Root surface debridement was
covered in the XVI European Workshop in Periodontol- achieved with slim ultrasonic tips and minicurettes, and care
ogy. Adjunctive antiseptics were found to significantly was taken to preserve the stability of soft tissues [59]. Using
reduce inflammation, and locally delivered or systemic clinical and radiographic evidence, this approach demon-
antibiotics were associated with significant clinical benefits strated similar efficacy to the minimally invasive surgical
[43–45]. Of note were the more frequent incidence of technique in the treatment of intrabony defects. In another
adverse events and growing concerns with antibiotic re- study, a mean pocket closure of 71.6 ± 15.7% was observed
sistance with the use of systemic antimicrobials, calling into for sites with an initial probing depth of >5 mm at the patient
urgent action the need to look for alternatives in the long level, indicating a similar if not better success rate compared
term. The combination of mechanical debridement with to traditional nonsurgical approaches [60]. Nibali et al.
host modulators may improve treatment outcomes, and assessed the healing of defects with a radiographic intrabony
locally delivered statin gels and subantimicrobial-dose component >3 mm following MINST in nonsmokers, and
doxycycline have been identified as potentially effective significant clinical and radiographic improvementswere
modalities [46]. Although the efficacy of probiotic therapy similarly observed [61]. These improvements were found to
is equivocal and current evidence does not support routine be stable after a five-year reassessment [32]. Aimetti et al.
use, future adequately powered multicentre trials may evaluated the addition of the enamel matrix derivative to
4 International Journal of Dentistry

≥3 mm intrabony defects following a MINST or MIST 30-year maintenance results of Axelsson et al. demonstrate
(minimally invasive surgical technique) approach, and the conclusively that a maintenance program tailored to indi-
MINST approach was found to have comparable clinical vidual needs may result in near-complete periodontal sta-
outcomes and a shorter treatment time [62]. bility [71]. A more recent study by Graetz et al. of up to 18
Healing following nonsurgical therapy typically begins years demonstrated that long-term tooth retention is pos-
with the formation of a blood clot, with eventual formation sible with a structured maintenance program, regardless of
of long junctional epithelium. It is speculated that the the patient baseline characteristics [72]. Thus, potential
MINST approach results in a more stable blood clot in the intervention (surgery or extraction) due to longitudinal
intrabony defect, which may result in bone apposition or an deterioration of the periodontium may be minimized by
increase in bone mineralization after nonsurgical therapy facilitating patient compliance, early detection using bio-
[61]. Similar to the minimally invasive approach to surgery, markers, and considering the quality of life as an endpoint of
preservation of supracrestal periodontal fibre attachment to therapy in tandem with clinical measures.
the cementum is also an important requirement [63]. These
observations indicate the potential of nonsurgical therapy as
5.1. Shared Treatment Goals and Facilitating Compliance.
a valid treatment option for intrabony defects. However,
Using a definition of patients who missed <30% of scheduled
more clinical evidence is required, and a clinical trial
maintenance visits or who never went two years without a
comparing a minimally invasive surgical and nonsurgical
maintenance visit, the number of complete compliers over
approach is underway [64].
20 years of observation was one in three [73, 74]. This is
The periodontal videoscope, introduced in 2002, is also
significant, and it is well documented in the literature that
worth a mention. By enabling direct real-time visualization
erratic compliers have more tooth loss and alveolar bone
and magnification of the subgingival tooth surface, im-
loss, resulting in a greater impact on the daily performance
provement in the quality of nonsurgical debridement and
(estimated by the functional performance, emotional sta-
healing outcomes could be achieved [65–67]. However, the
bility, and social performance) [74–76]. Furthermore, the
considerable cost of the device, lack of studies demonstrating
effect of poor prognosis teeth having a detrimental effect on
its efficacy, steep learning curve, and resistance to change
adjacent teeth increases with less regular recall intervals
from conventional techniques have meant that this device is
[77, 78]. These observations underscore the importance of
still not widely used [68].
the role of both clinician and patient in working towards a
shared treatment goal as both stakeholders may have initially
4.4. Long-Term Studies on the Comparative Efficacy of Surgical different perceptions and endpoints in resolving the pa-
Access Flaps and Nonsurgical Approaches. A recent system- thology of the disease. Patient factors influencing compli-
atic review on the efficacy of access flap surgery compared to ance are not well substantiated in the literature [79].
nonsurgical debridement demonstrated that greater probing Noncompliance is the net result of complex behavioural
depth reductions are achieved in deep pockets undergoing patterns and factors such as stressful life events, low self-
surgical therapy compared to nonsurgical therapy, but these efficacy, initial presentation of acute symptoms, and lack of
differences reduce over time with an additional effect of copayment options [80–82]. The lack of motivation appears
0.5 mm in the long term [69]. Moderately deep pockets to be an important factor in determining compliance [79],
(4–6 mm) had no differences in the outcome regardless of which highlights the importance of patient education and
whether surgery was done. In a network analysis comparing behavioural modification strategies such as goal setting, self-
minimally invasive nonsurgical and surgical techniques, monitoring, and motivation interviewing [83, 84]. Indeed,
nonsurgical techniques had a lower probability to be the best personalised oral health education has low additional in-
treatment option in terms of probing depth reduction and cremental costs and has been found to be both more clinical
clinical attachment gain, but limited studies and heterogenous and more cost-effective than standardized oral health ed-
data preclude a conclusive statement on this matter [70]. Thus, ucation programs [85–87]. Finally, the use of air-polishing
both nonsurgical and surgical treatment options may be devices for periodontal maintenance is associated with a
considered effective in the long term as a reduction in probing more favourable patient perception and may have utility in
depth after surgery may not be sustained. It is important to improving compliance [88].
mention that many of the classic longitudinal studies only
employed the use of access flaps such as the modified Widman 5.2. Utilising Biomarkers for Early Detection of Periodontitis.
flap, and these findings may not be applied to regenerative The use of biomarkers is emerging as an important tool for
approaches. However, this observation also suggests that monitoring periodontal health status. The inflammatory
factors other than the treatment performed are important in process of periodontitis is mediated by complex cytokine
sustaining pocket reduction, such as control of modifiable risk interactions at the cellular and molecular level, and they
factors and patient compliance to a maintenance program. exert regulatory control over immune cells in the perio-
dontium [4, 89]. Furthermore, virulence factors produced by
5. Minimizing Relapse periodontal pathobionts may mediate the immune response
in favour of inflammation [90, 91]. Potentially diagnostic
Periodontology is one of the few medical and dental dis- biomarkers are related to inflammation (interleukin-1-beta,
ciplines with the privilege of having long-term data, and the interleukin-6, and tumour necrosis factor-alpha), connective
International Journal of Dentistry 5

tissue degradation (matrix metalloproteinase (MMP)-8 and From a patient perspective, both surgical and nonsur-
-9, tissue inhibitors of metalloproteinase (TIMP)-1, and gical periodontal therapy significantly influence oral health-
aspartate aminotransferase), and alveolar bone resorption related quality of life scores [113, 114]. Nonsurgical treat-
(osteoprotegerin and carboxy-terminal telopeptide of type 1 ment has also been shown to effectively reduce psychological
collagen), as well as growth factors such as hepatocyte discomfort and dental pain over the long term [115]. In-
growth factor [92–94]. Indeed, the balance of cytokine terestingly, no further improvement to oral health-related
profile may determine progression and severity of the dis- quality of life scores was reported after surgical therapy,
ease [95, 96]. indicating that any added clinical benefits and necessity for
Biomarkers may be derived from gingival crevicular fluid the procedure may not be perceived by patients. On the
(GCF), which carries site-specific immunological content [97], contrary, no difference in postsurgical pain and discomfort
or saliva, which is a pooled surrogate fluid to GCF that could be detected by patients when comparing minimally
provides information on the overall state of the oral envi- invasive nonsurgical and minimally invasive surgical ap-
ronment [98]. Serum biomarkers, on the contrary, may not proaches, suggesting that minimally invasive surgical ap-
play an important diagnostic or predictive role as plasma proaches may be the preferred option if possible [70]. These
cytokine levels could be unrelated to the inflammatory changes results come with a caveat as the silent and chronic course of
occurring in periodontal tissues [99, 100]. In another study, the periodontitis progression means that the current instru-
greatest sensitivity came from saliva biomarkers, and the ments for evaluating the quality of life in patients with
greatest specificity was observed for GCF biomarkers [101]. periodontitis before and after periodontal therapy may not
More recently, however, newer biomarkers such as galectin-3 be adequately sensitive enough to detect changes, and
and nod-like receptor family pyrin domain-containing pro- though there have been calls to take quality of life factors into
tein-3 (NLRP3) inflammasome released during inflammatory consideration in assessing treatment needs and approaches
conditions in the serum and saliva may discriminate between a in the periodontal patient, clinical decisions should still be
state of periodontitis and periodontal health [102, 103]. assessed together with objective clinical outcome measures
The use of biomarkers is especially relevant in point-of- [35, 116].
care treatment, where saliva or gingival crevicular fluid can
be collected noninvasively from the patient, the former 6. Minimally Invasive Surgical Therapy
potentially being used for patient-specific screening while
the latter being used for site-specific identification of disease Minimally invasive therapy should first focus on improving
activity [97]. Indeed, the reliability of GCF in identifying the prognosis of the remaining dentition through nonsur-
cytokines is comparable to more invasive techniques such as gical therapy and adjunctive therapy where applicable and
gingival biopsies and blood serum, the latter being found to only progress to surgical therapy if this approach fails. The
be the least sensitive [104]. It is likely necessary to employ minimally invasive approach to surgery has been described
holistic approaches in identifying multiple biomarkers in as early as 1998, where Harrel described a surgical technique
specific combinations for this purpose, rather than single or utilising small incisions and minimal flap reflection for the
limited numbers of biomarkers [105, 106]. For example, treatment of periodontal defects [117]. Clinical results for
classification and regression tree analysis of a panel of sal- this technique were similar to traditional surgical ap-
ivary biomarkers including MMP-9, TIMP-1, and IL-1b was proaches involving larger flaps, with added benefits of re-
able to predict patients with periodontitis with an accuracy duced postoperative pain, improved rate of healing,
of close to 100% [106]. The advent of high-throughput gene maintenance of soft tissue height, and patient acceptance
microarray analysis and large-scale proteomics may greatly [118, 119]. Minimally invasive surgery subsequently evolved
contribute to the prediction and investigation of sites with into a microsurgical approach, described as the “minimally
disease activity, though this aspect remains largely unex- invasive surgical technique” by Cortellini and Tonetti
plored [97, 98], in part due to issues such as high costs and [120, 121]. The microsurgical approach facilitated gentle
low recoverability of low-abundance cytokines [107]. handling of tissues and precise wound closure, resulting in
a > 90% rate of primary closure reported by some studies
[120–122]. Other advantages include improved visual acuity,
5.3. Quality of Life as an Endpoint in Periodontal Therapy? enhanced revascularization, and maximum preservation of
Minimally invasive periodontology should also comprise a the tissue [123, 124]. Various double-layer suturing ap-
holistic approach to patient care, which does not only focus proaches have been suggested when a microsurgical ap-
on a biomedical paradigm that focuses on disease states and proach is used [120, 125, 126]. Today, key aspects of a
clinical outcomes but also on the psychological and social “minimally invasive” surgery are as follows: use of magni-
aspects related to the oral cavity. Tools that have been used to fication, minimal flap extension and reflection, preservation
measure the quality of life in the context of the oral cavity of the papilla and interproximal supracrestal soft tissue, and
include the General Oral Health Assessment Index (GOHAI) precise suturing technique. Various designs for a minimally
[108], the Dental Impact Profile [109], and the Oral Health invasive surgical approach have been developed, with
Impact Profile [110, 111]. While subjective health measures smaller flaps designed to optimize wound stability, flap
are often faced with complexities in measuring change, it can integrity, and healing by primary intention (Table 1).
be combined with objective assessments and is potentially Subsequent systematic reviews and meta-analyses have
useful in predicting treatment need [112]. established that regenerative outcomes with a minimally
6 International Journal of Dentistry

Table 1: Various designs for a minimally invasive surgery to facilitate wound stability and improved regenerative outcomes.
Study Technique Key design features Remarks
Two separate intrasulcular incisions with a Performed with at least 3.5x magnification, a
Minimally invasive connecting single horizontal incision (at the granulation tissue-removing instrument, and
Harrel [119]
surgery (MIS) palatal aspect for aesthetic areas) placed 2- high-speed finishing bur for root surface
3 mm from the papilla crest. smoothening.
Modified papilla preservation flap or
Mesiodistal extensions kept to a minimum, simplified papilla preservation flap for the
Minimally invasive
Cortellini and avoid vertical releasing incisions, and elevate interdental incision, extended to buccal and
surgical technique
Tonetti [120] only the defect-associated papilla where lingual aspects. A microsurgical approach with
(MIST)
possible. ×4–16 magnification and enamel matrix
derivative are used.
Modified papilla preservation flap or
simplified papilla preservation flap for the
Modified minimally
Cortellini and Mesiodistal extension extends only to the interdental incision, only extended to the
invasive surgical
Tonetti [121] midbuccal area of involved teeth. buccal aspect. A microsurgical approach with
technique (M-MIST)
×4–16 magnification and enamel matrix
derivative are used.
×2.5 magnifying loupes are used. Limited to
Only an envelope flap on the buccal and
intraosseous defects requiring buccal access.
oblique or horizontal incisions
Trombelli et al. Single-flap approach May be more suitable with an enamel matrix
interproximally following the profile of the
[127] (SFA) derivative ± bone graft approach, rather than
underlying bone crest. Interproximal
membrane + bone substitute due to wound
supracrestal gingival tissues are left intact.
dehiscence [128, 129].
Microsurgical instruments, surgical loupes
Buccal intracrevicular and single short
×3.3, and a specifically designed angled tunnel
Entire papilla vertical releasing incision, followed by
Aslan et al. [130] elevator are required. Regenerative material
preservation flap (EPP) interdental tunnel preparation below the
consisted of enamel matrix derivative + bone
papilla to access the defect.
substitute.
Root surface debridement performed up to the
first 2-3 mm of the pocket in question during
Buccal horizontal incision apical to the the nonsurgical phase to preserve fibers
Moreno Nonincised papilla
periodontal defect, followed by raising the attached to the root and to prevent
Rodriguez and surgical approach
flap coronally, allowing surgical access to the postoperative shrinkage. ×2.8 magnifying
Caffesse [131] (NIPSA)
defect without disrupting marginal tissues. loupes are used, and regenerative material
consisted of enamel matrix derivative + bone
substitute.

invasive surgery are superior to access flaps [28, 124]. Fur- minimally invasive surgical and nonsurgical procedures
thermore, the additional use of biomaterials or membranes has published in the literature showed that associated clinical
been used in combination with a minimally invasive surgery results are not inferior to traditional approaches. Additional
with successful outcomes of up to six years and low postsurgical benefits have been identified, such as increased clot stability,
morbidity [31, 132–137] but does not appear to enhance re- improved healing, enhanced revascularization, higher in-
generative outcomes, indicating enhanced healing potential cidence of primary closure, and better patient acceptance.
with a minimally invasive surgical approach [138–141]. Even if a Minimally invasive periodontology is often discussed in the
minimally invasive approach is adopted, factors such as patient context of clinical procedures, as shown by the literature
compliance to professional recalls and plaque control and in- search. However, the term “minimally invasive” should
herent anatomical risk factors such as defect configuration and encompass a holistic philosophy that includes treatment
gingival phenotype may influence successful outcomes planning from the first appointment. With the advent of
[58, 142]. At least two studies have compared a minimally implant dentistry, tooth extractions have been indicated
invasive double-flap to the minimally invasive single-flap ap- much more often. Dogmas that have been propagated in-
proach, and a better quality of early wound healing and lower clude (1) “periodontal overtreatment” or the claim that
postoperative pain were observed in the latter [143, 144]. continued periodontal treatment in an attempt to maintain
periodontally involved teeth compromises the surgical site
7. Discussion due to continued bone loss; (2) full clearance of remaining
periodontally compromised teeth reduces the risk of rein-
This literature review discussed a proposed treatment ap- fection [145]. On the contrary, we argue that a patient’s
proach emphasizing maximum preservation of teeth while perception of the usefulness of the tooth, i.e., functional, not
minimizing morbidity to the patient. Comparison of unaesthetic, and no physical, psychological, or social
International Journal of Dentistry 7

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