Received: 15 January 2019 | Revised: 29 April 2019 | Accepted: 5 June 2019

DOI: 10.1111/jcpe.13158

CLINICAL PERIODONTOLOGY

Supra‐alveolar attachment gain in the treatment of combined

intra‐suprabony periodontal defects by non‐incised papillae
surgical approach

Jose A. Moreno Rodríguez1 | Antonio J. Ortiz Ruiz2 | Raúl G. Caffesse3

1
Private Practice, Murcia, Spain
2 Abstract
Department of Stomatology, Faculty of
Medicine, University of Murcia, Murcia, Aim: To assess the effectiveness of non‐incised papillae surgical approach (NIPSA) in
Spain
periodontal reconstructive surgery of combined intra‐suprabony defects.
3
Postgraduate Periodontics, Complutense
University of Madrid, Madrid, Spain
Materials and Methods: Patients with deep periodontal defects treated with
NIPSA (n = 20) were analysed. Defects were treated with enamel matrix derivative
Correspondence
Jose A. Moreno Rodríguez, C/Ctra de
plus xenograft. Clinical outcomes were assessed before surgery and at 12 months.
Granada no. 46, Caravaca de la Cruz, 30400 Wound closure was assessed one week post‐surgery. Supra‐alveolar attachment gain
Murcia, Spain.
Email: joseantonio171087@gmail.com
(SUPRA‐AG) was recorded at 12 months post‐surgery.
Results: Non‐incised papillae surgical approach showed significant improvements in
clinical attachment gain (5.9 ± 2.38 mm; p < 0.001), recession reduction (0.25 ± 0.44;
p < 0.05) and tip of the papillae coronal displacement (0.4 ± 0.5; p < 0.05). It also
showed complete wound closure of the apical mucosal incision in the 85% of the
cases, with no interproximal tissue necrosis. SUPRA‐AG (1.9 ± 1.74) showed a posi‐
tive tendency, associated with complete intrabony defect resolution.
Conclusions: Non‐incised papillae surgical approach promoted primary intention
healing, wound stability and space provision for optimal periodontal reconstruction,
preserving supra‐alveolar soft tissue integrity.

KEYWORDS
periodontitis, reconstructive surgery, regeneration, surgical flaps

1 | I NTRO D U C TI O N complete removal of granulation tissue, providing the necessary

Regeneration is the ideal objective in the treatment of periodon‐
tal lesions (Polimeni, Xiropaidix, & Wikesjö, 2006). The possibility
of new attachment with the formation of cementum, periodon‐
tal ligament and bone has been demonstrated (Hiatt, Schallhorn,
& Aaronian, 1978; Linghorne & O’Connell, 1950; Nyman, Lindhe,
Karring, & Rylander, 1982). For optimal periodontal regeneration,
three conditions allow the innate potential of the periodontium to
re‐establish the periodontal complex: space provision, wound stabil‐
ity and primary intention healing (Susin et al., 2015; Tonetti, Prato,
& Cortellini, 1996). Periodontal reconstructive surgery permits the
space for re‐growth, exposing tissue capabilities (Susin et al., 2015).
Studies on regeneration showed that new formation of periodontal
attachment was possible using guided tissue regeneration (Caffesse,
Smith, Castelli, & Nasjleti, 1988; Gottlow, Nyman, Lindhe, Karring, &
Wernstrom, 1986; Nyman et al., 1982). At first, barrier membranes
were used, opening extensive flaps that permit flap mobility, to
guarantee primary closure and prevent bacterial contamination (De
Sanctis, Zucchelli, & Clauser, 1996). However, flap dehiscence was
frequent (Cortellini et al., 2001). Papillae preservation flaps were in‐
troduced to prevent exposure of the membrane and maintain the
integrity of the interproximal tissues (Cortellini, Prato, & Tonetti,

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928 | MORENO RODRÍGUEZ et al.
1995,1999; Takei, Han, Carranza, Kenney, & Lekovic, 1985; Tinti,
2007). With the advent of enamel matrix derivative (EMD), the flap
design became focused on the minimal approach concept, (Aslan,
Buduneli, & Cortellini, 2017; Cortellini & Tonetti, 2007, 2009; Harrel,
Wilson, & Nunn, 2010; Trombelli, Farina, Franceschetti, & Calura,
2009) improving tissue vascularization and providing greater blood
clot stability.
Studies on the treatment of periodontal intrabony defects re‐
ported significant clinical improvement (Cortellini, 1996; Cortellini
et al., 2001; Cortellini, Prato, & Tonetti, 1995; Cortellini & Tonetti,
2009; Trombelli et al., 2009) and, histologically, newly generated
periodontal attachment (Nyman et al., 1982; Yukna & Mellonig,
2000). However, supra‐alveolar defects are reported to be 3–9 times
more prevalent than intrabony defects (Nielsen, Glavind, & Karring,
1980; Papapanou & Wennstrom, ; Persson, Hollender, Laurell, &
Persson, 1998). There is little evidence of clinical success in regen‐
erating supra‐alveolar defects (Kassolis & Bowers, 1999; Kotschy
& Laky, 2006; Nemcovsky et al., 2006; Sigurdsson, Hardwick,
Bogle, & Wikesjö, 1994; Stahl & Froum, 1991; Di Tullio et al., 2013).
Histological studies show considerable variations in the healing pat‐
tern, with epithelial and connective adhesion, and frequently with
limited new periodontal attachment (Nemcovsky et al., 2006; Stahl,
1979; Stahl & Froum, 1991). Supra‐alveolar defects remain a chal‐
lenge, and regenerative treatments have a low rate of predictable
outcomes.
The minimally‐invasive surgical technique (MIST) (Cortellini &
Tonetti, 2007) associated with EMD for the treatment of supra‐al‐
veolar defects has shown positive results (Jentsch & Purschwitz,
2008; Di Tullio et al., 2013). However, it entails an incision of the
marginal tissue above the defect that may jeopardize wound stabil‐
ity and primary closure (Burkhardt, Ruiz Magaz, Hämmerle, & Lang,
2016; Moreno Rodríguez, Ortiz Ruiz, & Caffesse, 2018; Needleman,
Tucker, Giedrys‐Leeper, & Worthington, 2002). Recently, an apical
approach, the non‐incised papillae surgical approach (NIPSA) has
been proposed in the treatment of deep intrabony defects with opti‐
mal clinical outcomes (Moreno Rodríguez & Caffesse, 2018; Moreno
Rodríguez et al., 2018). This approach focuses on ensuring the integ‐
rity of the papillae and marginal tissues, promoting space provision
for the clot, primary healing and wound stabilization.
The objective of this study was to assess the clinical effective‐
ness of NIPSA in periodontal lesions with combined intrabony and
suprabony defects.
2 | M ATE R I A L S A N D M E TH O DS
2.1 | Patients
An evaluation was carried out in a private clinic in Murcia (Spain)
between January 2013 and June 2017. Inclusion criteria were (a)
no relevant systemic condition or disease; (b) diagnosis of peri‐
odontitis; (c) full‐mouth plaque score and full‐mouth bleeding
score <20%; (d) non‐surgical periodontal treatment and com‐
pliance with maintenance therapy for ≥1 year; (e) one residual
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Clinical Relevance
Scientific rationale for the study: This study evaluated
the clinical effects of raising the flap using a mucosal inci‐
sion placed far from the marginal tissue using a new surgi‐
cal technique for periodontal reconstruction.Principal
findings: Non‐incised papillae surgical approach (NIPSA)
improved clinical outcomes, even in the supra‐alveolar
component, reducing the risk of soft tissue collapse.Practical
implications: NIPSA is a promising new approach in perio‐
dontal reconstructive surgery, especially with regard to
aesthetics, by providing optimal supra‐alveolar soft tissue
stability.
active (bleeding on probing) interproximal pocket with horizon‐
tal bone loss plus an intrabony defect; (f) probing pocket depth
(PPD)> 5 mm; and (g) intrabony defect with a bone crest (BC)–
cementum–enamel junction (CEJ) distance of ≥4 mm. Exclusion
criteria were third molars and teeth with incorrect endodontic or
restorative treatment.
All clinical procedures were performed in accordance with the
Declaration of Helsinki and Good Clinical Practice Guidelines as re‐
vised in 2013. The study protocol was approved by the Research
Ethics Committee of the University of Murcia (Spain) (protocol num‐
ber: 2039/2018). All patients were informed about the study and
gave written informed consent to participate.
2.2 | Clinical parameters
All baseline and follow‐up measurements were made by one trained
examiner (AJOR). Intra‐surgical measurements were made by the
surgeon (JAMR). Measurements were made using a periodontal
probe and were rounded off to the nearest millimetre (PCP UNC 15.
Hu‐Friedy, Frankfurt, Germany).
PPD was measured from the gingival margin to the bottom of
the pocket. PPD reduction (PPDr) was calculated as the difference
between PPD at baseline and follow‐up.
Clinical Attachment Level (CAL) was measured from the CEJ to the
bottom of the pocket. Clinical attachment gain (CAG) was calculated
as the difference between CAL at baseline and follow‐up.
Recession Depth (REC) was measured from the CEJ to the gingival
margin on the mid‐buccal aspect of the tooth.
Location of the Tip of the papillae (TP), related to the CEJ. On the
tooth axis, the distance from the mid‐buccal cemento‐enamel junc‐
tion to the tip of the interproximal soft tissue papilla was measured
with a positive value if coronal to the CEJ or negative if apical to the
CEJ.
Local bleeding score (BoP) was recorded as positive when bleeding
on probing was present at the surgically treated site.
Keratinized tissue (KT) width measured from the gingival margin
to the mucogingival junction, at the mid‐buccal point.
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MORENO RODRÍGUEZ et al. | 929

(a) (b) (c) (d) (e) (f)

(g) (h) (i)

F I G U R E 1 Supra‐alveolar attachment gain (SUPRA‐AG) concept. Non‐incised papillae surgical approach (NIPSA) outcome (a–f) and
schematic illustrations (g–i). Black and white line border‐lining the cementum–enamel junction (CEJ); Black and white arrow: CEJ; yellow
arrow: pre‐surgery BC; yellow line indicating bone crest contour; blue arrow indicating location of probe tip (in figure e: blue arrow
indicating location of probe tip from figure d). (a) Pre‐surgical periapical X‐ray. Orange arrow indicating BD. (b) Pre‐surgical CAL = 8 mm. (c)
Intra‐surgical probing. CEJ‐BD = 12 mm. INTRA = 5 mm. CEJ‐BC = 7 mm. (d) 12 months after surgery CAL = 3 mm. (e) Re‐entry 18 months
after surgery, probe indicating differences from bone crest on the buccal (light arrow) and interproximal area (green arrow); SUPRA‐AG (light
blue line: distance between yellow and blue arrows), calculated as (intra‐surgical CEJ‐BC)‐post‐op CAL = 4 mm. (Photograph taken at the
time of treating an adjacent tooth treatment not included in the present study). (f) 18 months after surgery periapical X‐ray. g. Periodontal
lesions with combined intrabony and supra‐alveolar defect. (h) A positive SUPRA‐AG value indicates an attachment gain above pre‐surgery
BC (i). A negative SUPRA‐AG value indicate an incomplete resolution of the intrabony defect

Supra‐alveolar attachment gain (SUPRA‐AG) was recorded 2.3 | Experimental protocol

12 months after surgery. The most coronal portion of the bone
crest (BC) location was corroborated intra‐surgically with respect 2.3.1 | Pre‐surgical procedure
to the CEJ. Twelve months after surgery, CAL indicated the cor‐
One to two weeks before surgery, the area to be regenerated received
onal limit of the attachment gain. Subtracting the 12‐month CAL
pre‐surgical treatment with micro‐ultrasonic tips (After Five® Piezo
from the intra‐surgically BC‐CEJ provided the SUPRA‐AG result.
Scaling; Hu‐Friedy) only instrumenting the first millimetres of the
A positive value indicated clinical attachment gain (CAG) over BC,
pocket and all the exposed root surface (Moreno Rodríguez & Caffesse,
while a negative value identified an incomplete intrabony defect
2018). The surgical phase only proceeded when an excellent tone of
resolution (Figure 1).
the soft tissues overlying the defect was achieved. Patients received
Intra‐surgical clinical measurements were assessed after de‐
two grams of amoxicillin one hour before surgery. Post‐operative pain
bridement to determine defect morphology: (a) distance from the
and inflammation were controlled with ibuprofen: 600 mg was admin‐
CEJ to the bottom of the defect (CEJ‐BD); (b) distance from the BC
istered at the beginning of surgery, and subsequent doses were taken
to the CEJ (BC‐CEJ); (c) intrabony component (INTRA) of the defect
only if necessary to control pain, and were recorded by the patient.
defined as the distance from the BC to the BD; (d) 3‐wall intrabony
component of the defect (3‐WALL), defined as the distance from the
coronal limit of the three‐wall bony component to the BD. (3w‐BD); 2.3.2 | Surgical procedures
and (e) inter‐dental supra‐alveolar soft tissue (SUPRA‐ST) by adding
the TP to the BC‐CEJ. All surgeries were performed with magnifying loupes (X3) for im‐
Wound closure (WC) during early healing was assessed 1 week proved visual acuity and control (ExamVision, Galileo HD; Akura) by
after surgery (Moreno Rodríguez et al., 2018), indicating complete one surgeon with expertise in periodontal surgery (JAMR).
wound closure (CWC = 2), incomplete wound closure (IWC = 1) or NIPSA (Moreno Rodríguez & Caffesse, 2018; Moreno Rodríguez
necrosis (NT = 0) of interproximal tissue. et al., 2018) (Figures 2 and 3).
Post‐operative pain was evaluated according to ibuprofen con‐ One apical oblique or horizontal incision was made in the buccal
sumption in milligrams (mg). aspect of the alveolar mucosa, placed on cortical healthy bone, as

930 | MORENO RODRÍGUEZ et al.
(a) (b) (c)
(d) (e) (f)
(g) (h)
(i) (j)
far removed from the inter‐dental papillae and marginal keratinized
tissues as possible. Mesiodistally, the incision extended sufficiently
to allow correct granulation tissue debridement and intrabony defect
manipulation. The tissue coronal to the incision was reflected apico‐
coronally maintaining marginal tissue integrity. The papillae structure
was pulled coronally with a micro‐papillae elevator (Mamadent®;
Tuttlingen, Germany) to increase space provision in the supra‐alveo‐
lar component for debridement, biomaterial application and clot sta‐
bilization. Before defect debridement, the flap was protected with a
periosteal elevator (Mamadent®; Tuttlingen, Germany) and frequent
saline irrigation. Granulation tissue was detached from the bony walls
with micro‐curettes (Micro Mini Five® Gracey; Hu‐Friedy). Pocket ep‐
ithelium and granulation tissue attached to the base of the papilla
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F I G U R E 2 Non‐incised papillae
surgical approach (NIPSA). (a) Probing
depth before surgery. Firm marginal tissue
after non‐surgical treatment. (b) Periapical
X‐ray before surgery. (c) Horizontal
mucosal incision placed on healthy
cortical bone. Flap reflected coronally
and the papilla pulled. (d) Defect after
debridement. (e) EMD application. f. HA‐
graft and EMD mix placed into the defect.
(g) Double suturing. (h) Complete wound
closure at 1 week. (i, j) 12 months after
surgery, probing depth and periapical X‐
ray
and the inner surface of the coronal flap were cut with micro‐scis‐
sors (Mamadent®; Tuttlingen, Germany) and removed. Root planing
was performed considering the fibres attached to cementum and
the coronal limits of the flap reflected. Soft tissues not attached to
the root surface were removed with micro‐curettes and micro‐ul‐
trasonic instruments (After Five® Piezo Scaling tip; Hu‐Friedy).
After defect debridement and root surface instrumentation, 24%
ethylenediaminetetraacetic acid gel (Prefgel®; Straumann) was ap‐
plied on the root for 2 min. The area was carefully rinsed with saline.
EMD (Emdogain®; Straumann) was applied on the root followed by a
composite graft of deproteinized bovine bone xenograft (Bio‐Oss®;
Geistlich Pharma) and EMD (Emdogain®; Straumann). The mucosal
incision line was closed with a double layer of suturing (PGA 6.0;
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MORENO RODRÍGUEZ et al. | 931

F I G U R E 3 Non‐incised papillae (a) (b) (c)

surgical approach (NIPSA). (a) Pre‐surgery
situation, flat papilla. (b) Probing depth
before surgery. (c) Periapical X‐ray
before surgery showed a combined
intra‐suprabony periodontal defect. The
intrabony defect reach the apical root
area. (d) Apical incision. Flap reflected
coronally and the papilla pulled. Combined
intra‐suprabony periodontal defect. (e)
(d) (e) (f)
Biomaterials applied. (f) Double line suture
closing the apical mucosal incision. (g)
1 week follow‐up; (h–j). 12 months after
surgery: probing depth, and periapical X‐
ray. Improved papillary contour

(g) (h)

(i) (j)

Hu‐Friedy): first, with horizontal mattress sutures, placed 2 mm away
from the borders, promoting connective tissue contact, and then, sin‐
gle interrupted sutures placed as a second line of closure.
2.3.3 | Post‐surgical procedures
Patients were instructed to rinse with a 0.2% chlorhexidine digluco‐
nate solution twice a day for 4 weeks. Sutures were removed after
7 days. At 4 weeks, patients were instructed to start brushing with a
soft toothbrush and a roll technique. Patients were recalled for con‐
trol and prophylaxis at weeks 1, 2, 3 and 4 and at 3, 6 and 12 months.
The follow‐up was 12 months.
significant and a common standard deviation (SD) of 2.0. A drop‐
out rate of 0% was anticipated. (“Sample size and power calculator,”
https​://www.imim.cat/ofert​adese​r veis/​softw​are-publi​c/granm​o/).
Descriptive statistics were made of patient characteristics and
the specific site, defect morphology, pre‐surgical and post‐surgical
clinical measurements.
Quantitative variables were expressed as means and SD.
Outcome variables were assessed using Student's t test for paired
data. P‐values < 0.05 were considered statistically significant.
Cases were also categorized according to WC (=2 or < 2). Cases
with WC = 2 and cases with WC < 2 were compared to determine
which variables were associated with wound failure. P‐values < 0.05
were considered statistically significant.

2.4 | Statistical analysis

Twenty patients contributed one defect each. Therefore, the patient 3 | R E S U LT S

was considered as the statistical unit. The sample size (n = 20) was
calculated a posteriori using clinical attachment level (CAL) values, Twenty consecutive patients treated with NIPSA, that fulfilled the
accepting an alpha risk of 0.05 and a beta risk of 0.20 (power 0.8) in same inclusion criteria were selected (12 males and 8 females; age
a two‐sided test to recognize a difference of ≥5 units as statistically range: 30–60 years, five smokers and seven former smokers).
 1600051x, 2019, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13158 by Cochrane Japan, Wiley Online Library on [09/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
932 | MORENO RODRÍGUEZ et al.

Subject and defect characteristics of the sample population are
presented in Table 1.
3.1 | Clinical outcomes at 12 months
Clinical outcomes are shown in Tables 2 and 3. At 12 months, the
results showed statistically significant gains from baseline in PPD
and CAL (p < 0.001), significant reduction in recession (p < 0.02) and
a significant increase in TP (p = 0.002). No difference was obtained
in KT. Furthermore, after 12 months, the mean SUPRA‐AG value was
found to be positive.
3.2 | Wound healing and post‐operative pain
in structural and vascular support (Bosshardt, 2018). Pre‐surgical
minimally invasive conditioning of the periodontal pocket (Moreno
Rodríguez & Caffesse, 2018; Moreno Rodríguez et al., 2018) may
improve the quality of the connective tissue, optimizing the tone of
the marginal soft tissue at the time of surgery.
The interproximal tissues are nourished by a profuse vascu‐
lar network (McLean, Smith, Morrison, Nasjleti, & Caffesse, 1995;
Mörmann, Meier, & Firestone, 1979; Nobuto et al., 2005). However,
the dimensions and morphology of the inter‐dental tissues affect the
re‐establishment of blood perfusion (Kohl et al, 1961). A thin papilla
with a narrow base has a delicate terminal blood supply, which is
significantly affected by making an incision at its base and raising a
marginal mucoperiosteal flap (Nobuto et al., 2005; Retzepi, Tonetti,
& Donos, 2007). The apical incision performed and the lack of mar‐

CWC was present in 17 sites (85%) and IWC in three sites, with no ginal tissue reflected with NIPSA may permit better maintenance of

NT. One week after surgery, the mean WC value was 1.85 ± 0.34, the terminal blood supply to the papillae.

and no differences were found in clinical outcomes between WC = 2 Histological studies have shown different patterns of healing

and WC < 2 (Table 4). The mean dose of ibuprofen taken was after periodontal surgery, either by regeneration or repair (Caton,

1,470 ± 714 mg. Nyman, & Zander, 1980; Listgarten & Rosenberg, 1979). Under opti‐
mal circumstances, periodontal regeneration is achievable (Polimeni,
Susin, & Wikesjö, 2009; Wikesjö, Lim, Thomson, & Hardwick,

4 | D I S CU S S I O N 2003; Wikesjö & Selving, 1999; Wikesjö, Xiropaidis, et al., 2003).

Preserving the blood clot by wound stability is a primary objective

A residual active pocket results in inflammation and focal destruction in periodontal regeneration (Susin et al., 2015). Studies evaluating

that modifies the condition of the connective tissue, with changes healing have suggested that interfering with the adsorption, adhe‐
sion and maturation of a root surface‐adhering fibrin clot resulted
TA B L E 1 Patient and defect characteristics in the formation of a junctional epithelium (Hiatt, Stallard, Butler, &
Badgett, 1968; Linghorne & O’Connell, 1950; Polson & Proye, 1983).
NIPSA (n = 20)
Accessing the periodontal defect by raising the flap using a pap‐
Study population illary incision and intrasulcular detachment significantly improved
Sex (male/female) 12/8 PPD reduction, as already reported (Cortellini, Prato, & Tonetti, 1999;
Age (years) (mean ± SD) 47.3 ± 9.54 Cortellini & Tonetti, 2007; Moreno Rodríguez et al., 2018; Trombelli,
Non‐smoker/smokers/former smoker 8/5/7 Simonelli, Schincaglia, Cucchi, & Farina, 2012; Di Tullio et al., 2013);
Dental arch (upper/lower) 10/10 however, CAG and PPD were associated with an increase in REC and

Tooth type (incisors/canines/premolars/ 10/5/3/2

apical displacement of the tip of the papilla (TP), which indicate ten‐
molars) dency for soft tissue contraction (Farina et al., 2013; Moreno Rodríguez
Defect morphology measurements (mm) et al., 2018). The incision in the papillae and subsequent suturing over

CEJ‐BD (mean ± SD) 10.75 ± 2.59 the defect with limited connective tissue support may compromise the
nutrition to the overlaying soft tissue, increasing the risk of wound de‐
CEJ‐BC (mean ± SD) 5.25 ± 1.2
hiscence or interproximal soft tissue necrosis during the early healing
INTRA 5.3 ± 2.39
period (Farina et al., 2013; Moreno Rodríguez et al., 2018; Mörmann et
3‐wall 2.75 ± 1.62
al., 1979; Retzepi et al., 2007; Wikesjö, Lim, et al., 2003). The marginal
SUPRA‐ST 7.25 ± 2.34
soft tissue morphology, the inter‐dental space, the avascular nature of
Intrabony defect configuration
the root surface, the confined papillary dimension and the mechanical
1/3‐wall 14 forces acting on the wound margins may compromise the outcome,
2/3‐wall 1 increasing supra‐alveolar soft tissue contraction (Farina et al., 2013;
1/2‐wall 1 Sanz et al., 2004; Sigurdsson et al., 1994; Trombelli, Kim, Zimmerman,
3‐wall 1 & Wikesjö, 1997). Thus, marginal approaches may provide limited ca‐
2‐wall 0 pacity for space provision in non‐contained and supra‐alveolar defects
1‐wall 3 (Jentsch & Purschwitz, 2008).
The apical approach was evaluated (NIPSA; Moreno Rodríguez &
Abbreviations: CEJ, cemento‐enamel junction; INTRA, intrabony defect;
NIPSA, non‐incised papillae surgical approach; SUPRA‐ST, interproximal Caffesse, 2018; Moreno Rodríguez et al., 2018), to assess the clini‐
supra‐alveolar soft tissue. cal results in combined intra‐suprabony periodontal defects. NIPSA
 1600051x, 2019, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jcpe.13158 by Cochrane Japan, Wiley Online Library on [09/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MORENO RODRÍGUEZ et al. | 933

TA B L E 2 Clinical measurements
Baseline 12 months Change Significance, pf
(mm ± SD)
PPD 8.15 ± 2.48 2.55 ± 0.6 5.6 ± 2.48a <0.001
CAL 9.25 ± 2.71 3.35 ± 0.99 5.9 ± 2,38b <0.001
c
REC 1.1 ± 0.85 0.85 ± 0.93 0.25 ± 0.44 0.021
TP 2.00 ± 1.38 2.4 ± 1.35 −0.4 ± 0.5d 0.002
KT 3.5 ± 1.7 3.5 ± 1.7 – NS
SUPRA‐AG 1.9 ± 1.74e

Abbreviations: CAL, clinical attachment level; KT, keratinized tissue; mm, millimetres; NS, not
significant, p > 0.05; PPD, probing pocket depth; REC, recession; SUPRA‐AG, supra‐alveolar attach‐
ment gain; TP, tip of the papillae.
a
PPD change = PPDr.
b
CAL change = CAG.
c
Positive value in REC indicates decreased recession.
d
Negative value in TP indicates papillae coronal displacement.
e
Negative value in SUPRA‐AG indicates incomplete resolution of the intrabony defect.
*Paired t test.

TA B L E 3 Frequency distributions of CAL and PPD changes at and clinical advantages: space provision is created by pulling the in‐
1 year terproximal supra‐alveolar soft tissue coronally and by preserving the
architecture of the interproximal and marginal tissues. The unaltered
CAG PPDr
integrity of the supra‐alveolar soft tissue, acting as a dome protecting
n % n % the clot, enhances wound stability and supports mechanical traumas
0–1 mm 0 — 0 — during early healing. The fact that the incision is located apically, far
2–3 mm 2 10 3 15 from the marginal tissue on cortical bone and mucosa, facilitates pri‐
4–5 mm 9 45 8 40 mary closure during early healing: 85% of surgeries showed CWC com‐

6–7 mm 5 25 5 25 pared to 15% with IWC, with minimal flap dehiscence sealed by a fibrin
clot, far from the defects and the regenerative materials. Furthermore,
≥8 mm 4 20 4 20
inter‐dental soft tissue necrosis, which may increase contamination in
Abbreviations: CAG, clinical attachment gain; PPDr, probing pocket
the regenerating area (De Sanctis et al., 1996), and soft tissue contrac‐
depth reduction.
tion with unaesthetic results are avoided.
In this study, only intrabony defects associated with horizon‐
resulted in significant PPD reduction, CAG, REC reduction and TP tal bone loss were included, and the changes in the supra‐alveolar
coronal displacement, indicating its capacity to better preserve soft component were evaluated. SUPRA‐AG was introduced to assess
tissue level. NIPSA is being proposed as an approach to promote the the resolution of the intrabony defect. NIPSA showed a positive
conditions for optimal periodontal regeneration, even in supra‐alveo‐ tendency in SUPRA‐AG that means a complete resolution of the in‐
lar defects. As already described, its apical access has several technical trabony component. The apical approach may be also indicated in

TA B L E 4 One‐year changes in clinical

NIPSA
parameters (mm ± SD) in patients with
different early wound healing Variables (mm) WC = 2 (n = 17) WC < 2 (n = 3) Significance, pd

PPDr 5.94 ± 2.53 3.67 ± 0.58 NS

CAG 6.24 ± 2.41 4±1 NS
REC(Ch) 0.24 ± 0.44 0.33 ± 0.57a NS
TP(Ch) −0.47 ± 0.51b 0±0 NS
KT (Ch) 0±0 0±0 NS
SUPRA‐AG 2.12 ± 1.65 0.67 ± 2.08c NS

Abbreviations: CAG, clinical attachment gain; Ch, change; KT, keratinized tissue; mm, millimetres;
NS, not significant, p > 0.05.; PPDr, probing pocket depth reduction; REC, recession; SUPRA‐AG,
supra‐alveolar attachment gain; TP, tip of the papillae; WC, wound closure.
a
Positive value in REC indicates decreased recession.
b
Negative value in TP indicates papillae coronal displacement.
c
Negative value in SUPRA‐AG indicates incomplete resolution of the intrabony defect.
*t test

934 | MORENO RODRÍGUEZ et al.
cases when a buccal‐wall component is affected as part of the defect
(Moreno Rodríguez et al., 2018) or when the defect configuration
has a supra‐alveolar component that permits the access to the de‐
fect by pulling the supra‐alveolar soft tissue.
Enamel matrix derivative and a bone xenograft were employed
as regenerative materials. The positive effects of EMD and its ca‐
pacity to trigger regeneration have been widely reported (Arweiler,
Auschill, Donos, & Sculean, 2002; Groeger, Windhorst, & Meyle,
2016; Melloning, 1999; Miron, Dard, & Weinreb, 2015; Yukna &
Mellonig, 2000). Recent studies suggested that the additional use of
a graft material enhanced the clinical outcome of EMD (Matarasso
et al., 2015; Tu, Woolston, & Faggion, 2010), improving its space‐
making potential, by preventing collapse of the overlying soft tissues
into the area to be regenerated (De Leonardis & Paolantonio, 2013).
Although RCTs are required, NIPSA seems to create optimal
conditions for space provision, wound stabilization and primary
intention healing, avoiding collapse and soft tissue contraction by
maintaining the integrity of the marginal tissues and preserving the
papillary architecture intact.
AC K N OW L E D G E M E N T S
We thank Dr Manuel Canteras, Professor of Biostatistics, Department
of Social and Public Health Science, Faculty of Medicine, University
of Murcia, for carrying out the statistical tests.
C O N FL I C T O F I N T E R E S T
The authors report no conflicts of interest.
ORCID
Jose A. Moreno Rodríguez https://orcid.org/0000-0002-0284-3496
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How to cite this article: Moreno Rodríguez JA, Ortiz Ruiz AJ,
Caffesse RG. Supra‐alveolar attachment gain in the
treatment of combined intra‐suprabony periodontal defects
by non‐incised papillae surgical approach. J Clin Periodontol.
2019;46:927–936. https​://doi.org/10.1111/jcpe.13158​