PERIODONTOLOGY

The apically incised coronally advanced surgical technique

(AICAST) for periodontal regeneration in isolated defects:
a case series
Dino Calzavara, DDS, DrOdont/Segio Morante, DDS, DrOdont/Javier Sanz, DDS, DrOdont/
Fernando Noguerol, DDS/Jerian Gonzalez, DDS/Mario Romandini, DDS/Mariano Sanz, MD, DDS, DrMed

Objectives: The aim of this retrospective case series was to re-
port the performance up to 5 years of an innovative surgical de-
sign (the apically incised coronally advanced surgical technique
[AICAST]) for the regenerative treatment of one- or two-walled
intrabony periodontal lesions. Method and materials: After
completion of standard step I to II periodontal therapy, nine iso-
lated periodontal defects were treated through AICAST. The fol-
lowing clinical outcome measurements were collected before
the surgical intervention and at the last available follow-up:
probing pocket depth (PPD), recession depth (REC), and clinical
attachment level (CAL). Periapical radiographs of the treated
teeth were also taken at baseline and at the last available fol-
low-up (18 months or 5 years postoperatively). Results: A mean
(± standard deviation) PPD reduction of 6.05 ± 1.76 mm (P < .01),
REC reduction of 1.15 ± 1.97 mm (P = .119), and CAL gain of
7.20 ± 2.13 mm (P < .01) were attained when comparing preop-
erative results with the last follow-up visit. CAL gain of 6 mm or
more was reached in eight out of nine treated cases (88.9%), with
a residual PPD of 2 to 3 mm in all the cases. Complete radio-
graphic fill of the intrabony component was present in all the
defects, while detectable suprabony radiographic filling was
identified in two cases. Conclusion: AICAST represents an inno-
vative surgical design for the treatment of deep intrabony de-
fects and the eventual reduction of the associated gingival re-
cessions. Preliminary results show good performance in terms
of clinical attachment gains and maintenance of the marginal
tissues.(Quintessence Int 2022;53:24–34;
: doi: 10.3290/j.qi.b1763645)

Keywords: coronally advanced flap, enamel matrix derivatives (EMD), papilla preservation flap, periodontal regeneration,
periodontitis

Periodontitis has been recently defined as a chronic multifactorial
inflammatory disease associated with dysbiotic plaque biofilms
and characterized by progressive destruction of the tooth-sup-
porting apparatus.1 It has shown high prevalence in different pop-
ulations2-5 and, besides its relevant oral sequelae,1,6-9 it has been
associated with adverse systemic effects and even mortality.10-14
Intraosseous defects are a frequent finding in periodontitis
patients15 and place the affected teeth at increased risk for tooth
loss.16 Current guidelines for periodontal treatment identify the
presence of these lesions as a complexity factor, since they usu-
ally result in deep residual probing pocket depths (PPDs) after
nonsurgical therapy (steps I to II), which is considered the main
risk indicator for attachment loss progression.17,18 In these situa-
tions, if the intrabony component of these lesions is ≥ 3 mm,
their treatment should be carried out by regenerative surgical
interventions aiming to gain clinical attachment with PPD reduc-
tion, which will improve the prognosis of the affected tooth.19
Several regenerative surgical approaches have been evalu-
ated in the treatment of these defects, including the use of spe-
cific flap designs and soft-tissue management techniques,20,21
combined with various regenerative technologies.22-29 In particu-
lar, minimally invasive flap designs associated with papilla pres-
ervation techniques30-32 have been shown to provide space main-
tenance, wound stability, and primary closure, which are key
prerequisites for periodontal regeneration.33,34 However, even
with the use of these techniques aiming for maximum flap stabil-

24 QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022


1a 1b
Figs 1a to 1c Preoperative view of case 1; the location of the apical incision was performed at least 10 mm from the gingival margin.
ity, unwanted esthetic outcomes including postoperative buccal
gingival recession and loss of papilla height have been reported.32
To overcome these limitations, alternative flap designs have
been proposed, including the lateral approach to raise the inter-
dental papillae,35 the soft tissue wall technique,36-38 or surgical
designs involving an apical incision for accessing the intrabony
defect.39,40 Azzi et al40,41 firstly described a surgical approach to
reconstruct the interdental papilla by an apical incision in the lin-
ing mucosa. Recently (2016), Calzavara et al42 modified this apical
approach. This modification allows for the coronal advancement
of the gingival margin and of the interdental papilla, thus provid-
ing extra vertical space, which if filled with the appropriate scaf- f
fold, may potentially move the vertical limit of the attachment
gain, also including part of the suprabony component of the le-
sion. Moreover, this coronal advancement may allow the correc-
tion of preexisting gingival recessions and of interdental soft tis-
sue (papillae) deficiencies, thus improving esthetic outcomes.
It was the aim of this retrospective case series with a follow-up
of up to 5 years to report a modification of this surgical technique
(apically incised coronally advanced surgical technique [AICAST])
aimed for the periodontal regeneration of one- or two-walled
intrabony defects when the buccal wall was absent.
Method and materials
Patient selection
Nine stage III to IV periodontitis patients, receiving periodontal
therapy at the Postgraduate Periodontal Clinic of the Faculty of
Odontology at the Complutense University of Madrid, were
selected to be treated with the AICAST periodontal regenera-
tion approach when fulfilling the following inclusion criteria:
QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022
Calzavara et al
1c
■ at least 18 years old
■ < 20% full-mouth bleeding and plaque scores at reevalu-
ation after steps 1 and 243
■ presenting one- or two-walled intrabony defects, with a
missing buccal bone wall (residual PPD ≥ 6 mm and intra-
bony component ≥ 3 mm), located on single-rooted teeth
(excluding mandibular premolars)
The following patients were excluded:
■ pregnant or lactating women
■ patients undergoing systemic treatment that could alter
wound healing
■ patients smoking > 10 cigarettes per day
■ patients with defects involving mainly the palatal/lingual
aspect of the tooth.
Preoperative treatments
After the completion of step 1 of therapy (including oral
hygiene instructions), subgingival instrumentation was per-
formed in all the cases as part of step II of therapy.19 The subgin-
gival instrumentation on the defect-associated teeth and on
the adjacent teeth was performed as atraumatically as possible,
using P3 ultrasonic tips (EMS, Nyon) and rubber cups. When the
affected teeth presented negative vitality, these teeth were
also treated with appropriate root canal therapy. Patients were
reevaluated 8 to 12 weeks later19 and, when in presence of
deep residual PPDs and radiographically evident infrabony
lesions with an intrabony component of ≥ 3 mm, the third step
of therapy including periodontal regeneration surgery through
AICAST was planned.
25
 PERIODONTOLOGY
2a 2b
3b
3a Figs 3a to 3c Root instrumentation by means of ultrasonic devices, curettes, and burs.
Surgical technique (AICAST)
Once the area was fully anesthetized after infiltration with artic-
aine plus 1:100,000 epinephrine, intrasulcular incisions on the
affected and two adjacent teeth were carried with ophthalmic
microblades (Mini-crescent knives, Sharpoint, Surgical Special-
ties). Furthermore, a horizontal incision at a distance from the
gingival margin of at least 10 mm (to avoid vascular injury to
the flap) was made at the bottom of the vestibule through the
lining mucosa with a 15c blade. This incision extended mesiodis-
tally to include the affected and two adjacent teeth (Fig 1).
From this horizontal incision, a full-thickness mucoperios-
teal flap was raised in a coronal direction, until reaching the gin-
gival margin of the involved teeth. When raising the flap, the
defect-associated granulation tissue was raised together with
the flap by inserting a curette with its cutting edge towards the
bone (Fig 2). The granulation tissue was not removed, in order
to maximize the soft tissue thickness in the coronal part of the
flap and to take advantage of its possible regenerative poten-
26 QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022
Figs 2a and 2b Full-thickness flap elevation; the
granulation tissue was not removed, but raised together
with the flap by inserting a curette into the defect with
its cutting edge towards the bone.
3c
tial.44 Once the affected papilla and the flap were totally released
from the underlying bone, the root surfaces were instrumented
by means of ultrasonic devices, curettes, and burs (Fig 3). Then,
an ethylenediaminetetraacetic acid gel (EDTA; PrefGel, Strau-
mann) was applied onto the root surfaces for 2 minutes; once
irrigated with saline solution and subsequently dried, enamel
matrix derivatives (Emdogain, Straumann) were applied in
combination with a bovine bone-derived xenograft (Bio-Oss,
Geistlich), filling both the intrabony and the suprabony compo-
nents of the defect (Figs 4 and 5). The need for xenograft appli-
cation is explained by the non-self-containing nature of the
treated defects,45 with the consequent soft tissue tendency to
collapse into the suprabony component of the defects (and, in
some cases, also into the intrabony ones). The suture of the api-
cal incision was carried out in two planes using monofilament
resorbable 6/0 sutures. The first plane was realized with internal
horizontal mattress sutures, and the second one with inter-
rupted loop sutures to maximize primary intention healing
(Fig 6). Teeth presenting mobility degree 2 or 3 were splinted.

Figs 4a and 4b Application of EMD.
4a
Figs 5a and 5b Application of a bovine bone-
derived xenograft, to fill both the intrabony and the
supra-bony components of the defects, pulling
coronally the defect-associated interdental papilla.
5a
In situations (four out of nine cases) where a buccal gingival
recession was present preoperatively in the tooth affected by
the deep intrabony defect and there was indication to cover it,
a connective tissue graft (CTG) was incorporated to the AICAST
procedure. First, a free gingival graft was harvested from the
palatal mucosa and secondarily de-epithelized, then the graft
was either sutured on the inner aspect of the buccal flap by two
internal vertical mattress sutures or secured to the bone by
means of fixation pins. In these cases a suspensory suture in the
interdental papillae was performed to coronally pull the CTG
(described in Calzavara et al42) and then the apical incision was
sutured secondarily.
Postoperative protocol
After surgery, 600 mg ibuprofen three times a day for 4 days
and 500 mg of amoxicillin three times a day for 7 days were pre-
scribed. Patients were instructed to avoid tooth brushing and
using any kind of interdental cleaning during the first week.
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Calzavara et al
4b
5b
Then a surgical toothbrush was recommended for 2 weeks and
thereafter the standard mechanical hygiene procedures were
reestablished. During the first month, patients also rinsed with
0.12% chlorhexidine digluconate mouthwash twice daily for
1 minute. The sutures closing the palatal wound were removed
1-week postoperatively, and AICAST sutures were removed
after 2 weeks. Patients received periodontal supportive care
monthly for the first 6 months after surgery, and then subse-
quently every 3 months.
Outcome measures
Clinical parameters (PPD, recession depth [REC], clinical attach-
ment level [CAL]) were collected before the regenerative surgi-
cal procedure and at the last available follow-up by a single
calibrated investigator (DC) at six sites/teeth using a PCP15
periodontal probe (HuFriedy). CAL change was considered as
the primary outcome of the study. Moreover, periapical radio-
graphs of the treated teeth were collected at baseline and at
27
 PERIODONTOLOGY

Figs 6a and 6b Suspensory

suture in the interdental
papillae and suture of the
apical incision by means of
a first suture plane consisting
of internal horizontal mattress
sutures, and a second one
consisting of interrupted
sutures in order to attain
primary intention healing.
6a 6b

Table 1 Baseline (presurgical) clinical parameters of the defect-associated sites (mean ± SD)

Subgroup analysis: follow-up time Subgroup analysis: CTG application

All cases – last 18 months mean 5 years mean

Variables available follow-up follow-up cases follow-up cases CTG cases No CTG cases
46.30 ± 37.06 47.62 ± 40.17 41.66 ± 35.35 66.67 ± 40.82 30.00 ± 27.39
BoP (%) 75.92 ± 25.15 80.95 ± 22.42 58.33 ± 35.35 79.17 ± 31.55 73.33 ± 22.36
PPD (mm) 8.65 ± 1.61 8.52 ± 1.08 9.08 ± 3.65 8.17 ± 1.13 9.03 ± 1.96
REC (mm) 2.20 ± 1.69 2.31 ± 1.83 1.83 ± 1.65 3.12 ± 1.84 1.47 ± 1.30
CAL (mm) 10.85 ± 2.26 10.83 ± 2.48 10.92 ± 2.0 11.29 ± 2.14 10.50 ± 2.54
BoP, bleeding on probing; CAL, clinical attachment level; CI, confidence interval; PPD, probing pocket depth; REC, recession depth.

ative values were analyzed by the Wilcoxon rank sum test for
intra-group comparisons. Differences were considered statisti-
cally significant when P values were < .05. Subgroup analyses
are presented according to the length of follow-up and to the
use of a CTG. The statistical analyses were performed using the
IBM SPSS v22 software.

7
Results
Fig 7 Two-week healing of case 1, demonstrating
uneventful primary intention healing. At baseline, mean values of the clinical parameters were:
PPD = 8.65 ± 1.61 mm, REC = 2.2 ± 1.69 mm, and CAL = 10.85 ±
2.26 mm (Table 1).
After AICAST, healing was uneventful and primary closure
the last available follow-up. In two cases, the last available fol- was attained in all cases (Figs 7 and 8).
low-up was 5 years from the surgical intervention, while in the At the last follow-up, the mean values of the clinical param-
remaining 7 cases, it was 18 months. eters were PPD = 2.59 ± 0.92 mm, REC = 1.05 ± 0.92 mm, and
CAL = 3.65 ± 1.32 mm (Table 2). A resulting PPD reduction of
6.05 ± 1.76 mm, a REC reduction of 1.15 ± 1.97 mm, and a CAL
Statistical analyses
gain of 7.20 ± 2.13 mm were present (Table 3). While both PPD
Results are presented as mean ± standard deviation (SD). Changes reduction and CAL gains were statistically significant (P < .01),
in the clinical parameters between preoperative and postoper- REC reduction was not (P = .119).

28 QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022


Figs 8a to 8d Comparison of the
preoperative view (a and b) with 5 years
of follow-up (c and d) of case 1, demon-
strating increase in papilla height,
recession reduction, and radiographic
filling of both the intrabony (complete)
and suprabony (partial) components of
the defect.
8a
8c
Subgroup analyses regarding follow-up time revealed non-
statistically significantly higher PPD reductions and CAL gain
for the two cases with 5 years of follow-up, when compared
with the cases with 18 months of follow-up. On the other hand,
cases treated with the use of a CTG resulted in a nonstatistically
significantly higher recession reduction and lower PPD reduc-
tion than the cases treated without the addition of a CTG.
CAL gains of ≥ 6 mm were achieved in eight out of nine
treated sites (88.9%), and PPD of ≤ 3 mm was achieved in all
cases (Table 4).
Figures 9 and 10 depict the photographic and radiographic
changes, respectively. A reduction in depth of the preoperative
recession type 3 (RT3) gingival recession was present in four of
the cases. A gain in the height of the interdental papilla was
visible in one of the cases. Complete radiographic filling of the
intrabony component of the defect was apparent in all cases,
and filling of the suprabony component also occurred in two
cases (ie, follow-up bone level more coronal than the top of the
radiographic bone defect visible at baseline: cases 1 and 6).
Discussion
The present retrospective case series has shown how the
AICAST is able to consistently attain clinical and radiographic
findings compatible with complete periodontal regeneration
QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022
Calzavara et al
8b
8d
of the intrabony components of one- and two-wall defects.
Moreover, the application of this surgical technique also
achieved in selected cases a partial fill of the suprabony com-
ponent of the defects, a gain in the height of the interdental
papillae, and a reduction of preoperative RT3 midbuccal gingi-
val recessions.
With the application of classic minimally invasive papilla
preservation flap designs in periodontal regeneration (eg,
papilla preservation techniques, minimally invasive surgical
technique [MIST], and modified MIST [M-MIST]), the potential
for regeneration is limited by the space available under the
papillae, usually being the coronal aspect of the intrabony
component the anatomical limit for new attachment. It is
hypothesized that the AICAST is able to move coronally this
limit, since this surgical design allows for the advancement of
the interdental tissue coronally. The subsequent filling of this
space by xenogeneic bone replacement graft and a stabilized
blood clot supported by the biologic effect of EMD could allow
regeneration of part of the suprabony component of the lesion.
This effect was clearly demonstrated in two of the nine cases
included in this case series, with evident suprabony clinical
attachment gain and radiographic bone fill.
The clinical outcomes reported in the present case series uti-
lizing the AICAST flap design are comparable to those reported
in clinical trials using papilla preservation techniques,46 MIST,30
29
 PERIODONTOLOGY

Table 2 Follow-up (18 months to 5 years) clinical parameters of the defect-associated sites (mean ± SD)

Subgroup analysis: follow-up time Subgroup analysis: CTG application

All cases – last available 18-months mean 5-years mean follow-up

Variables follow-up follow-up cases cases CTG cases No CTG cases
Plaque (%) 12.96 ± 13.89 14.28 ± 14.99 8.33 ± 11.78 12.50 ± 15.95 13.33 ± 13.94
BoP (%) 9.26 ± 14.70 9.52 ± 16.26 8.33 ± 11.78 8.33 ± 16.66 10.00 ± 14.90
PPD (mm) 2.59 ± 0.92 2.85 ± 0.85 1.66 ± 0.47 2.75 ± 0.86 2.47 ± 1.04
REC (mm) 1.05 ± 0.92 1.17 ± 0.95 0.66 ± 0.94 1.04 ± 1.25 1.07 ± 0.72
CAL (mm) 3.65 ± 1.32 4.02 ± 1.24 2.33 ± 0.47 3.79 ± 1.65 3.53 ± 1.19
BoP, bleeding on probing; CAL, clinical attachment level; CI, confidence interval; PPD, probing pocket depth; REC, recession depth.

Table 3 Change in clinical parameters of the defect-associated sites between baseline and follow-up (mean ± SD)

Subgroup analysis: follow-up time Subgroup analysis: CTG application

All cases – last 18-months mean 5-years mean

Variables available follow-up follow-up cases follow-up cases CTG cases No CTG cases
Plaque changes (%) 33.33 ± 39.08* 33.33 ± 40.82 33.33 ± 47.14 54.16 ± 41.66 16.66 ± 31.18
BoP changes (%) 66.66 ± 23.57** 71.42 ± 23.02* 50.00 ± 23.57 70.83 ± 28.46 63.33 ± 21.73*
PPD changes (mm) 6.05 ± 1.76 5.66 ± 0.73* 7.42 ± 4.12 5.41 ± 0.93 6.57 ± 2.20*
REC changes (mm) 1.15 ± 1.97 1.14 ± 2.01 1.16 ± 2.59 2.08 ± 1.83 0.40 ± 1.92
CAL changes (mm) * 7.20 ± 2.13 ** 6.81 ± 2.19* 8.58 ± 1.53 7.50 ± 1.08 6.96 ± 2.83*
BoP, bleeding on probing; CAL, clinical attachment level; CI, confidence interval; PPD, probing pocket depth; REC, recession depth.
*Statistically significant (P < .05).
**Highly statistically significant (P < .01).

Table 4 Frequency distribution (number and percentage of treated lary approach, firstly described by Azzi et al,40 with a similar sur-
defects) of CAL gain and residual PPD at last follow-up
gical concept to the design described in the present report
(non-incised papilla surgical approach [NIPSA]48), has also
CAL gain Residual PPD
demonstrated suprabony clinical attachment gains. However,
Amount n (%) n (%) despite the obvious similarities, some differences between
0–1 mm 0 (0.0) 0 (0.0) AICAST and NIPSA are present, including the incision location,
2–3 mm 1 (11.1) 9 (100.0) the preservation of the granulation tissue, the coronal advance-
4–5 mm 0 (0.0) 0 (0.0) ment, the suturing technique and its possible combination with
≥ 6 mm 8 (88.9) 0 (0.0) a CTG. These differences in the present authors’ opinion are crit-
CAL, clinical attachment level; PPD, probing pocket depth. ical, since with the AICAST the coronal advancement of the inter-
dental tissue is favored. These surgical particularities may explain
the positive performance of AICAST in the regeneration of deep
isolated intra-bony lesions and, at least in two cases, the long-
term maintenance (5 years) of these regenerative outcomes.
M-MIST,31 single-flap approach (SFA),32 and entire papilla preser- In addition to this enhanced regenerative potential, the
vation (EPP).47 However, in all those studies, the reported clinical AICAST allows combination with the use of a CTG, with the
and radiographic findings were confined to the intrabony com- eventual secondary objective of reducing preoperative mid-
ponent of the defects. A recent modification of the apical papil- buccal RT3 gingival recessions.49 In contrast, most of the papilla

30 QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022

 Calzavara et al

9a 9b

9c 9d

9e 9f

9g 9h

Figs 9a to 9i Comparison of the preoperative photographs (left)

with those from the last available follow-up (right).

9i

preservation and minimally invasive surgical approaches for
periodontal regeneration have shown an increase in postoper-
ative gingival recession.35,50,51 Only the NIPSA and the soft-tissue
wall technique have shown a reduction in the preexisting gin-
gival recession,36,48 comparable with those reported in this case
series when CTG was used in combination with AICAST.
The main limitations of the present study are represented
by its retrospective design, the lack of a control group, the few
included defects, and the limited available data (eg, lack of
standardized radiographs to measure bone levels, and ab-
sence of clinical measurements of papilla height and kerati-
nized tissue).

QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022 31

 PERIODONTOLOGY

Figs 10a to 10i Comparison of

the preoperative radiographs (left)
with those from the last available
follow-up (right).

10a 10b

10c 10d

10e 10f

10g 10h

10i

32 QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022

 Calzavara et al

Conclusion Acknowledgment

The results from this case series show the performance of the The authors thank Periopixel for providing the graphic illustra-
AICAST in the treatment of one- or two-walled intrabony tions.
defects, with loss of the buccal bone wall, resulting in significant
clinical attachment gains and a reduction in preoperative gin-
Disclosure
gival recession. These results, however, must be interpreted
with caution, since this surgical design may have limitations The authors declare no conflicts of interest related to this study,
when applied to defects mainly involving the lingual/palatal which was self-funded by the authors and their institutions.
aspect and with complex anatomy or limited accessibility. The
generated hypothesis of possible suprabony periodontal regen-
eration must be demonstrated in well-designed clinical trials.

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Dino Calzavara Javier Sanz Associate Professor, Section of Graduate Periodon-

Dino Calzavara Assistant Professor, Section of Graduate Peri-
odontology, Faculty of Odontology, University Complutense,
Madrid, Spain
Segio Morante Assistant Professor, Section of Graduate Peri-
odontology, Faculty of Odontology, University Complutense,
Madrid, Spain
tology, Faculty of Odontology, University Complutense, Madrid,
Spain; and ETEP (Etiology and Therapy of Periodontal and Peri-im-
plant Diseases) Research Group, University Complutense, Madrid,
Spain
Fernando Noguerol DrOdont Candidate, Section of Graduate
Periodontology, Faculty of Odontology, University Complutense,
Madrid, Spain
Jerian Gonzalez DrOdont Candidate, Section of Graduate Peri-
odontology, Faculty of Odontology, University Complutense,
Madrid, Spain
Mario Romandini Research Fellow, Section of Graduate Peri-
odontology, Faculty of Odontology, University Complutense,
Madrid, Spain
Mariano Sanz Head, Section of Graduate Periodontology, Facul-
ty of Odontology, University Complutense, Madrid, Spain; and
ETEP (Etiology and Therapy of Periodontal and Peri-implant Diseases)
Research Group, University Complutense, Madrid, Spain

Correspondence: Mario Romandini, Universidad Complutense de Madrid, Facultad de Odontología, Plaza Ramón y Cajal 3, 28040 Madrid,
Spain. Email: mario.romandini@gmail.com

34 QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022

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