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Case Series
Microsurgical Approach to Periodontal Regeneration.
Initial Evaluation in a Case Cohort*
Pierpaolo Cortellini and Maurizio S. Tonetti
Background: Improvements in flap design and soft
tissue manipulation are considered key elements in
improving the outcomes of regenerative periodontal
surgery. Improved visual acuity and better soft tissue
handling resulting from the application of a micro-
surgical approach hold great promise to further
improve predictability of periodontal regeneration.
The aim of this study was to preliminarily evaluate
the outcomes of a microsurgical approach in the
regenerative therapy of deep intrabony defects.
Methods: This patient cohort study involved 26
patients with one deep interdental intrabony defect
each. They were treated with periodontal regeneration
using guided tissue regeneration membranes. Defects
were accessed with previously described papilla
preservation flaps performed with the aid of an oper-
ating microscope and microsurgical instruments. A
stringent plaque control regimen was enforced in all
the patients during the 1-year observation period.
Outcomes included evaluation of the complete pri-
mary closure of the interdental space (closure), gains
in clinical attachment (CAL), and reductions in prob-
ing depths (PD).
Results: Closure was achieved in all treated defects
and was maintained in 92.3% of cases for the entire
healing period. Associated gains in CAL were 5.4 ±
1.2 mm on average, corresponding to a CAL gain of
82.8 ± 14.7% of the initial intrabony component of the
defect. Average PD reduction was 5.8 ± 1.4 mm and
was associated with minimal increase in gingival
recession (0.4 ± 0.7 mm).
Conclusions: The use of a microsurgical approach
was associated with very high ability to obtain and
maintain primary closure of the interdental tissues
over the barrier membranes. The procedure resulted
in clinically important amounts of CAL gains and
minimal recessions. J Periodontol 2001;72:559-569.
KEY WORDS
Periodontal diseases/surgery; periodontal
regeneration; outcome assessment; surgical flaps;
periodontal attachment loss/prevention and
control; periodontal probes.
* Department of Periodontology, Eastman Dental Institute and Hospital,
University College London, London, UK.
J Periodontol • April 2001
Research conducted mostly in the past decade has
clearly established that the variability in the outcomes
of periodontal regenerative procedures is dependent
on a variety of factors.1-5 These include: 1) patient
factors such as cigarette smoking, control of peri-
odontitis, oral hygiene, etc.; 2) defect anatomy-asso-
ciated factors such as depth of the intrabony com-
ponent of the defect, width of the radiographic defect
angle, and probing depth; and 3) technical/surgical
factors. Among the latter group, membrane exposure
and contamination have been associated with reduced
outcomes.6-10 This is a frequent complication in GTR
therapy.7-14 Lack of primary closure of the flap in the
interdental area is almost universal whenever no spe-
cial precaution is taken to preserve the interdental
papillae. Reduced outcomes were also observed when
the regenerated tissue was not properly protected
with the flap, upon removal of non-resorbable barrier
membranes.1,15
Similar problems were encountered with bone
grafting; in a large case series, lack of primary clo-
sure of the flap was observed in a substantial pro-
portion of sites.16 This occurrence was associated
with exfoliation of the grafted material and greatly
reduced outcomes. These pieces of evidence clearly
indicate that a variety of factors associated with soft
tissue manipulation play an important role in deter-
mining the outcome of regenerative treatment.
Results of a controlled clinical trial published in
1995 demonstrated that different combinations of
surgical approaches and barrier membranes resulted
in different amounts of clinical attachment level
gains.17 This evidence strongly suggests that opti-
mization of the surgical approach and control of sur-
gical variables, particularly in relation to flap design
and management, can improve outcomes.
In fact, the ability to access the defect, apply the
chosen regenerative technology, and then seal the
regenerating wound from the contaminated oral envi-
ronment seem to be key requirements in regenera-
tive surgery.
These problems were already being addressed in
the 1980s, with the aim to improve graft retention.
Takei et al.18 described a papilla preservation flap
aimed at improving graft retention through buccal or
559
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Case Series
lingual positioning of the interdental incision. In the
context of guided tissue regeneration (GTR), several
specific flap designs were described.17,19-22 These
were aimed at the full preservation of the soft tissues
during access to the defect, proper selection and posi-
tioning of the barrier membrane, and accurate sutur-
ing techniques to obtain primary closure of the flap
over the membrane, avoiding the complications
associated with flap dehiscence and membrane
exposure. Experimental testing of these regenerative
flap designs reported great improvements in achiev-
ing primary closure during the surgical session, with
optimal interdental closure being obtained in virtu-
ally all cases.19,20 During the subsequent healing,
however, dehiscence of the interdental tissue and
membrane exposure were observed in up to a third
of the cases.
To further improve the ability of clinicians to
accomplish and maintain primary closure of the tis-
sues over a GTR membrane, a bone graft, and/or a
biological regenerative preparation, the use of a
microsurgical approach could be considered.
The microscope has been proposed as an opera-
tive tool in various fields of dentistry.23-28 Its advo-
cated advantages in dentistry, and in periodontal
surgery in particular, relate to the enhanced visual
acuity associated with magnification and improved
illumination of the field. Combining enhanced visual
acuity with the use of specifically designed micro-
surgical instruments could allow a more accurate and
atraumatic manipulation of the soft and hard tissues,
increase the ability to properly debride the defect and
the root surfaces, and enhance the possibility to
obtain primary wound closure. As of today, however,
no clinical studies have documented the use and pos-
sible advantages of operating microscopes in peri-
odontology.
The aim of the present study was to preliminarily
evaluate the outcomes of a microsurgical approach
in the regenerative therapy of deep intrabony defects.
MATERIALS AND METHODS
Study Population and Experimental Design
Twenty-six deep intrabony defects in 26 subjects
(mean age, 41.1 ± 10.6 ± 10.1; range 25 to 63 years;
15 females; 3 smokers) were included in this case
series. Admission criteria were: 1) Absence of rele-
vant medical conditions. Patients with uncontrolled
or poorly controlled diabetes, unstable or life threat-
ening conditions, or requiring antibiotic prophylaxis
were excluded. 2) Smoking status. Heavy smokers
(more than 20 cigarettes/day) were excluded. 3)
560 Microsurgical Approach to Periodontal Regeneration
Defect anatomy. The presence of at least one tooth
with a deep interproximal vertical defect, with clini-
cal attachment level loss of at least 6 mm and radio-
graphic evidence of a deep intrabony component.
Patients underwent initial therapy consisting of
scaling and root planing, motivation, and oral hygiene
instructions. Three months after completion of initial
therapy, baseline clinical measurements were
recorded. Surgical procedures, according to the prin-
ciples of GTR, were performed with the aid of an
operating microscope, microsurgical instruments, and
materials. Measurements of the defects were taken
during surgery. Patients were enrolled in a stringent
periodontal supportive care program for 1 year. At 1
year, clinical measurements were recorded. Surgery
and measurements were performed independently by
the 2 authors.
Clinical Measures at Baseline and at 1 Year
The following clinical parameters were evaluated at
baseline and 1 year after GTR therapy. Full-mouth
plaque scores (FMPS) were recorded as the per-
centage of total surfaces (4 aspects per tooth) which
revealed the presence of plaque.29 Bleeding on prob-
ing (BOP) was assessed dichotomously at a force of
0.3 N with a manual pressure-sensitive probe; full-
mouth bleeding scores (FMBS) were then calcu-
lated.11 Probing depth (PD) and recession of the gin-
gival margin (REC) were recorded to the nearest mil-
limeter with a manual pressure-sensitive probe at the
deepest location of the selected interproximal site.
All measurements and BOP were taken with a pres-
sure-sensitive manual periodontal probe at 0.3 N.
Clinical attachment levels (CAL) were calculated as
the sum of PD and REC. The radiographic defect
angle was measured on a periapical radiograph, as
previously described.30
Treatment Approach
The intrabony defects were treated with GTR ther-
apy.11,17,20 The appropriate treatment strategy in the
different cases was selected according to a previ-
ously described, evidence-based operative decision
tree21 (Fig. 1).
The surgical access to the defects was selected
from among 3 different surgical approaches: the sim-
plified papilla preservation flap (SPPF),20 the modi-
fied papilla preservation technique (MPPT),19 and the
crestal incision.21 The SPPF was performed when-
ever the smallest mesio-distal width of the papilla
was 2 mm or narrower. The MPPT was used at sites
with an interdental width greater than 2 mm, while the
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Figure 1.
Treatment decision tree. See text for explanation (modified from Cortellini and Tonetti,
reference 21). SPPF = simplified papilla preservation flap; MPPT = modified papilla
preservation technique; FGG = free gingival graft.
crestal incision was applied next to an edentulous
area.
Selection of the barrier membrane was based on
21
the defect anatomy. A non-resorbable expanded
polytetrafluoroethylene (ePTFE) titanium-reinforced
†
membrane was used when the defect anatomy was
not “supportive,” such as in wide and 1- or 2-wall
defects. A bioabsorbable membrane was preferred in
‡
“supportive” defects, like the narrow and 3-wall
defects.
The suturing approach was chosen according to
the defect anatomy or to the type of membrane
used.21 It consisted of 2 sutures: a deep one aimed
at relief of residual tension of the flap and coronal
anchorage of the tissues; and a more superficial
suture aimed at passive closure of the margins of the
wound in the area of the interdental papilla. In sup-
portive defects or in the presence of a titanium ePTFE
membrane, an internal horizontal crossed mattress
19
suture was used. In non-supportive defects and in
the presence of bioabsorbable membranes, an offset
internal mattress suture was preferred.
When a crestal incision was performed, internal
horizontal mattress sutures were applied. All these
sutures were aimed at relieving the tension of the flap
in the defect-associated interdental space. A second
suture was then positioned to obtain primary closure
of the papilla over the barrier membranes in the
absence of tension.
J Periodontol • April 2001
Case Series
The surgical procedures were performed
with the aid of an operating microscope§ at
a magnification of 4× to 16×. Microsurgical
instruments were utilized, whenever needed,
as a complement to the normal periodontal
set of instruments. Incisions were carried out
using delaminating microsurgical blades and
5-0 ePTFE sutures† were used to relieve the
tension of the flaps, while 6-0 or 7-0 ePTFE
sutures† were preferred to obtain primary
closure of the interdental tissues. Before ini-
tiation of the study, both clinicians completed
an 18-month learning curve specifically
designed to acquire periodontal microsurgi-
cal skills.
Primary closure of the flaps over the
membranes was recorded at completion of
surgery and at weekly recalls for a period of
6 weeks.
A protocol for the control of bacterial con-
tamination consisting of doxycycline (2/d.i.e.
for 1 week), 0.12% chlorhexidine mouth rins-
ing 3 times per day, and weekly prophylaxis
was prescribed. 11 Patients were requested to avoid
brushing, flossing, and chewing in the treated area for
periods spanning 6 to 10 weeks. Non-resorbable
membranes were removed after 4 to 6 weeks. Patients
resumed full oral hygiene and chewing function 2 to
4 weeks after membrane removal or when bioab-
sorbable membranes were fully resorbed; at that point,
patients were placed on monthly recall for 1 year.11
Clinical Characterization of Selected Sites
Defect morphology was characterized intrasurgically
in terms of distance between the cemento-enamel
junction and the bottom of the defect (CEJ-BD) and
total depth of the infrabony component of the defect
(INFRA), as previously described.31
Data Analysis
Data were expressed as means ± standard deviation
of 26 defects in 26 patients. No data points were
missing. Comparisons between baseline and 1-year
data were made using the t test (alpha = 0.05). Pri-
mary closure of the flap and clinical attachment level
20 gains (CAL gains) were the primary outcome variable.
Percentage fill of the baseline intrabony component
of the defect was calculated as: CAL% = (CAL gains)/
INFRA * 100.
† W.L. Gore & Associates, Inc., Flagstaff, AZ.
‡ Guidor AB Novum, Huddinge, Sweden.
§ Protege System, Global Surgical Corp., St. Louis, MO.
 Advanced Surgical Technologies, Sacramento, CA.
Cortellini, Tonetti 561
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Case Series
RESULTS interdental membrane exposure. In this case. the
Patient and Defect Characteristics at Baseline membrane was removed at week 5.
Full-mouth plaque scores and full-mouth bleeding 1-Year Clinical Outcomes
scores at baseline were 15.5 ± 3.5% and 11.7 ± 3.3%, The 26 patients presented at the 1-year follow-up
respectively (Table 1). Clinical attachment levels visit with FMPS and FMBS of 11.1 ± 3.1% and 7.2 ±
(CAL) of 10.2 ± 1.6 mm and probing depths (PD) of 2.2%, respectively.
9.1 ± 1.5 mm were recorded (Table 1). The radio-
graphic defect angle was 31.7 ± 8.8 degrees.
The distance from the cemento-enamel junction
to the bottom of the defect (CEJ-BD) was 11.2 ± 1.7
mm, and the infrabony component of the defects
(INFRA) was 6.6 ± 1.8 mm (Table 1).
Selection of Surgical Flap
The simplified papilla preservation flap (Figs. 2, 3,
and 4) was used in 6 sites, while the modified papilla
preservation technique (Figs. 5 through 9) was
selected in 14 cases (Table 2). The remaining 6 sites,
presenting with defects adjacent to edentulous areas,
were accessed with a crestal incision (Figs. 10 and
11). A total of 18 bioabsorbable membranes and 8
titanium-reinforced non-resorbable ePTFE mem-
branes were positioned (Table 2). The latter were
used in some of the wide interdental spaces in com-
bination with the MPPT and, in the edentulous sites,
in combination with the crestal incision.
Primary Closure of the Flap
In all treated sites, primary closure was obtained at
completion of the surgical procedure and maintained
at the 1-week follow-up, when sutures were removed
(Table 3). At week 2, one site, accessed with the
SPPF, was found opened, and the bioabsorbable bar-
rier membrane slightly exposed. At week 4, a second
site, accessed with the MPPT in combination with a
titanium-reinforced ePTFE membrane, showed an

Table 1.
Baseline Patient and Defect Characteristics
(N  26)

Characteristic Measurement

FMPS (%) 15.5 ± 3.5

FMBS (%) 11.7 ± 3.3

CAL (mm) 10.2 ± 1.6

PD (mm) 9.1 ± 1.5 Figure 2.

Case 1. A 7 mm pocket was detected at the mesial site of the upper
Rx-angle (degrees) 31.7 ± 8.8
first right bicuspid (A).The narrow interdental space (<2 mm; B)
CEJ-BD (mm) 11.2 ± 1.7 was accessed with a simplified papilla preservation flap.The 5 mm
intrabony defect (C) was covered with a bioabsorbable membrane
INFRA (mm) 6.6 ± 1.8 (D).

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Figure 3.
Case 1. The interdental tissues were sutured over the barrier
membrane with a combination of an offset suture to relieve flap
tension, and a second suture to obtain primary closure of the
interdental space (A and B). At suture removal, no dehiscence of
the soft tissues was noted, and the membrane was fully covered at
the buccal, lingual, and interdental sites (C and D).
J Periodontol • April 2001
Case Series
Figure 4.
Case 1. At 1 year, the soft tissues, including the interdental papilla,
were perfectly preserved: no gingival recession was noted (A and B).
The radiographs show the baseline defect (C) and the 1-year
remineralization of the intrabony component of the defect (D).
Cortellini, Tonetti 563
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Case Series
Figure 5.
Case 2. Upper left cuspid (A) presenting with a 5 mm intrabony
defect at the mesial site (B).The wide interdental space (>2 mm)
was accessed with a modified papilla preservation technique. A
titanium-reinforced ePTFE membrane was positioned to cover the
defect and support the soft tissues (C).The interdental space was
closed with a combination of a crossed mattress suture to relieve
flap tension and a second suture to obtain primary closure of the
interdental tissues (D).
564 Microsurgical Approach to Periodontal Regeneration
Figure 6.
Case 2. After 6 weeks, the interdental tissues were fully preserved
and the membrane still covered and protected (A). After membrane
removal, the defect appeared to be filled with regenerated tissue
(B).The regenerated tissue was carefully protected with the flap (C).
At 1 year, the interdental papilla and the buccal tissues did not show
any marginal recession (D). Note the spontaneous resolution of the
slight diastema between the lateral incisor and the cuspid.
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Case Series

Figure 7.
Case 2. Radiographs taken at baseline (left) and at 1-year follow-up
visit (right), showing the complete resolution of the intrabony
component of the defect.

The 1-year CAL was 4.8 ± 1.2 mm, with a clinical

attachment gain of 5.4 ± 1.2 mm. Differences in CAL
between baseline and 1 year were clinically and sta-
tistically highly significant (P <0.0001) (Table 4).
The 1-year CAL% was 82.8 ± 14.7%, with a range
of 57% to 100%. CAL reached 100% of the baseline
intrabony component of the defect in 35% of the cases.
Residual probing depths were 3.3 ± 0.6 mm, with
a PD reduction of 5.8 ± 1.4 mm.
Differences between baseline and 1-year probing
depths were clinically and statistically highly signifi-
cant (P <0.0001).
An increase of 0.4 ± 0.7 mm in gingival recession
between baseline and 1 year was noted. This differ-
ence was statistically significant (P = 0.004).

DISCUSSION
In the present study, an operating microscope and
microsurgical instruments were utilized to increase the
ability of the clinicians to control the surgical manipu-
lation of the soft tissues during regenerative periodon- Figure 8.
tal surgery. Overall rationale comes from the recogni- Case 3. Lower left first molar presenting with an intrabony defect 6
mm deep at the mesial site (A and B).The interdental papilla was
tion that lack of primary closure of the interdental space accessed with a modified papilla preservation technique. A
and consequent bacterial contamination of the regen- bioabsorbable barrier membrane was positioned (C) and fully
erating wound represent one of the most significant covered with the interdental tissues (D).
factors leading to compromised outcomes of regener-
ative surgery. An important element in improving
regenerative outcomes is the ability to achieve and
maintain primary closure of the flaps in the critical using specific flap designs to access the defects; 2)
interdental area. In this preliminary investigation, peri- optimize defect debridement and root instrumentation;
odontal microsurgery was applied with the objectives 3) ensure optimal delivery of the regenerative tech-
to: 1) improve tissue preservation and handling while nology; 4) optimize flap mobility in order to achieve pri-

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Case Series
Figure 9.
Case 3. Primary closure of the interdental space was maintained at
suture removal (A). At 1-year follow-up visit, a 3 mm probing depth
and no interdental recession were noted (B).The baseline (C) and
1-year (D) radiographs show the complete resolution of the
intrabony component of the defect.
mary closure of the interdental space; and 5) precisely
apply a 2-layered suture approach.
Results indicated that the clinical attachment level
gains at 1 year were 5.4 ± 1.2 mm. These results
were obtained in defects with an intrabony compo-
566 Microsurgical Approach to Periodontal Regeneration
Table 2.
Surgical Strategy
Type of Membrane
Flap N Bioabsorbable ePTFE Titanium
SPPF 6 6 0
MPPT 14 9 5
Crestal 6 3 3
Total 26 18 8
nent of 6.6 ± 1.8 mm. The percent clinical attachment
gain therefore was 82.8 ± 14.7%. This indicates that
a large part of the intrabony component of the defects
was resolved. Using the Ellegaard and Löe32 criteria,
resolution of the intrabony component of the defect
was either satisfactory or complete in all treated
cases. In particular, 35% of the defects had attach-
ment level gains equal to the baseline depth of the
intrabony component. Historical comparison with clin-
ical experiments using bone grafting or GTR clearly
indicates that the results of this trial are in the top per-
centiles in terms of attachment gains and defect res-
olution (for review see references 21 and 33).
The increment in recession of the gingival margin
between baseline and 1 year was only 0.4 ± 0.7 mm.
This excellent result could also relate to the soft tis-
sue preservation and atraumatic manipulation dur-
ing surgery, favored by the use of microsurgery. The
optimal clinical outcomes obtained with this micro-
surgical approach are further underlined by the shal-
low residual probing depths of 3.3 ± 0.6 mm observed
in the treated sites. These are relevant notations, since
one of the goals of regenerative treatment of intra-
bony defects is the reduction in probing depths while
causing minimal gingival recession.
With regard to primary closure of the flaps over the
barrier membranes, it was technically possible to
achieve complete primary closure in 100% of the
treated interdental sites. Closure was maintained in
92.3% of cases for the entire healing period. Under
these circumstances, it is reasonable to assume that
wound healing occurred in a sealed environment with
minimal levels of bacterial contamination and opti-
mal stability of the wound margins. It is also evident
that the ability to obtain and maintain primary clo-
sure allows optimal retention and biological activity
of materials applied into the wound environment to
differentially modulate the healing process.
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Case Series

Figure 11.
Case 3. Baseline radiograph (left) showing the depth and the extent
of the bony defect. At 1 year, the radiograph (right) demonstrates
the complete resolution of the intrabony component of the defect.

Table 3.
Number of Treated Sites With Primary
Flap Closure (%) Over the Membrane at
Baseline and at Each Follow-up Week
(N  26)

Time Primary Closure

Surgery 100

Week 1 100

Week 2 96.1

Week 3 96.1

Week 4 92.3

Week 5 92.3

Figure 10. Week 6 92.3

Case 3. The upper right cuspid (A) was a strategically important
abutment and showed an 11 mm distal pocket. A deep intrabony
defect involved the distal, palatal, and mesial aspect of the tooth (B).
The area was accessed with a crestal incision. A titanium-reinforced
ePTFE membrane was positioned and fully covered with the flaps
(C). At 1 year, the mesial probing depth was 3 mm (D).
In this study, all sites treated with the crestal inci-
sion remained closed over time; one of the 6 (11.9%)
treated with SPPF was found open at week 2; and
one of the 14 (7.1%) treated with MPPT was found
open at week 4. Historical comparisons with studies
performed by the same authors without the use of
an operating microscope show a clear advantage in
the use of a microsurgical approach. In fact, the
authors observed membrane exposure during heal-
ing in 33% of cases treated with SPPF20 and in 27%
of sites treated with MPPT.19 Furthermore, the results
of an independent, randomized, multicenter, con-
trolled clinical trial, testing the efficacy of GTR com-

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Case Series
Table 4.
Baseline and 1-Year Clinical Measurements
(mm)
Baseline 1 Year Difference Significance
CAL 10.2 ± 1.6 4.8 ± 1.2 5.4 ± 1.2 P <0.0001
PD 9.1 ± 1.5 3.3 ± 0.6 5.8 ± 1.4 P <0.0001
Rec 1.1 ± 0.9 1.5 ± 1.0 0.4 ± 0.7 P = 0.004
bined with SPPF to access defects, reported mem-
brane exposure in 53.6% of cases (unpublished data).
The advantages of using a microscope in GTR ther-
apy relates to the improved illumination and magni-
fication of the surgical field that allow a more precise
and atraumatic manipulation of the soft and hard tis-
sues. In particular, the surgical access to interdental
spaces is greatly improved. The delicate and narrow
interdental soft tissues can be sharply dissected with
a clear direct vision using microblades, thus avoid-
ing trauma and unnecessary removal of soft tissues.
Defect debridement and instrumentation of the root
surfaces are perfected. The control of membrane posi-
tioning and stabilization is extremely accurate. The
positioning and suturing of the flaps over the mem-
brane can be performed with the best chances to
obtain primary closure. Though anecdotal, authors
felt that the above-mentioned refinements and pos-
sibly the extra care and time devoted to the proce-
dure when doing microsurgery could somehow
explain the observed improvements in outcomes.
More investigations are needed to objectively evalu-
ate these reported advantages.
In conclusion, the use of a microsurgical approach
in this series of cases treated with regenerative peri-
odontal surgery was associated with very high abil-
ity to predictably obtain and maintain primary closure
of the interdental tissues over the barrier membranes.
The procedure resulted in large amounts of clinical
attachment level gains and minimal recessions at 1
year.
ACKNOWLEDGMENTS
This study was partly supported by the Accademia
Toscana di Ricerca Odontostomatologica, Firenze,
Italy and the Periodontal Research Fund of the Depart-
ment of Periodontology of the Eastman Dental Insti-
tute, London, UK.
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