Apical approach in periodontal reconstructive surgery with enamel matrix derivate and enamel matrix derivate plus bone substitutes: a randomized, controlled clinical trial

Objectives This parallel, randomized controlled clinical trial evaluated the influence of bone substitutes (BS) on the efficacy of the non-incised papillae surgical approach (NIPSA) with enamel matrix derivate (EMD) in resolving deep, isolated, combined non-contained intrabony and supra-alveolar periodontal defects, preserving the soft tissue. Material and methods Twenty-four patients were randomized to treatment with NIPSA and EMD or NIPSA plus EMD and BS. Bleeding on probing (BoP), interproximal clinical attachment level (CAL), interproximal probing depth (PD), recession (REC), location of the tip of the papilla (TP), and width of the keratinized tissue (KT) were evaluated before surgery and at 1 year post-surgery (primary outcomes). Wound closure was assessed at 1 week post-surgery, and supra-alveolar attachment gain (SUPRA-AG) was recorded at 1 year post-surgery. Results At 1 week, 87.5% of cases registered complete wound closure and there were no cases of necrosis, without differences between groups (p > .05). At 1 year, all cases showed negative BoP. A significant PD reduction (NIPSA + EMD 8.25 +/- 2.70 mm vs. NIPSA + EMD + BS 6.83 +/- 0.81 mm) and CAL gain (NIPSA + EMD 8.33 +/- 2.74 mm vs. NIPSA + EMD + BS 7.08 +/- 2.68 mm) were observed (p < .001) in both groups, without significant between-group differences (p > .05). The residual PD was < 5 mm in all defects (NIPSA + EMD 2.50 +/- 0.67 mm vs. NIPSA + EMD + BS 2.67 +/- 0.78 mm). Soft tissues were preserved without significant between-group differences (REC: NIPSA + EMD 0.25 +/- 0.45 mm vs. NIPSA + EMD + BS 0.17 +/- 0.58 mm, p > .05; KT: 0.00 +/- 0.43 mm vs. 0.08 +/- 0.67 mm, p > .05). There were improvements in the papilla in both groups (TP: NIPSA + EMD 0.33 +/- 0.49 mm vs. NIPSA + EMD + BS 0.45 +/- 0.52 mm, p > .05), which was only significant in the NIPSA EMD + BS group (0.45 +/- 0.52 mm; p < .05). In both groups, CAL gain was recorded in the supra-alveolar component, showing full resolution of the intrabony component of the defect in all cases (SUPRA-AG: NIPSA + EMD 1.83 +/- 1.11 mm vs. NIPSA + EMD + BS 2.00 +/- 1.76 mm, p > .05). Conclusions NIPSA and EMD with or without BS seem to be a valid surgical approach in the treatment of isolated, deep non-contained periodontal defects. In our study, both treatments resulted in significant PD reduction and CAL gain, that extended in the supra-alveolar component, without differences with the use of BS. Both treatments resulted in soft tissue preservation. However, the addition of BS may improve interdental papillary tissue. Clinical relevance NIPSA, with or without bone substitutes, resulted in significant periodontal improvement, with soft tissue preservation in isolated, deep non-contained periodontal defects. The application of bone substitutes may provide interproximal soft tissue gain.