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 673

Connective Tissue Graft Wall Technique and Enamel Matrix

Derivative for the Treatment of Infrabony Defects:
Case Reports

Giovanni Zucchelli, DDS, PhD1 The ultimate goal in periodontal

lham Mounssif, DDS, MSc2 therapy is the regeneration of a
Matteo Marzadori, DDS, MSc2 tooth-supporting apparatus that
Claudio Mazzotti, DDS, MSc2 has been destroyed as a result of
Pietro Felice, MD, DDS, PhD1 periodontal disease.1 Periodontal
Martina Stefanini, DDS, MSc, PhD2 regeneration is defined histologi-
cally as regeneration of the tooth’s
The present case report describes a modification of the connective tissue graft supporting tissues, including al-
wall technique with enamel matrix derivative applied to treat deep vertical veolar bone, periodontal ligament,
bony defects. The technique presented uses a palatal incision to gain access and cementum, over a previously
to the bony defect. Deep infrabony defects affecting two maxillary central
diseased root surface.2 Clinically, in
incisors associated with interdental and buccal gingival recession were treated.
At 1 year after surgery, 9 and 6 mm of interdental clinical attachment level ideal conditions, the gain in clinical
gain were seen in cases 1 and 2, respectively. The position of the interdental attachment level (CAL) following
papilla was improved, and complete root coverage was achieved. Radiographs regenerative therapy of infrabony
demonstrated bone fill of the infrabony components of the defects. This report defects should be equal to prob-
encourages the possibility to improve, in one surgical session, regenerative ing depth (PD) reduction; thus, gin-
and esthetic parameters in the treatment of deep infrabony defects. Int J
gival recession should not increase
Periodontics Restorative Dent 2017;37:673–681. doi: 10.11607/prd.3083
as a consequence of the treatment
procedures.3 Furthermore, gingi-
val recession represents the main
patient complaint when treating
the anterior segments of the denti-
tion. Therefore, minimizing gingival
recession must be considered one
of the principal goals, from a bio-
logic and clinical perspective, when
treating periodontal defects with
regenerative protocols. Critical clini-
cal components for successful out-
comes are wound and clot stability
Professor, Department of Biomedical and Neuromotor Sciences,
1
during the early healing phase,4,5
Bologna University, Bologna, Italy. space provision to allow migration
2Research Assistant, Department of Biomedical and Neuromotor Sciences,

Bologna University, Bologna, Italy.

and proliferation of cells from the
periodontal ligament and alveolar
Correspondence to: Dr Giovanni Zucchelli, Department of Biomedical and bone along the exposed root, and
Neuromotor Sciences, Bologna University, Via San Vitale 59, 40125 Bologna, Italy.
the completion and maintenance of
Fax: +00 39 0512088111. Email: giovanni.zucchelli@unibo.it
primary closure to ensure healing
 ©2017 by Quintessence Publishing Co Inc. without bacterial contamination.

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674

In recent decades, several peri- Recently, a novel technique was Case Report 1
odontal regenerative procedures introduced to improve root cov-
were proposed to obtain primary erage in gingival recession asso- A 35-year-old man was referred to
closure and flap stabilization above ciated with interdental hard and the Department of Biomedical and
the infrabony defect.6–9 soft tissue loss (Miller Class IV re- Neuromotor Sciences of Bologna
A microsurgical approach cession) by applying a connective University, Bologna, Italy, for treat-
for regenerative therapy has suc- tissue graft (CTG) in combination ment of severe, aggressive peri-
cessfully reduced patient morbid- with the enamel matrix derivative odontitis.
ity when treating deep, narrow (EMD) under a CAF. The patient’s medical history re-
intrabony defects.7 The minimally The CTG used in the study11 vealed no systemic contraindications
invasive surgical technique (MIST) acted as a buccal soft tissue barrier for dental treatment. The patient
and modification of this approach for the suprabony and infrabony presented several teeth with loss of
(M-MIST)8 were adopted to re- components of the defects and as periodontal support and infrabony
duce the extension of the flap, to a bilaminar technique to improve defects. His main concern was about
obtain primary closure of the in- root coverage. The capability of the maxillary left central incisor (tar-
terdental tissue, and to minimize the CTG under a CAF to improve get tooth). Clinical examination re-
gingival recession. Trombelli et al9 complete root coverage outcomes vealed that the tooth was extruded
proposed the single-flap approach has been extensively reported in (Fig 1) with buccal and interdental
(SFA) in conjunction with guided the literature.12–14 The use of CTG soft tissue recession located at the
tissue regeneration (GTR) with a to replace a missing buccal bone distal line angle. The distal interden-
bioresorbable membrane and graft plate has not been previously sug- tal papilla was extremely thin and
biomaterial. This procedure is spe- gested. However, the dense sub- narrow. The clinical parameters re-
cifically indicated for periodontal epithelial palatal connective tissue, corded at baseline were as follows:
reconstructive procedures in in- when firmly attached to the papil-
traosseous defects characterized lae neighboring the defect area • Distal site: CAL 12 mm,
by an extension prevalent on the and to the periosteum apical to the PD 11 mm, recession 1 mm
buccal or oral side. The basic prin- bottom of the bony defect, could • Buccal site: CAL 9 mm,
ciple of the SFA is the elevation of a represent a barrier rigid enough PD 8 mm, recession 1 mm
flap to access the defect only from to limit buccal soft tissue collapse • Mesial site: CAL 8 mm,
one side (buccal or oral), leaving the inside the bony defect and to help PD 8 mm, recession 0 mm
opposite side intact. The authors blood clot stabilization inside the • Palatal site: CAL 9 mm,
concluded that the SFA combined intrabony component of the de- PD 9 mm, recession 0 mm
with graft/GTR technique may heal fects. The coronal advancement
with a substantial CAL gain and of the buccal flap contributed to The radiographic examination
limited postsurgical recession, and minimizing soft tissue shrinkage showed a deep infrabony defect at
indicated that this technique might and helped blood clot stabilization the distal aspect and a shallower in-
represent a suitable option to sur- inside the intrabony defect. In this trabony defect mesial to the tooth.
gically treat defects in areas with case report, a modification of the The patient was treated with a
high esthetic demands. CTG wall technique was applied in cause-related therapy consisting of
To minimize soft tissue reces- the treatment of deep vertical bony scaling and root planing, motivation,
sion, Zucchelli and De Sanctis10 defects using a palatal incision to and oral hygiene instructions. Flap
proposed a novel approach com- gain access to the infrabony defect surgeries for pocket elimination in
bining papilla preservation tech- to minimize buccal and interdental the posterior areas were performed
nique and the coronally advanced soft tissue recession. prior to the treatment of the target
flap (CAF) for the esthetic zone. tooth.

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 675

Fig 1  Baseline situation in case 1. (a) The

central incisor was extruded with buccal and
interdental soft tissue recession located at
the distal line angle. The distal interdental
soft tissues were extremely thin and narrow.
(b) The radiograph showed a deep, one-
wall infrabony defect at the distal aspect
and a shallower intrabony defect mesial to
the central incisor.

a b

Fig 2  Case 1 surgical procedure. (a) The

supracrestal soft tissue was separated from
the palatal bone with a horizontal split-
thickness incision. (b) The supracrestal soft
tissue was gently pushed from the palatal
to the buccal aspect below the contact
point.
a b

The goals of cause-related the palatal anatomical papillae cov- low the contact point (Fig 2b). When
therapy in the area scheduled for re- ering the intrabony defects and at the buccal aspect of the supra-
generative surgery were to reduce the base of the two palatal papillae crestal soft tissue became mobile it
inflammation and minimize the soft of the interdental spaces neighbor- was time to elevate the buccal flap.
tissue recession. Elimination of supra ing the defects. The buccal flap was raised similiar
and subgingival bacterial plaque, The palatal incisions were bev- to the CAF designed for the treat-
toxins, and calculus was achieved by eled as much as possible in relation ment of multiple gingival recessions
means of ultrasonic devices. Small, to the palatal soft tissue thickness in soft tissue plastic surgery,15 with
thin ultrasonic points were used to elevate a split-thickness flap. The submarginal split-thickness surgical
to debride the root surface with objective was to reach the palatal papillae at the interdental spaces
minimal tissue contact to minimize bone as apically as possible and thus neighboring the defect area, while
currettage and subsequent tissue increase the extension of the palatal full-thickness elevation was per-
shrinkage of the interdental papilla soft tissue bevel. Once the palatal formed to complete buccal elevation
covering the intrabony defect. The bone was reached, flap elevation of the supra­crestal soft tissue com-
regenerative surgery was scheduled continued full thickness. Similar split- ing from the palatal aspect. Great
for 4 weeks after completing cause- thickness incisions were made at the care was taken to avoid trauma to
related therapy in the surgical area.10 base of the palatal papillae of the the supracrestal soft tissue during
The patient received preopera- interdental spaces neighboring the elevation. Once the supracrestal soft
tive antibiotics (amoxicillin 2 g). The defect to allow palatal flap eleva- tissue was completely raised (Fig
regenerative surgery consisted of tion as necessary to completely ex- 3), buccal flap elevation continued
palatal incisions to access the bony pose the palatal aspect of the bony split thickness to allow coronal ad-
defects and use of a combination of defect. The supracrestal soft tissue vancement of the flap. The remain-
EMD and a CTG under a coronally was separated from the palatal bone ing facial portion of the adjacent
advanced buccal flap. After local with a horizontal split-thickness inci- anatomical papillae was de-epithe-
anesthesia, horizontal split-thickness sion (Fig 2a) and then pushed from lialized to create connective tissue
incisons were made at the base of the palatal to the buccal aspect be- beds to which the surgical papillae

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676

covered the distance between the

two healthy papillae neighboring
the infrabony defect; the apicocoro-
nal dimension covered the distance
from the cementoenamel junction
a b (CEJ) of the healthy tooth to the buc-
Fig 3  Case 1 surgical procedure, buccal view. (a) The buccal flap was raised in a similar way
cal bone apical to the defect; the
to the coronally advanced flap designed for the treatment of multiple gingival recessions thickness was 1 mm.
with submarginal split-thickness surgical papillae at the interdental spaces neighboring In the coronal aspect, the CTG
the defect area and full-thickness elevation of the buccal flap. (b) After its complete
mobilization, the supracrestal soft tissue, coming from the palatal aspect, was gently was sutured at the base of the ana-
elevated, full thickness, together with the buccal flap. tomical papillae of the two teeth
neighboring the bony defect, while
apically it was secured at the peri-
osteum left in place on the buccal
bone apical to the bone defect with
single interrupted 7-0 polyglycolic
acid (PGA) sutures (Fig 4b).
Once sutured, the mid portion
a b
of the CTG resided buccally to the
bony defect and could act as a soft
tissue wall of the suprabony and in-
frabony components of the defect,
while the peripheral portions of the
CTG, covering the exposed buccal
root surfaces, might improve root
c d
coverage with respect to the CAF
Fig 4  Case 1 surgical procedure. (a) Buccal view after the flap elevation, showing the severe
infrabony defect. The deepest infrabony component measured 5 mm. (b) The connective alone.13,14 Coronal advancement
tissue graft (CTG) acts as a buccal soft tissue wall of the infrabony defect. The CTG was sutured of the buccal flap was obtained by
coronally at the base of the anatomical papillae of the two teeth neighboring the bony defect,
while apically it was secured at the periosteum left in place on the buccal bone apical to the
means of two split-thickness inci-
bone defect. (c, d) The flap was sutured using sling sutures suspended around the palatal sions: one deep, cutting the muscle
cingula of the treated teeth. The supracrestal soft tissue was pushed back in the palatal insertions on the periosteum, and
direction below the contact points, and a horizontal internal mattress suture was used to get
almost in contact the two beveled incisions of the supracrestal soft tissue and the palatal flap. one superficial, detaching muscle
Primary soft tissue closure was completed with single interrupted sutures at the palatal aspect. inserting in the inner aspect of the
mucosa lining the flap. Flap mobi-
lization was considered adequate
when the marginal portion of the
of the coronal advanced buccal flap tetracetic acid gel for 2 minutes to flap was able to passively reach a
were secured at the time of sutur- remove the smear layer. After the level coronal to the CEJ at every
ing. The granulation tissue filling the surgical area was rinsed with saline, tooth included in the flap design
infrabony defect was removed, and EMD gel was applied and left in and when the supracrestal soft tis-
root planing of the exposed root was place on the root surfaces and bony sue was able to be shifted coronally
performed. The deepest infrabony walls. A CTG16,17 deriving from the and passively fill the interdental
component measured 5 mm (Fig de-epithelialization of a free gingival space up to the contact point.
4a). The root surfaces were condi- graft harvested from the palate was All surgical papillae adjacent to
tioned with a 24% ethylenediamine­ prepared. The mesiodistal length the defects areas were anchored to

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 677

Fig 5  Schematic drawing of the suturing

technique. (a) The horizontal internal
mattress 6-0 PGA suture started perforating
at the base the buccal interdental soft
tissue just apical to the connective tissue
graft (1); perforated from inside the palatal
flap (2); perforated back from outside, 4
1 mm horizontally, the palatal flap (3); went 1
buccally and perforated from inside the
buccal flap 1 mm horizontally with respect 3
to the starting point (4); and was closed 2
with a knot. (b) Primary soft tissue closure
between the supracrestal soft tissue and
the palatal flap was achieved with single
interrupted 7-0 PGA sutures at the palatal
aspect.

a b

the corresponding de-epithelialized Primary soft tissue closure be- • Distal site: CAL 3 mm,
anatomical papillae using 6-0 poly- tween the supracrestal soft tissue PD 3 mm, recession 0 mm
glycolic acid (PGA) sling sutures, and the palatal flap was achieved • Buccal site: CAL 2 mm,
similar to those described for CAF with single interrupted 7-0 PGA PD 2 mm, recession 0 mm
treatment of multiple gingival reces- sutures at the palatal aspect (Fig • Mesial site: CAL 3 mm,
sions,15 suspended around the pala- 5b). PD 3 mm, recession 0 mm
tal cingula (Figs 4c and 4d). These The patient was instructed • Palatal site: CAL 3 mm,
sutures accomplished tight adapta- to rinse with a 0.12% solution of PD 3 mm, recession 0 mm
tion of the buccal flap to the dental chlorhexidine three times a day for
crowns and shifted the supracrestal 14 days (suture removal); he was The radiographic examination
soft tissue coronally. The supracrest- recalled once a week for profes- suggested complete fill of the in-
al soft tissue was pushed back in a sional tooth cleaning for the first 3 frabony component of the defects,
palatal direction below the contact months. Afterward, prophylaxis was both distal and mesial to the target
point, and a horizontal 6-0 PGA in- performed every 3 months until the tooth (Fig 6b). An enameloplasty at
ternal mattress suture was used to final 1-year visit. the target tooth was performed to
almost obtain contact with the su- correct the extrusion and align the
pracrestal soft tissue and the pala- incisal margin with the contralateral
tal flap11 (Fig 5a). This suture started Results incisor, and a restorative composite
perforating at the base of the buccal procedure was performed to re-
interdental soft tissue; perforated One year after the surgery, com- shape the target tooth to resemble
from inside the palatal flap; per- plete coverage of the recession of the adjacent contralateral incisor
forated back from outside, 1 mm the distal line angle was achieved. (Fig 6c). The patient was highly satis-
horizontally, the palatal flap; went The tip of the distal papilla was lo- fied with the esthetic appearance of
buccally and perforated from inside cated more coronal with respect to the treated area.
the buccal flap 1 mm horizontally the baseline position (Fig 6a). The 3-year follow-up visit re-
with respect to the starting point, The following clinical param- vealed clinical and radiologic
and was closed here with a knot. eters were recorded at 1 year: stability of the 1-year results with

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678

a b c
Fig 6  Clinical (a) and radiographic (b) results at 1-year follow-up visit of case 1. Note the esthetic improvement
of the interdental soft tissue; the tip of the distal papilla was located more coronally with respect to the baseline
position. The radiographs showed complete bone fill (c). A restorative composite procedure was performed to
correct the extrusion and reshape the target tooth to resemble the adjacent contralateral incisor.

Fig 7  Case 1 3-year clinical outcome (a).

Note the general improvement in the soft
tissue esthetic appearance and the increase
in soft tissue thickness. (b) Radiographic
examination at 3 years showed complete
filling of the infrabony defects and stability
of the radiologic outcomes over time.

a b

Fig 8  Baseline situation in case 2. (a)

The central incisor showed a buccal soft
tissue recession with lack of keratinized
tissue apical to the right central incisor. (b)
The radiograph showed a deep one-wall
infrabony defect at the mesial aspect of the
target tooth and the root canal therapy.

a b

further improvement of the inter- ment of an infrabony periodontal The neighboring teeth had no
dental soft tissues, filling the inter- defect affecting the maxillary right clinical or radiographic evidence of
dental spaces (Fig 7). central incisor. damage due to trauma. The target
The patient’s medical history tooth was previously splinted with
revealed no systemic contraindica- the adjacent teeth by the referral
Case Report 2 tions for dental treatment. The pa- dentist to reduce the mobility.
tient reported that 1 year before he At the time of the initial visit,
A 23-year-old man was referred to had a severe trauma in the anterior the clinical and radiographic exami-
the Department of Biomedical and maxilla. The target tooth underwent nation revealed a mesial infrabony
Neuromotor Sciences of Bologna root canal therapy due to irrevers- defect associated with a buccal gin-
University, Bologna, Italy, for treat- ible pulpitis. gival recession of 3 mm (Fig 8).

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 679

a b c
Fig 9  (a) Clinical results at 1-year follow-up of case 2: complete coverage of the gingival recession was achieved.
(b) At the 2-year follow-up, a restorative composite procedure was performed to reshape the target tooth and
reduce the interdental diastema. (c) Radiographic examination at 2 years showed filling of the infrabony defect.

The clinical parameters record- performed every 3 months until the for further improvement in the posi-
ed at baseline were as follows: final 1-year visit. tion of the tip of the interdental pa-
pilla. The patient was highly satisfied
• Distal site: CAL 3 mm, with the esthetic appearance of the
PD 3 mm, recession 0 mm Results treated area. The radiographic ex-
• Buccal site: CAL 8 mm, amination at 2 years (Fig 9c) showed
PD 5 mm, recession 3 mm At 1 year after the surgery, the buc- fill of the infrabony component of
• Mesial site: CAL 10 mm, cal gingival recession at the right the defect.
PD 10 mm, recession 0 mm central incisor was completely cov-
ered and the tip of the mesial pa-
The same regenerative proce- pilla was located a bit more coronal Discussion
dure used in case 1 was planned. with respect to the baseline position
The patient was treated with a (Fig 9a). The patient was very satis- The present case reports describe
cause-related therapy consisting of fied with the final esthetic outcome. a modification of the CTG wall tech-
oral hygiene instructions; scaling Some minor exposure of the graft nique for the treatment of deep
and root planing was performed in was visible at the buccal aspect of vertical bony defect associated with
the surgical area with a thin ultra- the left contralateral tooth. The fol- thin and narrow interdental soft tis-
sonic tip device to minimize trauma lowing clinical parameters were re- sue (case report 1) or buccal gingival
to the soft tissue. The previous splint corded at 1 year: recession (case report 2). The main
was removed and built in the palatal difference was the palatal incision to
aspect. • Distal site: CAL 3 mm, gain access to the infrabony defect.
The regenerative surgical pro- PD 3 mm, recession 0 mm This, combined with the use of the
cedure was scheduled 4 weeks after • Buccal site: CAL 2 mm, coronally advanced buccal flap and
completing cause-related therapy PD 2 mm, recession 0 mm the CTG wall, minimized buccal and
with a clinical protocol similar to that • Mesial site: CAL 4 mm, interdental soft tissue shrinkage and
used in case 1. The patient was in- PD 4 mm, recession 0 mm collapse.
structed to rinse with a 0.12% solu- By 1 year after the surgical treat-
tion of chlorhexidine three times a At 2 years after the surgery (Fig ment, complete coverage of the
day for 14 days (sutures removal); 9b), a restorative composite pro- buccal recession, clinical improve-
he was recalled once a week for cedure was performed to reshape ment of the interdental papilla, and
professional tooth cleaning for the the target tooth and reduce the significant interdental CAL gain and
first 3 months. Prophylaxis was then interdental diastema. This allowed PD reduction were achieved in both

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680

Fig 10  Schematic drawing of the surgical

procedure. (a) The dense subepithelial
palatal connective tissue graft (CTG)
might represent a barrier rigid enough to
compensate for the lack of buccal bone
wall and limit the collapse of the buccal
and suprabony soft tissue inside the bony
defect. (b) The CTG might help blood clot
stabilization inside the supra- and intrabony
component of the defects.

a b

cases. This clinical success was com- In the present case report, factors permitted improvement of
bined with radiographic fill of the in- deeper one-wall intrabony defects the position of the interdental soft
frabony component of the defects. with significat buccal and palatal tissue. (3) The palatal long beveled
In recent decades, several PD combined with buccal and in- incision allowed for increased con-
periodontal regenerative proce- terdental gingival recession were nective tissue contact between
dures were proposed to obtain treated. Both buccal and palatal the supracrestal soft tissue and the
primary soft tissue closure and flap flaps were raised to gain access to palatal flap at the time of suturing.
stabilization above the infrabony and visualize the bony defects. The This might improve primary soft tis-
defect. More recently, special at- primary objective of the treatment sue closure. (4) The palatal incision
tention was given to improvement was to regenerate the lost peri- reduced the risk of unesthetic out-
of the appearance of the soft tis- odontium apparatus, while the sec- come in case of nonideal soft tissue
sue covering and neighboring the ondary outcome was to treat the closure. (5) The dense subepithelial
infrabony defect.11,12 The CTG wall gingival recessions associated with palatal CTG might represent a bar-
technique suggested by Zucchelli the bone loss. rier rigid enough to compensate for
et al11 showed improved root cov- Several advantages can be as- the lack of buccal bone wall. It might
erage and interproximal periodon- cribed to the surgical procedure limit buccal and interdental soft tis-
tal parameters in the treatment of adopted in the presented case re- sue collapse inside the bony defect
gingival recession associated with ports (Fig 10): (1) The palatal incision and help blood clot stabilization in-
severe interdental bone loss. In this allowed the supracrestal soft tissue side the supra- and infrabony com-
technique, buccal access to the in- and the entire papillar complex to ponents of the defects. (6) The use
trabony defect and a single buccal remain connected to the buccal of CTG above the exposed buccal
flap approach were selected with flap and thus to be coronally ad- root surface combined with the CAF
the primary goal of improving root vanced with it. (2) The application allowed improved root coverage
coverage in Miller Class IV gingival of the CTG below the supracrestal and increased soft tissue thickness,
recession. The deep probing depth soft tissue prevented it from collaps- conditions that are necessary for
at the palatal/lingual aspect avoided ing inside the supra- and intrabony long-term stability of the root cover-
elevation of the palatal/lingual flap. components of the defects. These age outcome.

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 681

Conclusions References 11. Zucchelli G, Mazzotti C, Tirone F, Mele M,

Bellone P, Mounssif I. The connective tis-
sue graft wall technique and enamel ma-
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