• Users Online: 172
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2017  |  Volume : 7  |  Issue : 1  |  Page : 24-29

Minimally invasive surgical techniques in periodontal regeneration

1 Department of Periodontology and Oral Implantology, J. S. S. Dental College and Hospital, J. S. S. University, Mysore, Karnataka, India
2 Department of Public Health Dentistry, J. S. S. Dental College and Hospital, J. S. S. University, Mysore, Karnataka, India

Date of Web Publication3-Jul-2017

Correspondence Address:
Swet Nisha
Department of Periodontology Oral Implantology, Room No 9, J. S. S. Dental College and Hospital, S. S. Nagar, Bannimantap, Mysore - 570 015
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijohs.ijohs_20_17

Rights and Permissions

There are recent advances in periodontal surgical techniques, from resection to regeneration, the focus of surgical access has shifted to regeneration of lost tissues. To achieve goals of periodontal surgical therapy, minimal invasive surgery can be considered as a potential future for the treatment of periodontal disease with the concept of being minimal in our treatment approaches. This article reviews the various techniques, its applications, and future prospects of minimal invasive periodontal surgery.

Keywords: Minimal invasive periodontal surgery, minimally invasive surgery, periodontal regeneration

How to cite this article:
Nisha S, Shashikumar P, Samyuktha GS. Minimally invasive surgical techniques in periodontal regeneration. Int J Oral Health Sci 2017;7:24-9

How to cite this URL:
Nisha S, Shashikumar P, Samyuktha GS. Minimally invasive surgical techniques in periodontal regeneration. Int J Oral Health Sci [serial online] 2017 [cited 2023 Jun 1];7:24-9. Available from: https://www.ijohsjournal.org/text.asp?2017/7/1/24/209348

  Introduction Top

Surgery is a scary thing from the patient's perspective. Periodontal surgery targets access to the underlying bony defect, pocket elimination, periodontal regeneration, and maintenance of healthy periodontium. Traditional periodontal surgical procedures used extensive flap operation to access underlying disease area which causes bone exposure.[1]

With advances in surgical procedures, there is a paradigm shift from periodontal resection to regeneration.[2] Although periodontal resection remains surgical choice for definite pocket reduction, regeneration of lost periodontal tissues remains challenging to the clinician.[3] Any surgical procedure should be easy to perform from operators side, less time taking, less pain and postoperative discomfort, less costly and more acceptable, and beneficial to the general population. Taking consideration to all these in 1995, the term minimally invasive surgery (MIS) was introduced in periodontology by Harrel and Ress, to minimize wounds and flap reflection.[4]

The concept of minimal invasive surgery is being practiced for years in various field of medicine and surgery. Laparoscopic cholecystectomy, microsurgery of the eye, ear, nerve injury using surgical microscope has gained popularity. These procedures result in early wound healing, better patient acceptance.

MIS helps in handling hard and soft tissues gently during periodontal surgery. Isolated defects not extending beyond the interproximal site were considered ideal for this technique. Incisions were aimed at conserving the soft tissue as much as possible. In cases of multiple isolated defects, individual incisions for each site should be given.

Generalized periodontitis cases require quadrant surgery, long incision, and vertical releasing incision to gain access to deeper pockets.[5] This results in postoperative soft tissue recession.[6] The ideal surgical approach for periodontal regeneration would be one that allows access to the site to be regenerated without extending the surgical incision into adjacent healthy areas.[5]

Taking this into account, the first technical proposal introduced in periodontal regenerative surgery was MIS.[4] The authors suggested the use of MIS in combination with bone grafting material covered with a bioresorbable vicryl mesh to treat isolated and multiple intrabony defects. The technique consists of an initial intrasulcular incision around the teeth neighboring the defect, followed by an incision between the teeth, usually on the lingual aspect, to connect the preliminary intrasulcular ones. The papilla is sharply dissected from the underlying bone, and small buccal and lingual flaps are carefully reflected. The connective tissue within the osseous defect is dissected with a blade and removed with curettes and ultrasonic instruments, and the root is debrided. The authors suggested finalizing root planing with finishing burs. Root conditioning with citric acid is also suggested, followed by placement of decalcified freeze-dried bone allograft mixed with tetracycline hydrochloric acid to fill or slightly overfill the defect. The flap was sutured with vertical parallel mattress sutures to obtain primary closure.[5]

Wickham and Fitzpatric 1999 described the techniques of using smaller incisions as “MIS.”[7] Hunter and Sackier in 1993 described the minimal invasive approach as “the ability to miniaturize our eyes and extend our hands to perform microscopic and macroscopic operations in places that could previously be reached only by large incisions.”[8]

Tibbetts and Shanelec 1994 described periodontal microsurgical technique and concentrated on soft tissue regeneration and augmentation using a surgical operating microscope.[9]

  Minimally Invasive Surgical Approach for Periodontal Regeneration Top


  • Isolated, interproximal bone defect, not extending beyond the interproximal site [5]
  • Periodontal defects that border on an edentulous area
  • Periodontal defect that extend from buccal/lingual from interproximal site
  • Multiple separate defect sites within a single quadrant.


  • Generalized horizontal bone defect [5]
  • Multiple interconnected vertical defects, walls.[5]

General consideration for minimally invasive surgery

  • All incisions are designed to conserve soft tissues
  • Separate incisions are performed, continuous incisions are avoided
  • Vertical releasing incisions are avoided
  • Coverage of graft/membrane by soft tissue is achieved to promote periodontal regeneration, for example, if the bony defect is in esthetic areas, incision is given in palatal papilla [5]
  • Tissues are reflected by sharp dissection or combination of blunt and sharp
  • Adequate visualization of the procedure requires magnification and light source. Surgical microscope, loupes ×3.5 magnification can be used [5]
  • Root surface debridement becomes difficult as minimal flap reflection is performed to preserve tissues. Mechanical debridement can be performed tip of curette inserted vertically and shank held parallel to the tooth surface. Ultrasonic scalers can be used to break the granulation tissues
  • Placement of bone graft material – plastic plunger gun can be used for precise placement of graft material
  • Interproximal site can be closed by vertical mattress sutures. 6-0 resorbable suture can be used.

  Minimally Invasive Periodontal Surgical Therapy: Techniques Top

Cortellini and Tonetti proposed the minimally invasive surgical technique (MIST) in 2007.[10] Later, they introduced the concept of space provision for regeneration with the modified MIST (M-MIST, Cortellini et al. 2009).[15]

In the MIST approach, the defect-associated interdental papilla is accessed either with the simplified papilla preservation flap (SPPF)[24] in narrow interdental spaces or the modified papilla preservation technique (MPPT)[25],[26] in large interdental spaces.

The SPPF is a diagonal incision traced as close as possible to the buccal side of the papilla col, whereas the MPPT is a horizontal incision traced on the buccal side of the papilla [Figure 1]. Intrasulcular incisions are performed from the interdental side to the buccal and lingual sides of the teeth neighboring the defect; tiny buccal and lingual flaps are elevated to expose the residual bone crest. Periosteal incisions are performed only if needed to improve flap reflection. The soft tissue is sharply dissected from the osseous defect and debridement and root planing are performed with a combination of mini-curettes and power air-driven instruments [Figure 2]. Ethylenediaminetetraacetic acid is applied to the air-dried root surface for 2 min and then carefully washed away, and enamel matrix derivative is applied on the air-dried root surface. The suturing approach is based on the use of a single internal mattress sutures [Figure 3].
Figure 1: Modified papilla preservation technique incision

Click here to view
Figure 2: Open flap debridement

Click here to view
Figure 3: Suture placed

Click here to view

Cortellini and Tonetti [10] proposed the application of a single MIS technique to treat multiple adjacent defects. The surgical modification includes an extension of the flap to all the teeth involved by osseous defects. The larger flap is minimally reflected in accordance with the previously described principles.

More recently, Cortellini and Tonetti [15] proposed M-MIST. The surgical approach consists of a tiny interdental access in which only buccal intrasulcular incisions are performed and connected with a buccal horizontal incision of the papilla performed as close as possible to the papilla tip.

The tiny buccal triangular flap is elevated to expose the residual buccal bone crest. The papillary tissues are left untouched, carefully preserving the supracrestal attachment apparatus to the root cement of the crest-associated tooth. Access to the defect is gained through the tiny buccal “window.” The soft tissue filling the defect (i.e., the so-called granulation tissue) is sharply dissected from the papillary supracrestal connective tissue and removed with mini-curettes.

Then, the root surface is carefully debrided with mini-curettes and power-driven air instruments avoiding any trauma to the supracrestal fibers of the defect-associated papilla. The palatal tissues are not surgically accessed. The suturing approach is based on the use of a single internal modified mattress suture. Additional sutures can be applied to further increase primary closure, when needed. M-MIST cannot be applied to all periodontal defects.[11] Its limits are the access to the diseased root surface. Whenever a defect extending to the lingual/palatal side of a root is difficult to debride, the authors suggest raising the papilla and performing a MIST approach.

The MIS [4] and the MIST [27] include the elevation of the interdental papillary tissues to uncover the interdental space, gaining complete access to the intrabony defect, whereas the M-MIST [11] proposes an approach in which the access to the defect is gained through the elevation of a small buccal flap, without elevation of the interdental papilla.

Single-flap approach consists of a buccal envelope flap without vertical releasing incisions.[28] Sulcular incisions are performed following the gingival margin of the teeth included in the surgical area. The mesiodistal extension of the flap is kept limited while ensuring access for defect debridement and placement of any bone biomaterial or membrane.

An oblique or horizontal, butt-joint incision is made after the profile of the underlying bone crest at the level of the interdental papilla overlying the intraosseous defect; the greater the distance from the tip of the papilla to the underlying bone crest, the more apical (i.e., close to the base of the papilla) the buccal incision in the interdental area.

At wound closure, a horizontal internal mattress suture was placed between the buccal flap and the base of the attached oral papilla coronal to the mucogingival junction to ensure repositioning of the buccal flap. For each defect, a microsurgical periosteal elevator was used to raise a flap on the buccal side only, leaving the oral portion of the interdental supracrestal soft tissues undetached. Root and defect debridement were performed using hand and ultrasonic instruments. At the completion of the surgical debridement, defects were left to fill with a blood clot. A second internal mattress suture (vertical or horizontal) was placed between the most coronal portion of the flap and the most coronal portion of the oral papilla to ensure wound closure for primary intention healing.

The recent meta-analysis suggested no significant difference in treatment of intra-bony defects between the MIS plus biomaterials group and the MIS alone group [Table 1] indicating that it is important to take costs and benefits into consideration when a decision is made about a therapeutic approach.[23]
Table 1: Overview of Minimally invasive surgical Techniques with clinical outcomes

Click here to view

Summary of studies in a tabulate form is illustrated in [Table 1] providing an overview of different technique used in MIST with clinical outcomes.

Minimally invasive soft tissue grafting is predictable for root coverage procedures with advantage of (i) no surface incisions, thus no scarring; (ii) use of an allograft, which eliminates need for a palatal donor site; (iii) reduced patient discomfort; (iv) greater acceptance of treatment; and (v) ideal esthetics. Tunnel and pouch technique described by Allen includes minimal incision, soft tissue grafting, and precise suturing to gain optimal esthetic outcomes.[29]

Advantages minimally invasive surgical techniques in periodontal regeneration

  • Less postoperative pain
  • Improvement in rate of healing [5]
  • Chair time required to perform such a surgery is by far shorter than the chair time required for more conventional surgical approaches [30]
  • Improved retention of soft height and contour
  • Periodontal tissue regeneration
  • Good patient acceptance.


  • Technique sensitive
  • MIS needs improved instruments for root and osseous defect debridement, “micro” versions of the instruments
  • Expensive
  • Cannot be universally applied, only in suitable cases technique can be performed.[31]

  Videoscope Assisted Minimally Invasive Surgery  Top

The term videoscope-assisted MIS (V-MIS) is used to describe MIS performed with the aid of a videoscope. Harrel et al. in 2014 conducted a study to evaluate residual defects following nonsurgical therapy consisting of root planing with local anesthetic.[32] V-MIS was performed utilizing the videoscope for surgical visualization. Reevaluation, 6 months postsurgery, showed statistically significant improvement (P < 0.001) in mean probing pocket depth (PPD) and clinical attachment level (CAL) (PPD 3.88 ± 1.02 mm, CAL 4.04 ± 1.38 mm) in 1, 2, and 3 wall defects.

  Robot-Assisted Minimally Invasive Surgery Top

Robotically assisted MIS uses end effectors and manipulators of the robotic arms to perform the actual surgery on the patient. These arms can either be controlled by a telemanipulator or through computer control. However, it is cumbersome to use, expensive, and needs expertise.[33]

  Conclusion Top

The future for improvements in periodontal therapy is virtually limitless. Proper case selection, flap design, equipment will be beneficial in evaluating the efficacy of MIS toward periodontal regeneration. Limitations in case selection, cost, and mastering the technique are issues to be faced in acceptance of this technique. Studies have shown limited patient morbidity and excellent clinical improvements with MIS. MIS has a future potential to become a mainstream and eventually, the dominant therapeutic approach. The combination of positive scientific evidence and advances in technology will allow rapid advancement in the field of minimal invasive surgery.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Schluger S. Osseous resection; a basic principle in periodontal surgery. Oral Surg Oral Med Oral Pathol 1949;2:316-25.  Back to cited text no. 1
Garrett S. Periodontal regeneration around natural teeth. Ann Periodontol 1996;1:621-66.  Back to cited text no. 2
Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP, Dyer JK. Long-term evaluation of periodontal therapy: I. Response of four treatment modalities. J Periodontol. 1996;67:93-102.  Back to cited text no. 3
Harrel SK, Rees TD. Granulation tissue removal in routine and minimally invasive procedures. Compend Contin Educ Dent 1995;16:960, 962, 964.  Back to cited text no. 4
Harrel SK. A minimally invasive surgical approach for periodontal regeneration: Surgical technique and observations. J Periodontol 1999;70:1547-57.  Back to cited text no. 5
Anderegg CR, Metzler DG, Nicoll BK. Gingiva thickness in guided tissue regeneration and associated recession at facial furcation defects. J Periodontol 1995;66:397-402.  Back to cited text no. 6
Fitzpatrick JM, Wickham JE. Minimally invasive surgery. Br J Surg 1990;77:721-2.  Back to cited text no. 7
Hunter JG, Sackier JM, editors. Minimally invasive high tech surgery; into the 21st century. In: Minimally Invasive Surgery. New York: McGraw-Hill; 1993. p. 3-6.  Back to cited text no. 8
Tibbetts LS, Shanelec D. Periodontal microsurgery. Dent Clin North Am 1998;42:339-59.  Back to cited text no. 9
Cortellini P, Tonetti MS. A minimally invasive surgical technique with an enamel matrix derivative in the regenerative treatment of intra-bony defects: A novel approach to limit morbidity. J Clin Periodontol 2007;34:87-93.  Back to cited text no. 10
Cortellini P, Tonetti MS. Improved wound stability with a modified minimally invasive surgical technique in the regenerative treatment of isolated interdental intrabony defects. J Clin Periodontol 2009;36:157-63.  Back to cited text no. 11
Cortellini P, Nieri M, Prato GP, Tonetti MS. Single minimally invasive surgical technique (MIST) with an enamel matrix derivative (EMD) to treat multiple adjacent intra-bony defects: Clinical outcomes and patient morbidity. J Clin Periodontol 2008;35:605-13.  Back to cited text no. 12
Ribeiro FV, Casarin RC, Júnior FH, Sallum EA, Casati MZ. The role of enamel matrix derivative protein in minimally invasive surgery in treating intrabony defects in single-rooted teeth: A randomized clinical trial. J Periodontol 2011;82:522-32.  Back to cited text no. 13
Ribeiro FV, Casarin RC, Palma MA, Júnior FH, Sallum EA, Casati MZ. Clinical and microbiological changes after minimally invasive therapeutic approaches in intrabony defects: A 12-month follow-up. Clin Oral Investig 2013;17:1635-44.  Back to cited text no. 14
Cortellini P, Pini-Prato G, Nieri M, Tonetti MS. Minimally invasive surgical technique and enamel matrix derivative in intrabony defects: 2. Factors associated with healing outcomes. Int J Periodontics Restorative Dent 2009;29:257-65.  Back to cited text no. 15
Cortellini P, Tonetti MS. Clinical and radiographic outcomes of the modified minimally invasive surgical technique with and without regenerative materials: A randomized-controlled trial in intra-bony defects. J Clin Periodontol 2011;38:365-73.  Back to cited text no. 16
Trombelli L, Simonelli A, Pramstraller M, Wikesjö UM, Farina R. Single flap approach with and without guided tissue regeneration and a hydroxyapatite biomaterial in the management of intraosseous periodontal defects. J Periodontol 2010;81:1256-63.  Back to cited text no. 17
Mishra A, Avula H, Pathakota KR, Avula J. Efficacy of modified minimally invasive surgical technique in the treatment of human intrabony defects with or without use of rhPDGF-BB gel: A randomized controlled trial. J Clin Periodontol 2013;40:172-9.  Back to cited text no. 18
Harrel SK, Wilson TG, Nunn ME. Prospective assessment of the use of enamel matrix proteins with minimally invasive surgery. J Periodontol 2005;76:380-4.  Back to cited text no. 19
Trombelli L, Farina R, Franceschetti G, Calura G. Single-flap approach with buccal access in periodontal reconstructive procedures. J Periodontol 2009;80:353-60.  Back to cited text no. 20
Trombelli L, Simonelli A, Schincaglia GP, Cucchi A, Farina R. Single-flap approach for surgical debridement of deep intraosseous defects: A randomized controlled trial. J Periodontol 2012;83:27-35.  Back to cited text no. 21
Harrel SK, Wilson TG Jr., Nunn ME. Prospective assessment of the use of enamel matrix derivative with minimally invasive surgery: 6-year results. J Periodontol 2010;81:435-41.  Back to cited text no. 22
Ribeiro FV, Nociti Júnior FH, Sallum EA, Sallum AW, Casati MZ. Use of enamel matrix protein derivative with minimally invasive surgical approach in intra-bony periodontal defects: Clinical and patient-centered outcomes. Braz Dent J 2010;21:60-7.  Back to cited text no. 23
Liu S, Hu B, Zhang Y, Li W, Song J. Minimally invasive surgery combined with regenerative biomaterials in treating intra-bony defects: A meta-analysis. PLoS One 2016;11:e0147001.  Back to cited text no. 24
Cortellini P, Prato GP, Tonetti MS. The simplified papilla preservation flap. A novel surgical approach for the management of soft tissues in regenerative procedures. Int J Periodontics Restorative Dent 1999;19:589-99.  Back to cited text no. 25
Cortellini P, Prato GP, Tonetti MS. The modified papilla preservation technique. A new surgical approach for interproximal regenerative procedures. J Periodontol 1995;66:261-6.  Back to cited text no. 26
Cortellini P, Pini Prato G, Tonetti MS. Periodontal regeneration of human intrabony defects with titanium reinforced membranes. A controlled clinical trial. J Periodontol 1995;66:797-803.  Back to cited text no. 27
Cortellini P, Tonetti MS. Minimally invasive surgical technique (MIST) and enamel matrix derivative (EMD) in intrabony defects. (I) Clinical outcomes and intra-operative and post-operative morbidity. J Clin Periodontol 2007;34:1082-8.  Back to cited text no. 28
Allen EP, editor. Multiple tooth recession: Papilla retention pouch procedure. In: Contemporary Oral Plastic Surgery Procedural Manual. Dallas, TX: Center for Advanced Dental Education; 2004. p. 9-16.  Back to cited text no. 29
Cortellini P. Minimally invasive surgical techniques in periodontal regeneration. J Evid Based Dent Pract 2012;12 3 Suppl: 89-100.  Back to cited text no. 30
Harrel SK. Minimally Invasive Periodontal Therapy: Clinical Techniques and Visualization Technology. 1st ed. John Wiley & Sons: United States; 2015.  Back to cited text no. 31
Harrel SK, Abraham CM, Rivera-Hidalgo F, Shulman JD, Nunn ME. Videoscope-assisted minimally invasive periodontal surgery (V-MIS). J Clin Periodontol 2014;41:900-7.  Back to cited text no. 32
Tan A, Ashrafian H, Scott AJ, Mason SE, Harling L, Athanasiou T, Ara Darzi. A Robotic surgery: disruptive innovation or unfulfilled promise? A systematic review and meta-analysis of the first 30 years. Surg Endosc. 2016; 30: 4330-52.  Back to cited text no. 33


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]

This article has been cited by
1 Assessment of knowledge and practice behaviors about minimally invasive surgical technique in periodontics among dental students, dental practitioners, and academicians: An online questionnaire-based study
Vineeta Gupta, Supriya Mishra, Sheetal Dahiya, DeepeshKumar Gupta, MP Gazala, ShirishKumar Kujur
Journal of Indian Association of Public Health Dentistry. 2023; 21(1): 34
[Pubmed] | [DOI]
2 Latest advancement in periodontology
Shaik Ali Hassan,Sumit Bhateja,Geetika Arora,Francis Prathyusha
IP International Journal of Periodontology and Implantology. 2020; 5(3): 97
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
   Minimally Invasi...
   Minimally Invasi...
   Videoscope Assis...
   Robot-Assisted M...
   Article Figures
   Article Tables

 Article Access Statistics
    PDF Downloaded2127    
    Comments [Add]    
    Cited by others 2    

Recommend this journal