J Clin Periodontol 2009; 36: 157–163 doi: 10.1111/j.1600-051X.2008.01352.

Improved wound stability with a Pierpaolo Cortellini1,2 and

Maurizio S. Tonetti2
1
Private Practice, Florence, Italy; 2European

modified minimally invasive Research Group on Periodontology

(ERGOPerio), Berne, Switzerland

surgical technique in the

regenerative treatment of isolated
interdental intrabony defects
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: 157–163. doi: 10.1111/j.1600-051X.2008.01352.

Abstract
Aims: This paper describes a modified surgical approach of the minimally invasive
surgical technique (modified minimally invasive surgical technique, M-MIST) and
preliminarily evaluates its applicability and clinical performances in the treatment of
isolated deep intrabony defects in combination with amelogenins.
Material and Methods: Twenty deep isolated intrabony defects in 20 patients were
studied. Fifteen were surgically accessed with the M-MIST, while in five sites, which
presented a lingual intrabony component, the conventional MIST had to be applied.
The M-MIST consisted of a buccal incision of the defect-associated papilla, according
to the principles of the papilla preservation techniques. Only a buccal flap was raised
while the interdental papilla was left in situ. The granulation tissue filling the defect
was dissected and removed, leaving the interdental and palatal tissues untouched. Root
instrumentation and application of the regenerative material were performed before
suturing. Primary closure of the flaps was attained with a single internal modified
mattress suture. Surgery was performed with the aid of an operating microscope and
microsurgical instruments.
Results: The surgical chair-time of the M-MIST-treated sites (N 5 15) was
56  8.64 min. Early wound healing was uneventful: primary wound closure was
attained and maintained in all sites. No oedema or haematoma was noted. Patients did
not report pain or discomfort. The 1-year clinical attachment level (CAL) gain was
4.5  1.4 mm in defects 6  1.5 mm deep. Residual probing depths (PDs) were
3.1  0.6 mm. A minimal increase of 0.1  0.3 mm in gingival recession between
baseline and 1 year was observed. Key words: clinical trial; microsurgery;
osseous defects; periodontal diseases;
Conclusions: M-MIST was applicable on 15 isolated interproximal defects out of 20 periodontal regeneration
selected ones. It resulted in very limited patient morbidity and excellent clinical
improvements. These outcomes should be confirmed in a larger study. Accepted for publication 23 October 2008

Conflict of interest and sources of

In the last decade, some clinical inves- ling of the soft and hard tissues in
funding statement tigators have focused their interest on periodontal surgery (Harrel & Nunn
the development of minimally invasive 2001, Harrel et al. 2005). Cortellini &
This study has been self-supported by the
surgical approaches in periodontal sur- Tonetti (2001, 2002, 2004) and Wachtel
authors and the European Research Group
on Periodontology.
gery. Harrel & Rees (1995) proposed the et al. (2003) tested the use of operative
PC and MT have lectured for Straumann minimally invasive surgery (MIS) with microscopes and microsurgical instru-
(and previously for Biora). the aim to produce minimal wounds, ments to increase visual acuity and
minimal flap reflection and gentle hand- accuracy in the application of papilla
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158 Cortellini & Tonetti

preservation flaps in periodontal regen- treatment. All subjects gave informed 2. Defect anatomy. Presence of at least
eration. written consent. one tooth with probing pocket depth
Recently, a new surgical approach, Inclusion/exclusion criteria were as (PPD) and CAL loss of at least 5 mm
the ‘‘minimally invasive surgical tech- follows: associated with an intrabony defect
nique (MIST)’’, has been proposed to of at least 3 mm involving predomi-
treat isolated intrabony defects with nantly the interdental space of the
periodontal regeneration (Cortellini & 1. Patients in good general health. tooth. Teeth that presented a detect-
Tonetti 2007a). The background foun- Patients with uncontrolled or poorly able buccal and/or a lingual intrab-
dations for this technique are the con- controlled diabetes, unstable or life- ony component were excluded.
cepts of the (MIS, Harrel & Rees 1995) threatening conditions, or requiring 3. Smoking status. Only non-smokers
and the application of papilla preserva- antibiotic prophylaxis were excluded. were included.
tion techniques (Cortellini et al. 1995,
1999) with a microsurgical approach
(Cortellini & Tonetti 2001, 2005).
Results from a cohort study in isolated
deep intrabony defects showed marked
improvements in terms of clinical
attachment level (CAL) gains and PD
reduction, associated with very limited
gingival recession (Cortellini & Tonetti
2007b). The cited study also reported a
very limited patient morbidity and a
reduced length of the surgical procedure
following application of the MIST. The
same approach was effective in the
treatment of multiple adjacent intrabony
defects (Cortellini et al. 2008).
An enhancement of this technique,
the modified minimally invasive surgi-
cal technique (M-MIST Fig. 1), has
been recently designed to further reduce
the surgical invasiveness, with three
major objectives in mind: (1) minimize
the interdental tissue tendency to col-
lapse, (2) enhance the wound/soft tissue
stability and (3) reduce patient morbid-
ity.
The aim of the present study was to
describe the ‘‘M-MIST’’ and prelimina-
rily evaluate its applicability, clinical
performances and patient acceptance in
the treatment of isolated, interdental
deep intrabony defects.

Material and Methods

Study population and experimental

design

Patients with advanced periodontal dis-

ease, in general good health and pre-
senting with at least one isolated deep,
predominantly interdental intrabony Fig. 1. The modified minimally invasive surgery: a representative case. (a) A 7 mm pocket
defect were considered eligible for this distal to the upper right cuspid is associated with 9 mm of attachment level. (b) The drawing
study. Patients were included after com- depicts the buccal incision to gain access to the defect without interdental and lingual
pletion of cause-related therapy consist- incisions. (c) Clinical image of the buccal incision. (d) The minimally invasive buccal flap
ing of scaling and root planing, has been reflected and the granulation tissue removed from under the interdental papilla.
(e) A 4 mm two-wall intrabony defect is evident. The buccal wall is missing. (f) No incisions
motivation and oral hygiene instruc- have been performed on the palatal side. (g) An internal modified mattress suture is
tions. Flap surgery for pocket elimina- positioned to close the wound. (h) Primary closure of the interdental space. (i) The internal
tion in sites different from the modified mattress suture from the lingual side. (j) At 1 year a 2 mm probing depth
experimental ones was performed, is associated with a 5 mm clinical attachment level. (k) Baseline radiograph. (l) 1-year
when indicated, before the regenerative radiograph.
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 Improved wound stability with modified minimally invasive surgical technique 159

dontal probe at 0.3 N (Brodontic probe

equipped with a PCP-UNC 15 tip, Hu-
Friedy, Chicago, IL, USA). CAL were
calculated as the sum of PPD and REC.
The radiographic defect angle of each
defect was measured on a periapical
radiograph, as described previously
(Tonetti et al. 1993). The chair-time of
each surgical procedure was recorded.
Primary closure of the flaps was evalu-
ated at completion of surgery and at
weekly recalls for a period of 6 weeks,
along with the potential presence/absence
of oedema and/or haematoma. Patients
were questioned about the subjective
perception of intra-operative pain and/or
discomfort at completion of surgery, and
of post-operative pain and/or discomfort
1 week after surgery (Cortellini & Tonetti
2001, Tonetti et al. 2004).

Clinical characterization of the intrabony

defects

Defect morphology was characterized

intra-surgically in terms of the distance
between the cemento-enamel junction
and the bottom of the defect (CEJ-BD)
and the total depth of the intrabony
component of the defect (INFRA),
essentially as described previously (Cor-
tellini et al. 1993b). The defects were
described as 1-, 2-, 3-wall or combina-
tion defects.
Fig. 1. Continued.
Surgical approach (M-MIST)
4. Good oral hygiene. Full-mouth pla- stringent postoperative supportive care Flap elevation
que score (FMPS) 420%. programme with weekly recalls for 6
5. Low levels of residual infection. weeks, and then included in a 3-month The defect-associated interdental papilla
Full-mouth bleeding score (FMBS) periodontal supportive care programme was surgically approached either with
420%. for 1 year. the simplified papilla preservation flap
6. Compliance. Only patients with opti- when the width of the interdental space
mal compliance, as assessed during was 2 mm or narrower (SPPF, Cortellini
Clinical measurements at baseline and at
the cause-related phase of therapy, the 1-year follow-up visit
et al. 1999) or the modified papilla
were selected. preservation technique at interdental
7. Endodontic status. Teeth had to be The following clinical parameters were sites wider than 2 mm (MPPT Cortellini
vital or properly treated with root evaluated at baseline before regenera- et al. 1995). The interdental incision
canal therapy. tive therapy and at the 1-year follow-up (SPPF or MPPT) was extended to the
visit by an independent clinician. buccal aspect of the two teeth adjacent
Three months after completion of FMPSs were recorded as the percentage to the defect. These incisions were
periodontal therapy, baseline clinical of total surfaces (four aspects per tooth) strictly intra-sulcular to preserve the
measurements were recorded. The that revealed the presence of plaque entire height and width of the gingiva,
experimental sites were accessed with (O’Leary 1972). Bleeding on probing and their mesio-distal extension was
the M-MIST and carefully debrided. (BOP) was assessed dichotomously kept at minimum (ideally, within the
Measurements were taken during sur- and FMBSs were then calculated mid-buccal area of the involved teeth)
gery to characterize the defect anatomy. (Cortellini et al. 1993a) to allow the reflection of a triangular
EDTA and EMD (Emdogain, Institute PPD and recession of the gingival buccal flap to expose the coronal edge of
Straumann AG, Basel, Switzerland) margin (REC) were recorded to the the buccal bone crest. The interdental
were applied on the instrumented and nearest millimetre at the deepest loca- papillary tissues were partially dissected
dried root surfaces, and flaps were tion of the selected interproximal site. in a bucco-lingual and corono-apical
sutured with modified internal mattress All measurements and BOP were taken direction with a microblade (micro
sutures. Patients were enrolled in a using a pressure-sensitive manual perio- 6900, Advanced Surgical Technologies,
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160 Cortellini & Tonetti

Sacramento, CA, USA). The microblade Finally, the suture was tightened to accessibility. Data were expressed as
cut through the interdental tissues, split- reach primary closure of the defect- means  SD of 15 defects in 15 patients
ting the coronal part (basically the associated papilla (Cortellini & Tonetti (M-MIST) and five defects in five
supracrestal tissues) from the apical 2001, 2005, 2007a, b). patients (MIST). No data points were
part (i.e. the ‘‘granulation’’ tissue filling When persistent bleeding was missing. Comparisons between baseline
the intrabony component of the defect). observed at the end of defect/root instru- and 1 year CAL, PPD and REC were
The micro-blade was introduced with an mentation, a gauze wet with saline was made using the paired Student’s t-test
inclination suitable to intercept the buc- gently placed into the defect for 5 min. (a 5 0.05). Percentage fill of the base-
cal side of the lingual bone crest, as to halt bleeding before application of line intrabony component of the defect
close as possible to its coronal edge, to EDTA and EMD (Cortellini & Tonetti was calculated as: CAL% 5 (CAL
isolate the granulation tissue filling the 2007b, Cortellini et al. 2008). gains)/INFRA  100.
intrabony component of the defect from All the surgical procedures were per- CAL gains, residual PPD and position
the supra-crestal, papillary tissues. No formed with the aid of an operating of the gingival margin were the primary
interdental and/or lingual intrasulcular microscope (Global Protege, St Louis, outcome variables.
incisions were performed. The supra- MO) at a magnification of  4 to
crestal interdental tissues, therefore,  16 (Cortellini & Tonetti 2001, 2005).
remained attached to the root cement Microsurgical instruments were utilized, Results
of the crest-associated tooth, continuous whenever needed, as a complement to the Experimental population and
with the palatal tissue, and were not normal periodontal set of instruments. surgical approach
displaced.
Twenty intrabony defects in 20 subjects
Sites with a lingually extended (mean age 48.1  10.4, range 31–65
Defect debridement, EMD application defect component years, 12 females, and non smokers),
and suturing technique who fulfilled the admission criteria,
When the experimental defect extended
The granulation soft tissue was dis- far too much on the lingual side of the were included in this case cohort. The
sected from the buccal and interdental involved tooth, the interdental papilla M-MIST was applied in 15 of the
bony walls with the micro-blade and was elevated along with a lingual flap to 20 selected sites (mean patient age
carefully removed with a sharp mini allow a proper debridement and EMD 46.1  10.3, range 31–65 years, nine
curette (Gracey, Hu-Friedy) from under application at the lingual side. In these females). The remaining five sites
the papilla. The defect was debrided cases, surgery was thereby completed (mean patient age 54  9.0, range 44–
with the combined use of mini curettes following the rules of the MIST (Cor- 64 years, three females) presented
and power-driven instruments (Soniflex tellini & Tonetti 2007a, b). defects involving the lingual side and
Lux, Kavo, Germany) and the root was required the elevation of the interdental
carefully planed. Special care was taken papilla and the lingual flap to ensure
Post-operative period appropriate debridement and manage-
to reach all the parts of the exposed root
surface and residual bony walls, partly Post-operative pain was controlled with ment of the defect. The decision was
hidden by the non-elevated lingual and ibuprofen. Patients received 600 mg at taken during the surgery, after the
papillary soft tissues. To allow instru- the end of the surgical procedure and removal of the granulation tissue from
mentation, the buccal papillary flap was were instructed to take another tablet 6 h under the papilla. These defects were
slightly reflected, carefully protected later. Subsequent doses were taken only therefore treated with the MIST
with a periosteal elevator and frequently if necessary to control pain. Patients with (Cortellini & Tonetti 2007a, b).
irrigated with saline. Mini-curettes and contraindications to NSAIDs received
sonic instruments were also carefully 500 mg acetaminophen at surgery and M-MIST-treated population
inserted through the interdental pocket after 6 h. A protocol for the control of
of the defect-associated tooth, between bacterial contamination consisting of Patient and defect characteristics
the preserved interdental papilla and the systemic doxicycline (100 mg b.i.d. for at baseline
root surface, to reach the root surface for 1 week), 0.12% chlorhexidine mouth FMPSs and FMBSs at baseline were
debridement. Care was taken to prevent rinsing three times per day and weekly 13.1  4.7% and 5.8  3.0%, respec-
any disruption of the papillary fibrous prophylaxis was prescribed (Tonetti tively (Table 1). CAL of 9.7  1.8 and
attachment to the bone crest and to the et al. 2002). Patients were requested to PPDs of 7.7  1.5 mm on average were
crest-associated root, in order to pre- avoid brushing, flossing and chewing in recorded (Table 1). The radiographic
serve the stability of the papilla. At the the treated area for a periods of 2–3 defect angle was 32.1 
end of instrumentation, EDTA was weeks. Then patients resumed full oral 4.11. The distance from the cemento-
applied on the root surface for 2 min. hygiene. At the end of the ‘‘early healing enamel junction to the bottom of the
and then the defect area was carefully phase’’, patients were placed on a 3- defect (CEJ-BD) was 11.1  2.3 mm,
rinsed with saline. Before the applica- month recall system for 1 year. and the intrabony component of the de-
tion of EMD, a single modified internal fects (INFRA) was 6  1.5 mm (Table 1).
mattress suture was positioned at the Data analysis
defect-associated interdental area (6-0 Design of the surgical flap and surgical
or 7-0 e-PTFE Goretex, WL Gore & A total of 20 patients were enrolled in chair-time
Associates, Flagstaff, AZ, USA). The this case series. Five out of 20 were
suture was left loose. EMD was applied treated with the original MIST for The SPPF was used in five of the 15 M-
on the rinsed and air-dried root surface. reasons associated with the defect MIST-treated sites and in all the cases
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 Improved wound stability with modified minimally invasive surgical technique 161

Table 1. Baseline patient and defect characteristics of M-MIST treated cases (N 5 15) age MIST surgical chair-time was
64.8  4.6 min. (range 59–70 min.).
Variables Mean  SD Minimum Maximum
Primary closure was attained and
FMPS (%) 13.1  4.7 4 20 maintained for 6 weeks in all sites.
FMBS (%) 5.8 3 1 11 None of the patients reported any
PPD (mm) 7.7  1.5 6 12 intra-operative pain or personal feeling
REC (mm) 2  1.3 1 6 of the hardship of the procedure. At
CAL (mm) 9.7  1.8 7 14 week 1, no oedema or haematoma was
CEJ-BD (mm) 11.1  2.3 8 16
noted. Four out of five described the first
INFRA (mm) 6  1.5 4 9
X-ray angle (deg.) 32.1  4.1 25 40 postoperative week as uneventful. Only
one patient reported limited postopera-
FMPS, full mouth plaque score; CAL, clinical attachment level; CEJ-BD, cemento-enamel junction tive pain and discomfort that lasted
and the bottom of the defect; M-MIST, modified minimally invasive surgical technique; PPD, 3 days.
probing pocket depth.

Table 2. Clinical outcomes at baseline and 1 year after treatment of M-MIST treated cases
(N 5 15) Discussion
This clinical study was designed to
Variables Baseline 1 year Difference Significancen
explore the applicability, the clinical
PPD (mm) 7.7  1.5 3.07  0.6 4.6  1.5 po0.0001 outcomes and the patient perception of
REC (mm) 2  1.3 2.07  1.3 0.07  0.3 p 5 0.167 an M-MIST, an extension of the MIST,
CAL (mm) 9.7  1.8 5.13  1 4.5  1.4 po0.0001 designed to further reduce surgical inva-
n
Paired t-test.
siveness in the treatment of isolated
CAL, clinical attachment level; M-MIST, modified minimally invasive surgical technique; PPD,
deep interdental intrabony defects.
probing pocket depth. The design of this surgical approach
allows both access to root surface instru-
mentation and minimization of flap ele-
the buccal incision was restricted to between baseline and 1 year were not vation through the elevation of the
the defect-associated papilla. Vertical statistically significant (p 5 0.099 and buccal flap alone. This further enhances
releasing incisions were never per- 0.055, respectively). wound stability during early wound
formed. The average M-MIST surgical The 1-year CAL was 5.1  1 mm healing and prevents the collapse of
chair-time was 56.5  8.6 min. (range with a clinical attachment gain of the papilla into the defect: at the end
43–69 min.). 4.5  1.4 mm (range 3–9 mm). Differ- of the procedure, the buccal flap is
ences in CAL between baseline and 1 repositioned and sutured to the inter-
year were clinically and statistically dental supracrestal soft tissues, still
Primary closure of the flap and
highly significant (po0.0001). The 1-year anchored with their fibres to the root
post-operative period
CAL% was 75.5  10%, with a range cement. The improved stability of the
In all treated sites, primary closure was of 62.5% to 100%. soft tissues could play a positive role in
attained at completion of the surgical Residual PPDs were 3.1  0.6 mm, increasing the stability of the blood clot,
procedure. All the treated sites remained with an average pocket depth reduction a key factor in regenerative therapy
closed during the 6 weeks of the early of 4.6  1.5 mm. Differences between (Hiatt et al. 1968, Wikesjo & Nilveus
healing period. No oedema or haemato- baseline and 1-year PPDs were clini- 1990, Haney et al. 1993). In addition,
ma was noted in any of the treated sites. cally and statistically highly significant the potential prevention of the interden-
None of the patients reported any intra- (po0.0001). Only three sites showed a tal soft tissue collapse could preserve
operative pain and personal feeling of residual PPD of 4 mm; all the other sites more space for the regeneration to
hardship of the procedure at the end of showed a 1-year PPD of 3 mm or less. occur.
surgery. At week 1, none of the patients A minimal average change of On the other hand, the preservation of
reported significant postoperative pain. 0.07  0.3 mm in the position of the the ‘‘soft tissue roof’’ leaves a very
Three patients reported very limited gingival margin between baseline and limited buccal access to the intrabony
discomfort in the first 2 days of the first 1 year was observed. This difference did defect. The limited access requires the
post-operative week. Fourteen out of 15 not reach statistical significance use of an operating microscope or, at
described the first postoperative week as (p 5 0.167). least, of magnifying lenses with ade-
uneventful, reporting that they had no quate illumination, and microsurgical
feeling of having been surgically treated instruments. The granulation tissue is
after the second post-operative day. MIST-treated population
sharply dissected and carefully
‘‘carved’’ away from the intrabony
1-year clinical outcomes (Table 2) Patient/defect data and 1-year outcomes component. When the defect is deb-
that refer to the five MIST-treated cases rided, the buccal side of the lingual
The 15 patients presented at the 1-year are reported in Table 3. wall of the defect becomes visible: at
follow up visit with FMPS and FMBS of The SPPF was used in three out of this time, the clinician has to carefully
12.2  4.4% (range 5–20) and five MIST-treated sites. The buccal inci- inspect the lingual side of the defect-
3.7  2% (range 0–7), respectively. sion in three MIST cases involved an associated tooth to find the limits of
The differences in FMPS and FMBS additional interdental space. The aver- the intrabony defect. If the intrabony
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162 Cortellini & Tonetti

defect involves the lingual aspect, the explore the potential of the proposed combination of EMD and a grafting
lingual root planing becomes a very technique in depth. material.
difficult exercise. In this instance, it From a patient’s standpoint, this was
is suggested to extend the incision to a very well tolerated and relatively
Acknowledgements
the interdental and oral crevices in short procedure (surgical chair-time
order to elevate the papilla to allow 56.5  8.6 min., range 43–69 min.). This study was partly supported by the
a direct vision of the lingual side, Patients reported an uneventful post- Accademia Toscana di Ricerca Odontos-
performing the MIST (Cortellini & operative period with very limited/no tomatologica, Firenze Italy and the
Tonetti 2007a, b). pain and discomfort. European Research Group on Periodonto-
The defect population selected for The five cases treated with the MIST logy (ERGOPerio), Berne, Switzerland.
this study included only defects with a had very similar clinical outcomes, a
prevalent interdental intrabony compo- longer surgical chair-time and very low
nent. The M-MIST was applicable in 15 patient morbidity; however, no compar- References
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the conventional MIST had to be performed.
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applied. As discussed above, these In summary, M-MIST associated sive surgical technique (MIST) with enamel
defects showed a consistent intrabony with EMD resulted in improved clinical matrix derivative (EMD) to treat multiple
component extending to the lingual/ outcomes with no or minimal patient adjacent intrabony defects. Clinical outcomes
palatal side, which was detected during morbidity. It was easily applicable to and patient morbidity. Journal of Clinical
the procedure. isolated interproximal intrabony defects Periodontology 35: in press.
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a very shallow residual PPD (Table 2). In addition, the surgeon has to be aware flap. A novel surgical approach for the man-
The percent fill of the baseline intrabony of the possibility of extending the M- agement of soft tissues in regenerative pro-
component of the defects in terms of MIST incisions to a MIST approach to cedures. International Journal of
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(1993a) Periodontal regeneration of human
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does not allow any conclusion or com- minary outcomes and to investigate the surgical approach to periodontal regenera-
parison with other techniques: large potential of the M-MIST alone com- tion. Initial evaluation in a case cohort.
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Variables Baseline 1 year Difference Significancen Cortellini, P. & Tonetti, M. S. (2007a) A
minimally invasive surgical technique
FMPS (%) 9.6  4 9  2.2 – – (MIST) with enamel matrix derivate in the
FMBS (%) 4.4  2.9 4.8  2.2 – – regenerative treatment of intrabony defects: a
PPD (mm) 8  1.9 3  0.7 5  2.4 po0.0001 novel approach to limit morbidity. Journal of
REC (mm) 2  1.2 2.2  1.1 0.2  0.5 p 5 0.2 Clinical Periodontology 34, 87–93.
CAL (mm) 10  2.9 5.2  0.8 4.8  2.4 po0.0001 Cortellini, P. & Tonetti, M. S. (2007b) Mini-
CEJ-BD (mm) 11.2  2.8 – – – mally invasive surgical technique (MIST)
INFRA (mm) 6  1.9 – – – and enamel matrix derivative (EMD) in
X-ray angle (deg.) 33.2  11.1 – – – intrabony defects. (I) Clinical outcomes and
morbidity. Journal of Clinical Perio-
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Paired t-test. dontology 34, 1082–1088.
FMPS, full mouth plaque score; CAL, clinical attachment level; CEJ-BD, cemento-enamel junction Cortellini, P., Tonetti, M. S., Lang, N. P.,
and the bottom of the defect; M-MIST, modified minimally invasive surgical technique; PPD, Suvan, J. E., Zucchelli, G., Vangsted, T.,
probing pocket depth. Silvestri, M., Rossi, R., McClain, P., Fonzar,
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Clinical Relevance Principal findings. M-MIST was EMD in the treatment of isolated
Scientific rationale for the study. To applicable in most of the selected deep intrabony defects has the poten-
improve wound stability and reduce sites and its use in combination tial to allow clinically significant
patient morbidity, minimally inva- with EMD resulted in remarkable outcomes and to increase patients’
sive surgical approaches are being clinical improvements and very lim- acceptance of a regenerative proce-
developed for periodontal regenera- ited patient discomfort. dure.
tive therapy. Practical implications. Application
of M-MIST in combination with

r 2009 John Wiley & Sons A/S

Journal compilation r John Wiley & Sons A/S