Periodontal surgery: Is a minimally invasive approach effective for infrabony defects?

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In recent years a number of new ‘minimally-invasive’ periodontal surgical techniques have been proposed. These techniques aim to reduce the surgical area with potential benefits in terms of improved healing time and reductions in post-operative pain and infection.

The aim of this review was to evaluate the clinical performance and patient perception of minimally invasive periodontal surgeries in the treatment of intra‐bony defects and to compare the efficacy of these surgical techniques with more traditional flaps.


Searches were conducted in the Medline, Embase and Cochrane Oral Health Group trials databases. This was supplemented by searches in the journals, British Journal of Oral and Maxillofacial Surgery, Clinical Implant Dentistry and Related Research, Clinical Oral Implants Research, Clinical Oral Investigations, European Journal of Oral Implantology, Implant Dentistry, International Endodontic Journal, International Journal of Oral & Maxillofacial Implants, International Journal of Oral & Maxillofacial Surgery, International Journal of Periodontics & Restorative Dentistry, Journal of Clinical Periodontology, Journal of Endodontics, Journal of Oral and Maxillofacial Surgery, Journal of Oral Implantology, Journal of Periodontal & Implant Science, Journal of Periodontology up to November 2017.

Case series (CSs), controlled studies (CTs) and randomised controlled trials (RCTs) with a minimum of 10 patients reporting clinical, radiographic and/or patient‐related outcomes at least 6 months and published in English were considered.  Two reviewers independently selected studies, extracted data and assessed study quality. RCTs were assessed using the Jadad scale and cohort studies with the Newcastle-Ottawa Scale. The evidence level of the individual studies was assessed using the Oxford Centre for Evidence‐Based Medicine approach.  Dichotomous outcomes were expressed as relative risk s(RR) together with 95% confidence intervals (CI) and continuous outcomes as standardised mean differences (SMD) and 95%CI.


  • 25 studies (10 RCTs, 15 CSs) reported on minimally invasive periodontal surgery for infrabony defects with 18 studies contributing to the meta-analysis.
  • Sample sizes ranged from 10-87 patients and with follow up times varying from 6 months to 6 years.
  • All 25 studies assessed pocket probing depth (PPD) and clinical attachment gain (CAL) all but 2 assessed recession changes (REC),3 assessed radiographic bone fill and 9 studies assessed pain and discomfort.
  • 18 studies were included in the meta-analysis and results summarised below.
  All studies RCTs Only Case series only
PPD reduction 4.24mm (95%CI; 3.79-4.69) 4.18mm (95%CI; 3.63–4.74) 4.35 mm (95% CI; 3.57–5.14)
CAL change 3.89 mm (95%CI; 3.42-4.35) 3.71 mm (95% CI; 3.14–4.28) 4.25 mm (95% CI; 3.44–5.06)
REC increase 0.44 mm (95%CI; 0.11-0.77) 0.56 mm (95% CI; 0.13–0.98) 53% (95% CI; 41.4 -64.6%)
Radiographic bone fill 58.25% (95%CI; 42.3–74.2%) 59.29% (95%CI; 40.0-78.5%) N/A
  • 2 studies were included in a meta-analysis comparing the efficacy of minimally invasive periodontal surgery (MIPS) and traditional surgery. MIPS was seen to be more effective in terms of
    • PPD reduction SMD = 0.93 mm (95%CI; 1.71 to 0.15) and
    • CAL gain SMD =1 mm (95%CI; 1.75 to 0.24;) but not
    •  REC change SMD= 0.02 mm (95%CI = −0.51 to 0.55).


The authors concluded: –

Minimally invasive periodontal surgeries may be considered for the treatment of periodontal infrabony defects. However, the real effect cannot be systematically evaluated due to the paucity of studies comparing MIPSs to traditional flap for periodontal reconstructive surgery.


Three major databases and a broad range of relevant dental journals were searched for this review although a decision to restrict inclusion to papers published in English may have excluded some relevant studies. A majority of the included studies were case series which have a greater potential for bias. Study quality assessment for the RCTs was carried out using the Jadad scale which is problematic and has not been a recommended approach for many years. Sample sizes for the majority of the included studies were small so while the findings suggest that minimally invasive periodontal surgery may be an effective approach high quality well reported RCTs of appropriate size are required that not only assess clinical outcomes put also patient related ones.


Primary Paper

Clementini M, Ambrosi A, Cicciarelli V, De Risi V, de Sanctis M. Clinical performance of minimally invasive periodontal surgery in the treatment of infrabony defects: Systematic review and meta-analysis. J Clin Periodontol. 2019;46(12):1236–1253. doi:10.1111/jcpe.13201



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