Effect of Flap Design for Enamel Matrix Derivative Application in Intraosseous Defects

Abstract

Objective: To systematically review the literature addressing the focused question: What is the effectiveness of different surgical and nonsurgical procedures combined with enamel matrix derivative (EMD) on clinical, radiographic, and patient-centered outcomes in intraosseous defects? Methods: Electronic (Medline, Scopus, and Cochrane databases) and hand literature searches were performed for studies including at least 1 treatment arm where EMD had been applied according to 1 of the following procedures: modified Widman flap; papilla preservation variants (PPVs), including papilla preservation technique, modified papilla preservation technique, and simplified papilla preservation technique; minimally invasive variants, including minimally invasive surgical approach and minimally invasive surgical technique; single-flap variants (SFVs), including single-flap approach and modified minimally invasive surgical technique; or nonsurgical application (flapless approach). Data from 42 selected articles were used to perform a network meta-analysis, and a hierarchy of surgical and nonsurgical applications of EMD was built separately for EMD and EMD + graft based on 6- to 12-mo clinical and radiographic outcomes. Results: Among surgical approaches, EMD was associated with best regenerative outcomes when applied through SFVs, with a mean clinical attachment level gain of 3.93 mm and a reduction in the intrabony component of the defect of 3.35 mm. For EMD + graft, limited differences in regenerative outcomes were observed among surgical procedures. PPVs were associated with the highest residual probing depth for EMD (4.08 mm) and EMD + graft (4.32 mm). Conclusions: In the treatment of periodontal intraosseous defects, 1) SFVs appear to optimize the regenerative outcomes of EMD; 2) substantial regenerative outcomes can be obtained with SFVs and conservative double flaps (i.e., PPVs and minimally invasive variants) when EMD is combined with a graft; and 3) residual probing depth was higher following PPVs for EMD and EMD + graft. Knowledge Transfer Statement: The results of the present systematic review and meta-analysis can be used by clinicians to identify the most effective surgical or nonsurgical procedure to treat an intraosseous defect with EMD or EMD + graft. The main findings indicate that when EMD application is indicated, surgical access based on a single flap seems the most appropriate to optimize clinical outcomes. The application of EMD + graft can be effectively combined with single flaps and conservative double flaps.

Single flap approach with or without enamel matrix derivative in the treatment of severe supraosseous defects: a retrospective study

“…However, further studies are needed to comparatively evaluate the clinical effectiveness of different flap designs when treating SDs with and without EMD. In this respect, a recent systematic review on intraosseous defects showed that the use of EMD is optimized when the lesion is surgically accessed by SFA [ 27 ].…”

“…The basic principle underlying the SFA is the elevation of a single flap (i.e., on the buccal or oral aspect only, depending on the main extension of the defect) to access the defect, leaving the interproximal supracrestal soft tissue intact [15][16][17][18][19][20][21][22][23][24][25][26]. In the regenerative treatment of intraosseous defects, SFA was associated to greater clinical results (in terms of CAL gain and intrabony component reduction) when compared to double flap approaches (DFA) based on papilla preservation techniques [27].…”

Flapless application of enamel matrix derivative in periodontal retreatment: A multicentre randomized feasibility trial

“…The adjunctive application of enamel matrix derivative (EMD) on the surgically exposed root surface is well established in regenerative periodontal therapy for the treatment of deep residual sites associated with intrabony and furcation defects and has been shown to promote significant additional gain in clinical attachment levels and enhanced reduction of probing pocket depths (Cortellini & Tonetti, 2015;Miron et al 2016;Nibali et al 2020;Jepsen et al 2020;Trombelli et al, 2020). Positive effects were also observed in supra-alveolar periodontal defects (Jentsch & Purschwitz, 2008;Di Tullio et al, 2013;Graziani et al 2014).…”

The granulation tissue preservation technique in regenerative periodontal surgery—a randomized controlled clinical trial

“…There is conflicting data on whether EMD + graft material results in more CAL gain and greater PPD reduction than EMD alone. A recently published meta‐analysis looked at the treatment of infrabony defects using either EMD or EMD + graft material and differentiated the treatment outcome by flap design (Trombelli et al, 2021). They reported that EMD + graft material resulted in more CAL gain in minimally invasive variants (EMD: 3.69 mm; EMD + graft: 4.10 mm) and papilla preservation variants (EMD: 3.08 mm; EMD + graft: 3.65 mm) than EMD alone.…”