Volumetric Evaluation of the Entire Papilla Preservation Technique and the Non-Incised Papillae Surgical Approach: Effects on Soft Tissue Preservation and Periodontal Regeneration

Volumetric Evaluation of the Entire Papilla Preservation Technique and the Non-Incised Papillae Surgical Approach: Effects on Soft Tissue Preservation and Periodontal Regeneration | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Volumetric Evaluation of the Entire Papilla Preservation Technique and the Non-Incised Papillae Surgical Approach: Effects on Soft Tissue Preservation and Periodontal Regeneration Tom Kobe, Katja Povšič, Rok Gašperšič This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7171416/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Jan, 2026 Read the published version in Clinical Oral Investigations → Version 1 posted 9 You are reading this latest preprint version Abstract Objectives This randomized, controlled clinical trial compared two minimally invasive surgical techniques - the Non-Incised Papillae Surgical Approach (NIPSA) and the Entire Papilla Preservation Technique (EPPT) - in terms of their efficacy in preserving soft tissue architecture and promoting periodontal regeneration. Materials and methods Isolated intrabony defects of 40 patients with stage III/IV periodontitis were randomly assigned to either NIPSA or EPPT treatment. Clinical parameters including probing depth (PD), clinical attachment level (CAL), gingival recession (REC) and papilla height (TP) were evaluated at baseline and 6-months postoperatively. Results Both NIPSA and EPPT showed significant improvements in PD (5.3 ± 2.3mm vs. 4.6 ± 1.7mm) and CAL (4.4 ± 2.2mm vs 3.7 ± 1.9mm), with no statistically significant differences between the groups. Early wound healing was favorable in both techniques, with minimal fibrin clot formation and no biomaterial exposure. Digital analysis of intraoral scans showed comparable preservation of papilla height and width in both groups. Radiographic analyses confirmed defect filling and bone regeneration in both groups. Conclusions Both NIPSA and EPPT are effective surgical options for the periodontal regeneration of deep intrabony defects, offering excellent soft tissue preservation and clinical outcomes. NCT04782921. Clinical Relevance Both techniques remain viable, with the choice depending on the specifics of each defect and the surgeon's preference. clinical trial guided tissue regeneration microsurgery periodontitis surgical flaps Figures Figure 1 Figure 2 Figure 3 1 INTRODUCTION Regenerative periodontal techniques are essential for the treatment of deep intrabony defects [1]. The success of these procedures depends on two key factors: the biological potential for periodontal regeneration and the preservation of soft tissue architecture, especially the interdental papillae. Primary wound closure and wound stability are critical for stabilizing the blood clot and preventing the exposure of regenerative materials [2]. Maintaining the integrity of interdental papillae is crucial both functionally and esthetically, as their loss leads to the formation of black gingival triangles, phonetic problems and food impaction [3]. To reach deep intrabony defects, conventional surgical approaches incise and elevate the interdental papillae, compromising blood supply and negatively affecting healing due to the lack of primary closure in the early healing phase. A systematic review analyzing 220 intrabony periodontal defects reported flap dehiscence in approximately 12% of GTR-treated sites, with membrane exposure occurring in up to 28.8% of defects where barrier membranes were used [4]. These challenges have led to the development of more conservative surgical techniques aimed at preserving interdental papillae while allowing effective treatment of the underlying defects: the entire papilla preservation technique (EPPT) [5], a tunnelling method, and the non-incisional papillae surgical approach (NIPSA), which uses a mucosal incision, far from the marginal tissue [6]. These techniques limit the risk of premature wound failure, prevent the exposure of regenerative biomaterials and provide a stable environment for the blood clots in deep intrabony defects. A comparative study between NIPSA and the minimally invasive surgical technique (MIST) showed that while both techniques significantly improved clinical attachment levels and reduced probing depth, NIPSA resulted in significantly less recession of the interdental papilla [7]. An additional advantage of the papillae tunneling techniques is that they reduce the need for bioresorbable membranes, which can pose technical challenges in traditional papillae preservation methods [8]. Despite the promising results reported for both EPPT and NIPSA, direct comparative studies are scarce [9]. This randomized, controlled clinical trial aimed to compare their effectiveness in periodontal regeneration and soft tissue preservation. It was hypothesized that while both procedures yield significant improvements in clinical parameters, NIPSA may provide better results in soft tissue preservation and esthetics due to its completely non-incisional approach at the marginal gingiva. In addition to traditional clinical parameters, a recently proposed digital volumetric approach to assess papilla height preservation was also used to analyze early wound healing indices. 2 MATERIALS AND METHODS 2.1 Study Design and Population​ This was a single-centre, randomized, controlled clinical trial. ​ Ethical approval was granted by the National Medical Ethics Committee (protocol no. ​ 0120–653/2017/3), and the study was registered on ClinicalTrials.gov (NCT04782921). ​ All patients provided written informed consent before participation. ​ The study adhered to the Code of Medical Ethics of the Medical Association of Slovenia and the principles of the Declaration of Helsinki. Forty patients were selected from 112 consecutively assessed individuals seeking treatment of stage III/IV periodontitis [10] at the Department of Oral Medicine and Periodontology, University Medical Center Ljubljana, Slovenia, between March 2020 and August 2022. ​ The inclusion criteria consisted of: at least one isolated deep 3-wall intrabony defect with a partial 2-wall component [11]; involvement of the interproximal region of at least one periodontally affected tooth with probing depth (PD) ≥ 5 mm and clinical attachment level (CAL) ≥ 6 mm; presence of at least 16 scorable teeth (excluding third molars); full-mouth bleeding score (FMBS) and full-mouth plaque score (FMPS) less than 20% [12]. ​The exclusion criteria included: treatment with systemic antibiotics in the last 6 months, periodontal treatment in the last 6 months, heavy smokers (more than 10 cigarettes per day), subjects with systemic diseases (diseases affecting wound healing, diseases of bone metabolism, diabetes mellitus, HIV/AIDS, cancer), subjects with systemic therapy (non-steroidal anti-inflammatory drugs, calcium antagonists, antiepileptics, immunosuppressives) and pregnant or lactating women. ​ Teeth with inadequate endodontic treatment (periapical radiolucency on local radiograph) were also excluded.​ 2.2 Study protocol A full periodontal examination was performed with a manual periodontal probe (PCPUNC15, Hu-Friedy, USA) at the first visit and included the following clinical parameters: FMPS, FMBS, PD, gingival recession (REC), and bleeding on probing (BOP). CAL was calculated by adding PD and REC values. All examinations were performed by the same experienced, calibrated, blinded investigator (R. G.). A calibration exercise, with measurements repeated after one week, resulted in intraclass correlation coefficients for PD and CAL exceeding 0.9, and κ values for FMPS and BOP above 0.95, demonstrating excellent reproducibility. All subjects then received initial nonsurgical periodontal therapy: motivation and education regarding oral hygiene, removal of supra- and subgingival biofilm deposits (NSK Varios 970; G5 scaling tip; NSK dental, Japan), as well as scaling and root planing of sites with PD ≥ 5 mm (Micro Mini Five Gracey Curette; Hu Friedy, USA) under local anesthesia (Septanestepi; Septodont, France). ​ A full clinical exam was performed once again after 3 months (T0). One interproximal site with the deepest PD (PD ≥ 5mm, CAL ≥ 6mm) and an associated radiographic intrabony defect was selected per subject for inclusion in the trial [13]. Intraoral photographs (Canon EOS RP; Canon, Japan) were taken to identify the location of the papillae tips (TP) at the experimental site for comparison of initial and final conditions. A manual periodontal probe was used to calibrate the scale, and the TP position was measured in relation to the incisal edge of the adjacent tooth (using ImageJ; U. S. National Institutes of Health, USA). Each measurement was repeated three times, and the average value was calculated. An intraoral scan (TRIOS 3; 3Shape, Denmark) was performed for the assessment of changes in soft tissue morphology. In addition, a local radiograph of the site intended for surgery was taken and a radiographic analysis was performed. Distances were measured by projecting three reference points onto a straight line along the tooth’s long axis: the enamel–cement junction, the most apical point of the defect, and the tooth apex. Radiographic bone height relative to the root length was then calculated for comparison with radiographic outcomes 1-year after surgery. Additionally, the radiographic periodontal defect angle was measured [14]. The intrabony defects underwent surgical treatment with either the Non-incised Papillae Surgical Approach (NIPSA) [6] or the Entire Papilla Preservation Technique (EPPT) [5] according to a predetermined randomisation table. All surgical procedures were performed by the same periodontologist (T. K.). After local anesthetic administration (Septanestepi; Septodont, France), an intracrevicular incision was made around the teeth affected by the defect. Then, a short vertical semilunar incision was made in the buccal gingiva, just beyond the mucogingival line, as part of EPPT [5](Fig. 2 b). Alternatively, a single long horizontal apical incision was made in the mucosa, extending one tooth mesially and distally from the defect and apically to the bony ridge edge bordering the defect, as part of NIPSA (Fig. 1 b) [6]. Once a buccal full-thickness mucoperiosteal flap was elevated, a tunneling instrument (TKN1; Hufriedy, USA) was used in both approaches for tunnel preparation at the defect-associated papilla (Figs. 1 c, 2 c). The papilla was sharply dissected from the underlying granulation tissue, using microsurgical scissors (SPV; Hu Friedy, USA) and granulation tissue was excised with a small curette (Micro Mini Five Gracey Curette; Hu Friedy, USA) (Figs. 1 d, 2 d). The exposed root surface was cleaned with an ultrasonic scaler (NSK Varios 970, P10 periodontal tip; NSK Dental, Japan), and a small curette was used to remove any subgingival calculus or plaque. The surgical site was then thoroughly cleaned with sterile saline, and the intrabony defect was filled with collagenous corticocellular xenogeneic bone graft, pre-soaked in the saline solution (Gen-Os, granulometry ranging from 250 to 1000 µm; Osteobiol, Italy) (Figs. 1 e, 2 e). During the procedure, relative isolation was used to prevent contamination of the root surface with saliva. Microsurgical suturing with 6–0 or monofilaments (Nylon; Atramat, Mexico) were applied for wound closure (Figs. 1 f, 2 f). After surgery, gentle pressure was applied to the surgical site with a saline-moistened gauze for 1 minute to allow for the adaptation of the mucoperiosteal flap. Patients received instructions not to perform oral hygiene in the surgical area for 3 weeks and instead to rinse 2x/day with 0.12% chlorhexidine digluconate (Curasept ADS DNA 212; Curasept, Italy). One week after surgery, subjects reported any side effects or issues. Sutures were removed 2 weeks after the procedure and primary wound closure (WC) was assessed: complete WC = 2, incomplete closure with a fibrin clot (WC = 1), or biomaterial exposure (WC = 0) [15] (Table 2 ). As part of the maintenance protocol, T.K. performed professional dental cleanings on each patient every 2 months for the following 6 months. The final follow-up visit was scheduled 6-months (T6) after surgery and included a clinical exam, an intraoral scan, intraoral photographs and a local radiograph of the surgical site. The same parameters were recoded as at baseline (Figs. 1 h, 2 h). 2.3 Digital analysis of intraoral scans Intraoral scans were performed using an intraoral optical scanner and a standard scanning protocol [16]. The resulting 3D models were exported in Standard Tessellation Language (STL) format. Post-processing was conducted using GOM Inspect 2018 (GOM GmbH, Germany), utilizing the iterative closest point algorithm [17]. Initial alignments of each digital model pair (T0–T6) were carried out using the automated Prealignment tool across the entire model surface (soft tissues and teeth). Next, a secondary alignment was performed using the automated Local Best-Fit tool [18] using the surfaces of each selected tooth and its two neighbors as reference areas. An area of interest (interdental papilla) was then defined (Fig. 3 ). On each T0 scan, the gingival margins of the mesial and distal teeth adjacent to papillary surgical site were manually marked by placing 5–10 points with the Maximum curvature function, generating four curves (Fig. 3 b) [19]. The Distance between curves tool was then used to establish a midpoint between the buccal and the lingual/palatal curves (i.e., the gingival margins), and a sagittal cutting plane was traced through these points, oriented perpendicular to the occlusal plane (Fig. 3 c). A buccal line (LB) and a lingual/palatal line (LL/LP) were drawn between the most apical point of both the buccal and the lingual/palatal curves (Fig. 3 d). Next, a surface defect map was generated on the sagittal plane at the central point of the papilla using the Inspect section function, and papilla height and width were measured (Fig. 3 g). The ratio between height and width was then calculated, classifying the papillae as flat (h/w ratio 0.2). Additionally, the surface defect map allowed for the visualization of changes at all points on the vertical cutting planes through the use of Linear divergence points (LDPs) [20]. LDPs were plotted starting from the tip of the papilla, extending 0.7 mm apart in a corono-apical direction on both buccal and lingual/palatal sides, until either LB or LL/LP was reached, respectively (Fig. 3 h). 2.4 Randomisation and blinding Each patient's selected defect was randomly assigned to one of the two surgical procedures using numbered, opaque sealed envelopes. Randomization was ensured using a computer-generated table. The envelopes were opened by the operator just before surgery. The investigator was blinded throughout the study. 2.5 Statistical Analysis​ Sample size was determined using CAL gain as the primary outcome. ​ A difference of 1.25 mm in CAL gain was considered clinically significant, with expected standard deviation set at 1.4 mm [9]. ​ With α = 0.05 and 80 % ower, the calculated sample size was 20 surgical sites per group.​ Demographic variables were presented as means (± standard deviations) or as counts and proportions, depending on the context. Primary outcome variables included changes in CAL gain, PD, REC, and TP. Normality of distributions was assessed using the Shapiro-Wilk test. Intergroup analyses were conducted using Fisher’s exact tests, paired t-tests (for normal distributions) and Wilcoxon signed-rank tests (for non-normal distributions). Analysis was conducted using SPSS v. 26, with a significance level set at α = 0.05. 3 RESULTS Out of the 112 subjects screened for inclusion, 40 subjects were included in the study and all followed through to the last follow-up. The mean age of the subjects was 59.3 ± 9.7 years; 20 were males. No statistically significant differences between the NIPSA and EPPT groups were found at baseline in terms of demographic and clinical parameters (Table 1 , Table 2 ). Table 1 Patient characteristics and clinical parameters measured at baseline. NISPA (n = 20) EPPT (n = 20) p-value Study population Sex (male/female) 11/9 6/14 0.200 a Age (years) [mean ± SD] 59.4 ± 10.0 59.1 ± 9.6 0.936 b Smoking (nonsmokers/smokers) 18/2 14/6 0.106 a Dental arch (maxillary/mandibular) 10/10 14/6 0.333 a Tooth type (incisors/canines/premolars/molars) 12/4/4/0 16/3/1/0 0.304 a KT width (mm) [mean ± SD] 3.5 ± 1.6 4.1 ± 1.4 0.186 b Periodontal defect characteristics CEJ-defect bottom (mm) [mean ± SD] 11.9 ± 3.1 11.5 ± 2.7 0.623 b Intraosseous component (mm) [mean ± SD] 4.3 ± 2.3 4.4 ± 2.2 0.777 c 3-wall component (mm) [mean ± SD] 1.9 ± 1.2 1.9 ± 1.1kp 0.799 b Main defect configuration (− 1/−2/−3 wall) 0/16/4 0/18/2 0.661 a X-ray angle (deg.) [mean ± SD] 37.7 ± 13.9 32.6 ± 13.8 0.349 b PD (mm) [mean ± SD] 9.6 ± 2.3 8.9 ± 1.9 0.296 b REC (mm) [mean ± SD] 2.3 ± 1.5 2.6 ± 1.3 0.509 b CAL (mm) [mean ± SD] 11.9 ± 3.1 11.5 ± 2.6 0.862 b BOP (positive/negative) 17/3 15/5 0.695 a Abbreviations: CAL, clinical attachment loss; CEJ, cemento-enamel junction; KT, keratinized tissue; NIPSA, non-incised papillae surgical approach; PD, probing depth; REC, gingival recession; BOP, bleeding on probing; SD, standard deviation. a Fisher's exact test. b Independent-samples Mann–Whitney U test. c Independent-samples t‐test. Table 2 Wound closure, change in radiographic bone height and vertical cross section characteristics NIPSA (n = 20) EPPT (n = 20) p-value Wound closure (0/1/2) 0/3/17 0/2/18 1.000 a Radiographic change in bone height (%) 32.6 ± 20.1 30.6 ± 15.4 0.587 b Vertical cross-section characteristics Width (mean ± SD) 7.01 ± 1.45 7.61 ± 1.17 0.154 b Height (mean ± SD) 1.69 ± 0.67 1.95 ± 0.81 0.266 b Convex/flat profile (n/n) 13/7 14/6 1.000 a a Fischer's exact test. b Independent samples t-test. At the 1-week follow-up, only two sites treated with NIPSA and 3 sites treated with EPPT (p = N. S.) healed with fibrin cloth covering; no biomaterial exposure was observed. After 6 months, changes in PD, REC and CAL were comparable between both study groups and showed no statistically significant differences, although the values were slightly higher in the NIPSA group (Table 3 ). Only the TP recession was higher in the EPPT group, but was also not statistically significantly different to the NIPSA group. Table 3 Effect of surgical technique on average changes in CAL, REC, PD, and TP. NISPA (n = 20) EPPT (n = 20) p-value diffPD (mm) [mean ± SD] 5.3 ± 2.3 4.6 ± 1.7 0.165 diffREC (mm) [mean ± SD] -0.9 ± 0.8 -0.7 ± 0.7 0.475 diffCAL (mm) [mean ± SD] 4.4 ± 2.2 3.7 ± 1.9 0.529 diffTP (mm) [mean ± SD] -0.4 ± 1.0 -0.5 ± 1.0 0.496 Abbreviations: CAL, clinical attachment loss; d, Cohen's D; diff, difference between the baseline and 1 year; PD, probing depth; p-value, Welch two sample t‐test; REC, recession; SD, standard deviation; TP, location of papilla. The volumetric analysis of mean changes in LDPs for both surgical modalities are presented in Table 4 ; no statistically significant differences were found. The differences were more pronounced at the buccal aspect of the papillae. Convex papilla profiles were more prone to TP recession (0.5 ± 0.6 mm) in comparison to flat profiles (0.2 ± 0.7 mm), but again, the difference was non-significant (p = 0.194). The volumetric analysis (LDP0) correlated (r = 0.463, p = 0.006) with the manual measurement on digital photography (diffTP). Table 4 Mean LDP differences, compared between both treatment groups. NIPSA EPPT p-value a mean ± SD n mean ± SD n LDP0 -0.31 ± 0.48 17 -0.56 ± 0.75 17 0.245 Buccal sites LDP1-B -0.33 ± 0.42 20 -0.43 ± 0.68 19 0.611 LDP2-B -0.30 ± 0.46 20 -0.39 ± 0.59 19 0.568 LDP3-B -0.36 ± 0.43 19 -0.40 ± 0.48 18 0.820 LDP4-B -0.36 ± 0.33 18 -0.44 ± 0.45 17 0.537 LDP5-B -0.21 ± 0.23 11 -0.35 ± 0.34 10 0.291 LDP6-B -0.20 ± 0.33 7 -0.49 ± 0.31 3 0.239 LDP7-B -0.35 ± 0.39 3 -0.74 ± NA 1 0.482 Palatal sites LDP1-P -0.29 ± 0.44 20 -0.46 ± 0.69 20 0.348 LDP2-P -0.27 ± 0.41 20 -0.45 ± 0.63 20 0.297 LDP3-P -0.22 ± 0.34 20 -0.40 ± 0.52 20 0.218 LDP4-P -0.13 ± 0.28 18 -0.36 ± 0.45 19 0.075 LDP5-P -0.13 ± 0.20 13 -0.30 ± 0.38 13 0.157 LDP6-P 0.12 ± 0.23 8 -0.41 ± 0.33 6 0.076 LDP7-P -0.44 ± NA 1 -0.47 ± 0.39 3 0.948 a Independent samples t-test. LDP – linear divergence points. B – buccal. P – palatal/lingual. 4 DISCUSSION This study compared the clinical outcomes of NIPSA and EPPT in the treatment of intrabony periodontal defects. Our results showed that both surgical techniques were effective in improving clinical parameters, with no statistically significant differences observed between the two approaches. Minimal healing complications occurred at the one-week follow-up, with only two sites in the NIPSA group and three in the EPPT group demonstrating fibrin cloth coverage; no biomaterial exposure was observed in any group. The changes in PD, REC and CAL were comparable between the techniques. The change in TP was more pronounced in the EPPT group, but this difference did not reach statistical significance. More than five decades ago, Ellegaard and Löe[21] demonstrated that open flap debridement in intrabony defects reduces PD from 7–9 mm to 2–3 mm while improving clinical attachment, thus proving that periodontal regeneration is possible without regenerative biomaterials. Since then, treatment of intrabony defects has evolved to preserve soft tissue architecture and minimize flap size to improve wound stability. This has led to conservative approaches such as the papilla preservation technique [22], the modified PPT [23], the simplified PPT [24], the minimally invasive surgical technique (MIST)[25] and the modified MIST [26]. While new regenerative materials improved outcomes, Wachtel emphasized that primary wound closure is crucial, as closed sites respond better to regenerative therapy [27]. The EPPT by Aslan et al.[5] initially used a bone graft with enamel matrix derivative (EMD), which achieved complete primary wound closure with an average PD reduction of 7 mm after one year. Their subsequent study showed no significant differences between the sites treated with blood clots alone and bone grafts with EMD, suggesting that grafts are not essential with this technique [28]. NIPSA, introduced by Rodríguez and Caffesse [29], originally used EMD with a xenogeneic bone graft and achieved an average PD reduction of 7.3 mm. Subsequent studies showed that NIPSA promotes supra-alveolar attachment and outperforms conventional MIST in terms of wound stability and tissue regeneration [15]. Further studies found that bone grafting with NIPSA reduced papilla collapse but increased the incidence of residual pockets, suggesting that slowly resorbing grafts may compromise certain aspects of regeneration while providing better soft tissue support [30]. In line with these principles, our study showed that both NIPSA and EPPT resulted in a significant reduction in PD and attachment gain. Although the differences between the techniques were not statistically significant, the NIPSA group achieved a mean PD reduction of approximately 5.3 mm, while the EPPT group achieved a mean reduction of 4.6 mm. The comparable results between the two techniques indicate that effective pocket depth reduction can be achieved with both methods. The preservation of the interdental papillae is crucial for both the functional and esthetic outcomes of periodontal surgery. Using an advanced 3D comparison methodology with GOM Inspect software, we were able to accurately measure these soft tissue changes using vertical sectional planes and linear divergence points. Although the EPPT group showed greater loss at the papilla apex compared to the NIPSA group, this difference was not statistically significant. The digital approach provided a more accurate and reproducible measurement of soft tissue changes compared to conventional clinical assessments, although there was a correlation between manual and volumetric assessment of TP [19]. The slight difference in papilla height preservation could be due to the proximity of the first incision to the papilla in the EPPT technique. Several limitations must be considered when interpreting our results. First, the selection of sites and defect types was not completely homogeneous between the two techniques. These differences in defect morphology could potentially influence the comparative results. The selection of patients also excluded areas beyond the second premolar in the posterior region. In our previous study [31], the surgical approach (either EPPT or NIPSA) was determined based on anatomical landmarks. In the current study, however, patients were randomized to different surgical approaches. We still believe that certain approaches are more suitable for different regions. As previously mentioned, the close proximity of the mental nerve poses a challenge for the NIPSA approach. In addition, a deep muscle-releasing incision is required in the anterior mandibular region with NIPSA to achieve tension-free closure [32]. In the EPPT group, the authors noted challenges with tension-free adaptation of the flap after application of the biomaterial. This required a muscle-free incision, which could theoretically affect the blood supply and influence the outcome of periodontal regeneration [33]. Although our six-month follow-up provides valuable insight into initial healing and mid-term stability, longer observation periods would be beneficial to assess the long-term stability of the outcomes. Finally, our study was conducted at a single center, and the procedures were performed by a single surgeon, which may have limited the generalizability of our results to other clinical settings. 5 CONCLUSIONS Both NIPSA and EPPT showed comparable clinical results in the regeneration of intrabony defects, with no significant differences in the main outcomes. NIPSA may preserve the papillae slightly better by avoiding marginal gingival incisions, but this advantage was not statistically significant. Digital assessment methods enabled precise measurements of papilla morphology, highlighting the value of digital technologies for research. Larger sample sizes, longer follow-up periods and standardized defect criteria are needed to differentiate minimally invasive techniques. Both techniques remain viable, with the choice depending on the specifics of each defect and the surgeon's preference. Declarations Data availability statement: The data supporting this study's findings are available on a reasonable request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Funding statement: The study was supported by the Ministry of Science and Technology of the Republic of Slovenia, grant number P3-0293. Competing Interest: The authors declare that they have no conflict of interest. Ethical approval statement: All procedures involving human participants followed the ethical standards of the 1964 Helsinki declaration and the Code of Medical Ethics of the Medical Association of Slovenia. The study protocol was reviewed by the National Medical Ethics Committee (0120-653/2017/3) of the Republic of Slovenia. Patient consent statement: was obtained from all individual participants included in the study prior to inclusion. Author Contributions Statement T.K: Methodology, Investigation, Data curation, Formal analysis, Writing - Original draft, K.P.: Data curation, Formal analysis, Writing - Review & editing, R.G.: Conceptualization, Methodology, Formal analysis, Writing - Review & editing, Funding Acquisition. All authors approved the final version of the manuscript. Acknowledgments: None Clinical trial registration: NCT04782921, registered on March 4th, 2021. References Aimetti M, Fratini A, Manavella V, Giraudi M, Citterio F, Ferrarotti F, Romano F (2021) Pocket resolution in regenerative treatment of intrabony defects with papilla preservation techniques: A systematic review and meta-analysis of randomized clinical trials. J Clin Periodontol 48(6):843–858. https://doi.org/10.1111/JCPE.13428 Aslan S, Buduneli N, Cortellini P (2017) Entire Papilla Preservation Technique: A Novel Surgical Approach for Regenerative Treatment of Deep and Wide Intrabony Defects. Int J Periodontics Restor Dent 37(2):227–233. https://doi.org/10.11607/prd.2584 Aslan S, Buduneli N, Cortellini P (2020) Clinical outcomes of the entire papilla preservation technique with and without biomaterials in the treatment of isolated intrabony defects: A randomized controlled clinical trial. J Clin Periodontol 47(4):470–478. https://doi.org/10.1111/jcpe.13255 Besl PJ, McKay ND (1992) A Method for Registration of 3-D Shapes. IEEE Trans Pattern Anal Mach Intell 14(2):239–256. https://doi.org/10.1109/34.121791 Burkhardt R, Lang NP (2015) Influence of suturing on wound healing. Periodontol 2000 68(1):270–281. https://doi.org/10.1111/PRD.12078 Cairo F, Burkhardt R (2000) Minimal invasiveness in gingival augmentation and root coverage procedures. Periodontology 91:45–64. https://doi.org/10.1111/prd.12477 Cortellini P, Prato GP, Tonetti MS (1999) The simplified papilla preservation flap. A novel surgical approach for the management of soft tissues in regenerative procedures. The International Journal of Periodontics & Restorative Dentistry , 19 (6), 589–599. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10815597 Cortellini P, Prato GP, Tonetti MS (1995) The Modified Papilla Preservation Technique. A New Surgical Approach for Interproximal Regenerative Procedures. J Periodontol 66(4):261–266. https://doi.org/10.1902/JOP.1995.66.4.261 Cortellini P, Tonetti MS (2007) 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 34(1):87–93. https://doi.org/10.1111/J.1600-051X.2006.01020.X Cortellini P, Tonetti MS (2009) Improved wound stability with a modified minimally invasive surgical technique in the regenerative treatment of isolated interdental intrabony defects. J Clin Periodontol 36(2):157–163. https://doi.org/10.1111/j.1600-051X.2008.01352.x Cortellini P, Tonetti MS (2011) 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 38(4):365–373. https://doi.org/10.1111/J.1600-051X.2011.01705.X Cortellini P, Tonetti MS (2015) Clinical concepts for regenerative therapy in intrabony defects. Periodontol 2000 68(1):282–307. https://doi.org/10.1111/PRD.12048 Cortellini P, Tonetti MS, Lang NP, Suvan JE, Zucchelli G, Vangsted T, Adriaens P (2001) The Simplified Papilla Preservation Flap in the Regenerative Treatment of Deep Intrabony Defects: Clinical Outcomes and Postoperative Morbidity. J Periodontol 72(12):1702–1712. https://doi.org/10.1902/jop.2001.72.12.1702 Divya Elenora Martina BDS, Viswa Chandra B, Professor MDSR, Santosh D, Prabhandh Reddy V, Lecturer MDSS, G., Amarender Reddy MDS, Professor A (2022) A comparative evaluation of non-incised papillae and entire papilla preservation surgical approaches in treatment of intrabony defects – a clinical and radiographic study. Medrxiv , 2022.03.27.22273001. https://doi.org/10.1101/2022.03.27.22273001 Ellegaard B, Löe H (1971) New Attachment of Periodontal Tissues After Treatment of Intrabony Lesions. J Periodontol 42(10):648–652. https://doi.org/10.1902/JOP.1971.42.10.648 Kobe T, Povšič K, Gašperšič R (2024) Prehydrated collagenated cortico-cancellous heterologous bone gel and papillae tunneling for isolated intrabony defects: 12-month noninferiority trial. Clin Experimental Dent Res 10(1). https://doi.org/10.1002/CRE2.853 Kuralt M, Fidler A (2021) Assessment of reference areas for superimposition of serial 3D models of patients with advanced periodontitis for volumetric soft tissue evaluation. J Clin Periodontol 48(6):765–773. https://doi.org/10.1111/jcpe.13445 Kuralt M, Fidler A (2022) A novel computer-aided method for direct measurements and visualization of gingival margin changes. J Clin Periodontol 49(2):153–163. https://doi.org/10.1111/JCPE.13573 Kuralt M, Gašperšič R, Fidler A (2020) 3D computer-aided treatment planning in periodontology: A novel approach for evaluation and visualization of soft tissue thickness. J Esthetic Restor Dentistry 32(5):457–462. https://doi.org/10.1111/JERD.12614 Mancini L, Barootchi S, Pirc M, Marchetti E, Jung RE, Tavelli L, Thoma DS (2024) 3D surface defect map for assessing buccolingual profile of single tooth gaps following alveolar ridge preservation. Clin Implant Dent Relat Res 26(6). https://doi.org/10.1111/CID.13377 Moreno Rodriguez J, Caffesse R (2018) Nonincised Papillae Surgical Approach (NIPSA) in Periodontal Regeneration: Preliminary Results of a Case Series. Int J Periodontics Restor Dent 38(Suppl):s105–s111. https://doi.org/10.11607/prd.3195 Moreno Rodríguez, Jose A, Caffesse RG (2017) A New Papilla Preservation Technique for Periodontal Regeneration of Severely Compromised Teeth. Clin Adv Periodontics 8(1):1–16. https://doi.org/10.1902/cap.2017.170033 Moreno Rodríguez JA, Ortiz Ruiz AJ, Caffesse RG (2019) Periodontal reconstructive surgery of deep intraosseous defects using an apical approach. Non-incised papillae surgical approach (NIPSA): A retrospective cohort study. J Periodontol 90(5):454–464. https://doi.org/10.1002/JPER.18-0405 Moreno Rodríguez J Antonio, Ortiz Ruiz AJ (2022a) Apical approach in periodontal reconstructive surgery with enamel matrix derivate and enamel matrix derivate plus bone substitutes: a randomized, controlled clinical trial. Clin Oral Invest 26(3):2793–2805. https://doi.org/10.1007/s00784-021-04256-1 Moreno Rodríguez J Antonio, Ortiz Ruiz AJ (2022b) Apical approach in periodontal reconstructive surgery with enamel matrix derivate and enamel matrix derivate plus bone substitutes: a randomized, controlled clinical trial. Clin Oral Invest 26(3):2793–2805. https://doi.org/10.1007/s00784-021-04256-1 Nibali L, Cortellini P (2024) Periodontal Osseous Defects: A Treatment-Oriented Classification to Guide Regenerative Treatment Planning. Int J Periodontics Restor Dentistry 45(3):1–27. https://doi.org/10.11607/PRD.7125 O’Leary TJ, Drake RB, Naylor JE (1972) The plaque control record. J Periodontol 43(1):38–38. https://doi.org/10.1902/JOP.1972.43.1.38 Papapanou PN, Tonetti MS (2000) Diagnosis and epidemiology of periodontal osseous lesions. Periodontol 2000 22(1):8–21. https://doi.org/10.1034/J.1600-0757.2000.2220102.X Rojas MA, Marini L, Pilloni A, Sahrmann P (2019) Early wound healing outcomes after regenerative periodontal surgery with enamel matrix derivatives or guided tissue regeneration: A systematic review. BMC Oral Health 19(1). https://doi.org/10.1186/S12903-019-0766-9 Sanz M, Herrera D, Kebschull M, Chapple I, Jepsen S, Beglundh T, EFP Workshop Participants and Methodological Consultants (2020) Treatment of stage I-III periodontitis-The EFP S3 level clinical practice guideline. J Clin Periodontol 47(Suppl 22):4–60. https://doi.org/10.1111/jcpe.13290 . Suppl 2 Takei H, Yamada H, Hau T (1989) Maxillary Anterior Esthetics: Preservation of the Interdental Papilla. Dental Clin N Am 33(2):263–274. https://doi.org/10.1016/S0011-8532(22)01190-9 Tonetti MS, Greenwell H, Kornman KS (2018) Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. J Periodontol 89:S159–S172. https://doi.org/10.1002/JPER.18-0006 Wachtel H, Schenk G, Böhm S, Weng D, Zuhr O, Hürzeler MB (2003) Microsurgical access flap and enamel matrix derivative for the treatment of periodontal intrabony defects: A controlled clinical study. J Clin Periodontol 30(6):496–504. https://doi.org/10.1034/J.1600-051X.2003.00013.X Additional Declarations No competing interests reported. Supplementary Files COIsupplementtable1.docx Cite Share Download PDF Status: Published Journal Publication published 27 Jan, 2026 Read the published version in Clinical Oral Investigations → Version 1 posted Editorial decision: Revision requested 08 Oct, 2025 Reviews received at journal 07 Oct, 2025 Reviews received at journal 21 Sep, 2025 Reviewers agreed at journal 01 Sep, 2025 Reviewers agreed at journal 05 Aug, 2025 Reviewers invited by journal 04 Aug, 2025 Editor assigned by journal 22 Jul, 2025 Submission checks completed at journal 22 Jul, 2025 First submitted to journal 20 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7171416","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":495907845,"identity":"ada910c3-749f-4ab7-b6af-2caf9d8045ab","order_by":0,"name":"Tom Kobe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAx0lEQVRIiWNgGAWjYJACxgaGAwz8IFZCARHKeWBaJBtAWgxI0WJwAMQlRos9e3cC44yKO3LG51cnfnhgwCDPL3aAgC08ZzcwbjjzzNjsxtvNEkCHGc6cnUBAi0TuBsaHbYcTt904uwGkJcHgNpFa6jfPOLv5B/FaNrYdTjDg791GpC1nzm44OOPMM8MZN3i3WSQYSBD2C3t778aHPRV35Pn7z26++aPCRp5fmoAWEDgAJiXAKiUIK0cA/gOkqB4Fo2AUjIKRBACqekn9XUHLqQAAAABJRU5ErkJggg==","orcid":"","institution":"Private practice","correspondingAuthor":true,"prefix":"","firstName":"Tom","middleName":"","lastName":"Kobe","suffix":""},{"id":495907846,"identity":"3fa3378c-b47c-489e-bece-af898aa616fb","order_by":1,"name":"Katja Povšič","email":"","orcid":"","institution":"University Medical Centre Ljubljana","correspondingAuthor":false,"prefix":"","firstName":"Katja","middleName":"","lastName":"Povšič","suffix":""},{"id":495907847,"identity":"b56159f0-5d6d-4a1f-baed-513d4a1d2627","order_by":2,"name":"Rok Gašperšič","email":"","orcid":"","institution":"University Medical Centre Ljubljana","correspondingAuthor":false,"prefix":"","firstName":"Rok","middleName":"","lastName":"Gašperšič","suffix":""}],"badges":[],"createdAt":"2025-07-20 18:53:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7171416/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7171416/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00784-026-06746-6","type":"published","date":"2026-01-27T15:59:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88417099,"identity":"36384d71-f9f1-4b17-9349-8ff2dc213ddf","added_by":"auto","created_at":"2025-08-06 09:07:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":643150,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative case, treated with NIPSA. \u003cstrong\u003e(a)\u003c/strong\u003e Baseline measurement, \u003cstrong\u003e(b)\u003c/strong\u003e single horizontal incision, \u003cstrong\u003e(c)\u003c/strong\u003e \u003cstrong\u003e) \u003c/strong\u003einter-dental tunnel preparation, \u003cstrong\u003e(d)\u003c/strong\u003egranulation tissue removal, \u003cstrong\u003e(e) \u003c/strong\u003eapplication of bone substitute, \u003cstrong\u003e(f) \u003c/strong\u003esuturing, \u003cstrong\u003e(g)\u003c/strong\u003e healing after two weeks, \u003cstrong\u003e(h)\u003c/strong\u003e measurement after 6 months, \u003cstrong\u003e(i)\u003c/strong\u003ebaseline radiograph, \u003cstrong\u003e(j) \u003c/strong\u003e6-months radiograph.\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-7171416/v1/c65cd4456d76948f284040f4.png"},{"id":88416441,"identity":"3f5960b1-4486-46f5-b6f0-9a62f91ca0c2","added_by":"auto","created_at":"2025-08-06 08:59:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":631455,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative case, treated with EPPT. \u003cstrong\u003e(a)\u003c/strong\u003e Baseline measurement, \u003cstrong\u003e(b)\u003c/strong\u003e single vertical incision, \u003cstrong\u003e(c)\u003c/strong\u003e reflection of a small mucoperiosteal flap, \u003cstrong\u003e(d)\u003c/strong\u003egranulation tissue removal, \u003cstrong\u003e(e) \u003c/strong\u003eapplication of the standard slow-resorbing bone substitute, \u003cstrong\u003e(f) \u003c/strong\u003esuturing, \u003cstrong\u003e(g)\u003c/strong\u003e healing after two weeks, \u003cstrong\u003e(h)\u003c/strong\u003e measurement after six months, \u003cstrong\u003e(i)\u003c/strong\u003e baseline radiograph, \u003cstrong\u003e(j) \u003c/strong\u003e6-months radiograph.\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-7171416/v1/1de427682e43dbdd741e96c4.png"},{"id":88415089,"identity":"76d3e372-19fb-446a-a75e-2c5baedc6b6d","added_by":"auto","created_at":"2025-08-06 08:51:16","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":350277,"visible":true,"origin":"","legend":"\u003cp\u003eWorkflow for setting papillary boundries: \u003cstrong\u003e(a)\u003c/strong\u003e Superimposition of intraoral scans (IOS), \u003cstrong\u003e(b) \u003c/strong\u003eMaximum curvature function utilized for defining the boundaries of each tooth crown, \u003cstrong\u003e(c) \u003c/strong\u003eSagittal plane intersecting the midpoint between the papillae, \u003cstrong\u003e(d)\u003c/strong\u003e Parallel plane demarcating the buccal and lingual extension of the papilla, \u003cstrong\u003e(e) \u003c/strong\u003eSurface defect map illustrating the papilla, \u003cstrong\u003e(f)\u003c/strong\u003e Clinical measurements taken after six months, \u003cstrong\u003e(g)\u003c/strong\u003e A surface defect map illustrating soft tissue recession and incision line, \u003cstrong\u003e(h)\u003c/strong\u003e LDPs plotted on the sagittal plane.\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-7171416/v1/439acbd33cd1dd5e7c997526.png"},{"id":101691523,"identity":"61f71447-bf0b-4e49-a499-2ae6a95f7ede","added_by":"auto","created_at":"2026-02-02 16:13:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2996487,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7171416/v1/31144cd8-e775-43fb-921e-1528cc027e2b.pdf"},{"id":88415086,"identity":"8ce0ee39-40e3-4239-919a-4a034e4f2d84","added_by":"auto","created_at":"2025-08-06 08:51:16","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":41378,"visible":true,"origin":"","legend":"","description":"","filename":"COIsupplementtable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7171416/v1/6d1c56b346b398bf05b1d226.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Volumetric Evaluation of the Entire Papilla Preservation Technique and the Non-Incised Papillae Surgical Approach: Effects on Soft Tissue Preservation and Periodontal Regeneration","fulltext":[{"header":"1 INTRODUCTION","content":"\u003cp\u003eRegenerative periodontal techniques are essential for the treatment of deep intrabony defects [1]. The success of these procedures depends on two key factors: the biological potential for periodontal regeneration and the preservation of soft tissue architecture, especially the interdental papillae. Primary wound closure and wound stability are critical for stabilizing the blood clot and preventing the exposure of regenerative materials [2]. Maintaining the integrity of interdental papillae is crucial both functionally and esthetically, as their loss leads to the formation of black gingival triangles, phonetic problems and food impaction [3].\u003c/p\u003e\u003cp\u003eTo reach deep intrabony defects, conventional surgical approaches incise and elevate the interdental papillae, compromising blood supply and negatively affecting healing due to the lack of primary closure in the early healing phase. A systematic review analyzing 220 intrabony periodontal defects reported flap dehiscence in approximately 12% of GTR-treated sites, with membrane exposure occurring in up to 28.8% of defects where barrier membranes were used [4]. These challenges have led to the development of more conservative surgical techniques aimed at preserving interdental papillae while allowing effective treatment of the underlying defects: the entire papilla preservation technique (EPPT) [5], a tunnelling method, and the non-incisional papillae surgical approach (NIPSA), which uses a mucosal incision, far from the marginal tissue [6]. These techniques limit the risk of premature wound failure, prevent the exposure of regenerative biomaterials and provide a stable environment for the blood clots in deep intrabony defects. A comparative study between NIPSA and the minimally invasive surgical technique (MIST) showed that while both techniques significantly improved clinical attachment levels and reduced probing depth, NIPSA resulted in significantly less recession of the interdental papilla [7]. An additional advantage of the papillae tunneling techniques is that they reduce the need for bioresorbable membranes, which can pose technical challenges in traditional papillae preservation methods [8].\u003c/p\u003e\u003cp\u003eDespite the promising results reported for both EPPT and NIPSA, direct comparative studies are scarce [9]. This randomized, controlled clinical trial aimed to compare their effectiveness in periodontal regeneration and soft tissue preservation. It was hypothesized that while both procedures yield significant improvements in clinical parameters, NIPSA may provide better results in soft tissue preservation and esthetics due to its completely non-incisional approach at the marginal gingiva. In addition to traditional clinical parameters, a recently proposed digital volumetric approach to assess papilla height preservation was also used to analyze early wound healing indices.\u003c/p\u003e"},{"header":"2 MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Study Design and Population​\u003c/h2\u003e\u003cp\u003eThis was a single-centre, randomized, controlled clinical trial. ​ Ethical approval was granted by the National Medical Ethics Committee (protocol no. ​ 0120\u0026ndash;653/2017/3), and the study was registered on ClinicalTrials.gov (NCT04782921). ​ All patients provided written informed consent before participation. ​ The study adhered to the Code of Medical Ethics of the Medical Association of Slovenia and the principles of the Declaration of Helsinki.\u003c/p\u003e\u003cp\u003eForty patients were selected from 112 consecutively assessed individuals seeking treatment of stage III/IV periodontitis [10] at the Department of Oral Medicine and Periodontology, University Medical Center Ljubljana, Slovenia, between March 2020 and August 2022. ​ The inclusion criteria consisted of: at least one isolated deep 3-wall intrabony defect with a partial 2-wall component [11]; involvement of the interproximal region of at least one periodontally affected tooth with probing depth (PD)\u0026thinsp;\u0026ge;\u0026thinsp;5 mm and clinical attachment level (CAL)\u0026thinsp;\u0026ge;\u0026thinsp;6 mm; presence of at least 16 scorable teeth (excluding third molars); full-mouth bleeding score (FMBS) and full-mouth plaque score (FMPS) less than 20% [12]. ​The exclusion criteria included: treatment with systemic antibiotics in the last 6 months, periodontal treatment in the last 6 months, heavy smokers (more than 10 cigarettes per day), subjects with systemic diseases (diseases affecting wound healing, diseases of bone metabolism, diabetes mellitus, HIV/AIDS, cancer), subjects with systemic therapy (non-steroidal anti-inflammatory drugs, calcium antagonists, antiepileptics, immunosuppressives) and pregnant or lactating women. ​ Teeth with inadequate endodontic treatment (periapical radiolucency on local radiograph) were also excluded.​\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Study protocol\u003c/h2\u003e\u003cp\u003eA full periodontal examination was performed with a manual periodontal probe (PCPUNC15, Hu-Friedy, USA) at the first visit and included the following clinical parameters: FMPS, FMBS, PD, gingival recession (REC), and bleeding on probing (BOP). CAL was calculated by adding PD and REC values. All examinations were performed by the same experienced, calibrated, blinded investigator (R. G.). A calibration exercise, with measurements repeated after one week, resulted in intraclass correlation coefficients for PD and CAL exceeding 0.9, and κ values for FMPS and BOP above 0.95, demonstrating excellent reproducibility.\u003c/p\u003e\u003cp\u003e All subjects then received initial nonsurgical periodontal therapy: motivation and education regarding oral hygiene, removal of supra- and subgingival biofilm deposits (NSK Varios 970; G5 scaling tip; NSK dental, Japan), as well as scaling and root planing of sites with PD\u0026thinsp;\u0026ge;\u0026thinsp;5 mm (Micro Mini Five Gracey Curette; Hu Friedy, USA) under local anesthesia (Septanestepi; Septodont, France). ​\u003c/p\u003e\u003cp\u003eA full clinical exam was performed once again after 3 months (T0). One interproximal site with the deepest PD (PD\u0026thinsp;\u0026ge;\u0026thinsp;5mm, CAL\u0026thinsp;\u0026ge;\u0026thinsp;6mm) and an associated radiographic intrabony defect was selected per subject for inclusion in the trial [13]. Intraoral photographs (Canon EOS RP; Canon, Japan) were taken to identify the location of the papillae tips (TP) at the experimental site for comparison of initial and final conditions. A manual periodontal probe was used to calibrate the scale, and the TP position was measured in relation to the incisal edge of the adjacent tooth (using ImageJ; U. S. National Institutes of Health, USA). Each measurement was repeated three times, and the average value was calculated. An intraoral scan (TRIOS 3; 3Shape, Denmark) was performed for the assessment of changes in soft tissue morphology.\u003c/p\u003e\u003cp\u003e In addition, a local radiograph of the site intended for surgery was taken and a radiographic analysis was performed. Distances were measured by projecting three reference points onto a straight line along the tooth\u0026rsquo;s long axis: the enamel\u0026ndash;cement junction, the most apical point of the defect, and the tooth apex. Radiographic bone height relative to the root length was then calculated for comparison with radiographic outcomes 1-year after surgery. Additionally, the radiographic periodontal defect angle was measured [14].\u003c/p\u003e\u003cp\u003eThe intrabony defects underwent surgical treatment with either the Non-incised Papillae Surgical Approach (NIPSA) [6] or the Entire Papilla Preservation Technique (EPPT) [5] according to a predetermined randomisation table. All surgical procedures were performed by the same periodontologist (T. K.).\u003c/p\u003e\u003cp\u003eAfter local anesthetic administration (Septanestepi; Septodont, France), an intracrevicular incision was made around the teeth affected by the defect. Then, a short vertical semilunar incision was made in the buccal gingiva, just beyond the mucogingival line, as part of EPPT [5](Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb). Alternatively, a single long horizontal apical incision was made in the mucosa, extending one tooth mesially and distally from the defect and apically to the bony ridge edge bordering the defect, as part of NIPSA (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb) [6]. Once a buccal full-thickness mucoperiosteal flap was elevated, a tunneling instrument (TKN1; Hufriedy, USA) was used in both approaches for tunnel preparation at the defect-associated papilla (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec). The papilla was sharply dissected from the underlying granulation tissue, using microsurgical scissors (SPV; Hu Friedy, USA) and granulation tissue was excised with a small curette (Micro Mini Five Gracey Curette; Hu Friedy, USA) (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ed). The exposed root surface was cleaned with an ultrasonic scaler (NSK Varios 970, P10 periodontal tip; NSK Dental, Japan), and a small curette was used to remove any subgingival calculus or plaque. The surgical site was then thoroughly cleaned with sterile saline, and the intrabony defect was filled with collagenous corticocellular xenogeneic bone graft, pre-soaked in the saline solution (Gen-Os, granulometry ranging from 250 to 1000 \u0026micro;m; Osteobiol, Italy) (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ee, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ee). During the procedure, relative isolation was used to prevent contamination of the root surface with saliva. Microsurgical suturing with 6\u0026ndash;0 or monofilaments (Nylon; Atramat, Mexico) were applied for wound closure (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ef, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ef). After surgery, gentle pressure was applied to the surgical site with a saline-moistened gauze for 1 minute to allow for the adaptation of the mucoperiosteal flap.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003ePatients received instructions not to perform oral hygiene in the surgical area for 3 weeks and instead to rinse 2x/day with 0.12% chlorhexidine digluconate (Curasept ADS DNA 212; Curasept, Italy). One week after surgery, subjects reported any side effects or issues. Sutures were removed 2 weeks after the procedure and primary wound closure (WC) was assessed: complete WC\u0026thinsp;=\u0026thinsp;2, incomplete closure with a fibrin clot (WC\u0026thinsp;=\u0026thinsp;1), or biomaterial exposure (WC\u0026thinsp;=\u0026thinsp;0) [15] (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAs part of the maintenance protocol, T.K. performed professional dental cleanings on each patient every 2 months for the following 6 months. The final follow-up visit was scheduled 6-months (T6) after surgery and included a clinical exam, an intraoral scan, intraoral photographs and a local radiograph of the surgical site. The same parameters were recoded as at baseline (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eh, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eh).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Digital analysis of intraoral scans\u003c/h2\u003e\u003cp\u003eIntraoral scans were performed using an intraoral optical scanner and a standard scanning protocol [16]. The resulting 3D models were exported in Standard Tessellation Language (STL) format. Post-processing was conducted using GOM Inspect 2018 (GOM GmbH, Germany), utilizing the iterative closest point algorithm [17]. Initial alignments of each digital model pair (T0\u0026ndash;T6) were carried out using the automated Prealignment tool across the entire model surface (soft tissues and teeth). Next, a secondary alignment was performed using the automated Local Best-Fit tool [18] using the surfaces of each selected tooth and its two neighbors as reference areas.\u003c/p\u003e\u003cp\u003eAn area of interest (interdental papilla) was then defined (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). On each T0 scan, the gingival margins of the mesial and distal teeth adjacent to papillary surgical site were manually marked by placing 5\u0026ndash;10 points with the Maximum curvature function, generating four curves (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb) [19].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe Distance between curves tool was then used to establish a midpoint between the buccal and the lingual/palatal curves (i.e., the gingival margins), and a sagittal cutting plane was traced through these points, oriented perpendicular to the occlusal plane (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ec). A buccal line (LB) and a lingual/palatal line (LL/LP) were drawn between the most apical point of both the buccal and the lingual/palatal curves (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ed).\u003c/p\u003e\u003cp\u003eNext, a surface defect map was generated on the sagittal plane at the central point of the papilla using the Inspect section function, and papilla height and width were measured (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eg). The ratio between height and width was then calculated, classifying the papillae as flat (h/w ratio\u0026thinsp;\u0026lt;\u0026thinsp;0.2) or convex (h/w ratio\u0026thinsp;\u0026gt;\u0026thinsp;0.2). Additionally, the surface defect map allowed for the visualization of changes at all points on the vertical cutting planes through the use of Linear divergence points (LDPs) [20]. LDPs were plotted starting from the tip of the papilla, extending 0.7 mm apart in a corono-apical direction on both buccal and lingual/palatal sides, until either LB or LL/LP was reached, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eh).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Randomisation and blinding\u003c/h2\u003e\u003cp\u003eEach patient's selected defect was randomly assigned to one of the two surgical procedures using numbered, opaque sealed envelopes. Randomization was ensured using a computer-generated table. The envelopes were opened by the operator just before surgery. The investigator was blinded throughout the study.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Statistical Analysis​\u003c/h2\u003e\u003cp\u003eSample size was determined using CAL gain as the primary outcome. ​ A difference of 1.25 mm in CAL gain was considered clinically significant, with expected standard deviation set at 1.4 mm [9]. ​ With α\u0026thinsp;=\u0026thinsp;0.05 and 80 % ower, the calculated sample size was 20 surgical sites per group.​\u003c/p\u003e\u003cp\u003eDemographic variables were presented as means (\u0026plusmn;\u0026thinsp;standard deviations) or as counts and proportions, depending on the context. Primary outcome variables included changes in CAL gain, PD, REC, and TP. Normality of distributions was assessed using the Shapiro-Wilk test. Intergroup analyses were conducted using Fisher\u0026rsquo;s exact tests, paired t-tests (for normal distributions) and Wilcoxon signed-rank tests (for non-normal distributions). Analysis was conducted using SPSS v. 26, with a significance level set at α\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"3 RESULTS","content":"\u003cp\u003eOut of the 112 subjects screened for inclusion, 40 subjects were included in the study and all followed through to the last follow-up. The mean age of the subjects was 59.3\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7 years; 20 were males. No statistically significant differences between the NIPSA and EPPT groups were found at baseline in terms of demographic and clinical parameters (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient characteristics and clinical parameters measured at baseline.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNISPA (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEPPT (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eStudy population\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (male/female)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11/9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.200\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years) [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.936\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking (nonsmokers/smokers)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18/2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14/6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.106\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDental arch (maxillary/mandibular)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10/10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14/6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.333\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTooth type (incisors/canines/premolars/molars)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12/4/4/0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16/3/1/0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.304\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKT width (mm) [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.186\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePeriodontal defect characteristics\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCEJ-defect bottom (mm) [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.623\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntraosseous component (mm) [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.777\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3-wall component (mm) [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1kp\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.799\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMain defect configuration (\u0026minus;\u0026thinsp;1/\u0026minus;2/\u0026minus;3 wall)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/16/4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/18/2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.661\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eX-ray angle (deg.) [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37.7\u0026thinsp;\u0026plusmn;\u0026thinsp;13.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32.6\u0026thinsp;\u0026plusmn;\u0026thinsp;13.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.349\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePD (mm) [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.296\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eREC (mm) [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.509\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCAL (mm) [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.862\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBOP (positive/negative)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17/3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15/5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.695\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviations: CAL, clinical attachment loss; CEJ, cemento-enamel junction; KT, keratinized tissue; NIPSA, non-incised papillae surgical approach; PD, probing depth; REC, gingival recession; BOP, bleeding on probing; SD, standard deviation.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003eFisher's exact test.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003eIndependent-samples Mann\u0026ndash;Whitney U test.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ec\u003c/sup\u003eIndependent-samples t‐test.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eWound closure, change in radiographic bone height and vertical cross section characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNIPSA (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEPPT (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWound closure (0/1/2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/3/17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/2/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRadiographic change in bone height (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32.6\u0026thinsp;\u0026plusmn;\u0026thinsp;20.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.6\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.587\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eVertical cross-section characteristics\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWidth (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.01\u0026thinsp;\u0026plusmn;\u0026thinsp;1.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.61\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.154 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.95\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.266 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConvex/flat profile (n/n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13/7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14/6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e Fischer's exact test.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e Independent samples t-test.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAt the 1-week follow-up, only two sites treated with NIPSA and 3 sites treated with EPPT (p\u0026thinsp;=\u0026thinsp;N. S.) healed with fibrin cloth covering; no biomaterial exposure was observed. After 6 months, changes in PD, REC and CAL were comparable between both study groups and showed no statistically significant differences, although the values were slightly higher in the NIPSA group (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Only the TP recession was higher in the EPPT group, but was also not statistically significantly different to the NIPSA group.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eEffect of surgical technique on average changes in CAL, REC, PD, and TP.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNISPA (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEPPT (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ediffPD (mm) [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.165\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ediffREC (mm) [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e-0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.475\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ediffCAL (mm) [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.529\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ediffTP (mm) [mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e-0.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.496\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviations: CAL, clinical attachment loss; d, Cohen's D; diff, difference between the baseline and 1 year; PD, probing depth; p-value, Welch two sample t‐test; REC, recession; SD, standard deviation; TP, location of papilla.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe volumetric analysis of mean changes in LDPs for both surgical modalities are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e; no statistically significant differences were found. The differences were more pronounced at the buccal aspect of the papillae. Convex papilla profiles were more prone to TP recession (0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 mm) in comparison to flat profiles (0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 mm), but again, the difference was non-significant (p\u0026thinsp;=\u0026thinsp;0.194). The volumetric analysis (LDP0) correlated (r\u0026thinsp;=\u0026thinsp;0.463, p\u0026thinsp;=\u0026thinsp;0.006) with the manual measurement on digital photography (diffTP).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMean LDP differences, compared between both treatment groups.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eNIPSA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eEPPT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ep-value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003emean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003emean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLDP0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.245\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBuccal sites\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDP1-B\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.611\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDP2-B\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.568\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDP3-B\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.820\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDP4-B\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.537\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDP5-B\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.35\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.291\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDP6-B\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.49\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.239\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDP7-B\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.35\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.74\u0026thinsp;\u0026plusmn;\u0026thinsp;NA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.482\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePalatal sites\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDP1-P\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.348\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDP2-P\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.27\u0026thinsp;\u0026plusmn;\u0026thinsp;0.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.297\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDP3-P\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.218\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDP4-P\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.075\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDP5-P\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.157\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDP6-P\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.076\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDP7-P\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.44\u0026thinsp;\u0026plusmn;\u0026thinsp;NA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.948\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e Independent samples t-test. LDP \u0026ndash; linear divergence points. B \u0026ndash; buccal. P \u0026ndash; palatal/lingual.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"4 DISCUSSION","content":"\u003cp\u003eThis study compared the clinical outcomes of NIPSA and EPPT in the treatment of intrabony periodontal defects. Our results showed that both surgical techniques were effective in improving clinical parameters, with no statistically significant differences observed between the two approaches. Minimal healing complications occurred at the one-week follow-up, with only two sites in the NIPSA group and three in the EPPT group demonstrating fibrin cloth coverage; no biomaterial exposure was observed in any group. The changes in PD, REC and CAL were comparable between the techniques. The change in TP was more pronounced in the EPPT group, but this difference did not reach statistical significance.\u003c/p\u003e\u003cp\u003eMore than five decades ago, Ellegaard and L\u0026ouml;e[21] demonstrated that open flap debridement in intrabony defects reduces PD from 7\u0026ndash;9 mm to 2\u0026ndash;3 mm while improving clinical attachment, thus proving that periodontal regeneration is possible without regenerative biomaterials. Since then, treatment of intrabony defects has evolved to preserve soft tissue architecture and minimize flap size to improve wound stability. This has led to conservative approaches such as the papilla preservation technique [22], the modified PPT [23], the simplified PPT [24], the minimally invasive surgical technique (MIST)[25] and the modified MIST [26]. While new regenerative materials improved outcomes, Wachtel emphasized that primary wound closure is crucial, as closed sites respond better to regenerative therapy [27]. The EPPT by Aslan et al.[5] initially used a bone graft with enamel matrix derivative (EMD), which achieved complete primary wound closure with an average PD reduction of 7 mm after one year. Their subsequent study showed no significant differences between the sites treated with blood clots alone and bone grafts with EMD, suggesting that grafts are not essential with this technique [28]. NIPSA, introduced by Rodr\u0026iacute;guez and Caffesse [29], originally used EMD with a xenogeneic bone graft and achieved an average PD reduction of 7.3 mm. Subsequent studies showed that NIPSA promotes supra-alveolar attachment and outperforms conventional MIST in terms of wound stability and tissue regeneration [15]. Further studies found that bone grafting with NIPSA reduced papilla collapse but increased the incidence of residual pockets, suggesting that slowly resorbing grafts may compromise certain aspects of regeneration while providing better soft tissue support [30]. In line with these principles, our study showed that both NIPSA and EPPT resulted in a significant reduction in PD and attachment gain. Although the differences between the techniques were not statistically significant, the NIPSA group achieved a mean PD reduction of approximately 5.3 mm, while the EPPT group achieved a mean reduction of 4.6 mm. The comparable results between the two techniques indicate that effective pocket depth reduction can be achieved with both methods.\u003c/p\u003e\u003cp\u003eThe preservation of the interdental papillae is crucial for both the functional and esthetic outcomes of periodontal surgery. Using an advanced 3D comparison methodology with GOM Inspect software, we were able to accurately measure these soft tissue changes using vertical sectional planes and linear divergence points. Although the EPPT group showed greater loss at the papilla apex compared to the NIPSA group, this difference was not statistically significant. The digital approach provided a more accurate and reproducible measurement of soft tissue changes compared to conventional clinical assessments, although there was a correlation between manual and volumetric assessment of TP [19]. The slight difference in papilla height preservation could be due to the proximity of the first incision to the papilla in the EPPT technique.\u003c/p\u003e\u003cp\u003eSeveral limitations must be considered when interpreting our results. First, the selection of sites and defect types was not completely homogeneous between the two techniques. These differences in defect morphology could potentially influence the comparative results. The selection of patients also excluded areas beyond the second premolar in the posterior region.\u003c/p\u003e\u003cp\u003eIn our previous study [31], the surgical approach (either EPPT or NIPSA) was determined based on anatomical landmarks. In the current study, however, patients were randomized to different surgical approaches. We still believe that certain approaches are more suitable for different regions. As previously mentioned, the close proximity of the mental nerve poses a challenge for the NIPSA approach. In addition, a deep muscle-releasing incision is required in the anterior mandibular region with NIPSA to achieve tension-free closure [32].\u003c/p\u003e\u003cp\u003eIn the EPPT group, the authors noted challenges with tension-free adaptation of the flap after application of the biomaterial. This required a muscle-free incision, which could theoretically affect the blood supply and influence the outcome of periodontal regeneration [33].\u003c/p\u003e\u003cp\u003eAlthough our six-month follow-up provides valuable insight into initial healing and mid-term stability, longer observation periods would be beneficial to assess the long-term stability of the outcomes. Finally, our study was conducted at a single center, and the procedures were performed by a single surgeon, which may have limited the generalizability of our results to other clinical settings.\u003c/p\u003e"},{"header":"5 CONCLUSIONS","content":"\u003cp\u003eBoth NIPSA and EPPT showed comparable clinical results in the regeneration of intrabony defects, with no significant differences in the main outcomes. NIPSA may preserve the papillae slightly better by avoiding marginal gingival incisions, but this advantage was not statistically significant. Digital assessment methods enabled precise measurements of papilla morphology, highlighting the value of digital technologies for research. Larger sample sizes, longer follow-up periods and standardized defect criteria are needed to differentiate minimally invasive techniques. Both techniques remain viable, with the choice depending on the specifics of each defect and the surgeon's preference.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting this study\u0026apos;s findings are available on a reasonable request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was supported by the Ministry of Science and Technology of the Republic of Slovenia, grant number P3-0293.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures involving human participants followed the ethical standards of the 1964 Helsinki declaration and the Code of Medical Ethics of the Medical Association of Slovenia. The study protocol was reviewed by the National Medical Ethics Committee (0120-653/2017/3) of the Republic of Slovenia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient consent statement:\u0026nbsp;\u003c/strong\u003ewas obtained from all individual participants included in the study prior to inclusion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eT.K: Methodology, Investigation, Data curation, Formal analysis, Writing - Original draft, K.P.: Data curation, Formal analysis, Writing - Review \u0026amp; editing, R.G.: Conceptualization, Methodology, Formal analysis, Writing - Review \u0026amp; editing, Funding Acquisition. All authors approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial registration:\u0026nbsp;\u003c/strong\u003eNCT04782921, registered on March 4th, 2021.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAimetti M, Fratini A, Manavella V, Giraudi M, Citterio F, Ferrarotti F, Romano F (2021) Pocket resolution in regenerative treatment of intrabony defects with papilla preservation techniques: A systematic review and meta-analysis of randomized clinical trials. J Clin Periodontol 48(6):843\u0026ndash;858. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/JCPE.13428\u003c/span\u003e\u003cspan address=\"10.1111/JCPE.13428\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAslan S, Buduneli N, Cortellini P (2017) Entire Papilla Preservation Technique: A Novel Surgical Approach for Regenerative Treatment of Deep and Wide Intrabony Defects. Int J Periodontics Restor Dent 37(2):227\u0026ndash;233. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.11607/prd.2584\u003c/span\u003e\u003cspan address=\"10.11607/prd.2584\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAslan S, Buduneli N, Cortellini P (2020) Clinical outcomes of the entire papilla preservation technique with and without biomaterials in the treatment of isolated intrabony defects: A randomized controlled clinical trial. J Clin Periodontol 47(4):470\u0026ndash;478. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jcpe.13255\u003c/span\u003e\u003cspan address=\"10.1111/jcpe.13255\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBesl PJ, McKay ND (1992) A Method for Registration of 3-D Shapes. IEEE Trans Pattern Anal Mach Intell 14(2):239\u0026ndash;256. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1109/34.121791\u003c/span\u003e\u003cspan address=\"10.1109/34.121791\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBurkhardt R, Lang NP (2015) Influence of suturing on wound healing. Periodontol 2000 68(1):270\u0026ndash;281. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/PRD.12078\u003c/span\u003e\u003cspan address=\"10.1111/PRD.12078\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCairo F, Burkhardt R (2000) Minimal invasiveness in gingival augmentation and root coverage procedures. Periodontology 91:45\u0026ndash;64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/prd.12477\u003c/span\u003e\u003cspan address=\"10.1111/prd.12477\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCortellini P, Prato GP, Tonetti MS (1999) The simplified papilla preservation flap. A novel surgical approach for the management of soft tissues in regenerative procedures. \u003cem\u003eThe International Journal of Periodontics \u0026amp; Restorative Dentistry\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(6), 589\u0026ndash;599. Retrieved from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/pubmed/10815597\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/pubmed/10815597\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCortellini P, Prato GP, Tonetti MS (1995) The Modified Papilla Preservation Technique. A New Surgical Approach for Interproximal Regenerative Procedures. J Periodontol 66(4):261\u0026ndash;266. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1902/JOP.1995.66.4.261\u003c/span\u003e\u003cspan address=\"10.1902/JOP.1995.66.4.261\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCortellini P, Tonetti MS (2007) 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 34(1):87\u0026ndash;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/J.1600-051X.2006.01020.X\u003c/span\u003e\u003cspan address=\"10.1111/J.1600-051X.2006.01020.X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCortellini P, Tonetti MS (2009) Improved wound stability with a modified minimally invasive surgical technique in the regenerative treatment of isolated interdental intrabony defects. J Clin Periodontol 36(2):157\u0026ndash;163. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1600-051X.2008.01352.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1600-051X.2008.01352.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCortellini P, Tonetti MS (2011) 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 38(4):365\u0026ndash;373. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/J.1600-051X.2011.01705.X\u003c/span\u003e\u003cspan address=\"10.1111/J.1600-051X.2011.01705.X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCortellini P, Tonetti MS (2015) Clinical concepts for regenerative therapy in intrabony defects. Periodontol 2000 68(1):282\u0026ndash;307. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/PRD.12048\u003c/span\u003e\u003cspan address=\"10.1111/PRD.12048\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCortellini P, Tonetti MS, Lang NP, Suvan JE, Zucchelli G, Vangsted T, Adriaens P (2001) The Simplified Papilla Preservation Flap in the Regenerative Treatment of Deep Intrabony Defects: Clinical Outcomes and Postoperative Morbidity. J Periodontol 72(12):1702\u0026ndash;1712. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1902/jop.2001.72.12.1702\u003c/span\u003e\u003cspan address=\"10.1902/jop.2001.72.12.1702\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDivya Elenora Martina BDS, Viswa Chandra B, Professor MDSR, Santosh D, Prabhandh Reddy V, Lecturer MDSS, G., Amarender Reddy MDS, Professor A (2022) A comparative evaluation of non-incised papillae and entire papilla preservation surgical approaches in treatment of intrabony defects \u0026ndash; a clinical and radiographic study. \u003cem\u003eMedrxiv\u003c/em\u003e, 2022.03.27.22273001. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1101/2022.03.27.22273001\u003c/span\u003e\u003cspan address=\"10.1101/2022.03.27.22273001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEllegaard B, L\u0026ouml;e H (1971) New Attachment of Periodontal Tissues After Treatment of Intrabony Lesions. J Periodontol 42(10):648\u0026ndash;652. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1902/JOP.1971.42.10.648\u003c/span\u003e\u003cspan address=\"10.1902/JOP.1971.42.10.648\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKobe T, Povšič K, Gašperšič R (2024) Prehydrated collagenated cortico-cancellous heterologous bone gel and papillae tunneling for isolated intrabony defects: 12-month noninferiority trial. Clin Experimental Dent Res 10(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/CRE2.853\u003c/span\u003e\u003cspan address=\"10.1002/CRE2.853\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKuralt M, Fidler A (2021) Assessment of reference areas for superimposition of serial 3D models of patients with advanced periodontitis for volumetric soft tissue evaluation. J Clin Periodontol 48(6):765\u0026ndash;773. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jcpe.13445\u003c/span\u003e\u003cspan address=\"10.1111/jcpe.13445\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKuralt M, Fidler A (2022) A novel computer-aided method for direct measurements and visualization of gingival margin changes. J Clin Periodontol 49(2):153\u0026ndash;163. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/JCPE.13573\u003c/span\u003e\u003cspan address=\"10.1111/JCPE.13573\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKuralt M, Gašperšič R, Fidler A (2020) 3D computer-aided treatment planning in periodontology: A novel approach for evaluation and visualization of soft tissue thickness. J Esthetic Restor Dentistry 32(5):457\u0026ndash;462. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/JERD.12614\u003c/span\u003e\u003cspan address=\"10.1111/JERD.12614\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMancini L, Barootchi S, Pirc M, Marchetti E, Jung RE, Tavelli L, Thoma DS (2024) 3D surface defect map for assessing buccolingual profile of single tooth gaps following alveolar ridge preservation. Clin Implant Dent Relat Res 26(6). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/CID.13377\u003c/span\u003e\u003cspan address=\"10.1111/CID.13377\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoreno Rodriguez J, Caffesse R (2018) Nonincised Papillae Surgical Approach (NIPSA) in Periodontal Regeneration: Preliminary Results of a Case Series. Int J Periodontics Restor Dent 38(Suppl):s105\u0026ndash;s111. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.11607/prd.3195\u003c/span\u003e\u003cspan address=\"10.11607/prd.3195\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoreno Rodr\u0026iacute;guez, Jose A, Caffesse RG (2017) A New Papilla Preservation Technique for Periodontal Regeneration of Severely Compromised Teeth. Clin Adv Periodontics 8(1):1\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1902/cap.2017.170033\u003c/span\u003e\u003cspan address=\"10.1902/cap.2017.170033\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoreno Rodr\u0026iacute;guez JA, Ortiz Ruiz AJ, Caffesse RG (2019) Periodontal reconstructive surgery of deep intraosseous defects using an apical approach. Non-incised papillae surgical approach (NIPSA): A retrospective cohort study. J Periodontol 90(5):454\u0026ndash;464. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/JPER.18-0405\u003c/span\u003e\u003cspan address=\"10.1002/JPER.18-0405\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoreno Rodr\u0026iacute;guez J Antonio, Ortiz Ruiz AJ (2022a) Apical approach in periodontal reconstructive surgery with enamel matrix derivate and enamel matrix derivate plus bone substitutes: a randomized, controlled clinical trial. Clin Oral Invest 26(3):2793\u0026ndash;2805. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00784-021-04256-1\u003c/span\u003e\u003cspan address=\"10.1007/s00784-021-04256-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoreno Rodr\u0026iacute;guez J Antonio, Ortiz Ruiz AJ (2022b) Apical approach in periodontal reconstructive surgery with enamel matrix derivate and enamel matrix derivate plus bone substitutes: a randomized, controlled clinical trial. Clin Oral Invest 26(3):2793\u0026ndash;2805. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00784-021-04256-1\u003c/span\u003e\u003cspan address=\"10.1007/s00784-021-04256-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNibali L, Cortellini P (2024) Periodontal Osseous Defects: A Treatment-Oriented Classification to Guide Regenerative Treatment Planning. Int J Periodontics Restor Dentistry 45(3):1\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.11607/PRD.7125\u003c/span\u003e\u003cspan address=\"10.11607/PRD.7125\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eO\u0026rsquo;Leary TJ, Drake RB, Naylor JE (1972) The plaque control record. J Periodontol 43(1):38\u0026ndash;38. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1902/JOP.1972.43.1.38\u003c/span\u003e\u003cspan address=\"10.1902/JOP.1972.43.1.38\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePapapanou PN, Tonetti MS (2000) Diagnosis and epidemiology of periodontal osseous lesions. Periodontol 2000 22(1):8\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1034/J.1600-0757.2000.2220102.X\u003c/span\u003e\u003cspan address=\"10.1034/J.1600-0757.2000.2220102.X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRojas MA, Marini L, Pilloni A, Sahrmann P (2019) Early wound healing outcomes after regenerative periodontal surgery with enamel matrix derivatives or guided tissue regeneration: A systematic review. BMC Oral Health 19(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/S12903-019-0766-9\u003c/span\u003e\u003cspan address=\"10.1186/S12903-019-0766-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSanz M, Herrera D, Kebschull M, Chapple I, Jepsen S, Beglundh T, EFP Workshop Participants and Methodological Consultants (2020) Treatment of stage I-III periodontitis-The EFP S3 level clinical practice guideline. J Clin Periodontol 47(Suppl 22):4\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jcpe.13290\u003c/span\u003e\u003cspan address=\"10.1111/jcpe.13290\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. \u003cem\u003eSuppl 2\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTakei H, Yamada H, Hau T (1989) Maxillary Anterior Esthetics: Preservation of the Interdental Papilla. Dental Clin N Am 33(2):263\u0026ndash;274. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0011-8532(22)01190-9\u003c/span\u003e\u003cspan address=\"10.1016/S0011-8532(22)01190-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTonetti MS, Greenwell H, Kornman KS (2018) Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. J Periodontol 89:S159\u0026ndash;S172. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/JPER.18-0006\u003c/span\u003e\u003cspan address=\"10.1002/JPER.18-0006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWachtel H, Schenk G, B\u0026ouml;hm S, Weng D, Zuhr O, H\u0026uuml;rzeler MB (2003) Microsurgical access flap and enamel matrix derivative for the treatment of periodontal intrabony defects: A controlled clinical study. J Clin Periodontol 30(6):496\u0026ndash;504. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1034/J.1600-051X.2003.00013.X\u003c/span\u003e\u003cspan address=\"10.1034/J.1600-051X.2003.00013.X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"clinical-oral-investigations","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cloi","sideBox":"Learn more about [Clinical Oral Investigations](http://link.springer.com/journal/784)","snPcode":"784","submissionUrl":"https://submission.nature.com/new-submission/784/3","title":"Clinical Oral Investigations","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"clinical trial, guided tissue regeneration, microsurgery, periodontitis, surgical flaps","lastPublishedDoi":"10.21203/rs.3.rs-7171416/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7171416/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis randomized, controlled clinical trial compared two minimally invasive surgical techniques - the Non-Incised Papillae Surgical Approach (NIPSA) and the Entire Papilla Preservation Technique (EPPT) - in terms of their efficacy in preserving soft tissue architecture and promoting periodontal regeneration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIsolated intrabony defects of 40 patients with stage III/IV periodontitis were randomly assigned to either NIPSA or EPPT treatment. Clinical parameters including probing depth (PD), clinical attachment level (CAL), gingival recession (REC) and papilla height (TP) were evaluated at baseline and 6-months postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth NIPSA and EPPT showed significant improvements in PD (5.3 ± 2.3mm vs. 4.6 ± 1.7mm) and CAL (4.4 ± 2.2mm vs 3.7 ± 1.9mm), with no statistically significant differences between the groups. Early wound healing was favorable in both techniques, with minimal fibrin clot formation and no biomaterial exposure. Digital analysis of intraoral scans showed comparable preservation of papilla height and width in both groups. Radiographic analyses confirmed defect filling and bone regeneration in both groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth NIPSA and EPPT are effective surgical options for the periodontal regeneration of deep intrabony defects, offering excellent soft tissue preservation and clinical outcomes. NCT04782921.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Relevance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth techniques remain viable, with the choice depending on the specifics of each defect and the surgeon's preference.\u003c/p\u003e","manuscriptTitle":"Volumetric Evaluation of the Entire Papilla Preservation Technique and the Non-Incised Papillae Surgical Approach: Effects on Soft Tissue Preservation and Periodontal Regeneration","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 08:51:12","doi":"10.21203/rs.3.rs-7171416/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-08T05:58:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-07T18:01:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-21T18:10:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305095377829567710234391298732368102892","date":"2025-09-01T07:14:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164108414173305112971741557222211165134","date":"2025-08-05T09:21:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-04T11:04:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-22T23:57:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-22T23:57:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"Clinical Oral Investigations","date":"2025-07-20T18:38:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"clinical-oral-investigations","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cloi","sideBox":"Learn more about [Clinical Oral Investigations](http://link.springer.com/journal/784)","snPcode":"784","submissionUrl":"https://submission.nature.com/new-submission/784/3","title":"Clinical Oral Investigations","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"63f7c038-0e7f-43ad-b1e0-6a4b861fa7e9","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T16:10:32+00:00","versionOfRecord":{"articleIdentity":"rs-7171416","link":"https://doi.org/10.1007/s00784-026-06746-6","journal":{"identity":"clinical-oral-investigations","isVorOnly":false,"title":"Clinical Oral Investigations"},"publishedOn":"2026-01-27 15:59:10","publishedOnDateReadable":"January 27th, 2026"},"versionCreatedAt":"2025-08-06 08:51:12","video":"","vorDoi":"10.1007/s00784-026-06746-6","vorDoiUrl":"https://doi.org/10.1007/s00784-026-06746-6","workflowStages":[]},"version":"v1","identity":"rs-7171416","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7171416","identity":"rs-7171416","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}