Maximizing Minimally Invasiveness in the Treatment of Deep Intrabony Defects: When (Flap)Less is More

This narrative review aims to critically appraise the scientific rationale, clinical indications, execution protocol, adjunctive therapies, and clinical outcomes of the flapless approach for the regenerative treatment of deep intrabony defects. This approach is contextualized within the broader framework of minimally invasive periodontal therapy. The flapless technique refines the minimally invasive paradigm by eliminating incisions, preserving soft tissue integrity, and enhancing clot stability. Emerging evidence suggests it can achieve clinical outcomes comparable to minimally invasive surgical techniques (MIST), with adjunctive enamel matrix derivatives (EMD) providing an additional benefit. Histological data remain limited, but clinical trials report significant gains in probing depth reduction, clinical attachment level, and soft tissue stability, particularly in esthetic areas. Nonetheless, the flapless approach remains technically demanding, requiring precise case selection and operator expertise. The flapless approach represents an evolution in minimally invasive periodontology, offering a site-specific, biologically respectful alternative for treating residual deep intrabony defects. When preceded by rigorous inflammation control and supported by biomimetic adjuncts, it provides favorable clinical and patient-reported outcomes with minimal morbidity. Nonetheless, long-term multicenter trials and histologic studies are needed to substantiate its regenerative potential and broaden its indications.