Sequential regenerative therapy using biologic‐based regeneration and connective tissue graft wall technique for a severe infrabony defect: A case report

BACKGROUND: Regenerative therapy based on the principles of guided tissue regeneration (GTR) is an effective approach for the treatment of periodontal infrabony defects. However, complete resolution for deep and complex defects is not always predictable. The connective tissue graft (CTG) wall technique has recently been proposed to enhance outcomes in such challenging defects. This case report describes a staged regenerative approach combining biologic-enhanced regenerative procedure and CTG wall technique for the management of a severe infrabony defect accompanied with gingival recession. METHODS: A 47-year-old female presented with a severe infrabony defect at tooth #12 extending toward the apical region, accompanied by gingival recession. The first surgical procedure consisted of minimally invasive surgical technique using an allograft combined with recombinant human platelet-derived growth factor-BB. After 12 months, a second surgery using the CTG wall technique with a coronally advanced flap was performed to address the residual non-containable defect and associated soft tissue recession. RESULTS: Following the first surgery, probing depth was reduced from 8 to 3 mm, clinical attachment level gain was 5 mm. Radiographs demonstrated substantial bone fill, although a residual defect remained. After the second procedure, approximately 1.8 mm of buccal aspect root coverage was achieved, with improved papillary fill. Probing depth remained 4 mm with no bleeding on probing or mobility, and radiographs showed bone fill of the mesial defect. The gingiva margin remained stable. CONCLUSION: This case demonstrates that a staged regenerative approach combining tissue regeneration and CTG wall technique may provide a viable strategy for managing severe infrabony defects with associated gingival recession. Favorable hard and soft tissue regeneration outcomes were achieved, allowing preservation of a tooth that was initially considered for extraction. PLAIN LANGUAGE SUMMARY: This case report describes how an upper premolar was saved with staged periodontal treatment. The tooth had a deep bone defect, gingival recession, and complex root anatomy, and it had already been recommended for extraction. After initial therapy, the first surgery was performed. Bone graft and recombinant human platelet-derived growth factor-BB were used to improve periodontal regeneration and reduce probing depth. This helped improve the prognosis of the tooth, but a residual defect and soft tissue recession remained. In the second surgery, a connective tissue graft wall technique was used to treat the remaining defects and improve the gum. At follow-up, the tooth remained stable and vital, with less probing depth, improved bone filling, and better soft tissue appearance. This case shows that even a tooth with a poor initial prognosis may sometimes be saved with a carefully planned staged regenerative approach. KEY POINTS: A tooth initially considered for extraction was successfully preserved using a staged regenerative strategy. The first surgery improved prognosis through biologic-based periodontal regeneration, while the second surgery addressed the residual defect and soft tissue deficiency. This case highlights the potential value of sequential regenerative therapy in managing severe and anatomically complex infrabony defects.