Modified Minimally Invasive Regenerative Approach with Supracrestal Soft Tissue Separation for the Treatment of a Suprabony Periodontal Defect - 7-Years Follow-Up

Background: Periodontal regeneration is predictable in deep intrabony defects, but success declines in non-contained defects with a predominant supracrestal component due to the lack of space maintenance and blood clot stability. Objective: To conduct a literature review of the current possibilities and limitations of regenerative periodontal therapy and to present a modified regenerative technique incorporating supracrestal soft tissue separation and preservation as a wall of the defect in combination with the connective tissue graft wall technique combined with the connective tissue graft (CTG) wall technique, and to report its 7-year clinical and radiographic outcomes. Case Description: A 43-year-old systemically healthy non-smoker presented with a residual 8 mm pocket at tooth 42, associated with a wide one-wall defect, a 9.7 mm supracrestal component, and marked root proximity. Following initial periodontal therapy (Steps 1–2 EFP guidelines), a buccal split-full-split envelope flap was reflected. The supracrestal soft tissue was horizontally divided: the apical portion was excised and debrided, while the coronal portion was preserved attached to the roots and lingual tissue. Following root conditioning with 24% EDTA and application of enamel matrix derivative (EMD), the defect was filled with particulate bone substitute. A de-epithelialized CTG was sutured to the papilla bases as a buccal wall. The flap was coronally advanced and secured to the preserved supracrestal tissue. Results: Healing was uneventful by primary intention. At 7 years, probing pocket depth was reduced from 8 to 3 mm (62.5% reduction), clinical attachment gain was 6 mm (50%), and interdental septal height was radiographically maintained. Conclusion: Preserving the coronal supracrestal soft tissue provides internal structural support and creates a contained wound environment, extending regenerative indications to complex suprabony defects.