Periodontal regeneration: the NIPSA approach coupled with A-PRF

The treatment of infra-bony defects, particularly in the anterior aesthetic zone, requires the practitioner to maintain rigorous soft tissue management. The success of regeneration depends on two critical factors: the maintenance of papillary integrity and the absolute stability of the grafting material. The conventional surgical approach can sometimes compromise these parameters through excessive exposure of the site. It is in this context that the NIPSA (Non-Incised Papilla Surgical Approach) technique, a minimally invasive microsurgical method, becomes fully relevant.

This clinical study precisely evaluates the clinical and radiographic outcomes of the NIPSA technique when combined with a composite formed of advanced platelet-rich fibrin (A-PRF) and a xenograft. The objective was to analyze the efficacy of this protocol on 2 or 3-wall defects (depth ≥ 3 mm) in 10 healthy patients, with rigorous CBCT follow-up over 6 months.

L'hypothèse testée repose sur une synergie biomatérielle : l'A-PRF apporte l'activité biologique et les facteurs de croissance, tandis que la xénogreffe fournit le support structurel nécessaire à la néoformation osseuse. Pour le clinicien, l'enjeu est de démontrer qu'une approche sans incision papillaire permet non seulement de réduire la profondeur de sondage, mais aussi d'augmenter l'épaisseur gingivale et la densité osseuse de façon prédictible.

Methodology: the NIPSA approach and the A-PRF/xenograft composite

This clinical study evaluated the efficacy of a minimally invasive microsurgical approach on a cohort of 10 systemically healthy patients, aged 25 to 55 years. Inclusion criteria targeted 2- or 3-wall intrabony defects systematically involving the buccal wall, with an initial defect depth ≥ 3 mm, located in the maxillary or mandibular anterior sectors.

The experimental protocol was based on the NIPSA (Non-Incised Papilla Surgical Approach) technique, a papillary preservation approach without incision of the papilla. The site was treated according to the following steps:

• Filling: Insertion of a composite combining "Advanced" Platelet-Rich Fibrin (A-PRF) and a xenograft.
• Biological barrier: Covering the site with an A-PRF membrane.
• Follow-up: Clinical and radiographic evaluation over a 6-month postoperative period.

Measurements were performed at inclusion (baseline) and at 6 months using two main analysis methods:

• 3D radiographic analysis: Use of cone beam computed tomography (CBCT) to measure the total defect depth and bone density expressed in Hounsfield units (HU).
• Clinical analysis: Evaluation of probing depth (PD), clinical attachment level (CAL) gain and gingival thickness (GT).

The study compared the evolution of these clinical and statistical parameters between the day of the surgery and the end of the 6-month follow-up.

Significant clinical and radiographic gains at 6 months

The evaluation of the NIPSA (Non-Incised Papilla Surgical Approach) technique combined with A-PRF/xenograft composite in 10 healthy patients shows convincing results. After a 6-month follow-up, the study reports a statistically significant improvement in all periodontal and bone parameters.

Improvement of clinical parameters

On a periodontal level, preserving the integrity of the papilla allowed for optimal healing. Clinical measurements show an average reduction in probing depth of 2.69 mm. At the same time, the clinical attachment level (CAL) gain is established at 2.68 mm, while the gingival thickness increased by an average of 2.81 mm.

Analyse radiographique par CBCT

Three-dimensional imaging confirms tissue regeneration within infra-bony defects (2 or 3 walls). The total defect depth decreased by an average of 2.80 mm. The most significant result concerns the site mineralization: bone density, measured in Hounsfield units (HU), jumped from an initial value of 22.20 HU to 507.10 HU at the end of the 6 months.

These data highlight the efficacy of the NIPSA microsurgical approach in maintaining graft stability and soft tissue integrity, critical factors for regeneration success in the maxillary and mandibular anterior sectors.

Analysis of results and clinical impact

The results of this study demonstrate that the NIPSA approach, combined with an A-PRF/xenograft composite, allows for significant periodontal regeneration while preserving the integrity of the gingival architecture. Clinically, the average clinical attachment gain of 2.68 mm and the increase in soft tissue thickness (2.81 mm) highlight the effectiveness of this minimally invasive approach, particularly crucial in the anterior aesthetic zone. The spectacular jump in bone density, from 22.20 to 507.10 HU in just 6 months, suggests rapid and high-quality mineralization under the flap.

The originality of this work lies in the synergy between the mechanical stability offered by the NIPSA technique (non-incised papilla) and the biological contribution of A-PRF. By avoiding papillary incision, the practitioner ensures better protection of the graft and optimal vascularization. Compared to the seminal work of Moreno Rodríguez, this study suggests that the addition of A-PRF optimizes healing dynamics by serving as a reservoir of growth factors within the mineral matrix.

Limits and implications for practice

The major weakness of this study is its small sample size (n=10) and a follow-up limited to 6 months. Although the clinical and radiographic parameters are statistically significant, these results deserve to be confirmed on larger cohorts to validate the long-term reproducibility of the technique.

In the dental practice, this study validates the benefit of not incising the papilla to stabilize the filling material in 2- or 3-wall defects. For the implantologist or periodontologist, the use of this "biologically active" composite represents a less traumatic and effective therapeutic option for restoring supporting tissues in anterior sectors.

Summary of results

This clinical study shows that at 6 months, the NIPSA technique combined with an A-PRF/xenograft composite generates a clinical attachment gain of 2.68 mm and a probing depth reduction of 2.69 mm on 2- and 3-wall defects. CBCT imaging confirms massive bone densification (from 22.20 to 507.10 HU) coupled with an average gingival thickening of 2.81 mm.

In concrete terms, for the practitioner:

• Secure the aesthetic area: use the NIPSA approach to treat infra-bony defects without incising the papilla, thus ensuring maximum graft stability and optimal tissue integrity.
• Synergize your biomaterials: the A-PRF/xenograft mixture allows coupling the structural stability of the bone substitute with the biological activity of growth factors for accelerated regeneration.
• Strengthen the gingival phenotype: this technique offers a significant tissue gain, essential for the long-term protection of the treated site against periodontal recessions.

Technical lexicon of the study

NIPSA (Non-incised papilla surgical approach): Minimally invasive periodontal microsurgery technique using an apical approach to treat infra-bony defects without incising the interdental papilla, thus preserving soft tissue integrity and graft stability.

A-PRF (Advanced Platelet-Rich Fibrin): Next-generation platelet concentrate obtained by centrifugation of the patient's blood, used in this study for its biological activity and its ability to form a composite with a xenograft material.

Infra-osseous defect (2 or 3 walls): Periodontal bone lesion extending apically relative to the alveolar crest, presenting here an involvement of the buccal wall and a minimum depth of 3 mm.

Hounsfield Units (HU): Quantitative measurement scale of bone density used during CBCT (Cone Beam Computed Tomography) radiographic analysis to evaluate the mineralization of the filled defect.

Clinical Attachment Level (CAL): Clinical measurement evaluating the periodontal support of the tooth; the study reports a mean attachment gain of 2.68 mm after 6 months of healing.

Gingival thickness: Clinical parameter measuring the volume of soft tissue at the treated site, showing an average increase of 2.81 mm thanks to the regenerative approach used.

Xenograft: Bone substitute material of non-human origin providing structural support to the regeneration composite for filling deep defects.

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