Lateral approach for regenerative surgery of intrabony defects associated with edentulous alveolar ridge/third molar removal: A prospective case series

Lateral approach for regenerative surgery of intrabony defects associated with edentulous alveolar ridge/third molar removal: A prospective case series | 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 Lateral approach for regenerative surgery of intrabony defects associated with edentulous alveolar ridge/third molar removal: A prospective case series Filip Hromčík, Adéla Halusková, Lydie Izakovičová Hollá This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4425258/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This study evaluated the clinical efficacy of the lateral approach, designed explicitly for unchallenged isolated intrabony defects associated with edentulous alveolar ridges, combined with an enamel matrix derivative (EMD) and bovine-derived bone grafting in the regenerative surgical treatment. Methods Seven intrabony defects distal to the lower second molar were treated using a lateral approach combined with EMD and bone grafting. The primary parameters measured were clinical attachment level (CAL) and pocket probing depth (PPD). Clinical outcomes were assessed 6 months post-surgery and compared with the baseline values. Results Pocket closure and primary wound healing occurred in 100% of cases, and no complications were reported in terms of flap dehiscence, graft exposure, or suture failure. At the 6-month re-evaluation, the initial median CAL of 6 mm (interquartile range: 5–8 mm) was reduced to 3 mm (3–5 mm). The corresponding median PPD was reduced from 6 mm (6–8 mm) to 4 mm (3–5 mm). The differences were statistically significant for both primary parameters ( p <0.05). Conclusions The lateral approach is a valid technique for the surgical treatment of intrabony defects associated with the edentulous ridge. This method seems particularly suitable for distal intrabony defects in the lower second molars, which frequently develop after third molar extraction. Study Registration This study was not intended as a clinical trial and according to https://grants.nih.gov/policy/clinical-trials/definition.htm is not considered a clinical trial, since its main purpose is “solely to refine measures”. The registration was therefore not required by the Ethics Committee approving the study protocol. edentulous ridge intrabony defect regeneration periodontal surgery third molar removal case series residual pocket Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Regeneration of the periodontium is the ultimate goal of periodontitis treatment. However, successful regeneration requires addressing space provision, wound stability, undisturbed healing, and availability of specific cell types.( 1 – 3 ) This can only be successfully applied to periodontal defects with intrabony patterns of bone resorption.( 4 ) Most research in this field has focused on interdental intrabony defects associated with the papilla, as papillary management is considered a crucial aspect of regeneration. Many different surgical approaches have been proposed, evaluated, and compared to preserve the stability of related soft tissues and provide an appropriate environment for regeneration. Recent studies have confirmed that stable soft tissues, specific flap designs, and minimally invasive microsurgical techniques are crucial for periodontal regeneration, irrespective of the biomaterials used.( 5 – 7 ) In contrast, very little attention has been paid to defects associated with edentulous ridges. For example, little effort has been made to develop specific flaps for soft tissue management in cases where the papilla is not involved. To date, the widely accepted and unchallenged gold-standard flap design for such cases, as described by Cortellini and Tonetti,( 8 ) includes a crestal incision right above the treated site, sulcular incision, and, if necessary, release of vertical incision(s) and reflection of both buccal and oral flaps. The most common complications of this approach are membrane exposure, graft contamination, and marginal flap dehiscence, leading to improper healing and insufficient results.( 9 – 11 ) In cases treated with membranes, occurrence of such complications ranges from 50–100%.( 8 , 12 , 13 ) We propose a novel surgical technique with a specific flap design, called the ‘lateral approach for edentulous ridge’, to prevent these complications and guarantee an undisturbed healing environment (see Fig. 1 for comparison). The flap is defined with a curved vertical incision on the buccal side on the opposite aspect of the treated defect and a sulcular incision on the buccal and defect-associated aspect. A full-thickness flap is then elevated, the root surface debrided, and a regenerative strategy applied. The flap is closed using interrupted sutures of the vertical incision to clear the actual defect (Figs. 2 , 3 , and 5 ). Defects at the distal aspect of the lower second molars were chosen as suitable study models. Such defects represent intrabony lesions next to the edentulous ridge, and present a challenging clinical situation. They are also often resistant to non-surgical therapeutic efforts. They usually occur in conjunction with the removal of third molars, particularly when they are impacted mesially or horizontally.( 14 , 15 ) This is due to their relationship with the periodontium of the second molar.( 16 ) The development of a post-extraction periodontal defect on distal aspect of the second molar is presumed if there was a pre-extraction probing pocket depth (PPD) of ≥ 7 mm and a history of periodontitis.( 17 , 18 ) Analysis of this association was not within the scope of this trial. Herein, we have described and evaluated the lateral approach for the regenerative surgical treatment of intrabony periodontal defects associated with an edentulous ridge in a pilot case series. The goal of this method is to prevent the most common complications of the unchallenged gold-standard flap design for this specific indication, and to create more favourable conditions for periodontal regeneration. Methods The PROCESS (Preferred Reporting of CasE Series in Surgery) guidelines for improving the quality of reports( 19 ) were followed in the preparation of the present manuscript. Experimental design and study population The study protocol was approved by the Ethics Committee of St. Anne’s University Hospital, Brno, Czech Republic (approval no. 06V/2023; project no. IIT/2023/05), and was in full accordance with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all participants. This study was designed as a single-centre prospective case series. Individuals presenting with at least one periodontal defect with a residual PPD ≥ 5 mm at the distal aspect of the lower second molar were screened consecutively for eligibility. Only defects with an intrabony component ≥ 4 mm, measured on digital periapical radiographs, and in the absence of a third molar, were included, regardless of their association with a third molar removal. Surgical treatment was performed only once the non-surgical phase of periodontal therapy was completed, and a 3-month healing period was allowed. Patients were considered eligible to participate in this study only if they had good systemic health, were non-smokers, could maintain good oral hygiene (full-mouth plaque score [FMPS] < 20; full-mouth bleeding score [FMBS] < 20), and were willing to comply with the study protocol. Surgery All surgical procedures were performed at the St. Anne’s University Hospital by the same experienced surgeon (F.H.) from February to June 2023. The flap was defined as a curved vertical incision on the buccal side opposite the treated defect and a sulcular incision on the buccal and defect-associated sides. A full-thickness flap was raised and hyper-mobilised, ensuring proper access while maintaining the uncut soft tissues above the defect. For flap elevation, both sharp and blunt dissections were performed using instruments such as a periosteal elevator, micro-blade, and/or tunnelling instruments. After removing the granulation tissue, an adequate view of the distobuccal, distal, or even distolingual aspects of the treated molar was obtained using a micro-mirror, and checked for possible calculus deposits (see Fig. 4). The affected root surface was scaled using an ultrasound device (slim and furcation-dedicated tips) and a Gracey curette. Subsequently, a regenerative strategy was applied. Amelogenins (Emdogain®; Straumann, Basel, Switzerland) and bovine bone xenograft (BioOss®; Geistlich, Wolhusen, Switzerland) were used for all the cases treated within this series. Amelogenins were applied to dry root surfaces for 4 min and suctioned. A mixture of bone graft and amelogenins was used to fill the defect, and a slight overfill was accepted. Re-adaptation of the flap was passive. The vertical incision was closed with interrupted sutures (Resolon® 5 − 0; Resorba, Domažlice, Czechia). This procedure is illustrated in Fig. 3 . Post-Surgical Care Prophylactic systemic antibiotics (amoxicillin/clavulanic acid 875 mg/125 mg twice daily for 7 days) were prescribed, and patients were given specific instructions for home care, which included rinsing with 0.2% chlorhexidine digluconate thrice daily for 2 weeks. Brushing the affected area was not allowed for 3 weeks. All patients were required to follow a strict post-operative schedule. Nine days after the surgery, the patients were checked, and their sutures were removed. The treated area was disinfected, and patients were given specific instructions for at-home care. After 24 days, the wounds were checked again for possible late complications, and the patients were re-instructed regarding their at-home care. At 3 months, a dental hygienist conducted a check-up to remove any deposits and reinforce self-performed dental hygiene. Finally, a comprehensive check-up, examination, and re-evaluation were scheduled at 6 months. Clinical Parameters The primary objective of the present study was to evaluate the gain of clinical attachment level (CAL) and reduction in PPD at the distobuccal aspect of the lower second molar between baseline and 6 months post-surgery. As a secondary objective, we monitored the possible complications of this procedure, such as marginal flap dehiscence, graft leakage, oedema, post-operative abscess, and scar formation. Complementary periodontal parameters (bleeding on probing [BOP], suppuration, furcation involvement, mobility, and pulp sensibility) were recorded and analysed before and 6 months after surgery. All periodontal measurements were performed using a University of North Carolina probe (HuFriedyGroup, Chicago, IL, USA) at six sites per tooth. During each surgery, the number of bony walls was determined and recorded, along with the operation duration. Lastly, the study aimed to evaluate patient-reported variables throughout the study period: pain, swelling, need for analgesics, and discomfort during brushing. Figure 4. The distal wall of the treated tooth can be checked for plaque and calculus using a micro-mirror. Radiographic Analysis Digital periapical radiographs were obtained using the paralleling technique with a Rinn holder and a beam-guiding system at three time points: baseline (initial), immediately post-surgery to visualise the grafting material, and 6 months post-surgery. To maximise the comparability of the X-ray series, minor changes in the projection geometry were made through post-acquisition image processing, and a perfect overlap of images within each series was achieved. The image intensities were normalised based on the grayscale values of the surrounding air, dentin, and enamel of the examined teeth.( 20 , 21 ) Data Analysis Statistical analysis was performed using the R programming language (R Foundation for Statistical Computing, Vienna, Austria) in the integrated development environment R studio . Data were tested for normality using the Shapiro–Wilk test and graphically using Q-Q plots and histograms. The paired Wilcoxon test was used to compare variables at two time-points. Continuous variables were presented as medians and interquartile ranges (IQRs). Results with a p -value < 0.05 were considered statistically significant. Results Study Sample Seven systemically healthy non-smokers (2 men, 5 women; median age: 42 years; IQR: 35–60 years) were enrolled in this case series. None of the patients were lost to follow-up. All included patients showed excellent levels of self-performed plaque control, as represented by an FMPS of 8 ( 4 – 16 ) and FMBS of 6 ( 4 – 18 ). All patients had a single intrabony defect distal to the lower second molar (five on the right and two on the left), with 1–3 remaining bony walls containing the lesion (three with 3 walls, three with 2 walls, and one with 1 wall). All included teeth were vital and presented with the maximum first degree furcation involvement without increased mobility or suppuration. None of the variables changed during the study period. Clinical Outcomes All defects were treated using the lateral surgical approach, as described previously, with a median operation duration of 64 min (55–67 min). No patients experienced any relevant post-operative complications (severe pain, infection, bleeding, graft leakage, or flap dehiscence). Optimal plaque control levels were maintained throughout the study, and all patients adhered to the follow-up protocol. None of the patients reported pain, swelling, need for analgesics, or discomfort while brushing after > 9 days post-surgery. Pocket closure was accomplished in all of the cases, defined as PPD ≤ 5 mm.( 22 ) Primary wound healing was observed in 100% of cases. At 6-month re-evaluation, the initial median CAL of 6 mm (5–8 mm) was reduced to 3 mm (3–5 mm). The corresponding median PPD decreased from 6 mm (6–8 mm) to 4 mm (3–5 mm). Both CAL and PPD changes were considered statistically significant. The results are shown in Fig. 5 . The treatment had an unambiguously positive effect on both CAL and PPD. Clinical attachment gain and PPD reduction were observed in all the cases. A significant positive effect was observed in the distobuccal aspect, which represented the deepest part of the defect. The distolingual CAL and PPD measurements also showed positive but insignificant changes ( p > 0.05). The treatment did not affect other sites and parameters (tooth mobility, furcation involvement, and BOP). The deeper the initial probing, the greater the changes in CAL and PPD. The number of bony walls in the defect did not significantly affect the outcomes ( p > 0.05). Radiographic analysis showed bone-fill retention and partial remodelling of the grafting material 6 months postsurgery in all treated cases (Fig. 6 ). Discussion This report aimed to describe and evaluate the lateral approach for the regenerative surgical treatment of intrabony periodontal defects associated with the edentulous alveolar ridge, which occur frequently in association with the removal of the third molar. This is the first technique specifically designed for these neglected defects, in contrast to the various approaches for papilla-associated lesions.( 5 , 6 , 23 ) In this prospective case series, a clear benefit of the approach was shown, as evidenced by a statistically significant positive change in both CAL and PPD, pocket closure, and primary healing. In all cases, the general clinical objective of periodontal therapy (PPD ≤ 5 mm)( 22 ) was met, maintainable sulci were created, and good self-performed plaque control levels promise stable results.( 24 ) Comparable results were obtained in a previously reported pilot case, which did not participate in the present case series.( 25 ) The lateral approach, similar to other ‘conservative’ or papilla-preserving approaches in periodontal surgery, shares the common aim of creating a clinical environment in which the delicate biological process of regeneration occurs in a space where a very stable flap provides the room and stability of the clot and its biological protection. This was secured by only one vertical incision away from the defect, elevation of only the buccal flap, and preservation of the intact soft tissues above the defect. This resulted in primary healing, flap integrity, and no dehiscence, graft exposure, or infectious complications in all our cases. Studies using other ‘conservative’ techniques have confirmed that intact soft tissues covering the defect led to comparable results with or even without the use of biomaterials.( 5 , 7 ) During the 6-month observation period, this study successfully demonstrated a 100% pocket closure and achieved the overall clinical objective of periodontal therapy. The rather short study period of 6 months was sufficient to produce relevant data and show clear CAL gain and PPD reduction, which is likely to become even more evident with time. A 6-month observation period is typically considered the minimum interval for evaluating periodontal healing after regenerative treatment.( 26 , 27 ) The radiographic assessment revealed partial bone graft remodelling and marginal resorption (Fig. 6 ). The effect of grafting was more evident in the deeper lesions. Defects related to third molar extraction generally extend from the distal to the mid-buccal aspect of the second molar. Micro-CT imaging may also be more appropriate for assessing bone healing in the buccal part of the lesion. Intraoral radiographs were analysed to illustrate the bone changes in the distal part of the defects. Drawing conclusions regarding bone regeneration or gain was beyond the scope of this study. However, the specific flap design of the presented lateral surgical approach seems responsible for the improved graft stability, enhanced potential of the bone graft to guide new bone formation, and possibly periodontal regeneration. The goal of the technique is not only to reduce probing and create more favourable conditions for healing but also to prevent the most common complications of the gold-standard flap design for this indication (Fig. 1 ). These are mostly related to the incision immediately above the defect and use of membranes, leading to flap dehiscence and membrane exposure in 50–100% of cases.( 9 , 10 , 12 ) In this case series, no complications have been observed at all. (as shown in Figs. 2 , 3 , and 6 ), suturing was performed only where the former buccal vertical incision was, away from the actual defect and distant from the regenerative materials. Therefore, even in cases of suture failure and marginal flap dehiscence, the defect itself would not be affected, materials would not be exposed or infected, and regeneration would not be jeopardised. In contrast to the gold-standard technique defined by the crestal approach, as described in an epochmaking clinical guideline by Cortellini and Tonetti,( 8 ) the lateral approach does not require the use of a membrane. The intact flap above the defect serves as an additional stable ‘wall’, confers the stability to the blood clot underneath, supports undisturbed healing, and provides membrane-like protection of the grafting material. The lateral approach appears to be less costly, easier to perform, and less prone to complications. Similar to the lateral approach for papilla-associated defects, described as ‘entire papilla preservation flap’ by Aslan et al.,( 28 ) healing in this case series occurred with no complications and by primary intention in all of the cases. Though a direct comparison of the lateral and crestal approaches is attractive, the latter requires the use of a barrier membrane to compensate for unstable soft tissues above the defect. Therefore, these techniques can be compared rather indirectly. Within the limitations of this study, the presented lateral approach was shown to be safe and predictable, with a reasonable operation duration, low levels of morbidity, and consistent results. The lateral surgical approach is suitable for intrabony defects with 1–3 bony walls, which generally have good regenerative potential.( 5 ) Suprabony residual defects associated with the edentulous ridge should preferably be treated with access flaps or resective periodontal surgery.( 29 ) Based on clinical experience, the lateral approach is better and easier to perform if there is at least 1 cm of the horizontal bony crest at the ramus mandibulae distal to the second molar and a minimal amount of 2 mm of keratinised gingiva surrounding the treated tooth. Access to the defect may be adequate in all cases with the use of a curved vertical incision extending 5–10 mm past the MG junction, abundant distal mobilisation of the flap, and a micro-mirror. In this study, defect-bound granulation tissue was eliminated and replaced with a regenerative material (EMD + bone graft) that filled the lesion. In our previous work, the regenerative potential of granulation tissue itself was described.( 30 , 31 ) In this study, however, the retention of granulation tissue was not possible, in order to promote regeneration in the most predictable and evidence-based manner with the use of biomaterials.( 2 ) The limitations of the present study included the lack of a control group, a minimal acceptable observation period, and a relatively small sample size. The sample size was determined according to the anticipated CAL gain and adjusted to match the ethical criteria for testing a previously undescribed surgical method. The main strengths of this study are its focus on previously neglected defects, innovative flap design for edentulous ridge, and its prospective design, which included a systematic evaluation of very similar defects treated with the same uniform approach by the same operator, and a strict follow-up protocol. Future studies may further assess our findings, compare the outcomes of the lateral approach to other techniques, and extrapolate the principles of the lateral approach to localisations unrelated to the second lower molars. Future studies should also evaluate whether the technique is relevant for both mesial and distal defects in both frontal and distal areas, and whether the use of biomaterials is necessary for clinical success. Conclusions Within the limitations of this prospective case series, the following conclusions were drawn: The lateral approach is a valid technique for regenerative periodontal surgery, specifically tailored for the regenerative treatment of intrabony periodontal defects next to the edentulous ridge. Common complications of a gold-standard flap design can be prevented by shifting the most vulnerable area away from the regenerated site. The intact soft tissue above the defect protects the wound and keeps the regenerative material undisturbed during healing. The procedure is not time-consuming or difficult to perform. Fewer complications and better regeneration results may be expected compared with the standard flap design and use of membranes. The suggested approach presents a valid alternative for achieving the goals of clinical attachment gain, PPD reduction, bone grafting, and enhancement of periodontal regeneration with little predisposition to failure. We suggest using this approach, especially in distobuccal intrabony defects in the second molars, which frequently develop after third molar removal. Similarly, it may also be suitable for regenerating intrabony lesions associated with an edentulous ridge. Further studies are required to validate these findings. Abbreviations BOP – bleeding on probing; CAL – clinical attachment level; EMD – enamel matrix derivative; FMBS – full-mouth pbleeding score; FMPS – full-mouth plaque score; IQR – interquartile range; PPD – pocket probing depth; Declarations Ethics Approval and Consent to Participate The study protocol was approved by the Ethics Committee of St. Anne’s University Hospital, Brno, Czech Republic (approval no. 06V/2023; project no. IIT/2023/05), and was in full accordance with the Helsinki Declaration of 1975, as revised in 2000. Consent for Publication Informed consent was obtained from all participants before the treatment. Availability of Data The data that support the findings of this study are available on request from the corresponding author, FH. The data are not publicly available due to privacy of participants and ethical restrictions. Competing Interests All authors declare no conflict of interest related to this manuscript. Funding This study was supported by St. Anne’s University Hospital in Brno Support for Internal Pilot Research Projects, grant no. IIT/2023/5. Authors’ Contribution Filip Hromčík : Conceptualisation, Data Curation (equal), Funding acquisition, Investigation (equal), Methodology (lead), Visualization, Writing – original draft preparation. Adéla Halusková : Data Curation (equal), Investigation (equal), Methodology (supporting), Writing – review and editing (supporting). Lydie Izakovičová Hollá : Supervision, Writing – review and editing (lead) Acknowledgements This study was supported by St. Anne’s University Hospital in Brno Support for Internal Pilot Research Projects (grant no. IIT/2023/5). We would like to thank Mrs. Monika Skotáková, a statistician at the Department of Biostatistics, ICRC, St. Anne’s University Hospital, Brno, Czechia, for doing the statistical analysis of this study, Prof. Břetislav Lipový for the illustrations, and Mrs. Lucie Hromčík Brunclíková for the analysis of radiographs. References Dentino A, Lee S, Mailhot J, Hefti AF. Principles of periodontology. Periodontol 2000. 2013;61(1):16. Hägi TT, Laugisch O, Ivanovic A, Sculean A. Regenerative periodontal therapy. Quintessence Int. 2014;45(3):185-92. Sanz M, Jepsen K, Eickholz P, Jepsen S. Clinical concepts for regenerative therapy in furcations. Periodontol 2000. 2015;68(1):308-32. Carrassi A, Cortellini P, Trombelli L, editors. Atlas of Periodontology and Implant Therapy. Berlin: Quintessence Publishing; 2019. Cortellini P, Tonetti MS. 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Granulation tissue enriched by aspirin and omega-3 fatty acids in healing experimental periodontal lesion. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2021;165(2):216-223 Hromcik F, Vokurka J, Kyr M, Izakovicova Holla L. Granulation Tissue Enhanced with Aspirin and Omega‐3 PUFAs as a Local Adjunct to the Surgical Treatment of Periodontitis. Eur J Lipid Sci Tech. 2021;123(2):1-9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. 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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-4425258","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308561981,"identity":"edbc5f7b-9079-4b3f-8019-cb73ef9b96c6","order_by":0,"name":"Filip Hromčík","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYBAC9mbmhgOMDSAmYzPDBwYGHj6wuAFuLTyHGRFaGGcABdgIagGph2hhYGbmAZJshBzGw87YeLhwxz053fbDzca2OXYybAzcadIFBQzy8g04tDAzNhyeeabY2OxMYnNy7rZkoMN4t0nPMGAwbMShxR6khbctIXHbDcbmw7nbmCFaeAwYEphxOQxFi+W2eoQWXJ5C0ZLMuO0wQgsPPi0z2xLAfjHs3Xach42Zd7M1j4GE4QxcWvgPH/5c2JYgZ3b8+GOJn9uq7fnZezfe5vljgzPEQIAZG1cCt3pMLaNgFIyCUTAK0AAAo/lMu2JlW40AAAAASUVORK5CYII=","orcid":"","institution":"St. Anne’s University Hospital, Masaryk University","correspondingAuthor":true,"prefix":"","firstName":"Filip","middleName":"","lastName":"Hromčík","suffix":""},{"id":308561982,"identity":"31bacdf7-6273-446a-8b4b-d9dacb21e339","order_by":1,"name":"Adéla Halusková","email":"","orcid":"","institution":"St. Anne’s University Hospital, Masaryk University","correspondingAuthor":false,"prefix":"","firstName":"Adéla","middleName":"","lastName":"Halusková","suffix":""},{"id":308561983,"identity":"4c293ede-2d32-443c-a455-2fbc8d045b99","order_by":2,"name":"Lydie Izakovičová Hollá","email":"","orcid":"","institution":"St. Anne’s University Hospital, Masaryk University","correspondingAuthor":false,"prefix":"","firstName":"Lydie","middleName":"Izakovičová","lastName":"Hollá","suffix":""}],"badges":[],"createdAt":"2024-05-15 12:48:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4425258/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4425258/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57875243,"identity":"08d94d79-668a-45db-a177-9410acae0602","added_by":"auto","created_at":"2024-06-06 18:57:04","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":61006,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of incision lines and flap designs. \u003c/strong\u003eLeft – standard crestal approach; right – suggested lateral approach for edentulous ridge\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4425258/v1/27284e3bc43ae13649a76b5e.jpg"},{"id":57874933,"identity":"9eb936b1-be6b-4f8f-a808-b77f183e1b06","added_by":"auto","created_at":"2024-06-06 18:49:04","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":68279,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSurgical steps of the lateral approach for the regenerative treatment of intrabony periodontal defects associated with an edentulous ridge.\u003c/strong\u003e Defects related to third molar removal generally extend from distal to mid-buccal. Defects that are not related to third molar extraction present instead as distal defects\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4425258/v1/53a072eeede86f251150f298.jpg"},{"id":57874936,"identity":"cefd799a-2e9a-447a-b7e5-c6eb424e918d","added_by":"auto","created_at":"2024-06-06 18:49:04","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":172437,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRepresentative case of regenerative treatment of intrabony periodontal defect associated with edentulous ridge with the suggested lateral approach.\u003c/strong\u003e a – initial probing of 8 mm, a lesion distal do lower right second molar associated with a complicated extraction of a fully erupted wisdom tooth 15 years ago; b – adequate view and access to the three-walled defect obtained after elevation and hyper-mobilisation of the flap and granulation tissue removal; c – amelogenins applied for 4 minutes on the dry surface of the defect-associated root after its scaling and root planing; d – bone substitute mixed with amelogenins used to fill up the defect; e – final suture clear of the actual defect, also note the localisation and shape of the initial vertical incision; f – probing 6 months after surgery; g – initial radiograph with well-defined intrabony defect with marked corticalisation of its distal wall, extending close to the apex; h – immediate post-surgical radiograph with bone substitute filling up the lesion; i – 6‑month radiograph with well integrated and partly remodelled bone substitute, radiopaque tissue occupying the lesion, faded demarcation of the former defect\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4425258/v1/fcf30b58c0e47361c2a4542d.jpg"},{"id":57874931,"identity":"da16896c-9a22-4044-886b-7f06aab49c3b","added_by":"auto","created_at":"2024-06-06 18:49:04","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":18744,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe distal wall of the treated tooth can be checked for plaque and calculus using a micro-mirror.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4425258/v1/eb81c9d01a98d28fccdafa42.jpg"},{"id":57874934,"identity":"bc8b477c-4f88-4118-84e0-0efc11db1e57","added_by":"auto","created_at":"2024-06-06 18:49:04","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":45914,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDifference of CAL and PPD between initial and 6-month evaluations.\u003c/strong\u003e Expressed with respective p-values, paired Wilcoxon test.\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4425258/v1/9e341d3ceefd1acc533f039a.jpg"},{"id":57874937,"identity":"adfa4d61-184f-4f02-bdc3-68cbdb35d68f","added_by":"auto","created_at":"2024-06-06 18:49:04","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":146493,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOverview of all the cases treated within the presented report.\u003c/strong\u003e From left to right: initial radiograph; initial clinical situation; access to the defect after degranulation and scaling; final suture – note how far the suture is from the actual defect; 6-month radiograph\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4425258/v1/1ad95f754bbc26bf28d10d49.jpg"},{"id":61318611,"identity":"0d53d818-b459-4ec9-adbd-642345d3881d","added_by":"auto","created_at":"2024-07-29 12:33:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1032535,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4425258/v1/504d140b-47eb-4717-a415-7b23fde8fb6f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Lateral approach for regenerative surgery of intrabony defects associated with edentulous alveolar ridge/third molar removal: A prospective case series","fulltext":[{"header":"Background","content":"\u003cp\u003eRegeneration of the periodontium is the ultimate goal of periodontitis treatment. However, successful regeneration requires addressing space provision, wound stability, undisturbed healing, and availability of specific cell types.(\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) This can only be successfully applied to periodontal defects with intrabony patterns of bone resorption.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eMost research in this field has focused on interdental intrabony defects associated with the papilla, as papillary management is considered a crucial aspect of regeneration. Many different surgical approaches have been proposed, evaluated, and compared to preserve the stability of related soft tissues and provide an appropriate environment for regeneration. Recent studies have confirmed that stable soft tissues, specific flap designs, and minimally invasive microsurgical techniques are crucial for periodontal regeneration, irrespective of the biomaterials used.(\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e–\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn contrast, very little attention has been paid to defects associated with edentulous ridges. For example, little effort has been made to develop specific flaps for soft tissue management in cases where the papilla is not involved. To date, the widely accepted and unchallenged gold-standard flap design for such cases, as described by Cortellini and Tonetti,(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) includes a crestal incision right above the treated site, sulcular incision, and, if necessary, release of vertical incision(s) and reflection of both buccal and oral flaps. The most common complications of this approach are membrane exposure, graft contamination, and marginal flap dehiscence, leading to improper healing and insufficient results.(\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) In cases treated with membranes, occurrence of such complications ranges from 50–100%.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWe propose a novel surgical technique with a specific flap design, called the ‘lateral approach for edentulous ridge’, to prevent these complications and guarantee an undisturbed healing environment (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for comparison).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe flap is defined with a curved vertical incision on the buccal side on the opposite aspect of the treated defect and a sulcular incision on the buccal and defect-associated aspect. A full-thickness flap is then elevated, the root surface debrided, and a regenerative strategy applied. The flap is closed using interrupted sutures of the vertical incision to clear the actual defect (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDefects at the distal aspect of the lower second molars were chosen as suitable study models. Such defects represent intrabony lesions next to the edentulous ridge, and present a challenging clinical situation. They are also often resistant to non-surgical therapeutic efforts. They usually occur in conjunction with the removal of third molars, particularly when they are impacted mesially or horizontally.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) This is due to their relationship with the periodontium of the second molar.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) The development of a post-extraction periodontal defect on distal aspect of the second molar is presumed if there was a pre-extraction probing pocket depth (PPD) of ≥ 7 mm and a history of periodontitis.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) Analysis of this association was not within the scope of this trial.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eHerein, we have described and evaluated the lateral approach for the regenerative surgical treatment of intrabony periodontal defects associated with an edentulous ridge in a pilot case series. The goal of this method is to prevent the most common complications of the unchallenged gold-standard flap design for this specific indication, and to create more favourable conditions for periodontal regeneration.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe PROCESS (Preferred Reporting of CasE Series in Surgery) guidelines for improving the quality of reports(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) were followed in the preparation of the present manuscript.\u003c/p\u003e\u003cp\u003eExperimental design and study population\u003c/p\u003e\u003cp\u003e The study protocol was approved by the Ethics Committee of St. Anne’s University Hospital, Brno, Czech Republic (approval no. 06V/2023; project no. IIT/2023/05), and was in full accordance with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all participants.\u003c/p\u003e\u003cp\u003eThis study was designed as a single-centre prospective case series. Individuals presenting with at least one periodontal defect with a residual PPD ≥ 5 mm at the distal aspect of the lower second molar were screened consecutively for eligibility. Only defects with an intrabony component ≥ 4 mm, measured on digital periapical radiographs, and in the absence of a third molar, were included, regardless of their association with a third molar removal. Surgical treatment was performed only once the non-surgical phase of periodontal therapy was completed, and a 3-month healing period was allowed. Patients were considered eligible to participate in this study only if they had good systemic health, were non-smokers, could maintain good oral hygiene (full-mouth plaque score [FMPS] \u0026lt; 20; full-mouth bleeding score [FMBS] \u0026lt; 20), and were willing to comply with the study protocol.\u003c/p\u003e\u003cp\u003eSurgery\u003c/p\u003e\u003cp\u003eAll surgical procedures were performed at the St. Anne’s University Hospital by the same experienced surgeon (F.H.) from February to June 2023. The flap was defined as a curved vertical incision on the buccal side opposite the treated defect and a sulcular incision on the buccal and defect-associated sides. A full-thickness flap was raised and hyper-mobilised, ensuring proper access while maintaining the uncut soft tissues above the defect. For flap elevation, both sharp and blunt dissections were performed using instruments such as a periosteal elevator, micro-blade, and/or tunnelling instruments. After removing the granulation tissue, an adequate view of the distobuccal, distal, or even distolingual aspects of the treated molar was obtained using a micro-mirror, and checked for possible calculus deposits (see Fig.\u0026nbsp;4). The affected root surface was scaled using an ultrasound device (slim and furcation-dedicated tips) and a Gracey curette. Subsequently, a regenerative strategy was applied. Amelogenins (Emdogain®; Straumann, Basel, Switzerland) and bovine bone xenograft (BioOss®; Geistlich, Wolhusen, Switzerland) were used for all the cases treated within this series. Amelogenins were applied to dry root surfaces for 4 min and suctioned. A mixture of bone graft and amelogenins was used to fill the defect, and a slight overfill was accepted. Re-adaptation of the flap was passive. The vertical incision was closed with interrupted sutures (Resolon® 5 − 0; Resorba, Domažlice, Czechia). This procedure is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003ePost-Surgical Care\u003c/p\u003e\u003cp\u003eProphylactic systemic antibiotics (amoxicillin/clavulanic acid 875 mg/125 mg twice daily for 7 days) were prescribed, and patients were given specific instructions for home care, which included rinsing with 0.2% chlorhexidine digluconate thrice daily for 2 weeks. Brushing the affected area was not allowed for 3 weeks.\u003c/p\u003e\u003cp\u003eAll patients were required to follow a strict post-operative schedule. Nine days after the surgery, the patients were checked, and their sutures were removed. The treated area was disinfected, and patients were given specific instructions for at-home care. After 24 days, the wounds were checked again for possible late complications, and the patients were re-instructed regarding their at-home care. At 3 months, a dental hygienist conducted a check-up to remove any deposits and reinforce self-performed dental hygiene. Finally, a comprehensive check-up, examination, and re-evaluation were scheduled at 6 months.\u003c/p\u003e\u003cp\u003eClinical Parameters\u003c/p\u003e\u003cp\u003eThe primary objective of the present study was to evaluate the gain of clinical attachment level (CAL) and reduction in PPD at the distobuccal aspect of the lower second molar between baseline and 6 months post-surgery.\u003c/p\u003e\u003cp\u003eAs a secondary objective, we monitored the possible complications of this procedure, such as marginal flap dehiscence, graft leakage, oedema, post-operative abscess, and scar formation.\u003c/p\u003e\u003cp\u003eComplementary periodontal parameters (bleeding on probing [BOP], suppuration, furcation involvement, mobility, and pulp sensibility) were recorded and analysed before and 6 months after surgery. All periodontal measurements were performed using a University of North Carolina probe (HuFriedyGroup, Chicago, IL, USA) at six sites per tooth. During each surgery, the number of bony walls was determined and recorded, along with the operation duration.\u003c/p\u003e\u003cp\u003e Lastly, the study aimed to evaluate patient-reported variables throughout the study period: pain, swelling, need for analgesics, and discomfort during brushing.\u003c/p\u003e\u003cp\u003e \u003cem\u003eFigure 4.\u003c/em\u003e \u003cb\u003eThe distal wall of the treated tooth can be checked for plaque and calculus using a micro-mirror.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eRadiographic Analysis\u003c/p\u003e\u003cp\u003eDigital periapical radiographs were obtained using the paralleling technique with a Rinn holder and a beam-guiding system at three time points: baseline (initial), immediately post-surgery to visualise the grafting material, and 6 months post-surgery. To maximise the comparability of the X-ray series, minor changes in the projection geometry were made through post-acquisition image processing, and a perfect overlap of images within each series was achieved. The image intensities were normalised based on the grayscale values of the surrounding air, dentin, and enamel of the examined teeth.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis was performed using the \u003cem\u003eR\u003c/em\u003e programming language (R Foundation for Statistical Computing, Vienna, Austria) in the integrated development environment \u003cem\u003eR studio\u003c/em\u003e. Data were tested for normality using the Shapiro–Wilk test and graphically using Q-Q plots and histograms. The paired Wilcoxon test was used to compare variables at two time-points. Continuous variables were presented as medians and interquartile ranges (IQRs). Results with a \u003cem\u003ep\u003c/em\u003e-value \u0026lt; 0.05 were considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eStudy Sample\u003c/p\u003e \u003cp\u003eSeven systemically healthy non-smokers (2 men, 5 women; median age: 42 years; IQR: 35\u0026ndash;60 years) were enrolled in this case series. None of the patients were lost to follow-up. All included patients showed excellent levels of self-performed plaque control, as represented by an FMPS of 8 (\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) and FMBS of 6 (\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). All patients had a single intrabony defect distal to the lower second molar (five on the right and two on the left), with 1\u0026ndash;3 remaining bony walls containing the lesion (three with 3 walls, three with 2 walls, and one with 1 wall). All included teeth were vital and presented with the maximum first degree furcation involvement without increased mobility or suppuration. None of the variables changed during the study period.\u003c/p\u003e \u003cp\u003eClinical Outcomes\u003c/p\u003e \u003cp\u003eAll defects were treated using the lateral surgical approach, as described previously, with a median operation duration of 64 min (55\u0026ndash;67 min). No patients experienced any relevant post-operative complications (severe pain, infection, bleeding, graft leakage, or flap dehiscence). Optimal plaque control levels were maintained throughout the study, and all patients adhered to the follow-up protocol. None of the patients reported pain, swelling, need for analgesics, or discomfort while brushing after \u0026gt;\u0026thinsp;9 days post-surgery.\u003c/p\u003e \u003cp\u003ePocket closure was accomplished in all of the cases, defined as PPD\u0026thinsp;\u0026le;\u0026thinsp;5 mm.(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) Primary wound healing was observed in 100% of cases. At 6-month re-evaluation, the initial median CAL of 6 mm (5\u0026ndash;8 mm) was reduced to 3 mm (3\u0026ndash;5 mm). The corresponding median PPD decreased from 6 mm (6\u0026ndash;8 mm) to 4 mm (3\u0026ndash;5 mm). Both CAL and PPD changes were considered statistically significant. The results are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe treatment had an unambiguously positive effect on both CAL and PPD. Clinical attachment gain and PPD reduction were observed in all the cases. A significant positive effect was observed in the distobuccal aspect, which represented the deepest part of the defect. The distolingual CAL and PPD measurements also showed positive but insignificant changes (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The treatment did not affect other sites and parameters (tooth mobility, furcation involvement, and BOP). The deeper the initial probing, the greater the changes in CAL and PPD. The number of bony walls in the defect did not significantly affect the outcomes (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eRadiographic analysis showed bone-fill retention and partial remodelling of the grafting material 6 months postsurgery in all treated cases (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis report aimed to describe and evaluate the lateral approach for the regenerative surgical treatment of intrabony periodontal defects associated with the edentulous alveolar ridge, which occur frequently in association with the removal of the third molar. This is the first technique specifically designed for these neglected defects, in contrast to the various approaches for papilla-associated lesions.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn this prospective case series, a clear benefit of the approach was shown, as evidenced by a statistically significant positive change in both CAL and PPD, pocket closure, and primary healing. In all cases, the general clinical objective of periodontal therapy (PPD\u0026thinsp;\u0026le;\u0026thinsp;5 mm)(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) was met, maintainable sulci were created, and good self-performed plaque control levels promise stable results.(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) Comparable results were obtained in a previously reported pilot case, which did not participate in the present case series.(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe lateral approach, similar to other \u0026lsquo;conservative\u0026rsquo; or papilla-preserving approaches in periodontal surgery, shares the common aim of creating a clinical environment in which the delicate biological process of regeneration occurs in a space where a very stable flap provides the room and stability of the clot and its biological protection. This was secured by only one vertical incision away from the defect, elevation of only the buccal flap, and preservation of the intact soft tissues above the defect. This resulted in primary healing, flap integrity, and no dehiscence, graft exposure, or infectious complications in all our cases. Studies using other \u0026lsquo;conservative\u0026rsquo; techniques have confirmed that intact soft tissues covering the defect led to comparable results with or even without the use of biomaterials.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eDuring the 6-month observation period, this study successfully demonstrated a 100% pocket closure and achieved the overall clinical objective of periodontal therapy. The rather short study period of 6 months was sufficient to produce relevant data and show clear CAL gain and PPD reduction, which is likely to become even more evident with time. A 6-month observation period is typically considered the minimum interval for evaluating periodontal healing after regenerative treatment.(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe radiographic assessment revealed partial bone graft remodelling and marginal resorption (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The effect of grafting was more evident in the deeper lesions. Defects related to third molar extraction generally extend from the distal to the mid-buccal aspect of the second molar. Micro-CT imaging may also be more appropriate for assessing bone healing in the buccal part of the lesion. Intraoral radiographs were analysed to illustrate the bone changes in the distal part of the defects. Drawing conclusions regarding bone regeneration or gain was beyond the scope of this study. However, the specific flap design of the presented lateral surgical approach seems responsible for the improved graft stability, enhanced potential of the bone graft to guide new bone formation, and possibly periodontal regeneration.\u003c/p\u003e \u003cp\u003eThe goal of the technique is not only to reduce probing and create more favourable conditions for healing but also to prevent the most common complications of the gold-standard flap design for this indication (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). These are mostly related to the incision immediately above the defect and use of membranes, leading to flap dehiscence and membrane exposure in 50\u0026ndash;100% of cases.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) In this case series, no complications have been observed at all. (as shown in Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, and \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e6\u003c/span\u003e), suturing was performed only where the former buccal vertical incision was, away from the actual defect and distant from the regenerative materials. Therefore, even in cases of suture failure and marginal flap dehiscence, the defect itself would not be affected, materials would not be exposed or infected, and regeneration would not be jeopardised.\u003c/p\u003e \u003cp\u003eIn contrast to the gold-standard technique defined by the crestal approach, as described in an epochmaking clinical guideline by Cortellini and Tonetti,(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) the lateral approach does not require the use of a membrane. The intact flap above the defect serves as an additional stable \u0026lsquo;wall\u0026rsquo;, confers the stability to the blood clot underneath, supports undisturbed healing, and provides membrane-like protection of the grafting material. The lateral approach appears to be less costly, easier to perform, and less prone to complications. Similar to the lateral approach for papilla-associated defects, described as \u0026lsquo;entire papilla preservation flap\u0026rsquo; by Aslan et al.,(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) healing in this case series occurred with no complications and by primary intention in all of the cases. Though a direct comparison of the lateral and crestal approaches is attractive, the latter requires the use of a barrier membrane to compensate for unstable soft tissues above the defect. Therefore, these techniques can be compared rather indirectly. Within the limitations of this study, the presented lateral approach was shown to be safe and predictable, with a reasonable operation duration, low levels of morbidity, and consistent results.\u003c/p\u003e \u003cp\u003eThe lateral surgical approach is suitable for intrabony defects with 1\u0026ndash;3 bony walls, which generally have good regenerative potential.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Suprabony residual defects associated with the edentulous ridge should preferably be treated with access flaps or resective periodontal surgery.(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eBased on clinical experience, the lateral approach is better and easier to perform if there is at least 1 cm of the horizontal bony crest at the ramus mandibulae distal to the second molar and a minimal amount of 2 mm of keratinised gingiva surrounding the treated tooth. Access to the defect may be adequate in all cases with the use of a curved vertical incision extending 5\u0026ndash;10 mm past the MG junction, abundant distal mobilisation of the flap, and a micro-mirror.\u003c/p\u003e \u003cp\u003eIn this study, defect-bound granulation tissue was eliminated and replaced with a regenerative material (EMD\u0026thinsp;+\u0026thinsp;bone graft) that filled the lesion. In our previous work, the regenerative potential of granulation tissue itself was described.(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) In this study, however, the retention of granulation tissue was not possible, in order to promote regeneration in the most predictable and evidence-based manner with the use of biomaterials.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe limitations of the present study included the lack of a control group, a minimal acceptable observation period, and a relatively small sample size. The sample size was determined according to the anticipated CAL gain and adjusted to match the ethical criteria for testing a previously undescribed surgical method.\u003c/p\u003e \u003cp\u003eThe main strengths of this study are its focus on previously neglected defects, innovative flap design for edentulous ridge, and its prospective design, which included a systematic evaluation of very similar defects treated with the same uniform approach by the same operator, and a strict follow-up protocol.\u003c/p\u003e \u003cp\u003eFuture studies may further assess our findings, compare the outcomes of the lateral approach to other techniques, and extrapolate the principles of the lateral approach to localisations unrelated to the second lower molars. Future studies should also evaluate whether the technique is relevant for both mesial and distal defects in both frontal and distal areas, and whether the use of biomaterials is necessary for clinical success.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWithin the limitations of this prospective case series, the following conclusions were drawn:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThe lateral approach is a valid technique for regenerative periodontal surgery, specifically tailored for the regenerative treatment of intrabony periodontal defects next to the edentulous ridge.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCommon complications of a gold-standard flap design can be prevented by shifting the most vulnerable area away from the regenerated site. The intact soft tissue above the defect protects the wound and keeps the regenerative material undisturbed during healing.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe procedure is not time-consuming or difficult to perform.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFewer complications and better regeneration results may be expected compared with the standard flap design and use of membranes.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe suggested approach presents a valid alternative for achieving the goals of clinical attachment gain, PPD reduction, bone grafting, and enhancement of periodontal regeneration with little predisposition to failure.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eWe suggest using this approach, especially in distobuccal intrabony defects in the second molars, which frequently develop after third molar removal. Similarly, it may also be suitable for regenerating intrabony lesions associated with an edentulous ridge. Further studies are required to validate these findings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBOP \u0026ndash; bleeding on probing; \u0026nbsp;CAL \u0026ndash; clinical attachment level; \u0026nbsp;EMD \u0026ndash; enamel matrix derivative; FMBS \u0026ndash; full-mouth pbleeding score; FMPS \u0026ndash; full-mouth plaque score; IQR \u0026ndash; interquartile range; PPD \u0026ndash; pocket probing depth;\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics\u0026nbsp;Approval\u0026nbsp;and Consent to Participate\u003c/h3\u003e\n\u003cp\u003eThe study protocol was approved by the Ethics Committee of St. Anne\u0026rsquo;s University Hospital, Brno, Czech Republic (approval no. 06V/2023; project no. IIT/2023/05), and was in full accordance with the Helsinki Declaration of 1975, as revised in 2000.\u003c/p\u003e\n\u003ch3\u003eConsent for Publication\u003c/h3\u003e\n\u003cp\u003eInformed consent was obtained from all participants before the treatment.\u003c/p\u003e\n\u003ch3\u003eAvailability of Data\u003c/h3\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author, FH. The data are not publicly available due to privacy of participants and ethical restrictions.\u003c/p\u003e\n\u003ch3\u003eCompeting Interests\u003c/h3\u003e\n\u003cp\u003eAll authors declare no conflict of interest related to this manuscript.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThis study was supported by St. Anne\u0026rsquo;s University Hospital in Brno Support for Internal Pilot Research Projects, grant no. IIT/2023/5.\u003c/p\u003e\n\u003ch3\u003eAuthors\u0026rsquo; Contribution\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eFilip Hromč\u0026iacute;k\u003c/strong\u003e: Conceptualisation, Data Curation (equal), Funding acquisition, Investigation (equal), Methodology (lead), Visualization, Writing \u0026ndash; original draft preparation. \u003cstrong\u003eAd\u0026eacute;la Haluskov\u0026aacute;\u003c/strong\u003e: Data Curation (equal), Investigation (equal), Methodology (supporting), Writing \u0026ndash; review and editing (supporting). \u003cstrong\u003eLydie Izakovičov\u0026aacute; Holl\u0026aacute;\u003c/strong\u003e: Supervision, Writing \u0026ndash; review and editing (lead)\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eThis study was supported by St. Anne\u0026rsquo;s University Hospital in Brno Support for Internal Pilot Research Projects (grant no. IIT/2023/5). We would like to thank Mrs. Monika Skot\u0026aacute;kov\u0026aacute;, a statistician at the Department of Biostatistics, ICRC, St. Anne\u0026rsquo;s University Hospital, Brno, Czechia, for doing the statistical analysis of this study, Prof. Břetislav Lipov\u0026yacute; for the illustrations, and Mrs. Lucie Hromč\u0026iacute;k Bruncl\u0026iacute;kov\u0026aacute; for the analysis of radiographs.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eDentino A, Lee S, Mailhot J, Hefti AF. Principles of periodontology. Periodontol 2000. 2013;61(1):16.\u003c/li\u003e\n \u003cli\u003eH\u0026auml;gi TT, Laugisch O, Ivanovic A, Sculean A. Regenerative periodontal therapy. Quintessence Int. 2014;45(3):185-92.\u003c/li\u003e\n \u003cli\u003eSanz M, Jepsen K, Eickholz P, Jepsen S. Clinical concepts for regenerative therapy in furcations. Periodontol 2000. 2015;68(1):308-32.\u003c/li\u003e\n \u003cli\u003eCarrassi A, Cortellini P, Trombelli L, editors. Atlas of Periodontology and Implant Therapy. Berlin: Quintessence Publishing; 2019.\u003c/li\u003e\n \u003cli\u003eCortellini P, Tonetti MS. 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. 2011;38(4):365-73.\u003c/li\u003e\n \u003cli\u003eAslan S, Buduneli N, Cortellini P. 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. 2020;47(4):470-8.\u003c/li\u003e\n \u003cli\u003eTrombelli L, Simonelli A, Pramstraller M, Wikesj\u0026ouml; UME, Farina R. Single flap approach with and without guided tissue regeneration and a hydroxyapatite biomaterial in the management of intraosseous periodontal defects. J Periodontol. 2010;81(9):1256-63.\u003c/li\u003e\n \u003cli\u003eCortellini P, Tonetti MS. Clinical concepts for regenerative therapy in intrabony defects. Periodontol 2000. 2015;68(1):282-307.\u003c/li\u003e\n \u003cli\u003eMachtei EE. The Effect of Membrane Exposure on the Outcome of Regenerative Procedures in Humans: A Meta-Analysis. J Periodontol. 2001;72(4):512-6.\u003c/li\u003e\n \u003cli\u003eCortellini P, Pini Prato G, Baldi C, Clauser C. Guided tissue regeneration with different materials. Int J Periodontics Restorative Dent. 1990;10(2):136-51.\u003c/li\u003e\n \u003cli\u003eDe Sanctis M, Zucchelli G, Clauser C. Bacterial colonization of barrier material and periodontal regeneration. J Clin Periodontol. 1996;23(11):1039-46.\u003c/li\u003e\n \u003cli\u003eSanz M, Tonetti MS, Zabalegui I, Sicilia A, Blanco J, Rebelo H, et al. Treatment of Intrabony Defects With Enamel Matrix Proteins or Barrier Membranes: Results From a Multicenter Practice-Based Clinical Trial. J Periodontol. 2004;75(5):726-33.\u003c/li\u003e\n \u003cli\u003eJepsen K, Sculean A, Jepsen S. Complications and treatment errors related to regenerative periodontal surgery. Periodontol 2000. 2023;92(1):120-34.\u003c/li\u003e\n \u003cli\u003eSingh S, Gottumukkala SNVS, Konathala SVR, Penmetsa GS, Dwarakanath CD, Bypalli V. Periodontal status of mandibular second molar after extraction of impacted mandibular third molars- a prospective clinical trial. Eur Oral Res. 2022;56(3):110-6.\u003c/li\u003e\n \u003cli\u003eKan KW, Liu JKS, Lo ECM, Corbet EF, Leung WK. Residual periodontal defects distal to the mandibular second molar 6-36 months after impacted third molar extraction. J Clin Periodontol. 2002;29(11):1004-11.\u003c/li\u003e\n \u003cli\u003eYang Y, Tian Y, Sun L-J, Qu H-L, Li Z-B, Tian B-M, et al. The impact of Anatomic Features of Asymptomatic Third Molars on the Pathologies of Adjacent Second Molars: A Cross-sectional Analysis. Int Dent J. 2023;73(3):417-22.\u003c/li\u003e\n \u003cli\u003eKugelberg CF, Ahlstr\u0026ouml;m U, Ericson S, Hugoson A, Thilander H. The influence of anatomical, pathophysiological and other factors on periodontal healing after impacted lower third molar surgery: A multiple regression analysis. J Clin Periodontol. 1991;18(1):37-43.\u003c/li\u003e\n \u003cli\u003ePassarelli PC, Lajolo C, Pasquantonio G, D\u0026apos;Amato G, Docimo R, Verdugo F, et al. Influence of mandibular third molar surgical extraction on the periodontal status of adjacent second molars. J Periodontol. 2019;90(8):847-55.\u003c/li\u003e\n \u003cli\u003eMathew G, Sohrabi C, Franchi T, Nicola M, Kerwan A, Agha R. Preferred Reporting Of Case Series in Surgery (PROCESS) 2023 guidelines. Int J Surg. 2023;109(12):3760-9.\u003c/li\u003e\n \u003cli\u003eHuang H-L, Ma Y-H, Tu C-C, Chang P-C. Radiographic Evaluation of Regeneration Strategies for the Treatment of Advanced Mandibular Furcation Defects: A Retrospective Study. Membranes. 2022;12(2).\u003c/li\u003e\n \u003cli\u003eJeffcoat MK, Reddy MS, Magnusson I, Johnson B, Meredith MP, Cavanaugh Jr PF, et al. Efficacy of quantitative digital subtraction radiography using radiographs exposed in a multicenter trial. J Periodontal Res. 1996;31(3):157-60.\u003c/li\u003e\n \u003cli\u003eChapple ILC, Mealey BL, Van Dyke TE, Bartold PM, Dommisch H, Eickholz P, et al. Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89 Suppl 1:S74-S84.\u003c/li\u003e\n \u003cli\u003eNibali L, Koidou VP, Nieri M, Barbato L, Pagliaro U, Cairo F. Regenerative surgery versus access flap for the treatment of intrabony periodontal defects. A systematic review and meta-analysis. J Clin Periodontol. 2019.\u003c/li\u003e\n \u003cli\u003eMatuliene G, Pjetursson BE, Salvi GE, Schmidlin K, Br\u0026auml;gger U, Zwahlen M, et al. Influence of residual pockets on progression of periodontitis and tooth loss: results after 11 years of maintenance. J Clin Periodontol. 2008;35(8):685-95.\u003c/li\u003e\n \u003cli\u003eHromč\u0026iacute;k F, Haluskov\u0026aacute; A. Lateral approach for the regenerative treatment of intrabony defects associated with edentulous spaces. A pilot case. Poster session presented at: \u003cem\u003eInternational Symposium\u003c/em\u003e on \u003cem\u003eSoft Tissue Management around Teeth and Implants; 26-27 May 2023; Florence, Italy. Available from: https://www.researchgate.net/publication/370465469_Lateral_approach_for_the_regenerative_treatment_of_intrabony_\u003cbr/\u003edefects_associated_with_edentulous_spaces_A_pilot_case.\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003eCarvalho Dutra B, Oliveira AMSD, Oliveira PAD, Miranda Cota LO, Silveira JO, Costa FO. Effects of topical application of 1% sodium alendronate gel in the surgical treatment of periodontal intrabony defects: A 6-month randomized controlled clinical trial. J Periodontol 2019;90(10):1079-87.\u003c/li\u003e\n \u003cli\u003eSaito A, Bizenjima T, Takeuchi T, Suzuki E, Sato M, Yoshikawa K, et al. Treatment of intrabony periodontal defects using rhFGF-2 in combination with deproteinized bovine bone mineral or rhFGF-2 alone: A 6-month randomized controlled trial. J Clin Periodontol. 2019;46(3):332-41.\u003c/li\u003e\n \u003cli\u003eAslan S, Buduneli N, Cortellini P. Entire Papilla Preservation Technique: A Novel Surgical Approach for Regenerative Treatment of Deep and Wide Intrabony Defects. Int J Periodontics Restorative Dent. 2017;37(2):227-33.\u003c/li\u003e\n \u003cli\u003eGraziani F, Karapetsa D, Mardas N, Leow N, Donos N. Surgical treatment of the residual periodontal pocket. Periodontol 2000. 2018;76(1):150.\u003c/li\u003e\n \u003cli\u003eHromcik F, Vokurka J, Gopfert E, Faldyna M, Hermanova M, Kyr M, et al. Granulation tissue enriched by aspirin and omega-3 fatty acids in healing experimental periodontal lesion. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2021;165(2):216-223\u003c/li\u003e\n \u003cli\u003eHromcik F, Vokurka J, Kyr M, Izakovicova Holla L. Granulation Tissue Enhanced with Aspirin and Omega‐3 PUFAs as a Local Adjunct to the Surgical Treatment of Periodontitis. Eur J Lipid Sci Tech. 2021;123(2):1-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"edentulous ridge, intrabony defect, regeneration, periodontal surgery, third molar removal, case series, residual pocket","lastPublishedDoi":"10.21203/rs.3.rs-4425258/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4425258/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study evaluated the clinical efficacy of the lateral approach, designed explicitly for unchallenged isolated intrabony defects associated with edentulous alveolar ridges, combined with an enamel matrix derivative\u0026nbsp;(EMD) and bovine-derived bone grafting\u0026nbsp;in the regenerative surgical treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeven intrabony defects distal to the lower second molar were treated using\u0026nbsp;a lateral approach combined with\u0026nbsp;EMD and bone grafting. The primary parameters\u0026nbsp;measured were clinical attachment level (CAL) and pocket probing depth (PPD).\u0026nbsp;Clinical outcomes were assessed 6 months\u0026nbsp;post-surgery\u0026nbsp;and compared with the baseline\u0026nbsp;values.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePocket closure and primary wound healing occurred in 100% of cases, and no complications were reported in terms of flap dehiscence, graft exposure, or suture failure. At the 6-month re-evaluation,\u0026nbsp;the initial\u0026nbsp;median CAL\u0026nbsp;of\u0026nbsp;6 mm (interquartile range: 5–8 mm) was reduced to 3 mm (3–5 mm). The corresponding median PPD was reduced from 6 mm (6–8 mm) to 4 mm (3–5 mm). The differences were statistically significant for both primary parameters (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe lateral approach is a valid technique for the surgical treatment of intrabony defects associated with the edentulous ridge. This method seems particularly suitable for distal intrabony defects in the lower second molars, which frequently develop after third molar extraction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not intended as a clinical trial and according to \u0026nbsp;https://grants.nih.gov/policy/clinical-trials/definition.htm is not considered a clinical trial, since its main purpose is “solely to refine measures”. The registration was therefore not required by the Ethics Committee approving the study protocol.\u003c/p\u003e","manuscriptTitle":"Lateral approach for regenerative surgery of intrabony defects associated with edentulous alveolar ridge/third molar removal: A prospective case series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-06 18:48:59","doi":"10.21203/rs.3.rs-4425258/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0310abdd-978a-46d7-81ff-2827e4a3e99d","owner":[],"postedDate":"June 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-29T12:25:08+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-06 18:48:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4425258","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4425258","identity":"rs-4425258","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}