International Journal of Dental and Health Sciences Original Article Volume 05,Issue 06

THE FREQUENCY OF PRE-ORTHODONTIC SURGERIES: A PROSPECTIVE STUDY OF 191 PATIENTS M. Orafi 1, A. Buzariba 2, A. Taboli 3 1. Lecturer at Dental School, Benghazi University, and consultant at Aljala Trauma Hospital, Benghazi, Libya. 2. Senior house officer at Aljala Trauma Hospital, Benghazi, Libya. 3. Demonstrator at Dental School, Benghazi University, and SHO at Aljala Trauma Hospital, Benghazi, Libya.

ABSTRACT: Objective: To establish the frequency of surgical procedures requested by orthodontists. Materials and methods: A prospective study of 191 patients requiring 306 surgeries was conducted in private clinics in the cities of Benghazi and Almarj in the eastern part of Libya. Results: All the 191 patients included in this study were Libyans. There were 150 female and 41 male patients, and the female to male ratio was 3.6:1. The types of operations performed included the following: 234 (76.4%) surgical impaction extractions; 60 (19.6%) surgical impaction exposures, including 40 canines, 13 incisors, and 7 premolars; 4 (1.3%) upper labial frenectomies; 1 (0.32) lingual frenotomy; and 7 (2.28%) surgically-assisted rapid palatal expansions. Conclusion: The necessity of pre-orthodontic surgeries requires more research, as there is disagreement among authors concerning if and when surgeries should be utilized, especially regarding removing or retaining the impacted teeth. Key words: Impacted, Maxillary, Expansion, Frenectomy, Surgical, Exposure, Preorthodontic.

INTRODUCTION:

Minor oral surgery affecting either the requiring surgical management before teeth or soft tissues is performed to orthodontic treatment, with partially prepare the patient for impaction being the most common pre- subsequent orthodontic therapy.[1] In a orthodontic problem.[1-11] study conducted in Romania, about a quarter of 587 patients required pre- The surgical removal of impacted or orthodontic surgeries before orthodontic supernumerary teeth and odontomes, treatment, and the authors concluded the surgical exposure of impacted teeth that substitution of surgical-orthodontic with or without traction, frenectomies, treatments with only orthodontic and surgically assisted rapid palatal treatments might cause post-treatment expansion are all discussed in the recurrence of malocclusions. [1] literature to solve the problems mentioned above.(1-11) The need for surgery before orthodontic treatment has been well reported in the In the literature, these problems and literature. Impacted teeth, their solutions are discussed separately, supernumerary teeth, odontomes, and only a few articles considered all pre- (1) abnormal frenal attachment, and orthodontic surgeries together . maxillary transverse deficiency are issues Therefore, this study aims to establish the

*Corresponding Author Address: Dr. M. Orafi . E-mail: [email protected] M. Orafi .et al, Int J Dent Health Sci 2018; 5(6):783-789 frequency of surgical procedures diclofenac potassium and the antibiotics performed to facilitate orthodontic augmentin or cephalexin. treatment. For the localization of the impacted teeth, MATERIALS AND METHODS: intraoral periapical films (IOPAs), orthopantomographs (OPGs), and tube A three year prospective study of 191 shift techniques were used. patients requiring 306 surgeries was conducted in private clinics receiving The parameters we obtained were referrals from more than 5 orthodontists demographic data (age, gender, in the cities of Benghazi and Almarj in the nationality, medical history, type of eastern part of Libya. All the patients surgery), anatomic data (body mass were operated by the same surgeon, who index, gag reflex, mouth opening), and has 12 years of experience in the field of operative data (time, technique, oral and maxillofacial surgery. anaesthesia, flaps, suturing). Operative and postoperative complications were Simple orthodontic extraction was also assessed. excluded from the study because we focused on surgical procedures that RESULTS: started with incision and ended with sutures. The procedures included were as All 191 patients included in this study follows: the surgical removal of impacted were Libyans. There were 150 females teeth, supernumerary teeth and and 41 males, with a female to male ratio odontomes; the surgical exposure of of 3.6:1. Their ages ranged from 7-44 impacted teeth; frenectomy; and years; the age group 0-10 had 11 patients, surgically assisted rapid maxillary age group 11-20 had 88 patients, which expansion. was the highest number of patients, age group 21-30 had 82 patients, and age Surgical settings were the same among all group 31-40 had 10 patients. the patients. The operations were performed under either local (LA) or The majority of our patients did not have (GA), and a number previous illness or surgeries, except for 3 15 blade was used for all the incisions. patients with a history of Single interrupted sutures or blanket appendicectomy, tonsillectomy, and cleft sutures were used for closing the incision, repair. Two patients were asthmatic, and 3/0 polygalactin and 3/0 black one patient had succinyl-choline apnea, braided silk were used as suture and the oldest patient had diabetes. materials. The types of operations performed In the postoperative period, the included the following: 234 (76.4%) medications used were the analgesics and surgical impaction extractions, 60 (19.6%) anti-inflammatory agents ketoprofen or surgical impaction exposures, including

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M. Orafi .et al, Int J Dent Health Sci 2018; 5(6):783-789 40 canines, 13 incisors, and 7 premolars; flap was used in 216 operations, and the 4 (1.3%) upper labial frenectomies; 1 other types of flaps included 37 (0.32) lingual frenotomy; and 7 (2.28%) trapezoidal flaps, 41 triangular flaps, 7 surgically-assisted rapid palatal Lefort I sulcular flaps for buttress release; expansions. the rest of the procedures were frenectomies and the one frenotomy. Surgically extracted impacted teeth included 160 (68.38%) wisdom teeth, 36 For the cases of buttress release, sutures (15.38%) canines, 15 (6.41%), were placed using blanket technique, supernumerary teeth, including 7 whereas in the other surgeries, we mesiodenses, 13 (5.55%) premolars, 4 employed interrupted sutures. (1.7%) odontomes, 2 (0.85%) incisors, 2 Intraoperative complications included 3 (0.85%) remaining roots, and 2 (0.85%) cases of crown fracture of the wisdom deciduous teeth. teeth, 4 cases of envelope flap tearing, and 1 case of epistaxis, which occurred in The body mass index (BMI) in the study the buttress release case. This last case group ranged from 16 to 32.8. All the had a previous history of cleft lip and patients have a mouth opening of more operation. than 3 fingers in length, and no gagging observed during the operation. Thirty- Postoperative complications included five operations required 15-30 minutes to pain, numbness, , wound be finished. The operation time was more dehiscence, swelling, ecchymosis, and than 30 minutes in surgeries performed limited mouth opening. Postoperative for two cases of buttress release, one nasal was noted by one patient mesiodens extraction, one impacted who was treated for high impacted premolar, and two impacted canines; the canines. rest of the operations required less than 15 minutes. DISCUSSION:

Elevation only as a surgical technique The current literature lacks information was employed in 7 patients, three with regarding the incidence, prevalence, and supernumerary teeth and four with frequency of pre-orthodontic surgeries. [1] impacted wisdom teeth. An osteotomy G. Zegan et al. studied the frequency of was performed in 242 operations, while some minor oral surgeries performed on osteotomy with sectioning was both teeth and soft tissues prior to performed in 52 operations, and the orthodontic treatment in 587 patients remaining operations were frenectomies. and reported that 24% required minor oral surgeries before orthodontic Two patients were operated under GA treatment. In our report, it was difficult to for impacted teeth; the rest of the estimate the percentage of patients patients were operated under LA using requiring surgeries before treatment of either infiltration or blocks. The envelope 785

M. Orafi .et al, Int J Dent Health Sci 2018; 5(6):783-789 malocclusion because we received problems associated with impacted referrals from different private clinics. cuspids, such as resorption of the adjacent roots, referred pain, infection, Among the 191 patients in the current dentigerous cyst formation, which may study, 150 patients were female and 41 lead to ameloblastoma, and resorption of were male, and there was a female to the affected tooth, require management male ratio of 3.6:1. Consistent with of theses teeth.(5). As previously reported, [1] previous reports, there were more only the teeth with favourable positions female patients than male patients, were exposed to orthodontic traction. especially in the 11-20 age group. In our Impacted canines with abnormal opinion, this is because females are more positions obstructing the orthodontic concerned about aesthetics than males, movement were extracted surgically.[1] and in this age group, both patients and parents started recognizing the need for Impacted maxillary incisors can have a orthodontic treatment. significant impact on patients’ aesthetic and social behavior; the incidence of The most common surgery performed unerupted maxillary central incisors have before orthodontic treatment in our been reported as ranging from 0.13% (4) study was the removal of impacted teeth to 2.6%.(12) In the present study, the (76.4%), followed by the surgical frequency of impacted incisors, including exposure of impacted teeth (19.6%). This both upper and lower, was 5.1% (15 approximates the results reported by G. incisors out of 294 impacted teeth). Only Zegan et al. (1) if we exclude the serial and two incisors were removed because it orthodontic extraction. was challenging to bring them into the arch; the other impacted incisors were It is reported that 16.7% to 68.6% of third exposed for orthodontic traction. molars remain impacted (1,12); 65% of 600 orthodontists and 700 oral surgeons The removal of supernumerary teeth agreed that, sometimes, the third molars should be performed as soon as possible produce crowding of the anterior to avoid complications such as regional mandibular arch. If the wisdom teeth do dental crowding, root resorption of the not have enough space to erupt, their adjacent permanent teeth, and removal is indicated after the eruption of impaction. [1,10] Such complications can be the second molars for creating space in avoided by early detection and [1] the posterior dental arches, management of these extra teeth.[1] The mesiodens is the most commonly Canines are the most commonly occurring supernumerary tooth. The impacted teeth after the third molars; presence of this tooth may cause midline [2,5,8,] impacted canines registered a diastema, rotation of incisors, ectopic frequency of 0.8% to 2.8%.[1,9,12] Most of eruption, impaction of incisors.[10] the cases were in a palatal position with a Impacted incisors due to supernumerary palatal-labial ratio of 2:1.[5] Potential 786

M. Orafi .et al, Int J Dent Health Sci 2018; 5(6):783-789 teeth have a better prognosis than tube shift technique were the tools used incisors that fail to erupt due to other for localization of the impacted teeth. causes.(4) Cone beam computerized tomography (CBCT) was used in very few cases Odontomes occur more often in the because it is expensive and not readily permanent dentition and are rarely available. associated with the primary dentition. One third to one-half of odontomes In our report, soft tissue procedures were prevent the eruption of teeth. Generally, limited to 4 labial frenectomies to correct odontomes account for 65% of all the midline diastema and one lingual odontogenic tumours.[4] The best frenotomy. Those surgeries were low in treatment option for odontomes is frequency compared to other hard tissue surgical removal, which has a low procedures; this is consistent with the recurrence rate.[11] In the present study, study of G. Zegan et al.[1] in which they only 4 patients with odontomes were report the low incidence of midline found, representing a low percentage of diastema and that some diastemas are the total patients considered in this due to midline pathological causes.[3] study; all odontomes were treated by surgical removal. Midline diastema may be temporary and usually closes after the eruption of Surgical exposure of impacted teeth canines; no treatment should be initiated accounted for 19.6% of the operations in if space is physiological. However, this present study. Minimal approache treatment of midline diastema is was used for the exposure of impacted necessary to avoid problems related to teeth, including the creation of a small high frenal attachment, such as cosmetic window or an apically repositioned flap and phonetic deficiencies, and problems and the closed eruption technique, which related to oral hygiene and periodontal are surgical methods reported in the health.[3] A can be literature for this purpose.[4] In this study, performed before, during, or after the to expose the impacted teeth, we used orthodontic closure of the maxillary the closed eruption technique, in which a midline diastema, depending on the flap was raised, the impacted tooth was individual case.[13] On the other hand, exposed, and orthodontic traction was some authors recommend closure of applied; then, the flap was replaced and diastema before surgery because a sutured. It is mentioned in the literature formation can impede the closure of the that the closed technique resulted in diastema.[3] more aesthetically pleasing gingiva than the apically repositioned flap (4). An orthopaedic maxillary expansion is used to solve the problem of crossbite; Intraoral periapical films (IOPAs), however, this is effective only when the orthopantomographs (OPGs), and the interpalatine suture is still patent.(6) In a

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M. Orafi .et al, Int J Dent Health Sci 2018; 5(6):783-789 mature patient where the suture had maxillary deficiency in adults. This synostosed, the orthopaedic maxillary procedure was successful in 17 patients expansion will lead to teeth tipping, out of 18 patients. In one patient, the extrusion, periodontal membrane treatment was discontinued because compression, buccal root resorption, pressure necrosis of palate related to the alveolar bone bending, fenestration of appliance”. [14] buccal cortex, palatal tissue necrosis, pain and instability of the expansion. Due to One male and 6 females who were the problems related to orthopaedic healthy and within the ages range of 18 to expansion, surgically assisted rapid 28 were our candidates for surgically maxillary expansion has been assisted expansion. We only performed recommended. [6,7] osteotomy at the areas of maximum resistance to lateral movement to assist The literature recommends the maxillary expansion; the osteotomy consideration of age, sex and medical extended from the piriform aperture to conditions as criteria for selection of behind the zygomatic buttress without orthopaedic or surgically assisted performing a midpalatal split. This expansion. The exact age after which the approach can be justified by some reports surgery is mandatory is debatable; some that have shown midpalatal suture does authors recommend 12 years and others not offer much resistance to expansion. recommend 25 years of age to start the The areas of resistance to lateral surgically assisted expansion. The medical expansion have been classified as the conditions, such as metabolic and bone anterior support (piriform aperture diseases, can affect the flexibility of facial pillars), lateral support (zygomatic skeleton, rendering the expansion more buttresses), posterior support (pterygoid difficult (7). Michael and John reported junctions), and median support that a cemented palatal expansion (midpalatal synostosed suture).[7] appliance could be used successfully in adults up to 43 years of age and could be CONCLUSION: augmented with lateral maxillary The necessity for pre-orthodontic osteotomy in older patients. Lehman, surgeries requires more research, as Hass, and Hass also mention that an there is disagreement among authors “osteotomy of the zygomaticomaxillary concerning if and when surgeries should buttresses in combination with a rapid be utilized, especially regarding removing palatal expansion appliance is a or retaining the impacted teeth. dependable treatment for horizontal

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