Download on the necessity of minor oral surgery pretreatment orthodontics

Orthodontics
ON THE NECESSITY OF MINOR ORAL SURGERY PRETREATMENT
ORTHODONTICS
Georgeta Zegan1, Daniela Anistoroaei2, Loredana Golovcencu3
1. Assoc. Professor, Dept. Paedodontics-Orthodontics, ”Gr.T.Popa” U.M.Ph Iasi
2. Lecturer, Dept. Paedodontics-Orthodontics, ”Gr.T.Popa” U.M.Ph. Iasi
3. Assist Prof., Dept. Paedodontics-Orthodontics, ”Gr.T.Popa” U.M.Ph. Iasi
Corresponding author: Georgeta Zegan, e-mail: [email protected]
Abstract
The aim of the study was to establish the frequency of
some minor oral surgery performed on both teeth and on
the soft tissues, before any orthodontic treatment. The
sample group included 587 patients (240 boys and 347
girls), divided into 3 categories. The data base was created wtih patient records, the statistical analyses being
performed with the SPSS 17.0 software for Windows. The
frequency of malocclusions with minor oral surgery pretreatment orthodontics was of 24%, out of which the surgical interventions on teeth represented 85.41% (serial extractions – 21.87%, orthodontic extractions – 41.66%,
enucleation of third molars – 18.75%, discovery of impacted teeth – 2.08% and teeth enucleation – 1.04%) and
the surgical interventions on the soft tissues represented
14.59% (labial frenectomy: 12.60%, lingual frenectomy:
1.04% and discovery of pericoronal tissues: 1.04%) The
minor oral surgery pretreatment orthodontics upon both
teeth and soft tissues are not quite frequent, yet they are
necessary for a partial preparation of the patient for orthodontic therapy.
Key words: serial extractions, orthodontic extractions,
impacted teeth, frenectomy
INTRODUCTION
The treatment of malocclusions which require
minor oral surgery to either teeth or soft tissues
before orthodontic appliance, is performed for
partial preparation of the patient for subsequent
active orthodontic therapy.
The most frequently applied surgical pretreatment orthodontic is serial extraction or orthodontic extraction (1). Serial extraction of the deciduous teeth is indicated in dental crowding with
macrodentia, aimed at alignment of the permanent teeth, when the size of the teeth and of the
maxillaries does not match (2). The presence of a
supernumerary tooth erupted on the dental arch
requires its extraction as rapidly as possible, to
avoid crowding of the neighboring teeth (3, 4).
Multiple extraction of the permanent teeth for
272
orthodontic reasons is a minor oral surgical method,
associated with an active orthodontic therapy
(5), aiming at creating the necessary space for dental alignment, in cases of permanent dentition
with secondary crowding, diagnosed quite late.
Enucleation of third molars assumes removal
of the incompletely formed buds, being recommended in secondary crowding caused by the
mesial position of the lateral teeth, for creating
the posterior space necessary for dental distal
removal (6).
Discovery of impacted teeth with favorable osseous positions, bone resection for creating their
eruption way and the slow traction of the tooth towards the dental arch through orthodontic means
are methods of surgical-orthodontic treatment.
The most commonly oral surgery pretreatment orthodontics upon the soft tissues involves
the discovery of pericoronal tissues indicated in
late eruptions of the permanent teeth, caused by
the existence of a dense fibrous tissue. The surgical interventions upon the labial frenulum with
abnormal insertion are indicated in the orthodontic treatment of midline diastema, while surgical intervention upon the lingual frenulum is
recommended in ankyloglossia.
The study analyzes the malocclusions which
require oral surgery pretreatment orthodontics,
followed by therapies with various types of active orthodontic appliances, for calculating the
frequency of the minor surgical interventions on
both teeth and soft tissues, performed before the
orthodontic treatments.
MATERIALS AND METHOD
All patients were consulted in the Pediatric
Dentistry Clinics of the “Sf. Spiridon” Univer-
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ON THE NECESSITY OF MINOR ORAL SURGERY PRETREATMENT ORTHODONTICS
sity Hospital of Iasi, Romania, between January
1991 and October 2009. The malocclusion diagnosis was established – clinically and
radiologically – on 587 patients (240 boys and
347 girls), with ages between 6 and 28 years (average age: 10.76 years). 75.9% of the patients
came from the urban medium, and 24.1% from
the rural one. The subjects were divided into 3
categories: patients having required only orthodontic consult (187), patients with orthodontic
treatments (304) and patients with surgical and
orthodontic treatments (96).
The data base was created with patient
records, the statistical analyses being performed
with the SPSS 17.0 software for Windows, by
descriptive statistics. Also, to illustrate the results obtained, graphs were drawn in Microsoft
Office Excel.
RESULTS
FIGURE 2. THE FREQUENCY OF PREORTHODONTIC
CHIRURGICAL TREATMENTS ON TEETH
1,04%
enucleation of teeth
2,08%
impacted teeth
18,75%
enucleation of third molars
41,66%
orthodontic extraction
21,87%
serial extraction
0
0,1
0,2
0,3
0,4
0,5
Figure 3 illustrates the case of a 14.1 year-old
male patient who addressed the orthodontist for
some aesthetic disorders, being diagnosed with
Class II Angle division 1 malocclusion and deep
over-bite. The orthodontist recommended a surgical-orthodontic treatment, including the following stages: enucleation of third molars 18, 28,
38, 48; orthodontic extractions 14, 24; fixed treatment for retraction of the frontal upper group
and solving of the occlusion in vertical plane;
retention.
The surgically- and orthodontically-treated
malocclusions, requiring minor oral surgery
upon either teeth or soft tissues represented 24%
of all treatments performed on the sample group.
The most frequently applied oral surgery was
made on teeth – 85.41%, those made on the soft
tissues representing only 14.59% (fig. 1).
The oral surgery pretreatment orthodontics
on teeth registered a frequency of 21.87% for serial extractions of deciduous teeth, of 41.66% for
orthodontic extractions of permanent teeth, of
18.75% for enucleation of third molars, of 2.08%
for discovery of impacted teeth, and of 1.04%,
respectively, for the enucleation of teeth without
eruption potential (figure 2).
FIGURE 1. THE FREQUENCY OF PREORTODONTIC MINOR
ORAL CHIRURGICAL TREATMENTS
on soft tissues
14,59%
on teeth
85,41%
International Journal of Medical Dentistry
273
Georgeta Zegan, Daniela Anistoroaei, Loredana Golovcencu
Figure 3. a. – before to treatment; b. – after
enucleation of third molars and orthodontic
extractions; c. and d. – during the fixed treatment;
e. and f. – results of the treatment after retention
Figure 4 presents the case of a 23.2 year-old
female patient, who addressed the orthodontist
for some aesthetic disorders, being diagnosed
with Class II Angle division 1 malocclusion,
deep bite and erupted upper supernumerary
tooth (doubling of 22). The orthodontist recommended a surgical-orthodontic treatment, including the following stages: extraction of the
upper supernumerary tooth; enucleation of third
molars 38, 48; fixed treatment for dental alignment; retention.
274
Figure 4. a. – before to treatment; b. – after upper
supernumerary tooth and enucleation of third molars;
c. – during the fixed orthodontic treatment;
d. – results of the treatment after retention
Figure 5 illustrates the case of a 9.2 year-old
male patient who came to the orthodontist for
the absence of an upper frontal tooth, being diagnosed with Class I Angle malocclusion with
impacted teeth 21, caused by an unerupted upper supernumerary tooth. The orthodontist recommended a surgical-orthodontic treatment, including the following stages: enucleation of the
unerupted supernumerary tooth; discovery of
impacted tooth 21; application of a bracket on
tooth 21 and its traction off the dental maxillary
arch; fixed orthodontic treatment on the maxillary; retention.
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ON THE NECESSITY OF MINOR ORAL SURGERY PRETREATMENT ORTHODONTICS
FIGURE 6. THE FREQUENCY OF PREORTHODONTIC
CHIRURGICAL TREATMENTS ON SOFT TISSUES
pericoronal tissues
discovery
0,0104
0,0104
lingual frenectomy
0,125
labial frenectomy
0
0,02
0,04
0,06
0,08
0,1
0,12
0,14
Figure 7 illustrates the case of an 8 year-old
male patient who came to the orthodontist’s for
aesthetic problems, being diagnosed with Class
I Angle malocclusion with light dental crowding
and upper midline diastema caused by a labial
frenulum with low implanting. The orthodontist
recommended a surgical-orthodontic treatment,
including the following stages: frenectomy of the
upper labial frenulum; dental alignment and
closing of the midline diastema with maxillary
removal appliance.
Figure 5. a. – before to treatment; b. – after
enucleation of unerupted supernumerary tooth 21,
application of a bracket on 21 and its traction of the
dental maxillary arch with fixed orthodontic
treatment maxillary; c. – orthopantomography;
d. – results after traction of the impacted tooth
Oral surgery on the soft tissues was represented by labial frenectomy, lingual frenectomy
and discovery of the pericoronal tissues, followed by orthodontic treatments. Frenectomy of
the upper labial frenulum was performed in a
12.60% ratio in patients suffering from midline
diastema and frenectomy of the lingual frenulum, in a ratio of 1.04%, in patients suffering
from ankyloglossia, while discovery of the pericoronal tissues was performed in a 1.04% ratio,
in patients with impacted central upper incisor
(fig. 6).
Figure 7. a. – evidencing of the low implanting of the
labial frenulum through traction of the upper lip,
which caused whitening of the midline papilla
mucous membrane; b. – aspect of the labial frenulum
after frenectomy
Figure 8 illustrates the case of a 7.1 year-old
male patient who complained of speech disor-
International Journal of Medical Dentistry
275
Georgeta Zegan, Daniela Anistoroaei, Loredana Golovcencu
ders, being diagnosed with Class II-a Angle division 2 malocclusion, with ankyloglossia
caused by a too short lingual frenulum. The orthodontist proposed a surgical-orthodontic
treatment including the following treatment
stages: frenectomy of the lingual frenulum; dental alignment with a mandible removal appliance.
Figure 9. a. – eruption cyst 11; b. – evidencing of tooth
11 after discovery of pericoronal tissues
DISCUSSION
Figure 8. a. – evidencing of the short implanting of
the lingual frenulum and limited mobility of tongue;
b. – aspect of the lingual frenulum after frenectomy
and tongue’s mobility
Figure 9 presents the case of a 9.3 year-old
male patient who came to solve the absence of
an upper frontal tooth, being diagnosed with
Class I Angle malocclusion with anodontia 35
and eruption cyst 11. The orthodontist recommended a surgical-orthodontic treatment involving the following stages: discovery of
thepericoronal tissues of tooth 11; control of dental eruption.
276
The literature of the field makes mention of a
variable frequency of extraction decisions in permanent teeth (42.1%, 25 - 85%, 56.5%) for solving
of malocclusions with dental crowding (5,8,9),
the authors still debating which is the most suitable treatment: extraction or non-extraction (1,7).
Generally, for dental crowding, extraction is resorted to by orthodontists for obtaining space on
the permanent dental arches, on the basis of certain criteria of the relative factors, such as age,
sex, extent of dental crowding, Class Angle
malocclusion, over bite, over jet, biprotrusion,
angle of the mandibular plane and aesthetic facial lines (9 and 10).
In the present study, the frequency of orthodontic extractions of the permanent teeth was
specific to the dental crowding diagnosed after
the age of 12, which agrees with the data provided in literature. Selection of the extraction
treatment for solving the malocclusions with
dental crowding was made on the basis of the
Class Angle malocclusion. Thus, in Class I Angle with dental crowding, symmetrical extractions were performed on the 4 quadrants of the
dental arches, in Class II Angle with generalized
mesial position of the upper teeth – symmetrical
extractions on the maxillary arch, in Class II
Angle with lower dental crowding – symmetrical extractions on the two dental arches, while in
Class III Angle, symmetrical extractions were
performed on the lower arch. The most frequently selected teeth for extractions were the
primary or secondary premolars. The permanent
primary molars were only rarely selected for
volume 1 • issue 3 July / September 2011 • pp 272-278
ON THE NECESSITY OF MINOR ORAL SURGERY PRETREATMENT ORTHODONTICS
extraction, when their loss off the dental arches
was observed, the objective being to re-establish
dental symmetry. Extractions of other teeth from
the dental crowding involved the teeth placed
outside the dental arch, when the rest of the dental arch was perfectly aligned.
The authors of a comparative study performed in Scotland on the selection of teeth for
extractions with orthodontic causes demonstrated different frequencies on these teeth (11).
Also, the studies devoted to the selection of primary or secondary premolars for extractions
with orthodontic causes showed that, in the year
1999, extractions were performed in 57.5% of the
patients while, after the age of 21, the ratio increased to 84.5% of them. The statistical data
provided in the literature of the field on the selection of the permanent molars for extractions
with orthodontic reasons showed that, in 1984,
the extractions registered a frequency of 52%
while, in 1999, they came down up to 33.8%. The
orthodontic extractions of the lower incisors
were only rarely preferred, and exclusively from
periodontal reasons.
The serial extraction of the deciduous teeth
proposed as an early solution to dental crowding through macrodontia is based on the extraction of two temporary teeth for the eruption of a
permanent tooth, being performed in temporary
dentition or in the first stage of mixed dentition
(2). Application of such a procedure depended
on the age at which the patient first came to the
orthodontist, on the extent of root resorption of
the deciduous teeth and on the ortopantomography establishing the eruption sequence of the
permanent teeth. Regional dental crowding, root
resorption of an adjacent permanent tooth, impacted tooth represent complications determined by the eruption of the supernumerary
teeth, that may be avoided by their early diagnosis, followed by immediate extraction (3 and 4).
In the present study, enucleation of third molars was proposed after eruption of the secondary permanent molars, a procedure indicated for
creating space in the posterior dental arches,
where the third molars did not have sufficient
space for eruption, and the radiographic image
anticipated the occurrence, after the treatment,
International Journal of Medical Dentistry
of dental tertiary crowding. In a study performed by Laskin in 1971, addressing 600 orthodontists and 700 oral surgeons, 65% of them
agreed that, sometimes, the third molars produce crowding on the anterior mandibular arch
(12). Other studies show that 16.7% of the third
molars, of which 82.5 % are upper third molars
and 15.6% are lower third molars (14), remain
inserted (13).
Studies developed on patients with impacted
teeth indicate a frequency of 14.1% (14), while
the values registered for impacted cuspid teeth
show a frequency of 0.8% (15). In the present
study, the crown of the impacted teeth was discovery and brought in the occlusion plane exclusively for the inserted teeth with favorable positions, the tooth impacted horizontally being
removed by surgical methods, for avoiding degeneration of the compounding tissues.
The literature of the field registers a 12.59%
frequency of midline diastema in the population
of the United Kingdom, 3.40% in Kaukasus
population and 1.60% in South India population,
while the abnormal insertion of the labial frenulum causes 33.03% of midline diastema (16). A
study performed on 1,041 new-born children
identified the presence of ankyloglossia in 4.8%
of them (17), while other studies, developed on
patients affected by ankyloglossia at older ages,
indicate a variable frequency, ranging between 4
- 10% (18). The relatively low frequency values
indicated in studies devoted to malocclusion
caused by the abnormalities of the soft tissues
agree with the frequency of the surgical treatments on the soft tissues, discussed in the mentioned study.
The present research has the advantage of
providing a unitary, complete imagine on the
frequency of all types of minor oral surgery performed before to orthodontic treatments on both
teeth and soft tissues, upon the same sample of
subjects.
CONCLUSIONS
1. Minor oral surgery pretreatment orthodontics on teeth or on the tissues was performed in
¼ of the patients suffering from malocclusions.
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Georgeta Zegan, Daniela Anistoroaei, Loredana Golovcencu
2. The most frequent orthodontic extractions
were made on the permanent teeth.
3. Minor oral surgery on both teeth and soft
tissues was not frequently indicated by the orthodontist for partial preparation of the patient
suffering from malocclusions, being solved together with the oral surgeon.
4. The malocclusions having necessitated minor oral surgery before the orthodontic one were
hardly accepted by patients, in the absence of
any other variant of treatment.
5. Substitution of the surgical-orthodontic
treatments with only orthodontic treatments
may cause post-treatment recurrence of
malocclusions.
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