Analysis of pre-prosthetic surgeries performed in a private dental institution

Nurul Syamimi Binti Mohd Azlan Sunil1, Santhosh Kumar M P*2, Revathi Duraisamy3 1Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India 2Department of Oral and Maxillofacial Surgery, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India 3Department of Prosthodontics, Saveetha Dental College and hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India


INTRODUCTION
Pre-prosthetic surgery is part of the oral and maxillofacial surgery, which concerns restoration of facial form and oral function. Pre-prosthetic surgery is a surgery done under local anaesthesia to obtain a better anatomic environment and to provide proper supporting structures for denture construction (Taylor, 1960). Surgical modi ication of the alveolar process and surrounding structures is the concern of the procedure to allow the fabrication of a comfortable, well-itting and esthetic dental prosthesis (Devaki et al., 2012). The ultimate goal of pre-prosthetic surgery is to rehabilitate the patient's oral environment by restoring masticating function and restoration or improvement of facial esthetics.
Adverse changes in the denture bearing area which is caused by change in the jaw bone size, resulting in painful and ill-itting denture when the dentures are worn for a long period of time (Hopkins, 1987). If the denture bearing area is left untreated, it can cause dif iculty in speech and mastication. Painful and ill-itting dentures can be detrimental to oral health as such problems may lead to denture-related diseases such as denture stomatitis and affects the patient's general quality of life. (Rahman and Mp, 2017) The dental prosthesis has made great achievements in improving the successful use of prosthetic appliances in the edentulous patients through improved processing technique accuracy, development of better material and a good understanding of oral anatomy and physiology (Lytle, 1959;Hopkins, 1987). There is an increase in the number of elderly and medically compromised patients treated in dental clinics for bone loss. The bone loss pattern in maxilla and mandible differs.
Alveolar bones estimated to be subjected to mechanical loads for 15 to 20 minutes per day (Bates et al., 1976). As tooth is lost, irreversible alveolar bone resorption occurs (Atwood, 1963;Carlsson and Persson, 1967). A continuous resorptive process is observed in an alveolar process which is often affected after tooth loss and bone resorption follows a predictable pattern; the labial aspect of alveolar crest reduces in width irst followed by height reduction (Lindhe et al., 2015;Newman et al., 2006). In cases of completely edentulous patients, muscle training may be required to enhance gradual adaptation of the orofacial musculature to the denture. (Kumar and Sneha, 2016;Patturaja and Pradeep, 2016) Patients who require dentures, either complete or partial, may observe that the process of denture adaptation is quicker and easier after undergoing pre-prosthetic surgery. (Kumar and Rahman, 2017) Failure and success of prosthesis can be in luenced by the selection of surgical procedures into treatment plans for removable dentures. A study conducted by Kalk et al. reported that surface areas are approximately 180% in the vestibular region and 126% greater in sublingual regions in groups who have undergone pre-prosthetic surgery compared to groups who did not undergo surgery. The same study also found that there is stability indenture in groups receiving pre-prosthetic surgery . Some studies announced that patients with atrophic mandibular ridges who were surgically treated were more satis ied with wearing dentures compared to patients that were not surgically treated Matthew, 2007).
Over the past ive years, innumerable clinical trials (Jesudasan et al., 2015;Christabel et al., 2016), surveys (Kumar, 2017;Abhinav et al., 2019a) and article reviews (Packiri, 2017;Marimuthu et al., 2018) had previously been conducted by our team. Currently, we are focusing on the types of preprosthetic surgery performed. (Patil et al., 2017) This study aims to evaluate the various pre-prosthetic surgeries performed in a private dental institution. (Abhinav et al., 2019b) This allows us to understand the range, capabilities and limitations of our conduct in pre-prosthetic surgical procedures as well as to establish a clear treatment plan in close coordination with all specialities to provide the best treatment outcome. (Rao and Kumar, 2018;Jain et al., 2019)

Study design and study setting
This retrospective cross-sectional study was conducted in the department of oral and maxillofacial surgery, Saveetha dental college and hospital, Saveetha University, Chennai, to analyse the various pre-prosthetic surgeries performed at our institution from June 2019 to March 2020. The study was initiated after approval from the institutional review board with an approval number of SDC/SIHEC/2020/DIAS DATA/0619-0320.

Study population and sampling
After assessment in the Dental Information Archiving System (DIAS) of Saveetha Dental College, all case records of patients who underwent preprosthetic surgeries were included in the study with a total of 352 quadrants. The exclusion criteria Patients below 18 years of age, missing or incomplete data. Cross veri ication of data for errors was done with the help of an external examiner. Data was reviewed and information was veri ied with treatment photographs.

Data collection
Data on various pre-prosthetic surgeries that were performed were collected from digital case records by a single calibrated examiner.
The following parameters were observed and recorded: (i) Patient's age, (ii) gender, (iii) type of pre-prosthetic surgery and (iv) quadrant involved.

Statistical analysis
All data collected were entered in Microsoft Of ice Excel and analysed using SPSS version 23.0 and results obtained. Descriptive statistics were used to report the distribution of age group, gender and type of pre-prosthetic surgery. Chi-square test was conducted to analyse the correlation between types of pre-prosthetic surgery with age, gender and quadrant involved. Signi icance test level was set at p<0.05.
Alveoplasty was commonly performed in both males and females with 63.3% and 60.6%, respectively ( Figure 5) with more surgeries performed in males. The results were statistically signi icant (p<0.002).
The most common surgery for all four quadrants was valvuloplasty with the irst quadrant (51.4%), second quadrant (82.6%), third quadrant (50.4%) and fourth quadrant (78.5%). Most surgeries were performed in the third quadrant and the results were statistically signi icant (p<0.001) ( Figure 6). Figure 1, X-axis represents the age group and Y-axis represents the frequency of pre-prosthetic surgery performed. The age group of 51-60 years had a higher frequency of pre-prosthetic surgery performed (23.3%) compared to other age groups.
Figure 2, X-axis represents the gender and Y-axis represents the frequency of pre-prosthetic surgery performed. Frequency of pre-prosthetic surgery performed was higher in males (53.1%) compared to females (46.9%). Figure 3, X-axis represents the type of pre-prosthetic surgery and Y-axis represents the frequency of pre-prosthetic surgery performed Alveoloplasty (62.2%) was the highest pre-prosthetic surgery performed compared to other type of pre-prosthetic surgery.
Figure 4, X-axis represents the age group and Y-axis represents the frequency of pre-prosthetic surgery.

Figure 4: Bar chart depicting association between pre-prosthetic surgery and age group.
Figure 5, X-axis represents gender, and Y-axis represents the frequency of pre-prosthetic surgery. Preprosthetic surgery was performed more in males (53.1%) compared to females (46.9%). Alveoplasty was observed to be the most common surgery in both males (60.6% of males) and females (63.6% of females). Pearson chi-square value-23.099, p value-0.001 (p<0.002), hence statistically signi icant, proving pre-prosthetic surgery was performed more in males compared to females. Figure 6, X-axis represents the quadrant involved and Y-axis represents the frequency of preprosthetic surgery. Pre-prosthetic surgery was performed more in the third quadrant (32.1%) compared to other quadrants. Alveoplasty was the most common surgery in all the quadrants (51.4% in the irst quadrant, 82.6% in the second quadrant, 50.4% in the third quadrant and 78.5% in the fourth quadrant). Pearson chi-square value-105.447, p value-0.000 (p<0.001), hence statistically signi icant, proving pre-prosthetic surgery was performed more in the third quadrant compared to other quadrants Pre-prosthetic surgery is conducted to prepare both the hard and soft tissues of the oral environment to accept prosthesis to provide comfort, restore oral function, esthetic and facial form. The procedure includes eliminating pain and discomfort after dental extraction or before denture fabrication process by surgically modifying the denture bearing area for insertion of prosthesis or endosseous implants (Matthew, 2007). Failure to identify or address the need for preprosthetic surgery can be a burden for both clinicians and patients later on.

Figure 5: Bar chart depicting association between pre-prosthetic surgery and gender.
It may result in loss of productivity as patients require multiple visits to treat denture discomfort or failure. As a result of improved denture comfort and ef iciency, quality of life of the patient can be improved as fear of dentures failing when speaking or eating is eliminated.
In this study, we observe that the most common type of pre-prosthetic surgical procedure is alveoplasty (62.2%) followed by frenectomy (20.7%), vestibulopathy (6.5%), soft tissue excision (4%), ridge augmentation (3.4%), sinus lift (2.6%) and exostosis removal (0.6%). Pre-prosthetic surgeries are done more in males than compared to females. The most common age group to undergo pre-prosthetic surgery is the 51-60 years age group (23.3%). Our current study found that the most common preprosthetic surgery done was alveoplasty for both maxilla and mandible. Our study results are in accordance to that of studies conducted by Qiam et al. and Mishra et al. Both of the studies reported that valvuloplasty is the most commonly prescribed preprosthetic surgery (Qiam et al., 2014;Mishra et al., 2017). However, Ferri et al. suggested that sinus lift is a much more common pre-prosthetic surgery in the maxilla (Ferri et al., 2008). The variations in inding may be due to differences in age group, geographic location and socioeconomic status.
In our study, the most common age group to undergo pre-prosthetic surgery are patients of 51-60 years. Results of study by Gangmani et al. were similar to our study as they also reported patients of 60 years of age are common age groups who undergo pre-prosthetic surgery (Gangwani et al., 2018). It is observed in our study that alveoplasty is more common in patients above 40 years and frenectomy is highly prevalent in patients below 40 years. This inding has signi icant clinical implications in our dental practice.
Based on gender, it was observed that males underwent more pre-prosthetic surgery than females. The most commonly performed surgery for both genders was valvuloplasty. A previous study was similar to our study inding and found that alveoplasty was common in males (Gangwani et al., 2018).
In our study, the third quadrant was the most prevalent site for pre-prosthetic surgeries. Hillerupt et al. also reported in their study that mandible is the most common site for pre-prosthetic surgery (Hillerup, 1982). In our study, the most common pre-prosthetic surgery performed in all the four quadrants was alveoplasty.

Limitations of the study
This study has limitations as it is conducted as a university-based study and the research results are only based on the regional population.

Future scope
Extensive research needs to be done with a larger sample population. Future studies can include other factors which may in luence patients' acceptance and preference of pre-prosthetic surgery such as diverse location and socioeconomic status.

CONCLUSIONS
Within the limits of this study, it can be concluded that the most common pre-prosthetic surgery performed was alveoplasty. Pre-prosthetic surgery was performed more in males and the age group of 51-60 years, mostly in the third quadrant.