Awareness and Preference of General Dental Practitioners towards Pre-Prosthetic Surgery as an Adjunctive to Complete Denture Therapy

Materials and Method: An observational study was undertaken for 150 registered dentists with a Bachelor of Dental Surgery degree, currently practicing in different cities of Libya. Only 109 dentists respond to our questions. Dentists with less than 5 years in Practice and who have no experience with removable prosthesis were excluded. This study was approved by the research ethical committee of Faculty of DentistryBenghazi University. Previous studies were used to prepare a questionnaire which includes questions about personal data, awareness and preference of dentist of preprosthetic surgery. Questionnaire was assessed by two expert oralmaxillofacial surgeon and prosthodontist.


INTRODUCTION
The evolutionary cycle has selected a masticatory system, which is functionally efficient using natural teeth and an omnivorous diet [1]. This system would be designed in totally different fashion due to the loss of natural teeth after extraction [1] and bone resorption [2,3]. The results of this resorption are accelerated by wearing dentures and tend to affect the mandible more severely than the maxilla [2,4].
Dentures are rigid pieces of acrylic resin which are shaped to fit the soft tissue covering of the jaws and be compatible with the functioning and ever changing oral environment [1]. No denture, regardless of how well it is constructed, can overcome the limitations of the foundation on which it is placed [1,4].
In practice we encounter many patients for whom an ideal treatment from prosthodontics point of view is not possible without resorting to preconditioning of oral tissues by means of surgical procedures [1,2,4]. These procedures constitute the pre-prosthetic surgical preparation [1,2,4,5].
Pre-prosthetic surgery is an integral part of complete denture prosthodontics [5]. The ultimate goal of pre-prosthetic surgery is to prepare a mouth to receive a dental prosthesis by redesigning and smoothing bony edges which would otherwise cause hindrance in restoration of optimum health and function [5].
Preprosthetic surgery involves operations aiming to eliminate certain lesions or abnormalities of the hard and soft tissues of the jaws so that the subsequent placement of the prosthetic appliance is successful [1,2,4,5]. It is therefore important for oral and maxillofacial surgeon and the prosthodontist to be acutely aware of the problems faced by the other and to understand what can be done in a joint effort to resolve these problems [3]. The aim of this study is to evaluate the attitude and awareness of sample of Libyan dentists towards preprosthetic surgery.

RESULTS
Out of 150 dentists to whom the questionnaire was sent, only 109 answered the questions. The study included 64 (58.7%) male and 45 (41.3%) female with male to female ratio 1.4:1.
The age range of the participant was 30 to 52 years old.
Regarding the years of practice, 18.1% had 5 years, 26.7% had 5-10 years and majority (55.2%) had more than 10 years of experience in practice of removable prosthesis. 41.9% of participant constructing more than 10 dentures per year, 22.9% of dentists perform 5-10 denture insertion per year and 35.2% perform 3-5 dentures per year. surgeries respectively. Table 1 shows response to these questions. Allogenic bone graft (54.5%) was the most familiar method among the participant whereas frenectomy (59%) was the most selected answer among the soft tissue surgeries. Table 2 show the responses to types of bone graft and soft tissue surgeries. About 88% of our sample they have not known what is the percentage of vestibular loss that they have seen in the first year after a mandibular vestibuloplasty with a mucosal or a skin graft?

DISCUSSION
Majority of participant (55.2%) of this study had more than 10 years in practice of removable prosthodontics, and most of them (41.9%) construct more than 10 dentures per year.
Several clinicians and patients believe that the success of dental treatment is affected by the experience of dentists.
Prosthodontics experience of a clinician affected the satisfaction ratings of a complete denture wearer [7].
It is not a surprise to find approximately half of dentists questioned have not experience nor idea about ridge augmentation procedures in both atrophic mandible and maxilla as removable prosthesis are annoying to patients and dentists are usually concerned more about implant dentistry than unpredictable results of dentures and also rapid progress of dental implants attract dentists to solve problems of retention, stability and comfort of conventional dentures [8].
Even with prosthodontists still 6% had no preference and 9% lacked experience with ridge augmentation procedures [3].
29.2% and 34.3%of respondents of this study prefer dental implant as a method of augmentation of atrophic ridge of maxilla and mandible respectively. In a previous study [3]  It was mentioned that, the most commonly performed soft tissue procedure is frenectomy [14] and this is consistent with our results where frenectomy (59%), soft tissue excision (50%), and vestibuloplasty (47%) were most familiar among our group. These techniques along with soft tissues grafts were referred in a higher manner than other surgeries.
If vestibuloplasty and graft are to be performed on a patient, the tissue type preferred mostly by participant was palatal mucosa (44.6%), followed by buccal mucosa (19.8%) and skin (7.9%) and 33.7% of participants had no preference.
From these infers that there is no clearly superior type.
Mucosa is very resilient, provides a good colour match, and is easily obtainable from a nondistant secondary surgical site. However, it is limited in quantity and* has a tendency to ulcerate under pressure [3]. Moreover, when taken from the palate it can produce a painful donor site, and when taken from the cheek it can result in a contracted scar [3]. Skin, by contrast, is obtainable in much greater quantities, usually reacts to pressure by hyperkeratosis rather than ulceration, and is generally less painful under load [3]. However, it is less resilient, it requires a distant secondary surgical site, it has diminished touch perception, and, if cut too thick, it may result in growth of hair [3]. Since both skin and mucosa have major advantages as well as disadvantages, the prosthodontic considerations may be more important than the surgical considerations in making the final choice. There appears to be a need for greatercollaboration between the prosthodontist and the oral and maxillofacial surgeon in establishing specific indications for use of skin and oral mucosal grafts [3].
Buccal shelf area and mentalis region were perceived as the most critical in obtaining maximal depth in cases of vestibuloplasty. This is consistent with previous reports [15] and indicates high level of awareness of present study participants regarding this context.

CONCLUSION
It is clear from this survey that there is no consensus in many areas related to the surgical management of the prosthodontic patient, including adequate ridge height and the critical regions for attaining maximum vestibular depth. For surgeons to satisfy the needs of denture providers, it is advisable that oral and maxillofacial surgeons consult with the dentists who will construct the prosthesis rather than relying solely on their own opinion about what should be done for the patient.

LIMITATION OF THE STUDY
To determine the actual awareness of dental practitioner/ specialists, a representative and randomized sample is required. However, the primary aim of this study was to evaluate the attitude and awareness of a selected sample of Libyan dentists. Questionnaire is a well-established strategy for data collection. However, it has its own limitations. For example, social desirability bias and non-response rate which may affect the representativeness of the sample and the quality of the information [16]. However, no personal information was sought and the participation was voluntary.
So these biases would be of less impact in the current study. In addition the response rate in the current study was relatively high (72%).

FUNDING INFORMATION
No funding was obtained.

CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.

ETHICAL APPROVAL
The study was in accordance with the ethical standards of the institutional research committee of Benghazi University and approval was OBTAINED.

INFORMED CONSENT
Using the Google form software freely enables the responders DOI: https://doi.org/10.35702/dent.10008