Extraction of high inverted mesiodens via the labial, palatal and subperiostal intranasal approach：A clinical prospective study

Extraction of high inverted mesiodens via the labial, palatal and subperiostal intranasal approach：A clinical prospective study | 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 Extraction of high inverted mesiodens via the labial, palatal and subperiostal intranasal approach：A clinical prospective study Huifei Li, Yongfeng Cheng, Jun Lu, Pengfei Zhang, Yi Ning, Lei Xue, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1590128/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 As the potential risks of the development of the adjacent incisors and jaws, mesiodens, especially inverted mesiodens, should be prophylactically extracted in mixed or early permanent dentition. However, because of the limit of small clinical data, there is relatively inadequate and lacks systematic, comprehensive understanding on minimizing operation injury for high inverted mesiodens. The aim of this study is to provide reliable support for the choice of extraction of high inverted mesiodens, and minimize the operation injury for patients. Methods Thirty patients were randomly divided into three groups according to three different surgical designs in the extraction of high inverted mesiodens. The operation statistics, life quality of postoperative patients, and the operative injury/recovery were compared and analyzed. The laser Doppler blood flowmetry, laser speckle contrast imaging, and electric pulp testing were explored to detect the postoperative pulp and gingiva blood supply of adjacent teeth. Results For the clinician's primary concerns, the surgical time, the volume of osteotomy, and the amount of bleeding in the labial approach group and intranasal approach group were significantly less than that in the palatal approach group ( p <0.05). However, from the patient's perspective, the postoperative swelling and pain in the labial approach were far more than that in the intranasal approach group ( p <0.05), with unsurprisingly lower satisfaction ( p 0.05).Trauma was manageable in all patients. Conclusions With precisive operation, maxillary inverted impacted mesiodens could be extracted by three methods, and the controlled trauma would not affect the development of teeth and jaw. Under the inclusion and exclusion criteria of this study, the extraction of mesiodens by the intranasal approach achieved a delicate balance between reducing surgical trauma and optimizing postoperative recovery, which was of concern and merited further study. Trial registration The study was approved by the Ethics Committee of Shanxi Medical University School and Hospital of Stomatology (2019SLL022), and retrospectively registered at chictr.org.cn (ChiCTR2100054777). All patients provide written informed consent before participating in treatment. Mesiodens Supernumerary teeth Tooth extraction Subperiosteal intranasal approach Swelling Pulp vitality Gingiva blood supply Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Supernumerary teeth are extra teeth or tooth-like structures that vary in size, shape, and number in addition to the normal dentition [1,2]. When supernumerary teeth appear in the center of the jaw, either in deciduous or permanent dentition, they are called mesiodens [3]. The prevalence of mesiodens globally averages 0.15-1.9%, accounting for about 46-67% of the total number of supernumerary teeth [3]. Occlusion disorders are the most common complication of mesiodens, manifested as retarded eruption of permanent teeth, significant crowding or spacing of the anterior teeth [4]. Occasionally, mesiodens cause odontogenic cysts or ameloblastoma, leading to apical root resorption of the adjacent teeth, bone destruction, and even dento-maxillofacial deformities [5-7]. Most scholars believed that mesiodens, especially inverted mesiodens, should be prophylactically extracted in mixed or early permanent dentition [8-10]. Mesiodens are classified into six types according to their position and direction relative to the incisor [11]. In general, the higher and deeper position in bone, the closer to the apical root of the adjacent teeth, the more complication risk is involved in tooth extraction. In type IV, the mesiodens are located superior to the root apex of the adjacent incisors (high position and inverted oriented), which frequently led to increase postoperative complication rates such as severe pain, facial swelling, and decreased pulp vitality of adjacent teeth [12]. In addition to these perioperative surgical trauma, excessive surgical trauma could even affect the normal growth and development of the dentitions and jaws of children [13]. Extraction of high inverted mesiodens is usually done via the labial or palatal approach [14,15]. The main advantage of the traditional labial approach is that it provides an excellent surgical view, reducing surgical stress. But for extraction of high inverted mesiodens, osteotomy in the anterior maxillary area is likely to exacerbate the problem of postoperative swelling and pain. If the surgeon selects the palatal approach, there are fewer aesthetic problems in the anterior maxillary area, and the postoperative swelling degree is slight. While the extensive osteotomy and prolonged operation may decrease the blood supply and pulp vitality of the adjacent teeth. It is difficult to strike a balance between reducing surgical trauma and focusing more on the patient's quality of life after surgery. Up to now, there is no generally accepted surgical procedure to minimize operation injury for high inverted mesiodens. In 2011, a new surgical design named the modified maxillary vestibular approach with subperiosteal intranasal dissection was described by Sammartino G. et al. in a case reported [16]. However, this surgical design has not been intensively studied over the past decade, partly because some stomatologists worry about damaging nasal floor structure, breaking through nasal mucosa into the trachea, or even airway obstruction caused by misplacing mesiodens. Because of the limit of small clinical data, there is relatively inadequate and a lacks of systematic, comprehensive understanding of the indications, intraoperative safety, operation effect, and postoperative complications of this surgical design. This is the first prospective randomized study on the selection and optimization of surgical approach design to extract high inverted mesiodens. Three different surgical designs (via the labial, palatal, and subperiosteal intranasal approach) were compared by the operation statistics, life quality of postoperative patients, and the operative injury/recovery. This study provides reliable support for the choice of extraction of high inverted mesiodens, which will contribute to minimizing the operation injury for patients. 2. Materials And Methods 2.1 Ethics Statement This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments, and approved by the Ethics Committee of Shanxi Medical University School and Hospital of Stomatology (2019SLL022). The study was first registered on 27/12/2021 at chictr.org.cn (ChiCTR2100054777). Written informed consent was obtained from all subjects and their legal guardian (for those who age is less than 16yrs old) before participating in treatment. 2.2 Patients The study was a single-blind randomized controlled trial design, and carried out by the Department of Oral and Maxillofacial Surgery at the Shanxi Medical University School and Hospital of Stomatology from January 2020 to August 2020. The inclusion and exclusion criteria were as follows, and showed in Figure 1A: Ⅰ. Preoperative cone-beam CT examination was performed to identify one embedded mesiodens in the maxillary central incisor region. The length of the mesiodens was 6 to 8 mm, and the diameter of the crown of the mesiodens was 3 to 5 mm. Ⅱ. The mesiodens were all embedded in the high position; that is, the lowest point of the mesiodens was over the root of the adjacent central incisor teeth. Ⅲ. The mesiodens were inverted and were between 0 degrees and 30 degrees to the adjacent central incisor teeth. Ⅳ. The closest distance of labial and palatal bone to the mesiodens was more than 3mm. Ⅴ. The permanent central incisors of all patients have erupted normally. There was no cyst formation around the mesiodens and no symptoms of infection. The gingiva was thick gingival biotype. Ⅵ. All patients were healthy Han Chinese, non-nicotine users, without systemic or genetic disease, and did not take regular medications. Indications for tooth extraction were for orthodontic reasons. Before the operation, thirty patients (1:1:1) were randomly divided into three groups (Figure 1D) according to a table of random numbers produced by computer software: the LA group (via the labial approach), the PA group (via the palatal approach) and the IA group (via the subperiosteal intranasal approach). 2.3 Surgical protocol All patients required a brief hospitalization, and the surgical procedure was performed under general anesthesia. Perform corresponding operations according to the group conditions (Figure 2A). The details were as follows: The LA group: The surgeon should perform an arc incision approximately 1-2mm above the edge of the gingiva on the labial side of the operative area. The incision length was from the left lateral incisor to the right lateral incisor. After opening the mucoperiosteal flap, the labial surface bone of the mesiodens was exposed and removed by the piezosurgery; ten the teeth were sought and identified. After the teeth were separated by the dental high-speed turbine handpieces, the tooth fragments were taken out by the hemostat. The PA group: The surgeon should make a crevicular incision in the palatal gingival sulcus. It was worth noting that attention should be paid to protecting nasopalatine vascular and nerve bundles during the palatine lateral flap. After opening the mucoperiosteal flap, the palatal surface bone of the mesiodens was exposed and removed by the piezosurgery; then the teeth were sought and found. After the teeth were found, the other steps were the same as the labial group. The IA group: The surgeon should perform same incision with the LA group. After mucosal incision, the periosteum was cut to reveal the piriform aperture and the anterior nasal spine. Subperiosteal dissection was then continued in a dorsal direction. The nasal mucosa was elevated from the base of the nasal cavity with a periosteal elevator. The intranasal surface bone of the mesiodens was exposed and removed by the piezosurgery; then the teeth were sought and found. After the teeth were found, the other steps were the same as the labial group. After extraction, the residual dental follicle was removed and the extraction socket was flushed with 60 ml of sterile saline. Lastly, wounds were closed with tension-free interrupted sutures, 3 mm apart. 2.4 Index evaluation The researcher recorded the volume of osteotomy, the amount of bleeding, the total operation time, the time for searching and identifying mesiodens in operation [17-19]. During the postoperative 7-day observational period, the degree of pain (VAS), postoperative swelling, and patient satisfaction (according to OHIP-14) were recorded [20,21]. With the cooperation of oral and maxillofacial surgeons and otolaryngologists, the bilateral nasal inspiratory and expiratory volumes were recorded [22,23]. Before surgery and at 3 and 7 days postoperatively, patients returned for follow-up visits to assess pulp and gingiva blood supply of adjacent teeth [24,25]. The same equipment was used for each patient, and the tests were performed in order of the electrical pulp test, followed by the laser Doppler blood flowmetry (LDF) [26]. The blood flow of gingiva and pulp of central incisor teeth was assessed by the laser speckle contrast imaging (LSCI) [27]. Half a year after surgery, the continuity and gray-values of the cortical bone were evaluated using cone-beam CT examination [28]. 2.5 Statistical analyze SPSS Statistics 25.0 and R package 3.5.0 was applied to analyze the data. Measurement data were expressed as mean ± standard deviation, analysis of variance was used for comparison between multiple groups, and LSD-t method was used for pairwise analysis. Count data were expressed as percentage, and chi-square analysis was used for comparison between groups. P<0.05 was considered as statistically significant difference. Relevant details of sample size, study indicators, and quality control are available in the supplementary materials. 3. Results 3.1 Demographic characteristics Thirty patients (18 male and 12 female) with a mean age of 10.03 ± 1.92 were included in the study. Demographic and surgical characteristics were overall well balanced between study groups (Figure 1B, C and Appendix Table1). 3.2 Surgical time All operations were completed as planned and the surgical time was recorded (Figure 2B, Table 1). The total operative time in the labial approach group, the palatal approach group, and the intranasal approach group were 40.20±5.18 min, 51.90±5.74 min, 40.50±4.33min, respectively. The total operative time was significantly longer in the palatal approach group than in the other two groups. The operative time in the labial approach group was like that in the intranasal group. The time for searching and identifying mesiodens in the labial approach group, the palatal approach group, and the intranasal approach group were 9.40 ± 1.84 min, 12.80 ± 2.90 min, and 5.60 ± 1.17min, respectively. The time for searching and identifying mesiodens in the intranasal approach group was significantly shorter than in the other groups. There is a positive correlation between the total operative time and the time for searching and identifying mesiodens (Figure 2C). Table 1 Intraoperative and Postoperative Characteristic in the LA, PA, and IA Groups. Characteristic Group R 2 P Value LA （ n=10 ） PA(n=10) IA(n=10) Surgical time The total operative time, min 40.20±5.18 51.90±5.74 40.50±4.33 0.5572 <0.0001 The time for searching and identifying mesiodens, min 9.40 ± 1.84 12.80 ± 2.90 5.60 ± 1.17 0.6867 <0.0001 The volume of osteotomy, mm 3 37.37 ± 2.06 84.93 ± 11.31 17.96 ± 4.56 0.9452 <0.0001 The amount of bleeding, ml 11.75 ± 2.17 15.57 ± 3.82 5.69 ±0.87 0.7336 <0.0001 Postoperative swelling The angle of Line1-SnUL The difference between before and 3 days after surgery, ° 8.30±3.59 0.90±0.88 5.20±2.25 0.6210 <0.0001 The difference between before and 7 days after surgery, ° 5.80±0.92 0.20±0.42 1.70±1.42 0.8603 <0.0001 The angle of Line1-ULPg’ The difference between before and 3 days after surgery, ° 12.00±2.87 1.50±3.38 2.70±1.34 0.7743 <0.0001 The difference between before and 7 days after surgery, ° 5.50±2.32 0.20±0.42 0.90±0.88 0.7442 <0.0001 The angle of Line1-SnPg’ The difference between before and 3 days after surgery, ° 6.00±1.70 0.80±0.79 3.60±1.27 0.7465 <0.0001 The difference between before and 7 days after surgery, ° 3.20±1.23 0.60±0.70 1.50±1.08 0.5502 <0.0001 The time of swelling subsiding, day 11.70 ± 3.34 5.80 ± 1.48 7.90 ± 1.60 0.5564 <0.0001 Pulp and gingiva blood supply of adjacent teeth Electric pulp testing 3 days after surgery 13.50±3.41 14.90±3.48 14.30±3.34 0.0305 0.6581 7 days after surgery 14.30±3.86 13.50±5.15 14.30±4.19 0.0080 0.8975 The LDF measurements of adjacent teeth, AU 9.24 ± 2.74 9.15 ± 3.42 8.97 ± 3.19 0.0014 0.9807 The laser speckle contrast imaging The difference of average blood flow (zone A) 4.50±3.44 3.90±1.97 3.70±2.31 0.0180 0.7829 The difference of average blood flow (zone B) 7.70±3.27 6.70±4.35 7.10±3.93 0.0124 0.8455 The time of pain subsiding, day 7.90 ± 2.73 9.20 ± 1.48 5.90 ± 1.85 0.3201 0.0055 The score of patient satisfaction 82.10±5.69 80.30±5.08 89.30±5.21 0.3712 0.0019 Values are presented as mean ± standard deviation. P value refers to the difference among study groups. P value based on One-way ANOVA test. 3.3 The volume of osteotomy The volume of osteotomy is closely related to the postoperative response (Figure 2B, Table 1). The volume of osteotomy in the labial approach group, the palatal approach group, and the intranasal approach group were 37.37 ± 2.06 mm 3 , 84.93 ± 11.31 mm 3 , 17.96 ± 4.56 mm 3 , respectively. Compared with the labial approach group and the palatal approach group, the volume of osteotomy in the intranasal approach group was significantly decreased. 3.4 The amount of bleeding The amount of bleeding in the labial approach group, the palatal approach group, and the intranasal approach group were 11.75 ± 2.17 ml, 15.57 ± 3.82 ml, and 5.69 ±0.87ml, respectively (Figure 2B, Table 1). Compared with the labial approach group and the palatal approach group, the amount of bleeding in the intranasal approach group was significantly decreased. When the surgical field was clear, the safety of the operation was improved, and suffering was reduced for patients. 3.5 Postoperative swelling The time of swelling subsiding of the labial approach group, the palatal approach group, and the intranasal approach group were 11.70 ± 3.34d, 5.80 ± 1.48d, and 7.90 ± 1.60d, respectively. The difference between the postoperative and preoperative angle of Line1-ULPg’, Line1-SnPg’, and Line1-SnUL were shown in Figure 3A-E, and Table 1. Compared with the labial approach group, the lower degree of postoperative swelling in the palatal approach group and the intranasal approach group. 3.6 Pulp and gingiva blood supply of adjacent teeth The postoperative blood supply was well documented (Figure 3F-H, Table 1), which determines wound healing, infection prevention and function of adjacent teeth. At 3 days postoperatively, the value of electric pulp testing of adjacent teeth in the labial approach group, the palatal approach group, and the intranasal approach group were 13.50 ± 3.41, 14.90 ± 3.48, and 14.30 ± 3.34, respectively. There was no a statistically significant difference in the value of electric pulp testing among the three groups. The LDF measurements of adjacent teeth in the labial approach group, the palatal approach group, and the intranasal approach group were 9.24 ± 2.74 AU, 9.15 ± 3.42 AU, and 8.97 ± 3.19 AU, respectively. There was not statistically significant difference in the measurements of the LDF among the three groups. Using the laser speckle contrast imaging, the difference of average blood flow (zone A) in the labial approach group, the palatal approach group, and the subperiosteal intranasal approach group were 4.50 ± 3.44, 3.90 ±1.97, and 3.70 ± 2.31, respectively. By analyzing the three measurements described above, all surgical operations in this study did not affect the pulp and gingiva blood supply of adjacent teeth. 3.7 Postoperative pain Most of the patients had different degrees of pain within 24 hours after surgery (Figure 4C-D, Table 1), and the pain sensation was relieved or even disappeared within 7-10 days. According to VAS, the proportion of severe pain in the labial approach group, the palatal approach group, and the intranasal approach group were 30%, 50% and 10%. The time of pain subsiding of the labial approach group, the palatal approach group, and the intranasal approach group were 7.90 ± 2.73d, 9.20 ± 1.48d, and 5.90 ± 1.85d, respectively. Compared with the labial approach group and the palatal approach group, the severe pain and time of pain subsiding in the intranasal approach group was significantly decreased. 3.8 Patient satisfaction The score of patient satisfaction in the labial approach group, the palatal approach group, and the intranasal approach group were 22.50 ± 3.44, 20.00 ± 2.87, and 9.70 ± 3.47, respectively. There was a statistically significant difference in the score of patient satisfaction among the three groups (Figure 4E, Table 1). Patients in the intranasal approach group had mild postoperative pain and swelling, so the low scores of the OHIP-14 and the high satisfaction were not surprising. 3.9 Nasal ventilation During the surgery, the integrity of the nasal mucosa was carefully examined in the intranasal approach group. At 3 days postoperatively, the mean value of inspiratory volume (IC) was (1.34 ± 0.33) L/20s, and the mean value of expiratory volume (EC) was (1.32 ± 0.32) L/20s in the subperiosteal intranasal approach group. This intranasal approach did not affect the ventilation status of the patients (Figure 4F). 3.10 Tissue recovery Stitches were removed in all patients 7 days after surgery, and all incisions had achieved primary healing (Figure 4A). Half a year after surgery, patients in all three groups showed no significant abnormalities in maxillary development and underwent orthodontic treatment (Figure 4B). The continuity and gray-values of the bone in the socket returned to preoperative levels (Figure 4G). 4. Discussion Mesiodens is the most common form of extra tooth, which are supposed to be prophylactically extracted in mixed or early permanent dentition [4,29]. Generally speaking, the ideal surgical approach of minimally invasive extraction is to dislocate the mesiodens in the direction of its eruption. However, the crown of the high inverted mesiodens is oriented towards the nasal cavity. Extraction of mesiodens in the direction of its eruption would necessitate the destruction of the nasal floor, and some stomatologists fear that damaging the nasal floor structure could lead to several complications [30]. Therefore, most high inverted mesiodens is extracted after massive osteotomy via the labial or palatal approach, taking the price of more facial swelling, pain, or other complications [31]. In this study, three surgical designs (via the labial, palatal, and subperiosteal intranasal approach) were compared firstly in the clinical prospective study. Three aspects of these surgical designs were analyzed: The operation statistics (surgical efficiency and trauma), life quality of postoperative patients, and the operative injury/recovery. In indexes of operation statistics, there was no statistical difference in overall surgical time among the three groups. Compared to the labial approach group and the palatal approach group, the time for searching and identifying the tooth in the subperiosteal intranasal approach group was distinctly shorter. Through the subperiosteal intranasal approach, the surgeon identified the tooth in the shortest possible time, probably related to its clear operation field, the proximity of the incision line to the surgical area, and the absence of concern for the roots of the adjacent teeth when osteotomy. After identifying the mesiodens, the tooth was tied with ligating wire to prevent the tooth from falling into the space, which prolonged the operation time in the first few cases. At present, the surgeons in our research team can improve the operation process by filling the gap behind the affected tooth with gauze to prevent the tooth from falling out into the nasal cavity. Prolonged anesthesia is a predisposing factor of many perioperative complications. Therefore, the operative procedure will be continuously improved to reduce operative time in the future [32]. In this research, the volume of osteotomy and the amount of bleeding in the labial approach group was significantly less than that in the palatal approach group, but considerably more than that in the subperiosteal intranasal group. During extraction of the maxillary high inverted mesiodens, the subperiosteal intranasal group only needed to remove the bone of the circumference of the tooth to allow the mesiodens to be dislocated in the direction of the long axis toward the nasal floor. The reduction of bleeding can also improve the surgical field, which provides convenience to operators. Through the subperiosteal intranasal approach, the area of the flap and the range of osteotomy could be reduced. These results are similar to Hauer’s and Costa’s studies [14,33]. In contrast, the labial and the palatal approach group require grinding at least a bone window approximately 1/2 as long as the long axis of the mesiodens and as wide as the mesiodistal diameters, followed by segmental dislocation. As noted in the Strbac study, optimal surgical access can reduce damage to critical dental structures [34]. More osteotomy significantly increases intraoperative bleeding, which is more pronounced in the palatal approach group, where the field of view is inherently limited. In addition to the focus on surgical efficiency and surgical trauma, the life quality of postoperative patients should not be overlooked [35,36]. In the present study, postoperative facial swelling, pain, and patients' satisfactory rate were further analyzed. The postoperative swelling in the palatal approach group was the least severe among the three groups due to the dense, soft tissue on the palatal side. Compared with the labial approach group and the subperiosteal intranasal group, the degree of swelling in the subperiosteal intranasal approach group was slight, and swelling subsided quickly. Patients in the subperiosteal intranasal group had little postoperative pain and had the highest satisfaction with the treatment. The milder swelling and pain allow patients to begin normal socializing and to work sooner, with unsurprisingly high satisfaction levels. Zheng's study mentioned that the reducing trauma could facilitate the doctor-patient relationship [37]. Unlike past clinical research on dental extraction, this paper provides a unique perspective to focus on the operative injury/ recovery in adjacent tissues. What worries surgeons the most is the damage to the blood supply and peripheral nerve of adjacent teeth during the operation [38]. However，postoperative pulp vitality is not reflected by conventional pulp vitality test，as mentioned in Molnar's study, the detection of LSCI will be helpful in the selection of surgical incision and flap design [27]. In this study, the LDF and LSCI were explored to detect the postoperative pulp and gingiva blood supply of adjacent teeth. And the results showed that all surgical operations in this study did not affect the pulp and gingiva blood supply of adjacent teeth. High inverted mesiodens in the anterior maxillary region is adjacent to the piriform aperture and anterior nasal spine. In some of the patients in this study, the anterior nasal spine was disrupted to a small extent, but there was no postoperative bleeding, swelling, or nasal complications. Cho’s study also agreed on a similar theory that the anterior nasal spine was safe and reliable to osteotomy [39]. At half a year, postoperative CT showed the morphology profile of the adjacent structures was well recovered，which demonstrated the feasibility and practical prospect of the intranasal approach. 5. Conclusion And Future Work This is the first prospective and randomized control study on optimizing surgical procedures of mesiodens extraction. Under the inclusion and exclusion criteria of this study, the extraction of mesiodens by the intranasal approach achieved a new balance between reducing surgical trauma and optimizing postoperative recovery, which was worthy of further study. For the clinician's primary concerns, the surgical time, the volume of osteotomy, and the amount of bleeding in the labial approach group and intranasal approach group were significantly less than that in the palatal approach group. From the patient's perspective, the postoperative swelling and pain in the labial approach were far more than that in the intranasal approach group, with lower satisfaction. The result of pulp and gingiva blood supply of adjacent teeth, nasal respiration, and recovery of nasal floor structure demonstrated the feasibility and practical prospect of the intranasal approach. This study provided reliable support for the choice of extraction of high inverted mesiodens, which contributed to minimizing the operation injury for patients. In subsequent studies, more samples need to be included to further verify the indications for the surgical approach, and extend the follow-up time point to pay attention to the long-term impact of the surgical approach on the development of the patient's dentition and jaw. To improve the operative design, the researchers can proceed from the following aspects. On the one hand, the application of computer-aided design/computer-aided manufacturing (CAD/CAM) and navigation assistant systems has created new opportunities for the development of alveolar surgery [ 40 ]. On the other hand, Efforts are being made to develop special surgical instruments for the nasal floor to better hold the affected tooth in case of accidents. Researchers need to make more efforts to solve above problem. Abbreviations LDF: Laser Doppler blood flowmetry LSCI: Laser speckle contrast imaging Declarations 1. Ethical approval and consent to participants: Written informed consent was obtained from all subjects and their legal guardian (for those who age is less than 16yrs old) before participating in treatment. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments, and approved by the Ethics Committee of Shanxi Medical University School and Hospital of Stomatology (2019SLL022). The study was first registered on 27/12/2021 at chictr.org.cn (ChiCTR2100054777). 2. Consent to publication: We have obtained informed consent from all subjects and their legal guardian(s) for publication of identifying information/images (Fig no.3A and 4 B) in an online open-access publication. 3. Data availability: The data generated in this study was available from Chinese Clinical Trial Registry website ( https://www.chictr.org.cn/hvshowproject.aspx?id=139009 ) and the corresponding author, upon reasonable request. 4. Author contribution: Huifei Li wrote the manuscript. Yongfeng Cheng was involved in drafting the manuscript. Jun Lu, Pengfei Zhang, Yi Ning, Lei Xue, Yuan Zhang, Jie Wang, and Yujia Hao searched the references. Xing Wang were responsible for the design and critical revision of the manuscript. All authors read and approved the final manuscript. 5. Conflict of interest: The authors declare that they have no competing interests. 6. 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Pediatr Dent. 2010;32(4):304-309. Hauer L, Hrusak D, Jambura J, Gencur J, Hosticka L, Andrle P, Posta P. Modified maxillary vestibular approach with subperiostal intranasal dissection for surgical extractions of mesiodentes impacted in the floor of the nasal cavity. J Craniomaxillofac Surg. 2019;47(1):1-5. doi: 10.1016/j.jcms.2018.05.032. Alberto PL. Surgical Exposure of Impacted Teeth. Oral Maxillofac Surg Clin North Am. 2020;32(4):561-70. doi: 10.1016/j.coms.2020.07.008. Sammartino G, Trosino O, Perillo L, Cioffi A, Marenzi G, Mortellaro C. Alternative Transoral Approach for Intranasal Tooth Extraction. J Craniofac Surg. 2011;22(5):1944-945. doi: 10.1097/SCS.0b013e31821151ba. Senes AM, Calvo AM, Colombini-Ishikiriama BL, Gonçalves PZ, Dionísio TJ, Sant'ana E, Brozoski DT, Lauris JR, Faria FA, Santos CF. Efficacy and Safety of 2% and 4% Articaine for Lower Third Molar Surgery. J Dent Res. 2015;94(9 Suppl):166S-73S. doi: 10.1177/0022034515596313. Hu YK, Xie QY, Yang C, Xu GZ. Computer-designed surgical guide template compared with free-hand operation for mesiodens extraction in premaxilla using "trapdoor" method. Medicine (Baltimore). 2017;96(26):e7310. doi: 10.1097/MD.0000000000007310. Gorecki P, Rainsford KD, Taneja P, Bulsara Y, Pearson D, Saund D, Ahmed B, Dietrich T. Submucosal Diclofenac for Acute Postoperative Pain in Third Molar Surgery: A Randomized, Controlled Clinical Trial. J Dent Res. 2018;97(4):381-7. doi: 10.1177/0022034517744207. Gao Y, Lin Z, Rodella LF, Buffoli B, Wu X, Zhou Y. Piezoelectric ultrasonic bone surgery system in the extraction surgery of supernumerary teeth. J Craniomaxillofac Surg. 2014;42(8):1577-82. doi: 10.1016/j.jcms.2014.04.007. Tonetti MS, Cortellini P, Graziani F, Cairo F, Lang NP, Abundo R, Conforti GP, Marquardt S, Rasperini G, Silvestri M, et al. Immediate versus delayed implant placement after anterior single tooth extraction: the timing randomized controlled clinical trial. J Clin Periodontol. 2017;44(2):215-24. doi: 10.1111/jcpe.12666. Epub 2017 Jan 31. Prossegger J, Huber D, Grafetstätter C, Pichler C, Braunschmid H, Weisböck-Erdheim R, Hartl A. Winter Exercise Reduces Allergic Airway Inflammation: A Randomized Controlled Study. Int J Environ Res Public Health. 2019;16(11). doi: 10.3390/ijerph16112040. Huang Y, Bao M, Xiao J, Qiu Z, Wu K. Effects of PM2.5 on Cardio-Pulmonary Function Injury in Open Manganese Mine Workers. Int J Environ Res Public Health. 2019;16(11). doi: 10.3390/ijerph16112017. Strobl H, Haas M, Norer B, Gerhard S, Emshoff R. Evaluation of pulpal blood flow after tooth splinting of luxated permanent maxillary incisors. Dent Traumatol. 2004;20(1):36-41. doi: 10.1046/j.1600-4469.2003.00223.x. Dzeletovic B, Stratimirovic DJ, Stojic D, Djukic LJ. Linear and nonlinear analysis of dental pulp blood flow oscillations in ageing. Int Endod J. 2020;53(8):1033-9. doi: 10.1111/iej.13306. Emshoff R, Emshoff I, Moschen I, Strobl H. Laser Doppler flowmetry of luxated permanent incisors a receiver operator characteristic analysis. J Oral Rehabil. 2004;31(9):866-872. doi: 10.1111/j.1365-2842.2004.01373.x. Molnár E, Molnár B, Lohinai Z, Tóth Z, Benyó Z, Hricisák L, Windisch P, Vág J. Evaluation of Laser Speckle Contrast Imaging for the Assessment of Oral Mucosal Blood Flow following Periodontal Plastic Surgery: An Exploratory Study. Biomed Res Int. 2017;2017:4042902. doi: 10.1155/2017/4042902. Ha EG, Jeon KJ, Kim YH, Kim JY, Han SS. Automatic detection of mesiodens on panoramic radiographs using artificial intelligence. Sci Rep. 2021;11(1):23061. doi: 10.1038/s41598-021-02571-x. Cogulu D, Yetkiner E, Akay C, Seckin O, Alpoz R. Multidisciplinary management and long term follow up of mesiodens a case report. J Clin Pediatr Dent. 2008;33(1):63-66. doi: 10.17796/jcpd.33.1.212p1q4156625122. Colak H, Uzgur R, Tan E, Hamidi MM, Turkal M, Colak T. Investigation of prevalence and characteristics of mesiodens in a non-syndromic 11256 dental outpatients. Eur Rev Med Pharmacol Sci. 2013;17(19):2684-2689. Sanei-Moghaddam A, Hyde N, Williamson P. Endoscopic removal of a supernumerary tooth from the nasal cavity in an adult. Br J Oral Maxillofac Surg. 2009;47(6):484-5. doi: 10.1016/j.bjoms.2009.04.036. Farwell DG, Reilly DF, Weymuller EA Jr, Greenberg DL, Staiger TO, Futran NA. Predictors of perioperative complications in head and neck patients. Arch Otolaryngol Head Neck Surg. 2002;128(5):505-511. doi: 10.1001/archotol.128.5.505. Costa SM, de Jesus AO, Silveira RL, Amaral MBF. Supernumerary nasal tooth removed with a modified maxillary vestibular approach: case report and literature review. Oral Maxillofac Surg. 2019;23(2):247-52. doi: 10.1007/s10006-019-00763-4. Strbac GD, Schnappauf A, Bertl MH, Vasak C, Ulm C, Giannis K. Guided Osteotomy and Guided Autotransplantation for Treatment of Severely Impacted Teeth: A Proof-of-Concept Report. J Endod. 2020;46(11):1791-8. doi: 10.1016/j.joen.2020.07.024. Caltabiano ML, Croker F, Page L, Sklavos A, Spiteri J, Hanrahan L, et al. Dental anxiety in patients attending a student dental clinic. BMC Oral Health. 2018;18(1):48. doi: 10.1186/s12903-018-0507-5. Lopez-Jornet P, Camacho-Alonso F, Sanchez-Siles M. Assessment of general pre and postoperative anxiety in patients undergoing tooth extraction: a prospective study. Br J Oral Maxillofac Surg. 2014;52(1):18-23. doi: 10.1016/j.bjoms.2013.01.004. Zheng X, Zhao J, Liu S, Wang Z, Jia B, Lin X. Application of a surgical guide in the extraction of impacted mesiodentes: a randomized controlled trial. Clin Oral Investig. 2021;25(5):2999-3006. doi: 10.1007/s00784-020-03620-x. Schreiber A, Mattavelli D, Ferrari M, Rampinelli V, Lancini D, Ravanelli M, Bertazzoni G, Rodella LF, Buffoli B, Doglietto F,et al. Anterior superior alveolar nerve injury after extended endoscopic medial maxillectomy: a preclinical study to predict neurological morbidity. Int Forum Allergy Rhinol. 2017;7(10):1014-21. doi: 10.1002/alr.22001. Cho YS, Hwang KG, Park CJ. Postoperative effects of anterior nasal spine bone harvesting on overall nasal shape. Clin Oral Implants Res. 2013;24(6):618-22. doi: 10.1111/j.1600-0501.2012.02428.x. Louvrier A, Marty P, Barrabé A, Euvrard E, Chatelain B, Weber E, Meyer C. How useful is 3D printing in maxillofacial surgery? J Stomatol Oral Maxillofac Surg. 2017;118(4):206-12. doi: 10.1016/j.jormas.2017.07.002. Additional Declarations No competing interests reported. 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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-1590128","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":109134760,"identity":"d0810b2c-b2d3-4b0e-bed0-7126415537bf","order_by":0,"name":"Huifei Li","email":"","orcid":"","institution":"Shanxi Medical University School and Hospital of Stomatology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Huifei","middleName":"","lastName":"Li","suffix":""},{"id":109134761,"identity":"6b56e8e5-be14-4f7a-aa4f-b42bed905527","order_by":1,"name":"Yongfeng Cheng","email":"","orcid":"","institution":"Shanxi Medical University School and Hospital of Stomatology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yongfeng","middleName":"","lastName":"Cheng","suffix":""},{"id":109134762,"identity":"c5730c10-813e-4e03-8c20-fedb8dd4c4b8","order_by":2,"name":"Jun Lu","email":"","orcid":"","institution":"Shanxi Medical University School and Hospital of Stomatology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Lu","suffix":""},{"id":109134763,"identity":"3f793386-b638-4640-8475-d0cbac27f573","order_by":3,"name":"Pengfei Zhang","email":"","orcid":"","institution":"Shanxi Medical University School and Hospital of Stomatology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Pengfei","middleName":"","lastName":"Zhang","suffix":""},{"id":109134764,"identity":"29ab6ce0-38a5-4a09-b3fb-06dfc7099c77","order_by":4,"name":"Yi Ning","email":"","orcid":"","institution":"Shanxi Medical University School and Hospital of Stomatology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Ning","suffix":""},{"id":109134765,"identity":"73324819-4e3d-45ec-88e5-ba18670043af","order_by":5,"name":"Lei Xue","email":"","orcid":"","institution":"Shanxi Medical University School and Hospital of Stomatology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Xue","suffix":""},{"id":109134766,"identity":"7207bb44-5c5c-47a3-b838-8b5c676f6cbb","order_by":6,"name":"Yuan Zhang","email":"","orcid":"","institution":"Shanxi Medical University School and Hospital of Stomatology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Zhang","suffix":""},{"id":109134767,"identity":"2512f289-ac7e-4b64-9631-8728181969c6","order_by":7,"name":"Jie Wang","email":"","orcid":"","institution":"Shanxi Medical University School and Hospital of Stomatology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jie","middleName":"","lastName":"Wang","suffix":""},{"id":109134768,"identity":"8d8089b6-6da9-4f60-a12e-95873295097b","order_by":8,"name":"Yujia Hao","email":"","orcid":"","institution":"Shanxi Medical University School and Hospital of Stomatology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yujia","middleName":"","lastName":"Hao","suffix":""},{"id":109134769,"identity":"893b6835-489a-413a-81ed-3c4877aba5d2","order_by":9,"name":"Xing Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYNACAwYGfiiTsYFoLZINpGkB6TpArBaD42cPv+YpuGO3+fwZ0808DDayGw4wP3uAV8uZvDTLGQbPkrfdSEu7zcOQZrzhAJu5AT4tZgdyzAw+GBxONrvBfAyo5XDihgM8bBJ4tZx/Y2aQANRi3H+wDajlPxFabuQYPwDaYmfAkAyy5QBhLfY33pgxzjA4nCAB9MvNOQbJxjMPs5nh1SLZn2P8mefPYXv+/jNmN95U2Mn2HW9+hlcLEICdkdgAZoOCipmAepCSDyAHElY3CkbBKBgFIxYAAII7TdS15Oy8AAAAAElFTkSuQmCC","orcid":"","institution":"Shanxi Medical University School and Hospital of Stomatology","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Xing","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2022-04-24 13:44:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1590128/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1590128/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":22259618,"identity":"6b0a1bd7-d3df-4806-93fd-f69a20eec35e","added_by":"auto","created_at":"2022-06-04 19:52:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":409426,"visible":true,"origin":"","legend":"\u003cp\u003eStudy design and inclusion criteria. (A) Inclusion criteria of the study subjects. (B) Age characteristics of the LA group, the PA group, and the IA group. (C) Sex characteristics. (D) Study flowchart.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-1590128/v1/39479831a284122a2f9a4cdd.png"},{"id":22259614,"identity":"f529ee73-e626-4544-bd45-edda08e46fbd","added_by":"auto","created_at":"2022-06-04 19:52:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1647944,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical protocol and intraoperative indicators. (A) Specific surgical procedure of the LA group, the PA group, and the IA group. (B) Intraoperative indicators: the total operative time, the time for searching and identifying mesiodens, the amount of bleeding and the volume of osteotomy. (C) Correlation between the total operative time and the time for searching and identifying mesiodens. *p \u0026lt; 0.05.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-1590128/v1/d5d8cf4420f9e910247b8473.png"},{"id":22259616,"identity":"563ce396-7ae4-4534-9c10-3fc992ad8ddd","added_by":"auto","created_at":"2022-06-04 19:52:24","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":583036,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative swelling and pulp and gingiva blood supply of adjacent teeth. (A) Pattern diagram for swelling curve measurements (Informed consent from all subjects and/or their legal guardian(s) have been obtained before treatment). (B-D) The difference between the postoperative and preoperative angle of Line1-SnUL, Line1-ULPg’and Line1-SnPg’. (E) The time of swelling subsiding. (F) LSCI images. (G) Pulp vitality related measurements: the difference of average blood flow (zone A), the difference of average blood flow (zone B), the LDF measurements, and the value of electric pulp testing. (H) Principal components analysis of the electric pulp testing, the LDF and the LSCI. *p \u0026lt; 0.05.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-1590128/v1/740f15a29dfd71826b902001.png"},{"id":22259613,"identity":"0c978f76-52fb-468d-838b-35f21582d603","added_by":"auto","created_at":"2022-06-04 19:52:23","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1251926,"visible":true,"origin":"","legend":"\u003cp\u003ePartial postoperative indicators and tissue recovery. (A) Soft tissue recovery. (B) The changes of soft tissue profile and tooth socket during follow-up at 6 months (Informed consent from all subjects and/or their legal guardian(s) have been obtained before treatment). (C) The time of pain subsiding. (E) VAS. (F) The score of patient satisfaction. (G) The volume of nasal ventilation. (H) The gray-values of the bone in the socket. *p \u0026lt; 0.05.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-1590128/v1/45367e4cda70bf0ea80fd3b4.png"},{"id":26648198,"identity":"38d2f026-a9fb-40a9-961d-e545dd6e0891","added_by":"auto","created_at":"2022-09-19 12:29:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2867534,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1590128/v1/3034a81b-fa31-47cc-928e-8652ad001bba.pdf"},{"id":22259760,"identity":"2aae7fc9-141d-4e8b-a708-5ea559b2eab2","added_by":"auto","created_at":"2022-06-04 19:57:23","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22660,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-1590128/v1/9d87442691d1f70b0b47c58a.docx"},{"id":22259761,"identity":"bd8cb6f3-955b-4219-9ec8-8a2d584956df","added_by":"auto","created_at":"2022-06-04 19:57:24","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":38896,"visible":true,"origin":"","legend":"","description":"","filename":"rawdata.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-1590128/v1/f6c5a170954091fc5f5a1aa5.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Extraction of high inverted mesiodens via the labial, palatal and subperiostal intranasal approach：A clinical prospective study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eSupernumerary teeth are extra teeth or tooth-like structures that vary in size, shape, and number in addition to the normal dentition [1,2]. When supernumerary teeth appear in the center of the jaw, either in deciduous or permanent dentition, they are called mesiodens [3]. The prevalence of mesiodens globally averages 0.15-1.9%, accounting for about 46-67% of the total number of supernumerary teeth [3].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eOcclusion disorders are the most common complication of mesiodens, manifested as retarded eruption of permanent teeth, significant crowding or spacing of the anterior teeth [4]. Occasionally, mesiodens cause odontogenic cysts or ameloblastoma, leading to apical root resorption of the adjacent teeth, bone destruction, and even dento-maxillofacial deformities [5-7]. Most scholars believed that mesiodens, especially inverted mesiodens, should be prophylactically extracted\u0026nbsp;in mixed or early permanent dentition [8-10].\u003c/p\u003e\n\u003cp\u003eMesiodens are classified into six types according to their position and direction relative to the incisor [11]. In general, the higher and deeper position in bone, the closer to the apical root of the adjacent teeth, the more complication risk is involved in tooth extraction. In type IV, the mesiodens are located superior to the root apex of the adjacent incisors (high position and inverted oriented), which frequently led to increase postoperative complication rates such as severe pain, facial swelling, and decreased pulp vitality of adjacent teeth [12]. In addition to these perioperative surgical trauma, excessive surgical trauma could even affect the normal growth and development of the dentitions and jaws of children [13].\u003c/p\u003e\n\u003cp\u003eExtraction of high inverted mesiodens is usually done via the labial or palatal approach [14,15].\u0026nbsp;The main advantage of the traditional labial approach is that it provides an excellent surgical view, reducing surgical stress. But for extraction of high inverted mesiodens, osteotomy in the anterior maxillary area is likely to exacerbate the problem of postoperative swelling and pain. If the surgeon selects the palatal approach, there are fewer aesthetic problems in the anterior maxillary area, and the postoperative swelling degree is slight. While the extensive osteotomy and prolonged operation may decrease the blood supply and pulp vitality of the adjacent teeth. It is difficult to strike a balance between reducing surgical trauma and focusing more on the patient\u0026apos;s quality of life after surgery. Up to now, there is no generally accepted surgical procedure to minimize operation injury for high inverted mesiodens.\u003c/p\u003e\n\u003cp\u003eIn 2011, a new surgical design named the modified maxillary vestibular approach with subperiosteal intranasal dissection was described by Sammartino G. et al. in a case reported [16]. However, this surgical design has not been intensively studied over the past decade, partly because some stomatologists worry about damaging nasal floor structure, breaking through nasal mucosa into the trachea, or even airway obstruction caused by misplacing mesiodens. Because of the limit of small clinical data, there is relatively inadequate and a lacks of systematic, comprehensive understanding of the indications, intraoperative safety, operation effect, and postoperative complications of this surgical design.\u003c/p\u003e\n\u003cp\u003eThis is the first prospective randomized study on the selection and optimization of surgical approach design to extract high inverted mesiodens. Three different surgical designs (via the labial, palatal, and subperiosteal intranasal approach) were compared by the operation statistics, life quality of postoperative patients, and the operative injury/recovery. This study provides reliable support for the choice of extraction of high inverted mesiodens, which will contribute to minimizing the operation injury for patients.\u003c/p\u003e"},{"header":"2. Materials And Methods","content":"\u003cp\u003e\u003cstrong\u003e2.1 Ethics Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments, and approved by the Ethics Committee of\u0026nbsp;Shanxi Medical University School and Hospital of Stomatology\u0026nbsp;(2019SLL022). The study was first registered on 27/12/2021 at chictr.org.cn\u0026nbsp;(ChiCTR2100054777). Written informed consent was obtained from all subjects and their legal guardian (for those who age is less than 16yrs old) before participating in treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was a single-blind randomized controlled trial design, and carried out by the Department of Oral and Maxillofacial Surgery at the\u0026nbsp;Shanxi Medical University School and Hospital of Stomatology\u0026nbsp;from January 2020 to August 2020.\u003c/p\u003e\n\u003cp\u003eThe inclusion and exclusion criteria were as follows, and showed in Figure 1A:\u003c/p\u003e\n\u003cp\u003eⅠ. Preoperative cone-beam CT examination was performed to identify one embedded mesiodens in the maxillary central incisor region. The length of the mesiodens was 6 to 8 mm, and the diameter of the crown of the mesiodens was 3 to 5 mm.\u003c/p\u003e\n\u003cp\u003eⅡ. The mesiodens were all embedded in the high position; that is, the lowest point of the mesiodens was over the root of the adjacent central incisor teeth.\u003c/p\u003e\n\u003cp\u003eⅢ. The mesiodens were inverted and were between 0 degrees and 30 degrees to the adjacent central incisor teeth.\u003c/p\u003e\n\u003cp\u003eⅣ. The closest distance of labial and palatal bone to the mesiodens was more than 3mm.\u003c/p\u003e\n\u003cp\u003eⅤ. The permanent central incisors of all patients have erupted normally. There was no cyst formation around the mesiodens and no symptoms of infection. The gingiva was thick gingival biotype.\u003c/p\u003e\n\u003cp\u003eⅥ. All patients were healthy Han Chinese, non-nicotine users, without systemic or genetic disease, and did not take regular medications. Indications for tooth extraction were for orthodontic reasons.\u003c/p\u003e\n\u003cp\u003eBefore the operation, thirty patients (1:1:1) were randomly divided into three groups (Figure 1D) according to a table of random numbers produced by computer software: the LA group (via the labial approach),\u0026nbsp;the\u0026nbsp;PA group (via the palatal approach) and the IA group (via the\u0026nbsp;subperiosteal intranasal\u0026nbsp;approach).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eSurgical protocol\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients required a brief hospitalization, and the surgical procedure was performed under general anesthesia. Perform corresponding operations according to the group conditions (Figure 2A).\u0026nbsp;The details were as follows:\u003c/p\u003e\n\u003cp\u003eThe LA group: The surgeon should perform an arc incision approximately 1-2mm above the edge of the gingiva on the labial side of the operative area. The incision length was from the left lateral incisor to the right lateral incisor. After opening the mucoperiosteal flap, the labial surface bone of the mesiodens was exposed and removed by the piezosurgery; ten the teeth were sought and identified. After the teeth were separated by the dental high-speed turbine handpieces, the tooth fragments were taken out by the hemostat.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe PA group: The surgeon should make a crevicular incision in the palatal gingival sulcus. It was worth noting that attention should be paid to protecting nasopalatine vascular and nerve bundles during the palatine lateral flap. After opening the mucoperiosteal flap, the palatal surface bone of the mesiodens was exposed and removed by the piezosurgery; then the teeth were sought and found. After the teeth were found, the other steps were the same as the labial group.\u003c/p\u003e\n\u003cp\u003eThe IA group: The surgeon should perform same incision with the LA group. After mucosal incision, the periosteum was cut to reveal the piriform aperture and the anterior nasal spine. Subperiosteal dissection was then continued in a dorsal direction. The nasal mucosa was elevated from the base of the nasal cavity with a periosteal elevator. The intranasal surface bone of the mesiodens was exposed and removed by the piezosurgery; then the teeth were sought and found. After the teeth were found, the other steps were the same as the labial group.\u003c/p\u003e\n\u003cp\u003eAfter extraction, the residual dental follicle was removed and the extraction socket was flushed with 60 ml of sterile saline.\u0026nbsp;Lastly, wounds were closed with tension-free interrupted sutures, 3 mm apart.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Index evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe researcher recorded the volume of osteotomy, the amount of bleeding, the total operation time, the time for searching and identifying mesiodens in operation\u0026nbsp;[17-19].\u0026nbsp;During the postoperative 7-day observational period, the degree of pain (VAS), postoperative swelling, and patient satisfaction (according to OHIP-14) were recorded\u0026nbsp;[20,21]. With the cooperation of oral and maxillofacial surgeons and otolaryngologists, the bilateral nasal inspiratory and expiratory volumes were recorded\u0026nbsp;[22,23]. Before surgery and at 3 and 7 days postoperatively, patients returned for follow-up visits to assess pulp and gingiva blood supply of adjacent teeth\u0026nbsp;[24,25].\u0026nbsp;The same equipment was used for each patient, and the tests were performed in order of the electrical pulp test, followed by the laser Doppler blood flowmetry (LDF)\u0026nbsp;[26].\u0026nbsp;The blood flow of gingiva and pulp of central incisor teeth was assessed by the laser speckle contrast imaging (LSCI)\u0026nbsp;[27]. Half a year after surgery, the continuity and gray-values of the cortical bone were evaluated using cone-beam CT examination\u0026nbsp;[28].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eStatistical analyze\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSPSS Statistics 25.0 and R package 3.5.0\u0026nbsp;was applied to analyze the data. Measurement data were expressed as mean \u0026plusmn; standard deviation, analysis of variance was used for comparison between multiple groups, and LSD-t method was used for pairwise analysis. Count data were expressed as percentage, and chi-square analysis was used for comparison between groups. P\u0026lt;0.05 was considered as statistically significant difference.\u003c/p\u003e\n\u003cp\u003eRelevant details of sample size, study indicators, and quality control are available in the supplementary materials.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Demographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThirty patients (18 male and 12 female) with a mean age of 10.03 \u0026plusmn; 1.92 were included in the study.\u0026nbsp;Demographic and surgical characteristics were overall well balanced between study groups (Figure 1B, C and Appendix Table1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Surgical time\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll operations were completed as planned and the surgical time was recorded\u0026nbsp;(Figure 2B, Table 1).\u0026nbsp;The total operative time\u0026nbsp;in\u0026nbsp;the labial approach group, the palatal approach group, and the intranasal approach group were 40.20\u0026plusmn;5.18 min, 51.90\u0026plusmn;5.74 min, 40.50\u0026plusmn;4.33min, respectively.\u0026nbsp;The total operative time was significantly longer in the palatal approach group than in the other two groups. The operative time in the labial approach group was like that in the\u0026nbsp;intranasal group. The time for searching and identifying mesiodens\u0026nbsp;in the labial approach group, the palatal approach group, and the intranasal\u0026nbsp;approach group were 9.40 \u0026plusmn; 1.84 min, 12.80 \u0026plusmn; 2.90 min, and 5.60 \u0026plusmn; 1.17min, respectively.\u0026nbsp;The time for searching and identifying mesiodens in the\u0026nbsp;intranasal approach group was significantly shorter than in the other groups. There is a positive correlation between the total operative time and the time for searching and identifying mesiodens\u0026nbsp;(Figure 2C).\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eIntraoperative and Postoperative Characteristic in the LA, PA, and IA Groups.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u003cstrong\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"32.5%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLA\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003en=10\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"32.5%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePA(n=10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"35%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIA(n=10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical time\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe total operative time, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e40.20\u0026plusmn;5.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e51.90\u0026plusmn;5.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e40.50\u0026plusmn;4.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.5572\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe time for searching and identifying mesiodens, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e9.40 \u0026plusmn; 1.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e12.80 \u0026plusmn; 2.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e5.60 \u0026plusmn; 1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.6867\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe volume of osteotomy, mm\u003csup\u003e3\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e37.37 \u0026plusmn; 2.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e84.93 \u0026plusmn; 11.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e17.96 \u0026plusmn; 4.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.9452\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe amount of bleeding, ml\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e11.75 \u0026plusmn; 2.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e15.57 \u0026plusmn; 3.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e5.69 \u0026plusmn;0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.7336\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative swelling\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe angle of Line1-SnUL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe difference between before and 3 days after surgery, \u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e8.30\u0026plusmn;3.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.90\u0026plusmn;0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e5.20\u0026plusmn;2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.6210\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe difference between before and 7 days after surgery, \u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e5.80\u0026plusmn;0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.20\u0026plusmn;0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e1.70\u0026plusmn;1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.8603\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe angle of Line1-ULPg\u0026rsquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe difference between before and 3 days after surgery, \u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e12.00\u0026plusmn;2.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e1.50\u0026plusmn;3.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e2.70\u0026plusmn;1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.7743\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe difference between before and 7 days after surgery, \u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e5.50\u0026plusmn;2.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.20\u0026plusmn;0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e0.90\u0026plusmn;0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.7442\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe angle of Line1-SnPg\u0026rsquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe difference between before and 3 days after surgery, \u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e6.00\u0026plusmn;1.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.80\u0026plusmn;0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e3.60\u0026plusmn;1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.7465\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe difference between before and 7 days after surgery, \u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e3.20\u0026plusmn;1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.60\u0026plusmn;0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e1.50\u0026plusmn;1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.5502\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe time of swelling subsiding, day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e11.70 \u0026plusmn; 3.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e5.80 \u0026plusmn; 1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e7.90 \u0026plusmn; 1.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.5564\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePulp and gingiva blood supply of adjacent teeth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eElectric pulp testing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003e3 days after surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e13.50\u0026plusmn;3.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e14.90\u0026plusmn;3.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e14.30\u0026plusmn;3.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.0305\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e0.6581\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003e7 days after surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e14.30\u0026plusmn;3.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e13.50\u0026plusmn;5.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e14.30\u0026plusmn;4.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.0080\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e0.8975\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe LDF measurements of adjacent teeth, AU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e9.24 \u0026plusmn; 2.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e9.15 \u0026plusmn; 3.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e8.97 \u0026plusmn; 3.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.0014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e0.9807\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe laser speckle contrast imaging\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe difference of average blood flow (zone A)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e4.50\u0026plusmn;3.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e3.90\u0026plusmn;1.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e3.70\u0026plusmn;2.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.0180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e0.7829\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003eThe difference of average blood flow (zone B)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e7.70\u0026plusmn;3.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e6.70\u0026plusmn;4.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e7.10\u0026plusmn;3.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.0124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e0.8455\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe time of pain subsiding, day\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e7.90 \u0026plusmn; 2.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e9.20 \u0026plusmn; 1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e5.90 \u0026plusmn; 1.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.3201\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e0.0055\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.673469387755105%\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe score of patient satisfaction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e82.10\u0026plusmn;5.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e80.30\u0026plusmn;5.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp\u003e89.30\u0026plusmn;5.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.26530612244898%\"\u003e\n \u003cp\u003e0.3712\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.244897959183673%\"\u003e\n \u003cp\u003e0.0019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eValues are presented as mean \u0026plusmn; standard deviation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value refers to the difference among study groups.\u0026nbsp;\u003cem\u003eP\u003c/em\u003e value based on One-way ANOVA test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 The volume of osteotomy\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe volume of osteotomy is closely related to the postoperative response\u0026nbsp;(Figure 2B, Table 1). The volume of osteotomy\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ein\u0026nbsp;the labial approach group, the palatal approach group, and the intranasal approach group were 37.37 \u0026plusmn; 2.06 mm\u003csup\u003e3\u003c/sup\u003e, 84.93 \u0026plusmn; 11.31 mm\u003csup\u003e3\u003c/sup\u003e, 17.96 \u0026plusmn; 4.56 mm\u003csup\u003e3\u003c/sup\u003e, respectively. Compared with the labial approach group and the palatal approach group, the volume of osteotomy in the intranasal approach group was significantly decreased.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 The amount of bleeding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe amount of bleeding in the labial approach group,\u0026nbsp;the palatal approach group,\u0026nbsp;and the intranasal approach group were 11.75 \u0026plusmn; 2.17 ml, 15.57 \u0026plusmn; 3.82 ml, and 5.69 \u0026plusmn;0.87ml, respectively\u0026nbsp;(Figure 2B, Table 1).\u0026nbsp;Compared with the labial approach group and the palatal approach group, the amount of bleeding in the intranasal approach group was significantly decreased.\u0026nbsp;When the surgical field was clear, the safety of the operation was improved, and suffering was reduced for patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.5 Postoperative swelling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe time of swelling subsiding\u0026nbsp;of the labial approach group,\u0026nbsp;the palatal approach group,\u0026nbsp;and the intranasal approach group were 11.70 \u0026plusmn; 3.34d, 5.80 \u0026plusmn; 1.48d, and 7.90 \u0026plusmn; 1.60d, respectively.\u0026nbsp;The difference between the postoperative and preoperative angle of Line1-ULPg\u0026rsquo;, Line1-SnPg\u0026rsquo;, and Line1-SnUL\u0026nbsp;were shown in Figure 3A-E, and Table 1.\u0026nbsp;Compared with the labial approach group, the lower degree of postoperative swelling in\u0026nbsp;the palatal approach group and the intranasal approach group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.6 Pulp and gingiva blood supply of adjacent teeth\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe postoperative blood supply was well documented (Figure 3F-H, Table 1), which determines wound healing, infection prevention and function of adjacent teeth. At 3 days postoperatively, the value of electric pulp testing of adjacent teeth in the labial approach group, the palatal approach group, and the intranasal approach group were 13.50 \u0026plusmn; 3.41, 14.90 \u0026plusmn; 3.48, and 14.30 \u0026plusmn; 3.34, respectively. There was no a statistically significant difference in the value of electric pulp testing among the three groups. The LDF measurements of adjacent teeth\u0026nbsp;in the labial approach group, the palatal approach group, and the intranasal approach group were 9.24 \u0026plusmn; 2.74 AU, 9.15 \u0026plusmn; 3.42 AU, and 8.97 \u0026plusmn; 3.19 AU, respectively. There was not statistically significant difference in the measurements of the LDF among the three groups. Using the laser speckle contrast imaging, the difference of average\u0026nbsp;blood flow\u0026nbsp;(zone A) in the labial approach group, the palatal approach group, and the subperiosteal intranasal approach group were 4.50 \u0026plusmn; 3.44, 3.90 \u0026plusmn;1.97, and 3.70 \u0026plusmn; 2.31, respectively. By analyzing the three measurements described above, all surgical operations in this study did not affect the pulp and gingiva blood supply of adjacent teeth.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.7 Postoperative pain\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost of the patients had different degrees of pain within 24 hours after surgery\u0026nbsp;(Figure 4C-D, Table 1), and the pain sensation was relieved or even disappeared within 7-10 days. According to VAS, the proportion of severe pain in the labial approach group, the palatal approach group, and the intranasal approach group were 30%, 50% and 10%. The time of pain subsiding of the labial approach group, the palatal approach group, and the intranasal approach group were 7.90 \u0026plusmn; 2.73d, 9.20 \u0026plusmn; 1.48d, and 5.90 \u0026plusmn; 1.85d, respectively. Compared with the labial approach group and the palatal approach group, the severe pain and time of pain subsiding in the intranasal approach group was significantly decreased.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.8 Patient satisfaction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe score of patient satisfaction in the labial approach group, the palatal approach group, and the intranasal approach group were 22.50 \u0026plusmn; 3.44, 20.00 \u0026plusmn; 2.87, and 9.70 \u0026plusmn; 3.47, respectively.\u0026nbsp;There was a statistically significant difference in the score of patient satisfaction among the three groups (Figure 4E, Table 1).\u0026nbsp;Patients in the intranasal approach group had mild postoperative pain and swelling, so the low scores of the OHIP-14 and the high satisfaction were not surprising.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.9 Nasal ventilation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the surgery, the integrity of the nasal mucosa was carefully examined in the intranasal approach group. At 3 days postoperatively, the mean value of inspiratory volume (IC) was (1.34 \u0026plusmn; 0.33) L/20s, and the mean value of expiratory volume (EC) was (1.32 \u0026plusmn; 0.32) L/20s in the subperiosteal intranasal approach group. This intranasal approach did not affect the ventilation status of the patients\u0026nbsp;(Figure 4F).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.10 Tissue recovery\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStitches were removed in all patients 7 days after surgery, and all incisions had achieved primary healing (Figure 4A). Half a year after surgery, patients in all three groups showed no significant abnormalities in maxillary development and underwent orthodontic treatment (Figure 4B). The continuity and gray-values of the bone in the socket returned to preoperative levels (Figure 4G).\u0026nbsp;\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eMesiodens is the most common form of extra tooth, which are supposed to be prophylactically extracted in mixed or early permanent dentition\u0026nbsp;[4,29].\u0026nbsp;Generally speaking, the ideal surgical approach of minimally invasive extraction is to dislocate the mesiodens in the direction of its eruption.\u0026nbsp;However, the crown of the high inverted mesiodens is oriented towards the nasal cavity.\u0026nbsp;Extraction of mesiodens in the direction of its eruption would necessitate the destruction of the nasal floor, and some stomatologists fear that damaging the nasal floor structure could lead to several complications\u0026nbsp;[30].\u0026nbsp;Therefore, most high inverted mesiodens is extracted after massive osteotomy via the labial or palatal approach, taking the price of more facial swelling, pain, or other complications\u0026nbsp;[31].\u003c/p\u003e\n\u003cp\u003eIn this study, three surgical designs (via the labial, palatal, and subperiosteal intranasal approach) were compared firstly in the clinical prospective study. Three aspects of these surgical designs were analyzed: The operation statistics (surgical efficiency and trauma), life quality of postoperative patients, and the operative injury/recovery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn indexes of operation statistics, there was no statistical difference in overall surgical time among the three groups.\u0026nbsp;Compared to the labial approach group and the palatal approach group, the time for searching and identifying the tooth in the subperiosteal intranasal approach group was distinctly shorter.\u0026nbsp;Through the\u0026nbsp;subperiosteal intranasal approach, the surgeon identified the tooth in the shortest possible time, probably related to its clear operation field, the proximity of the incision line to the surgical area, and the absence of concern for the roots of the adjacent teeth when osteotomy.\u0026nbsp;After identifying the mesiodens, the tooth was tied with ligating wire to prevent the tooth from falling into the space, which prolonged the operation time\u0026nbsp;in the first few cases. At present, the surgeons in our research team can improve the operation process by filling the gap behind the affected tooth with gauze to prevent the tooth from falling out into the nasal cavity.\u0026nbsp;Prolonged anesthesia is a predisposing factor of many perioperative complications. Therefore, the operative procedure will be continuously improved to reduce operative time in the future\u0026nbsp;[32].\u003c/p\u003e\n\u003cp\u003eIn this research, the volume of osteotomy and the amount of bleeding in the labial approach group was significantly less than that in the palatal approach group, but considerably more than that in the subperiosteal intranasal group. During extraction of the maxillary high inverted mesiodens, the subperiosteal intranasal group only needed to remove the bone of the circumference of the tooth to allow the mesiodens to be dislocated in the direction of the long axis toward the nasal floor. The reduction of bleeding can also improve the surgical field, which provides convenience to operators. Through the subperiosteal intranasal approach,\u0026nbsp;the area of the flap and the range of osteotomy could be reduced. These results are similar to Hauer\u0026rsquo;s and Costa\u0026rsquo;s studies\u0026nbsp;[14,33]. In contrast, the labial and the palatal approach group require grinding at least a bone window approximately 1/2 as long as the long axis of the mesiodens and as wide as the\u0026nbsp;mesiodistal diameters, followed by segmental dislocation. As noted in the Strbac study, optimal surgical access can reduce damage to critical dental structures\u0026nbsp;[34]. More osteotomy significantly increases intraoperative bleeding, which is more pronounced in the palatal approach group, where the field of view is inherently limited.\u003c/p\u003e\n\u003cp\u003eIn addition to the focus on surgical efficiency and surgical trauma,\u0026nbsp;the life quality of postoperative patients should not be overlooked\u0026nbsp;[35,36]. In the present study, postoperative facial swelling, pain, and patients\u0026apos; satisfactory rate were further analyzed.\u0026nbsp;The postoperative swelling in the palatal approach group was the least severe among the three groups due to the dense, soft tissue on the palatal side.\u0026nbsp;Compared with the labial approach group and the subperiosteal intranasal group, the degree of swelling in the subperiosteal intranasal approach group was slight, and swelling subsided quickly. Patients in the\u0026nbsp;subperiosteal intranasal group had little postoperative pain and had the highest satisfaction with the treatment.\u0026nbsp;The milder swelling and pain allow patients to begin normal socializing and to work sooner, with unsurprisingly high satisfaction levels. Zheng\u0026apos;s study mentioned that the reducing trauma could facilitate the doctor-patient relationship\u0026nbsp;[37].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUnlike past clinical research on dental extraction, this paper provides a unique perspective to focus on the operative injury/ recovery in adjacent tissues. What worries surgeons the most is the damage to the blood supply and peripheral nerve of adjacent teeth during the operation [38]. However，postoperative pulp vitality is not reflected by conventional pulp vitality test，as mentioned in Molnar\u0026apos;s study, the detection of LSCI will be helpful in the selection of surgical incision and flap design [27]. In this study, the LDF and LSCI were explored to detect the postoperative pulp and gingiva blood supply of adjacent teeth. And the results showed that all surgical operations in this study did not affect the pulp and gingiva blood supply of adjacent teeth. High inverted mesiodens in the anterior maxillary region is adjacent to the piriform aperture and anterior nasal spine. In some of the patients in this study, the anterior nasal spine was disrupted to a small extent, but there was no postoperative bleeding, swelling, or nasal complications. Cho\u0026rsquo;s study also agreed on a similar theory that the anterior nasal spine was safe and reliable to osteotomy [39]. At half a year, postoperative CT showed the morphology profile of the adjacent structures was well recovered，which demonstrated the feasibility and practical prospect of the intranasal approach.\u003c/p\u003e"},{"header":"5. Conclusion And Future Work","content":"\u003cp\u003eThis is the first prospective and randomized control study on optimizing surgical procedures of mesiodens extraction. Under the inclusion and exclusion criteria of this study, the extraction of mesiodens by the intranasal approach achieved a new balance between reducing surgical trauma and optimizing postoperative recovery, which was worthy of further study. For the clinician's primary concerns, the surgical time, the volume of osteotomy, and the amount of bleeding in the labial approach group and intranasal approach group were significantly less than that in the palatal approach group. From the patient's perspective, the postoperative swelling and pain in the labial approach were far more than that in the intranasal approach group, with lower satisfaction. The result of pulp and gingiva blood supply of adjacent teeth, nasal respiration, and recovery of nasal floor structure demonstrated the feasibility and practical prospect of the intranasal approach.\u003c/p\u003e \u003cp\u003eThis study provided reliable support for the choice of extraction of high inverted mesiodens, which contributed to minimizing the operation injury for patients. In subsequent studies, more samples need to be included to further verify the indications for the surgical approach, and extend the follow-up time point to pay attention to the long-term impact of the surgical approach on the development of the patient's dentition and jaw. To improve the operative design, the researchers can proceed from the following aspects. On the one hand, the application of computer-aided design/computer-aided manufacturing (CAD/CAM) and navigation assistant systems has created new opportunities for the development of alveolar surgery [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. On the other hand, Efforts are being made to develop special surgical instruments for the nasal floor to better hold the affected tooth in case of accidents. Researchers need to make more efforts to solve above problem.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eLDF:\u0026nbsp;\u003c/strong\u003eLaser Doppler blood flowmetry\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLSCI:\u0026nbsp;\u003c/strong\u003eLaser speckle contrast imaging\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e1.\u003c/strong\u003e \u003cstrong\u003eEthical approval and consent to participants:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all subjects and their legal guardian (for those who age is less than 16yrs old) before participating in treatment. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments, and approved by the Ethics Committee of\u0026nbsp;Shanxi Medical University School and Hospital of Stomatology\u0026nbsp;(2019SLL022). The study was first registered on 27/12/2021 at chictr.org.cn (ChiCTR2100054777).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.\u003c/strong\u003e \u003cstrong\u003eConsent to publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe have obtained informed consent from all subjects and their legal guardian(s) for publication of identifying information/images (Fig no.3A and 4 B) in an online open-access publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Data availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data generated in this study was available from Chinese Clinical Trial Registry website (\u003ca href=\"https://www.chictr.org.cn/hvshowproject.aspx?id=139009\"\u003ehttps://www.chictr.org.cn/hvshowproject.aspx?id=139009\u003c/a\u003e) and the corresponding author, upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Author contribution:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHuifei Li wrote the manuscript. Yongfeng Cheng was involved in drafting the manuscript. Jun Lu, Pengfei Zhang, Yi Ning, Lei Xue, Yuan Zhang, Jie Wang, and Yujia Hao searched the references. Xing Wang were responsible for the design and critical revision of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5. Conflict of interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6. Funding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Natural Science Foundation of China [grant number\u0026nbsp;81801004 and 82071155];\u0026nbsp;Shanxi Province Key Research and Development Program [grant\u0026nbsp;numbers 201903D321148].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e7.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAcknowledgement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the patients who participated in the study.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAnthonappa RP, King NM, Rabie AB. Aetiology of supernumerary teeth: a literature review. Eur Arch Paediatr Dent. 2013;14(5):279-88. doi: 10.1007/s40368-013-0082-z.\u003c/li\u003e\n \u003cli\u003eKiso H, Takahashi K, Mishima S, Murashima-Suginami A, Kakeno A, Yamazaki T, Asai K, Tokita Y, Uozumi R, Sugai M, et al. 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Evaluation of Laser Speckle Contrast Imaging for the Assessment of Oral Mucosal Blood Flow following Periodontal Plastic Surgery: An Exploratory Study. Biomed Res Int. 2017;2017:4042902. doi: 10.1155/2017/4042902.\u003c/li\u003e\n \u003cli\u003eHa EG, Jeon KJ, Kim YH, Kim JY, Han SS. Automatic detection of mesiodens on panoramic radiographs using artificial intelligence. Sci Rep. 2021;11(1):23061. doi: 10.1038/s41598-021-02571-x.\u003c/li\u003e\n \u003cli\u003eCogulu D, Yetkiner E, Akay C, Seckin O, Alpoz R. Multidisciplinary management and long term follow up of mesiodens a case report. J Clin Pediatr Dent. 2008;33(1):63-66. doi: 10.17796/jcpd.33.1.212p1q4156625122.\u003c/li\u003e\n \u003cli\u003eColak H, Uzgur R, Tan E, Hamidi MM, Turkal M, Colak T. Investigation of prevalence and characteristics of mesiodens in a non-syndromic 11256 dental outpatients. Eur Rev Med Pharmacol Sci. 2013;17(19):2684-2689.\u003c/li\u003e\n \u003cli\u003eSanei-Moghaddam A, Hyde N, Williamson P. Endoscopic removal of a supernumerary tooth from the nasal cavity in an adult. Br J Oral Maxillofac Surg. 2009;47(6):484-5. doi: 10.1016/j.bjoms.2009.04.036.\u003c/li\u003e\n \u003cli\u003eFarwell DG, Reilly DF, Weymuller EA Jr, Greenberg DL, Staiger TO, Futran NA. Predictors of perioperative complications in head and neck patients. Arch Otolaryngol Head Neck Surg. 2002;128(5):505-511. doi: 10.1001/archotol.128.5.505.\u003c/li\u003e\n \u003cli\u003eCosta SM, de Jesus AO, Silveira RL, Amaral MBF. Supernumerary nasal tooth removed with a modified maxillary vestibular approach: case report and literature review. Oral Maxillofac Surg. 2019;23(2):247-52. doi: 10.1007/s10006-019-00763-4.\u003c/li\u003e\n \u003cli\u003eStrbac GD, Schnappauf A, Bertl MH, Vasak C, Ulm C, Giannis K. Guided Osteotomy and Guided Autotransplantation for Treatment of Severely Impacted Teeth: A Proof-of-Concept Report. J Endod. 2020;46(11):1791-8. doi: 10.1016/j.joen.2020.07.024.\u003c/li\u003e\n \u003cli\u003eCaltabiano ML, Croker F, Page L, Sklavos A, Spiteri J, Hanrahan L, et al. Dental anxiety in patients attending a student dental clinic. BMC Oral Health. 2018;18(1):48. doi: 10.1186/s12903-018-0507-5.\u003c/li\u003e\n \u003cli\u003eLopez-Jornet P, Camacho-Alonso F, Sanchez-Siles M. Assessment of general pre and postoperative anxiety in patients undergoing tooth extraction: a prospective study. Br J Oral Maxillofac Surg. 2014;52(1):18-23. doi: 10.1016/j.bjoms.2013.01.004.\u003c/li\u003e\n \u003cli\u003eZheng X, Zhao J, Liu S, Wang Z, Jia B, Lin X. Application of a surgical guide in the extraction of impacted mesiodentes: a randomized controlled trial. Clin Oral Investig. 2021;25(5):2999-3006. doi: 10.1007/s00784-020-03620-x.\u003c/li\u003e\n \u003cli\u003eSchreiber A, Mattavelli D, Ferrari M, Rampinelli V, Lancini D, Ravanelli M, Bertazzoni G, Rodella LF, Buffoli B, Doglietto F,et al. Anterior superior alveolar nerve injury after extended endoscopic medial maxillectomy: a preclinical study to predict neurological morbidity. Int Forum Allergy Rhinol. 2017;7(10):1014-21. doi: 10.1002/alr.22001.\u003c/li\u003e\n \u003cli\u003eCho YS, Hwang KG, Park CJ. Postoperative effects of anterior nasal spine bone harvesting on overall nasal shape. Clin Oral Implants Res. 2013;24(6):618-22. doi: 10.1111/j.1600-0501.2012.02428.x.\u003c/li\u003e\n \u003cli\u003eLouvrier A, Marty P, Barrab\u0026eacute; A, Euvrard E, Chatelain B, Weber E, Meyer C. How useful is 3D printing in maxillofacial surgery? J Stomatol Oral Maxillofac Surg. 2017;118(4):206-12. doi: 10.1016/j.jormas.2017.07.002.\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":"Mesiodens, Supernumerary teeth, Tooth extraction, Subperiosteal intranasal approach, Swelling, Pulp vitality, Gingiva blood supply","lastPublishedDoi":"10.21203/rs.3.rs-1590128/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1590128/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eAs the potential risks of the development of the adjacent incisors and jaws, mesiodens, especially inverted mesiodens, should be prophylactically extracted in mixed or early permanent dentition. However, because of the limit of small clinical data, there is relatively inadequate and lacks systematic, comprehensive understanding on minimizing operation injury for high inverted mesiodens. The aim of this study is to provide reliable support for the choice of extraction of high inverted mesiodens, and minimize the operation injury for patients.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e Thirty patients were randomly divided into three groups according to three different surgical designs in the extraction of high inverted mesiodens. The operation statistics, life quality of postoperative patients, and the operative injury/recovery were compared and analyzed. The laser Doppler blood flowmetry, laser speckle contrast imaging, and electric pulp testing were explored to detect the postoperative pulp and gingiva blood supply of adjacent teeth.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eFor the clinician's primary concerns, the surgical time, the volume of osteotomy, and the amount of bleeding in the labial approach group and intranasal approach group were significantly less than that in the palatal approach group (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05). However, from the patient's perspective, the postoperative swelling and pain in the labial approach were far more than that in the intranasal approach group (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05), with unsurprisingly lower satisfaction (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05). Under excellent surgical operation，there were no significant differences in pulp and gingival blood supply of adjacent teeth and jaw development (\u003cem\u003ep\u003c/em\u003e\u0026gt;0.05).Trauma was manageable in all patients.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions \u003c/strong\u003eWith precisive operation, maxillary inverted impacted mesiodens could be extracted by three methods, and the controlled trauma would not affect the development of teeth and jaw. Under the inclusion and exclusion criteria of this study, the extraction of mesiodens by the intranasal approach achieved a delicate balance between reducing surgical trauma and optimizing postoperative recovery, which was of concern and merited further study.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTrial registration \u003c/strong\u003eThe study was approved by the Ethics Committee of Shanxi Medical University School and Hospital of Stomatology (2019SLL022), and retrospectively registered at chictr.org.cn (ChiCTR2100054777). All patients provide written informed consent before participating in treatment.\u003c/p\u003e","manuscriptTitle":"Extraction of high inverted mesiodens via the labial, palatal and subperiostal intranasal approach：A clinical prospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-06-04 19:52:20","doi":"10.21203/rs.3.rs-1590128/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":"79a9b14d-5ee2-4105-8c41-13c9f407bd1c","owner":[],"postedDate":"June 4th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-09-19T12:29:27+00:00","versionOfRecord":[],"versionCreatedAt":"2022-06-04 19:52:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1590128","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1590128","identity":"rs-1590128","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}