complication of perio banu
TRANSCRIPT
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Complications
Following Flap Surgery
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Contents
Introduction
Classification
Factors to be considered to prevent or minimizecomplications.
Complications
Studies related to the complications
Conclusion
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Introduction
All surgical procedures should be carefully planned.
The patient should be adequately prepared medically,
psychologically and practically for all aspects of
intervention.
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Complications of Flap surgery
(Wang and Greenwell, 2001)Complications during surgery
1. Syncope
2. Anaphylactic shock
3. Hyperventilation4. Pain due to failure of
anesthesia
5. Excessive tissue injury
6. Flap perforation, abrasion,
tearing
7. Hemorrhage
8. Tissue emphysema
Complications after surgery
Pain
Hemorrhage
Swelling / Hematoma
Tissue emphysema
Root sensitivity,
Flap sloughing,
Infection
Root caries, resorption or ankylosis,
Some loss of alveolar crest,
Abscess formation
Irregular gingival contours
Gingival recession
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Factors to be Considered to Prevent or
Minimize the Complications of Flap
Surgery
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Preparation of the Patient
Re-evaluation after Phase I Therapy.
Every patient undergoes the initial or preparatory
phase of therapy, which consists of thorough
scaling and root planing and removing all irritants
responsible for the periodontal inflammation.
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These procedures
Eliminate some lesions entirely,
Render the tissues more firm and consistent, thus
permitting more accurate and delicate surgery,
Acquaint the patient with the office and the operator
and assistants, thereby reducing the patient's
apprehension and fear.
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The reevaluation phase consists of re-probing and re-
examining all the pertinent findings that previously indicated
the need for the surgical procedure.
Persistence of these findings confirms the indication for
surgery.
The number of surgical procedures, expected outcome andpost-operative care necessary are all decided before therapy.
These are discussed with the patient and a final decision is
made, incorporating any necessary adjustments to theoriginal plan.
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Premedication
Ariado 1969 reported reduced post-operative
complications including reduced pain and swelling
when antibiotics are given before periodontal
surgery and continuing for 4 to 7 days after
surgery.
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Other pre-surgical medications include
administration of a non-steroidal, anti-inflammatory
drug such as ibuprofen 1 hr before the procedure
and one oral rinse with 0.12% chlorhexidine
gluconate which minimizes the post-operative
complications.
(Sanz 1988)
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Smoking The deleterious effect of smoking on healing of periodontal
wounds has been amply documented (Jones 1992).
Patients should be clearly informed of this fact and requested to
quit or stop smoking for a minimum of3 to 4 weeks before and
after the procedure.
For patients who are unwilling to follow this advice, an alternate
treatment plan not including highly sophisticated techniques
should be considered.
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Measures to Prevent Transmission of Infection
Transmitting infections to the dental team or vice versa
has become apparent, particularly with the threat of
acquired immune deficiency syndrome and hepatitis B.
Autoclaving all surgical instruments to ensuresterilization.
Universal precautions, including protective attire and
barrier techniques are strongly recommended which
include the use of disposable sterile gloves, surgical
masks and protective eyewear.
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All surfaces possibly contaminated with blood or
saliva that cannot be sterilized must be covered
with aluminum foil or plastic wrap.
Aerosol-producing devices should not be used on
patients with suspected infections.
Special care should be taken when using and
disposing of sharp items such as needles and
scalpel blades.
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Complications
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Syncope or Transient Loss of Consciousness
The most common emergency.
The common cause is fear and anxiety.
Anxiety causes increased release of
catecholamines which cause decreased peripheral
vascular resistance, resulting in the peripheral
pooling of blood and fall in arterial blood
pressure. This results in hypotension and reduced
cerebral blood flow.
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Clinical presentation
Pre-syncope:
Nausea
Sensation of warmth
Diaphoresis
Pallor
Tachycardia
Syncope:
Hypotension
Bradycardia
Dilation of pupil
Peripheral chill
Visual disturbance
Loss of consciousness
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Management
The patient should be placed in a supine position with
the legs elevated; tight clothes should be loosened, and awide-open airway ensured.
Administration of oxygen is useful.
Crystals of ammonia can be placed under the nose to
trigger the respiratory reflex.
A history of previous syncopal attacks during dental
appointments should be explored before treatment isbegun and, if these are reported, extra efforts to relieve
the patient's fear and anxiety should be made.
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Anaphylactic Shock
Anaphylaxis is an IgE mediated acute, allergic
reaction that is characterized by a sudden and
severe collapse of the cardiovascular system
(hypotension), Respiratory compromise
(bronchospasm).
Other manifestations are urticaria, angioedema,upper airway obstruction and gastrointestinal
disturbances.
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Clinical presentation
Onset:
For injected medications 5-30mts
For oral medicationupto 2hrs.
The more immediate reaction, the more severe
it is.
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Clinical presentation
SkinFlushed
face, urticaria(itching,flushing),tingling (lips,axilla,groin,hand and
feet),angioedema(lips,eyes,tong-ue)
RespiratoryLaryngeal
edema
(Hoarseness,dysphagia,
lump in throat,airway
obstruction,drooling),
apnea,abnormal
breath sounds,coughing,
bronchospasm
CNSDiaphoresis,
altered / loss ofconsciousness,seizure, slurred
speech.
Cardiovascularcyanosis,
pallor,dizziness,
hypotension,tachycardia/
bradycardia,vascular
collapse,Myocardialinfarction,
cardiac arrest.
Gastrointestinaldisturbances
nausea,vomoting,diarrhea,
abdominal pain
RhinitisNasalcongestion,
itching, sneezing
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Management.
Place the patient in supine position
Administer 100% oxygen, ventilate if necessary Monitor pulse and blood pressure
Epinephrine 0.3-0.5mg (1:1000 solution)
administered sublingual or intra-muscular Start IV fluids ( 1000/500 ml normal saline/
ringers lactate).
If the patient is having bronchospasmadminister salbutamol inhalation,Dexamethasone 4mg IV/ hydrocortisone 100mgIV.
H l i
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HypoglycemiaCharacterized by decreased plasma glucose concentration to a
level
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Management:
Hypoglycemia can be treated with the oral
administration of glucose.
In advanced state of hypoglycemia ( seizure,
coma) treatment should be stopped or
postponed until the patient has received
adequate medical care.
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Hyperventilation
It is a condition where the patient is breathing
at a faster rate than their normal breathing.
Pattern and breathing more deeply than the
body requires to maintain the normal oxygen-
carbon dioxide balance.
It is usually triggered by an imbalance in the
bodys natural levels of O and CO.
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Clinical presentation
Anxiety
Nervousness
Stress
Pain Feeling of air hunger
Numbness/tingling ofhands and feet
Nausea
Vomiting
Headache
Epigastric pain
Diaphoresis
Vertigo Blurred vision
Loss of consciousness
Muscle cramps
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Management:
Terminate the procedure, Place patient in upright position,
Maintain airway,
Attempt to verbally calm the patient,
Monitor blood pressure/pulse,
Reduce CO eliminationby re-breathing into paper bag,
Diazepam 1-2 mg IV slowly.
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Sedation and Anesthesia
Periodontal surgery should be performed painlessly.
The most reliable means of providing painless surgery is
the effective administration of local anesthesia.
The area to be treated should be thoroughly anesthetized
by means of regional block and local infiltration
injections. Injections directly into the interdental papillae may also
be helpful.
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Apprehensive and neurotic patients require
special management with anti-anxiety or
sedative hypnotic agents.
Modalities for the administration of these
agents include inhalation, oral, intramuscularand intravenous routes.
The simplest, least invasive method to alleviate
anxiety in the dental office is nitrous oxide and
oxygen inhalation sedation.
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Oral Benzodiazepine Agents Commonly Used for
Pre-operative Anti-anxiety and Sedation
Drug Adult dose
(mg)
Onset (hrs) Half life (hrs)
Alprazolam 0.25-0.5 1-2 12-15
Diazepam 2-10 0.5-2 30-70
Lorazepam 1-4 1-6 10-18
Triazolam 0.125-0.5 1-2 15-5.5
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Soft tissue management
Tissue manipulation should be precise, deliberate and
gentle.
Thoroughness is essential, but roughness must be
avoided because it produces excessive tissue injury,
causes post-operative discomfort and delays healing.
Observe the patient at all times. Facial expressions,pallor, and perspiration are some distinct signs that may
indicate the patient is experiencing pain, anxiety or fear.
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Instruments must be sharp to be effective.
Successful treatment is not possible without
sharp instruments.
Dull instruments inflict unnecessary trauma
due to poor cutting and excessive force applied
to compensate for their ineffectiveness.
A sterile sharpening stone should be available
on the operating table at all times.
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Flap Perforation
Causes for flap perforation
Improper tissue handling
Thin gingival bio-type
Excessive pressure during flap reflection
Improper instrument stabilization
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Flap Tearing
Causes for tissue tearing
Injudicious use of instruments
Improper elevation of the flap
Exercise of excessive force on the flap
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Soft tissue abrasion
These injuries are caused by careless use of
rotary instruments.
Thermal injuries:
Caused when instruments taken out from
autoclave or hot air oven are used immediately
intraorally.
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Management of soft tissue injuries
If the tear, abrasion or perforation are large,
suturing should be done for closure.
Scars produced by thermal injuries can be
managed by application of petroleum jelly.
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Flap Necrosis
Causes:
Excessive tension from the sutures
Use of chemical irrigants
such as paraformaldehyde
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Avoid dead space
Failure to use pressure for adaptation of flaps andgrafts after suturing may lead to formation of a
large fibrin clot, resulting in down growth of the
epithelial attachment and bulbous contours . Large blood clot is an excellent medium for
bacterial growth and hinders effective healing
Inadvertently forcing the periodontal dressing
beneath the flap may result in permanent tissue
defects
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Injury to Lingual Nerve
During procedures in the posterior mandible, the lingual nerve
can be damaged, if the lingual flap is not retracted carefully.
Clinicians should be aware that 15 to 20% of the time the
lingual nerve is found at or coronal to the crest of bone lingualto the mandibular third molar.
On average, the lingual nerve is located 2 mm horizontally
from the cortical plate in the flap and 3 mm apical to the crest.
Lingual nerve is in contact with the cortical bony plate 22% of
the time.
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Therefore to avoid lingual nerve damage,
the elevator should be used to protect the
nerve located in the flap underneath the
periosteum, and the elevated tissue should
be managed gently to avoid inducing a
transient traction injury.
Whenever possible, lingual vertical
releasing incisions should be avoided.
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Tissue Emphysema (Raznik JC 1990)
Caused by inadvertent introduction of air into tissues under the
mucous membranes.
Air from a high-speed hand piece, air/water syringe or air
polishing or air abrasive device can be forced into a sulcus,
surgical wound, or a laceration in the mouth .
The air can follow the facial planes and create a unilateral
enlargement of the facial and/or submandibular regions.
It can appear during the procedure or several hours after
therapy.
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When the skin / mucosa is palpated, it usually
produces a crackling sensation as the gas is pushed
through the tissue. This is referred to as crepitus.
The crackling sound is diagnostic for tissue
emphysema, and pain is not a usual feature of
tissue emphysema.
Emphysema can also occur without crepitus.
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Management:
Treatment of tissue emphysema usually consists of
antibiotic and mild analgesic therapy, close
observation, and reassurance.
Antibiotics are prescribed because bacteria may
have been introduced into the tissue with the
compressed air.
Symptoms usually subside in 3 to 10 days.
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Soft tissue emphysema after irrigation of pocket with
3%hydrogenaperoxide under pressure.
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Hemorrhage
Periodontal surgery normally severs only smallblood vessels. So significant hemorrhage is not
a frequent complication of periodontal surgery
when local anesthetics and vasoconstrictor
drugs are used.
The average amount of blood loss during one
session of periodontal surgery has been
reported to be 37 ml. (Berdon, 1965).
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Excessive bleeding may be due to systemic disorders
such as platelet deficiencies, coagulation defects,
medications, and hypertension.
Abnormal bleeding may be related to unexpected onset
of menstrual period.
There may be accidental severing of larger blood
vessels during surgery, provoking extensive bleeding.
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As a precaution, all surgical patients should be asked
about current medications that may contribute tobleeding, any family history of bleeding disorders, and
hypertension.
All patients, regardless of health history, should have
their blood pressure evaluated prior to surgery, and
anyone diagnosed with hypertension must be advisedto see a physician before surgery.
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Patients with known or suspected bleeding
deficiencies or disorders must be carefully
evaluated before any surgical procedure.
A consultation with the patient's physician is
recommended and laboratory tests should be
done to assess the risk of bleeding.
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Bleeding
PrimaryCauses
1. Local infection
2.Tear of any major
blood vessel
ReactionaryCauses
1. Disturbance of theclot due to chewing,
gargling, alcoholconsumption andtaking warm food.
2. Reactionaryvasodilation of theblood vessel whichhad contracted duringadministration oflocal anaesthesia withvasocosntrictor..
Secondary- causes
1. Blood clot may beinfected by certainbacteria likestreptococci which
dissolve the clot andresult in bleeding
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Primary post-operative bleeding starts at the
time of the surgery.
Reactionary hemorrhage starts soon after the
surgery, after having stopped temporarily
following surgery. It is usually associated withbreakdown of an incomplete clot.
The secondary type of post-surgical
hemorrhage may start from 24hrs to 10 days
post-operatively.
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Bleeding
HereditaryHaemophilia
Acquired
1. Hypertension2. Anticoagulant therapy
3. Vitamin K deficiency
4. Thrombocytopenia
5. Liver disorders
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Management1. As soon as continuous bleeding is detected, apply digital
pressure for 2-3 minutes. If bleeding stops, close the wound
by using sutures, which help to stabilize the clot.
2. If the bleeding continues, pack the bony defect with gel
foam.
3. If the bleeding continues, identify the bleeding point and
cauterize it or the vessel may be ligated.
4. A sample blood may be send for testing to find out any
systemic involvement
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Hemostasis is an important aspect of periodontal
surgery because good intra-operative control of bleeding
permits an accurate visualization of the extent of
disease, pattern of bone destruction, anatomy and
condition of the root surfaces.
It provides the operator with a clear view of the surgical
site, which is essential for wound debridement, scaling
and root planing.
Hemostasis also prevents excessive loss of blood into
the mouth, oropharynx, and stomach.
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Periodontal surgery can produce profuse bleeding,
especially during the initial incisions and flap
reflection. After flap reflection and removal of granulation tissue,
bleeding disappears or is considerably reduced.
Control of intra-operative bleeding can be managed
with aspiration.
Continuous suctioning of the surgical site with an
aspirator is indispensable for performing periodontal
surgery. Application of pressure to the surgical wound with
moist gauze can be a helpful.
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Intra-operative bleeding that is not controlled
with these simple methods may indicate a
more serious problem and require additional
control measures.
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Excessive hemorrhaging following initial incisions
and flap reflection may be due to laceration of
venules, arterioles, or larger vessels.
Fortunately, the laceration of medium or large
vessels is rare because incisions near the posterior
mandible (lingual and inferior alveolar arteries)
and the posterior, mid-palatal regions (greater
palatine arteries) are avoided in incision and flap
design.
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Even when all anatomic precautions are taken, it is possible to
cause bleeding from medium or large vessels because
anatomic variations do occur and may result in inadvertent
laceration.
If a medium or large vessel is lacerated, a suture around the
bleeding end may be necessary to control hemorrhage.
Pressure should be applied through the tissue to determine the
location that will stop blood flow in the severed vessel. Then
a suture can be passed through the tissue and tied to restrict
blood flow.
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If the bleeding is an arterial spouting (Palatal arteries)
of light red blood, try to crush the cut artery with a
hemostat Hold the hemostat in position for several
minutes and remove it carefully.
If there is not enough soft tissue available to grasp withhemostat, try to seal the vessel by crushing the bone of
the nutrient bone channel.
If the cut surface is in the soft tissue, ball electrode
from a electrocautery or a hot instrument can be tried.
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Excessive bleeding from a surgical wound may
result from incisions across a capillary plexus.
Minor areas of persistent bleeding from capillaries
can be stopped by applying cold pressure to the site
with moist gauze (soaked in sterile ice water) for
several minutes.
The use of a local anesthetic with a vasoconstrictormay also be useful in controlling minor bleeding
from the periodontal flap.
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Both of these methods act via vasoconstriction,
thus reducing the flow of blood through incised
small vessels and capillaries.
This action is short lived and should not be
relied on for long-term hemostasis.
If a more serious bleeding problem exists or a
firm blood clot is not established, bleeding is
likely to re-occur.
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For slow, constant blood flow and oozing,
hemostasis may be achieved with hemostatic
agents such as :
1. Absorbable gelatin sponge (Gelfoam)
2. Oxydized cellulose (Oxycel),
3. Oxidized regenerated cellulose (Surgicel
Absorbable Hemostat) .
4. Microfibrillar collagen hemostat (Collacote,
Collatape, Collaplug)
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Absorbable gelatin sponge
It is a porous matrix prepared from pork skin that
helps stabilize a normal blood clot.
The sponge can be cut to the desired dimensionsand either sutured in place or positioned within
the wound (eg. extraction socket, intra bony
defect).
It is absorbed in 4 to 6 weeks.
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Oxydized cellulose
It is a chemically modified form of surgical
gauze that forms an artificial clot.
The material is friable and can be difficult to
keep in place.
It absorbs in 1 to 6 weeks.
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Oxydized regenerated cellulose
It is prepared from cellulose by reaction with
alkali to form a chemically pure, more uniform
structure than oxidized cellulose.
The material is prepared in a cloth or thin
gauze form that can be cut to the desired sizeand sutured or layered on the bleeding surface.
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It can be used as a surface dressing because it does not
impair epithelialization, and it is bactericidal against
many gram-negative and gram-positive
microorganisms, both aerobic and anaerobic.
Caution should be used when wounds are infected orhave an increased potential to becoming infected (e.g.,
immunocompromised patients) because the absorbable
hemostatic agents can serve as a nidus for infection.
Th bi
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Thrombin It is a drug capable of hastening the process of blood
clotting and intended for topical use only because it is
applied as a liquid or powder.
It should never be injected into tissues because it can
cause serious, even fatal intravascular coagulation.
It is a bovine-derived material, caution should be used
for patients with known allergic reaction to bovine
products.
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Generic Brand Directions Adverse effects Precautions
Absorbablegelatin
sponge
Gelfoam May be cut intovarious sizes and
applied to bleeding
surfaces
Encapsulation,cyst formation
and foreign
body reaction
possible.
Should not beplaced in deep
wounds- may
physically
interfere with
wound healing
and boneformation
Microfibrillar
collagen
Collacote,
Collatape,
Collaplug
May be cut into
various sizes and
applied to bleeding
surfaces
May potentiate
abscess
formation,
hematoma and
wound
dehiscence;
possible allergic
reaction
May interfere
with wound
healing; may
cause increased
pain
Generic Brand Directions Adverse effects Precautions
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Generic Brand Directions Adverse effects Precautions
Oxidized
regenerated
cellulose
Surgical
absorbable
hemostat
May be cut into
various sizes and
applied to bleedingsurfaces
May form nidus
for infection or
abscess
Should not be
over packed into
the wound.
Oxidized
cellulose
Oxycel Most effective when
applied to wound dry
as opposed to
moistened
May cause
foreign body
reaction
Extremely
friable and
difficult to
place; should
not be used
adjacent to
bone- impairs
bone
regeneration;
should not be
used as surface
dressing-
inhibits
epithelization
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Generic Brand Directions Adverse effects Precautions
Thrombin Thrombostat May be applied
topically to bleeding
surface
Allergic
reaction in
patients allergic
to bovine
materials
Must not be
injected into
tissues or
vasculature- can
cause severeclotting
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Pain
Beyond some soreness during the first 24hrsfollowing periodontal surgery, there should be
only minimal pain and discomfort, if the basic
principles of atraumatic surgery were observed
carefully.
Patient should be instructed to contact dentist
if significant post-operative pain develops.
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Pain within the first few days following
surgery results from:
1. Mechanical trauma during surgery,
2. Drying of the bone,
3. Traumatic bone surgery,
4. Incorrectly placed periodontal dressing.
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Periodontal pack impinging the soft tissue
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Do not prescribe analgesics without re-
examining the wound, as the pain may be a
warning that the dressing has had a
traumatic effect upon the tissues in the area
of the surgery.
After the dressing has been changed, the
patient may be given analgesics.
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Infection It is the state or the condition in which the wound is
invaded by an infectious agent which multiplies and
produces an injurious effect.
The prevalence of infections after a variety ofperiodontal procedures ranged from 1% to 5.4%. (Pack
PD 1988, Chechi 1992)
In the same studies patients not receiving antibioticsbefore, during, or after surgery had an infection rate that
ranged from 2.33% to 5.4%.
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Post-surgical pain related to infection usually does
not start until 2-4 days following surgery.
Such pain is usually accompanied by
lymphadenopathy and elevation in temperature.
The patient should be examined, temperature shouldbe recorded and the dressing should be removed.
Perform percussion test of the teeth in the area of
the surgery.
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If the temperature is not significantly
elevated and the teeth are not noticeably
tender to percussion, place a topical
antibiotic ointment over the wound and
apply a new dressing.
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If the temperature in the area of surgery is
significantly elevated or the teeth in the area
of surgery are noticeably tender to
percussion, the patient should be placed on
systemic antibiotic therapy.
However, severe infections are extremely
rare following periodontal flap surgery.
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Amoxicillin, 2 g, 1 hour before a procedure,
is adequate prophylaxis. (Binahamad, 2005)
But Hossein et al (2005) demonstrated that
a 1-day dose of antibiotics achieved the
same benefit as medication for 1 week.
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There are numerous scenarios in which a
judgment must be made by the clinician as to
the necessity of prescribing antibiotic coverage
for an extended period of time (e.g., if a
surgical procedure is complicated, takes aprolonged period of time, bone grafts were
placed, or the patient was medically
compromised).
(Esposito 2003)
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Immediately after the pack removal
S i /
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Swelling / Hematoma
A sequelea of traumatic periodontal surgery whichresults in blood effusion into the extravascular space.
Extensive soft tissue surgery such as high
mucoperiosteal flaps or distal wedge operations behind
last mandibular molar, may result in swelling.
Infections associated with periodontal surgery may
also induce swelling.
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Hematoma rarely develops in the palatal
region because of the density of tissue in the
palate and its firm adherence to the bone.
The possible complications of hematoma
are:
1. Pain
2. Trismus
3. Swelling
4. Discoloration of the region
Management:
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Management:
Ice packs or ice cubes held in the mouth,
have been used to reduce swelling.
Antihistamines also have been tried.
If there is symptoms of infection such as
elevation of temperature and
lymphadenopathy, antibiotics should be
prescribed.
If there is no evidence of infection no specific
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If there is no evidence of infection, no specific
therapy is indicated.
Facial hematomas may result from direct
trauma to the field of surgery
They may also be the result of bruising contact
by the operator to the skin surface of the jaws.
However it is a rare sequela to carefully
performed periodontal surgery.
D l d H li
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Delayed Healing In areas where part of the alveolar process has been left
exposed after periodontal surgery, where severe trauma
to the bone has occurred during the surgery or where
there is direct pressure on the bone from the
periodontal dressingbare bone may develop.
Such areas of exposed bone may become infected on
the surface. So the granulation tissue will not attach to
it.
Th ti b ill h t b b d b
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The necrotic bone will have to be resorbed by an
inflammatory process in the underlying tissues,
starting from the marrow spaces or the periodontal
ligament.
The dead bone is broken up by the resorptive
process and finally expelled as sequestra.
Such type of delayed healing may take several
weeks and during this time the area should be kept
covered by a periodontal dressing to minimize
infection and discomfort.
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Fortunately such an episode of delayed
healing does not seem to have anydetrimental long-term effect on tissue
attachment level of the teeth, although it
may lead to permanent loss of bone.
The chance of bare bone developing is
much greater following gingivectomy with
electrosurgery.
If i l ti ti d l l f
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If excessive granulation tissue develops as a result of
poorly fitting periodontal dressing or loss of the dressing
shortly after surgery, the granulation tissue should be
removed with a sharp instrument.
This can be accomplished without pain, since the newly
formed granulation tissue is not as yet innervated.
A well fitting periodontal dressing then should be placed
over the wound and left for one week.
R ti t P i d t l D i
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Reaction to Periodontal Dressing
Allergic reactions to periodontal dressings occurespecially in patients who have been wearing
dressings over a prolonged period of time due to
multiple episodes of surgery or delayed healing.
The sensitivity reaction is provoked by the the
eugenol in the zinc oxide eugenol type of dressings.
Very rarely with the non-eugenol containing
dressings.
Th fi t t f iti it ti t
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The first symptom of sensitivity reaction to a
dressing is a burning sensation in the buccal
mucosa and on the surface of the tongue where
contact with the dressing occurs.
The patient should be told at the time of
surgery of the possibility of such symptoms
and instructed to contact the dentist
immediately on experiencing them.
If the dressing is not removed the reaction
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If the dressing is not removed the reaction
progresses from erythema to vesicle formation and
edema.
If the patient is not treated, a generalized allergic
reaction may develop, including a dermatitis.
So it is very important that the surgical dressing is
needed to be removed completely as soon as any
initial symptoms of an allergic reaction appear.
If a new dressing is needed a non eugenol
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If a new dressing is needed a non-eugenol
containing type of dressing such as Coe-Pak
may be used.
Antihistamines can be administered for 4-5
days to intercept the allergic reaction.
In severe allergic reactions, the patient may
have to be hospitalized and given cortisone
therapy.
S iti it f th t th
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Sensitivity of the teeth
The root surfaces of the teeth that have been exposed tothe oral environment as a result of periodontal surgery
sometimes become extremely sensitive to heat and
cold, as well as to mechanical and chemical stimuli.
With optimal post-surgical plaque control, this
sensitivity usually abates over few weeks or months.
But it may persist over a long period of time.
Management:
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Management:
Desensitizing tooth pastes such as strontium chloride,
potassium nitrate, provide varying degrees of relief for
long term sensitivity.
Topical fluoride application are often used but only with
moderate success.
Combining fluorides and electrical current has been
claimed to reduce sensitivity.
Iontophoretic devices and dentifrices for root
hypersensitivity should be prescribed as possible means
of reducing discomfort, even though results may vary.
Gingi al recession
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Gingival recession
It is an inevitable consequence of periodontal therapy.
Since it occurs primarily as a result of resolution of
inflammation in the periodontal tissues, it is seen both
following non-surgical and surgical therapy.
Irrespective of the treatment modality used, initially
deeper pocket sites will experience more pronouncedsigns of recession than shallow initial probing depths.
(Badersten et al 1984, Lindhe et al 1987, Becker et al 2001)
Non surgically performed scaling and root planing causes
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Non-surgically performed scaling and root planing causes
less gingival recession than surgical therapy.
Surgical treatment involving osseous resection results in the
most pronounced recession. (Badersten 1984).
Long term studies reveal that initial difference seen in
amount of recession between various treatment modalities
diminish over time due to coronal rebound of the soft tissue
margin (Kaldahl et al 1996, Becker et al 2001).
Li dh d N 1980 t d th t
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Lindhe and Neyman 1980, reported that an
apically repositioned flap procedure, the buccal
gingival margin shifted to a more coronal
position (1mm) during 10-11 yrs of maintenance.
Van der veldon 1982Interdental areas denuded
following surgery showed an up-growth of
around 4mm of gingival tissue 3 yrs after surgery
with no significant change in attachment levels.
Gingival Recession
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Gingival Recession
Clinical attachment level(CAL)
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Clinical attachment level(CAL)
In sites with shallow initial probing depth both short term and
long term data suggest that surgery creates a greater loss of
attachment than non-surgical treatment. Whereas in sites with
deeper pockets(7mm) showed a greater gain of clinical
attachment. (Knowles 1979, Lindhe 1984, Becker 2001)
When CAL following surgery with and without osseous
reduction was compared, no difference in therapies was found.
Flap surgery without osseous resection produced greater gain
Lindhe et al 1982 developed the concept of
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p p
critical probing depth (CPD) based on the data
generated from a clinical trial comparing non-
surgical and surgical (Modified widman) root
debridement.
CPD means the level of pocket depth below
which clinical attachment loss would occur asa result of treatment procedure.
CPD is found to be cosistently greater for
surgical approach than for non-surgicalapproach.
For incisors CPD is 6-7mm and molars 4.5mm
Studies on Post-operative complications
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Studies on Post operative complications
The incidence and severity of postoperative complications
and pain in 304 consecutive periodontal surgical cases.
Comparisons were made between plastic soft tissue surgery,
osseous surgery and pure mucogingival procedures.
Postoperative complications were rated as moderate or
severe in only 5.5% of the cases.
Osseous surgery to be three times more likely than pure
mucogingival surgery to cause complications of bleeding,
infection, swelling or adverse tissue changes.
Minimal or no postoperative pain was reported by 51.3% of
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the patients. Pure mucogingival surgery was significantly
related to pain and was 3.5 times more likely to cause painthan osseous surgery and 6 times more likely than plastic soft
tissue surgery.
The duration of surgery was statistically significant for both
complications and pain.
The overall results of the study indicate the risks of
undergoing periodontal surgery, in terms of postoperative
complications and pain, are minimal.
(James W. Curtis, Jr., James B, 1985)
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Blood loss during surgical procedures.
determined that, on average, 134 ml blood was
lost (range: 16 to 592 ml) during one sextant of
periodontal surgery.
Baab et al. 1977.
The amount of blood loss will vary depending on several
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y p g
factors: time to complete the treatment, size of the
surgery, vasoconstrictor use, blood pressure, medications,
inflammation of tissues, and health status of the patient.
Clinicians should be aware that when blood pressure
decreases 20 mm Hg during a procedure, blood loss is
>500 ml or the patient experiences an increased heart rate
of 20%, enhanced medical management may be needed(e.g., intravenous solution), which could include referral
to a hospital. (Gladfelter IA 1988)
Intra-Operative Bleeding During Open Flap Debridement
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Intra Operative Bleeding During Open Flap Debridement
and Regenerative Periodontal Surgery - Hadar Zigdon,
J.Periodontol 2011)
In this study the blood loss during periodontal
flap surgery ranged from 6.0 to 145.1 ml with
an overall mean loss of 59.4738.2 ml.
This volume is relatively minimal when
compared with other surgical procedures
Preemptive Dexamethasone and Etoricoxib for Pain and
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Preemptive Dexamethasone and Etoricoxib for Pain and
Discomfort Prevention After Periodontal Surgery: Joao Paulo
Steffens,* Fabio Andre Santos,* Rafael Sartori, and
Gibson Luiz Pilatti. J. Periodontol 2010
This study evaluates the efficacy of using etoricoxib
and dexamethasone for pain prevention after open-flapdebridement surgery.
They concluded that etoricoxib or dexamethasone may
be considered effective for pain and discomfort
prevention after open-flap debridement surgeries
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Long surgical procedures and smoking may
increase the severity and frequency of certain
post-surgical complications such as
Postoperative pain and swelling.
Terrance J, J. Periodontol 2010.
Smoking negatively affects wound healing.Allessandro
scabbia J Periodontol Jan 2001; 73 43-49
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scabbia, J. Periodontol, Jan 2001; 73,43 49.
Smokers exhibited a trend towards less
favorable healing response following flap
debridement surgery compared to non-
smokers both in terms of pocket depth
reduction and clinical attachment gain.
Conclusion
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Conclusion
It is important to have a comprehensive knowledgeof the complications that may be encountered, how
they may be prevented and how they are best
managed if they occur.
Most of the complications that associated with
periodontal surgery are preventable by proper
diagnosis, attentive pre-operative and post-operative
care by a concerned and skillful surgeon.
References
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References
Clinical Periodontology 10th and 11th edition: Carranza,
Neuman &Takei Clinical periodontology and Implant dentistry 5th edition: Jan
Lindhe
The Incidence and Severity of Complications and Pain
following Periodontal Surgery. James W. Curtis, Jr., James B.McLain and Rowland A. Hutchinson
Smoking negatively affects wound healing.Allessandro
scabbia, J. Periodontol, Jan 2001; 73,43-49.
Gary Greenstein, John Cavallaro, George Romanos, andDennis Tarnow*Clinical Recommendations for Avoiding and
Managing Surgical Complications Associated With Implant
Dentistry: A Review. J Periodontol 2008;79:1317-1329.
Joao Paulo Steffens Fabio Andre Santos Rafael Sartori
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Joao Paulo Steffens, Fa bio Andre Santos, Rafael Sartori,
and Gibson Luiz Pilatti. Preemptive Dexamethasone and
Etoricoxib for Pain and Discomfort Prevention After
Periodontal Surgery: A Double-Masked, Crossover,
Controlled Clinical Trial. J.Periodontol 2010.
Terrence J. Griffin, Wai S. Cheung, Athanasios I. Zavras,
and Petros D. Damoulis. Postoperative Complications
Following Gingival Augmentation Procedures.
J.Periodontol 2010.
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Sigurd . P. Ramfjord, Major. M. Ash. Periodontology and
periodontics, modern theory and practice.
Stanley F. Malaed. Text book of local anaesthesia, 5th edition
S.M. Balaji.Text book of oral and maxillofacial surgery.
Dilip G Naik. Text book of periodontology and oral
implantology
James R Hupp. Dental clinical advisor.
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