Complications

Following Flap Surgery

Contents
Introduction

Classification
Factors to be considered to prevent or minimize

complications.
Complications Studies related to the complications Conclusion

Introduction
All surgical procedures should be carefully planned. The patient should be adequately prepared medically,

psychologically and practically for all aspects of

intervention.

Complications of Flap surgery

(Wang and Greenwell, 2001)
Complications during surgery

1. Syncope 2. Anaphylactic shock 3. Hyperventilation 4. 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

Factors to be Considered to Prevent or Minimize the Complications of Flap Surgery

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.

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.

 The reevaluation phase consists of re-probing and reexamining 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 and

post-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 the

original plan.

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.

 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)

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 of 3 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.

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 ensure

sterilization.
Universal precautions, including protective attire and barrier techniques are strongly recommended which include the use of disposable sterile gloves, surgical masks and protective eyewear.

 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.

Complications

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.

Clinical presentation
Pre-syncope: Nausea Sensation of warmth Diaphoresis Pallor Tachycardia Syncope: Hypotension Bradycardia Dilation of pupil Peripheral chill Visual disturbance Loss of consciousness

Management The patient should be placed in a supine position with the legs elevated; tight clothes should be loosened, and a wide-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 is

begun and, if these are reported, extra efforts to relieve

the patient's fear and anxiety should be made.

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.

Clinical presentation
Onset: For injected medications 5-30mts

For oral medication upto 2hrs.

The more immediate reaction, the more severe it is.

Clinical presentation

Respiratory Cardiovascular Laryngeal Skin Flushed cyanosis, edema face, urticaria Gastrointestinal pallor, (Hoarseness, (itching, disturbances dizziness, CNS dysphagia, nausea, flushing), hypotension, lump in throat, Diaphoresis, vomoting, tingling (lips, altered / loss of tachycardia/ airway diarrhea, axilla, obstruction, consciousness, bradycardia, abdominal pain groin,hand and seizure, slurred drooling), vascular Rhinitis Nasal feet), speech. apnea, collapse, congestion, angioedema abnormal Myocardial itching, sneezing (lips,eyes,tongbreath sounds, infarction, ue) coughing, cardiac arrest. bronchospasm

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 bronchospasm administer salbutamol inhalation, Dexamethasone 4mg IV/ hydrocortisone 100mg IV.

Hypoglycemia
Characterized by decreased plasma glucose concentration to a level <50 mg/dl.

Clinical presentation: Sweating Dizziness Tremor Headache Tachycardia

Hunger Loss of fine motor skills Anxiety Unconsciousness Seizures

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.

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 oxygencarbon dioxide balance.

It is usually triggered by an imbalance in the

bodys natural levels of O and CO.

Clinical presentation
Anxiety Nervousness Stress Pain Feeling of air hunger Numbness/tingling of hands and feet Nausea Vomiting Headache Epigastric pain Diaphoresis Vertigo Blurred vision Loss of consciousness Muscle cramps

Management:
Terminate the procedure, Place patient in upright position, Maintain airway, Attempt to verbally calm the patient, Monitor blood pressure/pulse, Reduce CO elimination by re-breathing into paper bag, Diazepam 1-2 mg IV slowly.

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.

 Apprehensive and neurotic patients require

special management with anti-anxiety or sedative hypnotic agents. Modalities for the administration of these agents include inhalation, oral, intramuscular

and intravenous routes.

The simplest, least invasive method to alleviate

anxiety in the dental office is nitrous oxide and

oxygen inhalation sedation.

Oral Benzodiazepine Agents Commonly Used for

Pre-operative Anti-anxiety and Sedation

Drug

Adult dose (mg) 0.25-0.5 2-10 1-4 0.125-0.5

Onset (hrs)

Half life (hrs)

Alprazolam Diazepam Lorazepam Triazolam

1-2 0.5-2 1-6 1-2

12-15 30-70 10-18 15-5.5

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.

 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.

Flap Perforation

Causes for flap perforation Improper tissue handling Thin gingival bio-type Excessive pressure during flap reflection Improper instrument stabilization

Flap Tearing

Causes for tissue tearing Injudicious use of instruments Improper elevation of the flap Exercise of excessive force on the flap

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.

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.

Flap Necrosis

Causes:

Excessive tension from the sutures

Use of chemical irrigants such as paraformaldehyde

Avoid dead space

Failure to use pressure for adaptation of flaps and grafts 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

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 lingual

to 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.

 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.

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.

 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.

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.

Soft tissue emphysema after irrigation of pocket with 3%hydrogenaperoxide under pressure.

Hemorrhage
Periodontal surgery normally severs only small

blood 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).

 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.

 As a precaution, all surgical patients should be asked

about current medications that may contribute to bleeding, 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 advised to see a physician before surgery.

 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.

Bleeding
Reactionary Causes 1. Disturbance of the clot due to chewing, gargling, alcohol consumption and taking warm food. 2. Reactionary vasodilation of the blood vessel which had contracted during administration of local anaesthesia with vasocosntrictor..

Primary Causes

1. Local infection
2.Tear of any major blood vessel

Secondary- causes 1. Blood clot may be

infected by certain bacteria like streptococci which dissolve the clot and result in bleeding

 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 with

breakdown of an incomplete clot.

The secondary type of post-surgical

hemorrhage may start from 24hrs to 10 days

post-operatively.

Bleeding
Hereditary Haemophilia

Acquired
1. Hypertension

2. Anticoagulant therapy
3. Vitamin K deficiency

4. Thrombocytopenia
5. Liver disorders

Management
1. 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

 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.

 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.

 Intra-operative bleeding that is not controlled with these simple methods may indicate a more serious problem and require additional control measures.

 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.

 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.

 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 with

hemostat, 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.

 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 vasoconstrictor may also be useful in controlling minor bleeding from the periodontal flap.

 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.

 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)

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 dimensions

and either sutured in place or positioned within

the wound (eg. extraction socket, intra bony

defect).
It is absorbed in 4 to 6 weeks.

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.

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 size and sutured or layered on the bleeding surface.

 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 or

have an increased potential to becoming infected (e.g.,

immunocompromised patients) because the absorbable hemostatic agents can serve as a nidus for infection.

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.

Generic Absorbable gelatin sponge

Brand Gelfoam

Directions May be cut into various sizes and applied to bleeding surfaces

Adverse effects Encapsulation, cyst formation and foreign body reaction possible.

Precautions Should not be placed in deep wounds- may physically interfere with wound healing and bone formation May interfere with wound healing; may cause increased pain

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

Generic Oxidized regenerated cellulose Oxidized cellulose

Brand Surgical absorbable hemostat Oxycel

Directions May be cut into various sizes and applied to bleeding surfaces

Adverse effects May form nidus for infection or abscess

Precautions Should not be over packed into the wound. Extremely friable and difficult to place; should not be used adjacent to bone- impairs bone regeneration; should not be used as surface dressinginhibits epithelization

Most effective when May cause applied to wound dry foreign body as opposed to reaction moistened

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 severe clotting

Pain
Beyond some soreness during the first 24hrs

following 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.

 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.

Periodontal pack impinging the soft tissue

 Do not prescribe analgesics without reexamining 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.

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 of

periodontal procedures ranged from 1% to 5.4%. (Pack

PD 1988, Chechi 1992) In the same studies patients not receiving antibiotics before, during, or after surgery had an infection rate that ranged from 2.33% to 5.4%.

 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 should

be recorded and the dressing should be removed.

Perform percussion test of the teeth in the area of

the surgery.

 If the temperature is not significantly

elevated and the teeth are not noticeably tender to percussion, place a topical

antibiotic ointment over the wound

apply a new dressing.

and

 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.

 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.

 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, placed, or the patient was takes a medically

prolonged period of time, bone grafts were

compromised). (Esposito 2003)

Immediately after the pack removal

Swelling / Hematoma
A sequelea of traumatic Extensive periodontal surgery which results in blood effusion into the extravascular space. 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.

 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:
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 prescribed. of temperature and

lymphadenopathy, antibiotics should be

 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.

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 dressing bare bone may develop. Such areas of exposed bone may become infected on

the surface. So the granulation tissue will not attach to

it.

 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.

 Fortunately such an episode of delayed

healing does not seem to have any

detrimental 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 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.

Reaction to Periodontal Dressing

Allergic reactions to periodontal dressings occur

especially 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.

 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

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

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.

Sensitivity of the teeth

The root surfaces of the teeth that have been exposed to

the 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:
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.

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 pronounced signs 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

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).

 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 1982 Interdental 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

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 critical probing depth (CPD) based on the data generated from a clinical trial comparing nonsurgical and surgical (Modified widman) root debridement. CPD means the level of pocket depth below which clinical attachment loss would occur as a result of treatment procedure. CPD is found to be cosistently greater for surgical approach than for non-surgical approach. For incisors CPD is 6-7mm and molars 4.5mm

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 the patients. Pure mucogingival surgery was significantly related to pain and was 3.5 times more likely to cause pain

than 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)

 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

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 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 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-flap

debridement surgery.
They concluded that etoricoxib or dexamethasone may

be considered effective for pain and discomfort

prevention after open-flap debridement surgeries

 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 scabbia,

negatively affects J. Periodontol,

wound Jan

healing.Allessandro 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
It is important to have a comprehensive knowledge

of 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
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, and Dennis 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,

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.

 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.

Thank You