implants - international magazine of oral implantology International Edition

I research 14 I implants1_2014 woundclosureisakeyfactorforsuccessinbonegraft- ingprocedures.Dissectionoftheperiosteumisacom- mon technique for elongation of the flap. However, excessiveperiosteumreleasingincisioncanalsoresult in overthinned or overstretched soft tissue, which whenplacedoverthebonegraftmayleadtoperfora- tion or flap necrosis. Full-thickness flaps should be preparedintheareaofthegraftedsiteandsplit-thick- ness flaps beyond the site to provide tension-free wound closure. Sharp edges of the graft should be carefully avoided to prevent them from injuring the flap or affecting the microcirculation of the tissue. Double layer wound closure, pouch or tunnel ap- proaches,andpedicleconnectivetissueflapsaresuit- abletechniquesforpreventionoftheseproblems.6 _Postoperative complications EarlyComplications 1)Haematoma, swelling and ecchymosis: Swelling is anormalsurgicaleffect,butitisalsoacauseofgreat concern to the patient. For this reason, patients must be informed that the surgical site or the face mayswell.Thepatientmustbeassuredthatthede- greeofswellingisnotanindicatorofthesuccessor failure of the surgery or the degree of difficulty of the case. Haematoma can complicate and prolong thepostoperativephase.Ecchymosisisprimarilyan aesthetic problem. Discoloration of the facial and oralsofttissueiscausedbyextravasationandsub- sequent breakdown of blood in subcutaneous tis- sues. Ecchymosis is more common in fair-skinned patients and in elderly patients with fragile capil- laries.Itisbasicallythedepositionofthebloodfrom the surgery in the interstitial tissue spaces and will beresorbed.Heparingelmayacceleratetheprocess ofresorption.5 2)Dehiscence and flap necrosis: These soft-tissue complications are frequently the result of vascular compromisecausedbyinadequateplanning,insuf- ficient flap range or excessive surgical trauma, es- peciallyinsmokingpatients.Also,mechanicalover- loading of the grafted area with a removable pros- thesis or through biting of the antagonist teeth couldalsobethecauseofcomplication,withexpo- sure of the graft to the complex microbiological spectrum in the mouth and graft infection which leads to graft degradation and total failure of the procedures.Dehiscencemayoccurbecauseofpre- mature separation of sutures as a result of inade- quate suture technique or tension of the soft tis- sues. Retraction of a soft tissue flap is most likely where the vestibule is shallow or the muscle pull is great.5 Latecomplications 1)Exposureofthescrews:Duringthehealingprocess, adecreaseingraftvolumeisanormalsignofthere- modelingprocess.Vorhoevenetal.2000reporteda loss of up to 25% of the overall height of bone graft.7 While the bone volume decreases, the fixa- tion screws stay in their original position and may emerge through the overlaying soft tissue. In the early stages of the healing, the screws have to stay in place for proper stabilisation of the graft. In the laterstage,exposedscrewcanberemoved.Thesoft tissue perforation will heal properly after a couple ofdays.5 2)Exposure of part of the graft: Knife-edge graft can provoke perforation of the overlying soft tissue with subsequent dehiscence. In addition, pressure from a removable temporary prosthesis can create local irritation and dehiscence, which will jeopar- dise the success of the operation. Hollowing out of existing provisional prosthesis to avoid direct con- tact with the wound bed is another key factor for successinbonegraftprocedures.5 Ifasmalldehiscenceoccursafterblockgrafting,treat- ing the site with chlorhexidine gel and mouth rinse can be attempted until wound closure. Exposed bone chips have to be removed. Exposed parts of the graft are considered to be contaminated and debridement with a bur has to be performed. Surgical intervention is used to achieve soft tissue closure only when the early stage of soft tissue healing is over. After the ini- tialhealingprocess,debridementofthegrafthastobe performed and a conventional flap design may be used to try to close the soft tissue. If the site is not covered with soft tissue during the first two weeks after intervention, the complete graft has to be re- moveds.5 _ Editorialnote:Tobecontinuedinthenextissueofimplants: internationalmagazineoforalimplantology,withanexten- sivedescriptionofcomplicationsandconclusion. Acompletelistofreferencesisavailablefromthepublisher. Dr Omar Soliman PhD Candidate Perioimplant Dentistry Tel.:+20 1009634358,+20 1201005457 Omar.Soliman77@yahoo.com Prof.Dr Dr Mohamed Nassar Professor of Perioimplant Dentistry Faculty of Dentistry,Tanta University,Egypt Tel.:+20 1121522221 prof_mnassar@yahoo.com _contact implants