Complications of the healing process after periodontal surgery

Unusual complications at the recipient site following periodontal plastic surgery procedures: a systematic review

OBJECTIVE

To identify and describe unusual soft tissue complications of periodontal plastic surgery procedures at the recipient site after periodontal grafts.

MATERIALS AND METHODS

Two independent reviewers performed a comprehensive search in MEDLINE, Cochrane, periodontics journals, reference lists, and grey literature for articles dated up to July 2021. Publications related to surgical interventions only around the teeth with an unusual complication at the recipient site were selected. No restrictions were made in the number of cases, follow-up period, or language. The Cochrane Collaboration's tool for assessing risk of bias, the Newcastle-Ottawa Scale (NOS), and two validated case report/series checklists were used to critically appraise the studies.

RESULTS

A total of 1434 articles were examined, of which 28 met the inclusion criteria: one RCT, two cohort studies, and twenty-five case reports/series. The periodontal plastic surgery procedures described in these articles were conducted to treat lack of attached gingiva and gingival recessions. The following unusual complications were found: bone exostosis, epithelial inclusion, root resorption, abscess, overgrowth, "liver clot" formation, and oroantral communication.

CONCLUSION

Bone exostosis and epithelial inclusions were the most prevalent unusual complications following treatment with subepithelial connective tissue graft, free gingival graft, and acellular dermal matrix allograft. Due to the nature of the reports, the clinical recommendations for diagnosis and treatment cannot be homogenized. Clinical studies reporting complications are required to develop management protocols (PROSPERO CRD42021230875).

CLINICAL RELEVANCE

Clinicians need to know the main complications that can occur in mucogingival surgeries as well as their clinical management to provide a successful and predictable treatment.

Post-Surgical Clinical Monitoring of Soft Tissue Wound Healing in Periodontal and Implant Surgery

Clinical features of surgical soft tissue wound healing in dentistry have been rarely discussed in the international literature. The aim of the present paper is to highlight both the main clinical findings of surgical wound healing, especially in periodontal and implant dentistry, and the wound healing monitoring procedures which should be followed. Wound inspection after careful food and plaque debridement is the essential part of wound healing monitoring. Periodontal and peri-implant probing should be performed only after tissue healing has been completed and not on a weekly basis in peri-implant tissue monitoring. Telephone follow-up and patient self-assessment scales can also be used the days following surgery to monitor the most common surgical complications such as pain, swelling, bleeding, and bruising. Wound healing monitoring is an important concern in all surgical procedures since it allows to identify signs or/and symptoms possibly related to surgical complications.

Microvascularization of gingival wound healing using corrosion casts

The healing process in a wound induced by removal of 6 X 6 mm of gingiva and periosteum from the maxillary attached gingiva of 48 adult mongrel dogs was observed to investigate the potential blood supply for grafts placed on denuded bone. Three-dimensional observations were performed over 12 weeks by scanning electron microscopy (SEM) following the manufacture of corrosion capillary casts by acrylic resin injection. Revascularization in the gingival wound was mainly through formation of new capillaries from those existing below the surrounding epithelium with little new capillary formation from the Volkmann canals. Moreover, the periodontium contributed greatly to the vascularization, which was fastest from the gingival margin. Further, simplification of new capillary loops was also fastest from this direction. Regeneration of the periosteum and periosteal vascular plexus was slow, taking about twice the time of connective tissue and capillaries below the epithelium. The results indicated that blood supply to grafts on denuded bone in the early postgraft period would mainly be provided by capillaries below the epithelium surrounding the recipient bed.

The incidence of clinical infection after periodontal surgery. A retrospective study

A large-scale retrospective study was undertaken to determine the incidence of clinical infection after periodontal surgery and the effectiveness of prophylactic antibiotic therapy in preventing postoperative infection. All second-year postgraduate students reviewed their patient records and completed a questionnaire. Eight infections were found in 884 operations performed without antibiotics, while one infection was found in 43 operations performed with antibiotics. Of 268 operations involving osseous surgery, six infections were noted while two infections were observed following 336 operations involving flap surgery without osteoplasty or ostectomy. The data indicated that the incidence of infection after periodontal surgery is very low in patients treated with or without antibiotics. It was concluded that unless there is a medical indication, there is no justification for using prophylactic antibiotic therapy to prevent infection following periodontal surgery.

Placement of free gingival grafts on denuded alveolar bone. Part I: clinical evaluations

Fourteen patients were examined and determined to lack an adequate zone of attached gingiva in the mandibular incisor region. Each patient was treated on the left side of the mandible by placement of a free gingival graft on denuded bone and 12 of the 14 patients received a free gingival graft on retained periosteum in the right mandibular anterior region. Two patients were treated on the right side by either bone denudation or periosteal bed preparation without graft placement to permit histological evaluation of wound healing under these circumstances. Grafts were retained for time intervals from 1 week to 24 weeks. All patients were evaluated clinically for graft "take", graft healing, graft shrinkage, and graft mobility.

A comparison of the continuous and interrupted suturing techniques

This investigation compared the efficacy of interrupted and continuous suturing for primary closure of the apically positioned flap. Twenty-two flap procedures were performed on contralateral sites in 10 patients. The 11 sites where interrupted suturing was used had a degree of presurgical periodontal involvement which was similar to that in the 11 contralateral sites where continuous suturing was used. At postsurgical assessment visits, after 3 months and 6 months, gingival health status was evaluated for both groups. Recession, residual pocket depth and loss of attachment were also measured. Analysis of the data for each of these parameters indicated no statistically significant difference between the two groups. However, the overall clinical impression was that interrupted suturing provided better flap adaptation.

Antibacterial properties of periodontal dressings

The relationship between the build-up of bacterial plaque at the dento-gingival junction and the development of gingivitis is well established. The susceptibility of patients requiring periodontal surgery to the pathogenic potential of plaque would seem to necessitate the protection of the surgically treated area by a periodontal dressing until adequate plaque control by the patient is possible. In the light of clinical experience, an investigation was undertaken into the antibacterial properties of certain proprietary periodontal dressings and a zinc oxide/eugenol material. None of these materials showed any marked degree of antibacterial activity. One of these materials, Coe-Pak, had been used alone or combined with Cross Pack for all the patients in the clinical survey with very satisfactory results, and it is concluded that this material is successful because of its physical properties and not its antibacterial ones. Careful attention to asepsis, gentle and controlled tissue handling, correct technique, and thorough removal of plaque and calculus are the prerequisites for successful periodontal surgery. The protection of the surgical wound by a dressing of adequate physical properties aids in ensuring uneventful healing. The use of potent antibacterial agents in the dressing is not necessary; a physical barrier to salivary/bacterial contamination and food impaction may be the most important factor.

A comparative clinical study of three periodontal surgical techniques

A comparative 4-month trial was performed after initial preparation. The procedures used were curettage, replaced flap and apically repositioned flap procedures with osseous recontouring respectively in a split-mouth technique in 17 male and 23 female patients, 22 to 65 years old. Changes were assessed with plaque and gingival indices, and measurements of pocket depths, attachment levels and tissue contours. All procedures reduced pocket depths. Apically repositioned flaps were the most successful, reducing overall mean pockets from 3.5 to 1.9 mm. Changes in attachment levels post-operatively showed only a small degree of variation among the three surgical procedures, and would not affect the choice of the apically repositioned flap as the most effective method for pocket reduction. A marked improvement in tissue contour was obtained in those areas treated by apically repositioned flap procedures and osseous recontouring. Despite failure to improve tissue contour, replaced flap procedures showed an equal degree of success in maintaining plaque control when compared to apically repositioned flaps, as evidenced by static plaque indices. Replaced flap procedures were also the only group to show improved gingival health over the 4-month post-operative period with lower gingival indexes. It would seem that good healing, followed by a high standard of oral hygiene, may overcome the presence of gingival and marginal osseous deformities.

Complications of free grafts of masticatory mucosa

A discussion has been presented and examples provided to illustrate some of the complications that may be encountered in conjunction with free grafts of masticatory mucosa. The clinical problems presented are seen infrequently, but the clinician must be aware of the possibility of their occurrence when counseling patients on the possible sequelae of such surgical procedures. A knowledge of complications that may occur in free soft tissue grafting procedures, and of the underlying mechanisms causing these problems, may aid the clinician in anticipating and avoiding similar experiences.