Post-operative morbidity following the use of the inverted periosteal graft: A case series.

Post-operative complications following flap surgeries or mucogingival procedures are important factors influencing patient's perception of periodontal procedures. Hence, it is important to foresee such complications and take adequate measures pre- and post-operatively. We treated five consecutive cases of gingival recession in the maxillary canine-premolar area using the inverted periosteal graft with a coronally positioned flap technique. Following each of these surgeries, the patients complained of post-operative swelling the next day involving the canine space or buccal space area. The swelling persisted for at least 5 days, however, it was painless. This paper highlights the post-operative complications associated with the said procedure and makes a case for detail enquiry in the form of controlled studies.

INTRODUCTION

Flap advancement is an integral part of root coverage procedures. When re-adapting flaps, coronal positioning facilitates healing by primary intention. This is superior to healing by secondary intention.[12] Possible complications documented in mucogingival surgeries include bleeding, pain, necrosis of the graft or the overlying flap, hemorrhage, ecchymosis and swelling. Occurrence of such post-operative complications is a major factor determining the patient's future attitude to the treatment procedures.

The inverted periosteal graft technique has been introduced recently in the periodontal literature.[3] It has been performed in Miller Class I gingival recessions. A recent study has shown comparable results with that of the connective tissue graft technique, which has the most predictable outcome for root coverage.[4] This technique is usually indicated in patients with a thick gingival biotype as in these cases, the periosteum has sufficient thickness and can be easily manipulated on to the root surface. It is also the technique of choice in cases where the patient is not willing to go for a second donor site surgery.

This is a case series involving gingival recession in five patients in the maxillary canine-premolar area, which were treated at our facility using this periosteal pedicle graft (PPG) technique. Although the procedure showed acceptable clinical results in terms of root coverage, excessive post-operative edema involving the canine space, was observed the next day after surgery, without exception in all the five cases. Although some amount of swelling is expected after coronal repositioning of a flap, the extent of swelling noted in these cases was unacceptable as it caused considerable patient morbidity and apprehension. No such complication has been reported so far in the literature using this technique. This article highlights the clinical appearance of this complication, its severity and discusses ways by which it may be prevented.

CASE REPORT

The case series comprised of three males and two females. This was an observation that the author came across while performing a randomized controlled clinical trial in assessing the efficacy of the PPG as a root coverage procedure. The mean age of the patients was 37.5 years (range 28-48 years). The patients were systemically healthy and none of the patients was a smoker. The recessions were present in relation to the maxillary canine or first premolar tooth [Figure 1], belonging to Miller Class I recession. There was a vertical recession depth of 4 mm in two of the cases, and 3 mm in the remaining three cases from the cement-enamel junction. Scaling and root planing was performed on all the five cases prior to the surgical procedure.

Figure 1

Gingival recession with respect to the maxillary right canine and premolar

The surgical procedure was performed by a single trained calibrated surgeon. A full thickness flap was elevated 3-4 mm apical to the osseous crest. An incision was made through the periosteum where the flap was still attached to the bone to create a partial thickness flap [Figure 2], and a periosteal pedicle flap raised and inverted over the planed and conditioned root surface [Figure 3]. The periosteum was stabilized using size 4-0 resorbable sutures (Vicryl, Ethicon). The overlying flap was then coronally positioned over the periosteal graft and sutured using size 4-0 surgical silk (Ethicon) [Figure 4]. A non-eugenol pack (Coe-Pak) was placed over the surgical area. Post-operatively, 400 mg of Ibuprofen (Brufen) was prescribed 3 times a day for 5 days. Chlorhexidine (0.12%) mouth rinse (Periex) was also prescribed to be used twice a day for 2 weeks.

Figure 2

Reflection of a partial thickness flap to expose the periosteum

Figure 3

Periosteal graft raised and inverted over the recession area

Figure 4

Partial thickness flap sutured in a coronal position

Three of the patients reported to the clinic with an extra-oral, painless swelling involving the right canine and buccal spaces on the 2nd day after surgery [Figure 5], out of which two cases also exhibited ecchymosis below the lower eyelid. The remaining two patients communicated the same over telephone.

Figure 5

Post-operative swelling in relation to the canine/buccal/periorbital spaces

The swelling was firm and tender on palpation and also extended to the lower eyelid in two of the cases. A considerable amount of apprehension and some skepticism regarding the treatment procedure was noted in all patients. Patients were reassured and advised to apply an ice pack intermittently over the swelling. Complete resolution of the swelling was seen by day 5. After initial observation of such an occurrence, in the first two patients; the patients who followed, were prescribed a serratiopeptidase containing tablet (Lyser-D) thrice daily for 3 days, post-operatively. Surprisingly, this too did not reduce the occurrence of the edematous swelling.

DISCUSSION

The success of any root coverage procedure not only depends upon the amount of root coverage achieved, but also upon the patient comfort and satisfaction following the procedure. The authors suggested this technique, as periosteum can be easily harvested near the surgical site itself and does not require a secondary donor site. Hence, the need for a second surgical site as in case of a sub-epithelial connective tissue graft is eliminated. Furthermore, periosteum has a rich vascular plexus, and the periosteal cells tend to release vascular endothelial growth factors, which may play a role in new attachment procedure. These qualities make periosteum a suitable graft over an avascular root surface.

Previously published articles have demonstrated the efficacy of the PPG procedure in recession coverage.[345] Patient discomfort was reported to be lesser in case of the PPG as compared to the connective tissue graft,[4] but no complications have been reported until date in relation to this technique. However, in our case, all the patients reported of severe post-operative swelling the next day involving the canine and buccal space area, which persisted for up to 5 days.

Swelling due to edema may require up to 72 h in order to peak and is guided by muscle attachments, fascia and bone. Reflection of the periosteum creates a dead space allowing the blood and inflammatory fluid to move in the direction of least resistance. When the surgical site is in the canine premolar area, the blood that gets collected in the infraorbital space tends to coagulate and can give rise to hematoma formation.[6]

Lengthy surgical procedures may create extensive tissue injury and prolong vasodilation that in turn permits more fluid to accumulate in the interstitial spaces and results in higher levels of biologic and inflammatory mediators.[7]

Thus, we suggest that post-operative complications such as swelling and hematoma formation may be minimized by:

Minimizing the duration of the surgery

Gentle handling of the tissues

Avoiding overt reflection of the flap in an attempt to obtain better coverage. Not controlling the bleeding from soft-tissue before suturing, can direct the blood and inflammatory fluid into the infra orbital space. It is advisable to control the soft-tissue bleeding by applying firm pressure with moist gauze on the flap prior to suturing.

CONCLUSION

Edema and related morbidity seem to be a constant and expected complication of PPG when used in the maxillary canine/premolar area. These complications can be minimized by some of the above mentioned precautions and post-operative care methods. The aim of this case series was to highlight one of the possible frequent complications of the PPG technique, which should be kept in mind while selecting this particular procedure for recession coverage.