Protocol for the management of oral surgery patients on warfarin utilizing a Point-of-Care In-Office international normalized ratio monitoring device

Purpose: This study was performed to assess the utility and safety of an In-Office INR Monitoring Device and present a safe and efficient protocol for the management of patients on oral anticoagulants and/or antithrombolytics requiring routine office oral and maxillofacial surgery. Patients and Methods: Sixty-one patients requiring “minor” oral and maxillofacial surgery being treated chronically with oral anticoagulation (warfarin) were entered into the study and compared in 2 groups. The control group (n = 29) was managed by discontinuing warfarin and any anti-platelet medication(s) prior to surgery. In the study group (n = 30), the decision to continue or withhold warfarin was determined by a protocol in which patients are 1) stratified based on risk for thromboembolism, and 2) classified as requiring “major” or “minor” surgery. Procedures categorized as “minor” surgery included dental extraction(s), dental implants, soft tissue and bone biopsies, and preprosthetic bone surgery, and incision and drainage. Warfarin and antiplatelet medication were not withheld in these patients, and a Point-of-Care In-Office INR Monitoring Device was used to obtain INR levels on the day of consultation and surgery. Local measures including removal of granulation tissue, packing, suturing, etc. were utilized for hemostasis. Results: The 30 patients in the study group maintained on warfarin readily achieved hemostasis using intraoperative local measures. The mean INR measured by the In-Office INR Monitoring Device was 2.36 with a range from 1.3 to 3.2. Study group patients underwent a total of 131 separate procedures including 108 dental extractions (impactions), placement of dental implants, preprosthetic bony surgery, bone cyst removal, soft tissue biopsies, facial skin cancer repair, and incision and drainage. One patient (3%) required “minor” intervention with removal of a “liver clot” on postop day 2 with repacking and suturing. The 29 patients in the control group discontinued off of war farin underwent a total of 99 procedures. One patient (3%) also required a “minor” intervention (repacking of extraction site). There were no “major” complications in either group. Conclusions: This study supports previous studies that minor oral surgery procedures can be safely performed while maintaining patients on warfarin minimizing the risk of a potentially devastating thromboembolic event. When deciding whether or not to withhold warfarin, this study supports the use of the proposed protocol based on 1) risk stratification for thromboembolism, 2) the need for “minor” versus “major” surgery, 3) and utilization of an In-Office INR Monitoring Device. An In-Office Point-of-Care INR measuring device can be a very effective tool to safely simplify and make the perioperative management of the anticoagulated patient more efficient for the patient and oral and maxillo facial surgeon.

Aesthetic gingival management: Preservation of the anatomical structures and the gingival aesthetics by immediate implant-insertion after loss of anterior teeth and premolars—Results of a 5-year prospective study with 348 inserted one-phase implants

Implant insertion is an alternative to classical treatment with bridges after tooth extraction or traumatic tooth loss in the anterior and premolar region of the upper and lower jaw. Nevertheless both types of prosthetic treatment inhere major gingival aesthetic pitfalls by physiological vertical and horizontal resorption. Aim of the study was to investigate if the immediate insertion of root analogue single-stage implants and prosthetic treatment could prevent gingival recessions and bone resorption thus keeping the natural gingival aesthetics untouched. Between 2003 and 2006, 348 root analogue Q1-Implants (TRINON Karlsruhe GmbH/Germany) were inserted in 342 patients’s premolar and molar regions immediately after tooth extraction or traumatic tooth loss and treated with provisional resin crowns. The observation period with recurring 6-month clinical and radiographic check-ups was a minimum of 5 years. Of 348 inserted implants 4 (1.15%) were lost resulting in an overall success rate of 98.85%. In the first 12 weeks after surgery a mean recession of the buccal gingival margin of 0.2 mm (SD 0.34) could be detected, after final prosthetic treatment an overall mean recession of 0.2 mm (SD 0.13) within the survey period. Immediate implant insertion of root analogue single stage implants and immediate prosthetic treatment with provisional resin crowns after minimal invasive tooth extraction seems to be appropriate to prevent bone resorptions of the buccal alveolar crest and the recessions of the gingiva and papillae and thus suggests to be the preferable treatment to keep the natural gingival and papillary aesthetics untouched preventing further traumatic surgical gingival reconstructions.

The transcrestal hydrodynamic ultrasonic cavitational sinuslift: Results of a 2-year prospective multicentre study on 404 patients, 446 sinuslift sites and 637 inserted implants

Introduction: In 2006 an ultrasound-surgery-based method to hydrodynamically detach the sinus-membrane utilizing the ultrasonic cavitation effect—the tHUCSL—was developed and a surgical protocol established. The aim of the study was to determine the indication-range and success-rate of this novelty procedure. Materials & Methods: Between 2007 and 2009, 404 patients were treated by 6 oral surgeons of different experience-levels with the tHUCSL in 446 sinussites. 637 implants were inserted and then prosthodontically treated and observed and documented until December 2011. The subantral space was augmented via the 3 mm transcrestal approach with an augmentation volume of 1.9 ccm (+/? 0.988 ccm) and an augmentation height of 10.7 mm (+/? 2.85 mm). Results: Within the survey-period 15 (2.35%) of the 637 inserted implants were lost, mostly before implant loading due to postsurgical infection and nonosseointegration in the augmentation site. 1 implant was lost after implant loading and prosthetic treatment within 1 year after loading. The overall success rate with functional implants in site is 97.65% evenly distributed among the participating surgeons. 86% of the patients were observed with no postsurgical swelling and 87% no postsurgical pain. Discussion: The results suggest the tHUCSL to be a safe minimal-invasive alternative to traditional lateral approach and transcrestal osteotome sinuslift-procedures applicable to all anatomical situations.

Flapless Piezotome-Enhanced Vertical Alveolar Crest-Split and Horizontal Distraction of Alveolar Crests (FPeCSWT) of Less than 2 mm Width: Results of a Prospective Comparative 3-Year Clinical Multicenter-Study with 239 Patients, 261 Crest-Split Sites and 488 Inserted Dental Implants

Alveolar crest-splitting and horizontal distraction is an established surgical technique to enable implant insertion into the narrow, lateral atrophic alveolar crest. This surgical technique is challenging for the oral surgeon and restricted to crest-widths of 3 - 5 mm: significant procedural bone loss at osteotomy, the need to prepare a full thickness mucoperiostal flap and milling a baseline-osteotomy to weaken the bone for distraction inhere significant risks of accidental fractures. Aim of the study was to investigate if the recently developed novel Flapless Piezotome enhanced Crest-Splitting and Widening Technique (FPeCSWT) could safely narrow down the indication for this procedure to narrow alveolar crests of widths of even less than 2 mm in a three-year survey-period. 239 patients underwent 261 FPeCSWT-surgeries and 488 implants were inserted simultaneously in the upper and the lower jaw and clinical parameters such as intrasurgical complications, patient morbidity, implant loss and vertical bone loss (VBL) in the first three years after surgeries were recorded comparing sites with less than 2 mm width with sites of more than 2 mm. After three years a significant difference (p = 0.24) of VBL could be observed between the group with less than 2 mm crest-width (mean: 0.97 mm, max: 2.0 mm/min: 0.0 mm;SD: 0.41) compared with the group with more than 2 mm crest-width (mean: 0.69 mm, max: 1.5 mm/min: 0.0 mm;SD: 0.36) but was still significant lower when compared with the results of similar studies published with a mucoperiostal-flap approach and baseline bone-cut. The cumulative 3-year-implant-survival-rate was 98.8%, no accidental fracture of the distracted buccal bone-plate occurred. The re-sults of the study suggest that the FPeCSWT narrows safely down the indication for crest-splitting to also crest-widths of only 1 mm. The procedure is highly predictable and significantly reduces the challenge of surgical skills and leads to negligible patient-morbidity. The higher VBL in crest-widths of less than 2 mm can easily be compensated by subcrestal placement of implants.

Impact of early eyelid weight placement on the development of synkinesis and recovery in patients with idiopathic facial paralysis

Determine the impact of upper eyelid weight placement at 3 months post onset of idiopathic facial paralysis(IFP)on the recovery of facial function in patients with lagophthalmos.Methods:This is a retrospective review of patients with incomplete recovery of IFPddefined as a Sunnybrook Facial Grading Scale(FGS)score of less than 100,3 months after onset.Only patients with FGS and Facial Clinimetric Evaluation(FaCE)scores recorded at 3 and 12 months were included.Patients were categorized into 3 groups:Group A,lagophthalmos with eyelid weight placement;Group B,lagophthalmos without eyelid weight placement;Group C,complete eye closure(CEC)without eyelid weight placement.The eye comfort domain and composite score of the FaCE questionnaire were analyzed.Voluntary eye closure,synkinesis with eye closure,overall synkinesis and the composite score of the FGS were also analyzed.Paired two-tailed t-test was used to evaluate the data comparing the 3 and 12 month FaCE and FGS scores within and between the 3 groups.Results:The change in composite FGS score significantly increased from month 3 to month 12 in Group A as compared to Group B(37 vs 4.25,P=0.01).While Group A had significantly lower eye comfort(-12.5,P=0.01),voluntary eye closure(-1.75,P=0.05)and overall FGS scores(-28.75,P=0.04)at 3 months compared to those in Group C,there were no differences between these two groups at 12 month follow-up.Conclusions:For patients with lagophthalmos at 3 months,early eyelid weight placement may lead to improved facial function at 12 months.