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Purpose. The aim of this prospective study was to ascertain the incidence of minor complications after mandibular
third molar surgery and to predict the risk of skin ecchymosis or mucosa petechiae related to the usage of an
absorbable gelatin sponge.
Patients and methods. One hundred and four patients subjected to surgical extraction of horizontally impacted lower
third molars were selected and investigated by means of questionnaires and clinical examinations. The independent
sample t test was used for numeric variables. The chi-square test was used for logistic variables to determine the
association between variables, and thereafter stepwise logistical regression was used.
Results. The older group ( 30 years old), with deeply impacted teeth, and long operation times ( 10 minutes) were
shown to have significantly higher swelling than the other groups (P .05). The patients who had deeply impacted
teeth or long operation times were shown to have significantly higher VAS scores compared to short operation times (P
.05). The use of an absorbable gelatin sponge in the extraction socket significantly decreased postoperative swelling,
mucosal petechiae, and skin ecchymosis (P .05).
Conclusion. The clinical variables related to postoperative bleeding disorder, pain, and trismus were identified. The
insertion of an absorbable gelatin sponge into the extraction socket was found to be a very useful method to prevent
postoperative bleeding problems.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:e4-e11)
e4
positive when patients claim it to exist.5,7,9 Also, trismus does not have a definite criteria in many reports
and is dependent on the patients response.5 These
definitions are more dependent on the socioeconomic
status of the patient and make it difficult to compare to
each other.
The main reason why there are few reports in minor
complications may be because of their reversible nature
and lack of postoperative treatment. Particularly, skin
ecchymosis or mucosal petechiae is quite unpredictable
and to our knowledge, there have been no published
reports concerning their incidence or characteristics.
The inflammatory reaction after extraction and subsequent fragility of the capillaries may be a major contributor on ecchymosis and petechiae.10,11 Hormonal
imbalance12 or underlying systemic disorder13 are
causes of post-extraction bleeding. Although both are
transient symptoms, skin ecchymosis is unaesthetic.
Therefore, its prevention is useful.
Absorbable gelatin sponges are a widely used hemocoagulants and are known to induce pronounced formation of connective tissue.14,15 The use of hemocoagulants have been usually limited to patients who
have a bleeding disorder. Based on observation that
these patients had enhanced clotting and less ecchymosis, we decided to undertake a prospective evaluation of
the effects of the absorbable gelatin sponge when ad-
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Volume 102, Number 2
Kim et al. e5
Frequency, n (%)
Female
Male
Yes
No
Shallow
Deep
Yes
No
Yes
No
Yes
No
Yes
No
62 (59.6)
42 (40.4)
22 (21.2)
82 (78.8)
46 (44.2)
58 (55.8)
9 (8.7)
95 (91.3)
32 (30.8)
72 (69.2)
28 (26.9)
76 (73.1)
57 (54.8)
47 (45.2)
Variables
Age, y
Operation time, min
Maximum mouth opening, mm
VAS, point
Facial swelling, mm
Mucosa swelling, point
Pre
Po1
Po7
Po1
Po7
Po1
Po7
Po1
Po7
Mean
SD
29.3
14.0
47.0
41.3
45.3
3.4
1.5
1.4
0.4
1.3
1.1
8.8
9.2
5.6
7.9
7.3
2.1
1.7
1.7
1.0
0.5
0.3
e6 Kim et al.
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August 2006
Statistical analysis
Recorded data were analyzed using the SPSS (Statistical Package for the Social Sciences; SPSS, Inc.,
Chicago, IL) program. The difference of swelling and
VAS score at 1 and 7 days postoperatively between
each group was analyzed with the independent samples
t test. The grouping variables were age, the degree of
impaction, the duration of the operation time, and usage
of the gelatin sponge. The null hypothesis was applied
for this study.
The indices were allocated to reflect postoperative
complications, and the others were dichotomized for
bivariate analysis. The predictor variables were mucosal petechiae at 1 day postoperatively, skin ecchymosis
at 7 days postoperatively, and the restriction of opening
mouth over 10 mm at 1 day postoperatively. The outcome variables were age, sex, the duration of the operation time, the degree of impaction, usage of the
absorbable gelatin sponge, and menses. The chi-square
test was used to determine the association between each
of the independent variables and the dichotomous dependent variables, by bivariate analysis. The multivariate logistic regression model maintained the importance of all the variables that were determined to be
significant by bivariate analysis. Stepwise logistical
regression was then used to determine those factors
associated with the index of postextraction complications. The statistical significance of the coefficients in
the logistic regression models was tested using Wald
statistics and the P .05 level was used to determine
the variables to be included in the regression model.
Odds ratios and confidence intervals were calculated
from the regression coefficients. Stepwise multiple regressions were used to analyze factors associated with
the index of postextraction complications. The statistical significance of the regression coefficients was tested
using the t test (0.05 level). A P value .05 was used
as the criterion for including variables in the final
logistics and linear regression models.
RESULTS
The summary of dichotomized variables is shown in
Table I and descriptive statistics of numeric values are
shown in Table II. The comparison of swelling at 1 day
postoperatively is shown in Table III. The elder group
(over 30 years old) was shown to have significantly
higher swelling than the younger group (under 30 years
old) (P .038). The patients with deeply impacted
teeth were also shown to have significantly higher
swelling than the other groups (P .049). Patients with
longer operation times (over 10 minutes) were shown to
have significantly higher swelling than the other groups
(P .001). The amount of swelling in the group where
the absorbable gelatin sponge was used was 1.36 mm
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Volume 102, Number 2
Kim et al. e7
Group (no.)
Mean, mm
SD
P value
30 yrs (66)
30 yrs (38)
Shallow (46)
Deep (58)
10 min (45)
10 min (59)
Yes (57)
No (47)
1.09
1.86
1.03
1.65
0.79
1.82
1.36
1.39
1.41
1.99
1.24
1.93
1.12
1.89
1.75
1.61
.038
.049
.001
NS
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August 2006
e8 Kim et al.
Table IV. Comparison of VAS score 1 and 7 days postoperatively in each parameter
Postoperative 1 day
Variables
Age
Impaction
Operation time
Gel-foam
Postoperative 7 days
Group (n)
Mean
SD
P value
Mean
SD
P value
30 (66)
30 (38)
Shallow (46)
Deep (58)
10 min (45)
10 min (59)
Yes (57)
No (47)
3.32
3.50
2.83
3.83
2.73
3.88
3.35
3.43
1.99
2.38
1.70
2.34
1.89
2.19
2.27
1.98
NS
1.35
1.68
0.96
1.88
1.02
1.81
1.47
1.47
1.52
2.05
1.13
2.01
1.39
1.90
1.52
1.91
NS
.013
.006
NS
.004
.016
NS
% Persons
3
17
15.0
85.0
14
6
70.0
30.0
4
16
20.0
80.0
3
17
15.0
85.0
4
16
20.0
80.0
14
6
70.0
30.0
Skin ecchymosis
Chi-square
P value
8.061
.005
0.457
5.894
15.842
4.033
% Persons
1
6
14.3
85.7
4
3
57.1
42.9
3
4
42.9
57.1
1
6
14.3
85.7
2
5
28.6
71.4
5
2
71.4
28.6
Chi-square
P value
2.568
NS
NS
0.129
.015
0.006
.000
4.975
.045
1.109
3.766
NS
0.435
% Persons
4
15
21.1
78.9
10
9
52.6
47.4
3
16
15.8
84.2
11
8
57.9
42.1
1
18
5.3
94.7
10
9
52.6
47.4
Chi-square
P value
4.674
.031
1.176
NS
7.623
.006
0.089
NS
0.338
NS
0.471
NS
NS
NS
.026
NS
NS
Table VI. Association between selected variables and mucosal petechiae at 1 day postoperatively
95% CI
Variable
Age
Inflammation
Impaction
Gel-foam
Menses
Smoking habit
Odds ratio
0.5407 (0.6928)
0.1351 (0.6719)
0.6890 (0.2525)
2.8491 (0.7874)
2.3986 (1.0676)
0.7029 (0.6879)
0.5823
0.8736
1.9918
17.2728
11.0080
2.0197
P value
0.1498
0.2341
1.2142
3.6908
1.3583
0.5245
2.2638
3.2601
3.2672
80.8369
89.2105
7.7768
NS
NS
0.0064
0.0003
0.0247
NS
duration of operation time were shown to have a significant relationship (P .05). The subjective pain is
significantly related to surgical trauma.5,25 Considering
that both variables are related to surgical trauma, significantly high VAS score can be explained. Significant
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Kim et al. e9
Table VII. Association between selected variables and skin ecchymosis at 7 days postoperatively
95% CI
Variable
Age
Inflammation
Impaction
Gel-foam
Menses
Smoking habit
Odds ratio
0.5139 (0.9364)
0.0202 (0.9702)
0.5763 (0.3260)
2.4127 (1.1669)
1.7076 (1.1821)
0.9640 (1.1895)
1.6717
1.0205
1.7795
11.1646
5.5157
0.3814
P value
0.2668
0.1524
0.9393
1.1338
0.5437
0.0371
10.4761
6.8339
3.3713
109.9330
55.9559
3.9254
NS
NS
NS
.0387
NS
NS
Table VIII. Association between selected variables and the restriction of opening mouth over 10 mm at 1 day
postoperatively
95% CI
Variable
Age
Inflammation
Impaction
Gel-foam
Menses
Smoking habit
Odds ratio
0.5791 (0.5518)
0.4805 (0.6340)
0.4126 (0.1871)
0.0256 (0.5404)
0.6227 (1.1589)
0.0154 (0.6013)
1.7844
0.6185
1.5107
0.9748
0.5365
1.0155
P value
0.6051
0.1785
1.0469
0.3380
0.0553
0.3125
5.2622
2.1429
2.1799
2.8111
5.2004
3.3003
NS
NS
.0274
NS
NS
NS
differences were still shown between pain and operation time or impaction at 7 days postoperatively (P
.016 and .004, respectively) and it was in accordance
with the previous report.26
The clinical variables associated with
postoperative bleeding disorder
The variables related to surgical trauma and bleeding
tendency were shown to have a statistically significant
relationship with mucosal hemorrhage at 1 day postoperatively (Table V). An interesting finding was that
menses and usage of the absorbable gelatin sponge
were more influential in mucosal petechiae than surgical trauma (Table VI). Recurrent purpura is related to
the menstrual cycle and it is due to capillary fragility
and platelet disorder.27,28 Considering that the capillary
fragility and platelet disorder are causative factors of
petechiae, the relationship between menses and mucosal petechiae is well explained.
Skin ecchymosis at 7 days postoperatively was significantly reduced with the usage of the absorbable
gelatin sponge (Tables V and VII). Absorbable gelatin
sponge can be used not only for hemostasis, but also as
a scaffold.29,30 Its preventive effects on mucosal petechiae may be due to the hemostasis effect.31 However,
its effects on preventing skin ecchymosis may be not
totally dependent on the hemostasis effect. Skin ecchymosis can be induced by a problem in the production of
coagulation factors by the liver, inadequate reticuloen-
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August 2006
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