Gelfoam in oral surgery

undred Fifty

Cases

PBIELlMlKXRY report. of the use of Gelfoam and thrombin ii; or’ai surgery in a limited series of cases was made several months ago,’ and a second report of twmtp cases in which Gelfoam and saline were used was published shortly t,herea:fter.” Since their original communications, the authors have cojlaborated in gathering data on a series of 250 cases in which Gelfoam+ was employed. On the basis of these experiences, we are now able to offer a more definitive report on the application of the absorbable gelatin sponge to oral surgical procedures. Originally, absorbable hemostatic agents were used in neurosurgery. Fibrin foam, a human blood fraction, and thrombin were the first to be usedS3 Following their introduction, synthetic absorbable surgical sponges were made: one an oxidized cellulose and the other a gelatin sponge.4, 5 These substances, used in eonjnnct,ion with thrombin, proved efficacious in controlling bleeding and were well tolerated by tissues.“’ il 8; g Their use in genera! surgery suggested possible application to oral surgery. Control of bleeding and obliteration of “dead space” have a,lways been of primary concern in surgery about the mouth. Efforts have always been aimed at the prevention of severe bleeding even in simple extractions, and methods have been sought to aid in the organization of clots in large cavities. Unless some dressing material is used, large clots will often break down with result,ant, delayed healing and complications. An absorbable dressing becoming aa integral part of the blood clot forms a matrix for the formation of the clot and In this way, postoperative eomplieahelps to insure its natural organizat,ion. tions are reduced, and correlatively postoperative treatment is minimized. At the same time, the dangers of primary and secondary hemorrhage are reduced becaase of the hemost,atic effect of the gel&in sponge. Although Gelfoam has been used with thrombin for neurosurgical and general surgical work, we find that it is not necessary to use thrombin with it, in most oral surgical procedures. The sponge itself has sufficient hemostatic properties to control most bleeding encountered in oral surgery. Unless actual hemorrhage is encountered or the patient is a true bleeder or has some blood dyscrasfa, Gelfoam ma.y be used either alone or wetted with saline solution. Actually, we prefer to use the wet rat,her than the dry sponge because it is more easily *Visiting Oral Surgeon, Hospital. **Visiting Instructor in Surgery Staff, Worcester City fThe Gelfoam use6 in Kalamazoo, Mich. Israel

Metropolitan

State Hospital:

Assistant

Oral Surgery and Anesthesia, Tufts Hospital. these investigations was supplied

in Dental

College Dental by

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Surgery,

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School ; Ora1 Company,

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handled and inserted into wounds. The actual application of Gelfoam is quite silmple. A sterile sponge is placed in saline s,olution, removed and wrung out, then reinserted into the saline. As it absorbs the liquid, the sponge swells. When it is thorhughly wetted it is removed from the saline, excess fluid is blotted off on a dry gauze sponge, and the Gelfoam is inserted into the wound. As the sponge absorbs blood it swells and fills the cavity wherein it was placed, thus giving structural support to prevent the col!apse of soft tissue. At the same time, hemostasis is affected and a matrix is supplied for the rapidly formed clot. It is our opinion that there are several uses to which Gelfoam is best put. First, it is invaluable in the control of bleeding. Second, it acts well to obIi-terat,e the large space left by the enucleatia’n of cystic areas or the removal It also has some application in third molar of buecal bone in a flap operation. areas. Even in simple extractions, severe bleeding is not infrepukntly encountered. In the past, hemostatic dressings, which might control bleeding, were placed in sockets. However, such dressings had to be removed, and slow healing resulted, Using Gelfoam it is with frequent postoperative treatment being required. possible to control postoperative bleeding effectively. At the sa.me time, since it is an absorbable agent, its removal is not necessary, and healing rather than being retarded is accelerated. Where extraetions must be done on a patient who has prolonged bleeding or clotting times, Gelfoam soaked in ‘thrombin should be placed in the sockets following the removal of teeth. We have used it in cases of patients with histories of past bleeding difficulties and have never encountered secondary hemorrhage. In a number of these cases Gelfoam was wetted with saline alone and Merely as a still it was hemostatic enough to control hemorrhage effectively. material for the control of bleeding without retarding normal healing, Gelfoam has much to recommend it; its other principal use, that of space obliteration, is equally as important. Figs. 1 and 2 are radiographs of a large dentigerous cyst of the mandible. Following the cystectomy in this case we packed the cavity with thrombinsoaked Gelfoam sponges, sutured the mucous membrane tightly, and were never required to do a postoperative dressing of the area. Fig. 3 shows another large cyst of the maxilla which was treated in the same way. The patients were observed postoperatively, but the wounds were never disturbed. There was no sepsis, and postoperative visits were minimized. In dea,ling with such large areas, were routine treatment followed, 8 wick or nonabsorbable dressing of some sort would have been placed in the cavity following the enueleation of the cyst. The mucous membrane incision would not have been closed entirely, but would have been left open to allow access for the dressing material. Frequent postoperative treatments would have been required, reducing the size of the dressing each time, until enough healing by secondary intention had taken place to allow for the elimination of a dressing. It is obvious that prolonged treatment and visits would have been necessary following this regime. The rationale for such

E’i g. l.-dnteroposter.ior with Gelfoam and mucous dressings were required.

view of tlentigerous cyst. Followin:: membrane was completely closed with

Fig.

I.-I,atera:

blew

of dentigerous

cyst,

Its remo\-al. area \vaz iilit’J iXo pc&operatice sutures.

635

GELF04M IN ORAL SURGERY

Fig.

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4.-Radiograph

taken

prior

3.- Large

to

cyst

of

arJicoectomy and placed in wound.

maxilla.

reu~~val

of

diseased

tissue.

Gelfoarn

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SURGERY

obvious that when a firm foundation or matrix is provided for such a space, a clot can form, organize, and the area will heal by primary intention, An absorbable sponge provides such a matrix, and healing is definitely accelerated. Moreover, since it is possible to close such an area off from the mouth by complete suturing, the hazards of secondary contamination, although not eliminated, Fig.

Fig.

months

Fig. 7.-Postoperative Fig. 8.--Postoperative after surgery was

7.

e.

dental film of W. D. taken nine months after surgery. cyst case) taken one films of W. D. (dentigerous performed. There is evidence of good bone formation.

year,

three

are reduced. Therefore, healing is given impetus. Naturally, the markedly minimized.postoperative treatment is an aid to both the patient and the surgeon. The cases we have presented are extreme, and Gelfoam is just as efficaciously

!.lsed in smaller cavities where small cysts have been removed, iipiweetomws done, or buccal plate lost. In the latt,er instances, (Gelfoam gives structural support and aids in the maintenance of an adequate ridge. (Figs. 4, 5, 6, 7, and S.) The use of Gelfoam in lower third molar areas is somewhat complicated by the peculiar problems attendant upon the removal of these teeth. In many instances, the removal of a third molar is indicated because of repeated exacerbations of pericoronal infection. In such cases, even though acute infection has been controlled, there is often an clement of subacute or chronic infection still yesent, at the time that surgery is performed. WC feel that the formation of a healthy clot in these sockets is hazardous because of the bacteria present, which maintain the subacute infection. The prescncc of infection will destroy a normal blood clot, with result,ant painful socket, and Gelfoam does not preclude the breakdown. It therefore seems wiser to dress potentially infected sockets with stable, obtundent materials in ant,icipat,ion of pain. It is true that treatment is thus prolonged, but nndue pain is avoided. Where impa.cted teeth that are not in infected areas are removed, Cielfoam can be used in the socket. both as a hemostatic agent and as a space obliterator. We should like, however, to interject one thought. The removal of an impacted third molar is often a somewhat traumatic operation, which is followed by considerable postopera.tive pain. When such an opera,tion requires bone removal or other traumatizing procedures, measures are better taken to control pain than to speed ultimate healing. We prefer to carry on prolonged trea.tment while maintaining the comfort of the patient than to reduce postoperative care by the use of Gelfoam and have the I)atient endure In cases, then, where the operation has of an initial period of discomfort. necessity been traumatic, we use an analgesic dressing in the socket and reserve the use of Qelfoam for those casts which have required litt,le t,raumatic manipulation.

Summary Having used (ielfoam in a series of 250 cases, we feel that the material is a,n aid to oral surgery. As we reported originally, the value of the ahsorbablc gelatin sponge is twofold, first as a hemostatic agent and second to obliterate “dead space.” Gelfoam has many applications to the routine practice of surgerv about the mouth, whether it he to control postoperative bleeding or to fill caavities created by the removal of bo& or cystic tissue. The use of Gelfoam in lower third molar sockets is subject, to local conditions encountered by the operator. It has its place in third molar sockets, we feel, when used with discrimination. In most cases; Gelfoam need not be combined with thrombin to affect hemostasis. The material alone or wetted with saline for easier handling will snffice to control bleeding, or act as a space filler. The sponge should, however, be soaked in thrombin when used on patients with bleeding difficulties or severe hemorrhage. The use of an absorbable dressing mate&\1 has been another &Vance in oral surgery. Postoperative complications and the necessity for prolonged treatment are often avoided by its use.

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References 1. Guralnick, vi’. C.: Absorbable Gelatin Sponge and l’hrombin in Oral Surgery, Am. J. Ort,ho,dontics and Oral Surg. (Oral Surg. Sect.) 32: 792-794, 1946. 2. Berg, L.: Gelfoam in Dentistry, Dental Items Interest 69: 3, 1947. and Immunological Studies on the 3. Bailey, 0. T., and Ingraham, F. D. : Clinical Products of Human Plasma Fractionation. XXI. The Use of Fibrin Foam as a Hemostatic Agent in Neurosurgery : Clinical and Pathological Studies, J. Clin. Investigation 23 : 591-596, 1944. 4. Correll, J. T., Prentice, H. R., and Wise, E. C.: Biologic Investigations of a New Absorbable Sponge, Surg., Gynec. & Obst. 81: 585-589, 1945. 5. Correll, J. T., and Wise, E. C.: Certain Properties of New Physiologically Absorbable Sponge, Proc. Sot. Exper. Biol. & Med. 58: ‘233-235, 1945. 6. Light, R. U., and Prentice! H. R.: Gelatin Sponge, Arch. Surg. 51: 69.77, 1945. 7. Light, R. II., and Prentice, H. R.: Surgical Investigations of a New Absorbable Sponge Derived from Gelatin for Use in Hemostasis, J. Neurosurg. 2: 435.455, 1945. 8. Pilcher, C., and Meacham, TV. F.: Absorbable Gelatin Sponge and Thrombin for Hemostasis in Neurosurgery, Surg. Gynec. & Obst. 81: 365-369, 1945. 9. Light, R. U.: Hemostasis in Neurosurgery, J. Neurosurg. 2: 414-434, 1945. 10. Thoma, K. H.: A New Method of Space Obliteration After Odontectomy, Am. J. Orthodontics and Oral Surg. (Oral Surg. Sect.) 31: 198, 1945. 114 BAY STATE ROAD, BOSTOK, 507 MAIN STREET, Wmoesmr:,

MASS.

M,iss