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Minor complications after mandibular third molar surgery:

type, incidence, and possible prevention


Jin-Cheol Kim, DDS,a Seong-Seok Choi, DDS,b Soon-Joo Wang, MD, PhD,c and
Seong-Gon Kim, DDS, PhD,d Kyoungki-do, Korea
HALLYM UNIVERSITY

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)

The removal of the lower third molar is a widely


practiced technique in dentistry. Major complications
can be defined as complications that need further treatment and may result in irreversible consequences.
There have been many reports of these complications,
such as abscess formation, excessive bleeding, mandible fracture, and nerve injury.1-4 Minor complications
can be defined as complications that can recover without any further treatment.
In the past, there have been reports concerning postoperative swelling, pain, and trismus.5,6 The main contributor for postoperative swelling is the duration and
difficulty of the operation.5 The effect of age and gender is still controversial.7,8 Many authors define the
pain as a dichotomized value and it is defined as a
a

Resident, Department of Oral and Maxillofacial Surgery, Sacred


Heart Hospital, Hallym University.
b
Resident, Department of Oral and Maxillofacial Surgery, Sacred
Heart Hospital, Hallym University.
c
Head, Department of Emergency Medicine, Sacred Heart Hospital,
Hallym University.
d
Head, Department of Oral and Maxillofacial Surgery, Sacred Heart
Hospital, Hallym University.
Received for publication July 25, 2005; returned for revision Sep 30,
2005; accepted for publication Oct 18, 2005.
1079-2104/$ - see front matter
2006 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2005.10.050

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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Kim et al. e5

Table II. Descriptive statistics of each variable

Table I. Summary of patients


Variables
Gender
Bone reduction
Impaction
Menstruation
Inflammation
Smoking
Gel-foam

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)

ministered as an intraoperative insertion during the


extraction of mandibular third molars. Considering that
ecchymosis is due to capillary fragility,10,11,16 its routine usage may reduce postoperative bleeding in both
skin and mucosa.
The aim of this prospective study was to ascertain the
incidence of minor complications after mandibular
third molar surgery; to obtain preoperative, intraoperative, and postoperative data associated with such complications; and to predict the risk of skin or mucosa
ecchymosis and postoperative trismus related to use of
the absorbable gelatin sponge.
PATIENTS AND METHODS
Patients
We studied 104 patients from June 1, 2004, to April
30, 2005, in the Department of Oral and Maxillofacial
Surgery, Sacred Heart Hospital, Hallym University.
Sixty-two females and 42 males were surveyed (Table
I; male to female ratio: 1:1.48). The average age was
29.3 8.8 years (Table II). At check-in, the clinic
dentist asked patients about their past medical history
and the presence of menses or a smoking habit. The
degree of impaction was evaluated in accordance with
a previous study.17,18 The evaluation was as follows
(Fig. 1): Position 1: highest portion of the tooth on a
level with or above the occlusal line; position 2: highest
portion of the tooth below the occlusal line, but above
the cervical line of the second molar; position 3: highest
portion of the tooth on a level with or below the
cervical line of the second molar. We defined position
1 as a shallow impaction, and positions 2 and 3 as deep
impactions.
The following determined the inclusion criteria: patients, ASA I and II,19 possessing horizontally impacted
mandibular third molars that required an incision and
flap reflection for their removal. The patients possess-

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

SD, standard deviation; Pre, preoperative; Po1, postoperative 1 day;


Po7, postoperative 7 days; VAS, visual analog scale of subjective
pain.

Fig. 1. The tooth impaction was classified as follows: a,


Position 1: highest portion of the tooth on a level with or
above the occlusal line; b, position 2: highest portion of the
tooth below the occlusal line, but above the cervical line of
the second molar; c, position 3: highest portion of the tooth on
a level with or below the cervical line of the second molar.

ing the following criteria were excluded from this


study: (1) ASA classifications of III or IV, (2) possessing a medical history of receiving operation under the
general anesthesia, (3) having systemic disease, (4)
showing complications needed for further treatment
(ex., persistent bleeding, dry socket, abscess formation,
and dysesthesia).
Surgical technique
The surgical technique administered was generally in
accordance with previously published papers.1,20 Patients underwent extraction while under local anesthesia. A buccal mucoperiosteal flap was raised, but lingual flap retraction was not carried out. Sterile highspeed handpieces and sterile saline solution were used
for bone reduction and odontomy, when necessary.
After tooth extraction, an absorbable gelatin sponge
was inserted for randomly selected patients. A 3-0
black silk suture was used for closing the wound.
Antibiotics and a nonsteroidal anti-inflammatory drug
were prescribed (usually, oral Augmentin 375 mg 3
times daily for 5 days and oral mefenamic acid 250 mg
3 times daily for 5 days). The patients who had a

e6 Kim et al.

Fig. 2. Postoperative swelling was evaluated by measuring


the distance between anatomic landmarks. Used landmarks
included the intertragic notch (a), corner of the mouth (b), and
soft tissue pogonion (c). The a-b and a-c distance were
measured.

smoking habit were strongly requested to stop smoking


during the wound-healing process. Follow-up studies
were carried out at 1 day and 7 days postsurgery. After
7 days, a surgeon removed the suture.
Collection of data
A statistically blinded single specialist examined
postoperative swelling, postoperative amount of maximum mouth opening, and minor bleeding disorders
(petechiae or ecchymosis). A handheld slide rule-type
visual analog scale (VAS) with values from 0 to 10 was
used to assess the subjective pain at the observation
point. To define the amount of postoperative swelling,
we used the criteria in a published article.21 Two distances were measured: the distance from the corner of
the mouth to the intertragic notch following the bulge
of the cheek, and the distance from the soft tissue
pogonion to the intertragic notch (Fig. 2). The measured distance was recorded preoperatively, 1 day postoperatively, and 7 days postoperatively. As there were
interpersonal differences in facial dimension, the difference between pre- and postoperative measurement in
the same patient was calculated. After averaging 2
subtracted values, it was used for statistical analysis.

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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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Kim et al. e7

Table III. Comparison of facial swelling 1 day postoperatively in each parameter


Variables
Age
Impaction
Operation time
Gel-foam

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

.NS, not significant.

and it was lower than the other groups (absorbable


gelatin sponge) (1.39 mm). However, the difference
was insignificant (P .05). There was no significant
difference in swelling in all variables at 7 days postoperatively (data not shown).
The comparison of VAS score at 1 and 7 days
postoperatively is shown in Table IV. Patients with
deeply impacted teeth were shown to have a significantly higher VAS score than the other groups at 1 and
7 days postoperatively (P .013 and .016, respectively). Patients with long operation times (over 10
minutes) were shown to have a significantly higher
VAS score than the other groups at 1 and 7 days
postoperatively (P .006 and .004, respectively).
However, there was no significant relationship between
VAS score and age or absorbable gelatin sponge usage
(P .05).
The incidence of mucosal petechiae at 1 day postoperatively was 19.2% (n 20). In bivariate analysis, it
was significantly associated with the duration of the
operation time (2 8.061, P .005), the degree of
tooth impaction (2 5.894, P .015), the usage of
absorbable gelatin sponge (2 15.842, P .001), and
the presence of menses (2 4.033, P .045) (Table
V). The multivariate logistic regression model maintained the importance of all the variables that were
determined to be significant by bivariate analysis (Table VI). The patients who had deeply impacted teeth
were 1.99 times more likely to have mucosal petechiae
at 1 day postoperatively than those without them (P
.0064). The patients who were not given the absorbable
gelatin sponge were 17.27 times more likely to have
mucosal petechiae at 1 day postoperatively than those
given the absorbable gelatin sponge (P .0003). The
patients who had menses were 11.01 times more likely
to have mucosal petechiae at 1 day postoperatively than
those without it (P .0247).
The incidence of skin ecchymosis at 7 days postoperatively was 6.7% (n 7). It was significantly associated with the usage of the absorbable gelatin sponge

(2 4.975, P .026) (Table V). The multivariate


logistic regression model maintained the importance of
all the variables that were determined to be significant
by bivariate analysis (Table VII). The patients who
were not given the absorbable gelatin sponge were
11.16 times more likely to have skin ecchymosis at 7
days postoperatively than those given the absorbable
gelatin sponge (P .0387).
The incidence of the reduced opening mouth over 10
mm at 1 day postoperatively was 18.3% (n 19). It
was significantly associated with the degree of tooth
impaction (2 7.623, P .006) (Table V). The
multivariate logistic regression model maintained the
importance of all the variables that were determined to
be significant by bivariate analysis (Table VIII). The
patients who had deeply impacted teeth were 1.51 times
more likely to have a restricted mouth opening at 1 day
postoperatively than those without them (P .0274).
DISCUSSION
The surgical extraction of the lower third molar has
been widely practiced and its complications are also well
reported1-9; however, there are very few reports about
minor complications and their prevention. In this study,
we focused on transient and reversible complications.
Some clinical variables were found to be related to postoperative complications. Particularly, use of the absorbable gelatin sponge was found to be useful for the prevention of mucosal petechiae and skin ecchymosis.
The clinical variables associated with
postoperative swelling and pain
The comparison of swelling at 1 day postoperatively is
shown in Table III. The variables that showed a statistically significant relationship with postoperative swelling
were age, the degree of impaction, and the duration of
operation time (P .05). These differences were statistically insignificant at 7 days postoperatively (data not
shown). Age has been reported as an important variable in
postoperative swelling after extraction.21 It may be due to
the different vascular permeability in elder patients. 22
Elder patients also tend to show higher inferior alveolar
nerve injury rates.1
The degree of impaction was found to be correlated
with the duration of operation time and the presence of
bone reduction (data not shown). Both variables are
related to surgical difficulties for extraction, which has
been shown to be related to postoperative swelling.5,21
The vascular permeability is shown to be directly proportionally increased with increasing tissue damage.23,24 Thus, increased swelling in difficult cases may
be explained by the increased tissue damage, and subsequent increased vascular permeability. However, we
could not find a statistically significant difference in the

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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

VAS, visual analog scale of subjective pain; NS, not significant.

Table V. Bivariate analysis


Mucosal petechiae
Variables
Time
10 min
10 min
Age
30 yrs
30 yrs
Impact
Shallow
Deep
Gelfoam
Yes
No
Menses
Yes
No
Sex
Female
Male

% 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

Reduced opening mouth

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

NS, not significant.

Table VI. Association between selected variables and mucosal petechiae at 1 day postoperatively
95% CI
Variable
Age
Inflammation
Impaction
Gel-foam
Menses
Smoking habit

Beta coefficient (SE)

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

95% CI, 95% confidence interval; NS, not significant.

absorbable gelatin sponge usage (P .05). Thus, the


usage of the absorbable gelatin sponge may not change
the vascular permeability.
The comparison of pain at 1 day postoperatively is
shown in Table IV. The degree of impaction and the

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

Beta coefficient (SE)

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

95% CI, 95% confidence interval, NS, not significant.

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

Beta coefficient (SE)

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

95% CI, 95% confidence interval; NS, not significant.

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-

dothelial clearance of fibrin degradation products, and


decreased production of platelets, which promote secondary fibrinolysis.32 As the absorbable gelatin sponge
can increase the synthesis of collagen, the fragile capillary walls around the wound may be strengthened and
fibirinolysis may be inhibited. However, further study
will be required for proving this hypothesis.
The clinical variables associated with
postoperative trismus
The reduced opening mouth over 10 mm at 1 day
postoperatively was significantly associated with the
degree of tooth impaction (Table V). However, there
were few cases presenting opening limitations at 7 days
postoperatively. As deeply impacted teeth need wider
flap reflection for the extraction, they may give more of
a chance to damage adjacent muscles.5,9 However, we
could not find any statistically significant relationships
in age, sex, menses, and absorbable gelatin sponge
usage.
CONCLUSION
In conclusion, clinical variables related to postoperative swelling, pain, bleeding disorder, and trismus
were identified.
1. Postoperative swelling at 1 day after surgery was
shown to have significant differences in age, the
degree of impaction, and the duration of operation

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e10 Kim et al.

2.

3.

4.

5.

time (P .05). However, there were no significant


differences at 7 days postoperatively.
The VAS score for subjective pain was shown to
have been significantly associated with the degree of
the impaction and the duration of the operation time
at 1 and 7 days postoperatively (P .05).
The incidence of mucosal petechiae at 1 day postoperatively was 19.2% and it was significantly associated with the duration of operation time (2
8.061, P .005), the degree of tooth impaction
(25.894, P .015), absorbable gelatin sponge
usage (215.842, P .001), and the presence of
menses (2 4.033, P .045) (Table V).
The incidence of skin ecchymosis at 7 days postoperatively was 6.7% (n 7) and it was significantly
associated with absorbable gelatin sponge usage (2
4.975, P .026) (Table V).
The incidence of the reduced opening mouth over 10
mm at 1 day postoperatively was 18.3% (n 19). It
was significantly associated with the degree of tooth
impaction (2 7.623, P .006) (Table V).

Absorbable gelatin sponge insertion to the extraction


socket was found to be a very useful method to prevent
postoperative mucosal petechiae and skin ecchymosis.
Therefore, routine usage of the absorbable gelatin
sponge is strongly encouraged in the extraction of the
mandibular third molar.
The authors are indebted to Michael Cho for his
contribution to the editing of this article.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.
21.

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Kim et al. e11


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Reprint requests:
Seong-Gon Kim, DDS, PhD
Department of Oral and Maxillofacial Surgery
Sacred Heart Hospital
Hallym University
#896, Pyungchon-Dong
Dongan-Gu, Anyang-city
Kyungki-do, 431-070, Republic of Korea
epker@chollian.net