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PRESENTER

DR.G.ARUN PRASAD
I  YEAR MDS
MAHATMA GANDHI  POST                            
GRADUATE  INSTITUTE OF DENTAL SCIENCES
GUIDE 
DR.K.SANKAR
INTRODUCTION
¾ Deep vein thrombosis (DVT)is formation of blood
clot(thrombus) within the deep veins of any parts of
the body. It is a form of thrombophlebitis.

¾ Deep vein thrombosis most commonly affects the


veins of lower limb/deep veins of pelvis.

¾ Clinical features include localized swelling, redness


and calf muscle tenderness.
¾ Most important consequences of DVT is pulmonary 
embolism which occurs when a part of clot becomes 
free and reaches the lung.
free and reaches the lung

¾ DVT occurs in 25% of all hospitalized patients.
of all hospitalized patients

¾ It occurs in more than 50% of patients undergoing 
orthopedic surgical procedures (hip/knee 
replacement)and in 10 to 40% of patients who 
undergo abdominal/thoracic surgery.
CASE PRESENTATION
A 40yr old women  presented with
C/o pain and swelling in Left lower
C/o  pain and swelling in Left lower 
Jaw and inability to open the mouth
fully  for about  6 days.

H/o Trauma (self fall) 6 days before
/ ,
There was no H/o Loc, vomiting  g
and bleeding  from nose/ear.

H/o childhood poliomyelitis


H/o childhood  poliomyelitis
Clinical Examination…
¾ General examination revealed left limb abnormality.

¾ Extra oral examination reveals tenderness in left


condylar region, angle of mandible and along the lower
border of the mandible. Mouth opening
p g was restricted.

¾ Intraorally‐ occlusion deranged, sublingual ecchymosis


was present
present‐ 34,35,36,38 are tender on percussion.38 was
fractured.
Contd…
Orthopantamograph (OPG) reveals radiolucent lines, 
one in angle region and one in parasymphysis region.
contd…
d
¾ After thorough clinical and radiographical evaluation
patient was diagnosed as suffering from fractured left
angle and left parasymphysis of mandible..

¾ Blood investigations were done and was posted under


general anesthesia for open reduction and internal
fi i
fixation..

¾ ORIF done under GA using


g 2no. 2 mm 4 hole with g
gap
p ss
plate
l andd 7 no.(2x8)
( ) Ti screws.

¾ Duration of surgery
g y was about 45 minutes.
Contd…
¾ On the second post operative day patient developed  
mild swelling in the left leg which on examination was 
not tender but of pitting type.
not tender but of pitting type

¾ On the 5th day after surgery, swelling became painful 
day after surgery  swelling became painful 
and  reaches above the knee and Calf muscle 
tenderness  was  elicited.
¾ Colour  Duplex Doppler examination of both lower limbs –
venous study was performed.

¾ Report reveals normal Doppler 
evaluation of the veins of right lower
limb and ilio femoro popliteal deep 
venous thrombosis in left limb.

¾ Patient was referred to vascular surgery
P ti t    f d t   l  
department of higher institute for 
further management.
Discussion
¾ Deep vein thrombosis and its potential complication, 
pulmonary embolism , is a major cause of morbidity 
l   b li    i     j     f  bidi  
and mortality in hospitalized patients(25%).

¾ Any major surgery lasting longer than 30 minutes 
under GA is significant risk factor for 
DVT(orthopedic/thoracic / abdominal)
Risk factors
¾ Surgery
¾ Trauma 
¾ Immobility, paresis
¾ Malignancy
¾ Increasing age
¾ Obesity
¾ Inherited/acquired hypercoagulability
¾ Pregnancy and postpartum period
¾ Previous DVT
P i  DVT
Stratification of surgical patients
Stratification of surgical patients 
according to DVT risk
¾ Low risk          ‐ Age <40 years, no risk factors, minor surgery

¾ Moderate risk ‐
d   i k  Age (40-60) years/major surgery/risk 
A  ( )  / j   / i k 
factor present.
¾ High risk         ‐
High risk          Age >60years/age>40years+major
surgery+ risk factor present.
¾ Highest risk    
Highest risk    ‐ Age 
Age >40years+major surgery and 
40years+major surgery and 
previous  DVT/cancer/hypercoagulable
condition/major trauma/hip surgery/spinal
cord injury.
Prophylaxis methods
Mechanical methods
Graduated compression stocking
I t
Intermittent pneumatic compression
itt t  ti   i
venous foot pumps
Pharmacological methods
Antiplatelet agents(aspirin,dextran)
Antithrombotic agents(LDUH/LMWH)
g ( / )
Vitamin k antagonist(warfarin)
Synthetic pentasaccharide factor xa inhibitor     
(fondaparinux)   
Accp Guidelines for Prophylaxis
Accp Guidelines for Prophylaxis
¾ Low risk          ‐‐‐ No specific prophylaxis; early and
aggressive  mobilization.
¾ Moderate risk ‐‐‐ low‐dose UFH,(every 12 hr)/
LMWH(<3400U/day)/GCS  or  IPC 
¾ High risk         ‐‐‐ low dose UFH(every 8 hr)/
LMWH(>3400U/day) or  IPC
¾ Highest risk    ‐‐‐ LMWH(<3400( U/day),fondaparinux,
)
warfarin(INR,2.0-3.0) or IPC/GCS + 
l
low‐dose UFH/LMWH 
d  UFH/LMWH 
Review of relevant literature
In review of literature, there are very few reports of
DVT associated
i d with i h surgery off the h orall and
d
maxillofacial region. To the best of my knowledge
there are only two cases reported with DVT in oral and
maxillofacial surgery published in Japanese Journal of
oral and maxillofacial surgery. One was a case of DVT
after orthognathic surgery in 19 yr old girl and other
was a case of DVT after mandibular reconstruction
with vascularized iliac bone graft in 30 yr old man.
man
CONCLUSION
Oral and maxillofacial surgery is not free of the risk of 
DVT   hi h   
DVT, which can cause fatal acute pulmonary 
 f l    l  
thromboembolism. Therefore we have to assess the 
patient for the risk of thromboembolism and proper 
prophylaxis  have to be done to prevent DVT in 
individual  with risk.
THANK YOU