Von Willebrand disease (vWD) is the most common hereditary bleeding disorder. A mutation inhibiting von Willebrand factor, which is a key clotting protein that binds to factor VIII, affects platelet adhesion during wound healing.1 Patients affected by vWD present with degrees of excessive bleeding, which may manifest in frequent nosebleeds, bleeding gums, and bruising. Female patients affected can have heavier menstrual periods. An uncommon symptom is severe internal bleeding or hemarthrosis. Clearly, vWD can pose a significant problem in a patient indicated for surgical procedures intraorally. Cases of dental surgery and extractions on vWD patients have been documented in the past, and complications with excessive gingival bleeding pose a concern.2
Managing excessive bleeding is nothing new in the field of medicine, and in particular, several methods have been shown to be affective for dental surgery.3 Local application of tranexamic acid (TA) and fibrin glue have been used in past cases to provide hemostasis before the procedure. TA acid is often used in major trauma cases at hospitals, as well as on hemophiliacs with excessive bleeding during dental procedures.4 It is typically delivered as a mouthwash for dental applications, but can be given orally or intravenously. TA acid is a synthetic derivative of lysine, and it binds to the lysine receptors on plasmin molecules to prevent the degradation of plasmin to fibrin. Fibrin glue is also commonly used to manage bleeding complications.5 Fibrin glue is composed of fibrinogen and thrombin, derived from human and bovine sources, and is used to help create a fibrin clot.
Specifically for vWD, desmopressin (DDAVP) has been used with success in managing bleeding after surgery.6 Desmopressin has a number of different effects on administration. The most applicable to patients with vWD is that DDAVP stimulates the release of von Willebrand factor from endothelial cells, which can promote the clotting cascade from occurring.7 Typically, DDAVP is administered intravenously at a dosage of 0.3 μg/kg in a 50 mL 0.9% saline solution. The DDAVP should be administered at least 1 hour before any surgical procedure and lasts for about 8 to 10 hours.8
A 21-year-old female patient with vWD presented to the Columbia University College of Dental Medicine clinics for comprehensive care. She had lost #30 because of caries, which was previously extracted about 1 year before. The optimal treatment plan was determined to be a single tooth implant (Figs. 1–3).
Previously, #30 was extracted after the patient received a single dose of desmopressin (DDAVP) from her hematologist, and the procedure was successful with no adverse events or complications with bleeding. After consulting with the patient's hematologist, it was again recommended that DDAVP be administered approximately 1 hour before the start of implant surgery. An hour before implant surgery, the patient received approximately 0.3 μg/kg of DDAVP in a 50 mL 0.9% saline solution intravenously (Figs. 4–6).
Additional accommodations were made to minimize the amount of surgeries and traumatic events to the tissue that would induce bleeding. A tissue-level implant was used to eliminate second-stage surgery and to provide adequate biological width away from the healing abutment to prevent bleeding during prosthetic visits. A flapless surgical technique was also used to prevent a full-thickness elevation of the surrounding soft tissue during the procedure. The ridge was assessed clinically and with a computed tomography radiograph to ensure adequate width of bone with minimal concavities (Figs. 7–10).
No postoperative complications were noted, and the patient reported no issues of excessive bleeding after the surgery. The implant was allowed 4 months for healing and was restored.
Successful treatment of patients with vWD, and other hemophiliac disorders, requires collaboration with the patient's hematologist for the appropriate method of treatment. Many successful cases of surgical procedures on patients with hematological disorders can be treated safely with minimal complications with proper intervention and treatment planning.9,10 In this particular case, the risk was minimized through careful collaboration with a hematologist and prophylactic DDAVP, but measures were taken in the surgical approach and the implant design as well.
Flapless approach to implant surgery has been shown to be successful, provided that the appropriate cases are selected.11 If adequate horizontal bone is present with minimal concavities present apically, a flapless approach provides a conservative approach with minimal risk of perforations. A cone-beam computed tomography scan and the use of a surgical guide is recommended if no flap is reflected to allow for visualization of the bone as the implant is placed. In the case documented, the flapless approach allowed for a minimally invasive approach and limited postoperative bleeding from the surgery.
Although bleeding soft-tissue trauma can be managed successfully,12 the use of dental implant design can also minimize trauma in both the surgical and prosthetic visits. Typically, the process of receiving a dental implant can involve multiple procedures that induce bleeding in the soft tissue. The most traumatic procedure involves the actual placement of a dental implant or the second-stage surgery to attach a healing abutment after integration. However, bone-level implant designs are more susceptible to incidents of soft-tissue trauma during the prosthetic phase. Irritation from prosthetic handling of the healing abutment, or dislodgement of the healing abutment, can result in soft-tissue trauma and a necessity to redo the second-stage surgery for bone-level implants. In 1-stage surgical approaches, the epithelium can adhere to the healing abutments and result in trauma and bleeding on removal after implant integration.13 For these factors, a tissue-level implant was used to limit incidents of bleeding during prosthetic fabrication.
This case study follows 1 example of treatment involving a patient with vWD, but the techniques and approaches cannot be extrapolated to every case. The patient's history and clinical parameters must be taken into account for each individual case. Additional clinical trials are needed to determine the optimal approach for patients with hematological disorders. However, on the basis of the existing literature, many cases with patients who have vWD and other hematological deficiencies can be treated successfully with limited complications.
A patient with vWD was successfully treated for implant surgery and restoration with no complications. Communication with the patient's hematologist was a key component of successful therapy. Several methods of hemostasis control and careful selection of the implant type can aid in providing a successful result and minimize the amount of trauma.
The authors claim to have no financial interest, either directly or indirectly, in the products or information listed in the article.
1. Sadler JE, Budde U, Eikenboom CJ, et al. Update on the pathophysiology and classification of von Willebrand disease: A report of the subcommittee on von Willebrand factor. J Thromb Haemost. 2006;4:2103–2114.
2. Siboni SM, Biguzzi E, Solimeno LP, et al. Orthopaedic surgery in patients with von Willebrand disease. Haemophilia. 2014;20:133–140.
3. Chen YC, Yang L, Cheng SN, et al. Von Willebrand disease: a clinical and laboratory study of sixty-five patients. Ann Hematol. 2011;90:1183–1190.
4. Whitman DH, Berry RL, Green DM. Platelet gel: An autologous alternative to fibrin glue with oral applications in oral and maxillofacial surgery. J Oral Maxillofac Surg. 1997;55:1294–1299.
5. Dunn CJ, Goa KL. Tranexamic acid: A review of its use in surgery and other indications. Drugs. 1999;57:1005–10032.
6. Federici AB, Sacco R, Stabile F, et al. Optimizing local therapy during oral surgery
in patients with von Willebrand disease: Effective results from a retrospective analysis of 63 cases. Hemophilia. 2000;6:71–77.
7. Windyga J, Dolan G, Altisent C, et al. Practical aspects of DDAVP use in patients with von Willebrand disease undergoing invasive procedures: A European Study. Haemophilia. 2016;22:110–120.
8. Sanchez-Luceros A, Meschengieser SS, Woods AI, et al. Biological and clinical response to desmopressin (DDAVP) in a retrospective cohort study of children with low von Willebrand factor levels and bleeding history. Blood Coagul Fibrinolysis Cell Haemost. 2010;104:984–989.
9. Zulfikar B, Koc B, Ak G, et al. Surgery in patients with von Willebrand disease. Blood Coagul Fibrinolysis. 2016;27:812–816.
10. van Galen KPM, Engelen ET, Mauser-Bunschoten EP, et al. Antifibrinolytic therapy for preventing oral bleeding in patients with haemophilia or Von Willebrand disease undergoing minor oral surgery
or dental extractions. Cochrane Database Syst Rev. 2015;12:CD011385.
11. Campelo LD, Camara JD. Flapless implant surgery: A 10-year clinical retrospective analysis. Int J Oral Maxillofac Implants. 2002;17:271–276.
12. Nickles K, Wohlfeil M, Alesci S, et al. Comprehensive treatment of periodontitis in patients with von Willebrand disease. J Periodontol. 2010;81:1432–1440.
13. Hermann JS, Cochran DL, Buser D, et al. Biological width around one- and two-piece titanium implants. Clin Oral Implants Res. 2001;6:559–571.