Inferior Alveolar Nerve Research Articles

Improving life quality via mandibular reconstruction: Innovations and techniques – A literature review

Mandibular abnormalities can arise from a range of causes, including illnesses, trauma to the face, and surgical excision of tumors. These conditions can significantly affect daily activities such as eating, speaking, and even grooming. These functions are impaired without appropriate repair, which has a major negative impact on an individual's quality of life. Mandibular reconstruction aims to preserve facial symmetry and allow patients to regain their normal ability to chew food by restoring both the structure and functionality of the jaw. A successful restoration also takes into account elements such as the positioning of implants to restore oral function and, in certain cases, the reconnecting of the inferior alveolar nerve to enhance feeling.Mandibular reconstruction has undergone a revolutionary change in technique over the years. These developments are still ongoing, with the goal of improving patient recovery and outcomes. This article highlights the continuous attempts to improve surgical techniques and integrate new technologies for improved patient care. It gives a general review of the historical evolution, contemporary approaches, and prospective future possibilities in mandibular reconstruction.

Comparison of different techniques used for inferior alveolar nerve block anaesthesia regarding the pain caused in cooperative children.

The aim of this study is to compare the application of inferior alveolar nerve block (IANB) anaesthesia in children with traditional plastic syringe (TPS) and computer-controlled injection device Dentapen® using two different modes [continuous mode (DC) and ramp-up mode (DR)] in terms of pain. This study included 96 children aged 7-12 who were determined to be positive (3) or definitely positive (4) according to the Frankl Behaviour Evaluation Scale and in need of treatment who had IANB anaesthesia indication in the right and left regions. Patients were divided into three groups and compared in terms of pain felt during IANB anaesthesia according to heart rate, oxygen saturation, Wong Baker Pain Rating Scale, Face Legs Activity Cry Consolability Pain Scale and patient preference distributions. Heart rate values increased significantly during the injection of IANB anaesthesia with all methods [TPS, DC and DR methods (p < 0.05)]. No significant differences were found in terms of pain between the TPS, DC and DR methods in the intragroup and intergroup assessments. However, among the patient preferences of TPS and DC methods, the number of patients who preferred the DC method was found to be statistically significantly higher those who preferred the TPS method (p = 0.026). Although the TPS group scored higher than the Dentapen® groups in terms of pain, the difference between the investigated IANB anaesthesia techniques was not statistically significant. However, the majority of the patients preferred the Dentapen® device compared to the TPS. It appears that more research is needed on the Dentapen® device in local anaesthesia applications in children.

Articaine Versus Mepivacaine in Inferior Alveolar Nerve Block for Patients With Irreversible Pulpitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Inferior alveolar nerve block (IANB) as an anesthetic strategy has shownconflicting results in terms of efficacy in the treatment of patients with irreversible pulpitis. Mepivacaine and articaine are anesthetic agents commonly used in the IANB technique for pulpal anesthesia. This review aimed to compare mepivacaine and articaine regarding pain and success rate. We conducted a search on the databases PubMed, Scopus, Web of Science (WOS), and Cochrane Central for randomized controlled trials (RCTs) assessing mepivacaine versus articaine until September 2024. The primary outcome of interest was success rate, while the secondary outcomes were pain intensity assessed by a 10-point visual analog scale (VAS) and incidence of severe pain. Data were pooled as odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) in a random-effect model using STATA. Five RCTs including 568 patients were included in the final analysis. While there was no significant difference between the two studied groups regarding the success rate (OR: 0.92, 95% CI: 0.69 to 1.21, p=0.54), articaine significantly reduced the pain intensity compared to mepivacaine (MD: 0.59, 95% CI: 0.31 to 0.86], p<0.001). Moreover, no significant difference was observed regarding the incidence of severe pain. Articaine reduced the intensity of pain post-procedure, with comparable results regarding success rate and incidence of severe painwith mepivacaine. Further large-volume RCTs are warranted to study the differences between the two options in the long term.

Postsurgical Paraesthesia in BSSO of the Mandible Following Preoperative Assessment of Position of Inferior Alveolar Nerve: A 5-year Follow-Up Study

Postsurgical Paraesthesia in BSSO of the Mandible Following Preoperative Assessment of Position of Inferior Alveolar Nerve: A 5-year Follow-Up Study

CBCT Guidance for Removing Foreign Object from the Jawbone: A Case Study

AbstractForeign objects lodged in the mandibular bone often result from trauma or dental procedures. Accurate localization of these foreign objects is crucial for guided surgical removal, especially when patients present with persistent pain. Conventional imaging modalities like periapical and panoramic radiographs may not provide sufficient detail for precise localization. Cone beam computed tomography (CBCT) has emerged as a valuable tool for guided surgical interventions owing to its superior imaging capabilities. We present two cases of foreign objects lodged in the mandible, where patients complained of prolonged pain, soreness, and numbness in the right mandible extending to the head and behind the ear. Both patients had undergone previous right mandibular tooth extractions and received treatment from a neurologist without resolution of symptoms. Both cases showed the control improvement in complaints, and no paresthesia or postoperative complications were found. CBCT-guided surgical removal was performed in both cases, revealing a metal specimen measuring 6 × 3 × 1 mm3 in the first patient and a remaining root measuring 5 × 3 × 2 mm3 in the second patient. Diagnosing foreign objects in the mandible poses challenges due to their varied size, composition, and proximity to vital structures. CBCT offers superior imaging resolution, enabling precise localization and assessment of anatomical relationships, such as the distance to the inferior alveolar nerve and surrounding boundaries. CBCT emerges as the preferred imaging modality for diagnosing and guiding the surgical removal of foreign objects in the mandible. Its advantages include accurate localization, low radiation exposure, and cost-effectiveness. Compared with CT scans, CBCT also offers faster scanning times, making it a valuable tool in clinical practice for managing such cases

A Novel Method of Correcting Lower Facial Asymmetry: Computer-Assisted Surgery with Contralateral Mandibular Outer Cortex Sandwich Grafting.

Lower facial asymmetry often results in an esthetically unpleasing appearance. The purpose of this study was to develop a novel method for correcting lower facial asymmetry using mandibular augmentation with sandwich bone grafts from the contralateral mandibular outer cortex (MOC), and to evaluate the efficacy of this method using computer-assisted techniques. The medical records of 16 patients with lower facial asymmetry who underwent mandibular augmentation with sandwich bone grafts from the contralateral MOC between January 2016 and December 2019 were retrospectively reviewed. Preoperative computer-aided design (CAD) was performed based on CBCT data, MOC grafts were harvested from the donor side using a 3D printed osteotomy guide template and grafted to the recipient side in sandwich manner to augment the contralateral mandible. Effectiveness was evaluated through pre- and postoperative CBCT data and FACE-Q questionnaire scores. Neurosensory recovery of the inferior alveolar nerve was assessed using the functional sensory recovery (FSR) scale. All procedure were successfully completed, and the asymmetry was effectively corrected three-dimensionally with no serious complications. The patients' FACE-Q scores for satisfaction with the lower facial area significantly increased from 52.19±7.51 to 86.69±7.50. No significant differences were observed in the pre- and postoperative lengths of mandibular ramus or body on either side. The donor site volume increased by 559.38±335.12 mm3 at 6 months postoperatively. The recipient site volume increased by 4415.94±1017.21 mm3 on the 7th day postoperatively and decreased by 202.63±300.85 mm3 at 6 months, reflecting a bone resorption rate of 5.67 ± 8.12%. The median FSR time for the chin and lower lip was 90 days. Mandibular augmentation with contralateral MOC sandwich grafts effectively increases mandibular width and volume witha low resorption rate. This method allows for three-dimensional restoration of facial symmetry in cases of mild to moderate lower facial asymmetry, achieving a harmonious and symmetric appearance. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. www.springer.com/00266.

Evaluation of the Rostral Inferior Alveolar Nerve Block via the Mental Foramen in Equids: In Vivo Efficacy Testing.

The use of proper sedative and regional anesthetic protocols is essential when performing equine dental surgical procedures under standing sedation. The efficacy of the rostral inferior alveolar nerve block via the mental foramen has not been previously studied. Aims of this study included determining the efficacy of the block, investigating whether any region (labial mucosa, alveolar mucosa, or teeth) was more reliably anesthetized, and if differences in efficacy existed between bilateral and unilateral blocks. In this blinded trial, 10 horses each were randomly assigned to receive a left unilateral block, right unilateral block or bilateral blocks and 5 horses were bilateral controls. For unilateral groups, the contralateral side of the horse acted as its own unilateral control. Mechanical nociceptive stimulus methods were used to determine response to stimulus at time points pre-sedation, post-sedation, and post-injection at 10, 30, 60, and 90 min. Results were evaluated in 4 groups: unilateral blocks, unilateral controls, bilateral blocks and bilateral controls. Overall, all groups were significantly less likely to respond to stimulus at time points post-sedation, T10, and T30, whereas only blocked sites were less likely to respond at T60 and T90 compared to pre-sedation. There was no significant difference in response to stimuli of blocked sites between the 3 regions at all time points. Overall, at T60 and T90, blocks produced regional anesthesia in 73% and 55% of sites, respectively. This study demonstrated the equine mental foramen regional nerve block has varied efficacy, producing partial or incomplete regional anesthesia in some cases.

Ocular complications associated with inferior dental nerve block: a systematic review.

SUMMARYOcular complications associated with anesthesia of the lower dental nerve may arise during or after administration of the local anesthetic, whether temporary or permanent. This situation generates concern for both the clinician and the patient. The purpose of this article is to identify ocular complications related to lower dental nerve block, analyzing signs, symptoms, gender, age, type of procedure, and duration of complications. MethodsIn September 2023, we conducted a systematic review using various databases, such as PubMed, ScienceDirect, and Google Scholar, using relevant search terms. There were no restrictions on the date or language of the articles. ResultsWe identified 39 articles that met the selection criteria, covering an analysis of 45 cases. Complications showed a higher incidence in women, with 65.11%, compared to 34.8% in men. The most frequent ocular complications reported were diplopia (44%), amaurosis (28%) and eyelid ptosis (17.77%). ConclusionsOcular complications related to lower tooth nerve block are rare, but they can occur. A higher incidence is observed in women than in men, and there is no specific age that predominates in its appearance. Diplopia is the most common ocular complication, followed by amaurosis, eyelid ptosis, and blurred vision. These complications may manifest during the infiltration of the anesthetic, immediately after the procedure, or a few hours later.

Evaluation of Cold and Electric Pulp Tests for Assessing the Success of Inferior Alveolar Nerve Block for Mandibular First Molars diagnosed with Symptomatic Irreversible Pulpitis

IntroductionFear of dentistry, often due to past painful experiences, is a significant barrier preventing patients from visiting dentists. Achieving effective pain control, especially during root canal treatments, is crucial. However, inferior alveolar nerve blocks (IANB) have a low success rate, influenced by factors such as anxiety, anatomical variations, and technique limitations, leading to anesthesia failure. Although numerous studies have examined the cold test and EPT in assessing the success of local anesthesia, no standardized method has been established. This study evaluated the effectiveness of electric pulp test (EPT) and cold tests in assessing the depth of anesthesia in patients with symptomatic irreversible pulpitis (SIP) in the mandibular first molar teeth. MethodsA cross-sectional study was conducted on 50 patients with SIP who met the inclusion criteria and exhibited lip numbness. Following the administration of the IANB and confirmation of lip numbness, cold tests and EPT were performed on all patients. Subsequently, the preparation of the access cavity (gold standard test) was initiated, and patients' responses during cavity preparation were recorded as either "presence of pain or discomfort" or "absence of pain or discomfort," indicating IANB failure and success, respectively. Sensitivity (SN), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratios (LR-/+), and accuracy (AC) with 95% confidence intervals (CI) were calculated for each test separately as well as for sequential testing. ResultsIANB failure was determined in 56% of the patients. A comparative analysis of diagnostic tests (cold test and EPT) showed no significant difference in SN, NPV, and AC; however, the cold test had higher SP, PPV, and LR+. Combining cold test and EPT evaluations improved SN, NPV, PPV, and LR-, but SP and AC were similar to EPT alone. No correlation was found between IANB success and patient age, sex, or initial pain. ConclusionsDespite evidence of lip numbness, a significant number of IANBs failed in cases of painful pulpitis. A positive result from the cold test strongly indicated anesthesia failure. The findings of the current study suggested that when the cold test yielded a negative result, further evaluation with EPT was necessary to confirm anesthetic success and ensure complete pain control.

Comparison of two ultrasound-guided versus anatomical landmarks techniques for inferior alveolar nerve block in dogs

Comparison of two ultrasound-guided versus anatomical landmarks techniques for inferior alveolar nerve block in dogs

THE IMPACT AND ROLE OF CRYOTHERAPY IN ENDODONTIC PROCEDURES

In the fields of medicine and dentistry, Cryotherapy is an effective method to relieve edema, pain, bleeding and inflammation. Cryotherapy has been used extensively in dentistry to treat pain after intraoral surgery. The objective of this paper is to study how cryotherapy is used in endodontics in relieving and preventing post-endodontic pain in clinical procedure, effect on root canal irrigation, vital pulp therapy, to improve the cutting efficacy of Ni-Ti rotary endodontic instruments, to increase the success rateof Inferior alveolar nerve block.

Mandibular third molar coronectomy in older adults and its effects on oral health-related quality of life.

The purpose of this study was to investigate the effect of coronectomy on postoperative quality of life in older adults. Coronectomy is an alternative to complete surgical removal of a mandibular third molar that lies close to the inferior alveolar nerve. This prospective study included patients >60 years old who had an indication for coronectomy of a mandibular third molar. Patients were asked to complete the Dutch version of the Oral Health Impact Profile-14 (OHIP-14) daily during the first postoperative week. Postoperative pain, swelling, limited mouth opening, chewing ability and infection were also recorded. Furthermore, the effect of the impaction pattern, state of eruption, presence of preoperative pathology, patient health status according to the American Society of Anaesthesiologists score, gender, smoking on the postoperative OHIP-14 and pain scores were investigated. Thirty patients (16 males, 14 females) with a mean age of 71.2 (SD 8.3, range 60-91) years were included in the study. OHIP-14 and pain scores were highest on the first postoperative day and gradually declined during the first postoperative week. Patients who underwent coronectomy of a fully impacted mandibular third molar had significantly higher OHIP-14 scores on the first postoperative day than those who underwent coronectomy on a (partially) erupted mandibular third molar. We did not observe any postoperative complications up to 1 year after the surgery. Mandibular third molar coronectomy seems to present a valid treatment option in older adults.

Cirurgia de remoção de terceiro molar inferior associado ao L-PRF – relato de caso

Platelet-Rich Fibrin (PRF) is an autologous process, which consists of removing a blood sample taken from the patient, where it is placed in a test tube, subsequently centrifuged, and deposited in the alveolus after the extraction of the third molar. This therapy is still in progress, often used more and more in third molar extractions, where it helps in bone and tissue regeneration. The objective of this work was to perform an extraction of the lower third molar (48) and insert the PRF in the alveolus after the extraction procedure. Blood collection and centrifugation, antisepsis of the patient and assembly of the surgical table were carried out, anesthesia of the Inferior Alveolar, Buccal and Ligual Nerve, intrasucular insertion, detachment, odontosection and osteotomy under continuous irrigation and elevation of the dental element, insertion of Rich Fibrin in Collagen and socket closure with Nyolon thread. Therefore, it is concluded that PRF is a process that is still in progress, however, it is a great alternative for regeneration of alveoli after third molar extractions, due to its unique biological properties.

Amaurosis After Inferior Alveolar Nerve Block Injection in a Seven-year-old Girl: A Case Report and Review of the Literature

A seven-year-old girl was referred for the treatment of her primary teeth. An inferior alveolar nerve block was administered using 1 mL of 2% lidocaine. Shortly after the injection, the patient experienced pain, erythema, blurred vision, and temporary loss of vision in her right eye. Based on these symptoms, a diagnosis of transient vision loss due to the anesthetic injection was made. The situation was explained to the child and her parents, assuring them that the complication was temporary. The right eye was covered with wet gauze, and all symptoms resolved within 20 minutes. A follow-up ophthalmological examination showed no abnormalities, and the procedure was successfully completed without further complications. A one-day follow-up revealed no issues

Measurement of mandibular anatomy associated with inferior alveolar nerve block anesthesia using 3D mandible models reconstructed by CBCT.

Measurement of mandibular anatomy associated with inferior alveolar nerve block anesthesia using 3D mandible models reconstructed by CBCT.

Military doctor, teacher, researcher (essay on M.S. Schwartz)

The purpose of the study is to provide brief information about the professional career of associate professor Major of the medical service Moisei Solomonovich Schwartz, who made a significant contribution to experimental dentistry and periodontology with his research. Material and methods. The article is prepared on the basis of information provided in the Russian literature on dentistry and maxillofacial surgery, as well as taking into account the memories of dentists who personally knew M.S. Schwartz, namely Colonel of the medical service V.P. Zabelin and associate professor Colonel of the medical service V.V. Fiolkovsky. Results. The paper notes that the major of the medical service, associate professor M.S. Schwartz, conducted a series of studies devoted to the study of the functional properties of the vessels of the jaws, mainly the lower jaw. He was the first in dentistry to apply the Kravkov-Pisemsky technique, which allowed him to study the effect of biogenic amines on the vessels of an isolated jaw. A comparative study using this technique of the vessels of the ear and jaw of the dog allowed to establish the increased sensitivity of the latter to acetylcholine, histamine and adrenaline, and in 1936 he experimentally reproduced periodontal disease (alveolar pyorrhea) with the help of chronic irritation (ligation) of the inferior alveolar nerve in a dog. The participation of M.S. Schwartz in the Soviet-Finnish (winter) War of 1939-1940, as well as the Great Patriotic War of 1941-1945, was noted. Conclusions. M.S. Schwartz was a great scientist, a good doctor with sound manual skills, including providing surgical assistance to the maxillofacial wounded. He was a thoughtful researcher and a demanding teacher. His contribution to the development of experimental dentistry and periodontology is difficult to overestimate.

A 3D-Planned Inward Fragmentation Technique for the Removal of Impacted Mandibular Third Molars: A Case Series.

Background/Objectives: The extraction of impacted mandibular third molars (M3Ms) carries significant risks, especially regarding the inferior alveolar nerve (IAN). This study aimed to evaluate the effectiveness of a 3D-planned inward fragmentation technique (3Dp-IFT) to improve surgical outcomes, reduce complications, and preserve bone structure in cases involving complex M3M impactions. Methods: Twenty-three patients aged between 18 and 36 years requiring M3M removal were included. Preoperative planning involved the use of cone-beam computed tomography (CBCT) for precise localization of the furcation area, followed by the creation of a 3D navigation template using PlastyCAD software version 1.7. The surgical procedure was performed under local anesthesia, with meticulous endoscopic assistance to ensure accurate access and minimize trauma. Postoperative outcomes, such as bone loss, pain, swelling, and mouth opening range, were carefully measured. The data were systematically organized and analyzed descriptively using Microsoft Excel. Results: No disturbances to the IAN or lingual nerve were observed. The mean buccal bone loss was 2.2 mm, with a standard deviation of 1.2 mm. Postoperative pain and swelling were generally low, with significant reductions within the first week. The use of the 3D navigation template significantly improved surgical access, enhancing safety and minimizing complications. Conclusions: The 3Dp-IFT technique represents a significant advancement in the minimally invasive removal of M3M by allowing precise access to critical anatomical areas while minimizing bone loss and postoperative complications. This approach is particularly beneficial for complex cases involving M3M near the IAN, thereby improving surgical safety and patient outcomes.

Assessment of Computer-Controlled Starpen Device and Conventional Aspirating Cartridge on Pain Perception in Paediatric Dental Patients – A Split-Mouth Crossover Study

Abstract Background: Local anaesthesia (LA) is the cornerstone for pain management of invasive dental procedures, but the process of delivering it may itself induce anxiety, especially in paediatric patients that can affect the pain perception. Advances such as the computer-controlled LA delivery system have expanded the horizons of LA and can serve as an alternative for painless injections. Objective: To examine the pain perception and anxiety reduction along with patient preference between computer-controlled Starpen device and conventional aspirating cartridge in LA administration for inferior alveolar nerve block. Materials and Methods: The patients were randomly allotted into two groups: Starpen and Septodont syringe where the LA injections were given using both the methods in the 1st week. After a washout period of 1 week, the crossover was performed and the other mode of LA administration was performed in the 2nd week. Pain scores were objectively recorded by the observer using the Face, Legs, Activity, Cry and Consolability (FLACC) scale during LA administration and extraction. Patients were asked to record the pain scores using the Visual Analogue Scale at three phases: (a) mucosa perforation, (b) needle insertion and (c) solution injection. The effect of pain perception on the vital parameters and the preference between the two techniques were assessed. Statistical Package for the Social Sciences (SPSS) version 23.0, Armonk, NY, USA: IBM Corp was used for statistical analysis, and Mann–Whitney U-test and unpaired t-test were utilised to compare the mean difference of two groups at significance level of 0.05. Results and Observations: Intergroup differences among the Starpen and Septodont syringe groups were found to be statistically significant (P &lt; 0.001) during both LA and extraction when pain was objectively assessed using FLACC. Conclusion: Computerised devices such as Starpen offer controlled release of local anaesthetics, effectively decreasing pain perception in paediatric patients and can form a mainstay for the behaviour management of young patients.

Histological assessment of potential inferior alveolar nerve injury following osteotomy of the mandibular buccal cortex using a piezoelectric saw.

The present study aimed to evaluate the effect of Piezosurgery on histopathologic features of the inferior alveolar nerve (IAN) damage after osteotomy of the buccal cortex of the mandible using piezoelectric devices in Hamdani sheep.A total of ten healthy mature female sheep were included. Each side of the mandible underwent two different experiments: the first experiment operated directly on the mental nerve by touching and activating the piezo tip on the nerve for ten seconds for the left side and thirty seconds for the right side. In the second experiment, the inferior alveolar nerve was touched by an activated piezo tip inside the mandibular canal for ten seconds on the left side and thirty seconds on the right side. All the nerve samples underwent histopathological evaluation, and the scoring system was performed to assess the nerve structures. Mental nerves exposed to piezo tip for 10 seconds showed mild abnormality including disruption of the perineurium with the endoneurium remaining intact. Mental nerves exposed for 30 seconds showed moderate injury with destruction of the perineurium and moderate degeneration of nerve fibers, nevertheless, the endoneurium remained continuous with normal node of Ranvier. Severe damage of the inferior alveolar nerve was seen after exposure to piezo tip for 10 seconds, which showed sloughing of the perineurium and severe vacuolar degeneration of nerve fibers, partial disruption of the endoneurium; however, the axons were still intact. Inferior alveolar nerves exposed for 30 seconds revealed destruction of the perineurium, marked vacuolar degeneration of nerve fibers, focal damage of axon and loss of endoneurium (axonotmesis).Piezosurgery devices have the potential to cause severe nerve damage during surgery and should be used very carefully.

Impacted third molar surgery in older patients—Is patient´s age really a risk factor for complications?

ObjectivesThe aim of this study was to analyze the influence of patients´ age on perioperative complications in impacted third molar surgery and how established risk factors are affected by age.Materials and methodsThe clinical findings, digital panoramic radiographs and perioperative data of 200 patients (554 impacted third molars) that had been subjected to tooth extraction, from July 2023 until July 2024, were analyzed. Perioperative complications (Inferior alveolar nerve (IAN) hypesthesia, oroantral communication (OAC), lingual nerve (LN) hypesthesia, postoperative bleeding, postoperative infection) as well as impaction patterns and risk factors (angulation type, bone coverage, depth- and risk scores) were analyzed by age (cut-off 30 years).ResultsThe population was divided into two groups by age (Group A = ≥ 30 years (n = 52) vs. Group B = < 30 years (n = 148)). Upper third molars showed significantly deeper bone coverage, higher depth scores, higher risk scores and different angulation types in patients aged < 30 years. Mandibular third molars showed significantly deeper bone coverage, higher depth scores, higher risk scores according and different angulation types in patients aged ≥ 30 years. However, IAN hypesthesia, LN hypesthesia, postoperative bleeding and postoperative infection did not show any significant differences regarding patients’ age.ConclusionThe current findings suggest that age (cut-off 30 years) does not statistically correlate with a higher risk for postoperative complications in impacted third molar surgery in contrast to recent publications.Clinical relevanceIn contrast to recent publications, the present study falsified a positive correlation between patients’ age and the occurrence of postoperative complications in impacted third molar surgery. Therefore, other risk factors should be investigated in order to minimize these procedure specific complications.