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1. PERIODONTALFLAP
SURGERIES

2. INTRODUCTION
“Periodontal Flap Surgeries are the procedures performed to
eliminate the microbial flora causing periodontitis and to reduce the
progression of the disease.”
Periodontal therapy is performed for the following purposes:
Controlling or eliminating periodontal disease.
Correcting anatomic conditions that favour periodontal disease or
esthetic impairment.
Placing implants to replace lost tooth and improving environment
for their placement and function.

3. HISTORICAL ASPECT
• 1884, Robicsek proposed deep gingivectomies with removal of bones.
• 1882-1958 , Robert Neumann described the first flap surgical technique used in
periodontal therapy was for gaining access to diseased root surface and alveolar bone.
He was the first person who described the principles of flap surgery and published a
book entitled ‘DIE ALVEOLAR PYRRHOEA UND IHRE BEHANDLUNG’ in 1912.
• 1916, Widman gave the modification of Neumann’s flap which was later published in
1918.
• 1932, Olin Kirkland presented the modified flap operation technique
• During 1930's and 1940’s Gingivectomy became the most popular method of pocket
elimination.
• 1950s-Staffileno developed Partial thickness palatal flap.
• 1954, Nabers described a procedure called “repositioning of the attached gingiva.” For
the first time, a mucoperiosteal flap was apically positioned after treatment.

4. • 1960-Wilderman developed Full thickness flap.
• In 1962, Friedman coined the term “apically reposition flap”.
• In 1965, Melvin L. Morris introduced flaps for reattachment ‘unrepositioned
mucoperiosteal flap’ – simple mucoperiosteal flap, combined with internal bevel incision
and osseous resection.
• In 1966 Robinson, he developed the Distal Wedge procedure in order to treat periodontal
pockets adjacent to the distal surfaces of the molars.
• In 1974 Ramfjord; Nissle, modified the technique initially described by Widman, in 1916,
turning it into a conservative procedure.
• In 1979, Carranza classified flap as full thickness flap and partial thickness flap.
• In 1985- Takei Et Al introduced PAPILLA PRESERVATION FLAP In order to preserve the
interdental soft tissue for maximum soft tissue coverage for treatment of proximal
osseous defects
• In 1990, Carranza classified flap according to their placement as non-displaced and
displaced flaps.

5. OBJECTIVES
• Access to roots and alveolar bone
• Enhance visibility
• Increase scaling and root planing effectiveness
• Less tissue trauma
• Modification of osseous defects
• Establish physiologic architecture of hard tissues through
regeneration or resection
• Augment alveolar ridge defects
• Repair or regeneration of the periodontium
• Pocket reduction
• Enhance maintenance by patient and therapist
• Improve long-term stability
• Provide acceptable soft tissue contours
• Enhance plaque control and maintenance
• Improve esthetics.

6. INDICATIONS
• Areas with irregular bony contours, deep craters & other defects
usually require surgical approach.
• Pockets on teeth in which a complete removal of root irritants is not
considered clinically possible may call for surgery. This occurs
frequently in molar & premolar areas.
• In cases of furcation involvement of grade II or III, a surgical
approach ensures the removal of irritants, any necessary root
resection or hemisection also requires surgical intervention.
• Intrabony pockets on distal areas of last molars, frequently
complicated by mucogingival problems, are usually unresponsive to
nonsurgical methods .

7. CONTRAINDICATIONS
 Poor Patient cooperation
 Cardiovascular disease
• Uncontrolled hypertension
• Unstable Angina
• Myocardial infarction
• Anticoagulant therapy
• Rheumatic endocarditis, congenital heart lesions, and heart/vascular implants
 Organ transplants
 Blood disorders
• Acute leukaemia’s
• Agranulocytosis
• Lymphogranulomatosis
 Hormonal disorders
• Uncontrolled diabetes
• Adrenal dysfunction
 Neurologic disorders
• Multiple sclerosis and Parkinson’s disease
• Epilepsy
 Smoking —more a limiting factor than a contraindication
 Poor plaque control and High caries rate.

8. Critical Zones
Criteria for the selection of one of the different surgical techniques
for pocket therapy are based on clinical findings in the soft tissue
pocket wall, tooth surface, underlying bone & attached gingiva.

9. Zone 1: Soft Tissue Pocket
Wall
• Morphologic features,
• Thickness & topography of the soft
tissue pocket wall &
• Persistence of inflammatory changes
in the wall
Zone 2: Tooth Surface
• Presence of deposits & alterations on
the cementum surface
• Accessibility of the root surface to
instrumentation.
• Evaluation of the results of Phase I
therapy should determine the need for
further therapy & the method to be
used
Zone 3: Underlying Bone
• Establish the shape & height of the
alveolar bone next to the pocket wall
through careful probing & clinical &
radiographic examination.
• Bony craters, horizontal or angular
bone losses & other bone deformities
are important criteria
Zone 4: Attached Gingiva
• Presence or absence of an adequate band of
attached gingiva when selecting the pocket
treatment method.
• An inadequate attached gingiva may be caused
by a high frenum attachment, marked gingival
recession, or a deep pocket that reaches the level
of the mucogingival junction. All these possible
conditions should be explored & their influence on
pocket therapy determined.
Critical Zones

10. INCISION
Incision is defined as “a cut or surgical wound made by a knife,
electrosurgical, scalpel, laser, or other such instrument.”
TYPES OF INCISIONS
Horizontal incisions
i. Internal bevel incisions
ii. Crevicular incisions
iii. Interdental incisions
Vertical incisions

11. INTERNAL BEVEL INCISION
• This incision is made to reflect the flap and to expose
underlying bone and root.
• It removes pocket lining
• Conserves the relatively uninvolved outer surface of gingiva.
• It produces a sharp, thin flap margin for adaptation to the
bone- tooth junction.

12. CREVICULAR INCISION
• This incision is made from the base of the pocket to the
crest of the bone. This incision, together with the initial
reverse bevel incision forms a V shaped wedge ending at
or near the crest of the bone.

13. INTERDENTAL INCISION
• The incision is made in a horizontal direction and close to
the surface of the bone crest, thereby separating the soft
tissue collar from the root surfaces and the alveolar
bone.

14. VERTICAL INCISION
• Vertical incision must extend beyond the mucogingival
line. It should be made at the line angles of the tooth
either to include the papilla in the flap or to avoid it
completely.

15. TYPES OF FLAPS
There are three basic types of flaps;
 Based on bone exposure after reflection:
• Full thickness flap
• Split/partial thickness flap
 Based on flap placement after surgery:
• Non displaced flap
• Displaced flap
 Based on Management of Papilla:
• Conventional flap
• Papilla Preservation flap

16. BASED ON BONE EXPOSURE
AFTER REFLECTION
FULL THICKNESS
FLAP
• All the soft tissues
including periosteum
is reflected to expose
the underlying bone.
SPLIT THICKNESS
FLAP
• The bone remains
covered by a layer of
connective tissue,
including the
periosteum.

17. BASED ON FLAP PLACEMENT
AFTER SURGERY
NONDISPLACED
FLAP
• The flaps which are
returned and sutured
to its original
position.
DISPLACED FLAPS
• These flaps are
placed apically ,
coronally, or laterally
to their original
position.

18. BASED ON MANAGEMENT OF
PAPILLA
Conventional Flap
• The interdental gingiva is
split beneath the contact
point of the two
approximating teeth to
allow for the reflection of
the buccal and the lingual
flaps.
• e.g. Modified Widman,
Apically displaced and flap
for reconstructive purposes.
Papilla
Preservation Flap
• Incorporates the entire
papillae in one of the flaps
by means of crevicular
interdental incisions to
severe the connective
tissue attachment and a
horizontal incision at the
base of the papillae,
leaving it connected to the
flap.

19. Pocket Therapy
Pocket Reduction:
Resective
• Gingivectomy
• Apically Displaced Flap
• Undisplaced Flap with/ or
without Osseous Resection
Regeneration
• Flap with grafts, membranes,
etc.
Pocket Elimination:
• Modified Widman Flap
• Undisplaced Flap
• Apically Displaced Flap

20. FLAP TECHNIQUE FOR
POCKET THERAPY
• Gingivectomy
• Neumann Flap
• Modified Flap Operation
• Undisplaced flap
• Apically repositioned flap
• Original Widman Flap
• Modified Widman flap
• Palatal Flap

21. GINGIVECTOMY
• The utilization of the gingivectomy procedure for the
elimination of periodontal pockets was pioneered by Robicsek
(1884) and documented in the latter part of the nineteenth
century as described by Zentler in 1918.
• Gingivectomy was later defined by Grant et al. (1968) as being
“the excision of the soft tissue wall of a pathological
periodontal pocket”.

22. TECHNIQUE:

24. Indications:
• Elimination of suprabony pockets, regardless of their
depth, if the pocket wall is fibrous and firm.
• Elimination of gingival enlargements.
• When bone loss is horizontal and no need exists for
osseous surgery
• Areas of limited access
• Unesthetic or asymmetric gingival topography
• For exposure of soft tissue impaction to enhance
eruption
• To facilitate restorative dentistry

25. Contraindications:
• The need for bone surgery or examination of the bone
shape and morphology.
• The situations in which the bottom of the pocket is apical
to the mucogingival junction.
• Aesthetic considerations, particularly in the anterior
maxilla.
• An inadequate zone of keratinized tissue.
• Highly inflamed or oedematous tissue.
• Shallow palatal vaults and prominent external oblique
ridges.
• Treatment of intrabony pockets.
• Patients with poor oral hygiene.

26. ExcisionalNewAttachmentProcedure(ENAP):
It is definitive subgingival curettage procedure performed with a knife.
The technique is as follows:
1. After adequate anesthesia, make an internal bevel incision from the
margin of the free gingiva apically to a point below the bottom of the
pocket. Carry the incision interproximally on both the facial and the
lingual side, attempting to retain as much interproximal tissue as possible.
The intention is to cut the inner portion of the soft issue wall of the
pocket, all around the teeth.
2. Remove the excised tissue with a curette, and carefully perform root
planing on all exposed cementum to achieve a smooth, hard consistency.
Preserve all connective tissue fibers that remain attached to the root
surface.
3. Approximate the wound edges; if they do not meet passively; recontour
the bone until good adaptation of the wound edges is achieved.
4. Place sutures and a periodontal dressing.

27. Healing After Gingivectomy:
• The initial response after Gingivectomy is the formation of a
protective surface clot.
• The clot is then replaced by the Granulation tissue.
• By 24 hours, there is an increase in new connective tissue
cells, mainly angioblasts, just beneath the surface layer of
inflammation and necrosis.
• By the third day, numerous young fibroblasts are located in
that area.
• Capillaries derived from blood vessel of periodontal ligament
migrate into the granulation tissue, and within 2 weeks, they
connect with gingival vessels.
• After 12 to 24 hours, epithelial cells at the margins of the
wound start to migrate over the granulation tissue,
separating it from the contaminated surface layer of the clot.

28. • After 5 to 14 days, surface epithelialization is generally
complete.
• Complete repair of the connective tissue takes about 7
weeks.
• Although the tissue changes that occur in post gingivectomy
healing are the same in all individuals, the time required for
complete healing varies considerably, depending on the area
of the cut surface and interference from local irritation and
infection.
• In patients with physiologic gingival melanosis, the
pigmentation is diminished in the healed gingiva.

29. NEUMANN FLAP
• Neumann in 1912.
• His technique involved up to 6 teeth, used vertical releasing incisions at the
interdental papillae that extended to the mucobuccal fold.
• Neumann described his technique as “the radical treatment of alveolar
pyorrhea.”

30. ComparisonBetweenNeumanFlapandWidmanFlap
NEUMANN FLAP WIDMAN FLAP
1. When no lingual pockets only buccal or
labial flap
Both buccal & lingual in all cases of
periodontitis
2. Provisional splinting must be done prior
to surgery.
Considers unnecessary as it interferes
with surgery & done only after surgery
if required
3. Divided mouth into sextants for surgery. Divided into three teeth area.
4. Used intra crevicular incision for lifting
the entire gingiva.
Gingival incision followed outline of
gingival margin.
5. Less tiring for the patients
Larger surgical area gave better results in
terms of tissue contour.
More tiring

31. MODIFIED FLAP OPERATION
• In 1931, Kirkland described a surgical procedure to be used in the
treatment of "periodontal pus pockets".
• Basically an access flap for proper root debridement.
• The first description of the flap procedure for the purpose of reattachment
was given by Kirkland in 1931, when he demonstrated the basic gingival
mucoperiosteal flap design of Neumann in 1920 for the original flap, but
instead of trimming the flap for surgical pocket elimination, he attempted
to eliminate the crevicular epithelial lining and the inflamed connective
tissue by curettage of the flap.

32. TECHNIQUE:

33. Advantages:
In contrast to the original Widman flap as well as
the Neumann flap, the Modified Flap Operation
did not include:
• Extensive sacrifice of non-inflamed tissues.
• Apical displacement of the gingival margin.
Another advantage of the Modified Flap Operation
was the potential for bone regeneration in
intrabony defects.

34. UNDISPLACED FLAP
• In 1965, Morris described a technique known as “Unrepositioned
Mucoperiosteal Flap”.
• Currently, the undisplaced flap may be the most frequently
performed type of periodontal surgery.
• In this technique, the soft tissue pocket wall is removed with the
initial incision, thus it may be considered as an “internal bevel
gingivectomy”.
• To perform this technique without creating mucogingival problem,
the clinician should determine that enough attached gingiva will
remain after removal of the pocket wall.

36. Advantage:
• Removes the pocket wall.
Disadvantages:
• Poor aesthetics.
• Root exposure leading to sensitivity and caries.

37. APICALLYREPOSITIONEDFLAP
• In 1957, Nabers proposed, replacing the marginal trimming of the gingiva
with an internal bevel incision This resulted in a thinner gingival margin that
was positioned apically and sutured loosely without leaving alveolar bone
uncovered.
• In 1957, Ariaudo and Tyrrell modified Nabers technique
• In 1962, Friedman proposed the term apically repositioned flap to describe
it more appropriately Friedman emphasized the fact that, at the end of the
surgical procedure, the entire complex of the soft tissues (gingiva and
alveolar mucosa) rather than the gingiva alone was displaced in an apical
direction.
The position of the flap displacement varies depending on the:
• Thickness of alveolar margin in operating area.
• Width of attached gingiva.
• Clinical crown length necessary for an abutment.

38. INDICATIONS:
• Pocket eradication
• Widening of zone of attached gingiva
• To lengthen the crown for prosthetic treatment
• To improve gingival and gingival- alveolar bone morphology

39. CONTRAINDICATIONS:
• Periodontal pockets in severe periodontal disease.
• Periodontal pockets in areas where esthetics is critical.
• Deep intrabony defects.
• Patient at high risk for caries.
• Severe hypersensitivity.
• Tooth with marked mobility and severe attachment loss.
• Tooth with extremely unfavourable clinical crown/root
ratio.

40. TECHNIQUE:

42. Forperiodontalpocketsonthepalatalaspectofthemaxillaryteeth,Friedman
describedamodificationoftheapicallyrepositionedflap, whichhe
termedthe“bevelledflap”.

43. Advantages:
• Minimum pocket depth post-operatively
• If optimal soft tissue coverage of the alveolar bone is
obtained, the post-surgical bone loss is minimal
• The post-operative position of the gingival margin may
be controlled and the entire muco-gingival complex may
be maintained.
• Preserves attached gingiva and increase its width.
• Establishes gingival morphology facilitating good oral
hygiene.
• Ensures healthy root surface necessary for the biologic
width on alveolar margin and lengthened clinical crown.

44. Disadvantages:
• Sacrifice of periodontal tissues by bone resection and
subsequent exposure of root surfaces (which may cause
esthetic and root sensitivity problems).
• May cause attachment loss due to surgery.
• May increase the risk of root caries.
• Unsuitable for treatment of deep periodontal pockets.
• Possibility of exposure of furcations and roots, which
complicates postoperative supragingival plaque control.

45. ORIGINALWIDMANFLAP:
• 1918 by Leonard Widman.
• Aimed at removing the pocket epithelium and the inflamed
connective tissue, thereby facilitating optimal cleaning of the
root surfaces.

46. TECHNIQUE:

47. Advantage:
• Less discomfort for the patient, since healing occurred by
primary intention.
• It was possible to re-establish a proper contour of the alveolar
bone in sites with angular bony defects.

48. MODIFIED WIDMAN FLAP
• Essentially the same procedure by Morris was presented in 1974 by Ramfjord
& Nissle, who called it the “Modified Widman flap”
• This procedure offers the possibility of establishing an intimate postoperative
adaptation of healthy collagenous connective tissue to the tooth surfaces and
provides access for adequate instrumentation of the root surfaces and
immediate closure of the area.
• The objective of the modified Widman Flap was not eradication of pocket
walls, but rather to obtain a "maximum healing in areas of previous
periodontal pockets with minimum loss of periodontal tissues during and
after the surgery."

49. Technique:

50. MODIFIEDWIDMANSFLAP

51. Advantages:
• The possibility of obtaining a close adaptation of the soft
tissues to the root surfaces.
• The minimum of trauma to which the alveolar bone and
the soft connective tissues are exposed.
• Less exposure of the root surfaces, this, from an esthetic
point of view is an advantage in the treatment of anterior
segments of the dentition.
• Amenable to oral hygiene procedures, with potential less
root sensitivity and fewer root caries problems.

52. Disadvantages:
• Inability to achieve pocket elimination.
• Difficult to perform in thin and narrow attached gingiva.
• Flat or concave interproximal architecture immediately
following removal of the surgical dressing, especially in
the areas of the interproximal bony craters.
• Following attempts to perform modified Widman flap
often gives poor results with residual inflamed and deep
periodontal pockets.
• Technically demanding and exacting
• Requires a high degree of technical skill

53. PALATAL FLAP
• The surgical approach to the palatal area differs from that of other areas
because of the character of the palatal tissue and the anatomy of the area.
The palatal tissue is all attached, keratinized tissue and has none of the elastic
properties associated with other gingival tissues. Therefore the palatal tissue
cannot be apically displaced, nor can a partial (split) thickness flap be
accomplished.
• The palatal flap procedure historically involved reflecting a full-thickness flap
to gain access to the underlying bone and remove necrotic and granulomatous
tissue. It was not until Ochsenbein and Bohannan (1963, 1964) described a
palatal approach for osseous surgery that precise palatal surgical techniques
were described and developed.

55. Indications (Ochsenbein and Bohannan):
• Areas that require osseous surgery
• Pocket elimination
• Reduction in enlarged and bulbous tissue
Contraindications (Ochsenbein and Bohannan):
• The palatal approach procedure is contraindicated when a broad,
shallow palate does not permit a partial-thickness flap to be raised
without possible damage to the palatal artery.

56. Advantages of the Palatal Approach (Ochsenbein and Bohannan)
• Esthetics
• Easier access for osseous surgery
• Wider palatal embrasure space
• A natural cleansing area
• Less resorption because of thicker bone
Disadvantages of the Buccal Approach (Ochsenbein and Bohannan)
• Esthetics
• Close root proximity
• Possible involvement of the buccal furcation
• Thin plate of bone overlying the maxillary molars where dehiscence and
fenestrations may be present

57. Distal Wedge Procedure
• Treatment of periodontal pockets on the distal surface of terminal molars is
often complicated by the presence of bulbous tissue over the maxillary or
prominent retromolar pads in the mandible. Deep vertical defects are also
often present in conjunction with the redundant fibrous tissue. Some of these
osseous lesions may result from incomplete repair after the extraction of
impacted third molars.
• The gingivectomy incision is the most direct approach in treating distal
pockets that have adequate attached gingiva and no osseous lesions.
• However, the flap approach is less traumatic post-surgically, because it
produces a primary closure of wound rather than the open secondary wound
left by a gingivectomy incision. In addition, it results in attached gingiva as
well as provides access for examination and, if needed, correction of the
osseous defects. Procedures for this purpose were described by Robinson,
1966 and Braden, 1969 and modified by several other investigators.

58. Technique:

59. RESECTIVEANDREGENERATIVEPROCEDURES
RESECTIVE PROCEDURES:
• With shallow bony defects with moderate periodontitis with
moderate periodontal pockets(5-6mm) resective procedures
such as apically positioned flap with or without osseous
resection help to create a shallow gingival sulcus and
physiologic morphology in which bone and gingiva are in
harmony so that an easy-to-maintain periodontal environment
is achieved.

60. REGENERATIVE PROCEDURE
• With deep intrabony defects resective procedures may result
in bone resection and reduction of supporting tissues.
• Therefore various regenerative procedures are performed.

61. Reconstructive Surgical Techniques
1. Non-Bone Graft-Associated Procedures:
A. Removal of Junctional and Pocket Epithelium
I. Curettage
II. Chemical agent
III. Surgical technique
B. Prevention or Impeding The Epithelial Margin
C. Clot Stabilization, Wound protection and Space
Creation:
I. Guided Tissue Regeneration(GTR)
D. Biodegradable Membrane

62. 2. Grafts Materials and Procedures:
A. Autogenous Bone Graft
I. Bone from Intraoral site
II. Bone from Extraoral site
B. Allografts
I. Undecalcified freeze-dried Bone allografts
II. Demineralised freeze-dried Bone allografts
C. Xenografts
D. Non Bone graft Materials
3. Biologic mediator
4. Enamel Matrix Protein
5. Combined technique

63. Flaps For Reconstruction and
Regeneration

64. PAPILLAPRESERVATIONTECHNIQUE:
• In order to preserve the interdental soft tissues for maximum soft
tissue coverage following surgical intervention involving treatment of
proximal osseous defects, Takei et al. (1985) proposed a surgical
approach called papilla preservation technique.
• Later, Cortellini et al. (1995, 1999) described modifications of the flap
design to be used in combination with regenerative procedures. For
esthetic reasons, the papilla preservation technique is often utilized in
the surgical treatment of anterior tooth regions.

65. Technique:

66. ModifiedPapillaPreservationTechnique
• To overcome the disadvantage of papilla preservation technique
developed by Takei, Cortellini et al. developed a modification of the
above mentioned technique in 1995.
• The rationale for developing this technique was to achieve and
maintain primary closure of the flap in the interdental space over
the membrane.

67. Technique:

68. Simplified Papilla Preservation Flap
• To overcome some of the technical problems encountered
with the MPPT a different approach i.e. Simplified Papilla
Preservation Flap, SPPF, was subsequently developed
(Cortellini et al. 1999).

69. MinimalInvasiveSurgicalTechnique(Mist)
• In order to provide even greater wound stability and to further limit
patient morbidity, a papilla preservation flap can be used in the
context of a minimally invasive, high-power magnification-assisted
surgical technique (Cortellini & Tonetti 2007).
• Such a minimally invasive approach is particularly suited for
treatment in conjunction with biologically active agents such as
enamel matrix derivatives or growth factors.

70. Periodontal Dressing
Periodontal dressings are mainly used:
• To protect the wound postsurgically,
• To obtain and maintain a close adaptation of the mucosal flaps
to the underlying bone (especially when a flap has been apically
repositioned) and
• For the comfort of the patient.

71. • A commonly used periodontal dressing is which is supplied in two tubes.
One tube contains oxides of various metals (mainly zinc-oxide) and
lorothidol (a fungicide).
Second tube contains non-ionizing carboxylic acids and chlorothymol (a
bacteriostatic agent).
• A light curing dressing, e.g. Barricaid (is useful in the anterior tooth region
and particularly following mucogingival surgery, because it has a favourable
esthetic appearance and it can be applied without dislocating the soft
tissue. However, the light curing dressing is not the choice of dressing to be
used in situations where the flap has to be apically retained, due to its soft
state before curing.
• Cyanoacrylates have also been used as periodontal dressings with varying
success. Dressings of the cyanoacrylate type are applied in a liquid directly
onto the wound, or sprayed over the wound surface. Its use is rather limited
at present.

72. PostOperativeInstructions:
• Patient should be given analgesics and antibiotics and told to start the tablets before
the effect of anesthesia wears off and continue the tablets for the require duration of
time. Aspirin should be avoided as it causes bleeding.
• Patient should be instructed that he should not consume any food for few hours after
the placement of periodontal pack (until it hardens) to prevent it from dislodgment. In
case the pack gets dislodge, the patient should immediately consult his periodontist.
• For the first 24 hours, patient should avoid hot liquids and should have only semisolid
or minced foods and should chew from the non – operated site.
• Citrus fruits, fruit juices, alcoholic beverages and highly spiced foods should be
avoided.
• Patient should not smoke.
• Patient should be asked to take adequate bed rest and avoid speaking.
• Patient should be advised not to brush on the operated area and use chlorhexidine
mouthwash.
• Patient should not try to remove the periodontal dressing himself.
• In case of bleeding he should immediately contact the periodontist and avoid spitting.
• To ease any postoperative swelling, patient should apply cold pack.

73. Complications of Flap Surgery
• Syncope
• Anaphylaxis
• Angina
• Acute Adrenal Insufficiency
• Seizures
• Haemorrhage

74. Post-Operative Complications
• Persistent Bleeding after Surgery
• Pain
• Swelling and Hematoma
• Sensitivity to Percussion
• Feeling of Weakness