13 October 2021

---

Implant rehabilitation in Von Willebrand's disease: a case resistant to desmopressin

Authors: Christian Bacci, Alessia Cerrato, Gastone Zanette, Anna Grigoletto, Ludovica Pampaloni, Ezio Zanon

---

Aim of the study: To describe a multidisciplinary approach in the treatment of a patient with VWD

Introduction: Von Willebrand disease (VWD) is an autosomal hereditary disease caused by quantitative or qualitative defects in the von Willebrand factor (VWF), with a prevalence of approximately 1%, caused by hereditary defects in the concentration, structure or function of VWF. The values of healthy patients could vary from 50/55 to 200 IU/dL.

Many patients respond favorably to the stimulation of the release of endogenous VWF by Desmopressin (DDAVP), otherwise the therapy of choice is the replacement with plasma-derived products with a substantial content of VWF and FVIII, clearly based on the type-related bleeding risk of surgery .

Implant surgery and oral surgery in general are in any case to be considered "minor surgery" in which the risk of blood loss is very low overall, therefore if possible, there is an indication for prophylaxis and therapy of perioperative bleeding with DDAVP, if the patient is responsive, with VWF rich FVIII concentrates in other cases.

Materials and Methods: 60-year-old male patient with VWD without other pathologies and under drug therapy, moderate smoker with request for rehabilitation for distal edentulism with impaired chewing function that caused TMJ dysfunction, muscle contracture and dental abrasion.

The treatment plan is shared between the oral surgeon, internist and anesthesiologist. From an internist point of view, since it is a patient with VWD type 2 B, an infusion with blood derivative of factor VIII and VWF (Haemate P, CSL Behring S.p.A) 2000 IU e.v. and tranexamic acid.

From the dental point of view, it was decided to perform implants with flapless technique, to perform a post-extractive implant in seat 44 and tilted implant in the left maxillary seat, as an alternative to sinus graft.

From an anesthesiological point of view, it is decided to proceed with local anesthesia associated with mild sedation with intravenous benzodiazepines in order to be able to provide adequate comfort to the patient by safely carrying out the scheduled surgery in a single session and to reduce the adrenergic stimulis with consequent hemodynamic stability.

At the time of surgery, the healing abutments were positioned directly to avoid a second surgery.

The operative and post-operative course was regular, without any bleeding.

Implant connection was performed with diode laser without therapy.

We then proceeded to the prosthetic and then conservative rehabilitation of the other dental elements without ever further systemic therapies and without recording bleeding episodes.

Results and Conclusions: The description of this case illustrates a valid and safe therapeutic possibility for the dental treatment, even invasive, of the patient with VWD.

Clinical significance: This case report provides an example of how these patients could be treated. Bleeding complications can be avoided using plasma-derived drugs and conservative treatments can be performed even without systemic teraphy.