Complications of tooth extraction and its management (oral surgery)
COMPLICATIONS OF TOOTH
EXTRACTION AND ITS MANAGEMENT
BY MUHAMMAD SHARIQ
FINAL YEAR BDS
1)Problems with a tooth being extracted
2)Injuries to adjacent teeth.
3)Post operative bleeding
5)Injuries to adjacent structures
6)Delayed healing and infection.
7)Injuries to ossoeous structures
8)Soft tissue injuries.
10)Fracture of mandible.
PROBLEMS WITH A TOOTH BEING EXTRACTED
3)Tooth loss into Phayrnx
INJURIES TO ADJACENT TEETH
1)Fracture or dislodgement of an adjacent restoration.
2)Luxation of adjacent tooth
3)Extraction of wrong tooth
POST OPERATIVE BLEEDING
1)Obtain a history of bleeding
2)Use of atraumatic surgical technique
3)Obtain good hemostasis at surgery.
4)Provide excellent patient instructions.
Oroantral Communication (OAC) is an abnormal communication between
the maxillary sinus and the oral cavity.
1)Conduct a thorough preoperative radiographic examination.
2)Use surgical extraction early and section roots
3)Avoid excessive apical pressure on maxillary posterior teeth.
INJURIES TO ADJACENT STRUCTURES
1)Injury to regional nerves
2)Injury to Temporomandibular joint.
DELAYED HEALING AND INFECTIONS
a)Most common cause of delayed wound healing
b)Seen usually which involves reflection of soft tissue flaps and bone removal.
c)Careful asepsis an thorough wound debridement can prevent this
d)Prophylactic antibiotic can be given.
a)Use aseptic technique
b)Perform atraumatic technique
c)Close the incision over intact bone.
d)Suture without tension.
3)DRY SOCKET(ALVEOLAR OSTEITIS):
a)Severe pain without usual signs of infection(Fever ,erythema etc).
b)Pain develops after 3 or 4 day after removal of teeth(usually lower molar)
c)Fibrinolytic activityLysis of blood clotExposure of bonepain
d)Treatment= Irrigation and placement of medicated dressing(Alvogel)
e)Alvogyl = Eugenol(anesthetic), Benzocaine/Butamben(anesthesia),
INJURIES TO OSSEOUS STRUCTURES
1)Fracture of the alveolar process
a)Thorough preoperative clinical and radiographic examinations
b)Donot use excessive force
c)use surgical technique to reduce the force required.
D)buccal corticol plate over maxillary canine an molars, Portions of floor
of maxillary sinus, Labial bone over mandibular incisors.
2)Fracture of maxillary tuberosity
a)Maxilary tuberosity fractures most commonly result from extraction
of the second molar, if it is last tooth in the arch.
b)Finger support can be used during fracture if bone is attached to peri
c)If mobile Splint the teeth and defer sugery for 6-8 weeks
Section crown from the roots.
D)If completely separated ->smooth sharp edges of remaining bone and
suture remaining soft tissue.
SOFT TISSUE INJURIES
1)TEAR OF A MUCOSAL FLAP:
a)creating adequately sized flaps.
B)Using controlled amount of retraction force.
C)Creating releasing incisions when indicated.
If a punture wound does occur in the mucosa the ensuring treatment
is primarily aimed at preventing infection and allowing healing to occur
usually by secondary intention.
3)STRETCH OR ABRASION:
a)By rotating shank of bur or by metal retractor.
B)If in oral mucosaregular oral rinsing heal in 4-7 days.
C)If on skinanbiotic oinment can be used.
1)Extraction of multiple impacted teeth with reflection of soft tissue and
removal of bone may result in moderately large amounts of swelling.
And can reach to its maximum in 36-48 hours after surgery.
2)Increase swelling after third day may be an indication of infection.
3)Initially ice packs and later on on 3rd or 4rth post surgical day heat may
help t oresolve swelling more quickly.
4)Patient reassurance an counselling about edema is necessary.
a)Excessive soft tissue manipulation.
B)Bone tissue removal.
C)Extended surgical time.
FRACTURE TO MANDIBLE
Associated almost exclusively with the surgical removal of impacted
Usually result of the application of force exceeded that needed to
remove a tooth .
The fracture must be adequately reduced and stabilized.
Root fracture: -most common - long,curved,divergent roots that lie in dense bone are most likely to be fractured. -careful procedure can be done to prevent it or open surgical technique can be used to remove tooth.Root displacement: 1)first try to access size of root diplaced2) secondly check that there is any infection or not3)asscess preoperative condition of maxillary sinus4)If displace tooth root is small 2-3mm and sinus have no preexisting infection surgeron should make brief attempt to rmove it.5)radiograph should be taken to asscess postion of root fragement6)irrigate thorugh socket and suction it so it occasionally flush out the fragement7)check suction solution an radiographically to confirm8)if this procedure not successful and if tip in uninfected so it can be left behind if its symptomless9)pateint should be ressasuure about condition10)oroantral communication sholud be managed11)root may be fibrose into sinus membrane with no subsequent problems.12)if root tip is infected so it can be reffere to maxilofacial surgeon and can be renove by caldwell luck aor endoscopic techniquetooth lost into phayrnx:1)Face the mouth of pateint toward floor2)patient sholud advice to cough and try to spit tooth out3)if no repsiratory distress r cough can be seen means teeth has been into osephagous4)it can be aspirated into vocal cords to trachea and into mainstream bronchus5)pateint should be transferd to emregency an radiographs should be taken to confirm the position of tooth .6)if aspirated maintain pateints breathing and airway and should prvovide supplemental oxygen7)if swalloed probably it will passed in 2-4 days from git.8)follow up radiographs shoul be taken.
Fracture: chances that restoratraion of ajdacent teeth can be damaged or there are chances of fracture or damage to opposite tooth ,chipping or fracturing a cusp.usually occurs in lower teeth because teeth require vertical traction. 1)avoid use of excessive tractional forces 2)the tooth sholud be luxate properly with apical buccolinugal and rotaional forces to minimixe need for vertical traction.. 3) if injury happens toot hshould be smoothend or restored as necessary to keep patents comfortable.Luxation: forceps with broad beaks shoul be avoided if teeth are crowded it may cause injury or luxation. 1)if adjacent tooh is luxated or avulsedtreament goal is to reposition tooth in its position and stabilize it so that adequate healing can occur 2)repsotion the toot hin socket and left alone 3)may be mobile so tooth should be stablized with semi rigid fixation to maintain the tooth n its position. 4)silk suture can be done and is suture to ajacent gingiva is usally sufficent 5)rigid fixation with circumdental wires and arch bars results in increased chacnes for external root resorption and ankylossi of toothwrong tooth: 1)should be placed in socket immediately2)if for orthodontic purposes try to evaluate if they says that original tooth has to be removed so it sohuld be deferd for 4-5 weeks untill replanted tooth fate can be assessed3)if wrong tooth gained its attachemnt if jaws ,original tooth can be removed in addition surgeon should not remove contralateral tooth untill alternate treatment plan is made.4)if no other option or you observed it in next visist so dental implant supported restoration is necessary
1)The tisues of mouth and jaws are highly vascularized2)extraction of tooth leaves an open wound,with soft tissue and bone remaining open which allows additional ozzing and bleeding3)patient xplore area of surgery with toungue and dislodge clots.4)salivary enzymes may lyse the blood clots.It is normal for the socket to ooze small amounts of blood for the first 12-24 hours.if more than 24 hours than surgeon have to worry.Chek the INR of pateint sholud be less than 3.0atrauamtic surgery,with clean insicions and gentle managemnt of soft tissues.Care should be taken not to crush soft tissues because crushed soft tissues tends to ooze for longer period.1)Pressure pack for 30 minutes.2)Gel foam(absorbale gelatin which forms a scaffold for blood clot formation,figure of eight suture is done,and gauze pack is applied3)Oxidized regenrated cellulose.(e.g surgicel)used for persistent bleeding4)Topical thrombin5)cold rinses,pressure pack,tea bag.6)local anasthesia to prevent bleeding by vasocontrictions.
Nerves: most frequently involve branches are mental nerve , the lingual nerve, buccal nerve, nasopalatine nerve.Mental nerve is damaged or sectioned there are chnces that its sensation will not return.Lingual nerve on retromolar pad region,it rarely regenerates if it is severely traumatized.Three corner flap with vertical incisions should be used in area of premolar and canine to prevent sectining of mental nerve.TMJ: support the mandible during extration donot force open the mouth too widely.If tmj injury to after extractionmoist heat,resting the jaw, a soft diet, medications(600-800mg of ibuprofen for sevral days every 4hours)
Wound dehiscene: separation of wound edges:a common area of exposed bone after tooth extraction is the internal oblique ridge.After extraction of the first and second molars, during initial healing the lingual flap becomes stretched over internal oblique(mylohyoid ridge). Occasionally bone perforates through the mucosa,causing a sharp projection of bone in the area.Treatment: 1)leave the projection alone 2)To smooth it with bone fileonce the patient pain has been decreased the ressing should not be replaced because it acts as a forigen body an further prolongs wound healing.1-Butamben: Anaesthetic 2-Iodoform: Antimicrobial 3-Eugenol: Analgesic
1)The surgeon who is suporting the alveolar process with fingers during extration usually feels the fracture of the buccal corticol plate when it occurs.At this time the bone remains attached to periosteum and usually heals if it can be separated from the totth and is left attached to the overlyng soft tissue.
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