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1. [DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY]
COMPLICATION AND MANAGEMENT OF
TOOTH EXTRACTION
PRSENTING BY: RAHUL TIWARI
1
(+919074166916)

2. Introduction
• Any adverse , unplanned events that tend
to increase the morbidity above what
would be expected from a particular
operative procedure under normal
circumstances.
2

3. Sources of complications
Surgical complications may arise from either one or a
combination of the following factors.
 THE PATIENT- Medically compromised pt. leading to an
persistent haemorrhage or delayed healing.
 THE CLINICIAN
-level of training , skills and experience.
-attitudes towards total patient care.
 THE SURGICAL PROCEDURE
risks depend on :-
-complexity of the procedure.
-local anatomy of the surgical site
-proximity of important vital structures.

4. Possible complications
Failure to -secure anaesthesia
-remove the tooth with either
forceps or elevator
Fracture of-crown of the tooth /root
-alveolar bone
-maxillary tuberosity
-adjacent or opposing tooth
-mandible
4

5. Dislocation of -adjacent tooth
-TMJ
 Displacement of the root
-into the soft tissues
- maxillary antrum
 Excessive haemorrhage
- During tooth removal
- on completion of the extraction
- postoperatively 5

6. Damage to
- gums/lips/tongue/floor of mouth
- inferior dental nerve & branches
- lingual nerve
Postoperative pain
- damage to hard & soft tissues
- dry socket
- acute osteomyelitis of mandible
- traumatic arthritis of TMJ 6

7. Postoperative swelling due to:-
• Odema
• Haematoma formation
• Infection
 Trismus
 Oro-antral communication
 Syncope
 Respiratory arrest
 Cardiac arrest
 Anaesthetic emergencies.
7

8. 1-Failure to secure anaesthesia
• Faulty technique
• Insufficient dosage of anaesthetic agent
8

9. 9

10. 2-Failure to -remove the tooth with either
forceps or elevator
• Tooth fails to yield to the application of
reasonable force applied with either forceps
or elevator.
• Tooth dissection
10

11. 3-Fracture of the crown of a tooth
• Weakened tooth- caries or large restoration
• Improper application of the forceps
• Excessive force
MANEGMENT:
• proper application of forceps or elevator will deliver the
tooth or Transalveolar method
11

12. FRACTURED CROWN
12

13. 4-Root fracture
13
Root pattern
Faulty technique
MANEGMENT
Decide whether to leave or not?
Radiographic examination & transalveolar ext.

14. 14

15. 5-Fracture of the alveolar bone
• Accidental inclusion of alveolar bone within
forceps blades.
• Pathological changes in the bone
• Shape of the alveolus
• Extraction of canine is frequently complicated by
fracture of the labial plate.
• Alveolar fragments which has lost one half of the
periosteal attachment should be removed. if it well
attached to periosteum, should be sutured back
15

16. 16

17. 6-Fracture of maxillary tuberosity
Predisposing cause –
• Pathological gemination between the erupted
maxillary second molar & unerupted max.
third molar.
• Overerupted isolated max molar
17

18. 7-Fracture of an adjacent or opposing
tooth
• Precautions :
• Careful pre-op examination (carious, heavily
restored, loose, line of withdrawal)
• No force should be applied to any adjacent
tooth
• Other teeth should not be used as fulcrum for
an elevator.
• Any loose, heavily restored tooth should be
noted & brought to the notice of anesthetist.
18

19. 8-Fracture of the mandible
Excessive or incorrectly applied force
 Pathological changes of mandible
 osteoporosis
Atrophy
Osteomyelitis
 Previous therapeutic irradiation
Unerupted teeth, cysts, hyperparathyroidism
or tumours may also predispose to fracture
19

20. 20 FRACTURED MANDIBLE DUE TO EXCESSIVE FORCE

21. 9-Dislocation of adjacent tooth &
TMJ
 Causes same as those giving rise to fracture of adjacent tooth
 Elevator should not be placed on the mesial aspect of first
permanent molar.
 During elevation a finger should be placed upon the adjacent
tooth to support it .
Dislocation of TMJ
 Application of excessive force
 Failure to support the mandible while extracting a difficult
tooth
 More likely to occur under general anesthesia when
mastication muscles are relaxed
21

22. 22 DISLOCATION OF MANDIBLE

23. Management
• Reduction is done with the thumb wrapped with
gauze or bandage to avoid injury by teeth and
placed on the occlusal surfaces of mandibular
posterior teeth and finger under the lower border
of the mandible.
• Mandible is then pushed downward backward
rotating the chin upwards .with this manpower the
condyles are moved downwards and backwards
over the articular eminences of temporal bone.
23

24. 24

25. • Patient should be warned not to open his mouth too
widely or to yawn for postoperatively .patient is
instructed to support the jaw during yawning.
• extra oral bandage support for the joint is applied and
worn until tenderness in the affected joint subsides.
• Failure to reduce dislocation reduction can be
attempted under 5-10mg of IV/IM valium
• Failure to reduce the dislocation or if there is resistance
encountered LA solution is injected high in the buccal
sulcus bilaterally adjacent to max third molar region
similar to the technique of posterior superior alveolar
nerve block. This helps in paralyzing lateral pterygoid
muscles and over comes Muscular spasm
25

26. 10-Displacement of a root into the
soft tissues
• Ineffectual attempts to grip the root when
visual access is inadequate.
• Maxillary premolar or molar- palatal root.
• Predisposing factor – large antrum
26

27. 27
DISPLACED PALATAL ROOT OF MAXILLARY 1ST MOLAR

28. Simple rules to avoid displacement:-
Never apply forceps to a maxillary post. teeth
unless sufficient of its length is exposed, both
palatally & bucally .
Leave the apical one third of the palatal root
of a maxillary molar.
Never attempt to remove a # maxillary root by
passing instruments up the socket.
Any previous history of antral involvement
should not be disregarded.
28

29. 11-Aspiration of tooth/root
• Under GA – more common
• Anaesthetic should be stopped immediately
& patient’s head brought forwards.
• After cough reflex has returned the mouth is
examined & pack carefully removed &
inspected
• Radiographs – socket & chest
29

30. 30

31. 12-Damage to adjacent tissues
Damage to the gum can be avoided by careful
selection of forceps & good technique.
The lower lip may be crushed between the
handles of the forceps & anterior teeth.
 Skilled use of operators left hand.
 Instruments should be allowed to cool before use
after being sterilized.
31

32. Inferior alveolar nerve
• close proximity of mandibular third molar
roots.
• Careless surgical technique,
• roots are curved around the canal or grooved
• damage can be prevented or minimized only
by pre-op radiographic diagnosis & careful
dissection.
32

33. Lingual nerve :
Lingual nerve is in close proximity to roots of
mandibular third molar .
• Risk of damage while taking incision and
during elevation of lingual periosteum.
• Risk of direct trauma form bur or chisels used
for removal of bone or sectioning of the tooth
• Mental nerve :
• Injury is caused due to surgery in the area of
mental nerve.
• Over extension of incision in the depth of
mucobuccal fold in premolar region
33

34. Prevention:
The nerve injury can be prevented by
Careful surgical technique –
• Proper placement of incision,
• Careful bone removal
• Retraction and less manipulation
Management :
Patient should be warned preoperatively about
the possible consequences and the probable
outcome on
• Tongue & floor of mouth damage can be
prevented by effective use of left hand.
34

35. 13-Post extraction Bleeding
35
• Local causes:
• Trauma
• Mechanical dislodgement of the clot
• Damage to blood vessel or soft tissue
• Fracture of alveolar bone
• Damage to nutrient blood vessel
• Infection
• Presence of granulation tissue
• Chronic inflammation of gingiva
• Acute infection of bone and soft tissue
• Local abnormality
• Unusually large bone marrow space
• Presence of Hemangioma

36. • Systemic causes
• Disorder related to systemic disease
– leukemia,Aplastic anaemias
– Platelet disorders: Thrombocytopenia
– Coagulation defects : Hemophilia
• Structural malformation : hereditary hemorrhagic
telengectesia
• drug therapy: aspirin, Anti coagulant therapy
36

37. Management
Physical methods
• Pressure packs
• Use of LA solution with vasoconstrictors
• Socket suturing
• Hemostatic forceps
• Splints
• Thermal measures- cautery , hot saline packs
37

38. Firm gauze roll should be placed upon the
socket & patient asked to bite upon it .
Horizontal mattress suture

39. Hemostatics
TOPICAL:
• VASOCONSTRICTORS
Adrenaline
• ABSORBABLE AGENTS
Oxidized cellulose
Oxidized regenerated cellulose
Gelatin sponge
Fibrin foam
Calcium alginate
THROMBOPLASTIC AGENTS
Thrombin
Russel viper venom
39

40. 40
CHEMICAL AGENTS:
Tannic acid
Ferric chloride
Zinc chloride
Alum
Hydrogen peroxide
SOCKET PLUGS:
Bone wax
Whitehead’s varnish on ribbon gauze

41. 41
Gel foam
Botroclot (hemocoagulase solution)
Surgicel

42. Systemic agents
ENDOGENOUS:
• Whole blood
• Fresh frozen plasma
• Cryoprecipitate
42

43. Exogenous agents
• ETHAMSYLATE - 2ml ampoules i.m/iv 1-2 hrs
before operation OR
2-3 ampoules following surgery followed by
1amp/2tabs every 4-6 hrs.
• VITAMIN K- Normally 10mg capsules, 10-20
mg oral/ i.m /i.v
43

44. 14-Postoperative pain
Due to traumatized hard tissues -
 Bruising of bone during instrumentation or overheating
of bur during bone removal.
Soft tissues :-
 ragged flap – heals slowly (incision not proper)
 Soft tissue become entangled with bur
 Proper Retraction
44

45. Dry socket / alveolar osteitis/
alveolitis sicca dolorosa
 Acutely painful tooth socket containing
bare bone and broken down blood clot.
Associated with fetid odor
Incidence -3%,
3rd molars-22%
Mandibular teeth common than maxillary.
45

46. 46

47. Predisposing factors :-
1. infection of socket : release of plasminogen
activators
2. Trauma - use of excessive force
3. Vasoconstrictors (contributory factor)
4. Mandibular extractions (dense & less
vascular, contaminated with food debris)
5. Bacteriological origin – Treponema
denticolum .
6. Pt. on oral contraceptives, smokers
47

48. Clinical features
• Pt. usually presents within 2-4 days : granulation
tissue appears in 2-4 days, it is absent in cases of
dry socket.
• Dull, boring pain to severe throbbing pain, may
radiate
• Gingival margin of socket – swollen & red
• Socket may be filled with food debris or a brown
friable clot on removal of which exposes the bare
bone which is severely tender to touch
• Regional lymph nodes may be tender
48

49. 49
DRY SOCKET CONTAINING DEGENERATING BLOOD CLOT

50. 50

51. • Prevention :-
1. Scaling & any gingival inflammation – (1
week prior to extraction).
2. Minimum amount of local anesthetic
3. Atraumatic tooth removal
4. Prophylactic use of antibiotics especially
metronidazole
5. nerve blocks preferred to LA infiltrations
51

52. Management –
1. Aim – relief of pain & speeding of resolution
2. Socket irrigation with warm saline & all degenerating blood
clot removed.
3. Sharp bony spurs - excised with rongeur forceps or
removed with a wheel stone
4. Loose dressing – zinc oxide & oil of cloves on cotton
wool is tucked into the socket.
5. Analgesic tab & hot saline mouth baths
6. Recall after 3 days 52

53. IRRIGATE THE SOCKET PLACE A ANTISEPTIC DRESSING
53
DRESSING ; First 24 hours then every alternate day then
every 3-4 days / or more than 2 weeks regular check up

54. 15-ACUTE OSTEOMYELITIS OF THE
MANDIBLE:
Mandible tender
Impairement of labial sensation
 pyrexia , pain is severe
Traumatic extraction of lower molar under LA in
P/o acute gingival inflammation predisposes to
acute OML
54

55. 55

56. May complicate difficult extractions if the
lower jaw is not supported.
The risk can be minimize if supporting the
mandible during surgery.
Difficult extractions Should be done
surgically.
Mouth prop used on contralateral side
56
16-TRAUMATIC ARTHRITIS OF THE
TMJ

57. 57

58. 17-Postoperative swelling
a. EDEMA :
1. If the soft tissues are not handled carefully during
an extraction traumatic edema may be formed.
2. The use of blunt instrument, the excessive
retraction of badly designed flap, or a bur
becoming entangled in the soft tissues predispose
to this condition.
3. IF sutures are tied too tightly post operative
swelling due to edema or haematoma formation
may cause sloughing of the soft tissues and
breakdown of the suture line.
4. Usually both conditions regress if the patient uses
hot saline mouth baths frequently for 2-3 days.
58

59. b. INFECTION :-
• pain and swelling
Mild - hot saline mouth baths
Severe – antibiotic & analgesics
59

60. 18-Trismus
 Inability to open mouth due to muscle spasm.
Caused by post op. edema, hematoma
formation or inflammation of soft tissue.
Intra oral heat by means of short wave
diathermy or use of hot saline mouth baths.
Antibiotics
60

61. 61
TRISMUS

62. 19-Oroantral communications
 An oroantral communication is created by the
extraction of maxillary tooth where
 The roots extend well beyond the maxillary sinus floor
 The extraction is difficult and traumatic
 There is a lone standing molar
 The tooth is ankylosed
 The periapical pathology e.g cyst or granuloma
extending beyond the sinus floor
62

63. 63

64. Diagnosis:
• Bubbling through the extraction site occurs when the nose is
blocked under pressure. The patient cannot suck through a straw.
Management:
• Replace the tooth and splint into position and plan to
extract surgically at a later date or
• Cover defect with anti septic – soaked ribbon/ gauze and
remove in 2-3 weeks to allow healing by sec. intention or
• Reduce bony socket edge and suture margins together
(interrupted horizontal mattress)
• Immediate closure with a buccal advancement flap
provided the sinus is clear of infection.
64

65. 65
The treatment of a freshly created oroantral communication

66. 66
Adjunctive measures:
Instruct patient not to blow nose
from 7-10 days
Analgesics
Antibiotics
Nasal decongestants

67. 20-Syncope / faints
• Pt. Collapse
• Feeling dizzy, weak, nauseated
• Skin is pale, cold , sweating
• Head end lowered by lowering the back
of the dental chair
67

68. MANEGMENT:
• Placement of unconscious patient in the supine
position with feet slighlty elevated and airway
patency maintained through use of the head tilt –
chin lift method.
68

69. 69
AROMATIC SPIRIT AMMONIA:
Aromatic ammonia spirit is used to prevent or treat syncope

70. 70
21-Respiratory arrest

71. Skelton Muscles become flaccid and pupils dilate
MANAGEMENT:
• Lay the pt flat on the floor
• Remove any foreign bodies by pulling the mandible
upwards and forwards, to extend neck fully
• Compress pt. nostril with thumb and finger, mouth-to-
mouth resuscitation be performed to raise the
chest every 3-4 sec.
• Check carotid pulse.
71

72. 72

73. 22-Cardiac arrest
• Unless reversed in 3mins,irreversible brain
damage could occur due to cerebral anoxia.
• Pt has deathly pallor & grayness.
• Cold and sweaty skin
• Pulse and apex beat cannot be felt
• Heart sounds cannot be heard
• CPR is carried out until hospital services are
available. 73

74. 74
Cardiopulmonary resuscitation(CPR):

75. 23-Anaesthetic emergencies
• Dentist must be alert for any warning sign
related to emergency related to anaesthesia
• In case of collapse STOP ANAESTHETIC
IMMEDIATELY
• CPR ,respiratory relief by tracheostomy,
laryngotomy must be performed.
75

76. Conclusion
Complications should be diagnosed as soon
as they occur & dealt promptly and effectively.
76

77. 77