Complications in oral surgery

Question 1

Common complications

Answer 1

Tooth fracture
Tooth displacement
Root displacement into maxillary sinus
Maxillary tuberosity fracture
OAC
Primary Haemorrhage
Late onset bleeding
Nerve injury
Dry socket
Odontogenic infection

Question 2

How to manage tooth fracture

Answer 2

• Remove the fragments using a root pick or straight elevator
• Leave small uninfected fragments in situ if close to sinus or IAN canal (unless patient desires implants)

Question 3

How to manage root displacement in max sinus

Answer 3

1. Identify size of the root
2. Assess if tooth was infected
3. Assess the pre-operative condition of the maxillary sinus
   More specifically:
   A. If the displaced tooth fragment is only a small root fragment (2 or 3 mm), and the tooth and sinus had no pre-existing infection, the surgeon should make a brief attempt at removing the root:
   B. If the tooth fragment is infected or the patient develops chronic sinusitis, refer to an OMFS for removal
   C. If, however, the tooth fragment is not visible radiographically or otherwise:
   * Abort the surgery
   * Suture the oral-antral communication
   * Provide sinus precautions
   * Refer the patient for an OPG/CT scan
   * Refer the patient to an OMFS
   o is raised below the infraorbital canal (1.5 cm window)
   o Incise sinus lining

Question 4

How to manage max tuberosity fracture

Answer 4

A. Abort procedure and splint tooth with dental wire (defer treatment for 6-8 wks)
B. Dissect the crown from the roots and allow the tuberosity and tooth root section to heal – later extract the roots with an open surgical technique
C. Remove tooth and tuberosity and follow with primary closure
* Check for oral-antral communication and provide additional treatment as necessary

Question 5

How to manage OAC

Answer 5

A. Communication is small: < 2 mm
* No additional surgical treatment is necessary
* The surgeon should ensure the formation of a blood clot
* Sinus precautions so as not to dislodge the clot:
o No nose blowing
o Open mouth coughing and sneezing
o No drinking through a straw or spitting
o No swimming, scuba diving, or flying in pressurized aircraft for a week
o Avoid smoking
o Nasal decongestant
 Maintains ostium patency (opening that connects the sinus to the nasal cavity)  reduced risk of sinusitis
o Prophylactic antibiotics – to reduce the risk of maxillary sinusitis
 5 days of amoxicillin, cephalexin, or clindamycin
B. Communication is moderate: 2-6 mm
* Additional measures need to be taken to maintain the blood clot in this area
* Sinus precautions
* Figure 8 suture is placed with a gelatin sponge (e.g. Gelatemp) held in place to stabilize the clot
C. Communication is large: > 7 mm
* Sinus precautions
* Consider closing communication with a trapezoidal mucoperiosteal buccal flap:

o Raise flap as outlined above
o Release the periosteum to advance the flap enough to cover the wound
o Smooth prominent buccal ledges
o Draw flap over the socket with as little tension as possible
o Close with sutures
o Disadvantage = up to 50% reduction in buccal sulcus depth

Question 6

How to manage primary haemorrhage

Answer 6

Local measures
IV fluid
Refer to hospital

Question 7

How to manage late onset bleeding

Answer 7

Local measures
Refer to hospital

Question 8

How to manage nerve injury

Answer 8

• Test all nerve fibre types by assessing reaction to heat, pain, light touch, vibration etc.
• Immediate repair if witnessed transection
• If numbness persists for more than 6 months, take an x-ray to assess continuity of the mandibular canal
• Consider surgical exploration for nerve decompression or repair

Question 9

How to manage dry socket

Answer 9

• Pain control until normal healing - LA and analgesia
• Gentle irrigation of the socket with warm saline to remove debris and bacteria
• Socket dressings are widely used, but they delay healing (e.g. Alvogyl = antiseptic + eugenol-based obtundent)
• Review in 2-3 days

Question 10

How to manage odontogenic infection

Answer 10

• Surgical
  Obtain drainage, maintain drainage, remove source of infection, remove necrotic tissue, and irrigate
• Medical
  Antibiotics, analgesics, fluids, nutrition, airway monitoring, intubation +/- ICU admission
• Supportive
  Hydration, nutrition, pain management, and rest

Question 11

What are the substances in alveogyl