Complications of Exodontia Flashcards
When a patient consents for exodontia, what did we need to warm them that are risks?
- Pain
- Bleeding
- Swelling
- Bruising
- Infection
- Reduced mouth opening
- Damage to adjacent teeth
- Dry socket
- IDN damage
- Oral sinus communication
What surgical complications can happen immediately?
- LA failure
- Haemorrhage
- Fracture of crowns/roots
- Damage to surrounding structures e.g. teeth, mucosa
- Oral antral communication
- Dislocation of TMJ
Explain how primary haemostasis occurs after an extraction (what triggers it and how it occurs)
Primary haemostasis is triggered by vascular damage:
- Endothelial damage
- Vasoconstriction
- Reduced blood flow
- Exposure of collagen to circulating platelets
First thing = vasoconstriction
Then = platelet activation and aggregation.
Platelets activate by binding directly to the endothelium. vWF is released from the endothelium which strengths the bond of platelets to the endothelium.
The activated platelets then releases stored granules into blood plasma to cause platelet aggregation.
How does secondary haemostasis occur?
This then occurs due to the coagulation cascade.
Formation of fibrin occurs through the coagulation cascade.
The coagulation cascade occurs through the extrinsic and intrinsic pathway.
In the extrinsic pathway (initiation of clotting) this involves tissue factor 10 and 7.
Then the intrinsic pathway amplifies the clotting cascade including factors such as 12, 11, 9 and 8.
The common pathway involves factor 10. Factor 10 mediates generation of thrombin from prothrombin. This results in the production of fibrin from fibrinogen. The fibrin proteins stick together forming a clot.
How long does it take for primary haemostasis to occur after extraction?
5 minutes
If a patient has issues with clotting, what measures can we take?
1 - Flush socket with saline to remove loose blood clots
2 - Then place an oxidised cellulose matrix in the socket
3 - Suture the socket
4 - Pressure on gauze for 10-15mins
5 - Use tranexamic acid on gauze to prevent conversion of plasminogen to plasmin to stop the degradation of fibin
If a patient is on warfarin, do we do the extraction?
Only of IRN is <4.
Then give patients local haemostatic measures.
If a patient has a bleeding disorder such as haemophilia or thrombocytopenia, do we treat them?
No - treatment in hospital setting only.
How can soft tissue injury occur and how do we deal with this?
Iatrogenic damage from the dentist or caused by a numb patient biting lips/tongue.
Give patient good post-operative instructions.
Protect soft tissue with retractors during surgery.
Raise muco-periosteal flap if sectioning roots.
How can fracture of a tooth/root occur and what do we do about it?
Occurs with brittle teeth, grossly carious/restored tooth, curved apex and inappropriate use of elevators/forceps.
We need to raise a MPF to remove some bone and then remove the rest of the tooth.
This also prevents displacement of root in antrum/soft tissues.
What happens if there is displacement of a root into maxillary antrum?
This needs to be removed.
Retrieval at time of surgery via trans alveolar route is preferable (flush with saline, good placement of light in socket, high volume suction, expand socket via bone removal with rose head bur.
This removal is done by a specialist.
How can fracture of a bone occur in extraction and how do we manage it?
Commonly happens in buccal part of cortical bone.
It occurs due to excessive force and thin buccal bone then lateral pressure can fracture the buccal plate.
Management:
- If bone is still within the site when fractures, it remains here and heals
To prevent this occurring, slowly mobilise the teeth to expand the socket, avoid excessive force.
How can the maxillary tuberosity fracture?
How do we manage this?
Occurs when extracting upper 7s and 8s.
Less likely to occur when you use an elevator to mobilize the tooth and then remove the tooth with forceps
If a small part comes off with the tooth then we close with sutures i there is an oral-antrum communcation.
If a large part comes off there may be an oral-antrum communication so we need to suture and may need to refer. Also, the palate may now be mobile so tooth may need to be surgically removed at a later date.
What are the risk factors of an oral-antrum communication?
Maxillary molars, long standing teeth, older patient.
If the communication has occurred, delay treatment, tell them to not blow through their nose and give antibiotics.
How do we treat an ora-antral communication?
We leave the communication for a while to allow tissue growth - giving patient antibiotics, nasal drops, steam inhalation and avoiding nose blowing
If after review it hasnt healed, then need to remove any fistulas and raise a 3 sided buccal flap and pull flap over and suture over to the palatal surface.
If the oral antra fistula persists, you need to work with ENT to look for underlying chronic sinusitis.
Work with ENT to get functional endoscopy of the sinus for surgery to help with drainage of the sinus and resolve the sinusitis so when we do remove the fistula it is more effective.
