COMPLICATIONS of extraction Flashcards
How do you know you encountered dentoalveolar fracture or tuberosity fracture during exo?
When you try to move tooth and tooth adjacent moves together
What are risk factor of dentoalveolar fracture or tuberosity fracture
Lone standing tooth Single isolated tooth Bulbous diverging roots Dilacerated roots Excessive uncontrolled force
How would you manage such encounter - tuberosity fracture or dentoalveolar fracture?
- Stop and stabilize the tooth and bony fragment with splint or wires for 4-6 weeks, reattempt exo after 6-8 weeks.
- If still indicated for immediate extraction, surgical removal of tooth by sectioning roots and sepetate tooth from fragments while stabilizing the bone. Elevation towards buccal taking caution to avoid palatal mucosal tear as it may cause tearing of the greater palatine vessels and nerve as well. Suture overlying mucosa. Then stabilize the fractured fragments.
Consequences of tuberosity fracture
Bleeding from pterygoid plexus or greater palatine nerve
OAC
Infection - sinus or socket infection
How to prevent maxillary tuberosity or dentoalveolar #
- Adequate finger support on buccal and palatal alveolus
- Tooth sectioning on diverging tooth roots
- Socket expansion buccally with elevators
- Extracting from most distal tooth if multiple teeth exo
What are complications u may encounter during MOS third molar (INTRAOPERATIVE complication)
- Fractured root
- Displaced tooth/roots
- Aggressive bleeding
- Aspiration
- Broken instruments
What are risk factors for root fracture?
Curved roots
Dense bone
Long thin roots
In what situations do you keep fractured tooth roots
Noninfected roots
<2mm length of root tip
If risk of other complications when attempting to remove tooth roots is more and causing permanent/unwanted side effect (e.g. nerve injury, displace roots into potential spaces like submandibular, infratemporal, max sinus)
Where would a lower molar fractured root be displaced to?
Mandibular canal
Submandibular space
How to determine location of displaces mandibular roots
Direct visualization from the socket
Radiographic
- PA to see extend and depth of root in vertical
- mandibular occlusal to see location of roots in buccal or lingual side
- CBCT for 3D visualization of the root
Whats ur next step after determining displaced root
- immediately place fingers on the medial surface and apply upwards pressure motion
- If seen thru socket, attempt retrieval using suction tip, root pick, small hemostat
- If unable to see, open lingual gingival flap extending anteriorly to canine. Careful subperiostal flap reflection all the way to below mylohyoid attachment or until root is visualised
- If unable to retrieve (d/t patient distress, bleeding, too deep), allow 3-4 weeks for soft tissue to heal with fibrosis and to allow stabilization, then attempt secondary procedure.
When can u leave displaced roots unremoved
displaced into mandibular canal without paraesthesia, root infection, asymptomatic, small .
Whats ur next attempt when roots displaced into max sinus
Placing patient upright to prevent posterior displacement of roots
Ask patient to blow while closing the nostrils to help push the roots towards opening of sinus
Suction at opening to bring the roots into extraction site
Sinus lavage and suction to flush root out
If attempt fail, caldwell luc at canine fossa.
What is caldwell luc approach
1.
Postop management of sinus surgery
Sinus precaution
Nasal decongestants to keep ostium open
Antibiotics to prevent sinus infection
Analgesias
Management of roots or tooth displaced into infratemporal space
Allow 3-4 weeks after attempted exo to allow fibrosis
Localize tooth wih 3D imaging (ct scan, cbct)
Procedure performed under Ga
Vestibular incision to expose lateral wall of maxilla all the way posteriorly towards pterygoid plates
Use curved hemostat to go above tooth to push them down for easier retrieval
Irrigate. Close wound. Antibiotics
What are methods for hemostasis
Local pressure
Vasoconstrictors (local)
Hemostatic agents:
- gelfoam: forms fibrin framework for bloodclot
- oxidized cellulose: forms matrix/scaffold for blood clot formation
- collagen plug
- anticibrinolytic topical: tranexamic acid 5% mw: prevents fibrinolysis
Systematic methods:
IV tranexamic acid 1.2g (max dose)
Factor replacements (FVIII, FIX)
Vitamin K replacement
Cryoprecipitate (fibrinogen, vWF, FXIII, FVIII)
Angiography embolization.
What are the causes of cervicofacial subcut emphysema?
Maxillofacial trauma Infection Tracheostomy Radical neck dissection Dental treatments - esp with rotary air instruments
Pathophysiology of cervicofacial subcut emphysema
Air entry into the fascial planes from exposure of loose connective tissues containing potential spaces which then spreads along the path of least resistance towards distant spaces
Potential spaces involved
- buccal/canine spaces
- periorbital space
- masticator space
- pterygomandibular space
- parapharyngeal space
- retropharyngeal space (space between post wall of pharynx and verterbral column)
- penetrate the alar fascia posteriorly to the danger spaces of Grodinsky -> which is in direct communication with mediastinum
- mediastinum space -> compression of venous trunks -> cardiac failure; or -> compresses the trachea -> asphyxiation
What are other complications of cervicofacial emphysema
Spread to mediastinum causing airway obstruction or cardiac failure
Pneumothorax
Pneumopericardium
Mediastinitis
Air embolism
Diff dx of cervicofacial emphysema
Cellulitis Cavernous sinus thrombosis Allergic reaction Anaphylaxis Angioedema Hematoma
Presentation of cervicofacial emphysema
- Rapid increase in swelling unilaterally
- Crepitus on palpation (characteristic & pathognomonic)
- Periorbital swelling
- Maybe assoc with dysphonia, dysphagia, dyspnea when parapharyngeal spaces & retropharyngeal spaces involved
- signs of acute cardiac failure/ asphyxiation when mediastinum space is involved
