Complications of Surgical Dentistry Flashcards
What is sequelae?
An after-effect of surgery inherent to the procedure
E.g. pain, swelling, trismus, ecchymosis
What is a complication?
An undesirable, unintended and direct result of an operation affecting a patient which would not have occurred if the operation had gone as well as could reasonably be hoped
How to differentiate complications from sequelae?
Suppuration, abscess formation
Systemic symptoms
Different timeline of pain and different progression
> Sequelae usually peaks at 2nd or 3rd day, either stays the same or gets better
Swelling extending to spaces beyond what is normal
> Pain on swallowing
> Voice changes
> Difficulty breathing
Types of pre-operative complications
Inaccurate diagnosis
Inappropriate treatment plan
Types of intra-operative complications
Intra-operative haemorrhage
Injury to adjacent tissues
Tooth fragment/foreign body left in-situ
Displacement of fragment or foreign body
Hardware failure
Aspiration/ingestion of fragment or foreign body
Surgical emphysema
Types of post-operative complications
Post-operative haemorrhage
Alveolar osteitis
Wound healing complications
Paresthesia
Types of haemorrhage
Primary
> Occurs at time of surgery
> Due to direct injury to vessels
> Can be arterial, venous or capillary
> Arterial blood is higher pressure and in spurts, high flow, requires intervention like packing
> Venous blood is darker, high flow, requires intervention like packing
> Capillary blood is lighter in colour than venous, oozing
Reactionary
> Within 24-48h of surgery
> Due to dislodgement of clot, cessation of vasospasm/vasoconstriction
Secondary
> Usually after 7 days
> Mainly due to infection, sloughing/necrosis of vessel wall
> Rare
Types of injury to adjacent tissues
Soft tissues
> Flap
> Papilla
> Cheek
> Lip
> Palate
> Tongue
> Nerve
Hard tissues
> Alveolar bone (buccal plate, max tuberosity)
> Mandible
> TMJ (e.g. dislocation)
> Teeth
Oral-antral perforation
Where can fragment/foreign bodies displace?
Max
> Caldwell-Luc procedure if displaced into max sinus
> Infratemporal fossa
Mand
> Sublingual space
> Esp if used too much force, fractured lingual plate
> Submand and pterygomandibular spaces
What to do if kena aspiration/ingestion of fragment or foreign body
Aspiration has a tendency to go into right bronchus as it is more vertical
Refer immediately if aspirated
If ingested, determine how safe the swallowed object is
> Small and round? Monitor stools
> Large, sharp or magnetic? Higher risk
Post-operative haemorrhage risk factors
> Family history
Medical history
Medications
Antiplatelets (aspirin, clopidogrel etc)
Anticoagulants (warfarin, apixaban etc)
Warfarin INR should be below 3.0!
Liaise with medical colleagues to correct coagulopathy
Controlling bleeding intra-operatively
Intra-operatively
> Minimize trauma
> Make clean incisions
> Remove granulation tissue (if any)
> Excessive, prolonged bleeding? Use Surgicel, hemostatics, compression, suture, electrocauterize
Controlling bleeding post-operatively
Post-operatively
> Monitor for 30 mins before discharging
> Post-op instructions
> Tranexamic acid gargle/soaked gauze
> Black jelly/curd-like substance outside socket, bleeding on poking? Liver clot - need to suction out whole clot and restart wound healing process
> Can happen if patient doesn’t bite properly on gauze, where clot forms outside socket
How to deal with uncontrolled bleeding
Uncontrolled bleeding?
> Suction
> Determine source
> Apply pressure to achieve hemostasis
> First, surgicel and suture. If not, move on to TXA soaked gauze
> If still doesn’t work, may be from a larger arterial vessel, so reopen wound and find exact bleeding spot, apply direct pressure or hemostatic, or bone wax if from cancellous bone
Adjuncts?
> LA
> Tranexamic acid soaked gauze/adrenaline soaked gauze
> Bite on teabag?
> Local measures
> Hemostatic agent
> Suturing
> Electrocautery
Presentation of alveolar osteitis
5-20%, most frequent painful complication of extractions!
Usually presents only around day 3-5, pain vv severe, cannot drink water or speak, can radiate
Risk factors of alveolar osteitis
Increased age
Smoking
Females
Prolonged/difficult extraction
Oral contraceptives
Mandible > maxilla, posterior > anterior
Infection
Dislodgement of clot??
Mx of alveolar osteitis
Self-limiting, will resolve after up to 2 weeks so just treat symptomatically
Irrigate, dress, apply alvogyl (anaesthetic, antimicrobial and analgesic)
Give painkillers like ibuprofen and tramadol
Signs and symptoms of alveolar osteitis
Bad smell
Exposed bone (can feel bone when probing instead of soft tissue)
Highly sensitive to gentle probing
Causes of alveolar osteitis
During trauma, there is release of plasminogen tissue activators
This causes plasmin-induced lysis of the blood clot, dislodging the clot and exposing bone
This causes inflammation of alveolar bone, lingering for several days until covered by epithelium
May also have bacterial influence, dislodging blood clot via enzymes and biofilm formation preventing healing over exposed bone
Wound healing complications
Wound dehiscence
Osteonecrosis of jaw
Infection
Paresthesia
IDN injury only 0.5-5% chance, with only 1% permanent
Can use CBCT in high risk cases
Can do coronectomy or just observe (if asymptomatic) if root and nerve are very close
Risk factors for paresthesia
Higher risk esp with darkening of root, diversion of canal and interruption of white line of canal
Operator skill
Anatomic factors such as deeper osseous impactions
Increased age
Where can infection spread?
Vestibular space
Buccal space
Palatal space
Sublingual space
Submandibular space
Maxillary sinus
Submasseteric space
Pterygomandibular space
Temporal space
Infection of muscles
Infection close to muscles causes inflammation of muscles, trimus and spasms
Under GA patient cannot open mouth, airways cannot be accessed, v dangerous
Red flags of infection
Infection spreading deeper/downwards
Infection spreading across midline
Infection causing airway obstruction
Infection spreading from lateral pharynx to retropharyngeal areas and further on to mediastinum to cause mediastinitis
Infection spreading to secondary spaces: send to hospital
> Dysphonia
> Dysphagia
> Dyspnea
Need to treat early and aggressively to avoid worsening of infection!
Mx of nerve injury
If patient scoring is 7 or more there is a good chance of complete healing
Give neurobion
Neurosensory re-education
> Close eyes, tap tap on one side of face then switch sides and tap tap
> Use different stimuli like tissues
> 3x a day for 5 days
Radiographic warning signs (low PPV but high NPV)
Darkening
Deflection
Diversion
Narrowing of root
Narrowing of canal
Bifid root apex
Interruption of white line of canal
Lingual nerve injury Mx
Refer ASAP because can do repair! Otherwise higher chance of permanent damage
Temporary 0-5.3%, permanent up to 1%
Lingual nerve injury risk factors
Incisions too lingual or breach of lingual cortex
Lingual angulation of 3rd molar
Vertical sectioning
Prolonged operating time
Surgeon’s experience
Lingual nerve injury symptoms
Drooling
Tongue biting
Thermal burns
Changes in speech
Swallowing and taste perception alterations
Unilateral atrophy of lingual papillae
Prevention of alveolar osteitis
Systemic antibiotics DONT work
Treat pericoronitis before op
OH must be satisfactory before op
Atraumatic exo with copious irrigation
Intra-alveolar medications like tetracycline (But minimised to reduce likelihood of giant cell reaction)
Chlorhexidine on day of surgery and several days after
Risk factors for infection
Age
Degree of impaction
Need for bone removal or tooth sectioning
Exposure of IA neurovascular bundle
Presence of gingivitis or pericoronitis
Surgeon’s experience
Use of antibiotics
Location of surgery (hospital vs office)
Length of surgery
Where can infection spread
Early or late post-operative period
Typically mixed infection with predominance of anaerobes (esp streps)
Max third molar infection can spread to max vestibule, buccal space, deep temporal space, infratemporal fossa
Mand third molar infection can spread to mand vestibule, buccal space, submasseteric space, pterygomandibular space, parapharyngeal space, submandibular space
Risk factors for secondary haemorrhage
Prevalence 0.2-5.8%
Influencing factors
> Soft tissue and vessel injury
> Over-guttering causing excessive bleeding
> Guttering outside of cortical bone which doesn’t bleed
> Haemangioma, AVF
> Systemic disease, liver disease
> Anticoagulants, dual antiplatelets
Risk factors for damage to adjacent teeth
Prevalence 0.3-0.4%
Influencing factors
> Teeth with large restorations or caries, high risk of fracture
> Max mesioangular impaction with pell and gregory position B and mand vertical impactions at slightly higher risk
Risk factors for periodontal problems
Prevalence 43.3%
Influencing factors
> Age >25
> Pre-op PD
> Close proximity between 2nd and 3rd molars
> Mesioangular or horizontally impacted 3rd molar
Where can teeth be displaced to?
Lingual/submandibular space
IDN canal
Infratemporal fossa
Lungs
Stomach
How do TMJ disorders occur?
Prolonged procedures can put a lot of load on TMJ and cause overloading or injury, so must note presence of myalgia before starting
> Opening wide for extended period of time
> Force exerted on mandible
Risk factors for mandibular fracture
Prevalence 0.0049%
Influencing factors
> Increased age
> Mand atrophy
> Cyst, tumour
> Osteoporosis
> Deeply impacted teeth
> Excessive bone removal or force applied
Risk factors for OAC
Prevalence 0.008-0.25% for 3rd molars
Influencing factors
> Max molars (1st > 2nd > 3rd)
> Widely divergent, abnormally long roots
> Pneumatization
> Little or no bone between root and sinus
> Adjacency to edentulous space
> Destruction of a portion of the sinus floor by PA lesions
> Injudicious use of instruments leading to perforation of floor/sinus membrane
> Difficult extraction
What did the oral surgeon say to the dental UG who extracted a tooth with diversion of IDN canal, darkening of roots and interruption of the canal?
You’ve got some nerve!
Risk factors for haemorrhage
> Local:
1) Soft tissue (vessels)
2) Bone (nutrient canals, central vessels)
3) Vascular malformations
> Systemic:
1) Systemic diseases
2) Medications
