EXAM II Extraction Complications Flashcards
what is the best way to manage surgical complications?
prevent it from happening
- preoperative assessment and treatment plan
what are considerations in the prevention of surgical complications?
- perform surgery within limits of training
- thorough review of medical history
- adequate images: see all structures
- good visualization (light), suction, retraction, ability to section and remove bone, control bleeding
soft tissue injuries usually result from ___
inadequate attention to delicate nature of mucosa, inadequate access, rushing, and excessive or uncontrolled force
what are the 3 ways to prevent soft tissue injuries?
- pay strict attention to soft tissue injuries
- develop adequate-sized flaps
- use minimal force for retraction of soft tissue
what is the most common soft tissue injury?
torn mucosal flap
what do torn mucosal flaps usually result from?
inadequate sized envelope flap being forciply stretched
T or F:
when a mucosal flap tears, it generally tears at both ends of the flap
false, it generally tears at one end
how can a torn mucosal flap be prevented?
- use adequate sized flap
- controlled force on flap
- use releasing incisions
how would you treat a torn mucosal flap?
suture it, then excise extra tissue
a ___ wound occurs from instrument slippage or use of uncontrolled force (usually a straight elevator or periosteal elevator)
puncture
how can puncture wounds be prevented?
use of controlled force and finger rests
how would you treat a puncture wound?
- leave it open and start the patient on antibiotics
- you don’t want to suture it because bacteria has been pushed up into the area, and you don’t want to trap it there
what do stretch, burn, or abrasion injuries usually result from?
a rotating shank of a bur or retractor; this can happen if a surgeon is too focused on the cutting end of the bur and not the surroundings
stretch, burn, or abrasion injuries occur in what time frame?
within 2 weeks
how would you treat a stretch, burn, or abrasion injury?
generally heals on its own but you want to cover it with antibiotic ointment (keep it within confines of wound, otherwise a rash can result) or vaseline
what is the most common problem in removing a tooth?
root fracture
to avoid root fracture during an extraction, the surgeon should be cautious about what?
- long, curved, divergent roots
- dense bone
how can root fracture during an extraction be potentially prevented?
- always consider the possibility of a root fracture
- open (surgical) extraction technique
- removal of bone
- do not use a strong apical force on a broken root
what is the most common root displacement?
maxillary 1st molar root into sinus
what things should you assess to avoid root displacement?
- size of root fragment +/- infection of root
- health of the sinus
what is the treatment of root displacement of a 2-3 mm root fragment in a healthy sinus?
- radiograph, irrigation/suction technique, leave in place?, inform patient, treat oro-antral opening
- if root tip is infected, refer to oral surgeon
if a large root fragment or entire tooth is displaced, what should you do?
refer to oral surgeon, they will use the cauldwell-luc procedure
displacement into infratemporal space can occur with ___
elevation of impacted maxillary 3rd molar
what should you do if a root/tooth is displaced into the infratemporal space?
- it is usually not visible, but if it is, you can make 1 attempt to grasp it with a hemostat
- if unsuccessful (usual case), close the wound, inform the patient, place on antibiotics and routine post-op care
- refer to oral surgeon
if a root/tooth is displaced into the infratemporal space, retrieval is unssuccessful by the general dentist, and the patient has been referred to the oral surgeon, how long should the patient wait and why?
3 weeks to allow fibrosis around displaced tooth which prevents further displacement during removal
how can the lingual displacement of a mandibular 3rd molar occur?
- lingual mandibular bone gets thinner as you go posteriorly
- pressure lingually can fracture the lingual plate
- fractured root or entire tooth can displace into the sublingual space, especially with apical pressure
what can you do if lingual displacement of a mandibular 3rd molar occurs?
- place index finger of left hand along lingual of mandible to identify and stabilize root and attempt to push it back into the socket and remove with a root pick
- if it is a small root tip, you may elect to leave it
what should you do if the retrieval of lingual displacement of a mandibular 3rd molar is unsuccessful?
refer to oral surgeon for lingual flap to find and remove the tooth or root
what risks are associated with lingual displacement of a mandibular 3rd molar?
risk to lingual nerve and vessels and submandibular duct
what should you do if a tooth is lost into the pharynx?
- position patient with head down and turned toward doctor
- encourage cough, spit, and suction
if a tooth is lost into the pharynx and cannot be retrieved initially, what should you do?
- determine if the tooth was swallowed or aspirated
- take to ER: chest and abdominal radiographs; supplemental oxygen?
- if tooth is in GI tract, usually no treatment needed
- if tooth has been aspirated, patient will need bronchoscopy to remove
injuries to adjacent teeth, such as fractures or dislodgement of adjacent restorations occurs due to what?
when the surgeon’s total attention is completely focused on one thing
what should you do to avoid injury to adjacent teeth?
- warn patient preoperatively, caution with elevators, beware of teeth in opposing arch
- recognize the potential to fracture a large restoration
- the assistant should warn the surgeon of pressure on adjacent teeth
if you have injury an adjacent tooth, what should you do?
inform the patient if a restoration is loosened or fractured
luxation of an adjacent tooth can occur from ___
inappropriate use of extraction forceps and elevators
ex. wrong size instrument, crowded teeth
what is the treatment if an adjacent tooth has been luxated?
reposition the tooth and stabilize with semi-rigid or rigid fixation (resin bond, for example)
often need to adjust occlusion or take out of occlusion
what is the most common cause of malpractice lawsuits against dentists?
extraction of the wrong tooth
extraction of the wrong tooth usually stems from ___
inadequate attention to the treatment plan
what are common reasons that extraction of the wrong tooth can occur?
- removing a tooth for another dentist
- different numbering systems
- radiographs mounted on different side
- orthodontic extractions
- referral, especially without a written referral slip
what should you do if you extract a wrong tooth?
- reimplant and stabilize (immediate or delayed recognition)
- orthodontic extractions
- immediately inform patient or guardian, referring dentist
- adjust treatment plan: implant, bridge, ortho
injury to osseous structures (fractures of the alveolar process) usually occurs as a result of ___
excessive force applied with forceps
what can be done to avoid injury to osseous structures?
- buccal bone msut expand to allow release of tooth from alveolus
- if it is not happening, surgical removal should be used
what is the most common area of concern with respec to injury of osseous structures?
buccal cortical bone over maxillary cuspid, maxillary molars (especially 1st), maxillary tuberosity, and mandibular incisors
how can fracture of the alveolar process be prevented?
- conduct thorough preoperative clinical and radiographic examination
- do not use excessive force
- use surgical extraction technique to reduce the force required
what are some considerations in assessing the risk of fracturing the alveolar process?
- root form, divergent or bulbous roots
- proximity to sinus
- thickness of buccal plate
- age of patient
in the management of alveolar fractures where bone and tooth have been removed from the socket, what should you do?
do not replace them; smooth bone and suture soft tissues as needed
if a surgeon feels an alveolar fracture before the tooth is removed, what should be done?
- stabilize the tooth with forceps and separate bone from the tooth with a sharp instrument (periotome, chisel, etc.) while still attached to the periosteum
- may need to section multirooted tooth
- stabilize with sutures as needed
fractures of the maxillary tuberosity occurs most commonly with extraction of what teeth?
maxillary 2nd or 3rd molars
what is the main concern with fracture of the maxillary tuberosity?
critical for denture retention, therefore preservation of the tuberosity should have high priority
also concern for oro-antral fistula
what is the management of maxillary tuberosity fractures?
same as for other alveolar fractures
describe injury to buccal and nasopalatine nerves
- branches often sectioned during surgical procedures
- area of innervation relatively small
- reinnervation of nerve endings occurs rapidly
- may be surgically sectioned without long lasting sequelae or discomfort
describe injury to the mental nerve
- if sectioned, permanent paresthesia/anesthesia is likely in lip and chin
- caution in reflecting flap, especially releasing incision, in bicuspid area
how is nerve injury prevented?
- be aware of the nerve anatomy in the surgical area
- avoid making incisions or stretching the periosteum in the nerve area
describe injury to the lingual nerve
- occasionally located in retromolar pad area of mandible
- avoid incisions into lingual side of retromolar pad area; stay on bone
- usually permanent parasthesia/anesthesia of tongue on that side if injured
describe injury to the inferior alveolar nerve
- occurs most commonly with 3rd molar removal; crush injury
- often permanent depending on degree of injury but some regeneration may occur over time
- occurs common enough that it is mandatory to inform all 3rd molar patients
what is the treatment of nerve injury?
- nerve grafting, sooner the better
- physical therapy of benefit?
what is a common way that the TMJ is injured?
subluxation of the mandible can occur during extraction of lower teeth with forceps
how can TMJ injury be prevented?
- support the mandible using contralateral bit block
- assistant can also support the mandible holding the lower border of the jaw
- use controlled force to extract teeth
- do not force open the mouth too widely
what should you advise the patient to do if they experience TMJ pain following an extraction?
moist heat, rest jaw, soft diet, and ibuprofen
what is a fistula?
oroantral communication
what are sequelae of oroantral communications?
- post-operative maxillary sinusitis
- chronic oroantral fistula
the probability of occurence of oroantral communications is related to what?
the size of communication and management of the problem
how is an oroantral communication diagnosed?
- bone adherent to root of tooth
- nose-blowing test (gently)
how can oroantral communications be prevented?
- conduct a thorough preoperative radiographic examination
- use surgical extraction early, and section roots
- avoid excessive apical pressure on maxillary posterior teeth
in cases of oroantral communications, when is additional surgery not needed?
when the communication is less than 2mm
describe the treatment of an oroantral communication that is 2-6mm
- figure 8 suture +/- clot-producing material (gelfoam, collagen, etc.)
- postop sinus precaution instructions: avoid sneezing, blowing nose, straws, smoking
- medication: antibiotic (amoxicillin, augmentin, cephalosporin) for 5 days, decongestant nasal spray, +/- oral decongestant
what is the treatment of an oroantral communication that is >7mm?
- repair with flap procedure (oral surgeon)
- buccal advancement flap
- lingual rotation flap
- sinus precautions, antibiotics, decongestants
- if pre-existing sinusitis, treat first with medication to eliminate infection before closing fistula
what are some reasons that post operative bleeding is common?
- oral tissues are highly vascular
- extraction leaves an open wound
- hard to apply dressing with pressure over wound that can control bleeding
- patients explore area with tongue, dislodging blood clots and initiates bleeding
- salivary enzymes lyse blood clots
what is the best way to prevent post-operative bleeding?
prevention
what ways can post operative bleeding be prevented?
- obtain a history of bleeding
- use the atraumatic surgical technique
- obtain good hemostasis at surgery
- provide excellent patient instructions
what is the normal post operative bleeding time frame?
12-24 hours; longer is suspicious
what are some things you should be looking at in your patients health history to avoid post operative bleeding?
- history of coagulopathy (consult with the patients physician)
- aspirin or ibuprofen products, anticoagulants (coumadin)
- chemotherapy
- alcoholism
- liver disease
- therapeutic anticoagulation: INR usually 2-3
- for extraction, need <2.5 INR
- let MD control before surgery
to treat post op bleeding, sockets should be checked for ___
granulation tissue
how can soft tissue arterial bleeding be treated?
cautery, suture
how is bone bleeding treated?
- crush the bleeder (vessel)
- pressure into socket
- hemostatic agents (gelfoam, collagen = collaplug, oxydized cellulose = surgicel) with figure 8 suture
- bone wax
- liquid thrombin on gelfoam
for patients returning with post op bleeding, once they have been treated, what should you do before dismissing them?
watch in office for 30 minutes
what can help with secondary bleeding?
have patient bite on a tea bag - has tannic acid and local anesthesia
what is a “liver clot” and how is it treated?
- liver clot is a partially coagulated blood that oozes out of the socket, needs to be removed completely
- LA, take curette and clean out clot, then put in hemostatis agent, suture, and bite on gauze
describe ecchymosis that can occur after a surgery
- occurs 2-4 days post op
- from bleeding into soft tissue
- not dangerous but alarming to patient
- reassure patient and follow up
what is trismus?
limited mouth opening from inflammation, trauma to muscles of mastication
what is trismus usually caused by?
- from injection of mandibular block, needle trauma to medial pterygoid muscle
- often accompanies 3rd molar removal involving multiple muscles of mastication
is trismus worrisome?
no, but can be alarming to patient
how long does trismus usually last, and how is it treated?
- 1-2 weeks
- treat with warm compresses
___ is the most common cause of delayed wound healing
infection
is infection common after dental extractions?
- no, but can occur from flap procedures with bone removal
- incomplete debridement under flap
- requires thorough irrigation under pressure to remove debris
- all visible foreign debris msut be removed with curette
patients predisposed to infections require ___ before surgeries
prophylactic antibiotics
___ occurs with unsupported soft tissue flap over inadequate bony foundation
wound dehiscence (separation of wound edges)
wound dehiscence can occur with sutures under tension by causing ___ of the flap margin, resulting in tissue necrosis
ischemia
what is a common area where wound dehiscence occurs?
mylohyoid (internal oblique) ridge - this tissue becomes ischemic
what is the treatment for wound dehiscence?
- if symptomatic, smooth with bone file and resuture
- if tolerable, leave alone and necrotic bone with slough off in 2-4 weeks
what is the prevention of wound dehiscence?
- use aseptic technique
- perform atraumatic surgery
- close the incision over intact bone
- suture without tension
is a dry socket an infection?
no
there is no swelling, fever, or erythema
a dry socket is also known as ___
alveolar osteitis
dry sockets are most common after removal of what teeth, and how long after extraction?
- mandibular 3rd molars (up to 20% of impacted 3rd experience dry socket), 3-4 days post op
- severity is proportional to degree of difficulty of removal
dry sockets can cause pain from exposed bone as a result of ___
- loss of blood clot in socket
- exposed bone is sensitive, moderately severe throbbing, and radiates to ear
___ has a bad odor and foul taste
dry socket
what is the cause of dry sockets?
unknown, but results from fibrinolytic lysis of clot
what is the treatment of a dry socket?
irrigation of socket, pack socket with medicated gauze dressing (eugenol, topical anesthetic, carrying agent like balsam of peru)
are fractures of the mandible common?
they are rare during tooth extraction but occurs if exceeded force is necessary to remove the tooth
fractures of the mandible are most comon with removal of which teeth?
impacted mandibular 3rd molars
___ mandible is susceptible to fracture
atrophic
what is the treatment for a fractured mandible?
refer to oral surgeon for reduction and fixation of fracture
