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3. Oral Surgery > Extraction Complications 1 > Flashcards

Extraction Complications 1 Flashcards

1
Q

What are the 3 classifications of complications of extractions?

A

Immediate (intraoperative)

Immediate post op (short term post op)

Long term operative

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2
Q

When do short temp post op complications occur?

A

Hours and days after extraction

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3
Q

When do intraoperative complications occur?

A

They occur during or within hour of procedure

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4
Q

What is the simple classification of X complications? (2)

A

Perio-operative

Post-operative

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5
Q

What are some peri-operative complications?

A

Difficulty in accessing tooth

Abnormal resistance

fracture of tooth or root - when trying to extract and we break crown off leaving roots

Fracture of tuberosity - breaks off with the tooth

Jaw fracture - pressure

Involvement of maxillary antrum - OAC or OAF

Loss of tooth - after x we can’t find it

Soft tissue damage

Nerve damage

Haemorrhage - can’t get pt to stop bleeding

Dislocated TMJ - ensure mandible supported as lots of pressure will be exerted as we extract

Damage to adjunct teeth - particularly if big resto

extraction of perm tooth germ - v rare

broken instruments

wrong tooth XLa

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6
Q

Describe difficulty of access and vision

A

This is where we have problems getting in and seeing what we are doing. - we need to see tooth, gum around tooth, where the forceps are going to ensure they are in the right place

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7
Q

What can make access difficult?

A

trismus - limited mouth opening caused by muscle spasm

congenital syndromes - small mouth

burns - pts with scarring so can’t open wide

crowded or malpositioned tooth

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8
Q

If teeth are very crowded or malpositioned what may we do for XLa?

A

We may turn to a surgical extraction to avoid risk to teeth either side

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9
Q

What is abnormal resistance?

A

This is when we cannot get the tooth out no matter what - DO NOT PUT MORE FORCE AS RISKS FRACTURE OF TUBEROSITY OR MANDIBLE

Often need to turn to surgical extraction

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10
Q

Why may teeth be difficult to remove? 5

A

Thick cortical bone (common in big males)

Shape/form of roots - can be divergent, hooked

Number of roots - 3rd root in lower molar can make mobilising tooth harder

Hypercementosis - extra cementum around the tooth

Ankylosis - tooth fused to bone (root to bone) - no PDL so hard to just extract tooth

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11
Q

What is hypercementosis?

A

xcessive buildup of normal cementum (calcified tissue) on the roots of one or more teeth. A thicker layer of cementum can give the tooth an enlarged appearance, which mainly occurs at the apex or apices of the tooth.

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12
Q

What is ankylosis?

A

fusion of roots of tooth and bone

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13
Q

What can fracture during extractions? 3

A

Tooth

Alveolus/tuberosity

Jaw

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14
Q

Why may the tooth fracture?

A

The crown can fracture off during extraction leaving roots lodged in socket

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15
Q

What makes a tooth more likely to fracture?

A

Carious tooth

misaligned or crowded teeth where harder to get forceps on properly

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16
Q

Where should forceps go?

A

below the crown of a tooth (beyond junction where root meets crown and get below bone)

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17
Q

What if we move forceps buccal only?

A

Crown will snap off

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18
Q

What is the correlation between size of tooth and fracture risk?

A

Small crown with big roots more likely to fracture

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19
Q

If fracture risk what do we tell the pt?

A

The tooth is decayed and has a very small crown with big roots so please don’t be alarmed if you hear a crack - I expect a fracture but we will get it out!

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20
Q

What are some root problems when extracting? 7

A 
Fused roots
convergent roots
divergent roots
extra roots
difficult morphology 
hypercementosis 
ankylosis
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21
Q

What plate usually breaks?

A

buccal plate

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22
Q

Before we do a buccal movement with forceps what do we do?

A

Use elevators and locators with small movement to get tooth movement

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23
Q

Why shouldn’t we squeeze sockets after extraction?

A

will reduce bone volume creating issues for implants

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24
Q

What can we do with ragged bone edges?

A

file them down using bone film to avoid poking through gums - never run finger along bone

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25
Q

What jaw is most likely to fracture?

A

Mandible or alveolar plate of maxilla

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26
Q

What are some predisposing factors to jaw fractures?

A

Wisdom tooth extraction

cyst in mandible which weakens jaw

atrophic mandible (edentulous its mandible if flexed can fracture)

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27
Q

How do we avoid jaw fracture?

A

provide jaw support - support the mandible with fingers either side of the alveolus and thumb under the jaw - if not then get assistant to support its mandible and hold head still

take radiographs to assess thickness of jaw

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28
Q

How do we manage a jaw fracture?

A

Infrom the pt - let them know what has happened and do it calmly

Take post op OPT if available

Then make a phone call referral to max fax unit or if not then a&e - if we can get pt straight to hospital then don’t interfere

WARN PT NO EATING ON ROUTE - may be going to theatre so can’t eat

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29
Q

If we can’t get pt to hospital for a few days what do we do?

A

Analgesia advice

Keep everything clean - salty water rinse

Any delay - put pt on antibiotics

can stabilise fracture with a think flexible ortho wire tied around crowns of couple of teeth on either side of fracture

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30
Q

What is an oac?

A

This is am immediate communication between oral cavity and maxillary air sinus

ACUTE

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31
Q

What is an oaf?

A

This is chronic and is when oac has been left for several days resulting in formation of epithelial lined tract between oral cavity and sinus

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32
Q

Where can an OAC occur from?

A

Canine back (more common in pre molar to molar region)

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33
Q

How can we identify its at risk of OAC?

A

Look at size of teeth, position of roots and sinus on radiograph - gives us an idea of risks

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34
Q

Why should we look at tooth after extraction?

A

Ensure all roots present and no chunk of bone on it (if we take floor off maxillary sinus this will be seen)

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35
Q

How do we dx a OAC/OAF

A

Look into the socket and we may see blood bubbling

can do nose holding test where pt blows and we can see movement of air but be very careful!!! - can tear membrane

use good direct vision and lights with gentle suction and we would normally hear an echo with big communication

use blunt drive to avoid creating bigger hole or a hole in general

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36
Q

What is a key indicator of a fractured tuberosity?

A

Tear on palate - fractured bone is sharp at edges and tears overlying gums and mucosa

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37
Q

Can we create an OAF?

A

NO - immediate acute situation is an OAC which over time becomes a fistula which is a epithelial lined tube between mouth and sinus

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38
Q

Even if a chronic OAF looks small what can there be?

A

Bigger area of bone loss underneath

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39
Q

What can we use to identify OAF?

A

Blunt probe or can squeeze and we may see pus

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40
Q

How do we initially manage OACs?

A

inform the pt what has happened

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41
Q

what is the oac is small or sinus is intact (1-2mm)?

A

We can encourage a clot to form

can suture margins to make tighter and help heal quicker

give pts antibiotics as oral bacteria and food can go int sinus

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42
Q

What do we want to encourage pts with OAC to do?

A

steam inhalations

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43
Q

What do we want pts with OAC to avoid doing?

A

blowing nose - let it drip instead

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44
Q

If the OAC is large or lining is torn what should we do asap?

A

close up with sutures

prescribe antibiotics as saliva has accessed sinus

provide nose blowing instructions, steam inhalation

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45
Q

How do we close a large OAC (>2mm)

A

Buccal advancement flap (tension free flap)

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46
Q

Why must we make sure our buccal advancement flap is tension free when closing OACs?

A

if not tension free then we will lose blood supply, the flap will breakdown and tear away from sutures

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47
Q

If we have an OAF how to we treat this?

A

We must cut fistula out - by cutting around the epithelial lined tract or else fistula will reform and won’t close over

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48
Q

Why must we cut around the epithelial lined tract in OAF?

A

Or else fistula will just reform and won’t close

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49
Q

What sutures do we use to close OAF or OACs?

A

non resorbing sutures for 2 weeks

see pt after a week to check they are ok and area remains closed

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50
Q

What do we do if we think a root is in the antrum/maxillary sinus?

A

Confrimr radiographically with opt, occlusal or PA

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51
Q

What do we do if root disappears?

A

Check to see if we have created hole between oral cavity and sinus - if so can we retrieve it with tweezers?

look for it in suction, pts clothes, antrum (otp needed)

52
Q

How can we retrieve root in antrum?

A

We can create a flap design - similar to OAC as once the root is out there is now a communication between antrum and oral cavity

53
Q

If there is a root in the antrum what may we need to open up hole further with?

A

Bone nibblers to clip away intraradicular bone which is left between roots or make the fenestration bigger

54
Q

Why dont we use an air roter to retrieve root from antrum?

A

It will force air into the sinus and soft tissues and can lead to surgical emphysema

55
Q

For curing bone and minor oral surgery what hand piece must we use? and not use?

A

electric handpick

we can’t use air rotor as this will force air into sinus and cause surgical emphysema

56
Q

What can cause a fractured maxillary tuberosity?

A

single standing molar and if we are extracting this the bone can be weaker and there is a lot of pressure on one tooth leading to fracture

unknown unerupted widow tooth

pathological gemination

extracting in wrong order

inadequate alveolar support

57
Q

Why can an unknown unerupted molar wisdom tooth cause a fractured maxillary tuberosity?

A

This is because it can undermine bone making it weaker

58
Q

What order do we take teeth out?

A

FROM THE BACK FORWARD (8 7 6) to avoid undermining bone

59
Q

How do we diagnose a fractured maxillary tuberosity?

A

If there is a cracking sound

if there is movement (tooth and a bit of bone moves)

if there is more than one tooth movement

tear on palate

60
Q

How do we manage a fractured maxillary tuberosity?

A

If small enough dissect out with tooth and close wound

reduce and stabilise (if large bit of bone) and then stabilise until remodelling and healing occurs

61
Q

How do we carry out a reduction?

A

Be careful if using fingers as bone is sharp

can use forceps

62
Q

How do we stabilise fractured maxillary tuberosity?

A

splint with wire

orate buccal arch wire spot

rigid fixation

63
Q

What is rigid fixation best for?

A

best method for healing and reducing risk of infection

64
Q

When we are splitting a fractured maxillary tuberosity what do we splint?

A

Rigid splint with wire and composite and include rigid fixed teeth on other side to hold in a fixed position

65
Q

Why is rigid fixation hard in fractured tuberosity?

A

nothing posterior to splint to

66
Q

What do we put the rigid splint on in maxillary tuberosity fractures?

A

onto intact teeth (8765 if needed) until we feel it has been rigidly splinted so that bone won’t move

67
Q

If after splinting bones are still moving what will happen?

A

Bones won’t heal with bony union - instead fibrous union

68
Q

What does rigid splinting if no movement allow for?

A

Bony union between fracture to occur

69
Q

How long should rigid fixation be left on fractured maxillary tuberosity?

A

8 weeks as it takes maxilla 6-8 weeks to heal (can take 12 weeks sometimes so never go in before 8)

70
Q

What must we prescribe if pt has fractured maxillary tuberosity?

A

Antibiotics - as if gums have been ripped its a compound fracture and bone has come through to oral cavity so pt will need antibiotic coverage, antiseptic mouthwashes, saltwater rinses

71
Q

What is a compound fracture?

A

An open fracture, also called a compound fracture, is a fracture in which there is an open wound or break in the skin near the site of the broken bone.

this is where the bone has penetrated through gum

72
Q

After we reduce maxillary tuberosity fracture what might be the problem?

A

Due to swelling around tooth ligament it may not be in exact position and can stand proud interfering with occlusion so what we can do is take bur and smooth cusps of teeth we will be XLaing - if we can’t do this then get the lab to make a splint

73
Q

After we extract a tooth what must we always ensure we have?

A

THE TOOTH!!

74
Q

If we can’t find the tooth after xla what must we do?

A

Stop what we are doing

suction and look for tooth

check pts clothes, the ground, suction

check pts tongue, under tongue, under tissue flap, in buccal sulcus

ask pt if they think they swallowed it?

WHERE? STOP! SUCTION RADIOGRAPH

75
Q

What do we say to radiology dept if we are missing a tooth?

A

Hi, I am missing a tooth - it could have been inhaled - what do you want me to do here?

76
Q

What is some damage that can happen to nerves?

A

crush injuries

cutting/shredding injuries with drill or scalpel

transection injuries

damage from surgery

damage from la

77
Q

How can crush injuries happen to a nerve?

A

If we lean on nerve with instrument or any post operative swelling compresses them

78
Q

What is a transection injury?

A

this is where the the nerve is completely cut through

79
Q

what type of complication is a nerve injury?

A

Perio and post op complications as happens perio operatively but effects seen post op

80
Q

What is neurapraxia?

A

Neurapraxia is the mildest form of nerve injury. It consists of loss of conduction without associated changes in axonal structure

contusion of nerve but there is continuity of epieneural health and axons are maintained

81
Q

What is axontmesis?

A

This is when there is continuity of axons but epineural sheath is disrupted

82
Q

What is neurotmesis?

A

This is complete loss of nerve continuity (nerve hasm been transected)

83
Q

What is anaesthesia?

A

Numbness

84
Q

What is paraesthesia?

A

Tingling

85
Q

What is dysaethesia?

A

Unpleasant snesation/pain

burning

neuralgic type pain - screaming nerve type pain

86
Q

What is hypoaestheisa?

A

Reduced sensation

87
Q

What is hyperaesthesia?

A

This is increased/heightened sensation that isn’t that painful but if touched pt feels it more

88
Q

What do we write in notes regarding warning about nerve damage?

A

we write that pt was warned about NUMBNESS, TINGLING, UNPLEASANT OR ALTERED SENSATION, PAINFUL SENSATION, NEURALGIC TYPE SENSATION - must use lay terms for law reasons and other alterations of sensations

89
Q

What can nerve damage be?

A

Temporary

Permenant in some case

90
Q

If pt has transection to nerve or damage to nerve shredding where there is granulation tissue and attempted healing around nerve what can we do?

A

Send pt to nerve specialist centre where they can try re connect nerve or clean off granulation tissue

91
Q

What pts would we be more likely to refer to specialist nerve centre?

A

those with neuralgic type pain - dysaestheisa

92
Q

What do we not recommend specialist nerve centre referral for?

A

Bit numb (anaesthesia) or paraesthesia as whilst it could help there is risk of dysaesthesia which is a painful type of nerve damage

93
Q

If there is suspected nerve damage what can we do?

A

We can wait few days-weeks incase of swelling but if unsure then we can just refer pt with URGENT referral as quicker the intervention the greater the chance of successful outcome

94
Q

Why is there a risk of venous bleeding following extractions?

A

This is because small vessels may be cut through or damaged by the needle and sometimes the socket wall can break and bone can catch small vessels

also if we dont put flap back tightly there is risk of bleeding

95
Q

Why can bleeding occur once LA wears off?

A

Contains vasoconstrictor so once it wears off vessels open up again leading to bleeding

96
Q

How do we know if its an arterial bleed?

A

Arteries are big and have pulse and muscular walls so will spurt with blood

97
Q

If an arteriole bursts and starts spurting what do we do?

A

Good pressure, suction and dont panic

98
Q

what is dental haemorrhage mostly due to?

A

local factors such as tears in mucoperisoteum, fractures in alveolar plate and socket wall

99
Q

What are very few bleeds due to?

A

undiagnosed clotting abnormalities such as haemophilia/von willebrans

100
Q

What can some bleeds be due to?

A

Liver disease - alcohol problems as clotting factors are made in liver so if pt has liver disease then reduced likelihood of clotting

101
Q

How do we ask pt about bleeding problems?

A

Do you have any bleeding problems?

do you have hepatitis?

jaundice?

when you cut yourself od you bleed lots? does it take a while to stop?

do you bruise easily?

102
Q

What medication can cause bleeding?

A

Warfarin

anti-plt agents (aspirin/clopidogrel)

103
Q

How do we apply pressure to soft tissue bleeding?

A

Damp gauze and apply pressure (must be dry to avoid it sticking to clot and dislodging)

firm even pressure but dont bite with all force as this can cause rebound bleed

104
Q

When may we need to use sutures for bleeds?

A

First pressure for 10 minutes

then for 15-20 mins

and if still bleeding after pressure has been applied for an hour then if socket is loose and soft tissue is loose we can pull socket together

105
Q

What stitches can we use to pull socket together?

A

horizontal mattress or two interrupted sutures

106
Q

How can we use LA to aid bleeding reduction?

A

We can use la with vasoconstrictor to shut down vessels in area allowing us to see better

107
Q

What is a diathermy used for?

A

This is used to cauterise or burn vessels and precipitates proteins to get protein plug in vessel to stop bleeding

108
Q

What can we use for larger vessel bleeds?

A

ligatures or artery clips

109
Q

What happens if bone is bleeding?

A

we must dry the bone, suction and get good vision with light and then apply pressure via a swab

we can apply la on swab or inject into socket

110
Q

If applying pressure to bone doesn’t work what can we do?

A

We can inject LA into base or walls of socket and onto swab and pack it in to shut the vessels down

111
Q

What haemostat agents are available?

A

surgicel

kaltostat

112
Q

What do homeostatic agents do?

A

composed of oxidised cellulose which form framework for blood to clot on to

113
Q

What can bone wax be used for?

A

To stop bone bleeds - use blunt instrument to apply it

114
Q

When can TMJ dislocation happen?

A

When taking lower tooth out we can dislocate TMJ (both joints or just the one)

can also happen with upper tooth as pt is open so wide and has fatigue and if prone to dislocation then pressure without support can lead to dislocation

115
Q

What do we do if TMJ is dislocated?

A

Relocate immediately before muscles go into spasm

116
Q

What happens when the TMJ dislocates anatomically?

A

The head of condyle jumps over articular eminence in maxilla and becomes stuck infronnt unable to go over eminence back into place without our help

117
Q

How do we reduce tmj dislocation?

A

push down and back straight away so the condyle can jump over articular eminence back into place

118
Q

After relocating TMJ what must we do?

A

Analgesia advice - will be sore with Tmd symptoms for few weeks

yawning advice - if you do need to yawn put fist under jaw to stop from going too wide

119
Q

If we can’t relocate dislocated tmj what can we do?

A

LA into master muscle intramurally to take away pain and discomfort and then try again once pt has pain relief

120
Q

If following master muscle lA we still cant relocate tmj what do we do?

A

Immediate referral - pt must go from practice to hospital

121
Q

Where do we stand when relocating TMJ?

A

Above the pt and push down and back and have some supporting pts head - we can have pt sit on chair, on floor

and we can stand in front or behind pt

122
Q

When might we damage other teeth during extractions?

A

We can hit opposing teeth with forceps which may take cusp off tooth

can crack fracture or move adjacent teeth with alevaots

can crack fracture or move adjacent teeth crowns/bridges or restos

123
Q

When is the only time damage to adjacent teeth is forgivable during xla?

A

if big overhang - if this is the case pt must be warned beforehand that this can fracture and if it does we will put a temp resto on and then you can come back and we will fix other tooth

124
Q

If we damage adjacent tooth during extraction what do we do?

A

Temporary dressing/resto

arrange definitive resto

warn pf of risk!!

125
Q

What can happen to permanent tooth germ during extraction?

A

It too can be extracted when removing deciduous molars - if we extract primary teeth and if the roots break then unless we can easily get them leave them in there to resorb to avoid damage to perm tooth germ

126
Q

How do we ensure we dont XLa the wrong tooth?

A

check clinical situation against notes and radigraphs - errors can occur

If there is mismatch of clinical appearance and notes then stop and q - ask pt what tooth they think is coming out and which tooth is sore?

count teeth - dont just assume last standing tooth is an 8 or 7 it could be a 6 and 7

if still unsure get someone else to verify

127
Q

What happens if we extract the wrong tooth?

A

Tell the pt you have done it - apologise and let them know that we will fix this for them with no charge

phone defence union!!

3. Oral Surgery (9 decks)

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