Extraction Complications 1 Flashcards
What are the 3 classifications of complications of extractions?
Immediate (intraoperative)
Immediate post op (short term post op)
Long term operative
When do short temp post op complications occur?
Hours and days after extraction
When do intraoperative complications occur?
They occur during or within hour of procedure
What is the simple classification of X complications? (2)
Perio-operative
Post-operative
What are some peri-operative complications?
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
Describe difficulty of access and vision
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
What can make access difficult?
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
If teeth are very crowded or malpositioned what may we do for XLa?
We may turn to a surgical extraction to avoid risk to teeth either side
What is abnormal resistance?
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
Why may teeth be difficult to remove? 5
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
What is hypercementosis?
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.
What is ankylosis?
fusion of roots of tooth and bone
What can fracture during extractions? 3
Tooth
Alveolus/tuberosity
Jaw
Why may the tooth fracture?
The crown can fracture off during extraction leaving roots lodged in socket
What makes a tooth more likely to fracture?
Carious tooth
misaligned or crowded teeth where harder to get forceps on properly
Where should forceps go?
below the crown of a tooth (beyond junction where root meets crown and get below bone)
What if we move forceps buccal only?
Crown will snap off
What is the correlation between size of tooth and fracture risk?
Small crown with big roots more likely to fracture
If fracture risk what do we tell the pt?
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!
What are some root problems when extracting? 7
Fused roots convergent roots divergent roots extra roots difficult morphology hypercementosis ankylosis
What plate usually breaks?
buccal plate
Before we do a buccal movement with forceps what do we do?
Use elevators and locators with small movement to get tooth movement
Why shouldn’t we squeeze sockets after extraction?
will reduce bone volume creating issues for implants
What can we do with ragged bone edges?
file them down using bone film to avoid poking through gums - never run finger along bone
What jaw is most likely to fracture?
Mandible or alveolar plate of maxilla
What are some predisposing factors to jaw fractures?
Wisdom tooth extraction
cyst in mandible which weakens jaw
atrophic mandible (edentulous its mandible if flexed can fracture)
How do we avoid jaw fracture?
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
How do we manage a jaw fracture?
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
If we can’t get pt to hospital for a few days what do we do?
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
What is an oac?
This is am immediate communication between oral cavity and maxillary air sinus
ACUTE
What is an oaf?
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
Where can an OAC occur from?
Canine back (more common in pre molar to molar region)
How can we identify its at risk of OAC?
Look at size of teeth, position of roots and sinus on radiograph - gives us an idea of risks
Why should we look at tooth after extraction?
Ensure all roots present and no chunk of bone on it (if we take floor off maxillary sinus this will be seen)
How do we dx a OAC/OAF
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
What is a key indicator of a fractured tuberosity?
Tear on palate - fractured bone is sharp at edges and tears overlying gums and mucosa
Can we create an OAF?
NO - immediate acute situation is an OAC which over time becomes a fistula which is a epithelial lined tube between mouth and sinus
Even if a chronic OAF looks small what can there be?
Bigger area of bone loss underneath
What can we use to identify OAF?
Blunt probe or can squeeze and we may see pus
How do we initially manage OACs?
inform the pt what has happened
what is the oac is small or sinus is intact (1-2mm)?
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
What do we want to encourage pts with OAC to do?
steam inhalations
What do we want pts with OAC to avoid doing?
blowing nose - let it drip instead
If the OAC is large or lining is torn what should we do asap?
close up with sutures
prescribe antibiotics as saliva has accessed sinus
provide nose blowing instructions, steam inhalation
How do we close a large OAC (>2mm)
Buccal advancement flap (tension free flap)
Why must we make sure our buccal advancement flap is tension free when closing OACs?
if not tension free then we will lose blood supply, the flap will breakdown and tear away from sutures
If we have an OAF how to we treat this?
We must cut fistula out - by cutting around the epithelial lined tract or else fistula will reform and won’t close over
Why must we cut around the epithelial lined tract in OAF?
Or else fistula will just reform and won’t close
What sutures do we use to close OAF or OACs?
non resorbing sutures for 2 weeks
see pt after a week to check they are ok and area remains closed
What do we do if we think a root is in the antrum/maxillary sinus?
Confrimr radiographically with opt, occlusal or PA
What do we do if root disappears?
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)
How can we retrieve root in antrum?
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
If there is a root in the antrum what may we need to open up hole further with?
Bone nibblers to clip away intraradicular bone which is left between roots or make the fenestration bigger
Why dont we use an air roter to retrieve root from antrum?
It will force air into the sinus and soft tissues and can lead to surgical emphysema
For curing bone and minor oral surgery what hand piece must we use? and not use?
electric handpick
we can’t use air rotor as this will force air into sinus and cause surgical emphysema
What can cause a fractured maxillary tuberosity?
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
Why can an unknown unerupted molar wisdom tooth cause a fractured maxillary tuberosity?
This is because it can undermine bone making it weaker
What order do we take teeth out?
FROM THE BACK FORWARD (8 7 6) to avoid undermining bone
How do we diagnose a fractured maxillary tuberosity?
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
How do we manage a fractured maxillary tuberosity?
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
How do we carry out a reduction?
Be careful if using fingers as bone is sharp
can use forceps
How do we stabilise fractured maxillary tuberosity?
splint with wire
orate buccal arch wire spot
rigid fixation
What is rigid fixation best for?
best method for healing and reducing risk of infection
When we are splitting a fractured maxillary tuberosity what do we splint?
Rigid splint with wire and composite and include rigid fixed teeth on other side to hold in a fixed position
Why is rigid fixation hard in fractured tuberosity?
nothing posterior to splint to
What do we put the rigid splint on in maxillary tuberosity fractures?
onto intact teeth (8765 if needed) until we feel it has been rigidly splinted so that bone won’t move
If after splinting bones are still moving what will happen?
Bones won’t heal with bony union - instead fibrous union
What does rigid splinting if no movement allow for?
Bony union between fracture to occur
How long should rigid fixation be left on fractured maxillary tuberosity?
8 weeks as it takes maxilla 6-8 weeks to heal (can take 12 weeks sometimes so never go in before 8)
What must we prescribe if pt has fractured maxillary tuberosity?
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
What is a compound fracture?
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
After we reduce maxillary tuberosity fracture what might be the problem?
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
After we extract a tooth what must we always ensure we have?
THE TOOTH!!
If we can’t find the tooth after xla what must we do?
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
What do we say to radiology dept if we are missing a tooth?
Hi, I am missing a tooth - it could have been inhaled - what do you want me to do here?
What is some damage that can happen to nerves?
crush injuries
cutting/shredding injuries with drill or scalpel
transection injuries
damage from surgery
damage from la
How can crush injuries happen to a nerve?
If we lean on nerve with instrument or any post operative swelling compresses them
What is a transection injury?
this is where the the nerve is completely cut through
what type of complication is a nerve injury?
Perio and post op complications as happens perio operatively but effects seen post op
What is neurapraxia?
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
What is axontmesis?
This is when there is continuity of axons but epineural sheath is disrupted
What is neurotmesis?
This is complete loss of nerve continuity (nerve hasm been transected)
What is anaesthesia?
Numbness
What is paraesthesia?
Tingling
What is dysaethesia?
Unpleasant snesation/pain
burning
neuralgic type pain - screaming nerve type pain
What is hypoaestheisa?
Reduced sensation
What is hyperaesthesia?
This is increased/heightened sensation that isn’t that painful but if touched pt feels it more
What do we write in notes regarding warning about nerve damage?
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
What can nerve damage be?
Temporary
Permenant in some case
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?
Send pt to nerve specialist centre where they can try re connect nerve or clean off granulation tissue
What pts would we be more likely to refer to specialist nerve centre?
those with neuralgic type pain - dysaestheisa
What do we not recommend specialist nerve centre referral for?
Bit numb (anaesthesia) or paraesthesia as whilst it could help there is risk of dysaesthesia which is a painful type of nerve damage
If there is suspected nerve damage what can we do?
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
Why is there a risk of venous bleeding following extractions?
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
Why can bleeding occur once LA wears off?
Contains vasoconstrictor so once it wears off vessels open up again leading to bleeding
How do we know if its an arterial bleed?
Arteries are big and have pulse and muscular walls so will spurt with blood
If an arteriole bursts and starts spurting what do we do?
Good pressure, suction and dont panic
what is dental haemorrhage mostly due to?
local factors such as tears in mucoperisoteum, fractures in alveolar plate and socket wall
What are very few bleeds due to?
undiagnosed clotting abnormalities such as haemophilia/von willebrans
What can some bleeds be due to?
Liver disease - alcohol problems as clotting factors are made in liver so if pt has liver disease then reduced likelihood of clotting
How do we ask pt about bleeding problems?
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?
What medication can cause bleeding?
Warfarin
anti-plt agents (aspirin/clopidogrel)
How do we apply pressure to soft tissue bleeding?
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
When may we need to use sutures for bleeds?
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
What stitches can we use to pull socket together?
horizontal mattress or two interrupted sutures
How can we use LA to aid bleeding reduction?
We can use la with vasoconstrictor to shut down vessels in area allowing us to see better
What is a diathermy used for?
This is used to cauterise or burn vessels and precipitates proteins to get protein plug in vessel to stop bleeding
What can we use for larger vessel bleeds?
ligatures or artery clips
What happens if bone is bleeding?
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
If applying pressure to bone doesn’t work what can we do?
We can inject LA into base or walls of socket and onto swab and pack it in to shut the vessels down
What haemostat agents are available?
surgicel
kaltostat
What do homeostatic agents do?
composed of oxidised cellulose which form framework for blood to clot on to
What can bone wax be used for?
To stop bone bleeds - use blunt instrument to apply it
When can TMJ dislocation happen?
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
What do we do if TMJ is dislocated?
Relocate immediately before muscles go into spasm
What happens when the TMJ dislocates anatomically?
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
How do we reduce tmj dislocation?
push down and back straight away so the condyle can jump over articular eminence back into place
After relocating TMJ what must we do?
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
If we can’t relocate dislocated tmj what can we do?
LA into master muscle intramurally to take away pain and discomfort and then try again once pt has pain relief
If following master muscle lA we still cant relocate tmj what do we do?
Immediate referral - pt must go from practice to hospital
Where do we stand when relocating TMJ?
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
When might we damage other teeth during extractions?
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
When is the only time damage to adjacent teeth is forgivable during xla?
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
If we damage adjacent tooth during extraction what do we do?
Temporary dressing/resto
arrange definitive resto
warn pf of risk!!
What can happen to permanent tooth germ during extraction?
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
How do we ensure we dont XLa the wrong tooth?
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
What happens if we extract the wrong tooth?
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!!
