Extraction complications Flashcards
what are the 3 types of extraction complications and when do they take place
Immediate/ intra-operative/ peri-operative
-Happens during extractions
Immediate post-operative/ short term post-operative
- Happens shortly after extractions
*Long term post-operative
-Happens a while after extractions
What peri-operative complications can happen
Difficult access
*Abnormal resistance
*Fracture of tooth/root
*Fracture of alveolar bone
*Jaw fracture
*Involvement of the maxillaryantrum
*Fracture of tuberosity
*Loss of tooth
Soft tissue damage
*Damage to nerves/vessels
*Haemorrhage
*Dislocation of TMJ
*Damage to adjacentteeth/restorations
*Extraction of permanent toothgerm
*Broken instruments
*Wrong tooth
What causes difficult Access
Trismus
Reduced aperture of mouth
Crowded/malpositioned teeth
What could the causes be of abnormal resistance
Thick cortical bone
Shape/form of roots e.g.divergent roots/hooked roots
Number of roots e.g.3 rooted lowermolars
Hypercementosis
Ankylosis
What could cause tooth/root fracture
Caries
Alignment
Size
root morphology
*Fused
*Convergent or divergent
*Extra root(s)
*Hypercementosis
*Ankylosis
Where does fracture of alveolar bone normally occur
Buccal plate
Usually in canines or molars
Where does a jaw fracture normally happen
Usually mandible
What could cause a fracture in the mandible
Often impacted wisdom tooth (takes up bone space), large cyst (takes up bone space) or atrophic mandible
Application of force used
If a jaw fracture occur what must you do
*Inform patient
*Post-op radiograph
*Refer (phone call)
*Ensure analgesia
*Stabilise
*If delay, antibiotic
Tell patient not to eat
What could you do to help improve difficult access
ask patient to move nad good lighting
If there is a fracture in the alveolar bone how would you assess it
Is bone still attached to the periostium
How big is the fracture and the chunk of bone fractured off
Can it be sutured back on
See if the fracture is jaggy but use a instrument to assess that not your fingers
If the alveolar fracture is big with no attachment/ blood supply/ cant stabilise it what do you do
Try and retain it first but if not possible surgically remove it
How could you help to prevent jaw fracture
Use proper technique and support the mandible when extracting
What is the term used for involvement of the maxillary antrum
Oro-antral fistula (OAF)/communication (OAC)
How could you cause a OAC/F
Tooth getting extracted already sits in the maxillary antrum so when extracted it creates a hole
If you are taking a tooth out and only 2 of the roots come out leaving 1 behind, and when you go in with your elavator to try and remove thte 3rd root you push it up instead into the sinus
Fractering the tuberosity
What is the differences between OAF and OAC
OAF
-Hole has been there a while and a thin layer of epithelium has grown over it
OAC
-When its just a hole so youve just created it
How do you diagnose a OAC/F
Size of tooth
Radiographic position of roots in relation to antrum
Bone at trifurcation of roots
Bubbling of blood at the socket
Nose holding test (careful as can create an OAC)
Direct vision
Good light and suction - suction might start to create a echo
Blunt probe (take care not to create an OAC)
What is the nose holding test
The patient is asked to close his nostrils and blow gently down the nose with the mouth open. Presence of OAF appears as a whistling sound as air passes down the fistula into the oral cavity
What are the risk factors of Involvement of Maxillary Antrum
Extraction of uppermolars and premolars
Close relationship of roots to sinus on radiograph
Last standing molars
Large, bulbous roots
Older patient
Previous OAC
Recurrent sinusitis
What are the types of Involvement of Maxillary Antrum
Chronic
Acute (just happened)
How do you manage Involvement of Maxillary Antrum
Inform patient and depends on what type:
If small or sinus intact
–Encourage clot
–Suture margins
–Antibiotic
–Post-op instructions
If large or lining torn
–Close with buccal advancement flap
–Antibiotics and nose blowing instructions
What nose blowing instructions do you give to patients with OAC
Avoid blowing your nose or sneezing with pinched nostrils as both actions increase the pressure in the sinus and could cause the repaired wound to breakdown, so if sneezing do it with mouth open
What is the aetiology of fracture of the tuberosity
Singlestanding molar
Unknown unerupted molar wisdom tooth
Pathological gemination
Extracting in wrong order
Inadequate alveolar support
How do you prevent a fracture of tuberosity happening
Use proper support when extracting
Take teeth out back to front
How do you diagnose fracture of tuberosity
–Noise
–Movement noted both visually or with supporting fingers
–More than one tooth movement
–Tear on palate
How do you manage a tuberosity fracture
Dissect out and close wound or reduce and stabilise
Reduction:
Fingers or forceps
Fixation:
-Orthodontic buccal arch wire spot welded with composite
-Arch bar
-Splints
If you loose a tooth doing surgery what do you do
Stop
Where
- patients bib/mouth/cloths, floor
-Ask if patient felt anything
-If cant find assumed swallowed
Suction
Radiograph
If patient did swalllow tooth what do you do
refer to A&E and you must keep patient calm and have proper comunication
Is soft tissue damage a common complication
yes
How do you minimise soft tissue damage
Using right instrument and technique
Initially place foreceps on crown then move down
Application point
-Make sure elevator/luxator is in space and then apply a small bit of presseure to make sure it doesnt slip
Controlled pressure
Sufficient but not excessive force
When does damage to nerves occur
Anytime but patient will only notice once LA wears off
How does damage to nerves occur and what type of injuries can they be
damage to nerve during surgery with drill or forceps
needle placement
You can crush the nerve, cut/shred the nerve, transect the nerve all with an instrument or the needle
What is neurapraxia
In neurapraxia, the nerve fiber is not actually damaged or severed but rather compressed
What is axonotmesis
the connective tissue surrounding the axon and the myelin sheath that insulates it remain intact, but the axon itself is damaged
Its crushed
What is neurotmesis
Complete loss of nerve continuity/nerve transected
Name the type of feelings that can occur after nerve damage and what they are
Anaesthesia- numbness
Paraesthesia- tingling
Dysaesthesia- unpleasant sensation/pain
Hypoaesthesia- reduced sensation
Hyperaesthesia- increased/heightened sensation
What may cause damage to a vessel
Sharp bone
What is the sign of a vein injury
Lots of bleeding
Whats the sign of a artery injury
Spurting blood
What is the sign of arterioles
Spurting/pulsating bleed
How may a haemorrhage happen
Most bleeds due to local factors –mucoperiosteal tears or fractures of alveolar plate/socket wall
Very few bleeds due to undiagnosed clotting abnormalities (haemophilia/vonWillebrands)
Some due to Liver Disease (alcohol problems) – clotting factors made in liver
Some due to medication – Warfarin/ antiplatelet agents (e.g. Aspirin/Clopidogrel)
How would you manage a haemorrhage in soft tissue
–Pressure(mechanical –finger/biting on damp gauze swab)
–Sutures
–Local Anaesthetic with adrenaline(vasoconstrictor)
–Diathermy(cauterise/burn vessels precipitate proteins which form proteinaceous plug in vessel)
–Ligatures/haemostatic forceps (artery clips) for larger vessels
How may you stop a haemorrhage in bone
–Pressure (via swab)
–LA on a swab or injected into socket
–Haemostatic agents
–Blunt instrument
–Bone Wax
–Pack
How would you manage a TMJ dislocation
Relocate immediately(analgesia and advice on supported yawning)
If unable to relocate try local anaesthetic into masseter intra-orally
If still unable to relocate – immediate referral
How may damage to adjacent teeth occur
Hit opposing teeth with forceps
Crack/Fracture/move adjacent teeth with elevators
Crack/fracture/remove restorations/crowns/bridges on adjacent teeth
How do you manage damage to adjacent teeth
Temporary dressing/restoration
Arrange definitive restoration
If large restoration next to extraction site warn patient of the risk
What is extrtaction of perm. tooth germ and how may it happen
Extraction of permanent tooth germe.g. when removing deciduous molars resulting in extraction or damage to developing permanent premolar
Very rare
