extraction complications Flashcards
types of complications
peri-op
post-op
OR
peri-op
immediate post-op
long-term post-op
perioperative complications
difficulty of access abnormal resistance fracture tooth/root fracture of alveolar plate fracture of tuberosity mandible fracture involvement of MS loss of tooth ST damage damage to nerves/vessels haemorrhage dislocation of TMJ damage to adjacent teeth/Rxs extraction of permanent tooth germ broken instruments wrong tooth
causes of difficulty of access and vision
trismus
reduced aperture (congenital or syndromes, scarring, muscle spasm or TMJ problems)
crowded/malpositioned teeth
abnormal resistance
thick cortical bone shape/form of roots e.g. divergent/hooked number of roots (3 rooted L molars) hypercementosis ankylosis
if abnormal resistance what should you do?
surgical - otherwise risk fractures
conditions that cause hypercementosis
sometimes none - often idiopathic over-eruption of a tooth inflammation associated with a tooth tooth repair PAGETS DISEASE of bone acromegaly goitre arthritis RF calcinosis Gardner's syndrome vit A deficiency
causes of tooth fracture
caries alignment size e.g. small crown large root root - fused - convergent/divergent - extra - morphology - hypercementosis - ankylosis always examine an extracted tooth
which jaw usually fractures?
mandible (if maxilla usually alveolar plate)
causes of jaw fracture
impacted wisdom tooth
large cyst
atrophic mandible
force - need to support jaw
management of jaw fracture
inform pt
post-op radiograph (pan)
refer - MF, if not A and E
if remote and can’t get them straight to hospital then ensure analgesia and advice on keeping clean
stabilise? - ortho/splint wire - tie around crowns on a couple of teeth both sides. not PDD teeth
if delay - antibiotic
instruct them not to eat en route in case of GA
where does alveolar bone fracture usually occur and why?
usually buccal plate, canines or molars
fused or may have moved buccally too early
management of molar alveolar bone fracture
periosteal attachment? - if the bit of bone is large and still attached then probably vascular supply so can push bone back in. suture so stays in place
if not good periosteal attachment/small - dissect free (don’t rip) - won’t be able to stabilise, may become sequestrum
management of canine alveolar bone fracture
stabilise
free mucoperiosteum
smooth edges - bone file
can affect making of dentures if lose bone in canine area
involvement of maxillary antrum
OAC/OAF
loss of root into antrum
fractured tuberosity - usually involves communication
diagnosis of an OAC
size of tooth radiographic position of roots (2D) bone at trifurcation of roots bubbling of blood nose holding test - care as can create OAC if only membrane intact direct vision good light and gentle suction - echo blunt probe - care not to create OAC "salty/metallic taste" usually pus "water through nose when drink"
what might you see if you squeeze the area of an OAF?
pus
management of a small 1-2mm/sinus intact OAC
inform pt encourage clot suture margins - non-resorbing irrigation - warm saline antibiotic POI - inc steam/menthol inhalation, avoid nose blowing refer if unsure
management of a large/lining torn OAC
close with BAF - tension free otherwise necrosis
need to release periosteum as gum not elastic enough - cut as little as possible for max benefit
non-resorbing sutures
irrigation - warm saline
antibiotic
nose blowing instructions
refer if unsure
chronic OAF management
excise sinus tract = otherwise will reform irrigation - warm saline BAF - 3-sided buccal fat pad with BAF - sturdier palatal flap - keratinised, finger sized bone graft/collagen membrane
reviewing pt after OAC
monitor
up to 2 wks to heal
1wk
remove sutures 10days-2wks
management of a root in antrum
confirm radiographically - OPT, occ, (PA)
check not in suction/get pt to stand up and shake collar etc
decision on retrieval - if tiny and not causing issues some pts opt to KUR - but risk of sinusitis etc
why shouldn’t you use an air rotor handpiece
surgical emphysema
air in STs
infection risk
aetiology of fractured maxillary tuberosity
single standing molar (bone weak) unknown UE 8/cyst pathological gemination extracting in wrong order - ext from back forwards inadequate alveolar support
if can’t ext without excessive pressure consider surgical
diagnosis of fractured maxillary tuberosity
noise
movement noted - visually or with supporting fingers
>1 tooth movement
tear on palate
- fractured bones sharp, often tear underlying mucosa
management of a fractured maxillary tuberosity if small
dissect out and close wound fresh scalpel cut gum around, relieving incision remove tooth and bit of bone often don't need BAF
management of a fractured maxillary tuberosity if large or >1 tooth
reduce and stabilise
reduction: fingers (sharp bone) or forceps - sometimes need to disimpact then reduce
fixation: keep bones against each other for bony healing
- ortho wire spot welded with composite
- arch bar
- mouthguard splints if near lab - cover with Vaseline when taking imp so don’t pull it out - not ideal
rigid fixation for fracture - inc teeth that aren’t moving - harder in tuberosity area as nothing posteriorly - come as anteriorly as you feel you need to
management of a fractured maxillary tuberosity - after initial management
remove or tx pulp if toothache/pulpitis - think reason for extraction
ensure occlusion free
- tooth will be sitting proud as odema in ligament
- if tooth to extract just reduce cusps
- if not extracting tooth make splint to relieve area - cut out a bit around those teeth
antibiotic and antiseptics
POIs - 6-12wks to heal
remove tooth 8wks later - SR
loss of tooth
where? STOP tx - suction - clothes, EO, ground - IO - back/under tongue - have quick look then encourage pt to cough radiograph GET advice inhaled - may need surgery lingual plate may fracture and tooth can disappear into FOM and neck, lung
causes of damage to nerves
crush cutting/shredding transection from surgery from LA swelling in 48hrs post-op can press on nerve might not know at time
needle into IAN
pt will leap, feel burning sensation across jaw
remove needle and replace as will have blunted it
neurapraxia
contusion of nerve but continuity of epineural sheath and axons maintained
axonotmesis
continuity of axons disrupted but not epineural sheath
neurotmesis
complete loss of nerve continuity/nerve transected
effects of nerve damage - technical
anaesthesia paraesthesia dysaesthesia hypoaesthesia hyperaesthesia temp/permanent
effects of nerve damage - pt terms
numbness tingling unpleasant sensation/pain reduced sensation increased/heightened sensation altered sensation temp/permanent
treating nerve damage
refer - always label as urgent
- earlier you intervene higher success
- but longer you leave nerve more likelihood of it just settling down
speak to defence union
effects of nerve damage will follow the distribution of the nerve - but hopefully won’t be the whole distribution
- if hit lingual nerve small risk of effect on taste - chords tympani
specialist nerve centres
clean, explore or reconnect
but risk of making it worse
most pts who decide this option have dysaesthesia
causes of damage to vessels during op
LA needle
scalpel (facial artery buccal aspect mandible)
sharp bone edges
lift flap and haven’t put it back down tightly enough
causes of damage to vessels after op
pt may accidentally open stitch
vasoconstrictor effect of LA wears off
may be anticoagulated
damage to veins
lots of bleeding but not pulsating
damage to arteries
spurting
haemorrhage
damage to arterioles
spurting/pulsating
dental haemorrhage causes
most - local factors - mucoperiosteal tears or fractures of alveolar plate/socket wall
v few - undiagnosed clotting abnormalities - pt likely to know already, maybe mild VW - GP referral
some - liver disease
some - medication
elderly - bruise easily, vessel walls, collagen etc more fragile
perio disease - lots of inflammation so lots of bleeding, just need pressure in area
what should you ask pre-op to reduce risk of dental haemorrhage?
do you bruise easily?
do cuts take a long time to stop bleeding?
management of soft tissue bleeding
mechanical pressure sutures LA with vasoconstrictor diathermy ligatures/haemostatic forceps (artery clips) - ensure not nerves
management of soft tissue bleeding - mechanical pressure
finger/bite down on damp gauze
firm even pressure - otherwise rebound
15mins, 20mins, refer?
management of soft tissue bleeding - sutures
extra
suture papillae together
suture relieving incision
management of soft tissue bleeding - diathermy
cauterise/burn vessels
ppt proteins - form proteinaceous plug in vessel
electrocautery units
need to be sure it is vessel
management of bone bleeding
pressure LA on swab/injected into socket haemostatic agents - surgicel/kaltostat blunt instrument bone wax pack
management of bone bleeding - pressure
bite on damp swab gauze
ribbon gauze - pack into socket, if nerves then protect them with instruments
management of bone bleeding - haemostatic agents
oxidised cellulose
scaffold for clot
some acidic so ensure not near nerve
don’t need to remove packs - will dissolve
management of bone bleeding - bone wax
get suction in
dry
apply wax
don’t need to remove - you are just smearing a waterproof layer on
- puts back pressure on the vessels to stop bleeding
if cant stop bleeding
phone for advice
- OS, MF, A and E
if worried phone ambulance otherwise send in car with gauze pressure
management of TMJ dislocation
relocate immediately - muscles will spasm, v difficult to relocate earlier
- down and backwards movement, above pt, have someone supporting head as lots of pressure
analgesia
advice on supported yawning
if unable to relocate try LA into masseter IO then relocate
if unable to relocate - urgent immediate referral
cause of TMJ dislocation
usually lower tooth extraction - lot of pressure and not supporting mandible
occ upper extraction - if opening really wide
damage to adjacent teeth/restorations
only forgivable if big adjacent overhang
if large adjacent restoration warn pt of risk
if it happens put temp in then definitive later
extraction of permanent tooth germ
don’t look for fragments of primary roots unless v easy to remove - leave to resorb as can damage permanent tooth germ
broken instruments
inappropriate use
radiograph
check suction, floor, get pt to shake clothes
if can’t find/retrieve phone for advice and refer - document who you speak to on phone
