Extraction complications Flashcards
3 classes of extraction complications
immediate/intra-operative/ peri-operative
immediate post-operative/ short term post-operative
long term post-operative
extraction complications around extraction time
peri-operative complications
extraction complications after extraction
post-operative complications
peri-operative extraction complications
Difficulty of access
Abnormal resistance
Fracture of tooth/root
Fracture of alveolar plate
Fracture of tuberosity
Jaw fracture
Involvement of the maxillary antrum
Loss of tooth
Soft tissue damage
Damage to nerves/vessels
Haemorrhage
Dislocation of TMJ
Damage to adjacent teeth/restorations
Extraction of permanent tooth germ
- Leave little primary roots to resorb away naturally – do not dig
Broken instruments
Wrong tooth!!!!!
what are the 2 fundamental needs for extraction
good lighting and vision
- access and vision
what can cause difficulty in access and vision for extraction (3 types)
trismus
reduced aperture of mouth (congenital syndromes - microstomia; scarring)
crowded/malpositioned teeth
abnormal resistance that can cause peri-operative extraction complications
Thick cortical bone
Shape/form of roots e.g. divergent roots/hooked roots
Number of roots e.g. 3 rooted lower molars
Hypercementosis
Ankylosis
3 fracture types that can cause peri-operative complications
tooth
alveolus/tuberosity
jaw
tooth fracture that can cause periopertive complicatons
crown or root
can be due to:
- caries
- alignment
- size
- root
how to minimise fracture in extraction
get forceps below crown and gum
get beaks on roots - unlikely to break crown
- use luxators and elevators to get in
root problems that can cause peri-operative extraction complications
- fused
- convergent or divergent
- ‘extra’ root(s)
- morphology
- hypercementosis
- ankylosis
alveolar bone that is fractured commonly in extraction
Usually buccal plate
Usually canines or molars
Molars:
- Periosteal attachment?
- Suture
- Dissect free
Canines:
- Stabilise
- Free mucoperiosteum
Don’t squeeze sockets post extraction – old technique – other haemostasis techniques
what to consider in periosteal attachment when extract
Size
> large – likely to have blood supply – put back and suture in place – possibility to heal
> small – take out as will cause pain – free up (dissect with scalpel)
- Smooth edges
jaw fracture in extraction
Usually mandible
Often impacted wisdom tooth, large cyst or atrophic mandible
Radiograph(s) are essential
Application of force
- Always support mandible
management of jaw fracture
Inform patient – do not eat on route
Post-op radiograph
Refer (phone call)
Ensure analgesia
Stabilise?
If delay, antibiotic
involvement of maxillary antrum in extraction can be
Oro-antral fistula (OAF)/communication (OAC)
Loss of root into antrum
Fractured tuberosity
why should you always examine extracted tooth post extraction
are all roots attached?
any bone or periosteum come out with the tooth?
oro-antral communication
diagnose by
Size of tooth
Radiographic position of roots in relation to antrum
Bone at trifurcation of roots
Bubbling of blood
Nose holding test (careful as can create an OAC)
Direct vision
Good light and suction - echo
Blunt probe (take care not to create an OAC)
palate tear - classic sign tuberosity broken
acute maxillary antrum extraction connection
oro-antral communication OAC
chronic maxillary antrum extraction connection
oro-antral fistula OAF
epithelium lined
management of oro-antral communication
Inform patient
If small or sinus intact:
- Encourage clot
- Suture margins
- Antibiotic
- Post-op instructions
If large or lining torn:
- Close with buccal advancement flap – need tension free – if tight = loose circulation, sutures tear away
- Antibiotics and nose blowing instructions
Steam inhalation to help small sinus communications be clean
how to deal with chronic OAF - key step
need to cut fistula out as otherwise will reform
how to confirm root in antrum
radiographically
- OPT
- Occlusal
- periapical
how to manage root in antrum
decision on retrieval after radiograph
- Flap design – bone nibbler or electrical but – not air rota for cutting bone
- Open fenestration with care
- Suction – efficient and narrow bore
- Small curettes
- Irrigation or ribbon gauze
- Close as for oro-antral communication
aetiology of fractured maxillary tuberosity
Single standing molar
Unknown unerupted molar wisdom tooth
Pathological gemination
Extracting in wrong order – take back forward so not undermining bone – don’t want left with last standing molar
Inadequate alveolar support
diagnosis of fractured maxillary tuberosity
Noise
Movement noted both visually or with supporting fingers
More than one tooth movement
Tear on palate
management of fractured maxillary tuberosity
dissect out and close wound
or reduce and stabilise
fixation of fractured maxillary tuberosity
orthodontic buccal arch wire spot - welded with composite
arch bar
splints - don’t want removable as will alter position; need rigid for bone fracture (as many firm teeth included)
when managing fractured maxillary tuberosity remember to
remove or treat pulp
ensure occlusion free
antibiotic and antiseptics
instructions post op
remove tooth 8 weeks later (SR)
lose tooth on extraction
stop
check suction
radiograph - inhaled/swallowed ? need operation
- Maxillary sinus, lingual plate – need further imaging
- Need phone radiology department/ hospital
- Chest x-ray, abdominal x-ray
Contact defence union
Hold tooth with fingers when elevating tooth – always be vigilant
4 possible damages to nerves on extraction
crush injuries
cutting/shredding injuries
transection - cut all the way through
damage from surgery or damage from LA
may not know at time
neurapraxia
contusion of nerve/continuity of epineural sheath and axons maintained
axontomesis
continuity of axons but not epineural sheath disrupted
neurotmesis
complete loss of nerve continuity/nerve transected
anaesthesia
numbness
paraesthesia
tingling
dysaesthesia
unpleasant sensation/pain
hypoaesthesia
reduced sensation
hyperaesthesia
increased/heightened sensation
5 possible damage to vessels on extraction
Veins (bleeding +++)
Arteries (spurting/haemorrhage +++)
Arterioles (spurting/pulsating bleed)
Vessels in muscle
Vessels in bone
dental haemorrhage
Most bleeds due to local factors – mucoperiosteal tears or fractures of alveolar plate/socket wall
Very few bleeds due to undiagnosed clotting abnormalities (haemophilia/von Willebrands)
Some due to Liver Disease (alcohol problems) – clotting factors made in liver
Some due to medication – Warfarin/ antiplatelet agents (e.g. Aspirin/Clopidogrel)
Note: Other anticoagulant drugs – Rivaroxaban (Pradaxa) and Dabigatran (Xarelto)
- Check up to date SDCEP
how to manage soft tissue bleeding
gums, cheek, tongue
Pressure – mechanical (finger, biting on damp gauze) firm, even pressure
- 20 mins min
Sutures
Local anaesthetic with adrenaline (vasoconstrictor)
Diathermy (cauterise/burn vessels – precipitate protein from proteinaceous plug in vessel)
Ligatures/haemostatic forceps (artery clips) for larger vessels
- Can tie of larger vessels pre surgery pre-cut to minimise bleed
how to manage bone bleeding
Pressure (via swab)
LA on a swab or injected into socket
Haemostatic agents - Surgicel/ Kaltostat
- Some acidic so be careful if near a nerve/ wisdom tooth area
Blunt instrument
- shiny non-sharp end excavators, flat plastic
Bone Wax
- dry, use round ended excavators and smear on – pressure on vessels to stop bleeding – need to be dry
Pack
dislocation of TMJ in extraction management
Relocate immediately (analgesia and advice on supported yawning)
If unable to relocate try local anaesthetic into masseter intaorally
If still unable to relocate – immediate referral
Lower down than you and support head
3 potential damages to adjacent teeth/restorations in extractions
Hit opposing teeth with forceps
Crack/Fracture/move adjacent teeth with elevators
Crack/fracture/remove restorations/crowns/bridges on adjacent teeth
Overhangs – warn pt and that will fix
management to damage to adjacent teeth/restoration in extraction
Temporary dressing/restoration
Arrange definitive restoration
If large restoration next to extraction site warn patient of the risk
when could extraction of permanent tooth germs happen
When removing deciduous molars – extraction or damage to developing permanent premolars
what to do if break instrument in extraction
E.g. Tips of elevators and luxators
E.g. Tips of burs
Radiograph/retrieve
If unable to retrieve - refer
extract wrong tooth?
Concentrate
Check clinical situation against notes/radiographs (mislabelling of radiographs/errors in notes can occur!)
Count teeth
Verify with someone else if still unsure
Phone the defence union if you do it!!!!
