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BDS3 Oral Surgery > Extraction complications > Flashcards

Extraction complications Flashcards

1
Q

3 classes of extraction complications

A

immediate/intra-operative/ peri-operative

immediate post-operative/ short term post-operative

long term post-operative

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2
Q

extraction complications around extraction time

A

peri-operative complications

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3
Q

extraction complications after extraction

A

post-operative complications

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4
Q

peri-operative extraction complications

A

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!!!!!

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5
Q

what are the 2 fundamental needs for extraction

A

good lighting and vision

- access and vision

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6
Q

what can cause difficulty in access and vision for extraction (3 types)

A

trismus

reduced aperture of mouth (congenital syndromes - microstomia; scarring)

crowded/malpositioned teeth

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7
Q

abnormal resistance that can cause peri-operative extraction complications

A

Thick cortical bone

Shape/form of roots e.g. divergent roots/hooked roots

Number of roots e.g. 3 rooted lower molars

Hypercementosis

Ankylosis

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8
Q

3 fracture types that can cause peri-operative complications

A

tooth

alveolus/tuberosity

jaw

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9
Q

tooth fracture that can cause periopertive complicatons

A

crown or root

can be due to:

  • caries
  • alignment
  • size
  • root
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10
Q

how to minimise fracture in extraction

A

get forceps below crown and gum

get beaks on roots - unlikely to break crown
- use luxators and elevators to get in

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11
Q

root problems that can cause peri-operative extraction complications

A
  • fused
  • convergent or divergent
  • ‘extra’ root(s)
  • morphology
  • hypercementosis
  • ankylosis
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12
Q

alveolar bone that is fractured commonly in extraction

A

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

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13
Q

what to consider in periosteal attachment when extract

A

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

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14
Q

jaw fracture in extraction

A

Usually mandible

Often impacted wisdom tooth, large cyst or atrophic mandible

Radiograph(s) are essential

Application of force
- Always support mandible

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15
Q

management of jaw fracture

A

Inform patient – do not eat on route

Post-op radiograph

Refer (phone call)

Ensure analgesia

Stabilise?

If delay, antibiotic

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16
Q

involvement of maxillary antrum in extraction can be

A

Oro-antral fistula (OAF)/communication (OAC)

Loss of root into antrum

Fractured tuberosity

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17
Q

why should you always examine extracted tooth post extraction

A

are all roots attached?

any bone or periosteum come out with the tooth?

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18
Q

oro-antral communication

diagnose by

A

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

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19
Q

acute maxillary antrum extraction connection

A

oro-antral communication OAC

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20
Q

chronic maxillary antrum extraction connection

A

oro-antral fistula OAF

epithelium lined

21
Q

management of oro-antral communication

A

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

22
Q

how to deal with chronic OAF - key step

A

need to cut fistula out as otherwise will reform

23
Q

how to confirm root in antrum

A

radiographically

  • OPT
  • Occlusal
  • periapical
24
Q

how to manage root in antrum

A

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
25
Q

aetiology of fractured maxillary tuberosity

A

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

26
Q

diagnosis of fractured maxillary tuberosity

A

Noise

Movement noted both visually or with supporting fingers

More than one tooth movement

Tear on palate

27
Q

management of fractured maxillary tuberosity

A

dissect out and close wound

or reduce and stabilise

28
Q

fixation of fractured maxillary tuberosity

A

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)

29
Q

when managing fractured maxillary tuberosity remember to

A

remove or treat pulp

ensure occlusion free

antibiotic and antiseptics

instructions post op

remove tooth 8 weeks later (SR)

30
Q

lose tooth on extraction

A

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

31
Q

4 possible damages to nerves on extraction

A

crush injuries

cutting/shredding injuries

transection - cut all the way through

damage from surgery or damage from LA

may not know at time

32
Q

neurapraxia

A

contusion of nerve/continuity of epineural sheath and axons maintained

33
Q

axontomesis

A

continuity of axons but not epineural sheath disrupted

34
Q

neurotmesis

A

complete loss of nerve continuity/nerve transected

35
Q

anaesthesia

A

numbness

36
Q

paraesthesia

A

tingling

37
Q

dysaesthesia

A

unpleasant sensation/pain

38
Q

hypoaesthesia

A

reduced sensation

39
Q

hyperaesthesia

A

increased/heightened sensation

40
Q

5 possible damage to vessels on extraction

A

Veins (bleeding +++)

Arteries (spurting/haemorrhage +++)

Arterioles (spurting/pulsating bleed)

Vessels in muscle

Vessels in bone

41
Q

dental haemorrhage

A

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

42
Q

how to manage soft tissue bleeding

A

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

43
Q

how to manage bone bleeding

A

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

44
Q

dislocation of TMJ in extraction management

A

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

45
Q

3 potential damages to adjacent teeth/restorations in extractions

A

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

46
Q

management to damage to adjacent teeth/restoration in extraction

A

Temporary dressing/restoration

Arrange definitive restoration

If large restoration next to extraction site warn patient of the risk

47
Q

when could extraction of permanent tooth germs happen

A

When removing deciduous molars – extraction or damage to developing permanent premolars

48
Q

what to do if break instrument in extraction

A

E.g. Tips of elevators and luxators
E.g. Tips of burs

Radiograph/retrieve

If unable to retrieve - refer

49
Q

extract wrong tooth?

A

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!!!!

BDS3 Oral Surgery (8 decks)

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