Extraction Complications Flashcards
What can extraction complications be divided into
immediate/intra-operative/peri-operative
immediate post-operative/short term post-op
long term post-op
What are peri-operative complications
difficulty of access abnormal resistance fracture of tooth/root fracture of alveolar plate fracture of tuberosity jaw fracture involvement of maxillary antrum loss of tooth soft tissue damage damage to nerves/vessels hemorrhage dislocation of TMJ damage to adjacent teeth/restorations extraction of permanent tooth germ broken instruments wrong tooth
What can difficulty of access and vision be due to
trismus
reduced aperture of mouth
crowded/malpositioned teeth
How does truisms cause difficulty of access
px can’t open mouth wide
How does reduced aperture of the mouth cause difficulty of access
if its a small mouth and the person can’t open side
some px may have congenital/syndromes e.g microstomia which is scarring and makes it difficult to open
How does crowded/malpositioned teeth create difficulty of access
hard to get to desired tooth
may have to opt for surgical extraction due to risk of mobilizing adjacent teeth
What is abnormal resistance due to
thick cortical bone shape/form of roots number of roots hypercementosis ankylosis
What shapes of roots cause abnormal resistance
divergent roots/hooked roots often seen on lower molars as they can trap interradicular bone between the curves making it harder
Why does number of roots cause abnormal resistance
3 rooted lower molars - the third root is often spindly and hard to mobilize
What is hypercementosis
Extra cementum
see big clumps of cementum and it makes it harder to remove
What can we fracture
tooth
alveolus/tuberosity
jaw
What can a tooth fracture be of
the crown or root
What can make tooth fracture more likely
caries
alignment
size
root
Where do we want forceps to reduce chance of fracture
beyond crown root junction to get into bone
sometimes bone won’t allow this and need luxators and elevators
How does root contribute to fracture likelihood
if crowns are tiny and roots are large suspect breakage
What are root problems that contribute to fracture
fused convergent/divergent extra roots morphology hypercementosis ankylosis
What part of the alveolar bone usually fractures
usually the buccal palate as there is a buttress area of thick bone around it
usually around the canines or molars
When fracturing alveolar bone around molars what do we consider
does it have periosteal attachment?
or no periosteal attachment?
If there is periosteal attachment what do we do?
put it nah and suture in hope it will heal
If there is no periosteal attachment what do we do?
have to dissect it free so gum isn’t ripped
has to be removed because its a dead bit of bone that will cause pain
Why do we try to save the bone in the canine region
as it creates the arch
What do we do if the canine bone region is fractured
stabilise
free mucoperiosteum
smooth edges
What jaw is usually fractured
mandible
What are risk factors for jaw fracture
impacted wisdom tooth, large cyst, atrophic mandible
How can an impacted wisdom tooth increase risk of jaw fracture
may have underestimated how much bone there is in the angle region meaning there is a space in the bone
How can a cyst increase risk of fracture
weakens jaw
How can an atrophic mandible increase risk of fracture
its thin and the force used may fracture
What is the management of jaw fracture
inform px post-op radiograph refer (phone call) ensure analgesia stabilise if there's delay then give AB
What is essential for reducing fracture risk
radiographs to see surrounding structures
application of force - always have finger on alveolus
if mandible is weakened then remove surgically or decoronate
Why may we need to stabilize a jaw fracture
if bone is rubbing against each other and its sore then may need to stabilize with wire that’s thin and flexible and rope around teeth on each side of fracture
don’t do on periodontally compromised teeth
What are issues which involve the maxillary antrum
oro-antral fistula
oro-antral communication
loss of root into antrum
fractured tuberosity
How do you diagnose an oro-antral communication
size of tooth
radiographic positions 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)
What is the difference between OAC and OAF
OAC is immediate acute situation
if goes unnoticed then doesn’t heal and become epithelial lined tube then it is a OAF
What is the management of an OAC
inform the patient
then manage depending on whether its small or large
What should be done if it is small or the sinus is intact
encourage clot
suture margins
antibiotic
post op instructions
Why is it a good idea to give antibiotics for a OAC
as there is saliva going up into this area, filled with bacteria
What is a large OAC or the lining is torn what should be does
close with buccal advancement flap
give antibiotics and nose blowing instructions
What should you do if there is a root in the antrum
confirm radiographically by OPT, occlusal or periapical
then make a decision on retrieval
What is the procedure for getting a root out of the antrum
you need to do a flap design similar to that for an OAC
open fenestration with care
then get suction and efficient and narrow bore
small curettes to see if it can be grabbed
irrigation or ribbon gauze to try and pull it out or move it forward
close as for oro-antral communication
What is the etiology of a fractured maxillary tuberosity
single standing molar unknown unerupted molar wisdom tooth pathological gemination extracting in wrong order ineqduate alveolar support
Why is a single standing more at risk fo fractured maxillary tuberosity
weaker bone and lots of force on one tooth
Why should you extract teeth in the right order to prevent tuberosity fracture
take out from the back forward, don’t take out 6,7,8.
take out 8,7,6 bc otherwise you are undermining bone as you go along and leaving yourself with a last standing molar
How can you diagnose a tuberosity fracture
noise
movement noted both visually or with supporting fingers
more than one tooth movement
tear on palate
What is the management of a fractured tuberosity
dissect out and close wound
or reduce and stabilize via fixation
What does reducing the maxillary tuberosity mean
putting it back where it came from
anatomically repositioning it and stabilizing it
How can you fixate the reduced tuberosity
orthodontic buccal arch wire spot that is welded with composite
splint
arch bar
What type of fixations o you need for a fractured tuberosity
rigid fixation
going to come as anteriorly as you have to until you got rigidity splinted and bone won’t be moving about
Why is rigid fixation so important
fractured bone doesn’t heal by bony union if moving, it will help by fibrous union instead
How long should we leave the splint in the place for the tuberosity fracture
8-12 weeks
For a fractured tuberosity what do we need to remember to do
remove or treat pulp ensure occlusion free antibiotic and antiseptic instructions post-op remove tooth 8 weeks later
How can damage occur to nerves
crush injuries cutting/shredding injuries transection damage from surgery or damage from LA may not know at the time
What is neurapraxia
contusion of nerve/continuinty of epieneural sheath and axons maintained
What is axonotmesis
continuity of axons but not epieneural sheath disrupted
What is neurotmesis
complete loss of nerve continuity/nerve transected
What is anaesthesia
numbness
What is paraesthesia
tingling
What is dysaesthesia
unpleasant sensation/pain
What is hypoaesthesia
reduced sensation
What is hyperesthesia
increase or heightened sensation
What vessels can be damaged
veins arteries arterioles vessels in muscle vessels in bone
If you damage a vein what would you expect
a lot of bleeding
waves of bleeding
If you damage an artery what would you expect
lots of bleeding and squirting as there is a pulse and muscular walls
would see spurting
If you damage an arteriole what would you expect
you would expect spurting still
What are most bleeds in dentistry due to
local factors such as mucoperiosteal tears or fractures of the alveolar plate or socket wall
How should you manage a bleed in soft tissue
pressure (mechanical) sutures LA with adrenaline diathermy ligatures/haemostatic forceps (artery clips) for larger vessels
What is diathermy
cauterise/burn vessels - precipitate proteins, form proteinaceous plug in vessel
What are the options for managing a bleed in bone
pressure via swab LA on a swab or infected into socket hemostatic agents (surgical or kaltostat) blunt instrument bone wax pack
What should you do if you dislocate the TMJ
relocate immediately and give analgesia and advice on supported yawning
if unable to relocate then try LA into masseter intra orally
if still unable to relocate then there should be immediate referral
How is it possible to cause damage to adjacent teeth and restorations
by hitting opposing teeth with forceps
crack/fracture/move adjacent teeth with elevators
crack/fracture/remove restorations/crowns/bridges on adjacent teeth
How should you manage damage to adjacent teeth and restorations
temporary dressing/restoration
arrange definitive restoration
if large restoration next to extraction site then warn px of the risk
What should you do about broken instruments such as tips of burs or elevators and luxators
radiograph and retrieve
if unable to retrieve then refer
How can you try and prevent taking out the wrong tooth
concentrate check clinical situation against notes and radiographs count teeth verify with someone if unsure phone defense union if done
