extraction complications

Question 1

how can complications be classified

Answer 1

• Immediate / intra-operative / peri-operative
• Immediate post-operative / short term post-operative
• Long term post-operative

Or can be classified as:
• Peri-operative complications
• Post-operative complications

Question 2

what are peri-operative complications

Answer 2

Ie things that will affect us during the surgery and just immediately afterwards
There are certain things that are not necessarily a complication but they just will result in a complication and make life more difficult

Question 3

list examples of peri-operative complications

Answer 3

• 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
• Haemorrhage
• Dislocation of TMJ
• Damage to adjacent teeth / restorations
• Extraction of permanent tooth germ
• Broken instruments
• Wrong tooth

Question 4

what is abnormal resistance

Answer 4

not being able to get the tooth out of the mouth

Question 5

where is the maxillary tuberosity

Answer 5

back of the maxilla beside the last standing molars

Question 6

what jaw is most likely to fracture

Answer 6

More commonly this would be the mandible

Question 7

what can cause difficulty of access and vision

Answer 7

• Trismus [Limited mouth opening]

• Reduce aperture of mouth
○ Congenital / syndromes
§ microstmia
§ Scarring [either from conditions inside the mouth or from burns]

• Crowded / malpositioned teeth

Question 8

what is microstomia

Answer 8

Microstomia ~ small mouth

Question 9

how can crowded or malpositioned teeth cause difficult of access and vision

Answer 9

○ For example an upper 4 could be palatally placed / lower 5 lingually placed meaning you cannot get the forceps onto the tooth without moving the teeth on either side

○ Sometimes have to wiggle away with luxators and elevators to create a little space and to get the tooth moving

○ Sometimes just have to revert to a surgical extraction and cut the crown off and drill around the roots

Question 10

what can help improve difficulty of access and vision

Answer 10

○ Need good lighting

○ If you need to stop what you are doing to move the chair or move the lights then do this

○ Need to see where your forceps are going

○ Need to be comfortable that you have got your instruments in the right place, where you want them to be, before you start taking the tooth out

Question 11

what can cause abnormal resistance

Answer 11

• Thick cortical bone
• Shape / forms of roots
• Number of roots
• Hypercementosis
• Ankylosis

Question 12

what patients are most likely to have thick cortical bone

Answer 12

○ Commonly seen in big, bulky, thick-set people

○ Big men often have thicker cortical bone than a smaller female

Question 13

how can the shape or form of roots cause abnormal resistance

Answer 13

○ Eg divergent roots / hooked roots

○ Especially lower 6s and 7s with 2 roots which seem to curve together don’t look like as if they should be a problem but sometimes they can trap a bit of the interradicular bone between the curve of those 2 roots which makes it more difficult

Question 14

how can the number of roots cause abnormal resistance

Answer 14

○ Eg 3 rooted lower molars

○ Teeth with extra roots are more difficult

○ In lower molars with 3 roots, often the 3rd root is tiny / spindley, but really makes it more difficult to get that tooth mobilised

Question 15

what is hypercementosis

Answer 15

Teeth with extra cementum around the roots

Sometimes there is no condition, the patient might just have hypercementosis

Question 16

how can hypercementosis cause abnormal resistance

Answer 16

Can see the big clumps of cementum around the tooth roots on x-rays ~ indicates a more difficult extraction

Question 17

what is ankylosis and how does it cause abnormal resistance

Answer 17

Abnormal stiffening and immobility due to fusion with the bone

Sometimes the PDL is gone (there may have been trauma in the past) and the bone is fused to the roots of the teeth

Question 18

how can you overcome abnormal resistance

Answer 18

• Sometimes just leaving the tooth alone for a minute helps
  ○ Because you have been putting pressure on the tooth, causes inflammation within the periodontal ligament
  ○ Leaving it for a minute might cause some oedema around the PDL which will eventually cause the tooth to become a little bit looser
• But if you cannot move the tooth and you have tried really hard then the answer is not more force
  ○ Sometimes as a student the answer might be a little more force because many students don’t put enough force on the tooth until you are used to dealing with it
• If the tooth is not moving then take it out surgically
  ○ Don’t apply more and more and more force and cause the alveolar bone / tuberosity / mandible to break / fracture
  ○ If you think you cannot get the tooth out without breaking part of the bone then take it out surgically

Question 19

what can fracture during an extraction

Answer 19

• Tooth
• Alveolus / tuberosity
• Jaw

Question 20

what can cause the crown of the tooth to fracture

Answer 20

• Caries
○ If the tooth is carious, it is much more likely for it to break off when you are trying to take it out

• Alignment
○ If it is crowded or in an awkward position it can be difficult for you to get the forceps where they need to be
○ Tip: always get the forceps beaks below the crown

• Size
○ Might be that the tooth has a tiny little crown with big sturdy roots and the laws of physics tell you that you are much more likely to break the crown off ~ be prepared
○ Warn patient that they should not be alarmed if they hear a cracking sound and the crown breaks off, it will get removed but it is anticipated that parts of it will break

Question 21

where is it important to place the forcep beaks

Answer 21

§ They need to go beyond the junction where the root meets the crown

§ They need to get below the bone

§ This is why you need to take your time to position your forceps and make sure they are beneath the gum and then start pushing them down or pushing them up so they move their way between the bone and the tooth

§ Ultimate aim (not always possible) is to get the beaks of the forceps just onto the roots ~ if you manage this then you are highly unlikely to break the crown

§ Cannot always do this, sometimes the bone doesn’t allow for this and you need to create some space using luxators and elevators or even a drill to be able to get to the roots

Question 22

how can the roots of teeth fracture

Answer 22

○ Might be a funny shape, might be hooked

○ Can either cause fracture of the crown or if the crown is removed and you are removing the roots, bits of this can be removed as well

Question 23

what are root problems in extractions

Answer 23

• Fused
• Convergent or divergent
• ‘extra’ root(s)
• Morphology
• Hypercementosis
• Ankylosis

Question 24

what is alveolar bone

Answer 24

The bone that is around the socket

Question 25

where is it most common for the alveolar bone to break

Answer 25

Usually buccal plate that breaks

Usually when extracting canines or molars

Question 26

what do you do if the alveolar plate fractures when removing molars

Answer 26

○ Periosteal attachment
§ Is the bit of bone still attached to the periosteum?
§ What size is it?
§ If it is a big bit of bone which is still attached to the periosteum then it will still have a blood supply so you could probably just push it back into place
§ If it doesn’t have a good periosteal attachment or it is quite small or it is not going to be able to stabilise then take it out

○ Suture
§ If the bit of bone is going to stay in place then just suture up around it, you might be able to get the gum closed over it or you might just be able to anatomically position it around where the tooth was
§ Want to check that it will stay in place
§ So if it is big enough and has got a blood supply and will stay in place then it will possibly heal [If it doesn’t it will work its way out or we can take it out]

○ Dissect free
§ A dead bit of bone will cause the patient pain until it works its way out of the socket or until you take it out
§ Remember even if you are removing it might be attached to the periosteum so it must be dissected free with a scalpel so that the gum is not ripped even further
§ So free it up before taking it out

This is a judgement call you have to make

Question 27

what do you do if the alveolar plate fractures when removing canines

Answer 27

○ Stabilise
§ Try and save it in the canine region as it has a job here in creating the shape of the alveolus (in the upper arch there is the big buttress area)
§ Often tends to be a bigger bit in the canine that has broken off (tends to be smaller in the molar region)

○ Free mucoperiosteum

○ Smooth edges
§ The edges of the bone are jaggy and ragged so you need to take a bone file or an instrument and smooth the edges of bone that you are leaving behind otherwise the jaggy edges you are leaving behind will pierce through the gum and probably break down the wound and probably cause problems

Question 28

why should you never run your finger along broken bone

Answer 28

Never run your finger along broken bone as it is sharp and jaggy ~ it will rip your glove and cut your finger

Don’t be tempted once you’ve smoothed it down to feel it with your finger, inspect it and have another feel at it with the file (the file will tell you whether it is sharp or not)

Question 29

why might the alveolar bone break

Answer 29

Bone might break off because it was fused to the tooth or it might be that we took the tooth buccally too quickly before we had it moving
Want the tooth moving first, use luxators and elevators, put pressure on the tooth using the forceps and do a few little movements first before you take it buccally

Question 30

do we squeeze the tooth socket once we take the tooth out?

Answer 30

do not squeeze sockets once the tooth has been taken out
○ Used to squeeze sockets as it made the socket smaller, crushed vessels and helped to stop the bleeding and it was thought that this helped it to heal nicely and make the whole area smaller

○ But what happens is that you take away the bone volume (and people will lose bone as well after they get a tooth out) and this wrecks things for implants

○ There are other ways to get the socket to stop bleeding

Question 31

what pre-disposing factors increases the chance of fracturing the mandible

Answer 31

• impacted wisdom teeth
• large cyst [can weaken the jaw]
• atrophic mandible [ie the patient might be edentulous and has been for years so the mandible is very thin]

Question 32

how can an impacted wisdom tooth cause fracture to the mandible

Answer 32

Impacted wisdom teeth have undermined how much bone there is in the angle region
There is a big space in the bone, and the tooth in there, which normally all would have been thick bone

○ On some occasions, when extracting a wisdom tooth in a very thin mandible, you can just remove the crown of it and leave the roots behind and tell the patient to see how they get on with that because if the roots were to be removed the jaw would be broken
§ Especially if the roots are all the way to the lower border of the mandible

Question 33

how should the jaw be supported during extractions

Answer 33

○ Always have the fingers on either side of the alveolus and the thumb underneath the jaw

○ If you are in a tricky position and cannot manage the support and getting the forceps in then you must get someone else to support the jaw

Question 34

how do you manage a jaw fracture

Answer 34

• Inform patient
• Post-op radiograph [If you have a panoramic machine and are able to do so]
• Refer (phone call)
• Don’t flap, deal with it calmly and get the patient referred

• Ensure analgesia
○ If you are working remotely and you cannot get the patient to the referral until the next day then you need to consider pain relief for the patient
○ Give the patient advice about analgesia because they will be sore
○ Also give the patient advise about keeping the socket clean [Mouthwashes, warm salty mouth washes, chlorhexidine mouthwashes]○ Fractured mandibles are usually compound fractures, the gum is ripped and has access into the oral cavity (dirty and has bacteria)
○ Need to give advice to keep the mouth / socket / wound clean

• Stabilise?

• If delay in getting the fracture fixed, antibiotic treatment
Until they can get to where they have got to go

Question 35

how should you refer a jaw fracture

Answer 35

○ Best place to call would be the maxillo-facial unit

○ Tell them you suspect / know there is a fractured mandible in my patient, how do I go about this, how do I get the patient to you?

○ If you don’t have a maxillo-facial unit then the patient needs to go to A&E

○ Dental hospital is not the first place you call to refer the patient, but if you just want advice you can phone them and they can be the intermediatory between getting them to A&E or to the maxillo-facial unit

○ Really just depends where you are working

○ If you can get the patient away to their referral then don’t interfere any further and send them on

○ Tell the patient not to eat on route because they might be going to theatre that day to have the mandible repaired
§ They might not but either way they need to go fasted

Question 36

how do you stabilise a jaw fracture

Answer 36

○ Bones rubbing against each other can be sore so might want to consider trying to stabilise the fracture

○ This can be done with a bit of ortho wire if you have any in the practice
Or some splinting wire

○ Needs to be thin and flexible

○ Just tie this wire around the crowns of a couple of teeth on either side of the fracture to almost rope the fracture together and stabilise it a little
§ If you are not happy about doing this then don’t do it
§ Don’t do it around periodontally compromised teeth or they might just come out with wire around them

Question 37

what is an OAF / OAC

Answer 37

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

Question 38

What is the difference between an OAC and OAF

Answer 38

○ You cannot create a fistula when you take a tooth out

○ The immediate acute situation is an oral-antral communication
§ It is a communication between the maxillary air sinus and the mouth

○ If you don’t notice the OAC or if it doesn’t heal (or if you do notice but you decide to wait to see if it heals itself) it then becomes a fistula
= It becomes epithelial lined if it doesn’t heal
§ Creates an epithelial lined tube between the mouth and the sinus

○ The chronic situation is a fistula

○ Acute = OAC

○ Chronic = OAF

Question 39

Where can you get an OAC / OAF

Answer 39

○ Can get this communication from any of the teeth from the canine back

§ More common with molars
But some people have bigger air sinuses which can come all the way forward to the canine

Question 40

how else can the involvement of the maxillary sinus cause problems

Answer 40

• Loss of root into antrum

• Fractured tuberosity
It is positioned just right next to the maxillary sinus so it usually involves a communication with the maxillary sinus

Question 41

how do you diagnose an OAC

Answer 41

○ Size of tooth
§ When you take a tooth out always examine it to make sure all the roots are there, to make sure the ends of the roots are there, to make sure there isn’t a chunk of bone on it

○ Radiographic position of roots in relation to antrum
[Cannot tell us 100% because it is a 2D picture it can give an idea as to whether there might be a risk there]

○ Bone at trifurcation of roots

○ Bubbling of blood within the pocket
§ Might notice this as the patient breathes / moves

○ Nose hold test (careful as can create an OAC)
§ Patient holds nose and blows and might see some movement of air between the mouth and the socket but if it is only the membrane that is attached this can cause it to tear

○ Direct vision

○ Good light and suction - echo
§ Use suction gently and carefully so as to not push the membrane
§ When you put the suction in you might be able to hear an echo ~ this is more so the case if it is a bigger communication present

○ Blunt probe (take care not to create OAC)
§ Explore base of socket using the blunt probe
§ The probe might just fall into a hole / pocket and you might find a communication
§ Again, be careful as to not make a communication
§ Probe may be blunt but they are still narrow and thin

Question 42

how do you manage an OAC

Answer 42

• Inform patient

• If small or sinus intact:
○ Encourage clot
○ Suture margins [Just to make it tighter and help it to heal up quicker]
○ Antibiotic [If there is a communication, everything in the mouth (saliva, bacteria, food etc) is going up into the sinus and could cause infection of the sinus]
○ Post-op instructions
§ Give instructions about steam inhalations ~ to help the area heal
§ Don’t blow their nose, just sort of let it drip onto a tissue
○ They more often than not heal when they are very small (1-2mm which you can barely see)

• If large or lining torn:
○ Close with buccal advancement flap [The best chance it has got of healing is to close it straight away]
○ Antibiotics and nose blowing instructions
§ Still give antibiotics after it has been closed as saliva with the bacteria etc has still gone into the sinus while there was a communication
§ Use steam inhalations
○ Still keep an eye on the patient ~ sometimes even though you close it, the closed communication can break down again / open [Especially in large communications]
§ Or where the closure has been tight ~ there is not enough elasticity on the flap (need a tension free flap when you close an OAC)

Question 43

when closing flaps in oral surgery what should the tension be like

Answer 43

§ Tip for an oral surgery: when closing flaps they should be tension free
□ Flap should not be blanching at the ages
The tighter it is means it will lose it’s blood supply and break down because of this loss and will also tear away from the sutures if it is really tight and the sutures are dragging it into place

Question 44

explain buccal advancement flap

Answer 44

Take a buccal flap of tissue and advance it over the hole
To do this you have to release the underlying periosteum because the gum is not elastic and you won’t be able to pull it across but when you go underneath and just take your scalpel lightly across the inner whitish / greyish periosteum that lines the inside of a full flap, then you will gradually see that flap release
Often have to go back in and out several times because you will find some of the periosteum is not released properly at the corners of the flap where you vertical relieving incisions stop at the base of the flap up in the buccal sulcus

Question 45

if it is an OAF instead of OAC how does this change the management of it

Answer 45

If it is chronic you need to cut the fistula out
- Need to go in and cut around the epithelial lined tract
If you just went in and pulled the flap over but there is a tube of epithelium going up into the sinus it will reform and won’t close over

Question 46

how is a root in antrum managed

Answer 46

• Confirm radiographically by OPT, occlusal or periapical

• make Decision on retrieval
○ Sometimes it is just sitting at the mouth of the hole that you’ve created
○ Sometimes it’s not gone right into the sinus and is sitting along the lining of the sinus

○ Get good light and good suction and see if you can grab the root
[Sometimes it might look like it is sitting at the mouth of the hole but remember an x-ray is a 2D image so it mightn’t necessarily be where you think it is, could be further back but this would only be seen in 3D]
○ Not going to do any harm if you are very careful in trying to retrieve it

• If you have broken a tooth and you are fishing around for the root ~ you need to see the root
○ Need good lighting and good suction
○ If you can’t get at the right and it isn’t mobile then you are going to have to remove bone to get at the root
○ You can’t blindly prod a luxator / elevator into a socket in the upper arch and not run the risk of pushing that root into the maxillary sinus

• Need to be careful, need to see what you are doing
• If it disappears then you need to check to see if you have created a hole, don’t go mad prodding in the area because you might just have pushed the root up and no more, might be sitting at the mouth of the sinus and might be able to grab it with tweezers and pull it back out
• Get nurse to check suction bottle to make sure it didn’t go up the suction, especially if it is a small root

• Also get patient to stand up and shake out their collar / bib etc in case root pops out there
Doesn’t happen all the time but just make sure you have looked where you need to look

Question 47

once you have the root out how are you going to close the communication

Answer 47

same as for OAC

Question 48

why should you not use an air rotator when working around the maxillary sinus

Answer 48

Do not use an air rotor ~ if you use one of these (that you cut cavities with) you will force air into the maxillary sinus and into the soft tissues around then you will get a surgical emphysema ~ this takes a week or two to go away and you get bubbles of air in the soft tissue that if you run your finger along them they will crackle
○ Not a big deal except they are at risk of getting infected and can bring a risk of death

Question 49

what can be used to retrieve a root in the sinus

Answer 49

• Suction - efficient and narrow bore
○ Gently suction with a narrow bore suction tip

• Small curettes
○ These look like tiny excavator instruments
○ Use these to see if you can grab the root and pull it forwards through the hole

• Irrigation or ribbon gauze
○ Irrigate - take some saline and squirt it gently up in the area to see if you can irrigate the root further forward
○ Only start doing this if you have not gotten the root by the other ways because at the same time while irrigating you might flush it out but you also might flush it further back
Ribbon gauze - damp it and tuck it up into the hole in the sinus ~ don’t tuck the whole thing up otherwise you will be looking for the ribbon gauze as well as the root, always leave a tail so you can pull it back out and then sometimes this will pull the root out along with it

Question 50

what is the aetiology for a fractured maxillary tuberosity

Answer 50

○ Single standing molar
§ Ie it is more risky if there is only one upper molar tooth because the bone is already weakened and you are going to be putting a lot of pressure and force on that one tooth
§ Always need to be careful that you have finger and thumb on either side of the alveolus when you are taking out maxillary posterior teeth (from the 3 back but realistically for any tooth you should have your finger guards in place to protect the soft tissues and the bone)

○ Unknown unerupted molar wisdom tooth
§ Undermines the bone and that can make the bone weaker and more at risk of fracturing
§ Or a cyst

○ Pathological gemination
§ Sometimes teeth are joined together / fused and it might be that two tooth germs have fused or it is one tooth germ that has split into two and the roots / whole tooth can then be fused together and can look like a 6 and a 7
§ Might consider a surgical removal rather than putting too much pressure or force onto the tuberosity area

○ Extracting in wrong order
§ Always take teeth out from the back forward
§ Don’t take out 6, 7, 8 ~ take out 8, 7, 6
§ Taking out 6-8 means you are undermining the bone as you go along and you are going to leave yourself with a last standing molar
Inadequate alveolar suppor

Question 51

how do you diagnose a tuberosity fracture

Answer 51

○ Noise

○ Movement noted both visually or with supporting fingers
§ Not just the tooth moving but also the bit of bone moving too ~ feel movement with your finger guard

○ More than one tooth movement
§ Unlucky to see 2 teeth moving ~ might be because they are joined together but might also be that the bit of bone that has fractured is quite big (ie the bit of tuberosity includes both the 7 and the 8, not just the 8)

○ Tear on palate

Question 52

how do you manage a fractured tuberosity

Answer 52

○ Dissect out and close wound
§ If you are going to dissect it out you need to take a fresh scalpel blade and cut away the gum from around this tooth and the bone ~ probably take a relieving incision
§ Usually don’t have to do a buccal advancement flap because you have lost the tooth and the bit of bone, you will find that the flap closes quite easily but you do need to close it over completely and treat it like an OAC and if it doesn’t close over easily then you will need to do a buccal advancement flap
§ However, if it is a massive bit of bone and has more than one tooth on it, don’t take it all out as you need to reduce it and treat it as a fracture

○ Or reduce and stabilise
§ Reducing a fracture means putting it back where it came from ~ trying to anatomically reposition it
§ Stabilising means finding a way to stop it waggling about and keeping the bone parts still against each other until they remodel and heal

○ Reduction:
§ Fingers or forceps
§ If it is all waggling about just push it back into place with your fingers
§ Sometimes you need to use forceps because sometimes it impacts in the wrong position

○ Fixation / stabilisation:
§ Orthodontic buccal arch wire spot - welded with composite
□ Spot welding orthodontic wire on
§ Arch bar
§ Splints
□ Some people might choice this if they have a lab nearby
□ The best thing is to splint it with some wire
§ Composite is usually the best as it comes off more easily
§ Can use GI but tends to take a bit more drilling to get it to come off when you are finished with the splint

Question 53

how and why would you take an impression of a patient with a fractured tuberosity

Answer 53

□ If you want to make the ones that look like sports mouth guards (has a little bit of flex) you need to take an impression but when removing the impression you could end up ripping the tooth out through the gum
® So need to put the tooth back into the position, jam the bone back into the right position then cover the whole area in vaseline
® So when you remove the impression it will come out easily and it will not pull on the tooth and the gum with it and the bit of bone
® Patient would only take this out to clean it and they would keep it in for as long as possible
® Not the most ideal as it is not the most stable as things can move when taking the splint in and out

Question 54

what is non-rigid fixation

Answer 54

Non-rigid fixation is when there is a little bit of flexibility with it

Question 55

what sort of fixation do you want when splinting teeth

Answer 55

When you are splinting teeth back together where there has been an avulsed tooth then often you are using semi-rigid or flexible fixation

Question 56

what sort of fixation do you need when sorting a bone fracture

Answer 56

when it is a fracture of bone you need as rigid as you can get fixation ~ to do this you include more teeth that are not moving
This is more difficult in the tuberosity area

Question 57

what problems arise in healing if fractured bones are moving

Answer 57

Fractured bones don’t heal with a bony union if they are moving ~ they can sometimes still heal but it would be by a fibrous union ie soft fibrous tissue between the bones so there could still be some movement afterwards

Question 58

after splinting, what else needs done in management of fractured tuberosity

Answer 58

○ Remove or treat pulp
§ If the tooth you were going to remove was an impacted / non-functioning wisdom tooth or something like that the tooth is fine and you won’t have to do anything to the pulp of that tooth
§ But if you were taking the tooth out because the patient had tooth ache then the pulp is inflamed and you might need to take the pulp out and dress that tooth cos you need to deal with the pain

○ Ensure occlusion free

○ Antibiotic and antiseptics

○ Instructions post-op

○ Remove tooth 8 weeks later (SR)
§ Want to leave the splint in place for at least 8 weeks (as it will take the bone in the maxilla at least 6-8 weeks to heal)
§ Sometimes it can take up to 12 weeks for fractures to heal so it is fine if you want to leave it a little bit longer
§ But definitely do not touch it under 8 weeks
See your patient to make sure they are keeping the splint clean and that it is not compromising the periodontal health and that they actually can clean it

Question 59

what do you do if youve lost the tooth

Answer 59

• Stop!
• Suction
• Look for the tooth

Radiograph

refer to radiology department

phone defence union for advice

be honest with patient

Question 60

what damage can happen to nerves

Answer 60

• Crush injuries
• Cutting / shredding injuries

• Transection
○ = when you cut all the way through

• Damage from surgery or damage from LA
[Some people can get permanent numbness from an IDB]

• May not know at the time
○ Also can be long term / permanent = post-operative complication

Question 61

what is neurapaxia

Answer 61

Contusion of nerve / continuity of epineural sheath and axons maintained

Question 62

what is axonotmesis

Answer 62

Continuity of axons but not epineural sheath disrupted

Question 63

what is Neurotmesis

Answer 63

Complete loss of nerve continuity / nerve transected

Question 64

what is anaesthesia

Answer 64

numbness

Question 65

what is paraesthesia

Answer 65

tingling

Question 66

what is dysaesthesia

Answer 66

Unpleasant sensation / pain

Question 67

what is hypoesthesia

Answer 67

reduced sensation

Question 68

what is hyperraesthesia

Answer 68

Increase / heightened sensation

Question 69

what happens when there is damage to veins

Answer 69

Bleeding +++
Because veins are quite big you can get huge amounts of bleeding
Wouldn’t be pulsating but you would get waves of bleeding

Question 70

what happens when there is damage to arteries

Answer 70

○ Spurting / haemorrhage +++
○ Arteries are big and have a pulse and have got muscular walls
○ In a dental practise you would have to be going some to actually cut a vein or an artery ~ usually have to be cutting deeper to cut these
○ If you are taking flaps in the region of the lower jaw don’t go wild and don’t cut deep because remember the facial artery crosses this region
Usually arterioles or venules

Question 71

what happens when there is damage to arterioles

Answer 71

○ Spurting / pulsating bleed

○ Most common that little vessels get damaged (tiny arterioles) when you are making cuts

○ Even though these are little they can still be frightening as they still spurt blood

○ Don’t panic but just apply pressure until you can find what the problem is
§ Pressure stops bleeding and buys you time

Question 72

what happens when there is damage to vessels in bone

Answer 72

Can be oozing in the bone at the base of the socket etc and this can take a bit more work to stop this from bleeding as you cannot get the pressure onto the vessel itself as it is inside the bone

Question 73

what happens when there is damage to vessels in muscles

Answer 73

Might happen if you are taking flaps back and you cut too deep into the muscle
Can bleed a lot

Question 74

what do most bleeds occur because

Answer 74

Most bleeds due to local factors
○ mucoperiosteal tears or
○ fractures of alveolar plate / socket wall

Question 75

what are other causes of bleeds

Answer 75

• Very few bleeds due to undiagnosed clotting abnormalities
- haemophilia / von Willebrands

• Some due to liver disease
○ alcohol problems
- clotting factors are made in the liver

> In elderly people, the vessels and muscular walls are all just a bit more fragile and can just bruise really easily because of their age

> Might see lots of bleeding in patients with periodontitis disease because the mouth is so inflamed ~ just need time and pressure in the area, don’t panic

• Some due to medication
○ Warfarin
- antiplatelet agents Eg aspirin / clopidogrel
- other anticoagulant drugs

Question 76

how to stop bleeding on soft tissues

Answer 76

○ Pressure

○ Sutures
§ If you think the socket / soft tissues are all loose then put more stitches in to tighten up the wound
§ Pull a socket closer together by suturing the papilla together

○ LA with adrenaline
§ Vasoconstrictor
§ So can put more LA into the area to constrict more vessels
§ This can be good to help to stop the bleeding so you can actually see what you are doing

○ Diathermy 
§ Cauterise / burn vessels 
	□ precipitate proteins 
	□ form proteinaceous plug in vessel
§ Need to make sure you are working on a vessel and not a nerve

○ Ligatures / haemostatic forceps (artery clips) for larger vessels
§ Used more in head and neck surgery
§ Can use smaller clips for smaller vessels

○ Don’t panic if it won’t stop bleeding
§ Keep the pressure on
§ Get the patient to a maxillo-facial unit / A&E

Question 77

how should pressure be applied to soft tissues to stop bleeding

Answer 77

§ Mechanical:
□ Finger
□ Biting on damp gauze swab [If you put in dry gauze / tissue it will stick to the clot that is forming so it stops the bleeding but when you pull the gauze / tissue out it will pull the clot out too so the patient will start bleeding again]

§ Not ferocious pressure / Don’t get patient to bit with all their might because when this pressure is lifted there will be a rebound bleed
□ If you have squashed it too tight when you let go it will rebound open again

§ Need to apply firm (enough to stop the bleed), even pressure to allow the bleed to naturally coagulate

§ Apply pressure for 10 minutes to start with, then maybe 15-20 minutes and then if it is still bleeding it has been done to apply pressure for up to an hour

Question 78

how to stop bleeding in bone

Answer 78

○ Pressure
§ Via swab or ribbon gauze or a bit of material
§ Be careful there are no nerves around, protect them

○ LA with adrenaline on a swab or injected into socket
§ Can put it on a swab and pack it back in so you are putting pressure and adrenaline onto the vessels in the bone

○ Haemostatic agents
§ Surgicel ~ looks like a bit of silk ribbon almost
§ Kaltostat ~ looks like a sort of felt material
§ If pressure and LA with adrenaline isn’t working then you can turn to these agents
§ These agents often form a framework / scaffold for the blood to clot onto
§ Pack these into the socket
§ careful using these when working near nerves as they are acidic

○ Blunt instrument
§ If you can see the bone and see where the bleed is coming from you can press on it with a blunt instrument (like a flat plastic or the curved end of some sort of excavator [ie the shing non-sharp end])

○ Bone wax
§ Rub this across the bone
§ Don’t need a huge amount
§ Get a small bit on your finger or on the end of a flat plastic
§ Only use your finger if there are no breaks on the bone
§ Dry it, get the suction in, get the wax in, quickly
§ If the wax goes in while it is still bleeding it will just come off so might need to do it in stages ie dry a bit then put wax on it, then dry a bit and so on

○ Pack
§ To do with pressure
§ Can sew a gauze pack in place and put stitches across and leave in place for a few hours and get the patient back later to check that it has all stopped bleeding
○ If it doesn’t stop you would be phoning to take advice and referring on

Question 79

how to manage a dislocation of TMJ

Answer 79

• Relocate immediately = best way to get the joint back before the muscles go into spasm

○ Analgesia
§ It will be sore so the patient will need pain killers

○ Advice on supported yawning
§ If they need to yawn they need to place their fist under their chin or their hand along the inferior border of the mandible and stop the yawn being big and wide

• If unable to relocate try LA into masseter intra-orally
○ Helps to take some of the pain and discomfort away
○ Then try to relocate the jaw again as soon as the patient has got some pain relief

• If still unable to relocate = immediate referral
• NEED to refer these patients urgently
○ Do not send them home
○ Do not tell them someone will contact them in the morning
○ The patient must go in a car to their referral or they must have some sort of transport to get to the appropriate unit to get their jaw back into place

○ If a patient’s jaw is dislocated then they cannot close their mouth and it will be really sore for them and they will be drooling and cannot swallow properly

Question 80

what happens that causes the jaw to dislocate

Answer 80

○ The head of the condyle jumps over the articular eminence in the maxilla

○ Now the head is stuck in front of the articular eminence

○ So unless the patient has a really slack jaw (might have conditions that cause this, some people are more prone to it in general just) it is really difficult for that head to go back over the articular eminence to get back into place

○ If you don’t push it down and back straight away then all the muscles start to spasm

○ The patient will be in pain but if the muscles have seized up then it is like trying to put a brick into place ~ it is really hard

Question 81

what damage can occur to adjacent teeth

Answer 81

• Hit opposing teeth with forceps
[especially if the tooth just suddenly gives way and you don’t have the appropriate finger supports in place]

○ Can break off cusps of teeth in the opposite jaw

• Crack / fracture / move adjacent teeth with elevators

• Crack / fracture / remove restorations / crowns / bridges on adjacent teeth
○ Only time this is forgivable is in a filling with a big overhang that is right on top of the adjacent tooth or there is a crown that is literally stuck to the adjacent tooth

• Temporary dressing / restoration

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

Question 82

how does extraction of a permanent tooth germ occur

Answer 82

Eg when removing deciduous molars ~ extraction or damage to developing permanent premolars

• Sometimes see it happening when children are getting lots of teeth taken out under GA

• Will see the permanent tooth germ on the end of the primary tooth that has been extracted
Shouldn’t happen

• If you are extracting primary teeth and you break a bit of the root, unless you can extract it quite easily you shouldn’t really dive in there to try and get them out
○ Just let them resorb
○ Tell the patient and parents

Be careful about digging in tooth sockets of primary teeth where you have used elevators, luxators etc because you can damage the developing tooth germ

Question 83

what instruments can break and how do u sort this

Answer 83

• Eg tips of elevators and luxators
• Eg tips of burs
• Can be from a defective instrument but that is usually not the cause
• Usually it happens when using an instrument for the wrong reason
○ Like using a luxator (thin and sharp) as an elevator and levating with it as this will fracture the tip of the luxator off
• Radiograph / retrieve
○ Take a radiograph to see if you can see it
○ Check the suction bottle
○ Check the area around and on the patient (clothes etc)

• If unable to retrieve ~ refer
• Keep good notes