Extraction Complications Flashcards
What are the different subheadings for extraction complications?
- Immediate:
intraoperative + perioperative
couple of hours following XLa - Immediate post op:
short term postoperative
hours/days following XLa - Long term:
postoperative
weeks/months
List examples of peri-operative complications (10)
Difficulty of access + Abnormal resistance (can’t move this tooth) CAN LEAD TO COMPLICATIONS
- Fracture of:
- Tooth/root
- Alveolar plate
- Max tuberosity
- Jaw (common in mandible) - Involvement of maxillary antrum
- Loss of tooth
- Damage:
- Soft tissue
- Nerve
- Adjacent teeth - Haemorrhage
- Dislocation of TMJ
- Extraction of permanent tooth germ (v rare)
- Broken instruments
- Wrong tooth
What to do if a primary tooth breaks and roots are retained? (2)
Leave the little primary roots to resorb away on their own
If we go digging we may damage the permanent tooth germ
What are some causes of difficulty of access + vision? (3)
- Trismus
- Limited mouth opening - Reduced aperture of mouth
- Crowded/malpositioned teeth
What can abnormal resistance be caused by? (4)
- Thick cortical bone
- Shape/number of roots
- Divergent or hooked - Hypercementosis
- Ankylosis
Factors that can contribute to a tooth fracture (3)
- Caries
- Out of alignment
- Crowded etc harder to remove - Size
- Tiny crown, big sturdy roots more likely to break crown off - Root
List some root problems (6)
- Fused
- Convergent or divergent
- Extra roots
- Morphology
- Hypercementosis
- Ankylosis
Whats a sequestrum
Dead bit of bone
What part of the alveolar bone do we normally end up breaking?
Buccal plate
Mostly canines or molars
Course of action if canine alveolar bone broken (3)
- Stabilise
- Free mucoperiosteum
- Smooth edges
Course of action if molar alveolar bone broken (3)
- Is there still periosteal attachment?
- If so has a BS so leave it - Suture
- Dissect free
What are some examples that can lead to a fractured jaw? (3)
- Impacted wisdom tooth
- Undermining the bone under the angle region - Large cysts
- Weakening the jaw - Atrophic mandible
Management of a jaw fracture (6)
- Inform patient
- Post-op radiograph
- Refer (phone call)
- Ensure analgesia
- Advice about pain
- Chlorrhexidine mouthwashes - Warm salty water rinse - Stabilise fracture
- If wobbly stabilise with ortho wire or splinting wire
AVOID around periodontally compromised teeth - If delay, antibiotics
What can an OAC develop in to?
OAF - epithelial lined tract between the mouth and max sinus
Chronic
What does involvement of the maxillary antrum cause? (3)
- OAF
- Loss of root into max antrum
- Fractured tuberosity
Define OAC
Communication between mouth and max sinus
More common with molars
How do we diagnose an OAC? (7)
- Size of tooth
- Radiographic position
- Of roots in relation to max sinus - Bone at trifurcation of roots
- Bubbling of blood
- Check when patient talks + breathes - Nose holding test
- Careful as can create an OAC - Direct vision + good light + suction
- Blunt probe
- Careful as can create an OAC
Management of OAC if small (2)
- Inform patient
- If small or sinus intact:
- Encourage clot
- Suture margins
- Antibiotics
- Post-op instructions
Management of OAC if large/lining torn
- Close with buccal advancement flap
- Antibiotics + nose blowing instructions
- Use steam inhalations
What flap is used most commonly to close an OAC?
Buccal advancement flap
How long are sutures kept in for an OAC
10=14days
Non resorbing - prolene
What should you avoid doing for a root in antrum
- Confirm radiographically by OPT, Occlusal or Periapical
- Decision on retrieval
DO NOT poke at socket or you will push root into max sinus
Management if root in antrum (6)
- Flap design
- Open fenestration with care
- Might need to open hole further - Suction
- Efficient + narrow bore - Small curettes
- Irrigation or ribbon gauze
- Close as for OAC
Why do we use an electric bur over an air router(cut cavities with?)
Danger of surgical emphysema
pushing air into max sinus
Electrical doesn’t blow air into the tissues
How can a tuberosity fracture be diagnosed? (3)
- Noise
- Movement noted both visually or with supporting fingers
- Tear on palate
Management of a fractured tuberosity
- If small enough dissect out + close wound (cant just pull the bone with forceps)
OR
- Reduction
- Fingers or forceps
Fixation
- Ortho buccal arch wire spot welded with composite
- Arch bar
- Splints
Why do we not need to do a buccal advancement flap for a fractured tuberosity?
Lost tooth + bit of bone so flap closes quite easuly
Whats the danger with making a splint for a fractured tuberosity?
Taking impressions for splint can end up ripping tooth out through gum
Need to put tooth back in position cover in vaseline then take impression so it comes out easily
> Send to lab to make quick splint
Fit it
Pt only takes it out to clean
Not ideal as will move when taking splint in and out
BETTER TO SPLINT WITH ORTHO WIRE
How do we achieve rigid fixation
For a bone fracture we need the splint to be as rigid as possible - might include more teeth that are not MOBILE
How do fractured mobile bones heal?
Not by bony unoin
Sometimes still heal but by fibrous union
What do we need to remember to do when tx-ing a fractured tuberosity?
- Remove or tx pulp
- Ensure occlusion free
- Antibiotics + antiseptics
- Instructions post-op
- Remove tooth 8wks later
When can damage to nerves occur?
Happens at time of injury (can be peri-op + post too)
As patient realises after op t
Can be longterm/permanent
How can damage to nerves occur? (4)
- Crush injuries
- Cutting/shredding injuries
- Transection
- Cut all the way through - Damage from surgery or damage from LA
- Can end up putting needle into ID nerve at lingual bit of mandible
- If pt leaps/feel burning sensation take needle out and start again
- Change needle
DAMAGE TO NERVE:
Define neurapraxia (mildest)
Contusion(bruise) of nerve
DAMAGE TO NERVE:
Define axonotmesis
Continuity of axons but epineural sheath not disrupted
DAMAGE TO NERVE:
Define neurotmesis (severe)
Complete loss of nerve continuity
Side effects of damage to nerves (5)
- Anaesthesia
- Numbness - Paraesthesia
- Tingling - Dysaesthesia
- Unpleasant sensation/pain - Hypoaesthesia
- Reduced sensation - Hyperaesthesia
- Increased/heightened sensation
Local factors that can lead to a dental haemorrhage (2)
- Mucoperiosteal tears
- Fractures of alveolar plate/socket wall
RARER
- Undiagnosed clotting abnormalities
- Haemophilia
- VWs - Liver disease
- Meds
- Warfarin
- Antiplatelet agents (Aspirin/Clopidogrel)
Management for bleeding from soft tissues (5)
- Pressure
- Sutures
- LA with adrenaline
- Diathermy
- Ligatures/haemosastic forceps
Management for bleeding from bone (6)
- Pressure (via swab)
- LA on swab or injected into socket
- Haemostatic agents
- Surgicel/Kaltostat - Blunt instrument
- Bone wax
- Pack
Management for dislocation of TMJ
- Relocate immediately
- Analgesia + advice on supportive yawning etc - If unable to relocate try LA into masseter intraorally
- If still unable to relocate immediately refer
