L58/80. Extraction Complications Flashcards
What are (immediate) intra-operative/ peri-operative complications?
Complications that arise either during the surgery, or shortly after (within a couple of hours~)
What are post-operative complications?
Post-operative complications can either be short-term (hours/ days after the surgery), or long-term (weeks/ months)
List some peri-operative complications?
- Difficulty of access;
- Abnormal resistance;
- Fracture of tooth/ root;
- Fracture of alveolar plate;
- Fracture of tuberosity;
- Jaw fracture (more commonly mandible);
- Involvement of maxillary antrum/ sinus;
- Loss of tooth;
- Soft tissue damage;
- Damage to nerves/ vessels;
- Haemorrhage;
- Dislocation of the TMJ;
- Damage to adjacent teeth/ restorations;
- Extraction of permanent tooth germ;
- Broken instruments;
- Wrong tooth.
What can cause difficulty of access to a tooth?
- Limited mouth opening/ trismus;
- Reduced aperture of mouth (congenital/ syndromes/ scarring);
- Crowded/ malpositioned teeth.
What is trismus?
Difficulty in mouth opening due to muscle spasms (MOM), sometimes referred to as lockjaw
What should you do if you’re struggling to access a tooth for extraction?
- Take time;
- Make sure you can see properly;
- Light;
- Patient position;
- Your position.
What can cause abnormal resistance?
- Thick cortical bone;
- Shape/ form of roots (divergence/ hooked);
- Number of roots;
- Hypercementosis (extra cementum);
- Ankylosis (fused to bone).
If you’re struggling to extract a tooth due to abnormal resistance, what should you do?
- Leave the tooth for a minute or two;
- This can help inflammation of the PDL (which has occurred due to pressure) subside;
- Lead to oedema which can help to loosen the tooth.
What can make a tooth more likely to fracture?
- Caries;
- Alignment (crowded/ position);
- Size;
- Crown:root ratio;
- Root(s).
What is the most important thing to do to prevent fracture of the crown of a tooth during an extraction?
- Position forcep beaks below the crown of the tooth;
- Beaks should be placed just on to the roots, below the bone and gum.
What areas of alveolar bone (bone around socket) are most likely to fracture during an extraction?
- Buccal plate of;
- Buttress around canines;
- Molar region.
[can happen anywhere]
What is the most important thing to do to prevent fracture of alveolar bone?
Mobilise the tooth (with elevators/ luxators) before pulling the tooth buccally
If alveolar bone is fractured during an extraction, what must you check on the fractured bone?
Periosteal attachment
[If present - still vascular - might be able to put back in place and suture; If absent - must remove as would otherwise necrose (become a sequestrum) and cause pain]
What must you be careful of with broken bone?
Sharp edges!
[use bone files to check for uneven edges]
What can increase the risk of fracture of the mandible?
- Impacted wisdom teeth;
- Large cysts (weakens);
- Atrophic mandible (very thin);
- Application of force.
What is the most important part of extraction technique to prevent fracture of the alveolar bone/ jaw?
Jaw support!
[Fingers on either side of alveolus and thumb under mandible - sometimes requires assistance]
How should you manage fracture of a jaw?
- Inform patient;
- Post-op radiograph (if you have access to OPT);
- Refer (maxillofacial/ A&E/ dental hospital);
- If they require a GA, inform them not to eat;
- Ensure analgesia;
- Stabilise (wire);
- If any delay, antibiotic cover.
What complications can arise with involvement of the maxillary antrum?
- OAC/ OAF;
- Loss of root/tooth into antrum;
- Fractured tuberosity.
What is the difference between an oro-antral communication (OAC) and oro-antral fistula (OAF)?
OAC: immediate (acute) situation, communication between maxillary antrum and oral cavity
OAF: epithelial lined OAC (chronic)
Which teeth are most likely to cause maxillary antrum involvement?
Canines and back
In what ways can you determine/ diagnose an OAC?
- Tear on palate (due to sharp fractured bone tearing overlying soft tissues);
Size of tooth upon extraction; - Radiographic position of roots in relation to antrum;
- Bone as trifurcation of roots;
- Bubbling of blood (when you look into socket);
- Nose holding test (be careful not to create an OAC doing this);
- Direct vision;
- Good light and suction, listen for echo;
- Blunt probe (be careful not to create an OAC doing this);
- Squeeze on area - puss.
How should you manage a small OAC? (i.e. if sinus in tact)
- Inform patient;
- Encourage clot;
- Suture margins;
- Antibiotic (sinus exposed to oral cavity);
- Post-op instructions;
- Monitor.
How should you manage a large OAC? (i.e. if lining torn)
- Inform patient;
- Close with buccal advancement flap (tension free!);
- Antibiotics and nose blowing/ steam inhalation instructions.
What is a buccal advancement flap?
- Used for closure of OAC/ OAF;
- If OAF, must remove epithelial lined tube;
- Use of buccal flap of tissue, advanced over hole to meet palatal mucosa;
- Must release underlying periosteum (allows tissue to become elastic);
- Sutured in place (generally non-resorbing for 2 weeks).
How should you confirm a root in antrum?
- Confirm radiographically (ideally OPT);
- Check patient;
- Check suction bottle;
- Use of good lighting/ suction.
How should you consider for retrieval of root from an antrum?
- Decision on retrieval (can this be done in your practice);
- Removal technique dependent on size/ position of lost root;
- Open fenestration;
- Suction;
- Small curettes (like excavators);
- Irrigation (warm saline);
- Ribbon gauze;
- Close as OAC;
- Antibiotics.
[refer/ ask for advice at any point - document this]
What must you never use to cut bone?
Air rota handpiece - this will force air into the sinus and surrounding soft tissues causing surgical emphysema
What can increase the risk of a fractured maxillary tuberosity?
- Single standing molar (weakened bone either side);
- Unknown erupted molar wisdom tooth/ cyst (weakened bone);
- Pathological germination (fused teeth/ roots);
- Extracting in the wrong order (start at back!);
- Inadequate alveolar support.
In what ways can you determine/ diagnose a tuberosity fracture?
- Noise (hear crack);
- Notable movement (visually or with supporting fingers);
- More than one tooth movement;
- Tear on palate.
What should you consider for treating a fractured tuberosity?
- Dissect out and close wound (after removal of bone/ tooth might be able to close without buccal advancement flap);
- Reduce (put back with fingers or forceps) and stabilise (best: ortho wire, arch bar, splints);
- Check if RCT is necessary;
- Check occlusion (if necessary reduce tooth to be extracted with burr);
- Leave in place for at least 8 weeks;
- Antibiotics/ antiseptic mouthwashes;
- Review patient regularly;
How do you achieve rigid fixation when of teeth?
Include more than just effected teeth
Why is rigid fixation important?
- To ensure healing with a boney union (over fibrous, which can occur when there is still slight movement);
- To reduce risk of infection.
How should you manage loss of a tooth?
- Where? (check patient (mouth/ tongue - encourage to cough/ clothes);
- Radiograph (if uppers - sinuses, if lowers - lingual plate area, throat, lungs, abdomen);
- Suction;
- Call defence union for advice how to proceed.
What is the most important part of extraction technique to prevent loss of a tooth?
Don’t lose focus until tooth is fully removed from oral cavity
How can nerves be damaged during oral surgery?
- Crush injuries;
- Cutting/ shredding injuries;
- Transection (cutting through);
- Damage from surgery or LA.
What is neurapraxia?
Contusion of nerve/ continuity of epieneural sheath and axons maintained
What is axonotmesis?
Continuity of axons but epineural sheath disrupted
What is neurotmesis?
Complete loss of nerve continuity/ nerve transected
What sensation does anaesthesia result in?
Numbness
What sensation does parasthesia result in?
Tingling
What sensation does dysaesthesia result in?
Unpleasant sensation/ pain
What sensation does hypoaesthesia result in?
Reduced sensation
What sensation does hyperaesthesia result in?
Increased/ heightened sensation
What nerves are at particular risk during oral surgery?
- Mental nerve;
- ID nerve;
- Lingual nerve.
What is the issue, regarding timing, for treating damaged nerves?
- The quicker you intervene, the more chance a nerve has of a successful outcome;
- However, sometimes a nerve just needs time to recover/ settle down so intervening could cause more damage.
[referral (urgent) covers you)
Why might damage to vessels result in bleeding later on, after the surgery?
- LA vasoconstrictor;
- Bleeding when this wears off.
What type of blood vessels would you expect spurting blood from, if damaged?
Arteries (and smaller arterioles - smaller spurts)
What type of blood vessels would you expect oozing blood from, if damaged?
Veins
What is the most important thing to check for assessing bleeding risk?
- Medical history;
- Medications.
Why can dental haemorrhage occur?
- Local factors (mucoperiosteal tears/ fractures of alveolar plate/ socket wall);
- Undiagnosed clotting abnormalities (rare);
- Liver disease (autoimmune/ alcoholism);
- Medication (ACs, anti platelet agents).
What questions can you ask to obtain someone’s bleeding history?
- Have you ever had any prolonged bleeds before?
- Have you had to go to hospital to stop yourself bleeding before?
- Do you bruise easily?
What should you do to control soft tissue bleeding?
- Pressure (finger/ biting on damp gauze);
- Sutures;
- LA (w vasoconstrictor);
- Diathermy (cauterisation);
- Artery clips.
What level of pressure should you apply to stop bleeding?
Firm and even (not too hard as otherwise will result in a rebound bleed upon removal)
What should you do to control bleeding from bone?
- Pressure (via swab);
- LA on a swab or injected into socket;
- Haemostatic agents (surgicel/ kaltostat);
- Blunt instrument (like flat plastic);
- Bone wax (waterproof layer - back pressure);
- Pack socket.
What are haemostat agents like surgicel/ kaltostat?
Oxidised cellulose (form a framework for blood to clot onto)
How should you manage dislocation of the TMJ?
- Relocate immediately (before muscles go into spasm);
- Analgesia and advice, like supported yawning;
- If unable to relocate, try LA into master intraorally;
How should you manage dislocation of the TMJ?
- Relocate immediately by pushing down and back, standing above the patient (before muscles go into spasm);
- Analgesia and advice, like supported yawning (prone to dislocation again);
- Monitor;
- If unable to relocate, try LA into master intraorally for pain relief;
- If still unable - referral.
How can damage to adjacent teeth/ restorations occur during extractions?
- Hit with forceps;
- Crack/ fracture/ move with elevators;
- Crack/ fracture/ remove restorations, crowns, bridges on adjacent teeth.
[warn patient if there’s higher risk of this due to overhangs close by]
How should you manage damage to adjacent teeth/ restorations?
- Temporise;
- Book patient back in to replace (don’t charge for this).
How can you prevent damage to a permanent tooth germ when extracting deciduous teeth?
- Leave primary roots and let them resorb;
- Avoid exploring sockets with instruments.
How should you manage broken instruments?
- Radiograph;
- Locate (check patient/ suction bottle etc.);
- Retrieve;
- Refer if you can’t retrieve.
How can you prevent extraction of the wrong tooth?
- Concentrate;
- Check notes against clinical examination;
- Count teeth;
- Ask for a second opinion if you’re still ensure.
