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3e. BDS3 CDS Oral Surgery > L58/80. Extraction Complications > Flashcards

L58/80. Extraction Complications Flashcards

1
Q

What are (immediate) intra-operative/ peri-operative complications?

A

Complications that arise either during the surgery, or shortly after (within a couple of hours~)

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2
Q

What are post-operative complications?

A

Post-operative complications can either be short-term (hours/ days after the surgery), or long-term (weeks/ months)

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3
Q

List some peri-operative complications?

A
  • 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.
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4
Q

What can cause difficulty of access to a tooth?

A
  • Limited mouth opening/ trismus;
  • Reduced aperture of mouth (congenital/ syndromes/ scarring);
  • Crowded/ malpositioned teeth.
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5
Q

What is trismus?

A

Difficulty in mouth opening due to muscle spasms (MOM), sometimes referred to as lockjaw

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6
Q

What should you do if you’re struggling to access a tooth for extraction?

A
  • Take time;
  • Make sure you can see properly;
  • Light;
  • Patient position;
  • Your position.
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7
Q

What can cause abnormal resistance?

A
  • Thick cortical bone;
  • Shape/ form of roots (divergence/ hooked);
  • Number of roots;
  • Hypercementosis (extra cementum);
  • Ankylosis (fused to bone).
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8
Q

If you’re struggling to extract a tooth due to abnormal resistance, what should you do?

A
  • 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.
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9
Q

What can make a tooth more likely to fracture?

A
  • Caries;
  • Alignment (crowded/ position);
  • Size;
  • Crown:root ratio;
  • Root(s).
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10
Q

What is the most important thing to do to prevent fracture of the crown of a tooth during an extraction?

A
  • Position forcep beaks below the crown of the tooth;

- Beaks should be placed just on to the roots, below the bone and gum.

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11
Q

What areas of alveolar bone (bone around socket) are most likely to fracture during an extraction?

A
  • Buccal plate of;
  • Buttress around canines;
  • Molar region.

[can happen anywhere]

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12
Q

What is the most important thing to do to prevent fracture of alveolar bone?

A

Mobilise the tooth (with elevators/ luxators) before pulling the tooth buccally

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13
Q

If alveolar bone is fractured during an extraction, what must you check on the fractured bone?

A

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]

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14
Q

What must you be careful of with broken bone?

A

Sharp edges!

[use bone files to check for uneven edges]

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15
Q

What can increase the risk of fracture of the mandible?

A
  • Impacted wisdom teeth;
  • Large cysts (weakens);
  • Atrophic mandible (very thin);
  • Application of force.
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16
Q

What is the most important part of extraction technique to prevent fracture of the alveolar bone/ jaw?

A

Jaw support!

[Fingers on either side of alveolus and thumb under mandible - sometimes requires assistance]

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17
Q

How should you manage fracture of a jaw?

A
  • 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.
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18
Q

What complications can arise with involvement of the maxillary antrum?

A
  • OAC/ OAF;
  • Loss of root/tooth into antrum;
  • Fractured tuberosity.
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19
Q

What is the difference between an oro-antral communication (OAC) and oro-antral fistula (OAF)?

A

OAC: immediate (acute) situation, communication between maxillary antrum and oral cavity

OAF: epithelial lined OAC (chronic)

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20
Q

Which teeth are most likely to cause maxillary antrum involvement?

A

Canines and back

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21
Q

In what ways can you determine/ diagnose an OAC?

A
  • 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.
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22
Q

How should you manage a small OAC? (i.e. if sinus in tact)

A
  • Inform patient;
  • Encourage clot;
  • Suture margins;
  • Antibiotic (sinus exposed to oral cavity);
  • Post-op instructions;
  • Monitor.
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23
Q

How should you manage a large OAC? (i.e. if lining torn)

A
  • Inform patient;
  • Close with buccal advancement flap (tension free!);
  • Antibiotics and nose blowing/ steam inhalation instructions.
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24
Q

What is a buccal advancement flap?

A
  • 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).
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25
Q

How should you confirm a root in antrum?

A
  • Confirm radiographically (ideally OPT);
  • Check patient;
  • Check suction bottle;
  • Use of good lighting/ suction.
26
Q

How should you consider for retrieval of root from an antrum?

A
  • 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]

27
Q

What must you never use to cut bone?

A

Air rota handpiece - this will force air into the sinus and surrounding soft tissues causing surgical emphysema

28
Q

What can increase the risk of a fractured maxillary tuberosity?

A
  • 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.
29
Q

In what ways can you determine/ diagnose a tuberosity fracture?

A
  • Noise (hear crack);
  • Notable movement (visually or with supporting fingers);
  • More than one tooth movement;
  • Tear on palate.
30
Q

What should you consider for treating a fractured tuberosity?

A
  • 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;
31
Q

How do you achieve rigid fixation when of teeth?

A

Include more than just effected teeth

32
Q

Why is rigid fixation important?

A
  • To ensure healing with a boney union (over fibrous, which can occur when there is still slight movement);
  • To reduce risk of infection.
33
Q

How should you manage loss of a tooth?

A
  • 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.
34
Q

What is the most important part of extraction technique to prevent loss of a tooth?

A

Don’t lose focus until tooth is fully removed from oral cavity

35
Q

How can nerves be damaged during oral surgery?

A
  • Crush injuries;
  • Cutting/ shredding injuries;
  • Transection (cutting through);
  • Damage from surgery or LA.
36
Q

What is neurapraxia?

A

Contusion of nerve/ continuity of epieneural sheath and axons maintained

37
Q

What is axonotmesis?

A

Continuity of axons but epineural sheath disrupted

38
Q

What is neurotmesis?

A

Complete loss of nerve continuity/ nerve transected

39
Q

What sensation does anaesthesia result in?

A

Numbness

40
Q

What sensation does parasthesia result in?

A

Tingling

41
Q

What sensation does dysaesthesia result in?

A

Unpleasant sensation/ pain

42
Q

What sensation does hypoaesthesia result in?

A

Reduced sensation

43
Q

What sensation does hyperaesthesia result in?

A

Increased/ heightened sensation

44
Q

What nerves are at particular risk during oral surgery?

A
  • Mental nerve;
  • ID nerve;
  • Lingual nerve.
45
Q

What is the issue, regarding timing, for treating damaged nerves?

A
  • 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)

46
Q

Why might damage to vessels result in bleeding later on, after the surgery?

A
  • LA vasoconstrictor;

- Bleeding when this wears off.

47
Q

What type of blood vessels would you expect spurting blood from, if damaged?

A

Arteries (and smaller arterioles - smaller spurts)

48
Q

What type of blood vessels would you expect oozing blood from, if damaged?

A

Veins

49
Q

What is the most important thing to check for assessing bleeding risk?

A
  • Medical history;

- Medications.

50
Q

Why can dental haemorrhage occur?

A
  • Local factors (mucoperiosteal tears/ fractures of alveolar plate/ socket wall);
  • Undiagnosed clotting abnormalities (rare);
  • Liver disease (autoimmune/ alcoholism);
  • Medication (ACs, anti platelet agents).
51
Q

What questions can you ask to obtain someone’s bleeding history?

A
  • Have you ever had any prolonged bleeds before?
  • Have you had to go to hospital to stop yourself bleeding before?
  • Do you bruise easily?
52
Q

What should you do to control soft tissue bleeding?

A
  • Pressure (finger/ biting on damp gauze);
  • Sutures;
  • LA (w vasoconstrictor);
  • Diathermy (cauterisation);
  • Artery clips.
53
Q

What level of pressure should you apply to stop bleeding?

A

Firm and even (not too hard as otherwise will result in a rebound bleed upon removal)

54
Q

What should you do to control bleeding from bone?

A
  • 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.
55
Q

What are haemostat agents like surgicel/ kaltostat?

A

Oxidised cellulose (form a framework for blood to clot onto)

56
Q

How should you manage dislocation of the TMJ?

A
  • Relocate immediately (before muscles go into spasm);
  • Analgesia and advice, like supported yawning;
  • If unable to relocate, try LA into master intraorally;
57
Q

How should you manage dislocation of the TMJ?

A
  • 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.
58
Q

How can damage to adjacent teeth/ restorations occur during extractions?

A
  • 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]

59
Q

How should you manage damage to adjacent teeth/ restorations?

A
  • Temporise;

- Book patient back in to replace (don’t charge for this).

60
Q

How can you prevent damage to a permanent tooth germ when extracting deciduous teeth?

A
  • Leave primary roots and let them resorb;

- Avoid exploring sockets with instruments.

61
Q

How should you manage broken instruments?

A
  • Radiograph;
  • Locate (check patient/ suction bottle etc.);
  • Retrieve;
  • Refer if you can’t retrieve.
62
Q

How can you prevent extraction of the wrong tooth?

A
  • Concentrate;
  • Check notes against clinical examination;
  • Count teeth;
  • Ask for a second opinion if you’re still ensure.

3e. BDS3 CDS Oral Surgery (5 decks)

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