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BDS M5 Oral Surgery > Oral surgery complications > Flashcards

Oral surgery complications Flashcards

1
Q

What are the 4 categories of operative complications?

A
  • intra-
  • post-
  • pre-
  • special-
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2
Q

What 6 categories can pre-operative assessment be split into?

A
  • of the environment and equipment
  • of the patient
  • of the operative site
  • of the tooth for extraction
  • including special investigations
  • of you as the operator!
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3
Q

What is involved in the preop assessment of the environment and equipment in OS?

A
  • appropriate accommodation
  • adequate equipment
  • time - yours, patients, and staff
  • staffing and expertise? of the whole team
  • appropriate infection control practices in place
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4
Q

What is involved in preop assessment of the patient?

A
  • physical/mobility
  • anxiety levels, fear, support needs
  • social support
  • medical background
  • medications/polypharmacy
  • social history - smoking, alcohol, recreational drugs
  • family history inheritable/congenital conditions
  • expectation
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5
Q

What is involved in preop assessment of the operative site?

A
  • anatomy
  • physical access (posture/special measures)
  • visual access
  • pathologies
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6
Q

What are some important aspects of anatomy that may have an effect during oral surgery?

A
  • small mouth, tight cheeks
  • trismus - limited mouth opening
  • thick buccal cortical plate
  • thick root of zygoma
  • bony extostocis
  • wide mouth opening bringing coronoid process close to lateral aspect of upper molars
  • LA anatomy differences
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7
Q

What is involved in preop assessment of the tooth for extraction?

A
  • identification of the correct tooth (WSS)
  • charting and note accuracy with presentation (WSS)
  • anatomy (size, position, rotation, relative to adjacent structures)
  • pathology (caries/perio/soft tissue health/disease)
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8
Q

What is involved in preop assessment including special investigations?

A
  • radiological assessment
  • are the images sufficient quality?
  • relevant local anatomical features
  • crown form/caries extent
  • bone levels and quality/periodontal disease
  • pathology/infection/cyst
  • root morphology, number, size, angulation
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9
Q

What categories can intraoperative complications be split into?

A
  • LA complications
  • bone and anatomy related
  • tooth/soft tissue
  • other
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10
Q

What needs to be considered under local anaesthetic complications?

A
  • LA volume
  • LA anatomy
  • LA failure and pain (testing)
  • LA toxicity
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11
Q

What needs to be considered under bone and anatomy related complications?

A
  • bone fracture - alveolus minimise, bone proper
    • mandible
    • tuberosity/maxilla
  • displacements
  • complications of the maxillary antrum
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12
Q

What needs to be considered under tooth/soft tissue complications?

A
  • tooth/root fracture
  • soft tissue damage
  • instrument failure/breakage
  • mobilising adjacent teeth
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13
Q

What are some of the ‘other’ possible intraoperative complications?

A
  • failure to complete and management strategies
  • bleeding
  • WSS
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14
Q

What is required to achieve local anaesthesia?

A

requires sufficient volume in the correct anatomical location

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15
Q

What may failure to give sufficient volume of anaesthesia result in?

A

partial anaesthesia

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16
Q

What nerve supplies the buccal mucosa of the molar region?

A

long buccal

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17
Q

In small children, how much LA may cause systemic toxicity?

A

can occur with as little as 2 cartridges

(rare in adults)

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18
Q

What pathway metabolises LA?

A

CYP450, enzymes 1A2/3A4

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19
Q

What drugs may affect LA metabolism?

A

any drugs which act as inducers, substrates or inhibitors of CYP450 1A2/3A4 enzymes

20
Q

What does LA systemic toxicity affect?

A

CNS (biphasic)

21
Q

What can be seen with low doses of LA systemic toxicity?

A

excitation muscle twitching, agitation, possible auditory changes and tinnitus, headache/light headedness

22
Q

What can be seen with higher doses of LA systemic toxicity?

A

depressant - perio-oral numbness and tingling, drowsiness, blurred vision, slurred speech,

ultimately apnoea respiratory arrest, can be fatal

23
Q

Why can LA systemic toxicity lead to death?

A
  • CVS (biphasic)
  • reduced excitability/contractility of myocardium
  • vasodilation
  • CVS collapse - maybe secondary to hypoxaemia from CNS
24
Q

How can LA systemic toxicity be prevented?

A

aspirate, slow injection, limit dose

25
Q

What do you do if LA systemic toxicity occurs?

A

STOP, BLS, call for help, monitor

26
Q

What bone fractures may occur as intra-operative complications?

A
  • alveolus
  • mandible - very unlikely, very robust bone
  • tuberosity
27
Q

Why do we try to remove teeth in a buccal direction?

A

easier to manage buccal alveolar fractures than palatal and lingual fractures

28
Q

If a buccal alveolus fracture occurs what do you need to determine?

A

size and mobility of fragments

29
Q

In what situations may the mandible fracture?

A
  • excessive use of forces and failure to know when to stop
  • selection of wrong instrument or poor instrument use
  • mandible very thin (usually linked to congenital condition, age, atrophy, weakened by ectopic teeth, UE 8, pathology)
30
Q

What is most commonly associated with tuberosity fracture?

A
  • extraction of maxillary 3rd molars
    often with
  • bone thinned at tuberosity (sometimes by maxillary sinus or sometimes proximity of tooth to post. maxilla or sinus)
  • ankylosis of U8 with bone in the site
  • divergent roots with no clear path of withdrawal
31
Q

What other complication is tuberosity fracture often associated with?

A

OAC

32
Q

What are the main options when tuberosity fracture occurs?

A
  • take out the tooth and associated bone by dissecting it from the soft tissues and closing and closing the socket
  • if fragment large may need to rigidly splint tooth if possible for 6 weeks until adequate bony healing has occurred, then attempt to remove tooth by different mechanism (often careful surgical)
33
Q

How is tuberosity fracture identified?

A

would normally hear a dull ‘thud’ and a crunching sound when mobilising the tooth, tooth moving not independent of underlying bone, when moving the palatal soft tissues moving with it, if you percuss the teeth those in sound bone will have high percussion tone, will be a dull percussion tone if fracture has occurred
- DO NOT PROCEED

34
Q

What kind of displacement injuries are there?

A
  • infratemporal fossa
  • subperiosteal
  • lingual tissues
  • inferior alveolar canal
  • maxillary antrum
  • other - oesphagus, lung/airways
35
Q

What is a displacement injury?

A

when attempting to remove a tooth or tooth fragment e.g. root and the root is shifted out from its normal anatomical location within the socket

36
Q

What does infratemporal fossa displacement usually relate to?

A
  • extraction of upper 3rd molar/root
  • set of aggregating circumstances
    • usually tooth only PE or subgingival if a root
    • root curvature distally which prompts posterior curved path on attempted elevation
    • crown of tooth very close to posterior of the tuberosity
37
Q

When does subperiosteal displacement usually occur?

A

when you’ve made an attempt to extract and are left with a small element of root at the apex and when you apply force down in an attempt to retrieve it it can be displaced

38
Q

Anatomically, when would a subperiosteal displacement tend to occur?

A
  • thin bone
  • buccally placed (usually displaced into buccal tissues)
  • common in upper molar mesial roots, upper 2nd premolars, and upper 1st premolars with divergent roots likely to fracture
39
Q

In terms of displacement, what is it important to do while elevating?

A

support the alveolus as if a root were to displace subperiosteally you could feel it under your finger

40
Q

What is an associated complication of subperiosteal displacement?

A

during surgical attempt at removal, raising flap may cause further and further displacement

41
Q

What is a notable site for lingual tissue displacements to occur?

A

lingual side of posterior mandible

42
Q

Why may displacement into the lingual tissues occur in the posterior mandible?

A

can be very thin bone lingually of molars, may have a root fragment left and when pushing may only have soft tissue left next to it and can displace into it

43
Q

What does risk of inferior alveolar canal placement depend on?

A
  • root proximity to IAC
  • thinness of bone between root and IAC
  • anatomy of IAC
44
Q

What are the risks of an inferior alveolar canal displacement?

A
  • crushing of IAN
  • altered sensation to everything supplied by terminal distribution of IAN e.g. lip
  • possibility lots of bleeding
  • act of retrieving root can itself be very risky
45
Q

What may be required if a lung/airway displacement occurs?

A

bronchoscopy or possibly even surgery to retrieve it

46
Q

What things may contribute to fracture of crown/root during extraction?

A
  • failure to understand root anatomy/curvature/additional roots/bulbosity
  • failure to appreciate extent/position of caries
  • inappropriate tooth moment (excessive force in wrong direction or too early in the process etc)
  • poor forcep selection
  • ankylosis
47
Q

What type of injury is common during extractions?

A

soft tissue injury - usually of minimal consequence just including the gingiva

BUT can be serious e.g. elevator slipping into mental nerve, forcep taking out a chunk of gingiva etc

BDS M5 Oral Surgery (8 decks)

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