Peri-operative Complications Flashcards
1
Q
What are peri-operative complications?
A
- immidiate complications
- while taking tooth
- immediately after extraction
2
Q
Provide examples of peri-operative complications
A
- difficult access
- abnormal resistance
- fracture of tooth/root
- fracture of alveolar bone
- jaw fracture
- involvement of maxillary antrum (sinus)
- fracture of tuberosity
- 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
3
Q
What can contribute to difficult access?
A
- trismus
- reduced aperture of mouth
- congenital/syndromes (microstmoia)
- scarring
- muscle spasming
- crowding/malpositioned teeth
- unusual eruption
- forceps not useful, luxators and elevators alone
- particularly upper 3s and lower 4s and 5s
4
Q
Why is difficult access a complication?
A
- may not be able to see tooth
- can position patient to improve view
- good lighting
- good operator positioning
- suction may help
- may not be able to position forceps
5
Q
What can contribute to abnormal resistance?
A
- thick cortical bone
- shape/form of roots
- divergent roots
- hooked roots
- bulbous apex common for lower premolars
- number of roots
- e.g. 3 rooted lower molars/ 2 rooted premolars
- hypercementosis
- excess build up of normal cementum on the root
- ankylosis
- tooth fused to surrounding bone
- no periodontal ligament
- may be trauma or pulp necrosis
- cannot be extracted with forceps
6
Q
How can abnormal resistance be managed?
A
- taking a break and trying again
- oedema from first attempt may loosen tooth
- may see new way of attempting extraction
- more force required
- surgical extraction required
7
Q
What can contribute to tooth/root fracture?
A
- caries
- decoronation if carious crown or carious ACJ
- difficult to place forceps - alignment
- size
- small crown with big roots increases decoronation risk
- root morphology
- fused (may have chunk of bone stuck between roots)
- convergent or divergent
- extra roots
- hypercementosis
- ankylosis
8
Q
How can tooth/root fracture be managed?
A
- sometimes inevitable
- must be discussed during consent process
- place forceps beaks on root surface
- if on crown higher chance of decoration
9
Q
What can contribute to fracture of the alveolar bone?
A
- usually buccal plate of canines or molars
- buttress of bone overlying long root of canine
- thicker buccal plate over molars
- inadequate expansion of socket
10
Q
How can fracture of alveolar bone be managed?
A
- preserve as much bone as possible
- especially for implant placement
- fracture can produce thin ridge for dentures
- possible management
- is bone attached to periosteum?
- reattach with sutures where possible
- remove if no blood supply - dissect free if still attached
- surgically extract tooth
- smooth bone edges to avoid wound breakdown
11
Q
What can contribute to jaw fracture?
A
- usually mandible
- often impacted wisdom teeth, large cyst, atrophic mandible
- likely at angle of mandible
- application of force
- fracture can occur post operatively
- not enough bone left
- bumping can cause fracture
- signs of fractured mandible
- cracking sound
- teeth not in occlusion
- trauma to gingiva
12
Q
How can fracture of the jaw be managed?
A
- radiographs must be taken
- pre and post operatively
- assess risk (length of tooth compared to bone)
- OPT to assess fracture
- support the mandible during extraction
- hold forceps in dominant hand
- fingers on either side of alveolus
- thumb under mandible
- inform patient
- of risk
- of suspected fracture
- refer
- phone OMFS
- refrain from eating or drinking (operation on same day)
- ensure analgesia
- sore and swollen
- stabilise
- splint teeth on either side of fracture
- prevents movement which causes pain
- antibiotic
- only if not attending emergency treatment
- will be given IV at hospital
13
Q
How can involvement of the maxillary antrum occur?
A
- oro-antral fistula/communication
- root has developed into sinus
- passage created on extraction
- fistula when left for a while and has epithelialised
- communication when first created
- loss of root into antrum
- usually on multi rooted teeth
- root pushed into sinus
- fractured tuberosity
14
Q
How is involvement of the maxillary antrum diagnosed?
A
- size of the tooth
- radiographic position of roots in relation to antrum
- bone trifurcation of roots
- may be floor of sinus
- bubbling of blood
- at socket
- air passing from sinus to mouth
- nose holding test
- can create OAC
- air passed down through sinus
- patient feels air in mouth - direct vision
- see empty space instead of bone
- good light and suction
- different noise from empty socket
- echo/high pitched noise
- blunt probe
- can create OAC
- fluid passing from mouth to nose
15
Q
What are the risk factors for maxillary antrum involvement
A
- extraction of upper molars and premolars
- close relationship of roots to sinus on radiograph
- last standing molars
- large bulbous roots
- older patient
- sinus gets bigger and moves downwards
- previous OAC
- recurrent sinusitis
- tooth in close proximity to sinus
16
Q
How is maxillary antrum involvement managed?
A
- inform patient
- if small communication or sinus is in tact
- left to heal
- encourage clot (seals OAC)
- suture margins
- antibiotic to manage infection risk
- post operative instruction
- if large or sinus lining torn
- close with buccal advancement
- large hole left behind by molars
- gum pulled from buccal aspect to palatal aspect
- vertical incisions, underside scored and pulled over
- tightly sutured with horizontal mattress sutures
- not placed under tension - antibiotic prescription
- nose blowing instruction
- steam inhalation
- decongestants
- do not want build up of mucus
- close with buccal advancement
17
Q
How is a root in the maxillary antrum managed?
A
- confirmed radiographically
- OPT, occlusal or periodical
- decision made of retrieval
18
Q
What is the aetiology of tuberosity fracture?
A
- single standing molar
- unusual but can be premolar or canine
- unknown unerupted wisdom tooth
- pathological gemination
- extracting in wrong order
- extract from back and move forward
- do not create last standing tooth
- inadequate alveolar support
- bone is weak so tuberosity can be fractured
- required adequate alveolar support during extraction
19
Q
What is the aetiology of tuberosity fracture?
A
- single standing molar
- unusual but can be premolar or canine
- unknown unerupted wisdom tooth
- pathological gemination
- extracting in wrong order
- extract from back and move forward
- do not create last standing tooth
- inadequate alveolar support
- bone is weak so tuberosity can be fractured
- required adequate alveolar support during extraction
- fusion of tooth germs
- trying to extract one tooth but two come out
20
Q
How is tuberosity diagnosed?
A
- noise
- movement noted
- visually
- supporting fingers
- more than one tooth movement
- tear on palate
21
Q
How is tuberosity fracture managed?
A
- dissect out and close wound
- reduce and stabilise
- reduce with fingers or forceps
- fixation with ortho wire, arch wire, splints
- tooth may need taken out of occlusion (cusps)
- extrapate pulp
- antibiotic and antiseptic prescription
- post op instruction
- remove tooth 8 weeks later
22
Q
How is a lost tooth managed?
A
- stop the procedure
- locate the tooth
- often on floor
- potentially patients clothing
- back of tongue
- buccal sulcus
- did patient feel or inhale anything?
- referral to A&E on inhalation - lingual sulcus into floor of mouth if fracture of bone
- use suction
- take radiographs
23
Q
How is soft tissue damage avoided?
A
- pay attention during procedure
- correct placement of correct instruments
- place beaks of forceps on crown and move down
- consider superficial position of lingual nerve
- take time positioning instruments
- correct application point
- prevents instrument from slipping
- controlled pressure
- sufficient but not excessive force
24
Q
How does nerve damage occur?
A
- crushing injuries
- cutting/shredding injuries
- transection
- damage from surgery or damage from local anaesthetic
- only noticed once local anaesthetic has worn off
25
Q
What types of nerve damage are possible as a result of extraction?
A
- neurapraxia
- contusion of nerve
- continuity of epieneural sheath and axons maintained
- axonotmesis
- continuity of axons
- epieneural sheath disrupted
- neurotmesis
- complete loss of nerve continuity
- nerve transected
26
Q
What are the possible symptoms of nerve damage?
A
- anaesthesia
- numbness
- paraethesia
- altered tingling sensation
- dysaesthesia
- painful or burning sensation
- unpleasant
- hypoaesthesia
- reduced sensation
- hyperaesthesia
- increased or heightened sensation
27
Q
What vessels can be damaged?
A
- veins
- profuse bleeding
- arteries
- spurting
- haemorrhage
- arterioles
- spurting
- pulsating bleed
- vessels in muscle
- vessels in bone
28
Q
Why may a patient bleed post operatively?
A
- anticoagulant medication
- sharp piece of bone remaining
- damage to vessels
29
Q
What factors may contribute to haemorrhage?
A
- local factors
- mucoperiosteal tears
- fracture of alveolar plate/socket wall
- rarely an undiagnosed clotting abnormality
- haemophilia
- von Willebrands
- liver disease
- alcohol problems
- clotting factors produced in liver
- medication
- warfarin
- anti platelet agents (aspirin/clopidegrel)
- DOACs (rivaroxaban, dabigatran)
30
Q
How is soft tissue haemorrhage managed?
A
- pressure
- mechanical (biting on damp gauze)
- sutures
- local anaesthetic
- with adrenaline - diathermy
- cauterise/burn vessels
- precipitate proteins to form proteinaceous plug in vessel
- ligatures/haemostatic forceps
- artery clips
- larger vessels
31
Q
How is bone haemorrhage managed?
A
- pressure applied
- local anaesthetic on a swab or injected into socket
- haemostat agents
- blunt instrument
- bone wax
- pack socket
- pack
32
Q
How is TMJ dislocation managed?
A
- unilateral or bilateral dislocation
- normally prone to dislocation
- usually lower tooth
- use non dominant hand to support mandible during extraction
- relocate immediately
- analgesia
- advice on supported yawning, minimal mouth opening
- put pressure downwards and backwards on the mandible
- considerable force required
- advise can dislocate again
- muscles spasm if not immediately
- try local anaesthetic into master intra-orally
- make an immediate referral - MFOS
- sedation may be required
33
Q
How does damage to adjacent teeth or restorations occur?
A
- hitting opposing teeth with forceps
- crack/fracture/move adjacent teeth with elevators
- crack/fracture/remove restorations/crowns/bridges
34
Q
How is damage to adjacent teeth and restorations managed?
A
- temporary restoration placed
- arrangement of definitive restoration
- warn patient of risk if large restoration next to extraction site
35
Q
How does extraction of permanent tooth germ occur?
A
- when extracting deciduous teeth, extraction or damage to permanent predecessor occurs
- very rare
36
Q
How are broken instruments managed?
A
- usually tips of elevators, luxators and burs
- may be faulty
- may be used incorrectly
- take radiographs
- retrieve instrument
- refer if unable to retrieve
37
Q
How are broken instruments managed?
A
- usually tips of elevators, luxators and burs
- may be faulty
- may be used incorrectly
- burs may be lost
- take radiographs
- retrieve instrument
- refer if unable to retrieve
38
Q
How is extraction of the wrong tooth avoided
A
- concentrate
- check clinical situation against notes and radiographs
- safety checks
- count teeth
- verify with someone else if still unsure
- contact defence union
