Peri-Operative Extraction Complications Flashcards
What are the different perioperative complications?
Difficult access
Abnormal resistance
Fracture of root/tooth
Fracture of alveolar bone
Jaw fracture
Involvement of maxillary antrum
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
What are the reasons for difficult access?
Trismus
Reduced aperture of the mouth
Crowding or malpositioned teeth
What are the reasons for abnormal resistance?
Thick cortical bone
Shape/form of roots eg - divergent/hooked
Number of roots eg - 3 rooted lower molars
Hypercementosis
Ankylosis
What are the reasons for peri-operative tooth fracture?
Caries
Alignment
Size
Root morphology - fused/extra roots, ankylosis
Where is fracture of alveolar bone most likely?
Usually buccal plate
Usually canines or molars
How should alveolar bone fracture be managed?
Assess periosteal attachment
Suture
Dissect free mucoperiosteum
Smooth edges
What are risk factors for jaw fracture?
Impacted 8s
Large cysts
Atrophic mandible
What causes a jaw fracture?
Application of force
How should a jaw fracture be managed?
Inform patient
Post-op radiograph
Refer to OMFU (phone call)
Ensure analgesia
Stabilise
If delay in tx, give antibiotics
How is an OAF/OAC diagnosed?
Size of tooth
Radiographic position of roots in relation to antrum
Direct vision
Blunt probe (can create OAC)
Bone at trifurcation of roots
Bubbling of blood
Nose holding test (can create OAC)
Good light and suction
What are the risk factors for involvement of a maxillary antrum?
Upper molars and premolars
Close relationship of roots to sinus on radiograph
Large, bulbous roots
Older patient
Previous OAC
Recurrent sinusitis
Last standing molars
How should an OAC be managed?
Inform patient
If small or sinus intact:
- encourage clot
- suture margins
- antibiotics
- post-op instructions
If large or lining torn:
- close with buccal advancement flap
- prescribe antibiotics
- give nose blowing instructions
What are the causes of tuberosity fractures?
Single standing molars
Unknown erupted 8s
Pathological gemination
Extraction in wrong order
Inadequate alveolar support
How is a tuberosity fracture diagnosed?
Noise
Movement noted visually or with supporting fingers
More than one tooth movement
Tear on palate
How should a tuberosity fracture be managed?
Reduce using forceps or fingers
Stabilise
Fix using a splint bonded with composite
Treat pulp
Antibiotics and antiseptics
Post-op instructions
Surgically remove tooth 8 weeks later
How should a lost tooth be managed?
Stop and find it
Use suction and take radiographs
How can soft tissue damage be prevented?
Pay attention
Correct placement/correct instruments
Take time positioning instruments
Application point
Controlled pressure
Sufficient but not excessive force
What are the causes of peri-operative nerve damage?
Crush injuries
Cutting injuries
Damage from surgery or LA
May be unknown
What is neurapraxia?
Contusion of nerve
Continuity of epineural sheath and axons maintained
What is axonotmesis?
Continuity of axons
Epineural sheath not disrupted
What is neurotmesis?
Complete loss of nerve continuity
Nerve transected
What different sensations are involved in nerve damage?
Anaesthesia - numbness
Paraesthesia - tingling
Dysaesthesia - unpleasant sensation/pain
Hypoaesthesia - reduced sensation
Hyperaesthesia - heightened sensation
What are the causes of peri-operative haemorrhage?
Most are local factors - mucoperiosteal tears or alveolar fracture
Undiagnosed clotting factors
Liver disease - clotting factors made in liver
Medications - warfarin/antiplatelets
How should haemorrhage in soft tissues be managed?
Pressure - damp gauze
Sutures
LA with adrenaline
Diathermy
Ligatures/haemostatic forceps
How should haemorrhage in bone be managed?
Pressure via swab
LA on swab or injected into socket
Haemostatic agents
Blunt instrument
Bone wax
Pack and suture
What can the damage of different blood vessels cause?
Veins - causes lots of bleeding
Arteries - causes spurting bleed or haemorrhage
Arterioles - causes spurting or pulsating bleed
Vessels can be in muscle or bone
How should TMJ dislocations be treated?
Relocate immediately - push mandible down and back
Give analgesia and give advice on supported yawning
If unable, try LA into masseter intra-orally
If still unable, refer to OMFU
How may adjacent teeth and restorations be managed peri-operatively?
Hit teeth with opposing forceps
Crack, fracture or move adjacent teeth with elevators
Crack, fracture or remove restorations, crowns and bridges on adjacent teeth
How should damage to adjacent teeth or restorations be managed?
Temporary dressing/restoration
Arrange definitive restoration
Warn patient of the risks
Describe the extraction of permanent tooth germ
Very rare
Damage or removal of permanent tooth when extraditing deciduous counterpart
What broken instruments are likely to cause damage?
Tips of elevators, luxators and burs
What should be done if instruments break peri-operatively?
Retrieve instruments
Use good light, suction and get radiographs
If unable to retrieve, refer to A+E
How can you prevent the wrong tooth from being extracted?
Concentrate
Check clinical view with radiographs and notes
Safety checks
Count teeth
Verify with someone if unsure
Contact defence union
