Peri-operative extraction complications

Question 1

What are the peri-operative complications

Answer 1

• difficulty of access
• abnormal resistance
• fracture of tooth/root
• fracture of alveolar plate
• fracture of tuberosity
• jaw fracture
• involvement of maxillary antrum
• 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

Question 2

What can give difficulty of access and vision

Answer 2

• trismus
• reduced aperture of mouth
• crowded/malpositioned teeth

Question 3

What can give abnormal resistance

Answer 3

• thick cortical bone
• shape/form of roots
• number of roots
• hypercementosis
• ankylosis

Question 4

What can fracture

Answer 4

• tooth
  
  • crown
  • root
• alveolus/tuberosity
• jaw

Question 5

why might a tooth fracture

Answer 5

• caries
• alignment
• size
• root

Question 6

Why might a root fracture

Answer 6

• fused
• convergent or divergent
• ‘extra’ roots
• morphology
• hypercementosis
• ankylosis

Question 7

Why might the alveolar bone fracture

Answer 7

• usually buccal plate
• usually canines or molars
• molars
  
  • periosteal attachment
  • suture
  • dissect free
• canines
  
  • stabilise
  • free mucoperiosteum
  • smooth edges

Question 8

why might the jaw fracture

Answer 8

• usually mandible
• often impacted wisdom tooth, large cyst or atrophic mandible
• radiographs are essential
• application of force

Question 9

how to manage a jaw fracture

Answer 9

• inform patient
• post-op radiograph
• refer
• ensure analgesia
• stabilise
• if delay, antibiotic

Question 10

what are the different ways you can have involvement of the maxillary antrum

Answer 10

• Immediate complication is an Oro-antral communication (OAC). If epithelium lined, it’s an oro-antral fistula (OAF)
• loss of root into antrum
• fractured tuberosity

Question 11

How to diagnose oro-antral communication

Answer 11

• size of tooth
• radiographic position of roots in relation to antrum
• bone at trifurcation of roots
• bubbling of blood
• nose hollding test (careful as can create OAC)
• direct vision
• good light and suction
• blunt probe

Question 12

management of oro-antral communication

Answer 12

• inform patient
• if small or sinus intact:
  
  • encourage clot
  • suture margins
  • antibiotic
  • post-op instructions
• if large or lining torn:
  
  • close with buccal advancement flap
  • antibiotics and nose blowing instructions

Question 13

How do you do a buccal advancement flap to cover an OAC/OAF

Answer 13

• take buccal bit of tissue and advance it over the hole
• need to release the underlying periostium because the gum is not elastic
• if its chronic you need to cut the fistula out or it won’t close over properly

Question 14

what do you do if you think there is a root in the antrum

Answer 14

• confirm radiographically by OPT, occllusal or peiapical
• decision on retrival

Question 15

What do you do if suspect root in antrum

Answer 15

• flap design
• open fenestration with care
• suction - efficient and narrow bore
• small curettes
• irrigation or ribbon gauze
• close as for oro-antral communication

Question 16

why might the maxillary tuberosity fracture

Answer 16

• single standing molar
• unknown unerupted molar wisdom tooth
• pathological gemination
• extracting in wrong order (Take out from the back forward (8,7,6) other wise you are undermining the bone as you go along and you will leave yourself with a last standing molar)
• inadequate alveolar support

Question 17

how might you diagnose a tuberosity fracture

Answer 17

• noise
• movement noted both visually or with supporting fingers
• more than 1 tooth movement
• tear on palate

Question 18

management of fractured tuberosity

Answer 18

• dissect out and close wound
• or reduce and stabilise
• fixation with ortho wire, arch bar, splints
• leave in place for at least 8 weeks

Question 19

what do you do if you lose a tooth

Answer 19

• find it
• stop what you are doing
• suction
• radiograph

Question 20

what damage to nerves can you get

Answer 20

• crush injuries
• cutting/shredding injuries
• transection
• damage from surgery or damage from LA
• may not know at the time

Question 21

Scientific names for the different types of nerve damage

Answer 21

• Neurapraxia
• Axonotmesis
• Neurotmesis
• Anaesthesia
• Paraesthesia
• Dysaesthesia
• Hypoaesthesia
• Hyperaesthesia

Question 22

what is neurapraxia

Answer 22

contusion of nerve/continuity of epineural sheath and axons maintained

It consists of loss of conduction without associated changes in axonal structure

Question 23

what is axonotmesis

Answer 23

continuity of axons but not epineural sheath disrupted

The axons and their myelin sheath are damaged, but the endoneurium, perineurium and epineurium remain intact

Question 24

what is neurotmesis

Answer 24

complete loss of nerve continuity/nerve transected

Question 25

what is anaesthesia

Answer 25

numbness

Question 26

what is paraesthesia

Answer 26

tingling

Question 27

what is dysaesthesia

Answer 27

unpleasant sensation/pain

Question 28

what is hypoaesthesia

Answer 28

reduced sensation

Question 29

what is hyperaesthesia

Answer 29

increased sensation

Question 30

what damage to vessels can you get

Answer 30

* veins (lots of bleeding) * arteries (pulsating bleed, lots of bleeding) * arterioles (spurting/pulsating bleed) * vessels in muscle * vessels in bone

Question 31

why might a dental haemorrhage happen

Answer 31

* most bleeds are due to local factors - mucoperiosteal tears or fractures of alveolar plate/socket wall * very few bleeds due to undiagnosed clotting abnormalities (haemophilia/ VWD) * liver disease (alcohol problems) - clotting factors made in the liver) * medication - warfarin/antiplaelet agents e.g. aspirin/ clopidogrel * other anticoagulant drugs

Question 32

how to treat soft tissue bleeding

Answer 32

* pressure * sutures * LA with adrenaline * diathermy (cauterise/burn vessels) * ligatures/haemostatic forceps for larger vessels

Question 33

how to treat bleeding from the bone

Answer 33

* pressure * LA on swab or injected into socket * Haemostatic agents - surgicel/kaltostat * blunt instrument * bone wax * pack

Question 34

how to deal with dislocation of TMJ

Answer 34

* relocate immediately (analgesia and advice on supported yawning) * if unable to relocate try LA into masseter intraorally * if still unable, immediate referal

Question 35

how do you deal with damage to adjacent teeth/restorations

Answer 35

* temporary dressing/restoration * arrange definitive restoration * if large restoration next to extraction site warn pt of risk

Question 36

how do you avoid extraction of a permanent tooth germ

Answer 36

don't go digging in sockets after taking out a primary tooth (rare)

Question 37

what do you do if there is a broken instrument

Answer 37

- radiograph/retrieve - if unable, refer

Question 38

how do you avoid taking out the wrong tooth

Answer 38

* concentrate * check clinical situation against notes/radiographs * count teeth * verify with someone else if still unsure * phone the defence union if you do it...