Peri-operative extraction complications Flashcards
What are the peri-operative complications
- 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
What can give difficulty of access and vision
- trismus
- reduced aperture of mouth
- crowded/malpositioned teeth
What can give abnormal resistance
- thick cortical bone
- shape/form of roots
- number of roots
- hypercementosis
- ankylosis
What can fracture
- tooth
- crown
- root
- alveolus/tuberosity
- jaw
why might a tooth fracture
- caries
- alignment
- size
- root
Why might a root fracture
- fused
- convergent or divergent
- ‘extra’ roots
- morphology
- hypercementosis
- ankylosis
Why might the alveolar bone fracture
- usually buccal plate
- usually canines or molars
- molars
- periosteal attachment
- suture
- dissect free
- canines
- stabilise
- free mucoperiosteum
- smooth edges
why might the jaw fracture
- usually mandible
- often impacted wisdom tooth, large cyst or atrophic mandible
- radiographs are essential
- application of force
how to manage a jaw fracture
- inform patient
- post-op radiograph
- refer
- ensure analgesia
- stabilise
- if delay, antibiotic
what are the different ways you can have involvement of the maxillary antrum
- 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
How to diagnose oro-antral communication
- 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
management of oro-antral communication
- 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
How do you do a buccal advancement flap to cover an OAC/OAF
- 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
what do you do if you think there is a root in the antrum
- confirm radiographically by OPT, occllusal or peiapical
- decision on retrival
What do you do if suspect root in antrum
- flap design
- open fenestration with care
- suction - efficient and narrow bore
- small curettes
- irrigation or ribbon gauze
- close as for oro-antral communication
why might the maxillary tuberosity fracture
- 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
how might you diagnose a tuberosity fracture
- noise
- movement noted both visually or with supporting fingers
- more than 1 tooth movement
- tear on palate
management of fractured tuberosity
- dissect out and close wound
- or reduce and stabilise
- fixation with ortho wire, arch bar, splints
- leave in place for at least 8 weeks
what do you do if you lose a tooth
- find it
- stop what you are doing
- suction
- radiograph
what damage to nerves can you get
- crush injuries
- cutting/shredding injuries
- transection
- damage from surgery or damage from LA
- may not know at the time
Scientific names for the different types of nerve damage
- Neurapraxia
- Axonotmesis
- Neurotmesis
- Anaesthesia
- Paraesthesia
- Dysaesthesia
- Hypoaesthesia
- Hyperaesthesia
what is neurapraxia
contusion of nerve/continuity of epineural sheath and axons maintained
It consists of loss of conduction without associated changes in axonal structure
what is axonotmesis
continuity of axons but not epineural sheath disrupted
The axons and their myelin sheath are damaged, but the endoneurium, perineurium and epineurium remain intact
what is neurotmesis
complete loss of nerve continuity/nerve transected
what is anaesthesia
numbness
what is paraesthesia
tingling
what is dysaesthesia
unpleasant sensation/pain
what is hypoaesthesia
reduced sensation
what is hyperaesthesia
increased sensation
what damage to vessels can you get
- veins (lots of bleeding)
- arteries (pulsating bleed, lots of bleeding)
- arterioles (spurting/pulsating bleed)
- vessels in muscle
- vessels in bone
why might a dental haemorrhage happen
- 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
how to treat soft tissue bleeding
- pressure
- sutures
- LA with adrenaline
- diathermy (cauterise/burn vessels)
- ligatures/haemostatic forceps for larger vessels
how to treat bleeding from the bone
- pressure
- LA on swab or injected into socket
- Haemostatic agents - surgicel/kaltostat
- blunt instrument
- bone wax
- pack
how to deal with dislocation of TMJ
- relocate immediately (analgesia and advice on supported yawning)
- if unable to relocate try LA into masseter intraorally
- if still unable, immediate referal
how do you deal with damage to adjacent teeth/restorations
- temporary dressing/restoration
- arrange definitive restoration
- if large restoration next to extraction site warn pt of risk
how do you avoid extraction of a permanent tooth germ
don’t go digging in sockets after taking out a primary tooth (rare)
what do you do if there is a broken instrument
- radiograph/retrieve
- if unable, refer
how do you avoid taking out the wrong tooth
- concentrate
- check clinical situation against notes/radiographs
- count teeth
- verify with someone else if still unsure
- phone the defence union if you do it…
