Perioperative Extraction Complications Flashcards
List potential peri-operative complications
- difficulty to access
- abnormal resistance
- fracture of tooth/root
- fracture of alveolar plate
- fracture of tuberosity
- jaw fracture
- involvement of the maxillary sinus (OAF)
- loss of tooth
- soft tissue damage
- damage to nerves or vessels
- haemorrhage
- dislocation of the TMJ
- Damage to adjacent teeth or restorations
- extraction of permanent tooth germ
- broken instruments
- wrong tooth extracted
what can cause difficulty of access and visual difficulty during an extraction
- Trismus: if a patient has trisms or limited mouth opening
- reduced aperture of mouth (congenital syndromes - microstomia or scarring)
- Crowded or malpositioned teeth
define Trismus
Trismus, also sometimes called lockjaw, is a painful condition in which the chewing muscles of the jaw become contracted and sometimes inflamed, preventing the mouth from fully opening.
What can cause abnormal resistance
thick cortical bone - larger males may have this
Shape and form of roots - divergent or hooked roots can cause issues
Number of roots - three rooted lower molars difficult
Hypercementosis - seen in paget’s disease, acromegaly and vitamin a deficiency
Ankylosis - PDL gone due to trauma and bone is fused to roots of teeth
When is a tooth more likely to fracture?
carious
alignment - awkward position or overcrowding
size - small crown and big roots are more likely to fracture
root - shape and size affected whether a tooth may fracture
If a tooth is not moving what do you do
remove surgically, do not use excessive force
when is a root more likely to fracture
- fused roots
- convergent or divergent
- extra roots
- odd morphology
- hypercementosis
- ankylosis
Why might the alveolar bone fracture
- could be fused to the tooth
- tooth was extracted buccally too quickly (before it was made mobile)
If the alveolar bone does fracture, where is it most likely to occur
- buccal plate
- in canine region
- or in molar region
what do you do if you have fractured the alveolar bone in the molar region
- if a large bit of bone is still attached to the periosteum then it still has its blood supply, so you can put it back in place and suture around
- if it is not a large part or does not have a blood supply, take it out as it will become necrotic
- suture
- dissect it free with a scalpel
what do you do if you have fractured the alveolar bone in the canine region
- try to save it as it has a job in creating shape in that area
- stabilise
- free mucoperiosteum
- smooth edges as it is jaggy and may break through the gum
What should you do if you fracture a jaw
- inform the patient
- take a post-operative radiograph
- refer to maxillofacial department or A&E (tell them not to eat on route, incase they go to theatre)
- Ensure analgesia and give advice on keeping clean (chlorohexidine)
- stabilise (if wobbling, splint around crowns of teeth around fracture)
- if delay, give antibiotics
What can cause an oro-antral communication
- loss of root into the antrum - usually the crown fractures and clinician pushes root up into the sinus
- fractured tuberosity - because of its position, beside the sinus, it usually involves a communication with the maxillary sinus
how do you diagnose an OAC
- size of tooth
- radiographic position of roots in relation to sinus
- bone at trifurcation of roots
- bubbling of blood in socket
- nose holding test (careful as can create an OAC)
- direct vision
- good light and gentle suction (hear echo )
- blunt probe
what are acute and chronic OAC
acute is the initial communication
chronic is an epithelial lined OAF
if the OAC is small or the sinus is in tact, what is the management
- encourage clot
- suture margin
- prescribe antibiotics
- give post-op instructions
- usually will heal if it’s 1-2mm
in an OAC if the sinus is large or lining is torn what is the management
- close straight away with a buccal advancement flap
- antibiotics and nose blowing instructions
- review regularly
- ensure flap has enough elasticity and is tension free
how do you treat a root in antrum
- confirm radiographically
- flap design
- open fenestration with care
- suction
- small curettes
- use irrigation or ribbon gauze
- close as for an oro-antral communication
what is more likely to cause a fracture to the maxillary tuberosity?
- single standing molar as bone is weakened and there will be a lot of pressure on single tooth
- unknown unerupted molar wisdom tooth
- pathological germination (teeth germs that have fused causing roots to fuse)
- extracting in wrong order (8, 7, 6 not 6, 7, 8)
- inadequate alveolar support
how do you manage a fractured maxillary tuberosity ?
- dissect out and close wound
- or reduce and stabilise
if you are going to dissect out a fractured maxillary tuberosity, how do you do so
- cut away gum from around the hole at socket
- distal relieving incision and dissect off the bit of bone and remove the ohhh and bit of bone
- the flap will usually close quite easily, if not do a buccal advancement flap
how do you reduce and stabilise a fractured maxillary tuberosity
- if fractured bit is large, do not remove
- reducing means put it back in place
- stabilise means finding a way to stop it moving until it heals
- reduce with fingers or forceps
- stabilise with splint, arch bar or orthodontic buccal arch wire
What can cause damage to nerves
- crush injuries
- cutting or shredding injuries
- transection injuries
- damage from surgery
- damage from LA (putting needle into nerve)
what is neurapraxia
confusion or nerve/continuity of epineural sheath and axons maintained
what is axonotmesis
continuity of axons but not epieneural sheath
what is neurotmesis
complete loss of nerve continuity / nerve transected
What word describes numbness
anaesthesia
what word describes tingling
paraesthesia
what word describes dysaesthesia
unpleasant sensation/pain
what word describes hypoaesthesia
reduced sensation
what word describes hyperaesthesia
increased/heightened sensation
how do you control bleeding from soft tissues
Pressure - mechanical pressure with finger or biting on a damp gauze
Sutures
Local anaesthetic with adrenaline - has vasoconstrictor properties, can see what you’re doing
diathermy - cauterise/burns vessels (precipitate proteins and forms proteinaceous )
ligatures/haemostatic forceps - artery clips for larger vessels
how do you control bleeding form the bone
Pressure - via swab or ribbon gauze, pack it into socket and put pressure on base. Protect nerves with instruments and make sure you’re not putting pressure on the nerves
LA on a swab or injected into socket
Haemostatis agents (oxidised cellulose - form scaffold for blood clot)
Blunt intrsument - flat plastic to give pressure
Bone wax - waterproof layer
What do you do if you dislocate the TMJ
Relocate immediately - before muscles go into spasm. Down and backwards movement
give anaesthesia and advice on yawning
if you cannot relocate try local anaesthetic into masseter
if still cant relocate, immediate referral
how can damage to adjacent teeth and restorations occur
- hit opposing teeth with forceps
- crack/fracture/move adjacent teeth with elevators
- crack/fracture/remove restorations/crowns/bridges on adjacent teeth
