Prevention & management of extraction complications Flashcards
T/F: Referral is ALWAYS an options
• Is a moral obligation to practitioners →primum non nocere
• Will provide peace of mind
True
The following are all associated with ______:
• Detailed surgical plan
• Needed instrumentation
• Pain/anxiety management
Comprehensive treatment plan
- Causes:
- Retraction tension on envelope flap that is too small for adequate visualization/access
- Lack of care when reflecting/elevating flap
- Prevention:
- Adequate sized flap with gentle retraction
- Pay attention to flap retraction (assistant)
TEAR OF MUCOSAL FLAP
• Causes:
• Slippage of instrument (elevator, elevator) due to
unprotected/uncontrolled force
• Prevention:
• Controlled and protected forces
• Finger extension during instrument usage
• Treatment:
• Irrigate wound and establish hemostasis w/ direct pressure
• Do not suture, allow to heal by secondary intention
PUNCTURE WOUND
• Causes:
• Excessive retraction to anesthetized lips/mucosa
• Burns/abrasions from shank of rotating bur
• Easy to occur when surgeon has tunnel vision only focusing on cutting end of
bur
• Prevention:
• Proper retraction
• Be aware of location of shank
• Treatment:
• Mucosal injury does not require much, keep area clean with regular oral
rinsing
• Skin injury requires ABX ointment for 5-10 days
STRETCH OR ABRASION
• Cause:
• Most often reason is due to abnormality of root structure
• Long, thin, dilacerated, embedded in dense cortical bone
• Prevention:
• Proper planning
• Back up plan for your back up plan
• Open extraction technique →surgical obliteration →
leave in place
ROOT FRACTURE
Most common ROOT displaced is the _______
maxillary molar palatal root, into sinus
Most common TOOTH displaced is the ______
maxillary 3rd molar
• Causes:
• Improper use of elevator while removing root tip
• Too much vertical pressure without finger extension
• Not being within PDL space when using elevator/root tip pick
• No direct visualization/access
• Treatment: Depends on
• Size of root tip
• Pathology associated with root tip
• Sinus pathology
• Healthy root tip displaced into a healthy
sinus will be easier to manage
Root displacement
- Localize radiographically
- Document position and size
- Through oroantral communication, flush with saline and suction
- Check suction fluid collection, and take radiograph to confirm removal
- If root is not removed →leave it
- Given patient sinus precautions
- Figure of 8 over oroantral communication
- Appropriate post-operative medications
- Inform patient what happened, and decision to leave it and why
- Regular follow-up for monitoring root and sinus
ROOT TIP <2-3 MM, NO PATHOLOGY
If root tip has pathology, can it be left or should it be removed?
Must be removed
- Localize radiographically
- Document position and size
- Through oroantral communication, flush with saline and suction
- Check suction fluid collection, and take radiograph to confirm removal
- Root MUST BE REMOVED
- Refer to oral surgeon
- Caldwell-Luc approach (aka. lateral maxillary antrostomy)
ROOT TIP <2-3 MM, WITH PATHOLOGY
• Causes:
• Too much posterior force with elevator
• Not enough buccal force
• Attempted removal of high impaction, poorly developed, conical 3rd molar
• Location:
• Posterior to tuberosity
• Lateral to lateral pterygoid plate
• Inferior to lateral pterygoid muscle• Treatment:
• If visualized, one attempt to grasp with hemostat and remove (do not push deeper)
• Unable to visualize or feel, leave in space for 4-6 weeks to fibrose and stabilize for possible
removal later, and give ABX prior to discharge
• At 4-6 weeks, if no functional or infective problems, okay to leave in place
• Removal could cause more problems than leaving tooth in place
• If fibrosed tooth is causing opening/closing interference, may have to remove
• Refer to OMS
• Obtain CT to localize radiographically
• Take to OR for surgical removal under general anesthesia
INFRATEMPORAL SPACE DISPLACEMENT
• Treatment:
• Make a single effort to retrieve it
• Could push deeper if multiple attempts taken
• Index finger palpates lingual sulcus
• Start as low as possible and work superior
• Attempt to push through socket that it came through
• If unsuccessful, place patient on ABX and refer to OMS
• Lingual flap elevation to attempt to visualize and retrieve
root/tooth
• May elect to leave it and follow the patient if no pathology
noted on root (as with max sinus displacement)
SUBLINGUAL/SUBMANDIBULAR SPACE
DISPLACEMENT
• Turn patient towards surgeon
• Face down as much as possible
• Encourage patient to cough
• Patient stops coughing and has no respiratory distress
• Tooth swallowed (possibly)
• Patient has violent coughing with SOA
• Tooth aspirated (possibly)
Treatment:
• Patient should be transported to Emergency
Department!!
• Plain film chest x-ray and KUB taken to locate
tooth or fragment
• If aspirated, patient will require bronchoscopy
under general anesthesia for retrieval
• If swallowed, patient will pass it in ~2-4 days
TOOTH LOST IN OROPHARYNX
• Causes:
• Luxation forces transmitted to large restorations directly next to tooth planned
for extraction
• Prevention:
• Warn patient the risk for potential fracturing or displacing restoration
• Avoid luxation directly on proximal teeth
• Seat elevator as deeply in PDL space as possible
• Can avoid luxation at all with straight elevators
• Treatment:
• Remove entire restoration to prevent aspiration
• Replace restoration with temporary material
• Inform patient what occurred
• Advise patient to see general dentist for restorability consultation of affected tooth
FRACTURE OR DISLODGEMENT OF ADJACENT
RESTORATION
• Causes:
• Improper elevation technique
• “Crowded” or “locked out” tooth
• Prevention:
• Proper elevator technique
• Use narrow beak forceps
• Treatment:
• Reposition tooth immediately
• If slightly loosened, relieve occlusion and advise patient to not eat on
that side
• If quite mobile, stabilize with flexible splint
• Light wire or paper clip bonded to that tooth and two teeth on each
side
• Composite bridge across tooth and adjacent teeth
LUXATION OF ADJACENT TOOTH
• Most common error with orthodontic extractions
• Causes:
• Lack of attention and concentration
• Incorrect diagnosis
• Prevention:
• Check with referring dentist preoperatively if any question exists
• Mark tooth to be removed on radiograph
• Have assistant double check immediately before using instrument
• Treatment:
• Immediately replace into socket and splint
• If orthodontic extraction
• Re-implant tooth
• Call orthodontist to see if tx plan can be revised: is so, proceed with new tx plan
• If tooth necessary & must be kept, stop procedure, splint re-implanted tooth and wait 3-4 weeks to reassess
• Any tooth completely luxated from its blood supply may become non vital and require
root canal therapy
EXTRACTION OF WRONG TOOTH
- Causes:
- Excessive buccal force with forceps
- Thin rigid buccal bone
- Dense bone in elderly with loss of PDL space on radiograph
- Prevention:
- Avoid excessive force
- Opposite hand used to “pinch” the buccal bone for tactile stimulus to possible fracture
- Pre-operative assessment
- Better option may be to start with open surgical extraction
- Treatment:
- If segment came out with tooth:
- Do not reinsert, discard, and smooth bone
- If large piece is still attached to periosteum:
- Stabilize tooth with forceps, use Woodson in an attempt to separate bone from root, leave bone in place
FRACTURE OF THE ALVEOLAR PROCESS
• Causes:
• Excessive force in removal of maxillary third molar or isolated maxillary molar
• Elderly with dense bone and lack of PDL space on radiograph
• Prevention:
• If no movement with strong force, reflect a flap and remove bone prior to attempted
delivery
• Start with open surgical extraction of isolated “island” maxillary molars
• Treatment:
• Separate tooth from bone prior to delivery if possible
• If it is a major bone segment, containing sinus floor or Hamulus:
• Abort procedure
• Splint tooth for 6-8 weeks and perform open surgical extraction
FRACTURE OF MAXILLARY TUBEROSITY
- Most common injured nerves:
- Mental nerve
- Lingual nerve
- Inferior Alveolar nerve
- Damage to nasopalatine and long buccal nerve is inconsequential
- Area of sensory innervation is small
- Reinnervation of affected area is rapid
- If an injury from stretch (neuropraxia), good chance of recovery
- If severed or badly crushed (neurotmesis, axonotmesis), poor chance of recovery
- Lingual nerve does not regenerate well, higher chance of neuroma formation
INJURY TO REGIONAL NERVES
_____ nerve does not regenerate well, higher chance of neuroma formation
Lingual nerve
• Spontaneous and subjective altered sensation that IS NOT PAINFUL/UNCOMFORTABLE
Paresthesia
• Spontaneous and subjective altered sensation that IS PAINFUL/UNCOMFORTABLE
Dysesthesia
• Excessive sensitivity of a nerve to stimulation
Hyperesthesia
• Decreased sensitivity of a nerve to stimulation
Hypoesthesia
• No sensation when stimulated
Anesthesia
- Causes:
- Improperly placed incisions or long releasing incisions (mental n.)
- Removal of third molars with close proximity to IAN (IAN)
- Distal releasing incision placed to lingual in mandibular molar surgical flap creation (lingual n.)
- Periapical surgery in area of mental foramen (mental n.)
- Injury during local anesthetic injections (any nerve)
- Treatment:
- Follow patient closely post-operatively, performing nerve testing of all sensory areas affected
- Record:
- Subjective changes per patient
- Objective changes tested
- Anatomic area involved
- Light touch (cotton wisp)
- Cold sensation
- Two point discrimination
- Dysesthesia
- Refer to oral surgeon early:
- After 6-9 months post-injury, less chance of return of sensation and successful surgical repair decreases
- Surgery likely if dysesthesia noted, likely from neuroma formation
Injury to regional nerve
- Causes:
- Application of significant force on mandibular teeth extraction without adequate support
- Lack of use with bite block
- Treatment:
- Acute TMJ dislocation
- Reduce dislocated joint/s, abort procedure that day
- TMJ strain
- Warm moist heat to opening muscles
- NSAIDs for 3-7 days (alternative to use APAP)
- Rest jaw with soft, non chew diet
Injury to TMJ
• Most common cause of delayed healing is ______
• Not common with routine extraction
• More common with reflection of flap and bone removal
• Prevention:
• Careful asepsis
• Wound debridement
• Copious irrigation after bone removal with hand piece or bone file
• Pre-operative examination of the immunocompromised patient and planning with pre-op and
post-op ABX as needed
infection
- Wound separated at margins after flap reapproximation
- Causes:
- Flap sutured under tension
- Remember the goal of suturing is approximation not strangulation
- Bony projection under flap approximation
- Treatment:
- Smooth bone under flap and replace sutures not under tension
- If no bony projection and no signs of infection, let granulate in via secondary intention
DEHISCENCE
- Pain that returns 3-5 days post-operatively after a period of feeling “normal”
- Severe, constant, throbbing, referred to ear
- Narcotic medication does not alleviate pain
- Foul odor and bad taste
- No swelling, no fever →not an infection
- Socket appears empty (potentially visualize bone in socket), devoid of clot
- Incidence:
- More common in mandibular sockets and with open vs closed extractions
- More common in females, age 18-22, on oral contraceptive
- Smokers
- Rare occurrence following routine extraction – 2%
• Localized osteitis
Dry socket
- Cause:
- Increased fibrinolytic activity resulting in lysis of clot
- Trauma to socket (sharp foods impacting socket)
- Smoking
- Infection of clot
- Failure to irrigate well at end of surgery
- Prevention: Speculative
- Minimize trauma & inflammation
- Peridex mouthrinses pre and post-op
- Placement of ABX medicaments into socket
- Thorough irrigation at termination
- Treatment:
- Irrigate with warm saline
- Local anesthesia may be required if significant pain
- Sedative dressing gently packing into socket
- Prolongs healing, but alleviates pain
- Have patient return in 2 days for re-evaluation
- Make sure your treatment is effective
• Localized osteitis
Dry socket
_____ is a cyst-like lesion present in the max sinus with serum inflammatory exudate
- No biopsy needed
- No epithelial lining
PSEUDOCYST OF MAXILLARY SINUS
ANTRAL PSEUDOCYST
Lingual developmental mandibular salivary gland depression
Developmental defect – lobe of submandibular gland fills defect
Well-defined radiolucent area
Between mandibular canal and inferior border
No treatment required
SUBMANDIBULAR SALIVARY
GLAND DEFECT
