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Oral Surgery 1 > Prevention & management of extraction complications > Flashcards

Prevention & management of extraction complications Flashcards

1
Q

T/F: Referral is ALWAYS an options
• Is a moral obligation to practitioners →primum non nocere
• Will provide peace of mind

A

True

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2
Q

The following are all associated with ______:
• Detailed surgical plan
• Needed instrumentation
• Pain/anxiety management

A

Comprehensive treatment plan

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3
Q
  • 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)
A

TEAR OF MUCOSAL FLAP

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4
Q

• 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

A

PUNCTURE WOUND

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5
Q

• 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

A

STRETCH OR ABRASION

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6
Q

• 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

A

ROOT FRACTURE

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7
Q

Most common ROOT displaced is the _______

A

maxillary molar palatal root, into sinus

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8
Q

Most common TOOTH displaced is the ______

A

maxillary 3rd molar

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9
Q

• 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

A

Root displacement

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10
Q
  • 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
A

ROOT TIP <2-3 MM, NO PATHOLOGY

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11
Q

If root tip has pathology, can it be left or should it be removed?

A

Must be removed

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12
Q
  • 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)
A

ROOT TIP <2-3 MM, WITH PATHOLOGY

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13
Q

• 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

A

INFRATEMPORAL SPACE DISPLACEMENT

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14
Q

• 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)

A

SUBLINGUAL/SUBMANDIBULAR SPACE

DISPLACEMENT

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15
Q

• 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

A

TOOTH LOST IN OROPHARYNX

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16
Q

• 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

A

FRACTURE OR DISLODGEMENT OF ADJACENT

RESTORATION

17
Q

• 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

A

LUXATION OF ADJACENT TOOTH

18
Q

• 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

A

EXTRACTION OF WRONG TOOTH

19
Q
  • 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
A

FRACTURE OF THE ALVEOLAR PROCESS

20
Q

• 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

A

FRACTURE OF MAXILLARY TUBEROSITY

21
Q
  • 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
A

INJURY TO REGIONAL NERVES

22
Q

_____ nerve does not regenerate well, higher chance of neuroma formation

A

Lingual nerve

23
Q

• Spontaneous and subjective altered sensation that IS NOT PAINFUL/UNCOMFORTABLE

A

Paresthesia

24
Q

• Spontaneous and subjective altered sensation that IS PAINFUL/UNCOMFORTABLE

A

Dysesthesia

25
Q

• Excessive sensitivity of a nerve to stimulation

A

Hyperesthesia

26
Q

• Decreased sensitivity of a nerve to stimulation

A

Hypoesthesia

27
Q

• No sensation when stimulated

A

Anesthesia

28
Q
  • 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
A

Injury to regional nerve

29
Q
  • 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
A

Injury to TMJ

30
Q

• 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

A

infection

31
Q
  • 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
A

DEHISCENCE

32
Q
  • 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%
A

• Localized osteitis

Dry socket

33
Q
  • 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
A

• Localized osteitis

Dry socket

34
Q

_____ is a cyst-like lesion present in the max sinus with serum inflammatory exudate

  • No biopsy needed
  • No epithelial lining
A

PSEUDOCYST OF MAXILLARY SINUS

ANTRAL PSEUDOCYST

35
Q

 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

A

SUBMANDIBULAR SALIVARY

GLAND DEFECT

Oral Surgery 1 (11 decks)

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