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OS and Pain Management 2 > Prevention & management of extraction complications > Flashcards

Prevention & management of extraction complications Flashcards

1
Q

Thorough preoperative assessment
(2)

A
  • MEDICAL HISTORY REVIEW!!
  • Adequate and up to date images
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2
Q
  • Comprehensive treatment plan
    (3)
A
  • Detailed surgical plan
  • Needed instrumentation
  • Pain/anxiety management
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3
Q
  • Careful execution of surgical procedure
    (3)
A
  • Clear visualization and access to surgical field
  • Use of controlled force → finesse
  • Asepsis, atraumatic handling of tissue, hemostasis, debridement (as needed)
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4
Q
  • Complications can STILL occur; however, the complications begin to become
A

more predictable and will become routinely
managed

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5
Q

PREVENTION OF COMPLICATIONS

A
  • Perform procedures that are within the limits of their capabilities
  • Be cautious of unwarranted optimism
  • Clouds judgment leading to increased post-op complications
  • Referral is ALWAYS an options
  • Is a moral obligation to practitioners → primum non nocere
  • Will provide peace of mind
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6
Q

TEAR OF MUCOSAL FLAP
* Causes:
(2)

A
  • Retraction tension on envelope flap that is too small for adequate visualization/access
  • Lack of care when reflecting/elevating flap
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7
Q

TEAR OF MUCOSAL FLAP
* Prevention:
(2)

A
  • Adequate sized flap with gentle retraction
  • Pay attention to flap retraction (assistant)
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8
Q

PUNCTURE WOUND
* Causes:
(1)
* Prevention:
(2)
* Treatment:
(2)

A
  • Slippage of instrument (elevator, elevator) due to
    unprotected/uncontrolled force
  • Controlled and protected forces
  • Finger extension during instrument usage
  • Irrigate wound and establish hemostasis w/ direct pressure
  • Do not suture, allow to heal by secondary intention
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9
Q

STRETCH OR ABRASION
* Causes:
(3)
* Prevention:
(2)
* Treatment:
(2)

A
  • 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
  • Proper retraction
  • Be aware of location of shank
  • Mucosal injury does not require much, keep area clean with regular oral
    rinsing
  • Skin injury requires ABX ointment for 5-10 days
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10
Q

ROOT FRACTURE
* Cause:
(2)
* Prevention:
(3)

A
  • Most often reason is due to abnormality of root structure
  • Long, thin, dilacerated, embedded in dense cortical bone
  • Proper planning
  • Back up plan for your back up plan
  • Open extraction technique → surgical obliteration →
    leave in place
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11
Q

ROOT DISPLACEMENT
* Most common ROOT displaced is the
* Most common TOOTH displaced is the

A

maxillary molar palatal root, into sinus
maxillary 3rd molar

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12
Q

ROOT DISPLACEMENT
* Causes:
(4)

A
  • 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
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13
Q

ROOT DISPLACEMENT
* Treatment: Depends on
(3)

A
  • Size of root tip
  • Pathology associated with root tip
  • Sinus pathology
  • Healthy root tip displaced into a healthy
    sinus will be easier to manage
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14
Q

ROOT TIP <2-3 MM, NO PATHOLOGY

A
  • 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
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15
Q

ROOT TIP <2-3 MM, WITH PATHOLOGY

A
  • 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)
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16
Q

TOOTH DISPLACEMENT
* Maxillary 3rd molar displacement into:
(2)

A
  • Maxillary sinus
  • Infratemporal fossa
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17
Q

Max sinus:
* Causes:
* Treatment:

A

Improper elevator forceps technique
Culdwell-Luc for direct visualization and removal

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18
Q

INFRATEMPORAL SPACE DISPLACEMENT
* Causes:
(3)
* Location:
(3)

A
  • Too much posterior force with elevator
  • Not enough buccal force
  • Attempted removal of high impaction, poorly developed, conical 3rd molar
  • Posterior to tuberosity
  • Lateral to lateral pterygoid plate
  • Inferior to lateral pterygoid muscle
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19
Q

INFRATEMPORAL SPACE DISPLACEMENT
* Treatment:

A
  • 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
20
Q

TOOTH DISPLACEMENT
* Mandibular molar

A
  • Through lingual plate to:
  • Sublingual space – above mylohyoid muscle
  • Submandibular space – below the mylohyoid muscle
  • Through superior cortex of IAN
  • Displaced into mandibular canal
21
Q

SUBLINGUAL/SUBMANDIBULAR SPACE
DISPLACEMENT
* Treatment:

A
  • 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)
22
Q

TOOTH LOST IN OROPHARYNX

A
  • 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)
23
Q

TOOTH LOST IN OROPHARYNX
* Treatment:

A
  • 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
24
Q

FRACTURE OR DISLODGEMENT OF ADJACENT
RESTORATION
* Causes:
(1)
* Prevention:
(4)
* Treatment:
(4)

A
  • Luxation forces transmitted to large restorations directly next to tooth planned
    for extraction
  • 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
  • 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
25
Q

LUXATION OF ADJACENT TOOTH
* Causes:
(2)
* Prevention:
(2)
* Treatment:
(5)

A
  • Improper elevation technique
  • “Crowded” or “locked out” tooth
  • Proper elevator technique
  • Use narrow beak forceps
  • 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
26
Q

EXTRACTION OF WRONG TOOTH
* Most common error with orthodontic extractions
* Causes:
(2)
* Prevention:
(3)
* Treatment:
(5)

A
  • Lack of attention and concentration
  • Incorrect diagnosis
  • Check with referring dentist preoperatively if any question exists
  • Mark tooth to be removed on radiograph
  • Have assistant double check immediately before using instrument
  • 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
27
Q

EXTRACTION OF WRONG TOOTH
(2)

A
  • Any tooth completely luxated from its blood supply may become non vital and require
    root canal therapy
  • Tell the patient and referring dentist
28
Q

FRACTURE OF THE ALVEOLAR PROCESS
* Causes:
(3)
* Prevention:
(4)
* Treatment:
(4)

A
  • Excessive buccal force with forceps
  • Thin rigid buccal bone
  • Dense bone in elderly with loss of PDL space on radiograph
  • 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
  • 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
29
Q

FRACTURE OF MAXILLARY TUBEROSITY
* Causes:
(2)
* Prevention:
(2)
* Treatment:
(4)

A
  • Excessive force in removal of maxillary third molar or isolated maxillary molar
  • Elderly with dense bone and lack of PDL space on radiograph
  • 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
  • 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
30
Q
  • Most common injured nerves:
    (3)
A
  • Mental nerve
  • Lingual nerve
  • Inferior Alveolar nerve
31
Q
  • Damage to nasopalatine and long buccal nerve is inconsequential
    (2)
A
  • Area of sensory innervation is small
  • Reinnervation of affected area is rapid
32
Q
  • If an injury from —, good chance of recovery
  • If —poor chance of recovery
  • — nerve does not regenerate well, higher chance of neuroma formation
A

stretch (neuropraxia)
severed or badly crushed (neurotmesis, axonotmesis),
Lingual

33
Q
  • Paresthesia
A
  • Spontaneous and subjective altered sensation that IS NOT PAINFUL/UNCOMFORTABLE
34
Q
  • Dysesthesia
A
  • Spontaneous and subjective altered sensation that IS PAINFUL/UNCOMFORTABLE
35
Q
  • Hyperesthesia
A
  • Excessive sensitivity of a nerve to stimulation
36
Q
  • Hypoesthesia
A
  • Decreased sensitivity of a nerve to stimulation
37
Q
  • Anesthesia
A
  • No sensation when stimulated
38
Q

INJURY TO REGIONAL NERVES
* Causes:
(5)

A
  • 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)
39
Q

INJURY TO REGIONAL NERVES
* Treatment:

A
  • 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
40
Q

INJURY TO THE TMJ
* Causes:
(2)
* Treatment:
(2)

A
  • Application of significant force on mandibular teeth extraction without adequate support
  • Lack of use with bite block
  • Acute TMJ dislocation
  • TMJ strain
41
Q
  • Acute TMJ dislocation
    (1)
  • TMJ strain
    (3)
A
  • Reduce dislocated joint/s, abort procedure that day
  • Warm moist heat to opening muscles
  • NSAIDs for 3-7 days (alternative to use APAP)
  • Rest jaw with soft, non chew diet
42
Q

INFECTION
* Most common cause of delayed healing is infection
* Not common with routine extraction
* More common with reflection of flap and bone removal
* Prevention:
(4)

A
  • 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
43
Q

DEHISCENCE

A
  • Wound separated at margins after flap reapproximation
44
Q

DEHISCENCE
* Causes:
(3)
* Treatment:
(2)

A
  • Flap sutured under tension
  • Remember the goal of suturing is approximation not strangulation
  • Bony projection under flap approximation
  • 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
45
Q

DRY SOCKET

A
  • Localized osteitis
  • 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%
46
Q

DRY SOCKET
* Cause:
(5)
* Prevention: Speculative
(4)

A
  • 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
  • Minimize trauma & inflammation
  • Peridex mouthrinses pre and post-op
  • Placement of ABX medicaments into socket
  • Thorough irrigation at termination
47
Q

DRY SOCKET
* Treatment:

A
  • 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

OS and Pain Management 2 (10 decks)

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