Surgical Management Of Impacted Teeth Pt2

Question 1

List the types of intra-operative complications of surgical dentistry

Answer 1

• intra-operative hemorrhage
• injury to adjacent tissues
• tooth fragment/foreign body left in-situ
• displacement of tooth fragment/foreign body
• hardware failure
• aspiration/ingestion of tooth fragment
• surgical emphysema (air enters subcutaneous tissue)

Question 2

How to classify intra-operative hemorrhage

Answer 2

Primary:
- at time of surgery
- Due to direct injury to vessels
- can be arterial, venous or capillary

Reactionary:
- within 24-48 hours of surgery
- due to dislodgement of clot, cessation of vasospasm/vasoconstriction

Secondary:
- usually after 7 days
- mainly due to infection and necrosis of blood vessel
- rare in surgery

Question 3

What are some local factors causing intra-operative hemorrhage

Answer 3

Soft tissue (arterial, venous, capillary)
Bone (nutrient canals, central vessels)
Vascular malformations

Question 4

Types of injury to adjacent tissues

Answer 4

• Soft tissue (flap, cheek, lip, palate, tongue, nerve)
• hard tissue (alveolar bone - buccal plate, maxillary tuberosity, mandible, TMJ, teeth)
• Oro-antral perforation

Question 5

Where can the maxillary third molars and mandibular third molars be displaced to?

Answer 5

Maxillary sinus, infratemporal fossa

Sublingual, submandibular and pterygomandibular spaces

Question 6

What are the post-operative complications

Answer 6

• post-operative hemorrhage
• alveolar osteitis/dry socket
• wound healing complications (wound dehiscence, osteonecrosis of jaw, osteoradionecrosis, wound infection)
• paresthesia

Question 7

How to prevent post-op hemorrhage?

Answer 7

1) Pre-op: identify risks
- family history
- medical history (coagulopathies, liver disease, cancer, chemotherapy)
- medication (anti-platelet: aspirin, clopidogrel, anti-coagulant: warfarin, apixaban
- may need to correct coagulopathy

2) intra-op precautions
- minimal trauma
- clean incision
- removal of granulation tissue if any
- if bleeding present (direct pressure for homeostasis, placement of hemostatic agents, suturing, electrocautery - silver nitrate)

3) post-op precautions
- monitor for 30 mins before discharging patients
- post op instructions
- tranexamic acid (inhibits plasminogen into plasmin) gargle/soaked gauze (bite down)

Question 8

How to manage uncontrolled bleeding?

Answer 8

• suction entire clot -> restart wound healing
• examine to determine source of bleeding (soft tissue vs bone)
• apply pressure homeostasis
• LA
• Adrenaline soaked gauze
• placement of hemostatic agent
• suturing
• electrocautery

Question 9

Describe the signs and symptoms of alveolar osteitis

Answer 9

5-20%

Symptoms:
- increasingly severe pain 3-7 days post extraction
- deep seated, severe aching or throbbing
- radiates to ear and homolateral side of head
- may last up to 1 or 2 weeks

Signs:
- bad smell
- exposed bone
- highly sensitive to gentle probing

Question 10

Describe the pathogenesis of alveolar osteitis

Answer 10

1) Birn’s fibrinolyic theory
- presence of high concentration of plasmin and increased fibrinolytic activity in dry socket
- during trauma from extraction, release of plasminogen tissue activators
- result in plasmin-induced lysis of blood clot
- dislodged blood clot
- exposed bone -> inflammation of alveolar bone
- pain of exposed socket to mechanical stimulation lingers for several days until bone becomes completely covered by healing epithelium

2) bacterial theory (unlikely main cause)
- fibrinolytic enzymes produced by bacteria such as treponema denticola
- dislodged blood clot
- expose bone covered by bacterial biofilm and prevent healing over exposed bone

Question 11

Name the risk factors for alveolar osteitis

Answer 11

1) site: mandible > maxilla, posterior > anterior
2) infection
3) smoking
4) difficult extraction
5) older age
6) female
7) oral contraceptives

Question 12

Describe the treatment of alveolar osteitis

Answer 12

• Self-limiting
• pain reduction
• placement of medicaments (alveogyl - hemostatic surgical dressing)

Question 13

Which types of root abnormalities are the hardest for extraction?

Answer 13

A: Darkening of root
B: Deflection of root
F: Diversion of canal

Question 14

What are some signs that can signal infection instead of secondary symptoms?

Answer 14

Systemic: fever, lymphadenopathy
Suppuration, abscess
Swelling extended to abnormal places
Dysphagia, dysphonia, dyspnea

Question 15

8 steps of managing odontogenic infection

Answer 15

1) determine severity
2) evaluate host defences
3) decide on setting
4) treat surgically
5) support medically
6) choose and prescribe AB therapy
7) administer AB properly
8) evaluate patient frequently