the adjacent structures so that wound will heal uneventfully with minimal post-operative prosthetic complications. 4 PREVENTION OF COMPLICATIONS IN GENERAL PREVENTION PREOPERATIVE INTRAOPERATIVE POSTOPERATIVE INTRA-OPERATIVE COMPLICATIONS 1. Inability to move the tooth CAUSE: May be due to anatomical peculiarity of the tooth Sclerosis of bone due to chronic long standing infection in that region. Ankylosis of root [rare] PREVENTION : A thorough examination of the radiograph of the tooth MANAGEMENT : Advice radiograph , examine carefully. Consider trans alveolar extraction in case of dilacerated roots. 2. FRACTURE OF TOOTH [CROWN / ROOT ] CAUSES: A. Wrong forceps used for extraction. B. Inappropriate force applied for extraction. D. Grossly carious tooth. PREVENTION : Select the correct forceps for the tooth, get the grip rite.
Forceps should be wedged into the PDL space as apically as possible to create a centre of rotation apically. MANAGEMENT : If the root is fractured at the apical third, use an apexoelevator to slowly tease the root out of the socket If only a small piece of tooth is remaining, it may even be left behind to resorb slowly.
If the tooth was infected or involved in any pathology, it may be absolutely necessary to remove it. 3.FRACTURE OF ALVELOAR PROCESS CAUSE: This can happen if excessive force is applied while extracting the tooth. PREVENTION:
While luxating a tooth, use only minimal force to move the tooth in the socket,the tooth should not be forced out with excessive force.
MANAGEMENT: sometimes only small pieces of tooth of bone may come out while extracting the tooth. This may be removed carefully along with the root. In some cases a large piece of the entire buccal or lingual cotical plates may rupture .In such cases it may be necessary to replace the bone in its position with its periosteal attachment intact 4.FRACTURE OF MAXILLARY TUBEROSITY CAUSE: while extracting an upper third molar the tuberosity may fracture with it. This may be due to excessive distal force that is applied while extracting PREVENTION: An upper third molar is best removed with an elevator, Force applied in the correct direction will prevent fracture of the tuberosity with tooth Management : Once the tuberosity has fractured,it is first important to check whether it has created oro-antral communication,if created should be managed accordingly 5.FRACTURE OF JAW: Improper use of instruments while extracting teeth can lead to fracture of the jaw Ex: if crossbar elevator is used with excessive uncontrolled force in the mandibular third molar region it can lead to fracture of angle of mandible PREVENTION: Great care should be taken along with the controlled force while extracting the teeth. MANAGEMENT: If the fractures are noticed the fragments are reduced,wired and intermaxillary fixation is made. Defentitive surgery may be done later 6.MUCOSAL LACERATIONS: CAUSE: Slipping of the forces elevators,tearing of flap due to inadequate size of flap.Mucosal tear due to inadequate reflection of the gingiva from tooth, this may lead to mucosa also being removed along with the tooth PREVENTION: use controlled force while applying elevators, use the other hand to retract tissues in such away that is away from fieled of operation MANAGEMENT: if the mucosa gets lacerated it can be approximated and suture if it is not under tension 7.PUNCTURE WOUNDS ON MUCOSA SURROUNDING TOOTH CAUSE: Puncture wounds again take place due to slipping of the instruments PREVENTION: Place the forceps carefully on the tooth, check before applying force to exact the tooth 8.ABRASIONS OR BURNS ON SOFT TISSUES: CAUSE: Use of rotary instruments to get heated and burn tissues that they are in constant contact with.
PREVENTION: Use of cheek retractors and other retractors to keep soft tissue away from the field of surgey
MANAGEMENT: Advice the patient to maintain good oral hygeine and do warm saline rinses.prescribe analgesics SOFT TISSUE INJURIES TEARING OF MUCOSAL FLAPS CAUSES Inadequately sized flap Improper reflection and retraction of flap PREVENTION Create adequate sized flap with releasing incisions when reqd Use small amount of retraction force. MANAGEMENT Careful suturing Excising jagged edges MANAGEMENT: if the restoration or the crown of adjacent tooth is dislodged patient must be informed, a temporary restoration is placed on the adjacent tooth and patient recalled after a week for permanent treatment 10.Luxation of the adjacent tooth: CAUSE:a single conical rooted adjacent tooth is in the danger of inadvertent luxation with the tooth being extracted if uncontrolled force is applied with an elevator to the adjacent tooth
PREVENTION: on the preoperative radiograph check the root of the adjacent tooth, if it is a conical single slender root MANAGEMENT: if the adjacent tooth has been luxated or avulsed it should be replaced in the socket and splinted for a period of 3-6 for healing 16 11.OROANTRAL COMMUNICATION CAUSE: Floor of maxillary Antrum extending into the alveolus is one of the main reasons for the formation of an oroantral fistula after extraction. If a maxillary premolar or molar root is fractured and excessive bone is removed in attempting to remove the root,oroantral communication is created,same applies to the maxillary posterior teeth. In case of largely divergent roots extending into the floor of antrum, there are chances of oroantral commumnication.tuberosity fracture and blind instrumentation in this region can also lead to oroantral communication. PREVENTION: Carefully check a pre operative radiograph for the proximity of maxillary antrum to the roots of the upper teeth MANAGEMENT: Firstly it is important to diagnose an oroantral communication. Various tests are done to confirm it. They include A. NOSE BLOWING TEST: The anterior nares are compressed and the patient is asked to blow from the nose. An increase in intra nasal pressure is seen as a whistling sound from the extraction socket. B. Escape of air bubbles from the orifice is indicative. C. A cotton wisp is held at the suspected opening, and the patient is asked to blow from the nose. The deflection of the cotton wisp is indicative. D. MOUTH MIRROR FOGGING TEST: Fogging of mouth mirror placed at the opening is indicative. E. Unilateral epistaxsis may be a suggestative of oro antral communication. Management: a. pressure pack b. visualize:stop of the bleeding c. Local anasthetic packs: ADRENALINE d. Sutures e. cautery: the area is dried as much as possible and a hot ball burnisher may be used to cauterize f. Ligation g. gel foam:which acts by disrupting platlets and establishing frame work with fibrin strands to create a clot h. Oxidised cellulose: release cellulosic acid, which leads to formation of artificial clot i. Bone wax: placing a small piece of bone wax firmly on the spot of bleeding causing the blocking the bleeding vessel
19 MANAGEMENT Small communication i.e lesser than 2 mm Mid sized communication i.e 2-6 mm Large communications ie above 6mm : CAUSE: During extraction if the tooth just seems to suddenly slip away and disappear, this complication should be suspected. They may into slip into sub mandibular space below the mylohyoid muscle. PREVENTION: Always support the alvelous on both sides and apply controlled force during extractions. MANAGEMENT: If the tooth is displaced into the lingual spaces, it must be removed it otherwise acts as foreign body and likely causes infection later.If the root fragment is small and uninfective, it may be left behind. Displacement of tooth into sub-mandibular space, infratemporal space and oropharynx 13.NERVE INJURY CAUSE: various branches of trigeminal nerves may be injuried during extraction. If the nerve is present in a bony canal such as the inferior alveolar nerve, the nerve tends to regenerate more easily and sensation may return over a period of time A. The lingual nerve is usually injured during procedures B.MENTAL NERVE : procedures done at the lower premolar region may injure the mental nerve C.INFERIOR ALVEOLAR NERVE:this nerve may be injured in cases where the lower molar root lies closer or perforates the canal .
PREVENTION: Radiographs help to locate the position of IAN in relation to the teeth that are being extracted. Incisions in the region of other nerves should be made with care to prevent injury MANAGEMENT: if IAN is injured, since the nerve lies with in a bony canal it usually tends to regenerate. Patient should be informed to check for improvement in the sensation over the region supplied by the nerve.
C.INFERIOR ALVEOLAR NERVE:this nerve may be injured in cases where the lower molar root lies closer or perforates the canal .
PREVENTION: Radiographs help to locate the position of IAN in relation to the teeth that are being extracted. Incisions in the region of other nerves should be made with care to prevent injury MANAGEMENT: if IAN is injured, since the nerve lies with in a bony canal it usually tends to regenerate. Patient should be informed to check for improvement in the sensation over the region supplied by the nerve.
14.HEMORRAGE: CAUSE: some amount of bleeding is normal after an extraction this usually stops by application of pressure in a couple of minutes. Excessive bleeding is seen in hypertensives and in cases where a vessels has be severed
PREVENTION: if a patient is hypertensive selective procedures should be done only if his blood pressure is controlled patients on anticoagulants should be investigated properly on a physicians opinion taken prior to extraction 15.DISLOCATION OF A JAW IT is an another rare complication. Types Primary bleeding Reactionary bleeding Secondary bleeding Primary bleeding when complete hemostasis is not achieved at the completion of the surgery. Reactionary bleeding occurs within the 48hrs of the surgery, this is due to local rise in B.P. Causing opening up of small divided vessels which were not bleeding at the end of surgery. Secondary bleeding-this occurs 7 days post-operatively, usually due to infection destroying the clot. 28 PREVENTION AND CONTROL BY LOCAL HAEMOSTATIC METHODS Collagen plug
Microfibrillar collagen
Regenerated oxidized cellulose
Collagen tape
Absorbable gelatin sponge
It is usually present after any surgical procedure.
It is important to keep the patient comfortable by prescribing anti-inflammatory analgesics. A normal extraction procedure is usually not associated with swelling. But trans-alveolar procedure involving bone cutting will cause some amount of swelling. Swelling could be due to 3 reasons : edema hematoma infection
Management: antibiotics and placing ice over the swelling. Also known as alveolar osteitis. It starts with moderate to severe pain on the 3 rd to 4 th
post-operative day. There is a loss of blood clot in the socket & socket appears empty. Severe inflammation of the soft tissue around the wound. Throbbing pain which may radiate to ear, bad odour & accompanying bad taste in the mouth. Etiology Due to high levels of fibrinolytic activity around the extraction socket resulting in lysis of the blood clot & thus exposure of the bone. bone is very painful on probing. Management relieving pain & socket is gently irrigated * an abtundant is placed.
Infection from surgical site may spread to adjacent facial spaces resulting in space infection. There is usually associated trismus with the involvement of the masticatory spaces due to spasm of the muscles involved. 36 Patient should be adviced to 1.Firmly bite on gauze piece placed on the extraction socket for a minimum of half an hour after the extraction
2.Not to rinse his mouth vigourously for the next 24 hrs.
3. To avoid any hot food for the next 24hrs . 4. Advised soft diet on the day of extraction
5. Not to suck from the straw on the day of extraction
6. Warm saline rinses and gentle brushing should be adviced from the next day 7. Anti inflammatory analgesics should be prescribed.
8. Inspite of all these precautions if there is profuse bleeding from the socket the patient should be adviced to return to the dentist. Contemporary oral and maxillofacial surgery- Peterson, Ellis, Hupp Oral and maxillofacial surgery- volume 2, Daniel Chitra chakravarthy