Complications of tooth extraction

COMPLICATION AND MANAGEMENT OF TOOTH EXTRACTION1 PRSENTING BY: RAHUL TIWARI (+919074166916) [DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY]

Introduction

Any adverse , unplanned events that tend to increase the morbidity above what would be expected from a particular operative procedure under normal circumstances.

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Sources of complications Surgical complications may arise from either one or a combination of the following factors.

THE PATIENT- Medically compromised pt. leading to an persistent haemorrhage or delayed healing.

THE CLINICIAN -level of training , skills and experience. -attitudes towards total patient care.

THE SURGICAL PROCEDURE risks depend on :- -complexity of the procedure. -local anatomy of the surgical site -proximity of important vital structures.

Possible complicationsFailure to -secure anaesthesia -remove the tooth with either forceps or elevator

Fracture of-crown of the tooth /root -alveolar bone -maxillary tuberosity -adjacent or opposing tooth -mandible4

Dislocation of -adjacent tooth -TMJ Displacement of the root -into the soft tissues - maxillary antrum

Excessive haemorrhage - During tooth removal - on completion of the extraction - postoperatively

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Damage to - gums/lips/tongue/floor of mouth - inferior dental nerve & branches - lingual nerve

Postoperative pain - damage to hard & soft tissues - dry socket - acute osteomyelitis of mandible - traumatic arthritis of TMJ

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Postoperative swelling due to:- Odema Haematoma formation Infection

Trismus

Oro-antral communication

Syncope

Respiratory arrest

Cardiac arrest

Anaesthetic emergencies.

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1-Failure to secure anaesthesia Faulty techniqueInsufficient dosage of anaesthetic agent8

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2-Failure to -remove the tooth with either forceps or elevator

Tooth fails to yield to the application of reasonable force applied with either forceps or elevator.

Tooth dissection 10

3-Fracture of the crown of a tooth Weakened tooth- caries or large restorationImproper application of the forcepsExcessive force

MANEGMENT: proper application of forceps or elevator will deliver the tooth or Transalveolar method 11

FRACTURED CROWN

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4-Root fracture 13

Root pattern

Faulty technique

MANEGMENT Decide whether to leave or not?

Radiographic examination & transalveolar ext.

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5-Fracture of the alveolar bone Accidental inclusion of alveolar bone within forceps blades.Pathological changes in the bone Shape of the alveolusExtraction of canine is frequently complicated by fracture of the labial plate.Alveolar fragments which has lost one half of the periosteal attachment should be removed. if it well attached to periosteum, should be sutured back15

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6-Fracture of maxillary tuberosity Predisposing cause Pathological gemination between the erupted maxillary second molar & unerupted max. third molar.Overerupted isolated max molar17

7-Fracture of an adjacent or opposing toothPrecautions : Careful pre-op examination (carious, heavily restored, loose, line of withdrawal)No force should be applied to any adjacent toothOther teeth should not be used as fulcrum for an elevator.Any loose, heavily restored tooth should be noted & brought to the notice of anesthetist.18

8-Fracture of the mandibleExcessive or incorrectly applied force Pathological changes of mandible osteoporosisAtrophyOsteomyelitis Previous therapeutic irradiationUnerupted teeth, cysts, hyperparathyroidism or tumours may also predispose to fracture

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FRACTURED MANDIBLE DUE TO EXCESSIVE FORCE

9-Dislocation of adjacent tooth & TMJCauses same as those giving rise to fracture of adjacent toothElevator should not be placed on the mesial aspect of first permanent molar.During elevation a finger should be placed upon the adjacent tooth to support it .Dislocation of TMJApplication of excessive forceFailure to support the mandible while extracting a difficult toothMore likely to occur under general anesthesia when mastication muscles are relaxed 21

22 DISLOCATION OF MANDIBLE

Management Reduction is done with the thumb wrapped with gauze or bandage to avoid injury by teeth and placed on the occlusal surfaces of mandibular posterior teeth and finger under the lower border of the mandible.Mandible is then pushed downward backward rotating the chin upwards .with this manpower the condyles are moved downwards and backwards over the articular eminences of temporal bone.

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Patient should be warned not to open his mouth too widely or to yawn for postoperatively .patient is instructed to support the jaw during yawning.extra oral bandage support for the joint is applied and worn until tenderness in the affected joint subsides.Failure to reduce dislocation reduction can be attempted under 5-10mg of IV/IM valiumFailure to reduce the dislocation or if there is resistance encountered LA solution is injected high in the buccal sulcus bilaterally adjacent to max third molar region similar to the technique of posterior superior alveolar nerve block. This helps in paralyzing lateral pterygoid muscles and over comes Muscular spasm

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10-Displacement of a root into the soft tissuesIneffectual attempts to grip the root when visual access is inadequate.Maxillary premolar or molar- palatal root.Predisposing factor large antrum 26

27 DISPLACED PALATAL ROOT OF MAXILLARY 1ST MOLAR

Simple rules to avoid displacement:-Never apply forceps to a maxillary post. teeth unless sufficient of its length is exposed, both palatally & bucally .Leave the apical one third of the palatal root of a maxillary molar.Never attempt to remove a # maxillary root by passing instruments up the socket.Any previous history of antral involvement should not be disregarded.

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11-Aspiration of tooth/rootUnder GA more commonAnaesthetic should be stopped immediately & patients head brought forwards.After cough reflex has returned the mouth is examined & pack carefully removed & inspectedRadiographs socket & chest29

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12-Damage to adjacent tissuesDamage to the gum can be avoided by careful selection of forceps & good technique.The lower lip may be crushed between the handles of the forceps & anterior teeth.Skilled use of operators left hand.Instruments should be allowed to cool before use after being sterilized.31

Inferior alveolar nerve

close proximity of mandibular third molar roots.Careless surgical technique, roots are curved around the canal or grooved damage can be prevented or minimized only by pre-op radiographic diagnosis & careful dissection.

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Lingual nerve :Lingual nerve is in close proximity to roots of mandibular third molar .Risk of damage while taking incision and during elevation of lingual periosteum.Risk of direct trauma form bur or chisels used for removal of bone or sectioning of the tooth Mental nerve : Injury is caused due to surgery in the area of mental nerve.Over extension of incision in the depth of mucobuccal fold in premolar region

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Prevention: The nerve injury can be prevented by Careful surgical technique Proper placement of incision,Careful bone removalRetraction and less manipulation Management : Patient should be warned preoperatively about the possible consequences and the probable outcome onTongue & floor of mouth damage can be prevented by effective use of left hand.

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13-Post extraction Bleeding35Local causes:TraumaMechanical dislodgement of the clotDamage to blood vessel or soft tissueFracture of alveolar boneDamage to nutrient blood vessel

Infection Presence of granulation tissueChronic inflammation of gingivaAcute infection of bone and soft tissue

Local abnormality Unusually large bone marrow spacePresence of Hemangioma

Systemic causesDisorder related to systemic diseaseleukemia,Aplastic anaemiasPlatelet disorders: ThrombocytopeniaCoagulation defects : HemophiliaStructural malformation : hereditary hemorrhagic telengectesiadrug therapy: aspirin, Anti coagulant therapy

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Management Physical methodsPressure packsUse of LA solution with vasoconstrictorsSocket suturingHemostatic forcepsSplintsThermal measures- cautery , hot saline packs

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Firm gauze roll should be placed upon the socket & patient asked to bite upon it .Horizontal mattress suture

Hemostatics TOPICAL:VASOCONSTRICTORSAdrenalineABSORBABLE AGENTSOxidized celluloseOxidized regenerated celluloseGelatin spongeFibrin foamCalcium alginate THROMBOPLASTIC AGENTSThrombin Russel viper venom

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Tannic acidFerric chlorideZinc chlorideAlumHydrogen peroxide

SOCKET PLUGS:Bone waxWhiteheads varnish on ribbon gauzeCHEMICAL AGENTS:

41Gel foam

Botroclot (hemocoagulase solution)

Surgicel

Systemic agentsENDOGENOUS:

Whole bloodFresh frozen plasmaCryoprecipitate

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Exogenous agentsETHAMSYLATE - 2ml ampoules i.m/iv 1-2 hrs before operation OR 2-3 ampoules following surgery followed by 1amp/2tabs every 4-6 hrs.

VITAMIN K- Normally 10mg capsules, 10-20 mg oral/ i.m /i.v

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14-Postoperative painDue to traumatized hard tissues - Bruising of bone during instrumentation or overheating of bur during bone removal.Soft tissues :- ragged flap heals slowly (incision not proper)Soft tissue become entangled with bur Proper Retraction 44

Dry socket / alveolar osteitis/ alveolitis sicca dolorosa Acutely painful tooth socket containing bare bone and broken down blood clot.Associated with fetid odorIncidence -3%, 3rd molars-22%Mandibular teeth common than maxillary.

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Predisposing factors :-

infection of socket : release of plasminogen activators Trauma - use of excessive force Vasoconstrictors (contributory factor)Mandibular extractions (dense & less vascular, contaminated with food debris)Bacteriological origin Treponema denticolum .Pt. on oral contraceptives, smokers

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Clinical featuresPt. usually presents within 2-4 days : granulation tissue appears in 2-4 days, it is absent in cases of dry socket.Dull, boring pain to severe throbbing pain, may radiateGingival margin of socket swollen & redSocket may be filled with food debris or a brown friable clot on removal of which exposes the bare bone which is severely tender to touchRegional lymph nodes may be tender 48

49DRY SOCKET CONTAINING DEGENERATING BLOOD CLOT

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Prevention :-Scaling & any gingival inflammation (1 week prior to extraction).Minimum amount of local anestheticAtraumatic tooth removal Prophylactic use of antibiotics especially metronidazole nerve blocks preferred to LA infiltrations

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Management Aim relief of pain & speeding of resolutionSocket irrigation with warm saline & all degenerating blood clot removed.Sharp bony spurs - excised with rongeur forceps or removed with a wheel stoneLoose dressing zinc oxide & oil of cloves on cotton wool is tucked into the socket.

Analgesic tab & hot saline mouth bathsRecall after 3 days

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IRRIGATE THE SOCKETPLACE A ANTISEPTIC DRESSINGDRESSING ; First 24 hours then every alternate day then every 3-4 days / or more than 2 weeks regular check up

15-ACUTE OSTEOMYELITIS OF THE MANDIBLE: Mandible tender Impairement of labial sensation pyrexia , pain is severe Traumatic extraction of lower molar under LA in P/o acute gingival inflammation predisposes to acute OML

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56May complicate difficult extractions if the lower jaw is not supported. The risk can be minimize if supporting the mandible during surgery. Difficult extractions Should be done surgically.Mouth prop used on contralateral side16-TRAUMATIC ARTHRITIS OF THE TMJ

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17-Postoperative swelling EDEMA : If the soft tissues are not handled carefully during an extraction traumatic edema may be formed.The use of blunt instrument, the excessive retraction of badly designed flap, or a bur becoming entangled in the soft tissues predispose to this condition. IF sutures are tied too tightly post operative swelling due to edema or haematoma formation may cause sloughing of the soft tissues and breakdown of the suture line. Usually both conditions regress if the patient uses hot saline mouth baths frequently for 2-3 days.

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b. INFECTION :- pain and swellingMild - hot saline mouth baths Severe antibiotic & analgesics 59

18-Trismus Inability to open mouth due to muscle spasm.Caused by post op. edema, hematoma formation or inflammation of soft tissue.Intra oral heat by means of short wave diathermy or use of hot saline mouth baths.Antibiotics 60

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TRISMUS

19-Oroantral communications An oroantral \ communication is created by the extraction of maxillary tooth where The roots extend well beyond the maxillary sinus floor The extraction is difficult and traumatic There is a lone standing molar The tooth is ankylosed The periapical pathology e.g cyst or granuloma extending beyond the sinus floor

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Diagnosis:Bubbling through the extraction site occurs when the nose is blocked under pressure. The patient cannot suck through a straw.Management:Replace the tooth and splint into position and plan to extract surgically at a later date or Cover defect with anti septic soaked ribbon/ gauze and remove in 2-3 weeks to allow healing by sec. intention orReduce bony socket edge and suture margins together (interrupted horizontal mattress)Immediate closure with a buccal advancement flap provided the sinus is clear of infection.

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The treatment of a freshly created oroantral communication

66Adjunctive measures:Instruct patient not to blow nose from 7-10 daysAnalgesics AntibioticsNasal decongestants

20-Syncope / faints

Pt. Collapse Feeling dizzy, weak, nauseated Skin is pale, cold , sweating Head end lowered by lowering the back of the dental chair67

MANEGMENT:Placement of unconscious patient in the supine position with feet slighlty elevated and airway patency maintained through use of the head tilt chin lift method.68

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AROMATIC SPIRIT AMMONIA:

Aromaticammonia spirit is used to prevent or treat syncope

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21-Respiratory arrest

Skelton Muscles become flaccid and pupils dilate

MANAGEMENT:Lay the pt flat on the floorRemove any foreign bodies by pulling the mandible upwards and forwards, to extend neck fullyCompress pt. nostril with thumb and finger, mouth-to-mouth resuscitation be performed to raise the chest every 3-4 sec.Check carotid pulse.71

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22-Cardiac arrest

Unless reversed in 3mins,irreversible brain damage could occur due to cerebral anoxia.Pt has deathly pallor & grayness.Cold and sweaty skinPulse and apex beat cannot be feltHeart sounds cannot be heardCPR is carried out until hospital services are available.73

74Cardiopulmonary resuscitation(CPR):

23-Anaesthetic emergenciesDentist must be alert for any warning sign related to emergency related to anaesthesiaIn case of collapse STOP ANAESTHETIC IMMEDIATELYCPR ,respiratory relief by tracheostomy, laryngotomy must be performed.75

Conclusion

Complications should be diagnosed as soon as they occur & dealt promptly and effectively.76

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