COMPLICATIONS OF EXODONTIA

By- Ragini Adhikari (III BDS)

EXODONTIA

According to Geoffrey L. Howe –

Exodontia or Extraction is the painless removal of whole tooth or tooth root with minimal trauma to the investing tissues, so that the wound heals uneventfully and no post-operative prosthetic problem is created.

Complications occurring during the surgical procedure:-1. Soft tissue injury2. Extraction of wrong teeth3. Fracture of the teeth during extraction4. Fracture of tooth root during extraction5. Fracture of the tuberosity6. Displacement of the tooth into the maxillary sinus7. Creation of Oro-antral fistula8. Fracture of Mandible9. Breakage of Instrument10. Luxation of the adjacent tooth11. Injury to inferior alveolar nerve12. Injury to lingual nerve13. Swallowing of teeth14. Dislocation of condyle

Complications occurring after the surgical procedure :-

1. Presence of bony spicule2. Haemorrhage3. Dry socket4. Infection

SOFT TISSUE INJURYTypes and Causes

Abrasion – these injuries are caused by careless use of rotatory instruments (like burs while bone cutting.)

Thermal injuries – caused when instrument taken out from Autoclave or hot air oven are used immediately intra-orally.

Mucosal injuries – caused due to injudicious used of instruments, improper elevation of flap or the exercise of excessive force.

Prevention Take extreme care during the handling of the rotary or other hand

instruments. Use well cooled instruments to prevent thermal injuries. Properly retract the cheek and lips during dental procedures.

Management If the tear or abrasion is large, suturing should be done for closure. Scars produced due to thermal injuries can be managed by the application of

petroleum jelly or topical antiseptic/analgesic.

Clinical appearance

EXTRACTION OF THE WRONG TEETH

Management

Inform the patient Replace the tooth inside the socket as soon possible and splint. If immediate replacement is not possible, place the tooth in a proper medium

like saliva, milk or water. Follow up as for traumatic avulsion and re-implantation.

FRACTURE OF THE TEETH DURING EXTRACTION Causes

Application of wrong forceps Improper application of forceps Extensively carious tooth Endodontically treated tooth Curved or hypercementosed root Ankylosed root

Prevention

Proper radiograph assessment of the tooth to be extracted Proper forceps technique Using transalveolar removal technique if intra-alveolar extraction is not feasible

Management

When the fracture involves the crown of the tooth appropriate restoration should be placed.

Clinical appearance

FRACTURE OF TOOTH ROOT

Causes

Improper technique Application of improper instrument and force. Ankylosed or Hypercementosed teeth Excessively curved roots Endodontically treated root Uncooperative patient

Consequences of retained roots Retained roots may acts as a source if infection. They might be chronic source of irritation giving rise to Neuralgic Pain. Large retained tooth may interfere with the proper functioning of prosthesis.

Methods of retrieval of fractured root Using appropriate elevators, forceps with slender beaks and Reamers for removal of fractured root at various levels.

Clinical appearance

FRACTURE OF TUBEROSITY

Causes

In cases where the antrum extends into the tuberosity, the extraction of the third molar can result in fracture of tuberosity.

Exertion of excessive force and improper force application Fusion of the roots of second molar with the un-erupted third molar

(concrescence) Divergent and hypercemetosed roots of the third molar.

Prevention

Proper analysis of the radiograph of tooth and surrounding structures. Correct technique of extraction with careful force application Support to the alveolus during extraction.

Management

In case of small fractured segment, a mucoperiosteal flap is elevated and the tuberosity is removed with tooth, followed by wound closure.

In case of large fractured segment, it should be replaced and splinted Removal of tooth should be done after the healing of fractured site.

Clinical appearance

DISPLACEMENT OF TOOTH INTO MAXILLARY SINUS

Causes

The roots of the maxillary posterior teeth are always in a close proximity to the maxillary sinus such that the large antral cavities may dip in between the apices of the teeth.

With advancing age the degree of pneumatisation of the maxillary sinus increases and the antral walls become very thin. Thus eventually the roots being covered only by thin lamellae of bone which fracture easily and result in the displacement of the root tip during its removal.

Sometimes the tooth may slips into the maxillary antrum like the ‘popping of an orange seed’ once the extraction forceps are applied.

Prevention

Application of appropriate force and proper handling of forceps. Avoid injudicious instrumentation to remove a broken tip. Proper radiographs should be taken before the extraction to access the

proximity of the root tip to the sinus Support the alveolus adequately before the extraction.

Management

Confirm the presence and location of the tooth or root tip in the sinus using radiograph.

Once the location is confirmed, keep a nozzle connected to a powerful suction devise at the entrance of the fistula to recover tooth

Pack a piece long roller gauze into the sinus through the opening and remove it with a jerk, the root tip might get removed with the gauze.

If none of the above procedure works, then Caldwell-Luc operation is carried out.

Radiographic appearance

CREATION OF OROANTRAL FISTULA

Causes

Close proximity of the posterior teeth to the sinus predisposes to an oro-antral fistula during the extraction of these teeth.

Injudicious instrumentation to remove a broken root tip.

All the conditions which apply to the cause of displacement of the teeth into the maxillary sinus.

Prevention Same as that for displacement of the teeth into the maxillary sinus.

Management As far as possible leave the clot as it is and do not disturb it. Prescribe antibiotics, analgesics, nasal drops and nasal decongestants to control

any infection. For large defects surgical closure is done.

Clinical appearance

FRACTURE OF MANDIBLECauses

Atrophic mandible as in old age. Existence of any bony pathology. Excessive force application In case of removal of vertically impacted third molar.

Prevention Proper preoperative assessment of the type of impaction and the density of

the bone before extraction Proper support of the jaw during extraction Application of adequate force.

Management Inform and reassure the patient. ORIF of the fracture accordingly.

Radiographic appearance

BREAKAGE OF INSTRUMENT

Causes

Application of excessive force Improper technique Defect in manufacturing of instruments Old and worn out instruments

Prevention

Proper selection of the instrument Proper handling and usage

Management

Remove the burs or elevator tips with a hemostat if it is possible. If impacted deeply, surgical removal of the instrument is advised, unless

contraindicated as in close proximity to vital structures.

Radiographic appearance

LUXATION OF ADJACENT TOOTH

Causes

Improper instrumentation. No support to the adjacent structures during extraction.

Prevention

Proper technique and careful handling of the instruments. Support the adjacent teeth adequately before extraction.

Management

Reposition the tooth inside the socket and splint it The tooth should be treated endodontically after one week.

Clinical appearance

Adjacent tooth

INJURY TO INFERIOR ALVEOLAR NERVE

Injury to the inferior alveolar nerve may result in paresthesia or anaesthesia of the nerve’s dermatome - tongue, lip or chin.

Causes

During the removal of an impacted mandibular third molar, which is in close proximity to the inferior alveolar nerve.

Careless manipulation of the instruments resulting in nerve damage.

Prevention

Proper radiographic assessment of the proximity of the impacted third molar to the inferior alveolar nerve before its removal.

Careful manipulation of the instruments.

Management 1. Nonsurgical management

Because most patients are known to recover spontaneously to some degree. 2. Surgical management

Decompression if impingement of nerve is present Micro neurovascular surgery.

Clinical appearance

INJURY TO LINGUAL NERVE

Causes

The nerve may be damaged during the removal of the third molar when the lingual cortex fractures.

There is risk of damage during the elevation of the lingual mucoperiosteum.

Prevention Proper technique and careful manipulation of the instruments.

Management

Reassure the patient, review regularly. If there are no symptoms of recovery or negative Tinel’s sign, attempt nerve

repair.

Clinical appearance

SWALLOWING OF TEETH

Causes

Careless handling of the instruments Improper technique.

Management

Confirm the presence of teeth in the GIT. Confirm the expulsion of the tooth using serial radiographs.

DISLOCATION OF CONDYLE

Causes

Exertion of excessive force Failure to support the mandible adequately during extraction Number of previous episodes of dislocation

Prevention

Proper exertion of adequate force Support the mandible during extraction

Clinical Appearance

Management

Take a radiograph of the area If the condyle is dislocated into the middle cranial fossa, refer to an oral

surgeon. Manual reduction of anterior displacement of the condyle requires downward

pressure on the retro molar region and simultaneous upward pressure on the chin.

Long standing dislocation may require prolonged traction on the mandibular ramus under general anaesthesia or open reduction.

PRESENCE OF BONY SPICULE

CauseImproper and careless technique of extraction

PreventionChecking the socket for any sharp edges before closure

ManagementFiling or removal of the bony spicule.

Bone Filer

HAEMORRHAGE

Bleeding is a common sequel of oral surgery.There are three types of Post-operative bleeding:-

1. Primary – Occurs continuously just after the surgery 2. Reactionary – Haemorrhage restarts after a period of about three hours.

3. Secondary – Occurs after few days of the procedure

Prevention

A proper medical history of patient to detect any systemic disorders. The necessary investigations such Bleeding Time and Clotting Time detection

test. Avoid incision, flap opening or soft tissue trauma.

Management

After extraction of tooth, apply digital pressure continuously for 2-4 minutes If bleeding continues from the socket, then pack the bony socket with

Gelfoam, fibrin foam, surgical or bone wax Put a gauze piece at the site of bleeding to stop bleeding and facilitate clot

formation.

Clinical Appearance

DRY SOCKETTerm given by Crawford in 1896. It is defined as a post-operative pain in and around the dental alveolus, which increases in severity at some moment between the first and third day after a dental extraction, accompanied by partial or total disintegration of the intra-alveolar clot, causing foul smell.

Synonyms - Necrotic Alveolar Socket

Alveolgia

Delayed extraction

Localised osteomyelitis

Fibrinolytic osteitis

Alveolar osteitis

Osteomyeliric post-extraction syndrome

Fibrinolytic alveolitis

Localised alveolar osteitis

 

Etiology1. Difficult or traumatic extraction Painful or more traumatic extraction would leads to: Delayed alveolar healing Thrombosis of the underlying vessels Lesser resistance to infection2. Use of oral contraceptivesEstrogens and other drugs activate the fibrinolytic system in an indirect way by increasing the factors II, VII, VIII, X and plasminogen; contributing to premature destruction of the clot and the development of dry socket.3. Hormonal changesChanging levels of endogenous estrogens during the menstrual cycle would also influence.4. TobaccoTobacco interferes with the alveolar healing is the incorporation of pollutants in the wound or the suction effect on the clot in formation.5. Inadequate Intra-operatory IrrigationUse of anesthesia solution with vasoconstrictor or an intra-ligamentous technique of anesthesia, where solution is deposited very near to the alveolus and if the Solution is colder than the corporal temperature increases the incidence of dry socket.

6. Advanced age

Old age people with immunocompromised state, extraction site in the mandible, excessive or exaggerated irrigation of the socket.

Symptoms

1. PAIN• Usually occurs on the 2nd or 3rd day after extraction and its usually lasts

either with or without treatment for about 10-15 days.• Pain is localized to the extraction socket which will be sensitive to even

gentle probing.• Pain is sharp in nature that increases with the suction or mastication.• It may radiate to the ear or ipsilateral side of the head.

2. HALISTOSISIt is the result of complex interaction between surgical trauma, local bacterial infection and various systemic factors. It is invariably present.

3. UNPLEASANT TASTE commonly sour taste.4. INFLAMMED GINGIVAL MARGIN at the site of extracted tooth.

Swelling Pain Foul Smell

Etiopathogenesis

Process of Normal Healing – takes place in five stages :-

STAGE – I Haematoma & Clot formation

STAGE – II Granulation Tissue Formation

STAGE – III Replacement of Granulation tissue by Connective tissue

STAGE – IV Replacement of Connective tissue by Coarse bone

STAGE – V Replacement of Coarse bone by Mature Bone

Formation of Dry socket

The classical triad of- early extraction socket clot loss/necrosis, pain and fetor oris has been termed as dry socket or Alveolitis sicca dolorosa.

Theories of Dry socket I – Birn’s Fibrinolytic Theory II – Bacterial Therory

BIRN’s FIBRINOLYTIC THEORYAccording to this theory, after the extraction of a tooth an inflammatory process begins that could effect the formation and retention of the clot. There is an increase in local fibrinolysis leading to disintegration of the clot. The fibrin would disintegrate due to the effect of kinase released in the inflammation process or due to direct or indirect activation of Plasminogen.

Active Plasminogen

Fibrin

Plasminogen

Fibrinogen Clotdissolution

No. of fibrin degradation products

BACTERIAL THEORYAccording to this theory, occurrence of dry socket is more due to existence of a high count of bacteria around the extraction site.E.g..- Actinomyces viscous and Streptococcus mutans (they retard the alveolar post-extraction healing)

Prevention

• A comprehensive history with identification of risk factors.• Pre-operative oral hygiene measure such as oral prophylaxis should be

instituted.• Avoid extraction of lower 3rd Molars in the presence of active infection or

ulcerative gingivitis.• Patients who smoke should be advised to cease smoking pre-operatively and

post-operatively at least for two weeks while the socket heals.• Appropriate antibiotic prophylaxis for immunocompromised patients and

patients with history of pericoronitis and Ulcerative gingivitis.• Patient should be advised to avoid vigrous mouth rinsing for the first 24 hours

post extraction and to use gentle tooth brushing and mouth rinses for seven days post-extraction.

DRY SOCKET

Management

• The affected socket should be gently irrigated with 0.12% warmed chlorhexidine and all debris should be delighted and aspirated.

• Intra-alveolar pastes consisting of Zinc oxide eugenol; anesthetic and antibiotic. Place a strip of paste soaked a surgical gauze in the socket and do not exert pressure on the socket while placing the strip.

• The topical use of application of an emulsion of oxytetracycline and hydrocortisol.

• Appropriate analgesics as the non-steroidal anti-inflammatory drugs for managing pain.

• Patient can be instructed in-home socket irrigation techniques using 0.12% chlorhexidine.

• Patient should be kept under review until they are pain free and socket healing is ensured.

Thank You!