Complications of exodontia

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.

1. COMPLICATIONS OF EXODONTIA By-Dr. Prathamesh Fulsundar

2. 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.

3. COMPLICATIONS OF EXODONTIA CAN BE DIVIDED INTO TWO TYPES 1- INTRAOPERATIVE 2- POSTOPERATIVE

4. 1-INTRAOPERATIVE COMPLICATIONS SOFT TISSUE INJURIES 1-Tearing of Mucosal Flap 2-Puncture wound of soft tissue 3- Abrasion injury COMPLICATIONS WITH TOOTH BEING EXTRACTED 1-Root Fracture 2-Root Displacement 3-Tooth lost into Oropharynx INJURIES TO ADJACENT TEETH 1-Fracture of Adjacent restoration 2-Luxation of Adjacent teeth 3-Extraction of Wrong teeth INJURIES TO OSSEOUS STRUCTURES 1-Fracture of Maxillary Tuberosity INJURIES TO ADJACENT STRUCTURES 1-Injury to Regional Nerves 2-Injury to Temporomandibular joint

5. 2-POSTOPERATIVE COMPLICATIONS Presence of bony spicule Haemorrhage Dry socket Infection

6. SOFT TISSUE INJURY 1-TEARING OF MUCOSAL FLAP- It is one of the most common soft tissue injury during extractions. It occurs as inadequately sized envelope flap is retracted beyond the tissues ability to stretch. Prevention Create adequately sized flaps to prevent excess tension on the flap Use small amounts of retraction forces on the flap .  

7. CLINICAL APPEARANCE MANAGEMENT The flap should bee carefully repositioned after surgery and suturing aids in healing

8. 2-PUNCTURE WOUND OF SOFT TISSUE The instruments such as straight elevator or periosteal elevators may slip from surgical field and puncture into adjacent soft tissue. PREVENTION Use of controlled force Special attention should be given to finger support and instrument stabilization Use of other hand to retract tissues from surgical field

9. CLINICAL APPEARANCE MANAGEMENT Apply a local hemostat in order to prevent bleeding Prevent infection at the site of injury Wound is usually not sutured

10. 3-ABRASION INJURY Abrasions or burns of lips and corners of mouth usually occurs due to rotating shank of the burs PREVENTION When the surgeon is focused on cutting end the assistant should beware of location of shank in relation to cheeks and lips

11. Management Scars produced due to thermal injuries can be managed by the application of petroleum jelly or topical antiseptic/analgesic . These abrasions usually take 5 to 10 days to heal. Clinical appearance

12. 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

13. Management   When the fracture involves the crown of the tooth appropriate restoration should be placed . Clinical appearance

14. 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 .

15. 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

16. DISPLACEMENT OF TOOTH INTO MAXILLARY   SINUS Causes The roots of the maxillary posterior teeth are always in a close proximity to the maxillary sinus With advancing age 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.  

17. 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.  

18. Radiographic appearance

19. TOOTH LOST INTO OROPHARYNX 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.

20. RADIOGRAPHIC APPEARANCE

21. INJURIES TO ADJACENT TEETH 1-LUXATION OF ADJACENT TEETH 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 .

22. Clinical appearance Adjacent tooth

23. 2-FRACTURE OF ADJACENT RESTORATION Causes Presence of large restorations on adjacent teeth Improper instrumentation Application of excessive forces Management Patient should be informed about his fractured restoration Prevent the restorative material from entering the tooth socket A temporary restoration should be done followed by a permanent restoration after 3 to 4 days.

24. 3-EXTRACTION OF 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 re-implantation.

25. INJURES TO OSSEUS STRUCTURES 1-FRACTURE OF MAXILLARY 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.

26. 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

27. FRACTURE OF MANDIBLE Causes 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 Do not use excessive force.

28. Management Inform and reassure the patient. The surgeon should make sure that the soft tissues has been replaced and repositioned over the bone structure to facilitate rapid healing. Radiographic appearance

29. INJURIES TO ADJACENT STRUCTURES INJURY TO REGIONAL NERVES The branches of the 5 th cranial nerve Mental nerve Buccal nerve Lingual nerve Nasopalatine nerve which innervate the mucosa & skin are mostly injured during extraction.

30. NASOPALATINE & BUCCAL NERVE Theses nerves are usually sectioned during the creation of flaps for removal of impacted teeth. They reinnervate easily & thus can be surgically sectioned without sequelae or complication. MENTAL NERVE During surgical removal of mandibular premolar roots or impacted premolar and periapical surgery in that area, care should be taken not to injure vthe mental nerve along its course. If injured the patient may have paresthesia or anesthesia of the lip and chin.

31. PREVENTION OF NERVE INJURY BE AWARE OF NERVE ANATOMY IN SURGICAL AREA. AVOID MAKING INCISIONS OF AFFECTING PERIOSTEUM IN NERVE AREA.

32. LINGUAL NERVE Lingual nerve located directly against the lingual aspect of the mandible in the retromolar pad region rarely regenerates if severely traumatized. Incisions made for surgical removal of impacted mandibular3 rd molars should be well enough to the buccal aspect. INFERIOR ALVEOLAR NERVE IAN is very commonly traumatized during mandibular 3 rd molar extractions, patients should be made aware of the possiblity of the nerve injury.

33. Injury to temporomandibular joint Removal of mandibular molar teeth requires application of substantial amount of force. If jaw is not supported adequately during extraction the patient may experience pain in this region. The use of bite block on the contralateral side may provide adequate balance of forces so that injury & pain do not occur. If pain is experienced the surgeon recommends use of moist heat, rest for the jaw, a soft diet, 1000mg aspirin every 4hrs for several days.

34. PREVENTION OF INJURY TO TMJ SUPPORT MANDIBLE DURING EXTRACTION. DO NOT OPEN MOUTH TOO WIDELY.

35. OROANTRAL COMMUNICATION If maxillary sinus is large, no bone exists between the roots of the teeth & maxillary sinus, if roots are widely divergent, then it is probable that a portion of the bony floor of sinus will be removed with the tooth. This may lead to postoperative maxillary sinusitis and oroantral fistula.

36. MANAGEMENT OF OROANTRAL COMMUNICATION If communication is small<2mm in diameter or less surgeon should ensure formation of high quality blood clot in socket & advice patient to take sinus precautions. Patient adviced to to avoid blowing the nose, violent sneezing, sucking on straw, smoking. If communication is moderate size 2-6mm additional measures should be taken. To ensure maintenance of blood clot in the area figure 8 suture should be placed. Antibiotics like penicillin or clindamycin should be prescribed for 5 days.

37. If the communication is large 7mm or larger, the surgeon should consider closing the sinus communication with a flap procedure. Most commonly used flap is buccal flap. PREVENTION Preoperative radiographs must be evaluated. If tooth roots are near the sinus floor closed forceps extraction is avoided & surgical removal with sectioning of tooth roots is done. Avoid excess apical pressure.

38. Postoperative bleeding Extraction of teeth presents severe challenge to the body’s hemostatic mechanism. If the postoperative bleeding continues for more than a day then it is a matter of concern. Prevention of bleeding is achieved by thorough medical history of the patient. Patient should be enquired about any medication they might be taking such as anticoagulants, anticancer chemotherapy or alcoholism. These tend to increase the postoperative bleeding.

39. Patient suspected with bleeding disorders is evaluated to determine severity of disorder by measuring the status of intentional anticoagulation with use of the International Normalized Ratio (INR) Normal= 2.0-3.0

40. MANAGEMENT OF POSTOPERATIVE BLEEDING AFTER EXTRACTION Different materials placed in the socket to gain hemostatsis . Most commonly used, least expensive, absorbable gelatin sponge. ( e.g.Gelfoam ) Oxidized regenerated cellulose.(e.g. Surgicel ) Liquid preparation of topical thrombin. (prepared from bovine thrombin) Collagen. (e.g. micro collagen- Avitene , plug type collagen- Collaplug , tape type collagen- Collatape ) Damp tea bag. (tannin in tea stops bleeding)

41. PREVENTION OF POSTOPERATIVE BLEEDING Obtain history of bleeding. Use atraumatic surgical technique. Obtain good hemostasis at surgry . Provide excellent patient instructions.

42. PREVENTION OF POSTOPERATIVE BLEEDING Obtain history of bleeding. Use atraumatic surgical technique. Obtain good hemostasis at surgry . Provide excellent patient instructions.

43. Delayed healing & infection INFECTION WOUND DEHISCENCE DRY SOCKET

44. PREVENTION OF POSTOPERATIVE BLEEDING Obtain history of bleeding. Use atraumatic surgical technique. Obtain good hemostasis at surgry . Provide excellent patient instructions.

45. INFECTION Most common cause of delayed wound healing but rare complication after routine extraction, primarily seen after oral surgery.

46. WOUND DEHISCENCE Wound dehiscence is the separation of the layers of a surgical wound; it may be partial or only superficial,  or complete with separation of all layers and total disruption. Wound dehiscence caused in these conditions- soft tissue flap replaced & sutured without an adequate bony foundation, suturing the wound under tension.

47. PREVENTION OF WOUND DEHISCENCE Use aseptic technique. Perform atraumatic surgery. Close incision over intact bone. Suture without tension.

48. DRY SOCKET Clinically the tooth socket appears to be empty, with a partially or completely lost blood clot, & bony surface of the socket are exposed. There is dull aching pain, usually throbs, radiates to the ear. The area of socket has a bad odor, patient has bad taste. Caused due to fibrinolytic activity. This condition in routine extraction is rare but frequent in removal of impacted mandibular 3 rd molars.

49. MANAGEMENT OF DRY SOCKET Gentle irrigation of the tooth socket with saline, entire blood clot not lysed , excess saline suctioned, iodoform gauze soaked with medication inserted in socket. Medication contains eugenol , benzocaine , balsam of Peru. Patient experiences relief from pain within 5 minutes PREVENTION OF DRY SOCKET Atraumatic surgery with clean incision & soft tissue reflection. Preoperative & postoperative rinces with antimicrobial mouth rinces - chlorhexidine

50. FRACTURE OF MANDIBLE Fracture of mandible during extraction associated with surgical removal of impacted 3 rd molars. Mandibular fracture result of application of force exceeding that is needed to remove tooth with use of dental elevators.

51. REFERENCES: Contemporary Oral & Maxillofacial Surgery Peterson, Ellis, Hupp , Tucker

52. Thank You!