Complications of exodontia..........pptx

Complications of extraction are divided according to their occurrence into intraoperative, postoperative, and late complications.
Complication of teeth extraction

1. Complications of Exodontia ORAL SURGERY Presented By: Dr. Asawer Ahmed Fayyad

2. Background Complications can be wide, ranging from common ones like dry socket and root fracture to uncommon and serious ones like displacement of a root fragment in the maxillary sinus and oro-antral fistula.

3. Intraoperative complications (immediate) Postoperative (delayed complications) Late complications Complications of Exodontia

4. Intraoperative complications (immediate)

5. Fracture of tooth Intraoperative complications (immediate) The most common problem associated with the tooth being extracted is fracture of its roots. Long, curved, divergent roots that lie in dense bone are the most likely to be fractured. The main methods of preventing the use an open extraction technique and remove bone to decrease the amount of force necessary to remove the tooth. Fracture of a tooth, alveolus, mandible, maxillary tuberosity

6. Fracture of alveolus The most likely cause of fracture of the alveolar process is the use of excessive force with the forceps, which fractures the cortical plate. If excessive force is necessary to remove a tooth, a soft tissue flap should be elevated and controlled amounts of bone should be removed, in the case of multirooted teeth, the tooth should be sectioned.

7. The most likely places for bone fractures are the buccal cortical plate over the maxillary canine.

8. and the buccal cortical plate over maxillary molars (especially the first molar), the portions of the floor of the maxillary sinus that are associated with maxillary molars, the maxillary tuberosity, and labial bone over mandibular incisors

9. Prevention of fractures of large portions of the cortical plate depends on preoperative radiographic and clinical assessments, avoidance of the use of excessive amounts of uncontrolled force, and the early decision to perform an open extraction with removal of controlled amounts of bone and sectioning of multirooted tooth

10. If the bone has been completely removed from the tooth socket along with the tooth, it should not be replaced. Once the bone and soft tissue have been elevated from the tooth, the tooth is removed and the bone and the soft tissue flap are reapproximated and sutured with suture.

11. Fracture of maxillary tuberosity Fractures of the maxillary tuberosity most commonly result from extraction of an erupted maxillary third molar or from extraction of the second molar if it is the last tooth in the arch.

12. The first is to splint the tooth being extracted to adjacent teeth and defer the extraction by 6 to 8 weeks, allowing time for bone to heal. If the tuberosity is excessively mobile and cannot be dissected from the tooth The second option is to section the crown of the tooth from the roots and allow the tuberosity and tooth root section to heal. After 6 to 8 weeks the surgeon can remove the tooth roots

13. If the maxillary tuberosity is completely separated from soft tissue, the usual steps are to smooth the sharp edges of the remaining bone and reposition and suture the remaining soft tissue.

14. Fracture of mandible Fracture of the mandible during extraction is a rare complication; it is associated almost exclusively with: atrophic mandibles or short man?dibular body height, or where attempts are made to remove an impacted tooth without use of surgical techniques. Fractures may also be encountered in patients with osteoporosis or abnormal pathologic processes in the area, such as cysts or tumours

15. it will be treated by methods usually applied for treating jaw fractures.

16. Burns and Lacerations of Oral mucosa The mobile lips and cheeks are the largest obstacle between the surgeon and the surgical site Lacerations usually occur as a result of inadvertent contact with the sharp metal instruments on their entry and exit from the oral surgical site. Burns are largely the result of inadequate retraction of the tissues when using a surgical handpiece and Punctures (elevator slipping off)

17. Luxation/removal of adjacent tooth Improper use of elevators may see them being placed between the tooth being extracted and an adjacent tooth, exposing the latter to extraction forces.

18. Once the tooth marked for extraction has been removed, standard trauma management of a luxated or avulsed tooth should be applied. The extraction must be completed carefully, without the use of elevators near the broken tooth.

19. Tooth Aspiration or Ingestion If a tooth is lost into the oropharynx, the patient should be managed according to basic life support protocols. If there are signs of impending respiratory obstruction, the patient requires immediate ambulance transfer to the nearest hospital for bronchoscopy and removal of foreign body.

20. Oroantral Communications An oroantral communication is a direct hole between the oral cavity and the maxillary sinus. Several causes cause OAF including the extraction of maxillary posterior teeth which is the most common cause, and other cause

21. This usually occurs in the context of lone-standing solitary upper first molars or high-impacted upper third molars; however, any tooth that has roots anatomically close to the sinus cavity may be at risk. Occasionally, oroantral communications can be associated with displacement of a tooth root or fragment into the maxillary sinus.

22. Clinical Features Primary complaints in established OAF cases are mainly oronasal regurgitation and burning sensation in sinus on having food. Patients may visit the ENT surgeon with complaints of acute sinusitis, secondary to infection of sinus via unrecognized OAF. In certain cases, there may localized pain, tenderness, foul smell, unpleasant tasting discharge, persistent nasal discharge and post-nasal drip. In long-standing untreated cases, there will be clinical and radiological features of chronic sinusitis.

23. If the communication is small (≤2 mm in diameter), no additional surgical treatment is necessary. If the opening between the mouth and sinus is of moderate size (2 to 6 mm), to ensure the maintenance of the blood clot in the area, a figure-of-eight suture should be placed over the tooth socket

24. If the sinus opening is large (≥7 mm), the surgeon should consider having the sinus communication repaired with a flap procedure. The most commonly used flap for small openings is the buccal flap. This technique mobilizes buccal soft tissue to cover the opening and provide for a primary closure.

25. Root Displacement in maxillary sinus The tooth root that is most commonly displaced into unfavorable anatomic spaces is the maxillary molar root when it is forced or lost into the maxillary sinus.

26. irrigation through the small opening in the socket apex and then suction the irrigating solution from the sinus via the socket. This occasionally flushes the root apex from the sinus through the socket.

27. If this technique is not successful, no additional surgical procedure should be performed through the socket, and the root tip should be left in the sinus. If the tooth root is infected or the patient has chronic sinusitis, Caldwell-Luc or endoscopic approach should be used to remove the root.

28. Displacement of root in infratemporal space During elevation of the tooth, the elevator may force the tooth posteriorly through the periosteum into the infratemporal fossa. The tooth is usually lateral to the lateral pterygoid plate and inferior to the lateral pterygoid muscle.

29. If good access and light are available, the surgeon should make a single cautious effort to retrieve the tooth with a hemostat. If this technique is not successful, no additional surgical procedure should be performed.

30. Displacement of root/tooth in lingual pouch Lingual cortical bone over the roots of the molars becomes thinner as it progresses posteriorly. Even small amounts of apical pressure can result in displacement of the root into that space.

31. If the root disappears during root removal, the dentist should make a single effort to remove it. The index finger of the left hand is inserted onto the lingual aspect of the floor of the mouth in an attempt to place pressure against the lingual aspect of the mandible and force the root back into the socket.

32. The usual definitive procedure for removing such a root tip is to reflect a soft tissue flap on the lingual aspect of the mandible and gently dissect the overlying mucoperiosteum until the root tip can be found.

33. Prevention Prevention of displacement into the submandibular space is primarily achieved by avoiding all apical pressures when removing mandibular roots. Triangular elevators such as the Cryer elevator are usually used to elevate broken tooth roots of mandibular molars.

34. Injury to the Temporomandibular Joint Removal of mandibular molar teeth frequently requires the application of a substantial amount of force. Controlled force and adequate support of the jaw prevent this. The use of a bite block on the contralateral side may provide an adequate balance of forces so that injury does not occur.

35. If the patient complains of pain in the temporomandibular joint area immediately after the extraction procedure: use of heat, resting the jaw a soft diet 600 to 800 mg of ibuprofen every 4 hours for several days. Patients who cannot tolerate nonsteroidal anti-inflammatory drugs may take 500 to 1000 mg of acetaminophen.

36. Nerve injury The most frequently involved specific branches are the mental, lingual, buccal, and nasopalatine nerves. The nasopalatine and buccal nerves are frequently sectioned during the creation of flaps for the removal of impacted teeth. The area of sensory innervation of these two nerves is relatively small, and reinnervation of the affected area usually occurs rapidly. Therefore the nasopalatine and long buccal nerves can be surgically sectioned without long-lasting sequelae or much bother to the patient.

37. Surgical procedures in the area of the mental nerve and mental foramen must be performed with great care. If the mental nerve is injured, the patient will experience paresthesia or anesthesia of the lip and chin. If the injury is the result of flap reflection or manipulation, normal sensation usually returns in a few days to a few weeks.

38. If the mental nerve is sectioned at its exit from the mental foramen or torn along its course, it is likely that mental nerve function will not return, and the patient will have a permanent state of anesthesia. If surgery is to be performed in the area of the mental nerve or the mental foramen, it is imperative that the surgeon be aware of the potential morbidity from injury to this nerve

39. The lingual nerve is usually anatomically located directly against the lingual aspect of the mandible in the retromolar pad region. Therefore incisions made for surgical exposure of impacted third molars or of bony areas in the posterior molar region should be made well to the buccal aspect of the mandible.

40. the inferior alveolar nerve may be traumatized along the course of its intrabony canal. The most common place of injury is the area of the mandibular third molar. Removal of impacted third molars may bruise, crush, or sharply injure the nerve in its canal.

41. Bleeding Intraoperative bleeding may result from trauma to the soft tissues, causing laceration of blood vessels, or from bone trauma, resulting in bleeding from nutrient canals or central bone vessels. It can be exacerbated by the presence of inflammation or infection, due to the vasodilatory effect of inflammatory mediators. In addition, to number of medical conditions.

42. Local anaesthetic infiltration Suturing Gauze pressure and impregnation Cellulose Gelatin foam Thrombin Fibrin Tranexamic acid mouthwash collagen is supplied as a plug (e.g., Collaplug) Calcium alginate Bone wax Use hemostatic agents

43. If generalised oozing: pack the socket with an absorbable haemostatic agent of choice and then place a retention suture over it. Additional pressure with haemostatic gauze soaked in 0.2% tranexamic acid solution or 1 : 100 000 adrenaline for 30 minutes increases the haemostatic effect

44. Postoperative complications (Delayed)

45. Dry Socket Dry socket is recognized as the most common complication that occurs after a dental extraction. The onset of dry socket typically occurs within one to four days after the extraction, marked by the partial or complete disintegration of the blood clot and the subsequent exposure of the alveolus.

46. Smoking traumatic extraction using vasoconstrictors such as epinephrine the amount of anesthesia administered pre-existing infections, non-compliant patient poor oral hygiene Systemic conditions such as age, gender, diabetes, chemotherapy, the use of oral contraceptives, and anti-inflammatory drugs have also been associated with an increased incidence of dry sockets Causes

47. Treatment options for dry sockets involve the removal of debris from the socket using 0.2% chlorhexidine or saline. Additionally, sedatives such as eugenol may be applied to alleviate pain. The use of antibiotics as a preventive measure has shown efficacy. Management

48. Postoperative edema/swelling Swelling usually reaches its maximum 36 to 48 hours after the surgical procedure. Swelling begins to subside on the third or fourth day and is usually resolved by the end of the first week. Increased swelling after the third day may be an indication of infection rather than renewed postsurgical edema.

49. Use ice packs or bags of frozen peas to help minimize the swelling The ice pack or small bags of frozen peas should be kept on the local area for 20 minutes and then kept off for 20 minutes over a period of 12 to 24 hours. They should also be warned that the swelling may tend to wax and wane, occurring more in the morning and less in the evening because of postural variation. Sleeping in a more upright position by using extra pillows will help reduce facial edema.

50. Hematoma/ecchymosis blood oozes submucosally and subcutaneously; this appears as a bruise in the oral tissues, the face, or both. Ecchymosis is usually seen in older patients because of their decreased tissue tone, increased capillary fragility, and weaker intercellular attachments. Typically the onset of ecchymosis is 2 to 4 days after surgery and it usually resolves fully within 7 to 10 days.

51. Trismus results from trauma and the resulting inflammation involving the muscles of mastication. Trismus may also result from multiple injections of the local anesthetic, especially if the injections have penetrated muscles. The muscle most likely to be involved is the medial pterygoid muscle, which may be penetrated by the local anesthetic needle during the inferior alveolar nerve block. Trismus

52. Physiotherapy with jaw stretcher (Heister) Heat therapy Warm saline rinse Analgesics Muscle relaxants Brisement force under sedation Treatment

53. Infection The most common cause of delayed wound healing is infection. Infections after routine extractions exhibit the typical signs of a fever, increased swelling, reddening of skin, a foul taste in the mouth, or worsening pain 3 to 4 days after surgery. Infected oral wounds look inflamed, and some purulence is usually present

54. Management Contamination of needles Improper preparation of site Needle passing through an area of infection LA solution deposited under pressure; as in intraligamental injection (deposit bacteria Analgesics Antibiotics Physiotherapy Muscle relaxants Incision and drainage Causes

55. Late complications

56. Causes Nerve damage: Anesthesia/paresthesia Injection of LA solution near a nerve with contaminated LA solution with cold sterilizing solution Trauma to nerve sheath Hemorrhage in and around nerve sheath

57. Management Reassurance to the patient (tincture of time): Prescribe B1, B6, B12 vitamin tablets. Observe the patient for two months; if no improvement, refer the patient to oral and maxillofacial surgeon. Most paresthesia resolve within 8 weeks

58. Osteomyelitis refers to an inflammation (“itis”) of the bone marrow (“osteomyel”) only but means an inflammation of the entire bone including the periosteum, the cortical, and cancellous bone as well as the bone marrow. Chronic osteomyelitis

59. The therapy of the acute and secondary chronic osteomyelitis mainly consists of the therapy of the infection and of the improvement of the local blood flow. This is achieved via antibiotics and removing of the infected parts of the bone. A decortication supports this and helps to get well-vascularized tissue onto the bone.

60. Contemporary oral and maxillofacial surgery Textbook of oral and maxillofacial surgery Oral and maxillofacial surgery for the clinician References

61. Thank You