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Complications of EXODONTIA
- 1. COMPLICATIONS OF EXODONTIA By- Ragini Adhikari (III BDS)
- 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 occurring during the surgical procedure:- 1. Soft tissue injury 2. Extraction of wrong teeth 3. Fracture of the teeth during extraction 4. Fracture of tooth root during extraction 5. Fracture of the tuberosity 6. Displacement of the tooth into the maxillary sinus 7. Creation of Oro-antral fistula 8. Fracture of Mandible 9. Breakage of Instrument 10. Luxation of the adjacent tooth 11. Injury to inferior alveolar nerve 12. Injury to lingual nerve 13. Swallowing of teeth 14. Dislocation of condyle
- 4. Complications occurring after the surgical procedure :- 1. Presence of bony spicule 2. Haemorrhage 3. Dry socket 4. Infection
- 5. SOFT TISSUE INJURY Types 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.
- 6. 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
- 7. 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.
- 8. 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
- 9. Management When the fracture involves the crown of the tooth appropriate restoration should be placed. Clinical appearance
- 10. 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.
- 11. 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
- 12. 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.
- 13. 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
- 14. 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.
- 15. 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.
- 17. 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.
- 18. 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
- 19. 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 Application of adequate force.
- 20. Management Inform and reassure the patient. ORIF of the fracture accordingly. Radiographic appearance
- 21. 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
- 22. 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
- 23. 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.
- 25. 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.
- 26. 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
- 27. 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.
- 29. 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.
- 30. 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
- 32. 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.
- 33. PRESENCE OF BONY SPICULE Cause Improper and careless technique of extraction Prevention Checking the socket for any sharp edges before closure Management Filing or removal of the bony spicule. Bone Filer
- 34. 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.
- 35. 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
- 36. DRY SOCKET Term 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
- 37. Etiology 1. Difficult or traumatic extraction Painful or more traumatic extraction would leads to: Delayed alveolar healing Thrombosis of the underlying vessels Lesser resistance to infection 2. Use of oral contraceptives Estrogens 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 changes Changing levels of endogenous estrogens during the menstrual cycle would also influence. 4. Tobacco Tobacco 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 Irrigation Use 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.
- 38. 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. HALISTOSIS It 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.
- 39. Swelling Pain Foul Smell
- 40. 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.
- 41. Theories of Dry socket I – Birn’s Fibrinolytic Theory II – Bacterial Therory BIRN’s FIBRINOLYTIC THEORY According 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 Clot dissolution No. of fibrin degradation products
- 42. BACTERIAL THEORY According 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.
- 43. DRY SOCKET
- 44. 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.
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