Complications of Extractionof Impacted Teeth

Outline

I. Soft Tissue InjuriesII. Complications with the Tooth Being ExtractedIII. Injuries to Adjacent TeethIV. Injuries to Osseous StructuresV. Injuries To Adjacent StructuresVI. Oroantral CommunicationsVII.Postoperative BleedingVIII.Delayed Healing & Infection

I. Soft Tissue Injuries

1. Tearing Mucosal Flap

CausesDue to an inadequately sized flap which is retracted beyond the tissue`s ability to stretch.As with a short envelope flap when the area of surgery is at the apex.

Prevention-Adequately sized flaps-Gentle Retraction

ManagementReposition the flap & sutureIf the tear is jagged, trim it before suturing

2. Puncture Wound of Soft TissueCause

Instrument Slippage

PreventionControlled force

ManagementSuturing to prevent infection & allow healing to occur

3. Stretch or Abrasion InjuryCause

Bur shank or retractor injury

PreventionCare

ManagementKeep it moist ( ointment )Heals within 5 – 10 days

II. Complications with the tooth Being Extracted

1. Root Fracture

CauseLong, curved, divergent rootsExcessive force during extraction

PreventionProper exposure & bone removal

2. Root Displacement

Into:• Mandibular Canal• Lingual Pouch• Infratemporal Space• Maxillary Sinus

III. Injuries to Adjacent Teeth

1.Luxation of Adjacent Teeth2.Fracture of Adjacent Restoration

CauseCarelesness

PreventionJudicious use of elevators

IV. Injuries to Osseous Structures

1. Fracture of Alveolar ProcessFracture of the Buccal or Lingual Cortex

CauseInadequate exposure & excessive force

PreventionAdequate bone removal & eposure

2. Fracture of Maxillary TuberosityCause

Excessive force

PreventionProper support and controlled force

ManagementIf still attached; dissect and remove the toothIf detached; smooth bone edges & suture

3. Fracture of the Mandible

CauseExcessive force

PreventionProper bone removal & controlled force

Photoelastic model of the mandible, showing the development of stress during a luxation attempt of the third molar when insufficient bone has been removed from the tooth peripherally

V. Injuries to Adjacent Structures

1. Injury to Inferior Alveolar NerveCause

-Excessive extraction force in case of curved roots-Sectioning the tooth all the way inferiorly

Prevention-Proper exposure & bone removal-Controlled force-Careful setioning, leaving a shell of the tooth

2. Injury to the Lingual NerveCause

-Placement of the retromolar incision far lingually-Sectioning the tooth all the way to the lingual cortex

Prevention-Proper incision-Careful sectioning, leaving a shell of the tooth

3. Injury to the TMJCause

Inadequate support of the mandible during extraction

PreventionUse of bite block

ManagementReduction

Vi. Oroantral CommunicationCause

During extraction of an impacted maxillary canine

-Excessive bone removal-Failure to locate the tooth

Prevention-Proper preoperative radiographic evaluation-Proper bone removal-Controlled force

VII. Postoperative Bleeding

Cause-Bleeding at wound margins-Bleeding at a bony foramen within the socket-Medical Problem

Prevention-Good history taking

(coagulopathy, medications…etc)-Atrumatic surgical extraction

(clean incisions, gentle management of soft tissues, smoothen bony specules, curette granulation tissue)-Obtain good homeostasis at surgery- Postoperative instructions

ManagementLocal Measures

• Pressure packs• Suturing• Ligate bleeding vessels• Burnish bone• Apply material to aid in hemostasis (surgicell,

collaplug)

VIII. Delayed Healing & Infection

1. InfectionCause

Debris left under the flap

PreventionIrrigation

ManagementDebridement & Drainage

2. Dry Socket (Alveolar Ostitis)Cause

-Lysis of a fully formed blood clot before the clot is replaced with granulation tissue.-Higher incidence with smokers & patients taking oral contaceptives.

Prevention-Presurgical irrigation with antimicrobial agents ,e.g: chlorhexidine-Intraoperative irrigation with saline

Management– Irrigate with warm saline– Remove old clots– Place sedative dressing– Prescribe mild analgesics– Reassess after 24 to 48 hours