COMPLICATIONS AND MANAGEMENT

COMPLICATIONS AND MANAGEMENT

PRE-OPERATIVE

INTRA-OPERATIVE

POST-OPERATIVE

PRE-OPERATIVE COMPLICATIONS

MEDICAL HISTORYConsider allergies, bleeding disorders etc.

DENTAL HISTORYConsider if the patient has had difficult

extractions in the past, are they anxious etc.

INFECTION, ACCESS AND VISIBILITY?

INTRA-OPERATIVE COMPLICATIONS

FAILURE OF LOCAL ANAESTHETIC

FAILURE TO REMOVE THE TOOTH

TRAUMA TO HARD TISSUES

TRAUMA TO SOFT TISSUES

DISPLACEMENT OF TEETH

DISPLACEMENT OF TMJ

ORO-ANTRAL COMMUNICATIONS

FAILURE OF LOCAL ANAESTHETICAcute infections prevent the Local Anaesthetic from working

Reasons why LA doesn’t work when there is an acute infection……Acutely inflamed tissues are more vascular, therefore the solution is removed more quickly from the site. The acidic conditions impedes the dissociation of the active components.Inflammation increases the nerve threshold and therefore a higher concentration of LA solution is needed to anaesthetise the nerve.

MANAGEMENTConsider block injections; the infra-orbital block, the posterior superior alveolar block, the ID block.Increase the LA solution given or a use concentrated LA solution such as 5% lignocaine.• Intra-ligamentary injections down the periodontal membrane will help

If you have absolute failure of anaesthesia, prescribe antibiotics and analgesics . Wait for 3-4 days to allow the infection to progress from acute to chronic before attempting extraction.

You might want to consider GA

FAILURE TO REMOVE THE TOOTH

• INCORRECT FORCEPS/ELEVATORS

• BONE SCLEROSIS• DIVERGENT ROOTS• HYPERCEMENTOSIS• BLADES OF THE FORCEPS

NOT THE RIGHT WIDTH FOR THE POINT OF CONTACTASSESS THE CAUSE OF DIFFICULTY

• APPLICATION OF CORRECT ELEVATORS/FORCEPS

• FOR MOLAR TEETH, DIVIDE THE TOOTH AND DELIVER ROOTS INDEPENDENTLY

• SURGICAL REMOVAL

POSSIBLE SOLUTIONS

TRAUMA TO HARD TISSUESFR

ACTU

RE O

F TH

E AL

VEO

LAR

BON

E

Occurs when the alveolar bone gets

included in the forceps.

Fracture of the alveolar buccal plate can occur when leaning

buccally to deliver the tooth .

Convergent roots or ankylosed roots may retain alveolar

bone when delivering the

tooth.

MAN

AGEM

ENT

IF THE FRACTURED BONE HAS LOST ITS PERI-OSTEAL ATTACHMENT:

The blood supply has been lost thus the

fragment should be removed to avoid

necrosis and infection of the bone.

MAN

AGEM

ENT

IF THE FRACTURED BONE IS STILL ATTACHED TO THE PERI-OSTEUM:

Squeeze the socket together and push the fractured bone into its original position

TRAUMA TO SOFT TISSUES

DAMAGE TO SOFT TISSUES

Damage to the gingivae should be avoided by

good technique. Always ensure that the forceps

are applied subgingivally.

Protect the lower lip so that it doesn’t get

crushed by handles of the forceps or burnt by a

surgical hand piece.

Uncontrolled and careless use of forceps

can traumatise the tongue and floor of

mouth .

DISPLACEMENT OF TMJ

Usually caused by not supporting the mandible adequately during the extraction. Using props and gags in the mouth which are too large can also displace the TMJ.

DISLOCATION OF THE TMJ

IMMEDIATELY REPLACE THE DISLOCATED TMJ Stand in front of the patient.Place your thumbs on the external oblique ridge intra-orally. Place your forefingers behind the angle of the mandible extra-orally.Manoeuvre the TMJ back into position by pushing down with your thumbs and up with your fingers. Post-op instructions should include a soft diet for 1 week, and advise not to open their mouth too wide.

MANAGEMENT

ORO-ANTRAL COMMUNICATIONS

• OAC: Is a communication between the oral cavity and the antrum which is not lined by an epithelium.

• OAF: Is a communication between the oral cavity and the antrum which is lined by an epithelium.

• It takes ~48 hours for the epithelium tract to form.

ORO-ANTRAL COMMUNICATIONS

CAUSES

• When the roots of the upper posterior teeth are in close proximity to the antral floor.

• When the extraction of upper posterior teeth has been traumatic.

• Bulbous curved long roots• Surgical extractions.• Hypercementosis / Ankylosis

of upper posterior teeth which make extractions difficult.

• Antral pneumatisation around a lone standing tooth.

• Cysts/infection associated with upper posterior teeth.

• Neoplasm

DIAGNOSIS

• If you suspect an OAC, ask the patient to blow whilst you occlude the nose: Bubbling indicates an OAC.

• Patients complain of nasal regurgitation of liquids which is unilateral

• Altered nasal speech• Bad taste (can also be

from a dry socket)• Unilateral nasal

discharge• Recurrent sinusitis on

the affected side

TREATMENT

• ANTRAL REGIME:

• Antibiotics• Analgesics• Decongestants• Mucolytics

• CLOSURE WITH A FLAP:

• Buccal Advancement Flap

• Buccal Fat Pad• Palatal Rotation Flap

POST-EXTRACTION COMPLICATIONS

HAEMORRHAGE

PAIN

INFECTION

HAEMORRHAGE

REACTIONARY HEMORRHAGEWhen the vasoconstrictor from the local anaesthetic wears off, there is a rebound

effect with vasodilatation to cause bleeding.

MANAGEMENT:Visualise the site of haemorrhage. Apply pressure with gauze or use a local anaesthetic with vasoconstrictor….Use surgicel and place a suture if need be!!

HAEMORRHAGE

SECONDARY

HAEMORRHAGEOccurs at least 5

days post-

operatively. The

blood clot is

broken down from an

infection.

MANAGEMENT

Curettage and debride the

socket.

If the site is not acutely inflamed,

place LA.

Place surgicel and a suture ….

bone wax if the bleeding is from

hard tissues.

Prescribe antibiotics if there are

signs of systemic involvement, or

the patient is predisposed to

infection(diabetic, immune

compromised…)

Re-emphasise post-op mouth

care

PAIN

Most patients will suffer from pain after an extraction. Therefore, recommend simple analgesia.

Use SOCRATES to diagnose post-op pain.

PAIN

Causes of post-extraction pain include:• Pain from the extraction.• Dry socket.• Retained root or bone spicules.• Damage to adjacent teeth causing pulpal pain.• Damage to adjacent soft tissues which are then

sore.• Dislocated mandible.• Bony fractures.

INFECTION

It results from the failure of the clot being retained due to vigorous rinsing or lytic organisms breaking down the clot. Dry sockets occur more frequently in patients who smoke.Classically presents as severe throbbing pain +/- lymphadenopathy. It tends to have an onset of 3-5 days after extraction. Grey/White bone is visible.

MANAGEMENT Irrigate the socket with Chlorhexidine, and pack in alvogyl. Review in a few days time

DRY SOCKET

COMPLICATIONS AND MANAGEMENT

PRE-OPERATIVE

INTRA-OPERATIVE

POST-OPERATIVE