complication of exodontias dr. rahaf al-habbab bds. msd. daboms diplomat of the american boards of...

Complication of Exodontias Dr. Rahaf Al-Habbab BDS. MsD. DABOMS Diplomat of the American Boards of Oral and Maxillofacial Surgery

Best way to deal with complications? Prevent It

How to Prevent Complications? Thorough pre-operative assessment Comprehensive treatment Planning Careful execution of the surgical procedure Dentist limitations and capabilities (Referral)

complications Soft Tissue

Soft Tissue Injuries Lack of attention of the delicate nature of the oral mucosa Inadequate access to perform surgery Use of excessive and uncontrolled force

Tear of a Mucosal Flap Most common soft tissue injury during surgical extraction Causes: Inadequate sized envelope flap Prevention: Create adequate size flap to prevent excessive tension. Use controlled amount of retraction force. Create releasing incision when indicated

Puncture Wound Frequently occurring injury Cause: Uncontrolled use of force Prevention: Controlled force Use finger rest or other hand support to prevent slippage. Management: Control hemostasis Leave it unsutured to allow for drainage if small infection occurs

Stretch or Abrasion Abrasions or burns of the lip, corner of the mouth, or flaps Causes: Rubbing of the rotating shank of the bur with the soft tissue Prevention: Surgeon and assistant full attention towards the shaft and soft tissue. Management: Keep it clean with regular rinsing Usually heals in 4-7 days (depending on the depth). skin: Cover with antibiotic ointment Heals in 5-10 days

Dental Injuries

You are extracting a tooth and you hear a crack? What happened? Why? Case

Root Fracture Most common complication associated with tooth extraction Causes: Long, curved, divergent roots that lie in dense bone. Using excessive force Prevention: Always plan for root fracture Surgical extraction if fracture is highly possible Do not use strong apical force on a broken root

You have a fractured maxillary first molar root, and while you are trying to remove it, the root disappeared What happened? Case

Root Displacement Maxillary Teeth Most commonly occur with maxillary molar roots. Using excessive apical pressure result in root displacement to the maxillary sinus Assessment: Identify the size of the root displaced into the sinus (root tip, several millimeters, or an entire root). Assess for the presence or absence of any tooth or periapical infection. Assess the pre-operative condition of the maxillary sinus.

How are you going to manage the situation?

Root Displacement Management Case: Small 2-3mm displaced root tip Tooth and sinus have no preexisting infection Management: Obtain radiograph to document the position and size of the displaced root. Irrigate through the small opening in the socket apex and suction the irrigation solution. Check for the root in the suction and radiograph If not removed, the small non infected root tip can be left in place Proper patient instructions

Root Displacement Management Management of the oroantral communication: Figure of eight suture over the socket Sinus precautions Antibiotics Nasal spray to keep the ostium open, decreasing the chance of infection. Most likely it will fibrose onto the sinus membrane with no subsequent problems

Root Displacement Management Case: Large root fragment Entire tooth displacement Infected tooth root Chronic sinusitis, or Patient should be referred to an OMFS for the removal of the root tip or the tooth through a Caldwell-Luc approach into the maxillary sinus

You are extracting a third molar and the whole tooth disappeared, panoramic radiograph showed no tooth in the maxillary sinus Where is the Tooth? Case

Infratemporal Fossa

Entire Tooth Displacement Infratemporal Fossa More commonly into the 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.

Entire Tooth Displacement (ITF) Management Single cautious effort to retrieve the tooth with a hemostat, if good access and light are available Failure to retrieve the tooth: Close incision and stop operation Patient should be informed Antibiotics should be given to decrease the possibility of infection Fibrosis and tooth stabilization will take place OMFS referral for radiographic localization and removal

While retrieving a fractured lower second molar root tip, the root disappeared Where most likely is the root tip? Case

Mandiblular Teeth The more posterior the tooth the thinner the lingual cortex become. Apical pressure should be avoided. Left hand index finger lingual pressure. Apical pressure on fractured roots can result in its displacement to the Submandibular Space. How to manage?

Mandibular Teeth Abandon the Procedure Refer the patient to an Oral and Maxillofacial Surgeon

Mandibular Teeth Root Displaced into the Submandibular Space: Small non infected root tip Large or infected root tip Risk of Lingual Nerve Injury

While extracting an upper third molar with a forceps, with the entire tooth almost out of the socket, the tooth disappeared Where is the tooth? Case

Tooth Displaced into the Pharynx Crown or entire tooth can be lost into the pharynx. Management: Patient is turned towards the surgeon with the mouth towards the floor as much as possible. Patient is encouraged to cough and spit the tooth out. Use suction to help removing the tooth. Failure

Where is the tooth?

Swallowed or Aspirated How to determine? Violent episodes of coughing or shortness of breath When do you take the patient to the ER? Location Management Post-operative Care

Injuries to Adjacent Teeth

Fracture or Dislodgment of adjacent Restoration The most common injury to adjacent teeth Prevention: Recognize the potential to fracture a large restoration Warn patient preoperatively Use elevators carefully Ask assistant to warn you of pressure on adjacent teeth.

Fracture or Dislodgment of adjacent Restoration Management Displaced restoration or broken tooth should be removed from the mouth. Irrigate the socket. Replacement of the displaced crown or placement of temporary restoration. Patient should be informed about the fractured tooth or restoration and that replacement is needed.

Injury to the Opposite Arch Usually occur when buccolingual forces inadequately mobilize a tooth and/or excessive tractional forces are used Sudden release of the tooth from the socket will take place striking the teeth on the opposite arch, chipping or fracturing a cusp More commonly with lower teeth because they require more vertical traction forces

Injury to the Opposite Arch Prevention Proper luxation is required The surgeon or assistant should protect the teeth on the opposite arch by holding a finger or suction tip against them Management: smooth or restore the injured tooth to keep the patient comfortable until a permanent restoration is constructed.

Luxation of Adjacent Tooth Causes: Improper use of extraction instruments Prevention Force control with the use of elevators and forceps If crowding and overlapping is present the use of narrow forceps is indicated.

Luxation of Adjacent Tooth Management If the adjacent tooth is significantly luxated or partially avulsed Reposition the tooth into its appropriate position and stabilize it so that adequate healing occurs Occlusion should be checked for hypereruption and traumatic occlusion If the luxated tooth is mobile then it should be stabilized with semirigid fixation (silk suture to the adjacent gingiva) Rigid fixation should be avoided if not indicated to decrease the chance of external resorption and ankylosis (circumdental wires or arch bars)

Extraction of the Wrong Tooth Most common cause of malpractice lawsuits against dentists. Causes: Removing a tooth for another dentist The use of different tooth numbering system Difference in the mounting of the radiographs. Orthodontic extraction in mixed dentition

Extraction of the Wrong Tooth Prevention: Careful planning Good communication with the referring dentist Clinical assessment of the tooth to be extracted Check and recheck, images and records to confirm the correct tooth. Management The wrongfully extracted tooth should be replanted quickly into the socket Contact the orthodontist and discuss the incident. 4-5weeks should be deferred before extracting the right tooth, till the fate of the replanted tooth can be assessed. Dental implant supported restoration.

Injury to Osseous Structures Fracture of the Alveolar Process Most likely place for bony fracture are: Buccal cortical plate over the maxillary canine Buccal cortical plate over the maxillary molar Floor of the maxillary sinus associated with maxillary molars Maxillary tuberosity Labial bone of mandibular incisors

Fracture of the Alveolar Process Causes: Use of excessive force with forceps Prevention: Proper assessment of the tooth and root clinically and radiographically Do not use excessive uncontrolled force Use surgical (open) extraction technique to reduce force required.

Fracture of the Alveolar Process Management Depending on the type and severity of the fracture If the bone is completely removed from the socket along with the tooth: It should not be replaced Smooth any sharp edges Proper soft tissue closure should be assured over the remaining bone to prevent delay healing

Fracture of the Alveolar Process Management If the bone is still attached to the periosteum: Separate it from the tooth Leave it attached to the overlying soft tissue Reapproximate the soft tissue and secure it with sutures What is the advantage of attached periostium?

Fracture of the maxillary Tuberosity What is the importance of an intact maxillary tuberosity? Causes: Extraction of erupted maxillary third molar Extraction of maxillary second molar if its the last tooth in the arch

Fracture of the maxillary Tuberosity Management Attached to the periostum vs. not attached If the tuberosity is excessively mobile and can not be dissected from the tooth: First Option Splint the tooth to be extracted to the adjacent tooth, and defer the extraction for 6-8 weeks Surgical extraction

Fracture of the maxillary Tuberosity Management Second option Section the crown from the roots Allow the tuberosity and sectioned roots to heal Reenter 6-8 weeks later and remove the roots surgically. What if the tooth was infected

In follow up visit after second mandibular premolar was extracted, the patient came back complaining of numbness in the lower lip and chin What most likely have happened? Case

Injury to regional Nerves Most commonly involved specific branches are: Mental nerve Lingual nerve Buccal Nerve Nasopalatine Nerve

Injury to regional Nerves Mental Nerve MN

Injury to regional Nerves Mental Nerve Causes: Surgical removal of mandibular PM roots or Impacted premolars Periapical surgery in the area of the mental nerve and mental foramen Three corner flap used in the area of the mental nerve

Injury to regional Nerves Mental Nerve If the injury is the result of flap reflection or manipulation: Normal sensation usually If the mental nerve is sectioned: Nerve function most likely will not return Patient will have permanent state of anesthesia

Injury to regional Nerves Buccal and Nasopalatine Frequently sectioned during the creation of flap for impacted tooth removal The area of sensory innervation of these two nerves are relatively small Re-innervation of the affected area usually occurs rapidly Buccal and Nasopalatine nerves can be surgically sectioned without long lasting sequelae or much bother to the patient

Case Following surgical extraction of a mandibular third molar, the patient came back for follow up complaining of numbness in the ipsilateral side of the tongue as the surgical side What most likely have happened?

Injury to regional Nerves Lingual Nerve The lingual nerve is usually anatomically located directly against the lingual aspect of the mandible in the retromolar pad region

Injury to regional Nerves Lingual Nerve Occasionally, the path of the lingual nerve takes it into the retromolar pad area itself Incisions made for surgical exposure of impacted third molar should be made well to the buccal aspect of the mandible. Excessive dissection and retraction also should be avoided Lingual nerve rarely regenerate if it is severely traumatized

Patient came for follow up visit following surgical extraction of mandibular third molar, complaining of anesthesia and impairment in speech, chewing, and altered sensation with shaving What's your diagnosis? Case

Injury to regional Nerves Inferior Alveolar Nerve Can be traumatized along the course of its intrabony canal Most common place of injury is the area of the mandibular third molar IAN can be bruised, crushed, or sharply injured during surgery

One week following the extraction of both mandibular third molars, patient is complaning of preauricular pain and tenderness with mastication started immediately after the extraction What's your diagnosis? Case

Injury to the TMJ Causes: Applying substantial amount of force during mandibular molars extraction Inadequate jaw support during the extraction Failure to use a bite block on the contralateral side

Injury to the TMJ Management Recommend the use of: Moist heat Jaw rest Soft diet 600-800mg of ibuprofen every 6-8hours for several days, or 500-1000mg of acetaminophen if ibuprofen can not be tolerated

Oroantral Communication Causes Greatly pneumatized maxillary sinuses Little or no bone exist between the roots and the sinus floor Widely divergent roots

Oroantral Communication Prevention Conduct a thorough preoperative radiographic examination Use surgical extraction early, and section roots Avoid excessive apical pressure

Oroantral Communication Diagnosis Examine the extracted tooth for attached bone Avoid sinus propping (membrane, contamination) Use Nose-blowing test (only used if necessary) Guess the size of communication 2mm or less: No additional surgical treatment Measures to insure high-quality blood clot formation in the socket Sinus precautions (to prevent clot dislodgment)

Sinus Precautions Avoid nose blowing Avoid violent sneezing Avoid sucking on straws, pipe, or cigar smoking

Oroantral Communication 2-6mm Communication: Additional measures should be taken to ensure the maintenance of the blood clot Figure of eight suture Gelfoam (gelatin sponge) Sinus precautions Antibiotics, nasal decongestant

Oroantral Communication 7mm or Larger communication: Refer the patient to an OMFS Communication repair with a flap procedure

Postoperative Bleeding Hemeostasis mechanism present a sever challenge, WHY? Highly vascular tissue Open wound after extraction Impossible to apply dressing material with pressure Patients tend to explore the surgical site with their tongue dislodging the clot Salivary enzymes may lyse the clot

Postoperative Bleeding Prevention 1- Obtain history of bleeding, Family history of bleeding (Consult hematologist) Medications (Anticoagulants, anticancer chemotherapy, aspirin) Systemic conditions (Alcoholics, liver disease)

Laboratory Evaluation Patients with suspected coagulopathy should be evaluated by laboratory testing before surgery, INR (International Normalized Ratio) is used to measure therapeutic anticoagulation status INR of 2.5 or less is acceptable. INR of up to 3 in minor surgery. INR of more than 3, physician should be contacted.

Postoperative Bleeding Prevention 2- Use atraumatic surgical procedure : Clean incision and gentle soft Tissue handling Granulation tissue curette (Anatomical restrictions) Remove or Smooth sharp bony spicules

Postoperative Bleeding Prevention 3- Obtain good hemostasis at surgery, Pressure Clamping bleeding artery, Suturing, Gelfoam gelatin sponge, Surgicel oxidized regenerated cellulose, Collagen If bleeding is not controlled in 5 minutes, local anesthesia should be given, block anesthesia instead of infiltration

Postoperative Bleeding Prevention (Collagen Plug)

Postoperative Bleeding Prevention 4- Provide excellent post-operative patient instructions

Thank You

complication of exodontias dr. rahaf al-habbab bds. msd. daboms diplomat of the american boards of...

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