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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!!
HAEMORRHAGESE
COND
ARY
HAEM
ORRHA
G
E
Occur
s at l
east
5
days
pos
t-
oper
ative
ly. T
he
bloo
d clo
t is
brok
en d
own
from
an
infe
ction
.
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