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Complications of Extractionof Impacted Teeth
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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
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I. Soft Tissue Injuries
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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.
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Prevention-Adequately sized flaps-Gentle Retraction
ManagementReposition the flap & sutureIf the tear is jagged, trim it before suturing
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2. Puncture Wound of Soft TissueCause
Instrument Slippage
PreventionControlled force
ManagementSuturing to prevent infection & allow healing to occur
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3. Stretch or Abrasion InjuryCause
Bur shank or retractor injury
PreventionCare
ManagementKeep it moist ( ointment )Heals within 5 – 10 days
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II. Complications with the tooth Being Extracted
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1. Root Fracture
CauseLong, curved, divergent rootsExcessive force during extraction
PreventionProper exposure & bone removal
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2. Root Displacement
Into:• Mandibular Canal• Lingual Pouch• Infratemporal Space• Maxillary Sinus
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III. Injuries to Adjacent Teeth
1.Luxation of Adjacent Teeth2.Fracture of Adjacent Restoration
CauseCarelesness
PreventionJudicious use of elevators
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IV. Injuries to Osseous Structures
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1. Fracture of Alveolar ProcessFracture of the Buccal or Lingual Cortex
CauseInadequate exposure & excessive force
PreventionAdequate bone removal & eposure
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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
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3. Fracture of the Mandible
CauseExcessive force
PreventionProper bone removal & controlled force
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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
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V. Injuries to Adjacent Structures
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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
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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
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3. Injury to the TMJCause
Inadequate support of the mandible during extraction
PreventionUse of bite block
ManagementReduction
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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
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VII. Postoperative Bleeding
Cause-Bleeding at wound margins-Bleeding at a bony foramen within the socket-Medical Problem
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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
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ManagementLocal Measures
• Pressure packs• Suturing• Ligate bleeding vessels• Burnish bone• Apply material to aid in hemostasis (surgicell,
collaplug)
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VIII. Delayed Healing & Infection
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1. InfectionCause
Debris left under the flap
PreventionIrrigation
ManagementDebridement & Drainage
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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
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Management– Irrigate with warm saline– Remove old clots– Place sedative dressing– Prescribe mild analgesics– Reassess after 24 to 48 hours