COMPLICATIONS OF EXODONTIA
By- Ragini Adhikari
According to Geoffrey L. Howe –
Exodontia or Extraction is the painless removal of whole tooth or
tooth root with minimal trauma to the investing tissues, so that
the wound heals uneventfully and no post-operative prosthetic
problem is created.
Complications occurring during the surgical procedure:-
1. Soft tissue injury
2. Extraction of wrong teeth
3. Fracture of the teeth during extraction
4. Fracture of tooth root during extraction
5. Fracture of the tuberosity
6. Displacement of the tooth into the maxillary sinus
7. Creation of Oro-antral fistula
8. Fracture of Mandible
9. Breakage of Instrument
10. Luxation of the adjacent tooth
11. Injury to inferior alveolar nerve
12. Injury to lingual nerve
13. Swallowing of teeth
14. Dislocation of condyle
Complications occurring after the surgical procedure :-
1. Presence of bony spicule
3. Dry socket
SOFT TISSUE INJURY
Types and Causes
Abrasion – these injuries are caused by careless use of rotatory instruments (like
burs while bone cutting.)
Thermal injuries – caused when instrument taken out from Autoclave or hot air
oven are used immediately intra-orally.
Mucosal injuries – caused due to injudicious used of instruments, improper
elevation of flap or the exercise of excessive force.
Take extreme care during the handling of the rotary or other hand
Use well cooled instruments to prevent thermal injuries.
Properly retract the cheek and lips during dental procedures.
If the tear or abrasion is large, suturing should be done for closure.
Scars produced due to thermal injuries can be managed by the application of
petroleum jelly or topical antiseptic/analgesic.
EXTRACTION OF THE WRONG TEETH
Inform the patient
Replace the tooth inside the socket as soon possible and splint.
If immediate replacement is not possible, place the tooth in a proper medium
like saliva, milk or water.
Follow up as for traumatic avulsion and re-implantation.
FRACTURE OF THE TEETH DURING
Application of wrong forceps
Improper application of forceps
Extensively carious tooth
Endodontically treated tooth
Curved or hypercementosed root
Proper radiograph assessment of the tooth to be extracted
Proper forceps technique
Using transalveolar removal technique if intra-alveolar extraction is not feasible
When the fracture involves the crown of the tooth appropriate restoration
should be placed.
FRACTURE OF TOOTH ROOT
Application of improper instrument and force.
Ankylosed or Hypercementosed teeth
Excessively curved roots
Endodontically treated root
Consequences of retained roots
Retained roots may acts as a source if infection. They might be chronic source
of irritation giving rise to Neuralgic Pain. Large retained tooth may interfere
with the proper functioning of prosthesis.
Methods of retrieval of fractured root
Using appropriate elevators, forceps with slender beaks and Reamers for
removal of fractured root at various levels.
FRACTURE OF TUBEROSITY
In cases where the antrum extends into the tuberosity, the extraction of the
third molar can result in fracture of tuberosity.
Exertion of excessive force and improper force application
Fusion of the roots of second molar with the un-erupted third molar
Divergent and hypercemetosed roots of the third molar.
Proper analysis of the radiograph of tooth and surrounding structures.
Correct technique of extraction with careful force application
Support to the alveolus during extraction.
In case of small fractured segment, a mucoperiosteal flap is elevated and the
tuberosity is removed with tooth, followed by wound closure.
In case of large fractured segment, it should be replaced and splinted
Removal of tooth should be done after the healing of fractured site.
DISPLACEMENT OF TOOTH INTO MAXILLARY
The roots of the maxillary posterior teeth are always in a close proximity to the
maxillary sinus such that the large antral cavities may dip in between the apices
of the teeth.
With advancing age the degree of pneumatisation of the maxillary sinus
increases and the antral walls become very thin. Thus eventually the roots being
covered only by thin lamellae of bone which fracture easily and result in the
displacement of the root tip during its removal.
Sometimes the tooth may slips into the maxillary antrum like the ‘popping of an
orange seed’ once the extraction forceps are applied.
Application of appropriate force and proper handling of forceps.
Avoid injudicious instrumentation to remove a broken tip.
Proper radiographs should be taken before the extraction to access the
proximity of the root tip to the sinus
Support the alveolus adequately before the extraction.
Confirm the presence and location of the tooth or root tip in the sinus using
Once the location is confirmed, keep a nozzle connected to a powerful suction
devise at the entrance of the fistula to recover tooth
Pack a piece long roller gauze into the sinus through the opening and remove it
with a jerk, the root tip might get removed with the gauze.
If none of the above procedure works, then Caldwell-Luc operation is carried
CREATION OF OROANTRAL FISTULA
Close proximity of the posterior teeth to the sinus predisposes to an
oro-antral fistula during the extraction of these teeth.
Injudicious instrumentation to remove a broken root tip.
All the conditions which apply to the cause of displacement of the teeth into
the maxillary sinus.
Same as that for displacement of the teeth into the maxillary sinus.
As far as possible leave the clot as it is and do not disturb it.
Prescribe antibiotics, analgesics, nasal drops and nasal decongestants to
control any infection.
For large defects surgical closure is done.
FRACTURE OF MANDIBLE
Atrophic mandible as in old age.
Existence of any bony pathology.
Excessive force application
In case of removal of vertically impacted third molar.
Proper preoperative assessment of the type of impaction and the density of
the bone before extraction
Proper support of the jaw during extraction
Application of adequate force.
Inform and reassure the patient.
ORIF of the fracture accordingly.
BREAKAGE OF INSTRUMENT
Application of excessive force
Defect in manufacturing of instruments
Old and worn out instruments
Proper selection of the instrument
Proper handling and usage
Remove the burs or elevator tips with a hemostat if it is possible.
If impacted deeply, surgical removal of the instrument is advised, unless
contraindicated as in close proximity to vital structures.
LUXATION OF ADJACENT TOOTH
No support to the adjacent structures during extraction.
Proper technique and careful handling of the instruments.
Support the adjacent teeth adequately before extraction.
Reposition the tooth inside the socket and splint it
The tooth should be treated endodontically after one week.
INJURY TO INFERIOR ALVEOLAR NERVE
Injury to the inferior alveolar nerve may result in paresthesia or
anaesthesia of the nerve’s dermatome - tongue, lip or chin.
During the removal of an impacted mandibular third molar, which is in close
proximity to the inferior alveolar nerve.
Careless manipulation of the instruments resulting in nerve damage.
Proper radiographic assessment of the proximity of the impacted third molar
to the inferior alveolar nerve before its removal.
Careful manipulation of the instruments.
1. Nonsurgical management
Because most patients are known to recover spontaneously to some degree.
2. Surgical management
Decompression if impingement of nerve is present
Micro neurovascular surgery.
INJURY TO LINGUAL NERVE
The nerve may be damaged during the removal of the third molar when the
lingual cortex fractures.
There is risk of damage during the elevation of the lingual mucoperiosteum.
Proper technique and careful manipulation of the instruments.
Reassure the patient, review regularly.
If there are no symptoms of recovery or negative Tinel’s sign, attempt nerve
SWALLOWING OF TEETH
Careless handling of the instruments
Confirm the presence of teeth in the GIT.
Confirm the expulsion of the tooth using serial radiographs.
DISLOCATION OF CONDYLE
Exertion of excessive force
Failure to support the mandible adequately during extraction
Number of previous episodes of dislocation
Proper exertion of adequate force
Support the mandible during
Take a radiograph of the area
If the condyle is dislocated into the middle cranial fossa, refer to an oral
Manual reduction of anterior displacement of the condyle requires downward
pressure on the retro molar region and simultaneous upward pressure on the
Long standing dislocation may require prolonged traction on the mandibular
ramus under general anaesthesia or open reduction.
PRESENCE OF BONY SPICULE
Improper and careless technique of extraction
Checking the socket for any sharp edges before
Filing or removal of the bony spicule.
Bleeding is a common sequel of oral surgery.
There are three types of Post-operative bleeding:-
1. Primary – Occurs continuously just after the surgery
2. Reactionary – Haemorrhage restarts after a period of about three hours.
3. Secondary – Occurs after few days of the procedure
A proper medical history of patient to detect any systemic disorders.
The necessary investigations such Bleeding Time and Clotting Time detection
Avoid incision, flap opening or soft tissue trauma.
After extraction of tooth, apply digital pressure continuously for 2-4 minutes
If bleeding continues from the socket, then pack the bony socket with
Gelfoam, fibrin foam, surgical or bone wax
Put a gauze piece at the site of bleeding to stop bleeding and facilitate clot
Term given by Crawford in 1896. It is defined as a post-operative pain in and
around the dental alveolus, which increases in severity at some moment between
the first and third day after a dental extraction, accompanied by partial or total
disintegration of the intra-alveolar clot, causing foul smell.
Synonyms - Necrotic Alveolar Socket
Osteomyeliric post-extraction syndrome
Localised alveolar osteitis
1. Difficult or traumatic extraction
Painful or more traumatic extraction would leads to:
Delayed alveolar healing
Thrombosis of the underlying vessels
Lesser resistance to infection
2. Use of oral contraceptives
Estrogens and other drugs activate the fibrinolytic system in an indirect way by
increasing the factors II, VII, VIII, X and plasminogen; contributing to premature
destruction of the clot and the development of dry socket.
3. Hormonal changes
Changing levels of endogenous estrogens during the menstrual cycle would also
Tobacco interferes with the alveolar healing is the incorporation of pollutants in the
wound or the suction effect on the clot in formation.
5. Inadequate Intra-operatory Irrigation
Use of anesthesia solution with vasoconstrictor or an intra-ligamentous technique
of anesthesia, where solution is deposited very near to the alveolus and if the
Solution is colder than the corporal temperature increases the incidence of dry
6. Advanced age
Old age people with immunocompromised state, extraction site in the mandible,
excessive or exaggerated irrigation of the socket.
• Usually occurs on the 2nd or 3rd day after extraction and its usually lasts
either with or without treatment for about 10-15 days.
• Pain is localized to the extraction socket which will be sensitive to even
• Pain is sharp in nature that increases with the suction or mastication.
• It may radiate to the ear or ipsilateral side of the head.
It is the result of complex interaction between surgical trauma, local bacterial
infection and various systemic factors. It is invariably present.
3. UNPLEASANT TASTE commonly sour taste.
4. INFLAMMED GINGIVAL MARGIN at the site of extracted tooth.
Process of Normal Healing – takes place in five stages :-
STAGE – I Haematoma & Clot formation
STAGE – II Granulation Tissue Formation
STAGE – III Replacement of Granulation tissue by Connective tissue
STAGE – IV Replacement of Connective tissue by Coarse bone
STAGE – V Replacement of Coarse bone by Mature Bone
Formation of Dry socket
The classical triad of- early extraction socket clot loss/necrosis, pain and fetor oris
has been termed as dry socket or Alveolitis sicca dolorosa.
Theories of Dry socket
I – Birn’s Fibrinolytic Theory
II – Bacterial Therory
BIRN’s FIBRINOLYTIC THEORY
According to this theory, after the extraction of a tooth an inflammatory process
begins that could effect the formation and retention of the clot. There is an
increase in local fibrinolysis leading to disintegration of the clot. The fibrin would
disintegrate due to the effect of kinase released in the inflammation process or
due to direct or indirect activation of Plasminogen.
No. of fibrin
According to this theory, occurrence of dry socket is more due to existence of a
high count of bacteria around the extraction site.
E.g..- Actinomyces viscous and Streptococcus mutans
(they retard the alveolar post-extraction healing)
• A comprehensive history with identification of risk factors.
• Pre-operative oral hygiene measure such as oral prophylaxis should be
• Avoid extraction of lower 3rd Molars in the presence of active infection or
• Patients who smoke should be advised to cease smoking pre-operatively and
post-operatively at least for two weeks while the socket heals.
• Appropriate antibiotic prophylaxis for immunocompromised patients and
patients with history of pericoronitis and Ulcerative gingivitis.
• Patient should be advised to avoid vigrous mouth rinsing for the first 24 hours
post extraction and to use gentle tooth brushing and mouth rinses for seven
• The affected socket should be gently irrigated with 0.12% warmed
chlorhexidine and all debris should be delighted and aspirated.
• Intra-alveolar pastes consisting of Zinc oxide eugenol; anesthetic and
antibiotic. Place a strip of paste soaked a surgical gauze in the socket and do
not exert pressure on the socket while placing the strip.
• The topical use of application of an emulsion of oxytetracycline and
• Appropriate analgesics as the non-steroidal anti-inflammatory drugs for
• Patient can be instructed in-home socket irrigation techniques using
• Patient should be kept under review until they are pain free and socket
healing is ensured.