Apply pressure pack

1. ‫سبحان ال وبحمده سبحان ال العظيم‬
Principles of Exodontia
Dr. Adel I Abdelhady
.)BDS, MSC, (Eg.) PhD (USA , Eg
.Oral and Maxillofacial Surgery Dept
.College of Dentistry, KSA
20/01/14

2. Complications of
Exodontia

3. Complications of Exodontia
• During anesthesia
• During extraction
• After extraction

4. Complications of exodontia
 During extraction:
• soft tissue laceration
• Broken tooth
• Haemorrhage
• Oroantral communication
• Luxation of the neighbouring tooth
• TMJ problem
• Fracture jaw
• Tooth ingestion or aspiration

5. Complications of Exodontia
Immediate or operative
Complications

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1- Fractures of teeth
2-Fracture of alveolar bone
3-Fracture of maxillary tuberosity
4-Fracture of the mandible
5-Dislocation of the mandible
6-Lossening or extraction of an
7-Extraction of or injury of
unerupted tooth
8-Disturbing artificial
restoration
9-Gingival laceration adjacent
tooth
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10-Bruising the lip or cheek
11-Injury of the tongue
12-Emphysema
13-Breaking of instrument
14-Injury of inferior alveolar
nerve
15-Forcing of the tooth into
the surrounding soft tissue
space
16-Forcing a tooth or root into
the maxillary sinus or opening
of maxillary sinus

6. Complications of Exodontia


1-Fractures of teeth
This is the commonest complication with
forceps extraction, the causes and management
have been discussed before

7. Complications of Exodontia


2-Fracture of alveolar bone
This occurs frequently when the extraction is
difficult .The fractured bone may be removed and
firmly attached to the tooth , it may remain attached to
the periosteum . The bone attached to the periosteum
should be replaced accurately and held in position by
sutures taken through the extraction socket

8. Complications of Exodontia

3-Fracture of Maxillary Tuberosity

This occasionally occurs when extraction of third
maxillary molars is attempted .It is liable to occur when
such a tooth is firmly ankylosed to the bone or isolated
or has divergent or hypercemtosed root formation.
Also liable to occur when the tuberosity is prominent.
If accident occurs , the operator find him/herself
grasping a large segment of bone , which sometimes
may still attached to the mucoperiosteum


9. .Fracture of Maxillary Tuberosity/ cont-3


Management : If it is a small fragment it should
be surgically excised. A gingival incision around
the involved teeth to raise a flap exposing the
bone with the tooth attached , the fragment is
then freed and removed.
In most cases the maxillary sinus is exposed , the
bone is debrided and the flaps reapposed and
sutured over the exposed sinus. If the fragment
is a large one and carrying more than one sound
tooth, it could be repositioned and fixed with
suitable immediate splint

10. Dislocation of the mandible


It is the dislodgment of the condyloid process from its
seat in the glenoid fossa .One or both joints may be
dislocated. This dislocation is usually the result of using
too much pressure during extraction and inadequate
support of the mandible.
The symptom is classical the mouth is opened and
rigidly set in position with the chin protruding . The
patient cannot close his mouth, depression in front of
the ear , some pain may or may not be present

11. Dislocation of the mandible


Treatment by reduction of the dislocation by the
following technique :
The operator wraps his thumps with gauze as a
safeguard against injury which may result from
immediate and quick closure of the jaw. Then the
thumbs are placed on the occlusal surface of the
mandibular teeth by which downward and backward
pressure is applied meanwhile the free fingers support
the jaw during the application of pressure and to raise
the chin. A bandage is applied to hold the jaw in place
for 48 hours. Analgesic are also indicated in the first
two days

12. Fracture of the mandible

It is uncommon as an
extraction complication. It is
occur as a result of using
excessive force or when
pathological changes have
weakened the jaw. Excessive
force should never be used to
extract teeth. If the tooth
does not yield to moderate
pressure, the reason should
be founded and remedied

13. Fracture of the mandible


The mandible may be weakened by senile
osteoporosis and atrophy , osteomyelitis, previous
radiotherapy , fibrous dysplasia or unerupted teeth,
cysts and tumors may also weaken it and predispose
to fracture .
In the presence of these conditions extraction should
not be attempted in the dental clinic , this patient
should be referred to oral surgery specialty center.

14. Loosening or Extraction of an
Adjacent Tooth


This complication is an avoidable accident , if sufficient
care is exercised in applying forceps or elevator. This
may occur in hasty manipulation or utilizing tooth as a
fulcrum during application of an elevator ,or lack of
good visibility from blood collection.
When such an accident occurs and the tooth is visibly
luxated it should be forced into its normal position and
ligated by wire to its adjacent tooth

15. Extraction of or Injury to an
Unerupted Tooth

This complication may occur
as a result of pushing the
beaks of the forceps beyond
the essential area when
extracting a deciduous tooth ,
when holding it with its
permanent successor , also if
the roots of a deciduous
molar by their arch- like
envelop the unerupted crow
of the permanent tooth
bud.It is also possible to
injury the successor tooth by
dental elevator pressure

16. Gingival Laceration

This can be the result of slipping or
misapplication of the instruments. Also the gum
may adhere to a tooth while being delivered
from its socket . In such a case the tooth should
be carefully dissected from the attached gum
with a scalpel before any further attempts to
deliver the tooth are made, the lacerated gum
may cause hemorrhage if not sutured back in
place

17. Bruising the lip or cheek

The lower lip may be crushed between the
handles of the forceps and the anterior teeth , if
sufficient care are not taken . Traumatization of
the cheek occur if the forceps slips from its
adjustment on the tooth during extraction
movement , proper attention should be taken to
avoid this complication.

18. Wounding of the Tongue

Trauma to the tongue or the floor of the mouth
may occur during the extraction of the lower
teeth as a result of carelessness or hasty
extraction or as a result of slipping of an
elevator. Profuse bleeding is a common finding ,
such wounds should be sutured.

19. Emphysema

It a swelling due to accumulation of air into the
connective tissue of intermuscular facial planes .
It usually follows prolonged reflection of large
flaps together with the use of drills, the swelling
is usually very rapid in onset, giving the affected
area elastic consistency with crepitations. The
condition is alarming to the patient but not
dangerous. It take 7-10 days to be absorbed

20. Injury to the Inferior Alveolar Canal

If the root is in an
intimate relationship with
the inferior dental nerve ,
damage can be prevented
by careful surgical
dissection of the root .
Careless curettage and
blind use of elevator to
remove root apices may
cause laceration of the
neuro-vascular bundle
Sometimes small bone
fragments may be displaced and
impinge upon the nerve this lead
to numbness and paresthesia of
half of lower lip and chin ,
however in most cases the
nerve usually regenerates within
6 weeks - 6 months

21. Injury to the Inferior Alveolar Canal
Deep Seated Teeth More Vulnerable to cause Nerve Injury
During Surgical Removal

22. Injury to the Lingual Nerve

The lingual nerve may be
damaged either by traumatic
extraction of lower third
molar, in which the lingual
soft tissue are trapped in the
forceps or by being caught
up with bur during bone
removal a retractor should be
used to protect the adjacent
soft tissues

23. Forcing a Tooth or Root into the
Surrounding Soft Tissues


In attempts to remove broken roots of the
mandibular molar, sometimes they are pushed
through the thin inner surface of the mandible
in the region of the submandibular fossa .
Also then lingual plate may be broken during the
process of root removal or has been perforated
by a chronic inflammatory process.

24. Maxillary Sinus Involvement


The maxillary sinus may be
accidentally opened and roots
of molar or premolar may be
displaced into it . This is
common if the teeth project
into the sinus .
Apical infection favor
perforation because the bone
between the root and the
sinus completely destroyed
by the process of chronic
infection
Oroantral
communication

25. .Maxillary Sinus Involvement Cont


If the opening of sinus is small , blood clot
filling the extracted socket and uneventful
healing will occur. In larger perforation surgical
closure is advisable , otherwise oro-antral fistula
will happened . If root or a tooth has been
forced into the antrum , its removal is indicated.
First clinical examination whether the root is
actually in the antrum or just slipped between
the outer wall of the bone and the periosteum .

26. .Maxillary Sinus Involvement Cont

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Tricks that may be tried to remove root from the
maxillary sinus :
1-Ask the patient to blow with the nostrils closed while
the perforation is carefully watches for the appearance
of the root
2-Use of suction tip in the socket may aid in the
removal
3-A long piece of iodoform gauze packed through the
socket into the antrum and pulled out in one stroke. It
sometimes removes the root by friction

27. .Maxillary Sinus Involvement Cont


4-In most instances a
mucoperiosteal flap on the
buccal surface of the jaw
after perforation enlarged
give sufficient access so that
the root can be seen and
removed
However , in all cases of
traumatic perforation of Max.
Sinus , the oro-antral fistula
should be closed by
approximating the buccal and
palatal mucoperiosteum at
Oroantral communication
the orifice of the socket
together and sutured them
tightly .

28. .Maxillary Sinus Involvement Cont
Buccal advancement flap
used for closure of oroantral fistula or
communication

29. Surgery for Oroantral
Communication
Etiology
• tooth extraction
• periapical lesions
• maxillary cysts surgery
•Closure of oroantral fistulas/ communication
Buccal flap
Palatal flap
Bony & soft tissue
defects
( Caldwell-Luc procedure)

30. Oroantral communication
Tooth extraction for 4m
post-extraction,
dull aching pain and soft tissue reaction
over the extraction socket
Water’s view
Shadowing
sinusitis

31. Closure of oroantral fistulas/
communication
Excision of fistula
Buccal flap
reflection

32. Buccal flap advancement
Extending the mucoperiosteal flap
C:Internal periosteal
releasing incision

33. Buccal flap advancement
Smooth the bony edge

34. Buccal flap advancement
Trim the excess
tissue
Suturing with mattress suture

35. Buccal flap advancement
Mattress suture
• Interrupted suture
•

36. Buccal flap advancement
3m post-op

37. DELAYED or POST-OPERATIVE
COMPLICATIONS
HEMORRAGE or Bleeding

Hemorrhage is the escape of blood outside the vascular system.

Types:

External : if blood escape outside the body or

Internal : if blood escapes inside one of the body cavities e.g.

submandibular , sublingual or deep neck spaces.

Hemorrhage could be : i-Arterial ii-Capillary iii-Venous

Also hemorrhage could be :

Primary ; Intermediary or Secondary

Primary Hge. Occurs at the time of operation

Intermediary Hge. Occurs withen 24 h. after primary bleeding has been controlled

Secondary Hge. Occurs at any time after the first post op.day

38. Causes of Hemorrhage

Local Causes

1-Interference by the patient to the formed clot , by
excessive spitting or sucking of the wound
2-Improper instructions for the use of pressure packs
3-Failure of the blood clot to form due to severed
vessels
4-The presence of nutrient canal in the wall of a bony
socket and failure of blood clot to form on the top of a
relatively large sized, severed vessels
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

39. Systemic Causes of Hemorrhage
The systemic causes of Hge. Could be either due to vascular
defect or coagulation disorder
 1- Vascular Defects
These are conditions in which there are structural or functional
defects of the vessels themselves affecting the normal vascular
contraction after the vessel is cut leading to bleeding e.g.
hereditary hemorrhagic telangectasia
 2-Coagulation Disorders
These are conditions in which bleeding is due to the absence of one
or more of clotting factors necessary for a normal coagulation
mechanism


40. Coagulation cascade
BV Injury
Contact/
Tissue
Factor
Neural
Blood Vessel
Constriction
Platelet
Aggregation
Coagulation
Cascade
Primary hemostatic plug
Reduced
Blood flow
Platelet
Activation
Stable Hemostatic Plug
Fibrin
formation

41. 
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What are the types of investigation that must
to be done in order to diagnose the cause of
bleeding?
???????
How we can differentiate between bleeding due
to local or systemic cause?????????

42. 
Normal hemostatic mechanisms are vascular
response, plt plug formation and activation of
coagulation factors with fibrin formation to
stabilize the plt plug.

43. Management of patients with Hemorrhage
after teeth extraction


Patient suffering from post extraction bleeding are
apprehensive from blood that is filling their mouth . In
dealing with patient suffering from bleeding the
following should be done :
1-Prevention and Treatment of Psychogenic Shock:
this type of shock due to fear , so its prevention
depends to a great extent on a dentist behaviour and his
calm attitude when he receives the patient ,by allaying
patient apprehension and assuring him that this
condition will be controlled , after that the patient
should be placed in a position facilitated cerebral
circulation and this produce quick recovery.

44. Management of patients with Hemorrhage
after teeth extraction
2-Diagnosis and looking for the Cause of Hemorrhage :
 The actual cause of bleeding should be discovered, look for
tendency of the blood to clot, if the blood have a tendency to
clot so the blood clotting mechanism is normal and the
bleeding is due to local factors and could be managed as
following.
 A-Clear the patient mouth from accumulated blood
 B-Examine the bleeding area to find out if the bleeding is
coming out from lacerated soft tissues or it is coming from the
bony socket
 C-In cases of bony socket bleeding the socket should be carefully
examined to fined out if bleeding is due to severed inferior
dental vessel , a nutrient canal or it is simply due to interference
of the patient to the blood clot

45. Management of patients with Hemorrhage
after teeth extraction

Patient with suspected coagulation disorder or systemic
hemorrhagic disease have to be hospitalized after local
measures to stop bleeding are carried on to minimize
the amount of blood loss

3-Treatment of the cause Hemorrhage :

1-If bleeding is due to soft tissue laceration should be
sutured
2-If bleeding is due to interference by the patient to the
formed clot, it is controlled by the use of pressure
packs and proper post-operative instruction


46. Management of patients with Hemorrhage
after teeth extraction



3-If bleeding is due to the presence of nutrient canal
this could be controlled either by bone wax to occlude
the canal or by crushing of some spongy bone into the
bleeding point by the tip of a blunt instrument
4-If hemorrhage is due to severed inferior dental vessels
a local haemostatic such as thrombin , oxidized
cellulose, fibrin foam or gelatin foam
5-If hemorrhage is due to systemic disease , the
treatment is directed to mange the underlying systemic
problem and by doing the required investigations.
Using local haemostasis by suturing or using local
haemostatic measure

47. DRY SOCKET

Dry socket , painful socket; or
alveolagia , localized osteomyelitis
all synonyms describing the faulty
healing of the socket. The
condition characterized by an
actual painful socket containing
bare bone and broken – down
blood clot.

Etiology and predisposing factors

1-Pre- existing infection about the
apex of the tooth root
2-Trauma to socket and
surrounding bone and soft tissue
especially using burs and repeated
application of elevators

Dry Socket

48. DRY SOCKET

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3-The use of high concentration of vasoconstrictors in
the LA used for infiltration, may prevent quick
formation of blood clot
4-Excessive or early use of mouth washes and sucking
on clots.
5-Curettage after extraction of acutely infected teeth
6-Extraction of teeth in patient having systemic disease
promoting to infection such as diabetes and leukemia
7-Patients under cortisone therapy, uncontrolled
diabetic and under contraceptive pill therapy are liable
to the development of dry socket

49. DRY SOCKET





Treatment :
1-The socket should be irrigated with warm normal
saline and all degenerated blood-clot is removed
2-Sharp bony spurs should be either excised with
rongeur forceps or smoothed with a bone file
3-A loose dressing composed of zinc oxide and oil of
cloves or a pack composed of white head varnish
4-Sedative and antibiotic could be prescribed

50. Facial Swelling





A-The post-extraction swelling
May be due to traumatic edema which
develops as a result of excessive
retraction of flaps or rotatory bur
traumatize the soft tissues.
The traumatic edema can be prevented
by the application of cold fomentation in
the first day after extraction
B-Infection of the wound
A more serious case of postoperative
swelling is infection of the wound. The
treatment of such infection is by the use
of mouth washes and antibiotic therapy.
If fluctuation is present the pus should
be evacuated before beginning antibiotic
therapy

51. Abnormal fistulous tract at the side of the nose
from chronic infection of the teeth No. 10,11 &12

52. TRISMUS
Trismus is defined as inability to open the mouth due to
mouth spasm. Trismus may complicate dental
extraction . It may be caused by post-operative edema ,
hematoma formation or inflammation of the soft
tissues.
A mandibular block injection may be followed by trismus
this is either due to infection or trauma from the needle
The treatment of the trismus varies with the underlying
cause . Hot saline mouth washes, gives relief in mild
cases but most patients require the administration of
antibiotic

53. Complications of exodontia
 Post extraction
• Haemorrhage
• Infection, dry socket
• Pain
• Numbness
• Referred pain