Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Complications of Exodontia


Published on

Anaesthesia & Exodontia
Third Year

  • Login to see the comments

Complications of Exodontia

  1. 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. 2. Complications of Exodontia
  3. 3. Complications of Exodontia • During anesthesia • During extraction • After extraction
  4. 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. 5. Complications of Exodontia Immediate or operative Complications          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        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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 21. Injury to the Inferior Alveolar Canal Deep Seated Teeth More Vulnerable to cause Nerve Injury During Surgical Removal
  22. 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. 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. 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. 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. 26. .Maxillary Sinus Involvement Cont     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. 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. 28. .Maxillary Sinus Involvement Cont Buccal advancement flap used for closure of oroantral fistula or communication
  29. 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. 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. 31. Closure of oroantral fistulas/ communication Excision of fistula Buccal flap reflection
  32. 32. Buccal flap advancement Extending the mucoperiosteal flap C:Internal periosteal releasing incision
  33. 33. Buccal flap advancement Smooth the bony edge
  34. 34. Buccal flap advancement Trim the excess tissue Suturing with mattress suture
  35. 35. Buccal flap advancement Mattress suture • Interrupted suture •
  36. 36. Buccal flap advancement 3m post-op
  37. 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
  38. 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   
  39. 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. 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. 41.    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. 42.  Normal hemostatic mechanisms are vascular response, plt plug formation and activation of coagulation factors with fibrin formation to stabilize the plt plug.
  43. 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. 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. 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. 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. 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. 48. DRY SOCKET      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. 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. 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. 51. Abnormal fistulous tract at the side of the nose from chronic infection of the teeth No. 10,11 &12
  52. 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. 53. Complications of exodontia  Post extraction • Haemorrhage • Infection, dry socket • Pain • Numbness • Referred pain