Complication and management of tooth extraction or exodontia
[DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY]
COMPLICATION AND MANAGEMENT OF
PRSENTING BY: RAHUL TIWARI
• Any adverse , unplanned events that tend
to increase the morbidity above what
would be expected from a particular
operative procedure under normal
Sources of complications
Surgical complications may arise from either one or a
combination of the following factors.
THE PATIENT- Medically compromised pt. leading to an
persistent haemorrhage or delayed healing.
-level of training , skills and experience.
-attitudes towards total patient care.
THE SURGICAL PROCEDURE
risks depend on :-
-complexity of the procedure.
-local anatomy of the surgical site
-proximity of important vital structures.
Failure to -secure anaesthesia
-remove the tooth with either
forceps or elevator
Fracture of-crown of the tooth /root
-adjacent or opposing tooth
Dislocation of -adjacent tooth
Displacement of the root
-into the soft tissues
- maxillary antrum
- During tooth removal
- on completion of the extraction
- postoperatively 5
- gums/lips/tongue/floor of mouth
- inferior dental nerve & branches
- lingual nerve
- damage to hard & soft tissues
- dry socket
- acute osteomyelitis of mandible
- traumatic arthritis of TMJ 6
2-Failure to -remove the tooth with either
forceps or elevator
• Tooth fails to yield to the application of
reasonable force applied with either forceps
• Tooth dissection
3-Fracture of the crown of a tooth
• Weakened tooth- caries or large restoration
• Improper application of the forceps
• Excessive force
• proper application of forceps or elevator will deliver the
tooth or Transalveolar method
5-Fracture of the alveolar bone
• Accidental inclusion of alveolar bone within
• Pathological changes in the bone
• Shape of the alveolus
• Extraction of canine is frequently complicated by
fracture of the labial plate.
• Alveolar fragments which has lost one half of the
periosteal attachment should be removed. if it well
attached to periosteum, should be sutured back
6-Fracture of maxillary tuberosity
Predisposing cause –
• Pathological gemination between the erupted
maxillary second molar & unerupted max.
• Overerupted isolated max molar
7-Fracture of an adjacent or opposing
• Precautions :
• Careful pre-op examination (carious, heavily
restored, loose, line of withdrawal)
• No force should be applied to any adjacent
• Other teeth should not be used as fulcrum for
• Any loose, heavily restored tooth should be
noted & brought to the notice of anesthetist.
8-Fracture of the mandible
Excessive or incorrectly applied force
Pathological changes of mandible
Previous therapeutic irradiation
Unerupted teeth, cysts, hyperparathyroidism
or tumours may also predispose to fracture
9-Dislocation of adjacent tooth &
Causes same as those giving rise to fracture of adjacent tooth
Elevator should not be placed on the mesial aspect of first
During elevation a finger should be placed upon the adjacent
tooth to support it .
Dislocation of TMJ
Application of excessive force
Failure to support the mandible while extracting a difficult
More likely to occur under general anesthesia when
mastication muscles are relaxed
• Reduction is done with the thumb wrapped with
gauze or bandage to avoid injury by teeth and
placed on the occlusal surfaces of mandibular
posterior teeth and finger under the lower border
of the mandible.
• Mandible is then pushed downward backward
rotating the chin upwards .with this manpower the
condyles are moved downwards and backwards
over the articular eminences of temporal bone.
• Patient should be warned not to open his mouth too
widely or to yawn for postoperatively .patient is
instructed to support the jaw during yawning.
• extra oral bandage support for the joint is applied and
worn until tenderness in the affected joint subsides.
• Failure to reduce dislocation reduction can be
attempted under 5-10mg of IV/IM valium
• Failure to reduce the dislocation or if there is resistance
encountered LA solution is injected high in the buccal
sulcus bilaterally adjacent to max third molar region
similar to the technique of posterior superior alveolar
nerve block. This helps in paralyzing lateral pterygoid
muscles and over comes Muscular spasm
10-Displacement of a root into the
• Ineffectual attempts to grip the root when
visual access is inadequate.
• Maxillary premolar or molar- palatal root.
• Predisposing factor – large antrum
DISPLACED PALATAL ROOT OF MAXILLARY 1ST MOLAR
Simple rules to avoid displacement:-
Never apply forceps to a maxillary post. teeth
unless sufficient of its length is exposed, both
palatally & bucally .
Leave the apical one third of the palatal root
of a maxillary molar.
Never attempt to remove a # maxillary root by
passing instruments up the socket.
Any previous history of antral involvement
should not be disregarded.
11-Aspiration of tooth/root
• Under GA – more common
• Anaesthetic should be stopped immediately
& patient’s head brought forwards.
• After cough reflex has returned the mouth is
examined & pack carefully removed &
• Radiographs – socket & chest
12-Damage to adjacent tissues
Damage to the gum can be avoided by careful
selection of forceps & good technique.
The lower lip may be crushed between the
handles of the forceps & anterior teeth.
Skilled use of operators left hand.
Instruments should be allowed to cool before use
after being sterilized.
Inferior alveolar nerve
• close proximity of mandibular third molar
• Careless surgical technique,
• roots are curved around the canal or grooved
• damage can be prevented or minimized only
by pre-op radiographic diagnosis & careful
Lingual nerve :
Lingual nerve is in close proximity to roots of
mandibular third molar .
• Risk of damage while taking incision and
during elevation of lingual periosteum.
• Risk of direct trauma form bur or chisels used
for removal of bone or sectioning of the tooth
• Mental nerve :
• Injury is caused due to surgery in the area of
• Over extension of incision in the depth of
mucobuccal fold in premolar region
The nerve injury can be prevented by
Careful surgical technique –
• Proper placement of incision,
• Careful bone removal
• Retraction and less manipulation
Patient should be warned preoperatively about
the possible consequences and the probable
• Tongue & floor of mouth damage can be
prevented by effective use of left hand.
13-Post extraction Bleeding
• Local causes:
• Mechanical dislodgement of the clot
• Damage to blood vessel or soft tissue
• Fracture of alveolar bone
• Damage to nutrient blood vessel
• Presence of granulation tissue
• Chronic inflammation of gingiva
• Acute infection of bone and soft tissue
• Local abnormality
• Unusually large bone marrow space
• Presence of Hemangioma
• Systemic causes
• Disorder related to systemic disease
– leukemia,Aplastic anaemias
– Platelet disorders: Thrombocytopenia
– Coagulation defects : Hemophilia
• Structural malformation : hereditary hemorrhagic
• drug therapy: aspirin, Anti coagulant therapy
• Pressure packs
• Use of LA solution with vasoconstrictors
• Socket suturing
• Hemostatic forceps
• Thermal measures- cautery , hot saline packs
Firm gauze roll should be placed upon the
socket & patient asked to bite upon it .
Horizontal mattress suture
• ETHAMSYLATE - 2ml ampoules i.m/iv 1-2 hrs
before operation OR
2-3 ampoules following surgery followed by
1amp/2tabs every 4-6 hrs.
• VITAMIN K- Normally 10mg capsules, 10-20
mg oral/ i.m /i.v
Due to traumatized hard tissues -
Bruising of bone during instrumentation or overheating
of bur during bone removal.
Soft tissues :-
ragged flap – heals slowly (incision not proper)
Soft tissue become entangled with bur
Dry socket / alveolar osteitis/
alveolitis sicca dolorosa
Acutely painful tooth socket containing
bare bone and broken down blood clot.
Associated with fetid odor
Mandibular teeth common than maxillary.
Predisposing factors :-
1. infection of socket : release of plasminogen
2. Trauma - use of excessive force
3. Vasoconstrictors (contributory factor)
4. Mandibular extractions (dense & less
vascular, contaminated with food debris)
5. Bacteriological origin – Treponema
6. Pt. on oral contraceptives, smokers
• Pt. usually presents within 2-4 days : granulation
tissue appears in 2-4 days, it is absent in cases of
• Dull, boring pain to severe throbbing pain, may
• Gingival margin of socket – swollen & red
• Socket may be filled with food debris or a brown
friable clot on removal of which exposes the bare
bone which is severely tender to touch
• Regional lymph nodes may be tender
• Prevention :-
1. Scaling & any gingival inflammation – (1
week prior to extraction).
2. Minimum amount of local anesthetic
3. Atraumatic tooth removal
4. Prophylactic use of antibiotics especially
5. nerve blocks preferred to LA infiltrations
1. Aim – relief of pain & speeding of resolution
2. Socket irrigation with warm saline & all degenerating blood
3. Sharp bony spurs - excised with rongeur forceps or
removed with a wheel stone
4. Loose dressing – zinc oxide & oil of cloves on cotton
wool is tucked into the socket.
5. Analgesic tab & hot saline mouth baths
6. Recall after 3 days 52
IRRIGATE THE SOCKET PLACE A ANTISEPTIC DRESSING
DRESSING ; First 24 hours then every alternate day then
every 3-4 days / or more than 2 weeks regular check up
15-ACUTE OSTEOMYELITIS OF THE
Impairement of labial sensation
pyrexia , pain is severe
Traumatic extraction of lower molar under LA in
P/o acute gingival inflammation predisposes to
May complicate difficult extractions if the
lower jaw is not supported.
The risk can be minimize if supporting the
mandible during surgery.
Difficult extractions Should be done
Mouth prop used on contralateral side
16-TRAUMATIC ARTHRITIS OF THE
a. EDEMA :
1. If the soft tissues are not handled carefully during
an extraction traumatic edema may be formed.
2. The use of blunt instrument, the excessive
retraction of badly designed flap, or a bur
becoming entangled in the soft tissues predispose
to this condition.
3. IF sutures are tied too tightly post operative
swelling due to edema or haematoma formation
may cause sloughing of the soft tissues and
breakdown of the suture line.
4. Usually both conditions regress if the patient uses
hot saline mouth baths frequently for 2-3 days.
b. INFECTION :-
• pain and swelling
Mild - hot saline mouth baths
Severe – antibiotic & analgesics
Inability to open mouth due to muscle spasm.
Caused by post op. edema, hematoma
formation or inflammation of soft tissue.
Intra oral heat by means of short wave
diathermy or use of hot saline mouth baths.
An oroantral communication is created by the
extraction of maxillary tooth where
The roots extend well beyond the maxillary sinus floor
The extraction is difficult and traumatic
There is a lone standing molar
The tooth is ankylosed
The periapical pathology e.g cyst or granuloma
extending beyond the sinus floor
• Bubbling through the extraction site occurs when the nose is
blocked under pressure. The patient cannot suck through a straw.
• Replace the tooth and splint into position and plan to
extract surgically at a later date or
• Cover defect with anti septic – soaked ribbon/ gauze and
remove in 2-3 weeks to allow healing by sec. intention or
• Reduce bony socket edge and suture margins together
(interrupted horizontal mattress)
• Immediate closure with a buccal advancement flap
provided the sinus is clear of infection.
The treatment of a freshly created oroantral communication
Instruct patient not to blow nose
from 7-10 days
20-Syncope / faints
• Pt. Collapse
• Feeling dizzy, weak, nauseated
• Skin is pale, cold , sweating
• Head end lowered by lowering the back
of the dental chair
• Placement of unconscious patient in the supine
position with feet slighlty elevated and airway
patency maintained through use of the head tilt –
chin lift method.
AROMATIC SPIRIT AMMONIA:
Aromatic ammonia spirit is used to prevent or treat syncope
Skelton Muscles become flaccid and pupils dilate
• Lay the pt flat on the floor
• Remove any foreign bodies by pulling the mandible
upwards and forwards, to extend neck fully
• Compress pt. nostril with thumb and finger, mouth-to-
mouth resuscitation be performed to raise the
chest every 3-4 sec.
• Check carotid pulse.
• Unless reversed in 3mins,irreversible brain
damage could occur due to cerebral anoxia.
• Pt has deathly pallor & grayness.
• Cold and sweaty skin
• Pulse and apex beat cannot be felt
• Heart sounds cannot be heard
• CPR is carried out until hospital services are
• Dentist must be alert for any warning sign
related to emergency related to anaesthesia
• In case of collapse STOP ANAESTHETIC
• CPR ,respiratory relief by tracheostomy,
laryngotomy must be performed.
Complications should be diagnosed as soon
as they occur & dealt promptly and effectively.