COMPLICATION OF EXTRACTION.

1. COMPLICATION OF EXTRACTION.

2. INTRODUCTION • Complication arise from errors in Judgment, Misuse of instruments, exertion of extreme forces & failure to obtain proper visualization prior to acting…. • The old adage “ TO DO GOOD YOU MUST SEE GOOD” is a apropos to exodontia & one might add “ DO WELL WHAT YOU SEE. ” • Undesirable situation are often encountered in dental practice by a dentist’s mistake, culpability of patient or unstable factors.

3. CLASSIFICATION • It is divided into : - 1) INTRA/PERIOPERATIVE COMPLICATION. 2) POST OPERATIVE COMPLICATION.

4. INTRA/ PERI OPERATIVE COMPLICATION :- • INABILITY TO MOVE THE TOOTH. • SOFT TISSUE INJURY. • FRACTURE OF THE TOOTH. • FRACTURE OF ALVELOAR PROCESS. • FRACTURE OF MAXILLARY TUBEROSITY. • FRACTURE OF MANDIBLE. • FRACTURE OF CROWN OF ADJACENT TOOTH/LUXATION OF ADJACENT TOOTH. • BROKEN INTRUMENTS IN TISSUES. • DISLOCATION IN TEMPOROMANDIBULAR JOINT.

5. SUBCUTANEOUS/SUBMUCOSAL EMPHYESEMA. • HEMORRHAGE. • DISPLACEMENT OF ROOT/ ROOT TIPS INTO SOFT TISSUE. • DISPLACEMENT OF IMPACTED TOOTH,ROOT/ROOT TIPS INTO MAXILLARY SINUS. • NERVE INJURY. • ORO ANTRAL COMMUNICATION. • EXTRACTION OF WRONG TEETH.

6. 2) POST OPERATIVE COMPLICATION :- • TRIMUS. • HEMATOMA. • ECCHYMOSIS. • POST EXTRACTION GRANULOMA. • FIBRINOLYTIC ALVEOLITIS (DRY SOCKET). • INFECTION OF WOUND. • DISTURBANCE IN POST OPERATIVE WOUND HEALING. • PAIN. • SWELLING.

7. PERI/INTRA OPERATIVE COMPLICATION • INABILITY TO MOVE TOOTH : - CAUSE : - • Due to anatomical peculiarity of tooth (bulbous root, flaring roots, dilacerated roots etc….). • Due to sclerosis of bone due to chronic long standing infection in that region. • Ankylosis of root (rare)

8. PREVENTION: - • A thorough examination of radiograph of tooth & its adjacent structures help in anticipating this problem. • MANAGEMENT: - • Advise radiograph. • Examine carefully. • Consider transalveolar extraction for widening flaring roots as a forcep extraction may ultimately fracture the roots.

9. SOFT TISSUE INJURY : - • Injuries to soft tissues of oral cavity are almost always the result of surgeon’s lack of adequate attention to delicate nature of mucosa & use of excessive & uncontrolled force. • The surgeon must continue to pay careful attention to soft tissue while working primarily on bone & tooth structures.

10. TEARING MUCOSAL FLAP: - • It is the most common soft tissue injury during extraction of tooth. • It occurs as a result of inadequately sized envelope flap, which is retracted beyond the tissue’s ability to stretch. • It results in tearing, usually at one end of the incision. • PREVENTION: - • Create adequately sized flap to prevent excess tension on flap. • Use small amount of retraction force on flap.

11. MANAGEMENT: - • If a tear does occur in flap, the flap should be carefully repositioned once surgery is complete. • In most patient, careful suturing of tear results in adequate but delayed healing. • If tear is especially jagged, the surgeon may consider excising the edge of torn flap to create a smooth flap margin for closure. • This step should be performed with caution, because excision of excessive amount of tissue lead to closure of wound under tension & probable wound dehiscence. • If area of surgery is near apex of tooth, an increased incidence of envelope flap tearing exists as a result of excessive retractional forces. In this situation a release incision to create a three cornered flap should be used to gain access to bone.

12. PUNCTRE WOUND ON SOFT TISSUE: - • CAUSES: - • Inadvertent manipulation of instruments( slippage of elevators during removal of teeth). • Uncontrolled force instead of finesse. • Areas where most often get injured are cheeks, floor of mouth, palate & retromolar area. • Injury by elevator may also occur at corner of mouth & lips because of prolonged & excessive retraction force & pressure during extraction of posterior maxillary & mandibular teeth especially when patient have a reduce aperture.

13. PREVENTION: - • Use of controlled force with attention given to support fingers/support opposite hand in anticipation of slippage. • MANAGEMENT: - • When puncture wound occurs, treatment aimed primarily at preventing infection & allowing healing to occur, usually by secondary intention • If wound bleeds excessively, it should be controlled by direct pressure on soft tissue. • Once hemostasis is achieved, wound is usually left open & not sutured so thet if small infection were to occur, there would be adequate pathway for drainage.

14. STRETCH/ABRASION INJURY: - • Abrasion/burns of lips & corner of mouth are usually the result of rotating shank of bur rubbing on soft tissue. • If such an abrasion develops, dentist should advise patient to keep it covered with vaseline or antibiotic ointment. • It is important that patient keep ointment only on abraded area & not to spred onto intact skin because it is quite likely to result in rash. • Patient should keep moist with ointment during entire healng peroid to prevent eschar formation, scarring & delayed healing as well as to keep the area reasonably comfortable.

17. FRACTURE OF TOOTH: - • CAUSE: - • Wrong forceps used for extraction. • Inappropriate force applied for extraction. • Wrongly placed forcep making centre of rotating higher than cemento-enamel junction. • Grossly carious tooth. • PREVENTION: - • Select correct forcep for tooth, take time & place the forceps to get firm grip on the tooth. • Forceps is wedged into PDL space as apically which prevent fracture of tooth.

18. If tooth carious with hardly any crown structure remaining, it may require the use of root forceps or splitting of root & removal of individual root separately. • MANAGEMENT: - • If tooth has extracted during extraction, DON’T PANIC!!!! First visualize what is remaining of the tooth most of time it is possible to remove remaining tooth using root forceps if only roots are remaining. • If roots is fractured at apical third, use apexoelevator to slowly take the root out of socket. • If only small piece of tooth is remaining it may even be left behind to resorb slowly. • Only if tooth was infected or involved in any pathology, it is necessary to remove it by transalveolar method if root cannot be removed by conservative method.

19. FRACTURE OF ALVELOLAR PROCESS • The extraction of a tooth requires that the surrounding alveolar bone be expanded to allow an unimpeded pathway for tooth removal. • However ,in some situation, bone fractures & is removed with the tooth instead of expanding. • The most likely cause of fracture of alveolar process is use of excessive force with forceps which fractures large portion of cortical plate. • If surgeon realizes that excessive forces is necessary to remove a tooth, a soft tissue flap should be elevated & controlled amount of bone removed so that tooth can be easily delivered

20. If principles is not adhered to & dentist continue to use excessive/uncontrolled forces fracture of bone will occur. • The most likely places for bony fracture are buccal cortical plate over maxillary canine, buccal cortical plate over maxillary molar, portion of floor of maxillary sinus associated with maxillary molars, maxillary tuberosity & labial bone on mandibular incisors. • PREVENTION: - • Conduct thorough pre-operative clical & radiographic examination. • Do not use excessive forces. • Use surgical (open) extraction techinque to reduce forces required.

22. MANAGEMENT • It depends on type & severity of fracture. • If bone is removed from tooth socket along with the tooth, it should not be replaced • Surgeon should simply make sure that soft tissue has been replaced & repositioned over the remaining bone to prevent delayed healing. • Surgeon must also smoothen any sharp edges that may have been caused by fracture. • If such sharp edges of bone exist, surgeon should reflect small amount of soft tissue & use of bone file to round off the sharp edges. • Surgeon who has been supporting alveolar process with fingers during extraction will feel the fracture of buccal cortical plate when it occurs. • At this time, bone remains attached to periosteum & will heal if it can be separated from tooth & left attached to overlying soft tissue.

23. Surgeon must carefully dissect the bone with its attached soft tissue away from tooth. • For this procedure, tooth must be stabilized with forceps & a small sharp instrument such as woodson periosteal elevator should be used to elevate buccal bone from tooth root. • It is important to realize that if soft tissue flap is reflected from bone, blood supply to overlying bone will be severed & bone will undergo necrosis. • Once bone & soft tissue have been elevated from tooth, tooth is removed & bone & soft tissue flap are reapproximated & secured with sutures.

24. FRACTURE OF MAXILLARY TUBEROSITY • It is a grave complication which depending on its extent, may create problem for retention of full denture in future. • It may occur during extraction of posterior maxillary tooth & is usually due to • Weakening of bone of maxillary tuberosity due to maxillary sinus pneumatizing into the alveolar process. In this case, risk of fracture is increased if the extraction of a molar is performed with forceful & careless movements. • Ankylosis of maxillary molar that presents great resistance to movements during the extraction attempt. An extensive fracture of buccal bone or distal bone surrounding the ankylosed tooth may occur • Decreased resistance of the bone of the region, due to a semi-impacted or impacted third molar.

25. TREATMENT: - • When fractured segment has not been reflected from the periosteum, it is repositioned and the mucoperiosteum is sutured. • In this case, scheduled extraction of the tooth is postponed, if possible, for appro. 1.5 -2 month, whereupon the fracture will have healed & the extraction may be performed with surgical techinque. • If however, the bone segment has been completely reflected from the tissues & oroantral communication occur, the tooth is first removed & the bone is then smoothed & the wound is tightly sutured. • Broad-spectrum antibiotic & nasal decongestant are then prescribed.

27. Fracture of mandible • It is unpleasant but fortunately rare, complication that is associated almost exclusively with extraction of impacted mandibular third molar. • This may occur during use of excessive force with elevators, when an adequate pathway for removal of impacted tooth has not been controlled. • It may occur during extraction of deeply impacted tooth, of tooth with firm anchorage, or of an ankylosed tooth even with small amount of force applied. • It may occur easily if mandible is atrophic or if bone has become weak such as when other impacted teeth are also present or in case of extensive edentulous region & presence of large pathologic lesion in areas of tooth to be extracted.

28. TREATMENT • When fracture occur during extraction, tooth must be removed before any other procedure is carried out, inorder to avoid infection alon line of fracture. • Afterwards, depending on the case, stabilization by way of IMF/RIGID INTERNAL FIXATION OF JAW SEGMENT is applied for 4-6 weeks & broad spectrum antibiotics are administered.

30. FRACTURE OF CROWN OF ADJACENT TOOTH/LUXATION OF ADJACENT TOOTH • Fracture of crown of adjacent tooth that presents extensive caries or large restoration is common complication during extraction procedure. • A single conical rooted adjacent tooth is in danger of inadverent luxation with tooth being extracted. If uncontrolled force is applied with an elevator with adjacent tooth being used as a fulcrum instead of interdental bone, adjacent tooth may get luxated.

31. PREVENTION • Pre-operative radiograph – check for root of adjacent teeth. • If it is conical single slender root, it may occur. • Adjacent tooth should be carefully supported with a firm pressure from index finger or thumb of the other hand when other tooth is being luxated with an elevator. This help to prevent removal of adjacent tooth.

32. MANAGEMENT • If adjacent tooth has been luxated or avulsed, it should be replaced in socket & splinted for period of 3-6 weeks for healing • Tooth may be relieved from occlusion to allow trauma free healing.

33. BROKEN INSTRUMENTS IN TISSUE • Breakage of an instrument in tissue is result of excessive force during luxation ot tooth & usually involves the end of blade of various elevators. • Anesthesia needle or bur may break during removal of bone surrounding the impacted tooth or root. • Breakage may result of repeated use of instrument altering in its metallic composition. • In these cases, after precise radiographic localization, broken pieces are removed surgically at same time as extraction of root or tooth.

35. DISLOCATION OF TEMPEROMANDIBULAR JOINT • It may occur during lengthy surgical procedure on patient who present a shallow mandibular fossa of temporal bone, low anterior articular tubercle & rounded head of condylar process. • In unilateral dislocation the mandible deviates towards the healthy side. • While in bilateral dislocation, mandible slides forward in gaping prognathic position. • Patient is unable to close their mouth & movement is restricted. • Inorder to avoid such complication, mandible must be firmly supported during extraction & patient must avoid opening their mouth excessively, especially those with history of “HABITUAL TMJ LUXATION”

37. TREATMENT • Immediately after dislocation, thumbs are placed on occlusal surface of teeth while rest of finger surround body of mandible right & left. • Pressure is then exerted downward with thumb & simultaneously upward & posteriorly with rest of fingers until condyle is replaced in its original position. • After repositioning, patient must limit any movement of mandible that may lead to excessive opening of mouth for few days when luxation is habitual, mandible is often repositioned in its original position sponatenously.

39. SUBCUTANEOUS/SUBMUCOSAL EMPHYSEMA • This complication may occur as a result of air entering loose connective tissue, when an air-rotor is used in surgical procedure for removal of bone or sectioning impacted tooth. • Clinically the region swells, sometimes extending into the neck & fascial area with characteristic crackling sound during palpation (crepitus). • There is no specific treatment. • It usually subside spontaneously after 2-4 days . If it is very large in size, paracentesis may help to remove the air. Some people recommend the administration of antibiotic.

40. HEMORRHAGE • It is common complication in oral surgery & may occur during simple tooth extraction or during other surgical procedure. • Hemorrhage may be due to trauma of vessels in region as well as to problems related to blood coagulation. • Severe hemorrhage diatheses ( eg. Hemophilia ) should be ascertained by taking a thorough medical history & management must be planned before surgical procedure.

41. Post-operative bleeding in healthy patient may result of poor homeostasis of wound due to insufficient compression or inadequate removal of inflammatory & hyperplastic tissue from surgical field. • TREATMENT: - • COMPRESSION. • LIGATION • SUTURING. • ELECTOCOAGULATION. • USE OF HEMOSTATIC AGENTS.

42. COMPRESSION:- It aims at causing vasoconstriction & decreasing the permeability of the capillaries, & is achieved by placing gauze over bleeding site with pressure • Placing pressure by biting on a gauze for 10-30 min over post-extraction wound or other superficial bleeding areas is usually sufficient. • If bleeding does not stop after applying pressure for aforementioned time, then there is a hemorrhagic problem to certain degree & blood flow must be arrested depending on the case. • Bone hemorrhage is treated by means of compression of bone the surrounding the vessels, inorder to obstruct blood flow. • This may be achieved by using a mallet & a small blunt instrument. • Sterile bone wax may also be used to arrest bone bleeding which is placed with pressure inside the bleeding bone cavity • Packing the iodoform gauze, which has antiseptic properties inside the alveolus may arrest bone bleeding. It may be kept inside depending on the case , for between 10 min & 3-4 days, after which it is removed.

43. SUTURING: - Suturing the wound mechanically obstruct the severed end of bleeding vessels. This technique is used for arresting soft tissue hemorrhage as well as postextraction bleeding that is treated with tightly suturing the wound margins. • If it is impossible to coat the wound margins, gauze pack is placed over the wound which is stabilized with sutures over the post extraction socket for 2-3 days.

45. LIGATION: - It is the most successful way to control soft tissue hemorrhage that involves a large vessels is severed during surgical procedure, a hemostat is used to clamp & ligate the vessels. • If a small-sized vessels is bleeding, then narrow hemostat is used to clamp bleeding area of the soft tissues, arresting hemorrhage within a few minutes, without ligation of the tissues. • ELECTROCOAGULATION: -It is based on the coagulation of blood through the application of heat, resulting in the retraction of tissues in a necrotic mass.

48. HEMOSTATIC MATERIALS: - Vasoconstrictor (adrenaline), alginic acid, desiccated alum etc have proven to be very effective in control of bleeding. • These material are used to arrest capillary hemorrhage & are used topically over the bleeding area. • Other materials are also used such as fibrin sponge, gelatin sponge, oxidized cellulose etc. whose hemostatic properties cause blood coagulation by creating a normal blood clot at the severed ends of bleeding vessels. • These materials are suitable only for local application & are used to arrest generalized capillary bleeding, especially to control bleeding of the postextraction alveolus. • The procedure for using hemostatic agents is usually as follows • In the case of relatively small hemorrhage, which persist despite biting on gauze pack over the postextraction wound, an absorbable hemostatic sponge is placed inside the alveolus & pressure is applied over the gauze, or the wound margins are sutured with figure-eight suture.

50. DISPLACEMENT OF ROOT/ROOT TIP INTO SOFT TISSUES • This complication may occur in following situation: - • When the buccal / lingual cortical plate,as well as the root tip region of maxillary posterior teeth is eroded. In this case, the roots or root tip may easily be displaced during luxation toward the buccal soft tissue or the floor of mouth or between the bone & mucosa of maxillary sinus respectively. • In the case of perforation of the bone as a result of continuous attempt to remove the root tip, which may be displaced as described above