This simplified lecture explain briefly the Complications occur During Dental Extraction and their Management. It is presented to the level of mind of undergraduate students

1. Trauma To Adjacent Tooth
Soft Tissue Injuries
Fracture Of The Alveolar Process
Fracture Of Maxillary Tuberosity
Fracture Of The Mandible
Broken Instruments In Tissues
Dislocation Of Tmj
Subcutaneous Or Submucosal Emphysema
Hemorrhage
Displacement Of Impacted Tooth, Root, Or Root Tip Into
Maxillary Sinus
Oroantral Communication
Nerve Injury
Trismus
Hematoma
Ecchymosis
Edema
Postextraction Granuloma
Painful Postextraction Socket
Dry Socket (Alveolar Osteitis)
Infection Of Wound
PERIO-OPERATIVE COMPLICATIONS
• Trauma to the adjacent tooth
• Soft tissue injuries
• Fracture of the alveolar process
• Fracture of the maxillary tuberosity
• Fracture of the mandible
• Broken instrument in tissues
• Dislocation of the temporomandibular joint
• Subcutaneous or submucosal emphysema
• Hemorrhage
• Displacement of an impacted tooth, root or root tip
into the maxillary sinus
• Oroantral communication
• Nerve injury
TRAUMA TO ADJACENT TOOTH
This is a common occurrence when the adjacent tooth
is used as fulcrum, which result in fracture of the crown
of the tooth, luxation or avulsion. The same situation
occur when extracting a deciduous molar, if the for-
ceps is inserted too deep into the sulcus it can grasp the
crown of the succedenous permanent premolar which
lies beneath that tooth.
Management:
If the tooth is luxated or partially avulsed, the tooth is
stabilized for 40-60 days. If there is still pain on per-
cussion after that period, RCT is indicated. If the tooth
is dislocated, it must be repositioned and stabilized for
3-4 weeks.
SOFT TISSUE INJURIES
Soft tissue injuries are common and occur due to incor-
rect manipulation of instruments. The areas most often
injured are the cheek, floor of the mouth, the palate,
and retromolar area. Many of these injuries occur due
to slippage of the elevator. Also burn may occur in the
lower lip if an overheated surgical handpiece comes in
contact with the lip. Abrasion occur when bur come in
complications during dental extraction
Osama Asadi, B.D.S, Published for Iraqi Dental Academy Blog
Undesirable situations or complications could occur in dental practice, due to dentist, patients, or certain
factors. These complications are divided into two parts:
• Perioperative complications: which occur during surgical procedure
• Postoperative complications: which occur during postoperative period
LECTURE OUTLINE
CHAPTER
1

2. contact with the tissue.
Management
When injuries are small and localized, no particular
treatment is needed. Vaseline may facilitate healing
(e.g., lip injuries). When the injury is extensive, and
bleeding occur, dentist should stop the procedure, con-
trol bleeding, and suture the wound.
FRACTURE OF THE ALVEOLAR PROCESS
This complication occur if the extraction force is abrupt
and awkward, or the tooth is ankylosed. In this case,
part of the labial, buccal, lingual, or palatal plate may
be removed with the tooth.
Fracture of lingual plate is the most significant, because
it may lead to trauma to the lingual nerve.
Management
If the broken part of the alveolar plate is small and
separated from the periosteum, it is removed, area is
irrigated with saline, sharp bone is smoothed and the
wound is sutured. If the broken part is still attached to
the periosteum, then it is stabilized and area is sutured.
FRACTURE OF MAXILLARY TUBEROSITY
This complication is a serious complication, which
may lead to problems in retention of the denture in the
future tense.
It could occur due to the following reasons:
• Weakened bone of the maxillary tuberosity, due to
large sinus
• Ankylosis of a maxillary molar
• Weakened bone due to impacted third molar
Management
If the fractured segment is not separated from the peri-
osteum, then it repositioned, and the wound is sutured.
And tooth extraction is postponed, if possible, for 1.5-2
months, when bone has been healed, and surgical tech-
nique will be used to remove the tooth.
If the fractured segment is separated from the perios-
teum and oroantral communication occurred, then
tooth along with the segment are removed, sharp bone
smoothed, and the wound is sutured. With prescription
of broad-spectrum antibiotic and nasal decongestants.
FRACTURE OF THE MANDIBLE
It is a rare and serious complication, associated with
extraction of impacted mandibular third molar. It oc-
cur due to excessive force applied by the elevator, an-
kylosed tooth, or large pathological lesion that weaken
the mandibular.
Management
The tooth must be removed first, to avoid infection at
the site of fracture. Then fixation is applied to frac-
tured segments for 4-6 weeks, with broad spectrum
antibiotics
BROKEN INSTRUMENTS IN TISSUES
It occur due to excessive force during manipulation of
the instrument. It localized with a radiograph and re-
moved surgically at the same appointment.
DISLOCATION OF TMJ
Ir occur in lengthy procedures, and in circumstances
when mandibular support is not provided during ex-
traction with the non-dominant hand.
In uni-lateral dislocation the mandible deviate to the
healthy side, while in bi-lateral dislocation the patient
present with open bite, and in both cases mandibular
movement is restricted.
Management
Immediately after dislocation, the thumbs are placed at
the occlusal surface of teeth and the rest of the fingers
are placed below the mandible on both sides.

Pressure is then applied with the thumbs downward,
and the rest of the fingers upward and posteriorly, until
the condyle return to its original position.
2

3. SUBCUTANEOUS OR SUBMUCOSAL
EMPHYSEMA
Occur as a result of air entering loose connective tissue,
when surgical handpiece with air is used during surgi-
cal procedure.
There is no specific treatment. It eliminated sponta-
neously within 2-4 days. For large one, paracentesis
(perforation) may be needed.
HEMORRHAGE
It is a common complication in oral surgery, it occur
either due to severing of blood vessels, or occur due
to patient’s tendency to bleeding due to blood diseases
such as hemophilia.
However, postoperative bleeding in patient with no
blood disorders can be a result of poor hemostasis, in-
sufficient wound compression or due to inadequate re-
moval of the inflammatory and hyperplastic tissue from
the surgical field.
Management
There are different ways of arresting bleeding, includ-
ing compression, ligation, suturing, and the use of he-
mostatic agents.
Compression of the wound by placing a gauze over the
surgical site and applying pressure on it for 10-30 min-
utes can stop postoperative bleeding.
If that did not stopped the bleeding, placing iodoform
gauze inside the cavity for 3-4 days can arrest the bleed-
ing.
Suturing of wound margin can also result in mechanical
obstruction of the bleeding site. If wound margins diffi-
cult to get sutured with each other, then placing a guaze
pack over the wound and suturing it can help.
Ligation can arrest the bleeding of large vessels. First
clip the severed vessel with a hemostat, then suture the
vessel to stop the bleeding.
Hemostatic materials such as vasoconstrictors (adren-
aline), alginic acid, desiccated alum, etc can be used
locally to control bleeding.
Alternatively, other materials such as fibrin sponge,
gelatin sponge, oxidized cellulose, etc.. Which has he-
mostatic properties can stop bleeding and cause coagu-
lation. They are placed into the surgical site and sutured
with figure-eight suture.
It is difficult for the dentist to control bleeding in cases
of blood disorders. In this situation, pressure pack is
applied and the patient is referred to the hospital.
DISPLACEMENT OF IMPACTED TOOTH,
ROOT, OR ROOT TIP INTO MAXILLARY
SINUS
It occur during extraction of maxillary posterior teeth
due to insufficient visualization and close proximity
of tooth to maxillary sinus, and due to injudicious and
blind use of elevator to explore the cavity for remaining
roots.
Management
If tooth or root tip can not be removed during the sur-
gical procedure, then dentist should stop any attempt
to find the tooth or root tip and the patient is informed.
A surgical removal is scheduled and should be as soon
3

4. as possible due to possibility of infection of maxillary
sinus.
OROANTRAL COMMUNICATION
It is a common complication occur due to an attempt
to extract maxillary posterior teeth that are close to the
maxillary sinus.
How to diagnose?
Valsalva test: ask the patient to close his nostrils, then
ask him to exhale gently through his nose. A bubbling
effect can be seen on site of extraction if communica-
tion exist. Note that patient should not exhale forceful-
ly or oroantral communication occur even if it is not
present.
Etiology
Displacement of impacted tooth or root tip into maxil-
lary sinus
Closeness of root tips to the floor of the maxillary sinus
Presence of periapical lesion that destroyed the bone
wall of maxillary sinus floor
Extensive fracture of maxillary tuberosity
Extensive bone removal for extraction of impacted
teeth or roots
Prevention
Careful evaluation of radiograph
Careful manipulation of instruments, especially during
luxation of root tip of maxillary posterior teeth
Careful debridement of periapical lesions that are close
to maxillary sinus
Avoiding luxating of root tip if can not visualized clear-
ly
Management
Management depend on the size of oroantral commu-
nication.
For small-sized oroantral communication, treatment
consist of suturing gingiva with figure-eight suture, af-
ter filling the alveolus with collagen, unless there are
enough soft tissue, in which case tight suture is enough.
For moderate to large size oroantral communication, or
when wound margin can not be sutured together, part of
the alveolar bone is removed with bone rongeur and the
wound margin is sutured easily by joining buccal and
lingual mucosa.
Antibiotic is not indicated. However, if the communi-
cation is result of extraction of tooth with periapical in-
flammation then broad spectrum antibiotic is indicated. 4
Also nasal decongestant is prescribed.
NERVE INJURY
This is a serious complication that occur during sur-
gical procedure. The most common nerve injuries are
of inferior alveolar nerve, mental nerve, and lingual
nerve.
Nerve injury can result in either anesthesia, paresthe-
sia or dysesthesia.
• Anesthesia or hypesthesia: is loss or decrease, re-
spectively, of sensation in an area.
• Paresthesia: is sensation of burning, tingling,
numbness in the area.
• Dysesthesia: is abnormal unpleasant sensation to
normal factors, such as feeling of burn after touch-
ing, etc..
Nerves injuries can be classified into three
categories:
• Neurapraxia: this is the easiest type of injury
which occur even after simple contact with the
nerve. The loss of sensation is temporary and re-
solve within few days to weeks.
• Axonotmesis: this is serious injury of the nerve
resulting in degeneration of the nerve axon, with-
out cut of endoneurium. Recovery is slower than
neuropraxia.
• Neurotmesis: is the hardest type of nerve injury
resulting in discontinuation of the nerve due to
severance of the nerve or due to formation of scar
at the area of trauma. This type of injury is perma-
nent and can result in scar formation that prevent
nerve regeneration.
POST-OPERATIVE COMPLICATIONS
• Trismus
• Hematoma
• Ecchymosis
• Edema
• Postextraction granuloma
• Painful postextraction socket
• Fibrinolytic alveolitis (dry socket)
• Infection of wound
TRISMUS
Usually occur in extraction of mandibular third mo-
lars, and characterized by restriction of the mouth
opening due to spasm of the masticatory muscles.
Etiology
• Injury to medial pterygoid muscle caused by

5. 5
needle (inferior block)
• Trauma to surgical site, especially during lengthy
surgical procedures
• Other factors such as inflammation of the postex-
traction wound, hematoma, and edema.
Management
It depend on the cause of trismus. Most cases require no
treatment and symptoms subside gradually.
When acute inflammation or hematoma is the cause,
hot mouth rinse are recommended initially, and broad
spectrum antibiotic is administered.
Other additional therapies:
• Heat therapy: application of hot compresses extra-
orally for 20 minutes every hour until symptoms
subside.
• Gentle massage of the TMJ area
• Administration of analgesics, anti-inflammatory
and muscle relaxant medications.
• Physiotherapy lasting 3-5 minutes every 3-4 hours,
which include closing and opening the mouth, as
well as lateral movement. Tongue depressor ex-
ercise can be used, beginning with a particular
number of tongue depressors then increasing their
number gradually each day.

• Administration of sedatives (bromazepam 1.5-3
mg twice daily) for management of stress. Because
trismus and inability to open the mouth can lead to
stress, which cause more muscle tension and more
trismus.
HEMATOMA
• This is a frequent complication of oral surgery. It
occur due to prolonged capillary hemorrhage inside
the tissue layers. It can be submucosal, subperioste-
al, intramuscular or fascial.
Management
Cold application extraorally for the first 24 hours, then
hot application. Analgesia for pain.
ECCHYMOSIS
Sometimes after surgical procedure, ecchymosis may
develop which appear as change in patient’s skin color
due to excessive force in retraction of such tissue.
No special management is required. Patient is in-
formed that the condition is not serious and color
change will resolve.
EDEMA
It occur due to soft tissue trauma, which result in sev-
ering of lymphatic vessels that will drain in tissue re-
sulting in swelling. Swelling is smooth, pale and taut.
When swelling due to inflammation, the skin has red-
ness.
Management
Small-sized edema require no treatment. For pre-
ventive reason, cold packs should be applied locally
immediately after surgery. They should be placed for
10-15 minutes every half hour, for the following 4-6
hours.
When edema is severe and does not subside, it should
be treated carefully, because it can lead to fibrosis and
symphyses. Administration of fibrinolytic agens is
indicated. If edema is inflammatory, then broad spec-
trum antibiotic is recommended.
POSTEXTRACTION GRANULOMA
This complication occur 4-5 days after the extraction
of the tooth. It resulting from presence of foreign body
in the alveolus such as amalgam remnants, bone chips,
small tooth fragments, calculus etc..
Management
It is treated with debridment of the alveolus and re-
moval of the causative agent.
PAINFUL POSTEXTRACTION SOCKET
This is a painful complication occur immediately after
the anesthesia wear off, due to sharp edges of alveolar
bone crest, or interadicular bone, which result in se-
vere pain and inflammation of the extraction site.
Management
Smoothening bone edges, and administration of anal-
gesics. Also gauze with eugenol should be placed over

6. the wound margin for 36-48 hours
DRY SOCKET
This complication occur after 2-3 days from the ex-
traction procedure. It occur due to disintegration of
blood clot from the socket.
Symptoms
Exposed bone
Sever throbbing, radiating pain
Foul odor
Bad taste in the mouth
Management
Irrigation of socket with warm saline and placement of
gauze soaked in eugenol in the socket and replaced ev-
ery 24 hours, until pain subside.
Another technique is gauze soaked with zinc oxide/ eu-
genol or iodoform gauze can be applied for 5 days.
INFECTION OF WOUND
Which occur due to non-sterile instruments or operat-
ing on non-sterile area.
Appropriate administration of antibiotic according to
the severity of the case is indicated.
REFERENCE
Oral Surgery Textbook by Fragiskos D. Fragiskos
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