Complications of Intra and Extra-Alveolar Extractions

1. COMPLICATIONS OF EXODONTIA
AND THEIR MANAGEMENT
Group K
KEZIAH MWANGI
SHARON WAVINYA
SHARLEEN LANGAT

2. Outline
• Soft tissue injury
• Problem with the extracted tooth
• Injury to adjacent tooth
• Injuries to osseous structures
• Oro antral communications
• Post operative bleeding
• Delayed healing and infection

3. 1. SOFT TISSUE INJURY;
• Probable causes;
i. lack of adequate attention to the delicate nature of the mucosa
ii. attempts to do surgery with inadequate access,
iii. use of excessive and uncontrolled force
They include;
a. Tearing of flap
b. Puncture wound
c. Stretch or Abrasion

4. a) Tear of mucosal flap
•This usually results from an initial inadequately sized
envelope flap, which is then forcibly retracted beyond
the ability of the tissue to stretch as the surgeon tries
to gain needed surgical access
•To prevent this:
(1) create adequately sized flaps to prevent excess
tension on the flap
(2) use controlled amounts of retraction force on the
flap
(3) create releasing incisions when indicated.

5. Management
• The flap should be carefully repositioned once the surgery is complete.
• If the flap begins to tear, the hard tissue surgery can be stopped and the
incision can be lengthened to gain better access before continuing
• If the tear is especially jagged, consider excising the edges of the torn flap to
create a smooth flap margin before closure;
• NB: Perform this with caution because excision of excessive amounts of
tissue leads to closure of the wound under tension and probable wound
dehiscence

6. b) Puncture wound
• Instruments, such as a straight elevator or periosteal elevator, may slip
from the surgical field and puncture or tear into adjacent soft tissue.
• It is the result of using uncontrolled force and is best prevented by the use
of controlled force with special attention given to using finger rests or
support from the opposite hand in anticipation of slippage.
Management:
• When a puncture wound does occur, the treatment is primarily aimed at
preventing infection and allowing healing to occur, usually by secondary intention.
• If the wound bleeds excessively, it should be controlled by direct pressure applied
to the wound.
• Once hemostasis Is achieved, the wound is usually left open unsutured so that if a
small infection were to occur, there is an adequate pathway for drainage.

7. c) Stretch or abrasion
• Abrasions or burns of the lips, corners of the mouth, or flaps
usually result from the rotating shank of the bur rubbing on the
soft tissue or on a metal retractor in contact with soft tissue.
Management
• If an area of oral mucosa is abraded or burned, little
treatment is possible other than keeping the area clean with
regular oral rinsing.
• such wounds heal in 4 to 7 days (depending on the depth of
damage) without scarring.
• If such an abrasion or burn does develop on the skin, advise
the patient to keep it covered with an antibiotic ointment or
simply Vaseline.

9. Points to note...
• The patient must keep the ointment only on the abraded area and not
spread onto intact skin because the ointment is likely to cause a rash.
• These abrasions usually take 5 to 10 days to heal.
• The patient should keep the area moist with the ointment during the
entire healing period to prevent eschar formation and delayed healing
• Scarring or permanent discoloration of the affected skin may occur but is
limited by proper wound care.

10. 2. COMPLICATIONS WITH TOOTH BEING EXTRACTED
a) Root fracture
b) Root displacement
c) Tooth loss into the pharynx
a) Root fracture
• The most common problem associated with the tooth being extracted is
fracture of its roots.
• Long, curved, divergent roots that lie in dense bone are the most likely to
be fractured.
• The main methods of preventing fracture of roots is to perform surgery
in the recommended manner
• You may use an open extraction technique and remove bone to decrease
the amount of force necessary to remove the tooth

11. b) Root displacement
• The tooth root that is most commonly displaced into unfavorable
anatomic spaces is the maxillary molar root, when it is forced or lost into
the maxillary sinus.
• If a fractured root of a maxillary molar is being removed with a straight
elevator being used with excess apical pressure, the tooth root can be
displaced into the maxillary sinus.
MX
• Identify the size of the root lost into the sinus. It may be a root tip of
several millimeters or an entire tooth root (you may need a radiograph)
• If the displaced tooth fragment is a small (2 or 3 mm) root tip and the
tooth and sinus have no preexisting infection, the surgeon should make a
brief attempt at removing the root.

12. • Then irrigate through the small opening in the socket apex and then
suction the irrigating solution from the sinus via the socket.
• This may flush the root apex from the sinus through the socket.
• Confirm radiographically that the root has been removed.
• If this technique is not successful, no additional surgical procedure
should be performed through the socket, and the root tip should be left
in the sinus.
• The small, non-infected root tip can be left in place because it is unlikely
to cause any troublesome sequelae

13. In cases of large fragments..
• If a large root fragment or the entire tooth is displaced into the maxillary
sinus, it should be removed.
• The usual method is a Caldwell-Luc approach into the maxillary sinus in
the canine fossa region and then removal of the tooth.
• Oral and maxillofacial surgeons perform this procedure

14. c) Tooth lost into the pharynx
• The crown of a tooth or an entire tooth might be
lost into the pharynx.
• If this occurs, the patient should be turned toward the surgeon and
placed into position with the mouth toward the floor as much as
possible.
• The patient should be encouraged to cough and spit the tooth out onto
the floor.
• The suction device can sometimes be used to help remove the tooth

15. Suppose it does not work…
Two possibilities;
• Swallowed (no coughing or respiratory distress)
• Aspirated (violent episode of coughing or shortness of breath)
• Nb//-In either case the patient should be transported to an emergency
room, and chest and abdominal radiographs should be taken to
determine the specific location of the tooth.

16. Mx cont..
• If the tooth has been aspirated, consultation should be requested
regarding the possibility of removing the tooth with a bronchoscope.
• The urgent management of aspiration is to maintain the patient's airway
and breathing.
• If the tooth has been swallowed, it is highly probable that it will pass
through the gastrointestinal tract within 2 to 4 days.
• Because teeth are not usually jagged or sharp, unimpeded passage
occurs in almost all situations.

17. 3. Injuries to adjacent tooth
a) Fracture/dislodgement of adjacent restoration
b) Luxation of adjacent tooth
c) Extraction of the wrong tooth

18. a) Fracture or dislodgement of adjacent restoration
• The most common injury to adjacent teeth is the inadvertent
fracture or dislodgment of a restoration or of a severely carious
tooth while the surgeon is attempting to luxate the tooth to be
removed with an elevator

19. • Prevention of such a fracture is primarily achieved by avoiding application
of instrumentation and force on the restoration
• The straight elevator should be used with great caution, inserting it
entirely into the PDL space
• You rather not use it when the adjacent tooth has
a large restoration

20. MX
• If a restoration is dislodged or fractured, the surgeon should make
sure that the displaced restoration is removed from the mouth and
does not fall into the empty tooth socket.
• Once the surgical procedure has been completed, the injured tooth
should be treated by replacement of the displaced crown or
placement of a temporary restoration.
• The patient should be informed if a fracture of a tooth or restoration
has occurred and that a replacement restoration is needed

21. Teeth in the opposite arch may also be
injured…
• as a result of uncontrolled forces.
• This usually occurs when buccolingual forces inadequately mobilize a
tooth and/or excessive tractional forces are used.
• The tooth suddenly releases from the socket, and the forceps strikes
the teeth of the opposite arch, chipping or fracturing a cusp.
• Common with extraction of lower teeth because these teeth may
require more vertical tractional forces for their delivery.
• Prevention of this type of injury can be accomplished by several methods.
i. the surgeon should avoid the use of excessive tractional forces.
ii. The tooth should be adequately luxated with apical, buccolingual, and
rotational forces to minimize the need for tractional forces.

22. Occasionally a tooth releases unexpectedly…
• The surgeon or assistant should protect the teeth of the opposite arch
by holding a finger or suction tip against them to absorb the blow should
the forceps be released in that direction.
• If such an injury occurs, the tooth should be smoothed or restored as
necessary to keep the patient comfortable until a permanent restoration
can be constructed.

23. b) Luxation of adjacent tooth
• Inappropriate use of the extraction instruments may luxate an adjacent
tooth.
• Prevented by judicious use of force with elevators and forceps.
• If the tooth to be extracted is crowded and has overlapping adjacent
teeth a thin, narrow forceps may be useful

24. MX
• The tooth simply be repositioned in the tooth socket and left alone.
• The occlusion should be checked to ensure that the tooth has not been
displaced into a hypererupted and traumatic occlusion.
• If the luxated tooth is mobile, it should be stabilized with semirigid
fixation to maintain it in its position.
• A simple silk suture that crosses the occlusal table and is sutured to the
adjacent gingiva is usually sufficient.
• Rigid fixation with circumdental wires and arch bars results in increased
chances for external root resorption and ankylosis of the tooth and
therefore should usually be avoided

25. c)Extraction of the wrong tooth
• This is usually the most common cause of malpractice lawsuits
against dentists
• A common reason for removing the wrong tooth is
that a dentist removes a tooth for another dentist.
• The use of differing tooth numbering systems or differences in the
mounting of radiographs can easily lead the treating dentist to
misunderstand the instructions from the referring dentist.

27. Mx
• When the wrong tooth is extracted, it is important to
inform the patient, the patient's parents (if the patient is a minor) , and
any other dentist involved with the patient's care.
• In some situations an orthodontist may be able to adjust the treatment
plan so that extraction of the wrong tooth necessitates only a minor
adjustment.
• And if the case did not involve orthodontic care, a dental implant
supported restoration may totally restore the patient's dental status as it
was before the inadvertent extraction.

28. INJURIES TO OSSEOUS STRUCTURES.
Fracture of the alveolar process
• The extraction of a tooth usually requires that the surrounding alveolar bone
be expanded to allow an unimpeded pathway for tooth removal.
• However, in some situations the bone fractures and is removed with the
tooth instead of expanding.
• The most likely cause of fracture of the alveolar process is the use of
excessive force with forceps, which fracture large portions of the cortical
plate.
• Most common likely places for bony fracture are the buccal cortical plate over
the maxillary canine, the buccal cortical plate over the maxillary molars
(especially the 1st molar), portions of the maxillary sinus floor associated with
maxillary molars, the maxillary tuberosity, and the labial bone on mandibular
incisors.
• Whenever excessive force is necessary, a soft tissue flap should be elevated,
and controlled amounts of bone should be removed so that the tooth can be
easily delivered or in the case of multi-rooted teeth, sectioning of the tooth.

31. Management
• Depends on the type and severity of the fracture
• If the bone has been completely removed from the tooth socket
along with the tooth, it should not be replaced.
• The surgeon should simply make sure that the soft tissue has been
repositioned as best as possible over the remaining bone to allow
healing.
• Any sharp edges caused by the fracture should be smoothened using
a bone file.

32. Fracture of the maxillary tuberosity
•The maxillary tuberosity is especially important for
the construction of a stable retentive maxillary
denture.
•Fracture of the maxillary tuberosity most commonly
results from extraction of an erupted maxillary third
molar or from a second molar if it happens to be the
last tooth in the arch
•If this type of fracture occurs during an extraction
extreme measures should be taken to ensure the
survival of that bony segment.
• If at all possible, the bony segment should be
dissected away from the tooth and the tooth
removed in the usual fashion. The tuberosity is then
stabilized with sutures.

34. Management
• If the tuberosity is excessively mobile and cannot be
dissected from the tooth, there are several options.
• 1. To splint the tooth being extracted to adjacent teeth and
defer the extraction for 6 to 8 weeks, during which time the
bone will heal. The tooth is then extracted with an open
surgical technique.
• 2. To section the crown of the tooth from the roots and allow
the tuberosity and tooth root section to heal. After 6 to 8
weeks, remove the tooth roots in the usual fashion.
• If the maxillary molar tooth is infected, these two techniques
should be used with caution.
• 3. If the maxillary tuberosity is completely separated from the
soft tissue, the usual steps are to smooth the sharp edges of
the remaining bone and to replace and suture the remaining
soft tissue. Carefully check for an oroantral communication
and treat as necessary.

35. INJURY TO ADJACENT STRUCTURES
Injury to Regional Nerves
• The branches of the 5th cranial are the adjacent structures most likely to be
injured during extraction.
• The most frequently involved specific branches are the mental nerve, the
lingual nerve, inferior alveolar nerve and the nasopalatine nerve.
• If the mental nerve is injured, the patient will have an anesthesia or
paresthesia of the lip and chin.
• Nasopalatine and buccal nerves can be surgically sectioned without long
lasting sequale or much bother to the patient.
• The lingual nerve is anatomically located directly against the lingual aspect
of the mandible in the retromolar pad region. The lingual nerve rarely
regenerates if it is severely traumatized.
• The inferior alveolar nerve may be traumatized along the course of its
intrabony canal. The most common place of injury is the area of the
mandibular third molar. Removal of impacted third molars may crush or
sharply injure the nerve in its canal. This complication is common enough
during the extraction of third molars that it is important to inform patients
on a routine basis that it is a possibility.

36. Injury to the Temporomandibular joint
• Removal of mandibular molar teeth frequently requires the
application of a substantial amount of force.
• If the jaw is inadequately supported during the extraction to help
counteract the forces, the patient may experience pain in this region
• Controlled force and adequate support of the jaw by holding the
lower jaw prevents this.
• Use of a bite block on the contralateral side may provide adequate
balance of forces so that injury does not occur.
• If pt complains of pain in the TMJ immediately after extraction, use
of moist heat, rest for the jaw, a soft diet and ibuprofen is
recommended (acetaminophen for those who cant tolerate NSAIDS)

37. Oro-antral communications
• Removal of maxillary molars occasionally results in
communication between the oral cavity and the maxillary
sinus. Factors predisposing to communications:
 If the maxillary sinus is large
 If no bone exists between the roots of the teeth and the
maxillary sinus,
 If the roots of the tooth are widely divergent
• The two sequelae of most concern are:
1. postoperative maxillary sinusitis
2. formation of a chronic oroantral fistula.
• The probability that either of these two sequelae will occur is
related to the size of the oroantral communication and the
management of the exposure.

38. • Preoperative radiographs must be carefully evaluated for the tooth-
sinus relationship whenever maxillary molars are to be extracted.
• If the sinus floor seems to be close to the tooth roots and the tooth
roots are widely divergent, the surgeon should avoid a closed
extraction and perform a surgical removal with sectioning of tooth
roots . Large amounts of force should be avoided in the removal of
such maxillary molars
Diagnosis of the oroantral communication can be made in several
ways:
1. examine the tooth once it is removed. If a section of bone is
adhered to the root ends of the tooth, the surgeon should assume
that a communication between the sinus and mouth exists. If a
small amount of bone or no bone adheres to the molars, a
communication may exist anyway.
To confirm the presence of a communication, the best technique is
to use the nose-blowing test (Valsava).

39. 2. The surgeon should guess the approximate size of the
communication because the treatment depends on the size of the
opening
• If the communication is small (2 mm in diameter or less), no
additional surgical treatment is necessary. Ensure the formation of a
high-quality blood clot in the socket and then advise the patient to
take sinus precautions to prevent dislodgment of the blood clot.
• Sinus precautions are aimed at preventing increases or decreases in
the maxillary sinus air pressure that would dislodge the clot.
Patients should be advised to avoid blowing the nose, violent
sneezing, sucking on straws, and smoking.
• The surgeon must not probe through the socket into the sinus with a
dental curette or a root tip pick
• If the opening is of moderate size (2 to 6 mm), additional measures
should be taken. a figure-of-eight suture should be placed over the
tooth socket
• Ensure the maintenance of the blood clot in the area. The patient
should also be told to follow sinus precautions. Finally, prescribe
several medications to help lessen the possibility that maxillary
sinusitis will occur. Antibiotics, usually penicillin or clindamycin, a
nasal decongestant to shrink the nasal mucosa to keep the ostium of
the sinus patent. As long as the ostium is patent and normal sinus
drainage can occur, sinusitis and sinus infection are less likely.

40. • If the sinus opening is large (7 mm or larger), the sinus
communication should be closed with a flap. The most commonly
used flap is a buccal flap. This technique mobilizes buccal soft
tissue to cover the opening and provide for a primary closure.
Sinus precautions and medications are usually required

41. Postoperative Bleeding
Extraction is a surgical procedure that presents a challenge to the body's
hemostatic mechanism, reasons being:
The tissues of the mouth and jaws are highly vascular
The extraction of a tooth leaves an open wound, with both soft tissue
and bone open, which allows additional oozing and bleeding.
It is almost impossible to apply dressing material with enough pressure
and sealing to prevent additional bleeding during surgery.
Patients tend to play with the area of surgery with their tongues and
occasionally dislodge blood clots, which initiates secondary bleeding.
The tongue may also cause secondary bleeding by creating small
negative pressures that suction the blood clot from the socket.
Salivary enzymes may lyse the blood clot before it has organized and
before the ingrowth of granulation tissue.

42. • One should not dismiss the patient until hemostasis has been
achieved. This requires that you check the patient's extraction
socket about 15 minutes after the completion of surgery. Initial
control should have been achieved. New damp gauze is then
folded and placed into position, and the patient is told to leave it
in place for an additional 30 minutes.
• Several different materials can be placed in the socket to help
gain hemostasis.
Asorbable gelatin sponge (e.g., Gelfoam). This material is placed
in the extraction socket and held in place with a figure eight
suture placed over the socket. The absorbable gelatin sponge
forms a scaffold for the formation of a blood clot, and the suture
helps maintain the sponge in position during the coagulation
process. A gauze pack is then placed over the top of the socket
and is held with pressure.
Oxidized regenerated cellulose (e.g., Surgicel). This material
promotes coagulation better than the absorbable gelatin
sponge, because it can be packed into the socket under
pressure.

43. A liquid preparation of topical thrombin (prepared from
bovine thrombin) can be saturated onto a gelatin sponge
and inserted into the tooth socket. The thrombin bypasses
all steps in the coagulation cascade and helps to convert
fibrinogen to fibrin enzymatically, which forms a clot. The
sponge with the topical thrombin is secured in place with
a figure-eight suture. A gauze pack is placed over the
extraction site in the usual fashion.
Collagen promotes platelet aggregation and thereby
helps accelerate blood coagulation. Collagen is currently
available in several different forms. Microfibular collagen
{e.g., Avitene) is available as a fibular material that is loose
and fluffy but can be packed into a tooth socket and held
in by suturing and gauze packs, as with the other
materials. A more highly cross-linked collagen is supplied
as a plug (e.g., Collaplug) or as a tape (e.g., Collatape).

44. • Even after primary hemostasis has been achieved, patients
occasionally call the dentist with bleeding from the extraction
site, referred to as secondary bleeding. The patient should be
told to rinse the mouth gently with chilled water and then to
place appropriate-sized, damp gauze over the area and bite
firmly. The patient should sit quietly for 30 minutes, biting
firmly on the gauze. If the bleeding persists, the patient should
repeat the cold rinse and bite down on a damp tea bag. The
tannin in the tea frequently helps stop the bleeding. If neither
of these techniques is successful, the patient should return to
the dentist.
• The surgeon must have an orderly, planned regimen to control
this secondary bleeding. The patient should be positioned in
the dental chair, and all blood, saliva, and fluids should be
suctioned from the mouth. Such patients frequently have large
"liver clots" (clotted blood that resembles fresh liver) in their
mouth that must be removed. The surgeon should visualize the
bleeding site carefully with good light to determine the precise
source of bleeding. If it is clearly seen to be a generalized
oozing, the bleeding site is covered with a folded, damp gauze
sponge held in place with firm pressure by the surgeon's finger
for at least 5 minutes.

45. • This measure is sufficient to control most bleeding.
• If 5 minutes of this treatment does not control the bleeding, the
surgeon must administer a local anesthetic so that the socket
can be treated more aggressively. The same measures described
for control of primary bleeding should be used. The surgeon
must then decide whether a hemostatic agent should be
inserted into the bony socket
• If hemostasis is not achieved by any of the local measures ,the
surgeon should consider performing additional laboratory
screening tests to determine whether the patient has a
profound hemostatic defect.

46. Delayed healing
Infection- primarily seen after oral surgery that involves the
reflection of soft tissue flaps and bone removal.
Prevention-Careful asepsis and thorough wound debridement
after surgery can best prevent infection after surgical flap
procedures.
This means that the area of bone removal under the flap must be
copiously irrigated with saline under pressure and that all visible
foreign debris must be removed with a curette.
Some patients are predisposed to postoperative wound
infections and should be given antibiotics preoperatively for
prophylaxis

47. Wound Dehiscence-separation of the wound edges
Causes-If a soft tissue flap is replaced and sutured without an adequate
bony foundation, the unsupported soft tissue flap often sags and
separates along the line of incision.
A second cause of dehiscence is suturing the wound under tension. the
soft tissue flap is sutured under tension ,the sutures cause ischemia of the
flap margin with subsequent tissue necrosis, which allows the suture to
pull through the flap margin and results in wound dehiscence
Thin mucosa
Movements during mastication and phonation
Poor suturing technique

48. •prevention
1 . Use aseptic technique.
2. Perform atraumatic surgery.
3. Close the incision over intact bone.
4. Suture without tension.

50. • Exposed bone
common area of exposed bone after tooth extraction is the internal oblique
ridge. After extraction of the first and second molar, during the initial healing,
the lingual flap becomes stretched over the internal oblique (mylohyoid)
ridge.
Occasionally, the bone perforates through the thin mucosa, causing a sharp
projection of bone in the area.
Treatment-
1 ) to leave the projection alone . If the area is left to heal untreated, the
exposed bone will slough off in 2 to4 weeks. If the irritation of the sharp bone
is low, this is the
preferred method
(2) to smooth it with bone file

51. Alveolar osteitis (dry socket)
Unpredictable complication follows between1-3 % of all extractions.
Occurs most commonly following:
• Extraction of a molars - Highest incidence follows the XLA of
impacted lower 3rd molars.
• Difficult extractions
Predispposing Factors:
Tobacco use by the patient has also been identified as a risk factor.
Use of oral contraceptives

52. It is a localized inflammation of the bone following either:
(A.)Failure of a blood clot to form in the socket due to:
• Relatively poor blood supply to the bone e.g. Osteopetrosis,
Paget's disease.
• Following radiotherapy
• Excessive use of vasoconstrictors in local anaesthetics
(B.) Premature loss or disintegration of the clot:
• may be washed away by excessive mouth rinsing
• may disintegrate prematurely due to fibrinolysis most likely as
a result of infection by proteolytic bacteria.

53. Pain-moderate to severe dull ,
-no signs of infection (fever, swelling or erythema.)
-3-4 days after extraction
-affects mostly the lower molars
Examination
• the tooth socket appears to be empty; with a partially or completely lost
blood clot, and some bony surfaces of the socket are exposed. The exposed
bone is sensitive and is the source of the pain
• frequently radiates to the patient's ear.
• The area of the socket has a bad odor, and the patient frequently complains
of afoul taste.

54. Prevention
Prevention of the dry socket requires that the surgeon minimize trauma and
bacterial contamination in the area of surgery.
The surgeon should perform atraumatic surgery with clean incisions and soft
tissue reflection.
After the surgical procedure, the wound should be irrigated thoroughly with
large quantities of saline delivered under pressure, such as from a plastic
syringe.
Small amounts of antibiotics (e.g. . tetracycline) placed in the socket alone or
on a gelatin sponge have been shown to help substantially to decrease the
incidence of dry socket in mandibular third molars.
The incidence of dry socket can also be decreased by preoperative and
postoperative rinses with antimicrobial mouth rinses, such as chlorhexidine.

55. Treatment
The goal of relieving the patient's pain during the period of healing consists
of irrigation and insertion of a medicated dressing.
First, the tooth socket is gently irrigated with sterile saline. The socket
should not be curetted down to bare bone because this increases the
amount of exposed bone and the pain. Usually the entire blood clot is not
lysed, and the part that is intact should be retained.
The socket is carefully suctioned of all excess saline, and as mall strip of
iodoform gauze soaked with the medication is inserted into the socket.
The medication contains
• eugenol, which obtunds the pain from the bone tissue
• a topical anesthetic, such as benzocaine
• a carrying vehicle, such as balsam of Peru.

56. The medicated gauze is gently inserted into the socket, and the patient usually
experiences profound relief from pain within 5 minutes.
The dressing is changed every other day for the next 3 to 6 days, depending
on the severity of the pain.
The socket is gently irrigated with saline at each dressing change.
Once the patient's pain decreases, the dressing should not be replaced,
because it acts as a foreign body and further prolongs wound healing.

58. FRACTURES OF THE MANDIBLE
Causes
Associated almost exclusively with the surgical removal of impacted third molars.
Usually the result of the application of a force exceeding that needed to remove a
tooth and often occurs during the forceful use of dental elevators.
However, when lower third molars are deeply impacted, even small amounts of
force may cause a fracture.
Fractures may also occur during removal of impacted teeth from a severely atrophic
mandible
Treatment
• The fracture must be adequately reduced and stabilized.
• The patient should be referred to an oral and maxillofacial surgeon for definitive
care.

60. COMPLICATIONS OF
IMPACTIONS AND THEIR
MANAGEMENT

61. 1. COMPLICATIONS ASSOCIATED WITH
IMPACTED/ADJACENT TOOTH
I. CARIES;
• Mesioangular and horizontal positions of third molars cause
development of distal cervical caries on the second molar
• Restoration may be difficult without extraction of the impacted tooth

62. II. DISPLACEMENT OF FRACTURED ROOT TO THE ANATOMIC SPACES;
• Removal should be avoided provided that the fragments are not
associated with pathological lesions like cysts, tumors and have no
clinical symptoms
III. DISPLACEMENT OF ADJACENT TOOTH
• Deciduous tooth, permanent tooth buds
• Occurs when the impacted teeth are in close contact with
neighboring teeth
• A result of uncontrolled force during extraction, loss of supporting
bone during surgery
• Treatment; place displaced tooth in the previous position and
immobilize for 3-4 weeks
• Fixation using additional sutures placed laterally across the occlusal
surface
• Dental wires, arch bars, composite splints

63. 2. DIPLACEMENT OF LOWER 3RD MOLARS
• Lingual, submandibular, pterygomandibular, infratemporal spaces
• Most commonly displaced tooth, distolingual angulation
• Lingual plate is thin and easy to perforate making it east to displace
into the sublingual and submandibular spaces
• Place finger or retractor lingually to avoid this mishap
• An intraoral surgical approach is done to retrieve the tooth
• Sometimes it may be necessary to combine it with an extraoral
approach with a submandibular incision in the neck
• Osteotomy of the lingual plate then approach the fragments

64. 3. DISPLACEMENT OF UPPER 3RD MOLARS
• Root fragments or crowns may be displaced into the infratemporal
fossa and maxillary sinus space
• To prevent displacement into the infratemporal fossa, use of a distal
retractor is recommended
• Excessive apical force during use of elevators and incorrect surgical
technique may cause displacement into the maxillary antrum
• Deeply positioned upper 3rd molars without formed roots are also
prone to this
• Surgical removal is recommended since the presence inside the sinus
may lead to complications such as infections

65. • The tooth can also be displaced into the buccally positioned Bichat’s
fat pad
• Incorrect use of the elevator may lead to a fracture of the buccal
bone, which consists mostly of trabecular bone with a thin cortical
layer and push the tooth into the buccal space
• Impacted upper canines or mesiodens if deeply positioned may be
displaced into the nasal cavity during surgery
• Improper excessive use of force when operating high speed
handpieces may cause displacement of burs into anatomical spaces
• Surgery should be done to retrieve them

66. 4. SOFT TISSUE COMPLICATIONS
I. Injuries to neighboring soft tissues – Bichat’s fat pad
-Deep incision during disimpaction
I. Hemorrhage
- Mandibular 3rd molars show a higher risk of hemorrhage than the
maxillary 3rd molars
- Bleeding disorders may cause uncontrollable bleeding
-Old patients are more prone to this complication

67. III. Hematoma formation;
- Size and spread of a hematoma depends on its vascular origin and
the tissue into which it is bleeding
- It stops expanding when the pressure of pooling blood exceeds the
vascular pressure at the bleeding site
- Often occurs during injection of LA
- Management; antibiotic therapy and follow up for the next 2-5
days
IV. Iatrogenic surgical subcutaneous emphysema;
- Occurs when an air-driven high speed turbine is used for tooth
sectioning
- Air is forced into the soft tissue through the reflected flap and
invades the adjacent tissues
- To avoid this, use a low speed straight handpiece with sterile saline
irrigation

68. 5. NERVE INJURY
• Common during extraction of mandibular impacted teeth
• Nerves prone to injury are; IAN, lingual, mental and facial nerves
• Nerves can be damaged by traumatic, toxic or compressive injuries
• When the causative factor is removed, the damage of the Schwann
cells and the impairment to the myelin sheath can heal completely

69. 6. BONE COMPLICATIONS
I. MANDIBULAR FRACTURES;
• Common at the angle of the mandible
• May result from high force impact or stress and certain medical
conditions that weaken the bones
• Risk increases in the presence of bone sclerosis, atrophy, dental
ankylosis

70. II. MAXILLARY TUBEROSITY FRACTURES;
• Associated with extraction of the upper molars
• Max tuberosity is more predisposed to fractures if the maxillary sinus
has enlarged between the teeth and into the tuberosity creating thin
bony walls
• Clinical signs; crunch or loud crack of bone breaking, sudden
loosening of the tooth and bone with segment still attached to soft
tissue and an observable opening into the maxillary sinus
• Management;
- Stop the extraction procedure
- In cases of small fractures without sinus perforation, dissection of
the fractured segment from gingiva and periosteum should be done
and sutured
- If sinus perforation occurs, dissection of the segment and closure of
the socket primarily and use of gelatin sponges to obturate the
opening

71. - In cases of larger bony fragments, extraction should be abandoned
- The mobile parts of the bone should be stabilized by means of
fixation for 4-6 weeks
- If it involves multiple teeth, stabilize for 6-8 weeks by wiring to the
adjacent teeth
- in case of oro-antral communication; mobilization of local flaps,
autogenous or allogenic bones or use of synthetic materials
-Antibiotics, Decongestants

72. 7. COMPLICATIONS ASSOCIATED WITH
SURGICAL EQUIPMENT;
• A result of metal fracturing because of effects of heat, torsion
• Improper excessive use of force during the surgery may lead to
breaks
• Torsional strength and flexibility of the instruments makes them
more prone to fracture under torsional stress
• Fractured fragments should be removed immediately

73. 8. SWALLOWING AND ASPIRATION;
• Accidental ingestion of extracted tooth and its fragments may occur
• Swallowing doesn’t cause any clinical symptoms thus most objects
are passed within 7-10 days after ingestion
• If symptoms of perforation occurs, surgical intervention is required
• Aspiration rarely happens due to the cough reflex
• Most common location of aspirated bodies is the right main stem
bronchus since it is wider, shorter and more vertical than the left
main bronchus
• Refer to a pulmonologist for location and removal of the foreign
object

74. • If foreign object is lost in the oropharynx, patient should be placed in
a reclining position and encouraged to cough vigorously
• Heimlich maneuver to relieve laryngeal obstruction
• Look out for signs of airway obstruction; chocking, inspiratory stridor,
labored breathing
• Chest X-ray to avoid unnecessary complications

75. 9. POST OP COMPLICATIONS
• Increase with;
1. Age of the patient
2. Position and location of the tooth
3. Duration of the surgical procedure
4. Sex of the patient

76. I.PAIN;
• Begins after the anesthesia wears off
• Reaches peak 6 -12 hours post-op
• Management; Analgesics alone or in combination with steroids and
narcotics
II. SWELLING AND SURGICAL EDEMA;
• Reaches a maximum level 2 – 3 days post op
• Should subside by 4 days and resolve by 7 days post op
• Patient comfort and post op swelling may decrease by use of
systemic corticosteroids pre-op and icing post-op
• Gentle manipulation of soft tissues and cheeks during retraction

77. III. TRISMUS;
• Presents as jaw stiffness with difficulty to brush, eat, talk
• Commonly affected muscle is the medial pterygoid muscle
• May be caused by injury caused by needles, swelling, hematoma and
inflammation
• Pre op use of steroids may help reduced trismus
• Post op mouth opening exercises should be done
• Muscle relaxants, chlorzoxazone, may help in management
IV. BONE/SOFT TISSUE HEMORRHAGE;
• Hermetically suturing the socket

78. V.INFECTION
• Post-op inflammatory conditions such as abcess, SSI, alveolar osteitis,
osteomyelitis are common
• Alveolar osteitis is a common complication characterized be post-op
pain in and around the extraction site accompanied by a partially or
totally disintegrated blood clot within the socket with or without
halitosis
VI. DELAYED HEALING
VII. WOUND DEHISENCE

79. THANK YOU