This document provides information on exodontia complications presented over multiple sessions. It discusses 14 common complications including dry socket, nerve injuries, hemorrhage and root fractures. For each complication, the causes, prevention, management and clinical presentation are outlined. The document emphasizes using proper technique, patient assessment, force application and hemostasis to minimize complications from tooth extractions.

1. GOOD MORNING

2. SESSION - 1
PRESENTATION

3. Presented By -
1. Dr. Abdullah Al Jobair
2. Dr. Sujauddin Faroque
Shohan
3. Dr. Habibullah Marzan
4. Dr. Shashwati Saha Dristi

4. EXODONTIA
According to Geoffrey L. Howe –
Exodontia or Extraction is
the painless removal of
whole tooth or tooth root
with minimal trauma to the
investing tissues, so that the
wound heals uneventfully
and no post-operative
prosthetic problem is
created.

5. COMPLICATIONS
F
a
c
i
a
l
Any adverse ,
unplanned events that
tend to increase the
morbidity above what
would be expected
from a particular
operative procedure
under normal
circumstances.
Dry Socket Fracture of maxillary
tuberosity
Haematoma Trismus

6. SOURCES OF COMPLICATIONS
SURGICAL COMPLICATIONS MAY ARISE FROM EITHER ONE OR A
COMBINATION OF THE FOLLOWING FACTORS -
. THE PATIENT-
-Medically compromised patient. leading to an persistent haemorrhage or delayed healing.
• THE CLINICIAN -
-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.

7. CATEGORIES
• Complications can be classified
into 4 groups-
1 . Pre-operative
2 . Operative
3 . Post-operative
4 . Persistant

8. PRE-OPERATIVE
Pre-operative complications are the problems that may be
encountered before treatment -
• Local
• Systemic

9. LOCAL
During insertion of the needles when administering LA these
complications could occur -
– Intravascular Injection
– Pain
– Needle Breakage

10. SYSTEMIC
- Anxiety
conditions in which anxiety dominates a person’s life or experiences in
particular situations
- Syncope
- Anaphylaxis
Allergic response a substance causing the body to be intensely sensitized.
Flushing, itching, nausea, vomiting, swelling of the mouth and tongue,
obstruction of airway may occur.

11. OPERATIVE
Are the problems that may occur during treatment -
• Local
• Systemic

12. LOCAL
– Anaesthesia failure
- Pain will still be present
– Haemorrhage-
The escape of blood from a blood vessel, externally or internally
– Fracture of;
• Roots
• Maxilla tuberosity;
• Mandible

13. - There may be a displacement of
Teeth/Roots
- Soft Tissues
-Surgical empysema (air in soft tissues producing crackling)
- Teeth/roots may be slipped into
• Buccal Space
• Sublingual/Submandibular Space
• Infratemporal Fossa
• Maxillary antrum

14. ......
– Oro-Antral Communication
– TMJ Dislocation

15. SYSTEMIC
– Fainting (Syncope)
loss of consciousness due to a decrease in blood pressure resulting in
insufficient blood supply to the brain
– Epileptic Fit
A disorder of the brain causing sudden onset of seizures.
– Acute Hypertensive Crisis
– Cardiac Arrest

16. POST-OPERATIVE
Are the problems that may occur after treatment.
• Local
• Systemic

17. LOCAL
– Pain
– Haemorrhage
– Dry socket
– Lip Trauma
– Wound Infection
– Needle Track Infection

18. CONTINUED..
– Space infection
– Haematoma
– Trismus
– Osteomyelitis
– Pathological fracture

19. SYSTEMIC
– Hypovolaemic Shock
– Allergy

20. PERSISTENT
A problems that may persist way long after treatment.
• Neurological
- Motor
- Sensory
• Scar Formation

21. 1 . FAILURE TO SECURE ANAESTHESIA
• Faulty technique
• Insufficient dosage of
anaesthetic agent

22. 2 . EXTRACTION OF THE WRONG TEETH
Management
• Inform the patient
• Replace the tooth inside the socket as soon possible and splint.
• If immediate replacement is not possible, place the tooth in a proper medium like saliva,
milk or water.
• Follow up as for traumatic avulsion and re-implantation.

23. 3 . BREAKAGE OF INSTRUMENT
Causes
 Application of excessive force
 Improper technique
 Defect in manufacturing of
instruments
 Old and worn out instruments
Prevention
 Proper selection of the instrument
 Proper handling and usage

24. CONTINUED…..
Management
 Remove the burs or elevator
tips with a hemostat if it is
possible.
 If impacted deeply, surgical
removal of the instrument is
advised, unless
contraindicated as in close
proximity to vital structures.
Radiographic Appearance

25. 4 . LUXATION OF ADJACENT TOOTH
Causes
 Improper instrumentation.
 No support to the adjacent structures during extraction.
Prevention
 Proper technique and careful handling of the instruments.
 Support the adjacent teeth adequately before extraction.

26. Management
 Reposition the tooth inside
the socket and splint it
 The tooth should be treated
endodontically after one
week.
Clinical Appearance
Adjacent
tooth

27. FAILURE TO REMOVE THE TOOTH WITH
EITHER FORCEPS OR ELEVATOR
• • Tooth fails to yield to the application of
reasonable force applied with either forceps
or elevator.
• • Tooth dissection
5.

28. 6 . FRACTURE OF THE CROWN DURING EXTRACTION
Causes
 Application of wrong forceps
 Improper application of forceps
 Extensively carious tooth
 Endodontically treated tooth
 Curved or hypercementosed root
 Ankylosed root
Prevention
• Proper radiograph assessment of the tooth to be extracted
• Proper forceps technique

29. Management
- Using transalveolar removal technique if intra-alveolar
extraction is not feasible.
Clinical appearance

30. 7 . FRACTURE OF TOOTH ROOT
Causes
 Improper technique
 Application of improper instrument and force.
 Ankylosed or Hypercementosed teeth
 Excessively curved roots
 Endodontically treated root
 Uncooperative patient
Consequences of retained roots
Retained roots may acts as a source if infection. They might be chronic source of
irritation giving rise to Neuralgic Pain. Large retained tooth may interfere with
the proper functioning of prosthesis.

31. POLICY FOR LEAVING ROOT FRAGMENTS
RISKS
 Roots may be
slipped into -
- Maxillary sinus
- Tissue spaces
 Nerve injury
But
when
• Root size less
than<5 mm
• No pathosis
• Very deeply
seated
 Inform the patient &
 Follow up

32. Methods of retrieval of fractured root
Using appropriate elevators, forceps with slender beaks and
Reamers for removal of fractured root at various levels.
Clinical appearance

34. REMOVAL OF ROOT TIP
Removal of the root tip using an endodontic
file. After the endodontic file enters the root
canal, the root tip is drawn upwards by
hand (a), or with a needle holder (b)

35. 8 . FRACTURE OF TUBEROSITY
Causes
• In cases where the antrum extends into the tuberosity, the extraction of
the third molar can result in fracture of tuberosity.
• Exertion of excessive force and improper force application
• Fusion of the roots of second molar with the un-erupted third molar
(concrescence)
• Divergent and hypercemetosed roots of the third molar.
Prevention
• Proper analysis of the radiograph of tooth and surrounding structures.
 Correct technique of extraction with careful force application
 Support to the alveolus during extraction.

36. Management
a . In case of small fractured segment, a mucoperiosteal flap is elevated and the
tuberosity is removed with tooth, followed by wound closure.
b . In case of large fractured segment, it should be replaced and splinted
c . Removal of tooth should be done after the healing of fractured site.
Clinical appearance

37. 9 . FRACTURE OF MANDIBLE
Causes
 Atrophic mandible as in old age.
 Existence of any bony pathology, eg- fibrous dysplasia, cyst, previous exposure to
radiotherapy
 Excessive force application
 In case of removal of vertically impacted third molar.
Prevention
 Proper preoperative assessment of the type of impaction and the density of the bone
before extraction
 Proper support of the jaw during extraction
 Application of adequate force.
 If any bony pathosis presents, then extraction should not be attempted in the dental clinic
& pt. should be referred to oral surgery speciality centre.

38. Management
 Inform and reassure the patient.
 Open reduction & internal fixation of the fracture
accordingly.
Radiographic appearance

39. 10 . DISLOCATION OF CONDYLE
If the dislodgement of the condyloid processfrom its seat in the glenoid fossa.
One or both joints may be dislocated.
Causes
• Exertion of excessive force
 Failure to support the mandible adequately during extraction
 Number of previous episodes of dislocation
Prevention
• Proper exertion of adequate force
 Support the mandible during
extraction

40. Clinical Appearance

41. Symptoms
a) The mouth is opened and rigidly set in position with the
chin protruding.
b) The patient cannot close his mouth
c) Depression in front of the ear
d) Some pain may or may not be present

42. MANAGEMENT
• A radiograph should be taken
• Manual reduction is done with the thumb wrapped
with gauze or bandage to avoid injury by teeth
• Then the thumbs are placed on the occlusal surface of
the mandibular teeth and mandible is then pushed
downward backward rotating the chin upwards
meanwhile the condyles are moved downwards and
backwards over the articular eminences of temporal
bone.

44. • Long standing dislocation may require prolonged traction on the
mandibular ramus under general anaesthesia or open reduction.
• 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 ( at least 48 hrs).
• Analgesics indicated for first 2 days.
Advice

45. 11 .SOFT TISSUE INJURY
Types and Causes
Abrasion – these injuries are caused by careless use of rotatory instruments (like burs while
bone cutting.)
Thermal injuries – caused when instrument taken out from Autoclave or hot air oven are
used immediately intra-orally.
Mucosal injuries – caused due to injudicious used of instruments, improper elevation of flap
or the exercise of excessive force.
Prevention
 Take extreme care during the handling of the rotary or other hand instruments.
 Use well cooled instruments to prevent thermal injuries.
 Properly retract the cheek and lips during dental procedures.

46. Damage to soft tissues
Clinical Appearance

47. Management
 If the tear or abrasion is large, suturing should be done
for closure.
 Scars produced due to thermal injuries can be
managed by the application of petroleum jelly or
topical antiseptic/analgesic.

48. 12 . INJURY TO INFERIOR ALVEOLAR NERVE
INJURY TO THE INFERIOR ALVEOLAR NERVE MAY RESULT IN PARESTHESIA OR NUMBNESS OF
THE NERVE’S DERMATOME – HALF OF LOWER LIP OR CHIN.
Cause
• During the removal of an impacted
mandibular third molar, which is in close
proximity to the inferior alveolar nerve.
• Careless manipulation of the instruments
resulting in nerve damage
Prevention
• Proper radiographic assessment of the
proximity of the impacted third molar to the
inferior alveolar nerve before its removal.
• Careful manipulation of the instruments.

49. Management
1. Nonsurgical management
 Most patients are known to recover spontaneously to some degree as
nerve usually regenerates within 6 weeks to 6 months
2. Surgical management
 Decompression if impingement of nerve is present
 Micro neurovascular surgery.
Clinical appearance

50. 13 . INJURY TO LINGUAL NERVE
Causes
 The nerve may be damaged during the
removal of the third molar when the
lingual cortex fractures.
 There is risk of damage during the
elevation of the lingual mucoperiosteum.
Prevention
Proper technique and careful
manipulation of the instruments.

51. Injured lingual nerve presenting
as a loss of tatse and sensation in
right tongue.
Repaired
lingual nerve.
Repaired
lingual nerve
protected by a
nerve collagen
collar.

52. Management
 Reassure the patient, review
regularly.
 If there are no symptoms of
recovery or negative Tinel’s
sign, attempt nerve repair.

54. 14 . HAEMORRHAGE
Haemorrhage is a common sequelae of oral surgery. It’s the escape of blood from the
vascular system.
There are three types of Post-operative bleeding:-
1. Primary – Occurs continuously at the time of the surgery
2. Reactionary – Occurs within 24 h.after primary bleeding has been controlled
3. Secondary – Occurs at any time after first post op. day of the procedure

55. CAUSES
Local causes:
• • Trauma
• • Mechanical dislodgement of the clot
• • Damage to blood vessel or soft tissue
• • Fracture of alveolar bone
• • Damage to nutrient blood vessel
• Infection
• • 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

56. SYSTEMIC CAUSES
• Disorder related to systemic disease
– Platelet disorders: Thrombocytopenia
– Coagulation defects : Haemophilia
• Vascular defects: hereditary hemorrhagic telengeactesis
• Drug therapy: Aspirin, Anti coagulant therapy

57. HAEMOSTATIC MECHANISM
Haemostatic plug
formation

59. • Provide excellent patient instruction.
• INR is used to measure therapeutic anticoagulation effects. Minor
surgery can be performed if INR is 3.0. if INR is more than 3.0
consult physician.
Prevention
• Obtain history of prolonged bleeding, previous episode of
bleeding, family history and drug history.
• Use atraumatic surgical technique
• Obtain good hemostasis at surgery

60. Primary control of bleeding
• Give clean incisions avoid crushing of soft tissues.
• Smooth sharp bony spicules.
• Curette all granulation tissue but avoid maxillary sinus and ID
canal.
• Inspect the soft tissue wound to locate obvious bleeding vessels. If
present apply pressure or ligate the artery with resorbable sutures.
• Inspect bleeding from bone, bleeding from small isolated vessel
from bleeding foramen.
• Foramen should be crushed with closed end of hemostat.

61. Continued…….
• Apply damp gauze pack directly over extraction socket.
• Patient should bite firmly on gauze for 30 min.
• Do not dismiss the patient until hemostasis is achieved.
• Check extraction socket after 30 min if bleeding is under control apply a
new damp gauze pack and instruct the patient to bite on it for 30 min.

62. CONTINUED……
• If bleeding persists and it is not of arterial origin surgeon should
take additional measures to control bleeding
• Application of gelatin sponge (gel foam)
• Application of oxidized regenerated cellulose.
• Application of topical thrombin.
• Application of collagen
Collagen
Topical
Thrombin

63. SECONDARY BLEEDING
• Occasionally even after primary control of bleeding is achieved
patient report the dental surgeon regarding bleeding this
bleeding is termed as secondary haemorrhage.
• In these cases when patient calls from home instruct the patient
to rinse the mouth gently with chilled water, and place a damp
gauze over extraction site and bite firmly for 30 minutes.
• If bleeding continues instruct to rinse mouth with chilled water
and bite over damp tea bag.
• If these measures fails instruct the patient to return to dental
office.

64. MANAGEMENT OF SECONDARY BLEEDING
• Place the patient on dental chair, suction all fluids from mouth,
and inspect the bleeding site with good light to determine
precise source of bleeding.
• If there is generalized oozing, the bleeding site is covered with
damp gauze and surgeon should apply finger pressure for 5
minutes.
• The cause of bleeding is secondary trauma caused by negative
pressure or excessive spitting.

65. CONTINUED……
• If 5 minutes of this treatment fails to control
bleeding, administer local anesthesia block, its
better to avoid infiltration as temporary
vasoconstriction effects of epinephrine fades and
reactionary bleeding occurs.
• After local anesthesia, curette the socket, and
locate point of bleeding. Bleeding can be from soft
tissue or nutrient artery from bone.
• Place gelatin sponge with topical thrombin in the
socket with the help of figure of 8 suture and damp
gauze pack should placed over it.
• Monitor the patient in office for 30 minutes, give
instructions and discharge.

66. CONTINUED……
• If bleeding persists perform coagulation profile screening tests
to detect any major clotting defect. PT, APTT, BT
• Take opinion of hematologist and manage accordingly.

67. HEMOSTATICS
TOPICAL:
 VASOCONSTRICTORS
Adrenaline
 ABSORBABLE AGENTS
• Oxidized cellulose
• Oxidized regenerated cellulose
• Gelatin sponge
• Fibrin foam
• Calcium alginate
• THROMBOPLASTIC AGENTS
• Thrombin

68.  CHEMICAL AGENTS:
• Tannic acid
• Ferric chloride
• Zinc chloride Alum
• Hydrogen peroxide
SOCKET PLUGS:
• Bone wax
• Whitehead’s varnish on ribbon gauze

69. SYSTEMIC AGENTS
• ETHAMSYLATE - 2ml ampoules i.m/iv 1-2 hrs
before operation OR 2-3 ampoules following surgery
followed by 1 amp/2 tabs every 4-6 hrs.
• VITAMIN K- Normally 10mg capsules, 10-20 mg
oral/ i.m /i.v
A. ENDOGENOUS:
• Whole blood
• Fresh frozen plasma
• Cryoprecipitate
B. EXOGENOUS

70. 15. DRY SOCKET
• A descriptive definition that could be used
universally as a standardized definition -
postoperative pain in and around the
extraction site, which increases in
severity at any time between 1 and 3
days after the extraction accompanied by
a partially or totally disintegrated blood
clot within the alveolar socket with or
without halitosis.

71. SYNONYMS:
• alveolar osteitis (AO),
• localized osteitis,
• postoperative alveolitis,
• alveolalgia,
• alveolitis sicca dolorosa,
• septic socket,
• necrotic socket,
• localized osteomyelitis,
• fibrinolytic alveolitis

72. ETIOLOGY
• Multifactorial origin
• Following have been implicated most commonly as etiological,
aggravating and precipitating factors:
1. Oral micro-organisms
2. Difficulty and trauma during surgery
3. Roots or bone fragments remaining in the wound
4. Excessive irrigation or curettage of the alveolus after
extraction
5. Physical dislodgement of the clot
6. Local blood perfusion & anesthesia
7. Oral contraceptives
8. Smoking

73. Etiology
1. Difficult or traumatic extraction
Painful or more traumatic extraction would leads to:
 Delayed alveolar healing
 Thrombosis of the underlying vessels
 Lesser resistance to infection
2. Use of oral contraceptives
Estrogens and other drugs activate the fibrinolytic system in an indirect way
by increasing the factors II, VII, VIII, X and plasminogen; contributing to
premature destruction of the clot and the development of dry socket.
3. Hormonal changes
Changing levels of endogenous estrogens during the menstrual cycle would
also influence.

74. 4. Tobacco
Tobacco interferes with the alveolar healing is the incorporation of pollutants in the wound
or the suction effect on the clot in formation.
5. Inadequate Intra-operatory Irrigation
Use of anesthesia solution with vasoconstrictor or an intra-ligamentous technique of
anesthesia, where solution is deposited very near to the alveolus and if the Solution is colder
than the corporal temperature increases the incidence of dry socket.
6. Advanced age
Old age people with immunocompromised state, extraction site in
the mandible, excessive or exaggerated irrigation of the socket.
Continued…..

75. SIGN & SYMPTOMS
1. The denuded alveolar bare bone may be
painful and tender.
Initially blood clot appears dirty gray
grayish yellow bony socket bare of granulation
tissue
2. Some patients may also complain of intense
continuous pain irradiating to the ipsilateral
ear, temporal region or the eye.
3. Regional lymphadenopathy (occasionally).
4. unpleasant taste (occasionally).
5. Trismus is a rare occurrence in mandibular
third molar extractions probably due to lengthy
and traumatic surgery.
disintegrates
Swelling
Pain
Foul Smell

76. Etiopathogenesis
Process of Normal Healing – takes place in five stages :-
STAGE – I Haematoma & Clot formation
STAGE – II Granulation Tissue Formation
STAGE – III Replacement of Granulation tissue by Connective tissue
STAGE – IV Replacement of Connective tissue by Coarse bone
STAGE – V Replacement of Coarse bone by Mature Bone
Formation of Dry socket
Partial or complete lysis and destruction of the blood clot was
caused by tissue kinases liberated during inflammation by a direct
or indirect activation of plasminogen in the blood.

77. Trauma or
infection
Causes
Release of
tissue
activators plasmino
gen
Converted
to
plas
min
Lysis of fibrin
Formation of
kinins
Dissolution of
blood clot
Pain
Inflammation of bone marrow
Etiopathogenesis

78. • Presence and formation of ‘kinin’
locally in the socket .
• Kinins activates the primary
afferent nerves, which may have
already been presensitized by
other inflammatory mediators and
algogenic substances as
bradykinin ,serotonin( even in
concentrations as low as 1 ng/ml)

79. Theories of Dry socket
I – Birn’s Fibrinolytic Theory
II – Bacterial Therory
BIRN’s FIBRINOLYTIC THEORY
According to this theory, after the extraction of a tooth an inflammatory process begins that could effect
the formation and retention of the clot. There is an increase in local fibrinolysis leading to disintegration
of the clot. The fibrin would disintegrate due to the effect of kinase released in the inflammation process
or due to direct or indirect activation of Plasminogen.
Active
Plasmin
ogen
Fibrin
Plasminogen
Fibrinogen
Clot
dissolution
No. of fibrin
degradation
products

80. BACTERIAL THEORY
According to this theory, occurrence of dry socket is more due to existence of a high count of bacteria
around the extraction site.
E.g..- Actinomyces viscous and Streptococcus mutans
(they retard the alveolar post-extraction healing)
1. Infection
2. Size of wound
3. Blood supply
4. Resting of part
5. Foreign bodies
6. General condition of the patient

81. With references in the literature correlating to the prevention of
dry socket can be divided into
1. Non- pharmacological and
2. Pharmacological preventive measures.

82. 1. Use of good quality current preoperative radiographs.
2. Careful planning of surgery.
3. Use of good surgical principles.
4. Extractions should be performed with minimum amount of
trauma and maximum amount of care.
5. Confirm presence of blood clot subsequent to extraction.

83. 6. Preoperative oral hygiene measures.
7. Encourage the patient to stop/limit smoking in
immediate postoperative period.
8. Avoid vigorous mouth rinsing for the first 24 hours of post
extraction
9. For patients taking oral contraceptives extractions
should ideally be performed during days 23 through 28 of
menstrual cycle.
10.Comprehensive pre and post operative verbal
instructions should be given.
Continued…

84. 1. Anti- bacterial agents
2. Anti- septic agents and lavages
3. Anti- fibrinolytic agents
4. Steroidal anti- inflammatory agents
5. Obtundent dressings
6. Clot supporting agents

85. Prophylactic antibacterials, either given systemically or used locally.
Systemic anti bacterials – penicillin
clindamycin
erythromycin
metronidazole
Preoperative administration of antibacterial agents is more effective.
A significantly reduced incidence of dry socket following light socket
irrigation with Betadine & topical application of Clindamycin in
Gelfoam.

86. Chlorhaxidine (CHX) is a bisdiguanide antiseptic with anti microbial
properties.
USE OF WHITEHEAD’S VARNISH:
Whitehead’s varnish is a combination of ‘iodoform, balsam
tolutan, styrax liquid I a base liquid.
RESULT:
Significant decrease in incidence of postoperative pain.
Haemorrhage and swelling.

87. Has been widely used in the management of dry socket and is
frequently mentioned in the literature.
It contains: butamben(anesthetic)
eugenol(analgesic)
iodophorm(antimicrobial)
Topical use of ‘para-hydroxybenzoic acid(PHBA) in extraction wounds
as Anti-fibrinolytic agents.
Apernyl- an alveolar cone with formulation of
32 mg acetylsalicylic acid
3mg propyl ester of PHBA
20 mg unknown tablet mass

88. Topical use of corticosteroids in the prevention of dry socket –
decreases immediate post – operative complications
failed to reduce the occurrence of dry socket
Immediate placement of eugenol containing
dressing into the extraction socket is
beneficial in the prevention of post extraction
complication.
Use of clot supporting agents such as
‘polylactic acid(PLA)’ was widely promoted
as ultimate solution for preventing dry
socket.

90. 1. Remove any suture to allow adequate exposure of extraction
site.
2. Irrigate the socket with isotonic saline gently,careful suctioning
of all excess irrigation.
3. Do not attempt to curette the socket.
4. Prescription of potent oral analgesics.
5. Patient is given with a ‘plastic syringe with curved tip for home
irrigation’ with chlorhexidine solution.

91. • Under block anesthesia
• Sharp margins were trimmed, rounded
• Any foreign bodies present were thoroughly removed
• Detached gingival margins are also scraped.
• Desired medications as well as precautions
• Patients was not only without pain but was also
comfortable both physically as well as psychologically from
the very next day.

92. DISPLACEMENT OF TOOTH/ROOT INTO
MAXILLARY SINUS
Causes
• The roots of the maxillary posterior teeth are always in a close proximity to the
maxillary sinus such that the large antral cavities may dip in between the apices of the
teeth.
 With advancing age the degree of pneumatisation of the maxillary sinus increases and
the antral walls become very thin. Thus eventually the roots being covered only by thin
lamellae of bone which fracture easily and result in the displacement of the root tip
during its removal.
 Sometimes the tooth may slips into the maxillary antrum like the ‘popping of an orange
seed’ once the extraction forceps are applied.
16.

93. Prevention
• Application of appropriate force and proper handling of forceps.
• Avoid injudicious instrumentation to remove a broken tip.
• Proper radiographs should be taken before the extraction to access the proximity of
the root tip to the sinus
• Support the alveolus adequately before the extraction.
Management
• Confirm the presence and location of the tooth or root tip in the sinus using
radiograph.
• Once the location is confirmed, keep a nozzle connected to a powerful suction devise
at the entrance of the fistula to recover tooth
• Pack a piece long roller gauze into the sinus through the opening and remove it with a
jerk, the root tip might get removed with the gauze.
• If none of the above procedure works, then Caldwell-Luc operation is carried out.

94. Radiographic Appearance

96. 17. ORO-ANTRAL COMMUNICATION & FISTULA
ORO-ANTRL COMMUNICATION
ORO-ANTRAL
FISTULA

97. OROANTRAL COMMUNICATION MAY BE THE RESULT
OF….
Displacement of an impacted tooth or root tip into the maxillary sinus during a
removal attempt.
Closeness of the root tips to the floor of the maxillary sinus. In this case the
bony portion above the root tips is very thin or may even be absent, where upon
oro-antral communication is inevitable during the extraction of the tooth,
especially if the alveolus is debrided unnecessarily.
Extensive bone removal for extraction of an impacted tooth or root.
Extensive fracture of the maxillary tuberosity, whereupon part of the
maxillary sinus may be removed together with the maxillary tuberosity
The presence of periapical lesion that has eroded the bone all of the maxillary sinus
floor.
Degree of pneumatisation with advancement of age

98. PREVENTION
• Perform a carefull preoperative radiographic examination
• Use surgical extraction if there is possibility of OAC.
• Avoid excessive apical pressure to elevate fractured roots.
• Avoid excessive force to remove maxillary molars.

99. WHICH MAXILLARY TOOTH ROOTS ARE CLOSER TO
MAXILLARY SINUS FLOOR
1st permanent
molar
2nd pre-molar
1st premolar
Closer than
2nd permanent molar

100. Results:
The distance between sinus floor and root tip was longest for the first
premolar root tip and shortest for the second molar buccodistal root tip for
both right and left sides. No statistically significant differences were found
between the right and left side measurements or between female and male
patients (P>.05).

104. DIAGNOSIS:
1. Examine the tooth once it is removed , if a section of bone is
attached with root ends , surgeon should assume that
communication is present
2. Nose blowing test: (valsalva maneuver)
This test involves pinches the nostrils together to occlude the
patient’s nose and asking the patient to blow gently through
the nose ,while the surgeon observes the area of tooth
extraction .
If communication exist , there will be passage of air through
the tooth socket and bubbling of blood in the socket.

105. 3. Radiograph
• Intra-oral periapical view
• OPG
• Warer’s view
• CT scan of the maxillary antrum
4.After diagnosis see the size of communication
• If no bone is attached to roots, size of communication is likely to be 2
mm or less.
• If piece of bone is removed with tooth, size of opening is measureable.
Oro antral
communication
in IOPA view
Oro antral fistula in CT
scan
FISTULA

106. MANAGEMENT
The best treatment can be achieved through:
1.Careful observation
2.Radiographs
3. Do not probe the defect
4.Promote good blood clot
5.Place suture

107. MANAGEMENT WILL BE DONE -

108. IMMEDIATE MANAGEMENT OF ORO-ANTRAL
COMMUNICATION

109. • The surgeon should take
measures to ensure the formation
of high quality blood clot in the
socket and advise to take sinus
precautions to prevent
dislodgement of the blood clot. Figure of 8 Suture

111. • Antibiotics usually amoxicillin or clindamycin –
prescribed for 5 days
• A decongestant nasal spray
-prescribed to shrink the nasal mucosa.
• Maintain follow up
Continued….

113. MANAGEMENT OF DELAYED CASES

116. Buccal flap technique
Palatal pedicle flap

117. Tongue Flap
Buccal pad of fat flap

120. COMPLICATION
1.Postoperative maxillary sinusitis
2.Formation of chronic oroantral fistula

121. POSTOPERATIVE MAXILLARY SINUSITIS:
• When an Oroantral communiaction is created, this allows the flow
of food, smoke or fluid from the mouth, via the maxillary sinus and
into the nose.
• Not just these but also bacteria, fungi and viruses. This can set up a
maxillary sinusitis, which depending on how long the
communication lasts for, may either yield an acute/chronic
maxillary sinusitis.

122. OROANTRAL FISTULA
• When chronic oroantral fistula defects
are wider than 5mm and persist for
more than 3 weeks, a secondary
surgical intervention is required
-buccal flap
-palatal flap
Treatment
Before closure of oroantral fistula, it is
imperative to eliminate any acute or chronic
infection within the sinus.
This may require frequent irrigation of the
fistula and sinus combined with the use of
antibiotics and decongestants

124. 18. TRISMUS
• Trismus, refers to reduced opening of the jaws
caused by spasm of the muscles of mastication, or
may generally refer to all causes of limited mouth
opening.
• It is a common problem and may interfere with
eating, speech, oral hygiene, and could alter facial
appearance. There is an increased risk
of aspiration.

125. NORMAL MOUTH OPENING
The normal range of mouth opening
varies from patient to patient,
within a range of 40- 60 mm,
although some authors place the
lower limit at 35 mm.
 The width of the index finger at the
nail bed is between 17 and 19 mm.

126. CONTINUED….
 Thus, two finger's breadth (40 mm) up to three fingers' breadth
(54-57 mm) is the usual width of opening.
 Evidence suggests that gender may be a factor in vertical
mandibubr opening.
 In general, males display greater mouth opening .
 Lateral movement is 8-12 mm.

127. DENTAL PROCEDURES
 Oral surgical procedures may result in limited jaw opening.
 The extraction of teeth may also cause trismus as a result either
of inflammation involving the muscles of mastication or direct
trauma to the TMJ.

128. • Another common cause of trismus often seen in general practice
is the limited mouth opening that occurs after 2-5 days of a
mandibular block has been administered. This is usually
attributed to inaccurate positioning of the needle when giving
the inferior nerve block.

129.  Ideally, the needle should be placed in the
pterygoid space, which is bound by the
internal oblique ridge of the mandible on
the lateral side and pterygomandibular
raphe on the medial side.
 Occasionally, the medial pterygoid muscle
is accidentally penetrated or a vessel is
punctured and a small bleed occurs.

130. Proper positioning of the needle for inf. Alveolar nerve block

131. CONTINUED…
 Trismus due to this cause can be protracted and quite severe.
 Hot packs, stretching exercises using wooden spatulas and
reassurance are usually sufficient for this condition, although
sometimes the haematoma becomes infected and requires
surgical evacuation.

132. MANAGEMENT OF TRISMUS

133. MANAGEMENT
 Treatment of trismus varies depending on the aetiological factor.
Some difficulty in opening the jaw on the day following dental
treatment in which a superior alveolar or inferior alveolar nerve
block was administered is frequently encountered.
The degree of discomfort and dysfunction varies, but is usually
mild.

134. CONTINUED…
 When a patient reports mild pain and dysfunction, an appointment for examination
should be arranged.
 In the interim, the practitioner should prescribe the following:
 Heat therapy
Heat therapy consists of placing moist hot towels on the affected area for 15-20 minutes
every hour.
 analgesics;
ANALGESICS
 a soft diet; and (if necessary)
 muscle relaxants
to manage the initial phase of muscle spasm

135. CONTINUED…
Barrett et al(1988) have described the adjunctive treatment modalities of
heat, cold, and electrotherapy for use in patients suffering from trismus.
Heat in particular is an effective adjunct to stretching.
It increases the extensibility of collagen tissue, decreases joint stiffness,
relieves pain and muscle spasm, increases blood flow, and helps to resolve
inflammatory infiltrates edema.

136. CONTINUED….
 Aspirin is usually adequate in managing the pain associated with
trismus; its antiinflammatory properties are also beneficial.
 A narcotic analgesic may be required if the discomfort is more intense.
 If necessary, diazepam (2.5-5 mg t.i.d.) or other benzodiazepine may
be prescribed for muscle relaxation.
When the acute phase is over, the patient should be advised to
initiate physiotherapy for opening and closing the jaws and to
perform lateral excursions of the mandible for 5 minutes every 3-4
hours.
 Sugarless chewing gum is another means of providing lateral
movement of the TMJ.

137. CONTINUED…
 Any trauma or event that may be suspected of having triggered the
TMD, should be recorded in the patient's dental record, as should the
findings and the treatment.
 Further dental treatment in the involved region should be avoided until
symptoms resolve and the patient is more comfortable.
If further dental care is needed, as with a painful infected tooth, access for
local anaesthesia may be difficult when trismus is present.
 The (closed mouth) nerve block usually provide relief of the motor
dysfunction, permitting the patient to open and allowing the practitioner to
provide the appropriate treatment.

138. In virtually all cases of trismus that are managed as outlined above, patients report
improvement within 48 hours.
 Therapy should be continued until the patient is free of symptoms.
 If pain and dysfunction continue unabated beyond 48 hours, the possibility of infection
should be considered

139. CONTINUED…
 Antibiotics should be added to the treatment regimen and continued for 7 days.
 If trismus is suspected to be associated with infection, appropriate antibiotics should be
prescribed.
 In the case of severe pain or dysfunction, if no improvement is noted within 2-3 days
without antibiotics or 5-7 days with antibiotics, or if the ability to open has become very
limited, the patient should be referred to an oral and maxillofacial surgeon for evaluation.
 Treatment for trismus should be directed at eliminating its cause.
 Diagnostic assessment should be made, before any type of therapy is applied.

140.  SCREW-TYPE MOUTH GAG:
-Application is limited to dentate or partially edentulous patients.
 Tongue blades
-Used as a wedge, tongue blades are effective only in a dentate
patient.
Internally activated appliances
-These rely on the patient’s depressor muscles to stretch the
elevator muscles.
e.g.: Tongue blades, Plastic tapered cylinder.

142. COMPLICATIONS SHOULD BE DIAGNOSED AS SOON AS
THEY OCCUR & DEALT PROMPTLY & EFFECTIVELY
HAPPY
DENTISTRY

143. THANKS To ALL

144. SESSION - 2
OPEN DISCUSSION