oroantral communication oroantral fistula

1. Complications of dental extraction 2
Senior lecturer Dr. Haydar Munir Salih Alnamir
BDS, PhD (BOARD CERTIFIED)

2. Hemorrhage
• Once an extraction has been completed, the initial
maneuver to control postoperative bleeding is the
placement of a folded gauze directly over the socket.
• The patient should be instructed to bite firmly on this
gauze for at least 30 minutes and not to chew on the
gauze. The patient should hold the gauze in place
without opening the mouth.

4. Hemorrhage
• Patients should be informed that it is normal for a
fresh extraction site to ooze slightly for up to 24
hours after the extraction procedure.
• Patients should be warned that a small amount of
blood mixed with a large amount of saliva might
appear to be a large amount of blood.

6. Hemorrhage
• If the bleeding is more than a slight ooze, the patient
should be told how to reapply a folded piece of gauze
directly over the area of the extraction.
• The patient should be instructed to hold this second
gauze pack in place for as long as 1 hour to gain control
of bleeding.
• Further control can be attained, if necessary, by the
patient placing a tea bag in the socket and biting on it
for 30 minutes. The tannic acid in regular tea serves as
a local vasoconstrictor

8. Hemorrhage
• The surgeon should inquire about any family history of bleeding. If
anyone in the patient’s family has or had a history of prolonged
bleeding, further inquiry about its cause should be pursued. Most
congenital bleeding disorders are familial, inherited characteristics
• The patient should next be asked about any medications currently
being taken that might interfere with coagulation. Drugs such as
anticoagulants may cause prolonged bleeding after extraction.
Patients receiving anticancer chemotherapy or aspirin, those with
alcoholism, or patients with severe liver disease for any reason
also tend to bleed excessively.

10. Hemorrhage
• The patient who has a known or suspected coagulopathy
should be evaluated by laboratory testing before surgery is
performed to determine the severity of the disorder
• The status of therapeutic anticoagulation is measured by
using the international normalized ratio (INR)
• Normal anticoagulated status for most medical indications
has an INR of 2.0 to 3.0. It is reasonable to perform
extractions on patients who have an INR of 2.5 or less
without reducing the anticoagulant dose.

12. Primary control of bleeding during routine
surgery depends on:
1. Surgery should be as atraumatic as possible, with clean
incisions and gentle management of soft tissue.
2. Care should be taken not to crush soft tissue because
crushed tissue tends to ooze for longer periods.
3. Sharp bony spicules should be smoothed or removed.
4. Granulation tissue should be curetted from the periapical
region of the socket and from around the necks of
adjacent teeth and soft tissue flaps

14. Extraction of teeth is a surgical procedure that presents a
severe challenge to the hemostatic mechanism of the
body. Several reasons exist for this challenge:
(1) the tissues of the mouth and jaws are highly
vascular;
(2) the extraction of a tooth leaves an open wound,
with soft tissue and bone remaining open, which
allows additional oozing and bleeding;
(3) it is almost impossible to apply dressing material
with enough pressure and sealing to prevent additional
bleeding during surgery;

15. Extraction of teeth is a surgical procedure that presents a
severe challenge to the hemostatic mechanism of the
body. Several reasons exist for this challenge:
(4) patients tend to explore the area of surgery
with their tongues and occasionally dislodge blood
clots, which initiates secondary bleeding, or the
tongue may cause secondary bleeding by creating
small negative pressures that suction the blood
clot from the socket; and
(5) salivary enzymes may lyse the blood clot before
it has organized and before the ingrowth of
granulation tissue.

16. Hemorrhage
• The surgeon should also check for bleeding from the
bone. Occasionally a small, isolated vessel bleeds
from a bony foramen.
• The surgeon should not dismiss the patient from the
office until hemostasis has been achieved.

18. Hemorrhage
• The patient should open the mouth widely, the gauze
should be removed, and the area should be inspected
carefully for any persistent oozing. Initial control should
have been achieved by then.
• New gauze is then dampened, folded, and placed into
position, and the patient is instructed to leave it in place
for an additional 30 minutes.
• If bleeding persists but careful inspection of the socket
reveals that it is not of an arterial origin, the surgeon
should take additional measures to achieve hemostasis

19. The most commonly used and the least expensive
is the absorbable gelatin sponge (e.g., Gelfoam).

20. Pain and Discomfort
• All patients expect a certain amount of discomfort after
any surgical procedure, so it is useful for the dentist to
discuss this issue carefully with each patient before the
procedure begins.
• The surgeon should also take care to advise the patient
that the goal of analgesic medication is management of
pain and not elimination of all discomfort.
• The first dose of analgesic medication should be taken
before the effects of the local anesthetic subside

22. The three characteristics of the pain that
occurs after routine tooth extraction:
(1) The pain is usually not severe and can be
managed in most patients with over-the-counter
analgesics,
(2) the peak pain experience occurs about 12 hours
after the extraction and diminishes rapidly after
that, and
(3) significant pain from extraction rarely persists
longer than 2 days after surgery

23. Analgesia
1. patients should avoid taking narcotic pain medications
on an empty stomach.
2. Ibuprofen has been demonstrated to be an effective
medication to control discomfort from a tooth
extraction Ibuprofen has the disadvantage of causing a
decrease in platelet aggregation and bleeding time
3. Acetaminophen does not interfere with platelet
function and may be useful in certain situations in which
the patient has a platelet defect and is likely to bleed

25. Analgesia
4. Codeine can be a useful post-extraction
analgesic because it carries little narcotic abuse
potential
5. When a combination of analgesic drugs is used,
the dentist must keep in mind that it is
necessary to provide 500 to 1000 mg aspirin or
acetaminophen every 4 hours to achieve
maximal effectiveness from the nonnarcotic

27. Edema
• Routine extraction of a single tooth will probably not
result in swelling that the patient can see,
• whereas the extraction of multiple impacted teeth with
reflection of soft tissue and removal of bone may result
in moderately large amounts of swelling.

28. Edema
•Swelling usually reaches its maximum 36 to 48
hours after the surgical procedure. Swelling
begins to subside on the third or fourth day
and is usually resolved by the end of the first
week. Increased swelling after the third day
may be an indication of infection rather than
renewed postsurgical edema

30. Treatment
• The ice pack or small bags of frozen peas should be kept on
the local area for 20 minutes and then kept off for 20
minutes over a period of 12 to 24 hour
• On the second postoperative day, neither ice nor heat
should be applied to the face
• On the third and subsequent postoperative days,
application of heat may help to resolve the swelling more
quickly

31. Trismus
• Extraction of teeth, administration of a mandibular
block, or both may result in trismus (limitation in
mouth opening).
• Trismus results from trauma and the resulting
inflammation involving the muscles of mastication.
• Trismus may also result from multiple injections of
the local anesthetic, especially if the injections
have penetrated muscles.

33. Trismus
• Surgical extraction of impacted mandibular third
molars usually results in some degree of trismus
because the inflammatory response to the
surgical procedure is sufficiently widespread to
involve several muscles of mastication

35. Trismus
•Trismus is usually not severe and does not
hamper the patient’s normal activities.
However, to prevent alarm, patients should
be warned that this phenomenon might
occur and that it will likely resolve within a
week.

36. Oroantral Communications
• Removal of maxillary premolars or molars
occasionally results in communication between the
oral cavity and the maxillary sinus.
• If the maxillary sinus is greatly pneumatized, if little
or no bone exists between the roots of the teeth and
the maxillary sinus.

38. Oroantral Communications
• If this problem occurs, appropriate measures are
necessary to prevent a variety of sequelae.
• The two sequelae of most concern are
(1)postoperative maxillary sinusitis and
(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 sinus
exposure

39. Fistula vs sinus

40. Fistula vs sinus

41. The diagnosis of an oroantral communication
can be made in several ways
1. The first is to examine the tooth once it has
been removed. If a section of bone is adherent
to the root ends of the tooth
2. Some advocate using the nose-blowing test to
confirm the presence of a communication

44. Oroantral Communications
• If the opening between the mouth and sinus is of
moderate size (2 to 6 mm), additional measures should
be taken. To help ensure the maintenance of the blood
clot in the area, a figure-of-eight suture should be
placed over the tooth socket

45. Oroantral Communications
• If the sinus opening is large (≥7 mm), the surgeon
should consider having the sinus communication
repaired with a flap procedure.
• This usually requires that the patient be referred to
an oral-maxillofacial surgeon because flap
development and closure of a sinus opening are
complex procedures that require special training
and experience
• The most commonly used flap for small openings is
the buccal flap

46. The buccal flap

47. Dr. Haydar Munir Salih

48. Oroantral Communications
• If the patient has a history of chronic sinus disease,
even small oroantral communications may heal poorly
and may result in a chronic oroantral communication
and eventual fistula.
• Therefore creation of an oroantral communication in a
patient with chronic sinusitis is cause for referral to an
oral-maxillofacial surgeon for definitive care

49. Soft Tissue Injuries

50. Tear of a Mucosal Flap
• The most common soft tissue injury during oral
surgery is tearing of the mucosal flap during surgical
extraction of a tooth
• This usually results from an initially inadequately
sized envelope flap that, as the surgeon tries to gain
needed surgical access, is then forcibly retracted
beyond the ability of the tissue to stretch. This results
in tearing, usually at one end of the incision.

51. Tear of a Mucosal Flap

52. Prevention of this complication is threefold
(1) creating adequately sized flaps to prevent
excess tension on the flap,
(2) using controlled amounts of retraction force on
the flap, and
(3) creating releasing incisions when indicated.

54. Tear of a Mucosal Flap / treatment
1. If a tear does occur in the flap, the flap should
be carefully repositioned once the surgery is
completed
2. In most patients, careful suturing of the tear
results in adequate but somewhat delayed
healing.

55. Puncture Wound
• The second soft tissue injury that occurs with some
frequency is inadvertent puncturing of soft tissue. An
instrument such as a straight elevator or a periosteal
elevator may slip from the surgical field and puncture or
tear adjacent soft tissue.
• best prevented by the use of controlled force, with special
attention given to using finger rests or support from the
opposite hand if slippage is anticipated.
• Once hemostasis is achieved, the wound is usually left open
unsutured;

56. Puncture Wound

57. Abrasion or Burn
• Abrasions or burns to lips, corners of the mouth,
or flaps usually result from the rotating shank of
the burr rubbing on soft tissue or from a metal
retractor coming in contact with soft tissue
• When the surgeon is focused on the cutting end of
the burr, the assistant should be aware of the
location of the shank of the burr in relation to the
patient’s cheeks and lips

59. Abrasion or Burn
• If an area of oral mucosa is abraded or burned,
little treatment is possible other than keeping the
area clean with regular oral rinsing.
• Usually 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, the
dentist should advise the patient to keep it covered
with an antibiotic ointment.