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Complication and management of tooth extraction or exodontia


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hello friends i am DR.RAHUL TIWARI ,this is my 1st upload on complication and management of exodontia,i hope you will like it...

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Complication and management of tooth extraction or exodontia

  2. 2. Introduction • Any adverse , unplanned events that tend to increase the morbidity above what would be expected from a particular operative procedure under normal circumstances. 2
  3. 3. Sources of complications Surgical complications may arise from either one or a combination of the following factors.  THE PATIENT- Medically compromised pt. 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.
  4. 4. Possible complications Failure to -secure anaesthesia -remove the tooth with either forceps or elevator Fracture of-crown of the tooth /root -alveolar bone -maxillary tuberosity -adjacent or opposing tooth -mandible 4
  5. 5. Dislocation of -adjacent tooth -TMJ  Displacement of the root -into the soft tissues - maxillary antrum  Excessive haemorrhage - During tooth removal - on completion of the extraction - postoperatively 5
  6. 6. Damage to - gums/lips/tongue/floor of mouth - inferior dental nerve & branches - lingual nerve Postoperative pain - damage to hard & soft tissues - dry socket - acute osteomyelitis of mandible - traumatic arthritis of TMJ 6
  7. 7. Postoperative swelling due to:- • Odema • Haematoma formation • Infection  Trismus  Oro-antral communication  Syncope  Respiratory arrest  Cardiac arrest  Anaesthetic emergencies. 7
  8. 8. 1-Failure to secure anaesthesia • Faulty technique • Insufficient dosage of anaesthetic agent 8
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  10. 10. 2-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 10
  11. 11. 3-Fracture of the crown of a tooth • Weakened tooth- caries or large restoration • Improper application of the forceps • Excessive force MANEGMENT: • proper application of forceps or elevator will deliver the tooth or Transalveolar method 11
  12. 12. FRACTURED CROWN 12
  13. 13. 4-Root fracture 13 Root pattern Faulty technique MANEGMENT Decide whether to leave or not? Radiographic examination & transalveolar ext.
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  15. 15. 5-Fracture of the alveolar bone • Accidental inclusion of alveolar bone within forceps blades. • Pathological changes in the bone • Shape of the alveolus • Extraction of canine is frequently complicated by fracture of the labial plate. • Alveolar fragments which has lost one half of the periosteal attachment should be removed. if it well attached to periosteum, should be sutured back 15
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  17. 17. 6-Fracture of maxillary tuberosity Predisposing cause – • Pathological gemination between the erupted maxillary second molar & unerupted max. third molar. • Overerupted isolated max molar 17
  18. 18. 7-Fracture of an adjacent or opposing tooth • Precautions : • Careful pre-op examination (carious, heavily restored, loose, line of withdrawal) • No force should be applied to any adjacent tooth • Other teeth should not be used as fulcrum for an elevator. • Any loose, heavily restored tooth should be noted & brought to the notice of anesthetist. 18
  19. 19. 8-Fracture of the mandible Excessive or incorrectly applied force  Pathological changes of mandible  osteoporosis Atrophy Osteomyelitis  Previous therapeutic irradiation Unerupted teeth, cysts, hyperparathyroidism or tumours may also predispose to fracture 19
  21. 21. 9-Dislocation of adjacent tooth & TMJ  Causes same as those giving rise to fracture of adjacent tooth  Elevator should not be placed on the mesial aspect of first permanent molar.  During elevation a finger should be placed upon the adjacent tooth to support it . Dislocation of TMJ  Application of excessive force  Failure to support the mandible while extracting a difficult tooth  More likely to occur under general anesthesia when mastication muscles are relaxed 21
  23. 23. Management • Reduction is done with the thumb wrapped with gauze or bandage to avoid injury by teeth and placed on the occlusal surfaces of mandibular posterior teeth and finger under the lower border of the mandible. • Mandible is then pushed downward backward rotating the chin upwards .with this manpower the condyles are moved downwards and backwards over the articular eminences of temporal bone. 23
  24. 24. 24
  25. 25. • 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. • Failure to reduce dislocation reduction can be attempted under 5-10mg of IV/IM valium • Failure to reduce the dislocation or if there is resistance encountered LA solution is injected high in the buccal sulcus bilaterally adjacent to max third molar region similar to the technique of posterior superior alveolar nerve block. This helps in paralyzing lateral pterygoid muscles and over comes Muscular spasm 25
  26. 26. 10-Displacement of a root into the soft tissues • Ineffectual attempts to grip the root when visual access is inadequate. • Maxillary premolar or molar- palatal root. • Predisposing factor – large antrum 26
  28. 28. Simple rules to avoid displacement:- Never apply forceps to a maxillary post. teeth unless sufficient of its length is exposed, both palatally & bucally . Leave the apical one third of the palatal root of a maxillary molar. Never attempt to remove a # maxillary root by passing instruments up the socket. Any previous history of antral involvement should not be disregarded. 28
  29. 29. 11-Aspiration of tooth/root • Under GA – more common • Anaesthetic should be stopped immediately & patient’s head brought forwards. • After cough reflex has returned the mouth is examined & pack carefully removed & inspected • Radiographs – socket & chest 29
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  31. 31. 12-Damage to adjacent tissues Damage to the gum can be avoided by careful selection of forceps & good technique. The lower lip may be crushed between the handles of the forceps & anterior teeth.  Skilled use of operators left hand.  Instruments should be allowed to cool before use after being sterilized. 31
  32. 32. Inferior alveolar nerve • close proximity of mandibular third molar roots. • Careless surgical technique, • roots are curved around the canal or grooved • damage can be prevented or minimized only by pre-op radiographic diagnosis & careful dissection. 32
  33. 33. Lingual nerve : Lingual nerve is in close proximity to roots of mandibular third molar . • Risk of damage while taking incision and during elevation of lingual periosteum. • Risk of direct trauma form bur or chisels used for removal of bone or sectioning of the tooth • Mental nerve : • Injury is caused due to surgery in the area of mental nerve. • Over extension of incision in the depth of mucobuccal fold in premolar region 33
  34. 34. Prevention: The nerve injury can be prevented by Careful surgical technique – • Proper placement of incision, • Careful bone removal • Retraction and less manipulation Management : Patient should be warned preoperatively about the possible consequences and the probable outcome on • Tongue & floor of mouth damage can be prevented by effective use of left hand. 34
  35. 35. 13-Post extraction Bleeding 35 • 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
  36. 36. • Systemic causes • Disorder related to systemic disease – leukemia,Aplastic anaemias – Platelet disorders: Thrombocytopenia – Coagulation defects : Hemophilia • Structural malformation : hereditary hemorrhagic telengectesia • drug therapy: aspirin, Anti coagulant therapy 36
  37. 37. Management Physical methods • Pressure packs • Use of LA solution with vasoconstrictors • Socket suturing • Hemostatic forceps • Splints • Thermal measures- cautery , hot saline packs 37
  38. 38. Firm gauze roll should be placed upon the socket & patient asked to bite upon it . Horizontal mattress suture
  39. 39. Hemostatics TOPICAL: • VASOCONSTRICTORS Adrenaline • ABSORBABLE AGENTS Oxidized cellulose Oxidized regenerated cellulose Gelatin sponge Fibrin foam Calcium alginate THROMBOPLASTIC AGENTS Thrombin Russel viper venom 39
  40. 40. 40 CHEMICAL AGENTS: Tannic acid Ferric chloride Zinc chloride Alum Hydrogen peroxide SOCKET PLUGS: Bone wax Whitehead’s varnish on ribbon gauze
  41. 41. 41 Gel foam Botroclot (hemocoagulase solution) Surgicel
  42. 42. Systemic agents ENDOGENOUS: • Whole blood • Fresh frozen plasma • Cryoprecipitate 42
  43. 43. Exogenous agents • ETHAMSYLATE - 2ml ampoules i.m/iv 1-2 hrs before operation OR 2-3 ampoules following surgery followed by 1amp/2tabs every 4-6 hrs. • VITAMIN K- Normally 10mg capsules, 10-20 mg oral/ i.m /i.v 43
  44. 44. 14-Postoperative pain Due to traumatized hard tissues -  Bruising of bone during instrumentation or overheating of bur during bone removal. Soft tissues :-  ragged flap – heals slowly (incision not proper)  Soft tissue become entangled with bur  Proper Retraction 44
  45. 45. Dry socket / alveolar osteitis/ alveolitis sicca dolorosa  Acutely painful tooth socket containing bare bone and broken down blood clot. Associated with fetid odor Incidence -3%, 3rd molars-22% Mandibular teeth common than maxillary. 45
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  47. 47. Predisposing factors :- 1. infection of socket : release of plasminogen activators 2. Trauma - use of excessive force 3. Vasoconstrictors (contributory factor) 4. Mandibular extractions (dense & less vascular, contaminated with food debris) 5. Bacteriological origin – Treponema denticolum . 6. Pt. on oral contraceptives, smokers 47
  48. 48. Clinical features • Pt. usually presents within 2-4 days : granulation tissue appears in 2-4 days, it is absent in cases of dry socket. • Dull, boring pain to severe throbbing pain, may radiate • Gingival margin of socket – swollen & red • Socket may be filled with food debris or a brown friable clot on removal of which exposes the bare bone which is severely tender to touch • Regional lymph nodes may be tender 48
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  51. 51. • Prevention :- 1. Scaling & any gingival inflammation – (1 week prior to extraction). 2. Minimum amount of local anesthetic 3. Atraumatic tooth removal 4. Prophylactic use of antibiotics especially metronidazole 5. nerve blocks preferred to LA infiltrations 51
  52. 52. Management – 1. Aim – relief of pain & speeding of resolution 2. Socket irrigation with warm saline & all degenerating blood clot removed. 3. Sharp bony spurs - excised with rongeur forceps or removed with a wheel stone 4. Loose dressing – zinc oxide & oil of cloves on cotton wool is tucked into the socket. 5. Analgesic tab & hot saline mouth baths 6. Recall after 3 days 52
  53. 53. IRRIGATE THE SOCKET PLACE A ANTISEPTIC DRESSING 53 DRESSING ; First 24 hours then every alternate day then every 3-4 days / or more than 2 weeks regular check up
  54. 54. 15-ACUTE OSTEOMYELITIS OF THE MANDIBLE: Mandible tender Impairement of labial sensation  pyrexia , pain is severe Traumatic extraction of lower molar under LA in P/o acute gingival inflammation predisposes to acute OML 54
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  56. 56. May complicate difficult extractions if the lower jaw is not supported. The risk can be minimize if supporting the mandible during surgery. Difficult extractions Should be done surgically. Mouth prop used on contralateral side 56 16-TRAUMATIC ARTHRITIS OF THE TMJ
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  58. 58. 17-Postoperative swelling a. EDEMA : 1. If the soft tissues are not handled carefully during an extraction traumatic edema may be formed. 2. The use of blunt instrument, the excessive retraction of badly designed flap, or a bur becoming entangled in the soft tissues predispose to this condition. 3. IF sutures are tied too tightly post operative swelling due to edema or haematoma formation may cause sloughing of the soft tissues and breakdown of the suture line. 4. Usually both conditions regress if the patient uses hot saline mouth baths frequently for 2-3 days. 58
  59. 59. b. INFECTION :- • pain and swelling Mild - hot saline mouth baths Severe – antibiotic & analgesics 59
  60. 60. 18-Trismus  Inability to open mouth due to muscle spasm. Caused by post op. edema, hematoma formation or inflammation of soft tissue. Intra oral heat by means of short wave diathermy or use of hot saline mouth baths. Antibiotics 60
  61. 61. 61 TRISMUS
  62. 62. 19-Oroantral communications  An oroantral communication is created by the extraction of maxillary tooth where  The roots extend well beyond the maxillary sinus floor  The extraction is difficult and traumatic  There is a lone standing molar  The tooth is ankylosed  The periapical pathology e.g cyst or granuloma extending beyond the sinus floor 62
  63. 63. 63
  64. 64. Diagnosis: • Bubbling through the extraction site occurs when the nose is blocked under pressure. The patient cannot suck through a straw. Management: • Replace the tooth and splint into position and plan to extract surgically at a later date or • Cover defect with anti septic – soaked ribbon/ gauze and remove in 2-3 weeks to allow healing by sec. intention or • Reduce bony socket edge and suture margins together (interrupted horizontal mattress) • Immediate closure with a buccal advancement flap provided the sinus is clear of infection. 64
  65. 65. 65 The treatment of a freshly created oroantral communication
  66. 66. 66 Adjunctive measures: Instruct patient not to blow nose from 7-10 days Analgesics Antibiotics Nasal decongestants
  67. 67. 20-Syncope / faints • Pt. Collapse • Feeling dizzy, weak, nauseated • Skin is pale, cold , sweating • Head end lowered by lowering the back of the dental chair 67
  68. 68. MANEGMENT: • Placement of unconscious patient in the supine position with feet slighlty elevated and airway patency maintained through use of the head tilt – chin lift method. 68
  69. 69. 69 AROMATIC SPIRIT AMMONIA: Aromatic ammonia spirit is used to prevent or treat syncope
  70. 70. 70 21-Respiratory arrest
  71. 71. Skelton Muscles become flaccid and pupils dilate MANAGEMENT: • Lay the pt flat on the floor • Remove any foreign bodies by pulling the mandible upwards and forwards, to extend neck fully • Compress pt. nostril with thumb and finger, mouth-to- mouth resuscitation be performed to raise the chest every 3-4 sec. • Check carotid pulse. 71
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  73. 73. 22-Cardiac arrest • Unless reversed in 3mins,irreversible brain damage could occur due to cerebral anoxia. • Pt has deathly pallor & grayness. • Cold and sweaty skin • Pulse and apex beat cannot be felt • Heart sounds cannot be heard • CPR is carried out until hospital services are available. 73
  74. 74. 74 Cardiopulmonary resuscitation(CPR):
  75. 75. 23-Anaesthetic emergencies • Dentist must be alert for any warning sign related to emergency related to anaesthesia • In case of collapse STOP ANAESTHETIC IMMEDIATELY • CPR ,respiratory relief by tracheostomy, laryngotomy must be performed. 75
  76. 76. Conclusion Complications should be diagnosed as soon as they occur & dealt promptly and effectively. 76
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