This document discusses complications that can occur during and after tooth extractions. It describes various complications that can happen during surgery such as soft tissue injury, extracting the wrong tooth, tooth fracture, alveolar fracture, displacement of a tooth into the maxillary sinus, and more. Post-operative complications discussed include dry socket, infection, presence of bony spicules, and hemorrhage. For each complication, the causes and management approaches are outlined. The document provides an extensive overview of potential risks from exodontia and guidelines for prevention and treatment of complications.

1. DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
COMPLICATIONS OF EXODONTIA
SUBMITTED BY:
VYSHNA.S
THIRD YEAR
SREE ANJANEYA INSTITUTE OF DENTAL SCIENCES.

2. EXODONTIA
The painless removal of the whole tooth or root with minimum trauma to the
investing tissues, so that the wound heals uneventfully and no post-operative
prosthetic problem is created.
[GEOFFRAY L. HOWE]

3. COMPLICATIONS OCCURING DURING SURGICAL PROCEDURE
 Soft tissue injury
 Extraction of the wrong teeth
 Fracture of the teeth during extraction
 Fracture of tooth root during extraction
 Fracture of the alveolus
 Fracture of tuberosity
 Displacement of tooth into the maxillary sinus
 Creation of oroantral fistula
 Fracture of mandible
 Breakage of instrument
 Luxation of adjacent tooth
 Injury to inferior alveolar nerve
 Swallowing of teeth
 Aspiration of teeth
 Dislocation of condyle.

4. COMPLICATIONS OCCURING AFTER SURGICAL PROCEDURE
 Presence of bony spicule
 Haemorrhage
 Dry socket
 Infection

5. SOFT TISSUE INJURY
TYPES AND CAUSES:
 Abrasion: Caused by careless use of rotary instruments.
 Thermal injuries: Caused when used intraorally immediately after taken from autoclave or hot air oven.
 Mucosal tears: Caused due to injudicious use of instruments, improper elevation of flap or exercise of
excessive force.

6. PREVENTION:
 Take extreme care during handling of rotary and other hand instruments.
 Cool the instruments properly before using to prevent thermal injuries. Mucosal tears can be prevented by
proper designing and elevation of flap, by proper handling of the flap and by gentle and effective manipulation
of the elevators.
 To avoid trauma from the instruments, properly retract cheek and lips during the procedure.
MANAGEMENT:
 Suturing should be done for closure, if the tear or abrasion is large.
 Application of petroleum jelly or topical antiseptic/analgesic is used to manage scar due to thermal injuries.

7. EXTRACTION OF WRONG TEETH
MANAGEMENT:
 Inform the patient
 Replace the tooth inside the socket as soon as possible and splint it
 If immediate replacement is not possible, place the tooth in a proper medium like saliva, milk or water
 This is followed by treatment and follow up as for traumatic avulsion and reimplantation

8. FRACTURE OF THE TOOTH DURING EXTRACTION
CAUSES:
 Application of the wrong forceps
 Improper application of the forceps
 Improper application of force
 Extensively carious teeth
 Root canal treated teeth
 Endodontically treated teeth
 Curved or hypercementosed root
 Ankylosed root

9. PREVENTION;:
 Proper radiographic assessment of the shape and degree of carious involvement of the teeth and the root and
the condition of the surrounding bone
 Proper forceps technique, i.e. proper selection of the instrument, proper application the forceps and proper
application of the force
 Using transalveolar removal technique whenever intra-alveolar extraction is not feasible
MANAGEMENT:
 When the fracture involves the crown of the tooth appropriate restoration should be placed
 In case of root fracture remove the tooth or root fragment completely whenever possible
 In case of close proximity of a small root fragment [less than 5mm] to the sinus or inferior alveolar nerve, leave
the root as it is unless it is infected

10. FRACTURE OF TOOTH ROOT
CAUSES:
 Improper technique
 Application of incorrect instrument and force
 Ankylosed teeth or hypercementosed teeth
 Condensing osteitis
 Excessively curved roots
 Endodontically treated teeth
 Teeth with gross filling
 Extensively carious teeth
 Uncooperative patient

11. CONSEQUENCES OF RETAINED ROOTS:
 Act as a source of infection
 Chronic source of irritation giving rise to neuralgic pain
 If large roots are retained in the submucosa just beneath the denture, the overlying mucosa gets constantly
inflamed and interfere with proper functioning of the denture
METHODS FOR RETRIEVAL OF FRACTURED ROOT:
 Roots fractured at various levels can be removed with appropriate elevators
 Forceps with slender beaks and reamers can be used to remove roots
 If above method fail, transalveolar removal should be attempted

12. FRACTURE OF THE ALVEOLUS
CAUSES:
 Improper application of the instruments
 Application of excessive force
 Lack of support to the alveolus during extraction
 Brittle alveolar bone
 Ankylosed teeth
PREVENTION:
 Proper radiographic assessment of the tooth and the surrounding alveolar structure
 Proper application of the forceps and elevators
 Avoid exertion of excessive force
 Support the alveolus properly during extraction

13. MANAGEMENT:
 When the bone fragment is completely detached from the periosteum it is advisable to remove it along with the
teeth and suture the flap back
 When the bone is attached to the periosteum, it can be replaced back and the flap closed

14. FRACTURE OF TUBEROSITY
CAUSES:
 In case where the antrum extends into the tuberosity, the extraction of third molar can result in fracture of the
tuberosity
 Exertion of excessive force and improper force application
 Fusion of the roots of the second molar with the unerupted third molar
 Divergent roots of the third molar or hypercementosed third molar
PREVENTION:
 Take radiographs before extraction to assess the conditions of third molar and surrounding structures
 Avoid exertion of inadvertent force
 Support the alveolus during extraction

15. MANAGEMENT:
 If the fractured segment is small, a mucoperiosteal flap is elevated and the tuberosity is removed along with the
tooth, followed by wound closure
 If the fractured segment is large and the mucoperiosteum is attached to the bone, it should be replaced and
splinted
 Prescribe antibiotics, analgesics and nasal drops if the fracture involves the antrum
 Removal of the tooth should be done after the healing of fracture site

16. DISPLACEMENT OF THE TOOTH INTO MAXILLARY SINUS
CAUSES:
 The roots of maxillary posterior teeth are always in close proximity to the maxillary sinus such that the large
antral cavities may dip in between the apices of the teeth
 With the 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 a thin lamellae of bone which fracture easily
and result in the displacement of the root tip during the removal
 Sometimes the tooth may slip into the maxillary antrum like a ‘popping of the orange seed’ once the extraction
forceps are applied
PREVENTION:
 Application of appropriate force which effectively removes teeth without any fracture of bone & teeth
 Avoid injudicious instrumentation to remove a broken root tip
 Proper radiographs should be taken before extraction to assess the proximity of the root tip to the sinus
 Support the jaw and the alveolus adequately before extraction

17. MANAGEMENT:
 Confirm the presence and the location of the tooth or the root tip in the sinus using radiograph
 Once the location is confirmed, keep a nozzle connected to a powerful suction device at the entrance of the fistula
to recover the root
 Pack a long piece of roller gauze into the sinus through the opening and remove it with a jerk, the root tip or the
tooth might sometimes be removed along with the gauze
 If none of the above procedures solves the problem then Caldwell-Luc operation is carried out

18. OROANTRAL FISTULA
OROANTRAL COMMUNICATION:
An un natural communication between oral cavity and maxillary sinus.
OROANTRAL FISTULA:
An epithelialised , pathological unnatural communication between oral cavity and
maxillary sinus
ETIOLOGY:
 Extractions
 Destruction of floor of maxillary sinus by periapical lesions.
 Injudicious instrumentation
 Forcing tooth/ root during attempted removal
 Extensive trauma to face
 Surgery of sinus, removal of large lesions involving sinus.
 Chronic infection such as osteomyelitis
 Teratomatous destruction of maxilla ,such as gumma involving palate
 Infected maxillary implant dentures.
 Malignancies.

19. SYMPTOMS:
Symptoms vary in fresh cases and late cases.
FRESH OROANTRAL COMMUNICATION:
 Escape of fluids
 Epistaxis-(unilateral)
 Escape of air
 Enhanced column of air
 Excruciating pain
LATE STAGE (ESTABLISHED OROANTRAL COMMUNICATION):
 Pain
 Persistent purulent or muco-purulent ,foul unilateral nasal discharge .
 Post nasal drip.
 Possible sequelae of general systemic toxaemic condition.
 Popping out of an antral polyp

20. INVESTIGATIONS TO CONFIRM PRESENCE OF FISTULA
1-SIMPLE PROBING
 A probe can be inserted into the opening to detect the presence of fistula.
2-NOSE BLOWING TEST
 A cotton wisp is kept near the fistulous opening.
 Patient is asked to blow the nose with closed nostril and open mouth.
 If oro-antral fistula present-air will pass through the defect and will displace the cotton wisp whereas any blood present
will be seen to bubble
3-MOUTH MIRROR TEST
 Patient asked to perform valsalva manouver, with a mouth mirror placed facing the oral opening of fistula.
 If the mirror gets fogged , indicates the presence of oroantral communication
4-SUCTION TEST
 Suction nozzle when placed over the fistula will create a sound similar to that produced by an empty bottle when blown.
 Not heard if sinus is chronically infected.
5- Ask patient to hold fluid within mouth ,fluid can be seen escaping through the nose.
Betadine can be mixed with fluid to differentiate between nasal secretion and rinsing fluid

21. MANAGEMENT
CLOSURE OF OROANTRAL FISTULA -TYPES OF FLAPS
 Buccal flap
- Von Rehermann flap
- Moczair flap
 Palatal flap
-Ashley’s flap
-Kruger’s modification of Ashley’s flap
 Combination of buccal and palatal flaps
- Bridge flap
 Buccal pad of fat
 Tongue flap
-Posteriorly placed dorsal tongue flap
-Laterally placed tongue flap
 Turnover flap or hinge flap
 Nasolabial flap
 Gold foil
 Polyglycol acid mesh
 ANTIBIOTICS
-Penicillin and its derivatives.
-Started with iv dose and later switch to oral.
-Penicillin V 250-500 mg sixth hourly(resistant to
penicillin--broad-spectrum antibiotic used.)
 NASAL DECONGESTANTS
-nasal drops , sprays ,inhalations
-encourage drainage of pus and secretions
-helps in aeration of sinus
 ANALGESICS
- Tab. ASPIRIN 500 mg 1-3 tab QDS
- Tab. PARACETAMOL 500mg TID
- Tab. IBUPROFEN 400mg TID
POST OPERATIVE CARE

22. FRACTURE OF MANDIBLE
CAUSES:
 Atrophic mandible as in old age
 Existence of any bony pathology
 Excessive or inadvertent 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
MANAGEMENT:
 Inform and reassure the patient
 Open reduction and internal fixation of fracture accordingly
 p

23. BREAKAGE OF INSTRUMENTS
CAUSES:
 Application of excessive force
 Improper technique
 Defect in manufacturing
 Old and worn out instruments
PREVENTION:
 Proper selection of the instrument
 Proper handling and usage
MANAGEMENT:
 Remove the burs or elevator tips with a haemostat if it is visible
 If impacted deeply, surgical removal of the instrument is advised unless contraindicated as in close proximity to
vital structures

24. 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
MANAGEMENT:
 Reposition the tooth inside the socket and splint it
 The tooth should be treated endodontically after one week
:

25. INJURY TO INFERIOR ALVEOLAR NERVE
CAUSES:
 During the removal of an impacted 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 impacted third molar to the inferior alveolar nerve before
its removal
 Careful manipulation of the instruments
MANAGEMENT:
Non-surgical management:
 Delaying surgical repair of injured inferior alveolar nerve is recommended because most patients are known to
recover spontaneously to some degree
Surgical management:
 Decompression if impingement of nerve is present
 Microneurovascular surgery

26. 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
MANAGEMENT:
 Reassure the patient, review regularly
 If there is no symptom of recovery, attempt nerve repair

27. SWALLOWING OF TEETH
CAUSES:
 Careless handling of the instruments
 Improper technique
MANAGEMENT:
 Check for breathing difficulty
 Check for dislodgement of teeth in pyriform fossa by radiograph/ indirect laryngoscopy
 Confirm the presence of teeth in the GIT
 Prescribe laxatives
 Confirm the expulsion of the teeth using serial radiograph

28. DISLOCATION OF CONDYLE
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
MANAGEMENT:
 Take a radiograph of the area
 If condyle is dislocated into the middle cranial fossa, refer to an
oral surgeon
 Manual reduction of anterior displacement of the condyle
requires downward pressure in the retromolar region and
simultaneous upward pressure on the chin
 Long standing dislocation may require prolonged traction on the mandibular ramus under general anesthesia or open
reduction

29. PRESENCE OF A BONY SPICULE
CAUSES:
Improper and careless technique of extraction
PREVENTION:
Checking the socket for any sharp edges before closure
MANAGEMENT:
Filing or removal of bony spicule

30. HAEMORRHAGE
Bleeding is a common sequel of oral surgery. There are three types of post-operative bleeding:-
1. Primary- occurs continuously just after surgery
2. Reactionary- haemorrhage restarts after a period of about three hours
3. Secondary- occurs after few days of the procedure
PREVENTION:
 A proper medical history of patient to detect any systemic disorders
 The necessary investigations such as bleeding time and clotting time detection test
 Avoid incision, flap opening or soft tissue trauma
MANAGEMENT:
 After extraction of tooth, apply digital pressure continuously for 2-4 minutes
 If bleeding continues from the socket, then pack the bony socket with gel foam, fibrin foam, surgical or bone
wax
 Put a gauze piece at the site of bleeding to stop bleeding and facilitate clot formation

31. DRY SOCKET
The term dry socket was used by Crawford in 1896.
It is defined as a post operative pain in or around the alveolus, which increases in severity in at some moment
between the 1st and the 3rd day after extraction, accompanied by partial or total disintegration of the intra-
alveolar clot, causing foul smell.
SYNONYMS:- necrotic alveolar socket, alveolagia, delayed extraction, localized osteomyelitis,
fibrinolytic osteitis, alveolar osteitis, osteomyelitic post extraction syndrome, etc
Etiology:
 Difficult or traumatic extraction
 Use of oral contraceptives
 Hormonal changes
 Tobacco
 Inadequate intraoperatory irrigation
 Advanced age of the patient

32. CLINICAL FEATURES:
 PAIN
-occurs on 2nd or 3rd day after extraction and usually last about 10 to 15 days ,with or without treatment.
-pain is localized, also sensitive even to gentle probing.
-sharp pain that increases with suction or mastication.
- pain may radiate to ear or ipsilateral side of head
 HALITOSIS
 UNPLEASANT TASTE
 INFLAMED GINGIVAL MARGIN

33. PREVENTION:
 Atraumatic surgery with clean incision and soft tissue reflection
 Preoperative and post operative rinses with antimicrobial mouth rinse- chlorhexidine
MANAGEMENT:
 Gentle irrigation of the tooth socket with saline, entire blood clot not lysed, excess saline suctioned, iodoform
gauze soaked with medication inserted in socket
 Medication contains eugenol, benzocaine, balsam of peru
 Patient experiences relief from pain with in 5 mins.

34. INFECTION
CAUSES:
 Contaminated needle
 Contaminated local anaesthetic needle
 Needle passing through an already infected site
 Inadequate aseptic preparation
PREVENTION:
 Antibiotics prophylaxis has been shown to decrease the risk of infection in certain types of surgery
 Use disposable needles
 Avoid repeated use of the same needle
 Aseptic preparation of the surgical site
MANAGEMENT:
 Empirical therapy should be primarily directed against staphylococcus
 Deep seated infections require broad spectrum antibiotics and investigation for possible surgical intervention