Complications in oral surgery

1. Complications
In oral surgery
Mostafa Heeba

2. Complications
In oral surgery
 Intraoperative Complications
 Postoperative Complications
 Prevention of Complications

3. Intraoperative Complications
Soft tissue injuries
 Tearing of mucosal flap
 Inadequate size
 Excessive retraction
 Careful reposition
 Suturing of the tear
 Excision of the margins

4. Intraoperative Complications
Soft tissue injuries
 Soft tissue puncturing
 Periosteal elevator
 Straight elevator
 Excessive force
 Inadequate finger support

5. Intraoperative Complications
 Soft tissue injuries
Abrasions or burns
Shank of rotating instruments
Excessive retraction
 Injuries to adjacent teeth
 Avoid using adjacent tooth as a fulcrum

6. Intraoperative Complications
Injuries to osseous structures
 Alveolar bone fracture
 Excessive force with forceps

 Buccal cortical plate
 Maxillary canines
 Maxillary molars
Managed by

7. Intraoperative Complications
 Maxillary sinus floor
 Maxillary molars
 Maxillary tuberosity
 Maxillary third molars
 Anterior mandibular labial plate
 Mandibular incisors

8. Intraoperative Complications
 Prevention
 Evaluation of alveolar process
 Root form of tooth to be removed
 Size
 Divergence
 Proximity of roots to sinus
 Thickness of cortical plate
 Prevention
 Evaluation of alveolar process
 Root form of tooth to be removed
 Size
 Divergence
 Proximity of roots to sinus
 Thickness of cortical plate

9. Intraoperative Complications
 Do not replace!
 Reflect small amount of soft tissue
 Smooth sharp edges
 Irrigate surgical site
 Reposition soft tissue
 If bone is removed from the site

10. Intraoperative Complications
 Bone attached to periosteum
 Dissect bone from the tooth
 Stabilize with forceps
 Woodson elevator
 Finish extraction
 Re-approximate soft tissue
 Suture

11. Intraoperative Complications
 Fractured tuberosity
 Splint the tooth
 Section the crown from the roots
 Delay treatment for 6-8 weeks
 Surgical extraction
 Use caution if the tooth is infected
 Check for oro-antral communication

12. Intraoperative Complications
Oro-antral communications
 Maxillary sinusitis
 Chronic oro-antral fistula
 Depends on size and management
 “Nose-blowing” test
 Determine the size of the defect
 <2mm, no treatment required

13. Intraoperative Complications
 Do not probe the defect
 Promote good blood clot
 Figure-eight suture
 Gel foam
 Collagen
 Antibiotics
 Amoxicillin
 Clindamycin
 Nasal decongestants
Management

14. Intraoperative Complications
 Large communications (>7mm)
 Flap closure
 Buccal flap
 Palatal flap
 Distant flap
 Perform early
 Supportive therapy
 Long term follow-up

15. Intraoperative Complications
 Mandibular fractures
 Rare complication
 Associated with impacted third molars
 Excessive force with elevator
 Severely atrophic mandible
 Reduction of the segments
 Adequate fixation
 Closed vs. open
Management

16. Intraoperative Complications
 Root fracture
 Most common complication
 Long, curved, divergent roots
 Dense bone

17. Intraoperative Complications

18. Intraoperative Complications
 Root displacement
 Maxillary molar roots into the sinus
 Identify size of root fragment
 Determine tooth infection
 Assess preoperative condition of the
sinus
 Small (2-3mm), non-infected fragment
 Flush with saline
 Apply suction through opening
 Inform patient
 Manage communication

19. Intraoperative Complications
 Large fragment or entire tooth
 Caldwell-Luc approach

20. Intraoperative Complications
 Injuries to adjacent structures
 Branches of V cranial nerve
 Mental nerve
 Lingual nerve
 Buccal nerve
 Nasopalatine nerve
 TMJ
 Excessive force
 Inadequate support

21. Intraoperative Complications

22. Postoperative Complications
Bleeding
Highly vascular tissues
Open wound
Difficulty to apply pressure
The tongue

23. Postoperative Complications
Questions ??????
History of previous bleeding?
Family history?
Medications?
• Aspirin
• Anticoagulants
• Broad spectrum antibiotics
• Alcohol
• Chemotherapeutic agents

24. Postoperative Complications
Questions ????
Systemic diseases?
• Nonalcoholic liver disease
 Hepatitis
 Cirrhosis
• Hypertension
• Coagulopathies

25. Bleeding control during surgery
A traumatic procedure
Clean incisions
Adequate flap reflection
Do not crush the tissue!!
Smooth down sharp bony edges
Remove granulation tissue
Direct pressure over surgical site

26. Bleeding control during surgery
Electro-cautery
Suture ligation
Placement of hemostatic agents
 Absorbable gelatin sponge (Gel-foam)
 Oxidized regenerated cellulose
 Collagen
 Topical thrombin

27. Postoperative Complications
 Secondary bleeding
 Suction the oral cavity
 Examine the site
 Apply pressure for 5 minutes
 Local anesthetic
 Curette extraction site
 Identify and control bleeding source
 Monitor for 30 minutes before discharge

28. Postoperative Complications
 Ecchymosis
 Bleeding into adjacent soft tissues
 More common in elderly patients
 2 to 5 days after surgery
 Warn patients older than 50
 Minimize soft tissue reflection

29. Postoperative Complications
 Infection
Rare complication
Careful asepsis and wound debridement
Prophylactic antibiotics (when indicated)
 Soft tissue dehiscence
Closure under tension
Lack of bony support

30. Postoperative Complications
 Dry socket
 Pain starts 2-4 days after surgery
 Moderate to severe pain radiating to adjacent areas
 Bone surface exposed in socket
 Bad odor and taste
 2% for routine extractions, 20% for impacted third molars

31. Postoperative Complications
 Prevention of dry socket
 Minimize trauma
 Minimize bacterial contamination
 Thorough debridement and irrigation
 Placement of antibiotic dressing
 Preoperative and postoperative antimicrobial mouthwash rinses

32. Postoperative Complications
Treatment of dry socket
 Goal is to address the pain
 Gentle irrigation
 Placement of medicated dressing
Eugenol
Topical anesthetic (benzocaine)
 Replace every other day as needed

33. Proper pre-surgical
planning prevents
postoperative problems

34. Prevention of Complications
 Thorough preoperative assessment
 Medical history
 Radiographs
 Comprehensive treatment plan
 Surgical plan
 Anxiety and pain

35. Prevention of Complications
 Evaluate training and ability
 Refer if necessary
 Thorough preoperative discussion

36. Prevention of Complications
Radiographs
 Entire surgical area
 Root apices
 Local and regional structures
 Maxillary sinus
 Inferior alveolar nerve
 Abnormal tooth morphology
 Modify treatment plan

37. Prevention of Complications

38. Prevention of Complications

39. Prevention of Complications
 Clear visualization
 Adequate access
 Adequate lighting
 Adequate soft tissue reflection
 Lips
 Cheeks
 Tongue
 Flaps

40. Prevention of Complications
 Adequate suction
 Unimpended pathway for removal
 Remove bone (remove any resistance)
 Section the tooth
 Controlled force (“finesse”)

41. Prevention of Complications
Surgical principles
Asepsis
A traumatic tissue handling
Hemostasis
Thorough debridement
Adequate closure

42. Thank you