Trauma To Adjacent Tooth

Soft Tissue Injuries

Fracture Of The Alveolar Process

Fracture Of Maxillary Tuberosity

Fracture Of The Mandible

Broken Instruments In Tissues

Dislocation Of Tmj

Subcutaneous Or Submucosal Emphysema

Hemorrhage

Displacement Of Impacted Tooth, Root, Or Root Tip Into

Maxillary Sinus

Oroantral Communication

Nerve Injury

Trismus

Hematoma

Ecchymosis

Edema

Postextraction Granuloma

Painful Postextraction Socket

Dry Socket (Alveolar Osteitis)

Infection Of Wound

PERIO-OPERATIVE COMPLICATIONS

• Trauma to the adjacent tooth• Soft tissue injuries• Fracture of the alveolar process• Fracture of the maxillary tuberosity• Fracture of the mandible• Broken instrument in tissues• Dislocation of the temporomandibular joint• Subcutaneous or submucosal emphysema• Hemorrhage• Displacement of an impacted tooth, root or root tip

into the maxillary sinus• Oroantral communication• Nerve injury

TRAUMA TO ADJACENT TOOTH

This is a common occurrence when the adjacent tooth is used as fulcrum, which result in fracture of the crown of the tooth, luxation or avulsion. The same situation occur when extracting a deciduous molar, if the for-

ceps is inserted too deep into the sulcus it can grasp the crown of the succedenous permanent premolar which lies beneath that tooth.

Management:If the tooth is luxated or partially avulsed, the tooth is stabilized for 40-60 days. If there is still pain on per-cussion after that period, RCT is indicated. If the tooth is dislocated, it must be repositioned and stabilized for 3-4 weeks.

SOFT TISSUE INJURIES

Soft tissue injuries are common and occur due to incor-rect manipulation of instruments. The areas most often injured are the cheek, floor of the mouth, the palate, and retromolar area. Many of these injuries occur due to slippage of the elevator. Also burn may occur in the lower lip if an overheated surgical handpiece comes in contact with the lip. Abrasion occur when bur come in

complications during dental extractionOsama Asadi, B.D.S, Published for Iraqi Dental Academy Blog

Undesirable situations or complications could occur in dental practice, due to dentist, patients, or certain factors. These complications are divided into two parts:• Perioperative complications: which occur during surgical procedure• Postoperative complications: which occur during postoperative period

LECTURE OUTLINE

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contact with the tissue.

ManagementWhen injuries are small and localized, no particular treatment is needed. Vaseline may facilitate healing (e.g., lip injuries). When the injury is extensive, and bleeding occur, dentist should stop the procedure, con-trol bleeding, and suture the wound.

FRACTURE OF THE ALVEOLAR PROCESS

This complication occur if the extraction force is abrupt and awkward, or the tooth is ankylosed. In this case, part of the labial, buccal, lingual, or palatal plate may be removed with the tooth.Fracture of lingual plate is the most significant, because it may lead to trauma to the lingual nerve.

ManagementIf the broken part of the alveolar plate is small and separated from the periosteum, it is removed, area is irrigated with saline, sharp bone is smoothed and the wound is sutured. If the broken part is still attached to the periosteum, then it is stabilized and area is sutured.

FRACTURE OF MAXILLARY TUBEROSITY

This complication is a serious complication, which may lead to problems in retention of the denture in the future tense.It could occur due to the following reasons:• Weakened bone of the maxillary tuberosity, due to

large sinus• Ankylosis of a maxillary molar• Weakened bone due to impacted third molar

ManagementIf the fractured segment is not separated from the peri-osteum, then it repositioned, and the wound is sutured. And tooth extraction is postponed, if possible, for 1.5-2 months, when bone has been healed, and surgical tech-nique will be used to remove the tooth. If the fractured segment is separated from the perios-

teum and oroantral communication occurred, then tooth along with the segment are removed, sharp bone smoothed, and the wound is sutured. With prescription of broad-spectrum antibiotic and nasal decongestants.

FRACTURE OF THE MANDIBLE

It is a rare and serious complication, associated with extraction of impacted mandibular third molar. It oc-cur due to excessive force applied by the elevator, an-kylosed tooth, or large pathological lesion that weaken the mandibular.

ManagementThe tooth must be removed first, to avoid infection at the site of fracture. Then fixation is applied to frac-tured segments for 4-6 weeks, with broad spectrum antibiotics

BROKEN INSTRUMENTS IN TISSUES

It occur due to excessive force during manipulation of the instrument. It localized with a radiograph and re-moved surgically at the same appointment.

DISLOCATION OF TMJ

Ir occur in lengthy procedures, and in circumstances when mandibular support is not provided during ex-traction with the non-dominant hand.In uni-lateral dislocation the mandible deviate to the healthy side, while in bi-lateral dislocation the patient present with open bite, and in both cases mandibular movement is restricted.

ManagementImmediately after dislocation, the thumbs are placed at the occlusal surface of teeth and the rest of the fingers are placed below the mandible on both sides.

Pressure is then applied with the thumbs downward, and the rest of the fingers upward and posteriorly, until the condyle return to its original position.

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SUBCUTANEOUS OR SUBMUCOSAL

EMPHYSEMA

Occur as a result of air entering loose connective tissue, when surgical handpiece with air is used during surgi-cal procedure.There is no specific treatment. It eliminated sponta-neously within 2-4 days. For large one, paracentesis (perforation) may be needed.

HEMORRHAGE

It is a common complication in oral surgery, it occur either due to severing of blood vessels, or occur due to patient’s tendency to bleeding due to blood diseases such as hemophilia.However, postoperative bleeding in patient with no blood disorders can be a result of poor hemostasis, in-sufficient wound compression or due to inadequate re-moval of the inflammatory and hyperplastic tissue from the surgical field.

ManagementThere are different ways of arresting bleeding, includ-ing compression, ligation, suturing, and the use of he-mostatic agents.

Compression of the wound by placing a gauze over the surgical site and applying pressure on it for 10-30 min-utes can stop postoperative bleeding.If that did not stopped the bleeding, placing iodoform gauze inside the cavity for 3-4 days can arrest the bleed-ing.Suturing of wound margin can also result in mechanical obstruction of the bleeding site. If wound margins diffi-cult to get sutured with each other, then placing a guaze pack over the wound and suturing it can help.

Ligation can arrest the bleeding of large vessels. First clip the severed vessel with a hemostat, then suture the vessel to stop the bleeding.

Hemostatic materials such as vasoconstrictors (adren-aline), alginic acid, desiccated alum, etc can be used locally to control bleeding.Alternatively, other materials such as fibrin sponge, gelatin sponge, oxidized cellulose, etc.. Which has he-mostatic properties can stop bleeding and cause coagu-lation. They are placed into the surgical site and sutured with figure-eight suture.

It is difficult for the dentist to control bleeding in cases of blood disorders. In this situation, pressure pack is applied and the patient is referred to the hospital.

DISPLACEMENT OF IMPACTED TOOTH-

ROOT- OR ROOT TIP INTO MAXILLARY

SINUS

It occur during extraction of maxillary posterior teeth due to insufficient visualization and close proximity of tooth to maxillary sinus, and due to injudicious and blind use of elevator to explore the cavity for remaining roots.

ManagementIf tooth or root tip can not be removed during the sur-gical procedure, then dentist should stop any attempt to find the tooth or root tip and the patient is informed. A surgical removal is scheduled and should be as soon

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as possible due to possibility of infection of maxillary sinus.

OROANTRAL COMMUNICATION

It is a common complication occur due to an attempt to extract maxillary posterior teeth that are close to the maxillary sinus.

How to diagnose?Valsalva test: ask the patient to close his nostrils, then ask him to exhale gently through his nose. A bubbling effect can be seen on site of extraction if communica-tion exist. Note that patient should not exhale forceful-ly or oroantral communication occur even if it is not present.

EtiologyDisplacement of impacted tooth or root tip into maxil-lary sinusCloseness of root tips to the floor of the maxillary sinusPresence of periapical lesion that destroyed the bone wall of maxillary sinus floorExtensive fracture of maxillary tuberosityExtensive bone removal for extraction of impacted teeth or roots

PreventionCareful evaluation of radiographCareful manipulation of instruments, especially during luxation of root tip of maxillary posterior teethCareful debridement of periapical lesions that are close to maxillary sinusAvoiding luxating of root tip if can not visualized clear-ly

ManagementManagement depend on the size of oroantral commu-nication.For small-sized oroantral communication, treatment consist of suturing gingiva with figure-eight suture, af-ter filling the alveolus with collagen, unless there are enough soft tissue, in which case tight suture is enough.

For moderate to large size oroantral communication, or when wound margin can not be sutured together, part of the alveolar bone is removed with bone rongeur and the wound margin is sutured easily by joining buccal and lingual mucosa.

Antibiotic is not indicated. However, if the communi-cation is result of extraction of tooth with periapical in-flammation then broad spectrum antibiotic is indicated. 4

Also nasal decongestant is prescribed.

NERVE INJURY

This is a serious complication that occur during sur-gical procedure. The most common nerve injuries are of inferior alveolar nerve, mental nerve, and lingual nerve.

Nerve injury can result in either anesthesia, paresthe-sia or dysesthesia.• Anesthesia or hypesthesia: is loss or decrease, re-

spectively, of sensation in an area.• Paresthesia: is sensation of burning, tingling,

numbness in the area.• Dysesthesia: is abnormal unpleasant sensation to

normal factors, such as feeling of burn after touch-ing, etc..

Nerves injuries can be classified into three categories:• Neurapraxia: this is the easiest type of injury

which occur even after simple contact with the nerve. The loss of sensation is temporary and re-solve within few days to weeks.

• Axonotmesis: this is serious injury of the nerve resulting in degeneration of the nerve axon, with-out cut of endoneurium. Recovery is slower than neuropraxia.

• Neurotmesis: is the hardest type of nerve injury resulting in discontinuation of the nerve due to severance of the nerve or due to formation of scar at the area of trauma. This type of injury is perma-nent and can result in scar formation that prevent nerve regeneration.

POST-OPERATIVE COMPLICATIONS

• Trismus• Hematoma• Ecchymosis• Edema• Postextraction granuloma• Painful postextraction socket• Fibrinolytic alveolitis (dry socket)• Infection of wound

TRISMUS

Usually occur in extraction of mandibular third mo-lars, and characterized by restriction of the mouth opening due to spasm of the masticatory muscles.

Etiology• Injury to medial pterygoid muscle caused by

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needle (inferior block)• Trauma to surgical site, especially during lengthy

surgical procedures• Other factors such as inflammation of the postex-

traction wound, hematoma, and edema.

ManagementIt depend on the cause of trismus. Most cases require no treatment and symptoms subside gradually.When acute inflammation or hematoma is the cause, hot mouth rinse are recommended initially, and broad spectrum antibiotic is administered.

Other additional therapies:

• Heat therapy: application of hot compresses extra-orally for 20 minutes every hour until symptoms subside.

• Gentle massage of the TMJ area• Administration of analgesics, anti-inflammatory

and muscle relaxant medications.• Physiotherapy lasting 3-5 minutes every 3-4 hours,

which include closing and opening the mouth, as well as lateral movement. Tongue depressor ex-ercise can be used, beginning with a particular number of tongue depressors then increasing their number gradually each day.

• Administration of sedatives (bromazepam 1.5-3 mg twice daily) for management of stress. Because trismus and inability to open the mouth can lead to stress, which cause more muscle tension and more trismus.

HEMATOMA

• This is a frequent complication of oral surgery. It occur due to prolonged capillary hemorrhage inside the tissue layers. It can be submucosal, subperioste-al, intramuscular or fascial.

ManagementCold application extraorally for the first 24 hours, then

hot application. Analgesia for pain.

ECCHYMOSIS

Sometimes after surgical procedure, ecchymosis may develop which appear as change in patient’s skin color due to excessive force in retraction of such tissue.

No special management is required. Patient is in-formed that the condition is not serious and color change will resolve.

EDEMA

It occur due to soft tissue trauma, which result in sev-ering of lymphatic vessels that will drain in tissue re-sulting in swelling. Swelling is smooth, pale and taut. When swelling due to inflammation, the skin has red-ness.

ManagementSmall-sized edema require no treatment. For pre-ventive reason, cold packs should be applied locally immediately after surgery. They should be placed for 10-15 minutes every half hour, for the following 4-6 hours.

When edema is severe and does not subside, it should be treated carefully, because it can lead to fibrosis and symphyses. Administration of fibrinolytic agens is indicated. If edema is inflammatory, then broad spec-trum antibiotic is recommended.

POSTEXTRACTION GRANULOMA

This complication occur 4-5 days after the extraction of the tooth. It resulting from presence of foreign body in the alveolus such as amalgam remnants, bone chips, small tooth fragments, calculus etc..

ManagementIt is treated with debridment of the alveolus and re-moval of the causative agent.

PAINFUL POSTEXTRACTION SOCKET

This is a painful complication occur immediately after the anesthesia wear off, due to sharp edges of alveolar bone crest, or interadicular bone, which result in se-vere pain and inflammation of the extraction site.

ManagementSmoothening bone edges, and administration of anal-gesics. Also gauze with eugenol should be placed over

the wound margin for 36-48 hours

DRY SOCKET

This complication occur after 2-3 days from the ex-traction procedure. It occur due to disintegration of blood clot from the socket.

SymptomsExposed boneSever throbbing, radiating painFoul odorBad taste in the mouth

ManagementIrrigation of socket with warm saline and placement of gauze soaked in eugenol in the socket and replaced ev-ery 24 hours, until pain subside.Another technique is gauze soaked with zinc oxide/ eu-genol or iodoform gauze can be applied for 5 days.

INFECTION OF WOUND

Which occur due to non-sterile instruments or operat-ing on non-sterile area.Appropriate administration of antibiotic according to the severity of the case is indicated.

REFERENCE

Oral Surgery Textbook by Fragiskos D. Fragiskos

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