extraction complications Flashcards

Question

where is it most common for the alveolar bone to break

Answer 1

Usually buccal plate that breaks | Usually when extracting canines or molars

Answer 2

○ Periosteal attachment § Is the bit of bone still attached to the periosteum? § What size is it? § If it is a big bit of bone which is still attached to the periosteum then it will still have a blood supply so you could probably just push it back into place § If it doesn’t have a good periosteal attachment or it is quite small or it is not going to be able to stabilise then take it out ○ Suture § If the bit of bone is going to stay in place then just suture up around it, you might be able to get the gum closed over it or you might just be able to anatomically position it around where the tooth was § Want to check that it will stay in place § So if it is big enough and has got a blood supply and will stay in place then it will possibly heal [If it doesn’t it will work its way out or we can take it out] ○ Dissect free § A dead bit of bone will cause the patient pain until it works its way out of the socket or until you take it out § Remember even if you are removing it might be attached to the periosteum so it must be dissected free with a scalpel so that the gum is not ripped even further § So free it up before taking it out This is a judgement call you have to make

Answer 3

○ Stabilise § Try and save it in the canine region as it has a job here in creating the shape of the alveolus (in the upper arch there is the big buttress area) § Often tends to be a bigger bit in the canine that has broken off (tends to be smaller in the molar region) ○ Free mucoperiosteum ○ Smooth edges § The edges of the bone are jaggy and ragged so you need to take a bone file or an instrument and smooth the edges of bone that you are leaving behind otherwise the jaggy edges you are leaving behind will pierce through the gum and probably break down the wound and probably cause problems

Answer 4

Never run your finger along broken bone as it is sharp and jaggy ~ it will rip your glove and cut your finger Don’t be tempted once you've smoothed it down to feel it with your finger, inspect it and have another feel at it with the file (the file will tell you whether it is sharp or not)

Answer 5

Bone might break off because it was fused to the tooth or it might be that we took the tooth buccally too quickly before we had it moving Want the tooth moving first, use luxators and elevators, put pressure on the tooth using the forceps and do a few little movements first before you take it buccally

Answer 6

do not squeeze sockets once the tooth has been taken out ○ Used to squeeze sockets as it made the socket smaller, crushed vessels and helped to stop the bleeding and it was thought that this helped it to heal nicely and make the whole area smaller ○ But what happens is that you take away the bone volume (and people will lose bone as well after they get a tooth out) and this wrecks things for implants ○ There are other ways to get the socket to stop bleeding

Answer 7

* impacted wisdom teeth * large cyst [can weaken the jaw] * atrophic mandible [ie the patient might be edentulous and has been for years so the mandible is very thin]

Answer 8

Impacted wisdom teeth have undermined how much bone there is in the angle region There is a big space in the bone, and the tooth in there, which normally all would have been thick bone ○ On some occasions, when extracting a wisdom tooth in a very thin mandible, you can just remove the crown of it and leave the roots behind and tell the patient to see how they get on with that because if the roots were to be removed the jaw would be broken § Especially if the roots are all the way to the lower border of the mandible

Answer 9

○ Always have the fingers on either side of the alveolus and the thumb underneath the jaw ○ If you are in a tricky position and cannot manage the support and getting the forceps in then you must get someone else to support the jaw

Answer 10

* Inform patient * Post-op radiograph [If you have a panoramic machine and are able to do so] * Refer (phone call) * Don’t flap, deal with it calmly and get the patient referred • Ensure analgesia ○ If you are working remotely and you cannot get the patient to the referral until the next day then you need to consider pain relief for the patient ○ Give the patient advice about analgesia because they will be sore ○ Also give the patient advise about keeping the socket clean [Mouthwashes, warm salty mouth washes, chlorhexidine mouthwashes]○ Fractured mandibles are usually compound fractures, the gum is ripped and has access into the oral cavity (dirty and has bacteria) ○ Need to give advice to keep the mouth / socket / wound clean • Stabilise? • If delay in getting the fracture fixed, antibiotic treatment Until they can get to where they have got to go

Answer 11

○ Best place to call would be the maxillo-facial unit ○ Tell them you suspect / know there is a fractured mandible in my patient, how do I go about this, how do I get the patient to you? ○ If you don’t have a maxillo-facial unit then the patient needs to go to A&E ○ Dental hospital is not the first place you call to refer the patient, but if you just want advice you can phone them and they can be the intermediatory between getting them to A&E or to the maxillo-facial unit ○ Really just depends where you are working ○ If you can get the patient away to their referral then don’t interfere any further and send them on ○ Tell the patient not to eat on route because they might be going to theatre that day to have the mandible repaired § They might not but either way they need to go fasted

Answer 12

○ Bones rubbing against each other can be sore so might want to consider trying to stabilise the fracture ○ This can be done with a bit of ortho wire if you have any in the practice Or some splinting wire ○ Needs to be thin and flexible ○ Just tie this wire around the crowns of a couple of teeth on either side of the fracture to almost rope the fracture together and stabilise it a little § If you are not happy about doing this then don’t do it § Don’t do it around periodontally compromised teeth or they might just come out with wire around them

Answer 13

Oro-antral fistula / communication (OAF) / (OAC)

Answer 14

○ You cannot create a fistula when you take a tooth out ○ The immediate acute situation is an oral-antral communication § It is a communication between the maxillary air sinus and the mouth ○ If you don’t notice the OAC or if it doesn’t heal (or if you do notice but you decide to wait to see if it heals itself) it then becomes a fistula = It becomes epithelial lined if it doesn’t heal § Creates an epithelial lined tube between the mouth and the sinus ○ The chronic situation is a fistula ○ Acute = OAC ○ Chronic = OAF

Answer 15

○ Can get this communication from any of the teeth from the canine back § More common with molars But some people have bigger air sinuses which can come all the way forward to the canine

Answer 16

• Loss of root into antrum • Fractured tuberosity It is positioned just right next to the maxillary sinus so it usually involves a communication with the maxillary sinus

Answer 17

○ Size of tooth § When you take a tooth out always examine it to make sure all the roots are there, to make sure the ends of the roots are there, to make sure there isn't a chunk of bone on it ○ Radiographic position of roots in relation to antrum [Cannot tell us 100% because it is a 2D picture it can give an idea as to whether there might be a risk there] ○ Bone at trifurcation of roots ○ Bubbling of blood within the pocket § Might notice this as the patient breathes / moves ○ Nose hold test (careful as can create an OAC) § Patient holds nose and blows and might see some movement of air between the mouth and the socket but if it is only the membrane that is attached this can cause it to tear ○ Direct vision ○ Good light and suction - echo § Use suction gently and carefully so as to not push the membrane § When you put the suction in you might be able to hear an echo ~ this is more so the case if it is a bigger communication present ○ Blunt probe (take care not to create OAC) § Explore base of socket using the blunt probe § The probe might just fall into a hole / pocket and you might find a communication § Again, be careful as to not make a communication § Probe may be blunt but they are still narrow and thin

Answer 18

• Inform patient • If small or sinus intact: ○ Encourage clot ○ Suture margins [Just to make it tighter and help it to heal up quicker] ○ Antibiotic [If there is a communication, everything in the mouth (saliva, bacteria, food etc) is going up into the sinus and could cause infection of the sinus] ○ Post-op instructions § Give instructions about steam inhalations ~ to help the area heal § Don’t blow their nose, just sort of let it drip onto a tissue ○ They more often than not heal when they are very small (1-2mm which you can barely see) • If large or lining torn: ○ Close with buccal advancement flap [The best chance it has got of healing is to close it straight away] ○ Antibiotics and nose blowing instructions § Still give antibiotics after it has been closed as saliva with the bacteria etc has still gone into the sinus while there was a communication § Use steam inhalations ○ Still keep an eye on the patient ~ sometimes even though you close it, the closed communication can break down again / open [Especially in large communications] § Or where the closure has been tight ~ there is not enough elasticity on the flap (need a tension free flap when you close an OAC)

Answer 19

§ Tip for an oral surgery: when closing flaps they should be tension free □ Flap should not be blanching at the ages The tighter it is means it will lose it's blood supply and break down because of this loss and will also tear away from the sutures if it is really tight and the sutures are dragging it into place

Answer 20

Take a buccal flap of tissue and advance it over the hole To do this you have to release the underlying periosteum because the gum is not elastic and you won't be able to pull it across but when you go underneath and just take your scalpel lightly across the inner whitish / greyish periosteum that lines the inside of a full flap, then you will gradually see that flap release Often have to go back in and out several times because you will find some of the periosteum is not released properly at the corners of the flap where you vertical relieving incisions stop at the base of the flap up in the buccal sulcus

Answer 21

If it is chronic you need to cut the fistula out - Need to go in and cut around the epithelial lined tract If you just went in and pulled the flap over but there is a tube of epithelium going up into the sinus it will reform and won't close over

Answer 22

• Confirm radiographically by OPT, occlusal or periapical • make Decision on retrieval ○ Sometimes it is just sitting at the mouth of the hole that you've created ○ Sometimes it's not gone right into the sinus and is sitting along the lining of the sinus ○ Get good light and good suction and see if you can grab the root [Sometimes it might look like it is sitting at the mouth of the hole but remember an x-ray is a 2D image so it mightn't necessarily be where you think it is, could be further back but this would only be seen in 3D] ○ Not going to do any harm if you are very careful in trying to retrieve it • If you have broken a tooth and you are fishing around for the root ~ you need to see the root ○ Need good lighting and good suction ○ If you can't get at the right and it isn't mobile then you are going to have to remove bone to get at the root ○ You can't blindly prod a luxator / elevator into a socket in the upper arch and not run the risk of pushing that root into the maxillary sinus * Need to be careful, need to see what you are doing * If it disappears then you need to check to see if you have created a hole, don’t go mad prodding in the area because you might just have pushed the root up and no more, might be sitting at the mouth of the sinus and might be able to grab it with tweezers and pull it back out * Get nurse to check suction bottle to make sure it didn't go up the suction, especially if it is a small root • Also get patient to stand up and shake out their collar / bib etc in case root pops out there Doesn’t happen all the time but just make sure you have looked where you need to look

Answer 23

same as for OAC

Answer 24

Do not use an air rotor ~ if you use one of these (that you cut cavities with) you will force air into the maxillary sinus and into the soft tissues around then you will get a surgical emphysema ~ this takes a week or two to go away and you get bubbles of air in the soft tissue that if you run your finger along them they will crackle ○ Not a big deal except they are at risk of getting infected and can bring a risk of death

Answer 25

• Suction - efficient and narrow bore ○ Gently suction with a narrow bore suction tip • Small curettes ○ These look like tiny excavator instruments ○ Use these to see if you can grab the root and pull it forwards through the hole • Irrigation or ribbon gauze ○ Irrigate - take some saline and squirt it gently up in the area to see if you can irrigate the root further forward ○ Only start doing this if you have not gotten the root by the other ways because at the same time while irrigating you might flush it out but you also might flush it further back Ribbon gauze - damp it and tuck it up into the hole in the sinus ~ don’t tuck the whole thing up otherwise you will be looking for the ribbon gauze as well as the root, always leave a tail so you can pull it back out and then sometimes this will pull the root out along with it

Answer 26

○ Single standing molar § Ie it is more risky if there is only one upper molar tooth because the bone is already weakened and you are going to be putting a lot of pressure and force on that one tooth § Always need to be careful that you have finger and thumb on either side of the alveolus when you are taking out maxillary posterior teeth (from the 3 back but realistically for any tooth you should have your finger guards in place to protect the soft tissues and the bone) ○ Unknown unerupted molar wisdom tooth § Undermines the bone and that can make the bone weaker and more at risk of fracturing § Or a cyst ○ Pathological gemination § Sometimes teeth are joined together / fused and it might be that two tooth germs have fused or it is one tooth germ that has split into two and the roots / whole tooth can then be fused together and can look like a 6 and a 7 § Might consider a surgical removal rather than putting too much pressure or force onto the tuberosity area ○ Extracting in wrong order § Always take teeth out from the back forward § Don’t take out 6, 7, 8 ~ take out 8, 7, 6 § Taking out 6-8 means you are undermining the bone as you go along and you are going to leave yourself with a last standing molar Inadequate alveolar suppor

Answer 27

○ Noise ○ Movement noted both visually or with supporting fingers § Not just the tooth moving but also the bit of bone moving too ~ feel movement with your finger guard ○ More than one tooth movement § Unlucky to see 2 teeth moving ~ might be because they are joined together but might also be that the bit of bone that has fractured is quite big (ie the bit of tuberosity includes both the 7 and the 8, not just the 8) ○ Tear on palate

Answer 28

○ Dissect out and close wound § If you are going to dissect it out you need to take a fresh scalpel blade and cut away the gum from around this tooth and the bone ~ probably take a relieving incision § Usually don’t have to do a buccal advancement flap because you have lost the tooth and the bit of bone, you will find that the flap closes quite easily but you do need to close it over completely and treat it like an OAC and if it doesn’t close over easily then you will need to do a buccal advancement flap § However, if it is a massive bit of bone and has more than one tooth on it, don’t take it all out as you need to reduce it and treat it as a fracture ○ Or reduce and stabilise § Reducing a fracture means putting it back where it came from ~ trying to anatomically reposition it § Stabilising means finding a way to stop it waggling about and keeping the bone parts still against each other until they remodel and heal ○ Reduction: § Fingers or forceps § If it is all waggling about just push it back into place with your fingers § Sometimes you need to use forceps because sometimes it impacts in the wrong position ○ Fixation / stabilisation: § Orthodontic buccal arch wire spot - welded with composite □ Spot welding orthodontic wire on § Arch bar § Splints □ Some people might choice this if they have a lab nearby □ The best thing is to splint it with some wire § Composite is usually the best as it comes off more easily § Can use GI but tends to take a bit more drilling to get it to come off when you are finished with the splint

Answer 29

□ If you want to make the ones that look like sports mouth guards (has a little bit of flex) you need to take an impression but when removing the impression you could end up ripping the tooth out through the gum ® So need to put the tooth back into the position, jam the bone back into the right position then cover the whole area in vaseline ® So when you remove the impression it will come out easily and it will not pull on the tooth and the gum with it and the bit of bone ® Patient would only take this out to clean it and they would keep it in for as long as possible ® Not the most ideal as it is not the most stable as things can move when taking the splint in and out

Answer 30

Non-rigid fixation is when there is a little bit of flexibility with it

Answer 31

When you are splinting teeth back together where there has been an avulsed tooth then often you are using semi-rigid or flexible fixation

Answer 32

when it is a fracture of bone you need as rigid as you can get fixation ~ to do this you include more teeth that are not moving This is more difficult in the tuberosity area

Answer 33

Fractured bones don’t heal with a bony union if they are moving ~ they can sometimes still heal but it would be by a fibrous union ie soft fibrous tissue between the bones so there could still be some movement afterwards

Answer 34

○ Remove or treat pulp § If the tooth you were going to remove was an impacted / non-functioning wisdom tooth or something like that the tooth is fine and you won't have to do anything to the pulp of that tooth § But if you were taking the tooth out because the patient had tooth ache then the pulp is inflamed and you might need to take the pulp out and dress that tooth cos you need to deal with the pain ○ Ensure occlusion free ○ Antibiotic and antiseptics ○ Instructions post-op ○ Remove tooth 8 weeks later (SR) § Want to leave the splint in place for at least 8 weeks (as it will take the bone in the maxilla at least 6-8 weeks to heal) § Sometimes it can take up to 12 weeks for fractures to heal so it is fine if you want to leave it a little bit longer § But definitely do not touch it under 8 weeks See your patient to make sure they are keeping the splint clean and that it is not compromising the periodontal health and that they actually can clean it

Answer 35

* Stop! * Suction * Look for the tooth Radiograph refer to radiology department phone defence union for advice be honest with patient

Answer 36

* Crush injuries * Cutting / shredding injuries • Transection ○ = when you cut all the way through • Damage from surgery or damage from LA [Some people can get permanent numbness from an IDB] • May not know at the time ○ Also can be long term / permanent = post-operative complication

Answer 37

Contusion of nerve / continuity of epineural sheath and axons maintained

Answer 38

Continuity of axons but not epineural sheath disrupted

Answer 39

Complete loss of nerve continuity / nerve transected

Answer 40

Unpleasant sensation / pain

Answer 41

reduced sensation

Answer 42

Increase / heightened sensation

Answer 43

Bleeding +++ Because veins are quite big you can get huge amounts of bleeding Wouldn’t be pulsating but you would get waves of bleeding

Answer 44

○ Spurting / haemorrhage +++ ○ Arteries are big and have a pulse and have got muscular walls ○ In a dental practise you would have to be going some to actually cut a vein or an artery ~ usually have to be cutting deeper to cut these ○ If you are taking flaps in the region of the lower jaw don’t go wild and don’t cut deep because remember the facial artery crosses this region Usually arterioles or venules

Answer 45

○ Spurting / pulsating bleed ○ Most common that little vessels get damaged (tiny arterioles) when you are making cuts ○ Even though these are little they can still be frightening as they still spurt blood ○ Don’t panic but just apply pressure until you can find what the problem is § Pressure stops bleeding and buys you time

Answer 46

Can be oozing in the bone at the base of the socket etc and this can take a bit more work to stop this from bleeding as you cannot get the pressure onto the vessel itself as it is inside the bone

Answer 47

Might happen if you are taking flaps back and you cut too deep into the muscle Can bleed a lot

Answer 48

Most bleeds due to local factors ○ mucoperiosteal tears or ○ fractures of alveolar plate / socket wall

Answer 49

• Very few bleeds due to undiagnosed clotting abnormalities - haemophilia / von Willebrands • Some due to liver disease ○ alcohol problems - clotting factors are made in the liver > In elderly people, the vessels and muscular walls are all just a bit more fragile and can just bruise really easily because of their age > Might see lots of bleeding in patients with periodontitis disease because the mouth is so inflamed ~ just need time and pressure in the area, don’t panic • Some due to medication ○ Warfarin - antiplatelet agents Eg aspirin / clopidogrel - other anticoagulant drugs

Answer 50

○ Pressure ○ Sutures § If you think the socket / soft tissues are all loose then put more stitches in to tighten up the wound § Pull a socket closer together by suturing the papilla together ○ LA with adrenaline § Vasoconstrictor § So can put more LA into the area to constrict more vessels § This can be good to help to stop the bleeding so you can actually see what you are doing ``` ○ Diathermy § Cauterise / burn vessels □ precipitate proteins □ form proteinaceous plug in vessel § Need to make sure you are working on a vessel and not a nerve ``` ○ Ligatures / haemostatic forceps (artery clips) for larger vessels § Used more in head and neck surgery § Can use smaller clips for smaller vessels ○ Don't panic if it won't stop bleeding § Keep the pressure on § Get the patient to a maxillo-facial unit / A&E

Answer 51

§ Mechanical: □ Finger □ Biting on damp gauze swab [If you put in dry gauze / tissue it will stick to the clot that is forming so it stops the bleeding but when you pull the gauze / tissue out it will pull the clot out too so the patient will start bleeding again] § Not ferocious pressure / Don’t get patient to bit with all their might because when this pressure is lifted there will be a rebound bleed □ If you have squashed it too tight when you let go it will rebound open again § Need to apply firm (enough to stop the bleed), even pressure to allow the bleed to naturally coagulate § Apply pressure for 10 minutes to start with, then maybe 15-20 minutes and then if it is still bleeding it has been done to apply pressure for up to an hour

Answer 52

○ Pressure § Via swab or ribbon gauze or a bit of material § Be careful there are no nerves around, protect them ○ LA with adrenaline on a swab or injected into socket § Can put it on a swab and pack it back in so you are putting pressure and adrenaline onto the vessels in the bone ○ Haemostatic agents § Surgicel ~ looks like a bit of silk ribbon almost § Kaltostat ~ looks like a sort of felt material § If pressure and LA with adrenaline isn't working then you can turn to these agents § These agents often form a framework / scaffold for the blood to clot onto § Pack these into the socket § careful using these when working near nerves as they are acidic ○ Blunt instrument § If you can see the bone and see where the bleed is coming from you can press on it with a blunt instrument (like a flat plastic or the curved end of some sort of excavator [ie the shing non-sharp end]) ○ Bone wax § Rub this across the bone § Don’t need a huge amount § Get a small bit on your finger or on the end of a flat plastic § Only use your finger if there are no breaks on the bone § Dry it, get the suction in, get the wax in, quickly § If the wax goes in while it is still bleeding it will just come off so might need to do it in stages ie dry a bit then put wax on it, then dry a bit and so on ○ Pack § To do with pressure § Can sew a gauze pack in place and put stitches across and leave in place for a few hours and get the patient back later to check that it has all stopped bleeding ○ If it doesn’t stop you would be phoning to take advice and referring on

Answer 53

• Relocate immediately = best way to get the joint back before the muscles go into spasm ○ Analgesia § It will be sore so the patient will need pain killers ○ Advice on supported yawning § If they need to yawn they need to place their fist under their chin or their hand along the inferior border of the mandible and stop the yawn being big and wide • If unable to relocate try LA into masseter intra-orally ○ Helps to take some of the pain and discomfort away ○ Then try to relocate the jaw again as soon as the patient has got some pain relief • If still unable to relocate = immediate referral • NEED to refer these patients urgently ○ Do not send them home ○ Do not tell them someone will contact them in the morning ○ The patient must go in a car to their referral or they must have some sort of transport to get to the appropriate unit to get their jaw back into place ○ If a patient's jaw is dislocated then they cannot close their mouth and it will be really sore for them and they will be drooling and cannot swallow properly

Answer 54

○ The head of the condyle jumps over the articular eminence in the maxilla ○ Now the head is stuck in front of the articular eminence ○ So unless the patient has a really slack jaw (might have conditions that cause this, some people are more prone to it in general just) it is really difficult for that head to go back over the articular eminence to get back into place ○ If you don’t push it down and back straight away then all the muscles start to spasm ○ The patient will be in pain but if the muscles have seized up then it is like trying to put a brick into place ~ it is really hard

Answer 55

• Hit opposing teeth with forceps [especially if the tooth just suddenly gives way and you don’t have the appropriate finger supports in place] ○ Can break off cusps of teeth in the opposite jaw • Crack / fracture / move adjacent teeth with elevators • Crack / fracture / remove restorations / crowns / bridges on adjacent teeth ○ Only time this is forgivable is in a filling with a big overhang that is right on top of the adjacent tooth or there is a crown that is literally stuck to the adjacent tooth • Temporary dressing / restoration • Arrange definitive restoration If large restoration next to extraction site warn patient of the risk

Answer 56

Eg when removing deciduous molars ~ extraction or damage to developing permanent premolars • Sometimes see it happening when children are getting lots of teeth taken out under GA • Will see the permanent tooth germ on the end of the primary tooth that has been extracted Shouldn't happen • If you are extracting primary teeth and you break a bit of the root, unless you can extract it quite easily you shouldn't really dive in there to try and get them out ○ Just let them resorb ○ Tell the patient and parents Be careful about digging in tooth sockets of primary teeth where you have used elevators, luxators etc because you can damage the developing tooth germ

Answer 57

• Eg tips of elevators and luxators • Eg tips of burs • Can be from a defective instrument but that is usually not the cause • Usually it happens when using an instrument for the wrong reason ○ Like using a luxator (thin and sharp) as an elevator and levating with it as this will fracture the tip of the luxator off • Radiograph / retrieve ○ Take a radiograph to see if you can see it ○ Check the suction bottle ○ Check the area around and on the patient (clothes etc) * If unable to retrieve ~ refer * Keep good notes

extraction complications Flashcards

(83 cards)