Peri-Operative Extraction Complications

Question 1

What are the different perioperative complications?

Answer 1

Difficult access
Abnormal resistance
Fracture of root/tooth
Fracture of alveolar bone
Jaw fracture
Involvement of maxillary antrum
Fracture of tuberosity
Loss of tooth
Soft tissue damage
Damage to nerves/vessels
Haemorrhage
Dislocation of TMJ
Damage to adjacent teeth/restorations
Extraction of permanent tooth germ
Broken instruments
Wrong tooth

Question 2

What are the reasons for difficult access?

Answer 2

Trismus
Reduced aperture of the mouth
Crowding or malpositioned teeth

Question 3

What are the reasons for abnormal resistance?

Answer 3

Thick cortical bone
Shape/form of roots eg - divergent/hooked
Number of roots eg - 3 rooted lower molars
Hypercementosis
Ankylosis

Question 4

What are the reasons for peri-operative tooth fracture?

Answer 4

Caries
Alignment
Size
Root morphology - fused/extra roots, ankylosis

Question 5

Where is fracture of alveolar bone most likely?

Answer 5

Usually buccal plate
Usually canines or molars

Question 6

How should alveolar bone fracture be managed?

Answer 6

Assess periosteal attachment
Suture
Dissect free mucoperiosteum
Smooth edges

Question 7

What are risk factors for jaw fracture?

Answer 7

Impacted 8s
Large cysts
Atrophic mandible

Question 8

What causes a jaw fracture?

Answer 8

Application of force

Question 9

How should a jaw fracture be managed?

Answer 9

Inform patient
Post-op radiograph
Refer to OMFU (phone call)
Ensure analgesia
Stabilise
If delay in tx, give antibiotics

Question 10

How is an OAF/OAC diagnosed?

Answer 10

Size of tooth
Radiographic position of roots in relation to antrum
Direct vision
Blunt probe (can create OAC)
Bone at trifurcation of roots
Bubbling of blood
Nose holding test (can create OAC)
Good light and suction

Question 11

What are the risk factors for involvement of a maxillary antrum?

Answer 11

Upper molars and premolars
Close relationship of roots to sinus on radiograph
Large, bulbous roots
Older patient
Previous OAC
Recurrent sinusitis
Last standing molars

Question 12

How should an OAC be managed?

Answer 12

Inform patient
If small or sinus intact:
- encourage clot
- suture margins
- antibiotics
- post-op instructions
If large or lining torn:
- close with buccal advancement flap
- prescribe antibiotics
- give nose blowing instructions

Question 13

What are the causes of tuberosity fractures?

Answer 13

Single standing molars
Unknown erupted 8s
Pathological gemination
Extraction in wrong order
Inadequate alveolar support

Question 14

How is a tuberosity fracture diagnosed?

Answer 14

Noise
Movement noted visually or with supporting fingers
More than one tooth movement
Tear on palate

Question 15

How should a tuberosity fracture be managed?

Answer 15

Reduce using forceps or fingers
Stabilise
Fix using a splint bonded with composite
Treat pulp
Antibiotics and antiseptics
Post-op instructions
Surgically remove tooth 8 weeks later

Question 16

How should a lost tooth be managed?

Answer 16

Stop and find it
Use suction and take radiographs

Question 17

How can soft tissue damage be prevented?

Answer 17

Pay attention
Correct placement/correct instruments
Take time positioning instruments
Application point
Controlled pressure
Sufficient but not excessive force

Question 18

What are the causes of peri-operative nerve damage?

Answer 18

Crush injuries
Cutting injuries
Damage from surgery or LA
May be unknown

Question 19

What is neurapraxia?

Answer 19

Contusion of nerve
Continuity of epineural sheath and axons maintained

Question 20

What is axonotmesis?

Answer 20

Continuity of axons
Epineural sheath not disrupted

Question 21

What is neurotmesis?

Answer 21

Complete loss of nerve continuity
Nerve transected

Question 22

What different sensations are involved in nerve damage?

Answer 22

Anaesthesia - numbness
Paraesthesia - tingling
Dysaesthesia - unpleasant sensation/pain
Hypoaesthesia - reduced sensation
Hyperaesthesia - heightened sensation

Question 23

What are the causes of peri-operative haemorrhage?

Answer 23

Most are local factors - mucoperiosteal tears or alveolar fracture
Undiagnosed clotting factors
Liver disease - clotting factors made in liver
Medications - warfarin/antiplatelets

Question 24

How should haemorrhage in soft tissues be managed?

Answer 24

Pressure - damp gauze
Sutures
LA with adrenaline
Diathermy
Ligatures/haemostatic forceps

Question 25

How should haemorrhage in bone be managed?

Answer 25

Pressure via swab
LA on swab or injected into socket
Haemostatic agents
Blunt instrument
Bone wax
Pack and suture

Question 26

What can the damage of different blood vessels cause?

Answer 26

Veins - causes lots of bleeding
Arteries - causes spurting bleed or haemorrhage
Arterioles - causes spurting or pulsating bleed
Vessels can be in muscle or bone

Question 27

How should TMJ dislocations be treated?

Answer 27

Relocate immediately - push mandible down and back
Give analgesia and give advice on supported yawning
If unable, try LA into masseter intra-orally
If still unable, refer to OMFU

Question 28

How may adjacent teeth and restorations be managed peri-operatively?

Answer 28

Hit teeth with opposing forceps
Crack, fracture or move adjacent teeth with elevators
Crack, fracture or remove restorations, crowns and bridges on adjacent teeth

Question 29

How should damage to adjacent teeth or restorations be managed?

Answer 29

Temporary dressing/restoration
Arrange definitive restoration
Warn patient of the risks

Question 30

Describe the extraction of permanent tooth germ

Answer 30

Very rare
Damage or removal of permanent tooth when extraditing deciduous counterpart

Question 31

What broken instruments are likely to cause damage?

Answer 31

Tips of elevators, luxators and burs

Question 32

What should be done if instruments break peri-operatively?

Answer 32

Retrieve instruments
Use good light, suction and get radiographs
If unable to retrieve, refer to A+E

Question 33

How can you prevent the wrong tooth from being extracted?

Answer 33

Concentrate
Check clinical view with radiographs and notes
Safety checks
Count teeth
Verify with someone if unsure
Contact defence union