2 A- Immediate or operative complications Fractures of teeth.Fractures of alveolar process.Fracture of maxillary tuberosity.Dislocation of the mandible.Fracture of the mandible.Lossening or extraction of an adjacent tooth.Extraction of or injury to an unerupted tooth.
3 Disturbing artificial restorations. Gingival laceration.Bruising the lip or cheek.Wounding the tongue.Emphysema.Breaking an instrument.Injury to the inferior dental nerve.Forcing a tooth or root into the surrounding tissue.Forcing a tooth or root into the maxillary sinus or opening of maxillary sinus.
6 1- Fracture of the teeth Causes: Devitalized teeth (with R.C.T) or badly decayed teeth.Teeth with sever curvature or hypercementosis.Abnormality of the supporting structures.Misapplication of forceps or levers.Improper extraction movements.
7 If this complication occurs we must inform the patient. If the tooth is fractured near the neck, it may be removed with forceps.In multi-rooted teeth it may be removed with forceps-elevator-or by open method.
9 2- Fracture of alveolar process This occurs when the extraction is difficult. The fractured bone may be removed with the tooth or remain attached to the periosteum.If the bone attached to the periosteum, it should be replaced in its position by one or two sutures through the gingival margins.
10 3- Fracture of the tuberosity of the maxilla This usually occurs when extraction of87 78Causes:Ankylosed tooth.Malposed tooth.Prominent tuberosity.Isolated tooth.Divergent or hypercementosed sea root formation.
11 3- Fracture of the tuberosity of the maxilla If this occurs, the operator finds himself grasping a large segment of detached bone. Extraction should not be continued.It may cause fracture tuberosity, lacerated soft tissues, opening of the antrum and profuse bleeding.
12 ManagementIf it is small fragment excision should be done and we remove the tooth and the fragment of bone.If the maxillary sinus is exposed, the bone is debrided, and the flaps are trimmed, reopposed and sutured and nasal drops is very important to facilitate drainage.If the fragment is a large one and carrying more than one sound tooth, it should be repositioned and fixed with suitable splint and the tooth removed later on by its dissection.
13 4- Dislocation of the mandible It is dislodgement of condyloid process from the glenoid fossa. One or both joints may be dislocated as a result of using too mush pressure.
15 The symptomsThe mouth is open and rigidly set in position.The patient can not close his mouth.A depression is visible anterior to the ear.If the dislocation is unilateral the jaw is directed towards the normal side.
16 TreatmentLower the dental chair.The operator wraps his thumbs with gauze to protect them from quick and immediate closure of the jaw.The thumbs are placed on the occlusal surface of the mandibular molar and applied dawnward and backward pressure.
17 A four tail bandage is applied to hold the jaw in place for 48 hour and patients instructed to restrict opening to the thickness of spoon for the next two weeks.
19 5- Fracture of the mandible A fracture is a break in the continuity of the bone. It is uncommon complication but it has occurred. The common sites are in the premolar region and the angle of the jaw..Causes:Excessive force.Senile osteoporosis.Atrophic mandible.Irradiated mandible.Osteomyelitis.Fibrous dysplasia.Unerupted teeth, cyst or tumors.
23 ManagementStop extraction and bandage should be applied.Referred the case to specialist in oral surgery center.
24 6- Loosening or extraction of an adjacent tooth CausesHasty or ill directed extraction movements.Using the tooth as a fulcrum during application of elevator.Lack of vision if an excess of blood is allowed to accumulate.In cases of fusion of two teeth.
25 ManagementWhen the complication occurs:The luxated tooth should be forced back into normal position by heavy thumb pressure.Ligated the tooth in its place.If completely extracted:Immediate replantation of the extracted tooth and splinting to the adjacent teeth.Relief the replant tooth from the bite by selective grinding of the opposing teeth.Proper postoperative instructions and follow up.
26 7- Extraction of or injury to an unerupted tooth This complication may occur as a result of pushing the beaks of the forceps beyond the essential area when extracting a deciduous tooth thus holding it with its permanent successor.ManagementThe permanent tooth bud should be repositioned in its place and the mucosa should be sutured over it.
27 8- Disturbing artificial restoration As a result of slipping of a forceps or an elevator during extraction.9- Gingival lacerationAs a result of slipping or misapplication of the instruments. Also in some cases the gum may adhere to a tooth.
28 ManagementThe tooth should be carefully dissected from the gum by scalpel or scissors.The lacerated gum should be sutured back in its place.
29 10- Bruising the lip or cheek CausesSmall mouth orifice.Presence of trismus.Following an inferior dental n.block as in children.Careless handling of the forceps.We found immediate swelling ecchymosis, a braded skin or mucous membrane, trauma to cheek.
30 ManagementProper attention to the position of the thumb and finger of the left hand and proper instruction after inferior dental block.
31 11- Wounding of the tongue CausesHasty extraction or slipping of an elevator. Profuse bleeding is a common finding. Such wounds should be sutured to control the bleeding.
32 12- EmphysemaCausesIt is due to accumulation of air into the connective tissue of intermuscular or facial planes.It also follows an oro-antral fistula. The swelling is very rapid in onset. It takes from 1-2 weeks to be absorbed.
33 13- Breaking an instrument The beak of the forceps, the blade of an elevator or the tip of a surgical drill may be broken.Any broken part should be immediately located and removed.
34 14- Injury to the Inferior Dental Canal CausesRoot related to the inferior dental nerve.Careless curetting and blind use of elevators to remove root apices.Traumatic extraction of lower third molar in which the lingual soft tissues are trapped in the forceps.
35 Signs and symptomsUsually the injury to the inferior dental N. accompanied by injury to the neurovascular bundle & cause.Severe haemorrhage.Sometime small bone fragment press the nerve and this will result in numbness and parasthesia of half of lower lip and chin.ManagementControl bleeding.The nerve usually regenerates within six weeks to six months.
36 15- Forcing a tooth or root into the surrounding soft tissues Sometimes during removal of broken roots of mandibular molar teeth, they are pushed in the region of submandibular fossa. Sometimes the fracture roots are pushed below the mylohyoid muscle and can not be reached easily by intra oral approach and removed through extra-oral approach.
37 16- Maxillary sinus Involved The maxillary sinus may be opened and the roots of teeth or whole teeth may be pressed into it.The first molars, second premolars, first premolars and canines are more common when the teeth project into the sinus.
38 During removal of fractured roots CausesDuring removal of fractured rootsApical infection and other pathological processes favour perforation because the bone completely destroyed “osteomylitis, tumor, cyst”.Sinus approximation.
39 Signs and SymptomsIf this perforation occur the patient is asked to blow air into the nose while holding the nostrils together, we found the air comes through the extraction wound.Bleeding comes from the site of perforation and from the nose epistaxis.Alteration of voice.Inability to blow-out the cheek.Regurgitation of liquids from the mouth into the nose.
40 If the root or tooth has been forced into the antrum, there are several tricks to remove the roots from the sinus.Ask the patient to blow with the nostrils closed while the perforation is carefully washed for the appearance of the root.The use of suction tip in the socket may aid in the removal.
41 A long piece of 1/2 inch wide iodoform gauze tape may be packed through the socket into the antrum. This is pulled out in one stroke sometimes removes the root by friction or because it strikes to the gauze.
42 Mucoperiosteal flap is prepared on the buccal surfaces after enlarged the perforation to give sufficient access and the root can be seen & removed by instrument.In other cases a cold well-luc operation is necessary.
43 After removal of the root or tooth from the sinus, the perforation of the sinus (oroantral fistula) should be closed by:Buccal flap.Palatal flap.Combination of buccal & palatal flap.Tongue flap.
44 Post operative instructions Maintenance of a pressure pack on the wound for at least six hours.Any suction, such as occurs when drinking from a straw, blowing the nose must be through the mouth.Ephedrin nasal drops should be prescribed to insure proper drainage.Antibiotic therapy as a prophylactic measure against infection.The patient should be instructed to return in 48 hours for follow up.
47 or Post-Operative Complications Delayedor Post-Operative Complications
48 1- HemorrhageIs the escape of blood outside the vascular system.TypesExternal if the blood escape outsideInternal if the blood escape inside the body cavities.e.g. Periotoneal or pleural cavities.e.g. Submandibular or sublingual space.
49 The common type of Hemorrhage in oral cavity is the external one The common type of Hemorrhage in oral cavity is the external one. Also the Hemorrhage may be:Arterial spuring or pumping bright red blood.Venous continuous flow of dark bluish blood.Capillary continuous oozing.
50 Also the Hemorrhage may be A-Primary occurs at the time of operation.B-Intermediate occurs within 24 h after operation.C-Secondary occurs at any time after 24 h e.x. 2 weeks.Intermediate Hemorrhage may be due to loose tie. The secondary Hemorrhage may be due to disintegration of the blood clot by infection.
51 Causes of Hemorrhage 1- Local causes Interference of the patient to the formed clot.Improper instructions for the use of packs.Laceration of soft tissue.Failure of the blood clot to form on the top of severed vessels. E.g. Root in the socket.Presence of nutrient canal in the wall of bony socket.e.g. nutrient canals: is a bony canals running in the alvealor bone contain nutrient vessels their common location is in the interseptal bone of lower mandibular teeth.
52 2- Systemic causesVascular Defects: Due to defect in the vessels E.g. hemorrhagic telangiectasia or scurvy.Coagulation Disorder: Due to absence of one or more factors necessary for normal coagulation. It may be acquired as a result of illness, drugs or genetically.
53 Mechanism of coagulation: in case of injured B.V. A- Primary hemostasis: It has 3 phases:Vasoconstriction of the injured vessel to reduce the blood flow.Extra vascular phase: Increase the extra vascular pressure which lead to obliteration of the vessel.Platelets adhere to the wall of injured vessel and aggregate one another to form platelets plug “thrombus”.In case of injured large vessels the platelets plug may be prevented by the active pumping action of the vessel so the bleeding vessel must be clamped.
54 B- Permanent hemostasis: Which involve the process by which the fluid blood is transformed into coagulated blood and formation of fibrinThere are 13 coagulation factors which are responsible for coagulation:I- Fibrinogen II- ProthrombinIII- Thromboplastin IV- CalciumV- Proaccelerin VI- Activated factorVII- ProconvertinVIII- Antihemophilic globulin (AHG)IX- Plasma thromboplastic component (PTC)X- Stuart-Bower factorXI- Plasma thromboplastin antecedent (PTA)XII- Hageman factor (HF)XIII-Fibrin stabilizing factor (FSF).
56 Management of Patient with Hemorrhage following Extraction of Teeth 1-Prevention and treatment of psychogenic shockCauses usually due to fear, colour of the blood:Calm the patient and relatives this prevent fainting.Put the patient in a position to help the increase of cerebral circulation.Clear the air way.Use of aromatic spirits “ammonia” for several breaths.
57 2-Diagnosis and Looking for the cause of hemorrhage Regarding the actual cause of hemorrhage we decide the line of treatment.Find out the tendency of blood clot by visual examination. If the blood has tendency to clot this means that the blood clotting mechanism is normal and the bleeding due to local factor.It the blood is watery does not show clotting tendency, this means that the blood clotting mechanism is disturbed.
58 Treatment of Hemorrhage due to Local Factor Clear the mouth from the accumulated blood by suction apparatus or gauze sponges.If the bleeding due to soft tissue laceration can be simply corrected by local suturing.Clamping and ligation of all accessible bleeding vessels.If bleeding due to interference by the patient to the formed clot: application of local pressure sponges, or dental compound.
59 Application of ice compresses: this will help hemostasis by causing vasoconstriction. The use of local hemostatic agents e.g. thrombin, epinephrine, oxidized cellulose fibrin foam and gelatin sponge “delayed healing”.If the bleeding is due to the presence of a nutrient canal bleeding: could be controlled either by the use of bone wax to occlude the canal or by crushing of some spongy bone into the bleeding point by the tip of a blunt instrument.
60 Management of patient with coagulation disorder or systemic hemorrhage The patient must be hospitalized after minimize the amount of blood loss.Careful family history.Evaluation of the patient’s liver, spleen, kidneys.Inspection for ecchymosis, petechiae.
61 or packed plasma transfusion. Laboratory procedure.B.TC.TPlatelet abnormalitytreated byFresh bloodor packed plasma transfusion.Fibrinogen deficiencytreated byFresh wholeblood transfusion or concentrated fibrinogen.
63 It is faulty healing of the socket, the blood clot disintegrates and falls leaving the bony socket bare of granulation tissue and results in sever neuralgic pain.The condition starts the day after extraction but sometimes occurs seven days after extraction and occurs in the mandible then in the maxilla due to better blood supply in the maxilla.
64 Etiology and predisposing factors Pre-existing infection in the apex before extraction.Trauma to socket and surrounding bone by burs or elevators.The use of a high concentration of vasoconstrictor in the L.A.Excessive use of mouth washes.Patients under cortisone therapy.Extraction of teeth in systemic disease e.g. Diabetes, leukemia.
65 TreatmentL.A.Irrigate the socket with warm normal saline solution.All the degenerating blood clot removed.Sharp bony edges excised with rongeur.Loose dressing composed zinc oxide and oil of cloves packed in the socket.Sedation and antibiotic could be prescribed.
66 3- SwellingIt is common after extensive surgical interference “open-method”. Cold applications to the face will prevent or reduce swelling. Sedatives are used for relief of pain.
67 4- TrismusIt is defined as inability to open the mouth due to muscle spasm.TypesOedema.Haematoma formation.Inflammation of soft tissue.Infection of the needle “mandibular block”.TreatmentHot fomentation “hot saline”.Ab and analgesic.
68 5- Acute osteomylitisIt is an extensive infection involving the bone, bone marrow and periosteum and affects a large area of the bone.Clinical pictureSevere pain.Pus may be seen.Swelling.Tenderness.In chronic cases there is sinus tracks or fistulas draining pus.Sequestration: separation of necrotic dead bone by osteoclastic activity.
69 The sequestration occurs with Staph infection which cause bone resorption, also there is a subperiosteal new bone formation which is the body defense mechanism “involucrum”.x-ray: irregular radio-opaque lesion surrounded by radiolucent line.TreatmentIntra bony drainage.Removal of sequestra (sequestrectomy).Ab and analgesic.