Professional Documents
Culture Documents
Introduction
Exodontia
Pre operative complication
o Syncope
o Failure to secure anesthesia
o Adverse drug reaction
Intra operative complication
o Fracture of
Crown of tooth being extracted
Roots of tooth being extracted
Alveolar bone
Maxillary tuberosity
Adjacent or opposing tooth
Mandible
o Dislocation of
Adjacent tooth
TMJ
o Displacement of a root
Into the soft tissue
Into the maxillary antrum
Under general anesthesia in the dental chair
Post operative complications
o Excessive haemorrhage
o Post operative pain due to
Dry socket
Acute osteomyelitis of the mandible
Tramatic arthritis of TMJ
o Post operative swelling due to
Odema
Haematoma formation
Trismus
Respiratory arrest
Cardiac arrest
Oro-antal communication
Post Operative instruction
Conclusion
References
Introduction
Extraction of a tooth has been considered a very formidable procedure by the layman,
and it is perhaps because of the horrifying experiences associated with tooth
extractions in the past that even today the removal of a tooth is avoided by the patient
almost more than any surgical procedure.
Dentist often considered tooth extraction a minor and unimportant operation and,
without proper training, attempt difficult cases, hoping that all will go well and then
depend on a specialist to help if complication are encountered or serious infection
begin. Before undertaking the extraction of tooth, one should thoroughly evaluate the
problem involved.
Exodontia
Definition:- An ideal tooth extraction is defined as "the painless removal of the whole
teeth, or tooth root, with minimal trauma to the investing tissues, so that the wound
heals uneventfully and no postoperative prosthetic problem is created."
Geoffrey L.Howe
Indications
molar.
Teeth involved in the fracture line.
Teeth involved in tumors or cyst.
Teeth as foci of infection.
Before radiation therapy in cancer patient.
Traumatic avulsion or intrusion due to fracture of the alveolar bone.
Teeth not treatable by apeoctomy.
Contraindication
Local
molar.
In acute dento alveolar abscess.
Teeth adjacent to the site of jaw fracture.
Patient with limited mouth opening.
Presence of acute infections such as necrotizing ulcerative gingivitis (vincent's
infection) or herpetic gingivostomatitis.
Systemic
uraemia.
Malignant disease such as leukaemia, lymphoma etc.
Cardiac diseases such as myocardial infection or stroke in the past 6 months.
Pregnancy.
Blood dyscrasias such as hemophillia, platelet disorders etc.
Patients on steroids.
Rheumatic fever in childhood is often forgotten by the patient, extraction could
affect the heart.
Complication
Definition
Pre operative
Operative
Post Operative
Persistant
Pre operative : Pre operative complications are the problems that may be
encountered before treatment.
It can be :- a) local
ii)
b) systemic
Operative : are the problems that may occur during treatment. It can be local
or systemic.
iii)
Post operative : are the problems that may occur after treatment. It can be
local or systemic.
iv)
It is the medical term for fainting. It refers to generalized weakness of muscles, loss
of postural tone, inability to maintain erect posture and loss of consciousness, while
faintness implies only lack of strength and sense of impending loss of consciousness.
Causes
I.
a)
b)
Hypovolaemia
c)
Arrhythmias
f)
Cough
Micturation
Mediastinal compression
Straining at stool evacuation
e)
d)
Vasovagal
Postural hypotension
Carotid sinus syncope
Antihypertensive drugs
AV blocks
Ventricular asystole
Ventricular tachycardia and fibrillation
Supraventricular tachycardia
Cerebrovascular disturbance
II.
Vertebrobasitar in sufficiency
Hypoxia
Anaemia
Prolonged bed rest
Anxiety neurosis
Clinical Features
Dizzyness, weak and nauseated, cold, pale and sweating skin.
Investigation
Treatment
the correct use of an elevator some pressure is transmitted to the adjacent tooth
through the interdental septum. For this reason an elevator should not be applied to
the mesial surface of a first permanent molar, because the smaller second premolar
may be dislodged from its socket. During elevation a finger should be placed upon
the adjacent tooth to support it and enable any force transmitted to it to be detected.
Dislocation of the temporomandibular joint occurs readily in some patients and a
history of recurrent dislocation should never be disregarded. This complication of
mandibular extractions can usually be prevented if the lower jaw is supported during
extraction. The support given to the jaw by the left hand of the operator should be
supplemented. It may also be caused by the injudicious use of gags. If dislocation
occurs it should be reduced immediately.
The operator stands in front of the patient and placed his thumbs intra orally on the
external oblique ridge lateral to any mandibular molars which are present and his
fingers extra orally under the lower border of the mandible. Downward pressure with
the thumbs and upward pressure with the fingers reduce the dislocation. The patient
should be warned not to open his mouth too widely or to yawn for a few days
postoperatively and an extra oral support to the joint should be applied and worn until
tenderness in the affected joint subside.
Displacement of a root into the tissue is usually the result of ineffectual attempts to
grip the root when visual access is inadequate. This complication can be avoided if
the operator attempts to grasp roots only under direct vision.
A root displaced into the antrum is usually that of a maxillary premolar or molar
and is most often the palatal root. The presence of a large antrum is a pre disposing
factor, but the incidence of this complication would be greatly reduced if the
following simple rules were
observed:i) Never apply forceps to the maxillary check tooth or root unless sufficient of its length
is exposed, both palatally and buccally, to allow the blades to be applied under
ii)
direct vision.
Leave the apical one third of the palatal root of a maxillary molar if it is retained
iii)
during forceps extraction unless there is a positive indication for removing it.
Never attempt to remove a fractured maxillary root by passing instrument up the
socket.
If root is lost while teeth are being extracted under general anaesthesia, the
anaesthesia should be stopped immediately & the patient's head brought forwards.
After the cough reflex has returned the mouth is examined & the pack carefully
removed and inspected. If proper safeguards have been taken the root is found in the
pack is most instances, but if the root cannot be located after removal of the pack,
radiograph should be taken of both the socket & the chest. The latter film is taken to
ensure that the root has not passed into the bronchi. If root is located in bronchi,
patient must immediately be referred to a hospital where it can be removed by
bronchoscopy before either a lung abscess or atelectasis supervenes. If the root is not
located the patient should be given an appointment for examination in 3 days.
Hemorrhage
Some slight oozing of blood for several hours following tooth extraction is
considered normal, although usually bleeding will stop after few minutes.
Persistent bleeding (primary haemorrhage) that cannot be controlled by 30 to
60 minutes of pressure from biting on a gauze pack, plus the use of an ice bag
on the face, requires more definitive therapy.
operation.
Reactionary Haemorrhage :- It is the one which occurs within 24 hours of
injury or operation. In many cases reactionary haemorrhage occurs within 4-6
hrs such haemorrhage takes place due to dislogment of blood clots on slipping
of ligature. This mostly occurs due to rise of blood pressure when the patient
is recovering from anaesthesia or shock. Such a bleeding may also occur due
to restlessness, coughing or vomiting which raises the venous pressure.
Secondary haemorrhage :- This occurs usually after 7-14 days of injury or
operation. This is usually due to infection and sloughing of part of the arterial
wall.
Clinical features of haemorrhage
In case of an external haemorrhage the bleeding is seen from outside and the
diagnosis is confirmed.
In case of an internal haemorrhage there is increase pulse rate, low blood
Management of Haemorrhage
b)
Rest
b)
c)
By operative methods
A.
Rest
prescribed to provide rest to the patient. If the patient become restless due to pain,
haemorrhage will be more.
subcutaneously.
Morphine is however contraindicated where there is respiratory depression in head
injuries, where chlorohydrate is more preferred. It is also contraindicated ion children
and in very old individual.
Injection pethidine is a better drug than morphine.
This is mainly a first aid technique sterile pieces of gauze & bandage may be
used as pressure bandage to reduce bleeding from external wound. If sterile
gauzes & bandage are not available clean linen cloth may be used as a
bandage to reduce bleeding from the wound. The gauze pieces are used as
package.
Use of tourniquet to stop haemorrhage has been obsolete. This is fact cannot
stop arterial bleeding, on the contrary causes venous congestion and increases
venous bleeding.
C.
By operative methods
The most commonly use & the least expensive is the gelatin sponge
(absorbable) eg. Gelfoam. This material is placed in the extraction socket and
held in place with a figure eight suture placed over the socket. The absorbable
pressure.
A liquid preparation of topical thrombin (prepared from bovine thrombin) can
be saturated onto a gelatin sponge & inserted into the tooth socket. The
thrombin helps to convert fibrinogen to fibrin enzymatically, which forms a
cloth. The sponge with the topical thrombin is secured in place with a figure
eight suture.
The final material which is used is collagen. Collagen promotes platelet
aggregation & thereby help accelerate blood co-agulation collagen is currently
available in several different forms. eg. Anitene, collaplug, etc.
The patient should be positioned in the dental chair and all the blood, saliva
the mouth.
If 5 min. of this treatment does not control the bleeding the surgeon must
administer a local anesthetic so that the socket can be treated more
aggressively.
bony socket.
The use of an absorbable gelatin with topical thrombin held in position with a
figure 8 stich and reinforced with application of firm pressure from a small,
damp gauze pack is standard for local control of secondary bleeding.
b)
lymphadenopathy.
This condition is more common in women and tobacco users, and is most
frequently associated with difficult or traumatic extractions and thus most
Birn's Hypothesis
Trauma and/or
Causes
infection
Inflammation of
Release of
bone marrow
Tissue activators
Plasminogen
Converted
to
Dissolution of
lysis of fibrin
formation of kinins
Plasmin
Treatment
The aim of treatment should be the relief of pain and speeding of resolution.
The socket should be irrigated with warm normal saline and all degenerating
blood clot removed.
Sharp bony spurs should be either excised with rongeve forceps or smoothed
Analgesics tablets and hot saline mouth baths are prescribed and arrangements
Acute Osteomyelitis
Definition:- Osteomyelitis is an inflammation of medullary portion of bone or bone
marrow or cancellous bone.
Acute suppurative osteomyelitis of the jaw is a serious sequal of periapical infection
that often result in a diffuse spread of infection throughout the medullary spaces, with
subsequent necrosis of a variable amount of bone.
Microbiology:- It is caused by pyogenic organisms. Most commonly found organism
in osteomyelitis is staphylococcus areus, staphylococcus albus, streptococcus
pyogenes. Anaerobes such as bacteroids, porphyromonas also predominate.
Aetiology
Site
It is more common in mandible and involves the alveolar process, angle of mandible,
posterior part of ranus and the coronoid process.
Clinical Features
A)
vomiting, anorexia.
Intermittent paraesthesia or anaesthesia of lower lip, which differentiate it
B)
Radiographic features
They are absent initially
The radiographical changes appear after one to two weeks. Diffuse lytic
Laboratory Studies
Shows mild leucocytosis (PMNL) & albumin urea.
Management:- The management includes:
A)
Conservative treatment
B)
Surgical treatment
protein diet.
Dehydration :- Hydration orally or through administration of IV fluid.
Blood transfusion :- In case RBC's and haemoglobin is low.
Control of pain :- It is controlled with analgesics. Sedation may be employed
b)
i)
ii)
iii)
Infectious arthritis
Traumatic arthritis
Osteoarthritis
Rheumatoid arthritis
Secondary degenerative arthritis
Traumatic arthritis of TMJ:- It may complicate difficult extraction of the lower jaw
is not supported. The risk of this unpleasant condition occuring can be minimized if
the operator uses his left hand correctly and the anesthetist or an assistant steadies the
mandible by holding it under the angles. If it is known that the patient has a history of
a previous dislocation of the temporomandibular joint it is a wise precaution to get
him to hold a dental puop during a dental extraction.
Causes:- TMJ traumatic arthritis could mainly by divided into two types:i)
ii)
Clinical features:
muscle pain.
TMJ traumatic arthritis could be clinically classified into : disk disorders,
synovitis,
masticatory
pathologically changes.
muscle
myositis,
joint
adhesion
and
mixed
TMJ treatment may range from conservative dental and medical care to
complex surgery.
Depending upon the diagnosis, treatment may include short term non steroidal
anti inflammatory drugs for pain and muscle relexation, bite plate, or splint
Oedema
Edema or odema formely known as dropsy or hydropsy, is an abnormal accumulation
of fluid in the interstitum, which are locations beneath the skin or in one or more
cavities of the body. It is clinically shown as swelling.
Mechanism
Six factors can contribute to the formation of odema:
probably result in swelling that the patient can see, whereas the tooth extraction of
multiple impacted teeth with the resections of soft tissue and removal of jaw bone
may result in moderately large amounts of facial swelling. The facial swelling usually
reaches its maximum size 24 to 48 hours after the surgical extraction procedure. The
facial swelling begins to subside on the 3rd or 4th day and is usually gone by the end of
the test week. Increased swelling after third day may indicate jaw infection at the
surgical tooth extraction.
Management
Once the surgical extraction is completed, the dental surgeon usually advices the
patient to use ice packs to help to minimize the swelling and make the patient feel
more comfortable. The ice pack should not be placed directly on the skin, but rather a
layer of dry cloth should be placed between the ice container and the tissue to prevent
superficial tissue damage. An ice bag or a small bag of frozen peas should be kept on
that local area of swelling for 20 min for 12 to 24 hours.
On the second day, neither ice nor that should be applied to the swollen area of
the face.
On the third day, a application of heat may resolve the swelling move quickly.
Heat sources such as hot water bottles and heating pads are recommended.
Patient should be wanted to avoid high levels heat for long periods to keep
An ecchymosis is the medical term for a subcutaneous purpura larger than 1cm or a
hematoma, commonly called a bruise. It can be located in the skin or in a mucous
membrane.
Presentation
After local trauma, RBCs are phagocytosed and degraded by macrophages. The blue
red color is produced by the enzymatic conversion of haemoglobin to bilirubin, which
is more blue green. The bilirubin is then converted into hemosiderin, a golden brown
color, which accounts for the color changes of the bruise.
Haematoma can be subdivided by size
By definition eccymosis are 1-2 cm in size or larger.
Petechial (1-2 mm or less) or pigmented purpuric dermatosis (0.3 to 1mm)
After the extraction procedure
Management
a)
Rest : Taking rest helps heal a trauma better than most other measures.
b)
Ice : Ecchymosis and hematoma are treated with intermittent ice packs (30
mins/hour) for the first 24 hours after surgery.
c)
Heat : Applying heat over patches can remove any obstruction in the affected
blood vessel. Put a warm cloth soaked in hot water over the region.
Patients should be advised that the discoloration is from bleeding into the
tissue and is not a bruise or a gangrenous process. They should also be told
that the discoloration from the accumulation of RBC and the subsequent
breakdown of the hemoglobin may take several weeks to disappears
completely.
Trismus
It can be defined as inability to open mouth due to muscle spasm and may complicate.
OR
It is defined as a prolonged, tetanic spasm of the jaw muscle by which the normal
opening of the mouth is restricted.
Causes
is slowly resorbed.
A low grade infection after an infection can also cause trismus.
Extraction of teeth may also cause trismus as a result either of inflammation
involving the muscle of mastication or direct trauma to the TMJ.
Problems
Chronic
Prevention
Management
beneficial.
One rare occasion, iodine may be necessary if the discomfort is more intense.
Muscle relaxation : Diazepam (approx 10mg Bio) or other benzodiazepine is
used for muscle relexation.
of the joint.
Antibiotics should be added to the regimen described and continue 7 full days.
Complete recovery from injection related trismus takes about 6 weeks, with a
range of 4 to 20 weeks.
For severe pain and dysfunction if no improvement is noted within 2-3 days
without antibiotics or within 5 to 7 days with antibiotics, or if the ability to
open the mouth has become limited, the patient should be referred to an oral
and maxillofacial surgeon for evaluation.
Respiratory Arrest
Respiratory arrest or failure is usually due to drug overdose during sedation. The
diagnosis is made by cessation of respiration, cynosis and rapid, weak pulse which
later become irregular and impalpable cardiac arrest may occur.
Management
Stop sedation
Lay the patient flat
Inspect and clear the airway
O2 should be given
Start cardio pulmonary resucilation eg. mouth to mouth breathing.
Consider flumazenil (an antidote to benzodiazepis)
Call an ambulance
Defer dental treatment
Pulpitis are initially reactive to light, may become dilated and fixed later one.
There is no measurable blood pressure.
Management
Assess the situation, state the patient and ask in a loud voice "Are you ok"? If
no response then:Can someone to get help or shout for medical help yourself.
Start basic life support (BLS) and cardiopulmonary resucitation (CPR), and
If any object is present, try to sweep out the object with 2 fingers.
If the person is not breathing, pinch the nostrils closed with your thumb and
index finger.
Tilt the head backward slightly to open the airway. Lift the chin forward.
Start mouth to mouth breathing even if the heart is beating, until the person's
CPR for an adult includes 15 chest compression & 2 breaths repeat many
times the procedure and watch for the person's chest to fall feel for air being
exhaled.
Oro-Antal Communication
The apices of the maxillary check tooth are often closely related to the antrum.
Sometimes the roots are separated from the antral cavity only by the soft tissue
lining of the all sinus.
be created.
If this complication is suspected, the patient should be asked to grip his nose
and thus occlude the wares. Men if he raises the intranasal & intra antral
pressure by attempting to blow air through his nose, in the presence of an oroantral communication, air will be hard to pass into the mouth, blood present in
the socket will be seen to bubble, or a whips or cotton wool held over the
socket will be deflected. If the test is positive or equivocal the lesion should
be treated immediately.
Treatment
Mucoperiosteal flap should be raised and the height of the bony socket reduced
without increasing the size of the bony defect. After loosely suturing the flaps across
the defect with an interrupted horizontal mattress suture the repaired soft tissues and
blood clot should be covering the area with either a quick acylic extension to an
existing denture or by a base plate. Alternatively a sheet of composition impression
material may be moulded to shape, cooled, trimmed and held in place over the area,
either by ligatures placed around adjacent teeth or by sutures. The patient should then
be referred for a second opinion. Under no circumstances should a patient with a
suspected oro-anteral communication be allowed to rinse out before the defect has
been repaired, because the passage of fluid from the mouth will contaminated be
allowed to rinse out before the defect has been repaired, because the passage of fluid
from the mouth will contaminate the air sinus with the bacterial flora of oral cavity.
Gauze to control the bleeding, bite firmly on the gauze placed in your mouth
(pressure pack)
Cold to reduce swelling, place an ice bag on the cheek, near the extracted
area.
Take the prescribed medium as recommended.
Rinse after eating food and avoid eating from the same side of the extraction.
Limit the activities for the first 24 hours.
Brush your teeth gently.
Adapt liquid or soft food diet for the first two days.
Drink cold things as it causes vasoconstriction of the blood. Vessels and
reduce bleeding.
Advice warm saline rinse mouth wash after one day.
Don't
One should not take any hot liquids as it causes lysis of clot avoid smoking.
Don't split as it will cause discoloration of blood clot.
Do not eat crunchy and sticky food.
Do not drink without straw.
Avoid chewing anything for at least 2 hours after tooth extraction.
Don't touch the site with tongue or finger.
Avoid brushing around the extracted site.
Don't speak too much.
Don't eat hard food.
Conclusion
The complications of tooth extraction are many and some may occur even when the
care is exercised. Other are avoidable if the plan of campaign, designed to deal with
difficulties diagnosed during a careful preoperative assessment, is implemented by an
operator who adheres to sound surgical principles during the extraction.
Prevention of complications should be a major goal of the surgeon. The surgeon who
anticipates a high probability of an unusual specific complications should inform the
patient and explain the anticipated management & squelae. Notation of this should be
made in the informed consent that the patient signs.
References