Complications of Extraction of Impacted Teeth

Outline
I. Soft Tissue Injuries II. Complications with the Tooth Being Extracted III. Injuries to Adjacent Teeth IV. Injuries to Osseous Structures V. Injuries To Adjacent Structures VI. Oroantral Communications VII.Postoperative Bleeding VIII.Delayed Healing & Infection

I. Soft Tissue Injuries

1. Tearing Mucosal Flap

Causes Due to an inadequately sized flap which is retracted beyond the tissue`s ability to stretch. As with a short envelope flap when the area of surgery is at the apex.

Prevention -Adequately sized flaps -Gentle Retraction

Management Reposition the flap & suture If the tear is jagged, trim it before suturing

Cause Instrument Slippage Prevention Controlled force

2. Puncture Wound of Soft Tissue

Management Suturing to prevent infection & allow healing to occur

Cause Bur shank or retractor injury Prevention Care Management Keep it moist ( ointment ) Heals within 5 10 days

3. Stretch or Abrasion Injury

II. Complications with the tooth Being Extracted

1. Root Fracture
Cause Long, curved, divergent roots Excessive force during extraction Prevention Proper exposure & bone removal

2. Root Displacement
Into: Mandibular Canal Lingual Pouch Infratemporal Space Maxillary Sinus

III. Injuries to Adjacent Teeth

1.Luxation of Adjacent Teeth 2.Fracture of Adjacent Restoration Cause Carelesness Prevention Judicious use of elevators

IV. Injuries to Osseous Structures

Fracture of the Buccal or Lingual Cortex

1. Fracture of Alveolar Process

Cause Inadequate exposure & excessive force Prevention Adequate bone removal & eposure

Cause Excessive force

2. Fracture of Maxillary Tuberosity

Prevention Proper support and controlled force Management If still attached; dissect and remove the tooth If detached; smooth bone edges &

3. Fracture of the Mandible

Cause Excessive force Prevention Proper bone removal & controlled force

Photoelastic model of the mandible, showing the development of stress during a luxation attempt of the third molar when insufficient bone has been removed

V. Injuries to Adjacent Structures

Cause -Excessive extraction force in case of curved roots -Sectioning the tooth all the way inferiorly Prevention -Proper exposure & bone removal -Controlled force -Careful setioning, leaving a shell of

1. Injury to Inferior Alveolar Nerve

Cause -Placement of the retromolar incision far lingually -Sectioning the tooth all the way to the lingual cortex Prevention -Proper incision -Careful sectioning, leaving a shell of the tooth

2. Injury to the Lingual Nerve

3. Injury to the TMJ

Cause Inadequate support of the mandible during extraction Prevention Use of bite block Management Reduction

Cause During extraction of an impacted maxillary canine -Excessive bone removal -Failure to locate the tooth Prevention -Proper preoperative radiographic evaluation -Proper bone removal -Controlled force

Vi. Oroantral Communication

VII. Postoperative Bleeding

Cause -Bleeding at wound margins -Bleeding at a bony foramen within the socket -Medical Problem

Prevention -Good history taking (coagulopathy, medications etc) -Atrumatic surgical extraction (clean incisions, gentle management of soft tissues, smoothen bony specules, curette granulation tissue) -Obtain good homeostasis at surgery

Management Local Measures

Pressure packs Suturing Ligate bleeding vessels Burnish bone Apply material to aid in hemostasis (surgicell, collaplug)

VIII. Delayed Healing & Infection

1. Infection
Cause Debris left under the flap Prevention Irrigation Management Debridement & Drainage

Cause -Lysis of a fully formed blood clot before the clot is replaced with granulation tissue. -Higher incidence with smokers & patients taking oral contaceptives. Prevention -Presurgical irrigation with antimicrobial agents ,e.g:

2. Dry Socket (Alveolar Ostitis)

Management
Irrigate with warm saline Remove old clots Place sedative dressing Prescribe mild analgesics Reassess after 24 to 48 hours