2 - Extraction complications

Question 1

What are the different time frames in which extraction complications can occur?

Answer 1

• immediate/peri-operative
• immediate post-operative/short term
• long term post-operative

Question 2

List the peri-operative complications that can occur during extraction.

Answer 2

• difficult access
• abnormal resistance
• fracture of tooth, root or alveolar bone
• jaw fracture, or involvement of maxillary antrum
• fracture of tuberosity
• loss of tooth
• soft tissue damage including nerves and vessels
• haemorrhage
• damage to adjacent teeth/restorations
• extraction of permanent tooth germ (when extracting primary teeth)
• broken instrument
• incorrect tooth extracted

Question 3

What causes difficult access during extraction?

Answer 3

• trismus
• reduced aperture of the mouth (microstomia/scarring)
• crowed or malpositioned teeth

Question 4

What causes abnormal resistance during extraction?

Answer 4

• thick cortical bone
• root morphology (eg divergent roots, hooked roots)
• number of roots
• hypercementosis
• ankylosis

Question 5

What causes tooth/root fracture during extraction?

Answer 5

• caries
• alignment
• size
• root morphology (fused, divergent, extra etc)

Question 6

What causes alveolar bone fracture during extraction?

Answer 6

• happens when bone is not mobilised properly before expansion
• usually buccal plate, often canines or molars

Question 7

How do you treat alveolar bone fracture surrounding a canine?

Answer 7

• stabilise
• free the mucoperiosteum
• smooth the edges

Question 8

How do you treat alveolar bone fracture surrounding a molar?

Answer 8

• periosteal attachment
• suture
• dissect free

Question 9

What causes jaw fracture during extraction?

Answer 9

• usually mandible
• often occurs with impacted wisdom teeth, large cyst or atrophic mandible
• radiographs are essential
• be cautious with application of force, mandible must always be supported

Question 10

How should you manage a jaw fracture?

Answer 10

• inform patient
• post-op radiograph
• refer to max-fac unit (phone call)
• ensure analgesia
• stabilise
• if there is a delay for treatment, split teeth and prescribe antibiotics

Question 11

How can the maxillary antrum become involved during extraction?

Answer 11

• loss of root into the antrum can form an OAF or OAC
• fracture tuberosity
• some roots sit within sinus

Question 12

Define OAF.

Answer 12

• oro-antral fistula
• an OAC that has been present for time, and been covered but a layer of epithelium

Question 13

Define OAC.

Answer 13

• oro-antral communication
• communication between oral cavity and the maxillary sinus

Question 14

How do you diagnose an OAC?

Answer 14

• size of tooth
  -radiographic position of roots
• bone at trifurcation of roots
• bubbling of blood
• nose holding test (valsalva manoeuvre, CAUTION as can create OAC where there was not before)
• direct vision
• good light and suction, can cause an echo
• blunt probe, CAUTION as can create OAC where there was not before

Question 15

What are the risk factors for OAC?

Answer 15

• extraction of upper molars and pre molars
• close relationship of roots to sinus on radiograph
• last standing molars
• large bulbous roots
• older patient
• previous OAC
• recurrent sinusitis

Question 16

How do you manage an OAC?

Answer 16

• inform patient
• if small, encourage clot, suture margins, antibiotic, post op instructions
• if large, close with buccal flap advancement (horizontal mattress suture), post op instructions and nose blowing instructions
• if root lost into antrum, confirm radiographically, decision of retrieval

Question 17

What causes tuberosity fracture during extraction?

Answer 17

• single standing molar
• unknown unerupted widest tooth
• pathological gemination (germs attached)
• extracting in wrong order
• inadequate alveolar support

Question 18

How do you diagnose a tuberosity fracture?

Answer 18

• noise
• movement noted both visually or with supporting fingers
• more than one tooth movement
• tear on palate

Question 19

How do you manage tuberosity fracture?

Answer 19

• dissect out and close wound, or reduce and stabilise
• reduce using forceps or fingers
• rigid fixation is vital, orthodontic buccal arch wore welded using composite
• remove or treat pulp
• ensure occlusion is atraumatic
• antibiotics
• post op instructions
• remove tooth 8 weeks later