1
Q
You can get extraction complications at 3 diff stages. What are these?
A
- Immediate/intra-operative/perioperative (basically immediately after to a couple of hours post-procedure)
- Immediate post-operative/short term post-operative (a few days after the procedure)
- Long term post-operative
2
Q
What are some examples of peri-operative complications? (big list! - 16)
A
- Difficulty of access
- Abnormal resistance
- Fracture of tooth/root
- Fracture of alveolar plate
- Fracture of maxillary tuberosity
- Jaw fracture
- Involvement of the maxillary antrum
- Loss of tooth
- Soft tissue damage
- Damage to nerve/vessels
- Haemorrhage
- Dislocation of TMJ
- Damage to adjacent teeth/restorations
- Extraction of permanent tooth germ
- Broken instruments
- Wrong tooth!!
3
Q
What things might cause difficulty with your access and vision?
A
- Trismus
- Limited mouth opening
- Can be muscle spasms, joint problems, burns
- Reduced aperture of mouth
- Congenital/syndromes – microstomia, scarring
- Crowded/malpositioned teeth
- Makes it difficult to access the tooth
- Might not be able to get the tooth without moving others
- Can’t get the forceps in so might need to use the luxators and elevators more
4
Q
What might cause abnormal resitance when trying to extract a tooth?
A
- Thick cortical bone
- Shape/form of the roots
- number of roots
- Hypercementosis
- Ankylosis
5
Q
In what patients are you more likely to have problems with thick cortical bone?
A
bulkier guys
6
Q
What shape or form of roots might cause abnormal resistance?
A
- Divergent roots
- Hooked roots
7
Q
How might the number of roots cause abnormal resistance when extracting a tooth?
A
- 3-rooted teeth
- Especially lower 6’s and 7’s that have roots curved together. This may not look like a problem but they can sometimes trap inter-radicular bone between the curve of the 2 roots which makes it very hard to remove (will break a sweat!).
- Roots can sometimes be fused with the bone
- Will need to be surgically removed
- Extra roots – makes it a lot harder to mobilise the tooth
8
Q
What is hypercementosis?
A
extra-cementum (can be seen on radiographs)
9
Q
What is ankylosis?
A
- Pathological fusion between alveolar bone and cementum
- Is pretty rare
10
Q
What might become fractured during an extraction?
A
- tooth
- alveolus/tuberosity
- jaw
11
Q
The tooth might fracture at the crown or the root. What makes it more likely for a tooth to fracture?
A
- Carious tooth
- More likely to break due to weakened structure
- Alignment
- Can make it difficult to get the forceps to where they need to be (below the crown)
- You need to get below the bone
- This is why it is so important to take the time to position the forceps correctly
- Size
- Might have a small crown and big sturdy roots
- Roots
- Fused
- Convergent or divergent
- ‘extra’ root(s)
- Morphology
- Hypercementosis
- Ankylosis
NOTE: Referring for a surgical extraction IS NOT admitting defeat.
12
Q
Where is the alveolar bone most commonly fractured?
A
At the buccal plate with canines or molars
13
Q
What do you need to assess if you break the alveolar bone?
A
Is it still attached to the periosteal?
14
Q
What do you do if the alveolar bone is still attached to the periosteal after fracture at the molar region?
A
it still has a blood supply so can put it back in place and hope for it to heal. Would place sutures
15
Q
What do you do if the bone is not stil attached to the periosteal?
A
Remove the bone (don’t place dead bone back in as will just cause the patient pain)
Need to remove by dissceting it free with scalpel (so don’t rip more bone out)
Suture the wound
16
Q
In the canine region, how would you manage an alveolar fracture?
A
- Try best to keep the bone here
- Stabilise
- Free mucoperiosteum
- Smooth edges
- Don’t be temped to use fingers to feel whether or not it is smooth as it can cut through gloves and cause a sharps injury
17
Q
What jaw tends to become fractured?
A
mandible
18
Q
What is often an underlying reason that a jaw may become fractured during an extraction?
A
Often something has weakened the jaw such as a large cyst or an atrophic mandible
19
Q
If extracting a tooth from a thin bit of bone, what might you want to do?
A
stop short e.g leave roots and jsut remove crown
20
Q
What actually causes the mandible to fracture during an extraction? How can you prevent this?
A
The application of force
Should alwyas be supporting the mandible and if cant then get your dental nurse to do it
21
Q
Explain how you would manage a jaw fracture.
A
- Inform the patient of what has happened
- Take post-op radiograph if have panoramic machine available
- Refer to maxillofacial unit (phone them)
- If no maxillofacial unit then can send to A&E
- Can also call the dental hospital for advice
- Ensure analgesia
- Stabilise?
- If there is a delay, give antibiotic
- Tell the patient to NOT EAT ON ROUTE TO THE HOSPITAL
- It is likely the surgeons will want to operate the same day so the patient needs to fast
22
Q
A
23
Q
How might the maxillary antrum/sinus become involved in an extraction complication?
A
- Oral antral fistula/communication
- loss of root into antrum
- fractured tuberosity (back part of the maxillar fracturing off)
24
Q
What might make a patient more at risk of an oral-antral communication occuring?
A
- size of tooth
- radiograohic position of the roots in relation to the antrum
- bone at the trifurcation of the roots
25
How would you diagnose an oral-antral communication?
-look at tooth and check it is all there and that there is no bone on the roots
- bubbling of blood (air passing when patient talking etc)
- nose hold test (careful though as this can create and OAF)
- Direct vision
- Good light and light suction (if can hear an echo of the suction then there is an OAF)
- Use a blunt probe and feel but be careful not to create and OAF
There are clinical pics in the powerpoint
26
How would you manahe an OAC if it is small or the sinus is intact?
- can leave it and encourae a clot to form
- suture the margins
- prescribe antibiotics to stop infection from food etc
- post op instructions (dont blow nose, steam inhalation)
27
How would you manage a large oro-antral communication?
- close it with a buccal advancement flap
- give antibiotics and nose blowing instructions
28
When creating a buccal advancement flap, what needs to be considered regarding tension? Why?
needs to be tension free
If its blanching then it wil lose its blood supply and tear away from the sutures
29
You need to free the gingiva from what and why when creating a flap?
The periosteum - the tissue becomes very elastic once no longer attached
30
If you were dealing with an oral antral fistula, what do you need to do first before using a buccal advancement flap to close?
Remove the epithelial lining as otherwise it wont close over
There are clinical pics on buccal advancement flaps
31
If you lose a root and think its in the antrum, what do you do?
Confirm this radiographically by OPT, occlusal or periapical radiographs
Then decide on how to retrieve
32
What do you need to think about when deciding if you can retrieve root from the maxillary antrum?
- that it could move if send to a hosptial
- need to decide whether ot not you can retrieve the root
note: you wont do any harm if you are very careful when trying to remove
33
Walk through what you would use and how to retrieve a root from macillary antrum.
* Think about flap design
* Needs to be similar to OAC design as will be closing in the same way
* may need to remove bone
* Open fenestration with care (the new opening)
* Use suction efficiently and with a narrow bore
* Use small curettes
* Can use irrigation or ribbon gauze if cant get it another way
* Dampen the ribbon gauze and put some up (not all) will sometimes pull the root out with it
* Close as for an oro-antral communication
Note: Can always refer if these dont work and call for advice
34
What is the aetiology of a fractured maxillary tuberosity? (what makes it more likely to happen?
* single standing molar
* Bone will have been weakened from tooth loss and will be putting a lot of pressure on the bone
* Unknown unerupted molar wisdom tooth
* Pathological gemination
* A cyst etc can make the bone weaker and more prone to fracturing
* Extracting in the wrong order
* You should take out from the back forwards so as to not compromise the bone
* Inadequate alveolar support
35
How would you diagnose/recognise a tuverosity fracture?
–Noise
–Movement noted both visually or with supporting fingers
–More than one tooth movement
–Tear on palate
36
How would you manage a fractured tuberosity?
–Dissect out and close wound
–Or reduce and stabilise
37
How would you dissect out a fractured tuberosity?
Use a fresh scalpel blade and do a relieving incison and create a flap
Remove tooth and bit of bone
If dissect usually makes it easier to close the flap and dont need to do a buccal advancement flap as lost the tooth and bone make up for this
This can be done for small pieces
38
If there is a big bit of the tuberosity fractured off, then how would you reduce and stabilise? (if you break a big bit then it has to be treated like a fracture)
Reduce the fracture by using fingers or forceps to move the bone back to where it came from (remember the bone will be sharp)
To fix can either:
- Use an orthodontic buccal arch wire spot – welded with composite
- Arch bar
- Splints (with wire is best)
Need to make it as rigid as possible
39
If there has been a fractured tuberosity you need to remember to what?
–Remove or treat pulp
–Ensure occlusion is free
–Antibiotic and antiseptics
–Instructions post-op
–Remove tooth 8 weeks later (SR)
maybe watch vid back as confused
40
If you lose a tooth, what do you need to think?
Where?
Stop!
Suction
Radiograoh
41
How might you damage a tooth during an extraction?
* Crush injuries
* Cutting/shredding injuries
* Transection
* Damage from surgery or damage from LA
* May not know at the time
42
What is the definition of neurapraxia?
•Contusion of nerve/continuity of epineural sheath and axons maintained
43
What is the definition of axonotmesis?
•Continuity of axons but epineural sheath disrupted
( the nerve sheath may remain intact but the axons may be divided)
44
What is the definition of neurotmesis?
Complete loss of nerve continuity/nerve transected
45
46
How would you describe the following sensations to a patient?
1. Anaesthesia
2. Paraesthesia
3. Dysaesthesia
4. Hypoaesthesia
5. Hyperaesthesia
* Anaesthesia (numbness)
* Paraesthesia (tingling)
* Dysaesthesia (unpleasant sensation/pain)
* Hypoaesthesia (reduced sensation)
* Hyperaesthesia (increased/heightened sensation)
47
48
What vessels might you damage during an extraction?
* Veins (bleeding +++)
* Arteries (spurting/haemorrhage +++)
* Arterioles (spurting/pulsating bleed)
* Vessels in muscle
* Vessels in bone
49
What are some reasons for dental haemorrhages?
* Most bleeds due to local factors – mucoperiosteal tears or fractures of alveolar plate/socket wall
* Very few bleeds due to undiagnosed clotting abnormalities (haemophilia/von Willebrands)
* Some due to Liver Disease (alcohol problems) – clotting factors made in liver
* Some due to medication – Warfarin/ antiplatelet agents (e.g. Aspirin/Clopidogrel)
Note: Other anticoagulant drugs – Rivaroxaban (Pradaxa) and Dabigatran (Xarelto)
50
How do you manage bleeding from the soft tissue?
–Pressure (mechanical –finger/biting on damp gauze swab)
–Sutures
–Local Anaesthetic with adrenaline (vasoconstrictor)
–Diathermy (cauterise/burn vessels – precipitate proteins – form proteinaceous plug in vessel)
–Ligatures/haemostatic forceps (artery clips) for larger vessels
51
How do you manage bleeding from the bone?
–Pressure (via swab)
–LA on a swab or injected into socket
–Haemostatic agents - Surgicel/ Kaltostat
–Blunt instrument
–Bone Wax (need to get in right after drying or wont stick due to blood)
–Pack (sew in gauze for a few hours)
52
How do you manage TMJ dislocation?
* Relocate immediately (thengive analgesia and advice on supported yawning)
* If unable to relocate try local anaesthetic into masseter intaorally
* If still unable to relocate – immediate referral
53
When might a TMJ dislocation occur?
when taking a lower tooth out
-can be one or both sides that dislocate
54
Why do you need to try and relocate the TMJ immediately?
Want to get it back in before the muscle spasms and the condyle is stuck in front of the articular eminenence
55
If you are unable to relocate the TMJ, what should you try?
Administering LA into the massester intraorally to take away pain and discomfort and try to relax it
56
If still unable to reloacte TMJ after LA injection, what should you do?
Immediate referral
57
How might you damage adjacent teeth/restorations during an extraction?
- hit opposing teeth with forceps
- crack/fracture/move adjacent teeth with elevators
- crack/fracture/remove restorations/crowns/bridges on adjacent teeth
58
How do you manage damage to adjacent teeth/restorations?
- Temporary dressing/restoration
- Arrange definitive restoration
Note: if there is a large restoration nect to extraction site then warn the patient of the risk
59
When might you extract permanent tooth germ?
When removing deciduous molars (extaction or damage to developing permanent premolars)
60
What instruments might break during an extraction?
- tips of elevators and luxators
- tips of burs
61
If an instrument breaks and dont know where it went, what do you do?
- radiograph to see where it is and retrieve
- if unable to retrieve - refer
Oral Surgery
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