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Dealing with local complications
Complications of tooth extraction
• Local complications • Immediate: • Failure of LA • Failure to move the tooth • Fracture of tooth, alveolus, mandible • Oro-antral communication • Displacement in soft tissues • Hemorrhage • TMJ dislocation • Damage to V1,2,3
• Delayed • Exessive pain, swelling, and trismus • Bleeding • Dry socket • A. osteomyelitis • Infection • Oro-antral fistula • Failure of the socket to heal • Nerve damage
• Late
• Chronic osteomyelitis
• Osteoradionecrosis
• Nerve damage
• Chronic pain
• Systemic complications • Immediate • Faint • Hypoglycemia • Hyperventelation/panic attack • Fits • MI • Addisonian crisis • Respiratory obstruction
Causes of difficult extractions
1. Excessively strong supporting tissues.
2. Misshapen roots.
3. Easily detached crowns.
4. Brittle teeth ( Glass in concrete ).
5. Sclerosis of the bone.
6. Burried and impacted teeth.
7. Ankylosis and geminated teeth.
8. Inadequate access.
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
- Postoperative instructions
Management
Local Measures
• Pressure packs
• Suturing
• Ligate bleeding vessels
• Burnish bone
• Apply material to aid in hemostasis (surgicell, collaplug)
Infection Cause
Debris left under the flap
Prevention
Irrigation
Management
Debridement & Drainage
Dry Socket ( Alveolar osteitis )
(The most frequent painful complication of extraction )
Dry Socket
• Aetiology: 1. Excessive trauma.
2. Impaired blood supply lower jaw > Upper jaw
3. Local anaesthesia.
4. Oral contraceptive ( oestrogens component causes increase in serum fibrinolytic activity)
5. Osteosclerotic disease.
6. Radiotherapy.
7. Smoking.
Dry Socket
• Pathology:
– Destruction of the blood clot either by:
1. Proteolytic enzymes produced by bacteria.
2. Excessive local fibrinolytic activity.
– Anaerobes are likely to play a major role.
– Destruction of the clot leaves an open socket, infected food and other debris accumulate.
Dry Socket
–Pathology:
• The necrotic bone lodges bacteria which proliferate freely, Leucocytes unable to reach them through the avascular material.
• Dead bone is gradually separated by osteoclasts.
• Healing is by granulation tissue from the base of the walls of the socket.
Dry Socket
• Clinical features: – Pain usually starts few days after extraction.
– Sometimes may be delayed for few days or more.
– Deep – seated, severe and aching or throbbing in character.
– Mucous membrane around the socket is red and tender.
– No clot in the socket ( Dry ).
Dry Socket
• Clinical features:
– When debris is washed away, whitish, dead bone may be seen or may be felt as rough area with a probe.
– Sometimes the socket becomes concealed by granulation tissue growing in from the edge.
– Pain may continues for week or two and rarely longer.
Dry Socket
• Prevention:
1. Minimal trauma.
2. Squeezed the socket edge firmly after extraction.
3. In case of dis-impaction of 3rd molars dry socket is more common:
- Minimum stripping of the periosteum.
- Minimum damage to the bone.
- Use prophylactic antibiotic.
Dry Socket
• Prevention: 4. In patient who have had radiotherapy, every possible
precaution should be taken.
5. In osteosclerotic disease:
• Little damage to bone (surgical extraction).
• Prophylactic antibiotic.
6. Stop smoking for two days post extraction.
Dry Socket
• Treatment: – Explain to the patient and warn them.
– The aim of the treatment is to keep the open socket clean and to protect the exposed bone:
1. Irrigate the socket by antiseptic solution.
2. Fill the socket with an obtudant dressing containing some non irritant antiseptic.
3. Frequent use of mouth wash.
Dry Socket
• Treatment: – A great variety of dry socket dressing has been
formulated: 1. Iodoform - containing preparation. 2. Alvogyl – which is easy to manipulate.
( The dressing should be: Obtudant, antiseptic, soft to adhere to the socket walls and absorbable ).
– In many cases, irrigation of the socket and replacement of the dressing has to be repeated every few days.
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