Contents 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
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Contents
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. The type of anesthesia to be used also should be carefully
considered, and a good radiograph should be taken to help in the recognition of
abnormalities that may make extraction difficult. In this way, hasty use of forceps can
be avoided, and the procedure can be selected that is most likely to yield the best
results.
Haste is the principle cause of all the complications which occur during the extraction
procedure.
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
Teeth affected by advanced dental caries and its sequalea.
Teeth affected by the periodontal diseases.
Over retained deciduous teeth.
Extraction of healthy teeth to correct malocclusion.
Extraction of teeth for esthetic reasons.
Extraction of teeth for prosthodontic reasons.
Unrestorable tooth.
Impacted and supernumerary teeth
Extraction of decayed first or second molars to prevent the impaction of third
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.
Teeth with non vital pulps.
Contraindication
Local
Teeth that are located within an area of tumor.
History of therapeutic radiation for cancer. Extractions performed in an area of
radiation may result in osteoradionecrosis.
Patients who have severe pericoronitis around an impacted mandibular third
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
Severe uncontrolled metabolic situation such as uncontrolled diabetes,
hyperthyrodism, osteoporosis, end stage of renal disease with uncontrolled
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
Complication is define as unanticipated problem that arises following, and is a result
of a procedure, treatment or illness. A complication is named so because it
complicates the situation.
Classification of complication
Complications can be classified into 4 groups:
i) Pre operative
ii) Operative
iii) Post Operative
iv) Persistant
i) Pre operative : Pre operative complications are the problems that may be
encountered before treatment.
It can be :- a) local b) systemic
ii) 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) Persistent : A problem that may persist way long after treatment.
Pre Operative Complication Syncope
Definition
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. Decreased Cerebral Perfusion
a) Inadequate Vasoconstrictive Mechanism
Vasovagal
Postural hypotension
Carotid sinus syncope
Antihypertensive drugs
b) Hypovolaemia
Haemorrhage (blood loss)
Addison's disease
c) Reduction of venous return
Cough
Micturation
Mediastinal compression
Straining at stool evacuation
d) Reduced cardiac output
Aortic stenosis or hypertrophic subaortic stenosis
Myocardial infarction
Cardiac temponade due to pericardial effusion
Pulmonary embolism
e) Arrhythmias
AV blocks
Ventricular asystole
Ventricular tachycardia and fibrillation
Supraventricular tachycardia
f) Cerebrovascular disturbance
Transitory ischaemic attack
Hypertension
Vertebrobasitar in sufficiency
II. Non Circulation Causes
Hypoxia
Anaemia
Prolonged bed rest
Anxiety neurosis
Clinical Features
Dizzyness, weak and nauseated, cold, pale and sweating skin.
Investigation
Measurement of serum electrolytes, glucose and haematocrit
Blood and urine toxological screens.
ECG, halter monitoring
Electrophysiological cardiac testing
Upright till table testing
Others depending on the cause eg. MRI, Doppler.
Treatment
The patient should be treated immediately with the first aid.
The head should be lowered by lowering the back of the dental chair.
With some designs of chair the use of this method may entail considered delay
and in these circumstances the patient's head should be put between his knees
after insuring that his collar has been loosened.
Care should be taken to maintain the airway and to insure that the patient cannot
fall out of the chair.
No fluids should be given by mouth until the patient is fully conscious.
When consciousness returns a glucose drink may be given if the patient has
missed a meal & is being treated under local anasthesia.
Alternatively, spr Ammon. Aromat BPC (sal volatile) 3.6 ml (I drachm) in
atleast one third of a tumbler ful of water may be administered.
If the circumstances permit, the blood pressure should be recorded at intervals
and an intravenous injection of 250mg of aminophylline injection 80 may be
given slowly.
Failure of Secure Anasthesia : is usually due to faulty technique or insufficient
dosage of the anasthetic agent. It is possible to extract teeth well unless both the
operator & the patient have complete confidence in the anasthesia under which the
operation is performed. When LA is employed its efficacy should be tested before the
extraction is started. After explaining to the patient that although he may feel
pressure he should not feel any sensation of sharpness, a blunt probe is pushed firmly
into the gingival crevice on the buccal and lingual surfaces of the tooth to be
extracted. If nothing is felt by the patient anaesthesia has been secured. If he feels
pressure but not pain, analgesia has been obtained, but pain indicate that a further
infection of local anaesthetic solution is required.
If a tooth fails to yield to the application of resonable force applied with either forceps
or an elevator the instrument should be put down and the cause of the difficulty
sought. In most cases the tooth will be better removed by dissection.
Intra Operative Complication
Fracture of the crown of a tooth during extraction may be unavoidable if the tooth
is weakened either by caries or a large restoration. However, it is often caused by the
improper application of the forceps to the tooth, the blades being either applied to the
crown instead of the root or root mass or with their long axis across that of the tooth.
If the operator chooses a pair of forceps with blades which are too broad and given
only 'one point contact' the tooth may collapse when gripped. If the forceps handles
are not held firmly together the blade may slip off the root and fracture the crown of
the tooth. Hurry is usually the underlying cause of all these errors of technique,
which are avoidable if the operator works methodically. The exhibition of excessive
force in an effort to overcome resistance is unwarrantable and may cause a fracture of
the crown.
When coronal fracture occurs the method used to remove the retained portion of the
tooth will be governed by the amount of tooth remaining and the cause of the mishap.
Sometimes a further application of the forceps or elevator will deliver the tooth, and
on other occasions the trans alveolar method should be used.
Fracture of the alveolar bone is a common complication of tooth extraction &
examination of extracted teeth reveals alveolar fragments adhering to a number of
them. This may be due to the accidental inclusion of alveolar bone within the forceps
blades or to the configuration of roots, the shape of the alveolus, or to pathological
change in the bone itself. The extraction of canines is frequently complicated by
fracture of the labial plate, especially if the alveolar bone has been weakened by
extraction of the lateral incisor and/or the first premolar prior to the removal of the
canine. If these three teeth are to be extracted at one visit, the incidence of fracture of
the labial plate will be reduced if the canine is removed first.
Fracture of the maxillary tuberosity: Occasionally during the extraction of an upper
molar, the supporting bone & maxillary tuberosity are felt to move with the tooth.
This accident is usually due to the invasion of the tuberosity by the antrum, which is
common when as isolated maxillary molar is present, especially if the tooth is
overerrupted. When fracture occurs the forceps should be discarded and a large
buccal mucoperiosteal flap raised. The fractured tuberosity and the tooth should be
freed from the palatal soft tissue by blunt dissection and lifted from the wound. The
soft tissue flaps are then apposed with mattress sutures which evert the edges and are
left in situ for at least 10 days.
Fracture of an adjacent or opposing tooth during extraction can be avoided.
Careful preoperative examination with reveal whether a tooth adjacent to that to be
extracted is either carious, heavily restored, or in the line of withdrawal. If the tooth
to be extracted is an abutment tooth, the bridge should be divided with a vulcarbo or
diamond disk before extraction caries and loose or overhanging fillings should be
removed from an adjacent tooth and a temporary dressing inserted before the
extraction. No force should be applied to any adjacent tooth during an extraction, and
other tooth should not be used as a fulcurum for an elevator unless they are to be
extracted at the same visit. Opposing teeth may be either chipped or fractured if the
tooth being extracted yields suddenly to uncontrolled force and the forceps strike
them. Careful controlled extraction technique prevents this accident.
Fracture of the mandible may complicate tooth extraction if excessive or incorrectly
applied force is used, or pathological change have weakened the jaw. Excessive force
should never be used to extract teeth. The mandible may be weakened by senile
osteoporosis and atrophy, osteomyelitis, previous therapeutic irradiation, or such
osteodystrophies as osteitis deformans, fibrous dysplasia or fragilities ossium.
Unerupted teeth, cysts hyperparathyroidism, or tumors may also predispose to
fraction. In the presence of one of these conditions, extraction should be attempted
only after careful clinical & radiographic assessment & the construction of splints
preoperatively. The patient should be informed before operation of the possibility of
mandibular fracture and should this complication occur treatment must be instituted at
once. If a fracture occurs in the dental surgery extra oral support should be applied
and the patient referred immediately to a hospital where facilities for treatment exist.
Dislocation of an adjacent tooth during extraction is an avoidable accident. The
causes are similar to those giving rise to a fracture of an adjacent tooth. Even during
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 direct vision.
ii) Leave the apical one third of the palatal root of a maxillary molar if it is retained
during forceps extraction unless there is a positive indication for removing it.
iii) 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.
Post Operative Complications of Exodontia
A. 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.
Primary Haemorrhage :- It is the one which occurs at the time of injury or
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
pressure, pallor, restlessness and deep sighing respiration (air hunger).
- Cold and clammy extermities, empty veins are also characteristically seen
when the bleeding is continuing.
Grading scale to measure severity of bleeding
WHO (World Health Organization) made a standardized grading scale to measure the
severity of bleeding.
Grade O - no bleeding
Grade 1 - petechial hemorrhage
Grade 2 – mild loss of blood (clinically significant)