4th year Oral and maxillofacial surgery Lecture

Lecture13
7
COMPLICATIONS OF TOOTH EXTRACTION

1-Local complication.
2-Systemic complication.
Some of these complications occur even when a careful procedure done,
others are avoidable if a good treatment plane was designed with good
preoperative assessment.

1 – Local complications: -
A- Occur during extraction
B- Post extraction complication

A/-Occur during the extraction.

1. Fracture of the crown or root due to:-
a. Badly carious tooth.
b. Improper forceps application.
c. Dense bone
d. Ankylosis or gemination of the root.
e. Dilacerated root

2. Fracture of alveolar bone :-

Fracture of the alveolar process could be due to :

a. Pathological changes of bone.
b. Divergent roots.
c. Improper forceps application.
d. The use of excessive force during the extraction procedure.
e. Ankylosed tooth or dense bone.

Treatment
a) When the broken part of the alveolar process is small and has been
separated from the periosteum, so it should remove with forceps and the
sharp edges of bone are smoothed. After that, the area is irrigated with saline
solution and the wound is sutured.
b) If the broken part of the alveolar process is large and still attached to the
periosteum, then the bony segment should be dissected away from the tooth,
and the tooth should be removed in the usual fashion. then we do a
stabilization and suturing of the mucoperiosteum.

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Prevention: If the surgeon realizes that excessive force is necessary to
remove a tooth, a soft tissue flap should be elevated, and controlled amounts
of bone should be removed so that the tooth can be easily delivered or in the
case of multirooted teeth, sectioning of the tooth. If this principle is not
followed and the surgeon continues to use excessive or uncontrolled force,
fracture of the bone commonly occurs.

3. Fracture of maxillary tuberosity

This complication may occur during the extraction of a posterior maxillary
tooth especially the upper third molar and is usually due to the following
reasons:
1 - Weakening of the bone of the maxillary tuberosity, due to the maxillary
sinus pneumatizing into the alveolar process. In this case, risk of fracture is
increased if the extraction of a molar is performed with forceful and careless
movements.
2- Ankylosis of a maxillary molar that presents great resistance to
movements during the extraction attempt. An extensive fracture of the
buccal bone or the distal bone surrounding the ankylosed tooth may occur.
3- Dilacerated roots of the upper third molar.

Treatment.
1-For a small segment of bone dissect the segment from gingiva and
periosteum and extract it with the tooth ,and smooth the sharp edges of the
remaining bone and reposition and suture the remaining soft tissue.
2-If the bone segment is large and remains attached to the periosteum,
should take measures to ensure the survival of that bony segment. If
possible, the bony segment should be dissected away from the tooth, and the
tooth should be removed in the usual fashion. The tuberosity is then
stabilized with mucosal sutures.
3- If the bone segment is large and is excessively mobile and cannot be
dissected from the tooth, the surgeon has several options:
a- The first option is to splint the tooth being extracted to adjacent teeth and
defer the extraction for 6 to 8 weeks, allowing time for the bone to heal. The
tooth is then extracted with an open surgical technique.
b- If the maxillary tuberosity is completely separated from the soft tissue,
the usual steps are to remove the fractured segment with the tooth and then
smooth the sharp edges of the remaining bone and then reposition and suture
the remaining soft tissue. The surgeon must carefully check for an oroantral
communication and treat as necessary.

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4. Fracture of adjacent or apposing tooth:- due to
a. Badly carious tooth
b. Heavily restored tooth with overhang filling
c. The use of adjacent tooth as a fulcrum for the elevator
d. The tooth removed from socket with uncontrolled force

5. Fracture of the mandible:- Due to

a. Extraction of isolated lower 2nd & 3rd molars in edentulous mandible
b. The use of excessive force especially during the extraction of impacted
mandibular third molar.
c. Pathological cyst or tumor
d. Presence of multiple impacted teeth at the same site.
e. Fractures may also occur during removal of impacted teeth from a
severely atrophic mandible.
if such a fracture occurs, it must be treated by the usual methods used
for jaw fractures. The fracture must be adequately reduced and
stabilized. Usually this means that the patient should be referred to an
oral and maxillofacial surgeon for definitive care.

6. Dislocation of the T.M.J.

The patient is unable to close his mouth (open bite) and movement is
restricted. In order to avoid such a complication, the mandible must be
firmly supported during an extraction and patients must avoid opening their
mouth excessively, especially those with a history of “habitual temporo -
mandibular joint luxation.” This complication occurs due to
a. History of recurrent dislocation of T.M.J.
b. Poor support of mandible

Treatment.
Immediately after the dislocation, the operator should stand in front of the
patient and the thumbs are placed on the occlusal surfaces of the teeth, while
the rest of the fingers surround the body of the mandible right and left.
Pressure is then exerted downward with the thumbs and simultaneously
upwards and backward with the rest of the fingers, until the condyle is
replaced in its original position.
After repositioning, the patient must limit any movement of the mandible
that may lead to excessive opening of the mouth for a few days.

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7. Injury to the Temporomandibular joint (T.M.J.)
Another major structure that can be traumatized during an extraction
procedure in the mandible is the temporomandibular joint. Removal of
mandibular molar teeth frequently requires the application of a substantial
amount of force. If the jaw is inadequately supported during the extraction to
help counteract the forces, the patient may experience pain in this region.
Controlled force and adequate support of the jaw prevents this.
If the patient complains of pain in the T.M.J. immediately after the
extraction procedure, the surgeon should recommend the use of moist heat,
rest for the jaw, a soft diet, and nonsteroidal anti-inflammatory drugs or
acetaminophen.

8. Displacement of root or tooth into the maxillary sinus

This complication occurs during the extraction of maxillary premolars and
molars or surgical removal of impacted maxillary third molar. the main
etiological factor is the close proximity of the roots of these teeth to the floor
of the maxillary sinus, or when the surgical procedure has not been carefully
planned.
Treatment.
The patient should be informed about the complication. Antibiotic treatment
and nasal decongestants are also administered, and surgical removal is
scheduled. It must be treated as soon as possible, because there is a risk of
infection of the maxillary sinus, which usually worsens due to the existing
oroantral communication. The exact position of the tooth or root tip must be
confirmed with radiographic examination. Removal of the tooth or root from
the maxillary sinus is usually achieved with a Caldwell–Luc approach.

9. Damage to the soft tissue

A. Gingiva
a. Improper separation of gingiva
b. Slippage of elevator
c. Wrong application of forceps
B. Lower lip
May be crushed between the handle of forceps and lower anterior teeth
during extraction of upper posterior teeth
C. Tongue and floor of mouth
a. Slippage of elevator
b. The tongue may be crushed by the forceps

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4th year Oral and maxillofacial surgery Lecture 13
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B/- The post extraction complications

1) Bleeding ==== (SYSTEMIC , LOCAL)

The local causes are: bleeding is either originate from the bony tissue or
from
the soft tissue as follow:
a. Insufficient squeezing of the socket.
b. Gross damage to the soft tissue
c. Damage to the bone & tear of periosteum
d. Presence of granulation tissue ---- granuloma---- chronic periodentitis and
due to inadequate removal of inflammatory and hyperplastic tissue from the
surgical field.
e. Damage to the major arteries ----- inferior dental artery---- greater palatine
artery

TREATEMENT===
If the patient coming complaining of post-operative bleeding, the patient is
seated on the dental chair and we examine the mouth in order to determine
the site and amount of bleeding. Almost an excess of blood clot is seen in
the bleeding area and this should be grasped in a piece of gauze and
removed, then a firm gauze pack is placed over the socket and the patient is
instructed to bite upon it for about five minutes then the pack is removed and
we will see the following:
A. If tear is present in the gingiva, then it is treated by suturing under local
anesthesia
B. When the bleeding is coming from the gingival margin, it is controlled by
a mattress suture.
C. When the bleeding is originated from a granulation tissue then it should
be removed by curation together with the use of local hemostatic agent and
suturing.

D. When the bleeding is coming from the bone of the socket it is controlled
as follow:
give local anesthesia to the patient and the clot that has been formed within
the socket is removed and the bleeding could be controlled by the following
I. The bleeder point of the bone is burnished with the blunt side of the
curette in order to obstruct the blood flow, and then we use a local
hemostatic agent such as gelfoam, surgicel (sterilized oxidized cellulose),
fibrin sponge or gelatin sponge, applied inside the socket. The procedure for

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using the hemostatic agents in the case of a relatively small hemorrhage,
which persists despite biting on a gauze pack over the post-extraction
wound, an absorbable hemostatic sponge is placed inside the alveolus and
pressure is applied over the gauze, also the wound margins are sutured with
a figure-eight suture.
II. Sterile bone wax may also be used to arrest bone bleeding, which is
placed with pressure inside the bleeding bone cavity.
III. Packing the socket with iodoform gauze, also could be used to arrest
bone bleeding as well.

Note:
a- When the bleeding originated from a large vessel that is severed during
the surgical procedure, a hemostat is used to clamp and ligate the vessel such
as the greater palatine artery
b- When the bleeding is originated from damage of the inferior dental artery,
it is treated by packing the socket with iodoform gauze. and send the patient
to a specialized center.

2) Trismus
Trismus usually is characterized by a restriction of the mouth opening due to
spasm of the masticatory muscles. The causes of trismus are:
a. Injury of the medial pterygoid muscle caused by a needle (repeated
injections during inferior alveolar nerve block)
b. By trauma of the surgical field, especially when difficult lengthy surgical
procedures are performed.
c. Inflammation of the wound with postoperative edema and swelling will
lead to a reflex spasm of the muscles of mastications such as massetter
muscle and medial pterygoid muscle. such as following surgical removal of
impacted mandibular third molar.
d. Hematoma

Treatment
management of trismus depends on the cause. Most cases do not require any
particular therapy. When acute inflammation or hematoma is the cause of
trismus, it is treated by:
a. Hot mouth rinses are recommended to reduce the inflammatory edema,
and this could be done after 24 hours following the surgical procedure.

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b. Heat therapy, i.e., hot packs are placed extra-orally for A few minutes
every hour until symptoms subside
c. Gentle massage of the temporomandibular joint area
d. Administration of analgesics, anti-inflammatory and muscle relaxant
medication
e. Physiotherapy which includes movements of opening and closing the
mouth in order to increase the extent of mouth opening, also we can use the
tongue blades to Gradually increase the mouth opening.

3) Hematoma
This is a quite frequent postoperative complication due to prolonged
capillary hemorrhage when the correct measures for control of bleeding are
not take (ligation of small vessels, etc.). In this case blood accumulates
inside the tissues, without any escape from the closed wound or tightly
sutured flaps under pressure. The hematoma may be submucosal,
subperiosteal, intramuscular.
Treatment.
If a hematoma is formed during the first few hours after the surgical
procedure, therapeutic management consists of placing cold packs
extraorally during the first 24 h, and then after 24 h heat therapy to help it to
subside more rapidly. And it is better to prescribe antibiotics to avoid the
secondary infection and suppuration of the hematoma.

4) Edema
Edema is a complication secondary to soft tissue trauma. It is the result of
extravasation of fluid by the traumatized tissues (inflammatory edema)
together with the destruction or obstruction of lymph vessels, resulting in the
cessation of drainage of lymph, which accumulates in the tissues. Swelling
reaches a maximum within 48–72 h after the surgical procedure and begins
to subside on the third or fourth day postoperatively.
Clinically, when swelling is due to inflammation, the skin presents with
redness, because of the local hyperemia, the edema ranges from small to
moderate and, rarely, severe. Sometimes, when the surgical procedure is
performed in the maxilla, the edema may extend as far as the lower eyelid,
because the tissues in this area are especially loose.
Treatment
1. For preventive reasons, cold packs are better to be applied locally
immediately after surgery. They should be placed for few minutes. every
hour, for the following 4–6 h.

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2. A small-sized edema does not require any therapeutic management. Just a
hot mouth wash after 24 hours of the surgical procedure.
3. When the edema is severe, then a broad spectrum antibiotic is prescribed
with a suitable anti-inflammatory drug, and the patient is instructed for a hot
mouth wash.

5) Oro- Antral Fistula

A communication between the oral cavity and maxillary sinus occur during
the extraction of upper posterior teeth.

6) Dry Socket (Alveolar osteitis)

The term dry socket describes the appearance of the extraction socket when
the pain begins. In the usual clinical course, pain develops on the third or
fourth day after removal of the tooth. On examination the tooth socket
appears to be empty; with a partially or completely lost blood clot, and some
bony surfaces of the socket are exposed. The exposed bone is sensitive and
is the source of the pain. The dull, aching pain is moderate to severe,
throbbing pain, and usually radiates to the patient's ear. The area of the
socket has a bad odor, and the patient complains of a foul taste. It occurs in
mandible more than maxilla due to rich blood supply of maxilla and limited
blood supply of mandible. The dry socket is not occurring in children due to
rich blood supply of both jaws.

ETIOLOGY
The cause of alveolar osteitis is not absolutely clear, but it appears to result
from high levels of fibrinolytic activity in and around the extraction socket.
This fibrinolytic activity results in lysis of the blood clot and subsequent
exposure of the bone. The fibrinolytic activity may result from subclinical
infections, inflammation of the marrow space of the bone, or other factors.
The occurrence of a dry socket after a routine tooth extraction is rare (2% of
extractions), but it is frequent after the surgical removal of impacted
mandibular third molars (20% of extractions in some series).

THE PREDISPOSING FACTORS

1. Trauma :Traumatic procedure and difficult extraction will enhance the
fibrinolytic activity which lead to disintegration of the blood clot.
2. Infection during or after or before the extraction of the tooth may
predispose for the dry socket such as extraction of a tooth associated with
pericoronitis may leads to a dry socket.
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3. Local anesthesia: There is a positive correlation between the amount of
local anesthesia and dry socket due to the effect of the vasoconstrictors
which decrease the blood supply.
4. Dense bone that has a poor vascularity more susceptible for dry socket.
5. Post extraction sucking or spiting which produce a negative pressure
resulting in the detachments of the blood clot from the alveolar bone and
development of dry socket.
6. Remaining root or foreign body in the alveolus.
7. General factors such as anemia, diabetes mellitus, T.B.

Treatment
The aim of treatment is to relieve the pain and to enhance the healing
process.
The Royal College of Surgeons in England laid down National Clinical
Guidelines in 1997, which were subsequently reviewed in 2004, on how a
dry socket should be managed. They suggest the following:
1. In appropriate cases, a radiograph should be taken to eliminate the
possibility of retained root or bony fragments as a source of the pain, usually
in cases when a new patient presents with such symptoms.
2. The socket should be irrigated with warmed 0.12% chlorhexidine
digluconate or with worm normal saline to remove necrotic tissue and so
that any food debris can be gently evacuated.
Local anaesthesia may occasionally be required for this.
3. The socket can then be lightly packed with a dressing to prevent food
debris entering the socket and to prevent local irritation of the exposed bone.
This dressing should aim to be antibacterial and antifungal and not cause
local irritation or excite an inflammatory response.
4. Patients should be prescribed non-steroidal anti-inflammatory drug
(NSAID) analgesia, if there is no contra-indication in their medical history.
5. Patients should be kept under review and steps 2 and 3 repeated until the
pain subsides.
There are different dressing materials used such as:
A. Ribbon gauze impregnated with iodoform paste usually the dressing is
kept inside the socket for three days and changed as needed until pain is
subsided and granulation tissue covers the walls of the socket.
B. Alvogyl which has an antiseptic and analgesic effect, Alvogyl is reported
to be non-resorbable, self-eliminating, as it does not adhere tightly to the
socket.

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C. Placing a gauze soaked in zinc-oxide/eugenol may be used, which
remains inside the alveolus for 5 days; However, it is important to remember
that such nonresorbable dressing is a foreign body in the socket and will
delay healing. The eugenol is also reported to cause local irritation and bone
necrosis

However, if any of the above dressings is to be used, the patient must be

recalled at least every two to three days to assess the pain, and during this
recall visit we either replace the dressing or remove the dressing when the
symptoms have subsided sufficiently and the bony walls of the socket are
covered by granulation tissue.
There is an important point have to be taken in consideration during the
treatment of dry socket that the curettage of the bony walls of the socket
should be avoided because it will delay the normal healing process, also it
causes the invasion of the infection to the surrounding bone.

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