Complications in Oral Surgery: ORS03-3003

Learning Objectives:
- Awareness of the different causes of complications in oral surgery
- Understand how to manage complications in oral surgery

Before starting an extraction, there must be a consenting of the possible risks that could occur
as a result. Without agreed consent, the treatment cannot occur.
These risks include: Post -operative pain, bleeding, swelling, bruising, infection, reduced
mouth opening, damage to the adjacent teeth, dry socket, inferior dental nerve damage, oral-
antral communication and tuberosity fracture.

Surgical complications can be classed as either immediate (intraoperative), early or

delayed/late.
Immediate complications include:
1. LA failure
2. Haemorrhage
Primary/ Secondary Haemostasis explained*
Haemostasis is required following surgery as there is a primary haemorrhage following
extraction. Patients must apply pressure using gauze; most patients with normal clotting
mechanisms should achieve haemostasis with local measures.
These measures are a saline flush to remove loose clots, pressure with gauze (tranexamic acid
if required), suture (horizontal or cross mattress suture) and oxidised cellulose
(surgical/curacel).
 3. Crown/Root Fracture
This occurs the most frequently of the complications. This can occur on brittle teeth (previous
RCT), grossly carious teeth, teeth heavily restored, curved apices, inappropriate use of
elevators/forceps etc. If fracture occurs, a surgical extraction may be required – a
mucoperiosteal flap is raised, bone is removed and the retained roots can be removed
preventing displacement into soft tissue or the maxillary antrum.
4. Damage to surrounding tissues
The surrounding bone has a risk of fracture due to excessive force being applied, ankylosed
roots, bone is compromised (Paget’s or osteogenesis imperfecta), force applied contrary to
path of removal etc. The management of this dependent on the extent of the bone. If a small
spicule of bone is attached to tooth root – ensure bony edges of socket are not sharp and
suture up. If the area of bone removed is large and still connected to the periosteum (e.g.
tuberosity) – consider splinting until bone healing is complete and then remove the tooth
surgically.
Tuberosity fractures are associated mostly with ULR7/8 extractions where the roots are
divergent, the bone is thin and the tooth has been overly elevated distobuccally. (care should
be taken when elevating upper third molars.
5. Oral antral communication
Has an incidence ranging between 5-13%. Intervention is required in order to prevent chronic
sinusitis and OAF (if left for more than 48 hours). He greatest risk comes from the upper
second molar. If for example, a root is displaced into the antrum – it will require removal as
an oral-antral communication has been created. It is preferred that the route is retrieved at the
time of surgery via a trans-alveolar route. The socket should be flushed and suctioned with a
narrow, non-perforated tip which may retrieve the debris. If this is not possible, the socket
can be expanded using a rosehead bur. If not, refer to oral surgery and a sinus lift procedure
may be required (Caldwell-Luc).
6. Loss/displacement of tooth into the antrum, stomach or lungs
7. TMJ dislocation
Use of non-dominant hand to support the mandible will prevent dislocations. Use of a bite-
block during treatment will prevent the mandible from locking up. Manipulating the
mandible downwards and backwards will correct a dislocation.

Early post-operative complications/risk:

- Pain, swelling and bruising
Some degree of pain is to be expected after treatment. Most post-operative pain is
inflammatory in nature; prostaglandins are released and so the effects of inflammation can be
minimised with pre-operative and post-operative analgesics namely NSAIDs.
- Trismus (lockjaw)
Occurs 1-6 days post-operatively. Trismus is the spasm of the jaw muscles, causing the
mouth to remain tightly closed. The symptoms are of varying severity. It can be caused by
TMJ dislocation, infection (lateral pharyngeal fascial space, masticatory), trauma to condyles,
IDB causing a haematoma (needle through medial pterygoid) etc. It should resolve itself but
if persistent, it should be treated using therabite or wood spatula exercise.
- Dry socket
Dry socket can occur on day three to four post-operatively on mandibular teeth. It occurs
with patients who smoke and rinse excessively. The blood clot lyses resulting in exposed
bone in the socket. The pain will be increasing in severity over time. This is non-infective but
can be managed using local measures; the socket must be irrigated and filled with an
obtundent dressing (alvogyl – contains eugenol, butamben and iodoform).
- Delayed Haemorrhage
A reactionary haemorrhage can occur 48 hours post operatively as a response to patient
overexertion (e.g. exercise) or by dislodgement of the stabilised blood clot. A secondary
haemorrhage starts up to a week later in response to infection or a sudden rise in INR say if
patient is wafarinised (international normalised ratio of prothrombin time of blood
coagulation is a value which shows how easily your blood will clot. If low, it means your
blood coagulates easily and high vice versa). Clinician should investigate where bleeding is
coming from and use local measures to achieve haemostasis once again.
- Prolonged Anaesthesia
Can occur due to damage suffered to inferior alveolar nerve or the lingual nerve upon
injection. The risk is said to increase when articaine is used (more concentrated LA) or when
performing an IDB, the risk also increases when multiple injections are administered.

Late post-operative complications/risk:

- Infection
Infection can spread into the soft tissues causing cellulitis – surgical drainage to remove
inflammatory/fluid exudate. If infection goes into bone, it can cause osteomyelitis which
gives the bone a moth-eaten appearance on the radiograph. The risk of osteonecrosis
increases with bisphosphonate use especially intravenous bisphosphonates.
Osteoradionecrosis a possibility*?

Bisphosphonates are a synthetic compound with a chemical structure similar to inorganic

pyrophosphate, an endogenous regulator of bone mineralisation. It is used to treat conditions
such as osteoporosis, Paget’s and cancers with bone spread. It compromises bone healing
ability and this compromised bone cannot cope with oral exposure and can leads to necrosis.

KCLH protocol for bisphosphonate patients:

Following a review of the literature a regime was decided on for

patients taking bisphosphonate medication

10ml Chlorhexidine mouthwash for 30 seconds pre-op

200mg Metronidazole TDS PO for 1 week or until mucosal
healing achieved Chlorhexidine mouthwash TDS until full
mucosal healing occurred
Initial review 2/52 post extractions
Regular reviews till 6/12 post extraction
No dentures for at least 4months following full mucosal healing