Oral Surgical Complications

Prepared by Dr. Amy Cabrera, DMD, MAT

CENTRO ESCOLAR UNIVERSITY FOR INTERNAL CIRCULATION ONLY 2020
 Outline:
● I. Soft tissue injuries
● 1. Laceration or tear
● 2. Puncture wound
● 3. Abrasion and burn
 Outline:
●II. Injuries to adjacent structures
●1. Problems with a tooth being
extracted
● 2. Injuries to adjacent tooth
● 3. Injury to the nerve
● 4. Injury to the TMJ
 Outline:

● III. Hemorrhage
● IV. Other Postsurgical Complications
● 1. Pain and discomfort
● 2. Edema
● 3. Infection
● 4. Ecchymosis
● 5. Dry socket
● Soft Tissue Injuries:
● I. Tear or Laceration
● 2. Puncture wound
● 3. Abrasion
1. Tear or Laceration
● Tear of mucosal flap - the most common
soft tissue injury during surgical extraction
of a tooth.
Prevention of soft tissue injuries:
1. Pay strict attention to soft tissue injuries
2. Develop adequate-sized flap.
3. Use minimal force for retraction of soft
tissue.
1.Tear or Laceration
● Mucoperiosteal flap badly torn due to
inadequate care during its reflection.
 1.Tear or Laceration

Management: Careful suturing

* If margins are jagged, excise the edges to create
a smooth flap margin.
Prevention:
(1) Extend the flap horizontally to gain better
access to the bone underneath
(2) Create a relaxing incision at the posterior end of
the envelope flap to minimize tissue tension
 1.Tear or Laceration

(3) Use controlled amount of retraction

force on the flap
(4) Detach the mucoperiosteum from its
attachment on the bone by initially using
a small instrument tipped instrument,
like the MPE #9 or gum separator
 2. Puncture Wound

● The second soft tissue injury that occurs with

some frequency is inadvertent puncturing of soft
tissue.
● Instruments such as a straight elevator or a
periosteal elevator may slip from the surgical
field and puncture or tear into adjacent soft
tissue.
● Once again, this injury is the result of using
uncontrolled force.
2. Puncture Wound

Management: Usually no need for suturing

* If small infection occurs, there would be
adequate pathway for drainage.
Prevention:
(1) Use controlled force when using the
elevator
(2) Always establish a fingerguard when
luxating a tooth with an elevator
Strict reminder: Always use a fingerguard
when using an elevator

Source: Fragiskos D.
Fragiskos. (2007) Oral
Surgery. p.84

Hold a piece of gauze pad on the lingual side to

protect your fingerguard and the tongue against
possible injury from the elevator
2. Puncture Wound

(3) Use an occlusal stop on the adjacent

tooth when elevator is being inserted
straight into the PDL space on a
parallel plane to the long axis of the
tooth
(4) No elevation should be attempted
along the buccal bone because it can
easily be fractured and slip into the
soft tissue
 Applying the elevator
as wedge

Establish an occlusal
finger stop.
Rationale:
Minimizes accidental
plunging of the elevator
into the surrounding soft
tissues.
Source: Fragiskos D. Fragiskos. (2007) Oral Surgery.
p.84
 3. Abrasion

● Abrasion of lower lip as a result of shank of

bur rotating on soft tissue. The abrasion
represents a combination of friction and heat
damage. The wound should be kept covered
with antibiotic ointment until an eschar forms,
taking care to keep the ointment off
uninjured skin as much as possible.
3. Abrasion

Management: Usually no procedure necessary

except to put topical antibiotic ointment and heals
in 4-7 days
Prevention:
1) from rotating shank of the bur, make sure the lip
and corner of the mouth is retracted properly
2) from instruments freshly out of the autoclave,
make sure to wait for instrument to cool down
● II. Injuries to Adjacent Structures
1. Problems of a Tooth Being
Extracted
2. Injury to Adjacent Tooth
3. Injuries to Osseous
Structures
● II. Injuries to Adjacent Structures

● Best avoided if the following

preparatory steps are undertaken:
● 1. thorough preoperative assessment
● 2. comprehensive treatment plan
● 3. careful execution of surgical
technique
● I. Prevention of Complications

1. Perform a thorough preoperative

assessment
❖ Obtain adequate imaging and
carefully view them (preoperative
radiographic evaluation)
● I. Prevention of Complications

Preop radiograph must include

- entire area of surgery
- apices of roots to be extracted
- local and regional anatomic structures
- adjacent parts of the maxillary sinus
- inferior alveolar canal
● I. Prevention of Complications
On preop radiograph -
- a. look for presence of abnormal root
morphology or signs of ankylosis.
- b. assess density of surrounding bone.
● I. Prevention of Complications

● 2. Prepare a comprehensive treatment

plan and present to the patient
● Thorough preoperative instructions and
explanations to the patient are essential in
preventing or limiting the impact of the
majority of complications that occur in the
postoperative period.
● I. Prevention of Complications

● 3. Follow basic surgical principles.

● There should be clear visualization and

access to the operative field which
requires adequate light, adequate soft
tissue retraction and reflection and
adequate suction.
● Utilize controlled force.
 A. Root Fracture
● the most common problem associated with the
tooth being extracted
● common with long, curved, divergent roots in
dense bone
● Prevention:
● 1. Always consider the probability of root fx
● 2. Use surgical extraction if high probability of
fracture exists
● 3. Do not use strong apical force on a broken
root.
 A. Root Fracture

● Management:
● 1. Use root tip elevators.
● 2. Proceed to open surgical procedure.
 B. Root Displacement - to Max Sinus
● Root of max molar - most commonly
displaced into the maxillary sinus
● Prevention
● 1. Evaluate tooth-sinus relationship whether
there is sinus approximation or none
● 2. If long divergent roots are seen section
the roots into single separate roots
 B. Root Displacement - to Max Sinus
● Prevention
● 3. Use surgical extraction if high probability
of fracture exists
● 4. Avoid excessive force when extracting
maxillary molars.
● 5. Do not use strong apical force on a
broken root.
 B. Root Displacement - to Max Sinus
● Management of displaced tooth:

➔ 1. Identify size of displaced root.

➔ 2. Localize position of root.
- whether pushed into the sinus cavity or
wedged between the Schneiderian
membrane & floor of sinus.
- Do not probe with curette or root tip pick.
➔ 3. Ask patient to do Valsalva maneuver to
check if blood form bubbles in the socket.
- (Be careful not to cause rupture of sinus
lining if it has not been perforated)
 B. Root Displacement - to Max Sinus
● Management of displaced tooth:
➔ 4. If displaced tooth fragment is a small (2
or 3 mm) root tip, and the tooth and sinus
has no preexisting infection, make a brief
attempt to remove the root.
- flush irrigating solution through the
small opening in the socket apex and
then suction to retrieve the small root tip.
- If unsuccessful, no additional surgical
procedure should be performed through
the socket, leave the root tip in the sinus
and refer to an oral surgeon.
 B. Root Displacement - to Max Sinus
● Management of displaced tooth:

★ Root fragment that couldn’t be

retrieved through the socket or a
tooth displaced into the maxillary
sinus is removed thru a Caldwell-Luc
or endoscopic approach into the max
sinus in the canine fossa region.
● Rationale for leaving non-infected root tip
➢ If root is non-infected and sinus is
not infected, root tip may be left in
place because attempt to retrieve it
may risk more serious injury.
➢ Fibrous tissue could grow around it
with no subsequent complication.
➢ Inform the patient about your
decision and give instructions for
regular monitoring.
 B. Management of Oroantral
Communications
● After root apex is suctioned out from
the sinus, closure of the orantral
communication (OAC) is performed
● Possible complications if the OAC is not
properly healed:
● 1. chronic maxillary sinusitis because
water & food will pass thru the nose.
● 2, oroantral fistula (OAF)
Management for small OAC (<2mm):
❏ - No additional surgical tx is necessary.
Just make sure to keep the healthy blood
clot protected.
● Management of Oroantral
Communications
❏ Management of OAC - 2-6mm opening
1. Create water-tight closure of the socket by
employing figure-of-eight suture over it to
protect forming blood clot.
2. Give instructions on sinus precautions to
prevent displacing the forming healthy clot
3. Prescribe antibiotics and nasal spray to
prevent infection & inflammation to keep
osteum opening patent.
● Protect the Healthy Blood Clot
● Management of Oroantral
Communications
❏ Management of OAC >7mm
1. Create water-tight closure of the socket
by employing a buccal mucosal flap to
protect forming blood clot.
2. Give instructions on sinus precautions
to prevent displacing the forming healthy
clot
3. Prescribe antibiotics and nasal spray to
prevent infection & inflammation to keep
osteum opening patent.
 B.Root Displaced to Other Areas

1. Max M3 displaced into the infratemporal

space
❏ usually lateral to the lateral pterygoid plate &
inferior to the lateral pterygoid m.
❏ If not retrieved after 1st attempt, abort and
refer to oral surgeon.
2. Mand M3 displaced to lingual sulcus or into
the submandibular space
 B.Root Displaced To Other Areas

2. Mand M3 displaced thru the thin lingual plate

into the lingual sulcus or the submandibular
space
● prevented by avoiding apical pressure in
removing fractured roots of the mand molar.
● Using finger guard against the lingual plate to
prevent the tooth from being pushed lingually.
● Use cryer instead of root tip pick, applying the
wheel & axle principle to remove the small root,
● 3. Tooth Lost into the Pharynx
● If this occurs, the patient should be turned
toward the surgeon and placed into a
position with the mouth facing the floor as
much as possible.
● The patient should be encouraged to cough
and spit the tooth out onto the floor.
● 2. Injuries to Adjacent Teeth

● When surgeon’s total attention is just

focused on the tooth being extracted,
injury to adjacent tooth may likely
happen.
1. when using bur to remove bone or
section adjacent embedded tooth
2. when adjacent tooth has large
restoration
 Injuries to Adjacent Teeth

● 3. when using dental elevator where

fulcrum used is the adjacent tooth.
● 4. when using too much traction forcep to
remove a tooth
● 5. improper angulation of forceps during
extraction
● 6. beak used is too wide for a tooth
Prevention of Injury to Adjacent Teeth

1. Use dental elevators judiciously.

2. Recognize the potential to fracture a
large restoration on an adjacent tooth
3. Use correct armamentarium.
4. Use forceps correctly.
● 3. Extraction of the Wrong Tooth

● A complication that every dentist believes can

never happen—but happens surprisingly
often—is extraction of the wrong tooth.
● This problem may be the result of inadequate
attention to preoperative assessment.
● A common reason for removing the wrong
tooth is that a dentist removes a tooth for
another dentist.
● The use of differing tooth numbering systems.
Prevention of Extraction of Wrong Tooth

1. Focus attention on the procedure.

2. Check with the patient to ensure that you
are extracting the correct tooth.
3. Check the preoperative radiograph to
confirm that you are extracting the correct
tooth.
3. Injuries to Osseous Structures

● A.Fracture of the Alveolar Process

● B.Fracture of the Maxillary
Tuberosity
● C.Fracture of the Mandible
 A.Fracture of the Alveolar Process

Cause:
1. Excessive force with forceps in extraction of
maxillary canine.
2. Extraction of maxillary 1st molars with widely
divergent roots with sinus approximation
3. Excessive force during extraction of maxillary
3rd molars with thin maxillary tuberosity.
A.Fracture of the Alveolar Process

Prevention:
1. Careful preoperative radiographic
assessment and clinical assessment
2. Avoidance of the use of uncontrolled
excessive force
3. Early decision to perform open extraction
procedure with removal of controlled
amount of bone
4. Sectioning of root of multirooted teeth
with widely divergent roots
A.Fracture of the Alveolar Process

Management:
1. If cortical bone still remains attached to the
mucosa and the tooth, use the gum separator
or MPE#9 to detach the tooth from the bone and
reposition the bone and suture the mucosa.
2. For multi-rooted maxillary molar, use surgical
bur to remove part of the crest of buccal
alveolar plate and section the roots into 3
separate single roots to remove one at a time.
 B.Fracture of the Maxillary Tuberosity

● The maxillary tuberosity fractures most

commonly result from extraction of an
erupted maxillary third molar or from
extraction of the second molar, if it is the
last tooth in the arch.
● The maxillary tuberosity is important for
the construction of a stable retentive
maxillary denture.
C.Fracture of the Mandible
● Commonly seen in fractures involving the
orofacial complex due to vehicular accidents
● Occasions where fracture occurs during
dental surgery:
- during forceful use of elevator
- during removal of the mandibular 3rd molar
impaction
- during extraction on a severely atrophic
mandible
C.Fracture of the Mandible

● The major therapeutic goal in

management of fractures is to maintain
the fractured bone in place and to provide
the best possible environment for healing
by splinting and keeping the fractured
bone segments undisturbed during the
healing period.
● 4. Injury to the Nerve
● 5. Injury to the Temperomandibular
Joint
 3.Injury to the Nerve

● The prudent surgeon preoperatively

evaluates all adjacent anatomic areas and
designs a surgical procedure to lessen
the chance of injury to these tissues.
 3. Injury to the Nerve
● The most frequently involved
1. mental nerve
2. lingual nerve
3. long buccal nerve
4. nasopalatine nerve
● The nasopalatine and buccal nerves are
frequently sectioned during the creation
of flaps for removal of impacted teeth.
 3. Injury to the Nerve

Prevention of nerve injury:

● Be aware of the nerve anatomy in the
surgical area.
● Avoid making incisions or stretching the
periosteum in the nerve area.
Management:
- Nerve repair
- Therapeutic dose of Vitamin B
 4.Injury to the Temporomandibular Joint

Cause:
● when jaw is inadequately supported
during forceps extraction of
mandibular teeth.
Prevention:
● use controlled force and stabilize the
mandible during forceps extraction.
● ask patient not to open mouth too
widely
● III. Hemorrhage
 Hemorrhage
● Causes:
(1) High vascularity of the tissues of the oral
cavity
(2) Extraction socket is an open wound which
allows additional oozing and bleeding
(3) Applying dressing material with enough
pressure and sealing to prevent additional
bleeding during surgery is difficult to
achieve
 Hemorrhage

(4) patients tend to explore the area of surgery

with their tongue and dislodge blood clots
or create small negative pressure that
suctions the blood clot from the socket
which initiates secondary bleeding
(5) salivary enzymes may lyse the blood clot
before it has organized and before the
ingrowth of granulation tissue.
Hemorrhage: Intraoperative Management

1. Bite on a piece of wet folded gauze as

pressure pack for 10 minutes to control
capillary bleeding..
2. If bleeding comes from bone surface, rub
blunt intrument on bleeding pointl
3. Apply local hemostatic agent.
Hemorrhage: Intraoperative Management

1. Bite on a piece of wet folded gauze as

pressure pack for 10 minutes to control capillary
bleeding..
2. If bleeding comes from bone surface, rub blunt
instrument on bleeding point
3. Apply local hemostatic agent.
Local Hemostatic Agents

● 1.Collagen - stimulates stimulation of platelet

adhesion, platelet aggregation and release
reaction, activation of Factor XII (Hageman
Factor) and serve as mechanical tamponade
● 2.Surgicel - oxidized oxycellulose that acts as
physical barrier when it becomes a sticky
mass that serves as an articicial coagulum
- but found to cause more pain amd delayed
healing
Local Hemostatic Agents

● 3.Gelfoam - gelatin-based sponge that is

water soluble and biologically resorbable but
initially delays healing.
● - stimulates intrinsic clotting pathway by
promoting platelet disintegration and
subsequent release of thromboplastin and
thrombin.
Gelfoam - a local hemostatic agent used
to control bleeding from extraction socket
Local Hemostatic Agents

● 4.Bone wax - non-absorbable material

composed 88% beeswax & 12% isopropyl
palmitate,
● - not anymore recommended because it
produces chronic inflammatory foreign body
reaction and retards healing.
● 5.Calcium sulfate - a bone graft material and
hemostatic agent that acts as physical
barrier & does not inhibit bone formation’
Local Hemostatic Agents

● 6.Epinephrine - acts as vasoconstor

● 7. Electrocautery - stops blood flow through
coagulation of blood and tissue protein that
causes tissue necrosis and eventual delay in
the healing process.

Source: Hargreaves, Kenneth and Berman, Louis. (2016) Cohen;s Pathway of the Pulp.
11th ed.
Hemorrhage: Postoperative Management

1. Bite on a piece of wet folded gauze as

pressure pack for 30 minutes.
2. If bleeding ensues, replace pressure pack
with another gauze or a piece of fresh teabag
and bite for 1 hour.
3. Minimize talking within 1st 24 hours
4. Stop smoking. Nicotine interferes with wound
healing.
Hemorrhage: Management

5. Avoid spitting within 12h post surgery

because it creates negative intraoral pressure.
6. Avoid using straws.
7. Avoid frequent mouth rinsing.
8. Avoid strenuous exercise. It would increase
BP and dislodge the blood clot.
9. Take liquid or soft diet;
10. Avoid taking anything hot for the 1st 24h
11. Prescribe tranexamic acid, 250-500 mg, tid
Hemorrhage: Management

Prevention of Postoperative bleeding:

1. Obtain a history of bleeding
2. Use an atraumatic surgical technique
3. Obtain good hemostasis at surgery
4. Provide excellent patient instructions
● III. Other Postoperative Sequelae
 1. Pain & Discomfort

● peaks @12 hours, status postsurgery.

● Management:
1. Prescribe analgesic for 3 days, prn
● 1st dose to be taken before anesthesia wears
off. Ex:
(1)Ibuprofen 400 mg q4-6h after a snack or meal
(2)Paracetamol 500 mg q4-6h
(3)Combination of NSAID & paracetamol tid
(4)Tramadol HCl 50 - 100mg bid (in case of
intolerance to NSAID)
 1. Pain & Discomfort

● 2. Diet should be liquid of soft diet during

the 1st 24 h to prevent irritation.
● Cool foods (high-calorie diet) and cold
drinks on the 1st day post surgery to sooth
pain,
 2. Edema

● peaks @36 to 48 hours, status post surgery

● Management:
● 1. Apply cold compress 20 minutes every hour
for 1st 24hours.
● 2. Apply warm compress 3rd day onwards
● 3. For expected prolonged procedure, preme
with antibiotic and/or steroid.
● Ex. 2-4h premed of glucocorticoid not to
exceed 3 days.
 3. Infection

● Management:
● 1. Prescribe antibiotics for 7 days
● Ex. Amoxicillin 500 mg q8h for 7 days.
● 2. Warm saline rinses from 3rd day
onwards until pain and swelling subsides.
 4. Ecchymosis

● onset is 2-4 days, Status post

● seen in elderly necause of increased
capillary fragility and weaker intercellular
attachment.
● resolves fully within 7-10 days.
● Management: Apply warm compress.
 5. Dry Socket (Local Alveolar Osteitis)

● bone inflammation not associated with

infection where socket is partially or
completely devoid of blood clot exposing
bony surface of the socket
● associated with removal of mand molars (esp
if procedure is traumatic) characterized by
foul smelling odor with moderate to severe
pain, usually throbbing that develops 3-4
days post surgery.
 5. Dry Socket (Local Alveolar Osteitis)

● Management goal is to relieve pain.

● No systemic antibiotics is necessary.
● Procedure:
● 1. Irrigate the socket with cupious amount of
NSS. --- DO NOT CURETTE --- Curettage will
just add trauma to the bone.
● 2. Gently insert iodoform gauze containing
eugenol as obtundent dressing .
● 3.Remove on 3rd day or replace & remove on 5th day
References:

Hupp, James R., Ellis, Edward III and Tucker, Myron R. (2019) Contemporary
Oral and Maxillofacial Surgery. 7th ed

Hargreaves, Kenneth and Berman, Louis. (2016) Cohen;s Pathway of the Pulp.
11th ed.

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