COMPLICATIONS OF TOOTH EXTRACTION: -

Lecture: 15
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 (Fig. 1). 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.

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.

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 Fig. 1 Fracture of the alveolar process.

3. Fracture of maxillary tuberosity (Fig. 2 )

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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 Fig. 2 Fracture of maxillary tuberosity

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:- (Fig 3 ) 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.

Fig. 3 Fracture of mandible

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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 (Fig. 4). 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.

Fig. 4 Reduction of the dislocation of T.M.J

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.

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 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. Fig. 5

Fig. 5 Removal of a root from the maxillary sinus using the Caldwell–Luc surgical technique

9. Damage to the soft tissue Fig. 6

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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Fig. 6 Trauma of the soft tissue

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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 Fig. 7.
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 currete 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 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 (Fig 8).

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 Fig (9)
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.

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 Fig 7 Mattress suture

Fig. 8 : a- Packing of the alveolus with hemostatic materials: gelatin Sponge , collagen, etc. b-
Suturing of wound margins with a figure-eight suture

Fig :8 b-Gauze pack, sutured over a postextraction wound

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 Fig 9: Diagrammatic illustration showing steps in the ligation of the palatine artery
after severance. a Severance of the vessel. b Vessel clamped by a hemostat.
c Ligation with a resorbable suture.

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.
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. fig .10.

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 Fig . 10 Attempt to open mouth with physiotherapy, in a case of trismus

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. Fig 11.

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.

Fig 11 : Hematoma as a result of surgical extraction

4) Edema Fig. 12 & 13

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.

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 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.
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.

Fig 12: Edema as a result of a difficult surgical procedure to remove an impacted mandibular
third molar.

Fig. 13: Edema of the lower eyelid as a result of the surgical removal of an ankylosed maxillary
canine.
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 Fig.14. 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.

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 Fig. 14 Dry socket

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.
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.

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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 Fig. 15.
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.

Fig. 15. Alvogyl dressing

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