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SURGICAL COMPLICATIONS OF MINOR ORAL SURGERY

The practice of oral surgery will at times result in complications from time to time. Although complications are uncommon, the patient must always be informed about the potential for problems to arise as a result of surgery – and informed consent obtained.
In clinical practice there can never be a guarantee that problems will not occur – although the clinician must reassure the patient that every effort will be made to minimise the likelyhood of things going wrong.

What is a Complication…?

Any adverse, unplanned events that tend to increase the morbidity above what would be expected from a particular operative procedure under normal circumstances.

Sources of Complications
Surgical complications may arise from either one or a combination of the following factors. 1. THE PATIENT – particularly those who are medically compromised,  leading to increased likelyhood of complications – such as persistent hemorrhage or delayed healing.

2. THE CLINICIAN – the risks are directly dependent on – - level of training - skill & experience - attitudes towards patient care.
3. THE SURGICAL PROCEDURE – risks depend on: * complexity of the procedure * local anatomy of the surgical site - access - proximity to important structures – nerves, blood vessels

1st stage.COMPLICATIONS OF ORAL SURGERY  As with all surgical procedures – complications can occur at each of the 3 stages. . Before surgery due to .inadequate surgical planning .poor case selection – medically compromised pt. who is a poor surgical risk.

poor technique .abnormal anatomy of the surgical site 3rd stage. post-op complications generally acute in nature. During Surgery .inexperience of operator .2nd stage. After surgery –early in the days following surgery.ie dry socket .

 The general way to manage complications is to consider the following principles : Preparation 1. Take an appropriate medical history 2. Identify high risk patients & take appropriate measures  .General principles of management of complications It is emphasised that common sense & cool must be maintained at all times in order to avoid turning a minor problem into a major disaster.

3.inform the pt. has the contact no. is essential .obtain consent: written / verbal . Clear communication with the pt. of what to expect and the surgical risks involved .make sure that the pt. Follow up appointments to monitor recovery and identify early warning of complications . in case of an emergency 4.provide the patient with written post-op instructions .

5.INTRA-OPERATIVE COMPLICATIONS The most common complications that may occur during surgery are as follows – 1. 3. 4. 2. Dental complications Soft tissue complications Bone complications Nerve complications Mx sinus complications Instrument breakage . 6.

DENTAL COMPLICATIONS Fracture of teeth Displacement of teeth Swallowing /Aspiration of teeth .

endodontically treated teeth Root – due to abnormal tooth morphology –fine curved apical root tips Adjacent Teeth / Restorations .due to clumsy use of instruments / force .gross caries .brittle teeth.excessive force .FRACTURES OF TEETH    Crown – due to .

Weigh the risk of removal of small root fragments vis a vis the potential complications that may arise if they are left in situ.Management :  Take radiographs to check root pattern Difficult teeth should be removed surgically Prescribe analgesics and possibly – antibiotics – and referral to a specialist.    .

posteriorly into the lateral pharyngeal space .DISPLACEMENT OF TEETH  Teeth or tooth fragments can be displaced into various tissue planes – potential spaces – or cavities.superiorly into the mx.lingually into the sublingual/submandibular space .laterally into the buccal space Mandibular teeth or tooth fragments . Maxillary teeth or tooth fragments .inferiorly into the inferior dental canal .sinus .

to allow fibrosis to occur in order to prevent further displacement during surgical retrieval. 2.MANAGEMENT 1.immediate removal if tooth is directly accessible in superficial tissues OR . Inform the patient Refer to specialist for: . Take radigraphs in atleast 2 planes to determine the position of the displaced tooth.removal at a later date if tooth is displaced into deeper tissues. . 3. Stop the procedure immediately to prevent the tooth being displaced further into deeper tissues. 4.

those who are semiconcious ( IV sedation) or .unconcious ( mask GA ) .patients placed in a supine position with unprotected airway .SWALLOWING OR ASPIRATION  Swallowing or aspiration of teeth is especially dangerous in .

urgent referal to ENT for pharyngoscopic removal of tooth Lower airway – chest xray is essential & referral for endoscopic removal of tooth. in a few days Chest radiograph is required to confirm that the tooth is in the alimentary canal rather than lungs Aspiration is a medical emergency & requires prompt attention Upper airway – perform Heimlich manoeuvre .  .  Swallowing has no serious consequence as the tooth is readily excreted.

SOFT TISSUE COMPLICATIONS Trauma Primary haemorrhage Surgical Emphysema .

. 3. 2.TRAUMA  Trauma to the surrounding tissues is caused by  Excessive retraction / uncontrolled forces Slippage of powered handpieces Use of hot instruments Leaning an instrument. against a numb lip eg micromotor 1. 4.

PRIMARY HAEMORRHAGE  Primary haemorrhage from surrounding soft tissues may be persistent in cases of  Excessive surgical trauma 2. topical thrombin 1. Inflamed tissues 3. Underlying bleeding tendency due to drug therapy. Management Check record of bleeding disorders Local measures: Direct pressure Suturing Gelfoam. . Surgicel. anticoagulants.

Extensive .SURGICAL EMPHYSEMA  Emphysema is the accumulation of air in tissues which in dental surgery may be caused by .use of hydrogen peroxide in the surgical wound Management – surgical emphysema crackles when palpated & usually resolves with time.Antibiotics .may lead to infection .increased intra-oral pressure through sneezing. coughing or nose blowing after minor oral surgery .use of high speed air rotor handpiece .

BONE COMPLICATIONS Haemorrhage # Maxillary Tuberosity TMJ Dislocation # Mandible .

replacing the extracted tooth especially in cases of significant haemorrhage caused by the disruption of vascular lesion in close proximity to extracted tooth. .Bone wax .HAEMORRHAGE  Blood vessels in the BONE may be controlled with: - Burnishing or crushing the bone with a blunt instrument .Packing the socket /bone defect with gelfoam/ collagen/ ribbon gauze soaked in adrenaline containing LA .

FRACTURE OF MAXILLARY TUBEROSITY  Predisposing factors: .Large & complex / hypercementosed root pattern in maxillary molars Management Replace the fragment  splint with sutures/wires for 4-6 weeks  then plan surgical removal once tuberosity has well healed OR remove fragment & close wound primarily with sutures Instruct patient to avoid nose blowing  .Lone standing maxillary molar in elderly pts .Ankylosed maxillary molars .

pt has a history of recurrent dislocations Patients on medication that have extrapyramidal side-effects eg phenothiazine tranquillizers .TMJ DISLOCATION Predisposing factors    Excessive mandibular force used to extract the mandibular teeth without proper mandibular support Lax joint ligaments .

diazepam or local anaesthesia into the joints may be helpful in relieving muscle spasm & discomfort of reducing the dislocated mandible.Management  Digital manipulation of the mandible back into place. .  The use of Narcotic analgesia .

osteopetrosis .excessive extraction forces on teeth in unsupported mandible .excessive bone removal Predisposing causes Buried tooth in an otherwise atrophic mandible Osteolytic pathology –cysts.poor surgical technique . tumors Brittle bone – osteogenesis impefecta.FRACTURE OF THE MANDIBLE  Fractures in the mandible are caused by: .

 Management Closed reduction – IMF Open reduction & internal fixation (ORIF ) Closed reduction with external pin fixation – in cases where pathology is involved. 2. 1. 3. .

NERVE COMPLICATIONS Lingual Nerve Damage Inferior Alveolar Nerve Damage Mental Nerve Damage .

hematoma formed by direct penetration of nearby blood vessels by the needle  Management Explanation + reassurance. Nerve will recover naturally in a few days  .NERVE INJURIES The inferior alveolar and lingual nerve are at most risk of damage from minor oral surgical procedures. particularly lower third molar extractions  Direct trauma – penetration of needle into the nerve trunk resulting in a sudden ‘electric shock’ pain followed by deep anaesthesia  Indirect trauma .

excessive retraction of lingual tissues .inadverent cutting of nerve with bur / scalpel .lingual split technique used for removal of lower third molar .LINGUAL NERVE DAMAGE  Lingual nerve damage may be caused by : .pressure from tongue retractor leaning against the lingual alveolus .

Inadverent severence of the nerve with bur.On attempted extraction. the root tip is displaced directly into the canal causing injury . .The roots may directly breach the inferior alveolar canal resulting in direct injury to the nerve on removal of the tooth .INFERIOR ALVEOLAR NERVE DAMAGE  Inferior alveolar nerve damage especially in the region of the apices of lower third molar can occur in one of the following ways: .

MENTAL NERVE DAMAGE  When the mental nerve emerges from the mental foramen.slipping of bur directly into the nerve . it is vulnerable to injury from surgery around the lower premolars especially during : .excessive retraction of buccal flap .apicoectomy procedures on mandibular premolars .

Review the patient to determine if sensation will improve with time. If there is no significant return of sensation within 6 weeks then prompt referral to a specialist is advised for nerve repair.General management if Nerve Injuries 1. The best prognosis for return of nerve function is if the required surgery is performed within 3 months of injury. 2. . 3.

MAXILLARY SINUS COMPLICATIONS Breach of Mx Sinus Displacement of tooth into Mx Sinus .

There is periapical pathology ie cyst / granuloma extending beyond the sinus floor.Lone standing molar .  .The roots extend well beyond the sinus floor . Diagnosis Bubbling of air through extraction site + escape of fluids through the nostril + patient cannot suck through a straw or cigarette.BREACH / BREAK OF MAXILLARY SINUS FLOOR An oro-antral communication can result from: .Tooth is ankylosed .Extraction is difficult & traumatic –injudicous use of root elevators .

not to blow nose for 7-10 days + analgesics + antibiotics + nasal decongestants & mucolytics .refer to a specialist  who may opt for immediate closure with buccal advancement flap –if sinus is clear of infection Instruct pt.MANAGEMENT  Immediate Treatment Options – depends upon the size of breach .cover defect with antiseptic soaked ribbon gauze & remove in 2-3 weeks to allow healing by secondary intention .reduce bony sockets edges & suture margins together .

. 2. 3.DISPLACEMENT OF TOOTH / ROOT INTO SINUS  If the tooth/root cannot be retrieved via the socket then: Stop the procedure to prevent further displacement Take x-ray to confirm position of tooth / root Inform the patient Prescribe analgesics + antibiotics + nasal decongestants Refer to a specialist 1. 4. 5.

 The specialist may elect to remove the tooth fragment either directly by enlarging the socket & suctioning it out and / or flushing out the fragment with saline OR  indirectly using the Caldwel Luc procedure via a surgical window through the anterior maxilla. giving great access to the sinus interior. .

. 3.SPECIAL PRECAUTIONS  Do not close a suspected oro-antral communication when : A tooth or root is displaced into the sinus Pus is liberated upon extraction of a tooth Clear fluid flows from the sinus upon extraction of a tooth indicating presence of a cyst or mucocele Unusual soft tissue prolapses through the extraction site. 2. 1. 4.

INSTRUMENT BREAKAGE .

3. burs + elevator tips are likely to break. 2.INSTRUMENT BREAKAGE  Needles. . 4. If the instrument is easily accessible then remove it immediately. 5. If displaced into deeper tissues then: Stop the procedure immediately Take x-rays to localise the instrument Inform the patient Give analgesics + antibiotics Refer to a specialist for further management 1.

POST OPERATIVE COMPLICATIONS Alveolar Osteitis Infections Haemorrhage Necrosis of Mucous Membrane Persistent Pain .

very tender exposed bone where clot has broken down within the extraction socket   Causes unknown –several factors have been implicated – excessive surgical trauma + smoking + poor blood supply + infection & clot breakdown.ALVEOLAR OSTEITIS Also called ‘dry socket’.very painful with inability to eat . ASD Classic presentation is that .it occurs about 3 days after extraction . . alveolagia.

 MANAGEMENT Local measures include – irrigation of socket with saline to clear out necrotic debris + socket dressing is placed which includes anaesthetic + analgesic ingredients such as eugenol. Analgesics + maybe antibiotics .

INFECTIONS  Causes .poor patient compliance .excessive trauma .hematoma formation – collection of blood in potential spaces which serve as a good culture medium for bacteria .general lack of resistance eg leukemia .surgery on inflammed tissues .

pulse & respiration Lymphadenopathy Malaise Increased WBC count . Clinically it manifests locally as pain erythema swelling pus and fistula formation systemic involvement Raised temperature.

rest + fluids + warmth .debride necrotic tissues + irrigate area Systemic measures .warm salt water rinses .antibiotics – culture sensitivity tests  .MANAGEMENT  Local measures .incise and drain fluctuant swelling eg pus or hematoma .analgesics .maintain drainage .

HAEMORRHAGE Delayed Heammorhage occurs within 24-48 hrs after surgery – increased BP or undiagnosed bleeding disorder Secondary haemorrhage occurs classically 10 days after surgery & occurs as a result of breakdown of clot due to infection. Management Good light + suction .determine site of bleeding Clean +irrigate + bite on gauze for 20-30 minutes If bleeding persists  gelfoam + surgicel + suturing .

NECROSIS OF MUCOUS MEMBRANE  Possible Causes .systemic disorders – neutropenia Management Local wound debridement + toilet of area to allow healing by secondary intention .compromised blood supply due to excessive stretching.tearing.poor flap design .poor wound care . base too narrow .palatal injection under excessive force .

has wrong tooth been extd ? !!! 2. Establish accurate history + eliminate possibility of any physical cause for pain such as co-existing disease( eg infected residual cyst) 3. Determine the response of pain to LA infiltration + analgesics .PERSISTENT PAIN  Pain persisting beyond the normal expected time for wound healing.in the absence of infection or delayed wound healing may be due to: .traumatic neuroma .psychogenic pain Management 1.causalgia ( phantom tooth pain ) . Reassess orignal diagnosis .

THANK YOU .

a surgical procedure should be considered.Response to a problem should be : Immediate recognition of a problem – in order to permit change of plan before a complication occurs – eg if a tooth cannot be extracted with the dental forceps. so rather than risk # the crown. .